PROGRESS IN THE THEORY AND PRACTICE OF LESIONS
IN THE ALIMENTARY TRACT.

JAMES TAFT PILCHER, M. D.

PHYSICIAN-IN-CHIEF TO THE PILCHER HOSPITAL.

BROOKLYN, NEW YORK.

THE most marked advance in our knowledge of pathologic conditions

of the esophagus and of their treatment is that made by Plummer (Sur-

gery, Gynecology and Obstetrics, Volume X, Number V, page 519) in

his elaboration of the nearly forgotten technique devised by Mixter and

Dunham regarding the value of a silk thread as a guide in instrumental

interference. He shows the extreme simplicity of its use and demon-

strates its safety and usefulness in both diagnosis and treatment, based on

a series of three hundred lesions.

Cardiospasm has begun to be recognized with much greater frequency

than heretofore, chiefly due to the paper read by the same author at the
American Medical Association meeting in Saint Louis, 1910, at which
time many radiographs were demonstrated showing the diagnostic charac-
teristics of the lesion and giving the pathognomonic clinical picture, which
is divided into three stages, first, that of the catching of the larger pieces.
of food at the cardia, but which pass through eventually from the peris-
talsis alone; second, the stage where the food remains proximal to the
obstruction for an indefinite length of time, but may be forced onward by
the use of intrathoracic pressure; and third, the stage in which solids will
not pass, and the consequent inception of regurgitation.

His treatment, which has been successful without exception, is the use
of a hydrostatic dilator, exerting a divulsive pressure against the cardia of
about fifteen pounds; usually one treatment, but occasionally two, is all

that is necessary to effect a complete cure. The silk guide is almost indispensable in this procedure. Myers (Journal of the American Medical Association, Volume LV, Number XVIII, page 1554) has also had considerable experience with this apparatus, and confirms Plummer's state

ments.

Ulcer of the stomach and duodenum may be considered jointly. The most thorough exposition of the present day conception of the latter condition is that given by Moynihan in his recent book on "Duodenal Ulcer," and the consideration of ulcer of the stomach by Graham, based on the clinical diagnoses made in several hundred operated cases of the Mayo Brothers, points out many errors which have been made heretofore. We note that duodenal ulcer is far more frequent than we had supposed. Five years ago its occurrence seemed a rarity; now, many men meet with at least a case a week. Its occurrence is much more frequent in men, and its symptomatology quite pathognomonic in most cases. The old idea of the majority of ulcers of the stomach being found in the female has been exploded, and we find that not more than thirty per cent of the cases occur in women.

The ingestion of food does not cause pain in uncomplicated ulcer of the stomach, at least in its most frequent situation, but on the other hand relieves it. This is backed up by thoroughly scientific experiments. Indeed, the older textbooks seem directly at odds with the present day teachings from the living pathology of the operating table.

The relationship between ulcer and cancer of the stomach has received much consideration. To be noted especially are the observations of Wilson and MacCarty (American Journal of the Medical Sciences, December, 1909), in which they state that in a series of one hundred and forty-nine cases of cancer, one hundred and nine had certainly developed upon a preceding ulcer, and later Wilson and Willis (Journal of the American Medical Association, Volume LV, Number II) were able to demonstrate that sixty-seven per cent of cancers of the stomach had developed on ulcer. Moynihan places the incidence at seventy-two per cent, and Sscapescho at ninety per cent.

The treatment of ulcer divides itself into camps of Von Leube and that of Lenhartz, with various modifications by many men, notably Minkowski, Senator, Zweig, Mayerle, Lüdin, Müller, Gerhardt, Mortiz, Lambert, Rosenfeld, Sternberg, Linossier, Rochester, et cetera, the relative merits of which cannot be considered here.

As accessory measures are the employment of almond milk or olive oil, Rutimeyer has reported striking results from its employment in one hundred cubic-centimeter doses every morning in one hundred cases (clinical), while Borhjaerg enhances its effect by suspending in it sixteen grams of bismuth. The carbonate of the latter being quite as efficacious as the subnitrate, according to Meyerle.

The results of the employment of horse serum by Hort in England, and Katzenstein and Fuld in Germany, are as yet far from conclusive, and the expense is prohibitive.

The styptics and vasoconstrictors have been finally discarded in the

treatment of gastric hemorrhage, and Kaufmann (American Journal of the Medical Sciences, June, 1910) shows conclusively that active or better continued bleeding is not a contraindication for the use of the stomach tube, but that in such cases it may be used many times with benefit.

Weinstein (Journal of the American Medical Association, Volume LV, Number XIII, page 1085) has brought forward a new test in the diagnosis of cancer of the stomach by the use of tryptophan, which has proved simpler and better than that foremrly used by Newbauer and Fischer (Deutsche Archiv of Klinical Medicin, 1909, XCVIII, page 499) in which glycyltryptophan was employed. Lyle and Kober New York Medical Journal, June 4, 1910, page 1151) report very favorably on the new reaction. Certainly it seems to bear further investigation.

Solomon's test has been discarded, further experimentation not having borne out the earlier statements. The skin reaction as evidence of hemolysis induced by the subcutaneous injection of normal red cells into a cancerous subject, devised by Elsberg, Neuhof and Geist (Medical Record, October 15, Volume LXXVIII, Number XVI, page 679) has been found positive in eighty-nine and nine-tenths per cent of cases which were amply controlled. It seems to be of diagnostic assistance in doubtful cases.

A great mass of literature has accumulated during the past year referable to the pancreas, chiefly the result of the more frequent recognition of its pathologic processes, due in part to exhaustive treatises on this subject by Robson, Codman, Mayo, Moynihan, Pilcher and others. The Cammidge reaction as a pathognomonic evidence of pancreatic involvement has been demonstrated to be absolutely misleading, if knowledge of the clinical history be eliminated. There is no apparent clinical relationship between disease of the pancreas and any of the various types of end reaction. These various types of reaction do, however, indicate metabolic disturbances of varying character and intensity, which if continued may be indicative of a lesion of the pancreas (Pilcher, Willis and McGrath, Surgery, Gynecology and Obsterics, Volume XI, August 1910, Number II, page 156).

Friedenwald and Ruhräh (American Journal of the Medical Sciences, Volume CXL, Number VI, page 93) have contributed to the advance of knowledge regarding dietetic treatment in diabetes in introducing the soy bean, an article of food capable of being prepared in a great variety of ways; it being efficacious in markedly reducing the amount of sugar present owing first to its containing practically no starch, and second, to its marked saccharifying properties. Mayo, Robson, and Louis S. Pilcher have written upon this subject dealing with its prophylaxis and treatment even after changes in the pancreas are established, considering operative interference indicated when any disturbance of gall-bladder function can be demonstrated; the indications being so absolute that we have in diseased conditions of this organ the etiologic factor of diabetes in many instances.

Regarding cholocystitis and the formation of gall-stones, Clark (Boston Medical and Surgical Journal, Volume CLXIII, Number XVIII, page 675) considers the metabolic, chemical, and histologic or mucous