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mentative action, and the development of sarcinæ in obstruction from chronic ulcer, as well as in cancerous or pyloric disease. It may be given in ǝi doses alone or combined with other agents; the hyposulphite is also given in similar cases. Charcoal directly absorbs gaseous evolution, and checks fermentative action, and in these instances of gastric ulcer it may be given for a short time with great advantage. Counter irritants are often of great service for the relief of pain and vomiting: a small blister should be applied to the scrobiculus cordis, or the croton oil be rubbed in so as to produce pustular eruption; some even use a seton; but I think that milder remedies may attain the same beneficial result with less suffering and distress to the patient.

If there be excessive secretion or haemorrhage, astringents may be given; thus mineral acids, as the sulphuric alone, or with Epsom salts; acetate of lead, tannin, and alum are also available; and when there is hæmorrhage without great irritability, small doses of turpentine with mucilage or yelk of egg are sometimes prescribed; but this is a remedy in which I have little experience. I have sometimes seen it aggravate the symptoms, beside being very offensive to the patient. When hæmorrhage has recently taken place, it is well to avoid the use of anything likely to distend or mechanically disturb the stomach, as carbonic acid. Ice, which tends to produce contraction of bleeding vessels, should be

allowed to the patient; and if there be much throbbing of the vessels it may be applied externally.

Pyrosis may be checked by the astringents just mentioned; but we have found the greatest benefit from nitrate or oxide of silver with opium, from creasote, from the compound kino powder; and, when other symptoms would bear it, from the astringent preparations of iron. The bowels should be acted upon, either by agents, which are not retained in the stomach, or irritating to it, as the aloes or colocynth pill with henbane, the effervescing citrate, the carbonate or Dinneford's fluid magnesia; in other instances enemata are useful, consisting of simple water or castor oil, or of turpentine; and occasionally a mercurial purgative will be found beneficial in thoroughly emptying the canal without increasing gastric irritability, as a few grains of grey powder, one or two of calomel, or of blue pill, with henbane, &c.; but to continue this form of medicine is, we think, injurious and prejudicial to the patient. In many cases of constipation with gastric disease minute doses of strychnia, or of the extract of nux vomica with aloes, act very beneficially.

In order to carry out the third indication of treatment, namely, in preventing the extension of the disease, sudden and violent exertion should be guarded against; and also the distension of the stomach by large meals, or by the formation of gaseous products, as the result of fermentative changes.

4th. In the treatment of the complications of gastric ulcer, arising from its extension to neighbouring parts, as when perforation has taken place, and the symptoms of peritonitis have been suddenly produced, there is still a slight chance that life may be prolonged; the patient should not be moved, nor anything introduced into the stomach, except a tea-spoonful of water or milk to assuage thirst. Opium must be given freely, as recommended by Dr. Stokes and Dr. Graves, so that the patient may be entirely under its influence, a grain every two or three hours; by this means peristaltic action is checked, the nervous shock diminished, extravasation prevented, adhesions promoted, and life may be thus preserved. For many days aperient remedies should be avoided, and food only taken in the most cautious manner.

If local suppuration have taken place, opium is still the best remedy, in order to diminish irritative fever, to relieve pain, and to place the patient in the most favourable condition for reparative action. If the disease have extended into the chest the prospects of recovery are still less, for sudden acute pleurisy and empyema, or asthenic pneumonia are almost certain to follow. Life may be prolonged by sustaining the patient, and the severity of the symptoms of acute disease of the chest may be partially relieved by ammonia and opium.

CHAPTER XVIII.

CANCEROUS DISEASE OF THE STOMACH.

THE stomach is one of the organs most frequently affected with cancer; and in this frequency a remarkable contrast is presented when compared with the rarity of strumous disease of the same organ. Every form of cancer is found to occur in the stomach, but instances of medullary and scirrhous cancer are the most numerous, whilst the epithelial, colloid, villous, and melanoid varieties are less constantly observed. It is seen, however, that these varieties pass the one into the other; and thus while one part has almost the firmness and structure of scirrhus, another has the characteristics of medullary growth; and again, the surface also of a medullary cancer may have the appearance of a villous structure. The disease originates in the mucous membrane of the stomach, or its submucous tissue, or it is propagated to the stomach by the affection of the glands in the neighbourhood of the pancreas; and the pylorus, lesser curvature, and cardiac extremity are the parts generally affected.

We are not acquainted with the determining cause

of the forms of cancer, or whether the opinion which is maintained by some pathologists can be established, that scirrhus is connected in its origin with the fibrous tissues of the part-medullary with the mucous surface or gland structure, and colloid especially with the latter-or, whether they are rather indications of the intensity of the morbid action. The part affected has a modifying influence on the character of the disease; the epithelial cancer of a surface covered by squamous epithelium is different from the same disease, where the epithelium is columnar, an instance of differentiation as applied to morbid changes. It would seem that scirrhous disease is less removed from normal nutritive change than medullary cancer; in the one there is a greater disposition to form fibroid tissue, in the other the growth is cellular, or nuclear.

During the earlier stages of cancerous disease of the stomach, especially before any growth can be detected on manipulative examination, the symptoms are often exceedingly obscure. It may be convenient to arrange the symptoms into three divisions, according to the respective stages of the disease. The first is the stage of organic dyspepsia before the development of any tumour; the second is that of abnormal growth; and the third, the disintegration of that growth by ulceration or sloughing.

The first symptoms are often deceptive and obscure; they are those of dyspepsia, and with it there is a

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