In cases of hemorrhage from the stomach the treatment; is the same as in the severe type of ulcer, with the exception that ice-cold ap-plications are made over the stomach instead of the warm poultices. Perfect rest is here absolutely necessary. The patient must keep very quiet and avoid any motion whatever; even turning from one side to the other is not permissible. The patient should be prohibited all conversation except it be to indicate his wants.

If the hemorrhage be profuse or if there are signs that the bleeding has not yet come to a standstill, hypodermic injections of ergot are advisable. One Pravaz syringe of the following should be injected two or three times a day in the gastric region:

℞ Extr. secal. cornut.,.....2.5 (Ʒss).

Aq. dest.

Glycerin.,.......aa 5.0(Ʒ i).

Gelatin may be administered internally, - one table-spoonful of a ten-per-cent solution being given every three hours, - or subcutaneously. In the latter case 100 gm. of a two-per-cent watery solution of gelatin are injected hypodermatically.

Suprarenal capsule in 3 to 5 gr. doses, principally in the form of suppositories, may also be advantageously tried.

Chloride of iron (5-15 drops in water) and acetate of lead 0.05 gm., one powder every two hours, which in olden times were used so frequently, do not in reality have much effect.

In case the haematemesis, however, recurs frequently, and the patient is running the risk of bleeding to death, Ewald 1 recommends resort to lavage with ice-cold water. For this purpose the pharynx must first be well cocainized, and the washing of the stomach then performed with the greatest care.

Collapse

In case the patient has sunk into a collapsed condition, camphor or ether should be hypo-dermically injected. An enema of warm wine or warm wine with egg should be administered, and a hot-water bag applied to the feet. In those instances where the high degree of anaemia endangers the life of the patient, transfusion of blood was formerly frequently resorted to. Nowadays a subcutaneous injection of a physiological salt solution (4 to 0 NaCl to aq. dest. 1,000), in quantities from a pint to a litre, is used. The solution and the apparatus (fountain syringe) must be thoroughly sterilized, and one or two quite thick Pravaz needles used. The solution, warmed to blood temperature, is then injected into the subclavicular region.

Perforation

If perforation has occurred perfect rest is absolutely necessary; nothing should be given by the mouth, ice bags should be placed over the abdomen, and large doses of opium, preferably in the form of suppositories, should be administered. In cases in which the stomach contains large quantities of food, Ewald suggests the washing out of the stomach, performed after cocainization of the pharynx and with all other necessary precautions. As soon as the symptoms of collapse appear, the above-described treatment is employed. The prognosis of perforation being so very unfavorable, notwithstanding all medicinal treatment, resort has been lately had to laparotomy, in order to master the situation surgically.

1C. A. Ewald: l c, p. 274.

A new variety of ulcer of the stomach is the "exul-ceratio simplex (Dieulafoy)" or superficial ulceration of the stomach.

It has been observed by several clinicians that extensive hemorrhages (even lethal) from the stomach may occur even when no distinct ulcer can be discovered in this organ. A few such cases with autopsies have been reported. The hemorrhages have been ascribed to parenchymatous bleedings (Faltenblutun-gen). Very small ulcerations causing fatal haBmatem-esis have been observed by Chiari 1 and Murchison.2 Chiari described a case of fatal bleeding from the stomach resulting from the erosion of a submucous vein within an abrasion of the mucous membrane, only the size of a large barley-corn. Murchison reported two cases of fatal haematemesis from minute ulcers perforating a small artery in the coats of the stomach. He says: "They are remarkable not only for the minuteness of the ulcers, which are little more than hemorrhagic erosions, but also for the absence of the usual symptoms of ulceration of the stomach. Neither of the patients had suffered from vomiting prior to the occurrence of the hemorrhage".

1Chiari: Prager medicinische Wochenschrift, vol. vii., p. 489, 1882. 2Murchison: Pathological Transactions, vol. xxi., p. 162, 1870.

Dieulafoy1 has minutely described a considerable number of similar cases of this affection under the heading "Exulceratio Simplex." This brilliant clinician gave a most vivid picture of the affection in question, which in the main we will make use of for our text. The term, "superficial ulceration" well characterizes the disease under consideration, and may also be used with advantage.

Steven2 likewise described two cases of severe gastric hemorrhage due to a very superficial abrasion of the gastric mucosa. In the middle of the affected area there were two pinhole openings through which a bristle could directly be passed into one of the primary lateral branches of the gastric artery.

Definition

A superficial, usually round, sometimes elliptical, loss of substance within the stomach, involving merely the mucous membrane and also slightly the muscularis mucosae and usually some small blood-vessel, but not penetrating deeper into the other coats of the organ, causing extensive hemorrhages.

Morbid Anatomy

The exulceratio simplex consists of an oval superficial defect of the gastric mucosa, varying in size from a five-cent to a fifty-cent piece. The defect involves merely the gastric mucosa and also the muscularis mucosae, but not the submucous or the other tunics of the stomach. The margins of this defect are not indurated and consist of almost normal tissue. In the middle of the defect very often a minute open blood-vessel is noticeable. Macroscopi-cally the exulceration can be discovered at the autopsy or at an operation only after a thorough search, the defect being so small that it easily escapes notice. Sometimes the ulceration may be situated under a fold of the gastric mucous membrane, and for this reason the rugae must be thoroughly examined. Occasionally the affected area is surrounded by a somewhat reddened ecchymotic zone. The microscopical examination shows that the defect is due to a disappearance of the gastric mucosa with its underlying muscularis. The mucous membrane of the stomach is otherwise healthy throughout.

The exulceratio simplex has no place of predilection and may be situated anywhere within the stomach.

1Dieulafoy: "Olinique Medical de l'Hotel Dieu." pp. 1-62, 1899.

2 J. L. Steven: "On Profuse Hoematemesisdue to 'Pore-like ' Abrasion of the Gastric Arteries - No Round Ulcer - Exulceratio Simplex of Dieulafoy." Glasgow Medical Journal, p. 5. 1899.

Etiology

The etiology of this affection is not yet known. Most probably the exulceratio simplex represents an acute and beginning stage of the ordinary ulcer of Cruveilhier. Whether a toxic element is the fundamental cause is still uncertain. The affection occurs principally in persons of twenty-five to thirty years of age.