Mild forms of syphilitic gastritis occurring in adult life are practically indistinguishable from the alcoholic variety, while in the more severe cases the progressive loss of flesh, excessive debility, anorexia, and profound anaemia, coupled with an absence of free hydrochloric acid from the gastric contents, are highly suggestive of a malignant growth. More than one case of this description has come under our care in which, if it had not been for the routine trial of iodide of potassium, we should have diagnosed cancer of the stomach ; and we have known several patients, who were condemned to carcinoma of the stomach or pancreas after an exploratory incision, who made a perfect recovery under anti-syphilitic treatment. Although traces of altered blood may appear in the vomit, severe haematemesis is rarely observed, unless the liver or spleen is also diseased.

Diagnosis

In the diagnosis of syphilitic ulcer of the stomach two elementary principles should always be kept prominently in mind. In the first place, every gastric ulcer is not due to syphilis simply because the patient happens to have suffered at one time or other from that complaint. It must be remembered that probably about 5 per cent, of the population suffer from ulcer at some period of their existence, and, since syphilis is also by no means uncommon, it must necessarily happen that the two diseases will frequently be associated in the same individual, independently of any causal relationship between them. In 308 cases of chronic gastric ulcer of which we possess clinical notes a history of former syphilis existed in 10 per cent. ; but in 132 cases of the disease which proved fatal, gummata or other evidences of syphilis were only observed after death in eight, or 6 per cent. We are, therefore, of opinion that only about 5 per cent, of all chronic ulcers of the stomach have any direct connection with syphilis, and that in the majority of these the connecting-link is to be found in arterial degeneration rather than in the formation of gummata.

The second point is this. Before it is accepted that the symptoms of gastric irritation in a syphilitic subject are due to the specific malady it must be clearly ascertained that they do not arise from injudicious medication. Many persons are very intolerant both of mercury and potassium iodide, and the prolonged administration of these drugs frequently gives rise to troublesome gastritis, accompanied by anaemia, loss of appetite, emaciation, and great debility. When these symptoms develop in a patient who has been under observation from the first, there is, of course, no difficulty in assigning the gastric, disorder to its proper cause, and in curing it by discontinuing the treatment. When, however, a patient of whom nothing is known, except that he has had syphilis, seeks advice on account of chronic gastritis, there is always a great temptation to overlook the possibility of toxic influences and to prescribe the same drugs which were originally responsible for the disease. A good instance of this recently came under our notice in the case of a woman who was sent to us with a diagnosis of cancer of the stomach on account of the pain after food, vomiting, and loss of flesh from which she had suffered for several months. We found upon inquiry that she had been under medical treatment for some time for an ulcer of the leg, and was inclined to attribute her indigestion to the pain and worry attendant upon that disease. As, however, she was obviously suffering from a gastritis of toxic origin, we preferred to take the view that the medicine, and not the sore on the leg, was the cause of the trouble, the assumption being that the former treatment had been directed against possible syphilis. Careful regulation of diet, combined with a rhubarb and bismuth mixture, afforded immediate relief, and within a month the patient reported herself as feeling perfectly well. It is therefore important to remember that gastritis occurring during the course of syphilis may result from injudicious treatment as well as from the disease itself.

Specific ulceration of the stomach has chiefly to be distinguished from the simple variety, from carcinoma, and from the gastric crises of locomotor ataxia. In every case of gastric ulcer the possibility of former syphilis should be borne in mind, and a search should be made for scars and other evidences of the disease. Excessive pain and vomiting, with great emaciation or profound anaemia, are always suspicious symptoms, while nocturnal attacks in which pain is felt in the long bones as well as in the abdomen are also suggestive of syphilis. The chief point of distinction, however, is the intractability of the disease to ordinary methods of treatment, while its symptoms rapidly subside on the administration of anti-syphilitic remedies. More than sixty years ago Andral diagnosed a syphilitic ulcer of the stomach from the fact that it was cured by the administration of mercury, and Galliard, Lancereaux, Wagner, Hayem, Rosanow, and Marc have all recorded instances in which the nature of the complaint was manifested in a similar manner,

The differential diagnosis of specific ulcer and cancer is often very difficult, especially when the former is accompanied by severe gastritis. In malignant disease, however, a tumour can usually be detected in connection with the stomach, the loss of flesh and strength is more rapid, nocturnal attacks of pain are infrequent, and the vomit often contains altered blood. The subjects of gastric cancer are also very intolerant of mercury and iodides, and after a few days' treatment with these drugs will usually volunteer the statement that the medicine is making them much worse. In the syphilitic affection, on the other hand, these remedies are the only ones which are found to afford relief.

The gastric crises of tabes occur at irregular intervals, and are seldom excited by the ingestion of food. There is little or no localised tenderness of the epigastrium, and the patient presents the usual signs of early ataxia. It is important to remember that syphilitic lesions of the central nervous system and of the stomach seldom, if ever, develop in the same individual.

The diagnosis of syphilitic gastritis is made by the absence of the usual conditions which excite inflammation of the stomach and by the discovery of a history or objective signs of syphilis. A few days' trial of iodide of potassium will usually suffice to clear up any doubt, since in ordinary cases of gastritis this drug greatly increases the dyspeptic symptoms, while the contrary result is observed in the specific disorder.

Treatment

Absolute rest is essential, and much time will be saved if the patient is confined to bed for the first fortnight. Milk should form the staple diet for the first three or four weeks, but as it does not always agree so well as in simple ulcer it may be necessary to dilute it with soda-water or Vichy water. When vomiting is a troublesome symptom the milk should be peptonised. Clear soups, broths, jellies, and junket may also be allowed if the patient can take them without discomfort. After the first month, should the case be progressing favourably, milk puddings, soft bread and butter, eggs, tripe, and oysters may be permitted, and the diet may subsequently be increased by the addition of pounded fish, finely minced sweetbreads, and chicken cream. Meat and green vegetables should be prohibited for at least six months. If vomiting is troublesome, it may be necessary to feed the patient by the rectum. When abdominal pain is severe the epigastrium may be constantly covered with a large linseed poultice, but as a rule the repeated application of a small blister is of greater value. With regard to medicinal treatment, it may be stated at once that mercury should always be combined with an iodide, since the latter is much less efficacious when given alone. In most instances it is sufficient to prescribe a mercurial pill of two grains, with an equal quantity of extract of hyoscyamus, night and morning, but in some cases drachm doses of the solution of perchloride of mercury are to be preferred. In young children inunctions of mercurial ointment or full doses of mercury and chalk are the most convenient methods of administering the drug. If there is any tendency to diarrhoea a small quantity of opium may be included in the prescription. The iodide of potassium or of sodium must be given in doses of from five to fifteen grains, and is most conveniently combined with carbonate of bismuth and liquid extract of sarsaparilla ; while the addition of ten minims of glycerine of carbolic acid often tends to relieve the oppression and flatulence which are experienced after meals. Should the bowels remain constipated in spite of the mercurial, a teaspoonful or more of the artificial Carlsbad salts may be given each morning before breakfast. Lavage is chiefly indicated in the cases of chronic gastritis accompanied by troublesome vomiting, or where an ulcer has caused partial obstruction of the pylorus, but it should be avoided when symptoms of active ulceration are present. In every instance the patient should be warned of the tendency of the disease to relapse, lest he be tempted to discontinue the treatment as soon as the urgent symptoms have subsided.