A system of practical medicine. By American authors. Vol. 2

by Unknown

FUNCTIONAL AND INFLAMMATORY DISEASES OF THE STOMACH.

BY SAMUEL G. ARMOR, M.D., LL.D.

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Functional Dyspepsia (Atonic Dyspepsia, Indigestion).

To difficulty in the physiological process of digestion the familiar name of dyspepsia has been given, while to a merely disturbed condition of the function the term indigestion is more frequently applied. This distinction, difficult at all times to make, may appear more arbitrary than real; and inasmuch as it involves no important practical point, the author of the present article will use the terms interchangeably as indicating functional disturbance of the stomach—i.e. disturbance of the digestive process not associated with changes of an inflammatory character, so far as we know.

Since it is one of the most common of all complaints from its association with various other morbid conditions, the term is not unfrequently vaguely employed. It is difficult, of course, to define a disease whose etiology is so directly related to so many distinct morbid conditions. Indeed, there are few diseases, general or local, which are not at some time in their history associated with more or less derangement of the digestive process. For purposes of limitation, therefore, it will be understood that we now refer to chronic functional forms of indigestion which depend largely, at least, on a purely nervous element, and for this reason are not infrequently described as sympathetic dyspepsia. Doubt has been expressed as to whether such forms of disease ever exist, but that we encounter purely functional forms of dyspepsia, corresponding to the dyspepsia apyretica of Broussais, would appear to be a well-recognized clinical fact.

What the precise relation is between digestive disturbances and the nervous system we may not fully understand, no more than we understand how a healthy condition of nervous endowment is essential to all vital processes. Even lesions of nutrition are now known to depend upon primary disturbance of nervous influence. This is seen in certain skin diseases, such as herpes zoster, which closely follows the destruction of certain nerves. And it is well known that injury of nerve-trunks is not unfrequently followed by impaired nutrition and failure in reparative power in the parts to which such nerves are distributed. Indeed, so marked is the influence of the nervous system over the nutritive operations that the question has been considered as to whether there are trophic nerves distributed to tissue-elements themselves whose special function is to keep these elements in a healthy state of nutrition. The proof, at least, that the digestive process is, in some unexplained way, under the immediate influence of the nervous system, either cerebro-spinal or trophic, is both varied and abundant. The digestive secretions are known to be the products of living cells which are abundantly supplied with nerve-fibres, and we can readily believe that the potential energy of this cell-force is probably vital and trophic. At any rate, it is unknown in the domain of ordinary chemistry. The digestive ferments, as clearly pointed out by Roberts, are the direct products of living cells. Their mode of action, he claims, bears no resemblance to that of ordinary chemical affinity. It has a distinctly physiological character. Nor do they derive their vital endowments from material substances. "They give nothing material to, and take nothing from, the substances acted on. The albuminoid matter which constitutes their mass is evidently no more than the material substance of a special kind of energy—just as the steel of a magnet is the material substratum of the magnetic energy, but is not itself that energy" (Roberts). That this living cell-force is partly, at least, derived from the nervous system is clear from the well-known effects of mental emotion, such as acute grief, despair, etc., in putting an immediate stop to the digestive process. Experiments on the lower animals have also shown the direct influence of the nervous system over gastric secretion. Wilson Philip showed by various experiments on rabbits and other animals that if the eighth pair of nerves be divided in the neck, any food which the creatures may afterward eat remains in the stomach undigested, and after death, when the nerve has been divided, the coats of the stomach are not found digested, however long the animal may have been dead. Bernard also excited a copious secretion by galvanization of the pneumogastric, and by section of the same nerve stopped the process of digestion and produced "pallor and flaccidity of the stomach." Recently doubt has been thrown on these statements of Bernard and Frerichs. Goltz concludes, from observations made on frogs, that nerve-ganglia, connected by numerous intercommunicating bundles of nerve-fibres, exist in the walls of the stomach, the irritation of which gives rise to local contractions and peristaltic movements of the stomach, and that these ganglia influence the gastric secretion. However this may be, it still remains true that these gastric ganglia are in connection, through the vagi, with the medulla oblongata, and are thus influenced by the cerebro-spinal nerve-centres. And clinical observation confirms what theoretical considerations would suggest. Thus, strong mental impressions are known to produce sudden arrest of secretion, and that which arrests secretion may, if continued, lead to perversion of the same.

Impressions made upon the nerves of special sense are also known to affect the salivary and gastric secretions. The flow of saliva is stimulated by the sight, the smell, the taste, and even thought, of food. Bidder and Schmidt made interesting experiments on dogs bearing upon this point. They ascertained by placing meat before dogs that had been kept fasting that gastric juice was copiously effused into the stomach. Other secretions are known to be similarly affected. Carpenter by a series of well-observed cases has shown the direct influence of mental conditions on the mammary secretion. The nervous association of diabetes and chronic Bright's disease is interesting in this connection, and the direct nervous connection betwixt the brain and the liver has been shown by numerous experiments. It is maintained by modern physiologists that "the liver—indeed each of the viscera—has its representative area in the brain, just as much as the arm or leg is represented in a distant localized area" (Hughlings Jackson). And in harmony with this view Carpenter long since pointed out the fact that if the volitional direction of the consciousness to a part be automatically kept up for a length of time, both the functional action and the nutrition of the part may suffer. It has been described by him as expectant attention, and it has, as we shall see, important practical bearings on the management of gastric affections. Sympathetic disturbance of the stomach is also connected with direct disease of the brain. This is seen in cases of concussion. The almost immediate effects of a blow are nausea and vomiting, and the same thing is observed in local inflammation of the meninges of the brain.

Many forms of functional dyspepsia due to nervous disturbance of a reflex character will be pointed out when discussing the etiology of the disease.

ETIOLOGY.—Among the agencies affecting the digestive process in atonic forms of dyspepsia may be mentioned—

First, predisposing causes;

Second, exciting causes.

In general terms it may be said that all conditions of depressed vitality predispose to the varied forms of atonic dyspepsia. These conditions range through an endless combination of causes, both predisposing and exciting. There is not a disturbed condition of life, extrinsic or intrinsic, that may not contribute to this end. In some cases it may be the effects of hot and enervating climates; in others the alterations in the elementary constituents of the blood may be apparent; while in still others the cause may be exhausting discharges, hemorrhages, profuse suppuration, venereal excesses, sedentary occupations, and long-continued mental and moral emotions.

Heredity may also predispose to functional dyspepsia. Certain faulty states of the nervous system are specially liable to be transmitted from parent to offspring—not always in the exact form in which they appeared in the parent, but in forms determined by the individual life of the offspring. For obvious reasons, growing out of our modern American civilization, the inheritance of a faulty nervous organization is apt to spend itself upon the digestive apparatus. The inordinate mental activity, the active competitions of life, the struggle for existence, the haste to get rich, the disappointments of failure,—all contribute to this end. The general tendency of American life is also in the direction of a highly-developed and morbidly sensitive nervous system, and functional dyspepsia is a natural sequence of this. The symptoms of dyspepsia thus caused usually manifest themselves at an early period of life.

Age also predisposes to weak digestion. The stomach becomes weak as age advances, in common with all the functions of the body, and consequent upon this weakness there is diminished excitability of the gastric nerves, with diminished muscular action of the walls of the stomach and deficient secretion of the gastric juice. Chronic structural changes are also apt to occur in advanced life. The gastric glands become atrophied and the arteries become atheromatous, so that with symptoms of indigestion there are often associated loss of consciousness at times, vertigo, irregular action of the heart, etc. These general facts have an important bearing upon the hygienic management of dyspepsia in the aged. They require, as a rule, less food than the young and vigorous. In times when famine was more frequent than now it was found that the older a human being was, the better deficiency of food was borne. Hippocrates tells us, in his Aphorisms, that old men suffer least from abstinence. Their food should be such, both in quantity and quality, as the enfeebled stomach can digest. There is less demand for the materials of growth, and consequently for animal food. Moderate quantities of alcohol, judiciously used, are also specially adapted to the indigestion of the aged. It has the double effect of stimulating the digestive process and at the same time checking the activity of destructive assimilation, which in old age exhausts the vital force. And in order to more effectively arrest destructive metamorphosis great caution should be taken against excessive muscular fatigue, as well as against sudden extremes of temperature. Loss of appetite from deficient formation of gastric juice is a common symptom in old age. This is not often successfully treated by drugs, and yet medicines are not without value. The sesquicarbonate of ammonium acts as a stimulant to the mucous membrane and to the vaso-motor nerve, and in this way becomes a valuable addition to the simple vegetable bitters. Dilute hydrochloric acid with the vegetable bitters may also be tried. Condiments with the food directly stimulate the action of the enfeebled stomach. The old remedy of mustard-seed is not unfrequently useful, and pepper, cayenne, horseradish, and curries act in a similar manner in torpid digestion. And in cases of great exhaustion associated with anæmia benefit may be derived from small doses of iron added to tincture of columbo or gentian.

Nor should it be forgotten that in the opposite extreme of life the digestive capacity is extremely limited. The infant's digestion is readily disturbed by unsuitable alimentation. For obvious reasons it does not easily digest starchy substances. The diastasic ferment does not exist in the saliva of young sucking animals, at least to any extent. No food is so suitable for early infantile life as the mother's milk, provided the mother herself is healthy. It contains in an easily digestible form all the constituents necessary to the rapidly-growing young animal. Van Helmont's substitute of bread boiled in beer and honey for milk, or Baron Liebig's food for infants, cannot take the place of nature's type of food, which we find in milk. If a substitute has to be selected, there is nothing so good as cow's milk diluted with an equal quantity of soft water, or, what in many cases is better, barley-water, to which may be added a teaspoonful of powdered sugar of milk and a pinch of table-salt and phosphate of lime. Lime-water may be added with advantage. Dilution of alimentary substances is an important condition of absorption in the infant stomach.

Anæmia is a common predisposing cause of indigestion. Indeed, as a widely-prevailing pathological condition few causes stand out so prominent. It affects at once the great nutritive processes, and these in turn disturb the functional activity of all the organs of the body. Not only are the gastric and intestinal glands diminished in their functional activity by impoverished or altered blood, but the movements of the stomach are retarded by weakened muscular action. It is impossible to separate altered blood from perverted tissue-structure and altered secretion. Indigestion produced by anæmia is difficult of treatment, on account of the complexity of the pathological conditions usually present, the anæmia itself being generally a secondary condition. Careful inquiry should be made, therefore, into the probable cause of the anæmia, and this should, if possible, be removed as an important part of the treatment of the dyspepsia. Nothing will more promptly restore the digestive capacity in such cases than good, healthy, well-oxidized blood. Indeed, healthy blood is a condition precedent to the normal functional activity of the stomach.

To these general predisposing causes may be added indigestion occurring in febrile states of the system. The cause here is obvious. In all general febrile conditions the secretions are markedly disturbed; the tongue is dry and furred; the urine is scanty; the excretions lessened; the bowels constipated; and the appetite gone. The nervous system also participates in the general disturbance. In this condition the gastric juice is changed both quantitatively and qualitatively, and digestion, as a consequence, becomes weak and imperfect—a fact that should be taken into account in regulating the diet of febrile patients. From mere theoretical considerations there can be no doubt that fever patients are often overfed. To counteract the relatively increased tissue-metamorphosis known to exist, and the consequent excessive waste, forced nutrition is frequently resorted to. Then the traditional saying of the justly-celebrated Graves, that he fed fevers, has also rendered popular the practice. Within certain bounds alimentation is undoubtedly an important part of the treatment of all the essential forms of fever. But if more food is crowded upon the stomach than can be digested and assimilated, it merely imposes a burden instead of supplying a want. The excess of food beyond the digestive capacity decomposes, giving rise to fetid gases, and often to troublesome intestinal complications. The true mode of restoring strength in such cases is to administer only such quantities of food as the patient is capable of digesting and assimilating. To this end resort has been had to food in a partially predigested state, such as peptonized milk, milk gruel, soups, jellies, and beef-tea; and clinical experience has thus far shown encouraging results from such nutrition in the management of general fevers. In these febrile conditions, and in all cases of general debility, the weak digestion does not necessarily involve positive disease of the stomach, for by regulating the diet according to the digestive capacity healthy digestion may be obtained for an indefinite time.

Exhaustion of the nerves of organic life strongly predisposes to the atonic forms of dyspepsia. We have already seen how markedly the digestive process is influenced by certain mental states, and it is a well-recognized fact that the sympathetic system of nerves is intimately associated with all the vegetative functions of the body. Without a certain amount of nervous energy derived from this portion of the nervous system, there is failure of the two most important conditions of digestion—viz. muscular movements of the stomach and healthy secretion of gastric juice. This form of indigestion is peculiar to the ill-fed and badly-nourished. It follows in the wake of privation and want, and is often seen in the peculiarly careworn and sallow classes who throng our public dispensaries. In this dyspepsia of exhaustion the solvent power of the stomach is so diminished that if food is forced upon the patient it is apt to be followed by flatulence, headache, uneasy or painful sensations in the stomach, and sometimes by nausea and diarrhoea. It is best treated by improving in every possible way the general system of nutrition, and by adapting the food, both in quantity and quality, to the enfeebled condition of the digestive powers. Hygienic measures are also of great importance in the management of this form of dyspepsia, and especially such as restore the lost energy of the nervous system. If it occur in badly-nourished persons who take little outdoor exercise, the food should be adapted to the feeble digestive power. It should consist for a time largely of milk and eggs, oatmeal, peptonized milk gruels, stale bread; to which should be added digestible nitrogenous meat diet in proportion to increased muscular exercise. Systematic outdoor exercise should be insisted upon as a sine quâ non. Much benefit may be derived from the employment of electric currents, and hydrotherapy has also given excellent results. If the indigestion occur in the badly-fed outdoor day-laborer, his food should be more generous and mixed. It should consist largely, however, of digestible nitrogenous food, and meat, par excellence, should be increased in proportion to the exercise taken. Medicinally, such cases should be treated on general principles. Benefit may be derived from the mineral acids added to simple bitters, or in cases of extreme nervous prostration small doses of nux vomica are a valuable addition to dilute hydrochloric acid. The not unfrequent resort to phosphorus in such cases is of more than doubtful utility. Some interesting contributions have been recently made to this subject of gastric neuroses by Buchard, Sée, and Mathieu. Buchard claims that atonic dilatation of the stomach is a very frequent result of an adynamic state of the general system. He compares it to certain forms of cardiac dilatation—both expressions of myasthenia. It may result from profound anæmia or from psychical causes. Mathieu regards mental depression as only second in frequency. Much stress is laid upon poisons generated by fermenting food in the stomach in such cases. It may cause a true toxæmia, just as renal diseases give rise to uræmia. Of course treatment in such cases must be addressed principally to the general constitution.

But of all predisposing causes of dyspepsia, deficient gastric secretion, with resulting fermentation of food, is perhaps the most prevalent. It is true this deficient secretion may be, and often is, a secondary condition; many causes contribute to its production; but still, the practical fact remains that the immediate cause of the indigestion is disproportion between the quantity of gastric juice secreted and the amount of food taken into the stomach. In all such cases we have what is popularly known as torpidity of digestion, and the condition described is that of atony of the stomach. The two main constituents of gastric juice—namely, acid and pepsin—may be deficient in quantity or disturbed in their relative proportions. A certain amount of acid is absolutely essential to the digestive process, while a small amount of pepsin may be sufficient to digest a large amount of albuminoid food. Pure unmixed gastric juice was first analyzed by Bidder and Schmidt. The mean analyses of ten specimens free from saliva, procured from dogs, gave the following results:

Gastric Juice of a Dog.

Water			973.06
Solids			26.94
Containing—	Peptone and pepsin		17.19
	Free hydrochloric acid		3.05
	Alkaline chlorides		4.26
	Ammonium chloride		0.47
	Chlorine		5.06
	Phosphates—	Lime	1.73
		Magnesia	0.23
		Iron	0.08

They proved by the most careful analyses that fresh gastric juice contains only one mineral acid—namely, hydrochloric; since which time Richet has been able to prove that "this acid does not exist in a free state, but in loose combination with an organic substance known as lucin," the chloride of lucin. And just here the curious and puzzling question arises as to the secretion of a mineral acid from alkaline blood. Ewald, the distinguished lecturer in the Royal University of Berlin, tells us that "a brilliant experiment of Maly's has thrown unexpected light upon this. There are fluids of alkaline reaction which may contain two acid and alkaline mutually inoffensive salts, but still have an alkaline reaction, because the acid reaction is to a certain extent eclipsed; for instance, a solution of neutral phosphate of soda (Na₂HPO₄) and acid phosphate of soda (NaH₂PO₄) is alkaline. Such a solution placed in a dialyzer after a short time gives up its acid salt to the surrounding distilled water, and one has in the dialyzer an alkaline fluid outside an acid fluid." He thus proved that the acid phosphate of sodium is present in the blood in spite of its alkaline reaction.

Lack of the normal amount of the gastric secretion must be met by restoring the physiological conditions upon which the secretion depends. In the mean time, hydrochloric and lactic acids may be tried for the purpose of strengthening the solvent powers of the gastric secretion.

EXCITING CAUSES.—The immediate causes of dyspepsia are such as act more directly on the stomach. They embrace all causes which produce conditions of gastric catarrh, such as excess in eating and drinking, imperfect mastication and insalivation, the use of indigestible or unwholesome food and of alcohol, the imperfect arrangement of meals, over-drugging, etc.

Of exciting causes, errors of diet are amongst the most constantly operative, and of these errors excess of food is doubtless the most common. The influence of this as an etiological factor in derangement of digestion can scarcely be exaggerated. In very many instances more food is taken into the stomach than is actually required to restore tissue-waste, and the effects of such excess upon the organism are as numerous as they are hurtful. Indeed, few elements of disease are more constantly operative in a great variety of ailments. In the first place, if food be introduced into the stomach beyond tissue-requirements, symptoms of indigestion at once manifest themselves. The natural balance betwixt supply and demand is disturbed; the general nutrition of the body is interfered with; local disturbances of nutrition follow; and mal-products of digestion find their way into the blood. Especially is this the case when the excessive amount of food contains a disproportionate amount of nitrogenous matter. All proteid principles require a considerable amount of chemical alteration before they are fitted for the metabolic changes of the organism; the processes of assimilative conversion are more complex than those undergone by fats and amyloids; and it follows that there is proportional danger of disturbance of these processes from overwork. Moreover, if nitrogenous food is in excess of tissue-requirement, it undergoes certain oxidation changes in the blood without becoming previously woven into tissue, with resulting compounds which become positive poisons in the economy. The kidneys and skin are largely concerned in the elimination of these compounds, and the frequency with which these organs become diseased is largely due, no doubt, to the excessive use of unassimilated nitrogenous food. Then, again, if food be introduced in excess of the digestive capacity, the undigested portion acts directly upon the stomach as a foreign body, and in undergoing decomposition and putrefying changes frets and irritates the mucous membrane. It can scarcely be a matter of doubt that large groups of diseases have for their principal causes excess of alimentation beyond the actual requirements of the system. All such patients suffer from symptoms of catarrhal indigestion, such as gastric uneasiness, headache, vertigo, a general feeling of lassitude, constipation, and high-colored urine with abundant urates, together with varied skin eruptions. Such cases are greatly relieved by reducing the amount of food taken, especially nitrogenous food, and by a systematic and somewhat prolonged course of purgative mineral waters. Europe is especially rich in these springs. The waters of Carlsbad, Ems, Seltzer, Friedrichshall, and Marienbad, and many of the alkaline purgative waters of our own country, not unfrequently prove valuable to those who can afford to try them, and their value shows how often deranged primary assimilation is at the foundation of many human ailments. The absurd height to which so-called restorative medicine has attained within the last twenty years or more has contributed largely to the production of inflammatory forms of indigestion, with all the evil consequences growing out of general deranged nutrition.

The use of indigestible and unwholesome food entails somewhat the same consequences. This may consist in the use of food essentially unhealthy or indigestible, or made so by imperfect preparation (cooking, etc.). Certain substances taken as food cannot be dissolved by the gastric or intestinal secretions: the seeds, the skins, and rinds of fruit, the husks of corn and bran, and gristle and elastic tissue, as well as hairs in animal food, are thrown off as they are swallowed, and if taken in excess they mechanically irritate the gastro-intestinal mucous membrane and excite symptoms of acute dyspepsia, and not unfrequently give rise to pain of a griping character accompanied by diarrhoea. Symptoms of acute dyspepsia also frequently follow the ingestion of special kinds of food, such as mushrooms, shellfish, or indeed fish of any kind; and food not adapted to the individual organism is apt to excite dyspeptic symptoms. Appetite and digestion are also very much influenced by the life and habits of the individual. The diet, for instance, of bodily labor should consist largely of digestible nitrogenous food, and meat, par excellence, should be increased in proportion as muscular exercise is increased. For all sorts of muscular laborers a mixed diet is best in which animal food enters as a prominent ingredient. Thus, it has been found, according to the researches of Chambers, that in forced military marches meat extract has greater sustaining properties than any other kind of food. But with those who do not take much outdoor exercise the error is apt to be, as already pointed out, in the direction of over-feeding. It cannot be doubted at the present time that over-eating (gluttony) is one of our popular vices. Hufeland says: "In general we find that men who live sparingly attain to the greatest age." While preventive medicine in the way of improved hygiene—better drainage, better ventilation, etc.—is contributing largely to the longevity of the race, we unfortunately encounter in more recent times an antagonizing influence in the elegant art of cookery. Every conceivable ingenuity is resorted to to tempt men to eat more than their stomachs can properly or easily digest or tissue-changes require. The injurious consequences of such over-feeding may finally correct itself by destroying the capacity of the stomach to digest the food.

But, on the other hand, in many nervous forms of dyspepsia the weak stomach is not unfrequently made weaker by severely restricted regimen, and especially is this the case with mental workers. Theoretical and fanciful considerations sometimes lead to physical starvation. This is apt to be the case with dyspeptics. Men who toil with their brain rather than their muscles, whether dyspeptic or not, require good, easily-digested mixed diet. It is a popular error to suppose that drugs can take the place of such food, especially drugs which are supposed to have a reconstructive influence over the nervous system, such as iron and phosphorus. The expression of Büchner, "No thinking without phosphorus," captivating to theoretical minds, has gained much notoriety, and has doubtless led to the excessive use of that drug in nervous forms of indigestion. There never was a period when phosphorus was so universally prescribed as the present. It enters into endless combinations with so-called nerve-tonics. Of the injurious influence of the drug in many cases of functional indigestion there can be no doubt; and the statement itself, so often quoted, that "the amount of phosphorus in the blood passing through the brain bears an exact proportion to the intensity of thought," is calculated to mislead. T. K. Chambers, author of the excellent Manual of Diet, makes the statement that "a captive lion, tiger, leopard, or hare assimilates and parts with a greater amount of phosphorus than a hard-thinking man; while the beaver, noted for its power of contrivance, excretes so little phosphorus that chemical analysis cannot find it in its excreta." In the wonderful adaptations and regulative mechanisms of nature we may trust largely to the natural law of supply and demand in maintaining a proper equilibrium. It may be doubted, indeed, whether we require at any time more phosphorus for brain- and nerve-tissue than can be found in such food as contains digestible phosphatic salts. The natural demand for food grows out of healthy tissue-change. An appetite to be healthy should commence in processes outside of the stomach.

Food may also be introduced into the stomach in an undigestible form from defects of cookery. The process of cooking food produces certain well-known chemical changes in alimentary substances which render them more digestible than in the uncooked state. By the use of fire in cooking his food new sources of strength have been opened up to man which have doubtless contributed immeasurably to his physical development, and has led to his classification as the cooking animal. With regard to most articles the practice of cooking his food beforehand is wellnigh universal; and especially is this the case with all farinaceous articles of food. The gluten of wheat is almost indigestible in the uncooked state. By the process of cooking the starchy matter of the grain is not only liberated from its protecting envelopes, but it is converted into a gelatinous condition which readily yields to the diastasic ferments. Roberts, in his lectures on the Digestive Ferments, points out the fact that when men under the stress of circumstances have been compelled to subsist on uncooked grains of the cereals, they soon fell into a state of inanition and disease.

Animal diet is also more easily digested in the cooked than in the raw state. The advantage consists chiefly in the effects of heat on the connective tissue and in the separation of the muscular fibre. In this respect cooking aids the digestive process. The gastric juice cannot get at the albumen-containing fibrillæ until the connective tissue is broken up, removed, or dissolved. Hot water softens and removes this connective tissue. Hence raw meat is less easily digestible. Carnivorous animals, that get their food at long intervals, digest it slowly. By cutting, bruising, and scraping meat we to a certain extent imitate the process of cooking. In many cases, indeed, ill-nourished children and dyspeptics digest raw beef thus comminuted better than cooked, and it is a matter of observation that steamed and underdone roast meats are more digestible than when submitted to greater heat.

Some interesting observations have been made by Roberts on the effects of the digestive ferments on cooked and uncooked albuminoids. He employed in his experiments a solution of egg albumen made by mixing white of egg with nine times its volume of water. "This solution," says Roberts, "when boiled in the water-bath does not coagulate nor sensibly change its appearance, but its behavior with the digestive ferments is completely altered. In the raw state this solution is attacked very slowly by pepsin and acid, and pancreatic extract has no effect on it; but after being cooked in the water-bath the albumen is rapidly and entirely digested by artificial gastric juice, and a moiety of it is rapidly digested by pancreatic extract."

It is a mistake, however, to suppose that cooking is equally necessary for all kinds of albuminoids. The oyster, at least, is quite exceptional, for it contains a digestive ferment—the hepatic diastase—which is wholly destroyed by cooking. Milk may be indifferently used either in the cooked or uncooked state, and fruits, which owe their value chiefly to sugar, are not altered by cooking.

The object in introducing here these remarks on cooking food is to show that it forms an important integral part of the work of digestion, and has a direct bearing on the management of all forms of dyspepsia.

Haste in eating, with imperfect mastication, is a common cause of indigestion in this country. Mastication is the first step in the digestive process. It is important, therefore, that we have good teeth and that we take time to thoroughly masticate our food, for by so doing we prepare it for being acted upon by the juices of the stomach. Time is also necessary in order that the salivary secretion may be incorporated with the alimentary substances. By the salivary diastase starch is converted into sugar and albuminoids are prepared for the action of the gastric juice. If these changes take place imperfectly, the stomach can scarcely regain in gastric digestion what was lost in imperfect mastication and insalivation. Haste in eating is one of the American vices. It grows out of the temperament of our people. We are jealous of lost time, and unfortunately this time is too often taken from the stomach. We bolt our food with unseemly haste, and pay the penalty in ruined stomachs. Many cases of indigestion are greatly relieved, if not permanently cured, by simply doubling or quadrupling the time occupied in eating.

Irregularity in the intervals between meals, such as taking one meal only in twenty-four hours or taking food before the preceding supply has been digested, is another fruitful source of indigestion. The digestive process, in the natural order of change, is confused; changes which should take place are delayed; and the results are such as arise from excessive eating. Moreover, the stomach lacks the rest so essential to digestion. The necessary interval, however, between meals varies with the nature of the food taken. "Between the extremes of the carnivoræ," says Ewald, "which feed once in twenty-four hours, and the herbivoræ, which never have done with the business of feeding, man holds a middle place, but not without permitting the recognition in the course of his life of a sort of transition from the herbivora to the carnivora. Infants should have the breast during the first three weeks as often as they wake; after that every two hours to the third month; then up to dentition every three hours; and later there should be five meals in twenty-four hours." But to this general statement there are, of course, many exceptions. Under certain pathological conditions food should be taken in small quantities at short intervals. This is especially the case in chronic gastric catarrh and in feeble digestion of nervous subjects. Such patients are not unfrequently improved by becoming again infants or herbivoræ. By the use of an exclusive milk diet or peptonized milk gruels, given in small quantities at comparatively short intervals of time, the stomach may be so accommodated that it will digest without discomfort a large amount of nourishment within a given time. To S. Weir Mitchell of Philadelphia we are indebted for some valuable observations bearing upon this point of forced alimentation.

To the causes of indigestion already alluded to may be added the habit of spirit-drinking, especially the habit of taking alcohol undiluted on an empty stomach, which rarely fails after a time to engender dyspeptic symptoms. It is a prominent factor in the production of chronic gastric catarrh—a condition more frequently present in painful indigestion than any that have been named. It is one of the most common diseases met with in practice. Indeed, all causes already alluded to involve, sooner or later, if they are constantly operative, irritative and catarrhal conditions of the mucous membrane of the stomach, so that we find it difficult at times—indeed impossible—to separate purely functional from subacute inflammatory forms of dyspepsia. Practically, we simply study the subject in the relative degrees of prominence of the one condition or the other.

But, in a still more comprehensive sense, indigestion is caused by disturbance of organs directly associated with the stomach in the digestive process. All organs closely associated with each other in their physiological functions are apt to become associated in morbid action. The clinical recognition of this is a matter of great importance in the management of gastric affections. And first in the order of importance in such association is the liver. So closely, indeed, are the liver and stomach functionally associated in the process of primary assimilation that they may be considered parts of the same great digestive apparatus. Hence disturbance of the liver—either in the formation of glycogen, the destruction of albuminoid matter, or the secretion of bile—is immediately communicated to the stomach. It may be difficult to say which of these separate and distinct functions of the liver is most at fault; that can only be a matter of physiological inference. In the one case, for instance, the dyspeptic may be fairly well nourished, yet his elimination may be bad. In the other there is no failure of the destructive and excreting functions, but those concerned in the assimilation of fat and peptones are disordered, so that the patient is not well nourished, so far as the fatty element is concerned. This is the more common form, and a form not unfrequently associated with pulmonary consumption. The liver finally becomes fatty—a condition usually found associated with the constitutional forms of phthisis.

The pancreas is also closely associated with the stomach, and its secretion is of essential value in the digestive process. It is to be regretted that our precise knowledge of its diseases is in such striking contrast with its importance in the animal economy, and yet it can scarcely be doubted that in dyspeptic symptoms associated with failure of digestion of starchy, albuminous, and fatty elements of food there is disorder of the secretion of the pancreas. Hence in the treatment of the early stages of pulmonary consumption and other disorders associated with deficient digestion and assimilation of fatty substances the importance of directing our attention to the condition of the liver and pancreas, as well as to the stomach.

That morbid states of the intestinal track occupy a prominent place in the etiology of dyspepsia is also a well-recognized clinical fact. Indeed, constipation of the bowels is an almost universal accompaniment of deranged digestion, and when persistent for years it is apt to lead to the most disastrous consequences. These are mainly in the direction of lessened elimination from the intestinal glandulæ. The general symptomatology of deficient excretion from these glandulæ is closely analogous to the same condition of the liver: there is impairment of the general health; the clear florid complexion disappears; the patient becomes of a greenish or sallow hue; the blood is altered in quality; fatigue is experienced after the slightest exertion; the nights are restless; and there is great tendency to mental despondency. Moreover, constipation often precedes the gastric symptoms. The diminished muscular activity of the intestinal track extends to the stomach; its movements are diminished; food is not properly mixed with the gastric juice, and by being too long retained in the stomach in a comparatively undigested state acetous fermentation in the saccharine and starchy articles of diet is set up, acid eructations and a sour taste in the mouth being commonly complained of. Dyspepsia associated with this condition of the intestinal track cannot be relieved until the constipation is relieved, and by overcoming the constipation the dyspeptic symptoms often disappear.

Mention has been made of the baneful influence of certain mental states in the production of dyspeptic symptoms. But there are forms of indigestion due to local nervous disturbance existing elsewhere than in the nerve-centres. This was ascribed by the older writers to what they termed consensus nervorum, or sympathy, by which "the operation of a stimulus is not limited to the nerves immediately irritated, but is extended to distant parts in known or unknown connection with the irritated nerves." An intimate acquaintance with this law of sympathy is of the utmost importance in the study of the functional forms of dyspepsia, for no other organ of the body is subjected to such a wide range of reflected nervous disturbance as the stomach. Morbid sympathetic impressions are transmitted mainly through branches of the vaso-motor nerve of the semilunar ganglia of the abdomen, and from the pneumogastric to the stomach. Thus, a pregnant uterus not unfrequently produces very troublesome vomiting; some females suffer from nausea and indigestion during each menstrual period; and the more chronic forms of pelvic irritation, such as a flexed uterus, and endometritis, cervicitis, or tender ovary, may be the continuous exciting cause of most troublesome forms of nervous dyspepsia. There is also close sympathy of the stomach with the lungs and heart through the distribution of the pneumogastric. So also may fixed points of irritation in any part of the nervous system be reflexly transmitted to the stomach, giving rise to most pronounced symptoms of indigestion. And it is evident that in all such cases but little can be accomplished in the way of relieving the dyspeptic symptoms until the cause upon which they depend is removed. The treatment must have reference mainly to the removal of such cause.

Lastly, all the causes mentioned finally concur in producing irregularities of the mechanism of digestion; and this may be done by disturbing either the muscular movements of the stomach or in suspending or perverting the gastric solvents, or in these two conditions combined.

SYMPTOMS.—1st. Referable to the Stomach.—The symptoms which attend and indicate the presence of functional dyspepsia are such as accompany in a greater or less degree almost all cases of chronic gastritis. Clinically, so far as the direct gastric symptoms are concerned, it is difficult to separate them. The more prominent of the local symptoms are—a sense of fulness and distension after meals, discomfort during the digestive process, derangement of appetite, acid eructations, flatulence, regurgitations of food, and sometimes nausea and vomiting. There is seldom severe pain; the sensation is rather that of uneasiness. Exceptionally, however, there may be pain, which radiates from the stomach to the shoulders, and may pass down the left arm so as to simulate angina pectoris. But it may be readily distinguished from that complaint by coming on after food, and not after exertion. In other cases a sense of constriction may be accompanied by dyspnoea, arising from impeded movements of the diaphragm from being pushed upward by the distended stomach, or there may be heartburn, with an ill-defined sense of burning felt in the epigastrium; but thirst, so frequently present in chronic gastritis, is, as a rule, absent in functional dyspepsia. These symptoms are manifested in varying degrees of prominence in individual cases, and some of them are rarely found present. Thus, nausea and vomiting are not characteristic features of the chronic forms of functional dyspepsia, and as a rule epigastric tenderness is entirely absent. In markedly hysterical subjects or in persons whose nervous system has been unduly excited by alcohol there may be shrinking from the slightest touch upon pressure; but in these cases the tenderness is not confined to the stomach, nor is it increased by deep pressure. In some cases there is an unnatural craving for food—a symptom rarely if ever observed in structural lesions of the stomach—and now and then it happens that the appetite becomes depraved, especially with hysterical patients. They crave indigestible and unnatural substances, such as earth, chalk, and substances wholly devoid of alimentary properties. Impairment of appetite, however, is the more common feature of this form of indigestion.

Flatulence and eructations are generally complained of, the flatulence being accompanied by a painful sense of fulness, affecting in equal degree the stomach and small intestines. It is derived principally from putrefactive or fermentative changes of the ingesta, which are imperfectly elaborated in the stomach. The gases consist of carbonic acid, sulphuretted hydrogen, hydrogen, nitrogen, and the hydrocarbons, the butyric and acetic fermentations furnishing the hydrogen and carbonic acid gas. In addition to these marsh gas is formed by a special fermentation, the basis of which exists in the cellulose taken with vegetable food. In excessive meteorism from paralysis of the intestines the gas is principally nitrogen; the marsh-gas fermentation results from the ingestion of certain easily-fermentable vegetables, such as cabbage, cauliflower, etc.

In a certain proportion of cases regurgitation occurs from the stomach. The liquor regurgitated may be intensely acid from the presence of some of the fatty acids, probably butyric, lactic, or acetic. Exceptionally, it may be insipid or brackish, constituting what is known as pyrosis, or water-brash. The fluid is usually tasteless and without smell, and in reaction it is neutral to test-paper. It contains sulphocyanuret of potassium, and it has been supposed therefore to be only saliva. The quantity thrown up may vary from a spoonful to a pint or more. It affects females more than males, and especially those who subsist upon coarse and indigestible food. It is best treated by astringents—such as kino, krameria, logwood, or tannin—administered in the intervals between digestion, so that they may act directly on the mucous membrane. The oxide and nitrate of silver are thought by some to be superior to the vegetable astringents.

Cardialgia is a painful condition of the stomach, usually referred to its cardiac orifice, and is popularly known as heartburn. It is met with in both functional and organic disease of the stomach. It is very constantly present in chronic catarrhal gastritis, and evidently depends upon the presence of an acid, for it is usually promptly relieved by alkalies, such as chalk, magnesia, soda, or alkaline saline waters. Food containing much fat, starch, or sugar should be avoided.

Nausea and vomiting are only occasional symptoms of functional dyspepsia. When vomiting does occur it may take place at different times and with varying degrees of severity, differing in this respect from the nausea and vomiting of subacute gastritis, which takes place, if at all, soon after the ingestion of food. The time of vomiting and the character of the matter ejected are liable to great variation in functional dyspepsia. It may be the result of direct irritation of morbidly sensitive gastric nerves, or it may be a reflex phenomenon; it may follow soon after the ingestion of food, or it may come on when the stomach is empty; the material vomited may be simply food but little altered or an alkaline ropy mucus; it may consist in the acid juices of the stomach or in a neutral watery fluid; or the ingesta may have undergone fermentative and putrefactive changes from either insufficient amount of the gastric solvent or from narrowing (constriction) of the pyloric extremity, in which case the yeast fungus (Torula cerevisiæ) or the Sarcina ventriculi may be found in great abundance in the vomited matter. Vomiting of this kind usually occurs some time after eating. The gastric juice itself checks putrefaction; so also does the admixture of bile. In the absence of these natural antiseptics fermentation takes place. But it would be erroneous to suppose that the fermentative dyspepsia is the primary disease; it is a symptom which can be permanently corrected only by correcting the condition upon which it depends.

Among the most noticeable of the phenomena referable to other organs than the stomach are those connected with the liver and the alimentary canal. The tongue in dyspeptic troubles varies much in character. In reflex sympathetic indigestion it is not unfrequently clean; in hepatic dyspepsia it is generally thickly coated with a white or yellow fur. The symptoms are such as pertain more especially to chronic gastro-duodenal catarrh, such as nausea, epigastric oppression, furred tongue, heartburn, acid eructations, flatulent distension of the stomach and bowels, unpleasant taste in the mouth, offensive breath, loaded urine, frontal headache, irritability, and hypochondriasis.

Constipation, as we have seen, is an almost universal accompaniment of functional dyspepsia, sustaining to it not unfrequently a causative relation. It is undoubtedly one of the most common of the slighter ailments of civilized life, and exerts a wide influence in deranging the general health. "It is quite extraordinary how many different derangements of health may result from imperfect action or a torpid state of the secreting and expelling structures of the large bowel. There may be violent and persistent nerve-pains, referred to the back, or hip, or groin, and certain other symptoms which lead pessimist practitioners, excelling in the discovery of neuroses, to diagnose structural changes in some part of the spinal cord or the antecedent state which is supposed to lead to them" (Beale). Pains in the loins and thighs, violent lumbar pain, and certain remediable forms of sciatica are sometimes due to imperfect excretion of the lower part of the alimentary canal. And it is even possible that a condition of hypochondria bordering on insanity may be brought about by long-continued defective action of the bowels. In exceptional cases of dyspepsia diarrhoea may be present. This is more frequently the case when indigestion is associated with a congested state of the liver, in which case the symptom should be regarded as curative. Excessive irritability of the muscular walls of the stomach, superadded to weak digestion, may also be followed by lienteric forms of diarrhoea. Undigested food hastily finds its way into the intestinal track, and not unfrequently appears in the fecal evacuations.

Functional derangements of the stomach are often accompanied by pale urate deposits in the urine. It may contain an excess of phosphates, and in microscopical examination crystals of the oxalate of lime are frequently found, constituting a special affection described by Golding-Bird as oxaluria. He associated it with irritative dyspepsia, hypochondriasis, and exhaustion of nerve-power. This form of dyspepsia is best managed by the mineral, vegetable, and acid tonics, to which may be added small doses of nux vomica, with the usual adjuvants of good air and exercise, freedom from anxiety and care, cold sea-water baths, and well-selected, generous animal diet.

Another form of dyspepsia is sometimes associated with a peculiar form of dizziness—gastric vertigo. German writers speak of it as abdominal dizziness, and Trousseau calls it vertigo stomicale. It is usually an acute symptom, begins without any premonition, and is liable to be confounded with disease of the brain. It sometimes occurs soon after a meal, but more often when the stomach is empty (Trousseau). It perhaps, in a majority of cases, depends upon dyspepsia, but it has to be differentiated from organic brain disease, from cerebral anæmia, cerebral hyperæmia, the slighter forms of epilepsy, Minière's disease, and general nervous exhaustion and depression. But in many cases it will be found that treatment directed against the dyspepsia cures the vertigo.

Dyspeptic patients are also liable to skin diseases, and especially is this observed in the gastro-duodenal forms of indigestion. Disorders of the skin, such as urticaria, erythema, lichen, eczema, and other allied conditions, are well-recognized external indications at times of disordered conditions of the gastro-intestinal mucous membrane. Thus, it is a matter of common observation that the gastric symptoms increase when the eruption on the surface disappears.

The general influence of the nervous system over the function of digestion is perhaps the most remarkable feature of the disease, so that disturbed innervation becomes conspicuous in its symptomatology. The phenomenon varies in individual cases. Languor, drowsiness after taking food, depression of spirits, irritability, hypochondriasis, sleeplessness, palpitation, dry cough, dyspnoea, are all of common occurrence; and the mental disturbance—the anxiety, gloom, and sadness—is to many dyspeptics more distressing than absolute pain.

It is impossible, however, to present, in this connection, a complete clinical history of functional dyspepsia, for the reason that it is associated with so many separate and distinct affections, the dyspepsia itself being symptomatic of these affections.

PATHOLOGY.—But little is known of the pathology of the purely functional forms of dyspepsia beyond what is expressed by the terms atony and asthenia. These express simply certain states of the system with which atonic dyspepsia is so frequently found associated. Pathological anatomy has shown, however, that some cases are dependent upon, or associated with, certain appreciable alterations of the stomach, such as atrophy of the mucous membrane or fatty degeneration of its walls; and not unfrequently it is the seat of the so-called amyloid or lardaceous degeneration, although this albuminoid infiltration or cloudy swelling is more frequently the accompaniment of chronic inflammatory process. But Jones and Fenwick have shown that these conditions may occur independently of inflammation. However, upon this point we are compelled to speak with caution. The boundary-line between functional and structural diseases is not always clearly defined. Functional and structural troubles of the stomach are certainly very intimately associated. Moreover, symptoms of purely functional dyspepsia are so frequently associated with the subacute forms of gastritis that the pathology of the disease becomes, from necessity, doubtful and complex. It can only be studied in connection with certain states or conditions of which functional derangement of the stomach is a symptom readily recognized during life. In the light of more advanced physiological and pathological researches we may expect the limits of purely functional dyspepsia to be much restricted.

DIAGNOSIS.—The diagnosis of atonic dyspepsia must have special reference to its etiology. It is usually a chronic disease, and has to be discriminated from subacute or chronic inflammation of the stomach. This is the more difficult because many symptoms exist in common in both varieties of indigestion. But in functional or atonic dyspepsia the symptoms are not so continuous; there is less epigastric uneasiness, less tenderness, less nausea or loathing of food, less thirst, and less acidity and heartburn, less emaciation, less cerebral and nervous disturbance, and the constitutional symptoms are also less severe. The tongue, as a rule, is not so thickly coated, is not so red or broad and flabby, the papillæ are less marked, the breath less offensive, and the urine, instead of showing a condition of lithæmia, is not unfrequently pale and sometimes neutral, depositing oxalates and phosphates, especially in feeble, broken-down conditions of the nervous system.

With other painful affections of the stomach, such as ulcer and cancer, it is not likely to be confounded, especially when in these affections pain, vomiting, and hæmatemesis are present.

TREATMENT.—The first and leading indication is to remove, as far as possible, all causes of the disease, and this requires patient research and much diagnostic skill. Suggestive hints of treatment may be found in connection with the discussion of the varied etiology of the disease. We can, in conclusion, only allude to the matter in a very general way. Special cases must furnish their own indications of treatment.

In many cases a condition of nervous asthenia will be found prominently present. A leading indication, therefore, irrespective of the special determining cause, is to improve the general health of the patient; and this is accomplished by all means which invigorate the system generally. And first in the order of importance are diet and regimen. It is evident that if a patient eat too much or too often, or if he eat indigestible or unwholesome food, or lead an indolent and luxurious life, nothing can be accomplished by way of drugs in the relief of the disease. Excessive alimentation is, as we have seen, a most prolific source of the disease. Tempted to excess by great variety and by the ingenuity of culinary refinements, the stomach is burdened beyond its capacity of digestion and beyond the actual requirements of the system; and especially is this the case with those who live sedentary, indoor lives. In all such cases it is absolutely essential that the digestive organs have rest. Better even in cases of doubt reduce the diet for a time below the actual wants of the system until waste products are thoroughly removed and appetite is revived. The benefit derived in some instances from the protracted use of purgative mineral waters is largely attributable to the restricted regimen enforced and to the washing out of the system the waste products.

On the other hand, too great or too protracted abstemiousness may equally impair the digestive process. In ordinary forms of atonic dyspepsia we should seek rather, by appropriate treatment, to raise the digestive capacity to the level of digesting good, healthy, nutritious food, than to reduce the food to the low standard of feeble digestion. But it is a mistake to suppose that this can be accomplished by simply forcing food upon a stomach that lacks capacity of digestion.

As to the kind of diet, no precise rule is suited to all cases. Within certain limits individual experience must be consulted. But these experiences are not always reliable. Dyspeptic patients, more than any others, are apt to have fancies. Certain general rules, therefore, should be insisted upon. The food should be wholesome and digestible; it should be well cooked, well masticated, and taken at regular and not too long intervals. The intervals of time between meals depend upon circumstances already referred to. In some cases small quantities of easily-digested food should be taken at short intervals. In cases of feeble digestion of nervous subjects milk diluted in Seltzer water, or milk and lime-water, or peptonized milk, may be taken in liberal quantities at comparatively short intervals of time. Sometimes isinglass, arrowroot, or ground rice may be advantageously combined with the milk, to which tender, undone meats may be added.

Peptonized Food.—Recently the attention of the profession has been attracted to artificially digested food. The essential acts of digestion are known to be chemical transmutations. Albuminoid substances are changed into peptones and starchy matters are changed into dextrin and sugar. To Roberts, in his excellent lectures delivered in the Lumleian course before the Royal College of Physicians of London in 1880, we are indebted for valuable information on the digestive ferments and in the preparation and use of artificially-digested food; and from these lectures we shall derive most of the information we possess at present. It has been demonstrated that an extract of the stomach or pancreas, in water, has to a certain extent the same powers as the natural secretions of these organs. Hence, says Roberts, it is possible for us to subject articles of food beforehand to complete or partial digestion. Heat approximatively accomplishes the same thing. In the practice of cookery we have, as it were, a foreshadowing of this art of artificial digestion. Heat and digestive ferments alike aid gastric digestion. In case of the lower animals the whole process has to be accomplished by the labor of their own digestive organs.

Artificially digested food may be prepared in two ways—either by following the gastric method with pepsin and hydrochloric acid, or by following the intestinal method and using extract of pancreas. Both of these plans have had special advocates. Roberts claims that the latter yields by far the better results. "The pancreas not only acts upon albuminous substances, but also upon starch. Pepsin, on the other hand, is quite inert in regard to starch. Moreover, the products of artificial digestion with pepsin and acid are much less agreeable to the taste and smell than those produced by pancreatic extract." The pancreas of the pig, according to Roberts, yields the most active preparation, but the pancreas of the ox or the sheep may be employed. The pancreas of the calf is not active on starchy materials. A very active extract of pancreas is now prepared, and is easily obtainable, with directions for making peptonized milk, milk gruel, milk punch, soups, jellies, blanc-manges, beef-tea, enemata, etc. It is important to remember that peptonized foods do not keep well, especially in warm weather. If a quantity sufficient for twenty-four hours be prepared at any one time, the quantity which remains over twelve hours should be reboiled before using. Food thus peptonized is indicated in feeble conditions of digestion and when the derangement of digestion results from causes pertaining to the condition of the stomach itself—i.e. catarrhal forms of dyspepsia.

As a rule, the food should be such as will require the least possible exertion on the part of the stomach. Raw vegetables should be forbidden; pastries, fried dishes, and all rich and greasy compounds should be eschewed; and whatever food be taken should be eaten slowly and well masticated. Many patients digest animal better than vegetable food. Tender brown meats, plainly but well cooked, such as beef, mutton, and game, are to be preferred. Lightly-cooked mutton is more digestible than beef, pork, or lamb, and roast beef is more digestible than boiled. Pork and veal and salted and preserved meats are comparatively indigestible. Bread should never be eaten hot or fresh—better be slightly stale—and bread made from the whole meal is better than that made from the mere starchy part of the grain. Milk and eggs and well-boiled rice are of special value.

But to all these general dietetic rules there may be exceptions growing out of the peculiarities of individual cases. These should be carefully studied. The aged, for obvious reasons, require less food than the young; the middle-aged, inclined to obesity and troubled with feeble digestion, should avoid potatoes, sweets, and fatty substances and spirituous liquors; persons suffering from functional derangements of the liver should be put, for a time, on the most restricted regimen; while, on the contrary, the illy fed and badly-nourished require the most nutritious food that can be digested with comfort to the patient.

The general regimen should be tonic and invigorating. The patient should have the benefit of the best possible hygiene. Under this head may be mentioned suitable clothing, fresh air, moderate exercise, sunlight, baths, rest, regular hours, and the abandonment of all bad habits. No single measure has such marked influence on the digestive powers of the stomach as systematic, well-regulated muscular exercise in the open air, and especially if the exercise be accompanied by a cheerful mental state. For this reason outdoor sports are of benefit. Hunting, fishing, boating, are known to excite the keenest appetite for food, and the stomach will digest substances that would distress it under other circumstances. Exhaustion, however, is to be carefully avoided. Horseback exercise is a remedy of much value, especially in the hepatic forms of indigestion.

The mental and moral treatment of the purely functional forms of indigestion are amongst the most powerful means we possess. As an etiological factor certain morbid mental states rank first, as we have seen, in the order of importance. Grief, despondency, and despair are effectual barriers to digestion, and in a less degree mental worry seriously interferes with the process. It is a matter of prime importance, therefore, that the patient's mind be pleasantly occupied, that he should be free from all care and mental worry, and that he especially be kept from dwelling, if possible, upon his own bodily ailments. This is often best accomplished by travel, when practicable, in foreign countries, where everything will be novel and new and calculated to lead him away from himself. Get him to travel, says Watson, in search of his health, and the chances are in favor of his finding it. We have the authority of Sir James Johnson also for saying that no case of purely functional dyspepsia can resist a pedestrian tour over the Alps.

We come now to discuss the medical treatment of dyspepsia, which, though not unimportant, is subordinate to the general hygienic measures already referred to. General hints of treatment have been made in connection with special causes mentioned in the text. We seek, in a general way, by therapeutic measures—

1st. To stimulate the secreting and muscular coats of the stomach;

2d. To supply materials in which it is supposed the gastric juice is defective;

3d. To lessen abnormal irritability;

4th. To combat special symptoms or conditions which may hinder the digestive process.

To meet these indications innumerable remedies have been recommended, but they are of benefit only as they counteract the conditions upon which the dyspepsia depends. For loss of appetite, if there are no contraindications to their use, the vegetable bitters are often useful, such as quassia, gentian, and columbo. Of these columbo is the simplest of its class, but none more generally useful than mistura gentianæ with soda. The Hydrastis canadensis has also peculiar claims as a bitter stomachic. It, perhaps more than any of the bitters, promotes gastric secretion in feeble digestion, and has at the same time peculiar salutary effects on the enfeebled condition of the chronically inflamed gastric mucous membrane. It is supposed also to have a stimulating effect on the pancreatic secretion. It may be given in the form of a fluid extract combined with glycerin and small doses of nux vomica.

Among the specific stimulating nerve-tonics, nux vomica, or its alkaloid, strychnia, deserves special mention. In small tonic doses it is specially indicated in conditions of general nervous prostration associated with a tendency to hypochondriasis. In such cases we frequently observe pale urine, containing an excess of the phosphates. The mineral acids are valuable additions to the bitter tonics in all broken-down conditions of the nervous system. In administering nux vomica care should be taken as to limitation of time and dose. The excessive or prolonged use of the drug is apt to produce serious general nervous disturbance, the secondary condition being often the opposite to that for which it was prescribed. Temporary saccharine diabetes is not unfrequently one of the results.

In atony of the mucous membrane, with morbid sensibility and slow digestion, ipecacuanha is a remedy of much value. It was first brought into prominent notice in connection with gastric affections by Budd, since which time it has been more or less used by the profession. In torpid, slow digestion, with depraved or lessened gastric secretion, it is of undoubted value. It should be given on an empty stomach at least half an hour before meals. The dose should be short of producing nausea. We may commence with two to four drops of the tincture or wine of ipecac, and gradually increase until we find the point of tolerance; or it may be given in the form of pill in doses of a quarter or a half grain before meals, combining it with rhubarb in three- or four-grain doses. Ipecacuanha may be administered at the same time we are giving the mineral acids, or mineral acids with pepsin.

Adjuvants to Digestion.—In atony of the stomach the gastric mucous membrane responds feebly to the stimulus of food. There is failure in both muscular movement and gastric secretion, with slowness of digestion as a result. To meet this condition we seek to increase the digestive power by the addition of certain principles natural to the digestive process—viz. the mineral acids, pepsin, and pancreatin. Of these acids, the hydrochloric should be preferred, because it is the natural acid of the gastric juice. Lactic, nitro-hydrochloric, and phosphoric acids have also been used with benefit. There can be no doubt of the efficacy of either of these preparations. They are best given when the stomach is empty, so that they may directly act on the relaxed atonic mucous membrane. Half an hour before or two hours after a meal is the best time for their administration, and to be of benefit they should be administered for a length of time. From fifteen to twenty minims of the dilute hydrochloric or nitro-hydrochloric acid may be given in some bitter tincture or infusion for months. An elegant preparation may be made by adding the acid to tincture of orange-peel and syrup of lemon. Aromatic tincture, tincture of ginger, or glycerin may be added in some cases. It is important that remedies administered in gastric affections should be made pleasant as possible to the patient.

Metallic preparations are of use in some cases. If for any reason they are preferred, the perchloride of iron is one of the very best preparations. Arsenic and zinc may also be tried in small doses.

Pepsin and its Uses.—Of the efficacy of pepsin as an artificial substitute for the normal solvent of the food adverse opinions have been expressed, but in spite of the most critical scepticism as to its action its use since first introduced into medicine has steadily increased. It has been shown to be the natural constituent of the gastric juice and glands, and as a natural ferment, when combined with hydrochloric acid, it constitutes the most important solvent of the nitrogenous portions of our diet (Habershon). There is a vast number of different preparations of pepsin in the market, and some of them are doubtless of little value. We ought to be quite sure that the article is what it purports to be. The pepsina porce is the best preparation, one grain of which, says Beale, ought to thoroughly digest one hundred grains of boiled white of egg in three or four hours at a temperature of 100° F. His test as to the value of pepsin is as follows: "One hundred grains of hard-boiled white of egg, cut into thin slices, may be placed in a wide-mouthed bottle or flask with one ounce of water and twenty drops of dilute hydrochloric acid. One grain of pepsin powder is to be added, and the mixture placed before a fire at a temperature of about 100° F. The flask is to be shaken from time to time. In about an hour the white of egg begins to look transparent at the edges, and in about four hours it will be completely dissolved if the pepsin is good." In cases of feeble digestion from deficiency of gastric juice pepsin is a valuable adjuvant to the digestive power, and may be given with advantage in connection with the mineral acids or with ipecacuanha or capsicum before meals.

Special Remedies.—There are certain symptoms characteristic of the different forms and complications of dyspepsia that require special remedies. Bismuth is often useful. It is especially indicated where there is a morbid painful condition of the gastric nerves. The subnitrate or carbonate of bismuth may be given in ten- or twenty-grain doses, suspended in water by means of mucilage of acacia, and flavored with ginger or peppermint. It should always be given on an empty stomach. Other elegant preparations supposed to be improvements upon these have been recommended, and may be tried.

In cases of anæmia, if there are no contraindications, iron may be tried. If digested and assimilated, it improves the blood, and this is often the first step in the direction of restoring functional activity. Of the preparations of iron, none is perhaps superior to the perchloride. The saccharo-carbonate and the ammonio-citrate are also valuable and unirritating salts of iron, and may be given with other tonics. Ferruginous mineral waters slightly charged with carbonic acid are well tolerated in small doses. The free dilution favors the action, and is frequently more acceptable to the stomach than the more concentrated forms. From one-half to one glassful may be taken at a time; and the use of iron in this form may be preceded or accompanied by the administration of small doses of quinia and of the bitter tonics. But it is a mistake to commence the treatment by the indiscriminate use of iron, quinine, and nerve-tonics. The contraindications to the use of iron are irritable and inflammatory states of the mucous membrane, or dyspepsia associated with deranged conditions of secretion, as manifested by dirty tongue and loaded urine.

When the nervous system is prominently at fault, nux vomica, arsenic, and the nitrate and oxide of silver often prove to be valuable remedies. Here also benefit may be derived from the lighter ferruginous preparations; indeed, few combinations have greater influence over the nervous system than the joint action of arsenic and iron. Much benefit may also be derived, in special cases, from methodical hydro-therapeutic treatment. If judiciously used it strengthens the nervous system, stimulates the organic functions, and increases the power of vital resistance. And in some cases of nervous dyspepsia electricity gives good results. In all cases of nervous prostration as much wholesome food should be taken as the stomach can easily digest.

In hepatic forms of indigestion there is no substitute for an occasional mercurial cathartic, for, notwithstanding adverse criticism, clinical experience has taught the great value of this drug upon the upper portion of the intestinal track. The mode of operation may be doubtful, but the result is unquestionable. In functional disturbance of the liver or morbid conditions of the upper portion of the intestinal track, as indicated by the loaded tongue, sallow complexion, want of appetite, and lithæmia, no remedy will give so much relief as a few broken doses of calomel, followed by a saline aperient; or eight or ten grains of blue mass, with a grain of ipecacuanha, may be administered at bedtime, followed by a saline draught in the morning. After the bowels are thoroughly unloaded by a mercurial, great advantage may be derived from a systematic course of the aperient mineral waters—the Friedrichshall, the Hunyadi, Carlsbad, or some of the mineral waters of our own country. The hepatic form of indigestion cannot be relieved until we relieve the congested hepatic portal system, and this is best accomplished by the general line of treatment here indicated. The simple vegetable bitters, with or without alkalies, may be used at the same time or subsequent to this treatment; but they are often worse than useless until we secure freedom of abdominal circulation. The diet should be light and nourishing, and the patient should spend most of his time out of doors. Horseback exercise is peculiarly advantageous.

But in many cases of the more chronic forms of dyspepsia the colon is as atonic as the stomach, and therefore the bowels require special attention. In colonic dyspepsia all active purgation should be avoided, and salines, such as sulphate of magnesia, the Hunyadi and other saline mineral waters, should be specially prohibited. The most useful aperients in such cases are rhubarb, aloes, senna, colocynth, or podophyllin. Few laxatives answer a better purpose than the ordinary compound rhubarb pill. It may be improved, in special cases, by combining with it extract of nux vomica or belladonna. When there is no affection of the rectum to forbid its use, the watery extract of aloes answers very well, and, unlike many cathartic substances, the dose need not be increased, nor does it disturb the digestive process. It may be given in one-sixth of a grain up to a grain or more, and its purgative action may be improved by being reduced to a state of very minute division and combining with it small doses of belladonna. Belladonna itself is a useful remedy. According to the observations of Harley, it "tones and tightens the longitudinal fibre, while it relaxes the circular;" and long before this theory of its action was suggested, Trousseau called attention to its singular efficacy in producing easy and natural evacuations from the bowels. It is important to observe its mode of use. It should be given in sixth of a grain doses of the extract in the morning a half hour or hour before breakfast. Its efficacy may be increased by combining with it small doses of the watery extract of aloes. In colicky conditions of the bowels two- or three-drop doses of tincture of colocynth sometimes act wonderfully well. In obstinate constipation the free use of diluents at the termination of digestion is often attended with excellent results. But the hygienic and dietetic treatment of constipation is even more important than the medicinal, such as outdoor exercise, the cold bath, rubbing, kneading the bowels, and the use of bread made of whole meal, oatmeal, and an abundant supply of fresh vegetables and fruits.

Nausea and vomiting, occasional symptoms of functional dyspepsia, may be relieved by various agents, such as effervescing draughts, lime-water, oxalate of cerium, hydrocyanic acid, creasote, ice, and alkalies.

When vomiting is dependent on fermentation or putrid action of the contents of the stomach with development of sarcinæ, it may be checked by carbolic acid or by creasote, or by the sulphite of soda or sulphurous acid; and in irritable conditions of the stomach bismuth is a valuable remedy. It may be given with alkalies or with finely-triturated animal charcoal.

Gastric pain needs treatment appropriate to the circumstances under which it arises. Sometimes it is relieved by regulating the ingesta or the intervals at which it is taken; sometimes by warm carminative stimulants or by chloric ether, ginger, or brandy. If the pain is more constant, approaching a condition of gastralgia, hydrocyanic acid and bismuth are more effective remedies. But it cannot be too strongly stated, in conclusion, that in the management of the atonic forms of dyspepsia hygienic treatment is of prime importance. The hopeful future of medicine lies in the direction of promoting healthy nutrition, and this is best accomplished by the careful adaptation of food and exercise and modes of living to individual cases of disease.

Gastralgia (Gastrodynia, Cardialgia, Spasm of the Stomach).

Under the head of neuroses of the stomach have been variously described the conditions indicated in the heading of this section; and a certain amount of confusion has arisen in the use of these terms from the fact that they represent subjective sensations common alike to organic and functional forms of indigestion: pain, for instance, is felt in gastritis, cancer of the stomach, and ulcer of the stomach. Indeed, it rarely occurs independently of some disorder of digestion or structural lesion of the stomach.

By gastralgia, considered as a distinct affection, however, we mean a purely neuralgic condition of the sensory fibres of the stomach, excluding inflammatory and structural changes on the one hand and chronic forms of atonic dyspepsia on the other. The attacks are usually periodical in character, with constricting pain in the pit of the stomach, and the intervals are not necessarily associated with symptoms of dyspepsia. It chiefly occurs in females of nervous temperament at the catamenial periods.

Two forms of the disease have been described—one depending on hyperæsthesia of the sensory fibres of the pneumogastric, the other on hyperæsthesia of the solar plexus. This may be correct in theory, but practically it can be of little importance to make the discrimination, even if it were possible to do so.

Clinically, the disease is presented to us in two forms. In one the pain is agonizing, comes on without premonition, is sometimes intermittent or remittent in character, and conveys to the sufferer the idea of spasm; hence it has often been described as colic of the stomach. If not relieved by appropriate remedies, the pain may last for hours or days. This is the acute form. In the other the pain is more of a neuralgic character and is not so severe. There may be varying exacerbations which may last for months or years. This is not an unfrequent form, and may consist simply in the more acute form becoming chronic.

ETIOLOGY.—With the limitation indicated, we have naturally to seek the causes of the affection, says Ziemssen, in two directions: either in the abnormal nature of the irritants to which the gastric nerves are subjected, or in an altered condition of the nerves themselves, which therefore react abnormally with the normal degree of irritation. This briefly covers the whole ground of the etiological relations of the disease.

The predisposing causes are such as produce general depressed vitality, embracing at the same time special conditions of extreme nervous excitability. Some of these general conditions were pointed out while speaking of atonic forms of dyspepsia. Indeed, the two conditions are often associated, and practically it may be difficult to separate them, although the connection between them is not necessarily an invariable one. Like atonic dyspepsia, gastralgia is apt to affect anæmic persons, and notably anæmic females at menstrual periods. Thus, the association between gastralgia, chlorosis, and hysteria is a matter of common observation. Of 350 cases noted by Briquet, only 30 had no signs of gastralgia; and this observation is a fair average expression of the experience of others.

Certain blood-poisons are also known to give rise to the disease. Infection of the blood by malaria was observed by Niemeyer to produce spasm of the stomach instead of the paroxysms of intermittent fever; and in malarious regions of the United States the same observation has been made. Gout and rheumatism are also known to sustain causative relations to the disease. Certain idiosyncrasies also enter as a factor into the somewhat complex etiology of the disease. Thus, some persons suffer immediately from eating certain kinds of food and fruits, such as shellfish, strawberries, honey, and even milk and coffee. The pain and spasm are produced by direct contact with the sensory fibres of the stomach; i.e. they react abnormally to normal stimulation. But disease of the nerve-centres may enter into the causation. This is seen by the effects of morbid growths impinging upon nerve-trunks; their terminal branches often become extremely irritable and painful, and this condition may be intensified by idiosyncrasy. Excessive acidity of the stomach, seeds of fruit, certain articles of food, the presence of worms in the stomach, and draughts of ice-water may simply act as exciting causes to a centric predisposition.

Of the more direct causes operating upon nerve-centres, all the depressing passions and emotions deserve special mention; so do all causes which produce an exhausted state of innervation, such as venereal excesses, onanism, the abuse of narcotics, etc.

But chief among the causes are those of a reflex kind. Painful affections of the kidneys, irritable conditions of the bladder, diseases of the liver, and, above all, morbid conditions of the female genital organs, sustain a direct and close relation to painful and spasmodic conditions of the stomach. It is a common accompaniment of versions, flexions, prolapses, inflammations, erosions of the os, as well as diseased conditions of the ovaries. When such local conditions are associated with anæmia and hysteria, patients rarely fail to have painful gastric complications.

SYMPTOMS.—The symptoms of gastralgia, like most of the neuroses, are characterized by severe pain occurring in paroxysms, followed by remissions, and sometimes by complete intermissions, again to recur with varying degrees of severity. The pain in the acute variety is of a violent, spasmodic character, and is referred to the epigastrium immediately beneath the ensiform cartilage. Frequently it extends from the epigastrium to the back and chest and into the right and left hypochondrium. No one has so briefly and so accurately described the immediate attack of gastralgia as Romberg: "Suddenly, or after a precedent feeling of pressure, there is severe griping pain in the pit of the stomach, usually extending into the back, with a feeling of faintness, shrunken countenance, cold hands and feet, and small, intermittent pulse. The pain becomes so excessive that the patient cries out. The epigastrium is either puffed out like a ball, or, as is more frequently the case, retracted, with tension of the abdominal walls. There is often pulsation in the epigastrium. External pressure is well borne, and not unfrequently the patient presses the pit of the stomach against some firm substance or compresses it with his hands. Sympathetic pains often occur in the thorax under the sternum, in the oesophageal branches of the pneumogastric, while they are rare on the exterior of the body. The attack lasts from a few minutes to half an hour; then the pain gradually subsides, leaving the patient much exhausted, or else it ceases suddenly with eructation of gas or watery fluid, with vomiting, with a gentle soft perspiration, or with the passage of reddish urine."

Besides the violent paroxysmal pain referred to the stomach, symptoms of derangement of other organs are often present. Prominent among these are hysterical phenomena which are protean in their manifestations, and if not recognized they are liable to mislead. Thus, with gastric pain there may be violent palpitation of the heart, with shortness of breath, cough, globus, hiccough, and convulsive affections, and in a certain proportion of cases there is marked melancholia or hypochondriasis.

The stomach is variously modified in its function. In many cases it is entirely unaffected. The desire for food may be indeed increased, and its ingestion may give a sense of relief. In others vomiting may be severe, while in still others there may be merely a condition of anorexia. The tongue is, as a rule, clean, the skin cool, the temperature undisturbed, and there is absence of tenderness over the epigastrium. Generally pressure relieves the pain.

DIAGNOSIS.—Functional and structural troubles of the stomach very markedly simulate each other; therefore the diagnosis requires to be made with great caution, and this is best done by a most rigid and careful exclusion; and this becomes difficult because the symptoms are mainly subjective.

It is a matter of great moment in differentiating the disease to take into account all constitutional states which predispose to nervous asthenia. Thus in conditions of chlorosis and hysteria the presumption is strong that the pain is neurotic or spasmodic in character; and this presumption is intensified if there be no accompanying constitutional symptoms which indicate inflammatory action. We exclude inflammatory conditions of the stomach by the frequent and complete intermissions, by the absence of thirst, tenderness, and all febrile movement. Moreover, the pain of inflammatory affections, unless produced by corrosive poisons, is rarely so severe as in neuralgic affections; nor are nausea and vomiting so uniformly present in neurotic affections. Then the time at which the pain is experienced is a matter of importance. In inflammatory affections it is felt immediately on taking food. In neurotic affections it may occur when the stomach is empty, and it is not unfrequently relieved by food. In ulcer and cancer of the stomach pain is a common element, and, as in gastralgia, it is referred to the epigastrium. But in gastric ulcer the pain is rarely absent; it is of a dull, gnawing character, is strictly localized in the centre of the epigastrium, and is aggravated by pressure and by food. Moreover, the vomited matter often contains blood. In cancer of the stomach the pain is not as severe and spasmodic in character as in gastralgia, the vomiting is a more prominent symptom, and the material vomited has the characteristic cancerous look. Cancer is more apt to occur too in advanced life, and it is characterized by a steady progressive emaciation.

Gastralgia may also be confounded with rheumatism of the abdominal muscles as well as neuralgia of the inferior intercostal nerves, and it is liable to be confounded with colic resulting from biliary calculi. Colicky pains in the transverse portions of the colon may also be mistaken for pains in the stomach. "It is no exaggeration to say," says Trousseau, "that in perhaps half the cases which are called gastralgia the affection is nothing more than cholalgia." The more fixed the pain is to one spot, and the nearer it is to the median line, the greater is the probability of its being gastric.

PROGNOSIS.—Notwithstanding the severe and apparently alarming nature of the symptoms, the prognosis of gastralgia is in the main favorable, although the prospect of a permanent and speedy cure is small. The duration of the disease depends on the nature and persistence of the exciting causes, and these are so often associated with an exhausted state of innervation that speedy recovery from the disease cannot be promised. In the simpler varieties, caused by improper food, the disease will disappear by removing the cause, and the hysterical forms are liable to disappear with advancing life. So also cases arising from malaria, anæmia, chlorosis, uterine disease, rheumatism, and gout may be relieved by removing the cause. But there are cases produced by unknown causes, and especially cases associated with a general and unexplained cachexia, in which the prognosis is not good.

TREATMENT.—This is both radical and palliative. The radical treatment must have reference to the diseases which have given rise to it. If, for instance, the gastralgia can be traced to sympathetic disturbances of the uterine organs, no remedy can be permanently effective until the cause is removed. Since chlorosis and anæmia are so often found associated with it, benefit may be expected from the ferruginous preparations in some form. Iron occupies a prominent place as a remedial agent. The precipitated carbonate is to be preferred on account of its peculiar influence over the nervous system, and especially over painful neuralgic conditions. It may be given in drachm doses, or even larger, combined with ginger or aromatic powder. If the stomach will not tolerate it, other preparations may be tried.

Quinia is a valuable addition to iron, and it is specially valuable in cases of suspected malarious origin. Sometimes a few large doses will break up the paroxysmal pains as no other agent will.

In the more chronic forms of the disease arsenic is one of the most reliable remedies we possess. It has a well-deserved reputation in the treatment of a great variety of nervous affections, and in none more than in the disease now under consideration. It should be given for a length of time—three or four minims of Fowler's solution, gradually increased and given immediately after food—and in cases of anæmia it should be associated with iron.

In irritable, broken-down conditions of the nervous system nux vomica, or its alkaloid strychnia, is a useful remedy. But it is a powerful stimulant to the spinal nerve-centre, and care should be used in the too protracted use of the remedy or in its administration in too large doses. It may be combined with the phosphate or the valerianate of zinc, or either may be given separately. The nitrate and oxide of silver have also been used with asserted success. Nitrate of silver may be given in pill form with opium.

If there is a strong hysterical element, the bromides and antispasmodics may be tried in connection with remedies calculated to strengthen the nervous system. The judicious employment in such cases of hydro-therapeutic measures is of great value. Good results are also obtained from electricity. The constant current should be preferred.

Among palliative remedies—i.e. remedies that act directly on the painful gastric nerves—the subnitrate of bismuth has long been regarded with great favor. Its action is mainly local; it may be given, therefore, in drachm doses or more three or four times a day. If there is nothing to contraindicate its use, aconite or dilute hydrocyanic acid may be given with the bismuth.

For the immediate relief of pain, however, there is no substitute for opium. The subcutaneous injection of morphia will generally give immediate relief. But there are many reasons why we should try other palliative remedies. In a disease so painful in character a remedy that gives such prompt relief is liable to abuse. The formation of the opium habit should be carefully guarded against. Spirits of chloroform may be tried, therefore, as a substitute for opium, followed by large draughts of hot water—hot as the patient can possibly sip it. Hot water of itself often gives immediate relief.

An important part of the treatment consists in well-regulated hygiene. Change of air, travel, pleasant mental surroundings, together with carefully regulated diet, are in a majority of cases more efficacious than drugs.

Acute Gastritis (Acute Gastric Catarrh).

Reasoning from the great functional activity of the stomach, from its daily periodical change of blood-supply, from its extensive glandular arrangement, and from its important relations to the functions of vegetative and animal life, we might readily infer that it would be frequently the seat of acute and destructive inflammation. But it is remarkable, all things considered, how seldom that is the case. Indeed, acute spontaneous inflammation of the stomach is almost unknown. When it occurs it most frequently results from toxic causes. In less severe forms, however, not attended with immediate danger to life, it is undoubtedly a disease of frequent occurrence, and in this more comprehensive sense the subject will be considered in the present section.

The mucous membrane alone is usually the seat of the disease, and for this reason it has become the custom of late years to describe it as gastric catarrh. This may be objectionable, for the reason that it does not include gastric inflammation of every grade of intensity. The term catarrh is generally applied to much more simple anatomical structures than those pertaining to the stomach. We shall consider the subject therefore under two forms—namely, (1) Catarrhal; (2) Erythematous gastritis.

ETIOLOGY.—Certain conditions predispose to the disease. Acute catarrhal gastritis is specially liable to occur in those who habitually suffer from a disordered stomach. This may arise from functional disturbance of the digestive process on the one hand, or mechanical obstruction on the other. Mechanical causes are widespread in their influence. Thus, weak heart-action from any cause tends to disturb the normal adjustment between the two sides of the circulation—arterial and venous. An abnormal amount of blood accumulates on the venous side of the circulation, and chronic passive hyperæmia of the abdominal viscera is the result. The effect of this upon the stomach is to lower its functional activity and to invite inflammatory action. The same condition results from structural diseases of the heart, lungs, or liver. Persons suffering from valvular diseases of the heart, emphysema of the lungs, or cirrhosis of the liver are strongly predisposed to diseases of the stomach. Gastric troubles are also apt to supervene during the progress of various diseases.

Gouty and rheumatic persons are specially prone to suffer from gastric catarrh; and eruptive disorders, such as scarlatina, diphtheria, etc., tend to erythematous forms of gastric inflammation. Catarrhal gastritis is also a very common sequence of the whole class of malarious fevers, including yellow fever, intermittents, and remittents. In its more acute form gastric inflammation supervenes in the course of yellow fever; and what is observed here in an extreme degree exists in a minor degree in all the so-called malarious fevers. Intermittent and remittent fevers are always attended with gastro-duodenitis and gastro-hepatitis. The degree of this inflammatory complication determines the continued character of the fever. Upon this point the writer has very decided views based upon a wide field of observation in malarious regions of country. We have lost ground in the treatment of these diseases by directing our attention almost exclusively to the febrile and malarious, to the exclusion of the inflammatory, elements. Quinia is inoperative in the cure of these troublesome and often fatal complications. Indeed, it is more than that: it is often positively injurious. Arrest the local phlegmasia and secure freedom of abdominal circulation, and we at once get the action of the specific remedy. It may be going too far to affirm, as did Broussais, that gastritis sustains a causative relation to all forms of fever, but that gastro-duodenitis is an important secondary condition in all forms of malarious fever, complicating and perpetuating the febrile state, there can be no doubt; and it is equally clear that it constitutes one of the most dangerous complications. Excessive alimentation, with the injudicious use of tonics and stimulants, so often resorted to in the treatment of these fevers in their early stages, only serves to intensify the local inflammation. Abolish the congestive and inflammatory element of a remittent, and it at once becomes an intermittent.

Mention has been made of weak heart-action as a factor in catarrhal gastritis; also mechanical impediments to the return of blood from the stomach to the heart. The stomach is thereby kept in a constant state of congestion, the nutrition of the mucous membrane is less active than in health, and its solvent juices are more sparingly secreted. Thus in long-continued congestion produced by mitral disease of the heart Samuel Fenwick found the formation of pepsin impaired. He made artificial gastric juice from the mucous membrane of three males dying of heart disease, and he found, on the average, only 2-9 grs. of albumen were dissolved, whereas the amount digested by the mucous membrane of persons who had died of other maladies was 4 grains. In the cases of three females a still smaller amount of solvent power was displayed. These facts have important bearings upon the question of alimentation in fevers and the conditions in which there is chronic congestion on the venous side of the circulation. Long-continued passive hyperæmia of the stomach from any cause not only impairs its functional activity, but strongly predisposes to inflammatory complication.

Acute erythematous gastritis is most frequently met with in children. It is a very common form of disease in early life, and the local nature of the malady is frequently overlooked. Few questions in practical medicine are more embarrassing to the physician. It has been known and described as gastric and remittent fever, as continued typhoid, and even as acute hydrocephalus. Writers and teachers describe and dogmatize, while practical men hesitate at the bedside. There is little doubt but in the background of these febrile manifestations in children there is often an acute erythematous gastritis, which is more successfully treated by a rigid milk diet, small doses of calomel and bismuth, mucilaginous drinks, cooling saline laxatives, and sometimes leeches applied to the epigastrium, than by the heroic doses of quinia so frequently resorted to.

We must not, in this connection, lose sight of the fact, so clearly pointed out by Broussais, that inflammation of the stomach is often secondarily repeated in the brain. The whole field of clinical observation abounds in illustrations of this. How often, for instance, we can trace the sick headache, the delirium, and even convulsive movements of the voluntary muscles, to primary gastro-intestinal irritation! In the play of the sympathies morbid irritative action is transmitted from the organic to the cerebro-spinal nerves; and of all portions of the abdominal viscera the stomach and upper portion of the intestinal track are the most frequent seat of these intense morbid sympathies. Remedies which cool the stomach and lessen inflammatory action diminish the excitement of the brain, and vice versâ.

EXCITING CAUSES.—Among the direct exciting causes of gastric inflammation—exclusive of acrid or corrosive poisons—the most frequent in this country is the excessive use of alcohol. It acts most injuriously when it is but slightly diluted and taken on an empty stomach. And next to this pernicious habit, in the order of importance, is the use of large quantities of food—more than the stomach has capacity to digest, and more than is necessary for the wants of the system. Excessive alimentation is a prolific source of gastric inflammation. It generally manifests itself, however, in a chronic or subacute form.

Acute erythematous gastritis, so frequently met with in children, is often present in scarlatina. It is evidently not catarrhal in character, for in the earlier stages there is no increased secretion of mucus and but little injection of the mucous membrane. The changes are observed in the deeper structures of the stomach, and principally in the gastric tubules. They are much distended by granular, fatty, and albuminous matter; and in this respect it is analogous to erythematous affections of the skin with which it is associated in scarlatina.

Finally, acute gastric catarrh may be excited by all causes that weaken the digestive power either by weakening the gastric juice or by retarding the movements of the stomach.

ANATOMICAL CHARACTERS.—No disease requires more knowledge and caution in determining post-mortem changes than those of the stomach. In the first place, it presents in inflammatory conditions markedly different degrees of intensity, with corresponding differences in anatomical changes. Its diseases also present many special forms, and changes take place after death which simulate morbid processes during life. Moreover, intense vascular injections are apt to disappear in the small superficial vessels after death. This applies to all mucous membranes, but specially to the mucous membrane of the stomach, which is the seat of varying amounts of blood in their physiological limits during life. For this reason the observations of Beaumont made upon a living subject are invested with peculiar interest. It will be remembered that in the case of Alexis St. Martin the appearances noted were such as belong to the milder forms of inflammation. Beaumont noticed in this case, after indiscretions in eating or abuse of ardent spirits, a livid erythematous redness of the gastric mucous membrane, with, at the same time, dryness of the mouth, thirst, accelerated pulse, and, at the height of the injection, an entire absence of gastric secretion. At other times there was considerable muco-purulent matter, with oozing of grumous blood, "resembling the discharge from the bowels in cases of chronic dysentery." The fluid taken out through the fistulous opening consisted mostly, however, of mucus and muco-pus which showed an alkaline reaction. He describes also a condition of ecchymosis and oozing of blood from certain red spots of the gastric mucous membrane, and when thus limited the constitutional symptoms experienced by the patient were correspondingly slight. Ecchymoses may be present in large number, with exudates of false membrane, which Beaumont describes as aphthous. Brinton also describes a severe form of gastritis which he terms ulcerative, in which he observed hemorrhagic erosions.

In the catarrhal form of gastritis the mucous membrane is covered with a thick, tenacious, stringy mucus; it is softer than usual, and generally thickened. It presents at the same time a dead-white appearance, corresponding to Virchow's cloudy swelling—a condition analogous to that which is observed in acute Bright's disease. Even casts of the tubes are sometimes met with.

This inflammatory change in the substance of the mucous membrane is especially observed in the acute erythematous form of gastritis complicating scarlatina. In the early stage there is no increased secretion of mucus, and at a more advanced stage the membrane may be even paler than usual.

In cases of acute toxic gastritis intense redness is seen over the entire surface of the mucous membrane, followed by rapid exudations and sloughing of portions of the membrane.

In all forms of the disease there is a tendency to extension of the inflammation into the duodenum and small intestines. In the more chronic forms we almost invariably encounter the condition of gastro-duodenitis.

SYMPTOMS.—The symptoms of inflammation of the stomach present wide differences in their intensity, depending upon the degree of severity in different cases. In acute inflammation caused by the direct action of poisonous irritants they are pronounced and highly diagnostic. The patient immediately complains of burning pain, referred to the epigastrium, followed by intense thirst and vomiting. The thirst is apt to be very great and the act of vomiting painful. The vomited matters contain mucus, saliva, sometimes bile, and not unfrequently, in fatal cases, black, grumous, coffee-ground material. There is marked tenderness on pressure, the pulse is frequent and small, coldness of the surface is marked, and hiccough is apt to occur. The expression of the patient is anxious, the abdominal muscles rigid, and, in fatal cases, the prostration becomes rapidly extreme. The patient dies by asthenia. These symptoms apply to acute cases of marked severity, usually of toxic origin.

In the milder forms of catarrhal gastritis more frequently met with there is seldom complaint of pain. The sensation is rather that of fulness, uneasiness, with more or less tenderness on pressure. The symptoms are such as belong to acute indigestion and the embarras gastrique of French authors. The phenomena may be those of a slight bilious attack. The tongue is foul, the breath offensive, the bowels confined, and the urine high-colored and scanty. There is also generally a sense of fatigue, and soon secondary cerebral symptoms supervene, such as cerebral hyperæmia, headache, vertigo, noises in the ears, palpitation, sighing, yawning, dyspnoea, faintness, and in severe cases marked physical and mental depression. Nausea and vomiting are common, and if the inflammation extends to the duodenum and liver, symptoms of gastro-hepatic catarrh manifest themselves. If fever supervenes, urticaria sometimes complicates these attacks.

In young children the inflammation is apt to involve a general catarrh of the whole intestinal track. Thirst is excessive, followed by vomiting and diarrhoea. The discharges are liquid, watery, offensive, acid, and out of all proportion to the amount of fluid absorbed by the stomach. The pulse becomes weak and fluttering, the skin pale, the features pinched, the eyes sunken, and the extremities cold. The tendency is toward rapid collapse and fatal issue. The symptoms describe what is usually known as cholera infantum. It has its analogue in the cholera morbus of adults.

In erythematous gastritis nausea and vomiting are as general as in the catarrhal form, but, unlike the catarrhal, pain at the epigastrium is a prominent symptom. It comes on directly after taking food. In phthisical cases the sensation is rather that of rawness of the oesophagus and stomach. Thirst is a troublesome symptom; the tongue is red or dry and glazed; tenderness of the epigastrium is marked; diarrhoea is generally present; and, as in the catarrhal form, the stools are fetid and unhealthy. The disease shows a marked tendency to become chronic.

DIAGNOSIS.—In the more acute forms of the disease the symptoms are all highly diagnostic. Vomiting, burning pain of the stomach, tenderness on pressure, intense thirst, with frequent and small pulse, point with almost unerring certainty to acute gastric inflammation. But vomiting of itself, however persistent, is not evidence of gastritis, for it may be present from many other causes. If the vomiting be attended by headache, it may be confounded with gastric irritability from brain disease. Thus, chronic meningitis with persistent vomiting strongly simulates gastritis, and in the case of children it is liable to be mistaken for it. In gastritis the nausea is from the first a pronounced feature of the disease. Vomiting in affections of the brain is often unattended by nausea. In gastritis the tongue is more frequently coated or red and glazed. Diarrhoea is also more frequently present, especially in early life. In affections of the brain the tongue may be clean and the bowels are usually obstinately confined. When there is much fever, gastritis may be confounded with remittent or typhoid fever. In periods of childhood this mistake is specially liable to occur, for there are many symptoms in common. In all such cases the early history of the case ought to be carefully inquired into. In gastritis we may be able to detect the cause in any particular case. The gastric symptoms are apt to occur suddenly, and, as already stated, are prominent from the first. In meningitis the skin is more frequently dry; in gastric catarrh perspirations are common. The more prominent and characteristic symptoms of typhoid should also be carefully excluded, such as the gradual invasion, peculiar eruption, bronchial catarrh, enlargement of the spleen, gurgling in the right iliac fossæ, with tympanitic abdomen. Peritonitis, with vomiting, may be mistaken for gastritis, but the diffuse tenderness, the fixedness of position, the rigidity of the abdominal muscles, and the tympanitic distension serve to guide us in our diagnosis.

PROGNOSIS.—The prognosis must have reference to the cause. The more violent forms of the disease resulting from corrosive poisons are generally fatal. Death is apt to take place in a few hours from a condition of collapse. The immediate cause of death is failure of heart-action. It is also a dangerous disease in the extremes of life. In its acute form in children it is apt to terminate fatally, especially if it is not recognized early and judiciously treated. The complications of the disease may also render the prognosis unfavorable. Milder cases tend to recovery.

TREATMENT.—The most important indication of treatment, applicable to all forms of gastric inflammation, is to secure complete or partial rest for the inflamed organ. In dangerous cases no food should be taken into the stomach. The patient should be nourished exclusively by nutrient enemata. If food is permitted, it should be restricted to milk and lime-water, administered in small quantities at short intervals. In acute and dangerous cases, suddenly manifesting themselves, the exciting cause should be carefully inquired into, and speedily removed, if possible, by an emetic, or, if need be, by the stomach-pump, if the poison be one which can be ejected; and following this antidotes are to be administered according to the nature of the poison.

To allay the intense thirst small pieces of ice should be swallowed at frequent intervals, or, what is often more grateful to the patient, iced effervescing drinks in small doses oft repeated. Injections of water may also tend to relieve thirst. To allay vomiting the physician is often tempted to try a great variety of remedies which are usually worse than useless, for they aggravate rather than relieve the distressing symptom. For the purpose of quieting the stomach opium is the most reliable remedy we possess. It is best administered hypodermically. Fomentations may be applied over the epigastrium. Stimulants are, of course, contraindicated on account of their irritating action on the inflamed membrane, but in case of rapid tendency to death by failure of heart-action they should be administered by the rectum or hypodermically.

In milder cases—which are much the more common—physiological rest of the organ is also a cardinal principle of treatment. Rest of the body is equally essential. In cases of any severity the patient should be kept quiet in bed. For the condition of acute indigestion known as embarras gastrique ipecacuanha in six- or eight-grain doses, given three times within twenty-four hours, will often produce healthy bilious stools, and in this manner accomplish the cure. One or two grains of calomel may be added to each dose of ipecacuanha with benefit. In all forms of catarrhal gastritis, especially if symptoms of portal congestion are present, mild mercurial cathartics are attended with benefit. Six or eight grains of calomel may be rubbed up with sugar of milk and placed dry on the tongue, followed by a cooling saline aperient. When diarrhoea is present in such cases, it should be regarded as conservative, and encouraged by the administration of half-grain or grain doses of calomel, combined with bismuth and bicarbonate of soda. The diet should be restricted to milk and lime-water or milk mixed with Vichy or Seltzer water. Demulcent drinks should be freely given. In the slighter attacks effervescing drinks are grateful to the patient; and if there be excessive formation of acid in the stomach, antacids and sedatives should be administered.

Bismuth has a peculiar sedative and antiseptic effect in the milder forms of inflammatory action of mucous membranes. It is especially valuable in gastro-intestinal troubles of children. Its action is mainly local surface action, and may therefore be given in liberal doses if necessary. Children may take from five to ten grains, and adults twenty grains or more. Hydrocyanic acid adds to its sedative qualities, or when pain is present, with diarrhoea, opium in some form may be added. The salicylate of bismuth is specially indicated when we want to add to the antiseptic qualities of bismuth.

The general principles of treatment indicated here are applicable to the so-called remittent fevers of children—namely, calomel in small doses, combined with bismuth and bicarbonate of soda, followed by occasional cool saline laxatives. Ipecacuanha is also a valuable agent in correcting morbid gastro-intestinal secretions. When there is early epigastric tenderness, with hot skin and elevation of temperature, two or three leeches should be applied to the epigastrium, followed by warm poultices of linseed meal. Dry cupping may also be used with benefit; and if decided remissions occur, with suspicions of a complicating malarious element, a few liberal doses of quinia may be tried. In many such cases, however, it will be found unnecessary, and not unfrequently hurtful. In acute gastro-intestinal inflammations of children—the temperature reaching 105° or more—no febrifuge, in the opinion of the writer, is equal to the cool or cold bath, repeated from time to time until there is a decided reduction of temperature. But the gastric inflammation, rather than the fever, should mainly claim our attention.

Great care is necessary during convalescence from acute gastric disease, particularly as regards the hygienic management. The apparent debility of the patient too often tempts the physician to the early and injudicious use of tonics, stimulants, and excessive alimentation, which, if persisted in, can scarcely fail to perpetuate a chronic form of inflammatory action.

Chronic Gastritis (Chronic Gastric Catarrh).

There is perhaps no malady more frequently met with than chronic gastric catarrh, and none more frequently misunderstood. It comprises many different forms of gastric derangement, which are grouped under the general head of inflammatory dyspepsia, with many symptoms strongly simulating ordinary functional dyspepsia. It includes, in the author's opinion, a large number of cases of obstinate chronic dyspepsia, which are badly managed because not recognized as of inflammatory origin.

ETIOLOGY.—In a more or less chronic form it is frequently met with as a result of the acute affections. Hence the etiology is mainly that of acute gastric catarrh. It may be caused—

1. By functional disorders of the stomach.

2. By mechanical causes which interfere with the portal circulation.

3. In connection with certain constitutional states, such as gout, rheumatism, phthisis, renal disease, certain eruptive diseases, and as a sequence of malarious fevers.

4. By the excessive use of alcohol and other gastric irritants.

5. By errors of diet, especially excessive alimentation.

6. By decomposition of ingested aliment owing to deficiency of gastric juice.

7. By all causes that weaken the digestive power and lower the general tone of the system.

Of all these causes, errors of diet are most apt to produce it, and to perpetuate it when once established. And next to this, in the order of importance, is the immoderate use of alcohol, especially by persons whose general health and digestive power are below a healthy standard. Such persons are apt to suffer from irritative and inflammatory forms of dyspepsia, which, in various degrees of intensity, alternate with the acuter forms of embarras gastrique.

The injudicious use of drugs may also be mentioned. There can be no doubt that many transient and functional forms of indigestion merge into the more chronic inflammatory forms of dyspepsia from the abuse of stimulants, tonics, and purgatives. Anxious for relief, and urged on by hope of recovery, the victims of functional dyspepsia are apt to have recourse to every grade of quacks and to be subjected to every form of harassing and mischievous treatment. Indeed, the use of potential and irritating drugs, administered for all kinds of ailments, real or imaginary, enters largely into the etiology of chronic gastric catarrh.

Mechanical causes deserve also special consideration. These are mainly such as offer impediment to the return of blood from the stomach to the heart. In acute cases the congestion may be very intense. Congestion of the same kind, but more gradual in its occurrence and less in degree, may be present from all conditions affecting the circulation of venous blood through the liver. General anæmia, by producing weak heart-action, disturbs the normal adjustment between the arterial and venous sides of the circulation. Blood accumulates in the veins and capillaries, and morbid action propagates itself in a direction contrary to the circulation. Hence in all conditions of general anæmia there is tendency to dyspnoea, pulmonary oedema, bronchorrhoea, special forms of liver disease, gastric catarrh, and even temporary albuminuria. All mechanical obstructions to the free transit of blood through the heart, lungs, or liver are followed by the same results. A free secretion of mucus into the stomach is one of the most commonly recognized. It is often vomited in large quantities. This alkaline mucus, while it dilutes the digestive juices of the stomach, furnishes favorable conditions for the development of low micro-organisms, which contribute to the fermentative process. We may not duly estimate the effects of these organisms on a mucous membrane softened by long-continued passive hyperæmia.

Malarious fevers, from their congestive tendency, give rise to the more acute forms of gastro-enteric inflammation. In the more chronic forms of intermittent and remittent fevers more or less gastric inflammation is invariably present. Indeed, in all forms of fever gastric inflammation is a complicating element, and the recognition of the fact has an important bearing on the treatment.

Certain constitutional diseases appear to involve special liability to this affection, such as scrofula, phthisis, gout, rheumatism, syphilis, and many chronic forms of skin disease; and in many cases the cause is not apparent.

ANATOMICAL CHARACTERS.—The gross appearance of the stomach in chronic gastritis is thus admirably described by Broussais, who faithfully recorded what he "observed during many years in the bodies of those who have long suffered from distaste for food, nausea, and vomiting." These observations were made long before morbid anatomy had thrown much light on the more minute structural changes of organs, and the general picture will be recognized as faithful to-day: "Softening, friability, and the reduction into a kind of gelatinous mass commonly occurs in the region of the lower part of the larger curvature of the stomach; and when closely examined it is perceived that it is not only the mucous membrane that has undergone that species of decomposition, but that the muscular has participated in it, and that the whole of the cellular tissue which united the three membranes has entirely disappeared. The parietes of the viscus are then reduced to a very thin lamina of serous membrane, commonly so fragile as to tear on the slightest handling, or even already perforated without any effort on the part of the anatomist. The pyloric region, on the contrary, has manifestly acquired more consistence and thickness; the mucous membrane there presents large folds, the muscular appears more developed, and the cellular and vascular are injected; sometimes even a true scirrhous state is observed there. The portion of the mucous membrane which covers this scirrhus is sometimes ulcerated, but that in the surrounding parts and at the border of the ulcer, far from being softened, is, on the contrary, tumefied, indurated, and injected. Finally, though there may or may not be ulceration of the pylorus, it is always manifestly hypertrophied, whilst the lower part of the great curvature is the seat of softening and atrophy."

These were the observations of the great anatomist apparent to the naked eye. At the present time we can only confirm them by stating that structural changes are particularly noticed in the pyloric region of the stomach. The mucous membrane generally is vascular and covered with a grayish, tough, transparent mucus. It is more opaque and thicker than natural. The surface is usually changed in color: it may be red, brown, ash-gray, slate-colored, or even black in spots. The darkened spots are due to pigmented matter, and this is generally most marked in the pyloric half of the stomach. It is most commonly met with in cases of prolonged passive congestion of the stomach from portal obstruction, and requires for its production the rupture of capillaries in the superficial layers of the membrane and the transformation of the hæmatin into pigment. The same condition often produces ecchymoses and hemorrhagic erosions in spots. In other cases the mucous membrane is strikingly uneven, being studded with numerous little prominences separated from each other by shallow depressions or furrows. This condition, which has been compared to granulations upon wounds, is called mammillation. It is the état mamelonne of Louis, and is considered by him as a sure and constant sign of inflammatory action. Like many other structural changes, it is usually found in the neighborhood of the pylorus. More rarely polypoid growths project from the membrane, and little cysts also frequently appear in the mucous membrane.

Chronic inflammation tends to thickening of the mucous membrane. It sometimes is not only greatly thickened, but acquires an extreme degree of toughness. Exceptionally, however, the membrane, either entire or in spots, may be abnormally thin. The thickening of the walls of the stomach, when it involves the pylorus, gives rise to constriction of the orifice and consequent dilatation of the stomach.

When the disease has been of long standing the interstitial tissue between the tubules becomes thickened, the stomach is changed in its normal structure, and the tubules themselves become confused, compressed, and much less straight and parallel than in the normal state. Or they may in some cases be enlarged, according to Flint, in consequence of swelling and parenchymatous or fatty degeneration of their epithelial cells. Microscopic examination often shows changes such as occur in other glandular organs. The glands and tubules become the seat of degenerative changes, such as are observed in Bright's disease of the kidney, and they are frequently found associated in the same case. The mouths of the gastric tubules become blocked up, while deeper parts are dilated into cysts; and at times they are atrophied or filled with granular fatty matter.

Many cases of persistent anæmia may be traced, according to Flint, to this degenerative process of the gastric tubules.

The SYMPTOMS of chronic gastritis are mainly those of difficult digestion of an aggravated kind, and are liable to be mistaken for those of ordinary functional dyspepsia. Some points of distinction were referred to in the section treating of functional dyspepsia; and while there are many symptoms in common, it is vastly important that the two forms of the disease should be early recognized, for they are radically distinct in their pathology and treatment.

We now speak of what is usually known as inflammatory, irritative, or gastric dyspepsia—a persistent and aggravated form of indigestion which has its origin in the stomach itself, in contradistinction to dyspepsia which originates largely from causes outside of the stomach and transmitted to it through nervous impression. The one is functional and indirect; the other is inflammatory and direct.

The symptoms referable directly to the stomach are mainly those of difficult and painful digestion, and are alike characteristic of all forms of indigestion, such as loss of appetite, sense of weight and fulness of the epigastrium, distress after taking food, acidity, eructations of gas, etc. But chronic gastritis is more frequently accompanied by a burning sensation in the epigastric region, accompanied by tenderness on pressure, which is generally increased after meals. Sometimes this tenderness amounts to actual pain, which is increased after meals. But we are liable to be misled by pain: gastric pain is not a characteristic symptom; subacute forms of the disease may exist without any fixed pain; the sensation is rather that of burning, uneasiness, and oppression of the epigastric region. The appetite, as a rule, is greatly impaired—indeed, the sense of hunger is rarely experienced—and nausea and vomiting frequently follow the ingestion of food. This is especially the case when catarrh of the stomach is associated with renal disease, portal congestion, or chronic alcoholism. Large quantities of mucus are brought up, the vomiting taking place usually in the morning, and on examination of the mucus it will frequently be found to contain sarcinæ and large numbers of bacterial organisms. When stricture of the pylorus is present the vomiting of putrid, half-digested food usually takes place about the termination of the digestive process.

The tongue presents characteristics peculiar to chronic inflammation of the stomach. In some cases it is small and red, with enlarged and red papillæ; in others, it is broad and flabby and somewhat pale; but in either case, on close inspection, the papillæ will be found red and enlarged, this being more apparent on the tip and edges. In children of scrofulous habits and in older persons of tubercular tendency the whole organ is redder than natural, the papillæ standing out as vivid red spots.

In other cases the catarrh of the stomach extends to the mucous membrane of the mouth. In all cases of oral catarrh the tongue, instead of being red and pointed, is large and apparently oedematous. It is uniformly covered with a white or dirty brownish coat, and frequently shows the impression of the teeth upon its edges. The secretions of the mouth are depraved, the breath heavy and offensive, and the gums spongy and unhealthy in appearance. Acidity is also common.

Thirst is a common symptom. It is rarely absent either in the acute or chronic form of the disease. It is most marked in the intervals between meals and in the evenings.

It is rare in gastric catarrh of long standing that it does not extend to the intestines, and occasionally from the duodenum to the ductus choledochus; in which case we have the combined symptoms of gastro-intestinal catarrh associated with jaundice. The nutritive system becomes implicated, and patients are especially prone to develop any diathesis to which they may be liable.

There remains a group of symptoms of great interest in the study of gastric inflammation—important because liable to mislead as to the real nature of the difficulty—namely, morbid conditions of the nervous system. Few diseases have such a wide range of morbid sympathies, and few, it may be added, are so generally misunderstood and misinterpreted. Two main facts, as formulated by Broussais, deserve to be restudied by the profession:

First, that irritations of the visceral parenchyma which do not implicate their serous membranes only give rise to ill-defined sensations, and they not painful;

Second, that most of the acute pains arising from visceral irritation are rather referred to external parts than to the viscera themselves.

Unless the seat of very acute inflammation, mucous membranes are remarkably free from pain, and yet the gastric mucous membrane is the seat of a most exquisite internal visceral sense and has a wide range of morbid sympathetic disturbances. These sympathetic phenomena are often treated for primary neuralgias. No fact in the clinical study of disease deserves more careful consideration than this. Absence of pain, then, is calculated to mislead. It is often only the sensation of uneasiness, depression and melancholy, want of appetite, thirst, nausea, loathing of food, and derangement of the bilious and gastric secretions, that directs our attention to the stomach. Moreover, in gastro-enteric inflammations pain is more frequently felt in parts sympathetically affected than in the stomach itself. "It is only when irritations of mucous membranes are in the vicinity of the openings of cavities that the irritations are distinctly perceptible in the seat they occupy" (Broussais). Morbid irritative action commencing in the stomach repeats itself in the cerebro-spinal system of nerves, and the secondary irritation may develop a more immediately dangerous inflammation than the primary. This is frequently observed in children, who are specially prone to irritation of the visceral apparatus. Many cases of primary gastric irritation terminate in acute cerebral inflammation. Indeed, the greater number of phlegmasiæ of the brain are only sympathetic irritations issuing from primary inflammation of the stomach. Short of inflammation, the transmitted irritation may merely give rise to reflex convulsions, and in adults to sick headache, or, if long continued, to conditions of hypochondria. Headache is a prominent symptom of gastric irritation. It is not usually acute, but rather a sense of fulness and pressure, sometimes felt in the frontal, at other times in the occipital, region. Many cases commonly called cerebral hyperæmia and cerebral anæmia are nothing more than malassimilation from chronic gastric catarrh. This fact deserves to be specially emphasized at present, for we are apt to consider the cerebral the primary lesion. Vertigo, as in functional dyspepsia, is also an occasional symptom, and very commonly patients complain of extreme degrees of sleeplessness and disturbed dreams and nightmare.

The heart's action is often disturbed in its rhythm, and sympathetic dyspnoea leads to suspicion of disease of the lungs. And to all these nervous phenomena may be added unusual languor, lassitude, irritability of temper, and a feeling of inability for either mental or physical exertion.

But in the play of morbid sympathies it must be borne in mind that the stomach may be secondarily affected. Irritations of all organs are constantly transmitted to the stomach from their very commencement. Hence the frequent loss of appetite, the thirst, the embarrassed digestion, the deranged gastric secretion, and the altered color of the tongue. This is markedly the case in all the malarious and essential forms of fever. Gastric complication in these fevers is rarely, if ever, absent, and if aggravated by the too early use of tonics and stimulants and by harsh irritating cathartics, it becomes too often a fatal complication.

Gastric symptoms are also associated with other constitutional disorders, such as phthisis, renal disease, rheumatism, gout, and almost all forms of chronic eruptive diseases.

Intestinal symptoms are rarely absent. Constipation is often obstinate, and especially is this the case if the catarrhal condition is confined to the duodenum. The lower down the inflammation the greater the probability of diarrhoea, and when present the stools are offensive and frothy; sometimes they are dry and scybalous and coated with a tough, tenacious mucus which may form casts of portions of the intestinal track. In other cases patients suffer from distressing intestinal flatulence and a sense of general discomfort. Piles is a complication frequently present without reference to complication of the liver.

The urine is more frequently disordered than in any other form of disturbance of digestion. The most common changes consist in an abundant deposit of the urates; exceptionally, however—especially in cases of long standing in which there are marked nervous symptoms associated with defective secretion of the liver and pancreas—it may be of low specific gravity and pale in color from the presence of phosphates. Slight febrile movement is not uncommon.

Finally, in all cases of chronic gastric catarrh the nutritive system becomes deeply implicated—much more so than in functional disturbances of the stomach. Emaciation is almost constantly present, the patient often showing signs of premature decay.

DIAGNOSIS.—The disease with which chronic gastritis is most liable to be confounded is atonic dyspepsia, the chief points of distinction from which have been already alluded to. In general terms it may be said that in chronic gastritis there is more epigastric tenderness, more burning sensation and feeling of heat in the stomach, more thirst, more nausea, more persistent loss of appetite, more steady and progressive loss of flesh, more acidity, more eructations of gas, more general appearance of premature decay, and greater tendency to hypochondriasis. And yet all these symptoms, in varying degrees of prominence, may be present in all forms of indigestion. To the points of distinction already mentioned, then, a few circumstances may be added which will afford considerable assistance in coming to a correct diagnosis:

1. The length of time the disease has uninterruptedly lasted. It is essentially a chronic disease.

2. The local symptoms are never entirely absent, as is not infrequently the case in functional dyspepsia.

3. The uneasy sensations, nausea, oppression, or pain, as the case may be, follow the ingestion of food. They are not so prominently present when the stomach is empty.

4. The result of treatment. In chronic gastritis it will be found that all the local symptoms are exasperated by the usual treatment of functional dyspepsia.

5. Stimulants and stimulating food are not well borne. Alcohol, especially on an empty stomach, produces gastric distress. There is also frequently slight febrile disturbance.

Chronic gastritis, with nausea, vomiting, hæmatemesis, general pallor, and loss of flesh, may be mistaken for cancer of the stomach. But in cancer vomiting is about as apt to take place when the stomach is empty as during the ingestion of food; pain is usually greater, especially when the orifices of the stomach are involved; the tenderness is more marked; the emaciation and pallor more steadily progressive; the vomiting of coffee-ground material takes place more frequently; and the disease is more rapid in its progress. The age and sex of the patient may also aid us in our diagnosis. Cancer is more frequently a disease of middle and advanced life, and localizes itself oftener in the stomach of males than females. Finally, the discovery of a tumor would remove all doubts. Hæmatemesis in chronic catarrh of the stomach is almost invariably associated with obstruction to venous circulation in the liver, heart, or lungs.

In rare cases it may be difficult to distinguish chronic gastric catarrh from ulcer of the stomach. In ulcer of the stomach pain is a more prominent and constant symptom; it is more centrally located; the vomiting after taking food is more immediate and persistent; the tongue may be clean; flatulence is not a constant symptom; the appetite is seldom much affected; the bowels are generally confined; and there is nothing characteristic about the urine.

TREATMENT.—In this, as in the more acute forms of the disease, rest of the stomach is important. From mistaken notions of disease we are prone to over-feed our patients, and thus seriously impair the digestive and assimilative processes. In chronic inflammation of the stomach a restricted diet is of prime importance. The physician should most carefully select the patient's food, and urgently insist on its exclusive use. This of itself, if faithfully persevered in, will often effect a cure.

The exclusive use of a milk diet—especially skim-milk—should be thoroughly tested. In testing it we should allow two or three weeks to elapse before any other food is taken. At the end of that time soft-boiled eggs, stale bread, and well-cooked rice may be added, with an occasional chop once a day. Some patients do not tolerate raw milk well. In such cases we should thoroughly test the peptonized or pancreatized milk or the peptonized milk-gruel, as suggested by Roberts. This artificially-digested milk agrees wonderfully well with many stomachs that cannot digest plain milk. Milk, in whatever form administered, should be given at comparatively short intervals of time, and never in quantity beyond the digestive capacity. Better err on the side of under- than over-feeding. Nothing should be left to the fancy or caprice of the patient. The food should be carefully selected by the medical adviser, and given in definite quantities at definite times. Even the moral effect of such discipline is healthful for the patient. After testing milk diet for a time, we may gradually add small quantities of rare and thoroughly minced meat. Milk, eggs, and rare meat are more easily digested, as a rule, than starchy substances. Farinaceous food is apt to give rise to excessive acidity. But stale bread may be added to the milk, and, if there is tendency to acidity, better have it toasted thoroughly brown.

In addition to the dietetic treatment of the disease, diluents, timeously administered, are of essential service. As a rule, patients are too much restricted from their use, under the supposition that they dilute the gastric juice and thereby impair the digestive power. This restriction is proper at, and for some time after, the ingestion of food. But at the end of the first hour after taking food several ounces of gum-water, or some mucilaginous fluid sweetened and rendered palatable by a few drops of dilute muriatic acid, should be administered, and repeated every hour during the digestive process. Diluents, thus administered, are not only grateful in allaying the thirst of the patient, but are at the same time an essential part of the treatment. The free use of demulcents at the termination of digestion in the stomach is especially useful.

Beyond these general principles of treatment, applicable to all varieties of gastric catarrh, we must have reference to the varied etiology of the disease. This, we have seen, is most complicated. Hence the difficulty in prescribing any rules of treatment applicable to all cases. We should seek here, as in all cases, to generalize the disease and individualize our patient.

Chief among remedial agents may be mentioned the alkaline carbonates. When combined with purgative salines they are specially valuable in gastro-duodenal catarrhs associated with disease of the liver. These are a very numerous class of cases, especially in malarious regions of country, and when present in a chronic form lay the foundation of widespread disorders of nutrition. No treatment in such cases is effective until we diminish engorgements of the liver and spleen, and nothing accomplishes this so well as the use of alkaline saline laxatives. These may be assisted in their action by small doses of mercurials. It was a cardinal principle among the older practitioners, in the absence of more minute means of diagnosis, to look well to the secretions; and what was their strength is, I fear, our weakness.

Wonderful results often follow a course of the Carlsbad, Pullna, or Marienbad waters, taken on an empty stomach, fasting, in the morning. While taking the waters a rigid and restricted diet is enforced. This is an important part of the treatment. And the fact that so many varied ailments are cured by a course of these mineral waters with enforced dietetic regulations only shows the prevalence of gastro-duodenal catarrhs and their relation to a great variety of human ailments. To a certain extent the potassio-tartrate of sodium and other saline laxatives may take the place of these waters if perseveringly used and taken in the same way. In feebler subjects minute doses of strychnia or some of the simple vegetable bitters may be used in conjunction with the laxative salines.

In chronic inflammatory conditions of the gastric mucous membrane, which frequently follow acute attacks, the protracted use of hot water is often followed by excellent results. There can be no doubt of the value of hot water in subacute inflammation of mucous membranes in any locality; and it is specially valuable in gastro-intestinal catarrh associated with lithæmia. Hot water, laxative salines, combined with restricted diet and healthful regimen, accomplish much in correcting morbid conditions of primary assimilation; and by accomplishing this many secondary ailments promptly disappear. A pint of water, hot as the patient can drink it, should be taken on an empty stomach on first rising in the morning, and it may be repeated again an hour before each meal and at bedtime. A few grains of the bicarbonate of sodium and a little table-salt may be added. In some cases three or four drops of tincture of nux vomica or some of the simple bitters may be taken at the same time with benefit. Alkaline bitters are natural to the upper portion of the digestive track. No food should be taken for a half hour or an hour after the hot water. This treatment, to be effective, must be persevered in for a length of time. A most rigid system of dietetics suited to individual cases should be enforced at the same time. This is an important part of the treatment.

In irritable and morbidly sensitive conditions of the mucous membrane the sedative plan of treatment is not unfrequently followed by good results; and of remedies belonging to this class bismuth is the most effective. It is specially indicated in the more irritable forms of gastric disturbance in which there is a sense of uneasiness and pain at the epigastrium after taking food. If there is much acidity present, it may be combined with magnesia or a few grains of finely-pulverized animal charcoal.

Chronic cases of long-continued inflammatory action, with intestinal complication, are often much benefited by the use of mercurials in small doses. The one-fifth of a grain of calomel, combined with bismuth or the bicarbonate of sodium, may be given for weeks without danger of salivation. Excellent results sometimes follow this treatment. In small doses calomel is undoubtedly sedative to the mucous membrane of the upper portion of the digestive track. In cases of long standing that have resisted other modes of treatment the more direct astringents have been found of great value. Of these, nitrate of silver is to be preferred, alike for its sedative, astringent, and alterative properties. It may be given in pill form in from one-quarter to one-grain doses, combined with opium, a half hour before each meal. The writer of this article can speak from much experience of the value of this drug. It proves in many cases a valuable addition to the hot-water and dietetic course already alluded to.

If large quantities of mucus are vomited from time to time, especially in the morning, we may resort with benefit to the use of other astringents, such as bismuth, oxalate of cerium, kino, and opium; and if we have reason to suspect stricture of the pylorus in connection with a catarrhal condition of the mucous membrane, the stomach-pump gives the patient great relief. It should be used about three hours after a meal, injecting tepid water, and then reversing the syringe until the water comes out perfectly clear. Niemeyer speaks highly of it in such cases. He says: "Even the first application of the pump generally gives the patients such relief that, so far from dreading a repetition of this by no means pleasant operation, they clamorously beg for it."

The gastric catarrh of phthisis is difficult to relieve. Artificial digestives may be tried, with dilute muriatic acid, as already indicated; and for the relief of pain and irritation there is no remedy so efficacious as hydrocyanic acid, which may be combined with bismuth and opium in case there is diarrhoea. Hot water may be also tried, with restricted animal food.

Habitual constipation must be overcome by suitable laxatives and by enemata. Castor oil is mild and efficient in these cases, or in cases of unusual torpor of the muscular coat of the bowels small doses of aloes and strychnia may be tried. The free use of diluents toward the close of digestion favors free action of the bowels. All harsh and irritating cathartics are to be carefully avoided.

When there is much tenderness of the epigastrium, benefit may be derived from counter-irritation, and nothing is so effectual as the repeated application of small blisters.

General hygienic measures are in all cases to be insisted upon. In morbid conditions of the liver and the upper portion of the digestive track the free supply of oxygen to the lungs is a remedy of much power. Hence patients should live as much as possible in the open air. They should be warmly clad, and, if not too feeble, frequent cold baths should be resorted to.

After local irritation has been subdued by appropriate treatment, tonics may be tried to counteract the enfeebled state of the stomach. They are such as are appropriate for functional diseases of the stomach. But they should be used with caution and judgment in irritable and inflammatory forms of dyspepsia. If we attempt to force an appetite by their use, and to crowd upon the stomach more food than it has capacity to digest, we may intensify the trouble and thereby add to the patient's general debility. Food and tonics fail to impart strength because the stomach is not in a condition to digest them.

One thing should be mentioned, in conclusion, as an important item in the treatment—namely, patience. Chronic gastric catarrh, it should be remembered, is essentially a chronic disease, and time becomes an important element in its cure.