dyspepsia. When vomiting does occur it may take place at different
times {450} 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 {451} 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 {452} 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. {453} 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 {454} 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 {455}
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 {456}
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.