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 {457} 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 {458} 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
{459} 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, {460} 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. {461} 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 {462} 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 {463} 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.