sulphuretted hydrogen who had vertigo and sudden collapse; symptoms
relieved by purgative (_Pacific Med. and Surg. Journ._, May, 1882, p.
539).]
The action of the heart is disturbed as in stomach indigestion.
Irritability of the heart and palpitation are in part due to anæmia and
in part to mechanical pressure and reflex influences. The nervous,
anæmic, thin dyspeptic has among his chief troubles a throbbing heart,
which keeps him awake at night and fixes his attention upon this organ
as the seat of his disease. The general circulation is languid; cold
hands and feet and cold sweats testify to this, and the irregularity or
suppression of catamenia follows upon the irregular blood-supply.
The urine is usually high-colored, has an abnormally high density, is
acid, and on cooling deposits lithates, uric acid, and oxalate-of-lime
{629} crystals. The urine is most heavily loaded with sediment when
digestion has been recently completed. Therefore, the morning urine
after a heavy dinner of the night before contains the largest amount of
lithates. Albuminuria is occasionally a symptom of indigestion in the
bowel. The eating of cheese or pastry in excess may cause it.[13]
Seminal emissions at night frequently occur. The action and reaction
upon each other of this perversion of the sexual function, the
indigestion, and the mental disorder, reduce the poor sufferer to a
most pitiable condition of despondency and prostration.[14]
[Footnote 13: Warburton Begbie's _Works_, Sydenham Society's
Publications, 1882, p. 359.]
[Footnote 14: The writer has observed cases in which an exaggeration of
the sexual instinct in men of middle age was associated with intestinal
indigestion.]
Anæmia is one of the earliest indications of impaired nutrition. It
precedes loss of flesh and the wrinkled and dry condition of the skin
which may be a marked symptom in cases of long standing. Various
eruptions appear on the skin. In the strumous dyspepsia of children the
white, almost waxy, skin is covered with dry scales, which may be seen
over the whole body from head to foot. No symptom is more
characteristic of intestinal indigestion and of imperfect fat digestion
and absorption than this. Eczema and psoriasis, pityriasis, impetigo,
and porrigo decalvans are forms of skin eruption seen.
Closely allied to the symptoms caused by indigestion in the intestine
are those due to functional disorder of the liver. The liver completes
the work which the intestine has begun. It receives directly from the
intestine blood laden with the products of digestion, and further
transforms them into substances to be used in the economy. The symptoms
which result from disturbances in the performance of these functions
are, as has been said, closely connected with the symptoms of
intestinal indigestion. This association is shown by the tendency among
older writers to trace all such symptoms to the liver, the terms
bilious and biliousness including all the phenomena of derangement of
the function of digestion in the intestine, as well of the function of
the liver. Later writers excluded the part of the liver to a great
extent in giving rise to the so-called bilious symptoms. Recent
physiological study has shown how closely the intestine and the liver
are associated in health and in disease. When the liver is implicated
in indigestion the symptoms which follow are due either to a deficiency
of the secretion of bile, and the resultant disturbance of digestion in
the intestine, or to a derangement in the transformation in the liver
of the products of albuminoid digestion. When the disorganization of
the peptones is imperfectly performed in the liver, instead of urea
there is a production of lithates and lithic acid, constituting the
condition called lithæmia. The lithates pass into the urine and are
deposited. The occurrence of this urinary sediment after excesses and
imprudences in diet is well known. The continuance of lithæmia leads to
the development of symptoms more or less characteristic. These are a
loss of appetite and coated tongue, flatulence, oppression after
eating, and constipation. The nervous system is soon disturbed, and
often to a marked extent. Vertigo, headache, disturbances of the
special senses, sleeplessness at night, drowsiness during the day,
annoy the patient and induce extreme hypochondria. He is worried,
moreover, with numbness and tingling in one or both arms or in the
{630} legs, and hence spring fears of paralysis. The heart is disturbed
in action, and is irregular and feeble. Emaciation in previously
corpulent persons is not unfrequent.
COURSE, TERMINATION, AND SEQUELÆ.--Acute dyspepsia in the bowel lasts
from a few hours to a day or two, and ends in leaving the patient as
well as before. A diarrhoea of indefinite duration may follow.
Chronic intestinal indigestion in infants and young children often
continues until the diet is changed to one suited to the powers of
digestion. In adults interference with so important a function cannot
but have the most serious results. While the progress is slow, lasting
many years, there is a steady march from bad to worse.
The character and conduct are so altered by the disease that a man may
be said to be just what his digestion makes him. Amiability under the
daily goad of intestinal dyspepsia is an impossibility. The
irreconcilables, the men out of joint with the world, are living
witnesses of the antagonism and disaffection within their intestines.
The deterioration in health paves the way for many diseases, and there
is hardly an organ in the body which may not ultimately become the seat
of organic change.
In the young, phthisis is frequently the ultimate result of the
malassimilation and malnutrition; in men beyond middle life
degenerative changes in the intestine, liver, and kidneys close the
series of morbid changes which began in the intestine. Thomas N.
Reynolds attributes bronchitis and phthisis in part to the local
influence of septic matter carried by the portal and lacteal vessels to
the lungs in cases of intestinal dyspepsia, with constipation and
septic fermentation of the ingesta.[15]
[Footnote 15: Paper read before section of Practical Medicine at
meeting of Am. Med. Assoc. in 1883.]
In many cases business and professions are abandoned, and men become,
under the influence of despair and complete absorption in their
symptoms, intellectual and moral wrecks, burdens to themselves and to
all around them. In this stage the primary cause, the dyspepsia, is
lost in the exaggerated prominence of the nervous symptoms.
DIAGNOSIS.--The acute variety is known by the seat of the abdominal
symptoms, the pain, distension, and movement of gas not being in the
stomach, but in the intestines. The pain is like colic; the abdomen is
sensitive to the touch; tympanites is general and may be very great. If
vomiting occurs, the symptoms continue after the stomach is empty.
Diarrhoea may quickly come on, and is followed by relief. The fever may
be quite high. There is no sleep, but restlessness, and in children
delirium. They may also have convulsions.
In the chronic form the history of the case and the study of the causes
are of great value in formulating an opinion. The persistent abuse of
the pleasures of the table sooner or later develops intestinal
indigestion. Inquiry into the mode of life, hours of eating, manner of
eating, kinds of food taken, etc. gives important information. The
teeth are defective, and mastication and insalivation are neglected.
There is distress in the pit of the stomach or in the right
hypochondrium, beginning about two hours after eating and lasting from
four to six hours; intestinal distension with gas, either in the small
intestine or colon, with borborygmi and constipation, is generally
present. The nervous symptoms are characteristic: they are depression
of spirits, irritability, sleeplessness, vertigo, and {631} headache.
The man is more completely altered mentally than in gastric dyspepsia.
The urine contains lithates in excess; anæmia and emaciation progress
rapidly. Seminal emissions and weight and heaviness about the loins are
present.
The following symptoms distinguish gastric dyspepsia, and do not occur
in intestinal indigestion unless the stomach is at the same time
involved: pain or weight in the epigastrium immediately after eating,
vomiting of unaltered food, of food in a state of acid fermentation,
eructations of ill-tasting or bad-smelling gas or of acid fluid,
water-brash, and heartburn. Loss of flesh may not take place to any
extent even in very bad forms.
The diagnosis of differences in the forms of indigestion due to defects
in the pancreatic, biliary, or intestinal secretions is not at present
a matter of precise knowledge. A pancreatic indigestion would be
followed, it might be supposed invariably, by fatty stools; but such is
not the case, since degeneration of the pancreas and closure of the
duct have occurred without fatty evacuations from the bowels.[16]
Moreover, ulceration of the duodenum is followed sometimes by fat in
the stools. Still, if the symptoms of intestinal indigestion include
rapid wasting and fatty diarrhoea, we may conclude that the pancreas is
at fault. The fat varies in appearance and amount. It may be seen as
oil-drops passed alone or with fecal matter, or as lumps of fat, pale
yellow and tallow-like. Glycosuria[17] bears some relation to
pancreatic diseases, and therefore may be an aid in diagnosis.
[Footnote 16: Ewald, _op. cit._, p. 95; D. S. Haldane, "Cancer of
Pancreas," _Edin. Monthly Journ. of Med. Sci._, xix. 1854, p. 77; J. S.
Bartrum, "Scirrhus of Pancreas and Stomach," _Assoc. Med. Journ._,
1855, p. 564; DaCosta, "Primary Cancer of Pancreas," _Proc. Path. Soc.
Philada._, 1857, vol. i., 1860, p. 8; S. W. Gross, "Primary Cancer of
Head of Pancreas," _ibid._, vol. iii., 1871, p. 94.]
[Footnote 17: Bright, "Cases and Observation connected with Diseases of
the Pancreas," _Med.-Chir. Trans._, vol. xviii. p. 1.]
A deficient excretion of bile is indicated by a whitish or yellowish
coating of the tongue, with loss of appetite and bad taste in the
mouth. The stools are scanty, dry, slate-colored or white, and
offensive in smell. The urine contains lithates. The complexion is pale
or muddy. The nervous system is much deranged. The patient is languid,
often irritable and hypochondriacal. He complains of headache, and is
dull and drowsy after eating. The heart's action is unsteady,
intermittent, or frequent. It is impossible to recognize indigestion
due solely to a deficiency of the intestinal juice or to feeble
peristalsis, granting that such forms exist.
PROGNOSIS.--A fatal result does not follow directly from intestinal
indigestion. Its complications and results are frequently the causes of
death. Treated early and with decision, a cure can be expected.
Everything depends upon the extent to which the patient submits to the
strict directions of his physician; his whole life must be made
subordinate to the plan of treatment.
When the general health has become profoundly altered there is less
chance to do good. Discouraging symptoms are anæmia, debility,
coexisting gastric dyspepsia, an inherited hypochondriacal tendency, or
the strumous diathesis in children.
When the disease has so far progressed that the patient is unable to
{632} rouse himself to the point of wishing to be well, only the most
severe measures directed to the control of an irresponsible person can
save him from ruin. In organic disease of the pancreas, intestine,
liver, or heart the result will depend upon the nature and curability
of the lesion.
TREATMENT.--Acute intestinal indigestion due to the presence of
undigested food and gas in the intestine is treated by relieving
present distress and procuring a free movement from the bowels. A large
enema or a quick cathartic followed by an opiate--hypodermic injection
of morphia, paregoric, or other preparation--may give early relief. A
strict diet, warm poultices over the abdomen, and an anodyne may be
needed for several days after.
The integrity of intestinal digestion depends upon the normal
performance of all the preceding stages of digestion. Perfect
insalivation, mastication, and gastric digestion are necessary to a
proper action of the intestinal juices. The first rule of treatment in
the chronic form is to examine into the condition of the mouth and
teeth--to insist upon a slow and thorough mastication of food,
especially of starchy food. Mastication is under the control of the
individual, and he refuses to exercise this salutary means of
prevention and cure at his own risk. The habit of chewing on both sides
should be cultivated. All habits which waste and weaken the saliva
should be given up, as smoking, chewing, and needless expectoration.
Where the teeth are imperfect they should be attended to; false teeth
should replace absent ones. All means should be used for improving
gastric digestion: complete solution of food here means easier work for
the intestine, and sometimes the cure of intestinal indigestion by
removal of its cause. The rules which more directly bear upon the
subject of intestinal dyspepsia are these: All the causes which have
acted to bring about the disease should be removed. A change from a hot
climate to a cooler and dry one will sometimes have an immediate good
effect. Especially is this the case if travel is combined with change
of scene. The substitution of exercise for inertia, of fresh for
confined air, and the abandoning of occupations and habits of dress
which hinder the freedom of movement of the abdominal muscles are of
the highest importance. The patient should be made to cultivate
pleasure instead of work if his mind has been overtaxed in his
profession or business. Relaxation of the strained energies is
indispensable to recovery. This rule is as applicable to
school-children as it is to the overworked adult, man or woman. The
benefits of travel, with change of scene and air, cannot be
overestimated. Pedestrian tours in the mountains for young men, a trip
to Europe for men and women in middle life, will secure the best
results. For men who work much with their brains nothing is more
conducive to aiding intestinal digestion than manual labor in the
garden or workshop as a recreation. Exercise on horseback is
pleasurable and improves a sluggish abdominal circulation. Rowing is
good for younger men if it is confined to the field of pleasure, and is
not made a task. For very feeble persons, especially for women, massage
serves the purpose of exercise. The Swedish movement cure expands the
thorax and abdomen, hastens the circulation, and quickens all the
functions of nutrition and secretion.
A course of treatment would be incomplete without suggestions as to
bathing. Life at the seashore would be of little service without the
daily plunge in the surf. Still salt-water bathing is better for
children and {633} delicate women. The reaction should be thorough to
secure the best results. It is much to be regretted that hydrotherapy
is not available and is not made use of more generally. A well-managed
establishment where appropriate regimen and good and sufficient food
could be combined with the renewal of the tissues by bathing would be
of great advantage in all forms of indigestion. Nearly all of the
benefit derived from the Hot Springs of Arkansas in chronic cachectic
diseases follows upon the immediate improvement of the digestion and
nutrition. The Warm and Hot Springs of Virginia have an equally good
effect upon torpid abdominal functions. The Russian bath, the very hot
bath, the cold plunge, the cold douche to the back or abdomen, and the
cold pack to the abdomen, are means which may be employed at home for
inducing a revolution ending in reform in the state of the digestive
organs.
Irregularity in the hours of eating is of so much injury that rules
must be given to enforce uniform habits. Instead of the light breakfast
and heavy dinner, a good breakfast, a midday dinner, and a light tea
are to be preferred. It is of much value to regulate the appetite
according to the needs of the body and to avoid excess in everything.
In this disease eating too little or starvation to a moderate degree
gives that rest to the intestine which is necessary to its restoration
to health.
The selection of the food should not be left to the patient; the
dietary should be chosen for him with a view to lessening intestinal
labor. In general terms, this should consist of a moderate amount of
albuminoid food of the most digestible kind, and of farinaceous food
and fats in an acceptable and digestible form. In other words, as the
intestine digests proteids, starch, and fats, no exclusive diet can be
devised which will secure a perfect result. In each case the
examination of the stools and experience with different articles of
diet must be made the means for determining upon a suitable regimen.
The exclusive milk diet is the best starting-point in feeding a patient
suffering from acute or chronic indigestion. In addition to the fact
that milk has all the elements of a perfect food, it contains sugar and
fat in the most favorable condition for absorption; the casein of milk
alone requires transformation into peptone. The pancreatic juice has
the greatest activity in its effect upon milk, as is easily
demonstrated by the artificial digestion of milk by pancreatic extract.
In milk, therefore, we find a most easily digestible and most highly
nutritious food for such cases. Instead of milk with cream, skimmed
milk will be found sometimes to serve better the purpose of an
exclusive diet, because it has less fat and because larger quantities
can be taken without distaste or a sense of repletion. Koumiss may be
added to the milk diet; it is digestible, palatable, and nutritious.
The peculiar and very active diastatic ferment of pancreatic juice
converts starch into sugar very readily. Farinaceous articles of diet
can be added to milk with advantage. Digestion takes place more slowly
and more thoroughly in consequence, and an additional article of
nutriment is obtained. Thus, milk can be diluted with a thick gruel of
barley or oatmeal, or some of the best of the various artificial foods
can be stirred in. To the milk diet may be added animal broths or soups
prepared with vegetables, animal jellies, or some of the ready-prepared
beef-essences. They may not in themselves be highly nutritious, but
they contain at least {634} the salts of meat, and act as stimulants to
the appetite and to the secreting glands.
Such a rigid diet cannot be kept up for a very long time without
change; the appetite craves variety. Therefore solid albuminoid food in
small quantity may be added to milk and farinaceous diet. Sweetbread
boiled in milk, without dressing of any kind, is well suited for a
beginning of animal diet. Oysters for some palates make an agreeable
variety without putting much strain upon the digestive powers. They
should be eaten uncooked, as cooking in any way renders them less
digestible, and for greater precaution the hard part, or the adductor
muscle which serves to keep the two shells together, should be removed.
Fish boiled or plainly cooked and eaten without sauce is very easily
digested. White-fleshed fish which has but little fat incorporated with
the muscle-fibre is to be preferred. The patient may have eggs uncooked
or slightly boiled, but one to two daily will be as much as he can well
digest. The meat of poultry and game, especially that from the wings
and breast, may be given even in a very feeble state of the digestive
organs. When a more solid or satisfying diet is craved the patient may
have beef or mutton cooked rare. Tripe and rabbit are suitable to some
cases.
Bread, one day old and made light and porous, need not be denied the
patient. Toast disagrees with some. To many, well-made biscuits or
crackers are agreeable.
Vegetables should be given in small quantities, as the intestine is
almost solely the seat of their digestion, and excess will tax too much
a function which should be allowed as much rest as possible. The green
vegetables contain less starch, and are therefore to be preferred.
Lettuce, cabbage, kale, spinach, and celery come under this class, but
even these are to be given to patients under treatment in moderation,
with the intention of pleasing the palate rather than for purposes of
nutrition. Macaroni and rice are easily digested.
Fruit contains very little nitrogenous matter and much water, and
therefore has but little nutritive value, but it may be given to
relieve the tedium of a restricted diet of milk or broths. Grapes,
oranges, figs, strawberries, blackberries, raspberries, and peaches are
the most digestible. But fruit should never be given as food.
Fruit-juices, especially if acid and fresh, are unobjectionable. Coffee
should not be allowed; its effect upon the nervous system is sufficient
objection to its use. Tea can be given diluted largely with milk;
cocoa, racahout, and broma are nutrient and make pleasant drinks. Sugar
need not be excluded if used sparingly, and butter and oil in
moderation may be permitted.
If the stomach is not disturbed thereby, wine may be taken with food to
excite appetite. But except in the case of those who have always taken
it, and cannot do without it, it is better to dispense with alcohol
altogether. A red wine well diluted with water is a pleasant addition
to the meal. Old wine is to be preferred to new, as being softer and
less alcoholic. Good pure American wine from California or Virginia
will answer the purpose when reliable French wine cannot be secured.
The value of mineral waters in the treatment of indigestion is great,
but without proper dietetic regimen they can accomplish but little. The
good results following a visit to Saratoga, Bedford, or other
watering-place are due to other causes than the waters. In combination,
however, {635} with the advantages of change of scene, air, good hours,
and a simple diet the mineral waters aid in bringing about a cure. They
are especially useful in men who drink too little water at home, in
gouty and plethoric subjects, and in states of acid stomach digestion
and chronic constipation. The alkaline and saline waters are the best,
the former containing a notable proportion of the carbonate or
bicarbonate of sodium, potassium, or lithium--the latter having neutral
salts in considerable quantity.
The articles of food to be avoided are pastry, cheese, much butter or
fat, meat richly dressed or over-cooked, pork, veal, lobsters, crabs,
vegetable matter in excess, very cold or very hot fluids or solids.
All of the methods so far described are designed to accelerate the
circulation in the abdominal organs and in the tissues generally, to
quicken the secretory and nutritive processes, and to give to the
intestinal secretions the foods which they can most readily digest. In
the event of such means failing to accomplish the desired end, is there
any direct stimulus which can be brought to bear on the intestinal
glands concerned in digestion? The pancreas being the most active and
most important of these, it would be desirable to have some agent which
could excite its gland-structure to greater activity. Sulphuric ether
has been found to have this effect; it may be given before meals. The
salivary secretion begins pancreatic digestion (the digestion of
starch), and therefore its outflow should be stimulated at the same
time; but thorough mastication does this usually without need of
further aid.
When all plans fail to secure a thorough digestion in the intestine,
and unaltered food and fat are passed, while the patient grows thinner
and feebler daily, artificially-digested food may be given. The
intestine is thus relieved of labor, and time is given for a
restoration of activity by rest and an improved tone of all the tissues
and organs. Rice, bread, baked flour, potatoes, or barley may be given
in combination with malt extract, which converts starch into
grape-sugar and dextrin.