Columbia tEbtittntfftp tntljfCitpofilrttjgork THE LIBRARIES iflebical Htbrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/chronicdisordersOOvanv The Chronic Disorders of Tin: Digestive Tube BY W. W. VA~N VALZAH, A.M., M.D. Formerly Demonstrator of Clinical Medicine, Jefferson Medical College New Vork J. H. VAIL ,t CO. 1893 I \ < '.il'YRlCHT HV W. W. VAN VAI./AH, M.D. nisi or NEK, Ll»«« * CO. r« * f<. RE»DE ST., HEW YORK. PREFACE. This little book, with the exception of the chap- ter on habitual constipation, is made up of com- munications during the past year to the Journal of the American Medical Association, the New York Medical Journal, and the Medical Record. I have been persuaded to combine and reprint tin sse articles under one cover, in order to present to the profes- sion, in an easily accessible form, a short and practical study of the chronic disorders of the ali- mentary tract. Originally intended for serial pub- lication, no very great changes haA'e been found necessary to adapt them to the present form. Great pains have been taken to make each chap- ter complete in itself. This plan has both its advantages and disadvantages. It relieves the busy reader of the necessity of going through the book in order to find the author's treatment of a particu- lar disorder; but it also renders it impossible to avoid repetition of certain basic and controlling principles. The importance (in the opinion of the writer) of these principles is a satisfactory explana- tion and apology for their frequent statement. Y '& iv PREFACE. Popular opinion places seasickness among the disorders of the stomach. This contention is shown to be erroneous, and an attempt is made to explain the nature of this neglected disease. A justification for iis consideration under this title maybe found in the fact that to secure healthy digestion and motility before and during the voyage is the besl way to prevent the gastro-intestinal disturbances secondary to this peculiar sensory form of vertigo. No. i" East Forty-third Street, New York, December 1-1. 1892. CONTENTS. CHAPTER I. General Therapeutic Considerations, ... 1 CHAPTER II. The Chronic Disorders of Gastric Digestion, . . 13 CHAPTER III. A Clinical Study of Intestinal Indigestion, . . 4(5 CHAPTER IV. The Causation and Treatment of Chronic Diar- rhoea, sl > CHAPTER V. The Curative Treatment of Habitual Constipation. 102 APPENDIX. I. A Clinical Paper on the Treatment of Func- tional and Catarrhal Diseases of the Stomach and Bowels, 113 II. The Nature and Preventive Treatment of Sea- sickness, .... 132 THE CITRO'NTr DISORDERS DIGESTIVE TUBE. CHAPTER I. GENERAL THERAPEUTIC CONSIDERATIONS. The results of the surgical treatment of disease are palpable and often brilliant. The wonderful achievements and rapid advances of modern sur- gery are manifest, and its results can be built up into statistics that will not yield to scepticism's destroying touch. It is not so in medicine. Our great triumphs are in the prevention and control as well as in the cure of disease, and the entire good that we do cannot be known. The surgeon believes in the knife because he sees its power, recognizes its limitations, brings other powerful means to its aid, and proceeds, in a way often clearly marked out in every detail, to the accom- plishment of a definite purpose. The physician's l •„'. GENERAL THERAPEUTIC CONSIDERATIONS. scepticism is born of the obscurit)' of therapeutic results, faulty and narrow methods, and a failure to recognize the limitations imposed, by* the nature and stage of the morbid process. I'>ui we do more than we know, or are able to explain. We are powerless at the bedside only when therapeutic ni- hilism has boldly swept away every landmark and light, [n the hour of transcendenl need the physi cian, standing in the dim twilight, bends forward into the darkness to cure, to strengthen, and to bless. In the chronic disorders of the digestive tube scepticism finds an almost impregnable stronghold, well barricaded by professional and popular opinion againsl successful assault. These troubles rarely disappear in the course of nature, for they pO£ an inherent power of self-perpetuation, and many physicians seem to have a little too much faith in the unaided power of drugs. These invalids too frequently fail to get the slightest benefit from the few magical prescriptions of even the best and greatest men of our profession, and turn to folk- lore for relief, and a little later a few more victims are added to the list of the consumers of the many patent medicines "good for digestion and the liver, and diarrhoea and constipation." And thus oui profession falls into disrepute. It might be well to prescribe a little less medicine, and he a little more explicit and full and emphatic in orders concern ing hygiene and dietetics. Drugs, by affording an excuse for the neglect of other more powerful n-u)t- dies, too often become the world's grave-diggers; and this little book Bhall not accomplish its purpose GENERAL THERAPEUTIC OONSIDKRATIONS. » if it fails !•' establish the essential utility of rigid living and a proper diet in the treatmenl of the chronic disorders of digesl ion and nutrition. Medi- cal practice knows no more brilliant results than those obtained by the right management of these diseases. But the treatment must be well defined, comprehensive, and thoroughly and systematically carried out. It may bo well to go into detail and define the basis, purpose, and some of the necessary limitations of the therapeutics of these chronic dis- orders of the alimentary canal. Disease is in its primitive nature a perversion of force which determines the fixed pathological changes and often dominates the symptomatic ex- pression. This fundamental truth must be recog- nized before therapeutics can claim to be a science rather than an art based on the contradictory testi- mony of experience. Curative therapeutics must go beyond the symptoms and morbid tissue changes to the disturbance of the normal relations that cells, or aggregate of cells, or the organism, bear to their environment. It must not be directed solely against the symptom group, nor be controlled by the mor- bid anatomy alone, nor find its only guide in the perversion of the physiological processes. The chronic disorders of digestion and nutrition are, in their incipiency, the expression of either a chemical lesion of the fluid in which the cell lives, or a nutri- tive defect in the structure and composition of the cellular protoplasm. It is the alterations of tbe composition of the fluids of the body, and the con- sequent indefinable defect in the structure of the cellular protoplasm so intimately related to the un- I GENERAL THERAPEUTIC CONSIDERATIONS. healthy variations in the functions of the cell, which make up the canvas <>n which the clinical picture is painted in the colors of morbid anatomy. Tt is the faulty assimilation of imperfectly prepared nutrient material, as embodied in a badly constituted proto- plasm, thai gives the progressive quality to these dis- orders, and the one hope 6f relief and the -rand pur pose of treatment is to secure in some way a better quality of cellular content s ; to corrert tl lis nutritive defect. This cannot he done by starvation any more than it can he accomplished hy forced feeding. It is the combination of means that will remove as well as build up, that break down as well as regene- rate, which will yield a permanent result. An ex- t reme nicety of the digestion and of the preparation of the nutrient material, its proper distribution to the tissues by the blood, the quick solution and re- moval of waste products, and the conservation of nerve force, place the cell in an environment which is most favorable to its nutrition and life. The promotion of a high degree of healthy nutrition is the one essential purpose ; and, in the present state of knowledge, cell life can be appreciably influenced or controlled only by modifying its environment. A treatment based on this principle is causative and (inative. and scorns a plan that only aims to secure the suppression of symptoms. As we have already seen, these chronic disorder- arise from the persistent and almost imperceptible disturbance of the continuous adjustment of rela- tions as manifested in the life processes — the inte- gration of structure, the evolution of force, or the elimination of waste products. The diatheses are GENERAL THERAPEUTIC CONSIDERATIONS. 5 ■examples of these evil tendencies indelibly stamped upon the organism in the process of its making, and may manifest themselves directly or indirectly, through nerve or blood or lymph changes, as dis orders of the digestive system and its appended glands. Now it is a predisposition to the develop- ment of lowly organized cells — a defect of nutrition in which the power of assimilation is in abeyance — a vice of constitution in which the tissues yield readily to incident disturbance and have little con- structive power ; of such a nature is the inherited nutritive dyscrasia which forms so favorable a soil for tuberculosis. Now it is the fibrous tissue which shows the evil tendency and stamps the organism with the fibroid diathesis. Or it is a hgemic or he- patic state that manifests itself as rheumatism or gout. Now it is a fault of the more highly evolved nerve centres, and the patient falls a victim of some neural disorder or is skilfully conducted through life on a sleeping volcano. Or it may be some de- fect of elimination which permits the accumulation of some such waste product as uric acid in the sys- tem. These evil tendencies, when inherited, which underlie many cases of disordered digestion, can- not be completely eradicated by treatment, and our purpose in therapeutics is limited to the prevention or control of the manifestations. Again, the treatment of these chronic disorders is limited by destruction, degeneration, and atro- phy of the anatomical elements, and by deformity. In acute disease the incident disturbance falls directly on the functionating cells, which recover or redevelop more or less completely when the morbid 6 GENERAL THERAPE1 PIC CONSIDERATIONS. influence passes away ; or function is perverted by tin- compression of unorganized inflammatory pro duels. In chronic disease the cells are sometimes involved indirectly by the formation of new tissue and by compression. The new connective tissue may simply irritate, but it usually contracts from and dies itself and destroys other neighboring tissue. A cure is possible only in the formative stage, when the chronic productive inflammation may resolve. Therapeutics is thus limited by the nature, relations, and age of the pathologically formed tissue. Chronic disorders, again, often arise from de- generation or atrophy or deformity. The persist- ence of the symptoms is clue to the persistence of the damage done by former disease. We can do nothing in a medical -way to remove the cicatricial stenosis of the pylorus or stricture of the bowel. When chronic disease falls directly on the anal i mi i cal elements of an organ, it is commonly a degene- rative or atrophic process, and if the cells be repro- duced they are imperfectly and lowly organized. When gastric atrophy occurs from age, little can be done to stay the progress of decay, for it is usu- ally accompanied by a like condition of the duode- num and of the other viscera ; life slowly dissolves beneath its burning rays. But when atrophy occurs in the developmental or vigorous periods of life, as in the gastric atrophy following typhoid fever, or the intestinal atrophy resulting from prolonged dis- tention by the gases of organic fermentation, treat - nient is limited but of some avail. An accurate anatomical diagnosis defines and limits therapeutics. GENERA L TIIKi; A PEUTI< ( fONSIDERATIONS. Having briefly indicated the primitive nature and the basis of the cure of these chronic disorders, and advocated the necessity and the utility of a well- defined and comprehensive treatment, turn we to a consideration of the remedies to bo systematically employed. Our therapeutic purpose in chronic disease is never so narrow as the prescription of this or thai drug ; it is the combination of many means to meet complex indications, the treatment of the whole man as disturbed by disease. As we grow old and gray in the service of our calling, the less do we rely on drugs alone. By the proper use of drugs we can often snap the thin-spun thread of evil se- quences, and we will not be persuaded to cast away means of such power and precision. I believe our object is best accomplished by a systematic combi- nation of remedies. And our first aim should be the promotion of a high degree of healthy nutrition with a view to increasing the resistance and activ- ity of the tissues and to securing physiological cell structure ; and, secondly, the regulation of the pa- tient's life and diet with a view to the readjustment of the damaged organism to vital demands ; and. in the third place, the rational use of drugs as based on their physiological actions and as confirmed by clinical experience. This forms the great tripod of treatment. If one will take the trouble to turn through medi- cal literature he will be surprised to learn the con- spicuous part which has always been assigned in aetiology to " impairment of the general health." In many cases of acute disease the most robust const i- 8 GENERAL THERAPEUTIC CONSIDERATIONS. i in ion yields to the shock of the violent onset. It is, however, more of ten the weak and tired who are forced to the wall. But a well- nourished body not only resists invasion; it also limits and conditions and controls the morbid process— has a curative power. A problem to solve in all of these chronic disorders is the problem of nutrition, and upon its solution depends the possibility of relief. And it is n«»l ci i. M i-l i to adapt the quant it y and quality of the food to the vice of nutrition we wish to correct or the state of nutrition we wish to establish, though this is oi' very great importance. It is not enough to adapt the quantity and quality of the food to the present state of nutrition, the capability of the di- gestive organs, the activity of the emunctories, and the evolution of force as conditioned by habits of lite and environment— though if this he nol don. success will rarely crown our efforts. But the pa- tient must he kept under daily supervision, and the physician must see that the diet is fulfilling its Hum apeutic purpose, and readjustments be made to meet the varying indications afforded by the clinical guides to nutrition and digestion. The ability to use one's knowledge in the treatment of disease Is a distinguishing mark of the practical physician. In tin' chronic disorders of the digestive tube it is sential to have it made clear to us how the food is being worked up and utilized in each particular case. This cannol be easily determined with exact ness ; our guides are not absolute, because our knowledge is not complete. Rut this is no reason why we should not employ them so far as we know t hem worthy of trust. I could just as willingly and GENERAL THERAPEUTIC CONSIDKRATI0N8. V easily dispense with physical examinal ion in 1 he l' victory. In the management of chronic disease tacl and common sense are worth almosl as much as medi cal knowledge. The course is a long one and tests the endurance of the physician. Such is the soli darity and such arc the intimate relations of the nutritive processes that an unhealthy variation of olio soon forces theothers to fall into harmony with it : consequently these disorders are not self limited, hut progressive. And it requires as much time to re-establish the normal state as to arrest and correct the primitive perversion of force. I would empha- size the importance of Long-continued supervision and minute instructions. The physician, as doc-- 1 lie surgeon, succeeds most often when he is a strict observer of detail, when he knows and remem- bers and does little things. My plea is for a broad and comprehensive and well-defined therapeutics ; a plea for the paramount importance of hygiene and dietetics; a plea for the considerate use of drugs; a plea for the bedside >1 ndyof this highest comportment of medical knowl- edge in which science and art lie down together. CHAPTER II. THE CHRONIC DISORDERS OP GASTRIC DIGESTION. The clinical therapeutics of the diseases of the stomach is a subject of great practical importance. The diseases of no other organ come more fre- quently under the care of the physician, produce more annoyance or suffering, and yield more surely to judicious treatment. This chapter on the chronic disorders of gastric digestion is not intended to be an exhaustive one. ^Etiology, pathology, and symptomatology will be considered only in so far as they bear on differ- ential diagnosis and treatment. The cure of any chronic disease is largely comprised in its aetiology, and a correct diagnosis is an essential preliminary to rational treatment. It is not often possible to make a complete ana- tomical diagnosis of a disease of the stomach. Moreover, morbid anatomy is only a symptom, and a lesion of the mucous membrane is not always present. Neither is an ^etiological classification practical. The same cause may originate a variety of disorders. Alcohol may produce hydrochloric superacidity or subacidity, or gastritis. Tuber- culosis may be accompanied in its early stage by chemical or motor insufficiency of the stomach, with cough and vomiting from the irritation of the II CUKoNli' l>lsoKl>KKS <>\- i.AVI'lill DIGESTION. supersensitive ends of the vagus by the food. The inadequacy is uol due to a gastric Lesion, but to tubercular toxaemia. Hydrochloric superacidity sometimes aids in the preparation of the nutritive soil. Gastritis with a raw and fiery tongue, an- orexia, ami diarrhoea is the form which belongs to advanced phthisis. Chronic digestive disorder, with and without a Lesion of the mucous membrane, -'•.ins to be the most useful general classification. However closely dyspepsia, in the end, may be associated with errors in diet, the derangement of 1 1 it- process of digestion is nearly always due, iii the beginning, to disturbance of cell secretion or to im- paired muscular movements. There is no Lesion of the mucous membrane. Ih'iic- dyspepsia may be briefly defined as gastric insufficiency without al- tera! inn of structure. The impaired movements and defective secretion are the local manifestations of a constitutional state. "Who would find the cause of dyspepsia must look beyond the stomach to the thin and im- pure blood, to the weak and tired nerve centres, to impaired cell activity throughout the body. Per- verted secretion is often the result of defective cell nutrition. The fault may lie in the lack of tissue- forming material in the blood; or this important nutritive fluid may be surcharged with the pro ducts of defective metabolism, or with poisonous materia] absorbed from the alimentary canal or left in the circulation in hepatic or renal insuffi- ciency. Thus we find it in the anaemias, chloro- sis. p>ut. chronic rheumatism, lithaemia, malaria. syphilis, and chronic nephritis ; or it may prove to CHRONIC DISORDERS OF GASTRIC DIGESTION. L5 be the legacy of former acute illness or infection disease. Tuberculosis and alcoholism are also com mon causes. But the chief factor in the causation of dyspepsia -always present, always active, affecting either secretion or muscular movement, or both i impaired nerve supply. This weakness or perver- sion of the regulating or controlling action of the nervous system may be of central origin or re- flected from a distant or functionally associated or- gan. The great clinical masters have often noted the frequency with which dyspepsia occurs in the neurotic; — an individual with congenital instability of nerve. The part that heredity plays preponde- rates ; but impaired innervation is not rarely the result of the reckless perseverance and unrest of modern life. Dyspepsia finds many a victim on the rugged highway along which honors lie to be gath- ered and worn. Sudden reverses of fortune, in- tense emotion, moral shock, great sorrows, the prolonged strain and often intense agony of the critical periods of life, leave exhausted nerves and dyspepsia. These patients are all primarily, or as a result, neuropathic. Nothing further need be written, we hope, to impress the principle that, if we wish to cure dyspepsia, our therapeutic purpose must reach beyond the stomach to the underlying defect of constitution, or vice of nutrition, or patho- logical nerve state. But this is not all. Defective alimentation — over- eating, improper food. and. indirectly, starvation through exhaustion of the nerves of organic life — must be considered as a possible cause by destroying the equilibrium that obtains in health between the l(j CHRONIC DISORDERS OF OASTRIC DIGESTION. quantity of gastric juice secreted and the chemical work required of it. Thus the stomach is unequal to its task. An excessive use of the carbohydrates is a well-recognized cause of lithaemiaandof neuras thenia, and these originate dyspepsia through their depressing psychical states ami the exhaustion of the nerves presiding over secretion and muscular action. There is, however, no satisfactory reason for doubting thai errors of diet always give rise, al all events in the beginning, to the lesions of gasl ric catarrh. Chronic gastritis is frequently the sequel of dys- pepsia. It often follows the acute disease, which is only rare because it is not recognized. Occasional transgression of dietetic laws seldom results in per- sisted pathological changes. Habitually recurring patchy congestion, initiated by some mechanical or chemical irritant contained or developed in the food, may not subside while the stomach is taking it- rest, and the tissues and nutritive processes are moulded into conformity with the morbid condition. Passive congestion of the stomach in disease of the liver. Lungs, heart, or spleen, or from venous ob- struction by the pressure of a tumor or enlarged gland, is accompanied by the secretion of a large quantity of mucus and a diminution of hydrochlo- ric acid, and undue fermentation with its conse- quences results. Aineinia with its weak heart act- in a similar manner. Chronic gastritis may he sec- ondary to renal disease, or form a part of the his- tory of arterio capillary fibrosis. Not a few of the most obstinate cases have for their cause an endar- teritis of loiii;- standing, or amyloid defeneration CHRONIC DISORDERS OF OASTRIC \)U I KSTlnN. L7 from exhausting purulent formation. Again, ;< naso-pharyngeal catarrh or bronchitis may initiate and food the fermentative process by the decom- posing mucus or pus finding its way into I In- i<> mach. The successful management of chronic gas- tritis depends largely on the detection and removal of the underlying cause that gives its type to the disease. Gastric ulcer is a common lesion. It is pre-emi- nently a disease of women, and is usually preceded and accompanied hy a disease of the blood, such as anaemia, chlorosis, or the thin blood after labor ; by diminished alkalinity of the blood, as in oxalu- ria and uricaemia ; and hy hydrochloric superacid- ity of the gastric juice. Virchow's theory that the simple ulceration results from the plugging of the nutrient artery of the part and digestion of the in- farct, seems to satisfactorily explain many cases. The endarteritis, thrombosis, or embolism may be the consequence of the diminished alkalinity and the fibraemic state of the blood. Syphilis and tu- berculosis are well-known causes of the specific ulcers. A predisposition to cancer is inherited ; its devel- opment is supposed to be excited by chronic irrita- tion, and, probably, by a specific germ. Atrophy of the gastric glands is due to paren- chymatous or interstitial inflammation, to acute or chronic degeneration, to infectious or wasting dis- ease like typhoid fever or tuberculosis, and to innu- trition from prolonged distention or extreme dila- tation of the stomach. Chronic inflammation, ulceration, cancer, and atrophy are the lesions of L8 CHRONIC DISORDERS OF GASTRIC DIGESTION. the mucous membrane which often accompany the chronic disorders of the digestive process. Bui gastric inadequacy is nol always manifested in morbid tissue changes. What are the varieties of dyspepsia, and in wiial way can we deted the un- healthy variations from tin- physiological process i The modern methods of examining the gastric juice are familiar to the profession and o 1 not be reviewed in tins short chapter. Always of value, the analysis is in some cases essentia] to a correct secre tory diagnosis, and often enables us to see where we could only guess at the truth. It is a useful guide in the administration of drugs to supplemenl the gastric juice. But it is too great a burden to the physician and too disagreeable to the patient to become popular with the profession. Stomachal chemistry is of very great scientific interest, is an aid to treatment and diagnosis, but it is n<>1 so easy, nor so essential, nor so clear in its sugges tions (the inferences drawn from it are remarkably contradictory) as to allow one to conscientiously urge its general adoption. A word of warning should also here be given. Stomachal chemistry is reducing treatment to a very simple formula — hj drochloric superacidity demands alkalies in large doses, subacidity indicates the administration of hydrochloric acid. We shall see, a little further on, how narrow and irrational is this method of treat nient. Again, it is assumed that a certain secre tory defect is so indelibly stamped on the mucous membrane that it continuously goes wrong in tin- way and in no other. This is a general truth ap- plicable to the grand types. But no other organ is CHRONIC DISORDERS OF GASTRIC DIGESTION. 19 so fantastic and variable in its work as fche sto- mach- a thought, a feeling, an emotion may infln ence it ; and to a degree its secretion changes with every varying stimulus or nerve sl.it <■ or blood supply. The most important constituent of the gastric juice, from a pathological point of view, is fche hydrochloric acid. It is not the state (combined or free) of the hydrochloric acid, but the quantity se- creted by the mucous membrane, that is the guide. A large quantity of albumin requires only a very small amount of pepsin for its hydration in a proper medium ; and it has not been demonstrated that too little pepsinogen is ever secreted in any other condi- tion than glandular atrophy. Theoretically this is true, but practically the administration of pepsin is of great utility when it is necessary to prescribe a largely nitrogenous diet in glandular atrophy, com- bined with hydrochloric acid, and without hydro- chloric acid in defective absorption. The presence of a large quantity of peptones arrests peptoniza- tion, but the process of hydration recommences on the addition of a new supply of pepsin. The ab- normal quantity of hydrochloric acid secreted is the index of the disturbance of the second and prepara- tory stage of the successive development of the di- gestive process, which reaches its climax of chemi- cal changes in the intestine. But from a clinical point of view gastric motility is even more impor- tant than gastric secretion. When the movements of the stomach are perfect and the pylorus does its work efficiently, there are no gastric symptoms un- less the mucous membrane be supersensitive. The •.'(• CHRONIC DISORDERS OF CiASTRIC DIGESTION. stomach does a grand chemical and preparatory work of its own in peptonization, uncovering starch, liberating fat, and unbinding muscular tis sue; bul it is its duty also to proted the duodenum and fco dispense to it slowly and within the righl time the properly prepared and well-mixed chyme. h is "ii the unhealthy variations of hydrochloric arid and the abnormal muscular movements of the stomach thai we have found it of mosl value at the bedside to base the classification of dyspepsia, and it is accordingly as these two factors arc increased, diminished, or irregular that a deviation from the state of health can he said to exist. (iastric dyspepsia with increased formation of hydrochloric acid is usually associated with one of the neuroses, and occurs in two varieties — super acidity and supersecretion. In simple superacidity the fasting stomach is found empty ; in continuous supersecretion the stomach in the early morning, before eating or drinking, contains one or more ounces of gastric juice, which may or may not be superacid. Both predispose to gastric ulcer (mark- edly so in anaemic women), and are frequently ac- companied by dilatation from pyloric spasm and organic fermentation, and sometimes also by down ward displacement of the stomach and of the first part of the duodenum. The hydrochloric acid may he secreted in such quantity and so rapidly as to at once stop the action of the saliva, which should continue in the stomach from tvn minutes (Ewald) to half an hour (Van den Velden). Organic fer- mentation docs not occur unless -as may happen when dilatation and more or less atrophy are pre- CHRONIC IHSORDIOKS OK OASTRIC DIGESTION. 21 sent — the hydroehlorie acidity falls below ".7 per cent. Tliis is theoretically line, as may be demon- strated in a test tube ; hut, clinically, in the sto- mach we not infrequently find organic fermenl and fermentation when the gastric juice is super acid from excess of hydrochloric acid. In simple superacidity the appetite is increased; eructations are extremely acid, but usually without much gas ; epigastric pain is paroxysmal and severe, comes on soon after meals, and is often relieved by the inges- tion of water and nitrogenous food. Proteids and albuminoids are rapidly digested when the food mass is small and permeable, the fats are partly decomposed by the free hydrochloric acid and the fatty acids give rise to heartburn, and intestinal di- gestion is delayed or arrested by the superacidity of the chyme. Diarrhoea is often present. The stomach wall is tonically contracted with painful peristaltic waves. The urine is quite alkaline dur- ing digestion, but regains its normal acidity, or may become excessively acid, in the interval. In super- secretion the appetite is variable ; eructations are very acid, often fetid and gaseous ; pain is more or less continuous, becoming paroxysmal (immediately or) about three hours after meals and about 3 o'clock in the morning, and is almost completely relieved by vomiting. Gastric digestion is slow and imperfect, and gastric absorption is very much di- minished. The vomit is sour, often foul and of acetic odor, and contains organic ferments and un- digested food eaten a day or two before. The signs of dilatation are present, the greater curvature is on a level with or below the umbilicus, and morn- '.'•J CHRONIC DISORDERS OF GASTRIC DIGESTION. ing splashing and sometimes seething are easily eli- cited. The stomach may be distended and the pylorus displaced downward, and small quantities of bile frequently regurgitate, or in other cases (which are somewhal rare) almost continuously flow, into the stomach. Constipation is the rule, but morning diarrhoea is not rare. The urine is almost continuously alkaline ami precipitates the phosphates. These varieties seem to be stages (the duration of which is very variable) in the orderly develop- ment of one disease. What is the probable ex- planation? The digestive disturbance seems to be- gin with supersensitiveness of the nerves of the mucous membrane and consequent excessive toni- city and excessive (and sometimes continuous) se- cretion through over-excitation of the motor, vaso- dilator, and secretory nerves. Dilatation here does not result from atonicity of the muscular coat. Its pathogenesis is the same as the dilatation above an intestinal stricture, the same as 1 he dilatation of the left ventricle in aortic stenosis, the same (and the analogy is very close) as the dilatation of the l.l.nl del' t'i( mi excessive i nit a I tility of its neck or of the deep urethra. The pylorus, the powerful auto- matic protector of the duodenum, contracts and obstructs; the gastric "walls become irritable and hypertrophy ; fermentation and distention and loss of compensation and dilatation supervene. Dimin- ished absorption, mucous catarrh, destruction or atrophy of the gastric glands, and diminished secre- t ion complete the picture. Ulceral ion may occurat any stage. On this interpretation will he based the CHRONIC DISORDERS OF GASTRIC DIGESTION. '.':! curative treatment, so far as it depends on the ad- ministration of drugs. Dyspepsia with diminished formation of hydro- chloric acid is met with most frequently in individ uals with "weak stomachs." Digestion is slow and the lactic-acid stage is prolonged. The excess of lactic acid is formed from the sugars (and in sni.ill quantity from the starches) through the agency of numerous fermentation organisms; it may be split up into water, butyric and carbonic acids, and hy- drogen. The hydrochloric acidity, even at the li eight of digestion, does not often rise above 0.7 per cent. A little too much work or mental worry and a little too much food suffice to derange the digestive process. The flatulence and acidity are most marked two or three hours after meals. Irregularity in the secretion and muscular move- ments of the stomach is due to sympathetic disturb- ance. The stomach, through its complex nerve connections, is in intimate relation with nearly every organ in the body. Habitual speedy vomit- ing without preceding nausea is nearly always re- flected. The gastric disturbance comes on suddenly and without warning, and varies in kind from day to day. In individuals with impressible nerve centres and weak inhibition the stomach is the organ toward which every little local storm seems to wend its way. Exaggerated muscular movement of the stomach is a rare derangement of the process by which food is made ready for assimilation. The pathological unrest falls primarily on the muscular layer. The exaggerated peristalsis commonly extends to the ■J I CHRONIC DISORDERS OF GASTRIC DIGESTION. inteBtine, the two being intimately associated in their movements a principle utilized to excite a free discharge of bile and to cause a dilated stomach to empty itself by means of the cold-water enema, and imt only the solution bul the absorption oi aliment is prevented. It is often associated with hyperses- thesia of the mucosa and a ravenous appetite and obstinate insomnia. Gastric atony incidental to a state <>f weakness and relaxation of the whole muscular system is a common gastric defect. Brain workers who lead sedentary lives furnish the Largest number of its victims. The muscular layer lacks tone and peri- staltic movement is weak. The face wears an ex- pression of fatigue ; the heart is weak and irritable, and arterial tension is low : the muscles of the throat are flaccid — there is a general want of tone. The gastric juice is normal ; digestion is slow, but complete if not interfered with by fermentation. The appetite is unimpaired and the bowels are con stipated. A sensation of uneasiness rather than of distinct pain ; a feeling of weight or heaviness from long-continued pressure of the food on the same spot; flatulence from muscular weakness and vaso- motor relaxation (as in the intestinal paresis of peri- tonitis), or from regurgitation of gas through the open pylorus— complete the clinical picture. The extreme nerve-tire explains the want of muscular tonicity, and the weak stomach, on account of the prolongation of its labor, gets little rest. Unless the process he controlled hy judicious treatment and the organ and system strengthened, extreme dila tation will surely supervene. These patients are CHRONIC DISORDERS OF GASTRIC DIGESTION. i~> only cured by the combined treatment of digestion, nutrition, andthe nervous system. II isa profound error to throw them into the greal drag-net — neu- rasthenia. There is another form of gastric atony that fre- quently comes under the care of 1 he physician, and which dates its beginning in early life. One cannot closely study these cases without detecting hcred- ity's powerful hand in their development — a variety of the " weak stomach " in which the inherited or early acquired or early manifested defect falls on the muscular rather than the secretory system. The muscular layer is undeveloped, atrophic as well as atonic, and peristaltically weak. Atrophy of the gastric and intestinal glands may rapidly follow dilatation, and death from malnutrition close the scene before the morning of life has passed ; or the curse may be suspended while the years roll by, un- til finally the sword falls and " slits the thin-spun life/'' The stomach may be strengthened by care- ful feeding, but the vice of constitution is irremedi- able. Dilatation in either form of gastric atony is com- monly associated with a like condition of the large (and small) intestine. Malnutrition of the local ganglia in all probability has something to do with the glandular atrophy. In no other condition do the symptoms of auto-infection become so promi- nent. The epithelium throughout the alimentary canal is lowly organized, and here and there the wall is as thin as parchment and free from glands. These pouches (favorite sites of which are the cae- cum and hepatic and splenic flexures of the colon) 20 CHRONIC DISORDERS OF GASTRIC DIGESTION. are filled with decomposing and fermenting faeces. The peptones fail to be reconverted into serum al- bumin, and the emulsified and split-up fats cannot be built up into glycerin neutral fats on their way through the mucous membrane to the centra] lac- teal or blood vessel. Absorption is imperfect, un- selective; assimilation is disordered and nutrition fails. Emaciation is marked, and the products of fermentation and decomposition and Incomplete di gesl ion absorbed from the alimentary canal congest the liver, irritate the nerve centres, and inflame the kidneys. Hysteria, insomnia, or a demon-like mel- ancholy which no effort can throw <>\'i' fastens itself on the victim. The clinical history, self-infection, the absence of hypertrophied walls and visible move- ments, easily exclude dilatation from pyloric ob- struction, functional and organic. Three methods have been suggested, apart from the clinical history, subjective symptoms, and phy- sical signs, to aid in the diagnosis of motor insulii cieney. A pint of olive oil (Klemperer) is intro- duced, and what remains of it in the stomach after two hours withdrawn. The difference represents the quantity that has gone into the duodenum. The objections to this method, and the liability to errors, are too great to allow serious consideration. Of more utility is the salol test, if the kidneys are sound and the read ion in the duodenum is alkaline. In health salicyluric acid appears in the urine in balf an hour (Ewald and Sievers), and disappears in twenty-four hours in health, thirty-six hours in atony, and forty-eight hours in dilatation iSilher- steint. The third and a verj 'j;>»"\ method is to CHRONIC DISORDERS OP GASTRIC DIGESTION. 27 administer Leube's test meal or Ewald's test break- fast, and examine the contents of the stoni;i.ch at varying periods thereafter. The differential diagnosis of dyspepsia and chronic gastritis requires close study and careful reasoning. The two diseases merge into one another, and in vague cases without clear-cut features it is difficult to learn at the bedside with which form we have to deal. The history of the case, the order of appear- ance, and duration of the symptoms must be taken into consideration in the formation of a conclusion. The known nature Of the disease to which the gas- tric disorder is secondary may help to clear up the obscurity. A careful chemical or microscopical examination of the blood, of the gastric juice, and of the excretions will always prove of value. The local signs of chronic gastritis are persistent, while those of dyspepsia are intermittent and ca- pricious. The pain of chronic gastritis is more severe when the stomach is full ; in dyspepsia it may occur only when the stomach is empty, and be relieved by taking food. Violent paroxysms of pain in chronic gastritis are made worse by pressure ; in dyspepsia firm pressure may give relief, and an interval of comfort follows each attack. Repeated vomiting of mucus, or of mucus mixed with undi- gested food, is pathognomonic of catarrhal gastritis. Increased hydrochloric-acid formation is present only in dyspepsia ; in chronic gastritis the quantity of hydrochloric acid is diminished. This is true as a general rule. In the beginning of gastritis the irritable mucous membrane not rarely supersecretes a superacid fluid ; this is particularly true if the 2S CHRONII DISORDERS OP GASTRII DIGESTION. gastritis be the sequel of a secretory neurosis. Thirst, uausea, and anorexia are more frequently linked to an alteration of structure. In certain mild forms of gastric catarrh a morbid sensation, closely allied to the sense of hunger and radiating backward between the scapulae, recurs at regular intervals; its disappearance on the taking of the first mouthful of food is followed by nausea; the slighl irritation of the food seems sufficient to pro- duce dilatation and stasis of the Mood current in the previously hyperaemic mucosa. In simple ca- tarrhal gastritis there is excessive secretion of mucus. The symptoms vary very much with the extent and destructiveness of the inflammatory process, with the degree of glandular atrophy and dilatation. The dilatation is mechanically produced by the accumulating mass of fermenting food, or by infiltration of the muscular layer by inflamma- tory products ; when well marked its diagnosis pre- sents no difficulty. It is not on any one sign, bul on the symptom group and the results of the ex- amination of the contents of the stomach, that the diagnosis must he based. The diagnosis of gastric atrophy can he based with certainty only on the long-continued absence of hydrochloric acid, pepsin, and the lab-ferment, as proved by repeated examination of the gastric juice. If there be no stasis of the food mass in the stomach, the duodenum may completely supplement the gastric insufficiency and no symptoms of dys- pepsia make t heir appearance. The symptoms of ulceration are those of super- acid dyspepsia — local pain, hsematemesis, and local CHKONIC DISORDERS OP GASTRIC DIGESTION. 29 tenderness. The tender spot, is usually circum scribed and Located a few inches below (and to the left of) the tip of the ensiform cartilage; ils dia gnostic features are its strict Localization and it- persistency. The pain of the accompanying super acidity is relieved temporarily by food and drink ; the pain of the ulceration is increased or excited bj eating. Haemorrhage, if it occurs, is usually pro- fuse : care must be taken to exclude acute inflam- mation, portal obstruction, cancel-, and toxaemia. Enlargement of the spleen is also accompanied by gastric haemorrhage. In hepatic cirrhosis the blood may come from rupture of a dilated oesophageal vein. Ulceration may occur at any age, is of indefinite duration, irregular in its progress, and is often relieved and cured by treatment. Even with the aid of a complete clinical history, of the subjective symptoms and the physical signs, we may be un- able to state whether ulceration is or is not pre- sent. Perforation may be the first and only sign. Sudden and large intestinal haemorrhage (large, tarry movements), preceded by paroxysmal gas- tralgia, extreme pain in the right hypochondrium. and more or less duodenal dyspepsia of long stand- ing, are the symptoms of duodenal ulcer. In gas- tric ulcer the constitutional state is proportionate to the digestive disorder. In cancer the patient is above -10 years of age ; haemorrhage is small and slow ; there is rapid and progressive decline, and cachexia ; hydrochloric acid soon permanently disappears from the gastric juice ; a tumor may be felt ; treatment gives little relief. 30 CHRONIC DISORDERS OF GASTRIC DIGESTION. ;iinl tlif constitutional state is oul of all proportion fco the disturbance of gastric digestion. The exacl diagnosis of disease lias its peculiar charms; at all events, in difficult cases it is the floweringof medical science. Bu1 after the flow- ers should come the fruit. Turn we now to treat in. 'lit -t.> tin 1 consideration of the moral manage in. 'lit. h\ -'inn', diet , and medicinal agencies which clinical experience lias shown to be of value in the palliation or cure of the chronic disorders "I" gastric digest ion. The moral management of these diseases has not received the attention that it merits. We wish t<> urge its importance in the cure of those cases in which the weakness or derangement of the central nervous system is well marked when this state is a primary a etiological factor. In the cure of neu- rasthenic dyspepsia it is the keystone to the arch; it is the one means of rolling away the cloud that darkens the pathway of the neurotic. These indi- viduals have no will power or reserve force, and in no other way can we aid them in throwing off the delusion that they are incurable. It is our duty to make every endeavor to impress the patient with the fact that his case is thoroughly understood. A correci anatomical and pathological diagnosis will enable the physician to state with precision what can be done. Firmness and kindness of heart are the means of winning confidence. Faith, inspired by truth, honesty, and manly bearing, stimulates and tones the nervous system and unbinds the will. No one doubts the power of expectant attention. Digestion is dominated by the nervous system, and CHRONIC DISORDERS OF GASTRIC DIGESTION*. 31 the centres controlling secretion and muscular move ment are re-represented in the cortex. The physi cian who fails in the moral management loses an essential aid in the cure of these chronic cases. Not the moral management alone is of import- ance ; the life of the patient must he on a physio- logical basis. Insist on slow and regular eating, and not too great a variety. The stomach is only confused and disordered by course dinners. A resl of half an hour before and an hour after each meal is a duty. Clothing should receive consideration, and in our climate the whole abdomen should be protected at all times by a knitted bandage of wool, wool and silk, or silk. The elasticity supports also the dilated stomach and gives comfort in obesity. The method and frequency of bathing should be suited to the patient's general condition. Careful attention to every detail is the price of success. Hours of work, recreation, and rest are to be pro- portioned to the severity of the case. In the mild cases the patient should live in the open air during the hours of sunshine. A daily drive, or a ramble and view of a favorite landscape, may lift the mind away from self and the worries of business and life's daily cares. In the severer cases confinement in- doors may be obligatory, the bedroom must be kept full of fresh air, and the day be spent in quiet enjoyment in a sunny room. In the grave cases, when the nervous system is a wreck and the func- tion of every organ in the body is in abeyance — a condition closely allied to prolonged shock — isola- tion, absolute rest in bed, massage, electricity, oxy- gen inhalations, and a tissue-building diet will f re- .;.' CHRONIC DISORDERS OP GASTRIC DIGESTION. quently enable the patient to emerge from the restorative process fresh as if from Medea's charms. But of more importance than all else in the treat - in. 'lit of these diseases is the selection of a proper diet. This is "the greal and master thing" the question of feeding. A.nd right here it is essential that we should clearly define the principles which may best guide us in the adaptation of a diet to in- dividual cases of disease. And first we must protest against the guidance of a morbid appetite and of morbid desires. The " natural instincts " of the patient must aot "have tree play." though " they have grown up under the regulating force of universally acting biological laws, under the pressure of the sleepless vigilance of tlie law of survival of the fittest, and the sure incidence <>f the laws of heredity*' (Sir William Roberts). It might be well to suggesl the possi- bility of the development of types from unhealthy variations, which might serve fittingly to illustrate the self -avenging power of Nature's laws. Every form of force is modified by the nature of the me- dium which manifests it. and the •'natural in- stincts" of the invalid are no better guides to alimentation in disease than are the delusions of insanity guides to conduct. "Find out that course of life which is best," writes Pythagoras, " and habit will render it most delightful." If reason, then, must define the diet, on what knowledge should its dictates be based \ The answer is a simple one —on "the rational stan- dard of diet, as revealed in the customs and habits of the people," as Sir William Roberts rightly ob- CHRONIC DISORDERS <>K GASTRIC DIGESTION. ■>■> serves, and as corrected by the known, digestibility and nutritive value of the various articles and classes of food ; on the capability of the digestive organs ; and on the state and needs of general nu- trition. A cursory view reveals the fact that the inhabi- tants of the temperate zone live on a mixed diet of proteids, albuminoids, fats, and carbohydrates. It would be interesting to know something of the effect of these classes of food on destructive meta- bolism and the building-up of tissue. The albu- minoids and proteids increase nitrogenous waste. When administered along with the fats or carbo- hydrates in sufficient quantity to supplement and raise the force evolved in the splitting-up of the al- bumin in the circulating fluids to the level of the requirements of the vital processes, or when the storage of fat in the system can be utilized for this purpose, none of the cells of the body are destroyed. When the quantity of albumin circulating with the nutritive fluids is not all required to meet the de- mands of the vital processes, within certain limits, as defined by the inherent activity of the cells and that delegated or withheld by the nervous system, new cells are generated. Peptones furnish energy, but do not form tissue. Tissue is built up out of unchanged or incompletely digested proteids and al- buminoids. Thus albumin is the great sustainer of life, and, under proper conditions, the great builder of tissue. It cannot be supplanted, beyond a certain point, by any other food. It makes the blood richer in red corpuscles and in haemoglobin, as any one can easily demonstrate by the haemocytometer and 3 3-1 CHRONIC DISORDERS OF GASTRIC DIGESTION. haemoglobinometer in anaemic and chlorotic dyspep- tics on an exclusively animal diet. It is fche only class of food that can alone support life, and it forms the physical basis of life in its simplesl and primordial form. The assimilation of fche Eats is aided by the pro- teids and albuminoids. Fat diminishes nitrogenous waste, and is intimately concerned in the nutrition of the nervous system, and forms nearly all tin- fatty t issue of the body. The carbohydrates never enter into the formation of tissue, hut aid the or- ganization of albumin and fat by supplanting them in destructive metabolism. Thus it is evident that the nut rition of the body can be most economically maintained at a high point by a due admixture of these three classes of food. But in disease the ca- pability of the digestive organs, or. in the special diseases under consideration, the capability of tip- stomach, imperatively demands a compromise. But an early and cautious return to a suitable mixed diet will suggest itself to the common sense of the physician as the best method of avoiding the evils of exclusiveness. The excessive or exclusive use of the carbohydrates tends to dilatation and disease of the stomach and intestines, and the individual is pale, thin-blooded, weak, and bloated. A long and exclusive use of the proteids and albuminoids ti'\\<\> to certain circulatory derangements and to nervous irritability ; while the malassimilation of fats is the most important factor in the production of the emaciation in the pre-bacillaiy stage of tuberculo sis. The physician, like the general he should he. must avail himself of every opportunity to advance. OHEONIC DISORDERS OF GASTRIC DIGESTION. 36 or be ready to retreat under cover on the first note of warning, until bis object has been attained. In the meantime the strength of the enemy unit be correctly estimated, or, to drop the metaphor, the capability of the stomach must not be exceeded. That all of the food taken undergoes digestion and absorption is made known by the absence of the clinical signs of fermentation or putrefaction, but chiefly by the chemical or microscopical examina- tion of the urine, blood, faeces, and contents of the stomach about four hours after meals. The sto- mach should be free from fermentation organisms, and the stools show no undigested food or unusual fcetor. The blood should become constantly richer in red corpuscles, or in haemoglobin, or in whatever element it is found defective in the first examina- tion. Eosinophile cells diminish in number, poiki- locytosis becomes less and less marked, and the flat red corpuscles grow fuller and more biconcave. The changes in the blood from day to day form a very good index of assimilation. While the pa- tient is on an animal diet, the presence of indican in the urine (if there be no pus in the body) points to intestinal putrefaction, indol being a product of the putrefaction of albuminoids. The information obtained in this way is at once practical, scientific, accurate, and sure ; in a large clinical experience it has proved to be a satisfactory guide. The application of these general considerations to the treatment of the special forms of the chronic disorders of digestion may now briefly command our attention. In dyspepsia with increased formation of hydro- CHRONIC DISORDERS OF GASTRIC DIGESTION. chloric acid the patient musl be held strictly to a diet of lean meats. The keeping, selection, and cooking of meats cannol be discussed In the limits tions of this chapter. All lean meats Bhould be broiled or roasted, never stewed or fried. Thesta pie food should be the muscle pulp <>r beef scraped or chopped free of fibrous tissue, steak, roast, beef, or mutton chops or roasl mutton. For the sake of variety one can ring the changes od the whin' inr.it of poultry plainly cooked, fresh white fish, or raw oysters (care being taken net fco swallow the tou^li [>a it i served oil half-shell with lemon, or the white of egg cooked just enough to hold together. The juice of a few tender splits of eeleiV or of watercress or of horseradish, extracted with lemon juice, may he used to give flavor. In the way of drinks, a small cup of black coffee (if there is no contra-indication) after breakfast and dinner, and a small cup of clear tea at noon, should he rec- ommended; hut no wines or alcoholic drinks what- soever. As soon as healthy secretion is restored, the crust of French roll, stale bread dry toasted, and a few fcablespoonfuls of well-cooked rice oi cracked wheat, or California wafers served with a little butter and salt, jand, a few weeks later, spi nach, fresh English peas, string beans, a floury potato, maybe added as the patient is cautiously conducted on the way to a normal diet. The juice of ripe fruits may now also he taken without harm. In dyspepsia with diminished formation of hy- drochloric acid, and also dyspepsia with impaired muscular movements, a diet of animal food should be ordered until there is no longer any evidence CHRONIC DISORDERS OF GASTRIC DIGESTION. ■>,' of fermentation, and the patient be then slowly brought around to a normal diet. The crust of roll, or stale bread toasted so dry that it will sn;i|>. are peptogenic, are more easily digested than starch, are not so liable to ferment, and may be given along with lean meat in the beginning of treatment. A few tablespoonfuls of bouillon before dinner will also increase the secretion of pepsinogen. Animal fat— as butter, or a slice of the boiled side of bacon, •or cod oil — should be given as soon as the stomach and intestines are free of fermentation, to aid in toning and building up the central nervous system. But if the fat denudes the tongue or encrusts it with a layer of dead epithelium, or excites nausea or eructations, it must be at once withdrawn. In- unctions of animal fats or pancreatized cod oil as a nutrient enema may then aid. A glass of hot ste- rilized milk will often prove of value when sipped very slowly in the interval between meals, or at the beginning of the meal as a soup. The tea may be made more delicious by a slice of lemon and a tea- spoonful or two of old velvety rum. A little old whiskey or brandy may be permitted if the heart is weak. The rule to return to a mixed diet suited to the state and needs of general nutrition, as rapidly as the capability of the stomach will permit, here also obtains. In dilatation, soups and milk do not agree ; the small bulk and high nutritive value and digestibility without irritation make lean meats the staple food. Fats must be watched. In dyspepsia with exaggerated peristalsis the diet must be bland and unirritating. Milk and its pre- parations, lean meats, and light farinaceous food. I BRONIC DISORDERS OF GASTRIC DIGESTION. without succulenl vegetables and condiments, should be ordered until the condition is controlled by drugs. In dyspepsia from sympathetic disturbance the diel should be fluid and non-irritating as pepton- ized milk or milk gruel, koumiss, matzoon, butter- milk, white of f-i;\ the juice of beef or ol her meats — while the disease of which the dyspepsia is a re- flex is discovered and palliated or cured. In chronic gastritis clinical experience lias taught us in the beginning of the treatment to withhold starches, fats, ami sweets : and the less the chances given for fermentation and putrefaction the sooner we may expect a cure. The treatment proceeds along the same line as in weak stomachs. Imt pro- gress is slower and minute attention must be given to every detail of management and every aid be brought to bear. In venous stasis, the stomach be- ing kept clean, the diet should be such as will least irritate, and only enough albumin and fat to main tain the nutrition of the body be given. If the liver is involved, fat must be supplanted by care- fully selected cereals and fresh vegetables. In threatened cardiac insufficiency, after diminishing the work of the heart and prolonging the period in which it may take its rest, give, along with the al- buminoids and proteids, enough carbohydrates to enable some of the albumin to be organized, and thus guarding also against the storage of fat. The diet of dilatation has already been given, and arti- ficial digestion is the only additional indication af- forded by gastric atrophy. Many details have been written at the risk of becoming tiresome, and many CHRONIC DISORDERS OF GASTRIC DIGESTION. 30 more must be left to the good sense <>(' fche phj cian. The diet of gastric ulcer must be unirritating to the lesion of the mucous membrane and adapted to the hydrochloric superacidity. It is essential to healing that the ulcerated surface should !><• given rest and that distention of the stomach be can •fully avoided. An exclusive milk diet, since its use and recommendation by Cruveilhier, has given some very brilliant results. Milk, sweet and fresh and partially peptonized, and rendered alkaline by lime water or (better) by calcined magnesia or the lac- tate of magnesia, may be a good diet to begin with, administered in small quantities every three or four hours. It is unirritating and gives the stomach little chemical and motor work to do, since it is almost entirely digested in the duodenum. But milk cannot be given in sufficient quantity to maintain nutrition without stomachal distention ; and when, on account of the superacidity, it does not agree (as is often the case), it does a good deal of harm. It requires nutrient enemata to supplement it, is a very treacherous food, and no one can tell beforehand when its casein is going to coagulate in clots, sour, and decompose. Leube, in a very large experience, has obtained the best results from his sarco-peptones (prepared also by Eudisch, New York). This preparation is concentrated, nutri- tious, and unirritating, but very unpalatable. Pref- erence might be given to Mosquera's beef meal and peptone jelly, on account of tkeir greater pleasant- ness to taste and smell. Meat juices, white of egg. and fine muscle pulp of beef, with fresh pepsin, are tO CHRONIC DISORDERS OP GASTRIC DIGESTION. \-t\ valuable arid counterad the superacidity by combining with the free hydrochloric acid. We are Beldom able to accomplish much by rectal feed- ing, bul must resorl to it when the stomach is much disturbed and during haematemesis. Rest in bed and the curative treatment <>f the superacidity nun two very important indications. The strict din must he continued for some time after the disap- pearance of all symptoms. The treatment of cancer is purely symptomatic. A rest iif di- gesl ion. Dosing with nauseating mixtures can onrj do harm. Drugs should be given with a definite purpose in view, and our aim in prescribing should be to combine simplicity, elegance, and power. The capability of the stomach may be increased in many ways. In subacidity the mosi plausible thing to do is to give hydrochloric acid. It is a temporizing expedient, and, if it does any good whatever, certainly has no curative value. If ad- ministered it should be given in small doses re peated three or four times during the active period of peptonization, to avoid producing artificial super- acidity. It is more rational and curative to excite secretion by massage, faradization, and drugs. Tile administration of alkalies in superacidity suppresses a symptom temporarily, hut afterward excites acid secretion ; to relieve the pain it is necessary to use. along with the alkali, an analgesic. Calcined magnesia and the lactate of magnesia are preferable to the alkaline carbonates, although '•soda-mint tablets' 9 are popular and also efficient. Thecura live treatment strikes at the cause by diminishing the irritability' of the mucous membrane from which the si i pei--ecretion results. The fluid extract of coca (P., D. & Co. ». the tincture of piscidia erythrina in small doses, and the English or Squibb's extract of cannabis indica, are the three reliable drugs for this purpose Papoid is of value when given before the hot water to aid in the removal of mucus. CHRONIC DISORDERS OP GASTRIC DIGESTION. \'> Then one or more of the following drugs, on account of their physiological action, may be selected to meet the varying indications of defective secretion and impaired movements : The simple bitters in- crease the acidity of the gastric juice, and are sup- posed to diminish the secretion of mucus; thepro- per time to administer them is half an hour before meals ; all of them are local irritants, and their use should not be continued longer than three or four weeks. Ipecac promotes the secretion of mucus, and in small doses allays irritability. Opium, mor- phine, and codeine diminish acidity, allay irritabil- ity, and check peristalsis without affecting absorp- tion. Nux vomica increases the acidity of the gastric juice and tones and strengthens the muscu- lar layer. It is the one drug to use in dyspepsia with diminished muscular movement. It also in- creases the quantity of nerve force radiating through- out the body, and this important action may often be used to promote tissue building. If too long con- tinued the discharge is excessive and waste of tis- sue results. Subnitrate of bismuth is astringent, antiseptic, and sedative. Nitrate of silver allays irritability and is supposed to exert a specific action in catarrhal inflammation. Arsenic inhibits the ac- tivity of the hepatic cells, and is prescribed empiri- cally in the neuroses ; in the neuroses of the sto- mach Fowler's solution in drop doses, before meals, is of some value ; or the bromide of arsenic or of potassium or of sodium may meet an indication. Iron, the alkalies, oxalate of cerium, and the stimu- lating antispasmodics are at times of value ; also calomel, cascara sagrada, ipecac, aloes, rhubarb, 44- CHRONIC DISORDERS OP OASTRIC DIGESTION. senna, and podophyllin are useful to gently touch the liver or to keep the. bowels in a proper state. Saliein. chloroform, and camphor are antifermenta- li\e. hut the best way to prevent fermentation is to keep the Btomach clean, give the proper food, and see that enough hydrochloric acid is present. To discuss every indication in the treatment oi these diseases of the stomach would be to write a volume on therapeutics. To summarize, in conclu- sion : 1. Chronic gastritis is rarely, and dyspepsia al- most never, a primary local disease. Ulceration is a local trouble engrafted on a secretory neurosis and a blood condition. Atrophy may result from local or constitutional disease. Cancer may he primary, or. rarely, is secondary. l\ An accurate diagnosis means more than the discovery of defective gastric digestion. We must know the anatomical state of the mucous membrane We must also know the nature of the disturbance — whether of secretion, movement, or both ; the source of the disturbance— whether in had habits of life, in acquired or inherited defect of constitution, in vice of nutrition, in fault of elimination, or in disease of a distant or functionally associated organ. The solidarity of the organs of digestion is a facl of very great importance in clinical medicine, and dominates the method of managing their disorders and diseases. Their intimate relation through a common nerve supply ; the mingling in the portal vein, on its way to the liver, of the various materials absorbed from the alimentary canal ; the division and community of theii labors: the integration of CHRONIC DISORDERS OP GASTRIC DIGESTION. \'i their differentiated functions, make them one in ac tion and in purpose. .">. The treatment embraces more than the man agement of the local disturbance. The Local treal ment is important ; the stomach must be kept rlcin and sweet, its work diminished, its capability increased. But the whole man commands pre-emi- nent consideration — his mental, moral, and physi- cal condition. And this necessitates the study of the character of the patient, the regulation of his habits of life, the prescription of palliative and cu- rat ive remedies, and a well-regulated diet. And a well-regulated diet does not mean the arbitrary and indiscriminate use of certain articles of food, but a diet sanctioned by reason and experience, adapted to the state and needs of general nutrition, and to the capability of the stomach and to the peculiari- ties of the patient. But of more importance than all else is the complete digestion of the food taken ; this the physician must see to by daily observation, little changes in quantity, quality, or frequency, and by wearisome and prolonged supervision. The mere suppression of symptoms will do the patient no permanent good. It is better to restore than to supplement secretion, and to correct than to neu- tralize superacidity. The curative treatment is di- rected against the chemical lesion of the fluids of the body and the malnutritive state of the cellular protoplasm. CHAPTER III. A CLINICAL STUDY <>!•' [NTESTINAL LNDIGESTION. In the clinical study of the disorders of digestion the stomach cannot be considered the most impor i.nii division of the alimentary canal. In the light of modern research this position must be assigned to the small intestine, and chiefly to its upper pari. It is in the duodenum, and in the duodenum only, that a mixed diel can he perfectly prepared for absorption. The work begun in the kitchen and continued in the mouth and stomach reaches the climax of chemical changes at this point. Tin' pre- ceding stages of digestion have heen preparatory and progressive. Duty and responsibility go hand-in-hand. When the duodenum with its two great appended glands was supposed to play a subordinate and supple- mentary part, not much attention was given to the intestine in the disorders of digestion, and the logi- cal sequence was failure in treatment. The sto inaeh has been much abused by laymen, and a physician of genius has seen in it the origin and source of every form of chronic disease. No other organ has heen so maligned and maltreated. It is now time that the responsibility should rest where it belongs, and much of the blame must be trans ferred to the intestine. Vicarious suffering is not a principle of law or of Nature or of disease. CLINICAL STUD'S OF INTESTINAL INDIGESTION. I! The stomach is an antiseptic receptacle which doles out its contents to the duodenum in a soft, semi-fluid, mixed, and slightly changed form. Its secretion, as docs the saliva, only acts on one class of foods and in a very incomplete manner. No very great quantity of nitrogenized food is con verted by hydration into peptones, and the precipi tated casein, proteoses, liberated granulose, and fat are discharged into the duodenum. But be it un- derstood that it is not our purpose to underestimate the utility of the work done by the stomach. There is much reason for believing that it would be disas- trous to have all of the proteids and albuminoids converted into trypsin peptone, which is essentially a decomposition or erosion product, and one form of which is utilizable only in the production of en- ergy and animal heat. Gastric peptones can be readily converted by anhydration into serum albu- min and are available for tissue building. Pure peptones suffice to keep up nutrition (Maly, Adam- kiewicz). Moreover, unchanged albumin intro- duced into the rectum is absorbed and can maintain nutrition (Ewald and Eichhorst), and proteoses are even more readily drawn into the circulation. In- complete peptonization cannot, therefore, ""be ad- mitted as an argument against the usefulness of the work of the stomach in digestion. Careful ali- mentation can maintain nutrition in the dog and in man without the intervention of a stomach. This proves that the work of the stomach is not essen- tial and can be delegated, in certain favorable con- ditions, to the duodenum. It detracts not one iota from its value, and the richness of resource results Is CLINICAL STUD"\ OP INTESTINAL INDIGESTION. from the developraenl in duplicate and the multi- ple relation of function to structure in the evolution of ill*- digestive system. The stomach also does important police duty in destroying pathogenic bacteria and ejecting indigestible, irritating, and poisonous substances. The cardia and pylorus open and close opposedly. The eyelid, by a beautiful provision of Nature, protects the organ of sight. The muscular pylorus holds the door to the intes tine. Bui the chemical work of the stomach is not all important, and this pouch is simply an antisep- tic, protecting, distributing, and chiefly preparatory receptacle. 'The intestine is a digesting, absorbing, and elimi- nating tube, Our study is restricted to the disor- ders of digestion, and absorption and elimination can only receive consideration as causative factor-. Elimination may disorder the digestive process by altering the chemical reaction of the intestinal con- tents or by originating a diarrhoea. If the intesti- nal epithelium loses its selective power, auto-infec tion, with its pernicious influence on the system and on digestion, may result. An excess of the diffus- ible products of digestion interferes with the fur- ther action of the ferments, and deficient absorp- tion predisposes to superdigestion and organic pu- trefaction and fermentation. The part that the secretion of Brunner's glands plays in the conversion of the food into a Liquid and diffusible product is not well known. This juice liq- uefies proteids and albuminoids, acts vigorously on a ptyalin product, maltose, and probably also on cane sugar, and by iibs intense alkalinity aids in the CLINICAL STUDY OF [NTE8TINAL INDIGESTION. 49 neutralization of the gastric juice. Its defective secretion may add to the work that must be done lower down in the alimentary canal, and we would naturally ascribe to its absence a predisposition to the simple duodenal ulcer. Incomplete also is our knowledge of the h : K3TION. and organic decomposition is less when bile is pre- sent, [ts antiseptic properties are very feeble i though it seems doI fco be a v ery good food for bac- teria), and it exerts its favorable influence by pro- moting pancreatic digestion, absorption, and peri- stalsis. The liver is of greatest use in metabolism. The pancreatic juice puis the crown on the chem- ical process of digestion, and its work gradually loses itself in organic decomposition. It prepares QO way, is regal in its advancement, hut its rule is limited by precedent and hedged about with chem- ical and vital law. It is with this code that we are chiefly concerned. Perfect duodenal digestion requires (a) a medium of proper reaction, (6) normal secretion, (c) a pro- portionate quantity of digestible food in a proper physical condition, and (cl) the normal movements of the food mass. It may be supposed that the best reaction for the food mass to possess is the one which is most fa- vorable to the action of the digestive ferments — the trypsin, amylopsin, steapsin, and milk-curdling fer- ment. In perfect health this is probably true ; in disordered assimilation rapid digestion and rapid absorption may both be undesirable. But our study is limited to disordered digestion, and it is our pur- pose to consider the changes in the environment and in the conditions which disturb and delay the process. It is well known that the pancreatic fer- ments are most active in a slightly alkaline me- dium. The essential condition is complete neutral- ization of the hydrochloric acid. In the presence of bile a feeble acidity due to organic acids does not CLINICAL STUDY OF [NTESTINAL tNDIGBSTION. 5] inhibit but probably increases their activity (Lin- denberg). The chemical equilibrium may be de- stroyed by a too acid chyme, by a deficiency of the duodenal secretions, by excessive organic fermenl.i- tion, and by too little enteric juice. The excess of acid may be taken in the food, or it may be devel- oped by organic fermentation or fat-splitting in the stomach, or it may be the result of excessive secre- tion of hydrochloric acid when the pancreatic fer- ments are not only rendered inactive but are also destroyed. Duodenal dyspepsia from defective secretion is a frequent disorder. There may be too little pancre- atic juice or too little bile, or there may be too much bile of a bad quality, producing excessive peri- stalsis. Normal chyme is probably the best stimu- lant of duodenal secretion. There is the same or- derly sequence in secretion as in the digestive pro- cess. Through nervous association salivary is fol- lowed by gastric secretion, and then the duodenum and its appended glands are aroused to action. The alkaline saliva promotes the secretion of the acid gastric juice, which in its turn puts the duodenum to work. Duodenal acidity and faulty secretion are not the only disturbing factors, but the chemical process in the intestine may be disordered by an improper composition, or faulty preparation, or excess of the chyme. Gluttony is a frequent cause. An excess of proteids or of carbohydrates or of fats is no less pernicious in its ultimate effects. Either form of excess throws too much work on the duodenum, which will inevitably become inadequate. Not 52 CLINICAL STUD'S OF [NTBSTINAL INDIGESTION. i >nly is the influence direct, birl indirect also 1 1 1 rough defective preparation by the mouth and'stomach. The result, however brought about, isa chyme ab Qormal in quanl it 3 or quality. The intestinal wall contains two sets of muscular fibres which are often dissociated in their action the one regulates the calibre of the gut, the other the movements of its contents. Peristalsis and to- nicity often act in unison, bul just as often apart from each other. Hot water increases peristalsis (Kicord), but diminishes tonicity ; cold water in- creases tonicity and ma\ or may 0.0I influence peri- stalsis. The dilated stomach spasmodically emp- ties itself, and the same is also true of the dilated colon. The investigations of G-lenard show very plainly that hypertonicity and inadequate peristal- sis coexist in enteroptosis. The habitually relaxed pylorus often allows the food to be hurried into I he duodenum. Neurasthenic-soften have flat bellies, cord-like intestines, and constipation. And it is important clinically to remember that these two kinds of muscular action may be variously com- bined and localized, and restricted to divers parts of the digestive tube. Hypertonicity disorders dic- tion by diminishing the area of absorption and in- terfering with the circulation of the blood. The food mass is not churned and brought into ever- varying contact with the mucosa. Insufficient and irregular and excessive peristalsis delays and disor- ders and decreases digestion and absorption. Ato- nicity permits stasis. Perfect digestion requires nor- mal chemical and muscular action. The physical factor is no less essential than the chemical one. CLINICAL STUDY OK INTESTINAL INDIGESTION. 53 The recent brilliant discoveries in the chemical pro- cess have drawn our eyes away from the muscular layer. Unhealthy variations in intestinal tonicity and peristalsis are probably more pernicious in their influence than defective duodenal secretion. From these proximate causes turn we now to the consideration of the remote ones. Digestion is di:- ordered by every disease which is not purely local in its nature and effects. And our knowledge would naturally lead us to expect this, since perfect digestion requires, in addition to a right quantity of healthy food, normal nerve centres, a normal supply of pure blood, normal secretory and absorb- ing cells, and normal tonicity and peristalsis. These conditions are incompatible with every disease which is not strictly local and which involves a part that is not a component of the digestive sys- tem, be that disease discoverable with the micro- scope in the destruction, arrangement, or produc- tion of cells, or hidden under the word "func- tional " in intracellular change. The neuroses, de- nutrition, alcoholism ; anaemia, chlorosis, malaria, and other forms of toxaemia ; organic disease of the haematopoietic or metabolic, respiratory, elimina- tory, circulatory, or nervous systems, or of the di- gestive tube and its appended glands, may be the aetiological factors. To enumerate the remote causes of intestinal dyspepsia would be to pass in review the entire number of chronic disorders and diseases capable of disturbing one or more of the conditions of perfect digestion. If we carefully consider the clinical history, the subjective symp- toms and their order of development, the physical :»| CLINK \i. STUD? OF i\ti>ti\\i. [NDIGB8TIOK. signs, .-ukI the result of the chemical and micro- scopical examination of 1 1 1 « * blood, secretions, and excretions, \w will commonly !"■ able to adopt a. rational supplementary treatmenl directed against the remote cause. 'Hi.' symptoms of intestinal dyspepsia are consti- tutional and local : the two symptom groups are born and develop and live and decline and r.ill to getlier. Wo are well aware that we are now t read- ing on disputed territory ; the battle yet rages fiercely and the existence of neurasthenia and this great class of dyspepsias is staked on the issue. Specialism has joined the fray, and the war is to the knife. Are these symptoms, including those that are localized in the digestive tube, due to neu- rasthenia, to a functional nervous state without anatomical change (Beard), or to hyponutrition of the nervous system (Arndt), or to a general neuro- pathy affecting alike the digestive tube with all or- gans (Charcot), or to dilatation of the stomach with auto-intoxication sequential to chronic gastritis (Leube), or to weakness and relaxation of the mus- cular layer (Bouchard), or to dilatation of the as- cending (Bouveret) or descending (Trastour) colon, or to enteroptosis (Glenard) ? These questions can best be answered at the bedside by the general practitioner. His is the eagle eye that sweeps the whole field in a flash and takes in every detail. The vision of specialism is all the more intense because of its exclusiveness, but on broad questions is very apt to be wrong because perfect truth conns full circle. It seems probable that the neurologist and specialist in the disease of the digestive system, CLINICAL STUD'S OF I XTKXTI \ A I, INDIGESTION. 00 though diametrically opposed, are walking in the same beaten pathway, in the same virions circle, which was long ago established when nutrition, circulation, and the nervous system were linked together in the one law of being. It may be the nervous system that is robbed of its food and rest, and brought to a premature fall by hard hunger and an overreaching ambition; it matters not whether the force be scattered in the shock of the lightning flash or slowly wasted beneath some burning ray, the result is the same — a nervous wreck more or less complete. The beginning may have been small —a slight malaise. The end is complete prostra- tion. And associated with the gradual decline or the rapid fall are divers disorders of the digestive process. Neurasthenia is one of the grand causes of gastric and intestinal dyspepsia, and affects pri- marily and chiefly the neuromuscular factor, the physical process. Associated with it there may be normal secretion (or even hyperchlorhydria) or defi- cient secretion. There may be hypertonicity with a small stomach and cord-like intestine, or there may be flaccid dilatation. But there are essentially and primarily diminished peristalsis and constipa- tion, and sometimes complete stasis. Now, it is the digestive system that first fails, and the primary disorder is in the chemical process, as is usually the case also when there is " somewhat wrong with the blood. " Neurasthenia is an entity ; so is intestinal indigestion. The one may cause the other. Each may exist alone. Both may result from a common cause. Both are parts of the same circle, which often becomes a vicious one. What, then, are the 56 CLINICAL STUDY OF INTESTINAL INDIGESTION. symptoms of intestinal dyspepsia, and on what can its diagnosis be based with certainty 1 Habitual malaisi and gem ralcU bility are the two earliest and most persistent symptoms. A little work easily tires ; sleep does not refresh ; the mind is uncontrollable, wandering, flighty. The thinker cannot concentrate his attention: thought lo^es both in intensity and extension. The broadview and firm grasp require a supreme effort which leaves relaxation and exhaustion. The philosopher heeomes gloomy and apathetic, or pessimistic and crabbed. The preacher grows ascetic and the brightness of hope is replaced by the gloom of de- spondency. The poet loses some of the sweetness and clearness and continuity of Ins song. Theai- fcisi fails in conception and trembles in execution. The musician turns from his instrument — cannot rest, cannot compose. The statesman becomes sour and oppressive and defiant. The merchant is swallowed up in competition. Poet and plowman, priest and philosopher, one and all, lose energy, per- tinacity, strength, and happiness because the intes- tine does not do its work well, and the liver gets clogged, and the blood contaminated, and the nerves irritable and tired and without reserved store of force. Probably neurasthenic first, dyspeptic after- ward— the vicious circle is established, and neither rest nor diet alone, but both combined, will cure. The malaise is worse a few hours after meals ; the general debility is most felt after a little forced work; both are usually at their height about the middle of the afternoon. Habitual malaise and general debil- CLINICAL STUDY OF INTESTINAL [NDIOESTION. 5"i ity begin and rise and decline an< I fall with the dis- order of digestion. Insomnia, in many cases, is a most obstim.o- symptom, and most frequent in the early morning hours. Alcoholic drinks aggravate it, and the onl\ hypnotic that will give refreshing sleep is a clean digestive tube. Sensory disturbances are frequent. Neuralgia, hyperesthesia, paresthesia, anesthesia, even lan- cinating pains like those of locomotor ataxia, are not rare. These symptoms bear no definite marks, and are mentioned only on account of their associa- tion with, and proportionate relation to, the degree of the digestive disorder. The heart symptoms are reflex or mechanical or due to auto-infection. Tachycardia, which may be paroxysmal, is not rare. Tire heart muscle is nearly always weak and the peripheral circulation poor. "Vertigo from cerebral anemia or auto-intoxication is only too common. Palpitation seems to be about as often found as in gastric dyspepsia. But the chief cardiac sign is the condition or behavior of the right ventricle. Flatulence, especially in the transverse colon, interferes with the action or filling of this ventricle, and the heart is pushed up and laboring or rapid, the respirations are quick and shallow, the pulse small and compressible, and the veins are full. The dyspnea may be increased by the clogging of the liver, auto-infection, and con- traction of the pulmonary arterioles. The symp- toms may be intermittent or remittent or parox- ysmal, accordingly as may be the strength and adequacy of the right ventricular wall. The heart 58 CLINICAL STUD? OF INTESTINAL INDIGESTION. may be Qol only inadequate but also irregular. The diagnosis of dilatation of the right ventricle is not difficult, and the therapeutic fcesl of fche relation of tlir cardiac trouble to the disorder of digestion is conclusive. Treatment directed to the heart alone fails. Digitalis and drugs of a similar nature do harm. Strychnine and oitrogrj cerin aid, but alone arc inefficient or useless; but, combined with real and a diet to control flatulence and to cure the in- testinal dyspepsia, will sometimes restore the equili- brium, even when the heart is near the stage of asystole. Distress and pain and tenderness are among the local symptoms, but cannot be considered as path- ognomonic. The central figure on the canvas does not make the complete picture, and it gets a good deal of its meaning from its relations and associa- tions: two peasants standing with heads bowed in devotion may not attract more than a passing recognition, but the dropped work, characteristic scenery, and sound of the distant church bells wake into expression a grand and touching historical truth. It is not on any one sign, but on the symp- tom group, that our diagnosis must rest. Very little meaning can be attached to the time of appearance of these symptoms. Their location should be con- sidered. But the most valuable sign is a bruised and heavy feeling in the belly during the restless hours of the early morning. Persistent flatulence in the snu it I intestine is an almosl pathognomonic sign of intestinal dyspepsia. It is greatest when organic putrefaction and fer- mentation are most active, and this usually occurs CLINICAL STUDY OF [NTE8TINAL [NDIGESTION. 59 two or three hours after a meal. It is by no means rare to have gas diffused from the blood into the intestine, but this occurs irregularly and intermit- tently, and chiefly when the intestine is empty, and is not related to the quality of the diet. When poured into the duodenum from tin; stoniaHi tin- clinical history and physical signs will suggest its source, and the urine and stools will contain no- thing indicative of intestinal indigestion and decom- position. Dilatation and displacement of the intestine is a physical condition and sign of some value. It may be due to either distention or relaxation ; uneven tonicity, especially when combined with localized atonicity, may produce stasis of the intestinal con- tents ; deficient peristalsis and chemical and bac- terial decomposition mechanically distend. The flexures of the colon finally are displaced and fall from lax ligaments and a flaccid abdominal wall. This condition develops par excellence in the neuro- muscular form of dyspepsia. Constipation and irregular stools vary with the quantity of the bile, the chemical and physical quali- ties of the intestinal contents, and the disorder of the muscular layer. Organic acids, scatol, carbonic- acid, hydrosulphuric acid, and marsh gas excite peristalsis ; nitrogen, hydrogen, indol, and phenol have no influence (Bokai). The urine is more or less characteristic. Indol is formed by the decomposition of tyrosin, a product of trypsin superdigestion, and by the bacterial de- composition of nitrogenous compounds, and it ap- pears in the urine as indican. This process normally GO CLINICAL STUD? OF [NTB8TINAL [NDIGBSTION. aever occurs in the small intestine; and a urine containing an excess of urates, occasionally a few crystals of uric acid, of specific gravity about L.020, a trace of bile, and indican in excess, is almost pathognomonic of intestinal indigestion, if the large bowel has been previously washed out. The defi- ciency of acid in the urine gives some idea of the amount of BC1 secreted (Ewald), provided the in- creased alkalinity of the urine is not due to the ab- sorption of alkalies from the food (Roberts'), or t<» loss of HC1 by vomiting, or to delayed absorption after secretion, or to the formation of insoluble chlorides (Jones and Quincke). This is a more trustworthy index if the neutral or feebly acid urine precipitates the earthy phosphates on boiling. The alkaline secretions diminish the alkalinity of the blood and increase the acidity of the urine (Hi'ibner, Sticker, Jones, and Quincke). An excessively acid urine of normal or high specific gravity, and which, after standing forty-eight hours, only deposits, it may be, a few crystals of uric acid or oxalate of lime, is produced in this way. In hyperchlorhydria the abstraction of acid is followed by the with drawal of alkali in excess to neutralize it, and the reaction of the urine is unchanged or vacillates. Excessive organic fermentation and consequent ex- cessive secretion of the alkaline intestinal juice are the conditions underlying the formation of the clear, highly colored, excessively acid urine which very much delays deposition. The stools are often characteristic from the fer- mentation and putrefaction to winch they testify. CLINICAL STUDY oi<' [NTESTINAL ENDIQESTION. 01 or from the excess of unutilized starch ,-ind f';it which they contain. The diet, test is the sure proof, and is based on the intolerance of starches, fats, sweets, and wines. Milk consequently is one of the first of the common foods to disagree. Starches, unless permitted to he destroyed hy stasis' and fermentation, are voided in excessive quantity. Fats escape in like manner in the faeces. Sweets add proportionately to the flatu- lence. All wines, except the oldest and lightest, are badly tolerated. Make carefully selected and scientifically prepared and easily digested and nutri- tious meats the basis of the diet, give one or more of the badly tolerated class of foods in an easily di- gested form and not in excess, regulate peristalsis. examine the stools, apply our knowledge of physio- logical chemistry, and the results will be pretty de- finite and conclusive. Such are the particular symptoms of which the symptom group is composed, and it is on the ever- varying combination that the diagnosis of intestinal indigestion is based — a diagnosis which is always difficult and requires the very closest clinical stud}". The chemical condition of the stomach, both during and in the interval of digestion, the time and thor- oughness with which it empties itself, its size and the tonicity or flaccidity of its walls, can by a few examinations and tests be readily ascertained with a good deal of certainty. But the disorder in the intestine is enshrouded in difficulty and well pro- tected against chemical exploration. But a meth- odical study of the symptoms and of the physical signs, the examination of the urine and of the 62 CLINK \l. STUD'S OF tNTBSTINAL [NDIGESTION. stools, and a carefu] use of fche diel test, will make it possible to forma right and definite conclusion. To each symptom we assign its possible causes— what conditions and where Located would produce it. In turn we iivat cadi prominent symptom in this manner. We then apply the same method 1" ill.- symptoms as combined until we arrive at the possible explanations of the symptom group. In this procedure the chemical or physical process of digesl ion will be found more or less faulty, and pos- sibly also fche special detect be revealed. The ex- amination of the urine for decomposition products, after the large bowel has been previously thoroughly washed out, will confirm or further limit our con elusions and supplement our knowledge. The diet test may then be made, and a positive result will give to our inferences a high degree of moral cer- tainty. Thismethod will turn on more light than any other with which I am acquainted, hut it re- quires time, close ol^ci-vation, careful reasoning, and disagreeable work. The solution of a difficult problem and the rational treatment of the patient are the rewards of the conscientious endeavor. It remains to differentiate intestinal from gastric- dyspepsia, and then to separate the disorder into its three great varieties. But be it understood thai certain forms of gastric dyspepsia always lead to disorder of the duodenal process, and, rice versa, that intestinal indigestion frequently deranges the functions of the stomach ; and that the two are sometimes inseparably hound together as the main' testation of a common cause or as the expression of one disease. CLINICAL STUDY OK INTKKTINAI, [NDIGESTION. 63 Heartburn, acidity, pyrosis, nausea, vomiting, epigastric pain and tenderness, are more or l<- characteristic of gastric dyspepsia. Flatulence can be located in the stomach and in the intestine by the physical signs. The time of appearance of the distress or pain must not be given too much consid eration and value ; the pylorus is not an incorrupt- ible guard ; gastric peristalsis is not a fixed quan- tity. The food does not, like a sparrow — to adopt a favorite simile of early English song — fly in at one window and, after a brief sojourn, disappear through the other. The entrance is usually rapid and surprisingly abrupt, at least such is the custom in America ; the duration of the rest is very vari- able, and the time of departure of each individual traveller is conditioned by varying circumstances. Nothing is more remarkable. than the likes and dis- likes, the whims and fancies and conduct, of the human stomach. If it be remembered that the stomach can be filled with swallowed air or with gas regurgitated from the duodenum or diffused from the blood, the time of appearance and loca- tion of the flatulence, pain, and discomfort will be available in differential diagnosis. Auto-infection is more common in intestinal indigestion. It may well be doubted that even in the flaccid gastric dila- tation of Bouchard the toxines are formed in the stomach and enter the system from this point, as the neuromuscular form of intestinal indigestion is the usual accompaniment of this condition. Simple emaciation without cachexia, or a full and ruddy face with vaso-motor unrest, is the rule when the disorder is limited to the stomach ; the muddv com- r.l CLINK \l. STUDY OP INTESTINAL INDIGESTION. plexion of severe cases of Intestinal indigestion is well known. The mine is sometimes characteris lie; tlif diet fcesl is of inestimable value ; and the physical signs of gastric dilatation, and of dilatation or contraction of the colon, may be of very r great weight. It is not so easy a matter as mighi be sup posed to diagnosticate and Locate dilatation. In using inspection, palpation, and percussion it is es- sential to remember the surface anatomical mark ings. About five-sixths of the stomach lies to the left of the median line in the epigastric and hypo- chondriac regions, and is entered by the oesophagus behind the sternal insertion of the cartilage of the seventh rib : the pyloric extremity (about one- sixth) is to the right of fche median line, and ter- minates in the duodenum on a Level with the tip of the ensif orm cartilage, and about two inches to its right, behind the end of the eighth costal cartilage. Whi'ii gently distended the fundus rises to the level ot'thetifth rib, and the greater curvature sweeps forward and downward to the right, passing just above the umbilicus. It is easy to see how the overdistended stomach produces dyspnoea and pal- pitation by interfering with the action of the right heart and diaphragm and the expansion of the lung. The cardiac end is fixed, the lesser curva- ture is only slightly movable, and the position of 1 1n' greater curvature is conditioned by the degree of distention of the stomach and the displacement of the pylorus, which in disease can sometimes be felt below the lower border of the liver. Only a small area of the organ is superficial and in contact with the abdominal wall below and bevond the left CLINICAL STUDY OF tNTESTINAL [NDIGESTION. 65 lobe of the liver and with the left anterior thoracic wall, the latter forming the half =moon-shaped space of Traube. The colon begins with the blind pouch hi'the right iliac fossa, ascends in front of tin- righi. kidney and forms the hepatic flexure near but to the right of the gall bladder, arches backward across the abdomen above the navel in a line join- ing the tips of the eleventh ribs, bends beneath the lower border of the spleen, and descends to the upper part of the left iliac fossa, where it terminates in the sigmoid flexure. The large bowel is very movable, the transverse arch is particularly free, and the caecum, the hepatic, splenic, and sigmoid flexures are the favorite sites of dilatation. In the diagnosis of gastric dilatation the methods of Fre- nch (distention by CO 2 generated in the stomach), of Lente (palpation by the sound moved about in the stomach), and of others (pumping in air, to dis- tend the viscus, through the stomach tube) are not available in private practice. The clinical history, the discovery of the peculiarly shaped asymmetri- cal bulging on the left side and the perception of peristalsis, the examination of the vomit, succus- sion splashing and seething, the location by pal- pation and percussion of the greater curvature on a level with or below the navel, will commonly estab- lish the existence of extreme and moderate dilata- tion without a resort to heroic procedures. If, after emesis or stomach- washing, a glass, or even a pint, of water is introduced into the stomach, the hue of water dulness in the erect position, which is sup- planted by resonance when the patient lies down, will locate the lower limit of the stomach (modified 5 66 CLINICAL STUDY OF INTESTINAL INDIGESTION. after Penzoldt). The pitch of the percussion note is higher in clonic dilatation, is commonlj associated with large and foul diarrhoea) movements alternat- in-- with constipation ; the dilated pari can be flushed out with a saline purge and enema, and in- Bated with air through a long rectal tube ; and if the stomach is not dilated the vomit and clinical symptoms peculiar to gastrectasia are absent. It is on these considerations that the differential dia- gnosis is founded. A classification for use at the bedside should be simple and each division clearly characterized by distinct symptom groups. The disorders of diges- tion may or may not have a basis in pathological anatomy, and morbid tissue change may underlie or accompany the unhealthy variations in the phy siological process. We will, therefore, consider dis- coverable lesions as links in the etiological chain, and classify intestinal indigestion ac.-oidingly as the chemical or motor process or both are disordered. The third is a union of the first two varieties, which are joined by a common bond, the one being dietet- ic or neurosecretory, and the other neuromuscular. There are two sets of nerve fibres (or one set having a double function) controlling secretion, the one in- fluencing the functionating cells and the other the blood supply. The blood and the nerves, through their intimate relations with nutrition, commonly fall together, and it is chiefly a matter of historical or scientific curiosity as to which was first in the field ; when the patient consults the physician the two forces are usually closely allied in a self-de- stroying war. CLINICAL STUDY OF INTESTINAL INDIGESTION. h' [NTESTINAL INDIGESTION. 69 flower. The influence of the mind on function, particularly on digestion and nutrition, is very groat. This is the thread of gold, the bright line of truth, which runs through many a grand error or delusion. Suggestion (or expectant attention), all unconscious though it he, is the wonder-working power in amulets, relics, magnets, in "Christian science,'' in the "faith cure," in hypnotism. Dis- belief prevents or breaks the spell. The full confi- dence and hearty co-operation of the patient the physician must jjossess in order to be master of tlte situation ; and a hopeful, cheerful, contented mind is a power which makes for health. It is the business of the physician to instruct as well as to bless. To do the best that others have done and that he himself can think of for the relief or cure of disease is not the fulfilment of his high call- ing. The physician's office is a university hall as well. And the remarkable ignorance which pre- vails, among even the most enlightened people, of the plainest and simplest rules of healthy living, re- veals only too clearly the maimer in which these public duties are performed. Dyspeptics are as ignorant and perverse as little children, and we must first tell them how to keep well before direct- ing them how to get so. A very large percentage of the disorders of digestion are either caused or nurtured by bad habits, and it is most useful aud essential to enforce physiological living as regards bathing, eating, rest, exercise, work, sleep, clothing, mental and moral control. A good morale, physiological living, and a proper diet comprise the treatment of the mild cases. 70 CLINICAL STIDV OF INTESTINAL INDIGESTION. Benefit Avill also be derived from mild local and general faradism, massage and Swedish move- ments, outdoor life in a pure atmosphere, and gene- ral tonics. These patients with slight disorder of the digestive process are usually too much drugged. Thisoverzeal on the part of the physician is to he attributed to the impatience of the dyspeptic. Per manent results come slowly. The digestive organs have beeu habituated to the performance of bad work, and it requires time to eat away the iron chains. It takes anywhere from three months to as many years to correct the unhealthy variation, which has an inherent power of self-perpetuation, and to make, through force of habit, normal diges- tion the law of being. Physiology and pathology diverge on a plane inclined downward, and progress becomes faster and easier every day along the route selected by circumstance. Law is supreme and ir- repressible both in disease and in health, and we direct and fix the vital force in the right channel by the proper changes in the physical, chemical, nutritive, mental, and moral circumstances by which its action is conditioned. Not the relief simply, but the cure, of these chronic disorders of di- gestion requires time. But in the severe cases the treatment must com- prehend other remedies and meet other definite in- dications. The one general condition which rises above all others in its evil influence is self-infection. Careful alimentation and strong natural barriers (active oxidation and a good liver) will arrest or de- stroy, while active elimination will remove, the im- purities and poisons. The most powerful eliminat- CLINICAL STUDY OF INTESTINAL INDIGESTION. 71 ing agent at our command is water (pure, either at spring water temperature or hot) in large quantities. Self -poisoning is most frequent in indigestion ac- companied by dilatation and deficient peristalsis — in the motor variety of the disorder ; in a mild form it is not rare in chronic chemical dyspepsia. It is well known how frequent an accompaniment it is of acute dyspeptic attacks, both when primary and when engrafted on the chronic trouble. The special treatment of the disorders of the mo- tor process includes many remedies of very great power — electricity, massage, stomach and colon washing, abdominal support, and drugs which give tone and strength and regular action to the muscu- lar layer. Faradism is the form of electricity that is of greatest utility. Central galvanization, when both secretion and motility are faulty, seems to pay for the time expended in its application. The anode is placed over the cilio-spinal centre and the cathode is pressed in over the solar plexus, and an uninter- rupted current of about ten milamperes passed during a short seance. Mild general and local fara- dization imparts strength and tone to muscles and nerves. Local faradization also excites and regu- lates secretion. One broad electrode is placed be- hind over the cardia or lumbar region and the other slowly moved all over the stomach, intestine, and liver. With the intragastric use of electricity I have no experience. Massage, like electricity, strengthens the abdo- minal muscles, increases gastric and intestinal to- nicity and peristalsis, improves the local blood and ; .' CLINICAL STUDY OF INTESTINAL LNDIGESTION. Lymph circulation, and promotes secretion. The time, duration, ami frequency of the sittings and ruhbings arc determined by their objects and the effect produced, each individual case and Condition being a. law unto itself. Both remedies air contra indicated by inflammation, malignant disease, ul- ceration, and generally also by the active period of digestion. stomach-washing is a very popular remedial pro- cedure. I find myself using it less and less everj day. It is the remedy par excellence when there is spasmodic or organic stricture or obstruction of the pylorus. But in atonic dilatation the pylorus is yielding or already wide open. The stomach is then best cleaned and emptied by copious draughts of hot water, massage, and local faradization. This method stimulates and aids and encourages the or- gan to empty itself in the normal way. Stomach washing, on the contrary, leaves the viscus clean hut flaccid. The same objection applies, though in a less de- gree, to washing out the dilated colon. Mechanical distention does not improve tonicity and peristalsis. The procedure is useful to secure cleanliness while we stimulate and encourage by massage, electricity, and drugs the weak and lazy bowel to the perform- ance of its work. Sulphate of strychnine, in minute doses, is be- yond question the best drug for this purpose. Tim tures and wines aud syrupy mixtures are object ion able. Coca and damiana may also aid. Aloin, ipecac, senna, rhubarb, or stronger purgatives ma\ be required for constipation. CLINICAL STUD'S OF [NTESTINAL [NDIGESTION. 73 The abdominal or pelvic supporting band a a remedy in dilatation and displacement we owe to the genius of Glenard. II, should extend high enough to support the stomach when it is also di lated, and be loose above and lightest along the lower iliac segment. The relict is often instantane ous and remarkable. A silk-and- wool knitted ab- dominal protector may be worn beneath it. The special treatment of chemical dyspepsia is vested in remedies to regulate and supplement se- cretion. We possess few drugs which have a selec- tive action on the pancreas. Ether is probably one of them, but its value on account of this property is more than counterbalanced by the harm it does in other ways. Pilocarpine in small doses is a remedy of some utility and power. But to increase pancreatic secretion we are forced to depend od con- stitutional remedies — massage, electricity, and nerve tonics. It is equally difficult to supplement the pancreatic juice. Pancreatin given by the mouth is either wholly or partly destroyed, partly absorbed, and partly passed on into the duodenum. If ab- sorbed it is eliminated by the pancreas and liver, and in large doses may produce temporary diabetes by increasing the formation of hepatic sugar (De- fresne). Clinical experience commends its adminis- tration under the protection of bicarbonate of so- dium against the hydrochloric acid of the gastric juice. Many remedies promote the flow of bile, but nearly all of them possess the disadvantage of in- terfering with gastric or duodenal digestion. Merck's salicin sweetens and tones the stomach and in- 74 CLINICAL BTUDY OF [NTB8TINAL INDIGESTION. creases, bul aot to a very great degree, the flow of bile. It has not the inhibiting influence of salicy- late of sodium on gastric and salol on duodenal di- gestion. It may, however, be necessary to admin- ister a cholagogue, regard lessor the temporary harm which it does. The administration of bile by the mouth lias been highly praised by Dr. William H. Porter. Bile arrests artificial peptonization, hut in the stomach exerts no disturbing influence on the chemical process, increases secretion, sharpens the appetite, and promotes nutrition (Dastre, Oddii. Those are very strong statements, and are, of course, based on the introduction of a small quantity of bile into the stomach, from which it is absorbed to rapidly pass to the liver, the biliary salts thus gain- ing access to the entero-hepatic circulation. Bile is a digestive secretion, but an excretion as well. Nature and clinical experience seem to agree that it is well to keep it out of the stomach. A chola- gogue is more apt to put some new, fresh bile into the duodenum, where it seems to belong. My lim- ited experience with its administration by the mouth has been unsatisfactory. To increase intestinal secretion, ipecac in small doses is a pretty reliable remedy. Large doses of an alkali may be required to supplement the alka- line carbonate of the intestinal juice. To control gross symptoms we have all of the symptom drugs of the materia medica at our com- niand. We should be careful to select such as do least harm to digestion. Antiseptics are popular, but do not seem to do much good. Cleanliness and regular peristaltic drainage are much better than CLINICAL STUDY OF INTESTINAL [NDIGESTION. 75 antisepsis. Symptom drugs are rarely required if the remedies which impart systemic; and loc:al tone and strength, regulate or supplement secretion, and secure normal muscular movement are combined with a proper diet. There is no other disorder of digestion in which the dietetic indications are so clear and so absolute. Intestinal errors are final, and occur right in the gateway of nutrition. A certain degree of freedom can be given the gastric dyspeptic, for the duode- num may correct the blunders or negligence of its assistant. But the diet of intestinal indigestion must be marked out in hard-and-fast lines. In the one a limited license may be tolerated ; in the other the tyranny is unrelenting. In the one, concessions may result in a patched-up peace ; in the other, the rule is of iron. Additions to the diet may be cautiously and reluctantly made while the patient is under the eye of the physician, but in the beginning the control must be absolute and the firm grasp only slowly relaxed as the digestive ability of the intestine increases. I am now speak- ing of the cases in which there is an established defect of secretion or of motility, be it functional or organic, it matters not, so long as the Capability of the digestive system is the dietetic guide. The best diet in intestinal indigestion — audi state it with all the force of a wide experience — is a diet of lean meats. The worst foods are those that re- quire the bile and intestinal juice to digest and absorb them. Intestinal dyspeptics digest incom- pletely and with the greatest difficulty sweets, fats, starches, and wines. We know that a good deal I LINICAL BTUDY OF INTESTINAL [NOIGESTION. of starch in some way disappears in the absence of pancreatic juice, the steapsin only splits neutral fata into tatty acids -and glycerin -while cane Bugar is inverted almost exclusively by the intestinal juice. Milk occupies an intermediate position, be cause the intestinal juice lias uothing to do with its digest ion. It is a popular error to suppose thai this mixed food is chiefly digested in the stomach. The casein is divided by the Lab-ferment of the stomach into hemicasein-albumose, which is absorbed (with or without further peptonization), and caseogen, which unites with the alkaline earths to form cheese and passes with the other ingredients on to the duodenum (Arthus). In the beginning milk may completely relieve the gastric symptoms, hut the objections to it are fatal. It does not give the duo- denum rest; it contains fat, lactose, and casein ; an excessive quantity must be given to maintain nutrition ; it cannot be employed when gastric di- latation is present as a complication. An exclu- sively milk diet is essentially a starvation cure (Ewald). Whatever be the explanation, the phy- siologist and chemical pathologist may decide. I base my contention on clinical experience, and 1 know that a diet of lean meats is the one most cer- tain to give brilliant results. The diet may be ar- ranged in three classes — the exclusive, rigid, and advanced. Exclusive Diet. — The lean meat of beef or mut- ton and the white meat of chicken. The muscle pulp, free from fat and fibrous tissue, of the adult animal only is permitted. The American chopper in this country, and the ( lalante -Debove pnlpifier CLINICAL STUDY <>i-' [NTESTINAL [XDIGESTION. 77 in France, are the best instruments. Skimmed meat juices. Whites of eggs cooked just enough to hold together. And to this list maybe added Mosquera's beef meal. Lemon juice with or with out horseradish. A cup of weak coffee or tea with out sugar and cream, or a glass of hot water. This is the diet of the severest cases, and is soon supple mented by the articles of the second class. Rigid Diet. — The articles of the exclusive diet. Broiled beefsteak or roast beef. Roast leg of mut- ton or broiled chop. White meat of fresh fish (sole. whiting, flounder). Soft part of raw, roasted, or broiled oysters. Cooked celery, watercress, crust of stale French roll. Dry toast with a little butter. Clear and unsweetened coffee or tea. A little di- luted brandy or whiskey may be tried. Advanced Diet. — To the preceding articles may be added broiled game, venison in season, sweet- bread, eggs (poached), rice, cracked wheat, Califor- nia wafers, wheatina — thoroughly cooked. Baked floury potato, French peas, string beans, tomatoes, and spinach (if no lithaemia). Purees of fresh vege- tables. The juice of a few grapes. Milk warm from the cow or sterilized as soon as drawn. Tea or coffee without cream or sugar. Light claret or old dry sherry. A little Worcestershire sauce. N< > veal, lamb, hog meats, goose, duck, cod, herring, salmon, or other very firm and fat fish ; no old or raw vegetables, pastry, very acid or sweet fruits ; no cheese. This dietary is adapted alike to the chemical and motor varieties of dyspepsia, the varying element being the quantity of fluid taken with the meals. > CLINICAL BTUD1 OF [NTBSTINAL INDIGESTION. The dry diet, firsl advocated by Chomel, is to be used in dilatation and deficient secretion. The five or six ounces of fluid should be slowly drunk after tlif meal, so that the stimulating action <>f the dry food on salivary and gastric secretion may be ob tained. Starving these patients for fluid will not cure them; in the interval (which should lie long) between meals enough water should be ordered to keep the urine in the proper condition, avoiding distention of the stomach and emptying it by the means already delineated. Hot water is rapidly absorbed and promotes downward peristalsis, in- creases primary oxidation and elimination, and is almost essential in the exclusive diet. In hyper- chlorhydria water can be taken freely as a diluenl and to prevent pyloric spasm against the passage of a hyperacid chyme. Detailed and dogged supervision is the price of success. To prescribe a diet and then not to Bee that it is digested and assimilated is to court failure. By the right quantity and quality of food and wa- ter the urine should be kept free from deposit, of normal slight acidity, of specific gravity about 1.014 or 1.018, and without excess of coloring mat ter ; the stools healthy, the patient without local distress related to eating and without abnormal flatulence, and the blood gathering haemoglobin and red corpuscles. These are the clinical guides in the continued use of the systematic treatment. Intestinal indigestion is not curable by drugs alone. The treatment must draw on a richer store of remedial powers. The much-drugged and neg- lected baby soon withers and falls away ; the well- clinical study OF [NTB8TINAL INDIGESTION. 79 fed and carefully nursed child is of more vigorous growth. The one is a flower without roots and as weak as a life without good hygiene and the righl foods. The very drugs, the warm sunshine which should be its strength, only hasten the approaching decay. Curative treatment is of a more vigorous growth, running down into the underlying sysi»- mic causes and twining its tender feeders about each unhealthy variation, and rising in its gathered strength, through physiological living, normal secre- tion and excretion, and careful alimentation, to a right performance of all the nutritive processes. We treat digestion, nutrition, and the nervous sys- tem, the physician and patient standing shoulder to shoulder in the struggle to bring the organism under the dominion of the gentle forces which make for health. The powers of evil that one can- not stay with iron chains the sweet influences of hope, contentment, and quietude will sometimes lightly bind. CHAPTEE IV. THE I M'sA'l'h »N Wl» TREATMENT OP CHRONIC DIARRHCEA. Iris not always possible to connect chronic diar- rhoea with a distinct lesion of the intestine, aor can we limit its origin to functional or organic defect of the digestive system. It is by no means rare to find it one of the symptoms of disease of a distant organ, or disorder of nutrition, or defect of elimination. But chronic diarrhoea is a symptom so frequent thai ii may serve as a convenient point from which to begin investigation, so important as to often com- mand our whole attention, and so predominant as to dictate the treatment. WTienever present it -lands out in bold relief in the clinical picture and necessitates a search for its hidden meaning. The term " chronic diarrhoea " may be made to serve a useful clinical purpose, and no apology need he of- fered for selecting it as the subject of a paper based on invest igations at the bedside. Fluidity is the most const ant characteristic of the diarrhoea! stool. This physical qualit v results from excessive secretion or transudation, or increased peristalsis and diminished absorption. The stools are also altered chemically and microscopically, but the character of the discharges varies very much with the age, diet, the nature and location of the disturbance. The frequency of the evacuations is TREATMENT OF CHRONIC DIARRHOEA. 81 also no criterion, and varies widely both in health and in disease. But habit and oilier influence establish a certain routine which, though it varies with each individual, maybe taken as a standard. The character and freijuency of the stools Avill nearly always enable us to make out the presence of the symptom. Moreover, diarrhoea, whether conservative or not, is always an exhausting pro- cess, and when long continued must inevitably af- fect the general health. Hence chronic diarrhoea maybe denned as the frequent evacuation of the fluid, and usually abnormal, contents of the intes- tine, with more or less impairment of the general health. A classification of chronic diarrhoea based on the changes in the stools is not desirable. A careful study of the stools will not fail to yield some useful information. But in the same case the character of the stools varies from day to day, and bears no defi- nite relation to the lesions. A classification based on etiology would be more scientific, and stands in direct relation to the ad- vanced treatment which strives to go beneath the surface and strikes at causation. A careful review of the possible causes will aid very much in formu- lating a rational treatment, but our knowledge at present is too incomplete to enable us to make a scientific etiological classification. A nomenclature based on pathological findings is neither desirable nor practical. Morbid ana- tomy is only a symptom of unhealthy cell activ- ity, and widely different processes find expression in the same tissue changes. But the lesions must 6 THE CAUSATU >N A.ND be taken into consideration in formulating the treat int'iit. In studying a case of chronic diarrhoea I con- stantly keep before me t wo objects of commanding importance : the detection of the proximate and re- mote causes, and the discovery of the nature and Location of the intestinal lesion. In this way we gain all the information that is of mosl value in the management of the case. The proximate cause of every diarrhoea is Located in the intestinal wall. The intestine is a secretin-, absorbing, and eliminating tube, which propels its contents in a peculiar way, and in which the most important part of digestion takes place. In diar- rhoea too much fluid is poured out from the mucous membrane, or too little fluid is absorbed, or the contents of the intestine are hurried along too rapidly. It is common to find two, or even all, of these factors active in a particular case. Diarrhoea from supersecretiou is a frequent va- riety. It is commonly due to local irritation, with here and there patches of catarrhal inflammation, Jt is also found in chronic nerve or blood states, and may often he traced to auto-infection as the remote cause. Chronic dyspeptic diarrhoea maybe taken as the type of this form. Much mucus and a dis- proportionate quantity of undigested food, espe- cially starch, are found in the stools. The excess of fluid may be an exudate, as in a condition of the mucous membrane analogous to an ec/eina or herpes. Or the fluid may he transuded in passive congestion, such as occurs in hepatic cir- rhosis, obstructive disease of the lungs, or imcom- TREAT.VIKNT ni<' cllljo.MC DIARRHOEA. 83 pensated valvular disease of the heart. The pathog- uomonic sign of this variety is the presence of serum albumin in the stools. The intestinal mucous membrane is also an eli- minating organ, and diarrhoea is qo1 rarely due to exaggeration of this function. The diarrhoea of chronic Bright's disease and septic* emia are I y | m is of this form. Diminished absorption maybe the starting poinil of a diarrhoea. But a diarrhoea originating in this way will not long remain simple, as the resulting superdigestion, fermentation, and putrefaction will produce supersecretion, exudation, and excessive peristalsis. Impaired absorption always forms one of the links in the etiological chain, and has as much to do with the persistence as with the causation of diarrhoea. The stools contain completely digested products. Diarrhoea from excessive peristalsis is neuromus- cular in origin, and occurs in its simplest form in neurotics with lively reflexes or with hypersesthetic mucous membranes. Exaggerated peristalsis, how- ever, usually results from a local irritant. A stool occurs regularly and rapidly after each meal, and consists chiefly of unaltered food. From this it will appear that diarrhoea is wholly or in part a conservative process in every variety, except that which is purely nervous in origin, and this variety, it must be admitted, is but rarely met with. These divisions are based on unhealthy variations in the physiological processes — the surface-play of concealed forces. While it will not clearly reveal, M THE CAUSATION wi- the manner of appearanoe of tho diarrho>a will sug- gest the salient features of the underlying disturb ance. Tho kind of fruit or flower will enable us to infer something of the nature of the seed and the development of the plant. It is always difficult, and sometimes impossible, t<> discover the remote cause, be it located iii a disorder of nutrition or hid- den in the disease of a distant organ. Disease <»f the kidneys, heart, liver, lungs, and spleen must usually be well marked in order to pro- duce a diarrhoea. Anaemia, gout, leukaemia, Hodg- kin's disease, scurvy, syphilis, tnhercnlosis, and septicaemia must also he passed in review and ex- cluded. A very large percentage of all cases of chronic diarrhu'a find their origin in derangement of one of the three great processes of nutrition —digestion, ab- sorption, and metabolism. The perfection of each one is essential to the integrity of the whole ; tins constitutes the solidarity of the nutritive proce- From a therapeutic standpoint it is of great utility to locate the primary disturbance. The presence in the urine of the incompletely elaborated products of tissue waste, such as uric acid and the mates in ex • ess, and of pathological urobilin, would point to faulty kataholism ; peptones, albumin, or sugar in the urine might implicate assimilation ; while the discovery in the stools of the digestive products in a fluid and diffusible form would suggest defective absorption. But the nutritive disorder more often takes its origin in the digestive tube, either in ga.-t ric d\ spepsia or inflammation, with alteration either in the chemical process or in the muscular movement - ; TREATMENT OK OMKONIC DIARRHOEA. or in intestinal indigestion from faulty chyme, bile, pancreatic secretion, or intestinal peristalsis. An insufficient diet, of which simple emaciation will be the evidence ; unhealthy food and impure drinking water, an improperly constituted diet, will often l»<- found the initiating causes, though secretion and muscular movement be in every way normal. An important connecting link in 'the causation of chronic diarrhoea is auto-infection, which may be from the digestive or from the general system. Absorption of the products of superdigestion, fer- mentation, and putrefaction is one source ; defects of assimilation and disassimilation, increased cell activity and tissue waste, and incomplete elimina- tion are others. The quantity of toxin es formed in health may be increased, or new ones may be manu- factured in defective nutrition, or bacterial pro- ducts be absorbed, and self -poisoning will result un- less elimination is very rapid. Some of the toxines dilate and others contract the blood vessels ; some alter the blood as well as the blood pressure, thus impairing secretion or causing exudative or produc- tive inflammation. Some paralyze, others excite, the nerves ; all exercise a pernicious influence on nutrition. The prevention and treatment of auto- infection is the most important part of the manage- ment of chronic diarrhoea. It has been ably maintained that we never have a diarrhoea without the presence of an enteritis. But it is now a fact pretty well established by care- ful autopsies that diarrhoea frequently is not ac- companied by noticeable lesions of the intestine. From a practical point of view the detection of the THE I LUS \ rioN \ND cause is of much greater utility than the diagnosis and location of the lesion. The chief advantage of a knowledge of the anatomical state of the mucous membrane is the light it throws on prognosis. But the nature and Location of the Lesion afford certain indications in treatment. I have been in the habit of grouping all my ca into two la rge classes, according as tin-re is or is not a marked lesion of the intestine, and try to de* cide whether or not ulceration is present. This classification is somewhat arbitrary, but it is usu- ally possible to group the cases on this wide basis. Our standpoint is at the bedside, and this broad classification, in which minute anatomical distinc- tions are not made, has a practical bearing. In the functional disorder the symptoms are mild or and may be intermittent; there are no persist- ent [joints of tenderness and no thickening of the bowel, and the stools contain no products of inflam- mation. A large number of chronic cases with intestinal lesions follow acute attacks that have their remote cause in the digestive system, or form part of the clinical history of the acute infectious diseases. The persistenceof pain, tenderness, and fever would indicate the presence of an important lesion. The discovery in the stools of much epithelium, mucus, and unaltered bile pigment, of pus, blood, false membrane, and pieces of tissue from the intestinal wall, would ] >rove the trouble to be organic. Chronic gastritis with chronic diarrho -a is accompanied by chronic enteritis. Ulceration of the intestine is simple, syphilitic, TREATMENT OP CHRONIC DIARRHfEA. tubercular, or malignant. The signs of a Lesion, in many cases the strict localizal ion and persistence of a painful and tender point, the presence and con- tinuance of much pus, blood, and mucus without tenesmus, and the detection of bowel tissue in the stools, establish the diagnosis of ulceration. Intes- tinal carcinoma is usually locate* I in the rectum, and can commonly be felt by the finger throng] 1 the anus ; cachexia and rapid decline will also point to malignancy. Simple ulceration results from a se- vere catarrh, or from acute or chronic follicular in- flammation, and commonly involves a large extent of surface. Syphilitic and tubercular ulceration is more strictly localized, and the disturbance of the digestive process above the lesion is from excessive peristalsis. In syphilis we may get a specific his- tory or characteristic skin lesion, or a persistent headache with periodical exacerbations and at- tended by insomnia and unwonted irritability of temper, an early endarteritis, or other sign of this protean malady. Tubercular ulceration is almost never found apart from pulmonary tuberculosis, and the rapid pulse, dry skin, hectic fever, and lo- calized physical signs will confirm the suspicion. The absolutely pathognomonic sign is the discovery of the tubercle bacillus in a shred of the bowel tis- sue found in the stools. The character of the stools, the persistent points of tenderness, and other physical signs, taken along with the clinical history, will locate the lesion with a good deal of exactness. The lower the lesion the more frequent and more painful are the move- ments. It is rare to find the small bowel alone dis- 88 THE < A.USATION A.ND eased. The large bowel is nearly always involved. Commonly associated with it is disease of the lower ileum. It is near the ileo-caecal valve thai bacteria aboundj that fermentation and putrefaction are mosl active, that irritants long remain in contact with the mucous membrane. When either the small intestine or the colon i> alone diseased there will be periodical attacks of diarrhoea; when both are involved the diarrhoea is likely t<> be continu- ous. Pain occurring jusl before a movement is usually located in the colon. Tenesmus is presenl only in proctitis, [ndicanuria, tally stools, recur- ring shghl icterus, and persistenl flatulence in the small intestine are pathognomonic of duodena] de- fect. Much unaltered bile pigment and mucus in- timately mixed with the fasces point to the small intestine. When the trouble is located in the as- cending colon the stools are soft, muco-feculent, and little yellow globules of mucus are visible, and hard fecal lumps coated with mucus from the lower half of the large gut. When from the rec- tum the stools consisl of yellowish or blood-stained white-of-egg mucus or mucus and fibrin shreds ; and the lower colon ami rectum may furnish ;i shred or cylinder. Conned of a network of fibrin tilled with mucus, with here and there an epithelial cell on the surface, or exfoliated casts of false mem hrane. Having briefly reviewedsuch points in aetiology, differentia] diagnosis, and Localization as can he utilized at the hedside. turn we now to the treat- ment. Good hygienic surroundings, a regulated lite, and TREATMENT OP CHRONIC DIARRHCEA. 89 a proper .diet will often suffice to cure a mild diar rfioea. But the severe cases must l>e subjected to a rigid regime. Many of th<'se patients have tried everything, done nothing thoroughly, andlostfaith andhope. An important strategic point is already gained if we win the confidence and arouse so strong a desire to get well as to cause every energy to be bent in the direction that we dictate. The successful management of these cases depends as ninch on the co-operation of the patient and the de- tailed observance of directions as on the skill of the physician. It is not enough to order, but instruc- tions must be carefully and cheerfully obeyed. Of so great importance are co-operation and attention to detail that I no longer try to cure these patients against their expectation and will. They must ac- quire a soul-forwardness toward health — every thought, feeling, and emotion must be enlisted in the work. Having secured the confidence and hearty co-ope- ration of the patient, we give minute directions as to clothing, bathing, rest, and exercise. From mal- nutrition and auto-infection the vaso-motor centres are weak and irritable, and paling of the surface leads to a corresponding internal congestion. Hence the necessity for warm clothing, especially over the abdomen, to protect against sudden chan- ges or extremes of temperature and loss of body heat. The rapidity and completeness of reaction guide in the selection and the mode of bathing. In the beginning a warm plunge or sponge bath in a warm room should be advised, and the difference between the temperature of the air and the water 90 THB CAUSATION AND cautiously increased from day to day. The bath Improves the function and nutrition of tin -skin and tones the nervous system. It has been demon- strated that the toxicity Of tli<- urine is increased during the administration of the Brand treatment of typhoid fever, and the increased elimination of fcoxines is qo1 the least of the henetits derived from bathing. If the stools are frequent and exhausting, absolute rest in bed must lie enjoined ; during con- valescence moderate exercise and fresh air will has- ten the cure. Overfatigue, mental and physical, must be scrupulously avoided, temperance and moderation being the guide of conduct. The mode Of life must he put on a physiological basis and .is much energy and vitality conserved as possible. The curative treatment of a chronic diariboal disease has very little to do with the control of the symptom by the use of opiates and astringents ; Ave must go behind the lesion of the mucous membrane and strike boldly ;it causation. Behind the veil a re the hidden forces at work, beneath the surface are the sources of evil. It is a waste of time to strike at the shadow; it is useless to close the volcano's mouth while the subterranean fires are still burn- ing. The curative treatment of a chronic diarrhoea must be aetiological. Active elimination by all of the emunctories is also a sheet anchor in the treatment of chronic diarrhoa. Free drainage is the first law of surgery, and free drainage is a controlling principle in the treatment of a chronic disease accompanied by or resulting from auto-infection. We have already seen that a chronic diarrhoea is largely a conservative process, TREATMENT OF CHRONIC DIARRHOEA. 91 ;in septic wound. Checking a chronic diarrhoea by astrin gents and drugs that paralyze muscular movement before the digestive tube is made clean and sweet. can only produce a violent explosion which will widen old rents or find new points of exil where resistance is weakest. So great is the danger of auto-infection from the alimentary canal that Na- ture has well barricaded the system against inv,i sion from this quarter. An active peristalsis tjp di- vert the enemy, mesenteric glands and the liver to arrest and destroy, oxidation to burn, the skin, kidneys, and liver to turn aside or sweep away— these are the strong barriers which our treatment must support and strengthen. Impaired digestion, defective absorption, malassimilation, auto-infec- tion, are heavy blows against nutrition. To build up the blood so that it may perform its work is a controlling object. Healthy nutrition is a hope that only careful alimentation can realize. These are the important general considerations : on the one hand the bright side of the shield, a well-fit- ting armor, a determination to conquer, and on the other the removal of the cause, careful alimenta- tion, and active elimination. Of no less importance are the local indications : 1. To cleanse the alimentary canal and keep its con- tents sweet. 2. To secure perfect digestion of the food taken. 3. To promote absorption. 4. To di- minish the work of the diseased part. 5. To treat the lesions, 6. To treat the sequela?. 7. To con- trol the harmful symptoms. Our first object is to cleanse the alimentary canal, !•■.' THE CAUSATION \ SD and cholagogues ami purgatives will render efficienl service iD its accouiplishmeiit. An increased flow of healthy bile will meet more ilian one indication it is not irritating, is Laxative, and also aids in digestion, absorption, and the prevention of decora position. Podophyllin, ipecac, salicylate of sodium (or, better, salicin and bicarbonate of soda), and the bichloride and biniodide of tnercury arc the mosl useful cholagogues. To gel their selective action on the liver these drugs should begiveniu minute doses. Small doses of calomel also acl well, espe dally if the kidneys are sound, or the heart dis- eased, or arterial tension is high, or the bile ducts distended. Cascara sagrada is the mosl valuable laxative -it inriv;is,s peristalsis hy its act ion on the nerve -apply of the intestine, washes out the glands and follicles by augmenting their secretion, ami in laxative doses is unirritating, an important negative quality thai often secures for it prefer- ence. Those drugs should be, selected which least irritate the diseased part ; too much care cannot he exercised in this respect, as these remedies cut both ways ami can do harm as well as good. Stomach washing will also help us to clean a pari of the ali mentary canal. When this important viscus is di- lated and incapable of emptying itself completely, when the muscular movement is defective and the food is fermenting, decomposing, or undergoing superdigestion, the procedure is a valuable one, hnt must not he repeated too frequently. But when not dilated, and strong enough to empty itself, the stomach can be efficiently ami agreeably washed out by copious draughts of hot water. Hot water TREATMENT OP CHRONIC DIARRHGCA. 93 is also a powerful hepatic stimulant, Liquefies iln- hile, and washes out the Liver, which is often in fected from a septic, duodenum or through the por tal vein or hepatic artery. The liver is the greal ccniral depot tor the, arrest, destruction, and elimi nation of toxic material, and the entero-hepatic circulation should he frequently flushed out. Hot water does this very rapidly and efficiently. The large bowel is the seat par excellence of fermenta- tion and putrefaction, and the most frequent source of auto-infection. It can he thoroughly washed out with warm or cold water, to which an alkali should he added if there be much mucus in the stools. The use of antifermentatives and antisep- tics is rendered necessary by the inefficiency of lavements, cholagogues, and laxatives to accom- plish our purpose — the cleansing of the digestive tube. I use only a few of the drugs of this class, the- ones that I have found the most efficient — sali- cin, the biniodide of mercury, salol, and the subni- trate of bismuth. Salicin is the best sweetener of the stomach, given in ten- to twenty-grain doses, two hours after meals, or one hour before breakfast and retiring. The biniodide of mercury is valuable in small doses when the decomposition is in the small bowel, chiefly on account of its action on the liver. Salol is by far the best duodenal antiseptic. These three drugs act locally, and also by exciting a free flow of the natural intestinal antiseptic — healthy bile. Cholagogues spur onward the entero- hepatic circulation, as Kosenthal has shown that both bile and the biliary salts are hepatic stimu- lants. Calomel is also an antiseptic-, and some aid 9 t THE CAUSA HON AND is derived from its passage along tin* intestine. Subnitrate of bismuth reaches fche Large bowel, but is ii"t of much value unless given in very large doses. These drugs are very useful in combating putridity and maintaining fche sweet oess of fche ali mentary canal. It has been suggested thai bacteria have something to do with digestion ; L gravel] suspecl thai enough will be left for this purpose after we bave exhausted our means in fche efforts to exterminate them. It is also important fco administer clean and sweel food and pure drinking water. This is a matter of more moment than fche little attention we bestow upon it would seem fco indicate. How rapidly a septic colitis subsides when an impure drinking water is withdrawn ! How great a change is some- times wrought by forbidding a food that is \<«> "high" or lias not been scientitieally prepared? Attention to little details like these sometimes changes fche whole course of the disease. Having secured, as nearly as we can, a dean and sweet state of the digestive tube, our next object is to get perfect digestion of the food taken. This is an aim second to no other in importance. Undi- gested food in the wrong part of the intestine is an irritant. Rapid absorption is the chief barrier against superdigestion, fermentation, and putrefac- tion, and perfect digestion is the essential prelimi nary to the easy and healthy performance of this function of the mucous membrane. We attempt to realize this high aim by a proper diet, and by increasing or supplementing whatever digestive juice we have reason to suspect is defective. If th ■ TREATMENT OF CHRONIC' DIARRHOEA. 95 stomach is at fault in its chemical work we keep our eye on the acidity of the secretion, for the EC! is an important and the most frequently varying constituent of the gastric juice. The dilute EC! should he given in two or three doses of live or leu < I rops each, within two hours following the meal, and a small quantity of fresh pepsin may be added. I suspect that a dose of toxines is often given in the name of this ferment. In the meantime we give such drugs as are known to increase or dimin- ish the acidity of the gastric juice. If the liver or pancreas he at fault we use the drugs that have a selective action on these glands, and supplement with fresh bile and pancreatin by the mouth. It is best to precede their administration by an alkali. The time of giving them is two and a half or three hours after meals, except on the milk diet, when the proper time is just before each feeding. 'Duo- denal digestion is thus made to begin in the sto- mach. If the muscular movements of the stomach and intestines are defective, strychnia, massage, and electricity will render important aid. Diar- rhoea not infrequently has its cause in localized de- fective peristalsis — the contents collecting in the weak and dilated parts and undergoing putrefac- tion, fermentation, and hardening. With a clean digestive tube, the secretions and movements of which have been regulated and supplemented, it remains to select a proper diet. This is the most difficult and most important part of the treatment. And here the physician should dismount from his "■hobbies'- and renounce so-called '"fads" and " cure-alls." Vegetarianism will rarely fail to do a 96 'I'll I : l IUSATION \M> good deal <>i harm ; the milk diel in its many forms is noi a panacea ; a diet of animal food will not often fail t" benefit, and has a very wide range of usefulness. In selecting a diel wq have a good many things to take into consideration. The evils of exclusive iics^ .ill are ready to admit. In any dietary the primary principles must be made t<> preserve a cer- tain proportion in obedience to the laws of physio- logical chemistry, and such proportion arbitrarily altered i<> suit the needs and capabilil Les of general nutrition. But laboratory results need to lie cor- rected and controlled by the testimony of the hu- man digestive system. The diet habits of mankind and of the different nations of the earth furnish a rich store of information; for man. when per- mitted to do so, eats what most pleases the palate, keeps him well nourished and strong, and gives the Least after-pain. Climate, age, activity, peculiari- ties, and the capability of the digestive organs are other important considerations. Now, in the diet of a chronic diarrhoea the food must he chietly digested by the stomach, contain the right propor- tion and proper quantity of proximate principles to meet the requirements of secretion, nutrition, and the production of animal heat, and leave no ir- ritating or indigestible residue. Denutrition must be guarded against, and the diseased intestine given physiological rest and kept free from irritation. An exclusive diet of milk, or a diet of meat free from fibrous tissue, would fulfil these indications — the one more completely than the other, perhaps— but both must be perfectly digested. Milk is a fluid, TREATMENT OF CHRONIC DIARRHCEA. '■>', but becomes semi-solid during digestion. Meat is a solid, but becomes a fluid in its preparation forab sorption. Milk may be a little more easily assimi- lated, but, bulk for bulk, is not so nutritions. The final product of the perfect digestion of the one is about as easily absorbed and unirritating as that of the other. Both require great care in selection and the meat must be properly prepared and cooked. However, it is difficult to get, day after day, milk which is free from pathogenic bacteria : it readily undergoes, both in and out of the stomach, chemical and bacterial changes with the forma- tion of irritating and poisonous products ; and I have found it well-nigh impossible to secure ifs con- tinued perfect digestion during a period long enough for a cure to take place. When the gastric juice is hyperacid, or duodenal catarrh or portal congestion or excessive fermentation is present, milk will not agree. The supreme test is the one at the bedside. In my experience a meat diet is much more valu- able, less dangerous, and of a much wider range of application than milk in the treatment of chronic diarrhoea. Exclusive in the beginning, the meat must be supplemented by bread, cereals, and the more easily digested vegetables in the manner de- tailed by me in a paper printed elsewhere in this book. 1 It is the duty of the physician to see that whatever food be taken is completely digested and assimilated, and he has in the daily physical exami- nation of the digestive system, and the analysis of the urine and the inspection of the stools as often 1 See clinical paper " On the Treatment of Functional and Catar- rhal Diseases of the Stomach and Bowels," Appendix, p. 113. 7 THE CAUSATION \N!> as may be necessary (aided, if needed, by the micro- scope), a pretty sure guide. It' the patient feels no pain nor discomfort nor drowsiness after meals, if there is no flatulence, if tin mine contains no al> normal coloring matter nor excess of phosphates, orates, or uric acid, and the Btools contain no undi- gested products, we know thai the food is being digested and assimilated, and. if there be no Loss of strength, absorbed in sufficient quantity to meet the demands of life. To avoid denutrition is not alone requisite: the barriers musi be made strong; the body must be protected and defended and built up. Not only a pure and adequate hut also a rich blood is needed. And the quality of the blood, its gain or I"-- of richness from day to day. can be detected by count ing the corpuscles and measuring the haemoglobin. No physician would now assume the management of a disease of the heart <>r lungs without the evi deuce and guidance of physical signs. No physi cian should now attempt to diagnosticate or treat a disease of nutrition without a study of the blood and excretions. When we have an alimentary canal clean and sweet, and the lining washed free from mucus, con t a ining a completely digested and uninilai ing fluid, much has already been done to promote absorption. An active entero-hepatic circulation and the control of excessive peristalsis Bhould complete the work. The relief of portal engorgement and the slhnn Lating of the liver will aid the one, while the re moval of local irritation and the quieting of the nerve endings and centres, and the strengthening TREATMENT OF CHRONIC DIARRHCEA. 98 of them by active elimination and improved nutri- tion, 'hav.e done much to realize the other. These are the curative means, hut it is often necessary to control excessive peristalsis in order to keep the contents in contact with the mucous membrane long enough for absorption. Antacids, bismuth, and antispasmodics should housed instead of opium and narcotics. The control of flatulence also in- creases the absorptive surface. The value of rest in the treatment of a disordered or inflamed part cannot he overestimated. .Repair is more complete, healing goes on more rapidly. An exudation in the process of organization is easily broken up by movement. Absolute rest of a dis- eased intestine cannot be attained without stopping drainage, but a great deal can be done by keeping the part free from irritants, and by the use of drugs that will lessen the exaggerated irritability, that will quiet the pathological unrest. The diet should also be selected so as to diminish the work of the diseased part. When the duodenum is the centre ( >f disturbance (as it often is) the stomach must be made to do the work. When the disease is lower down the diet must be such as is quickly digested and rapidly absorbed, and excessive peristalsis con- trolled. When the stomach and duodenum are able to do their work well, and the disease is in the colon only or low down in the ileum, a milk diet, if it agree, is superior to any other. In the severe cases of chronic diarrhoea, when the muscular layer is atrophied or cedematous, or infil- trated with inflammatory products, constipation is very apt to supervene as soon as irritation is re- Id" THE CAUS LTION A\i> moved. 1 would like to emphasize this important clinical fact thai these weak points in the intes- tinal wall are often Localized, and the obstruction in tli«' drain must be overcome by massage, laxa- tives, and lavements. To clear oul these depots of fermentation and putrefaction Is an essential pari of the treatment ; until this is done there can be no rest, no healing. The indications afforded by the Lesions have been partly me1 by cleanliness, rest, and the prevention of irritation. If the lesion be syphilitic, specific treatment must not be neglected. When situated in the Large bowel something may be accomplished by medicated Lavements. The treatment of the sequelae resolves itself into the treatment of atrophy and deformity- the re suits of degeneration and destructive inflammation. A proper diet and a regulated Life will aid Nature in the readjustment of the organism to the changed conditions. The deformity may demand the sur- geon's skill. The special and general treatment of chronic diarrhoea must often lie modified or supplemented by the treatment of the causative disease. In conclusion, the indications for the treatment of chronic diarrhoea may he thus briefly stated : 1. To remove or treat the cause, which presupposes iis detection. 2. To improve nutrition and conserve energy. 3. To secure active elimination and pre- vent auto-infection. 4. To cleanse the alimentary 'anal and keep its contents sweet. 5. To secure perfect digestion of the food taken. <>. To promote absorption. 7. To diminish the work of the dis- TREATMENT OP CHRONIC DIARRHOEA. L01 eased part. 8. To treat the lesions. 9. To treai tlie sequoia;, lo. To control the harmful symp torus. A broad and comprehensive and a'tiological treat- ment, and one which I have found successful — a union of many powers which make for health, a union in which "all are needed by each one." It is not sufficient to meet the controlling indications, but regulations must descend into minute details. The moral management of the patient has a power- ful and practical bearing. Two important elements of success are individualization and the persistent doggedness with which one enforces right living. The prescription of drugs is a very small part of the work which we have to do. The chief aim, the definite therapeutic purpose, is to secure healthy nutrition by careful alimentation, perfect digestion, and complete elimination, thus keeping in active circulation a pure and rich nutritive fluid. In no other way can we control and strengthen cell life than by placing it in the best environment and ob- taining the substitution of new protoplasm for that which is old and diseased. This is the basis of cure, the grand purpose which gives unity and system to the management. CHAPTER V. THE CURATIVE TREATMENT OF HABITUAL CONSTIPATION. Habitual constipation, as it will be considered h\ this short chapter, may be defined as chronic inade- quate intestinal peristalsis. The defect is a purely neuromuscular one, and must be carefully differ- • utiated from cases in which there is more or less stasis and retention of the intestinal contents from obstruction. Here it is not inefficient peristalsis, but the obstruction, whatever be its nature, that is the disease. Peristalsis is normally under the control of the nervous system through the reflex stimulus of the intestinal contents, and consequently there are three ways in which the disorder maybe produced — by defect on the part of the nervous system, or of the muscular layer, or of the peripheral excitation <>l the sensory nerves of the mucous membrane. Now, the one fact, on which a good deal of what follow s will be based, is that the normal stimulus of intes- tinal peristalsis is the unabsorbed product of healthy digestion, and, consequently, when there is no pri- mary neuromuscular defect we must look for the origin of the trouble in indigestion, defective secre- tion, or in the quantity or quality of the food and drinks. TREATMENT OF HABITUAL CONSTIPATION. L03 The physical properties of the intestinal contents depend on the nature of the diet, the quantity of fluid swallowed, and the rapidity of absorption and elimination. In polyuria, and when too little water is drunk, the faeces quickly become hard and dry. Absorption from the stomach and the duodenum is not very great as compared with its activity lower down in the small intestine and in the colon. A diet containing a large quantity of indigestible mat- ter will prove to be mechanically too irritating. An abuse of starches is the most common cause of dis- ordered peristalsis depending on the nature of the diet. It has been demonstrated on a grand scale that the starchy army diet produced either diarrhoea or constipation. And it has been conclusively proven that when fatigue, irregular habits, and unsanitary surroundings are excluded, a diet of starches, in healthy men, causes constipation and diarrhoea. Severe irritation sets up diarrhoea. Mild, long-continued irritation will just as surely establish constipation. The mucous membrane be- comes too tolerant. Habitual constipation may be either the cause or the result of disordered digestion. We have already seen in the preceding chapters how intimately as- sociated are the chemical and motor functions of the digestive tube. The digestive changes that the food undergoes are about finished at the ileo-caecal valve. The chemical alteration of the food mass in the colon is chiefly due to organic fermentation and decomposition, and, by a beautiful provision, nature has made these decomposition products (scatol, H 3 S and C0 2 ) the active exciters of peristalsis. I" I THE CURATIVE TREATMEK I But, union unately, these substances are more or Less poisonous, and when nol expelled undergo absorp- tion along with abnormal products, and coprsemia with its restlessness, giddiness, insomnia, pains and mental depression, anaemia, chlorosis, palpitation, cold hands and feet, and digestive disturbances, results. A.uto-infection disorders digestion, de- ranges the nervous system, and lowers nutrition. It is thus thai the vicious circle is established and continues its unceasing revolutions. The constipa- tion results from the diminished sensibility which follows the chronic irritation or inflammation or distention produced by the imperfectly digested and decomposing and fermenting food mass. In the same way constipation originates in the abuse of purgatives and neglect of the normal promptings of nature It is the pill-taking American, and mod- est woman, and husy or lazy or negligent man who most often contract the habit in this way. WTien the call to stool is unanswered the faecal matter is either regurgitated by reversed peristalsis into the sigmoid flexure, or accumulates unheeded in the tolerant rectum to undergo hardening by absorp fcion. Thus is the unhealthy variation established by had habits and unphysiological living. We have already considered the relation of neu- rasthenia to the neuromuscular form of dyspepsia. Peristalsis and tonicity are inadequate, because too little nerve power is radiated out to the mus cular system. There is a lack of muscular power, and a lack of muscular tone develops from dis use. It matters not what may be the disease of which the neurasthenia is the symptom, or the OP HABITUAL < ONSTI IWTloN. L05 nature of the cause— emotive shock, overwork, traumatism, or malnutrition of which it is the result. The lowered nerve lone, the nerve weak- ness, is the cause of the diminished vitality and denutrition of the muscular layer and the inade (mate peristaltic power. The neuromuscular in- sufficiency is so often associated in families as to suggest the influence of heredity ; but, while not prepared to deny the possibility of the inheritance of the specialized defect of constitution — it being well known that unhealthy variations are trans- mitted with the same certainty as are the useful ones — it seems more plausible to suspect that the vice which arrogance is wont to attribute to the sins of another is nearly always acquired by bad habits, a faulty environment, and unhealthy living. Infectious and mineral poisons like lead seem to produce constipation by their influence on the nerve supply. Chronic diseases of the brain and spinal cord are also accompanied by obstinate constipa- tion. The cerebro-spinal and ganglionic nerves may be efficient in the performance of their work, and con- stipation result from atony, or degeneration, or atrophy, or oedema of the muscular layer. Here the disorder has a muscular and not a neural basis. A weak diaphragm and flaccid abdominal wall and general muscular flabbiness are commonly associ- ated with the atonicity of the muscular layer. The inactive centres of old age go along with the athe- roma and fatty degeneration and weak involun- tary muscles. But more frequently the muscular inadequacy is the accompaniment or legacy of a Hit; THE I tka Tl\ i: rREATMENT diseased mucous membrane, peritonitis, or malnu- trition iron i the distention of gases, or the pressure of accumulated and hardened faeces ; or the oedema of heart disease, or portal obstruction, or Blight's disease, or of a watery blood. Habitual constipation is without urgent distn it is slow in its destructive work and insidious in undermining the general health. But intestinal ob- struction is not rarely engrafted on habitual con- stipation, and whenever it supervenes the symp- toms atonce become severe. The condition is no longer simply a disturbing but a deadly one. It becomes, then, our duty, before a prognosis can be given and a rational treatment adopted, to differen- tiate chronic inadequate intestinal peristalsis and chronic constipation accompanying other diseases and conditions ; to differentiate l.eeal impaction se- quential to habitual constipation and faecal impac- tion or stasis due to the intestinal paralysis of peri- tonitis, the caeca! paresis of appendicitis, and com- plete obsl met ion produced by other causes. Chronic constipation is a frequent symptom of a diseased rectum or anus. It is advisable, in search- ing for the cause of the constipation with a view to arriving at a correct diagnosis on which to base an opinion and palliative or curative treatment, t<> make a careful rectal examination. When pain accompanies and follows defecation this examina- tion is imperative. An ulcer, or a fissure, or a blind or complete fistula, or a sensitive pile, or an irritable and powerful sphincter, will frequently be found the disease; which demands treatment. The fissure I or ulcer or hemorrhoid may be the result of the OF HABITUAL CONSTIPATION. L(W constipation, in which case the neuromuscular dis- order will persist after the cure of the Local trouble. An eczema in the region of the anus (frequent in infancy) becomes a common cause of constipation through voluntary or reflex inhibition of defeca- tion. The little child strives to prevent the suffer- ing associated with the act. It is through frequent voluntary resistance that the sphincter is overde- veloped and the rectum made tolerant. Excessive hypertrophy of the body of the uterus, or a retro- verted or retroflexed uterus, may be another cause of constipation. Chronic intestinal obstruction must be estab- lished as the cause of the chronic constipation by the sequence of symptoms as revealed in the clini- cal history, by the detection of the causative lesion, and by the presence of additional symptoms to those ordinarily produced by habitual constipation. Very large and foul movements should excite sus- picion. Habitual constipation is temporarily and painlessly relieved by the proper dose of a purga- tive, which would excite colicky pains above the site of obstruction. The mode of origin is of more importance than the symptoms. Previous severe inflammation would suggest bands or adhesions or constricting organized fibrous tissue. Ulceration is a common cause of stricture. Acute intussuscep- tion, ending in recovery by the formation of adhe- sions and the separation and discharge of the in- carcerated part of the bowel, may be followed by chronic obstruction. The intestine just above the obstructed point hypertrophies ; peristalsis and thickening may be seen and felt ; dilatation may Ins THE CURATIVE TREATMENT alter the configuration of the abdomen. The form of the faecal discharge may be important if piles art- absent, or the prostate is not enlarged, or the uterus is movable and in its normal position. The trouble may be revealed by the finger or the rec tal bougie, or by filling the colon with water or by inflating it with air. It is not always possible to form a definite conclusion after the mosl careful and exhaustive study. Obstruction by faecal impaction, or the complete and insuperable stasis of tin- intestinal contents, as a sequence of habital constipation, is usually located in one of the flexures of the colon or in the caecum. It is more f requenl in women. A history of long- continued constipation becoming more and more obstinate, the slight tenderness over a faecal tumor which can be felt and indented, are the diagnostic signs. The normal temperature, the marked abdo minal distention without tenderness, the late occur- rence of vomiting which is almost oever faecal, the extreme foulness of the breath, the increasing rap- idity of the pulse and the gradual exhaustion- by chronic shock and inanition, and the fact that the acute symptoms followed the administration of ,i purgative, aid in the differentiation from the impac- tion of mechanical obstruction as well .is the impac- tion produced by local intestinal paralysis. The cardinal symptoms of obstruction a] id st ran gulation are the same — abdominal pain, vomiting. and obstinate constipation ; but strangulation is acute, the onset is sudden without premonitory signs, collapse is early, an external strangulated hernia mav be detected or a histoiv of abdominal OF HABITUAL OONBTIPATION. I')'.» injury- obtained, a little bloody serum and mucus may be passed, and the urine contains albumin rather than indican. Faval impaction located in the CSBCUm is both a cause and a result of appendicitis. Primary appen- dicitis and peri appendicitis do not seem much more frequent than primary salpingitis and local peritoni- tis. The analogy between tubal disease and disease of the appendix is close enough to be instructive. Perityphlitis and abscess are about as rare as pel- vic cellulitis and pelvic abscess. Typhlitis, on close study, will not be found much less frequent than endometritis. Pelvic peritonitis without tubal dis- ease is as rare as localized peritonitis in the right iliac fossa that is not caused by a diseased appendix. In both we get closure or obstruction of the mouth, and accumulation of the secretions, and tubal or ap- pendicular colic. The lumen of either tube may be the site of stricture. Sepsis may extend from the endometrium or from the mucous lining of the cae- cum. Purulent inflammation may travel in the same way. Pyosalpinx has its analogue in the ac- cumulation of pus in the appendix. Chronic recur- rent appendicitis is as difficult to cure without re- moval as chronic catarrhal or productive salpingitis. The analogy serves a useful purpose in emphasizing the aetiological relation of faecal impaction of the caecum and typhlitis to appendicitis. Dilatation or distention of the caecum may also open the mouth of the appendix and permit foreign bodies, winch may become incarcerated and produce ulceration and perforation or gangrene, to enter. The caecal paresis and faecal accumulation associated with ap- 1 in THE CURATIVE I RE \ IMI'.N C pendicitis, and produced reflexly or by contiguity of tli»' inflammation in and around the appendix, is ac- companied by fever. When the appendix is Bound fever is usually absent, since perityphlitis and Local peritonitis are so rare without appendicitis as to be almost excluded from consideration. The differen- tiation of the caeca! accumulation sequential to hab itual constipation and producing appendicitis, from the accumulation of faeces in the caecum resulting from peri-appendicitis, cannot be made in the dim light turned on by the clinical history and the phy- sical signs. The curative treatment of habitual constipation is comprised in four special indications of command- ing importance : 1. To set uie perfect digestion. 2. To tone the nervous system. 3. To strengthen the muscular layer. 4. To attend to the hygiene of defecation. To correct the special defect, to establish normal and adequate peristalsis as the habit of life by obeying the laws that condition it, is to make the basis and purpose of treatment rational and cura- tive. A popular way of curing habitual constipation is to prescribe an indigestible diet and force it through with a purgative. Such treatment is irrational, harmful, and never cures, but produces a tempo- rary and deceptive improvement. Excessive irrita- tion need not be expected to yield a very brilliant result when chronic irritation has been the cause of the trouble. The worst kind of a laxative is un- digested food undergoing organic fermentation and OF IIA KIT! A I, CONSTIPATION. I I I decomposition, and it docs not seem to be a rery good plan to derange the stomach and duodenum in ordor to make the colon empty itself. Artificial indigestion is not a cure Cor habitual constipation. The needs of general nutrition and the capability of the digestive organs are the guides in the selec tion of the diet. The method of securing perfect digestion has already been fully discussed. The quantity of fasces passed varies with the nature of the diet, the completeness of digestion, the activity of absorption and secretion, and the rapidity of peristalsis. When digestion and absorption are good and the food is digestible, the patient must not resort to the pill box, because a stool that ana- lysis proves to be normal in composition is small. The drinking of too little fluid is a common cause of habitual constipation. Purgative and laxative mineral waters are constipating in their after-ef- fects. Cold water increases tonicity. Hot water, as is well -known, is an active exciter of peristalsis. The urine should be kept at about 1.014- specific gravity, and the stools soft by abundant drinks and active intestinal secretion. The constitutional measures and drugs for the improvement of secretion and motility have already been considered. To tone and strengthen the neuro- muscular element, massage, electricity, and strych- nine are the most useful remedies. The accessory muscles of defecation should also receive attention. The healthy stimulus of a normal digestive pro- duct and adequate neuromuscular power should be supplemented by regular habits. The unhealthy variation often originates in negligence, voluntary 11*3 ri;i; \i\n.\ I OF HABITUAL CONSTIPATION, resistance, and irregularity. Frequent infraction of tin' laws of health is an influential factor in the causation of chronic disorders ; physiological Living i-- a |i«>w erful remedy in their cure. The materia medica supplies us with two drugs which, when rightly used, exeri a curative influ ence in habitual constipation -aloin and cascara sagrada. Purgative doses do only harm. Aloes in large doses produces griping pains, congests all the pelvic viscera, ami causes albuminuria. In small doses it is tonic, a mild cholagogue, non-irritating, and increases secretion and peristalsis. Its valu able selective and stimulant action on the muscular layer of the colon and rectum, without irritating the mucosa, make- it ;i valuable curative drug. It i- not followed by constipation, and its long-continued administration docs not lead to the formation of a pill habit. Aloin. one-tenth I te-fifth grain, i- better than the crude drug and may be combined with ipecac, mix vomica, or a bitter tonic, as may he indicated. Cascara sagrada is a valuable laxative with cura- tive properties. It tones and increases peristalsis and intestinal secretion, and is a general tonic with a selective influence on the sympathetic system. The curative properties are also only manifested whengiyen in small doses short of a laxative effect. Purgatives, injections, suppositories of glycerin, etc., and other symptomatic remedies, do not come up for consideration in the curative treatment, which is comprised in good digestion, the hygiene of defecation, physiological living, and the strength- ening of the neuromuscular layer. APPENDIX. A Clinical Paper on the Treatment of Func- tional and Catarrhal Diseases of the Stomach and Bowels. The purpose of this paper is to present the essen- tial features of certain methods of treatment which I have found to be very useful. I shall endeavor to state them in a distinctly clinical manner, so as to show their practical application. It will be impos- sible to so enunciate them as to fit all cases, but I hope to convey an idea of measures that can be ad- justed as they are needed. There is such a vast range between a functional derangement and an old chronic gastro-intestinal catarrh that no system of set rules can be made for uniform application. Ac- cordingly, much will remain to be done in the way of wise adaptation by the good sense and skill of the physician. It is hoped, however, that the methods here outlined will prove to be generally ap- plicable and of great service in one of the widest fields of practical work. The first step in the treatment of functional and catarrhal diseases of- the stomach and bowels, whether moderate or severe, is to obtain full con- Ill riNiTliiNAL AND CATAKltllAL DISEASES trol of the mental condition of the patient. Too much emphasis cannot be put on iliis point, as fail- ure here is sure to mean failure in the future. If* there is a mental antagonism on the part of the pa i i.'n f to what the physician is attempting to do ; if there is a lack of faith and w illing co-operation; if tliciv is, from first to last, a sort of send indiffer ence and resistance then all treatment, no matter how judiciously advised and how worthily applied, is almost sure to result in failure. On the conl rary, if the physician first obtains the confidence and re- Epect of his patient, secures his cheerful submission to all instructions and requirements, and lias liis glad and hearty endeavor to help bring about a cure, then the principles and methods I am about to offer are almost absolutely sure to result favorably. even in the worst of cases. All this can be done by patience and tact, and it is of first importance lo- calise of that close relation existing between the brain, the sympathetic nervous system, and the or- gans of digestion. The influence of the mind over the body is simply tremendous, and both the patient and physician need to have such a great vital force working with determinate action toward health. The second step in the treatment of these cases is no less important than the first. It consists in thor- oughness, and repeated thoroughness, in examini ig into the patient's condition. It is in the highest de- gree essential to interrogate over and over again every organ, and to find out just how it is doing its work. To obtain the desired information there is no better method than carefully inquiring into the patient's habits of life, the duration and severity of OF THE stomach and BOWEL8. 115 his subjective symptoms, tin; significance of every physical sign, and then supplementing .ill this with a microscopical and chemical study of the blood, the urine, and the f aecal discharges. Careful, scientific study of the products of the system, made daily, is eminently important and useful. The reason lies in the fact that, if the machinery of the system is out of order, its products will be faulty ; and hence, by studying abnormal products, one is enabled to read, as it were, the condition of the organs that made them so. If a study of the urine reveals the state of the kidneys, is it not just as reasonable to believe that a microscopic study of the blood and faeces will disclose the state of the stomach, bowels, and blood- making organs ? It would seem to need no argu- ment, then, to prove that a daily thorough investi- gation of the excretions and products of the system is in the highest degree useful. It is the only means of accurately determining to what extent patients are digesting their foods, to what degree the liver and kidneys are doing their work, and just what quality of blood is being made. As a third preliminary consideration it is highly necessary to place every patient under the most favoring hygienic conditions. In those cases where the affection is slight or limited it may not be necessary to impose more than a few reasonable restrictions upon diet, habits of life, and hours of work and rest. On the contrary, where there is very much catarrhal disease of either the stomach or bowels, it is usually necessary to confine the pa- tient to his home for a time, and carefully regulate his work, recreation, diet, and medical treatment. 11''. FUNCTIONAL AND CATARRHAL DISEA8E8 [ndeed, everything pertaining to habits of business and lit«- should be so regulated as to save nerve power, and the severer the disease t lie greater 1 1 1» • necessity of this. To insure this result in had cases the patient should rest half an hour before meals and an hour and a half after meals. In other and still severer cases it is better to insist on the pa tient's resting, sleeping, if possible, from one to two hours every forenoon, or else on his not getting up until an hour and a half after breakfast, and re- tiring immediately after lunch and remaining in bed until the next morning. The great object and end is to so regulate the life of the patient as to avoid "overwork and underrest," economize nerve force, and acquire a quiet, calm, tranquil state of body and mind. Having thus first gained the confidence and good- will of the patient and directed him in regard to In- habits of life, his diet and rest, the next thing is to endeavor to remove fro m his stomach and intestines, and also from the kidneys and liver, all morbid material. As you are well aware, the lining of the stomach and bowels in the diseases under consider- ation becomes coated, as it were, with the morbid products of supersecretion and fermentation. The secretions, being in excess for a long time, become thick, tough, and stringy. They are highly acid and laden with the germs of fermentation. Moreover, as a rule, the liver and kidneys are in an abnormal state and burdened with an immense amount of morbid material. All these vitiated and unhealthy accumulations need to be eliminated from the sys- tem. In other words, the surfaces of the alimentary OK THE STOMACH AMi BOWELS. 117 tract need to be washed off and the organs flushed out in order to put them in a healthy condition. Especially is it necessary to remove the bile from the blood and stomach. Every one knows thatthe effect of a large amount of bile in the stomach of a well person is to greatly interfere with the appetite and with the stomach digestion. If such is its effed in people who are otherwise well, it is not difficull to imagine what its presence does in the stomachs of those who are in poor health and suffering from catarrhal disease of the stomach. Hence the im- portance of freeing the stomach of vitiated, offen- sive mucus and bile by giving to it a rapid downward action. This can be done in several ways, but I know df none so simple, so grateful, and so effective as washing it out by drinking hot water. Long ex- perience has now shown that-quantities of hot water dissolve and liquefy the mucus and bile, stimulate the secretory and excretory glands, and excite downward peristalsis of the bowels. It is believed that morbid substances are rapidly eliminated from the system in some such manner. And this leads me to say that in such cases hot water needs to be taken systematically, under the direction of a physi- cian who appreciates its utility and knows what effect is to be achieved. At the beginning of treat- ment it is a good rule to order the patient to take one glassful an hour or an hour and a half before each meal and on retiring, increasing or decreasing the quantity according to the rule to be given fur- ther along. It should not be taken too hot, but about as hot as after-dinner coffee, or at a temperature of from 110° to 120° F. The patient should be charged IIS FUNCTIONAL IND I ITARRHAL DISEASES to take it very slowly, consuming fifteen or twenty minutes in sipping a glassful, in order to avoid scald- ing the mucous surface of the throat and stomach. Water taken too hoi mayinjure the lining of the stomach, produce a dry, feverish condition, or art too powerfully and promptly on the skin. There are other precautions to observe, which T will nun tion. It' the glassful <>r more taken at bedtime causes too frequent urination during t be night, it call be dispensed with; ifthepatienl has a weak heart, large quantities of hoi water should be taken verj slowly; if the patient has a tendency to haemor- rhages, the water taken should not be much more than lukewarm and should be taken very slowly ; and if the patient is a woman subject to long-con- tinued or excessive menstruation, she, too, should take water very slowly and at alow temperature. These precautions need to he observed so as to avoid ill effects and dangers that might otherwise super- vene. If at anytime the hot water is disagreeable to the patient, a little salt, pepper, lemon juice, aromatic spirits of ammonia, or any innocent flavor ing extract may be added to suit the taste. If hot water seems to nauseate the patient, its use should still be persisted in, since this is a positive evidence that the stomach is in a foul condition and needs cleansing ; and, as evidence that cleansing does take place, it can be said that, after an abundance of hot water has been used for a time and the bowels get to acting from two to four times daily, as they Ere quently do, the discharges are often either black and sticky, or granular like coffee-grounds, or else they contain masses of exfoliated, gelatinous mucus. <>l<' THE STOMACH AND BOWELS. L19 We often he .r it said that the free and prolonged use of hot water tends to injure the system. Some say that it is weakening, that it weakens the nerves of the stomach, that it causes anaemia of the sto- mach, that it interferes with digestion, that it tends to produce a flushed face and cerebral hyperaemia, that it debilitates the alimentary tract, and that it causes a host more of most direful evils. As a rule, all these objections are theoretical and come from those who never used it intelligently and system- atically, and hence are ignorant of the facts. In reply to such objections, all I can take time to say is that I have used hot water daily for six years without the slightest perceptible injury, and have seen only uniformly good results in persons for whom I have prescribed its daily and long-contin- ued use. As all are aware from experience, it is always a difficult problem to successfully feed patients who are suffering from diseases of the stomach and bowels. There has ever been a demand for some article of food that would not ferment, that would afford a maximum amount of nourishment, and that would be promptly and easily digested. At last such a food has been found, for we know that an animal diet, or, to speak more specifically, good, well-prepared muscle pulp of beef, can be relied upon for the purpose before named. Inasmuch, however, as beef varies greatly in its quality, it is necessary to exercise care in selecting that which is best, and this is found in the centre of the round of a well-fatted, corn-fed animal from three to six years old. This portion is freest from fat and is 120 FUNCTIONAL \M> CATARRHAL DISEASES fche richest in those nutritive elements required by the human system. It should be given to the pa- fcient in the form of beef pulp, which may he pre- pared bythe process of Bcraping, or by passing ii through a " chopper " made for the purpose. The object of such preparation is to remove all of the fibre and leave the pulp in a condition to be both palatable and easily digested. When the fat and fibre are entirely removed, the pulp can be made into cakes containing the number of ounces the pa i ient is able to digest. These cakes should be ii half to three-quarters of an inch in thickness, care being taken not to pack them too firmly. The cake of beef pulp is then to be broiled over a slow fire, preferably charcoal, until it is so cooked that the outside is of about the color of ordinary broiled steak and the inside of a pinkish hue. Great care should always be taken not to overcook the beef cake and so make it dry, brown, juiceless, and in- digestible. If it is cooked just right, patients will not tire of it, it is more easily and thoroughly di- gested, and all dangers from tapeworm are avoided. In rare instances beef prepared thus is not palatable at first, and when such is the case it can be broiled between two pieces of dried or chipped beef, or a lew oysters may be broiled with it so as to imparl their flavor, or a few spoonfuls of beef blood or ex- pressed beef juice freshly extracted from the beef may be added. The effort should be to employ simple means to make the beef palatable to the peculiar tastes and fancies of the patient. The beef pulp thus prepared should he given in small quantities at first, not over four or six ounces in a OF THE STOMACH AND BOWELS. I i I day, until its effects have been carefully noted. Later on, as the stomach and bowels become cleansed and more tolerant, the quantity may he increased to eight, ten, twelve, fourteen, or sixteen ounces at a meal. If patients tire of beef prepa red in this manner, or if it is very distasteful to them, it is better not to insist on their taking it for a time, but to let them have instead a lean chop, or a small plain steak, or a little game of some kind, like broiled grouse or pheasant. This change, however, should be as temporary as possible, and an early re- turn made to beef pulp, for from this comes the maximum nourishment from the minimum effort. If the functional or catarrhal condition is not too severe, a limited quantity of starchy food may be given, such as a small piece of stale roll, or a piece of dry toast about one or two inches square. It sometimes happens in these cases, and under this restricted animal diet, that the patient's appetite will seem to fail. When such is the case it is in- variably due to either bile in the stomach, to undi- gested food, to a tired and depressed state of the nervous system, or else to a combination of all these conditions. Under such circumstances an effort should be made to cleanse the stomach as rapidly as possible by an even freer use of hot water, limit- ing to a greater degree the quantity of food taken, and insisting on more physical and mental rest. At the same time the nerve tone should be improved as rapidly as possible by tonics, massage, and elec- tricity. But, inasmuch as patients differ and dis- eases vary in severity, it is easy to understand that .set rules in regard to the quantity and temperature L22 FUNCTIONAL \\l> CATARRHAL DI8KA8E8 of water, or to the amount of animal food to be given, cannot be laid down. The amount of ho1 water should be sufficient to maintain the specific gravity of the urine at aboul L.014, and the quan- tity of meat should be as much as can be digested. Whether the patient is drinking enough or is di gesting his food properly is to he decided by the physician and never by the caprice of the sick one. It is to be borne in mind that the object of the use of hot water and a strictly animal diet is to prevent excessive fermentation, which is the underlying cause of the diseased condition, and therefore it should be employed systematically and persistently. It is alleged by some, who are ignorant of facts, that this single article of* diet will bring on dyspep sia, Blight's disease, and other serious troubles, and that it tends to establish a sort of meat habit, so that the organs of digestion will not tolerate other kinds of food. I will not take time to discuss asser- tions and theories, but simply Bay tli.it. in the treat- ment of hundreds of cases according to the methods here given, I have never seen any evil results. On the contrary, patients are gradually brought around to a mixed diet as soon as safe for them ; the great majority get well, so that they can eat a reasonable .iin« unit of any kind of food, and in old chronic cases of twenty or thirty years' standing they are made comfortable and able to eat all that is necessary 1 « i supply the requirements of their system. Having thus far dwelt on the general principles of treatment, T will now speak a little more specifi- cally of the treatment of functional diseases of the stomach. In cases of this nature the patient should OF THE stomach AND BOWELS. 1^5 beheld very closely to some form of animal food such as the muscle pulp of beef, beefsteak, lean mutton, white meats of fisb and poultry, the pulp of oysters, well-fried bacon, and soft-boiled or poached eggs. The prepared, muscle pulp of beef may be used, but more to furnish variety than be- cause really essential. But, as a rule, these cases will do better if the physician advises an almost constant use of either broiled or roast beef or mut- ton, eaten slowly and thoroughly masticated before being swallowed. It is also well to allow a very small quantity of starchy food, in the proportion of three or four parts of animal to one of starchy food by bulk. It is safest to advise a very small piece of dry toast — so dry that it will snap — or a piece of stale roll, or a small piece of stale bread, or a table- spoonful of well-cooked rice or cracked wheat dressed with butter, salt, and pepper. In the mat- ter of vegetables it is well to advise a few tender sprigs of celery, a little watercress, or a little horse- radish, prepared with lemon juice instead of vinegar. Moreover, the patient should be directed not to swallow coarse particles of any of the substances named, and to eat a moderate quantity and very slowly. The drinks to be allowed at meal times are a single after-dinner cup of black tea or black coffee, sweetened with saccharin if desired. If these are not well borne a cup of hot water, flavored or not with lemon juice, may be taken. If the functional cases are at all recent and these precau- tions are observed, it will require but a few days to show a marked difference in the fermentation and in the comfort of the patient. As soon as the un- .' 1 FUNCTIONAL AND CATARRHAL DISEASES comfortable feelings have disappeared, the products of fermentatioD eliminated from the blood, 1 1 1 * * symptoms and physical signs of fermentation gone, and as soon as the urine shows normal characteris tics, being absolutely free from biliary coloring mat- ter, the patienl may be given a larger proportion of Starchy food — say, one of staivby to two of animal food. In functional cases of stomach and bowel disease patients are to be kepi on this routine as to food and drink for a few weeks or months after the evidences of excessive fermentation have ceased. At the end of this time the patient may be led up, little by little, to other food, such as fresh garden peas, string beans, half of a baked potato, and a few peaches, prunes, or grapes. These should, be given in small quantities at first, and if they cause any trouble they should be discontinued and re course had to a rigid animal diet until the digest ion has returned to a normal state. And here let me say that it is surprising how little gas is contained in the intestines of people whose digestion is ab- solutely healthy. It is equally surprising to note the serious disturbance of the mucous membrane after a few weeks or months of excessive fermenta- tion. On the one hand I have seen cases that have given evidence that fermentation had existed in ex- cess for twenty or thirty years wit hout perceptibly affecting the general health. On the contrary, I have seen many cases where the most serious struc- tural changes had resulted after only a few weeks of indigestion and fermentation, either in the sto- mach or bowels, or else in both. It can only be said in explanation of this that one is endowed with OP THE STOMACH AND BOWELS. L25 great resisting power, while the other is not so blessed. In other words, these conditions work hut little injury in robust persons, while in others of less resistance and stamina they may cause decided damage and great suffering. Therefore I do not put very great stress upon fermentation and gas when they occur in people of good health ; but they do have a very decided meaning when the health be- gins to fail and there are indications of serious struc- tural change in the mucous surfaces of the stomach or bowels. In the more strictly catarrhal states of the sto- mach or bowels, or of both, their lining becomes coated with an excess of sour, offensive, adherent mucus.. This material is in a large degree a fer- ment, and, as a consequence, sweet and starchy foods are soon transformed into a sour, yeasty, irri- tating, and injurious liquid. If this state of things is long continued it almost inevitably causes either vomiting of highly acid irritating liquids, or else frequent discharges from the bowels of gaseous jDro- ducts, undigested food, and thick, stringy, gelatin- ous mucus. The mucus thus cast off may be like the white of an egg, only more yellow ; or a thin, black, gelatinous substance ; or a thin, stringy ma- terial resembling wet tissue paper ; or, lastly, a dis- tinct membranous exfoliation. It is in cases of this kind that an abundance of hot water, long con- tinued, is of the highest utility for washing out the products of fermentation and keeping the surfaces in a fit condition for digestion and absorption. This practice must be continued and persevered in for month ; and years before the alimentary tract be- L26 i'i NOTIONAL IND CATARRHAL DISEASES comes thoroughly cleansed and restored to the power and function of normal digestion. In catar- rhal cases of the stomach the besi food is the muscle pulp <>f beef, prepared in accordance with the meth- ods described, and given as the patienl is able i«» di- gest. It is well i<» hold patients on this diel from mu- to three months, because it is the only one thai <-;ui lie anywhere near perfectly digested. Later on < it In 'i' foods can lie resumed, but with great caution. Among the first foods to be given should be fresh garden peas, string brans, fresh warm milk from the cow, a little tomato, or a few prunes, peaches, or grapes. The foods allowed at first should be guarded!) chosen and taken in a cautious manner. Little by little the diet should he extended until ordinary diet can he taken with comfort. If at anytime the patient shows signs of not digesting his foods, he should be brought hack at once to the rigid animal diet and held there until the or- gans again do perfect work. If the patient is thus promptly and strictly returned to a restricted animal diet, he will be all right in a few days. On the con- trary, if he is not so treated the former manifesta- tions of disease will occur. It is impossible fora per- son ever to get so well hut that, if he becomes sick again, it will be the weak organs that are assailed. Like causes will certainly produce like effects. It is to be borne in mind that the mucous membrane, while it may be sound, is still delicate and sensitive, and must be restored and strengthened up to it - natural state. And if you consider particularly the changes that have taken place in advanced cases. not only in the mucous membrane but in the con- OF THE STOMACH AND BOWELS. I'.', nective tissue, glands, and sympathetic nerves, it stands to reason that a good condition must lx: kept up long after the evidences of tin: disease have dis- appeared. And I might add in this connection that, in my experience, it takes from one to three years to bring about such changes and to cure a catarrh of the stomach and bowels. In catarrhal disease of the bowels much the same line of treatment is to be followed. The use of hot water and the rigid animal diet must be persevered in until all traces of the disease have disappeared from the blood, the urine, and the faeces. After this system of alimentation has been persevered in thus long, there may be a very gradual return to the vegetable and starchy regimen already defined. At times there may be slight relapses, but these will be readily corrected by a return to a rigid use of the hot water and animal diet for a few days. But, despite drawbacks, there will be a prompt resto- ration of comfort and a gradual progress toward health until recovery is complete. The extent to which I have gone into the general principles of treatment and diet may lead to the be- lief that I am indifferent to the place and power of medicines in dealing with the functional and ca- tarrhal diseases of the stomach and bowels. Such, however, is not the case, for there are medicines of very great utility and upon which I have come to rely with confidence. In my judgment there are four leading indications for the use of medicines in these cases. There is a need for those that supple- ment the gastric juice, that stimulate the appetite, that invigorate the nervous system, that excite or i'.'s FUNCTIONAL AND CATARRHAL DISEASES retard the Becretioiis, and thai bear upon oomplica- tdons which may arise. l. Among those of the first class is to be named pepsin, which is especially useful in aiding the di- gestioa of animal food. Tothisuseful agent may he added either bismuth, ginger, or ipecac, as needed. •_'. Of the medicines calculated to stimulate the appetite I have found benefit to result from the preparations of cinchona, gentian, fluid extract of stillingia, and FothergilTs antidyspeptic pills. 3. Ju cases that need ;i decided nerve tonic to in- vigorate a feeble nervous system, and especially the nerves supplying the organs of digestion, there is nothing more advantageous than the preparations of strychnine and damiana. 4. For remedies to regulate the secretions I have obtained good results from the guarded use of Carlsbad salts, compound licorice powder, fluid ex- t pact of cascara, mild laxative pills, and hydrastin. On thecontrary, when secretions become too free I often prescribi mild tonic astringents, like the fluid extract of blackberry root, fluid extract of hamamelis, bismuth, or chalk mixture. In catarrh of the stomach, duodenum, or bowels a combina- tion of hydrastin and bismuth has rendered most excellent service. Hydrastin and bismuth seem to exert a peculiar and salutary effect upon mucous surfaces. In those cases where there is a marked tendency to acidity and fermentation, salicin alone. or with bicarbonate of sodium, or charcoal and magnesia, have given good and prompt results. Salicin usuallv affords excellent results, because it OF THE STOMACH AND BOWELS. 129 does not disturb the stomach, is tonic, in its action, and is one of the best agents we have to counter act acidity and the evils of fermentation. There are, of course, many other remedies to be used in the treatment of the diseases under consideration, but these are the principal ones which, if properly prescribed, are of great service. In conclusion, there are two features in the clini- cal history of cases treated after the manner here outlined that are worthy of special note. In the first place, there is a natural tendency for the pa- tient to gradually get weaker and thinner. The deprivation of starch, sugar, and fat cuts off, so to speak, the "kindling wood" of the system that af- fords immediate strength and heat. Not only that, but excessive fermentation, especially alcoholic, is to some extent a stimulant, and it is the loss of its chrome effects that is felt by the system. No inju- rious consequences follow this weakness, however, if the patient believes what has been told him and does as advised. After a time the blood becomes richer, the nervous system stronger, and renewed strength takes the place of former debility. If nec- essary, as a matter of bridging over temporary weakness, the patient can be given from a tea- spoonful to a tablespoonful of old whiskey or brandy, in water, from one to two hours after meals. And, secondly, in catarrhal cases of the bowels where the movements occur several times daily, it is sometimes necessary to bring them under con- trol with simple remedies, like external heat, rest in bed, and the internal use of mild doses of bis- 9 L30 II Si PIONAL VN1> CATARRHAL DISEASES iniiili. chalk mixture, or fluid extracl of ginger. These rather frequenl movements, while they some- times weaken, are, after all, salutary*. They are, as it were, Nature's "house cleaning," removing the products of fermentation, exfoliations of mucus, and other i noil >id material. Before or during these frequent movements or clearings the patienl may experience Local or general muscular or neuralgic pains, bul all of these temporary disi iirbances soon pass away. Such, then, art> the methods which, in my judg- ment, are the best of all for removing the causes of functional and catarrhal diseases of the stomach and bowels, restoring the quantity and quality of the blood, augmenting the force of the nervous system, and putting the general health on a solid basis. As you have already heard, they consist — 1. In securing a willing, obedient, hopeful, and confident mental condition. 2. In making a careful diagnosis, based on the usual methods, and, in addition, a frequent micro scopical and chemical study of the products of the system, as the blood, the urine, and the faecal dis- charges. :'>. In placing the patient, under the most favoring hygienic conditions. 4. In an intelligent and systematic use of hot water for the purpose of cleansing the surfaces of the stomach and bowels, stimulating the secretory and excretory functions of the liver, kidneys, and other glands, and supplying the system with the requisite amount of liquid. OF THIO STOMACH AND BOWELS. L3J 5. In using an article of diel that undergoes bul slight if any fermentation, that can be easily di- gested, absorbed, and assimilated, and that will make, in time, the maximum amount of blood and nerve force. The great object is not to arbitrarily put the patient on a particular article of diet, bin rather on one that will meet the above-named re quirements and tide him over until well enough to resume the use of various articles. For this pur- pose I have not found any food comparable to the muscle pulp of beef, prepared and used as before de- scribed. To afford the greatest service it must be carefully prepared, properly eaten, and thoroughly digested. To know whether it is well digested, re- liance must be placed on the usual signs and symp- toms, and on a frequent microscopical and chemi- cal study of the blood, the urine, and the faeces. The latter method affords the most accurate means of determining what manner of work is being done in the laboratory of the system. 6. In the use of medicines in so far as they im- prove the appetite, excite or retard secretions, re- store the blood and nervous system, and meet vary- ing conditions and complications, if any develop. II. On the Nature and Preventive Treatment of Seasickness. Nowadays inventive genius and the progress of science have made travel by sea rapid and safe. The greal steamers pass quickly and triumphantly againsl wind and wave from poinl In |».«in1 and from shore to shore. Tin 1 world IS made smaller, nation is drawn closer 1" nation. Seasickness is the chief barrier thai remains; it is the almost cer tain affliction of those who use this mode of travel, be it for health, pleasure, education, or the pur- poses of hade. This peculiar form of vertigo it is that Neptune imposes as a tax on all of his subjects, excepl a favored few. It is estimated that only about three per cenl of all sea-goers are exempt. Mechanical science has very materially shortened the duration of the disease by increasing the rapid ity and comforts of travel. The layman has pretty thoroughly discussed the subject, and seems never to tire when considering its humorous side. The medical profession has done very little, ami written and thoughl less. It is with the desire to excite serious study of this neglected disease that this article is written. X<> effort is made to discover '•some new thing"; no claim will be made for ori ginality. The united thought of the profession ma\ he able to lift the cloud 1 hat obscures the nature of NATURE AND TREATMENT OP SEASICKNESS. L33 the trouble, and devise some means for its preven- tion or alleviation. On account of the nature and limited adaptability of our organism, which is fitted, by creation and habit, to life on the stable and solid lai id ; on account of the great change in the environment when on the restless sea, it is folly to hope that the evil can be wholly overcome. So long as the rolling and pitching ship is at the mercy of every wave, and, impressing its restlessness on every object that can be felt and seen, takes from us the guides and gov- ernors of co-ordination and of equilibration ; so long as these disordering and uncorrected sensory im- pressions possess correlatives in consciousness, the vertigo of mariners will be produced. For seasick- ness is essentially and primarily a disordered sense of equilibrium and of space, a sensory form of ver- tigo. The symptoms and their order and manner of de- velopment confirm this view. The first and essen- tial sign of every case of seasickness is a feeling of dizziness or lightness of the head, or vertigo. It is the most invariable, and the most persistent, and sometimes the only symptom. It is alone present in the prelude; though overshadowed, is never ab- sent from the scene ; and is the last to leave the stage when the curtain falls. It is commonly asso- ciated with headache, an indefinable nervousness, sensitiveness to light, a contracted pupil, and a keen sense of smell. The temper is extremely irri- table, the face is flushed or pale, or rapidly changes from the one to the other state — the vaso-motors and inhibition are struggling for the mastery. The <>N Tin: \ \ n i;r. wi» condii ion is one of hyperemia and instability of the sensory and sympathetic nerve centres. These epi phenomena may be absent and the voyage com pleted with only varying degrees of vertigo. Bu1 more "Hen the Bimple vertigo is followed by ner vous exhaustion and mental depression, muscular inco-ordination and relaxatioD, a nv.-ik heart, low arterial t<-nf seasickness -sensory vertigo, sensory vertigo with cerebro-spinal irritability, and vertigo with prosl ration. The form and degree and duration of the attack depend on Hie nature andintensity <>t' tin' move ments <>fih<' ship, on the susceptibility and adapt- ability of the individual, and the incidence of fche disturbance. When the cerebro-spinaJ system i- most involved, vertigo, headache, and nervousness are marked ; when the sympathetic is weakest, the nausea, vomiting, and prostration are mosl ])i<>ini- ni'iit . The nervous irritability may be explained as the result <>f the cerebral excitement ami t he uncommon and oumerous sensory impressions. The cerebro- spinal hyperemia is due partly to the increase of functional activity, and partly to the tonic contrac- tion of all the muscles driving the blood out of the musculo -venous reservoir. Every peripheral exci tation determines neural discharges and causes an augmentation of potential energy. It is also well PREVENTIVE TREATMENT OF SEASICKNESS. I ■'>■'> known that the pupil contracts under the influence of exciting sensations, as docs also the whole reflex muscular system. The vomiting, in the popular mind, constitutes the essential part of the malady. Many physiriaie. it must be admitted, adopt this idea and embody it in their treatment. Now, we would state with em- phasis that acute dyspeptic attacks must not be confounded with seasickness. Acute dyspepsia is a powerful predisposing cause of the disease, bul has no relation whatever to the movements of the ship. The cause must be sought in overeating, irregular habits, loss of sleep, overwork, worry, anxiety, grief, the abuse of drugs — in some gross violation of the hygiene of digestion. The disturbance of the stomach is primary and would have occurred under similar circumstances on land. The vomiting of seasickness seems to be the effect of the cerebral anaemia produced by the weak heart, vaso-motor disturbance, and muscular relaxation — all due to paresis of the sympathetic from fatigue of the nerve centres by sensory overexcitation, or from emotive shock, or from excessive inhibition through a sense of defective motor innervation and of failure to preserve the equilibrium of the body. From this analysis it will appear that the symp- toms referable to the nervous system are primary and controlling, and that the essential sign of sea- sickness is vertigo. This, then, limits the explana- tion to the production of the vertigo by the ever- varying and complicated movements of the ship, for all observers agree that this is the remote cause. How is the vertigo produced ? on' THE NATURE ANl> The process is nol a simple one. Many theories fall short of the mark because they do nol include enough ; because it is incorrectly assumed that onlj one line connects the cause with the effect. It is 11 iy purpose to show that the motion of the ship is connected with the vertigo by many routes that the mechanical cause splits up and reunites id the biological effect. On the one hand we have the movements of the ship, and on the other are the disturbed sense of equilibrium and of spare mani test in consciousness as vertigo. How. then, dothe movements of the ship disturb these two senses in this peculiar manner '. It is foreign to our purpose to discuss the nature of the sense of equilibrium, whether it be the corre- late in consciousness of afferent sensory impressions or a central sense of motor innervation. Nor would .- 1 uy thing be gained by disproving the existence of so-called spinal and muscular perception. It is the realil y and composition, and not the location, of the sense of equilibrium with which we are concerned. The sense of equilibrium is a compound one and is correlated in consciousness with many peripheral impressions— muscular, tactile, labyrinthine, visual, and from pressure. Through the muscular we are cognizant of the state and position of a part as re- lated to the rest of the body. By the other sens. .1 y impressions we are informed as to the relation of the body to surrounding objects and to the vertical position. Now, the perfection of the sense of equi librium is dependent on the integrity of the sensor} impressions which compose it, When the informa- t ion is false or falsely interpreted the motor inner- PREVENTIVE TREATMKN'f OK SEASICKNESS. Hit vation will be wrong and the resull bewildering. When the perception of id.il ions is incomplete and deceptive and uncorrected, there result inco-ordina- tion and unsteadiness and \ r erl igo. The disordered sense of equilibrium is suf'ficienl alone to produce the vertigo of mariners, for the blind are not exempt. Deafness seems to confer a certain degree of immunity, and closing the eyes will often diminish the vertigo. It is through the sense of sight and the perception of the muscular changes of convergence and divergence and accom- modation that the sense of space is built up. In- sufficiency and inco-ordination of the ocular mus- cles often give rise to vertigo. It is through the eye also that we are chiefly made cognizant of our position in space. Where the perceiving subject is in motion the false perception of relations is pro- jected outward as an illusion of moving objects. The subjective feeling of this disorder is vertigo. The dizziness of high altitudes and openness or void arise from a disordered sense of space. Vertigo may be divided into three large classes : It may be cardio-vascular, as the vertigo of cerebral anaemia or of arterial sclerosis ; it may be of central origin, as the vertigo of properly located brain tu- mors ; or it may be the peripheral or sensory form, of which the vertigo of Meniere's disease and sea- sickness may be taken as a type. We have already stated that the vertigo of seasickness with pros- tration is partly due to cerebral anaemia, or. in other ^vords, is also cardio-vascular. But the es- sential and primary vertigo is of a purely sensory origin. ON I Hi: MATURE \ N D The preservation of equilibrium is dependent on •. (1) the integrity of afferent impressions; (2) on proper motor innervation guided by pasl experience, and grouped and limited so as to produce a pur posive movement or maintain a definite relative position ; (3) on proper muscuL r response, (4) fche result of which is reflected to the co ordinating and higher centres, and there is appreciated as efficient ordefective. Wnenonan irregularly moving bod) none of these conditions can be realized, and on board a Bhip, in a rough sea, fche difficulty may be insurmountable. The sensori-motor nerve circuit carries within itself fche power of co-ordination with- out the connection or intervention of fche higher centres, though the higher centres may regulate or coi it rol. Equilibration is commonly an unconscious process. We arc not conscious of nil the peripheral impressions winch are co-ordinated into vertiginous movements; we merely have a sense of the defec- tive motor innervation. The defect, the discord, the false association, the confusion of relations, are ('.■It as vertigo if they rise into consciousness or me not displaced by a more potent feeling. With these explanations turn we now to the con- sideration of the manner in which the senses df equilibrium and of space me disturbed by the move ments of the ship as it pilches or rolls or mixes the two motions. The body is constantly thrown out of equilibrium, and the position of the surface which supports it cannot be appreciated. The sensations of contact and of pressure ever vary in degree and in direction now slight as the ship sinks, the in- dividual I'eeling .-is if left in midair; now great as I'UKVKNTIVK TKKATMKNT OF SEA8ICKNE88. L39 the ship rises and presses against the descending body. The same uncommon and confusing sensory impressions arise also from the movable visrcni ;inf physiology and patho- logy. It best explains all the phenomena, and the Cause acting in the manner indicated will produce the vertigo to which, and to the condition of the cerebro-spinal and ganglionic uerve centres, all the symptoms are sequential. It may be of interest to mention briefly and in the order of their publication the theories which at different times have commanded the most consid- eration and credence : 1. It is due to fear (Plutarch), proof of which is that infants who cannot reason, and animals, are exempt (Gerepratte). This theory is only interesting because it still sur- vives in the pretty widespread relief that the develop- ment of seasickness can be influenced or prevented by the exercise of the will and a mental attitude of indifference. Nothing can be more ludicrous than a traveller t tying to ward off seasickness by force of will, unless it be a philosopher striving to suppress a toothache, or a poet to charm away the gout by the power and sweetness of his song. Strong feel- ings and powerful emotions can temporarily sup- plant in consciousness the sensation of vertigo. Animals are not exempt, though they do not vomit. The cause alleged is inadequate, and the evidence is made up of false observation. 2. It owes its existence to sympathy between the PREVENTIVE TREATMENT <>l'' SEASICKNESS. Ill brain and peripheral nerves disturbed by the move ments of the ship (175(5, (iillchrist). In the early dawn of physiology this is ;i very shrewd guess. 3. It is due to cerebral congestion and irritation arising from minute concussions of the brain by the fluids of the body during the descent of the ship, analogous to the rise of the mercury as the baro meter is dropped (1810, Wollaston) Minute concussions would produce headache ana- logous to that from riding a rough horse, but not vertigo. The onset should always be gradual and slow. Slight movements should have no effect. A simple change in the character or cessation of the movements should never remit or inaugurate the trouble. The cause is inadequate, cannot be shown to be operative, and the blood vessels are fortunately not dead,, rigid tubes. Infancy with its soft blood vessels, and old age with its hard arteries, are alike almost exempt. 4c. It is produced by the influence of the visceral movements on the diaphragm (1824, Jobard and Kerandreu). Again the influence is inadequate. The symp- toms are not reproduced or explained in the order of their development. And fixation of the viscera by an abdominal band exerts only a slight influ- ence by diminishing the peripherally excited im- pressions. 5. The movements of the ship in an arc-like zig- zag line arouse a centrifugal force which so influ- ences the circulation in the aorta as to diminish the amount of blood going to the brain. The anaemia 1 12 I >N THE N ITU RE \ Vl» of the brain results in cerebral depression, which through ili«' sympathetic invokes vomiting. This author considers tli«' vomiting a conservative pro cess induced to supplement the deficienl quantity of blood senl to the head I i s »7. Pellarin). This is an exquisite use of "occult influences" and the reputed "beneficent purposes"of Nature. 6. It is intoxication by a marine miasm developed in the decaying animal and vegetable matter of the sea, and aroused from its hiding place during the agitation of the water by the ship or wind or wave ( L850, Semanas). If this theory were fresh from a bacteriological laboratory it might command nowadays a great deal of consideration. It was based ona false analogy. I '.in tlie large doses of quinine recommended may be of benefit by producing anasmia of the semicircular canals I if this condition be true). 7. The proximate cause of seasickness is the heap- ing of the brain mass upon itself by centrifugal force, and subjecting the part to pressure against the bony casement, or to the hurtful centrifugal movements of the cerebro-spinal fluid, which also leave parts of the brain exposed to injury. Prefer- ence is given t<> the latter view | L856, Fonssagrives). This is a further stage in the development of the mechanical theory, which is fast approaching an absurdity. s. The proximate cause is hyperemia of the spinal eord, especially in those segments related to the stomach and muscles concerned in vomiting, induced directly or reflexly by the irritating movements of the brain, spinal cord, abdominal and pelvic viscera, I'KKVKNTI VK TRKAT.MKXT OK SKASICKNB8S. L43 and by jcj-ks on the spina] Ligaments. The invokm tary muscles aredisturbed by fche unwonted number of impulses transmitted to them from the preter naturally excited spinal cord (1864, Chapman). This theory marks the beginning of a new era. A good many threads of truth run like gold through the dark web, and physiology is in an able manner brought to the aid of the old theories of small con- cussions and mechanical irritations. The treatment by means of the spinal ice-bag does not seem to have increased the comfort of travellers. 9. It seems to be due to the sudden and recurring- changes of the relations of the fluids to the solids of the body (1868, Barker). 10. It is due to the disordering movements of the cerebro-spinal fluid, from which results an inter- mittent anaemia and a certain degree of commotion of the cerebral mass. Children are exempt through expansibility of the fontanelles (1S6S, Autric). It does not seem plausible that a force sufficient to cause the fontanelles to bulge would not compress the very yielding blood vessels of childhood, and children with widely open fontanelles are not always exempt. 11. It is due to the continued action on the brain of a certain set of sensations, more particularly the sensation of want of support (Carpenter, Bain, and (1872) Pollard). This is a development of the very shrewd guess of Gillchrist. It stands at the beginning of new views. The mechanical theories do not seem to have gone much beyond " possibilities " in their explanation of the symptoms. Experiments, observed order Ill DM THK NATUKE AND of sequences, and Logic now nun on a flood of light. L2. Seasickness is a functional disease <>!' the con* tral nervous system, mainly of the brain, but in some instances of the spinal cord also, the result of a series of mild concussions ( i s ^>. Beard . The cause is inadequate, and functional disease of the central nervous system is not very definite or lucid. The preventive treatment by bromization, however, was a greal advance in therapeutics. 13. Motion produces sickness by disturbing the endolymph in the semicircular canals, the viscera in the abdomen, and possibly the brain and subarach- noid fluid at its base ( 1881, Irwin |. 14. All the symptoms of seasickness can be ex- plained by paresis of the sympathetic (1887, skin- ner). This is a very important factor, but how is the paresis induced \ It is an epiphenomenon, and an imp. trtanl indication in t he drug t real ment. 15. Vertigo and vomiting are the essential symp- toms. The movements of a ship in a storm, par- ticularly its quick descent, cause movements of the cerebro-spirial fluid, and cerebral blood is displaced and the 1 nain subjected to shocks and the cen •helium to commotion ; or movements of the abdominal visceraand conl factions of the diaphragm, with their resulting local action and reflex inhibitory influ- ences I l svv . Pampoukis). 16. The symptoms of seasickness are those of cerebral anaemia. The uncommon and disordering movements that are felt derange and diminish reflex muscular tonicity and contraction, which maintain PREVENTIVE TREATMENT OF SEASICKNESS. L45 equilibrium and regulate the return venous circula- tion. Then results a muscular relaxation, of which the loss of equilibrium is the sign and the cerebral anaemia the consequence (1890, Rochet j. It seems that too great prominence is given to loss or diminution of reflex muscular tonicity. Fatigue is chiefly central, and the most highly endowed and the most differentiated tissue is the first to become exhausted. We have seen that in the production of the paresis of the sympathetic and prostration central fatigue is one of the factors. It seems that muscular relaxation would have to be pretty well marked before there could be much interference with the return venous circulation. And vertigo is present when the pupil is contracted under exciting sensations and the traveller is walking in the dark. The theory makes a deferred result the active cause, but withal is the best explanation yet given. There are varying degrees of susceptibility to the disease. We have seen how powerful a predis- posing cause is acute dyspepsia. The anaemic, the neurotic, the neurasthenic yield very readily to it, as do all who have weak and easily excited nerve centres. Athletes in training have been prostrated, while delicate women were laughing at their dis- comfort. Infancy and old age are more exempt than middle life. Individuals subject to vaso-motor disturbances are predisposed to the malady. All the symptoms have been often reproduced on land, after the lapse of months, by association of ideas. Seasickness is not a fatal disease. Deaths have been recorded as due to it, but in these cases it only caused the already suspended sword to fall. Sea- 10 1 (i; ( »\ THE N A II" UK AND sickness is an e\ il ; it is never " very g I at times *' (Burt «)in, nor " salutary "' (Johnson). All the good effects of sea travel are obtained without it. It is a dangerous malady when organic disease of the hear! or blood vessels, or of 1 1 1 * * stomach, or of the nervous system, or of t he lungs, liable to be at tendril by haemoptysis, is present, [t nearly always delays or disorders menstruation, and, asiswel] known, has often terminated pregnancy. It sometimes persists for a variable period after the voyage, and some never completely recover their sense ofequi librium and of space. Bad treatment is the natural sequence of false views of causation. When we know how a symp- tom or disease is produced theimanagement becomes rational, though nol always efficient. To the consid oration <>f the preventive treatment a few practical suggestions will be added on the management of the attack. In the prevention of seasickness we work along two lines — the removal of the predisposing causes and the diminution of the action of the exciting ones. In each instance we strike at causation, and the effect of the double blow is commonly satisfactory. My attention was first drawn to this method of prevention by the comparative immunity from sea- sickness of patients who were under my treat ment, before and during the voyage, for someone of the many disorders and diseases of nutrition. So far my experience with the method has not been very great, only a few more than one hundred cases hav- ing been managed in this manner. The number of cases is only large enough to suggest rather than PREVENTIVE TREATMENT <>K SEASICKNESS. L47 establish the value of the treatment. But if it, be iindcisl (I that more than half of these travellers had been previously so sick that they turned with honor from the repetition of the voyage, and that more than three-fourths of tliem completed the p ;t sage under the influence of my method without the slightest qualm, and subsequently, when neglecl rag my directions, became fearfully ill, it may be thought advisable to state the method to the profes- sion with a view to having its utility thoroughly tested. The treatment as directed to the digestive system has one important object in view — to diminish the irritability of the sensory-nerve endings of the mu- cous lining of the alimentary canal by keeping the digestive tube functionally active, clean, and sweet, and the consequent prevention of acute dyspeptic attacks. And we follow up the advantage thus gained by securing active elimination and perfect assimilation and disassimilation, thus strengthening and saving from the irritation of an impure blood the nerve centres, whose overexcitation and fatigue play so important a role in the development of the malady. In a few words, we strive to promote a high degree of healthy nutrition, because we believe that a strong man is best prepared to resist the encroachments of disease. Good nutrition is a well- fitting armor that turns aside many a deadly blow. If we succeed in realizing this high endeavor, I do not believe that the anaemic stage of seasickness will be developed. Close attention to the hygiene of nutrition will enable us to get the vital processes on a physiologi- IIS ON THE \ vn RE \M> cal basis. I >nly a Eew days will be required for this purpose if there be but slight disorder of one or moreof the nutritive processes. The week before sailing is commonly one of excitement, dissipation, ami worry. All preparations lor the voyage should be completed several days before going aboard the bowels regulated by laxatives, the secretions righted and supplemented if requisite, elimination keep free, and a plain, easily digested, and easily assimilated diet should be adopted. In a general way the sweetsand starches should be limited, and Lean meats made the staple food. But the age, ac- tivity, peculiarities, habits, the needs of general nu- trition, the capability of the digestive organs, must all be taken into consideration in the select ion of the diet. The means must be varied to suit each special ease, for individualization is the secret of success. But the aim is simple and definite — to secure the perfect digestion and assimilation of a sufficient quantity of food to meet the requirements of nutri- tion. If the patient gels eight hours of restful sleep every night, and feels no pain or discomfort or drowsiness after meals ; if there is no flatulence ; if the urine contains no abnormal coloring matter nor excess of phosphates, urates, or uric acid, and the stools are normal -we know that the food is being digested, absorbed, and assimilated in sufficient quantity, if there be no loss of strength to meet the demands of life, and that the excretory products are changed into their simplest and most soluble and most unirritating forms. Until this state of nutrition is established the patient is not prepared for the voyage. The same simple and regular and PREVENTIVE TREATMENT OF SEASICKNESS, I I'.i temperate way of Living and eating tnusl be ob served throughout the passage. When there is a serious derangement or disea e of the digestive; system, the proper treatment nm-i be instituted to secure the one aim of healthynu trition. How this can be undertaken with the greatest hope of success lias been outlined by me in articles published in the New York Medical Journal. The second part of the preventive treatment is intended to diminish the activity of the exciting causes until the organism can adapt itself to the Hew environment and become inured to the disor- dering sensations. During the first forty-eight hours it is advisable to remain in bed and sleep as much as possible. The effort to maintain equilibrium is diminished, "the confusion through, the sight of moving objects is limited, the life of relations is " cabined and con- fined," consciousness is diminished at last. Four light meals should be taken a day and very little fluid drunk. The danger of a mechanical hyper- emia of the nerve centres, by excessive muscular tonicity forcing the blood out of the musculo-venous reservoir, will be obviated. The only drink should be a single cup of hot water with each meal. After the expiration of this preliminary period, during which the action of the exciting cause is weakened and the organism is being accustomed to the disordering sensations, the time, except that which is regularly given to sleep, should be spent in the open air on deck. The sensory vertigo which is ever ready to arise into consciousness must be sup- L50 ON mii: \ LTURB \m» planted by purposive movements, the efficiency of which can be verified, as walking, etc., and by men fcal occupation or diversion. It is well known thai intense Tear or excitement or absorbing thought will dissipate "the bw dng sickness on the dismal sea." The vertiginous sensation is driven out of consciousness by the commanding presence of a powerful emotion, feeling, or thought. A widely known method of diminishing the ao; tion of the exciting cause is by the use of the bro- mide <>t' sodium, which must be pushed to its full l>h\ siological effects and the influence kept up dur- ing the entire voyage. The neuro-muscular disor- der is controlled, and sensory perception, both peri- pheral and central, is dulled. The drug influences favorably the simple vertigo, prevents the develop- ment of the hypersemia, but it intensifies the misery of the anaemic form. The treatment is often effi- cient, but it should never be tried except on the advice and under the supervision of a physician. Seasickness itself is not so harmful as may be bro- mi/ation. The large doses usually upset the sto- mach, and the drug irritates all the organs by which it is eliminated. The bromides, when pushed to the point of poisoning, often exert a persistent and per- nicious influence on the nervous system. The treatment during the attack is quite different in the anaemic and the hyperaemic varieties. When hvpera'iiiia is present the influence of the exaggerated reflex muscular tonicity can be dimin- ished by voluntary muscular movements, which re- quire muscular relaxation as well as contraction for their performance. The vertical position is an ad- vantage. A hot foot bath will also draw the blood PKEVENTIVE TREATMENT OP SEASICKNESS. I 5 1 away from tlio nerve centres, as keeping the Eeet in very hot water for somo time has produced syncope. A very powerful effect can be produced by placing the hands and feet in hot water and applying Lee to the head and spine. Counter-irritation is a proce- dure of questionable utility. Caffein will suppress the sense of central fatigue. Antipyrin or bromide of sodium by the rectum may be of some use In the ana3inic stage such drugs as must be ab- sorbed to produce an effect should be given hypo- dermically. Atropin is the best drug to stimulate the paretic sympathetic, but nitroglycerin must be given simultaneously to dilate the arterioles. Strychnin and the natro-benzoate of caff em also meet obvious indications. Ergotin, on account chiefly of its action on the urine, is also valuable. The judicious use and combination of these five remedies will meet the indications from the side of the muscular, nervous, and circulatory systems. Whiskey (and food also) may be required by the rec- tum. The horizontal position, with the head low, should be persistently maintained. The vomiting will also be favorably influenced by the preceding drugs. Copious draughts of hot water, to wash out and soothe the stomach, is a remedy of great value. Frequently repeated and small doses of creosote, with lime water and an infinitesimal quantity of ipecac, may be effectual. Oxalate of cerium, in five-grain doses every hour for three or four ad- ministrations, is another good remedy. If these preventive precautions and remedies fail, the pa- tient must content himself until he can again get into his element, the place where he was created and educated to. live — on land. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE r ppc nnTT m pp'f "D"n t "^ r i ' y i. i -X *- * \ v s ...• ' ^ *? ■ -A. \ * C28 (IO-53) 100M SOUTH PROPERTY «c8oi V37 Van Valzah 1892 Chronic disorders of the digestive tube. SOUTH PRO" T\CBot 179*. I