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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.
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