On diseases of the stomach : the varieties of dyspepsia, their diagnosis and treatment

Front matter

f

DISEASES OF THE STOMACH

ON

CHAPTER I. Pagh

On tue Changes of Digestion at different Periods

AND Conditions of Life.. ». 7

CHAPTER n.

On the General Sympathy op the Stomach in Disease 26

CHAPTER in.

On the Symptoms of Disease of the Stomach .. .. 39

CPIAPTER IV.

On the General Treatment of Disease op the

Stomach 86

CHAPTER V.

On the Remedies for Indigestion, and their Abuse .. 'Jl

CHAPTER VI.

Dyspepsia from Weakness; Atonic Dyspepsia .. ..' Ill

CHAPTER Vll.

Dyspepsia from Congestion .. .. ' 130

CHAPTER VIII.

Inflammatqry Dyspepsia 138

CHAPTER IX.

Vlll

CONTENTS.

CHAPTER X.

Page

Rheumatic and Gouty Dyspepsia •• I'jO

CHAPTER XI.

Renal Dyspepsia

CHAPTER XII.

Mechanical Dyspepsia

CHAPTER XHI.

1 70

Sympathetic Dyspepsia ..

CHAPTER XIV.

CHAPTER XV.

Duodenal Dyspepsia

CHAPTER XVI.

CI ' 211 Degeneration of the bTOMAOH

CHAPTER XVn.

CHAPTER XVIII.

Cancerous Disease of the Stomach 243

CHAPTER XIX.

Spasm of the Stomach - Spasmodic Contraction of the Pylorus

ON

DISEASES OF THE STOMACH.

The Varieties of Dyspepsia: their Diagnosis and Treatment.

Although nearly every year new works have appeared on diseases of the stomach, still the maladies affecting this organ are so numerous, and of a character so diversified, that there is ample scope for the records of individual experience. It is not my intention to enter into the scientific and pathological bearings of gastric disease ; this I have already done to a great extent in my former work on ' Diseases of the Abdomen.' My object in the following pages is ratlier to direct attention to the practical consideration of the subject, and to those divisions of a common disease which are brought imder tlie daily notice of the physician. The opinions advanced are based upon facts educed in the clinical study of disease ; and, if it had been thought desirable numerous instances might have been appended in support of every statement: we have preferred simply

B

THE YAEIETIES OF DYSPEPSIA:

recording tlie result of our own experience, leaving each one to test by individual practice the ctDrrectness of our deductions.

The organisation of the human frame is so nicely and delicately adjusted that every part maiijtains its harmonious relation to the whole ; and, if the attention is called at any time to the performance of any of its functions, we may rest assured that the healthy state is disturbed, and that disease in some form, however mild, has abeady commenced, and demands the attention of the physician. Healthy digestion is performed unconsciously ; and the physical movements, the chemical solution, and the subsequent absorption produce no sensory phenomena. The replenishment of the natural wants of the system excites a consciousness of healthy vigour, and of capacity for new exertion; and, as exercise produces waste, the demand for fresh material, by which the deficiency may be restored, is expressed by a healthy hunger, and by a thhst which is soon satisfied.

It is the function of the stomach to carry on the work of digestion ; : therefore, when widigestion arises we must trace it to some cause- by which this natural process is impeded. To enumerate all the causes of dyspepsia we must trace the daily life of an individual from earliest years to advanced age ; and not only must we note the external and physical conditions, but the subtle workings of the mind amidst its joys and sorrows, its

THEIE DIAGNOSIS AND TREATMENT.

gratifications and disappointments, its corroding cares and its seasons of buoyant happiness, its thirst for sensual enjojrment, as well as • its highly intellectual pursuits. Were we to depict all the varieties of dyspepsia, we must comprehend every form from the trifling malady, which may scarcely be regarded, to those which are so severe as to rob life of its enjoyment; and even the same symptoms may in the one case be a mere temporary disturbance, and in the other they may indicate the commencement of serious organic disease ; and, still fiu-ther, the measures available in the treatment of these multifarious comjDlaints are even more comprehensive than the symptoms ; and were we to enter upon a minute detail of the whole subject, we must include the rules of hygiene, as well as those of therapeutical practice ; for the diet and the -clothing, the exercise and rest, the air we breathe and the water we drmk are most important ; and not less essential are mental rest and disciphne in their effects on the physical organism. A full description of these remedial measures would lead us beyond our intended space, and we must content ourselves with general indications concerning them, still bearing in mind the fact, that they should never be placed in a position subordinate to the mere administration of medicinal substances.

As dysphagia indicates impaired action of the oesophagus, so dyspepsia is a term applied to corresponding defect in the stomach ; and as the varieties of

THE VAEIETIES OF DYSPEPSIA :

dysphagiia comprise the diseases of the oesophagus, so the forms of dyspepsia include the maladies of the stomach. The want of gastric power cannot however always be designated dyspepsia, for during the paroxysms of fever, as well as in the exhaustion of chronic disease, the stomach fails in common with every other part, and the local sign is almost disregarded in the general affection. We are fully aware of the danger attached to the special study of one class of disease ; and we must ever be on our guard, lest in directing attention to the local symptoms we overlook the constitutional character of the malady.

In my former work on ' Diseases of the Abdomen ' I arranged these affections of the stomach according to the physiological divisions, by referring to the various parts implicated, and then considered them in the following order : — 1st. The dyspepsia arising from disorder of the mucous membrane of the stomach and its secretion ; 2nd. That arising from the muscular movements of the stomach being impeded ; 3rd. From an abnormal state of the vascular supply; 4th. From chafiges in the condition of the nervous system ; and lastly from improper diet, or from chemical decomposition taking place during the digestive process. My present intention is to enter into a more minute consideration of the varieties of the disease as observed in daily practice.

The first that we shall notice is dyspepsia from

THEIR DIAGNOSIS AND TREATMENT.

weakness, whether from general imperfect nutrition and diseased vessels, or from exhaustion of the cerebrospinal nervous system, or from failure of the nerve of organic life ; atonic dyspepsia, as it might aptly be termed.

2nd. Dyspepsia from congestion, as observed in chronic disease of the lungs, heart, and bronchi, and also in chronic disease of the liver.

3rd. Inflammatory dyspepsia, whether arising from irritants, excesses, or improper diet.

4th. Hepatic dyspepsia, or " bilious indigestion."

5th. Rheumatic and gouty dyspepsia.

6th. The dyspepsia connected with disease of the kidney.

In the varieties of dyspepsia thus alluded to, the mucous membrane and its secretions are especially affected, there being either deficiency or excess in the gastric juice, or its character being changed by defective secondary assimilation or continued congestion. We shall then describe,

7th. Dyspepsia from mechanical interference with the muscular movements of the stomach.

8th. Nervous or sympathetic dyspepsia.

9tli. Dyspepsia from fermentation of, or chemical change in, the contents of the stomach, and,

10th, Duodenal dyspepsia.

Still further we shall refer to it as a symptom of more serious organic diseases, as ulceration and cancer.

THE VAEIETIES OF DYSPEPSIA.

In the earlier stages of these diseases the only indications of abnormal action are of a functional character, and a correct prognosis then requires the closest investigation, and a full knowledge of disease in all its relations.

CHAPTEE I.

On thk Changks of Digestion at Different Periods AND Conditions of Life.

The phenomenon of life does not present an unvaryingseries of actions, nor the constant repetition of tlie same living functions performed in an identical manner ; but we find in vegetable, as in animal life, that there are stages of existence and phases of development ever changing and progressive in their action.

In the first germ of the seed plant there is living gi'owtli of a peculiar kind, namely, the gradual formation of the germ leaf, the cotyledon, and of the rudimentary root ; and, at the same time, a supply of nutriment is stored up for the period of independent and separate existence ; there is a vitality in the seed wliich may exist for an almost indefinite period, till, by the application of the needed stimulus, fresh changes take place of an entirely different character in connection with the sprouting of the seed; then, for a time, another stage of vegetable life follows, that of growth and development. But, with the growth of tlie plant there are cyclical changes daily and hourly evolved, and in those plants of an exogenous kind each year witnesses remarkable variations, for the leaves, having fulfilled their purpose, their circulation becoming occluded, they fade and fall ; but on returning spring the old stock is not in the same condition as before, for the past year had left its trace ; so with each yearly cycle, till at length more general decay occurs, and the old weather-beaten stock, that has withstood the stormy blasts of many a winter, succumbs and dies.

With equal distinctness of demarcation do we find that human life has its stages ; we have infancy and youth, succeeded by manhood in its strength and prime, and then the gradual fading of the powers, first the physical, and then the intellectual ; but the differences impressed upon the whole organism at these respective periods are accompanied with a physical state also changing, and the one is dependent upon the other. A child, with its freshness of thought, the wildness of its imagination, and the quickness of its new powers, has a brain structurally differing from that of the old man, with his maturer thoughts, and his calmer reason, whose brain is acted upon by the impressions stored up in the memory, rather than by new objective observations. The -elasticity of the youthful step, and the enjoyment of vigorous exercise, are marks of strength of lung, and power of circulation, which an octogenarian does not possess ; and not less apparent are the functional peculiarities of digestion during the different periods of life.

AT DIFFERENT PERIODS OF LIFE.

During the earlier months there is the greatest activity in all the functions of life, the nervous system is very easily disturbed, the muscles are readily excited to contraction and convulsive movement ; the respiration is more hurried, and the heart beats with greater frequency, 130 to 140 as compared with 60 to 80 of adult life; the temperature of the body is more variable, and there is less ability to resist sudden changes.

The helplessness of infancy, and its entire dependence on the fostering care of others, is connected with a delicacy and sensibility in the organism, which is easily acted upon, and is adapted only for peculiar conditions. The physical organisation of an infant is designed for fluid food, and for its reception in a particular manner, namely, by suction ; although destitute at first of teeth, the muscular development of the mouth is sufficiently complete, and the clavicle, more ossified than any other bone, serves as the support for the arms and hands, which are secondary helps in the process.

An infant is only able to digest substances of the simplest Idnd ; and milk, the natural form of diet, is best suited for its wants. Milk not only contains hydrocarbonates, the oily part or cream, and sugar, also a heat-supplying material, but a large quantity of nitrogenous substance, the casein, and in proportion as the diet approaches this standard, is it suited for its especial purpose. Mere starchy food, such as arrowroot, rice, the ordinary corn-flour (washed maize)," only contain one ingredient of the infant's food, and are not sufficient to maintain health and to promote growth. Dr. Edward Smith in. his work on ' Cyclical changes during health ajid disease,' has well shewn, that during infant life " there is the maximum of oxidation of the elements of nutrition, and the maximum of highly organised food supplied;" and assuming three pints of milk as the quantity taken by an infant, he estimates that the food taken is, in proportion to the weight of the body, three to six times greater than that taken by adults. A method could scarcely be conceived fraught with greater mischief to infant life and health, than the administration of hard and solid food, especially when stimulating drinks are added. Too often do we find that great irritability of the mucous membrane of the stomach and other jjarts of the alimentary tract is set up by injudicious diet. Vomiting and diarrhoea, feverish and convulsive symptoms, fretfulness and peevishness, wasting and general exhaustion, are found to follow these gross departures from the rules which have been naturally laid down for infant life. Another peculiarity of infant requirement is that the supplies of nutriment must be frequently given. A healthy vigorous infant should be fed every two or three hours, and if there be weakness or exhaustion, the period must be lessened to intervals of an hour, or even one quarter of an hour. It is a mistake even during the hours of night to allow

AT DIFFERENT PERIODS OF LIFE. 11

a very young infant to sleep too long without food. In the absence of the mother's milk, the ordinary substitute is cow's milk, with one-third of water, and a small quantity of white sugar ; if the mucous membrane be very sensitive, ass's milk is often a better substitute; and as the child passes from month to month, its food should be thickened by the addition of some cereal grain ; the best are the preparations from wheaten flour, " tops and bottoms," Kobb's biscuits, dried flour, biscuitpowder, &c,, but, however the food may be prepared, it is essential that- it be free from any hard portions, which would be less easily acted upon by the digestive organs. If too long an interval is allowed to elapse, then a greater quantity is given at one time than can be easily digested ; for although digestion is more active than at any other period of life, it is more easily disturbed ; food is also absorbed with greater rapidity, and the eliminated products, as urea, are excreted in larger proportionate quantity ; but if, on the contrary, the process be checked, rapid prostration and emaciation ensue, and in a few hours infant life may thus be reduced to its lowest ebb.

Many of the preparations sold as infants' food are destitute of its most important ingredient, and consist merely of starch. This is insufficient for healthy growtli, and unless a large quantity of milk be added to supply the deficiency, the health is impaired. So sensitive, indeed, is the infant organism, that after a

ON THE CHANGES OP DIGESTION few hours of severe diarrhoea, an infant becomes cold and almost pulseless, its countenance is haggard and wasted, its muscles are flabby and soft, and unless the cause of exhaustion be checked life will quickly cease ; the passage of coagulated milk through the pylorus will sometimes suddenly produce collapse, resembling that which follows the administration of an ii-ritant poison. Again, a few doses of an exhausting remedy, such as tartar emetic, will render an infant pale and prostrate, and in not a few instances it will destroy life ; for, although the vaso-motor nerve is more active than at any other period, its power more quickly ceases. The same excessive irritability is found in the cerebro-spinal system of nerves'; thus, a small dose of a narcotic such as opium suffices to induce fatal convulsions ; and just as a child walking alone more easily falls when the foot trips, because the height of its centre of gravity is less, and the radius of the circle described by that height as a radius, is smaller, so the circle of the living functions in an infant is also smaller, but performed with more rapidity, and with greater facility are those cyclical movements disturbed in their course.

The condition of the glands connected both with primary and secondary assimilation are undergoing remarkable changes during the earlier years of life. The liver, a gland notoriously connected with the digestive process, is relatively much larger during infant life than at a subsequent period ; before birth its

AT DIFFEKENT PEEIODS OF LIFE.

proportional weight to the rest of the body is said to be as 1 to 18, and at about four or five years of age it attains the proportion which is afterwards maintained, that of 1 to 86. The mesenteric glands are very large and distinct ; they are more vascular than at any other period of life, and their function appears to be connected with the elaboration of the chylous fluid after absorption by the lacteal vessels, and prior to its discharge into the blood. If a non-nutritious diet be administered, low organised or strumous product is very prone to occur in these parts, and the same result is found if the system be exhausted from other causes. Again, stimulants and irritating food so disorder the mucous membrane, that acute Lypersemia in these mesenteric glands quickly follows. They may even be felt through the abdominal parietes, and when diarrhoea and general exhaustion exist at the same time, the malady is very apt to be mistaken for organic and incurable "tabes;" and although the enlargement may be merely hypergemic, there is gi-eat liability to the deposition of inorganic product of a strumous kind. If health be restored, the old diseased glands will be found in subsequent years us a semi-cretaceous mass.

In youth, whilst growth is rapidly advancing, the digestive organs are taxed to furnish materials, not only to maintain ordinary wear and tear, but to supply that which is needed for additions to the frame ; and if the blood be rendered unhealthy, and growth impeded, then, there is a greater tendency to the deposition of strumous product, and all its attendant degenerative changes. Many instances of consumption have arisen fi-om the nourishment during months of residence at school being of an improper kmd, or so unsuited to the taste, that it was altogether refused ; functional integrity soon becomes disturbed, growth is defective, and low organised deposit takes place under a very slight exciting cause. A large quantity of suitable nom-ishment is essential at this period for the natural activity of youth and the healthy development of the frame, as much as the system can digest and assimilate ; wliilst stimulants, and a diet which panders to the appetite rather than supplies requisite material for the growing organism, should be avoided.

In an ordinary state of health malt liquors and wine are both unnecessary and injurious ; and if the system be exhausted by disease, more than usual care is required in their administration.

During the strength of manhood there is less energy, but greater uniformity in the process of digestion. The development of the system has attained its maximum, and the functional activity is less powerful than during infancy and youth, but more so than iu the declining steps of advancing years. The lungs are fully developed, and the larger quantity of air inspired, and of carbonic acid exhaled, indicate a condition of system capable of bearing vicissitudes of temperature more easily. Longer

AT DIFFERENT PEEIODS OF LIFE. 15

intervals suffice to elapse between the meals, and larger quantities are taken. Dr. Edward Smith has educed some very interesting facts, especially bearing upon digestion in ordinary adult life, that, " in the morning hours digestion and assimilation are performed in their most natural and therefore most healthful manner, and that period especially demands an abundant supply of nutriment and to quote again from the same talented author, " that the rate of pulsation and respiration, and the evolution of carbonic acid were found to be the gi-eatest in one or two hours after breakfast, and at about four or five hours after the meal it was reduced to the lowest point of the working day, a point about ten pulsations higher than that of the lowest period of the night." But although digestion is more active at the earlier part of the day, and least so in the evening, still it is an unwise plan for those who are engaged in pursuits involvmg much intellectual and physical fatigue, to allow the whole afternoon and evening to elapse Avithout partaking of some sustaining diet; it is not sufficient to take a substantial mid-day meal, without anything of a really nourishing land afterwards, for the sleep is less refreshing, in consequence of greater exhaustion during the night. The processes of digestion are often, and that very properly, lost sight of, and doubtless much irregularity and indiscretion are borne with impunity, still, the penalty is afterwards paid ; irregularity and excess cannot bo continued without future detriment ; and many of tlie forms of severe dyspepsia are produced and perpetuated by inattention to the simplest rules of diet or regimen.

Tlie quantity of food required by the system ranges from twenty-two to forty or even forty-five ounces of solid food, and eighty to ninety-five ounces of fluid. The solid part must contain albuminous substances, fatty substances, also carbo-hydrates and salts, the second and third forms being especially used in the system for mamtaining animal heat. Still these alone will not suffice, unless some fresh vegetable food or fruit be commingled; and we frequently find that disease is caused or aggravated by the avoidance of vegetable diet altogether. This fact we have often witnessed in those who from actual or supposed weakness of the stomach refrain from all fresh vegetable substances, as requiring greater digestive power.

Dr. Parkes in his work on ' Hygiene,' quoting from Moleschott, gives the following table, as showing " the water and food required daily for a working man of average height and weight;" but in those who take more generous diet, the albuminous and fatty substances may be half as much more :

Grammes. ' Ounces avoir.

Albuminous substances .. 130 .. .. 4'587

Carbo-bydrates 404 .. .. 14-2o7

3448 121-446

AT DIFFERENT PERIODS OF LIFE.

and again, that 104 grains of nitrogenous substances equal to 3*671 ounces is the lowest amount a working man ought to have. The least amount for active life, according to Dr. Parkes, is 14 to 1-5 ounces of dry nitrogenous substance, but with this weight and strength are lost.

Still the quantity and even the quality may be all that is desired by the physiological chemist, but the stomach may refuse to receive it, or to deal with it in a friendly manner, because the palate is offended, and the sameness and character of the diet is opposeel to the tastes and wishes of the patient ; the idiosyncracies of diet are best known to individuals themselves, and in abnormal states of disease these peculiarities become marked with increasing distinctness.

In advanced years the activity of life gradually lessens, and the physical organisation presents corresponding change. The arterial vessels which carry the supply to every gland gradually become opaque and rigid; the glands themselves waste, and are comparatively inactive ; and although the higher powers of mind and thought may remain still in their full strength, it is impossible to hide the habiliments of age. The drier and more shrivelled aspect of the skin is an indication that the minute sudoriferous glands are inactive ; and, the mucous membrane of the alimentary tract, a mere inversion of the external investment, is likewise wasted, it becomes much thinner, its glands smaller, and in fact,

C the mesenteric glands are with some difficulty found ; the same mesenteric glands, which during earHer life are so essential in the elaboration of the chyle, before it is poured into the blood. The digestive process is feebler during advanced life than at any previous period ; and this lessened functional power is accompanied with an inability to take the same vigorous exercise as formerly. During the strength of earlier Hfe, when the respiratory act was in its full energy, it would seem that effiSte materials could be rapidly removed, and at the same time warmth and heat maintained; in age, the cycle of functional life slowly revolves, till it ceases altogether, or is stopped by the slightest impediment.

The actual condition of the stomach itself in its atrophied glands expresses the fact of lessened power ; the muscular coat is often wasted, unless there be some impediment to the passage of food at the pylorus or elsewhere, when the increased power required is followed by hypertrophy. There is a marked contrast in the condition of the involimtary fibre of the alimentary tract in early and advanced life ; in the former period contraction is readily induced, and the stomach at once empties itself by vomiting ; so also the intestines hurry on their contents, producing diarrhoea, and muscular contraction will even impel one part of the intestine into another, causing intussusception; in the latter period, flatulent distension takes place from the lessened (tontractive power ; and the distensioa becomes a cause of

AT DIFFEEENT PERIODS OF LIFE.

constipation, dyspepsia, and of general distress. The sacculi of the colon and the appendicse epiploicae become enlarged, and unable to empty themselves, and concretions form in the bowel, although natural relief may take place daily.

The mucous membrane is more vascular, the valvulas conniventes and vilK of the intestines are in their full activity in early life ; but in age, the arteries are diseased, the circulation sluggish, and the absorbent system wasted and comparatively inactive. We find, also, that in age the pancreas has a larger quantity of fibroid tissue, as another indication of ceasing energy. The liver and kidneys undergo like changes ; and still further, in the examination of the large central ganglia of the sympathetic, there is a manifest difference in the appearance of the cells at the extremes of life, for in old age the cells are dark, and often loaded with pigment, as if the vital meclianism were gradually coming to a state of rest. This diminished energy requires that the supply of food should be more constant, and that long intervals should not elapse: it is often noticed that headache, disturbed vision, and symptoms resembling threatening apoplexy or paralysis, arise from an insufficient nutrient supply ; and the mistake is sometimes made of exhausting by powerful purgatives, mercmials, or even actual depletion, when ammonia or stimulants would be more appropriate.

Some of those who have attained to advanced age are

c 2

ON THE CHANaES OF DIGESTION very unwilling to depart from the habits of earlier years ; it is with them very important that, during the hours of the night some bland nutriment should be taken, if there be wakefulness ; and although late heavy meals are very undesirable, still the exhaustion of the night hours are often followed by impeded circulation and faintness. It is thus, that the heart, during the night, not very rarely ceases in its action altogether ; and the man who had retired to rest without any consciousness of danger is found in the morning lifeless. It is equally injurious so to excite and oppress the system by improper diet and stimulant, as to endanger the integrity of the minute ossified vessels of the brain, and thus cause an apoplectic attack.

In advanced life sudden changes and excitement are borne with great difficulty, and as in the earlier years, exhaustion is easily induced ; with steady and slow pace the revolutions of functional work may move on, but with any violence to the system the powers of life will cease altogether.

In old age, as in infancy, we find that some remedies must be used with great caution, thus mercurials and powerful purgatives more easily cause great depression ; and it would seem that opium will so act upon the urino-genital organs, as to produce retention of urine.

The atrophied condition of the glandular organs connected with the stomach, to which we have already

AT DIFFEEENT PERIODS OF LIFE.

referred, and the weakened digestive power, render the use of condiments sometimes of great service, and the stimulating effect of wine rightly administered assists in the maintenance of health. These agents, which in infant life irritate and disturb, now give that additional stimulus which the fading powers of life require.

There are some conditions of ordinary life which require notice, for the digestive process is in them strangely modified ; and the whole system sympathizes with the important processes that are being carried on, we refer to pregnancy and to lactation. The former state induces remarkable change in the vaso-motor or sympathetic nerve of the abdomen ; there is the closest union between the uterus and the stomach ; a state of irritability is frequently induced, so that the stomach rejects its ordinary supply, and it does so especially in the morning, the period at wliich digestion is generally most active. This irritability of the gastric surface is sometimes so severe that all food is rejected quite independent of mere pressure on the viscus ; the months of gestation are periods of wearisomeness and distress ; the gastric disturbance, however, at once ceases on delivery. In some cases the disturbance of the stomach has been referred to the secretion from the kidney becoming disordered and changed, and this, in some instances, is doubtless an aggravation of the symptom. Again, direct pressure greatly increases the distress of this kind, but neither of these conditions suffice to explain the state we refer to ; it would seem as if tlie large nerve ganglia supplying the abdominal viscera were disturbed by the greater energy of the uterine plexus. Again, there are those in whom conception at once removes all symptom of indigestion; so that pain and flatulence, which for many months previously have induced indisposition, are no longer felt, and there is the enjoyment of health and strength not experienced at other times. Unfortunately in some of these instances one trouble returns as soon as the other trouble is over, and before physical strength has been thoroughly regained, the digestive process is again impaired ; the uterine activity of function seems to induce equable and healthy action of the stomach.