Dyspepsia, its varieties and treatment

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Preface

The scheme upon which the present work is based was drawn up by the author more than sixteen years ago. Only a few chapters had been written, however, before it became evident that the subject was infinitely more complicated than had been imagined, and the manuscript was accordingly put aside until sufi&cient knowledge had been gained to warrant a fresh attempt. In the meanwhile a series of special researches were undertaken upon the etiology of the various forms of dyspepsia, and monographs dealing with such cognate subjects as Disorders of Digestion in Childhood, Ulcer of the Stomach, and Cancer of the Stomach were published.

The present volume is the outcome of the clinical experience gained by the personal examination and treatment of more than eighteen thousand persons suffering from indigestion; but since the data thus obtained proved too unwieldy for analysis, the statistical enquiries quoted in the text were confined to one thousand examples of the complaint, five hundred of which were examined in hospital and five hundred in private practice. These were taken in the order in which they came under observation and were all subjected to the same methods of investigation, so that the results probably indicate with a fair degree of accuracy the relative frequency of the different types of dyspepsia in general and special practice, respectively.

The difficulties which beset the clinical study of indigestion are due in great measure to the almost universal disposition to regard the condition as a substantive disease dependent upon a primary failure of the gastric functions, whereas, in a large proportion of the cases, the symptoms originate entirely

8 PREFACE.

in the intestines and ensue from a derangement of the liver, pancreas, or bowel. Moreover, a disturbance of digestion in the stomach itself is rarely due to a primary disorder of that viscus, but is usually a consequence of serious disease of another and perhaps remotely situated organ of the body. The truth of this apparent paradox will be appreciated when it is remembered that the majority of the secretory, motorial, and inflammatory affections of the stomach result from the failure of some other organ to execute its proper functions.

It is also seldom understood that chronic indigestion is never due to the perversion of a single physiological process, and that the digestive apparatus is of such delicate construction and perfect adjustment that the slightest disturbance of one of its parts will eventually throw the entire mechanism out of gear. Thus, a continuous secretion of gastric juice, secondary, perhaps, to disease of the appendix, will in the course of time produce inflammation of the mucous membrane of the stomach, gastrectasis, and motor insufficiency, which in their turn may be followed by functional derangements of the liver and pancreas, enteritis, and even by ulceration of the duodenum. It is only by careful investigation of each individual case that the initial disorder can be ascertained and a clue obtained to the numerous and diverse conditions which so often obscure the original complaint.

The problems of dyspepsia are further complicated by the imaginative nomenclature with which the subject has been clothed and by the exaggerated importance accorded to phenomena of a secondary and purely subsidiary character. The term "dilatation of the stomach" appears to be regarded by the medical profession not only as an invariable accompaniment of indigestion, but as an actual disease of the stomach, which through the medium of "fermentation" and "autointoxication" is capable of producing every symptom which the human mind can conceive. Quite apart, however, from the fact that gastrectasis can rarely be diagnosed by the methods

PREFACE. 9

commonly employed for its detection and that it is usually confounded with gastroptosis, those who worship this fetish of their imagination never comprehend that gastric dilatation is not a primary condition, but is merely a consequence of some long-standing functional or organic disease of the viscus. No true clinician would dream of maintaining that dilatation of the heart was a primary disease or would be content to treat it without making some attempt to ascertain its cause; yet how few ever regard dilatation of the stomach as the result of a definite lesion or grasp the fact that gastrectasis is not a disease, but merely the consequence of one. The existence of gastric dilatation in a case of dyspepsia, although of importance from the point of view of prognosis and treatment, no more explains the nature of the indigestion than does the discovery of a dilated heart indicate the disease from which it has arisen.

In the first chapter a short scheme is offered for the clinical differentiation of the various forms of dyspepsia. This was originally drawn up for the benefit of those medical men who attended the author's demonstrations upon diseases of the stomach, but since it has stood the test of time and appears to have been of some use, it is now published for the first time.

Its sole value is to concentrate attention upon such clinical indications as serve to distinguish one form of the complaint from another and to emphasize the importance of discriminating between disorders of function as opposed to mere symptoms. It makes no claim to exceptional accuracy, nor can it be usefully employed unless the student possesses a good general knowledge of the diseases to which it refers. It cannot be too clearly understood that the science of gastric diagnosis is the art of taking trouble, that it is at all times diametrically opposed to guess-work, and that an accurate recognition of the nature of a complaint is the only possible basis for curative treatment.

One of the most interesting varieties of dyspepsia is that which ensues from a continuous secretion of the gastric juice.

lO PREFACE.

Hitherto it has been the custom to regard this hypersecretion as a primary neurosis of the stomach, but there can be httle doubt that it is really a secondary phenomenon dependent upon an organic lesion of the digestive organs. It is in this connection that the relationship of latent disease of the appendix vermiformis to dyspepsia becomes apparent, since in almost every instance where the appendix is diseased some perversion of the gastric secretion may be detected. Thus, when the organ is ulcerated or contains a calculus a typical hypersecretion is usually found to exist, while if it be merely thickened, twisted, or adherent, owing to a previous attack of acute inflammation, a form of chronic gastritis is apt to supervene after' a time, which not only obscures the original disorder of secretion, but closely simulates the clinical features of nervous indigestion.

The long-continued existence in the stomach of a hyperacid fluid is apt to induce severe gastritis accompanied by numerous erosions of the mucous membrane. These minute losses of tissue sometimes occasion profuse haemorrhages, but since they only appear as bleeding points when the stomach is opened at operation, the condition is erroneously ascribed to a morbid affection of the blood vessels. In several of the cases which are included in the table relating to the etiology of hypersecretion, recimrent attacks of haematemesis and melaena were observed, which disappeared along with the previous symptoms of indigestion as soon as the diseased appendix had been removed. A simple erosion of the stomach or duodenum is, however, always liable to be converted into a genuine perforating ulcer by the persistent irritation of the gastric secretion, and consequently many cases of primary appendicular hypersecretion are eventually complicated by these lesions. The biliary form of hypersecretion is also frequently followed by duodenal ulcer from the same cause, while that which ensues in the first instance from a simple ulcer is often attended in the course of time by gall-stones and appendicitis. These

PREFACE. II

three organic complaints appear, therefore, to be etiologically linked together by a secondary perversion of the gastric secretion which is common to each. The occasional failure of gastro-jejunostomy to remove the symptoms of a duodenal ulcer is often attributable to concomitant disease of the gall-bladder or appendix which had been overlooked at the operation.

The exact significance of simple hyperchlorhydria is at present difficult to define, since, although a temporary increase in the acidity of the gastric juice is of frequent occurrence, it is extremely doubtful whether persistent hyperacidity ever exists independently of hypersecretion.

In the chapter which deals with gastric myasthenia, special attention is directed to the latent period of the complaint and to the comparative rarity of true gastrectasis. The subject of inflammation of the stomach as a cause of dyspepsia has been condensed to the smallest possible compass, and only those varieties are described which are endowed with practical interest. If it were always borne in mind that chronic inflammation of the stomach is invariably due either to toxic poisoning or to serious disease of some other vital organ of the body, the term "chronic gastritis" would no longer be applied indiscriminately to every form of dyspepsia, nor would its existence be regarded as a matter of so little consequence.

Displacements of the stomach constitute a subject of great clinical interest, to which either too much or too little importance is usually attached. The fact that gastroptosis exists in many persons who never suffer from dyspepsia appears to indicate that the abnormal position of the stomach is quite compatible with perfect digestion; while the existence of impaired motility or of some secretory disorder in every case which exhibits symptoms of indigestion serves once more to emphasise the necessity of distinguishing between primary diseases and their consequences. Gastroptosis is so exceptionally frequent in the subjects of migraine, that future investigations will prob-

12 PREFACE.

ably demonstrate a causal connection between the two complaints.

Special prominence is accorded to those varieties of dyspepsia which develop during infancy and old age, and attention is directed to the pathological changes which occur in the mucous membrane of the alimentary tract at these periods of life.

Former writers were wont to lay much stress upon sympathetic disturbances of the stomach, and although this conception of the etiology of secondary dyspepsias has been abandoned, a study of gastric digestion when other important viscera of the body are attacked by disease serves to throw considerable light upon certain vicarious functions of the stomach and constitutes a subject of the highest practical importance.

Intestinal indigestion almost defies exact clinical analysis. In addition to the symptoms that ensue from the usual composite variety, those which arise from a primary fimctional derangement of the duodenum, liver, and pancreas are accorded separate descriptions, while a short account is given of those recurrent attacks of abdominal pain due to a tetanic contraction of the intestine which are usually confounded with gastralgia.

The treatment of the various subjects is considered upon broad lines and no attempt is made to enumerate the vast number of drugs which at one time or another have been recommended for the relief of indigestion. The author's sincere thanks are due to Dr. Herbert Rhodes for his kind assistance during the passage of the work through the press.

W. SOLTAU FeNWICK.

29 Harley Street, London, June, 1910.

Contents

CHAPTER L

PAGE

The Vaeieties op Dyspepsia and their Differential Diagnosis ... 17 Gastric and Intestinal Indigestion — The Causation of Gastric Dyspepsia— Scheme of Classification — The Relative Frequency of the Various Functional Disorders of the Stomach — Scheme of Differential Diagnosis of Acute and Chronic Dyspepsias.

CHAPTER II. Dyspepsia dtje to Abnormalities of Secretion 30

Hyperacidity: Etiology — Symptoms — Treatment. Hypersecretion: Acute and Chronic Varieties — ^Their Dependence upon Organic Lesions of the Digestive Tract — The Appendicular Form — The Biliary Form — ^Hypersecretion due to Ulcer — Symptoms — Complications — Diagnosis — ^Prognosis — ^Medical and Surgical Treatment. Achylia Gastrica: Etiology — Diagnosis — Treatment.

Chapter III

Dyspepsia due to Failure of the Muscular Power of the Stomach . 106 Myasthenia Gastrica: Frequency — Influence of Heredity — Incidence at Different Ages — ^Etiology — ^Primary and Secondary Varieties — Sjonptoms — ^The Latent Stage — ^The Stage of Food — Stagnation — The Stage of Food — Retention — ^Physical Signs — Chemistry of Digestion — Diagnosis — ^Prognosis — Diet — Massage — ^Electricity— ^Lavage — ^Medicinal Treatment.

CHAPTER IV. Dyspepsia due to Inflammations of the Stomach 145

Acute Gastritis: Primary and Secondary Forms — Etiology — Pathology — Clinical Varieties — Simple Acute Gastritis — Febrile and Afebrile Forms — Diagnosis— Treatment. Acute Toxic Gastritis: Pathology — Symptoms — ^Treatment. Chronic Gastritis: Etiology — ^Frequency — Its Dependency upon Diseases of Other Viscera — Toxic Varieties — ^Pathology — Symptoms — Course and Prognosis — Diagnosis — Treatment — Lavage — Climate — Diet — Mineral Waters — Drugs. Atrophic Gastritis: Etiology — ^Pathology — Clinical Varieties — Prognosis — Use of Artificial Digestives — Diet — Driigs.

14 CONTENTS.

CHAPTER V. Dyspepsia due to Disturbances of the Nervous Mechanism of the

Stomach

Gastric Hyperesthesia: Etiology — Symptoms — Four Clinical Stages — Physical Signs — Diagnosis — Treatment. Gastric Neurasthenia: Etiology — Symptoms — The Mild Form — The Severe Form — Complications — ^Prognosis — Diagnosis — Treatment. Nervous Eructation: Etiology — Symptoms — Treatment. Habitual Regurgitation : Etiology — Symptoms — Treatment.

CHAPTER VI. Dyspepsia due to Displacements of the Stomach 242

Anatomical Considerations. Upward Displacement: Symptoms — Physical Signs — Treatment. Vertical Displacement: The Angular, Fish-hook and Straight Forms — ^Etiology — Symptoms — ^Physical Signs — ^Prognosis — Diagnosis — Treatment. Total Descent of the Stomach (Gastroptosis) : Frequency — Causation — Symptoms — The Dyspeptic Form — The Bilious Form — The Asthenic Form — ^Physical Signs — ^Auscultatory — ^Percussion — ^Artificial Inflation — Gastrodiaphany — Complications — ^Prognosis — Diagnosis — Medical and Surgical Treatment.

Chapter VII

Dyspepsia due to the Presence of Foreign Bodies and Living Creatures in the Stomach 275

Hair-balls — Bezoars — Gastroliths : Etiology — Symptoms — Complications— ^Physical Signs — ^Treatment. Insects: Diptera — Coleoptera — Lepidoptera — ^Modes of Infection — Symptoms — ^Treatment. Slugs — Lizards — Worms — Leeches — ^Amphibious Animals — Snakes.

CHAPTER VIII. Dyspepsia in Infancy AND Old Age 303

The Dyspepsias of Different Periods of Life. Chronic Gastroenteritis IN Infancy: Frequency — Morbid Anatomy — Pathology — Atrophy of the Stomach and Intestine — Etiology — Symptoms — Chemistry of Digestion — Complications — ^Prognosis — Diagnosis — Infant Feeding — Gavage — ^Antiseptics — Treatment. Senile Dyspepsia: Etiology — ^Pathology — Symptoms — Treatment.

CONTENTS. 15

CHAPTER IX. Dyspepsia dependent upon Diseases of Other Organs 359

Lung Disease — Tuberculosis. The Dyspepsia of Phthisis: Pathology— Symptoms — Treatment. Heart Disease — Liver Disease — Kidney and Urinary Diseases — Specific Fevers — Syphilis — Diabetes — Anaemia and Chlorosis — ^Nervous Disease — ^Pregnancy — Drug Dyspepsias.

Chapter X

Physiology of Intestinal Digestion: Its Complex Character — Influence of Gastric Digestion — Intestinal Compensation — Duodenal Intubation — Test-meals — Chemical Examination of the Faeces — Estimation of Nitrogen—Estimation of Fat — Carbohydrate Fermentations— Micro-organisms. Chronic Intestinal Indigestion: Frequency — Etiology — Symptoms — Varieties — Diagnosis — Treatment. Duodenitis: Etiology — Symptoms — Varieties — Relapsing Form — Its Simulation of Gall-stones — Diagnosis — Treatment. Chronic Pancreatitis : Anatomy — Pathology — Symptoms — Chemistry — Prognosis— Medical and Surgical Treatment. Enterospasm: Its Reality — Etiology — Occurrence in Childhood — The Adult Variety — Symptoms— ^Prognosis — Diagnosis — Treatment.

Bibliography 454

Index 463

DYSPEPSIA.

Chapter I The Varieties Of Dyspepsia And Their Differential Diagnosis

The classification of dyspepsia has always been a matter of the greatest difficulty, and it only requires a glance through the literature of the subject to understand what an amount of ingenuity and trouble has been expended upon the problem of assigning the various symptoms of maldigestion to their proper causes. As might naturally be expected, a purely symptomatic nomenclature held almost undisputed sway through many centuries; and, indeed, it was not until the study of physiology had made considerable progress that derangements of function as opposed to the so-called morbid states of the stomach became clearly recognised; while the subsequent rapid advance of pathology helped still further to eliminate the effects of organic disease and to establish the true relationship of gastric inflammation to certain disturbances of digestion. As a result of these various researches, the so-called flatulent, acid, and irritative forms of dyspepsia which were included in the ancient description of the disease were superseded by such expressions as atonic, inflammatory, and nervous indigestion, while many symptoms which had hitherto been regarded as gastric in origin were now accurately referred to a disturbance of the intestinal functions. 2 17 l8 THE VARIETIES OF DYSPEPSIA.

The introduction of lavage by Kussmaul in 1869 and the subsequent adoption of a soft tube for exploration of the stomach has led to a great increase of our knowledge respecting the chemistry of digestion under both normal and pathological conditions, and although the subject is still very obscure and even the most careful and extended observations upon the same disorder bristle with apparent contradictions, it is yet possible to attribute certain subjective phenomena to definite alterations in the secretory, motorial, or absorptive functions of the alimentary tract.

Such a statement will probably be considered far too qualified, and, indeed, many modern writers seem to be of the opinion that experimental research has not only solved all the problems of indigestion, but has also revolutionised the treatment of functional disorders of the stomach. Far from this being the case, however, it will be conceded by most practical physicians that many ancient empirical methods are still of the greatest value, despite the fact that experiments are supposed to have proved them to be unscientific in origin and useless in application. In like manner, attempts to treat disorders of digestion upon lines laid down in the laboratory reveal still further discrepancies between what the human stomach is expected to do and what it actually does, with the result that the various artificial aids to digestion, drugs that are supposed to control gastric secretion and motility, as well as the numerous foods that have been prepared so as to ensure their immediate absorption, although excellent in their way, are all found in practice to possess one inherent drawback — they seldom do what is expected of them. This failure of clinical experience to corroborate the deductions from physiological research is obviously due to the profound difference that exists between the subjects of the two classes of experiment— a healthy dog and an unhealthy man. In my opinion two elementary distinctions must always exist between an animal used for such experiments and a dyspeptic individual,

DIFFERENTIAL DIAGNOSIS. I9

namely, the absence of psychical influences in the animal and the invariable disturbance of all the functions of the human stomach which ensues from the derangement of one. In the case of the animal the stomach is perfectly healthy, and in so far as psychical influences are concerned the organ is practically a machine. But in the human subject the all-controlling influence of the nervous system is perpetually in evidence, altering the composition of the various secretions, exciting or inhibiting peristalsis, and retarding or accelerating absorption through the influence of accidental psychical impressions or as the result of some constitutional defect of the organism. This all-powerful nervous influence constitutes the greatest obstacle to the treatment of every form of dyspepsia, and its existence in the human subject is of itself sufiicient to nullify most of the conclusions which might otherwise have been drawn from experimental research.

A simple clinical illustration will suffice to make this fact clear. In the disorder which is known as hypersecretion, careful dieting and treatment will usually secure immunity from pain, vomiting, and other symptoms for a considerable time, while repeated analyses of the gastric contents show a corresponding diminution of the acid secretion. But if during this period of latency the patient sustains a physical shock, experiences some violent emotion, or even receives depressing news, the former symptoms will recur within an hour or two, spasmodic closure of the pylorus produces food retention, a marked increase of hydrochloric acid occurs, and not infrequently a serious attack of gastric intolerance supervenes. This sequence of events is not the exception, but the rule; and it is highly probable that, were it not for the intimate connection between the secretory activity of the stomach and the central nervous system, hypersecretion would usually be susceptible of cure.

But the second distinction is of equal importance. The term dyspepsia, if it means anything, is an acknowledgment of a disorder of the gastric functions, and consequently the results of experiments conducted upon a healthy stomach, whether it belongs to an animal or to a man, can never logically be compared with those obtained from the viscus in a state of disease. Moreover, there is no such thing as a derangement of a single function of the stomach, for it can easily be proved that the slightest disturbance of any portion of the intricate machinery of digestion will throw out of gear the entire mechanism, and that an alteration of secretion, for example, is soon followed by a perversion of motihty and sensibihty, as well as by a profound derangement of the intestinal functions. In illustration of these facts the condition known as subacidity may be instanced. Pawlow has shown that in a dog the strongest stimulants of gastric secretion are water and meat extract, and it has consequently been assumed that the administration of soup or broth at the commencement of a meal should excite both the appetite and the gastric secretion of a person suffering from this chemical indication of impaired digestion. But in cases of gastric subacidity the perversion of secretion is not a primary complaint, but is usually an expression of chronic inflammation of the stomach attended by an impairment of motility and other abnormal conditions of the digestive organs. It is, therefore, invariably found that the administration of water or broth at the commencement of a meal in such cases not only destroys any remnant of appetite that may have existed, but, by diluting the already enfeebled gastric secretion and distending the too distensible stomach, intensifies the very symptoms which the treatment was intended to allay.

It would appear that Abernethy foresaw the future influence of theoretical teaching upon medical practice when he uttered the well-known words, "The stomach is neither a stew-pan nor a test-tube, but a stomach."

The Varieties of Dyspepsia. — Dyspepsia may ensue from a disorder of any part of the digestive tract or of the various organs, whose secretions are necessary to the solution and absorption of the food. Two primary varieties must, therefore, be recognised, the gastric and the intestinal.

Gastric dyspepsia may arise in many different ways. Thus, if the secretion of the organ be poured out in insufficient quantity or if it be lacking in hydrochloric acid, the carbohydrate constituents of the meal will undergo excessive fermentation with the production of various gases and organic acids; while an excess of hydrochloric acid causes the stomach to empty itself more rapidly than usual or produces a painful spasm of the pyloric muscle. In like manner, a continuous secretion of gastric juice deprives the viscus of its necessary periods of rest and, by irritation of the mucous membrane, occasions severe discomfort and secondary inflammation of the organ. Enfeeblement of the muscular coat of the stomach causes food to stagnate and to undergo decomposition, the gaseous products of which, by distending the organ and stretching its tissues, still further diminish its muscular power. Derangements of the nervous mechanism are more obscure in their effects than other fimctional disorders, but it is certain that an exalted sensibility of the gastric mucosa is attended by severe pain immediately food is brought into contact with the abnormally sensitive structure; while interference with the adequate closure of the cardiac orifice causes the constant regurgitation of small quantities of chyme. A mixed neurosis affecting both sensation and motility, and accompanied by symptoms of general neurasthenia, constitutes the obscure and complex disorder known as neurasthenia gastrica or nervous dyspepsia.

Alterations in the position of the stomach, whether congenital or acquired, oppose a mechanical obstacle to the propulsion of food into the duodenum, and by causing secondary perversions of the other gastric functions may give rise to a form of dyspepsia which can only be distinguished from gastric neurasthenia by careful examination of the abdomen. But in addition to primary aberrations of function and to abnormalities of position, the stomach, like other organs of the body, is extremely liable to suffer from inflammation, the result of which is to diminish both its secretory and motorial activity and to increase the sensibility of its inner surface. The dyspeptic symptoms that ensue from gastritis are consequently of a mixed type and liable to become chronic owing to the organic changes which occur in the mucous membrane. All substances that find their way into the stomach do not necessarily contribute to the nourishment of the body, and if, owing to their nature, size, or consistency, they remain for a long time in the viscus, they are apt to set up violent irritation accompanied by the symptoms of persistent indigestion. The occasional formation of hair-balls and other concretions in the stomach should, therefore, be considered in every etiological study of dyspepsia, as well as the existence of living creatures, such as maggots, larvae, beetles, and other insects, which sometimes find harbourage in the organ. Lastly, it is convenient, from a clinical stand-point, to notice those types of dyspepsia which occur in infancy and old age, as well as the various functional and organic lesions of the stomach that ensue from disease of other viscera of the body. Such, then, is briefly the scheme which I shall adopt in the clinical description of that complex collection of symptoms which constitutes what is commonly known as dyspepsia or indigestion.

The Classification of Dyspepsia: {A) Gastric indigestion. (i) Disorders of Secretion. (a) Hyperacidity or an increase of hydrochloric acid. ih) Hypersecretion or continuous gastric secretion, (c) Subacidity (achylia) or diminished gastric secretion.

(2) Disorders of Motility.

Myasthenia gastrica (atonic dyspepsia) or enfeeblement of the muscular coat of the stomach.

(3) Disorders of the Nervous mechanism.

(a) Hyperaesthesia of the stomach or exalted sensibility of the mucous membrane.

(&) Neurasthenia gastrica (nervous dyspepsia) or loss of nervous energy.

(c) Nervous eructation and regurgitation from interference with the closure of the cardiac orifice.

(4) Dyspepsia due to Inflammation of the stomach.

(a) Acute gastritis.

(b) Chronic gastritis.

(c) Atrophic gastritis.

(5) Dyspepsia dependent upon displacements of the stomach.

Gastroptosis.

(6) Dyspepsia due to the presence of Foreign Bodies and Living Creatures in the stomach.

(7) Dyspepsia peculiar to Infancy and Old Age.

(8) Dyspepsia due to Diseases of Other Organs.

(B) Intestinal indigestion.

In order to determine the proportionate frequency of the various forms of dyspepsia included in this scheme of classification, I have analysed the notes of five hundred hospital patients suffering from indigestion, who came under my notice in the course of eighteen months, and also those of an equal number of dyspeptics who consulted me privately during the same period of time, and have arranged them in the table on the following page.

The first, or hospital series, probably indicates with a fair degree of accuracy the relative frequency with which the different types of the complaint are met with in general practice; while the second, or private series, represents the subject from the point of view of the specialist.

THE VARIETIES OF DYSPEPSIA.

AN ANALYSIS OF ONE THOUSAND CASES OF DYSPEPSIA ARRANGED ACCORDING TO THEIR CAUSE.

Cause

Hospital cases

Private cases

Total

Per cent.

Total

Per cent.

Myasthenia gastrica . . .

Hyperaesthesia gastrica. .

Neurasthenia gastrica . .

Gastroptosis

Intestinal indigestion . .

25 160

51 15 71 72

15 67

4.8

5 32 10.2

3 14.2 14.4

3 13-4

62 88

9.2 32.4

5-2

1.6 13.2

12.4

17.6

8.4

Totals ......

As might have been expected, dyspeptic conditions among the poorer classes are most frequently due to that enfeebled condition of the musculature of the ahmentary tract which results from bad hygiene, exhausting occupations, and badly cooked food, or from inflammation of the stomach engendered by visceral diseases, the abuse of stimulants or frequent exposure to cold.

On the other hand, the specialist rarely sees such forms of indigestion as hyperaesthesia. and acute gastritis, which either pursue a brief course or are readily cured by treatment; while the majority of the cases that come under his notice consist of the more obscure varieties, such as hypersecretion and gastroptosis, or of those which are pecuharly intractable to treatment, hke chronic gastritis and neurasthenia gastrica.

In order to formulate a scheme of differential diagnosis it is necessary in the first instance to divide cases of dyspepsia into two classes: the acute and the chronic; the former of which includes those varieties that commence suddenly and endure for a limited period of time, while the latter comprises all those which are more or less permanent in character.

The class of acute dyspepsias, strictly speaking, only includes two forms, namely, acute gastritis and acute hypersecretion; but inasmuch as the disorder known as migraine is accompanied by very similar symptoms and is usually regarded by patients as a form of indigestion, it is advisable to place it in the same category. These three diseases have certain general symptoms in common: they all commence abruptly, pursue a definite course, and exhibit a tendency to periodic recurrence. They are all attended by more or less epigastric discomfort, nausea, vomiting, headache, anorexia, and constipation, and in each the digestive disturbance is sufficiently severe to render it a matter of grave concern to the individual affected. It may be observed, however, that while in gastritis and hypersecretion the initial symptoms are invariably referred to the stomach, violent headache is always the first manifestation of an attack of migraine. The mere history of the case will therefore permit immediate recognition of the nervous disorder. On the other hand, the symptoms of gastritis and hypersecretion are so much alike in their general characters that the most careful attention to a patient's description of his attack will fail to afiford a definite clue to the nature of his malady. Examination of the vomit, however, will at once serve to distinguish acute inflammation of the stomach from acute hypersecretion. Thus, in gastritis the ejecta are scanty, alkaline in reaction, and composed entirely of tenacious mucus; while in acute hypersecretion the vomit consists of an acid liquid tinged with bile or brown from altered blood, and which, when tested with red congo-paper, is found to contain free hydrochloric acid. The presence of the free mineral acid in the ejecta is pathognomonic of hypersecretion.