loss of blood, etc., and over-exertion predispose to downward displacements
of the abdominal viscera. Glenard's original hypothesis that a dislocation
of the hepatic flexure of the colon caused by a stagnation of faecal matter is
the beginning of a general ptosis is probably less correct than the theory that
the condition is due to factors such as those mentioned above. Of late the
idea has been advanced that there may be a congenital predisposition to
visceroptosis since in the foetus and even in the newly-born child the viscera
may occupy an analogous position in the abdominal cavity.
The fact that the displacement may not involve all the abdominal organs
must not be overlooked, for it is not unusual to find a kidney, the stomach,
the liver or the spleen in abnormal locations.
Symptoms. These are indefinite and indeed the condition may exist
without causing any symptoms whatever. In general, however, the patient
complains of various dyspeptic symptoms, such as poor appetite, sensations
of distention and weight and eructations and rumblings in the digestive tract.
Rarely the appetite may be increased; the bowels are usually constipated,
though the opposite condition may be present. The breath may be foul,
the tongue coated and the mouth dry. Nervous manifestations, such as
dizziness, depression of spirits, headache, sleeplessness, palpitation, and tin-
gling and sensations of cold in hands and feet are frequent. Considerable
bodily emaciation is not rare.
A chlorotic condition of the blood often accompanies this condition.
Physical examination reveals an abdomen prominent and baggy in its
lower part, relaxed and thin of wall. On palpation the abdomen has a
characteristic doughy feeling and splashing sounds may be easily elicited.
The edge of the liver, when this organ is displaced, may be felt lower than
normal, the kidneys and spleen may be palpated. Percussion of the liver
shows its upper limit to be displaced downward. The displacement of the
stomach may be demonstrated by any of the means described under gastric
dilatation (p. 362 and ff.) and it may be shown to be in a position more vertical
than normal, its cardiac end usually being in the normal situation and the
pylorus far from its proper site.
Treatment. Drugs have no great part in the management of this condition
368 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
the principal object being to replace the abnormally situated viscera and to
maintain them in their normal position. This may best be done by putting
the patient in bed, keeping him there and fattening him. He should be over-
fed and as adjuvants to this treatment faradic electricity and the high fre-
quency current may be employed. Physostigmine salicylate in doses of gr.
y^o" (0.0006) three times a day is usefiil to restore the tonus of the intestinal
musculature. This may be given alone or in combination with strychnine
sulphate gr. ^o" to -j^ (0.003-0.0025) and capsicum, gr. i (0.065).
The bowels should be kept open by means of vegetable laxatives such as
aloes or rhamnus purshiana if necessary, but the diet should be depended
upon to regulate this function in so far as possible, fruits and foods leaving
an undigested residue being particularly indicated. When diarrhoea is present
it may be controlled by intestinal antiseptics such as bismuth subsalicylate,
resorcinol or benzo-naphthol, and when gastric analysis shows hydrochloric
acid to be diminished in quantity this substance may be supplied.
When the cure by means of rest in bed is inconvenient or impossible the
patient may receive much relief from wearing a properly fitting abdominal
binder such as can be furnished by any reliable truss maker. The patient
should be taught by his physician how to replace the viscera and this should
be done in bed each morning and the belt applied before the erect position
As a substitute for the abdominal band strapping with zinc oxide adhesive
plaster (preferably spread on moleskin) strips has been suggested and often
achieves excellent results (Rose).
It should hardly be necessary to state that tight lacing is contraindicated
in ptosis of the viscera and that women should be advised to wear skirts
suspended from the shoulders rather than from the hips.
Physical methods such as massage either by the physician or the patient
himself, moderate exercise, such as bicycling, golf, etc., and hydriatic pro-
cedures have a place in the management of this condition after the rest cure-
has succeeded in restoring the organs to their normal situations.
The dietetic treatment of visceroptosis offers difficulties. The problem
in hand is to fatten an individual whose powers of digestion and assimilation
are impaired and to over-feed such a patient without disturbing his already
poor digestive ability is not an easy task. And again the difficulty is enhanced
by the fact that the regimen for each patient must be chosen with reference to
his particular capabilities. During the early part of the rest cure a milk
diet should be instituted if the patient can digest and is satisfied with it, later
more latitude may be allowed and, if the digestive powers permit, a general
diet should be prescribed.
If the patient is not undergoing the rest cure and is up and about he should
not eat large quantities at a time lest the stomach become over-loaded and the
NEUROSES OF THE STOMACH. 369.
ptosis accentuated; here four or five small meals per day of concentrated
food stufis are preferable to three of large or ordinary size. Fats may be eaten
if they can be digested. Gastric analysis and observation of the case in hand
will indicate far better the proper diet than can any list of food articles arbi-
trarily set down.
Surgical measures, such as taking reefs in the lengthened mesenteries,
suturing the lesser curvature of the stomach or its anterior wall to the anterior
parietes of the abdomen and suturing the edges of the recti abdominis
muscles together after having removed the intervening tissues, have been
employed with varying results.
NEUROSES OF THE STOMACH.
Synonyms. Gastric Hyperacidity; Gastrosuccorrhoea; Gastroxynsis; Nerv-
ous Hypersecretion of Hydrochloric Acid.
Definition. Excessive secretion of hydrochloric acid by the gastric tubules
occurs in various gastric disorders but there is a class of cases in which there
is a hypersecretion of gastric juice which takes place in the absence of food or
of any inflammatory condition. It is usually considered a neurosis and exists
in two chief forms.
a. Paroxysmal hyperchlorhydria.
h. Continuous hyperchlorhydria. This is a chronic state and was first
described by Reichmann whose name has since that time been associated
with the condition.
.etiology. Hvperchlorhydria has no distinct causative factor. It is
most frequently observed in persons of neurotic temperament. It is more
common in the young and middle-aged and is often seen in chlorotic subjects;
it is predisposed to by various mental influences such as grief, worry, etc.
Some subjects are afflicted with it directly after eating or drinking certain
Symptoms. These are practically identical in the two forms except that
in the paroxysmal variety they appear intermittently while in the continuous
type they are always present. The most prominent symptoms are pain refer-
red to the stomach, "heart burn," the eructation of gas, thirst and nausea.
Vomiting is infrequent and when present the very acid taste of the vomitus
is noticed. Headache is common. The appetite is usually good and the
bowels are, as a rule, constipated. The acidity of the urine may be reduced
owing to the excess of gastric acidity.
In the paroxysmal form of the disease the symptoms may last only a few
hours or may be prolonged for a number of days to be terminated by treat-
370 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
ment or in an attack of vomiting. In the continuous type the pain is more
marked and if untreated the patient may lose flesh and strength. In long
standing cases anaemia is not rare.
The prognosis as regards improvement is very favorable and cures are
The diagnosis can be made certainly only by means of chemical analysis
of the gastric contents. A test-meal removed two or three hours after ingestion
will consist of a small amount of thoroughly digested food containing an
excess â€” jsometimes very large â€” of combined, and especially, free, hydro-
chloric acid. If the stomach is washed and several hours later â€” nothing
having been ingested in the meantime â€” the contents of the organ is expressed
this will be found to consist chiefly of gastric juice, where normally none
should be present.
Treatment. The neutraHzation of the excessive acidity present in the
stomach by means of the alkaline carbonates â€” sodium bicarbonate in par-
ticular â€” has its disadvantages, the resulting sodium chloride from the com-
bination of sodium bicarbonate and hydrochloric acid being ready for forma-
tion into still more of the offending substance; however, certain observers
claim that benefit results from the administration of considerable doses of
sodium bicarbonate â€” lo to 30 grains (0.66-2.0) â€” after meals; a far preferable
antacid, however, is heavy magnesia which results in the formation of mag-
nesium chloride which acts as a laxative and is carried off from the body.
Some clinicians prefer to give it with sodium bicarbonate, but it is better
administered in a combination such as the following : I^ magnesiae ponderosae,
gr. X (0.66); pulveris rhei, gr. v (0.33); extracti belladonnae, gr. j-q (0.018);
to be taken J to i hour after each meal. Sodium bicarbonate in amount
equal to that of the magnesia may be added with benefit in some cases. Other
useful formulae are: I^ potassii carbonatis, magnesiae ponderosae aa gr. xii
(0.75); extracti belladonnae gr. yt(o-oi8); sacchari lactis gr. xv (i.o). Misce
et signa, to be taken about an hour after meals. Sodium bicarbonate may be
added to this formula also. I^ sodii bicarbonatis, cretae praeparatae, mag-
nesii carbonatis aa gr. iii (0.2). Misce et signa, to be taken after meals.
Belladonna is said to lessen the secretion of the gastric juice and it and
atropine are also useful in combating the severe pain. This symptom may
be rendered less distressing by various narcotic drugs as weU, codeine and
strontium, ammonium or sodium bromide being most frequently prescribed.
Morphine should not be administered.
Pain which resists drug treatment may be relieved by gastric lavage, which
removes the hyperacid contents of the stomach. To the last of the water
used it is well to add sodium bicarbonate. Washing with a mixture contain-
ing bismuth subgallate and bismuth subcarbonate of each i drachm (4.0)
to the quart (litre) of water is an excellent measure.
HYPERCHLORHYDRIA. 37 1
Intra-gastric sprays of silver nitrate solution (i-iooo) are said to have the
double effect of lessening the secretion and relieving the discomfort. Follow-
ing this procedure the stomach should be washed with warm water.
The drinking of considerable quantities of Carlsbad water, natural or
artificial, tends to lessen the production of hydrochloric acid by the stomach
and in hypochlorhydria in lithaemic subjects the use of artificial effervescent
solutions made according to the following formulae is beneficial.
Sodium bicarbonate 5^^ (8.0). gr. Ixxv (5.0).
Sodium borate 5^5 (2.0). gr. xv (i.o).
Sodium salicylate gr. xxxvii (2.5). 5ss (2.0).
Each of these mixtures is to be added to a quart (litre) of ordinary carbonic
water and before breakfast a half tumbler of solution a is to be taken. After
meals a half tumbler of solution b should be drunk.
Constipation usually yields to the treatment directed at the neutralization
of the acidity. If obstinate, the saline waters, abdominal massage, intestinal
lavage and the preparations of rhubarb will prove effectual.
Electricity in the form of intragastric galvanism may be employed, the
anode to be applied inside the stomach, which should be partially filled with
lukewarm water, while the cathode is placed upon the epigastrium or back.
Diet. Certain clinicians advocate a diet consisting chiefly of proteid
substances, since the albuminous foods combine with the excessive hydro-
chloric acid, while others consider much carbohydrate and little proteid to be
better adapted to the gastric condition because the latter class of foods tends
to cause increased hydrochloric acid secretion, but the proper method of
deciding upon a suitable diet in these cases is to study each patient. It is
probably true, however, that more patients will do well upon a diet principally
of proteid. Of the meats, beef, mutton, veal, pork, raw or cooked ham and
fowl are allowable, as are eggs, Roquefort and Swiss cheese, cocoa and milk.
Fats are not contraindicated but it is generally considered that vegetables
containing large amounts of starch are better omitted. Since the period of
starch digestion is shortened, owing to the abnormally early secretion of
hydrochloric acid after the ingestion of food in this condition, starchy foods
should be eaten, when possible, dextrinized, toast, zwieback and the like
being preferable to plain bread.
Coffee, beer or other alcoholics should be forbidden but the drinking of
considerable quantities of alkaline waters with meals is permissible since by
this means the excessive gastric juice is diluted.
All substances likely to increase the secretion of gastric juice, such as
condiments, spices, fruits containing seeds or enveloped in skins, etc., should
not be eaten and the food should be taken finely divided and neither very hot
372 DISEASES OF THE DIGESTIVE SYSTEM AKD PERITONEUM.
nor very cold. The patient should be advised to masticate thoroughly so
that mouth-digestion may be as fully accomplished as possible. The chewing
between meals of substances calculated to excite the secretion of saliva has
been advocated with the idea that the swallowing of this secretion in large
amounts tends to neutralize the gastric acidity, but is of slight value.
An attack of pain after the evening meal may be relieved by a glass of warm
milk, a cup of broth containing an egg, a soft boiled egg or some raw ham
finely scraped. Any of these substances takes up a large quantity of hydro-
The treatment of paroxysmal hyperchlorhydria consists in the employment
during the attack of the means suggested for chronic hyperacidity on p. 370,
together with gastric lavage and the application of a mustard paste or hot
water bag to the epigastrium. Strontium bromide or ammonium bromide,
^ drachm (2.0) three times a day is said to shorten and to lessen the fre-
quency of the paroxysms. The general management of the condition consists
in abstention from mental over-activity and in regulation of diet and exercise.
Alcohol, tobacco, coffee and aU other stimulants should be interdicted
and a life of recreation and free from care and worry should be ordered, and
exercise out of doors â€” the bicycle, golf, tennis, riding, swimming, etc. â€” should
be advised. Dietetically and otherwise the treatment may be carried out
along the lines laid down for continuous hyperchlorhydria.
Hypochlorhydria, subacidity or hypochylia, is a condition of the stomach
in which the gastric juice contains an abnormally small amount of hydro-
chloric acid and also of the digestive ferments. It exists in various abnor-
malities of the organ, such as gastritis and cancer, in anaemic conditions,
during the infectious diseases and in neurotic states; the subacidity of these
last conditions, the true nervous hypochylia, occurs in hysteria, locomotor
Entire absence of hydrochloric acid which is denominated achylia gastrica
occurs in hysteria and neurasthenia, in carcinoma, and as a result of the
atrophy of the gastric glands due to chronic inflammations.
The symptoms of diminution or entire absence of hydrochloric acid and
gastric ferments are not typical and the condition may exist for long periods
without causing complaint on the part of the patient; when, however, in addi-
tion to the secretory disturbance, the motor power of the organ is impaired,
the consequent fermentation of stagnant food results in distention, eructations,
sensations of weight and fidlness and at times marked gastralgia. Diarrhoea
may be present.
The diagnosis can be made only on chemical examination of the stomach
contents withdrawn after a test-meal. This shows diminution or entire
absence of both free and combined hydrochloric acid and of the gastric fer-
ments. Lactic acid is rarely found in nervous hypoacidity.
The treatment of both hypochylia and achylia consists in the administration
of dilute hydrochloric acid to supply the lack of this substance in the stomach.
The dose should be regulated with regard to the amount present in the gastric
secretion. When the acid is wholly absent as much as 15 to 20 drops (i.o-
1.33) may be given half hourly after meals until 3 doses have been taken.
It must be plentifully diluted and taken through a tube. The administration
of pepsin, pancreatin, and especially of fresh pineapple juice, which contains
a digestive ferment, may supply the loss of the normal digestive ferments.
Loss of appetite may be relieved by basic orexin and by gastric lavage
with solutions of the vegetable bitters such as gentian or quassia. In atony
of the gastric musculature strychnine nitrate in large doses â€” gr. 3^ to -2V
(0.002-0.003) is indicated and this drug also exerts a favorable action upon
any co-existent neurotic condition. Stagnated and decomposed food should
be washed out and the stomach irrigated with a disinfectant solution (see
p. 339); electricity and hydrotherapeutic procedures are useful adjuncts to
The diet should be adapted to the digestive capabilities of each patient.
Meat need not be interdicted, in fact it is better that the patient eat some
meat, this should, however, be taken in a finely divided condition. Green
vegetables and puree soups may be taken; fats in the form of cream and
butter are allowable unless they cause fermentation. Salty substances such
as anchovy paste, caviar, etc., taken before meals in small quantities, increase
both the appetite and the gastric secretion.
Synonym. Cramp of the Cardia.
This is a spasmodic contraction of the gastric musculature at the cardiac
end of the stomach and is usually the result of some irritation such as h)^er-
acidity, or distention of the stomach by air or gas. It also occurs as a symptom
of neurasthenic and hysterical conditions and very rarely as a true neurosis
of the motor system of the organ. It exists in an acute and in a chronic form;
the former appears paroxysmally and lasts but a short time, the latter is a
serious condition and one difficult of management. The acute variety, when
occurring in an empty stomach, gives no symptoms; on a full stomach it
produces a spasmodic and cramp-like pain which soon passes; if food or
drink is taken during the cramp there may be obstruction to deglutition.
In the chronic form the patient may also have difficulty in swallowing and feel
that the food stops before entering the stomach. If he continues to eat the
374 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
oesophagus gradually fills and finally the food is regiu-gitated little changed
and containing no gastric juice. The inability of food to reach the stomach
brings on a progressive emaciation which is likely to cause suspicion of carci-
noma, and the accumulation of ingesta in the oesophagus may result in dilata-
tion or diverticulum formation. There is likely to be obstruction to the
passage of the stomach tube.
Treatment. This consists in the appropriate treatment of any co-existent
inflammation or secretory disorder of the stomach. The food should be
non-irrhant, easily digestible and taken in finely divided form. In the severer
grades of this condition milk diet or feeding through the stomach tube may
be necessary although it is stated that at times solids are more easily swallowed
than liquids. Any constitutional neurotic condition should receive proper
treatment. The insertion of a firm tube of good size through the cardiac
orifice and allowing it to remain in place for a half hour at a time is an approved
method of treatment. Before eating, the gastric mucosa at the cardia may
be cocainized by a small sponge fixed at the extremity of a stomach tube by
means of a thread passed through the tube. The sponge should be saturated
with 2-4 percent, cocaine hydrochloride solution, the tube passed as far as
the cardia and the cocaine solution expressed by puUing the thread. An
intragastric spray of cocaine, or cocaine and menthol solution may also be
employed to produce anaesthesia. The use of the galvanic current is an
excellent measure in spasm of the chronic type; the anode is introduced
into the cardia, the location of which has previously been ascertained by
measurement, the cathode is applied to the back of the neck and a current
of about 25 milliamperes is employed for 10 minutes; the anode is then placed
over the stomach and the cathode within the cardia and the process repeated.
This condition is analogous to cardiospasm, but takes place at the pyloric
extremity of the stomach. It occurs in excessively acid states of the organ,
accompanying gastric dilatation, as a result of the action of caustics, and as a
concomitant of pyloric ulcer or cancer.
The interference with the passage of stomach contents through the pylorus
results in stagnation and fermentation and finally in dilatation with the accom-
panying symptoms of these conditions. In thin subjects the gastric peris-
talsis may be visible and in some cases reversed peristalsis with vomiting
Treatment consists in the exhibition of sedatives, such as the bromides,
strontium bromide, 15 to 20 grains (i. 0-1.33), codeine phosphate, ^ to ^ a
grain (0.016-0.03) or extract of belladonna, ^ to ^ a grain (0.016-0.03) three
times a day. Hydrated chloral may be used but is dangerous because of the
GASTRIC HYPERPESISTALSIS. 375
possibility of establishing the habit. The spasm may be controlled by the
intragastric cocaine spray, and intubation of the pylorus, allowing the tube to
remain in place for about 10 minutes is recommended. The galvanic current
may be used as described under the treatment of cardiospasm. All food
which may irritate the stomach, and over-burdening the organ with large
amounts of food should be avoided.
Synonym. Peristaltic Unrest.
This is a condition characterized by rapid and continuous contractions of
the stomach. The movements are most marked after meals, but sometimes
occur when the stomach is empty and may persist through the night. Little
or no pain is present but the patient complains of uncomfortable sensations
referred to the stomach. Gastric hyperperistalsis is the result of an increased
irritability of the sensory or motor nerves of the organ due to a reflex result-
ing from gastric hyperaesthesia or to irritation from excessive acidity, fermenta-
tion or distention; it may occur with pyloric stenosis.
The contractions may be felt by the examiner's hand and at times when
very active, may be seen as well. The symptoms are loss of appetite, eruc-
tations, nausea and vomiting. In severe cases the patient may lose flesh and
strength and the continuous discomfort brings on a neurotic condition. At
times the small intestine may take part in the excessive peristalsis and cause
the regurgitation into the stomach and even the vomiting of intestinal contents.
Treatment. The drug treatment is identical with that of pyloric spasm
and the patient should be advised to lead a regular and quiet life, avoiding
mental and physical exertion. Intragastric galvanism and hydrotherapeutic
procedures are useful adjuvants. Only easily digestible foods shoifld be
aUowed in order to avoid all irritation of the stomach and possibility of dis-
tention by means of fermentation products. A rest cure with rectal alimenta-
tion continued for a fortnight may bring about good results in severe cases.
MERYCISM OR RUMINATION.
Definition. This is a condition in which the patient voluntarily causes his
food to return to the mouth where it undergoes further mastication and is
swallowed again or expectorated.
It occurs in individuals of neurotic habit as a rule and in marked cases
the food is regurgitated after every meal, the patient often asserting that the