act causes pleasant sensations.
The condition of the gastric secretions is not uniform but a subacidity
seems to exist in most cases.
376 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
Treatment consists in the correction of secretory disorders by the use of
hydrochloric acid or alkalies as the case may be. The patient's nervous
and general condition should receive attention and he should be enjoined to
masticate slowly and thoroughly. He should be encouraged to resist the
impulse to raise his food and to combat the habit with the utmost strength
of his wiU. Bits of cracked ice taken after meals are said to be useful and
intra-gastric electricity may be employed. The administration of lo grains
(0.66) of quinine sulphate after each meal may break the habit by rendering
the food unpleasantly bitter.
The diet of these patients should consist chiefly of easily-digested fluids
and semi-solids.
NERVOUS ERUCTATION OF GAS.
This symptom is often seen in hysterical and neurasthenic patients. The
gas raised is usually tasteless and consists chiefly of swallowed air, and various
gastric symptoms may or not be co-existent. The belching frequently occurs
in paroxysms but at times is almost continuous.
Treatment consists in teaching the patient to guard against swallowing
air. This is a habit which a little thought and attention on his part can stop;
keeping the mouth continuously open for a half hour or so at a time may
be tried for air cannot be swallowed when the mouth is open. The neuras-
thenic or hysterical condition should receive general treatment to which
massage and hydrotherapeutic measures are useful adjuncts. The bromides,
arsenic and belladonna may be employed, and the following pill may be found
effectual: I^ extract! physostigmatis, gr. yV (0.006); extract! belladonnas,
gr. -g- (0.012); strychninse sulphatis, gr. yg- (0.0015). Signa; one pill three
times a day.
Purinaemic conditions may result in neurasthenia and when such are accom-
panied by nervous eructation the treatment is plainly that of the causative
factor.
GASTRIC HYPERESTHESIA.
This is a sensory disturbance of the stomach in which the ingestion of food
results in pain referred to the organ, at times so great as to cause reluctance
on the part of the patient to eat. Hysterical individuals may assert that
only certain articles of food cause the distress while others may be eaten with
impunity This neurosis often occurs in anaemic and chlorotic conditions,
after periods of over-eating or indulgence in indigestible foods and as a result
of sexual or alcoholic excesses.
Another cause is hyperacidity and the condition may also exist in organic
nervous diseases such as locomotor ataxia.
GASTRALGIA. 377
Symptoms. These are distress after eating and nausea, often followed by
vomiting. When the stomach is empty they are absent. Often pulsation of
the aorta is complained of and constipation is usually present. Diffuse
tenderness over the region of the stomach is frequently observed and other
nervous manifestations such as headache and various neuralgias are common.
Examination of the stomach contents reveals nothing characteristic.
Treatment. Attention should be given to the constitutional condition,
if this is the causative factor, and a rest cure is frequently effectual. The
pain itself may be controlled by hot applications and the use of an intra-gastric
spray of cocaine and menthol, care being taken to control the amount of the
former drug. Intra-gastric galvanism is appropriate, and when the intra-
gastric electrode cannot be used external galvanism with the electrodes applied
to the abdomen may be employed. Silver nitrate gr. I (0.016) in 2 drachms
(8.0) of peppermint water taken in water a half hour before each meal has been
suggested, and the bromides and codeine may produce good results.
The diet should at first be of milk taken a small quantity at a time. Later,
as the condition becomes ameliorated, eggs and semi-solids may be allowed,
and finally a return to solid food may be permitted. Later massage, hydro-
therapeutic measures, moderate exercise, and a change of climate are to be
recommended.
Alcohol, tobacco and the abuse of tea and coffee should be forbidden.
GASTRALGIA.
Synonyms. Gastrodynia; Gastric Neuralgia.
This is an affection characterized by severe paroxysmal pain referred to
the stomach. The pain may be localized in the epigastrium or may radiate
to any part of the abdomen or to the back. It occurs in motor and secretory
neuroses, and in various other gastric lesions such as ulcer and cancer, in
certain nervous diseasel, such as tabes dorsalis, during infectious diseases,
especially malaria, in nervous and hysterical conditions and as a reflex pain
the result of diseases of the genito-urinary organs, particularly in women.
Idiopathic gastralgia occurs in chlorotic and anaemic states, in convalescent
conditions, nephritis and various toxaemias, and especially in incipient pul-
monar}^ tuberculosis. The fact that it often manifests itself in early phthisis
is responsible for much mistaken diagnosis and treatment, many of these
patients putting themselves in the hands of the gastrologist who is apt to
miss the true causative factor of the condition.
The attacks of pain usually begin suddenly and are at times so severe as to
be almost unendurable, perspiration appears upon the forehead, the pulse is
weak and may be faster or slower than normal. There may be suppression
of urine; the bowels are usually constipated. The patient is much prostrated.
378 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
As the severity of the paroxysm wanes the patient begins to yawn, belches gas
and may vomit.
Treatment consists in the proper management of the underlying cause
when this can be ascertained. If no cause can be found symptomatic treat-
ment must be instituted. Various analgesic drugs such as codeine sulphate,
^ grain (0.03) every 3 or 4 hours, chloroform water, i to 2 drachms (4.0-
8.0), hydrated chloral, 10 to 15 grains (0.66-1.0), hyoscyamus, belladonna,
etc., may be employed. In cases with cardiac depression compound spirit
of aether may be given and stimulation by means of aromatic spirit of ammonia
or alcohol may be necessary. Acetanilide, methyl acetanilide (exalgin),
pyramidon (a derivation of antipyrine) and other antineuralgics are recom-
mended. In cases characterized by very severe pain opium may be em-
ployed but only with the greatest caution lest the habit become formed.
It is best given in the form of opium and belladonna suppositories or hypo-
dermatically as morphine sulphate in connection with atropine. These
drugs are useful only in lessening the patient's pain and have no curative effect;
the routine employment of electricity is an excellent method of treatment.
The faradic current may be employed but the galvanic is likely to accomplish
better results, a current of 25 milliamperes at least, being necessary. Large
flat electrodes are used, they are moistened in water as hot as can be borne
and applied, the anode to the epigastrium and the cathode to the interscapular
region. Gastric lavage with a mixture of a pint (500.0) of camphor water,
and bismuth subgallate 5i (4.0), and bismuth subnitrate 5ii (8.0) is said to be
efficacious. The camphor water should be measured as it returns and not
more than an ounce (30.0) allowed to remain in the stomach.
The diet shoidd consist of easily digestible foods. Spices, condiments
alcohol and excessive amounts of tea and coffee are to be avoided.
BULIMIA. ,
Synonym. Hyperorexia.
Bulimia is a condition characterized by an excessively large appetite. It
occurs chiefly in persons affected with functional or organic nervous disease
such as hysteria, epilepsy, brain tumors, etc., with intestinal parasites, uterine
diseases and various gastric conditions. The hunger comes on suddenly,
at times even directly after a full meal. The symptom is almost irresistible
and if it is not appeased palpitation of the heart, paleness, faintness, noises
in the eg-rs and gastric pain ensue. In some cases even small amounts of
food suffice to cause a disappearance of the symptoms.
Treatment must be instituted with a view to improvement in the cause of
the neurosis. The nervous system, the genito-urinary system, the stomach
or whatever part may be at fault must receive appropriate treatment. The
ANOREXIA NERVOSA. 379
bromides are useful, Fowler's solution in doses increased to the limit of tolerance
is recormnended and the administration three times a day of one drachm (4.0)
of camphorated tincture of opium or of 2 drops (0.13) of the tincture of bella-
donna in 2 or 3 drachms (8.0-12.0) of simple elixir may prove effectual.
Gastric atony, if present, may be treated by massage and strychnine and
intra-gastric faradism should achieve good results. Lavage with warm and
cold water alternately may be employed.
ANOREXIA NERVOSA.
Nervous anorexia is a state in which the appetite is wholly lost and the
sense of hunger unknown. This manifestation may last for months, even
while the digestive apparatus is perfectly normal in condition. The neurosis
is more commonly seen in female subjects and is predisposed to by hysteric
and neurasthenic conditions. It also occurs in chlorosis and in individuals
addicted to the abuse of drugs, especially alcohol, tobacco and opium. The
degree of the distaste for food determines the prognosis of the affection. Those
subject to this manifestation become progressively anaemic and lose flesh and
strength, the pulse is weak, the extremities are cold. Insomnia is common.
The diagnosis of the affection is simple but that of its cause is more difficult.
Treatment consists in combating the anaemia and the nervous condition by
appropriate medication and in properly managing any co-existent organic dis-
ease. The rest cure — putting the patient away from outside influences and in
the hands of a trained attendant, and over-feeding him — is an excellent
method; in this connection electrical and balneo-therapeutic measures and mas-
sage are to be employed, as well as any means in the line of suggestion that the
physician may be able to use. If the refusal to eat is carried to extremes there
should be no hesitancy in employing forced feeding by gavage. If the repug-
nance to taking food is due to discomfort attendant upon this act the admin-
istration of sodium bromide — 10 to 15 grains (0.66-1.0) — before meals may
overcome this disinclination. Orexin — 5 to 10 grains (0.33-0.66) — before
such meals in a little warm bouillon may cause a distinct increase in appetite
and the following formulae may be found useful: I^ tincturae cinchonae, 5ss
(2.0); acidi sulphurici diluti, Tixvii (0.5); syrupi zingiberis, Siiiss (14.0). Misce
et signa, take before meals through a tube in a claret glass of water. ^ fluidex-
tracti condurango, ir^xlv (3.0); strychninas sulphatis, gr. ^^^q- (0.0015); acidi
hydrochlorici diluti, tt^x (0.66); elixiris gentianae, q.s. ad Sss (15.00). Misce
et signa, take in wine glass of water before each meal through a tube.
CYCLIC VOMITING.
Definition. Cyclic, paroxysmal, periodic or recurrent vomiting is a con-
dition seen in children and characterized by the sudden appearance of violent
380 DISEASES OF THE DIGESTIVE SYSTEM AND PERITON^UM-
and persistent emesis which may persist long after the stomach has been
entirely emptied. The attacks usually appear when the child is about two
years old and recur with a lessening degree of frequency as puberty approaches
when they cease. The intervals vary in different cases, being from a few weeks
to a few months, and at times the vomiting is so severe and continuous as to
bring about a condition of collapse which has been known to result fatally.
The aetiology of this condition is not definitely known but it is probable that
it is a disorder of metabolism. Both acetone and diacetic acid have been
foun^ in the urine preceding or diiring the attack.
Treatment at times will be found to have little effect but the administration
of large doses of sodium bicarbonate — 100 to 125 grains (6.66-8.33) P^^ ^^.y —
is the most approved method and may succeed in aborting or cutting short
the paroxysm. It has been suggested that fats — except fresh butter —
are. not well borne by patients subject to this manifestation and that too large
a carbohydrate content in the diet may produce digestive changes which favor
the occurrence of the vomiting. During the attack it is better not to attempt
to feed the patient but if the paroxysm is protracted rectal feeding may be
instituted and at aU times it is well to administer water by this route to allay
the thirst — 6 to 8 ounces (300.0-500.0) 4 or 5 times a day being sufl&cient
quantity. When the attack has ceased the first foods allowed may be broths,
smaU amounts of cold milk and lime water, equal parts, and barley water.
Attention should be given to the patient's general hygiene during the intervals
of the paroxysms.
H^MATEMESIS.
The vomiting of blood is a symptom of various morbid conditions of the
stomach and has been discussed at length in the sections devoted to the dif-
ferent affections in which it occurs. It results from the rupture into the
viscus of blood-vessels in its walls, from the regurgitation of blood from the
intestine or from the swallowing of blood — later to be vomited — which has
been extravasated from vessels of the nose, pharynx, or oesophagus. That
blood may be raised from the respiratory tract, swallowed and finally vomited
must not be forgotten.
Haematemesis occurs in injuries of the stomach, either from outside trauma-
tism or as a result of the ingestion of caustic substances, in neoplasms of the
organ, in diseases of the organ, such as gastritis of any kind, ulcer, etc., in
diseases of other organs, notably hepatic cirrhosis, in malignant forms of the
infectious diseases, yellow fever, smallpox, etc., and in constitutional diseases
such as purpura, haemophilia and pernicious anaemia. Vomiting of blood
has been observed after the rupture of aneurysms into the oesophagus.
The condition of the blood vomited depends upon the length of time which
DISEASES OF THE INTESTINE. 38 1
it has lain in the stomach. If fresh it may be bright in color and otherwise
little changed. If it has been subjected to the action of the gastric juice it is
likely to be dark and may be of "coffee -ground" appearance. The differ-
entiation of haematemesis from haemoptysis may usually be made on the
following points: Vomited blood is usually dark in color, not frothy, and
often is acid in reaction, while blood from the respiratory tract is light red
or pinkish, is likely to contain an admixture of air and is consequently frothy,
and is alkaline in reaction. In haemoptysis the stools are not "tarry,"
while in gastric haemorrhage the blood which has passed through the pylorus
appears in the stools, imparting to them a black color.
The symptoms of gastric haemorrhage are those of loss of blood from any
other part, viz., paleness, prostration, rapid, feeble pulse, subnormal temper-
ature, air hunger, depression, faintness, and cold clammy skin. Fortunately
death, from this cause primarily, seldom occurs.
The treatment of haematemesis has been fully dealt with in the section
relating to the management of gastric ulcer (p. 352).
DISEASES OF THE INTESTINE.
SIMPLE ACUTE CATARRHAL ENTERITIS.
Synonyms. Acute Diarrhoea; Acute Intestinal Catarrh; Acute Ileo-colitis.
Definition. An acute inflammation involving the small intestine and at
times the upper portion of the colon.
.Etiology. This disease is more common during the hot months and espe-
cially in children. The heat is not so much a direct cause as it is a predis-
posing one, since it diminishes the bodily resistance and increases the suscep-
tibility of the intestinal tract to the influences of over-eating or improper
food. Acute intestinal catarrh often follows excessive indulgence in food or
drink, particularly if the substances taken are impure, such as unripe or
decayed fruit, decomposed food, contaminated drinking water or the like.
The ingestion of irritant drugs such as mercury bichloride or arsenic may
cause intestinal inflammations and the condition is also predisposed to by
any sudden chilling of the body. Excessive or diminished secretion of bile
may be mentioned as causes, the latter since it may favor fermentation by
depriving the intestine of the supposed antiseptic effect of this fluid.
Enteritis often accompanies certain of the infectious diseases and is pre-
disposed to by conditions of congestion of the intestine such as occur in cardiac
and hepatic lesions and by inflammations of adjoining structures such as the
peritonaeum. Chronic wasting disease, tuberculosis, cancerous states, anaemia,
etc., may be complicated by acute diarrhoea.
Pathology. The mucous membrane lining the intestine is first congested,
382 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
red and swollen; the secretion is at first diminished but later there is an exces-
sive production of mucus, with exfoliation of the epithelial cells; the solitary-
follicles are hypersemic and swollen and may become filled with pus; such
tiny abscesses may rupture leaving an ulcerating surface. In severe forms
of the inflammation the agminated follicles also may be involved in like
manner. Chronic inflammation may resiilt in rare instances.
Symptoms. Diarrhoea is the most characteristic of these. The evacua-
tions at first consist of ordinary faecal matter, but as they continue they
contain bile, mucus, and finally become watery. In severe cases blood may
be present. They vary in number from 5 or 6 to 15 or 20 per day, and may
be accompanied by colicky pain and tenesmus. They are likely to be foul
at first and accompanied by gas, later they may lose their odor. Loss of
appetite is the rule and nausea and vomiting may be present. A rise of tem-
perature of 2 or 3 degrees F. may accompany the diarrhoea, and thirst and
diminished urine are noted as a result of the loss of water through the intes-
tinal tract.
Physical examination reveals little more than slight diffuse abdominal
tenderness, meteorism and gurglings in the intestine.
When the inflammation is localized various symptoms may call attention
to probable involvement of particular portions of the intestinal tract. If
the skin, conjunctivae and urine are colored with bile pigment it is probable
that the inflammation particularly affects the duodenum. If the jejunum
and ileum are involved to the exclusion of the large intestine diarrhoea is
absent, but the pain, distention and other symptoms are present; the diagnosis
of inflammations affecting this portion of the alimentary tract alone is difficult
and of little practical value. When the morbid condition involves both the
small and large intestine mucus is present and may be observed distinct and
separate from. the faeces which may contain bits of undigested food. The
diagnosis of acute intestinal catarrh should present no great difficulties; it
may be differentiated from enteric fever by its short duration, lack of charac-
teristic temperature curve, absence of exanthem and of Widal reaction. The
condition is not a serious one, recovery under proper treatment taking place
within a few days.
Treatment. In mild cases the patient need not be confined to his bed but
should refrain from exertion of any sort. Certain cases need no treatment
further than a strict milk diet, for as soon as the intestine has by its own action
rid itself of the cause of the inflammation, spontaneous recovery takes place.
In most cases, however, it is better to aid nature by administering a laxative
which shall hasten the passage of the offending substance. The laxatives most
frequently employed are calomel and castor oil. The former is best given in
doses of i to ^ a grain (0.016-0.03) every half hour until 6 doses are taken,
it exercises, in addition to its purgative action, an antiseptic effect upon the
CHRONIC CATARRHAL ENTERITIS. 383
intestine, while castor oil, which should be given in single dose of 2 to 4 drachms
(8.0-16.0), has the advantage of a slightly constipating after-effect. The
emptying of the bowel may be facilitated, especially in children, by irrigation
of this viscus vAih warm normal saline solution by means of a rectal tube or
soft rubber catheter and a fountain s}Tinge.
W^en intestinal astringents or antiseptics are necessar}' on account of the
prolongation of the diarrhoea, any of the salts of bismuth may be given, the
subsalicylate — gr. x to xx (0.66-1.33) every 4 hours — being especiaUy eft'ectual.
Bismuth naphtholate (orphol) 5 to 15 grains (0.33-1.0), resorcinol — gr. ii
to %dii (0.13-0.5) — or phenyl salicylate (salol) — gr. ii to v (0.13-0.33) — may
also be employed. If the diarrhoea still persists, opium in sufficient doses
of the powder, the tincture or of Dover's powder, as suppositories or in
the form of an opium and starch enema — one or two teaspoonsful of starch,
I to 2 grains (0.065-0.13) of powdered opium, 8 ounces (240.0) of warm water,
should be given.
For the constipation resulting from the use of opium laxatives need not be
given since the bowels will, as a rule, move normally after a few days. The
h\^odermatic administration of morphine may be necessary in severe cases
when frequent vomiting and purging preclude the exhibition of opium by
mouth or rectum.
The abdominal pain may be controlled by hot or cold compresses.
Diet. During the first day or two of the attack as little food as possible
should be allowed and that preferably in the form of milk. As the condition
becomes ameliorated other non-irritating foods such as bouillon, soft boUed
eggs, milk toast, etc., may be eaten to be followed as the diarrhoea ceases by
sweetbreads, calf's brain, scraped beef, meat jeUies, the white meat of chicken
and mashed potatoes. Green vegetables, fruit and all irritating and indigesti-
ble articles of diet should be omitted from the diet for some time.
CHRONIC CATARRHAL ENTERITIS.
Synonyms. Chronic Diarrhoea; Mucous Colitis; Chronic Entero-colitis;
Ulcerative Colitis.
Definition. A chronic catarrhal inflammation of the small and large intes-
tine, characterized by the excessive production of mucus, and at times, the
development of ulcers.
^Etiology. This disease may follow attacks of acute entero-colitis or of
dysentery. The disease may occur primarily, and it is predisposed to by
cardiac lesions, hepatic cirrhosis or any other condition attended by chronic
h}'per£emia of the digestive tract, by conditions of feeble nutrition, purin-
aemic states, and chronic wasting diseases such as anaemia, nephritis or phthisis.
It may foUow the infectious diseases, notably malaria and cholera.
384 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.
Pathology. At first the pathological state is that of acute catarrhal enteritis;
these lesions become permanent and in marked cases ulcerations of the lymph
foUicles take place with consequent haemorrhage, and, when the ulcers heal,
cicatricial contractions which may result in stenosis. Pigmented spots in the
diseased mucous membrane are sometimes observed and the destruction
of the intestinal glands by the inflammation may result in atrophy of the
mucous membrane and at times of the muscular and peritonaeal coats of the
bowel.
Syj^ptoms. While diarrhoea is the rule in acute entero-colitis, in the chronic
form of this inflammation this is not the case. The bowels may be consti-
pated, there may be diarrhoea or there may be an alternation of these condi-
tions. A fairly constant symptom is the presence of mucus in the movements
from the bowels. This mucus is variable in quantity, from a small amount
mixed with the fsecal matter to large masses discharged in the form of casts
of the intestine. If ulceration exists there may blood in the stools.
The type of the disease characterized by the passage of casts of the bowel
is seen usually in neurotic women. Constipation is usually present and at
intervals stools of the type described above are passed, accompanied by tenes-
mus and abdominal pain and tenderness.
Subjective symptoms may be wholly absent in chronic entero-colitis, the
appetite and gastric digestion are often good but there are at times abdominal
discomfort and flatulence.
Physical examination may reveal nothing characteristic, although at times
tympanites may be detected. When the intestinal contents is fluid, palpation
may elicit gurglings and in the type of the disease of which constipation is a