Part 106

Diseases of the pancreas seriously embarrass digestion in the intestine. Lesions of this organ, as catarrh of the duct, cancer, fatty degeneration, etc., may result in impaired emulsification of fats, fatty diarrhoea, and wasting.

Intestinal indigestion accompanies hyperæmia and catarrh of the intestinal mucous membrane, diseases of the heart, lungs, and liver, and all other causes which impede portal circulation.

SYMPTOMS.--Intestinal indigestion cannot be so clearly pictured as that of gastric dyspepsia. This is owing to the frequent concurrence of the two conditions, the gastric symptoms taking precedence of the others. The more complex nature of the intestinal function is another reason, intestinal indigestion having more modifications in its phenomena. In the stomach there is only one active secretion; in the intestine there are three, all participants in the act of solution. An alteration in the quality or quantity of one of these--the bile, for example--would lead to different symptomatic results than would follow another defective secretion, as that of the pancreas, for instance. Clinical study has not yet fully differentiated the forms of indigestion due to these several deficiencies. But there are certain well-defined symptoms associated with intestinal disorders which are distinguished by their seat, time of their appearance, and their character from analogous symptoms connected with the stomach.

Intestinal indigestion may be acute or chronic. The latter is the more typical and more common form.

When a sudden attack of indigestion in the intestine results from the entrance into the duodenum of food in such a state that it cannot be digested, the result is the rapid development of pain, flatulence, borborygmi, and frequently of fever, ending in diarrhoea, with the escape perhaps of the offending matter: a condition then exists which may be called acute or subacute intestinal catarrh or acute intestinal indigestion. One name would be as correct as the other. Slight acute forms are marked by a coated tongue, loss of appetite, headache, pains in the limbs, distress in the epigastrium or right hypochondrium, flatulence, and constipation. These might be accompanied by symptoms indicating a disorder of the liver functions--light-colored stools, slight jaundice, lithates in the urine. But intestinal indigestion alone can cause these symptoms without the condition of so-called biliousness being present. The local symptoms are due to the presence in the intestine of an {627} imperfectly-altered mass and the development of gas; some of the general symptoms are reflex; others, as headache and lassitude and pain in the limbs, come from the absorption into the blood of the gases, particularly sulphuretted hydrogen. The participation of the stomach in acute attacks of this sort modifies the symptoms as here described. Such attacks are apt to recur at intervals.

If the causes which bring about acute disorder in the intestine are allowed to continue, the intervals between the acute or subacute attacks diminish, and there is in time a fixed state of chronic intestinal dyspepsia in which the partly-altered food coming from the stomach is not properly prepared for absorption. Instead of digestion there is decomposition; the transition is easy from the one to the other of these states. The symptoms connected in this case with the digestive organs are pain, occurring from two to six hours after eating, in the right hypochondrium, the epigastrium, or the umbilical region, due to distension of the intestine with gas. This pain is dull, not always fixed, lasts from one to three hours, and is accompanied by tenderness on pressure over its seat.

Tympanites, borborygmi, and a sensation of fulness in the abdomen accompany the pain or may exist without it. Gaseous accumulations in the intestine, the cause of these symptoms, have an independent source, being produced by decomposition in the gut itself, and are not due to the descent of gases from the stomach through the pylorus. What is a physiological and temporary condition becomes in disease a distressing symptom of long duration. In intestinal indigestion the gut is nearly always inflated with gas, which in its movement produces rumbling noises. In acute indigestion it is rapidly formed in large amount, and by the stretching of the wall of the bowel and pressure on nerve-filaments causes intense pain--colic. In the chronic form the distension excites uneasy sensations, prevents sleep, and may be so great as to cause dyspnoea by pushing the diaphragm upward. When the small intestine is distended the greatest swelling may be about the umbilicus, or the abdomen may be evenly rounded. When the colon is chiefly or solely inflated, its outline across the upper part or at the sides of the abdomen can be easily made out.

Constipation is a common feature. It is produced by a loss of contractility of the intestinal wall. The more direct causes are over-distension of the gut and disturbance in the circulation and innervation of its walls. The stools are hard and dry, and are expelled with difficulty. Sometimes they are coated with shreds or films of mucus, the product of a chronic catarrh of the mucous membrane of the colon, or mucus from the small intestine is intimately mixed with the mass. Diarrhoea may alternate with constipation. The passage of unaltered food, as fragments of meat, vegetables, or fruit, clearly shows the extent to which indigestion exists. By the microscope particles of food which have escaped complete disintegration may be detected. The stools vary in color. Very dark-green or black discharges show an excess of bile; light-yellow or gray slate-colored, a deficiency. Stools of the latter character are highly offensive in odor.

Hemorrhoids are often present, being due to the sluggish portal circulation and to the pressure of hard fecal masses in the rectum. The appetite is not impaired, as a rule, but it may be fitful or irregular. A bad {628} taste in the mouth, and a swollen, relaxed, and coated tongue may exist without any decided gastric disease.

The symptoms of disorder of the nervous system are more marked than in gastric dyspepsia. This results not so much from the depressing influences of pain as from the peculiar malnutrition of the nerve-tissue. In order to have furnished to the blood the pabulum out of which the nerve-elements are reconstructed the digestion of fat must be normally performed. Lecithin, which is found conspicuously in the brain and nerves, is a complex fat containing phosphorus and nitrogen. Anæmia and waste follow directly from interference with the digestion and absorption of fats and starch in the intestine, but the most delicate, the most easily-disorganized solid of the body, the nerve-tissue, is the first to feel and to manifest its want of natural supply. And so the dyspeptic whose intestine is at fault becomes depressed in spirits, hypochondriacal, absorbed in the contemplation of his sufferings, analyzing them and referring them to the most serious organic changes. There are sleeplessness, disturbing dreams, the habit of waking at a fixed hour, dizziness, uneasy sensations or pain in the head, and disturbances of the special senses, as buzzing in the ears, muscæ volitantes, and attacks of blindness. Headache assumes often the form of hemicrania; it may be in the forehead or about the eyes. Attacks of vertigo and sensations as if the ground were rising beneath the feet accompany intestinal flatulence. Confusion of thought, loss of the power of application, and mental inertia are frequent sources of anxiety. Paralysis has been noted as following indigestion. Epileptiform convulsions and milder epileptic attacks can be traced to undigested matter in the intestine. Various modifications of general sensibility also happen: there are pains in the back and limbs, hyperæsthesia, and anæsthesia. An inaptitude for exertion, especially for mental labor, forces the boy to give up school and college life. Successful careers are abandoned by men who at the cost of neglecting all the rules of health have succeeded for a brief period in passing their fellows in the race. Sudden attacks of fainting have been noted, with very grave collapse. These are the effect upon the nervous centres of the absorption of sulphuretted hydrogen which has been evolved in large quantities in the intestine. The daily occurrence of vertiginous and other morbid sensations, with melancholia, may be due to the daily toxic absorption of gas from the intestine.

The action of the heart is disturbed as in stomach indigestion. Irritability of the heart and palpitation are in part due to anæmia and in part to mechanical pressure and reflex influences. The nervous, anæmic, thin dyspeptic has among his chief troubles a throbbing heart, which keeps him awake at night and fixes his attention upon this organ as the seat of his disease. The general circulation is languid; cold hands and feet and cold sweats testify to this, and the irregularity or suppression of catamenia follows upon the irregular blood-supply.

The urine is usually high-colored, has an abnormally high density, is acid, and on cooling deposits lithates, uric acid, and oxalate-of-lime {629} crystals. The urine is most heavily loaded with sediment when digestion has been recently completed. Therefore, the morning urine after a heavy dinner of the night before contains the largest amount of lithates. Albuminuria is occasionally a symptom of indigestion in the bowel. The eating of cheese or pastry in excess may cause it. Seminal emissions at night frequently occur. The action and reaction upon each other of this perversion of the sexual function, the indigestion, and the mental disorder, reduce the poor sufferer to a most pitiable condition of despondency and prostration.

Anæmia is one of the earliest indications of impaired nutrition. It precedes loss of flesh and the wrinkled and dry condition of the skin which may be a marked symptom in cases of long standing. Various eruptions appear on the skin. In the strumous dyspepsia of children the white, almost waxy, skin is covered with dry scales, which may be seen over the whole body from head to foot. No symptom is more characteristic of intestinal indigestion and of imperfect fat digestion and absorption than this. Eczema and psoriasis, pityriasis, impetigo, and porrigo decalvans are forms of skin eruption seen.

Closely allied to the symptoms caused by indigestion in the intestine are those due to functional disorder of the liver. The liver completes the work which the intestine has begun. It receives directly from the intestine blood laden with the products of digestion, and further transforms them into substances to be used in the economy. The symptoms which result from disturbances in the performance of these functions are, as has been said, closely connected with the symptoms of intestinal indigestion. This association is shown by the tendency among older writers to trace all such symptoms to the liver, the terms bilious and biliousness including all the phenomena of derangement of the function of digestion in the intestine, as well of the function of the liver. Later writers excluded the part of the liver to a great extent in giving rise to the so-called bilious symptoms. Recent physiological study has shown how closely the intestine and the liver are associated in health and in disease. When the liver is implicated in indigestion the symptoms which follow are due either to a deficiency of the secretion of bile, and the resultant disturbance of digestion in the intestine, or to a derangement in the transformation in the liver of the products of albuminoid digestion. When the disorganization of the peptones is imperfectly performed in the liver, instead of urea there is a production of lithates and lithic acid, constituting the condition called lithæmia. The lithates pass into the urine and are deposited. The occurrence of this urinary sediment after excesses and imprudences in diet is well known. The continuance of lithæmia leads to the development of symptoms more or less characteristic. These are a loss of appetite and coated tongue, flatulence, oppression after eating, and constipation. The nervous system is soon disturbed, and often to a marked extent. Vertigo, headache, disturbances of the special senses, sleeplessness at night, drowsiness during the day, annoy the patient and induce extreme hypochondria. He is worried, moreover, with numbness and tingling in one or both arms or in the {630} legs, and hence spring fears of paralysis. The heart is disturbed in action, and is irregular and feeble. Emaciation in previously corpulent persons is not unfrequent.

COURSE, TERMINATION, AND SEQUELÆ.--Acute dyspepsia in the bowel lasts from a few hours to a day or two, and ends in leaving the patient as well as before. A diarrhoea of indefinite duration may follow.

Chronic intestinal indigestion in infants and young children often continues until the diet is changed to one suited to the powers of digestion. In adults interference with so important a function cannot but have the most serious results. While the progress is slow, lasting many years, there is a steady march from bad to worse.

The character and conduct are so altered by the disease that a man may be said to be just what his digestion makes him. Amiability under the daily goad of intestinal dyspepsia is an impossibility. The irreconcilables, the men out of joint with the world, are living witnesses of the antagonism and disaffection within their intestines. The deterioration in health paves the way for many diseases, and there is hardly an organ in the body which may not ultimately become the seat of organic change.

In the young, phthisis is frequently the ultimate result of the malassimilation and malnutrition; in men beyond middle life degenerative changes in the intestine, liver, and kidneys close the series of morbid changes which began in the intestine. Thomas N. Reynolds attributes bronchitis and phthisis in part to the local influence of septic matter carried by the portal and lacteal vessels to the lungs in cases of intestinal dyspepsia, with constipation and septic fermentation of the ingesta.

In many cases business and professions are abandoned, and men become, under the influence of despair and complete absorption in their symptoms, intellectual and moral wrecks, burdens to themselves and to all around them. In this stage the primary cause, the dyspepsia, is lost in the exaggerated prominence of the nervous symptoms.

DIAGNOSIS.--The acute variety is known by the seat of the abdominal symptoms, the pain, distension, and movement of gas not being in the stomach, but in the intestines. The pain is like colic; the abdomen is sensitive to the touch; tympanites is general and may be very great. If vomiting occurs, the symptoms continue after the stomach is empty. Diarrhoea may quickly come on, and is followed by relief. The fever may be quite high. There is no sleep, but restlessness, and in children delirium. They may also have convulsions.

In the chronic form the history of the case and the study of the causes are of great value in formulating an opinion. The persistent abuse of the pleasures of the table sooner or later develops intestinal indigestion. Inquiry into the mode of life, hours of eating, manner of eating, kinds of food taken, etc. gives important information. The teeth are defective, and mastication and insalivation are neglected. There is distress in the pit of the stomach or in the right hypochondrium, beginning about two hours after eating and lasting from four to six hours; intestinal distension with gas, either in the small intestine or colon, with borborygmi and constipation, is generally present. The nervous symptoms are characteristic: they are depression of spirits, irritability, sleeplessness, vertigo, and {631} headache. The man is more completely altered mentally than in gastric dyspepsia. The urine contains lithates in excess; anæmia and emaciation progress rapidly. Seminal emissions and weight and heaviness about the loins are present.

The following symptoms distinguish gastric dyspepsia, and do not occur in intestinal indigestion unless the stomach is at the same time involved: pain or weight in the epigastrium immediately after eating, vomiting of unaltered food, of food in a state of acid fermentation, eructations of ill-tasting or bad-smelling gas or of acid fluid, water-brash, and heartburn. Loss of flesh may not take place to any extent even in very bad forms.

The diagnosis of differences in the forms of indigestion due to defects in the pancreatic, biliary, or intestinal secretions is not at present a matter of precise knowledge. A pancreatic indigestion would be followed, it might be supposed invariably, by fatty stools; but such is not the case, since degeneration of the pancreas and closure of the duct have occurred without fatty evacuations from the bowels. Moreover, ulceration of the duodenum is followed sometimes by fat in the stools. Still, if the symptoms of intestinal indigestion include rapid wasting and fatty diarrhoea, we may conclude that the pancreas is at fault. The fat varies in appearance and amount. It may be seen as oil-drops passed alone or with fecal matter, or as lumps of fat, pale yellow and tallow-like. Glycosuria bears some relation to pancreatic diseases, and therefore may be an aid in diagnosis.

A deficient excretion of bile is indicated by a whitish or yellowish coating of the tongue, with loss of appetite and bad taste in the mouth. The stools are scanty, dry, slate-colored or white, and offensive in smell. The urine contains lithates. The complexion is pale or muddy. The nervous system is much deranged. The patient is languid, often irritable and hypochondriacal. He complains of headache, and is dull and drowsy after eating. The heart's action is unsteady, intermittent, or frequent. It is impossible to recognize indigestion due solely to a deficiency of the intestinal juice or to feeble peristalsis, granting that such forms exist.

PROGNOSIS.--A fatal result does not follow directly from intestinal indigestion. Its complications and results are frequently the causes of death. Treated early and with decision, a cure can be expected. Everything depends upon the extent to which the patient submits to the strict directions of his physician; his whole life must be made subordinate to the plan of treatment.

When the general health has become profoundly altered there is less chance to do good. Discouraging symptoms are anæmia, debility, coexisting gastric dyspepsia, an inherited hypochondriacal tendency, or the strumous diathesis in children.

When the disease has so far progressed that the patient is unable to {632} rouse himself to the point of wishing to be well, only the most severe measures directed to the control of an irresponsible person can save him from ruin. In organic disease of the pancreas, intestine, liver, or heart the result will depend upon the nature and curability of the lesion.

TREATMENT.--Acute intestinal indigestion due to the presence of undigested food and gas in the intestine is treated by relieving present distress and procuring a free movement from the bowels. A large enema or a quick cathartic followed by an opiate--hypodermic injection of morphia, paregoric, or other preparation--may give early relief. A strict diet, warm poultices over the abdomen, and an anodyne may be needed for several days after.