Part 70

The dilatations become enlarged by retention of food, and are liable to undergo inflammation, ulceration, and perforation.

DIAGNOSIS.--The diagnosis will depend upon the symptoms of dysphagia, regurgitation, and so on, and upon the evidence furnished by auscultatory indications, palpation with the oesophageal sound, and, in some instances, the existence of a tumor in the neck, enlarging after meals, and {434} from which food or mucus can be forced up into the pharynx by pressure externally.

Stethoscopic auscultation of the oesophagus during the deglutition of water indicates an alteration in the usual form of the gulp, which seems to trickle rapidly in a larger or smaller stream according to the degree of dilatation. If the dilatation be annular and located high up, auscultation is said to give the impression of a general sprinkling of fluid deflected from its course. The peculiar gurgle is often audible without the aid of stethoscopy. Palpation with the oesophageal bougie is competent to reveal the existence of a large sac by the facility with which the terminal extremity of the sound can be moved in the cavity. In the case of a diverticulum, however, the sound may glide past the mouth of the pouch without entering it, although arrested at the bottom of the sac in most instances.

In annular dilatation any constriction below it is usually perceptible to the touch through the sound; but, on the other hand, the ready passage of the bougie into the stomach, while excluding stricture, does not positively disprove the existence of a circumscribed dilatation. If high up, the dilatation may be detected externally by its enlargement when filled with food after a meal, and the subsidence of tumefaction when the sac is emptied by pressure from without, or by regurgitation. If the dilatation occupy a position which exercises compression of the trachea, dyspnoea will ensue when it is distended. The intermittence of the tumefaction serves to differentiate the swelling from abscess or morbid growth. From aneurism of the aorta, which it may simulate (Davy), it is to be discriminated by absence of the usual stethoscopic and circulatory manifestations. The diagnosis of congenital dilatation is based upon a history of difficulty in deglutition dating from the earliest period of recollection.

PROGNOSIS.--The prognosis is not favorable in any given case unless the cause can be removed, and not even then unless food can be prevented from accumulating in the distended portion of the tube. Nevertheless, cases sometimes go on into advanced age. On the other hand, they may terminate fatally within a year (Lindau). The danger of perforation adds additional gravity to the prognosis, for life may be suddenly lost by this accident. Death usually takes place by inanition. A case of death by suffocation has been recorded, attributed to the pressure of the distended oesophagus upon the intrathoracic vessels (Hannay).

TREATMENT.--If the dilatation be due to stricture or to an impacted foreign body, the treatment should be directed to overcoming the one and removing the other.

General dilatation from chronic oesophagitis requires treatment for that disease.

Much depends upon preventing the accumulation of food in a sac or diverticle; the best means of accomplishing which is the systematic administration of all nutriment by means of the stomach-tube. When this is not advisable, care must be exercised in the selection of such food as is least likely to irritate the parts if detained in the pouch.

{435} As far as general treatment is concerned, stimulants are usually indicated, as the patients become much reduced. If paralysis of the muscular coat of the oesophagus is believed to exist, the administration of preparations of phosphorus and of strychnine are indicated on general principles of therapeutics. Stimulation of muscular contractility by the oesophageal electrode has been recommended, but the prospects of success hardly justify the risks of serious injury in the domain of the pneumogastric nerve.

It has not yet been determined whether surgical procedures are competent to relieve dilatation. In cases of pouched dilatation high up it would not be difficult, as suggested by Michel, to expose the sac and excise it in such a manner that the sutures uniting the walls of the oesophagus shall occupy the site of the mouth of the diverticulum, and, thus obliterating it by cicatrization, restore the normal path of the food from the pharynx to the oesophagus. Gastrostomy, too, should hold out some hope of rescue, no matter what portion of the oesophagus be dilated.

{436}

FUNCTIONAL AND INFLAMMATORY DISEASES OF THE STOMACH.

BY SAMUEL G. ARMOR, M.D., LL.D.

Functional Dyspepsia (Atonic Dyspepsia, Indigestion).

To difficulty in the physiological process of digestion the familiar name of dyspepsia has been given, while to a merely disturbed condition of the function the term indigestion is more frequently applied. This distinction, difficult at all times to make, may appear more arbitrary than real; and inasmuch as it involves no important practical point, the author of the present article will use the terms interchangeably as indicating functional disturbance of the stomach--i.e. disturbance of the digestive process not associated with changes of an inflammatory character, so far as we know.

Since it is one of the most common of all complaints from its association with various other morbid conditions, the term is not unfrequently vaguely employed. It is difficult, of course, to define a disease whose etiology is so directly related to so many distinct morbid conditions. Indeed, there are few diseases, general or local, which are not at some time in their history associated with more or less derangement of the digestive process. For purposes of limitation, therefore, it will be understood that we now refer to chronic functional forms of indigestion which depend largely, at least, on a purely nervous element, and for this reason are not infrequently described as sympathetic dyspepsia. Doubt has been expressed as to whether such forms of disease ever exist, but that we encounter purely functional forms of dyspepsia, corresponding to the dyspepsia apyretica of Broussais, would appear to be a well-recognized clinical fact.

What the precise relation is between digestive disturbances and the nervous system we may not fully understand, no more than we understand how a healthy condition of nervous endowment is essential to all vital processes. Even lesions of nutrition are now known to depend upon primary disturbance of nervous influence. This is seen in certain skin diseases, such as herpes zoster, which closely follows the destruction of certain nerves. And it is well known that injury of nerve-trunks is not unfrequently followed by impaired nutrition and failure in reparative power in the parts to which such nerves are distributed. Indeed, so marked is the influence of the nervous system over the nutritive operations that the question has been considered as to whether there are {437} trophic nerves distributed to tissue-elements themselves whose special function is to keep these elements in a healthy state of nutrition. The proof, at least, that the digestive process is, in some unexplained way, under the immediate influence of the nervous system, either cerebro-spinal or trophic, is both varied and abundant. The digestive secretions are known to be the products of living cells which are abundantly supplied with nerve-fibres, and we can readily believe that the potential energy of this cell-force is probably vital and trophic. At any rate, it is unknown in the domain of ordinary chemistry. The digestive ferments, as clearly pointed out by Roberts, are the direct products of living cells. Their mode of action, he claims, bears no resemblance to that of ordinary chemical affinity. It has a distinctly physiological character. Nor do they derive their vital endowments from material substances. "They give nothing material to, and take nothing from, the substances acted on. The albuminoid matter which constitutes their mass is evidently no more than the material substance of a special kind of energy--just as the steel of a magnet is the material substratum of the magnetic energy, but is not itself that energy" (Roberts). That this living cell-force is partly, at least, derived from the nervous system is clear from the well-known effects of mental emotion, such as acute grief, despair, etc., in putting an immediate stop to the digestive process. Experiments on the lower animals have also shown the direct influence of the nervous system over gastric secretion. Wilson Philip showed by various experiments on rabbits and other animals that if the eighth pair of nerves be divided in the neck, any food which the creatures may afterward eat remains in the stomach undigested, and after death, when the nerve has been divided, the coats of the stomach are not found digested, however long the animal may have been dead. Bernard also excited a copious secretion by galvanization of the pneumogastric, and by section of the same nerve stopped the process of digestion and produced "pallor and flaccidity of the stomach." Recently doubt has been thrown on these statements of Bernard and Frerichs. Goltz concludes, from observations made on frogs, that nerve-ganglia, connected by numerous intercommunicating bundles of nerve-fibres, exist in the walls of the stomach, the irritation of which gives rise to local contractions and peristaltic movements of the stomach, and that these ganglia influence the gastric secretion. However this may be, it still remains true that these gastric ganglia are in connection, through the vagi, with the medulla oblongata, and are thus influenced by the cerebro-spinal nerve-centres. And clinical observation confirms what theoretical considerations would suggest. Thus, strong mental impressions are known to produce sudden arrest of secretion, and that which arrests secretion may, if continued, lead to perversion of the same.

Impressions made upon the nerves of special sense are also known to affect the salivary and gastric secretions. The flow of saliva is stimulated by the sight, the smell, the taste, and even thought, of food. Bidder and Schmidt made interesting experiments on dogs bearing upon this point. They ascertained by placing meat before dogs that had been kept fasting that gastric juice was copiously effused into the stomach. Other secretions are known to be similarly affected. Carpenter by a series of well-observed cases has shown the direct influence of mental conditions on the {438} mammary secretion. The nervous association of diabetes and chronic Bright's disease is interesting in this connection, and the direct nervous connection betwixt the brain and the liver has been shown by numerous experiments. It is maintained by modern physiologists that "the liver--indeed each of the viscera--has its representative area in the brain, just as much as the arm or leg is represented in a distant localized area" (Hughlings Jackson). And in harmony with this view Carpenter long since pointed out the fact that if the volitional direction of the consciousness to a part be automatically kept up for a length of time, both the functional action and the nutrition of the part may suffer. It has been described by him as expectant attention, and it has, as we shall see, important practical bearings on the management of gastric affections. Sympathetic disturbance of the stomach is also connected with direct disease of the brain. This is seen in cases of concussion. The almost immediate effects of a blow are nausea and vomiting, and the same thing is observed in local inflammation of the meninges of the brain.

Many forms of functional dyspepsia due to nervous disturbance of a reflex character will be pointed out when discussing the etiology of the disease.

ETIOLOGY.--Among the agencies affecting the digestive process in atonic forms of dyspepsia may be mentioned--

First, predisposing causes;

Second, exciting causes.

In general terms it may be said that all conditions of depressed vitality predispose to the varied forms of atonic dyspepsia. These conditions range through an endless combination of causes, both predisposing and exciting. There is not a disturbed condition of life, extrinsic or intrinsic, that may not contribute to this end. In some cases it may be the effects of hot and enervating climates; in others the alterations in the elementary constituents of the blood may be apparent; while in still others the cause may be exhausting discharges, hemorrhages, profuse suppuration, venereal excesses, sedentary occupations, and long-continued mental and moral emotions.

Heredity may also predispose to functional dyspepsia. Certain faulty states of the nervous system are specially liable to be transmitted from parent to offspring--not always in the exact form in which they appeared in the parent, but in forms determined by the individual life of the offspring. For obvious reasons, growing out of our modern American civilization, the inheritance of a faulty nervous organization is apt to spend itself upon the digestive apparatus. The inordinate mental activity, the active competitions of life, the struggle for existence, the haste to get rich, the disappointments of failure,--all contribute to this end. The general tendency of American life is also in the direction of a highly-developed and morbidly sensitive nervous system, and functional dyspepsia is a natural sequence of this. The symptoms of dyspepsia thus caused usually manifest themselves at an early period of life.

Age also predisposes to weak digestion. The stomach becomes weak as age advances, in common with all the functions of the body, and consequent upon this weakness there is diminished excitability of the gastric nerves, with diminished muscular action of the walls of the stomach and deficient secretion of the gastric juice. Chronic structural changes are {439} also apt to occur in advanced life. The gastric glands become atrophied and the arteries become atheromatous, so that with symptoms of indigestion there are often associated loss of consciousness at times, vertigo, irregular action of the heart, etc. These general facts have an important bearing upon the hygienic management of dyspepsia in the aged. They require, as a rule, less food than the young and vigorous. In times when famine was more frequent than now it was found that the older a human being was, the better deficiency of food was borne. Hippocrates tells us, in his Aphorisms, that old men suffer least from abstinence. Their food should be such, both in quantity and quality, as the enfeebled stomach can digest. There is less demand for the materials of growth, and consequently for animal food. Moderate quantities of alcohol, judiciously used, are also specially adapted to the indigestion of the aged. It has the double effect of stimulating the digestive process and at the same time checking the activity of destructive assimilation, which in old age exhausts the vital force. And in order to more effectively arrest destructive metamorphosis great caution should be taken against excessive muscular fatigue, as well as against sudden extremes of temperature. Loss of appetite from deficient formation of gastric juice is a common symptom in old age. This is not often successfully treated by drugs, and yet medicines are not without value. The sesquicarbonate of ammonium acts as a stimulant to the mucous membrane and to the vaso-motor nerve, and in this way becomes a valuable addition to the simple vegetable bitters. Dilute hydrochloric acid with the vegetable bitters may also be tried. Condiments with the food directly stimulate the action of the enfeebled stomach. The old remedy of mustard-seed is not unfrequently useful, and pepper, cayenne, horseradish, and curries act in a similar manner in torpid digestion. And in cases of great exhaustion associated with anæmia benefit may be derived from small doses of iron added to tincture of columbo or gentian.

Nor should it be forgotten that in the opposite extreme of life the digestive capacity is extremely limited. The infant's digestion is readily disturbed by unsuitable alimentation. For obvious reasons it does not easily digest starchy substances. The diastasic ferment does not exist in the saliva of young sucking animals, at least to any extent. No food is so suitable for early infantile life as the mother's milk, provided the mother herself is healthy. It contains in an easily digestible form all the constituents necessary to the rapidly-growing young animal. Van Helmont's substitute of bread boiled in beer and honey for milk, or Baron Liebig's food for infants, cannot take the place of nature's type of food, which we find in milk. If a substitute has to be selected, there is nothing so good as cow's milk diluted with an equal quantity of soft water, or, what in many cases is better, barley-water, to which may be added a teaspoonful of powdered sugar of milk and a pinch of table-salt and phosphate of lime. Lime-water may be added with advantage. Dilution of alimentary substances is an important condition of absorption in the infant stomach.

Anæmia is a common predisposing cause of indigestion. Indeed, as a widely-prevailing pathological condition few causes stand out so prominent. It affects at once the great nutritive processes, and these in turn disturb the functional activity of all the organs of the body. Not only are the gastric and intestinal glands diminished in their {440} functional activity by impoverished or altered blood, but the movements of the stomach are retarded by weakened muscular action. It is impossible to separate altered blood from perverted tissue-structure and altered secretion. Indigestion produced by anæmia is difficult of treatment, on account of the complexity of the pathological conditions usually present, the anæmia itself being generally a secondary condition. Careful inquiry should be made, therefore, into the probable cause of the anæmia, and this should, if possible, be removed as an important part of the treatment of the dyspepsia. Nothing will more promptly restore the digestive capacity in such cases than good, healthy, well-oxidized blood. Indeed, healthy blood is a condition precedent to the normal functional activity of the stomach.

To these general predisposing causes may be added indigestion occurring in febrile states of the system. The cause here is obvious. In all general febrile conditions the secretions are markedly disturbed; the tongue is dry and furred; the urine is scanty; the excretions lessened; the bowels constipated; and the appetite gone. The nervous system also participates in the general disturbance. In this condition the gastric juice is changed both quantitatively and qualitatively, and digestion, as a consequence, becomes weak and imperfect--a fact that should be taken into account in regulating the diet of febrile patients. From mere theoretical considerations there can be no doubt that fever patients are often overfed. To counteract the relatively increased tissue-metamorphosis known to exist, and the consequent excessive waste, forced nutrition is frequently resorted to. Then the traditional saying of the justly-celebrated Graves, that he fed fevers, has also rendered popular the practice. Within certain bounds alimentation is undoubtedly an important part of the treatment of all the essential forms of fever. But if more food is crowded upon the stomach than can be digested and assimilated, it merely imposes a burden instead of supplying a want. The excess of food beyond the digestive capacity decomposes, giving rise to fetid gases, and often to troublesome intestinal complications. The true mode of restoring strength in such cases is to administer only such quantities of food as the patient is capable of digesting and assimilating. To this end resort has been had to food in a partially predigested state, such as peptonized milk, milk gruel, soups, jellies, and beef-tea; and clinical experience has thus far shown encouraging results from such nutrition in the management of general fevers. In these febrile conditions, and in all cases of general debility, the weak digestion does not necessarily involve positive disease of the stomach, for by regulating the diet according to the digestive capacity healthy digestion may be obtained for an indefinite time.