CHAPTER VII.

DISEASES OF THE DIGESTIVE TRACT (continued).

SOME of the diseases of the stomach are closely allied to those of the intestines already described. Acute or milk dyspepsia, gastralgia, and vomiting are so; all these being symptomatic or functional diseases. They have no morbid anatomy, and for this reason they are of somewhat uncertain nature. Herein lies a puzzle to the student, because the symptoms which to one writer indicate-let us say, for example, acute dyspepsia, to another suggest gastric fever, to another perhaps dentition fever. Gastralgia may in like manner be, for all we can say positively to the contrary, a colic, or a nerve storm in some other part of the abdomen, just as well as an actual affection of the stomach itself.

I shall therefore as far as possible avoid the use of terms the correctness of which we are not sure of, and describe as cases such sets of symptoms as are common in childhood, and which are attributed, both popularly and professionally, to gastric disorder.

And first of all, let us take a case of fever: gastric fever if you will, but that the gastric origin is uncertain; acute dyspepsia if you will, but even true dyspepsia is doubtful.

A healthy child of twelve months, with its two lower incisors cut, ailed for a day or two with feverishness, constipation, and occasional vomiting. When seen first, it was fretful, with a temperature of 100.4°, and a quick pulse and full abdomen. The temperature went up to 103°, remained up for two days and a half, and then fell rapidly to normal; the tongue was thickly furred, the bowels confined, the mo

tions light in color, and there was occasional vomiting, The bowels were opened freely by rhubarb and soda, and acetate of ammonium was given internally. A week later one of the upper incisors was cut.

Such cases as this are very common. They occur during the progress of dentition, but have often no definite relation to the eruption of a tooth. They occur, moreover, at the time of weaning, before the stomach has become accustomed to the change in its dietary. They occur notably sometimes after errors in feeding. They will sometimes speedily relieve themselves by vomiting, so that there is some reason at any rate for considering them of gastric origin. They are somewhat erratic in course and duration. Sometimes the temperature will run up quite suddenly at night, and come down again, and remain normal, after the following morning, apparently in obedience to a febrifuge, but quite as likely in dependence upon what may be called the initial vitality of the fever. Sometimes the pyrexia is more prolonged, and we perhaps begin to discuss the question of enteric fever. In such cases, the idea suggested by the term infective gastritis may contain a germ of truth, and at any rate, in dealing with an affection of the nature of which we are quite in the dark, some fugacious erythema of the gastro-intestinal tract may be suggested as a possible cause of the elevated temperature.

In older children something of the same kind happens, the fever being associated with an acute bronchitis of the larger tubes.

Emily W. has been a frequent attendant, between the ages of two and a half years and six years, with attacks which come on quite suddenly, with vomiting, confined bowels, delirium, and high fever. In one of these attacks her face was flushed, temp. 103°, pulse 160; the tongue thickly furred with white fur, and red papillæ showing through; the

respiration rapid, harsh all over, with copious dry râles, but no other physical signs. These symptoms are always relieved by a dose of castor-oil, and in two or three days she is quite well again.

In another class of cases, fever and cough are combined with vomiting and purging. A boy of three years was brought for fever and cough, which had come on quite suddenly, and after which the bowels were loose, and he was frequently sick, the attack extending over a fortnight. A little rhonchus was audible in various parts of his chest, but no other physical sign, and he rapidly improved by careful dieting and a simple citrate of potassium mixture.

The treatment in all these cases is dietetic and aperient. In the case of infants, 3j of castor-oil may be given at once, and, if the child be of sufficient age, I must confess to a liking for small doses of calomel and Dover's powder, a sixth of a grain of each every two hours, for three or four doses, following the aperient. It may be difficult to explain the action of these drugs, but the fever seems to subside more rapidly with them than without them. Another good mixture is a combination of the tr. camph. co.,* acetate of ammonium and citrate of potassium (F. 29). Another, salicylate of sodium with liq. ammonii acetatis (F. 2).

In the gastric fevers of older children a couple of grains of jalapin with two of calomel, or a piece of Tamar Indien, form good and easily disguised aperients. They should be followed by such gentle laxatives and alteratives as fluid magnesia 3ij, or 3j of confection of sulphert three times a day; or rhubarb and soda (F. 11).

* Tr. Camph. Comp. Br. P. is similiar to Tr. Opii Camph. U. S. P.—ED. + Confectio Sulphuris, Br. P., contains:

A tonic is usually necessary afterwards, and none is better than Easton's syrupus ferri et quiniæ et strychniæ phosphatum: half a teaspoonful in water three times a day.

Abdominal Neuroses.-Another large group of so-called stomach cases exhibit more chronic symptoms. The fever is absent or very slight, but the tongue is furred, the breath foul, the appetite capricious, the bowels irregular, and superadded is a frequent dry hollow cough, which is often called a "stomach cough." The condition upon which these symptoms depend is a very indefinite one, if we attempt to treat of it pathologically, but distinct enough as a clinical fact. We have a dull, languid state, with opaque and greasy skin, pallor and wasting. The tongue is flabby, moist, and covered with a whitish fur; the appetite is capricious-sometimes ravenous, sometimes dainty, sometimes replaced by an inordinate thirst. There is a liability to severe stomachache, which in some children attacks them when they wake in the morning, in others appears to be excited by the ingestion of food. The bowels are perhaps confined and relaxed alternately for days together. The constipation may attract but little attention, but the diarrhoea, particularly if combined with vomiting, makes the parents anxious. The child is said to be subject to bilious attacks; or a dry, hollow, frequent cough frightens every one around into the idea of consumption. Nor should this cough be passed over without alluding to the close sympathy that exists between the stomach and the lungs. The diseases of the one organ are so frequently reflected in perverted functions of the other, that it is quite worth while bearing the fact in mind. It must not be supposed that all these symptoms are to be found in any one case. Some children will require treatment for griping abdominal pain of a paroxysmal kind, others for bilious attacks, others for pain in the side, others for cough, yet others perhaps for nightmare;

but when we come to investigate cases, certain other features are found in common-viz., pallor, wasting, furred tongue, foul breath, irregular bowels, etc. Now these are all symptoms which might be due to a great variety of causes, and they are not associated with any known anatomical lesions. Nevertheless, as a group they have much constancy, and it becomes necessary to assign them a place, and for purposes of recognition, a name also, amongst gastrointestinal disorders. Dr. Eustace Smith, in his "Wasting Diseases," proposes the name "Mucous Disease." He considers a soft, flabby, indented tongue, smeared over with a gum-like mucus, to be particularly characteristic; and the side-pain, stomach-ache, etc., to be due to accumulations of mucus in the bowel, and its evacuation to be the cause of the periodical diarrhoeas. As an accurate picture of the affection we are now engaged upon, the student cannot do better than read the chapter referred to in Dr. Eustace Smith's book.* But I should hesitate to indorse the term "Mucous Disease," first because I have not been able to satisfy myself of the discharge of any such large quantities of mucus from the bowel in such cases; secondly, because it is by no means certain that mucus, even if it should collect, would give rise to such symptoms; thirdly, were it to do so, it would still have to own some cause behind it. But no doubt these chronic gastro-intestinal derangements are a part of the series which are so described.

For my own part, I am persuaded that although they may seem to be caused by temporary conditions, such as errors in diet, these varied pains and aches are often but the expression of a constitutional build. They are an evidence of nervous instability, and they are found in nervous children or nervous families. By this I mean that children subject

* " Wasting Diseases," 3d edition, p. 199.