INTESTINAL INDIGESTION IN ITS CLINICAL ASPECTS. BY HENRY S. UPSON, M. D., Professor of Diseases of the Nervous System in the Western Reserve Medical School, Cleveland. REPRINTED FROM THB Neto ¥orit JRSetJtcal .journal for June 19, 1897. _ Reprinted from the New York Medical Journal for June 19, 1897. INTESTINAL INDIGESTION IN ITS CLINICAL ASPECTS* By HENRY S. UPSON, M. D., PROFESSOB OF DISEASES OF THE NERVOUS SYSTEM IN THE WESTERN RESERVE MEDICAL SCHOOL, CLEVELAND. In introducing to your notice the subject of digestion as a causative factor in nervous disorders, it is hardly ne- cessary to more than indicate the very unsatisfactory state of our knowledge of the digestive processes. We may regard the gastro-intestinal tract as, in its upper part, a laboratory for the digestion and absorption of food, and in its lower part a breeding ground for bacteria, al- ways present in vast numbers in health, and in disease either increased in number or changed in kind. The processes of digestion which are carried on in the stom- ach are of prime importance in their relation to the nerv- ous system. It is, however, disturbances of the intes- tine, the so-called intestinal indigestion or intestinal dys- pepsia, of which I wish to speak at present. The chemi- cal part of this subject has been very carefully worked up and presented to this society by Herter, who followed up Baumann's discovery that the organic sulphates found * Read before the American Neurological Association, June, 1896. Copyright, 1897, by D. Appleton and Company. 2 INTESTINAL INDIGESTION. in the urine are almost invariably the result of putrefac- tive changes in the intestine. The somewhat varied symptoms which may accom- pany the increased excretion of these sulphates, and the fact that it is by no means certain that all the poisons elaborated in the intestine are so excreted in the urine, make the study of the clinical types of intestinal indiges- tion not entirely devoid of interest. I wish to call your attention, therefore, in brief to three cases, one of nerv- ous phenomena from poisons formed by a known and very familiar germ in the intestinal canal, another from the action of a germ equally well marked in its charac- teristics and of the same habitat, and the third a case presenting nerve symptoms quite similar in kind, but of somewhat more uncertain cause. A medical student, twenty-four years of age, was brought to the Lakeside Hospital, October 1, 1895, at the end of probably the first week of typhoid. He had had headache, backache, and lassitude for two or three weeks; had had a great deal of nosebleed, and a rise of temperature had been present as nearly as we could judge for a week. His temperature on admission was 103.2°; the spleen was enlarged; there were no rose spots. The bowels were constipated; the patient was even thus early very delirious at night, and his mind was somewhat wan- dering during the day. There was no tympanites. He had been very restless and had not slept for several nights. He was put on a milk diet, given hydrochloric acid, ten drops after each glass of milk, and thymol, two grains every two hours. In spite of twenty grains of Dover's powder and five minims of Magendie's solution of mor- phine hypodermically he slept practically not at all. Without giving the case too much in detail it will suf- fice to say that the delirium increased, there was subsultus tendinum, and at last coma vigil for the whole twenty- four hours with extreme tympanites for several days. INTESTINAL INDIGESTION. 3 During the week attempts had been made to clear the bowels with small doses of calomel and frequent rectal in- jections, with only partial success. The patient was then, on the afternoon of the 6th, given an eighth of a grain of calomel every hour during the day and every two hours during the night. At the end of twenty-four hours he had had a good movement of the bowels, was much less restless, and began to sleep fairly well at night. After the first movement of the bowels he slept several hours. The tongue, which was very dry, cleaned off and became moist. The calomel was continued for a time, and later, after about ten days, was replaced by mag- nesium sulphate every two or three hours, and this was continued until the temperature was normal. He was given three or four baths at 75° at about the time the bowels were cleared. The temperature was brought down about a degree by each bath; it was at no time during his illness a threatening symptom, and ranged from 101° to 104°. I cite this case, not as proving anything regarding the treatment of typhoid fever, but as showing for compari- son a very familiar clinical picture of general poison- ing of the nervous system from the intestines, which we may see duplicated in many of its details in widely different conditions. The great improvement in the pa- tient's condition did not coincide with a drop in his tem- perature, and it occurred at the beginning of the third week, not during defervescence during the fourth week. It was coincident with a clearing out of the intestinal canal and a washing of the skin. In the second case the aatiology is not quite so ob- vious, as the original disease had been recovered from, and the symptoms supervened when the patient was up and about. Mr. F., sixty years of age, a merchant. First seen October 23d. The patient was fairly well until six weeks 4 INTESTINAL INDIGESTION ago, when he had a severe attack of dysentery. For a month or two, however, he had felt restless and a little below par. He made a good recovery from the dysentery, although the attack was a very obstinate one. He was given opium and bismuth in fairly large quantities. The stools were bloody and contained mucus. There was no known cause for the attack. Convalescence was well established and the patient began to eat solid food, when a week ago, without any apparent cause, he developed very excessive nervousness. This comes on in attacks, always in the afternoon, at times varying between one and six o'clock; there are great restlessness, headache, dull and frontal in character, and a distressed feeling. The patient is unable to sleep, and has had morphine in moderate quantity, and chloral, about fifteen grains at a dose. He then gets a good night's rest and feels better in the morning, only to be attacked again in the after- noon. On examination, the patient is fairly well nourished but very bloodless. He is much depressed, cries readily, insists that he " must go home," and is, in general, one of the most abject specimens of mental misery that I have seen. His condition may best be described as one of rest- less melancholia. He breathes rather rapidly, and turns his head from side to side, but is perfectly rational. The pupils are equal and react to light. The field of vision and the optic discs and retinae of both eyes are quite nor- mal. Knee-jerks are lively. Motion, station, and sensa- tion are good in every respect. The pulse is full, regular, soft, and compressible, 80. There is no fever; the heart and lung sounds are normal. A very little abdominal tenderness is noted in the left hypogastrium; the area of splenic dullness is somewhat enlarged. The abdominal organs are otherwise apparently normal. His urine is yellow, acid, 1.013; it contains no albumin, sugar, or indican. The microscope shows slight deposits of epi- thelial cells. There was ordered a glass of milk every hour with nothing else to eat; strontium salicylate, ten grains, four times a day; calomel, a sixth of a grain every two INTESTINAL INDIGESTION. 5 hours; chloral, fifteen grains by rectum in the evening to induce sleep. October 24th, 9 A. M.-The patient is of a slightly better color than yesterday and, as always in the morning, is somewhat quieter. He slept fairly by chloral and mor- phine, a sixth of a grain, during the night. 25th, 9 A. M.-There was no nervous attack yester- day afternoon, the first afternoon without one for a week. The patient slept well without chloral or morphine. He still cries rather easily. He had a movement of the bow- els in the night and another this morning. The move- ments are dark, fluid, and offensive. 27th.-The patient has had no severe nervous attacks, but was slightly restless for a time yesterday. He has felt much better all day to-day. The stools for the last thirty- six hours have been much lighter in color and have a strong smell of whey. To-day they are less fluid, but are still very soft. 29th.-A soft egg, toast in moderate amount, and boiled rice were added to the patient's dietary, beginning yesterday morning. He felt well until yesterday after- noon, and then was restless. He had a little pain in the abdomen during the night and was quite restless and did not sleep much until twelve o'clock, when fifteen grains of chloral were given him. He then had a good sleep, and feels a little better this morning. Milk diet was resumed, each glass to be followed in half an hour by hydrochloric acid. 31 st.-The patient was better till last night, when he had a nervous attack, and spent a rather sleepless night. There seems to be a periodicity about these attacks. They came every afternoon when he was at home; they now come about every other day, but do not always occur at the same time of day. Examination of the blood fails to show malarial plasmodia. He was ordered Warburg's tincture instead of the calomel, and quinine, four grains four times a day, in place of the salicylate. From this time on the patient's condition improved in the main, although slowly. He was for a time some- 6 INTESTINAL INDIGESTION. what more restless every other day, but had no very se- vere attacks. The stools were fairly light colored and be- came gradually less offensive. He was given salol, four grains, and calomel, a sixth of a grain, every two hours, with Fowler's solution for some days. He made a good recovery. The nature of the putrefactive changes in this case is not quite clear. The patient's place of business is on the edge of a mill pond, and malaria is moderately prevalent in his native place. His dysentery may have been amoebic in origin and his subsequent symptoms malarial. Many clinical facts point to the occurrence of the Plasmodium malaria in the intestinal contents. The pabulum, most nearly like its native swamps, is certainly furnished by the faeces. In malarial cachexia, in which the germs are not found in the blood in an active state, the symptoms are partly due to poisons produced pre- sumably by active bacterial action, and are largely intes- tinal, pointing strongly to the presence of the germs in the intestinal canal. Cholera, typhoid fever, dysentery, and malarial dis- ease are the only diseases known to be water borne. In the other three the germ certainly inhabits the intestinal canal; that of malaria may reasonably be expected to do the same. The plasmodium is very difficult to find, which may account for the fact that it has not been found in the faeces, as have the germs of typhoid fever and cholera. The Amoeba coli was absent in this case, as was to be expected after the cessation of stools containing mucus. The next case is that of a woman, Mrs. S., aged fifty- four years. She was first seen August 29, 1895. The INTESTINAL INDIGESTION. 7 patient is quite fleshy, and has always been quite well until last spring. Then, in March, her husband acci- dentally shot himself, and she was called to the hospital to see him. He made a good recovery, but she felt the shock very much and was a good deal depressed by it. She showed much anxiety during his illness. Since then she has been downhearted, cries rather easily, has abso- lutely no appetite, and feels weak. There have been no hallucinations or delusions. She has more or less head- ache, the bowels are quite constipated, and she has to take pills to induce a movement. She sleeps very badly, lies awake in a very restless condition a good part of the night, and arises unrefreshed. She is unfitted for her work, and is, in fact, so much depressed that she is afraid she will be sent to the asylum. She has a great deal of pain and rumbling of the bowels. She ceased menstruat- ing eight or nine years ago; she had no special trouble at that time, and has had no discharge of any kind since. Her pupils are equal and react to light and with accommo- dation. She has no paralysis or anaesthesia. The pulse is soft, full, and regular, the rate not noted. The heart and lung sounds are normal. The spleen and liver are not enlarged. The urine is yellow, acid, 1.024, and contains no albumin or sugar. It was examined a few days after treatment was begun and contained oxalate of lime crys- tals; the patient pleaded guilty to having tasted some toma- toes which she was canning. On subsequent examinations no oxalate of lime was found. A few epithelial cells were seen microscopically, but no casts. She was put on a milk diet, one glass to be taken every hour, and strontium salicylate was prescribed in doses of ten grains four times a day. On the 5th of September she was again seen. She had slept very well every night for the past week, except the night of the 4th, when she was somewhat restless. She had regained her appetite, and begged to be allowed something to eat. She had adhered to her milk diet fair- ly well, had nibbled an occasional cracker, and tasted stewed tomatoes once, as above noted. The same treat- 8 INTESTINAL INDIGESTION. ment was continued. Improvement was steady for sev- eral weeks. She lost fifteen or twenty pounds in weight, which she could well afford to do, but was quite cheerful when seen. The rumbling and flatulence had entirely disappeared. On September 24th she was put on a diet of broiled and roasted beef, mutton or chicken, soft eggs, stale bread, cooked fruits, and boiled rice. At the end of a week of this diet the salicylate was stopped. She continued to do well for three weeks. At the end of that time she visited a friend who was quite sick, was much troubled about it, and began to be somewhat restless, and to have more or less rumbling in the bowels. The diet was continued, and benzosol was ordered in doses of three grains three times a day. This patient has been seen several times since. She has been very well as long as she adhered to a fairly strict diet. As soon, however, as she began to eat fresh bread, raw fruits, and acids, or rich, greasy articles of diet, she had a relapse. These attacks have invariably yielded to moderate care in eating and the administration of a sim- ple antiseptic, such as one of the salicylates or benzosol. The last case cited is typical of many similar ones which I have seen. Mankind may be divided into two classes, the constipated and the loose. I have seen cases of intestinal indigestion go on for some years in peo- ple with naturally loose bowels, without giving rise at any time to acute toxic symptoms. These persons are apt, however, to become quite anaemic. In such cases mor- phine or other agent to check the action of the bowels is apt to set up a toxaemia by giving time for greater ab- sorption from the intestinal canal. In treating these cases one of three things may be done: kill the germ, starve it, or drive it out. Needless to say, the ideal antiseptic, sure death to all germs wher- ever located, has not been found. None the less, the state- ment recently made, that by count the germs passed in INTESTINAL INDIGESTION. 9 the faeces are not less in number while an antiseptic is given, is by no means conclusive that germicides given by the mouth are valueless. Consider that the gut is twenty-seven feet long; that bacteria mostly abound in its lower part; that absorption is most active in its upper part; and it is easily seen that germ action may be strong- ly inhibited in the stomach and upper gut by drugs, as it probably is by the gastric juice and the bile, without de- creasing perceptibly the swarms that normally occupy the lower bowel. It is possible that poisoning may be set up in some cases without increase in either the germs or the toxines formed. The lower bowel has a comparatively non-ab- sorbent surface. It has been shown that the bladder, which normally absorbs no poisons, when inflamed takes them up freely. The same may be true of the intestine, and it always contains toxines. I usually, therefore, in such cases give an antiseptic, believing that if the small amount of creosote in smoke inhibits putrefaction in meat outside the body, and if a moderate amount of salicylic acid added to milk prevents it from fermenting for several days, the same substances may inhibit these processes, for a time at least, in the stomach and upper gut, where the most harm is done. Second. Diet is more important than medicine. I am told, by an extensive breeder of hogs, that the dis- ease which is most common and fatal in that animal is indigestion. He receives so many letters of inquiry from different parts of the country in regard to animals so afflicted that he keeps a stock letter in reply, advising that the animal be turned into a pasture or wood lot, be fed nothing, but left to shift for himself, and be com- pelled to live on what grass and roots he can find. This 10 INTESTINAL INDIGESTION. is called the " root-hog-or-die " treatment. It finds its analogue in the milk-diet treatment of indigestion in the human body. Milk is by most people easily digested, not enough can be taken to supply much nutritious ma- terial to the blood, so that the assimilative organs have a rest, and little residue finds its way to feed the bacteria in the lower bowel. When other articles of diet are added, experiment is often a sufficient guide in choosing them, and two classes of substances are especially apt to give trouble-the vegetable albuminoids in cases with ex- cess of the ethereal sulphates in the urine, the animal albuminoids in cases of the so-called uric-acid diathesis. Starches should be given in their more digestible forms; sweets and pastries should be withheld. In the third place, the bowels should be kept open. Nature often does that; but it is not enough that the patient have frequent diarrhoeal movements from the lower bowel. The duodenum should be unloaded regu- larly. Three cases do not constitute statistics. I can only state my conviction, from a somewhat extended experience in this class of cases, that the type of nerve disturbance found in typhoid fever, and in connection with and after diarrhoea and dysentery, is found in intestinal indiges- tion without the intervention of these disorders. It may be easily confounded with mild melancholia or neuras- thenia. It presents many points of resemblance to nico- tine poisoning; it must be carefully distinguished from nerve disorders arising from reflex; it is amenable to treatment, which should not consist solely in the adminis- tration of an antiseptic. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. 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