CHRONIC GRASTRIC CATARRH.

Arthur J. Rayson, M. D., B. Sc., M. P. S., Altoona, Mich.-I do not keep tables of percentages, as they are of no use to me; I cannot, therefore, give the percentage of chronic following acute gastritis, but in most of the cases there is this history.

I am unable to give any tabulated statement of these cases in my practice, but they almost all arise from indiscretions in diet or the want of discretion in diet-a too restricted and unsuitable dietary.

There is often some valvular mischief of the heart, a weak action and a struggling against toxæmia. Sometimes there is congestion of the liver, often lithiasis, cholelithiasis, temporal neuralgia, renal inadequacy and back of it all may be malaria; this may not be the order of their frequency though.

The mouth is clammy and dry not nearly so moist as it should be. The breath is foul and a nasty, bitter taste is complained about at the base of the tongue in the morning, which may be slightly furred. The tongue is not always foul and coated; it does not always indicate the condition, nor is anorexia always present. Flatus is the bugbear they come about and the oppression at the heart. Flatus is mostly gastric, inoffensive but abundant; the pain is referred to the ensiform cartilage and epigastrium. Sometimes it is duodenal; there is tenderness over the gall-bladder. Very little vomiting is present. There may be a muddy and itching skin and naso-pharyngeal catarrh. There is some hyperaesthesia. Temperature may be subnormal or slightly raised. Nausea, slight headache, great mental despondency, an irritable temper and consciousness of it, insomnia at the earlier part of the night, horrible dreams, constipation and a general want of effective elimination are all present.

I find the tongue does not have the same appearance in every case; it may be clean, slightly

clean or foul. It was very foul in a case complicated with lobular pneumonia, nor would it clean up altogether.

The urine is generally loaded with lithates; no albumen, but of a dark red-brown color tinged with yellow.

I seldom see a vomit, nor have I any facilities or opportunities to deal with a test meal; this is the work for a hospital, not for a general practitioner.

I do not practice lavage, as I do not believe so much in doing unnatural things. My predecessor told me he lavaged a patient's stomach, but could not get the return flow, so he left it with her. It appears I got her afterwards, for she petulantly said: "Doctor So and So washed out my stomach and had to leave it in." So the lady consumed her own smoke, as it were. Malaria was behind it all. I got her well without lavage; she is well now and rapidly advancing to an octogenarian.

The general principles of treatment are embodied in elimination and assimilation-to get rid of all effete material from the body, unload the portal system and silence any inconvenient and troublesome symptom. An effervescent saline aperient which I can modify and regulate myself I sometimes use. I use other drugs. There is an absence of enzymes. I am in the habit of prescribing what perhaps hardly anyone else knows at all about; it is certainly beneficial. Exceptional opportunities have made me familiar with, and enabled me to do my own treatment with my own formulæ, and I do not propose to disgorge all that I know in this direction; partly because it would not be understood and therefore of no use, for I do not prescribe from the United States Pharmacopoeia nor proprietaries or hardly any tablets, because I do not believe in them, and partly because a general practitioner should not, because he cannot, afford to give away his original methods as can a practitioner holding some public appointment, who looks to his own breth

ren for patronage and support; this he is more likely to gain or retain by occasionally modifying some old method or elaborating a new, and partly because professional etiquette is dead out here, and I may be forgiven, I hope, for not giving anyone a chance to stab me with my own weapon.

I do not use any of the mineral waters; they are not obtainable here.

Vomiting is not troublesome so that it needs special attention.

The bromides may relieve the pain, but if incessant an opiate does. I never give morphine hypodermically, because I do not believe in it. It prevents you from properly gauging the condition of the patient and misleads treatment, besides it is contra-indicated. The coal tar products are not objectionable.

I do not give tonics unless it be a cardiac tonic. That weak, all-gone feeling all passes away when they clean up; it is apparent only.

I knock off all nitrogenized food from their dietary and put them on a light easily digested diet. Fruit if they can take it, but they usually tell you that they cannot eat fruit, that it disagrees with them. The appetite is capricious. I often order two cups of very hot water twice a day. Vegetables are good. Huge quantities of French vintage grapes with bread are excellent. They are mostly women bordering on forty and over it, that I get with chronic gastric catarrh. I insist on their sitting at the table half an hour for each meal and deny them fluids until they have finished, so they have to chew and masticate their food and insalivate it whether they like it or not. It teaches them obedience and gives them a period of quiet. I ask for cheerful conversation in place of the dead silence and grim earnestness which characterizes most dining tables. It puts an end to the bolting of food and what they call being smart at meals, for which they allow themselves six minutes. They eat old cows that have calved every year and been in milk all the time; they live all the winter on fat pork, indifferently fed, and buckwheat pancakes are eaten every morning soaked in "grease." A threelayer cake, with twice the amount of sugar necessary in it, potatoes warmed up from the previous day with plenty of lard stirred in, adorn the table, together with navy beans, often hot biscuits and always tea. Is it to be wondered at that dyspepsia should stalk the land under such a dietary and so restricted? Goldwin Smith says, speaking of Canada and America: "The cooking is vile!" Women may refuse to have babies and epidemies may be a thing of the past and our profession may be getting fewer and fewer demands for its services; of one thing rest assured, that while

that ignis fatuus-"quick at meals, quick at work-flouts, there will always be something for our profession to do. American women do not like housekeeping, and while they prefer the frivolities of life to the weightier matters of home, improvement must not be expected. Meal times are too far apart; they eat too much of the same thing and they eat too quickly and they have not that variety of food which ensures mens sana in corpore sano.

I have never used electricity in the treatment of any of these cases.

Dr. G. G. Bulcom, Lake Wilson, Minn.: I do not keep any records of the history of chronic gastric catarrh cases coming to me in my practice, but do not think that many of them are the result of acute gastritis. The most direct causes I find to be the use of tobacco and liquors, and poor diet. Closely associated with this disease are catarrhal troubles in the duodenum, causing jaundice, anemia, constipation and chronic diarrhea. General symptoms most common are pain and distress in the stomach after eating, anorexia, vomiting, heart-burn, headache, indisposition to mental or physical exertion; anemia in drunkards. I have observed no characteristic appearance of the tongue; in the urine of drunkards I find a brick dust deposit, and sometimes mucous. Examination of the stomach contents shows a greatly decreased amount of hydrochloric acid. I sometimes practice lavage, and when doing so use a stomach tube and funnel, and a mild antiseptic, such as listerine, the normal salines, etc. My general principles of treatment are to get the stomach clean every morning by large draughts of warm water, regulate the diet and give tonics. I do not use mineral waters. Vomiting is controlled by washing out the stomach, applying counter irritants, such as a mustard plaster, and give ipecae in small doses, or nux vomica.

I never give more than one tonic at a time, then usually prescribe hydrastis, ipecac or nux vomica.

For a dietary I prescribe milk, hot milk, buttermilk, dry toast, oysters and fish. The milk should be warm, not boiled; if diarrhea is present, add lime water. I do not use electricity.

Dr. Henry Creasey, Maybee, Mich.: The majority of my cases of chronic gastric catarrh is caused by acute gastritis. Direct causes of the disease are constipation and errors of diet; sometimes too much indulgence in drink, home-made wine and cider in particular. The disease is almost always associated with constipation, sometimes followed typhoid. General symptoms are dull pain, bloating, eructations of gas.

Sometimes excessive appetite but usually the contrary; constipation, distress after eating, headache, general weakness, palpitation of the heart are other symptoms. The tongue is coated, sometimes trembling; urine is highly colored and contains urates in excess.

I do not examine stomach contents, nor do I practice lavage. My general principles of treatment are free elimination always, and stomachic tonies; no opium; regulation of diet as far as can practically be done in country town. I employ mineral waters very rarely. I control vomiting by free elimination and if necessary use bismuth subnitrate, gr. V, added to charcoal and soda gr. V every three hours. For pain and discomfort I prescribe comp. spts. ether and peppermint put up in Elix. Lact. pepsin efficient for pain.

For a tonic I give: Tinet. gentian Co.; Tinet. hydrastis; tinet capsicum; tinet nux vomica; aa 3ii; Elix. lact. pepsin adzV.

Sig. Teaspoonful every two hours.

For dietary I prescribe avoidance of greasy diet and everything that seems to cause distress after ingestion. If there is much bloating and distress, I add to foregoing mixture 2 drachms of Spts. Ether Comp. I have never seen a case which was not relieved greatly in a week or two, and old chronic cases cured if treatment persisted in long enough. I have never used electricity. For elimination I use the AntiConstipation tablets, two or three as required every night, also attention to the establishment of regular hours of stool.

Dr. W. F. Smith, Huntington, Ind.-As to the percentage of chronic gastric catarrh caused by acute gastritis, I am not at all certain, as so many chronic cases come to my attention that I have not been able to get the complete history of, but I would say probably 60 per cent. The majority of cases are brought about by improper

diet, alcohol and highly seasoned foods; a small per cent by liver trouble, and a still smaller by heart disease. Closely associated with the disease are diseases of the liver and heart. The general symptoms most commonly found are nausea, slight to extreme, moderately coated, broad, flabby tongue, pyrosis, belching of gas. The tongue usually has a white, slick, dirty coat, sometimes clear white with red under the white heavily showing; he urine is scanty for periods and alternately extremely free on abatement of congestion.

Examination of the stomach contents shows lack of hydrochloric acid and an excess of lactie acid. In lavage of the stomach I use the Turck Gyromeli method, following with normal saline solution of listerine, or mild solution of Tr.

Myrrh and boric acid; also in some cases using vibration in addition to above.

My general principles of treatment are as follows: Absolute restriction of solids for a week, then I have the patient take cereals, custards, brown bread, if any, in some cases oatmeal, roast potatoes; if starchy foods are used, I prescribe diastase. I do not use mineral waters. If appetite is poor I give nux vomica and hydrochloric acid dilute, having the patient carefully abstain from all stimulants.

Vomiting is controlled by hot spice poultice, vibration and nux vomica, bismuth sub.; not all of these but what seems best suited to the individual case. To relieve pain and discomfort I give chloroform water, dioscorea vill., essence of pepsine; for distention of gas, I give bismuth, charcoal and soda. For a tonic I give nux vomica, gentian, hydrastis, berberis aquifolium-not all, sometimes a combination of two.

As to diet, I prescribe no solids for a week, nothing but sweet milk or fruit juice, or light broth without fat and no medicine; then the patient can eat cereals and fruits, with the exception, usually, of apples, roast potatoes and custards.

I have used galvanic massage without any perceptible relief; believe mild vibrations would be better.

Dr. William J. Stapleton, Jr., Detroit, Mich.I have no exact data, but would say that 50 per cent or more of my cases of chronic gastric catarrh is caused by acute gastritis. As to the other direct causes of the disease, I find the following in order of their frequency: Use of alcohol; irregularity of meals; food not properly prepared or food that is not the right one for the patient; eating too fast. Associated with this disease I find others usually of the heart, lungs, liver or kidneys. The general symptoms most commonly found are: Loss of appetite; gnawing in the stomach; heartburn; distention as result of decomposing gases; nausea and bowling of food after eating; constipation. In alcoholic patients vomiting of colorless fluid from empty stomach.

The tongue is almost always coated; urine highly colored, with phosphates and urates in excess. Examination of the stomach contents usually shows a lessened amount of hydrochloric acid and an excess of mucous. I practice lavage, using a stomach tube, with a salt solution, soda bicarbonate and sometimes boric acid.

As to treatment, besides medicinal measures I try to have the patient get as much mental and physical rest as possible, recommending change of climate if possible.

Q. What forms of electricity are applicable to gastric neurasthenia, and how applied?

A. Herschell recommends three forms of electrical treatment, the condensation couch, the sinusoidal current, and the constant galvanic current. The condensation couch should be given daily for several weeks, with a dosage not exceeding 350 m. a. No advantage is to be gained from the use of the enormous currents produced by some of the apparatuses, and the element of danger is not absent. Of the sinusoidal current either the triphase or the monophase will give good results, the triphase being preferably administered by electrodes. The monophase, if used, is given by means of a water bath. This latter mode, by-the-way, is an easy and convenient way of treating neurasthenia, as it can be rigged up in the patient's house and applied by

himself, or with the aid of a nurse. The triphase

alternating current is especially useful in that form of neurasthenia which depends upon involvement of the splanchnics and the large nerve plexuses of the abdomen. Hence it is our best remedy in cases of nervous indigestion accompanied by varying degrees of muscular atony.

Good results are obtained by the use of the constant galvanic current properly applied. It is best applied by means of a large electrode to the solar plexus, the anode being placed upon the epigastrium and the kathode upon the lumbar region. The dose should be from 20 to 50 m. a. In the treatment of muco-membraneous colitis and other intestinal complications of neurasthenia, excellent results have been obtained

by the use of the hydro-electric rectal douche, employing the constant galvanic current.

Q. What is the proper method of testing the olfactory sense, and how are the tests to be interpreted?

A. To test this sense we employ substances with markedly different odors, such as cologne, assafoetida,, oil of anise, etc. We ask the patient to smell each of them, closing first one nostril and then the other. It is convenient at the same time to test the trigeminus nerve, employing for this purpose acetic acid and ammonia. The two sides must be tested separately. If any differ

ences appear we must not attribute them to the olfactory or trigeminus nerve until we have made sure that they do not depend upon an altered condition of the mucous membrane. This we do by a careful rhinoscopic examination.

If a true paralysis of both olfactories be made out, then it is most likely due to cerebral compression, having the same significance as a choked disc. A unilateral diminution of smell, without discernible local cause, is most frequently an accompaniment of hysteria and of traumatic neurosis. It is purelv functional. The hemiplegia due to a lesion of the capsule is not usually attended with any disturbances of the sense of smell.

Q. What is the significance of an increased secretion of urine?

A. The quantity of urine in pathological conditions depends, first, on the condition of the

secreting renal tissue, and second upon the rapidity of the blood current in the kidney. It will, therefore, be affected both by a circulatory disturbance and also by disease of the kidney tissue. In the latter case, both kidneys must be diseased in order to appreciably alter the quantity of urine, for otherwise the healthy kidney would assume the total function, as always happens in unilateral nephrectomy. The more acute the nephritis, the more the amount of urine falls below the normal; the more chronic the course of a nephritis, the more the amount rises above the normal. Chronic parenchymatous nephritis sometimes increases and sometimes decreases the

quantity of urine. Amyloid kidney exhibits the same variation. Diseases of the heart and lungs, leading to passive congestion, are usually attended by a diminution of the urine, which plainly depends upon a slowing of the renal circulation. In such diseases, therefore, the estimation of the daily amount of urine is of the highest diagnostic and prognostic importance, and should be systematically carried out.

Q. I have heard of a test for sugar in the urine with hydrobromic acid. Is there such a test, and if so, how is it performed?

A. A test of this nature was described by Fenton in 1906. It is of sufficient delicacy to

detect 2 per cent, or even less, of sugar in the urine. Four or five ces. of urine are poured on to an excess of solid anhydrous calcium chlo

ride so as to form a semi-solid mass. To this 10 cc. of toluene, containing two or three drops of phosphorus tribromide, are added. The mixture is boiled for a few minutes, and this must be done with care, owing to the inflammable nature of the toluene. The toluene solution is then poured off and cooled, and to it is added 1 cc. of malonic ester and a little alcohol. The solution is neutralized by adding alcoholic potash drop by drop, and this produces a characteristic pink color. The mixture is now diluted with alcohol and a few drops of water, and if any sugar is present the urine liquid will give a beautiful blue fluoresence. Fenton declares that the reaction is a specific one for carbo-hydrates which contain six or more atoms of carbon in the molecule, so that it will differentiate hexoses from pentoses.

Q. What is the best way of dealing with constipation in young children?

A. Our correspondent does not specify whether the patient in question (assuming he has a special case in mind) is an infant, or an older child, and if the former, whether a breast-fed or, bottle baby. If it be a breast-fed baby, possibly an analysis of the feces and of the mother's milk might furnish a clew to the cause of the trouble, which being removed, the constipation would clear up. If a bottle-fed baby, careful attention to the preparation of the food is to be recommended. If the stools are dry, give water often and freely. If the trouble seems due to a paucity of fat, give a teaspoonful or two of cream before each feeding. Or alternate feedings of milk with oatmeal water.

In older children it is possible that the diet has been too exclusively cereal, and the addition of broth and light meats is needed. Corn, wholewheat bread, with plenty of treacle and ripe fruits, are frequently useful. Stewed prunes may be added to the dietary, or washed figs, which most children are very fond of. Cotton recommends that chopped figs be soaked in a decoction of senna (half an ounce of the dry leaves to a quart of water, and be given to the child at night to promote a morning evacuation.

Q. What is the best position to lie in during sleep?

A. Perhaps we may be pardoned for replying to this query, first, by stating what is the very worst position for sleep, namely, on the back with the shoulders raised. To be sure, in cer

tain diseased conditions, such as asthma and heart disease, this position is necessary, but as

a habit it is exceedingly bad, tending to produce round shoulders and flat chest, besides causing nightmare by overheating the spinal centres and crushing the abdominal organs between the weight of the body and the backbone.

As to the best position for sleeping, children usually sleep best who lie prone on their abdomens. In adults, who have not been accustomed to such a posture, it would be hard, because of the strain upon the abdominal and back muscles. For adults in general the best position is the half-prone posture, lying on the right side with the body turned well forward. This posture is most favorable to the repair process which goes on during sleep.

Lying on the abdomen is a fine gymnastic exercise for the diaphragm muscle, since it is then obliged, in every descent, to practically lift the weight of the body. In some cases of great relaxation of the abdominal muscles, it is a good plan to have the patient lie on his abdomen over a cushion or pillow, which should not be too thick but rather firm, for by so doing, not only are the abdominal muscles greatly strengthened, but a large quantity of blood stagnating in the abdomen is forced out into the general circulation.

Q. What is the difference between mixed and compound astigmatism?

A. Compound astigmatism is that form of astigmatism in which the two chief meridians of the eye are both defective in the same way, i. e., both myopic or both hyperopic, so that a lens of the same curvature, but of different strength is necessary to correct the best and the worst meridian respectively. Correction of this kind of astigmatism is made by bringing the worst meridian up to the same degree of defect as the best, by means of a cylinder of appropriate strength, which renders the remaining error a spherical error, to be corrected with a spherical lens of appropriate strength.

Mixed astigmatism is that form of the trouble in which both meridians are defective, but in different curvatures, i. e., one myopic and the other hyperopic, so a lens of one curvature is necessary to correct the best meridian and a lens of the opposite curvature to correct the worst meridian. Correction of this form of astigmatism is accomplished by over-correcting one of the meridians to the same degree of opposite error as the other. This makes the remaining error a spherical one, which is then corrected by an appropriate spherical lens.