Chronic Gastritis.

Synonyms:—Chronic catarrhal gastritis; chronic gastric catarrh; chronic catarrh of the stomach; chronic dyspepsia; chronic catarrhal dyspepsia.

Definition:—A chronic catarrhal inflammation of the mucous membrane of the stomach, characterized by a free outpour of mucus and changes in the quantity and character of the gastric juice, permitting fermentation of the food and otherwise interfering with the normal digestion, resulting in marked local and constitutional symptoms.

Etiology:—The causes of this disease are similar to those of acute gastritis. These being long continued, result in the changes which interfere with secretion from the mucous membrane and from the various gastric glands, resulting in changes in the quantity of the gastric juice, or irregular changes in the quantity of the several constituents of this fluid, thus causing deficient, excessive, irregular or imperfect gastric juice. This imperfect secretion is itself a potent cause of those symptoms which are directly referred to the stomach. Deficient hydrochloric acid results in an increase of abnormal ferments, as it is the function of this acid to destroy these micro-organisms. These ferments, as stated farther on, produce substances which exercise a mischievous influence. Furthermore, an excess of mucus, alkaline in character, neutralizes much of the already deficient hydrochloric acid, encouraging the formation of butyric and lactic acids, and covering the ingested food, it interferes with the direct action of the imperfect gastric fluids.

Two most common causes are the use of alcohol and tobacco, and bad habits of eating. There are probably but few who are addicted to the use of alcohol who are entirely free from this disease. Tobacco, stimulating undue secretion of saliva, and causing local irritation, is a conjoint cause with alcoholism. Among the bad habits of eating are too rapid eating, which is very common, imperfect mastication and consequent imperfect insalivation, the eating of too much food, eating at irregular times or in irregular quantities, the use of strong coffee, and the taking of liquids with the food, and the taking of the food or beverages either too hot or too cold. The too free use of liquids with the food dilutes the gastric juices to such an extent as to interfere with the proper exercise of their function, thus making it necessary at times for the food to remain in the stomach until the fluid has passed out, permitting fermentation and acting as an irritant. The taking of irritating condiments or of irritating substances, as medicine, and the pernicious habit, so common to American people, of depending upon the regular use of physic to overcome intestinal inactivity are frequent causes. Chronic medication is a bad habit, and may lead to chronic dyspepsia. For this the physician and the manufacturing pharmacist are in part to blame.

Another fault is lack of care of the mouth and teeth, which results in imperfect mastication or insalivation, or from decomposition of food particles in the mouth, which permits the introduction of bacteria into the stomach.

Local congestions are a common cause of this disease. Congestion of the portal circle, or chronic hepatic congestion, or other affections of the liver, notably cirrhosis, chronic pulmonary congestion, and anything that will induce imperfect heart action, will lead to it. Other conditions to which this disease is secondary are tuberculosis, anemia, chlorosis, syphilis, chronic malarial disorder, Bright's disease and diabetes. It is exceedingly common in patients suffering from the uric acid diathesis—lithemia—consequently rheumatic and gouty patients are especially liable to it as a complication. Patients suffering from cystitis, or other disease of the bladder or urethra, or who are recovering from acute kidney disease, and patients suffering from disease of the uterus, ovaries or fallopian tubes are apt to be sufferers from chronic gastritis. It is also very common among patients who suffer from prolapsus of the bowel, rectal ulceration, fissures and hemorrhoids. The theory of the reflex influence of irritation at the anal sphincter in the causation of this and other chronic ailments is largely overestimated.

This disease is frequently of nervous origin. It is quite common with neurasthenic patients. With some of these patients it is one of the primary causes of the disease, but in a large number of neurasthenics it is the natural result of seriously impaired or deficient nerve tone, and consequent deficient nerve action. This results also in some cases in deficient functional operation of all the vital organs. While the deficiency is seen in a single organ only, it is frequently observed to be uniform in all the vital organs.

Symptomatology:—There is considerable variation in the symptoms of the various cases of chronic gastritis. But few are characteristic. At first there is an erratic appetite, with long periods of anorexia. Occasionally the appetite is abnormal, both in the desire for an excessive quantity of food and in the desire for substances that are plainly injurious, or for inordinate quantities of certain foods or condiments. Usually even a small quantity of food will produce a sensation of distention or oppression in the gastric region, a sensation of extreme fulness, or a sensation as if a hard substance was within the stomach, producing discomfort or steady, dull pain. The pain may be griping in character, occasionally with a sensation of burning. At other times there are eructations of gas, either at the beginning of the meal, or most frequently, however, from one to two hours after eating. Occasionally there is regurgitation of partially digested food, or food mixed with the gastric secretion, or a free regurgitation of an acid watery fluid (pyrosis, waterbrash). With neurasthenic patients I have observed regurgitation, at the end of each meal, of food which is apparently unchanged and unmixed with the stomach secretions.

The tongue presents a variety of appearances. When there is excessive acidity, the tongue is broad and thick, sometimes filling the mouth, and, with the mucous membrane of the mouth, is pale. The tongue is flabby and easily indented with the teeth, and is coated with a moist, uniform white coat. When there is disturbed liver action, there is a yellow stripe in the center of the tongue, which may become brown. When there is extreme inactivity of the stomach under these circumstances, the white coat becomes heavy, and may be yellowish or dirty white in color. Where there is a deficiency of the acids throughout the system, the mucous membranes of the mouth are dark, the tongue is dark, and there may be only a slight brown coat in the center. When with deficient acidity there is extreme atonicity, the tongue becomes glazed, a violet or scarlet color, and is usually dry. When there is a deficiency of the hydrochloric acid only, I have observed the tongue to be nearly normal in appearance, with greatly elongated papillae, which are coated white on the tips, but show red at the base through the coating. When this disease is complicated with intestinal inactivity, and chronic constipation or intestinal irritation are present, the tongue may be very rough, fissured and indented and the papillae of irregular length.

There is usually a bad taste in the mouth; this is especially complained of upon rising in the morning. Nausea is not uncommon, and vomiting frequently occurs, especially in alcoholic gastritis, when it occurs before breakfast and causes a disgust for food.

Flatulence is a distressing symptom, and is a common cause of pain. Acute pain may occur immediately food is taken into the stomach, or it may not occur until gas accumulates, from one to two hours after eating. In other cases there is a tender, sore sensation in the stomach, increased on pressure, with increasing tensive pain, which occurs from two and a half to three hours after eating, or just before the next meal. This I have attributed in part to the immediate contact of the inflamed walls of the stomach, when collapsed after the expulsion of the stomach contents. Fermentation sometimes causes spasm of the pylorus, or a simultaneous spasm at both the pyloric and cardiac orifices. This causing the gases to be retained, may induce excessive distention, with severe pain. Palpitation from this distension, and in some cases from the presence of any quantity of gas, becomes a very troublesome and alarming symptom with many patients. I have especially found this true of neurasthenic patients, when the palpitation will induce extreme exhaustion, cold sweats, a rapid, irregular and easily compressible pulse, and apparently threaten a serious termination, alarming not only the patient, but the attending physician. From this exhaustion or extreme weakness the patient may be from two to six days in recovering. I have not observed any more serious results than this.

Other patients suffer from vertigo, exhibited in several forms. There may be simple dizziness or an interference with the vision, as from floating objects before the eyes or an impossibility to see but one-half of each object, or an obscuring of only that portion of the object immediately before the eye. I believe many of these remote symptoms are due to auto-intoxication from the absorption of toxins from the undigested, fermenting food and from the direct absorption of the gases.

From the imperfect character of the digestive fluids, and from inaction of the muscular coats of the stomach, the digestion of food proceeds very slowly, often food being vomited or regurgitated that was known to have been taken at least twenty-four hours previously. In other cases, either from the presence of undigested food or from muscular irritation inducing increased peristalsis, there may be a large, free bowel movement immediately after each meal, usually accompanied with colicky pain.

Another common symptom is dulness and drowsiness after eating. This is so great with some patients as to make it impossible for them to accomplish anything until they have taken a nap. This class of patients are those most likely to suffer from insomnia. They pass restless, sleepless nights, rise in the morning with considerable exhaustion, and suffer from more or less headache. This latter condition is very common among dyspeptics. It may occur after the taking of each meal, or when the food should have been digested and the stomach emptied, just before a meal, or there may be some dull discomfort nearly always present. With others the headache is paroxysmal. It appears once in from eight to fourteen days, and gives premonition of its approach by increased stomach disorder and eructations of gas, nausea and mental and physical depression. As the headache increases the patient vomits frequently, and nausea is more or less constant for a period of from one to three days. This is known as "sick headache." It is more common when there is excessive acidity than when the acids are deficient. Occasionally, as in intestinal irritation, a reflex cough is present, which is often a misleading symptom. These patients, as the disease persists, become irritable, morbidly sensitive, weak, indisposed to mental or physical exertion, hypochondriacal or hysterical, emaciated and anemic. Eruptions of the skin occur, among which furuncular eruptions, severe acne, eczema, lichen, urticaria and herpes are the commonest disorders.

It is of but little avail to undertake to cure these eruptions by local measures. Anders believes that if so cured, the gastric trouble increases. The cure of the stomach disorder, and ultimately of all the constitutional conditions which it has entailed, will be followed by amelioration of these eruptions, which will then promptly yield to local measures.

Diagnosis:—There are a few classic symptoms in this disease, in the absence of even a part of which it is difficult to differentiate between uncomplicated gastritis and other disorders of the stomach. The diagnosis depends largely upon the slow development of the disease, upon the presence for a long period of indigestion, with a sensation of fulness or apparent distention upon the taking of but little food. Upon examining the contents of the stomach, a large quantity of mucus is found; there may be either an excess or a deficiency of hydrochloric acid, with a great increase of butyric and lactic acid. Imperfectly digested food, or the products of the decomposition of food, will be found in the stomach at all times. It may be distinguished from gastric ulcer by the circumscribed tenderness and pain of the latter condition, with the occasional vomiting of blood. However, ulceration sometimes occurs during the course of chronic gastritis. From cancer of the stomach it may be distinguished by the fact that in this latter condition there is an excess of lactic acid and an absence of hydrochloric acid, and later by the vomiting of coffee-ground material. As cancer progresses there is usually local hardening and enlargement, with cachexia.

Prognosis:—In uncomplicated cases the prognosis is in every way favorable, provided the patient's co-operation with the physician in carrying out the curative measures is assured. Complication with constitutional dyscrasia or other severe organic disease, gastric ulcer or tumor, or cancer renders the prognosis doubtful or unfavorable.

Treatment:—Hygienic Measures.—Whatever measures are adopted in the treatment of this disease, three things are essential: First, the physician must have the complete confidence of the patient; second, the patient must be willing to faithfully carry out the instructions of the physician; and third, all habits of the daily life, either the domestic or business life, and habits of eating, which have exercised an influence in the causation of the disease, must be abandoned.

In severe cases it is necessary for the patient to have a complete change, as this condition is most common in people of sedentary habits. The careful adoption of a course of outdoor exercise is important. If the patient has had no opportunity for physical exercise, or has been using the mind at the expense of the body, as is quite common, much care must be exercised lest this should be overdone at the first. Walking, bicycling or horseback riding are the commonest recreations, but may easily be carried too far. In no case should the patient suffer much fatigue from the exercise. It can easily be adjusted to the strength of the patient and slowly be increased as the strength increases. One patient, of his own accord, purchased a quantity of cord wood and a wood saw, and beginning carefully, sawed and split enough wood each day only to meet the essential requirements of that day for physical exercise. He found this all-sufficient.

Patients suffering from mental exhaustion often will find complete relief of the gastric symptoms by leaving their work entirely and spending a few weeks, fishing, boating or mountain climbing. This has resulted in a complete cure in several cases under my observation. Bathing is important to these patients, but should not be overdone. Those of good vitality may obtain the best results from cold bathing, or from a hot bath followed by a cold shower. Those of poor vitality should have a medium warm bath, twice each week, followed by a salt rub. Lithemic patients of reasonable vitality should have a hot bath or a Turkish bath, with proper care protracting the perspiration as long as consistent without inducing exhaustion.

Where there is extreme soreness or tenderness in the region of the stomach, good results are attained by applying a cool, wet compress over the stomach at bed time, which should be covered by several thicknesses of a wool or silk bandage. In winter time patients suffering from this disease should be carefully and warmly clothed, as they are often deficient in power to resist cold.

An early examination of the urine is important in all cases, to determine the manner in which metamorphosis and elimination are taking place in the system, what the habits of the system are in elimination, and what is the condition of the fluids of the body at that time. Three of the constituents of the urine must be estimated upon—uric acid and the urates, the phosphates, and sodium chlorid. I believe there is a certain class of cases in which sodium chlorid is present in excessive quantity in the urine that would be materially benefited by omitting this substance from the food entirely for a period of from three to six weeks. If lithemia is present, this condition must be overcome; if the waste of phosphates is excessive, these must positively be restored to the system.

Dietetic Measures:—No measures that may be adopted in the treatment are of as much importance as the dietetic measures, and an arbitrary course with all patients alike is by no means advisable. An intelligent patient will soon have made observations which will be of importance to the physician in adjusting the diet, if he wisely allows himself to be guided by them. In severe cases it is a good plan to begin the treatment by a fast of from eighteen to twenty-four hours, permitting only water, or water to which a little milk is added. On the second day the patient may sip hot milk, and eat either a graham cracker three or four times during the day, or a piece of dry toast or zwieback.

If there is a scanty quantity of urine, with high specific gravity, I exclude meats from the diet for two or three weeks, and advise the patient to eat toast and non-acid fruits. These, however, may usually be selected according to the taste of the patient, advising those in season, when possible. One of my patients was cured by adhering to an almost exclusive diet of ripe grapes. At breakfast the patient should have a cooked cereal, or some palatable cereal food which he may select according to his own taste. Oatmeal is about the only cereal that I have found to be objectionable, and this may be readily appropriated with some patients. With others there may be times only when it is not digested. With this he should take some fruit, or a dish of sauce and a glass of milk; this may be drunk hot, if preferred.

Upon rising in the morning, the patient may drink a full glass of cold water, and perhaps eat a ripe apple. I have advised patients who were very weak to have a glass of hot milk, to which a pinch of salt was added, brought to the bedside when they were first awakened. This they should drink without the patient being disturbed, and lying quietly on the right side, he should compose himself to sleep for perhaps a half hour longer. This milk, passing into the duodenum, it is claimed, will be absorbed with ready digestion, and will impart much necessary strength and supply food that would require much effort on the part of the stomach later to digest. As the use of fluids during the meal is often detrimental, it is advisable for the patient to take a drink of water, if necessary, before each meal. The arbitrary rule which advises the taking of from eight to twelve ounces of hot water before all meals is usually a good one.

However much a patient dislikes to be put on a rigid diet when this simple course is suggested to him as preliminary, he will seldom complain at being obliged to follow it closely for a couple of weeks, at which time the observation of the physician will enable him to suggest a course which will be agreeable to the patient, and which may be followed indefinitely, or as indicated later. At that time the physician will adroitly enlist the patient's judgment to assist him in planning a beneficial diet. He should begin not by naming those substances which are to be excluded, but to name the most agreeable articles which are to be permitted. I believe it advisable with nearly all patients to permit a small quantity of food about once in three hours, with regularity, rather than insisting on three full meals each day. But few patients, unless the condition is very severe, will submit to this readjustment of the hours of eating.

If the patient becomes hungry from ten to eleven o'clock, he may have a few crackers, salted, or graham crackers, with a few sips of water. If he desires dinner at the noon hour, he may have a baked potato, and if meat and coffee are not excluded, a piece of roast beef which is devoid of fat, and some lettuce. He may drink a cup of coffee made by heating a half of a cupful of milk or cream and adding to this as much weak coffee, with sugar, to suit the taste. At supper time he may eat two or three soft-boiled eggs, another baked potato, if he desires, and fruit or sauce. This course should be varied on consecutive days, for three or four days, when he may return again to the same course. As stated, no prescribed method can be rigidly enforced. It must be adjusted to each patient. I have found many patients to be able to take a very light breakfast; late in the morning, a soft-boiled egg; an oyster stew or raw oysters, or carefully prepared sweetbreads, at noon. During the late afternoon he may eat a few crackers or drink a glass of milk, or take a dish of ice-cream, and may have his meat dinner at six o'clock, as advised above for the noon hour. When these patients are suffering from more or less debility or nervous exhaustion, restless nights or insomnia are not uncommon. I have found it of great benefit to allow them to drink a glass of hot milk or a bowl of hot beef tea, prepared from the extract of beef, to be taken with dry crackers or with graham crackers, the last thing before retiring.

The patient must learn that the condition of the mind has much to do with the digestion; that worry, anger, undue excitement, mental concentration and exhaustion will all interfere with the digestion. He must sit down to his meals free from all these things, must have an abundance of time, must eat slowly, and if possible with the pleasantest of surroundings, and, as stated, must thoroughly masticate the food. He must compose himself to quiet and rest after eating and must do no mental work. If inclined to dulness or sleep, there is no objection to taking a nap. In most cases with patients above middle life this is very desirable.

If the patient finds, after the physician has advised an article of diet, that it cannot be taken without discomfort or disturbance of the digestion, he is to avoid it until the physician can be consulted. On the other hand, if he finds that substances which the physician has advised him to avoid can be taken with relish, do not disturb the digestion and seem to him to be beneficial, he may partake of them sparingly until he can state these facts to the physician, who should be governed in his advice by the patient's suggestion.

It will be observed that some patients will do much better, not only in avoiding liquids at meal times, but in taking their food as dry as possible. I have found that with these, juicy meats are digested with difficulty, and soups and broths will produce much discomfort. With these I advise dry toast, a cooked or malted cereal, with the least quantity of milk or cream and dry meats. The thoroughly broiled thin slices of steak, or the outside cuts of roast beef or mutton, are preferable, avoiding pork and veal. I have found other patients who could eat chipped dried beef, either uncooked or cooked in thickened milk, or cold boiled tongue, without discomfort. Occasionally purees may be taken when thin soups are in every way objectionable. Broths are always preferable to soups.

Occasionally it becomes necessary to put the patient upon a milk diet alone for several days. This with me has occurred only in rare cases. When the symptoms have abated the patient may have broiled, tender beefsteak, rare, roast beef, roast mutton, and occasionally a limited quantity of roast turkey. He must avoid fried meats, boiled or fried chicken, all gross vegetables and fruits pronouncedly acid, pork and veal in any form, and all cured meats, except as stated. Hot bread, biscuits, griddle cakes, pastries, puddings and pies are detrimental, almost without exception. Rice, macaroni, tapioca and sago, properly cooked, will be acceptable to nearly all patients. Fats are to be avoided, with the exception of butter, which seldom produces discomfort; cream is acceptable to most patients, as well as buttermilk, whey and kumyss.

In the adjustment of food to the individual patient, during the treatment of this disease, it will be observed that food, objectionable either in taste or in its influence at one time will later become acceptable and beneficial; on the other hand, that which produces no discomfort for a period of time may finally become unpleasant and injurious. Again, other foods can be taken with relish and benefit at given periods, as once each week, or for two or three days at a time, every two weeks.

I have found cases where the stomach was exceedingly sensitive to any substance, with much severe pain, and when digestion was feeble and imperfect, to be greatly benefited by the application of a moist hot compress over the stomach, regularly after each meal, the patient lying down quietly the while, and if possible composing himself to sleep.

Medicinal Measures:—In the early stage of the treatment I endeavor to adjust an artificial digestive to each patient's individual necessities, so that as much as possible of the stress of the digestion be taken off of the stomach, and to insure the complete digestion of the ingested material. If an excess of the acids is present, as evidenced by the characteristic phenomena, the administration of from fifteen to thirty grains of sodium bicarbonate in one-fourth of a glass of water, twenty minutes after eating, will neutralize the excess of acids and promote digestion. When hydrochloric acid is deficient in the stomach, from ten to thirty minims to a full quantity of water may be given after eating, every half hour, until three or four doses are taken. Pepsin is of value in a limited number of cases. Pancreatin will materially assist in the digestion of fats, but is best given in conjunction with an alkali. It is available when there is distress from an hour and a half to three hours after eating. Takadiastase is of value in the digestion of starch. It prevents constipation, flatulence, malaise and vertigo. Ingluvin is of service where there is loss of appetite with persistent nausea and evident gastric irritation, and where with these symptoms the tongue is red, thin and pointed. It will be found serviceable when gastritis is present with pregnancy. I have found paw-paw to cover a larger number of these faults of digestion than any other one remedy. It may be given in either an acid or alkaline medium. It prevents fermentation, assists both in the digestion of starches and of fats. I have been able to relieve pain in the stomach more quickly with this remedy than with either of the others, when the pain was due to the presence of undigested substances.

Lavage of the stomach is a serviceable measure in some cases. In others it is detrimental. Its influence can be determined by a trial. If beneficial results are apparent, it may be repeated at longer or shorter intervals as seems desirable. If the benefits continue, it should be continued. If no benefits are apparent from its use, or irritation or other undesirable results occur, it should be repeated or continued with caution. The introduction of the lavage tube is disagreeable to most patients, but if they can be made cognizant of its benefits they will not seriously object to its repetition, until finally they become used to it. With some the sensitiveness of the throat is so great as to prevent its use. For this irrigation, plain warm water, or the physiological salt solution, or a dilute solution of boric acid, may be used. With weak patients, or where gastric ulcer is thought to be present, one volume of milk may be added to four or five volumes of water. Where the acidity of the stomach is extreme, a solution of calcined magnesia may be used and allowed to remain within the stomach for a short time.

The single remedy which I am inclined to think has exercised the most direct influence in the relief and cure of this disease is hydrastis canadensis. Almost the entire profession of Eclectic physicians will corroborate this statement. I have been able to persuade other physicians to use it, and have observed that their results were equally satisfactory. Any of the pharmaceutical preparations of the drug will exercise a beneficial influence. Where the case is of somewhat recent origin, from five to ten grains of the powdered drug may be given in capsules after each meal. Where there is dilatation of the stomach and muscular relaxation, I would give the colorless hydrastis, with a good fluid extract of hamamelis or collinsonia. Where there is ulceration, I would use hydrastin or the hydrochlorate of hydrastin.

Other fluid preparations of this remedy, or a well prepared elixir, can be administered almost ad libitum, but always with reference to its influence upon the individual patient. It very seldom if ever produces gastric irritation. For simple cases I have for years prescribed the yellow alkaloid of hydrastis—hydrastin or berberin—in capsules, with nux vomica, xanthoxylum, or capsicum, and perhaps a small quantity of the carbonate of iron. This combination has a very wide influence. It improves the function of the gastric glands, it corrects the secretions of the gastric fluid, it restores tone to the mucous membrane, it improves the tone of the nervous system, both locally and in general, and materially benefits the functional action of the large glandular organs, and restores the character of the blood.

A number of physicians attest to the power of hydrastis in its direct influence upon the digestion. The remedy is in no sense a digestive, but it improves and enforces the influence of all the other digestives.

When the tendency to fermentation is extreme, and the tongue is coated with a pasty yellowish or yellowish-white coat, the sodium sulphite or the sodium hyposulphite in doses of from five to ten grains should be given every three hours for a few days. When the outpour of mucus is large, bismuth sub-nitrate is indicated. It must be given in from ten to fifteen grain doses, of a pure salt, every three hours. Smaller doses at shorter intervals will not prove so satisfactory. It is indicated when pyrosis is an aggravating complication. Bismuth sub-gallate may be given in uncomplicated cases of recent origin. Strontium bromid may be prescribed in from fifteen to thirty grain doses every three, four or five hours, when with local tenderness, hyperacidity and flatulence there is a nervous irritability or excitability, with or without insomnia.

The pronouncedly chronic cases, with excessive hyperacidity, are especially resistent to curative measures of any kind. They represent an aggravated and intractable form of the disease. For these cases I have frequently advised Prof. H. K. Whitford's method, which, if correctly adjusted with auxiliary treatment, gives satisfactory results. He uses the following formula, carefully prepared, of the very best drugs:

Mix. Sig. From half to a teaspoonful of this may be given in two ounces of water, after eating.

When first used it may be given for a few days every three hours. Where the hyperacidity is extreme, an equal quantity by weight of pure sodium bicarbonate is added, and the remedy is given every three or four hours in about the same doses. When the patient is feeble or anemic, the precipitated carbonate of iron, in doses of one or two grains to every half dram of this powder, may be given. I have added capsicum or xanthoxylum in the real atonic cases with poor capillary circulation, and have been pleased with their action. This combination is not pleasant of administration, but it is so prompt in its action that the patient will take it after the first few doses without complaint.

In cases where excessive mucus secretion is persistent, with tenderness, or when doubt may exist as to the probable presence of a small ulcer, I am partial to the action of geranium maculatum. Ten minims of the specific remedy every two or three hours, which may, if preferred, be given in conjunction with hydrastis, will exercise a desirable influence, especially if the ulcer is actually present.

When a pyloric stricture with spasm is the cause of acute pain, a simple course will sometimes give prompt relief. Add fifteen drops of the tincture of lobelia seeds to four ounces of water, and give a teaspoonful every fifteen minutes until the pain has abated, which should not require more than four or five doses. Where torpor of the liver complicates cases of hyperacidity, especially if constipation results from the torpidity, sodium phosphate should be given in full doses. From ninety to one hundred and twenty grains of an effervescing preparation may be taken upon rising in the early morning, and thirty grains may be taken before meals. I have obtained good results from an elixir of hydrastis to which the tincture of leptandra in one or two minim doses is added, or the use of leptandra and nux vomica in a little port wine will be found to be excellent. In some cases chionanthus will be indicated.

For the diarrhea, or where there is colic and loose bowel movements after each meal, I have obtained excellent results from the use of five minims of Fowler's solution of arsenic, taken at the end of each meal. For the palpitation, which in a few nervous cases becomes an alarming complication, I use the tincture of ginger, or peppermint, or an infusion of capsicum, freely. For the nervous regurgitation of food occasionally present, from ten to twenty drops of specific eupatorium perfoliatum (boneset) every two hours has been sufficient.

Constant vomiting, which I have found to be rare, should be treated with free evacuation of the bowels, aided by a high colonic flush and careful gastric lavage. A mixture of one dram each of bismuth and ingluvin in three ounces of cinnamon water should be well shaken and given in teaspoonful doses every half hour, or hour for short periods.

As the total symptoms improve, careful tonic treatment should be adjusted to each patient.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.