# •V;'. jflTf^ilDalV.UI;1 . ' «: li::lJl;'*:!':>-"-Ji»UWJ» •„V U»'' r«t-r!rn-l:'t jC):yf.«!j::;:Jt«i:; fW\fmw^^'-m} ':'ll'C!iV;''!,' 'i.:!ia.-i:i: V^Y^ •'.I'.'ii . iCJfn'fl\g;'fifaViVi^\:!V(ii'iV:|-:t;>i 'Jli:iii!.t.-J l-i(i-::i:j'fi:r:ii!" :ii-il.V-'-|-ji;:i;:-.: 'f It V. i' ^lV./.1-'li|!,:t#!;i;\f; .:V i-,,'-iV ..,i''i.|-..'V,.:!-i,.;:i'ii.'!i'.yMi:;>.;i . 1*. • ■; f'--..^-.,w."i:":& (y j». ^W'-i^ ' •?■>*** ■ft^v.-.*- ■-'*i- '. '-.-, »■#&■; "■ ''//■'■'J DISEASES OF THE STOMACH. BY THE SAME AUTHOR. PATHOLOGICAL AND PRACTICAL OBSERVATIONS on DISEASES OF THE ABDOMEN. COMPRISING' those of the STOMACH AND OTHER PARTS OF THE ALIMENTARY CANAL, CESOPHAGUS, CECUM, INTESTINES, AND PERITONEUM. Third English Edition, Revised and Enlarged. Heavy paper, five lithographic plates, and other illustrations. Cloth, $5.00. /. ON DISEASES OF THE STOMACH, THE VARIETIES OF DYSPEPSIA, THEIE DIAGNOSIS AND TEEATMENT. BY S. 0. HABEESIION, M.D. Lond. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS J SENIOR PHYSICIAN TO, AND LATE LECTURER ON THE PRINCIPLES AND PRACTICE OF MEDICINE AT GUY'S HOSPITAL J ETC. THIRD EDITION* PHILADELPHIA: LINDSAY AND BLAKISTON 1879. WIA 1879 fiLlryy aJ0- l>tf76 , 7\t, I COLLINS, PRINTER. PREFACE. This third edition is now presented to the pro- fession in the hope that it may prove of practical value in the diagnosis and treatment of disease. It is now many years since I published some "Pathological and Practical Observations on Dis- eases of the Abdomen," a work which has now reached its third edition, in which I detailed the examination and investigation of numerous in- stances of disease; but it had been intimated to me, that my own experience, without these patho- logical observations, would be useful to the prac- titioner; and in the present volume, the result of many years of experience in hospital, as well as in private practice, is placed before the notice of my readers. There are some truths which are continually im- pressed upon the mind of the physician, and per- vi ' PKEFACE. haps none more forcibly than the importance of endeavoring to cure the patient, rather than of merely seeking to ' treat the disease. There is an unity of morbid as well as of healthy action in the living organism, for one part cannot be affected without the sympathy of the whole; and thus, whilst the present work is exclusively devoted to some clinical observations upon gastric disease in its various forms, I have sought to regard it in its general relation to other parts of the system. The careful analysis of individual cases has led me to follow that mode of grouping which is, I believe, truthful in its character, and most useful for diagnosis and treatment; to remove the cause of abnormal action is more effectual for the relief of the patient, than to attempt the alleviation of isolated symptoms of disease. 70, Brook Street, (hosvenor Square. CONTENTS. CHAPTER I. PAGE THE VARIETIES OF DYSPEPSIA : THEIR DIAGNOSIS AND TREATMENT 13 CHAPTER II. ON THE CHANGES OF DIGESTION AT DIFFERENT PERIODS AND CONDITIONS OF LIFE.......19 CHAPTER III. ON THE GENERAL SYMPATHY OF THE STOMACH IN DISEASE . 40 CHAPTER IV. ON THE SYMPTOMS OF DISEASE OF THE STOMACH ... 54 CHAPTER V. ON THE GENERAL TREATMENT OF DISEASE OF THE STOMACH . 107 CHAPTER VI. ON THE REMEDIES FOR INDIGESTION, AND THEIR AB0SE . . 112 CHAPTER VII. DYSPEPSIA FROM WEAKNESS: ATONIC DYSPEPSIA . . . 135 CHAPTER VIII. DYSPEPSIA FROM CONGESTION . . . . . .157 CHAPTER IX. INFLAMMATORY DYSPEPSIA ....... 166 viii CONTENTS. CHAPTER X. PAGE HEPATIC DYSPEPSIA . . . . . . . .185 CHAPTER XI. RHEUMATIC AND GOUTY DYSPEPSIA ..... 191 CHAPTER XII. RENAL DYSPEPSIA ........ 200 CHAPTER XIII. MECHANICAL DYSPEPSIA ....... 206 CHAPTER XIV. SYMPATHETIC DYSPEPSIA ....... 211 CHAPTER XV. FERMENTATIVE DYSPEPSIA ....... 227 CHAPTER XVI. DUODENAL DYSPEPSIA ........ 239 CHAPTER XVII. DEGENERATION OF THE STOMACH ...... 248 CHAPTER XVIII. ULCERATION OF THE STOMACH ...... 255 CHAPTER XIX. CANCEROUS DISEASE OF THE STOMACH ..... 285 CHAPTER XX. SPASM OF THE STOMACH—SPASMODIC CONTRACTION OF THE PYLORUS.........302 ON DISEASES OF THE STOMACH. CHAPTEE I. THE VARIETIES OF DYSPEPSIA: THEIR DIAGNOSIS AND TREATMENT. Although nearly every year new works have appeared on diseases of the stomach, still the mala- dies affecting this organ are so numerous, and of a character so diversified, that there is ample scope for the records of individual experience. It is not my intention to enter into the scientific and patho- logical bearings of gastric disease; this I have already done to a great extent in my former work on 'Diseases of the Abdomen.' My object in the following pages is rather to direct attention to the practical consideration of the subject, and to those divisions of a common disease which are brought under the daily notice of the physician. The opinions advanced are based upon facts educed in the clinical study of disease; and, if it had been 2 14 THE VARIETIES OF DYSPEPSIA : thought desirable, numerous instances might have been appended in support of every statement; we have preferred simply recording the result of our own experience, leaving each one to test by indivi- dual practice the correctness of our deductions. The organization of the human frame is so nicely and delicately adjusted that every part maintains its harmonious relation to the whole; and if the attention is called at any time to the performance of any of its functions, we may rest assured that the healthy state is disturbed, and that disease in some form, however mild, has already commenced, and demands the attention of the physician. Healthy digestion is performed unconsciously; and the phy- sical movements, the chemical solution, and the subsequent absorption produce no sensory pheno- mena. The replenishment of the natural wants of the system excites a consciousness of healthy vigor, and of capacity for new exertion ; and, as exercise produces waste, the demand for fresh material, by which the deficiency may be restored, is expressed by a healthy hunger, and by a thirst which-is soon satisfied. It is the function of the stomach to carry on the work of digestion; therefore, when indigestion arises, we must trace it to some cause by which this natural process is impeded. To enumerate all the THEIR DIAGNOSIS AND TREATMENT. 15 causes of dyspepsia we must trace the daily life of an individual from earliest years to advanced age; and not only must we note the external and physical conditions, but the subtle workings of the mind amidst its joys and sorrows, its gratifications and disappointments, its corroding cares and its seasons of buoyant happiness, its thirst for sensual enjoy- ment, as well as its highly intellectual pursuits. Were we to depict all the varieties of dyspepsia, we must comprehend every form from the trifling malady, which may scarcely be regarded, to those which are so severe as to rob life of its enjoyment; and even the same symptoms may in the one case be a mere temporary disturbance, and in the other they may indicate the commencement of serious organic disease; and, still further, the measures available in the treatment of these multifarious complaints are even more comprehensive than the symptoms; and were we to enter upon a minute detail of the whole subject, we must include the rules of hygiene, as well as- those of therapeutical practice; for the diet and the clothing, the exercise and rest, the air we breathe and the water we drink are most important; and not less essential are men- tal rest and discipline in their effects on the physi- cal organism. A full description of these remedial measures would lead us beyond our intended space, 16 THE VARIETIES OF DYSPEPSIA: and we must content ourselves with general indica- tions concerning them, still bearing in mind the fact, that they should never be placed in a position subordinate to the mere administration of medicinal substances. As dysphagia indicates impaired action of the oesophagus, so dyspepsia is a term applied to cor- responding defect in the stomach; and as the varieties of dysphagia comprise the diseases of the oesophagus, so the forms of dyspepsia include the maladies of the stomach. The want of gastric power cannot however always be designated dys- pepsia, for during the paroxysms of fever, as well as in the exhaustion of chronic disease, the stomach fails in common with every other part, and the local sign is almost disregarded in the general affection. We are fully aware of the danger attached to the special study of one class of disease; and we must ever be on our guard, lest in directing attention to the local symptoms we overlook the constitutional character of the malady. In my work on 'Diseases of the Abdomen' I arranged these affections of the stomach according to the physiological divisions, by referring to the various parts implicated, and then considered them in the following order:—1st. The dyspepsia arising from disorder of the mucous membrane of the stom- THEIR DIAGNOSIS AND TREATMENT. 17 ach and its secretion ; 2d. From an abnormal state of the vascular supply; 3d. From changes in the condition of the nervous system ; 4th. That arising from the muscular movements of the stomach being impeded; and lastly from improper diet, or from chemical decomposition taking place during the digestive process. My present intention is to enter into a more minute consideration of the varieties of the disease as observed in daily practice. The first that we shall notice is dyspepsia from weakness, whether from general imperfect nutri- tion and diseased vessels, or from exhaustion of the cerebro-spinal nervous system, or from failure of the nerve of organic life ; atonic dyspepsia, as it might aptly be termed. 2d. Dyspepsia from congestion, as observed in chronic disease of the lungs, heart, and bronchi, and also in chronic disease of the liver. 3d. Inflammatory dyspepsia, whether arising from irritants, excesses, or improper diet. 4th. Hepatic dyspepsia, or " bilious indigestion." 5th. Eheumatic and gouty dyspepsia. 6th. The dyspepsia connected with disease of the kidneys. In the varieties of dyspepsia thus alluded to, the mucous membrane and its secretions are espe- cially affected, there being either deficiency or ex- 2* 18 THE VARIETIES OF DYSPEPSIA. cess in the gastric juice, or its character being changed by defective secondary assimilation or continued congestion. We shall then describe, 7th. Dyspepsia from mechanical interference with the muscular movements of the stomach. 8th. Nervous or sympathetic dyspepsia. 9th. Dyspepsia from fermentation of, or chemi- cal change in, the contents of the stomach, and, 10th. Duodenal dyspepsia. Still further we shall refer to it as a symptom of more serious organic diseases, as ulceration and cancer. In the earlier stages of these diseases the only indications of abnormal action are of a func- tional character, and a correct prognosis then re- quires the closest investigation and a full know- ledge of disease in all its relations. ON THE CHANGES OF DIGESTION. 19 CHAPTER II. ON THE CHANGES OF DIGESTION AT DIFFERENT PERIODS AND CONDITIONS OF LIFE. The phenomenon of life does not present an un- varying series of actions, nor the constant repetition of the same living functions performed in an iden- tical manner; but we find in vegetable, as in ani- mal life that there are stages of existence and phases of development ever changing and progres- sive in their action. In the first germ of the seed plant there is living growth of a peculiar kind, namely, the gradual formation of the germ leaf, the cotyledon, and of the rudimentary root; and, at the same time, a supply of nutriment is stored up for the period of independent and separate existence; there is a vitality in the seed which may exist for an almost indefinite period, till, by the application of the needed stimulus, fresh changes take place of an entirely different character in connection with the sprouting of the seed; then for a time, another stage of vegetable life follows, that of growth and 20 ON THE CHANGES OF DIGESTION development. But, with the growth of the plant there are cyclical changes daily and hourly evolv- ed, and in those plants of an exogenous kind each year witnesses remarkable variations, for the leaves, having fulfilled their purpose, their circula- tion becoming occluded, they fade and fall; but on spring returning the old stock is not in the same condition as before, for the past year has left its trace; so with each yearly cycle, till at length more general decay occurs, and the old weather- beaten stock, that has withstood the stormy blasts of many a winter, succumbs and dies. With equal distinctness of demarcation do we find that human life has its stages; we have in- fancy and youth, succeeded by manhood in its strength and prime, and then the gradual fading of the powers, first the physical, and then the in- tellectual ; but the differences impressed upon the whole organism at these respective periods are ac- companied with a physical state also changing, and the one is dependent upon the other. A child, with its freshness of thought, the wildness of its imagination, and the quickness of its new powers, has a brain structurally differing from that of the old man, with his maturer thoughts and his calmer reason, whose brain is acted upon by the impres- sions stored up in the memory, rather than by new AT DIFFERENT PERIODS OF LIFE. 21 objective observations. The elasticity of the youth- ful step, and the enjoyment of vigorous exercise, are marks of strength of lung and power of circu- lation, which an octogenarian does not possess; and not less apparent are the functional peculiarities of digestion during the different periods of life. During the earlier months there is the greatest activity in all the functions of life; the nervous system is very easily disturbed, the muscles are readily excited to contraction and convulsive move- ment, the respiration is more hurried, and the heart beats with greater frequency, 130 to 140 as com- pared with 60 to 80 of adult life; the temperature of the body is more variable, and there is less ability to resist sudden changes. The helplessness of infancy, and its entire de- pendence on the fostering care of others, is con- nected with a delicacy and sensibility in the organ- ism, which is easily acted upon, and is adapted only for peculiar conditions. The physical organization of an infant is designed for fluid food, and for its reception in a particular manner, namely, by suc- tion ; although destitute at first of teeth, the mus- cular development of the mouth is sufficiently complete, and the clavicle, more ossified than any other bone, serves as the support for the arms and hands, which are secondary helps in the process. 22 ON THE CHANGES OF DIGESTION An infant is only able to digest substances of the simplest kind ; and milk, the natural form of diet, is best suited for its wants. Milk not only con- tains hydro-carbonates, the oily part or cream, and sugar, also a heat-supplying material, but a large quantity of nitrogenous substance, the casein, and in proportion as the diet approaches this standard, is it suited for its especial purpose. Mere starchy foods, such as arrowroot, rice, the ordinary corn- flour (washed maize), only contain one ingredient of the infant's food, and are not sufficient to main- tain health and to promote growth. Dr. Edward Smith, in his work on ' Cyclical Changes during Health and Disease,' has well shown, that during infant life "there is the maximum of oxidation of the elements of nutrition, and the maximum of highly organized food supplied;" and assuming three pints- of milk as the quantity taken by an infant, he estimates that the food taken is, in pro- portion to the weight of the body, three to six times greater than that taken by adults. A method could scarcely be conceived fraught with greater mischief to infant life and health, than the admin istration of hard and solid food, especially when stimulating drinks are added. Too often do we find that great irritability of the mucous membrane of the stomach and other parts of the alimentary AT DIFFERENT PERIODS OF LIFE. 23 tract is .set up by injudicious diet. Vomiting and diarrhoea, feverish and convulsive symptoms, fret- fulness and peevishness, wasting and general ex- haustion, are found to follow these gross departures from the rules which have been naturally laid down for infant life. Another peculiarity of infant re- quirement is that the supplies of nutriment must be frequently given. A healthy vigorous infant should be fed every two or three hours, and if there be weakness or exhaustion, the period must be lesssened to intervals of an hour, or even one quarter of an hour. It is a mistake even during the hours of night to allow a very young infant to sleep too long without food. In the absence of the mother's milk, the ordinary substitute is cow's milk, with one-third of water, and a small quantity of white sugar; if the mucous membrane be very sensitive, ass's milk is a better substitute ; goat's milk often agrees very well, and the so-called Swiss milk ; and as the child passes from month to month, its food should be thickened by the addition of some cereal grain; the best are the preparations from wheaten flour, " tops and bottoms," Robb's biscuits, dried flour, biscuit powder, etc.; but, however the food may be prepared, it is essential that it be free from any hard portions, which would be less easily acted upon by the digestive organs. Chicken-broth, beef- 24 ON THE CHANGES OF DIGESTION tea, are gradually added to the infant's dietary, then yolk of egg, bread and milk, etc. If too long an interval is allowed to elapse, then a greater quan- tity is given at one time than can be easily digested; for although digestion is more active than at any other period of life, it is more easily disturbed; food is also absorbed with greater rapidity, and the eliminated products, as urea, are excreted in larger proportionate quantity ; but if, on the contrary, the process be checked, rapid prostration and emacia- tion ensue, and in a few hours infant life may thus be reduced to its lowest ebb. Many of the preparations sold as infant's food are destitute of its most important ingredient, and con- sist merely of starch. This is insufficient for healthy growth, and unless a large quantity of milk be added to supply the deficiency, the health is im- paired. So sensitive, indeed, is the infant organism, that after a few hours of severe diarrhoea an infant becomes cold and almost pulseless, its countenance is haggard and wasted, its muscles are flabby and soft, and unless the cause of exhaustion be checked life will quickly cease; the passage of coagulated milk through the pylorus will sometimes suddenly produce collapse, resembling that which follows the administration of an irritant poison. Again, a few doses of an exhausting remedy, such as tartar AT DIFFERENT PERIODS OF LIFE. 25 emetic, will render an infant pale and prostrate, and in not a few instances it will destroy life; for al- though the vaso-motor nerve is more active than at any other period, its power more quickly ceases. The same excessive irritability is found in the cerebro-spinal system of nerves; thus, a small dose of a narcotic such as opium suffices to induce fatal convulsions; and just as a child walking alone more easily falls when the foot trips, because the height of its centre of gravity is less, and the radius of the circle described by that height as a radius is smaller, so the circle of the living functions in an infant is also smaller, but performed with more rapidity, and with greater facility are those cyclical move- ments disturbed in their course. The condition of the glands connected both with primary and secondary assimilation are undergoing remarkable changes during the earlier years of life. The liver, a gland notoriously connected with the digestive process, is relatively much larger during infant life than at a subsequent period; before birth its proportional weight to the rest of the body is said to be as 1 to 18, and at about four or five years of age it attains the proportion which is afterwards maintained, that of 1 to 36. The mesenteric glands are very large and distinct; they are more vascular than at any other period of life, and their function 3 26 ON THE CHANGES OF DIGESTION appears to be connected with the elaboration of the chylous fluid after absorption by the lacteal vessels, and prior to its discharge into the blood. If a non- nutritious diet be administered, low organized or strumous product is very prone to occur in these parts, and the same result is found if the system be exhausted from other causes. Again, stimulants and irritating food so disorder the mucous mem- brane, that acute hypersemia in these mesenteric glands quickly follows. The glands may even be felt through the abdominal parietes, and when diarrhoea and general exhaustion exist at the same time, the malady is very apt to be mistaken for organic and incurable "tabes;" and although the enlargement may be merely hyperaemic, there is great liability to the deposition of an organic pro- duct of a strumous kind. If health be restored, the old diseased glands will be found in subsequent years as a semi-cretaceous mass. In youth, whilst growth is rapidly advancing the digestive organs are taxed to furnish materials not only to maintain ordinary wear and tear, but to supply that which is needed for additions to the frame ; and if the blood be rendered unhealthy, and growth impeded, then there is a greater tendency to the deposition of tubercular product, and all its attendant degenerative changes. Many instances AT DIFFERENT PERIODS OF LIFE. 27 of consumption have arisen from the nourishment during months of residence at school being of an improper kind, or so unsuited to the taste that it was altogether refused; functional integrity soon becomes disturbed, growth is defective, and low organized deposit takes place under a very slight exciting cause. A large quantity of suitable nour- ishment is essential at this period for the natural activity of youth and the healthy development of the frame, as much as the system can digest and assimilate; whilst stimulants, and a diet which panders to the appetite rather than supplies requi- site material for the growing organism, should be avoided. In an ordinary state of health malt liquors and wine are both unnecessary and injurious ; and if the system be exhausted by disease, more than usual care is required in their administration. During the strength of manhood there is less energy, but greater uniformity in the process of digestion. The development of the system has attained its maximum, and the functional activity is less powerful than during infancy and youth, but more so than in the declining steps of advanc- ing years. The lungs are fully developed, and the larger quantity of air inspired, and of carbonic acid exhaled, indicate a condition of system capable 28 ON THE CHANGES OF DIGESTION of bearing vicissitudes of temperature more easily. Longer intervals suffice to elapse between the meals, and larger quantities are taken. Dr. Edward Smith has educed some very interesting facts especially bearing upon digestion in ordinary adult life, that "in the morning hours digestion and assimilation are performed in their most natural and therefore most healthful manner, and that period especially de- mands an abundant supply of nutriment;" and to quote again from the same talented author, " that the rate of pulsation and respiration, and the evo- lution of carbonic acid were found to be the great- est in one or two hours after breakfast, and at about four or five hours after the meal it was re- duced to the lowest point of the working day, a point about ten pulsations higher than that of the lowest period of the night." But although diges- tion is more active at the earlier part of the day, and least so in the evening, still it is an unwise plan for those who are engaged in pursuits involv- ing much intellectual and physical fatigue to allow the whole afternoon and evening to elapse without partaking of some sustaining diet: it is not suffi- cient to take- a substantial mid day meal without * anything of a really nourishing kind afterwards, for the sleep is less refreshing, in consequence of greater exhaustion during the night. The pro- AT DIFFERENT PERIODS OF LIFE. 29 cesses of digestion are often, and that very impro- perly, lost sight of, and doubtless much irregularity and indiscretion are borne with impunity; still the penalty is afterwards paid; irregularity and excess cannot be continued without future detriment; and many of the forms of severe dyspepsia are produced and perpetuated by inattention to the simplest rules of diet or regimen. The quantity of food required by the system ranges from twenty-two to forty or even forty-five ounces of solid food, and eighty to ninety-five ounces of fluid. The solid part must contain albu- minous substances, fatty substances, also carbo-hy- drates and salts, the second and third forms being especially used in the system for maintaining ani- mal heat. Still, these alone will not suffice, unless some fresh vegetable food or fruit be commingled; and we frequently find that disease is caused or aggravated by the avoidance of vegetable diet altogether. This fact we have often witnessed in those who, from actual or supposed weakness of the stomach refrain from all fresh vegetable sub- stances as requiring greater digestive power. Dr. Parkes, in his work on 'Hygiene,' quoting from Moleschott, gives the following table, as show- ing "the water and food required daily for a work- ing man of average height and weight;" but in 3* 30 ON THE CHANGES OF DIGESTION those who take more generous diet, the albuminous and fatty substances may be half as much more:— Grammes. Ounces avoir. Albuminous substances . . 130 4*587 Fatty.....84 2-964 Carbo-hydrates . . .404 14 257 Salts.....30 1-058 648 22-866 Water.....2800 98-580 3448 121-446 and again, that 104 grains of nitrogenous substances equal to 3-671 ounces is the lowest amount a work- ing man ought to have. The least amount for active life, according to Dr. Parkes, is 1*4 to 1*5 ounces of dry nitrogenous substance ; but when the quantity is thus reduced, both weight and strength are lost. Still the quantity and even the quality of the food may be all that is desired by the physiological chemist, but the stomach may refuse to receive it,' or to deal with it in a friendly manner, because the palate is offended, and the sameness and character of the diet is opposed to the tastes and wishes of the patient; the idiosyncrasies of diet are best known to individuals themselves, and in abnormal states of disease these peculiarities become marked with increasing distinctness. AT DIFFERENT PERIODS OF LIFE. 31 In advanced years the activity of life gradually lessens, and the physical organization presents cor- responding change. The arterial vessels which carry the supply to every gland gradually become opaque and rigid; the glands themselves waste, and are comparatively inactive; and although the higher powers of mind and thought may still re- main in their full strength, it is impossible to hide the habiliments of age. The drier and more shrivelled aspect of the skin is an indication that the minute sudoriferous glands are inactive; and the mucous membrane of the alimentary tract, a mere inversion of the external investment, is like- wise wasted, it becomes much thinner, its glands smaller, and in fact the mesenteric glands are with some difficulty found; the same mesenteric glands which during earlier life are so essential in the elaboration of the chyle, before it is poured into the blood. The digestive process is feebler during advanced life than at any previous period ; and this lessened functional power is accompanied with an inability to take the same vigorous exercise as formerly. During the strength of earlier life, when the respiratory act was in its full energy, it would seem that effete materials could be rapidly removed, and at the same time warmth and heat maintained; in age the cycle of functional life slowly revolves, 32 ON THE CHANGES OF DIGESTION till it ceases altogether, or is stopped by the slight- est impediment. The actual condition of the stomach itself in its atrophied glands expresses the fact of lessened power; the muscular coat is often wasted, unless there be some impediment to the passage of food at the pylorus or elsewhere, when the increased power required is followed by hypertrophy. There is a marked contrast in the condition of the involuntary fibre of the alimentary tract in early and advanced life; in the former period contraction is readily induced, and the stomach at once empties itself by vomiting ; so also the intestines hurry on their con- tents, producing diarrhoea; and muscular contrac- tion will even impel one part of the intestine into another, causing intussusception; in the latter period, flatulent distension takes place from the lessened contractive power; and the distension becomes a cause of constipation, dyspepsia, and of general distress. The sacculi of the colon and the appendicse epiploicas become enlarged and unable to empty themselves, and concretions form in the bowel, although natural relief may daily take place. The mucous membrane is more vascular, the valvulse conniventes and villi of the intestines are in their full activity in early life; but in age the arteries are diseased, the circulation sluggish, and AT DIFFERENT PERIODS OF LIFE. 33 the absorbent system wasted and comparatively inactive. We find, also, that in age the pancreas has a larger quantity of fibroid tissue, as another indication of ceasing energy. The liver and kid- neys undergo like changes; and still further, in the examination of the large central ganglia of the sympathetic, there is a manifest difference in the appearance of the cells at the extremes of life* for in old age the cells are dark, and often loaded with pigment, as if the vital mechanism were gradually coming to a state of rest. The diminished energy requires that the supply of food should be more constant, and that long intervals should not elapse: it is often noticed that headache, disturbed vision, and symptoms resembling threatening apoplexy or paralysis, arise from an insufficient nutrient supply ; and the mistake is sometimes made of exhausting by powerful purgatives, mercurials, or even actual depletion, when ammonia or stimulants would be more appropriate. Some of those who have attained to advanced age are very unwilling to depart from the habits of earlier years ; it is with them very important that, during the hours of the night some bland nutriment shoul'd be taken, if there be wakefulness; and al- though late heavy meals are very undesirable, still the exhaustion which comes on during the hours of 34 ON THE CHANGES OF DIGESTION the night is often followed by impeded circulation and faintness. It is thus that the heart, during the night, not very rarely ceases in its action altogether ; and the man who had retired to rest without any consciousness of danger is found in the morning lifeless. It is equally injurious so to excite and oppress the system by improper diet and stimulant, as to endanger the integrity of the minute ossified vessels of the brain, and thus cause an apoplectic attack. In advanced life sudden changes and excitement are borne with great difficulty, and as in the earlier years, exhaustion is easily induced; with steady and slow pace the revolutions of functional work may move on, but with any violence to the system the powers of life will cease altogether. In old age, as in infancy, we find that some re- medies must be used with great caution, thus mer- curials and powerful purgatives more easily cause great depression ; and it would seem that opium will so act upon the urino-genital organs, as to pro- duce retention of urine. The atrophied condition of the glandular organs connected with the stomach, to which we have al- ready referred, and the weakened digestive power, render the use of condiments sometimes of great service, and the stimulating effect of wine rightly AT DIFFERENT PERIODS OF LIFE. 35 administered assists in the maintenance of health. These agents, which in infant life irritate and dis- turb, now give that additional stimulus which the fading powers of life require. There are some conditions of ordinary life which require notice, for the digestive process is in them strangely modified, and the whole system sympa- thizes with the important processes that are being carried on: we refer to pregnancy and to lactation. The former state induces remarkable changes in the vaso-motor or sympathetic nerve of the abdo- men. There is the closest union between the uterus and the stomach. A state of irritability is frequently induced, so that the stomach rejects its ordinary supply, and it does so especially in the morning, the period at which digestion is generally most active. This irritability of the gastric surface is sometimes so severe, that all food is rejected quite independent of mere pressure on the viscus ; the months of gestation are periods of wearisome- ness and distress ; the gastric disturbance, however, at once ceases on delivery. In some cases the dis- turbance of the stomach has been referred to the secretion from the kidneys becoming disordered and changed, and this in some instances is doubtless an aggravation of the symptom. Again, direct pres- sure greatly increases the distress of this kind, but 36 ON THE CHANGES OF DIGESTION neither of these conditions suffices to explain the state we refer to; it would seem as if the large nerve ganglia supplying the abdominal viscera were disturbed by the greater energy of the uterine plexus. Again, there are those in whom conception at once removes all symptoms of indigestion; so that pain and flatulence, which for many months previously had induced indisposition, are no longer felt, and there is the enjoyment of health and strength not experienced at other times. Unfortu- nately in some of these instances one trouble returns as soon as the other trouble is over, and before physical strength has been thoroughly regained, the digestive process is again impaired; the uterine activity of function seems to induce equable and healthy action of the stomach. But, although there may be irritability of the stomach, digestion is often sufficiently active, and the symptoms are actually relieved by partaking of nourishment. It would seem as if the gastric juice were secreted in excess, for the sickness and heart- burn, etc., may be relieved by a little bread or biscuit. These facts tend to show that the closest sympathy exists between the stomach and the uterus. Care should be taken as to the diet at this time; nourishment without excess, especially in stimulat- AT DIFFERENT PERIODS OF LIFE. - 37 ing beverages is more likely to be followed by healthy and vigorous offspring, and by the more easy completion and recovery from parturition itself. After delivery, the digestive process soon becomes more than usually active ; and skilful accoucheurs of the present day have ceased to follow the starva- tion system, as if child-bearing were a state of active disease. In most instances, however, it is well not to excite the system by a too generous diet, nor by stimulants, whilst absolute rest of mind and body is the state most conducive to speedy restoration. The activity of digestion during lactation is often very remarkable, and a generous diet is to many persons essential, if nursing is to continue. Although too much stress has sometimes been laid upon substances as likely to be injurious to the new-born babe if partaken of by the mother, there is no doubt that the milk is very quickly changed by both food and medicine, and the infant may be in this way influenced beneficially or otherwise. As to medicines, saline aperients taken by the mother become absorbed into her blood, and enter the milk, the infant thereby suffering pain and diarrhoea. Opium is said also to influence the child, but this has doubtless been exaggerated. In an instance of a lady a few weeks after confinement, 4 38 ON THE CHANGES OF DIGESTION. to whom the hyposulphite of soda had been given in solution to relieve excessive flatulence, the medi- cine, in itself nearly tasteless, soon showed its char- acter by producing sulphurous eructation, so that the mother maintained she had taken sulphur, and the infant suffered griping pain and vomiting, the vomited milk also smelling of sulphur. Numerous instances might be adduced to show how easily the infant is thus affected, although the parent might be quite unconscious of any disturbance in her own system. Each period of life has its own peculiarity stamped upon it, and when the natural rules of health are broken through, the result is soon experienced in a general disturbance of the system. These periods may be regarded as climacteric in their character ; gradually the boundary lines are passed as years revolve, and as each succeeding step is attained. The term climacteric is often especially made to that time in female life when menstruation ceases. Andral and Gavarret have stated that the carbonic acid evolved during the catamenial years remains the same, and on the cessation that there is for a time a slight increase of carbonic acid evolved. However this may be, there is no doubt that a marked change in the system takes place, and symptoms are produced due to this organic altera- AT DIFFERENT PERIODS OF LIFE. 39 tion. The gastro-intestinal tract sympathizes in the changes, as well as the nervous and circulatory functions; headache, sense of oppression, flushes of heat, throbbing of the heart, sometimes irritability of the stomach and bowels, are often induced. The time ranges from 45 to about 53, and imperceptibly passes into a condition of more uniform health; then for several years an almost stationary condition is attained, gradually passing into the period of old age. In men the commencement of old age is often- times marked by indications of change that have also received the name climacteric, but commencing at a somewhat later period, 53 to 60 or from 56 to 63—a time of unsettled health—at the close of which a sort of equilibrium is again attained, unless organic disease has already sapped the remaining strength. 40 ON THE GENERAL SYMPATHY CHAPTER III. ON THE GENERAL SYMPATHY OF THE STOMACH IN DISEASE. It is the tendency of the clinical study of any isolated class of disease, or of the affections of any particular organ, to exclude the consideration of other portions of the body, as if one part could be separated from the other. The nervous system is so connected with every individual structure that ; it sympathizes with changes in any of them, and may be thrown into a state of general disturbance by a comparatively trifling injury. The important function of respiration becomes affected when there is general febrile excitement; and in some func- tional diseases of the nervous system the respira- tion becomes as rapid as the pulse. Again, the central organ of the circulation, the heart, is equally susceptible of changes induced by sympathy with other structures; but it is not the mere fact of organic and functional sympathy to which we would draw attention, but to the equally important fact that the sympathy of one part with another is not OF THE STOMACH IN DISEASE. 41 equally intimate. This truth will be more apparent if we consider what is meant by this term of sym- pathy, and what are some of those means by which in the human frame it is brought about. By the word sympathy we mean that an organ of the body may become functionally disturbed by irritation of a structure external to itself: in this way severe pain and abnormal sensation may be induced in parts far removed from the original seat of disturb- ance. This sympathy will be generally found to be regulated by one of three things,—1st, it is in proportion to the direct nervous connection of one part with another; 2d, it is in proportion to the connection of function'; 3d, it is in proportion to the mutual dependence of one organ on another for its vascular supply. Amongst these sympathetic affections arising from disease of the stomach, we will first notice dis- turbances in the cerebrospinal system, and these sym- pathetic symptoms may be arranged as follows:— Affections of the cerebrum, by which the mind, the memory, and the perceptions are changed. Of the senses, so that the sight is perverted, the hearing disturbed, the smell changed, taste rendered unnatural, and ordinary feeling altered from its normal condition. 4* 42 ON THE. GENERAL SYMPATHY Of the spinal system, so that irregular muscular movements are produced by gastric irritation. Affections of the cranial and spinal nerves, indu- cing pain or numbness in the head itself. The mind is dependent for the fulfilment of its ordinary phenomena upon the functional integrity of other parts. The organism by which the mind operates is easily disturbed, and it has long been acknowledged that the stomach easily affects thought and judgment, reason and memory. Whilst digestion is going on, the mind is less active, whether the effect be due to a larger quantity of blood being sent to the stomach, or to the blood being altered by the influx of new material; and in states of exhaustion, the slight additional disturb- ance to the vaso-motor and cerebro-spinal system of nerves is sufficient to induce a sense of faintness, giddiness, or of actual syncope. If the contents of the stomach be difficult of solution, or of a too stim- ulating character, these cerebral modifications are still more manifest; and if such be the case in ordi- nary health, during dyspepsia the faculties of the mind become more evidently disturbed. Mental oppression, and an inability to exert thought with the ordinary energy, is a common symptom, and the powers of reason and judgment often become perverted. The hypochondriac sees everything OF THE STOMACH IN DISEASE. 43 under an erroneous aspect, and forms his judgment accordingly. The manner in which the senses are disordered by gastric disturbance is very remark- able. The functional alterations of the sight are not always identical. There may be a general hazi- ness, but more frequently sight is perverted by ir- regular vision or partial obscurity, so that only part of an object is discerned, or irregular zigzag lines are noticed, or spots of an object become quite indistinct, or half a word is discerned ; again sparks of light may be perceived, or dark floating specks be seen, or even the color modified. To some patients one or other form of disturbed vision is the certain effect of disordered digestion, and the kind of attack is recognized by the character of per- verted visual phenomena. Some care is, however, required, lest the symp- toms of commencing organic disease of the eye— such as the various forms of amaurosis—be as- cribed simply to mal-assimilation. We have known instances where most valuable time was in this way lost, and measures which might have greatly re- tarded the organic changes in the retina needlessly postponed, till irreparable mischief had been done. The sense of hearing is not less easily disturbed, and the perception is either generally diminished, and partial deafness induced, or there is noise in the 44 ON THE GENERAL SYMPATHY ears of various kinds and degrees,—singing or whistling, humming or droning, the noise of bells, of steam, of falling water ; sometimes the sensation is compared to throbbing, to pulsation, and to " tick- ing" like a watch in the ear, etc. These symptoms sometimes become extremely distressing, but are frequently of a purely functional character, and, although not the only cause, the stomach is often greatly at fault in these cases. States of anaemia, and exhaustion, and organic disease of the ear itself, must be regarded in an altogether distinct category. The sense of smell is less easily recognized as undergoing change from stomach disturbance ; and the sense of taste is perverted oftentimes in a direct manner by change in the buccal secretions; thus, during indigestion, the'natural alkalinity of the saliva is lessened, and patients often complain of a sour or bitter taste in the mouth. But beside these, there are other changes more directly affecting the gustatory nerve; substances are said to taste differ- ently, and this sense is sometimes almost benumbed. The sense of touch and ordinary feeling is often strangely implicated in functional disease of the stomach. Thus in many cases a general extreme irritability of the cutaneous nerves is induced, or especially the nerves supplying the palm of the OF THE STOMACH IN DISEASE. 45 hand and the sole of the foot; but beside these there are local affections arising from gastric disturbance of a sympathetic kind, but probably due to direct nervous connection; the little and ring fingers be- come painful and hypersesthetic in indigestion. This affection is due to the closer connection of the sympathetic nerve with the ulnar, which supplies those fingers, rather than with the median; a local pain, about one inch in superficial extent, is often complained of below the left mamma, and this is to be attributed to the splanchnic nerves, which are the large nerves of the semilunar ganglion, and thus connected with the stomach; the splanchnic nerves have their origin from the lower dorsal nerves, commencing with the 5th or 6th, and these dorsal nerves also send sensitive branches below the breast. Again, the sense of oppression and weight across the chest in indigestion is of a sympathetic kind, and is explained in a similar manner. But not only do we find hyperesthesia induced thus sympa- thetically in gastric disease, but also anaesthesia, so that the fingers may become transiently benumbed. Other parts of the nervous system are intimately connected with the stomach. We have already referred to hyperaesthesia, local or general, and to conditions which might be mistaken for commenc- ing paralysis; but still more grave sympathies are 46 ON THE GENERAL SYMPATHY found, especially in young subjects, or those in whom the nervous system is easily disordered. Crude semi-digested food in the stomach has often been the exciting cause of violent convulsions in children : it would seem as if the connection was so intimate, that the peripheral irritation in the stomach sufficed to produce the most severe convul- sive movements of a general kind, even epileptiform in their character. Of a distinctive kind, but differing from the sym- pathetic affections already noticed, are the pains in the head, in the course of the branches of the 5th nerve, at the forehead or vertex, or in the lines of distribution of the branches of the 2d and 3d cervi- cal nerves at the sides of the head and at the occi- put. It is common enough to have severe frontal headache, as the effect of excess and consequent in- digestion ; but in numerous other instances pain in the head is induced, sometimes at the forehead, or on one or other side, or centrally ; in many cases of exhaustion, with feebleness of digestive power, the pain is at the vertex; and in others, especially of a rheumatic and gouty character, the pain is at the occiput; when lateral, it has been designated hemi- crania; with some a sense of coldness of the head is induced. It is a common symptom of dyspepsia to find OF THE STOMACH IN DISEASE. 47 abnormal sensibility in the branches of the 5th nerve supplying the face, and the branches of the 1st division are more frequently affected than the others; thus itching of the nose, pain in the eye, etc., are familiar illustrations of the fact. As to the converse of these symptoms, numerous cerebral diseases induce gastric irritation and change. After concussion of the brain a very common symptom is violent vomiting; and some of the most irritable conditions of the stomach we have ever witnessed have arisen from abscess in the brain. In threatening hydrocephalus of children the stomach is often disturbed, and the dangerous—nay, even fatal—mistake is made of considering a terri- ble disease as a trifling " bilious attack ;" and when this inflammatory disease has become severe, it is often noticed that the least attempt to raise from the recumbent position is followed by violent vomit- ing. The same symptom is observed in tubercular disease of the brain and in tumors. Again, during the premonitory symptoms of apoplexy, especially in some of the more severe forms, vomiting comes on. Another instance of this sympathetic connection between the brain and the stomach is shown in mental disturbance and anxieties. Bad news will entirely destroy the appetite, and great mental dis- 48 ON THE GENERAL SYMPATHY tress places the digestive process almost in com- plete abeyance. In mania the appetite is changed, digestion altered, the bowels confined, and some- times the strangest substances are swallowed. The connection of the stomach with the lungs and heart may be regarded in a threefold as- pect :—- 1st. As it regards the entrance of nutriment into the system : if, from irritability or inability to re- ceive the supply required for the maintenance of health and strength, the blood becomes impover- ished, then tubercular disease in the lungs or glands is more readily produced. 2d. In reference to the nerve supply to these several parts : the pneumogastric, one of the most important nerves in the body, from the character of the organs to which it is directed, is largely dis- tributed, both to the stomach, the lungs, and the heart; and in addition to this, the connection of the large semilunar ganglia, which sends branches to the stomach and abdominal viscera, is a very in- timate one .with the pulmonary and cardiac ganglia of the vaso-motor nerve. 3d. The action of these important structures, the lungs and heart, in the circulation of the blood, has a direct effect on the function of digestion ; for if the course of the blood be impeded by disease of OF THE STOMACH IN DISEASE. 49 the lungs or heart, the portal system of vessels be- comes necessarily congested, the secretion from the mucous membrane is changed, and digestion is em- barrassed. From one or other of these reasons we find that there is a very close sympathy of the stomach with the lungs and heart; thus indigestion frequently produces hurried breathing and dyspnoea, with dry cough; and as to the heart, the symptoms are often so distinctive, that is difficult to convince patients that they are not suffering from organic disease; palpitation of the heart is induced, and irregularity, which greatly alarms the patient, and even faint- ness or actual syncope, if the heart be feeble. The converse symptoms are equally important, and early disease of the lungs, especially from peri- pheral irritation of the branches of the pneumo- gastric by miliary tubercles at the apex of the lung, is often accompanied by excessive irritability of the stomach, so that the practitioner may sup- pose that the stomach is at fault; the diminished nourishment increases the constitutional weakness, and thus leads to a rapid increase in the original disease; too often the mistake is made, " that it is all stomach," and many of the so called cases of gastric phthisis are of this kind. In whooping- cough a similar connection between the stomach 5 50 ON THE GENERAL SYMPATHY and the lungs is noticed, and the former becomes almost as irritable as the latter; the spasmodic cough is very often accompanied by actual vomit- ing. In chronic bronchitis, and in obstructive disease of the heart, whether from the state of the valves or the muscular tissue of the heart, gastric symp- toms arise from the third cause mentioned, namely, from interference with the free circuit of the blood, and the consequent distension of the gastric veins. The capillaries of the stomach thus become intense- ly injected, a thick layer of catarrhal mucus is secreted, and digestion is greatly hindered. In acute disease of the heart and of the peri- cardium the stomach sometimes becomes irritable. The stomach is so closely connected with the liver in the function of digestion, that one organ can scarcely be seriously disordered without the other becoming more or less implicated ; but there are other conditions which show the closest sym- pathy, independent of their functional connection. The violent vomiting that is induced by the pas- sage of a gall-stone is due, not only to the direct transmission of spasmodic contraction from the involuntary fibres of the duct to those of the stom- ach, but it also arises from the connection of the OF THE STOMACH IN DISEASE. 51 hepatic and gastric filaments by means of the pneu- mogastric and vaso-motor nerves. In diseases of the kidney the gastric disturbance is susceptible of a twofold explanation ; in some forms of acute renal disease, as calculus, the vio- lent vomiting is from the connection of the renal nerves with the gastric; but in chronic Bright's disease of the kidney it has been shown, that the secretions of the stomach become unusually irrita- ting from the presence of urea. In Addison's disease of the supra-renal capsules (melasma supra renale), irritability of the stomach is often present; and although, after death, local irritation and superficial ulceration of the mucous membrane have often been detected, we regard the direct nervous connection as having the m<~>re im- portant causative relation. The sympathy of the stomach with the urino- genital organs is so well known that it scarcely needs comment; and this is due to the same nerve union, namely, the hypogastric plexus with the semilunar ganglia. Diseases of the bladder and prostate are often associated with gastric and gene- ral symptoms, due to the vasomotor nerve, as rigors, irritability of stomach, hiccough, etc.; and the changes in the uterus and ovaries are often marked by characteristic irritability; sometimes 52 ON THE GENERAL SYMPATHY the extreme sensibility of the stomach continues during the whole period of utero-gestation, whilst in other cases digestion is performed more comfort- ably and effectively during gestation than at any other period. We have known all the symptoms of dyspepsia disappear as soon as conception has taken place, and they have remained in entire abey- ance until parturition has been completed. The lining membrane of the alimentary tract is continuous with the skin, and in one sense it is ex- ternal to the living organism, so that the stomach and other parts of the intestinal canal have been spoken of as inversions of the external investment; the intimacy of their connection bears out that form of expression, although the union between the stomach and the skin does not require continuous irritation to explain the phenomena. At the onset of nearly all the exanthems the stomach sympathizes, and vomiting is a common symptom. Thus the commencement of erysipelas, of small-pox, of scarlet fever also, is often thus in- dicated ; and equally distinct is the sympathy in chronic forms of cutaneous disease. How often do we find in lichen and in eczema that the gastric symptoms increase when the irritation of the sur- face is lessened; and in other conditions, distur- bance of the stomach will greatly increase the cutaneous malady; thus in children strophulus, OF THE STOMACH IN DISEASE. 53 lichen, and eczema are greatly aggravated by gastric irritation and by muco-enterite. In the forms of nettle-rash from the Crustacea, etc., it might be said that the irritation on the skin is due to the absorption into the blood of irritating extraneous material. We can scarcely designate by the term sympathy, in the sense in which we have hitherto used it, the anorexia, and the inability to digest food, which occur during fever, whether intermittent or con- tinued, or during the febrile state of symptomatic fever. In these conditions the stomach is affected in common with the whole system, all the glandular organs have their action retarded, the blood is modi- fied, and the whole organism is disordered. The furred state of the tongue is often expressive of a general condition, rather than a mere local indica- tion of the state of the digestive mucous membrane. With sympathies so widely pervading the whole system, it is not surprising that gastric disease should present most varied indications in the dis- turbance of other organs ; and, in like manner, that gastric phenomena of an abnormal kind should result from irritation, far removed from the stom- ach itself. The closest circumspection is required to discriminate between sympathetic affections and those of a strictly local origin. 5* 54 ON THE SYMPTOMS CHAPTEE IV. ON THE SYMPTOMS OF DISEASE OF THE STOMACH. If we were only to judge by the severity of symp- toms in diseases of the stomach, constant mistakes would be the result, especially in the earlier stages of disease; for in functional maladies, that is to say, those in which no structural change can be detected, the symptoms are often extremely urgent. The irritability of the stomach may be excessive, so that every portion of food is at once rejected, the pain may be severe, and the general distress constant, although the ailment is curable, and of a corhparatively slight character. It will be well to consider seriatim the symptoms which are present in diseases of the stomach, and their relative value. The two symptoms which are regarded as of special diagnostic value are vomiting and pain* in the region of the stomach. We have already referred to the intimate connec- tion of the nerves of the sympathetic plexus with * The remarks on pain and vomiting are in great measure taken from my larger work on ' Abdominal Disease.' OF DISEASE OF THE STOMACH. 55 all the abdominal viscera, and with the spinal nerves; and this connection serves to explain the uncertain indications of these symptoms. Asa sign of disease, pain is of doubtful value; oftentimes it is a certain guide to the locality, if not to the character of morbid action; at other times, on the contrary, its presence misleads, or its absence disposes us to under-estimate changes which may be going on in the system. Generally speak- ing we find that the mucous membranes, except where they approach the outlets of their respective canals, are free from ordinary sensibility, and may undergo very marked changes in their condition without any painful manifestation. Acute disease may take place in the mucous membrane of the kidney or bladder with complete immunity from suffering. A similar fact is observed in relation to the parenchymatous viscera; thus the substance of the liver and the kidney is often changed in a marked degree; and if disease, such as abscess, arises in their structure without much distension, the' patient may be unconscious of morbid change. On the contrary, in serous membranes an opposite condition is found to exist; almost any change is appreciated, and in sudden or acute disease the pain is often extremely severe in its character. All physicians well know the stabbing pain of pleurisy, 56 OX THE SYMPTOMS the agony of acute peritonitis, and the intense suffering of severe synovitis. In each of these latter diseases, rest is a very essential element in the alleviation of the malady, and this rest can be attained to a great extent without the cessation of life. In pericarditis, on the contrary, we find, as was shown many years ago by Dr. Addison, that there is an absence of pain, unless there be pleurisy occurring at the same time. In the pericardium, however desirable rest may be, it is impossible, as the heart must beat as long as life lasts. Pain.—In reference to pain as an indication or non-indication of disease we have to remark, I. That acute inflammation and disease of the stomach may exist, with entire freedom from pain, if the mucous membrane only be affected. Acute gastritis is generally regarded as an exceedingly rare form of disease, excepting when produced by irritant poisons. This may be the case ; but we are of opinion that in many instances the absence of pain has led to this belief. In the gastro-enteritis of children, and not very unfrequently in that also of more advanced life, conditions of great irritability with cessation of the right function of the stomach, and probably with hyperaemia, must be regarded as closely approaching the character of gastritis. How- ever this may be, we have evidence from the action OF DISEASE OF THE STOMACH. 57 of irritant poisons, that, while the mucous mem- brane is only affected by them, pain may be entirely absent, excepting that which is consequent on the violent muscular action exerted in the act of re- peated vomiting. Thus, in a patient who had taken a large dose of oxalic acid, violent vomiting, with failing pulse and a sense of exhaustion, was produced, but no pain. In a few days, after taking demulcent forms of diet, she completely recovered. In an instance of poisoning by strong sulphuric acid, where a large portion of the mucous mem- brane of the stomach was destroyed, although the patient survived eleven days, she did not appear to suffer from any pain at the stomach. The same fact was still more strikingly shown in a case of poisoning by chloride of zinc, in which life was pro- longed for three months ; there was a remarkable absence of suffering till eight days before death, and the pain then induced was evidently caused by the formation of an abscess in the left hypochon- driac region. I have witnessed the same immunity from suffering in poisoning by arsenic and by cor- rosive sublimate; and we are warranted in the belief, that acute disease may take place in the mucous membrane of the stomach without any pain. II. Organic disease of the mucous membrane, as 58 ON THE SYMPTOMS for instance cancer, may be comparatively free from pain. It frequently happens in cancerous disease of the liver, that after death tubercles or growths of a similar character to the primary disease are observed on the mucous membrane of the stomach, of which there had been no indication during life. Thus, a patient aged 60, died from cirrhosis, and after death a large villous growth was found at. tached to the anterior surface of the stomach. There was no complaint of pain at the stomach, neither had she any vomiting; and it is probable that the burning sensation she experienced before admission into the hospital was of the character often observed in ordinary dyspepsia. The freedom from any obstruction at the orifices of the stomach, and the fact that the growth involved only the mucous membrane, were, we think, the explanation of the absence of pain. • No supposition was enter- tained of the presence of this growth in the stomach during life. We have witnessed the same immu- nity from pain, and indeed from any recognizable symptom, in extensive lardaceous degeneration of the gastric mucous membrane. III. Diseases extending to the muscular and peritoneal coats produce severe pain, as observed in ulceration or cancer. This symptom is present as one of the most ordinary signs of ulceration of the OF DISEASE OF THE STOMACH. 59 stomach ; and in several instances, in which the suffering was very severe, we have found branches of the pneumogastric nerve involved in the thick- ened, dense, and fibrous edges of the ulcer. The pain often comes on in these cases directly after food has been taken. IV. Over-distension of the stomach produces severe pain. The formation of the stomach and its peritoneal attachment are such as to allow moder- ate distension to take place during digestion ; but whenever the distension becomes greatly increased pain is the result. V. Disease, especially of an acute kind, affecting the peritoneum is also, with few exceptions, accom- panied with severe pain. In reference, however, to the position of pain in peritonitis, it is not al- ways a certain guide to the precise seat of injury. I well remember a young woman who was seized with sudden and severe pain at the scrobiculus cordis towards the left side, which was followed by rapid collapse. From the seat of the pain perfora- tion of the stomach was diagnosed ; it was, however, found to be perforation of the appendix caeci. VI. Dr. Osborne has shown that in some cases of gastric ulcer the position of greatest ease to the patient may serve as a guide to the exact seat of the disease; that if the ulcer be on the posterior 60 ON THE SYMPTOMS surface of the stomach, lying upon the face would be the most comfortable position, and vice versa. Food, on its entrance into the Stomach, generally passes directly along the lesser curvature, and if the viscus be contracted, it would come in contact with an ulcer, whether placed on the anterior or posterior aspect of the median line of the curvature. If more distended, there might be less direct appli- cation to the diseased surface. In the case of severe suffering from gastric ulcer previously referred to, the patient was most easy when leaning somewhat forward and towards the left side, a position which allowed fluids to gravitate from the ulcer. VII. In disease of the lesser curvature, even near the pyloric orifice, pain is sometimes experi- enced by the patient as soon as the food enters the stomach, and in some cases, this conveys the idea of disease at the oesophageal orifice. This fact may lead to the supposition that the oesophagus is the part affected, and the erroneous opinioD may be strengthened by the rejection of food almost before it has reached the stomach. VIII. Many conditions of functional disease are entirely free from pain. It is, indeed, well for us that there is such insensibility, otherwise the least deviation from healthy action might be followed by OF DISEASE OF THE STOMACH. 61 suffering, and the strict rules of a dyspeptic would then be essential in ordinary life. IX. The pain in many functional diseases of the stomach is exceedingly severe ; but it is often pro- duced by a mal-condition of the nerves or nerve- centres, and it arises from the intimate connection of the spinal and sympathetic nerves. In some states of exhaustion the whole of the nervous sys- tem appears to be in a state of great irritability, and the sensibility of structures becomes greatly increased. We often find in these conditions that the stomach is incapable of bearing the presence of food ; it is at once rejected, or produces intense pain, or flatulent distension is set up, or a sense of faint- ing ; and the means best calculated to relieve are those which invigorate and strengthen the whole system. Of this class are the stomach diseases observed in connection with uterine disease, with loss of blood, exhaustion, mental anxiety, etc.; the deficient nervous supply also interfering, perhaps, with the right secretion of the gastric juice. X. The effect of a diseased condition of the pneu- mogastric nerve at its centre, or at its peripheral branches, is of great importance in connection with stomach disease, and it is probable that pain is sometimes the result. We have, however, more frequently observed vomiting rather than pain 6 62 ON THE SYMPTOMS produced by an irritable condition of the pneumo- gastric nerve. XI. In some forms of functional disease of the stomach, in which severe pain comes on three or four hours after food, it is probable, as we have elsewhere stated, that extreme irritability of the pyloric orifice exists. XII. The absence of pain often arises from the destruction of the pneumogastric nerve. This fact is sometimes remarkably shown in disease of the oesophagus, as well as of the stomach. XIII. Pain at the epigastrium, simulating disease of the stomach itself, also arises from spinal disease, the pain being referred to the extremity of the irri- tated nerve. XIV. Severe pain at the scrobiculus cordis is frequently present in chronic bronchitis and in ob- structive valvular disease of the heart; in fact, from any state which leads to over-distension of the cavities of the right side of the heart. In these conditions we very generally find that food pro- duces pain and flatulence, and is very imperfectly digested ; the vessels of the stomach and of the whole of the chylopoietic viscera are much engorged ; and the surface of the stomach is very generally covered with a thick layer of mucus; a state of chronic ca- tarrh of the mucous membrane is produced. Many OF DISEASE OF THE STOMACH. 63 observers, however, attribute the almost constant pain at the scrobiculus cordis in these instances to the over-filled cavities of the right side of the heart, and we are disposed to refer part of the distress to this cause. XV. In aneurism of the abdominal aorta we have sometimes observed pain of an intense kind, and the disease might very easily have been mistaken for cancerous disease of the stomach, with glandular infiltration, producing pressure upon the aorta. In one instance, which I watched with much in- terest, the aneurism existed at the position of the cceliac axis; it was rightly diagnosed, and the patient became exhausted and died from the in- tensity of the pain, the false sac not having given way. I dissected large branches of the sympathetic nerve spread out upon the surface of the tumor; and the intense suffering and fatal exhaustion ap- peared to arise from the implication of the nerve structures. No other cause of death could be found on very careful inspection. XVI. Abscess in the parieties of the abdomen near the scrobiculus cordis, at its earlier stage, simulates disease of the stomach itself. XVII. Disease of the pancreas, especially of an inflammatory kind, is apt to be mistaken for dis- ease of the stomach. 64 ON THE SYMPTOMS XVIII. The pain and vomiting consequent on obstruction in the duodenum closely resembles dis- ease of the stomach. Thus large biliary calculi in some rare instances ulcerate through the walls of the gall-bladder, and become impacted in the duo- denum. Other symptoms, however, when rightly estimated, will generally guide to correct diagnosis. XIX. The neuralgic pain produced by herpes zoster, or shingles, may for a short time mislead, but the pain of shingles is not generally so local in its character, and extends backward to the spine. XX. Whilst considering pain at the stomach, we are led to remark on the expression often made use of, namely spasm at the stomach. Does such a state really exist ? It has justly been said that in many instances some undigested substance remains in the stomach, and is the source of the pain; and we have known a portion of undigested steak con- tinue in the stomach undissolved for ten days, and no effectual relief could be obtained till it was re- jected. Again, many such instances are due to distension of the stomach ; others to pain in the course of the spinal nerves; in others there is con- traction at the pyloric valve; but there are cases which cannot be so explained, and they are appa- rently attributable to a state of extreme irritability OF DISEASE OF THE STOMACH. 65 of the sympathetic nerves and ganglia, inducing unusual contractility of the muscular fibres. As to the time and persistence of pain, we may remark that when arising from disease of the stom- ach it is generally aggravated by food. It often extends through to the back, but is less persistent in its character than when it arises from other causes. Vomiting.—Although the causes of vomiting are very numerous, it is generally at first referred to the condition of the stomach itself, or to the parts immediately connected with it; and this opinion is so often fraught with danger, that we cannot too strongly urge the importance of close investigation. The causes of vomiting are even more varied and complex than those which result in pain, and they may be divided into those which originate in the stomach and intestines, and secondly, into those which are sympathetic in their source; to several of the latter we have incidentally referred in the last chapter. In the first division we must place, as causes of vomiting,— 1. Inflammation of the stomach, gastritis, and gastro-enteritis; 2. The presence in the stomach of undigested food, or foreign bodies; 6* 66 ON THE SYMPTOMS 3. Irritants and medicines; 4. Great irritability of the mucous membrane; 5. Ulceration of the stomach; 6. Obstructive disease of the pylorus; 7. Cancerous disease of the stomach; 8. Peritonitis, acute and chronic; 9. Pressure on the stomach—as in ascites, tumors, etc.; 10. Diseases of the duodenum; 11. Hernia, intestinal obstruction, intussusception; 12. Pharyngeal and oesophageal regurgitation; In the second division are— 13. Diseases of the liver and gall-bladder; 14. Diseases of the supra-renal capsules; 15. Diseases of the kidney; 16. Diseases of the uterus and ovaries; 17. Diseased conditions of the blood and general nervous system, as at the onset of the exan- thems, fever, pyaemia, erysipelas, etc., ague, yellow fever, and cholera, may perhaps be classed among these, as arising from blood change; 18. Diseases of the spine; 19. Diseases of the brain; 20. Diseases of the lungs. I. There is something remarkable in the presence of vomiting when pain is absent; and in acute dis- OF DISEASE OF THE STOMACH. 67 ease of the stomach, where only the mucous mem- brane is affected, the patient may be free from all suffering at the region of the stomach, except that produced by the violent straining of the muscles. Vomiting is a more persistent sign of inflammation of the stomach than is pain. We need only refer for confirmation to instances of poisoning by oxalic acid, by sulphuric acid, by arsenious acid, and by corrosive sublimate, cases of which have occurred without pain at the stomach; and in the symptoms of gastro-enteritis the same immunity from gastric pain occurs, whilst vomiting greatly distresses the patient. II. Undigested substances often remain in the stomach for some time without producing pain, unless they pass within the pyloric valve; and we sometimes find that they are retained for many hours, or even days, before they are rejected by vomiting. III. In reference to vomiting caused by medicine and by irritants, it is only necessary to mention that in some instances the action appears to be one of primary irritation of the stomach, in others it is secondary, through the medium of the blood; but whether this secondary action and its consequent vomiting arise from the excretion of the medicinal substance from the mucous membrane of the stom- 68 ON THE SYMPTOMS ach is doubtful; thus, tartar emetic produces vom- iting when injected into the blood, as well as when taken directly into the stomach. IV. A state of functional irritability of the stom- ach is sometimes induced, and is generally associated with uterine or ovarian disease, or it is produced by irritation of the pulmonary branches of the pneumogastric nerve acting in a reflex manner upon the nerves of the stomach. In these instances food of every kind is at once rejected; and it is to this condition that Sir H. Marsh has given the name of regurgitative disease, in which food is rejected without any effort, and often without cor- responding emaciation. In his valuable paper on this subject he refers to its connection with pulmo- nary and with uterine disturbance. V. In ulceration, vomiting often comes on as soon as food enters the stomach, or a period of variable length intervenes, the pain increasing till the rejection takes place. VI. In obstructive disease at the pylorus, the vomiting is generally deferred till nearly the close of the digestive process; much, however, may be done to diminish this symptom by the use of suit- able diet of a fluid kind. VII. Cancerous disease, affecting the orifices of the stomach, constitutes a common cause of persist- OF DISEASE OF THE STOMACH. 69 ent vomiting. It must, however, be borne in mind that vomiting is not a constant sign of cancerous disease of the stomach ; if the orifices he free, it may be entirely absent, although the disease is very extensive; and again, if sloughing take place, even when the orifices are diseased, vomiting often sub- sides, sometimes in consequence of the obstruction being removed by the sloughing; at other times, apparently from the destruction of the branches of the pneumogastric nerve. Further, the period at which vomiting occurs does not always indicate the seat of the cancerous obstruction. In some instan- ces of obstruction at the pylorus, with disease at the lesser curvature, vomiting takes place immedi- ately after food has entered the stomach, so as to convey the idea of obstruction at the cardiac orifice, or in the oesophagus itself, and this symptom has been regarded as dysphagia rather than vomiting. VIII. Acute peritonitis, especially when the gas- tric peritoneum is involved, is often accompanied with severe vomiting. The statement has been made, that it does not take place in acute peri- tonitis unless the peritoneum in the neighborhood of the stomach is impjicated; but although this is generally true, it is not constantly the case. Chro- nic peritonitis is also a cause of vomiting; so also is local peritonitis and effusion near the stomach. 70 ON THE SYMPTOMS In some of these instances the stomach is affected by its direct implication in the disease ; in others vomiting arises from the pressure of effused pus, or the constriction of adhesions. IX. Pressure on the stomach is a direct cause of vomiting. In ascites and ovarian diseases the stom- ach is sometimes so compressed that vomiting comes on soon after food has been taken, apparent- ly from this cause alone; and when paracentesis has been performed, the pressure being removed, the sickness ceases. When glandular tumors in the neighborhood of the pancreas itself, exert pres- sure on the stomach, the symptoms closely resem- ble those produced by primary disease of the stomach, and the diagnosis is exceedingly difficult; but, since the pancreas receives a branch from the pneumogastric nerve, it is not easy to ascertain how far vomiting, in some of these cases, is due to nervous irritation, and how far it is due to direct pressure. In those cases in which the pancreas has been diseased without great enlargement, and without pressure on the stomach or duodenum, I have not observed that vomiting is a prominent symptom. In anuerismal disease of the abdomen, the remark which we have made in reference to disease of the pancreas holds good; and the sanie OF DISEASE OF THE STOMACH. 71 difficulty arises in determining how far the vomit- ing is due to pressure, or to sympathetic irritation. In some cases we have found direct pressure made by the patient at the scrobiculus cordis the cause of vomiting; and in an instance of a boy, some years ago, in Guy's Hospital, it was only after very careful watching that the true character of the complaint and the deceit of the patient were ascertained. X. As to vomiting not depending on the con- dition of the stomach itself, we have to refer to morbid states of other abdominal viscera; and first, to disease of the duodenum, as inflammation of its mucous membrane, ulceration, and obstruc- tion. There is great similarity between the diseased conditions of the first portion of the duodenum and of the stomach. A form of dyspepsia, in which vomiting, with pain at the seat of the duodenum, comes on at the close of digestion has been attri- buted to the duodenum ; but whether this class of cases is connected with an abnormal irritability of the pylorus itself, we cannot affirm. Again, in some cases of acute jaundice, febrile symptoms with violent irritability of the stomach, arise with- out .pain ; and the disease has been attributed to mischief commencing in the duodenum, and ex- 72 ON THE SYMPTOMS tending to the biliary ducts. In some fatal cases of this kind, great congestion in the duodenum has tended to confirm the idea, so also the fact that these symptoms have been observed after intem- perance. Ulceration of the first portion of the duodenum produces many of the symptoms of like disease in the stomach ; and obstruction, as from an impacted gall stone, causes most severe vomiting. XI. In hernia, obstructive disease of the intes- tines, and intussusception, vomiting is generally present. If the obstruction be in the small intes- tine, the vomiting comes on very quickly ; but if the colon, sigmoid flexure, or rectum be the seat of the disease, vomiting is often postponed for a con- siderable time, unless irritant medicines and vio- lent purgatives have been administered. As the vomiting continues, the ejected matters present the character of the fluids at the seat of obstruction ; and, if that obstruction be intestinal, their odor and appearance have more or less of a fecal char- acter. XII. The regurgitation of food, which is con- sequent on disease of the pharynx, larynx, or oesophagus, must be distinguished from actual vomiting. By carefully observing the process of deglutition, the seat of mischief may be accurately OF DISEASE OF THE STOMACH. 73 ascertained. In paralysis of the muscles of the soft palate, and of the pharynx, deglutition cannot be properly completed, and food is rejected through the nares ; so also when the epiglottis is ulcerated from strumous, syphilitic or cancerous diseases, the act of deglutition is scarcely performed before the substance swallowed is violently ejected, and severe pain in the throat and cough are set up. It is remarkable too, in these cases, how a solid bolus of food may be formed and swallowed, slipping be- yond the diseased surface, whilst the smallest quan- tity of fluid produces most violent pain and dis- tress. In obstruction of the oesophagus the act of deglu- tition is completed, and then regurgitation takes place. Very extensive disease may, however, af- fect the oesophagus without this rejection of food ; for ulceration or sloughing may have removed ob- struction, or the branches of the pneumogastric nerve and the whole wall of the canal may be de- stroyed. Other causes of vomiting are expressions of the general and intimate connections of the stomach ; they are properly designated sympathetic in their relationship, and their study is of essential import- ance in the diagnosis of disease of the stomach. As with the previously mentioned causes of vomiting, 7 74 ON THE SYMPTOMS we shall do little more than enumerate them, and the first of this class to which we shall allude is, XIII. Disease of the liver and of the gall-bladder. Large branches of the pneumogastric nerve extend to the liver, as well as numerous nerves from the large sympathetic ganglia. In gall-stone, violent vomiting is generally associated with intense pain; and in many conditions of hepatic disease irrita- bility of the stomach is a frequent symptom. I have several times noticed that, during the severe pain produced by the passage of a gall-stone, the urine has become albuminous ; the kidney is affected by its nervous sympathetic union. In one instance uraemic poisoning came on. XIV. In disease of the supra-renal capsule— Addison's disease—vomiting is rarely absent; but sometimes it is a sign of such prominence as to simulate primary disease of the stomach. On post- mortem examination we have found arborescent in- jection of the mucous membrane of the stomach, and sometimes slight ulceration; but it must also be remembered that the pneumogastric nerve sup- plies branches to the supra-renal capsule, and that its connection with the semilunar ganglia is a very intimate one. XV. Diseases of the kidneys and renal calculus constitute other causes of vomiting. During the OF DISEASE OF THE STOMACH. 75 passage of a calculus down the ureter, vomiting is a very distressing symptom. In acute albuminu- ria, vomiting is also associated with nausea; and in chronic albuminuria it is sometimes the precursor of a fatal termination. So severe, indeed, may be this symptom in ischuria renalis, as even to suggest the possibility of intestinal obstruction, as shown by Dr. Barlow. The vomiting in albuminuria is not only due to the direct connection of the nerves constituting the renal plexus with those of the stomach, but to the urea excreted from the mucous membrane of the stomach and intestines. Urea is found to be present in large quantity in the blood and is separated in all the excretions and secretions; and in the stomach this abnormal excrementitious substance appears to act as a direct irritant. XVI. Both functional and organic diseases of the uterus are causes of vomiting. In dysmenorrhcea, most distressing irritability is occasionally set up; and in pregnancy, vomiting may be so severe as to exhaust and to completely prostrate the patient. Functional and organic diseases of the ovaries pro- duce distressing nausea and sickness. I have known commencing ovarian disease mistaken for cancerous disease of the stomach, in consequence of the severity of the gastric symptoms; all these symptoms sub- 76 ON THE SYMPTOMS sided when the ovarian cyst had attained a large size. XVII. At the onset of acute diseases—especially the exanthems, fevers, pyaemia, erysipelas, etc.— vomiting is often present. It is not known how this is produced, whether directly by the altered condition of the nervous system, or secondarily from the state of the blood. Sudden nervous shock, fright, etc., will produce vomiting; and in some more chronic diseases, when the blood is altered in character, as in renal disease and even gout, the same symptom is occasionally very intractable, as previously mentioned. Dr. Graves, in his ' Clinical Medicine,' makes the following valuable remarks in reference to this subject:—" Every fever which commences with vomiting and diarrhoea, whether it be scarlatina, or measles, or typhus, is a fever of a threatening aspect; and in all such fevers the practitioner should be constantly on the watch, and pay the most unremitting attention to the state of the brain. There is much difference between the vomiting and diarrhoea of gastro-enteritis and this cerebral diar- rhoea and vomiting. The latter sets in generally at a very early period of the disease, perhaps on the first or second day, and is seldom accompanied by the red and furred tongue, the bitter taste of OF DISEASE OF THE STOMACH. 77 the mouth, the burning thirst, and the epigastric tenderness which belong to gastro-enteric inflam mation." He also states very truly, that in cere- bral disease there is often a large quantity of bile ejected by vomiting, and passed also by stool: and that leeching the abdomen is less efficacious in cere- bral inflammation than in gastro-enteritis. Very little is known as to the proximate cause of vomiting in cholera and yellow fever, but we sometimes find in the intermittents of our own country that it is a prominent symptom; and we have several times witnessed instances in which vomiting, excited possibly by uterine or hepatic mischief, assumed regular periodicity in those who had been exposed to miasmatic poison. XVIII. The remaining causes of vomiting arise from the condition of the nervous system, and are most interesting and important in the correct diag- nosis of disease ; the first of these is a diseased con- dition of the spine. The splanchnic nerves pass from the spinal cord to the large sympathetic gan- glion of the abdomen, and constitute an intimate connection between these centres of nerve force; in those diseases, however, of the spine in which we have observed irritability of the stomach, other sources of disturbance have been present. XIX. Irritation of the peripheral branches of the 7* 78 ON THE SYMPTOMS pneumogastric nerve in the abdomen has already been referred to as one cause of vomiting in disease affecting the organs to which they are supplied; but the same nerve may be irritated at its periph- eral branches in the chest, and at its origin in the brain. Disease of the brain, then, is another cause of vomiting, and one which it is important to bear in mind in the diagnosis of disease; too often the so-called bilious attacks of children are the first in- dications of acute hydrocephalus. The irritability of the stomach is sometimes so great that vomiting is at once produced when the patient is raised from the recumbent position. The diagnosis of these cases is sometimes exceedingly difficult when com- mencing with symptoms of true gastro enteric dis- ease ; but it would be well if the remark of that great authority in clinical medicine just quoted were borne in mind, that " in all feverish complaints, where during the course of the disease the stomach be- comes irritable without any obvious cause, and where vomiting occurs without any epigastric tenderness you may expect congestion or incipient inflammation of the brain or its membranes." In simple cerebral disease the abdomen is gene- rally collapsed ; in primary abdominal disease there is, on the contrary, distension. The difficulty in diagnosis is not, however, limited to very young OF DISEASE OF THE STOMACH. 79 subjects. In strumous disease of the brain the vomiting is sometimes excessive: so also in dis- ease of the ear extending to the membranes of the brain. After concussion, vomiting comes on, and in some cases, when inflammatory disease has followed, and suppuration has taken place, this symptom is ex- cessive. One of the most severe cases of secondary vomiting which I ever witnessed was of this kind. A man in middle life had received a blow at the back of the head; cerebral symptoms came on, and suppuration took place at the origin of the pneu- mogastric nerve; the membranes were adherent at that part for the space of half an inch, and about a drachm of pus was effused. The vomiting had been excessive, and anything swallowed was rejected with violence beyond the extremity of the bed. XX. Disease of the lungs, or irritation of the pulmonary branches of the pneumogastric nerve, is the last cause of vomiting to which we refer. The vomiting in whooping-cough appears to be of this kind, and equally so that which is often present at the early stage of phthisis ; the same symptom may occur in acute as well as in chronic disease of the lung. Sir Henry Marsh has mentioned early phthisis as one of the causes of the irritability of stomach, to which he has given the name of regur- 80 ON THE SYMPTOMS gitative disease; and too frequently this irritation leads to the unfortunate expression, that the symp- toms of early tubercular disease of the lung are "all stomach." There may be no physical signs produced by scattered tubercles studded through- out the lung tissue, and by overlooking the true character of the disease the period of effective treat- ment, by change of climate and other means, may quickly pass by. It seems, that as the pulmonary disease advances, and disorganization takes place, this condition of irritability is lessened, although we too often find that the paroxysms of cough are pro- ductive of violent vomiting. At the onset of acute disease, both of the pleura and of the lung, it is very frequent to find irrita- bility of the stomach induced, with loss of appetite and furred tongue; and we have many times seen the true character of the disease entirely overlooked from the neglect of proper examination of the chest. If acute pleurisy take place on the right side, the severe pain with vomiting is at once attributed to disease of the liver; and if on the left side, espe- cially when effusion has taken place, and when the heart is pushed over to the median line, pain and tenderness at the scrobiculus cordis is regarded as an indication of gastric complication. Proper ex- amination will prevent these mistakes; but if the OF DISEASE OF THE STOMACH. 81 acute inflammatory disease be confined to the dia- phragmatic surface, the stethoscopic signs are for a short time obscured, until the costal pleura becomes involved. In a patient lately under my care, the malady had been regarded as acute hepatitis, from the circumstance above mentioned; and in another, the complaint was said to be wholly gastric, although the left pleura was full of fluid. Pyrosis, or Water Brash, is a symptom to which especial reference must be made. It is one of fre- quent occurrence, and it receives its appellation from the fact of the rejection of a thin watery mucus. The poorer classes of society, and espe- cially its female portion, are the ordinary subjects of this disease, but it is not confined to them. Half a pint of watery fluid, somewhat resembling the white of an egg, is sometimes vomited or regurgi- tated at once; the discharge is generally neutral in its chemical reaction, and often tasteless, but some- times it is found to be slightly alkaline, and the patient complains of its saltness. The period at which the discharge of fluid takes place varies both as to the hour of the day and the frequency of the recurrence of the attack. The vomiting, however, generally occurs when the stomach is empty, and it is accompanied with a sense of contraction and of pain at the epigastric region and at the spine. 82 ON THE SYMPTOMS With some patients the attacks come on in the fore- noon, with others during the night, at one or two in the morning, and even several hours after retir- ing to rest. The tongue may be clean, the pulse normal, the patient fairly nourished or anaemic and enfeebled; headache is often present, and in some instances water brash alternates with more severe gastralgia. It may be the only symptom of disease, but more frequently it is associated with others of a distinctive character. Thus it may be present with chronic ulcer, and we have witnessed a form of pyrosis in connection with colloid disease of the stomach; still, in simple functional disease, pyrosis may be so severe and so persistent as to lead to the diagnosis of organic mischief. It is the opinion of Dr. Handfield Jones that pyrosis is a chronic catarrh of the stomach similar to blenorrhcea from the bronchi. Dr. Chambers, however, favors the idea that the oesophagus is the source of the discharge. We know that bile often flows backward into the stomach, and it is possible that the pancreatic secretion -may take a similar course; for with relaxed condition of the pylorus, and contraction of the duodenum, this would readily be the case. Pyrosis often occurs during fasting, and also at night, when the recumbent position would favor a retrograde course from the pancreatic OF DISEASE OF THE STOMACH. 83 duct. The discharge is not ordinary mucus, and if it were from the stomach we should expect more generally an acid reaction. This condition comes on after the continued use of oatmeal, and hence it is more common in the north. It may follow symptoms of chronic gas- tritis : it is produced by great anxiety of mind, by over-fatigue, or by an overworked frame. It also occurs during pregnancy, and it is met with amongst the symptoms of commencing cancerous disease of the stomach. We may briefly state that the remedies which relieve pyrosis are astringents and tonics, as the sulphate of iron with the extract of logwood ; qui- nine with aloes and myrrh ; nitrate of bismuth alone or with conium and nux vomica; an alterative of blue pill with rhubarb is sometimes beneficial. Solution of potash, with hydrocyanic and bitter effusions, is of great service where there is much pain. Other astringents may be advantageously employed with sedatives, anodynes, and tonics, as the compound kino powder, catechu with morphia or opium, oxide of silver, sulphate of copper, strych- nia, or the infusion, tincture, or extract of nux vomica. Bleeding from the Stomach. Hsematemesis. —Another symptom of disease of the stomach, to 64 ON THE SYMPTOMS which we must separately allude, is bleeding from the stomach, inducing either vomiting of blood, haematemesis, or its discharge by the bowels, melsena. Great alarm is naturally excited by the rejection of blood from the stomach whether in small or large quantities; but the import is very different, for whilst in some cases it is a symptom free from danger, in others it is the indication of serious, if not of fatal disease. The causes of haematemesis are,— 1. Ulceration of the stomach. 2. A congested or obstructed state of the portal circulation. 3. Vicarious menstruation. 4. Cancerous disease. 5. A vitiated state of the blood, as in purpura, yellow fever, typhus, etc. 6. Aneurism. The hemorrhage may, however, have its origin in parts connected with the mouth, the throat, and the oesophagus, arising from ulceration, cancerous disease, aneurism, varicose condition of the minute oesophageal veins; and the rejection of blood from these sources may be erroneously regarded as haematemesis; or, it may proceed from the nose, the larynx, and the lungs, and in some cases con- OF DISEASE OF THE STOMACH. 85 siderable difficulty arises in distinguishing the source of the discharge, for the blood may be swal- lowed and afterwards vomited. As to the quantity of blood exuded, there is the greatest diversity ; sometimes it is only recognized by the most careful, or even microscopical, exami- nation ; at other times several pints, or even quarts, are rejected at once; and if a large vessel has been divided, the first hemorrhage may cause fatal syn- cope. Blood which is thus discharged into the stomach is generally coagulated, and is often deep- ened in color by the action of the gastric juice; it is devoid of the bright frothy appearance presented by blood from the lungs, which is consequent on the admixture of air. A portion of the blood in the stomach becomes still further acted upon by the gastric juice, and passes into the duodenum. As it extends along the small and large intestine, the depth of the color is increased, and at last it is discharged as a pitchy liquid stool, constituting melaena. Sometimes this black evacuation or me- laena is the only symptom of hemorrhage into the stomach, for no blood may be rejected by the mouth; and when the blood is effused into the small or large intestine, and discharged, the depth of the color is proportionate to the length of the tract through which the blood has passed, but it 8 86 ON THE SYMPTOMS never assumes the black color to which we have referred. The green fluid which is sometimes vomited in states of great irritation of the stomach has been regarded by Dr. Fraser as altered blood: and the coffee-ground substance, so often rejected towards the close of organic disease of the stomach, consists also of blood which has slowly exuded, the haema- tine being acted upon by the gastric juice. In some cases of purpura a similar appearance is presented, and from a like cause. Much discussion has arisen as to the' possibility of the transudation of blood through unruptured capillaries; but although this is now recognized as a possible occurrence, and the white corpuscles—leucocytes—often transude from the vessels in morbid processes, still the ex- amination of a portion of intestine distended with blood, and presenting points of ecchymosis, as found after disease of the mitral valve, will suggest the probable explanation of instances in which blood has been vomited or discharged, and in which no apparent perforation of vessels has subsequently been found. In such a portion of intestine as is present with mitral valve disease, some of the capillaries are found to be beautifully injected, whilst others are collapsed, and blood is extrava- sated around them, but limited by the basement OF DISEASE OF THE STOMACH. 87 membrane, thus constituting a point of ecchymosis; if the basement membrane had given way, the blood previously extravasated would have escaped, and no ruptured vessel would have been detected. A simi- lar action takes place in the stomach; ecchymosis is produced, but the action of the gastric juice prevents our observing the changes with the same facility as in the intestine. There is little doubt that the capillaries thus become over distended, and then ruptured in the ordinary form of haematemesis, when no ulceration has taken place. In reference to the oozing of blood from the stomach, which often precedes death, it is doubtful whether obstruction on the right side of the heart, with ante-mortem coagulation and consequent dis- tension of the branches of the vena porta? and gas- tric vessels, is not associated in some cases with increased action of the gastric juice, so that the solution of the mucous membrane, which often fol- lows death, may actually precede it. The symptoms which precede haematemesis are a sense of faintness, followed by weight at the scrobi- culus cordis; the countenance becomes pallid, the pulse compressible and failing, the extremities cold, and sometimes actual syncope takes place; vomit- ing is then produced, and several pints, or even quarts, of half coagulated blood are rejected; the 88 ON THE SYMPTOMS patient becomes faint, blanched, and the bleeding is checked. After a few days or hours there may be return of hemorrhage, till at last, in some cases, the patient appears almost drained of blood. The subsequent symptoms are especially due to this loss, as found in other instances of anaemia ; severe headache, noise in the ears, disturbed vision, dilated pupil, palpitation or irregular action of the heart, with a sharp but compressible pulse, are present. If a large vessel has been divided, the first attack may, as we have before remarked, lead to fatal syncope. This sudden termination is, however, unusual; the patients generally slowly rally, and after a few hours the black pitchy discharge of altered blood takes place from the bowels. The character of the disease which has led to the hemorrhage must necessarily modify the preceding, as well as the general symptoms and their termina- tion. Thus in ulceration of the stomach, and in cancerous disease, the peculiar symptoms of those maladies are present. In aneurism a pulsating tumor may sometimes be felt, and severe local pain, or pain in the course of the spinal nerves, may be experienced. In congested portal system the signs are those of engorged liver, as shown by pain in the right side, dyspepsia, a sallow or semi- jaundiced complexion, furred tongue, occasional OF DISEASE OF THE STOMACH. 89 nausea or vomiting, impaired appetite, spasmodic pain at the stomach or in the region of the colon, constipation of the bowels, disturbed sleep, and pain in the head; enlargement of the liver and hemor- rhoids are also frequently present. In vicarious menstruation, local congestion of the mucous membrane, or of the edges of a pre-existing ulcer, as we sometimes find in an ulcer on the leg, leads to the effusion of blood. We may have very slight symptoms, as absence of the proper menstrual discharge, pain in the side, and periodical vomiting of blood, without constitutional disturbance, and without the blanched countenance that we find in hemorrhage from other causes. With this vicari- ous discharge we not unfrequently find hysteria, neuralgic pains, and leucorrhoea, etc. In purpura haemorrhagica there is a blanched countenance, faintness, etc.; but we have indication of the cause in the changed character of the blood, and its effusion from other mucous membranes as well as into the skin. The haematine is probably acted upon, and the corpuscles broken down, so that actual exosmosis of colored serum takes place. During the course of fever, hemorrhage from the bowels, apparently of a critical character, occasion- ally takes place. The patient, who may be in a state of great prostration, with a dry and brown 8* 90 ON THE SYMPTOMS tongue, may rapidly amend, and hence the dis- charge of blood has been regarded by some as in- dicating a " crisis" in the disease. In the cases of profuse hemorrhage during fever, which have come under our own observation, the effusion of blood has probably taken place from ulcerated surfaces. In one instance, minute ulcers were found in the stomach, from which a profuse and fatal hemor- rhage took place. In another instance, a young woman, whilst prostrate from typhoid fever, suf- fered from hemorrhage from the bowels to a great extent; the patient became blanched, the pulse for many hours could scarcely be felt, but very slowly she completely recovered. When blood is poured out from the oesophagus or mouth, it is regurgitated or rejected without effort rather than vomited, and we generally find either dysphagia or ulceration of the throat. Blood from the lungs is sometimes so retained in a vomica or dilated bronchus, that it loses its frothy appearance and florid color, and the patient is often scarcely able to tell us whether he vomited or coughed it up. No actual cough may be pro- duced, for the blood is easily brought up into the throat, and then spat out, or it may be swallowed and then vomited, or discharged by the bowels. In these cases we attach much importance to the OF DISEASE OF THE STOMACH. 91 general signs of disease, and to the physical exami- nation of the lungs and heart. As to the prognosis in hemorrhage from the stom- ach, we must bear in mind that it is rare for a patient to die from .simple haematemesis, although such cases do occur. Patients often appear to be almost bloodless, but steadily convalesce. Still the cause of the symptom must be our guide as to its termination ; sudden and large bleedings after symp- toms of organic disease should always be regarded with alarm, for ulceration often extends into the larger arteries, and the dense fibrous tissue prevents contraction of the vessels, and thus the hemor- rhage persists unchecked; these cases often termi- nate fatally. The treatment of the bleeding must be according to the cause of the disease. When it takes place from ulceration or cancerous disease, the use of styptics is advisable: alum with dilute sulphuric acid, acetate of lead, gallic acid, catechu, tincture of iron, oil of turpentine, or Euspini's styptic may be used. But in cases where it arises from conges- tion of the liver, I have generally looked upon the haematemesis as to a great extent curative, and pre- scribed remedies calculated to relieve the congested liver, as a grain or two of blue pill with conium and magnesia mixture, so as to remove the effused 92 ON THE SYMPTOMS blood from the intestines; sulphate of soda with sulphate of magnesia may be combined with dilute, sulphuric acid. Ice and cold drinks are grateful to the patient, and beneficial in producing contraction of bleeding vessels; but food should be abstained from, because coagula may be removed by it from divided vessels and hemorrhage be again produced. After a short time, fluid demulcent nourishment may be given, but it should be in a nearly cold condition; and when there is the evidence of a cessation of the hemorrhage, solid substances, easy of digestion, may be taken in small quantities. Vegetable ton- ics with mineral acids, and the milder preparations of steel will then be found of service ; but we shall be often much disappointed by the various astrin- gents, as gallic acid, alum, etc., which afford only partial relief. Oil of turpentine in doses of t^xx, has been much recommended, and has been fol- lowed by beneficial results. It is exceedingly important, that the patient should avoid those habits or excesses which have led to the disease; but advice on this subject is generally disregarded. In vicarious menstruation, our efforts should be directed to establish the proper and natural dis- charge, rather than immediately to check that from the stomach, unless it be excessive. Hip-baths, steel, aloes, and myrrh, change of air, exercise, OF DISEASE OF THE STOMACH. 93 the avoidance of all tight lacing or unnatural ex- citement, will probably restore the health. This form of haematemesis may, however, continue for a considerable period. Purpura haemorrhagica is generally best relieved by preparations of steel with acids, as the tincture of the sesquichloride of iron or the sulphate of iron, with sulphuric acid ; and I have more confidence in these than in gallic acid or the oil of turpentine. The latter sometimes produces vomiting, and pa- tients complain of its offensive character. Buspi- ni's styptic has in the hands of some been found most efficacious. Distension of the Stomach and Eructation.—■ Amongst the symptoms of gastric disease, flatulent distension and eructation are very distressing. There is usually some gaseous fluid present in the stomach even when in a quiescent state; but in abnormal conditions this becomes enormously in- creased. Several sources of gaseous formation have been described:— 1. That the gas is swallowed. 2. That it is produced by the decomposition of food in the stomach. 3. By the decomposition of the gastric mucus. 4. That it is evolved from the blood. 94 ON THE SYMPTOMS 5. That it passes from the duodenum or colon or some communicating abscess. 6. It may be produced by sloughing growth in the stomach. Ordinary food contains some atmospheric air in- corporated with it, and in the act of deglutition some air is also passed downwards with the food, or even with the saliva that is from time to time swallowed. If effervescent drinks are taken, then the exhaled carbonic acid must necessarily distend the stomach. But these causes are quite insufficient to explain the cases of distension of the stomach which are frequently met with in practice. The second source of gaseous repletion we have men- tioned, namely, the decomposition of food in the stomach itself, is doubtless frequently present in dyspepsia. It has justly been compared to fermen- tation ; and according to the changes induced we have carbonic acid evolved from a form of alcoholic fermentation. This, may be accompanied with the formation of the sarcina ventriculi of Goodsir; and with the development of vegetable growth lactic or butyric acid may also be produced. This kind of fermentation with sarcina we frequently find in cancerous disease affecting the pyloric extremity, in chronic ulcer and in spasmodic contraction of the pylorus. It may be well, however, to remark OF DISEASE OF THE STOMACH. 95 that the presence of sarcina is not an invariable sign of organic disease of the stomach; and sarcinae have been detected in other animal products, in the urine, in the feces, in pus, in pulmonary abscess, and even on the healthy mucous membrane. Again sulphuretted hydrogen gas is formed in the stomach by putrefactive decomposition of the food, and is generally accompanied by eructation of offensive gas. Distension of a distressing kind takes place, how- ever, from evolved gas in the stomach, even al- though no food has been taken; and the fact of chemical decomposition does not suffice to explain all these cases. It will frequently be found in those of enfeebled digestive power, that the very absence of food induces flatulent distension of the stomach. To pass for an hour or two beyond the accustomed period of refreshment is, with some, certainly fol- lowed by this symptom of fulness, if not of severe pain. Again, fermentation does not explain those instances in which from nervous excitement or hysteria great and sudden distension takes place quite unconnected with food. An explanation of these cases has been sought in the decomposition of mucus in the stomach, whilst others refer it to an evolution of gas from the blood itself. The quantity of mucus in the stomach in an ordi 96 ON THE SYMPTOMS nary state of the viscus is comparatively small, still it is quickly secreted, and a large quantity of saliva is swallowed ; these secretions very readily undergo change. Still there is nothing incompatible with the structure of the walls of the gastric vessels, that in some abnormal conditions probably con- nected with exhausted function of the vaso-motor nerve, an action should take place somewhat simi- lar to that which is the usual functional action of the capillaries in the lungs; and this view of the subject, a gaseous exosmosis from the blood, is con- firmed by the character of the gas itself, as consist- ing especially of nitrogen and carbonic acid gases, which are always present in venous blood. An occasional source of gas in the stomach con- sists in its regurgitation from the duodenum, or its passage through some fistulous communication with the colon. Gas of this kind contains a large quantity of sulphuretted hydrogen gas, and it has a fecal odor ; such instances are exceptional, and do not require further comment here. So also in in- stances we have known where an abscess communi- cated with the stomach, and the presence of offensive gas was explained by decomposing pus. And lastly, we may mention that when sloughing takes place in the stomach, gaseous evolution necessarily follows. OF DISEASE OF THE STOMACH. 97 Prominence of the epigastric region, however, does not always arise from distension of the stom- ach ; the fulness may be deceptive, and proceed from curvature of the spine, or the parietes of the abdomen may be weakened by constant artificial support, so that on its removal, especially if there have been firm bands around the lower part of the abdomen, distension is observed, which simulates gastric fulness. Again, enlargement of the colon is frequently mistaken for that of the stomach; and lastly, when there are effusions within the chest, the depression of the diaphragm leads to greater fulness than normal in the epigastrium. When the stomach thus becomes distended, the sensation produced is one of fulness and tightness, and if excessive, severe pain is the result; if spas- modic contraction of the pyloric fibres is induced, the pain, which is known familiarly as " spasm," at the stomach takes place. This painful symptom is relieved by gaseous eructation, and the discharge of flatus is promoted by stimulating, antispasmodic, and aromatic medi- cines ; the relief is generally speedy, but in condi- tions of great exhaustion in the stomach becomes apparently paralyzed, and the distension so increases that the viscus nearly fills the whole abdominal 9 98 ON THE SYMPTOMS cavity, and the impediment to the circulation be- comes the immediate cause of death. In organic obstruction and contraction of the pylorus the muscular walls of the stomach gradually yield, and the cavity becomes greatly distended; the greater curvature of the stomach may be seen reaching to the left iliac fossa, and it extends across the abdomen; the lesser curvature, with a depres- sion in the centre, is seen at the scrobiculus cordis, and in this state peristaltic movements may be seen passing from one side to the other of the distended stomach. After some hours, enormous quantities of fluid are ejected from this distended sac; the pain is sometimes severe, at other times the patient becomes faint. The heart is embarrassed, and death takes place from syncope. The distension of the stomach becomes so great that the muscular fibre is paralyzed. In close connection with the symptom just men- tioned is an offensive state of the breath; and the remark is often incidentally made, that in conse- quence of this condition the stomach "must" be disordered. It is frequently the result of the gaseous effusion or transfusion into the stomach, and small quantities are silently discharged, as op- posed to more sudden eructation. There are several OF DISEASE OF THE STOMACH. 99 fallacies, which have only to be enumerated to put the practitioner on his guard :— 1. Caries of the teeth. 2. Local disease of the nose or ear. 3. Disease of the tonsil; and sometimes the secre- tion from these glands is quite sufficient to produce the symptom referred to in a very marked degree. 4. Ulceration of the throat or oesophagus. 5. Diseases of the lungs and bronchi; cases of offensive breath from pulmonic disease are not confined to instances of empyema and asthenic or sloughing pneumonia, but are found in chronic bronchitis; purulent decomposition takes place from the retention of mucus and pus in the more dependent bronchi, and sulphuretted hydrogen is abundantly produced. 6. Purpura. Not only in severe purpura hemor- rhagica, with bleeding from, the gums, but in less degrees of purpura in connection with albuminuria and chronic hepatic disease, the breath becomes very offensive from decomposing blood ; the odor is peculiar and very characteristic, and at once recognized from that dependent on gastric disease. It must, however, be borne in mind, that during some forms of indigestion the saliva loses its natural alkaline reaction, the ptyalin more readily under- 100 ON THE SYMPTOMS goes decomposition, and thus communicates a per- ceptible odor to the breath. Siveetness of the breath is a condition very often observed in connection with gastric disturbance, when hepatic disease is also co-existent. It is very frequently, we might say almost constantly, the case, that in gastro-hepatic disturbance of young children the breath has a sweet smell. But it is not con- fined to them alone, it is also observed in older persons similarly affected. It may be, that this symptom is to be attributed to those chemical changes connected with saccharine products that the researches of modern physiologists have de- tected. There is still another condition of the breath to which we must refer. It is very commonly found, that in renal disease the stomach is easily disordered, and in some of these instances the breath has a pe- culiar odor; some have said, that it has an urinous smell, due to the abnormal presence of urea in the gastric and other secretions. Still it is not in every case of gastric irritation with Bright's disease that this can be detected, but in some chronic diseases and in acute urasmic poisoning. The condition of the gustatory sense is often some guide to the state of the digestive function. We do not refer to the state of the appetite, although loss OF DISEASE OF THE STOMACH. 101 of appetite is a common sign of indigestion and disordered stomach; and it is well that in acute irritation of the stomach the appetite should be stayed, for time is thus allowed for the disturbed organ to recover; but this is not always an advan- tageous symptom, for in atonic dyspepsia the ina- bility to relish food is a circumstance wjiich greatly retards recovery. The sense of taste is, however, perverted, so that dyspeptic patients complain of a sour or bitter taste, or it may be acid or saline, nauseous or sweet, arising from the conditions to which we have just referred. The condition of the tongue is an indication of the state of the digestive organs, and is an important guide in estimating the changing condition of the mucous membrane. It is the epithelium upon the mucous membrane, and upon the papillae of the tongue, which constitutes the characteristic "fur;" and since local changes are connected with the general state of the system, so these epithelial modi- fications indicate not only the condition of the mucous membrane, but of the whole organism. But since the tongue receives a large vascular supply, the state of its capillary vessels points to the condition of the circulatory system, not only of the mucous membrane, but also generally; and again, the tongue, as a muscular organ, has also a 9* 102 ON THE SYMPTOMS general as well as a special import. We shall not attempt to describe all the morbid conditions of the tongue, and the respective diagnostic value of each, but we may allude to several general conditions: First, as to the "fur;" in febrile states nutrition is hindered, and the tongue has a whitish fur; if the secretions b.e disordered, the fur is thicker and more distinct; if the strength be impaired, and the epithelial -covering readily undergo degenerative changes, the fur becomes browner in color, and in great prostration it becomes even black, as in typhoid conditions of the system. Secondly, as to the injection of the tongue, if the mucous membrane be in an irritable and congested state, the papillae of the tongue become congested, and often stand out distinctly from a whitish fur, the substance of the tongue is also rather smaller than normal. If more severe, the sides and tip of the tongue are redder than usual, and are preternaturally congested. In more chronic forms of irritation and ulceration, especially when the small intestine is affected, this congestion of the tongue is very marked; some- times it is merely the centre, which presents a clear reddened stripe, or there are reddened patches, or the whole tongue has a red beefy appearance; this state is often well marked in typhoid ulceration of the small intestine, and in strumous peritoneal dis- OF DISEASE OF THE STOMACH. 103 ease. Thirdly, in reference to the substance of the tongue itself, in irritable conditions the muscle is contracted, as we have just mentioned; but in atonic dyspepsia, in feebleness of the system gene- rally, as we find in anaemia with loaded colon, the tongue appears pale and large, and is indented by the teeth. The appearance of the tongue is, however, modi- fied by the state of the mouth, as- well as by food or medicine which may have been taken. A de- cayed tooth will produce a fur upon, that side of the tongue, and an irregularity of the tooth may cause local redness or ulceration ; nor must we lose sight of local disease of the tongue itself. In cy- nanche tonsillaris the whole mucous membrane of the mouth is involved. In some diseases of the nose the buccal mucous membrane becomes chroni- cally red and congested. Again, we find that in mercurial poisoning the salivary mucous mem- brane and its glands are inordinately affected. In syphilis and cancerous disease, also, local disease of a peculiar and distinctive kind is often present. In some irritable conditions of the stomach we find that aphthous ulceration takes place in the mouth ; and this state is sometimes present with general disorder of the digestive organs. The next symptom of gastric disease, or rather 104 ON THE SYMPTOMS of-indigestion in its various forms, is a disordered condition of the bowels. Sometimes we are told that the bowels act with great regularity, and that the evacuations are of a healthy kind, but more fre- quently we find that constipation exists, and that there is difficulty in obtaining ordinary relief with- out some foreign help; and when, as is often the case, there is more general disturbance of the chylopoietic viscera, and the liver and pancreas are also disordered, the evacuations become ir- regular, sometimes loose and changed in appear- ance, and paler or deeper in color than natural; and when intestinal affection also exists, the dis- charges are light or frothy, mixed with decompo- sing mucus, with changed epithelial products, or even with blood. A morbid state of the urine is an exponent of secondary assimilation rather than of any primary defect in the digestive process; but still it is ex- ceedingly important in gastric disease carefully to note the state of the renal secretion. Disorders of the stomach at once react upon the kidney and bladder, especially if there be any undue sensibility of these parts. Disturbed primary assimilation, the formation of a cruder chyle, and the absorption from the stomach of irritating products, are an ad- ditional tax on the excretory organs ; it may be, OF DISEASE OF THE STOMACH. 105 that an unusual quantity of lithates in the urine expresses the separation of effete material; but, if there be organic disease of the kidney or calculus, if there be any tendency to chronic cystic disease, to stricture of the urethra from any cause, then the gastric disorder is severely felt. In gouty dys- pepsia the urine contains an abnormal quantity of uric acid, and equally expressive are its indications in rheumatism, and in the imperfect digestion con- nected with hepatic and renal disease, with cardiac and pulmonary affections, with functional and or- ganic disease of the brain, and with diabetes. During the earlier part of the digestive process, the urine has been shown by Dr. Bence Jones to undergo remarkable change; it loses partially its acidity, and may even have an alkaline reaction. It is well also to remember the interesting observa- tions of Dr. Edward Smith, namely, that in children, in whom waste and oxidation are proportionately in excess, there is a larger quantity of urea present than in adults and in aged persons; and the same observer remarks, that in summer also the quan- tity of urea excreted is larger than during the winter months. Oxalic acid, with lime in the form of beautiful crystals, is often present in the urine of the dyspeptic, even when no article of diet con- taining that acid has been taken. In atonic dys- 106 SYMPTOMS OF DISEASE OF THE STOMACH. pepsia we have an excess of phosphates, and the crystals of the ammonio-magnesian phosphate. Other symptoms of gastric disease are connected with the vaso-motor or sympathetic nerve, or with the connection of that nerve with the cerebro-spinal system. Many of these we have alluded to in speaking of the sympathies of gastric disease: as the disturbance of the senses; the irritation of the extremities of the alimentary tract; itching of the nose and mouth or of the anus ; the irregular pains or perverted sensations of the extremities; the dis- turbance of the heart and of the respiration, produc- ing in the one case irregularity of the pulse and distress, in the other dry and irritable cough ; the irregular flushings of heat, and burning of the hands and feet; and, lastly, the disordered workings of the brain in its important functions, so that the dyspeptic becomes excitable and restless or depres- sed and melancholic, his days are passed in weari- some inertia, and his nights in restless dreams or in continued watchfulness. These symptoms, the burden of the dyspeptic, we have already spoken of, and need not further dwell upon them than to remark, that in functional disease the severity of the symptoms and the distress of the patient are often out of all proportion to the magnitude of the affection. TREATMENT OF DISEASE OF THE STOMACH. 107 CHAPTEE V. ON THE GENERAL TREATMENT OF DISEASE OF THE STOMACH. In no class of diseases is it more important to regard the system in its entire character than in the maladies before us, and amongst these general considerations the state of the mind stands foremost, for as long as that is unsettled and disturbed, mere medicinal treatment will have very little effect in relieving the symptoms. Intense mental anxiety will cause such an irritability of the stomach that the meal is at once rejected, and the only effectual remedy is to calm the mind, and to remove the causes of anxiety. Mental repose has a wonderful effect in conducing to the healthy performance of digestion. Anxiety will destroy the appetite, so will pleasurable excitement or intense exercise of thought; and as soon as the stimulus ceases, it is followed by a sense of exhaustion. Amidst beau- tiful scenery there may be no sense of bodily fatigue whilst the mind is entranced; hunger is not experi- enced ; but when at length the excitement is les- 108 ON THE GENERAL TREATMENT sened, the exhausted system may be unable to take the required refreshment, or, if taken, there is the inability to digest it. Sudden alarm, unexpected news, whether pleasurable or painful, take away the appetite, and may even induce rejection of food. In the treatment of these gastric maladies, perhaps more than in any other, the confidence of the pa- tient in the skill and diagnosis of the practitioner is an essential element of success. Without that confidence, every suggestion will probably result in an aggravation of the symptoms, and with it the simplest placebo will sometimes suffice to relieve functional disease. The effect of climate is very perceptible in stoma- chic disease. A damp relaxing atmosphere, a locality upon clay, where moisture is retained and preternatural humidity induced, have a marked in- fluence in perpetuating the symptoms of gastric affection, especially where atony exists, where the powers are enfeebled, and where a strumous dia- thesis renders the functions generally more easily disturbed. A dry bracing air tends to invigorate and to strengthen, and to the dyspeptic accustomed to a damp, confined situation it will often suffice effectually to ameliorate his symptoms. It is scarcely necessary to refer to the injurious influence of impure and miasmatic conditions of the atmos- OF DISEASE OF THE STOMACH. 109 phere, as affecting the gastric in common with other functions of the body. The ideas handed down to us from past centuries as to the "influence of the season upon the health, have been confirmed by the scientific observations of Dr. E. Smith, that there is the greatest amount of general vigor in the spring, and the least at the autumnal season ; and he infers, that the greater quantity of effete material during the summer months leads to the frequency of diar- rhoea and intestinal diseases. Amidst the multitudinous occupations of ordinary life there are some which tend in a greater degree than others to induce gastric complaints. Seden- tary pursuits, especially when associated with late hours, and with pressure upon the stomach, greatly impair healthy digestion; and too often the neces- sities of the system are disregarded, and insufficient time allowed for meals, or they are taken at too long intervals. Again, several hours spent in a hot and oppressive atmosphere, containing an ex- cess of carbonic acid, produces a sense of exhaustion and oppression, and the organic functions become less energetic. Some professional duties involve great irregularity as to the hours at which food is taken, and the strong and vigorous system can alone bear with these repeated disturbances with- out injury. 10 110 ON THE GENERAL TREATMENT As to numerous mechanical occupations, some are injurious from pressure upon the scrobiculus cordis, and from constrained position, as with the shoemaker, the tailor, the hand-loom weaver; in others the air is loaded with dust, but in these the respiratory organs suffer more severely than the digestive; and, lastly, the exhaled fumes may be of a poisonous character, as with lead, mercury, phosphorus, etc. Many of those whose trade requires the tasting of tea, cheese, butter, sugar, etc., become affected with troublesome dyspepsia. In general, an out- door occupation is better than one requiring con- finement; and that which is connected with vigorous exercise is better than one which demands a con- strained position. Another valuable agent in affording relief to the symptoms of functional disease of the stomach is change of scene. The mental effect produced by travelling tends in a powerful degree to act upon the functions of organic life. The locality may be really less healthy than the home, but the change is beneficial; the diet may be less digestible, but it is more easily assimilated; and it often happens that, when the thoughts continually revert to an organ affected with apparent or with real disease, anything that will draw the attention into other OF DISEASE OF THE STOMACH. Ill channels promotes cure or relief. Still more marked is the beneficial effect of change, when the anxieties of professional and commercial life are left behind, and when the confined atmosphere of a large town is exchanged for the invigorating influence of sea or mountain air. Lastly, we must refer to the ordinary circum- stances of the dwelling as greatly affecting digestion. In some cases we almost involuntarily ask our- selves, How can any one live in rooms so over- heated and ill-ventilated as many of our dwellings are ?—with a deficient quantity of oxygen gas to renovate, and an excess of the excreted carbonic acid—-it may be with the impurities of town gas, added to the defect of a small sleeping apartment. The strength becomes impaired, and a relief to the sense of exhaustion is often attempted by the use of alcoholic stimulants, which still further interferes with sound digestion. Having made these brief remarks as to the gene- ral treatment, we pass on to those measures which directly affect the stomach. 112 ON THE REMEDIES FOR INDIGESTION, CHAPTEE VI. ON THE REMEDIES FOR INDIGESTION, AND THEIR ABUSE. It would almost seem that during the last few years there is a mania for new remedies, and that the charm of novelty casts into disrepute those means which had previously been found of an effi- cacious character. The remedies we possess are more than sufficient if we know how rightly to use them ; and we are able to effect more by regulating the physiological conditions of digestion, than by confining ourselves to the mere administration of medicines. The remedies of diseases of the stomach may be divided into four classes. 1. Those which regulate the work the stomach has to perform. 2. Those which increase the digestive power by the addition of some of those agents, chemical or otherwise, which are naturally in operation during the digestive process. 3. Those remedies which remove the impediments of digestion. AND THEIR ABUSE. 113 4. Those general remedies which only act upon the stomach in a secondary manner; but to this latter class we have already referred in the last chapter. In the first class of remedies for gastric disease— namely, those which regulate the work the stomach has to perform—we find agents more powerful than any other in counteracting diseased action and functional irregularities. The numerous questions suggested by the requirements of the system as to diet and exercise become doubly important during functional disturbance, but there are several facts to be borne in mind which it may be well to notice en passant. Digestion must be regarded as not confined merely to the stomach, for it really com- mences in the mouth, and extends beyond the stomach. Starchy substances begin to undergo chemical change as soon as they are incorporated with the saliva: and although it is said that this change continues in the stomach itself, in that viscus it is rather nitrogenous food that undergoes solution. It seems probable also that the gastric juice is especially secreted under the stimulus of food, or from the intermitting action of the vaso- motor nerve. The experiments and observations made on Alexis St. Martin are most interesting on this subject, in whom an accidental perforation 10* 114 ON THE REMEDIES FOR INDIGESTION, through the parieties of the stomach enabled Dr. Beaumont to watch these otherwise hidden' pro- cesses, and a table was the result of his research, showing the length of time each substance required for its solution; but this knowledge is a very im- perfect guide in the treatment of the forms of indigestion. Other considerations are of paramount importance. Thus we have to consider— The proper intervals of food and the importance of regularity. Its right quantity. Its thorough mastication. The quality of the food and the changes by cook- ing. The necessity of variety. The effect of exercise on digestion. The interference produced by mental excitement. 1. The proper intervals of food might be con- sidered in reference to health and disease, and in relation to the age and habit of the patient. In early life it is necessary that supplies of nourish- ment be administered very frequently. At first every two hours; the interval is gradually increased to three and then four hours. At first by night as well as by day; but the nightly repetitions are gradually lessened, till they cease altogether. Again, in very advanced life, the intervals of the AND THEIR ABUSE. 115 meals must be again lessened, and food taken even during the night. This is very important in the feebleness of advanced life; the stomach is unable to bear very ample meals, and exhaustion is the result of long-continued abstinence. The majority of persons in ordinary health take three substantial meals during the day, at intervals of from four to five hours, but some regard two meals as ample for the necessities of the system and by habit this arrangement can be borne with- out any discomfort. During disease, however, the stomach is unable to bear the rules of ordinary life, and the system may require other methods. In states of great exhaustion it is necessary that food be given very frequently, varying from every two hours to every quarter of an hour; and we have known many in- stances of otherwise fatal exhaustion in serous dis- ease averted by the assiduous attention to this repeated administration. In irritable conditions of the stomach, where ingesta produce pain and cause their rejection, small quantities of bland nutriment are capable of being borne, whilst solids in the ordi- nary quantities are quite inadmissible. But it is not sufficient to allow of proper intervals between the meals; regularity as to the hours is needful, especially for the dyspeptic; to dine at every hour 116 ON THE REMEDIES FOR INDIGESTION, of the day, from noon till late at night, is an effec- tual method of producing and of perpetuating dys- pepsia. It has often been said that a larger quantity of food is taken than is absolutely needed; and this is very apt to be the case when the meals are hurried, and when the appetite is tempted by a great variety of dishes. We have already referred to the absolute quantity of food required by the system; but in this respect there is a great differ- ence in health and in disease. Imperfect mastication greatly increases the work of the digestive organs; for when the portions of aliment are thoroughly divided, they are more easily dissolved by the gas- tric secretions; and when left in large crude masses, they remain in the stomach even for many days, irritating and producing severe spasmodic pain. The action of the saliva upon the starchy portions of farinaceous food is also facilitated when sufficient time is allowed for the food to be thoroughly mixed. Again, the diet may be so changed by the modes of preparation as to be hard and indigestible, or be so acted upon by heat and admixture with other substances that secondary chemical action is very soon induced, and indigestion is the result, or if it has already existed, the malady is greatly aggrava- ted. It might seem strange, that if the diet be in AND THEIR ABUSE. 117 itself of a suitable character, it is still important that there should be variety; nevertheless change is needful for several reasons. The requirements of the system may demand for a short time the avoidance of animal and even of vegetable food, but if there be a too long continuance of farinaceous substances, the palate may become wearied till the stomach refuses to digest them; and so with the ordinary diet, it may be well adapted for the sys- tem, but be quite unpalatable. This needful va- riety in diet is often overlooked in laying down rules especially for the dyspeptic; and some of those things that may be in themselves less suitable may be found really more easy of digestion, because more agreeable to the palate. Although a simple milk and farinaceous diet may be continued for some time, we find that after about a month or six weeks some fruit or vegetable is required for the maintenance of health. I have known severe scurvy, with pupura and vibices, spongy gums and faintness produced in a dyspeptic, who for several months refused vegetable food. If active exercise be taken soon after a meal, unless digestion be rapid and in thorough integrity, flatulence is very likely to be induced, and some- times severe colic is the result. Semi-digested portions are more easily extruded through the py- 118 ON THE REMEDIES FOR INDIGESTION, lorus, fermentative changes are caused in the small intestine, and pain distresses the patient. The con- stant repetition of these practices—namely, hurried meals and active exercise immediately afterwards— induce oftentimes persistent dyspepsia. Not only should every meal be partaken of slowly, but a short time should elapse before active exertion is made. This is one among other reasons why the confirmed dyspeptic is greatly benefited, and able to pass his usual bounds, when on the Continent, and away from his usual avocations. He will sit down at the table d'hdte, occupying perhaps more than an hour at his repast, instead of the usual twenty minutes or quarter of an hour ; but moderate exercise one or two hours after a meal, promotes the digestive process; those portions of food which have undergone solution have probably passed the pylorus, and the stomach is less distended than when digestion is at its commencement. During the performance of any function in its full energy, more blood is sent to that part; thus, whilst diges- tion is going on, the pulse beats more quickly, but if at the same time the brain is actively at work, and demanding its full supply of nutrient material, there would seem to be a hindrance to the stomach's work, and digestion is less perfectly executed, and still more if the nervous system be so engrossed AND THEIR ABUSE. 119 that the action of the vaso-motor and pneumogas- tric are interfered with; the process is then rendered slow or almost checked. It is notorious that any sudden intelligence of an exciting char- acter, whether pleasing or distressing, completely destroys the appetite, and food can scarcely be taken; and if the senses be engrossed, the mind ab- sorbed, and the attention wholly directed to any subject, the sense of hunger is forgotten or not ex- perienced, so that even faintness may after a time be induced. An overwhelming sorrow appears to act not only upon the mental, but upon the physi- cal state; and if food be placed in the stomach after persuasion, it will remain as if unacted upon for a prolonged period. How essential, therefore, that the mind should rest, and that calmness should if possible be at- tained during the performance of ordinary diges- tion ! 2. A second class of remedies in gastric disorders are those which increase the digestive power by the addition of some of those principles which are natu- rally in operation during the digestive process. As we have before stated, digestion can scarcely be limited to the stomach alone, for the action of the pancreas and of the liver are important second- ary agents. Inspissated bile has long been used, 120 ON THE REMEDIES FOR INDIGESTION, and more recently a pancreatic emulsion. Among these remedies, then, we place pepsin, hydrochloric acid, lactic acid and lactates, inspissated bile, pan- creatine. Pepsin is one of the normal constituents of gas- tric juice, and, with the assistance of hydrochloric acid and of lactic acid, or both, it constitutes the most important solvent of the nitrogenous portions of our diet. If this constituent be insufficiently se- creted, the solution of food is imperfect, and it must remain undissolved or be taken in a smaller quan- tity ; and the object for which pepsin is administered medicinally is to promote artificially the solution of fleshy portions of food. Thus it was introduced by Corvisart, and into England by Dr. Ballard. It has been extensively used, and many have spoken very highly of its beneficial effects, when given alone, or variously combined; but when the vaso-motor nerve acts inefficiently, and the appetite is lost, it is far better to seek to restore these than to supply the lacking energy by extraneous help. The gastric juice contains lactic and hydrochloric acids, which, with the pepsin, constitute the most important chemical principles of the medium by which solution of the food is accomplished. Lt has been proposed to promote the digestive process by the addition of these acids. For a long period hy- AND THEIR ABUSE. 121 drochloric acid, in its dilute state, has been em- ployed, and we have frequently noticed its benefi- cial effect; but we find that its good result is due not only to the chemical reaction of the hydro- chloric acid as increasing the gastric solvent power, but to the effect upon the system generally, and to its local action upon the mucous membrane. Hy- drochloric acid is invigorating to a degree beyond that which is explained by its mere acidity. In this respect it differs from lactic acid and other lactates as medicinal agents. They are merely excretory in their character, and it is doubtful whether the lactic acid found in the stomach is really an essential ingredient. Lactic acid is abun- dantly produced in the secondary chemical changes which organic compounds of the food undergo, and is not in itself a beneficial and tonic medicine. Hy- drochloric acid is of service in those instances espe- cially in which we find digestion very slow, the appetite poor, the tongue large, clean, and marked by the teeth ; the food often remains in the stomach partially digested, and a sense of weight or painful distension from secondary chemical change is the result. The acid, then, tends to promote solution when given soon after a meal; but in these cases, even when given independently of food, its action is serviceable, for it appears to strengthen and in- 11 122 ON THE REMEDIES FOR INDIGESTION, vigorate the vaso-motor nerve. The lactates are of no service in this respect, and they tend after their absorption to oppress the system rather than to in- vigorate. The pancreatic secretion exerts an important change upon the oleaginous substances in the chyme, and, according to M. Corvisart, it acts upon the ni- trogenous also ; and pathological observations tend to confirm the opinion that the secretion from the pancreas, being of an alkaline character, serves, by its combination with the elements of oleaginous food, to promote their absorption into the system. In strumous disease, and in some forms of phthisis, fat is with difficulty assimilated, and the greatest benefit is observed to follow the administration of an oil easy of assimilation, such as cod-liver oil. Dr. Horace Dobell traces the proximate cause of phthisis, etc., to some imperfect action of the pan- creas, and has proposed that an emulsion should be formed from the pancreas of lower animals, and states that thus used it may promote the absorption of fatty portions of food. This remedy may be placed in the same category with the secretion from the liver, as given in the form of inspissated bile. Bile naturally acts as an aperient; it retards fermentative changes, and when from numerous causes the liver seems to act ineffi- AND THEIR ABUSE. 123 ciently, and the bowels are confined, it has been proposed as a substitute for the natural supply. These remedies are one step in advance of the phi- losophical remedy of phosphorized oil when the brain substance is defective. 3. A third class of remedies in gastric disease are those which remove the impediments of digestion; but these will be noticed especially in the consider- ation of the different forms of dyspepsia. A state of active or of passive congestion of the mucous membrane interferes with the healthy secretion of the gastric juice, and thus prevents normal diges- tion ; or the mucous membrane becomes so intensely irritable that it cannot tolerate the presence of food ; and to lessen this sensibility is to take away a o-reat hindrance to the normal work of the stomach. Again, the secretion may become of an unhealthy character from other disease, such, for instance, as in Bright's disease of the kidneys, when the gastric juice contains urea; or direct pressure may be exerted upon the stomach, so that the requisite expansion and movements cannot be executed; and, lastly, fermentative changes are in some in- stances induced in the semi-digested mass, gaseous and acid products are formed, and numerous dis- tressing symptoms are the result. It is our object to ascertain what are these impediments to the 124 ON THE REMEDIES FOR INDIGESTION, healthy exercise of functional energy, and if pos- sible to remove them. It is not by the blind treat- ment of any mere symptom that we can effectually do this, but rather by the removal of the causes themselves, although we may be compelled by the urgency of some particular symptom to make its relief the primary object of treatment. Alkalies are given to diminish irritability, espe- cially soda and potash, as also magnesia and lime in solution, nitrate of bismuth, nitrate and oxide of silver, and, at Dr. Leared's suggestion, the black oxide of manganese. Sometimes anodyne and anti- spasmodic remedies assist materially in diminishing this same abnormal sensibility—morphia, opium, henbane, belladonna. Active and passive congestions are relieved by mercurials, which stimulate the glandular organs generally, and act upon the bowels, thus unloading the portal system, as well as by purgatives and by ipecacuanha. A relaxed and atonic state is miti- gated by sulphuric acid, nux vomica, and tonics generally. Fermentation is checked by carbolic acid and by creasote, by the hyposulphites and sul- phites, by charcoal. But these and other agents that remove the local hindrances of digestion, and facilitate the process, we shall have to notice more particularly. AND THEIR ABUSE. 125 4. A fourth class of remedies in disease of the stomach of a functional kind are those general agents which act in a secondary manner upon the stomach. They are amongst the most important and powerful remedies that we possess for the alle- viation of these maladies. To those in whom the cares and fatigue of an active life have exhausted the strength of the system, and in whom the stomach, as part of that system, is in an enfeebled state, the invigorating effect of rest and change, of bracing highland and mountain air, of a complete unbending of the mind, and repose from its wonted pursuit, is more effective than merely medicinal treatment. Mental distress and anxiety are effectual barriers to digestion, and far more easy is it to pre- scribe a medicinal stimulant than to calm the mind and quiet perturbed feelings; and we believe that the province of the physician extends much farther than the mere thought of the present bodily ail- ment, if he would restore to healthy exercise the living organism in all its working powers. There are medicinal substances, however, which, in their stimulant and tonic character, serve to assist in exciting the vaso-motor nerve to more energetic action. On the Hypodermic use of Remedies, and Inhala- tionm—As the most easy method by which medicines 11* 126 ON THE REMEDIES FOR INDIGESTION, can be absorbed is through the stomach, it is gene- rally made to bear the presence of agents which greatly interfere with its own function. Thus as- tringents are applied to its surface, whilst it is often expected to exert its full energy; irritants are brought into contact with it; alkalies neutralize its secretion, and thus destroy the solvent power of the gastric juice; opiates deaden its sensibility, whilst they also check its secretion. It must be confessed that the stomach is often used amiss. It is over- taxed in health, and during the progress of disease, whilst it suffers as part of the general system, it is made to bear the presence of all kinds of remedial agents—a sort of living fulcrum on which the phy- sician exercises his powers of controlling and stay- ing disease. But although generally a willing agent, it sometimes becomes rebellious and uncontrollable. Other methods, however, are in use, and may be applied with some prospect of success. There is the epidermic, as well as the endermic mode of admin- istering remedies. The use of enemata might be employed more frequently than it is with great benefit, and the inhalation of remedies is a method that has been often lost sight of, because more troublesome in its application. As to the epidermic method, a thick layer of epithelium renders absorp- tion very slow, so that this is one of the most tardy AND THEIR ABUSE. 127 means of inducing medicinal action. Continuous contact upon the surface of the skin is used, as when a belladonna plaster is applied, or iodine pencilled upon the part affected; or inunction is employed, as when oleaginous substances are rub- bed in, whether of a simple kind, or containing irritants, as croton oil; or the remedy may be used in the form of a bath, as the sulphurous or nitro- hydrochloric acids, and in this way nutrient mate- rial has been introduced into the system, as by bath- ing, or placing portions of the body in milk. The endermic or hypodermic method has of late years been extensively employed, first, by Kurzack, Eeid, and Eynd, for the relief of symptoms by local injection into the skin, and then for the production of general symptoms by Dr. Hunter. Modern chemistry has so separated the active principles of many medicines in the form of vegetable alkaloids, that a full dose may be administered in a very small quantity of solvent; and it must be borne in mind that the hypodermic method insures the most rapid absorption into the system ; a smaller dose is therefore required to produce the same effect as that produced by ordinary absorption from the mucous membrane. A quarter of a grain of mor- phia might be taken with comparative impunity by an adult, but the injection into the cellular 128 ON THE REMEDIES FOR INDIGESTION, tissue of this minute quantity has been known to induce almost fatal coma. Quinine, atropia, and aconite may be used by this method, but the latter alkaloids require extreme care. Amongst the valuable remedies we possess for the relief of gastric disease, there are some which have in many instances, by their improper employ- ment and abuse, produced serious results ; we refer especially to the unwise use of alkalies, purgatives, mercurial medicines, and ardent spirits. Alkalies.—Some of the familiar symptoms of gas- tric disorder are correctly attributed to an excess of acid in the stomach, whether from direct secretion of gastric juice, or from secondary formation conse- quent on chemical reaction. Heartburn, and other allied conditions, thus induced, are often immedi- ately relieved by the carbonated alkalies of potash, of soda, or of magnesia; and many persons on the return of the symptom at once resort to this pallia- tive measure, and repeat the alkaline remedy, or the habit is acquired by some of taking an alkali after nearly every meal. In this way the solvent power of the gastric juice is greatly interfered with, for its natural acidity is destroyed, and we have known a state of general weakness and exhaustion gradually induced by such practice. There are also other conditions in which alkalies AND THEIR ABUSE. 129 are given with advantage, even in large doses, and for a considerable time; we allude to the presence of calculus in the kidney, to diseases of the bladder, to gouty dyspepsia, and to rheumatism, etc. The excessive use of alkalies, even in these cases, greatly injures healthy digestion, and is followed by ex- haustion, pallor, irritability of the nervous system ; the blood is apparently changed in character, and the relative quantity of the red corpuscles dimin- ished. As an alkaline salt, the chloride of sodium, common salt, is an important ingredient of our or- dinary food ; but in excessive quantities it is not only an irritant, but when by habit the mucous membrane can tolerate its presence, the blood is changed, and we have seen marked purpurous spots covering the skin from this cause. A patient had been in the habit of thickly spreading table salt on his bread, morning and evening, nearly a quarter of an inch in thickness; the purpura disappeared when the habit was discontinued, but he felt it a great deprivation to be debarred from his baneful excess of salt. The salts of magnesia have in some instances been found in concretions in the intestine, but it is only when the carbonate or the simple magnesia has been taken in very large quantities or for lengthened periods, that such a result has followed. 130 ON THE REMEDIES FOR INDIGESTION, Piirgatives.—Few remedies afford greater relief in many forms of dyspepsia, especially those con- nected with portal and hepatic congestion, than a free purgative action on the bowels ; a sense of depression and exhaustion is often associated with congestion of the biliary organs, and free action is followed by renewed feelings of healthy elasticity and strength. This circumstance has led to the too frequent use of the Abernethian remedy of a blue-pill and black-draught; and it is unfortunately given when an opposite plan of treatment is re- quired. Again, it has been supposed that a daily relief from the bowels is essential to health, and purga- tives are often given to induce this action; and when, especially in early life, constipation becomes obstinate, purgatives are unfortunately repeated, and persisted in, so as to compel a continuous ef- fect. Irritation of the mucous membrane is the result of this mal-treatment; and we have fre- quently witnessed chronic inflammation of the colon, and the discharge of mucous secretion induced, so as to trouble the patient for many months. The stimulus thus acting upon the alimentary tract must be repeated to produce similar action, and the strength of the remedy is gradually in- creased ; inactivity of the bowel follows, with dis- AND THEIR ABUSE. 131 tension ; for, with increased size, greater contractile power in the involuntary muscular fibre is required. This distension of the colon is a troublesome and distressing symptom ; the abdomen is enlarged, the stomach is pressed upon by the enlarged transverse colon, and it often happens that an inactive condi- tion of the sigmoid flexure and rectum distress the patients for a lengthened period. By entirely leaving off medicinal irritants, and using measures calculated to invigorate and strengthen the system, especially walking and horse exercise, the healthy tone of the alimentary tract is gradually regained. The diet must be regulated; enemata are often of great service, and in some cases an electro-galvanic current will act as an effectual stimulant to the enfeebled mus- cles. Mercurials.—With all the vaunted improve- ments of modern science in therapeutics, mercurial medicines are given in a very indiscriminate man- ner, and most injurious results often follow their use. Because relief is produced in some cases, therefore, if a patient have a furred tongue, with pale evacuations, or constipation, he is pretty sure to have the benefit of blue-pill or calomel. In children this injudicious proceeding is the cause of hyperemia of the mesenteric glands, and often, I 132 ON THE REMEDIES FOR INDIGESTION, believe, of strumous deposit; and in adults, a form of chronic muco-enterite is induced. If the action be excessive, great prostration is soon evident; and if the mercury be continued so as to affect the system, the vaso-motor nerve is enfeebled in its action, nutrition is impaired, pallor is produced by the diminution of the red corpuscles in the blood, general cachexia follows, and many months may be required to regain strength. Alcohol.—Great responsibility attaches to medi- cal practitioners in their recommendation of ardent spirits in the treatment of disease ; and the public are too prone to resort to them for the imme- diate relief of gastric symptoms and of weak- ness. There can be very little doubt that the relief of flatulent distension of the stomach is often pro- moted by these means ; but we especially see the beneficial result in the direct stimulant action to the vaso-motor nerve. Severe pain may be re- lieved ; and in states of great nervous exhaustion, and in feebleness of the circulation, wine and ar- dent spirits may enable the patient to partake of food, and to digest it, when otherwise none would be taken. Ammonia, steel, and such remedies, will not supply the place of alcoholic stimulants in these cases. Many lives have been saved by the right AND THEIR ABUSE. 133 use of alcoholic liquors, but unfortunately that which the physician may prescribe as the require- ment for shortening disease becomes the habit: and, however diluted they may be, ardent spirits as a constant beverage are productive of injury. And although many of the direct experiments that have been made in reference to ardent spirits checking digestion are comparatively valueless, because the alcohol was used in a strength very rarely, if ever, voluntarily taken, there is no doubt that alcohol irritates the mucous membrane, especially if given in a concentrated form, so that the mucous mem- brane becomes reddened, and the secretion of the normal gastric juice is checked. From the free use even of wine and malt liquors we often find a state of sub-acute inflammation of the stomach produced ; congestion of the liver and enlargement follow. This state gives place to chronic dyspepsia, very frequently to the vomiting of blood and to a disordered state of the whole ab- dominal viscera. Organic degeneration of the liver and kidneys often succeeds, or chronic ulcer of the stomach, with its attendant miseries ; an athero- matous condition of the arteries and capillary ves- sels is another sequence of alcoholic imbibition; and this again becomes the cause of valvular dis- 12 134 ON THE REMEDIES FOR INDIGESTION. ease of the heart, and it may endanger life from apoplectic effusions into the brain. Alcohol may be a most valuable medicine, but the abuse of it entails innumerable miseries, and that which may be of temporary benefit becomes direct injury when unnecessarily continued ; the temporary requirements of disease and of a failing circulation are never meant to be the guide of nor- mal health; and if large doses of stimulant be continued, organic disease will almost invariably follow. DYSPEPSIA FROM WEAKNESS. 135 CIIAPTEE VII. DYSPEPSIA FROM WEAKNESS.—1. FROM IMPERFECT NUTRITION AND FROM DISEASED VESSELS. 2. FROM EXHAUSTION OF THE CEREBRO-SPINAL NERVOUS SYSTEM. 3. FROM EXHAUSTION OF THE NERVE OF ORGANIC LIFE.—ATOXIC DYSPEPSIA. As an expression in the science of medicine, weakness is both indefinite and of various import, and we should be unwilling to make use of it in describing imperfect functional energy of the stom- ach, did we not recognize a class of cases to which the term may be justly applied. Want of strength may be real or imaginary, real, when due to gene- ral exhaustion, imaginary, when any impediment to the performance of healthy function or the sepa- ration of excreta embarrasses the system ; and when in exhaustion and general weakness the stomach cannot perform its digestive function, the feebleness is increased, because the supply of fresh formative material is cut off. The varieties of exhaustion may be traced to three sources. 1st. The exhaustion connected with diseased vessels, as exemplified in advanced life. 136 DYSPEPSIA FROM WEAKNESS: During thevearlier stages of life, general functional activity is maintained at a high standard, the wear and tear of the system is considerable, and fresh increment is required for the general growth of the body; but during its later stages a contrary state exists, the organism works at a slower pace, the wear and tear is less, and it is not necessary that the same energy of the digestive organs should persist. It is well known, that in old age the ves- sels become rigid and atheromatous, the blood is less freely distributed, and there is less ability in the economy to restore preternatural disturbance, and less elasticity of the system ; as in the autum- nal leaf of the tree, the nutritive changes are more sluggishly performed, the vessels gradually become obstructed, and at length almost obliterated, so that in course of time the connection with the parent stem is easily severed; thus also in ad- vanced life functional activity lessens, till at length it fails altogether. The same diminished power is observed in the enfeebled digestion of aged persons, as we have previously remarked; they are conscious that the function is not so energetic as it formerly was, and, indeed, they are aware that the necessity for supply is also lessened, the bodily activity is less, and the appetite for food is proportionately small. The ATONIC DYSPEPSIA. 137 fact of this decreased functional power is testified by the structural changes in the several organs themselves: the muscles are less vascular, they contract with less power, and undergo degenerative changes; the inner membrane of the arteries be- comes rough and atheromatous, the minute capil- lary vessels become thickened and degenerated, and present highly refracting particles from fatty metamorphosis. In the nerve centres there is a large quantity of pigmental deposit, the bones be- come more brittle, the fibrous tissues are more dense, and undergo partial ossification, and the glandular organs diminish in size; thus in every structure there is the manifestation of the same fact, and the weakness of digestion is only a part of the general debility. It is doubtful whether this condition of weakened digestion is due to the want of energy in the glands, or to the impeded flow of blood from atheromatous vessels, or to the degeneration of the nervous ele- ments of the large ganglionic centres ; still the fact remains, and it often becomes a question of the greatest importance, how the failing power of the stomach may be revived, and how renewed energy may be given. AVe have already stated, that the appetite in old age is lessened, but it is sometimes found that it almost wholly fails, and the other 12* 138 DYSPEPSIA FROM WEAKNESS: vital functions and reparative changes are reduced to the lowest degree. If food be taken, there is no ability to digest it, and it remains in the stomach, producing pain, and a sense of weight and oppres- sion ; these symptoms may be accompanied by headache and faintness, and not unfrequently are followed by flatulence, and sometimes severe colic. The functions of the brain may become so disturbed, that symptoms of threatening apoplexy are pro- duced, as loss of consciousness, impaired or dis- turbed vision, and vertigo; the tongue appears to lose for a time its right muscular movement, the pow- er of speech is gone, the words cannot be spoken, or the wrong word is substituted; numbness of the hands, or even temporary loss of power, is expe- rienced, and these symptoms singly or together produce considerable alarm to the patient and his friends. The vessels of the brain in advanced life become rigid and atheromatous; and we often find the middle cerebral and the basilar arteries at the base of the brain resembling bony tubes; the minute capillaries in the pia mater, and in the brain sub- stance, are similarly affected, so that it is not sur- prising that with functional derangement of the stomach these serious symptoms of threatening brain disease should occur. The valves of the heart in advanced life become ATONIC DYSPEPSIA. 139 also atheromatous, and its muscular fibre undergoes degeneration, so that from trifling causes the action becomes irregular, and dyspnoea and palpitation are soon induced; thus patients affected with gas- tric disturbance frequently refer the ailment to the heart. Again, the difference that is presented by the abdominal glands in early and advanced life is most marked, and is shown in every part of the organism. The mesenteric glands in infancy constitute dis- tinct, oval glands, which are highly vascular, and evidently possess great functional activity; in old age it is, on the contrary, often difficult to find them, and they may then only weigh a few grains. The liver in early life has proportionally a much larger volume than in old age, so also the kidneys; and although it is an opinion only based on hypothesis, we do not doubt that the gastric glands undergo similar atrophy. To this circumstance, then, we must look for one cause of the imperfect solution of food, which takes place in aged persons; but the diminished appetite and general feebleness have reference also to the state of the nervous system, and especially of the vaso-motor nerve. Still it would be both erroneous and injurious in its tendency to regard this lessened functional activity as necessarily constituting dis- 140 DYSPEPSIA FROM WEAKNESS: ease, or to seek to attain the standard of early or middle life. The wants of the system do not require such a condition; and it is remarkable that comfort- able health and vigor are often maintained for months, and even for many years, upon a diet form ■ ing only a small relative part of that which is usually taken in middle life by the same person. This feebleness of digestive power in aged per- sons is of great importance when disease affects other parts of the system, for then greater work is required from an organ, the functional activity of which may have been reduced almost to a minimum. Now, although we cannot restore organs already degenerated, or revive the elasticity of youth, still much may be done to remedy this state, and there are three sources of alleviation available to us:—1. The administration of such a diet as the enfeebled stomach can digest, and the judicious use of stimu- lants. 2. The regulation of the general habits and condition of the patient, so that as far as possible strength may be economized, and the necessity for unusual activity of the digestive power guarded against. 3. The right use of medicines, as far as they may be called for. In reference to the first, as to the proper diet, it will often be found that the stomach may be spared very much by the use of fluid diet, and by farina- ATONIC DYSPEPSIA. 141 ceous food; and when this atonic dyspepsia is severe by an imitation of infantile food, milk with soda- water, cream with arrow-root, soups, etc. Nutri- ent enemata are of some service in extreme cases, but especially when acute disease supervenes upon this state of exhaustion. When the symptoms are less severe, and solid diet can be digested, we must still give that which is easily assimilable, and free from hard and insoluble ingredients. As to stimulants in the atonic dyspepsia of ad- vanced life, if taken in excess they increase the ex- haustion, because they interfere with glandular activity and integrity; but, with wise precautions, stimulants excite the stomach to more active se- cretion, and more powerful digestion ; a small quan- tity of brandy or other spirit may in this way be advantageously added to milk, and wine judiciously administered often acts in a similarly beneficial manner. The second object of treatment is very import- ant, namely, to spare strength by the avoidance of excessive fatigue, whether physical or mental, to take every precaution against sudden extremes of temperature, and to maintain as far as possible an equable atmospheric condition. Moderate exercise is greatly conducive to the maintenance of strength, and to the healthy performance of every function; 142 DYSPEPSIA FROM WEAKNESS: and it affects no function in a greater degree than that of digestion. The habit of snuff-taking and smoking produces a relaxed condition of the mucous membrane of the stomach, and impairs its digestive powers ; and al- though for many years the habit may have been indulged in apparently with impunity, still when the strength is diminished, this additional cause of exhaustion may prove extremely detrimental. Strong tobacco acts as a powerful sedative, but when the grains of snuff are directly applied to the stomach, as in inveterate snuff-takers they certainly are, the injury is much greater than such patients are willing to allow. In advanced life we have found this habit, although for thirty or forty years persisted in with apparent impunity, then become most pernicious in its effects. 3dly. Medicines are not without value in these instances. We may briefly indicate some of them, and the first that we may mention is the sesqui- carbonate of ammonia; its primary action is as a stimulant to the mucous membrane and to the vaso-motor nerve, and in this way it serves a doubly beneficial purpose. Condiments with food have a direct stimulant action on the stomach, and one can understand that the old remedy of mustard seed ATONIC DYSPEPSIA. 143 was of service ; pepper, cayenne, curries, etc., act in a similar manner. It will be found that a more beneficial stimulant effect may be induced by small doses of the prepa- rations of iron, as the tincture of iron with chloric ether and tincture of calumba, or a dinner pill con- taining a small quantity of steel pill with cayenne and rhubarb, or if needful a small admixture of the aloetic pill. Dilute hydrochloric acid with vege- table bitters may be tried, and as a natural con- stituent of the gastric juice, the acid promotes solu- tion of food; the preparations of pepsin may be used, but we must not expect much benefit from them. It is less, however, by any direct medicinal treatment that we can relieve the atonic dyspepsia of advanced life, than by careful attention to those rules of health and diet by which declining strength may be spared. Special symptoms and causes of disturbance will require special attention and are amenable to right treatment; but medicine is not the chief means at the disposal of the physician in these cases. A second cause of atonic dyspepsia will be found in exhaustion of the cerebrospinal nervous system. Mental distress and excitement, great anxiety and 144 DYSPEPSIA FROM WEAKNESS I physical fatigue, constitute this most frequent cause of dyspepsia. After much anxiety of mind, close intellectual application or research, whether the result of lite- rary pursuit or the competition of commercial en- terprise, the impress of the mental state is stamped upon the whole physical organism. The linea- ments of the countenance portray the operations of the mind, the sunken eye, the contracted pupil, the careworn expression, the restlessness of manner, all show that the mind has been taxed beyond the power of the body. In a subject of this kind, there is pallor or sallowness of the countenance, sleep is very transient, easily broken, and often disturbed by dreams; there is headache or giddiness, the tongue is slightly injected in its papillae, and has a whitish fur, sometimes it is large, indented, and clean; the pulse is sharp, compressible, and irrita- ble ; palpitation of the heart, throbbing sensations, and often pain in the head are produced; there is sometimes nausea, or actual vomiting; the bowels are constipated or irregular, the appetite is dimin- ished, or entirely absent, and if food be taken, it is felt to remain as an undigested mass, producing weight and pain at the scrobiculus cordis; some- times it is followed by a throbbing sensation in the abdomen, and almost over the whole body, with ATONIC DYSPEPSIA. 145 languor or drowsiness ; at other times there is faint- ness after food; and when undigested portions pass into the pylorus and duodenum, violent cramp or spasmodic pain is produced. Ingesta may be retained in the stomach for many hours, and in some cases even for days, in a crude state ; the secretion is not sufficient to dissolve what is placed in the viscus; the irritation produced by the retained food aggravates the ailment, and fer- mentation or decomposition is set up, with flatu- lence, pain, heartburn or severe gastralgia. This imperfect solution, however, may arise from excess of food, rather than from diminished solvent power of the gastric juice. After any sudden mental shock, this state of comparative cessation of the digestive powers is painfully shown, the smallest quantities of food ex- citing pain, headache, and distress; the heart, al- ready feeble in its action, is still more disturbed by attempted digestion, and actual syncope may be the result, or colic and vomiting ; the bowels are in this state generally confined, but they sometimes become irritable. It may be, that in this condition of nervous ex- haustion the stomach receives an insufficient supply of blood, and that the mucous membrane is in an amemic state; but there can be very little doubt 13 146 DYSPEPSIA FROM WEAKNESS: that the intimate connection of the vaso-motor or sympathetic nerve of the stomach with the cerebro- spinal centres determines this marked effect upon the digestive function. Numerous instances of this effect of the mind upon the physical organism might be adduced; it is familiar to every one how bad news will destroy the appetite, and that the sight of disagreeable and offensive objects disturbs the stomach ; but graver and more persistent symp- toms arise when the mind is overcome by the sudden removal of some beloved relative, or when it is agitated by great alarm and sudden fright, or over- whelmed by unexpected reverse of fortune.' It will often be found that, whilst others may have forgotten some event which for the time produced universal sympathy, the effects are long seen by the physician, upon those immediately concerned; years may elapse, and the effect on the physical or- ganism may still persist, and it is frequently found that a functional disturbance of the stomach thus produced, is followed by organic change; this dys- pepsia at first may be only functional, but it slowly gives place to the signs of cancerous disease of the stomach or liver; thus it was with the great Napo- leon at St. Helena, and thus it has been with very many who have come under our own observation. The same connection of nerve supply explains ATONIC DYSPEPSIA. 147 the loss of appetite, and the inability to digest food after great physical fatigue; how often is it found that strength is so reduced that a person cannot partake of nourishment! A strong and vigorous young man may be so exhausted by the fatigue of a mountain climb as to be utterly unable for a time to take that which the system so urgently requires; and in a less degree the same state is continually observed. The large nerve ganglia of the abdomen may, however, not only be affected secondarily by the state of the mind, and by the centres of ordinary sensation and motion, but they may become direct- ly involved; and this leads us to a third source of atonic dyspepsia, namely, exhaustion of the nerve of organic life. A certain amount of nervous energy is required for the digestive process, in order that gastric juice in sufficient quantity, and of a healthy kind, may be poured out, that the necessary mus- cular movements may be performed, and that the temperature best fitted for the solution of food may be maintained. In chronic disease, as the powers of life gradually wane, there is inability to take or to assimilate the nourishment the system so much requires; and it is often in vain that we afterwards search in the stomach itself for the cause of this feebleness, al- 148 DYSPEPSIA FROM WEAKNESS: though sometimes we find the mucous membrane affected with fatty degeneration, or the minute capillaries of the surface involved in lardaceous disease. This form of atonic dyspepsia is of very common occurrence amongst those who are in circumstances of poverty and want; hard labor and corroding care, insufficient rest and pining hunger, induce a condition' that is very familiar to those who have seen much of hospital and dispensary practice, or who have seen disease amongst the poor. The spare appearance, the dejected and careworn coun- tenance, the complexion partially bronzed, irregu- larly sallow, the eyes sunken, the tongue clean, or irregularly furred and injected at the tip and edges, irritable cough, the pulse sharp and compressible, pain at the scrobiculus cordis, and flatulence after food, mark this state; very frequently the stomach becomes so sensitive that the food taken is quickly rejected, the bowels are easily disturbed, so that diarrhoea supervenes. It might be thought that in dyspepsia from exhaustion the appetite would be craving, and that a generous diet would at once be digested. This is, however, not the case; the appetite is lessened ; and the solvent power of the stomach is so diminished, that solvents cannot be ATONIC DYSPEPSIA. 149 dissolved, and if swallowed they produce headache, vomiting, and pain. In early manhood, especially if growth has been rapid, a state of general weakness is often induced, and atony is the result; inactivity of body, head- ache, dilated pupil, compressible pulse, and feeble- ness of digestion follow. There is a sense of appa- rent exhaustion, the mind often becomes dejected and melancholy, the more so if these symptoms be associated with any other cause of undue loss of strength. Trashy publications and advertisements tend to increase the mental depression, and the practice of the imposter is to magnify the symp- toms to increase his own gain. This state is still more marked in young women, in whom the sys- tem undergoes even greater change at the period of commencing menstruation; and without great care, the stomach, at first irritable, induces painful digestion ; the supplies are gradually lessened, and disease becomes confirmed ; animal food is left off, and simply tea or dainties are preferred; exercise in the open air is avoided if possible, from the con- sequent fatigue and exhaustion; this still more increases the atony, and at length marked chlorosis results; then we have a waxen countenance, dilated pupil, severe headache, nervous depression and ex- citement, throbbing of the heart, pain under the 13* 150 DYSPEPSIA FROM WEAKNESS: breast, pain at the stomach after food, sickness, flatu- lence, constipation or irregular bowels, as the symp- toms. In this state of exhaustion, tubercular deposit may take place in the brain, lungs, mesenteric glands, ovaries, etc., and one or other form of phthisis be induced. I have had patients under my care, who had gradually reduced their scale of diet, till one article after another had been left off, and the die- tary consisted only of small quantities of bread with tea; the countenance becomes as pale as white paper, and the physical strength is gone. With right treatment and perseverance in it, such atonic dyspepsia is entirely removed. This state is closely connected with that form of sympathetic dyspepsia, especially observable in young women, to which the term of " regurgitative disease" has been applied by Sir Henry Marsh, of which the prominent symp- tom is excessive irritation of the stomach; but to this further reference will be made. After child- bearing, and especially when that is followed by prolonged lactation, the whole power of the nutri- tive system becomes well nigh exhausted, and atonic dyspepsia is a common symptom. The face, and especially the forehead, often becomes irregularly bronzed in patches, the headache is severe, either at the vertex or at the temple, the mind is de- pressed in some cases, disturbed by vague apprehen- ATONIC DYSPEPSIA. 151 sions, or prompted to suicidal or homicidal acts, distressing dreams suddenly arouse the patient at night; ringing noises in the ears are experienced; the eyes are intolerant of strong light; the pulse is. compressible ; the stomach and bowels are irritable, causing either diarrhoea or vomiting, or both; the appetite is poor, and faintness is often felt, or there is a sensation of abdominal exhaustion and empti- ness. The same condition is observed in the exhaustion from other causes; from severe hem- orrhages, from excessive menstruation and leucor- rhoea, and in the convalescence from acute diseases. Mercurial medicines, if continued so as to affect the system, cause general depression, exhaust the nervous energy, and relax the mucous membrane, and thus induce dyspepsia of this form. Tobacco is a powerful depressant, and although, after its moderate use, it has a soothing effect on the nervous system, and it renders the intellectual power more vigorous, we often witness that in habitual smokers the heart is enfeebled, the mucous membrane re- laxed, the appetite is lessened, and a form of atonic dyspepsia results. This is still more apparent in great snuff-takers, especially if smoking be com- bined. The state of the nervous supply to the mucous membrane of the stomach and its glands is the probable cause of these * symptoms. Large 152 DYSPEPSIA FROM WEAKNESS: branches are sent from the semilunar ganglia upon the coronary arteries to every part of the stomach, and it is by their influence that the gastric juice is poured out at its proper time, and in its proper quantity. The mere presence of food in the stom- ach will not induce further gastric secretion, if nervous energy be wanting. The enfeebled state of the nerve power is not, however, limited to the stomach, but the heart and its cardiac plexus are in a like state, and the supply of blood to the stomach is thus rendered insufficient. The attacks of faint- ness may be explained in the same way, namely, that a larger supply of blood being sent to the stom- ach, less is conveyed to the brain, causing a tem- porary failure of power. I have observed actual syncope, as the result of the slight disturbance to the circulation from urging exhausted patients to take solid food. In persons who are inordinately stout, we find feebleness of digestion, and this is in part due to the state of the vaso-motor nerve. The symptoms arise from the feeble condition of the heart and circulation, and are increased by an in- active state of the liver. A greater amount of food may be taken than can either be digested, or is needed for the system, and it consequently induces a sense of weight and exhaustion. Although the appetite is often small in stout persons, it is not ATONIC DYSPEPSIA. 153 always so, it may be both fastidious and one that has been pampered with highly seasoned and indi- gestible diet; the hydrocarbons are stored up, in- stead of being removed in the ordinary changes of re'spiration, etc.; but the mischief is still further increased when the heart is irregular from an excess of fat about it, or when the feeble circulation of the brain manifests itself in vertigo and disordered sensations. Much relief is afforded by occasional alteratives, by aloes, rhubarb, and taraxacum, or by nitro-hydrochloric acid with bitter infusions; stim- ulants should be cautiously given, and outdoor exercise gradually increased. To such patients horse exercise is often most serviceable. Although in some of these cases of atonic dyspepsia superficial ulceration may take place, and from the want of power the other coats of the stomach be perforated, as we shall afterwards have to describe, it will generally be found that with proper treatment and care the symptoms slowly subside. The object of the treatment is to rouse vital energy, at the same time that a diet, as sustaining as possible, is administered. The following are some of the medicinal agents at our disposal: the carbonates of ammonia induce a direct stimulant effect, and aromatics, with mild vegetable infusions, act in a similar manner. If the tongue be large 154 DYSPEPSIA FROM WEAKNESS: and flaccid, and the food remains as a weight at the stomach, mineral acids are of great service, and assist digestion. At a later period steel and quinine may be used, but care is required both as to the form of adminis- tration and the mode of combination. It is well always to give ferruginous preparations directly after a meal; the medicine thus becomes incorpo- rated and absorbed, without any excitement or pain being produced. . The milder preparations of iron should be tried, the am monio-citrate, potash-tartrate, the phosphate, the reduced iron, or the dialyzed iron. Quinine often disagrees, and if the tongue be in- jected, the medicine is likely to cause sickness, headache, and increased distress; the liquor cincho- nas is a more elegant and less bulky preparation than the decoction, and it is often borne better than quinine itself. There is a remedy, which I have found of great service, namely, nux vomica and its alkaloid strych- nia ; as a tonic, it proves beneficial, especially in promoting the contraction of involuntary muscu- lar fibre, thus relieving flatulent distension and constipation; but it requires a careful administra- tion, as it will sometimes produce a sense of most distressing faintness and exhaustion, even when given in small doses. ATONIC DYSPEPSIA. 155 Pepsin is an artificial substitute for the normal solvent of the food ; it was proposed by M. Corvi- sart, and introduced into English practice by Dr. Ballard. It has been employed dried, in doses of 2 to 5 grains, and is also given in a fluid form. Great care is required in the preparation of pepsin as a remedy,1 and several formulae have been intro- duced into medical practice in which pepsin is the active ingredient; but it is better to remove the cause of the natural defect than to supplement the deficiency in this imperfect manner. Stimulants are of great value in this form of dys- pepsia, but should only be used with nourishment, or to enable the stomach to perform its normal func- tion ; strong alcoholic liquors taken in excess dur- ing digestion, retard the solution of food ; and most injurious results may follow, if the transient stimu- lant of wine or ardent spirits be made to supply the place of nutriment, and be habitually resorted to, as a remedy for the sensation of weakness and ex- haustion. Ipecacuanha increases the secretion of the gas- tric juice, thus it is often given with capsicum and rhubarb, as a dinner pill, and proves of great service. ' See Squire's companion totho ' British Pharmacopoeia,' p. 223. 156 DYSPEPSIA FROM WEAKNESS. The judicious use of stimulants and tonics should only be subservient to the restoration of healthy function; and in proportion as health is restored, these should be discontinued. DYSPEPSIA FROM CONGESTION. 157 CHAPTEE VIII. DYSPEPSIA FROM CONGESTION. The mucous membrane of the stomach is ex- tremely vascular; the minute bloodvessels form a series of beautiful plexuses, which are arranged not only around the minute crypts from which the gas- tric juice is poured, but throughout the whole sub- stance of the membrane. These vessels are received by the smaller coronary veins of the stomach, and then reach the vena portae. The large venous sinus, the vena portal, passes to the liver, and then reaches the right side of the heart; here it meets with blood from other parts of the body, before it is propelled by the force of the right ventricle to be aerated and oxygenated in the lungs. If any ob- struction take place in the heart, the lungs or the liver, the onward course of the blood is stayed, and passive distension of the extreme veins which first receive the blood takes place. If the obstruction be in the liver, then the branches of the vena por- tac at once are over-filled, and passive venous en- gorgement is the result; but if the impediment be 14 158 DYSPEPSIA disease in the lungs, then the same congestion takes place by successive steps, first the lungs, then the right side of the heart, then the liver, and lastly the branches of the stomach and other parts. Should valvular disease on the left side of the heart be the cause, it leads to the same sequence, and con- gestion of a similar kind follows. In each case the veins and capillaries of the stomach become filled, and at length distended, even to the rupturing of their coats and the extravasation of blood. The minute capillaries form circular plexuses around the crypts of the mucous membrane, and are found with beautiful distinctness after continued distension. It must also be remembered that this congestion is of a passive venous kind, and very different in its effects from the congestion produced by active hy- peraemia of irritation or inflammation. In the former it is the veins, in the latter the arteries which are filled ; in the one, the redness is of a duller color and diffused ; in the other it is of a brighter color and in arborescent patches. Although it is essential for the right action of the gastric glands, and for the secretion from the mucous membrane, that there should be a proper supply of blood, still, whenever the blood is de- delayed in its course, or congestion arises from irri- tation, the secretions are changed; and as a neces- FROM CONGESTION. 159 sary result of this venous congestion, the mucus is secreted in excess, and covers over the whole mem- brane as a tenacious layer. The mucus is some- times found to be alkaline in its reaction, is with difficulty washed off by water, and consists of mu- cous corpuscles, nuclei, and epithelium. When in this state aliment is introduced, it is enveloped in mucus, and solution by the gastric juice is retarded. The mucus secreted in such excess readily under- goes chemical change, and gaseous formation arises, and also flatulent distension. The action of the glands or follicles which se- crete gastric juice is lessened by the venous con- gestion, and that fluid is insufficient for the solution of large quantities of nitrogenous food. Another result of the long-continued congestion is that serous transudation takes place into the substance of the membrane, and all the coats ap- pear thickened and cedematous, and the surface granular; not only the mucous membrane, but the submucous and subperitoneal cellular tissue, be- come thus affected. This condition arises in great measure from serous transudation; but if the capillaries give way, as is not unfrequently the case, extravasation of blood results. If the extrav- asation be still limited, by the basement membrane, points of ecchymosis are observed; but if, on the 160 DYSPEPSIA contrary, this bounding membrane also give way, the blood is effused into the stomach, it becomes mixed with the mucus, and is passed into the intes- tine or rejected by vomiting. The action of the gastric juice upon this effused blood produces change in the color, so that it would be scarcely known as blood ; when small in quantity, it as- sumes the appearance of coffee-grounds; if the quantity be great, it is darkened and coagulated; and if it pass downwards, the color is still more deepened, and the appearance becomes that of fluid pitch. The points of extravasation may be preceded or followed by superficial ulceration, and several of such minute ulcers may be found upon the surface of the stomach, as " hsemorrhagic erosions." The thickened mucous membrane becomes discolored from the deposition of pigmental granules conse- quent on the long-continued congestion; the folli- cles of the stomach are found very distinct, and filled with nuclei and cells; and this state has been well designated " chronic catarrh." The symptoms produced by the state just de- scribed, and which might be designated as consti- tuting dyspepsia from passive venous congestion, are characteristic; but they are always associated with other symptoms produced by the primary FROM CONGESTION. 161 and the more important disease, whether that be of the heart, or of the lungs, or bronchi, or, lastly, chronic disease of the liver; each of these have their own symptoms, but in all, digestion is inter- fered with in a similar manner. The appetite is diminished, and if solid food, especially of a nitro- genous kind, be taken, pain is experienced at the scrobiculus cordis, with a sense of weight and op- pression ; in fact, the substance is so covered with mucus, that it is very imperfectly acted upon by the gastric juice ; vomiting is occasionally produced, and if the food pass into the duodenum and intes- tine, colic also follows. Flatulent distension results from the imperfect solution of the food, and from chemical changes both in it and in the mucus; this distension increases the pain, which extends to the back, and if the affection be cardiac or pulmonary the pressure upon the diaphragm still further dis- tresses the patient by increasing the dyspnoea. The tongue is generally furred, and, although pain in the back is present, it is much less severe than in many other forms of gastric disorder ; sometimes, however, intense pain and distress are produced by the gastric distension, and the embarrassed action of the heart. This kind of flatulent distension be- comes exceedingly distressing, so that scarcely any food can be taken with comfort, and nearly every 14* 162 DYSPEPSIA solid form of it is discarded ; an attack of haemate- mesis, or of bleeding from haemorrhoids, etc., may remove the congestion, and afford comfort to the patient, but the symptoms are very quickly repro- duced. The dyspnoea and palpitation of heart disease, or the cough and gasping for breath of chronic bronchitis, engage the attention of the patient, and obscure the less urgent symptoms of disease of the alimentary canal; it is when the for- mer have been relieved that attention is directed to the abdominal complication. The diagnosis of this state is free from difficulty : but there are two dangers to be guarded against. 1st. That in our consideration of the primary and the more important malady, this complication be so overlooked, that those means which would relieve much secondary distress are not used; or, 2ndly, the primary disease may have become so quiescent that this secondary one may be regarded as the only source of disease. As to the prognosis, it must entirely depend upon the original malady; when that can be relieved and the congestion diminished, the gastric symp- toms are alleviated. Too often the disease is ulti- mately fatal; but a great deal may be done to remove the distressing symptoms, and to prolong FROM CONGESTION. 163 life for many years. In the treatment we have three means at our disposal:— 1st. To attempt the relief of the congestion, 2d. To remove the excessive mucus, and, 3d. To regulate the diet, so that the stomach may -not be unnecessarily taxed beyond its capa- bilities. Some appear to consider, that because the disease cannot be cured, therefore nothing can be done; this is both untrue and unwise, as well as unjust to the suffering patient; much may be done, and great relief afforded. To relieve the congestion the bowels should be well acted upon, and to effect this various remedies may be employed. Purgative enema serve, not only to empty the bowels, but to relieve the portal congestion second- arily through the inferior mesenteric veins. Salt, soap, castor oil, colocynth, turpentine, may thus be used; more frequently purgatives will be resorted to as less trying to the patient. Extract of colo- cynth with henbane, rhubarb pill with henbane, jalap and scammony, are useful aperients: but a free mercurial purge, whether of blue-pill, calomel, black oxide, or gray powder, are more effective, and often afford great relief, not only by unloading the bowels, and thus diminishing congestion, but 164 DYSPEPSIA by stimulating all the abdominal glands to greater activity. The podophyllin resin also may be ad- vantageously used with the extract of henbane, or, dissolved in rectified spirit, it may be given with tincture of jalap and tincture of ginger. Saline purgatives diminish the portal congestion, and in this way the sulphate of magnesia is often of ser- vice. Croton oil and elaterium are rarely called for in these cases. The second object of treatment is to remove the excessive mucus ; and although this might be effect- ually done by vomiting, having previously dis- tended the stomach by large draughts of warm water, still in cardiac disease this would not be an advisable remedy, and in severe chest complaint would greatly distress the patient. Purgatives in their action serve to clear away large quantities of mucus; but this may also be promoted by mineral acids, either in combination or alone. These acids may be combined with purgatives, as for instance, with the compound gentian mixture of the London Pharmacopoeia. The saline mineral waters of Chel- tenham, Leamington, Carlsbad, Ems, Freidrichshall, Hunyadi Janos, Pulna, etc., cautiously given, greatly mitigate some of the symptoms to which reference has been made; and if general anaemia exist with this local congestion, the saline chalyb- FROM CONGESTION. 165 eates may be tried, as Tunbridge Wells, some of the Harrowgate and Buxton Springs, the Brighton Spa, or Schwalbach, Franzensbad. The third object of treatment is to regulate the diet. Solid nitrogenous food requires the complete action of the stomach ; and in most of these instan- ces, if the symptoms be severe it cannot be borne. Soups, and the forms of nitrogenous diet most easy of digestion may be tried ; but generally bland fari- naceous food best suits the patient. Milk cannot always be taken, for it often coagulates, and a ca- seous semi-digested mass produces pain and flatu- lence. Eggs are more easily digested. As to stim- ulants of an alcoholic kind, caution is required; malt liquors are generally injurious, they will in- crease the flatulence and distress; so also sweet and effervescent wines; the astringency of port wine contraindicates its use also, and if any wine must be given, dry sherry, claret, or burgundy, are the best. Brandy and other ardent spirits, although they give temporary relief by stimulating the stom- ach and relieving the flatulence, do not lessen the portal congestion, and are therefore only a partial benefit; still in some cases they are absolutely necessary. 166 INFLAMMATORY DYSPEPSIA. CHAPTER IX. INFLAMMATORY DYSPEPSIA. Inflammation is a term that has been applied to certain associated symptoms of disease ; but the unfounded hypotheses that have been made in con- nection with it have led to so much misapprehen- sion, that we would gladly renounce the word alto- gether ; we feel, however, that it has become so interwoven with medical phraseology, that it is almost impossible to substitute any other term. When inflammatory action arises in any form, the whole of the structural character of the part affected is altered, as indicated by the modified cir- culation and character of the blood, by change in the nervous system, by the condition of the solid structure, and still more by the functions of the organ being interfered with. Thus redness and preternatural heat are excited at the part affected, the sensibility is increased, the structure of the tis- sues becomes swollen from the effusion of sero-al- buminous or fibrinous products, and the functional energy is lessened. For instance, in inflammation of the stomach, every part is changed; the capillary INFLAMMATORY DYSPEPSIA. 167 arteries become surcharged with blood, and if the disease be severe and acute, active hyperaemia gives place to one of comparative stagnation of blood; the mucous membrane acquires such in- creased sensibility, that the presence of anything in the viscus causes pain and vomiting; the mem- branes of the stomach are all thickened, especially when the morbid process has continued for a con- siderable time, and the function of the organ is more or less checked, for the stomach is unable to dissolve nitrogenous substances, and to form chy- mous fluid. It is not only in severe disease that these indica- tions of abnormal action exist; but even in acute dyspepsia the same changes are apparent, although • differing in degree; and the remarkable opportunity Dr. Beaumont had of witnessing the interior of the stomach in Alexis St. Martin has elucidated facts of peculiar interest; thus he saw through an open- ing in the side the effects produced by ardent spir- its upon the mucous membrane; erythematous in- flammation was at once set up, and the surface of the stomach became preternaturally red and con- gested, and also drier than in health, showing that the gastric juice was not properly secreted. These changes were transient; but when irritation is per- sistent, an oedematous state of the membrane from 168 INFLAMMATORY DYSPEPSIA. serous effusion is followed by true thickening from fibrinous product; the surface becomes mamillated, and the cellular tissue is rendered more dense and opaque. The lining membrane of the mouth and of the oesophagus secretes an alkaline fluid, which is in- creased in quantity by the additions from the large salivary glands. The purposes served by the saliva are not only to facilitate mastication and degluti- tion, but it has also a truly digestive function, and on this account we are led to notice it more par- ticularly. A peculiar principle is present in saliva, to which the term ptyalin has been given, and it has the property of converting the particles of starch into dextrin and into sugar; saline ingredi- ents are also present, soda, potash and lime, com- bined with phosphoric acid, with some lactic acid, and with a variable quantity of sulpho-cyanogen. It is from these saline substances that an alkaline reaction is obtained, and the alkalinity is more ap- parent during active mastication; but a fact of greater importance in the consideration of indiges- tion is, that the saliva loses its alkaline and acquires an acid reaction during irritable states of the ali- mentary canal, and the organic principle ptyalin, always prone to decomposition of a putrefactive kind, is during disease more readily changed, and the breath thus acquires a faint and sickly charac- INFLAMMATORY DYSPEPSIA. 169 ter. Imperfect mastication, therefore, and insuffi- cient salivary reaction, as well as a .variable quan- tity of saline ingredients transmitted to the stomach, have each a causative relation with indigestion. Still more important are the secretions from the lining membrane of the stomach : in addition to the ordinary secretion from the mucous membrane, minute glands pour out a fluid which is essentially digestive in its properties, and which is known by the name of the gastric juice. These secretions are changed in inflammatory dyspepsia; the inner sur- face of the stomach becomes drier than natural, and the power of solution of food is diminished, or alto- gether checked; when the stomach is inactive, and no digestion going on, the reaction by test paper may be neutral or even alkaline; but when active solution of food is in progress, the fluid formed is always acid. The gastric juice is a clear watery fluid, acid, but containing a considerable quantity of saline material. The.acid consists principally of hydrochloric acid, probably derived from chloride of sodium, and lactic acid is generally also present ;J but an equally essential element is pepsin, an or-a ganic principle closely allied to albumen and fibrin, 1 According to Gmelin and Tiedmann, acetic acid is present, and M. Blondlot attributes the acid reaction to superphosphate of lime.—Simon's Chemistry, Sydenham Soc. 15 170 INFLAMMATORY DYSPEPSIA. and which is soluble in water, but insoluble in al- cohol. The solvent power consists in the combined action of the pepsin and acid; and an artificial di- gestion may be effected, if proper heat be main- tained (98 to 100°), so as to dissolve albuminous substance. It is this gradual solution of nitroge- nous food that goes on in ordinary digestion ; it is really more of a chemical than of a vital process, but it is the living action of the stomach that sepa- rates the reagents necessary to execute the re- quired changes. The solution thus formed differs in its properties from those previously possessed by the fluid albumen, for it does not coagulate by heat. Anything that interferes with the proper formation of the gastric juice and the due propor- tion of its components is therefore a cause of indi- gestion. The proportions of these ingredients are thus given by Schmidt:— Water.......954.13 Pepsin.......0.78 Sugar, Albuminates, Lactic Acid, Butyric Acid and Ammonia .... 38.43 Chloride of Potassium .... 0.70 Chloride of Sodium .... 4.26 Potash.......0.17 Phosphate of Lime . .... 1.03 Phosphate of Magnesia .... 0.47 Phosphate of Iron .... 0.01 INFLAMMATORY DYSPEPSIA. 171 Hydrochloric acid was also found when the stom- ach was excited to full action, but it exists in varia- ble proportions ; and of the saline substances also, a considerable quantity is poured into the stomach in the saliva. The saliva readily undergoes putre- factive change, but the reverse is the case with the gastric juice, which may be kept at a temperature of 100° for several days. In numerous microscopical examinations of the mucus upon the gastric membrane, we have found great diversity in the size and development of the epithelial and mucus cells ; in some instances they are large, with distinct nuclei, and in fact these cells, if isolated, might be depicted as typical speci- mens of cancer cells, although no such disease ex- isted ; in other cases they are smaller, of a simple and rounded form, and evidently of more rapid growth ; these varieties in form were not accidental circumstances, but were indications of a previous modification of vital process. Again, the facility with which the secreting cells from the gastric folli- cles are evolved, although generally the result of post-mortem oedema from the lining membrane of the follicle, may really evince an exudative change. In my larger work on diseases of the abdomen, I have dwelt on other changes in the mucous mem- brane, the result of inflammatory or of degenera- 172 INFLAMMATORY DYSPEPSIA. tive action, in the former instance leading to effu- sion of fibrin and contraction, in the latter causing the production of highly refracting fatty particles instead of healthy cells. In the consideration of this form of disease, we do not refer to acute inflammation of the stomach arising from the accidental or voluntary introduc- tion of corrosive fluids and other powerful chemical reagents ; neither do we at present refer to the con- ditions of superficial or aphthous ulceration, nor to the perforating and chronic ulcer. As to diphtheri- tic ulceration and suppuration, they are rare se- quences of inflammatory mischief in the stomach. Inflammatory dyspepsia is associated with ulcera- tive changes, but it frequently exists independently of any destruction of tissue whatever; in a short time superficial ulceration may supervene, but the irritability of the stomach may also continue for a considerable period without such effect being pro- duced. It is very common to find aphthous ulce- ration of the mucous membrane of the mouth; such minute abrasions entirely disappear without leaving any trace, and we believe that a similar state is often present in the stomach, associated with symp- toms of irritability, but of a transient character. Although the characteristic symptoms of inflam- matory dyspepsia are sometimes obscured by at- INFLAMMATORY DYSPEPSIA. 173 tendant circumstances, still they are sufficiently diagnostic when considered in their general aspect. Three indications are usually present, whilst others are less constant and of secondary importance. The three signs referred to are, 1, tenderness at the scrobiculus cordis; 2, irritability of the stomach; and 3, a desire for cold drinks. 1. Tenderness at the scrobiculus cordis differs greatly in its intensity; sometimes it is only mani- fest on pressure or on percussion, at other times it amounts to severe pain passing through to the back between the shoulder-blades; in any case, how- ever, pressure at the pit of the stomach is distress- ing to the patient. In many other diseases, the pain is more severe and persistent, as for instance in ulceration and in cancerous growth, whilst in the one under consideration it is only described as " soreness." 2. The irritability of the stomach is often (^pro- portionate to the severity of the pain; and the blandest form of diet is retained with difficulty. An affection of the mucous membrane alone is not productive of the intense suffering so frequently observed in chronic ulcer of the stomach, and in other organic diseases. It is only when the deeper tissues are involved by the extension of disease to the muscular coat, or when distension of the viscus 15* 174 INFLAMMATORY DYSPEPSIA. occurs, that pain in its severity is experienced. An exceptional instance must, however, be adduced when the mucous membrane in the immediate neighborhood of the pyloric valve is especially affected, but whether this unusual sensibility is due to spasmodic contraction of the valve is doubtful: many of these patients describe the pain as being worst at the close of the digestive process, and characterize it as the passing of food " over a raw surface" at the site of the valve. The vomiting in ulceration of the stomach is preceded by pain, the patient often stating that the pain persists till the food is either rejected or has passed onwards: not so, however, in inflammatory dyspepsia; the stom- ach rejects its contents almost at once, but unless the vomiting be very persistent, little complaint is made. 3. The desire for cold drinks is usually present in the dyspepsia under our consideration; and ice or cold water is exceedingly refreshing to the patient, and easily tolerated by the stomach. As to other symptoms, the tongue is generally injected at its tip and edges; it is covered with an abundant yellowish-white fur, and the papillae appear as distinct red points on its surface; it does not present the large and indented appearance noticed in atonic states of the primae viae. INFLAMMATORY DYSPEPSIA. 175 Headache, mental depression, lassitude, distur- bance of vision and ringing noise in the ears, are 0 often complained of. The countenance is expres- sive of anxiety, the eyes are sunken, the skin is slightly sallow, dry, and often parched, there is occasional febrile disturbance, with a burning sen- sation at the palms of the hands and soles of the feet. A short dry cough is a frequent symptom, the pulse is irritable and compressible, and the bowels are generally confined, although when the erythematous condition of the stomach passes down- wards into the intestine, constituting gastro-enterite, diarrhoea is set up. The urine is high colored, and urea is generally in excess; it deposits lithates freely, or with nitric acid it assumes a deep color. It is very important to distinguish this form of dyspepsia from those previously noticed: the first atonic, from an atheromatous condition of the vessels, from an exhausted cerebro-spinal system of nerves, or from a like state of the vaso-motor; the second from passive venous congestion occurring as a sequence of disease of the liver, lungs, or heart; but this is of a more acute kind, and is generally produced by indiscretion in diet or excess, or by the immoderate use of wine or ardent spirits. There are three forms of inflammatory dyspepsia deserving of separate description and notice; the 176 INFLAMMATORY DYSPEPSIA. first is that which we find in children after sudden changes of food, or after an unsuitable diet; the symptoms are characteristic and sometimes alarm- ing, not only in their primary, but in their second- ary effects. The disturbance produced during weaning might be adduced as exemplifying this condition, and so also that set up by hard and in- digestible diet or by stimulants; a state of peevish excitement is induced, especially at night, with headache, and often with more or less delirium; the child becomes fretful, its natural appetite is gone, and it craves for improper substances or for cold water; convulsions are sometimes induced; the skin is hot, with remissions, so that the state has sometimes been termed gastric remittent fever; the tongue is white and injected at the tip and edges, or with distinct papillae. The bowels are loose, and the abdomen is enlarged. In many cases the irritability of the stomach is excessive, and the blandest nourishment is rejected, and if associated with diarrhoea, rapid prostration of strength ensues, a haggard wasted appearance is presented, and the little countenance has the painful expression of old age in miniature. In some cases improper diet induces severe colic, with prostration and collapse; thus the coagulation of milk in the stomach and intestines has led to exhaustion so INFLAMMATORY DYSPEPSIA. 177 speedily, that the effects have been attributed to poison. Minute points of ulceration have sometimes been detected on the post-mortem examination of the stomach of children thus affected with acute gastric symptoms; these ulcers have been called "follicu- lar ;" they vary in size from one-sixteenth to one- fourth of an inch, and sometimes stud the whole surface, being not limited to the lesser curvature alone; they do not extend beneath the mucous membrane. They are not confined to children, but have been found where no indication of disease of the stomach had existed, excepting perhaps the vomiting of coffee-ground substance. This form of ulcer is, however, distinct from the superficial or aphthous ulceration to which reference has been made. The second form is that in which the stomach is disordered by some accidental indiscretion in diet or by intemperance. There is headache, with ver- tigo and disturbed vision, sleep is broken, the appe- tite is taken away, the sight of food is intolerable, but cool drinks are grateful; the tongue is furred, the stomach irritable, and if the vomiting be violent, green bilious fluid is rejected; tenderness at the scrobiculus cordis is also associated with pain at the back, the bowels are irregular, and flatulence dis- 178 INFLAMMATORY DYSPEPSIA. tresses the patient. It must not, however, be sup- posed that every attack of this kind must necessarily be referred to known indiscretion in diet, for the cause may lie in the air we have breathed or the water we have drunk; impurities in the one or the other may induce this inflammatory dyspepsia; a malarious atmosphere, or one charged with im- purities from imperfect drainage, has often induced this condition, and not less frequently organic im- purities in water. A third form of inflammatory dyspepsia is the result of long-continued excess in food or in stimu- lants. The countenance assumes a peculiar rest- lessness, the pupil of the eye is contracted and the conjunctiva suffused; the sleep is disturbed by dreams or entirely taken away, or it is short and broken, and without refreshment; the cheeks are irregularly flushed, and the capillaries often pecu- liarly distinct; the tongue is furred, or unnaturally red, sometimes like raw beef, or it has red patches upon it, as if deprived of epithelium, and the patient complains of an offensive taste in the mouth; the appetite also is depraved or destroyed, and highly seasoned dishes are longed for; the bowels are variable, and sometimes hemorrhoids distress the patient; the urine is scanty and high colored, and deposits an abundance of lithates or of uric acid, INFLAMMATORY DYSPEPSIA. 179 and in some cases it becomes highly albuminous; there is also flatulence, spasmodic pain or "cramp" in the abdomen; to these symptoms is added a sense of weakness and exhaustion, which the patient seeks to remedy by fresh potions of stimu- lants, until the stomach becomes so irritable, that everything is rejected; tenderness also comes on at the scrobiculus cordis, with pain across the chest or in the back. These patients are generally hy- pochondriacal, and often believe themselves to be the subjects of serious disease of the liver. With other disturbances of the nervous system already mentioned, we find perverted special sensibility, as indicated by double vision, muscae volitantes, noises in the ears; and the nerves of general sense are also affected, as manifested by a numbness, formi- cation, etc. In strumous subjects, there is a special tendency in the mucous membrane of the stomach to become very irritable. The gums become spongy, the mouth and pharynx apthous and painful; vomiting is occasionally a troublesome symptom, and also diarrhoea. The pain at the stomach is increased by every kind of food. This form of disease is of a very obstinate character, and may persist month after month; and although we have no evidence of actual ulceration and destruction of the mucous 180 INFLAMMATORY DYSPEPSIA. membrane, still there is probably chronic inflam- matory change. It must be distinguished from the sympathetic irritation of the stomach produced in the early stage of disease of the lung and of the brain; but it closely resembles that condition of exhaustion with irritability, which we find towards the close of phthisis, of cirrhosis, of strumous peri- tonitis, etc. The latter state is associated with hectic symptoms, and generally with peculiar fret- fulness and irritability of temper. The symptoms of inflammatory dyspepsia from excess may pass into delirium tremens, or may lead to chronic disease of the liver; and in reference to the stomach itself, the subsequent effects will be scarcely less disastrous. It may be that the state of chronic engorgement of the vessels is suddenly relieved by the rupturing of its capillaries; hemor- rhage takes place into the stomach, and the blood is either vomited in a dark clotted state, or passed downwards in a semi-digested condition, constitu- ting black alvine discharges. We have seen cases where this natural relief has mitigated the former symptoms, although it may have completely blanched the patient, and for a time placed his life in apparent jeopardy ; or superficial ulceration may supervene, followed by hemorrhage of a more severe and dangerous character; or chronic ulcer INFLAMMATORY DYSPEPSIA. 181 may be set up, with all its attendant misery, and with symptoms only to be subdued by the most careful treatment, and by attention to strict hy- gienic rules. In reference to the prognosis, this form of dys- pepsia will generally be relieved, and patients may entirely recover, if they will be controlled in their diet and adopt other suitable measures. The principles of treatment consist in diminish- ing the irritation and in relieving the congestion; and these objects are effected by removing anything from the stomach which perpetuates disturbance by allowing rest as far as possible to the viscus, and by medicines, if any be given, which directly soothe the inflamed surface. If undigested substances remain in the stomach, an emetic of ipecacuanha or of sulphate of zinc is the most effectual remedy. The most bland forms of diet are desirable, and those articles which tax all the energies of the stom- ach to dissolve them should be avoided, as solid animal food ; animal soups, and even beef-tea, are often injurious, whilst farinaceous substances are well borne. Stimulants, especially ardent spirits, malt liquors, and generally wine also should be abandoned; whilst cold drinks and ice are often extremely 16 182 INFLAMMATORY DYSPEPSIA. grateful to the patient, as well as curative in their effects. As remedies, those which act upon the bowels, as saline purgatives, especially magnesia and the salts of soda are of service. These not only unload the congestion of the gastric capillaries, but they act upon the whole portal system. Mercurial purga- tives and alteratives act in a similar manner, and afford speedy relief to many of the distressing symp- toms. Unfortunately this has led to their too gen- eral adoption. Mucilaginous drinks sheathe the irritable mem- brane ; lime water is often of great service as an alkali in diminishing the extreme sensibility of the stomach; but we have still greater confidence in bismuth when combined with salines and mucilage ; the dose of it may, however, be much larger than that usually given. I generally begin with doses of 10 grains, or 5 grains of the carbonate, but I have known 9 i. doses of pure nitrate given three times a day, with relief to the symptoms, and with- out any injurious consequences. A very elegant and useful preparation is the effervescing citrate of bismuth, prepared by Savory and Moore. The fluid solutions of bismuth are less useful in these than in other cases of gastric disease. Carbonic and INFLAMMATORY DYSPEPSIA. 183 hydrocyanic acids act as sedatives to the disturbed parts. In acute forms of inflammatory dyspepsia of adults, leeches to the scrobiculus cordis and coun- ter irritants have often afforded great relief; and in these patients, but especially in infants, the bicar- bonate of potash alone, or combined with the chlo- rate, tends to mitigate the distressing sensibility of the stomach by diminishing the acidity of the se- cretions. I have found few remedies of greater value when oftentimes repeated, and given in some bland mucilaginous fluid. In the gastro-enterite of children, it is of the greatest importance to adapt the diet to the condition of the mucous membrane and to the requirements of the system. It is often necessary, in children thus affected, to avoid milk altogether, and to give cream with water, or only rice water, and to some ass's milk; and by adults milk may sometimes be agreeably taken with soda water. In chronic inflammatory dyspepsia, the same principles of treatment must, if possible, be carried out—namely to prevent fresh sources of irritation from improper diet, to unload the congested struc- tures, to clear away effete materials from the system and to restore healthy action. Saline aperients, with vegetable tonics, assist in 184 INFLAMMATORY DYSPEPSIA. effecting the latter objects. Mercurial alteratives, when cautiously administered, stimulate the lacking energies of the glandular system, and small doses of ipecacuanha tend to promote healthy secretion from the mucous membrane, whilst they diminish capillary stasis. The beneficial effects of the saline mineral waters are often in these cases very evident, especially those which contain sulphates of soda and magnesia. In our own country we may especially mention Cheltenham, Leamington, Purton Spa, Epsom, Scarborough, Harrowgate; and on the con- tinent, Carlsbad, Franzensbad, Seidlitz, Marienbad, Ems; but the attendant circumstances, the change of scene, the rest, both physical and mental, the attention to hygienic rules, the rigid observance of moderation in diet, with regularity, conduce most effectively to restore health and vigor. HEPATIC DYSPEPSIA. 185 CHAPTER X. HEPATIC DYSPEPSIA. The liver is frequently blamed for disturbance with which it has no connection; but there can be no doubt that in some forms of dyspepsia the liver shares in the disorder of the stomach, and that this unhealthy state perpetuates the gastric symp- toms. The veins of the stomach pass into the vena portae, and thus directly to the liver; and any irri- tating ingredient or stimulant, after exciting the mucous membrane of the stomach, also.. creates similar abnormal action in the liver. Thus ardent spirits, exert their action at once upon the liver; and although the erythematous inflammation of the stomach thus produced very quickly sub- sides, less readily does that of the liver; for the secretion of the bile is changed, it is diminished in quantity, or it becomes of an unusually irritating character ; the elements of bile are thereby retained in the blood, and thus the balance of the whole economy is upset. If the offending cause is only 16* 186 HEPATIC DYSPEPSIA. temporary, then the irritation it has excited soon diminishes, and the attack is what is so often called a "bilious attack:" but if, on the contrary, the irritation is renewed day by day, then the conges- tion of the stomach becomes persistent, its secre- tions are disordered, its mucous membrane thick- ened, its submucous coats infiltrated, and the liver still more seriously suffers. There is inflammatory effusion into Glisson's capsule, leading to enlarge- ment and afterwards to contraction of the gland; the serous surface becomes thickened and inflamed, the secreting cells atrophied, and the bile ducts changed in their character. The depuration of the blood is hindered, effete materials are retained, en- gorgement of the portal system is consequent, and the disease thus leads to organic change in the liver and to dropsy. Hepatic dyspepsia is the first step in this most serious downward course of disease; and what are its symptoms? Many of them are referred directly to the stomach, others to the liver. The former is irritated and irritable, and vomiting is a common symptom, sometimes only sufficient to empty the viscus, but more generally severe and leading to regurgitation of bile into the stomach. This also is rejected, and the patient regards it as proof of excess of biliary secretion. Still more severe is vomiting in some instances; and the stom- HEPATIC DYSPEPSIA. 187 ach remains so irritable that for many days it will not bear the presence of any food, however bland its character. This irritability of the stomach is preceded by foul and furred tongue, by bitter or unpleasant taste in the mouth, and is often accom- panied with severe headache, with vertigo and disturbed vision, and it may be, with noises in the ears. The headache is often very severe in acute temporary disturbance of the stomach of this kind, and is experienced across the eyebrows, at the fore- head, or at the back of the head ; sometimes the whole head is felt to throb with each pulsation of the heart. The countenance is sallow and the mind depressed; sleep is greatly disturbed, and every- thing is seen mentally through a distorted medium; the physical strength is apparently lessened, and the patient complains of exhaustion, a weakness the result of impeded action, rather than of actual loss of power. The kidneys act imperfectly, and the urine is scanty and loaded with lithates; the bowels are often confined, but sometimes irreg- ularly purged, with accompanying pain; the mo- tions are mottled and clay-colored, or of very dark and offensive character, and as an additional dis- comfort, haemorrhoids distress the patient. Another class of cases are those in which, with- out any gastric irritant whatever, bilious vomiting 188 HEPATIC DYSPEPSIA. comes on, and is connected with extreme irritability of the stomach. Languor and headache often pre- cede the attack, and tenderness at the scrobiculus cordis follows. These symptoms closely resemble those of inflammatory dyspepsia. The condition thus described is an easily reme- diable one, but the first and essential means of relief is to avoid perpetuating the disturbance by fresh excitement, by indigestible or rich viands, by fermented liquors or ardent spirits. The most manifest treatment is to allow the stomach to rest, having first removed irritating matters from it, if need be, by an emetic; and at the same time it is well to unload the bowels and the portal system by a free purgative ; thus the congestion of the liver is lessened, and the first step towards relief ob- tained. After a time, saline drinks, soda water, or carbonic acid water, with or without milk, may be taken. Soda water is very often resorted to, and its benefit is partly due to the sedative action of the carbonic acid, and to the diluent action of the water; in fact, free potions of cold water are a very serviceable remedy in this condition, it cleanses away offending excreta by acting on the bowels, on the kidneys, and in fact, on all the abdominal glands. A free mercurial purge is often productive of HEPATIC DYSPEPSIA. 189 great benefit; as four or five grains of calomel, blue-pill, or gray powder, followed by a saline purge. If the stomach continue irritable, bismuth may be given, with magnesia or its carbonate. Still the most bland nourishment only should be allowed: as arrowroot made with water, mutton broth, thin gruel, etc. If the dyspepsia be of a chronic kind, and the secretions have been already acted upon, we have found great benefit from the use of the nitro- muriatic acid with taraxacum ; and as a purgative, small doses of the resin of podophyllum, with rhu- barb, capsicum, and henbane. If the secretion from the stomach be defective in quantity, ipecacuanha is an excellent addition. Another form of treat- ment is the combination of dried rhubarb with dried carbonate of soda; the bowels are thereby gently acted upon, and the tonic effect of the rhu- barb strengthens, whilst the alkali diminishes the irritability of the membrane; these medicines in a fluid state, although less palatable, can be given in more effective doses. Still, too often some fresh indiscretion renews the complaint, or the patient cannot be persuaded to discontinue ardent spirits, or wine in excess, or large draughts of malt liquors, and the physician is 190 HEPATIC DYSPEPSIA. expected to remove the effect, whilst the cause is allowed to remain. The vigorous diet and strict regime of the hydropathic establishments often prove of signal service in these cases; for it is found to be easier to go from one extreme to an- other, than to observe rules of hygiene commensu- rate with the wants of the system and the healthy activity of its functions. When the stomach has become weakened by attacks of this kind, extreme regularity as to the time of meals should be observed; sufficient time should be allowed for thorough mastication, and the articles of diet, although of a proper character, should not be unwisely mixed together. RHEUMATIC AND GOUTY DYSPEPSIA. 191 CHAPTER XL RHEUMATIC AND GOUTY DYSPEPSIA. It is not our intention to enter into a description of the symptoms of rheumatism and gout; these diseases have some symptoms in common but they are not identical in their character; nor are they combined as rheumatic gout, for this latter disease is now generally recognized as rheumatic arthritis. Their origin has been referred to defective secondary assimilation, a term comprehensive in its character, but one that is often used to veil our ignorance of the phenomena of the healthy organism; after ab- sorption has taken place into the blood, and the pabulum which is to supply the wants of the system has been brought into intimate relation with its several structures, growth is the result. This growth and manifestation of function involves chemical change and rearrangement of elementary composition ; the glands grow whilst they receive elements from the blood, and pour forth their nor- mal excretions, whether it be the liver, the kidney, the pancreas, or the mammary gland. Similar 192 RHEUMATIC changes ensue in relation to the muscular system and to the substance of the brain itself. During functional activity there is the entrance of fresh material, and the discharge of effete product; these changes constitute the life of the part, and in their aggregate they are the life of the whole. The phe- nomena themselves present new manifestations of force, whether in the development of heat, the pro- duction of motion, the putting forth of nervous energy. The result of these changes is variously shown ; the presence of urea and of uric acid prove a readjustment of nitrogenous compounds, and may to some extent be taken as an estimate of the amount of that internal change which is going on in the system. If the eliminative processes of these substances be checked, the products may be re- tained in the blood, and induce other changes in the system : and as the result of one form of defect- ive secondary assimilation and of elimination, gout takes place. Dr. Garrod has demonstrated that there is excess of uric acid in the blood in gout; this excess, however, does not constitute gout; that is essentially caused by some antecedent defect of which this excess of uric acid in the blood is only a sign. The primary changes which induce gout affect the whole system, and hence the production of other symptoms beside the paroxysm of gout. AND GOUTY DYSPEPSIA. 193 So also with reference to rheumatism, it has been been referred on insufficient data to an excess of lactic acid in the system ; but this, if correct, is an insufficient explanation of the disease; we should next have to inquire why such acid is generated in the system, and again we are referred back to de- fective secondary assimilation, or to deranged chem- ical transformation in the nutritive changes of the tissues. In both gout and rheumatism we frequently find peculiar functional disturbance of the stomach ; and we may correctly speak of " gouty dyspepsia;" we do not mean that the disease of the stomach is an essential part of gout, but that the state of the sys- tem, which issues in a paroxysm of gout, also in- duces characteristic dyspepsia. And, although the secondary changes which follow the absorption of food into the blood have more especially to do with the proximate cause of gout, still the primary solu- tion of food has also a causative relation. In patients so affected, the stomach is often taxed by overwork, and over-stimulated at the same time; but frequently this is not the case, and the gouty patient may be abstemious in all his habits. The symptoms of dyspepsia are sometimes well marked, and are in part referred to an abnormal state of the gastric juice; it is preternaturally acid, 17 194 RHEUMATIC and is the cause of the heart-burn so often com- plained of. Acid eructations are also present, "sourness at the stomach;" there is pain at the scrobiculus cordis, the tongue is often furred, and the pulse is irritable. The hepatic secretion is often disordered, and sallowness of the countenance, with irregular action of the bowels, and very dark or clay-colored motions are induced ; the urine also is high colored, and there is abundant deposit of lithates. The urine, however, more frequently pre- sents a large quantity of uric acid deposit, red dust, or gravel, as it is sometimes called, and under the microscope the crystalline character of the deposit is well shown, rhomboidal crystals, or clusters of acicular ones. These gastric and other symptoms may be accom- panied with some pain in the joints, as in the great toe; or with deposit of lithate of soda in and about the joints, or in the ears; but the external signs may be undeveloped, and the only indication of gout is an hereditary tendency in the parents or grandparents, the brother, or some other member of the family. In numerous instances the symptoms of indiges- tion are vague and ill-defined; there may be sense of oppression at the region of the stomach, with mental inertia, and incapacity for exertion, and AND GOUTY DYSPEPSIA. 195 sense of weakness. Sometimes severe pain in the head or neck is induced, with disturbance of the sight, of hearing, and even with vertigo and partial loss of consciousness; or, again, aching pain in the loins and in the limbs occurs, as neuralgia or scia- tica ; or, there is irritability of the bladder, and, in persons advanced in life, the symptoms of stricture. We have witnessed the gastric affection so severe as to simulate the dyspepsia of organic disease, and these symptoms have entirely disappeared with the lessened tendency to gouty attack. There are, however, two symptoms of gouty dys- pepsia which deserve especial attention, namely, irregular action of the heart, and severe paroxysmal pain, known as "gout in the stomach," or if in the bowels, constituting a severe form of colic. The close sympathy of the cardiac plexus of nerves with the large nerve centres of the abdomen is frequently shown in this dyspepsia ; the pulse becomes small, irregular, and intermittent, and the patient is dis- tressed by palpitation, and by breathlessness on exertion ; he is disturbed at night by broken sleep, and may even be unable to lie down. The embar- rassment of the heart's action is sometimes less de- fined, and is manifested by dyspnoea on taking any exertion, even on stooping to the ground or kneel- ing. The sensation is one of distress rather than of 196 RHEUMATIC pain, and sometimes it compels absolute rest, the patient feeling as if the heart would cease to beat altogether unless quietness were maintained; the character of the symptom is that of " breast pang" —angina pectoris. It may be that a cardiac bruit is produced from atheromatous thickening of the valves; but this abnormal sound is often entirely absent, and the heart disease is purely of a func- tional character. These and other symptoms often entirely disappear when the gouty dyspepsia is re- moved, and they sometimes cease after a paroxysm of gout itself. Again, whilst these gastric and general symptoms may persist with very little pain, sometimes pain is a prominent symptom, especially after food, and it may trouble the patient for months, as if there were organic disease; or, intense pain at the region of the stomach comes on, without vomiting, but soon followed by extreme prostration, compressible pulse, a haggard countenance, and in rare instances a fatal issue soon follows. Although some of these cases may really be explained by the presence of undi- gested substance in the stomach, and in others by gall-stone, or renal calculus, or lead colic, still there are patients affected with gout, who, without any such exciting cause, suffer from intense pain at the stomach of a most alarming character. We lately AND GOUTY DYSPEPSIA. 197 witnessed a case of most severe colic, which, after lasting about forty-eight hours, gave place suddenly to severe gout in theibot, as well as in the small joints of the hands ; after a few days the gout sub- sided, without any return of abdominal pain. It is when these anomalous dyspeptic symptoms exist without any gouty deposit in the neighbor- hood of the joints, or in the fibrous tissues, and without previous paroxysms of gout, that the diag- nosis is accompanied with difficulty ; but when gout has become manifested by these outward signs, the organs of primary assimilation are found to be very easily disturbed. In chronic gout, degeneration and contraction of the kidney often occur; albuminuria is found to exist without dropsical effusion, and the gastric symptoms are greatly aggravated. Some of these patients who have consulted me, merely complained of drowsiness; and on investigation the urine was found albuminous, and the kidney organically af- fected. With great care a fatal issue may be warded off; but too often cerebral disease and apoplexy ensue from degeneration of the minute capillaries of the brain. In rheumatism, both of an acute and of a chronic kind, the gastric functions are disordered; in the acute form the tongue presents a white and creamy 17* 198 RHEUMATIC fur, and there is loss of appetite, with more or less constipation; and in chronic rheumatism we often find that there is troublesome gastric affection. The most effectual relief for this gouty dyspepsia is to promote the separation of the excreta retained in the blood; saline purges with colchicum, and the cautious employment of neutral salines or car- bonated alkalies with vegetable infusions should be used, and if there be much depression these reme- dies should be given with aromatic spirit of ammo- nia. The saline waters of Karlsbad, Vichy, Wies- baden, Wildbad, Bath, Cheltenham, etc., are often very serviceable. A few doses of mercurial medi- cine serve to stimulate the abdominal glands to more vigorous action. If the gastric pain be severe, bismuth and the carbonated alkalies of potash, soda, or magnesia, with hydrocyanic acid and chloric ether, may be used,; and when the pain is intense, opium or chloroform should be administered, or a minute quantity of morphia should be used hypodermically. But the most powerful remedial agent in the treatment of gouty dyspepsia is the maintenance of a healthy state of the skin, with a well-regulated diet; there should be the spare use of nitrogenous food, and only of the more easily digestible forms, and a free allowance of vegetable diet, and of ripe AND GOUTY DYSPEPSIA. 199 fruit—of the former, greens and similar productions; of the latter, strawberries, grapes, oranges, etc. Wine, if taken at all, should only consist of the lighter kinds, and of these claret is perhaps the best; but ardent spirits as a rule should be entirely avoided. Another essential part of right treatment in these cases is outdoor exercise, either as horse or carriage exercise, walking, yachting, etc.; the free inhalation of pure oxygen tends not only to invigorate and strengthen, but to remove effete material. I have tried the salts of lithia in these cases, but without the benefit expected from the laudatory terms of its introducer. Dr. Garrod, from the fact of the greater solubility of the compounds of uric acid with lithia, considered that this alkali would effect more readily the separation of redundant uric acid. The dose of these salts, as the carbonate or citrate of lithia, is five to ten grains with aerated waters or with vegetable infusions. Equal, if not greater, benefit arises from the use of the iodide of potassium with the bicarbonate, or the potash tar- trate with bitter infusions; and if the heart be en- feebled, the ammonia citrate or potash tartrate of iron may be advantageously conjoined. 200 RENAL DYSPEPSIA. CHAPTER XII. RENAL DYSPEPSIA. The connection of disorder of the stomach with diseased conditions of the kidney is scarcely less intimate than that which exists between the liver and the stomach, but this connection is of two kinds: 1st, it has its origin in the intimate union of the nerves supplying the two organs; and, 2d, the imperfect depuration of the blood in disease of the kidneys produces gastric disorder. The first form of malady is seen in the acute vomiting and extreme irritability of stomach pro- duced by calculus in the kidney or ureter; intense pain comes on in the region of the kidney, in the course of the ureter and of the genito-crural nerve, and at the same time vomiting of a most severe kind ensues. The sudden onset of the paroxysm of agonizing pain is caused by the impaction of a calculus in the ureter; and, as the pain radiates across the abdomen, it is frequently mistaken for colic, or, from the sympathetic affection of the stomach, it is regarded as primary gastric disorder. RENAL DYSPEPSIA. 201 If the structure of the kidney be unaffected, the gastric symptoms disappear when the pain ceases; and the patient rightly states, that as soon as the pain has subsided, a hearty meal can be taken, and well digested without any renewal of pain. This condition then is due to the relation of nervous structures; the renal plexus of nerves is intimately connected with the semilunar ganglion, and branches of the pneumogastric nerve also pass directly to the kidney; the stomach also receives its nerve supply from both these sources, the pneumo- gastric nerve and the semilunar ganglion; these instances are not really dyspepsia at all, nor even disease of the stomach in any sense, although not a few instances have been brought under my notice as such. The second form of gastro-renal disease is from organic disease of the kidney; the blood is imper- fectly purified, urea is retained in it, and as a symp- tom of this uraemia, gastric disturbance is produced. From this blood-contamination all the secretions become changed, and the gastric juice itself is altered from the presence of urea in it. The symptoms of this disorder are loss of appe- tite, nausea coming on without any assignable cause, and vomiting of clear watery mucus; any- thing placed in the stomach is at once expelled, 202 RENAL DYSPEPSIA. even the blandest diet is with difficulty digested; distension and pain are excited ; and when the vis- cus has become composed, any indiscretion is suffi- cient to bring on a recurrence of the irritability. These symptoms are often less severe, and we may find the urine highly albuminous, without any dis- order of the stomach. This dyspepsia is accompanied by other charac- teristic symptoms of renal disease, such as anaemia and anasarca, but in numerous instances this is not the case; the anaemia may not be remarkable, and the only evidence of anasarca may be an oedematous condition of the conjunctiva and of the eyelids. Pain in the head, and at the back of the neck, or an unusual disposition to sleep, may, however, be the indication of an urasmic state. These instances of disease are of a most serious kind, and great care is required lest the already dis- eased kidney almost cease in its action, and the case terminate fatally. In sudden suppression of urine, vomiting is sometimes as marked a symptom as in intestinal obstruction, as shown many years ago by Dr. Barlow. When vomiting is persistent in albuminuria, and especially when it is accompanied with purging, we regard it as a very unfavorable symptom. The whole mucous membrane of the alimentary canal RENAL DYSPEPSIA. 203 becomes oedematous, and the serous discharge pro- duces irritation, disturbs the ordinary functions, and exhausts the patient. With renal dyspepsia, other cerebral symptoms are often conjoined, as occasional momentary loss of consciousness or epi- leptiform attacks ; the senses are also affected, and amaurotic symptoms come on from degenerative change of the retina; the hearing is perverted, and ringing or other noises are excited as subjective phenomena; these perverted sensations are followed by general diminished power of the sensory organ affected. It is a wise precaution, in all cases where vomiting is a prominent symptom, carefully to ex- amine the urine. These varieties of disease are excited by the causes of acute or chronic renal affection ; we have seen numerous instances in connection with the in- temperate use of ardent spirits, in which a single glass will at once produce a return of the albumi- nuria ; with other patients gouty diathesis is asso- ciated, and a very severe form of sympathetic dis- turbance of the stomach is observed when diabetes is coexistent with albuminuria. I have witnessed this complication in young children producing epi- leptiform convulsion and speedy death; and, on the contrary, in others it had apparently lasted for many years. 204 RENAL DYSPEPSIA. In the treatment of renal dyspepsia, if the bowels are confined, they should be acted upon freely; the skin should be excited to increased action by dia- phoretics, as by the acetate of ammonia, by hot air, or Turkish bath, and a cupping glass may be applied to the loins. In chronic disease of the kidney a blister to the loins often proves of great service. Sedatives, as effervescing medicines, hydrocyanic acid, bismuth, have very little effect in quieting the stomach ; they may, however, be tried, and in some cases partial relief follows. It is of greater service to act upon the kidney, and thus remove the cause of the gastric disturbance. Salines of potash and soda, the acetate of ammonia, and free doses of the compound jalap powder, effect greater benefit than remedies directly influencing the stom- ach itself. The compound jalap powder is often very efficacious at first, but afterwards it entirely fails. Elaterium should then be tried, in doses of one-sixth to one-fourth of a grain, administered with the bitartrate of potash ; but when thus given, it often acts as powerfully upon the mucous mem- brane of the stomach as upon that of the intestine, and violent vomiting takes place. This effect is partially obviated by giving the drug, in the form of a pill, with the extract of henbane ; and very small doses of elaterium, as one-twentieth of a RENAL DYSPEPSIA. 205 grain, repeated every two to four hours, are also, in some instances, found to distress the patient less, and to act very efficiently. The resin of podo- phyllum, I have found in some cases of chronic al- buimnuria, prove more serviceable than either jalap powder or the elaterium, especially when the renal is associated with hepatic disease. The resin of jalap sometimes produces more certain result than the powder. Again, I have had several cases of this kind un- der my care, in which erysipelas of the lower ex- tremities and abdomen has been followed by marked relief to the renal and gastric symptoms. It is scarcely necessary to mention that ardent spirits should be avoided, and, if possible, every form of alcoholic stimulant. 18 206 MECHANICAL DYSPEPSIA. CHAPTER XIII. MECHANICAL DYSPEPSIA. It is not sufficient for the completion of the di- gestive process that the mucous membrane alone should possess its functional activity and integrity ; the muscular coat is essential, in order to execute the churning movements performed in the process, and then to propel the fluid mass onwards through the pyloric valve. Anything that interferes with these normal movements may become a cause of dyspepsia; and we may arrange these mechanical impediments into three groups ; 1. Displacements of the stomach. 2. Pressure upon the stomach in its normal site. 3. Changes in the muscular fibre itself, fibroid disease of the pylorus, causing contraction, and atrophic distension. It is more especially to the simple displacements that we refer, in speaking of the functional mala- dies of the stomach. The common causes of these displacements are external pressure, from stays or belts, or the pressure from leaning over a table or MECHANICAL DYSPEPSIA. 207 desk, or against instruments used in mechanical occupations ; but a frequent source of displacement is internal, and consists in abnormal intestinal ad- hesions. The stomach is naturally placed almost horizontally, the pyloric being only a small dis- tance below the cardiac extremity; and from its greater curvature, the omentum extends to the transverse colon and spreads over the small intes- tine. When the lower ribs are firmly compressed, es- pecially during active growth and development, the stomach assumes an almost vertical position; the pylorus is then pressed downwards to the um- bilicus, and the natural churning movements of the stomach, as well as the passage of the food along the lesser curvature, and backwards towards the cardia by the greater curvature are interfered with ; the semi-formed chyme gravitates unnaturally to- wards the pyloric valve, and portions pass into the duodenum before they have undergone complete solution. In this semi-dissolved state of the in- gesta, irritation of the intestine is set up, and pain produced. Borborygmi and flatulent eructations distress the patient, and a fertile source of hysteri- cal complaint arises. When direct pressure is made upon the scrobiculus cordis, the movements of the 208 MECHANICAL DYSPEPSIA. stomach are differently modified ; the firm pressure whilst digestion goes on, not only interferes with free movement, but excites irritation. Again, cases are far from unfrequent where the omentum, attached as we have just said to the greater curvature of the stomach, becomes adhe- rent at the lower part of the abdomen, or is fixed by hernial attachment. The free distension that accompanies normal digestion is prevented, for the stomach is tied down; we find that pain in the side of a fixed character is produced, and this distress is increased by anything that distends the viscus, therefore especially by digestion; and the pain recurs after nearly every meal. Another form of dyspepsia of a mechanical kind is that arising from pressure upon the stomach by dropsical and other effusions. As the effusion accumulates in the peri- toneal cavity, an uniform pressure is exerted upon the stomach, and no inconvenience may be felt as long as the stomach is not distended; but directly it is required to perform its normal work and neces- sary movements, with which are also generally as- sociated some increase in the volume of the stom- ach, either from food or gaseous evolution, pain is produced, and is frequently followed by the rejec- tion of the contents of the stomach. And although MECHANICAL DYSPEPSIA. 209 the primary disease—the cause of the dropsy, whether it be chronic disease of the liver, of the kidney, or of any structure—may itself produce dyspepsia as one of its symptoms, still this mechan- ical pressure greatly aggravates the gastric disturb- ance. The patient becomes physically unable to take food: pain, eructation, and a sense of almost insufferable distension are produced. When the fluid or the pressure is lessened, the symptoms sub- side ; and we have very frequently noticed that the stomach has suddenly regained its power after para- centesis abdominis had been performed. Abdomi- nal tumors whether carcinomatous, hydatid, or of any other kind, sometimes exert pressure upon the stomach, and thus mechanically interfere with its healthy action. 3. As regards the changes in the coats of the stomach, they belong so exclusively to organic dis- eases that we shall not enter upon the consideration of them here ; but it may be mentioned, that in fibroid disease of the pylorus, the stomach some- times attains enormous proportions, so that with the pyloric valve close to the pubes, the viscus fills nearly the whole of the abdomen ; and that without such valvular obstruction, the muscular coat be- comes sometimes atrophied, and the cavity enor- is* 210 MECHANICAL DYSPEPSIA. mously distended, so that it is unable to contract upon its contents. In this latter case the principal symptom is the tympanitic distension of the abdo- men, with feebleness of digestion. We shall have again to refer to distension of the stomach in speak- ing of fermentative changes. SYMPATHETIC DYSPEPSIA. 211 CHAPTER XIV. SYMPATHETIC DYSPEPSIA. The extensive connection of the stomach with other parts of the system, by means of its supply of nerve filaments, leads to frequent disturbance of its function from disorder in other parts; and an intimate acquaintance with these sympathetic mal- adies is of the utmost importance ; for without this knowledge, not only is the true source of disturb- ance overlooked, but, as a necessary sequence, the treatment is ineffective, because applied in a wrong direction. It is not our attention to describe the nerves that supply the stomach, but only to state that this supply is from two sources; first, from the large branches of the vaso-motor nerve of the semilunar ganglia of the abdomen, by which it is connected, not only with the adjoining viscera in the abdomen, but with nearly every part of the body; this con- nection gives rise to disturbances of sight and hear- ing, and of the intellectual and sensory centres generally; the second source is from the pneumo- 212 SYMPATHETIC DYSPEPSIA. gastric nerve, which also supplies the lungs and the heart. Perhaps the most important form of sympathetic disturbance of the stomach is that connected with disease of the brain ; and the consideration of this is the more necessary, because in such cases the true nature of the malady is often overlooked. There are some peculiarities, however, which serve to distinguish this form of malady; in one class the subjects are young, of an active mind, intelli- gent, and precocious. There may be some head- ache, and temporary disturbance of vision, grinding of the teeth, disturbed nights, and restless activity of mind during the day; they are generally pre- cocious children, of bright and joyous disposition; and, without any very apparent cause, vomiting is set up, and the illness is regarded as a "bilious attack." This may soon be followed by more marked symptoms of cerebral disturbance, by severe headache, convulsion, and gradually increasing coma, in fact, by all the symptoms of acute hydro- cephalus; or there may be a succession of such attacks, each slight in itself, but, as the mind is allowed to rest, and the irritation of the brain di- minished, the diseased state gradually subsides. This repeated disturbance of the brain favors the deposition of tubercular deposit in the membranes, SYMPATHETIC DYSPEPSIA. 213 and at length acute hydrocephalus is developed, to the inexpressible anguish of the relatives of the child. Sometimes the symptoms of cerebral affec- tion are preceded by those of gastric remittent fever, and then it is difficult without careful inves- tigation to decide whether the disease is really wholly abdominal in its character, and whether the brain disease is not secondary rather than primary. In another class of cases, the patient is more ad- vanced in life, it may be in early manhood, when severe pain in the head, and vomiting without any real gastric disturbance, usher in most serious and fatal disease, as in abscess of the brain, or tumor, or in the first stage of ingravescent apoplexy. The same sympathetic connection is witnessed after concussion of the brain. As the patient be- gins to rally from the first effects of the blow, vom- iting is a frequent result; and, if local inflammation of the membranes of the brain take place, the irri- tability of the stomach is sometimes excessive, especially if the disease extend to the origin of the pneumogastric nerves. These cases are often set down as "bilious attacks," which is the most serious mistake that could be made, for the sole attention is then directed to the stomach and the liver; the nature of the malady is overlooked, and the treatment misdirected. In the 214 SYMPATHETIC DYSPEPSIA. diagnosis of these cases, where irritation of the brain is the cause, the head is hot, the pupils gene- rally small, the tongue clean, the abdomen con- tracted, and the bowels confined. Another cause of sympathetic disturbance of the stomach is disease of the spinal cord ; but although irritability of the stomach is sometimes to be traced to this source, more frequently the pain at the scro- biculus cordis, and flatulent distension of the stom- ach and abdomen, are really signs, the one of irritation at the peripheral extremity of the spinal nerves, the other of paralysis, which prevents the muscles forming the abdominal parietes, and the involuntary muscular fibre of the intestine, from contracting in their normal manner. In disease of the lungs, especially of a tubercular kind, the implication of peripheral branches of the pneumogastric nerve in the morbid action sets up reflex disturbance of the stomach; we find delicate strumous subjects thus affected with such extreme sensibility of the stomach, that food of almost every kind is at once rejected; no cough may be present, but on examining carefully the apices of the lungs, some difference in the resonance on percussion will be found, and the respiratory murmur will be heard more feeble than natural, or irregular, or the expi- ratory murmur coarse and prolonged, even if more SYMPATHETIC DYSPEPSIA. 215 advanced indications of organic change do not exist. This state of sympathetic gastric disturbance some- times subsides as the phthisical condition becomes fully developed, or it may continue to harass the patient throughout the whole course of the com- plaint. It may be argued by some, that the gastric al- together precedes the pulmonary mischief, and that in the weakness from the impaired power of diges- tion we have the cause of the low organized deposit in the cell structure of the lungs. If such were the case, the gastric disease would continue at least pari p>assu with that in the lung, and be detected after death; whereas, we never find tubercular deposit or strumous ulceration in the stomach, and the utmost that can be noticed is the fatty degeneration or atrophy occasionally found in phthisical patients, although not exclusively in them. Too often have we found that most important time has been lost during early phthisis by this error of supposing that the disease is " all stomach." In this state of functional disturbance of the stomach, preceding or accompanying phthisis, there is unusual irritability of the mucous membrane. As Dr. Theophilus Thompson has shown, the state of the gums is peculiar, a red injected line of con- gested mucous membrane being observable along 216 SYMPATHETIC DYSPEPSIA., the margins of the teeth; nausea, loss of appetite, disrelish for fatty substances, pain at the scrobicu- lus cordis may also coexist; severe vomiting may be followed by cough, and after a time by haemop- tysis, and by the general signs of tubercular disease of the lung. It is during this early stage of phthisical disease that remedial measures are of inestimable value. Far better is it at this period to seek to invigorate and strengthen the system by change of climate and generous diet, than to wait until disease has become firmly established; for too often patients are re- moved from the comforts of home when the strength is entirely exhausted, and they are sent away to die among strangers, and in foreign lands. We more frequently have sympathetic disturb- ance of the heart from functional disease of the stomach than the converse, namely, stomach irrita- bility from heart affection, except that consequent on passive venous congestion. In the disease of the supra-renal capsules, which received so much attention from Dr. Addison, and which is generally associated with discoloration of the skin, irritability of the stomach is one of the characteristic symptoms ; and although in some of these instances we have found superficial ulceration of the stomach, and a condition of the mucous mem SYMPATHETIC DYSPEPSIA. 217 brane indicative of more than mere functional change, namely, arborescent vascularity, still we are led to regard to regard the very intimate con- nection of the stomach by means of large nervous filaments with the semilunar ganglion, and the union of the same ganglion with the supra-renal capsules by still larger branches, as an important fact in explaining the irritability of the stomach in cases of disease of the supra-renal capsules. In the sympathetic disturbance of the stomach from disease of the kidney, we do not refer to instan- ces of Bright's disease and albuminuria, in which the changed character of the gastric secretion leads to vomiting and other signs of stomach disturbance; but we would notice cases of calculus in the kidney, in which vomiting is a constant and characteristic symptom, though evidently not connected with sim- ple disorder of the stomach ; for patients often state, that when the pain has subsided, they can digest a hearty meal, as we have before said, and we have had cases brought before us of this kind mistaken for ordinary abdominal colic. That diseases of the uterus and of the urino-gen- ital organs set up vomiting, is a fact familiarly known. Many persons, during the whole period of utero-gestation, suffer severely by this sympathetic 19 218 SYMPATHETIC DYSPEPSIA. disturbance, and a greater number are affected during the earlier months. Any abnormal congestion and inflammation about the ovaries may lead to similar gastric distress; and in men, disease of the bladder, prostate and tes- ticles induces almost corresponding symptoms. In the treatment of these forms of sympathetic disease, correct diagnosis is of the utmost import- ance, for it is worse than useless to direct the whole attention to the stomach, when it is only secondarily involved. Our chief concern then must be with the cause of the complaint; thus, in disease of the brain, if we can diminish the cerebral mischief, the gas- tric will soon subside. Still, although the stomach is not primarily implicated, and its structure is not changed, it is in an unfit state to digest an ordinary meal, and great care should be used to lessen the quantity of the diet, and to tax the energy of the organ only by bland and unirritating food. Medicine may also assist in quieting even this secondary irritation, and in enabling the stomach to tolerate the presence of food. Effervescent medi- cines, carbonic acid, etc., appear to act directly upon the nerve filaments of the stomach, and to diminish sensibility. Hydrocyanic acid, with alka- lies, acts also as a sedative, and lessens irritability, so also bismuth. SYMPATHETIC DYSPEPSIA. 219 In renal calculus, alkalies with rest are the most likely measures to afford relief, after having quieted the pain by chloroform, ether, or opium. Some- times the inhalation of chloroform, may be advan- tageously used, especially if the improved method be employed, namely, of mixing the chloroform with atmospheric vapor, in definite proportions, before the inhalation ; the object to be sought for is, by so diluting the chloroform, as to allow of its very gradual absorption, and in this way pain may be removed without narcotizing the patient; or a free dose of Battley's sedative solution of opium may be combined with tincture of henbane and chloric ether. Belladonna may also be tried. The hypodermic method of employing morphia is a valuable means of quickly subduing the intense pain, and sometimes an opiate enema may be used with advantage. The bowels should be acted on during the passage of a renal calculus, for the colon is generally inactive and the bowels confined. Morphia suppositories or enemata are of service, especially in ovarian irritation and inflammation with gastric disturbance, but it is most important to remove if possible the local disease. In utero- gestation, mineral acids, with chloric ether are per- haps the most effectual means of relieving vomiting, although too often ineffective whilst the cause re- 220 SYMPATHETIC DYSPEPSIA. mains. In these instances of gastric irritation from uterine activity, the bowels should be gently acted upon, and the effervescing citrate of magnesia con- stitutes both a grateful and effective remedy. Much may be done, however, by careful regulation of the diet, the disturbance is sometimes quieted by the repeated administration of small quantities of food ; and in all cases large meals should be withheld, and all external pressure upon the stomach itself taken away. In young persons, especially those affected with hysterical susceptibility, with dysmenorrhoea or leucorrhoea, a state of extreme irritability of the stomach is sometimes induced. The contact of any substance with the mucous membrane is followed by its instant rejection, and this may take place without previous nausea or pain ; and what is still more remarkable, there may be very little emacia- tion, although this condition have existed for many weeks or months. Sometimes pain at the scrobic- ulus cordis exists, but more frequently the pain is of a neuralgic kind, and is situated beneath the left breast; the pulse is irritable, the tongue has gene- rally more or less injection of its papillae, and the bowels are confined. It is to this state that Sir Henry Marsh has applied the term of " regurgita- tive disease ;" because the food is rather regurgitated SYMPATHETIC DYSPEPSIA. 221 than vomited. These cases require careful watch- ing and treatment; they nearly all after a time completely recover. These cases may, however, be associated with gastric ulcer, when the pain and more persistent symptoms of that state will be also present. The first question is as to the food, which must be of a bland and easily digestible kind, as soup, mutton broth, soda water with milk, farinaceous food. If these be rejected, then the quantity must be diminished, and only a very small portion given, as a few teaspoonfuls of milk, with soda water or with lime water every quarter or half-hour, and if the pulse be failing, a small quantity of brandy may be added. If the regurgitation still continue, then it is well to allow the stomach to rest entirely, and to administer by enemata nutrient fluids three or four times a day, as a cupful of strong meat soup, thickened with flour, and with the addition of five or ten drops of laudanum, and a tablespoonful of brandy. We have known many obstinate cases entirely cured in this way. In one patient the in- jections were continued for a fortnight, and only a few teaspoonfuls of cold water were given to relieve the thirst. The bowels should be gently acted upon by aloetic pill, alone or with steel, with hen- bane, or with the extract of nux vomica, 19* 222 SYMPATHETIC DYSPEPSIA. I have often found the nitrate of bismuth, with carbonate of soda and chloric ether in mucilage mixture, very useful; the black oxide of manga- nese in dose of gr. x to xx, is recommended by Dr. Leared. The salts of cerium are praised by some, but I have found other remedies more effica- cious. When the extreme irritability has lessened, there must be a gradual return to more strength- ening diet; the milder preparations of iron are then very serviceable, as the ammonio-citrate of iron with carbonate of ammonia, the phosphate and hypophosphite of iron with dilute phosphoric •or hydrochloric acids; sometimes also the sulphate of iron, in half-grain doses, with sulphate of qui- nine and extract of henbane is useful. Other remedies are often tried, as hydrocyanic acid; alkalies, magnesia or its carbonate creasote, chloroform and chloric ether, opium. Opium does not act so well in these cases, as in ulcer of the stomach. If the pain be severe, a small quantity of morphia may be used hypodermically. Bella- donna is better than opium. Small blisters applied to the scrobiculus cordis or to the spine sometimes. alleviate the symptoms. Calomel has been used as a sedative to the mucous membrane of the stomach in some of these SYMPATHETIC DYSPEPSIA. 223 cases of extreme sympathetic irritability. This condition is, however, so frequently associated with an anaemic, chlorotic, or hysterical state, that the administration of mercurials, except as occasional aperients, is better avoided. Still we have wit- nessed instances, where one grain of calomel, given several times during the day, has been followed by cessation of the symptoms. There are several other conditions of dyspepsia which are atonic in their character, but appear at the same time to be sympathetic, and connected with the state of the cerebro-spinal system. In some men we observe a state closely resembling^ hysteria, as shown by flatulence, loss of appetite, sensibility of the surface of the abdomen, sensations almost amounting to globus hystericus, disturbed cerebral function, depression, anaesthesia, incapacity for exertion, etc. In this condition, which is often combined with distended colon, I have found marked benefit result from the use of aloes com- bined with steel; fresh air and vigorous exercise are important remedial agents, when they can be obtained. In other cases, the head is badly formed, and the forehead narrow, showing that the brain is likely to be easily disturbed, or there is hereditary tendency to mental disease, as mania, melancholia, 224 SYMPATHETIC DYSPEPSIA. and epilepsy. The body is well nourished, but the patient complains of pain at the scrobiculus cordis and in the back, or in various parts of the body ; the mind is depressed, and the appetite irregular. Although muscular, a man may be quite incapaci- tated for exertion; the tongue may be clean, the bowels regular, the evacuations normal or pale, the pulse tolerably full or depressed and irregular. It would seem that dyspepsia has arisen from ordi- nary causes, but the sympathetic nerve reacts upon the cerebro-spinal centres, and these being easily disturbed from their healthy balance, again react upon the sympathetic nerve, perpetuating and ag- gravating the original and slighter malady. In young children the susceptibility of the ner- vous system during first dentition is universally acknowledged, although frequently too much is attributed to this cause, and every disturbance of the brain or of the digestive system is attributed to this circumstance; but the same susceptibility, though less energetic, is manifested at a later period. We have often found young persons, between the ages of eighteen and twenty-five, affected with vague nervous and dyspeptic symptoms during the passage of the wisdom teeth through the gums; the mind is oppressed, so that there is an incapacity for directing fixed attention to any subject, and SYMPATHETIC DYSPEPSIA. 225 slight disorder of the gastric function is associated, irregular appetite, occasional nausea, etc.; and in some instances we have known severe epileptiform attacks come on. These states of sympathetic dyspepsia, with nerv- ous irritation, require attention. The bowels should be freely acted upon, so as to unload the colon; and the diet should be sustaining without being of a stimulating character. If there be any direct pres- sure upon the gum, free incision should be made; but what is of still greater importance is the gene- ral treatment of the patient: the mind must have rest from close application; exercise in the open air is desirable, especially horse exercise; hot rooms and exciting pleasures should be avoided ; and when it can be attained, several months of travel and change of scene are greatly conducive to complete restoration of health. Less severe, but more distressing, is the dyspepsia in hypochondriasis. We might have spoken of it in connection with atonic dyspepsia, for there is great feebleness in the vaso-motor nerve, leading, it may be, to a deficient secretion of gastric juice; or we might have described a very similar state as being produced by gouty dyspepsia; or, lastly, as arising from an over-worked mind and body.. In these instances the whole attention is occupied with 226 SYMPATHETIC DYSPEPSIA. the diet; the mind is depressed, and its energies enfeebles; one change after another is tried, but pain and discomfort equally follow; the stomach is sometimes exceedingly irritable, the bowels are over-anxiously watched, the sleep is unrefreshing, and life rendered miserable. To tell the patient nothing is the matter, would be to drive him to some one who would give an opinion more in uni- son with his feelings. By carefully regulating the diet and the bowels, by cold sponging, by taking frequent exercise, either walking or on horseback, or a pedestrian tour when it is possible; by keeping the mind free from anxiety, and by cheerful society and occupa- tion, all the symptoms may be greatly relieved. Such patients often take too spare a diet, leaving off one thing after another as unsuitable; and consider- able improvement follows a more generous diet, especially when the mind is encouraged and cheered by the prospect of restored health. FERMENTATIVE DYSPEPSIA. 227 CHAPTER XV. FERMENTATIVE DYSPEPSIA. The chemistry of digestion is a subject full of interest, and one that has received considerable elucidation from the researches of later years. The food begins to undergo change as soon as it is brought into contact with the secretion from the salivary glands, and passes through the process of mastication, but this is especially the case with starchy and farinaceous substances, which are con- verted into sugar. The saliva is naturally alkaline in its reaction, and contains a substance to which the name of ptyalin has been applied; this chemi- cal substance resembles diastase. It induces a re- arrangement of the elements of the starch, so that saccharine principle is produced; the saliva also contains sulphocyanides and a large quantity of saline material. Thus, thorough mastication serves a double purpose, not only to break down the solid portions of food, so that they may more readily undergo solution by the gastric juice, but to incor- porate the salivary fluid, so that it also may be 228 FERMENTATIVE DYSPEPSIA. brought into contact and exert its energy upon the starchy elements. This metamorphosis is extremely rapid, and it continues throughout the whole'of the masticatory movements, during deglutition, and till the food reaches the stomach ; and even then it is not checked, although more important reactions take place by means of the gastric juice. In the duodenum and small intestine the same action per- sists as was commenced in the mouth, but with less energy. It is of great importance, therefore, that mastication should be thoroughly and efficiently executed, and the defect in this process is the first step towards the abnormal fermentative changes in the form of dyspepsia, which we have now before us. In the stomach a different set of glands, peculiar to itself, secretes an acid fluid, known familiarly as the gastric juice; this secretion contains a nitro- genous substance, pepsin, and an acid, variously regarded by chemists as hydrochloric or as lactic acid, besides saline materials and water. The pep- sin acts upon fibrinous substances, causing their solution, without itself entering into combination or becoming decomposed; the fluid that is formed, although fibrinous or albuminous, possesses differ- ent properties from a mere solution of a protein compound, for it is not coagulable by heat; the FERMENTATIVE DYSPEPSIA. 229 term peptone has been applied to it, and the whole solution has been designated chyme. The chemical solution of the nitrogenous portions of food by the pepsin is limited, but it is greatly increased by the presence of the acid of the gastric juice, and by the heat of the stomach and the churn- ing movements of the muscular walls. The food rotates along the lesser, and then from right to left backwards by the greater curvature; as the chym- ous fluid is formed, it passes by the pyloric valve into the duodenum, when it is mixed with the bile and with the pancreatic secretion before it reaches the jejunum and ileum, and is absorbed into the system by the capillary veins and by the villi of the intestine. This process of solution or digestion requires ac- cording to the nature of the food, from two to four or five hours; and many substances that are taken cannot be dissolved at all, but pass in their crude state into the'intestine; and although the solvent powers exerted by the gastric juice are especially upon the protein compounds,—the nitrogenous ele- ments,—still the changes upon the starchy portions commenced in the mouth are not entirely checked; the oleaginous elements are more thoroughly divided, and the saline and aqueous constituents are diffused completely through the semi-fluid aliment. 20 230 FERMENTATIVE DYSPEPSIA. In a normal state the solution should be completed after a certain time, and as one part after another passes into the duodenum or becomes absorbed, the stomach is left in a quiescent state. But, far different are the conditions found in dyspepsia of the kind we are considering; when, either from improper food, or from insufficient secretion of gas- tric juice, or because the fluid when formed is un- able to pass from the stomach, fermentative changes take place. The gaseous exhalations into the stomach consist of nitrogen and carburetted hydrogens, or fermen- tation takes place accompanied with the evolution of carbonic acid, or butyric acid is formed, or lastly, putrefactive changes arise, and sulphuretted hydro- gen is produced; these several forms of fermenta- tion arise from different causes, as we have before mentioned in speaking of distension of the stomach as a sign of gastric disease ; they produce diverse symptoms, and are amenable to various forms of treatment. We have already enumerated several sources of gaseous distension of the stomach, and shall not again enter upon their full consideration. We have stated, 1st, that gas may be swallowed; or, 2dly, produced by the decomposition of food in the stom- ach ; 3dly, that it may be evolved from changes in FERMENTATIVE DYSPEPSIA. 231 the mucus secretions themselves ; 4thly, transuded from the blood ; 5thly, regurgitated from the duo- denum, or from a fistulous communication with the colon, or from some adjoining abscess; 6thly, gas of an offensive kind is produced by the decompo- sition of a growth in the stomach, as cancerous tumor. The first form of gaseous distension that we have to notice, is quite independent of food, or rather is frequently produced by the want of it. The gas consists of nitrogen mixed with carburetted hydro- gens and some carbonic acid; it is often suddenly evolved, and is especially connected with an ex- hausted state of the nervous system; it is often peculiarly marked in hysterical patients, and in others it may be induced by mental excitement or depression, and abstinence from food is a very common cause of it. This form of dyspepsia is of an atonic character; the want of power being due either to general loss of strength, or to deficient supply of nourishment. It is marked by a sense of sinking at the stomach, distension, and pain as that distension increases; the pain often commences in the back, and seems to pass round the body or through it to the scro- biculus cordis: headache is often present, and some- times faintness; if the pain become severe, the 232 FERMENTATIVE DYSPEPSIA. pulse assumes a compressive character, the tongue is not necessarily changed; eructation takes place, and with that relief the pain subsides; or the gas passes downwards, and the pain then moves from the stomach, and entirely ceases as the gas is evacu- ated. This form of dyspepsia sometimes produces extreme prostration and collapse, and the severity is so great, that perforation of intestine is simulated. At the commencement of this state, if a small quan- tity of nourishment can be taken, the symptoms may be checked ; stimulants may be given, as wine and brandy with nourishment; but if the distension have become severe, then antispasmodics are neces- sary, chloric ether, ether, camphor, ammonia, and when pain has supervened, opium should be given. We have known severe collapse quickly relieved by opiates freely administered; but it is always very important, so to strengthen the system and regulate the diet, as to guard against these attacks. A second form of gaseous distension arises from fermentation of the food itself, whether from its im- proper character, from defective gastric secretion, or from obstruction ; a short time after a meal has been taken distension and pain arise ; and three or four hours later, or it may be at the close of the day, several hours after food, a large quantity of fermenting substance is ejected, sour and acid in its FERMENTATIVE DYSPEPSIA. 233 reaction, and with a frothy surface. It might be compared to the fermentation produced by yeast in alcoholic or vinous fermentation, and carbonic acid is also evolved. It is not unfrequent, especially when associated with gastric ulcer, or with pyloric disease, to have the sarcina ventriculi of Goodsir present. These minute confervoid growths, in their bale-like quadrangles, appear to indicate some peculiarity in the fermentative process, and al- though often associated with organic disease, are not pathognomonic of it. In this form of fermentative dyspepsia, pain at the stomach and in the back, flatulent distension, colic, eructation, furred tongue, are the common symptoms; the pain is often very severe, and the distress considerable. It would, however, be an erroneous supposition to think that the fermentation to which we have referred is the primary disease, for it is only a symptom ; and it is the consequence of previous ab- normal action. The gastric juice checks fermenta- tion, but if it be insufficient for this purpose, or if the dissolved aliment be unable to escape, either from constriction or spasmodic contraction at the pylorus, secondary changes rapidly follow. Some forms of diet are more prone than others to produce this effect. Saccharine and starchy sub- 20* 234 FERMENTATIVE DYSPEPSIA. stances, cruciferous vegetables, and hard and indi- gestible products generally favor similar action. To relieve this distressing symptom of gaseous distension from chemical change, our first object is to remove the cause, and then so to regulate the diet, as to give those articles least likely to induce this reaction ; but if necessary directly to check dis- tension, then we find the value of those reagents, which in the laboratory of the chemist stop alco- holic fermentation ; the sulphites and hyposulphites powerfully absorb oxygen, and may be given with great advantage: and a still more energetic sub- stance is carbolic acid and creasote, and in many instances we have witnessed, their efficacy. The cases, however, must be carefully selected; for in irritable conditions of the mucous membrane car- bolic acid and creasote cannot be borne, and bis- muth with alkalies will be found to be more effica- cious. Charcoal may also be used, and it is certainly very valuable, in some instances, in directly ab- sorbing gaseous substances in the intestinal canal. Carefully prepared wood charcoal, finely triturated, may be given with simple mucilage mixture; and some patients prefer this to the charcoal biscuits. Dr. Leared strongly advocates the use of charcoal in capsules. We have many years ago seen it ex- tremely serviceable as an enema in relieving second- FERMENTATIVE DYSPEPSIA. 235 ary fermentative changes in the colon; and given by the mouth, we have found it of greater value in intestinal than in gastric distension, for the latter we could obviate by more agreeable treatment. Another form of fermentative dyspepsia results in the production of butyric acid. This organic acid is closely allied to lactic acid, and it is that which gives the peculiar sourness to the vomited matters in dyspepsia. Fatty matters, milk, cheese, especially when these are partaken of in disordered conditions of the digestive apparatus, lead to this chemical change, and butyric acid is formed. The symptoms are severe heartburn, regurgita- tion of food into the throat, pain at the scrobiculus cordis and in the back, foul tongue, disordered state of the liver, the urine often high colored, and the bowels irregular. This state may come on as occasional attacks from indiscretion in diet, or it may be more persistent and is then most trying to the patient; almost everything that is taken be- coming, as the sufferer says, "sour" on the stomach. The most powerful means of relieving this con- dition are thoroughly to unload the portal system, to exclude as much as possible substances capable of butyric acid fermentation, and to strengthen the mucous membrane of the stomach by vegetable tonics. 236 FERMENTATIVE DYSPEPSIA. During the severity of an acute attack, salines of potash, soda, and magnesia most effectually relieve the pain and heartburn. The last condition of fermentative change to which we have to allude is that in which sulphu- retted hydrogen is formed ; a putrefactive action in which the patient complains of the offensive char- acter of the eructation, or of the unpleasant odor of the breath, or of the taste in the mouth. It would seem that some varieties of food contain- ing sulphur, more readily than in others, thus be- come decomposed. With some the sulphur present in egg is at once the cause of this offensive gaseous formation. The sources of fallacy upon which we have pre- viously dwelt must be borne in mind, that the gaseous tint may exist in the mouth, in the tonsil, the nares, and the throat, or be produced in the respiratory passages. And, again, regurgitation may take place from the duodenum, or from a fistu- lous communication with the colon, but here we have a fecal odor conjoined. Sloughing in the stom- ach itself, as of a cancerous or other tumor, decom- posing blood, and the communication with an ad- joining abscess, are other sources of fetid gaseous formations in the stomach. When it is truly gastric in its character and FERMENTATIVE DYSPEPSIA. 237 arising from dyspepsia, beside the more prominent and distressing symptom of the taste of rotten eggs, the secretions are vitiated, and we find other symp- toms are conjoined: sallowness of the complexion, headache, sense of weakness, a furred tongue, and an irregular condition of the bowels, the evacua- tions are dark and offensive, and often loose in character ; a sense of malaise or of general inability for exertion is also present. We do not find the same amount of pain as in the last mentioned form "of dyspepsia, but an atonic state exists, the bolus of food is not properly dissolved, it soon putrifies, or if dissolved, decomposition commences before it passes from the stomach. The gastric juice itself checks putrefaction, so also does the admixture of bile ; but in these cases the action of the gastric juice is insufficient. It is probable that to some extent symptoms resembling those produced by the inhalation of sulphuretted hydrogen accompany this form of dyspepsia, and that the blood becomes contaminated by the absorption of this gas from the stomach ; we refer especially to the sense of exhaustion that is induced, and the irregular action of the bowels. The diet must be carefully regulated ; and when no obstruction exists, it is well to administer warm saline aperients, as the sulphate of soda, or tartrate 238 FERMENTATIVE DYSPEPSIA. of potash, with the aromatic spirit of ammonia and the bitter vegetable infusions of orange peel, calumba, cascarilla, or gentian. The old formula of Guy's, rhubarb, soda, and calumba may be ad- vantageously tried; but creasote, while it checks the decomposition, is not so effective in these, as in the cases previously described. DUODENAL DYSPEPSIA. 239 CHAPTER XVI. DUODENAL DYSPEPSIA. The duodenum, the commencement of the small intestine, may be divided into three parts : its 1st and horizontal position, its 2nd and vertical, and its 3rd again horizontal, as it joins the jejunum. The 1st part is intimately connected with the stomach, in its physiological as well as in its pathological relations; the 2nd with the liver and the pancreas ; and the 3rd with the intestines. The pyloric valve separates the stomach from the duodenum ; this valve receives nervous supply from the pneumogastric, and so also does the first part of the duodenum, and consequently diseases affecting the mucous membrane of this part of the intestine, immediately beyond the valve, closely simulate the same disease of the stomach ; thus, we find congestive conditions, altered enervation, super- ficial and chronic ulceration, sudden perforation, and cancerous diseases, which are with difficulty diagnosed from disease on the gastric side of the valve. But it will be generally found that the 240 DUODENAL DYSPEPSIA. position of the pain and tenderness, and the dura- tion of time after the food has been taken before the attack comes on, will enable us to form a cor- rect opinion as to the nature of the disease. Three or four hours after food, that is, at the close of the digestive process, the pain commences. But there are instances in which the rapid passage of fluids from the stomach induces pain in the region of the duodenum almost at once. The pancreatic duct opens into the duodenum close to, and frequently in common with, the bile duct; and, as the bile is known to regurgitate into the stomach, it is probable that the pancreatic secretion may in a similar manner pass backwards and be vomited. In irritable conditions of the stomach, large quantities of mucus are often brought up in conjunction with bile; and it may be that the pancreatic fluid alone is rejected -through the stomach. The symptom to which the term pyrosis has been applied has been variously explained: it consists in the regurgitation of a watery fluid, sometimes saline in its taste, some- times tasteless; it is accompanied with some pain at the scrobiculus cordis, and with burning pain at the back of the mouth, or in the gullet, usually de- signated heartburn. The fluid is ejected at irreg- ular intervals; the mouth may be filled with this DUODENAL DYSPEPSIA. 241 fluid almost without warning, or it may be expelled soon after a meal, or even in the middle of the night. Other symptoms of gastric disorder may be present, but it is often unaccompanied by any of these symptoms. Some have regarded the oeso- phagus as the source of this pyrotic fluid ; it is generally referred to the stomach, and the question naturally arises, Can the pancreas be the origin of it? However it may be produced, pyrosis or water-brash is a distressing symptom to the patient, and is often associated with a state of general dyspepsia. AVe have previously referred to it as a symptom of gastric disease. There are two forms of duodenal dyspepsia that require especial consideration; the one arising from excessive irritability of the mucous mem- brane, the second from inflammatory congestion. Great credit is justly due to M. Corvisart for the investigation he has carried out in reference to the function of the pancreas, and its connection with duodenal dyspepsia; and doubtless this large gland, situated at the commencement of the small intestine, has an important relation to the func- tional activity of the ileum and jejunum. With- out entering upon the consideration as to the agency of the secretion in promoting the solution of nitrogenous products, there can be no doubt that 21 242 DUODENAL DYSPEPSIA. its function is as important, and probably analo- gous to that of the salivary glands ; and that with the function of the pancreas the minute duodenal glands, Brunner's glands, are closely connected. The first condition to which we have referred, abnormal irritability, is probably of a functional rather than of an organic kind; but, in some in- stances, the symptoms are so severe, that we have feared superficial ulceration. Such patients are generally in a weak and enfeebled state, the mind is restless, and the countenance anxious. There is tenderness to the right of the scrobiculus cordis, and the statement generally made is, that all goes on very well for about two or three hours after a meal; then, that soreness is felt, and a trying sense of pain with faintness is induced, the pain is sometimes described as a feeling of " tightness," " grasping;" at other times, as if there were " a raw surface," which was disturbed when the food was made to pass over it. Other portions of the mucous mem- brane may be irritable, and vomiting is not very unfrequent. The tongue is irregularly congested or patchy, the bowels may be in a normal or irritable condition, the pulse is compressible, but the most distressing symptom is the general feeling of malaise and exhaustion. It may be, that these symptoms are due to an unusual sensibility of the pyloric DUODENAL DYSPEPSIA. 243 valve; and we believe that this state does some- times exist. It is, however, difficult precisely to localize these symptoms, for both stomach and duo- denum are supplied with branches from the pneumo- gastric nerve, and the first part of the duodenum is closely allied in function with the stomach. That this state may precede one of organic change, and be followed by ulceration of a serious kind, is doubtless the case; but with care, we have known the symptoms entirely subside. After years of free- dom, they may return, but again yield to judicious treatment. The condition we have just described is one in which the strictest attention to hygienic rules and to a restricted dietary is essential to restoration. The diet should be of a bland, unirritating cha- racter. Sufficient time should elapse between the meals, and stimulants should be avoided if possible, especially ardent spirits and malt liquors. Physical rest, in a recumbent position, is also important; for exertion of a violent kind, even horse exercise, tends greatly to increase the pain and susceptibility. If these means can be used thoroughly and con- tinuously, medicine may be almost or entirely dis- regarded ; if the bowels be confined, mild saline aperients should be used, as Karlsbad salts, Rochelle 244 DUODENAL DYSPEPSIA. salts, or the carbonate of magnesia with hydro- cyanic acid. The nitrate of bismuth with carbonate of soda, in ten- or fifteen-grain doses, and if the pain be severe with small doses of morphia, is extremely useful in some instances; or minute doses of opium may be given; but the great disadvantage of opium is soon felt, that it confines the bowels, and inter- feres with free secretion. Acute inflammation of the duodenum is sometimes found after the administration of poisons; and after severe burns, the mucous membrane of this part of the alimentary tract becomes in some cases greatly congested; and, as first remarked by Mr. Curling, ulceration may supervene. He describes diarrhoea and the discharge of blood, as having arisen from this condition of the duodenum, and sometimes severe haematemesis and prostration. In some in- stances of severe burns, death has taken place as the consequence of perforation of the duodenum, causing peritorTitis. And after such severe injury to the skin, which, as we have before remarked, always evinces the closest sympathy with the mu- cous membranes of the stomach and intestines, it is not surprising to find, in connection with the gene- ral disturbance of the circulation, that congestion of this part occurs. In some instances, the free use DUODENAL DYSPEPSIA. 245 of stimulants may have conduced to this inflamma- tory disease of the duodenum. Gray discoloration of the mucous membrane of the duodenum is produced by long-continued con- gestion. It is of a uniform or punctate character, and it arises from the deposition of pigmental grains in the substance of the mucous membrane, or in the coats of the capillaries. This chronic hyperaemia is observed in connection with pulmonary and hepatic congestion—in fact, in any disease which leads to distension of the vena porta:; and we also find a less general condition of vascular repletion of the first part of the duodenum in disease of the pylorus, whether it be simple fib- roid degeneration and hypertrophy, or true cancer- ous disease. The mucous membrane becomes thick- ened, its vessels congested, and its glands enlarged; sometimes, indeed, so much so that the glands might easily be mistaken for minute cancerous tubercles; the continued irritation having led to hypertrophy of the glands of the mucous mem- brane, as we find in other similar structures. This state of chronic engorgement is best relieved by diminishing portal and hepatic congestion, and by stimulating the abdominal excretory organs to increased action, as we have described in speaking of congestive dyspepsia. 21* 246 DUODENAL DYSPEPSIA. There is, however, a state of acute hyperaemia of an interesting kind described by Sir H. Marsh and by Dr. Stokes. It is induced by exposure to cold,. by great mental anxiety, and sometimes by irregu- larity in diet and by stimulants. There is sallow- ness of the complexion, often followed by jaundice, with febrile excitement and headache. Vomiting is a very troublesome and distressing symptom, and induces a sense of great exhaustion, with faintness and pallor of the countenance. After intemperance there is the same violent bilious vomiting, but with a furred state of the tongue; loss of appetite and loathing of food, diarrhoea, tenderness of the right hypochondriac region being followed by jaundice. The inflammatory hyperaemia probably com- mences in the duodenum, and extends into the biliary ducts, and along the course of Glisson's cap- sule ; the ducts become obstructed by the changed secretion, and jaundice is the consequence. These instances occur independently of the excitement from stimulants, and sometimes are very alarming in their character. The febrile condition is accom- panied with cerebral oppression, with a semi-coma- tose state, or with violent delirium. This brain complication may perhaps be due to the glandular structure of the liver becoming involved, and the DUODENAL DYSPEPSIA. 247 depuration of the blood being consequently inter- fered with. The pain in these cases is much less than in gall- stone; and the disease differs from ordinary inflam- matory jaundice in the mode of commencement, the symptoms being at first those of intestinal or gastric irritation. The prognosis is generally a favorable one, unless the cerebral symptoms become inordinately severe. In some instances general hepatic disease has been induced. The treatment must be directed to quiet the irri- tation of the stomach, and to relieve the hyperaemia of the affected parts. As to the former, scarcely anything must be administered by the mouth. Soda-water and milk, arrowroot, broth, and similar forms of diet, are alone admissible. Alkalies, as lime-water, effervescing citrate of magnesia, carbo- nate of soda with hydrocyanic acid, also serve in some degree to soothe the stomach. A free Mercu- rial purgative is very desirable in these cases, as five grains of calomel or gray powder, followed by a saline aperient; and hot fomentations may be applied externally. 248 DEGENERATION OF THE STOMACH. CHAPTER XVII. DEGENERATION OF THE STOMACH. The stomach is not independent of the general law, that when one part of the body is affected with disease, other parts also become implicated either in a primary or secondary manner. Purely local disease is of very rare occurrence, and this is still more manifest when we regard degenerative changes; thus, degeneration of the stomach is not unfrequently observed, but it is only a part of other more general morbid conditions. We find the stomach affected with— 1. Atrophic degeneration or wasting. 2. With fatty degeneration. 3. With lardaceous disease. 4. With fibroid disease, implicating especially the pylorus. 1. Atrophy.—The mucous membrane and the other coats of the stomach are sometimes found in chronic disease to be exceedingly thin and pale, as If, with the gradual decline of the general nutritive power, the organ connected with primary assimila- DEGENERATION OF THE STOMACH. 249 tion had also proportionately wasted ; the glandular follicles are less distended with cells, the muscular coat is indistinct, and the coats are semi-transparent. 2. Fatty wasting.—Sometimes the cells of the fol- licles, instead of presenting a simple nucleus, con- tain a great number of highly refracting particles, and almost resemble an inflammatory granule cell, while the appearance of the stomach itself indicates an otherwise healthy condition. At other times, the stomach is found to be pale, and studded with white points, somewhat resembling solitary glands, but not at all elevated above the surface. A section of the membrane at this part shows that around the crypts are collected highly refracting granules and fatty particles, giving to the vertical section the appearance of a dark border. This form of degene- ration has been observed in phthisis, in struma, in exhausting suppuration, and is often associated with a fatty condition of the liver. A more advanced condition of atrophy shows the follicles to be en- tirely destitute of secreting cells, only containing granules of fat. 3. Lardaceous disease.—In ordinary cases this form of albuminous degeneration is found to affect the liver, the spleen, the kidneys, etc., but the mucous membrane of the stomach is also similarly affected. With the iodine test, the mucous mem- 250 DEGENERATION OF THE STOMACH. brane becomes deeply colored, and under the microscope, the section shows that the minute capil- laries have undergone remarkable change; their walls are greatly thickened, they appear of a homo- geneous consistency, and the free circulation of the blood is greatly impeded. Beyond loss of appetite, exhaustion, prostration, and the inability to take food, or if taken by con- straint, to digest it, we are not acquainted with any symptom which indicates these states of degenera- tive change. They are part of a general state of exhaustion, and are indications, that pari passu with disease in other structures, the stomach takes part. 4. Fibroid degeneration.—After chronic inflam- mation of the mucous membrane, the structure ap- pears thickened, dense, and the mere rudiments of gastric follicles remain. This appearance arises from fibroid degeneration, which gradually extends so as to induce follicular atrophy; and it is from the contraction of this fibroid deposit the true " mammillation" of the surface of the membrane is produced. We would call this true mammillation in contradistinction to that which is observed in a healthy stomach, from the contraction of the mus- cular layer. Beside this general condition of fibroid degenera- DEGENERATION OF THE STOMACH. 251 tion, there is one perhaps of greater importance, although of a local character, we refer to fibroid disease of the pylorus. This state has by some pathologists been considered as a form of cancerous disease ; if, however, the diseased structure be care- fully examined, no evidence of cancer will be found in it, or in the adjoining parts. The disease appa- rently commences in the submucous cellular tissue, which undergoes fibrous thickening, while the mu- cous coat is in many cases unacted upon. This deposit leads to obstruction of the valve ; the mus- cular coat then becomes hypertrophied, and the amount of that hypertrophy is an indication of the degree of obstruction. The growth beneath the mucous membrane is whitish in color; it is firm, sometimes almost car- tilaginous in hardness, but without any "juice" as cancer ; it consists of elongated or wavy fibres, re- sembling a fibroid tumor, and with acetic acid it presents numerous elongated nuclei; bands of simi- lar tissue pass between portions of involuntary muscular fibre, and externally the omentum may be contracted, and adhesions may have been formed with adjoining structures. The mucous membrane of the stomach may present a gray and thickened appearance, and simple chronic ulcer or the cicatrix of one, are occasionally present. At the pylorus 252 DEGENERATION OF THE STOMACH. the mucous membrane may be quite healthy, hav- ing distinct or even hypertrophied gastric follicles; but the irritation may have excited secondary dis- ease and ulceration. The glands near the pancreas are not usually affected. The symptoms closely resemble those of cancer- ous obstruction, and they consist in chronic dyspep- sia, followed by emaciation; vomiting occurs several hours after food, preceded by pain; distension of the stomach, eructation, fermentation, and the de- velopment of sarcina ventriculi are also sympto- matic ; the bowels are generally constipated; ex- haustion gradually comes on, till at last the patient sinks from inanition. The abdominal walls are wasted and collapsed, and a tumor is often felt at the epigastric region, consisting of the thickened tissues at the pylorus. If, however, the stomach be free from adhesions, the thickened pylorus is often pushed downwards so as to be felt near the umbilicus, or even near to the pubes. Pain is not generally a marked symptom of this form of pyloric disease; but tenderness on pressure is sometimes experienced, arising probably from peritoneal ad- hesions. We are not acquainted with the predisposing nor with the exciting causes of this fibroid disease; but it is probable, that long-continued irritation, as in- DEGENERATION OF THE STOMACH. 253 dicated by dyspepsia, generally precedes it. The intemperate do not appear to be more liable, and one sex is as prone to it as the other; although it is more common in advanced age, still it does occur in early and middle life. The diagnosis is sometimes obscure, and the pre- sence of other more acute disease may entirely mask the complaint; the duration of life is greater in this fibroid degeneration of the pylorus than in the ordinary forms of cancer, especially the medullary and epithelial varieties, nor do we find in the former disease the peculiar cachexia of malignant diathesis. As to treatment, although we cannot remove the obstruction, we can often afford relief to the symp- toms, and greatly prolong life. The change from solid and irritating food to that of a fluid and bland kind is often followed by marked benefit. In this way spasmodic contraction at the pylorus is less- ened, and the fluid slowly passes onwards. If, however, the stomach be very irritable, the best way of affording relief, is to allow it to rest entirely, and to sustain life by nutrient enemata for several days. Towards the close of the disease we are driven to this means of prolonging life. The secondary fermentation in the stomach may be greatly diminished by other remedies, by car- bolic acid and by creasote, by the sulphite and 254 DEGENERATION OF THE STOMACH. hyposulphite of soda, and by charcoal: whilst the irritability is lessened by alkalies, by bismuth, by hydrocyanic acid, by opium, or morphia, etc. It is remarkable, that with these several forms of degenerative change we do not find the stomach subject to strumous disease of a tubercular or ulce- rative kind ; and although tubercles are often found upon the serous membrane, the mucous membrane is always free. The term " gastric phthisis" is, we think, very apt to be misunderstood on that account, and likely to prove very injurious in drawing at- tention away from the true source of disease, namely, the lungs. ULCERATION OF THE STOMACH. 255 CHAPTER XVIII. ULCERATION OF THE STOMACH. Dyspepsia is par excellence the symptom of ulcer- ation of the stomach, for the process of digestion is then especially difficult and painful. The. destruction of the surface of the mucous membrane and of the coats of the stomach by ulcer- ative process occurs in several forms and condi- tions ; and we have already referred to some of these in describing the varieties of dyspepsia, with some of which they may be associated. 1. Ulceration may be the sequence of acute in- flammation, and may be connected with abscess, or with sloughing of the surface ; these are, however, instances of an unusual kind, and are caused by local mischief, or by poisons or irritating sub- stances. 2. Although diphtheritic inflammation does oc- cur in the stomach, it is of rare occurrence. Dr. Fen wick believes that it is frequent with scarlet fever. We have never witnessed diphtheritic ulcer- ation. 256 ULCERATION OF THE STOMACH. 3. Ulceration of a superficial kind, or of the cha- racter of aphthous ulceration, is not uncommon; it is the result of subacute inflammatory change, and is present in inflammatory dyspepsia, and in that connected with hepatic engorgement. After the irritability of stomach present in Addison's dis- ease of the supra-renal capsules, this form of ulcer- ation has also been observed. It is not necessary again to describe the symptoms connected with these states, having already done so in a former chapter. In this form of ulcer the mucous mem- brane only is destroyed in small irregular patches, generally about the lesser curvature or towards the pyloric extremity. Other portions of the mucous membrane show arborescent injection consequent upon a hyperaemic state of the part. 4. Ulceration sometimes occurs as numerous minute points, and it has been designated follicular ulceration ; the parts destroyed are very small, about one-sixteenth of an inch in diameter, and are thickly spread over the surface of the membrane. This condition has been observed in connection with the gastro-enterite of children ; and after the symptoms have subsided it is probable that the surface of the stomach entirely regains its normal appearance. 5. Another ulcerated state has been designated hsemorrhagic erosion, and is especially observed in ULCERATION OF THE STOMACH. 257 chronic catarrh of the stomach, and is caused by the long continued congestion of obstructive disease whether in the heart, lungs, or liver. The intensely congested capillaries having given way, blood is effused in small points or in larger patches; if the former, mere specks of ecchymosis are the result; if the latter, the surface of the membrane gives way, and a small ulcer is produced, having an ir- regular margin, and it is generally covered by a clot of blood, almost resembling a slough. 6. Beside these conditions, which it is not neces- sary to describe again more fully, we have that state which is especially meant when we speak of ulcer of the stomach. It has been variously desig- nated as simple ulcer, chronic ulcer, perforating ulcer; and in its consideration the description of the symptoms is facilitated by dividing into two classes :— 1. Ulceration perforating without adhesion, and 2. Ulceration perforating u-hen adhesions have taken place. When the coats of the stomach are destroyed by ulceration, and no adhesion has taken place, acute peritonitis is suddenly induced from the extravasa- tion of the gaseous or fluid contents of the stomach into the peritoneal serous membrane; intense in- flammation is thus set up, and the life of the patient 22* 258 ULCERATION OF THE STOMACH. is at once placed in imminent jeopardy—in fact, these are terrible instances of disease, and from apparently good health, without any warning, a few hours of intense suffering is followed by a fatal issue. The ulceration which leads to this unto- ward result may be small in size, from a quarter to half an inch in diameter, and it has on its internal aspect a peculiar appearance: the mucous mem- brane is ulcerated to a greater extent than the mus- cular, and the muscular than the peritoneal, so that it has a bevelled aspect towards the mucous mem- brane, and the opening through the peritoneum is small and round like the hole of a punch. This form of disease is most frequent in young women between the ages of fifteen and thirty, and appears to be connected with an enfeebled state of general nutritive power. The second form is that in which adhesions take place. Here the action is of a slower kind, the mucous membrane and the muscular coat are de- stroyed in a similar manner ; but when the perito- neal surface is approached, the irritation suffices to set up change in the adjoining serous membrane ; fibrin is effused, this becomes organized, and firm adhesions surround the opening and thereby extra- vasation is prevented. The edges of the ulcer are rounded and elevated; and in consequence of lono-- ULCERATION OF THE STOMACH. 259 continued irritation effusion takes place at the edges ; this product becomes firm, it is fibrous in its character, and as it increases it incloses fibrillae of the pneumogastric nerve, thereby producing severe pain. The ulceration slowly increases in size, so that the ulcer may vary from the size of a four- penny-piece to that of a crown-piece. Dr. Law mentions one six inches in length. The peritoneal surface, the lowermost in the stomach, also becomes at length destroyed, and the floor of the ulcer is then formed by the tissues, the adjoining viscera, to which adhesions have taken place. It may be that the floor consists of one structure, more fre- quently, however, of several parts covered by a thin stratum of fibrin. If the disease be at the pos- terior aspect, the pancreas forms the greater portion of the base ; if towards the anterior, then the abdom- inal parieties and the liver bound it. Sometimes it is the right, sometimes the left lobe of the liver, or the diaphragm, or several of these parts com- bined. With all this protective adhesion, perfora- tion sometimes happens in a secondary manner. The adhesions are only partial, and after some unusual distension, rupture takes place into the peritoneal cavity, and inflammation which is fatal in a few hours is the result. This opening is sometimes just on the edge of an ulcer with dense edges, or it may 260 ULCERATION OF THE STOMACH. be in the centre of one with but feeble adhesions. It is not always that the perforation extends into the serous membrane, for it may be into the cellu- lar tissue, and an abscess is then formed. An ab- scess of this kind may reach towards the spine, or extend upwards to the diaphragm; it may perfo- rate that muscle, and communicate with the pleura, setting up intense inflammation there. We have known the earlier symptoms so insidious, that the pleurisy was almost the first indication of any ab- normal change. In such instances, empyema en- sues in a very short space of time. In an instance I have recorded elsewhere, a sinuous opening ex- tended through the diaphragm into a sloughing vomica in the lung. A secondary cavity filled with air from the opening in the stomach sometimes exists below the diaphragm, and simulates pneumo- thorax. The ulcer sometimes extends into the sac of the lesser omentum, and forms an abscess bounded by the spleen, diaphragm, pancreas and liver; or it communicates with the colon or even with the pari- eties. A communication sometimes exists with the colon, but this appears generally to extend from the intestine to the stomach, and the opening is at the greater curvature. In one instance of this kind two other openings existed at the greater curvature ULCERATION OF THE STOMACH. 261 into the sac of the lesser omentum, and a large fecal abscess, which extended into the lung, had formed. Dr. H. Davies records a case of simple chronic ulcer extending into the colon. There had been dyspepsia and fecal vomiting whenever the bowels were confined. The patient gradually sank. The base of the ulcer, or the cicatrix as it might be termed, when a healing process has taken place, is smooth, of a whitish color, and consists of fibro- elastic tissue, or it has a minutely granular appear- ance. The edges become exceedingly firm, and are composed of dense fibro-elastic tissue. Minute fibrillae of the pneumogastric become involved in this tissue, and thus cause severe pain ; sometimes the nerves pass along the floor of the ulcer, and when sloughing follows, pain suddenly ceases from the destruction of these sensitive and exposed nerves. Glandular mucous membrane is not re-formed in these cicatrices, and when the liver or pancreas forms part of the boundary of the ulcer, their tissue is hardened. The adjoining liver structure assumes a white and dense appearance. Both forms of ulcer thus described, may be accompanied with hemorrhage, from the ulceration 262 ULCERATION OF THE STOMACH. having extended into the vessels. Bleeding is, however, especially present in the latter, or if in the former, it immediately precedes the fatal perforation. Thus a small ulcer—it may be, not larger than a sixteenth of an inch in diameter—may extend into a vessel, causing profuse hemorrhage, so that even the first sudden hemorrhage is fatal; and such an ulcer, if it had rapidly increased, would have per- forated into the peritoneum without adhesion More frequently severe hemorrhage takes place from the slower form of ulcer; the vessel has gradually become perforated, and if its walls are prevented from retraction by the effused tissue, the loss of blood is very great; and indeed, if it extend into one of the larger vessels—the splenic, coronary, or pancreatic—it is often fatal. Several attacks of bleeding may take place, and where an ulcer is ex- tending, the destruction of the minute capillaries at the margin of the ulcer may be the source of it. The hemorrhage may be so slight, and the blood so incorporated with the secretions, as only to be de- tected by careful, or even microscopical examina- tion. In one instance, in the museum at Guy's Hospital, both the splenic and pancreatic arteries were opened. Hemorrhage often takes place in primary ulcera- tion; but frequently after cicatrization secondary ULCERATION OF THE STOMACH. 263 destruction ensues, followed by renewed hemor- rhage. The perforated vessel is often closed by a small clot, or a drop of blood may be pressed from it, and in large ulcers the vessel may be seen as a small papillary eminence. The form of the stomach is often greatly changed, either by adhesions external to the viscus, or by contraction of the walls of the ulcer. When the ulcer is situated in the centre, the cavity may ap- pear double like an hour-glass, from puckering at the seat of the diseased part, and from irregular contraction. Two or three ulcers sometimes exist in the stom- ach. A large chronic ulcer may have been the source of much suffering, but a second and smaller one may be more serious by inducing sudden hem- orrhage or fatal perforation. The form of these ulcers is generally circular, but when two become united an irregular reniform margin is produced; and sometimes the pyloric orifice is thus nearly surrounded, especially if cancerous disease super- vene upon the simple ulcer. As to the site of the disease, the ulcer is generally at the lesser curvature, towards the anterior or posterior aspect. If in the former part, it has a greater tendency to produce perforation; if in the latter, hemorrhage. The ulcers are situated nearer 264 ULCERATION OF THE STOMACH. to the pyloric, than to the oesophageal orifice. Dr. Brinton gives the following table, which must be' regarded as relating to cases in which perforation takes place without antecedent adhesion. In every 100 such cases, the ulcer is situated— On the posterior surface in . . .2 At the pyloric sac in . . . . .10 At the middle sac in . . . .13 At the lesser curvature in . . .18 At the anterior and posterior surface at once in 28 At the cardiac extremity in . . .40 At the anterior extremity in . . . .85 Whereas in ulcers of the stomach generally, he almost reverses the order; that in 43 per cent, the ulcer was at the posterior surface, in 27 at the lesser curvature, in 16 at the pyloric extremity, in 6 at both the anterior and posterior surfaces, often at opposite places, in 5 at the anterior surface, in 2 at the greater curvature, and in 2 at the cardiac pouch. Ulceration of the stomach is more frequent in women than in men. Dr. Brinton found, out of 654 cases, that 440 were female and 214 male; and that in one out of every five cases more than one ulcer was present; whilst in one out of every seven or eight cases perforation took place. As to the age of those who are the subjects of this affection, the cases of cancer which have come under ULCERATION OF THE STOMACH. 265 my own immediate notice have been more advanced in life, than those who were the subjects of ulcera- tion of the stomach. Dr. Brinton has collected statistics from a large number of cases, and he shows that the ulcer generally "affects the periods of middle and advancing life, with a frequency which gradually increases up to the extreme age allotted to man." But the cases of ulcer in which perfora- tion happens, "seems not only to select another period of life, but to exhibit a marked contrast of age in the different sexes, the period of life in which it is most liable to occur being quite a different epoch in the male and in the female," in the female being between the ages of 14 and 30, in the male from 50 to 60, the diminished risk of the female at the latter periods of life rendering the total risk in the same number of cases nearly equal. Dr. Lees mentions that he has seen perforation of the stom- ach from ulcer " in a girl of eight, and a boy of nine years of age." The symptoms of ulceration of the stomach may be considered first in reference to those instances in which sudden perforation takes place without any adhesion. Such cases have much general, as well as pathological interest, on account of their usually disastrous termination. They often occur in young women affected with chlorosis and amenorrhcea, or 266 ULCERATION OF THE STOMACH. with painful menstruation. The previous gastric symptoms are very slight or altogether unnoticed, although there is generally impaired health, with leucorrhoea or chlorosis, neuralgic pain in the side, and symptoms of hysteria. The onset of the fatal attack is unexpected, and is generally after slight muscular exertion, or after a full meal. Intense pain comes on, followed by a rapid prostration and collapse. The skin becomes cold and clammy, the pulse fails, the pain in the abdomen becomes gene- ral ; tympanitis follows, and occasionally vomiting supervenes. Death ensues in from five to twenty- four hours, although life is sometimes prolonged for several days, and in rare cases the patient recovers. Various suggestions or hypotheses have been made in reference to these cases of perforation. The ulceration is said by some to be of an inflam- matory character; by Rokitansky it has been attributed to congestion, extravasation, and necro- sis of tissue; Yirchow has supported an embolic theory, others refer it to the state of the nervous system; and we have ample proof of the close connection of the gastric sympathetic nerve with the ovarian and uterine ganglia. The pain below the mamma in leucorrhoea arises probably from the connection of the splanchnic with the dorsal nerves. ULCERATION OF THE STOMACH. 267 The cause is equally obscure as to the part of the stomach usually affected with ulceration. Why the lesser curvature, either at its anterior or pos- terior portion, should be so generally involved, is not known. This is the part least free in its move- ments—in fact, it is almost stationary—the stomach in its general expansion and consequent movement turning upon its lesser curvature. This also is the region along which the branches of the pneumo- gastric nerve pass. The symptoms of chronic ulceration are at first those of ordinary dyspepsia, and are often very obscure, and imperfectly marked. Thus slight uneasiness after food and constipation may be the only evidence of disease. Afterwards, the pain, with tenderness in the region of the stomach, espe- cially at the scrobiculus cordis, attracts more attention from the patient. It is sometimes slight; at other times intense, and of a peculiar gnawing character. The pain is generally increased by food, and relieved by the rejection of it; vomiting is therefore generally present, and sometimes py- rosis or water-brash. The other symptoms are, pain between the shoulders, more or less of ab- dominal uneasiness, constipation, emaciation, and a peculiar pallor and cachexia. Haematemesis, the rejection of food by vomiting, and melasna, the 268 ULCERATION OF THE STOMACH. discharge of blood from the bowels as black pitchy stools, are present in most cases at one or other stage of the disease. The pain is not always of the same character, but may be regarded as a symptom present in al- most every instance. It may be almost constant, but generally undergoes degrees of exacerbation, being increased by food. The patient often states, that pain comes on as soon as the ailment reaches the stomach, and continues as long as it is retained. Sometimes it is so intense, that the patient is com- pletely exhausted, as I have several times found when branches of the pneumogastric nerve have been involved in the dense edges of a chronic ulcer. In a case under my care, in which other signs of ulcer were present, the patient stated that the pain was sometimes relieved by firm pressure against the back of a chair. Position has, in not a few instances, a marked effect as to the severity of the pain; and I have several times been able to confirm the statement of Dr. Osborne, that the position of the pain serves as a guide to the seat of the ulcer, according as the contents of the stomach gravitate towards or away from the injured part. Thus in an ulcer at the posterior part of the lesser curvature the patient has been most easy when leaning forwards and towards the left side. On the ULCERATION OF THE STOMACH. 269 contrary, I have seen the pain continue, whatever position might be assumed. In young women suffering from well-marked ulceration of the stom- ach, with chlorosis, neuralgic pain in the side may be present at the same time that tenderness and pain are experienced at the scrobiculus cordis from ulcer; and in these patients we find in- crease of pain during or prior to the menstrual periods. Pain in the back is rarely absent in chronic ulcer of the stomach: it is generally less severe, and comes on later, than the gastric pain, but is some- times complained of more urgently than that at the stomach itself, the patient often stating that the pain goes through to the back. In speaking of the diagnostic value of pain, Dr. Lees states, "The occurrence of pain will often be of great assist- ance in the diagnosis between simple ulcer and can- cer ; for it is an important fact, that there is seldom pain in cancer of the stomach, unless great obstruc- tion of the pyloric orifice prevents the passage of food out of this viscus." And again, " The mere fact of severe pain constantly occurring after food should lead you to diagnose simple ulcer of the stomach rather than cancer. The pain, moreover, in simple ulcer, is often of a gnawing character, causing a sense of sickening depression; it is 23* 270 ULCERATION OF THE STOMACH. variable and remittent, sometimes being very severe and then ceasing for days or even for weeks ; but in malignant disease, the pain, although not often severe or lancinating, yet is almost always constant after it has once commenced." All observers will bear testimony to the general variability and the gnawing character of the pain in ulcer of the stom- ach ; still in some cases, as we have before said, the pain in ulceration is terribly constant and severe. Again, we have known cancerous disease of the pylorus, where no pain was acknowledged on re- peated questioning of the patient as to present symptoms and previous history; and in other in- stances of cancer, when the suffering is extreme, the relief is often very great on the avoidance of solid and indigestible food, and during the use of anodyne remedies. Other causes of pain must be borne in mind ; these we have explained in speak- ing of pain as a general symptom. The period at which vomiting takes place in ulcera- tion of the stomach is equally varied; sometimes the food is at once rejected, in other instances it is retained for many hours or even days. In an in- stance where the thickened edge contained a large branch of the pneumogastric nerve, the stomach almost instantaneously rejected food, and the patient died exhausted. Fermentation, with the develop- ULCERATION OF THE STOMACH. 271 ment of the sarcina ventriculi of Goodsir (merismo- podia ventriculi.—Robin) takes place in some cases of chronic ulcer, as well as in cancer and diseased pylorus. The sarcina can scarcely be considered as a proof of obstruction, for its development occurs without any impediment. Vomiting, however, as a sign of gastric ulcer, must be regarded with great care, since in so many instances it is purely sympa- thetic in its origin. Pyrosis also is often present in disease of a less serious character, and is amongst the signs of functional disturbance. Chronic disease of the abdominal viscera is marked by an anxious and dejected countenance, with emaciation; in gastric ulcer this appearance is present, and is associated with pallor arising from the condition of general nutrition. In cancerous disease, a careworn expression is found, with cache- tic sallowness; and in the anaemia of chlorosis and amenorrhcea there is in extreme cases a waxen ap- pearance, which is very peculiar; so also in the anaemia after considerable loss of blood. Again, in many instances of struma and of glandular disease, pallor is present; but in ulcer of the stomach, the anxious countenance of abdominal disease, con- joined with the emaciation and pallor of imperfect nutrition, afford a very characteristic morbid ex- pression, and as a symptom is rarely absent. 272 ULCERATION OF THE STOMACH. Hemorrhage takes place in most cases of gastric ulcer; vomiting of several pints or even quarts of blood, may be amongst the earliest symptoms of disease; in other instances the bleeding is slight, or entirely absent. The first hemorrhage from the stomach is occasionally fatal; in ordinary cases the discharge of blood is preceded by a sense of weight and coldness, followed by faintness or actual syn- cope, then rejection of dark-colored blood takes place. The action of the gastric juice confers this deepened color; but if the effusion be very rapid, the color is more bright; a portion of blood passes onwards into the duodenum and intestines; and if life is prolonged, so that it may be discharged per rectum, a black tarry evacuation is the result. Sometimes, however, the whole of the blood is thus discharged, and there is melaena without haemate- mesis ; these two symptoms are generally combined. Instances have been recorded where sudden hemor- rhage into the stomach was followed by fatal syn- cope, without the discharge of blood either by vomiting or by purging; more frequently the hemorrhage is oftentimes repeated. Unless hemorrhage, however, takes place, we cannot with any certainty diagnose ulceration of the stomach; cachexia, emaciation, pallor, pain, and vomiting, all arise without ulceration, in cases ULCERATION OF THE STOMACH. 273 of gastrodynia and irritability of the stomach, sym- pathetic or otherwise. But hemorrhage is not in itself pathognomonic of ulceration; it often arises from over-distended capillaries in an engorged state of the portal circulation, and in cancerous disease; and although less frequent in cancer than in simple ulceration, it does occasionally arise. Disease of the oesophagus and aneurism sometimes produce the same symptom. Abercrombie distinguishes three modes of fatal termination of ulcer of the stomach. 1. Gradual exhaustion; 2. Hemorrhage; and 3. Perforation into the peritoneal cavity. Another might also be mentioned : the production of inflammation by ex- tension to adjoining viscera, as in a case in which the disease extended through the diaphragm into the lung, and produced acute pleurisy. The dis- ease, however, sometimes remains in a passive con- dition, and the patient dies of some other complaint. It is not very rare to find cicatrices in the stomach; and in those cases where there has been extensive destruction of surface, and of the muscular and peritoneal tissue, the adjoining viscera are found covered with a smooth fibrous investment. The duration of life after the development of symptoms of ulcer of the stomach, as compared with cancer, is generally very different. Setting aside 274 ULCERATION OF THE STOMACH. those cases in which perforation into the peritoneal sac takes place, the ulcer is more curable and its duration is much greater. A long period may elapse, and some have mentioned cases of gastric ulcer which have continued for twenty years. I have several times observed patients in whom there were marked and severe gastric symptoms—men of middle life, with sallow complexion, with pain at the scrobiculus cordis, vomiting of food, occa- sional haematemesis, loss of flesh, etc.—who have lost their symptoms under proper treatment and care; they have regained flesh and comfortable health, and have had no return of symptoms for many years. In cancer, after the disease is fairly developed, we rarely find that a year passes, and frequently only three or four months, before a fatal termination takes place; and it is probable that many cases of supposed cancer of the stomach, in which the patient survived for many years, were really chronic ulceration. It has yet to be fully shown whether the cicatrix of a chronic ulcer ever becomes the seat of cancerous deposition ; but seve- ral instances warrant such a supposition. There is much obscurity as to the cause of ulcera- tion of the stomach. Some cases are produced by a state of chronic inflammation of the whole mucous membrane, produced by intemperance or irregu- ULCERATION OF THE STOMACH. 275 larity in diet. In others, it appears probable that the general state of nutrition and of the nervous system act as predisposing causes. Mental depres- sion or anxiety, scanty food, late hours at night, and insufficient exercise, pressure upon the scrobi- culus cordis, either by direct girthing of the abdo- men, or by constant and constrained position, as in milliners and shoemakers, or the striking of the epigastrium by the shuttle of the weaver, are also causes of gastric ulcer. The causes of the sudden perforating ulcer are still more doubtful, as we have previously intimated. There arc several objects to be sought for in the treatment of ulceration of the stomach. 1. The promotion of reparative action by sustain- ing and increasing general nutritive power. 2. The relief of distressing symptoms, pain, vomiting, hemorrhage, pyrosis, constipation, etc. 3. The prevention of the extension of the disease. 4. The removal of its complications. 1. The promotion of reparative action is in many instances most effectively secured by allow- ing the affected organ to rest; and much more can be done in this way than is usually supposed. If absolute rest could be afforded, the ulceration would in many cases rapidly heal; but, since this is almost impossible, it must be our object to give such forms 276 ULCERATION OF THE STOMACH. of nutriment as will spare the stomach; and in seeking to accomplish this purpose it must be borne in mind, that the especial office of the stomach, for which its peculiar sceretion is adapted, is the solution of nitrogenous compounds. These elements are found in the flesh of animals, in beef and mutton, etc. Hence we generally find that solid food produces pain and vomiting in cases of gastric ulcer, and must therefore be avoided, If, however, these elements of food be given, they must be in an unirritating form, as the less oleaginous kinds of fish, the sole, whiting, cod, etc., or poultry ; or in a fluid state, as veal and mutton broth, clear soups, etc.; beef-tea often creates nau- sea and vomiting. Still more must hard and indi- gestible meats, preserved meats and cheese, be avoided. Oysters and sweetbread can often be taken when more irritating diet would be rejected. Starchy food is converted into sugar by the saliva and by the secretions in the intestine, and in that state is readily absorbed. So also oleaginous sub- stances are converted into an emulsion by the alka- lies in the secretions of the mouth and intestine, and in the bile ; so that these forms of diet, whilst they are demulcent and soothing to the diseased gastric surface, do not require the action of the stomach in order to place them in a state ready for ULCERATION OF THE STOMACH. 277 absorption. Good stale bread, biscuits, milk, starchy substances, as arrowroot, tapioca, maize or Indian cornflour, rice, etc., may thus be given to the pa- tient. Eggs often disagree, but may be taken in the form of light puddings; milk, also, when re- fused in its simple character, may be better tolerated by combination with isinglass, as in blanc-mange, or with soda-water or lime-water, and even cream and bacon are occasionally well borne. If there be flatulent distension, it is often advisable to avoid both saccharine and farinaceous food, which easily undergo fermentation, and for a time at least to allow only milk with soda-water, and chicken or mutton broth. Rich soups, highly seasoned dishes, pepper, mus- tard, etc., are better abstained from ; so also pas- tries, and food containing much insoluble material as salads, unripe raw fruit, green vegetables, etc. It is, however, undesirable altogether to abstain from vegetables, for we may thus defeat our object by inducing cachexia. Oranges, lemons, etc., may be often taken with benefit. Again, it is most important that food should be slowly and thoroughly masticated ; and it is better to take small quantities at a time, and to repeat the allowance more frequently, than to distend the stomach by a large and bulky meal. About three 24 278' ULCERATION OF THE STOMACH. to four hours should intervene in ordinary cases ; but where there is great exhaustion, with irrita- bility of the stomach, food may be required more frequently, and in very small quantities. Exertion, both mental and physical, should be avoided di- rectly after meals; in fact, everything should be done to facilitate the process of digestion. It is well to abstain from alcoholic liquors, if possible; they tend to aggravate the disease, and should not, I think be given, unless the circulation be failing, and there be tendency to syncope; but when re- quired, brandy in small quantity, and well diluted, or the forms of sherry which contain the least sugar, are best. New wines, port, and imperfectly fer- mented malt liquors generally disturb and distress the patient. It is desirable to use every means in our power to improve the health, as by exercise in the open air, but over-fatigue or constrained positions should be avoided. Moderate horse exercise, and bracing air, will sometimes afford more relief than medici- nal agents, even when long continued ; but violent shaking is injurious. When a chlorotic or anaemic state has been produced, the preparations of steel, by restoring a more healthy condition of the blood greatly facilitate reparative changes. We prefer the milder preparations, as the ammonio-tartrate or ULCERATION OF THE STOMACH. 279 citrate. The compound steel pill, with aloes and myrrh, or quinine with iron, as the sulphates or citrates conjoined, may also be beneficially pre- scribed. It is obviously most desirable to administer that form of aliment which will nourish the body, so that healing may be favored, but without irritating and disturbing the process which is going on to- wards recovery. The difficulty is still more in- creased by the occasional irritability of the stomach itself. And this leads us to the consideration of the means we possess for the mitigation of distress- ing symptoms, pain, vomiting, hemorrhage, pyrosis, constipation. For the relief of pain, opium or its alkaloid mor- phia is often the best remedy, in doses of a quarter to one grain of the former two or three times a day, or a few minims of the solutions of the latter. Chloric ether, in doses of 10, 15 to 20 t^, will be found very efficacious, especially when combined with nitrate of bismuth and carbonate of soda in 10- to 20-grain doses. The constipating effect of the preparations of bismuth must be counteracted by gentle aperients or enemata; for if the trans- verse colon be distended, the gastric symptoms are increased in severity. Ohlorodyne is spoken of as being a valuable substitute, but I have no expe- 280 ULCERATION OF THE STOMACH. rience in its use. Dilute hydrocyanic acid, in doses of 3 to 5 »n,, is also a useful adjunct in some cases, especially when given with alkalies. Both potash, soda, lime, and magnesia have been used ; they neutralize acid secretion, and oftentimes in- crease the anodyne power of remedies previously mentioned, opium, morphia, chloric ether, etc. If, however, there be constipation, dryness of the tongue, and opium is not well borne, conium, hen- bane, belladonna, etc., may be used as substitutes. The nitrate and oxide of silver, in doses of a quar- ter to half a grain, in some instances diminish the pain and irritability of the stomach, especially when the gastric symptoms are associated with pyrosis. Carbolic acid or creasote in 1 n^ doses, we have found useful in relieving pain, when it is accom- panied with irritability of the stomach, vomiting, and fermentative changes in the food. Again, car- bonic acid, as in ordinary soda-water, is effective in relieving pain, as well as vomiting. So also the use of cold water and ice, which are often very grateful to the patient. The black oxide of man- ganese in similar doses to bismuth is said to be an effective remedy, although not equal to the latter preparation. Vomiting is a very distressing symptom in many cases of ulcer of the stomach. It is best combated ULCERATION OF THE STOMACH. 281 by only partaking of fluid diet, and of that in moderate quantities. The remedies we have al- ready mentioned are of service, but especially bis- muth, hydrocyanic acid, creasote, ice, and alkalies. Sir W. Jcnner has pointed out the value of the sulphite of soda in checking the fermentative action, and the development of sarcinae in obstruction from chronic ulcer, as well as in cancerous or pyloric disease. It may be given in 9i doses alone or com- bined with other agents; the hyposulphite is also given in similar cases. Charcoal directly absorbs gaseous evolution, and checks fermentative action, and in these instances of gastric ulcer it may be given for a short time with great advantage. Counter-irritants arc often of great service for the relief of pain and vomiting : a small blister should be applied to the scrobiculus cordis, or the croton oil be rubbed in so as to produce pustular erup- tion ^ some even use a seton ; but I think that milder remedies may attain the same beneficial result with less suffering and distress to the patient. If there be excessive secretion or hemorrhage, as- tringents may be given; thus mineral acids, as the sulphuric alone, or with Epsom salts ; acetate of lead, tannin, and alum are also available ; and when there is hemorrhage without great irritability, •24* 282 ULCERATION OF THE STOMACH. small doses of turpentine with mucilage or yolk of egg are sometimes prescribed; but this is a remedy in which I have little experience. I have some- times seen it aggravate the symptoms, beside being very offensive to the patient. When hemorrhage has recently taken place, it is well to avoid the use of anything likely to distend or mechanically disturb the stomach, as carbonic acid. Ice, which tends to produce contraction of bleeding vessels, should be allowed to the patient; and if there be much throbbing of the vessels, it may be applied externally. Pyrosis may be checked by the astringents just mentioned ; but we have found the greatest benefit to arise from nitrate or oxide of silver with opium, from carbolic acid or creasote also, and from the compound kino powder ; and, when other symp- toms do not contraindicate their use, from the as- tringent preparations of iron. The bowels should be acted upon by agents which do not irritate the stomach, as the aloes or colocynth pill with hen- bane, the effervescing citrate, the carbonate, or Dirineford's fluid magnesia; in other instances ene- mata, consisting of simple water or castor oil, or of turpentine, are useful. Mercurial purgatives will be found beneficial in thoroughly emptying the canal without increasing gastric irritability, as a ULCERATION OF THE STOMACH. 283 few grains of gray powder, one or two of calomel, or of blue-pill, with henbane, etc.; but the contin- uance of these medicines is, we think, injurious and prejudicial to the patient. In many cases of constipation with gastric disease minute doses of strychnia, or of the extract of nux vomica with aloes, are useful, not only from their astringent, but from their tonic effect. In order to carry out the third indication of treatment, namely, to prevent the extension of the disease, sudden and violent exertion should be guarded against ; the stomach must not be dis- tended by large meals; and the formation of gaseous products by fermentative changes ought to be counteracted by a well-regulated diet and by medicinal agents. 4. The complications of gastric ulcer, arising from its extension to neighboring parts, are of a most serious kind, and require most careful treatment. When perforation has taken place, and the symp- toms of peritonitis have been suddenly produced, there is still slight chance that life may be pro- longed ; the patient should not be moved, nor any- thing introduced into the stomach, except a tea- spoonful of water or milk to assuage thirst. Opium must be given freely, as recommended by Dr. Stokes and Dr. Graves, so that the patient may be 284 ULCERATION OF THE STOMACH. entirely under its influence, a grain every two or three hours; by this means peristaltic action is checked, the nervous shock diminished, extravasa- tion prevented, adhesions promoted, and life may be thus preserved. Aperient remedies should be avoided, and food only taken in the most cautious manner. If local suppuration have taken place, opium is still the best remedy, in order to diminish irritative fever, to relieve pain, and to place the patient in the most favorable condition for reparative action. If the disease have extended into the chest, the prospects of recovery are still less, for sudden acute pleurisy and empyema, or asthenic pneumonia, are almost certain to follow. Life may be prolonged by sustaining the patient, and the severity of the symptoms of acute disease of the chest may be par- tially relieved by ammonia and opium. CANCEROUS DISEASE OF THE STOMACH. 285 CHAPTER XIX. CANCEROUS DISEASE OF THE STOMACH. The stomach is one of the organs most frequently affected with cancer; and in this frequency a re- markable contrast is presented when compared with the rarity of strumous disease of the same organ. Every form of cancer is found to occur in the stom- ach, but instances of medullary and scirrhous can- cer are the most numerous, whilst the epithelial, colloid, villous, and molanoid varieties are less constantly observed. It is seen, however, that these varieties pass the one into the other; and thus while one part has almost the firmness and struc- ture of scirrhous, another has the characteristics of medullary growth ; and again, the surface also of a medullary cancer may have the appearance of a villous structure. The disease originates in the mucous membrane of the stomach, or its submucous tissue, or it is propagated to the stomach by the affection of the glands in the neighborhood of the pancreas; and the pylorus, lesser curvature, and cardiac extremity are the parts generally affected. 286 CANCEROUS DISEASE We are not acquainted with the determining cause of the forms of cancer, or whether the opinion which is maintained by some pathologists can be established, that scirrhous is connected in its origin with the fibrous tissues of the part—medullary with the mucous surface or gland structure, and colloid especially with the latter—or, whether they are rather indications of the intensity of the morbid action. It would seem that scirrhous disease is less removed from normal nutritive change than medul- lary cancer ; in the one there is a greater diposition to form fibroid tissue, and in the other the growth is cellular or nuclear. During the earlier stages of cancerous disease of the stomach, especially before any growth can be detected on manipulative examination, the symptoms are often exceedingly obscure. It may be con- venient to arrange the symptoms into three divisions, according to the respective stages of the disease. The first is the stage of organic dyspepsia before the development of any tumor; the second is that of abnormal growth ; and the third, the dis- integration of that growth by ulceration or slough- ing. The first symptoms are often deceptive and ob- scure, they are those of dyspepsia, and with it there is a peculiarly sallow and anxious expression OF THE STOMACH. 287 of countenance; pain at the stomach may be en- tirely absent, or there may be severe gastrodynia; pyrosis is frequently present. There is emaciation and general feebleness; but the tongue may be clean, and the bowels quite regular in action. In the second stage, a tumor is felt in the region of the stomach, and the symptoms become more distinctive; vomiting is generally a marked sign, especially when the disease is situated at the pylorus or cardia ; and the rejection of food takes place, according to the seat of obstruction or irritation of the gastric surface, either a short time or several hours after a meal. If the orifices are free, vomit- ing may be absent throughout the whole course of the disease. In some instances the vomiting so quickly follows deglutition as to lead to the suppo- sition of oesophageal disease. The pain also be- comes more severe, and is generally of a more lanci- nating character than that experienced in chronic ulcer of the stomach. The vomited matters are often frothy and fermenting, and present us with abund- ant sarcina ventriculi. Haematemesis is occasion- ally present. Flatulence distresses the patient, and eructations are frequent; the bowels become con- stipated ; emaciation steadily advances, and the countenance becomes more haggard and cachectic. On careful examination a tumor may generally be 288 CANCEROUS DISEASE felt at the region of the stomach or of the pylorus; it often increases rapidly, and on account of the wasted condition of the parietes becomes very apparent. The growth is often pulsatile in its character, either from contact with the large abdo- minal vessels, or from its own excessive vascu- larity. In the third stage of the disease, that of disinte- gration, the symptoms are more severe, and the emaciation is extreme; the vomiting of coffee- ground substance often precedes a termination. The vomiting sometimes ceases on account of the sloughing of the growth, the obstruction thereby being removed; or the branches of the pneumo- gastric nerve being destroyed, there may be cessa- tion of consequent irritation; the pain also dimin- ishes from similar causes, and as the exhaustion becomes typhoid in its character, it may entirely cease; but throughout the course of the disease there may be immunity from suffering. Again, it has been shown by Dr. Kennedy, that the size of the tumor may actually lessen from the sloughing process. The immediate cause of death in gastric cancer differs greatly: the fatal exhaustion may depend, 1st, on the interference with the absorption of nu- triment, and with the completion of the digestive OF THE STOMACH. 289 process; 2d, on the sloughing of the growth, and * subsequent septic changes in the blood ; the patient in such a case becomes rapidly prostrate with typhoid symptoms, the breath is offensive, he is seized with hiccough, and pneumonia of an asthenic kind is induced ; 3d, the fatal termination may en- sue from hemorrhage; when the ulceration pro- duces only slight oozing of blood, the haematine becomes blackened by the gastric juice, and we find that the vomited matters have the appearance of coffee-grounds; but if a larger vessel have become divided, the effusion of blood is more abundant, sudden pallor is produced, and blood may be re- jected by the mouth, or pass as a black semi-fluid dejection from the bowels, or, again, without dis- charge of any kind, fatal syncope may at once take place; 4th, the extension of disease to adjoining parts may greatly modify the later symptoms of disease; if the liver become involved, or the bile ducts pressed upon, jaundice is the result; if the peritoneum be invaded, acute changes may be in- duced in the serous membrane, or ascites may fol- low. When sloughing extends to the surrounding parts, the colon, the skin, or the diaphragm may be perforated; of these parts the transverse colon is most frequently invaded, it becomes adherent to the stomach, and a valvular and sloughy communi- 290 CANCEROUS DISEASE cation is established; if the opening be small, gas only is extruded, and fecal eructation results; but if the passage be more free, feces pass from the colon into the stomach. Dr. Gairdner states that fecal vomiting is more likely to take place when the pylorus is free ; but Dr. Murchison, on the con- trary, and we think correctly, remarks- that fecal vomiting is regulated by the size of the communi- cation between the stomach and colon. The adhe- sions and sloughing occasionally reach the external parietes; and, if a communication also exist with the colon, an artificial anus is the result. We have, however, more frequently found this perforation of the skin, in instances of cancerous disease, affecting primarily the transverse colon. The cancerous disease is generally found to have involved the glands in the small omentum at the lesser curvature. Next in frequency we find the liver also invaded, sometimes to a great extent, so that it is difficult to state in which structure the disease commenced. Next in order of frequency, the glands in the anterior or posterior mediastinum are implicated, and tubercles are found on the pleura or in the lungs; and, lastly, other abdomi- nal viscera, the peritoneum, kidneys, and spleen, contain cancerous growths. In cancerous disease also, we observe that the coats of the stomach be- OF THE STOMACH. 291 come infiltrated, and in this respect contrast with the condition which we find in fibroid degeneration of the pylorus. In any form of obstructive disease at the pylorus, the muscular walls of the stomach become hypertrophied; but, if there have been ulceration at the pylorus, and the obstruction has subsequently been removed, the hypertrophy may be exceedingly slight; so also when the central portions of the stomach or the cardia are affected. The symptoms of gastric cancer are modified by several circumstances. 1st, by the position of the disease; 2d, by its character; 3d, by its origin, whether primarily affecting the stomach, or second- arily by extension from adjoining parts; and 4th, by the vascularity of the growth. 1. The position. If the disease be located at the central part of the organ, and the orifices be free, the symptoms may be exceedingly slight, and un- recognized for a longer period, than if the orifices are affected. Vomiting is absent, or only occasional; and the prominent symptom may be continued and profound cachexia, with progressive emaciation. If the cardia is diseased, the vomiting occurs im- mediately after food, so that the symptoms resemble cancerous disease, or obstruction of the oesophagus. 2. The character of the disease also modifies the symptoms as well as the duration. Scirrhus more 292 CANCEROUS DISEASE generally involves the pylorus, whilst soft medul- lary cancer invades any part, and increases with unusual rapidity. 3. In secondary disease of the stomach, the symptoms may also be very obscure, and the diag- nosis doubtful. It sometimes happens that cancer- ous disease of the liver is followed by infiltration of the glands of the head of the pancreas; these glands become united to the pylorus, and without having infiltrated the mucous membrane, they lead to obstruction of the pylorus and to hypertrophy of the muscular coat of the stomach; the symptoms of obstruction are those produced by primary can- cer of the stomach itself. In some instances the pneumogastric may be traced through the medul- lary tumors of the stomach ; and either the nerve fibres may be found to present their ordinary micro- scopical appearance, or be entirely destroyed. It is this destruction of nerve fibres which sometimes leads to a cessation of pain, and of the extreme irritability of the stomach in the later stages of disease. 4. The symptoms are modified by the vascu- larity of the growth. When the pancreas is dis- eased, or the glands at the lesser curvature are in- filtrated, or the posterior part of the left lobe of the liver affected so as to press upon the aorta or other OF THE STOMACH. 293 large vessels, pulsation may be communicated, and the disease then resembles aneurism; but when the growth in the stomach is very vascular, pulsation may be felt in it from this cause alone. This pul- sation is less affected by position than the instances just referred to, of glands pressing upon the aorta. If both sides of the stomach be affected by a vascu- lar growth, the intervention of fluid modifies the pulsation to some extent. In the diagnosis of cancer of the stomach, there are several conditions so closely resembling this malady, that we are in danger of forming an erro- neous opinion as to the nature of the disease. 1, ulceration; 2, aneurism ; 3, disease of the glands of the lesser curvature ; 4, disease of the liver; 5, ab- scess at the pancreas; 6, cancerous disease of the pancreas; 7, similar disease of the omentum; 8, affections of the transverse colon ; 9, local peritoni- tis ; 10, fibroid disease of the pylorus. The symptoms of cancer closely resemble those of chronic ulcer of the stomach. Both are preceded by a period of dyspeptic suffering, during which the diagnosis is exceedingly obscure. The expression of countenance in both is indicative of distress, but in chronic ulcer there is pallor; in cancer, cachectic sallowness. Vomiting of blood is more frequently observed in ulceration than in cancer, but in the 25* 294 CANCEROUS DISEASE closing stages of cancerous disease the rejection of coffee-ground substance is of frequent occurrence. The pain of chronic ulceration is often very intense, even more so than in cancer; but it is of a gnawing character in the former, more acute and lancinating in the latter. Again, the vomiting is often more severe in ulceration than in cancer. The tumor of cancer is generally much larger and more percepti- ble than the thickening around an ulcer. The ema- ciation in both may be gradual, progressive, and extreme ; but the termination in ulcer is more fre- quently by hemorrhage or perforation, whilst in cancer it generally arises from the typhoid exhaus- tion consequent on the degeneration or sloughing of the growth, the absorption of decomposing mate- rial into the blood, or the extension of disease to adjoining structures. Both diseases may occur at the same age, but it is more common to find chronic ulceration at an earlier period than cancer. In my own experience of cases, the average age of cases of ulceration of the stomach is 37, of cancer 52. From 40 to 60 years is the age at which we are most likely to have cancerous disease of other organs, and the law holds good with the stomach. The age will in some measure assist us in the diagnosis even at the later stages, but still more in the earlier; for the varied forms of dyspepsia, gastrodynia, pyrosis, OF THE STOMACH. 295 etc., are very frequent at a period long antecedent to the age at which cancer generally manifests itself: dyspepsia being exceedingly common among young females, whilst cancer is almost unknown. In aneurismal disease in the gastric region, the stomach itself often suffers remarkably little. Di- gestion may be sound, the food being taken and absorbed in a healthy manner. The pain of aneu- rism is of a different kind, and is uninfluenced by the diet. It is generally a dull constant pain in the back, but with severe and even intense paroxysms at night; sometimes the pain at the pit of the stom- ach is very severe, and it is increased by exertion and movement rather than by food. The pulsation is uniform, not changed by position. A bruit, if audible at all, may be systolic or almost diastolic. In diseased glands at the lesser curvature of the stomach, the tumor may be marked, but the pain and vomiting are less distinctive than in disease of the stomach itself; the latter often becomes involved, however, before the close. In disease of the liver, also, the position is some guide to us, so also the absence of severe gastric symptoms; but when the left lobe of the liver is diseased, and pressure exerted upon the stomach, the correct diagnosis is very difficult, jaundice being often absent in hepatic cancer. 296 CANCEROUS DISEASE In inflammation and abscess at the pancreas, a tumor may form at the epigastric region, with severe pain, vomiting is produced by pressure, the counte- nance becomes haggard, and the pulse compressi- ble. The symptoms are more sudden than in ordi- nary gastric cancer ; but this will not always save us from mistake, for we remember an instance of cancer in a sailor, who was said to be quite well, in whom sudden pain came on at the scrobiculus cordis, of so severe a character that he fell down on deck, and soon afterwards a large tumor of a can- cerous kind was found. Cancerous diseases of the pancreas, although be- hind the stomach, and accompanied with cachexia, leave the stomach free to perform its function. Fatty evacuations have been recorded by some, but such a sign is certainly not always present. Diseases of the omentum would only produce any doubt, when adhesion to the stomach has taken place, and when there is pressure from the size of the growth. Cancerous disease of the transverse colon is some- times a source of obscurity in diagnosis; for, adhe- sions with the greater curvature of the stomach having formed, the disease often extends into the stomach so as to cause extravasation of gas or feces; the pain in cancer of the colon comes on at a much OF THE STOMACH. 297 later period after food; and discharge of blood from the bowels is more frequent than in gastric disease. Local peritonitis induces peritoneal adhesion and external hardness; and when local extravasation has followed so as to form a fecal abscess, the ema- ciation is progressive, the hectic is severe, pain is sometimes excessive ; and in the certainty of fatal issue, the disease approaches the character of the worst forms of cancer; but we do not find the ma- lignant cachexia. The pain is more superficial, and digestion is less directly disturbed than in gastric disease. Fibroid disease of the pylorus is regarded by some as of a cancerous nature; still it has neither the pathological character nor the physical history of that disease. As in cancer, there is progressive emaciation with cachexia, and too often a steady downward course; but the duration is longer, the tumor less distinct, hemorrhage is less frequently, if ever, observed, and the disease is more amenable to treatment. The constant ejection of food at the close of the digestive process, from the obstructive disease of the pylorus, and the presence of sarcinae of Goodsir, have led many to form a more unfavor- able diagnosis than the case has warranted. The statistical tables of Dr. Brinton in reference 298 CANCEROUS DISEASE to the age of the patient affected with gastric can- cer, and the position of the disease, are of great interest. The pyloric extremity is the part most frequently affected, and the disease extends upon the posterior or upon the anterior surface. Next in frequency is the lesser curvature; then the oesophageal extremity and the cardia; and lastly the middle of the stomach. When the greater curvature alone is affected, the mischief has nearly always extended from the transverse colon or omentum. As to the duration of chronic ulcer compared with cancer, the former disease extends over a longer period. In cancer the duration may be from three to six or twelve months, or even two years; but in ulceration the disease will be found continu- ing three, four, or even many years, with varied ac- cessions of severe symptoms. Ulceration may heal, and a cicatrix be formed, and instances have oc- curred in which twenty years have intervened between the commencement of the symptoms and their fatal termination. The one is a curable dis- ease ; the other tends to increase with more or less rapidity till it terminates in death. In the treatment of cancer of the stomach, the same remedies which have been mentioned in chro- OF THE STOMACH. 299 nic ulceration may afford great comfort to the patient, although they are ineffectual for cure. On the earliest symptoms of organic disease of the stomach becoming developed, the diet should be so regulated that any renewed excitement and hyperaemia of the mucous membrane may be pre- vented. The food should be of the blandest kind, and of that form which does not easily undergo fermentation, as milk, simple soups, chicken and mutton broth ; asses' milk is often of great service in the later stages of the disease. Irritability of the stomach is best counteracted by the prepara- tions of bismuth in combination with alkalies, and with spirit of chloroform or with morphia. The preparations of cerium do not afford so much relief, in my experience, as those of bismuth; and al- though I have seen the black oxide of manganese effective when the bismuth has failed, the latter is generally the more efficacious remedy. Flatulence and painful distension are often relieved by carbolic acid or by creasote in combination with belladonna or henbane, and with aperient medicine, as the rhu- barb or colocynth pill; extreme sensibility of the surface of the mucous membrane is mitigated by the oxide and nitrate of silver, by the administra- tion of morphia and opium alone or in combination. If there be obstruction at the pylorus, pills are 300 CANCEROUS DISEASE better avoided, as they sometimes act as local irri- tants. Charcoal affords temporary relief in some instan- ces to the flatulent distension, but it is of greater service in functional derangement of the stomach. If there be any hemorrhage into the stomach, as evinced by free haematemesis, by coffee-ground ejecta, by black evacuations from the bowels, as- tringents may be used with partial relief, as lead with opium, gallic acid with opium, sulphuric acid, alum, sulphate of iron, and tincture of iron, oil of turpentine, etc.; the latter remedies, however, are of such an irritating character, that the stomach cannot generally bear their presence. Ice may be used externally, or minute portions may be swal- lowed ; and the temperature of all the food taken should be reduced. Simple rest and the abstinence from food will often be found the best means of checking hemorrhage. When ulceration has been set up, and the disease has extended to adjoining structures, opium and morphia afford more relief than any other remedy ; and the hypodermic injection of morphia is often a source of great comfort to the patient; a few drops of the solution of morphia alone, repeated at fre- quent intervals, serve to maintain a quiescent state in the irritable nervous filaments, without affecting OF THE STOMACH. 301 the mind. Aconite internally I have found too de- pressing in its effect, and have been compelled very quickly to discontinue it. External anodynes afford only partial benefit, but should always be tried, as chloroform and bel- ladonna liniments on spongio-piline or cotton wool. Counter-irritation by blisters is less advantageous than in simple ulceration of the stomach. During the later stages, life is prolonged and ease obtained by the administration of nutrient enemata. The distressing flatulence and fermenta- tion produced by food, the violent and painful vomiting also, are often greatly lessened by the rest thus afforded to the stomach, and the sufferer is nourished by this imperfect means more than by ineffectual attempts to induce normal digestion. 26 302 SPASM OF THE STOMACH. CHAPTER XX. SPASM OF THE STOMACH—SPASMODIC CONTRACTION OF THE PYLORUS. Previous reference has been made to pain at the stomach as a symptom of gastric disease; but the malady popularly expressed by the name which we have prefixed to this chapter is deserving of sepa- rate consideration. Pain at the stomach is described in different terms : with one it is a sensation of sore- ness, with another a rawness of the surface, or again it is a sense of burning. These are each character- istic of special conditions, but none of them convey the idea of " spasm of the stomach." The attack commences with pain to the right of the scrobiculus cordis, which passes round to the back, and often appears to penetrate through to the front of the chest; the pain is somewhat grad- ual in its onset, but soon becomes most severe and distressing; it is spoken of as of a "cringing" or "grasping" kind, and the popular designation con- veys with some accuracy the idea of its true char- acter, "spasm." This word suggests muscular con- SPASMODIC CONTRACTION OF THE PYLORUS. 303 traction ; and the malady, by whatever cause pro- duced, consists, we believe, in abnormal irritability and contractility of the muscular fibres of the stom- ach, pylorus, and duodenum. The muscular walls of the stomach are beautifully adapted for the per- formance of the churning movements connected with the process of digesting food : a triple layer of muscle, transverse, longitudinal, and oblique con- verges at the pylorus, where a strong circular con- tractile ring forms a valve, which regulates the passage of the dissolved aliment into the smaller bowel, the duodenum. These muscular fibres of the stomach become spasmodically contracted in the malady under consideration, and especially those fibres which constitute the pyloric valve. Whilst pain is the principal symptom of this spasmodic attack, we find that other indications are present; the countenance is expressive of suffering, but sometimes it assumes a death-like pallor, and the patient appears to be in a state of collapse. This condition induces great alarm, not only to the friends, but to the practitioner, and he may be sur- prised to find that with the subsidence of the suffer- ing the evil forebodings have also passed away. In an instance some years ago in the wards of Guy's, a few grains of opium soon lessened the severe spas- modic pain, and the patient, cold and collapsed on 304 SPASM OF THE STOMACH. admission, left the hospital on the following day convalescent. In young children also the coagula- tion of milk in the stomach will sometimes induce an almost fatal collapse from this spasmodic con- traction of the pylorus. The pulse shows the sympathetic connection be- tween the cardiac and gastric ganglia of nerves ; at first irritable and excited, in severe cases it becomes feeble and compressible, and also intermittent in character. Profuse perspirations indicate the severity of the pain ; other symptoms are occasionally present, as flatulent distension of the stomach, especially when the ailment has resulted from indigestible food ; and when the spasmodic muscular contraction is propagated to the walls of the duodenum, bilious vomiting may be induced from the regurgitation of bile into the stomach. This ailment consists, as we have said, in spas- modic contraction of the muscular coats of the stom- ach, and especially of the pyloric valve, and it is referable to several causes. Where the mucous membrane has been irritated, and is in a state of partial inflammation, it is more easily excited; so also when there is increased nervous irritability from weakness and exhaustion; for the pylorus receives branches from the large pneumogastric SPASMODIC CONTRACTION OF THE PYLORUS. 305 nerve, and it is in close connection with the branches of the vaso-motor ganglia. The pain is not sudden in its commencement, but gradual, and it radiates from its point of origin, the pylorus, extending both over the stomach and in the course of the duode- num ; vomiting or eructation are produced in the one case, and bilious regurgitation in the other. In many instances, especially where there is much spinal irritability, the abdominal muscles are more susceptible, and are readily thrown into spasmodic contraction, so that the rectus muscle in one or other part is felt as a hard and rigid mass beneath the hand. Patients affected with organic disease of the heart are very susceptible of this spasmodic contraction, for in them there is great congestion of the mucous membrane of the stomach and of the glandular structure of the liver. Gout is another condition of the system in which gastric spasm occurs; and we must confess that Ave believe in intense gouty pain at the stomach quite independent of undigested food or inflammation; for exposure to cold and nervous shock alone will excite it in those who are predisposed to such attacks. It has been regarded as a form of inflam- matory disease; for the sudden disappearance of the signs of inflammation from the joints at the 26* 306 SPASM OF THE STOMACH. same time that the intense suffering comes on at the region of the. stomach, is considered as a proof of the transference of morbid changes from one part to the other. This theory of metastasis is not, however, substantiated by known facts. Again, subacute gastritis, resulting from intem- perance, is often accompanied with severe gastric pain, irritability, and pyloric spasm. It is not, however, every attack of sudden pain in the region of the stomach that comes within the appellation of spasm of the stomach ; and this leads us to the consideration of some of those conditions with which it may be mistaken. Amongst these sources of fallacy are—■ Gall-stone. Aneurism of the cceliac axis., Omental adhesions dragging down the colon. Shingles. Spinal disease. Sudden distension of the stomach. Disease of the transverse colon. Renal calculus. Perforation of the stomach. 1. Gallstone.-—-In the ordinary attacks of gall- stone the calculus as it passes into the bile duct produces intense spasmodic pain at the extremity of the tenth rib. The pain radiates from this point SPASMODIC CONTRACTION OF THE PYLORUS. 307 as from a centre; it is soon followed by vomiting; and if the obstruction reach the common bile duct so as to prevent the passage of bile into the duode- num, jaundice quickly results. It occasionally happens that the gall-stone does not reach the com- mon duct, and there is no hindrance to the flow of bile from the liver into the intestine; the gall-stone has either become impacted in the duct, or it has fallen back into the gall-bladder: in such a case there is no jaundice, and it may be very difficult to diagnose whether there has simply been spasmodic contraction of the pyloric valve or gall-stone. In an instance which I saw, in consultation, some time ago, the symptoms were those of gall-stone, but without jaundice ; in a few days uraemic poisoning came on, followed by insensibility and death. An inspection was made, and a gall-stone had dilated the first half-inch of the duct nearly to the size of the little finger, and had then fallen back into the gall-bladder. In gall-stone the pain is more sudden ; it is situated more to the right; the vomiting is also more severe; and if there be repeated attacks of severe pain in this region without any jaundice. it is in itself an argument against the disease being gall-stone: but sometimes ulcerative communica- tion takes place between the gall-bladder and the 308 SPASM OF THE STOMACH. duodenum, or local abscess is set up, and in these cases we have pain without jaundice. 2. In aneurism of the cceliac axis, and commence- ment of the abdominal aorta, the pain is situated at the site of the pylorus and scrobiculus cordis, but it is not likely to be confounded with spasmodic disease of the stomach after ordinary observation and watchfulness: although there are sudden pa- roxysms of pain, especially at night, the pain is more constant and extends more directly to the back; the gastric symptoms, as pain after food and vomiting, are less prominent. It might be supposed that a pulsating tumor could always be felt, but this is not the case when the aneurism is situated close to the diaphragm and between its crura. 3. The omentum is attached along the greater curvature of the stomach; and when it is fixed by adhesion to the lower part of the abdomen, or in- carcerated in a hernial sac, the movements of the stomach become restrained, and pain sometimes sudden and severe in character is produced. In these cases the pain is generally easily excited and more persistent, and the fact of omental hernia be- ing present will put the observer upon his guard in the clinical examination of the case. 4. The pain which precedes shingles or herpes zoster could only be mistaken for spasm in its SPASMODIC CONTRACTION OF THE PYLORUS. 309 earliest stage, and it will generally be found that the pain is really in the course of the dorsal nerve. 5. In spinal disease it is well known that the pain extends in the course of the nerve, and may be only referable to the peripheral termination ; but the fallacy is not likely to occur in well-marked cases of organic disease of the spine; it is in in- stances of weakness where the bones are unaffected, that we have repeatedly found neuralgic pain attri- buted to spasmodic irritability of the stomach after much weariness and fatigue. AVith mental anxiety this form of neurosis is apt to occur; it is remedied by treatment quite inapplicable to the disease un- der consideration; and some of the instances of neuralgia relieved, by the internal administration of arsenic are, we believe, of this kind. AVe have had such cases, which for months had been treated as gastric ailments, that we found to be traceable to a spinal origin. 6. The pain at the stomach, which occurs from sudden distension, although in a sense muscular, is different from the pyloric spasm, both in its character and position : it is more diffused, and is often at once relieved by gaseous eructation. 7. The transverse colon is situated immediately beneath the greater curvature of the stomach, and irregular peristaltic movements, with distension, 310 SPASM OF THE STOMACH. are sometimes the cause of sudden and severe pain. The symptoms are to some extent aggravated by food, on account of the increased movements and distension of the stomach, but they are less truly gastric in their character. In an instance some years ago under my care in the hospital, a patient had been admitted who was affected with cancerous disease at the right bend of the transverse colon, and whose malady had been attributed to spasmodic contraction from gall-stone. 8. It may seem strange to mention renal calculus as one of the conditions likely to mislead us in the diagnosis of functional disease of the stomach, but the sudden severe pain is sometimes situated well- nigh in the region of the stomach ; the vomiting is excessive, and the collapse almost extreme, from the agonizing pain. With these symptoms it is not surprising that attention should be directed to the stomach, es- pecially as the indications of renal disease, shown by the presence of blood, may be so insignificant as only to be recognized by careful microscopical ex- amination. A lady consulted me some time ago, in whom renal calculus had thus been mistaken for hepatic, then for gastric disease, and lastly, it was supposed to be an affection of the colon. The renal calculus was too large to pass, but with SPASMODIC CONTRACTION OF THE PYLORUS. 311 perfect rest for several weeks the symptoms entirely ceased. , 9. Perforation is one of the causes of sudden and intense pain at the region of the stomach, which is occasionally mistaken for functional spasm; and the popular remedy—the dose of brandy or of castor oil—given by mistaken friends in such cases, seals the fate of the unfortunate patient; for it passes through the small ulcerative opening, and aggravates the intense peritoneal inflammation. In sudden and intense pain of the stomach it is less hazardous to give a full opiate than at once to administer purgatives and stimulants. 10. Colic of severe form is sometimes mistaken for gastric spasm. There are varieties of this painful affection which are due to irregular mus- cular contraction, and which are very obscure in their character. The partial contraction of an old ulcer, or the interference of peristaltic movement from an old peritoneal adhesion, may be the source of some of these attacks of transient colic; but the position of the pain, and the manner in which it commences, as well as the absence of ordi- nary gastric symptoms, will in most cases show that it is not due to disease of the stomach. One other point connected with the diagnosis of these cases should be especially borne in mind; 312 SPASM OF THE STOMACH. namely, that the spasmodic contraction, which we have said radiates from the pylorus, in passing to the duodenum, reaches the central part of this latter viscus, where the common bile duct opens into the intestinal canal. The spasmodic contrac- tion extends to the bile duct, the biliary discharge is less free, and transient jaundice of the skin is the result. Some of these instances are at once referred to the liver, and are erroneously regarded as due to the passage of a gall stone, or even con- sidered as acute yellow atrophy. The obstruction of the duct arises, not from the mechanical hin- drance of a gall-stone, but from spasmodic occlusion which only reaches the bile duct by its direct con- tiguity with the adjoining muscular fibres of the intestine and stomach. In ordinary instances of simple gastric spasm our prognosis is a favorable one: after a short time the pain subsides, and the patient is in his usual state of health, only complaining of the exhaustion and soreness consequent on the severity of the suffer- ing. Sometimes the spasmodic pain continues for several days, the partial subsidence being followed by a fresh paroxysm of intense suffering. We have witnessed this persistence in some of those cases in which the malady had been caused by SPASMODIC CONTRACTION OF THE PYLORUS. 313 indiscretion, and in which repeated doses of ardent spirits had been taken to " keep up the patient." Our view of the case is, however, less favorable where there is organic disease of the heart, the embarrassed circulation being unequal to the additional excitement produced by distension of the stomach, accompanied by vomiting and severe pain. In the cachexia of chronic gout, sudden intense pain may be followed by fatal exhaustion ; and we cannot be unmindful that the severity of the pain may in itself be sufficient to destroy life. The indications of treatment are to lessen the spasmodic contraction, to diminish the irritability of the mucous membrane, and to counteract any known predisposing cause. In reference to the first, namely, the lessening of the spasmodic contraction, we possess both power- ful and effective means. Opium, and its alkaloid morphia, may be advantageously used. In the solid form the opium is often more easily tolerated by the stomach than when given in a fluid state; and although morphia is an elegant and valuable medicine, the stomach will often bear the bime- coniate of morphia, or Battley's sedative solution, more readily. In this fluid form, however, a greater effect may be produced by giving a small 27 314 SPASM OF THE STOMACH. _ dose of opium or morphia in combination with henbane, belladonna, and the spirit of chloroform. The most effective method, and the most speedy in its operation, is the hypodermic injection of mor- phia, in doses of from one-sixth to one-third of a grain. If the stomach be very irritable, opium, in the form of a suppository or enema, may be em- ployed with advantage. In the continuance of this treatment, when the pain does not at once subside, watchfulness must be exercised, lest a poisonous dose be administered; and whenever the pupils be- come contracted, and the respiratory act is reduced in frequency, the medicine must be withheld, as its poisonous symptoms are already becoming devel- oped. Chloroform is another valuable means of lessen- ing spasm; and it may be employed in various ways. Its alcoholic solution, as spirit of chloro- form or chloric ether, is extensively used alone or in combination, or the chloroform may be given with camphor. If, however, the pain be very in- tense, it is better to allow the cautious inhalation of chloroform than to give excessive doses of ano- dyne medicines. It will also be found that chloro- form may be applied externally with great relief; either as the chloroform liniment of the pharma- copoeia, upon flannel or spongio-piline, or the chlo- SPASMODIC CONTRACTION OF THE PYLORUS. 315 roform may be mixed with belladonna liniment, and similarly used ; and although the combination of the chloroform and belladonna liniments—the one an oily, and the other a spirituous compound— is less elegant, it is in some respects more applicable by being less pungent to the skin, and it may be applied more extensively. Belladonna as an internal remedy, although val- uable in combination, is less effective when given alone, than those medicines just mentioned; the same remark applies to the internal use of henbane. Aconite is one of the valuable agents we possess in diminishing many forms of severe neuralgia, but it has a powerful sedative action upon the heart, and we have often been obliged to discontinue it on that account. This also renders it less applicable in gastric than in some other affections, on account of the marked depression in the power of the pulse which occurs in severe stomach complaints. AVe have found a single minim of the pharmacopoeia tincture produce such a sense of faintness and ex- haustion as to compel the discontinuance of the medicine. As to external remedies, they are helps, but we should not trust to them alone. Hot fomen- tations, whether of water, flannels, bran, or linseed poultices, may be used; the turpentine stupe is a painful but a valuable mode of counter-irritating 316 SPASM OF THE STOMACH. the skin ; the chloroform and belladonna to which we have before referred, or again the conium poul- tice, may each be called into requisition. In order to diminish the irritability of the mucous membrane, we must direct especial attention to the diet. Ardent spirits, especially brandy, are often first employed to relieve the pain, but too generally they have been the cause of the attack, by inducing subacute gastritis and irritability of the muscular coat. As a rule, it is better to avoid the use of brandy in these cases altogether; but if it be found that crude undigested food in the stomach has caused the spasmodic pain, then an emetic, or a warm aperient draught should be given before the anodyne remedies ; for hard and undigested animal food may be detained in the stomach day after day, and be the source of constant irritation. Having removed any immediate source of dis- turbance, it is well to allow the stomach to rest unless there be excessive prostration, as in the spas- modic affection accompanying gout, when brandy, or ammonia with opium may be given at once. The blandest forms of diet are alone applicable, as arrowroot with milk, soda-water with milk, mutton or chicken broth, in small quantities; %but unfortu- nately, where there has been the free use of ardent spirits, these farinaceous substances are often very SPASMODIC CONTRACTION OF THE PYLORUS. 317 distasteful, and the milk is said to disagree. It is, however, most important that fresh stimulants should not be applied to an already inflamed mem- brane, and the diet must be most carefully regulated. The bowels should be acted upon ; a few grains of calomel with dried carbonate of soda lessen gastric irritation, and act upon the hepatic and abdominal glands; or a magnesian draught in effervescence may be given or other saline purgative. It will be found, when the tongue is injected, and chronic irritation has subsisted, that bismuth, as the pure subnitrate or carbonate, in combination with carbo- nate of soda, with spirit of chloroform, or solution of morphia, and with almond emulsion, constitutes a valuable means of soothing the irritated mucous membrane of the stomach. AVhere there is flatu- lent distension, the internal use of carbolic acid or creasote, with a purgative, as aloes, lessens irrita- tion by checking fermentative changes. In order to counteract any known predisposing cause—whether that cause consist in intemperance, in indiscretion in diet, in gout, or in general weak- ness and exhaustion—we must avail ourselves of hygienic measures, and endeavor to establish the healthy vigor of the system. 27* INDEX. PAGE Abekcombie ....... 273 Abscess in parietes ..'.... 63 Acid, hydrochloric, in gastric juice .... 120, 171 lactic........i2n, 169 Aconite ......... 315 Age, in relation to digestion ...... 31 advanced, dyspepsia in......136 climacteric ........38 of patients affected with ulceration or cancer . . 298 Alkalies, use of . . . . . . . 124 12S Alcohol, use and abuse ...... 132 141 Andral .......... 38 Aneurism........63, 295, 308 Atonic dyspepsia ........ 135 Atrophy of glands . .....32, 34 of stomach ........ 248 Ballard, Dr. ......... 120 Barlow, Dr..........202 Belladonna.........315 Bowels, disorder of ....... 104 Brain, sympathetic disturbance of . . QQ, 78, 212 Breath, state of. ........ 100 Brinton, Dr. ......... 264 Burns, congestion of duodenum in . . . . . 244 Butyric acid ......... 235 Canckk of stomach ........ 285 Catarrh of stomach ........ 160 Cerebro-spinal system, sympathetic connection . . 41 320 INDEX. PAGE Cerebro-spinal system, exhaustion of ... 143 Cervical nerves, sympathetic affection of . . • .46 Chambers, Dr..........82 Charcoal as medicine ....... 234, 300 Children, hydrocephalus of ...... 47 Chloroform . . . . . • • • .314 Climacteric changes ........ 38 Climate, effect of........108 Colic...........311 Colon, disease of.......296, 309 Congestion, dyspepsia from . . . . • .157 Corvisart, M..........1-2 Curling, Mr..........244 Davies, Dr..........261 Degeneration of stomach ....... 248 Digestion, impediments of. . . . . . . 123 periods of greatest activity .... 28 Diphtheritic inflammation. . . . . . "255 Distension of stomach.....59, 93, 309 Dobell, Dr. H..........122 Duodenal dyspepsia.......71, 239 Duodenum, ulceration of.....66, 72, 244 Dwellings, effect on health......Ill Eructation ......... 93 Exhaustion, dyspepsia from......135 Fenwick, Dr..........255 Fermentation, dyspepsia from......227 Fibroid degeneration........248 Fifth nerve, sympathetic affection of. . . . 46,47 Follicular ulceration........177 Food, quantity required.....29, 30, 114 Fraser, Dr..........86 Gairdner, Dr..........290 Call stone.........74, 306 INDEX. 321 PAGE Garrod, Dr. ...... . 192, 199 Gastric juice ...... . 120, 169, 170 Gas in stomach ...... . 230 Gavarret, M. . . . . . 38 Glands, connected with digestion . 25 Gout, dyspepsia of .... . 191 Graves, Dr. ...... 76 Haematemesis ...... . 83 Hemorrhage ...... 83, 256, 272, 281 Hemorrhagic erosion of mucous membrane . 160, 256 Heart disease, dyspepsia from . . 157 sympathy with stomach . . 49 Hearing, disorder of . . . 43 Hepatic dyspepsia ..... . 185 Hernia ....... . 72 Herpes zoster ...... . 308 Hypodermic use of medicines . . 125, 127 Hysteria, dyspepsia with .... . 220 Indigestion, atonic ..... . 135 "bilious" .... . 186 congestive .... . 157 duodenal .... 71, 239 fermentative .... . 227 gouty and rheumatic . 191 inflammatory . 166 mechanical .... . 206 sympathetic .... . 211 ulceration in. . . . 255 Infancy, digestion in . 22 Infantile food ...... . 21, 23, 37 Inhalation ...... . 125 Involuntary muscular fibre . 32 Jenner, Sir William..... . 281 Jones, Dr. Bence..... . 105 Dr. Handfield..... 82 322 INDEX. PAGE Kennedy, Dr..........288 Kidney disease of, dyspepsia from . . • . 33, 66, 200 sympathy with stomach ..... 51 Lactation .......... 37 Lardaceous degeneration ....... 248 Law, Dr...........259 Leared, Dr.........124, 234 Lees, Dr..........265, 269 Life, periods of digestive power ...... 18 Lithia, use of ........ . 199 Liver......25, 33, 50, 66, 74, 295 sympathy with stomach ...... 50 Lungs,, sympathy with stomach .... 49, 66, 79 sympathetic dyspepsia ...... 214 Manganese........124, 280 Manhood . ........27 Marsh, Sir H.......68, 79, 220, 246 Mechanical dyspepsia ....... 206 Melaena..........84 Menstruation, vicarious . . . . . . 84, 89, 92 Mercurials, injurious effects of . . . . . .33 use of ....... . 131 Mesenteric glands ........ 25 Milk, changed by absorption ...... 24 Mind, effect of, on digestion . . . . . 41, 47 affecting treatment . . . . . .41, 107 Mineral waters.......164, 184, 198 Moleschott.........29 Mucous membrane, organic disease of .... 57 irritability of . . . .66 Murchison, Dr..........290 Nervous system, disturbance of.....106 dyspepsia from exhaustion of 143, 147 Night, digestion during ....... 33 Occupation, effects of.......109 Omentum..........308 INDEX. 323 PAGE Opium, action on urinary organs . 34 action on milk .... . 37 in treatment of gastric ulceration . . 279 in cancer ..... . 299 in gastric spasm .... . 313 Osborne, Dr. ...... 59, 268 Pain, value of as symptom 56, 267 Pancreas ....... 33, 63, 296 cancer of .... . . 296 Pancreatic juice ..... . 122 Parietes of abdomen, abscess . 63 Parkes, Dr. ...... 29, 30 Pepsin ....... . 120, 155, 170 Periods of life, changes of digestion . . 19 Peritoneum, pain ..... . 59 inflammation of . ' . .69 Phthisis, dyspepsia ..... . 215 Pneumogastric nerve..... . 48, 62, 78 Pregnancy ...... 35, 217 Pressure on stomach ..... . 70 Ptaylin '....... . 168 Purgatives ...... . 130 Purpura ....... . 86, 93, 99 Pylorus, disease of . . . .60, 32, 66, 6^, 248, 297 Pyrosis ....... 81, 240, 2S3 Quantity of food ..... . 29 Regurgitation of food .... . 73 Regurgitative disease .... . 220 Remedies, and their abuse . 112 Renal dyspepsia ..... . 200 calculus ...... . 310 Rheumatism, dyspepsia with . 197 Sight, disorder of .... . . 43 Senses, disorder of . 43 Smell, sense of, disordered 44 324 INDEX. PAGE Soda, hyposulphite, absorption in milk .... 38 Smith, Dr. E.......-22, 28, 105, 109 Snuff, injury from ........ 142 Spine, disease of, sympathetic dyspepsia . . 66, 214, 309 pain ......... 62 Stomach, degeneration of . . . . . . • 248 cancer of.....58, 66, 68, 84, 285 distension of.....93, 98, 309 inflammation of. . . . . . 56, 65 perforation ...... 256, 257 pressure on ....... 66 ulceration .... 58, 66, 68, 87, 177, 293 spasm of ....... . 302 Stokes, Dr..........246 Sympathetic ganglia ........ 20 dyspepsia ....... 213 Sympathy of stomach in disease ..... 40 with lungs and heart. . 48, 216 with liver ..... 50 with suprarenal capsules 51, 66, 74, 217 with urino-genital organs 51, 75, 217 with skin \ . 52 Tabes..........26 Taste, sense of, disordered ..... 44, 101 Thompson, Dr. T.........215 Tongue, state of ........ 101 Touch, sense of, disordered ...... 44 Ulceration, follicular......177, 256 of stomach......255, 293 Urine, state of ........ 104 suppression of . . . ... . . 202 Urino-genital organs, sympathy of ... . 51, 75 Vomiting, as symptom.....35, 47, 65, 280 Youth, digestion in........26 « te*'