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DISEASES OF THE STOMACH.
BY THE SAME AUTHOR.
PATHOLOGICAL AND PRACTICAL
OBSERVATIONS
DISEASES OF THE ABDOMEN.
COMI'RISING THOSE OF THK
STOMACH AND OTHER PARTS OF THE ALIMENTARY
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y
DISHASI-S OF TUB STOMACH,
AND IHE VARIKTIES O)
DYSPEPSIA,
WITH DIAGNOSIS AND TREATMENT,
S. O. HABERSHON, M.D.,
■ K rilVSIi-I^N TO, AND L.M'K I.ECTIIRBR ON THK 1'RINCII'I.ES AND PRACTICE Ol MKUICINi:. A r
GI'V'S HOSPITAL.
THIRD REVISED EDITION,
i'HlLADElJ'HlA:
P. BLAKISTON. SON & CO.,
IOI2 WALNUT STREET.
1882.
C/C. 3
I ^.
m
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 PEEFACE.
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 welf as of healthy action in the
living organism, for one part cannot be affected
without the sympathv 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,
Grosvenor Square.
CONTENTS.
CHAl'TKR I.
PAOR
TllF VAUIETIKS OK PYSrErSIA : TIIKIU DIAC.NOSIS AND TRKATMF.NT 13
CHAl'TKU II.
ON THE CHAXCE8 OF IHOEHTION AT KIKKEKE.VT rKKIops AXT)
CONDITIOKS OF LIFE . . . . . . .11'
ClIAl'TliU III.
OS THE OE.NERAL SVMPATIIY OF THE 8TOMACH IX I)I.'*EA.'*E 4l'
CHAPTKU IV.
<)X THE SYMPTOMS <)F IiISEASK OK THE SToMAril . 'i 4
CIIAI'TKR V.
ox THE fJEXEKAI, TBEATMEXT OF IHSEASE OF THE STOMACH . K'"
CIIArTKU VI.
ox THE REMEDIES FOR IXIHGESTloX, AXI> TMKIR AIICHK . .112
niAPTKR VII.
I>V.^PEPSIA FROM WFAKXES.X : ATOXIC DYSPEPSIA . Ki'i
CHAPTKK VIM.
DYSPEPSIA FROM COXORSTIOX . If*?
rilAl'TKU IX.
IXKI.AMMATOUY DYSPEPSIA ....... 1 <!<i
Vlll CONTENTS.
CHAPTER X.
PACK
HEPATIC DYSPEPSIA ........ 185
CHAPTER XI.
HHEUMATIC 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.
CnAPTKR 1.
THE VARIETIES OF DY'Sl'EPSIA : THEIR DIAGNOSIS
AND TREATMENT.
ALTHOUfUl nearly every year new works have
appeared on diseases of the stomach, still the mala-
dies affecting this organ are so unmerous, and of a
character so diversified, that there is ample scope
for the records of individual exjierience. 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 uj)on 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, bv
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 ^digestion
arises, we must trace it to some cause by which this
natural process is impeded. To enumerate all the
THEIR DIAGNOSIS ANI> TREATMENT. 15
causes of dyspepsia we must trace tlie 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 tiie varieties of dy.spcpsia, we
must comf»rehend every form from the trifling
malady, which may scarcely be regarded, to those
which arc so severe as to rob life of its enjoyment;
and even the same symptoms may in the one case
bo a mere temporary disturbance, and in the other
tlu'V niav 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
})ractice ; 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 eflects 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 thej 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
falls 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. Rheumatic and gouty dyspepsia.
6th, The dy.spepsia connected with disease of
the kidneys.
In the varieties of d3-spepsia thus alluded to,
the mucous membrane aud 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. Dj'spepsia 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 dj^spepsia.
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 11.
ON THE CHANGES OF ])IGESTION AT DIFFERENT
PERIODS AND CONDITIONS OF LIFE.
The plicnomcnon of life does nor present an un-
varying scries of actions, nor the constant repetition
of tlio same living functions performed in an iden-
ticiil maimer; Imt we timl 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 see<l jilaiit 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 .^^eparate existence; there is a
vitality in the seed which may exist for an almost
indefinite period, till, V>y the application of the
needed stimulus, fresh changes take place of an
entirely difl'erent 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 witli 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 difiering from that of the
old man, with his maturer thoughts and liis 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 an<l power of circu-
lation, wiiich an octogenarian docs not possess;
and not les» apparent are the functional peculiarities
of digestion during the different perimls of life.
During the earlier months there is the greatest
activity in all the functions of life; the nervous
system is very ea.sily disturbed, the muscles are
readily excited to contraction and convulsive move-
iiK'iit, the respiration is more iiurried, and the heart
beats with greater frerjucncy, loO to 14<> as com-
pared witii (50 to 80 of adult life; the temjH'rature
of the body is more variable, and there is le.^'s
aliility to resist sudilen changes.
The helj)le8sness of infancy, and its entire de-
pendence on the fostering care of others, is con-
nected with a delicacy and st?nsi>)ility in the organ-
ism, which is easily acted upon, and is adapted only
for peculiar conditions. The physical organization
(»f an infant is designed for fluid food, an<l 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, n)ore ossified than any
other bone, serves as the support for the arms and
hands, which are secondary helps in the process.
22 0:S THE CHANGES OF DIGESTION
An infant is onlj 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
inftint 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, tiic 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, a.ss'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,'' Eobb'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 tl\an 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. 2o
emetic, will render an infant pale and prostrate, and
in not a few instances it will destroy life; for al-
tliougli the vasomotor nerve is more active than at
any other period, its power more quickly ceases.
The same excessive irritability is found in the
ccrebro-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 sm.aller, but performed with more rapidity,
and with greater facility are those cyclical move-
ments disturbed in their course.
The condition of the glands connected botli with
l»rimary 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 is, and at about four or five years
of age it attains the proportion which is afterwards
maintained, that of 1 to 3G. Tiie mesenteric glands
are very large and distinct ; they are more vascular
than at any other period of life, and their function
3
26 ox 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 hypera^mia 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 hypera?mic, there is
great liability to the deposition of an organic pro-
duct of a strumous kind. If health be restored,
the old diseased glands wnll be found in subsequent
years as a serai-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 DIFFERKN'T PERIODS OF LIFE. 27
of consumption have arisen from the nourishment
durinj' months of residence at school beinj? of an
improper kind, or so uusuited 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 sliglit
exciting cause. A large quantity of suitaV)le nour-
ishment is essential at this pcrio<l for tlie natural
activity of youth and the healtiiy development of
the frame, as much as the system can digest and
assimilate; whilst stimulant.s, and a diet which
panders to the apjx?lite ratlier tiian supj)lics requi-
site material for the growing organism, should be
avoided.
In an ordinary state of health malt liquors and
wine are both unnecessjiry and injurious; and if the
system be exhausted Ity di.seas<\ more than usual
tare is required in their administration.
During tiie strength of vmuhoml thtrr i> los
energy, but greater uniformity in the process of
digestion. The development of the system lias
attained its maximum, an<l the functional activity
is less powerful than during infancy and y<^uth,
but more so than in the declining stcj)s 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 ox THE CHANGES OF DIGESTIOX
of bearing vicissitudes of temperature more easily.
Longer intervals suffice to elapse between the meals,
and larger quantities aie 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 s^'stem 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. Parkcs, in his work on TTygiene,' quoting
from Molcsohott, 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 : —
Gnimmes. Ounces avoir.
Albuminous substances .
. 130
4-587
Fatty ....
84
2-964
Carbo-hydrates
. 404
14257
Salts ....
30
1-058
648
22-866
Water ....
. 2800
98-580
3448 121-446
and again, that 10-i grains of nitrogenous substances
equal to 3"G71 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 I'o
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 oft'ended, 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 DIFFERKNT PERIODS OF LIFE. 31
In advanced years the activity of life gradually
lessens, and the physical organization presents cor-
responding change. The arterial vessels Avhicli
carry the supply to every gland gradually become
< "paque and rigid ; the glands themselves waste,
and arc 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
llic minute sudoriferous glands are inactive; and
the mucous membrane of tlic 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 arc with
some difliculty found ; the .same mesenteric glands
which during earlier life are so essential in the
elaboration of tlie chyle, before it is poured into the
blood. Tlic digestive process is feebler during
advanced life than at any previous period ; and this
les.sened functional power is accompanied with an
inability to take the same vigorous exercise as
formerly. During the strength <»f earlier life, wlicn
the respiratory act was in its full energy, it would
.seem that effete materials could be ra{)idly removed,
and at the same time warmth and heat maintained ;
in age the cycle of functional life slowly revolves,
32 ox THE CHANGES OF DIGEStlOK
till it ceases altogether, or is stopped bj 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 earh?^ and advanced
life ; in the former period corrtraction 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
appendicae epiploicse 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
valvulee 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 MFFEREXT 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 ditTerence in the
aj>pearancc of the cells at the extremes of life ; for
in old age the cells are dark, and often loaded with
pigment, as if tlic vital mechanism were gradually -
coming to a state of rest. The diminished energy
requires that the supply of food should l>c more
constant, and that long intervals shovild not elapse :
it is often noticed that headache, disturbed vision,
and symptoms resembling threatening apoplexy or
pandysis, arise from an insufficient nutrient supply;
and the mistake is sometimes made of exhausting
by jiowerful purgatives, mercurials, or even actual
depletion, when ammonia or stinmlants would be
more approjiriate.
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
should 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 bj impeded circulation
and faiutness. 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 sj'stem 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 difficult}'-, 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 wnth the stomach, to whicli 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 healtb.
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 tlie digestive process is in them
strangely m^xlified, and the whole system sympa-
thizes with the important processes that are being
carried on : we refer to pregnancy and to lactation.
Tiie former state induces remarkable changes in
tlic vaso-motor or sympathetic nerve of tiic abdo-
men. Tlierc is the closest union between the
uterus and the stomach. A state of irritability is
frequently induced, so that the stomach rc^jects its
ordinary su[)ply. and it does so especially in the
morning, tjjc porio<l at which digestion is generally
most active. Tiiis 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-
ncss 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
aggravaticm of the symptom. Again, direct pres-
sure greatly increases the distress of this kind, but
36 ox 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
health}^ 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 DIFFEHE.VT 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
di.scase. In most instances, iiow. ver, it is well not
to excite the system by a too generous diet, nor by
stimulant.s, whilst absolute rest of mind and b<Kly
is the state most conducive to sjxjedy 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
niotht-r bocoiiic absorbed into her blood, and enter
the milk, the infant thereby suflering pain and
diarrhu-'U. Ojiiurn is said also to influence the child,
but this has (louV)tless been exaggerated. lu an
in.stance of a lady a few weeks after confinement,
4
38 ON THE CHANGES OF DIGESTION.
to whom the lijjDosiilphite of soda bad 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 suftered griping pain and vomitiug, 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 sj^stem. 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-iutestinal 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 GO or from 50 to
(j;^ — 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
strciitrth.
40 ON THE GENERAL SYMPATHY
CHAPTER III.
ON THE GExVERAL SYMPATHY OF THE STOMACH IN
DISEASE,
It is tlie 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 sympatliy we mean that an organ of the body
may become functionally disturljed by irritation of
a structure external to itself: in this way severe
pam and aVjnormal 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.
Aniong.st these .sympathetic affections arising
from disease of the stomach, we will first notice dis-
turbances in the renhro-si'inal sj/st'in^ and the.se sym-
pathetic symptoms may be arranged as follows : —
Affections of the cerebrum, by which the mind,
the memory, and the perceptions are changed.
r)f 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 ox THE GENERAL SYMPATHY
Of the spinal system, so tliat 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. Jf 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
tlie powers of reason and judgment often become
perverted. The hypochondriac sees everything
OF THE STOMACH IN DISEASE. 43
under an erroneous aspect, ami forms his judgment
accordingly. The manner in which the senses are
di.sordercd by gastric di.«<turl)ance is very remark-
able. The functional alterations of tlie 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 tliat only
part of an object is discerned, or irregular zigzag
lines are noticed, or spots of an object Wcome quite
indistinct, or half a word is discerned ; again sparks
of light may l)e jHirceived, or dark floating sjHJcks
be seen, or even the color nnxlilied. To some
patients one or other form of disturbed vision is
the certain eftect of disordered digestion, atid the
kind ol' attack is recognized by the character of per-
verted visual phenomena.
Some care is, however, required, lest tlie symp-
toms of commencing organic disea.se of the eye —
such as the various forms of amaurosis — be aa-
cril>ed simj)ly to mal-assimilation. We liave 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 needles.sly
postponed, till irreparable mischief had l)een d«)ne.
The sense of hearinj is not less easily disturljcd,
and the perce|)tion is either generally diminished,
and partial ihafness indue* d, or then^ is noise in the
4:4: 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 aneemia,
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 IX 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 hyperajsthetic in indigestion.
Tliis aflection is due to the closer connection of the
sympathetic nerve with the ulnar, which supplies
those fingers, rather than with the median; a local
j)ain, about one inch in sujxjrficial 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 0th, and these dorsal
nerves also send sensitive branches IkjIow the breast.
Again, the sense of op|)ression 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 liyperresthesia induced tlms symj)a-
thctically in gastric disease, but also ana-sthesia, so
that the fingers may become transiently benumbed.
Other ])arts of the nervous system are intimately
connected with the stomach. We have already
referred to hyper;esthesia, 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 IX DISEASE. 47
abDormal sensibility in the branches of the 5th
nerve supplying tlie face, and the branches of the
1st division are more frequently afl'ccted than the
others; thus itching of the nose, pain in the eye,
• tc, arc familiar illustrations of the fact. As to
the conver.se of these symptoms, numerous cerebral
di.scas<.'s induce gastric irritation and change. After
eoncu.ssion of the brain a very common symptom is
violent vomiting; and some of the most irritable
I onditions of the stomach we have ever witnessed
have arisen from at)scess in the brain.
In threatening hydrocephalus of children the
stomach is often disturbed, and the dangerous — nay,
even fatal — inistakc is made of considering a terri-
ble disefi.se as a trifling " bilious attack ;" and when
this innammatory di.seasc has become .severe, it is
'•IUmi noticed that the least attempt to raise from
the recundjent position is followed by violent vomit-
ing. The saine .symptf)m is observed in tubercular
di.sea.sc 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, liad 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 IX 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 difiicult to convince patients
tliat they are not suftering from organic di.sease ;
palpitation of the heart is induced, and irregularity,
which greatly alarms the patient, and even faint-
ness or actual syncope, if tlie heart be feeble. The
converse symptoms are equally important, and
early disease of the lungs, esjiecially from peri-
])1ut;i1 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 j)hthisis are of this kind. In whooping-
cough a similar connection between the stomach
5
50 ON THE GENEEAL SYMPATHY
and tlie luni2;s 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 IX DISEASE. 51
hepatic and gastric filaments by means of the pneu-
mogastric and vaso-motor nerves.
Til 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 ; an<l although, after death, local
irritation and superlicial ulceration of the mucous
membrane have often been <letected, we regard the
direct nervous connection as having the m^^re im-
portant causative relation.
The svmpathy 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 ple.xus with the
semilunar ganglia. Diseases of tlie blatlder and
prostate are often associatetl with gastric and gene-
ral symptoms, due to the vaso motor nerve, as
rigors, irritability of stomach, hiccough, etc.; and
the changes in the uterus and ovaries are often
marked by charac' eristic 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
sj^mptoms 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
lirlien. 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 c)f symptomatic
frvrr. In tlicsc conditions the stomach is aftected
ill romrnon with the whole system, all the glandular
organs have their action retarded, the bhxxl 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 di.sease
should present most varied indications in the dis-
turbance of other organs; and, in like manner, that
gastric ]»henomena of an abutiniial kind should
result from irritation, far removed from the stom-
ach itself. The closest circumspection is required
to discriminate between symj>athetic affections and
those of a strictly local origin.
54: ON THE SYMPTOMS
CHAPTER lY.
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
comparatively 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. OO
all the abdominal viscera, and with the spinal
nerves ; and this connection serves to explain the
uncertain indications of these symptoms.
As a sign of disease, j^ain 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 rai.sleads, or its
ab.sence 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 immunit}' from
suffering. A similar fact is observed in relation to
the }>arenchymatous viscera; thus the substance of
tiic liver and the kidney is often changed in a
inarkcd degree ; and if disease, such as abscess,
arises in their structure uithout 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 ON THE SYMPTOMS
the agonv 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 malad}^, 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
or DISEASE OF THE STOMACH. 57
of irritant poisons, that, while the mucous mem-
brane is only afifected 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, whore 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-
lonfjcd for tiiree months ; there was a remarkable
absence of suflering 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-
ro.sive sublimate; and we arc 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. TTe 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
wlicncver 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 caici.
YI, 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 scat 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 aff'ected, and the erroneous opinion may be
strengthened by the rejection of food almost before
it has reached the stomach.
YIII. 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. AVe 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 arc the stomach diseases
observed in connection with iitoriiic 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-
niogastric 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 ox THE SYMPTOMS
produced by an irritable condition of the pneurao-
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 w^e 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 STOMACU. 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 dis[)osed 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 miglit very Ciisily 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
j)atient 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
XYIII. 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 tho.se which originate in the
stomach and intestines, and secondly, into those
which arc symjtathctic 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;
QQ ON THE SYMPTOMS
3. Irritauts 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, pyemia, 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 ar.-^cnious acid, and by
corrosive sublimate, cases of which have occurred
without pain at the stomach; and in the symptoms
of gastro-cnteritis 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 })a.ss within the })yloric 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 acticm 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 ox THE SYMPTOMS
acli 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.
Y. 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.
YI. 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.
YII. 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 maj
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,
apparentl}' from the destruction of the branches of
the pneumogastric nerve. Further, the period at
which vomiting occurs dogs not always indicate the
seat of the cancerous obstruction. In some instan-
ces of obstruction at the ])ylorus, 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 iu 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 iu acute peri-
tonitis unless the peritoneum in the neighborhood
of the stomach is implicated ; 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 cftusion near the stomach.
70 ON THE SYMPTOMS
In some of these instances the stomach is affected
bj 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 perform.ed, the pressure being removed,
the sickness ceases. WJien 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 same
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 itsplf, we have to refer to
morbid states of other abdominal viscera ; and
first, to disease of the dnodenum^ as inflammation
of its mucous membrane, ulceration, and obstruc-
tion.
There is great similarity between the diseased
conditions of the first portion of the du<xlenum and
of the stomach. A form of dyspepsia, in which
vomiting, with pain at the seat of the duotlenum,
comes on at the close of digestion has been attri-
buted to the (lu(xleniim ; but whether this class
of cases is c(mnccted 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 dnodonum, 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
])lace. 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 tlie canal may be de-
stroyed.
Other causes of vomiting arc 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,
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 pneuraogastric 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
ursemic 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-
mortera 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. (D
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
bv 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 abn<jrmal excrcmentitious
substance appears to act as a direct irritant.
XVI. Both fuiu'tioiial and organic diseases of the
uterus are causes of vomiting. In dysnienorrha'a,
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. Sadden nervous shock,
fright, etc., will produce vomiting ; and in some
more chronic diseases, when the blood is alrered 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
rnation." 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 yellnv /ever, 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 arc
most interesting and important in the correct diag-
nosis of disease ; the first of these is a diseased con-
dition of the s}me. 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
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 o-reat that vomitino-
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 durin<j the course of the disease the stomach he-
comes irritable tcitliout any obvious cause, and ivliere
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 cft'used. 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
})iilmonary branches of the pneumogastric nerve, is
the last cause of vomiting to which w^e 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-
(^uent occurrence, and it receives its appellation
from the fact of the rejection of a thin watery
mucus. The poorer clas.scs of society, and espe-
cially its female portion, arc 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 di.schargc is generally neutral in
its chemical reaction, and often tasteless, but some-
times it is found to be slightly alkaline, and the
]»atient 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 Avhen the stomach is empty, and it
is accom{)anied 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 blenorrhoea 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 arc 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 ]K)tash, with hydrocyanic and bitter
effusions, is of great service Avhcrc 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, Ilsematemesis.
— 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,
heematemesisj or its discharge by the bowels,
melsena.
Great alarm is naturally excited by the rejection
of blood from the stomach whether in small or laro-e
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 ha^matemesis 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 larjmx, 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
mehena. Sometimes this black evacuation or me-
la^na 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
cofiee-ground substance, so often rejected towards
the close of organic disease of the stomach, consists
also of blood which has slowly exuded, the ha3ma-
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 tfnruptured 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 iutestine 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 aronnd them, but limited by the basement
OF DISEASE OF TUE STOMACH. 87
membrane, thus constituting a point of eccbjmosis ;
if the basement membrane had given way, the blood
previously extravasated would have escaped, and no
raptured vessel would have been detected. A simi-
lar action takes p]a<ie in the stomach ; ecchymosis is
produced, but the action of the gastric juice prevents
our observing the changes witli the same faciHty
as in the intestine. There is little doubt that the
capillaries thus become over distended, and then
ruptured in the ordinary form of hnematemesis,
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 autc-mortciii coagulation and consequent dis-
tension of the branches of the vena portai 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 wliich precede ha^matemesis are a
sense of faintness, followed b}^ 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 antemia ; 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 Ave 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 \vc 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 leucorrha?a, etc.
In purpura hivmorrhagica there is a blanched
countenance, faintness, etc. ; but we have indication
of the cause in the changed character of the blood,
and its eilusion from other mucous membranes as
well as into the skin. The htematine 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.
AYhen 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
i§ 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 h«3matemesis, 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 Ruspini'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 bj 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 aftbrd only
partial relief. Oil of turpentine in doses of "ixx,
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 htematemesis may, however, continue for a
considerable period.
Purpura htemorrhagica 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. Ruspi-
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 insufhcient
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 justl}^ 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 afiecting 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 sarcinje
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
clicmical decomposition does not suffice to explain
all these cases. It will frequently be found in those
of enfeebled digestive power, tliat the very absence
of food induces flatulent distension of the stomach.
To pass for an hour or two beyond tlie 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; juirulcnt decomposition takes place
from the retention of mucus and pus in the more
dependent bronchi, and sulphuretted hvdrogcn 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.
Siueetness 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 uraemic 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 ^vcll tliat in acute
irritation of the stomach the appetite should be
staved, 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 which 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 tomjne 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 papilla3 of the
tongue, which constitutes the characteristic "fur;"
and since hjcal 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
supjily, 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 ox 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 be 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 papilla? 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 preter naturally 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 antemia 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 rod 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 yastric disease, or rather
104 ON THE SYMPTOMS
of indigestion in its various forms, is a disordered
condition of the hoivels. 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 litbates 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 liepatic 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,
tho urine has been sliown by Dr. Bcnce 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 wlioni 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 liave an excess of phosphates, and the
crystals of the ammonio-magnesian phosphate.
Other symptoms of gastric disease are connected
with the vaso-motor or symj^athetic nerve^ or with
the connection of that nerve with the cerebrospinal
system. Many of these we have alluded to in
speaking of the sympathies of gastric disease : as
the distnrhance of the senses ; the irritation of the
extremities of the alimentary tract ; itching of the
nose and mouth or of the anus ; the irregular j^ains
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
irre(jidar 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
CHAPTER y.
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 entraneed; hunger is not experi-
enced ; but when at length the excitement is les-
108 OK 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 bj 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 v(\\x\x\X\x(Y\no\is 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 witli 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, Avhen 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 dtoelling 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 delicient 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.
Plaving 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,
CHAPTER 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 ef&-
cacious character.
The remedies we possess are more than sufficient
if we know how rightly to use them ; and we are
able to efl'ect 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 digestiv^e process.
3. Those remedies which remove the impediments
of digestion.
AND THEIR ABUSE. 113
4. Those general remedies which only act upon
tlie stomach in a secondary manner ; but to this
latter class we have already referred in the last
chapter.
In the Jirst 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 eft'ect 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 Yery 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
faintncss produced in a dyspeptic, who for several
months refused vegetable food.
If active exercise be taken soon after a meal,
unless digestion be rai)id 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 dlidte^ 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 i)assed 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-
})crienced, so that even faintncss 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
])ersuasion, it will remain as if unacted upon for a
prolonged period.
IIow 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 ichich increase the digestive power hy 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 adm'inistered
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. It 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 "\ve 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 efl^cct 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 wc 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 difiiculty 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 ineflfi-
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
V>rain substance is defective.
3. A tJiird 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 diflferent 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
great 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 FOE 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 yeneral
cvjents which act in a secondary manner xipon 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 ])rescnt 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-
tion.— 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,
Keid, and Rynd, 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 ox THE KEMEDIES FOR INDIGESTION',
Purgatives. — Few remedies afford greater relief
in many forms of dyspepsia, especially tliose 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 raucous 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
I)ale 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
hyperaemia 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 EEMEDIES 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
CHAPTER VII.
DYSPEPSIA FROM WEAKNESS. — 1. FROM IMPERFECT
NUTRITION AND FROM DISEASED VESSELS. 2. FROM
EXHAUSTION OF THE CEREHRO-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 imjiediment
to the pcrforniancc 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 the earlier 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, "We 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
ATOXIC DYSPEPSIA. 139
also atlieromatous, 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 easil}^ 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 po werful 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 aflects no function in a greater degree than
that of digestion.
The habit of snuflf-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 remedv of mustard seed
ATOXIC DYSPEPSIA. 143
wa«; 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 cavenne
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 ffxxl ; the preparations of pepsin mav be
used, but wc mu.«t not expect much benefit from
them.
It is less, however, by any direct medicinal
treatment that we can relieve the atonic dvsi>epsia
of advanced life, than by careful attention to tho>c
rules of heiilth 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 phy.«jician in
these cases.
A second cause of atonic dyspepsia will be found
m fxhanstion of the cerehro-spmal nervous system.
Mental distress and excitement, great an.xiety and
144 DVSPEPSIA FROM WEAKNESS:
phj'sical fatigue, constitute this most frequent cause
of dyspepsia.
After mucli 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. 1-15
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
painfull}^ 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
anaemic 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 npon
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 tlie 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 oidy 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 su])ply 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 (he nerve of
oryanic 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:
tliongh 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, eitlier
at the vertex or at the temple, the mind is de-
pressed in some cases, disturbed by vague apprchen-
ATOXIC 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 aVxlominal exhaustion and empti-
ness. The same condition is observed in the
exhaustion from other causes; from severe liem-
orrhages, from excessive menstruation and leucor-
rhoea, and in the convalescence from acute diseases.
Mercurial medicines, if continued so as to aft'ect 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 insuf&cient. 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 liave 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
respiration, 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 j)ropcr 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 FKOM \YEAKXESS:
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 ammonio-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-
nae 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 bj 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,' 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 tothc ' British PliarmacopoMa,' 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 COXaESTIOX. 157
CHAPTER YIII.
DYSPEPSIA FROM CONGESTIOX.
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 portal. The large venous
sinus, the vena portcC, 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-
taB 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. Id 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 tlie 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-
pertemia 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-
FEOM COXGESTIOX. 159
sarv 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 raucous 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 witli 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
nmcus, 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 tlie 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 distenslbn, and the embarrassed action
Df the heart. This kind of flatulent distension be-
3omes exceedingly distressing, so that scarcely any
food can be taken with comfort, and nearly everv
14*
162 DYSPEPSIA
solid form of it is discarded ; an attack of "haemate-
mesis, or of bleeding from luemorrhoids, 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 ^e disease is ulti-
mately fatal ; but a great deal may be done to
remove the distressing symptoms, and to prolong
FROM CONGESTION, 168
life for many years. la the treatment we have
tliree 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
ma}'- 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 suflcring patient; much may be done, and great
relief aflbrded.
To relieve the comjestion the bowels should be well
acted upon, and to eiiect 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 i)ill 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
bj 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 CONGESTIOX, 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.
CHAPTEE 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
Avhcn 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
dift'ering in degree; and the remarkable oppor.tunity
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 effasion 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 ;'
but an equally essential element is pepsin, an or-
ganic principle closely allied to albumen and fibrin,
' 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 wliicli is soluble in water, but insoluble in al-
coliol. 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 devcloi)ment of the
epithelial and mucus cells ; in some instances they
are large, with distinct nuclei, and in fact these
cells, if isolate<l, 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 arc 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.
tivc 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 efl'ect 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 difters
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 ]»aticnt. In many other disefises, the
jiuin is more severe and persistent, as for instance
in ulceration and in cancenms growth, whilst in
the one under consideration it is onlv described as
" soreness."
2. The irritability of the stomach is often diftpro-
portionate to the severity of the pain; ami the
blandest form of diet is retained with difhculty.
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 iu 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 vise.
INFLAMMATORY DYSPEPSIA. 175
Headache, mental depression, laasitude, distur-
bance of vision and ringing npise in tlie ears, are
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,
tlic pulse is irritable and compressible, and the
bowels arc generally contincd, although when the
erythematous condition «jf the stomach passes down-
wards into tiic intestine, constituting gastroentorite,
diarrlia'a is set iij>. The urine is high colored, and
urea is generally in excess; it deposits lithates
freely, «>r witli nitric acid it assumes a deep color.
It is very important to distinguisii 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 lieart ;
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 papillas. 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 efifects have been attributed to
poison.
Minute points of ulceration have sometimes been
detected on the post-mortem examination of the
stomach of children thus aftected 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 ma}^ 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 alxlomen ; 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 jmiii across the chest
or in the l»a<-k. These jiatients are generally hy-
pochondriacal, and often believe themselves to be
tlie subjects of serious disease of the liver. "With
other disturbances of the nervous system already
mentioned, \vc find jierverted special sensibility, as
indicated by double vision, muscat volitantcs, noises
ill the cars; an<l the nerves of general sense are
also aflbctcd, as manifested l)v a numbness, formi-
cati(m, 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 pharyn.x apthous and painful ; vomiting
is occasionally a troublesome symptom, and also
diarrlui'a. The pain at the stomach is increa.sed 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 efllccts 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 cither 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 |»roj^no.sis, 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 objecMs areeftectod by removing anything
from the stomach which perjietuates disturbance
by allowing rest as far as possible to the viscus, and
by me<licines, if any be given, which directly soothe
the inflamed surface.
If undigested substances remain in the stomach,
an emetic of ipecacuanha or of sulj)hatc of zinc is
the most etVcctual remedy.
The most bland forms of diet are desirable, and
those articles wliich tax all the energies of the stom-
ach to dissolve them should be avoided, as solid
animal fo<Kl ; animal soups, and even beef tea, are
often injurious, whilst farinaceous substances are
well borne.
Stimulants, especially ardent sj^irits, malt liquors,
and generally wine also should bo abandoned;
whilst cold drinks and ice are often extremely
16
182 INFLAMMATORY DYSPEPSIA.
grateful to tlie 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
afibrd 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
alkaU 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 arAite 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
tlie stomach by diminishing the acidity of tlie se-
cretions. I have found few remedies of greater
value when oftentimes repeated, and given in some
bland mucilaginous fluid. In the gastro-enterife of
children, it is of tlie 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 dyspep.sia, the same
principles of treatment must, if po.'^sible, be carried
out — namely to prevent fresh sources of irritation
from improj)cr diet, to unload the congested struc-
tures, to clear away effete materials from the system
and to restore healthy action.
Saline apcrient.s, 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.
Thk liver is frc'iuontly blamed for disturbance
with whieh it lias 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
j)orta', 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 (juickly 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 tlie blood, and thus the balance of the whole
economy is upset. If the oftending cause is only
1(3*
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, eftete 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 Avill
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
unplea.'^ant taste in the mouth, and is often accom-
panied with severe headache, with vertigo and
disturbed vision, and it may be, with noi.ses in the
ears. The heiidache is often very severe in acute
temporary disturbance of the stomach of this kind,
and is experienced acro.ss the eyebrows, at the fore-
licad, or at the back of the head ; sometimes the
whole head is felt to throb with each pulsiition 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 phy.sical strength is aj)i)arcntly lessened, and
the patient complains of exhaustion, a weakness
the result of imj)cded action, rather than of actual
lo.ss of power. The kidneys act imperfectly, and
the urine is scanty and loaded with lithates; the
bowels are often contined, but sometimes irreg-
ularly jnirgcd, with accompanying pain ; the mo-
tions are mottled and clay-colored, or of very dark
and oflcnsive character, and as an additional dis-
comfort, luemorrhoids 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 i)o\vder, followed by a saline
purge.
If the stomach continue irritable, bismuth mav
be given, with magnesia or its ciirbonate.
Still the rno.st bland nourishment only should be
allowed: as arrowroot made with water, mutton
broth, thin gruel, etc.
Tf the dy.spepsia be of a chronic kind, and the
st'cretions have been already acted upon, we have
found great Injucfit from the use of the nitro-
muriatic acid witli taraxacum; and as a |)urgative.
small doses of the re.sin 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 arc thereby
gently acted upon, and the tonic eftect of the rhu-
barb strengthens, whilst the alkali diminishes the
irritability of the membrane; these medicines iji a
lluid state, although less palatal)le, 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
CliAlTKK Xr.
RHEUMATIC AND GOUTY DYSPEPSIA.
It is not our intention to enter into a description
of the symptoms of rheumatism and gout ; tlicse
• liseases liave some symptoms in common but they
are not identical in their character; nor are thev
combined as rlicumatic 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 blocnl, and the
pabulum which is to supply the wants of the system
has Ixjcn 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 KHEUMATIC
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 thoir
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 Avhich 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 w' hole 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 V)oth gout and rheumatism we frequently find
peculiar functional di.sturbance of the stomach ; and
we may correctly speak of " gouty dyspepsia ;" we
'lo not mean that the disea.se of the stomach is an
-sential part of gout, but that the state of the sys-
tem, which i.ssiu's in a paro.xysm of gout, also in-
duces characteristic dyspop.sia. And, although the
secondary changes which follow the ab.sorption of
food into the bloo<l have more especially to do with
the proximate cau.sc of gout, still the primary .solu-
tion of food ha.s'al.so a causative relation.
In patients so aftccted, 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 j)reternaturally 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 tlie 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 GOLTY 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
I0.SS of consciousness; or, again, aching pain in the
loins and in the limljs occurs, as neuralgia or scia-
tica ; or, there is irritability of the bladder, and, in
persons advanced in life, the symptoms of stricture.
We liave witnessed the gastric aflcction so severe
as to simulate the dys|>epsia of organic disease, and
these symptoms liave entirely disappeared with the
lessened tendency to gouty attack.
There arc, however, two symptoms ol gouty dys-
pepsia wiiich deserve especial attention, namely,
irregiihir action of the heart, and severe paroxysnuil
])uin, known as "gout in the stomach," or if in the
bowels, constituting a severe form of colic. The
cIo.se symjiathy of the cardiac jilcxus of nerves with
the large nerve centres of the alniomen is frequently
slu)wn in this dyspepsia ; the i)ulse becomes small,
irregular, ami intermittent, and tlic patient is dis-
tressed by jtali)itation, and by breathle.ssness on
exertion ; he is disturbed at night by V)roken 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 dyspnwa on taking any
exertion, even on stooping to tlie ground or knoel-
in<;. 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 the foot, as well as in the small
joints of the hands ; after a few days the gout sub-
sided, without any return of aWuminal jiain.
It is when these anomalous dys|>cptic 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 prinuiry assimilation are found to be very
easily disturl>ed.
In chronic gout, degeneration and contraction of
the kidney often occur; albuminuria is found to
exist without dropsiail ctYusion, and the gastric
symptoms arc greatly a^'gravatcd. 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 arc 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 GOLTY 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 o.xygen tends not only to invigorate and
strengthen, but to remove eflete material.
I have tried the .salts of lithia in these ca.ses, 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, ^rhe dose of these salts, as the carbonate or
citrate of lithia, is five to ten grains with aerated
waters or with vegetable infu.sions. Equal, if not
greater, benefit ari.scs from the use of the iodide of
])otassium 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 unaftected, the
trastric symptoms diaaj)|x;ar when the pain ceases;
and the patient rigljtly states, that as soon as the
l)ain has subsided, a liearty 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 branciies of the jmeumogastric nerve also pass
directly t<> the kidney ; the stomach also receives its
nerve suj>|»ly fn^m Intth 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 gaslro- renal disease is from
organic dist^ase of the kidney; the blood is imj)er-
fectly purified, urea is retained in it, and as a symp-
tom of this urii'inia, 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, nau.sea 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 antemia
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 oedcmatous
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 uraemic 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 cedematous, and the serous discharge pro-
duces irritation, disturbs the ordinary functions,
and exliausts the patient. With renal dyspepsia,
other cerebral symptoms are often conjoined, as
occa.sional momentary loss of consciousness or epi-
leptiform attacks; the senses are also aftectcd, and
amaurotic symptoms come on from degenerative
change of the retina ; the hearing is perverted, and
ringing or other noises arc excited as subjective
phenomena; these pcrvcrte<l sensations are followed
by general diminished power of the sensory organ
aft'ectcd. 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 actitc or chronic renal aft'ection ; we have
seen numercms instances in connection with the in-
temperate u.sc 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
Avith 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 <lisca.sc. The resin of
jalap sometimes protluces more certain result than
the powder.
Aj/ain, I have had several ca.scs of this kind un-
der my care, in which erysipelas of the lower ex-
tremities and alxlomen has l>ecn followed by
marked relief to the renal and gastric symptoms.
It is scarcely ncccssiiry 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 tlic 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 j^ylorus, 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
(.Icsk, or against instruments used in mechanical
occupations; but a frequent source of displacement
is internal, Jind consists in abnormal intestinal ad-
hesions. The stomach is naturally placed almost
horiz«nitally, the pyloric l)eing 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.
Wiien the lower ribs are firmly compressed, es-
])ecially during active growth and development,
the stomach assumes an almost vertical jxjsition :
the pylorus is then i)ressed downwards to tlie um-
bilicus, and the natural churning movements of the
stomach, as well as the passage of the fooil along
the lesser curvature, and backwards towards the
cardia by the greater curvature arc interfered with ;
the semi-formed chyme gravitates unnaturally to-
wards the pyloric valve, and portions pass into the
duodenum before they liave 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 di-scasc — 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 mcehan-
iciil pressure greatly aggravates the gastric disturb-
ance. The patient becomes physically unable to
take fo«xl: pain, eructation, and a sense of almost
insufterable distension are pr(Kluce<l. When the
nui<l or the pressure is lessened, the symptoms sub-
side ; and we have very frequently noticed that the
stonuich has suddenly regained its power after para-
centesis alxlominis had l>een performed. Abdomi-
nal tumors whctiier carcinomatous, hydatid, or of
any otiier kind, sometimes exert pressure upon the
stomach, an<l thus meciianically interfere with its
healthy action.
3. As regards the changes in the coats of the
stonuich, they l>elong so exclusively to organic dis-
eases that we shall not enter upon the con.sideratitm
of them here ; but it nuiy Ix; 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 tvilliout
such valvular obstruction, the muscular coat be-
comes sometinics 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-
ingr 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 nut our uttcnliun to describe tlic nerves that
supply the stomach, but only to state that this
supply is from two sources; first, from the large
branches of the vasomotor 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. 218
and at length acute liydroccphalus 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 anotiier class of ca.scs, 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
involuntar}" 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 resonaoce 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
arlvanced 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 bo argued by some, that the gastric al-
together precedes the pulmonary mischief, and that
in the weakness from the impaired power of diges-
tion wc have the cause of the low organized deposit
in the cell structure of the lungs. If such were the
case, tlie gastric <liscase would continue at least pari
pas.sii 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-
jTCSted nmcous mcinV)rane bcin": observable alons
216 SYMPATHETIC DYSPEPSIA.
the margins of the teeth ; nausea, loss of ajjpetite,
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 arc 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
uni<m 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 liright's disease and albuminuria, in which
the changed character of the gastric secretion leads
to vomiting and other signs of stomach disturbance;
but we woulfl notice cases of calculus in the kidney,
in which vomiting is a constant and characteristic
symptom, though evidently not connected with sim-
j»le disorder of the stomach ; foe patients often state,
that when the pain has subsided, they can digest a
hearty meal, as we liave 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-gcn-
ital organs set up vomiting, is a fact familiarly
known. Many persons, during the whole period of
utero-gestation, suffer severely by this sympathetic
lit
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 Avorse 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 Ave 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 unlit 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. Hydroc^-anic acid, with alka-
lies, acts also as a sedative, and lessens irritability,
so also bismuth.
SYMPATHETIC DYSrEPSlA. 219
In renal calculus, alkalies with rest are the most
likely measures toallorJ relief, after having quieted
the pain by chloroform, ether, or opium. S<mie-
times the inhalation of chloroform, may Ikj advan-
tageously used, es|x?cially if the im pro vet! method
be employed, namely, of mixing the chloroform
with atmospheric vajior, in definite proportions,
l>efure the inhalation ; the object to besought for is,
by so diluting the chloroform, as to allow of its
very gradual absorption, and in this way pain may
l)e removed without narcotizing the patient; <>r a
free dose of lialtley's sedative solution of opitim
may Ik; combined with tincture of henbane and
chloric ether. Belladonna may also be tried. The
hyp<Klermic method of employing morphia is a
valuable moans of quickly sulxluing the intense
pain, and sometimes an opiate enema may Ix; used
with advantage. The bowels should l>e 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 aci«ls, with chloric ether are per-
haps the most efYectual means of relieving vomiting,
although too often inefl'ective 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 tlie
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 dysmcnorrha\T. 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 ; tlic 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 DVril'EPSIA. 221
than vomited. These ca.ses 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 laudanuni, and a tiil)lespoonful 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.
222 SYMPATHETIC DYSPEPSIA.
I have often found tlie 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 dilate 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 stomacli in some of these
SYMPATHETIC DYSPEPSIA. 223
cases of extreme sympathetic irritability. This
condition is, however, so frequently associated with
an aniemic, 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
cessiition of the symptoms.
There are several other conditions of dyspepsia
wliicli 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, anx'sthesia, incapacitv
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, tlic 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
sliglit 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
Ik; freely acted upon, so as to unloatl the colon ; and
the diet should be sustaining without being of a
stimulating character. If there be any direct pres-
sure upon the guTn, 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 apjdication ; exercise in the open
air is desirable, esj>ecially horse exercise ; hot rooms
a!iil exciting plea.«<ures should be avoided ; and w Immi
it I'UM Ik" attained, .several months of travel and
change of scene are greatly c<»ndiK'ive to complete
restoration of liealth.
T/Css severe, but more distressing, is the dyspej>sia
in hyj)ochondriasis. 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 ilelicient 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 tlie 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 DYSrEPSIA. 227
CIIArTKR XV.
FERMENTATIVE DYSPEPSIA.
The clicrnistry of digestion is a subject full of
interest, and one tliat has received considerable
tlucidation frmn the resca relies of later years, Tlie
food Ix-gins to undergo change as soon as it is
bnmght into contact with the secretion from the
salivary glands, and })assc8 through the process of
mastication, but this is especially the case with
starchy and farinaceous substances, which are con-
verted into sugar. Tlie 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
-accharine princij)lc is produced; the saliva also
contains sulphocyanidcs and a large quantity of
saline material. Thus, thorough mastication serves
a double purpose, not only to break down the solid
|iortions of food, so that they may more readily
undergo solution by the gastric juice, but to incor-
porate the salivary fliiid, 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
1
FERMENTATIVE DYSPEPSIA, 229
trrrn peptone has been applied to it, and the whole
sohjtion has been designated chyme.
The chemical solution of the nitrogenous portions
of foml by the pepsin is limited, but it is greatly
increased b}- the presence of the acid of the gastric
juice, and by tlie heat of the stomach and the churn-
ing movements of the muscular walls. The food
rotates along the lesser, an<l then from right to left
backwards by the greater curvature; as the chym-
ous lluid is formed, it pa.s.scs by the pyloric valve
into the (huxlenum, when it is mixed with the bile
and with the pancreatic secretion l>eforc it reaches
the jejunum and ileum, ami is absorbed into the
system by the aijullary veins and by the villi of the
intestine.
This process of solution or digesti<in rt'i[uiros ac-
cording to the nature of the fo«Kl, from two to four
or five hours; and many substances that are taken
cannot be dissolved at all, but pass in tiieir cruile
state into the intestine; and altliough the solvent
powers exerted by the gastric juice are especially
upon the pri>tein eonipoiinds, — the nitrogenous ele-
ment.s, — still the changes upon the starchy portions
commenced in the mouth arc not entirely checked ;
the oleaginotis elements are more thoroughly
divided, and the saline and aqueous constituents are
diffused completely through the semi-fluid aliment.
20
230 FERMEXTATIVE 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 carbu retted 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. 281
tlie muctis secretions themselves ; 4tlily, transuded
from the blo<xl ; othly, regurgitated from the duo-
denum, or from a fistulous communication with the
colon, or from some adjoining abscess; Othly, gas
of an offensive kind is produced by the decompo-
sition of a gn^Nvth in the stomach, as cancerous
tumor.
The first form of gaseous distension that we have
to notice, is r^uitc independent of focnl, or rather is
frequently produ(;cd 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
jicculiarly marked in hysterical patients, and in
others it may be induce<l by mental excitement or
depression, and abstinence from fo«)d is a very
common cause of it.
This form of dysj>epsia is of an atonic character;
the want of power being due either to general loss
of strength, or to delicient 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 tiie 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 Avith 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
comj)are<J to the fermentation produced bv 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
disca.se, to have the sarcina ventriculi of Goodsir
present. These minute conforvoid growths, in
their bale-like quadrangles, apj>ear to indicate some
peculiarity in the fermentative proccs.'^, 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 tlie 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 tlie fermentation to which we have
referred is the primary disea.se, 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 sj>asmodic contraction at the
pylorus, secondary clianges 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 stoj) 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 iu
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-
FKRMENTATIVE DYSPEPSIA. 235
ary forrnontativc changes in the colon ; and given
by the mouth, we have found it of greater value in
intestinal tiian in gastric distension, fur the latter
we could obviate by more agreeable treatment.
Another form of fermentative dyspepsia results
in the pnxluction of butyric acid. This organic
acid is closely allied to lactic acid, and it is that
which gives the [>oeuliar sourness to the VDtnited
matters in dyspepsia. Fatty matters, milk, chee.se,
especially when the.se are partaken of in disordered
conditions of the digestive ajtparatus, k-ad to this
chemical change, and butyric acid is formed.
The symj)toms are severe heartburn, regurgita-
tion of food into the thn»at, pain at the scrobiculus
cordis antl 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
niav be more persistent an<l is then most trying to
the patient ; almost everything that is taken be-
coming, as thesulVerer 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 eflectually relieve
the j^ain 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 distres.sing 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 c(»mmences before it
passes fn)m the slomach. 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 sympt«)ms resembling those pnxluced 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 XVT.
DUODENAL DYSPEPSIA.
The dufKlcnum, the commencement of tlie small
intestine, may be divided into three parts : its 1st
and horizontal position, its 2nd and vertical, and its
.*5rd again horizontal, as it joins the jejunum. The
1st part is intimately connected with the stomach,
in its physiological as >yell as in its pathological
relations; the 2nd with the liver and the pancreas;
and the 3rd with the intestines.
The pyloric valve sejjarates the stomach from
the duodenum ; this valve receives nervous supply
from the pneumogastrio, and so also does the first
part of the duodenum, and consequently diseases
aflfecting the mucous membrane of this {tart 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
diagno.sed 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 ceso-
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
if.' However it may be pro<luced, pyrosis or
water- lirasli is a distressing symptom to tlie patient,
and is often associated with a state of general
dyspepsia. We have previously referrdd to it as a
symptom of gastric di.sease.
'J'licre are two forms of duodenal dyspepsia that
requires especial consideration; the one arising
from excessive irritability of the mucous mem-
brane, the second from inllammatory congestion.
Great credit is justly due to M. (Jorvisart for the
investigation he has carried out in reference to the
fiiuctioM 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 nlceration. 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 symj)toms
are due to an unusual sensibility of the pyloric
DUODENAL DV.SPEl'.SIA, 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 ])art of the duodenum is
closely allied in function with the stomach.
That this state may j)recede one of organic change,
and be followed by ulceration of a serious kind, is
d(jubtlc8s the case; but with care, we have known
the symptoms entirely subside. After years of free-
dom, they may return, but again yield !«• Juilicious
treatment.
The condition we have just described is one in
which the strictest attention to hygienic rules and
to a restricted dietary is es.*;cntial to restoration.
'I'he diet should be of a bhnul, unirritating cha-
racter. SufTicient time should elapse between the
meals, and stimulants should be avoided if possible,
especially ardent spirits and malt li(iuors. Physical
rest, ill a iTi'iiiiibcnt jxtsition, is also important; for
exrrtion 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. lie describes diarrhoea
and the discharge of blood, as having arisen from
this condition of the duodenum, and sometimes
severe liasmatemesis and prostration. In some in-
stances of severe burns, death has taken place as
the consequence of perforation of the duodenum,
causing peritonitis. 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 tliis 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 j)unctate 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 hypera3mia is ob.scrved in connection
with pulmonary and hepatic congestion — in fact, in
any di.sease which leads to distension of the vena
jtortii;; and we also lind a less general condition of
vascular repletion of the lirst 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 l)ecomes thick-
ened, its ves.sels 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 raucous mem-
brane, as we find in other similar structures.
This state of chronic engorgement is best relieved
by diminishing jiortal and hepatic congestion, and
by stimulating the abdominal excretory organs to
increased action, as we have described in speaking
of congestive dyspepsia.
246 DUODENAL DYSPEPSIA.
There is, liowever, a state of acute hyperiemia of
an interesting kind described by Sir H. Marsh and
by Dr. Stokes. It is induced by exposure to coki,
by great mental anxietj^, 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 hyperoemia 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
DIODEXAL DYSPEPSIA. 247
depuration of tlic blood being consequently inter-
fered with.
The pain in these ca.scs is nuich less than in gall-
stone; and the disea.se ditVers from ordinary inflam-
matory jaundice in the in<Mje of commencement,
the symptoms being at first those of intestinal or
gastric irritation.
The prognosis is generally a favorable one, unless
tiie cerebral symptoms become inordinately severe.
In some instances general hepatic disease has been
induced.
The treatment musi \)c directed to ([uict the irri-
tation of the stomach, and to relieve the hyperaitnia
of the artected parts. As to the former, scarcely
anything must be administcrod by the mouth.
Soda-water and milk, arrowroot, broth, and similar
forms of diet, aro alone admissible. Alkalies, as
lime-water, etVcrve.^i^cing citrate of magnesia, carbo-
nate of soda with iiydrocyanic acid, also .^erve in
some degree to soothe the stonuich. A free mercu-
rial j)urgative 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 tlie general
law, that when one part of the body is aflfected 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
P3"lorus.
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-
IfKGEXEKATION 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 xcastimj. — Sometimes the cells of the fol-
licles, instead of presenting a simple nucleus, con-
tain a <rroat number of highly refracting particles,
and almost resemble an inflammatory granule cell,
while the aj)poarance 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 arc collected highly refracting granules and
fatty particles, giving to the vertical section the
aj»])earancc 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 atrojihy shows the follicles to bo en-
tirely destitute of secreting cells, only containing
granules of fat.
:'. 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
atTected. With the iodine test, the mucous mem-
250 DEGENERATION OF THE STOMACK.
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 jmri 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 Jihroid
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 j)arts. The disease appa-
rontly commences in the submucous cellular tissue,
which undergoes fibrous thickening, while the mu-
cous ('oat 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 meml^rane is
whitish in color; it is firm, sometimes almost car-
tilaginous in hardness, but without any "juice" as
cancer ; it c»)nsists of elongated or wavy fibres, re-
sembling a fibroid tumor, and with acetic acid it
j)resents 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 memljrane
of the stomach may present a gray and thickened
appearance, and simple chronic ulcer or the cicatrix
of one, are occasionally jirescnt. 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 afl'ected.
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 diagnijsis 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 dr) wc lind in tlie former
disease the peculiar (uichoxia of mali^aiant diathesis.
As to Irratincnl, although we cannot remove the
obstruction, we can often aftbrd relief to the symp-
toms, and greatly prolong life. The change from
solid and irritating foo<l to that of a llnid 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 aftbrding 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 l)y other remedies, by car-
bolic acid and by creasote, by the sulphite and
22 t
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.
ULCEKATION OF THE STOMACH. 255
CIIAPTKR XVTTT.
ULCERATION OF THE STOMACH.
DYSl'ErsiA iH jHtr cxcclUnce tlie symptom of ulcer-
ation of the stomach, for tlic j)r<x;ess of digestion
is then especially diflicult 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
the.sc in describing the varieties of dyspe|)sia, with
some of which they may be associated.
1. Ulceration may 1)C the .sequence of acute in-
flammation, and may be connected with ab.sce.ss, or
with sloughing of the surface ; these are, however,
instances of an unusual kind, and are cau.sed by
local mischief, or by poi.sons or irritating sub-
stances.
2. Although diphtheritic inflammation docs oc-
cur in the stomach, it is of rare occurrence. Dr.
Fcnwick 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 arc 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
hiemorrhagic erosion^ and is especially observed in
ULCERATION OF THE STOMACH. 2o7
chronic catarrh of the stomach, and is caused by
the long continued congestion of obstructive disease
whether in the lieart, lungs, or liver. The intensely
congested capillaries having given way, blood is
eft'uscd 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 pnxluccd, 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, wo have that
state which is especially meant when we speak of
vlrrr of the stomach. It lias been variously desig-
natcMl as simple ulcer, chronic ulcer, perforating
ulcer; and in its consideration the description of
the symptoms is facilitated by dividing into two
classes : —
1. UlceraticMi perforating without adhesion, and
2. Ulceration perforating when adhesions have
taken j>hiet'.
AVheu the coats of the stomach arc 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 tlius 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 long-
ULCERATION OF THK STOMACH. 250
continued irritation effusion takes place at the
eilge.s ; this product becotne.s firm, it is fibrous in its
character, and as it increases it incloses fibrilUc of
the pncumogastric nerve, thereby producing severe
pain. The ulceration slowly increases in size, so
that the ulcer may vary from the size of a four-
jifuny-piece to that of a crown-piece. Dr. l^iw
mentions one six inches in length. The peritoneal
surface, the lowermost in the stomach, also becomes
at length destroyed, and tiie floor of the ulcer is
then forme<l by the tissues, the adjoining viscera,
to which adhesions liave taken place. It may be
that the lioor consists of one structure, more fre-
<|uently, however, of .»<evcral parts covered by a
thin stratum of fibrin. If the disease be at the pos-
terior aspect, the pancreas forms the greater portion
of tiie ba.se ; if towarils 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 (lia])hragm, or several of the.se j)arts com-
biiHiJ. 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 tiine. 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. 201
into the sac of the lesser omentum, and a large
fecal abscess, which extended into the lung, had
formed. Dr. II. Davies records a case of simple
chronic ulcer extending into the colon. There
had l)cen dyspepsia and fecal vomiting whenever
the bowels were confined. The patient gradually
sank.
Tiie V)a.se of the ulcer, or the cicatrix as it migiit
be termed, when a healing process has taken jdace,
is 8m«wth, of a whitish color, and consists of tibro-
elastic tissue, or it has a minutely granular apjx'ar-
aiico. The edges Ixjcomc exceedingly firm, and are
composed of dense fibro-elastic tissue. Minute
librillio of the j>neumogastric become involved in
this tissue, and thus cause severe pain ; sometiincs
the tierves pass along the lloor (»f the nicer, ami
when shiughing follows, j)ain suddenly ceases from
the destruction of these .sensitive and exposed
nerves.
Glandular mucous membrane is injt re-foniaHl in
these cicatrices, and when the liver or ])ancreas
ri)rms part of the boundary of the ulcer, tiieir 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^t 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 ftital. Several attacks of
bleeding may take place, and where an nlcer-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,
loth 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 paj»illary eminence.
The form of the stomach is often greatly changed,
cither by adhesions external to the viscus, or by
contraction of the wall.*? of the ulcer. When the
ulcer is situated in the centre, the cavity may ap-
pear double like an hour-glas.s, from puckering at
the scat of the disea.scd part, and fn>m irregular
contraction.
Tuo or three ulcers sometimes exist in the stom-
ach. A large chronic ulcer may have l^en the
source of much suflcring, but a second and smaller
one may be more serious by inducing sudden hem-
orrhage or fatal i)erforati«)n. 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 tlie site of the disease, the ulcer is generall}'
at the lesser curvature, towards the anterior or
posterior aspect. If in the former part, it has a
greater tt-ndcncy to produce perforation; if in the
latter, hemorrhage. The ulcers are situated nearer
261 ULCERATIOX 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
At the pyloric sac in
At the middle sac in
At the lesser curvature in
10
13
18
At the anterior and posterior surface at onco in 28
At the cardiac extremity in . . . .40
At th<' 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 OK THE STOMACH. 265
my own immediate notice have been more advanced
in life, than those who were tlic subjects of ulcera-
tion of the stomach. Dr. Brinton has collected
Htati.stica from a large numlxjr of cases, and he shows
that the ulcer generally "aft'ects the periods of
middle an«l advancing life, with a frequency which
gradually itu'rea.»ies uj) to the extreme age allotted
to man," Hut the ca.scs of ulcer in which perfora-
tion hap{)en.H, "seem.** not only to select another
|H'ri«Kl of life, but to exhibit a marked contrast of
age in the diflerent 8cxe«, the period of life in which
it is most liable to occur ))cing quito a dilTerent
rj)och in the male and in the female," in the female
In-ing Ijctwcen the ages of 14 and .'iO, in the male
from 50 to 60, the diminished risk of the female at
the latter j>cri<xls of life rendering the total risk in
the same numlwr of cases nearly eqtuil. Dr. Ix'es
nientions that he has seen j>erforation of the stom-
ach from ulcer " in a girl of eight, and a boy of nine
years of age."
The symptoms t)f \ilccration of the stomach may
l>e 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 aflectcd with chlorosis and amenorrhcea, or
23
266 ULCERATIOX 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 j»ain in the abdomen becomes gene-
ral ; tympanitis folK)ws, 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 ; Virchow 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 leucorrhcea arises probably from
the connection of the splanchnic with the dorsal
nerves.
ULCERATION OF TUE STOMACH. 267
The cause is equally obscure as to the part of
the stomach usually afFcctcd with ulceration. "Whv
the le-sscr curvature, either at its anterior or pos-
terior portion, sliould be so generally involved, is
not known. This is the part least free in its move-
ments— in fact, it i.«« almost stationary — the stomach
in its geneml expansion and consequent movement
turning up<»n its lesser curvature. This also is the
region along which the branches of the pneumo-
gastric nerve pa.ss.
'i'lic symptoms <»f rhronic ulceration arc at first
those of ordinary dyspepsia, and arc often very
<»bs<'uro, and imperfectly markc<l. Thus .slight
uneasiness after AmxI and constipation nuiy be the
Illy cviflencc of disease. Afterwards, the pain,
with tenderness in the region of the stomach, cspc-
' ially 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 increa.'^ed by
fo<Hl, and relieved by the rt^jection of it ; vomiting
is therefore generally present, and sometimes jiy-
rosis or water-brash. The other symptoms arc,
pain l)ctween the shoulders, more or less of ab-
dominal uncjisine.'JS, constipation, emaciation, and a
peculiar pallor and cachexia. Ilicmatcmcsis, the
rejection of food by vomiting, and mehcna, 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 2^(^^'>i' 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. 209
contrary, I luive seen the pain continue, whatever
position might be assumed. In young women
suftering 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 ex|>erienced at the scrobiculus cordis
from ulcer; and in these patients we find in-
crea.sc of pain during or j»rior to the menstrual
perioiJs.
Pain in the back is rarely aUscnt 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 it.sclf, the patient often stating that
the pain goes through to the back. In speaking
of the diagnostic value of pain, Dr. Ixies states,
"The occurrence of pain will often be of great a.ssi.st-
ance in the diagnosis Ix-twccn .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 pa.ssage of
food out of this vi.scus." 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 .sen.sc 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 2:)eriodat which vomitiny 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
iiieiit of the sarcina vcutriculi of Goodsir (merisino-
j)o<iia ventriculi. — Ii<jbin) takes place in some cases
of chronic ulcer, as well as in cancer and diseased
j»ylorus. The siircina can scarcely be considered as
a proof of obstruction, for its development occurs
without any impe<liment. Vomiting, however, as a
sign of gastric ulcer, must be regardeil with great
care, since in so many instances it is purely sympa-
thetic in its origin. Pyrosis nUo is often present in
disease of a less serious character, and is amongst
the signs of functional disturbance.
Clironic disejuse of the alKloiuiual viscera is
marked by an anxious and dejected countenance,
with emaciation; in ga.><tric ulcer this apj)earance
is present, and is a.'^sociatcd with jmllor arising from
the condition of general nutrition. In cancerous
disea.^e, a careworn expression is found, with cache-
tic «u//oM7i<'55; and in the an;emia of chlorosis and
amenorrhu'a there is in extreme ca.ses a waxen aj)-
jK-araiHT, which is very peculiar; so also in the
jliKiiiiia after considerable h)S.s of blood. Again, in
irumy Instances of struma and of glandular disoa.se,
pallor is present; but in ulcer of the stomach, the
anxious countenance of abdominal disease, con-
joinrd with the emaciation and j>allor of imperfect
nutrition, atVord a very characteristic morbid ex-
])re.ssi()n, 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 })cr
rectum, a black tarry evacuation is the result.
Sometimes, however, the whole of the blood is thus
discharged, and there is melana without hasmate-
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
rLCERATION OF THE STOMACH. 273
of gastrod ynia 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 cancerou.s disease ;
and although less frequent in cancer than in simple
ulceration, it does occasionally arise. Disease of
the oisophagus and aneurism sometimes produce
the- same .symptom.
Alxjrcrombie distinguishes three mo<les of fatal
termination of ulcer of the .stomach. 1. Gradual
exhaustion; 2. Hemorrhage; and 3. Perforation
into the peritoneal cavity. Another might al.so be
mentioned: the pnxluction of inllammation by ex-
tension to adjoining viscera, as in a ca.><c in which
the (li.sease extended through the diaphragm into
tilt; lung, and pnxluced acute pleuri.sy. The dis-
ease, however, sometimes remains in a pa.ssive con-
dition, and the j)aticnt 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 difterent. Setting aside
27-i ULCERATIOX 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 haimatemesis, 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 scat of cancerous deposition ; but seve-
ral instances warrant such a supposition.
There is much obscurity as to the caiise 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
liirity 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 an.xiety, .scanty food, late hours at night,
and insuHicient exerci.se, pressure upon the .scrobi-
oulus cordi.s, either by direct girthing of the abdo-
men, or by constant and crmst rained position, as in
milliners and shoemakers, or the striking of the
epigastrium by the .shuttle of the weaver, are also
cau.scs (»f gastric ulcrr. The cau.ses of the sudden
perforating ulcer arc still more doubtful, as we
have previou.sly intimated.
There are several objects to be .sought for in the
(rrntment of ulceration of the stomach.
1. The promotion of re[)arative action by sustain-
ing and increasing general nutritive power.
2. The relief of distressing symj)toms, pain,
vomiting, hemorrhage, pyrosi.s, constipation, etc.
3. The prevention of the extension of the di.sease.
4. The removal of its complications.
1. Tlie promotion of reparative action is in
many instances most efltcctivcly secured by allow-
ing the atVected organ to rest; and much more can
be done in this way than is usually suppo.sed. If
ab.solute rest could be aftbrdcd, the ulceration would
in many cases rapidly heal ; but, since this is almost
impo.ssible, it must be<^tir 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 secretion 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. 2<7
absorption. Good stale bread, biscuits, milk, starchy
substances, as arrowroot, tapioca, maize or Indian
cornflour, rice, etc., may thus l^e given to the pa-
tient. Eggs often disagree, but may be taken in
tlic form of light puddings ; milk, also, when re-
fu.«;ed in its simple character, may be better tolerated
by combination with isingla.ss, 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 advisiible to avoiS
both saccharine and farinaceous food, which easily
undergo fermentation, and for a time at least to
allow only milk with so<la-wa1cr, and ciiickcn or
mutton broth.
Rich soups, highly seasoned dishes, pepper, mus-
tard, etc., are bettor abstained from ; so also pas-
tries, and food containing much insoluble material
as salad.s, 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. r)ranges, 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 sjmcope ; 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 ancemic
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 STOMACK. 279
citrate. The compound steel pill, with aloes and
inyrrh, 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 irrital)ility of the stomach
itself. And this leads us to the consideration of
the moans we possess f(^r the mitijdtion of distress-
iivj syviptums^ jiuiii, vomiting. iMMnorrhage, pyrosis,
constipati<^n.
For the relief of y>a<"«, 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 tiie solutions of the latter.
Chloric ether, in doses of 10, 1') to 20 itl, will be
found very efficacious, especially when combined
with nitrate of bismuth and carbonate of soda in
H>- to 20-grain doses. Tiic 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. Chlorodyne is spoken of as
being a valuable sub.stitute, 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 b'jen 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 ni 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 eftective
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.
Vomitinfj is a very distressing symptom in many
cases of ulcer of the stomach. It is best combated
LLCERATION OF THE STOMACU. 281
by only partaking of fluid diet, and of that in
moderate quantities. Tiic remedies we have al-
ready mentioned arc of service, but especially bis-
muth, hydrocyanic acid, creasote, ice, and alkalies.
Sir \V. Jcnncr has pointed out the value of the
sulpiiite of soda in checking tlie fermentative action,
and the development of siircinie 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 /or 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 rub])cd in so as to jmxJuce pustular erup-
tion ; some even use a seton ; but I think that
milder remedies may attain the same beneficial
result with less suftering 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
thore is lu'morrlin^-^e without great irritability,
24*
282 ULCERATION OF THE STOMACH.
small doses of turpentine Avith 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
Dinneford'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
ULCKRATIO.V OF THK 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
• onstipation with ga.^tric d»ease minute doses of
strychnia, or of the extract of nu.v v»»mica with
aloes, are useful, not only fn>m their astringent,
but from their tonic eflcct.
In order to carry out the third indication of
treatment, namely, to prevent the extension t»f the
<iisca.se, sudden and violent exertion should Ix;
gimrded against ; the stomach must not be dis-
tended by large meals; and the formation of
gaseous protlucts by fermentative changes ought
to be counteracted by a well-regulated diet and by
medicinal agents.
I. The complications of gastric ulcer, arising from
its extension to neighboring parts, are of a mo.st
serious kind, and reriuirc most careful treatment.
When perforati»)n has taken jtlace, and the symp-
toms of peritonitis iiavc been suddenly produced,
there is still slight chance that life may l)c j)ro.
long('(l ; the patient should not be moved, nor any-
thing introduced into tiic stomach, except a tea-
s{)Oonful of water or milk to assuage thirst. Opium
must be given freely, as recommemled by Dr.
Stokes and Dr. (iraves, so tliat 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.
I
CANCEROUS DISEASE UK THE STOMACH. 285
CIIAPTKR XIX.
CANCEROUS DISEASE OK THE STOMACH.
The stoniacli is one uf the organs most frequently
jilVeotccl with cancer; and in tliis frequency a re-
markable contrast is presented when compared with
the rarity of strumous disease of the same organ.
Mvery 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 melanoid varieties are less
constantly observed. It is seen, however, that these
varieties j»ass 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 tht;
mucous memVjranc of the stomach, or its submucous
tissue, or it is |»ropagated to the stomach by the
aflection of the glands in the neighborhood of the
pancreas; and the pylorus, lesser curvature, and
cardiac extremity arc the parts generally affected.
2S(5
iWNrKlUMS IMSKASK
\Vo aro not .'U\\uaintoii with tho dotormining
Oiiuso ot' tho tonus ot oanoor, or whothor tho o[>iuion
which is luaintaimHl bv somo pathoh\uisis oan ho
ostablishoil. thai soirrhous is oomiooioil in its origin
with tho tihroiis tissuosot' tho part nu\liiUai'v willi
tho muoous siirlaoo or glaml sinuMiiro. aiul ov^lUn*!
ospooially with tl»o hittor v>r. wholhor thov aro
ratlior indioativMis ot" tho intousity ot' tho morbid
aotioiu It wiMiUl sooiu that soirrlious ilisoaso is h«ss
roinovoil tVom tionnal mitritixo ohaiiuo than inodub
hiry oanoor ; in tho i>no thoro isa i^roator »HiH>sitiou
to ton\i libroiil tissuo, anil in tho othor tho growth
is oolhihir or mioloar.
IHiring tlio cai'lirr stngos of oanoorous ilisoaso ot'
tl>o stoniaoh. I'spooially bot"ori> any growth oaii bo
dotootod on inanipuhitivo oxainination, tlio si/ntp(oviS
aro ot'ton oxooodingly i4»souro. It may bo ooti-
voniont to arrango tlio symptoms into throo
divisions, aoooriling to tho rospootivo stagos ot' tho
disoaso. Tho tirst is tho stai;o i^t" ori;anio dyspopsia
botoro tho dovoU>iMnont ot' any tunn>r; tho sooond
is that ot' abiuM'inal i;r»>\\th ; and tho third, tho tbs-
intogration ot' that grvMvth by ulooraiion or sKxigh-
ing.
Tho tirst symptom^ aro otton dooojMivo and ob-
souro, tliov aro thoso o[' dyspopsia, and witli it
tlioro is ji poeuliarly s;iUow anil anxious oxprossioii
OF THE STOMACH. 287
of countenance : pain at the stomach may be en-
tirely al^sent, or there may be severe gastrotlvnia ;
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 scat of obstruction or irritation of
the gastric surface, either a short time or several
hours after a riiciil. 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 o'sophageal disease. The pain also be-
comes more .severe, and is generally of a more lanci-
nating character than that ex{>erienccd in chronic
ulcer of the stomach. The vomited matter.'^ are often
frothy and fermenting, and present us with abund-
ant .<arcina vontriculi. ILcmatemesis is occasion-
ally present. Flatulence distresses the patient, and
eructations are frequent; the bowels become con-
sti{>ated ; emaciation steadily advances, an<l the
countenance Injcomes more haggard and aichectic.
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 slougliing of tlie growth, and
subsequent septic changes in tlie blood; the patient
in such a case becomes rapidly prostrate with
typhoid symptoms, the breath is oftcnsive, he is
seized with hiccough, and pneumonia of an asthenic
kind is induce<l : .'id, the fatal termination may en-
sue from hemorrhage; when the ulceration pro-
duces only slight oozing of blo<j<l, the hivmatine
l)ccomcs blackened by the gastric juice, and we find
that the vomited matters have the appearance of
coftce-groun<ls; but if a larger vessel have l>ecome
divided, the efl"usion of blood is more abundant,
sudden pallor is pnxluced, and blorxl may be rc-
jecte<l by the mouth, or i)ass as a black semi-fluid
dejection from the bowels, or, again, without dis-
charge of any kind, fatal syncope may at once take
jtlace ; 4th, the «*.\tension of disease to adjoining
juirts may greatly m<Klify 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-
fluccd ill the serous membrane, or ascites iii;iy fol-
li)u . When sloughing extends to the surrounding
parts, the colon, the skin, or the dia{)hragm may
be perforated ; of these parts the transverse colon
is most frequently invaded, it becomes adherent to
the stomach, and a valvular and sloughy comn)uni-
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. Miirchison, on the con-
trary, and wc 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, aftecting
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 TIIK STOMACH. 291
coinc infiltrated, and in tliis respect contrast with
the condition which we lind in libroid 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
Ixj exceedingly slight; so also when the central
portions of the stomach or the cardia arc aftected.
The symptoms of gastric cancer are modified by
.several circumstances. 1st, by the position of the
iliscase; 2<1, by its character; 3d, by its origin,
whether primarily afl'ecting the stomach, or second-
arily by extension from adjoining jmrts ; and 4th,
l)y the va.scularity of the growth,
1. The ]>os'(i(>n. If the disease be locate<l at the
central part of the organ, and the orifices be free,
the symjUoms may be exceedingly slight, and un-
recognized lor a longer peri(Kl, than if the orifices
are affected. Vomiting is absent, or only occasional ;
and the j>rominent symptom may be continued and
profound cachexia, with progressive emaciation.
]f the cardia is diseased, the vomiting occurs im-
mediately after food, so that the symptoms resemble
cancerous disea.se, or obstruction of the (esophagus.
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
syn),ptoms 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 })ylorus 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
pncumogastric may be traced tlirough the medul-
lary tumors of the stomach ; and cither 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 tlie
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; 0, cancerous disease of the
jtancrcas; 7, similar disease of the omentum; 8,
affections of the transverse colon ; 0, local peritoni-
tis ; 10, fibroid disease of the pylorus.
The symptoms of cancer closely resemble those
of r/iroiiic xiker of the stmnach. Botli 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 c^inccr, but in the
2^*
294 CANCEROUS DISEASE
closing stages of cancerous disease the rejection of
coft'ee-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 gnawingr
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 gcncrallj 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 int(i 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. Vtowi
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,
OK THE STOMACH. 295
etc., are very frequent at a period long antecedent
to the age at which cancer generally manifests
itself: dy.spepsia being exceedingly common among
young females, whilst cancer is almost unknown.
In ancurismal disea.sc in the gastric region, the
stomach itself often sufters remarkably little. Di-
gestion may Ix; .sound, the fotxl Ix'ing taken and
ab.sorlx'd in a healthy manner. The pain of aneu-
rism is of a dift'crent kind, and is uninfluenced by
the diet. It is generally a dull constant pain in the
l)ack, but with severe and even inten.sc paroxysms
at night ; sometimes the j>ain at the pit of the stom-
ach is very severe, and it is increased by exertion
ami movement ratiicr than by food. Tiie pulsation
is uniform, not changed by position. A bruit, if
audible at all, may be .systolic or almost diastolic.
In disiasal tjhnuls at the lesser curvature of the
stomach, the tumor may be marke<l, but the pain
and vomiting are less distinctive than in di.sea.sc of
the .stomach it.self; the latter often becomes involved,
however, bof(»re the close.
In disease of the Uver, also, the position is some
guide to us, so also the ab.sence of severe gastric
.symptoms; but when the left lobe of the liver is
di.scased, and pressure exerted upon the stomach,
the correct diagnosis is very dillicult, jaundice being
often absent in hepatic cancer.
296 CAXCEROUS DISEASE
In infiammation 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 jmncreas, 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
OK THE STOMACH. 207
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 lociil extravasation
has followed so as to form a fecal abscess, the ema-
ciation is progressive, the hectic is severe, pain is
sometimes exces-sive ; and in the certainty of fatal
i.«wue, the disease approaches the character of the
worst forms of cancer; but we do not tind tho ma-
lignant cachexia. The pain is more superficial, and
digestion is less directly disturlx'd than in gastric
disease.
Fiftroifl disease of the jnjlnrus is regarded by some
jis ot a cancerous natiire; still it has neither the
pathological character nor the physical history of
that di.sease. .\s 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 fcxxl at the
close of the digestive proccs.s, from the obstructive
disease of the pylorus, and the presence of sarcin;«
of (loodsir, have led many to form a more unfavor-
able diagnosis than the case has warranted.
The statistical tables of I>r. liriuton 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 tlie
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
hyperiemia 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, |)ill,s are
300 CANCEROUS DISEASE
better avoided, as they sometimes act as local irri-
tants.
Charcoal afifords 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 hrematemesis, by coifee-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 greatl}'- 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 jDaiu 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 COXTRACTIOX OF THE PYLORI'S. 303
traction ; and the malady, by whatever cause pro-
duced, consists, we believe, in abnormal irritability
and contractility of the muscular fibres of thestom-
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
h>owel, the duodenum. These muscular fibres of the
stomach become spasmodically contracted in the
malady under consideration, and especially those
librcs which constitute the pyloric valve.
Whilst pain is the principal symptom of this
spasmodic attack, we find that other indications are
l)resent ; the countenance is expressive of suffering,
l)ut sometimes it assumes a death-like pallor, and
the j)ationt 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 tins 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 we
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
20*
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 tlieory 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 coeliac 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. Gall-stone. — 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 j)yloric 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 uriemic 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 coeliac 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 alone: the srreater
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. With 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. "We 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 SPA3M 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 arc varieties of this
]iainful aflcction which are due to irregular mus-
cular C(Mitraction, and which are very obscure in
their character. The partial contraction of an old
ulcer, or the interference of peristaltic movement
from an old ])eritoneal adhesion, mjiy 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
mdiscretion, 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 lesse7i the
spasmodic contraction, to diminish the irrilahility of
the mucous membrane, and to counteract any known
predisposing cause.
In reference to the first, namely, the lesseninr/ 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
814 SPASM OF THE STOMACH.
dose of opium or morphia in combination witli
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.
Arjmite is one of the valuable agents we possess
ill diminishing many forms of severe neuralgia, but
it lias 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 tlie marked depression in the power of the pulse
which occurs in severe stomach complaints, "We
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, thej' 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 diinimish the ^n•^Ya/;^7^Y?/ of the mucous
membrane, we must direct especial attention to the
diet. Ardent spirits, especially brandy, are often
first emploj^ed 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. Where 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.
Abekcombie ....
Abscess ill parietes
Acid, hydrochloric, in gastric juice
lactic ....
Aconite .....
Age, in relation to digestion
advanced, dyspepsia in
climacteric ...
of patients affected with iilcerat
Alkalies, use of ...
Alcoliol, use and abuse
An<lral .....
Aneurism .....
Atonic dyspepsia
Atrophy of glands
of stomach .
Kai,i,.viu>, Dr. ....
Harlow, Dr. . . . .
lii'Uadonna ....
Howels, disorder of .
I'rain, sympathetic distiirbance of
Breath, state of.
Ihinton, Dr. ....
Burns, congestion of duodenum in
Butyric acid ....
Cancer of stomach .
Catarrh of stomach .
Cerebro-spinal system, sympathetic connection
PAQR
. 273
. g:3
120, 171
120, 1G9
315
31
13G
38
298
124, 128
132, 141
. 38
63, 295, 308
. 135
32, 34
. 248
. 120
. 202
. 315
. 104
G(j, 78, 212
. 100
. 264
. 244
. 235
285
160
41
320
INDEX.
atfe
Cerebro-spinal system, exhaust
Cervical nerves, sympathetic
Chambers, Dr. .
Charcoal as medicine .
Children, hydrocephalus of
Chloroform
Climacteric changes .
Climate, effect of
Colic
Colon, disease of
Congestion, dyspepsia from
Corvisart, M. .
Curling, Mr.
Davies, Dr.
Degeneration of stomach
Digestion, impediments of
periods of greatest activity
Diphtheritic inflammation
Distension of stomach
Dobell, Dr. H. .
Duodenal dyspepsia .
Duodenum, ulceration of
Dwellings, effect on health
Eructation
Exhaustion, dyspepsia from
Fenwick, Dr.
Fermentation, dyspepsia from
Fibroid degeneration .
Fifth nerve, sympathetic affection
Follicular ulceration .
Food, quantity required .
Eraser, Dr.
Gairdner, Dr.
Gall stone .
ion of
ction of
of
PAOB
. 143
. 46
. 82
234, 300
. 47
. 314
. 38
. 108
. 311
296, 309
. U>7
. 122
. 244
59,
66,
. 261
. 248
. 123
. 28
• 255
93, 309
. 122
71, 239
72, 244
. Ill
. 93
. 135
. 255
. 227
. 248
46,47
. 177
29, 30, 114
. 86
. 290
74, 306
INDEX.
321
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
7G
H^MATEMESIS
. •. .83
Hemorrhage ......
83, 256, 272, 281
Hemorrhagic erosion of mucous memhrane
. 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
IsDioESTioN, atonic
. 135
"bilious" ....
. 186
congestive ....
. 157
duiMlenal ....
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 libra
. 32
Jesner, Sir William
. 281
Jones, Dr. Bence
. 105
Dr. Handfield
. 82
322
INDEX.
Kexxedy, Dr. ....
Kidney disease of, dyspepsia from
sympathy with stomach
Lactation ....
Lardaeeous degeneration .
Law, Dr. ....
Leared, Dr. ...
Lees, Dr. ....
Life, periods of digestive power
Lithia, use of . . •
Liver ....
sympathy with stomach
Lungs, sympathy with stomach
sympathetic dyspepsia
Manganese
Manhood ....
Marsh, Sir H. . . .
Mechanical dyspepsia
Melsena ....
Menstruation, vicarious
Mercurials, injurious effects of
use of
Mesenteric glands
Milk, changed by absorption
Mind, effect of, on digestion
affecting treatment .
Mineral waters .
Moleschott
Mucous membrane, organic disease of
irritability of
Murchison, Dr
Nervous system, disturbance of
dyspepsia from exhaustion of
Night, digestion during
Occupation, effects of
Omentum ....
33,
68,
FAQE
. 288
33, 66, 200
. 51
. 37
. 248
. 259
124, 234
265, 269
. 18
. 199
66, 74, 295
. 50
49, 66, 79
. 214
124, 280
. 27
9, 220, 246
. 206
. 84
84, 89, 92
. 33
. 131
. 25
. 24
41, 47
41, 107
164, 184, 198
. 29
. 57
. 66
. 290
. 106
143, 147
. 33
. 109
. 308
INDEX.
823
Opium, action on nrinary organs
action on milk
in treatment of gastric nlceration
in cancer
in gastric spasm .
Osltorne, Dr.
Pais, value of as symptom
Pancreas ....
cancer of
Pancreatic juice
Parietes of alxlomen, abscess
Parkes, Dr. . . .
Pepsin ....
Peri(Kls of life, changes of digestion
Peritoneum, pain
inflammation of
Phthisis, dyspepsia .
Pneumogastric nerve .
Pregnancy
Pressure on stomach .
Ptaylin ....
Purgatives
Purpura ....
Pylorus, disease of . . . . G(», 62
Pyrosis ....
QlAXTITY of food
RF.OfUOITATIO.N of food
Regurgitative disease
Remedies, and their abuse
Renal flyspepsia
calculus .
Rheumatism, dyspepsia with
Sight, disorder of
Senses, disorder of
Smell, sense of, disordered
66,
PAGE
34
37
279
299
313
59,
268
.56,
267
33, G3
296
296
122
63
29, .30
•', 10.0,
170
19
59
69
.
215
48, 62, 78
35,
217
70
168
130
86, !)3
,99
8, 248,
297
1, 240,
283
29
73
220
112
200
310
197
43
43
44
324
INDEX.
PAGE
Soda, hj-^posulpliite, absorption in m
ilk
.
.
38
Smith, Dr. E
22, 28,
105,
109
Snuif, injury from
•
142
Spine, disease of, sympathetic dyspe
psia .
66,
214,
309
pain ....
.
62
Stomach, degeneration of .
•
248
cancer of .
r)8
, 66,
68
,84,
285
distension of
93
, 98,
309
inflammation of .
56
, 65
perforation
256,
257
pressure on
66
ulceration .
. 5
B, 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 1
leart
48,
216
with liver
,
.
50
with suprarenal (
5apsu
Ics 51
, (J6, 74
217
with urino
-genit
al orj.
ans
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,
4:
, 65
280
Youth, digestion in .
26
63 5
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