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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 

CANAL,  (ESOPHAGUS,   CiECUM,   INTESTINES, 

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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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