The indigestions, or, Diseases of the digestive organs functionally treated

Front matter

V, c . i

THE INDIGESTIONS

OH

Introduction

Section 1. — Principle intended to be conveyed in the title of the volume. — Importance of the subject. — General peculiarities in diseases of the digestive viscera. — Value of attention to them in the management of remote diseases.

Section 2. — -Divisions of the subject adopted in the future volume, and explanations of terms used.

Section I

The name "indigestion," or "dyspepsia," speaks to the mind of the physician of a very large class of morbid phenomena, various in their nature and appearing under a great variety of circumstances. There are those who would banish the term from our nosology ; some because the outward manifestations are so diverse that it is impossible to bind them together in any symptomatic nomenclature ; some because the parts of the body whose morbid states induce indigestion are so doubtful and numerous that it cannot be brought under any anatomical arrangement. It is quite true that a definition of it cannot be given according to the symptoms, and equally true that it cannot be called a lesion of one part or of any set of parts or tissues. When symptomatic phenomena are made the principle of classification, those attendant on this morbid state are so numerous and so discordant that they appear in every class ; and if the organs that originate diseases are employed to give them names also, there are very few in the body which are not sometimes concerned in producing the disorder in question. Still to the

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practitioner the name has a distinct meaning, and is a definite guide to action. No symptomatic, anatomical, or even chemical considerations have prevailed over it, simply hecause it indicates a true method of classification, a natural linking of facts.

The link drawing into one class the morbid phenomena which are the subject-matter of this volume is a partial defect in the necessary supply of that of which the body is built up, before it arrives at the medium of distribution.

It is worth while to pause a little over this definition and on what it implies. The essence of " digestion " consists in absorption from a canal communicating with the external air into a closed system of tubes where is contained the nutritive fluid. Preparatory to this absorption is solution, aided by nerves and muscles ; and the end of it is assimilation, or the conversion of the substances received into a like nature with the fluid they float in. Till this has been clone they cannot be used for the nutrition of the body.

The blood is the floating capital lying between assimilation and nutrition — a treasury liable to continuous drafts from the latter, and requiring therefore constant supplies from the former to keep up its efficiency.

" Indigestion," then, or the incompleteness of digestion, is a defect anterior to constructive assimilation and to the blood, intervening between life and the new matter by which it seeks to renew itself.

This explains the fact mentioned before and familiar to us all, of indigestion affecting more or less all the functions of the body, and producing such an almost infinite variety of morbid phenomena as immediate or remote consequences. It perverts incipient life at its very source, and therefore perverts all its future manifestations.

It explains also why morbid anatomy here gives us less help than in any other classes of disease ; why the degenerations of the viscera found in the dead body have less causal relation to the phenomena during life than in other cases. The changes seen by the morbid anatomist are those of solids exhibiting faulty processes essentially posterior to the blood, dependent on perverted nutrition, or mal-directed or arrested destructive assimilation.

Let my use of a negative word as a title be held to indicate my

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persistent belief in what I have made it my chief aim to urge in all my teaching of medical theory for some years ; namely, that all disease is for the physician essentially a deficiency of life, an absence of some fraction of the individual organization of force. I think all just views of disease must have a direct reference to health, just as the — must be preceded by an expressed or implied + for it to have an arithmetical power. A former work, out of which this present volume has grown, " Digestion and its Derangements," is divided into two parts with an equal number of corresponding chapters with similar headings, each as it were complementary to the other ; the organ being exhibited by the first book in its typical state, by the second in its deviations ; as both being in fact equally manifestations of physiological laws. My reasons for now omitting the first part of the subject are mainly a desire to diminish the size of the volume, and partly a feeling that recent special writers on physiology have placed in the hands of our countrymen most of the information which, when I wrote, existed only in foreign periodicals and theses. All that, and more, is now so easy of access in a readable form, that one may be excused from reprinting it.

But I am more than ever convinced, as years roll on, of the principle intended to be intimated, and perhaps only timidly shadowed forth, namely, that the organic laws of health and disease are one, that the essence of the latter is a deficiency of the vital action which characterises the former, and that all successful medical treatment is a renewal of that vital action.

It is almost impossible to exaggerate the importance of the digestive viscera to the cure of disease. In every acute case, surgical or medical, the modification of the result produced by our efforts depends almost entirely on how far, how wisely, or how foolishly, these organs are watched over ; whether they are well or ill treated, either by the scientific guidance of the skilled physiologist, or by the empirical rules of the routine practitioner, or according to the tradition of the nurse, or the instinct of the patient. Each of these may be in their fashion a useful guide ; but the first is at least most capable of improvement by labour.

To an unhealthy state of the digestive viscera physiology enables us to trace, by steps more or less distinct, many

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chronic diseases not manifested in the organs themselves, hut affecting the whole hody. If nothing but gout, tubercle, and degeneration were referable to it, that would be enough to engage our closest attention.

Whatever value we may attach to the evidence of the dependence of disease on the digestive organs, it is very clear that we look to them for relief from disease. Out of the six or seven hundred forms of medicines in habitual use, very few indeed are not occasionally offered to the stomach for acceptance, and an overwhelming majority of them are adapted for use only in this way. If we are still to employ this timehonoured agency in our attempts to cure bodily ailments (and I see no threatening of a change at present), it is surely a matter of great interest to secure the active working condition of what our forefathers in anatomy picturesquely called the portal. It is waste toil to try and enter locked doors. A great advantage of paying special attention to the digestive organs is that, as a rule, they are more directly curable, and that by their means distant parts, otherwise out of our control, may be favorably influenced. The evil of neglecting them is obstinate disobedience of the body of the patient to any medicine administered.

When a sudden poison or paralysis has fallen on this gate of entrance, our hands are paralysed too; the staffs we lean on fail us. What buckets of physic used to be poured through the half-dead bowels in our first epidemics of cholera ! It might just as well have been thrown at once into the night-pan — its ultimate destination if the patients lived long enough* Calomel pills, and calomel powders, and opium, and cayenne pepper, were a frequent constituent of cholera stools ; and I verily believe that nine tenths of what was swallowed in the stage of collapse followed the same fate, or the patients could not have outlived the poisonous doses which are recorded to have been given.

Watch a case of typh-fever, and see what immediate improve-

* I once found a drachm of ipecacuanha, which had been administered with other emetics three hours before death, safe in the cardia of a collapsed patient, in whom it had produced no vomiting, and had not been moved towards the pylorus.

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ment follows the shedding of the dead epithelium with which the mucous membranes have been coated — a change which is ushered in by what is called the " cleaning of the tongue," but which foreshadows much more, in fact the cleaning of the whole intestinal tract. See how immediately on this the poisoned nervous system begins again to renew its life, and delirium ceases, as new nervous matter fit for duty is generated. Or watch another less fortunate case of the same malady, how as the tongue gets dirtier and dirtier and drier and browner each day, the weakness of the nervous and muscular system increases, and hope is more and more clouded over.

In both instances the difference between one case and another, between the patients who are a credit and a joy to us and the patients who continue to wring our heart with anxiety, mainly lies in the more or less vitality of the digestive mucous tract.

We must remember also that it is of no use to employ the best possible means of staying the morbid symptoms, unless the digestive organs assimilate sufficient material to replace that which is diseased, and to remove which we are bestowing our pains. Labour is wasted in clearing away abnormal structure, if new structure does not take its place. To that end the only path is to ensure the assimilation of food. And to ensure the assimilation of food, the stomach and its colleagues must be in working order. So that in point of fact the only fair trials of depletory measures must be connected with feeding, and those who would uphold the good fame of such expedients must be careful of their patient's digestion.

But even if diseases of the digestive organs had not so much influence as they possess on the duration of life, their extreme frequency would alone entitle them to attention. Unfortunately, it has had a contrary effect : medical men are apt to set down what is so common as inevitable. They neglect indigestion as unimportant, forgetful that though its removal may not perhaps in every case lengthen life, yet that it would at all events double its value.

The digestive tract has not the advantage enjoyed by the respiratory and by the upper part of the urinary apparatus, and other parts, of being double. An animal has two lungs, two

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kidneys, two hemispheres to the brain, two testicles or ovaries, two sides to his hody generally; hut only one stomach, and one intestinal canal. A further reason for great caution in preserving the integrity of the latter — there is less to spare for disease to affect. A deposit of tubercle -(for instance) the size of a nut in the pulmonary tissue may be neither here nor there, may be never known hy its effects. But put it in the peritoneum, or in Peyer's glands, and what a disturbance is produced ! A man may lose a leg or an arm, and enjoy life very fairly afterwards ; hut let him lose the use of his oesophagus or his rectum, and where is he ?

This singleness helps to explain the powerful influence which derangement of any one of its parts has not only over the whole tract, but over the whole hody and mind. No chain is stronger than its weakest link, and an interruption of the function at one point is an interruption of the whole.

It also has a bearing of considerable importance on the treatment. It is extremely difficult to obtain that rest which is so essential in the management of disease. If you have pneumonia you may rest one lung and generally recover with the other ; but if you have an equally acute inflammation of the oesophagus or stomach, you are in great danger, because they are in constant use.

Indigestion is a chronic disease. By that I mean that its natural path is straight on from bad to worse, unless from the interposition of some extraneous circumstances of accidental or designed origin foreign to the phenomena of the disease itself. Hence it is not difficult to test the action of a remedy upon it. A cautious observer may from a moderate number of well-considered cases come to a rational conclusion as to its value. While the tendency of acute disease, as I understand it, is to progress in a circle towards the recovery of health; each process, however dangerous and abnormal it may be, being a step towards the final arrival at that result, if only the patient's strength hold out* Art, therefore, modifies it much less glaringly ; a

* Dr. Pierre Petit, in the Preface to his ' Commentary on Aretams,' compares acute diseases to race horses, which run round to the goal, unless they founder on the way.

The Greek primary division of diseases into " acute" and " chronic" is turned

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small experience is sure to lead to fallacies, and it is only on the numerical comparison of a large number of unprejudged cases that an opinion can be formed.

For this reason the failure of homoeopathy in the cure of the digestive function is very conspicuous. More than a third of the private patients who come to me with dyspeptic ailments have tried this system, and confessedly tried it without advantage ; though some of the same people still continue to think that in acute disease, scarlatina, catarrh, measles, rheumatic fever, pneumonia, and the like, their convalescence is brought about by homoeopathic drugs.

My object in this chapter has been to point out the importance of a skilful management of the digestive organs in disease. I mean in disease generally, and not only that which specifically affects those organs alone. Let us not be deceived by the expression " merely symptomatic " sometimes applied to the derangements of digestion where organic changes exist. All parts and functions of the body are so knit together in one to form the great circle of life, that their comparative value to individual existence is more a question of time than of power. The failure of any one shortens the days more or less, and the immediate cause of death is as often " a mere symptom " as an organic change.

On stating in consultation an opinion that some viscus is chronically degenerated, one is often met by the remark, "Well, what is to be done ? — we cannot cure that." Very likely not ; then let us try and find something else which we can cure. In the great majority of patients this curable something may be found in functional impediments to the entrance of nutriment into the medium of assimilation ; and when once nutriment can be got in, a cure is begun. Do not, therefore, let us give way to despair even after it has become certain that the principal viscus which gives a name to the disease is past remedies, and

to such excellent therapeutical account hy Aretajus, that the loss of his introduction, in which he probably defined acuteness, is much to be regretted. Galen misses the practical point, when he introduces the artificial element of time, pedantically limiting acuteuess to a definite number of days. And several of our contemporaries have fallen into the same error ; as if there could be any natural difference between an inflammation lasting twenty-one days and an inflammation lasting twenty-two days !

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though little can be prescribed for the part mainly affected. It is seldom too late to try and administer to the failing organ the most potent of all remedies, the human blood of the patient himself, made healthy by the means adopted, and flowing in continuously by its natural channels.

I remember, when I was physician to St. Mary's, talking in the wards to the pupils on this subject, as was my frequent habit, when we came to a new patient, an undergrown, undeveloped girl, the mitral orifice of whose heart was narrowed by rheumatic inflammation in childhood. On her being earned into the hospital, her face was like that of a corpse, and she could not stand without fainting. I presume no sane student expected to see means used for the dilatation of that vessel, whose contraction was the source of evil : despair was not an illogical conclusion from the diagnosis I dictated to the clinical clerk, and I was but little surprised to hear behind my back the remark, " This, at all events, is not much of a case for treatment." Yet observation of the functional state of the alimentary canal, indicated by the edematous tongue and fauces, made me improve the opportunity by expressing an opinion that she would " walk home with colour in her cheeks." A month afterwards I was able to say, at a clinical lecture on the case, " This she has been able to do, and the better-nourished heart now beats steadily and evenly ; though its mitral orifice is as small as ever, if the ear and stethoscope are to be trusted."

And not once, but almost weekly, have I demonstrated to the same class, with respect to many a consumptive, how little it helped us to know that half of the upper lobe of each lung was filled with crude tubercles : pulmonary remedies had been of no benefit; but the reflection that the stomach was secreting an excess of mucus at the same time with the lungs, led to effectual means for the relief of both together.

In the folio wing chapters I intend the sketches I give of morbid phenomena, and the simple classes into which I divide dyspepsias, to apply equally, whether they are alone, or whether they are united to obvious and more fatal organic changes.

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Section II

There is no pedantry in definitions when their ohject is to lead the writer and reader hetter to understand one another. So I shall not shrink from a charge of over precision when, the first time I use in the following pages a word capable of various interpretation, I often stop to say what I mean by it. And at the present stage of the volume let us not grudge a few pages to dividing the subject, assigning it a nomenclature, and trying to turn that nomenclature to practical profit.

Healthy digestion is quick, complete, and easy. There can be no excess of it, for food cannot be too quickly and completely converted into chyme and taken into the blood, and there is no such thing as too much health and bodily comfort. \i In ill health digestion is impaired in one or more of these qualities— it becomes slow, defective, and painful.

We may use Greek words, and call the above-named erring qualities of the digestion Bradypepsia, Apepsia, and Dyspepsia ; only let it be remembered, that making the old adjectives into new substantives adds no whit to knowledge, — nay, unless care be taken, runs some risk of being a stumbling-block to its progress. For when we have in this way given a proper name with a capital letter, we are apt to think (like a naturalist with a new butterfly) that we have defined an individual and active motive power, instead of what is really the deficiency of a function. And thus we fall into the errors of our fathers, whose dangerous aims at destroying their abstract foe the " Disease," instead of restoring the existing patient, led to so much bad practice in the generation now passing away. I shall generally use the English adjectives, but first I will say shortly what I mean by them in this connection.

By digestion being slow I mean that the act in some part of the alimentary canal is not completed by the time when the convenience of the individual requires that it should be completed. The stomach may retain so much of a former meal that it is not in a fit state to receive the new one which is needful for the sustenance of the body. Hence arises a want of the natural appetite and (when long continued) imperfect nutrition,

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amemia, debility, &c. Or, if we attempt to force food too quickly on the unwilling stomach, we have chemical decomposition and defective digestion as consequences.

The average time by which the stomach should have naturally emptied itself varies in different healthy persons from two to three hours. The intestines have extracted all that they are capable of absorbing in eight or nine hours ; and the relics of complete digestion are ready for expulsion from a vigorous young person in twenty-four hours.

By defective digestion, I would imply that food capable of nourishing the body cannot do so from lack of certain changes which it should naturally undergo in the alimentary canal. It is passed from thence either unaltered or chemically decomposed. There are seen in the faeces, either by the naked eye or the microscope, masses of starch, muscular fibre, fat, &c. I have several times had them brought to me, under the idea that they were worms, pieces of intestine, or other foreign bodies. Or else the products of their decay, consisting of various obnoxious gases and acids, are developed in quantity subversive of comfort.

Painful digestion maybe both defective and slow; but, on the other hand, it not unfrequently also is complete and performed with sufficient quickness. All that it is intended to express by the word is its accompaniment, at some stage of its progress, by feelings varying from slight discomfort to absolute agony.

A few days ago a patient depicted to me very well the first-named sensations by saying, in answer to the question whether he had any pain, no, but that he felt where his stomach was, and knew where his food went to. And on the other hand I have heard the consequences of an ordinary meal described by a theologian, who ought to know, as "the tortures of the damned."

A very practical division of cases of indigestion is derived from the substance Avhich is indigested, namely, which of the chief constituents of the diet, whether (1) Starchy and Saccharine, (2) Albumenoid, (3) Fatty, or (4) Watery food most exhibits the failure of the function. This is to be learnt partly from the patient, and partly from observation of the consequences which ensue to the alimentary mass. On it is grounded an important pari of the treatment, namely, the dietetic; and as its indica-

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tions are simple as well as valuable, it will come first for consideration.

A very essential step in the cure of indigestion consists in the removal of its external causes, Avhere these are removable. The following chapter therefore will be on " Social Habits," by which I mean causes dependent on the patient's will. There is one obvious practical distinction between these and other causes, namely, that the discovery of them is the true cure. You may bid a man cease from over-eating, over-fasting or smoking, but you cannot bid him cease from being poor or sorrowful, having tubercles in his lungs or an ulcer in his stomach.

The symptoms of these errors of the function may be divided according to the period of digestion at which they occur ; some being exhibited before the alimentary mass has left the stomach; some during its way along the intestines'; some after the passage of the ilio-csecal nerve.

Now, remark, I avoid calling these phenomena diseases of the salivary or gastric glands, of the intestines, or of the colon. They are not so, and must not be treated as such. The discomforts felt soon after a meal, for example, may be due to organs far away from the stomach, — to the uterus, to the kidneys, to the lungs, — yet they must be called by the same names as when they are owing to anatomical changes in that part. So those occurring later often are traceable not to anything wrong in the duodenum, ilia, or colon, but to excess of gastric mucus or deficiency of pepsine.

Let it be understood then that when I speak of the first stage of digestion I mean, before the food has passed the pylorus ; by the second stage, its transit along the small intestines ; by the third stage, all that takes place beyond the ilio-csecal valve.

These phenomena almost always require separate treatment of themselves in addition to the general condition from which they originate. Indeed they are such a prominent part of the ailment that some writers, with a considerable show of reason, have divided indigestions according as one or other of them is the distinguishing features, as for instance M. Chomel does into " dyspepsie flatulente, dyspepsie gastralgique, dyspepsie boulimique, dyspepsie acide," &c. There is a certain amount of convenience in this in very marked cases : the worst of it is that

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many invalids exhibit several of the nomenclating symptoms all at once in equal degrees, and it is difficult to assign them their place : while in some the dyspepsia (or rather the patient) is flatulent one day, gastralgic another ; at one time has acidity, at another alkalinity in excess. I have thought it better therefore in this treatise to discuss each symptom, separately where it requires separate treatment, or in groups of several together, where the pathology and therapeusis admit of union. These will fill a few successive chapters.

Let it be understood that I speak of "Heart-burn," "Acidity," " Vomiting," &c, in these chapters as diseases independent of the cause from whence they arise; referring them indeed to that cause where it is known, but not placing them in a separate class where it is unknown.

A chapter will follow on some of the structural changes in the digestive organs themselves which impede their functions.