An essay on morbid sensibility of the stomach and bowels, as the proimate cause, or characteristic condition of indigestion

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Preface

The following Essay is re-printed from the Fourth Edition (just published) of my Work on the " Influence of Tropical* Climates on European Constitutions," for the convenience of those who may be in possession of former Editions, or who may not be inclined to possess the present one.

The subject of this Essay has occupied the pens of so many able writers, of late, that some excuse may seem necessary for another tax on the Public. The present, however, is not a very heavy tax on the purse or patience of the reader ; for if it he a bad, it is, at all events, not a large book. I shall not therefore offer an apology, since no apology will procure a favourable reception for him who obtrudes himself unnecessarily on the time and attention of his professional brethren.

The materials of this Essay have been drawn entirely from personal observation, and not a few of them from personal suffering ; and if I have questioned certain popular doctrines, and insisted on a more rigorous system of self-control than may A

IV PREFACE.

suit the ideas of many people, both in and out of the Profession, I have done so on the sure ground of experience. Those who disrelish the precepts I have laid down — •or who may think the promised advantages too dearly purchased by the proposed sacrifices, have only to go on, till time and ill health induce them to think more seriously on the work of reformation. I have not preached Utopian doctrines on the subject of diet — I have proposed nothing but what has been practised by many others as well as by myself with advantage — and I am confident that he who fives the plan a fair trial, will never conemn it, even if he have not fortitude to pursue it.

In this Essay I have endeavoured to investigate the operation of moral causes on the digestive organs, more minutely than has generally been done ; and to trace, with more care, the reaction of these organs on the mental faculties. The amount of suffering which is inflicted on the body through the agency of the mind, is only equalled by the retributive misery reflected on the mind through the medium of the body. The play of affinities and reciprocity of sympathies between the intellectual and material portions of our nature, have not been sufficiently attended to in the investigation and management of dis-

PREFACE.

eases ; and I am not without hope that this Essay may be instrumental in lessening the extent of human maladies by increasing our knowledge of their moral as well as physical causes.

In the treatment, I have ventured to expose the injury which is done to the stomach by a farrago of tonics and stimulants, as well as by violent purgation — while I have shewn the efficacy of some simple remedies when judiciously employed. — But, above all, I nave endeavoured to demonstrate the true principles on which the plan of diet and regimen should be constructed, not only in indigestion, but in a host of mental and corporeal discomforts which are little suspected of having their origin in the stomach. Having long suffered from this class of complaints, in my own person, my attention has been strongly drawn to it in others. The result of my experience is here given, in as small a space as possible, and the Public will decide whether or not my observations have been correct, and the deductions from them legitimate.

JAMES JOHNSON.

Part I. Diseases And Regimen Of Invalids From Hot Climates

Page The Youth setting out, and the Invalid returning home, contrasted -------..8

Dangers on returning to a Cold from a Hot Climate - - 10

The lungs liable to take on Disease - - . - - 11

Conduct on the Voyage Home from India - - - 19

Necessity of strict Abstemiousness on Embarking for Europe 13

The Danger of Hypochondriasis after returning 14

Debility on the Voyage Home ------ 15

Great Danger from too much Food - - - - - 16

Rules for Food and Medicine 17

Bowel Complaints on the Passage Home 22

Dietetic and Medicinal Treatment of - - 23

Sympathetic Affection of the Chest, on the Voyage Home - 32 Observations on Dyspeptic Consumption, as it is improperly

Stages — Diagnosis by Auscultation — Treatment - - 35

Organic Disease of the Liver 39 Deceptive Methods of ascertaining Organic Disease of this

Diagnosis of Disease in the Liver ----- 42

Different Kinds of Organic Disease of the Liver 43

Wasting of the Flesh a characteristic Symptom - 45

Treatment of Organic Disease of the Liver 47

PARTE.

on morbid Sensibility of the stomach and bowels, &c. &c.

Prevalence of this Disease among all Classes of Society - 52

Various Designations by which it is known 53 Indigestion, Dyspepsia, Hypochondriasis, Bilious Disorder,

all only forms or features of the disease 54 Distinction between the Ganglionic and Cerebro-spinal

Different Kinds of Sensibility in different Nerves ib. Illustrations of this Difference of kind, in the Sensibility of

Organic and common Sensibilities of the Stomach ib. Danger of exciting common Feeling or Sensibility in the

Food and Drink ought to produce no Sensation in the

Stomach - - - - - - ib.

excite Sensations of Comfort during Health in distant Parts of the Body - - - - - - ib.

Irritation of the Stomach produces unpleasant Sensations in

distant Parts of the Body, with or without Pain in the

Stomach itself -- ------ 5S

Two Classes of Sympathetic Effects from Irritation in the

Stomach 59

Class I, — Morbid Sensibility of the Stomach and Bowels, with

obvious Disorder of those Organs - - - - 63

CONTENTS. Vii

Page

Symptoms of a Fit of Intemperance ----- 64 The Manner in whicn Morbid Sensibility is formed, and the

Foundation of Indigestion established 66

Strictures on Dr. Philip's Stages of Indigestion - - ib. •* Indigestion " a Conventional Term — the Author's Reasons for using the Term tw Morbid Sensibility " of the

Gastric and Intestinal Nerves ----- 67

Symptoms of Liver and Stomach Affection combined - 68 Distressing Effects of vitiated Bile on the Digestive Organs,

and through them, on the Mental Functions - - 69 Effects of Biliary Irritation on the Tongue, Eyes, Kidneys,

and other Parts of the Body - ' - - - - 71 Distressing Sense of Debility, varying with the State of the

Stomach 73

Tenderness of the Pit of the Stomach, a deceptive Symptom 74 Strictures on Dr. Philip ? s Remarks on this Subject, and on

the Organic Diseases to which Indigestion is said to lead ib.

Pain in the Region of the Stomach, Remarks on - - 78

Hardness of the Pulse, Remarks on - - - - - 79

Febrile Symptoms, Remarks on- - - - - -82

Changes produced in the Mucous Membrane of the Stomach by a long Continuance of Irritation there - - ib. Sympathetic Affections of various Parts of the Body from

Irritation of the Digestive Organs 83

Sympathetic Affections of the Brain - - - - 85

of the Nerves of Sense, as of Sight and Hearing ib.

of the Heart - - - - - - -86

of the Lungs ------- 87

of various other Parts of the Body - - - 88

Class 11. — On Morbid Sensibility of the Stomach and Boiveb, .

without any obvious Disorder in those Organs themselves 89

Physical Causes of this Morbid Sensibility - - - ib.

' bad Air — want of Exercise — late Hours - - 90

Diet, the chief Physical Cause - - - 91

Criteria of the injurious Effects of Diet 99

Drink, a powerful Physical Cause - - - 93

Moral Causes of Morbid Sensibility, as Anxiety of Mind

— Modes in which they act on the Stomach - - 96

Effects on Moral Causes exasperated by Food and

Hypochondriasis, Remarks on the Doctrines which have

been broached respecting this distressing Malady - 97

Doctrines of Cullen, Broussais, Falret, and of the

Hypochondriasis, Doctrine of Villermay, appears the nearest to truth — namely, Change in the Organic Sensibilities of the Visceral Nerves ------ 99

Graphic Sketch of this Disease - - - - 100

People most liable to it - - - - - - 103

Symptoms of its early approach - - - - 104

Exasperated and mitigated by Diet " - - - 105

Vlll CONTENTS.

TREATMENT OF MORBID SENSIBILITY OF THE STOMACH AND BOWELS, DIETETIC AND MEDICINAL.

DIETETIC TREATMENT. Page

Simplification of the Indications to be pursued - - - 107

Chief Indication, the Removal of the Sources of Irritation - 108

Regulation of Diet, the first object - - - - - ib. Danger of prescribing Medicines in this Disease, without first

establishing a System of unirritating Diet ib. Rules for establishing a Regimen adapted to the Degree of

Morbid Sensibility, or to the Digestive Power of the

Stomach 109

Criteria respecting the Quantity and Quality of Food that

may be taken without injury - - - - -110

Observations on Drink - - - - - - -114

Necessity of Firmness and Resolution in pursuing proper

MEDICINAL TREATMENT.

State of the Secretions to be first ascertained - - - 116

Hints for ascertaining the State of the Secretions - - 117

Danger of irritating Purgatives in Dyspeptic Complaints - 118

Various FormulfE for Aperients ------ 119

Cases where Mercury may be necessary, or not - - - lril

Observations on White Mustard Seed - 122 Means for reducing the Morbid Sensibility of the Gastric

Counter-irritation externally ------ if,.

Anodynes, with Blue Pill and Ipecacuan - 123

Hyosciamus with Blue Pill, a valuable Sedative - - - ib.

Vegetable Bitters and Tonics - - - - - - 124

Danger of their too early Administration - %b.

Nitrate of Silver, an important Sedative in Morbid

Sensibility of the Gastric and Intestiual Nerves - 125

-Cases in Illustration of its Utility ib.

Sulphate of Quinine, the best, and almost the only Bitter

Tonic that is necessary - . - - - - - log

Rules for administering this remedy in Dyspepsia - - 129 Treatment of Sympathetic Affections of various Parts of the

Body 130

MORAL AND PHYSICAL REMEDIES COMBINED. Rules for the Management of Exercise - - - - 134 MORAL AND PHYSICAL EFFECTS OF TRAVELLING. Plan of a three months' Tour for the Restoration of Health 137 Amount of Active Exercise taken by the Author on a Tour 139 Routine of Exercise, Diet and Rest - - - - 140 Investigation of the Moral Effects of Travelling - - 1 42 Investigation of the Physical Effects of Travelling - - 145 Effects on the Sensibility of the Body to external

impressions of the Atmosphere - - - - 146

Effects of the Lungs of Phthisical People - - 148

Effects on the Organs of Digestion - 149

Effects on the Absorbent System and Secretions 150

Effects on Dropsical Dispositions - _ - ib.

Effects on the Heart and Circulating System - L*2

Effects on the Blood itself - - - - 153

PART I.

OHST&RVATI0X&

ON THE

OF

ON THEIR RETURN FROM

HOT AND UNHEALTHY CLIMATES.

The English youth leaves his native shores, with vigorous health and buoyant spirits, for a foreign land of promise, where he is to meet with adventures, acquire fame, and realize a fortune. All the happy events, real or ideal, of his future journey through life, are painted by his ardent imagination, in prominent characters, on the foreground of the scene; while reverses, sickness, disappointments — death itself, are all thrown into the shade, or, if suffered to intrude, only serve as incentives to the pursuit which has been commenced.

During the short span of existence to which man is doomed on earth, it is a merciful dispensation that youth anticipates no misfortune; and that, when the evil day arrives in after life, Hope comes, on glittering wing, and gilds the scene even till the last ray of our setting sun is extinguished ! B

I have already pourtrayed, in another place, the dangers which the tropical sojourner runs, the diseases to which he is subject, the remedies which experience has found most effectual, and the regimen which appears to me most appropriate in the Torrid Zone. A task remains, which I have not hitherto undertaken ; but which the experience and observation of twenty years may now enable me to accomplish. The nature of that task is explained in the title of this part of my work.

An epoch, sooner or later, arrives (and most welcome it generally is) when the completion of a period of service; the acquisition of competent fortune ; or, what is more frequent than any other, the loss of health, points to a return to our native land — a land which the more constantly engrosses our daily thoughts and nightly dreams, the farther we are distant and the longer we are absent from it ! None but those who have sojourned for years on foreign shores, can appreciate the feelings of the European, who wastes the prime of life beneath a tropical sun, languishing in body, and pining in thought to revisit the scenes of his youth,

While every form that Fancy can repair From dull Oblivion glows divinely there I

If he crossed the seas, in early life, full of anticipations, that can, alas ! be but rarely realised ; he shapes his course back again across the same pathless deep, with chastened but scarcely less ardent hopes of health and happiness on the soil which gave him birth. — Here, too, he is destined to encounter dangers as well as disappointments. The powers of the constitution, however plastic, cannot immediately accommodate themselves to great and len changes of climate, even when the transition

Froifi a bad to a good one: and the tropical inva-

OF INVALIDS FROM HOT CLIMATES. 1C

lid requires full as much caution and prudence in approaching the shores of England, as he did in landing at a former period, on the banks of the Ganges.

When the European has become much debilitated by liver affection, dysentery, or fever and its consequences, his main hope of recovery rests on change of climate, and under such circumstances, the sea voyage will often effect the cure. Indeed the instances are not few where more benefit is oh-- tained by the voyage home, than by subsequent residence in England. The voyage, though not totally free from inconvenience, presents not the thousand temptations to deviate from regular habits and regimen, which afterwards assail the tropical invalid, when he mingles with society in his native country. Besides, the uniformity and salubrity of the sea-air, aided by the mental exhilaration of a homeward voyage, produce surprising effects on the animal economy. During this voyage the effects or sequelae of fevers generally disappear, and both appetite and strength return. But chronic dysentery and hepatitis are not so easily removed, and these the tropical invalid most commonly brings with him to Europe — sometimes considerably mitigated, but at others, rather exasperated, especially if stormy wet weather is experienced off the Cape, or if the ship arrives in the channel at an unfavourable period of the year. By residence in a hot climate, the constitution becomes assimilated to it, and, in some measure changed. The return, therefore, to a cold, though more healthy latitude, is liable to produce, if great care be not taken, a determination to those organs which have been weakened by previous disease; and thus a more or less acute inflammation is often set up in the mucous membrane of the bowels ; or they are rendered more irritable than before the invalid left India. A

11 OP THE DISEASES AND REGIMEN

subacute inflammation of the liver is sometimes thus superinduced on a chronic disease or torpid state of that organ, requiring not only the subduction of the stimulus of food and drink, but even local abstractions of blood from the region of the liver.

But the most serious consequence of a return to Europe, after long residence in a tropical climate, is the aggravation or even production of disease in the chest. The mucous membrane of the lungs sympathises readily with that of the stomach, and thus produces what is called a stomach cough. Chronic diseaseof theliver produces the same thing, whether by means of sympathy, or simply by contiguity with the diaphragm, which is so intimately connected with the organ of respiration. Now, in a great majority of instances, these affections of the chest are only symptomatic, even when the invalid has returned to Europe, and will subside in proportion as the functions of the stomach and of the liver are restored. But, on the other hand, there are many cases where the symptomatic affection of the chest has continued so long as to induce actual disease there ; which disease will not be removed, nor even materially relieved by the remedies prescribed for the liver or stomach complaint.

In this country, the symptomatic aflection of the lungs in chronic hepatitis and indigestion, has excited much attention, and has been treated of under the names of ' f hepatic phthisis, " dyspeptic phthisis," and " stomach cough." Where there is evidently derangement of the liver or stomach, and the patient is lately from a hot climate, the English practitioner sets down any pulmonary affection that may be complained of, as symptomatic, of course, of the abdominal disorder ; and thus, that time is lost in abortive attempts to remove both classes of complaints by striking at the original one, which might have saved the lungs from irremediable disorganization. Many are the instances I have seen, and continue to see, where patients have been pronounced to be labouring under symptomatic disease only, while a few minutes' examination of the chest by percussion and auscultation detected organic chan ges in the lungs or heart which had passed the period when any chance of recovery could be expected. This, in fact, is one of the greatest dangers which the tropical invalid runs, when he embarks for his native climate, where pulmonary complaints are the prevailing diseases. On this account, he should, from the moment he goes on ship-board, pay the utmost attention to his dress, and most cautiously avoid all exposure to wet and cold on the voyage homewards. This caution is not le*ss necessary for the invalid affected with the usual consequences of tropical diseases only, and where the chest is free at the time he embarks. As he approaches the Cape, and afterwards the Channel, he is much more liable to pulmonary affection than a person who has never suffered from hepatic or stomach disorder; and, if the chest once becomes affected, he is much more exposed to fixed and dangerous disease there. If the pulmonary affection, even of the mildest kind, and purely symptomatic, has manifested itself between the tropics, he is in still more danger; and if the English practitioner faiis to make the most rigid examination of the chest, on his arrival, he becomes morally responsible iox all the serious consequences which may subsequently result from this neglect. In short, I have no hesitation in asserting, that the disorder of the chest, even if purely symptomatic, demands more attention, and is really of more importance than the abdominal disorder from which it arose. There is little or no organic disease of the liver in one case out of the twenty of those who return to this country labouring under " liver complaint" — and this re~ B 2 mark is still more applicable to the stomach — consequently j there is but little risk of life. But if the lungs once become affected in structure; if symptomatic be confounded with organic derangement, or suffered by neglect to pass into that state, the case will rarely be otherwise than fatal.

The surgeon of the ship, therefore, should take an early opportunity of examining the chests of all invalids complaining of cough, or who are easily put out of breath on ascending ladders, &c. If they cannot lie low in bed, or take in a deep inspiration without exciting cough ; and still more, if they feel uneasiness in any part of the chest, the case should be immediately attended to before the patient gets into the high latitudes, where the malady will certainly be increased. A blister, a few leeches, or a crop of pustules excited by tartar-emetic, aided by warm dress, abstinence from stimulating drink, and some gentle diaphoretic to act on the skin, would save many a day's sufferings afterwards — nay, many a valuable life. But of this more hereafter.

It is on the voyage to England, where there are many circumstances favourable to the object in view, that the invalid should seriously think of adopting a system of diet and regimen that might not only obviate any injurious effects of a sudden transition from a hot to a cold climate, but contribute materially to the removal of those complaints contracted by residence in the former. It cannot, indeed, be too strongly impressed on the mind of the tropical invalid, that without a firm resolution to coerce his appetites into complete subjection, and make them subservient to the restoration of his health, he will gain little by a return to his native skies ; but, on the contrary, he will either confirm those maladies under which he already labours, or, what perhaps is worse, convert them into forms less formidable indeed in appearance, but effectually subversive of every enjoyment, mental or coporeal, which can render life desirable. Of all the miseries to which man is liable, by the frailties of his nature, there is none more terrible to endure, or difficult to remove, than that hypochondricaal despondency which is sure to settle on the tropical invalid, in his own country, in the midst of his friends, and in the possession of wealth, unless he succeeds, by timely and proper measures, in correcting those morbid conditions of the digestive organs, from which this daemon draws a gigantic power and influence, that tyranize over all fortitude, philosophy, and even religion itself! The extent of this evil is so great in these isles, that it has been suspected, and not without probability, that our tropical colonization has introduced and propagated, by hereditary descent, a strong disposition to stomach and liver affections beyond that which is observed in any other country.

Be this as it may, the instances of insanity and suicide, from this cause, are not exceedingly rare; while the number of hypochondriacs, cursed, I might almost say, in the possession of reason, but driven to despair by the torture of their own morbid feelings and nervous irritation, which may be seen in all parts of the British dominions, but especially at watering places, is truly astonishing! Of these, our tropical invalids form no inconsiderable portion ; and although the wretchedness of their sensation is only known to themselves, their medical attendants, and some of their intimate acquaintances, the amount of it is great beyond all calculation. That this unhappy winding up of a life spent under a burning sun, in the acquisition of wealth, and in the vain expectation of enjoyment in declining years, cannot always be prevented, is but too true; yet, at the same time, I know from repeated examples and multiplied observation, that a rigid system of self-control adopted as soon as the individual withdraws himself from under the deleterious influence of a hot climate, and persisted in for a certain time after his arrival in Europe, would, in nine cases out of ten, be fallowed, not only by restoration of health, but by an equilibrium of spirits and mental serenity which none but the temperate, the abstemious, and the prudent, can possibly appreciate. This system will be detailed farther on.

The principal states of indisposition under which an invalid embarks for Europe, are debility from long-continued disease of the liver, or the remedies unavoidably employed for that complaint ; debility from fever, or a continuance of regular or irregular paroxysms of the disease ; and bowel-complaints.

Debility can only be removed, of course, by the introduction of nutriment into the system; but this does not always follow the introduction of food into the stomach, even when taken with considerable relish. One of the first effects of the sea-air is an increase of appetite, and the invalid hails this as a favourable omen, and indulges the propensity to eat. The debility of the various organs, however, and their previous desuetude to much nourishment, seldom permit this new propensity to be satisfied, without subsequent detriment. Indigestion, feverishness, or irritation of the bowels is almost sure to follow too free an indulgence of the appetite, and consequently there is no increase of strength from this temporary return of desire for food. Jlppetite, indeed, is a bad criterion for taking food; digestion - — easy digestion, is the only sure guide. If we feel uneasy after four ounces of food, but comfortable after the ingestion of two ounces, we shall derive more support from the latter than from the former. The quantity and the quality of the food must be both carefully regulated ; and, in general, the invalid's own feelings will warn him when he

OF INVALIDS FROM HOT CLIMATES. Id

has erred on either point. But this is not always the case. There is no effect of indigestion more common than dejection of mind, when no corporeal inconvenience appears to follow. The nerves of the stomach and upper bowels will be irritated, and this irritation will be propagated to the whole nervous system, and all its moral and intellectual attributes, by quantities and qualities of food which excite no sensible uneasiness in the organs of digestion, and produce no change in the secretions or excretions by which the evil might be detected. A want of attention to this circumstance — or rather a want of knowledge of it, has led, and leads daily, in numerous instances, to states of mental despondency, ending ultimately in complete hypochondriacism. In insanity, the morbid condition of the mind is invariably dependent on a morbid condition of the body, (whether indu#ed by moral or physical causes,) although the latter is rarely cognizable by external corporeal symptoms. This holds equally good in hypochondriacism. The mental despondency is invariably dependent on some disorder of the body, and, in nine cases out of ten, it is immediately dependent on a morbid or irritable slate of the nerves of the stomach and bowels. Of the truth of this I have had such multiplied proofs, that not a doubt remains on my own mind respecting it. It is as useless to attempt the removal of this mental despondency by moral means or mere persuasion, as to try to remove a fever or an inflamation by argument. The attempt, indeed, betrays a great ignorance of the real nature of the complaint in the physician. Moral means may certainly contribute to improvement of the general health, and this will much improve the state of the digestive organs, on which the mental despondency depends. It is only in this way that moral means can have any influence on hypochondriacism. But of this, more hereafter.*

If the invalid only labours under that debility produced by fever and the remedies used for it, the sea-air and the gradual increase of tone in the digestive organs will generally be sufficient to renew the strength, under the caution above-mentioned respecting diet. In such cases it can rarely be prudent to exhibit direct tonics at the beginning of the voyage. A warm bitter is quite sufficient, as equal parts of infusion of ginger and gentian, with four or five grains of carbonate of soda, and a drachm or two of any bitter tincture in each dose. The bowels should be regulated by mild aperients that do not produce thin or watery discharges — an operation which should be avoided, but which, I am sorry to say, continues to do infinite mischief. Many practitioners and patJlnts are absolutely infatuated with the benefit to be derived from the blue pill at night, and the black dose in the morning. This medicine certainly sweeps away abundance of thin, fetid, and unhealthy secretions, and the patient feels lighter and more comfortable for a time; but a repetition of the practice produces the very secretions which it is designed to carry off or prevent. After clearing the bowels in this way, the great object is to procure formed motions, if possible, and that not oftener than once in the 24 hours. That medicine which goes slowly and without irritation along the intestinal canal, permitting the nutriment to be taken up by the absorbents, and gently stimulating the large intestines to discharge the useless residue, is the one to which we should have recourse. Aloes is the basis of such medicine; but as, in the class of patients now under consideration, there is generally

* The functional and organic diseases of the liver will be treated of presently, in conjunction with dyspepsia, from which they are rarely free, in tropical invalids.

a defective or vitiated condition of the billiary secretion, and an irritable state of the gastric and intestinal nerves, together with a torpid skin, it is necessary to combine other medicines with the aloes. A grain of blue pill, three or four grains of extract of hyosciamus, and a quarter of a grain of ipecacuan, combined with as much aloes as is sufficient to move the bowels once daily, will be found a valuable form of aperient for the invalid on the voyage home. The hyosciamus allays the morbid irritability of the nerves of the digestive tube; the blue pill gently excites the hepatic secretion as well as the pancreatic .and gastric ; the ipecacuan acts mildly on the skin ; while the aloes carries the whole slowly along the canal, and finally expels the faecal remains in the course of the ensuing day. Some little time may be necessary to ascertain the proportions of these medicines that may suit individual cases; but there can be little difficulty in obtaining the proper result in the end. It is supposed that a disposition to haemorrhoids is an insuperable objection to aloes, or the compound extract of colocynth. This has been proved to be an error, and aloes is now commonly given by some of the best London practitioners for haemorrhoids. It is too much purging that increases and irritates piles rather than the kind of purgative. Where it is desirable to procure one free and copious operation in the morning, a common seidlitz powder taken at 7 o'clock, and before breakfast, will pretty certainly have this effect.