A treatise on indigestion. With observations on some painful complaints originating in indigestion, as tic douloureux, nervous disorder, &c.

Front matter

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Preface

TO

THE FIRST EDITION

The liver is a gland of waste ; the stomach and small intestines are organs of supply — (a supply of the most important and imperious nature): the former is an insensible viscus, comparatively speaking, loosely connected with the other abdominal viscera, and with the general habit ; the latter are organs of elevated sensibility, not only intimately associated with every part of the system, but themselves forming the chief viscera of the abdomen; and with their blood-vessels, nerves and membranes making up the great bulk of this cavity. From this, I believe, we rightly infer, that the liver is an organ in the animal economy of far inferior importance to the digestive tube; and I maintain, that its disorders are by no means to be compared with those of the extensive surface of this canal, either in frequency, or severity, or consequence to the welfare of the constitution, A

IV PREFACE.

principal object of the following observations is to enquire into the evidences of this fact, and to show, that the organization, vital properties, functions, and sympathies, of this canal, when contrasted with those of the liver, tend to prove, that what are commonly called "liver and bilious complaints" are, nine times out of ten, in reality affections of the stomach or bowels, — and, that combined with a consideration of the symptoms, and effects of remedies, the above circumstances become irresistibly convincing of the truth of this assertion.

My attention was early excited towards ascertaining the correct pathology of those maladies, so generally named "liver complaints" from a persuasion, that, in the nature of things, disordered or diseased liver is not likely to be, in any degree, so often met with, or of such consequence, as disorder of the functions of the alimentary canal, — that centre of sympathies, to which we are incessantly and immediately applying stimulants and irritants, so numerous and dissimilar \ and from finding, that when these evils were treated in the too common way, with active mercurials, they never failed to increase instead of disappearing, being not seldom confirmed, so that the parts affected ever after remained debilitated, and subject to frequent disorder : whereas, a different treatment directed, in the first instance, towards restoring the impaired ener-

PREFACE.

gies, and healthy secretions of the digestive tube, rarely failed to remove all complaint. It is not a little singular, that the sentiments of Mr Abernethy and Dr Hamilton, in regard to the paramount frequency of disorders of the stomach and bowels, and the effectual relief to be obtained in them from the exhibition of mild aperients and alteratives, should have gained such general confidence among medical men, when their practice is so seldom and imperfectly followed, especially that of the former writer ; the liver still being harped upon continually, as bearing the onus of disease, and calomel accordingly administered with an unsparing hand.

The light thrown upon the subject of the first part of this treatise by morbid anatomy has been draw T n exclusively from the records of dissections, contained in the writings of men of professional eminence, rather than from any cases and examinations of my own ; because those records are before the public, and as the dissections they describe were not instituted to serve my purpose, they will with justice be received as more satisfactory and conclusive than any I might produce from my own practice.

Though I consider that mercurial preparations are extensively exhibited in such doses, and for so great a length of time, as constitute them active poisons rather than remedies ; yet, let it be remem-

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bered, that I do not here inveigh against their proper use, but only against their abuse. This is an evil of some magnitude in Great Britain ; and it appears to me imperative upon the profession, to take a closer and more impartial view of the properties and operation of mercury, particularly of calomel, than has yet been witnessed ; seeing, as we do, that scrophula, hydrencephalus, consumption, and indigestion, are fast increasing upon us. These are all diseases of debility, and the last, though not the most formidable, is perhaps now the most frequent. In its treatment, it has been too general to disregard altogether the important principle, that " the relief of irritation is the great object of medicine ;" and it appears evident, that in endeavouring to remove supposed disease of the liver, our violent and deleterious measures have greatly multiplied real disorder and weakness of the digestive canal.

PREFACE

THE SECOND EDITION

I would take the opportunity presented by the publication of a second edition of this volume to say, that its contents are solely the result of personal observation and experience, and I therefore must hold myself responsible for the correctness of the opinions herein advanced. Many of these sentiments are at variance with those widely received on the same subjects, and some of them lead directly to the adoption of a treatment the very reverse of what is too commonly, perhaps I ought to say generally, followed ; but when our conclusions are drawn from close observation of the course of a disorder, and the operation of different remedial measures upon it, no difference from general sentiments, however great, ought to deter an author from the statement of his opinions. On the contrary, the greater this difference, on points involving practical consequences, the more desirable is it that

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the conclusions should be fully stated, and I have here therefore proceeded on this conviction.

If it is lawful to judge from the effects of remedies on my own dyspeptic system, on that of a near relative who is always in my house, and on the constitutions of the many patients I have seen, I must infer that the principles on which indigestion is generally treated admit of great and manifest improvement. It appears to me that we may come to the same conclusion, in regard to the indications which regulate the treatment of chronic disease in general, and I think, notwithstanding the multitude of medical books now in being, that a Treatise describing at length the nature and correct principles of treatment of chronic disease in general^ is a work much wanted, and, from the greatly increased and increasing number of chronic maladies, capable of being made of more real service to the public, than any other single medical publication that has been, or could be written. In the absence of such a book, the young medical practitioner cannot too sedulously yield himself to the study of the principles of management described in the fourth chapter of this volume, which will be found to be those of the greatest importance in all chronic disorders.

Croyden, Surrey.

CONTENTS,

Preface «... iii

Chapter I

Nature and symptoms of Indigestion . . 13 Prominent evils in the Medical practice of the present day 1 3 Origin of the terms nervous and bilious . . 15 Frequency of liver conplaints questioned . . 16 The acute sensibility, nervous connexions and superior importance of the stomach and intestines . 18 Influence of the sympathetic nerves . . 19 Inferior sensibility and importance of the liver . 20 Extensive influence of the assimilating viscera over the other

organs of the economy . . .23 Principal causes of the prevailing idea respecting the uncommon frequency of bilious and liver complaints . 26 Swelling and pain in the pit of the stomach and right side 28 Mr Abernethy's treatment of such cases contrasted with the

ordinary mode . . . .28

Means of distinguishing affections of the liver from those of

the digestive tube ... 30 Symptoms indicating irritation of the mucous membrane of

the stomach, duoi&num and colon . . 30

Remarks upon the situation and affections of the duodenum 32

The colon and its affections . . . 34 Dr Curry's opinions . . . .39 The nature and origin of discoloured stools, commonly

called bilious . . . . 41

Origin of bloody discharges by the mouth, &c. . 45

of black vomit and bilious discharges . 50

Superior value of Dr Jackson's works on fever . 51 Opinions of Portal and Howship relative to the nature of

black evacuations .... 53

X CONTENTS.

Erroneous opinions of Dr Ayre respecting the source of the

blood discharged by vomiting . . .54

Refutation of these opinions by Andral, Abernethy, &c. 56

Dr Ayre's pathological opinions relative to hepatic influence

in marasmus condemned . . . 57

Dr Pemberton's views on marasmus . . 6 1

Yeasty discharges, with a case by Dr Blackall . 63

Dr Good, too fond of making the liver a vortex of disease 66

Remarks of M. Andral, Jun., relative to the pathology of

diarrhoea, dysentery and lientery . . 68

The stomach and bowels the true seats of disorders popularly

termed bilious . . . . 72

Effects of mercurials . . . .72

Mr Abernethy not one of those who consider the liver to be

the root of all evil in diseases of the chylopoietic viscera 76 The investigations of Broussais, Andral and other continental authorities, show that the liver is much less frequently effected than the English physicians generally suppose 80

Dr Curry's erroneous opinion of his own case . 81

Powerful influence of climate in modifying the operation of

remedies . . . . .84

Large doses of calomel prescribed in the Indies and some

parts of the United States . . . 85

Yellowness of the eyes not ne'eessarily connected with disease of the liver . . * .88 Intermittent pulse and fluttering at the pit of the stomach 94 Increased mortality in Great Britain from apoplexy and palsy 97

CHAPTER II. Varieties of Indigestion ... 98

Situated in the stomach . . ' . .99

■ small intestines . * . iqo

biliary organs . . . iqi

large intestines . . \q

Diagnostic symptoms of the different forms of dyspepsia 104

Character of the pulse . . . . 1 05

Forms of dyspepsia which are most common and intractable 106 The bowels- the seat of those internal disorders which prevail in autumn, as well as the source of gout, tic-douloureux,

scrophula, &c. . , . # iq6

States of the general system in dyspepsia . 108

CONTENTS. . XI

CHAPTER III. Causes of Indigestion . . . 110

Sedentary living and mental anxiety the principal . 112

Repletion . . . . 113

CHAPTER IV. Treatment of Indigestion . • .116

General principles . . . . Hf

1. To restore healthy secretions . • H7

2. To augment the strength . . 117

3. To relieve irritation . . .117 Debility a frequent source, of depraved secretions 119 The relief of irritation a grand principle . 121 Particular remedies . . . .123

Mercury to be used with caution . .125

Different effects from the same preparation given

in large and in small doses . . 126

Testimonials against salivation . .127

The admirable effects produced by mercurials in

some cases has led to its abuse . 131

Effects of mercurials upon the nervous system 134

Opinions of Drs Hamilton, Alley, &c. relative to the

poisonous qualities of mercury . .135

Permanency of its deleterious effects . 137

The mercurial combinations most useful in dyspeptic complaints . . .139 Valuable qualities of rhubarb and ipecacuanha 139

tartarized antimony . 144

nitric acid . 145

alkaline solution . 148

Proper aperients for dyspeptics . . 158

Nitro-muriatic acid bath . . 158

Indigestion depending upon a contraction of the

Treatment of local pain and uneasiness occurring

in Indigestion . . . 1 60

Treatment of the inflammatory or excited form of

dyspepsia . . . .161

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When this should consist of vegetable substances 163

When of animal, with the best kinds . 163

Nature of fish . . . 164

Comparative digestibility of fluids and solids 164

Most suitable drinks . . .165

Opinion of malt liquor . . 168

Useful auxiliaries . . . 172

Chapter V

Of tic douloureux, gout, and fulness of blood in the head, as dependent on indigestion . . .174

Appendix

Notice of the "Dyspeptic's Monitor" . . 183 Dr Abercrombie's treatise on diseases of the stomach, &c. . . . .192 — Mr Halstead's "new method of curing dyspepsia" ... 194 Professor Hitchcock's " Dyspepsia forestalled and resisted" a a . 206

TREATISE

ON

INDIGESTION

Chapter I

ON THE NATURE AND SYMPTOMS OF INDIGESTION, AND WHAT ARE USUALLY CALLED, BILIOUS OR LIVER COM- PLAINTS.

There appear to me to be two prominent errors in the medical practice of the present day : one, is the mistaking severe disorders of the stomach, and intestinal canal, for disease in the liver; the other, is the employment of large doses of mercury, for the cure of these supposed " liver complaints." The mischief that arises from these errors is incalculable. They are wide spreading evils, whose destructive influence is unhappily felt by persons of every age, rank, and condition, and which call aloud for a remedy.*

* The evils here adverted to, though exceedingly prevalent throughout the United States, are more especially so in those situated towards the south and west, where they exert an almost universal influence over the practice of medicine. — Edit. C

The term " liver complaint" is now in the mouth of every one ; and it is well known, that mercury in some form, generally the most injudicious, is the universal medicine for all kinds and degrees of disorder in the digestive organs. A patient suffering from such disorder, which is usually denoted by oppression at the stomach after eating, want of appetite, weakness, depression of spirits, irregularity of the bowels, discoloured motions, &c, can at this time hardly consult his physician or apothecary, without being told he has a " liver complaint" and, as a necessary consequence, being soon loaded with calomel or blue pill. Indeed, it is a fact, of which I am convinced from ample experience, that even the slighter forms of derangement in the assimilating viscera are often designated by the above fashionable term, and treated accordingly.*

It is much to be regretted, that there is a fashion in medicine, as well as in the other affairs of life. A few years ago, the majority of ordinary complaints were said to be on the nerves : now, they all depend upon, and centre in the liver. On this subject, a modern writer has well observed, " the princess, afterwards Queen Anne, was subject to hypochondriacal attacks, which her physicians pronounced to be spleen, vapours, or hyp, and recommended Rawleigh's confection, and pearl cordial, for its cure ; this circumstance was sufficient to render the disease and remedy fashionable, and no

* See the valuable little work of Dr Hall on the Mimoses.

other complaint was ever heard of in the precincts of the court but that of the vapours. Some years afterwards, in consequence of Dr Whytt's publication on ' Nervous Diseases,' a lady of fashion was pronounced to be nervous — the term became general, and the disease fashionable ; and spleen, vapours and hyp, were consigned to oblivion. The reign of nervous diseases, however, did not long continue, for a popular work appeared on Biliary Concretions, and all the world became bilious."* It is an unhappy circumstance, that the world still continues in this state, and that both the disease and its remedy have taken so deep a root in the professional mind, that there is yet no appearance of a change to another ideal fashionable malady, whose favorite remedy, we might hope, w r ould be a medicine more like pearl cordial or Rawleigh's confection than calomel, and therefore more congenial to the human constitution, and which, if it were not attended with any sensible benefit, would possess, at least, the advantage of being innocent.

Those disorders, which are, in common language, called bilious and liver complaints, are denoted by some or all of the following symptoms, viz. a sense of distention and oppression after eating, with flatulent, acid eructations ; diarrhoea, or constipation and uneasiness of the bowels ; furred tongue ; impaired appetite and strength ; discoloured motions, they being either green, dark-coloured, black, or

* Paris's Pharmacologia, vol. i.

much too light; nausea, headach, and bilious vomiting; palpitation of the heart, with or without occasional pain in that organ ; pain in the pit of the stomach and towards the right side ; sallowness of complexion ; and depression of the spirits : — and if the chief, or the whole of these symptoms are present, especially if in a severe degree, it is usually considered Efficient to justify the opinion, that a liver disease exists. But according to my experience, a very large majority of those maladies are not liver complaints, but properly disorders of the stomach, and intestinal canal ; and this fact will form the subject of consideration in the first part of this book.

It is acknowledged, ttrat in every severe disorder of these viscera, the liver participates, and its secretions are consequently vitiated ; but this is a secondary affection, and very different from the state in which that organ is usually considered to be found. They are not, as is erroneously imagined, primarily and chiefly liver diseases, in which there is, at least, incipient disorganization of that viscus, or a condition nearly approaching to it, which is the idea commonly intended to be conveyed to patients, and generally received by them, from the use of the term liver complaint; but are functional derangements of the stomach and intestines, the liver being affected secondarily and sympathetically ; and so far from requiring large and repeated doses of mercury, for the restoration of its healthy functions, that they can be permanently re-established only by the use of means directed to correct the original morbid affection. Among these means, we shall see that mercury is not always admissible, even in minute doses, and that in large ones it is invariably pernicious.

So vast a sink of disease has the liver been thought of late, that it is considered by some men, of no small professional eminence, as amongst the greatest improvements of modern medicine, that the attention of the practitioner is duly awakened to the "remarkable sympathy" which it exerts in its functions with all the other viscera ! This sentiment appears to me utterly inconsistent with our physiological knowledge, and with the light thrown on the pathology of abdominal disease by morbid anatomy : it seems invalidated by established facts. When we remember the dull sensibility of the liver, and the loose* connexion it has with the other viscera of the abdomen, and with those of the chest, by reason of the small number of its nerves, we are at a loss to conceive how this "remarkable

* I wish the reader to bear in mind, that throughout this book, when contrasting the abdominalconnexions and general sympathies of the liver with those of the stomach and intestines, I speak relatively. It cannot be my desire to endeavour to show that the liver is really slightly connected with the other abdominal viscera and general system, but that this connexion is much inferior to that of the stomach and bowels. It is on this inferiority of connexion and sensation, that I found my opinions of its inferior importance to the well-being of the whole frame, which if I succeed in proving, is all I require to show that other language, and more lenient treatment, than is commonly employed, ought to be adopted.

sympathy" can exist between them; and if our judgments are unbiassed by theory— unwarped by bile, surely we are naturally led to question it; but if it be transferred, as it ought to be, to the alimentary canal, we are so far from being unable to perceive the source of that intimate and important sympathy subsisting between this and every other organ, and indeed with the remotest parts of the body, that we are surprised it has so long escaped due attention. For whilst the anatomist notes the comparative paucity of nerves distributed to the hepatic viscus, he is struck with the number and variety of them, almost innumerable, which ramify and subdivide upon the alimentary canal and mesentery, especially upon the upper part of the former. These, by their connexions with each other, with the nerves of the spinal marrow throughout, and with those of the chest and head, establish such an intimate intercourse of sensations and afFections between themselves, and every other part of the body, as readily explain the marked and powerful influence they exercise over the functions of every organ, even the most distant, and of both the external and internal surfaces. In these nervous connexions, and in the elevated sensibility arising from and dependent upon them, we at once recognise the foundation of the constitutional origin of local diseases, and the source of those wandering pains, and indescribable sensations as well as of that great nervous depression, and general disorder and debility, invariably accompanying an unhealthy state of these assimilating viscera. By reason of these extensive and diversified associations, the stomach and bowels become a centre of sympathies, and disorder, originating here, rapidly propagates itself to every other part. Thus we see the propriety and necessity of attending closely to the state of these internal viscera, in diseases of every class and degree, whether original or sympathetic.

Though I do not consider the nerves as the exclusive instruments of sympathy, they are unquestionably the chief sources of it ; and, therefore, it is a natural inquiry, where this "remarkable sympathy" clearly appears from disordered liver, and how does it arise, situated as this viscus is, so much without the nervous connexions established between the remaining assimilating viscera, and all other parts of the body, by the important system of the great sympathetics, and the par vagum? These sympathetic nerves are the principal links which unite the internal nutritive functions, to those which keep up the relation of the animal with external objects; and it is by this bond of union that the derangement of their important functions, whether by acute or chronic disease, is necessarily attended with proportionate changes in all the acts of the animal economy, in the same manner as the defects of one wheel interrupt or disturb the mechanism of a whole machine. But, as was observed above, so imperfect are the sensibilities of the liver, that though acute inflammation of any portion of the alimentary canal is invariably marked by the acutest suffering, and the most alarming symptoms, which, if not checked, speedily terminate fatally, inflammation of the liver will be making destructive progress when the patient slightly complains only of a flux, — frequent inclination to stool, — gripings and watery motions ; the heat of the surface being but little increased, and the pulse neither hard nor quick ; and thus hepatitis generally appears, even under the burning sun of the east. Morgagni mentions several instances of inflammation of the liver, marked by no peculiar symptoms, an occurrence with which our naval and military surgeons, who have served long in tropical climates, are very familiar.* In the

* Dr Archibald Robertson, in his Medical Topography of New- Orleans, in describing the frightful march of dysentery, which 6i knew neither pause nor hindrance, but, like the fabled vulture of ancient mythology, pursued its cruel task from day to day" amongst the British troops before that place, observes : — " Oftener the complaint would make its attack with the common introductory symptoms, and no pain in the right hypochondrium was felt throughout the disease, either on inspiration, or strong pressure under the false ribs. In whatever garb of disguise it made its appearance, disease of the liver (as I have before stated,) and, consequently, a vitiated state of its secretions, were undoubtedly the primary cause of the mischief. Dissection of the fatal cases showed structural derangement, — a soft friable condition, and generally suppuration of that gland. I have often found two separate abscesses in the parenchyma of its large lobe, the one generally less deep-seated than the other, and containing, in some instances, a quart of pus, similar in colour and consistence to what is usually found in psoas abscesses. How such extensive disorganization and formation of matter could take place, without any preceding palpable indication of local mischief is to me still a mystery :

ordinary chronic affections, also, of this viscus, occurring in this country, so great is its insensibility, so indistinctly do the other viscera of the abdomen, and the general system sympathize with it, that extensive organic mischief has often been detected in it by the knife of the anatomist after death, when the patient during life was uncon-

But such was the fact." In noticing the appearances on opening the abdomen of a naval officer, who fell a martyr to dysentery off New Orleans, he says,—" After the liver had been removed, and laid out for minute inspection, I found an abscess of such extent and so lined in its inner surface with a thick, fretted, and irregular exudation of coagulable lymph, that it resembled a familiar and homely object, viz. a large winter glove, lined with worsted ! On accurate examination, a second abscess was found, lower down in the large lobe, containing a pint of pus."

" This officer had never, at any period of the disease, felt any ■pain in his side : From his general intelligence, and from the accurate descriptions he gave me daily of his minutest sensations, I am convinced he would have mentioned that pain, had it existed, even to the extent of a 'sensus molestise.' Besides, he was one of the last men in the world that one would have suspected of hepatic affection, being florid in complexion; and having previously enjoyed the best health all his life."

" Instructed by this insidious case, I had my eye to the liver ever afterwards; but pain of side, or pain on pressure under the ribs, was by no means often felt, though dissection after death brought to light hepatic disorganization, equally extensive as in the above case." — Dr Johnson on Tropical Climates, page 438.

Though I cannot agree with Dr Robertson, that this hepatic disease should be considered as the chief and primary cause of dysentery, it being regarded by me as one only, and most certainly not the principal, in a series of morbid causes ; yet these extracts tend irresistibly to convince us of the truth of what I here advance, and which it is material for the profession and the public to reflect upon, — the natural and conspicuous insensibility of the liver, and the inferior importance of its functions.

scious of any thing wrong in that region. These persons, when alive, had shown no yellowness or sallowness of complexion, had complained of no pain in the right side, or shoulder, nor suffered under any perceptible weakness, or any other symptom which could lead their friends or physician to suppose, that so large a viscus w 7 as actually in a state of irremediable disease. Are not these facts irreconcileable with the hypothesis, of an important and remarkable sympathy existing between hepatic derangements, and all the other acts of the animal economy ? Do they not, on the contrary, forcibly convince us how comparatively imperfect the relation of the liver is, how inferior its sympathy, with other parts ; proving most satisfactorily the error and folly of calling the prevailing disorders of the digestive organs, bilious complaints ? And when we reflect upon the extensive nervous influence, the exalted sensibilities, and the great importance of the functions of the stomach and bowels, do not the probability and rationality of considering these affections as centering here, and not in the liver, become apparent ?

The fact of positive disease frequently taking possession of the liver, without the constitution, or any single viscus sympathizing with it, and, therefore, without its being discovered during the life of the patient, cannot be denied. In order to overcome the powerful argument thence derived, against the supposition of so " remarkable a sympathy" being exerted by this viscus, in its functions \ with all the remaining viscera, will it be asserted, that it is not the organic injury, but the simple derangement of function in the liver, that is attended by effects so extensive and pernicious ? This follows of course : But it is, at least unreasonable, and contrary to what takes place in any other organ ; having for its support, merely the discoloured appearance of the alvine discharges, and the power of mercury in restoring them to their natural colour, w 7 hich we shall presently see is a weak prop. Those w T ho maintain this opinion have the cause of an improbable anomaly to explain, for we meet with nothing similar in the lungs, the head, the digestive tube, or elsew 7 here. Here the favorable prognosis of the physician is in proportion to the freedom of the affected viscus from structural disease, and the degree in which the remaining viscera sympathize with it, and in which the general habit emaciates and sinks, is also generally in the same proportion. This accords with all we know respecting the laws of organic life ; and before it can be admitted, that these laws are reversed in favour of hepatic derangements, we must assuredly possess some clearer and better reasons for it than have hitherto been attempted.

The stomach, and first intestines, unquestionably perform the most important offices in the frame, and are the grand sympathizers with all the local and constitutional derangements of the system, the cause of which has been pointed out as arising chiefly from the enlarged and varied communications of those nervous apparatus, known by the name of the great sympathetics, and par vagum. These assimilating viscera carry with them in their action all the other organs of the economy ; "they summon to their aid the whole system of the vital powers ; and this sort of derivation is the more conspicuous as the organization is more delicate, the sensibility more lively, the susceptibility greater." In short, it may be truly remarked, that they are the great arbiters of health and disease, of life and death. Yet, in the modern fashionable system of the pathology and treatment of abdominal disease, these are considered parts of far inferior consequence to the liver ; this is regarded as the fruitful "fons malorum" and thus we retrograde in our knowledge of diseases, and in our acquaintance with the means of cure.