]S T o. 4. Price, 35 Cents.

PUBLISHED I $8.00 SEMI-MONTHLY. LIBRARY '/ PER YEAR. OF Medical Classics. Oct. 15, 1881. Indigestion and Biliousness,

BY

J. MILNER EOT H ERG ILL, M. D.,

MEMBER OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON ; SENIOR ASSISTANT

PHYSICIAN TO THE CITY OF LONDON HOSPITAL FOR DISEASES OF THE

CHEST ; LATE ASSISTANT PHYSICIAN TO THE WEST LONDON

HOSPITAL ; ASSOCIATE FELLOW OF THE COLLEGl>*rti PHYSICIANS OF PHILADELPHIA.

“What is one man’s meat is another man’s poison.”

NEW YORK: BERMINGHAM & CO., PUBLISHERS, 1260 & 1262 BROADWAY.

Library ofMedical Classics.

Published by Bermingham & Co., No. 4. Nos. 1260 & 1262 Broadway, New York. Price 35 Cents. INDIGESTION AND BILIOUSNESS.

J. MILNER FOTHERGILL, M.D.;

MEMREI OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON; SENIOR ASSISTANT PHYSICIAN TO THE CITY OF LONDON HOSPITAL FOR DISEASES OF THE

CHEST (VICTORIA PARK) ; LATE ASSISTANT PHYSICIAN TO THE WEST LONDON HOSPITAL; ASSOCIATE FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA.

'* What is one man’s meat is another man’s poison.”

PREFACE.

The study of chronic disease has compelled digestion, in its various forms, becomes intel- the writer to pay minute attention to the sub- ligible. Chaos “without form and void” ject of assimilation and its disturbances. thus becomes “dry land and waters.” Research in the deadhouse, even when aided The disturbances of the digestion are terri- by the microscope, can never supply more bly on the increase in the present day; and a than the anatomical factors of disease. It is chapter is appended on “The Failure of the important to instruct us as to disturbance of Digestive Organs at the Present Time.” function. Physiology —an acquaintance with For a contribution to this subject, as well function in health, can alone guide us to a as other favors, I here acknowledge my in- knowledge of disordered function. debtedness to Duncan Bulkley, M. D., of New The following book is written from a physi- York. ological standpoint. For aid in revising the proof-sheets I have The history of normal digestion precedes to express my thinks to David J. Johnson, and introduces the subject of indigestion; first Esq., M. B. in the alimentary canal, then, secondly, in the 23 Somerset Street, Portman Square, W liver. By such study the management of in- June 21st, 1881.

CONTENTS.

Chapter I.—Introduction 2 Chapter VIII.—Diet and Drink 38 Chapter II. —Natural Digestion—Starch— Chapter IX. —TheFunctions of the Liver. 41 Albuminoids—Fat 3 Chapter X. —The Phenomena of Liver Chapter III. —Primary Indigestion 7 Disturbance—Biliousness 46 Chapter IV. —Suitable Forms of Food— Chapter XI.—Phenomena of Liver Dis- Artificial Digestive Ferments 12 turbance (continued )—Liver Indiges- Chapter V. —Tissue Nutrition 20 tion 56 Chapter VI. —Secondary Indigestion— Chapter XII. —The Treatment of Liver

— — Neurosal — Reflex Cardiac —Toxae- Disturbance Medicinal and Diet- mic 24 etic 68 Chapter VII.—Indigestion as an Intercur- Appendix.—The Failure of the Digestive rent Affection 35 Organs at the Present Time 79 INDIGESTION AND BILIOUSNESS.

CHAPTER I. ture. If digestion were merely a deficiency of gastric juice due to disease of the walls of INTRODUCTION. the stomach, its treatment would be ren- There are many ailments, many disturb- dered very simple; it would consist in giving ances of health, which embitter our existence, after a meal so much gastric juice derived and limit our power of labor, that are not from our omnivorous congener—the pig. In illumined by any side-light from the dead- many cases, doubtless, this is enough to house. They are essentially the maladies of achieve what is required; but this is not the the living! whole, nor even the main part of the rational It is not disputed that in certain cases treatment of the various forms of indiges- changes are found in the dead-house, enab- tion. ling the cases to be classed as chronic gas- Starch, albuminoids, and fats; each of tritis, gastric ulcer, gastrid cancer, or gastric these has its own digestion, its own portion dilatation; but then, these are the ultimate of the digestive act; which must be allowed changes at the end of the case. Before these for in our diagnosis, and in the selection of pathological conditions have been developed, our remedial measures. The treatment of in- there has been a long preceding his- digestion is like the fitting of a suit; there are tory of functional disturbance; and even the three component parts of the suit—coat, when they are fully developed, the waist-coat, and trousers—to be seen to. Two stomach retains some of its functional may fit; but the third does not. So in dys- powers until the last; or until very near the pepsia! Or the whole may be badly made, or last. Such mere anatomical division of the ill-fitting. The treatment of a complex mal- maladies of the stomach is useful diagnostic- ady, is like the makingof a suit; it has got to ally, and, prognostically; even more so fit the individual exactly. Some persons can in the aeadhouse; byt for all purposes go into a ready-m,ade shop, and buy an article of rational treatment such division is as ster- which may fit very fairly. So some dyspep- ile as a Vestal virgin. tics only require pepsin wine for their cure. To be of practical avail to the patient, the But this is not the rule; rather is it the ex- stomach must be looked on from the stand- ception. Some people are “ bad to fit,” in point of its physiological function; which is tailor’s phrase; and tailors differ in their ca- not abolished by the particular form of the pacity. Some people arenot “easy to treat;” disease. In all those myriads of cases where and perhaps all medical men are not alike in there is no gross disease, but where there is their capacity. Then again, there are some only decided dyspepsia, any classification persons, whom even very competent tailors, founded on pathological changes is powerless cannot fit; only one tailor cap manage tp fit to help us. them. So there are a proportion of persons Nor are we correct in thinking that the who find out that one medical man alone can greatest activity of the digestive act, is to be prescribe satisfactorily for them. With tailors found in the stomach; really, the seat of and doctors alike this last class, fortunately a greatest activity is beyond the pyloric ring, in very small one, really is unpopular; nor is the duodenum. The stomach is specially the there any difficulty in conceiving that this seat of the digestion of albuminoids in an should be so. acid medium; consequently the morbid Then again, “biliousness,” is connected changes in the coats of the stomach are not with disturbance of the digestive process in the anatomical substrata of all disordered the liver; a matter we now do kpow some- function. In certain mofbid conditions of thing about. Until recently, yea very re- the stomach, the mucous coat is found dis- cently, vye really did know nothing, or little eased, and the gastric follicles more or less more than nothing of the function of this mutilated; but what would this tell us even if huge viscus. But lately, thanks to such we could see it with the eye in life? It would physiologists as the late Claude Bernard, Lud- demonstrate the necessity for encouraging wig, and Pavy, and Lauder Brunton, in our other parts of the digestive system than the own country; our knowledge has of late made stomach! How this can be done,, will.be giant strides; and enlarged physiological shown further on. We will never under- knowledge has led the way and broken a path stand digestion, its disturbances, and how to for a rational comprehension and treatment of meet them, by poring over the morbid changes the disturbances of the liver. The chemical found in the post-mortem room; even when composition of the bile-acids tells of their aided by the microscope. We might aswell at- albuminoid origin; and speaks with no indis- tempt to study the construction of a building tinct utterance of the dietetic management of from the examination of it in ruin, and by biliousness, as well as the remedial measures minute inspection of the material of which it to be employed. consisted. It is this study of the digestive The chemical composition of the urine canal after life has fled, which has led us solids has long years ago cleared up the gene- astray from the real study of the digestion as alogy of gout; but we recognize nevertheless, a physiological process; how it comes to be that gout does not take its genesis solely in deranged, or defective; and how to remedy port wine and gluttony. Certainly these two the . different disorders, according to their na- can, in the course of time, provoke gout, if NATURAL DIGESTION-^STARCH—ALBUMINOIDS—FAT. 3 sufficiently persisted in; even in the healthiest become familiar with each section of the systems. whole. Consequently it is only in acquaintance Our knowledge of the digestive act, as with the digestive act, and the disturbances said in the Introduction, is very recent; con- thereof, first intelligently comprehended, and sequently medical teaching, until the last de- then carefully reasoned upon in the consider- cade, had littLe to say on the matter. Now ation of assimilation as a physiological pro- physiology has acquired articulate speech; cess, that we can lay the foundation of a and can talk sufficiently well to tell us much, rational comprehension of the maladies—in- of the greatest importance, on subjects which digestion, biliousness, and gout; and of a interest the medical practitioner in almost treatment which is successful, except by a every case which comes under his notice in lucky guess. But lucky guesses do not run his every day round of professional duty- thirteen to the dozen. Systematic study, much that adds most materially to his power leading to the fulness of knowledge, may be to be of service to his suffering patients. a laborious, toilsome way of acquiring the The subject has received a distinct stimulus requisite and desired skill, but it is infinitely by the delivery of the Lumleian Lectures be- surer, as a rule, and more to be relied upon, fore the Royal College of Physicians, last than those flashes of inspiration whose occa- year, (1880) by Dr. William Roberts, F.R.S., sional occurrence is not denied; but whose ap- of Manchester. To this able physician and pearance cannot be calculated upon with any his lucid lectures on “The Digestive Fer- approach to certainty. Sap and mine is a ments,” and “Artificial,,Digestion,” I,,owe slow but sure way of gaining a fortress; much for further information on a subject escalade may carry it by storm, but it is nota- which- has long interested me in the. treat- bly a hazardous measure, often ending in fail- ment of chronic disease. I shall avail my- ure, sometimes in grave disaster, self (by his permission, most generously and It is the systematic study of assimilation, gracefully granted) of his lectures in these as a normal process, and, by its light, mal- pages very fully; nor will it be possible, I assimilation, or the derangement thereof,, fear, by the mechanism of inverted commas, which alone, can enable,us to grapple success- always to indicate every, piece of .indebted- fully with maladies which are the, bane of ness; especially when the subject does pot many an existence; which usually dp not kill permit of verbatim quotation. By the study pf .directly, but which often induce consequen- of the action of the ferments, put ., the tial changes incompatible with the continu- body, much has been learnt of their action ance of life. The albuminuria which heralds within the living organism. ; jj ,, the advent of the final change in old gouty A “ferment” is.a body which works changes kidneys, is,but the, outcome of a mprbjd pro- in other, substancps, altering their chemical cess which has, been established for years, ft constitution somewhat. Thus yeast is a fer- tells of the end of the case; but directly, it ment used in the making of .bread. In the throws no ray pf light upon the origin of saliva we find a ferment,; in the gastric juice these morbid modifications of nutrition, in another ferment; in the pancreatic secretion a which the gouty kidney takes it origin. It is third—the most complete of all. but the thunder of the storm; not the electrjc Now let us, consider the digestive act in and atmospheric disturbances which bring the outline. thunder-storm about. To understand the First, tfie starch of our food is acted upon thunder-cloud we do not confine ourselves to by the saliva;, which converts it info .sugar; as observations of the lightning and; the thunder; ■soluble sugar in the stomach, it is absorbed we go , further back into the genesis of the into the bipod. Then the albuminoid con- storm, and strive to comprehend the forces stituents of our fopd are apted upon by the which brought it about. In practice; it is not stomach in two ways., By the movements of enough to test for albumen, or examine the the stomach, the mechanical disintegration excreted urine solids; it is necessary to exam- commenced by mastication, is, completed; and ine the digestive processes themselves, In the food is reduppdtQ minute fragments, upon order to comprehend the malady properly. which the gastric juice can operate : success- In order then, to rationally understand the fully. Thus muscular fibre, the type, of al- nature of: indigestion, biliousness, and gout, buminoid food, is crushed by the teeth, and we must commence with a clear comprehen- then rolled oyer in the stomach until - the sion of the digestive act in health. After minute fibres fall asunder. So, disintegrated, that, and after that only, we may hope to every . fibre can be acted upon by the solvent form some fair conception, of its disturb- juice, and digested. The removal of a por- ances. . : 1 |,,,, tion of, the starch , as soluble sugar, leaves the albuminoids more freely exposed to the action of the gastric juice. , . CHAPTER II. During, this, time fat fias undergone;, no NATURAL DIGESTION — STARCH — ALBUMIN- change. The saliva does not exercise any in- fluence upon matters; neither the — fatty OIDS FAT. does gastric , juice.. But when the partially di- It may be well to first take a bird’s-eye gested , food passes the pyloric ring, 1then in- view of the digestive act; and then, after that, testinal digestion commences; and,the activ- each of to examine part piece-meal and minutely. ity the digestive act reaches its .height. ,,,, By this means tie reader will be enabled to The saliva ferment is only operative in an grasp the subject as a .whole; and then; to alkaline, medium; consequently, when the 4 INDIGESTION AND BILIOUSNESS. stomach, or rather its contents, becomes acid fant period, when the food is found for them in the digestive act, the digestion of starch by their parents. Just as the chick in the egg ceases. When the acid contents pass the lives upon the material stored up Within the pyloric ring, they meet with the alkaline bile- shell; so the seed lives upon the starch and salts, which at once arrest the action of the the fat, also stored up within the husk. These gastric juice, which is only operative in the stores of material for the life of the young presence of an acid. But the scene only plant are garnered for human food. The di- changes; not the act. In this alkaline medi- gestion of starch within the body is allied in um the secretion of the pancreas comes into nature to that process by which the infant play. This complex secretion continues the plant feeds upon the starch within the husk. digestion of the albuminoids in an alkaline The seed undoes the material built up by the medium; the conversion of starch into sugar adult parent plant, by means of a ferment is once more in progress, and the fat is emul- contained within its tissues. In malting bar- sionized. We see a totally new process in- ley the ferment within the grain of barley stituted. Hitherto, fat has been untouched changes the starch in the transformation into by the digestive act. Now it is emulsionized, malt, just as it does in germination within reduced to the tiniest of particles, which are the earth. When the subject of artificial di- taken up by the villi of the intestine. Each gestion is considered, we shall see how this microscopic villus may be seen crammed with ferment of barley, diastase , is utilized to trans- fat globules some time after each meal. form the starchy matter of our food, when In the duodenal or intestinal digestion, the the natural digestion of starch is defective. starch converted into sugar finds its way into The plant pulls the starch granules to pieces the intestinal veins; so do the digested albu- and renders the insoluble starch soluble; and minoids; while the fat is taken up by the that is just what happens in human digestion. villi, the terminal ends of the lacteals. The For digestion is solution; disintegration non-digested materials pass on to form the precedes solution; the insoluble starch must faeces. be converted into soluble grape sugar, to “ In the faeces there are to be found, in the pass from the digestive canal into the blood. first place, the indigestible and indigested While the teeth are crushing the food, and constituents of the meals, shreds of elastic the tongue is rolling the mass over and over, tissue, much cellulose from vegetables, and it is being mixed and inter-penetrated with some connective tissue from animal food, saliva. Saliva contains a ferment identical in fragments of disintegrated muscular fibre, fat its properties with the diastase of barley. The cells, and more unfrequently undigested saliva of man possesses more of 'this di- starch-corpuscles. The amount of each must astatic power than any other animal. For vary very largely, according to the nature of long centuries now, man has cooked the the food, and the digestive powers, temporary starchy material of his food; and so the sali- or permanent, of the individual. In the sec- vary glands of man have become functionally ond place, to these must be added substances very active. In the form of the ground ce- not introduced as food, but arising as part of, reals, we find the action of the teeth supple- or as products of, the digestive secretions ” mented. Disintegration is largely performed (Michael Foster). We see in the feces the for us. Then by cooking, the starch granule remnants of a feast. The uneatable gristle, is prepared by the action of the digestive fer- the bones, fragments of meat and bread— ment, by having its capsule ruptured. When the debris which remain, and have to be bread, a biscuit, or pastry is chewed, the sa- cleared away. The rest disappears, carried liva is mixed with the farinaceous particles, away by the guests. So all the nutrient part and the transformation of starch into grape- of our food, or most of it, is carried away in sugar is instituted. The insoluble starch is the digestive act; the offal only remains. liquefied by hydration, that is by the addition Such then is a bird’s eye view of the digest- of a molecule of water, into dextrine and ive act. We now can profitably examine each grape-sugar. step in it in detail; bit by bit. We can un- The formulae for these are: “ . derstand how the nature of the food” and Dextrine C g H 10 O B ‘ ‘ the digestive powers, temporary or perma- Grape-sugar C gH 12O g . nent, of the individual ” influence the process, Food could not be stored in a soluble form; and its results: see how the diet can be modi- it would be washed away. So the digestive fied with advantage to meet the powers of the act is the dissolving of food, till, in fluid individual: how improvement in the digestive form, it can pass through the walls of the di- powers of the individual can be made opera- gestive canal into the blood. There it is tive in securing more perfect digestion of the turned back, dehydrated by the removal of food. the added molecule of water, and stored up Starch. Starch is a hydro-carbonaceous in the body. When the digested starch in material found in the seeds of plants, espe- the form of dextrine, the soluble or grape- cially the cerealia, in palm-pith as sago, as sugar, is taken into the blood of the portal tapioca from the cassava, and as arrowroot vein, and reaches the liver, it is dehydrated from other tubers, or as potato starch. Its back into glycogen or “animal starch.” As chemical formula is C 12 H 20 O 10 . It is the rapidly as the starch is liquefied into soluble material upon which the young plant feeds sugar it passes through the walls of the stom- until it can get its own nutriment; except as ach; and so does not interfere with the di- sago. gestion of albuminoids going on therein. Like animals, vegetables have an early in- This diastatic action can only go on in an al- NATURAL DIGESTION —STARCH—ALBUMINOIDS—FAT. 5 kaline or neutral medium; as soon as the the process is at the bottom one of hydra- contents of the stomach become acid, the tion.” (M. Foster). The solvent action of diastatic digestion of starch is arrested. What the gastric juice is greatly aided by the mus- starch is left over from the salivary digestion, cular movements of the stomach ; as the con- remains unaffected by the gastric digestion. tents are rolled over and over thereby, they When the food passes the pyloric ring, and is are brought into immediate contact with the mixed with the alkaline bile, then the digestion digestive pepsin and the acid. Muscular of starch is once more resumed under the in- fibres fall asunder, and gradually disappear in fluence of the amylolytic ferment in the pan- the stomach as the digestive act progresses; so creatic secretion. other proteids are rendered soluble in this Albuminoids. From the albumen in the acid solvent medium. The whole of the egg, the tissues of the embryonic chick are proteids are not digested in the stomach, but formed. From the albumen in the seed of are passed through the pyloric ring, the plant, the tissues of the germinating when it relaxes towards the termination seedling are fashioned. Tissues are formed of gastric digestion. The two rings, from albuminoids, with some auxiliary assist- the one at the foot of the gullet, ance from hydrocarbons. Liebig long ago the cardiac orifice, as well as the pyloric ring pointed out how the presence of nitrogen in at the intestinal outgoing orifice of the combination with hydrogen and carbon, in- stomach, are contracted during the time of terfered with their ready union with oxygen. its activity; and as the contents become dis- Albumen has the' formulaaccording to Hoppe integrated, the pyloric ring relaxes. The food Seyler, quoted by M. Foster : has fallen to pieces in the stomach, such of it as will, little bits of gristle and vegetable Og Hj.j C o• 9 N 15 . 4 6S . 7 S 0 . 8 fibre being left en masse; and so is prepared for further intestinal digestion. The fat is to to 1-3 to 1 • to 54-5 to g o 23-5 6 5 stored in the body in areolar tissue, in the con- Containing nitrogen, albuminoids do not nective tissue, or packing material, and as readily oxidize; and thus the body-tissues are such consists of fat in an albuminous en- formed of albuminoid materials. The hydro- velope. In normal digestion that envelope is carbons, or fuel food essentially, burn by dissolved, and the fat set free. But fat itself oxidation in the system, while the tissues hitherto has undergone no change whatever. themselves do not burn. It is like the coal “ On fats gastric juice is powerless. They burning in the steam-engine, while the iron- undergo, by reason of it, no change whatever work does not burn. Nevertheless the iron- in themselves; when adipose tissue is eaten,all work wears out by a slower process of oxida- that happens is that the proteid and gelatini- tion, known as “ rusting.” So it is with the genous envelopes of the fat-cells are dissolved, albuminoid tissues of the body they do not and the fats are set free; the fat itself under- burn properly, but they slowly oxidize, or goes no change except the very slightest rust as they wear away. emulsion.” At times the liberation of fat in- Albuminoids are not affected by the saliva; terferes with gastric digestion. the gastric juice is their solvent. On the Fat. —It is only after the food has passed digestion of starch the gastric juice exercises the pyloric ring that the digestion of fat com- no effect; except to arrest the action of the mences. Some decomposition at times takes saliva upon it. “ When digestion is proceed- place, and a fatty acid is formed, which irri- ing comfortably and normally, a certain in- tates the stomach, and constitutes one form of terval elapses before the acidity of the dyspepsia. “ The digestive change under- stomach becomes considerable, and during gone by fatty matters in the small intestine, the interval, the salivary diastase continues consists mainly in their reduction into a state and has time to accomplish a good deal of emulsion, or division into infinitely minute of work.” It is upon albuminoids that particles. In addition to this purely physical “ pepsin,” the gastric ferment, exercises its change, a small portion undergoes a chemical sole action. The gastric juice contains pep- change whereby the glycerine and fatty acids sin and hydrochloric acid. “ In one im- are dissociated. The fatty acids thus liber- portant respect pepsin, the ferment of gastric ated then combine with the alkaline bases of juice differs from ptyalin, the ferment of the bile and pancreatic juice, and form soaps. saliva. Though saliva is most active in a The main or principal change is undoubtedly faintly alkaline medicine, there seems to be an emulsifying process, and nearly all the fat no special connection between the ferment taken up by the lacteals is simply in a state of and any alkali. In gastric juice, however, emulsion, and not of saponification.” Bile there is a strong tie between the acid and the exercises some influence upon fats. “ It has ferment, so strong that some writers speak of a slight, but only slight, emulsifying power. pepsin and hydrochloric acid as forming to- A mixture of oil and bile separate after shak- gether a compound pepto-hydrochloric acid.” ing, less rapidly than a mixture of oil and (M. Foster). Before digestion an albuminoid water; this action is probably due to the alka- is termed a “ proteid ;” the digested proteids line nature of bile. Oil passes with considera- are termed “ peptones.” As peptones, albu- ble ease through a filter-paper kept wet with minoids readily pass through the walls of the a solution of bile salts in company with one digestive canal into the blood. The change is kept constantly wet with distilled water. Bile caused by adding a molecule of water ; therefore must be said to have a slight action * ‘ judging from the analogy with the action of even on fats. 11is probable, however, that saliva on starch, we may fairly suppose that it is more useful when combined with pan- 6 INDIGESTION AND BILIOUSNESS.

creatic juice than when acting by itself.” (M. the amyloids of our food, are stored for the Foster). needs of the body, and given off as required. A fat is a hydro-carbon, containing a small The after history of peptones is very inter- proportion of oxygen. It is formed when the esting, as far as it is known. They disap- assimilation of hydro-carbon is in excess of pear in the blood, and are not found in it, the body needs; the surplusage is stored as “neither in the portal blood, nor in the fat or adipose tissue. The reserve is con- chyle, nor in the general blood during diges- sumed when the food is insufficient in supply, tion, is there any appreciable quantity of and disappears on starvation. This is the peptones.” (M. Foster). In a recent arti- formula of stearin, the firmest of the fats. cle, “The Practitioner,” October and No- S., (Cl Hg O), ) vember, 1880, Dr. Lauder Brunton, F. R. 8 5 q discusses the possibility of C H peptones escaping 8 8 the dehydrating process, and thinks “that The others, oleine and margarine, are much the liver, to some extent at least, serves the the same chemically. Oleine is the most purpose of preventing any peptones from fluid and then comes margarine. Speaking getting into the general circulation, which broadly the digestibility of a fat is in propor- may have escaped transformation in the por- tion to its stiffness when cold. The best cod tal blood before meeting it.” Indeed, from liver oil is frozen at a low temperature, to the time the peptones disappear, to the time freeze out the margarine and stearine, and is of their final change and appearance as ex- nearly pure oleine. Cod liver oil is most creta, as bile acids and urine solids, we, as digestible on account of its fluidity, as well yet, do not know their history; yet it is what some bile in it. Then comes the fluid fat of we would most certainly like to know. From bacon, butter and then cream, oils and animal the albumen in the liquor sanguinis the tis- fats. sues are fed. This is termed “Interstitial Intestinal digestion. When the food, now Nutrition.” Finally, there are the salts of known as chyme, rendered fluid or semi-fluid the blood to be considered. We do not know in the stomach, passes the pyloric ring, it of any digestion of the salts of the body meets the alkaline bile and becomes alkaline. beyond mere solution of them in fluids. Con- Then the digestion of pepsin stops. Just as ditions of spansemia are produced from their the acid gastric juice arrests the salivary di- deficiency, either from the food not contain- gestion of starch, so the alkaline bile kills the ing a sufficiency of them, or their disappear- action of pepsine. ance, as in profuse night-sweats. They are To this alkaline mass is poured out the se- useful in digestion somehow; for I have no- cretion of the pancreas. This is a most po- ticed again and again at the City of London tent solvent fluid. It contains (1), a diastase, Hospital for Diseases of the'Chest, how the digesting starch; (2), trypsin, a ferment di- appetite of the consumptive patient improves gesting proteids in an alkaline medium; and within two or three days of the arrest of se- (3), an emulsive ferment which acts upon vere night-sweats. Prof. M. Foster, F. R. fats. Like the gastric secretion it contains a S., writes— •ferment which curdles milk—an action neces- “The effects of salt as food.—All sary to the digestion of milk. Under its in- food contains, besides the potential sub- fluence the digestion of the starch left in the stances which we have just studied, certain stomach after the salivary action is arrested, is saline matters, organic and inorganic, having resumed. The proteids are converted by the in themselves little latent energy, but yet trypsin into peptones. The fat is emulsion- eitherabsolutelynecessary, orhighly beneficial ized in the presence of bile. The soluble to the body. These must have important sugar, and the soluble peptones pass into the functions in directing the metabolism of the blood of the portal vein. The fat is taken body; the striking distribution of them in up by the lacteals in the intestinal vlli and the tissues, the preponderance ofsodium and carried into the thoracic duct. The waste is chlorides in blood-serum, and of potassium, passed on to be voided; being still acted on and phosphates in the red corpuscles, for to some extent by the succus entericus, or in- instance, must have some meaning; but at testinal juice. present we are in the dark concerning it. Such, then, is the digestive act. The element phosphorus seems no less im- After being made soluble, to pass through portant, from a biological point of view, than the walls of the digestive canal, sugar and carbon ornitrogen. It is as absolutely essential peptones are turned back by dehydration, for the growth of a living being like Penicil- into starch and proteids. They have been lum as for man himself. We find it prob- dissolved so as to pass readily through or- ably playing an important part as the con- ganic membranes; now they are to be stored spicuous constituent of lecithin, we find it up, so they are changedback; otherwise they peculiarly associated with proteids, appar- would escape out of the blood as easily as ently in the form of phosphates; but we they got into it. When the liver is unequal cannot explain its role. The element sul- to dehydrating the sugar of the portal vein phur, again, is only second to phosphorus, into glycogen as rapidly as the sugar is formed, and we find it as a constituent of nearly all the sugar passes out by the kidneys, consti- proteids; but we cannot tell what exactly tuting glycosuria. This may be produced in would happen to the economy, if all the any one by excess of sugar, at once. When sulphur of the food were withdrawn. We the disturbance is pronounced, it constitutes know that the various saline matters are es- “Diabetes.” As glycogen or animal starch, sential to health; that when they are not PRIMARY INDIGESTION. 7 .present in proper proportions nutrition is made up for and compensated by the later affected, as is shown by certain forms of digestion of pancreatic diastase), but the food scurvy: we are aware of the peculiar de- is insufficiently chewed; and is therefore swal- pendence of proteid qualities on the pres- lowed in an unprepared state for the disin- ence of salines; but beyond this we know tegrating action of the stomach. To grudge very little.” time for the proper mastication of food is as Lecithin is a “ complex nitrogenized fat, irrational as was the revolt of the members with the formula C 44 H 9 N.P0 9 occurs wide- against the belly. If the digestion be not ly spread throughout the body. Blood, gall, perfect, then the rest of the body will suffer and serous fluids contain it in small quan- from want of pabulum. The food should be tities, while it is a conspicuous component slowly taken and thoroughly chewed: if the of the brain, nerves, yolk of egg, semen, teeth will permit. Even when a glass of pus, white blood-corpuscles, and the elec- milk is swallowed, or a cup of beef-tea, con- trical organs of the ray” (M. Foster). taining some baked flower, it is all the better Iron is a necessary component of haemo- for being taken slowly, and being to some ex- globin, a most'complex substance, contain- tent mixed with saliva previous to being ing C.5s H 7 N lg 081 S. 4 F. 4. swallowed. When farmers’ wives and daugh- “Haemoglobin is a so-called ozone car- ters'fed calves “off the finger,”so that they got rier” (M. Foster). Here is a very complex their milk slowly; they did better and had less body in the red corpuscles, upon which diarrhoea than now when the calves are al- depends the giving off of carbonic acid, and lowed to take their milk greedily, so that it the taking up of oxygen. curdles too firmly in the stomach. The ad- Lecithin is a phosphorized fact which mixture of some form of ground farina to seems to be the food of the nervous sys- prevent the formation of too firm a curd tem par excellence. would be desirable; if the demands of mod- Where these infinitely complex bodies are ern agricultural life can no longer afford the formed we do not know. Yet we clinically time for feeding calves “off the finger.” recognize that there is anaemia in which the Too firm curdling of milk is a common cause .absence of iron in the food plays a part. of diarrhoea both in human and bovine in- It seems possible that the imperfect forma- fants. The curd is indigestible, so it is got tion of “lecithin” may be the cause of rid of as readily as possible by ejection from much lack of nervous energy associated the bowels. In all cases where a milk diet is with impaired nutrition. The failure of the required, this too firm curdling should be .assimilative processes to build up these com- looked to; it is the equivalent of imperfect plex bodies may coexist with power to form disintegration. the ordinary products of digestion. We are Bad teeth are a fertile cause of indigestion. ‘ beginning to see, albeit ‘ through a glass They not only forbid perfect mastication, but darkly,” the clinical value of a good knowl- the pain of mastication often causes the food edge of digestion, in its power to aid us to be bolted; even when the individuals know in the treatment of many maladies, which full well they will have to suffer for it. The take their origin in failure of the digestive present grave increase in the spread of dental processes. caries is matter for the most serious thought, as regards the next and ensuing generations. If this spreads as it is doing at the CHAPTER III. present time, such a thing as a natural tooth will PRIMARY INDIGESTION. scarcely ever be seen. As soon as the crowns All digestion, then, is a process of solu- protrude from the gum they will require the tion for which previous disintegration is es- care of the dentist; maybe it will become nec- sential. Indigestion then may be due to, (i) essary to nip off the crowns almost as soon as imperfect disintegration; and (2) defective fully developed, in hopeless despair of their solvent power. Of course, if the food taken remaining fairly sound. be of an unsuitable nature, be indigestible in Bad teeth lead to impaired digestion in two itself, then indigestion follows; for which the ways, (i) theyinterfere with the properadmix- digestion processes are not to blame. ture of saliva with the starchy matters of the Imperfect disintegration. This is mainly food, by which the amylolytic action of sali- •due to insufficient mastication. Certainly, vary diastase is lost or thrown away; and (2) when uncooked seeds are eaten the disinteg- by imperfect mastication the food is not pre- ration is never sufficient; but most of our pared for the further disintegrating action of food requiring thorough disintegration, is the stomach, and so great and abnormal mus- prepared for us by first grinding, and then cular movements of that viscus are required cooking. The defect lies either in the bad in order to carry on the disintegration of the practice of eating hurriedly; or, in a growing unchewed, or imperfectly chewed food. In cause of indigestion, bad teeth. As to the prac- all cases of indigestion then, the teeth ought tice of eating too hastily it is to be con- to be critically examined, and if found de- demned without extenuating circumstances. fective put in working order; after which the The habit of eating in company and chatting, troublesome symptoms may pass away without is conducive to good digestion, by prolong- requiring further medical attention. ingjthe meals; and allowing thedisintegrating Imperfect disintegration may be due to de- action of mastication to go on efficiently. It fective action in the stomach. There the is not merely that the effect of saliva upon atrophy of the muscular coat impairs the en- starch is lost, or largely so (that might be ergy of the movements of the stomach; as is 8 INDIGESTION AND BILIOUSNESS. notably seen in gastric dilatation; or there them, for the latter to be successful. Precis- may be an abnormal quantity of gastric mu- ion in diagnosis as to anatomical change cus thrown off, in which the food is rolled has been insisted upon usque ad nauseam, over and over, until a thick mucus layer is considering the barrenness of results attained formed which most effectually resists the sol- thereby. But precision in diagnosis from ob- vent action of the gastric juice, so that the servation of physiological functions, and its action of the salivary diastase alone goes on, disturbances, has yet to be attained; but and the food is passed into the intestines in when attained it will be most fertile in re- no way advanced by gastric digestion; or an sult. ulcer on the walls of the stomach may arrest For the stimulation of the salivary glands the muscular movements of this viscus, and we possess few agents, little if ever resorted so lead to impaired disintegration. In all to for the purpose of stimulating the salivary these cases there is lessened disintegrating glands. The chief of these are mercury, power in the stomach, and consequent indi- jaborandi and pellitory. Some persons chew gestion. ginger or cinchona bark; but such measures Now in all cases of indigestion due to im- are of comparatively little service, contrasted paired disintegrating action, the sole remedy with the resort of vegetable diastase to supple- is to modify the diet accordingly; if the cause ment the digestion of starch by the salivary of the impaired disintegration be not, as is diastase. often the case, removeable. Bolting the food This matter will receive attention in the may be remedied; bad teeth may be supple- next chapter, devoted to the consideration of mented by the skill of the dentist; imperfect the Artificial Digestive Ferments. muscular movements in the stomach may be For the stimulation of the gastric secretion improved by the administration of strychnine. we possess several agents. There are a num- But in the bulk of cases the treatment ber of articles of our pharmacopoeia which in- lies in suitable food. It must be prepared so crease the flow of gastric juice. Among as not to require disintegration. In mild cases them are agents which produce severeinflam- it is sufficient to avoid pastry, veal, pork and matory symptoms in the stomach if taken in other things which are not easily disintegrated; large quantity, of which arsenic is the type. and to adopt a dietary of fish, white meat, Alcohol possesses the same power. In small milk puddings, and stewed fruit. But when doses both these agents produce a flow of the case is one of gastric catarrh, ulcer, dila- blood to the lining membrane of the stomach, tation, or cancer, then a strict regimen is ab- which increases the flow of juice. U hen solutely necessary. The food must be in empty the mucous coat of the stomach is pale fluid, or semi-fluid form; and consist of such and bloodless. When food is taken it be- materials as require neither mastication nor comes red, turgid with blood, and bedewed the exercise of much muscular movement in with secretion exuding from the orifices of the the stomach; if there be gastric catarrh such gastric tubules. Consequently the glass of as can not well be rolled up into a mass, and sherry, or even gin and bitters, is not out of covered with tenacious mucus. It does not place, or out of time, in all cases. Where it is matter what the gastric lesion, the digestive undesirable to resort to alcoholic stimulants act is the same; and requires identical man- the old-fashioned dinner-pill of ipecacuanha, agement. It must then consist of milk, or milk- cinchona and aloes and myrrh pill is indi- gruel; or beef-tea, or mutton broth with some cated. Ipecacuanha in small doses excites baked flour added. Such then briefly is the the mucous membrane of the stomach; in management of indigestion due to imperfect larger doses it excites vomiting. Further, it disintegration. is a powerful stimulant to the liver. Conse- Imperfect solvent action. This may be due quently it is indicated as a constituent of to impairment in the saliva, the gastric juice, primary importance in the dinner-pill. Then or the pancreatic secretion. The first will there are bitters of world-wide reputation give us impaired digestion of all amyloid both to whip the appetite and to increase the materials; the second impaired digestion digestive power of the stomach. Ringer has of albuminoids; while the third will ren- found that the contact of an alkali to the der the assimilation of fat imperfect. lining membrane of the stomach induces a Deficiency in the first two may be met by in- subsequent flow of gastric juice if taken be- creasing the activity of the last by ap- fore a meal. By the judicious fitting of such propriate measures. But deficiency of fat- measures to each case, good results may digestion by impaired pancreatic secretion often be obtained without further measures cannot be compensated. In each case before being required. These other measures are us, it is necessary to arrive at clear views as the utilizing of the gastric secretion of our to what it is we wush to remedy. It will not omniverous congener, the pig, to help to do be found either successful or satisfactory to the digestion for us. prescribe at a venture either medicine or arti- So long as the stomach was supposed to be ficial digestive agents, in a hap-hazard way. the sole, or almost sole seat of the digestive To give bitters, hydrochloric acid, or even act, measures intended to act upon it were pepsin wine, when it is the digestion ofstarch alone sought for, and enquired after. But and fat which is defective. "Nor preparations when physiological research discovered that of malt diastase when it is the digestion of the stomach only played a part, a compara- albuminoids which is impaired. There must tively subordinate part in the digestive act, be a precision in diagnosis preceding the other means were searched for, and found; therapeutic efforts, guiding and giving aim to viz., measures which stimulate the secretion PRIMARY INDIGESTION. 9 of the pancreas and the liver. I low the ac- be well now to consider some concomitant tion of this last large viscus has so long re- states which require attention, before pro- mained shrouded in Stygian darkness, it is im- ceeding to review the matter of the inability possible to say. Practical medicine has to digest fats; often a very grave affair, es- ‘gleaned a scrap or two of empirical lore about pecially when found with profuse night- it. But sciencewas dumb, or scarcely articu- sweats. late, until this sneer was justifiable, “ it was In gastric catarrh not only must the food be taught by physiologists, sixteen hundred fluid or semi-fluid, and utterly free from per- years ago, that the urine was formed by the ceptible particles, such as may be rolled into liver and separated by the kidneys; and those a ball and enveloped in a covering of catarrhal who come after us may judge whether the mucus; but means must be used to check the nineteenth century have made any real pro- catarrh. Compound kino powder is a great gress in this matter compared with Galen.” favorite in the treatment of gastric catarrh; Certainly it was not till late in the nineteenth the pill of sulphate of copper and opium is century that any real advance was made in often useful. Other combinations of opium our knowledge of the physiology of the liver and astringents may be used. T. King Cham- and pancreas; such as is of practical use to us bers has pointed out that in gastric catarrh in our essays to aid, or remedy disturbed as- these combinations do not produce constipa- similation. tion to the extent that might be anticipated; For the stimulation of the pancreas we their astringent action apparently being spent possess only one agent of whose properties upon the morbid mucous lining of the we are at all assured; and that is sulphuric stomach. ether. Dr. Balthazar Foster, of Birming- In gastric ulcer it is well to give an opiate ham, first used ether to stimulate the pan- an hour before food is taken. This lessens creas to increased secretion in cases where the pain, and diminishes the movements of cod-liver oil, taken alone, disagreed, or was the stomach, so that vomiting is prevented to not assimilated. The addition of ether led a great extent. It allows the food to pass to satisfactory results. Dr. Foster’s express- through the stomach into the duodenum, es- ions of opinion and practice led to a Com- pecially when it consists of milk-gruel already mission being formed in the United States to partially digested. Bismuth is also very investigate the subject. Their results useful. corroborated Dr. Foster’s views. In gasttic cancer an opiate is equally indi- Instead, however, of stimulating the pan- cated. Both in ulcer and in cancer, when creas in some cases, it is more convenient to the surface is raw, the acid of the gastric juice employ a preparation containing the different causes acute pain, so the food should be pancreatic ferments, as the Liquor Pancreati- “ sheathed with an alkali.” cus, giving it according to the directions fur- In gastric dilatation itis desirable to empty nished in the next chapter. the stomach artificially from time to time, and For the stimulation of the liver we can use then wash it out with a solution of the sul- a variety of agents whose actions have been phites. The diet always to be most carefully much elucidated by the work of Prof. Ruther- attended to in each case. ford of Edinburgh, who investigated the ac- In diarrhoea, especially when it comes on tion of drugs upon the liver. These agents immediately after food, the contents of the are ipecacuanha, iridin, and euonymin, as small intestine are swept along too rapidly for vegetables; and the sulphate of soda as a absorption to go on properly; and therefore saline laxative or purgative, according to the the system is badly nourished. Here opi- dose. By the use of these agents the liver is um and bismuth are especially indicated, to- stimulated; a fact quite corroborated by clini- gether with a strict milk dietary. Often there cal observation. Sulphate of magnesia is a is acidity, especially with infants, and then stimulant to the intestinal glands and a purga- lime water, prepared chalk, or light magnesia tive; but it will not clean the tongue and un- —some or other of the fixed alkalies, should load the liver like the sulphate of soda. It be added to the milk. is this fact which led me to substitute ‘ * Sodas Astringents containing tannin, or the min- Sulphat.” for “ Mag. Sulphat.” in so many eral astringents, as sulphate of copper, and prescriptions in the second edition of my opium are indicated in true ordinary diar- “ Practitioner’s Handbook of Treatment, or rhoea. Sometimes larger doses are required the Principles of Therapeutics ” (1880). than those in ordinary use. When the diar- Especially when there are deposits in the rhoea is frequent, teasing, and the amount urine, and pale stools, with a furred tongue, small in quantity and no relief is obtained, and a bad taste in the mouth in the morning, then it is well to give a full dose of castor oil, is the use of these hepatic stimulants to be or rhubarb, ifit persist after this the rectum resorted to: and the results so attained are should be explored, for a mass will probably satisfactory when a proper dietary is added be found in the colon, preventing the passage thereto. As to the efficacy of hepatic stimu- of solid faeces. lants there can be no more doubt than that In constipation it is well to give a pill at these are stimulants to other glands. Mer- bedtime, and if necessary a saline purgative cury is especially indicated in some cases; next morning. The pill may consist of Pil. chiefly when the blood is surcharged with Al. et Myrh, Pil. Col. Co., according as a nitrogenized waste, whether bile acids or urine mild or a more powerful laxative is required. solids. Then next morning a dose of effervescing cit- Some Concomitants ofIndigestion. It may rate of magnesia, or a purgative water, or 10 INDIGESTION AND BILIOUSNESS. some black draught; or, better still, some nal. Not uncommonly purgatives have beera soda sulphate, with Rochelle salts in a taken by the patient, once or oftener, to re- bitter infusion containing a carmina- move it. If mercury have been no part of tive, taken warm. A morning laxa- the remedies employed, no effect has fol- tive taken warm acts at once, more promptly, lowed, as regards improvement in the condi- (a great matter for business men), and more tion of the tongue. A mercurial will usually efficiently. At other times Trousseau’s plan make the desired alteration; but not always. of a suppository of hardened honey, or soap In some cases, however, the relief is not so may be tried; or it may be enough to resort readily furnished; and the mercurial must be to an enema. In very severe constipation it repeated, and a mixture containing nitro-hy- is well to give potent cathartics, scammony, drochloric acid and small doses of sulphate of podophyllin, or gamboge at night, and a sa- soda, is requisite for a week or even more, line purgative in the morning. But the case before the digestive organs are restored to must be followed up actively, and the consti- their normal working condition. pation relieved somehow; else the indigestion In some cases the tongue looks normal till cannot be remedied. (Dyspeptics with con- placed in a side light, and then by looking firmed constipation are very difficult patients across the tongue a brown shade can be ob- to manage, and require a medical adviser of served. Here the same line of treatment is determined will, as well as considerable skill required; and, however anaemic the patient in the wielding of remedial agents. may be, it is useless, worse than useless, to When there ispruritus ani (itching of the give chalybeates; for when the liver is dis- fundament) also present, then hepatic ■stimu- turbed, iron never agrees. lants are required for relief. This may be There are certain states of the digestive due, however, to the presence of * 4 Seat organs when the patient complains that the Worms,” which require sharp cathartics and sight of fat produces repugnance and loath- injections of infusion of quassia. ing; but where there are no decided objective Anal fissures, ulcers, piles, fistulae, &c., re- symptoms. But they cannot digest fat, at quire treatment that cannot be described here. least in its ordinary forms. Whether it is The regulation of the bowels by an appro- the fat interferes with gastric digestion, and priate dietary will be given in Chap. VIII. is intolerable to the stomach; or there is also But laxatives are commonly required as well some inability to digest the albuminous cap- in cases. sule of the fat granules in adipose tissue; or At other times there is gastric irritability what the particular objection is, is not yet to be dealt with. Then the tongue, our only known; the fact remains that fat is most ob- index of the state of the intestinal canal, is jectionable to them. raw, and denuded of epithelium, either in a What to do with these cases as regards broad furrow up the middle, or over the sur- their dietetic management will be given in the face generally. When this condition obtains, next chapter, in the section devoted to the whether alone, or along with pulmonary con- practical measures to be adopted when the sumption, or other malady, it claims our at- assimilation of fat is disturbed. tention exclusively; at least all other matters It is clear from what has so far been writ- must only be subordinate. This imperative- ten that the old impression of the stomach ness is too commonly not fully recognized, being the sole seat of the digestive act must with disastrous results. But experience tells be abandoned in favor of views more sound, that it must be the chief object of our solici- and in accordance with the teachings of mod- tude. “ Needs must when the devil drives,” ern physiology; if we are to be exact in our and this condition of denuded, or but par- treatment of the disturbances of the assimi- tially grown epithelium, cannot be relegated lative processes. to a second place in our remedial measures, SYMPTOMS. with due regard to the patient’s safety. As a A few of the prominent symptoms pro- skilful general changes his front according to duced by indigestion may now be given his enemies’ tactics, so the wary physician, briefly. One of the frequent outcomes of in- when he sees this change coming on, changes digestion is the production of an acrid acid his line, when the malady puts on this new in the stomach. This seems to be one of the aspect. Bismuth and alkalies, a milk diet, fatty acids, probably butyric, and is very acrid with the alkaline sheath; firmness, patience, in its properties. It is usually not produced and perseverance, are all required to see the early, but rather late on in the digestive act. patient safely through “the valley of the It causes a bitter pungent taste felt at the shadow of death;” when aphthae appear the foot of the gullet. This sensation is termed efforts must be redoubled. When the tongue “ cardialgia ” or “heart-burn.” Anoth'er is recovers its normal aspect, and*the epithelium “pyrosis” or “water-brash.” This consists is no longer half-grown, but quite matured, in the eructation of a fluid into the fauces, then the treatment may advance to mineral sometimes acid, sometimes alkaline; at other acids; but so long as the bareness remains, times acrid, or even feeling “ cold.” Certain so long must the treatment be directed, if not articles of food, notably oatmeal, are apt to exclusively, still mainly, to the state of the produce it. A third is “regurgitation” of lining membrane of the digestive tract. the food; sometimes sour, sometimes sweet. Then there is “ thefurred tongue" where With some persons, this act, analogous to there is a perfect layer of debris of food and “chewing the cud,” is habitual; a certain dead epithelial scales, indicative of the state number say it is not disagreeable to them. of the lining membrane of the digestive ca- Allied to this is the “ eructation of wind’" PRIMARY INDIGESTION SYMPTOMS. 11 or “belching,” to many persons a great “hawk up phlegm,” which gathers on the source of annoyance. When highly-flavored fauces. In some cases there is a turgid state articles of food are eaten, the taste is often of the fauces, little dendritic vascular twigs very pronounced in the eructated wind. The being very visible. Less frequently, there ‘ cockney phrase for this is an expressive one— are ‘ purple-like elevations of the mucous their food “repeats,” they say. “Flatulen- membrane,” at times even “ follicular ulcer- cy” is another outcome of disordered diges- ation;” or the uvula is relaxed and elongated, tion, and often creates a most uncomfort- tickling the throat and producing troublesome able sense of distension. Frequently the cough. “ Aphthae ” are not usual except in pressure of this elastic gas in the stom- children, or adults the subjects of severe ad- ach produces “palpitation.” Betwixt the vanced exhaustion. heart and the stomach lies the thin dia- The tongue should always be carefully in- phragm only; and gas in the stomach, or spected. Sometimes it is “swollen,” “re- transverse colon, presses upon the heart and laxed,” and “indented with the teeth;” at interferes with its movements; producing other times it is “raw” or “irritable,” being either “ palpitation ” or “ intermittency ” in denuded of its epithelium. In other cases it ” its stroke, as the case may be. “Vomiting” is “ foul” or “ loaded;” and this “ fur may is not very common except in acute indiges- be yellow, or brown, especially when the tion; and gives immediate relief, as it does in liver is disordered. Or there may be a gastric ulcer. It is most frequent in ‘ ‘ gas- “ strawberry ” tongue: sometimes like a red tric catarrh” in the morning; especially where strawberry with the papillae like the red seeds; too much alcohol has been taken the pre- more commonly it resembles a white straw- vious evening. In acute dyspepsia it is the berry, the tongue being generally white with natural form of attaining relief. It is often red papillae protruding the fur, closely resem- followed by sharp diarrhoea, sweeping away bling the red seeds upon a white strawberry. such part of the contents of the stomach as Less commonly the papillae are enlarged, have passed into the intestinal tube. At looking like small inflamed warts; these are other times “ diarrhoea” is provoked by each the large papillae, fifteen totwenty in number, meal. “Itching at the seat” is found in near the root of the tongue. At times a foul other cases, and it is a most torturing, dis- streak is seen along the mesial line of the tressing affection. When it is due to seat- tongue, the edges being very clean; at other worms it is readily amenable to treatment in times this is reversed, a clean streak running most instances; but not in all. up the middle of the tongue. Sometimes one Then there is “pain” at the pit of the side of the tongue is fouler than the other; ” stomach. When due to “ gastric ulcer it is here there is a local cause. “ Fissures ” of provoked as soon as the stomach has become the tongue are not rare; most commonly as- acid, and is aggravated by the muscular sociated with the practice of drinking hot movements dragging on the base of the ulcer; fluids, especially tea. “Deep sulci” are thus vomiting gives immediate relief. So usually syphilitic, especially when the tongue long as the stomach is at rest, and in its alka- generally is smooth as if the papillae were line state of quiescence there is no pain. In shaven cleanly off with a razor. Such a sign “ ” gastric cancer there is also sharp pain not is of great importance, as some cases of indi- always relieved by vomiting; nor alone pro- gestion have been incurable till an anti-syphil- voked by food, but felt at other times at first, itic treatment has been adopted for some and ultimately continuous and persistent. other ailment; and then, presto, the indiges- Pain is commonly found along with other tion has disappeared. evidences of indigestion, and may occur im- “Psoriasis” is also significant. There mediately after a meal; or at a later period seems some evidence that the stomach is when the contents of the stomach are passing sometimes the seat of analogues to skin affec- the pyloric ring; when felt at this time it is tions; as it certainly is the seat of an erup- duodenal. “Nausea,” or a sense of sick- tion in some cases of small pox. ness, is a very common symptom either “Skin eruptions” are very frequently found along with pain, or alone. It may be linked with digestive disturbances, and only present almost habitually; but be accom- curable by putting the digestive organs in panied by actural vomiting only when the order. Eczema with pruritis of the genitals, disturbance of the digestive act is unusually or anus, is always associated with dyspepsia great. in some parts of the digestive tract. “ ” Constipation is a common concomitant In some cases there is a “ taste in the of dyspepsia; not rarely its exciting cause. mouth,” especially a hot burning taste on So long as constipation is permitted to con- awaking in the morning. This is due to tinue, so long will dyspepsia persist. By some abnormal products of the later part of perseverance, patience, and determination, the digestive act, and is often a troublesome the most obstinate constipation may be over- symptom. In certain cases there is a sour come. Too frequently, however, the patient taste in the mouth, less commonly a sweet grows indifferent, or tires of the treatment, taste, or the saliva may be clammy with a and as a consequence relapses into the hab- sensation of heat in the mouth; this is com- itual condition. It is the bane of their lives monly found along with constipation. to many persons; still it is much more amen- “ Headache ” is a very common outcome able to treatment than is generally supposed. of dyspepsia. It varies in character from a The throat often feels sore, or uncomfort- dull weight to acute agony. It may be con- able; at other times there is a tendency to fined to the temples, the forehead, or the 12 INDIGESTION AND BILIOUSNESS.

occiput; or it may be general. It may be where there is palpitation or irregular action, accompanied by “ swimming ” in the head, or tortures the unhappy sufferer. The remem- “intolerance ” of light or of sound. At times brance of this impression hangs like a dark the slightest sound is simply unbearable; in cloud over the intervals of comparative health; other cases (comparative) ease can only be while the anticipation of another attack is secured by lying in a dark room like the Rev. projected like a shadow thrown in front of it, Mr. Irwine’s sister Anne, in “ Adam Bede,” indeed “coming events cast their shadows Miss Kate was spongingthe aching head with before.” When there is great pulsation of fresh vinegar when he went into the room so the abdominal aorta the dyspeptic is worried darkened by blinds and curtains that Miss with the apprehension that there may be an Kate could not knit at the best. “ It was a aneurism present. There is, indeed, a pan- small face, that of the poor sufferer; perhaps phobia, a general sense of dread, of impend- it had once been pretty, but now it was worn ing evil, which embitters the sufferer’s exist- and sallow. Miss Kate came towards her ence, and every uncomfortable sensation is brother and whispered—‘ Don’t speak to her; interpreted as an indication of structural dis- she can’t bear to be spoken to to-day.’ ease somewhere. Annie’s eyes were closed, and her brow con- The physical sufferingis aggravatedby men- tracted as if from intense pain.” Miss Anne tal misery, compared with which it is as noth- Irwine’s headaches were those of indigestion ing: for peace of mind is rendered absolutely evidently; and very bad headaches they were! impossible to the unfortunate dyspeptic; he They belonged to that variety which or she lives with the sword of Damocles hang- comes on the day after the meal which ing overhead. has provoked them; where there are some noxious products of late diges- CHAPTER IV. tion poisoning the half-starved brain. SUITABLE FORMS OF —ARTIFICIAL In such cases the duodenum is found to be FOOD. the seat of morbid change, when the patient DIGESTIVE FERMENTS. passes into the dead-house. In most cases Having described the various disturbances the headache accompanies other evidences of of the digestive tract, interfering with the gastric disturbance, and is felt early or after proper and ordinary assimilation of the main a meal. The face is often flushed, and the constituents of our dietary, starch, albu- hands and feet are cold. In many cases the minoids, and fat; it may be well to review the headache is distinctly that of anasmia,—the means of preparing the various forms of our blood being drawn to the abdominal viscera food. Starch in it natural state, raw and un- by the digestive act. There is often a sensa- cooked, is scarcely digestible by man. In tion of “swimming in the head” felt along animals, probably starch is largely digested with the pain, or “dizziness.” The pain in by the pancreatic diastase. But in man the vertex often experienced is symptomatic starch is largely digested by the sali- of cerebral anosmia. vary diastase. “ It has been noted that More distressing than the actual physical the saliva of man possesses more dias- pain is the sense of misery experienced by tatic power than that of almost any other ani- many. The mental discomfort, the sense of mal. Among the herbivora, which are such wretchedness, of utter unfitness for work, and large consumers of starch, the saliva has inability to collect the thoughts, is to many comparatively little diastatic power; and in dyspeptics their greatest trouble. some, as the horse, it is almost altogether The brain is disabled for the time, no mat- wanting. 1 apprehend that this is due to the ter what its capacity under favorable circum- fact that man alone has learnt to cook his stances; and the sense of intellectual paraly- starchy food, and that the diastatic power of sis is very distressing. Here there is positive his saliva has become developed with the op- toxaemia, from abnormal products of diges- portunity for its exercise. Diastatic power tion finding their way into the blood; as well would be thrown away in the saliva of the as an insufficient supply of blood to the brain. horse, because he eats his food in the raw or To brain-workers this is a great draw-back; uncooked state, and saliva is almost without indeed, the dyspeptic is handicapped very action on raw starch.” This is a very in- heavily in the race of competition to gain a teresting observation by Wm. Roberts, and living, or amass a fortune. The dyspeptic as regards the horse, no attempt has been can earn less, and must spend more on (suit- made to cook his food for him. But with the able) food than others do; and where the in- animals the farmerwishes tofatten for market, come is a small one, the dyspeptic is really especially oxen, the cooking of their food is to be pitied. Indigestion cuts down the in- regularly performed by our most advanced dividual far more than is generally credited. agriculturist. Starch is prepared by cooking In the modern keen struggle for existence cereals previous to their being given to cattle; the dyspeptic is like a man fighting with one as it is found cheaper to so prepare the starch hand tied. for fatting cattle, than to leave them to do This mental attitude of gloom, apprehen- the whole of their digestion for themselves. sion, distrust and incapacity intensifies the The Lincolnshire farmer has solved, in part physical discomfort, and tends to cause the at least, the problem of the conversion of sufferer to have misgivings that the malady starch into sugar, or approaches thereto; as is something more than mere indigestion. A well as the scientific physiologist. And one haunting fear that the brain is the seat of of the most instructive conversations on the disease where there is headache, the heart means of preparing starch for food, I ever SUITABLE FORMS OF FOOD ARTIFICIAL DIGESTIVE FERMENTS. 13 remember listening to, was down in the Fens is toasted cheese, which also resists the disin- one evening, when some farmers were dis- tegrating action of dyspeptic’s stomach very cussing the subject of the cheapest means of effectually. Some persons cannot eat suet fattening stock. It was soon clearly apparent pudding, as ordinarily made, without a severe that they were working in precisely the same penalty from dyspepsia: but if the cook adds direction as the physiological physician moves, to the floor a certain quantity of bread- when he comes to diet a child with a weak crumbs, then the digestion of the pudding is digestion; with this difference —the physician painless. Gluten once cooked remains non- desires to feed the child little regardless of adhesive; so the bread-crumbs cause the the cost; while the farmer’s aim is to produce masses of pudding to readily fall to pieces in so much fat at the least cost. When inspect- the stomach. Probably some baked flour ing the measures adopted by Collinson Hall, would do just as well, if added to the ordi- at his large dairy farm in Essex, my attention nary flour. Maize flour is not nearly so ad- was arrested by a huge heap in one of the hesive, as its albuminoids are not in the form rooms, where crushed oats and partially of tenacious gluten; so much so, that without malted barley, were fermenting the starch in- some wheaten flour it would not make leav- to dextrine and maltose. ened bread. Consequently, for the prepara- In cooking starch the granule is cracked, tion of puddings, and still more for pastry for and the starch largely gelatinized, so that the delicate children and dyspeptics, it would be salivary diastase readily liquefies it, and con- well to add some maize flour to the ordinary verts it into soluble sugar. During baking, flour. In precisely the same way we try to starch, or part of it, is undoubtedly converted prevent milk forming too firm a curd in the into dextrine. The action of yeast converts stomach, by mixing it with some starch. part of the starch into sugar, and this again The presence of the starch granules interferes into ‘ ‘ alcohol and carbonic acid gas; the lat- with the solidity of the curd, and causes it to ter, in its efforts to escape from the fall to pieces readily in the stomach. On the dough with which it is mixed, distends it, other hand, oysters are spoiled in cooking. forming vesicular spaces in its interior, and ‘ ‘ Our practice in regard to the oyster is so causing it to become porous and light. exceptional, and furnishes a striking ex- Much of the alcohol is dissipated in the pro- ample of the general correctness of the cess of baking” (A. Hill Hassall). Conse- popular judgment on dietetic questions. quently we see that intuitively and without The oyster is almost the only animal sub- the light of science, man has commenced the stance which we eat habitually and by prefer- artificial digestion of starch, when only a ence, in the raw or uncooked state; and it is savage, and long before the dawn of history. interesting to know that there is a sound phy- We at the present are emerging out of the siological reason at the bottom of this prefer- early darkness, and stepping forward by the ence. The fawn-colored mass which consti- morning light on the path to the artificial di- tutes the dainty of the oyster is its liver, and gestion of starch; by so doing economizing this is little less than a mass of glycogen; as- the body-energy which would otherwise be sociated with the glycogen, but withheld from consumed in the conversion of insoluble actual contact with it during life, is its appro- starch into a soluble saccharoid, otherwise priate digestive ferment—the hepatic diastase. diastatic digestion. Consequentlyfarinaceous The mere crushing of the dainty between the materials are first ground and then cooked; teeth brings these two bodies together, and this constitutes the first part of the digestive the glycogen is at once digested, without act. other help, by its own diastase. The oyster, Now it is a matter of no little importance in tha uncooked state, or merely warmed, is, to understand intelligently how cooking may in fact, self-digestive. But the advantage of affect the digestibility of prepared starch. this provision is wholly lost by cooking, for When farina is simply boiled or baked with the heat employed immediately destroys the milk, the preparation is at once simple and associated ferment, and a cooked oyster has digestible, and the saliva is readily mixed to be digested, like any other food, by the therewith in the mouth. But when eggs are eater’s own digestive power.” This graphic added, then the disintegration in the mouth is description by Dr. Roberts tells us how it is not nearly so perfect, and much more chew- that oysters au naturel are so much in vogue ing is required; because the coagulated albu- for invalids, as they deservedly are. Also, men holds the starch granules together. Con- why oysters should not be cooked in oyster sequently milk puddings for invalids are bet- sauce, but put into the prepared sauce just ter made without eggs. as it comes to table. Why, as King Cham- Then again, everybody, medical and lay, bers insists, in a beef-steak pudding, the oys- knows how indigestible is pastry of all kinds. ters should not be cooked, but a flap of the When the farina and fat are closely mixed to- paste raised, and the oysters popped in, just gether in the act of “ kneading the dough,” as the pudding is served. In making oyster the adhesive property of the gluten of flour is pates, the paste is cooked in bread-crumbs, somehow so increased, that the act of masti- which is then taken out and the oysters put cation is rarely equal to efficient disintegra- in; after which, the pates are just warmed, tion in those whose digestion is feeble. The and no more, and then brought up to the stomach is incited to active muscular move- dinner table. The idea that long cooking ments to continue the disintegration, and increases the digestibility of food, is not al- acute pain is experienced. A piece of pie- ways correct. crust is rank poison to many dyspeptics. So But “cooking” is essentially a part of the 14 INDIGESTION AND BILIOUSNESS. digestive process, not only in man, but in altered. In the raw state this solution is at- some domesticated animals as well. Thepro- tacked very slowly by pepsin and acid, and ducts vary according to the skill of the cook, pancreatic extract has no effect upon it; but and the adjustment of the process to what after being cooked in the water-bath, the al- physiological knowledge tells us is correct bumin is rapidly and entirely digested by arti- and sound. When the cook makes a hash of ficial gastric juice and a moiety of it is rapidly meat already cooked, instead of making the digested by pancreatic extract.” The em- gravy first, and when fully prepared then ployment of raw meat pounded is therefore putting in the slices of meat, and just warm- not an advantage though advocated by some ing them before serving—the only way by medical men. Personally I have never seen which a hash is tolerable to a delicate stom- a case in which raw meat seemed to be indi- ach—she too often stews it well in the gravy, cated. The connective tissue which binds believing that thereby she increases its digest- the fibrillae of muscle togetheris soacted upon ibility. But ask dyspeptics about meat so by heat, in cooking, that the fibres fall cooked a second time, and their tale of woe readily to pieces in the stomach; and so are is most instructive. easily acted upon by the solvent gastric juice. Now as to the effects of cooking upon the Mastication or chewing breaks down the proteid elements of our food. “It is this masses of meat, and their disintegration is- well-established fact, the easier digestibility completed by the gastric movements. of loosely-aggregated tissue, that has led me Mastication, as a disintegrating matter, is to repudiate raw meat in the diet of invalids. separable from the admixture of starch with Cooking, the action of heat, disassociates or- saliva in the act of chewing. So is the disin- ganic tissues, destroys the cohesion of muscu- tegrating action of the stomach separable lar fibres, and must, therefore, render all from the "solvent action of the gastric saliva. kinds of meat easier to dissolve, to digest. Mastication exerts no influence upon albu- To give meat raw, however finely chopped, is minous matters, of a solvent character; nor to forego all the advantages gained by judi- does the action of the stomach affect fats, ex- cious cooking, and to force on the digestive cept by the solution of the albuminous enve- organs double work. Moreover, raw, un- lopes which surround fat as found in the cooked meat may contain the ova of human bodies of animals. There is a digestive act entozoa, of the various species of tape-worms, in mastication, viz., the conversion of starch and of the trichina,” (James Henry Bennett, into sugar by the salivary diastase: and a pre- “ Nutrition in Health and Disease”). Again, paration of albuminoids, for the action of the Dr. Roberts writes: “With regard to the gastric juice. In the stomach there is the staple articles of our food, the practice of digestion of proteids, and the preparation of cooking it beforehand is universal. In the fats for the action of the bile and the pancre- case of farinaceous articles, cooking is in- atic secretion, by the digestion and solution dispensable. When men under the stress of of the albuminous envelope of animal fat— circumstances have been compelled to sub- the connective tissue in which the fat globules- sist on the uncooked grain of the cereals, are stored in the body. There is then pre- they have soon fallen into a state of inanition paration for coming acts, as well as actual and disease. By the process of cooking, solvent action in mastication, and the gastric starch is not merely liberated from its protect- portion of digestion. ing envelopes, but it suffers a chemical Now, meats differ in their digestibility ac- change, by which it is transformed into a cording to the closeness of fibre, and the gelatinous condition, and this enormously firmness with which the fibres are bound facilitates the attack of the diastatic ferments. together. Pork, veal, beef, mutton, lamb, A change of equal importance seems to bS in- stand in the inverse order of their digestibility duced in the proteid matter of the grain. I as regards the readiness with which their fi- found that the gluten of wheat was incom- bres fall asunder; the effects of cooking upon parably more digestible, by both artificial the fibre itself probably being much the same, gastric juice and by pancreatic extract, in the viz, the effect of heat upon albumen in ren- cooked than in the uncooked state. In regard dering it more easily acted upon by pepsin to flesh meat the advantage of cooking con- and trypsin. The hare and rabbit are fairly sists chiefly in its effects on the connective digestible as to disintegration. Then come tissue, and the tendinous and aponeurotic the flesh of fowls of all kinds; the finer fibre structures associated with muscular fibre. of game being specially digestible. Then These are not merely softened and disinte- comes the flesh of fish; for reptiles are not a grated by cooking, but are chemically con- part of an ordinary diet. But fish varies—- verted into the soluble and easily digested the Tunny fish tribe are hard of digestion. form of gelatin. I made some instructive Salmon is often digested with difficulty, and observations on the effects of cooking on the so is fried sole. It is not merely the question contents of the egg. The change induced of the firmness or looseness of fibre only, by cooking on egg-albumin is very striking. there is the method of cooking; where the For the purpose of testing this point I em- fibres are soaked in fat, a weak stomach can- ployed a solution of egg-albumin, made by not digest them comfortably; there is dyspep- mixing white-of-egg with nine times its vol- sia often with the eructation of a fatty acid. ume of water. This solution when boiled in Then, all kinds of white fish are most digest- the water-bath does not coagulate nor sensi- ible, especially when boiled. The disintegra- bly change its appearance, but its behavior tion of muscular fibre in the preparation of with the digestive ferments is completely meats for potting is complete; with them the SUITABLE FORMS OF FOOD —ARTIFICIAL DIGESTIVE FERMENTS. 15 solvent part of the digestive act is alone re- In order to secure exact results it is there- quired. On thin stale bread, with the butter fore essential to use precise means, guided by in limited quantities and well rubbed into the the light physiological observation is throw- tiny holes and interstices of (stale) bread, and ing upon this hitherto obscure subject of then a little potted meat spread over, a very digestion. digestible little meal is obtained. Such sand- And now to the consideration of the third wiches, with a cupful of beef tea, are special- division of the subject, the digestion of fats. ly indicated where the patient cannot take We do not know as yet any change ex- milk. ercised upon fat by heat, by the act of Then there are the vegetable albuminoids, cooking, except that of rendering it fluid. especially the pulse tribe, or legumes, which Certainly cooking renders fat more tooth- are capitally disintegrated by cooking, and some, and in the case of fat exposed directly best by boiling or baking. Thus beans, har- to great heat, as in the case of the fat of a icots and broad, peas, lentils, dahl, etc., are beef steak, or a mutton chop, the action of all well broken up by heat. The disintegrated the heat upon the albuminous capsule of the flour can easily be passed through a sieve, adipose tissue, is to make it decidedly tasty. and then the disintegration factor of the di- But heat does liquefy fat, and separates (we gestive act is disposed of. There can be believe) olein, from stearin and margarin. The no question about the fact that with some liquid portion of fried bacon is digested by persons vegetable albuminoids are much more many who cannot digest the solid portion of easily digested than animal albuminoid; and bacon fat. This is a well-known fact. The I quite agree with Sir Henry Thompson in fluid is the olein. Fats vary in their digesti- his remarks upon this subject. Besides, too, bility. The late Dr. John Hughes Bennett fat spreads easily over the disintegrated par- said: “ The main causes of tuberculosis ticles of cooked vegetable albuminoids, as is were the dearness of butter and the abund- well seen in the baked beans and fat pork of ance of pastry cooks; the poor not getting New England. Indeed by such,, means fat sufficientt fat, and the upper classes disorder- can often be taken without offence to a stom- ing their digestion by puff paste.” Now but- ach that cannot otherwise tolerate it; and ter consists of the fat globules of milk re- much of the digestibility of fat depends upon moved from their envelopes of caseine by the the fineness of the particles into which it is act of churning; thus getting rid of the subdivided. Haricot beans well boiled, albuminous envelope which is one of the passed through a sieve, and then the floury difficulties in the digestion of animal fat. part mixed with milk, makes an excellent How far it is this envelope ; how far it is soup; quite equal in food value to any the presence of firm stearin which constitutes made with meat stock. The ordinary the difficulty in the digestion of animal fats, lentil soup is at once a most economical in each case; we cannot always say. Then and a most valuable soup for ordinary per- again to speak broadly, the lower the tempera- sons; though scarcely perhaps quite adapted ture at which fat ceases to be liquid the easier for persons with indigestion. But “ the proof its digestion. In the best cod-liver oils, the of the pudding is in the eating thereof,”—if stearin and margarin are taken out by freez- it does not disagree, there is certainly no ob- ing; the liquid olein being poured off. Beef jection to its use. fat and mutton suet are less digestible than Now a few words as to the digestion of lard, bacon dripping, and butter; the latter milk caseine. As milk it is the most digesti- only becoming firm at a much lower tempera- ble of proteids, i. e. , with those with whom it ture than is sufficient to render beef and mut- agrees. It differs in its digestion from other ton suet hard. Cod-liver oil is the most easily forms of albumen. “Milk is much more digestible of all forms of fat. In that lies its easily digested by pancreatic extract than by great utility. It can be digested when other artificial gastric juice; but in the case of egg- fats are beyond the reach of the digestive albumen the advantage lies decidedly with the processes. Some have thought this due to gastric juice,” Using the one part in the basyle with which the fatty acids are in ten of water solution of egg albumen union, being propyline, instead of glycerine, and boiling it in the water bath, like other fats. “Others, again, have at- Dr. Roberts found with pepsin and hydro- tributed it to the minute quantities of iodine- chloric acid the transformation went on and others to the biliary matters found in the swiftly and without interruption to its close. oil; the last seems far the most reasonable Whilst the pancreatic ferment was only able supposition ” (Lauder Brunton). In addi- to convert a part of the albumen into pep- tion to this there seems to be something tone. There is one point of the greatest in the presence of a little free fatty practical moment about the observation, and acid, as found in certain cod-liver it is this—when meat or egg digestion is to oils. “The different behavior of two be artificially aided it is well to use pepsin specimens of the same oil, one perfectly neu- and hydrochloric acid. But when the digest- tral, and the other containing a little free ion of milk is to be practically assisted by a fatty acid, is exceedingly striking. I have digestive ferment, it is desirable to use tryp- here before me two specimens of cod-liver oil sin; the pancreatic secretion in an alkaline —one of them is a fine and pure pale oil, vehicle. “ Tryptic digestion of milk is rapid such as is usually dispensed by the better and leaves only a very slight residue—where- class of chemists; the other is the brown oil as peptic digestion of milk is slow, and leaves sent out under the name of De Jongh. I put a large residue.” a few drops of each of these into these two* 16 INDIGESTION AND BILIOUSNESS,, beakers, and pour on them some of this solu- It may now be well to consider the use of tion, which contains two per cent, of bicar- Artificial Digestive Agents in practice. bonate of soda. The pale oil you see is not First it may be desirable to consider their in the least emulsified; it rises to the top of use as additions to the natural digestive fer- the water in large clear globules; the brown ments; and then to proceed to the use of ar- oil on the contrary yields at once a milky em- tificially digested food. ulsion. The pale oil is a neutral oil, and Starch is digested by the salivary diastase yields no acid to water when agitated with it while the food is being chewed, and in the —in other words it is quite free from ran- stomach before, and until its contents are cidity; but the brown oil when treated in the acid; and afterwards by the diastase of the same way causes the water with which it is pancreatic secretion. The latter can best be shaken to redden litmus paper.” (When the discussed when artificial pancreatic secretion inhabitant of Arctic regions prefers his fat is spoken of; the salivary diastatic action rancid, probably he is only following out alone will be reviewed now. what experience has taught him is good in Starch is converted into sugar, is trans- his liberal consumption of fat). “ The bear- ferred from an insoluble to a soluble matter ing of these observations on the digestion of by the action of diastase of the saliva. It is fat is plain. When the contents of the stom- equally well acted upon by the diastase pre- ach pass the pylorus they encounter the bile pared from cereals, i. e., the digestive dias- and pancreatic juice, which are alkaline, from taste of the embryo-plant. Such preparations the presence in them of carbonate of soda. under different names as “malt extract,” So that the fatty ingredients of the chyme, if “ maltine,” &c., are now placed upon the they only contain a small admixture of free market by enterprising manufacturing chem- fatty acids, are at once placed under favor- ists. They are mainly given to children; able circumstances for the production of an though there exists no reason why they emulsion without the help of any soluble fer- should not be more largely given to adults. ment, the mere agitation of the contents of In their adoption it must be borne in mind the bowels by the peristaltic action being suf- they act upon starch solely and exclusively, ficient for the purpose ” (Roberts). Possibly and have no effect upon other articles of our some fats containing a large proportion of food. Sugar does not require them; it is sol- oleine emulsionize more readily than others. uble without a ferment. But for starch, lique- But the whole subject is in its infancy so far faction precedes saccharification. Conse- ” as our acquaintance with it is concerned. quently “ malt diastase should be given so Certainly in some cases of imperfect diges- that it may be operative before the contents tion of fats it seems that a pill containing of the stomach become acid. It should then some dried oxgall and castile soap, taken an be added to milk-gruel, and milk puddings, hour or so after food, is indicated as likely to before they are taken; or at latest immedi- be of service. ately after they are swallowed, and before the After this review of the digestion of the other articles of a meal are eaten. Thus with different ingredients of our food, we can see children, their milk porridge, made with oat- the digestion of, meal, hominy, or crushed cereals, should be Starch by saliva and pancreatic diastase; taken first for breakfast with the malt with Proteids by pepsin and trypsin; them, or immediately afterwards; after an in- Fat by pancreatic secretion; terval a little fat bacon or cold meat (ham is will lead us to the proper and exact use of to be preferred) may be added, with bread artificial digestive agents; about which at and a little cocoa, or coffee with cream in it. present the wildest confusion obtains both by Such would be a scientific and physiological the manufacturing chemists and the profes- use of vegetable diastase; which is a treacly- sion generally. The chemists may take um- looking thing as usually seen, of sweet taste, brage at this statement, but they will find a and therefore well adapted to admixture with difficulty in disposing of it. When malt pre- milk porridge immediately before being sup- parations are directed to be taken after food ped; or by itself immediately afterwards. when the stomach is acid, that is at the time While children are suckling there is little nat- when the salivary diastase, or its vegetable ural diastase found, and it is not till the sixth substitute is at once rendered inert; when or seventh month that it is found in the saliva malt extract is added to cod-liver oil directed in sufficient quantity to be operative. “ Until to be taken “during or immediately after a this period it is therefore not advisable to ad- meal,” an admixture which is certainly pala- minister farinaceous food to infants.” It table; but the vegetable diastase is little would seem the irritation set up by the teeth likely to be operative in the acid stomach, excites more efficient secretion in the salivary while the oil is taken too soon to be acted glands. upon; a combination which is certainly not If malt diastase cannot be given as recom- physiological; and when an emulsion of cod- mended above, it will be well to continue the liver oil and pepsin is commended by the digestion of starch by resort to artificial pan- Btitish Medical Journal \n a recent review, creatic secretion. At least, that is the con- dead in the teeth of all that physiology teaches us (March iqth, 1881).* fect nutrition—dose. 3 to 5 grains.’’ This compound, or rather “ jumble,” to be taken apparently any time * *' Peptodyn. a combination of the whole of the the patient prefers, is a marked illustration of what is •digestive secretions—pepsine. pancreatine, diastase or written above as to disregard of time and place of the ptyalin. etc., forming a valuableremedy in the treat- portions of the digestive act. (This is advertised in ment of dyspepsia, and diseases arising from imper- the “ British Medical Journal,” April 2and, 1881). SUITABLE FORMS OF FOOD—ARTIFICIAL DIGESTIVE FERMENTS. 17 elusion warranted by the present state of our vent in its digestive action. It is then useless to knowledge. add it to cod liver oil; if it be desirable to ad- Proteids, or albuminoids, are the matters minister both these agents, let the pepsin be specially digested in the stomach. “ Proteids given early after a meal, when it will be ser- are attacked by the digestive ferments at two viceable; and then afterwards the oil, when points in the alimentary canal; by pepsin in its time arrives. But to combine them is the stomach, and by trypsin in the small in- simply to set the lessons of physiology at testine. Between these two acts of digestion defiance; to ignore the place and time of the there is a complete break in the duodenum, different factors in the digestive act. owing to the abrupt change of reaction, from We now come at last to the digestion of acid to alkaline, which occurs at that point. fat. Hitherto, neither in the diastatic diges- Gastric digestion is, in all creatures, an essen- tion of starch, nor in the gastro-pepsin diges- tially acid digestion.” At the present the tion of albuminoids, has fat been acted upon- acid gastric digestion of proteids by pepsin is The fat of adipose tissue is liberated from its being considered exclusively. albuminoid envelope in the stomach—that is The observations of Dr. Beaumont upon all.* But when the contents of the stomach Alexis St. Martin, who had the front wall of pass the pyloric ring into the duodenum, and the stomach and abdomen blown away by a are mixed with the bile, then fat commences gunshot wound, were made at a time when to undergo a transformation. It is not di- our physiological knowledge was too imper- gested by any change, or metabolism in its fect to be much guide to him. More recently chemical composition, any hydration by the C. Richet had an opportunity of examining addition of a molecule of water, as is the case the act of gastric digestion in a young man when starch is converted into sugar, and pro- whose stomach was artificially opened for a teids into peptones; it is, so far as we yet stricture of the gullet. Thus our knowledge know, merely emulsionized. This emulsion- is not confined exclusively to the observations izing of fat, by the reduction of it to minute made upon animals. ' “ Richet found that globules, renders it small enough to be taken the acidity of the contents of the stomach up by the intestinal villi; without such emul- during digestion, although it varied sionizing fat could not enter the tiny terminal through considerable limits, had a marked endings of the lacteals in the villi of the intes- tendency to maintain the normal average. tine. For such emulsification an alkaline If acid or alkali were added to the di- medium is essential. The bile renders the gesting mass the mean was presently re- food acid in the stomach, alkaline in the in- stored automatically—the stomach in the for- testines. In an alkaline medium the pancre- mer case ceasing to secrete acid, and in the atic secretion is active; and in an alkaline latter case secreting an increased quantity of medium only. In this alkaline medium the acid.” Gastric juice contains a digestive fer- pancreatic diastase resumes the digestion of ment only active in an acid medium. “The re- starch; trypsin converts proteids into pep- action is distinctly acid, and the acidity is tones; and fat is further emulsionized. So normally due to free hydrochloric acid. This we see that when fat assimilation is defective is proved by the fact that the amount of hy- the use of an artificial pancreatic secretion drochloric acid is more than can be neutral- aids the further digestion of starch and albu- ized by the bases present. Lactic acid and minoids, as well as acting upon fat. Conse- butyric and other acids when present are sec- quently when we resort to an artificial pancre- ondary products, arising either by their re- atic secretion we must take care to see that it spective fermentations from articles of food, is not killed, or rendered inoperative forever, or from decomposition of their alkaline or by some gastric acid remaining in the stom- ” other salts (M. Foster). ach. It is this “ acid gulf” in the stomach To aid this portion of the digestive act which we have to guard against, else our arti- when defective we give pepsin, with or with- ficial pancreatic secretion is useless, of no out an acid—usually with hydrochloric acid. earthly avail. It is necessary then to protect the Pepsin is precipitated by alcohol in great artificial pancreatic secretion by a solution of quantity. It is sold as a wine, but it is better soda; and soda is unpalatable, to put it mildly. prepared with glycerine. It is sold by chem- Dr. Roberts therefore advocates ten or fifteen ists in various preparations. It is commonly grains of bicarbonate of soda, to be taken sold or prescribed along with hydrochloric with the dose of Liquor Pancreaticus at ‘ * the acid. “In gastric juice there is a strong tie tail of the digestive act.” This passes it between the acid and the ferment, so strong safely through the stomach: just as a guard of that some writers speak of pepsin and hydro- soldiers sees a merchant conveyed over an un- chloric acid as forming a compound pepto- settled frontier infested by robbers. What- hydrochloric acid ” (M. Foster). ‘ ‘ The essen- ever preparation of pancreatine be adopted tial property of gastric juiceis the power of dissolving proteid matters, and of converting * Probably even the digestion of the albuminous them into peptones ” {Ibid.). envelope goes on 'n the stomach to a limited extent only. As the envelope is digested, the free fat re- When resort then we to the use of pepsin as mains, and so prevents the acid gastric juice from act- an artificial digestive agent, we must clearly ing upon the centre of the piece of adipose tissue. bear in mind is the Thus theperiphery only is digested in the stomach. that it digestion of albu- In medium, solely, the alkaline so soon as trypsin dissolves minoids that we can assist by its the albuminous corpuscles, the fat, so fre*-d. is emul- means. It should be given after a meal has sionized. and thus the trypsin can act upon the inter- been taken, when the natural gastric solvent nal portion. 1 hus the digestion of fat, even as adi- pose tissue, is mainly the work of the pancreas aided is being poured out in order toassist that sol- by thebile. 18 INDIGESTION AND BILIOUSNESS. there seems nothing for it but the alkaline them will incline many readers to order the guard to see it through the stomach. An oil liquor pancreaticus for their patients, who, emulsionizedby the admixture of a small quan- without the formulae, might not see the prac- tity of bile and a small amount of pancreatic tical forms in which it may be made useful. secretion would, in all probability, aid the If, in doing so, I can incline some to try this natural pancreatic digestion. On this matter, preparation who might otherwise have re- however, we can only speculate in theory; mained unacquaintedwith it, it will be grati- clinical facts alone can positively determine fying; and will make some amends for the the matter. The proper time to administer loan of them to me for my book. Here the the artificial pancreatic secretion is when the reader will see a great many forms of food contents of the stomach are finally escaping which can be peptonized with advantage, and through the pyloric ring, at least an hour without destroying their toothsomeness. and a half after an ordinary meal. The For the purposes of general indigestion, time varies in different individuals, and how to the liq. pancreaticus is mainly indicated, and determine this we do not yet know. But when will be found to be of much advantage. the gastric digestion is over no more juice is In those cases of imperfect assimilation of secreted, and what has been secreted has albuminoids, where there is a plentiful sup- probably spent itself upon the food-contents ply of fat in the body, but the muscles are of the stomach. The alkali neutralizes any flabby and ill-nourished; or in those cases remaining acid, and so protects the trypsin where there is pain and discomfort immedi- from the deadly effects of an acid upon it. ately after food, —the cases in which the late Soda is the natural alkali in bile; and there- Dr. Arthur Leared said there was dyspepsia fore the alkaline guard of the trypsin should from “ insufficiency of gastric juice;” it may be a solution of soda. be well to give the liquor pepticus. So used and guarded artificial pancreatic i.—For the Preparation of Pepton- secretion contains the greatest promise in dyspeptic cases. A four ounce bottle off ized Food. Liquor Pancreaticus contains 32 doses of one In peptonizingor partially-digesting food by teaspoonful (that is an old-fashioned small means of “ Liquor Pancreaticus (Benger),” it teaspoon) or rather one drachm each. To is important to remember that the liquor give 32 doses of bicarbonate of soda (fifteen must not be added to food of any kind at a grains), involves a solution of one ounce of higher temperature than 140° Fah. This tem- the soda in sixteen ounces of water; dose, perature can be estimated with sufficient ac- one tablespoonful with each teaspoonful of curacy, should no suitable thermometer be at Liquor Pancreaticus. hand, by tasting. Tf too hot to sip without In many cases the administration of Liquor burning the mouth, it would entirely destroy Pancreaticus causes the most satisfactory im- the activity of the liquor pancreaticus, and provement in the patient’s condition. The must be allowed to cool before such addition muscles become plump; the subcutaneous fat is made. once more fills out the wrinkled skin; the Peptonized Milk. —Apint of milk is diluted brain is fed; and with this comes back the with a quarter of a pint of water, and heated lost sense of energy, of fitness for work. to a temperature of about 140° F. (60° C.), In some cases the disablement of the diges- (or the diluted milk may be divided into two tive organs is such that it becomes impera- equal portions, one of which may be heated tively necessary to resort to artificially digest- to the boiling point and then added to the ed food. This is much better than feeding cold portion, the mixture will then be of the by the bowel, which soon becomes so painful required temperature). Two or three tea- that it is impossible to continue it. Feeding spoonfuls of liquor pancreaticus, together by enemata is a last resource, only to be ad- with ten or twenty grains of bicarbonate of opted in critical emergencies, when it is in- soda (about half a small teaspoonful) are then valuable; but it can only be resorted to for a mixed therewith. The mixture is then poured brief period. In acute gastric disturbance, into a covered jug, and the jug is placed in a in catarrh, ulcer, and cancer, it is well to do warm situation under a cosey, in order to away with the necessity for movement in the keep up the heat. At the end of an hour, or stomach as far as lies in our power, by giving an hour and a half, the product is boiled for the food already digested to a great extent. two or three minutes. It can then be used Milk and milk-gruel can readily be digested like ordinary milk. The object of diluting by the methods advocated by Dr. Roberts, to the milk is to prevent the curdling which would be given shortly. Otherwise occur and greatly delay the pepton- Partially digested foods can be purchased; izing process. The addition of bicarbonate but personally, I have never prescribed them. of soda prevents coagulation during the final But milk and milk-gruel digested by the boiling, and also hastens the process. The Liquor Pancreaticus, have done me Yeoman purpose of the final boiling is to put a stop to service in many an intractable case. the ferment action when this has reached the They are prepared as follows, and the desired degree, and thereby to prevent cer- enema appended is worthy of careful con- tain ulterior changes which would render the sideration; when an enema has to be resorted product less palatable. The degree to which to, it is highly important that it have as the peptonizing change has advanced is best high a food value as can be given to it. judged of by the development of the bitter In thus giving Dr. Roberts’ directions flavor. The point aimed at is to carry the verbatim, I am hopeful that the perusal of change so far that the bitter taste is distinctly FOR THE PREPARATION OF PEPTONIZED FOOD. 19 perceived, but is not unpleasantlypronounced. delicate palate could not accuse of having The extent of the peptonizing action can be been tampered with. Soups were prepared regulated either by increasing or diminishing in two ways. The first way was to add what the dose of the liquor pancreaticus or by in- cooks call ‘ stock ’ to an equal quantity of creasing ordiminishing the time during which peptonized gruel or peptonized milk-gruel. A it is allowed to operate. By skimming the second and better way was to use peptonized milk beforehand, and restoring the cream af- gruel, which is quite thin and watery, instead ter the final boiling, the product is rendered of simple water, for the purpose of extracting more palatable and more milk-like in appear- shins of beef and other materials employed ance. for the preparation of soup. Jellies were pre- Peptonized Gruel.—Gruel may be prepared pared simply by adding the due quantity of from any of the numerous farinaceous articles gelatine or isinglass to hot peptonized gruel, which are in common use—wheaten flour, and flavoring the mixture according to taste. oatmeal, arrowroot, sago, pearl barley, pea or Blanc-manges were made by treating pep- lentil flour. The gruel should be very well tonized milk in the same way, and then add- boiled, and made thick and strong. It is ing cream. In preparing all these dishes, then poured into a covered jug, and allowed it is absolutely necessary to complete the to cool to a temperature of about 140° F. operation of peptonizing the gruel or the Liquor pancreaticus is then added in the milk, even to the final boiling, before adding proportion of a tablespoonful to a pint of the stiffening ingredient. For, if the liquor gruel, and the jug is kept warm un- pancreaticus be allowed to act on the gelatin, der a cosey, as before. At the end of a the gelatin itself undergoes a process of di- couple of hours, the product is boiled, and gestion, and its power of setting on cooling finally strained. The action of the pancreatic is utterly abolished. extract on gruel is two-fold: the starch of Peptonized Beef-Tea. —Half a pound of the meal is converted into sugar, and the al- finely minced lean beef is mixed with a pint buminoid matters are peptonized. The con- of water and twenty grains (half a small tea- version of the starch causes the gruel, how- spoonful) of bicarbonate of soda. This is ever thick it may have been at starting, to simmered for an hour and a half. When it become quite thin and watery. Peptonized is cooled down to about 140° Fahr. (6o° C.) gruel is not generally, by itself, acceptable a tablespoonful of the liquor pancreaticus is food for invalids, but in conjunction with added. The mixture is then kept warm un- peptonized milk (peptonized milk-gruel), or der a cosey for two hours, and occasionally as a basis for peptonized soups, jellies and shaken. At the end of this time, the liquid blanc-manges it is likely to prove valuable. portions are decanted and boiled for five Peptonized Milk-Gruel.—This is the minutes. Beef-tea prepared in this way is preparation of which I have had the most ex- rich in peptone. It contains about 4.5 per perience in the treatment of the sick, and with cent, of organic residue, of which more than which I have obtained the most satisfactory three-fourths consist of peptone; so that its results. It may be regarded as an artificially nutritive value in regard to nitrogenized mate- digested bread and milk, and as forming by rials is about equivalent to that of milk. itself a complete and highly nutritious food When seasoned with salt, it is scarcely dis- for weak digestions. It is very readily made, tinguishable in taste from ordinary beef-tea. and does not require the thermometer. First, Another way—One pound of finely-minced a good thick gruel is prepared from any of the lean beef is mixed with a pint of water, and farinaceous articles above mentioned. The simmered for an hour and a half. The re- gruel, while still boiling hot, is added to an sulting beef-tea is then decanted off into a equal quantity of cold milk. The mixture covered jug. The undissolved beef-residue will have a temperature of about 125° F. (52° is beaten with a spoon into a pulp or paste, C.). To each pint of this mixture, two or and added to the beef-tea in the covered jug. three teaspoonfuls of liquor pancreaticus and When the mixture has cooled down to 14O0 twenty grains of bicarbonate of soda (half a Fahr. (or when it is cool enough to be tole- small teaspoonful) are added. It is then rated in the mouth), a tablespoonful of the kept warm in a covered jug under a ‘ cosey,’ liquor pancreaticus is added, and the whole for a couple of hours, and then boiled for a well stirred together. The covered jug is few minutes, and strained. The bitterness of then kept warm under a cosey for two hours; the digested milk is almost completely covered and the end of this time the contents of the in the peptonized milk-gruel;and invalids take jug are boiled briskly for two or three min- this compound, if not with relish, without the utes and finally strained; it is then ready for least objection. use.

Peptonized Soups, jfellies, and Blanc- The extreme solubility of digested products, Manges.—I have sought to give variety to whether of starch or of proteids, detracts peptonized dishes by preparing soups, jellies, from their acceptability to the healthy. To and blanc-manges containing peptonized ali- them they appear thin and watery; they miss ments. In this endeavor I have been assisted the sense of substance and solidity which is by a memberof my family, who has succeeded characteristic of their ordinary food. But to beyond my expectations. She has been able the weak invalid without appetite, this sense to place on my table soups, jellies, and blanc- of substance or thickening is generally an manges, containing a large amount of di- objection, and they take with more ease an gested starch and digested proteids, possess- aliment which they can drink like water. The ing excellent flavor; and which the most jellies and blanc-manges, on the other hand, 20 INDIGESTION AND BILIOUSNESS*

give to invalids of more power that sense of process, or the preparations of pepsin, or of resistance and solidity which is desired by the vegetable papuan, which is a most potent those of stronger appetite. The greater vari- agent in the digestion of albuminoids—vege- ety which can now be given to this form of table though it be. food will obviate the monotony sometimes complained of under the continuous use of peptonized milk-gruel. CHAPTER V. The Use of Liquor Pancreaticus as an TISSUE NUTRITION. “ Addition to Food shortly before it is Eaten. — From the food the blood is fed; from the Certain dishes commonly used by invalids—- blood the tissues are fed.” In the first place, farinaceous gruels, milk, bread and milk, then, we must have healthy blood for the milk flavored with tea, or coffee or cocoa, formation and maintenance ofhealthy tissues. and soups strengthened with farinaceous The blood in its ceaseless round carries matters or with milk—are suitable for this pabulum to the tissues of the body. The mode of treatment. A teaspoonful or two of little artery, with its vitalizing fluid, carries a the liquor pancreaticus should be stirred up supply of albuminoid material to the tissues with the warm food as soon as it comes to in excess of their wants. A large quantity table. And such is the activity of the prepara- flows on through the capillaries into the cor- tion that, even as the invalid is engaged in responding venule, and soon rejoins the bulk eating—if he eat leisurely, as an invalid of the circulating fluid. A portion of the should—a change comes over the contents of serum passes through the capillary walls and the cup or basin; the gruel becomes thinner; feeds the tissue; the surplusage being taken the milk alters a shade in color, or perhaps up by the lymphatics, and so preserved for curdles softly; and the pieces of bread soften. future use. It is desirable to have clear The transformation thus begun goes on for a views about this matter of tissue-nutrition. time in the stomach; and one may believe The whole of the serum does not flow through that, before the gastric acid puts a stop to the capillaries into the small veins, a part the process, the work of digestion is already passes into the tissues. In order to maintain far advanced. a balance betwixt the parts and their supply This mode of administering liquor pancre- of pabulum, there is the lymphatic vessel. aticus is simple and convenient. No addi- The surplusage is taken up by this lymphatic, tion of alkali is required, and of course and returned to the blood by the thoracic no final boiling. The only, precaution duct. Thus the surplusage is removed from to be observed is that the tempera- the tissue and saved from waste, or even ture of the food, when the extract is being positively harmful. If the surplusage added, should not exceed 150° F. (65° C.). were not removed, there would be over-nutri- This point is very easily ascertained; for no tion of the part with hypertrophy. Thus, liquid can be tolerated in the mouth, even when John Hunter placed a cock’s when taken in sips, which has a temperature spur in a cleft made in the bird’s above 140“ (6o° C.). If, therefore, the food comb, the spur grew to a most abno- is sufficiently cool to be borne in the mouth, mal extent. When there is a disturbance in the liquor pancreaticus may be added to it this natural balance betwixt supply and de- without any risk of injuring the activity of mand, then hypertrophy is the result. The the ferments. son of a friend of mine wore a high shoe on Hut the high shoe was the 2. —For Medicinal Administration. one foot. on sound leg. He had a enlargement of When given with view aiding great a of the di- the other leg from obstruction in the lym- gestion of starchy food, one to two teaspoon- phatics, and it grew disproportionately from fuls should be in a little warm administered the nutritive fluid in the tissues; so with Taken in this it excess of water meals. way acts much so, that he high on the same manner as Malt but had to wear a shoe in Extract, the foot of the normal limb. more powerfully. much Such elongations of limbs from chtonic in- When liquor pancreaticus is given with a flammation in their joints, is a not-uncommon view of aiding intestinal digestion, one to phenomenon. We know that when the teaspoonfuls, with a pinch ofbicarbonate two venous system is engorged from valvular dis- of soda, dissolved in half a wine-glass of ease of the heart, we get a development of should be taken two or three hours water, pathological connective-tissue in the different after a meal. viscera, especially the liver, spleen, and kid- 3. —Liquor Pancreaticus as an Addition neys; though the lungs, the brain, and the to Nutritive Enemata. uterus, may be enlarged, or rendered of den- Liquor pancreaticus is peculiarly adapted ser texture, or both. Around a chronic ulcer for administration with nutritive enemata. there is a vascular zone, which produces The enema may be prepared in the usual way epidermal scales in excess, and on which the with milk-gruel and beef-tea; and a dessert- hairs grow to a gigantic size. Some diseases spoonful of liquor pancreaticus should be ad- tend to produce local disturbances of nutri- ded to it just before administration. In the tion, notably syphilis, and struma. Syphilis warm temperature of the bowel, the fer- produces nodes under the periosteum, and ments find a favorable medium for their ac- gummata elsewhere,—active proliferation of tion on the nutritive materials with which connective-tissue corpuscles. Cancer is the they are mixed; and there is no acid secretion production of histological elements out of tointerfere with thecompletion of the digestive place or out of time. Scirrhus is cartilage TISSUE NUTRITION. 21 where no cartilage should be. Colloid, so ciency in the assimilation of fat. One of the often found in the ovaries, is only the sarcode difficulties of modern, or rather recent times, of the umbilical cord. Osteocephaloma is a is the growing inability to take fat; children growth of cells from the bone identical with now, in a great many instances, simply loathe the cells of the marrow of the foetal bones. fat, especially a lump of adipose tissue. They It is then not truly heteromorphic; it is nor- can take cod-liver oil, even like it; they can mal tissue, out of place, or out of time. Col- take the fluid fat of fried bacon; they can loid in the ovaries, marrow cells in the cancer take butter; but animal fat en masse they springing from bone; these tell of an associa- turn from with repulsion. Granting that in tion which is certainly not accidental. many instances the objection has no better Struma is essentially a disease of hyper- foundation than a silly notion that it is “ vul- plasia of connective tissue; a growth, in ex- gar” to eat fat, still there remains an unpleas- cess, of cells of inferior quality. The en- antly large proportion in whom therepugnance larged glands, the thickened epiphyses of the to fat is genuine and unaffected. When this long bones; what are they but hyperplasia of rejection of fat has proceeded a certain length, •elements found there normally? The neo- then phthisis looms up. A certain amount of plasm is an inferior or degraded form of cell- fat is apparently essential to the formation of life; nothing strictly new. In tubercle there perfectly healthy tissue; and when the system is a growth of lowly cells along the course of is imperfectly supplied with fat, then tissue the tiny arteries. These imperfect cells crowd deterioration is apt to show itself. This holds upon each other; and if this crowding goes good of animals as well as man. Tubercle is so far as to press upon the nutrient arterioles, common in the lungs of sheep and oxen; and then there is danger of their death, of molecu- it is quite a frequent occurrence to find with- lar necrosis. Thus tubercle softens, breaks ering tubercular masses in the animals when down, and is expectorated. If the crowding fatted—a recovery after the starvation of a of these imperfect cells in a gland passes previous hard winter. When starved or par- a certain point, the gland structure breaks tially so, these inferior cell-elements are down into a scrofulous abscess. It is formed; when the nutrition is improved the same method of procedure, viz., the then normal tissues are formed, healthy and development of cell elements about the sound,—and the lowly histological elements nutrient vessels, which causes the ripe wither. With the consumptive, we try to get apple to drop off; which fills up two of the them to take fat, the easily assimilable cod- three holes in a cocoa-nut, and then gradually liver oil being the fat mainly used; but, in fills up the third, till the fibres can no longer some cases, other oils or cream will do very bear the weight, the nut drops off from its well; if they can take it and assimilate it, then attachment, and comes to the ground. So recovery takesplace. Fat is so furnished for when the abnormal cell elements accumulate histological elements, and then the tubercular till they press on the nutrient arteriole, the process is stayed; and the patient’s life is part so cut off from its pabulum dies. Thus saved. we find we have disturbances of tissue—nu- It is not asserted that this is all, the com- trition in the direction of excess—of excess of plete whole, of the production and cure of ■quantity with deterioration of quality. tubercle; but it is an important part of the Then there is atrophy from mal-nutrition, subject, this inability to assimilate fat. With- local or general. Phthisis, consumption, or out a sufficiency of fat the cell-elements are 41 a wearing,” the old vulgar term for wasting imperfect, they are produced in excess with disease, is general mal-nutrition from impair- deterioration of quality. In the present state ment of the digestive and assimilative pro- of our knowledge, we are unacquaintedwith cesses. any agents which act directly upon tissue- Then we see persons, at other times, with nutrition. The tissues are fed from the flabby ill-fed muscles, yet well clad with fat. blood; and ‘ * deteriorated tissues need for Their adipose tissue is sufficiently fed, but their regeneration the baptism of healthy not their muscles. Here there is defective blood;” to improve the blood is the way assimilation of albuminoids, while the diges- to the regeneration of the tissues. We can tion of starch and fat is normal and unaffected. only feed the body through the blood; the Indeed, as is well seen in chlorotic girls, blood is fed from the food we eat. I f we can there is an inverse proportion established, the improve the blood we can feed the tissues. muscles are flabby, while there is a positive We know that we may have anaemia with accumulation of fat. They are breathless; fair, indeed good general tissue-nutrition partly because they are anaemic, partly be- The assimilative and constructive processes cause their heart and diaphragm are half- are equal to the commoner tissues; but they starved. The assimilation of albuminoids is cannot build up haemoglobin. Haemoglobin impaired, and especially is the formation of has this formidable looking formula: C N complex body haemoglobin , , Sq that interfered 5 3 • 8 5 > H 7 . 82 lg . 17, O g 4 . g 4 . 3 g , Fe. 4g with. The red corpuscles are deficient, and with some 3 to 4 per cent, of water of crys- oxidation is impaired. When improvement is talization, (M. Foster). We can readily un- inaugurated the red corpuscles are increased derstand how the power to construct less com- in number; the muscles fill out, while the fat plex bodies may be retained, yet the capacity in the body is diminished. Such are the va- to build up haemoglobin may be lost for a rious steps in the process of the restoration of time; and require medicinal treatment for its •health. restoration. We see how certain blood-pois- Then at other times there is a distinct defi- ons, lead, mercury, malaria, gout, and syph- 22 INDIGESTION AND BILIOUSNESS. ilis, may render a person anaemic; yet their nutrition, restricted to the nervous system. general nutrition may be little, if at all, The serous fluids, including the serum of the affected. We know that when there is such blood, contain lecithin in small quantities ; a toxic element present iron will not cure therefore exhaustion of this substance in the the anaemia, however potent in simple anae- nervous system would require time for its re- mia, until the specific in each case be added: pair; and if the nervous system is still called and then improvement sets in. With the upon, it must furnish evidences of exhaustion two mineral poisons it is necessary to elimi- and diminished capacity, until the normal nate them from the system, to relieve it from proportion of lecithin is restored. Rest for their presence, ere blood-formation can pro- the nervous system permits of the re-accumu- ceed. In malaria we give quinine, in gout lation of this complex phosphorized fat. lithia and potash, in syphilis mercury or Then we find phosphorus advocated for iodide of potassium, with iron; and then the nervous exhaustion and depression. “Ohne iron is operative: without the specific, chal- phosphor keine gedanke,” was Moleschott’s ybeates are like an arrow without a head. dictum now so widely known—(“Without The clinical relations of anaemia teach us a phosphorus there is no thought.”) But this valuable lesson as to the loss of power in the phosphorus has to be formed into a fat before system to construct the complex substance, it can be of service. Not only thought, but haemoglobin. motor messages involve the oxidation of this Another lesson in the same direction is complex fat. Lecithin, cerebrin, andneurin, taught us by the nervous system; the loss of are complex substances, found in the nervous nervous energy, the prostration, the unfitness system; though the two latter are simpler, not for toil, necessitating a holiday, now so com- containing phosphorus. But the decomposi- monly experienced. Here it would seem, tion of these complex bodies is essential to there is impairment of the ability to construct nervous energy. Neuralgia is like most pain, lecithin. Lecithin is complex fat containing the prayer for healthy blood. “ Pain is the phosphorus and nitrogen. prayer of a nerve for healthy blood,” wrote “ , , Lecithin C 44 1I90 , NP0 9 occurs wide- Romberg; and most certainly this is true of ly spread through the body. Blood, gall, neuralgic pain. Neuralgia is intimately and serous fluids contain it in small quanti linked with the presence of poisons in the ties, whileit is a conspicuous component of blood —mineral, malarial, or produced within the brain, nerves, yolk of eggs, semen, pus, the body. Neuralgia is at other times the white blood-corpuscles, and the electrical offspring of simple anaemia, mere bloodless- organs of the ray.” This is what Michael ness. Neuralgic pain tells of unhealthy Foster says about lecithin. The well- blood; blood either containing a positive known association betwixt a heavy seminal poison, or itself deficient in nutrient ma- expenditure and the loss of nervous energy, terial. The rest of the body may be fairly- upon which quacks and charlatans have well nourished; but neuralgia, and a sense of traded so largely, is thus intelligible and lethargy or unfitness for work, may tell that comprehensible. Its presence in the elec- the nervous system is underfed—that the trical organs of the ray is not devoid of sig- organism is unequal to the formation of nificance. This lecithin is a subject upon those complex substances, the food of the which we will have soon to know more than nervous system. we do at the present time. Just as the com- So far as we know it is in the preparation plex haemoglobin is a constituent factor of of these complex matters for the blood and red blood-corpuscles, so we will find this the nervous system—neither of which exists complex fat—lecithin—a constituent factor in plant life—that animal synthesis exhibits of nerve-cells and fibres. We do not know itself. Bone is the infiltration of lime into enough of the subtle changes which lie at the ordinary cartilage: but haemoglobin and leci- foundation of the loss of nervous energy so thin are complex bodies, built up in the ani- well or intimately as the associations of anae- mal organism. Starch, sugar, fat, are built mia; but there is much pointing in this di- up from carbonic acid and water; albumen rection, viz., that it is linked with an insuffi- from these and free ammonia in the air. All ciency of lecithin. It is either used up too are synthetically built up by vegetable life, freely by overwork, or worry, which is still and appropriated by animals. Animals more exhausting; or it is formed imperfectly evolve energy by the union of these sub- from some impairment in the assimilative stances with oxygen; they pull to pieces and processes. It seems probable that this com- oxidize the construction of plant life, and plex fat is the food par excellence of the ner- in doing so evolve heat and force. But the vous system. That without it nervous energy oxygen-carrying haemoglobin, the force-liber- cannot be manifested. Further we may not ating lecithin, are essentially the creation of yet affirm. animals themselves; who build them up from But it is perfectly legitimate to throw to- less complex substances. gether a few clinical facts bearing on the mat- The complexity of these nervine matters ter, which speak with a not quite in articulate are associated somehow with the immense sound. When the nervous system has been “ liberating-power” that they possess. The severely overtaxed for a considerable time, it respiratory centre occupies a little space in may give out evidences of exhaustion; while the medulla, but its rhythmic discharges set the muscles are well-nourished, and the adi- off a large series of muscles; and when its pose tissue of the body is not diminished. It explosions are stimulated by the presence of is clear that here there is a localized mal- carbonic acid in excess in the blood, all the TISSUE NUTRITION. 23 muscles of the body may be more or less valid, as a person pulled down with dysen- thrown into action. No wonder then that at tery, or tropical fever. At a distance, the times the system is unequal to the construc- tottering gait, the unsteady step, the bowed tion of these elaborate compounds; when it figure leaning on a stick, may belong to each can carry on successfully the digestion, assim- alike; but on nearer approach, the resemb- ilation, and transformation of ordinary mate- lance fades out, and the points of dissimilarity rials—built up by vegetables originally, and become obvious. Nevertheless, it is by no appropriated by animals. No wonder either means rare to see cases in which “ heart- that when the power to build up these pro- starvation ” has been mistaken for the “fatty ducts of animal synthesis is lost, it may re- heart.” Indeed, the resemblance is so close, quire some time before the system can regain and the general practitioner has so many it. The conversion of spare hydrocarbons things to attend to on the one hand; while on within the system into fat, and even spare the other, our acquaintance with the heart proteids, though this is rather fatty histoly- “as a muscle” has not kept pace, or any- sis, and the development of adipose tissue is thing like it, with our acquaintance with the not to be compared to the construction of valvular diseases of the heart, of which the haemoglobin and lecithin, the two most com- “murmur” is the indication par excellence; plex products of the body; the two which that such mistake does not always involve must, and only can be built up by animal either carelessness or culpable ignorance. synthesis. So much then for the loss of pow- But in the absence of the significant mur- er to construct complex bodies. mur, the presence of distinct debility in the At other times there exists a loss of power heart is mystifying to the ordinary practition- to assimilate albuminoids, and then the mus- er, and calls up the fear of “ fatty degenera- cles suffer chiefly; and especially the two tion;” and not unnaturally so. muscles in constant action,—the heart and The knowledge which one man acquires the diaphragm. This is a practically import- by the sweat of his brow, after years of ant matter, as a heart so weakened is not un- patient toil and painstaking observation, can- commonly mistaken for a heart undergoing not be transferred in its entirety to another; fatty degeneratiqn. In the general evidence there is no “ royal road ” to knowledge. of loss of power in the heart the two condi- Individual acquired skill cannot be passed tions are almost identical. There is this dif- from brain to brain, any more than the jug- ference, however, “fatty degeneration” is a gler who can keep six balls in the air at once, condition the gravity of which it is impossi- can endow an onlooker with like capacity, by ble to underrate; while “ heart starvation” is merely showing him “ how it is done.” The a condition carrying with it little cause for muscles, and still more their representatives apprehension, except in those conditions of in the motor area of the brain-hemispheres, acute failure in pyretic states of blood poison- require a long training before this manual ing, where the heart’s action becomes exceed- skill can be acquired. So it is in other jnat- ingly rapid and fluttering; a condition fraught ters. It is not difficult 1o say how the diag- with extreme danger. But “ heart starvation” nosis between the “ fatty heart” and “ heart as ordinarily seen is a condition of some per- starvation” is to be made; but without in- manency, and not a truly “acute” condition. dividual toil to acquire the requisite capacity, When the digestion of albuminoids is de- the reader cannot attain it. There is no fective then the blood cannot furnish to the royal road to the disciimination betwixt two muscular structures the pabulum required for allied conditions, especially when the re- the maintenance of their integrity; conse- semblance is so close as it is betwixt the fatty quently they are ill-nourished and their func- heart and its double,—heart starvation. tional activity is impaired. When the heart There are in each the same signs on is so enfeebled and the diaphragm also half- physical examination of the heart; in each starved, then there are disturbances in the the same cold extremities, indicating circulation which closely resemble the symp- want of blood in the arteries; in each the evi- toms of the fatty heart. The heart-sounds dences of cerebral anaemia; in each the same are ill-defined and less audible than normal, incapacity for exertion and breathlessness on while the heart’s impulse is lost or nearly so. effort; a whole group of symptoms, indeed, The pulse is feeble and compressible. There is found present in both. But in the fatty is a tendency to fainting, while the mental heart there are found evidences of senility all operations are confused, the brain being im- over the body. The skin is degenerate, un- perfectly supplied with blood. There is a naturally smooth and greasy, or furred with feeling of unsteadiness, or lack of self- myriads of wrinkles; the eyeexhibits an arcus reliance, which is very distressing. The senilis (arcus is a “bow” not a “ring”), patient sighs, and there are seizures when the seen under the upper eyelid long before it is respiration is arrested. Indeed, the symp- present in that portion of the eye which is toms and sensations are those given by Da seen, and which is exposed to light; while the Costa, in his admirable work “ Medical Di- temporal artery is seen tortuous and meander- agnosis,” as some of the indications of the ing like a brook in a flat meadow. He was “ fatty heart. But fatty degeneration” as a a wise man, a keen observer, and an accurate jjisease of advanced life is distinctly senile in thinker, who said “ a man is no younger than “ its aspect, while heart starvation” is a mal- his arteries ” (S. Wilks): and it is the condi- ady of middle life. One presents the tout tion of the arteries which is our trustiest guide ensemble of age, —of widespread senile de- in making the diagnosis. In the fatty heart generative change; the other is rather an in- the arteries are usually atheromatous, rigid, 24 INDIGESTION AND BILIOUSNESS. and tortuous. In a well-marked case, the observed, there may be an increase in the temporal arteiy may be seen to elongate, amount of subcutaneous fat. Indeed, in as well as to widen on the ven- anaemic states, fat is apt to be deposited. tricular systole ; the radial artery is The farmer often bleeds his oxen to make felt to undergo the same transient them fatten, when they do not feed satisfac- change. The arteries feel like tendons, torily. or even pipe-stems. If, at the same Tissue-nutrition might not inappropriately time, the pulse is irregular or intermittent,then be otherwise termed “protoplasmic metabol- the fatty heart is present almost to a positive ism or digestion.” certainty. But where evidences of age are wanting, then in all probability the condition CHAPTER VI. present is that of heart starvation; it not be- SECONDARY INDIGESTION—NEUROSAL. —RE- ing denied that fatty degeneration is found FLEX. —CARDIAC.—TOXJEMIC. in certain rare states even in comparatively We now come to the consideration of young persons. But for once that fatty de- those forms of indigestion and mal-assimila* generation is so found, fifty times fatty de- tion which are secondary conditions, due to generation is diagnosed when heart starva- distuibances elsewhere, or to the presence of tion is the actual state of matters. The di- poisons in the body. These will be found to gestion of albuminoids is defective and the be a large widespread series. capacity of the heart and diaphragm is im- The first of this group of dyspepsiae is that paired; furnishing a group of symptoms due to disturbance of the nervous system, as closely resembling those manifested when overwork, worry, anxiety, suspense, or emo- the heart is the subject of that molecular tion; where the encephalic disturbance inter- decay, known as fatty degeneration, or ne- feres with the digestive act. “ How thin crosis. Even when there may be ground for you are getting!” we remark to an acquaint- the gravest .suspicion as to the integrity of ance. “Yes, I have been a good deal wor- the fibres of the heart, the condition may ried of late; I have a lot of work ; and lately still be one where “ starvation ” is also pres- I have had a good deal on my mind;” is the ent; that is, there is actual degeneration of common response. Such is the effect of some of the fibrillae, while there is starva- mental disturbance persisting for some time. tion in those fibrillae remaining structurally Acute indigestion is the result of sudden sound. Such cases are met with from time perturbation. “That the secretion of gastric to time, (see “ Heart Starvation,” H. K. juice is affected in a very marked manner by Lewis; reprinted from the Edinburgh Medi- conditions of the nervous system, is indicated cal and Surgical Journal, May, 1881). by the effect of the mental emotions in put- Here it is most important to remember ting an immediate stop to the digestive pro- that a small quantity of albuminoids, proper- cess, when it is going on in full vigor,” (Car- ly and completely digested, will furnish more pentei). We are all only too familiar with tissue-nutriment than a large meal, none of the consequences of bad news, or other “ up- which is thoroughly digested. A dietary of set,” when at meals. Unconscious previous- fi-,h, white meat, eggs, milk puddings, with ly of the possession of a stomach, or the pro- fruit, will digest and feed up a starved heart cess known as the digestive act, we suddenly and diaphragm; when liberal meals rich in feel a lump in the epigastrium, and an ac- meal fail to do so. It is not the amount companying conviction that the meal is swallowed, it is the amount digested, which wasted. 'Phis is the effect upon perfectly is to be the measure of the active nutritive healthy persons; more marked is the disturb- material in the blood; and from it the nutri- ance in those who suffer from indigestion. tion of the starved tissues. In such cases, it Vomiting may occur, or diarrhoea; either is well to aid the feeble natural digestive clearing away the spoiled victuals, but by a powers by the addition of pepsin, or the process the reverse of pleasii g. If neither pancreatic preparations. It is somewhat occur, then the undigested material is the difficult to induce the friends of the patient source of disturbance for some time after- to believe that such an apparent insufficient wards. The reaction of this upon the ner- dietary is the one calculated to repair debili- vous system is productive of great discom- tated conditions of muscles ; but instances fort; indeed, in some, acute misery is induced can be accompanied by explanation, and thereby. the results convince the doubtful and convert Dr. Carpenter, F. R. S., the author of the them to conviction. well-known works on Physiology, has paid The recognition of ill-fed muscles from im- considerable attention to the effects of men- pairment in the power of assimilating albu- tal conditions upon the organic processes ; minoids. as a condition involving the heart and it may be well to make several quota- and diaphragm, is a matter which must en- tions from his writings on the subject. By gage the attention of the profession in a lit- so doing, the reader will be put in possession tle time; indeed, when it is sated with nerve of the views of the illustrious physiologist; pathology and poison-germs, and can turn its which may carry with them, too, more weight attention to something else. than my unsupported word. After giving In pernicious anaemia there is great mus- the effects of emotion upon other secretions, cular asthenia, and the heart is the subject of he proceeds to speak of those connected with actual “fatty degeneration.” There is a the digestive act. growing general malnutrition of the muscu- “ The flow of saliva, again, is stimulated lar system especially, though, as Addison by the sight, the smell, the taste, or even by SECONDARY INDIGESTION—NEUROSAL.—REFLEX. —CARDIAC. 2 5 the thought of food; especially of such as is attributable to some such affection of the of a savory character. On the other hand, blood, than to a primary disturbance of the violent emotion may suspend the salivary se- secreting process itself. Although there can cretion; as is shown by the well-known test, be no doubt that the habitual state of the often resorted to in India, for the discovery emotional sensibility, has an important in- of a thief amongst the servants of a family—- fluence upon the general activity and per- that of compelling all the parties to hold a fection of the nutritive processes—as is shown certain quantity of rice in the mouth during by the well-nourished appearance usually a few minutes, the offender being generally exhibited by those who are free from mental distinguished by the comparative dryness of anxiety, as well as from bodily ailment, con- his mouthful at the end of the experiment. trasted with the “lean and hungry look” of There is much reason to believe that the those who are a prey to continued disquietude, secretion of thz gastric fluid is affected, in —yet it is not often that we have the op- the same manner as that of the saliva, by the portunity of observing the production of impressions made by food upon the senses; change in the nutrition of any specific part, for it has been ascertained by Bidder and by strong emotional excitement. In the two Schmidt, that it is copiously effused into the following cases, the correspondence of the stomach of dogs that have been kept fasting, effects to their alleged causes may when flesh or any other attractive food is have been only casual; and a much placed before them. That the secretion, on larger collection of facts would be the other hand, is entirely suspended by pow- need to establish the rationale here advanced erful mental emotion, seems almost certain, as probable. But so many analogous though from the well known influence which thishas less strongly-marked phenomena are pre- in dissipating the appetite for food, and in sented in the records of medical experience, suspending the digestive process when in and the influence of the emotions upon the active operation. As a cheerful state of products of secretion is so confirmatory, that feeling, on the other hand, seems to be de- there does not seem any reasonable ground cidedly favorable to the performance of the for hesitation, in admitting that the same ex- digestive function; it probably exerts a bene- planation may apply here also. The first of ficial influence, as to both quantity and these cases, cited by Guislain, from Ridard, quality, in the secretion of gastric fluid, of is that of a woman, who, after seeing her the influence of mental states, or other secre- daughter violently beaten, was seized with tions concerned in the reduction and appro- great terror, and suddenly became affected priation of the food, (such as biliary, pan- with gangrenous erysipelas of the right breast. creatic, and intestinal fluids), neither ob- But a still more remarkable example of local servation nor experiment has as yet afforded disorder of nutrition, occasioned by powerful any satisfactory information. It is a prevalent emotion, and determined as to its seat by the and perhaps not an ill-founded opinion, that intense direction of the attention to a particu- melam holy and jealousy have a tendency to lar part of the body, is narrated by Mr. increase t he quantity and tovitiate the quality, Carter, “On the Pathology and Treatment of of the biliary fluid. Perhaps the disorder of Hysteria.” “ A lady, who was watching her the organic functions is more commonly the little child at play, saw a heavy window- source of the former emotion than its con- sash fall upon its hand, cutting off three of sequence: but it is certain that the indulgence its fingers; and she was somuch overcome by of these feelings produces a decidedly mor- fright and distress, as to be unable to render bific effect by disordering the digestive pro- any assistance. A surgeon was speedily ob- cesses, and thus reacts upon the netvous tained, who, having dressed the wounds, system by impairing its healthy nutrition.” turned himself to the mother, whom he found This last is a very significant remark, and seated, moaning and complaining of pain throws much light upon many cases where in the hand. On examination, three fingers, there are evidences of mal-nutrition of the corresponding to those injured in the child, nervous system, taking itsoriginin emotional were discovered to be swollen and inflamed, disturbance. This transient disturbance per- although they had ailed nothing prior to the turbs the assimilative processes; and these, in accident. In four-and-twenty hours, incisions turn, lead to persisting mal-nutrition of the were made into them, and pus was evacuated; nervous system. sloughs were afterwards discharged, and the Again, “ there is abundant evidence that wounds ultimately healed.” The influence a sudden and violent excitement, or some de- of the state of expectant attention in modify- pressing emotion, especially terror, may pro- ing the processes of nutrition and secretion, duce a severe and even a fatal disturbance of is not less remarkable than we have already the organic functions; with general symptoms seen it to be in the production or modifica- (as Guislain has remarked), so strongly re- tion of muscular movements. It seems cer- rembling those of sedative poisoning, as to sain that the simple direction of the conscious- make it highly probable that the blood is ness to a part, independently of emotional directly affected by the emotional state, excitement, but with the expectation that through nervous agency; and, in fact, the some change will take place in its organic emotional alteration of various secretions, activity, is often sufficient to induce such an just alluded to,* seems much more probably alteration; and would probably always do so, if the concentration of the was * The urine, the sexual secretions, the sweat, and attention more than all, the milk—the secretion of the mammary sufficient.” This last matter will be referred land. to again in the consideration of hysterical 26 INDIGESTION AND BILIOUSNESS. dyspepsia, and hypochondriasis. It has cer- the muscular movements of the stomach. tainly much to do with the occurrence, if not These observations are in perfect accord and the production, of the “mother’s marks” so harmony with our practice of giving agents, commonly met with. which so act upon the stomach when the di- In considering the question of how emo- gestive act is defective. Persisting emotions tion affects the digestive process, Dr. Car- act in the same way but less potently, pro- penter says experiments have not led to ducing the same results through longer and agreement among observers. He writes slower operations. Thus worry, anxiety, “ Bernard, with many others, considers that “ calking care," and other depressing influ- the division of these nerves (the pneumogas- ences, cause a persisting loss of flesh, even trics), instantaneously checks the secretion of when no uncomfortable sensations are com- the gastric fluid, and therefore, puts a stop to plained of; while exhilarating conditions digestion; and he points to the pallor and lead to more perfect and complete digestion flaccidity of the stomach which immediately and nutrition. Shakespere wrote: succeed the operation, the slight and super- “ Let me have men about me that are fat: sleek- ficial digestion of the alimentary headed men, and such as sleep o’ nights. Yond’ mass which Cassius has a lean and hungry look; he thinks too takes place, and to the additional circum- much: such men are dangerous. Would he were stance, that in the rabbit there is a* sudden fatter! But I fear him not:”— change in the reaction of the urine from al- and we all know how persons emaciated by kaline to acid, the latter being the normal worry and anxiety, “pickup flesh,” when condition in the fasting state, and therefore, their minds are once more at rest after much showing that all action on the food must have perturbation. stopped. He further observes, that in gal- The observation that “small quantities of vanizing the pneumogastrics, an abundant meat or other food were digested readily flow of gastric juice takes place. Longet,how- enough, though large masseswere only super- ever, maintains that division of the ficially digested” is one pregnant with in- pneumogastrics operates rather in par- struction as to the dietetic requirements of alyzing the muscular movements of many dyspeptics. It shows that when the the stomach, than in stopping the secre- digestion is impaired small quantities of food tion of the gastric juice; for he states that if are digested “ readily enough;” while larger a small quantity of milk were given to the amounts were only digested on the surface, the animal, 24 or even 48 hours after the section, interior being untouched. Not only is the and when, therefore, there could be no gas- secretion of gastric juicediminished notably, tric juice remaining in the stomach, it has but the movements are abolished so that the invariably clotted after death, or upon mak- disintegration is not accomplished, which fits ing the animal vomit; and small quantities of the food for admixture with the bile and the meat or other food were digested readily pancreatic secretion, which is so large a part enough, though large masses were only su- of the function of the stomach; probably perficially digested, because the muscular more important than even the digestion of power of the stomach being paralyzed, the albuminoids in an acid medium, because this food was not properly intermingled with the last may be supplemented by the pancreatic gas ric juice.” digestion of albuminoids in an alkaline These interesting observations point to medium. It shows that in enfeebled assimi- several matters of clinical moment. They lation to give small quantities of food is to tell that section of the pneumogastric nerves secure complete digestion, while larger meals arrests the secretion of gastric juice with undergo little digestion, and have therefore “ pallor and flaccidity of the stomach little nutritive value; as is insisted upon in that is, the arterioles of the stomach dilate the preceding chapter when speaking of the in the act of digestion, when the mucus dietary in “ heart starvation.” Such then is lining at the same time is wet with the flow a part of the aid which physiological research of the gastric juice. Thus we see that both can give to practical medicine. (r) disintegration by the muscular move- Impaired nutrition is, then, often the direct ments; and (2) the production of the solvent outcome of mental disturbance. The most gastric juice, are arrested; no wonder then pronounced inveterate case of anaemia, lever that the digestion is hindered ! Such proba- met with personally, occurred in a girl of bly is the effect of fear and depressing emo- splendid physique and magnificent family tions. On the other hand, galvanizing the history. She was the type of health when pneumogastrics produces an abundant flow her father fell down by her side at market, of gastric juice. This is analogous to pleas- and died there and then. She immediately ant emotions aiding digestion; and may throw became anaemic and remained so, despite some light upon the time-honoredpractice of most varied treatment. taking wine with food. Paul urged upon Pernicious anaemia about which so much Timothy to “ drink no longer water, but has been written lately, is probably a per- have a little wine for thy stomach’s sake and version of nutrition due to nervous disorder, thine often infirmities;.” it seems probable rather than a local disease, “ atrophy of the that Timothy had indigestion among his “ in- gastric glands ;” if atrophy of the gastric firmities.” Pleasurable emotions of a cheer- glands is actually found after death, it is ful, enlivening character, act like a stimulus probably the consequence, rather than the through the pneumogastrics, and dilate the cause of the anaemia; instead of beinga rational gastric arterioles, promoting the secretion of explanation, in the face of the powers of th gastric juice; while increasing the energy of pancreatic secretion, it seems rather lik SECONDARY INDIGESTION NEUROSAL. REFLEX. CARDIAC. 27 *" putting the cart before the horse.” It is a the present “ struggle for existence,’’ and case of distinct loss of the power to assimilate “fight for a competency” is telling with albuminoids, a matter discussed in the pre- deadly effect upon the organic processes and ceding chapter. It appears that “ there is their nutritive products. Not only do we •often a considerable amount of subcutaneous recognize mental factors in the production of fat;” yet “almost without exception the heart the disturbance of the digestion, in the diges- is in a state of fatty degeneration; its walls tive act in the stomach—ordinarily spoken of are pale, flaccid and friable; the interior of as if it were the whole of the digestive act; the ventricles, and especially of the left ven- but we see the liver may be disordered by tricle, shows irregular whitish striae running mental disquietude. Jaundice has been transversely across the muscular bundles, and known to be produced by fright, and more especially the papillary muscles ” (S. Coup- chronic functional disturbance of the liver is land). It is a disease only observed in re- linked with persisting mental perturbation. cent times; and is one of the increasing num- Diabetes is set up actually by mental emotion; ber of perversions of nutrition with which chronic overwork leads to a more lasting form we are becoming familiar now-a-days. of mental taxation. Recently Clifford All- The mental associations of diabetes are butt, F. R. S., urged with his wonted able very interesting in relation to this subject. advocacy, the mental relationships of chronic Talking one day, with Mr. Van Abbott, renal disease. In his opinion enduring men- whose biscuits for diabetics have such a well tal anxiety and worry over business difficul- deserved renown, I asked him,—“Who are ties, is a potent factor in the production of your diabetics mostly ?” The reply was very chronic Bright’s disease with albuminuria. significant—“ Business men comparatively Indeed a huge mass of evidence is being old and grey for theiryears; men who look as collected to show that excessive toil in that if they had a deal in their minds.” This was portion of the brain which is devoted to the the response. It stands in a suggestive rela- intellectual processes, leads to deterioration tionship to the fact of acute diabetes being of the functions of the viscera, which form set up by shock, or other mental perturba- part of the organic life. The viscera which tion; or of its artificial production, by the provide the pabulum for the intellectual and puncture of the floor of the fourth ventricle. motor processes, i.e. the brain and muscular The direct nervous connection betwixt the system, become affected in time by the de- •brain and the liver has been shown by Cvon mand upon them, and give way under the and Aladoff. It contrasts with the mere strain. glycosuria, so common in stout men, where More pronounced is this effect when the the digestion of starch is perfect, and the posterior lobes, which are linked with our liver only dehydrates enough into glycogen subjective states and our emotions, are in- for the wants of the system; the surplusage volved. Loss of appetite, the power of all running off by the kidneys. Here, if it were digestion is the common outcome of acute not for this “ waste pipe,” the individuals grief. The production of new matters in the would become inordinately fat. Such gly- blood is shown by the hair turning grey sud- cosuria is a totally different matter from the denly; even in a single night, as was the case, diabetes, whichleads to wasting; where either it is said, with Marie Antoinette and the (i) the liver has lost the power of dehydra- Prisoner of Chillon. It is quite common to ting the sugar, brought to it by the portal see the hair acquire a distinct grey hue vein, the more probable hypothesis; or (2) the when the person is subject to acute severe ferments in the liver hydrate the glycogen, or mental trouble, a lawsuit, the death of a animal starch into sugar again, too swiftly loved rela ive, intense suspense in speculation for the wants of the body; and the “ fuel- or business, indeed any cause of profound food ” escapes unburnt. In either case it be- emotion; and to see it lose this temporarily comes necessary to feed the patient on food acquired hue, when the cause of the mental which is not saccharine, and therefore liable perturbation has either passed away, or the to these perversions of dehydration, and blow has been softened by time. The secre- secondary hydration. If food can be taken tion of milk in woman is profoundly affected in sufficient quantity and assimilated, which by mental emotion, indeed may become a undergoes no saccharine transformation, the deadly poison. Sir Astley Cooper observed diabetic is preserved: if not he perishes. S. two cases of arrest of the secretion from emo- Haughton, F. R. S. tells of the diabetic tion and wrote—“ Those passions which are patient dying of inanition, that in the delir- generally sources of pleasure, and which, ium which preceded the final change, he when moderately indulged, are conducive to •cried out “Fat! roasted fat from the angels health, when carried to excess, alter, and of heaven!” even entirely check, the secretion of milk'.” Such perversion of the assimilative pro- According to Dr. Carpenter, many observer cesses which is so marked in its various forms have noted fits of passions in a suckling at the present day, will be considered in rela- mother followed by convulsions and death in tion to its rapid increase, and the prospects the infant after being put to the breast. of the next generation and their successors, Thus, in one case a tumult arose between a —if they have any—in a succeeding chapter. soldier and a carpenter in whose house he The failure of the teeth it will be seen is but was billeted; the carpenter’s wife rushed in, -one part, one factor in a wide-spread de- wrested the sword from the soldier, and terioration of the digestive processes. The broke it in pieces. “ While in this strong fiferrific demand upon the nervous system in excitement, the mother took up her child 28 INDIGESTION AND BILIOUSNESS. from the cradle, where it lay playing, and in highest commendation. He omitted from the most perfect health, never having had a his calculation the matter of his health. His moment’s illness; she gave it the breast, and digestion broke down, he began to sweat at in doing so sealed its fate. In a few min- nights, and his left lung was not above sus- utes the infant left off sucking, became rest- picion. Fortunately his employers, knowing less, panted, and sank dead upon its mother’s his value, took alarm and sent him to me at breast.” It is clear that the disorder in the once,before the mischief had gone any length. secretion provoked by mental emotion pro- He was put upon tonics, and advised to go a duces some very active poison, acting rapidly trip into the Mediterranean in one of their upon the nervous system with deadly effect. vessels; and then to go to France for a time, Convulsions usually are provoked; nor is this so as to acquire the language without over- perversion of secretion in emotion confined working. The result of his overwork was a to human beings. Carpenter writes, “An- breakdown: a very common matter. He other case was that of a puppy, which was just lost the time which would have enabled seizedwith epileptic convulsions, on sucking him to have acquired French in a less violent its mother after a fit of rage.” hurry. He is now well, and free from any Such are the acute perversions which pro- chest ailment. duce toxic matters in the milk of a mother Such then are examples of a class of cases when she is emotionally excited. sadly too numerous at the present time. In The mental disturbance sets up modifica- this generation men will not be content to tions of secretion which result in the forma- move at the leisurely pace of their grand- tion of a poison acting mainly, if not entire- fathers. Mr. Deane, in “ the Mill on the ly, upon the nervous system. Floss,” spoke to his nephew Tom Tulliver as So in more chronic and persisting condi- follows:—“ The world goes on at a smarter tions. A mental upset disturbs the nutritive pace now than it did when I was a young processes, and the changes so induced react fellow. Why, sir, forty years ago, when I upon the nervous system: consequently we was much a strapping youngster as you, a can comprehend how persisting depraved nu- man expected to pull between the shafts the trition can be traced to a particular period of best part of his life, before he got the whip mental disturbance by the sufferer, with a in his hand. The .loom went slowish, and fair show of reason for what is stated. The fashions didn’t alter quite so fast; I'd a best most intractable case of dyspepsia with ma- suit that lasted me six years! Everything laise, lethargy, inability for exertion, a disor- was on a lower scale, sir, in point of expen- dered state of thebowels, with furred tongue, diture, I mean. It’s the steam, you see, that a hot bitter taste in the mouth on waking; has made the difference; it drives on every all the evidences indeed of disoidered diges- wheel double pace, and the wheel of fortune tion with the production of abnormal “ by- with ’em.” And so men push, and strive, products of digestion,” which ever came un- and struggle, and attain their end, —or break der my notice, was that of a returned East down in trying. It is the old Anglo-Saxon Indian. This gentleman came of a healthy plan to find out what can be done by over- stock, was a well nourished person, took a doing, and so learning the extreme limit. A very high place in the examination for the butcher’s boy was spokesman for his race, East Indian Civil Service; continued his la- when summoned before the magistrates at bors; took one thing after another, far out- Teddington, for furious driving; the consta- stripping all his competitors: with what re- ble stated the mare was going thirteen miles sult? This! His digestive apparatus be- an hour, when the boy triumphantly refuted came so thoroughly disordered that he was him by saying,—“ She can’t do it; she has compelled to retire from duty, to come home not got it in her!” He evidently knew to a to England, to do nothing. A confirmed nicety what she could do, by noting what she dyspeptic, his bodily comfort destroyed, his could not do. So it is in the present pace of prospects clouded darkly, crippled in the life. It is faster! faster! Our steeplechasers race for life; he has to sit helplessly looking gallop faster than their old-fashioned half-bred on, while his old competitors diminish the predecessors; our fox-hounds run faster than space betwixt him and them, and then over- of yore, till our hunters have to be nearly take him; after that, see them going on- thorough-bred to keep pace with them. It is ward leaving him hopelessly behind. If he the pace at which we live that overtaxes our- were not a man of high moral principle he organic processes, and the digestive processes would be driven to suicide! breaking down under the strain. It is the Another more ordinary case was that of a early period at which the pace is put on gentleman in a business house in South which is telling. Our racehorses are trained Wales. He had charge of a branch of the so young, that they soon are unfit for the business, was an energetic active man, indus- racecourse; how few horses are there now trious, persevering, and painstaking. Feel- who are good for anything at six years old! ing it would be an advantage to be acquaint- Old Forrester was racing long years after ed with the French language, he sat up at any horse is now put to the stud; but proba- nights to learn it. Under this additional bly he never ran as a two-year old. Eclipse strain his health broke down. He seemed was five years old before he was trained. As rather surprised when told that he had been, with horses, so with men. A man used to from a medical point of view, guilty of a be satisfied to have earned a competency at piece of consummate folly: for, from a busi- 60; now he strains to retire at 45 with a for- ness point of view his conduct merited the tune. As with men, so with racehorses; the SECONDARY INDIGESTION —NEUROSAL.—RENLEX. CARDIAC. 29 difficulty is to keep up their appetite and di- to occult powers, in all ages and nations, gestion. This it is which bothers the trainer. often produce the predicted maladies in the The young horses “ go off their feed,” and subjects who are credulous enough to believe then the training is suspended. Quinine, in their efficacy. Such was formerly the case withacids and gentian, is in vogue in trainers’ among the negroes of the British West establishments, to keep up the young scions Indies, to such a degree, that it was found of a famous stock. In the high-bred racer, necessary to repress what was known as the digestive organs give way under the de- “ Obeah practices,” by penal legislation; a. mands upon them, made too early. As the slow pining away, ending in death, being the trainer has to whip up the appetite of his not uncommon result of the fixed belief on two-year-old: so the Lincolnshire grazier the part of the victim, that “ obi ” have been finds it pay him to cook a part of the food for put upon him by some man or woman re- his stall-fatted stock. Perhaps in a few ported to possess the injurious power. Sa years it may be necessary, or anyhow, profit- great, indeed, was the dread of these spells, able, to give these oxen tonics. To what, that the mere threat of one party to a quar- then, are we coming? Tonics, artificial di- rel to “ put obi ” on the other, was often suf- gestive agents, or even artificially digested ficient to terrify the latter into submission.. food, may be palliative as regards the indi- And there is adequate ground for the asser- vidual, but they cannot be regarded as cura- tion, that even amongst the better instructed tive as to the race. For our successors classes of our own country, a fixed belief something else is necessary; and what that that a mortal disease had seized upon their “something” must be will be seen in a sub- frame, or that a particular operation or sys- sequent chapter. tem of treatment would prove unsuccessful, There is another aspect of this subject, of has been in numerous instances, the real oc- the effect of mental attitudes upon the casion of a fatal result.” organic processes, which needs a little con- I introduce this paragraph verbatim, to sideration, especially for those whom it con put the dyspeptic on his guard about the cerns, viz., the hypochondriac; and those study of his subjective sensations; as much as who, though not exactly belonging to the to warn the hypochondriac that it is well to class “ malade imaginatre,” still give too try to put away his, or her, morbid dwelling much attention to their subjective sensations. on ideal conditions. It is clear that it is de- It may be well again to quote Dr. Carpenter sirable the dyspeptic be cured as soon as may verbatim in this matter: • be; not only for his, or her, comfort or well “ The influence of the state of expectant being, but in order to obviate the danger of attention in modifying the processes of nutri- disordered function leading to structural tion and secretion, is not less remarkable change from the direction of the attention than we have seen it to be in the production thereto. There is no imaginary danger, as of muscular movements. The volitional di- Dr. Carpenter shows. Even when the sen- rection of the consciousness to a part, inde- sations of discomfort are present, it is well pendently of emotional excitement, suffices not to let them absorb the attention; the suf- to call forth sensations in it, which seem to ferers should turn their thoughts in other di- depend upon a change in its circulation; and rections, or have them distracted for them. if this state be kept up automatically by the Certainly it is within my personal experience attraction of the attention, the change may that persons who have long been troubled become a source of modification, not only in with indigestion, have died of cancer of the the functional action, but in the nutrition of stomach. Nor do I regard these as acci- the part. Thus, there can be no doubt that dental relationships, or mere coincidences. real disease often supervenes upon fancied Long gastric trouble culminated in cancer of ailment, especially through the indulgence of the pyloric ring, not that such is a common what is known as hypochondiiacal tendency to occurrence; but certainly in a number of dwell upon uneasy sensations; those sensa- cases either gastric cancer had a far reaching tions being themselves, in many instances, history of indigestion preceding it; or long- purely ‘subjective.’ In many individuals, standing functional disorder led to structural (especially females), whose sympathies are change; whichever way the reader chooses to strong, a pain in any part of the body may be put it. produced by witnessing it in another, or It is most desirable then that such sensa- even hearing described the sufferings ®cca- tions as arise from disordered function, are sioned by disease or injury of that part; and put away as much as possible by actual suf- if this pain be attended to, and believed in, ferers; while those whose maladies are cen- as an indication of serious mischief, in- tric, and due rather to disturbance within jurious consequences are very likely to fol- the posterior lobes of the cerebral hemi- low. So, again, the self-tormenting hypo- spheres, than to actual disorder in the viscera,, chondriac will imagine himself the victim of will be wise to attend as little as they can to any malady that he may “fancy;” and if this their abnormal feelings. Dr. Hughlings fancy should be sufficiently persistent and en- Jackson, F.R.C.P., holds that the liver, in- grossing, it is not unlikely to lead to real dis- deed, each of the viscera, has its representa- ease of the organ to which it relates. His tive area in the brain, just as much as the persistent direction of the attention has a arm or leg is represented in a distinct and much greater potency, when combined with localized area. The hypochondriac feels his the expectation of a particular result; and sensations in the part to which he refers thus it happens that the spells of pretenders them; just as other sensations are experienced. 30 INDIGESTION AND BILIOUSNESS. which are unreal. The lunatic is not the only trustworthy evidence that permanent amend- individual who has what others regard as hal- ment of a kind perfectly obvious to others has lucinations. What each one feels is known shown itself in a great variety of local to himself. A patient of mine once felt hairs maladies when the patients have been in his mouth; there were no such hairs. But sufficiently possessed by the expectation the impresston lasted the remainder of his of benefit, and by faith in the effi- lifetime. In such a case there must have cacy of the means employed.” It been a centric disturbance referred to a pe- is quite clear in this matter, that the confi- ripheral cause, in accordance with our com- dence of the patients will rest upon the con- mon experience. “ Phantom limbs” are a fidence with which they are told that they not uncommon phenomena; and a man will will be cured. If the curer, or thauma- feel the little finger ache with cold in an arm turgus, believe not in the cure, he cannot in- amputated years before. So in hypochondri- spire the patient with faith. If the medical asis, probably the disturbance is the primi- man speak to the patient with doubtful ac- tive sensation in the cerebral area, not the cents and hesitating utterances, he does not part to which it is referred; but the persistent inspire confidence; he really sows distrust. direction of the attention to the said viscus This is the explanation of the successful may in time lead to actual functional disor- treatment of a case by one man, where an- der, which in its turn may set up structural other has failed; the remedial measures being change in the course of time. much the same. The one carries the pa- The relations betwixt the brain and the di- tient with him to the restoration of health; gestive organs are intimate and interesting. the other intensifies a morbid state, and Disturbances in the viscera disorder the brain tends to make it permanent. directly, as well as by the abnormal products This is a matter too ltttle thought about. which reach it through the blood. Disturb- Just as a weak-willed medical man fails to do ance in the posterior lobes, those portions of certain patients good; and lack of decision of the hemispheres connected with our internal character unfits a medical man for dealing sensations, may lead in time to disorder in with emergencies, where the judgment must the viscera associated therewith. The direc- be prompt and the action energetic; so the tion of the attention operates banefully upon therapeutic nihilist, who doubts the effi- the organs to which it is turned. There are cacy of drugs, and leaves the patient to na- actions and reactions within the complex ture, disheartens many patients, and leaves microcosm; and the organic nervous system them chronic valetudinarians, when in the has not been denominated “ the sympathetic” hands of an enthusiast, the cases would soon without good and sufficient reasons. This is move onward to a satisfactory termination. an aspect of the subject which must be con- There are some men who are “doubting sidered and reflected upon. Its considera- Thomas’:” there are others who decry what tion may be disturbing to sundry nervous they do not understand, and depreciate reme- persons; but that is simply unavoidable, how- dies with whose potency they are unac- ever undesirable. It is all very well for cer- quainted, who do infinite, immeasurable tain enthusiastic individuals to deny them- harm to their patients. An eclipse of faith selves wine, which would do them good, in in medicines has now existed some time; but order to set an example ofabstinence to those the darkness is beginning to move away, and who yield to alcoholic temptation; but the a return of faith, stronger, firmer, more ca- bulk of humanity do not carry their “altru- pable of giving a raison d'etre for its exist- ism ” to such lengths. Such a way of regard- ence, than in the past, is dawning,—the day- ing the linked intimacy of mental states and break of happier times for those who are morbid digestive processes may be alarming stricken down with illness, or crippled in to sundry invalids and valetudinarians, but their working power by incapacity in their its consideration will be beneficial to a large viscera. This therapeutic nihilism is a pass- •class, and after all Jeremy Bentham was ing wave of opinion, a temporary mental right when he insisted upon “ the happiness state, the end of which is at hand; and the ■of the greatest number” being the thing to be sooner it is over the better for all. The pa- mmed at; for, on the other hand, a mental tient’s prospects will be all the brighter; the state may operate beneficially. medical man all the happier for feeling that “ Dr. Carpenter continues— the patient has got some value received” in “ But, on the other hand, the same mental return for his outlay. A healthier condition state may operate beneficially in checking a of thought on matters medical will generally morbid action and restoring the healthy state. obtain; for quacks, charlatans, and irregular That the confident expectation ofa cure is the practitioners of all kinds, are to a great ex- mostpotent means of bringing it about, doing tent fostered by the recent want of faith in that which no medical treatment can accom- the medical profession. When a man is plish, may be affirmed as the generalizedresult sick, what he wishes is to get well; the means ofexperiences of the most variedkind, extend- is to him a matter of comparative indiffer- ing through a long series of ages.” He then ence. If he gets his health again, he recks instances cases of “ cures” effected by faith little whether it is by the means of a notori- and says, —“ For although there can be no ous quack, or by those of some one possessed doubt that in a great number of cases the of the “ hall-mark ” of the venerable College patients have believed themselves to be cured of Physicians. when no real amelioration of their condition This is a moral aspect of the question &ad taken place, yet there is a large body of which that ancient institution has been rather SECONDARY INDIGESTION—NEUROSAL.—REFLEX. —CARDIAC. 31 nodding over for some years past; and it is phenomena manifested elsewhere. Irritation quite time that it awakened up to a proper is not always felt where it arises; the pain is consideration of the subject. The public very commonly in the knee when the disease will not rest patiently quiet till its slumbers is in the hip-joint ; in the right shoulder are completed; and the sooner the period of when the liver is involved. We know that awakening arrives the better for all. Stronger the pregnant uterus, especially in the early faith in the profession as a body, will lead to months before it has escaped from the pelvis, more belief in the individual units of it; and commonly produces very troublesome vomit- this in turn will inspire the public. Perhaps ing; or it may produce a persisting cough, those acrid personages who have a distinct known in Scotland as “a cradle cough.” line of faith, or rather the want of it, those Vomiting is a common outcome of injury to, individuals who believe in Homoeopathy, or acute mischief in the testicle, as it is a pro- and talk flippantly of “Allopaths,” who nounced symptom of a calculus in the kidney. deny the utility of the Contagious The old term “ the sympathetic nerve ” was Diseases Act (Human), who are anti-vacci- founded on the appreciation of the fact that nators; who are blended compounds of scep- one part was influenced by, or sympathized ticism and credulousness; those who are ut- with, another through the fibrils of this terly unteachable from prejudice and igno- r.erve. Currents may arise in the ovary and rance “ vaunting itself as knowledge,” can- be felt—not there when they arise—but at not be benefited; not even if their chief di- some far-distant point, where they run out. urnal instructor, their “ guide, philosopher, If a number of ivory balls be suspended in a and friend,” the Daily News, was to modify row, touching each other, and a tap be given its attitude, and show a livelier interest in to either terminal ball, it is the one at the matters affecting the public health, and a lit- other end which flies from its place. Conse- tle more decent respect for the observations quently waves of nerve-perturbation, arising of “the natural man.” They are an un- in the ovary, manifest themselves by disturb- hopeful class, the obstructionists of all prog- ances elsewhere. The glittering flash which ress in matters sanitary and hygienic; whose glances out from some female irides is the self-satisfaction in their ignorance on matters external indication of ovarian irritation, and medical, is simply as aggressive and imperti- “ the ovarian gleam” has features quite its nent, as that ignorance is appalling. They own. The most marked instance which are blinded guides in their self-appointed ever came under my notice was due to irri- mission of directingthe opinions of mankind; tation in the ovaries, which had been forced hut their faith in themselves is unbounded! down in front of the uterus and been fixed Such then are the cerebral relations of dis- there by adhesions. Here there was little turbances in the digestive processes. They sexual proclivity, but the eyes were very re- do not necessarily involve a disordered markable. They flashed and glittered un- tongue, or constipation, or diarrhoea; or man- ceasingly, and at times perfect lightning ifest those evidences of dyspepsia, found bolts shot from them. Usually there is a when the indigestion is primary. bright glittering sheen in them which con- There is another form of indigestion due trasts with the dead look in the irides of to nervous disturbance elsewhere, which also sexual excess, or profuse uterine discharges. carries with it obvious signs of the digestive Cough, palpitation, faceache, usually on the tract being the sole seat of trouble, as a bare, right side, inframammarypain, usually in the or raw, or a foul, or furred tongue; but left or sixth or seventh intercostal nerves, where constipation is commonly found. This and gastric irritation are the ordinary out- is due to a tender ovary, mostly the left. comes of uterine flexion, or ovarian disturb- This lies near the rectum, and the passage of ance. The most important matters clinic- fasces causes pain; the pain inhibits the move- ally are the gastric symptoms reflexly ex- ments of the bowel, and constipation is the cited by pelvic irritation. result. The accumulated fasces keep up the So important and so common are these ■ovarian tenderness, and the voiding of them maladies, and so utterly unsatisfactory their produces still more pain. And so the action treatment under the usual remedies—as bis- and reaction work in a downward direction. muth, hydrocyanic acid, oxide of silver, etc. Such indigestion is properly termed “ reflex.” —that they deserve to be treated at some It is a very common malady which has been length. In the first place the stomach has overlooked. It is mentioned by Negrier, different nerve-fibrils—those from the vagus, Robert Barnes, and Lombe Atthill. I had and those from the sympathetic. Claude to learn to decipher it for myself, and first Bernard observed that the application of a described it in an article on “Ovarian Dys- galvanic stimulus to the vagus fibres caused pepsia,” in the American Journalof Obstet- free secretion of the gastric juice; while the rics and Diseases of Women and Children, same stimulus applied to the sympathetic Jan., 1878, though it may have been deline- fibrils issuing from the semi-lunar ganglia, ated elsewhere; but if so, I am not acquaint- caused a diminution and complete arrest of ed with the article. the seeretion. The action of sympathetic “ The reproductive organs of women are nerve fibrils is to excite contraction in the the source of most of her troubles during that arteries and arterioles; that of the pneumo- period of her life when they are functionally gastric fibrils to dilate these vessels. Conse- active. Often will far-away irritation in the quently we can readily understand how cur- womb, or ovary, be found to be the cause, of rents coming in by the sympathetic tracts the most prominent objective and subjective from pelvic, or other irritation, may contract 32 INDIGESTION AND BILIOUSNESS. the gastric arterioles and arrest the flow of rian origin: and it is by the study of such gastric juice, If the irritation be sufficiently well-marked cases that the student will learn powerful then vomiting is set up. In ordi- to recognize the less marked or imperfect nary digestion the gastric blood-vessels are cases. Nor does it necessarily follow that dilated and there is a free flow of gastric the symptoms shall stand in a definite pro- juice. The irritation coming in from without portion to each other in each and every case. checks both these processes, and then imper- Sometimes the chief disturbance is uterine, at fect digestion with pain, or nausea is the re- other times mainly gastric. When the latter, sult. This may not proceed farther than the case often runs as follows—a girl, usually loss of appetite, dyspepsia, and nausea: or of the neurosal diathesis, betwixt nineteen there may be severe persistent vomiting set and twenty-four years of age, becomes the up by the introduction of food into the subject of intractable vomiting. This goes stomach, till a very serious condition may be on till such weakness is produced that the reached. In either case the tongue is clean, patient is confined to bed, and her life appar- and there are no evidences of disturbance in ently endangered. The least particle of food the gastro-intestinal canal, as in primary is immediately rejected, more or less com- gastric indigestion. Such is the dyspepsia so pletely. All sorts of combinations of drugs common in women. Primary dyspepsia is no are tried, and fail to procure any alleviation more frequent in women than in men, and of the condition. The medical attendant is presents the same features in both sexes. nearly worried out of his life, consultants are But reflex dyspepsia has other and quite dif- called in without avail; the friends of the ferent associations. In both forms of dyspep- patient are worked up to a state of feverish sia there may be constipation, or diarrhoea, anxiety; the sufferings of the patient are not excited by the undigested food irritating the inconsiderable; and so the case wears on for intestines, but these are incidental or coinci- weeks. Bismuth, hydrocyanic acid, opium, dent collaterals. In reflex dyspepsia effervescing mixtures, champagne, milk and there are usually the intercostal neu- seltzer water, beef tea, hot and cold, raw ralgia, with the three tender spots of meat, pounded, maltine, all are tried and Valleix, one under the mamma, the second fail; sometimes enough is retained to support at the base of the left scapula, the third at life; at other times it becomes necessary to the exit of the posterior rootlet of the sixth 'resort to nutritive enemata. All who have or seventh intercostal nerve from the spinal seen much practice are familiar with such column; and palpitation. Less commonly cases, which are very trying to all parties con- faceache or cough, and in middle aged wo- cerned, and which are unaffected by the dif- men flushings. Then there are the uterine ferent remedial measures resorted to;and which out-comes of the ovarian mischief—leucor- seem at last to wear themselves out,and are fol- rhoea, with or without menorrhagia, while at lowed by long and tedious convalescence. A times the menstrual flux is lost, or all but lost, year or two afterwards the patient is in good in the profuse leucorrhoea. The generative health, often a happy mother. Here the ab- organs of women become turgid with blood sence of local indication throws the medical during sexual excitement, approaching the man off the scent as to the real nature of the erectile condition of the male organ under malady with which he is brought in contact, excitement. Ovarian irritation sets up vas- and the ovaries are unsuspected. All the cular turgescence in the female parts which remedies are futile and inoperative, because continues more or less persistently. The not directed to the origin of the trouble. The consequence is that there is profuse secretion, case lingers on till it would seem the general often with excessive catamenial losses. Fre- mal nutrition starves down the congested quently, too, there are erotic dreams, recur- ovary into quietude, and then the reflex dis- rent orgasms, during sleep, “ the period par turbances cease. Were the true origin of the excellence of reflex excitability.” In more case known or discovered, then the successful prenounced cases, these discharges take treatment would soon be forthcoming. As a place in the waking state, without any refer- case in point I may mention a girl who came ence to psychical conditions,being found alike under my care some time ago at the West in married women cohabiting with their hus- London Hospital. For many months she bands, and in spinsters and widows. That had been under medical treatment for per- sexual excitement may be produced, or kept sistent retching and vomiting. The girl was up by lewd thought may not be denied; but pale and anaemic, with lack-lustre eyes, and this is not necessarily the psychical attitude a peculiar but characteristic expression, here. The uterine centres in the cord and which may be observed but cannot be de- the centres presiding over the bladder lie in scribed, indicative of ovarian trouble. The close proximity to each other. The irritable left ovary was found congested and exquisite- condition of the lumbar centres of the repro- ly tender, pressure over it almost producing ductive organs is communicated to the vesical syncope, and exciting acute nausea. The centres, and then a very distressing condition ovary was treated, and in ten days the girl results, viz., a state of weakness and irrita- left the hospital—well, but I doubt if perma- bility in the bladder, and the call to make nently cured. water is sudden and imperative, and must be What is the treatment of these cases? It attended to at once, or a certain penalty be consists of several factors, each essential and paid for non-attention. Such are the objec- complementary to the others. The bowels tive and subjective phenomenaexhibited in a should be unloaded, so that there shall be no complete case of “reflex dyspepsia” of ova- pelvic congestion. A small quantity of sul- SECONDARY INDIGESTION NEUROSAL. REFLEX. —CARDIAC. 33 phate of magnesia in each dose of medicine food. This is rarely absent in cases of car- will useually attain this end. If not quite diac failure in elderly persons, indeed, itis in -sufficient an aloetic pill at bed-time is indi- old persons that it is mainly felt; though it is cated. In small doses, as said before aloes not uncommon in young persons with severe excites the hemorrhoidal vessels; in fuller mitral disease. It arises from obstruction to doses it depletes them. The bowels should the circulation, due to some lesion in the be emptied at bed-time. A load in the bowels heart—usually a valvular lesion; but at times during sleep produces vascular turgescence in occasioned by the yielding of the muscular females whose reproductive organs are out of wall. This obstruction causes a damming of health, just as it produces chordee in a man the blood at the point, which works back- with gonorrhoea. Then comes the other fac- wards into the veins and venules. ‘ tor—the reflex manifestations. Instead of ‘ Sooner orlater, the right heart yields, treating the stomach an agent must be given either by the tricuspid ostium becoming so which will influence the nerve tracts over large as the muscular walls dilate, that the which the perturbatory waves travel. Bro- valves become insufficient; or by secondary mide of potassium deadens the nerve fibrils implication of the tricuspid valves rendering along their course andat their peripheral end- them no longer equal to the closure of the ings. Both at the periphery in the ovary and normal ostium; or, by a combination of both. at the terminus, the stomach, is its influence Then the venae cavae become distended, and felt. It blunts the nerve endings while it the jugular veins are seen to pulsate. Some deadens the conductive power of nerve fibrils. jugular pulsation may be seen before the Consequently a combination like the following tricuspid becomes insufficient; it is caused by is useful: the reflux of blood through the tricuspid be- flaps are driven together Mag. Sulph. fore its on the ven- 3i. tricular contraction. All the branches of the Potass. Bromidi 3i. venae cavae become distended; and especially Mist. Camphorse, § i., ter in die. is this the case with the portal circulation, If the stomach reject this a hypodermic in- which is not provided with valves. Splitting jection of half, or a third, of a grain of up as it does in the liver, the portal vein is morphia will usually produce such effects that partially protected by minute divisions in the stomach will tolerate the medicines. the liver, otherwise great disturbance Nutritive enemata may be needed for a day would be occasioned by the want of or two. As soon as the bromide is tolerated valves in it, on tricuspid regurgitation. But, and retained, matters improve. Sometimes in consequence of this sub-division in the it is well to substitute infusions of gentian liver, that viscus becomes gorged with blood for the camphor mixture as a vehicle; it acts in tricuspid regurgitation, and pulsates with beneficially upon the stomach, as do all bit- the regurgitatingcurrent driven backwards by ters, and renders it more tolerant of the medi- the hypertrophied right ventricle. Liver- cines. Local treatment in the shape of a pulsation is a distinct symptom of diagnostic blister over the tender ovary is of much value; value; while the venous fulness of the liver not only does it produce a mental impression, leads to a development of connective tissue but we have reason to suppose that nerve-waves corpuscles in the inter-lobular areolar tissue; can meet and neutralize each other—likerays first there is increase of bulk in the liver, then of light—under certain circumstances. The cirrhosis or atrophy as the connective tissue ordinary Emplastrum Cantharidis 2X2 ap- contracts; the liver tissue becoming more plied over the offending ovary on going to firmer and harder than normal. The liver is bed will usually be found to produce vesica- easily deranged by an excess of food when so tion by the morning. Some slight soreness affected, and great care in diet is requisite for follows, but the relief afforded to the internal the proper performance of its functions. pain far outweighs this. In some rare in- There is serous effusion from the gorged stances a crop of boils follows the blister; but venules into the bile-passages attending it, so so rarely as not to militate against its use. that Oppolzer has given to this condition By these measures combined, the reflex gas- the term “ albuminicholi;” and he further tric disturbance is effectually removed. sta'es that in this condition there is congestion There remains the leucorrhoeal loss to be of the mucous lining of the bile ducts with •considered. Higginson’s syringe, or the jaundice, and that both these conditions are common enema syringe for infants, are pre- readily affected by a common cold. The dis- ferable to the glass syringe, which is brittle, turbances and changes in the liver are much and accidents sometimes occur. First an in- more marked in some persons with tricuspid jection of plain water to removeall discharge, failure than in others. and then of a little alum water, not stronger The spleen is implicated in this congestion than an ounce to two quarts of water, will of the portal circulation; it becomes enlarged usually soon reduce the loss. If there also from the development of connective tissue in be menorrhagia the usual measures must be it, larger than normal, and of firmer consis- adopted.” (The Practitioner s Handbook 0f tence, resembling a beefsteak in appearance Treatment, 2nd edition.) when cut open. We know, as yet, nothing Another form of “ secondary indigestion,” of the symptoms or disturbance of the func- is that due to venous fulness from valvular tions of the spleen. disease of the heart. Its chief indication is The stomach and intestinal canal are also that “sense of fulness” experienced by the deranged,and the disturbances set up in them patient, even when the stomach is empty of by tricuspid failure are distinct and pronounc- 34 INDIGESTION AND BILIOUSNESS. ed. There is fulness of the venules of the at length in the Chapter on the Gouty Heart. stomach, and from that springs catarrh, with The genito-urinary system is disturbed by its pathogomonic indication, “sense of ful- the venous congestion. There may be vesi- ness,” even when the stomach is empty. cal catarrh, prostatic fulness, or urethral ca- The feeling of being constantly “too full ” is tarrh, or even hydrocele from congestion of a very common outcome of advanced cardiac the pampiniform plexus (Oppolzer). failure. The secretion of gastric juice is im- In women, there are catarrhal and menor- paired, and it is diluted with a serous fluid. rhagic troubles from congestion of the veins of Consequently its digestive power is impaired. the uterus and vagina. Oppolzer thought The catarrhal mucus is readily folded over that profuse menses often accompanied the any solid food, which so covered cannot be arterial fulness of aortic regurgitation, and acted upon by the solvent juices, themselves regarded it as a symptom of some value in impaired in power. Dyspepsia is the result that form of cardiac disease. My own ob- of taking any but liquid food; and this con- servations have not been numerous enough to dition of the stomach should ever be borne in enable me to corroborate this statement. mind in the treatment of cases where the tri- Dr. Angus Macdonald has recently pub- cuspid has begun to leak. In this condition lished a work on the “ Bearings of Chronic of the mucous membrane, gas is often disen- Disease of the Heart upon Pregnancy, Par- gaged very freely in many elderly persons, turition, and Childbed,” which is of the great- and the eructations are persistent, and often est interest; but unfortunately he does not very loud. The patient’s condition is very discuss the questions of whether leucorrhcea distressing; and the pressure on the dia- is common in women with heart-disease, or phragm,and on the right ventricle,causes much what is the effect upon the amount of the disturbance of the respiration and dyspnoea, menstrual flux. So far as my impressions go, with very unpleasant palpitation. This al- for I have no exact data on the subject, these tered mucous membrane also causes morbid outcomes of fulness of the pelvic veins are sensations and cravings for highly-spiced or not so influenced by disease of the heart as unsuitable food; and this may lead to differ- might a priori have been expected.” ences of opinion betwixt patient and doctor. When this condition of venous fulness is The intestinal canal is involved, and may the cause of indigestion, it is obvious that the be disturbed in two directions. There may therapeutic measures must be directed to the be irregular and defective action of the bowels improvement of the circulation. If the circu- from imperfect nutrition of the muscular fibre lation can be relieved, the uncomfortable' of the bowels, calling for warm aperient sensations will pass away along with the ca- medicines,—(for here, the aperients must be tarrh with which they are casually related. warm and contain carminatives as much as in Astringents, as compound kino powder, are the case of the menopause)—enemata, or very efficacious in simple primary gastric ca- soap suppositories (Trousseau). Or the con- tarrh; but in those cases where the circulation gestion of the venules of the intestinal canal is the cause of the catarrh, they are also use- may lead to diarrhoea, which often furnishes ful, but to a much less extent. It is better great relief, and should never be interfered practice to put the patient in bed, so as to with without good reason, nor until becoming give the heart as little work as possible to do; unquestionably excessive. King Chambers to improve its condition by giving agents like says, that in conditions of gastric and intesti- digitalis and strychnia, which act directly nal catarrhs, the use of compound kino pow- upon the heart and increase the vigor of its der is indicated, and that under these circum- contractions, so that the heart fills the arter- stances, especially gastric catarrh, it rarely ies by emptying the veins—for that is really constipates. Alterations of constipation and the function of this “blood-pump;” and to purging may occur. Bleeding piles, or he- relieve the fulness of the venous radicles by morrhoids, are frequent in the subjects of evacuants, as hydragogue cathartics, and dia- cardiac failure. Hemorrhage from these phoresis produced by the application of heat. piles often gives great relief, should not When the blood is relieved of a quantity of be rashly checked. When no bleeding has water by these measures, then the venous occurred for some time a flow of blood from fulness is relieved, and with it the catarrh some other organ may take place, ashaemop- which is its consequence. Strict dietary is tysis, for instance, and be followed by distinct indispensable to the relief of such cases. An relief. error in diet is fraught with mischief which If there also be old-standing kidney dis- may persist for a long time. Indeed, the ease, there may be found old, small, con- correct regulation of the dietary will tax the re- tracted granular casts alongside the dark re- sources of the physician to the utmost. But cent casts; or, according to Basham, casts in the results to the patient are very grateful and a state of fatty degeneration. The kidneys agreeable, as well, too, as to the doctor’s self- are found enlarged, swollen, injected with pride. blood, and from the venous congestion a There is still another form of “ secondary growth of young connective-tissue corpuscles indigestion ” which remains to be described; is set up in them. While attending the and that is, the “ toxaemic ” form. Pathological Institute at Vienna, it was quite Mal-nutrition, the result of a poison in the common to see these recent changes from blood, is far from an uncommon occurrence. heart failure alongside the evidences of old The presence of the poison interferes with as- standing renal mischief. The two were quite similation generally, and the formation of the distinct. This subject will be treated more complex body—haemoglobin, in particular. INDIGESTION AS AN INTERCURRENT AFFECTION. 35 Consequently anaemia is a common feature in sible it might be found to do so. That the the case of mineral poisons, as mercury and underlying factor was the unrecognized lead; in miasmatic poisons, like that of mala- syphilis, in all probability, and that the speci- ria; in poisons acquired or produced, as syph- fic treatment might cure the indigestion as ilis or gout. These two latter poisons com- well as the pain. He improved much after monly interfere largely with the assimilative this treatment was adopted. organs and their functions. As gout will be Doubtless there are many such cases if they dealt with in extenso in the second part of were only recognized. We are beginning to this work, nothing more need be said about its be familiar with “ visceral syphilis,” in the effects upon nutrition here. But itis necessa- form of structural changes set up by it in the ry to say something about syphilis. Young viscera; but as a cause of functional derange- persons with congenital syphilis often present ment, its influence has scarcely yet been recog- conditions of mal-nntrition and ansemia, es- nized. In time, probably, this will generally pecially the latter, where the ordinary meas- be admitted. ures, including the administration of chaly- Such then are some of the relations of in- beates, are impotent to initiate improvement; digestion, which are not described in our or- but where the addition of mercury or iodide dinary text-books; but of which the practi- of potassium acts like a charm. The syphi- tioner must know something, in his own in- litic infant is a sorry spectacle. Its puny terests as well as those of his patients. They limbs, the skin either hanging in folds, or dry, require for their recognition that careful in- harsh, and dirty; its wasted muscles; its with- terpretation of subjective phenomena which ered face, approaching the wrinkled face of has been largely lost sight of in recent years, age; its sore eyes, often with a discharge; the in the too exclusive devotion to the signs fur- characteristic “ snuffles;” its whining, moan- nished by physical examination. Indeed, it ing, feeble cry; the presence of a coppery- is the individual which must be studied; not a tinted blush upon its nates and around its diseased entity, described bya word or a phrase, anus, sometimes with condylomata, some- presenting certain objective indications. Fur- times with a general rash more or less devel- ther, the successful treatment of these sec- oped. It is, indeed, an object in more senses ondary forms of indigestion, involves some- than one. It is pitiable for its own sake, thing more and outside mere dietary, however from pure humanity; it is pitiable morally, as indispensable; and the administration of the an illustration that the sins of the father are usual remedial agents: it comprises attention undoubtedly visited upon the children; it is to the exciting cause and measures strictly pitiable to see the fond mother’s love given to adapted thereto. When made thus compre- so sorry a babe. Ordinary measures are im- hensive, the treatment contains the elements potent here to affect any good. Mercury is of success—at least potentially. the specific. When this is added the child fattens, its little wasted limbs grow plump; the rash disappears; the “snuffles” vanish; CHAPTER VII. the eyes recover their normal aspect; it is the INDIGESTION AS AN INTERCURRENT AFFEC- difference betwixt a changling, an elfish gob- TION. lin, and a human baby. This is a very important matter for the pa- But it is not in children only that such tient, and not insignificant for the practi- “ toxsemic” mal-assimilation is found. The tioner. The aspect of a case may suddenly following case illustrates this form of indiges- be clouded, like a bright April day may sud- tion. A friend of mine wrote to me in the denly alter with the swift oncome of a dark spring of 1880 a most dolorous account of his rain-cloud, racing up with the wind. It may sufferings from indigestion, which had proved show at first “ like a man’s hand ” arising out most intractable, indeed, had defied all the re- of the sea, as did that which caused Elijah to sources of a careful, painstaking, provincial send word to Ahab, yet ‘ ‘ it came to pass in physician. I wrote to him, sketching out a the meanwhile, that the heaven was black dietary, to be strictly adhered to, in addition with clouds wind, and there was a great to the medical treatment, which was all that rain.” So the prospects of a case may be could be desired. No improvement took suddenly obscured; and almost before danger place, the indigestionbeing as unpleasant as is scented, the aspect may be profoundly ever. Late in the autumn he presented him- changed. A little nausea, the surface of the self with a local malady, a persistent pain, tongue altering, a rise of temperature, and which was found to be due to a periosteal the case doing well, may be suddenly endan- thickening, nipping a sensory nerve. I found gered; as the Eurydice, sailing with her stun- out a history of syphilis long years ago, which sails set, was sunk bodily by a squall coming had been forgotten, until cross-examination up unnoticed behind Shanklin Downs. brought it to mind, so little indication of its The wary and experienced practitioner presence had it given. In order to be quite knows the import of such threatenings; a rise sure about the diagnosis, on which hung in the temperature is as significant, and om- both the prognosis and the treatment, I took inous withal, as a sudden fall of the bar- him to Jonathan Hutchinson for his opinion. ometer tells of a coming storm. Just as the He quite coincided with the view taken. seaman furls his topsails, and puts the ship The patient was put upon iodide of po- under bare poles, unless it be a storm-jib, tassium with immediate improvement asto the when the barometer suddenly falls for a ty- pain; not only that, but the indigestion has phoon; so when the medical man sees the disappeared. I had told him that it was pos- thermometer suddenly rise, he is on the alert 36 INDIGESTION AND BILIOUSNESS. .as to the other indicia of coming storm. morphia had to be given per rectum. In a But there are other semeia of threatening case of intense vomiting seen when a youth, danger even earlierthan this palpable change, I remember my father giving a dram of laud- like the stormy petrel that precedes the gale, anum in a starch enema, with excellenteffects. the tongue grows irritable, red, angry-look- In a couple of hours the stomach tolerated ing, or abnormally bare and smooth; there is a morphia draught, which acted topic- restlessness, some nausea, the appetite is lost ally upon the stomach as well as or very capricious, the sleep is disturbed; such systemically; after the crisis was passed, are the symptoms which immediately arrest the management of the case was com- our attention, or ought to do so. The rise of paratively simple. Now the hypodermic temperature converts suspicion into cer- syringe has diminished the difficulties mate- tainty; but usually it is well not to wait for rially, and in the hands of a man at once wary this corroboration, but to act promptly on the and courageous is simply invaluable in emer- first suspicion. The case may be one of gencies. Sometimes, when the symptoms are pneumonia, it may be of surgical operation, not quite so threatening, or the case so ur- or of typhoid fever. No matter what the gent, it is sufficient to give a tiny mite of a form of disease, when these indications of pill, as a grain of the extract, opii. at bed- acute disturbance in the digestive tract show time, or to add to it gr. of morphia. So themselves, it behooves the practitioner to put small a thing does not irritate the stomach by the hands on deck; the craft is in danger, its presence, a matter of the very highest im- more or less imminent. The coming risk portance. If there be great thirst, and the must be faced. To use another simile, when patient gulps fluid down eagerly, it will be a general sees that he is being threatened with up again immediately, having done no good, a flank movement, he make his disposition and only furthered the exhaustion. Let a accordingly; he changes his front so as to face chip of ice slowly dissolve in the mouth and his new foe. cool the fauces, the local seat of thirst. A So it must be with the medical practitioner. little cream ice is at once cooling and nutri- He must meet the new danger; and many a tive; or iced milk may slowly be sipped, or patient is needlessly lost for want of this sucked through a straw, or a glass tube. rapid change of front. If the new intercur- But a little at once: or it is an instance of rent attack proceed to vomiting, then the “ the more haste the less speed.” Patience prospect becomes vastly grave, indeed. If and watchfulness must be combined with food cannot be retained, the patient will sink. promptness of action, when the time for ac- Nutritive enemata may keep the case floating tion arrives. Judicious nurses, whose muscles a while; but only a little while, not for long. of expression are under complete control, so In many cases, the change is due to pushing not to betray their inward anxiety, are to alcoholic stimulants too freely; in others, be desired. All injudicious and emotional alcohol is urgently called for. All depends friends are to be banished, energetically and upon the precise facts of each case. The remorselessly; it is no time for folly, no mat- medicines previously given are often to be ter how near the tie, how close the relation- withheld; however strong the necessity for re- ship! The link of blood does not justify cul- sort to them may seem. The usual mixture pable homicide in the interests of the indi- of bismuth and soda in calumba, with a drop vidual dangerouly ill. A darkened room; or two of hydrocyanic acid, or a few grains perfect quiet; no disturbing element must be of bromide of potassium, alone is permissible. allowed to enter by eye or ear. Brain and The blandest of food, a little white-wine stomach alike must have absolute rest. A whey, or milk and lime-water; if the milk is cool, clear-headed pilot at the helm, and a at all likely to be curdled, a few grains of pre- capable crew tendering willingobedience, and pared chalk, or light carbonate of magnesia, the craft may be steered through the peril in- may be stirred into it, or a little baked flour to smooth water. A wrong move at the crit- to lessen the firmness of the curd. If beef- ical moment, and all is swiftly over; and re- tea be given, let it contain some baked flour, gret is unavailing. To meet a grave emergen- to give it some more actual food value, com- cy coming on swiftly, taxes all the resources, pared to what it possesses alone. all the capacity, of the medical attendant: and Let whatever be taken, be small in quantity is a sharp test of the man, as well as the prac- at once: little and often! If the outlook be titioner. Wealth of resource, fertility of very clouded, it may be well to resort to the thought, the moral courage to accept the re- partially digested milk, or milk-gruel of Dr. sponsibilityofenergetic action; allare required Wm. Roberts. If there be tympanitis, a in these times of extreme peril. turpentine stupes, or a liniment of chloro- When the stomach is irritable it must be form on a few folds of lint, covered with an compromised with; there is no alternative. overlapping piece of oil-silk are good. If So long as it is patient and tolerant medicine vomiting actually set in, give a hypodermic to affect other parts may be given, but when injection of morphia at once, sufficient to the stomach itself is out of order its moods “quiet” the stomach. If there co-exist must be met; it must be humored and con- danger of paralyzing the respiration or the ciliated. It is no good to attempt to master heart by the dose of morphia, give with it a it! Just as Mahomet had to go to the moun- little sulphate of atropia, (morphia gr. liq. tain, when the mountain did not go to him, atropia sulph. gtt. ii.); this obviates any so when the stomach is in active revolt it danger arising from the morphia. Before the must be compromised with and soothed. hunger to be ing beverage is baneful; after a while the as- felt acutely; and then the voracity induced similation becomes decidedly impaired, the by the bulimia is great, but unsatisfying. blood is ill fed; the weak bit of lung is starved This is often well seen after measles , in chil- and breaks down. And the individual goes dren, they are hungry all day long. They down with it; or survivesa wreck, a dismantled eat and eat unceasingly to appease the pangs *hulk, fit for no more active service. of hunger; but in vain. The more they eat It is this relation of the “weak spot” the worse they thrive, because they digest lit- to intercurrent indigestion which demands tle or none: and unless they are restricted to such careful consideration when determining proper meals they virtually eat themselves to upon a rough life abroad. death. They die of hunger—an actual starva- tion —in the midst of' unlimited food, and everlasting eating. _ To and digest CHAPTER VIII. eat to are not, then, one and the same thing. DIET AND DRINK. Let me here quote a sentence from Dr. These two practical matters require a few Lauder Brunton. He describes the man words to themselves. Of course what is who is “run down” and needs a holiday. written here only admits of a general appli- “Not only does the brain seem exhausted, cation to cases of indigestion; each case re- but the whole system appears to be languid quires to have the treatment fitted to it, just and weak; instead of the man being able for as a tailor fits a suit. Nevertheless some gen- a twenty or thirty miles walk, one or two eralizations may be useful; chiefly in the di- miles produce fatigue, and sometimes an in- DIET AND DRINK. 39 tense languor is felt without any exertion at Wine, two glasses of the wines mentioned, all. And yet all this time he may have been or a glass of Bucellas; or perhaps, if the pa- trying to keep up his strength. He takes tient be very sure that it does good, and suits butcher’s meat three times a day, perhaps also better than anything else—one glass of port strong soups, to say nothing of wine, or wine; or a little spirits and water. Aerated brandy and soda to pick him up. His tissues waters are objectionable, they are too gas- ought tp be getting sufficient nourishment to eous; while alkaline waters are not good at enable them to do their work, and yet it is meal times, they reduce the acidity of the evident that they are not in a condition to do stomach, which is essential to the digestive so. The man, and very likely his friends action in the said stomach. also, wonder at' his condition, and when he Now as to dessert. Perhaps I am going goes to his medical attendant to describe his to be heretical; perhaps only “ a little ad- case he says—‘ I take all sorts of strength- vanced.” Nuts are certainly not to be advo- ening things, and yet I feel so weak.’ If cated for the dyspeptic. Oranges, pomfeloes instead of using these he were to say, and shaddocks, are like grapes, unobjectiona- ‘ Because I take all sorts of strengthening ble if the juice only be swallowed; apples, things I feel so weak;’ he would express a pears, plums, gooseberries, cherries, straw- part, at least, of the truth.” Dr. Brunton berries, each and, all are good. The salts, holds that the mal-products of digestion are potash and others, of sub-acid fruits are good positive depressant poisons. The subject for “the blood.” Often these fruits are for- will be referred to again more at length fur- bidden unnecessyily. If they disagree let ther on. Enough here to show that “strong them be avoided; experience must be the sole food does not necessarily involve strength;” judge of their admissibility. Only they need rather the opposite when the digestion is im- not be eschewed wholesale, as is too much paired. A little, well digested, feeds the the rule. blood, and from it again, the tissues, better Bananas, figs, pine-apples, raisins (Sir W. than a large meal, none of which, or very lit- Gull, Bart., stated his partiality for raisins tle indeed, is properly digested. before a Royal Commission, therefore there Strong beef tea, made from almost fabulous can be no doubt about their value), preserved amounts of beef, on which the housewife peaches and apricots, when the fresh fruit proudly dilates—well, it is the fashion, so it cannot be obtained, are also good; candied must be spoken of* with circumspection—is a fruits perhaps are not as a rule admissible. fraud! or something akin thereto. Its food We eat far too little fruit in Great Britain to value has yet to be demonstrated! Not long our meals. ago calves-foot jelly was indispensable in con- Supper; a draught of milk and an arrow- ditions of debility; its day is now over, it is root biscuit is the best and lightest. It is little heard of. Strong beef-tea, meat essen- rarely required except after an early dinner. ces, meat juice, are pleasant; and certainly Some persons, however, must take their food patients think they are proper things for the at short intervals, because they can only di- debilitated. Well they may be so; if and gest little at once. provided they take something .else as well. When the fast betwixt supper and breakfast But to give the starving patient, starving in is too long a little milk and a biscuit in the the midst of plenty, these things to feed him, small hours of the morning may be taken; or is giving him a stone when he asks for bread. a tumbler of milk, with a teaspoonful of rum A little light food which can be digested is or brandy in it, may be taken on getting out infinitely better for him. of bed to dress. With some persons this en- This is something like what should be ar- ables them to take a fair breakfast. rived at. * Some persons can eat no breakfast. Not Breakfast; porridge, oatmeal or hominy, uncommonly “theyeat their breakfast before with milk, to start with; to set the children a they go to bed;” they make a good supper good example! Then a little cold meat, or this is very common with business people bacon, or fish; with a cup of coffee, tea or who work hard all the day and have no rest cocoa. Some fruit. till supper time. The mistress of a business Lunch; some potatoes mashed with plenty requiring much personal attention is apt to do of milk and butter, better still cream, pep- this. She commonly becomes a dyspeptic; pered and salted, and browned before the if her digestion can stand this outrage, usually fire. A little cold minced meat in a thin lay- she ultimately becomes the subject of gout, in er, not to be further cooked but only to be some or other of its many forms. made hot, may be added. Some cold milk Some dyspepticsfind that they must take no pudding, left over from the dinner of the day fluids with their food, and have to live on a before, and some stewed fruit. A glass of very dry dietary, an Arab dietary. Others milk, a glass of carlowitz, claret, or sherry, require more fluids than they allow them- may be permissible; with others only a little selves. brandy, or whisky and water agrees. Let it Others require a biscuit, or some light arti- be little. cle of food, “betwixt meals.” When this is No glasses of wine betwixt meals to “ whip made an excuse for a glass of sherry it is to one up.” Such habit is bad, very bad! be closely criticized as a questionable habit, Dinner; a little light soup, some boiled ‘ ‘ more honored in the breach than the ob- fish, very little joint, or some game, or entree servance.” To take some fruit would be like sweetbread, or spinach and a poached better in every way. Some succulent fruit egg; some milk pudding, and stewed fruit. would satisfy the craving “ for something,” 40 INDIGESTION AND lUElOUSNESS^ and would not require the beverage ‘ ‘ to get As to the mischievousness of alcoholic in- it down.” Such use of fruit ought to be more dulgence, all, “ the total abstainer,” and his general than it is at present. In all house- less rigid brothers and sisters, are agreed. It holds where the expense does not forbid it is bad physically, intellectually, and morally ! a large dish of picked fruit of various kinds, But what would be decided excess in one per- when the season permits of it, should be son is not “excess” in another. Also this placed on the side-board every morning, with varies in the individual. There are times of ‘ a label ‘ Help yourself” on it, (as is found in debility when generous wine may be freely the waitingrooms of several London consult- drunk, not only without injury but with ants). Children would soon cease to over- benefit: but the desire for them passes away eat themselves, just as do the assistants in as the indications for them 'disappear. (It is confectioners’ shops, when they realize that it not forgotten that careless medical instruc- is to be a constant affair, not an occasional tions to drink wine freely, have led to sorrow- treSt to be made the most of. Such an idea is ful results; nor that a patient may interpret well worthy of adoption. If the “temper- medical so as to make an ance” section of society would set the example excuse for alcoholic indulgence). So long as it wouldsoon be followedby others, to the ben- alcoholic drinks improve the appetite, do not efit of the digestive organs of many, while heat the patient, and do not disturb the it would be agreeable to all. Fresh gathered tongue, it is impossible to say they are doing fruit out of the garden and orchard ought to harm; and it is certain they are doing good be placed on the breakfast-table every morn- and agreeing. The physician must speak out ing. For those who experience a bitter or with a distinct utterance, i. e. , if his ideas are hot taste in the morning on awakening such well-defined and chiselled-out. He must addition to the breakfast-table would be most neither pander to a popular taste for alcoholic acceptable. beverages; nor be afraid of the strictures of And now a few words as to the beverages “The TemperanceRecord,” or “The Alliance to be taken. Americans are a dyspeptic peo- News;” and my friends, the editors of these ple; they drink much iced water at meals, two earnest publications, must excuse me, if ergo, iced drinks at meal-times are bad! They I thus take up a position distasteful to them. may be, when carried to excess; this is not They must allow for others what they claim denied. But iced drinks are not the cause of for themselves,—i.e., “the courage of their the wide-spread dyspepsia in the U. S. A. convictions.” There is a certain unstable There are other potent factors in action. Iced temperament in certain persons, perhaps a drinks are very grateful to the thirsty, but too part of the neurosal tendency of the age much indulgence therein produces a torturing which must be taken into consideration. thirst; as the person who indulges in eating Alike in rural Devonshire, in the manufactur- snow in the Arctic regions discovers quickly. ing districts of Lancashire and Yorkshire, Just as snow-balling causes the hands first to the magistrates are aghast at the amount of feel cold and then to glow with heat, if con- Asylum accommodation they are called upon tinued, so the constant application of an iced now-a-days to provide; so great is the spread fluid to the fauces, at first grateful, becomes of lunacy. . All nervous affections are on the a source of intense discomfort; for the blood- increase. Consequently there is a growing vessels are first contracted and ultimately class for which it is more or less undesirable paralyzed, and then the fauces glowwith warm to advise stimulants, especially alcohol. We blood, like the skin of the snow-baller’s hands. caunot now order a glass or two of wine daily Iced fluids are not desirable for dyspeptics, with the carelessness of yore. It is growing to say the least of it. Ordinarily at dinner, yearly more and more unsafe to do so. Each the ice-pudding is followed by a glass 'of case must be the subject of conscientious liquor—“ to correct it.” A certain tempera- thought in this matter. It is this “ unstable ture is requisite for digestion, and too much temperament,” against which the medical man cold is undesirable. must be on his guard when recommending So too, the stoftiach is acid after a meal, alcoholic beverages. for the gastric digestion is acid; therefore Remembering then that he is using an alkaline waters are contra-indicated at meal- “edged tool ” that may cut both ways, and in times. They should be taken before meals, full consciousness of what he is doing, the properly, when the stomach is alkaline. The medical man may order alcoholic beverages. milder effervescing waters are comparatively And now I will say what I personally think— unob jectionable. dogmatism would be improper. Then as to the medicated “temperance” The use of a light wine is not undesirable drinks. The ’zones and ’dones ! They mostly with many persons, from Timothy down- contain phosphorus and iron, and other medi- wards. “ Wine which maketh glad the heart cinalmatters;and therefore, may not be taken of man,” sang the Psalmist, in a hymn of indiscriminately, or with impunity. For well- praise and thankfulness; and it is the use of nourished persons, and still more, stout, wine, not the abuse of it, which is being con- florid, plethoric individuals, they are unsuited. sidered here. The emotional temperament For the pallid, “limp,” listless beings, they may be drunk with other excitement than are well adapted, but too much fluid, even a that set up by alcohol. “ They are drunken, “ beverage free from alcohol,” is not without but not with wine; they stagger, but not with its drawbacks. strong drink.” Excess, or indulgence in wine As to alcoholic beverages, they are good or is bad, as is excess in anything else—medi- harmful according to the use made of them. cated non-alcoholic beverages not excepted ! THE FUNCTIONS OF THE LIVER. 41 But it should be drunk with meals; “ to eat,” Finally, tea and coffee are more or less ob- as they say in France and elsewhere. jectionable and disturbing to dyspeptics. A little light white or red French wine is Cocoa, not too full of fat, but thin, is better : admissible; Hock is more apt to be a manu- ora glass of milk: or the tumblerful of syrup factured wine. Hungarian wine, white or of the continent, for breakfast. The cup of “ Carlowitz,” and Australian wines are mak- tea before getting up is utterly uncalled for, ing good their claim to the confidence of the and unmitigatedly bad. Kettledrum is as public; some Italian wines are very palatable; well let alone; while the cup of strong tea or Greek wines also, for those who do not dis- coffee after dinner should be avoided scru- like the flavor of resin in them. The wines pulously. of Spain and Portugal are too potent for or- The incubus of fashion and conventionality dinary use, still a glass of sound sherry or is a heavy burden for most dyspeptics. They port is often very good; albeit, more money, should not even bathe before breakfast, if that can ill be spared, is thrown away upon they have sufficient strength of mind to brave port-wine, than is pleasant to think of. A the strictures of Mrs. Grundy. If they have glass of good ripe port, or of Bucellas, in not, I am sorry for them; nor do I think the season, and in the right time, towards the position of their medical adviser one to be close of a meal, is not to be branded as a coveted. Neither the doctor nor the patient malefactor, and banished from society. Mar- has then a fair field, if there be lack of cour- sala is usually a trustworthy wine, and its age moral, or other, on either side ! bitter flavor is in its favor as a wine for in- valids. CHAPTER IX. With others, again, a little plain spirit, brandy or whiskey—Scotch, Irish, or Bour- THE FUNCTIONS OF THE LIVER. bon, even “old rye” not absolutely forbid- The liver is the largest gland in the body; den, is their best beverage, diluted with some indeed, is facile princeps among these or- its size and the water. » gans, both as regards impor- With others plain water—“ Adam’s ale”— tance of its function. To many readers, is the best beverage. then, especially the junior members of the Malt liquors are scarcely suited to the dys- profession and students, to whom the works peptic; and a little sound bitter ale alone of of M. Foster and other physiologists are the series may be permitted to the sufferer familiar, it will seem strange, that up to a re- from indigestion. cent period, the liver was spoken of as a mys- But for the dyspeptic no rule “absolute” terious terra incognita, a sort of Central can be laid down in beverages any more than Africa in the map of the organism. Much in food. Each case requires its own regimen had been learned empirically as to disorders all through. Many cases of dyspepsia, es- and disturbances of health referred, not inac- pecially when there is morning sickness, some curately, to the liver; and their appropriate catarrh, excessive flatulence, a foul tongue, treatment had been determined with much and an unsteady eye, are due to alcohol clinical acumen; still it was an empiricism wholly and solely; and no reliance, what- unilluminated by scientific knowledge. ever, can be placed on the word, statement, The shrewd practitioner shook his head affirmation, or assertion corroborated by sol- sagaciously in certain cases, and oracularly emn oaths, of a drunkard; for “ a drunkard is pronounced the word “ liver;” ordered slops a liar !” And this holds good of both sexes, and a light diet; the patient followed his in- and all ages; everywhere and ever. structions, and felt the better for the treat- Moderation is food, especially albuminoids; ment. The bulk of empirical testimony, so a little, properly digested, is more nutritive accumulated, was such as to carry with it than a feast, none of which is properly or conviction in most minds; to entitle it to re- completely digested. spect from all! But the wave of disbelief, Moderation in drinks, especially alcoholic; which is now beginning to break, swept the- via media, neither total abstinence nor many minds away with it; and because infant excess. physiology could not speak accurately as These are two grand rules to be observed. to the fnnction of the liver, and could only Whey, when it can be procured fresh, or lisp out a few limping utterances, the store skimmed milk, is a splendid beverage for dys- of empirical lore had to be thrown aside peptics. There is a quantity of nutritive as lumber,—without value or claim to any sugar of milk in it, whileit contains all the consideration. To such a humiliating end salts of milk. then the observation of centuries had to be This leads up to a matter not altogether relegated; according to a scepticism as con- unimportant; yet rarely remembered; it is ceited as it was unwarranted. A few of the this,—sugar is a very easily digested hydro- harder-hearted practitioners clung tenaciously carbon. Though it disagrees with many, to what experience had taught them; and are with most dyspeptics it can be taken in now rewarded for their constancy by seeing greater or less quantity, in their tea or coffee; modern physiology testifying to the accuracy orwith their spirit and water. When the ap- of the lessons of this experience of their own petite is very defective, if the alcohol be given and of observant predecessors. When the with hot water and sugar, its food-value is old practitioner classed “liver and kidney” greatly enhanced. Unfortunately, it cannot together, when speaking of maladies where always be so taken: and alone with cold the urine was altered in its appearance and re- water, plain or aerated, must it be drunk. action, he spoke from an experience which 42 INDIGESTION AND MLIOUSNESS. dated back as far as Galen at the least. That Not that Dr. Murchison did not owe much to historic physician knew that the urine solids others, as he himself readily and generously came from the liver; how he knew, how he or acknowledged; but the array and order into some one else arrived at such a conclusion, which he cast a huge series of isolated facts with the means they then possessed, it is sim- and observations, entitle him to be regarded ply impossible to say. They were keen ob- as the preacher of the new faith to the medi- servers, these old physicians, and could sum cal profession in England. up the evidence before them with minds emi- Of course there were many others working nently judicial. When scientific knowledge in the same direction as Dr. Murchison,if did not exist in any form such observations less ably and less enthusiastically, and to were all that medicine had to rely upon. whom his work came as a perfect boon. When chemistry began to break a path for Slowly something was being learned about a truly scientific knowledge of the physiology the liver. Chemistry told us that the great of the body the matters easiest to examine condiment of our food, chloride of sodium, were taken first. The urine naturally tempt- was split up in the body into hydrochloric ed the curiosity of chemists, aud the presence acid for the gastric juice, and soda for the of nitrogen in the urine solids disclosed their bile. The utility of common salt in the or- descent from the albuminoids of our food. ganism and the universal craving for it, were The kidneys were exalted to honor. In old- alike demonstrated. The long travel alike of standing gout the kidneys were found to be African tribes and American buffaloes for salt extensively diseased. The imagination then “ licks,” became intelligible; and the wicked- bounded to the conclusion that the kidneys ness of the salt tax in India dawned upon the formed uric acid and urea, from pre-existing mind. The liver secreted bile; that much products of retrograde nitrogenized metamor- was certain; and bile was not merely an ex- phosis in the blood. I can well remember crementitious matter, but fulfilled a useful when the statement that urea was formed in purpose. The liver then had a raison d’etre and by the liver, and only excreted by the in scientific medicine. Perhaps to give the kidneys, was received as the latest utter- views of the late Dr. Kirkes as expressed in ance of a school not entitled to the confi- his well-known “Handbook of Physiology” dence of the student-mind. The promulgators in the very zenith of its fame, still edited by of that view were regarded by the steady old- the accomplished author and therefore repre- fashioned teachers much as Melancthon and senting the views of that erudite physician Luther were regarded by the court of Rome, and physiologist; in the fourth edition pub- viz., as unsound heretics. “ There is no pain lished in i860, will demonstrate most con- like the pain ofa new idea,” said the late Mr. clusively the advances made in very recent Bagehot; and to many minds a new idea, un- years. He places the secretion of bile first, settling the old-established notions, is exces- as might be expected from that time of day. sively painful. Unless, at the same time that He recognized the presence of glycocholic it brings down the old edifice, it is prepared and taurocholic acids in union with soda; but with a new erection to take its place, they will no account of their chemical composition is have none of it. They wilfully shut them- given to throw light upon their origin. He selves up in a shell, and, having once assumed gives the process of secreting bile, which he this attitude, nothing can coax them out of regards as ‘ ‘ constantly secreted for the puri- it. The storm of controversy, the intense in- fication of the blood;” a vague phrase, in terest in the agonosphere, affect them not. In harmony with the general vagueness of the the language of the late Lord Beaconsfield, knowledge of that time. He recognizes bile once applied to a political opponent, about a to be excrementitious and digestive , and that, measure he disapproved, they “passionately as the latter,—“bile is a light elaborated embraced a corpse.” They hugged their de- fluid, formed of materials which do not pre- funct impression till the odor of putrescence exist in the same condition in the blood, and compelled them to cast it away. Such is the secreted by cells in a highly organized gland;” present position of the generation of medical nevertheless, he writes—“ The general tend- men who are beginning to pass from us. ency, however, of modern observation is to The Croonian Lectures of that accomplish- the effect, that bile has very little influence on ed physician the late Charles Murchison, de- the process of digestion.” He adds—“The livered before the Royal College of Physicians bile, however, like the gastric fluid, has a in 1874, took the medical world by surprise. strongly antiseptic power, and may serve to By those prepared for and seeking a new faith prevent decomposition of the food during the they were hailed with the utmost delight, as time of its sojourn in the intestines.” He bringing within their reach the scientific says—“ Respecting the nature of the influence knowledge they thirsted for; to such they exercised by the bile in digestion, there is, were as welcome as a well to the traveler in however, very little at present known. It is the desert. supposed by some, that the bile assists in con- In the present and following chapters I verting the chyme into chyle, especially by shall avail myself as largely of the work of emulsifying the fat, and thus rendering it Murchison, as 1 did of that of W. Roberts, capable of being absorbed by the lacteals.” in the preceding section of the work; and ac- So much for the bile. The light is little yet. cordingly do now make full acknowledgment He goes on—“ The secretion of bile, as al- of my indebtedness to Dr. Murchison for all that ready observed, is only one of the purposes he told us in these said lectures on “The fulfilled by the liver. Another very impor- Functional Derangements of the Liver.” tant function appears to be that of so acting THE FUNCTIONS OF THE LIVER. 43 upon certain constituents of the blood passing few more years had taught us upon this sub- through it, as to render some of them capa- ject. The gigantic stride made between i860 ble of assimilation with the blood generally, and 1874 will tell in no indistinct language and to prepare others for being duly elimina- the light modern physiology has thrown upon ted in the process of respiration. From the the digestive processes; and with that the labors of M. Bernard, to whom we owe most service it has rendered to practical medicine. of what we know on the subject, it appears We see how the grand physiologist Claude that the low form of albuminous matter, or Bernard was opening up for us, knowledge of albuminose, conveyed from the alimentary incalculable value as to digestion; as one of canal by the blood of the portal vein, requires the numerous subjects he was investigating. to be submitted to the influence of the liver His range was a wide one; his grip was as before it can be assimilated by the blood.” tight as his grasp was extensive. He it was, This is the beginning of a most important above all others, who has forced nature to re- matter in physiology, or rather the beginning veal some of her most important secrets; and of the recognition of the matter, viz.: that we must all be grateful.to him accordingly— imperfectly assimilated albuminoid matter, grateful in proportion to what we have re- the product of digestion in the gastrointesti- ceived from him. In a few more years his nal canal, is further elaborated by the liver, views were clearer, more precise, more ad- so that the tissues may be fed therefrom. vanced. Not only this: but they were ac- The liver was recognized by M. Claude Ber- cepted by the leading physiologists, espec- nard as being connected with the higher ially by Ludwig of Leipsic, and the school elaboration of the albuminoid constituents of of which he is the illustrious and honored our food; by it the peptones, produced by head. the digestive act in the stomach and small We may summarize the matter as standing intestines, are further fitted to feed the blood, in 1860, something near this. and from it, again, the tissues. So far! so 1. The bile was not merely excrementitious good! as regards the blood; it was useful in the di- Dr. Kirkes also recognized the relation of gestive act, emulsifying fat. the liver to the saccharine materials of our 2. The crude albuminoid products of di- food. “ The saccharine principles of the gestion in the gastro-intestinal canal were food undergo, in their passage through the further elaborated in the liver, and fitted liver, some transformation necessary to the for the nutrition of the tissues of the or- subsequent purpose they have to fulfil in rela- ganism. tion to the respiratory process, and without 3. The saccharine elements of our food which, such purpose could not be properly underwent some change in the liver, being accomplished, and the substances themselves converted into glycogen, or animal starch; would be eliminated as foreign matters by the and this again, in the presence of an animal kidneys.” Thanks again to M. Bernard, some ferment, was once more transformed into light was breakingupon “glycogen,” or “he- sugar, which was burnt in the blood. patic,” or “animal starch,” asit was variously Further that the liver in the carnivora could termed; and its utility in the economy of the form this glycogen from the albuminoid ele- ‘ body. They have also begun to note ‘ that ments of their food. the liver possesses the remarkable property of The physiologist was on a scent which forming sugar out of principles in the blood, he ran upon rapidly and swiftly, until in which contain no traces of saccharine or amy- 1874, Dr. Murchison placed the matter as laceous matter.” This was a step forward. follows. We will note the day-break passing It was seen that the liver in the Carnivora, into morning light, in further acquaintance constructs sugar out of the materials of their with the utility of bile; the relation of the food. The utility of sugar as the respiratory liver to albuminoid matters, both construc- food is beginning to be seen; as also its stor- tively and destructively: and in the matter of age in the liver from intermittent meals for storage of glycogen. The importance of constant use. Like the granary into which some knowledge on these subjects to the phy- we pour our corn after the annual harvest, sician in his everydaywalk in life, it is simply and from which we take it again for our daily impossible to over-estimate. wants! He says of the glycogen—“ It mani- The first thing to be noted is the change in fests a remarkable tendency to pass into su- the arrangement. Instead of the secretion of gar in the presence of an animal ferment.” bile it is the ’“glycogenic function of the lie sums up thus—“The liver may be re- liver ” which stands first. garded as an organ engaged in forming two ‘ ‘ The most valuable contributions towards kinds of secretion, namely bile and sugar, or our knowledge of this matter have been the rather the glycogenic substance readily con- researches of Claude Bernard and other ob- vertible into sugar. The experiments of servers, who have shown that the liver has the Lehmann led him to believe that the liver- power of making and storing up for a time sugar is converted into lactic-acid, previous within its cells glycogen (C 6 H 10 O s ) a sub- in to being finally disposed of respiration.” stance resembling dextrine (C 8 FI 10 O b ), in From this we see that in i860 our ideas as its chemical composition and reaction, and to the function of the liver were beginning to like it capable of conversion into sugar by the take shape; that chaos was coming into some action of albuminoid ferments. This sub- approach to order. We will next see how stance always exists in the liver in larger Dr. Murchison arranged the order of the dif- amounts during digestion, than during fast- ferent functions of the liver; and how much a ing, attaining its maximum usually about four 44 INDIGESTION AND BILIOUSNESS. or five hours after a meal.” lie then pro- inated by the kidneys. First, there seems to ceeds to show that glycogen when present in be little doubt that the albumen and fibrin of excess in the liver may be converted into fat. the blood become largely disintegrated in the We are all familiar with the huge fatty liver liver. Lehmann and Bernard have shown of the goose which furnishespate defoiegras). that while the portal blood contains much Also that glycogen can be formed by the fibrin, blood from the hepatic vein contains liver in a dog fed on albuminoid matters little or none.” Further he writes—“ More- alone, and that the decomposition of a pep- over, there are grounds for believing that, tone produces glycogen and the nitro- while white-blood corpuscles take their origin genous matters leucin (C c H]s NO a ) in the liver, the red-corpuscles are destroyed and tyrosin (C 9 H 41 N0 3 ) which are there, and that the nitrogenous coloring mat- ultimately resolved into urea (CH 4 N a O). ters of the urine are partly the result of the Not only does this glycogenic function of the destructive process.” liver supply an easily oxidizable matter readily There is strong evidence of the destruction converted into carbonic acid and water, pro- of albuminoid matters in the liver. It is the ducing heat; but there are good grounds for grave of the red blood-corpuscles; further it believing that it assists in cell-growth. Sugar is, in all probability, the furnace in which all is found in the cells of the placenta, in foetal forms of albuminoid waste are oxidized into tissues, in the inflammatory products of pneu- the ultimate product urea, which is cast out monia, and in new growth whenever cell- by the kidneys. formation is active. Nor is this confined to He then gives observations from various animals; the same occurs in plant-life.” authorities, and writes: “It is important Further—“ In the early stages of foetal life to add, that the formation of urea in the liver the blood-cells multiply throughout the entire is always greatly increased after food. Lithic mass of blood; but when the liver begins to be acid has also been found repeatedly in the formed, this process ceases, and a very active liver of man and mammalia, but always in formation of colorless blood-cells is set up in small quantity; whereas, in birds, in which the liver, these colorless cells undergoing a lithic acid takes the place of urea, as the gradual change by the development of color- great eliminator of nitrogen, it also takes the ing matter in their interior into red corpus- place of urea in the liver, as it probably does cles. According to Kolliker, this new forma- in the human liver under certain pathological tion of blood-corpuscles in the liver continues conditions. All these observations point to during the whole of the foetal life of the mam- the liver as being largely concerned in the malia. The observations quoted above make destructive metamorphosis of albuminoid it probable that the liver in the adult con- matter, the products of which are eliminated tinues to perform the functions which pertain by the kidneys; although it is not improbable to many different tissues of the feetus, the that other glandular organs, and even the glycogen secreted in its cells combining with corpuscles in the circulating blood, as be- nitrogen and forming an azotized protoplasm, lieved by H. Ludwig and Fuhrer, may con- which maintains the nutrition of the blood tribute to the process.” A certain amount of and tissues.” Further—“ The process of body-heat is formed by these processes going assimilation may soon go on to the produc- on in the liver. Again, Galen is corroborated tion of fat in the liver, or it may stop short in his opinion, “ that the liveris a greatcentre at the formation of another principle which of animal heat.” escapes from the liver, and is elsewhere This second function of the liver, namely, transformed into fat. Lastly, there are good the oxidation of waste and surplus nitrogen- grounds for thinking that both glycogen and ized material, is one of the greatest moment sugar serve some purpose in muscular action; in the treatment of liver-derangements. It at all events, it has been found that the quan- is in the metabolism of albuminoids that we tity of sugar in the blood becomes greatly di- find the origin of many maladies. minished in passing through the vessels of Dr. Murchison writes: “The third func- contracting muscles. According to Bernard tion of the liver is the secretion of the bile. this destruction of sugar in muscles is due to The composition of this substanceis complex, lactic fermentation.” It is as lactic acid that and its uses are not yet sufficiently known.” sugar is probably burnt in the organism. The coloring matter of bile is formed from ‘ Galen held that the liver was engaged in haemoglobin ‘ by the hepaticcells, in the pas- sanguification. Dr. Murchison holds that sage of the blood through the liver.” Then Galen was right; and proceeds—“ But mod- again, “There are, on the other hand, ern research has made it probable that the grounds for believing that bile-pigment is in liver is endowed with a function not sus- its turn converted into urinary pigment. It pected by Galen, and which from a patho- is also a well-known clinical fact, that nothing logical point of view is even more important influences so much the characters of the urin- than that which we have been considering. ary pigment as functional or structural disease Many observations, pathological as well as of the liver.” Blood-pigment is first con- physiological, point to the conclusion that the verted into bile-pigment, and finally into liver is not only a blood-forming but a blood- urinary pigment. destroying or purifying organ, and that it The important matters of bile are the two contributes in a great degree to the destruc- bile acids in union with soda. “ The bilc- tion of albuminous matter derived from the acids in human bile are two—glycocholic acid urea (C NO«). and acid (C food and textures, and the formation of a6 H 4g taurocholic 8e Il4 are 7 S). and lithic acid, which subsequently elim- ; N0 Both acids are derivatives of albu- THE FUNCTIONS OF THE LIVER 45 men and contain nitrogen; and taurocholic chemical changes which go on in the liver and acid, to which the bitter taste of the bile is portal circulation; while part is excrementi- due, contains all the sulphur of the bile. Both tious, and, in passing along the bowel, stim- are in bile combined with soda, and both ulates peristalsis and arrests decomposition.” are what are called conjugate acids; that Such is where Dr. Murchison leaves the is to say, they are composed of cholic acid subject in 1874. The advance made during (C 24 H 40 O5), which contains neither nitrogen these fourteen years from i860 to 1874 was nor sulphur, in combination with taurin mainly due to the labors of Claude Bernard, s (C 2 H,NO S) which contains both nitrogen whose death has for a time checked the in- and sulphur, and glycocin (C 2 H 5 N0 2 ) which quiry. Others are making themselves certain contains nitrogen, but no sulphur.” In the about the facts and then progressing. bile is found also a fatty substance cholesterin This summary throws much light upon 26 (C H 440), the main constituent of gall- many matters of great clinical interest. Cer- stones. “The amount of bile secreted by tainly derangement in the glycogenic function the liver has been shown experimentally to of the liver gives us diabetes; but the derange- increase suddenly after a meal, reach its ments of the liver are mainly connected with maximum in about two hours, and then gradu- the metabolism of albuminoids. And this ally decline; while by abstinence it is greatly fact is a matter the practical physician must lessened.” Of this, but a very small portion keep clearly in his mind’s eye, well focused is expelled by the bowels. “ A large propor- and distinct, in his plan of treatment, in the tion of the bile secreted by the liver is again interests alike of the patient and himself. absorbed, either by the biliary passages, or Such summary brings us up pretty well to by the mucous membrane of the bowels. our time, and gives the reader the results of From what is now known of the diffusi- years of patient investigation, in a condensed bility of fluids through animal membranes, it form, convenient for his use. We recognize is impossible to conceive bile long in contact then that the liver is the storehouse of our with the lining membrane of the gall-bladder, fuel food, in the form of glycogen. This is bile ducts and intestines, without a large por- converted into sugar as is required for the tion of it passing into the circulating blood. wants of the organism, by a ferment in the The constant secretion and reabsorption of liver itself. It is the same process in the bile is, in fact, merely part of that osmotic body as in the plant. The plant digests its circulation constantly taking place between stored starch as it requires, by first convert- the fluid contents of the bowel and the blood, ing it into sugar. The liver takes from its the existence of which is too little heeded in store of glycogen as it requires for the wants our pathological speculations and in thera- of the body. By such means a regular sup- peutics.” Further, “ How many times this ply of sugar is furnished to the blood. Upon cycle of movement is repeated before the bile this subject our information is fairly ex- is extruded from the system we have no means plicit. of knowing; but in the course of the osmotic As to the second function of the liver we circulation much of the bile appears to become have much to learn. We recognize its action transformedinto products which are eliminated in the destruction of waste and surplus al- by the lungs and kidneys, while at the same buminoids; we see that urea is formed by the time this circulation assists in the assimilation liver, not by the kidneys; we begin to see that of the nutritive materials derived from the lithiasis, or lithsemia, is primarily a derange- food. In the first place it assists in the ab- ment of the liver, and that the waste matter sorption of fat. It is a well-known clinical in the blood produces in time structural fact that when the common bile-duct becomes changes in the kidney; we can see that when obstructed from any cause in man the fat oxidation is imperfect the nitrogenous matters throughout the body wastes.” It is also ex- suffer most. All this we discern. But what crementitious, in that it contains materials we do sincerely desire to know more about is,, which by conversion are cast out of the body the further elaboration of the proteid mat- as excrementitious matter. Further, bile ters which have been converted into peptones stimulates the'peristaltic action of the bowel in the digestive canal. The liver has to do and prevents putrefaction in the intestines. with this matter. A further elaboration goes Dr. Murchison sums up thus: on in the liver, and disturbance in the liverleads “ From what has been stated it follows that to malnutrition. Further, it seems very prob- the functions of the liver may be summed up able that the huge gland is a filter, allow- under three heads, viz.: ing certain nutritive matters to pass onward, “ i. The formation of glycogen, which while arresting other matters whose presence contributes to the maintenance of animal heat in the blood is deleterious. Dr. Lauder and to the nutrition of the blood and tissues, Brunton, F.R.S., wrote (Oct., 1880): “It and the development of white corpuscles. seems not at all unlikely, then, that the liver “2. The destructive metamorphosis of al- has got another function besides those usually buminoid matter, and the formation of urea assigned to it, viz., that of preventing the and other nitrogenous products, which are digestive ferments from reaching the general subsequently eliminated by the kidneys, these circulation so as to act upon the tissues.” chemical interchanges also contributing to the This is a very interesting subject—this capa- development of animal heat. city of the liver toconfine the digestive ferments “ 3. The secretion of bile, the greater part of to their own proper domain where they are which is reabsorbed, assisting in the assimila*- eminently useful; and preventing their emer- tion of fat and peptones, and probably in those gence therefrom into the general circulation 46 INDIGESTION AND BILIOUSNESS. where they would in all probability be dis- the peptones disappear from the portal blood tinctly harmful. before it reaches the general circulation. In- It would appear also that peptones when deed, Ludwig and Schmidt-Muhlheim found escaping into the general circulation are de- that even in the portal blood, before it reaches pressant agents. I will quote Dr. Brunton the liver, very little if any peptone is to be again—“ Professor Albertoni has found that found. They have not succeeded in discover- peptones have a most remarkable action upon ing where the peptone undergoes change. the blood, completely destroying the coagula- Plosz and Gergyai, and also Drosdorff, have bility in dogs, while they have little power in discovered peptone in the blood of the portal this respect over the blood of rabbits and vein; and Plosz and Gergyai have been led sheep. He and Dr. Schmidt-Muhlheim in- by their experiments, to regard the liver as dependently made the discovery that peptones the seat of the transformation of peptones. prevented the coagulation of the blood in In consideration of the more recent experi- dogs, and the latter, under Ludwig’s direc- ments of Ludwig and Schmidt-Muhlheim, we tion, has also investigated their action upon cannot entirely adopt the views of these au- the circulation. He finds that when injected thors, though it is nevertheless possible that into the veins, they greatly depress the circu- they are to a certain extent right, and that lation, so that the blood-pressure falls very the liver, to some extent at least, serves the considerably; and when the quantity injected purpose of preventing any peptones from is large, they produce a soporose condition, getting into the general circulation, which complete arrest of the secretion by the kid- may have escaped transformation in the por- neys, convulsions and death. From these tal blood before reaching it.” Such then is experiments it is evident that the normal our very latest information on the matter. products of digestion are poisons of no incon- There is digestion, there is also a filtering siderable power, and that if they reach the process in health. We may suffer that form general circulation in large quantities they may of indigestion known as “biliousness,” either produce very alarming, if not dangerous symp- from imperfection in the elaboration of the toms.” It would appear that in certain con- products of digestion in the gastro-intestinal ditions, as a consequence of disturbance in canal, or from imperfection in the filtering the working of the liver, the organism is not process. In either case the system is ill-fed, only ill-fed from the absence of normal pro- and at the same time poisoned by the want of ducts of assimilation, but is actually poisoned certain constituents, and the presence of oth- by the presence of products which are posi- ers in the blood. The liver then is a most tively harmful. Here there are blended the important organ in the elaboration of the pro- evidences of anaemia and toxaemia. No ducts of digestion, as well as in the destruc- wonder then that nervous depression is found tion by oxidation of waste and surplus album- along with indigestion. inoid material. Disorder of the liver then “ The action of digestive ferments is just will give us maladies, of which some account beginning to find a practical application in will be furnished in the ensuing chapter. medicine, and sometimes undoubtedly they are of very great service; but unless their ac- CHAPTER X. tion is investigated more thoroughly than it THE PHENOMENA OF LIVER DISTURBANCE. has been up to the present, it is just possible BILIOUSNESS. that we may find that the digestive ferments, From what has been said in the preceding like all other powerful agents, may do much chapter as to the function of the liver, the harm as well as good.” This is a useful hint reader will be prepared for an explanation of from Dr. Brunton to thg effect that “chil- certain well known, and equally well-marked dren should not play with edged tools.” The clinical phenomena. indiscriminate use of artificial digestive fer- It is quite a common experience, with chil- ments may do for them what indiscriminate dren especially, to see an acute “bilious use has done for many a useful agent, viz. attack” follow free indulgence in rich food. bring them into disrepute. We must use Some children are “ upset” by what are quite these agents with all the knowledge and skill ordinary meals with other children. Even a we can bring to bear upon them—wielding little rich cake is sufficient in some to disturb them discreetly. It seems possible that in the digestive system, to produce nausea with some cases and under certain conditiens, they headache, followed by actual vomiting, giving might act injuriously. By granting this, we great relief, and sometimes by purging; after must not be deterred from resort to them for which the child resumes its wonted state of the relief of evils we know, by the possible health. Every medical man of any experi- existence of hypothetical drawbacks. It is ence at all has seen this over and over again. well, however, to bear the matter in mind so About the clinical facts no doubt or differ- far as not to forget such a possibility. ence of opinion obtains. But about the ex- But to return to the more strictly proper planation a wide difference will be noted in subject matter here, and follow Dr. Brunton the opinions founded upon these data. I a little further: —“ And now comes the ques- mean the moreremote, not the obvious explana- tion. How is it that in healthy conditions of tion. The mother of the child will tell you, the intestine, peptones do not pass into the with the most unhesitating confidence, that—- general circulation, and are therefore unable “ it was the sweets, and the rich cake. Any- to exert any poisonous action upon the nerve- thing too rich, either with sugar or butter, centres ? This question is one we cannot at always upsets that child!" The old family present answer quite satisfactorily. Usually doctor nods his venerable head in complaisant THE PHENOMENA OF LIVER DISTURBANCE. BILIOUSNESS. 47

” harmony; and * ‘ that child is carefully usually, soon over without any future conse- watched in the future as to its eating, espe- quences. In a few instances the liver re- cially with reference to saccharine and fatty mains irritable, and is easily upset by any food, in anything like excess. error in diet for some time afterwards; a con- ” Yet this theory, however widely accepted, dition to which the term “ bilious fever was contains a fallacy; and it is important in the applied by a past generation. interest of that child, of other children simi- Now this acute bilious attack is undoubted- larly circumstanced, and indeed in the inter- ly preceded by indulgence in rich food, by est of a number of adults, that this matter be which is usually meant sugar and butter; but thrashed out. The fallacy is one which only it will not do to overlook the eggs used in the revealed itself when chemistry explained the preparation of “good things ” in which the composition of bile; previous to that epoch, youthful appetite delights. the fallacy lay too well-concealed to be sus- This view of the maternal parent and the pected to be a fallacy. The relations of family doctor is quite in harmony with the cause and effect were too clear for a scintilla views held by persons more widely, and more of doubt to suggest itself. Nevertheless a specially informed than they were, or profes- fallacy does underlie these familiar clinical sed to be. Even Liebig thought that bile phenomena. was formed from the hydro-carbonaceous ele- From what was said in the last chapter, it ments of our food; following the formula for is abundantly clear that it is the metabolism cholic acid (C 24 H 40 O 5 ). Von Gorup-Bessa- of albuminoids in the liver which caused these nez held the same view; “ and it was a favor- disturbances. The readily oxidizable hydro- ite theory, some five and thirty years ago, carbons burn up quickly without trouble, un- that the bile was derived chiefly from the de- less it is the heart-burn excited by some fatty composition of the fats; in fact, to return toa acid in the stomach. As said before, Liebig much older belief that the bile was a kind of pointed out that the union of nitrogen with soap.” Tn 1852, in an article published by other elements, interfered with the ready ox- “ Bidder and Schmidt, doubts were cast on idation of the compound so formed. The this hypothesis. “ Bidder and Schmidt albuminoid tissues of the body do not them- however, noticed that upon an exclusive selves burn, while the fuel-food burns in diet of fat, the secretion of bile at once them; just as the works of a steam engine do fell to the level of that in an animal from not burn with the coals burning in the furnace. whom all food was withdrawn; so that they It is the albuminoids, which in their under- think that the nitrogenous elements of the ground hidden career, from peptones to bile food must be looked on as the chief acids and uride solids, which cause the source of the bile.” To follow the subject troubles of the liver. The filtering of pep- further—“ H. Nasse in his earlier work saw, tones, the elaboration ofalbuminoids, the con- however, a great increase of the secretion of struction of white corpuscles, the relations of bile, when with fat nitrogenous foods were the liver to matters of histogenesis on the one also given. Ritter found that in a dog fed hand; its relations to histolysis on the other; only on potatoes, or on potatoes and fat only, Its being the furnace in which waste and sur- the amount of bile daily excreted fell very plus nitrogenized material, old effete blood- low.” These are important observations corpuscles, are burnt; and the luxus consump- pregnant with information as to the dietary tion of albuminoids which are split up into which excites “ biliousness.” These quota- fat and urea; these are the matters which tions are made from the learned treatise of Dr. cause those disturbances of health, which we Wickham Legg on “Bile, Jaundice and Bilious recognize as associated with “the liver.” In Diseases,” 1880; a perfect storehouse of in- the form of the acute bilious attack here des- formation and research, to which reference cribed, it is the second part of the function of will frequently be made in this chapter. One the liver which is involved, viz. the oxidation further quotation will illustrate even more of waste and surplus nitrogenized matters. clearly the point I am driving at, as to the ‘ The attack is the old fashioned “surfeit,” source of the bile. ‘ The amount of nitrogen that is, a meal where the palate is followed in glycocoll, and of nitrogen and sulphur in regardless of the wants of the body; in other taurin would certainly seem to point to an words the individual eats more than is good origin in the albuminous bodies of the blood for him, or her, as it is in delicate girls this or food. Some part of these bodies is thought trouble is most frequently seen; while it is to be split up in the liver into taurin and gly- boys, rather, who are given to eating to ex- cocoll, while another part goes to form leucin, cess. An excessive quantity of food is taken tyrosin, xanthin and hypoxanthin-bodies con- and the assimilative organs are upset thereby. taining nitrogen. Meisner would probably Unless a portion of the inordinate meal be go a step further, and say that urea also was got rid of by vomiting, or by purging, it is by formed abundantly in the liver. Do the pep- oxidation that it must be removed. All are tones at once furnish these nitrogenous bodies, familiar with the very sharp pyrexia, the sud- or are they derived from the products of the den and marked rise of body temperature decomposition of the tissues? Karl Voit which accompanies acute indigestion. The would answer that the bile acids, are derived, system is holding a bonfire to the great dis- like the urea, from the tissues, the great comfort of the child, the dismay of its mother dependence of the bile-making functions upon and nurse, and the benefit of the family doc- the glycogenetic function would seem rather tor! An emetic, a dose of laxative medicine, to suggest that they come immediately from containing a mercurial, and the attack is, the splitting up of the peptones.” 48 INDIGESTION AND BILIOUSNESS. We may make bricks without straw, but we ty these people had worked in a wrong direc- cannot make them without mortar! The tion, and took the things they should have nitrogenized elements in the bile-acids, to say avoided, and avoided the things they should nothing of the sulphur in taurin, point con- have taken. Of course it it true that any in- clusively to their origin from the albuminoids dulgence in saccharine or oleaginous food in of our food. There is no evading that con- addition to their ordinary food made them clusion; unless we assume that the animal worse; but how that is brought about has body builds up, by synthesis, complex sub- been explained above. They never tried to stances containing nitrogen, from hydro-car do without cheir albuminoid food, and that is bons; an hypothesis which will not hold water the point.” What was written as my experi- for one moment. The complex haemoglobin ence in 1877 remains my experience still in and lecithin are necessarily built up in the 1881. animal body; but as regards the ordinary The chemical composition of the bile acids matters there is “metabolism” not “con- points to their origin in the albuminoids; the struction;” and this metabolism results in de- application of this to practical medicine gives structive metamorphosis by oxidation. satisfactoiy results. I discussed the matter The explanation should stand so:—(i) with some of our best authorities, including There is an over-abundance of food taken; (2) Dr. Murchison, who recognized the impor- the more readily oxidizable hydrocarbons tance of the subject, at that time; and their burn first; (3) leaving the less readily com- agreement with my own view was almost bustible albuminoids to be burnt as best may complete. The lessons taught us by the liver be. It is this residuum of nitrogenized ma- disorders of hot climates is eminently sugges- terial which produces the excess of bile, with tive. To quote again from the article above r the general disturbances produced therefrom. —“And again the subject of indulgence in The rich food is the cause of the bile, but nitrogenized food crops up. If in the tropics,, not “ directly,” only “ indirectly.” The im- fruit, vegetables, oils, and other hydrocar- portance of this distinction is this, erroneous bonaceous food alone be taken, the liver is hypothesis leads to an improper dietary; the not so disordered as when meat is added. It correct theory suggests the appropriate dietary. is the second function of the liver which is so “ Ritter found that in a dog only fed on po- serious a matter in hot climates; and there tatoes, or on potatoes and fat only, the and elsewhere the best way to give physiolog- amount of bile daily secreted fell very low.” ical rest to a disturbed liver, is to relieve it as Yes; that is it! On a non-nitrogenized die- far as possible from the labor of disintegrating tary, orone containing very little nitrogen in- albuminoid matter. It apparently taxes the deed, the amount of bile produced was very liver little to store up glycogen and give it small. This is the secret of the successful out again; but the breaking up of nitrogen- treatment of Biliousness. In the Philadel- ized bodies is the labor which tests it most phia Medical Times for June 23rd, 1877, is severely. In tropical climates, then, hydro- an article on “ Biliousness and its Manage- carbonaceous food should form the staple of ment ” by the writer. As a more extended diet; and that, too, only in stinted quantities experience merely corroborates what is there by those whose livers are unequal to high stated, it maybe well to quote from this article, functional activity.” which shows that the views expounded here If this was made the rule, then, the amount have not been hastily seized upon, but are the of bile would be reduced, as in the case of outcome of protracted thought; and are sus- Ritter’s dog. There would be just that tained by an experience extending over a amount of bile which is required for the emul- number of years. “The next matter is to see sionizing of the fat, enough, that is; and no what bearing the details given above have surplusage to disorder the system. Those upon the right treatment of the condition of Europeans who follow the habits of the na- biliousness. I am of opinion that they throw tives as to the avoidance of meat and alcohol, a whole flood of light upon the treatment, know comparatively little of bilious disorder; both dietetic and medicinal. They lead to and do not develop that bronzed look which conclusions somewhat different from what are used to be associated with a Nabob, i. e., generally held, especially about the ordinary that individual of marvellous constitution and bilious attack—that is where the bile acids are vitality, who survived an Indian experience the chief matter. It has been held, and is and returned to his native shores, a curiosity yet too much held in reference to these per- in everyway. The returned East Indian now sons, that: ‘ as a rule those articles of diet is not distinguishable from the ordinary are most apt to disagree which contain much Briton. What one man may do with impu- saccharine or oleaginous matter, and not, as nity is forbidden to others. Some persons might perhaps have been expected, nitrogen- can eat meat and drink bottled beer, to say “ ous food; plainly cooked.’ On this matter I nothing of pegs” of brandy and soda, and am at issue with Dr. Murchison. I have yet live and work in Bengal; but they do not seen bilious individuals whoasserted that they run thirteen to the dozen. While most of could only take a little lean meat, bread, and those who try to do this are overtaken by a tea, getting no better, but worse, on this die- Nemesis in the shape of a liver disorder, tary; who were all the better for a dietary ex- which interferes most materially with their clusively hydro-carbonaceous. Of course bodily comfort and their power of work. So they commenced with the full expectation it is at home: there are individuals, adults of being much worse, but were agreeably as well as children, who are upset by what surprised to find themselves better. In reali- would not be regarded asindulgenceby others, THE PHENOMENA OF LIVER DISTURBANCE. BILIOUSNESS. 49 and which can be taken by them with impun- state of the stools, and a loss of all appetite. ity. After reviewing the production of Here the last, by leading to the rejection of bilious attacks the article proceeds: “From all food, permits of the system recovering it- this consideration of the production of an or- self. The surplus of albuminoid material is dinary bilious attack in a fairly healthy per- burnt up by oxidation into urea; and so the son, it is comparatively easy to proceed to system clears itself by this starvation. It is the consideration of the production of allied Dame Nature’s plan of striking a new equili- bilious attacks in those who are abnormally brium! and, as such, ought to be treated liable to them. Dr. Murchison repeats the with respect, and not with recipes to restore thoughtful suggestion that ‘ most persons have the appetite, which, if successful, would only more liver, just as they have more lung, than further embarrass the organism. is absolutely necessary for the due perform- Now it is the prevention, rather than the ance of its function. But in others, not un- treatment, of such cases that calls for our at- frequently the offspring of gouty parents, the tention. The avoidance of the surfeit is too organ in its natural condition seems only just palpably called for, to need a word about it. capable of performing its healthy functions But it is the fallacy as to the precise causation under the most favorable circumstances, and of the excess of bile, which renders it neces- functional derangement is at once induced sary to lay stress upon the form of food by articles of diet which most persons digest which produces bile. So long as the fat and with facility.’ In those persons with livers the sugar are held to blame, so long will the which if not abnormally small in size are of child be erroneously fed. It will be allowed limited functional power bilious disturbances albuminoids, and be restricted in the matter are readily produced, just as they are in per- of hydrocarbons; and so the tendency to be sons whose livers are crippled by organic bilious will be directly fostered. Adult or disease.” All are familiar with instances of child, the ordinary dietary is a little lean individuals who have suffered from bilious meat, dry bread, and tea or coffee without disturbance in India, who come home and sugar or cream. You will be told, milk is are fairly well; but if they venture back to “bilious,” eggs are “bilious,” butter is India with the disabled liver they are quickly “ bilious,” porridge is distasteful! Yes, this ill again. This is well seen in cases where is a story with which one has long been fa- liver-abscess has existed and been survived. miliar; is familiar at the present time, and It is thoseindividuals with the maimed liver of likely to be “acquainted with” for some abnormally low functional activity who must time to come—probably the rest of one’s life- be so watchful about their dietary, so scrup- time; as I do not belong to a family of cen- ulous to avoid any indulgence approaching tenarians, but only of fair longevity. The excess. They must never forget what Id. proper dietary is thus studiously avoided, Nasse found, “ a great increase of the secre- and the evil perpetuated. tion of bile, when with fat nitrogenous foods What is the appropriate treatment dietetic were also given.” and medicinal of this state of affairs? Diet- It is “high tea,” as well as dinners etically it is the avoidance of albuminoids and suppers, which upset these beings (see p. 137) in all forms, in any quantity. with the congenitally incapable, or with The food should consist of farinaceous mat- maimed livers. Tea, with cream and ters, fruit natural or stewed, vegetables, fish, sugar, tongue or potted meat with bread or a little white meat. Butter, cream, oil, or and butter, or buttered toast, or muffins; fat are not forbidden, if and provided nitro- then these last with jam or marmalade, fol genous material be not taken too freely there- lowed by cheese-cakes, jam-puffs, and a good, with. Medicinally, an hepatic stimulant of slice of pound-cake or plum-cake to finish up some kind, in a dinner-pill, or at bedtime with this is the sort of meal to properly up- with a vegetable laxative, and next morning set a child whose liver is not all it might be. a saline purgative. Many a chimney does Such a “feed” is well enough for healthy not draw properly because the flues are not children, with an appetite of a polar bear well swept. So it is with the bilious; it is and the digestion of an ostrich; but for the necessary “to sweep the flues,” i. e., to keep bilious child or adult it is an instance that the bowels open. When this is done certain “ one man’s meat is another man’s poison.” desirable foods are no longer found to be “ After this party-tea” the child goes home to “ bilious.” They agree', instead of disagree- bed, and awakens sick and feverish. It ing as before. Exercise, plenty of exercise vomits freely, and gets relief. Or it is not so to increase the oxidyzing processes, is most quickly relieved. It is is in high fever, 105® desirable. By the union of these measures or so in an hour or two; a cold is suspected, the “bilious” individual is usually much ben- not a “surfeit,” and it goes on until it vom- efitted. But infinite care is required, inces- its a quantity of pure bile, usually followed santly and unintermittingly. Occasional by purging; and then it gets relief. Or an lapses upset the individual for some time emetic, accompanied by a purgative (some afterwards. The congenitally inefficient calomel and ipecacuan is the common com- liver is only equal to the most moderate de- pound) is given, and these processes institu- mands upon it; consequently it must be com- ted artificially, with the effect of procuring promised with. It is a case of Mahomet relief and a fall of the temperature. At other and the mountain; it would not come to him times, more usually in adults, the attack is so he had to go to it! So the liver not be- less acute. There is headache, a foul tongue, ing equal to what an ordinary normal liver with a bitter taste in the mouth a vitiated can do, it becomes necessary to reduce 50 INDIGESTION AND BILIOUSNESS. the food taken to what it can dispose “bilious attack” is passing away. They of. There is no alternative. There is no commonly have headache, and usually their getting another liver; the individual will temper is irritable. They are not, as a rule, have to remain content, or discontent as the lively people; rather they are gloomy, or case may be, with the viscus dame Nature morose. The dark, swarthy Stuarts were a has givenhim ; and he must just accommodate bilious people. After reproaching the Duke of himself, or herself, to the inevitable. It is, Grafton on his descent from Charles the Sec- no doubt, very hard that such watchful care ond, Junius says : “There are some hered- is imperatively necessary, and socially very itary strokes of character by which a family irritating ; but there it is. may be as clearly distinguished as by the Other individuals there are who cannot blackest features of the human face. Sullen take certain wines without suffering for their and severe without religion, profligate with- indiscretion. Some persons can get through out gaiety you live like Charles the Second, a good dinner very fairly provided they are without being an amiable companion; and not tempted to taste the port wine. But if for aught I know, may die as his father did, indiscreet enough “ to try a glass of port,” without the reputation of a martyr.” The at the solicitation of their host, next day their swarthy skin, the peculiar turn of mind, are liver resents the indiscretion. In others it is each a part of the bilious temperament; alike champagne which alone must not be touched the outcome of something which is causal on any consideration. While with others to both. The old Greeks used the word this is the only wine which they can take “melancholia” for mental depression; “black without consequential suffering. Why one bile,” as it means, was they held the physi- wine alone should disagree with certain livers cal cause of a state of mental depression. is a refinement which physiology is not yet When under the influence of a bilious at- able to explain. The alcohol, the ethers, the tack this mental attitude is aggravated, and salts are much the same ; what is then the the irritability and depression are pronounced. minute matter which constitutes the differ- The character of James the Second is in har- ence ? We must answer that in the present mony with a persisting biliousness. state of our knowledge; we do not know. Now the bile acids and the coloring mat- The clinical fact remaining all the same ! ter of bile are not the same thing; just as the Now it is time to consider in some detail coloring matter of the urine and the urine- two kinds of “ Liver Disturbance.” (i) Bil solids (proper) are not the same thing. But iousness proper; (2) lithiasis or lithsemia, a high-colored urine is usually a urine of which takes the form of indigestion, rather high specific gravity. And an icteric hue is than that which is known as gout. In the usually found with biliary disturbance. Both first, bile-acids are the offending matter. In the coloring matters of bile are nitrogenized the second, the formation of lithates by the matters. liver is the malady par excellence. Bilirubin C g N O . 1. Biliousness (proper) is the form of hep- II 18 a a Biliverdin C II N O . atic disturbance found in persons naturally 16 a0 a e ‘ ” ‘ bilious. Such persons are ordinarily dark, tell of their derivation from albuminoid ma- often swarthy ; but by no means necessarily terial originally, if immediately the pro- so. The typical bilious individual is dark, ducts of the destruction of haemoglobin. with black hair. The skin is thick, wanting Glycogen which unites with cholic acid to ” in transparency even ifnot actually ‘ ‘muddy, form glycocholic acid has the formula C a II g, there is a large development of pigment. NO a ; and t’urin Cs H 7 NO s S. The eyes are dark, the conjunctive have a The bde coloring matter and the bile acids distinctly yellow hue. When very marked go together. Where the one is the other is the individual looks “steeped” in bile ; the not far away. Taurocholic acid is the ma- yellow stain showing itself everywhere. The terial which gives the bitter taste in the dark skin not uncommonly presents a num- mouth in biliary disturbance; it does not give ber of freckles on the face. The hands are the yellow hue to the fur on the tongue, but dark, and never white ; indeed the hue is the two go together clinically. The tongue that of tne lighter colored of the dark races. is usually furred, the fur being yellow or Why there should be this development of even brown, first thing in the morning; if pigment, the black hair, thedarkly pigmented persisting all day, worse then. Along with irides, it is impossible to say, as we do not this is experienced a bitter taste in the mouth. know the relations of pigment to the color- Sometimes the tongue looks quite clean when ing matters of bile. But there is some asso- a bitter taste is complained of; but if the pa- ciation, that is clear enough. tient be placed in the light and then the eye These bilious individuals may be active, is brought near to a level with the tongue so- may be lethargic, may be circumspect in their as to look along it, then the yellow or brown living, or may be careless, but they suffer for hueis perceptible, which was unnoticeable be- their indiscretions ! fore; just as a dyer holds up a skein of silk Their digestive canal is their bane in life. sideways to the eye when he wishes tobe Their appetite is capricious ; and that is an very certain about the shade of color. Where advantage, as the loss of appetite lessens the there is co-existing old standing debility the amount of food taken, and, therewith the de- tongue is swollen, pale, flabby and showing mand upon the liver. Their bowels are the indentations of the teeth at its edges, rarely regular; commonly they are consti- while its surface is whitish and its papillae pated, ordinarily with diarrhoea when the are long. “If the liver be somewhat con- THE PHENOMENA OF LIVER DISTURBANCE. BILIOUSNESS. 51 gested with these appearances we may often when passed. This condition I have met observe the fungiform papillae on the tip and with in elderly women with anaemia and edges larger and redder than natural. In large livers; it is common to hear them other cases, and especially when there is at complain of the offensive character of their the same time more or less gastric catarrh, urine: “ I can’t abide myself,” is a frequent the whole surface of the tongue is uniformly expression with them. It would seem that covered with a thick fur, sometimes whitish, there is present in the urine some substance but occasionally of a yellowish or brownish possessing the properties, to the nose at least, tint. According to Sir James Paget, psoriasis of skatol or indol. Certain it is there is of the tongue, difficult to distinguish from some perversion of assimilation, or metabol- syphilitic psoriasis, occasionally results from ism, or oxidation which shows how closely gout,’’ (Murchison). The tongue is worthy the liver and the urine are linked together. of careful study and minute inspection, in all At other times they are lumpy, dark-colored, cases of disturbance of the chylopoietic vis- and offensive, as if too long in contact with cera. the intestinal secretions. Such stools often Disorder of the bowels is common. There alternate with diarrhoea, when the stools are is torpor often with flatulence. The bowels charged with bile producing the sensation of are irregular; either constipated always, or scalding at the vent, as if the motion consisted constipation alternates with looseness. Often of “ red-hot sand;” leaving behind it a good acidity is complained of in the intestines, deal of irritation. Chronic conditions of anal with a headache of its own. Prout, in his itching are always the concomitant of biliary well-known work on “Stomach and Urin- disturbance in persisting indigestion. These ary Diseases,” says of this trouble—“ When stools, black and offensive, have a term for acidity prevails in the lower portion of the them, viz, “vitiated,” an expressive, old- intestinal canal, and particularlyin the ccecum, fashioned phrase. The urine is usually high- the treatment must be modified to meet the colored, but clear; at other times it contains a circumstances. The soluble antacids in this deposit, which may vary—may be white, case have comparatively little effect, from fawn-colored, or “brick-dust” in hue. In- their being neutralized and absorbed before deed, the whole phenomena are those of ex- they reach the seat of the affection; hence cess of bile, poisoning the whole system, and the insoluble antacids, and particularly mag- chiefly disturbing the digestive canal. The nesia, will in general be found most useful bile-acids here are the disturbing agents, in in such cases. The shortest mode, however, all probability at least. of gettingrid of the immediate inconvenience The following is Murchison’s summary. — of acidity in the lower bowels, is usually to “ The symptoms, usually associated with a inject a pint or two of warm water (or of deficient excretion of bile, are an irregular, soap and water), and thus of removing the usually costive state of the bowels, the stools offending cause. By this simple remedy I being insufficiently colored with bile, and of have often seen the severe nervous headache, a pale yellow drab, or whitish color; loss of and other unpleasant symptoms usually ac- appetite, a white or yellowish tongue; a dis- companying acidity in the lower bowels, im- agreeable, often bitter taste in the mouth, mediately removed. Those who suffer from especially in the morning; flatulence; a yel- such causes usually require the aid of purga- low or muddy tint of skin (indicating, unless tives, which in general are better taken at there be concurrent hyperaemia of the liver, bedtime. Purgatives of a mild but effectual anaemia rather than jaundice); dingy con- kind, such as the Decoct. Aloes Comp, with junctivse; languor and disinclination for ex- magnesia often suit well; as do pills taken at ertion; frontal headache; dulness and heavi- a late dinner if duly adjusted to the circum- ness, drowsiness after meals; great depression stances of the case. Drastic purgatives in of spirits, and sometimes hypochondriasis; general should be avoided; for though they and frequent deposit of lithates in the urine sometimes give immediate relief, they usually on cooling. These svmptoms are very apt leave the patient more inveterately disposed to be induced, especially towards middle life, to the disease. Neither this class of diseases, by sedentary and indolent habits, the habitual nor the remedies adopted to remove them, use of rich or indigestible food, neglect of have been so carefully studied as they de- the bowels, great, or protracted anxiety of ” serve to be What Prout complains of in mind, or by a general want of vigor, con- the concluding sentence, still continues to sequent upon disease of the heart or of some hold good. Matters requiring “ careful other organ; and the tendency to them is, in study” never have been, never will be, prop- many cases, inherited. They are commonly, erly attended to, unless humanity undergoes and perhaps correctly, ascribed to what is some prepared modification affecting the called “ torpidity of the liver,” but the non- multitude, and disposing it favorably to excretion of bile may possibly be merely one earnest thought; which will be about the ad- of the symptoms, rather than the cause of vent of the Millennium! the morbid state; the real cause being the re- The stools are sometimes pale, “want- tention in the system, not of bile, but of ing in bile,” we say; and this is common those products of disintegration which it is when there is a deposit of lithates in the the purpose of the kidneys to eliminate. At urine. Commonly they possess a very of- the same time, it is very probable that en- fensive odor. At other times the stools are gorgements of the liver with bile interfere pale and putty-like, while the urine pos- with the normal processes of disintegration sesses a very offensive odor immediately of albumen which takes place in the gland.” 5 2 INDIGESTION AND BILIOUSNESS. And it certainly is probable that there is a sooner or later, the natural eliminating action surplusage of bile in those cases. Useful in comes into play, giving relief. The diarrhoea, normal amount in the assimilation of fat, of which the patient complains, and asks for freely poured out and freely absorbed more a remedy, is the natural means of restoring than once, a large quantity of bile may be an equilibrium once more. It is the thunder- accumulated, that portion normally cast out storm which clears the air: and therefore the by the bowels being reabsorbed; why, we patient should be grateful for it. But it is cannot tell in the present state of our know- not in humanity, in this sublunary state any- ledge, the clinical fact remaining all the how, to be grateful for what is unpleasant. same. The purgatives which are operative Now a very interesting question suggests in such cases are those which act upon the up- itself, but does not bring with it a complete per part of the intestine, and sweep away a or satisfactory answer; and it is this. Is it quantity of bile too swiftly for its absorption the excess of bile-acids which produces the by the bowel lower down. Such are notably lethargy, the depression, the “ melancholy,” mercury, rhubarb, aloes (as well as acting on of the bilious attack; or is it that in a bile- the colon), and podophyllin, or gamboge. laden state the liver is impaired in its filter- The utter inability of purgatives like sul- ing power, and allows peptones, or other phate of magnesia and castor oil to relieve crude matters of gastro-intestinal digestion, conditions of biliousness is well known. The to pass through it into the general current of patient with the furred tongue, bad taste in the blood ? the mouth, and general languor and malaise, The question is one which at least is wor- states that the bowels have been freely thyof consideration, even if a positive answer opened by these agents; yet no sense of relief cannot be given to it. Such consideration is experienced therefrom. A laxative contain- will enlarge our acquaintance with the sub- ing mercury brings away some bile-laden ject; and that is good, even if but imperfect stools,and the sense of relief is marked; while good. One part of the subject is clear the tongue cleans, and the bitter taste in the enough anyhow, and it is this. The normal mouth disappears. Such a remedial agent a products of digestion give us agreeable sen- by-past generation called an “alterative,” a sations, a part of which is a sense of energy. term justified by the clinical facts; but not to But this varies. A small meal is more be explained satisfactorily otherwise in the apt to give the sense of energy and well- present state of our knowledge. When the being ; while a full meal gives a very surplusage of bile is swept away, the system pleasant sense of well-being combined with a feels relieved, the appetite returns, and as- feeling of dolce far niente, of disinclination similation is restored. It is clear from this to exertion. But that the mental associa- that a certain amount of bile only is required tions of normal digestion are pleasant, there for the purpose of digestion, and the over- can be no doubt. Charity dinners demon- plus can truly be regarded as excrementitious. strate the belief in the effects of a good meal In this matter we must still look to the utter- upon the generous impulses. Young ladies ances of clinical medicine, as physiology, talk to their papas after dinner about their just yet, is not in the position to speak an- lovers, when they know that some objections thoritatively. Probably, ere many years have exist to them in the paternal mind. Mammas passed away, it will have much to tell us that know this too. “ A hungry man is an angry ” we will be very glad to hear; as in the past man ; when a man’s stomach is full he is so probably in the future, our clinical obser- inclined to be amiable. That is a well re- vations will be corroborated as well as ex- cognized fact. But when the products of plained by advancing physiological knowl- digestion are abnormal, then a very differ- edge. At least there is every reason to be- ent mental state is produced. There is de- lieve so from the lessons of the past. pression, with irritability ; no matter whether In the meantime it is not unwarrantable, the state is one of ordinary “biliousness," nor yet out of place, to throw together a few or one of “lithaemia.” Whether lithates or matters which will at least be suggestive in bile-salts are the offending matter, the men- the aggregate; if nothing more can be claim- tal state is not one of well-being, but the op- for them. The bile is a fluid which passes posite. Nor is it the posterior sensory lobes very easily through animal membranes; not of the hemispheres alone which are involved. only that, but when such membranes are wet- We know that Cyon and Aladoff have traced ted with bile, oil easily passes through them. a direct nervous communication betwixt the It is easy then to comprehend how bile may liver and the posterior lobes of the brain, very readily escape out of the bowels into the that portion of the cerebrum, indeed, which portal venules, if allowed to remain in con- is linked with our subjective sensations. tact with the bowel. It is secreted under a There is this matter of nerve-communication very low pressure, a fact, the importance of by fibres of the sympathetic to be borne in which we scarcely are yet in a position to mind; this “sympathy,” as well as the di- fully realize. It is a fluid evidently which is rect effect upon the sensorium of the abnor- freely poured out and readily absorbed, and mal matters—abnormal in character or in may circulate in the chylopoietic viscera in amount, circulating in the blood. Such abnormal quantities some time, before being poisoned blood, too, produces modifications cast out of the system by the act of sponta- of sensation. neous purgation; sometimes accompanied by There is the general cutaneous itching of vomiting. jaundice, well-recognized ; and the itching of When such an accumulation of bile exists, lithiasis, the general prurigo of inefficient THE PHENOMENA. OF LIVER DISTURBANCE. BILIOUSNESS. 53 renal action, seen in the subjects of chronic wrong. A man who has previously borne Bright’s disease. There are burning or the crosses of life with equanimity, and been scalding patches, and sometimes “lightning amiable to those about him, gradually be- ” flashes of acute pain, and hypersesthesia in comes disconcerted by trifles; his mind those who are the subjects of lithiasis; as broods upon them, and he makes all around sudden sometimes as the pains of locomotor him unhappy, and himself the most misera- ataxy. There is neuralgia. Also severe ble of all. His relatives perceiving no other cramps. While headache is almost invaria- sign of indisposition, and failing to recognize bly present. It may be “megrim,” or it the true cause, too often put down the ebul- may be “frontal,” throughboth temples ; or litions of temper to something mentally or it may be “ vertical,” or “occipital,” or even morally wrong; to moral depravity, or failure it maybe general. Usually it is accompanied to make any mental effort, but remedial by a sense of nausea and anaemia. measures calculated to restore the liver to Alterations of vision, dimness of sight, healthy action, if resorted to in time, will etc., or modifications of hearing, sounds in often remove the irritability, and either the the ears, buzzing, or ringing, may be ex- patient’s improvement under such treatment, perienced. One eye may be more affected or an attack of gout, reveals the cause of the than the other, or one ear ; or there may be patient’s bad temper.” So writes Dr. Mur- vertigo, ora sense of dizziness, or swimming chison. And there is no doubt much of experienced. Even convulsions are not what Americans call “pure cursedness” is unknown as the result of such toxaemia. due to a toxsemic state of the blood, contain- More striking still is the cardiac disturb- ing as it does “bile-poison.” The subjec- ance set up by this poisoning by bile in the tive sensations of the individual are unenvia- blood. Bile has been found experimentally ble, to put it as mildly as possible. I remem- to have “a direct paralyzing action on mus- ber a lady of very fine sentiments and strong cles” by Ranke, and Wickham Legg agrees religious feeling, who became quite alarmed with him as to the action. Rohrig first at what she regarded as her own perversity clearly showed that it is the bile-acids, and and innate wickedness, and the inefficacy of not the bile-pigment or cholesterin which prayer—who recovered her normal state of causes the slow pulse. At other times there mind on a line of treatment which filled her is a lowering of the blood-pressure, with that brain with healthy blood. In some cases rapidity of the pulse which is linked there- the second factor—the direct sympathy be- with ; and this slow pulse, or rapid pulse, twixt the liverand the posterior lobes of the depends upon the condition of the sympa- brain, exercises a distinct influence; and the thetic system, according to Traube. It ap- sensory portion of the brain is more affected pears, too, that bile acids in any quantity in than the rest of it, i. e., the posterior portion the blood are destructive to the red corpus- supplied by the vertebral arteries* which is cles. related to the subjective sensations, is more There is then another factor in the depres- affected than the intellectual or motor areas. sion produced beyond that (i) of the direct Consequently we find a peculiar state of action of the bile laden blood upon the brain; mind. There is perverted emotion with a and (2) the sympathy betwixt the liver and distinct perception of the perver- the posterior lobes, by their direct nerve- sion. Thus Jean Jacques Rosseau communication; there is (3) the effect upon wrote, “I feel bitterly my wrong the circulation, lowering the blood pressure conduct and the baseness of my suspicions; in the brain aswell as elsewhere. No won- but if anything can excuse me it is my der then that there is depression linked with mournful state, my loneliness.” The intellect irritability; the depression of brain actually here was perfectly conscious that there was a ill-fed, with the irritability caused by the morbid condition of the emotions which it positive presence of a blood-poison. “The was evidently unable to control. The late influenceof the liver upon the animal spirits Thos. Carlyle knew what this horrible feel- hasbeen recognized by medical writers in all ing was—“ The accursed hag dyspepsia had ages. To the belief in the existence of such got me bitted and bridled, and was ever an influence may be traced the origin of such striving to make my living-day a thing of terms as hypochondriasis and melancholia. ghastly night mares; I resisted what I could, Although it is not contended that the mor- never did yield or surrender to her; but she bid states of mind, to which at the present kept my heart right heavy, my battle being day we apply these terms, have their origin sore and hopeless.” Yet he strove on under in the liver, they are unquestionably, in the infliction; his experience fully bearing many instances, accompanied and aggrava- out what is written in the initial sentence of ted by derangement of the organ; and it is this book. There is little real difference be- equally true that, independently of either hy- twixt the action of bile-acids or lithates in pochondriasis or melancholia, persons with their toxic effect upon the brain-cells. Both functional derangement or structural disease actpotently. It is scarcely, however, a com- of the liver are subject to fits of great de- plete consideration of the subject to leave it pression of spirits, and often groundless fears here. To revert to Dr. Brunton’s paper, it of impending danger, which cease when the would seem that there are gases evolved in liver is restored to its normal state. Irrita- bility of temperis another common symptom ♦Not only is the blood supply special, but thesyra* of functional derangement of the liver, and pathetic nerve supply to the vertebral arteries is de- the first rived from the lower cervical ganglia; that of thein- is sometimes indication of anything ernal carotids from the superior cervical ganglia. 54 INDIGESTION AND BILIOUSNESS. certain states of disorder of the assimilative feet upon the cerebral hemispheres. These organs which are distinctly toxic in their ef- two halves of the subject are well worth fects. He follows Dumarquay as to the ab- keeping in mind and contrasting. sorption of sulphuretted hydrogen from the So much for the consideration of the ner- intestine. “ In cases of indigestion this gas vous phenomena provoked, or set up by dis- seems to be not unfrequently found, because turbance of the function of the liver. persons often complain of the taste of rotten We may now consider the effect of the eggs in the mouth, or in the eructations. bile-laden blood upon the heart. In using, Even in such small quantities it is not im- here the term “ bile-laden,” it is intended it probable that itmay exert a deleterious influ- shall embrace these other products which- ence both upon the nervous system, and upon may co operate with the bile in producing, the blood, foritis a powerful poison, in its act- nerve-disturbances. We saw at p. 53 that bile ion somewhat resembling hydrocyanic acid, is a poison acting upon the heart. We saw though not so strong.” In some cases the further, that its action was not alike in all- production of sulphurettedhydrogen may be cases; and that Traube held this difference to- a factor in the nervous depression produced. be due to the condition of the sympathetic He writes:—“ The greatest care appears to system. What actually occurs in practice have been taken in the construction of the bears out the views of Traube. At times liver to prevent the bile from coming in con- patients present themselves with deep de- tact with the blood; the ultimate radicles of pression of the nervous system, while the the bile-ducts or biliary capillaries being heart’s action is slow and feeble. Here placed as far from the blood capillaries as the there is direct action upon the cardiac ven- structure of the liver will allow. Notwith- tricles through the inhibitory fibres of the standing this care, the distance between the vagus. The depressing effect of the bile- blood and the bile capillaries is small, though laden blood upon the cerebral hemispheres it is sufficient under ordinary circumstances is intensified by the comparative anaemia of to prevent the absorption of bile into the the brain, consequent upon the arrested blood. But, whenever an obstruction takes action of the heart. The defective blood- place to the exit of bile, and the pressure of supply produces the symptoms of cerebral bile in the biliary capillaries increases, an anaemia, and blends them with those of bil- absorption of this secretion occurs. Bile is iary toxaemia. The pulse is slow, frequently secreted under a very low pressure, and a unequal, corresponding to the stroke of the very slight increase in this is sufficient to ventricle. This irregular action of the heart cause reabsorption..” alarms the patient, already depressed by the He goes on:—“But bile is not the only effects of the bile upon the brain, and causes substance which produces a depressing effect the impression of “something wrong with upon the circulation, when absorbed into it the heart” to take possession of the patient’s from the portal circulation. In many cases imagination, and to cause him or her much of nervous depression we find a feeling of needless alarm. But it is not easy to con- weakness and prostration coming on during vince them that the alarm is needless, and digestion, and becoming so very marked without real foundation. Impressions founded about the second hour after a meal on subjective sensations are not easily laid at has been taken, and at the very time when rest; they raise their hydra-headed front absorption is going on, that we can hardly do again and again, in spite of all the efforts otherwise than ascribe it to actual poisoning made to keep them in subjection. The hor- by digestive products absorbed into the cir- rible sensations and the irregular action of culation. From the observation of a num- the heart will range themselves together in a ber of cases, I came to the conclusion that most suggestive manner. Just as the Hydra the languor and faintness of which many grew another head as fast as one was cut off, patients complained,andwhich occurredabout so the disordered imagination will yield to the eleven and four o’clock, was due to actual suggestive associated facts, and put its own poisoning by the products of digestion of interpretation on the linked phenomena. breakfast and lunch; but at the time when I ar- Assure them that there is no actual disease of rived at this conclusion I had no experimental the heart, they depart comforted; for the data to show that the products of digestion time. But in a little while the impression were actually poisonous in themselves, and comes back, with a rebound as it were; and only within the last few months have I seen the apprehensions of organic disease are as the conclusions, to which I had arrived by clin- dominant and dominating as ever. Yet ical observations, confirmed bv experiments when the function of the liver is restored, and made in the laboratory. Such experiments the blood is once more freed from bile, and its have been made by Professor Albertoni of kith and kin, the mind escapes from the in- Genoa, and by Dr. Schmidt-Muhlheim, in cubus which bestrode it; and the reason once Professor Ludwig's laboratory at Leipsic.” more resumes its wonted sway. The condi- (What these observations were is given at p. tion passes away, like a bad dream, leaving 164). We thus see that there are many fac- behind it for a time a painful feeling, which tors in the production of the nervous depres- haunts the sufferer like the refrain of mourn- sion, and disturbance linked with normal ful music—a melancholy symphony! action in the liver. If the nervous system At other times the symptoms are those of strongly affects the liver when perturbed a low blood pressure, with a rapid pulse. (Chap, ix), it is also abundantly clear that the Here there is palpitation at times; often se- liver, when disordered, produces a potent ef- vere, and alarming the patient. It is well THE PHENOMENA OF EIVER DISTURBANCE. BILIOUSNESS. 55 known that with a low blood pressure in the most careful as to diet. What is impor- arteries the heart’s action is rapid. The roots tant also to note is, that in most of these of the vagus are not freely supplied with cases there are no obvious symptoms of blood, and then the accelerator fibres of gastric dyspepsia; the appetite may be good, “ that rope of varied strands,” the vagus, are too good in fact; the bowels may be regular; thrown into action. At times this leads to and there may be no pain, flatulence, or oth- positive palpitation, the contraction of the er discomfort, after meals; but there will be ventricle being so quick and vigorous. It is found an unusual tendency to the deposit of indeed a true form of neurosal palpitation, lithates in the urine, and very often other not influenced by effort. It also disappears phenomena of a so-called gouty diathesis.” when the functional activity of the liver is Such is a brief summary of the phenomena regained under appropriate measures: the associated with sleeplessness, when the pa- first step being to get rid of superfluous bile- tient is not otherwise ill; in the less grave ca- products, and other albuminoid matters, and ses indeed. to so feed the patient as to give the liver but Such are then the disturbances of a neuro- little to do. A dietary containing little albu- sal nature, which belong alike to biliousness., minoids is the one most suitable, as taxing and to lithsemia, or lithiasis. Whether it is the liver little in the metabolism of nitrogen- bile-acids, or lithates, which are the disturb- ized matters. ing matter, the phenomena are much alike as Sleeplessness is another symptom much regards the subjective sensations; instead of complainedof by these bilious patients, and the buoyant sensations, the sense of energy it is linked with the cardiac disturbances given by the normal products of digestion, very closely. The patient complains of ina- there is depression and panphobia, the out- bility to sleep; in vain it is courted for hours; comes of a blood laden with abnormal pro it will not be wooed. The sleepless hours are ducts, or with natural products of albuminoid in themselves barely tolerable; but when, in metabolism in excess. As they will be re- addition to this, the disturbed cardiac action ferred to in the next section, it will not be nec- is present, the condition becomes almost un- essary to write them here. Such then is a bird’s bearable. The sleepless patient feels at eye view of the symptoms produced, when times as if the heart would really stop, its the liver is embarrassed or hindered in its pulsations become so slow and feeble. De- working, either by too much to do from too pressed before, this deepens the gloom; and many albuminoids being taken in the food, a sense of misery is intensified by apprehen- or by some cause of disturbance to its func- sions of approaching dissolution. When tional activity. It fails to elaborate the pro- there is palpitation the case is different. In ducts of gastro-intestinal digestion as it ought the silent watches of the night the sufferer is normally to do; while it produces bile-acids suddenly wakened out of sleep by a violent in excess, or it conducts the metabolism of paroxysm of palpitation. This is alarming the digested proteids on a downward course, enough; but when the violent beats are suc- splitting them up into uric acid and urates. ceeded by apparent sudden stoppage then the It is a deeply entrancing subject this, of how dread indeed is acute. So longas the heart is the liver acts upon the digested proteids, in- violently beating the sufferer is comparative- stead of further elaborating them, so as to ly easy in mind, but when the sense of stop- furnish pabulum to the tissues; it arrests page comes then the sensation is that of dy- their further progress and sends them pre- ing. The evil effects of this are not imme- maturely upon a retrograde career, splitting diate only, the shock upsets the patient for them up into bile or urine solids. It is like a sometime afterwards, and is only slowly and batch of bread spoiled in the baker’s oven. not rarely imperfectly recovered from. Dr. The flour and water have been well mixed, Murchison writes: “ Sleeplessness may, of the yeast incorporated therewith; the fer- course, arise from many different causes, but menting action of the yeast is operating one of its causes is that derangement of the on the starch granules ; the dough is ris- liver which produces lithaemia. When this ing nicely ; it is cut into loaves and placed in is the case the patient is often heavy and the oven. But the oven is too hot or too drowsy after a full meal, and he may fall cold, and instead of wholesome nutritious asleep at once on retiring to rest; but after bread, we get a sodden, or burnt mass, unfit one, two, three or four hours he awakes, and for food, and only so much good material then he either lies awake for hours, or he is converted into waste ; we all know the stout- constantly falling asleep, dreaming, or hav- hearted determination of the youth “to ing the nightmare, and awaking four or five make a spoon or spoil a horn!” In this case times, or even oftener, in the course of one it is a promising horn spoiled and no spoon hour, until the morning comes, when he made! The peptones are wasted ; instead of. drops into a quiet sleep of an hour or more, tissue-pabulum, they are turned aside to un- or he is obliged to get up tired and irritable. dergo a retrograde metamorphosis by a pre- This sleeplessness, like the vertigo we have mature oxidation. The aborted proteids already considered, is often induced by par- only furnish so much waste matter, which ticular articles of diet, or by some unwhole- the system must get rid of as excrementitious some combination of them. What will ex- material. Instead of so much pabulum to cite headache, giddiness, or disorders of the the tissues, there is only so much waste mat- circulation in some patients, will in another ter to be eliminated. cause sleeplessness. Sometimes, however, The management, medicinal and dietetic, of this symptom will occur when the patient is thiscondition willbe given in the next chapter. 56 INDIGESTION AND BILIOUSNESS. A less pronounced condition than this just positive expression of opinion, clear and de- described, has been commonly seen in the cisive. recent east winds, whieh proved so disastrous These deposits in the urine are, then, sig- to the late Lord Beaconsfield ; and in the nificant of disordered functions in the liver. persistent north-east wind which prevailed They belong to indigestion proper. They throughout May, 1880. were held, are perhaps held still by some, to They found out every person who “ had a be the evidencesof kidney disease. “Gravel” liver,” without respect to persons. Patient of course indicated kidney mischief, and after patient at the hospital had to have the “sand” was a form of gravel! Diuretics plan of treatment arrested for the time, in and potash gave relief, and these agents favor of one adapted to the intercurrent state acted upon the kidneys; could. the evidence of liver disturbance. Private patients re- be more complete ? Yes, it is true that to quired the same “change of front.” The give potash is to give relief. With potash east wind finds out the liver, albeit it lies uric acid makes a most soluble salt, and in snugly ensconced under the diaphragm and such combination uric acid is readily drained protected by the abdominal walls ; and the out of the blood. expression “a bilious chill,” extends from Toillustrate the action ofpotash.it is enough an acute condition, resembling a cold in du- to add some liquor potassae to a specimen of ration, to a more persisting state. Nor is urine turbid from lithates; it quickly clears. the expression an undesirable one, though it The stronger base potash ousts the soda and Las been sharply criticised by some. The ammonia from their union with the uric acid, patient complains of malaise, of incapacity forms with it a soluble salt; and the turbid for exertion; bodily toil is taxing, mental urine becomes clear. Could anything be work is irksome; they are unfitted too for more delightfully simple! their usual occupation. The bowels are But it is not the mere excretion of uric acid more or less'disturbed, loose or constipated, that we have to deal with; it is the more im- there is a bad taste in the mouth, and the portant as well as more remote matter, its tongue has more or less a brown-hued fur formation in the system, which we wish to in- upon it. The urine is either high-colored fluence. To go back to our analogy of the and dense, or laden with lithates, according thunder-storm, it is not enough to study the as the liver is capable of converting the nitro- lightning and the thunder; we must proceed genized waste into urea, or only splitting up to investigate the genesis of the storm, to the peptones into uric acid and urates. consider the forces which brought it about. Here again the nutrition was affected and To dissolve out the offending uric acid by the peptones diverted from their normal potash, is like putting up a lightning con- course and turned to destruction—wrecked ductor—a very useful thing in its way; the on the way, indeed. In all cases iron and utility of which I have no wish to under-esti- tonics had to be withdrawn, and hepatic mate. But no simile runs on all-fours: and stimulants and laxatives, with a restricted though the administration of potash may be dietary substituted therefor. It was clear analogous to the lightning-rod, we can influ- the liver was incapacitated for the time from ence the genesis of the lithiasis; if we can- taking any part in the elaboration of the not yet, in the present state of our knowl- crude products produced in the digestive edge, exercise any control over the produc- canal. In some cases, but not in all, there tion of the thunder-storm. A little while was some pain and distension experienced in ago, we knew no more how to do this, than the region of the liver. In all, without ex- we yet know how to abort a thunder-storm. ception, there was more or less of that cere- It has long been held that uric acid is the bral irritation, that mental disquietude, poison of gout; and Prof. Garrod has de- which has been described earlier on as being monstrated that it is “ gout poison,” par ex- the outcome of disturbance in *the function cellence. But while granting this, there is a of the liver. form of indigestion of which the abnormal formation of lithic acid and lithates is a prominentsymptom, which should rather be CHAPTER XI. classed under the head of “liver indigestion” that of The PHENOMENA OF LIVER DISTURBANCE (Con- than “gout.” two overlap, and the old phrase “ liver and kidneys,” if vague, tinuea).—liver indigestion. was certainly not inaccurate. To formulate When Dr. Murchison delivered his Croo- “ what is gout?” I should make the essay nian Lectures before the Royal College of to this effect:—Gout is due primarily to Physicians, and came to the subject of “Ab- functional derangement of the liver in the normal Disintegration,” he said: —“ I need splitting up of albuminoids; the blood is sur- not remind an audience such as that which I charged with nitrogenized waste, and this in have the honor to address, that deposits in time leads to structural changes in the kid- the urine of lithic acid, or lithates, are not neys ! But there is a form of lithiasis, which due to any morbid condition of the kidneys. is more properly to be considered a liver de- What I wish to insist is. that the frequent rangement than gout. “Gout” is a term occurrence of these deposits in the urine which will be made to embrace a wide area ought always to be regarded as a sign of in Part II.; and it need not be unduly ex- functional derangement of the liver, arising tended by including “ liver indigestion” un- from causes, sometimes temporary, at other der that heading. When gout is described, it times more or less permanent.” This is a will be necessary to revert to this matter, but PHENOMENA OF LIVER DISTURBANCE. LIVER INDIGESTION. 57 it need not further engage our attention at questioned, however, whether the expression! the present stage of the inquiry. —“ in each there is defective oxidation”— In speaking of uric acid, M. Foster says: doesnot require a little explanation. “De- —“ Tbis, like urea, is a normal constituent fective oxidation” is found in both states,, of urine, and, like urea, has been found in but the conditions do not depend for their the blood, and in the liver and spleen. By production on defective oxidation solely;, oxidation, a molecule of uric acid can be split there is the perverted metabolism as well. up into two molecules of urea, and a molecule But both are outcomes of liver disturbance,, of mesoxalic acid. It may, therefore, be linked with defective oxidation; and the of- spoken of as a less oxidized form of a proteid fending matters are alike of albuminoid ori- metabolite than urea; but there is no evidence gin and descent. whatever to show that the former is a neces Uric acid, as has often been pointed out,, sary antecedent of thelatter; on the contrary, is found alike in birds of a high temperature, all the facts known go to show that the ap- and in cold-blooded reptiles; and, therefore, pearance of uric acid is the result of a meta- is not due to defective oxidation merely. It bolism slightly diverging from that leading to is rather the form of excreted urine solids, urea.” It must, then, be regarded as the suited to “solid” urine; while urea is the “ product of perverted metabolism in the liver. form found in fluid” urine (M. Foster). Prout held uric acid to have another source Dr. Henry Bennett, in his valuable work on. than urea, to be formed largely from the “Nutrition in Health and Disease,” 2d gelatinous forms of our albuminoid food, Edit., 1876, writes: “ I have repeatedly al- while urea was held to be derived from ordi- luded to the presence of morbid salts in nary albuminoid matters. This view was the urine as a result and an evidence of im- soon abandoned, and it was thought uric perfect digestion. I believe their presence acid was a normal product, viz., a sort of to be the most delicate and most easily recog- nitrogenized waste preceding urea and con- nized test that we can bring to bear in the verted into urea by further oxidation, or by diagnosis of defective digestion; and I am a splitting up into urea and oxalic acid. Now also of opinion that its value, though recog- we regard it as a product of perverted meta- nized, has not been fully appreciated by the bolism in the liver. The appearance of lith- profession. They consist principally of uric ates in abundance in the urine about the acid, urate of ammonia, purp'urine or color- time when the liver is actively engaged in ing matter, oxalate of lime, the triple phos- the digestive process, renders it highly prob- phates, the neutral phosphate of lime, pus able that certain peptones, instead of under- or blood globules, epithelial scales, and fi- going further elaboration are turned aside, brinous casts of the uriniferous tubules of the and broken up prematurely into lithic acid kidney.” Thus we see uric, or lithic acid,, and lithates. That these lithates do not in alone, or combined with ammonia, stands, any way represent tissue waste, for they first, and after that the phosphates. “ Phos- have never been tissue ! They stand in the phatic deposits are principally observed in same relations to the tissues that a still-born those persons in whom the nervous system child bears to an estate that it would have in- has been too greatly and too continuously herited had it been born living and viable. So used, and the general vitality thereby low- the material which forms uric acid might ered. When this is the case, there is of have been tissue under more favorable cir- course a more rapid disintegration of the cumstances. Such is the position, to put it phosphatic salts which enter so largely into- broadly. the structure of the brain, and of the nerv- Now as to the clinical relations of these ous system generally. The acid phosphate, lithates, the outcomes of perverted meta- which, by its reaction on the triple phos- bolism in the liver, in other words, the pro- phate and the phosphate of lime in the ducts of “ liver indigestion.” In the article healthy urine, secures its solution, is no on “biliousness,” referred to before in the longer in sufficient quantity to prevent the earlier section of this article, is written : precipitation of the abnormally abundant “ Biliousness may take one of two directions. phosphates, and they are thus more or less In some persons there is the regular bilious copiously deposited.” It is not yet possible attack —headache, furred tongue, disturb- to say very much on this subject, but the re- ance of the alimentary canal, vitiated stools, lation of phosphatic deposits to disturbance and fullness over the hepatic region, the in the nervous system stands in a most sug- urine being merely high colored. In others, gestive relationship to the formation of again, there is rather a dyspeptic con- lecithin, the phosphorus of which is nor- dition, with the appearance of lithates in mally derived from the phosphates of our the water, especially two or three hours food. Further than this may not be af- after a meal. There is no essential difference firmed. betwixt the two; in each there is defective He proceeds in this matter by making the oxidation. But in the one the bile acids observations: “Sufficient time, also, must seem to preponderate, while in the other the be allowed to pass for the processes of diges- urinary products of nitrogenized waste take tion to be accomplished and for the chyle to the leading place. The first is rather the reach the blood. As soon as the chyle has condition of the congenitallybilious, the lat- reached the circulation the kidneys commence ter of the congenitally gouty.” This divis- their functions of filtration and elimination if ion, further experience corroborates, and it it is unfit for assimilation. This eliminatioa seems really a fairly correct one. It may be they continue until the blood is thoroughly 58 INDIGESTION AND BILIOUSNESS. purified. Thus, for some hours after the in- A view which has much to recommend it to gestion of food by a dyspeptic patient, the the attention of the profession. urine will remain clear, because the chyle He proceeds—“ Uric acid crystals are found has not reached the circulating fluid. Then more or less abundantly under the same cir- for a longer or shorter time it becomes tur- cumstances as the double urates, and often in bid, and throws down in cooling a deposit of the same patients. I have in vain endeavored, pinkish, orpale hue owing to its being loaded in some cases, to find a distinct cause or with urate of ammonia. In the same speci- reason for their absence, as also their ap- men will constantly be found, on microscopi- pearance and disappearance in the same per- cal examination, uric acid, oxalate of lime, son. Their constant existence undoubtedly or phosphatic salts. After this it again be- indicates a more decidedly depraved state of comes clear, because the blood has been puri- the digestive functions, and a more debili- fied of the impure chyle, and the urine has tated, broken-down condition of the general reverted to its normal character.” Here we health than is shown by the presence of urate see Dr. Bennett speak of the higher pro- of ammonia alone. It is frequently ob- cesses of digestion, viz., when the matters served in persons presenting the gouty or rendered soluble by the digestion in the ali- rheumatic diathesis or constitution.” We mentary canal, have entered the blood as will follow Dr. Bennett to his conclusion: “chyle.” A younger man would probably “ I am thus disposed to think that the pres- use a more modern nomenclature. He goes ence of uric acid and of lithates in the urine on: “ Such being the case, to test the di- in such abnormal quantities as to constitute gestion of food by the state of the urine, we a deposit is very much more frequently the must examine that which is secreted by the result of defective digestion than defective kidney during the hour or two which follows metamorphosis of tissue, especially in dys- the completion of digestion, and the entrance peptic individuals. -This is not the generally of the chyle into the blood. This period received opinion, but that it is really the case varies, of course, according to the length of appears to me evident, from the circumstances time that the food ingested takes to digest, that I am able, in the majority of such cases, which itself varies, as we have seen, accord- to trace them to the food digested a few hours ing to the nature of the food and according previously, and that they disappear from the to individual peculiarities. Milk, eggs, vege- urine secreted after a long fast.” Dr. Ben- tables, fish, etc., take about two hours, so nett has made such careful study of the mod- the urine should be examined two or three ifications produced in the urine by indigestion hours after their ingestion. Fowl, game, that I put his views before the reader at beef, veal, etc., take from two to three or some length, believing them to be worthy of four hours. With some persons the stoma- all attention. chal and intestinal digestion is so slow that a Dr. Murchison delivers himself as follows, much longer time elapses before the chyle as to the production of uric, or lithic acid, reaches the blood, and is thus abnormally and lithates. eliminated by the kidneys. In others the “ Excluding those cases in which deposits digestive processes, on the contrary, are very of liihic acid or lithates are thrown down in rapid, and the morbid deposits must be the urine, not until twelve or twenty hours sought for at an earlier period.” after its emission, as the result of sponta- It will now be clear and intelligible to the neous changes, to which Scherer has given reader why I did not discuss the urine and the name of acid urinary fermentation, and its modifications earlier on under ordinary those which are due to a marked deficiency indigestion. Urine deposits belong to that of urinary water, deposits of lithic acid, lith- part of the digestive act which goes on after ates and abnormal pigments, which appear in the soluble matters have entered the blood ; the urine as soon as it cools, are chiefly met not with that part which relates to rendering with under the following conditions: the food soluble. They have entered the 1. In febrile diseases, in which we know blood, and here the digestive act in the ali- that the liverbecomes enlarged and congested, mentary canal has performed its part, and is and its gland-cells loaded with minute gran- over and past. It is with the metabolism ules, and in which there is always an in- after the products of digestion have entered creased disintegration of albuminous matter. the portal circulation that urinary deposits Every one, for example, is familiar with the are concerned. Therefore they do not be- copious deposits of lithates, which are socom- long to the first forms of indigestion, but to mon during an attack of ordinary febrile ca- the latter, or “ liver indigestionand must tarrh. be considered in the section devoted to this 2. In many structural diseases of the liver, last matter and its disturbances. Conse- and particularly in those which are character- quently, as Dr. Bennett insists, a certain ized by an increased amount of blood in the time must be allowed to elapse after a meal organ, such as inflammation, cirrhosis, can- before the urine is examined for the mal- cer, and simple hyperaemia, whether mechan- products of disordered assimilation. He ical or active. holds that even in pyrexia the deposits of 3. In functional derangement of the liver, lithates, so well known at the breaking of a either temporary or persistent. common cold, “ is in a great measure owing Lithuria, like glycosuria, is very often due to the imperfect indigestion and assimilation to a functional disease of the liver, although of the food given, and not to the retrograde even glycosuria is still ranged in some text- metamorphosis of the nitrogenized tissues.” books with albuminuria and diseases of tfie PHENOMENA OF LIVER DISTURBANCE.—LIVER INDIGESTION. 59 kidney. In other words, abnormal disintegra- urate deposit. Functional derangement of tion of albuminous matter in the liver may the digestive organs are also generally ac- lead to a morbid condition of the blood and companied by pale urate deposits in the of the entire system, which often manifests urine.” (W. Roberts.) This is an observa- itself in lithuria.” tion not without much clinical value. Many Now a very well marked instance of the old practitioners observe the color of the second division of Dr. Murchison, including urine deposits very carefully. There is a ■“ simple hyperaemia, whether mechanical or general consensus of opinion that the pale- active,” is seen in the urine in cardiac colored, chalky-looking deposits are found •dropsy. along with indigestion, especially those de- As the heart fails in power the bulk of posits found from two to five hours after a urine falls pari passu. The bulk of urine is meal, as described by Dr. Henry Bennett. in strict proportion to the blood pressure On the other hand, deep-colored pink, or •in the arteries; and this, again, to the even crimson deposits are rather found usu- vigor with which the heart pumps the blood ally in old gouty subjects, at least, in my ex- into the arterial system. When the heart be- perience. Nor is the matter to be dismissed gins to fail the blood is less vigorously as of little or no practical importance. pumped into the arteries, the blood pressure The production of bilirubin, or the non- •then falls, in the kidneys as elsewhere, and production of it, may depend upon states with it the bulk of the urine—in other words of the liver which differ considerably. the amount of water passed. This morbid While not wishing to be too precise, it may •change may proceed a considerable length be said that in acute liver indigestion there without the urine being otherwise altered is little bilirubin found from which the urine than being scanty and dense or concentrated. coloring matter is derived; in old gouty cases But when the liver become involved in the it is freely produced. This may indicate a venous fulness and begins to enlarge from difference in the metabolism going on in the passive congestion then the urine changes. liver. Again we approach the border lands, It now contains lithates in abundance, fawn- the frontier of the agonosphere—the un- colored or pink, sometimes more than pink. known which possesses so much interest for The congestion of the liver interferes with its us. Uric acid is generally regarded as indi- functional activity and then lithates appear cating another state of affairs though Dr. in the water, the proof of the derangement of Bennett thinks it a difference of degree indi- the liver. cating a more pronounced morbid state; This is the more liable to happen when while Roberts remarks as follows: “ There the plan of treatment adopted is a very “ sus- is this difference between the conditions fa- taining” one. The patient is encouraged to vorable to the deposit of free uric acid and the take the most strengthening “ things;” that amorphous urates—that a high density (or is, albuminoids in as great quantity as possi- concentration) favors the latter and a low ble, and then the crippled liver is unequal to density (or dilution) favors the former,” carrying on the ordinary metabolism and thus making it largely a matter of solution or lithates make their appearance. The asso- density. This difference of opinion illus- ciation of such lithates with the disablement trates that the subject is as yet far from being i(more or less) of the liver ought to be made a settled definitely. point of importance in the dietetic manage- Connected with the relations of the urine ment of the case. In the face of such evi- to conditions of functional disorder of the dence it is of the most questionable utility to liver stands azoturia or baruria, as it has been force albuminoids upon the patients when termed by various writers, in which there is the liver is thus evidently unequal to dealing an excess of urea in the urine. Prout first with them, and the dietary should be modi- described it and Willis followed him. Prout fied and made proportionate to the reduced divided these cases into “excess of urea power of the liver gorged with venous blood. without diuresis and excess of urea with Of course a dense urine is apt to deposit diuresis. ” In the first, though there is great urates after being passed sometime, espe- susceptibility to derangement, as well as to cially in cold weather. But still there is the actual disease of the assimilating and other ■difference betwixt the dense, high-colored functions, I am not aware that any one de- urine, which remains clear for a considerable rangement of any one organ can with cer- time, and the urine which becomes turbid tainty be pronounced to be characteristic of with urates shortly after being passed. The an excess of urea in the urine. In the sec- latfer tells clearly of functional embarrass- ond, modifications of the disease, in which ment of the liver. the quantity passed is excessive; besides most As regards the color of the urates thrown of the symptoms above enumerated in an ag- down much might be said. “The frequent gravated form there exists, in addition, more or constant occurrence of a brownish or red or less of thirst and morbid craving after urate deposit without or with only a feeble food. The patient likewise complains of degree of pyrexia is a circumstance to awaken general coldness and great bodily weakness. suspicions of some serious organic disease; In some instances also there is considerable but the indication is more general than emaciation, though not to the same remark- special. Organic disease of the lungs, heart, able extent as in diabetes. The causes pre- liver, spleen or other part attended with disposing to an excess of urea in the urine emaciation and waste of the tissues is usually seem to be nearly allied to those predisposing accompanied with abundant deep-colored to diabetes. Most of the subjects of the dis- 60 INDIGESTION AND BILIOUSNESS. ease in the forms above described have been a train of nervous symptoms,—turned out, on middle-aged men of spare, thin habit, with a more exact investigation, to want a special sort of hollow-eyed anxiety of expression feature indicated by Prout as the essential on their countenance, unusually nervous and one; namely, an absolute increase in the susceptible, but by no means always hypo- daily discharge of urea. Nevertheless, some chondriacal ; and also free from gout, and, facts, rarely observed, have left an impres- as far as could be ascertained, from struc- sion on my mind that Prout’s description is tural disease of the urinary or any other or- not altogether fanciful.” He then gives gans. With respect to the proximate cause notes of a case, where more than 500 grains or intimate nature of the disease, I have been of uiea were passed daily. In this case, as long of the opinion that it depends upon de- in Parkes’, there was a trace of sugar pres- rangements of the secondary assimilating pro- ent. As to the causation of these cases, Dr. cesses, rather than the primary.” Having Roberts says:—“ In the case just related, the related a case at some length, where the pa- cause of the complaint was mental anxiety; tient so largely recovered as to be practically and in all the instances which I have been well, he goes on: “ The second case I shall inclined to pass in this group, the origin of recite is one that occurred to Dr. Elliotson, the disorder could always be traced to some at St. Thomas’s Hospital; who furnished me kind of mental emotion.” with the urine for examination every week, Perhaps Prout was not far astray in re- so as to enable me to ascertain the effects of garding such cases as pathologically related the remedies employed. March 5th, 1819. to diabetes; and Roberts admits: —“ That Rodman, aged fifty-five. Symptoms re- there is some relation between the two con- sembling diabetes. There is a constant crav- ditions seems not improbable.” Dr. Hand- ing for food, a sense of coid over the whole held Jones has described six cases of like body, and a frequent desire of passing urine, disease under the' head of Baruria, Brit. which, in twenty-four hours, amounts to Med. Jour., Oct 12th, 1861. While the late sixteen pints. The urine of this man was Dr. Fuller, without acquaintance with what pale-colored; its specific gravity was 1.020; had been done by Prout and others, brought and it contained a very large proportion of before the Medico-Chirurgical Society, papers urea; but not the least particle of saccharine ‘ ‘ on Excess of the Urea in the Urine as a Guide matter. On standing, it also deposited crys- to Diagnosis and Treatment of Certain forms tals of lithic acid. Orderedopii.gr. 1 x/2 bis of Dyspepsia,” (Trans,, Vol. 40, 42, and die, (opium in this case was ordered by Dr. 51); in which he described similar cases. E., on the supposition the disease was dia- Passing through all of them was, then, a his- betes). March 20th. —Feels much better. tory of nervous trouble, which gave them a Urine reduced to two pints in twenty-four certain character and generic resemblance. hours. Pergat. The urine was now some- They stand in an interesting and suggestive what deeper colored; and deposited a copi- relationship to the excessive quantity or urea ous sediment consisting partly of lithic acid found in the urine in the early stages of crystals, and partly of lateritious sediment. chorea. Its specific gravity was increased to 1.034; In connection with this subject, closely evidently from its having become more con- linked thereto indeed, stands albuminuria. centrated than natural. The quantity of urea The presence of albumen in the urine is was abundant, but not in the proportion in usually regarded as the evidence of disease of which the urine was concentrated. the kidney. It is not necessary to discuss The man became so well shortly after the whole subject here ; it is enough to say the above date, that he did not return to the that it is much easier to detect the presence hospital till August 19th. Disease returned of albumen in the urine than to know what six weeks ago. Feels as ill as ever—very it means, or what its significance is when it weak. Bowels costive. Quantity of urine is found. The student is taught the various in twenty-four hours, about four pints. Or- means by which a trace of albumen may be dered opium, as before. The urine was now demonstrated in the urine ; but he is not transparent. Its specific gravity was 1.023, taught, and in the present state of our knowl- and urea was abundant. Under the above edge, there is no one who can teach him what plan he speedily became better, and soon af- its precise significance is when found. We terwards ceased to attend the hospital.”— know that in certain conditions its presence (On the Nature and Treatment of Stomach is of the most sinister omen ; we have learned and Urinary Diseases; being an Enquiry into that at other times it is devoid of significan«e. the Connection of Diabetes, Calculus, and I shall here review merely its relation to dis- other Affections of the Kidney and Bladder, turbance of the digestive organs. Such rela- with Indigestion, 3rd Edit., 1840”), Wm. tion of albuminuria was entertained by the Roberts thinks, “ precise facts in support of late Dr. Parkes, who “ inclined to the opin- Prout’s view are wanting;” but refers to a ion that the liver plays an important part in case recorded by the late Dr. Parkes, (On the development of albuminuria ; he thinks, the Composition of the Urine, p. 374), where through some failure in preparation, either a man, on the ordinary diet of University by the stomach or the liver, albumen enters College Hospital, passed 1130 grains of urea the right side of the heart, still in a crude daily, and concludes thus: —“ In my own ex- state, and in a condition similar to that in- perience, I have usually found that cases troduced into the jugular vein in Bernard’s which at first sight appeared to belong to this experiment.” (Claude Bernard found that category—cases exhibiting a dense urine and crude albumen injected into the jugular vein PHENOMENA OF LIVER DISTURBANCE. LIVER INDIGESTION. 61 produced temporary albuminuria.) It is there is good reason for believing it to be so; well known that if two or three raw eggs are the albuminuria being unattended by any eaten at once, albumen makes its appearance other symptom of renal disease, varying in the urine. It would seem that here the greatly in quantity and sometimes absent;, quantity of crude albumen passing from the and the urine being of normal quantity, of alimentary canal into the blood, overruns the high specific gravity, and habitually loaded power of the liver to deal with it, and a cer- with lithates, lithic acid, oxalates, and pig- tain portion passes through the liver in its ments; and there being very often cutaneous' crude state, and as such escapes through the eruptions, dyspepsia, and other evidence of kidneys. The late Dr. Basham, in discuss- hepatic derangement. I have met with sev- ing the presence of albumen in the urine, eral instances of this sort, where the patient wrote : was subject to severe attacks of what at first “ There is yet ano'her subject of interest seemed to be hepatic colic, but where there connected with the long continuance of albu- was no jaundice, and the paroxysm was follow- men in the urine ; associated as it universally ed by a temporary yet extraordinary increase is with a diminution of the urea, the leading of lithates and albumen in the urine. Lastly, characteristic of healthy urine. Can it be so often have I observed albuminuria, as- said in these cases that the albumen is the sociated with hepatic disorder which has pathological substitute for urea? The fact disappeared completely and permanently cannot here escape notice, that cases fre- when this has been set to rights, that I quently occur in which the urine continues have little doubt that we have in the liver for months, and even years, persistently al- a cause of albuminuria, to which attention buminous. I know two cases of near four has not yet been sufficiently directed. The years duration, the patients’ health being pathology of the albuminuria in these cases, fairly re-established ; all the chief functions may be similar to that of certain cases of being performed with undeviatingregularity, diabetes already referred to, the liver hav- and with no obvious disorder, except in the ing too much work to do, and permit- composition of the urine. The character of ting some albumen to pass through in a- this being the presence of albumen, with form which cannot be assimilated; or pos- diminution of urea. Although we are as yet sibly there may be some defect in the de- without proof, yet it has appeared to me structive functions of the liver, in conse- probable, that the albumen in the urine (in quence of which the albuminous matter, in- these long standing cases) must, in some way, stead of being converted into urea, does not take the place of urea, and become, as it even reach the stage of lithic acid. It is pos- were, its pathological substitute.” sible that in many of the cases now referred The remarks of the late Dr. Murchison to, the albuminuria may indicate an early are so replete with knowledge, and given stage, not yet described, of the contracted or with such judgment, that it appears better gouty kidney; yet it is certain that the symp- to give them verbatim than to attempt to tom may persist or recur, during many condense them. “ There are also reasons years, without any symptom of renal disease, for believing that albuminuria may be in- and with but little impairment of the general- duced by hepatic derangement independently health.” of structural disease of the kidneys. It is What Dr. Murchison says here, should be now generally acknowledged that albumin- well weighedby every practitioner. I en- uria, even when copious, and in the absence tirely agree with what is said; and for of any acute febrile disorder, does not neces- some time past I have treated certain- sarily indicate renal disease, Very often, in cases of albuminuria by a farinaceous these cases, the albuminuria is intermittent non-nitrogenized dietary, with the best or remittent, and the albumen has peculiar effects; the patient feeling better, along chemical characters; the previous addition, with a corresponding diminution of the for example, of a few drops of mineral acid, amount of albumen in the urine. It will not- preventing to an unusual extent the sub- do in practice to run away with the idea that sequent coagulability by heat. Errors in albuminuria is pathognomonic of renal dis- diet are one of the most common causes. In ease; to do so is to alarm the patient unneces- some persons, peculiarly constituted, tem- sarily, and when time has disproved the- porary albuminuria is a constant result of doctor’s vaticinations, to bring him individu- certain articles of food, such as uncooked ally and the profession generally into disre- eggs. In several instances I have known pute. Nor is it possible to plead that the the urine passed at night to contain albumen, present views of the infallibility of the test often associated with lithates and a high tube are justified by our experience; laziness specific gravity, whereas the morning urine and indifference are too large factors in the was clear, of low specific gravity, and present attitude of slothful satisfaction and contained no albumen. Again, in certain blind confidence in the chemical test to enable cases of exophthalmic goitre the urine, at it to be said that the position is excusable. some hours of the day, usually after Having often elsewhere entered my opinion food, is loaded with albumen, whereas at on this subject in writing, and protesting others it contains none; and this state of against the abject attitude of the profession matters may last for many months, and then at large, to objecting to reason on the phe- completely disappear. Now, it is not con- nomena, but accepting the presence or tended that in all these cases the liver is the absence of albuminuria as full, ample and organ primarily at fault, but certainly in some complete proof of the state of the kidneys— 62 INDIGESTION AND BILIOUSNESS. of the presence or absence of disease in them tack was set up by “ the actual presence in —I feel it desirable here to transcribe the the vessels of the lungs of the materials taken views of others, men whose opinions are up from the stomach and intestines.” He entitled to the greatest respect. One word pointed out how an attack provoked by a full more: “ Usually the whole albuminous con- meal taken late in the day, could be averted; stituents of our food are so transformed in the if the sufferer would sit up instead of going stomach, intestines and liver that no albu- to bed until the hour of attack was passed. minous substances of the kind which can By so doing, the respiratory centre could pass through the kidneys get into the general better and more successfully resist the irrita- •circulation. But if one takes such a quantity tion set up by the irritant material. The of eggs as to completely overtask the digest- fact that if a certain hour or period could be ive powers the egg-albumen will pass un- so passed, the attack did not come on, is changed into the blood and be excreted by suggestive. It was not postponed; it was the kidneys. Other albuminous substances, averted. Awake, the poison was inopera- the products of intestinal digestion, and pep- tive, asleep, it certainly set up an asthmatic tones also, occasionally make their appear- paroxysm. This certainly connects it with ance in the urine as egg-albumen” (Lauder the latter portion of the digestive act; while Brunton). its association with a full meal renders its From what has been said above it will be connection with the digestive act all the more abundantly clear to the reader that the per- certain. Dr. Murchison says:—“Asthma, versions of the metabolism of albuminoids in like gout, is an heredi ary disease; it is com- the liver are very interesting in relation to the mon among persons springing from a gouty presence of lithic acid and lithates, of excess stock; it is not unfrequently associated with of urea, and even of crude albumen in the gout, gall-stones, or other hepatic derange- urine. All, separate or combined, may ments in the same individual; and attacks of be so produced without kidney disease asthma have been known to alternate peri- necessarily being present, or even be- odically with attacks of gout. Moreover, an ing the consequential result for a very asthmatic paroxysm, like an attack of gout, considerable time. (1.) Crude albumen of vertigo, or of sleeplessness, is often excited may pass unchanged in the liver into by a fit of indigestion, and by the use of par- the general circulation and pass out by ticular articles of diet.” the kidneys. (2.) The metabolism may take They are related to those attacks of what the direction of an excess of urea. Or (3) the Basham called “inexplicable dyspnoea,” splitting up of albuminoids may result in the found in the subjects of chronic gouty kid- production of a large quantity of lithic acid, neys. It may, however, be questioned wheth- usually in combination with ammonia or er any irritation is conveyed up the pneumo- soda. Such conditions may be temporary, gastric nerves to the medulla,—an hypothesis as the result of “acute liver-indigestion;” or which has been violently stretched to explain they may be less pronounced, but permanent, a variety of respiratory affections; but rather and then, in the language of George Johnson, by a direct action of the products of abnorm- “ renal degeneration is a consequence of the al digestion in the blood, upon the respira- long-continued elimuiation of products of tory centre. At other times, bronchitis faulty digestion though the kidneys.” seems to be induced; while chronic bronchi- Such then is the production oflithiasis. But tis is a very common occurrence in chronic in the full consideration of this subject we gout; at times, not unfrequently, an attack must include the disturbances which this of acute bronchitis takes the place of a gouty “ waste-laden” blood produces in its wake. paroxysm. In Part II. the matter of consequential renal Disturbances in the Heart are very com- changes will be discussed at length, together mon. There is palpitation, which is not that with the changes in the heart, arteries and form excited by gas in the stomach, or trans- other organs, i. e,, the phenomena of gout or verse colon, pressing up the thin diaphragm lithiasis. Here it will be sufficient to re- against the heart, and by its “ elastic pres- view the symptoms and disturbances sure ” interfering with the heart’s movements; which belong to acute conditions of a well-known form of palpitation. The pal- lithiasis, or lithsemia (Murchison’s pitation of lithsemia is not always felt along term), provoked by “liver-indigestion;” or with flatulence, but irregularly, as regards perversion of metabolism in the latter portion its connection with meals. It is casually of the digestive act, as seen in persons who linked with imperfect assimilation and evi- are not the subjects of confirmed gout. dences of waste in the blood; with a high ar- Asthma. —This is one of the outcomes of terial tension, and at times, with an ill-fed or nitrogenized waste being present in excess in half-starved heart; andits origin is the same as the blood; especially nocturnal asthma. This that of the imperfect angina pectoris vaso- is not to be confounded with the asthma motoria, to be spoken of a little later on. which is set up by some irritation with swel- Then there is irregularity in the heart’s ac- ling of the bronchial lining membrane, often tion, allied to that spoken of in p. 190, in the result of a cold. It comes on suddenly which the heart’s action is depressed; in in sleep, after a late meal. Dr. Todd other cases there is irregularity in the volume thought that there was a materies morbi as well as the rhythm of the pulse; or there which acted through the pneumogastrics may be intermissions, with or without flut- upon the respiratory centre in the medulla. tering of the heart’s action. In others, Dr. Hyde Salter was of opinion that the at- again, there is pulsation of the abdominal PHENOMENA OF LIVER DISTURBANCE.—LIVER INDIGESTION. 63 aorta. Dr. Baillie drew attention to this ingestion of food is followed by the forma- subject long ago, in a paper entitled “Upon tion of lithates, they become aware of their a Strong Pulsation of the Aorta in the Epi- presence as soon as the urine reaches the gastric Region,” and Sir Charles Scudamore bladder, owing to the sudden pain they oc- in his work on “ Gout and Gravel, and Gen- casion. I have attended many patients suf- eral Observations on Morbid States of the fering from irritable bladder from this cause, Digestive Organs, 4th Edit., 1823,” wrote: who have been erroneously thought to labor “ The pulsation in the epigastric region, under stone, stricture of the urethra, or in- which is sometimes felt to an alarming de- flammation of the neck of the bladder.” He gree, by dyspeptic persons, is seldom met says that fibrinous casts of the kidney tub- with in persons who are subject to acute ules are sometimes found. “ Their presence gout.” It is frequently found during the is generally considered to indicate severe ir- time of the digestive act, mostly in persons ritation or even disease of the kidney. Mere of a highly developed nervous system; and fibrinous casts, however, not containing oil is unaccompanied by any severe disturbance corpuscles or epithelial casts, are constantly of the general health. “ The undue pulsa- present in simple cases of dyspepsia, in tion in these cases is often subdued by treat- which the kidneys are evidently neither the ment directed against the liver,” (Murchison). seat of great irritation, nor ofactual disease.” Angina Pectoris.— This is quite a common He concludes: “When morbid deposits in malady with those who suffer from “liver in- the urine, the result of defective nutrition, digestion,” and is not unfrequently met with are thus the cause of irritability of the urina- in the sons of fathers who have died of ang- ry organs, it is vain to hope for relief until ina, and who may themselves die of angina the digestive functions been restored to in advanced life, when their heart-walls be- a more healthy state, and until the urine has come the seat of fatty degeneration. From ceased to be loaded with the lithatic salts. the researches and observations of Eulen- The latter keep up constant irritation in the berg, Nothnagel, Lauder Brunton and oth- bladder and urinary passages, in the same ers, we have learned that angina pectoris is way as sand constantly thrown into the eye not a neuralgia of the heart, as thought by would keep up irritation or inflammation of Ileberben and those who have followed him, the conjunctiva.” so frequently as a vaso-motor affection. It Lithic acid teases the whole urinary tract is due to spasm of the small arteries, excited from the tubules of the kidney, which are by the irritant presence of nitrogenized waste not rarely found blocked with small calculi in the blood in excess. This causes a high of lithic acid, to the meatus itself. This ir- blood-pressure in the arteries which may ritant urine often excites pruritus vulvse, or provoke an attack of palpitation or of angina even an eczematous condition of the genitals. pectoris vaso-motoria, as the case may be. Such is the direct effect of the presence of As chronic states, hypertrophy of the left lithic acid. ventricle and atheroma of the arteries are set Skin Affections are common; and pruritus up by this spasm. When the gouty heart ani, with or without eczema, is sadly com- passes into the stage of failing hypertrophy mon in liver indigestion. General pruritus, from fatty degeneration, these attacks be- or itching, is found in jaundice, or in lithse- come vt ry serious. The rotten heart-walls mia, and is an outcome of blood-poisoning fail, and angina is as grave then, as it is com- by the products ofindigestion. Urticaria is comparatively free from danger while the so associated, as is eczema, some other skin heart-walls are structurally sound. If the affections, and also boils and carbuncles. reader wishes to pursue this matter further, Diabetes is also accompanied by phlegmon- he will find it discussed in a chapter of its ous or carbuncular inflammations. A sug- own, in my work On the Heart and Its Dis- gestive relationship! eases (2nd edit., 1879). Nervous Symptoms.—Upon no tissue does The tendency to arteriole spasm is evi- the lithic acid exert a more irritant influence dencedby the hands “ dying” at times, or the than upon the brain cells, and of this the feet being painfully cold in the subjects of most prominent is disturbance of temper. lithiasis. The most constant symptom, in my mind, is The tendency of vitiated states of the blood, irritability of temper, in conditions of lithae- when laden with lithic acid and lithates, to mia. Even naturally good-tempered persons produce inflammation of the veins, is rec- get cross, irritable, peevish, and waspish, ognized by Sir James Paget (on gouty and when their blood is so poisoned. With some some other forms of phlebitis). It is, how- who are indolent, this toxaemia may spur ever, rather found in acute paroxysms in them into activity, if the blood is at the same those who suffer from gout. When the time well-fed; and these are usually stout, urine is laden with these productsof perverted well-nourished persons. But in others, metabolism, it possesses irritant qualities. where the brain is ill-fed, as well as poisoned Gouty urethritis simulating gonorrhoea, is no by lithates, the results are far from pleasing. rare affection; or chordee, or even orchitis In the first edition of my work On the Dis- may be so excited. Stone in the kid- eases of the Heart (1872) is written: “It ney or bladder is often found in per- would often be satisfactory and agreeable to sons generally well, entailing their own explain anomalous and indefensible acts by symptoms; or as Dr. Bennett writes: “ I have this theory, and to lay some of human frailty met with some patients so extremely sensi- to the charge of uric acid.” To this is ap- tive in this respect that even in health, if the pended a foot-note, evidently inspired by 64 INDIGESTION AND BILIOUSNESS. some recent experiences, the memory of maimed condition; but when individuals which yet remains sharply defined. “It manifest impaired mental action, instead of may seem somewhat out of place to allude to recognizing an infirmity we at once accuse impressions formed by the writer as them of “giving way to their temper,” or to the effect of retained urine salts on mental “not exercising proper self control,” or in processes here, even in a foot-note; some other recognized phrase blame them but this excess of urine salts morally. But to do so is to act without ra- does seem to have a stimulant effect tional self-control on our own part. Per- upon the brain, and gouty people are usually haps they exercise all the control in their possessed of some talent. The conclusions, power, only it is unequal to completely sub- so far, seem to indicate that many persons of duing the irascibility excited by the toxic good brains, but lacking in energy and incli- matters in the blood circulating in the brain. nation to think, are stimulated by retained They often merit a consideration and a sym- uric acid into excellent thinking, and attain pathy which is not exhibited towards them a reputation late in life. While in others, by most persons. They have claims to our with small, irritable, * foxy’ brains, the dis- charity, much stronger than they get credit turbing effect of these retained excreta makes for. the cares of business, etc., quite intolerable. The causes of such Functional Derange- Retirement from business at first gives relief; ment of the Liver, may now be considered but soon this irritability excites them to have by the light of what has been said before. something to do, and this too commonly is It is quite clear that first and foremost effected by becoming members of boards and stands an excess of albuminoid food. About committees, when this mental irritability takes this there can exist no scintilla of doubt, or the form of mischievous perversity, of ill- question. Wheu albuminoid food is taken controlled interference with everything and in excess of the tissue needs, the surplusage, everybody. In this condition they remind or luxus consumption, is split up in the the writer of nothing so much as a cancerous liver; and it is in this function of the liver gland—no longer fulfilling any useful pur- we find the disturbance which leads to the pose, but merely a source of irritation to excessive production of lithic acid and li- everything around them.” A further experi- thates. It is not necessary to review the ence only endorses this opinion; and such subject again here, but, to speak broadly, persons are “social nuisances;” they “ can- instead of urea we find the liver producing not agree with themselves,” and of course, it the less oxidized and less soluble uric, or is needless to say, they cannot agree with lithic acid. There is a vicious habit formed anybody else. A relative of the writer used which tends to perpetuate itself. The vice to say that “ she felt as if she could fight persists, until the gouty habit, or cachexia is with a feather,” when her brain was teased engendered: and then this condition of the with these lithates. Irritability of temper production of lithic by perverted metabolism is pronounced, and little things put the suf- in the liver is rivetted on it. Not only then fererout to an extent quite disproportionate to must albuminoids be given in sparing quanti- the exciting cause; while the positive mental ties, but it does not seem a matter of indif- suffering and annoyance is aggravated by the ference which form of albuminoid material is consciousness that there is unreasonableness taken as food. Clinical observations tend to in it, a something wrong within themselves. point in the direction of the avoidance of Often there is a sleepless night, the patient meat-albuminoids; especially the flesh of not getting off to sleep till late in the morn- beasts, as compared with that of birds and ing; he, or she, awakes not feeling refreshed, fishes. While caseine seems indicated as the but irritable and cross to a degree, ready to form least liable to be split up into lithic take offense at anything or nothing at times, acid; either as milk, the well recognized milk the dread of the household if in authority. dietary; or as the vegetable legume, of which If the head of a business firm, the underlings Revalenta Arabica is the best known type. are apt to have a bad time of it; for however We are not as yet in a position to be very reasonable and considerate ordinarily, at dogmatic on this subject, but such conclusion these times he is simply unbearable. seems suggested; like the shadow of the The ordinary explanation, “he got out of coming reality projected forward, in front of the wrong side of the bed,” is strictly appli- it. But to this we will revert in the next cable to these cases, Minutiae are criticised chapter. Here the great matter to insist or quarreled with, and the objections raised upon is the avoidance of the too free indulg- certainly come often under the heading ence in the toothsome and palatable albumin- “ frivolous and vexatious.” Nor is it only oids, especially flesh. others whohave to suffer; the subjective sen- The next matter is a sufficiency of oxygen, sations of the individual are far from envia- which involves fresh air and exercise. The ble. They know they are misbehaving them- liver-indigestion of the city-man is often the selves, yet cannot exercise sufficient inhibi- consequence of an insufficiency of oxygen to tion to control their morbid impulses. There expedite the metabolism and splitting up of is irritability blended with depression; that is albuminoids in the liver. The amount taken the mental attitude. Life is a discord, not a as food and digested by the gastric juice and musical note! Yet they do not receive the trypsin of the pancreas may not be excessive; sympathy and consideration fairly due them. but from want of a sufficiency of oxygen the When the cripple halts in his walk, we do liver cannot deal efficiently with the preteids not blame him; we readily recognize his borne to it in the blood of the portal vein. PHENOMENA OF LIVER DISTURBANCE. —LIVER INDIGESTION 65 Consequently we find the products of subox- the heat-producing capacity of the mere hy- idation, to use the language of the late Bence drocarbon of the alcohol itself. When the Jones, formed instead of the normal urea. habit of taking alcohol to excess has been The air of many business places is not cal- formed, and especially taking it in large culated to provide the active oxygen required quantities on an empty stomach, the liver for the oxidation of albuminoids. The im- begins to enlarge; and soon a quantity of provement which follows upon a day or two pathological connective-tissue is formed, in the country tells at once its own tale, as which gives it greater firmness and density of to what is requisite in this class of case. texture; at the same time, its functional ca- Long ago Mr. Alexander Shaw pointed pacity is impaired, especially its power of out (Medical Times and Gazette, July and dealing with albuminoids, as seen by the September 1842) how the movements of the presence of lithates in the urine. The sub- diaphragm facilitate the flow of blood through jective phenomena of indigestion are com- the liver, brought to it by the valveless portal monly seen in drunkards. The addition of vein. A deep inspiration sucks the blood alcohol to a dietary rich in all material, es- into the liver, while expiration expels it with pecially albuminoids, is a fertile factor in the a jet, Exercise, especially horseback ex- production of liver indigestion; and of all the ercise, that time-honored remedy, is alcoholic beverages, those prepared from then indicated in these cases of malt act most potently for evil. liver-indigestion due to an imperfect Before proceeding to discuss two matters supply of oxygen. In all cases where there of great, indeed, cardinal importance, in this is a tendency to the formation of the vicious perverted metabolism in the liver, which habit of the production of lithic acid in ex- leads to the production of lithic acid in ab- cess, in persons much confined indoors in ill- normal quantities, it may be well to say a ventilated chambers, it is desirable that few words on some other factors. ' fresh air in the country, and best by the sea- Disease of the heart, and to a lesser ex- side, should be obtained if possible. tent disease of the lungs, may lead to em- The deficiency of oxygen in tropical tem- barrassment of the liver functionally, by peratures has a marked effect in the produc- gorging it with venous blood; as a conse- tion of the bilious maladies, the disorders of quence of the ruckwirktmg , or ‘ ‘ back-work- the liver, so commonly seen in returned ing ” from the obstruction offered to the blood East Indians. Ny doubt their indulgence in flow. When there is such a lesion as im- animal food has much to do with it. Those pedes the flow of blood through the lungs, races who live on rice and dahl (a legume) or the right ventricle becomes enlarged, and so other of the leguminosa suffer little from the driving power is increased. biliary derangement. Experimentation has But the enlargement usually entails a cer- corroborated this view founded upon clinical tain amount of regurgitation through the observation, extending over centuries; and tricuspid valve, and then the veins from the animals which are exposed to a high temper- liver become enlarged, and the flow through ature are found to have degenerative changes the liver is obstructed. The liver becomes instituted in their livers. This is a division enlarged in turn, and can be felt to pulsate of the subject which recommends itself to with the impact of the venous blood driven those who meditate a residence in tropical backwards through the insufficient tricuspid climates. valve, each time the big right ventricle Then there is no doubt about the effect of strikes. This “liver-pulsation” is often a alcohol in producing liver derangement. We diagnostic sign of the greatest value in cer- all know how enlargement of the liver, fol- tain cases. The liver so engorged with this lowed by subsequent contraction, is induced regurgitating venous blood, is embarrassed, by the abuse of alcohol. About this no one maimed, or crippled in its functional work- entertains any doubt. But alcohol taken ing, and a free production of lithates is the even sparingly disagrees with some persons consequence. In the consideration of this whose livers are easily upset, and. they have matter it must not be forgotten that, whether scrupulously to avoid it; for it is, indeed, a disease of heart or lung, the oxidizing pro- poison to them. Even the form of alcohol cesses are impaired by defective chemical in- is not unimportant. With one a glass of terchanges in the thorax; and so a deficiency champagne, with another a single glass of of oxygen is an operating factor, not to be port is sufficient to upset the liver; and a re- overlooked. curring experience tells unmistakably the re- Then all structural disease of the liver lations being those of cause and effect, and mutilates the organ and limits its functional not mere coincidence. To speak broadly, it capacity. When an abscess of the liver has would seem that alcohol stimulates the liver destroyed a great portion of the viscus, it to give off some of its stored glycogen, and leaves the remainder scarcely equal to the de- -hus unlocks a quantity of heat-giving ma mand upon it. This is seen by the diminu- terial, possibly, perhaps probably, by increas- tion in the amount of urea formed when the ing the amount of blood in the hepatic artery, liver is the seat of extensive disease. Dr. a recognized cause of the liberation of glyco- Parkes found in examining the urine of cases gen or animal starch; and its conversion by of liver-disease from India, the amount of the hepatic ferment into sugar. This is in urea varied greatly. When the injury was accordance with the fact that a glass of wine, extensive, so as to have destroyed a large area or its equivalent, will often excite a glow and of the liver structure, the amount was les- a feeling of warmth, not commensurate with sened in a degree in strict proportion to the 66 INDIGESTION AND BILIOUSNESS. extent of the destruction worked: while in than by muscle-work. Such results are al! other cases, where there was no destruction of the more likely to ensue if the diet has been the liver structure but engorgement of it with such as favors hepatic derangement—if, for blood, increasing the activity of the liver-cells, example, to drown grief the patient has in- the amount of urea was increased as was also dulged in stimulants—and the habits have that of lithic acid. In acute yellow atrophy been sedentary. There is also good evidence the amount of urea is largely decreased while that nervous agencies may not only cause that of leucin and tyrosin is largelyincreased. functional derangement, but even structural In cirrhosis also, the amount of urea is di- disease of the liver. Acute atrophy, in which minished and the same occurs in cancer of the secreting cells are rapidly disintegrated, the liver as seen in cases quoted by several and the functions of the organ arrested, ap- authorities. When the structure of the liver pears in many instances to have a purely ner- is destroyed its functional power is lessened vous origin; very often the first symptoms of in a corresponding degree. Consequently, the disease have occurred immediately after a the causes which derange the liver usually, severe fright or an outburst of passion, in a are specially operative upon persons whose person previously healthy. An impression livers are the seat of structural changes. made upon the brain appears to be reflected Derangements of the liver may be conse- to the liver and deranges its nutrition. Many quent upon primary and preceding disorder of observations have satisfied me that the ex- the gastric or intestinal organs of digestion. trusion of gall-stones from the gall-bladder, Crude or abnormal or partially digested mat- as well as their formation, may be traced to- ters absorbed into the blood of the portal nervous agency. Dr. Budd has also observed vein from the alimentary canal may, in the that mental anxiety or trouble has great in- course of time, lead to secondary disorder of fluence in the production of gall-stones; and the liver. This, however, it must be admit- I have repeatedly known attacks of biliary ted, is founded a good deal on apriori rea- colic from gall-stones, excited by some sud- soning, and though the features of cases den emotion. Lastly, even cancer of the often suggest this, it can scarcely be regard- liver appears sometimes to result from the ed as demonstrated to a conviction. There functional derangement induced in the first remain two matters connected with functional instance by mental trouble. I have been sur- derangement of the liver, still to be consid- prised at the frequency with which patients ered, of the greatest interest. The one is the suffering from primary cancer of the liver effect of nervous influences; and the other is have traced the commencement of their that of what may be termed congenital insuf- ill-health to indigestion, following pro- ficiency in the liver. tracted grief or anxiety. The cases have As to nervous influences they have been been far too numerous to be accounted for on very fully considered in Chap, vi., pp. 86- the supposition that the mental distress and 109. It was there pointed out that mental the cancer have been mere coincidences. A disturbance exercises a profound influence similar observation has, I believe, been made over the digestive organs, and very specially by Sir Robert Christison, and by other emi- the liver. The extent to which such influ- nent authorities. ” These are very definite and ence affects the liver is almost inconceivable, equally strong and decided expressions of until the literature of the subject is examined. opinion. For centuries we have been more or less Dr. Budd wrote (“Diseases of the Liver.” familiar with the effects of indigestion and third edition, 1857): “Another condition tha mal-nutrition upon the brain and nervous sys- seems to me to have great influence on the tem; but the converse, the effect of nervous production of gall-stones, or at least ofbiliary disturbance upon the liver and alimentary gravel, is mental anxiety or trouble.” canal, is one with which our acquaintance is It is indeed abundantly shown that mental more recent. Dr. Murchison sums up the disquietude disturbs the functions of the liver, matter very completely and tersely, and as his one and all, “ stock, lock and barrel;” and, views will give corroboration to what I have not only that, but may set up even structural written elsewhere, I will give them verbatim: disease, to-the extent of cancer itself. “ Many facts show the great influence of the “ Congenital insufficiency” of the liver is, nervous system upon the secreting organs. there is every reason to believe, the cause of Sudden fear, or other severe mental emotion, much of the trouble to which “bilious” per- has been known to arrest the secretion of sons are liable. Dr. Budd, a keen observer, milk and saliva; and we have already seen one of a large family of medical men, all of how injuries and diseases of nerve-tissue may whom were remarkable for their acumen and produce diabetes by deranging the glycogen- their incisive thought, expressed himself on ous function of the liver. But many other this subject as follows: ailments of the liver besides diabetes have a “ In most persons, perhaps, a portion of nervous origin. Prolonged mental anxiety, the liver may waste or become less active, worry, and incessant mental exertion not only without sensible derangement ofhealth. They interfere with the proper secretion of bile, but have more liver, as they have more lung, than too often derange the processes of sanguifi- is absolutely necessary. In others, on the cation and blood-change, in which the liver is contrary', the liver, from natural conforma- so deeply concerned, and induce lithaemia, tion, seems only just capable of effecting its with many of the symptoms already described. purpose in favorable circumstances. They Gravel and gout are acklowledged -to be the are born with a tendency to bilious derange- frequent lot of those who live more by nerve ments. This innate defect of power in the PHENOMENA OF LIVER DISTURBANCE.—LIVER INDIGESTION. 67 liver has its counterpart in the deficient re- this cause, is in some instances quite incur- spiratory power in persons with vesicular em- able and can only be palliated. It is a sad physema of the lungs, and, like the latter de- legacy that the gouty from self-indulgence fect, and most other peculiarities of physical often leave to their children, even when they structure, is no doubt frequently inherited. themselves are free from it. Singularly Persons who inherit this feebleness of the enoughit does not show itself necessarily in liver, if we may so term it, or in whom, in all the children of a gouty father or mother, consequence of disease, a portion of the liver but only in one or more of the number. The has atrophied, or the secreting element of the children of gouty parents ought more espe- liver has been damaged, may suffer little in- cially to follow the hygienic and dietetic laws convenience as long as they are placed in laid down in these pages if they wish to es- favorable circumstances, and observe those cape much suffering. As a rule they ought rules which such a condition requires; but to be all but water-drinkers throughout life; whenever from any cause—as a hot climate, they have to pay the penalty of their progen- gross living, indolent habits, constipation—a itor’s excesses or dietetic errors. If the gouty more abundant secretion of bile is requisite to diathesis is strongly marked they should be purify the blood, the liver is inadequate to its most moderate and abstemious in their food office, and they become bilious and sallow.” habits and lead as active and muscular a life as Such, then, is a very shrewd observation and possible. Indeed they should never lose sight explicit expression of opinion in one of our of the fact that a miserable, gouty old age most trustworthy authorities, none the less de- may be their fate should their life be pro- serving of confidence because he used the longed unless they make many sacrifices to phraseology of his day and did not know that ward off the impending danger.” This rela- the liver was largely engaged with the albu- tion of indigestion with the gouty diathesis, minoid material of our food. Had he been i. e., a constitution which is gouty by inher- aware of this he would have employed a more itance, is one which is the more extensively comprehensive expression than that of “a recognized as the subject is more investigated. more abundant secretion of bile is requisite to There is a well-known story which may be purify the blood.” He would have grasped quoted in proof thereof. An old clergyman the subject more efficiently, as Dr. Murchi- once ejaculated, “ I have been a dyspeptic for son, possessed of more recent and more ex- fifty years. Thank God for it! ” The rea- tended knowledge, has done. He quotes Dr. son of his satisfaction, expressed so devout- Budd, and adds: “ The person is born with a ly, was the fact that all his brothers were tendency to biliary derangements. Gout and dead and buried, cut off by gouty affections; diabetes, which we have found to originate ip he alone remained of the family. Dyspepsia hepatic derangement, are hereditary diseases; had saved him from the fate which overtook and the liver isalways very readily disordered in the rest. The dyspeptic then is under certain persons who inherit a tendency to gout. This circumstances a better life, in insurance constitutional tendency to hepatic derange- phrase, than those who are free therefrom. ment is too often lost sight of by patients, But is longevity worth the price, many will and perhaps sometimes by their medical be tempted to ask ? advisers. The habitual use of alcohol Dr. Leared commences his little work “ On is often recommended for various ailments, Imperfect Digestion” as follows: “The without due regard to the tendency of the in- digestive power may be compared to dividual to hepatic derangement, and thus se- the physical strength. Every individual rious consequences may ultimately arise from can, without inconvenience, carry a alcohol taken with a medicinal object. Again, certain weight, while any addition to a patient often argues that his liver troubles it is accompanied by a proportionate sense of cannot be due to what he eats or drinks be- oppression. In the same way, what is called cause he is most careful as compared with indigestion, is often simply a result of excess. friends who indulge largely and suffer noth- The amount of food which each man is capa- ing forgetting the adage: ‘ One man’s food ble of digesting with ease has always a limit.” is another man’s poison.’ One man, for Quoting Cicero’s gratitude that his advancing instance, may drink a bottle of wine and be years had diminished his inclination to eat none the worse, whereas another has his and drink, he points out that: “At all stages liver deranged by a single glass.” Doubtless of adult life, but particularly during its de- the explanation offered above is a reasonable cline, the appetite is over-stimulated by con- one and tells us fairly satisfactorily why one diments, and tempted to excess by culinary man cannot eat and drink without suffering refinements. Dyspepsia is not the worst re- for it, what wonld be quite a moderate amount sult of this. Gout, and still more serious for another person, who can habitually take maladies connected with an impure state of that much, and more, without any inconve- the blood, closely follow. Infringements of nience supervening thereupon. the laws of digestion are constantly, and in The subject has not escaped the observa- many cases unconsciously, committed. One tion of other authorities and Dr. J. Henry man digests with ease an amount of food “ Bennett writes: The gouty diathesis when which would be fatal to another. Animal it is the result of hereditary taint has proved food is easily digested by some persons twice in my experience the cause of some of the or even three times daily, while, if taken by most intractable forms of dyspepsia, both in others more than once, it is sure to induce male and female, that I have met with. In- suffering. Nevertheless, the diet of persons deed, I believe that dyspepsia, recognizing associated together is apt to be the same, and 68 INDIGESTION AND BILIOUSNESS. sufficient individuality in matters of eating a lady, .when his means will permit it, drinks -and drinking is seldom observed.” most abstemiously, and yet his enemy has There is much force in the way in which him on the slightest provocation. There Dr. Leared here points out the diversity of must be a reason for this, surely! And prob- individuals in their digestive capacity, like ably the explanation lies, as Dr. Budd wisely any other capacity; and also that the power suggested, in some congenital impairment in is not always the same in the same individual, the functional capacity of the liver. The fact but is diminished with age. That we are apt that the children of the alderman who could to eat alike, whatever our individual capaci- perform such gastronomic feats, do not pos- ties, is certain; and the dyspeptic who moves sess their progenitor’s capacity, is one well much in society, or “ goes out at all,” is al- recognized. Indeed it is simply impossbile to ways being tempted, inveigled, or goaded by avoid the conclusion, that there exists a sec- jeers and jibes, into eating a great deal in- tion of society who are hereditarily feeble in finitely better avoided; with the person who the liver, either actuallybilious bybile-acids, or suffers from “ liver-insufficiency,” any indis- the subject of lithiasis, from the liver being cretion is swiftly punished, and suffering fol- unequal to the normal transformations of al- lows closely on the heels of the offense. buminoids. Such persons step into their in- This congenital incapacity in the liver de- heritance, whether they like it or not. Some serves an attention it does not receive either persons inherit unstable nervous systems, from the patients who suffer or the medical others weak lungs, while indubitably others men who advise them, as a rule. Just as we inherit incapable livers; and the sooner the “ see poor wretches with flat, narrow chests, fact of liver-insufficiency” is generally recog- and we recognize that in consequence of their nized, the better for those who suffer (poten- badly developed chests they will readily suc- tially) therefrom. cumb to disease of the respiratory organs; After this rather lengthy consideration of because at the best they only possess as much “ Biliousness" and “ Liver Indigestion,” we lung as will barely carry them on in a make- can approach all the more satisfactorily the shift way. So we should learn to recognize subject of the treatment of these allied con- the other fact —that of the congenitally in- ditions; and comprehend all the more clearly competent liver. If such recognition were the why and wherefore of what will be recom- more general it would be well for those so mended in the ensuing chapter. born imperfect. They must eat in propor- tion to the capacity, or rather the want of it, CHAPTER XII. in their livers; not according to their appe- tite or the habits of society, if they wish to THE TREATMENT OF I.IVER DISTURBANCE— exist in (comparative) comfort. I remember MEDICINAL AND DIETETIC. well a gentleman of good descent, in my Tiie reader will now be fully prepared to early experience in Westmoreland when I enter upon the question of how to improve took my father’s practice, who was embar- the condition of persons who labor under rassed by one of these incapable livers. hepatic derangement. For a certain class of Straitness of means and a waxing family com- readers this section of the subject will possess pelled him to live very sparingly and econ- little interest, and a languid curiosity is all omically; and partly by that, partly by long that it will arouse. But I venture to think hours every day in the open air, in the gar- there is a much larger class who will eagerly den, or on the roads with a rake, a life of in- read this chapter; viz., that portion of the dustry comparing favorably with that of medical profession who not only are sin- many field-hands, he managed to keep him- cerely desirous of doing what good they can self in health and comfort. But the slightest to their fellow creatures; but who feel that omission or relaxation of his dietetic or hy- they would be glad to give their patients gienic arrangements was followed by retribu- something like “value received” for their tion, swift and sufficient to keep him at his money. A valid excuse may be tendered for round of self-denial and self-imposed toil for simply watching a case of uncomplicated a considerable time to come afterwards; pneumonia, or typhoid fever, running its and occasionally, but rarely in fact, he went course; prepared to take the requisite active away to visit a more affluent brother for a steps when the necessity for them arises. But week, with the invariable result of well- such mere observation of cases of derange- marked articular gout being established in ment of the liver is what no one would at- him. For many long years this went on, and tempt in the possession of his reasoning this poor gentleman taught me much about faculties, be the same more or less; and if it congenital impairment of the assimilative or- w'ere essayed, the patient would soon express gans. Probably this is a well-marked in- his opinion on the subject—and emphatically, stance, a very well-defined instance indeed, I expect. of the influence of descent in impairing the And in doing so he would be held justified digestive processes. The plebeian alderman by all: when we think how important it is eats (or is reputed to do so), vigorously with that a man be enabled to work in comfort, undiminished zest and appetite, free from or an approach to it; and not only that, but gout or dyspepsia, into good old age; giving also to have his health as long as possible. the lie to the statement that “of all carnal We all know how, as age advances, the di- pleasures cometh satiety at the last.” While gestive and assimilative organs begin to fail. the well descended gentleman gets gout on Gout is a disease of middle age and advanced the slightest provocation; eats as daintily as life. The work which the liver has to do day THE TREATMENT OF LIVER DISTURBANCE. 69 by day tells upon it, and instead of the ordi- ploded doctrine; they would as soon think of nary normal metabolism in it, disturbances reverting to the Pythagorean teaching of the and perversions arise. The arrangements transmigration of souls. But, perhaps, they which change grape-sugar into glycogen, and will find after a while that a mercurial pill, glycogen back again into grape-sugar, be- succeeded by a smart purgative, isa very good come disturbed, and then diabetes is the con- plan of treatment in certain cases; provided sequence. Or the splitting up of albuminoids that they follow it up by a rational dietary, so is perverted, and then lithic acid is largely as to prevent future accumulation of waste formed, instead and in lieu of urea, and then matter in the blood. gout is the result. Now it behoves the med- It was the neglect of this latter which ical man to keep well in view the future, as brought the mercurial remedy into disrepute. well as to recognize the present necessities, By attention to it in the future, the mercurial in cases of liver derangement. It is not only pill, followed by a saline laxative will have its desirable to give relief at the time; but it is day again; liable, however, to be again dis- well to include the future in the therapeutic carded if abused! Colchicum has been in scheme. It is not only the immediate trouble and out of the pharmacopoeia some half-dozen of the patient, it is what is looming in the times at least, according to the ebb and flow distance which must be calculated for in the of medical belief and the fashion of the times. estimate. This factor it was, which, being Unbounded faith is often the precursor of an omitted from the calculation, ultimately equally blind, irrational unbelief, as history brought such discredit on the ‘ ‘ blue-pill and tells us. Such oscillations of belief simulate black-draught” treatment. Such means gave at first the overthrow of a superstition, and immediate relief; about that there can exist no by some are thought to be such a movement question. But what was the consequence? until time disproves it. The trying for witch- Possessing a ready means of procuring relief, craft, and the general belief in witches, their our predecessors went on their way rejoicing—- wholesome detection and cruel punishment, ate, drank and were merry, as in the day be- culminated in a reaction as swift as it was fore the flood, “and knew not till the flood complete; and the belief of one generation came and swept them all away.” So it was was the scoff and scorn of the next immedi- with them. They set no bounds to their in- ately succeeding it. Sir Thomas Browne, dulgence, and fell back on the blue-pill and the renowned author of Religio Medici, be- black-draught when inclined, until an unreme- lieved in witches, and once as a witness swore diable condition was established. Instead of in court ‘ ‘ that he was clearly of opinion that righting itself, the system became accustomed the persons were bewitched.” Yet the men to this artificial means of restoring the who believed in witches and the judicial pun- equilibrium, until the power of self-restoration ishment of witchcraft were, as Leeky points of the balance became irretrievably lost; and out, quite as capable of forming an accurate then a permanent cachexia settled down upon opinion on other matters of life as other peo- the remainder of their days. So conspicuous ple have been. So the men who practised did the evil become, that the stream set in in medicine with the use of the blue pill and the opposite direction so effectually that now black draught were in the possession of their many peasons, yes, and many medical men senses; only abuse led to reaction. Now too, look upon the ltaercurial pill as if it were the dread and horror of a mercurial in any “possessed of a devil.” The reaction came case, and under all circumstances, is leading and swept reason away in its current as it a large section of men to the opposite ex- often does; and one extrejne begat the other. treme—of its avoidance in season and out of I remember well, not many months ago, read- season; and that portion of my audience ing a paper before a large suburban society looked upon me as if I were a nineteenth upon the desirability of sweeping the accumu- century would-be imitator of Julian “ the lated nitrogenized waste out of the blood, in apostate.” The heroic plan of treatment, the certain cases of dilated heart with enlarged lancet and the blue pill, has been followed by liver; when, in the discussion which followed, a reaction which has extended to Nihilism several gentlemen of various ages asked if I with many as regards drugs; while an un- thought a mercurial at times permissible in bounded faith in beef-tea, and the sustaining such cases, as timidly as if they felt them- plan of treatment now generally obtains with selves liable to be suspected of wishing to re- them. Nevertheless, in many cases a mercu- suscitate the Druidical faith, or exhibiting a rial and a saline afterwards form a very good latent belief in the old notion that “ nine live plan of therapeutic attack in emergencies. lice upon a piece of bread and butter ” were Admitting, at the same time, that the natural the most appropriate and effectual treatment loss of appetite leading to abstinence, is much of an attack of jaundice. And on assuring better in many cases. Nor does this confes- them that I not only thought such remedial sion of faith in mercurials as a cholagogue agent permissible and lawful, but even ap- involve a retrograde movement which will ex- proved thereof, they seemed immensely re- tend to a resuscitation of a belief in witch- lieved; while several and sundry others pres- craft, or the tenets of Druidism. To advo- ent interchanged a significant glance, as if cate the proper use of mercury as a chola- they thought I was the subject of incipient gogue is not, then, the revival of an exploded general paralysis; indicating, too, that my superstition. Still it is now acknowledged utterances in future would receive no regard that it is not well to resort to the habitual use or countenance from them. They clearly of mercury as a cholagogue; for it is found would have none of this renewal of an ex- that once accustomed thereto, the liver does 70 INDIGESTION AND BILIOUSNESS. not respond to other less potent stimulants; But whether this plan will obtain or not till like the toper who, familiar with brandy and the millennium is reached, is a subject which a split seltzer cares little for a draught of cannot be settled out of hand. It may safely hock and soda-water. be said, that it ought to obtain. The subject will be reverted to a little fur- Especially should such rule be observed by ther on. persons who have resided in tropical climates, But our choice of remedial agents should or been the subject of hepatic disorders. Dr. be profoundly influenced by the fact that, as Budd makes a remark which may profitably be age proceeds, the assimilating organs lose quoted here, viz.: “ In persons who die of some of their pristine energy. Nor does the yellow fever, the liver presents various mor- mature organism require the material which is bid appearances, which have been minutely essential to the building of the tissues in described by Louis; that depend not on the growth, and in that consolidation of the sys- products ofinflammation, or on the state of the tem which follows growth of stature. The vessels, but on the condition of the cells. energy of manhood will enable the system to The damage done to the liver in this way burn up much food, perhaps not absolutely may last for years. It is probable that the demanded, but which is, at least, not harm- bilious disorders of many men on their return ful. But when advancing years limit the en- to this country from India, and other hot cli- ergies, then such consumption becomes bane- mates, are, in great measure, owing to per- ful; while a less liberal supply of oxygen ren- manent injury done to the secreting element ders the task of oxodizing albuminoids more of the liver.” This remark is pregnant with difficult than it once was. A natural failure suggestiveness, that in many cases the secret- of the appetite follows; which should be re- ing cells of the liver, by which the metabolism spected, and not struggled with. There is and splitting up of albuminoids by oxidation then, in the first place, what to avoid; when are carried on, become impaired functionally; this spontaneous anorexia, or loss of appetite if not always structurally. Such modifica- manifests itself—its lesson is to leave it alone: tions should be remembered when the pa- lessened body-wants no longer require an tient’s dietary is being laid down; nor need active, keen appetite; and attempts to whipup such considerationbe restricted to returned the appetite by bitters are to be discouraged. East Indians; it might quite well be extended The appetites vary with advancing years. to those who, though they may not have re- The mistress gives way to the cook; and the sided in tropical countries, nevertheless have skill of the latter, like the charms of the for- suffered from biliary and hepatic disturbances mer, is fraught with an element of danger to It maybe well to proceed to the consideration the owner. The temptation to eat more than of acute bilious congestion of the liver. In either is required or good for him, to which such cases in children, it may be well to ad- the middle-aged man of means is exposed, the minister an emetic of ipecacuanha, with a natural weakness or lack of strength to resist small dose of a mercurial, followed by a pur- temptation, should induce him, if reason ruled gative. But this should not be resorted to the roost, to discharge his cook for one of less, habitually in consequence of unrestricted in- instead of more skill, when the natural decay dulgence in food. It should only be a dernier of the appetite begins to manifest itself. Such, resort in emergencies. Very often the loss of however, is not the case, and is not likely to appetite and languor lead to spontaneous re- be the case for a long time to come. So the storation of the health: afid, even at the risk cook, the more skillful the more dangerous, is of shocking some anxious mothers, or impul- the first matter to be decided. He or she sive practitioners, it may be said that such is, must, or ought to be, discharged ; or with delicate children, much better for them handed over to the possessor of a more in every way; educating the system to take youthful appetite and vigorous set of digest- care of itself, and proving a very good lesson ive organs. Then the family medical attend- for future guidance. Still, the emetic and ant should pledge himself, by solemn oath purgative may, at times, be indicated. and covenant, never to prescribe bitters when In acute congestion of the liver of warm the appetite is defective, or capricious; the climates, I may quote Sir Joseph Fayrer, K.- patient equally binding himself never to whip C.S.I., F.R.S.L. and E., written for me or flog the jaded appetite by bitters, either for my Practitioner's Handbook of Treat- hop bitters or Angostura with a little gin, or ment:—" In reference to the treatment dry sherry before dinner. If such compact of the functional derangements of the liver were made and kept faithfully, many a liver which arise from congestion, and I think would be able to hold its own, and fulfill its more especially that form in which it is ac- functions fairly well, which, under the pres- companied by anaemia, such a condition, in ent arrangement, is prematurely worn out short, as is so frequently seen in persons years before its potential exhaustion. It is who have lived long in hot malarious cli- but human to sacrifice the future to the pres- mates like India, the West Indies, and the ent; and an appetite which is waning ought Coast of Africa, I may say this. Beyond to be conserved, its owner thinks! Certainly; mere swelling of the liver from engorgement the question is how best can it be conserved ? with blood, other changes—fatty or amyloid It is not preserved by stimulating the appe- —will no doubt supervene, and it is often tite and the stomach to consume more food difficult to determine how far the functional than the liver can dispose of. Rather the ju- is due to the structural change. The treat- dicious plan is to follow the indications of the ment I generally find most effective, is atten- appetite, and when it flags to eat accordingly. tion to diet and drinks. Avoid much THE TREATMENT OF LIVER DISTURBANCE. 71 fatty, sugary, and alcoholic fluids. No notwithstanding, should be prescribed. The beer. Claret and water for drink. Warm experiments of Rutherford countenance and clothing, so as to keep the skin moist. An corroborate the conclusions at which clinical occasional dose of colocynth or calomel, or empiricism had arrived. Potash for the kid- blue pill, and every morning, or every other ney, ammonia for the lungs,soda for the liver: morning, a dose of saline aperient, such as these are the bases of the salts to be used, ac- sulphate of magnesia, with quinine and gen- cording to the circumstances of cases. Sul- tian, sufficient each time to produce two or phate of soda is best taken in the morning, three loose motions. Counter-irritation by first thing on getting out of bed. Then some tincture of iodine over the loins. When the bicarbonate of soda, or Rochelle salts, must portalcirculation is relieved, some preparation be added; with a carminative of some kind, of iron may be very useful. The urine is a in a bitter infusion, warm. Such a draught, good test of the hepatic condition; it will im- first thing, is of the greatest service. prove under the above treatment, but it is The carminative not only covers the objec- well to give the patient some alkaline waters tionable taste of the salts, but is itself useful. —Vichy, Vais, or Carlsbad. Albuminuria, Dr. Budd wrote: “ Pepper, ginger and other will be present at times, when the kidneys, hot spices are also supposed, and perhaps like other abdominal viscera, are congested, justly, to render the liver more active and in- or are irritated by lithic acid. In my opin- crease the secretion of bile.” It is well b> ion, too much importance is attached to this bear this in mind in prescribing for hepatic sympton in some cases. Indeed, I think the derangement under all circumstances. subject of albuminuria would bear rewriting. Chloride ofammonium has always had warm Albuminuria may be functional in such cas- advocates for its utility as a cholagogue. es, and pass away like the other symptoms.” Mercury in all its forms and preparation- Certainly looked at by our most recent light, has been in use for centuries in liver deranges such albuminuria may be but a part of the ments. Sad and disastrous are the conse- hepatic derangement, and pass away with it quences of the abuse of this powerful medi- accordingly. Now is it unfriendly criticism of cine. The indiscriminite and inordinate re- Sir Joseph Fayrer’s practice to say, that in sort to mercury has brought the treatment of his line of treatment, the matter of albumi- the services into well-deserved disrepute. noids is omitted ? Yet to withhold them is in Potent for good, still more potent for evil all probability also very desirable, and would when abused, mercury has fallen from its be accompanied by improvement in the symp- high estate into comparative disgrace or ne- toms. The patient should be kept upon rice- glect. Its claims, however, must be consid- water, or other simple starchy matter, which ered rationally. Highly as it was once ex- gives the liver the least labor. Or a little tolled, it is now equally abused and depre- beef-tea with baked flour in some form might ciated. Nor can we wonder at this, when we be sparingly; where procurable, a milk die- think how it has come about. The terrible tary might be substituted, or whey, where conseqnences of the administration of mercu- there is anorexia with much thirst. Probably ry till free salivation was produced formed a a liberal supply of subacid fruit is always de- lesson which many took to heart, in some sirable, as well as grateful to the patient. cases too earnestly. The zealots who ordered As regards permanent biliousness as seen patients to be salivated to so many pints a in England, my practice has been modified day simply dethroned their idol in public by the light of advancing physiology, with opinion. Then followed the quack-salvers, advantage, I firmly believe, to my patients. with their patent medicines, who announced I no longer allow them to consume albumi- with all the flourish of trumpets at their com- noids in any quantity; but instruct them in mand, that their pills “ contain no mercury.” this, as in other elements of their food. But The reaction actuallyextended to the point of this is the dietetic management to be discussed abandoning mercury in the treatment of syph- further on. ilis. Slowly the tide of indignation against It is well to give them a pill containing a the use of mercury has ebbed, until its use in hepatic stimulant, to be followed by a mineral syphilis is once more universal. saline next morning. Two copious motions, The late Prof. John Hughes Bennett hated one before, the other after breakfast, furnish mercury with a virulence scarcely conceivable much sense of comfort in cases where the by those who did not know him. He de- bowels are sluggish; that is in the bulk of nounced it, he inveighed against it, he poured cases. By such treatment they are greatly all the power of ridicule he possessed, and that improved; even in cases where “ congenital was no slight amount, upon it; he shot every insufficiency of the liver ” is presumably pres- arrow of sarcasm in his quiver, and it was a ent. pretty full one, at the misguided, wicked per- At this point, it may be well to review sons who dared to advocate the administration those medicinal agents which act upon the of a single grain of calomel. Peace to his liver. ashes! An iconoclast, he did a good Soda and its salts are found to act potently service in his way. Still, the crusader upon the liver. Consequently while sulphate of is an enthusiast, and an enthusiast is magnesia is a capital purgative when the intes- not a person of a judicial frame of mind. tinal glands alone require stimulating this salt The crusade against mercury is now passing acts little, if at all, upon the liver; and when away, having played a useful part; the ten- it is desirable to “rouse the liver,” as the dency at present is the other way, and the phrase runs, sulphate of soda, its bitter taste cautious and rational use of mercury is once 72 INDIGESTION AND BILIOUSNESS. more finding numerous advocates. In speak- remedy worse than useless, not only in hepatic ing of mercury Dr. Budd wrote: “ The diseases but in syphilis; itcannot, therefore, be marked temporary benefit often resulting from that the convictions forced upon me by expe- mercury given for this effect has, from the rience are the result of preconceived opinion.” difficulty ofdistinguishing the various diseases Dr. Murchison was a pupil of the late J. of the liver, and the consequent indiscrimin- Hughes Bennett. So was I; and I can also ate use of the drug led to great evils. This plead that my belief in mercury has been medicine was at one time, by English prac- “forced upon me by experience,” for Ben- titioners, given almost indiscriminately and nett’s thunderingdiatribes dominated my mind long persevered in for disorders of digestion, for a long time, and the impression made by many of which did not depend on fault of the him upon my youthful mental processes was liver at all, but on local disease of the stom- only ground out by the resistless action of an ach or intestines or on faulty assimilation, the accumulating experience. result of debility which the prolonged use of When the kidneys are extensively diseased the mercury but too often increased.” This a marked intolerance of mercuryis often man- is a judicial expression of opinion by a man ifested; and, like opium, it must be given whose opinion is entitled to every respect. with much caution then —though its utility The way in which the German writers have with red and pink lithates is incontestable. condemned the English use of mercury has In the white deposits of true liver-indigestion done much to help on the growing disuse of it is not indicated. A broad rule may be the drug; their condemnation has been whole- struck to this effect, when there is atony and sale, thorough-going and indiscriminate it- asthenia mercury is contra-indicated, but when self; and has been sometimes the blatant ut- there is fair power without anaemia it may be teranceof ignorance as well as at times gen- given. Always bearing in mind that broad uine honest criticism. rules do not apply to every case, and where Dr. Murchison has put the position of mer- individual experience has demonstrated that cury very pointedly. After giving the re- mercury does not agree scrupulously avoid it. sults of numerous experiments he proceeds : The old-fashioned plan of six or eight grains “ Mercury and allied purgatives produce bil- of calomel for acute indigestion may suit ious stools by irritating the upper part of the some strong persons; but it is within my own bowel and sweeping on the bile before there personal experience, not of my own prescrib- is time for its reabsorption. The fault of ing it is almost needless to say, that such mercury standing at the bottom of the scale reckless practice has done immense harm to a of cholagogues of Rbhrig’s experiments is ac- delicate patient. Mercury is one of those counted for by its surpassing other chola- “ edged tools” which must be handled with gogues in this property; for of course the care and judgment. When the patient has larger the quantity of bile that is swept down found opium to disagree, whether you find the bowel the less is reabsorbed and the less any albumen in the urine or not, my youthful escapes from a biliary fistula. It would ap- readers, just hold your hand about mercury; pear that mercury by increasing the elimina- it is not necessary to insist upon this for old tion of bile and lessening the amount of bile readers—they have found it out for them- and of other products of disintegrated albu- selves. Another broad rule may be put thus: men circulating with it in the portal blood is persons of the gouty, sanguine or arthritic after all a true cholagogue, relieving a loaded diathesis bear mercury much better than do liver far more effectually than if it acted by those of the strumous diathesis. With the first merely stimulating the liver to increased se- the action of mercury in disintegrating albu- cretion as was formerly believed and as some minoids acts beneficially as a rule, but upon authorities yet maintain; for in this case it the defective constitutions of the strumous, might be expected to increase instead of di- with their imperfect tissue building (page —), minishing hepatic congestion.” This is very mercury acts too energetically and in a very judicial. But Dr. Murchison propounds an- undesirable manner. other view very essentially his own. After When to give a dose of mercury in con- describing that patients ofundoubted intelli- ditions of lithiasis and albuminuria, where gence are certain about the benefit they de- it will do good; and when to avoid it, as rive from mercurials, he writes: “It is not you would a Cobra-di-Capello, is a problem, impossible that the good effects of mercury in each case to be solved, which will task the on the liver, and in some forms of inflamma- natural powers and the acquired skill of the tion, may be due to its property of promoting practitioner to the utmost. Consequently I disintegration. It seems not improbable that think it well to quote a passage from the second mercury, which we know from experience to edition of the “ Practitioners’ Hand-Book”; reach the liver, may under certain circum- “ Dr. Broadbent informs me that in the stances act beneficially by promoting or in numerous cases of albuminuria in the London some way influencing the disintegration of Fever Hospital towards the decline of the af- albumen. The remarkable effect of mer- fection, when only small quantities of albu- cury on constitutional syphilis perhaps ad- men remain, mercury in limited doses usually mits of a similar explanation. But in what- leads to the entire disappearance of the albu- ever way it is to be explained, the clinical men. It is a remedy, however, which should proofs of efficacy of mercury in certain de- be resorted to cautiously; while quite a safe rangements of the liver are to my mind over- measure in the hands of so careful a physician whelming. I say so the more advisedly be- as Dr. Broadbent, it may be a very danger- cause I was taught to regard mercury as a us agent in the hands of some practitioners.” THE TREATMENT OF LIVER DISTURBANCE. 73 So in certain cases of albuminuria, not conse- action upon the bowels. But this action of quential upon acute fever, a little mercurial opium is useful when the liver-ferment con- may be very beneficial; but in every instance verts glycogen too freely into sugar; and so it should not be given until the case has been is useful in the treatment of diabetes. In made the subject of patient thought. Given azoturia, or baruria, where there is a neurosis carelessly most deplorable results may follow. of the liver splitting up the albuminoids into A tense pulse is usually a fair indication for urea, and therewith a certain amount of buli- it. The whole subject is one on which we mia, opium also is useful. It puts a check desire more precise information. upon the activity of the liver; and this, Aloesis an agent long recognized as having though it constitutes a drawback to its admin- an effect upon the liver. So is rhubarb. istration ordinarily, is useful in some cases of “ Many persons have succeeded in warding excessive action of the liver cells. off bilious attacks to which they are subject, In the liver disturbance due to pyrexia, by taking habitually, before dinner, a few quinine lessens the morbid activity of the vis- grains of rhubarb. A rhubarb pill will often cera. relieve a slight bilious disorder, even before it Then there are mineral remedies to be con- has purged” (Budd). sidered. Nitro-muriatic acid taken by the Taraxacum is a reputed liver stimulant, mouth, is often useful when an attack of much in vogue with the world at large, and jaundice is passing away. Some like foot- with herbalists; but little used by regular med- baths containing it; others, a lotion of it ical practitioners. upon lint over the liver. The free chlorine Jalap,colocynth, and senna, are also chola- in 4this acid is generally regarded as the po- gogues of some potency. tent factor. Chloride of ammonium is often Ipecacuan is an hepatic stimulant, not only given therewith. “ It goes with either acids of time-honored repute, but the observations or alkalies ” (Murchison). of clinical medicine are borne out by the Acids, Murchison thinks, may not act di- physiological experimentalist. Rutherford rectly upon the liver, but may do good indi- found it to be one of the mostpotent of chola- rectly by improving gastric digestion. In gogues. Personally, I am very fond of giving some cases, he holds, both acids and alkalies ipecacuan, especially in a “dinner-pill;” in may be given advantageously—the alkalies that, following a practice which has been all before, the acids after a meal. This is in ac- but obsolete for a long time, but which seems cordance with what Ringer advocates; the al- likely to be revived. It seems to obviate the kalies taken when the gastric mucous mem- action of opium upon the liver, when com- brane is alkaline excite a better flow of gas- bined with that drug, as Dover’s powder. tric juice. The acids given during the period To the same class of hepatic stimulants be- of gastric digestion probably aid therein. long “ Iridin,” extracted from the root of the Alkalies are more in favor as a rule than Iris Versicolor, now much in vogue. Still acids, in the treatment of hepatic affections. more popular is “ Euonymin,” derived Where the alkaline bile is insufficientto coun- from the bark of Euonymus Atro-purpureus; teract intestinal acidity, fixed alkalies are in- a drug now much nsed in the United States as dicated as Prout held (p. 183). well as in Great Britain. “ Hydrastin,” from Soda is the alkali for the liver par excellence. the root of the Hydrastis Canadensis, pos- Of the common condiment of our food, the sesses allied properties; and so does “ Jug- hydrochloric acid goes to the gastric juice; landin,” a resin from the root of the butter- the soda to the bile. nut (Juglans Cinerea). It is officinal in the The alkalies are good, especially potash, in U. S. A. “Baptisin’’ from the root of the rendering lithates soluble. According to Wild Indigo (Baptisa Tincturia) also possesses Bence Jones, alkalies are of great service in a moderate stimulant action on the liver. aiding the oxidizing processes which go on Where a powerful cathartic is required, as in the body. Some persons, however, cannot well as a liver stimulant, then it is well to take alkalies without extreme depression. I prescribe podophyllin; a drug entitled to be know a stalwart Yorkshireman who could not ranked as a potent cholagogue, as well as a take a teaspoonful of effervescing citrate of purgative. Of allied character is a croton- potash for three mornings consecutively, oil, popular a generation ago for the treat- without experiencing such prostration, pro- ment of lumbago connected with lithiasis. duced thereby, that he was unfitted for busi- These agents are all useful according to the ness. Others again can take large quantities, indications in each case in liver trouble, bil- not only with impunity, but with positive iousness, or lithiasis; and may be used with benefit. Murchison recommends that alka- advantage, as cholagogues and hepatic stimu- lies should be suspended for a time, as they lants. may, when long-continued, interfere with Of a totally opposite character in its action gastric digestion. This must depend upon is opium. We cannot separate one action of the evidences of each case. The acid bi- a drug from its otheractions, except by block- phosphate of soda is an excellent solvent of ing out the objectionableaction, by combining lithic acid, according to Ritter von Schroff, an agent of antagonistic properties. Thus, I and might be substituted for the ordinary al- systematically use belladonna with opium in kali. When alkalies, and especially potash, the severe cough of phthisis, to keep off the depress it is well to give them with a tonic. night sweats induced by it. The co-adminis- Potash is a muscle poison, often acting pow- tration of ipecacuan largely prevents the erfully upon the heart. It is easy to counter- action of opium upon the liver; a laxative its act this action by giving with it an agent 74 INDIGESTION AND BILIOUSNESS. which increases the vigor of the cardiac con- the peristaltic movements of the bowels, es- tractions. When alkalies are indicated, they pecially indicated where there is flatulence. should not be taken with meals, or during Phosphorus was often of service in lithsemia the time of the gastric digestion. This is too according to Murchison. Arsenic he thinks obvious to require much insistance. Even often useful when chalybeates disagree—a alkaline waters, as Vichy, Vais, Seltzer, or statement corroborated by my own experi- Bath water, should not be drunk at meals; ence. neither should potass, or lithia, or artificial Now the junior section of my readers may seltzer water be taken with wine or milk then; feel as if they couldlike some more precise in- as alkalies neutralize the acidity and there- dications about the use of the agents just with the activity of the gastric juice. The mentioned. Under what circumstances to waters of Carlsbad, Marienbad, Tarasp, etc., prefer one agent, and why at other times an- may be drunk early in the morning; as may other should be selected. This is very nat- the more potent waters of Pullna, Friedrich- ural, and as far as the subject permits of such shall, Hunyadi Janos, Estill (Ky.), or Bed- handling I will try to tell them. But unfor- ford (Pa.) springs; all the more efficacious tunately only very broad rules can be laid with a little warm water. down, and each case requires its own individ Sulphur springs are useful in some cases of ual treatment just as each man requires his biliousness and the crowds at Harrogate, clothes to fit him, as differentiated from some drinking the waters and “clearing the sys- one else. It may then be said that tem,” as they term it, of the vestigia of per- hepatic stimulants are indicated for sistent over-eating and drinking, tell how the permanent use, to “give a fillip” to inhabitants of the manufacturing towns which the liver, as the common phrase runs. These line each side of the slopes of the back-bone are, ipecacuan, hydrastin, euonymin, iridin, of England, believe in periodical purgation and baptisin, and their congeners, with aloes, as a means of warding off the evil conse- rhubarb, colocynth, jalap, or senna, as laxa- quences of over-indulgence of the palate. tives, with carminatives in pill, combined as Homberg has a like story to tell, and so required; or the more potent podophyllin, have other watering places. As the subject croton oil, or gamboge, where there is stub- of mineral waters will be discussed fully in born constipation. To these may be added the succeeding Part II., when gout is being arsenic or strychnia, according to the phenom- specially considered, it is unnecessary to go ena exhibited by certain cases. Such may be into the subject further here. termed the permanent treatment of the disor- Chalybeates, either as natural waters or in der; to be continued for some time. more strictly medicinal form, are contra-indi- Then for conditions of aggravation, or cated in all cases where the action of the liver acute disturbance, it is well to give a pill con- is embarrassed, and never should be pre- taining some mercurial at bedtime; and next scribed until the tongue is perfectly clean and morning some sulphate of soda with an alkali. the digestion and assimilation restored by ap- Twice or thrice a week this may be done with propriate measures. Iron may increase the decided advantage to the case: the dietary at activity of the oxidizing processes under the same time being carefully regulated and certain circumstances, but when there are ac- adapted to the patient. tive symptoms of hepatic disturbance present In some cases warm baths seem to have an it does harm and not good. About that I excellect effect both upon the liver and the have long been certain. If the reader wish skin; while at other times a large hot poultice to know more about this matter he can con- over the liver stimulates it most satisfactorily. sult the article “ When not to give Iron,” A poultice is clearly indicated with those per- The Practitioner , Sept. 1877, or the second sons who either cannot take much medicine edition of my Practitioner's Handbook. by the mouth, or who are disinclined to try. “ Murchison says: “ In simple lithaemia I In cases of bilious chill,” such a measure, have constantly known iron to increase the in addition to the medicine appropriate there- tendency to deposits of lithates in the urine, to, is often of service. But “the acquired constipate the bowels and aggravate any experience of the individual,” won by the symptoms from which the patient may have sweat of his brow, can no more be transferred previously suffered.” Dr. Garrod writes: bodily to another, than can how to wield a “ It is important that great attention should stethoscope, or see correctly through a micro- be paid to the condition of the bowels and scope; or the apparently simpler matter, allud- liver during the exhibition of iron prepara- ed to before, of keeping six balls in the air at tions, which he thinks “ are for the most part once, a common juggler’s feat, or Mr. Mas- ■contra-indicated ” in conditions of lithiasis. kelyne’s skill in keeping his numerous plates The wish to hasten the patient’s convalesence spinning. The aspirant maybe told “how ” is a laudable one, but to give iron prematurely to do” each of these ; but to “do them he is often to illustrate the adage “the more must learn for himself; there is no “ royal ” “ ” Baste the less speed.” road to it, nor can a crammer do it for Tonics generally are of questionable value him. until their appropriate time has arrived, viz., Beyond the medicinal treatment lies the after a certain progress has been made. The dietary, on which it is not now necessary to lighter bitters as quassia, gentian, chiretta or be diffuse after what has been said in the two cascarilla suit better than cinchona or quinine preceding chapters. The great fact there in- as a rule at first. Strychnia or nux vomica is sisted upon, and reiterated, is, that it is not a capital tonic, stimulating the liver as well as the hydro-carbons of our food, but the albumi- THE TREATMENT OF LIVER DISTURBANCE. 75 noids which are the source of trouble; alike in enjoyment of the eating against the pains of “biliousness” and in “liver-indigestion.” the “bilious attack.” In such cases little can The readily oxidizable hydro-carbons, when be done; for there are some persons whom an excess of food is taken, are burnt up first; even experience cannot teach. Still, counsel or in other words, upon the hydro-carbons and warning may do some good if persisted the respired oxygen is expended, leaving the in. These are the persons who, instead of less readily oxidizable albuminoids imperfect- practicing moderation when their Nemesis ly acted upon. In such manner is a certain overtakes them, or even when they apprehend portion of disturbance in the metabolism of that punishment is in pursuit of indulgence, albuminoids brought about. This, indeed, is fly to the anti-bilious pill and the morning the explanation of the derangement set up by draught, eitherblack draught, Hunyadi Janos, a “surfeit” by over-indulgence in food. This or effervescent citrate of magnesia. By so must be clearly differentiated from the per- doing they educate, or cultivate a vicious version of metabolism which is a vicious hab- habit, and like other foolish people “reap as it, the albuminoids being split up into uric they have sown,” and become, in time, the acid rather than urea. The reader must dis- subjects of well-established hepatic derange- tinguish betwixt these two forms of hepatic ment. Such “bilious” individuals, lacking derangement, else his practice and treatment in discretion, are usually to be found amongst will be unsatisfactory. For the first, more the female sex, but not exclusively so; and discretion is indicated in the future, especially are usually comparatively young. with those who possess a congenitally incom- This brings up the matter of clinical ob- petent liver. Nevertheless, with all children servation that such “ bilious” individuals be- dren it is well to avoid excess in eating. come, in middle-age, dyspeptic or gouty. Probably the children of the present are not This is a very interesting matter for consider- any more addicted to 'over-eating than their ation; the explanation, however, not yet being predecessors; but it is probable they cannot cleared up. The liver seems to become fur- do it with the same impunity. The digestive ther disordered, and instead of an excess of organs are not in “these degenerate days ” bile acids, produces an excess of lithates. It equal to those tremendous displays of would appear, for it would not be judicious to capacity with which our ancestors, in their put the matter more strongly, that in the sys- juvenile years, have been credited: on the tem, while young, any excess takes the direc- other hand juvenile parties, the increasing tion of biliary disturbance, the bowels being use of sugar—due to its comparatively low chiefly implicated, and the urine high colored, price—and the prevalence of rich cakes at the and of high specific gravity, but not otherwise present time, constitute a species of tempta- altered in character; while in more advanced tion to the present generation which they can- life there is indigestion with the production not always successfully resist. That a bilious of quantities of lithates, usually of pale color, attack is a corrective as well as a curative when any indiscretion in diet has been com- agent must be admitted; and the memory of mitted. While the explanation is not yet the suffering helps the future resistance to forthcoming, still it is well to bear the associa- temptation. Still, children are but children, tion in mind, as throwing a strong light upon and a superintendence by their seniors is the function of the liver, and the relations, requisite and necessary. Most children can be clinical as well as chemical, betwixt the bile- controlled; but there are some unwholesome acids and the urine solids.* children who will, fully conscious of the con- This matter tells very articulately that the sequences, gorge themselves when a supply of dietary adapted to lithiasis is also that suited “good things” is available, and will not prac- tobiliousness, viz., a non-nitrogenized dietary. tice moderation. Such children are usually If I seem to insist on this matter, usque ad the offspring of foolish parents, who will not nauseam , my apology must be that the im- look ahead in the matter of consequences; pression that it is the hydrocarbons of our and upon whom all warnings fall unheeded. food which are at fault is so universal, so Maudsley says that the difficulty of dealing deep-rooted, that it is necessary to be explicit. with the insane lies chiefly in their half- It is not “ flogging a dead horse” to speak cracked relatives. So with these foolish chil- dogmatically on this matter, for multitudes of dren the difficulty lies in their silly parents; persons are making themselves ill, destroying who do not see, or will not be made to see, their prospect of future comfort and physical what the future consequences will be, that the well-being, by erroneous impressions leading ■child will grow up the subject of biliary to injurious practices. They live upon the disorder which will cripple its working lean of a chop, some dry bread, and tea or power and embitter its existence. For such coffee without sugar or cream, with much self- children, some one interested in them, who denial, in the vain and delusive search after has their welfare at heart, must exercise for them, and in their behalf, the control in * It may be well to contrast the chemical formulae: which they themselves are deficient With Taurin C H N0 S adults the case is different; and they individ- 2 7 8 Glycogin C 2 H 6 N0 2 ually know better, if they only will try to ex- Bilirubin 6..H, # N 2 0, ercise self-restraint. Yet often such persons Urea C H N 0 “ 2 4 are willful, arguing that they may 8 2 as well Uric Acid C 4 0 H 4N 4O 6 have a good rue (regret) as a bad one,” i. e. , -f4HO BiliverdinC 1#H 20N 2 OB are going to make themselves ill they if they There is a generic resemblance, nothing more or mi ght as well do it thoroughly; balancing the closer. 76 INDIGESTION AND BILIOUSNESS. health, or an approach thereto: instead of a sue-waste! It is not necessary to refute this farinaceous dietary, with stewed fruit. This at length. If not a “dead horse,” it cer- is open heresy flaunting itself, I am quite tainlyought to be. Such an idea should be aware, in their eyes. Further, I am also as extinct as the dodo. quite aware that such a meal as has just been This is a digression, but not a waste of described is more digestible at the time it is time, I venture to think. It helps to intro- taken; will admit it is perhaps the only sort or duce what I am about to say as to the dietary kind of meal which can be taken without dis- in conditions of “ biliousness” and of “liver comfort. Nevertheless, it distinctly tends to indigestion.” perpetuate the trouble; while the other dieta- A certain portion of the albuminoid ele- ry, less attractive at first, perhaps even re- ments of our food passes into the albumen of pulsive and provocative of repugnance, is the liquor sanguinis; another portion passes the one calculated to produce an improve- into the bile-acids; while a third passes into ment ultimately. It is the question of the urea. This is solid ground. The liver per- future versus the present. Present comfort forms the work of elaboration in the first and future discomfort; or present self-denial case; of destructive metamorphosis in the sec- with future improvement. It is the old, old ond, and third. Has the liver a selective story of resisting temptation, or giving way to function ? Does anything go on in the liver it, with future rewards and punishments meted such as goes on in human manufactories, out accordingly. namely, a selection of the fit, with a rejection In great matters so in small, to resist pres- of the unfit? In Messrs. Rogers’ Cutlery ent temptation is to secure future happiness establishment at Sheffield, bones and ivory —to merit a future reward; and in this case the are cut up for knife handles: of these only certainty of the reward is such, while not too some pieces are fit to be used. The fit pieces far distant, as to make it blind follynot to prac- are passed on to the knife-handle maker, to tice fhe present self-denial which is requisite be made into the hafts of knives: the rejected for its ultimate attainment. As in theology, pieces are passed on to the refuse heap, to be so in hygiene, the whole question is whether ground up into bone-duet used to clean plate. the faith is a living faith—vital and capable Is there any analogous action in the liver; any of inspiring confidence—or not. A faith that selective choice by which certain proteid mat- is not equal to inspiring confidence is a hol- ter is selected for further elaboration; while low gourd, a delusion and a snare, if not in- other proteid matter is rejected and either deed a sham. burned up into urea, or utilized in a lowlier Another matter there is about which some- form as the bile-acids? We donot know; we thing may be appropriately said at this point, may never know. It is not likely anyhow just as well as anywhere else, which is con- that this can be ascertained in the life-time of nected with the liver, on which an erroneous the present generation. We can only see opinion is prevalent. We have seen that through a glass darkly. Our successors may urea is a product of the liver. We know that be able to see all in the bright light of noon- the liver is the furnace in which effete blood- day. Some such selective action seems prob- corpuscles and tissue-debris are burnt; there able. Is this the smoke which precedes the is no question about that. But, while ac- flash; asis said on the Russian steppes? Is knowledging all this, it doesnot follow that all this the shadow projected forward of a future the urea has once been tissue. That is an as- solid something; of what physiology may some sumption not warranted by the facts. We day in the far distance make solid ground for know that the liver also disposes of the luxus us ? We cannot say. This much may be consumption of the albuminoid materials of averred, that some such “ notion ” would our food. Let us see what Prof. M. Foster make “ a good working hypothesis,” which says:—“ In dealing with the statistics of nu- would be a useful guide to us in our daily trition, our attention will be drawn to the fact practice. that the introduction of proteid matter into It would help to clear our views, that of the the alimentary canal is followed by a large proteid elements of our food, a portion only and rapid excretion of urea, suggesting the passes on into tissue. That much of the re- idea that a certain part of the total quantity mainder is either burnt as so much fuel, a fuel of urea normally secreted comes from a direct leaving a tremendousresiduum ofash; orisutil- metabolism of the proteids of our food, with- ized in a lowlier form. The ash is the urea. out these really forming a part of the tissues The lowlier form is the bile acid,which emul- of the body ” (3rd edit., p. 404). Yet for some sionizes fats in the duodenum. The matter years back we have been told of the amount must be left here; and our curiosity must of urea passed by fever-patients, as repre- pause unsatisfied, nay dissatisfied, led up to senting so much tissue-waste. It wasassum- the gate of the promised land—and left there. ed, quite gratuitously it would appear, that From this vision, mirage, or reality, who urea was the final stage of what was once tis- can tell, we may now turn, and scrutinize the sue, whether ordinary muscular fibre or blood- reality of clinical facts. These facts we corpuscle; and on this hypothesis rested one know, recognize, and are familiar with in side of the arch. The fact that in fever the practice; albeit a bit muddled from erroneous muscles waste, and that at a high temperature explanation. The theory that bile comes the albuminoid tissues melt down, constituted from the hydrocarbons of our food, is an ignis the base of the other half of the arch. The fatuus, which led our predecessors into a complete arch was this—the amount of urea morass. It underlay the dietary spoken of found in the urine is the measure of the tis- recently, (p. 172), which though acceptable to THE TREATMENT OF LIVER DISTURBANCE. 77 the palate and perhaps to the alimentary canal, dices a patient against a dietary more power- —the solvent portion of the digestive act, is fully than poverty in the number of dishes nevertheless the perpetuating factor of the available. A short list is distinctly deterrent. hepatic derangements. Such at least I hold So it is well to point out that in addition to it to be. Too exclusively albuminoid, it the fruits which are indigenous, and which maintains and keeps up the morbid condition. are readily available each according to their It throws too much work upon the liver, if season, there are a large variety now to be easy of digestion in the alimentary canal. procured at any time, put up in tins. For Starch may be hard of digestion as regards its instance there are grapes, cherries, strawber- solution and progress to grape-sugar in the ries, raspberries, figs, peaches, apricots, portal vein; but then it gives no further pineapples, apples, pears, plums, pumpkins, trouble in its future history. The lean of a melons, cranberries, guavas, and others. Or chop may neither cause pain nor flatulence, the dried fruits, Normandy pippins, apple on its way to being converted into peptones; rings, dried peaches, prunellos, French but its after history is less satisfactory. The plums, figs; all of which are excellent advocates of raw meat for the treatment of stewed. Then the mile pudding can be indigestion may claim that it is acceptable to made with corn flour, hominy, rice, tapioca, the stomach: but the liver may not be pleased sago, crushed cereals, and other farinaceous therewith. A young man may find favor in a matter, so as tofurnish variety. With a little girl’s eyes, but her parent may not be satis- exercise of her ingenuity, the housewife can fied with him. Acceptable enough to her; make a number of combinations rendering the very qualities which weigh favorably with anything like monotony out of the question. her, may be those on which her father spe- That is if she will try! One thing it is well to cially founds his objections. That food bear in mind, that in these cases where it is which is acceptable to the stomach may be desirable to avoid albuminoids, it is well to the very matter which disturbs the liver. In- make these milk puddings without eggs. deed it is these very albuminoids which are They are almost as toothsome without, and the subjects of gastric peptic digestion, and suit much better. Then there are blanc- which sit easily upon the stomach, that we manges, made without Isinglass, which may suspect as most readily “ taking to evil be utilized. Or there are various fruit creams, ways” in the liver; and instead of proper which can be had according to the season. metabolism or elaboration, proceeding down- Strawberries, gooseberries, (gooseberry fool is wards to bile acids or urine solids. They also good), black-currants, wine-currants, red are the suspected any how! In practice it is and white, which may be made with creams, necessary to discriminate betwixt the imme- or eaten as they are. The dread of sweets diate present and that which lies outside and which has obtained will interfere to prevent beyond it. A patient may truthfully affirm the adoption of such a dietary; but I ask the that the lean of a chop, a little dry bread, patient to give it a fair trial. When this is with a cup of tea without milk or sugar, is done I venture to think the results will please the meal which causes the least suffering; them; as they have proved satisfactory to me. and agrees the best. But it does not follow, The salts in fruits may not be great in quan- I assert, that this is the food therefore indi- tity, but they are certainly operative, as we cated for the patient, or really best suited to see in the prevention of scurvy. A recent ex- the requirements of the case. Physiology pedition in the Arctic regions found under must be our guide and interpreter; and not the the snow a little sour redberry which they subjective sensations of the patient during gathered and preserved in barrels for use in the digestive act. Not that these latter are their sledge expeditions, and so prevented to be utterly disregarded: but they must not scurvy; their conduct in this respect contrast- dominate us, or be allowed to silence all other ingfavorably with the contemptuous disregard voices in their own assertive tones. They of such well-known facts as the efficacy of the must be listened to, but only so far; no sub-acid fruits, especially of all vegetables, in further. staving off scurvy, exhibited by the English Having thus differentiated clearly betwixt under Captain Clements Markham. These what is agreeable and what is good; what is salts are good: while the use of fruit regu- acceptable at the time, and what is clearly lates the bowels, a matter of importance in all desirable in the future interests of the pa- derangements of the liver; whether bile-acids tient; it may be well to lay down rules for or lithates are involved. In consequence of the dietary in conformity with what physi- the amount of egg in it, custard is objection- ology teaches. When the patient is advised able. The yolk of an egg added to the milk, to make stewed fruit and cream, or a milk- however, is 'permissible. This combination pudding, a staple article of diet; to have it of fruit with milk and farinaceous matters prepared always for dinner, and to have what should be made one of the cardinal points of is left over at dinner for breakfast next morn- the dietary. If the patient feel “bilious” ing; dismay spreads over the features. There under this regimen, a morning laxative once is something so utterly un-English in such a or twice a week will be found to carry off any breakfast, that the patient looks horrified. superfluity which is disagreeing in the dietary. Yet a great variety of fruit, and of dishes Then there are vegetables to be considered. of milk and farinaceous matters are avail- Potatoes boiled, steamed, mashed, or passed able for the purpose; and this does not in- through a sieve, eaten with milk and butter, volve monotony, a thing most carefully to are good for lunch or dinner—provided al- be avoided in all dietaries. Nothing preju- ways that they be thoroughly disintegrated. 78 INDIGESTION AND BILIOUSNESS. Few things offend a stomach more than a Toast tempts some. Farinaceous matter piece of hard, unchewed potato,, upon which may be cooked with milk, as oatmeal- the stomach can exercise no influence what- porridge, hominy, steam-crushed cereals, ever. The same applies to greens generally, “Cerealine,” a delightful combination, good brocoli, Brussels sprouts, cabbages and cauli- in many ways. Boiled with milk and poured flowers; and holds good of vegetable marrow. into a pie-dish to stand over night; and, next This last, like cauliflower, may be cooked, au morning, cut in slices and fried, it looks like eratin, but should be eaten with care and the most tempting white fish, and is delicious. sparingly. Peas and beans, French beans, Hominy, so treated also, is good. Indeed, and scarlet runners, are all admissible, in lim- if farinaceous foods agree with the patient, a ited quantities only—as containing a large large variety of simple dishes can be prepared, proportion of albuminoid matter, caseine. especially with milk. Then there are carrots, turnips, parsnips, Soups are contra-indicated, unless it be a beet, asparagus, sea-kale, boiled celery, little gravy soup, the poorer the better. onions and leeks. All these are permissible, Pastry is objectionable on account of its as regards their chemical composition, and do indigestibility in the stomach. But with those not tax the liver; but there is the stomach to with whom it does not disagree, there is no foe consulted, and that is a matter not to be objection to its use. forgotten. In each case, therefore, it must For further information as to dishes and be made a matter of experience, what agrees their preparation, the reader is referred to, and what does not; and this, and not any Food for the Invalid, the Convalescent, the rule of thumb, must be made the guide for the Dyspeptic, and the Gouty, by the writer, future in the dietary. The same must be said published by Messrs. Macmillan & Co. of salads in their various forms. They are (Each dish requiring such indication, is ■not to be prohibited, provided they do not dis- marked with certain initials; the interpretation agree. of which is given therein at pp. 26-27. It is Now of fishes, salmon certainly is objec- well to follow what is written there, and all tionable, least so plain boiled, hot or cold, dishes containing meat should be taken in and it is well to avoid cucumber with it. Then moderation.) fried sole is very indigestible; plain boiled it The sort of daily dietary to be arrived at is permissible. Mackerel and herring are un- has been sketched out in Chap, viii., as desirable, unless plain boiled. The flesh of suited for indigestion; and to this the the turbot, brill, halibut, skate, or plaice, is reader may return, and peruse it, and re- admissible, and so is that of the gurnet, and peruse it with advantage. John Dory, what there is of it. Cod-fish is Then as to drinks. Alcohol is undesirable very well suited, whether fried, boiled, or au except in limited quantities. Alcohol is a gratin, or as a fish pudding with mashed po- powerful stimulant to the liver. When taken tatoes. Ling is unobjectionable, so is the fasting, it often produces an amount of heat haddock. Whiting, “ the chicken of the sea,” out of proportion to that evolved in its com- is excellent. So is red mullet; less so grey bustion. It seems to liberate so much of the •mullet. Trout are good in limited quantities. liver-glycogen, by dilating the branches of Eels are apt to disagree with the stomach. the hepatic artery; and so converting so much Shrimps and prawns are good, so are cray- glycogen into grape sugar. When this is fish. The lobster and crab are apt to upset carried beyond a certain amount, then the the stomach, otherwise they may be eaten in vascularity of the liver is increased, and it •moderation. Oysters are good, and so are becomes enlarged in size; subsequent con- mussels, for those who like them. traction follows, with ascites and dropsy in Of fowls fair quantities may be taken; but its wake. It is then to be taken sparingly. A their flesh is rich in albuminoids, be it re- little claret, Carlowitz, Graves, or Hock, may membered. First comes the chicken, boil'ed; be taken by those who feel that some such ►cold, with or without salad, if the stomach beverage is required to enable them to eat, approves. Then the pigeon, the pheasant, and enjoy their food. Others find a little and the partridge, grouse, black-game, caper- simple spirit, as brandy or whiskey, in plain cailzie, prairie fowls, quails, snipe; all in lim- or aerated water, agree best with them, Po- ited quantities are permissible. The duck and tent wines, and all malt liquors, are to be the goose, and the turkey, unless it be a little avoided. of the breast, are to be avoided. Aerated water alone, or with a little milk, Of “ flesh-meat” pork is poison. Beef is or some syrup are also indicated. If also less objectionable, and so is mutton. A little alkaline, it is well not to take them during of either, cold, may be taken at lunch. Veal gastric digestion at least. is to be avoided, unless it be in the form of Beyond the dietetic and medicinal treat- sweet-bread. Lambs-fry is permissible, or ment of conditions of hepatic derangement, lamb’s head boiled is often nice for a weak lie the matters of change of air, and mineral stomach. springs. It may be laid down as an axiom “ Of potted meats they offer no difficulties in that bilious persons are always worse in a the way of disintegration; any may be taken low-lying, and warm locality; and are the sparingly as sandwiches, made with thin slices better for being in a fairly bracing atmos- of stale bread, with the butter rubbed well in- phere.” For instance, to take London, such to the bread, and spread not too thick. persons are never well in the basin of the Bread maybe eaten,best stale, or as whole- Thames, and are always improved by getting meal bread; then biscuits are digestible, to the hills that skirt the valley. In Brixton APPENDIX. —FAILURE OF THE DIGESTIVE ORGANS. 79 they feel good for nothing, and are always But each case requires its own manage- ailing. On the slopes of Hampstead and ment adapted to the patient’s wants, require- Highgate they are comparatively well; or on ments and exigencies. The attempt has here the Surrey hills around the Crystal Palace. been made to describe the digestive act in the This illustration will serve for other neigh- alimentary canal first and then after that the borhoods. The oxidizing processes are much function of the liver; to give the readers the favored by a bracing locality. Consequently the broad lines upon which to proceed. they should not return to India or the tropics, Sometimes the track is clear and distinct, if there be any reason to suppose that the se- sometimes broken and indistinct, despite the creting structures of the liver have received light which advancing physiology is throwing any permanent damage. A liver which may upon it. The liver is the largest of all the suffice, with care, to carry on its function glands—has a function proportioned to its in Great Britain may be quite unfit for a life size. Up to a recent period we knew in India. The injury inflicted upon the liver nothing of its functions except the produc- by one residence in India, the West Indies, tion of bile. Now, however, we recognize Guiana, or Guinea, incapacitates the organ that it possesses a most important action for another such experience-—which, there- on the one hand—(i) upon the further elab- fore, should not be adventured. And what- oration of the crude products of digestion ever applies to a liver unaltered in size and in the alimentary canal; and, on the other free from any mutilation of structure, as that hand, (2) upon the destructive metamorphosis caused by an abscess, applies even more of albuminoids. It is then intimately re- stringently to a liver which has been crippled lated on one side with indigestion and mal- by disease. To speak broadly, then, in hepat- assimilation; and on the other with lithiasis, ic derangement it is well to avoid warm, or gout in its widest sense. Its relations damp, low-lying localities, either as tem- with the first have been given: in Part II. I porary or permanent residences; unless it be will strive to describe its relations with the when an east wind is blowing. This disturb- second; and, therewith, the disturbances and ing element upsets all ordinary calculations, diseases to which such lithiasis gives rise in and when in action must be allowed for. its turn. Consequently in summer the east coast is to The fat of our food does not, as do sugar be preferred to the south or west. Again, and albuminoids, pass into the venules of the Ilfracombe is to be selected rather than Tor- portal vein, and thence to the liver; but is quay or Dawlish. The Welsh resorts must taken up by the lacteals. The liver, then, be classed by the same rule, and so must all takes no part in the assimilation of fats; ex others over the face of the globe. For such cept that its bile aids in the emulsionizing of as are fortunate enough to be able to afford fat in the upper bowel. it it would be well to change their residence (While these sheets have been passing in winter and summer. through the press, a copy of “ Observations Then, as regards watering-places, the same on the Constitutional Origin and Treatment rule will obtain, viz., a bracing locality, ex- of Local Diseases,” by the famous John cept when the east wind is blowing. Sul- Abernethy, F.R.S., dated 1809, has been phur springs, with a laxative in the water, lent me by a patient, who was re-arranging suit biliousness; alkaline waters are adapted his library; and coming upon the volume, for the treatment of lithiasis. But periodical opened it, read some of it, and was struck excursions to such watering-places must not by what was written there, as being almost be made an excuse for indulgence in the in- the very remarks made by myself about his terval, as is the case with ordinary individuals. regimen. It is gratifying to find myself in The patients “ with a liver” will soon find accord with so capable a man. Medicine has that this is a practice not adapted to their forgotten a good deal, as well as learnt much individual requirements, nor calculated to this century!) improve their condition. Abstinence and self-denial must rule them in their every-day APPENDIX. walk in life. But all are human, and as such liable to err—toslip on the narrow path; and if a family festival, or an important cele- THE FAILURE OF THE DIGESTIVE bration, should lead to some departure from ORGANS AT THE PRESENT TIME. the beaten track, a mercurial pill and mineral The perusal of the foregoing chapters will laxative are permissible; but they should be have shown the reader that there actually resorted to with distinct sense of failing, of exists, or at least I hold there exists, a strong weakness—like the conviction of sin experi- tendency to failure in the organic processes enced by a penitent at the altar. at the present day. These organic processes When at the sea-side it is not advisable for furnish the elaborated pabulum for the organs persons who suffer from any form of hepatic of active life: —albumen for the tissues gen- derangement to bathe much in the sea, es- erally, hsemoglobin for the red blood cor- pecially in the early morning. The “ dip” puscles, and lecithin for the nervous system. should be brief and far short of any chill. It The tremendous demands made upon the should be taken about 11 a. m., and be fol- nervous system at the present time is believed, lowed by a walk. The warm bath, followed by others as well as myself, tobe the cause of by an hour or two in bed, to keep up the ac- this failure. The effects of mental worry, tion of the skin, is a measure whichhas much to and emotion upon the digestive and se- be said for it, and agrees with many very well. cretory functions is given in Chap, vi., 80 INDIGESTION AND BILIOUSNESS. The increased demand upon the nervous it is now quite usual to send the young An- system, and especially the cerebral hemi- glo-Indian to Europe to be reared and edu- spheres in the present day, is telling upon cated. It is said that in the third generation the whole of the digestive organs, and the Anglo Indian dies. Be this the exact especially upon the liver; which carries on the truth, or only an approach to it, it is a fact of further elaboration of the crude products of grim significance. digestion in the alimentary canal. As we The same fatality has been found to at- saw, glycogen is stored by the de-hydration tach itself to the aborigines of large towns. of the grape sugar in the portal vein; and It appears that without regular and repeated from these stores regular rations are given off infusions of new blood by incomers from the by hydration, under the action of the liver country, the town-dweller would perish off ferment, to the blood for the production of the face of the earth. A deterioration is body-heat and force. Then the liver not only wrought by a protracted residence in a elaborates the products of thegastro-intestinal large town. What said Lugol, the great French digestion of proteids; but it is the furnace in authority, about the inhabitants of Paris: — which effete, waste, and surplus albuminoids “ Scrofula shows itself in the third genera- are burnt. The bile aids the pancreatic tion of those whose ancestors entered Faris secretion in the emulsifying of fats. full of health and vigor, and from the third Now it was abundantly shown that mental generation the malady rages even to the utter states profoundly modify these processes, as extermination of the family name.” This is temporary conditions. Not only that; but a very frank statement, without reserve, by there is much pointing in the direction that an eminent authority; and its frankness is the pace at which we live nowadays, is quite equalled by its gravity. ‘‘To the utter exercising a persisting effect upon the digest- extinction of the family name,” i. e., to com- ive organs, of a deteriorating character. The plete extermination. From this it would dental caries, so prevalent, indeed universal seem town-dwellers are a doomed race. at the present day, is but a part of the gen- The population of towns is now in excess eral widespread failure of the digestive or- of the country in Great Britaiu. The food gans. Our grand-parents hardly ever heard of town-dwellers is inferior to that of the the word “ dentist,” but the present genera- peasant population, as all familiar with the tion know him well; and if they do not re- subject only know too well. The revelations gard him with affection, at least recognize his of the Factory Commission amidst the toiling utility. The increase in the demand for lax- millions of our manufacturing towns, especi- ative medicines is demonstrated by the per- ally those where spinning mills are common, petual advertisements which meet the eye, are as instructive as they are appalling. The from natural waters, through an almost end- evidence of Dr. Ferguson, of Bolton, before less series, to Holloway’s pills. Constipa- the Commission, told a terrible tale as to the tion is not claimed to be a modern malady; infant mortality, and the deterioration of the what is asserted is, that it is on the increase. physique of the young mill-hands when ap- Up to the days of our parents, children had pearing to be certified for work in the mills. porridge and milk for breakfast, took them Dwarfing was on the increase in spite of the well, digested them (for “ porridge” always Factory Acts. (And the improvement which requires the plural with it), and throve on resulted from these beneficent acts is readily them. The American on the boundless admitted by those who knew the mill dis- prairie is “ raised upon hominy,” and in his tricts on each side of the slopes of the back- physique is a contrast to the product of the bone of England, before and after the pas- Eastern States—the advantage not lying sing of these acts.) One bright spot alone with the New Englander. The diastase of was visible amidst the darkness and the the cerealia has only of late years been gloom, and that was the good effects of a cer- pressed into the service of man, to supple- tain amount of milk in the dietary, in the ment the failure in the natural diastase of the improvement of the physique. Those who salivary secretion. Our predecessors knew feel interested in this matter can consult The as little of diastase and its functions, prac- SanitaiyRecord for July 17th and Sept. 25th, tically, as did the chemist, scientifically. 1875. Pepsin derived from animals, or even a A dietary of tea and bread and butter was plant —the papua, Is also of recent date. much improved when a certain amount of The pancreatic secretion, scientifically and milk was added to it. Now the steady in- practically, is a matter strictly of our own crease of the population of towns is a fact; times. that the increase will go on further and fur- Whence comes the profound modification ther is as certain as that to-morrow’s sun will of the organic processes, the commissariat of rise. The subject is one of the gravest im- the active or animal part of the body? It is portance to us ; of even greater im- the effect of modern demand upon the ner- portance to succeeding generations. Of vous system, it is believed; and not without a course, for the toiling millions, little can be good amount of evidence for the belief. done beyond the building of airy and com- We know that the body is influenced in the paratively healthy suburbs, and the estab- direction of deterioration by subtle forces. lishment of workman’s trains, night and The inability of the Anglo-Saxon to inhabit morning, into the larger towns; and the in- India is a well recognized fact. The chil- culcation of broad principles about food and dren of Anglo-Saxon parents, born and drink, fresh air, pure water, and effective reared in India, deteriorate so markedly, that drainage, The poor have a hard lot indeed! APPENDIX. —FAILURE OF THE DIGESTIVE ORGANS. 81 But for those whose means permit of their indicates something wrong with it elsewhere. consulting the health of their little ones, The air of these Hampshire downs is very something more may profitably be said. Un- bracing, and whets the appetite of the human palatable much of what is to be written will beings as well as racehorses who reside on, or be to many. Impossible, perhaps, to a few. near them. But as children owe a duty to parents, so My enquiries were directed to the matter parents owe a duty to those children whom of any possible failure of the digestive organs they call into being. The State now takes in the racehorses of the present, due to the care that the children shall have at least the excitement and mental tension of their mode rudiments of an education; it protects them of life. This may seem somewhat whimsical from small-pox by compulsory vaccination, to some readers; but the racehorse, I am one of the most beneficent of all discoveries. credibly informed in the absence of any per- It guards their dietary by the Food Adulter- sonal knowledge, lives a life of much ex- ation Act. Then milk is brought in tins citement and full of incident. Some enjoy from the mountain pastures of Switzerland, the race; others dislike and dread the event, in unlimited quantities; about the purity of or, to use the precise expression for it for which no doubt can reasonably be enter- which we have no equivalent in ordinary tained. The fat-containing maize is brought English, “funk” immensely when being to us in numerous forms. There is no diffi- got ready for the race. It seemed, there- culty in providing milk and a farinaceous die- fore, desirable, in order to make my observa- tary for our town infants. Much can be tions on the matter of the nervous relations done for them; but more must be done still. of indigestion as complete as possible, to ex- Artificial digestive agents may be given with tend my enquiry to animals whose existence suitable food, to aid in and perfect the nat- entails much demand upon the nervous sys- ural digestion. But something more is de- tem; as the life of a racehorse undoubtedly sirable. does. The results of my enquiries were For our animals, and more especially val- strictly negative; at least as regards these uable stock like race-horses, breeding stations Hampshire training stables. But there is in healthy localities are provided. Surely much analogy betwixt the existence of race- the offspring of cultured human beings are as horses and human beings. Especially young valuable, and worthy of as much care as the racehorses, run as they now are so largely at descendants of “ Stockwell ” and of “West two and three years old. It seemed quite Australian!” Something similar is desirable in possible, that this early training and nervous the shape of institutions, placed in suitable tension might affect the young horse; just as localities and under proper supervision; life in a large town affects human infants in where town-born children could be received the way of failure of the digestive organs. in tender years, and reared. Plenty of exer- But so far there is no evidence of any such cise, in the open air, would secure an appe- cause and effect; and this I am inclined to tite for simple food, as well as the perfect attribute to the fact of young racehorses be- oxidation of all waste matter; and the child ing reared in the country, in the healthiest placed under such favorable circumstances, localities that can be secured for the purpose. would be as free from deterioration as is the When we consider the life of children of racehorse. For, though much has been said the present day in large towns, we become about the deterioration of the racehorse, it painfully aware of the truth underlying the does not appear that any falling off actually old adage:—“You cannot both eat your exists. Certainly the practice of training cake and have your cake.” The town-child them so early, as is now the fashion, is not is provided with innumerable and many very good for these immature scions of a noble elaborate complex toys in its nursery. It is race; but from personal enquiries made of constantly carried to sights which will please Mr. John Day, the well-known trainer at it, and, in doing so, excite it. Its little life Danebury, and his neighbor, Mr. Tom Can- is a round of gaiety, so far as its indulgent non, the equally well-known jockeyand train- parents can manage it. It is taken to the er, no falling off is discernable in the racing circus, to the pantomime; it has its children’s stock of the present. Indeed, in the opinion parties, and balls; it is educated to mimic of the latter authority, the young stock of the the life of pleasure, Heaven save the mark! present is actually an improvement upon of its seniors. Everything to “force” its anything which has preceded it. This came brain is aggregated. And a forced product out casually during an enquiry into the feed- it is, in its precocity! But precocity, the late ing of racehorses, and their training; which Prof. Laycock held to be an undesirable is very severe and trying. One of the great- matter, as incompatible with a full est sources of anxiety to the trainer is the and complete development in the failure of the appetite. This entails the sus- adult; and those who have paid atten- pension of the training. It was said be- tion to the matter agree with him. The fore, that the use of tonics and bitters little infant of the Lemuridae, a lowly form is not unknown among the training establish- of monkey, will follow its mother the day it ments for racehorses; but in neither of these is born; but it is only a Lemur when its full Hampshire training stables are these adju- potentiality is realized. vants adopted. Indeed, in Mr. Cannon's The little Baboon baby rolls on its back, opinion, simple loss of appetite in a healthy and gazes at its extremities in perplexity and young racehorse, never occurs; he holds that wonder for about a month before it com- when the young horse is “ off his feed,” it mences its peregrinations; but it develops 82 INDIGESTION AND BILIOUSNESS. into an anthropoid ape ultimately, capable of This is rather wandering from the exact much that is impossible to the Lemur. The subject matter,—pursuing a side-issue in human baby passes through a longer and legal phraseology, but it bears on what is more protracted period of helplessness, but being discussed here, viz., the development it possesses the potentialities of a man in it; of a healthy physique, endowing its possessor and may develop into an engineer who can with greater potentialities in the future. The span a river, throw an iron girdle over an child reared in the country has a brisker ap- estuary; or an astronomer who can weigh the petite and a better digestion than the town- stars in his balance, and calculate the pertur- child. If his growth is slower, he ultimately bations of the planets, or the erratic path of attains a larger stature. Quetelet “ Sur a comet. l’Homme ” proved this about the physical Early development is not to be desired, stature; it is equally true about the mental and the forced products of town life can no and intellectual stature. How far imperfect more last well, than does the racehorse raced digestion and assimilation is the cause of the long before his period of growth is com- arrested development, either wholly or in pleted. The promising two-year old, and part, may scarcely be apportioned; but it is a the quick-witted town-child, neither possess factor, beyond question. Girls develop more much prospect for their later years. The com- rapidly than boys; but their ultimate de- paratively dull, stupid, heavy country child velopment is less than that of boys. This has a farbrighter future before it. It is keeping side issue is intimately linked with the exact its cake, not eating it. It is building up a matter under discussion, viz., the rearing of stalwart frame; its brain is comparatively in- town bred-and-born children in the country. ert “ lying fallow;” its energies are not ex- Of course the objection will be raised, that pended in a round of variety and excitement; it is impossible to send the children away. it is slowly developingits utmost potentiali- Well ! The Anglo-Indian has to do it. And ties, not being exhausted prematurely. This there is no evidence that Anglo-Indians are is an aspect of the subject which cannot be wanting in family affection, only they have overlooked in any scheme for the improve- learned to subordinate their own feelings to ment of future generations. Lugol found their children’s welfare. And the town-resi- struma grow up in town-bred children; and dent at home, not in Great Britain alone, but what is struma but an impaired protoplasmic wherever the Anglo-Saxon has raised his digestion, a tissue deterioration? Such chil- tent-pole over the face of the earth, must dren if born of country people and reared learn to do likewise. The ghost of the R'd in the country would have been free from Indian flitting around the old burying-places, any such tissue-degeneration. and dreaming of the old wigwam standing This subject is one which has long engaged where a huge town now exists, has the sinis- my attention, and in November, 1877, I de- ter consolation of thinking that the white livered a lecture before “ The Londo7i School- man cannot live on the land he has usurped ” Mistresses' Association upon “ The Rela- —without special precautions. The red- tions of Growth to Education,” which was man’s grave is covered with the white man’s subsequently republished by them as a buildings, solid, massive, immense; but his pamphlet. More recently the matter has first-born die in them. Colonel Pyncheon “ been fully considered in a pamphlet “ The erected The House of the Seven Gables,” Physiologist in the Household, Part I., Ado- where Matthew Maule had built his rude hut, lescence” (published by Balliere, Tiftdall & “shaggy with thatch;” but a Nemesis hung Cox, 1880); which I venture to believe is around the land snatched from the murdered worth perusal by those specially interested in man. “God!” said the poor man, on his this subject. Oliver Wendell Holmes in way to the scaffold, innocent of the crime of his quaint pithy way alludes to this subject in witchcraft for which he was condemned to his “Autocrat at the Breakfast Table.” die,—“ God will give him blood to drink.” He writes—“ Men often remind one of pears So may the ghost of the red-man of the in their way of coming to maturity. Some present possessor of his land, too. The are ripe at twenty, like human jargonelles, Anglo-Saxon has exterminated the Red In- and must be made the most of, for their day dian, “Thou shalt want ere I want” has is soon over. Some come into their perfect been his creed. The waning Indian had to condition late, like the autumn kinds, and vacate his possessions for the Yengees, that these last better than the summer fruit; and they might increase and multiply on the face some like the winter helis, have been hard of the earth. And now what is the result ? and uninviting until all the rest have had The Anglo-Saxon is a dying race, perishing their season, get their glow and perfume long beside the tomb of the red-man whom he after the frost and snow have done their worst slew. It is “ Naboth’s vineyard,” in the with the orchards. Beware of rash criticisms; nineteenth century! the rough and stringent fruit you condemn What if this grim and terrible fact be an may be an autumn or a winter pear; and that undoubted fact; and it seems that the threat- you picked up beneath the same bough in ened extinction of the old population, so im- August, may have been only its worm-eaten mediate for Massachusetts, is being inaugu- windfalls. Milton was a Saint-Germain with rated in Ohio. The nutrition of the Ameri- a graft of the roseate Early-Catherine. Rich, can-born woman is often unequal to feeding juicy, lively, fragrant, russet-skinned old a second organism; or if that second organ- Chaucer, was an Easter-Beurrfi; the buds of ism has successfully struggled into an inde- anew summer were swelling when heripened.” pendent existence, it is unequal to its main- APPENDIX. —ON THE FAILURE OF NUTRITION IN CHILDREN. 83 tenance for long. The spectre of the exter- tlmm by no tie of blood. All this may be minated Red man sees death reaping a rich very repulsive; but unfortunately it is una- harvest among the babes and sucklings of voidable! Some such practice, which will, his enemy; there are other graves being dug enable children to be reared in the country, alongside those of his ancestors’. The angel must be adopted before long. Food of the of death is smiting the usurper in turn. If most digestible character may be supple- this be so, the American has the sorry conso- mented by artificial digestive agents; but lation of knowing that in his old home, in this is only palliative as regards the individ- the cradle of his race, the same phenomenon ual,— it is not curative as regards the race ! is to be observed; only not yet to so distinct The town-population in Great Britain now and terrible an extent. The Anglo-Saxon constitutes the majority of the people. The exterminated the native British; there was no issue is a sharp one: and must ere long occu- compromise; the conquered Briton did not py the attention of our legislators. But it is become “a hewer of wood and a drawer of to be feared that any such action must be water”—the serf of his victorious assailant; preceded hy much outside discussion of the he perished, died out absolutely. The An- question. How, and by what precise meas- glo-Saxon settled down on the vacated lands ures the evil has to be met, and, if possible,, and increased and multiplied. For genera- vanquished, it is not for me to say here. tions this process went on, successful and First the evil must be fully appraised before unchecked. Dirt, filth, the disregard of all adequate measures for dealing with it can be hygienic laws, the neglect of the sanitary ar- formulated. My duty extends to pointing rangements of old Roman civilization; the out the actual facts, and indicating the di- crowding, the narrow tenements; indeed, the rection the proposed measures must take; to necessity for regarding a town as a fortress go further would savor of impertinence, and. in the interminable wars of the dark ages, over-weening vanity. The actual solution of and erecting the houses accordingly, brought the problem will engage many minds, and plagues in their wake, often exterminating exercise many intellects, before “Eureka” the inhabitants, and causing the markets to can be shouted. be held in the open country at some distance. In order, however, to grapple with the dif- Now the scene is changed, but not the venue. ficulty in a practical form, and to do what Where the wattled huts of the ancient Briton can be done, until such arrangements can. once stood, amidst sacred groves devoted to actually be made for the rearing of town- Druidical rites, now we see the many-storied children in the country, I give some valua- mill, the long chimney belching forth smoke, ble remarks by Prof. L. Duncan Bulkley,. the endless rows of cottages inhabited by the M. D., of New York, the wearer of an hon- toilers who work in the mill. The angel of ored name. Dr. Bulkley and myself dis- death is busy still. With the practical turn cussed most earnestly the question of the of his race the town-inhabitant protects him- coming race—if there is to be one at all—on self and his young, so far as lies in his power; the banks of the Cam, at the Annual Meet- brings his water from long distances, con- ing of the British Medical Association, 1880; structs elaborate sewerage arrangements, and now, by his courtesy, I am enabled to thus copying the wisdom of the old heathen lay before the reader what he has found de- at last; further, he has appointed medical sirable in the interests of the children in the officers of health and analysts, still more to U. S. A.; whose necessities are indeed greater guard him and his. He has learned that than ours. poison germs may lurk in his water, and still more in his milk supply, since Dr. M. W. Taylor, of Penrith, first pointed out the dan- “ON THE FAILURE OF NUTRITION ger hidden in the milk-can (1858); and re- IN CHILDREN, WITH ITS TREAT- peated outbreaks of the scarlatina, following BY DR. BULKLEY. milk supply, have driven the lesson home. MENT, He has provided so far as in his power lies, The nutrition of the body is dependent on against these fluid-borne diseases; and the very many different factors, all of which tale of the dead so slain is but as a unit must be perfect to constitute perfect health. against myriads. For one victim to zymotic Nutrition in children has to do with two disease, a holocaust perish from failure in quite different elements; first the growth of their digestive processes. For one infant ly- the body, and second the repair of waste. ing in its last sleep from specific germ carried Failure in nutrition to a greater or less ex- pyrexia, a thousand wasted marasmatic atom- tent must involve defect in one, or both of ies are to be found in their graves from im- these respects; when the growth of the body proper food and an imperfect digestion. is interfered with, the actions of life are de- It is time then that some general united ranged. Failure in nutrition in children has effort be made to arrest this slaughter of the two great causes, which are hereditary or innocents; compared to which Herod’s acquired. Far too much stress has ordinarily massacre was as nothing. It may be been placed upon the former, which, of costly; it may entail many sacrifices ; course, is irremediable; whereas the latter, the parent may have to consent to separa- upon which in reality the greatest measure tion from the child; children may have to of the difficulty rests, is quite amenable to grow up no longer under the parent’s eye, careful and judicious treatment. We will except at intermittent periods; but under the first, therefore, briefly dismiss the former, or skilled supervision of guardians bound to hereditary causes of failure of nutrition, in 84 INDIGESTION AND BILIOUSNESS. •order to devote more thought to the second the constitution of the patient; and this is or acquired causes, upon whose proper recog- especially true with regard to children. But nition and understanding must rest much if a reasonable amount of care and judicious of success in medical practice. thought be given to the cases, these features In regard to hereditary causes of imperfect may be understood and developed by one nutrition in children, all cases may be divid- who has but recently met the person affected. ed into three great subdivisions; first, those And success in practice depends to a very exhibiting the influence of the strumous hab- large measure upon the grasp which the phy- it; second, those showing the gouty; and sician takes upon the idea as to the constitu- third, those characterized by the nervous tion, or state of the child he is to treat. temperament, or habit. There can be no But if the knowledge and appreciation of doubt that as children manifest to a greater these feature are valuable in the treatment or less extent certain physical peculiarities of of disease, or the restoration to health of form and feature, and also certain mental those suffering from imperfect nutrition; a idiosyncrasies; and as certain diseases, as perfect comprehension of the elements next syphilis, can undoubtedly be transmitted to to be considered is, if possible, yet more im- offspring; and certain conditions of system, portant. For the features which have been or tendencies thereto, such as phthisis, gout, dwelt upon belong so completely to the con- rheumatism, and cancer, can likewise be stitution or state of the individual, that fre- transmitted; that the less pronounced states quently they cannot be altered to any very of physical constitution can in like manner great extent by the physician; whereas the be handed down, so that the individual with elements relating to the daily life of the pa- the strumous, gouty, or nervous habit, or tient, next to be treated of, are such as the condition, transmits the same even to the physician can affect; and upon his proper child at its youngest period of life. Thus management of them, will rest, to a large de- we may have developed and exhibited in the gree, the success. infant these stages to a greater or less de- We come therefore to the second, or most gree, and they may act as sufficient causes in important element, or factor of failure of nu- modifying its nutrition. trition in children, namely, the acquired We therefore see a certain number of in- causes of its beginning and continuance. fants, or very small children, exhibiting signs There is no one who has even the slightest of imperfect nutrition, which are intimately knowledge of botany but recognizes that the dependent upon the state or habit of body plant-life is different, not only in various sec- which they have acquired with birth. The tions of the earth, but in different portions of strumous child speaks plainly by its light the same tract of territory, according to the delicate hair, its pasty-white complexion, and relations existing. Not only is there the vast its enlarged lymphatic glands and flabby difference between the products of the earth, muscles; either with very light or very dark of temperate and tropical climates; but in the eyes, long eye lashes, large nose, thick upper temperate zone we find the greatest varieties lip; and- if skin lesions form they will be in nature, according to the soil, situation, characterized by the development of pus and moisture, and sunlight, etc. We would a tendency to the formation of thick scabs, never expect to find the lily of the valley, or crusts, not accounted for by the intensity or wood violet on top of a mountain, nor the of the inflammation. Its failure of nutrition mountain shrub pine in the depths of the will be exhibited rather by the great appe- valley. Certain plants absolutely require a tite, decayed teeth, swollen abdomen, often certain soil; if they are placed in any other, filled with wind; tendency to constipation they wither and die. One will require a and intestinal worms. The gouty child will great amount of moisture; others but little, show a tendency to an acid stomach, as an or none. The same is true of the animal infant will often vomit milk, will have occa- creation; one animal thrives upon food on sional attacks of constipation, alternating which another would perish. Therefore, with diarrhoea. Will very frequently be upon the proper selection and administration restless at night as a result of its indigestion; of food, or the proper regulation of the hy- and if skin lesions manifest themseves they giene and surroundings of the patient, de- will be characterized rather by a redness of pends the measure of health which it is to surface, great itching, tendency to watery enjoy. The cause of failure of nutrition in exudation, drying into thinner scales or children, in by far the larger proportion of crusts, with much less tendency to pus for- instances, has to do with external factors mation. The child with the nervous habit rather than with hereditary states. The diet or temperament will show its failure of nutri- and hygiene of the child require to be regu- tion by an irregular and fitful appetite, and lated with the utmost nicety, if we would se- easily deranged digestion, especially inter- cure perfect nutrition. Even as a hot-house fered with by nerve causes, as over-excite- in which delicate plants are being reared, re- ment, &c. It will be wakeful rather than quires careful skill and thought; ignorance in restless at night, and irritable during the one will be followed by evil results, quite as day. surely as ignorance in the management of the These states, or conditions which belong other. more or less markedly to infantile cases, are Instinct is undoubtedly given to living be- important to recognize. And there is un- ings for the purpose of the preservation of doubtedly no little truth in the old idea, in the species: and when allowed to operate un- regard to the family physician understanding disturbed may be very largely and safely re. APPENDIX. —ON THE FAILURE OF NUTRITION IN CHILDREN. 85 lied upon. In the lower animals instinct un* drank should be diminished, especially if it doubtedly is all sufficient for the maintenance is used in excess. Milk answers best in the of perfect nutrition in the young as well as in large proportion of instances, for the mother, the adult; provided that other causes do not and if it is not well borne at first the habit of operate in too great a degree. But animals taking it can be acquired. Very frequently and birds can readily be made sick by temp- it is necessary to add a little alkali, and the tations offered them in the way of food; also liquor potassse, io or 15 m., may be added to by deprivation of air, light, etc. The natural each tumbler-full of milk. instinct of the young infant is for milk; and In not a few instances the milk furnished upon proper milk it thrives. Older children by the mother is absolutely too weak to sus- are quite satisfied with very simple food, pro- tain the child properly, and the mother’s vided they are not attracted by other things. health must be improved by such tonics as It must be remembered, however, that in- iron, bark, cod liver oil, etc. stinct cannot be trusted to entirely in chil- The nursing child with mal-nutrition may dren because of the many perturbations to also be benefitted by the exhibition of certain which life is subject, and of the many temp- remedies; although in the main the proper tations which appear on all sides to trans- supply of milk, with sun-light and fresh air, gress the rules of health. The child is then and absence of nervous excitement, will gen- dependent upon the intelligence and knowl- erally be all sufficient. Constipation is a far edge of those older than itself; and it certainly more common state even in infants, than is does not answer to allow the tastes of usually supposed; and many will be found the infant, or child, to be the guide in who are dependent for their daily action of the matter of diet and hygiene. On unsuita- the bowels upon enemata, or suppositories of ble food, given in an improper manner, per- soap, etc. The occasional administration of fect nutrition certainly will not be main- a proper dose of calomel, will in some cases tained; and for the perfect development of' be of the very greatest service in promoting the child care and thought should be exercised the nutrition of infants. This of course by its guardians. should not be persisted in to any great ex- As failure in nutrition may be due to im- tent; but occasionally it may be given with proper food, so it may also be due to imper- advantage as often as every few fectly prepared food. Coming now to the days. Pepsin, or lacto-peptine may actual facts, the food which the infant feeds be used with very great advan- upon, the mother’s milk, may often be great- tage at times in even very small infants ly impaired in its quality; and where there exhibiting imperfect nutrition; either a little is failure of nutrition in the infant child at placed dry on the tongue, or held in suspen- the breast this should always be looked to. sion in flour-water, or the like, taken at each In nursing infants with eczema it will con- time of nursing. stantlybe found that the health of the mother In many instances, especially in strumous is not perfect, and a careful investigation will children, cod-liver oil will be found to be of always find elements to be corrected in it. It the greatest service, even in very small in- is very common to find that the mother is in fants; although their power of digestion of the habit of consuming large quantities of fats being small, it should be given in very tea, or perhaps beer, ©r ale, or takes wine small quantities, and not too often. It may pretty freely; or perhaps she is taking strong sometimes be used with great advantage in chocolate, or milk, in order to promote lac- the way of inunction; and linseed oil, or tation, and these disagree with her, causing sweet almond oil may be substituted for this dyspepsia. Or she is constipated, or in her purpose. urine she has disorders indicative of derange- Again, very many children, especially those ment of digestion and assimilation. Now, if of a '‘gouty stock,” will have their nutrition these elements exist, if the mother’s secre- very greatly benefitted by the administration tions, as from the bowels, kidneys, skin, of a small quantity of alkali; for this purpose, liver, etc., are not healthy, certainly the se- perhaps, lime water answers very well, hav- cretion of milk is not healthy—and thus it ing the additional advantage of supplying the cannot afford the proper nutriment for the elements necessary for the growth of the ■child. In the case of nursing infants, there- bones. But sometimes this is distasteful, fore, exhibiting the signs of failure of nutri- and sometimes it seems to fail; we may then tion the attention should always be turned use the liquor potassse with advantage. In- first towards the mother; and in a very large quiry should always be made in regard to the percentage of cases, errors of assimilation and urine of these little ones, and if it is found integration will be found in the mother, to stain the diaper much, an alkali should be which must be corrected before we can hope used, with remedies calculated to act upon for or expect great and permanent benefit to the kidneys. For this purpose the following the child. It must never be forgotten that prescription will often be found of very great the mother may have extensive oxaluria as value: almost the sole indication of mal-assimilation, 1$ Potassse Acetatis 3 i.— 3ii. •or she may have simply a coated tongue, acid Spiritus Ether Nitrosi 3 i-— 3 ii. taste in the mouth, or other signs, or she may Liquor Ammon. Acetatis § ii. shave a general tired feeling, especially in the A teaspoon ful three or four times daily morning after sleep. The nursing mother near the time of nursing. should not be allowed, as a rule, to take fer- If there is much restlessless at night, and mented liquors; and generally the quantity any tendency to feverishness, a little aconite 86 INDIGESTION AND BILIOUSNESS. may be added to this mixture with great ad- pr one which has been found serviceable in vantage. what seems a similar case. These cases can- Many infants receive, in addition to the not be treated upon a written plan. The parent’s milk, or perhaps in place of it, diet habit, or constitution of the child must be which is entirely erroneous. A number of investigated; its diet and mode of life, pow- infants suffering from imperfect nutrition are ers of sleep and bathing, and also anything found to be taking large quantities of starchy which can conduce in any way to its health, food, such as corn starch, bran, etc.; and. in must come under the scrutiny of the physi- many instances, far too much sugar is given cian. with the food. Sometimes, however, there When the child arrives at somewhat older are very great errors committed with regard years, the elements of schooling, and its in- to the diet of these little ones; and one tercourse with others, must be taken very finds constantly among the poor classes of carefully into consideration. Every child children of the most tender years, those who cannot be submitted to the same routine of are allowed to partake of anything eaten by life; every child cannot bear the same amount adults for which they may crave. And it is of schooling, or even of home instruction. not at all uncommon to find children, even Nor can every child be allowed the free ex- less than a year old, who are allowed to par- ercise of its will in regard to its exercise, and take of tea, and coffee perhaps, even more many other matters of life; just as all adults, than once a day. And one may often see in or even animals, cannot be submitted to the the hands of very small children the most in- same work, confinement, nervous strain, etc., digestible substances, to say nothing of crack- and yet maintain health. ers, candy, etc. It would seem almost, at Far too little attention has been paid in first sight, as though these errors could not past and recent times to the value of milk as prevail among the upper classes; but we have a nutrient. This can be advantageously only to remember that the nurses, to whom added to the diet of very many individuals— so much is often committed, all come from even of adults; and it can even be taken in the lower ignorant classes; and unless they the intervals between the meals, or made to are watched and directed otherwise, they supplement them. Should it cause any of will tend to practice just what they have been the elements recognized under the general brought up to, and taught at home. term of “biliousness,” this tendency may One sees a great many children in whom be more or less averted by the administration imperfect nutrition has resulted from the con- of an alkali at the same time, together with tinuance of nursing long after the suitable care in the regulation of the bowels, etc., period has passed, or after the mother has etc. ceased to secrete milk which is properly We have thus seen that failure of nutrition nutritious. The manner in which little in- in children in a large number of instances, is fants so impoverished will pick up when not always one and the same, depending up- placed upon proper and suitable nutriment, on identical causes; but that there are many is sometimes amazing. The greatest benefit elements connected with it, each one of may be often derived from the addition of which may be of more, or less importance in the yolk of an egg once or twice daily to the individual cases. And as the chain is only diet of very small children; this may be given strong in the perfect integrity of each and either raw or lightly cooked, mingled with every link, so health is only maintained at a the milk, or taken separately. perfect standard by the integrity of action of After children have passed from thebreast, every organ; and the proper supply of nutri- there is danger of very great errors being ment for the growthand repair of each portion committed in regard to the nutrition of the of the body. The hereditary tendency of the child. Far too often it is allowed to select child, must he to a greater or less extent its own food indiscriminately from that used recognized in each instance therapeutically by adults. And even if it does not fail in ind the main general line of treatment must securing the elements required for the forma- be more or less altered in accord therewith. tion of its frame, it will very commonly be But by far the largest share of causation of found that it has induced an indigestion which the failure of nutrition, is to be found in the may be kept up by the same means; and thus surroundings of every day life; and only by have its nutrition materially impaired. The careful study and acquaintance with these, weak, strumous, irritable child therefore, can a case be guided into health. should have its diet looked to, and directed Internal medication can undoubtedly do a with even greater care than its lactation. In- great deal to improve nutrition even in the jurious articles must beabsolutely interdicted youngest subjects; but it must be ever re- with a firm hand; and the proper nutriment membered that the action of the medicant is, for the case must be insisted upon at all haz- and will be but temporary; while the errone- ards. Some of the element of “ indigestion, ous diet or mode of life may go on long after biliousness, or gout in its protean aspects” the patient has ceased to take medicine. And may be very commonly discovered; ultimately as treatment cannot restore the patient to to be developed elsewhere. These must be more than the condition of perfect health diligently sought for and remedied. It is previously enjoyed; so when the diseased useless, when called upon to improve the state is removed, there will be naturally the condition of a growing child, simply to give tendency to return to it, if the same causes this or that remedy; either one which has are continually at work, and in operation. been recommended by some one or another, In addition to the cod-liver oil so corn- INDEX. 87 monly required by strumous children, and PA«E. the alkalies or service in the gouty state, we Angina Pectoris 63 find very great improvement in many in- Apex-Consolidation of Lung 37 stances from the use of arsenic. And when Appetite, Natural Failure of the.. ■ • ....70 combined with iron, it forms one of the Artificial Digestion 16 most powerful means of restoring nutrition Artificial Digestive Ferments 12 and vitality. The following combination Asthma. 62 will be found of great service in many in- Attack, Bilious 46 stances: Attention, Influence of Expectant 29. 1$ Liquor Potassse Arsenitis, 3 ss.— 3 i. Azoturia 59 Ferri Ammon. Cit., 3 ss.— 3 i. Bile, Effects of Diet upon Bile, Effects of, Potassse Citrat, 3 i.— 3 ii. upon the Heart 54 Vini Ferti Dulcis (Malaga), § iii. Bile, Effects of, upon the Nervous System. 54 Teaspoonful after eating. Bilious Attack 46 The syrup of lacto-phosphate of lime is Biliousness 46 often very valuable in improving the nutri- “ Chronic 48 tion of children, as also the syrup of the “ Effects on the Mind. 53 phosphates of lime, soda, and iron. Care “ Symptoms of 50 must always be exercised, however, in ad- “ Treatment of 49 ministering these tonics, that the action of Bladder Symptoms 63. the bowels be as perfect as possible, and that Brain and Digestive Organs, Relations of.. 30 the kidneys do their work. Many cases will Brunton, Dr. Lauder, Views of 45 be found, where iron, cod-liver oil, and vari- Cancer, Gastric 9 ous tonics have been previously employed Caries, Dental 80 without effect, in which success was attained Cardiac, Indigestion 33 rapidly after very moderate attention to the Caseine of Milk..: 15 emunctory organs of the body. Catarrh, Gastric 9 The condition of the skin as an organ, Cause of Indigestion, Syphilis as a 34 should never be forgotten in connection with Causes, Mental, of Diabetes 27 failure of nutrition in children. It is not “ “ Indigestion 24 very common that they are bathed too little, Causes of Decay in Children 80 although this sometimes occurs. Probably Derangement of the Liver 64 they are more often bathed too frequently; Diabetes...... 6, 27 and are perhaps too often chilled in the bath Children Diseases of, Treatment of Actual 84 or afterwards, and the repulsion of the blood Ditto, Preventive 80 from the surface may result in internal disor- Children, Types of 84 ders. Climates, Hepatic Unfitness for Hot 70 Cold hands and feet are a very frequent Clinical Relations of Uric Acid 58 indication of imperfect nutrition in children. Color of Tongue 50 These should be attended to; the children Urates 59 should not be allowed to go to bed with icy Confident Expectation, Effects of 30 feet, which will often be the means of caus- Congenital Insufficiency of the Liver 66 ing wakefulness for some length of time after Congestion of the Liver, Uric Acid in... 59 retiring. Consolidation of Lung Apex 37 The feet should be warmed either artifi- Cooking, Effects of, on Albuminoids 14 cially by putting them in hot water, or by “ “ Fat 15 “ warm application to them, and wearing of “ Starch 13 socks. Or if there is sufficient vigor, a reac- Decay in Children, Causes of 79 tion may be obtained by a quick plunge into De-hydration. 6 cold water. The hands and feet are always Derangement of the Liver, Causes of 64 an evidence of imperfect circulation; and Diabetes 6, 27 this of itself does most frequently cause an “ Mental Causes of .27 indigestion. When the hands and feet are Diarrhoea.... 9 cold, the bath should be used in moderation. Diastase 13 Diet 38 “ Effects of, upon Bile .48 Dietary in Indigestion. . . .39 INDEX. Digestion, Intestinal 6 Natural 3, PAGE. of Albuminoids 5 Action of Saliva 4 “ “ Fat 5 Action of Stomach, Imperfect Solvent.... 8 “ Starch 3 Actual Treatment of Children 84 Digestive Artificial Ferments .12 Acute Indigestion 36 ‘‘ Organs and Brain Relations of. 30 in Typhoid Fever 36 “ Power, Failure of 79 Affections of the Skin 63 “ Variety of 67 Albuminoids, Digestion of 5 Dilatation, Gastric 9 Effects of Cooking on 14 Disintegration 4 Albuminuria 60 Imperfect 7 Sir Joseph Fayrer on 60 Disorder, Functional, of Liver, Treatment Alcohol 40, 78 of 77' 88 INDIGESTION AND BILIOUSNESS.

PAGE. PAGE. Disturbances in the Heart 62 Indigestion, Ovarian 31 “ Phenomena, of Liver 46 Reflex 31 Disturbance, Treatment of Liver 68 Secondary 24 Drinks. 39 Symptoms of 10 “ Iced 5 Symptoms of Mental II ‘ ‘ Temperance 40 Syphilis as a cause of 34 Dr. Kirkes’ Views 42 Toxaemic 34 Dr. Lauder Brunton’s Views 45 Influence, Nervous 66 Dr. Murchison, Views of 43 “ of Expectant Attention 29 Effect of Bile upon the Heart 54 Irritability, Gastric 10 “ “ “ Mind 53 Insufficiency, Congenital, of the Liver... .66 “ “ Nervous System.54 Intestinal Digestion 6

PARKE, DAVIS & CO, Manufacturing' Chemists, HVn±oItL±^£tm__ Would respectfully ask the attention of the profession to the following drugs of more recent introduction and of reputed value in functional diseases of the digestive apparatus. CASCARA SAUK ADA.—' 1’his drug, (Rhamnus Purshiaua) a native of the Pacific slope, has since its introduction to the profession found a high place among the agents employed in intestinal indigestion and constipation. Its physiological property is to impart tonicity to the exhausted muscular fibre of the intestinal tract, the stomach in- cluded, and thus to place it in a condition the better to discharge its functions. There are few cases of indigestion in which cascara sagrada will not he found to be indicated. We prepare a fluid extract of this drug. CASCARA CORDIAL.— This preparation is an agreeable combination of the fluid extract of cascara sagrada and berberis aquifolium with aromatics. It combines the stomachic, eccoprotic, tonic, and alterative properties of its two chief ingredients, and is in such form as to make it acceptable to the palate of the most fastidious. BOLUO.— This drug has been introduced from South America. It possesses marked tonic and stomach properties and exerts a very beneficial influence in cases of dyspepsia complicated with hepatic torpor. Its combination of the better and slightly astringent principles makes it. very valuable in the treatment of atonic dyspepsia. PEPSINE (Saccharated). —The properties of pepsine are too well-known to require enumeration, and the only question is that of the proper preparation of any given brand. In our pepsine especial care has been taken to eliminate remains of the mucous mem- brane and to secure nothing but the active principle. We present it as a pure and reli- able preparation of definite aud invariable strength. LACTATEI) PEPSIN. —1"his preparation is a combination (non copyrighted) of diastase, pancreatine, pepsine, maltose, lactic acid and hydrochloric acid, —a combination indicated in almost all forms of digestion. It is placed on the market unprotected by copyright or other device at variance with the ethical rules of the profession. HAGER’S DIGESTIVE PELLETS. (3A grs.)—We prepare these pellets after the formula of the illustrious author : Cinchonidia Suiph. 1-5 gr. Pepsine, 1 1-5 gr. Powd. Ginger, 8-25 gr. Powd. Cardamon, 3-25 gr. Powd. Pimento, 3-25 gr. Powd. Gentian Hoot, 6-25 gr. Powd. Althea Root, 6-25 gr. Powd. Tragacantli, 6-25 gr. Glycerine, 2 5 gr. Acid. Hvdro-chloric, 6-25 gr. Water, 6-25 gr. MOORE’S DYSPEPSIA PILLS are also prepared by us after the following

formula : Sulphate Cinchonidia, 1-2 gr. Ext. Capsicum, 1 8 gr. Powd. Rhubarb, 1 gr. For fuller particulars regarding any of the above, apply for our descriptive circulars, PARKE. DAVIS & CO.. HVCiclxigaxx.