Presented by George L Hampton, D. 0. COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA -; ,: I m ;p I m . : . ; ' ' ./ " r <^e. THK INDIGESTIONS; ..-i DISEASES OF THE DIGESTIVE ORGANS FUNCTIONALLY TREATED. BY THOMAS KING CHAMBERS, r PHT-H.-IA.X TO H. K. H. THE PRINCE OF WALES, COSSCLTISO PHYSICIAN AND LICTCRBB ox THB PRACTICE OF MEDICINB AT ST. MARY'S HOSPITAL, COH8CI.TISO PHYSICIAN TO TBB LOCK HOSPITAL, AUTHOR OF " LECTURE* CHIEFLY CLINICAL," BTC. SECOND AMERICAN mm SECOND AND REVISED LONDON EDITION. I'll I LA UKl.ril IA: 1 1 K N R Y C . LEA 1868. C 4 q PHILADELPHIA . COLLINS, I'KIMEK, 705 JAYXE STUEET. PREPACK. 1 N 1856 I published a small volume on the same subject that I arn now % atrain taking up. It has been a good while out of print, for I was not content with it enough to sanction a reproduction in the same shape. But I have always intended to handle it again some time or another. During the last year I have been looking over my old notes of cases, and It struck me that it would be interesting to pick out such as bore upon indigestion, to classify them according to the points they illustrate, and see how far they upheld or overthrew my previous views. Then linking them together, after the fashion of a clinical teacher, with a running commentary, I made them tell their own tale, and added such observations as either occurred to me at the time I had the patients under my eye or have flowed from after experience. So grew up, not the new edition I had thought of, but what consistency bids me call a new work. It has therefore a new title, pointing to the diiVfrent aspect in which the subject is viewed. In the former work it was anatomically, hen- it is functionally treated. So pleasant has been the holiday task thus t.) tl; of sweet silent thought To summon up remt'inl>run<-<' <>f things past." that 1 am lain to dwell upon it, and to try to lead others towards -.line source off njoyraent by describing the way in which my store has been heaped M i is needless to say I did not iv PREFACE. lean on raj memory alone, or the number of trustworthy histories would have been few indeed. The cases of those who are named as inmates of St. Mary's Hospital in the following pages are copied mainly 'from the diary kept by the clinical clerks. I have been always used to make this a chief source of teaching. The clerk was instructed to take notes with the sick person, before him, and in his own words ; and when he read them out at my visit, I added my observations, sometimes in the hospital case books, sometimes in my own. These formed the groundwork on which to build my clinical lectures for the current week. They are irregular in wording, but preserve a fair record of the disease. The details of private practice have been kept in a shorter and more mechanical way. I make it a rule, to which exceptions need be very few, to write all prescriptions and papers of advice in a copying-book, which makes a duplicate of them by means of transfer paper ; and at the back of this transcript I write, usually with the patient before me, his history, at least so far as to explain my reasons for the advice, before I go on to the next page. The periodical indexing of these sheets is an easy job for an hour of weariness ; and the whole time consumed is so crumbled up that it is never missed, and neither business nor amusement feels itself robbed. Some people tell me they can make their notes of the day's work more fully and scientifically when it is over, and they are quiet in their study. I do not like the plan so well. For one thing it interferes with the relaxation needed to keep the mind healthy and broad. That time belongs to rest datur hora quieti and should not be wasted on labor. An instinctive feeling of the truth of this causes a duty which is put off to such an opportunity to be put off often still further, often altogether. Again, unless an immediate note be made, the new and the strange in the day's experience are stamped in the !' R K F A C E . V mind deeper than the common-place, and so they are apt to up more than their fair share of room in the diary ; while personal friendships, the social standing of the patient, and other considerations will sometimes blot out, sometimes unduly brighten our recollections of the case. To these brethren in art then, as well as to others more emphatically who have hitherto failed to put by any written record at all of their acquired knowledge, I earnestly commend the method. Independently of the advantages to patients of being able to cast back to their antecedents, wherever you see them again and at whatever interval, the not perhaps wholly selfish satisfaction of living over again at will any portion of your professional life is worth tenfold the trouble it gives. ;ilue to the public is directly proportioned to the value of the individual himself; his experience is a simple fraction of himself. I cannot expect the reading of my notes to be as agreeable to others as it is to me. Still the gracious way in which even rough clinical sketches are received in the shape of lectures, makes me hope that these studies, being of a quasi-clinical nature, may have some of the same favor shown them. A still higher reward would be that my testimony to the pleasantness of the task .should lead others, richer dowered than I am, to unbarn the harvest of their experience in its own living form, instead of merely the distilled essence of it in their opinions. In this second edition I have added a few cases which seemed more illustrative oi' the matter in hand than those previously quoted: but I have not altered the form of a running com- mentary, in which the work was first put before the public, and whieh re: ! me they tind agreeable. T. K. C. '2'lK. l>i: CONTENTS, < II A 1'TKK I. 1. \TRi.l.l TluN 17 (MIAl'TKK FI. I.MiH.KSTluN OF VARIOUS FOODS '_".) CHAPTER III. II AI;IT> OF SOCIAL LIFE LEAPINO TO INDIGESTION . . .92 HAPTER I V A HIM, MIX. \i. I'AINS ......... 134 CHAPTER V. VnMlTIV. \\\~2 (' II A I'TK K VI. Kl.ATM.ENCK ">4l < ii A i-T K u vii. IhAKlUltKA 260 (Ml A I'TKII VIII. . U'ATHiN AND COSTIX KNKSS "2~, '2 <' ii A I'T i: i; i.\. fK DlflOEIttBS OOffNBOTXD WITB I MIH;I->TI . 305 A I. I'll A I'.K I I. A I. I M>K.\ . . 317 THE INDIGESTIONS. CHAPTER I. INTRODUCTION. SECTION 1. Meaning intended to be conveyed by the title of this volume. Importance of the subject. General peculiarities in diseases of the digestive vi-i-era. Value of attention to them in the management of diseases of dif- ferent nature. SECTION 2. Divisions of the subject adopted, and explanations of terms used. SECTION I. THE name " indigestion," or "dyspepsia," speaks to the mind of the physician of a very large class of morbid phenomena, various in their nature and appearing under a great variety of circumstances. There are those who would banish the words from our nosologies; some because the outward "manifestations are so diverse that it is impossible to bind them together in any ification of symptoms ; some because the parts of the body whose morbid states induce indigestion are so doubtful and numerous that it cannot be brought under any anatomical no- menclature. It is quite true that a definition of it cannot be rts depends almost entirely on how far, how wisely, or how foolishly, th :is are watched over; whether they are well or ill treated, either by the scientific guidance of the skilled physiologist, or by the empirical rules 20 INTRODUCTION. of the routine practitioner, according to the tradition of the nurse, or the instinct of the patient. Each of these may be in their fashion a useful guide ; but the first is at least most capa- ble of improvement by labor. As regards chronic diseases also, science enables us to trace, by steps more or less distinct, many of them not manifested in the organs themselves, but affecting the whole body, to an abnormal state of the digestive viscera. It is needful only to name gout, tubercle, and anaemia, to engage our closest attention to their causes. Whatever value we may attach to the evidence of the depend- ence of disease on the digestive organs, it is very clear that we look. to them for relief from disease. Out of the six or seven hundred forms of medicines in habitual use, very few indeed are not occasionally offered to the stomach for acceptance, and an overwhelming majority of them are adapted for use only in this way. If we are still to employ this time-honored agency in our attempts to cure bodily ailments (and I see no threaten- . ing of a change at present), it is surely a matter of great interest to secure the active working condition of what our forefathers in anatomy picturesquely called the portal. It is waste toil to try and enter locked doors. A great advantage of paying special attention to the digestive organs is that, as a rule, they are more directly curable, and that by their means distant parts, otherwise out of our control, may be favorably influenced. The evil of neglecting them is obstinate disobedience of the body of the patient to any medicine administered. When a sudden poison or paralysis has fallen on this gate of entrance, our hands are paralyzed too ; the staffs we lean on fail us. What a cataract of physic used to be poured through the half-dead bowels in our first epidemics of cholera ! I once found about a drachm of Ipecacuanha safe in the stomach ; and Calomel pills and powders, and Opium, arid Cayenne pepper, were a frequent constituent of the stools ; and I verily believe that ninety-nine hundredths of what was swallowed in the stage of collapse followed the same fate, or the patients could not have outlived the poisonous doses which are recorded to have been given. Watch a case of typh-fever, and see what immediate improve- INTRODUCTION. 21 ment follows the shedding of the dead epithelium with which the mucous membranes have been coated a change which is ushered in by what is called the "cleaning of the tongue," but which foreshadows much more, in fact the cleaning of the whole intestinal tract. See how immediately on this the poisoned nervous system begins again to renew its life, and delirium ifl new nervous matter fit for duty is generated. Or watch another less fortunate case of the same malady, how as the tongue gets dirtier and drier and browner each morning, the weakness of the nervous and muscular system increases, and is more and more clouded over. In both instances the diiVerence between one case and another, between the patients who are a credit and a joy to us and the patients who continue to wring our heart with anxiety, mainly lies in the more or less vitality of the abdominal mucous canal. We must remember it is of no use to employ the best possible means of staying the morbid symptoms, unless the absorbents assimilate sufficient material to replace that which is diseased, and to remove which we are bestowing our pains. Labor is wasted in clearing away a worn-out wall, if a new structure does not take its place. To that end the only path is to insure -si inflation of food. And to insure the assimilation of food, the stomach and its colleagues must be in working order. So that in point of fact the only fair trials of depletory measures must be connected with feeding, and those who would uphold the good fame of such expedients must be careful of their patient's digestion. lint even if diseases of the alimentary organs had not so much influence as they possess on the duration of life, their extreme frequency would alone entitle them to attention. Unfortunately, it has had a contrary effect: medical men are apt to set down what is so common and inevitable. They neglect indigestion as unimportant, forgetful that though its removal may not perhaps in every case lengthen lite, yet that it would at all events treble :lue both to the individual and to society. The digestive tract has not the advantage enjoyed by the re- spiratory and by the upper part of the urinary apparatus, and other parts, of being double. An animal has two lungs, two kidneys, two hemispheres to the brain, two testicles or ovaries, 22 INTRODUCTION. two sides to his body generally ; but only one stomach, and one intestinal canal. A further reason for great caution in preserv- ing the integrity of the latter there is less to spare for disease to affect. A deposit of tubercle (for instance) the size of a nut in the pulmonary tissue may be neither here nor there, may be never known by its effects. But put it in the peritoneum, or in Peyer's glands, and what a disturbance is produced ! A man may lose a leg or an arm, and enjoy life very fairly afterwards ; but let him lose the use of his oesophagus or' his rectum, and what can he hope for ? This singleness helps to explain the powerful influence which derangement of any one of its parts has not only over the whole tract, but over the whole body and mind. No chain is stronger than its weakest link, and an interruption of the function at one point is an interruption of the whole. It also has a bearing of considerable importance on the treat- ment. It is extremely difficult to obtain that rest which is so essential in the management of disease. If you have pneumonia, you may give a holiday to the smitten lung and generally recover with the other; but if you have an equally acute inflam- mation of the oesophagus or stomach, the danger is great, because necessarily they are in constant use. Indigestion is a chronic disease. By that I mean that its natural path is straight on from bad to worse, unless from the interposition of some extraneous circumstances of accidental or designed origin foreign to the phenomena of the disease itself. Hence it is not difficult to test upon it the action of a remedy. A cautious observer may from a moderate number of well-con- sidered cases come to a rational conclusion as to its value. On the other hand, the tendency of acute disease, as I understand it, is to progress in a circle towards the recovery of health ; each process, however dangerous and abnormal it may be, being a step towards the final arrival at that result, if only the patient's strength hold out. 1 Art, therefore, modifies it much less 1 Dr. Pierre Petit, in the Preface to his " Commentary on Aretaeus," compares acute diseases to race-horses, which run round to the goal, unless they founder on the way. The Greek primary division of diseases into " acute" and " chronic" is turned to such excellent therapeutical account by Aretseus, that the loss of his intro- INTRODUCTION. 23 glaringly ; a small experience is sure to lead to fallacies, and it is only on the numerical comparison of a large number of un- prejudged cases that an opinion can be formed. For this reason the failure of homoeopathy in the cure of the digestive function is very conspicuous. I suppose a good third of the private patients who come to me with dyspeptic ailments have tried this system, and confessedly tried it without advan- tage; though some of the same people still continue to think that in acute disease, in scarlatina, catarrh, measles, rheumatic fever, pneumonia, and the like, their convalescence is brought about by homoeopathic drugs. My object in this chapter has been to point out the import- ance of a skilful management of the digestive organs in disease. I mean in disease generally, and not only that which speci- fically affects those organs alone. Let us not be deceived by the expression " merely symptomatic" sometimes applied to the derangements of digestion where organic changes exist. All - and functions of the body are so knit together in one to form the great circle of life, that their comparative value to in- dividual existence is more a question of time than of power. The failure of any one shortens the days more or less, and the immediate cause of death is as often " a mere symptom" as an organic change. It is also a serious consideration that in respect of the patient in chronic pathological states this is in reality often the whole duty of the medical adviser. Often, on stating in consultation an opinion that some viscus is chronically de- generated, one is met by the remark, "Well, what is to be done? we cannot cure that." Very likely not ; then let us try and find something else which we can cure. In the great majority of patients this curable something may be found in functional impediments to the entrance of nutriment into the medium of assimilation; and when once nutriment can be got in, a cur.- is begun. Do not, therefore, let us indulge despair even after it dnction, in which he probably defined acuteness, is much to be regretted. Galen tli.- iirnctit-al point, when he introduces the artificial element of time, jied.-uitically limiting acuteness to a definite nuinher of d.iy-;. And several of our rc>i]tem]H>rari.'> have fallen into t ; ; ror : as if there could he any natural difference between an inflaunnatiuu lasting twenty-one days and an intlauiniation lasting twenty -two days! 24 INTRODUCTION. has become certain that the principal viscus which gives a name to the disease is past remedies, and though little can be pre- scribed for the part mainly affected. It is seldom too late to try and administer to the failing, organ the most potent of all remedies, the human blood of the patient himself, made healthy by the means adopted, and flowing in continuously by its natu- ral channels. I remember, when I was physician to St. Mary's, talking in the wards to the pupils on this subject (as was my frequent habit) when we came upon a new patient, an undergrown and undeveloped girl, the mitral orifice of whose heart was narrowed by rheumatic inflammation in childhood. On her being carried into the hospital, her face was like that of a corpse, and she could not stand without fainting. I presume no sane student expected to see means used for the dilatation of that valve, whose contraction was the source of evil : despair was not an illogical conclusion from the diagnosis I dictated to the clinical clerk, and I was but little surprised to hear behind my back the remark, "This, at all events, is not much of a case for treat- ment." Yet observation of the functional state of the alimen- tary canal, indicated by the cedematous tongue and fauces, made me improve the opportunity by expressing an opinion that she would " walk home with color in her cheeks." A month after- wards I was able to say, at a clinical lecture on the case, "This she has been able to do, and the better nourished heart now beats steadily and evenly ; though its mitral orifice is as small as ever, if the ear and stethoscope are to be trusted." And not once, but almost weekly, have I demonstrated to the same class, with respect to many a consumptive, how little it helped us to know that half of the upper lobe of each lung was filled with crude tubercles : pulmonary remedies had been of no benefit ; but the reflection that the stomach was secreting an excess of mucus at the same time with the lungs, led to effectual means for the relief of both together. In the following chapters I intend the sketches I give of morbid phenomena, and the simple classes into which I divide the indigestions, to apply equally, whether they are alone, or whether they are united to obvious and more fatal organic changes. INTRODUCTION. 25 SECTION II. There is no pedantry in definitions when their object is to lead the writer and reader better to understand one another. So I shall not shrink from a charge of over-precision when, the first time I use in the following pages a word capable of vari- ous interpretation, I often stop to say what I mean by it. And at the present stage of the volume let us not grudge a few s to dividing the subject, assigning it a nomenclature, and trying to turn that nomenclature to practical profit. llKAi/niY digestion is quick, complete, and easy. There can be no excess of it, for food cannot be too quickly and com- pletely converted into chyme and taken into the blood, and there is no such thing as too much health and bodily comfort. In ILL HEALTH digestion is impaired in one or more of these qualities it becomes slow, defective, &ndpainfnL We may use Greek words, and call the above-named erring qualities of the digestion Bradypepsia, Apepsia, and Dyspepsia; only let it be remembered, that making the old adjectives into new substantives adds no one whit to our knowledge nay, unless care be taken, runs some risk of being a stumbling-block - progress. For when we have in this way given a proper name with a capital letter, we are apt to think (like a naturalist with a new butterfly) that we have defined an individual and active motive power, instead of what is really the deficiency of a function. And thus we fall into the errors of our forefathers, whose efforts to destroy their abstract foe the " Disease," in- of restoring the existing patient, led to so much bad practice in the generation now passing away. I shall generally use the English adjectives, but first I will say shortly what I mean by them in this connection. By digestion being slow I mean that the act in some part of the alimentary canal is not completed by the time when the convenience of the individual requires that it should be < I. The stomach may retain so much of a former meal that it is not in a fit state to receive the new one which is need- ful for the sustenance of the body. Hence arisr< a want of the natural appetite and (when it is long continued) imperfect nutrition, an;emia, debility, &c. Or, if we attempt to force 26 INTRODUCTION. food too quickly on the unwilling stomach, we have chemical decomposition and defective digestion as consequences. The average time by which the stomach should have natu- rally emptied itself varies in different healthy persons from two to four hours. The intestines have extracted all that they are capable of absorbing in eight or nine hours ; and the relics of complete digestion are ready for expulsion from a vigorous young person in twenty-four hours. By defective digestion, I would imply that food capable of nourishing the body cannot do so from lack of certain changes which it should naturally undergo in the alimentary canal. It is passed from thence either unaltered or chemically decom- posed. There are seen in the feces, either by the naked eye or the microscope, masses of starch, muscular fibre, fat, &c. I have several times had them brought to me, under the idea that they were worms, pieces of intestine, or other foreign bodies. Or else the products of their decay, consisting of various ob- noxious gases and acids, are developed in a quantity subversive of social comfort. Painful digestion may be both defective and slow ; but, on the other hand, it not unfrequently also is complete and per- formed with sufficient quickness. All that it is intended to express by the word is its accompaniment, at some stage of its progress, by feelings varying from slight discomfort to absolute agony. A few days ago a patient depicted to me very well the first- named sensations by saying, in answer to the question whether he had any pain, no, but that he felt where his stomach was, and knew where his food went to. And on the other hand I have heard the consequences of an ordinary meal described by a theologian (who ought to know) as "the tortures of the damned." A very practical division of cases of indigestion is derived from the substance which is indigested, namely, which of the chief constituents of- the diet, whether (1) Starchy and Saccha- rine, (2) Albumenoid, (3) Fatty, or (4) Watery food most exhibits the failure of the function. This is to be learnt partly from the patient, and partly from observation of the consequences which ensue to the alimentary mass. On it is grounded an important INTRODUCTION-. 27 part of the treatment, namely, the dietetic; and as its indica- tions are simple as well as valuable, it will come first under consideration. A very essential step in the cure of indigestion consists in the removal of its external causes, where these are removable. Til-- liillowing chapter therefore will be on "Social Ilabits," by which I mean causes dependent. on the patient's will. There is one obvious practical distinction between these and other causes, namely, that the discovery of them is the true cure. You may bid a man cease from over-eating, over-fasting or smoking, but you cannot bid him cease from being poor or sorrowful, from having tubercles in his lungs or an ulcer in his stomach. The symptoms of these errors of the function may be divided according to the period of digestion at which they occur ; some being exhibited before the alimentary mass has left the stomach : some during its way along the intestines ; some after the passage of the ilio-cajcal nerve. Now, remark, I avoid calling these phenomena diseases of the salivary or gastric glands, of the intestines, or of the colon. They are not so, and must not be treated as such. The discom- forts felt soon after a meal, for example, may be due to organs far away from the stomach to the uterus, to the kidneys, to the lungs yet they must be called by the same names as when they are owing to anatomical changes in that part. So those occurring later often are traceable not to anything wrong in the duodenum, ilia, or colon, but to excess of gastric mucus or deficiency of pepsine. Let it be understood then, that, when I speak of theirs/ stage of digestion I mean, before the food has passed the pylorus ; by the second stage, its transit along the small intestines ; by the ////'/v/ stage, all that takes place beyond the ilio-caecal valve. These phenomena almost always require separate treatment of themselves in addition to the general condition from which they originate. Indeed they are such a prominent part of the ailment that some writers, with a considerable show of re; have divided indigestions according as one or other of them is the distinguishing features, as for instance M. Chomel does into 7" /v/ / ;//Y'//', (A/tyy.x/-! loHlt'i,. dy*2 'V," & c> There is a certain amount of convein 28 INTRODUCTION. in this in respect of very marked cases : the worst of it is that many invalids exhibit several of the name-giving symptoms all at once in equal degrees, and it is difficult to assign them their due place: while in some the dyspepsia (or rather the patient) is flatulent one day, gastralgic another ; at one time has acidity in excess, at another alkalinity. I have thought it better there- fore in this treatise to discuss each symptom, separately where it requires separate treatment, or in groups of several together, where the pathology and therapeusis admit of union. These will fill the succeeding chapters. Let it be understood that I speak of "Heart-burn," "Acidity," " Vomiting," &c., in these chapters as diseases independent of the cause from whence they arise; referring them indeed to that cause where it is known, but not placing them in a separate class where it is unknown. A chapter on the influence exercised by the functional de- rangements of the digestive viscera over the nervous system will conclude the volume; 29 CHAPTER II. INDIGESTION OF VARIOUS FOODS. SECTION 1. Defects of digestion as exhibited in Starchy and Saccharine food. ON 2. In Albuminoid food. SECTION 3. In Fatty food. SECTION 4. In Watery food. SECTION 5. Treatment based on articles indigested. SECTION 6. Treatment based on pathological condition. SECTION I. Indigestion of Starch and of Sugar, or Vegetable Food. Ix its original condition, either raw or when broken up by boiling, it does not appear that starch is capable of being absorbed by the alimentary canal. But on its first introduction nt the mouth it meets with a fluid capable of converting it into one of the most absorbable of alimentary substances: indeed its change into sugar by the saliva may be fairly regarded as its ng to be a part of a plant and becoming a food. The reduction of it makes it into a complementary food duly repre- sented in our type of a perfect diet, milk, by its peculiar form of saccharine matter "sugar of milk." This metamorphosis begins immediately with the introduc- tion of the morsel into the mouth, and is almost instantaneous in all parts with which it is brought into contact by the action of chewing. A good deal of the secretion is carried down into the stomach and continues its influence, though much retarded 1)\ the necessary acidity of the gastric juice. Should any of -larch granules have escaped rupture, or if it be eaten raw, the gastric juice (if strong) dissolves the albuminoid envelope, and sets some more amylaceous mutter free. When the mass pa.-.-es through the pylorus its acidity is neutralized, the action of the remaining saliva recommences on the starch yet uncon- vrrted or lately set free. ; ami tin- action is reinforced by the pancreatic juice. 30 INDIGESTION OF VARIOUS FOODS. Of the-sugar made, a very great part is absorbed in the mouth, and gullet, sometimes all of it, for chemists have great difficulty in finding sugar in the stomach. The most essential part of the digestion of vegetable food is doubtless the osmosis of the sugar through the mucous coat of the alimentary canal. A great part of the excess is converted into lactic acid to aid in the solution of flesh food, and the rest is taken up by the intestines. For the reduction of starch, then, so as to bring it into a con- dition capable of digestion, it is necessary, first, that the salivary glands should secrete a sufficiency of fluid suited to convert it into sugar ; and that not only at the moment of chewing, but that they should go on supplying it as long as any starch remains unconverted. Now, the salivary glands are more exposed to derangement by circumstances external to themselves than any organ not directly subject to the will. Temporary emotion affects them temporarily, and continued emotion affects them chronically. "We all know the dry mouth of the coward, the lover, the pitiful, and how the tongue clings to the roof when bad news is brought. We see too how for days, or even for weeks, " bread eaten in sorrow" can hardly be swallowed, so long it takes to moisten the morsel. Even in the healthiest person bodily exertion parches the throat. Again, there is scarce any morbid condition that does not make itself felt in the fauces and seen in the tongue. Numerous analyses of the saliva in inflammatory, and in other affections which seem remote (such as uterine disease, phthisis, chlorosis, ague), show that the changes are marked enough to be detected by chemical examination. 1 These changes are all in the direction pointing to want of vitality : either the animal constituents are deficient, producing a watery saliva ; or they are turned sour or putrid by decomposition. It was to have been expected, therefore that all defects of general vitality should give rise to them. Besides the saliva, another digestive secretion practically comes into play in the solution of starch, to wit, the gastric juice. Cookery, even when most efficient, rarely ruptures the whole of the amilaceous granules. Many escape in the best, and in 1 They may be found in Simon's "Chemistry," vol. ii. p. 9 (Sydenham Society's Translation). INDIGESTION OF VARIOUS FOODS. 31 bad cookery the majority escape. They cannot, therefore, be <:d by the saliva, till their albuminous envelope has been Ived by the gastric juice. Then they may be converted into grape sugar, either rapidly by the saliva present, or more slowly by the pancreatic and other intestinal secretions. The digestion of amylaceous and saccharine matters without inconvenience requires also the oesophagus to be throughout in a normal state ; for, as before remarked, in health the greater part of the sugar made should be absorbed before it arrives at the stomach. In the lighter cases of dyspepsia, and in the tem- porary dyspepsia of excess, it is probably this power which principally fails; and the consequent symptoms probably arise from the presence of an excess of sugar thus passed on and apt to ferment in the intestinal canal. Requiring so much, and so much that is soon affected by outward circumstances, the digestion of starchy food may be easily understood to suffer the first, the most completely, and the commonly. Let us take as an example the simplest of all forms of deficient vitality, the consequences of an imperfect supply of that which vitality most requires for its manifestation, allmrnenoid food and pleasurable emotion. How familiar is such a case as the following, upon which I fall on turning over only a very few leaves of my hospital note-book ! I. Caroline P , aged 49, a musician's widow, who formerly with her husband earned an easy subsistence by her profession, had been for a year living (as she called it) on needlework and looking on life with despair. On JUT ad mission to St. Mary's in April, 1860, she is described as a long-faced c:n hectic woman with sharp features, thin lips and hair still brown. II- r complaint was of pain and an intolerable feeling of weight at the epigastrium coming on an hour after eatinjr. flatulence 1 either breaking off from the mouth or aftenvanls distending the abdomen. So that she almost dreaded to take food. Hut what was this food? liread, potatoes, tea, sometimes a bit of bacon, hardly ever a hit of meat. However, she had got not to care, eating at all was so distasteful to her. When ordered two meals of fresh meat daily, she could not indeed at first relish it without half a glass of port wine to wash it down. But that disrelish soon passed away. In a fortnight she had re- 1 By " flatulence" I mean the superabundant collection of gas in the alimen- tary canal, whether it pass aw;iy upwards or downwards, or reiuaiu iu the abdomen. 32 INDIGESTION OF VAKIOUS FOODS. covered her appetite, and moreover was able to take even vegetable food. In another week she was well enough to leave the hospital. Gastric juice is required to rid the digestion of starch by dis- solving the albuminous envelopes of the granules: gastric juice is a highly animalized fluid ; to make it animalized fresh blood is a sine qud non: and the material of which that is quickest made is meat food. Such is the rationale of these satisfactory cases. "Where the starvation and consequent anaemia fall by accident on a patient less acclimatized by gradual grinding inevitable poverty to them, they produce symptoms not probably more fatal, but more marked and more painful to the sufferer. For the nervous system retains its sensitiveness its instinctive courage, as it were and complains loudly of the partial death forced upon it. Here is an example, illustrative of a more sensitive indigestion also following inanition. CASE II. Mr. V , aged 50, a periodical writer, usually well paid and usually healthy, from loss of employment during the spring and summer of 1866 was reduced to great straits, and for long periods at a time had barely enough food to keep body and soul together. After a time he ceased to feel hunger, and the principal warning he had of starvation was the feeling of an extraordinary lack of muscular power. He did not perceive his intellectual energies flag at all. After he got into luck again he found it impossible to take advantage of the plenty poured around him. Eating anything was followed in ten minutes or a quarter of an hour by intense pain in the epigas- trium extending downwards over the hypogastric region. The sensation was " as if the navel were gripped with an iron hand." The mildest liquids, such as tea, brought on this agony quite as much as the most insoluble viands or strongest stjraulants. He was much troubled with flatulence after vegetables, both upwards and downwards. Meat did not indeed induce so much flatulence, but its ingestion was followed almost immediately by the intense pain at the epigastrium. If he could bear this, he digested it pretty completely. Then he noticed how emaciated he grew, so that the balance testified to a loss of two stone of flesh. He was not conscious of this during the starvation. Now, too, he became sensible of a failure of mental power, especially in the hours when the flatulence oppressed him most. "When I saw him in October, he presented a pitiable aspect of distress and emaciation ; his abdominal pain was growing worse and worse, his urine was of extremely low specific gravity (I have lost the note of the exact figure). I prescribed for him a draught of Hydrocyanic Acid with Battley's Seda- tive Liquor (four minims of the first and five of the second), to be taken a few minutes before each of the daily meals. In three weeks' time he came INDIGESTION OF VARIOUS FOODS. 33 to report favorable progress. He had gained flesh, lost his pain in a great meusurf. and was able to take a meal often even without the aid of the draught. Hut In- -till had some degree of gaseous distension of the abdomen, able by the hand and eye; still his brain was not so clear for work as could be wished. I gave him my usual Quinine and Strychnine mixture, with three minims of Hydrocyanic Acid and a grain and a half of Iodide of Potas- sium, to take twice a day. under the use of which he got quite strong again. Observe here how the digestion of vegetables was slow and <>v, while that of meat was only painful. For the cure was a needful medicine, and therefore the first thing to be done towards the cure, was artificially and by drugs to stay this inconvenient pain. To have stayed the pain without supplying the meat would have been merely palliative or allopathic treat- ment; to make the anajsthesia a stepping-stone to the formation of gastric juice out of albuminous food was strictly restorative. The Iodide of Potassium in the last prescription was designed to promote the activity of the salivary glands. I have found that it does so in my own person, and it has seemed to me that the saliva is not merely increased by the addition of water, as the urine is by nitre and other neutral salts, but that it converts more starch into sugar by the augmentation of its special fer- ment. But it has also seemed to me that this action of the Iodide of Potassium was a very temporary one, that it lasted but a few days, and that a continuance of the drug could not be trusted to for producing a continued effect. We must therefore it just at the right moment, and not waste it by beginning too soon or pushing it too long. The use of larger doses does not obviate the difficulty, and I therefore do not give them. The larger dose in the accompany- ing ease was given lor another purpose. 1 1 1. Mr. Wm. S , an artist of middle age, was my patient in the autumn of lM0 fur f doubtful origin. Among other experiments I tried the effect of Iodide of I'ntassium in doses of thirty grains a day. It did no good to tin- di.-raM- of the skin or nails, but the patient at first took a great fancy to . t enabled him, he said, to take his meals of mixed food without consequent discomfort, lie could digest even potatoes and beer, a fortnight or so, however, he was forced to confess that his stomach was not what it was in youth, and that he was not to In- exempted from the ' care for his meat and diet" which the Son of Sirach considers chanu ' of a good man of intellect. 3 34 INDIGESTION OF VAEIOUS FOODS. The appetite is a very important part of the animal functions. The loss of it is familiarly known to be a consequence, but it is also often a cause of bad health. And the mode in which it affects the health seems to be by diminishing the supply of albumenoid food, and so indirectly the quantity of gastric juice. CASE IV. In November, 1861, 1 admitted to St. Mary's a pleasing, well- grown girl of twenty, named Margaret C . She was extremely pale, and BO weak that she could hardly raise herself in bed ; yet no organic disease or pathological state of any of the solid parts of the body could be discovered to account for her condition. She attributed her illness to the close smell of a workshop in which she had been employed, which spoiled her appetite, making her at first crave for unwholesome things, and reject what was set before her, afterwards destroying the desire for victuals altogether. She observed it did not seem to make the other apprentices ill, who were not so squeamish. Perhaps the accident of her having been more tenderly nurtured, and so more sensitive than her companions perhaps the responsibility of being placed over them as forewoman contributed to this result. The end was, that the loss of appetite induced anaemia, swelled ankles, amenorrhcea, and a certain amount of hysteria. 1 Then, though removed from the original cause of the disease, she took a disgust to all articles of food, complained that vegetables especially produced flatulence, and had to come into the hospital, she was so weakened. When put npon the diet of milk and Liquor Calcis every two hours, with a pint of beef-tea in divided doses daily, she digested it without inconvenience, but at first without relish. After two days she was able to take an egg, and after twelve days of gradual additions of this 1 Dr. Reynolds remarks, in the Introduction to his System of Medicine, that " by ' hysteria' is conveyed some meaning or none at all, and, when the former, a meaning as various in character as are the individuals who use the word." I take this opportunity of saying that by it I intend no reference to the womb (urTfpa), from which the Greeks derived the word in deference to a false theory of its origin ; which unfortunate derivation often leads to a bad practice. By it I mean a peculiar state of the individual in which the emotions exercise a sway over the functions of mind and body usually subject to voluntary control, and produce spasmodic contractions and paralysis of involuntary muscles. Its pathology must be sought for in that puzzling part of the circle of life which lies between spirit and matter. We know so little about the chain which connects the two, that its links are reckoned by us as few and short, we have no names for any of them ; and in default of names for even the healthy func- tions, we must not expect an accurate nomenclature for their aberrations. So that the most we can do in trying to classify forms of hysteria is to trace how near their origin lies to one or other extremity of the series of vital actions which are interfered with ; what relation their phenomena bear on the one hand to mind ; and what on the other to body. We shall thus have set in a natural series the varieties of the disease, with pure insanity at the one end, and epilepsy traceable to organic lesion at the other. INDIGESTION OF VARIOUS FOODS. 35 sort she arrived at the full allowance of " ordinary diet" mutton, porter, ;i. mill milk. She lost her flatulence, and soon picked up her good looks. For medicine she had Iron three times a day, and pills of Aloes and Myrrh, at first every night, afterwards not so often. In a clinical lecture given at the time I laid the condition of the patient at the door of the digestive canal. The circum- stances to which I have traced the illness act, directly or indi- rectly, both on this part. In the first place the mental exertion involved in an untoward responsibility thrown on a conscien- tious person would lessen the life of the involuntary muscles which carry along the mass of food through the alimentary canal. We know well how heavy pur food lies in our stomach if culled to a serious case just after a hearty meal ; how long it is in leaving it, and how enervated the parietal muscles feel. Then at the same time that mental causes thus slackened the mechanics of nutrition, the unwholesomeness of the air in the close shop where the patient was employed poisoned the mu- cous membranes, diminishing the vitality of the epithelium, and causing them to be abnormally covered with a thick layer of mucus. By this tenacious coating the entrance of alimen- tary substances into the veins and absorbents was impeded, and the owner pined in the midst of plenty. So all the usual signs of starvation followed. First irregular hunger by no moans a constant companion of chronic deprivation of food, yet some- times present as here; then loss of appetite a much more frequent phenomenon; then paleness, languor, weariness; then anasarcous oedema, and all the other more marked symptoms of anaemia in their order. The deficiency of digestive power was exhibited principally in respect of potatoes, pastry, sugar, porter, all of which pro- duced ilatulence and pain at the epigastrium, and wore hi sequence at first omitted from the dietary. She digested easily i'n>m the beginning small quantities of milk and bool'-toa. It is obvious that if I had written down ever so many "full diets," one to whom the very sight of food was an abomination would have gained nothing by it; she would simply have gone with- out oaeh meal. So I directed no meals at all to be taken, and no solid food ; but a cup of milk with a third part of lime-v in it to be given us medicine every two hours, and a p: 36 INDIGESTION OF VARIOUS FOODS. beef- tea in divided doses during the day. I remarked to the students that our object must be to make the patient a carni- vorous animal in order to make her omnivorous. After a short time, shorter perhaps than one can always hope for, the selected nitrogenous food restored the digestive juices to their full powers, and she was able to take without pain, even the most difficult to digest of all aliments, a hospital potato. Sometimes the condition which originates the indigestion is an organic and incurable degeneration. Yet in spite of the persistent cause growing of course worse and worse, the indi- gestion may not proceed beyond that of starch. For instance, Bright's disease of the kidneys may have this effect. CASE V. Maria R , aged 52, had suffered for four winters from cough and shortness of breath, which went away when the weather became mild. Her appetite was generally good, and she did not suffer from indigestion. In the spring of 1861, as she got better from her winter attack, she found she could not get about from swelling of the legs. This anasarca grew worse, she got ascites as well, and came into St. Mary's. The urine was found to be albu- minous. It was not till she had been in the ward above a week that she com- plained of bad nights from flatulence, and a sensation of fulness in the epigas- trium, which shortly after dinner became pain. Hydrocyanic Acid and Soda did not relieve this, but the change from ordinary diet to fish without potatoes did so immediately. The patient remained in the hospital more than three months, for abscesses and sloughs formed in the cellular tissue of her legs from distension, and she was a long time on a water-bed. She finally got well enough of the dropsy to be discharged, but never was able to digest well, though no more severe symptoms were produced than those detailed. Of a more common form of the dyspepsia accompanying albuminuria I find an instance a few pages further on in the case-book. CASE VI. Frances S. , aged 63, a superannuated governess, was admitted June 7, 1861, with general dropsy of three weeks' duration, dependent on albuminuria. She had for some time suffered a good deal from flatus, occur- ring soon after meals, and followed by vomiting of the ingesta. When, for a few days from time to time, the victuals were retained, griping and diarrhosa were often the consequence. In these sort of cases it is to be observed that the symptoms are much more severe, not confined to amylaceous food, and producing the phenomena of vomiting, which will be a matter INDIGESTION OF VARIOUS FOODS. 37 for future consideration. If vomiting fails to be producd, diarrhoea often ' place. 1'isease of the heart produces sometimes a very marked indi- >n. This, I think, mostly occurs where it is aggravated by an atonic condition of the arteries, so that the abdominal circulation is especially obstructed. CASE VII. Mr. James L , aged 63, came under my care March llth, He h;ul for a year past been growing very wheezy and short-winded. On examination of the heart, it exhibited a tumbling action; its stroke was uneven and irregularly intermittent; the sounds were distant and not accom- panied by morbid murmur. The pulse at the wrist was more irregular and intermittent than the heart. The urine was albuminous, of the spec. grav. 1 .nits when warm from the bladder, and was free from tube-casts after standing. For the last few weeks he had been unable to sleep at nights, suffering much from flatulence. This did not arise from overloading the stomach, for his appetite was gone. The skin had become yellower than usual, indeed the yellowness of his complexion was visible through the fixed russet-apple tint of hearty old age which appeared in his cheeks. I prescribed two grains of Aloes ami Myrrh pill ever)' night, and two tablespoonfuls twice a day of the follow- ing mixture: R. Ferri et Quinise Citratis, gr. 40. Tincturae Digitalis, fl. oz. -1 Jheris, fl. oz. Aquae, fl. oz. 15. On the 19th, he said he was twice the man he was in both breath and bowels. And indeed he looked so, for the skin was clearer, his appetite and were better, and the pulse was nearly regular. The urine was 1.015 in i-p. irrav., but still albuminous. So that all improvement was traceable to the heart, not to the kidneys. The amelioration in this case seemed due to the tonic action of the Digitalis on the arteries, combined with the arteriali/a- tion of the blood by Iron. Sometimes the organic disease producing amylaceous dyspep- sia is not one of t -ue-cluin^es which are capable of ana- tomical demonstration, and with which we are familiar from urns and drawings, but those more recondite alterations in the nervous system which are provisionally termed functional. For example CASE VIII. James L , a bricklayer, aged 32, was admitted to 8 under my care in August, 1857, principally for a loss of power and of sensi- 38 INDIGESTION OF VARIOUS FOODS. bility in the legs, due to some extraordinary exertion six weeks previously. Besides this he complained of pain at the epigastrium, not increased by pres- sure, but only by taking food. His tongue was dryish and white, his pulse feeble. When this was observed, potatoes were omitted from his dietary, which had previously contained them, and the discomfort ceased. He after- wards had Quinine and full meat diet, with an extra allowance of bread to "take the place of potatoes, and remained in hospital altogether three weeks, without any return of the epigastric pain. Here subtraction of diet was possible and effectual, and its effect confirmed the diagnosis. Potatoes, as usually cooked, are probably the most objectionable article of food which can be presented to a weak digestion. The starch granules are but half ruptured, and are held together by cellular tissue, so that they are reduced by mastication only into small pellets, which require long soaking in gastric juice before they can be broken up. Mashing them expedites this process very much, but even then a good deal escapes digestion. Mixing them when mashed with meat gravy is a further expedient which is also useful. The relation of muscular exhaustion to indigestion was inci- dentally alluded to in the last case. There are several forms of its exhibition. The most common is that which we see more as members of general society than as physicians, namely, where in a healthy person some extraordinary exertion brings on a temporary inability to digest all food more or less, but especially vegetable. CASE IX. A healthy young woman, after being on horseback eight hours in a hot sun, first took a short nap, and then sat down to dinner, of which she partook moderately, having but little appetite. In the evening she suffered much from tightness across the chest ; in the night was unable to sleep for flatulence coming up in eructations, and rolling about the bowels ; she vomited, went to sleep, and the next day was well. Sometimes the disturbance proceeds further CASE X. In 1863, during my autumn holiday in Switzerland, I had saun- tered up from Zermatt, and spent the afternoon on the Riffelberg. I remember it well, for it is the last Alpine climb I shall ever have. A little before dinner I was joined by a gentleman whom I had seen some days before stepping out well on the Theodule glacier, and who was evidently used to the high Alps. He had now just come from the ascent of Monte Rosa in a shorter time than usual, and both he and the guides confessed to being tired. He dined moder- INDIGESTION OF VARIOUS FOODS. 39 ately well, and after dinner proposed to accompany me back to Zermatt. We set off accordingly, bat long before we arrived at our destination he was taken with flatulence and eructations, which shortly led to gripings and diarrhosa, with extraordinary explosions of wind. I felt very glad that darkness had cleared the road of all wayfaring spectators, and that we had a guide with us. However, we got down all right, and the next day he was none the worse. Sometimes the diarrhoea is later in its supervention CASE XI. S. G. S , after a tedious ride across the Sierra in Andalusia, vomited a luncheon of bread and cheese which he had eaten. Feeling a want of appetite and a disgust to meat, he afterwards dined lightly on soup, bread, and vegetables. In the night and next morning he had frequent eructations, ami in the afternoon of the day following the exertion, griping and diarrhoea, with much flatulence. Throughout the attack the urine was very high- colored, being as dark as porter, though not scanty. A day's rest set all to rights. In these temporary attacks there is a general feverishness of the system,' not, indeed, marked by rigors, but by anorexia, high-colored urine, thirst, and dryness of throat. They are not evidences of bad health, for they arise only in consequence of such exertions as no one need take without they like. But as a rule I doubt if such violent exercise contributes to good health, especially in middle-aged persons, and it is not a wise employment of those short holidays which we Londoners can afford ourselves. Another form, more suited for medical treatment, is where the indigestion of starchy food recurs habitually after even moderate exertion, an exertion such as does not tire the re- mainder of the body. CASK XII. John E , a sturdy, hard-featured fox-hunter, aged 73, who had lived in the country, farming and riding to hounds all his life, and never been ill before, came to me in November, 1863, complaining that for the two months past, whenever be undertook any of the usual exertion entailed by his active life, he was overwhelmed with flatulence. The abdomen swelled up, and he passed wind first upwards and then downwards ; after which he felt relief, if he took rest, lie was well so long as he kept quiet, lint each fresh occasion for muscular effort brought back the uncomfortable 1 symptoms. Pre- scribed (Quinine and Strychnine, more sedentary habits as suitable to his time of life, and to take luncheon and late dinners, instead of a heavy midday meal aud high-tea, as his custom had been. 40 INDIGESTION OF VARIOUS FOODS. In this instance it was pretty clear that the defective vital power of the stomach was the first indication of approaching old age, and was a warning that habits more suitable to that inevitable event must be adopted. The older the stomach is, the less it can bear either long abstinence or the overloading which is consequent thereon in a person of active pursuits. Sometimes the agency which brings on chronic indigestion is of a much more sudden character. CASE XIII. "William S , aged 37, came to me August 1, 1861. He said that ten years before he had exerted himself violently at Epsom on the Derby- day in hallooing and running. He was suddenly attacked with a severe stitch in the side and excessive flatulence. He vomited, and that temporarily carried off the pain. Before that period his digestion had always been per- fectly strong, but ever since he has suffered from eructations of tasteless air from the stomach, within an hour after meals. Recently, after any mental annoyance, he had had attacks of vomiting. Latterly, too, his general health had become affected ; his muscles were flabby and tremulous, like those of a spirit-drinker, and his temper had become irritable. There was no pain on pressing the epigastrium. The appetite was moderate, and the evacuation of the bowels was daily. After taking Iron for a fortnight, his nervous symp- toms were much amended, but he complained of the flatulence, and the bowels were costive. He was ordered Quinine with Strychnine, and pills of Aloes and Myrrh', which seemed to suit him well, for I find no note of any future change of medicine. It may be presumed from the permanence of a chronic effect arising out of a temporary cause, that in such cases as this some structural change takes place in the organ primarily affected. But what that change is nobody knows. It is not chronic in- flammation, ulceration, or thickening ; or else pain on pressure, either sharp or dull, would be found. Perhaps it is a sort of dilative paralysis, such as occurs in hollow organs like the bladder from sudden unwonted stretching. But this will be spoken of hereafter, when we come to speak of the structural changes of the viscera. At present we have to do with it only as a cause of the lightest degree of indigestion, the amylaceous. The use of Aloes and Myrrh (the Pilula Aloes" et Myrrhse of the British Pharmacopoeia) has been spoken of as ordered in this case. It is not merely a purgative, nor would any other purgative do as well. On the contrary, most purgatives would probably have been injurious. Gamboge, Senna, Sulphate of INDIGESTION OF VARIOUS FOODS. 41 Magnesia, Colocynth, Mercury^ and several others which pro- duce elimination of serum and increase secretion generally, do harm just in proportion to. their activity. It seems established, by the experiment of making them act when injected in a fluid form into the circulation, that their soluble principles have a destructive agency upon the blood ; whereas the soluble alkaloid in Aloes (aloine) is a bitter tonic, and the purgative power tea in its insoluble resin. It is very moderately eliminative in small doses it but adds to the solid excreta of the colonic Is, and elicits matter feculent in smell and of consistent f >rm whilst at the same time it strongly restrains by its bracing bitter the formation of mucus. See its effect on moist piles, how it dries them up and often makes them smart! And we may judge from this what its action on the gastro-intestinal mucous membrane is. At the same time, by the more vigorous peris- taltic movement and by the solid mass passed along the gut, the already existing mucus is cleared away. Aloes is thus employed strictly as a clearer of the intestinal membrane, and it is joined with Myrrh, partly to divide it minutely and make a small dose go further, and partly to give the patient the benefit of the extra resin. I am particular in enlarging upon this point from a fear lest any words of mine should be construed as an encouragement to an unfortunate tendency, common to both the public and our profession, towards commencing treatment habitually with destructive remedies. Some call this "clearing the decks for action ;" in a majority of instances they may be said to throw overboard much of the best tackling in the ship and loosen her armor-plates. A so-called "sluggishness of the liver" is a ire.|nent pretext. In a half-nourished person (and all invalids are ex vi termini but half-nourished) the feces are apt to be light-colored and scanty, inasmuch as the blood they come from is light-OOlored and scanty. Blue Pill gives them imme- diately a darker hue and increases their quantity, but sadly at the cost of tin; patient's strength, while the temporary change soon passes off. Meat and Iron produce the same result, by LMvitiir them more to l.e made out of, and this improvement is a real and permanent one. 42 INDIGESTION OF VARIOUS FOODS. I have hitherto said nothing about the influence of the mind in inducing indigestion. Perhaps to that more often than to any other cause the history of it may be traced in the classes of society placed above the chance of physical want. I have no notes of ever having attended any patient suffering only temporarily from this cause ; it is scarcely a case for a doctor ; but probably every one's personal experience will supply him with an instance of it. More commonly our professional ex- perience supplies us with examples like the following : CASE XIV. My old patient T , an anxious lawyer aged between 30 and 40, with a young family, complains that whenever he has to see a worrying client (and clients seem to become more worrying than they used to be), his mouth gets dry, his hands and feet get cold, his eyeballs burn, his head gets in a whirl. He goes home to dinner with a pain in his loins, but with a good appetite. His food lies like lead on his stomach, and seems to produce an intense headache. Once in bed, he drops to sleep ; but he is woke up, at four in the morning at the latest, by either eructations or wind in the bowels. If this can be passed off he feels somewhat better, and can go to sleep again. I persuaded him to give up his house in London and sleep in the country, which seemed for some time almost to make him a new man, but he still suf- fers in some degree from his weakness of nervous power, whenever he has any but the most routine business to do. I suppose such cases will always be common, so long as society demands brain- work, highly rewards it and concentrates in such places as this metropolis. Eemark the sequence of events : the mind occupies the whole business of the brain ; no nervous energy is left to preside over the secretions ; the mouth is dry from lack of saliva, and if we could see them we should probably find the oesophagus and stomach dry also ; the amylaceous food is not converted ; it lies like a weight at the epigastrium till it undergoes a chemical instead of an organic solution; it ferments, and gives out carbonic acid. In the mean time the tired brain is causing headache, and laying the blame of its pains on the stomach ; whereas its own weakness was the cause of all the troubles. It is a foolish plan for a lawyer to sympathize too deeply with his clients they do not want his sympathy, they want his help and his reason ; and they will get both of a better quality, if he does not make himself ill by overcaring. Where the nervous system is so irritable, Strychnine does INDIGESTION OF VARIOUS FOODS. 43 not seem to avail. I gave it as a tonic in this case, but without lit. Charcoal brings temporary relief, but it is a bulky, troublesome, gritty powder, and in chronic cases a man cannot go on for ever taking it. Occasional courses of Quinine and occasional courses of mild Alkalies seem of most use. Sometimes the determining agency to the stomach is a sud- dou mental shock, such as this : CASE XV. Edward F , a man of 40, had had dysentery in 1852, but had been fairly strong again till a few months before he came to me early in May, I860, when the failure of a bank completely upset him. He began to suffer from a feeling of weight at the epigastrium, and of palpitation of the heart after dinner, which, however, would be relieved by eructation. He had noc- turnal flatulence, he lost his marital vigor, and grew thin. His nose too had got red, which a man of 40 still careful of his appearance does not like. I saw him again twice in June, by which date some powders of Strychnia and IVpsine, which I ordered him, and time, seemed to have been effectual in setting his digestion right, and he was able to gratify a wish to travel on the Continent. More commonly the mental distress is of a wearing character rather than a sudden shock. 1 K XVI. John C , aged 55 (Dec. 2, 1862), had been slowly becoming bankrupt for some years, though in point of fact he was safe from physical want. He was also unhappy at home through the misconduct of a wife. During this time he first began to suffer habitually from oppression at the epigastrium after meals, so as to grow particular in his diet, and from ex- perience to eschew potatoes. After food he felt something " working up and down" as if flatus was trying to come up. He had grown emaciated, and lost as much as thirty pounds in weight, and his fecal evacuations were scanty and irregular. In the last instances quoted there was no previous state of the internal viscera which could be suspected of having determined the weakness to the stomach. But that is rather the excep- tion than the rule. Mental causes are much more powerful Avhen joiiifi.l to some previous pathological condition. As in the followin : CAM XVII. Mrs. P.. iiL'fd CO, came under my care in July. 1861. She had li.ir several winters, luit had suffered little from h'-r stomach. In tin- early part of the year she hail nursing a son-in-law, a patient of mine, with pulmonary voinica. ami had 44 INDIGESTION OF VAEIOUS FOODS. naturally experienced much anxiety on his account. This was followed by pain in the right hypochondrium and a sensation of cramp in the stomach when it was empty. Vegetable food produced flatulence and was avoided. Apparently in consequence of that the bowels had become costive. She also occasionally suffered from water-brash. Is it not fair to assume that the catarrhal condition which had affected the pulmonary travelled to the gastric mucous mem- brane? that the patient, in fact, had a catarrhal diathesis which by the slowness of digestion resulting from the mental worry was fixed in the stomach? So that the dyspepsia remained though the external cause of anxiety was removed. The chief mode in which chronic catarrh induces dyspepsia I believe to be by enveloping the food and impeding the gastric juice from freely mixing with it in the stomach; thus the starch which had escaped the mixture with saliva by being unbroken remains still undissolved. The mucus further on in the ilia and in the colon by its slipperiness and elasticity pre- vents the muscles of the gut from duly urging forwards the mass. Hence we have the starch fermenting and generating gases and morbid acids, relieving pain, indeed, for a certain period after it is swallowed, but by the above-mentioned chemical decay producing infinite distress in the later periods of digestion, failing to afford nutriment in the intestines, and causing costiveness when it gets lower down, making the feces lumpy, slimy, and hard. I shall in a future chapter recur to this connection between the mucous membrane of the lungs and of the stomach, when I review the subject of what is called phthisical dyspepsia, where a permanent pathological condition of the respiratory viscera produces, or seems to produce, a very obstinate form of derange- ment of the digestive viscera, as a secondary consequence. At the latter end of the cholera epidemic of 1854, when the plague was becoming more general but less fatal, I used to see a good many such cases as the following : CASE XVIII. Joseph W , aged 42, a laborer, had an attack of the prevailing diarrhoea in August. From that time till he came to St. Mary's on October 27, though his appetite was good, his bowels had never recovered their healthy action, being always either costive or relaxed. Lumps of un- digested vegetable food used to appear in the feces. For the last three weeks INDIGESTION OF VARIOUS FOODS. 45 al-n lie had suffered from pyrosis. The tongue was large, flabby, and redder than natural, as if skinned. The epigastrium was tumid and drummy. The kidneys seemed quite to have recovered the choleraic congestion, for the urine was acid, clear, and free from albumen, though (as in most dyspeptics) of low specific gravity, l.nlt;. lie was treated with rest in bed. liquid animal f.M.d. I'.ismntli. warm baths, and < 'astor Oil. And the treatment seems to uitcd, for he was discharged "cured" (which means in hospital language ' well enough to go to work") on November 1. But I presume some symp- toms remained, for he was ordered to take a store of Bismuth with him. This is an instance of the partial paralysis of the vital powers of the digestive organs which often succeeded to choleraic diar- rhn-a I think more often in moderately mild cases than in the most severe. I suppose because they got about too soon; just as dropsy oftener occurs after slighter scarlet fevers than after dangerous attacks. It is wrong to class .such cases as inflammation of the stomach ami bowels, for there are none of the usual accompaniments of inflammation, such as heat of skin, quick pulse, thirst, or even loss of appetite. So that unless the word inflammation is to be m;ulo coextensive with disease, it cannot include them. A return to the district infected by the cholera poison will be apt to cause a relapse in those who have got rid of their tliurrhci.-a by temporary removal, as happened in the following incident of the visitation, which now in trembling hope we call " the late epidemic." CASK XIX. Mr. V , aged 35, a chemist and druggist at the east end of London, came to me on the 13th of October, 1866. During the prevalence of the epidemic in the early summer months he had experienced an alt ark of choleraic diarrhu-a, with cramps. Arc. On his recovery he was too weak in attend to business, so he left London for a six weeks' holiday, and then felt quite well. On returning to his work, he was careful not to over-exert him- self; but still he had no sooner be^un to sleep in the house than his rest was disturbed by flatulence and diarrlm-a; this morbid looseness of bowels often alternating with costiveness. giddiness, and confusion of ideas. The feces, instead of being formed, homogeneous, and of natural odor, as in the country, cuiitaineil large lumps of unaltered food, and smelt like rotten hV>h. A second absence from home relieved in a few days the-e symptoms, and again a return brought them back. A third holiday was air.iin effectual, and now in October he was very anxious to ir't hack to work : but still he has a slight threatening of the indigestion of food in the described himself as being woke up at four in the morning by a feeling of discomfort about and above the navel, then there was as it were a working or fermentation in the belly generally, and sometimes a burst of wind upwards by eructation, but more commonly a resonant gurgling, and then followed a feeling of relief without any explosion per anum necessarily taking place. After breakfast there was again discomfort and flatulence. The stools were cithor watery or pultaceous, with occasional lumps of ragged matter. The urine was variable, often pale and watery, often thick and highly colored. Tin- pulse had the emptiness and sharpness indicating the inelastic arteries of old age. and was quicker than natural. The palms were hot and dry. The te was white and furry. The appetite was good, and the usual diet of the easy classes was taken with satisfaction and without any consequent epi- gastric distress. I found that he had a "dinner-pill" of his own, consisting of Colocynth, Ipecacuanha, and Henbane, which he took before dinner, and then he said there was after an action of the bowels before going to bed, and the morning di-'-uinfort was alleviated if not prevented. Still it returned again, and he thought it got worse. He therefore had somewhat lost faith in his favorite pill, and having to his surprise experienced much solace from a few drops of Chlorodyne taken at night, came to consult me about it. I advised him entirely to give up the purgative pill, to take the Chlorodyne for a short period, then to try and do without it, and to have a bouillon and a glass of wine for breakfast, instead of the ordinary British fare. Doubtless the production of indigestion after acute illnesses is most frequent where those illnesses have specifically affected the alimentary canal. Yet we find it follow also other serious (lisv;i>.->, though quite unconnected with that mucous membrane. Thus \ XI. Harriet R , a pale single woman, aged 42, was ill enough to be admitted an in-patient at Saint Mary's, July 12. 1862, a time of year when slight cases are usually kept out. She complained of pain at the epigastrium re that she. tnok hardly any solid food, living mostly on tea. The mouth was dry and sticky, her appetite was gone, the urine was of the specific gravity of only 1.010 and scarcely acid, the pulse 108, quick and small, the catamenia hui XII. The immediate cause of M. A. S coming under my care on January 23, 1855, was an attack of cramp-like pain after a meal at which she 48 INDIGESTION OF VARIOUS FOODS. had eaten both rice and potatoes. But I found that she had suffered after vegetable food for many months, and that this weakness was traced by her to her last child-labor, up to which time she had always been strong. Her stomach was so blown out by the immediate illness, and so painful for several days, that I had to put on some leeches and feed her on milk and lime-water, but I doubt not that a lesser degree of the same condition was habitual to her. She seemed to have been flatulent, and had costive bowels ever since the birth of her last child. Those in whom dyspepsia is produced by a mucous diathesis of the internal membranes are peculiarly affected by climatic influences. The union of cold and damp found in an ordinary English winter is the most common exciting cause, making familiar such cases as this. CASE XXIII. Henry L , a schoolmaster, first made himself ill at the age of 28 by reading too hard for an University degree. His nervous system was completely prostrated. This was at the end of the summer of 1860. In the succeeding winter he began to feel a weight at the epigastrium after eating, and a strange kind of vertigo, as if the ground were falling away from under his legs. He would have sudden flushes and perspirations. If he could eructate any considerable amount of flatus there was an immediate relief to the symptoms. His nights were disturbed by cramps and by wind rolling about in his bowels, as if tbey were going to act. But no, they were consti- pated. He found acid often rising in the throat, and occasionally vomited a mass of stringy mucus. During the summer he was much better, and he was able to play at cricket, but when I first saw him, in December, 1861, his old miseries were returning with double force. He was getting very weak and nervous, his tongue was white and tremulous, his pulse very rapid, and he said that occasionally he was quite hysterical. Iron did not seem to suit him, in spite of the evident anaemia. But Quinine regularly, and pro-re-natd doses of Valerian were of use. He has diligently gone on with occasional courses of this treatment, and suffers very much less. He is quite well every summer, but at the beginning of each Christmas holidays he is threatened with a re- lapse and comes to be encouraged to ward it off. In the last case the failure of the nervous system was a cause of the failure of the digestive powers, but the circle of events sometimes turns the other way round in this class of cases which are affected, as now described, by climatic influences. CASE XXIV. Mrs. R , aged 34, the mother of four children, is the wife of a thriving tradesman, and certainly as little exposed to any strain on the mental powers as any one I know. But she is fat, leuco-phlegmatic, subject to leucorrhoea and to mucous discharge with prolapsus of the rectum. She is costive, and was much in the habit, till I told her not, of taking purgatives. INDIGESTION" OF VARIOUS FOODS. 51 to take toll from each passing delicacy at the tai>]e-d'hote. But vou will soon see them returning to tea and toast at the one, and restricting their performances at the other more and more to t: ; >!es ami the maccaroni. unot s;r with those who attribute to this vege- tal .lc diet the comparative freedom from indigestion; such an MS to me a confusion of cause and effect. For we all more or less, I suppose, admit the value of meat diet in curing such complaints. The freedom seems to me the rather due to that vigorous condition of the mucous membranes which the climate insnr .ipare, for example, the amount and the intensity of such a di>< ' "nronic Bronchitis in Italy and in England. At St. Mary's Hospital, London, in the patients admitted between 1853 and isill inclusive, 1 in every 32 was a case taken in for Chronic Bronchitis. In the statistics of Milan Hospital which I have compared with them in a little volume published last . there is oniy 1 in SS23. 1 dry ness of the air without excessive heat or cold renders it needless for the mucous membranes to put on their slimy winter coats. They are in a more active condition for the work of absorbing oxygen, digesting, extracting nutriment or water, or whatever else they are required to do. They are filled with :, and pass it on rapidly with its fresh burden of ren< life to the rest of the body.- 1 "Some Effects of the Climate of Italy," p. 41. 2 Tin- teim 1'V which anatomists have designated this tissue is apt to lead even tin- most thoughtful of us into a fallacy. . \.-iv.- members of named after the work which is their most important occupation. Tim industry of the lawyer is the administration of the law ; the doctor iu any faculty ought at any rate to lie learned enough to teach; the duty of bishops and overseers is iirtffxtirH* to ovri>fe each their several depai fluent-. Hut the cl mucou- m-iiil.] mucus. It is most active wh- doinc so. and it- activity i just in proportion to the copiousness of the mucus. Typical health certainly consists in its ahsi-nce ; robust people pass weeks without expectorating; many lind their handkerchiefs clean and unfolded att'-r si-veral days in their pockets, spite of all the voluntary and in- voluntary irritants to which the Sclnieideriaii memhraiie is subject; and the urinary and intestinal outlets ordinarily contribute only an intinite-imal quan- tity, wliich may fairly be attributed to a temporary defect in some fraction of their large area. The real office of mucous membrane is to offer a passage inwards for oxygen, 52 IXDIGESTIOX OF VAEIOUS FOODS. The indigestion of starch is in point of fact the indigestion of sugar, for it is into the latter substance that it is converted by either the action of the saliva immediately, or, in lack of that, "by the contact with the mucous membranes slowly. It is there- fore quite natural to find that any excess of sugar taken ready- made induces discomfort in dyspeptic patients. It is undigested, and the greater part of it undergoes acetic fermentation by the second or third hour after it is eaten. Some perhaps may undergo alcoholic fermentation, and generate the excess of carbonic acid, which fills the alimentary canal with flatus. During its fermentation it also encourages fermentation in other articles of food, and by its presence oleaginous food is apt to be rendered indigestible also. Great discomfort will some- times go on for a long time from this cause without being sus- pected, and cease by the simple expedient of leaving off so little necessary a constituent of diet as sugar. CASE XXXI. Edward W , a gentleman farmer, aged 45, and inclined to corpulence, came to me in March, 1848, complaining of extreme pain running up the back of the sternum in the third hour after almost every meal, but especially after breakfast. This was followed by intense headache and giddi- ness, so that he feared he was going to have apoplexy. On examination of the stomach it was not painful on pressure, but drummy to percussion close up to the cardiac pulsation. I gave him a course of Colocynth and Mercurial purgatives, and saw him again in July. The headache and the fear of apoplexy was then relieved, but the dyspeptic pain was as bad as ever, and the tongue was very yellow and thickly coated. I desired him to abstain from sugar and to take his morning tea with a slice of lemon in it. In March, 1850, he came to me for a gonorrhoea which had become obsti- nate, and I asked him about his dyspeptic symptoms. He said abstinence from sugar had quite cured them. In addition to these pains caused by its fermentation, sugar will in some instances cause pain immediately on its ingestion. It has seemed to me most probable that in such cases there is some rawness or local morbid sensitiveness of surface in the primae via3, and that the pain is analogous to the peculiar sort of twinge which the presence of sugar will cause in a tooth water, fat, albumen, and other useful substances, and to defend the less easily renewed ^.issues beneath it from the deleterious action of external agents. These functions it best fulfils when it is bedewed with a moderate exhalation, and not with mucus. INDIGESTION OF VARIOUS FOODS. 53 unnaturally sensitive from caries, or even from neuralgia with- out solution of continuity. This pain arises too immediately to be due to decomposition. Syrup does not cause it, but only lull'' : SECTION II. Uyestion of Albumen and Fibrin. Grazing animals are obliged to take their food leisurely, so mix it up with the secretions of the mouth, and many of them even to bring it up and chew it again, if they would not have it ferment in the bowels and risk a rupture. On the other hand, to beasts of prey the only use of saliva seems to be the keeping their throats moist. They need to chew the morsel only enough to prevent it sticking in the oesophagus. It would appear that while vegetables require for their perfect digestion a perfect condition of the whole alimentary canal as sketched out in the previous section, flesh-meat is at least inde- pendent of the salivary glands. And this observation, drawn from natural history, is quite confirmed by physiological experiment, which finds the peculiar solvent of albumen and fibrin in the gastric glands. These tem . quired to produce even an acute temporary dvspepsia of : 5-i INDIGESTION OF VAEIOUS FOODS. And I may observe that it is through the nervous system in almost all instances that proteinous indigestion ari.se*. We will begin with the least rare shape in which we see the disease. CASK XXXII. Lucy P , aged 22, a servant of all work, debilitated pre- viously by a long rheumatic fever and a hard place, was admitted to St. Mary'? for scarlatina anginosa on February 22, 1861. The throat was much inflamed and a little ulcerated. On the 2d of March she was ordered ordinary meat diet, but the ingestion of it brought on such severe pain in the epigastrium that it was obliged to be left off. An example of making the mistake of overhaste in the desire to renew the flesh lost after acute fevers. A good example, because in anginous scarlatina, if in any acute fevers, you would expect the salivary glands to have more particularly suffered. You would expect the indigestion of starch to have been the marked feature. But it was not so, and the deficiency of life manifested was a following of the genus fever, not of the species anginous the injury to the whole patient took the precedence of the injury to the part. On that ground I preserved a record of the case, for often as it must have happened in other instances that my patients have been allowed solid meat too soon, I cannot find another note of the fact. And I must trust my memory and my reader's expe- rience to assert that the evil consequences are not confined to scarlatina. When I say " evil consequences," I do not mean merely the temporary pain, but an attack of feverish indigestion, sometimes of vomiting, which throws the patient back some days. It is to be remarked that it is not so much the chemical com- position as the form of the aliment which renders it improper for incipient convalescents. Through the whole course of a typh-fever a continuous supply of liquid flesh in the shape of beef-tea has been kept up. If the stomach could not digest it the intestines did, and so the patient's strength was sustained. But give him a meal of roast beef, and it rolls about in the stomach till it decays ; digestion is impossible, and it causes diarrhoea. This caution is most requisite in cases where a relapse is INDIGESTION OF VARIOUS FOODS. 55 Me. As for example in fever, of either typhus or typhoid type, where the bowvls have become inflamel. Here solid inav bring back the worst features of the lid meat in causing relapses of rheumatic fever. In acute diseases the condition of the stomach which pre- vents it from digesting meat is merely temporary, and all that is requisite is patience. But where the failure of the organ is chronic the affair is much more serious. A state of anaemia is induced which is a long time in being recovered from. \ X XIII. Kmma Ch , a :<f weakness that she was obliged tn In- kept in l>ed. 'I'll',' pulse was 11 '2. there was a systolic limit with the "iind of the heart ; the Im-atli'mir was very short on slight exertion, the caiami-iiia had ceased, and the complexion had lu-.-om.- .-leap and pale like wax. She i niiiplained of extreme latitude and headache. The howels we'-e irregular, reported costive on admission. l>ut affected l>y diarrlnra during the second day of admission after taking Woth with meat in it. It appeared that she alway- avoided meat, that -he was disgusted with the si^ht of it. and that it caused pain in the epi-a-trinm. There was also a painful spot on the dor- 56 INDIGESTION OF VARIOUS FOODS. sum of the tongue, impeding deglutition of solid meat, and this, spot and others near it were denuded of epithelium so as to give a marbled aspect to the part. For this reason she had lived on vegetables, gruel, bread, and tea. A gradual return to a meat diet, through beef-tea, eggs beaten up in wine, and cocoa at short intervals, aided by absolute rest, Borax, Iron, and Chalk, restored her so by January 10th that she was able to get up and dress. Her pulse was 80, and firmer, the systolic bruit was not nearly so loud as at n'rst, and she had some color in her cheeks. On the 12th she was able to eat the mixed " ordinary diet" of the hospital. On the 15th she wanted to discharge herself from my care ; but when she lay down. I found the systolic bruit was still audible; so I kept her in for a little longer rest, on the excuse of having her vaccinated. She left hospital early in February. It is impossible for a growing girl to make red blood without meat, and the longer she goes without, the less able is she to digest it ; the power of the gastric juice is lowered by the absti- nence. As to the organic cause of the complaint in this instance, I presume one may be allowed to judge of the unseen by the seen, and to conjecture that the state submitted to our sight in the most conveniently visible portion of the alimentary tissue (the tongue) was also present lower down. And we may rationally suppose it to have been worse lower down, for the special gastric functions were defective, while the special oral functions re- mained unaffected. This superficial aphthous state, where the epithelium is destroyed instead of being raised into blisters, is common in the throat, tonsils, and os uteri, and may by stimu- lating applications have the edges so raised and the centre so depressed as to look exactly like ulceration. Borax and Quinine soon cure it, and are therefore probably equally good for the stomach under the same circumstances. In some. cases of pulmonary consumption we find the stomach affected with indigestion of albuminous food. It is so easy to trace out a physiological chain of causation from diminished . diet, to atrophy, deposit of tubercle and phthisis, that it is com- monly too readily assumed that such is the invariable course of events. I do not think so. It seems to me extremely probable that the condition of mucous membrane induced in the lung by the presence of tubercle, may be communicated to the stomach-, and that the latter may be in fact an effect, not a cause. Though still it is a most serious effect, which reacts upon and aggravates IN'DIGKSTION" OF VARIOUS FOODS. 57 tlif pulmonary injury. This is a practical point, for if it is an may lia\v more hopes of curing it, and so arresting _ul loping consumption winch is so imminent. XXXI V. (Jeorge C , aged 24. came under my care at St. Mary's, r I'.'. 1 -.".."). llr wa* miii h emaciated, and had occasionally expectorated b! ly streaks in the mucus from liis bronchi. He had also slight hectic, and -e iit'ctnrnal perspirations. On examination bronchial breathing with sibilant rales was found in the upper part of the thorax on the right side, and that part also w.is Hatter than the cm-responding part on the other side. Ihiring the last two or three months he had experienced pain during diges- tion. He had pain in the epiuast rium and occasional diarrhoea alternating with constipation. After eating there was a feeling of weight at the pit of mai-h. This was especially noticed after animal food. Milk even d it if taken without bread. He got a good deal better on rest. Quinine, and Iron, and was able to take a mutton-chop. Hut what seemed to do him most good was Cod-liver oil, by the use of which he improved in spirits, in power of taking meat, and in weight. He increased as much as ten pounds avoirdupois between October J'.Hh and November Tth, and was discharged as well on the 9th. The deficient digestion of animal food in phthisis is a. very serious thing. It keeps the patient in such a weak state that 1'ata! i-lVi-cts follow shocks which could otherwise be borne up liSt. XXX V. Thomas H , aged 25, a tobacco-pipe maker, was ad- mitted to St. Mary's. September lf>th. 1>.">2. having sutl'ered from haemoptysis, cough, and other phthisical symptoms for sixteen months, during which time he had been out-patient to the Hrompton and other hospitals. There appeared to be crude tubercles to a moderate amount at the apices of both lungs. !!< complained of a feeling of coldness at the epigastrium, which inciva pain after meals when they consisted of meat. He had also frequent vomit- in ir: even the broth diet of the hospital brought it on. Hydrocyanic Acid checked it u little, and Bismuth also seemed to deaden the pain iu the B] trium. so that he gained a pound or so in weight, in spite of what we thought ning of the tubercles under the left clavicle. He was able to digest fish with Irs* pain than meat. 1 Miring this time hi* father was ill at home with the same complaint as oar patient, and on October l.'.th he had news of his death. He was much affected. but the special symptom* did not. seem aggravated, ami he left the ward for ln'iiie at his own desire next iimrniiiLr. Two days afterwards he died quite suddenly; and the immediate <-aue nf decease was reported by his friends to have been grief ut the loss of his father. Ill this case it i.s to be 1 that vomiting was pn- 58 INDIGESTION OF VARIOUS FOODS. which is a grave symptom. Its connection with phthisis shall be discussed in the special chapter to be devoted to that subject, Other local morbid conditions besides those of the stomach will sometimes cause indigestion of meat especially of all victuals. CASE XXXVI. In February, 1849, Mr. K came up from Wiltshire to be under my care. His complaint was of vomiting, especially of meat. The morsel seemed to stick at the back of the sternum, to cause a boiling and a gurgling there, and to be rejected, apparently without arriving at the pit of the stomach. He was much reduced in strength and flesh by this enforced abstinence from meat. A fair trial of Prussic Acid was made without success. But a drachm of Bismuth three times a day deadened the morbid sensibility of the part affected so far, that he was able to swallow meat, considered him- self cured, and returned home. Here I felt no doubt that the seat of injury was in the oesophagus, which for some reason or another rebelled against conveying meat. I suspect that it is the form, rather than the chemical con- stitution, of mammalian muscular fibre which causes it to be objectionable. For in the following case we were enabled to get animal food, reduced to a liquid shape, conveyed past a sore spot as easy as vegetable. CASE XXXVII. Elizabeth S , aged 25 r died at St. Mary's, March 3d, 1852, of an ulcer of the oesophagus perforating- the pericardium. She had been in the ward since January 23d, and during that time a great variety of articles of diet had been tried, to find which easiest would pass into the stomach. Meat she could never swallow at all, but eggs beaten up with wine and thick cocoa, she could retain better than even quite fluids. And, indeed, for some time before the accident which caused death, she got a good deal of nutriment. Even the friability of the fibre will make a difference. Thus in the case of Thomas H., quoted page 57, it is noted that fish could be borne though red meat was not. I cannot lay my hand on another similar case, but the idea is familiar. Yet there are cases when the very softest animal food is objected to as experimentally proved to cause pain. INDIGESTION OF VARIOUS FOODS. 59 XXX VIII In Oct.. l.i T. I-"-. Mr. George R , aged 54, first came under my chapjc. He wa- 'y thin and miserable to look at, bnt I could novcr discover any organic disease in any part. He said that from a boy lie had never been able to eat animal food without great consequent pain. Fluid or liquor made no difference. "Even an egg," he said, caused it. and often brought on eructations of sulphuretted hydrogen, though taken in small quantities. He has often constipation with severe headaches. There was slight pain on pressure of the pyloric region of the epigastrium, a very white (nervous) tongue, and a red nose. What had especially troubled him lately was an impression, whenever he attempted to eat meat, that there was a pin in it. He was always quite aware that it was a delusion, but still could not shake it otT. He had never l>een a spirit-drinker, nor a taker of medical drugs; though, like most dyspeptics, he had given homoeopathy a trial. I -inc. by the use of which he had gained a little weight before he left town. I saw him again next August, with respect to an eruption of purpura on the legs, and he said his old failings had got much better, though he could not quite shake off the fancy about the pin. The habitual indigestion of meat is allied to the indigestion of fat. There are transitional cases between the two, that is to uses where there is partial indigestion of both, when taken in the slightest excess, or in certain forms, but no very glaring ivenience or illness under usual circumstances. We find, for instance, people who can eat mutton easily, but not beef. Xo\\- the main difference between mutton and beef lies in the infiltration of the bundles of muscular fibres by fat. Some of persons are close observers enough even to find that they can eat beefsteak, but not roast beef, which difference is capable of a similar explanation. Perhaps the entire absence of fat in fish may be a part reason why it also is easier digested. SECTION III. Indigestion of Fat. The ili,Lr'.-tion of fat is quite independent of the salivary and i<; fluids:. 11. iir,-. even when they are in a morbid con- dition, ami when the digestion is so slow that the meals are detained Ion;.' enough f ( >r the fermentation set up to extend itself to the lattv matters present, ami to develop butyric and other oily acids, .-till sufficient fat is digested to keep up the nutrition of that tissue in the body. Nay. patients with indigestion of i and albumen will sometimes even get o' !y if '. specimens may be found in this volume. 60 INDIGESTION OF VARIOUS FOODS. The most familiar instance of the indigestion of fat is found in that disease which gets its name from the characteristic phe- nomenon arising out of that indigestion Phthisis. In tuber- cular consumption the body wastes away, cot because of the destruction of fat being increased, but because of its renewal being arrested. Its renewal is arrested primarily and directly by any disease which affects the ilia, such as diarrhoea especially, because the ilia are the immediate instruments of its absorption; secondarily by the inefficiency of the secretions which assist in its solution and alkalization, such as the pancreatic juice and bile; in a less degree by the colonic or fecal viscera; and by the other organs of the body just in proportion as they influence indirectly these. As illustrations of the agency of its renewal and non -renewal, compare the following cases. CASE XXXIX. In September, 1857, I was called to see Mrs. B , aged 45, reported as in an incipient stage of consumption. There were old scrofu- lous scars in her neck, and apparently a moderate deposit of tubercle in both pulmonary apices, indicated by bronchial breathing under each clavicle, and by sibilant, occasionally crepitant rales on the left side. This did not seem to account for the emaciation, and anatomically justified the diagnosis of incipiency. But it appeared that she had tried to take Cod-liver oil and failed ; and that the cause of the failure was its induction of diarrhoea ; so that the more she took the thinner she got. Also after every meal which included the smallest quantity of any fatty matter diarrhoea followed. The stools were like peasoup, and when she was taking the Cod-liver oil, drops of the oil used to be seeu floating on the surface of them. Attempts to change this condition failed, and she never got any better, I know, though I did not attend her to the last. CASE XL. Ellen L , an ill-starred orange-girl in her 19th year, left alone in the world from all her relations having died of consumption, came into St. Mary's Hospital, January 8th, 1856, in the third stage of the same disease. Indeed she had been an invalid long enough for the catamenia never to have appeared, being probably arrested by her ill-health. She was a flabby-faced, strumous-looking girl with grayish-brown eyes, much emaciated, and with the finger-nails curved into claws. She had much cough with blood-tinged ex- pectoration, for which she had been in several hospitals, always with relief. The upper'part of the left ribs was flattened, and there was that large crepi- tation and metallic bubbling to be heard which distinguishes a vomica, while at the right apex there was fine crepitation with tubular breathing. She rested but little, and the lips were livid from the imperfect aeration of the blood in the obstructed pulmonary tissue. INDIGESTION OF VARIOUS FOODS. 61 was anxious to come into the hospital, because she liked Cod-liver oil, took it -with a relish." and -rot better on it. Her bowels were always costive. . inly did improve on Cod-liver oil and Quinine. Her hectic abated. she got a good appetite ; the pulse was fuller, and she lost her cough. So at her own request she returned to her occupation on February 10th. XL!.-- In April. lK">s, I met in consultation Dr. C. IJ. Williamson tin- case of Alice (' . aijed 14, who we made out to have a small amount of tubereiilar < ;he apex of one lung, and in the bronchial glands adjoin- -he had a great deal of cough, and was much emaciated. Up to that iie had lii-eii most carefully attended to and actively treated. Blisters, Iodine. Iron, tonics, had been assiduously administered. Having made our :<>te out a prescription of numerous materials in accordance with the orthopraxy of the day. During the performance of this duty, I re- membered that I had seen our patient (who was the daughter of an intimate friend) at luncheon eating some fat mutton, and it struck me that this capa- bility had never received full play. When, then, the prescription was written I proposed that it should be put away for six weeks, and the patient have no .ue at all. except whatever she fancied to eat. It was a struggle to a good prescription, but yet that was agreed to, and in the six weeks so much pro_ made by change of air, and scene, and diet, that the father declared that had she taken three globules, to those three globules he could ii"t but have attributed the cure. This was eight years ago, the patient a sea voyage, and is careful during the winter; the air does not enter her left apex so well as the right, and she is shortish of breath ; but she run.*, and riie.-. and hunts, and dances, and has plenty of flesh on her II. Just after Lady-day, 1861, Harriet B , a maiden lady, aged 30, whose " father and mother had both died of decline," was pl.iccd under .re by Dr. liuckell of t'hichester. She had evidence of a small focus of tubercle in the apex of the left lung, producing pain, dulness, and crepitation (from the partial condensation of the lung round it), but no marked pulmo- nary ailment. 1 thought that the quantity of tubercle was slowly iuci- from week to week. What she complained of, however, was emaciation and diarrhn-a, accompanied by the passage of pus and sometimes streaks of blood iu the inn. She was soon relieved uf this by appropriate rem- and with a store of ll.i.-matox\lum and Copper was able to go on a long summer visit to some country cousins. I heard of her as going on well, and did not expert to M-e h.-r again, or to inak- available for science. lut a- .-he returned through London in September, proclaiming lu-r>clf quite stout and hearty, I had an opportunity of examining her clu-.-t a-jaiu. I could then detect by neither percu.--ion nor the ear any di-.-a.-e at all in the lun-_'-. The pulmonary tubercle had become dormant. Two years afterwards I saw her walking briskly through the .-tree!.-, looking well. 1 XI. 111. -1. I'.. 1', aged twenty-, -i^'nt. and actively engaged in retail buMiic.-s when well enough, was put under i;, . The history given me by h;.- medical man (Mr. fcskaife of Northampton .Square) 62 INDIGESTION OF VARIOUS FOODS. was as follows. He had been a great consumer of beer, but always in fair health till the beginning of 1865, when he began to pass uric acid gravel in his urine. This continued a year, when by dint of careful dieting it was cured. In the spring of 1866 he had a dysenteric diarrhoea, passing in the stools a great quantity of mucus and occasionally blood for many weeks. He was seen several times by Dr. Brinton in consultation with Mr. Skaife, and cured by Alkalies. This diarrhoea reduced him excessively, so that he lost nearly two stone in weight. He regained his weight, and continued well till December, when he began to cough, and was troubled a good deal with that symptom. In the morning he expectorated transparent mucus with it, but during the day it was dry. Then he began to sweat of nights, and again rapidly to lose weight. So that during the six weeks before I saw him he had lost fifteen pounds, the loss being very often as much as half a pound daily, at which rate it was then going on. The rapidity of the emaciation drew attention to the urine, which I found, after exertion during the day, clear, full-colored, free from albumen and sugar, and of the specific gravity 1.027. The chest was narrow and did not expand freely. It was normally reso- nant. Scattered about, in the upper lobes especially, there were spots in which a full inspiration revealed crackles and occasionally interrupted (" wavy") breath sounds. There was extreme slowness of digestion, especially of flesh food, and espe- cially at the later periods of the day. Between three and four hours after a meal he would have eructations of nauseous taste and smell like rotten eggs. The quantity taken made no difference ; they followed a light snack as often as a heavy dinner. His appetite was fair, but yet he could not eat more than two meals a day on account of these eructations. For they were brought on by anything solid or liquid he took after a two o'clock dinner. Supper espe- cially he could never take, though he had tried all sorts of victuals. The attempt kept him awake all night with flatulence upwards and downwards and feverishness. The bowels acted naturally, but the stools were apt to be fetid. I prescribed for him g^th of a grain of Strychnia and 2 grains of Quinine twice a day, and a bottle of claret for drink, mixed diet and no tea or supper at present. On February 6th his weight had become quite stationary, none having been lost since he began the treatment. The specific gravity of the morning urine was 1.022. The night sweats were much diminished and he felt stronger altogether. So much so indeed that, visiting a friend's gymnasium on the 4th, he tried his hand at raising a weight by a pulley. This exertion was fol- lowed the next day by severe pain between the sternum and left shoulder, which remained at the time of his coming to me. On examination it appeared due to tenderness at the insertions of the pectoral muscle in the ribs. A fortnight afterwards he had gained six pounds in weight, and on the 8ih of March a pound and a half more. On the 25th of March he was stationary in that respect. The night-sweats had diminished to a mere dampness during INDIGESTION OF VARIOUS FOODS. 63 ond or morning sleep. He was able to take meat, sometimes fat meat, .i day. ami toasU-d cheese, without the nidorous eructations which for- merly followed. lit- was alarmed, it is true, by the appearance in the urine of some fine pow.Ii-ry ml deposit, which on examination proved to be uric acid; and he doubted about tin- wisdom of continuing the hi^h-feedim:. Iut I pointed out how much rather to be chosen it is than the emaciation, which had been really on the verge of currying him to the grave; and to overcome Bordered some Hydrochloric acid instead of Citric as a solvent for the Quinine. Ol. serve the difference between these patients (not picked it such as are constantly occurring), and observe wherein it lies. In the power of assimilating fat. The first had not the power, and lost her life with enough healthy lung in her chest to have lasted her for many years; the second had the power in extraordinary force, so that she was able to take an excessive quantity of oleaginous nutriment, and so to bear up for a time against a most formidable amount of softening de- structive tubercle; the third had not, indeed, any extraordinary power, but she had less amount of disease to bear, and she bore it ; the fourth and fifth .had lost the power, but regained it, and with it overcame the morbid diatl It is truly by aid of the digestive viscera alone that con- sumption can be curable. Medicines addressed to other parts lie indirectly useful sometimes, but they more commonly impede the recovery ; whereas aid judiciously given in this quarter is ahvavs beneficial and often successful. The chest is tin- battle-field of past conflict, the lymphatic duct the drill-ground lor new levies of life. Remark in the orange-girl the costiveness and the amenor- rlio'u. I>oth of these are good things in consumption. I do not mean good signs, which they are not, but advantageous in tin- prolongation of life. Fur in such a condition, the lat taken in is not exhausted by even the natural drain abnormally requisite it is abnormally retained. Th- of Cod-liver oil 1> ;;nd less a marvel the 6 we know of physiology. The instinctive de-ire -hown by all nations for an oleaginous dirt, and their association of Mnces of this nature with proverbial ideas of happin> all ages, show the value of a certain amount of it to man's 6i INDIGESTION OF VARIOUS FOODS. comfort. The "butter and honey" of the prophet, used as a phrase for royal food, and the constant reference in the Bible to oil as a luxury (though it could have been no rarity in "a land of oil-olive") these are sufficient to prove its estimation among the Hebrews. The Hindoo laborer, when he devours his gallon of rice for a meal, will spend all the pice he can get on the clarified butter of the country; and "as good as ghee!" is his expression of unqualified admiration. It was a mistake in Baron Liebig to state that oily foods are disgustful to natives of hot climates. All races of men require them and seek after them; and the taste of the Esquimaux, so often quoted, depends mainly on the abundant supply of the article which the sea places at his disposal, coupled with a scantinesss of other pro- visions. Throughout mankind there is an instinctive apprecia- tion of the importance of this aliment, independent of accidental differences of nation or locality. It seems felt to be, as science shows that it really is, a necessary material for the renewal of the tissues, and the desire for it becomes synonymous with a desire for augmented life. An easily assimilated oil comes, in fact, into the short list of directly life-giving articles in the pharmacopoeia; for it is itself the material by which life is manifested. Hence, under its use, beneficial influences are exerted throughout the whole body ; old wounds and sores heal up ; the harsh wrinkled skin regains the beauty of youth; debilitating discharges cease, at the same time that the normal secretions are more copious ; the mucous membranes become clear and moist, and are no longer loaded with sticky epithelium ; the pulse, too, becomes firmer and slower that is to say, more powerful, for abnormal quickness here is always a proof of deficient vitality. Such are the effects, perfectly consistent with physiology, of supplying a deficiency of molecular base for interstitial growth. 1 But that supply is useless unless the absorbents are fit to take it up, unless they are prepared (as the fourth case) by proper tonics for its reception. To find the easiest assimilated oil, and to prepare the diges- 1 See "Lectures, chiefly Clinical," by the author, p. 275, &c. INDIGESTION OF VARIOUS FOODS. 65 tion for the absorption of oil, are the main problems in the cure of consumption. Closely allied to this condition is what is called in children " strumous" or " rickety" dyspepsia, because it leads to struma and rickets. Cases are commop enough among the ignorant and the poor. The following includes as many of the ordinary typical symptoms, and as few individual peculiarities as any I could select : X LIV. James A , aged 7, admitted to St. Mary's, August 9th, 1856, had an angular countenance of grave expression, with gray eyes and long fringed eyelashes. The veins of the eyelids and temples were large and conspicuous. The arms and legs were very attenuated, in strange contrast with the swelled and drummy, but flaccid, belly, on which also the parietal veins were enlarged. The skin of the limbs was dry and unrenewed, giving them a dirty look. In bed he was restless, picking his nose, rubbing his anus, fitl;rr ting his head about, kicking off the clothes, and getting inU) all sorts of odd postures ; but when dressed he was preternaturally grave and quiet, and crii-d when he was roughly touched by any one. He ground his teeth and perspired profusely when asleep. Though so thin, he was said to have a ravenous appetite. His tongue was pinkish with white spots; he was thirsty. His stools were copious, pale colored, as if entirely deficient in bile; with inky stains in parts, as if Iron had been taken, which, however, was denied. There were no worms in tli- in. though the presence of these parasites had been reported. Their smell was very nauseous, resembling that of the macerating-tub of a dissect- ing-room. I Miring a fortnight that he was in hospital, the stools became natural under the use of purgatives, Iron, and meat ; and in close ratio to the improvements of the stools, was the patient's increase of flesh. Examination by the microscope of stools like those shows them to contain lumps of unaffected muscular fibre, undissolved i'at, and free oil-globules in great quantity. In such quantity, indeed, that their whitish color might really be due to the emulsioned oil. Fat is here taken down truly "down" to chemical decay; but not taken up up to living tissue by the lympliat The passage of free oil shows the imperfect action of the in- the lumps of fat the imperfect action of the stomach. Dr. E. Schroder found that in the healthy stomach of a woman with gastric fistula, adipose tissue which was swallowed became so far disintegrated that the oil was freed from the areolar sacs 5 66 INDIGESTION OF VARIOUS FOODS. which contained it, united into drops, and floated free in the fluids around it. 1 In the already quoted cases there has been no deficiency of appetite. Fat is swallowed, but is not absorbed. And this would seem to depend on the fault of the lower part of the in- testinal canal, of the intestines with their lymphatic vessels. In other patients there is found a disgust to fat and to all that contains it so great as to induce nausea when the attempt is made to force the inclination. In these it seems to me probable that the upper parts of the digestive apparatus, and especially the pancreas, whose duty is the emulsification of fat, are to blame. The nausea often takes the aspect of repugnance to meat, for all flesh is scented by its own peculiar adipose tissue, and owes to that its distinctive odor, which is unavoidably associated^in the mind of the patient with the meat itself. CASE XLV. Miss A. M , aged 20, was first placed under my care No- vember 3d, 1865. She was excessively emaciated, the cheeks were hollow, the abdomen fell in so that the first thing you felt on pressing it was the spine, and the haunch bones stuck up like the arms of a chair. The space made dull by the liver on percussion was very small. The skin of the body was harsh and dry. The bowels were excessively costive, not having acted for years without strong purgatives or laxative enemata. The mind was un- naturally quiet and retiring ; she avoided speaking of her ailments, and would go and cry in solitude if pestered about them. She expressed an excessive disgust to animal food, especially if moist or savory. The only chance of getting her to eat a bit of meat was to have it so dried up that most people would refuse it. There was no hallucination or morbid fancy about her diet, but she persisted that she had severe headaches and pain in the abdomen after it, till such time as it was removed by action of the bowels. Cod-liver oil, which, naturally, a medical man had ordered for her, had caused such ex- cessive nausea and vomiting, that it was impossible to persist in it. She had a craving for alcoholic stimulants. With all her atrophy the color had not left her cheeks, the lips were full and red, and she retained a peculiar delicate style of beauty like a hectic consumptive. The urine, too, was of a natural quantity, color, and smell, and of the mean specific gravity of 1.018. So there was naught of what could be. called anaemia. The muscles, too, were well nourished and innervated, so that she could walk, and would walk if permitted, more than was prudent ; and it was after these exertions that she used to urgently ask for wine. The heart and lungs, whose sounds and 1 Succi Gastric! Human! Vis Digestiva, &c., auctore Ernesto de Schroder. Dorpati, 1853, p. 30. IXDIGESTIOX OF VARIOUS FOODS. 67 motions the skeleton condition of the chest exhibited with anatomical dis- tinctness, were i|iiiti> healthy. The only ana-rnia was amenorrhoea, which had existed for eight months. The hi-tory was derived from a most kind and observant step-mother. It appeared that Miss M and her sisters had. during their father's widowhood, been under the care of a horrible French school-mistress, who with a sort of wickedness conceived a hatred to the family, and actually tried to starve them to death to spite the father. One died, but the circumstances were so painful, that I could not cross-examine into particulars. The elder ones are alive and hearty. And this one seemed to get quite strong. She was plum]*, and the catamenia came on at sixteen. But soon after that she began to full into her present condition, and the catamenia ceased, as above stated, gradually. She had tried vegetable tonics, Iron, mineral acids, baths, hydropathic packing, homoeopathic remedies, &c. &c., without consequent benefit or injury, so far as I could discover. Also, in passing from one hand to another, usually the purgatives were increased in intensity and variety. Her father, a physician, was growing sceptical of his profession. I commenced treatment by leaving off all purgatives and giving her un- known to herself. Opium in half-grain doses, with a view of stopping the pain, which she said she always had when the bowels were not open. I took it to be an abnormal sensibility of the intestinal canal, which would not allow the requisite food to lie there a sufficient time. In such a case the orthodox " bowels open once a day" is a diarrhoea. This plan was successful, for with the exception of warm-water enemata twice a week during the winter, she had taken no purgatives since, and now the bowels are open of their own accord, and the Opium pills are left off. I irave her Pepsine, which seemed quite inert; and then Strychnine, which brought back the pain and curiously prostrated her. It was bad practice. 1 have already said Cod-liver-oil was out of the question. On .January 17th I began to educate her gradually to use Dobell's Pan- creatic Kmulsion, and she has continued to take from one to three doses daily ever since. I hear of her from time to time as slowly improving; any acquaintance who have not seen her for several weeks, invariably remark on her gain of flesh. The appetite is better, and the bowels open naturally three or four times a week. (July Gtk, 18G6.) Remark how the deficiency in the assimilation of fat (induced ably ly tin.- starving alluded to, though not assigned to that by thf narrator) made no sign In 'fore puberty. Up to that period apparently enough had been taken in for the ordinary purposes of life, but after it the supply was insuflieient and the failure in health followed accordingly. What lias puberty to do with fat ? Certainly something : in normal health girls In-fore the change naturally dislike fat, but afterwards take to it instinctively. Under ordinary circuni- 68 IXDIGESTIOX OF VARIOUS FOODS. stances and with the restraints which society teaches us to lay on our appetites, especially in youth, the instincts are scarcely made apparent ; but accidental occurrences will sometimes ex- hibit their existence in a somewhat unsuspected manner. The following anecdote shows what a strongly marked line can be drawn between the child and the woman in their relish for food, and how full development is not exhibited in this or that organ exclusively, but in the whole person simultaneously. It was narrated to me by the chief actor. CASE XLYI. In 1825 or '26 the late Mr. Kidout, a much respected surgeon in the neighborhood of Russell Square, was summoned to St. Albans, to see the apprentices who to the number of sixty were employed in the Abbey silk-mills at that place. A great number of the inmates of the house were suffering from a variety of obscure symptoms of various degrees of intensity. On the examination of the invalids he arrived at the suspicion that their illness depended on the poison of lead, and advised their being treated accord- ingly. In the mean time, specimens of the water were reserved for analysis, the milk-vessels made of crockery were examined for the metal in question ; but nothing deleterious was found, nor had any part of the building been re- cently painted. Still fresh cases kept occurring, and those who had recovered relapsed, and had colic a second time. The cause of the evil was evidently permanent. Now the surgeon in ordinary attendance had been loth to agree to the diagnosis which assigned the symptoms to lead-poison, from some connection which seemed to exist between the occurrence of the disorder and the uterine functions. Not only were the catamenia arrested in those attacked, but it was observed, that all the girls under puberty had wholly escaped, while all who had ever menstruated, from the maiden of fourteen to the matron super- intendent, were affected in various degrees. The search was still pursued for the avenue by which the lead had entered the system, and the mystery was at last solved on probing to the bottom of a salting trough in which fat pork was kept. It was found to be lined with the deleterious metal, and to have impregnated the outside of each joint with the poisonous carbonate. Inquiries were then made of the apprentices themselves for some link which would connect this discovery with the anomalous escape of some parties, and injury to others. It appeared that this fat pork was placed on the table three times a week, but never alone, being always accompanied by some fresh meat, and the girls were at liberty to take which they liked. Now on questioning them it came out, though not previously observed, that the older apprentices and adults always ate the pork, while the little girls all, that is, under puberty invari- ably chose mutton. The disease which had attacked the one and spared the others, was a test of the truth of the statements which they had made. INDIGESTION OF VARIOUS FOODS. 69 The newly-acquired desire for fat meat at the age of puberty is a most interesting and curious fact. It is more observable in the female sex, from the deep influence on the vital actions of the whole individual which that change exerts in them, but indications of the same thing may be seen in boys. How shall we associate this fact with what we know of the other corporeal functions of this period ? The mere growth of the body in size is much the same before and shortly after puberty. Nor is it easy to conjecture what the evacuation of the catamenia can have to do with oleaginous matters. There is, however, a change that takes place in the excretion of one organ, which modern chemistry has taught us to allay with the chemical changes of all carboniferous substances in a strict and peculiar manner. It is to the lungs that we would look for -tance in explaining the circumstances before us. It appears from the researches of MM. Andral and Gavarret, 1 that the excretion of carbonic acid by the lung increases in quantity during childhood very exactly in proportion to growth, the augmentation steadily progressing up to the period of pu- berty. In boys it would seem but little affected by that new function ; but with girls the case is entirely different ; there the occurrence of menstruation puts a complete stop to the increase in the amount of carbon thus passing away, and sometimes even causes it to make a retrograde movement. Thus a child of thirteen years of age exhaled 6.3 grammes of carbon hourly; a girl of fifteen years and a half, who had not menstruated, 7.1 grammes; while another, also fifteen years and a half, but in whom the flow was regular, gave out only 6.3, the same quantity as the one two years and a half younger. The same observation was the result of experiments on healthy women of twenty-six, thirty-two, and even forty-five years of age, who still continued to experience their monthly evacuations. After the change of life has occurred, the exhalation of carbonic acid begins to in- -o again, and in elderly women is much the same as in elderly men. What is still more curious is, that when from either pregnancy or illness the catamenia are stopped, then 1 " Annales de Chiinie et de Phys.," vol. viii. p. 129. 70 INDIGESTION OF VARIOUS FOODS. temporarily the pulmonary excretion is augmented and occupies a vicarious position in respect to the other functions. The uterus, then, and vital actions which are expressed by it, play an important part in the decomposition of carbon in the system. When we reflect on this, changes in the digestion which supplies that carbon and changes in the instincts which supply the digestion will not surprise us, when they accompany the radical alteration which the generative organs experience at puberty. 1 This digression has been so long that it has taken us away from the patient before us. The chief practical point of remark is the importance at that critical period in woman's life of watching over the digestive organs, especially in respect of their appropriation of fat, then so eminently necessary. A condition leading to the non-assimilation of fat may, like other kinds of indigestion, be brought on by overstrain of the mind, as well as of the body ; a fact of the utmost importance in tracing the history and applying it practically to the cure of the patient. CASE XLVII. Miss A. D had an ambitious intellectual governess, who finding her pupil very retentive of learning and persevering, from fourteen to fifteen pressed her forwards in her education with great energy. The nutri- tion of the mind went on, that of the body was stayed ; she was very sharp and learned, but she ceased to grow. The menses appeared for once, and never again. Tt was also observed that she loathed her food, and anything "rich" (that is, greasy) made her peculiarly uncomfortable afterwards, so that she sometimes threw it up. Her temper became queer and her conscience fanciful, and she distressed herself needlessly about her failing powers of ob- servation and work. It was noticed too that sometimes in reading a kind of cataleptic stiffness would come over her ; she stopped for a minute or so as if a parenthesis was snipped out of existence, and then went on with her em- ployment, unconscious for the most part that anything out of the way had happened. By rest and quiet treatment her wish for food returned, but still she got more and more emaciated, so that at seventeen Dr. Gibbs Blake, under whose care she was, desired my assistance in the case. I found her on March 6th last presenting an appearance very similar in many respects to Case XL V. described a few pages back. The tongue, lips, and cheeks were fully colored ; the pulse was firm and rather slow, only 55 when asleep. The temperature of 1 " Gulstouian Lectures," by the Author, in the Lancet, for 1850. INDIGESTION OF VARIOUS FOODS. 71 the body at night was 9G Fahr. The heart and lungs were perfectly normal. The urine was clear, of the specific gravity from l.Ol'i! to l.(iL'6. The bowels were open daily. But the skin was harsh and dry, the emaciation was ex- treme; and the mamma*, which at fifteen and sixteen began to swell, had completely disappeared. The menses had not again shown, though the pu- denth. 1860. She had been subject to shortness of breath for a long time; but this symptom had been aggravated since the previous March, when she seems to have caught cold. Since 1 then also she had been able to eat her food only very dry, for if she took fluid with it. nausea and vomiting occurred. This was worse when the asthma was worst. The kidneys and heart were healthy. Her appetite was good. ll'iulaches also were very frequent, but they seemed independent of the gastric ailments, for they are reported when these latter are described as better. The usual physical signs of pulmonary emphysema were present, and she was treated accordingly with Quinine. Her diet was meat and Pepsine. She was discharged '-cured" on July 13th; the "cured" referring to the indiges- tion for which she was registered, not to the emphysema I presume. It may be remarked that in this last case the rejection of the T by the digestive organs was gastric, whereas in the two former it was intestinal. There is in this fact no significance of the locality of the impediments to circulation patients with pulmonary disease quite as often have the gurgling on move- ment, and cardiac patients will sometimes vomit. Indeed, when you are thinking of them only as mesttaijeries of the blood, the he;irt and lungs are one. An illustration of the third law of osmosis may be found in almost all cases of dyspepsia. Let the reader note first on himself what takes place as a consequence of food in the normal condition of the stomach. him take the specific gravity of his urine on rising and look at the color. Then let the stomach be thoroughly roused to acidity by a healthy breakfast at which the usual quantity 76 INDIGESTION OF VARIOUS POODS. of fluid is taken. Observe the urine passed during the next two hours. It is paler, of lower specific gravity, neutral, per- haps alkaline. The fluid contents are augmented in greater proportion than the solid, the basic elements in greater propor- tion than the acid. If pickled fish and light white wines form part of the breakfast, the limpidity is still more decided. The explanation of this I believe to be that the acid of the stomach being at that period in special excess, the osmosis of water through its walls into the alkaline blood is peculiarly rapid. Water with salts and solids soluble in water enter into the circulation quickly, and fill it. They pass away quickly by the kidneys, carrying off often some of the blood's soda with them, and so increasing the fixed alkali of the urine. When the stomach gets to rest again and is neutral, the fluids do not pass so fast into the blood, or away by the renal tubes ; then the urine resumes its full color, acidity, and average specific gravity. As the body gets tired with the day's work, the digestion is not so active. And hence after luncheon this physiological variation of the urine is not so marked, and still less after dinner. Now observe an invalid, the vitality of whose stomach is below par. The physiological variations are much less marked, the urine is never so high and rarely so low as that of a healthy person in healthy condition. Its acidity also alters little during the twenty-four hours. The interpretation of this I take to be the imperfect acidity of the walls of the stomach causing a delay in the absorption of its aqueous contents, which lie there un- changed or decomposing ; in either case a burden, giving rise to pain and inconvenience, sometimes to vomiting. The importance of obtaining for analysis specimens of urine taken at various periods of the day, instead of trusting to one, is too obvious to require much comment. Take for an example the following, which the date allows to be quoted from me- mory. CASE LIT. A gentleman came to me yesterday forenoon about a defi- ciejicy in his generative powers and other symptoms unnecessary to detail. The specific gravity of some urine he passed was 1.015, and it appeared pro- bable that it was upon this ground that the medical man who sent him to me INDIGESTION OF VARIOUS FOODS. 77 had been giving him Iron. I told him to come again this morning, and bring a specimen made on rising, as well as another specimen of that after break- fast. The latter was again about 1 015, but the nocturnal collection was 1 ."-i'.. showing that the vitality of the blood and assimilation were sufficient. SECTION V. Treatment of Indigestion Based on the Article of Food not Digested. In former writings on this subject 1 1 attempted a division of the form in which dyspepsia is manifested according to the glands whose secretion may be supposed to be affected. I thought we could assign some to the oral and cesophageal, some to the gastric and some to the intestinal portions of the alimen- tary canal. I anticipated that we might find a "salivary" dyspepsia of starch, a " gastric" dyspepsia of albumen, an u intestinal" dyspepsia of fat. Further experience has not confirmed my hopes of finding any such trenchant anatomical distinction of the cases which came before us. It seems to me now that a healthy state of stomach and duodenum is as essential healthy state of mouth to the digestion of amylaceous matters ; that the salivary and intestinal secretions aid power- fully the digestion of albumen ; and that even fat is affected by an imperfect activity of the stomach. I have therefore in this chapter based the division solely upon the element of food the ilip-stion of which is most prominently deficient. It must be understood that "prominently" does not mean "solely;" that where one article of diet suffers, the other suffers with it, though perhaps in a minor and masked manner. This prominence of the indigestion of one or other of the food elements, to what should it lead us in practice ? Some, influ- rnr.-d by purely cheiniral considerations, have answered off-hand that ire lia\ only got to omit the objectionable article from the dietary and all is done. That which causes pain is to be left oil', and the pain ceases. True, but man is an omnivorous animal, and requires omnigenous food. He can be kept alive perhaps fora time on one food, but not in health. Take an ex- ample of the carrying out of such a treatment a /',// .Y"/*ee in respect of vegetable food : 1 "Digestion and its Derangements." 78 INDIGESTION OF VARIOUS FOODS. CASE LIU. E. H , a Liverpool merchant, aged 30. of muscular build, but rather bloated flabby aspect, came to me in December, 1859. He com- plained of a foul taste in the mouth like bad fish, low spirits, and want of appetite for breakfast. He had also occasional attacks of headache accom- panied by nausea and vomiting, which nevertheless did not relieve his per- manent condition. He had been gradually getting into his present state for six years : the administration of bitters and acids had done him temporary good occasionally, but worked no cure. He said that in deference to medical advice he had been most careful in his diet, eating nothing but lean meat and stale bread or biscuit. Vegetables had been forbidden, because they had at first caused flatulence and heartburn, which did not occur at all under the use of the carnivorous dietary. On examination of the mouth, the tongue was seen to be coated with smooth yellow epithelium, especially at the sides ; the gums were loosened from the teeth, swelled, red-edged and soft. The patient said they often bled when he cleaned his teeth. I thought at first some of his medical advisers must have given him Mercury, but I could get no history of pills or powders, in which that metal is usually administered, and I am disposed to attribute the whole of his existing symptoms to an exclusively meat diet For direct treatment I advised him to eat milk porridge and water-cresses for breakfast, salad and meat and stale bread for luncheon and dinner, and lemonade or fruit-water ice instead of tea. As an indirect aid I prescribed some Bark and Chlorate of Potash. He soon got well. It is singular how slight a change of diet will bring on minor manifestations of scorbutus. CASE LIV. During his attendance upon me after a severe operation, one of the leading surgeons in Europe related a bit of personal experience apro- pos of my complaining of gastralgia after salad or strawberries, I forget which. He said he took a house out of London one summer, and used after his daily work to join his family (who dined early) at tea and mutton chops. After a time he found spots of purpura on his legs, boils, etc. He exchanged the tea for vegetables and beer, and immediately regained his accustomed health. Patients and doctors both make a great mistake in shunning absolutely all that causes pain or inconvenience. They ought to consider whether the thing shunned is or is not an essential to high health : if it be so, every effort should first be used to get it borne without pain ; where that goal cannot be reached, wisdom and duty will often guide us to submit to the pain for the sake of the accompanying advantage. It may be remarked that the designed attainment of any high degree of voluntary pleasure always involves endurance INDIGESTION OP VARIOUS FOODS. 79 eii'lurancc of disagreeable sensations which coming upon us against our will would be real torture. A day's hunting, a h at cricket, an Alpine tour, even a picture-gallery or a ball, success in love, literature or war, are impossible to those who recoil from bearing immediate pain. This ought to be and (experto en r which will ignore it. The avoidance of meat on account of the inconvenience caused by it may bring on an equally undesirable morbid con- dition, though not so distinctive in its character as the scorbutus exhibited in the last patient. :-: LV. In October, 1865, a maiden lady of 34 was placed under my can- Ky Dr. M'Call Anderson, of Glasgow, who quite agreed with me in my view of the case, though circumstances prevented him from attending to her .f. Since girlhood her bowels had been very costive. The presence of the retained feces produced disagreeable sensations, to relieve which for twenty years she had been in the habit of almost daily taking purgatives of her own accord. For the last few years pain in the epigastrium had gradually become habitual with her, and as it was immediately increased by taking solid -he had entirely ceased to take meat. The consequence was inti 'ness, increased sensitiveness of epigastrium, increased debility. The catamenia diminished in quantity and frequency, makiug a scanty show for a day <>r two about three times a year during the height of summer, and never in winter at all. Her complexion was pink and white, and her lips not pale, but she was very thin. hud an opportunity of breaking out of all her old associations and habits by u visit to some country friends in France, and I urged her to accept it, and to make a complete change in her mode of life. I desired her to let her bowels go unopened for as long as four days if they chose, and then use a simple water enema, if necessary to bear the pain cause.] by the first lew mouthl'uls nf each meal, and to eat more ami more meat at it each day with- out flinching to drink Burgundy. To aid her in this I gave her for a few weeks Quinine and Strychiiie three times daily. The last report I have of her is dated March U.'id. lM',0, and states that she required no cnemata. the bowels acting of their own accord every three days; that food scarcely ever causes her pain, though she eats nearly as much as Other people ; that the catatuenia had reappeared in the I'ebruury even of this backward spring, after being absent since the previous July. 80 INDIGESTION OF VARIOUS FOODS. I said just now that as much injury was done by leaving off meat as by leaving off vegetables. But perhaps I ought to say greater, for though it is not so prominent, and has not such a distinctive name, the condition induced by it is longer in getting well, and might just as easily prove fatal. Eemark in Case LV how amenorrhoea was a disease of the stomach ; it usually is so. The habit of taking purgatives much increases abnormal sen- sitiveness of the alimentary canal, especially of the stomach. To break through the habit is essential to a cure. I will speak about that in the next chapter. The injudicious omission of fat from the dietary must doubt- less produce similar effects to those which follow the indigestion of fat, in fact the converse of the effects which we aim at pro- ducing when we intentionally administer an excess of it as a remedy. As under the use of an easily assimilated oil the skin becomes elastic and firm, the debilitating fluxes cease from the mucous membranes and are replaced by normal secretions, the nerves feel joyous life instead of perpetual pain, and old sores heal up ; so we may expect to arise from a deficiency of this article of food a dry wrinkled surface to the body, a persistence of leucorrhoeal and other mucous discharges, that feeling of enduring uneasiness which denotes scant life, a deterioration instead of a renewal of all the tissues. But I am not able to find any good illustrations of the matter. Where fat has been omitted, meat seems to have been omitted also in most of the instances I have referred to, and the symptoms might fairly enough be attributed in a great measure to that ; or else there has been a complication of other causes of disease ; or else the omission has been intentionally remedial, designed to reduce an over-abundance in the body. A few years ago, during the prevalence of the attention ex- cited by Mr. Banting's case, I did indeed hear reports of per- sons having injured themselves by adopting with over- strictness the system by which that famous man tells us he regained the sight of his toes, forgetting that no similar mountain to his had ever impeded their view. But I never saw a real case in point. If the experimenters are really over-corpulent, they feed INDIGESTION OF VARIOUS FOODS. 81 on their own fat, and submit with ease and advantage to the discipline; if they are not so, the instinctive desire becomes so strong that they cannot resist the sight of the forbidden luxury on the table. The possible rectification of their circumference is not worth such stoicism, and they stop in good time. I do not think, then, that we profit much from those off-hand advisers who suppose they accomplish everything by forbidding the use of the sort of food which produces the symptoms. Neither in the indigestion of vegetable, animal, oleaginous, or ry articles of diet does this restore health. On the con- trary, as I have shown by examples which every one may cap out of his own patients, if he will but turn them over in his mind, an actual state of disease may arise from persistence in the remedy. A short repose for a time, and abstinence from an unnecessary excess in the undigested dishes, is doubtless wise. But that abstinence must not be complete or final. What the patient wants, when he complains he cannot eat so-and-so, is not to have " don't" said to him his stomach has said so already but to be enabled to eat it like other people. The temporary repose may be accomplished often by a change in the mode of preparation of the articles which cause most in- convenience, often by the substitution of something else, not so agreeable perhaps or so common, but which will not be objected to for a time. The following details may furnish examples and limits. IN* STARCH OR SUGAR INDIGESTION. The use of sugar in such quantity as to cause a sweet taste may be left off. Tea may be taken in the Russian fashion, ing the hot tea on a slice of lemon with the skin on, thus retaining all the aromatic stimulus of the drink without its indigegtibility. And all lo/en^es and sn^ar-j'lnms and sweet confectionery will be interdicted. The best substitute is or;i or lemons. For ordinary bread may be substituted biscuit, toast, or Stevens' unrated l>real. Ixiker's bread is usually easier of digestion than home-made. 6 82 INDIGESTION OF VAEIOUS FOODS. Potatoes may be finely mashed and mixed with meat gravy. As vegetables, stewed lettuces, cabbages, spinach (hot), and golden cress, water-cress, and salad (cold), may be taken. A small quantity only of these is required to keep up the health, and nobody eats so much of them as they do of potatoes. From green vegetables possible of digestion by weak stomachs must be carefully excepted peas, beans, and, in short, all the papilionaceous plants usually eaten green. They are famous for producing flatulence. M. Chomel attributes this to the evolution of atmospheric air contained in their spongy husks ; but I think the cause lies deeper than that perhaps in the specific action of their empyreuma, arresting the absorption of air in weakly persons. * Else why do they not produce equal effects in the healthy ? An example of the mechanical differences made by cookery in the form of starchy food, are the two sorts of crust known as "short" and "puff" paste. In the former, the butter is thoroughly incorporated with the dough, so as to divide the starch-granules one from another, and permeate the gluten ; while in the latter the dough forms thin layers, like a quire of buttered paper. If the teeth are imperfect or mastication care- less, those 'strata of dough are well known to form in the stomach a solid mass, which is difficult of solution in the upper part of the intestines ; whilst the friable paste (the " short") is mixed with the rest of the food, and if the butter be fresh, causes no discomfort. !Now, some dyspeptics are such delicate measures of good or bad cookery, that they can take " short" pastry, but not " puff." It is always worth while to make the trial. There is an advantage in not mixing too much the animal and vegetable food. In a weak stomach they interfere with one another's digestion. A light luncheon of bread and butter, rice pudding, fruit, and vegetables with a little vinegar, can often be borne without inconvenience, which with the addition of meat would have caused flatulence. The dinner after this may be restricted to meat without injury. Particular care should be taken that vegetables are thoroughly boiled soft all the way through, and dried on a cullender. A certain quantity of oleaginous matter renders vegetables INDIGESTION OF VARIOUS FOODS. 83 in which there is much combined water, less massive in the stomach. Thus, milky rice pudding does not collect into a lump as plain rice is apt to do. In making the latter dish up fur baking, eggs should never be used. Baked albumen is one of the most insoluble forms of albumen. Plain 1it.il.-il rice should always have a little fresh cold butter mixed up \vith it. In that way it makes an accompaniment of at dim Stewed pears ami roast apples are a good substitute for sweets. itle butter improves them also. But melted butter sauce is an abomination. Nine times out of ten it is rancid, or becomes so five minutes after it is swallowed, that is to say, directly the flour in it is converted bv the saliva into glucose. The best sauces are pepper and vinegar. IN CNDIG KSTION OF ANIMAL FOOD, it will be found to be gene- rally the form rather than the chemical constitution of the aliment against which the stomach rebels. c Observe the preparation of food as arranged by nature for the delicate stomachs of the new-born. It is completely fluid; the various elements are intimately mixed together, and are further aided in their solution by the lactic acid into which it decom- poses. Milk is not only a type, but is also itself the most ood for extreme weakness. I have never yet met with a stomach which could not bear it either made into whey, or prevented from coagulating by the admixture of lime-water. This fluid meat will pass through the stomach unaltered, the : ic juice will trickle through the pylorus at its leisure after it. and with the intestinal juice will digest the casein in the intestii, I do not think any one could deserve better of his country than by the establishment of a farm where the milk treatment could he systematically carried out, as at Ga'is and elsewhere in Switzerland. The chief aid olYen-d by art to the conversion of albuminoids into the state of peptone is to increase their softness and per- meability by water, so that the converting juice may h;; to every particle as soon as possible. The mechanical condition of the nitrogenous aliments is of tenfold more importance than 84 INDIGESTION OF VARIOUS FOODS. the quantity of nitrogen they contain. If enveloped in an insoluble layer of their own or other substance, they are in fact as useless as gold locked up in a box. Next to milk, the most digestible form of animal food is pro- perly made beef-tea. The following is the best receipt for dietetic purposes. Recipe for malting Beef-tea nutritious. Let the cook understand that the virtue of beef-tea is to contain all the contents and flavors of lean beef in a dilute form ; and its vices are to be sticky and strong, and to set in too hard a jelly when cold. When she understands this, let her take half a pound of fresh-killed beef for every pint of tea she wants, and carefully remove all fat, sinew, veins, and bone. Let it be cut up into pieces under an inch square, and set to soak for twelve hours in one third of the water required to be made into tea. Then let it be taken out, and simmered for three hours in the remaining two thirds of the water, the quantity lost by evaporation being replaced from time to time. The boiling liquor is then to be poured on the cold liquor in which the meat was soaked. The solid meat is to be dried, pounded in a mortar, and minced so as to cut up all strings in it, and mixed with the liquid. When the beef-tea is made daily, it is convenient to use one day's boiled meat for the next day's tea, as thus it has time to dry and is easiest pounded. Some persons find it more palatable for a clove of garlic being rubbed on the spoon with which the whole is stirred. The utility of decoctions of animal food depends on several circumstances which modify the advantages accruing from their liquid state. Heat seems to have an effect in some degree pro- portioned to the period of application, rendering albumen more or less insoluble, at the same time that to a delicate palate there is a decided loss of savor. Thus soups and stews which are " kept hot" are wholesome enough during the first few hours, may be digested at a railway refreshment room for some hours after, but on the second or third day give the rash stranger beguiled into a Palais Eoyal two-franc dinner an infallible diarrhoea. (Probatum est.) Though finely divided, the minute fragments of muscular fibre seem to be individually rendered insoluble by continued heat. Good soup is that which is made most like the above-described beef-tea, and is a highly digestible article ; bad soup, that which least resembles it, and is to be avoided as poison. Next to good soup in digestibility comes sweetbread. INDIGESTION OF VARIOUS FOODS. 85 At a very early stage of the treatment of albuminous indiges- tion, tender roast leg of mutton can be borne. A chemical view of the process of roasting shows it to fulfil all the indications of perfect cookery. The heat radiated from the open range coagu- the outer layer of albumen, and thus the exit of that still fluid is prevented, and it becomes solidified very slowly, if at all. The areolar tissue which unites the muscular fibres is converted by gradual heat into gelatine, 1 and is retained in the centre of the mass in a form ready for solution. At the same time, the fibrine and albumen take on, according to Dr. Mulder, 8 a form more highly oxidized, and, especially in the case of the former, more capable of solution in water. The fat also is melted out of the fat-cells, and is partially combined with the alkali from the serum of the blood. Thus the external layer of albumen becomes a sort of case, which keeps together the important parts of the dish till they have undergone the desirable modification by slow heat a case, however, permeable in some degree by the oxygen of the free surrounding air, so that most of the empyreumatio oils and products of dry distillation are carried off. This is no loss either to our stomachs or our palates. If acetic acid be generated it is probably carried off, and if not carried off it is neutralized by the alkaline carbonates, as certainly roast meat is not acid to test-paper if quite fresh. The little that may remain probably renders the muscular fibre more soluble. Roasting, therefore, is as scientific and wholesome, and there- fore as economical a process as it is a palatable one, and. is well worth the extra expenditure of fuel which is entailed. Baking can never take its place, especially for invalids ; for it concen- s in the meat all the empyreumatic products of slow com- bustion. Rapid boiling may effect in some minor degree the case- hardening of the meat above described, but the interior albumen seems after this process also more solid and less digestible. Slow boiling at a low temperature makes, it is true, a nourish- ing soup, but converts th$ muscular fibre into a mass of hard 1 Not, however, the sarcolemma, which an experiment of Professor Kiilliker's seems to remove from the class of substances yielding gelatine. See Kulliker'a " Mikros. Anat.," vol. ii. \>. * QuoU'.l in Muleschott's " Diiitetik," p. 450. 86 INDIGESTION OF VARIOUS FOODS. strings, which, eaten or not eaten, are in nine cases out of ten equally wasted. The relics to be found in the feces exhibit all the transverse strise of their original state, quite unaffected by their intestinal journey. The ojily way to make bouillon digestible is to beat it up in a mortar to a fine pulp and mix it with the soup, as prescribed above in the recipe for beaf-tea. Of all meats, mutton is the most digestible, because it is, when roast, the closest grained, most friable, and least infiltrated with fat. Birds, on the other hand, when roasted, still more when baked, are apt to be too much dried up. And, therefore, if you cannot trust thoroughly the goodness of your patient's cook, he had better have his fowls and his partridges boiled. Other birds are either too dry, too oily, or too empyreumatic for invalids. I have sometimes found toasted cheese borne by a stomach to which meat gave pain. The cheese must be quite new, and toasted very soft. In this form it is both digestible and palatable. The quantity of albuminous food should be gradually in- creased from day to day ; but the invalid's plate should never be overloaded. The look of more than he can eat sets him against it. Judicious times for pressing food should be selected. A cup of beef-tea on going to sleep can often be borne, when ordinary meals excite nausea. Ladder of meat-diet for invalids. Whey. Turtle soup. Milk and lime-water. Sweetbread or Tripe. Milk and water. Boiled partridge. Plain milk. Boiled chicken. Milky rice-pudding. Boiled lamb's head and brains. Beef-tea. Mutton chop. Plain mutton broth. Eoast joint of mutton. Scotch broth. In cases where there is a repugnance to fat, light friable fish, such as boiled sole, or turtle fins, or water soojee, will be toler- INDIGESTION OF VARIOUS FOODS. 87 at.-d, while red meat excites disgust. It is not nearly so soluble in gastric juice, nor so nutritious, but it makes a variety. Oysters are best eaten raw, in which state they carry with them their own pepsine for their digestion. Cooking toughens them. The u.se of Pepsine, or artificial gastric juice, as a remedy, is ially indicated in the indigestion of flesh food. But I think that since its introduction to general use through the 11 ions preparation of Dr. Corvisart, it has caused more dis- appointment than satisfaction. This is because it has been jiven in unsuitable cases, and because impossible expectations have been founded upon it. The cases in which it is really useful are those where a pro- -ive aiuemia is accompained by an inability to digest albu- minous food. This inability is exhibited in three ways: first, by meals of such diet, even in very small quantities, being fol- lowed by a sense of great weight and oppression at the epigas- trium, and sometimes by actual vomiting; secondly, by the tge of loose fetid stools containing much unaltered muscu- lar fibre, lumps of fat, and such like remnants of a recent meal ; thirdly, by loss of appetite and a nausea roused by the bare of fle.-h food. Often all three phenomena exist together; but each one may be found separately, and is of itself a suffi- cient indication of the patient's state. The state of the stomach when these symptoms occur is often an excessive secretion in the upper part of the alimentary canal of alkaline mucus, which envelops the food, and prevents the action of the gastric juice upon it. The consequence is, either its rapid ejection unaltered, or its decomposition, and the evo- lution of fetid gas. If vegetable food be mixed with the meat, it ferments into acetic arid ; and thus you may have sour eruc- tations from the stomach, and diarrhoea. If this excessive secre- tion of mucus is recent and moderate, the appetite may remain uninjured nay, may sometimes In- morbidly increased; but a long continuance. My if joined to progressive pulmonary is sure to induce an an;emic condition of the alimentary anal, which results in a disgust for food. This state of tliiir_ r > it is very important to check. If it goes on, the patient cannot take in sufficient quantities the meat 88 INDIGESTION OF VARIOUS FOODS. which should refresh his degenerating muscles and pale blood ; he cannot, if phthisical, take the Cod-liver oil which is to replace his emaciating tissues; he cannot, from weakness, take the ex- ercise which might renew his whole diseased system. And I do not know any remedy which more readily, obviously, and directly does what it can towards checking such a state than Pepsine. It acts immediately and surely. We must not, however, raise our expectations of the power of Pepsine too high, or we shall be disappointed. I said just now it " does what it can," and I would have understood clearly what position this agent holds in the rational materia medica, and then we shall know what good results may be de- manded with reasonable hopes of obtaining them. It is an artificial, and therefore a partial, substitute for a natural process. Gastric juice from a healthy animal is mixed with the food, in- stead of that which the patient's stomach ought to prepare. And it acts in the body just as it would out of the body under the same circumstances of heat and motion. The chewed meat is dissolved by it just as white of egg suspended in a beaker is dissolved by it ; and the putrefactive process is arrested by it in the intestinal canal just as the putrefactive process is arrested by it in the laboratory. For you may observe that albumen suspended for twelve hours in Pepsine is quite sweet, whereas that soaked for the same time in saliva is most fetid. It is, therefore, a substitute for the natural secretion, and to a certain extent supplies its place. But like all imitations of nature it is coarse and imperfect. The solvent, instead of being gradually and continuously poured "on the outside of the mass of food, is mixed up in the middle part of it, and acts merely chemically, without any of the mechanical and physiological helps belonging to natural digestion, and consequently soon exhausts its energies. The chyme, or albumen prepared for absorption, instead of being wiped off and swept away by the stomach, remains for some time mixed up with the Pepsine, so that the latter is not freed for the solution of a new portion. By this imperfect process only a very small portion of meat can be dissolved. The small quantity of Pepsine in the powder is ridiculously inadequate to the wants of a healthy stomach. INDIGESTION OP VARIOUS FOODS. 89 If therefore a patient hopes that by the aid of Pepsine he can get a full and sufficient meal digested at once, he will fail. But let him take about half a mutton chop with the remedy the first day ; and if that is digested well, next day a whole chop ; but then he has got to the end of his tether, and the digestion of a larger quantity will not be at all assisted by arti- ficial solvents. After a chop has been digested and absorbed twice, or even once, a day by this means for about a week or ten days, the expedient has probably done all the work that can be fairly asked of it, and the stomach has either recovered suffi- cient to digest alone, or will require different remedies to enable it to do so. Therefore, for the Pepsine to be completely successful first, it must be given only to those who cannot digest half a mutton- chop without it ; secondly, more than a chop must not be given at once; thirdly, it must not be required to go on alone improv- ing the patient's condition for more than a week or ten days. But for the time named I advise its being given alone, and the action not interfered with in general by other medicines. Many will really prevent its chemical effect, and all will confuse your judgment of the advantage gained. In this time it will generally be found that the repugnance of the patient to meat has been overcome, and that a small quantity of it at a time can be relished and digested ; the morbid fetor of the stools diminishes, and the flatulence and distress arising during their passage, through the bowels ceases. A renewed strength and a renewed power of assimilation commences, the sleep becomes more natural, with the diminution of night-sweats and hectic ; while, at the same time, the pulmonary symptoms of cough, dyspno3a, &c., relax, and a step at any rate is taken in the right direction towanls the cure of the disease. It is remarkable, too, what a slight improvement in the digestive powers will often enable the patient to take Iron and Cod-liver oil. These are acknowledged the mainstays in the treatment of tubercular consumption, ami any expedient, however temporary, which will pave the way for their administration, is a great boon. Iv TIIK ixniGF.sTiox OF FAT a purpose si milar to that assign. '>! to Pepsine in the last paragraphs is performed by Panereatine. 90 INDIGESTION" OF VARIOUS FOODS. In a classification of curative agents I have put the two together as "Constructive" or "Histotrophic" remedies. 1 But in the form of pancreatic emulsion, as devised by Dr. Dobell, the solvent and substance to be dissolved are united together, and their mutual reaction has already partly taken place. I have already spoken of the necessity for and advantages of this union. It is better than Cod-liver oil, because it carries the agent of its own solution along with it. THE INDIGESTION OF WATER as a consequence of anasmia is cured by the administration of Iron. Where it results from heart disease or emphysema, it indicates a mercurial purgative, and is temporarily relieved by its emptying the congested portal circulation. An observant patient of mine with emphysema tells me that she finds it a good rule never to drink with her meals. SECTION VI. Treatment based on pathological condition. It cannot but strike any one who reviews either the typical cases I have collated from my notes, or those (not essentially different, I am sure) which have occurred in his own practice, that a general deficiency of the vital powers is more notably exhibited in indigestion than in any other disease. And this is equally apparent in each form of indigestion from whatever cause arising. I always, therefore, look forward to giving tonics as the prime therapeutical aim in all cases. Sometimes that part of the treatment can be commenced forthwith, some- times it will be necessary to relieve temporarily certain of the prominent symptoms first, but without tonics no cure is effected. My favorite tonic is Quinine, in two-grain doses in lemon- juice sufficient to dissolve it, and diluted with water to a con- venient bulk. Its action seems to be principally on the mucous membrane of the mouth, oesophagus, and stomach, which it astringes and tones up to a healthy state, restraining the secre- tion of mucus, and making the special secretions more active. To Quinine I usually add from 2 \th to ^gth of a grain of Hydrochlorate of Strychnia, unless there are some contra-indi- 1 " Lectures, chiefly Clinical," 2d Introductory Lecture in 4th edition. IXDIGESTIOX OF VARIOUS FOODS. 91 cations to its use. It relieves flatulence, and that feeling of sinking when the stomach is empty, which arises from a slug- gish state of the involuntary muscular fibres ; and in cases of constipation reinforces the expulsive action of the peristaltic fibres on the mass of feces. The principal contra-indication s use is an over-sensitive state of the nervous system. I been obliged to leave it off in several cases of hysterical en because of the neuralgia which followed it, and in two uces of men agitated by business I have had want of sleep and excitement of mind attributed with apparent justice to liuine. In the doses quoted cramps never are produced, and the slight inconveniences I have named cease immediately the alkaloid is omitted. In large quantities Strychnine may sometimes produce spasmodic action of the muscles. I have had this happen in hospital, when administering it for other complaints. But even then not the slightest harm accrues, if the amount is diminished. Some persons have a fear of its accumulating in the body, and the effect of successive doses being concentrated into one, which to me seems impossible in a soluble diffusible salt. The fallacy urobably arisen thus in cases of paralysis, for which hnia was originally prescribed, the nervous system is usually so prostrate as not to respond to even considerable quantities: utter a time the patient becomes more healthy and more sensitive, and then the dose which had been given day after day without effect, acts perceptibly, and perhaps vigorously acting thus, not because it has accumulated, but because the nerves have at last become well enough to be conscious of it. A soluble and diluted salt of Strychnia seems to me one of the most manageable drugs we have in the Pharmacopoeia, because you can graduate the dose accurately to your requirements. The extract of Nux Voniica is dangerous, because you never know the exact strength of the preparation sold. This treatment of indigestion does not interfere with remedies addressed to check pain, pyrosis, vomiting, or any of the other morbid phenomena, which will be discussed in future chapters. Neither does it interfere with the use of Iodide of Potassium as a temporary augmentation of the salivary secretion. I ; found it the most universally applicable, and therefore I do not mention others of less value. 92 CHAPTEE III. HABITS OF SOCIAL LIFE LEADING TO INDIGESTION. SECTION 1. Eating too little. SECTION 2. Eating too much. SECTION 3. Seden- tary habits. SECTION 4. Tight lacing. SECTION 5. Compression of the epi- gastrium by shoemakers. SECTION 6. Sexual excess. SECTION 7. Solitude. SECTION 8. Intellectual exertion. SECTION 9. Want of employment. SEC- TION 10. Abuse of purgatives. SECTION 11. Abuse of alcohol. SECTION 12. Tobacco. SECTION 13. Tea. SECTION 14. Opium. IN the cases cited in the last chapter the causes of the indi- gestion were, as a rule, out of the power of the patient to modify. Nobody for their own pleasure falls into poverty, catches cholera, is ruined in trade, lives upon potatoes, is worried by clients, nurses the dying, &c. ; or at all events they do it with the hope of reward here or hereafter, and it is useless telling them not. The complaint cannot be cured by removing the cause : either it is past and gone ; or it is incapable of being removed, as much out of our control, as the changeable weather which in some cases brought on the complaint. In this chapter I purpose discussing some of the habits of social life which are in a great measure voluntary, which do not promise any sufficient reward, which are persisted in by reason- able persons principally from ignorance, and which therefore we can require our patients to give up, as the principal step towards their cure. " Sulaltd causa tollitur effectus" is a very practical motto when the cause is not too heavy for us to lift. SECTION I. Eating too little. I do not know of anything which more excites our wonder in reading contemporary sketches of the social life of our fore- fathers than the gross manner in which they indulged their HABITS LEADING TO INDIGESTION. 93 To pass over the bestialities of the philosophic heathen, as recorded by Juvenal and Petronius, our disgust is equally aroused in civilized Christian times by the mighty emperor warrior and statesman Charles V washing down his six or seven daily meals, his supper at midnight and his heavy breakfast at six in the morning, with great draughts of beer and wine, whether in camp or cloister, or by his saturnine son Philip racking his stomach with enormous loads of pastry till the chronic gastralgia visible in his countenance became a prominent feature in his portraits, or by the genial coarseness of our middle classes as photographed by Chaucer with sympa- thetic appreciation of all that is human. One is not surprise 1, in reading such unconscious records of deficient control over the animal propensities, at theologians and physicians both preaching the opposite extreme, and placing abstinence in the niche sacred to temperance. Hence springs the popular notion, too deeply rooted by long growth for increased knowledge to dissipate under several generations, that abstinence is a sine qud in all medical treatment, and is a cure for all disease. CASE LVI. In November, 1856, J. M. V , a young mercantile man, aged 36, came to me for slight flatulence and constipation. I gave him some Myrrh and Aloes pills to take occasionally, and saw no more of him then. He went on very well till 1860, when he was persuaded by some foolish friend to adopt a system of extreme abstinence, not that his health was to be called bad, but he wanted it to be better than good. The consequence was a relapse into a state much worse than the first. Three or four hours after eating, flatulence bursting upwards from the stomach, rolling about in suppressed thunder among the intestines, or passing off by the rectum, used to cause great in- convenience, especially by night. And the absence of taste and smell in the ev;i-u;ited air showed it to be the carbonic acid of decomposed amylaceous food. The nervous system was equally deranged. There was great wake- fulness in bed, and an inability to apply the mind to anything l>y day, which steadily increased upon him, and prevented his attending to his business. I gave him some Quinine, and desired him immediately to resume a full flesh diet. A week afterwards he came and said the flatulence and other symp- toms were very much better, but the full dose of Quinine made his head ache. He was ordered then-fore to take only half a grain twice a day, to keep u]> his appetite to its work; and then he was able to engage again in business so as to think no more about his health. Instead of decreasing the dose of Quinine, I have often simply added six or eight minims of Chloric Etber to each draught, 94 HABITS LEADING TO INDIGESTION. and have found it quite effectual in preventing headache. This was in cases where I chanced to be very anxious to have the full dose taken. Here I did not think the magnitude of the dose important. That Quinine, however, or some equivalent nerve-renewer is valuable in such cases I feel persuaded by the rapidity with which patients get well under its use, and the long convales- cence they have without. CASE LVIL Miss H. W , January 28, 1860. The patient is a very thin, nervous-faced young woman of twenty-three, who complains of a weight at the pit of the stomach brought on by swallowing any solid. This first began eighteen months ago at a catamenial period, and she immediately persuaded the family doctor to interdict all solid food, and she has taken none ever since. She has lost 21 pounds in weight, though never stout previously, and has become dreadfully flatulent and hysterical. The heart has become weak and irregular in strength, and sometimes intermittent. She was a long time in recovering even under an improved dietary, so that I find noted in April, 1861, that though her muscles had become firm and the general health good, yet there was still some pain at the epigastrium after dinner, which I attributed to tight lacing. I attributed it at the time to tight- lacing, but I have seen reason afterwards to view it as one of the consequences of her condition, to deficient nerve-power in the stomach. Even in much more chronically ingrained disease of much longer duration than in the instances cited a partial improve- ment may be effected very quickly by the aid of drugs. CASK LVIII. The Rev. J. S , a parish priest and Union chaplain, aged 48, in February, 1866, tells me that when reading hard for his degree at the University he first became sensible of pain after eating. His theory was that he ought to eat less ; and so he did, less and less ; and, with the hope of working a cure all at once, actually lived a whole year on bread and water only. In consequence he is troubled with flatulence, debility, and frequent attacks of palpitation of the heart. The pulse is uneven, and occasionally intermits. As far as I can ascertain by questioning, he feels more pain now after eating than he used to when he began this ascetic life nearly a quarter of a century ago. A generous animalized diet, taken frequently, with wine, Quinine, and Strychnine, while at the same time the oversensitive nerves were deadened. by Opium and Hydrocyanic acid, enabled me to allow him to return home in ten days ; but I of course did not promise that he would ever be the man he might have been naturally under a rational dietary. HABITS LEADING TO INDIGESTION. 95 On July 17th he tells me he is able to eat more and more without pain week by week. His pulse is regular, and he has no flatulence. He has left off all medicine except ;i quarter of a irrain of Opium every night. He is more robust than ever I expected to see him. The above is an instance how ascetism will be persisted in on theoretical grounds in spite of nature's daily warnings to the contrary, and how unobservant even highly educated people are of physical facts. How one whose profession makes him daily conversant with the poor and down-trodden, while his ! habits throw him among the rich, can fail to remark the symptoms of deficient diet, is difficult for us physicists to under- stand. I used the word " ascetism" in the last observation. Perhaps it was hardly right to do so ; for though in familiar conversation applied to abstinence from pleasure with whatever intention, such is not its proper meaning, and it ought strictly to be con- fined to those self-restraints where the motive is nobler than the mere bodily health, where it is an active devotional exercise, a mode of honoring God. Where this form of devotion is part of the established worship of any religious community, it is usually made the subject of minute regulations, designed with a view of securing practical Ita without injury to sanitary condition. The principles of these regulations seem to be that abstinence should not be ex- ve, and above all not continuous. Moreover, the spiritual patient is never to prescribe for himself. In the Church of England it certainly does not constitute any portion of the regular religious services demanded of its members. Truly in the homily "On Fasting" a low diet on in days is urged ; but the preacher destroys the force of his advice by inserting the weakening argument that its general adoption would be a great encouragement to our fisheries. The method o i>m being thus left to individual management, its intention is often mistaken, and its practice abused. Instead of looking upon it as an exercise, as a sacrificial service, in its intermittent, occasional, and departing from its essence it' not intermittent and occasional, men treat it as a me- "ying the instinctive 96 HABITS LEADING TO INDIGESTION. CASE LIX. Last February (1866) an Anglican rector, aged 32, consulted me on account of increasing inability to perform the duties of his ministry. Fits of mental depression more and more frequently came over him, accom- panied by a feeling of loss of volition over the limbs. At all times he was weak and incapable of muscular exertion, and was thrown into a cold sweat by any bodily or mental effort. There was loss of appetite, pain at the epi- gastrium and flatulence after eating, with palpitation of the heart. This local condition of the stomach seemed to have been more prominent a symptom previous to his visit to me, for I remarked that the pit of the stomach had been blistered, by the advice of a former physician I presume. This state of things had been gradually coming on for about two years. He had several times taken short holidays, but with no permanent benefit. On conversation with him, I found his notion of the relation between soul and body was that of a constant antagonism. It seemed to him that the aim of the former should be to subdue the latter continuously and permanently not only to knock it down, but to keep it down. He ate merely to enable him to visit and preach and pray ; he drank whatever liquid came first ; he had married because the world must be peopled, and because he wanted a help-meet in his work. But he rejoiced when his appetite failed, and when he felt no pleasure in his victuals or wish for wine ; and as soon as his sweet young wife had borne him two children, they ceased by mutual consent from bodily matrimonial intercourse. The last-named final blow to the flesh had been given four years before. (March, 1867). A year's complete rest, and a constant recurrence to Quinine and Strychnia, have been necessary before he could be pronounced fit for the duties of his profession, as I have certified him now to be. Surely this is Stoicism or Gnosticism, rather than the religion of the Bible. I am not fond of preaching, especially to clergy- men, or of turning texts into traps; but people should not forget the threatenings at the end of Ecclesiastes, where we are told that God will bring us to judgment and make us account for our missed opportunities of enjoyment, for not being cheer- ful in our youth and loving the beautiful ; and where we are urged on those grounds to " remove sorrow from the heart and put away evil from thy flesh." Forgetfulness in youth of the Creator and His creatures, disregard of the Giver as exhibited in His gifts, and neglecting to render Him thanks by using them, always entails a punishment on either mind or body. A joyless man becomes an unhealthy man ; in body if they are bodily joys that he has foregone, in mind if they are mental. HABITS LEADING TO INDIGESTION. 97 SECTION II. Eating loo much. Habitual gluttony is as rare now as it was common in the ilays of old. An occasional careless excess in the pleasures of the table may be indulged in, but people feel it to be an excess, promise themselves that it shall be only occasional, and do not go to a doctor for its consequences. It suggests and often spontaneously carries out its own cure, and the shame which accompanies it causes the " remorse of a guilty stomach" usually to be concealed. So that I have no notes on the subject to quote. I can, however, remember two instances where over-eating really deserved sympathy rather than contempt, and I will transcribe one of them here, it being always pleasanter to reflect the bright than the dark side of human nature. I dare say I shall find some future opportunity of introducing the other also. I LX. In November, 1859, 1 was requested to visit a lady past middle life, who, when I entered her library, certainly looked the picture of robust bloom. "Dr. Chambers," said she, "what is a British matron to do who habitually eats too much ?" The question suggested the shortest of replies. A\v, it's very easy for you to say 'Don't;' but, if I didn't, I should be a willow in a week. You know how old and infirm Lord C is. He has always been used to feed highly, and if I cut the dinner short, or did not encourage him by my example, it would be his death." It seemed that the symptoms of eating too much were a sense of repletion and a want of sleep during the night, feverishness in the morning, a sort of worrying fidget in the !, sometimes followed by constipation, sometimes by fetid semi-liquid evacuations, never by natural motions, frequent headaches, and a tendency to depression of spirits. Sometimes she was attacked in the night by what she called "spasms," that is to say, severe pain in the epigastric and umbilical as. If that ended in vomiting she experienced rapid relief, and was bet- ter than usual for several days. My prescription was an Aloes and Myrrh pill before dinner daily, and a recommendation of a dry diet as mixed ami varied as possible, avoiding only soup, slops, butter, and Int. I'.ut I doubt if it was quite successful, till the ug cause of this virtuous intemperance bore his many years and honors to the grave. I question if my recommendation of a mixed diet was v. It would have been better for her to have taken a prepouder- 7 98 HABITS LEADING TO INDIGESTION. ance of meat one day and a preponderance of vegetables another, but more generally the latter. The majority of exceeders have not such a good excuse for their violation of the rules of propriety, and would with reason suppose themselves to be laughed at if asked, " 'Is it for fear to wet a widow's eye' that you eat so much?" They seldom have the discernment shown by the last-named patient in recognizing the habit which is the cause of their ill-health ; but they are ready enough to give it up when brought to see that they are committing a contemptible excess. CASE LXT. Mrs. L , aged 32, the wife of a rich manufacturer, came to me in the spring of 1860, complaining of a weight and distension felt at the epigastrium half an hour after meals, and lasting for several hours. It was followed by eructations or returns of small quantities of food, not sour and not accompanied by flatulence. The bowels were loose, the motions never formed, but ragged, and sometimes diarrhceic. There was a nasty taste in the mouth in the morning, feverish and restless nights, and frequent dull head- aches, with low spirits and hysteria. The catamenia were irregular and some- what profuse. She said that these symptoms had commenced nearly two years previously, when her husband had some pecuniary troubles. I ques- tioned her strictly as to keeping up her spirits by indulging in alcohol at that time or since, and believed her not guilty. But she confessed to having become very fond of good eating, and having a great appetite for anything "nice." She was a large-framed woman, and comely, though her outline was growing rather out of drawing. Eemark how in a weaker-minded person the mind becomes affected, while the more robust and educated intellect shown in the previous case bears up and gains strength by resistance. The error in diet which in a woman produces hysteria, in a man declares itself by melancholy. CASE LXII. Richard R , aged 48, a white-faced and fat clerk, came to me a month ago, November, 1866, persuaded that he had diseased heart by the palpitations of that organ which he experienced, especially in the morning. He had lost interest in life, having succeeded in obtaining a comfortable in- come more than sufficient for his wants, and having laid by a provision for old age. He was passing a drab-colored existence, taking no pleasure, fol- lowing no hobbies, and occupied only with the routine of his office and atten- tion to his health. Of the latter he had a bad opinion, and considered that he was delicate and required abstinence from excitement and constant support. Besides his regular meals he was in the habit of taking a slight anticipatory HABITS LEADING TO INDIGESTION. 99 lumheon at 11. an intercalary snack at 4 preparatory to dinner at 6, and a small refresher along with his glass of grog at bed-time. The consequence was sleepless nights, flatulence of stomach, palpitations of heart, returns of small quantities of food by the oesophagus, irregularity of stools, increased y, and desponding views concerning time and eternity. To his great terror, I made him go quickly up and down stairs, and examined the heart, the sounds and beat of which were quite natural after this natural excitement But the stomach was large, and gave a drummy sound on percussion quite up U> the apex of the ventricle. A counsel to leave off bacon at breakfast, to eat i'uly at meal-times, and a short course of Hydrochloric Acid, made a new man of him. How easily such a person as this might be turned into a hypochondriac or a lunatic by coddling and sympathizing! If the last patient had really got a diseased heart, I should have given him probably a treatment not very different in prin- ciple, but I should have especially cautioned him against gorg- ing himself even at meals. For now and then cases occur like the following. CASK LXIII. John B , aged 71, a cheerful old gentleman, came to me in May. If.VJ. He said he had always taken great care of his health, but had not consulted a medical man since he had rheumatic fever at fifteen years of age. His reason for taking care of his health had been a tendency to short- ness of breath, which he said he had experienced so long ago as the beginning of the ceutury, when reading Shakspeare to the young ladies of the period. Examination of the heart showed it to be very weak, irregular in time and strength, with a confusion in its valve sounds, and a dulness on percussion extending four inches in width from the epigastric across the cardiac region. The pul-i- at the wrist was equally weak. He had always enjoyed his table, but latterly had found that taking the quantity requisite to satisfy him oppressed his chest and made him faint. Nobody could discern better than the patient himself the true pathology of his case, nor give better advice than his own reason suggested. But unfortunately he was not able to follow it, for a few weeks afterwards I had a letter from young Mr. B , saying that his father had eaten heartily of an indigestible mixed dinner, and lay back in his chair dead. It very often excites the astonishment of these patients, after having it explained to them that their danger lies in over-eating, to be told to increase the number of their meals. Yet such is in most instances the best way of meeting the case. Small quan- tities frequently taken are the best device for introducing a full supply of nutriment without overloading the alimentary canal. During the day, four hours is the longest time that an invalid 100 HABITS LEADING TO INDIGESTION. should be allowed to pass without eating something ; and for some two hours is a sufficient interval. Very soon the appetite begins to accommodate itself to these habits, and the little meal that is committed to the stomach at once, instead of lying dormant in the paralyzed organ for hours, as was the case under former customs, is enabled to pass away rapidly. The excess in eating is not uncommonly rather relative than positive. It would not be an excess under normal circum- stances, but it is made so by those present. Of this acute examples are given in cases IX, X, XI, in the last chapter, where an ordinary meal was an excess under extraordinary temporary circumstances. The following is a chronic result of a chronic cause. CASE LXIV. T. J , a lawyer, naturally inclined to be corpulent, aged 52, was well till October, 1865, when he sprained his ankle rather severely. He was always used to a good deal of bodily exercise, and of course in his profession equally employed his mind ; so that it was not to be wondered at that he habitually fed largely. This did him no harm till the accident to his leg, after which he began to suffer from indigestion. The bowels were cos- tive, and the stools never homogeneous, but consisting of rags of solid matter in much fluid ; he had acid risings in the mouth, eructations, wind rolling about at night in the intestines, and breaking off per anum in the morning. What most distressed him and brought him under my care was want of rest at night. He either could not sleep at all, or else woke up after a short nap and could sleep no more. Opiates had made him worse. Worried in this way, he had lost two stone in weight in the six months since his illness began, and appeared to have been striving to replace the loss of flesh by keeping up his usual high feeding. But analysis of the urine showed that there was no lack of active metamorphosis going on, for it was at all times of the day fully acid, clear, and with a constant specific gravity of 1.024 to 1.025, varying singularly little with circumstances. He was nervous and irritable, and, like all nervous people, had a smooth, white tongue. There is small doubt but what a return to active habits would have restored his usual health, but un- fortunately some remains of lameness precluded it. He was astonished when told he ate too much, and doubted if that was possible when a man was losing flesh. But experiment proved to him what the symptoms led me to pro- nounce, namely, that the ingesta were in excess of what was required for the nutrition at the time, though they were not too much for him when he was living more actively. In this instance the headache which frequently accompanies excess of mixed diet was absent. The loss of flesh is interesting. HABITS LEADING TO INDIGESTION. 101 Loss of flesh is rather an exceptional accompaniment of the dyspepsia of excess. The following is a much more common case, causing me a little difficulty in selection, so many are alike. CASE LXV. Mrs. II , a very stoat lady of about sixty, came to me in June, 1KV2, to consult principally about her obesity. But I found her a martyr to gastric dyspepsia, which produced a feeling of emptiness only to lie Mil-veil tiy taking food. This overeating increased her dyspepsia, so that she had a constant diarrhcea, and frequent vomiting. Yet with all this her corpulence increased more and more. Restriction of diet relieved her stomach symptoms considerably, but her bulk was unreduceable. I believe the cause of her death some years afterwards was pneumonia. Dyspepsia certainly does not prevent corpulence. In thirty - os of obese persons, which I printed in a tabulated form some \ -ears ago 1 , five of the number suffered in this way. In t is not impossible that one cause of that hypertrophy may ie delay of the victuals, both animal and vegetable, in the stomach, and the setting up in the carbonaceous material of a fermentation instead of digestion. This obesity of persons with weak gastric digestion is peculiarly distressing: the defect in muscular power prevents the use of exercise for a time suffi- cient to prevent its increase, and hence it becomes a daily rro win i: inconvenience. The encroachment, too, of the adipose 11 pmi the other tissues, and the dilute spread of the insufficient blood through an unnaturally large quantity of capillaries, tend to produce atrophy of important parts; and hence we find as consequences of corpulence, dilatations and degenerations of the heart, fatty deposits on the same, Bright's kidneys with dropsy, &c. The addition of many pounds to the body in the shape of fat, i --ertainly a very large, although not perhaps a pro- portionate, addition of blood and bloodvessels to nourish it; .line In-art has still to undertake this extra labor. The balance then between the systemic and the pulmonary circula- tion must be destroyed, and the lungs be unequal to the excre- - of so much more carbon than they were intended to pro- vide r<>r: hence the blood becomes more venous, more liable to form congestions, and to dilate the yielding walls of the heart by its retarded pace. The elVect of diminished circulation in 1 " On Corpulence," p. 139. London, 1850. 102 HABITS LEADING TO IXDIGESTIOX. also producing degeneration of other parts need not be enlarged upon. SECTION III. Sedentary habits. Among the originators of dyspepsia we commonly find in- cluded in books sedentary habits. But when I come to look over my notes, I cannot extract any cases which would exhibit this fact. I do not know by experience if a sedentary life, such as that of a clerk or bookkeeper for example, would induce the defect unless it were joined to some other cause. Alone, with a properly regulated diet, it seems consistent with quite healthy digestive powers. We find it so in the bed-ridden under our care, whose life may be viewed as the type of a sedentary one, yet they do not suffer except from some more than ordinary folly in diet, or from the misuse of some drug. When therefore those who come before us for indigestion attribute their state to a sedentary life, we must not stop there, but search further for other and more certain causes. For example : CASE LXYI. M. S , editor of a weekly newspaper, aged about forty, laid on the many hours he spent in the office-chair the blame of enteric dys- pepsia, which spoilt his night's rest by waking him in the early morning with flatulence. Charcoal gave him only temporary relief, but dividing his meals more, taking a good luncheon and a light dinner, seems to have set him up completely. This was in 1856, and now he seems quite equal to his official duties, and looks as robust as any leucophlegmatic men ever do. Let it not be supposed that I underrate the value to health of exercise in the open air. The fresh oxygen, the cheerful occu- pation, the distraction of the mind from injurious tension, must, however, be taken into account by the physiologist, and not all the benefit set down to muscular motion, which latter element is but a small part of what is usually included under the recom- mendation of " exercise" by a rational physician. I have come across more brain-laborers whose digestion has been injured by injudicious excess in muscular exertion than by the reverse. Let not those whose avocations are necessarily sedentary, despair of finding by judicious experiment a mode of passing their lives in complete, though not of course blooming health. HABITS LEADING TO INDIGESTION. 103 The division and arrangement of the meals according to the me >de of life is a very important part of the science of digesting them. Much must be left to individual experience, but regular try men, and others who do routine work at the desk, I generally find are better for taking a meat luncheon and only a liuht dinner after the day's labor. And if they take a glass of . it should be at bed-time. Great late meals washed down with a quantity of alcohol do not suit them. On the other hand, those who pass a muscular life often suffer from eating in the middle of the day. For instance, I recom- led the following to dine late, and to take at most a glass of wine and a biscuit in the middle of the day. LX V II. A. W , a schoolmaster, always dined with his boys at one o'clock, and tried to work off his dinner by playing at cricket with them in tin- afternoon. But the more he played at cricket the more he suffered from rnfort at the epigastrium followed by intense headache. R LXVIII. A Welsh country gentleman, aged 57, was under my care in 1-62 for weight at the epigastrium, acid efuctations, headache, and sleep- *a. He said the beginning of it was over-smoking at Cambridge; but since then he had been to a number of physicians, and taken a great deal of mrilioine, homoeopathic and allopathic. He had been in the habit of much ise, and always dined at two o'clock. Dining late relieved his symptoms, but he did not seem satisfied without medicine. Laborers, sportsmen, pedestrians, postmen, are all instances of ready access, from whom it is easy to learn that habitually to eat heavily during the hours of bodily toil produces sooner or later indigestion, and that health and comfort are secured by making supper the principal meal. SECTION IV. Tight-lacing. One wet winter day at Florence I had been spending the morning in the studio of a sculptor of world-wide reputation. AV>' had discussed the perfections of female beauty, and I felt that I was sitting at the feet of a thinker, as well as an "elegans i rum spectator" In the evening we met at a hospitable palazzo, and under cover of the waltz music from a quiet corner of observation saw whirling by us in the llesh much that we had 104 HABITS LEADING TO INDIGESTION. been thinking of in the marble and the clay ; and both our eyes could not but follow one particular face, famous for the assistance its great natural beauty received from art. " Face," I said, but the mind of Hiram Powers was penetrating deeper, for he exclaimed, after a short silence, " That is all very well, but I want to know where Lady puts her liver !" Where, indeed ! for calculating the circumference of the waist by the eye, allowing a minimum thickness for the parietes of the chest, an area for the spine, oesophagus, vena cava and aorta, the sec- tion of the waist seemed to admit of no room for anything else at all. In such a body the liver must be squeezed down into the abdomen, elbow like a big bully its hollow neighbors, and infringe upon their shape. Fortunately for itself it is singu- larly tolerant of pressure, and may be deformed out of all recog- nition by the anatomist of external forms, without ceasing to do its duty as a bile maker, as may be seen well displayed in Dr. Murchison's graphic woodcuts in the "Medical Times" (March, 1867). But yet the whole portal circulation must 'be carried on under great mechanical difficulties, the due supply of arterial blood reduced, and its return by the vena cava resisted. What an inconceivably tough person that must be who does not become pot-bellied from the downward pressure, red-nosed from the hepatic obstruction ! And must not, there- fore, the style of dress which gives birth to such deformities be an abomination and an eye-sore to the artist ? The organ most deserving pity is the unresisting stomach, which is dragged and pushed out of all form during the con- tinuance of this packing process. The longer the continuance the more it suffers. If it is constant, we get cases like the following : CASE LXIX. Emily K , aged 16, was a full-grown woman in form, and had been catamenial for three years ; but when admitted to St. Mary's, in March, 1864, she was still wearing an old tough black pair of stays made for her when a child. The consequence was that she had never been thoroughly well all that time. The catamenia occurred every three weeks, and, for a girl of her age. were at first profuse, lasting six days ; but latterly they had lasted only three days. She had constant pain after eating, frequent vomit- ing, and frequent rising of the food in the throat, on which latter occasions it was sometimes tinged with blood, especially at the menstrual periods. This constant ill-health had made her thin and hysterical, but her lungs, heart, and HABITS LEADING TO INDIGESTION'. 105 all the solid organs seemed perfectly normal. When admitted she was vomiting nil IUT meals. At first she had Hydrocyanic Acid, but was no bet- ter in any respect for it; but on the 6th of April she was pat upon a course of cold showerbaths every morning, with Valerian three times a day. This, with the removal of the obnoxious stays, seems to have been immediately efTcrtual. for on the l'2th it is reported she had not vomited for two days, and on the 18th she was discharged "cured." "Cured" of her stays. Easy task in such a case as the al>ove, but presenting insuperable difficulties much more often. Women have a very strong won't. I. XX. G.'s " Anonyma," 1 aged 28, was brought to me in August, 1859, by a gentleman whose mistress she then was. She had borne several children in the course of her career, but still retained a beautiful slim figure which she had when a maiden. This she had accomplished by bandaging very tightly after each confinement, and sternly refusing to have any change made in the shape of her corsets. The consequence was that for several years she never took a meal without throwing some of it up afterwards, and suffered from obstinate constipation, for which she was in the habit of using violent purgatives. She seemed quite as aware as I could make her of the cause of vomiting, but resolutely refused to do anything which might imperil her out- line. In fact, she implied she lived by her beauty, and intended to keep it at all hazards. I do not know how to answer an argument of that sort. Another difficulty lies in the diagnosis of the true cause of the evil. Asking questions is useless ; " aucune femme ne se serre," remarks M. Chomel of his countrywomen, 2 and I am sure we may say the same of the confessions of ours. More- over, if you try to detect them by passing your hand under- neath the stays, as M. Chomel used to do, they stinge in, and defend the honor of their corset by a fraudulent kind of gym- nast ic. So you gain nothing by what is in truth rather a rude proceeding. The best way is to make an excuse to have the clothing taken off, and observe whether it has crumpled and marked the skin by pressure; then to desire the patient to tab- a full breath, and notice whether the lower ribs are dul\ 1 I borrow this term from the newspapers in no scoffing spirit, but pitifully and sadly to describe one who has lost her maiden family name by losing maidcn- hood and family ties, without ac'iniriiiw' a rUht to any other. It is hard to smilo at the loneliness which "no name" expresses. * " Lea Dyspepsies," p. Ii51. 106 HABITS LEADING TO IXDIGESTIOX. panded, or whether the intercostal muscles and diaphragm have lost power by misuse. By that means you can find it out when the tight-lacing is still continued at the time you see the patient. But in most cases it has been left oft' on account of the increasing pain it causes, and a suspicion that it causes the other symptoms as well ; or perhaps it is temporarily left off for the visit to the doctor. And I suspect that such is the case with a large pro- portion of the instances of habitual vomiting, soreness of epigas- trium, of haematemesis, of ulceration of the mucous membrane, flatulence, and hysteria, which come before us. These symp- toms are most common in the other sex why ? because their reproductive organs differ from ours ? Surely not, or we should find the same peculiarity universal among females throughout the animal kingdom, or at least throughout mammals. Yet we read in veterinarian pathology no hint of a distinction between the stomachs of our bulls and of our cows. Is it not more reasonable to conclude that the important difference lies in the clothes, which we can see, rather than in some mysterious in- visible influence of 'the generative viscera over the digestive, of which there is no evidence ? I should, therefore, in all women where these symptoms ap- pear, suspect at least, for no harm is done by the suspicion, tight- lacing, though I should not find it still persevered in or confessed. As an alteration of form is sometimes diagnostically useful, it may be mentioned that the prominent abdomen of a tight- lacer generally sticks out straight from above the pubes, some- times overhangs it: that of a naturally short-bodied stout woman slopes up to the umbilicus at an angle of 45 . 1 In a long-bodied woman, such as in the Phidian proportion, the abdomen ought to be flat. In men there is not the same temptation to compress the viscera for ornamental purposes among those who have the regulation of their own dress. But it has often struck me that the tight trowser-bands and buttoned-up uniform jackets, which French schools delight to enforce, must be very unwholesome, inde- 1 See Albert Durer's " Outlines of Proportion." HABITS LEADING TO INDIGESTION. 107 pendent of the impediments they offer to cricket and football, does not wonder at the pale greasy, old looks of the poor lads. They must certainly suffer from indigestion, and proba- bly it is this chronic ill-health which induces certain obscene habits said to be common amongst them. SECTION V. ' pression of epigastrium by shoemakers. Indigestions such as I have attributed to the pressure of stays in women, are common in one class of men, namely, cobblers ; arising in them from a cause of physiologically exactly the nature, the compression of the epigastrium by the last on which the boot or shoe is worked, producing on the stomach ;he same effects as its compression by the liver in cases of tiirht.-lacing. The following history shows the result in an in- cipient stage. LXXI. Joseph James D , aged 19, just out of his apprenticeship -lioemaker, was admitted to St. Mary's Hospital under my care October li'.th. 1861. He complained of weakness in the wrists, which became painful after work, and of constipation ; he spoke also of pain in the chest, which in- duced us to examine his lungs. These, however, were found healthy, and he had no cough. On further inquiry it appeared that the pain he spoke of was in th-- epigastrium, and was increased by pressure and by taking food. Rest nml Quinine improved him rapidly, so that he was made an out-patient within a week. The loss of power in the wrists, arising from atrophy of the rmi-eles in overworked parts of persons whose stomachs do not take in a sufficient supply of nutriment, in some instances pro- is to a much greater degree ; and there is a case recorded somewhere in my St. Mary's notebooks of a shoemaker in whom the two arms, even to the deltoids, were completely paralyzed by overwork in giving that artistic jerk to the thread which workmen affect. But I cannot lay my hand on it now. Perhaps I may find it by the time I come to a future chapter on the nervous symptoms produced by digestive d li'-mark how soon the evil had commenced, on the very threshold of the life the poor lad had chosen! The next case exhibits a further stage of the same condition. 108 HABITS LEADING TO INDIGESTION. CASE LXXII. Philip B , aged 36, shoemaker, was admitted into St. Mary's under my care November 9th, 1855. He had not been in health for nine years, suffering from what he called " spasms in the chest," that is, pain across the epigastrium, and irrepressible paroxysms of belching. The pain in the epigastrium was always increased immediately after taking food, and was accompanied by a great secretion of gas. When he could get off some of this by eructation, the pain somewhat abated ; but the eructations would sometimes continue as long as three hours. During the last nine months he had become emaciated, and felt a good deal of universal debility. The urine was smoky-colored, of the specific gravity only of 1.010, though natural in quantity and free from albumen ; the sleep was broken, the appetite good. He stated that unless he took purgatives his bowels would remain unopened for a fortnight together. Philip's first medicine was Bismuth in Iron. But the Iron did not seem to agree with him ; he got into a feverish catarrhal state and had sore throat. During this attack he was kept in bed, had six leeches and afterwards a blister applied on the epigastrium, and took a quarter of an ounce of Castor-oil oc- casionally. All this time, however, he was gaining flesh ; so that between the 27th of November and the 10th of December he had gained four pounds in weight ; and the urine was increasing in specific gravity, so that, by the 1st of December it was 1.028, but was a little cloudy from lythates. After the acute febrile symptoms had abated he received much comfort from the following draught three times a day, viz. : R. Mixturse Rhasi co., fl^j. Tincturse Opii, TTLV. Acidi Gallici, gr. v. He left on December 13th, much improved in health and spirits. In this instance it will be seen that the evil was much more ingrained by time, and the symptoms were worse and more difficult of relief in proportion to the greater time it has lasted. The intention of the draught was to soothe the oversensitive nerves with the Opium, at the same time that the Gallic Acid astringed the mucous membrane, and restrained the oversecre- tion of mucus, which the patient's general catarrhal diathesis otherwise displayed rendered probable to be present in the stomach. The Rhubarb, I think, was designed to prevent con- stipation arising from the other ingredients. As a rule I like Aloes best for that purpose in gastric cases, and I do not know why I ordered Rhubarb here. Sometimes when lads begin shoemaking early, before the bones have got quite hard, a peculiar deformity is produced, which acts like a perpetual pair of stays for life. HABITS LEADING TO INDIGESTION'. 109 \ XIII. William II , aged 25, bootmaker, was admitted to St. Mary's, Jane 7th, 1856, for pain at the pit of the stomach which had been almost constant for tour years, and was increasing. The pain was accom- panied by a local sensation of cold, and what he described as a "dragging." lie ulVu frit nausea, but never actually vomited. On examination of the ejiiL'astrium there was seen an indentation of considerable depth, and deepest in the middle, which he said was caused by the wooden instrument used in bootmaking, at which he had worked " all his life." The part was painful on II.- ireneral health did not seem much broken, and the specific gravity of the urine was 1.0'JO. With rest, Nitrate of Bismuth, and Iron, he lost his symptoms, and was discharged from care June 21st. But of course it was to be expected that his symptoms would return ; for these men spend fourteen hours a day with their heads bent down close to their knees, pressing a hard stick into -tomach; and the injury which was once done could not but be aggravated by time. The final blow to the stomach given by this trade is exempli- fied in this next case. CASE LXXIV. James P , a shoemaker, aged 37, was admitted to St. Mary's, May 4th, 1860. He said he had never been well since he was one-and- twi'nty. His bowels were never moved of their own accord, he occasionally vomited, and he had a perpetual pain in the right side of the epigastrium, winch he called his "liver." He continued in this state till 1855, when, as he was vomiting, there came up a sudden gush of blood. Since then the same thing had happened five times, the last time the night before admission. He did not throw up any blood when in the ward, but his statement was confirmed by the passage of a considerable quantity, liquid and clotted, from the bowels. A. date of Lead stopped the hemorrhage, and by dint of complete rest and Pepsine he was able to take the ordinary diet of meat and vegetables, with the addition of a pint of beef tea at dinner, for a week before he went out on tin- 'J.")th, taking Quinine three times a day. The rapid, though probably only temporary, relief of the pain in the epigastrium and the regained power of taking food, shows how mueh might be done in these cases by rationally removing the original cause of the complaint. No greater blessing to the artisan was ever invented than tin- rpriuht Shoemaker's Table, introduced by Mr. Sparkes Hall to the trade. At it the work- man stands or sits on a high stool at will, holding his work i by a strap and stirrup regulated by the foot. Thus all pressure OIL the epigastrium is avoided, and Mr. Hall tells me that many of his most skilled hands who used to be oiV work 110 HABITS LEADING TO INDIGESTION. from illness nearly half their time, and driven to drink to drown pain the rest, can now earn daily wages, and are become tempe- rate rich men. The difficulty lies in the change of method by no means a light difficulty. A visit to the Egyptian room at the British Museum shows that shoemakers have worked in a doubled-up posture at least since the days of the Pharaohs, and we cannot expect them to alter in a moment what certainly has some con- veniences. Moreover all do not suffer. A stomach in a perfectly robust condition probably can resist even this daily compression. But when occasionally it is joined to fusty cold workshops, long abstinence, tippling, accidental illness of any kind, then it tells chronically, and the injured part is unable to recover itself. The dura ilia make a bad use of their blessings by deterring the weaker vessel from the trouble of learning a new method, and are aided by the lazy conservatism natural to the ignorant. Still I think it is our bounden duty to advise all shoemakers we come across as patients to adopt the upright bench, and perhaps in time- we may succeed. I have not found this evil of compressed stomach from the constrained posture of tailors. They generally suffer from drinking and bad ventilation. SECTION VI. Sexual excesses. I alluded in the last paragraph of the fourth section to a perversion of the sexual instinct to be found sometimes accom- panying indigestion. I have seen it named as a cause, indeed it is so named by M. Chomel in the work I quoted. My expe- rience does not enable me to agree in this, though I cannot deny the possibility of it. Still I believe that more searching inquiry into those cases where the two morbid phenomena are associated together, will often enable us to discover a different sequence, and to call the quasi-voluntary act of lust an effect of feelings perverted by disease. A perfectly healthy lad never invents this for himself; and if he has taken it up from imitation, curi- osity, or the suggestions of infamous pornographic literature, disgust and boyish honor soon break him of it. Where it is HABITS LEADING TO INDIGESTION". Ill continued there is almost always some mental or bodily disease requiring medical care. As for example: CASK I.X X V.- Augustus T , aged 24, came to me in October, 1863, say- ing that for some years till lately he had been in the habit of solitary lust, and that he was suffering from excessive flatulence, and from pain produced at the epigastrium by any quantity of food sufficient to nourish the body. I ! hat) broken himself of the habit, but was dreadfully distressed in mind at the degradation of ever having indulged in it, and attributed to it the low state of bodily health lie endured. But I found on inquiry that from childhood he had been a greedy boy, morose and weakly, that he had suffered from worms ; and that his education was neglected on account of his health, long before the nasty practice he told me of had been adopted. On the other hand, I can remember in my notes records of at two cases where the obscenity had been learnt by imitation and practised as often on the average as twice daily for a sue- on of years without the alimentary canal suffering at all, whatever other functions may have failed. The natural sexual excess is also said by French writers to produce indigestion. I do not happen ever to have seen an instance. The digestion of prostitutes (whose trade may be considered an excess) has always seemed to me exceptionally good. Their health is less injured by riotous living and spirit- drinking than that of other people who equally indulge. I speak of the class who are patients at the Lock Hospital, where I have been the physician for some years. SECTION VII. Solitude. Eating in a dull heavy kind of way without enjoying it often produces dyspepsia in a moderate form. I . \ X V I. Rev. N. R , a bachelor of middle age, was my patient in the autumn of lsr.4. for flatulence of bowels accompanied by confusion of in- i during the second stage of digestion, and sleeplessness. By regula- tion ..f the diet, and (Quinine with Strychnine, he got well at that time. In N"\ ( -iiiln T. l"t'.."i. he ( nine to me again, saying that when he dined in company 'ild digest anything, and never sull'ered. however rash he had been at table. I5ut when he took hi.- meals alone for several days together, his old symptoms of the previous year returned, and no carefulness or abstemiousness prevented them. 112 HABITS LEADING TO INDIGESTION. I should conjecture the pathological condition to be a partial paralysis of the solar plexus, from attention being directed to it. Several commercial and literary men have complained to me of attacks of vomiting (that is, temporary paralysis of the stomach 1 ) when they took dinner alone, and so were apt to let the mind dwell deeply on some interesting subject; and they have told me in wonder that they could dine out and eat and drink all sorts of rich things with impunity. They did not seem aware of the preservative value of frivolous conversation. CASE LXXVII. A famous scientific man of middle age, deeply occupied with his pursuits, and never in the habit of "wasting his time," as he called it, on amusement of any kind, complained to me that when he dined alone, as he usually did on the plainest food, he invariably vomited afterwards. But that in dining out he never suffered even from nausea. At one time he used to read at meals, but that seemed to make no difference at all. Which is waste of time, work or play ? Truly sometimes one and sometimes the other, but each out of their due season, and proportion. The epithet "frivolous" (from the same root as " frio" = what may be easily rubbed out and forgotten) is not necessarily depreciatory. Light thoughts, light occupations that are easily rubbed out and leave no care or impression behind them, are good for mind and body and worldly estate. SECTION VIII. Intellectual exertion. The overuse of the mind sometimes induces indigestion in those previously not very strong. CASE LXXVIII. Rev. G. B , aged 50, after being invalided home from India, got well enough to take the post of secretary to a society. But the brain-fag consequent upon that, without any other change of his habits, brought on nocturnal flatulence, nightmare, and seminal emissions. And during the day his spirits were so depressed that existence was a burden. This was in November, 1862, and a month afterwards he came to report that assistance in his work had been granted him, and that he was quite set to rights, except a little weight at the epigastrium. It is to be observed that what I am speaking of here is not the original condition of mind which was described as a cause 1 See chapter on Vomiting, in a later part of the volume. HABITS LEADING TO INDIGESTION. 113 of the intion of starchy food especially, in the last chapter XIV. &c.), but rather the wrong mode of using it. Unavoidable evils were then described, TOO consequences of which might be alleviated, hut the causes were either past or irremediable. In this chapter I am tracing the complaints to habits which are voluntarily taken up, and can be laid down at will. I do not believe it is the quantity, so much as the quality of intellectual occupation which does harm. Composition, the tion of thoughts, even the putting of old thoughts into new forms, is not, in my experience, injurious. Where it is enjoyed, I believe it a peculiarly healthy occupation. It is the dreary routine work, invito genio and against time, which knocks up a man's stomach. In reality I believe the last two cases are exceptional, and that you will more commonly find some other cause at work in those who accuse intellectual occupation. For example: CASK I. XX IX. Joseph W , an engineer past middle age, with the broad forehead, square jaw, and shrewd eye of a mind like the iron he bent to his will, came to me in Man li. lst;3, complaining of flatulence, with spasmodic pain in the epigastrium, and that he was quite knocked up by the toil of invention, to which he attributed his bodily illness. On inquiry I found that In' had ticri) stimulating thought by champagne luncheons, and that it was after these he felt distress. SECTION IX. Want of Employment. The concentration of the mind upon itself we are assured by psychologists will produce mental disease. I confess myself that 1 have some doubts whether we ought not rather to say that it makes evident and brings into prominence previously ause the same class of observers generally also go on to say that the fixing of the mind oh any portion of the body will cause morbid phenomena to be therein developed. Now this is an experiment I have often amused mvse-lf by Irving in a leisure hour; I have looked at, thought about, argued about, and in imagination di.-sei-ted. my finger tips, nose, toes, epi trium, kn">. ,v-.. till the power of attention was wearied out; 8 114 HABITS LEADING TO IXDIGESTIOX. but no pain, or redness, or throbbing, or swelling, no stiffness, or coldness, or anaesthesia, has followed. What really happens however in consequence of a concentration of the mind upon the body is this should there be already existing any slight morbid condition capable of declaring itself to the nervous system, but not in such a way as to draw off from other objects the engaged mind; then, should the attention be unfortunately attracted to this part, the pain is noticed, is in idea multiplied and exagge- rated. Anxiety and distress follow attention, and then at last the bodily functions are interfered with (for these passions, as has been illustrated in the second chapter, lower the powers and secretions of the digestive canal), the saliva and gastric juice fail, and the digestion suffers. From thence perhaps, as a tertiary effect, may ensue deteriorated nutrition of the local injury. CASE LXXX. An old blind soldier, who lived near the Chelsea Dispensary when I was physician there, used constantly for several years to come to me from time to time complaining of excruciating pain in the abdomen. He had his pension, and was comfortably off in circumstances. No one on looking at him could doubt the reality of his feelings ; yet there was never anything in his state of health apparent to account for them. The only cause I could trace them to was his being occasionally left alone by his wife and family ; and then his blindness prevented his mind being drawn off to surrounding objects, and he would sit still, allowing any little abdominal discomfort to be depicted in exaggerated colors on his vacant fancy. He had in truth always a little flatulence, but never the " excruciating pains," except on these occa- sions. I have not seen much of blind people, but such as come under my notice are always disposed to exaggerate in this way any slight bodily discomforts into real tortures. From want of mental distraction, their internal sensations occupy too promi- nent a place in their psychical life. Just in the same way people who voluntarily deprive their minds of occupation, find out the existence of innumerable pains in various parts of their bodies ; the anxiety and worry thus occasioned really does deprive them of sleep, injures their diges- tion, and by the time they are driven to the doctor makes them materially as well as mentally ill. Sometimes these pains arise from actual organic change which had existed for many years unnoticed, and therefore without effect on the general health, 11 AH ITS LEADING TO INDIGESTION. and unaffected l>y it. But when once it is thought about so as to create anxiety, it feels the innutrition hence arising, and grows rapidly \v- I.X X XI. A paper-maker, utterly uneducated, though very wealthy, TH. \\-as brought to me by his wife ami doctor in March, 1861. He had had a slight catarrh of the bladder, following an old stricture, many years ; - long as he was iu business he never suffered materially from it. Having more money than he could possibly want, he thought he would retire and " enjoy himself." I'.ut alas, he had nothing to enjoy himself with, except, ';. his money, which is not of much use without tastes to spend it upon. look to thinking about his health, considered what was wholesome and what not, what to eat, drink, and avoid, for the sake of his defective urinary . Tin- coiisiMjiu'iice was that his digestion failed, he complained of after food, vertigo, flatulence, and " intolerable" pain in the epigastrium. peet, as he sat rubhinjr the pit of his stomach when introduced to me, was one of abject misery. The urine contained a little pus, but he made no complaint about his bladder. He had the white tongue of a nervous man, and his bowels were costive. My next report of him is dated August, 1 >(',_>. when I saw him in much the same unhappy state of feeling. But the bladder had trot a good deal worse ; there was more pus and albumen in the urine, and the specific gravity was only 1.015. I do not detail the treatment, for it was various and useless ; and a few weeks after his last visit I received a card from the family announcing his funeral. As a more cheering illustration per contra, I will choose an nee of the same anatomical condition as the last, in order >\v that urinary disease is not necessarily depressing to the mind. I A X X 1 1. J. B , a confidential clerk at the India House, getting on for 60 years of age, was sent to me by Mr. Coulson in June, 185G. lie had enlar- and vesical catarrh, but managed to avoid all serious incon- venience in that quarter by using a catheter. Now and then his stomach got out of order, but he could jjeuerally trace that to a good dinner or soin social imprudence; and then his bladder discharged more pus. So he went on some years, till I began to observe he was coming to me rather mot i|iiently. and that he had a care-cumbered face, leading me to ask him u hat lie had been doing lately. "I \. -thing. I am a gentleman at la rue now ned off." 1'oor Charles Lamb \ also an India Ilou.-e clerk, I thought of him and his humorous pathos <> being pensioned off. and said immediatc-lv that it would never answer, it was poison to mind and body. Ah. there's a good deal in win : as the spring comes on I and Mrs. 15. will take to gardening : she has a family taste that way. And ! gardening they took, and I saw him much seldomer. and heard no complaints of his vesical trou though he dropped in at the end of 1 -('.-! to introduce a patient to me, and see 116 HABITS LEADING TO INDIGESTIOX. how I was. I trust they still continue to plant their cabbages and bud their roses, and to make wierd skeleton bouquets of dissected leaves for their friends, and to be as happy and as little ashamed as Adam and Eve in Milton. Those in whom tastes have been implanted for simple amuse- ments cannot be too grateful for them. And I hold it one of the wisest things we can do in busy middle age to keep up or acquire such tastes. When once the inevitable pensioning off comes, it is usually too late to go through the necessary educa- tion. I have indeed seen a diplomatist, who had held in his grasp the destiny of nations, commencing at sixty-five the study of Italian, for the sake of reading Dante ; and I thought at the time it showed more courage even than his old trade of bullying into reason the masters of armies. Such courage is rare, and more generally the mind's mirror gets dimmer and dimmer, till there arrives with premature haste the state of things so graphi- cally painted in the last chapter of Ecclesiastes. I am sorry to say the stock example of this is a member of our own profession, Sir Astley Cooper, who, when in retirement satiated with wealth and honors, is described as looking over the trees of his park with a conviction that some day he should hang himself from one of them. He had wasted his life in routine work, and it was too late to educate the mind to anything else. The class of patients instanced in the last two cases are such as have some structural disease, of which I have described the aggravation by idleness acting through the digestive organs. More common still are those who have no existing organic change in any part of the body ; and in these the digestive organs act upon themselves only, and produce distress and functional derangement. A state of things arises pithily sketched by Dr. Markham in a letter introducing a patient to me a few months ago " he formerly was poor, worked hard, had plenty of appetite, little dinner, and little time to eat it ; now he is rich, with lots of time and dinner, but no stomach." Sometimes the vacancy of mind left by the surrender of in- voluntary occupation is such that absolute mental aberration is the result. There are actual delusions about facts, persua- sions that they have happened when in reality they have not. Under those circumstances diagnosis is much impeded by the HABITS LEADING TO INDIGESTION. 117 difficulty of knowing what is true and what is false of the various >y n q it i MILS related to you, if they are not in themselves til-void of internal probability. In the-'' cases I have been much assisted by the observation of a peculiarity in the mental state of the half-insane, which isplayed in the following: I . \ X X 1 1 1. M r. < J , aged 53, was till the early part of last year en- i in active business. He then gave up his occupation, and supposed he luul sufficient mental resources to pass life agreeably. So he settled at a fa.-hionable watering-place, and took to desultory art and literature. But tin- i-li'L r :uicies of life sit oddly upon him, for he is a grim-featured harsh-man- nt.Ti.-il man, unlikely to find much favor in that society whose business is !!< had the aspect of strength and health, but complained when I saw him that he had 1 n-en for several weeks a dreadful sufferer from excruciating pains in the abdomen coming on at night and entirely preventing rest. I had no reason for doubts, till I observed a painful anxiety, which increased as he talked, that I should believe him, joined to an evident suspicion that I did not do so. I however pn-scribed him some Valerian at night. When I saw him again in a week the Valerian had evidently made him f< vt-ri^h. and he said the nocturnal pains were worse than ever. I then eliritod that last autumn, in fact after he had been trying idleness for some months only, he had been exceedingly low-spirited, and that he used to get nervous and fidgety at niifht and have paroxysms of causeless terror. I huve since seen reason to conclude that the pains by night and the wake- fulness were purely imaginary. I have always in my lectures on the practice of medicine in- 1 much MI the aid to the diagnosis of mental disease ail'onled by the peculiar suspiciousness of itself which the mind exhibits. I remember a lady coming into my study saying, " I am nt one of your nervous patients" the exordium alVonled me immediate evidence that she was so, as the result l>rived. All lunatics, even in their wildest mood, seem to me to recogni/e a difference between their delusions and facts, and this inakt-s them often so furiously to insist upon them. I. talk ami shallow faith always run together. This is still more remarkable in the halt-insane: at an early stage of insanity. r on, namely in the halt-insane stage of recovery, the ; . :iar suspiri" much less marked : indeed an amiable t rust t'u 1 ness often takes its placf. With the earlier stage- non-specialists are most concern. -d, and 1 am sure what 1 have named is a valuable aid to di. 118 HABITS LEADING TO INDIGESTION". The peculiarity is rarely, or only cursorily, alluded to in mono- graphs on insanity, for the simple reason that specialists do not experience the difficulty, and therefore do not value any means of overcoming it. Nobody is brought to an asylum without there being abundant evidence of mental aberration, and the slighter indications therefore are of no practical moment. Our patients are probably never in a state to render restraint legal, or desirable on any account, remain useful and unnoticed mem- bers of society all their lives, and perhaps only manifest a delu-- sion in intercourse with their physician. We hail, therefore, with gratitude any thread to guide us out of the dilemma between a fact and a fancy. It is not absolutely necessary to have been a hard worker first for idleness to lead the thoughts inwards to the digestion, and put it out of order. Some who have been Lotus-eaters all their lives, still do not get acclimatized. CASE LXXXIY. Miss M. J , aged about fifty-five, has as tough a con- stitution as most people I know of, and had consulted me about catarrhs or some trifling ailments occasionally. When I was away from England in 1>65. she took a whim to go and live at an hydropathic establishment. She was not hydropathized, and it is a pity she was not, for it would perhaps have kept her out of mischief. But she used to listen to the inmates talking about their insides, and having very limited mental though plenty of pecuniary resources, she had nothing else to think of. The consequence was she began to suffer from gastralgia, even after the excellent wholesome diet and fine air she was getting at the place ; and when she came to London to consult me on my return she was seriously out of health, always feeling a weight at the epigas- trium after meals, having acid eructations and sometimes vomiting, and the tongue appearing pale and coated. I made her leave the noxious moral atmosphere, and adopt the physically worse alternative of close London lodg- ings with their well-known greasy cookery. Then she engaged a companion of her own age and position to talk to. and aided by some Quinine and Strych- nine soon got well enough to run over for a trip abroad, with a strict caution to keep clear of spas and invalids. My main object in this section has been to save these poor sufferers from drugs, which confirm their ailments. HABITS LEADING TO INDIGESTION. 119 SECTION X. Ab'ise of Purgatives. There is no habit so pernicious to the gastric digestion as inatieally taking purgative drugs. And there is none more common. It is commenced sometimes from mere caprice and imitation. I .X X X V. I saw last week a fine tall girl of seventeen at home for a few days I'runi M-ln><>l. Her mother untieing how pale and listless she was, inquired into her daily doings, and got out a confession that nearly all the scholars were addicted to drenching themselves with pills; this made them thirsty, and they tupped up with another purgative, "Lemon Kali" (an adulte- Uitartrate of I'otash) several times a day. As ray young friend had never taken physic in her life, except a few homoeopathic globules at a former sehuul. and some conventional draught? during the measles, this discipline made her ill : and it opened my eyes to the ease with which bad habits may be acquired. Kven in her case it had begun to produce a sensitiveness to the :ice of anything iu the excretory viscera, which very quickly grows in intensity, and renders the abstinence from purgatives soon a positive depriva- tion. (.' mlr, 18GG.) Tt is the increase of sensitiveness which does the harm ; for shortly this sensitiveness, commencing probably in the intes- - to the stomach, and the presence of food there 3 pain and cannot be borne, for the time requisite to normal 4ion. The food being undigested, costiveness results ; an ased demand for purgatives is made; sometimes even a medical man is induced to order them or to sanction them, and the difficulty of breaking the habit becomes really formidable. ;d even a homoeopathic physician, who placed his dan under my care, had been persuaded to allow the growth in her of this living on poison. The ill-health induced by purgatives is all the more serious in that it affects the most important classes of aliments. In XLV an illustration is given of the indigestion of fat, in LV of the iii i of meat arising from this cause. There is usually givat difficulty in eliciting evidence of pur- re habits; all the more so the higher in rank and more ated the victim< ar and then a sensible country girl will make a confession which puts .to shame her more re- liiu | ; 120 HABITS LEADING TO INDIGESTION". CASE LXXXVI. Emma W , aged 25, a well-built strong country-woman, had to come to London in the summer of 1851 as a nurse to the children of an old friend of mine. Since then she had suffered from pain in the epigas- trium (originally excited by tight lacing), waterbrash and debility. Her tongue and face were getting anaemic. For some months her fellow-servants and mistress had been dosing her with purgatives. She said she certainly did feel lighter after she took them, but in spite of that she had sense to remark that she was getting worse and worse, and could not but attribute it to the drugs. Yet she fancied she could not do without them, and feared she should be obliged to leave London and her comfortable place. This was on December 4th that she was sent to me. Before the end of the month, by simply leaving off purgatives gradually, and taking a little Iron, she lost her gastralgia and other stomach symptoms, gained strength and spirits, and remained in London many years a valuable servant, till the junior branches of the family left the nursery. In the above case it is mentioned that purgatives were left off " gradually ;" this I usually accomplish by giving moderate doses of Aloes and Myrrh in pill, and with each change of pre- scription increasing the proportion of Myrrh and diminishing that of Aloes, then dividing the pill into two, and at last omit- ting it altogether. Another expedient is to recommend small cold-water enemata which are not really purgative at all, and allow the bowels to act spontaneously, at the same time as they cool the rectum and take off any feeling of congestion and tenesmus, acting in fact as a sort of shower-bath. I have known the continued use of purgatives kept up by a medical practitioner with a vain hope of making the fecal evacuations of his patient more healthy in aspect. CASE LXXXYII. I was summoned in April, 1861, some distance into the country to see a young married woman, whom I found confined to bed with hysterical paralysis of the lower extremities and occasional vomiting. As my coming had been debated and arranged some days, I found prepared for my reception a long row of vessels, set in order of time, containing what had passed from the bowels. Each one was more unnatural, more fetid, more ragged, and with more undigested matter in it than the former. The medical attendant had been purging vigorously, and intended to go on purging vigor, ously, in spite of the obstinacy with which the patient got worse. When the gray powder, &c., was exchanged for beef-tea enemata, milk, mutton chops, and Pepsine, a rapid improvement followed. In subsequent letters I heard no more of foul stools. There is a very curious superstition about the use of mercu- rials. They are supposed to make the alvine excretion normal, HABITS LEADING TO INDIGESTION. 121 though the only visible result is its becoming more abnormal with cadi dose. They are supposed to do good by "acting on tin' liv.T." whether the liver is acting too little or too much. Tln-v are supposed to "act on the liver," though it has been slmwn by Dr. Scott's experiments' that the quantity of bile is not increased, nav, is rather diminished when Mercury is taken. All that the metal can be really seen to effect on the hepatic function is a poisoning of the bile, so as to prevent absorption by the ilia, and to cause the secretion to be rejected in a liquid form per amun : ami tliat is a very doubtful advantage to most invalids. The only effect at all desirable following mercurial purgation, and which in fact seems to constitute for patients the attraction , is the relief of certain cerebral symptoms, *giddiness, must-re volitantes, dark globes in the sight, singing in the ears, &c., which result from excess of venous over arterial blood in the brain. It acts in this case as a destructive upon the venous blood, and adjusts the balance' by subtraction. Time after time as the rough expedient is resorted to, the strength is lessened by it, and the necessity for its use appears greater more and more subtraction is required. The good and true way of re- storing the circulation to its normal conditions is by addition, by increasing the supply of new-made blood to the arteri SECTION XI. Abuse of Alcohol. The immediate effect of diluted alcohol on mucous membranes is first to dry them by staying the aqueous exhalation, and shortly to dump tl't-m with an abnormal formation of rauci illary circulation, and to deaden the sensibility of the nerves. The last action is its use. Where there is risk to health from undue sen.-itivrn.-ss. alcohol in moderation is an in- valuable remedy. It may be considered as an antidote to the condition discussed in tli< tion; and if a man were con- demned to take unm-ressary purgatives, ho could not do !> for his stomach than counteract part of their evil eiVect l>y mix- ing them with alcohol. Kxperirnce > have led to the 1 Beale's "Archives," vol. i. p. 209. 122 HABITS LEADING TO INDIGESTION. same conclusion as science, and we find the most popular drench- ing recipes have either alcohol or some equivalent anaesthetic in their composition. It is equally antidotal where the sensi- tiveness is the manifestation of weakness in the nervous system, either from exhaustion or imperfection. And thus it becomes the daily food or daily physic (I care not which it is called) of those whose daily life brings their nerves into this state. To the health of the bulk of mankind the habitual moderate use of alcohol is probably quite indifferent. One day they may want a little, and therefore be the better for it ; another day they would be in a more perfect condition without it. So a balance is struck by the habitual users ; and their chief argu- ment in favor of fermented liquids remains the unanswerable one that they are nice. No mean argument either, for it weighed with our Divine Master, when He first showed His power by treating the merry-makers of Cana to better wine than they were accustomed to. The effects of habitual excess (which in some people is taking any alcohol at all, in others is taking what is universally allowed to be "to much") is on the gastric area very similar to that of any other anaesthetic. A partial paralysis of it is in- duced, it ceases more and more to perform its peculiar functions for the owner ; " he cannot eat but little meat, his stomach is not good," though he may still digest vegetables and feel a re- lief from filling the void with them. If the appetite for food remains large, the weakened walls of the receptacle are liable to yield to the dilatation, as in the fol- lowing instance. CASE LXXXYIII. Mr. F , a burly farmer of middle age, came to me in December, 1856, complaining of a constant sinking at the epigastrium, relieved indeed for a short time by taking food, and partially by a glass of spirits. He ate, however, without appetite, and did not even enjoy his brandy, for it had become a mere matter of supposed necessity with him. Latterly animal food caused disgust and nausea, his bowels, from being cos- tive, had become relaxed, with yeasty fermenting stools, and he had got very down-hearted about himself. The condition had, however, been coming on very gradually he knew not how many years, and he was without difficulty brought to see the connection it had with a habit of taking spirits between meals. The tongue was coated with patches, showing sharp defined edges, of epi- TTABITS LEADING TO INDIGESTION. 123 t helium on a bright red base. It was described as being more generally all red, like a beefsteak. Tin- nmpanitie iv;onan--e on percussion of the stomach extended right up into the c:irdi:ie region and down nearly to the navel, and laterally in proportion; and the abdomen was prominent as well from accu- mulation of tat in the omenttim and parietes. 1 put him on a 1'anting diet, with at first some liquor potassje to dee; :-pulei)ee. and 1 ordered fifteen grains of Boudalt's IVpsine powder to n with animal food to assist in its digestion. I persuaded him also to promise that no spirituous liquor should be taken between meals; but he said he had sooner die than surrender a glass of brandy-and-water at supper. I must confess I had some doubts about the observance of the promise. Yet 1 was wrong; he did leave off spirits, and he did get much better and more active in business, and continued so for nearly two years. Then some temptation arose, he resumed his old habits, and was brought up again to London in 1858, in the same state as before. The same advice was given, but I have no record of the result. Persons with dilated stomachs are very apt to become obese, though the flesh digested is not sufficient to sustain the muscular strength. And this sort of obesity is very difficult to manage, from the impediment which the muscular weakness offers to taking exercise. In women, perhaps, from the bondage of the dress, the stomach does not in my experience become dilated from the paralyzed condition induced ly alcohol. The following case represents the more common injury done to the viscus. I A XX IX.- Mrs. P f aged 33, came under my care October 3d. She lived in the country in easy circumstances, had no family or . to attend to. and had become lazy, fat, flatulent, and low-spirited.' For several years she had been gradually getting into the habit of alleviating her uncomforta'- 'ions by small doses of brandy, which she took morning, noon, and night, but never in such a quantity as to get into her head. The rea-oii of her coming to me was the inability, which was growing upon her, of keeping the smallest quantity of food upon her stomach. It was vomited almost immediately. She was very hysterical, and the catamenia \va-; irregular. Leaving off brandy and taking some Valerian and shower- baths stayed the vomiting; but two months afterwards I was obliged to go abroad, and lost sight of her. The sudden leaving <>fV excess of stimulants will in clderly >ns sDiiietiriifs cause disturbed cardiac action, even when vmptums an- relieved by it. Mr-. 15. an elderly lady habitually rather short-winded, came tor, 1864, Si. ring from loss of appetite, 124 HABITS LEADING TO INDIGESTION. with frequent nausea and vomiting, which I attributed to a habit recently acquired of taking brandy between meals. The pulse was then regular. I urged her to give up the dangerous habit forthwith, and saw her again on the 2d of November. The nausea and vomiting had ceased, and she felt some return of appetite. But she had a new sensation of sinking at the epigas- trium, and was shorter of breath. On examination of the pulse I found it irregular and intermittent. The heart-sounds were normal. I gave her some Valerian, and on the 18th found her still bravely resisting the temptation to brandy, and dismissed her with a prescription for some Quinine and Strych- nine. I am used to quote to such patients as the last in terrorem an experience I once had of want of resolution in breaking off dram-drinking an experience happily rare, and not cited here as illustrative of a class, but still instructive as an extreme warning. CASE XOI. In September, 1857, I was called by Dr. Jephson to a con- sultation in the case of an unfortunate middle-aged woman, who was dying prostrated by uninterrupted vomiting. It is needless to detail the symptoms, which were those of simply retching and sinking, and the nature of the case was made apparent by her desiring her maid to bring her a glass of brandy even while I was speaking to her. Our attempts to feed her with beef-tea enemata and Opium were unavailing, and she died next morning. She told me the habit had been acquired only the previous year, while staying with some friends in Scotland at their shootings, where a nip of whiskey was the regular preparative for breakfast. But dram-drinking is by no means confined to uneducated persons, those whose "talk is of bullocks," or to idle women. I am ashamed to say I have been consulted about its conse- quences by several members of our own profession, who ought to know better and set a better example. Quis custodiet ipsos custodes? They tell me the temptation is very great in country practice, sitting in tedious conclave in lone farmhouses during a lingering labor, or watching some long-dying patient with no person that can understand your thoughts within many miles. There is nothing else to do but drink ; and then the next day you have to be at work at the usual early hour, and the work can hardly be done without a hair of the dog that bit you. The last sentence, expressing the necessity for staving off alcoholic reaction, reminds me to mention a test which I am used to apply to discover whether the amount of alcohol taken is such as really to injure the stomach. I ask whether the HABITS LEADING TO INDIGESTION. 125 :it over is in the habit of taking it in the forenoon. If so, 1 at once feel sure t hat the stomach has suffered. When a con- siderable interval intervenes between the indulgences, and the reaction is allowed to have its way till ordinary digestion is red, the constitution may very often be still uninjured. But I have not yet met with a forenoon tippler, even though In- never got drunk in his life, without a condition of stomach which most infallibly shortened his days. I find it a great advantage in the selection of lives for insurance to substitute a poiir- 'ion on this head for the usual aimless inquiry whether the proposer is "sober and temperate." Nobody is anything else, of course; and the answer is a mere declaration of opinion. But "do you take spirits in the forenoon? Is that a habit?" require categorical statements of facts, which if wilfully false would vitiate the policy. The way in which life is shortened by this stomach affection Jierally secondarily through the liver, originating anaemia and ascites : sometimes through the pancreas ; when the ema- oiated L r in-drinker, such as Hogarth drew, is produced. More rarely the kidneys break down, and Bright's disease arises. In ilie nearer, physiologically speaking, the organ to the stomach the more likely it is to suffer. When a patient is persuaded to give up dram-drinking, he often has such a dreadful depression of spirits that his resolution is apt to pive way, though he is convinced he is acting right. And sometimes he may have a kind of delirium tremens from the sudden shock, before he can get into the temperate habit of taking stimulants only at dinner, or of giving them up alto- gether, according to the nature of the case. Still it is best to ce the absolute rule of no alcohol between meals, and to supply its place temporarily by an Kther and Ammonia draught, then by Ammonia, either alone or with a bitter, and then to stop it altogether. BBCTIOH XII. Tobacco. The more usual toxical of the alkaloids absorbable from the Tobacco plant are exemplified in the following typical 126 HABITS LEADING TO INDIGESTION". CASE XCII. Smoking. Five years ago a young married man of about 32 rushed to me in a great state of alarm, stating that he had suddenly become impotent. This was not strictly true, but still he certainly was less fit for matrimonial privileges than was right in a husband of two years' standing. The next complaint he made was of cardiac palpitation (on examination I found the heart beating unevenly and irregularly), of frequent cold sweats, nervous agitation and causeless fears by night and day too. I found he had recently returned from sheep-farming in Australia for several years. When there he used to smoke strong Shag in a short cutty-pipe all day and almost all night. He had brought his dear though dirty companion with him to London, and continued the habit with a certain amount of modi- fication. In the fresh air of the wild downs he had never suffered the slightest illness, but no sooner had he been in London a few weeks than the symptoms detailed had come upon him, and had gradually increased. He could not at first understand why I should attribute them to the Tobacco, why it should be so bad for him in England, when abroad it seemed to pre- serve his health. But at last becoming convinced of the difference between British and Australian air, he drew his little black pet from his pocket and broke it in my fire-place. He would never smoke again, rather than risk de- priving his wife of her just claims on his attention. I took the tide at the turn and clenched the promise, which was certainly kept long enough for the palpitations, nervous fears, &c., to be cured without physic. CASE XGIII. Snuffing. October 22d, 1866. Eev. C. W , a country clergyman of literary and sedentary habits, has usually enjoyed good health, and in spite of a fondness for his study and dislike of parochial work, visits in his district, and has regularly done two full services every Sunday. It is a difficulty in properly performing the last-named duty which brings him to me. For several months he has noticed that his manner in the pulpit has been getting awkward, and he feels hurried and has an unreasonable desire to get to the end of what he is about. He sometimes cannot help skipping over the latter half of a sentence so as to go on with the next. For some weeks this hurry of manner has been extending itself to his social and pro- fessional intercourse on week-days, and to-day in speaking to me he is exces- sively precipitate and nervous. He can scarce keep his hands still, and clutches at and handles all the little things around him in my study, though evidently ashamed of his solecism in demeanor. His appetite is good, he has no flatulence, he can eat anything he likes, and drink a bottle of port without feeling any inconvenience, in short he is evidently unaware of having digestive organs. The actions of the bowels and kidney are quite healthy, but he evacuates the bladder more frequently than is needful. On inquiry I find he is a devoted snuffer, having his pocket box filled up every day, and keeping a second relay ou his table as well. I said at once I would not prescribe for him unless he would make at once at least a step towards giving up this habit. He readily consented to keep HABITS LEADING TO INDIGESTION. 127 a box only on his table, and to have it filled only twice a week. To supply temporarily its place, 1 allowed him two teaspoonfuls of Tincture of Valerian twice a <: w him again in a week much improved, and in a fortnight after that he I <|iiite to have regained his natural dignified manner and to be recon- ciled in abandon his snuff-taking. These histories give a pretty full detail of all the important mieiKi usually produced by excess of Tobacco, according \I>erience. Others are merely a repetition of these, in which it may be observed that the digestive organs seem re- markaMy free from injury. In fact the only two cases I can iinil iu my note-books where the alimentary viscera have suffered are the following. XCIV. Mr. William T , aged apparently about 50, came to me iu March. l>f>6, complaining of costiveness, pain in epigastrium about three hours after food, flatulence, and dryness of mouth. I could not find any r snail'-taking as the deeided efficient i-au.-i! of indigestion, so that t pTOTfl nothing tor .M.-U-H- titie purpo, ( . s: ,,: XVIII. f,.r example) the -howii to be a libel l>v the symptoms not ceasing when the alleged cause had been long reiiK- 1 l! I am surpri.-. iveral medical wri1 u to consider it a matter of course that the pleasures oi' the pipe 128 HABITS LEADING TO INDIGESTION. should have a special deleterious effect on the salivary glands and stomach. Dr. Prout says, " The severe and peculiar dyspeptic symp- toms sometimes produced by inveterate snuff-taking are well known ;" so well apparently, that he does not enumerate them, so that perhaps he may mean the nervous weakness described above but then he goes on to remark, "I have more than once seen such cases terminate fatally with malig- nant disease of the stomach and liver." 1 The insinuation is that Tobacco causes malignant disease ; which is proved false by the fact of cancer of all the organs being more common among women than among men ; and among men being quite as common among those who do not smoke as among those who do. It is very clear that Dr. Prout has misapprehended the pains of incipient cancer, and ascribed them to the Tobacco which was taken to solace them. I must allow that I myself took such ideas as Dr. Prout's for granted, and supposed that of course the salivary and gas- tric secretions must be the chief sufferers from Tobacco, till I came to review my experience and drew out these two solitary specimens of their being possibly affected by it. They, there- fore, must not be considered as the type of a class. The poison of Tobacco smoke seems to attack more particu- larly the nervous system. Intermittent pulse, palpitation of the heart, shaky hands, nervousness, imaginary impotence, and the like, are produced by it, but not primary affections of the digestive organs, as a rule. And in snuffing the large quan- tity of the drug which goes down the oesophagus seems to pass the mucous membrane with little injury, and to affect the system only by the absorption of its alkaloids soluble in the blood. This last sentence may afford a hint as to the method of treating our patients. It is avowedly, almost proverbially, diffi- cult to get them to resign the soothing herb. Few of them take such a wholesome alarm as Case XCII, or, if they did, would not act upon it. They say the sudden deprivation is too much for their strength of mind. Now if a Tobacco is pre- 1 " Stomach and Urinary Diseases," page 25. HABITS LEADING TO INDIGESTION. 129 1 by abstracting the main deleterious agent, Nicotina, a step by which the patient may be let down easy, and not run the risk of an abrupt change. For smokers a convenience of this sort is afforded by the Vevay or other Swiss cigars, which are the common leaf fitted for use in cigars by soaking in water till one-third of its substance is abstracted. I do not know of any kind of snuff manufactured on a similar plan, and consequently there is not the same aid to persuading a victim to surrender the indulgence ; but one old snuffer told me he had broken himself of it by the aid of kitchen salt finely pounded, of which he mixed more and more daily with the contents of his box, till it was nearly all salt. Then he took plain salt, and soon gave that up. I have heard also of ginger j employed in the same manner. Another, who had ac- quired the habit at Cambridge many years ago, and did not like the look of it on leaving the University, used to carry for some time a vinaigrette of Aromatic Vinegar for the same pur- pose. SECTION XIII. Tea. The following case, illustrative of the pernicious consequences of excessive tea-drinking, is extracted from my Clinical Lectures at St. Mary's Hospital. \ ' V 1 . M aria D , a spinster of thirty-two by her own confession, but probably older, has been a general servant in a light place for seven years. She has been happy, and has enjoyed pretty good health, interrupted only by occasional h> : but for some time lately things have seemed to ;muoy her more than they ought to do. Three months ago, she had a bad 'bilious" headache, which was followed by Rome paroxysms of laughing and i-ryiiiL'. Five wn-ks l>:n-k she had an attack of diarrluea. from which she got better, ami wrnt to work again in spite <>f weakness, for she was loath to IK h-r mistress want her. But exertion was in vain, for she no sooner tried to clean a grate than she fell down speechless, and had a succession of hys- terical tit>, losing her senses, but not biting her tongue. Then she began vomiting everything >he t.mk. and this had lei-n going on for three weeks, and seemed to amount to ;i complete rejection of all her food immediately it was swallowed. When you saw her. there was excessive flatulence, the air bursting up from the stomach in roaring eructations while one was talking to her. In this woman, the effect of the wide pupil and sympathetic hemipt. 9 130 HABITS LEADING- TO INDIGESTION. not hidden even by the disfigurement of blear edges to the eyelids; and it quite accords with the droll earnestness of her manner, which increases gradually as you let her go on talking about herself, leaving no doubt of her strong hysterical diathesis. As to cause, that is still more directly traceable to the stomach than even in the last case. 1 It would seem that for some years she has been becoming more and more addicted to tea-drinking. She confesses to caring for little else, so long as she could get her favorite food or physic or poison I do not know exactly how to call it. Her mistress was quite angry with her for eat- ing so little meat ; and with a far-sighted economy not common in her class of life, took much trouble to keep up the health of a faithful servant. But the weakened stomach refused meat, and she was literally starving in the midst of abundance. (Nov. 1, 1861.) Much, ill-health arises among women of the lower orders in this country from the custom of sluicing themselves with tea. (I am not aware if similar results follow in Holland and Portu- gal, the only other tea-drinking populations in Europe.) Want of appetite for the quantity of coarse albuminous food neces- sary to working people is induced. In the upper ranks not so much harm is done by the five o'clock kettle-drums and similar sloppy proceedings now so common, because their bill of fare is more attractive to the palate, and they usually get as much flesh food as is good for them in spite of it. Besides which, educated persons have usually the instinct to stop in time a custom which really depends on a mere whim. Still it cannot under any circumstances be a wholesome habit. Tea seems more injurious to the stomach in the usual form of infusion than otherwise. I remember some years ago being puzzled in viewing lives for insurance by some singularly colored tongues which I saw in those who came before me. On inquiry, I found their occupation was "tea-tasting" for the greater part of the day. Now, tasting tea is performed partly by sipping some of the infusion, but principally by sniffing up the aroma into the nostrils and chewing a few leaves in the mouth. I was given to understand that they sometimes found themselves nervous after a long day's work, that possibly the hand might shake a little in those who worked too hard, and that the tongue acquired this curious smooth orange-tinged coating, but that the digestion and appetite did not suffer from the trade. 1 A very similar case not necessary to be repeated in this connection. HABITS LEADING TO INDIGESTION. 13,1 SECTION XIV. >Wl. An occasional effect of the Salts of Opium on the stomach is exhibited in the following case : Xt'VII. Jane B , a domestic servant, thirty-seven years of age, was under ray care at St. Mary's for some painful tumors of the abdomen affecting the uterus and bladder, in March, 1861. On account of the pain, she was ordered a grain of Acetate of Morphia every night She had never isly hud any narcotics. She only took one dose, for that was followed by vomiting, very severe during the night, and recurring at intervals during the next four days. The possibility of an idiosyncrasy of this sort is no reason for shrinking from the essay of a good and useful medicine, but it well to know that it may occur. The more chronic effects upon the organ are shown in the next : VIII. August 12th, 1853. George N , an assistant-surgeon^ aged 35, states that for eight years he has been in the habit of taking large quantities of Opium. He began the practice in the first instance to prevent ling the want of food, when, as a surgeon's assistant, he was obliged to wait many consecutive hours without anything to eat. He at first confined !l tn twenty drops of Laudanum a day; but he gradually increased the amount till he finished a fiuidounce of Laudanum daily, and quarter of an of crude Opium in addition weekly. He tried several times to leave it off. but was prevented \\\ the nausea and pain in the epigastrium which he experienced. He had lost much flesh, and got miserably weak ; but he pro- bably would have gone on with his poison had he not been frightened by a numbness and partial paralysis of the left arm, and a loss of memory, which made him think he was going to have a stroke, and caused him to put himself under my care. I immediately restricted him to one grain of Opium at night, and conse- quently found him next day in miserable pliirht. vomiting, with pain in the epigastrium, and with a most melancholy aspect. I gave him strong beef-tea uud port wine. Imt got afraid next day that he would slip through my fingers, and so I added some Chloroform draughts. These relieved the sickness. I'.y the 17th he begun to get better, and the Chloroform could then be omitted. On the 20th he felt very sinking for the want of it, but yet fancied he was re- covering his appetite. He had, at his own request, a mutton chop and half ti pint of porter. On the 2 lid In- remarked his memory was improved, and ho iri't up and dressed. Then his bowels got irregular, and following that lead I . ic.t the quantity of Opium to what he had in some Chalk and 132 HABITS LEADING TO INDIGESTION. Opium powders, ordered to be taken when there was diarrhoea. By Septem- ber 1st he was able to leave it off entirely and take care of himself. It appears from this to be the digestion of meat and fat which is mainly impeded bj Opium. It requires, however, to be taken in great excess for the effect to be produced. And even then the result is not by any means immediate. That is shown by the case quoted ; and I remember also, in 1838 or 9, a sweeper of a lucrative crossing coming to swear an affidavit before my father as a magistrate that the bearer of the said affidavit was in the habit of using two drachms of solid Opium daily. The reason of this measure was that the shop where he was accustomed to deal for the drug had changed hands, and the new-comers refused to serve him with such a dangerous quantity. He was nigh crazy with the restriction, but armed with his legal document he felt safe for the future, and I used to see him at his post many years afterwards. On the whole, Opium-eating does less harm than is generally supposed very often much less harm than the pains which it is taken to counteract. The great objection to it seems to be the difficulty of leaving it off, when, as in the case of the surgeon's assistant, it had from its monstrous excess begun to tell on the health. But this difficulty has been very much exaggerated, as well as the temporary pleasures of indulgence, from the descrip- tion having fallen into the hands of the imaginative De Quincey a man whose world was in himself, and whose whole biogra- phy, when published, let us into the secret of " The English Opium-eater" being really a work of fancy. The same may be said of Coleridge's "Recollections." I find in my notes a special memorandum of the scorn with which the difficulty was treated by a genuine strong-minded man. CASE XCIX. During the year 1859 I saw from time to time, for some trifling ailments of which I have no accurate record, Captain B , a fine, hearty, God-fearing sailor of the old school, seventy-two years of age. He told me that twice in his life he had been a decided Opium-eater, taking as much as a drachm in solid form daily. I expressed my surprise at his having given up to the practice, which surprise he did not at all understand, saying, " Why, I should be ashamed of both my philosophy and my religion, and turn sceptic, if either singly would not strengthen me with resolution enough for that.' 1 The occasion for which he took the Opium, some trying mental cir- HABITS LEADING TO INDIGESTION. 133 ciimstancos. having passed away, he diminished the quantity by five grains daily till he ceased entirely ; and I must say his constitution appeared none the worse. I hear from his daughter he is still alive and well at 80. Opium is given medicinally, that is for the relief of certain bodily or mental pains, and when it succeeds in relieving those pains, it does not seem to produce its special toxical \vhere it is really wanted it rarely does harm. For instance, in inflammation of the serous membranes, as pericar- ditis, I have given to young persons who never took it before i rli as three grains every three hours, without producing constipation or over-sleepiness till such time as the inflamma- tion had subsided. (See "Lectures chiefly Clinical," Lect. XV, " On Pericarditis.") Of course I did not arrive at this quantity all at once, but began with a grain or a grain and a half, and increased rapidly. I have myself taken Opium for the relief of various incon- veniences arising from an amputated limb, but I have never felt the slightest temptation to continue its use beyond the neces- sary period, or any inconvenience from leaving it off. The box stands alongside of my razors, and I do not feel one more dan- gerous than the other. It is only when taken in great excess, or when persisted in, spite of \varning, that Opium seems seriously detrimental to the digestion. All the habits in this chapter instanced as causes of indiges- tion are voluntary and capable of being changed. The cure, therefore, of the indigestion lies first and foremost in that change. It must be made a sine rt of the cardia; but if it is spat out, no relief follows. of the passage of this augmented secretion into the irh will be shortly described under the heading of " Water- brash," in a future section. Though the sensation is that of a cramp, and the (.esophagus is a muscular organ, I do not think there is any real tonic contraction of the fibres. There is no movement in the throat, such as may be readily felt on volun- tarilv gulping. There is certainly no visible contraction of the : of the fauces. Indeed, when the sensation gets there, it is rather one of relaxation, as if smoke escaped, say the patients. Moreover, if a little fluid be swallowed, its passage is not re- i by any stricture. There appears to me to be a subjective perturbation of sensibility, rather than of contractility, in the milder eases I call " heartburn." Where there is a real spasm, " waterbrash" is produced, as I will explain under that heading. Though this morbid phenomenon is manifested by the oeso- phagus, its causes do not lie in the oesophagus. Cancer, ulcera- or stricture of that organ, do not originate it in the ma- jority of cases of these lesions, whereas it is a very common equence of the slighter morbid conditions of the stomach. W<- Miav ! mark that it is easier produced by general than by local states of th . and rather by slight than by severe ' ant ly find cancerous tumors and con- sidernble ulcerations. in the gastric walls without any sun to the deficiency of this fluid, considering it rather as an eft'ect of the sluggishness natural to old age. At that period of li! .ercise is taken and less food required; so that the quantity of the diet should be accommodated to the years. If it be not so, the overladen organ labors. CI. M . d 10, consulted me in April. 1857. about an inter- mittent hemicrania \vlii--h had come on recently through living in an aguish district. She had a look of chronic invalidism more than was justified by the malarious infection, and on inquiry I found that for many years she had suffered from what she called "risings in the throat," which came on about three hours after meals. Dinner was the most painful meal. If nothing came ti], as was usually the case, the " risings" continued two hours or more, and went away gradually. Hut if by a semi-voluntary effort she turned the rising" into an ejection of a small quantity of food and air, relief followed. On these occasions what she brought up was very acid to taste and smell. She had been physicked at various times in previous years for this heartburn with- out benefit, and had learnt to bear it. She found, indeed, that Soda gave temporary ease ; but fancied the symptoms were aggravated by a persi- in the remedy, and despaired of beinir ever better. She came to be cured of her headache. For this 1 prescribed, and killed two birds with one stone, for she was later led to volun 1 that the l^niume I gave her to cure the hemicrania did the heartburn good also. 138 ABDOMINAL PAINS. It is this last observation which leads to my here quoting the case By three hours after meals the stomach ought so far to have emptied itself that the cardia should not be distended, and the orifice, relieved of the pressure of acid matters, should be enjoy- ing the change of a trickling flow of alkaline saliva. Though the general contents of the stomach may, and indeed ought, to remain acid longer than that, yet the lower orifice of the oeso- phagus requires a period of alkalinity, and suffers if it does not get some. Note that the throwing up of a small quantity gave relief, because it brought the stomach into a normal condition as to contents. Note that what is brought up in heartburn was acid, show- ing a free communication with the stomach, and therefore that the oesophagus was pervious, not spasmodically contracted, as the patient's sensations led her to believe. This form of heartburn frequently comes on at night, pre- venting sleep. Sometimes the patients will say they have "pain before food," which pain on inquiry turns out to be postponed heartburn arising from the last meal. CASE GIT. Eev. E. M , aged 26, has worked so hard to raise himself to be fellow and tutor of his college that he has injured his digestion. The false appetite which intellectual exertion brought on, made him overload the stomach at dinner with more than it could part with by next meal. This induced a pain not exactly like that of hunger before each meal, accompanied by a sensation as of something rising up into the fauces. No vomiting or eructation, though the stomach evidently was not empty. He had besides some curious nervous symptoms, for which I gave him Quinine and Strychnine, and he got better of all together. CASE CIII. Mr. John H , aged 42, came to me February 7th, 1866, com- plaining of pain at the epigastrium towards the left side, rising up in parox- ysms to the fauces, and which was shown to be only heartburn by the absence of tenderness on pressure. He declares it does not come on till full four hours after food, and it passes into hunger for the next meal. It is almost as common in practice, especially among the educated classes, to find heartburn complained of as coming on within the first hour after meals. ABDOMINAL PAIXS. 139 \". Ilonry S , aired about H). a solicitor in large country prac- ,une t> mi- in March, ls.~>('.. complaining, among other things, of heart- burn commencing within an hour of every meal. He had sometimes made a strong effort at eructation and brought up some of the contents of the stomach, hut it gave him no relief. What he brought up did not taste particularly soar, and consisted of whatever he had eaten. I prescribed him a course of Hydrocyanic Acid ("liv in Infusion of Gentian three times a day). He con- tinue. 1 tn take that till quite well, and remained well till a hasty journey to Vienna in the autumn of 1860 brought on an attack of diarrhoea and great ition. After this his old symptoms returned, and were again appeased by Hydrocyanic Acid and a Blister to the scrobiculus cordis. It is among anxious sensitive persons that we usually find this kind of heartburn, even although they may not be so intel- ;:tlly and SBfltbetioally endowed as the last-named sufferer. < \-K TV. Mr. W , a cheesemonger, aged 30, came to me last January for a feeling of pain rising up from the epigastrium to the back of the throat, -!imke arose from the stomach, usually under three quarters of an hoar after meals. If he ate supper, this would happen in bed and give him sleep- Jit-:. lie was an uneducated soul-less man, but had worried himself a good deal about his trade, and was also anxious about his health, so that his tongue had the quiver and the wet white coat of an overwrought intellectual woman's. n fill doubtless the largeness of the meal contributes -.sly to the severity of the heartburn with acidity, it is by no means an essential in its production. l CVI. During 1801 and 1862 I attended the wife of a retired Anglo- Indian physician, aged about 40, for general sluggishness of the alimentary canal. accompanied by a tendency to mucous discharge p<>r union. She puflercd at fir.-t a -reat deal from "acidity" within the first three hours after meals. Imt .-one-times sooner. She constantly averred, and indeed at my re- quest subjected the matter to the test of experiment, that a small quantity of bread, or any other simple food, brought on the acidity as certainly as a full meal. That this was due to sluggish action of the gastric muscular fibres was evidenced by her deriving benefit from Strychnine; but that it was not wholly M> to lie debited, its early supervention showed. Now in the first, second, third, and fourth of th'se specimen cases we may fairly accuse the stomach of atonic sluggish by which its normal! its arc detained too Ion their passage, and the n- 1 too long to that acid. But in the next two the pain cannot be debited to prolo 140 ABDOMINAL PAINS. exposure, for it would be an exceedingly abnormal thing if the cardia were not acid at that time. There must have been an over-sensitiveness of the gastric plexus. The last (Case CVI) is a transition case, which, though it stands alone here, really represents a larger number than the others, namely, those which are a transition between the classes, presenting the character- istics of both in various degrees. We may take the marked cases as the two ends of the scale, between which the majority of our patients vibrate. Although, therefore, it is impossible to make a clear division of our patients into the two classes, yet has the distinction an importance, for the nearer the symptom occurs to the meal the more is it due to hyperassthesis, and the further off the more to slow digestion. And with an eye to this pathology are the patients best treated. First, as regards the immediate popular relief by alka- lies : when the heartburn does not come on till four hours or so after a meal, an alkali may 'be safely taken even habitually; it is time for the stomach to be losing its acidity, and there is no harm in assisting nature. Still it must be remembered that this temporary antidote, taken in this way, is not a cure. But if the heartburn comes on within about an hour of the inges- tion of food, an alkaline neutralization of the gastric contents is positively abnormal and injurious. 'It prevents the due digestion of the food, and so deprives the body of nutriment. It induces anaemia, debility, and possibly some of the further ills to which these powerful degenerators lead. In the cases with a preponderance towards the latter class local anesthetics come into play. Opium and its salts, Bismuth, Zinc, Silver, Henbane, are all of use as a change, but the main stay of the practitioner is Hydrocyanic Acid. It does more good combined with less harm than any other remedy. Car-- bonic Acid is also a harmless anesthetic, and indeed a normal one, for the natural atmosphere of mucous membranes is Car- bonic Acid. I have sometimes persuaded people to take Car- bonated (aerated) Water instead of Soda, and they have experi- enced an equal relief. I have sometimes combined a Blister with Hydrocyanic Acid, from my observation of the effect of ABDOMI.VAI, PAIN'S. - in pleurodvnia, ami I am inclined to think it anaes- thetic in :i. But it is a disagreeable measure. Mineral acida are of more use in the heartburn of sluggish indigestion tlian in the hyperaesthetic ; but I think they seldom cure without the aid of other more potent tonics. One great tion to their use is their injurious action on the teeth. '.11 me that we physicians make more work for them than any other external enemy to the integrity of the grinders by our administration of mineral acids. In consequence I have mad- -vials of Acetic Acid as a substitute, but without much encouragement to persevere. In hypera-sthetio heartburn the chewing a piece of Liquorice slowly in the mouth will often be of great service, especially when it occurs in pregnant women, to whom one is loath to administer drugs without strong cause. Howsoever, the final reliance of the physician for cure must be in a renewal of the rs of life by tonics, especially by nerve-tonics, especially v "iinine and Strychnine: and then, when a step of progress has been made with these, by the restoration of the blood with Iron. I will not tarry over the shapes in which these remedies be administered I am careless of the form so that I get instance. Some forms may be better than others, but all are good, and all distance competitors so far, that their mutual rivalry is of no moment. It will be seen that in all the c I quote resort is had to these. They are always at hand, always and within the reach of all purses; which last cannot be <>f the tonic I am now coming to. I have spuken of alkalies as a temporary palliative in heart- burn. There is another way in which they are sometimes em- d with advantage, and which may be described fairly as their "restorative" use. I refer to their administration in a ourse, the dose bein^ taken rather at the times when tin-re is no heartburn than when there is. The effect aimed at is that consequence of alkalies pointed out by Claude .ml, the augmentation of the acid -a.-tric juice, and so of .onua! | , , ( f the stomach. Tl. 'ceneiit bein.i: derived from a course of alkali is the dose not re,|,iirin- to be increased as the patient goOf taking it, but on the contrary being capable of being diminii 142 ABDOMINAL PAINS. gradually, while relief from the recurrence of heartburn con- tinues still to be experienced. This shows that the real health of the stomach is being restored ; that a renewed life is de- veloped. But should the patient be driven by recurring pain to take larger and larger doses, it is evident that the palliation is simply a neutralization of the normal acid of the gastric contents. This induces in the end weakness and over-sensitiveness, and such patients will in a very short time appear again under medical care, usually in a worse condition with each recurrence; or they will become chronic druggers for life, or perhaps be finally cured by some clever quack who amuses their fancy while he bids them abstain from active remedies. Now I think that the due administration of a course of alka- lies is best secured by the systems followed at certain Continental spas. I believe their reputation as panaceas of all bodily ills to spring from the renewal of the digestion which this mode of administration of an alkaline course is likely to bring about, and from the intimate connection which there is between the digestion and all other parts of the body. "We must not let ourselves be prejudiced against courses of mineral waters by the little packets of nonsense, brought by post under various foreign stamps, which set forth in laughable Anglo-French the omnipotence of their own " Abana and Phar- par." Doubtless, like the lady in Hamlet's play, they do " protest too much ;" but there is some good in them for all that. Patients get there something more than the over-puffed and many-tested springs Air, Best, Gentle Exercise, New Diet, Change of Scene, Freedom from Domestic Nagging, and per- haps from Domestic Physicking, &c. These would do good, were the waters even moderately poisonous. But the fact is they are not at all poisonous, and many of them contain not only Carbonic Acid, which is a gentle normal anesthetic to mucous membrane, but also Carbonate of Soda, which rightly administered has been shown capable of increasing the digestive powers of the stomach. The right administration consists in giving it, not when the organ is full, and ought to be acid, but when it has parted with nearly all its contents, at a time as distant as possible from the meals. ABDOMINAL PAINS. 143 When, therefore, I wish to prescribe a course of alkali, I think a better plan cannot be devised than sending the patient -pa containing that ingredient, and desiring them to arrange with the superintendent times for taking the waters in accord- ance with the above rules. Of the two most famous alkaline spas, Vichy and Vals, I r the latter, because the water contains such a large pro- portion of Iron (retained in a state of Carbonate by the excess of Carbonic Acid), which assists much in the restoration of strength to the stomach. Moreover, Vals is further off, and in the neighborhood of beautiful and romantic scenery, enough iijtt the patients to a tour, and to help them to shake off the invalidism which associating with sick people at the spa is apt to induce. In reflecting upon the purely medicinal, exclusive of the psychical, benefits conferred by spas, we must remember not to attribute all even of them to the salts contained in the analysis. Water itself is an important constituent of the gastric juice, and an augment to its quantity and power. It is a direct re>t<>rative agent, perhaps the most powerful of all drugs. No minutiae, therefore, of its administration are frivolous, and the following additional hints as to drinking at the spa are not to be consi- ; impertinent. Let the drinker reflect on the physiolo.-- action of temperature on the gastric nerves. Small quantities i coM act as a tonic shower-bath, and remove local coi tion ; but if much is drunk at a time, a great depression of vitality follows. Let therefore the cold doses be small. But !y the same reason warm or tepid springs may be taken in considerable quantities, and a renewal of vitality be expe- rienced. 1 The local application to the epigastrium of variations of tem- :ire is often of use to persons with a diathesis to heartburn, i-led there is no catarrh of the- gastric mucous membrane. It mav be applied by the alternation of a cold and hot douche to pit of the stomach in which case the alternations must be rapid, and the time of application short, say one minute or two 1 I am told by travellers in Central America that the Indian porters preparing for a Ion.;, hard journey will driuk several quarts of quite hot water. They say it gives them strength. 144: ABDOMINAL PAINS. minutes each ; or to the back, in the situation of the dorsal and upper lumbar vertebrae when a very much longer application is desirable, namely, as long as the patient can bear it without losing the consequent reaction. In spite of the thickness of various tissues which lie between the skin of the back and the stomach, the dorsal douche is very efficient. When a regularly built douche bath is not accessible, a hydropult garden machine is a good substitute, or a slab of ice or ether spray may be in- geniously made to take its place. I have been led on by the frequency of heartburn in cases of indigestion to pass from its special treatment into that of the general management of the patient. Perhaps the reader will have said that the last few pages would have been more in place at the end of the second chapter. It will be easy to sup- pose them transferred there if he wishes it. But yet I am not sorry to let it be seen how difficult it is to separate either in fact or fancy the two subjects, and to point out that the cure must not stop short at the arrest of a symptom, but must proceed to the renewal of active life in the organ whose sluggishness and deficient power of resistance to sensation is causing the symptoms. SECTION II. Acidity. What is usually called "acidity" is the ejection from the stomach, with or without heartburn preceding, of a small quan- tity of sour fluid. There is no objection to the name, if it be remembered that it means merely acidity out of place or too Ions continued, and be not allowed to lead to our viewing the o / o normally acid state of the gastric contents as an evil to be com- bated. The fault of doing that has been commented upon in the previous section. It is not rare to find acidity misinterpreted even by those who ought to know better. I have heard it spoken of as an excess, " excess of gastric juice" that is to say, too much of a vital act, too much life. Such a mode of speaking, if it leads to anything, must lead to faulty thinking and bad treatment. Instead of being an excess, acidity itself is a proof of deficiency. ABDOMINAL PAINS. 145 VII. A medical imin complained to me a year or so ago of what he called " over-abundance of gastric juice." " Why do you call it over- abundance of pastrie juice ?" " Oh, because acid rises np in my mouth, and three or four hours after dinner I sometimes throw up my victuals so sour as ko my throat quite sore." ' Well, now," I said, "observe what comes up. look at mie of the pieces of meat in it, and yon will see it hardly altered from tin- conilition in which it was swallowed. But look at what a healthy person throws up when made to vomit, say by sea-sickness, four hou/s after a meal ; it is all homogeneous, and the lumps of meat are quite broken up. If you really secreted an over-abundance of gastric juice, you would have I your meat more quickly, instead of less quickly than the healthy ii." We know by experiments on artificial digestion, that an in- the quantity of the solvent secretion quickens the solution of albumen. "We find, for instance, that the amount of pepsine contained in twenty grains of Boudault's powder will 've a piece of hard-boiled white-of-egg much sooner than five grains. The same thing would of course happen in the stomach : were there more gastric juice, there would be quicker digestion. But in acidity such is notoriously not the case; the aliments lie for a long time in the upper part of the digestive canal, and often are passed still undissolved in the feces. It is a chemical act of decomposition directly opposed to the vital act of digestion. I call a " vital" act any which forms part of the great circle of life, such as is the conversion in the stomach of albumen, previously incapable of solution and absorption, into peptone capable of entering the circulation. Now, when this vital act of conversion is carried on with rapidity by a stomach makinir abundance of gastric juice strong in pepsine, then chemical decomposition i> prevented : nay, it is even arrested after it has commenced, ;ls j,, . n by putrid meat not becoming more but less putrid as it passes through the body of a healthy animal. But when the conversion is slowly or imperfectly rmed, then the chemical change has time to take place, and does so very soon, being favored by the heat, moisture, and ttio matter in a state of change. If the food remain too without becoming chyme, the protein compounds putrefy with extreme rapidity under such circumstan The following simple experiments make the matter verv dear 10 146 ABDOMINAL PAINS. to yourself or a class. As far as his own improvement is con- cerned, the skilled physiologist may skip the next page or two without loss. Compare some hard-boiled white-of-egg which has been im- mersed in saliva at the temperature of 100 Fahr. for a day, with another portion from the same egg kept the same time in distilled water. Your nose warns you of the difference directly ; the first is intolerably fetid, the second quite sweet. Exactly similar is the fate of undigested albuminoid matter, whether animal or vegetable, in contact with the mucous membrane inside the body. But how does that affect the case of acidity ? Try another experiment. Put in one beaker some syrup of grape sugar, and it remains for hours quite neutral and natural. Set to soak in some of the same a piece of putrefying albumen for a few hours, and keep the mixture at the temperature of the body. You find that a piece of litmus paper put in it is strongly reddened, showing the copious formation of lactic acid. In another beaker, the formation of butyric acid from fresh butter by the same means may be shown. Just so all the grape sugar and fat swallowed meeting in the stomach or intestines* with decomposing animal food, collected in a mass or glued to the side by a too sticky mucus, ferments quickly throughout, and forms lactic and butyric acids in great quantity. Eemember, the grape sugar swallowed seems something much more important than merely the gtape sugar put in the mouth. Take some boiled starch, and heat some of it with potassio- tartrate of copper. There is no change in the blue color of the salt. Now put some in the mouth, and hold it a few moments. When it is again heated with potassio-tartrate of copper, the metal is precipitated, and shows by its brilliant yellow color an abundant quantity of sugar. The saliva then begins to convert starch into sugar immedi- ately ; very soon it will transform the whole mass. A mouthful of boiled starch held in the mouth for five minutes will show afterwards scarce a trace of starch remaining. As, even amongst wealthy meat-eating nations, from half to five sixths of the solid ABDOMINAL PAINS. 147 food !' stan-h, 1 it is evident that one of the most bulky contents of the .-tomach must be the sugar which has been n. by the saliva out of amylaceous food. Here, then, is ample material for the formation of lactic acid to almost any amount. Add to this the. oleaginous substances which it is impossible to avoid in any diet, and which from being insoluble in water turn into peculiarly acrid and concentrated acids, and you will have no difficulty in accounting for acidity, without recurring to a theoretical excess of gastric juice. Acidity, then, is an evidence of chemical, and therefore of decreased, vital action a proof of incomplete digestion, of deficient activity, in the stomach. There is nothing in acidity to contra-indicate the employment of acids as remedies. They are often most beneficial, especially if taken shortly before a meal. The best to select are those to which the digestive canal is most used, Hydrochloric or Lactic in plain water. The way in which they act is probably by neu- tralizing the alkline saliva and mucus which the slow digestion allowed to accumulate in the stomach, and so setting at liberty the pepsine ; for in laboratory experiments it is found that saliva arrests the solvent power of pepsine in close proportion to its amount, and that by acidifying the mixture the action may be restored. ther is there anything in the use of acids inconsistent with a contemporaneous course of alkalies, so that, of course, they are not mixed immediately they are swallowed. They mav each act separately with benefit on the mucous membrane and nerves, and then the sooner they neutralize one another into a salt and are got rid of the better. I have indeed heard physiologists deride the idea of taking nie.lieines f'-r ''acidity," as if it implied our ignorance of the omach being normally acid, especially at its most comfortable times. The 1-est answer to them is that we give medicine for acidity of //">////,, which they cannot assert to be normal. It is a superficial answer, but the objection is super- ficial also. Of course in reality a man is not a retort or a tube. the dietaries of soldiers, prisoners, laborers, and others, analyzed hy Dr. in " Die Normal IM.it, " j.. G. Berlin, ! 1-iS ABDOMINAL PAIXS. Some patients will perhaps think that their physician is blowing hot and cold, or rendering inert his own treatment, by ordering acids at one time and alkalies at another ; and he will find it a wise plan to give an educated person a short physio- logical lecture on the subject, explaining the reason of his pro- cedure. He may explain also that the acids given as medicine do something more than in the laboratory; they stimulate the mucous membrane, and so actually increase the quantity of secretion while they intensify its power. There need be no fear, which I have heard some express, that the use of these substitutes for the natural constituents of the gastric juice, or rather the supply of that which ought to exist in the gastric juice, will teach the stomach to be lazy as doing a servant's work for him makes him less equal to doing it himself. On the contrary, the new vigor put into the system by the healthier and more copious chyme that is formed, renders the organ more active; so that it soon is enabled to go on secreting for itself what is wanted, and to do without the artificial substitute. If patients derive benefit from it, they will be able soon to leave it off. There is a singular febrile disease mentioned by M. Chomel in "Les Dyspepsies" as an acute acid dyspepsia, in which the whole body, in point of fact, turns sour. As might be ex- pected, it seems to be invariably and rapidly fatal. I confess I do not recognize it from his description. The case he gives seems more like one of pyaemia than anything else in my expe- rience. But its extreme rarity takes away most of the interest which would attach to it, and its incurability the rest. SECTION III. Waterbrash (or Pyrosis) has so far a similar local pathology with heart- burn, in that the manifestations of the phenomenon is in the oesophagus. There is, however, this difference, that the spasm which there seems to be subjective only, is here exhibited as a muscular contraction. The tube is closed by it, and the pas- sage into the stomach of the saliva trickling downwards is pre- ABDOMINAL PAINS. 149 vented, so that it collects in considerable quantities, and gushes iij> into the mouth without any effort of vomiting. The fluid in its pure state is therefore alkaline, and exhibits under the microscope no other formed contents except the buccal, faucial, ami oesophageal epithelium. In his valuable monograph on the diseases of the stomach Dr. Ilandfield Jones has represented waterbrash as a watery catarrh of the mucous coat of that organ, analogous to bron- chorrhcea, for example. Now, if that were so, it would contain ic and not salivary elements; and it would also be filled with mucous globules, as the flux of nasal or bronchial catarrh is. It would also always be ejected by a distinct effort of vomiting and nausea, which is the case only when the contents of the stomach are mixed with it. The alkaline nature of the fluid of waterbrash, contrasted with the acidity of ordinary regurgitations, has been made by some a groundwork for a primary division of indigestions into aci'l and alkaline. It will be seen by the following pages that I should consider this an arbitrary and artificial division, with- out practical utility or basis in nature. Acid and alkaline ;ions are often found on the same day in the same person; so, if the stomach were a mere alembic, they would cure one another. But it does not answer to treat of a living body, as if it were a chemical laboratory. The following case exhibits the principal features of the dis- : i \ ' 1 1 1.- Margaret S , aged 22, an Irish maid-of-all-work in a small -man's family, stupid, ignorant, and bowed down in spirits, applied for advice at Si. Mary's, April li'.th. lHf>.">, for what she called " sickness at heart" ''in) and vomiting." She had been ill about two months, during which time what she called sickness" had occurred daily. She looked in pain, and prc-.Mire on the pit of the stomach showed it to be tender when < d wiili one finger's point in the canliac region, though the flat palm laid on the spot cau>ed no mie;isine.->. This pain was also increased by eat- ing, especially potatoe-. I. read, and tea. of which her diet chietly consisted. She was admitted as an in-patient, and then we had the opportunity of ob- serving that what she called vomiting had not really that character. She : nctatioiir- two or three hours after meals. Hut this in- eonvi-nience mostly occurred at ni-lit. eea>;ii^ Inwards morning with the deptll of sleep. \\ \\t n .-lie began to move about for the plirpo.-e of ri>ills. r IX Midden L r u.-h of fluid would come into the mouth once and auain. but seldom 150 ABDOMINAL PAINS. or never a third time. There was no retching or effort, and no marked sen- sation of distress or of relief. The quantity was seldom more than five to six ounces. Preserved in a vessel, it was colorless, slightly opalescent, alkaline, and a little adhesive, like thin saliva. Under the microscope it exhibited large pavement epithelium and a few granular globules. Later in her resi- dence in the hospital it was sometimes found less transparent and acid, as if some remaining contents of the stomach were mixed with it. The tongue was red in the centre, with white coated edges ; the catamenia had been irre- gular for some months. She had had a similar illness the previous year, but had recovered by rest and medicine. Both attacks she attributed to hard work and bad food. She was treated with Mustard poultices and Leeches in several relays, at first four being applied, and then three every other evening, for a week or ten days, on the tender spot of the epigastrium, with 15 grains of Bismuth thrice a day for ten days ; then with Iron pills and Shower-baths. Her diet was principally broth, with milk and Lime-water. The Leeches and the Bismuth seemed to relieve the eructations and the pyrosis, but the cardiac pain remained till she got to Shower-baths and Iron. Perhaps the most conspicuous effect was that which is to be credited to the diet, for she gradually gained twenty-one pounds in weight, advancing from 7 st. 11 Ib. to 9 st. 4 Ib. between the 27th of April and the 8th of June, when she left the hospital well. Observe that the loss of blood by leeches did not prevent her gaining blood and flesh by the improvement of her digestive powers. The local benefits to such an important organ as the stomach more than counterbalanced the inevitable abstraction of what, truly enough, she could ill spare. Some may cry out against such treatment as inconsistent. It is feeding up the patient with one hand and robbing him of his pabulum vitae with the other. The reproach is just in a certain sense, but that a very limited one, and it may be levelled against half the operations of daily life. We are con- stantly suffering a small loss for the sake of greater gain " necesse est facere sumptum qui quserit lucrum" And I reckon the absence of a little blood as of no moment at all compared with the advantage of securing freer circulation or diminution of congestion in the alimentary canal. Do not let us be led away by the superficial notion that blood is blood, and blood is life. That is not true, for blood varies immensely in its compo- sition, some being very valuable, and some worthless. To lose' a portion of his imperfect circulating fluid is but little loss to an invalid, and that little loss is amply repaid by the additional ABDOMINAL P A I 151 nutriment which a more rapid blood-stream will enable him to absorb. The deficiency is soon made up under the restorative plan of treatment. \Vhere there is localized pain in one spot of the epigastrium need by pressure at all times, I take the pathological con- dition to be some local change producing at least sanguineous ''stion of the veins, if not tissue-thickening, at that point. :ve the importance in investigating such cases of using the ends of the f nid not the flat palm, otherwise the phe- nomenon may be passed over. It is, perhaps, needful to say th:it the pressure exerted should be steady and moderate. It -v to try on yourself what amount a healthy epigastrium ou -lit to endure. < >1 iser ve the use of Shower-baths. Their effect is first to drive the blood inwards from the skin, then by nervous reaction to draw it out again. Thus mechanically the capillary circulation is quickened and continues quicker vires acquirit enudo. Com- what was said (page 73) about the increase of osmosis through membranes in the direction of increased current. It is remarkable how in waterbrash a separation is effected by the sphincter extremity of the oesophagus between that tube and the stomach, and what a barrier it places between the two. There is no particular evidence of this in waterbrash which occurs when the stomach maybe empty of food, in the night or early morning, as is most usual. But sometimes it comes on at or immediately after meals, and then much surprise is caused to the uninitiated by seeing nothing of that which is swallowed brought up again. CASK CIX. Last Anpnst a retired surgeon, aged 64, consulted me for asthma produced by emphys.-matous lungs. Latterly, also, his digestion had troubled him a L'reat deal; In- had. after exertion, pain at the scrobiculus cor- 'd to in-- more in the stoma-li. lie had also wati-rbra>h occurrinir immediately after, sometimes even during meals. He was obliged to leave the room and throw off several ounces, as much as five or six. of frothy, clear, cold-tasting fluid. Although this sometimes made him retch, yet the contents of the trastric cavity were never mixed with it. I gave him Quinine and Strychnine with apparent advantage. being frothy arose from the nearness of the period of its 152 ABDOMINAL PAINS. secretion. When it has rested in the oesophagus a few hours it becomes quite bubble-less, as in matutinal waterbrash. In the next case a few more details of variety in the symptoms are given, and a pretty good original name for the disease was invented (I believe) by the patient. CASE CX. Mary F , a widow of 60 years of age, had always enjoyed good health, and supported herself comfortably as a market-woman till she "broke her arm in crowding to see her son off in a transport for the Crimean campaign. This was in January, 1855, and she was thus naturally stricken down in body and mind, and was almost starved, eating nothing but ill-cooked vegetables. In May she heard of her son's death, and this was the final blow to her health. The flatulence and pain which she had frequently felt at the pit of the stomach became more constant, and she experienced a sensation of coldness there. She often found her mouth suddenly filled with a "jet" of watery fluid, a symptom which she called " watery mouth." She could swal- low the fluid by a voluntary effort, but the doing so was often followed by retching and actual vomiting of the contents of the stomach, smelling sour and tasting acid, but small in quantity. Often in the downward passage of this or of anything else she felt a resistance as of " a ball in the throat." I The greatest quantity of fluid was brought up on getting up in the morning, when it sometimes amounted to half a pint; but "watery mouth" occurred at all periods of the day, and sometimes immediately after meals. The tongue had a white coat on the edges, and was clean in the centre. The bowels were costive. The urine was slightly acid, of low specific gravity 1.012, 1.011, are the numbers recorded in the case-book of the mixed urines. Her appetite for both food and drink was quite gone, and she felt an especial aversion to animal food. She was admitted to St) Mary's under my care July 6th, and discharged well on August 17th, 1855. She was treated with rest, Bismuth, two pints and a half of milk with a pint of lime-water daily, and a graduated approach to animal food. After eating she was to take flsss of Alistura Ferri Com- pnsita (Pliarm. Lond.). By the 16th of July she proposed to eat a whole instead of a half mutton-chop which had been ordered. On the 20th " no complaint whatever" is the report, but then she had a relapse, and ejected some more fluid, and also some rancid oil. She was then ordered Carbonate of Potash and Infusion of Gentian, on which she improved slower but steadier. Pains in the epigastrium, darting through the chest, are alluded to in my notes, but are not particularly described. It has been mentioned that waterbrash is sometimes called vomiting by the patient "easy vomiting," or "retching of spittle." It is so even when it is evident that the cesophageal ABDOMINAL PAINS. 153 ^e is an obstruction of a permanent character preventing the passage downwards of the saliva. As for instance in the following cases. CXI. Francis P , a laborer, aged 57, was admitted to St. Mary's liter 28th. 1852. Four months previously he first began to experience ;nfort in eating and nausea. Often the first few mouthfuls swallowed would be rejected, after which he would be able to finish his dinner. He com- plained also of pain in the centre of the sternum, running through to the back, which kept him awake of nights. He stated also that he frequently " vomited," but the matter thrown up was found to be rejected with slight, if any, effort, and to consist of clear alkaline fluid, frothy at top. He stayed under my care three months, now better, now worse, sometimes relieved by Bismuth and gaining a few pounds in weight. But the pain -and dyspepsia were not cured, ami were considered, probably correctly, to be due to ulceration of the ceso- phagus. CASE CXIL Mary S , aged 69, was admitted May 25th, 1855, for diffi- culty of swallowing solids. The dysphagia seemed dependent on two obstruc- tions, one felt at the top of the sternum and the other at the tip of the ensi- form cartilage. She complained also of " vomiting," but what she threw up was found to consist of diluted milk in an alkaline condition, thai is, diluted with an alkaline fluid, and evidently recently swallowed, or else of saliva. Yet she called it vomiting, and certainly seemed to retch with it. It was never more in quantity than five ounces. Several remedies were tried without and she left on June 8th, discontented at not receiving an immediate cure. The association of an irritability of diaphragm, exhibited in vomiting, with an irritability 1 of oesophagus, exhibited in the spasm of waterbraah, is again shown in the following case. 1 ' \ 1 1 1.- Mary Ann F , a carpenter's wife, aged 52, was admitted to iry's August 4th. lsf>l. She had been in the habit for some time of taking her meals very hurriedly, but previous to that she seemed to have suf- fered from various forms of dyspepsia, originally due probably to wearing tiirht stays as a girl, for her chest is very much contracted by that compres- sion. The last live weeks she had found pain, followed by vomiting, come on about an hour to an hour and a half after taking food. The vomiting relieved her. Imt if it did not oeeiir. .-he had for tin- rest of the day u painful feeling of weight at the epigastrium. At various times of the day also, unless relieved by vomiting, she found clear water rise into her mouth, which was usually >ss, but sometimes had a bitter flavor. From the frequency of the vomit- ing she had become much emaciated. The catamenia had ceased naturally - before. 1 I use the word, not as explaining anything, but simply to fix the locality of the vital act. 154 ABDOMINAL PAIXS. The rest of the hospital and well-prepared food stopped the sickness, so that we saw nothing of it for some time ; but she hud several attacks of water- brash of clear alkaline fluid. Afterwards the vomiting returned, and some- times was mixed with the pyrotic fluid, and sometimes contained strings of gastric mucus. She was treated at first with this pill R. Pil. Rhsei comp. gr. v, Argenti Nitratis gr. . Omni nocte et mane. But in a fortnight she felt very little better. She then took R. Ferri Sesquioxidi gr. x, Bismuth! Trisnitratis 9j, ter die. On this she got well and left the ward on September 4th. In the last three cases it will be observed that a great part of the motive cause of the illness may be fairly assigned to the innutritious nature of the patient's diet. Its innutritiousness arises principally from its insolubility, and that insolubility principally from bad cookery. But yet this cause was not suffi- cient to produce disease in a healthy body ; there was alwavs superadded some depressing influence on the vitality, of either a mental or physical nature. This is to be noticed even in the waterbrash of the Scotch oatmeal-eaters, where the dietetic cause is so constantly the same, and so powerful as to establish the disease as an endemic. Dr. Morgan, of Manchester, who formerly practised for a short time extensively in the Western Highlands and Islands, in a letter to me on the subject, says " Cases were so similar in their leading characteristics that after seeing some three or four all others were but a simple repetition of symptoms. The history of a typical case was something of this kind. From some cause or other the vitality of the system in an oatmeal-eater ivas lowered. Thereupon the customary diet, whether in the form of cake or porridge, proved a source of irritation ; the patient then lost flesh, and complained of a sense of burn- ing heat in the epigastrium and along the course of the oesophagus. Coin- cidently with these symptoms considerable quantities of water (a pint or more) " came up" rather than were vomited. . . . Women seem to suffer to a much greater extent than men." I believe the same is the case still more strongly with the potato-nourished peasantry of Ireland, whose more sensitive nervous system renders depressants of the vitality more com- mon. But I have no written records of the fact. ABDOMINAL PAINS. 155 I>r. Morgan goes on to attribute the innutritiousness of the diet to the form of preparation : I always considered that the eating oatmeal in a semi-cooked state had much to do with it. As it rule, the people do not sufficiently boil the porridge, while in the form of oat-cake the food was still less thoroughly pre- pared. In usiiiL r an oat-meal diet 1 believe that it is very important to carry tin- cixikinir sufficiently far to lilienite the contents of thp starch-granules. "Where this i< not done, not only does the food fail to nourish, but it proves ric irritation. . . . If oat-meal is boiled for about half an hour it i. even though coarsely ground, reduced to a gelatinous mass, and in this fonn it is comparatively innocuous so far as existing pyrosis is concerned at lea>t such is my experience." Seeing the importance of cookery, the occupation of the next at ought to have preserved her at least from the results of bad ait. But the occupation may be baneful, as well as its products. < ' V-K ('XIV. Elizabeth P , a cook, aged 26, came under my care at St. Mary's July 30th, 1852, for pain in the epigastrium, increased after meals and by pr> -lie had also frequent attacks of morning waterbrash. Her tc.ni.Mie was white, but otherwise she seemed in good health; the catamenia and the evacuation of the bowels were regular. She was blistered on the scritliieulus cordis, and took fifteen grains of Bismuth three times a day and 1'i-oth diet. On the Tth of August she was well enough to eat a mutton-chop. On the Hth the Bismuth was left off. as the local symptoms were relieved; and on the Isth. there being no return of waterbrash, she was discharged. The exposure to heat involved in the occupation of cook pro- duces general congestion of the portal system, and an after- >sure to cold draughts inclines to a catarrhal condition of -tomach. Hence arise slow digestion, oppression at the epigastrium, and a feeling of faintness, which often leads to dram-drinking. A further stage, more certain if this desire for alcohol be indulged, is pain immediately after food, and then pain on ] Observe tin' use of external local treatment. That was :t-d to in tin- ea>! of Klixabrth 1* because there was pain on pressure as well as after nn-als. The pain on pressure is an evidence, though not truly an absolute proof, of the existence of anatomical lesion, cither continuous congestion or thickening or uleeration. And 1 find that where it exists local blistering does good, and leeching more good. Kveu when it is not made 156 ABDOMINAL PAINS. out in a clearly defined spot, I am still inclined to suspect in waterbrash such a condition of tissue as is capable of being renewed to a more normal one by the alterative action of counter-irritants. For so many cases occur, like those which follow, where waterbrash is associated with indubitable signs of local lesion. In this, for instance, there was not only the peculiarity of the pain running backwards to the spine, but also a blood-stain in the mucus to show a solution of continuity in the capillary bloodvessels. CASE CXV. John N , a painter, but without any signs of lead poison exhibited in the gums, aged 35, was admitted to St. Mary's April 10th, 1855, suffering from waterbrash, sometimes of a sour character, and sometimes alternating with vomiting of intensely sour greenish liquid. After he had been in the ward a few days it was observed that the vomit contained tawny mucus like that expectorated in pneumonia, and sometimes streaks of blood. He had also pain running backwards from the pit of the stomach to a spot between the shoulders, which pain was increased by pressure of the finger on the cardiac region. When he was at his worst the waterbrash was least marked, but still it was a feature of the disease. Pepsine gave no relief. Hyposulphite of Soda was tried without benefit. A blister to the epigas- trium made him better for a couple of days after it, but he then relapsed. Most advantage seemed gained by the application of a few Leeches to the epigastrium. He became an out-patient on May 13th. In the next the blood evidently came from an ulcer. CASE CXVI. Sarah G , aged 33, a housemaid, was admitted at St. Mary's, under my care, August 22d, 1857. She had been an out-patient with un- accountable languor and anaemia, which was at last detected to arise from loss of blood by the alimentary canal. After admission it was found she had also waterbrash, and pain on pressure of the pyloric region. And then the locality of the injury in the stomach was fixed by her vomiting blood, both red and brown. The hemorrhage was stayed by means of Acetate of Lead and Opium, and then the waterbrash seems to have got worse. It was con- siderably relieved by iced milk and by Bismuth, but more by a blister. A grain and a half of Sulphate of Copper daily, which was given for a fortnight, seemed to act as a tonic and enable her to digest better, quicker, and with less pain. She was still taking it when she was made an out-patient October 16th. It does not appear that the fluid ejected by the brash was ever bloody, thus showing that it does not come from the stomach, as sometimes represented, but from the oesophagus. ABDOMIXAL PAIN'S. . 157 11 : tried Sulphate of Copper in simple waterbrash without ha-:: >eneticial action in this case would i to offer an encouragement for doing so. In tlu- history of John N (CASE CXV) it is mentioned that painter. Though no blue lime in the gums denoted nee of lead in the body, I am not sure that we can quit i- acquit that subtle poison of causing the disease. In the following instance the accusation was brought by the patient. V 1 1 . M r. Kd win S , aged 30, a master painter and glazier, came July Ttli. 1 -;_'. He suffered from excessive waterbrash, bringing up -.mi's upwards of two pints of clear fluid in the course of the night and early morning. Sometimes this was relieved by vomiting. The matters vomited .it-id and frothy, and continued to ferment and swell after being brought up. 1 had no opportunity of searching them for s/ riculi. He had also often heartburn about two hours after eating. His tongue was unnatu- rally red und clean. Tin-si- i-viN. lie said, were always much aggravated by anxiety in business, and it w;is for such aggravation that he consulted me. But he had suffered in the stomach more or less from boyhood, when he used to work with lead paint. 1 irave him half a drachm of Hyposulphite of Soda daily, and fifteen grains of Uismiith every night. In a few days with the medicine and rest he was better, and I prescribed some Iron next with Bismuth. I had no opportunity of seeing more of the case, as his family doctor did not send him again to me. The Hyposulphite of Soda was administered as an agent to prevent fermentation. I cannot say whether it was effectual or' not in this case, as the patient did not vomit afterwards; but I have thought in others that it seemed to effect its intended pur- pose. That purpose, however, must be well understood to be a limited one, for it does not cure the cause of the fermenta- tion, namely, the slowness of digestion which retains the con- of the stomach so long as to ferment and communicate their fermentation to new arrivals. This cure must be efiV l>v invigorating the vital energy of the failing organ. The violent shock to the vitality of the mucous membrane-; in cholera will somet: iiind it a condition of stomach productive of waterlirash. ' > \ VII I.- .Jo-t'j.h W . a laborer, utr'-d !-. admitted to St. Man's October 'JTth. 1. -.VI. had gone through an attack of choleraic diarrhu .1 .11 158 . ABDOMINAL PAINS. August, and since that time had not digested his food properly. The epi- gastrium was tumid and tympanitic on percussion. The tongue was large, flabby, and red, as if flayed. For the last three weeks previous to admission he had suffered from attacks of waterbrash. He was treated with gr. xv of Bismuth three times a day, but was not considered ill enough to remain as an in-patient beyond November 1st, so that I probably saw him only once. An operating cause of similar nature in dysentery. CASE CXIX. Mr. Henry M , a man of middle age, had several attacks of dysentery in Australia, and has never been quite strong since. He suffers from diarrhoea from the slightest error in diet. It was one of those attacks, brought on by taking a cup of bad coffee at a coffee-shop, that induced him to consult me. I gave him Sulphate of Copper and also Bismuth, which both he said had done him good before. On inquiry I found that he very fre- quently suffered from waterbrash in the morning and during the night, though very careful of his diet. He traced this to the dysentery, and both to spirit- drinking, which he felt sure predisposed people to dysentery in Australia. It is also sometimes associated with phthisis pulmonalis, and then the defective nutrition which it implies brings on a con- dition of general degeneration. This is important from the possibility which exists of staying the degenerative tendency, and so arresting the downward course of the phthisis by atten- tion to the stomach and oesophagus. CASE CXX. William J , aged 21, a carpenter, on admission to St. Mary's, August 21st, 1857, was much emaciated, and presented indubitable signs of solid tubercle in the upper lobes of both lungs, of such duration as to have made the upper ribs flat and immovable. The date of his consumption, from the period of his having " caught cold" and spat blood, was two years. Latterly he had suffered from waterbrash of a morning. It was difficult to make out whether he had pain in the epigastrium, as there was stitch in both sides of the waist, which had its origin in the pulmonary disorganiza- tion. After a few days' Cod-liver oil and Iron the albumen disappeared from the urine, and then the patient began to gain weight. Between the 28th of Au- gust and September the 5th he increased 2 lb., and by the 12th 1 Ib. more. The extent of further increase is not noted, but he was bettered enough to leave the hospital on October 3d. The disappearance of the albumen from the urine shows that the derangement of the kidneys was only temporary. But in pulmonary consumption we find such temporary derangements soon end in permanent disorganization, if allowed to become ingrained. ABDOMINAL PAIXS. 159 It may he observed that in several previously quoted exam- the supervention of waterbrash has been at the period of the normal cessation of the catamenia. It is also apt to follow upon such states of body as cause the arrest of the periodical nation in younger women. In the following case there was also joined an occupation which, as we have seen, tends to produce derangements of the upper organs of digestion. XI. Kllen R , a cook, aged 82, admitted to St. Mary's Novem- ber 4th, l>.'ii'i. had been -retimi: ill frradually Tor some months, at first suffer- ing from feverishness. headache, and constipation, then finding her monthly I, though --In 1 >till had leucorrhoea and pain in the back at the time when they oiiL'ht to appear. The. last-arrived symptoms were a drib- bling of saliva from the mouth, and on rising in the morning a gush of clear watery fluid from the oesophagus. This fluid was sometimes made acid by the admixture with it of some of the contents of the stomach ejected by vomit- ing. She once also, while in hospital, threw up some greenish fluid (? altered blood). Hie was treated with Bismuth and ultimately discharged well. Green vomit may arise from the admixture of bile which has regurgitated through the pylorus. This only happens after violent retching and straining, and the bile may be recognized 1 1\ its bitter taste. It may also arise from the admixture of blood altered by the gastric juice like the porraceous stools of dysen- . and in such case there is likely to be very little straining and no bitter taste. The notes are not full enough to decide of which nature Ellen R 's vomiting was, probably the latter, as bilious vomit is rarely joined to waterbrash. Indeed, bile is seldom thrown up in chronic diseases, and appears rather a guarantee of a considerable amount of health. In nearly all the cases I have quoted waterbrash has occurred in young or middle-aged persons. And perhaps this fairly represents the habits of the disease. Yet it is not unknown in the old, as the following instances will show, an occasional attacks i.f vomitiiiir. 1 1 I almut 70. He i;t well on Hismuth. I saw him again in lt51, for some jaiu in the pyloric region of the stomach 160 ABDOMINAL PAIXS. without waterbrash. However, there was no cancer, for I recollect seeing him several years afterwards in the streets at the time of the cattle-show. CASE CXXI1L Mrs. B , aged 66, was under my care in July, 1861, for waterbrash. accompanying indigestion brought on by anxiety of mind in nurs- ing a consumptive son-in-law. CASE CXXIV. Mrs. A , aged 60 (but older than her age reckoned by annual revolutions of the sun, for the catamenia had ceased eighteen years), consulted me in August, 1863, for indigestion, marked by waterbrash occur- ring at various times of the day, not confined to the morning. CASE CXXV. Mr. Thomas S , aged 72, was sent to me by Dr. Ellison, of Windsor, January 26th, 1867, respecting severe pyrosis which had on the present occasion afflicted him upwards of six weeks. It occurred daily, and was getting worse ; he had several times brought up as much as two and a half pints in twenty-four hours. The sensation was described as of something working in the right side of the epigastrium, and then there was suddenly and forcibly ejected a great jet of liquid. It was almost always quite clear and tasteless, and resembling saliva in appearance. There was often pain at the cardiac extremity of the stomach half an hour before the supervention of the brash, by which it is alleviated. Mr. S. was a robust man of rubicund healthy appearance, but he said he had been subject for more than a quarter of a century to this waterbrash from time to time; never, however, so bad as during December and the Janu- ary when he came under my care. I desired him to come again on the 30th, and to bring with him some of the pyrotic fluid collected. In the mean time I prescribed R. Quiniae Sulphatis gr. iss, Strychnia? Hydrochloratis gr. 5 \j, Succi Limonum q. s. ad ilia solvenda, Aqua ad fl^viiss, Sps. Bosmarini fl^ss, ter die sumendus. On the appointed day he returned, but without the expected morbid speci- men. During the first thirty-six hours he brougMTup a good deal, and he thought there would be time enough to collect it afterwards. But after the fifth dose of the medicine a great explosion of flatus occurred, and continued for several hours. Since then his disease had quite disappeared. I hear to-day (April 3d) from his son-in-law that MrisS has continued quite well. He has continued taking the medicine irregularly from time to time since I saw him. So I say I think he has had quite enough of it. The following case, on the other hand, is exceptional from the youth of the patient. CXXVI. Miss S , aged 15, an undergrown girl, was in my hands in July, 1858, for waterbrash accompanied by a feeling of oppression at the ABDOMINAL PAINS. 161 -'riiim occurring when the stomach was empty, and relieved 1y meals. Sh>- was weakly, and retained the insignia of former ill-health in the shape of scrofulous scars in the neck. In this last example mention is made of the relief which some us aftected by waterbrash experience on taking food. Tliis so frequently occurs in heartburn, and so rarely in ulcera- tion, that I am disposed to view it as an evidence that the -h does not, where it is found, depend on any serious anatomical alteration of tissue. I have never seen it amount to "bulimia." The patients went to eat often, but they are not often hungry, and they do nut want to eat much. I cannot recognize the truth of the ' it-lit made by some writers, that indigestion leads to buli- mia, as I understand the term. It is a relief which may be prudently allowed to them, so that care be taken that what is eaten be easily digestible. Indeed, a judicious management may turn it to a means of cure by preventing the overloading of the stomach by "spoiling the meals," as it is technically called. The treatment of waterbrash has been almost sufficiently de- tailed in the histories given. It consists of sedative alkalies, and the best are those which lie longest undissolved, such as Nitrate of Bismuth. I give this in doses of from ten grains to half a drachm, either alone in a powder, or in a draught with Carbonate of Soda and Hydrocyanic Acid. The Soda I give where there is much acid rising, the Hydrocyanic Acid where there is local pain on' swallowing or on pressure. In the robust ancient described in Case CX XV it will be seen that Quinine and Strychnine um-xpeetedly alone effected a cure. They should tin-ret'ore not be omitted as part of the treatment at le. Iron is useful in ana-mi.- The red rust goes very \ in a powder with the Bismuth, and may perhaps render anv other tonic superfluous. KinO And Opium powder is also a good astringent to the upper part of the prima 1 hardens the over-sensitive ner\ 11 162 ABDOMINAL PAINS. the oesophagus, but I cannot lay hand on any cases in which I have used it alone. The local application of Leeches and Blisters must depend on our diagnosis. They are of use in those numerous instances where there is pain on pressure elicited by the finger rather than the palm of the hand not otherwise, I think. The water-cure by compresses usually does harm; it renders the part more sensitive, and the local application of cold is too depressing. In food all insoluble matters (such as those consisting chiefly of cellulose, chlorophyll, and raw starch), waxy potatoes, peas and beans, cucumbers, sodden pastry, new bread, half-cooked porridge (according to Dr. Morgan in the letter quoted page 155), and the like, must be avoided. Fresh meat- broth, beef- tea, milk guarded with lime-water, must be the food trusted to. I have found raw oysters well borne ; but they must be quite fresh and well chewed. SECTION IV. Spasms, or " The Spasms," or "Stomach-ache," as sometimes called, is a peculiar pain, resembling that felt in cramp of the voluntary muscles, extending across the epigastrium. It remits from time to time, but does not intermit like heartburn. Though the pain resembles that of cramp, there is no evidence of any muscular contraction ; indeed, examination of the epigastrium shows the stomach distended with a more than ordinary amount of solid matter and air. This pain arises in a stomach rendered atonic, either temporarily by some depressing agent, such as heat or fatigue, or more permanently by general debility, when the organ is filled with some insoluble matters. It is a con- dition analogous to the over-distension of the bladder with retained urine, in which the pain has a similar remittent character. It usually commences from five to six hours after the food which has produced it, becomes gradually more intense, and passes oft' either by the insoluble mass getting through the pylorus or by vomiting. The seat of the pain is not easy to fix when it is severe. In the lighter cases, and as it passes away, it seems to tend towards ABDOMINAL PAINS. 163 tlic ].yl<>ri.- s|hinri.>r. and to become located there. The very 'ilar nature of that part may serve to explain the tendency of this, more than any other gastric pain, to be associated with \B of voluntary muscles. Other characteristics will be sketched in the cases which follow. i XXVII. In the summer of 1842 the writer started, without his breakfast, curly in a row boat from the top of the Lago di Como. He was out in the sun without food till noon, when he bought his hatful of hard :,es and littlf green figs, and finished them at a sitting. In the afternoon ]i:tiu across the epigu.-triurn gradually came on, but still he ate his dinner. That seemed to ea>c the pain for a time, but it came on again worse and in paroxysms, just like cramp. He travelled on in an open carriage from Coino to Milan, but the pain was very bad. On the road he vomited, not his dinner, but the skins of the figs and the peaches in the state in which they were swallowed. After arriving at Milan at midnight he vomited again, this time the dinner eaten in the afternoon. The masses of food had therefore got reversed in their position in the stomach. Soon after the second vomiting the spasmodic pains abated and ceased with sleep. \ V 1 1 1. The same party in the following year lunched on a dozen or so of pears at l.eipsic after a hot dusty journey from Dresden. Again the pain was relieved by dinner, but returned afterwards. An emetic of mustard- and-wuter gave relief rather sooner than waiting for the spontaneous evacua- tion of the stomach. CASK ( X X 1 X. The same party, when not in very strong health this spring, committed the imprudence of seeing a troublesome patient before breakfast. At noon pain in the epigastrium came on, was relieved by a mutton-chop at lunch, returned worse an hour afterwards. In the evening vomiting was in- duced, and the first things that came up were the toast and water-cress eaten at break fa.-t. With >li-ep the attack passed off, but the epigastrium still remained abnormally tumid and resonant on percussion. I promised in a former chapter (page 97) to introduce another case in which gluttony was an act of virtue, if not of heroism it i.s. CASK ('XXX. Mrs. D , aged 50, sent for me one afternoon this spring of '(i .-re I), r a few iii.l.-s down the rouiitry. 1 found her .-lowly Meot from an attack of "spasms of the . li--t ' M-pi-. r a>triuin), which had la.-ted twenty-tour hours. leawni: the epiira-trium tumid and druinmy on pen i, Slie had pas.-ed one small liht-mlored pultaceous stool, so I gave h r a Hhuburb and Peppermint draught to elicit another or two. I directed my principal attention to discover the exciting cause of the stomach-ai-lie. and believed that 1 riirhtly fixed on a lar^e cold curly dinner, 164: ABDOMINAL PAIXS. accompanied by a quantity of salad and cucumber. I gave a warning against tfyis, and then went to the village hard by to see an old patient, a poor cousin of the one who had summoned me, making my visit to the wealthy relative an excuse for not taking a fee. A short time afterwards I received a second summons; found Mrs. D had another attack of spasms, had vomited, and was better. But what was my surprise to see in the basin a large quantity of cucumber, against which I had given such a strong warning. I found reason for believing that this apparent act of gluttony was committed as an excuse for getting me to see the less fortunate neighbor again. The vomiting made the attack pass over quicker than the former one, and no purgative was required. The contents of the basin were very slightly acid. Mark the last sentence it is clearly not acid, but distension, that causes these pains. The preceding cases have exhibited spasms arising after a heavy meal of insoluble matters taken at an unnatural hour. When the atony or paralysis is induced by dinner, then the attack assumes a different and to the patient a more alarming character. He is woke up by it in the early morning, and I think it is usually more sharp and severe. CASE CXXXI. E. N. S , an energetic but not strong business-man of middle age, has had several of these morning attacks, which he can always trace to a dinner of insoluble matters after an anxious day's work. He is always a good deal alarmed at the time, but they pass off in the course of the forenoon, either by vomiting or pultaceous stools. The matters vomited I have never seen, but he says they retain the taste of food, and are not acid or fermenting. In whatever parts it may occur, atony, or defect of voluntary and normal action, has a tendency to alternate with involuntary and abnormal action. It is when the legs are tired with over- walking that they are apt to be racked with cramp ; it is when the whole body is debilitated and incapable of designed control that it is agitated by chorea. The atony of purely involuntary parts most generally pro- duces these contractions, not in themselves, but in the neigh- boring systems of muscles, subservient in most cases to the concatenated acts of the said involuntary parts. Thus, over- distension of the bladder causes stricture in the urethra ; over- hard and bulky feces bind up the sphincter ani. I have already pointed out how chronic slowness of gastric ABDOMINAL PAIX3. 165 digestion first is evidenced by heartburn, which appears to be relaxation, and then by waterbrash, dependent on contraction of the oesophagus. Ju.st so acute atony of the stomach, or stomach-ache, will sometimes produce cramps of the abdominal parietes, even while it is it.-elf distended and palsied. CASK < 'XX XII. At the end of last June I was requested by Mr. Paget a young man of nineteen, reported to have cholera. The history I found to be this. He had been working hard at inorganic chemistry, to pre- pare fur :ni examination, torturing the metals and himself with repeated tests, in it shrinking from exposure to Sulphuretted Hydrogen, and, what was still worse, not carinir if tin- laboratory stank of Arsenic. Then came the exami- :i. The evening before it he came home tired and anxious, but ate a good dinner, probably with the false appetite of intellectual toil. He went !> li.-il and to sleep, but was awoke before sunrise by a spasmodic pain in the epigastrium, not increased but rather lightened by pressure. As this got lie tried to ease it by forcing an action of the bowels, but his su brought no relief to the pain. Breakfast made him somewhat better, and he went to the laboratory. But by eleven o'clock he got so bad that he was home and went to bed. In the afternoon cramps came on in the abdo- minal parietes, and could be alleviated only by the constant rubbing^of two sturdy housemaids. These cramps extended from time to time into the legs and arms. The epigastrium was tumid and drummy on percussion. His face was shrunken, pale, and livid, the eyes leaden and anxious, the pulse small and extraordinarily quick (nearly 140 in a minute), the skin cold and clammy. Indeed, I did not wonder at the household calling it cholera. But I was comforted by finding no vomiting or diarrhoea, and by seeing a fair quantity of full-colored urine in the chamber utensil. Towards sundown the pain gradually abated ; he had a pultaceous stool, went to sleep, and when I saw him again the next morning was well, though he said his belly was very sore after the cramps. The pulse had sank to 80. These cramps have, I suppose, the same pathology as those \vhieh so general I v accompany the collapse of cholera. In that disease they art; ilt-veloped in e"ii--.|iience of the whole alimen- ' anal, but more especially the ilia, being devitalised and paralyzed ly an extraneous poison ; whereas here the stretch in g of the stomach by the overpowering weight of a mass, which it cannot move on, is the paralyzing agency. In the ease eit.- with the illness, but their sp >nous actions were not in any way manil'este'l in the >ymp- toma. 166 ABDOMINAL PAINS. Spasmodic pain will sometimes in weakly and elderly persons be a consequence or an accompaniment of flatulence. At least the pain resembles spasmodic pain, and moves about from one part of the abdomen to another, not being usually fixed in the stomach like that described above. It may be easily relieved by a diffusible treatment at the moment, but care must be taken lest a habit of dram-drinking be thus encouraged, for in good truth it is often among those who are too much inclined that way that periodical spasms occur. I therefore prefer to order an officinal draught to the vague recommendation of a glass of spirits when they feel bad, as medical men often do. The strengthening of the stomach by nerve-tonics is the best cure. CASE CXXXIII. An old man-of-war's-man, turned wine merchant, was sent to me by Mr. Way, of Portsea, Feb. 20, 1867, on account of spasmodic pains, which occurred from time to time in the epigastrium. There was no pain to be produced by pressure on the affected part, and indeed, " when the spasms are on," pressure palliates them, he said, and he lies with his stomach firmly driven against the edge of a table or chair with considerable relief for a long time together. They always pass away with a great explosion of wind. Bad attacks of these spasms came on about once a week, but he had often slighter paroxysms at night between times. He had fallen away in flesh a good deal, and the lips had grown paler, and the cheeks patchy in color; his tongue was pale, wet, and smooth ; his bowels were open daily ; the urine was pale, acid, of the specific gravity 1.015, not albuminous. His habits hare been usually active, as he is fond of shooting and sea- fishing, and has opportunities of indulging his tastes. His worst habit seems to be that of occasional schnaps of spirits in the evening, but he cannot be called an intemperate man. He was ordered two grains of Quinine and 2 ' s of a grain of Strychnine dis- solved in lemon juice twice a day, and told to eat as much flesh meat as he could find an appetite for, and to abstain from spirituous liquors. I also told his wife to have ready for him in case of an attack of spasms as much Bicarbonate of Soda as will lie on a florin, the same quantity of Mag- nesia, a teaspoonful of Sal Volatile, and ten drops of Laudanum. A close resemblance to the pain above described is sometimes found as a manifestation of malarious poison. These cases may usually be distinguished by the entire absence of all other gastric derangement, or the indication of any such derangement in the general health, by the intermission of the pain and its entir'e absence during the intervals, or by the previous presence of other proofs of ague poison. The following is an example: r- ABDOMINAL PAINS. 167 I \\IV.-In Nov.-ml.rr. 1*:7, I was consulted by Mr. J. W. W , a young-looking man of 40. concerning the occurrence at intervals, sometime* regular ami sometimes irreirular, of a violent "spasmodic pain," as he called it. in the epigastrium. Its usual time of invasion was between three and four o'< l"ck in the morning, after goinj; to bed in perfect health. It would last an hour or two. and then cease with the eruption of considerable sweating. It was worse towards the right side of the epigastrium. His tongue was clean, and he had habitually two natural solid stools a day. He had never had ague, but his house was buried in tall trees in a damp valley in the west of Shrop- shire, and even he allowed it to he ill-drained. One of his children had died of low fever. He had just had a more than ordinary severe attack of spa-ins during a night journey by rail. His aspect, however, was that of perfect health, and there was not a trace of tenderness in the abdomen. I desired him to take two grains of Quinine in a little whiskey twice a day for three weeks at once, and in future to take the same course for a week whenever he returned home from a temporary absence. Karly in 1858 he came to report that the treatment was completely success- ful, though he had in the meanwhile broken an arm; and later in the year I had a message to the same effect It is characteristic of this neuralgic pain that it is not de- veloped by external pressure or by food, and that there is no tenderness of the epigastrium. By this it is distinguished from a kind of spasmodic pain by which the wearing pain of ulcer is sometimes diversified. I would always give the Quinine without acid in these cases, for it is wanted to act directly on the nerves of .the alimentary canal. SECTION V. Gripes. Sometimes, instead of the pain caused by food remaining in the t.-pi^astrium, or extending upwards towards the fauces, it nds to the lower bowels and is felt as a twisting sensation about the umbilical and hypoirastric regions. This is usually followed and ended by the passage of one or two light, loose, i frothy stools, in which may be not seldom detected articles of diet swallowed scarce half an hour before. Patients do not call this "diarrhosa," for it is excited only by lood, and MM68 inini.-diat-l y with the evacuation. '! usually describe it Bi -.'' One gentleman, who had 168 ABDOMINAL PAIXS. been reading the ancients, denominated it " lientery," and I dare say it is what our forefathers in art meant by that word. It will be seen by the cases used for illustration that it is usually dependent upon some morbid condition of the lower bowels, either the last part of the ilium or the colon. Why a lesion in that situation should cause the contents of the stomach to pass through the pylorus too rapidly, when lesions of the stomach itself, duodenum, liver or jejunum, do not do so, though much nearer, is not explained. The following example presents that which is the most un- fortunately common shape in which this ailment is found : CASE CXXXV. On September 29th, 1857, I was consulted about a lady, aged 45, who complained that immediately after taking food a pain came on in the centre of the epigastrium, which gradually proceeded downwards with a twisting wavy movement, till within half an hour it ended in a motion of the consistence of pea-soup, which varied in appearance according to the nature of the food it followed, and often smelt of that food in case of its hav- ing any characteristic odor. There was no pain on pressure at the epigastrium, but in the right iliac fossa there was. Ulceration probably existed in that locality; and the scars of juvenile abscesses in the throat, together with con- solidation of the two apices of the lungs, made almost certain the conclusion that they were of a tuberculous character. Sulphate of Copper, Morphia, Logwood, and Bismuth, were tried in succession, with only the merest tem- porary advantage. . She soon afterwards died. In mentioning this fatal termination of tubercular ulceration of the digestive canal, I do not mean to imply that such is the necessary history of every case. CASE XLII is an instance to the contrary; but I do not find any mention there of the griping and emptying of the stomach immediately after the meals, as in Mrs. B . And this I have generally found an omen of very bad import. In point of fact, it is not so much the diarrhoea as the effect of that diarrhoea upon the upper part of the digestive canal, especially upon the stomach, which proves so deadly. CASE XLII shows that it is very wrong, when tubercular disease of the lung exists, to despair of effecting a cure of the diarrhoea existing alone ; but I must say I have never come across a case of a favorable termination in consumptive cases where the upper regions of the primae vise were affected by it. ABDOMINAL PAIXS. However, in non-consumptive cases much more may be done in spite of the gastric complication. OAOI TXXXVI. - In September, is:.*, \V. .7 pnt himself under my care. His age was f)0. He had lived an active business life without any severe ill- ness. But for the last three years or more he had become affected on the slightest provocation with looseness of bowels. This had gradually become constant, a pain coming in the epigastrium immediately after food and ending in a motion. Examination of the chest detected no lesion of the lungs. I managed to check this with small doses of Castor-oil and Opium, and extract of Hajmatoxylum. But it recurred again in December, and then I found there was pus and streaks of red blood in the stools, and gave him Sulphate >f Topper. This was soon effectual. In February, 1861, it again returned gradually, and I give him Bismuth for a month, but it did not stay the symp- toms, and we were obliged to have recourse to his old friend Sulphate of Copper, which set him up again. In 18(3 he came to consult me about a couuh. but made no further complaint of loose bowels or epigastric griping. The streaks of red blood in the stools render it most probable that the lesion was in the colon, and the absence of any com- plaint of pain in the ilio-caecal region confirms the diagnosis. I am convinced Sulphate of Copper is the most effectual remedy in these cases. Next to it comes Ilcematoxylum, and next Opium. So far as immediate effects are concerned, perhaps Opium should rank higher, but the good it does is by no means permanent. By beginning with {-grain doses, Sulphate of Copper may be carried to two grains with safety. The annexed case gives a detailed history of the origin of the ili>-;ise in non-tubercular persons. CUa T X X X VII. J. B. C , 17 years of age, had a severe acute diarrhoea, brouirht on by the eflluvium from an offensive drain in the house where he was at school. This was in 1858. From that time he became subject to fre- quent attacks of diarrhcra, brought on by very slight causes, and especially in . I uiie. iM'il. had one when at college, which was dysenteric, that is, accom- panied by sanguineous stools. After this his meals brought on pain in the !rium, which was followed almost always by a thick pulpy motion, in which he had looked for blood, but never saw any. In the long vacation In- vent to an hydropathic establishment, where he said he got worse and \v.is halt' starved. Whether in consequence of that or the disease, he was very much reduced, perspiring at ni:,'ht and emaciating rapidly, and so weak that I \v. nt to visit him at his lodirinirs several time-. He had never sum-red from i-ouirh. and was quite sure that there was no hereditary tendency to consumption in his family. 170 ABDOMINAL PAIXS. When I first saw him in November of the same year I put him on Haema- toxylum for five days. It was of no use. I then prescribed R. Cupri Sulphatis, gr. ; Pulv. Ipecacuanhas co., gr. ij. In pilula ter die. The employment of this for six days removed the pain in the stomach, and reduced the motions to one after breakfast and one at night, of a solid con- sistence and greenish brown-color. He then resumed the Haematoxylum, which proved sufficient to restore his appetite and strength. C continued quite well and went into the army. In 1863, after a long review day at Aldershot, topped up by drinking a quantity of Moselle cup. he got an attack of diarrhoea, and, fearful of a relapse of his old complaint, he came up to see me in London. But it was easily stayed with a little Chalk Mixture and rest. He called at my house in 1864, when I was ill in bed. to leave a card and say he had got a promotion, so that there is no reason to believe he has con- tinued anything bat well. It is surprising that a state of bowel which has been so long coming on should be so readily and quickly cured. Such cases as these are very wholesome to the mind, strengthening it in faith that efficient treatment is discoverable, if we will only take the trouble to look for it. Eemark the extreme state of weakness indicated by night sweats and emaciation. A mere looseness of bowel would not induce that, but only a looseness which secondarily affects the stomach. The relaxation of the bowels is not always so immediate in time. Take the following instance. CASE CXXXYIII. Miss Louisa P (age uncertain), in September, 1857, complained to me solely of general languor and pain at the epigastrium of an obscure character, and I put her on Citrate of Iron and Prussic Acid, with milk and meat diet, and directed her to be careful not to press upon the pit of the stomach when sitting at her work of keeping large girls' school. "When I saw her again in October I found that the pain at the epigastrium came on about twenty minutes or more after food, that it went downwards to the bowels, and was followed by a soft, sometimes liquid, stool. I put her then on Bismuth and Iron, which she went on with to the end of the month and got well. Sulphate of Copper would probably have acted quicker. ABDOMINAL PAINS. 171 SECTION VI. Weight. This is a feeling like that often locally experienced at the :ming of sore-throat, coryza, influenza on the chest, leucor- rhcea, gonorrhoea, or irritable bladder. In those diseases it notice that the internal lining membrane of the spot is red, swollen, soft, and beginning to be coated with adhesive mucus. In the more advanced stages, as soon as pus is formed, the sen- sation ceases. In all these situations it is sometimes called "oppression," sometimes " tightness," sometimes " distension ;" but I think the word I have chosen is that most commonly applied to the epigastrium. It is so in my notes taken from word of mouth. Patients will sometimes say they feel as if they had eaten too much, but their account of their meals does not show such to be the fact. And in those whom we know to eat too much we do not find this feeling at all universal, as may be seen by refer- ence to a former chapter (page 97). Besides, if the feeling arose from over-fulness of the stomach, it would be felt most when the stomach is fullest, namely, during a meal ; but such is not their experience. The first inclination therefore of the medical pathologist is to refer it, when complained of in the epigastrium, to the develop- ment inside the stomach of the catarrhal condition alluded to above. And his inclination will be strengthened by the perusal in his note-books of such cases as the following. < \\XIX.-In the Post-mortem Register of St Mary's Hospital tlnT- is an account of the autopsy of Kliza Ann S , who died November 'J.")th. 1853, aged 14, of dyspnrea from diseased heart, consequence of rheuma- tic fever, and towards the end of her life albnminuria with dropsy. It is need- less to detail the appearances of the heart and lungs, on which I am not going to comment, except to eay that they fully accounted for the illness and death. On opening the stomach its inner surface was found covered throughout with a coat of mucus of extraordinary thickness and toughness. \\< tran.-parrney lined by tin- admixture with it of a good-deal of yellow-brown matter. Tin- microscope showed this not to be bread-crust by proving the ab.>en. - ,.|' starch-irranulrs. and rendered it probable that it was digested blood. The microscope exhibited al-< the |MFM6M6 Of Mattered spccinn-ns of surcina vcn- tricula. The membrane itself was stained with many spots of punctate con- 172 ABDOMINAL PAINS. gestion, and the principal contents of the stomach besides mucus was coffee- ground colored fluid of neutral reaction. She had been under me in the wards for several months, and on referring back to the record of the case during life for symptoms in the epigastrium, I found frequent mention made of " weight," as complained of in that situation, and no other term ever used to describe the sensation. I find also that she very frequently vomited sour matters, and had a sour taste in her mouth : and that the vomiting and the weight embittered the poor little sufferer's last days. Her appetite was good, so that she took a variety of food, sometimes in re- stricted quantities, sometimes not ; but neither dietary nor medicine seemed to alleviate the gastric symptoms. The vomit during life had several times been examined by the house-sur- geon for sarcinse, and they were not found ; nor was it frothy ; nor had it ever contained the coffee-ground fluid found after death, but was intensely acid. The natural conclusion is that the weight and other gastric symptoms were caused by the continually recurring congestion and pouring out of mucus in the parietes of the stomach. And the symptoms and post-mortal appearances were marked enough to make one view this as a typical case. I must, however, in justice, tell that in twenty-three cases collected by Dr. Handfield Jones, in which an excess of mucus was found after death, no mention is made of weight at the epigastrium among the symptoms during life. 1 Possibly it was not considered of sufficient importance to make a note of. Possibly the diseases of which the patients died, most of them acute and painful diseases, masked even to the sufferers them- selves the minor evil. I may remark in passing on the difficulty almost universally presented by this last-named factor in the calculation, when an attempt is made to connect the post-mortal appearances with the phenomena recorded during life in all diseases which are not the immediate causes of death. Like other things pain cannot be in two places at once (I speak of course metaphorically), and when you are having a tooth out you fail to notice the operator treading on your toe. The greater ill hides the lesser. Weight is most c6mmonly felt towards the right side of the epigastrium, and no sensation is conveyed up the oesophagus 1 Handfield Jones " On the Stomach," p. 74, and " Medico-Chirurgical Transac- tions," vol. xxxvii. p. 109. ABDOMINAL PAIN'S. 173 towards tin- : it is in the pyloric region, according to Dr. Handheld Jones, tliat tlie catarrhal state of mucous mem- brane commonly occurs, and I am disposed to attribute to the nerves of the pylorus, and to a morbid state of that part of the 8, this peculiar gastric sensation. In CASE CXXX1X the lesion of heart was adhesion of the inlium with enlargement. In the next instance pure val- vular lesion without enlargement would seem to have been capable of producing a similar state, if one may judge from the symptoms. [ L. Kllen W , aged 18, a domestic servant, was in St. Mary's under my care for six weeks, from February 13th, 1852, and again was ad- mitU'tl in January. 1853, for a fortnight. There was a harsh systolic murmur, heard loudest at tin- level of the aortic valves, the sound fading away gradu- ally towards the apex of the heart. The pulse was always from 105 to 120. and she complained of palpitation when asked about it. She was very pale and weak, unable to do her work, bursting into a perspiration when talked to, and having a violent hysterical fit when a patient in the ward had an ai opened. But luy chief complaint was of weight, sometimes amounting to a<-tual pain, in the epigastrium, and of vomiting. She was treated at first with small doses of Hydrargyrum cum Cretd, and saline draughts. She got worse under this treatment, and the pulse remained quite as quick. She was then put on Decoction of Bark with Quinine, and the pulse fell. Mustard plasters to the epigastrium seem also to have been of use. Then the weight at the epigastrium diminished, and the vomiting ceased : but coincident with that the patient began to have a cough ; and as the expectoration of mucus from the bronchi increased, so the gastric symp- toms were alleviated. Then she regained her color, got stronger and heavier by a few pounds. The pulse went down to 84, and she was made an out- patient. 11 owever, she was admitted again at the beginning of next year, and gave us a history of chronic invalidism. She had been allowed to lie in bed and indulge her feelings of languor. There was no cough, but she said that another mucous membrane, the vaginal, was affected, and she frequently had leucorrhcea. She complained of palpitation of the heart, but not of the gas- Mnptoms so much. Remark here how the effects were produced now on one . now on another, not on both at once, but in suc- :on. The supervention of the bronchial relieved the gastric eatarrh, and the leueorrhceal, brought on by lying in bed and coddling, raooeedecL Such cases can seldom be cured in the short time which hospital neee.-.-itic.- allow. 174 ABDOMINAL PAIXS. Mercurials seem very bad treatment, but just at that epoch somebody had been recommending them in gastric complaints, and I thought that such a one as this, if any, ought to be benefited. A minor degree or weight at the epigastrium is sometimes produced where the heart is merely excitable, without organic lesion. CASE CXLL G. K. R , a civil engineer, aged 33. September 26th, 1861. He suffers a good deal from palpitation of the heart, which is brought on by even the slightest mental cause, but not by any ordinary bodily exertion, and there is a feeling as if the heart beat irregularly at times. The stethoscope and percussion detect no abnormality of shape and sound in the organ, except the quickness of beat after a short examination. He is used to the palpita- tion, and what he would complain of is that when he comes out in the cold after breakfast, to go to his work in London from Greenwich by the steamer, he experiences an oppressive sensation at the pit of the stomach, which con- tinues at least the greater part of the forenoon. The stomach feels as if a weight lay there, or as if it were tumid with wind, which on examination is found not to be the fact. R was directed to eat milk-porridge for breakfast, to wear thick flannel over the epigastrium, and to take four minims of Hydrocyanic Acid a quarter of an hour before food. On the llth of October he comes to me again, saying that all the local dis- tress has passed away, and that he feels only weakness, for which he is ordered Quinine and Strychnine. He finds milk-porridge a very couvenient breakfast. This action of the cold air is just what one feels in nasal or bronchial catarrh. Flannel is a very good preservative, and acts as a counter-irritant as well, in those who are unaccustomed to it. The milk-porridge was intended to be a mass of even moderate temperature, in fact an internal poultice, which would at the same time be sufficiently nutritious for a man in hard work. Hydrocyanic Acid was designed to act on the whole of the pneumogastric nerve, inasmuch as it was through its chronic sensitiveness in the heart that this temporary condition of the stomach was induced. Doubtless in CASE CXLI the weather had considerable influ- ence in determining the condition. In the next it seemed the sole factor. ABDOMINAL PAINS. 175 D , aged 50, but old for her age (for the catamenia had ceased four years), requested my advice in November, 1K">(), for constipation, which was always worst in wet weather. Butoninquiry I found that this was not all : she hiid flatulence and an oppressive sense of weight at the epigastrium, extending to the right bypochondrium, after meals, and it was this which was vati'il hv the hygrometric state of the air. She lived in one of the little old-fashioned damp Cinq Ports, and a removal to Ventnor' for the winter made all the difference to her. I am surprised in looking over my notes not to find flatulence more often associated with weight at the epigastrium. The patirnts so frequently speak about their being "blown out" tliat one expects it in every case, but manual examination of the abdomen does not detect it. I am led therefore to conclude that this feeling "blown out" must be mainly a subjective sen- u. True flatulence is usually associated with more purely neuralgic conditions, and does not, like the subject of the present section, lead to the diagnosis of catarrh. Moreover, the sensation of tumidity is by no means a marked feature in real tumidity. Patients often omit to notice it. There was, however, flatulence in Case I* along with weight, and again probably in the following: t'XLIII. During the spring and summer of 1857 I had several visits from a thin, withered old gentleman, T. S. S . His principal complaint was of " weight" at the pit of the stomach, but he must also have suffered from flatulence, as I see that I have prescribed for some time Charcoal and Strych- nine in Powders, which I should not have done except for that symptom. Costiveness is a very usual accompaniment, and in the follow- ing case benefit seemed to accrue from a purgative drug. I I.I V. Thomas K , aged 45, an Irish manufacturer, asked my advice .July 1-lth. K>7. for costive bowels. Confusing cause and effect, he attributed to that costiveness a constant "pressure" on the epigastrium, low spirits, want of sleep, and anapliroilisia. I gave him a prescription for five grains of Aloes and Myrrh pill with onc-twellth of a grain of Strychnine every night, and de.-ired him to take them for a week, and return to London to see me airain at tliat time. To his surprise they had not acted as purgatives, but Hieited matured >tnoU. ||.- was very much better in every respect, and con- tinued to take small <|iiautities of the two drugs till he was well. 1 There are two climates at Wntiior. the one soft and suitable for sore lungs, the other, which is ht-re i>i?.-cribt)d, dry aud bracing, though uot cold. 2 Page 31. 176 ABDOMINAL PAIXS. The lowness of spirits which usually accompanies weight at the stomach sometimes amounts to thorough hypochondriasis. CASE CXLV. Mr. W , aged 30, was brought to me by Dr. Dunfield, January 19th, 1866, on account of the persistency of a sensation of weight towards the right side of the epigastrium, coming on three-quarters of an hour after meals, by which he had been led to give up business since 1864. He was, however, none the better for giving up business. His nights were rest- less, and he was often woke up by headache. His spirits were at all times low ; he had no actual delusions, but he took the gloomiest view possible of everything, and was inclined to be miserly in the management of his income, which was ample enough for his wants. The tongue was covered with a white fur with transverse cracks. The gums were edged with a pink line, but were not sore. The urine contained floating crystals of oxalate of lime. I advised him to travel abroad. I suppose it must be from depression of mind being so often associated with discomfort in the pyloric region of the stomach or the right hypochondrium that we derive the term hypochon- driasis as descriptive of that mental state just as irritability of temper is called " the spleen" because it so often accompanies a stitch in the splenic region of females. The white furred tongue with transverse cracks is very dis- tinctive of an irritable condition of stomach, but it does not always accompany weight. The pink edges to the gums are also a gastric symptom. They are often found in the dyspepsia of early phthisis ; but they are pathognomonic of the dyspepsia, not of the phthisis. As in this instance of Mr. W , they are often found without any tendency to pulmonary disease. The deposit of oxalate of lime, instead of urates or uric acid, in the renal excretion, is common in such dyspeptic cases as manifest nervous symptoms. I have sometimes found with it spermatozoa, involuntary seminal emissions being also frequent in the same class of cases, if the patients lie on a soft bed or with the head low or on their backs. The hypochondriasis is apt to take a form engendered by the situation of the discomfort. The patient will fancy he has something strange and abnormal in the stomach. CASE CXLYI. At the end of June, 1857, I saw a few times a Mr. B , a middle-aged man, who complained of weight at the epigastrium and right ABDOMINAL PAI 177 hypochondrium. IIo and I <|uurn'lU'd because I refused to treat him for tape- worm in tin- stomach, or to believe that In- had urn- inside him anywhere. The tongue was coated with white, with cracks across it ; the complexion was thick and muddy. The patient was excessively nervous and fearful, and complained ;ally of a "scratching at the back." What is tliis sensation which people call "scratching at the ; ?" I find it used in a letter to me from a girl with hys- terical paralysis of the legs, and I have certainly heard it from other nervous patients, but cannot recall the circumstances, nor - it convey any definite meaning to my mind. As a rule, weight and heartburn do not go together. Patients quite understand the diiTerence, and when skilled by unhappy rience in gastric symptoms treat them as excluding one another. Thus CX I. VI I. Colonel B , aged 43, consulted me July 30th. 1866, about ain loss of power and pain in the legs. Tracing these symptoms to the stomach, I inquired about the habits of that organ. He said it was a weak L Did he suffer from he.irtlmrn then? No, he was " remarkably free from heartburn," he said, though he knew what it was very well. What he felt was a weight at the pit of the stomach and in the liver," better in a bracing climate, worse in a damp relaxing one. Y'-t such a thing does happen as the conjunction of weight ami heartburn, and when it does the general symptoms are more than commonly severe, even when the catarrh is not bad enough to cause vomiting. ' \LVIII.-J. II. R , a commercial traveller, aged 42, was sent to me by his family doctor who had watched the case. September '-'nth. 1858. He had always l>eeii a fairly temperate man. and presented a healthy weat he r- '. but with a look of distress or pain in his face. Naturally in the exercise of his calling lie had been a good deal exposed to changes of temperature and to wet. and to irregularity of meals. Gradually he 1 to suffer from iudig<>tion. which ^n \\ \\oi>e and wor>e. He had an almost iiit weight at the pit of the stomach, especially towards the ri^l.: Hut he had also decided heartburn and rising of fluid in the mouth of uncer- tain character, and probably consisting of regurgitated food. This led the -\iiiptoins. to vertigo ami occa.-i"ii;d .-tumbling, and to such confusion of thoughts and difficulty in fixing the attention that he was quite unfitted for business. He was cupped to a small amount on the back, was bli.-tered. and had gr. xv of Hismuth tlnv.- times a day. and a small .Vine's and Myrrh pill with one-twelfth of a grain of .Strychnine i\erv ni-ht. 12 178 ABDOMINAL PAINS. His dietary was to be as follows : For breakfast. Stale bread or biscuit, with minimum quantity of fresh butter, milk and soda-water in equal quantities to drink. For dinner. Lean meat once cooked, stale bread, one spoonful of mashed potatoes mixed with gravy, weak sherry and water to drink. Tea. Same as breakfast. Supper. A biscuit and a cup of beef-tea. In ten days the stomach symptoms quite passed away, and the vertigo was much better. I have quoted here the dietary, as a specimen of what is required in a case of moderate intensity. It was arranged to relieve the stomach without starving it. Cupping on the back disperses gastric congestion, and is more convenient than on the epigastrium. At the same time, it may aid in adjusting the disturbed balance of circulation in the brain, which is hinted at by vertigo. To recapitulate I think the sensation of weight at the epi- gastrium is one of the most important evidences of a catarrhal state of the mucous membrane of the stomach. It may exist at all times, but the presence of food intensifies it by increasing the amount of mucus present. Its spontaneous relief by vomiting when intensified by food indicates directly one of the most important parts of the treat- ment, namely, that the food should be as liquid, light, soft, and as quickly soluble as is consistent with a full amount of nutrition. As in all catarrhs, Alcohol is injurious ; -but in those who habitually take it, dilute wine and water must be conceded in the chronic treatment. Local treatment of congestion by abstraction of blood and by blistering seems useful. It may be used when the amount of digestion still carried on and the appetite for food justify its employment. Even a considerable amount of anaemia need not centra-indicate it. The most efficient pharmacopceial agent is Quinine, the con- junction with which also of Strychnine seems likely to assist the peristaltic muscles of the viscus in shaking off their adher- ent coat of mucus. Where there is an obvious increase of discomfort very soon A I', Iu>MI\ A L PAINS. 179 food IIydroey;i!iie .Vih even into the arms and legs. These have been set down me as distinctive of cancer. They are not so ; I have seen them where simple ulcer was found after death, and I have seen cases of cancer without them. One characteristic feature rarely absent is its keeping the patients awake at night. The situation of it points out the locality of the tissue change. iM-ea-e of the pylorus is felt in the right hypochondrium, of the rior wall of the stoma<-h and pani-reas between the shoul- !so disease of the cardiac is usually but not always felt. If any gastric symptom has preceded wearing pain, the most il is weight. Wearing pain is always in my experience increased by pres- sure, not always immediately, but after an interval. The p: is l>ad: it is pn-tty sure to return, for it depends on some organic change of tissue whieh cannot be red to its i onditiou. I cannot call to miml 180 ABDOMINAL PAINS. having seen an example of pain in the stomach wearing and constant, so as to interfere with the nightly rest, in which I have had reason from the future progress of the disease to infer a normal state of the gastric parietes. In cases of ulcer proved by the fatal event, whenever pain has been noticed, it has been of this character. It is not indeed perennial during all the years that the ulcer has lasted, but it is constant during the time when the degenerating movement is progressive, when the ulceration is marching onwards. In nearly all cases where bloody vomiting otherwise inex- plicable has rendered the diagnosis of ulcer the most probable one, there has been this sort of pain, occurring for considerable periods together. Cancer of the pylorus causes this pain in the right hypo- chondrium, even before ulceration, quite as soon as any tumor can be detected by -manual examination. Cancer of other parts of the stomach usually causes pain between the shoulders equally early. I shall cite a series of cases of wearing pain, and make short comment's on them .afterwards. It will be observed that I treated and prognosticated all as if there was structural lesion of some sort, though of the nature of the lesion there was no absolute evidence. CASE CXLIX. Hannah W , aged 34, a cook, was admitted to St. Mary's April 21st, 1854. She had a worn, unhappy look, and rather sallow com- plexion. Her body was stated to be a good deal emaciated compared with what it formerly had been. She had enjoyed good health up to about two months previous to her entering the hospital, at which period she was taken with a severe attack of vomiting "a bilious attack." Yomiting had returned 'occasionally since, but not with the same severity. Her principal distress was a continued wearing pain in the epigastrium, which rendered her miser- able throughout the day and broke her rest by night. It was increased by pressure, and to a certain degree by meals, unless the food was very soft and in small quantities at a time. She attributed it to the heat of the kitchen she worked in. Opiates gave temporary relief, and helped her to sleep at night. So that, after a good dose of Morphia, the tongue, usually coated with a white fnr, was noticed to become clean. Six Leeches were applied to the epigastrium, six grains of Bismuth given three times a day, and the diet restricted for a week to broth without meat in it, and to cold milk and water. ABDOMINAL PAINS. 181 It appeared that previous to admission the patient had been freely treated by means of purgatives, her bowels being very costive. They were entirely left off, and in consequence the bowels opened themselves only once in five days. This rest seemed of great use. On the 'JTth .-he ftmud herself able to eat a bit of beef given her, and the next day some bread, so she was allowed to have it. On May 2d she had lost her epigastric pain, and on the 6th was able to return home. On the 20th she came to show herself to me, and to report that a.- yet she had no return of the pain. < I . Hannah P , aged 48, was admitted to St. Mary's August 17th, She was the wife of a laboring man unable to work by reason of paraly- :.d she had for some time supported him by going out to field labor; so iie liveil very hard, and, moreover, had lost thirteen teeth, so that even Mtrh food she did get was improperly chewed. Up to the previous Feb- ruary, however, she had been in strong health. Then she began to suffer pain in the epigastrium at odd times ; but it did not prevent her earning her wages till the summer, when it became constant, and she was entirely invalided, partly from the pain and partly from giddiness and a feeling of prostration. On admission her countenance was worn and sallow, her appetite was good, the pulse small and weak, the tongue cleaner and redder than natural, the bowels costive. The pain at the epigastrium was constant, and increased by she complained of want of sleep. At first she was treated with Hydrocyanic Acid, but no benefit at all resulted. Then a blister to the epigastrium, on which great relief immedi- ately be^an. Then she had a grain of Opium every night and the following draught : R. Misturse Ferri co. fl.^j. Acidi Galilei, gr. iv ter die. was able to take a pint and a half of milk with Lime-water in the day, ami egg and other diet as well. Hut she did not lose her pain in the stomach till I cut her down to the milk and Lime-water only, and gave her a drachm of I!i~muth three, times a day. The latter prescription and the keeping of the blistered surface open for a month was at last successful, so that on Sep- tember 19th she was able to begin eating half a mutton-chop daily, and on -th was discharged. I. Mary Ann S , aged TJ. admitted to St. Mary's January 'J.'M. attributed her illness to debility induced by her last confinement. She M subject to pains in the epigastrium, which came on about once a fort- night and /* during the period of the attack. One of these attacks had commenced on the ISth, when the pain was :_' across the pit of the ,-tom.icli. On tin- I'.Hh it passed over to the right side, where it became fixed and constant. She attributed this attack to a meal at which she ate both rice and potatoes. It had much diminished on her ad- n to the ward. On examination of the abdomen there was found a circumscribed spot to the outside of the right red us alulm:. le, and within two inches of the 182 ABDOMINAL PAINS. costal cartilages, which was excessively tender on pressure. This spot appeared also somewhat tumid and tense ; the patient said it had been more tumid two days before, and had been reduced by the application of a sinapism. There was resonance on percussion between this spot and the liver, the extent of whose dulness was quite normal. Six Leeches were put on the epigastrium, followed by the continuous appli- cation of a bran poultice. She had gr. xv of Bismuth three times a day, and a diet of milk and Lime-water, with a pint of beef-tea daily. She entirely lost her pain, but eating a bit of meat at supper on the 31st brought back a short relapse, which was immediately checked by the fresh application of half a dozen Leeches. She was made an out-patient on February 2d. CASE CLII. Sarah B , aged 40, was admitted to St. Mary's March 11, 1864. She had suffered seven years from frequent attacks of continuant /"?/'// in the epigastrium, sometimes accompanied by vomiting ; and sometimes the vomiting had contained blood, though it did not do so when in the hospital. She had found by experience that hot food was apt to bring on these attack?, and that the danger was closely proportioned to the degree of temperature. She had consequently acquired the habit of taking everything cold and iced if she could get it. (The notes of this case are imperfect.) CASE CLIII. William G , aged 33, country gentleman, February 1st, 1866. He has suffered for eight months from almost constant pains in the right side of the epigastrium, which is increased by pressure and by external cold. His countenance has got sallow, and he has lost more than fourteen pounds in weight. He has no cough, and the chest seems healthy. On manual examination of the painful spot it is resonant on percussion. The bowels are costive. They were regular before he took a quantity of Mercury and purgatives. The pain was increased by riding but not by food. His rest was broken by it. He did not vomit. I put him on two grains of Quinine dissolved in lemon-juice, with three minims of Hydrocyanic Acid twice a day and sent him to Bath till March 5th. By that time the constancy of the pain was much abated, and he w-.is enabled to ride without increasing it. He had gained two pounds in weight. He continued to improve till the middle of May, when he returned to his home in Lincolnshire, a low aguish district, and almost immediately relapsed and returned to me in London. He said he had found several times before that a visit to Lincolnshire made him worse, but he thought the summer weather would make it safe. " To keep him out of harm's way" I have re- commended him to travel for a year or two, as it is to be feared these relapses may constantly occur on exposure. . CASE CL1V. James N , an upright military-looking country gentleman of 50, was always hearty and strong till he had the smallpox in 18G4, after which he became costive in the bowels, and got into the habit of taking so much purgative medicine that without it no action could be secured. In the summer of 1866 he began to suffer from discomfort at the epigastrium, which grew gradually more frequent, so that when I saw him in October it was always produced by food, and often also arose at other times, especially when ABDOMINAL PAIN'S. 183 in bed. T gave him a tonic of Quinine and Strychnine with some pills of Alni'-s and Myrrh with Strychnine. This at first seemed to afford a little tem- porary relief. and the patient was anxious to make the best of matters. Hut med to get weaker and thinner, and then the pain became constant, and was observed to be increased by riding on horseback or in a rough carriage. Ami I thought after a fair trial that the bitter drugs made the pain worse, so I left them off and ordered only some Cod-liver oil. Also one spot in the of the epigastrium I found tender on pressure, and at the same point 1 could feel the pulsation of the aorta with abnormal clearness, not stronger perhaps than natural, but more readily felt by the finger. On these grounds I held it my duty to give a bad prognosis. After this 1 heard no more of the case for nearly three months, when Mr. Faithorne, under whose care he then was, wrote to me to say that Mr. X had persevered in taking medicines for some time, when ho found himself no 1 ictter and left off. He was growing gradually weaker, and derived relief to i ic pains only from Morphia. There was no tumour in the epi- iim. CLV. Miss B , a thin, active person of slight muscular develop- ment, who looks about five-and-thirty, has been in the habit of walking to church every morning at eight o'clock without taking any food; then swallow- ing her breakfast and passing the greater part of her day in "parishing," laden with a great pocket full of books, rice, tea, sugar, loaves, &c., fastened round her waist. For some mouths past she has experienced a pain in the pit of the stomach ten minutes or a quarter of an hour after she begins to eat, and lately this has become, cnn^nnt. She has also occasionally vomited meals, and has noticed mucus and blood in what has been thrown up. - ymptom has no connection with the monthly period. Lately she has i. -posed to be hysterical, but being of a strong-minded, cheerful tem- perainent of mind, has not given way to it. Catamenia and al vine excretions natural. Feet apt to be cold. On examination of the bare abdomen, there is pain developed not by gently touching, but by firmly prcssini: with the finger-tips, the middle of the epi- :um. just below the ensiform cartilage. 1 .".'/'(. l-''.i'i. To leave off entirely tea and all viands containing su-rar. To lie in bed till half-past eight, and never go out till she has had a good meal. To leave off stays, and the weights sn-p^nded round the waist, and when she is stronir enough to carry burdens, to carry them in a basket. To \ nuina draught twice a day. and to lie provided with a bottle of ainmo- 1 tincture of Valerian, of which 'ake two teaspoonfuls in water whenever she feeds inclined to have a cry. .I'liiinirij 'JT'/i. 1-''.T. A strict conformity to rule- has I. ecu rewarded with i.-ralile improvement . and she ha- hail no occasion to take the Valerian. .in on pressure of the eiiiuM-trium. 'I'o wear a pii-ee of Kniplastruin I' i:tn- on the e trium, and to take four grains of I \> lina and Iron in the st- a her med. 184 ABDOMINAL PAIXS. February 28th. A return to her old home, and, I fear, its associated dnties, has caused a relapse into her former state. She appears also nervously ex- cited, to judge by her letter received to-day. R. Tincturae Valerianae Amm. fl^ij ter die. Advised to travel, if she has a chance, in the South of France and Italy for the spring, but to avoid Rome, Pisa, and the like. April 24:th. Has remained at home, steadily persevering in the tonic. Has gained much flesh, but not entirely lost her pain. CASE CLVI. A lady's maid, Sarah S , aged 33, was admitted to St. Mary's September 10th, 1852, for constant wearing pain at the epigastrium, made sharp by pressure or by eating, vomiting and emaciation. She had also suffered from waterbrash of clear fluid, and acidity. She said that in every spring for the three years previous she had had an attack of bloody vomiting. She attributed it to her having worn a long busk to her stays, which conse- quently she had left off. CASE CLVII. James M , aged 32, a potman, was attacked at the begin- ning of April, 1860, with pain of a continuous character in the pit of the stomach. This continued getting worse till the 16th, when in the act of vomiting, to which he had become subject, he brought up about half a pint of blood black in color. In the afternoon of the next day he brought up as much as three pints of thick black blood in masses so tough as nearly to choke him. The tongue, however, remained clean and moist, and the pulse was only 74 ; the heart and lungs were healthy, and he had lost the pain in the epigastrium even when it was pressed. All which things considered, it was not thought right to detain him above four days in hospital, especially as he wanted no medicine. CASE CLYIII. Sarah G , aged 33, housemaid, always enjoyed good health to the middle of June, 1857, when she was laid up with sore throat at first. This passed into a wearing pain at the epigastrium aggravated by food, and accompanied by several attacks of vomiting, during which she threw np blood. She became an out-patient at St. Mary's under Dr. Markham's care ; and he, finding her weakness and paleness increase with alarming rapi- dity, and seeing the tongue dry and furred as in hemorrhagic fever, recom- mended her being admitted on August 22d. We then found as Dr. Markham had suspected, but the patient constantly denied, that she passed blood by the bowels whenever they were opened. This required to be done by artifi- cial means, for she was very costive. On one occasion the feces contained a clot of fibrin, washed colorless, as big as an egg. After observing and exa- mining her for a few days, I gave her R. Plumbi Acetatis gr. ij, Opii gr. ^. In pilula ter die. She took this for three days, and then her bowels were open of their own accord, and she passed a dark feculent solid stool containing no blood. The pills were therefore left off, and she was treated with occasional doses of Castor Oil to clear the bowels of the remedy. ABUOMIXAL PAINS. 185 But. for some reason or another, perhaps a relapse of the hemorrhai:'-. I began tin- Acetate of Lead again on September 1 lit h, giving it her only at night, however. On the 21st she passed a quantity of flocculent fibrin with- out blood. On the 23d, a blue border was observed along the gums, so the was again left ofT, and she does not seem to have lost any more blood during her residence in the hospital, viz. till October 16th. X. -Klixa F , aged 35, was admitted August 21, 1860, having for a fortnight suffered from vomiting of her food, tasting and smelling sour. That morning she had begun to consider her case serious, from having thrown up in addition some clotted blood to the extent of a few ounces. There was pain in the epigastrium, niiinimj thrimted blood. Then her bowels became costive, and she took only some Decoction of Cinchona, and was discharged on September 7th. Tn CASE CXLIX it may be remarked that the disease is attributed to the high temperature to which her occupation exposed the patient. I question whether this accusation I >ne: but probably the heat caused pain to the injured part, an;i was rendered probable by the hemorrhage being joined to the continuity of wearing pain. In CLIX the running of the pain through to the back is noticed. SECTION VIII. Soreness on pressure. Soreness on pressure is so generally in all naturally inscnsi- xirts an indication of structural change that we all of us matter of course apply this diagnostic sign to the organs of digestion. Where it is constant in any one part, independent of the presence of food, and proportioned in its degree to the amount of pressure, it appears to me pathognomonic, and can hardly arise from any other cause. It is sometimes immediate, and sometimes does not come on till the lapse of a certain in- 1. In the former case there is a little vagueness in the . for some people are so much more sensitive than others, and 'to having the epigastrium i that they cry out without sufficient OC - requisite not to be ved by the hy; -ia. The pain which comes on alter an interval, on the other hand, is a very determinate svmp- tom. and is never simulated or imaginary. It gives very ac- curate information that an organic change of some kind has taken place in t' 'ire of the stomach. Whenever, then, tenderness on pressure constant 1\ whether accompanied or not by constant or wearing pain, and whatever the other symptoms may be. whether heartburn, :!, I think we are justified in employing 188 ABDOMINAL PAIXS. local alternative means, mustard poultices, blisters, leeches, or cupping. Water compresses are not so efficient ; I think those who fancy they have found them useful must have fallen in with other forms of gastric pain and mistaken them for tender- ness. An all-important part of the treatment is complete rest. The action of this may be seen by the rapidity with which the patients get well in the hospital. Tenderness on pressure does not centra-indicate an analeptic restorative treatment being conjoined with the local. Indeed, it demands it. Numerous instances of this may be seen in cases already cited, perhaps the most striking from the symptoms being capable of being depicted in. number and weight, is CASE CVIII, of a young Irish woman, who gained twenty-one pounds of flesh in twelve days, in spite of being leeched every other night during nearly all the time for waterbrash, with intermit- tent pain at the epigastrium and tenderness. 1 Pain felt only on pressure in a part does not require any palliatives except not to press. This is a platitude perhaps ; but still both doctors and patients are the better for having the fact brought to mind, since these out of anxiety find it difficult to keep their fingers away, hoping each minute to find the pain gone, and those are tempted by a love of accuracy, hard to blame, into a needless frequency of examination. SECTION IX. Anomalous pains. CASE CLX. Mrs. S , aged 40, used to visit my house frequently in 1849 with a daughter, whom I was attending for cutaneous disease. One day, though at the time in perfect health, she desired my advice about a curious pain in the pit of the stomach, which from time to time assailed her. It came on gradually, was not severe enough to lay her up, but constant and worry- ing while it lasted, namely, for about a week or ten days at the most. The first thing I made out about it was that it usually succeeded to any mental worry or unusual bodily exertion for several days. On further inquiry I found it invariably coincident with the catamenial periods, which, however, were regular, not excessive, and accompanied by even less pain in the loins, uterus, or groins, than most women accuse. It appeared in fact to be a dysinenor- rhceic pain, misplaced at the wrong end of the abdomen. 1 See page 149. ABDOMINAL PAIXS. 189 I gave her a course of Quinine and Iron for the nonce, and desired her to take a special d.-e .if Hydrocyanic Acid and Opium if the pain came on again. This seems to ha\c I-. > n suo c->ful, for though she brought her daughter il times during the next year she said no more about herself. Though she appeared in perfect health, the mere fact of being an anomalous pain showed weakness, and constituted the periodi- cal discomfort which is the normal portion of the sex, or dys- menorrhoea. The above is a specimen of the most usual degree in which uterine pains are felt in the stomach, but sometimes they are more serious, as in the following instance: \ I -Jane R , aged 25, a housemaid, was admitted under me at the hospital l-Yliriiary 16th, 1852. She was a personable robust country- M.-inan, who had lately come up to service in London. Her tongue was clean, her pulse H4. full and strong, her skin normal, her urinary and fecal excretions reported natural. Her mistress said that for three days Jane had complained of pain in the lower part of the chest in front. That it was increased by food, nseiiueiitly she had "eaten nothing," that is to say, had taken only liquid food. She got an out-patient's letter to the hospital, but on her way to use it was taken so much worse that she was obliged to be admitted. She sat up in bed rubbing her epigastrium with her hand, and expressed hers. -If as in great pain. Rubbing, however, gave her no relief, nor did pres- sure ; but it could be borne without any increase of pain. The catamcnia had been absent two months. A large Linseed poultice was applied to the abdomen, she took a four-grain Calomel powder imme- diately, and a Senna draught three hours afterwards. The same day the eata- nicnia occurred, not copious (they were never so, she said), but sufficient. tln> pain instantly ceased, and she was well enough to be discharged on the 18th. The disgorgal of the portal veins, by a mercurial and a pur- gat ive, is a capital way of l>ringing on thecatamenia in a robust, fiill-bluodetl prison. Kemember, however, that I do not recom \ it in those more common eases where the amenorrhooa is v an evidence of the absence of menstrual blood to be dis- eharged. It has seemed to me that pains in the loins, closely re- semliling those of the renal ealeulus, might sometimes be traced to the stomach. Ml. Henry L , a lithe active Scotchman with golden hair, ap- parently 1. .Hid m. on his return South after grouse-shouting in the 190 ABDOMINAL PAIXS. autumn of 1866, began to suffer from pain in the loins. This got better with- out any special medication, but about Christmas, when tossing a child up in the air, he felt a sudden stab, as it were, in the right loin, so sharp thut he was within an ace of dropping the child. The pain in this situation, some- times better, sometimes worse, but never absent, continued up to the time of his coming to me February 8th, 1867. Very often the pain ran sharp down into the front part of the pelvis, there was an ache in the right testicle, and that organ was strongly retracted against the body. He had been treated by a first-rate surgeon with Alkalies, Alkaline Mineral Waters, and with Iodide of Potassium and Turkish baths without success. Indeed he thought he grew worse. On examination there was pain on pressure with a finger just below the ribs outside the psoas muscle on the right side. The urine was pale, just acid, of the specific gravity only 1.006, probably from the joint influence of the alkalies and a habit of taking a glass of whiskey toddy at bedtime in lieu of wine at dinner. Treatment prescribed, February 8. To wear a belt with loin stifieners. to take port-wine at dinner, and a nap on the sofa before the meal. At 11 and 4 o'clock daily to take a couple of grains of Quinine. On the 12th the spec. grav. of the urine examined was 1.025. On the 23d the pain in the back was to be elicited by very hard pressure only. With some Iodide of Potass added to his mixture (I forget why) he was dismissed with orders to continue the treatment for a week. After that he wanted no more doctoring for a time. But at the beginning of April he dined out twice running, and indulged on each occasion in the fermenting mixture which London dinner-givers are fain to call Champagne, and the consequence was a return of the peculiar lumbar pain, though the urine remained quite natural. I prescribed for him a return to the former prescription. This was in passion week. On Easter Monday he still felt the pain, but like a true patriot joined his corps at the Volunteer Review. The reward has been a complete cure of his pain. Now, had it been rheumatic or renal, as might have been suspected, or anything else but abnormally placed pains of indigestion, it is clear that reviewing on the Dover Downs in English spring weather would have made him worse. The retention of feces in the bowels is frequently assigned by the public as a cause of pain in the epigastrium. Their fond- ness for purgatives doubtless often leads to error on this head, but still I do think they are sometimes right, and that the mere retention in the colon and rectum of matters ready for evacua- tion may give rise to considerable pain in the epigastrium. It is not very easy to hit upon a good illustration of this, for most usually costiveness and even constipation depend on some morbid condition of the stomach or of the whole alimentary ABDOMINAL PAINS. 191 1 or of the whole body, and it ia difficult to separate the s of the retention from those of the condition which 1ms idem! it. Thus, for example, you will find that nearly all the chronic cases quoted in the first chapter had confined bowels, but no one would attribute the epigastric pains to that cause, seeing that an obvious indigestion existed in the stomach, oat of those pains. In the following case, however, the of the retention of the feces was quite extraneous, and there was no proof of anything being the matter with the digestive organs. X III. Anne M , aged 23, a domestic servant, was admitted to St. Mary's October 15th, 1856, complaining iu various parts of the body of obscure pains, which, however, after admission, set-med tu have their definite seat in the epigastrium, and to be worst always after food. She had palpita- tion of the heart, nausea, and a tendency to faint Her face was flushed, the skin hot, and the tongue coated ; but otherwise her aspect was healthy. After a few days the nurse observed that her linen was stained, and the patient her- self stated that she had a vaginal discharge. But actual examination found the organs of generation quite normal, and that the pus came from a small papilla, the remains of an old haemorrhoid, on the edge of the anus. This was exquisitely sensitive, and the patient confessed that she had voluntarily retained her feces on account of the pain which defecation gave her. Warm liaths and sui'tenin.i: eiiemata, with the aid of Valerian draughts, reduced the hypeni-.-the-ia, and with the emptying of copious solid stools from the coloa the pain at the epigastrium ceased, and she got good rest at night. In cases of misplaced pains, I mean pains not in the locality of the parts truly affected, Valerian is a very useful medicine. Its calmative effect on the nervous system is remarkable. That was the reason of its administration to this young woman. It would have been cruel to forcibly open her bowels by purga- -. without first deadening the abnormal sensitiveness which hail eau.-el her to con.-tipate them. 192 CHAPTEE Y. VOMITING. SECTION 1. General remarks on the physiology of the process. SECTION 2. Vomiting of pus. SECTION 3. Vomiting of mucus. SECTION 4. Vomiting of blood. SECTION 5. Acid fermentation of vomit. SECTION 6. Fecal vomiting. SECTION 7. Vomiting of unchanged food. Hysterical vomiting. SECTION 8. Vomiting in pulmonary consumption. SECTION 9. Occasional causes of vomit- ing. SECTION 10. Sea-sickness. SECTION 11. Review of remedies employed. SECTION I. General remarks on the physiology of the process. IN the normal passage downwards of food the involuntary nerves and muscles of the fauces, the gullet, and of the stomach are in vigorous action ; whilst the voluntary abdominal muscles and the diaphragm exert no influence over the digestive canal. In vomiting a converse condition exists the involuntary oasophagus is wholly or partially paralyzed and relaxed, the involuntary peristaltic wave of the stomach ceases, and at the same time .the diaphragm and abdominal muscles are degraded from agents of volition to purely automatic instruments. The ceasing of the peristaltic wave allows the pylorus to close. It is converted from a portal somewhat stiffly held open by the circular fibres (as if in a sort of erection) into a collapsed valve. The pylorus being closed and the cardia open, it would not require any such very strong muscular effort to empty the stomach. But the muscles thus abnormally perverted into compressing the stomach are very large and powerful. Hence vomiting is a violent and explosive act. In spite, however, of the violence and explosiveness, a correct pathology must look upon vomiting as a lowering of the vital powers, as an atony of the digestive tube and its appendages, VOMITI 193 when the fac' ;t in tlio order and light above sketched out. Thus it becomes clear why vomiting is an accompaniment of :i which there is a diminution, or arrest, or of muscular action. Unusual or too long-continued bodily exertion, exposure in cold or heat, and such like circum- cculiarly exhaustive of muscular and nervous power, re eating even a moderate meal, will in some persons c ted. The same result follows in fainting, or when, from excessive mental emotion, the nerves of the gullet experience a temporary paralysis: so that vomiting is produced by disappointment, anxiety, nay sometimes even by sudden joy and pleasure. Still strikingly is it brought on by structural disease of the stomach, by which the peristaltic wave is arrested, or at least interfered with. Or by a stoppage of the same in the intestines, such as occurs in ileus, hernia, intussusception, and peritonitis. Vomitii g in these latter cases has been sometimes referred to a reversal of that muscular act which carries the alimentary onwards to an awft'-peristaltic motion. But there seems t<> me no evidence that such is the case; indeed, an attentive leration of the phenomena of the act itself would seem to > the contrary. Observe peristaltic motion it is . continuous, and uniform ; po indeed strength in its . but no irresistible impetus. Compare the :md note the diil'erence: in vomit in _ .ive a violent explosive power, like a force-pump, throwing the ejected m. out to a considerable distance. Can there be a greater contrast en two acts of the same part ? The explanation given h more nai iraliy to suit tin- phenomena. In son" ifl in vomiting from cere- bral diseases of a \^i. . In others it appears to \ample in the action ndariiy on the limbs; and possibly in some it may be entirely local an approach to which is made in the quickly acting em such as Sulphate of Zinc, wl, depression than mo>t other mc.i ii all th L8 19-i VOMITING. state in vomiting to be one of relaxation or atony, and to view as the main muscular manifestation of atony in the stomach a tendency to vomit. Vomiting seems less dependent upon the previous or chronic condition of the stomach, and more upon the idiosyncrasy of the individual, than any of the phenomena already discussed. There are dyspeptics who, whatever may be the matter with them, never throw up their food ; whilst others do so on the slightest occasion. Even pleasant associations will, in some people, bring on this most unpleasant consequence ; an occasional patient of mine, a healthy young lady, has been sometimes taken with retching on entering a ball-room where she expects an agreeable evening, whilst it never happens in going to a stupid party. On the other hand, I have had a patient with cancer of the stomach, and others with various sorts of severe dyspepsia, who could take the most repulsive drugs without inconvenience. The mere fact of vomiting, therefore, affords in itself no clue to the local condition of the stomach. But the time of its occur- rence, the circumstances which increase it, and the nature of the matters thrown up, may be most suggestive to the practi- tioner. Vomiting when the stomach is empty, or that which, though it accidentally occurs at other times, is most frequent and dis- tressing then, may be safely set down as arising not from any fault of the viscus itself. Such is the morning sickness frequent in pregnant women, and in cases of diseased heart, of abdominal tumor, and sometimes of pulmonary consumption. This has been explained as a reflex action of the vagus nerve excited by the irregular irritation of some of its branches; and on the same principle may be interpreted the more rare cases where it has been caused by foreign bodies in the ear or nose, by tumors in the neck, &c. When it occurs with a full stomach, we may reckon, as a general rule, that the smaller the quantity of food that produces it, and the sooner it takes place after eating, the nearer to the mouth is the cause. An ulcer of the oesophagus causes rejection of the food before it has got down ; of the cardia, or smaller curvature, very soon after it has got down ; and a similar lesion VOMITING. 195 of the pylorus or liver, after an interval sometimes of several hours. When vomiting arises from the paralysis of the oesophagus vlm-1 1 is induced by a congestion of the brain, as in apoplexy or drowning, or by poisoned nerve, as in dead drunkenness, it is increased by the hori/.ontal posture; when it arises from de- ficient supply of blood, as in i'ainting and anaemia, that same ion relieves it. Sea-sickness also is often warded oli' by lying down with the head low. The contents of vomit may often afford valuable indications to the practitioner, and will appropriately divide into cl: he meets with. They will here serve the purpose of the headings of sections. SECTION II. / of pus. XI V. Klizabeth S , aged 25, was admitted at St. Mary's Janu- ary 'J.".d, l-.vj. sin- IKK! suffered for three months from vomiting, at first ,.>nal, tint latterly :it every meal, so that, in spite of a good appetite and plenty to eat, she had grown pale and thin. After this had continued u mouth, she began to experience a difficulty in swallowing, which has gradu- ally ii. -lionuh tin- pain caused by it is not so great. The mouthful seemed to lodge somewhere at the back of the manubrium of the sternum, and either to l>e rejected or retained with great pain, which ran through to a >pot In twi i n the shoulders. Besides this, she used to have occasional ag and occa.-ional vomiting of glairy and frothy matter, with opaque : pus in it not unlike the sputa of early phthisis. (Iruel. arrowroot, cocoa, raw eggs, and milk were swallowed and kept down, so that >ln -ionally uot sick for a day or two together. l>ry Kismuth powd' o kept down, and thought they relieved the pain. But Sul- pliatc of Copper made her vomit on each occasion that it was tried, as was done M-vcral times with the idea of stimulating the ulcerated surface to healing action. At length she seemed to catch a cold on the chest, and died suddenly after >t'a>t one morning. On examination after death its immediate cause was found to be the opening of a fistulnu- communication |,etween the ulcerated surface of the (r.-oplia-u-s and the pericardium, ly which pus and food had made their way into the serous sac. The stomach, &c., were healthy. The pus iii the vomit me from the cellular 196 VOMITING. tissue around the oesophagus, which was being eaten through by the fistula. Eemark in passing the use of which Bismuth seemed to be to the raw surface. Some persons have found it of equal use in phthisical diarrhoea from ulcerated bowels. I confess I find it in this latter disease less efficient than Sulphate of Copper; but in the upper part of the digestive canal the comparative force of the two drugs would seem to be reversed. Another instance of the use of Bismuth in ulcerated oesophagus will be quoted afterwards (CASE CCVI). I felt considerable satisfaction that this poor woman never had any probang put down her throat. It would have thrown no light upon the diagnosis, and might have gone into the pericardium and been the cause of death. Imprimis non nocere is the first commandment in medical morals. CASE CLXV. James G , aged 32, dairyman, admitted to St. Mary's June 27th, 1856, after an illness of a month, during which he had attended as an out-patient. He complained of soreness of throat and of difficulty of swallowing solids. He said he never vomited, but after admission he beg;\u to throw up a considerable quantity of pinkish or flesh-colored purulent matter. Sometimes it was ejected by retching, sometimes with less effort. There was nothing abnormal to be seen or felt in the fauces or upper part of the oesophagus. After he had been in for a fortnight a small tumor of carti- laginous density was felt behind the ramus of the jaw, just below the right ear. During the time he remained in hospital he had a Laurel leaf poultice to the neck and Cod-liver Oil; but as no conscientious hope of future amend- ment could be expressed, it was not thought right to occupy the much-wanted space in the ward with an incurable case, and so I lost sight of him. There could be but one end to what was indubitably a can- cerous ulceration of the oesophagus, and I do not think a hos- pital ward is the happiest place in which to await that end ; so neither for the patient nor the public do I think it right to retain such cases in a charitable institution. It is quite different where any doubt exists about the diagnosis. CASE CLXVI. Edward J , aged 56, greengrocer, was admitted into St. Mary's November 16th, 1857, complaining of pain in the left side of epigas- trium immediately after eating. This was relieved by vomiting. His illness had first come on during a voyage to America the previous April. Previous to that he had always enjoyed good health, and weighed 12 stone; but now he was reduced to 9 st. 2 Ib. His vomit usually consisted of his food ; but VOMITINTr. 197 on on- 'la quantity of creamy pus mixed with a strongly arid Huid. A hard tuumr >vered below the cartilages of the ribs on the left ' side. He left the hospital December 14th, probably dissatisfied at the little relief it was possible to give him. These are the only cases I can find where there was pus in the vomit, viz., common ulceration of the oesophagus, cancer of the Gjsophairus, cancer of the cardia. It does not appear to be thrown up in common ulceration of the stomach, still less in rh of the stomach. The gastric and cesophageal mucous w;ills are very different from the bladder or urethra. These secrete pus on the slightest irritation ; an undue stretching, a hard substance, however smooth, an essential oil, moderate alkalinity of the urine, the infection of a catarrh so weakly poi- sonous as gonorrhoea, and other equally mild forces, arrest their vitality down to the pyogenic stage. The fauces, gullet, and stomach are much tougher ; fortunately indeed, for if stretching, hanl substances, spicy oils, alkalies, or acids hurt them, or if moderate doses of morbid or common poisons acted on them ' y, who would insure a man's life for a week ? To purulent inflammation they are not prone, and therefore we cannot expect to find pus in that which is ejected from them in their usual ises. When there is pus in vomit, either a malignant tumor has destroyed the walls and taken their place, or there is an u It-. .-rat ion with adhesions into the surrounding cellular tissue. Care should be taken to ascertain the condition of the lungs, and make sure that the pus does not come from a vomica, the emptying of which will sometimes be accompanied by vomiting. SECTION III. 'fi'ny of mm Murus is found in the vomit in what is called English cholera, or acute sumnuT irastrir X.VII.- Kdmiind K . aired Irt, was found by a policeman at half- .v in tin- ni'iriiiiii: of Septeiiiiier -ttli. I -.">!. staggering some ji.ilinir-i. and unalde to walk, from a violent pain in the liclly. whirli had sn.l- '.;cd him on the way to work. !! was taken to St. Mary's, and 198 VOMITING. kept vomiting 1 mucus and bile all day. The pulse was 90, the tongue dry. Pain on pressure of the epigastrium. No collapse, cramps, or retention of urine occurred. He had a dose of Calomel immediately, followed by diarrhoea; a dose of Opium at night; and was discharged well next day. The green matter in the vomit of these acute attacks is shown to be bile by its bitter taste to the patient, and sometimes by its smell to the bystanders. The presence of bile is a proof of pre- vious health, and an assurance that the cause which is disturb- ing it is a temporary one, however severe it may be, and that the vitality is not deeply smitten. You do not see it in the vomiting of chronic disease, you do not see it in that of fatal epidemic cholera ; but you do see it thrown up by the hearty landsman who is roaring over the gunwale of a Channel steamer, and it is hailed as a good sign in a convalescent from cholera collapse. Give an emetic to a healthy man, and you see plenty of bile ; give it to a broken invalid, and you most likely will not. Bile, then, is to be looked upon as a bird of good omen. It is regurgitated from the liver into a fairly healthy stomach, and not into an unhealthy one. Mucus, mixed also with bile, is thrown up in those less severe exhibitions of gastric disorder which are called " biliou.- attacks." CASE CLXYIII. John D , a retired schoolmaster, aged 55, became my patient February 7th, 1863. For at least ten years he had been subject to " bilious attacks," occurring in the winter, and generally half-a-dozen times each season. He described them as commencing with a hawking up of phlegm ; which phlegm did not seem to come from the air-passages, but from the gullet. This usually took place of a morning ; and in the evening a severe attack of headache came on, and a vomiting of phlegm and bile. He came to me because he found them getting more frequent and severe, and because he began to doubt if the traditional mode of treating them with purgatives were really the best. I put him on Quinine and Strychnine, and saw him again on the 23d. He said that in the meanwhile he had been threatened with a bilious attack, but it had been warded off, he thought, by the medicine. I heard of him in 1866 from a relative as a much heartier man than he used to be. The summer gastric disorders, which I first exampled, are' probably brought on by the absorption into the body of some poison diffused through the air or water, and which, when wide- VOMIT1 199 1 ami intense, constitutes the terrible epidemic cholera. fall on the robust equally often with the weakly. These winter liilions attacks are more like what we called " catching enM." ami are certainly induced by changes of temperature in damp climates. Like colds in the head or chest, they aft'ect delicate-formed and delicate-coristitutioned persons principally. Much may be done, therefore, to ward off the attacks by strengthening the constitution. Quinine and Strychnine is the treatment ; purgatives do harm. I say purgatives do harm, tse an unprofessional friend of mine, who used formerly to artem antiquam, finds even homoeopathic than purgatives; and restorative treatment would be still better than homoeopathic, would she but try it. Another thing which seems to me a broad hint against pur- gatives for " bilious attacks" (by which I mean attacks of gastric catarrh in a body healthy enough to eject bile by vomiting) is, that where there is purging arising without the aid of drugs, the sickness lasts much longer than if there is none. He must be indeed a devoted admirer of the pharmacopoeia who imagines that the artificial diarrhoeas excited by its help can do good where nature's diarrhoeas do harm. Compare the more usual forms of bilious attack, of which I have quoted examples, with the following: CI.XIX. Kli/.alieth J , a domestic servant, aged 32, came in' Mary's October 18th, 1855. Since the first week of the month she had com- plained >f headache and weiirlit at the epigastrium, and on the loth was .-ri/ed with diarrlura. which still continued, though less severe than at first. On the ITtti she was. in addition, attacked with pain in the epigastrium and vomiting, which was very frequent on admission. The pain waf much relieved \>\ mustard cataplasms. The toiiirue was red and clean, the pulse weak and quick. The millions were gp-en, and the vomit was ^iveii too, with shreds of mucus stained with port wine that had I n administered to her. The vomiting was somewhat appeased ]>\ Hydrocyanic Acid in effervescing draughts ; and she also took some Chalk and Opium, with a little gray Oxide rcury in it. P.ut tin- vomiting did not cease till the 'JOtli. after which she liciran to amend, a-ked for food, and was able to get up on the 22d, and : home on the 'Ji'.ih. < I. X . \.-Anne C . ai_'..,l t'.i. was admitted July :Ust. \^:>~. She had been in her usual L r "od health up to a month previously, when she caught (old from exposure, and distrcs.-ini: naii-ea and vomiting en-ued. which in a few hours W as followed liy purging: the stools being watery, I'm thy. and live 200 VOMITING. from offensive odor. The skin then was cool, her tongue clean, the pulse 85. The purging continued at the rate of four motions daily. She vomited after each attempt to eat; the ejecta being green and yellow, mixed with clots of mucus and undigested food. The patient had also considerable anasarca of the lower extremities, and she suffered from palpitations. The force of the heart was weak, but the sounds natural, and the lungs healthy. She was treated without drugs, but had five grains of Pepsine powder three times daily, half a pint of beef-tea, and milk diet guarded with lime-water, food being administered in small quantities every three hours. By the 8th of August she was so much better in all respects, that she was able to eat mutton chop, and to take a grain of Quinine dissolved in Tartaric Acid three times a day. On the 12th she had the full hospital diet. The bowels having become costive^an Aloes and Myrrh pill was ordered every night. On the 15th, there being still some pain at 'the epigastrium complained of, the solid diet was reduced to half, and a pint of beef-tea given for supper. There was also, on the 17th, a threatening of return of diarrhoea; but it was promptly stayed with Chalk mixture, and she was discharged well on the 19th. Eemark how in the first of these two cases the preceding diarrhoea did not prevent the occurrence of stomach symptoms, and how long they endured in the second case where the diar- rhoea had come on at the same time. I abstained from perturbative practice during the height of the disorder, not out of scepticism in the pharmacopoeia, but the contrary ; there was no physical condition capable of estab- lishment by its means which I would induce. The costiveness of the bowels after a natural diarrhoea is a very usual reaction. Had astringents been given, one might have attributed it to them. The weakness of this patient was shown by the anasarca ; but we had no reason to suppose that there was any chronic de- generation of the viscera, or she would have been retained in hospital. In the next case the character of the disease is much more chronic. CASE CLXXI. Helena F , a domestic servant, aged 40, February 25th, 1858. Since the beginning of December she had complained of uneasiness' at the epigastrium after meals, accompanied by nausea. Six weeks before admission she began to relieve the feeling of weight by vomiting her food several times a day, and in the morning to vomit frothy and stringy matter VOMITING. 201 onally streaked with blood. She never threw up any riots of blood, ami alwa\s iif ;t d;irk color. Siiu-c her illness the catamenia had cea.-ed. having been previously copious and painful; she had got very much emaciated. and in good truth she presented an aspect closely resembling that of pulmo- nary rnii.-umption. Hut stethoscopic examination of the chest showed it to :ie healthy, and she had no cough. The absence, however, of cough is no proof of the absence of pulmonary lesions in the sort of case which at first blush hers tl to resemble. For instance \ XII. Mr. J. P came to me May 30th. 1860, complaining of flatulence, and of uneasiness without pain in the epigastrium, and of having i musciilarly weak and nervous. He frequently threw up, as he said. from the stomach, stringy mums especially after eating. But it was not mixed with food in ireneral. He had no cough. He remained under my care till the 10th of June, when I examined his chest and was obliged to tell him that I found bronchophony, crackling rales, and dulness on percussion at the ..f one lung, He seemed dissatisfied with the diagnosis, and I did not have another v. T should like to have made out for sure whether the mucus really came from the stomach, or whether it was the contents of the bronchi thrown up by a nauseating effort instead of a cough. Vomiting certainly does occur in phthisis, and the vomit con- tains mucus. But that mucus is also often purulent, which gastric mucus rarely is, so that it is probably swallowed or ejected from the bronchi by the emetic strain. Such cases as the last should remind us always to examine the chest, cough or no cough, in any forms of disease which are ever assoeiat'-d with consumption. And the only way to guard oneself from the imputation of mistaking the disease is to declare tin- diagnosis to somebody at once, for the patient will often break down very suddenly while you are casting about for an opportunity of letting his state be known. SECTION iv. I" uiitinrj of bio The immediate symptoms diiV-Tin^ from ordinary vomiting whieh precede and ai-e.omjiany the vomiting of blood aiv scribed in the annexed e;: CV-K ri.XXIII. May nth. HI','.'. \Ir~. II .aired !->. uw,.k- at two in the morning, feeling very hot and resiles.-: a sudden faintness and dread came 202 VOMITING. ovor her; she felt pick ; the sickness felt somewhat better, and she got out of bed. Almost immediately, if not in the very act of rising, a flood of blood or bloody fluid gushed up from the stomach. She had not previously considered herself an invalid, but had for several months had irregular catamount, and for three days before her attack had experienced a dull pain at the epigastrium and right shoulder. On examination of the epigastrium, it was painful on pressure, but not one spot more than another. A feeling of nausea was ex- cited by the examination, and also by taking food. The tongue was somewhat dry. She did not bring up her food ; not even when the swallowing a cup of hot tea suddenly (on the 16th) had caused her to retch violently. A pill was administered on the 13th containing four grains of Acetate of Lead, and on the 14th she was ordered R. Acidi Sulphurici diluti n^xx, Olei Terebinthinae rr^x, Infusi Hoematoxyli fl5j, ter die and had no return of vomiting. CASE CLXXIV. James P , aged 37, was admitted into St. Mary's Hos- pital May 4th, 1860. He had been long subject to vomiting, and had five times vomited blood, for the last time the night before admission. The blood, he said, always came up with a sudden gush, and was dark in color. He de- scribed the symptoms preceding the haamatemesis as commencing with head- ache and pain in the right side ; after this he felt heavy and drowsy ; then he got giddy ; and then the blood came up. The tongue was dry and furred, the pulse 92 and bounding. The pulsation of the aorta in the epigastrium was very distinctly felt. (Further particulars of the history of this man may be found at page 109, where his case is repeated on another account.) The above are the ordinary symptoms which occur without prognosticating any immediate danger. When a fatal result is to be feared, they are more severe. CASE CLXXV. Hannah H , aged 48, a cook, was admitted to St. Mary's June 24th, 1852, for haematemesis. She said she had brought up a great quantity of fluid blood the day before, and that while she was throwing it up she felt complete inability to move her limbs. While in the hospital, between that date and July 3d. she several times vomited blood, the vomiting always coming on quite suddenly without previous warning, but being followed by deadly faintness and by an increased pallor of face. On the last-named day, as the house-surgeon was going his morning rounds, he saw her suddenly turn paler, and so he laid her back on the pillow. In ten minutes after she threw up a quantity of liquid florid blood, mixed with clots. She did the same an hour afterwards, and again in the evening. She continued hiccuping. lay with her brows knit, but in no pain. The pulse rose to 136. the skin grew burning hot, the tongue coated with a white gelatinous fur. The voice was reduced to a whisper. In this state of hemorrhagic VOMIT: -203 -he continued, without beconiiic_r eomato-e. till she died, about fifty-five hour-* after HIT last vmiiitiiiir of blood. in. It was i'uii ml that au ulcer had eaten into the coronary artery of tin- stomach. Tlio svmptm< in;r. rly as severe in cases which do ultiinat- e fatal. \ \ V I V _':'-;-. I was summoned to M:- M -. ;. :<-d 82, wliu had fallen down that morniiiu.s illness at such a time of life. 'opes of age the following 0) have an interest, for I think it i- th- lest patient with this complaint t hav.- iia-1 uii'l'T my char \\>- a^ai i vomit. -d. and this time nearly a i|iiart of blood, britrht-eolored. and with dots in it. but not frothy. Tin-re \va> slitrht of the epiLfastriuin. but this, she said, was much in at the time of the ha- -d 1'lack blood by stool. The normal. was but little pulled d^wii by her attack. So, after a forti: in the hospital, she wc-ut out. VOMITING. Vomiting of blood may occur again and again without risking life. Sometimes it is an annual affair, as in CASE CLYI, and again in the following. CASE CLXXVI1I. Henry H came under my care at St. Mary's in Xo- vember, 1862, having in October, on two occasions, in going home from his work, thrown up what seemed to him near a pint of blood. The same patient had, in October, 1861, also been in St. Mary's for haematemesis. It is right, however, to remark that he had emphysema of the lungs as well ; so there might perhaps be a question about the certainty of the diagnosis of the blood coming from the stomach. In the following cases there were intervals of three and four years. CASE CLXXTX. In the middle of September? 1855, Selina Y , a widow of 48, was woke up at two in the morning by a single attack -of profuse hsemate- mesis. She was my patient at St. Mary's for the weakness thence arising, but she was not alarmed at the occurrence, as she had been ill in the same way three years previously. This woman experienced again another gush of blood in October, 1859, and was under my care at St. Mary's afterwards. Whilst in the house she had waterbrash one morning, and ejected a cupful of clear aqueous fluid with streaks of red in it. She reported that in the interval of the two admissions she had lost no blood. It is remarkable that in this case there was no tenderness of the epigas- trium. CASE CLXXX. Catherine C . a servant, aged 28, was admitted to St. Mary's October 19th, 1858, for an attack of hajmatemesis which had just oc- curred. She described herself as a person of good constitution and strong body, but she acknowledged to having had a similar illness three years pre- viously, which had reduced her more than the present one. The ejecta had consisted of what seemed to her a pint of blood, at about 4 P. M. on three successive afternoons, with very slight antecedent symptoms. Again a longer interval : CASE CLXXXI. Elizabeth F , a servant, aged 23, retched up a tumbler- ful of blood a few days before her admission to St. Mary's, May 30th. 1862. She said the same thing happened eight years before to a greater extent, and that ever since she had, besides irregularity of the catamenia and debility, suffered from time to time with sickness after meals, but had not seen any red in it till the present occasion, a few days before admission. She had again several attacks of vomiting whilst in the hospital, but threw up no sanguine- ous fluid. VOMITIN'i. 205 Ami airain a longer: \\.\II. \: tip I'jinnincr of February, 1862, I was reqn hy Sir Kanald Martin to meet in consultation on the case of a gentleman about f.o years of aire. who was gradually dying of excessive vomiting. He was an olil Indian, and he described ill tuning of his gastric ailments, least- :n' first thin^ which drew his attention to the stomach, to be an attack thirty years previously. Twelve years after that he had an- other, and two or three at shorter intervals which I forget. But during the final attack of vomiting, of which he died in the course of the spring, he lost no blood, the cause of death being the excessive exhaustion and emaciation only. It was diagnosed all along, and proved by autopsy to be due to gastric It would probably not be difficult to fill up all the inter- mediate years with instances, but those quoted are enough to its apparently most probable source, I i tin- patient first with pur-rat ivt- cnemata. and then with ti-n-biiithinate and astrinsrcnt (Iron Alum) cnemata, and -rave her also Decoction of I5a> !, which i- >aid tu act most on the lower ln.wel. Nothinjr stopped it till she tnuk n\.xx df Sulphuric Acid with rr^ iij of IJattley's Liquor Scdativus three A fi-w days alter commencing this she had a natural fecal ition. and then improved rapidly under the use of Quinine. It is dear that the lust-used course of treatment must have ; upon the stomach principally, for it certainly does not stop iiiLf from the colon. And from the stomach came the hemorrhage on a former occasion; so that I presume it di- of .Inn--. L857, when .-die was laid up with sore threat at fii-t. 'l'\\i- pa^.-cd in!<> a w.-ai iiiL r l>ain at the epigastrium. . vated l>y f.Kid. and accmiipanied by si-vi-ral attacks of voinitin.ir. (hiring which sin- threw Qp blood. >ln- liecame an out-patient at St. .Mary'.- under I'r. Markham'- ml lie tindiii.ir her weakness and palene.-s in alarminir rapidity. :u. the tuiiiiui- dry and furred as in licni.n rha-ic iniiieiided her liein-r admitted on Aiiuru.-t 'J'Jd. \\ e then found, as I IT. Mark ham had susjiected. but the patient constantly denied, that she ] blood ly the bowels whenever they were opened. This required to be done by artificial means, for si.' .'. e. On t. lined a clot of librin. wa.-hi-d OOlorl \% as an eirg. After observing and examining her for a ! her H. Pliimbi A ij. Opii ^r. j In pilula ter die. She took this for th. md then iier i re open of their own 208 VOMJ.TIXG. accord, and she passed a dark feculent solid stool containing no blood. The pills were therefore left off, and she was treated with occasional doses of Castor-oil to clear the bowels of the remedy. But, for some reason or another, perhaps a relapse of the hemorrhage, I began the Acetate of Lead again on September 16th. giving it her only at night however. On the 21st she passed a quantity of flocculent fibrin without blood. On the 23d a blue border was observed along the gums, so the Lead was again left off, and she does not seem to have lost any more blood during her residence in the hospital, viz. till October 16th. This is the worst of Acetate of Lead you are so likely to have the chronic poisoning peculiar to the metal induced by it. It seems to occur in direct proportion to the length of time the salt is taken, and not to the dose. It is better on this score to give a very few large doses, even to run the risk of griping your patient, than many small ones. A couple of doses of ten grains each will likely enough be sufficient. I have so adminis- tered it in haemoptysis with great satisfaction. More usually the bloody vomiting and black stools occur at the same time, and then there is no difficulty in discovering the true cause of the latter. The following is the most familiar history : CASE CLXXXVIIL Eliza F , aged 35, was admitted to St. Mary's August 21st, I860, having for a fortnight suffered from vomiting of her food, tasting and smelling sour. That morning she had begun to consider her case serious, from having thrown up in addition some clotted blood to the extent of a few ounces. There was pain in the epigastrium, running through to the back, and increasing by very slight pressure. She was ordered a Blue pill and Castor-oil, and then twenty minims each of Sulphuric Acid aud Oil of Turpentine in a mixture three times a day; also ice, milk, and cold beef-tea, like all other patients with haematemesis : but the next day the treatment was discontinued, as the vomiting had ceased. There was no more blood thrown up till the 23d ; the medicines were re- sumed, and it ceased. But all along she was passing black stools, as of digested blood. Then her bowels became costive, and she took only some Decoction of Cin- chona, and was discharged on September 7th. (These two last cases have been related before, as instances of " wearing pain.") To find the remains of blood in the stools is very satisfactory in hospital practice, in order to confirm the statements of the patients, which are not always to be trusted. They \\ill talk VOMITI 209 about throwing up blood to excite attention, when in reality it ily simple vomiting. Besides designed imposition, we have also to guard against ii stake of confounding blood coming from another source with that from the stomach. Thi v enough to run into. xample of the doubt has been given in CASE CLXXVIII. Water! >];,.-!! is sometimes found along with vomiting of blood. It is remarked in CASE CLXXIX, Selina Y , and also in .. VI, Sarah S . It was observed again in the following. X X X I X. Mary S , a cook, aged 23. was admitted to St. Mary '3 July 27th, 18.">3. She stated that her health had always been excellent till six months previously, when she began to experience pain in the chest, and frequently to vomit after her meals. She brought np her food mixed with a yellow (? saniruineous) fluid. She was under medical treatment and got cured. Hut six weeks before admission the pain returned. Frequently instead of vomiting she used to eject a quantity of clear watery fluid (waterbrash). But what brought her to the hospital as an in-patient, was her having three times lately thrown up blood by vomiting. Previous to the hxmatemesis there had been felt darting pains in the epigastrium. Rest for ten days in the hospital, and half-a-dozen leeches to the epigastrium, put a stop to all her symptoms, and at her own desire she returned to her situation ; so there was evidently no sham in the > 1 -aspect in these cases, where waterbrash is joined to bloody vomiting, that the lesion which occasions the latter is near the cardiac orifice. You do not have here the pains in the right shoulder which point to pylorio lesions. I have spoken without hesitation of haBmatemesis as arising from some lesion of the mucous membrane, by which a more or :. umber of larger or smaller bloodvessels have been broken. liae mode in whii-h the rupture is effected is not easy to rtain. Hut it dor- j> lire any very great violence. A blow on the epigastrium not hard enough to bruise the outside skin may, ior example, cause it; as in the following. Misan L , a-. d l.'i. ill'- tli--![>.ited drunken wife of a laboring man. had a tijrht with her husband, and L'<>t her eye blacked, her bark kieked, ayd a punch on the lielly. The two form not the latter. She was brought to the hospital April 3d, lti.~G. because on going uut into the U 210 VOMITING. Edgware Road the day after the fight she felt very faint, and threw up a good deal of blood. It was at first considered to have come from the thoracic vis- cera, seeing that she had no bruises or pain on pressure in the abdomen. But examination with test-paper, and what she had thrown up on her clothes, showed it to be acid, and to have come from the stomach therefore. The pulse was hardly to be felt ; she was delirious, the skin clammy, and the feet cold ; so that we had to rouse up her ebbing life with hot water and mustard. She had also rr^xx of Oil of Turpentine every hour ; but as at night she still continued vomiting blood, a slab of ice was laid on the epigastrium, and Alum and Tannic Acid administered by the mouth. Next day the bleeding had ceased, the pulse became more perceptible, and the mind clear. There was no return of the symptoms, but I kept her in till the 21st for safety. In the last history it was mentioned that there being no pain in the epigastrium made the diagnosis doubtful at first blush, though the injury was proved so indubitably to be in the stomach by after events and observations. In the case of Selina Y (CASE CLXXIX) there was also no pain in the epigastrium. Perhaps a clue to the condition existing under such circum- stances may be afforded by the following. CASE CXCI. Elizabeth A , a cook, aged 35, but unmarried, was admitted to hospital under me June 10th, 1861. She had the appearance of good health, and said she had always enjoyed it till five days previously, when she felt so nauseated and giddy that she thought a bilious attack must be impending. A disagreeable rising in the throat lasted all day, and at 10 P. M. she vomited violently and threw up blood. There was perhaps also bile mixed with it, as she said it tasted bitter. This was on Wednesday, and on Friday she again vomited blood and passed black motions, and on the Monday came to St. Mary's. In the mean time she had been taking pills bought at a small chem- ist's shop, and therefore probably containing Mercury, the usual panacea in counter practice. At all events, she was salivated on admission. In this case there was no pain in the epigastrium without or with pressure. The liver on admission was found much enlarged laterally and vertically, yet neither was it painful on pressure. She had no medicine. On the 12th the liver was much smaller. The black color had disappeared from the motions, and she had no more vomiting of blood, and went out on the 28th. . I suppose the cause of hgematemesis here was congestion of the liver a condition which is said often to occur in practice, though I confess I can seldom make it out by percussion. VOMITING. 211 From the above > MB 1 ''ild conclude that the vomiting of i deiiot.-s. if not perhaps an open bloodvessel, yet such u ; pathological state of the mucous membrane as requires a completely alterative renewal, and that such alterative renewal -t brought about by general analeptic remedies, by the ;oval of congestion, and by the restoration of capillary circulation through local depletion. I should infer also that -ters of the immediate hemorrhage are Turpen- tine and Aeetate of Lead internally, and ice externally. SECTI.ON V. Acid fermentation of vomit. The contents of a healthy stomach ejected by any accidental cau.-e have a certain amount of acid reaction from the presence of the acid gastric juice, and indeed this is necessary to their solution. And a degree of sourness in the viands consumed seems to favor their digestion. So that acidity in itself is not a morbid phenomenon in vomit. it be understood, then, that I do not refer in this section to the ordinary normal acidity of the gastric contents, but to the ntation, principally into acetic acid, of the whole mass, to ion of undigesting food. 1 -<>r truly in some cases of vomiting the excessive acidity of the mass is a very marked feature. The throat is burned by it, the teeth roughened and the eyes made to smart, just as by talcing into the mouth a strong solution of acetic acid. And the sour smell of an acid volatile at a low temperature is dill' through the air. In fact, the whole mass of the ejecla has me acid, in.-tead <>f m. -rely having acid mixed with it. Tl.< ention in the stomach of the remains of the meal so long that they have had lei.-nre to ferment through- out, instead of 1. they beran 1 by the 1C jui.-e. | of the retention mo.-: coating of the liriinir membrane with adhe-ive mucus, which impedes the peristalt; - and pr6V6Hta the ^a.-trie sol- vents from pen.-tratin-' tli.- ma-s. The acidity does not Q indigestion, but tin- i 1 I the acidity. lining t. ng that any internal decom- 212 VOMITIXG. position to which it may be from its nature apt is aided by time, the mucus also in itself is an encouragement to chemical action. A familiar instance of this is the rapid decay of the urine in a catarrhal bladder. The mucus is probably itself in a state of chemical change which is thus propagated to the mass. The decomposition of the mucus is shown by the frequency with which different sorts of low parasitic growths, or moulds, are developed in it. The well-defined species Sarcina Ventriculi is the most distinctly marked of these, which, though detected occasionally elsewhere, certainly finds its most congenial home in the stomach. In other places it has been found in completely dead matter (as by Virchow in gangrenous lung) or else a float- ing wanderer in excreted fluids, 1 but on the lining membrane of the stomach it may be seen fixed and growing in the mucus. It is not often that an opportunity occurs of proving to the eye that such is the habitat of the Sarcina we frequently find it vomited, but the patients seldom die during their illness, the complaint not being a fatal one. One indeed has offered itself to me in CASE CXXXIX, a girl of fourteen, who died in St. Mary's Hospital of enlarged heart. 2 She had frequent attacks of sour, but not frothy vomiting, before death, and at the au- topsy we found the great curvature of the stomach thickly clothed with a stringy mucus, very difficult to detach, in the outer layer of which a considerable quantity of Carcinae were imbedded. It is pretty clear from this that the mucus, and not the stomach's contents, is the root-soil of the Sarcina. Being fixed then in a permanent home, and rapidly replacing with new growths those which are wiped away by the food, the Sarcina is probably not inert. A great number, perhaps all, of those cryptogamous plants whose nature is to grow upon decomposing organic matter, have the property of promoting decomposition, so that they are not only consequences, but causes also, of decay. It is found, for example, that the gutta- percha covering to electric-telegraph wires, when laid down near the roots of oaks, becomes rapidly rotten from the presence of a fungus peculiar to that tree. Put your jam in a new cup- 1 Parkes, " On the Urine," p. 213. 2 See page 171. VOMITING. 213 l>o;ird, and it will keep much longer than in one where mould Las previously grown. Saving housewives used formerly to what they called a "vinegar-plant;" it is a simple-celled cryptogam found in old If placed in sugar and water, it makes the whole undergo the acetous fermentation in two or thive weeks, instead of the process occupying several months. The mould found in yeast (the Torula Cerevisiae), though not ;ial to alcoholic fermentation, certainly augments the rapidity of its induction ; so that it is entirely in accordance Avilh known physical laws if the presence of sarcinas, or of the plant, on the mucus of the stomach should bring on fer- mentation in the food before the obstructed absorbents have time to take it up. Both have been found in the contents of the stomach ejected; and it is shown by the case I quoted, that sarcinae at least may exist adherent to the mucus without being thrown up, at least in quantities sufficient to be discovered. Probably oftencr than we fancy these moulds are unseen pro- moters of the rapid fermentation which takes place so mys- teriously in the stomach of invalids. The chief factors in this fermentation, then, I take to be mucus adherent to the walls of the stomach. With this mucus there gets intimately mixed up some dead animal matter which Mnl moulds and so encourages the fermentation. lead animal matter often is blood exuding from the gastric : for the mucus is so tough that the food taken into the inch has much difficulty in blending with it. The following cases are typically illustrative. <'X< '11. rornelius K , a laborer, was admitted to St. Mary's June 27th. lH"ti.snlj>liiti> p)j. Acidi Hydrocyanic! tliluti n\,v, ;I-;L- ('amphorae fl3J. Ter die. try. 1' -A mutton chop; stale bread ; water. i's. Milk, with one-quarter of its bulk of lime-water; stale brr;ul or captain's liisciiit. II' vomited just after leavinir my room, but only once again after commenc- ing tlie use of tlic medicine-. After a week he was troubled with some intes- tinal flatulence, which was entirely obviated by fifteen grains of Charcoal every iiL r ht and smut' I'epsine at dinner. He had also some Strychnine as a . al remedy for his indigestion. SECTION VI. Fecal vomiting. To quote instances and discuss this subject in detail would be to travel out of the province of "The Indigestions" too far; formal notice of it can scarcely be omitted from an enu- meration of the morbid matters ejected in vomiting. Feces, or more strictly speaking matters having a feculent smell, are found in vomit only where a mechanical impediment has completely arrested the onward movement of the peristaltic in a lower part of the intestinal canal. It lasts as long as the impediment lasts, and ceases with its ceasing. The cure -olely in the direct removal of the cause. il vomiting is popularly ascribed to a reversal of the -taltic motion; but I do not think it desirable to resort to such a strained explanation. When we reflect that about twelve quarts of secretion, bile, and intestinal juices together, not counting food, are daily poured into the intestines, 1 it is to see that the onward wave and absorption have only to be for the ilia to be overfilled, and for their contents to overflow upwards into the stomach. Then- they naturally pro- duce vomiting, just as they would if swallowed. No reversal is oeoasaarj. N - - h an arr> place most notably and obviously in strangulated hernia, in which without any inflammatory action 1 Bidder and Schuii.lt. 216 VOMITING. having arisen we have vomiting, which does not endure long without becoming feculent. And a like paralysis falls upon the muscles and absorbents of the bowels in peritonitis, also inducing vomiting. It is true that this vomiting in either case, though it tends to become feculent, does not always arrive at the point of being so. There may be too little feces already prepared in the canal to odorize the great mass of liquid ; or the arrest of movement may take place too high in the ilia ; or it may be just complete enough to fill the ilia while yet some feces drain off' at the lower end. These circumstances do not alter the essential nature of the act. I think the smell is derived from the contents of the lower ilia. I doubt much if liquids can overcome the ilio-c?ecal valve, even when paralytic. It is a valve, not a sphincter, and offers a resistance even in the dead body. SECTION VII. Vomiting of unchanged food, and hysterical vomiting. By far the most common cases of vomiting are those in which the ejecta consist of food scarcely if at all changed from the state in which it is swallowed. Sometimes it is moderately acid from the admixture of a small quantity of gastric juice ; sometimes it is neutral. It is not my intention here to discuss accidental or occasional vomiting from external causes, which may be considered rather the business of the physiologist, but such as having a deleterious influence on the general health comes under the care of the physician. This sort of vomiting happens soon after food has been taken, and is always preceded by a feeling of discomfort at the epigas- trium, often by nausea ; indeed, it seems often to be a sort of semi-voluntary movement to relieve that discomfort. I do not know but what in all vomiting there is something of an exertion of the volition ; but in some cases there is a much more marked feature, and the voluntary character may be made use of in the treatment. It is an important point to observe, VOMITIM,. 217 and I shall therefore cite first some typical examples of its being under the control of the will. 1 VI. Mi.-s Kllon H , aged 14 or 15, was under my care in the spring iif 1 -'>:'-. for treneral ill-health and emaciation. There were some jrhm- dular swellings in the abdomen and groin, but hardly enough to account for \treine decree of emaciation, dry skin, and depression of spirits. On further inquiry it appeared that for four years she had experienced discom- fort around the waist after eatinir. and had been in the habit of going away ly soon after meals and vomiting up what she had taken. She said she could not help it. but yet it appeared that when circumstances prevented her aient. she was able to restrain herself for a time. Acting on this hint, ; red her parents to exert their authority and forbid the ejection of food. e her (with the Iodine ordered for the glandular swellings) some Cod- liver Oil. and sent her to be amused at the sea-side. In a fortnight I heard from her father that she had become convinced of the importance of keeping off vomiting, but that still from habit the food would rise, on which she swal- lowed it a<:ain. according to her own very appropriate phrase "chewing the cud." The best evidence he could give of the success of treatment was, that she had gained in weight four pounds the first week and four pounds the second. This girl, though neither hysterical nor insane, was yet very original in her notions, and had apparently out of her own head devised the vomiting as a relief to epigastric discomfort. The vomiting may at first have been wholly intentional, but latterly it seemingly assumed a more involuntary and reflux character, as shown by the rising of the contents of the stomach into the fauces in spite of the efforts of the patient to keep them down. In the following case the vomiting was at first involuntary, and then when the patient got better and was really able to prevent it, she designedly induced it as a relief to her discom- fort. r\r VII. Emily d 20. maid-servnnt, presented herself at St. Mary's September L'lth. ls>. She was reported subject to hysteric fits, for which she had already l>eeii an in-patient in ls.">7. She was very pale and iihle^matic. ami the cataiuenia were irreirular. She had an hysteric fit on the 25th. On the 2sth she complained much of headache, and begun vomiting after all food. Tin- next morning the catameuia appeared. The vomitiuir continued very obstinate, in spite of Valerian in decoction and tinc- ture, and Uroinide of |'OT:I ;MIU. Showerliatlis at last stopped it. and then she designedly brought it back by putting her fingers down her throat. In the 1 -nenial t med to bring on the vmptums. In the next it relieved them. 218 VOMITING. CASE CXCYIIT. Mary H , aged 16, was admitted into St. Mary's Decem. ber 16th, 1853. She was complaining of flatulence in the bowels, eructations, and vomiting of food. She had been wearing a large wooden busk to her stays. The catamenia had been regular since the age of fourteen, except the last period, which was overdue ten days. She continued vomiting everything she tried to swallow all that day, the next, and the next after that. On the 20th she vomited part of her breakfast, and then the catamenia appeared, and she vomited no more, though kept in a few days to see if the symptoms returned. The frequent connection of vomiting in the female sex with that same state of constitution which induces hysteria and also irregularity of the catamenial periods, leads one to employ Valerian even when the menses are regular; and it is often successful. CASE CXCIX. Mary Ann T , aged 18, was an in-patient at St. Mary's December 3d, 1855, for an attack of continuous vomiting of all food, which had lasted six weeks. She said she had been subject to attacks of this sort since her childhood ; but they had not prevented her arriving at puberty at fourteen, and menstruating regularly ever since, having a good appetite, and growing up a plump, cherry-cheeked girl. She was given simple diet with milk and lime-water, with a mixture of Rhubarb and Gallic Acid three times a day. The sickness continued as bad as ever on the 5th, the bread and the milk taken being rejected exactly as swallowed. Then she was ordered R. Infusi Valerianse fl^j, Tincturse Valevianae co. fl^j. Ter die. An immediate good effect followed. She did not eject the medicine, and the next day she was able to retain the milk. She had a little relapse of sickness on the 10th, but after that continued well, and left on the 20th. Functional vomiting is sometimes so bad that no remedies can be kept on the stomach, and then a very good expedient is to give that organ a complete rest. CASE CC. Esther D , a stout young woman of 21, was admitted to St. Mary's August 23d, 1859. She had been ailing for a fortnight with headache and general malaise, and pain in the left hypochondrium. On the 21st she had an hysterical fit, and afterwards commenced vomiting very violently. She had great pain across the pit of the stomach, and the vomiting and this pain were immediately induced by an attempt to swallow. She lay on her back, with the knees drawn up like a person with peritonitis. But, very unlike a person with peritonitis, the abdominal muscles were vio- lently exerted in breathing. Her skin was hot and dry, her pulse 120, her tongue coated with a yellowish fur. Altogether, she was extremely ill, but a ITIXG,, 219 good di>al of her febrile s- ! due to her being partially under the in- flu< nee of Mercury, which hail heen assiduously given up to her admission. The -.nuns were ulcerated, and blood oozed from some part of the fauces staininir the vomit with streaks of blood. T-n I. . ches were put on the epigastrium, but they did not seem to relieve the pain. She was ordered to have no food or medicine by the mouth, but half a pint of heel-tea in an enema, with five drops of Laudanum every three hour-. She was fed in this way for ten days, when some warm beef-tea was ; her ; that she threw up. hut was able to retain it when quite cold. After this she wax alile t<> retain her food for a week or so. But then the vomiting re- turned, though not so bad as before. She was treated with Valerian, with mine, and with IMisters ; hut the success of each remedy was very tem- porary. On Octoher 10th, a cold shower-bath was ordered to be taken every morniu?, and an immediate stop was put to her vomiting. The symptoms did not occur at all again, though she was kept in till the 28th to be watched and to have haths. Entire rest given to the stomach for a few days will put a st<>]>, final or not I cannot say, to vomiting of a much more chronic character, and even where the souring of the mass seems to point to something more than the functional nervous lysis which has caused it in the hysterical cases already quoted. ' I. Charlotte S , a dusky, tongh-looking spinster of 28, admitted M.i'-\ - M arch LM'ith. isfio. Kiirhteen months previously she had causrht cold, and after three days was taken with vomiting very soon after eatinir. Tin- matters vomited are the food she has been taking, often accompanied by -idmlile quantity of fluid tasting sour. This has made her weak ami diminished the catamenia. which are scanty, though regular, and accompanied by a pood deal of pain. The last six weeks she had got worse, and could keep no food on her stomach at all. On admission her pulse was 96, full and strong enough, the tongue was furred, the h-.wels wrc costive, the urine was sliirhtly alkaline, not alhnminoiis. For two days -lie remained in hospital, vomiting all her food, hut taki medicine : for, either hy areident or intention. I had written no prescription. On the L'-tii -lie wax ordered to have no food by the mouth at all. but half a pint of hcef-tca with live drops of Laudanum as an enema every three hours. She retched no more. On the 151st some milk and Lim-water, in small quantities at a time was given her to drink, and she kept it down. Still, however, the mem., trusted to as the chief nutriment. Vpril 4th sh" tried a muttou-c!j,.p. and succeeded iu retaining it. Ofl the loth .-he left well. 220 VOMITIXG. It was observed that when she took to meat again the urine was acid, deposited urates, and contained a little albumen. In the following case the habit was still more ingrained by time, and also the color of the vomit induced a suspicion that there was hemorrhage of the mucous canal in some part, either oesophagus or stomach, yet it was cured by a temporary rest. CASE CCII. Mrs. S , a small, swarthy, bright-eyed woman of 22, was brought under my care March 9th, 1861, for constant vomiting of three years' duration, which she attributed to having caught cold during a monthly period, having her courses checked for several months at nineteen years of age, when a virgin. Her food was always returned by the mouth within ten minutes after swallowing, and was unchanged in appearance. Besides this, she also vomited at other times, when the stomach was empty, if her mind was excited. Indeed she did so in my own room, ejecting some reddish-brown granular and flocculent matter, which looked exceedingly like semi-digested blood. She was not much emaciated ; her catamenia had returned ; she had mar- ried six mouths before I saw her, and had a miscarriage at an early term of foetal life four months after marriage. All which proofs of vigor seemed to show that a good deal of nourishment must escape the rejection by vomiting. She said she felt constantly hungry, and was evidently of a hysteric tempera- ment. I advised that she should be kept entirely without food and nourished by enemata of beef-tea and Laudanum for a week, whilst at the same time the stomach was further quieted by the application of a few Leeches to the epi- gastrium, and some Bismuth. On the 17th I heard from Dr. Woodhouse, of Hertford, who had undertaken to watch the case, that they had not arrived at continuing the treatment a full week, but that for two days the patient had taken food and kept it down. He reported well again on the 18th. But on the 20th he said the sickness had returned with great pain in the right groin. It was again stopped by a recur- rence to the treatment for a week. The whole number of days' rest was thir- teen or fourteen. On the 28th Mrs. S was able to take four meals a day, and began Iron and Quinine, which on April 29th she was going on with, h;ivinjr had no return of her sickness. In the spring of 1866 I heard from her sister that she had continued well ever since. In a former case (Esther D , CASE CC), the agency of complete rest to the stomach and of shower-baths may have been compared. The first seems more calculated to work a powerful and immediate effect, but that of the latter was more permanent. In the next case I trusted to shower-baths at once, and with apparent success. VOMITING. 221 : (Till. Miss Frances C , aged 21, a younjrer sister of tha last patient, is ;t very plump girl, with a pink and white doll's complexion; but when >lie th -t earn.- io me, on the 4th of April 1866, she and her mother posi- tively alii rmed that she hardly ever, for five years, passed a meal without vomiting. She seems a calm, sensible person, impressionable perhaps, but not hysterieal. She says that by a violent effort she can keep things down; but that effort produces violent pain at the upper part of the sternum. The vomiting had been worse and her efforts to restrain it more ineffectual since a violent purgative course which had been administered by an occulist to an inflammation of the tarsi. Since then, also, her bdfrels had been very !ered her a cold shower-bath at twelve o'clock every day, and the fol- lowing draught : R. Acidi Hydrocyanic! dil. *n.iv, Tinct. Valerianae com p. fl^j, Infusi Valerianaj fl.5J. Bis die semi-horam ante cibum. On the 12th this medicine was changed for four drops of the Prussic Acid before meals, and R. Zinci Valerianatis gr. iij, Opii gr. $. Omni nocte et mane. On the 28th she called to show herself as quite well ; but she purposed to continue the shower-baths every morning as a substitute for the British tub- bing. The hereditary nature of the constitution tending to this disease is shown \>y the two sisters being afflicted in a similar \v:iv. Si-rim: their mother one day I took the opportunity of mining her, and found that though she had never been subject to vomiting, yet she used to have regular hysterical fits when a maiden. Strong mental impressions sometimes have a singular effect both in hriirjini: on and stopping chronic vomiting of this sort. An np.-'-ttiirj- .-hock will indu : a calmative control, or the idea thereof, will arrest it. Hannah M , a::e t ] 1'.'. was sent to me by Mr. Ay res, of 1! mi-'_Mte. in January. 1-. ' of hysteria, she had suffered daily from rejeetioii of food for six months, sometimes throwing up every- thing euteil. but always unehaiiired in aji;>i-aranee. She had al-o frequently .dlowinir. so immediate w.t> the rising ,,f j] u . L r,, r ^r t . a t food. * .ileriau, and -h* I well. Then .-he went home to 222 VOMITING. Ramsgate ; and, being soon afterwards frightened by a chimney catching fire, was attacked by vomiting again. She returned to London and sent for me. Immediately on my visit with- out any remedy the vomiting ceased, and she swallowed everything easily. It was the most "veni, vidi, vici" cure I ever saw. The cure here was purely moral. And of shower-baths, too, I think we may class a great part of the strength among psychical agents. To take a; cold shower-bath demands a certain control over the wifc, even when you are driven into it by a stern nurse, and the bracing up the mind to the resistance to the instinctive shrinking against the shock is the best possible lesson which the physician is at liberty to prescribe. Strength of will is gained by willing. I have already said that I looked upon the temporary paraly- sis of the oesophagus as the most essential pathological condition in vomiting, A confirmatory evidence of this is found in some cases 'where temporary paralysis of other parts is exhibited along with the vomiting. I extract the following case out of my clini- cal lectures for 1863 : CASE CCV. I will call your attention to a case of vomiting, namely that of Hannah P , aged 18. She is a respectable farmer's daughter, and seems to have been much petted at home. She has large black pupils to the eyes, and puffy eyelids, and allows that before her present illness she used to have hysterical fits, but not since she has suffered from what she came here for, namely, chronic vomiting. I should rather call it a rejection of food, for it occurs even while food is being taken, almost always before it is swallowed. This happens at every meal, and has lasted a year and a half, and during that time she has been for a short time in her county hospital with relief but not cure. She has also pains in the back and in the splenic region. She declared she was unable to walk or even to stand without assistance, and when placed upright in the middle of ttte room she fell down at first. Nevertheless, after a scolding and a decided command to exert her will vigorously, she at last began to put one leg before the other, and progressed a few steps even on the first day. The catamenia had been absent three months, and indeed hud never been established at regular periods. This girl, after retaining mutton-chops and porter for a fortnight, and ex- hibiting her muscular powers by a walk to Oxford Street and back, went home well July 13th. While in hospital (convalescent) she was employed about the wards ; and being thus brought in contact with a young woman recovering from rheumatic fever, she infected her also with a desire to vomit, which, how- ever, was checked in the bud. And I afterwards heard, from one of my pupils, VOMITI 223 ho next winter not only n-lajisi-d into IHT former condition, but again coinmuuirutfd it to a neighbor of her own age. , There is a peculiarity about hysterical paralysis which in a lee to its nature and guiding to its nature is here more than anywhere a most important step in the cure. :i you set the patient up on the floor, assisting her with one or two hands, or with your hands under the axilla?, according to the degree of paralysis and the amount of aid wanted, the is immediately thrown forwards, and all yo9r strengtli is called tor to prevent her falling on the face. Other paralytics fall to one side or the other, or backwards, and do not stumble forwards in this way. The peculiarity was well marked in the above instance, and aided the diagnosis. So also in the vomiting which is associated with it in its nature there is a peculiarity which is a diagnostic guide. It can rally be controlled by a violent effort of the volition. And thus to exert the volition is a help not only to the diag- 3, but to the cure, as has been shown by several instances of a typical sort. Mention was made in a parenthetic addition to the history of this last case of the communicability of this kind of complaint. an instance of the mysterious power of sympathy which influences so much of our outward life from the cradle to the . In this instinct of imitation there are indeed de^ 1 but no essential differences between that which helps the infant to acquire the power of speech, and that morbid condition in which the mind and body are slavishly enchained to reflect the engendered by the feelings of another. It is innate in all, but is weak or strong in proportion as the mind is capable of 2 alone, or is necessarily in the habit of depending on others. This is the reason why it prevails so much among the female sex. I have had so many instances of hysteria, ci and allied i Ifhoee pathology lies between mind and matter, lieinir caught by lookers-on, that I cannot h. call their transmit- >n an infection by the c\ e must be taken to distinguish from tl. : of cases in which from some mechanical impediment <>r le.-i.m the f"d cannot be swallowed, such as that cited in illustration of 224 VOMITING. another part of the subject at page 194, or the following, where the result being happier, more doubts might have been expressed as to the diagnosis. CASE CCVL A respectable cabman's wife, Ann A , aged 32, was ad- mitted to St. Mary's July 22d, 1853. She was exceedingly emaciated, weak, anasmic, and had a loud murmur, probably from anaemia, with the first sound of the heart. For a month she had been obliged to reject her victuals after chewing them, from inability to pass them further than the back of the throat. They seemed toetick at the level of the os hyoides. From this point a pain ran to the back of the neck, between the shoulders. Quite at the posterior part of the fauces the mucous membrane looked redder than elsewhere, and was redder still lower down. She was ordered rations of beef-tea and milk, and the following electuary : R. Bismuthi Trisnitratis 3J, Sacchari fsecis 3iss. Fiat electuarium quotidianum, cujus lambat panxillum subinde. When able to swallow better, she had some Bark and a blister on the throat. She lost the pain, was able to swallow, and left much relieved on August 7th. It will be seen here that the food is not swallowed at all, and there is no emetic effort. It is simply rejected. I am glad of the opportunity in citing this case of again recording the good effects of Bismuth, alluded to under Case CLXIV. To sum up, I would deduce from the very common class of cases of which I have cited typical examples : 1st. That the chronic vomiting of matters swallowed un- changed immediately after swallowing is almost peculiar to women. 2d. That it is allied to hysteria. 3d. That, like hysteria, it is now more a mental, now more a bodily affection ; now more under the patient's control, now less. 4th. That the efficient employment of drugs being in a manner barred by their rapid ejection, other means are more imperatively called for in this disease than in most others. 5th. That the weakening of the patient's will being the marked feature of this morbid constitution, the strengthening of the will is the best antidote. 6th. Rational persuasion is available in some few, extremely voluntary, cases. V n M I T 225 7th. The most powerful remedy is the cold shower-bath, for the reasons irivfii above. 8th. When physic can be retained, the most efficient is i;in. i'th. A forcible change of habit by resting the stomach, and Diving it nothing to bring up, is a valuable aid ; but it is doubt- ful how tar it wuuld answer without other remedies. SECTION VIII. 1 ' nonary consumjition. VII. Cyrus K . u<_"-.i '-"-'. ' Mine in July, 18.")."). with a complaint of laniMiMi-. sleepiness of an afternoon, weight at the epigastrium an hour or two after meals, and occasional vomiting in the morning. He had had a good deal of hard work latterly, and attributed his indigestion to that. But his mentioning a cough induced me to examine his chest, where I found marked deh'c-ienry t.f respiration and dtilness in the apex of the left lung, and crack- ling in the lower lobe of the same side, lie was also a good deal emaciated, and he owned to having spat blood before he was ill. I thought there was tuben-le just beginning to soften ; gave him for a time Lime-water and milk, Coil-liver Oil. and Steel \Vine after meals. And then I urged him to go to the West Indies, where he had connections, for the winter. In October, l.-t'.l. he came again, telling me that he had gone to Bermuda and stayed, not only for the winter, but ever since. In 1858 be had spit tin*; of blood, and he had yellow fever in 1859, but had grown fat in spite of them ; and he had continued well till he was now come to England, where, after a few months' holiday, he found his old dyspepsia returning, and was wisely re- >ol ved to go back to his more appropriate home. There was crackling in the apex previously dull, but I do not think the lungs had got materially worse. This is the slightest degree of stomach derangement, for it did not even prevent the taking of Cod-liver Oil. V 1 1 1. An unmarried lady of 32 was sent up to town for my opi- nion by Mr. Gardner, of 1'aiuswick. May Hiid, IM'.:>. She had l>een ill since the previous October with vomiting after meals. The food returned at short intervals in mouthfuls in an undigested state. '1 lie matters rejected were almost always free from aridity. Sometimes this would begiu in the morning and continue all day. sometimes would not come on until the evening. She had a slight feeling of weight or oppres.-ioii at the epigastrium, but there was no distension or tenderness. Her general health had not sum-red much, the meii-es remaining regular, and at these periods she thought she was better. Though she. haii cough, it was not a marked feature in the ca 15 226 VOMITIXG. On examining the chest, I found evidence of crude latent tubercle in the lungs. There was deficient respiration in the right apex, and a bronchial interrupted expiration in the left. The degree of dyspepsia and the degree of tuberculosis are not proportioned to one another. There was in this case much more vomiting and less tubercle, or less advanced tubercle, than in the last. Perhaps it was because of the patient's sex. CASE CCIX. William J , aged 21, was admitted to St. Mary's August 21, 1857, for pulmonary consumption of two years' duration. (The upper part of the chest was much flattened, and the shoulders drawn forwards ; there was bronchophony and bronchial breathing, and various creaking rales in the apices of both lungs, most in the right.) He suffered from several dyspeptic symptoms, and among them from vomiting. He stated, however, that this latter only occurred if he attempted to move about and take bodily exercise after meals. He was able to keep down Cod-liver Oil if he remained quite quiet after- wards; and upon that, and Iron after meals, he gained two pounds in weight between August 28th and September 5th. He was then treated for a week with Hyposulphite of Lime (eight grains three times a day) , but gained only one pound in that time. His sickness never troubled him as long as he kept quiet and rested in the hospital. The sickness only on exertion looked as if it depended on general weakness, rather than on any morbid condition of the stomach. I introduced the last clause in the history, not as especially bearing on consumptive vomiting, but to take an opportunity of saying that I have not found Hyposulphite of Lime such a good renewer of life as Cod-liver Oil. Some consumptive patients did not gain any weight at all under its use, in spite of the improved diet of the hospital. The next two cases exhibit the coming on of vomiting in consumption coincident with the first haemoptysis. CASE CCX. Emma K , aged 25, was sent from a penitentiary to St. Mary's Hospital, on account of her failing health, July 22d, 1853. She des- cribed herself as having been weakly for a couple of years, but had no marked symptoms till a fortnight before, when she began coughing up blood. At the same time she commenced vomiting, and continued to throw up everything she took. She was rapidly losing flesh. On stethoscopic examination the apex of the right lung was found dull and very painful when pressed. VOMITING. 227 " (Jnllir Acid (for the haemopn-;- . Hydrocyanic Acid, Morphia. Quinine, .illy given, without any advantage to the sickness. Chloroform in c-i^lit miuiin doses was of temporary use. but the most effectual remedy was Opium in grain doses. Under this her sickness ceased, and she immediately : to gain flesh and strength, and left the hospital in fair condition 181 'JlUli. "With the vomit there was at first a good deal of light green fluid, probably bltMid swallowed and digested. \I. Bridget S , a domestic servant, was admitted to St. Mary's January L'llth. K>7. with pulmonary consumption of eighteen months' dura- tion. It had liegun with hemoptysis and vomiting. The vomit usually was merely the contents of tin- >toiua-h. but sometimes she brought up clots of i at the same time. The good effects of Opium in checking the vomiting of con- sumptives was alluded to in CASE CCX ; the following illus- trates it still more strongly. CCX II. B.'s Anonyma, aged about five-and-twe.nty, was placed under my (are in March. 1861. She had a large vomica in the upper lobe of the left luug. and the greater part of the lower lobe impervious with tubercles ; but .-he had suffered very little from pulmonary symptoms, would not h< her being in a consumption, and talked ubout going to dances in a low dress as soon as she could get about again. But she was utterly prostrated to her bed by the constant vomiting of all she ate, and retching when she ate nothing. The bowels were obstinately costive, and she had taken as much as twelve grains of Kxtract of Colocyuth without efl'ect, \e !MT Opium, beginning with a grain and augmenting it to six grains daily. Then the vomiting ceased, and she recovered her appetite and fond- er luxurious living. She ate twelve shillings' worth of strawberri April' daily, and an immeasurable quantity of brown bread ice. Her bowels red their functions, and she pa.-sed naturally colored and formed Bt in spite of the Opium. She slept naturally and easily without excess or stupor. She died in the summer, but was able to keep off her vomiting to the last by the help of the Opium. I think, however, she increased the dose. So that her ending was made much more easy, and probably postponed by it. A diiVeivnt fonn of phthisical vomiting, sadly common, is that which occurs in an advanced stage of lar^c vomica', from the nans. of the sputa. It is very distressing to the patient; and almost equally so to tin- physfciau, for his remedies all'ord little or no relief. This vomiting is more frequently found when the vomica occupies the lower or middle parts of the lung than when it is 228 VOMITING. at the apex, for the reason that in these first-named situations the cavity is more apt to eat itself into the neighborhood of the ribs, and it is the contact of bone which makes the pus grow so horribly fetid. CASE CCXIII. Captain H , a man of fine build and healthy family, aged about 36, came under me in August, 1862. He had long been subject to cough, but had never spat blood. His complaint was of considerable pain in the right side, which, as an old Indian, he attributed to what they call "liver." In the lower lobe of that lung there were dispersed cracklings to be heard with the ear, and there was slight general dulness on percussion diffused through the lobe. This was in front ; behind the sounds were healthy. The sputa consisted of transparent mucus. Leeches and Chloroform considerably relieved the pain for the time, so I suppose it was dependent partly on pleural inflammation. In October of the same year his pain in the side was less sharp. The ex- pectoration and cough were worse. There was very marked dulness with absence of respiration in the right infra-mammary and infra-scapular regions. He went to the South of France for the winter. In the May of 1863 I saw him again. He suddenly, during a violent fit of coughing, had thrown up a pint of pus, and continued coughing it up. If the cough ceased for a little time, the pus would collect, and then, on being expectorated, tasted and smelt so intolerably nauseous that vomiting inva- riably was produced. This took place always every morning, when the matter had collected during the night. I one day examined some of this fetid sputa under a microscope, and found pus-globules of various sizes, some regular and normally granular, some swol- len and exhibiting their nucleus, fat in globules, granular masses (? rotten fat), tabular crystals of cholesterine, and spicular crystals which my microscopic lore was not sufficient to enable me to identify. It was anything but " laud- able." Poor Captain H was very patient, but a more distressing case I have rarely seen, so excessive was the disgust from the constant vomiting and fetor of the expectorata. He got a little better for a time at Malvern in the summer, and was kept from sinking by Cod-liver Oil and Quinine. But the abscess or vomica never healed up, and continued to secrete fetid pus. The dulness on percussion also increased in extent, so that there was scarce any breathing over the whole lung ; I supposed that a fresh deposit had taken place of tubercle, or whatever other matter solidified the pulmonary tissue. He died at Lisbon the next winter in an extreme state of consumption. However, he never had any diarrhoea. The vomiting and fetid expectoration never seemed bettered by any medi- cine, except perhaps Quinine, and that he could take very little of, such a headache it gave him. VOMITING. 229 It is impossible to bring to bear on a pulmonary lesion any of the usual applications that surgeons make to fetid absce or else in siu-h a case as the above one would be glad to use them. To bore an opening through the thoracic walls would ably be a great comfort to the patient and a prolongation of life; and I should be glad to find the operation consented to. IJut it is impossible conscientiously to speak of it as likely to a cure, and naturally the knife is shrunk from I do not expect ever to try it. SECTION IX. Occasional causes of vomiting. ('('XI V. Wilson M , aged 29, a coach-painter, was taken in by me at St. Mary's Hospital the morrow of Christmas Day, IHG'2. He had always tieen a strong man till the middle of November, when he was aware of a pain across the loins and down the thighs, a tightness across the belly, and head- ache. At thi- same time he noticed first his face, then his body, swollen of a morning before going to work. He got himself cupped in the loins, but thought it did the pain no good. On admission, the whole person was anasarcous ; the pain in back and belly remained ; the bowels were regularly open once a day; his appetite for food was sufficient ; his thirst more than natural ; the urine was albuminous, anty, of the specific gravity l.ol'J. Hot oaths, a dose of Jalap, and Nitre draughts three times a day, were prescribed. He was kept in bed. On the 3lst of December the legs were natural, and on the 3d of January J anasarca was nearly gone. He was ordered li. Tiucturac Ferri Scsquichloridi n\,xv, Tinetnra- l>i;:iialis n\,x. Mist lira- ('amphora' tl^j Ter die. During the use of this his feverish thirst diminished. He was made an out-patient ou January Kith, his urine remaining albuminous. On the iMh <>!' I-Yliruary he was readmitted as too ill to be an out-patient. He had In-come very feverish and thirsty ai_'ain, his tongue was white, and he had di/./.iness of head and oli.-eiiration of ey>ii_r|it. At the same time lie had ittaeked with vomiting, and thrown up as many as twelve times in the day. He had no return at all of the dropsy, though the urine remained altiuminous. A <: 11 lied reduced the frequency ..f the vomiting to once a day. Itut that and the leveri.-hne<-; contained for several days longer. Hydrocyanic .- d to do him gi 230 VOMITING. This case shows that it is the albuminuria, and not the dropsy (as some have suggested), which causes vomiting in Bright's disease. I think it very likely that the gastric glands may in the more obstinate of these cases be degenerated after the same fashion as the kidneys. In a continuous series of a hundred post-mortem examinations recorded by Dr. Handfield Jones in the "Medico-Chirurgical Transactions" for 1854, 1 out of twenty- four cases of real degeneration only seven had the glandular structure of the stomach completely healthy. CASE CCXV. Ann F , aged 52, married, was admitted under me at St. Mary's March 18th, 1853, complaining of a general throbbing, faintness, and what are recorded in the book as "general dyspeptic symptoms," of which the most marked were vomiting and tightness across the chest. On auscultatory examination, the ribs were found rounded and immovable, and the cardiac region overlapped by emphysematous lung, so as to be, with ali the rest of the chest, unnaturally resonant. Hydrocyanic Acid and Chloroform relieved the dyspeptic symptoms some- what. The remainder of the history has no bearing on my present subject. CASE CCXVI. Jane K , aged 27, having had a distorted spine from childhood, it was impossible to ascertain precisely the anatomical condition of the lungs ; but, as the heart was healthy, the probability is that the short- ness of breath she suffered from arose from pulmonary emphysema. The reason of her coming into St. Mary's in June, 1856, was frequent vomiting, which exhausted her very much. This did not occur in any relation to meals, but at night. She was benefited by Hydrocyanic Acid, a Jalap purge, and a fortnight's rest ; after which she went out without complaint. It is worthy of remark how the worst time of the twenty -four hours for the lungs of the broken- winded is also the worst for their stomach. It is at night that their paroxysms of dyspnoea come on, and at night this woman had hers of vomiting. Dr. Hyde Salter, in his useful monograph, remarks: "It is very rare to see an asthmatic with a perfectly sound, strong stomach, about which he has never to think, and in the history of whose case dyspepsia has no place. Sometimes the dyspeptic symptoms exist in a very aggravated form, and they are fre- quently such as to imply that the stomach disturbance is one of deranged innervation that its sensibility, or its movements, or the nervous superintendence of its secretion is perverted. In Vol.'xxxvii. page 87. VOMITING. 231 he stomach and lung symptoms are part of one morbid condition; the whole thing is deranged pneumogastric inncrvation, the dyspeptic symptoms being the manifestation of the irastric portion of this deranged innervation, and the asthma of the pulmonary portion of it." He gives then a good example of the alternation of the diseases, asthma and vomiting. 1 It has been observed already, in CASE LI (page 75), that liquids often disagree more than solids with emphysematous and cardiac asthmatics. Some cases of intermittent vomiting seem connected with ague poison. ('XVII. Stephen A . aped 54, an active, well-to-do farmer from the marshy neighborhood of Colchester, came to town to consult me May I'ltli. l-i'.n. Hi- stated that he had always been a temperate man, and ap- 1 to speak the truth. He had suffered from weight at the pit of the stomach, especially in wet weather, for near upon ten years, and at various times has occasionally thrown up some stringy phlegm from the stomach. rie i-iit'irrh. See " Weight.") In the summer of 1859 he had rather a severe touch of ague, which pulled him down a good deal, and he had never Keen quite the same man since. The stools were sometimes "yeasty," some- 'lark, rarely natural. Since his ague he had vomited every other day, and at tin- time of the vomiting had a spasmodic pain just beneath the en- sifiirm cartilage. He occasionally had vomiting and occasionally had pain at other times, lnit seemed pretty clear as to their general tertian character. I ordered him five grains of (Quinine every night and morning, and as I did not hear of him again I presume it was sufficient to effect a cure. In the following case, a living irritant seemed the cause of vomiting. (VXVIII. Uridget W , aged 20, spinster, was admitted to St. Mary's January llth. l-t>l. She had very obstinate vomiting, especially in tin- morning, which resisted Oxalate of Cerium, Bismuth, and Pepsine, which wer- severally tried. Of the three, Pepsine seemed of most use. Then she had a diarrlm-a. ami parsed two worms (prolialily the ordinary Round-worm, lint I did not see them). It was found that she had been very subject to wcnins since the age of fourteen, and was of a very mucous diathesis, having lem nrrhiea and frequent catarrhal coughs. She was ordered Turpentine, but I have no note of the result. II t-rnati'mesis has been spoken of as the result of violence. Chronic vomiting also m.iy U: produced by the same cause. 1 Salter, "On Asthma," chapter xii. section a, page 216 (Edit, of 1860). 232 VOMITING. CASE CCXTX. George S , aged 21, a porter, was admitted to St. Mary's September 25th, 1858. He had had a fall six months previously, cutting his head and otherwise knocking him about. He was very giddy afterwards, and felt a violent pain near the navel, to which Leeches were applied with relief. The pain extended backwards to between the shoulders. The next day vomiting of nearly all ingesta commenced, and continued more or less all the six months. On admission, there was dulness on percussion, and tenderness to the right of the epigastrium ; but this proved afterwards to be due to feces impacted in the colon. The vomiting was very constant. He was obliged to be fed on a couple of mutton-chops very slightly done and pounded up, of which a teaspoonful was given every two hours with a little milk. He had fifteen grains of Pepsine every four hours. But he kept on vomiting, and lost 2 Ibs. in weight. On October 9th he was put upon Liquor Calcis, and milk and beef-tea, con- tinuing the Pepsine. Then he did not vomit for eighteen days, and got back to meat ; but had to leave it off after a few days and resume the liquid. He gained at one time six pounds in weight while free from vomiting, but lost some of it during a relapse. A good deal of hard feces was brought away by clysters, apparently with relief. He complained of much pain in the epigastrium, which was relieved by a Blister dressed with Acetate of Morphia sprinkled on the raw surface. He got gradually better, with occasional relapses; due perchance to impru- dences, and was discharged November 24th. The pathological explanation of this case I take to be partial paralysis of the intestinal canal by a sudden shock to the solar plexus, very much as the voluntary nerves are paralyzed in a concussion without lesion of the brain. This would account for the loss of vitality in the colon and stomach and oesophagus at the same time. Remark how gradual and slow was this man's restoration. In all physical lesions of the nervous tissue, the main ele- ments in the treatment are time and repose. With these the foolishness of prescriptions scarce impedes the cure ; without these the most judiciously selected means fail. The slowness of renewal is very distinctive of the nervous system, and is ex- plained in a great measure by the difficulty exhibited in that tissue of parting with its substance by vital metamorphosis. In his experiments on the effects of inanition, M. Chossat, com- paring the losses of substance in different tissues, found that the nervous suffered least; and indeed it retained its full weight VOMITING. 233 after several weeks' starvation. 1 It is the true ultimum mortens of physiological interstitial decay, and of course it is the last and slowest renewed. I have already, in a chapter on the social habits leading to indigestion, given examples of alcohol as an occasional cause of chronic vomiting ;* but I omitted to mention a drug which I have found useful in that complaint. It was first used in this way by Dr. Marcet. : ('('XX. Jonathan B , a middle-aped gentleman, asked my advice in May. lst',1. for nervous trembling, indigestion of food, and vomiting, arising from indulgence in spirit-drinking between meals and in the forenoon. I gave him R. Zinci Oxidi. Pilulaj Aloes cum Myrrha, aa ^iss. M. fiaut pilul.r xx, quurum sumat unam ter die. After taking these for ten days, as he afterwards informed me, he was quite well. Of course he had left off the excess of alcohol. Still I think the Zinc was useful. ( '( ' X XI. Charles W . a patient with tubercular lungs, who used to consult me in the spring of 1862, had lodgings at Greenwich in an open situa- tion for the sake of the air. He seemed to get all the worse, and took to vomit inir in the morning, and having pain in the epigastrium. He always felt so much better during the day, and got so much worse during the night, that 1 \vu- led to inquire more particularly into the peculiarities of his Im!. I liranl liis bedroom was colored green, and on his bringing by my desire a of the wall-paper, I found it tinted with a light powdery arsenite of copper. He lost the dyspeptic symptoms when he changed his apartments. I feel no doubt that here the arsenicated water color was the cause of the vomiting, though that is not its universal effect. When made into an oil paint, Scheele's green is not nearly so dangerous. Mechanical compression of the epigastrium by tight lacing, and l>y handicrafts whore that part is exposed to injury, has alrcadv been spoken of as a (MOM of rinetic Indigestion. Another mechanical cause is umbilical hernia, though I cannot now lay my linger on a ease in point I have m;i-< n day suhstituted for it. In three .lays her appetite had returned, the vomiting and nansea had i. and she spontaneously asked for meat. She continued taking that with relish and without vomiting. It would be easy to cite cases where drugs had effected the same purpose, but I chose rather to select an instance of the simplest form of restorative treatment (namely, the direct re- ment of a deficient digestive solvent, so as to aid formative nutrition'), in order to direct the reader's thoughts to the true theory of healing. SECTION X. Sea-sickness. The principal cause of the vomiting produced in those un- use.l to it by the motion of a ship or carriage, by swinging, waltzing, and the like, I believe to be the relaxation of the oesophageal sphincter by the vibration. The body being at or rotated on itself, and the oesophagus hanging somewhat loose in it, the jar is strongly felt, and the involuntary plexus supplying the.se muscular fibres is temporarily paralyzed by it. In fact, a succession of small strokes produces the same ell'ect in unaccustomed nerves as one single severe concussion. In both cases use begets hardness : those who are exposed to much knocking about wrestlers, prize-fighters, huntsmen, &c. will get to stand blows that would once have stunned them ; aul the jar and swinging of the gullet and stomach in time ceases to be followed by relaxation of the sphincter. And some >ns and animals, from perhaps a peculiar structure (I will not call it a malformation) of the parts, never experience sea- sickness at all. The earliest notice one has of this cesophageal palsy is faint- >r !_ r ir from swinging motions. The relaxation of sphincters is always followed by the expul- ' See "Lectures chiefly Clinical," lid Introductory Lecture," Disease and Cure." 236 VOMITING. sion of the contents of hollow organs. Directly the anus is opened, the abdominal muscles act in forcing out the feces. So also with the bladder. And immediatly after the relaxation of the oesophageal fibres, the diaphragm and its colleagues ener- getically press upon and empty the stomach. Even after it is emptied, they continue to be spasmodically contracted, and the unhappy landsman lies retching and roaring, with nothing to throw up except a little bile, which the squeez- ing has forced backwards through the pylorus. This is the worst part of the ailment, just as cramp of a stump or of a limb lying loose is more painful than when the muscles have some resistance to act upon. Exposure to cold, either local or general, makes sea-sickness worse, by lowering the vitality of the nervous tissues partially numbing them, in fact. Artless landsmen often aggravate their misfortunes by remaining on the wet, chilly deck in blustering weather ; the more experienced sufferers have avoided a great deal by immediately going below and getting warm and com- fortable before the nauseating stinks begin to be rife. Sitting with the back leant against the funnel is also of use, if you cannot get below. I have never had any valid experience of the proposition made of putting ice down the back as a preventive, not having travelled in any weather rough enough to be a good test since it was made public. I am interested in the result, as it would a good deal affect my view of sea-sickness. Its having been set forth as a specific for cholera probably may prejudice the public against it, but should not influence the calm judgment of an experimentalist. A thick belt or Spanish faja will sometimes keep off sea sick- ness, partly from the local warmth over the epigastrium, partly perhaps from the compression keeping the stomach and its neighbors mechanically steady. The benefit of lying flat on the back arises probably from a similar cause. Temporary stimulants ammonia, spirituous liquors, chloro- form, opium keep it off for a short time in some individuals ; but oftener, I think, the reaction comes on very soon, and their last state is worse than the first. The beneficial action of sti- mulants lasts longer if they are combined with carbonic acid, VOMITING. 237 as in effervescing drinks. Aboard our Channel packets, "Soda and IV is popular : and I have found devilled lobster and cham- a ival Messing in some rough weather off the coast of igal : I have also tried good bottled porter non sine glorid. The powerful effect of mental emotion in bracing us up -ickness is very remarkable, and associates its pa- thology closely with that of other functional paralyses. This '1 to be observed in a striking manner in shipwrecks, when fright renders every soul alert, though before there was any danger they had been exclaiming that they recked not what :ic of them. Of that I have no experience; but I remember ate with nausea in a Peninsular steamer, when the captain, knowing I was a doctor, begged me to come and <1 to an engineer who had got rolled into the machinery. Only one finger was crushed, but the binding up that and the jcment of the frightened man quite cured me, though to an unapt surgeon the mixture of blood, -grease, and coal-dust, entailed by a machinery accident, is not agreeable. Almost always, the inconveniences of sea-sickness in a pre- viously healthy person cease with the cause: landing or smooth r sets all to rights. But sometimes, as in the following case, there is illness afterwards : CASK ('('XXIII. S. S , a middle-aged gentleman in fair health, accus- tomed to suffer in rough weather, went for a day's trip from Sorrento to Capri in an open boat. There was a good deal of wind both going and i Mining; but, contrary to his custom, he was not sick. He remained well that night ; but on the morrow he was attacked with spasmodic pain in the right side of the epigastrium, so that I almost thought he must be passing a gall-stone ; Imt tin- bowels were opened naturally with formed feces of normal coloring. The pulse also was unaffected. He made himself vomit with warm and putting his finger down tin- throat, and brought up unaltered food whii-h he had cut en the day before. This vomiting was of no immediate use in giving relief, but it otaKlished the diagnosis of stomach-ache rice gall- stones. The pain spread over the epigastrium, and as it spread became less, and gradually ceased the next night, helped probubly by hot fomentations. But a certain soreness remained for a couple days more. I fancy in this case the paralysis hal affected the muscular fibres of the stomach more than those of the oesophagus, a; a morbid condition was engendered. d< in a former chap- 238 VOMITING. ter as spasmodic pain of the epigastrium, or stomach-ache. 1 The gastric glands were also paralyzed ; so the food was undigested, and not being of a fermenting nature, was unaltered. Sometimes sea-sickness passes into a condition of chronic vomiting. CASE CCXXIV. Eliza W , a young single woman, was quite well till the beginning of October, when she came up by a Hull steamer to London during the equinoctial gales. She was violently sick on the voyage, and fancied she twisted something inside her. On landing the sickness did not cease, but continued till her admission to St. Mary's, November 14th, 1863. She had also got very hysterical, and said that one day she was quite paralyzed. Her tongue was very foul, her pulse natural, her bowels constipated, the urine painful to pass. Her right eye also became painful, and she could not raise the lid. Under Quinine and a Chloroform poultice she got much better by the 26th of November. Then on its being found that the pupil of the painful eye was dilated, and the internal rectus oculi paralyzed, it was thought right to. leech her temples. On the 17th of December she was attacked with vomiting again, and on the possibility that the brain was inflamed the head was shaved and blistered, and Iodide of Potassium given. Apparent relief followed, but the patient got very hysterical. Finally the vomiting was stopped with Valerian, but not till the end of February. I have never heard of such a thing as chronic vomiting arising from sea-sickness in a man ; and I suspect that the pathological interpretation is the passing of the temporary morbid condition into that which was described in a previous part of this chapter as hysterical vomiting ; hysteria being much more common in the female sex than in ours. I should presume Shower-baths and Valerian would be the best cures ; but I have not the authority of experience, as the contingency is rare. SECTION X I. Review of treatment. Ice or iced water swallowed is often most useful in the acute vomiting of fevers and of cholera. It stops the straining and relieves the distress. I presume it acts on the same principle 1 Page 162. VOMITIM;. 239 as a. shower-bath, by a revulsive shock to the nervous system. It is also a good astringent in bloody vomiting. Rest in the horizontal posture and absence of excitement is a rful remedy. It was adopted iu all the cases quoted in previous pages. Milk awl Lime-water as a sole diet for a few days is an appli- cation of the same principle of rest. It also was a processus Leeches will be seen to have often stopped vomiting. Not only in gastric ulcers, but in all anatomical lesions, including congestion of the stomach, their utility is readily understood. J! randy j plain or burnt, in teaspoonful doses, is a favorite domestic remedy. It relieves the faintness which accompanies vomiting, and perhaps may be some check in acute cases, such a-sickness (q. v.). But it is obviously unsuited for severe or chronic disease. Champagne and other effervescing stimulants come into the same category. I fancy the effervescence diffuses the stimu- lating ethers more quickly than when they are taken flat. ' 'hloroform internally may also be classed with them. Kxter- nally on the epigastrium it has not appeared to me of certain use. Hydrocyanic Acid, when the vomiting arises not so much from a fault of the stomach itself as from a secondary condition of the nervous system, as in pregnancy, diseased heart, abdominal tumor, and in pulmonary consumption. But in pulmonary consumption the most powerful remedy is Cjj'i'i/i/i. In gastric ulcer also it is invaluable, and in painful malignant tumors. The Valerian and Shower-baths are both useful to the same class of cases. There are no remedies by which I have oftener stayed chronic vomiting; simply because nervous debility is the most usual cause of it. Donates < '.' x/a, Soda, and Ammonia, and Hyposulphite /", are especially indicated where there is acid or alcoholic fermentation <>f the vomited matters, whether Surcina ventri'-nH. "Uinl there or not. They a--t palliatively in arresting the imposition. is an uncertain remedy. I confess I cannot find what ,itet| to. It loD6 any -ood where the other remedies have l>een in, :ed. 240 VOMITING. The administration of food in cases of chronic vomiting is a matter of much moment. We must not let our patients sink for want of it. Even when milk and Lime-water does not check the retching, it is by far the best diet ; and in teaspoonfuls it can almost always be kept down. The risk of being starved to death from vomiting is not purely hypothetical. A young woman came under my care at St. Mary's in 1857, who had been deserted by her lover. She had had violent hysteria, and an utter inability to keep any- thing on her stomach for some days already ; l^ie pulse failed, and the tongue was dry and brown. An attempt was made to restore life by means of nutritive enemata, but in vain. At the post-mortem examination every organ was in a completely normal state, and the catamenia were still flowing from the uterus. She had died of inanition only. The nutritive enemata were proved right, however disappointing the result was. The treatment of sea-sickness has been discussed a page or two .back. 241 CHAPTER VI. FLATULKNCK. SECTION 1. General Remarks. SECTION 2. Knu-tation. SECTION 3. Intestinal flatulence. SKCTIO.N 4. Colouic datuleiice. SECTION 5. Treatment of the several sorts. SECTION I. General remarks. \VHKX we r-pi-ak of flatulence it must be remembered that we must not set down all the air contained in the intestinal canal as morbid : we are not like old-fashioned nurses to be always looking upon " wind" as an evil. A certain amount of _en is wanted to aid in the acidification which is necessary to digestion ; and as this oxygen is to be derived from the atmo- spheric air, it implies the presence of still more nitrogen. Car- bonic acid is a sedative to mucous membranes, it is the natural atmosphere of all internal parts, and they become irritated and inflamed if they are deprived of it. Growth in wounds and normal secretion in mucous membranes go on naturally only when thus defended against external influences. Again, it is an important agent, indeed it may be called a great moving t, in the digestion and circulation through the body of aliments needful to growth. There are several elements of nutrition, such, for instant- the carbonate of lime and phosphate of lime, wanted for the bones and nerves, which are insoluble in water, but are soluble in water saturated with carbonic acid. This saturation is etVeetetl by the gas which remains in the Itowrls as a reservoir as a reservoir, too, where a certain amount of compression is (I, and the taking up of the carbonic acit important one. 16 242 FLATULENCE. For the nitrogen I do not know how to find a use in the nu- trition or modification of the tissues. Some of it is probably taken up by the blood, and excreted by the lungs, as in the expired air a considerable proportion of this gas is known to be found, forming, according to the latest experiments of M. Barral, one per cent, of the whole, and some may perhaps be made into ammonia. But to that which remains still in the alimentary canal an employment may be assigned, humble indeed, yet contributing most exceedingly to our comfort and health. The feces when they arrive at the ilio-cascal valve are almost fluid, and are so largely mixed with water saturated by salts, that they are of greater specific gravity than ordinary water, and either sink in or become mingled with it. If now our digestive organs are not performing their duty well, or pass the mass on too quickly, it comes into the external air in a very similar state to that above described. It is a heavy, un- formed, half-liquid pulp, diffusing itself inconveniently ; but if partially dried by the gas present, and lightened by the admix- ture, it is much less offensive to the senses, and easier retained by the sphincter ani. It is only then when in excess that I would speak of air in the alimentary canal as " flatulence." SECTION II. Eructation. In approaching the subject of eructation it must be remarked .that gaseous contents of the hollow viscera are differently cir- cumstanced from liquids and solids ; their high degree of ex- pansibility by heat and their low specific gravity give them an inherent force which urges them outwards without any aid from the muscular system. Other contents of the stomach require the action of the expiratory muscles to expel them, whereas gas warmed by the body tends to rise through the oesophagus directly that tube is relaxed. The essential condition is the relaxed and open state of the cardiac end of the gullet. The air, instead of being retained by the contraction of this powerful sphincter, finds its way upwards in greater or less quantity. The passage of the bubble towards FLATULENCE. 243 the mouth, except in completely paralytic patients, causes a reaction, ami l>y the time it gets to the fauces it is compressed l>y tin- stimulated muscles, and is suddenly expelled. Hence the noise is greater than is caused by the mere bubbling of air up the throat, such as you produce in moving a dead body, or an apoplectic patient. There is a combination of relaxation with spasm, the former taking the initiative. The relaxation is by no means so complete as in vomiting. The bubble of air is allowed to pass, and then the oesophagus acts again immediately. The following table exhibits a comparison of several analyses of the air found in different parts of the healthy human intes- tinal canal : I.i STOMACH. Volume perci-nt. IN IT.IA. Volume per cent. IK Cm.nx. Volume per cent. Carbonic acid ( 14 (Ckevrrxl) 1 ( 25.2-27 8 (Clifvillof) ) 24.39 (Chevrent) (43.5 -70 (ChevrtuD \ 23.11-93 (CheviUot) (11 (Clirvrr.nl) \ (Chevreiil) ( (Ch> u *yg en \ 8.2-13.0 (CheviUot) f 2-3 (CheviUot) \ 2-3 (Che i: ill nt) Nitrogen ( 71.45 (Ch't-rnil) [ \ 66.8-59.2 (C/trvillot) J 20.08 (Chevreut) \ 18.40-51. 03 (CV/r ( 95.2 -90.0 (CheviUot) ( Z.bb(Chrvrrnl) \ >' llr "8 \ trace (Ck~iU)\ 55.53 (Chevreul) Sulphuretted * hydr 1.0 (Marehantf) C:irliur'tt'd ( 5.47-11.6 (Cherrrnl) hydrogen ... \ 28.0 (Cluvillot) With regard to the gaseous contents of the stomach, as exhi- bited above, it may be observed readily that more than four- tit'ths is atmospheric air, and the rest is carbonic acid in much proportion than in the breath which is passing out of the trachea by expiration, and which constitutes the air of the mouth and saliva. This fact -ivcs us a strong hint of its source. It is evidently in a healthy person swallowed with the food and frothy saliva in such quantities as to fill the organ up to the points of normal distension. I think too in the majority of eases also, where the collection and evacuation of air from the stomach is so abundant and in- convenient as to be considered a disease, that we may trace out the same source of it. Observe paroxysms of sobbing, globus 24-i FLATULENCE. hystericus, epilepsy, or chorea, and you will see great quantities gulped down. Watch those who are suffering from heartburn, and you will see them swallow air or frothy saliva, as if to relieve their discomfort. Other persons have a careless, vulgar way of eating with the mouth open, which makes them swallow a quantity of air. Others have a trick of half- unconsciously gulping it down; and a very silly aspect it gives them, something like that of a gob- bling turkey-cock : you may notice them bridling up and tucking in their chins. I fancy the feeling leading them to do it must be something like that which makes horses crib-bite a sort of modified heartburn ; but it is more trick than anything else. In health all the air swallowed is readily absorbed. There are many individuals who never pass It away, upwards or down- wards, for months together ; indeed, so long as the perfect type of health is preserved, it may be said to be never excreted. After a meal their abdomen is as usual distended with air, but it is all removed by absorption before the next. In many morbid conditions this is not done. When the vitality is lowered, probably the function most generally inter- fered with is absorption. The air collects, is swelled by heat, and expelled, although in no excessive quantity. Should the oesophagus be easily relaxed, there is eructation ; should it be contracted, there is intestinal flatulence. So far, the bulk of air swallowed has been supposed to be increased only by heat and expansion. But in some cases it is further augmented by gases disengaged from decomposed food. The occurrence of alcoholic fermentation in the digestive canal is proved by instances of vomiting, in which the matters ejected are visibly undergoing this chemical change. They are frothy with carbonic acid like yeasty beer, and they continue frothing up even when left to stand after ejection. (See CASES CXCII, CXCIII, CXCIV, CXCV.) We can easily imagine what a dis- turbance in the stomach this must make, and are not surprised at the ejection of such a turbulent guest. Fortunately this spread of alcoholic fermentation through the saccharine contents of the stomach is rare. Its features are s6 marked, and the discomfort it causes so great, that we should be sure to hear more about it were it common. The fact is, that FLATfLKXCE. 245 even where it beting and gives rise to the disengagement of some carbonic acid, it is rapidly stopped by the conversion of the sugar into lactic acid, a kind of fermentation more congenial to tin.' temperature of the body. So that the " acidity," which in a former chapter has been spoken about as an evil, is a defence n^ainst one much more serious. It will be seen from what has gone before that I class the > of eructation which come before us into three groups : 1. Those where there is simply a relaxed oesophagus, and the air, though only in natural quantity, breaks upwards. 2. Where tjiere is an excess of atmospheric air swallowed from habit, or in the attempt to relieve an uncomfortable ferling arising either from the stomach itself, or some of the neighboring viscera, as the heart for instance. 3. Where carbonic acid is formed by alcoholic fermentation, unchecked by acetification. This grouping has a bearing mainly on treatment, and a reference to the cases recorded will show readily to which class they belong. In the majority of patients it is the escape of air from the stomach that is complained of; but sometimes a retention of it - place with considerable inconvenience. It may (especially in elderly persons and cardiac patients) collect in such quanti- M a paralysis of the muscular coat of the stomach, and put them in considerable danger by impeding the action of the heart and diaphragm, and causing deadly faintness. I use the epithet " deadly" from recollection of the following case. CASK OCX XV. When I was physician to the Chelsea Dispensary, I saw occasionally for shortness of breath a fat single woman of from forty-five to fifty years of a#e. She complained <>f eructations, and of the upper part of the belly beiny swollen with wind, which I attributed to over-fat diet and slupjrish habits. One day they sent for me suddenly to say she was d\ n_'. and when I pot to the house she was dead. On a post-mortem examination, the heart was indeed slightly dilated ami perhaps pale, but appeared ni^re e|iial to work than the majority of hearts we see. But it was really quite difficult to tret it out of the chest, so pressi-d-np was tin- diaphragm by the stomach enormously distended by its gaseous contents, devoid of smell, and certainly not. therefore, the product of post-mortal decomposition. This dis- u Deemed to have ! I ! death. 2-i6 FLATULENCE. More generally matters do not go quite so far as that. CASE CCXXVI. Mr. James L , a hale-looking man of 63, came for my opinion at the beginning of March, 1867, about excessive dyspnoea by day and orthopnoea by night, with which he suffered. Sponges and other instruments had been put down the throat (? into the larynx) without any benefit. On examination of the pulse, this want of success was readily explained by an excessive irregularity and intermittence. The heart was also irregular, but not so intermittent as the pulse. The sounds were normal, but diffused. As the urine was also albuminous, I gave an unfavorable prognosis. But, to my surprise, a few days' dosing with Strychnine, Digitalis, and Iron reduced the action of the heart to regularity, and so far relieved the dyspnoea, that the patient was able to take exercise with ease. He said he had broken off wind from the stomach in several great bursts, and that new relief had followed each explosion. It was necessary to modify jny prognosis. In three weeks' time he was really as hearty and well as any one can be at sixty-three. This sudden relief of the stomach by paroxysmal explosions is exemplified in a former case, also an elderly man, where the cure of a long-continued waterbrash followed thereon (CASE CXXY). The pathology of such cases seems to be that there is a paralysis of the gastric walls ; air is drawn into the dilating organ, swells from heat, further dilates it and increases the paralysis, till such time as the sudden contraction of the circular fibres is brought about by nature or art, and then all is expelled at once, sounding the triumphal note of cure rather than being its cause. It is, however, in the flatulence of dyspeptic hysteria that the explosions are most remarkable ; they occur again and again, and are graphically described in CASE XCVI as " roaring eructations." When they are repeated so quickly as this, the air can of course be collected only by being swallowed. The pathological etiology of eructating flatulence is to be sought in causes which lower the local vital force of the gastric involuntary nerves, and so make the muscular action inter- mittent and irregular. Such, for example, is starvation in CASES I, II, CX, &c., the pressure of the last in the shoemaker CASE LXXII, excess of tea-drinking in CASE XCVI, extraordinary fatigue in CASES IX, XIII, &c. FLATULENCE. 247 SECTION III. Intestinal flatidence. A reference to the short table given in the second section will show that in the gaseous contents of the ilia there is an increase in the quantity of carbonic acid relatively to the :en, or, if we like so to regard it, a decrease of the latter. At the same time hydrogen, scarcely present in the stomach, forms a good half of their bulk. This hydrogen cannot be swallowed air, and is not likely to be excreted from the blood ; i'>r we do not know of any gas besides carbonic acid owing its origin to anv important amount from the circulating fluid. It must, I conceive, arise from the chemical changes going on in the remains of the food. I do not think any large quantity of air passes the pylorus, but that the bulk of the gas in the ilia comes from decomposition of their contents. In a state of health this gas is reabsorbed nearly as soon as formed, so that only for a short time after meals is the abdomen I'UtVy ; but, as I explained before, lowered vitality promotes the collection of air by arresting absorption. Lowered vitality also increases the extent of decomposition, by diminishing the flow of bile. The action of this secretion on food is exhibited in the experiments made by MM. Bidder and Schmidt upon dogs. 1 They found that when the flow of bile into the intestine was cut off by tying the ductus communis choledochus, rapid chemical changes took place in all sorts of food. When the animals were fed on flesh, the feces smelt like carrion ; there was a continual rumbling of the abdomen and an evacuation of fetid air. When they were fed on bread only, odor! : id sour feces were passed. No further injury iid emaciation and weakness followed during the eiirlit wei-ks of the experiments. From them we have a right to infer that one of the chief functions of the bile is to act on albuminous matters as an antiseptic, preventing their putrid decomposition, and preserving them safely to lie exposed as much as possible to the absorbents of the alimentary canal : and that at the same time the . formation of acid from vegetables is chr- 1 Bidder and Schmidt, " Die Verdauuiigasilfte," p. 230. 248 FLATULENCE. so that it may proceed gradually and as required by the digestive process, In fact, the condition produced in dogs by mechani- cally stopping the functioning of the liver answers exactly to the intestinal flatulence of dyspeptics in our species. It may be observed that it is a long time after a meal, in fact just before the next meal, that the bile is normally poured in greatest quantities into the duodenum: in dogs in twelve or fourteen hours, in men about four or five. Now this is just the period when it is most wanted to prevent decay, and just the period when intestinal flatulence from its deficiency most usually occurs. Excess of gas in the small intestines is the most troublesome sort of wind. Should it escape upwards through the pylorus into the stomach, it is apt to cause vomiting ; or sometimes it constitutes a most nauseous eructation of sulphuretted hydro- gen. Luckily this is rare. There seems too to be some diffi- culty about the passage of air downwards through the ilio-caecal valve. Hence intestinal flatus often rolls about in the abdomen from the changes in position which the motion outwards of the alimentary masses involve, and causes the well-known and dis- tressing grumblings of the belly or " borborygmi," aptly called in English a " glug-glug." The abdomen will be distended for several days with it, without its being expelled or absorbed Its escape into the colon, even without making its way out of the body, gives immediate relief (see CASE XX, page 46). There is very often considerable pain in one side or the other, most generally the right hypochondrium. The patients, espe- cially if they are old Indians, will say they have got " liver." Where there is most pain in the side there is least grumbling of the belly : so I suppose it must arise from the long-continued immovable distension of one part of the gut. Flatus in the intestines is troublesome during the day, from the tumidity of the abdomen, and noise on motion, and pain in the sides ; but when it comes at night it causes still more incon- venience by preventing sleep. It is hard to explain why this should be ; in many cases there is not enough pain or discom- fort to account for it, yet a complete wakefulness and apparent want of wish for sleep prevail. It is to be remarked, also, that this insomnia is in many instances made worse by Opium. FLATULENCE. 249 Sometimes the patient will go to sleep easily and naturally on first lying down, and will then wake up in an hour or two, finding the abdomen tumid and uncomfortable, and will remain entirely without rest for the remainder of the night; or if there be a lapse into unconsciousness for a few minutes, the uneasy sleep seems rather to aggravate than to relieve the feverish i ess, and to cause headache. During this unnatural repose men are often annoyed with disgusting erotic dreams' and abnormally frequent seminal emissions. I have never ascertained whether any analogous t is produced in the female sex. The line of causation cannot at present be traced, the bowels and the generative organs appearing to have so little to do with one another. The persons most liable to this troublesome affection are women, especially those of weak muscular fibre, anaemic dia- t lies is, and a tendency to form fat. We may attribute it, under circumstances, to a naturally sluggish portal circulation, which does not so quickly absorb the contained air as a freer current through the bloodvessels would do. CASK ('('XXV II. Mrs. R , aged about 40, has been from time to time a patient of mine during the last six years, on account of increasing corpulence, inability to walk without violent perspirations or exhaustion, palpitation of heart ami ana-mic irregularity of catumcnia. Last week (March, 1867) she caim- to town in considerable pain all over the abdomen, starting from under the right ribs. The abdomen was very large, and I thought at first she had .ttin.tr fat again : but she denied having increased in corpulence as to the other parts of her body lately. It was very tympanitic on percussion. This swelling of the abdomen made her very short of breath, and at night she could hardly lie down, and was frequently woke up by discomfort. Tin- bowels were fidgety in their action; sometimes confined, but more usually open in small quantities several times daily. The feces were semi- fluid, lijjht-colored. and very offensive. Flatus was not now passed per anum with them, thoiisrh that escape was habitual in ordinary health. The appetite was deficient, the tongue coated. The catamenia had been the last few period.- rather more profuse than ordinary. 1 am giving her Valerian and Strychnine to strengthen tho peristaltic action, and a small dose nightly of Aloe's to augment temporarily the excre- tion of bile. Remark here that when she wa> in health the tras escaped by the usual passage, but that in illness it was retained : ami was 250 FLATULENCE. retained immovably, as shown by the pain in the right side. The feces are just those of the dogs experimented upon by MM. Bidder and Schmidt. The sulphuretted hydrogen and hydro- sulphate of ammonia formed by the decomposition of animal viands unguarded by bile seem to be purgative poisons, and where they are found the stools are semi-liquid. In looking over the foregoing pages for chronic conditions in which intestinal flatus was conspicuous, I find Bright's dis- ease, CASE IV; Old age, CASE XII; Eachitis, CASE XLIV. Immediate causes mentioned are Anxiety and application of mind, CASES XIV, XV, LXXVIII ; Loss of blood, CASE XLIX ; Over-eating, CASES LX, LXII, LXIV; Irregularity and other bad habits of meals, CASES LXXVI, LXXIX. In many other similar cases recorded in Chapters II and III, where flatulence is spoken of, the subject of the present section is intended. Disease of the stomach seems as a rule to exclude intestinal flatus. Thus it may be observed to be conspicuous by its ab- sence in the Chapters on "Abdominal pains" and " Vomiting." SECTION IV. Colonic flatulence. Flatulence in the colon may be distinguished from that in the small intestines by its position ascertained by percussion, by the absence of rumbling (except a little bubbling through the ilio-caecal valve just before it escapes), and by its passing out freely per anum. A reference to the table in page 243 will show in the normal gaseous contents of this part of the bowels the presence of sul- phuretted and carburetted hydrogen. But in health the quan- tity of the former is not enough to overcome the prevailing odor of feces. In some cases of disease the sulphuretted hy- drogen, arising from the decomposition of albuminous matter unchecked by the normal flow of bile, is in excess, and may then be readily detected. In other cases scentless carburetted hydrogen and carbonic acid seem the prevailing gases. In the former there is albuminous, in the other starchy dyspepsia. FLATULENCE. 251 When much sulphuretted hydrogen is present, there may be a diarrhoea of feculent matter; but colonic flatulence is more commonly accompanied by costiveness and constipation. The colon does not appear to be so sensitive to poisons as the ilia. I- is intestinal wind that is generally complained of by pa- tients who are bad enough to be driven to a doctor, and is that which is generally alluded to as "llatulence" hi the cases in an earlier part of the volume. onir llatulence is not nearly so distressing as intestinal, and not cause so much wakefulness or other nervous disorders. SECTION V. Treatment of the several sorts of flatulence. / "'ion may in some cases be stayed by solely a direct restorative treatment of the cause. The defective digestion may jtlaced by artificial gastric juice. For example X X VIII. James B , a laborer of 50, was taken in at Pt. Mary's April 20th, 1856, for a catarrhal cough of ten weeks' standing, with some (. Miration of the lower part of the lungs. The object of admitting him was liis cough the benefit of the regulated temperature of the ward, with \u cough medicines were considered needful. lUit he complained that after meals he had throughout his illness been troubled with wind breaking up from the stomach. It was tasteless and inodorous. Fifteen grains of I'.oiidault's lYpsine Powder was administered daily with his dinner. On the l!5th the flatulence was relieved, and he went out well on the 1st of May. Where excess of air is swallowed from abnormal sensibility and breaks up in eructations, Valerian and Ammonia are useful, but above all shower-baths. I do not know any disease in which their value is more marked. The more the patients can bear of them the better, and the sooner they can get educated i" take them in full quantity and cold the better. First let tin-in In- administered tepid, then with the shower cold and the foot-pan warmed with hot wat-r. then make them all cold, and each day let the ijnaiitity of water be gradually increased till the full extent that the bath will hold be arrived at. Kxamples of this principle of treatment are given in (.' CXOTII, CO, CClll, 00V. 252 FLATULENCE. When the eructations depend on the formation of carbonic acid by alcoholic fermentation, the Hyposulphite of Soda is in- dicated. See Case CXCV. Eructation from this cause is rare without vomiting. The aim of the treatment mentioned is to prevent decomposi- tion of organic matters. In the laboratory we find that nothing is so powerful in this respect as Sulphurous Acid ; and accord- ingly it is used in various processes of the arts for the purpose. Sulphur is burnt by wine-growers in casks used a second time to arrest the fermentation which is apt to be going on in the liquids soaked up by the cracks or porous parts of the staves, and the acid vapors effectually do their duty. The agents of the Board of Health find no disinfectant for sewers so quick and certain in its action as Macdougal's, the chief ingredient in which is Sulphite of Lime. Muscular tissue may be prepared on the same principle, and keeps as well as when salted or dried ; and we may test even on such a delicate substance as yelk of egg how fresh it keeps with sulphite of salt. The same effect is produced by taking as a medicine Hyposulphite of Soda ; the fermentation of the contents of the stomach is arrested, and the evil effects of that fermentation prevented. But it must be remembered that the digestion of the meat is also checked. Dried, salted, or otherwise chemically prepared victuals are not so soluble as fresh ; indeed, if completely dry they are not soluble at all ; and to continue the Hyposulphite of Soda long would put the patient into the condition of a sailor reduced to salt junk. A safer, but equally powerful arrester of chemical changes is Charcoal. When soup has begun to turn in hot weather, economical cooks heat it up with a little bag of Charcoal in it, and it becomes quite sweet. This shows that the carbon does something more than merely condense the gases formed. The same agent will accomplish the same result in the alimentary canal. I myself have used it truly only in cases where decom- position producing flatulence occurs in the intestines ; but I should not hesitate to give it in gastric fermentation also, if Hyposulphite of Soda chanced to disagree or had failed in its' effect. FLATULENCE. 253 The general treatment of indigestion by Quinine and Strych- nine, as several times here advocated, is specially indicated in eructation, inasmuch as the most failing function is that of the contractile fibres of the oesophagus and stomach, and to these our remedy first arrives. An example of their rapid action may be read in CASE CXXV. As stated in the last leaf but one, intestinal flatulence exhibits best the power of charcoal, because the air has more difficulty in being got rid of without some such help, and the air formed by decomposition is peculiarly copious and troublesome. In ordinary cases there are usually joined several other reme- dies to the Charcoal, such as Quinine and Strychnine (for the n given a few sentences back), and Soda and Valerian, or (ialbanum, or Assafostida, so that the action of the Carbon is complicated. I have therefore selected for the nonce, to exhibit necial and independent action, a rather out-of-the-way in- stance, in which the collection of air took place in consequence of a mechanical lesion entirely preventing its passage (for the small exit must have been always blocked up by feces), and in which the only antiseptic and absorbent used was Charcoal. CASK CCXXIX. Elizabeth C , aged 63, was admitted to St Mary's under my c;irv J;um:iry lf>th, l>r>7. Though thin and not muscular, she had always i hard-working active woman, and had borne thirteen children, of whom but two were dead, one of phthisis and one of scarlatina. She herself could recollect no illness except scarlatina and child-bearing, till five months agone, when she noticed that the left side of the abdomen was often swelled, and that the swelling was relieved by a copious explosion of wind by the anus. A like swelling she also perceived some time afterwards on the right since which she had not so often been relieved by the passage of wind. She lr.nl also frequently a feeling of numbness and iiivoluiitary twitches in the legs. She l:iy on her back, when I visited her, with the abdomen raised up by a great collection of air. It measured thirty-eight inches in circumference. N<> solid tumor could be felt. The bowels were very coii.-tipated, and under the influence of purgatives only a little fluid feculent nutter, but no air, was An attempt was made to relieve her by passim: :i tube up the rectum, but no air was let off even thus. A many-tailed bandage was bound tightly round the belly, but no diminution in six.e followed. Turpentine, too, was adminis- tered, luit it was frit/ On the 'JlM 1 ordered a drachm of Charcoal to be gi\ :her hour, 254 FLATULENCE. the bandage being still kept on. On the 25th she was much better, the dis- tension being much less. On the 27th she had increased somewhat, so I added l-12th of a grain of Strychnia to the powders on those occasions daily. From that time we continued to find the abdomen softer, the patient lost her pain and gained strength, but with occasional relapses of distension. On the 20th of February she was able to get up. Her bowels were regu- larly opened by a simple enema, with sometimes a few drops of Cajeput Oil. Her tongue was clean, and the general health was good, and in the beginning of March she was actually assisting in the work of the ward. She herself pronounced that she was well enough to return home, and arranged to do so on the 23d. However, early in the morning of that very day she suddenly died, the only warning of her being worse having been a certain relapse of distension on the 21st. On post-mortem examination there was found in the lower part of the ileum, on the right side, an occlusion, as of a hard contracted scar, without any peritoneal adhesions. The occlusion, at first view, seemed quite com- plete ; but on further manipulation a dissecting probe was passed through it by a winding passage. Above this the intestines were greatly distended with air and semi-fluid black feces. But what surprised us was the entire absence of fetid odor in all this matter so long retained. It was not nearly so un- pleasant as that found in a corpse accidentally killed in full health. The last observation is my reason for my citing here this somewhat long and painful case. If the Charcoal can so act where a mechanical impediment confines the gases to the in- testines as by a ligature, and half kills them by strangulation, it must be still more powerful when it is aided by the vital force still remaining only slightly arrested, as in ordinary cases. For, in truth, people may be very flatulent without being very ill. Charcoal being tasteless is not disagreeable to take when you have got over the grittiness in the mouth. The only other objection I have had raised is its color. A wit of the Midland Circuit told me I was turning his " colon" into a " coalhole." It is scarcely needful to say that easily fermentable articles of diet must be for some time shunned, if the patient would avoid a recurrence of the complaint. Great advantage arises in intestinal flatulence from the use of such expedients as restore the flow of bile in full quantity a chief business of that secretion being the prevention of chemical decomposition in organic matters. Temporary use may be made of drugs for this purpose. FLATULENCE. 255 Tin' Salts of Mercury (viz., the gray oxide and calomel) were found in some experiments made by Dr. Handfield Jones on animals to increase the production of yellow matter in the hepatic cells. But when this metal was given there was also great sanguineous congestion of the liver, which, on the con- trary, was pale alter an administration of drugs which had not augmented the yellow matter. M- :,''!> iinjanese and Cokhicum had also the like effect. 'fie acid during life caused a flow of bile per anum in a cat; but there was no excess of yellow matter in the hepatic cells post-mortem. Aloes, Oil of Turpentine, and JRhubarb, acted much as Nitro- muriatic Acid. Antimony promoted in the liver, as in all the mucous mem- branes, a copious flow of water and mucus. 1 "We have thus in our Pharmacopoeias most powerful agencies for modifying the quantity and quality of the bile. And it cannot be doubted that further inquiry may extend widely our knowledge of the nature of our already existing numerous tools, so as to confer incalculable benefit on rational medicine. Che- mistry cannot render a reason of their mode of action; it has in it something essentially vital, or if you like the term better, .tially physiological. Still we must bear in mind that, as lar as we can see, it is temporary; and, since no one would wish to continue their use for life, we must mainly depend in the end on more direct restoratives of life for final cure, such pointed out in the experiments on food. Mercury certainly is a powerful temporary relief, but the sanguineous congestion of the liver seen in Dr. Jones' experi- ments should warn us against tru.-ting to it. Again and again the rough clearance has to be resorted to, till increasing n< sity for it alarms the patient, ami points to the ana-mia and weakness which are the inevitable consequences of an habitual employment of that drug. I understand there is the same objection to Colchicum. -e I know nothing about. 1 " M"lir-niirnriM.-.il Tran.-artions," vol. xx\v. j>. 240, an the organic solid constituents, it does not have the like effect on the amount of salts. On the other hand, it was found by Bidder and Schmidt that fatty fond instead of increasing, as might have been expected on chemical grounds, the quantity of bile, extraordinarily dimi- s it. Thus in a mean of three experiments on cats, the hourly discharge after a diet of pure fat was of bile 0.327, of solid matter in it 0.036 of a gramme. We might have sup- 1 that the formation of a substance which is the most hydro -carbonaceous in the body would have been promoted by a peculiarly pure hydro-carbon aliment: but such is not the Nay, so far from it, that the numbers given above correspond most closely to what would probably have been the quantity of bile secreted by the animals in a state of complete deprivation of food. Fat appears to be eminently "bilious," as the vulgar tongue expresses it, that is to say, it diminishes the vitality of the liver. Alcohol also by arresting metamorphosis 1 must be hurtful, as tending to diminish the normal formation of bile. The rules then of diet in intestinal flatulence should be (1) to Use a full allowance of lean meat and water ; (2) to Avoid utter, and rich sauces ; and (3) to Diminish the allowance of alcohol. None of these special items of treatment however diminish the importance of general treatment. Iron when there isanaemia, and the nerve-tonics Quinine ;md Strychnine when there is not, are what I use myself, and it is very rare that I wander from old inend< into the fields of experiment without regret- tinir it. Indeed the general treatment will oft-times render DeedlefSfl the special, as it did in the following recent instance. t'i XXX. A maiden l:idy past furty. of span- wiry built! and sharp decided manners, came in ihc tirst week "f l-i'-T. on account of tin- inconve- nience, nay po.-sildy scandal, which >he *uff largest, .-die had Ml palpi- tations ,,f the heart and in the epi-n-trium. especially when sitting still for longer than usual. The ankles ulso frequently were pally, taking the uaurk ;!y Clinical," L>ct. L, "On Alcojiol." 17 258 FLATULENCE. of the boot in an unaccustomed way. The catamenia were quite regular and sufficient, the tongue was clean, the bowels were natural in action ; and the only abnormal secretion was the urine, which was sometimes thick, and caused pain apparently from excess of acidity. There was no hysteria. The abdomen was tight and round, and large for a person of her stature. It was very resonant on percussion throughout. There was no glugging on pressure, and the patient stated that air very rarely escaped per anum even at stool. I desired her to wear an Elstob's belt, and to take -i of a grain of Strychnia with three grains of Quinise et Ferri Citras twice a day ; also at night another similar dose of Strychnia in a pill with two grains of Aloes and Myrrh mass, and the same quantity of Extract of Hyoscyamus. I saw her twice more at intervals of about ten days, and as the belly became softer was able to make sure of the absence of any solid substructure to the tumefaction. She went home quite slim and comfortable, but still denied having expelled any explanatory amounts of air by the external vents. As to the cause of her disease, I found that she kept house for her father, an old and infirm medical man in a remote province. Whenever she consulted him about any little ailments, he always gave her purgatives, and the more abnormal the alvine secretions became, the more purgatives he gave her. I suppose this treatment had produced anaemia and reaction of the ilia, which as a chronic condition, continually tending to increase itself, had gone on from worse to worse till the parietal muscles had also become relaxed. It is true that general anaemia, indicated by a pallid condition of the lips, tongue, and mucous membranes, had not as yet arisen ; but yet it might have existed in the local organs affected. I have noticed that persons of middle age become generally anaemic in consequence of imperfect digestion much more slowly than the young. For the life of the latter rapid renewal of the tissues is such an essential feature, that a check to the rapidity tells much more severely on their health than it does in the case of adults, and still more of old people. Probably this is the reason why con- sumption is so " galloping" in youth, so sluggish in old age ; and why starvation makes such havoc among young paupers, while on the same dietary their grandparents may struggle on with a half life to the extreme term. The intention of the belt prescribed in the above case was to strengthen the contractile force of the abdominal muscles, just as a bandage is put round a woman after childbed to restore her pristine figure. It affords the fibres a firm basis of contrac- tion, so that they recover from the half-palsied state, and do FLATULENCE. 259 not again fall into it. Its pressure therefore should be even, ami need not be very great. I mention this because patients are apt to mistake the object of the appliance, to suppose that it is designed to expel the retained air by compression, to be disappointed when it does not do so, and to tighten it too much. N"W too great constriction acts unevenly, and produces the bad local e fleet of ill-litting i-v in (he colon requires the same medicinal and dietetic treatment as that of the intestines. "When there is a tendency to congestion of the rectum and to piles, as not unfrequently happens, cold water enemata are useful, and in elderly persons a rarininative, such as Extract of Rue, or a few drops of Ether, may bo added to the enemata. When the abdomen is not much more dilated than natural by flatulence, efforts should always be made to retain the air inside the bowel till the period of fecal evacuation. For not uncommonly the parting with it induces a condition of consti- pation. If retained, it may roll about uncomfortably for a time, l>ut will soon either become absorbed or mixed up with the feces, and so assist their normal evacuation, as described in a previous page. 1 The proof of that is that it is not afterwards -ed. 1 See page 242. 260 CHAPTEE VII. DIARRHOEA. Difference of diarrhoea from mere frequency of evacuation. Subdivision of forms. Their causes and indications. Supplementary and reflex diarrhoea. Infantile. Diarrhoea in typh-fever. Ulceration of bowels. Mucous flux. Copious solid diarrhoea. Acid diarrhoea. Use of opium. Riding in chronic cases. Cautions to travellers. WHEN the absorbing power of the intestines is defective, the consequence is an excess in the quantity of matters which pass through them ; that which ought to be taken up is carried along out into the normal draught, and so constitutes a true diarrhosa. It is of great practical importance to distinguish this from the mere frequency of evacuation, which is quite consistent with a natural or even with a deficient amount of feces. The number of motions, or the number of times an inclination is felt to void them, is often increased, while even less than the average quantity may be passed in the twenty-four hours. This affection is of the nature of tenesmus, and arises from some tissue lesion of colon or rectum ; whereas true diarrhoea, as aforesaid, depends upon defective function of the ilia. The arrest of function, as declared by the prevailing contents, of the stools, constitutes the best principle of division which has been moreover adopted in the chapter on Vomiting ; and according to it we may speak without much danger of being misunderstood of Crapulous, Bilious, Serous, Dysenteric, and Choleraic diarrhoea. Crapulous diarrhoea is simply an excessive quantity of food taken, or the natural quantity arrested in its solution by sus- pension in the gastric function. I call it " crapulous," because it is most usual after a debauch ; but in weakly persons it is not necessary that the intemperance should be' absolute; that which is moderation for others may be an excess in them. An exami- DIARRH(EA. 261 nation of the feces exhibits a quantity of undigested food as the prominent feature, sometimes fetid ami fermenting, and deficient in the bile which should prevent decomposition. /.' i diarrhu-a is the next simplest form of the disorder. Bile, normally poured out by the liver to the extent of from three to four pints, a day, if not concentrated by the intestinal rption, adds largely to the excrements, where its presence lared by its well-known smell, and by a color exhibiting various shades of yellow, brown, and olive-green, according to its absorption of oxygen and mixture with feces. The arrest of the absorbing powers of the intestines and the -'quent rejection of bile, mixed at first with feces, and aug- mented by the exudation of water from the intestinal pariei what so often happens in comparative health from the impression of cold, from irritation of the alimentary canal by unwholesome food, and from mental emotion. It is possible also that the qualities of the bile itself may be altered in some cases, or its quantity may be increased. It may be poisoned by drugs, as by Calomel or by Senna, and so rendered incapable of absorp- and be poured through the ilia without their being in fault. 11. cnn:_'.-stion of the liver and of the portal veins, such as pecially frequent in Europeans resident in warm climates, causes the bile to be at one time deficient, and afterwards to be poured out in excess. Or irritation of the stomach and duo- denum may cause it to be retained in the liver and gall-bladder till it is unfit for absorption. In such cases bile is rejected per a tin, a and constitutes the matter excreted in true bilious diarrhoea. \Ve should distinguish this symptom from a different one sometimes confounded with it viz., the presence of a light BOD matter in the stools. This is not bile at all, but altered blood, and denotes inflammation of the mucous mem- brane, a state requiring very opposite treatment from that proper for bilious diarrhoea. Our best aids to diagnosis are first, the smell: in real bilious -tools the odor of the hepatic secretion can always be ] i. in spite of the feces mixed with it; while in the Ifl tin- smell is not of bile, but more or less putrid. Secondly, the microscope exhibits in 262 DIARRHCEA. the mucus the usual globules mixed with small shreds of fibrin and blood-globules. In Serous or Watery diarrhoea it is probable that there is an increased exhalation of aqueous fluid from the bloodvessels of the intestines, as well as an arrest of its absorption. In this form, when pure, if the feces are retained by a voluntary effort, they may be concentrated nearly to their normal condition by the removal of the water, and thus a test afforded that their state depends mainly on the addition of this constituent. For that which can be so readily taken up again into the blood cannot be of a nature very foreign to it. For example, in the diarrhoea produced by a saline purgative you may feel several pints of fluid rolling about in the bowels; but if you resist the inclination to stool, it goes off at last, and you void afterwards little more than the ordinary amount of semi-solid feces. It is not so in bilious or inflammatory diarrhoeas : you cannot cause the absorption of the fluid by forcible retention. Watery diarrhoea, when not arising from the action of drugs, indicates a congested state of the venous plexus of the alimentary canal, and a consequent morbid proneness to deficiency in ab- sorption. The vitality of the mucous membrane is deficient ; and if it be not restored, local death, exhibited in the form of ulcers and sloughs, must result. The exhalation, however, tends to become habitual, and so continues beyond the period of congestion, so that the whole mass of blood is relieved of its water, and in this way sometimes dropsical swellings may be reabsorbed and pass off through the bowels. In Dysenteric or Afuco-purulent diarrhoea, water is also in excess, but the characteristic feature is the presence of mucus or pus mixed with it ; in which also there are shreds of fibrin, blood-globules, and flakes of the epithelium of the bowels. Should any of these products of inflammation be unmixed with feces, then it is probable they come from the colon or rectum ; but if they are mixed up with a large quantity of watery fluid, and still more if that watery fluid shows itself to be the serum of the blood by coagulating with heat, then there is little doubt of their source being the mucous membrane of the ilia. The fluid in muco-purulent diarrhoea is always highly alkaline, and if it be examined with the microscope, phosphatic DIABRH(EA. 263 tre found scattered through it. If allowed to stand, it into two parts: the one serous, varying from trans- parent whiteness through all the shades of yellow to deep brown; or, where blood be present, to red and black, in which are the flakes of fibrin, the ammoniacal crystals, and floating globules; the other i /?/, consisting principally of gray, irranular matter, the debris of food mixed with more or less of loring matter of the bile and half-digested blood. The degree of serosity and the proportion of the products of inflammation in the first, show the extent to which inflamma- tion has gone in the mucous membrane; whiteness, bloodiness, putridity, alkalinity, being bad signs; yellowness, opacity, the 11 of bile, and the absence of putridity, being good. The second, or sedimentary portion proves the condition of the general system rather than of the ilia in particular. If it be copious in proportion to the fluid, then the normal function of destructive assimilation is shown to be little interfered with ; uitv, then we know this process to be arrested, the effete .'s are not removed from the body, and we have to do with a more grave state of affairs. The quantity of solid matter is the ' of an advance towards health, or departure there- from, in all cases where there is this state of the bowels. The most common examples of muco purulent diarrhoea are found amongst acute diseases, in low fever, enteritis, and dysen- ly in the teething dysentery of children. Amongst chronic in ulceration of the bowels, whether a conse- quence of phthisis or low fever, it is the most usual course for the symptoms to take. -A/ diarrh libe.l, shows recent inflammation. When it is in clots, either black or fibrinous, with the globules partiallv washed away, that a bloodvessel of notable si/e has be. MI opeiifl, probably by ulceration. Should pus be mixed with it, the S O 5 *? s - i S "3 -3 o = S h 1 -: = . a 00 O ~ _= ' = ^ 7- X '^" ^ -L - > : = J B ^ ; I' r-^ i H ;' _= 1-11 *" 'S S = i 3 S t> 5 :T=^ a o a> o ^ ^ .= . ^ K E : Z PH ^ 5 r T ~ = ^> * ^ c 2.2 . K e r. ~ i. si nifi 'C '^ o -5 j: /. 'C ^ 8 '- r- ~ T3 - ft "3 "3 . EJ 9 P = i . as g tc S "Q J fc fc X *- bJO | . '- & a ** n ^" a >>' d of^||_ 1 "/. ~r^ ^ ^ ~ ^ | "3 "=5 i=-l~.S-5- 9 S | o I 'flifl^l X. 1-H * v c- - ^ a ^ '- ~ > *> r-\ > S -^ ^,,2 S " 2 2 | O) 73 31 = i sg'S's i; > 3! js 5 d 3 | 3 r: ^ 1 ** - S S i - r, ~ s oj lllll 9 t o S i *I if t -~ 5 9 f V > 'O o S3 * - * ^4 A < a > - ~ o " ~> 3 ^ "H ^ -= i * "* ^ .g 08 08 > "5 "5 == >. at ' i o IT, k l^lls | 41jj g^-flg | ' rr s. - ^7 - ~ '~ r C. S ^ - -r 3 * jjsi ^. / ^_ C -r = T 5 i = '- 1 -2 c , a | f E r.f^ f S - ~ -' X '' i? O . j J - -^ ^ - '- ~ NJ = ^ n ~ - '- r. - - ^ H f L =. -' = I ~ -=' o '- ~ I, -. 1- 3 266 DIARRHCEA. In some rare instances of mucous flux the stools are acid from time to time. There is nothing special in the pathology of this. It arises simply from so much acid being formed from the de- composition of undigested food, that it cannot be neutralized by the alkaline juices. The acidification takes place apparently in the caecum, during the delay of the decomposing aliments there; for considerable pain is often experienced in the right iliac region, and in the course of the colon, just before the evacuations. In all forms of diarrhoea from affections of the small intes- tines, the evil is twofold : first the aliment, which ought to con- tribute to the support of the system, is hurried through the abdomen, and so the supplies are cut off; and secondly, de- struction is carried on at an increased rate by exhalation from the mucous membrane of the bowels. The stick is being cut away at both ends, and hence there is nothing which produces such rapid emaciation. Where so-called " diarrhoea" is reported to you as lasting for any length of time without emaciation, always let your suspicions of the correctness of the nomencla- ture be roused, and observe carefully whether the quantity of excrement be really in excess, or whether the ailment have not rather the nature of tenesmus, and arise from the colon or rectum. You will generally find such to be the fact, and must vary your treatment accordingly. Sometimes diarrhoea seems to be the transference of a ten- dency to exudation of serum from another tissue to the alimen- tary canal. Such is that which sometimes comes on of its own accord or may be artificially induced in ascites, and which cer- tainly sometimes diminishes the abdominal collection. Such is the diarrhoea of uraemia, which, however, does not usually re- lieve anasarca, but rather increases it from the weakening of the blood which follows. Hence it is a very bad, almost a fatal symptom, in Bright's disease. The most important part of treatment is the diet. It must be such as does not need a perfect state of the digestive organs for its absorption, while at the same time it is nutritive to the patient. The best of all is milk and Lime-water. In feverish cases it may be iced, and Soda-water may be occasionally substi- tuted for the Lime. Keeping a person solely on this diet is often alone sufficient to cure all sorts of diarrhoea not dependent DIARRH(EA. 267 on a permanent chronic cause ; and even where there is such a for it, much temporary benefit is derived, and a sounder starting-point for medical treatment than the previous state is gained. In a temporary diarrhoea without other disease, the loss of the normal supply to the body is not of much consequence; a short starvation perhaps does good to a person otherwise health v. But in severe acute disease, or in long-continued chronic diarrho.-a, this is an important consideration, and care must IK? taken to allow for it. Since food in the usual quanti- at once cannot be borne, and is rejected undigested, give it very frequently in small portions. The alkaline milk diet T just recommended allows this to be done most conveni- ently. A jug of the liquid must be kept close at hand and sipped from time to time, so that as much nutriment may be taken in the twenty-four hours as would be done by a healthy person. It is a good rule when there are lumps of feculent matter in the stools and a smell like that of normal excrement, to give purgatives, and when there is no normal smell present, to abstain. For it is only the remains of previous constipation that require to be got rid of, and when they are not present, harm is done by purgation. I have known cases of chronic diarrlnea much injured by the routine practice of so beginning treatment. Where the products of acute inflammation are found mixed in the stools, such as white and opaque mucus, flakes of fibrin, epithelium, blood-streaked mucus, bright green matter, &c., as above described, then Leeches, Fomentations, warm Hip-baths, and poultices to the abdomen are appropriate and should not lie dflaved. In children, the whole abdomen and loins maybe ied up in a large circumambient Poultice, which they cannot wriirirle, away i'rom, a Leech put on near the navel, and the bite allowed to bleed for a little time. The artie'< matt-ria medica I have m>-t trust in are Opium, [peoaoaanb*, ami Carhonate of Soda. A syrup may !> made often drops of Laudanum, two grains of Ipecacuanha powder, and a scruple of Sda in an ounce of half t : .d half water, ami dt>se> >!' not "nt'ul given at hour intervals. 1 have found this 268 DIARRHCEA. answer better than the old plan of administering Calomel. In teething infants this treatment is of the most marked utility. I suppose the anodyne soothes their neuralgia. In their case, too, lancing the gums will sometimes stop a most violent diarrhoea where the stools show evident proofs of the inflamma- tory condition of the ilia. The action of the lancing is probably much the same as that of Leeches, viz., a relief to the conges- tion of the mucous membrane. Upon the protrusion of the teeth it can hardly be supposed to have any influence, but that it alleviates toothache any adult may experience for himself, though it is impossible to get from his little patients an account of this remedial effect. But there is no doubt that the most active cure in infantile diarrhoea is change of diet. Bringing up by hand or unwhole- some states of the breast-milk are generally at the bottom of the ailment. No remedy is equal to a healthy wet-nurse, or where prejudice forbids that, as near an imitation as can be made of human milk by that of animals, such as the donkey's, or the cow's diluted and slightly sweetened. In low fever the presence of diarrhoea still suggests to many practitioners, and used to suggest to many more, the employ- ment of Mercury. The effect of this is the increase of solid sedimentary matter in the stools; in other words, a restoration of the destructive assimilation going on in the body. The motions are diminished in number and in fluidity, but not in actual quantity. In fact more solid effete matter is excreted, and thus the tissues devitalized by the typh poison are removed, and room is made for new nutriment. This increase of solid matter is taken as an evidence and test of benefit accruing from the use of Mercury, and as a prognosis of good. But I must say, without reserve (and am glad of the opportunity of so doing), that I think this an unwise hurrying of nature ; for only the destructive assimilation is augmented, not the constructive, and thus the powers of the body and its resistance are lowered. Now the use of Hydrochloric Acid both stops diarrhoea and increases at the same time absorption in the intestinal canal. For some years therefore I have employed no other remedy in' low fever, and with decided success, as I have more largely set forth in my published " Clinical Lectures." DIARRHffiA. 269 Where, in the absence of fever, blood is passed by the bowels, tin' two most powerful means of checking it I have found to be Turpentine ami Acetate of Lead. especially the latter. Its direct influence as a poison on the bowels would have led to an ration of this. If the hemorrhage has gone on for some time, I am inclined to think it must be sometimes due to a clot distending the bowel, and preventing it contracting upon the iing spot, for certainly a dose of Castor oil, in the results of whose action a quantity of pale clots were exhibited, has al times in my experience stopped bleeding. l>iarrlnjea from ulceration of the ilia tends to prolong itself; for the weaker the system is, the more irritable are the sore aid the less can the morbid actions they set up be It is wrong, therefore, to let it go on an hour longer than we can help. The readiest means for arresting it are such as M unt the sensibility of the ulcerated spots. Milk-and-lime- liet should be used first, then Chalk and Opium, which appear to act on the sore mucous membrane just as they do on a raw blistered surface of skin. If these fail, Sulphate of Copper should be used in doses increased from a quarter of a grain up to two grains. Where there is a simple flux of transparent mucus without : or pain on pressure, and no fibrin or blood in the motions, vegetable astringents, such as Logwood, Bark, Kino, and Tannin, are often of great use. In such cases, too, I have pre- d Iron, in the form of the Tincture of the Sesquichlo: with seeming benefit. I must, however, say, that I feel doubt- ful in the greater number of cases whether this form of flux be not due rather to the colon than to the ilia. Where the solid matter is pale, fetid, and consists mainly of undigested food, inspissated bile may be given with benefit ; the stools Itecom. id and less frequent under its employ- ment. This is particularly the ease in children whose rnesenterie glands are diseased. IVp.-ine also diminishes the fetor of the motions in the best way namely, by promoting the normal solution of the food, and acting as a -at ut' fecal collections; and if it is found difficult to :i any other spot, it is wise to take it for granted that this is the failing one, and direct our local applications accordingly. We should not be satisfied with the one or two very copious stools which will follow these efforts; the treatment must be vered in until the bowel has recovered its tone, or there will be great risk of relapse. When there is much flatulence with the constipation, Tur- pentine and Rue may with advantage be added to the enemata. SECTION II. Costiveness. In costiveness the absolute quantity of feces is always too si) mil. It is in fact a deficient excretion into the alimentary canal. That the greatest part of the matters which ought to be thus ted come from the liver we have not the means of knowing, but the main point, that they are derived from portal blood, we are justified in asserting; so that the solution of the former question is of the less importance. And, at least, that a great deal of the color of feces is due to bile we may know from the phenomena attendant on obstructed gall-ducts. 11 when there is complete occlusion of the communi- cation between the liver and intestines, the i'eces by no means ntirely of undigested ibod ; there is in them a great proportion of yelhnvish-gray granular matter which appears in the healthy Mate, and still makes up the bulk of the solid In deficiency, therefore, of tin- ftXOietive pOWWH of the intes- tine- generally (rul,j,> " costiveness" or "biliousness"). th> a diilerent substance retained than is : vhen local lesion 276 CONSTIPATION AND COSTIVENESS. of the liver or gall-bladder obstructs the passage of bile. There is a partial retention of the whole matters destined for depura- tion from these quarters, instead of a complete retention of one constituent. Hence there is not, as happens in mechanical retention of the bile, the well-known stain of jaundice communicated to the blood and skin, nor are the stools clay-colored. But there is a dinginess of complexion, and the stools are scanty. The skin is greasy and opaque, the countenance sometimes puffy and bloated, sometimes thin and pale, the lower eyelid especially sallow and discolored. The sebaceous follicles on the alse nasi are stopped up with black matter. There is seldom any decided emaciation, nor is there always even loss of muscular power ; but still there is great sluggish- ness of body and apathy of mind, and often a miserable want of decision and energy. Digestion is accompanied by a good deal of discomfort and flatulence, but rarely by actual pain, and the distress does not begin till several hours after eating, so as to be with difficulty referred to any particular meal. In the least complicated cases of checked intestinal secretion the stools are dark, hard, and dry ; but their appearance may be varied by several circumstances. Sometimes there is an augmented secretion of mucus, and then they are intimately mixed up with it, forming a black, slimy, almost gelatinous mass. Sometimes, from the appetite not suffering, the patient will eat largely, and then there appears irregularly from time to time a quantity of fetid, semi-digested food, constituting a sort of diarrhoea accompanied with pain and colic. And this diar- rhoea will often be the occasion of your patient's first coming to you, so that you might be deceived into a false impression of the case. The congestion of the portal vessels in the upper part of the alimentary canal is often followed by the same state in the lower, and thus piles are formed, which add much to the general distress. Costiveness is a common accompaniment of anemia, chlorosis^ and debility in both males and females, of diseased hearts, especially where the muscle is dilated rather than hypertrophied, CONSTIPATION AND COSTIVENESS. 277 of contracted liver, and, in short, of anything which makes the abdominal circulation sluggish. Sometimes it is found in c of pulmonary tuberculosis, but hardly ever in consumptives under middle ad. But what is the consequence of leaving off Mient ? The renewal of the blood and tissues not having ha;i, whey, soda-water, Seltzer- water, &c., substituted for them. 1'erhaps it i.s on account of their temporary arrest of destrue- milation, that general tonics, such as Cinchona and Quinine, rarely agree well in those cases. I find it better to pure bitters, such as Oak-bark, Quassia, and ' was the occurrence as often as twice a month of intense headaches, lasting several days. They occupied the whole head, obscun-d tlie sight, and ren- dereil him unfit for his dericul duties during the paroxysms. I found that each attack was preceded l>y irastric symptoms, complete anorexia, and some- tiin>'s by vomiting. A holiday trip to the seaside, when the cares of the parish were forgotten in boating, sketching, riding, and society, entirely re- lieved them and kept them off for many weeks afterwards. After each attack he was used to have pain in the anus and urethra, and pain on passing urine, which was acid, and deposited copious clouds of lithates on standing. iiir-continued course of non-purgative doses of Taraxacum, the habitual use of Potash-water as a drink at dinner, and some occasional short courses of ( v >i.inine, have made M r. S a much stronger and heartier man, and relieved him from the dominion of his headaches. It is possible too that he takes the world easier as he trets older, and being convinced of the evil consequences of worry, avoids it more. Sorry should I be to advocate selfishness, yet truly it has a rd in this life, by preventing the stomach being disturbed by the business of others. In such cases as the above one cannot avoid seeing that the path of events is first the arrest of the ic digestion by the accumulating influence of over-thought on the stomach, and by this latter organ retaliating on the brain to disable its functions. It seems a fair application of the nis. The gouty constitution of the patient shows him to have a Aveak sensitive stomach, easily put off work, and unable at such times to bear its ])<<. v^iry load. The alkaline drink probably ioted the secretion of gastric juice, and the Taraxacum the secretion of bile, but I question if such remedies can be trusted to alone, as I liave remarked in the preceding chapter. Nerve tonics are needful to complete a cure. The mental causes acting on the stomach need to be very slight in weakly excitable temperaments, such as women have. -uCCXXXII. Mrs. James R , aged 39, came to me in May. lsi',1. She was married, but childless, thouirh the catamenia were copious and regu- lar. About every fortnight the slightest annoyance or bodily fatigue brought en n:iu.-i-a. loss of appetite, and a throhliin;: i" the teiii|l"s. This was gene- rally in the evening, and the next morning after a restless night she awoke with an intense headache, so that she could not raise her neck from the pillow. 284 NERVE DISORDERS This lasted till next night, and then went away, almost always suddenly, and she found herself quite well without any abnormal evacuation. I gave her Steel wine after food, and the intervals of the headaches seemed to grow longer ; but I only saw her twice afterwards, and do not know if she were entirely cured. CASE CCXXXTTI. Miss H , a red-faced, dairymaidish woman of 40, had thrown upon her the charge of a large inn in a market town, where she was kept going all day among farmers and troublesome barmaids in consequence of the difficulty I found in curing her father of rheumatic gout, so as to enable him to take his share. She could get on very fairly, were it not for attacks of sickness and fluttering at the epigastrium, accompanied or followed by intense headaches at night, so severe as to awaken her up out of sleep with pain. Otherwise the bodily functions were healthily performed. She came to me April 19th, 1861, and I gave her Iodide of Potassium and Tincture of Sesquichloride of Iron. I saw her again on May 6th, when she said her haad was much better since the last prescription, but that her legs were swelled. On inspection, this proved to be due to lumps of Erythema nodosum. I then gave her Citrate of Quinine and Iron. She went on with this some weeks, and was quite well as long as she took it ; but on leaving it off her headaches, &c., relapsed, and she came up to London again about them. So I desired her to take Sesqui- oxide of Iron with her daily food as long as the untoward exertion of mind and body, to which she was exposed, lasted. This seems to have been effectual. I have cited this last case for the sake of noticing by the way the connection of Erythema nodosum with gastric derangement. It is so connected mostly in cases where the nervous system suffers. Thus we shall find that hysterical women are subject to that cutaneous affection, especially when the hysteria is due to the stomach. In these last two cases I ordered Iron, but I do not think it such an important agent as Quina, which in the second pre- scription of the two I have joined with it. However, the Iron did not disagree, even in the red-faced and apparently red- blooded patient. Indeed, where we see other evidences of need for tonics, our diagnosis of the anaemic condition of the blood by the color of the face must be very guarded. The tint of the inside of the lips is a safer guide. The frequent occurrence of instances like these, where a mental responsibility which to a man would be a flea-bite^ overwhelms a woman, should be a caution to those who are desirous of equalizing the brain-work of the two sexes. CONNECTED WITH INDIGESTION*. 285 It was mentioned in CASK X X XI that the patient was fearful of "apoplexy" from the giddiness which accompanies these headaches. Such a fear doubtless makes the nervous symptoms 1 it ought to be dispersed by all possible means con- ,t with truth. The idea is not confined to bad observers, but was exhibited in the following instance by a medical man. ((XXXI V .Nov. 29th, 1866. H. W , aged 47, a country surgeon, who has inherited and kept up a first-class, steady practice, has become lately anxious about his health, and he is fearful of apoplexy, of which his father died. So that he thought even of disposing of his practice. What causes hi- anxiety is that at least every month he has, generally the day after some unusual mental exertion, an attack of violent headache. It begins at day- break, and gets rapidly worse, so that he is unable to get up, indeed can hardly raise his head from the pillow. It is accompanied with great nausea, but rarely with vomiting, and goes off rather suddenly in about forty-eii:ht hours. His tongue is pale and flabby, the pulse beats soft and rather quick- end he notices that of late his complexion has grown paler and that he is yellower " about the gills." Ordered to take 2 grs. of Quinine and ^th of a grain of Strychnia twice a day. In case of being surprised by a headache to take 2 drachms of Ammo- uiated Tincture of Valerian every three hours till it disperses. To avoid all purgative drugs, to drink light Burgundy, and at dinner only. By all means t> persist in following his profession, and to take interest and pleasure in it. I lieard from a patient of his in March, 1867, that he had become quite well and easy about his health. The counsel to the above, to continue the practice of his pro- on, was given with a view of avoiding the hypochondriasis aii'l stomach derangement often thereon consequent, which so often is produced by forsaking an active life for idleness. The Valerian was designed as a temporary relief only, the ba.-ie treatment being Quinine and Strychnine with the hygienic measures detailed. That such treatment will cure even very obstinate headache, deeply ingrained l>y time, is shown by the following narrative: 1 ' ' \ \ \ V A very respectable licensed victualler, aged 44, of moderate and regular married habits, was introduced to me by his medi< al man. Ir. Slight. I'e'-. L'l-t. iHiG. For more than cL'ht years he had .-u tie red from sick-headache*. They used to come on once in six weeks, but had n gradually worse and more frequent, so that then lie was never a fort- night without an attai-k. lie almost always has warning of its approach two or three days beforehand conveyed by hi- frauds noticing an unusual bright- 286 NERVE DISORDERS ness and clearness of his eyes. Then the day before he feels a giddiness in the head and a coldness of the extremities. Then at night or in the early morning on comes the headache so bad that he cannot raise his head from the pillow, much less get up to business. This continues till he vomits, which brings immediate relief. He had taken at various times much Pilula Hydrnr- gyri, but latterly Dr. Slight had very properly substituted Podophylliu for that " blue ruin" to chronic disease. I continued in the same spirit the alteration in the treatment by giving him Aloes and Myrrh for a few days only, and then leaving off purgatives alto- gether. I prescribed also R. Quiniae Sulphatis gr. xl, Succi limonum recentis q. s. ad illam solvendam, Tinct. Valerians flsiiss, Aquae ad Oj. Coch. ij max. ter die. R. Tinct. Valerian* Ammoniatae, Coch. ij min. in aqua soluta sumantur alterna quaque hora imminente cephalalgia. On February 20th, 1867, I was informed by Dr. Slight, who came to me about other business, that our patient was much improved, and that he thought he was getting quite well. On March 4th I saw him. He had just had one paroxysm of the bad sick- headache, but that was the only one since Dec. 21st. He had however fre- quently headaches of a hemicranic character of a morning, which are relieved by a cup of strong coffee. Thinking his constitution might be becoming too habituated to the Quinine, I changed it for the Quinias et Ferri Citras, of which he was to take six grains twice a day. Since then he has been free from headache (April 6th). The pain in the last case is described as HEMICRANIC when getting better, so I presume that when that peculiarity occurs that the prognosis may be considered more favorable than when it persists all over the cranium. In the ensuing instance again there was hemicrania, and it may be described as a mild curable case. CASE CCXXXVI. James C has been a frequent patient of mine since early in 1861, when he was a widower of 60 years of age. Thirty years previously he had rheumatic fever and inflammation of the heart, the remains of which are discernible in an irregular pulse, a sharpish beat in the heart and a systolic murmur. He had an appointment affording him the blessing of regular occupation, but latterly he had found himself growing unequal to the ' mental calls upon him. Any unusual exertion brought on six-headaches, beginning with dizziness and oppression at the vertex, but usually fixing on one side or the other, and ending with vomiting. CONNECTED WITH INDIGESTION. 287 This was invariably the case if he went too long without food. \ often a heudai -he would begin before breakfast, but if he could manage to eat ial HUM! it would go oil'. Sometimes in the intervals of the headache he was much troubled with Mttleraab. 1 had him leeched at the back of the neck, and I afterwards gave him Citrate of (Quinine and Iron ; but what I found did most good was the advice never as much as four hours without food. He convinced himself by experience this was the best treatment. In the autumn he took it into his head to marry, and that brought back a relapse of headaches. But a return to his former treatment took them away, and he is still able to go on with his occupation at least he was so able when I last saw him in the spring of 1866. Kemark the nettlerash, a near relation of Erythema no>.los >/,//, aft'ecting the same habits. I feel sure both these cutaneous disorders originate in the stomach, and are propagated to the surface by a sensitive nervous system. I am sorry I had him leeched ; it was a foolish concession to the opinion of another. ( >n the other hand, when sick-headaches are growing worse they seem usually to occupy the whole head, or the bade j>art of the head, as described in the history given by the next. X X X V 1 1./-*, l.rimry 23d, 1867. Mr. W. S , aged 44, a dork ieiitary habits, was always very well till eighteen months ago. never suffering from anything except occasional piles, so usual in sedentary men. At about that period he began to have sick-headaches, which now occur at i -nee a fortnight. They be^in with what he calls, basing his nomencla- ture I suppose on some false medical theory, an attack of "liver:" that is to say 1, - appetite, and can eat nothin.i: from nausea and disgust tor two d:i\-. II'- then becomes prostrate, has a grasping pain" at tin- back of the head, and in the ri.uht hypochondrium. The urine becomes dark and hk'h-colored. and then thick. I'ur.L'atives had been prescribed for him in a hope of warding off attacks, and in consequence the bowels had become exceedingly cocti as to .-cciii to re'piire a continued use of such drugs, li. ( t M]iiiia- Sulphatis trr. ij. Strychnia: hydrochloratis n tl: to forsake the plastic art and take to painting, as requiring .Hiding, and giving wider scope for inventive genius, of which he has a lhare. He had from boyhood been subject to sick-headaches, and had Keen used to be purged for them. The purgatives seemed to relieve im- mediate discomforts ; but he thought the attacks were thereby aggravated. me latterly more and more severe and frequent; and they ::.panied l>y such giddiness that he was unable to stand or to employ his mind at all. Bright globes rolled before his eyes, and any attempt brought on nausea like sea-sickness. This was occurring every ten ..: I'-a-t. and he was so evidently an invalid, that a marriage he was on the point of contracting was objected to by the intendedfather-iu-law on the "f his ill-health. The purgatives had made his bowels very irregular and costive. re him first four grains of Aloes and Myrrh pill with 2 ' th of a grain of Hydrochlorate of Strychnia nightly. and5ij of Ammoniated Tincture of Va- lerian thrice a day. After a fortnight, during which he was free from the pill was diminished to two and a half grains of the first ingre- dient and z ' 4 th of a grain of the latter. The Valerian was exchanged for (.^iiin >v him several times in July. He had but one slight attack of ver- he had been able to leave off the pills, as the bowels were spontaneously 1 by solid feces daily after breakfast. I recommended him now to go to a good surgeon and have his legs attended to. In October I found he had continued well till he had his varicose veins . !ed upon, and then the pain and distress of the operation (which was ,1) laid him up again with his old vertigo and headache. Hut a week's Strychnine and Quinine set him up again. I recommended him in future to take his course of the same medicine the first ten days in i month. Again in this case it will be seen that purgatives made the patient worse. I think this functional disturbance of the brain is especially frequent when the indigestion tak Tin of intestinal flatu- 'nt lady of :>_>. fir^t came to me in May. 1868. She had lost her husband thre.- ioii-ly. ju-t at the period of ti, i. it time had sutl'ered from indigestion 111 various forms. Latterly she had been miirh alarmed by the occurrence of frequent attacks of giddiness ; and her son. a medical man, thought these miirht be due to di-'-;i---d heart. I found these attacks of giddiness were - coincident with the rolling of wind about in the bowels, that they were 19 290 NERVE DISORDERS relieved when it passed away, and were also relieved by a strong purgative though they came on worse again after its action. The administration of Valerian and Charcoal always does this patient good, but I have never seen her lately. This very frequent degree of giddiness has been explained as a sort of drunkenness, caused by the absorption of alcohol evolved by the fermentation of sugar in the alimentary canal. But there are several reasons against that explanation. First, in producing alcohol capable of intoxicating an adult, say five or six ounces at least, a bulk of carbonic acid would be formed enough to burst the bowels all to bits. Whereas in fact they are dilated only to the extent of a few cubic inches. Again, when we see that fermentation has been going on in the stomach, as in certain catarrhal conditions of the organ with the tendency to parasitic growth mentioned in a former chap- ter, we do not find as a rale any remarkable giddiness com- plained of. Again, the breath is not scented with alcohol, as it probably would be were much alcohol absorbed. Again, the symptoms are not all like those of drunkenness. In respect to the last observation, it is true that inexperienced persons, such as the estimable lady last quoted, may sometimes tell their physician that they feel, when giddy, as if they had been " taking too much" (alcohol) ; but the more habitual devotee knows the difference of the two sensations, and draws a broad line between them. CASE CCXLI. Herr V. J , aged 30, a musician and teacher of music, consulted me in June, 1866, concerning a peculiar kind of giddiness, which would seize him at all sorts of inconvenient times, and quite disqualified him for the exercise of his profession. He would, in going through the streets in a hurry to keep an appointment with a pupil, suddenly become so giddy and blinded that he tumbled against passengers, and was forced to catch hold of neighboring railings for support. Yast dusky globes of mysterious gloom rolled before his eyes, he lost sight of the ground before him, so that a billowy gulf yawned under his feet, and he swayed helplessly on the brink. It was a continual renewal of the punishment of the company of Korah. " Haven't these symptoms some connection with your indulging in the gifts of Bacchus as well as singing their praises ?" " No, indeed no one knows better than I do, I am sorry to say, the effects of taking too much ; but this is quite different; it is nothing like either being screwed or t/e !<>wn out with exbOMive flatulence; if he could explode, all 11 : hut if not, then the ulmve-mentioned symptoms supervened. Some- time, however, vomiting would relieve him: and if he had a succession of the attacks, a stout drench brought temporary alleviation. He said he had taken much and various purgative medicine for this purpose, and felt sure that the general effect afterwards was deleterious. ('('XI. II. Another patient, A. W , whom I saw in consultation with Mr. Hewer in April, 1867, and where the intestinal flatulence ow> origin \e bloodletting alter some sort of fit long ago. complained to in.- that the irround seemed to lie ;/>///;/ Ixhiiul him as he walked, so that he . on>taiit fancy that he was going to be overwhelmed. This was a sen- i unt dis>imilar to that noticed by the last two. ( >nce a shrewd fellow made a quaint play of words describing the connection of the brain and the stomach, which may serve as a reminder of the fact. X I.I 1 1. Mr. II , a railway traffic manager of 40, complained to me in September, 1862, that for seven years he had suffered, from the frequent occurrence of very fetid stools, unformed and pultaceousj passed usually in the morning on first rising with a little griping. What most annoyed him was at these times he experienced great difficulty in transacting business requiring attention; the amount of fetor in the stools was an inverse measure of the mental powers; us he expressed it, "the addled eggs in the motions addled the brain." !! o dine in the middle of the day, and, I think, derived some benefit from my advice to him to postpone the heavy meal till evening. Ipe- ..nlia and Opium also seemed of use to him. The confusion of thoughts usually comes over the subject of it just at the very times when it is most inconvenient; and it rhis iliiVerence from hysteria, that the more exertion is uuul' .irol, the worse it grows. < VX 1.1 V. A tutor of a large and rising college at Oxford, aged _''.. in March. 1 Mil .was frightened by the unaccii>tomed occurrence of trembling, and u tendency to lose the recollection of his whereabouts during divine service a circtim>tan< e most particularly annoying to him from his having recently appointed a chaplain. lie had always I n free from .. in wine, tobacco, women, or secret lust ; but he read very hard for his in fellowship, and took a good deal of beer at dinner. He did not acknowledge to any indigestion affecting the stomach: but on inquiry it ap- 1 that he had latterly had that peculiar looseness of bowels and fetor of which ji. i.i impelled 'iuu> :. .ml in the eveuiuguot 292 NERVE DISORDERS unfrequently was harassed with a glugging sound in the bowels. He some- times perceived black specks floating before his eyes previous to the occur- rence of the faintness. I gave him Quinine and Strychnine, and advised his playing at rackets, in- stead of taking dull constitutional walks. A fortnight afterwards he came to report himself as much better. This ortopia, or mental helplessness, would seem to bear a close relation to the vertigo last discussed. It is one of the symptoms falsely represented by the terrorist advertisements of quacks as due to former habits of masturbation, and doubtless creates on this score a good deal of secret alarm among the young and sensitive. By secret alarm it is much aggravated. As mentioned in CASE XCIII, it is sometimes caused by snuffing, sometimes by mental causes, as LXXVI and LXXYIII. As mentioned in CASE XIX, it will sometimes alternate with diarrhoea and flatulence; and sometimes, as in the last tale related, the intestinal derangement will be by no means pro- minent, and only to be identified by cross-questioning. Another form of cerebro-spinal disorder dependent on faulty digestion is EPILEPSY. CASE CGXLV. Late one night in June, 1854, I was summoned to see a patient of the late Mr. Tegart, Miss W , aged 13, whom I found in a violent epileptic fit. The closeness of the sleeping nursery showing a careless, un- physiological management, I suspected corresponding neglect in the dietetic discipline as well. I accordingly administered a stout purge and the next day was shown a chamber utensil full of hard lumps of feces, mixed with hulf- digested fruit and other rubbish. The patient had no more epileptic fits. A somewhat similar occurrence to this quoted in page 70, where the indigestion of an unaccustomed amount of adipose aliment induced a single attack of epilepsy not repeated at least not repeated during the eight months which elapsed after I wrote that narrative. As acute morbid conditions of the alimentary canal promote acute epilepsy, so chronic morbid conditions promote chronic epilepsy, that is to say, epilepsy of a milder but more confirmed character. CASE CCXLYI. In November. 1863, Dr. Wallace of Parsonstown sent to consult me Mr. James E . It appeared that he had become subject to CONNECTED WITH INDIGESTION. 293 attacks of sometimes partial, sometimes complete, loss of sensibility, preceded and accompanied by a cramp in the arms and twitching of the face. Observa- tion of the stools elicited the fact that they frequently contained mucus. A tonic pill of Myrrh, Aloe's, Turpentine, and Henbane, stayed this formation of mucus. Coincident herewith there was a marked improvement in the ner- vous symptoms. I then prescribed Quinine and Strychnine, but have no further note as yet. In the next case of improvement by management of the diet tlu-re is recorded the symptom which I take to intimate the collection of mucus in the stomach. 1 XI. VII. Benjamin M , aged about 40, first came under my charge October 23d, 1858. A letter he brought from his medical man des- cribed him as subject to confirmed epilepsy for two years. Several times a week he got giddy, was unable to stand, sometimes lost his senses, sometimes was convulsed, but rarely bit his tongue. After the paroxysms he always felt tired, and usually went to sleep. He had always been temperate in eatiiiLr, drinking-, sleeping, and matrimonial matters, and could assign no for his epilepsy. On examination, I found tenderness on pressure at the pit of tip- stomach, and the patient said that he felt as if a weight were laid on that part, especially during wet and cold weather. To restrain the secretion of mucus, I ordered him a quarter of a grain of Nitrate of Silver night and morning, and some Bismuth and Sesquioxide of Iron twice a day. l>ut the most important part of the prescription was as follows : Avoid beer, pastry, fruit, sugar, tea, and coffee. In place of the latter, take milk and soda-water, with stale bread or biscuit, for breakfast. At dinner eat once-cooked plain meat, stale bread and green vegetables." ,11 November 18th, 1858; no improvement had resulted, and all I could do was to encourage him to persevere. I did not receive another visit till July 5th. ISIiO. when he reported that he hardly ever had any attacks of giddiness; indeed, never except after violent To my surprise, and at first consternation, he said he had been continuing the Nitrate of Silver, with occasional intermissions of a week or so. up to that time. No discoloration of the skin had occurred, however. I then gave him some Citrate of Quinine and Iron, which a letter from his wife reports set him in strong health in a few weeks. II.- had no more tits till IMI-J. when over-attention to business seems to have deranged his digestion, and he had a few slight epileptic attacks while dn in the morning. 1 advi.-ed a recurrence to his former dietary and to the lu.-t- prescribed medicine. In the spring of \-M he called to report that he had pot quite well, and kept so up to that date by dint of adhering to a strict plan of diet, grounded on the one I had written out in 1- p.'ige 171. 294 XERVE DISORDERS The omission of a single article from the diet- table will suffice sometimes. CASE CCXLYIII. Rev^ George , aged about 24, married, was first my patient in August, 1856, for non-syphilitic periosteal rheumatism which completely crippled him. but vanished with remarkable rapidity under the use of Iodide of Potassium. He continued well till September, 1861, when he began to have epileptic fits. He came to me in May, 1862, when I kept him a month in London, and seeing the former success of Iodide of Potassium in one disease in his case, tried it again in another. While in London he was free from fits, but no sooner did he return home than they became worse than ever, though he increased the dose of the Iodide. So he left it off, and when I next heard he was taking, under advice, mercurial alteratives " to act on the liver" and so on, not apparently with any advantage. I next saw him in January, 1867, when he said the fits had become so fre- quent and occurred at such inconvenient times, that he had been forced to give up his clerical work. I had originally advised that, and indeed it was in consequence of that advice that he had deserted me. However, that idle- ness did no good, till some person recommended him to give up beer, and from that date the epilepsy began to improve. The said drink had always made him flatulent, and he had found his digestion much better since he took only water. He was anxious to try some Bromide of Potassium, and I allowed him to do so, but still urged him to persist in his abstinence, as to that I attributed his improvement. In March he called to report that he had had only one fit, and in that con- sciousness was not entirely lost. Iodide and Bromide of Potassium seem to have a peculiar restorative action over the white fibrous tissues. They were first brought under the notice of the profession by the effect of Iodine in scrofulous diseases of the glands, and then by their cure of syphilitic periostitis. A notion got into the profession that they had some antagonistic, or controlling, or evacuating power over syphilitic virus; but the more recent surgical writers, such as Mr. Lee, think there is evidence against that idea, and that they benefit by curing the diseases arising out of the pre- sence of the virus, and not by removing the virus itself. They cure the patient's tissues without specially affecting the materies morbi, equally in rheumatic as in venereal cases of periosteal disease, ^yhen recently affected, these patients are restored to health as readily as the subjects of secondary syphilis; and the apparent resistance in some cases to the remedy is due to the protracted nature of the ailments ; just as syphilitic periostitis, when it has lasted a long time without medical aid, is very CONNECTED WITH I \ 1>I GESTION'. 295 Mate also. On the ground that Iodide of Potassium has a .il restorative power over the white fibrous tissues, I should liivct benefit from it in epilepsy to those cases where epilepsv is lue to some le.-ion of the membranes of the ral or other masses <>t' nerve substance, whether that lesion nporarv or permanent : ami I am not surprised at its failure in the gastric cases we are now discussing. In the i the flatulent distension of the bowels before the :' the epilepsy with deranged digestion. Perhaps the disease is too ]..; tined for cure; perhaps I did not p;iv sufficient attention to dietetics at that date; but, at all events, favorable results have not followed the use of drugs. \ 1 .1 X . A . < ; , aged about 40, first came to me iu January, 1851, after having been a patient <>t' the late Dr. \V. F. Chambers for five years for epileptic attacks, occurring about every fortnight or three weeks. He had Keen taking Sulphate of /ine (gr. iij bis die) and much purgative medicine, and I continued the prescription. w him from time to time during the next two years, and found that the fits wen- invariably preceded by flatulence and distension of the bowels, but immediately announced by perspirations and pale urine. By the end of 1852 the fits hud In-come li-ss violent, and assume'! a regular periodicity, coming on very eighth night between ten minute- before and ten minutes after twelve- I do not think he made any more attempts to get well. I am afraid one cannot in such cases find much fault with a despairing patient: so few are the instances in which an epi- whieh has assumed a regular periodicity, at the same time that it grows milder, ever is cured. It is possible there may i structural brain disease, and that the indigestion was only the motive cause of the eilepsy. There is a sort of modified chronic chorea which seems de- pendent on chronic causes in the alimentary canal, just as acute ID dependent on acute rauses. I call worms (for example) acute, ' movable and temporary, and directly they are gone the derangements, tend to get well of their own accord. 1 the distinctions drawn ' Mmnir" in th- Intro- duction. i'.-iir- '-- an.i note. S-f ;il.-" hielly Clinical," 'ire xxx. 296 NERVE DISORDEES CASE CCL. C. J , aged 26, an accountant, came to me on February 5. 1867, in much shame-faced fear, tinder the idea that his state of health was the delayed retribution for nasty habits of se'cret lust practised when he was a boy. He was troubled with involuntary twitches of the facial muscles, low spirits and causeless fears. His breath felt hot to him ; his scalp and anus itched ; and the abdomen seemed to burn as he lay in bed. His sleep was disturbed by terrible dreams. The spasmodic movements of the face were. however, what troubled him most as a man of business, for they made him ridiculous, and the more he endeavored to control them, the worse they were. The urine was natural. Indeed, I could detect nothing contrary to nature in the functions of the body, except in those of the alimentary canal, whose excretions were reported very fetid at times. He had taken Zinc and other specifics without advantage. I gave him Valerian for two days with some improvement of the sleep (but it is possible that improvement may have been due to his mind being set at rest respecting his youthful nastiness) and then put him on Quinine and Oil of Rosemary, which he continues to take with some benefit. Symptoms like these are, again, engines bj which the adver- tising quacks extort money. It is difficult to avoid having their obscene literature thrust into one's hands, and it often leaves torturing scars on the mind for life. Minor degree of reflex manifestations of nervous action assume more familiar forms. Thus we have very commonly what is known as " STOMACH COUGH," that is to say, cough without any bronchial secretion or other morbid condition of the lungs, and connected with, aggravated by, and yielding simultaneously with, catarrhal relaxation of the mucous coats of the stomach. Usually we may infer this gastric derange- ment from the symptoms ; sometimes we have the confirmation (afforded in the case I will quote as an illustration) of a similar catarrhal condition appearing at the visible extremity of the alimentary canal. CASE CCLT. Henry L , a manufacturer, aged about 30 when he first consulted me in January, 1861, complained of a constant hacking cough, with- out expectoration generally, but still aggravated by damp chilly weather, and of pain in the left mammary region. His face was pale and flabby, and he had a tendency to grow fat. The chest was quite healthy as far as could be ascertained by the ear. He got better under the use of Quinine, and after a few visits I did not see him again till November, 1863, when he came to me with a recurrence of his former symptoms. He in addition complained that "his chest" (pointing to his epigastrium) "gets stuffy and feels too large." The uvula was much relaxed, and on looking into the throat, it seemed to be CONNECTED WITH INDIGESTION*. . 297 redder as you go down deeper. Acting on this hint I have since accompa- nied tin- tonics by gargles of Oak-bark and Alum, and subsequent a; jot better the quicker for them. On leaving England, in December. I commended him to another doctor; but he came to me in October, -nying that he had been quite well till then, when exposure in the coun- try during the wet autumn had brought on an unusually bad attack. I never saw his throat so red, and he said he could feel his oesophagus all the way down to the pit of the stomach. A course of Quinine restored him to his usual health. Hut a<:ain in April he has come again with a sore throat and ness, and this time, as in 1861, he has got a hacking cough, and is con- vinced. as is also his wife, that he is going into a consumption. The chest is quite normal on examination, but the uvula is much lengthened and the throat red. There is great weight at the epigastrium after food, and a sensa- tion in the oesophagus leading him to hawk mucus continually. Apropos of the relaxation of the uvula, I may mention that he made it much worse at the first by violently causticing the back of the fauces with Nitrate of Silver. These cases are best treated by astringents, but changes of :ier must be guarded against with especial care. Without the aid of the stethoscope they might readily be mistaken for pulmonary consumption. The following is a very fair typical example of symptoms such as these occurring, as they often do, in a gouty constitu- tion. CARE CCLII. S , a burly country gentleman of 50, used to have regular attacks of acute gout in the small joints three times a year till 1863, when they ceased, liut their place is taken by a worse enemy. For as October mines round annually his throat gets sore and livid red, or else he has a fre- quent liackinir cou^h. and sometimes both evils together. There is a 1'i-uliug of weight at the epigastrium after food, and a discomfort scarcely to be called pain, on pressure of the lower part of the stomach. The bowels are apt to be loose, but lie usually restrains the looseness from proceeding to diarrhoea by Opium. (Dt<: I'.''/,. 1*66.) Iti tin* last case the pains of gout alternated with the stomach cough and sore throat, but in some unfortunates they may both occur ( ' \-' : i ( 'I.I 1 1. C. ' . ! 11. H tlie 1 1 rot her of n patient who ha< Keen under my care for gout, and ha* him>elf lieeii bald from an early air- 1 . He reports also that f. inner L'eneratinn< of the family have been uouty. He h.i- been under my can- sinre Novemli, : intermittent sciatica and tiff-neck, much dependent uti the condition of the .-tomac h. and which 1 con- 298 NERVE DISORDERS sider therefore to have a gouty character. He was desirous of reporting im- provement in this as time went on, but I cannot say I thought it any better in January, 1867, when he began to have cough and then a red swollen throat. The lower lobes of the lungs are apt also to become congested occasionally ; but he never expectorates with his cough, which seems to vary much with the weather and state of the stomach. I treated him for some time with Quinine, Iodide of Potassium, Baths, c., without any advantage. In Feb- ruary I gave some unpalatable, or impracticable, advice as to change of climate and lost sight of him. Another form of the influence of gastric derangement upon the nervous system is the production of morbid ANAESTHESIA. As I remarked respecting headache the most frequent instances are found amongst those who have already made the nervous system susceptible of disease by overstraining it. CASE CCLIV. An American speculator, aged 48, was sent to me in June, 1866, by Dr. Forsyth Meigs, of Philadelphia. He had lost a fortune of ten thousand a year by the civil war, so that he had to begin life orer again an ordeal not so severe in the United States as in England, but still an ordeal anywhere ; he had worked energetically to recover his position ; he had thrown himself into the turbulent, rather than the quiet joys of life ; and he had also gone through certain matrimonial difficulties not unscathed. In August, 1864, he was taken with vomiting and loss of appetite, general debility, defi- cient sleep, and occasional flatulence. These ordinary digestive derangements were the only trouble till the end of September in the same year, when he found gradually creeping over his hands and feet a peculiar sensation of numb- ness ; not what is commonly called "pins and needles," but a bluntness of perception especially in the finger-tips, so that he did not know when he was touching a small object, unless he saw it ; and he often tripped from not de- tecting a small impediment in walking. On resuming matrimonial privileges, after an interval of abstinence on account of his health, he found that emission occurred immediately on entrance, or even before entrance was effected. His head had been bald since the age of twenty, but in general respects he is a young-looking man. The specific gravity of the urine before breakfast is 1.025, after breakfast 1.015. Under the use of nutritious diet, abstinence from alcohol, and from over-much anxiety in business, and of Nux Vomica and Quinia, prescribed by Dr. Meigs, his digestion had strengthened and the sensation was returning by degrees to his extremities. I thought he could not do better than take a course of the same drugs for ten days in each month, and follow strictly the plan of life laid down for him by his first-rate physician. It is proposed that he shall spend a few years in taking his daughter round the chief cities of Europe. He called on me early this spring of 1867 to report improvement. Cases such as this last receive all sorts of names, according to the prevailing theories of the period ; which nomenclature CONNECTED WITH INDIGESTION. 299 does the patient no harm so long as the theory does not influ- the treatment. The principal danger is lest he may fall into the hands of a counter-irritator, who should depress the vital powers lv making sore places over the spots where he supposes chronic inflammation to exist. Electricity probably no harm, but it will be observed that recovery is always coincident witli an improvement in the digestion, and I think attention to this function is our leading duty; and alone it may be followed by a cure, so that there is no need of additional bment The loss of nervous function in some cases is manifested in the nerves of motion principally, or even solely. We must ;me that it depends on the specialities of the nervous system itself in each individual which portion of it be affected, and that the influence of the alimentary canal is general ; otherwise we should be able to map out certain tracts as ruled over by certain viscera, and not find motor and sensory fibres indifferently injured by imperfection of the stomach. I/V. Colonel IJ , aged 43, applied for my opinion on the 30th of July. IH'I(. about a loss of power in the legs. He has always had a "weak stomach." feeling a weight at the epigastrium if he takes liberties with his diet, or is exposed to a damp cold. In the summer of 1H>."> his siom.irli difficulties were particularly bad. and then he began to notice what he called a " iidiretine<" nf the !;:-. inducing him to kick and stretch them about. Then he found 1 - and |*M able to walk, and then there was pain in the leirs felt, imperially after any exertion. A mile was the utmost he was able to walk when I saw him. He had been galvani/.cd and had tried a variety of medical treatments, without any advantage that he could discover; the only improvement lie could ever notice, was when he was in the bracing air of Scotland. On this hint 1 sent him thither, with a prescription for Quinine and Strychnine. I heard from him in August that he digested better and walked better, but that the pains were bad in the legs at night I added therefore to his mixture four grains per dose of Iodide of 1'ota-siuin. In this instance the >eus.>ry tracts do not seem to be injured at all. And the paralysis is not sufficiently complete to cause atrophy from deficient use of the muscles. Indeed, in gastric -iif I may so cali it I 1 have never seen the loss of power :;s to deprive the mu.-eles <>f that amount of motion which is conducive to /ients can alway- 300 NERVE DISORDERS about a little, are willing to do so, and very often disposed to exert themselves too much. This is an important point in the treatment ; for if what I have remarked is true universally, we shall be doing harm by following the common practice in telling the patients to employ and exercise the muscles as much as possible ; we ought rather to impress upon them the necessity of avoiding such an amount of motion as nature warns us against by the sensation of conse- quent fatigue. When atrophy of the muscles has any connection with de- rangement of the digestive organs, it is usually to be traced to overwork rather than to underwork. Of this I will quote an instance which I have previously made use of in the later editions of my Clinical Lectures. CASE CCLVL (Clinical, St. Mary's, June I3th, 1863.) Nathaniel B is a top-sawyer by trade, aged 45, and was always a hearty fellow, able to do a good day's work, till ten months ago ; when, after violent exertion in turning over a mass of timber, he got what he calls " a wrench" in the pit of the stomach, and '' has never been the same man since." The appetite failed, and therewith the strength ; the muscles wasted, and the whole body grew emaci- ated. The loss of appetite then became entire, and then increased to an utter loathing of food. He went into Guy's Hospital three months ago, but left apparently dissatisfied and ungrateful. On gaining admission to St. Mary's, May 22d, he seemed much cast down, expecting never to get any better. He was able to walk about, and the chief loss of power seemed in the shoulder-muscles, the deltoid and biceps ; and when he tried to " put up" the latter, that is to throw into it the contractile nervous force, it felt quite soft, without any of the corky elasticity which distinguishes a sawyer's arm. He is the father of thirteen children, but since the commencement of his present illness he has entirely lost virile power. He states himself to be a perfectly sober moderate man, and has a good character on that score from his employer. It is scarcely necessary to say that the epigastrium and hepatic region were carefully examined for evidence of cancerous degeneration, and none was found. The lungs also were thoroughly auscultated, and nothing abnor- mal was detected, beyond a suspicion of slight comparative dulness in the right apex. He had not suffered from habitual cough or had any diarrhoea. He was at first kept in bed and given milk and beef-tea every two hours, with ten grains of Boudault's Pepsine powders three times daily. In a few days his excessive nausea and lowness of spirits had abated, and he was ordered six grains of Quinine and three drachms of Cod-liver Oil daily in addition. In a few days more he was tried with half a mutton-chop, digested CONNECTED WITH INDIGESTION". 301 it well, and on the 6th of June was able to take oar whole ordinary diet a ])int of milk. and a pint <>f beet-tea, and a pint of porter. On the l-il, terday; In- was so much better that I thought it was scarcely justifiable to let him o.-ciipy a place in the hospital any longer, and I trust he will be able to :i as an out-patient. he was confined to bod at first, it was not convenient for some days to put him in the scales ; but on May tlu> 24th we found his weight 8 st. pounds : on the 30th, 8 stone 7 pounds ; on June 6th, 8 stone 10 pounds; on June llith, 8 stone 10$ pounds; his height being 5 feet 6. inches. Tlu- only day on which he did not take Pepsine was May 29th, when our stock was accidentally exhausted, lie then complained of pain at the epi- irastrhim, and attributed that to the omission of his powders. A -omewhat similar case is related page 37 (CASE VIII). Now, had this sawyer been a gentleman in easy circum- stances, the excessive waste would not have been habitual, and lie would not have had muscular atrophy of the limbs. The 'wrench" would have been confined to the stomach, and he would probably have suffered only from imperfect indigestion, like the sporting-man (CASE XIII) whose partial paralysis of the stomach dated from hallooing and running* on Derby-day. As he went on in life, any extra exertion would have induced flatulence, as in the old fox-hunter (CASE'XII). Or if he had been in vigorous bloom, the paralysis would have been only temporary, as in CASES IX, X, XL The proneness to muscular atrophy may have long existed; but no harm happened so long as the stomach was able to go on supplying nutriment en< to compensate the extreme waste of the violent exertions. No sooner does its debilitated condition fall below a certain point than atrophy is exhibited suddenly and proceeds at a frightful The only cases in which the easy classes are likely to be similarly affected is when injudicious friends urge them to exer- tions for the good of their health, or where brain-work occupies the hostile post held by body-work, as in the instance befor- ther symptom of gastric weakness which obscene adver- wont to turn to their profit, as well a- ami chorea, is Fi.rsiiiM; OF THK FACK, or Causeless blushing. Tins would be sufficient to show that it common in healthy persons; but rarely does it grow bad enough to consult a physician about. 302 XEftVE DISORDERS CASE CCLVII. Mrs. R , aged 56. put herself under my charge in June, 1866, stating that for the last half-dozen years in fact, since the cessation of the catamenia she had suffered from flushings of the face at irregular times, accompanied by palpitations of the heart, so severe that she thought that organ must be organically diseased. On examination, I found it healthy in all respects. On inquiry, I elicited that she suffered excessively from intestinal flatulence, especially of an evening, and not uncommonly had heartburn at night, if she ate pastry or took sugar in her tea. When she came to me she had been latterly much worse than usual, and this I traced to annoyance about a love difficulty of her favorite son. A month's course of Quinine and Strychnine twice a day dissipated gradually the inconvenience she suffered ; but she remained, and probably considering her age always will remain, a very nervous subject. A higher degree of the same phenomenon constitutes NETTLE- RASH, which is always partially traceable to the stomach, as is shown by the relief afforded by a change of diet, a change sometimes seemingly insignificant. CASE CCLVIII. Miss C. R , aged 35 or so, was a patient of mine in the summer of 1866 for nettlerash, which for the last six years had made her mornings miserable to her, coming on in her legs directly they are put out ot her warm bed. She had tried all sorts of treatment in vain; nothing seemed to do her any good. The chief things which make her worse are being worried, and getting wet through when riding. I have given her Soda, Liquor Ammoniae, &c., without any apparent effect; but what really seems to afford the greatest relief is leaving off all alcoholic liquids, tea, and fruit. CASE CCLIX. R. V. E , aged 50, a commercial man, requested my advice in February, 1850, about a peculiar kching papular eruption. Observ- ing that it ran in straight lines, and was only in the front parts of the body commanded by the hands, I questioned him further, and found that it only appeared when scratched, and in the morning assumed the form of " wheals." He confessed that eating pickles and drinking hard beer used to bring on these " wheals," but that he had for some time carefully avoided all acids. The only unnecessary that I could detect among his ' non-naturals" was the use of tobacco. lie allowed that strong shag, in which he indulged, certainly did somewhat upset his stomach and make his hand shake. Leaving off smoking at night, and using only light cheroots by day, cured him, with the help of a little Liquor Ammonise. His nettlerash got well, when his nerves and his stomach returned to their duty together. That nettlerash is a phenomenon connected with imperfect innervation I have the evidence of the following personal expe- rience. A few years ago I was unfortunate enough to have a CONNECTED WITH I .VDIOESTIO.V. 303 eal aneurism. When this came to press habitually upon the nerves of the ham, of which my sensations gave me due notice, 1 remarked that bathing in cold water brought on nettle- rash, invariably confined to the alVeeted leg only, and never since su tiered from. v, when an individual has a nervous system less powerful than the rest of the body, let them be females, feminine men, or men with habits debilitating to innervation, any gastric derangement is liable to bring on nettlerash among other svmptoms, just as the cold water brought on nettlerash in the leg whose innervation was partially cut off. That is my theory, and that is why I introduce nettlerash in this somewhat unusual ;.ection. In the next case the eruption on the skin, though clearly dependent on the digestive organs, was not of such a char, as to be correctly called Nettlerash ; it was rather an "Erythema circumscrijitum." (I presume in cutaneous pathology one may be allowed to invent a nomenclature that best suits the case in hand, inasmuch as no one treats the patient in obedience to the nomenclature.) The depression of spirits and causeless fears point out that connection of the pathology of the case with the nervous system, which I have alluded to above. 1 ' ' I.X. \V. L , a country gentleman of 52, of robust jovial aspect, square set and muscular, comes of a pouty family; but he has never developed in hi> own person his damnosa hcf"l-i the u.-ual eour.-e. About every three or four weeks he finds a dreadful depression of spirits comes over him, without any cause or previous excitement ; the urine become- ly copious and pale colored, and is I with preat frequency. Then commences pastric flatulence, i burst in;: up from the stomach in luicli i|iiantities as to wake him up at niirht ; mid at the >ame period the heart thumps airain-l the ril>s \\ith extraordinary and frequency. The appetite is quite lost, and disgust to food takc> its place. I'.ut there is con>iderable thir>t. and the toiipue is furred, clammv, iiml dry. The urine now :rets scanty, and a- h it'll colored sometimes as porter, but never thick. Then lie begins to brinp up clear fluid from the mouth nearly every hour in pushes of ' -everal "itncc, at a time. The fluid is alwavs sour, and after meals i> intensely 80 to tin- t:it.-. Th-.-e attacks have ordi- narily ceased in about four days, and ih-- from them is almost always announced l.y a peculiar eruption on li. dally <>u thai of the 304 XERVE DISORDERS. belly and legs. Sometimes they last longer, and notably on the occasion of his first coming to my house he had been ill off and on for three weeks, occa- sionally having a remission but never quite free. When 1 saw him the tongue was much furred, he had no appetite, and had been throwing up the acid fluid already that morning. In spite of a round red face he really had the aspect of great mental distress, quite incommensurate with the degree of pain expe- rienced. In spite of the depression of spirits his mind was quite clear, and capable of business (if he had any), and there was no vertigo or headache. During the three weeks he had lost fifteen pounds in weight. The epigas- trium was very drummy on percussion, the resonance stretching to an abnor- mal extent from side to side, so as to show a very large stomach. The belly however was flat, though he is a broad dumpy man. I prescribed (May 17th, 1867) R. Quinise Sulphatis, gr. ij, Strychnia? Hydrochloratis, gr. 2 \y, Succi Limonum quant, suff., ad ilia sol venda, Aquae ad fl,5j, Potassii lodidi, gr. iij ; bis die. R. Pilulae Aloes cum Myrrha, gr. iv, Strychnia? Hydrochloratis, ^ ; omni nocte ; and desired him to call again in four days. He was advised to take no stimu- lants at all. On the second visit I had an opportunity of seeing what he had described as the convalescence from his attacks. He reported that with each dose of the medicine from the time of beginning its use he had felt relief. The flatu- lence and ejection of sour fluid had ceased ; and on the second day his appe- tite returned. He had celebrated the return of it by eating whitebait and spitch-cock eels, and drinking some weak brandy and water at dinner. The consequence was one attack of the sour waterbrash ; but since then he had been free. The urine had become nearly natural. On the skin of the arms and abdomen he showed me spots as large as sixpences of a red erythematous eruption, closely resembling measles. He said it did not itch, but pricked, like what Indians call " the prickly heat." The next day it was still more like measles, for the centre of the spots had begun to fade while the circumference had spread, like fairy-rings on the green sward. ANALYSIS THE cases in this volume form a sort of skeleton, which I have articulated together by argument, and tried to make muscularly act i ve by practical observations. A list of them, indexed accord- ing to the subjects they profess to illustrate, will serve as a memorandum, just as the dry bones recall succinctly the struc- ture of the animal frame to the anatomical student. CllAETER II. Indigestion of various Foods. ? 1. Of starch. I and II. Flatulence after starvation and sorrow. HI. To illustrate the action of Iodide of Potassium on the salivary glands. IAM IV. Flatulence, &c., following loss of appetite induced by disgust and anxiety. ml VI. Flatulence and diarrhea in cases of Bright's disease of the kidneys. V II. Flatulence from disease of heart and arteries. CASK VIII. Pain after vegetable food from loss of nerve-power induced by bodily exertion. CASE IX. A ute attack of flatulence and vomiting from bodily exertion in a healthy person. Case X. The same. Flatulence and immediate diarrhoea. CASK XI. The same. IMarrlura later. XII. Flatulence recurring habitually after moderate exertion in old age. CASE XIII. Chronic condition following one bodily imprudence. Flatulence and nervousness. CASK XIV. Flatulence and insomnia from overstrained attention of mind in a nervous in.ui. 20 306 ANALYSIS. CASE XV. Chronic condition following one mental shock. Flatulence, im- potence, red nose. CASE XVI. Chronic condition from continued anxiety. Flatulence, emacia- tion, weight after me^ils. CASE XVII. Flatulence, spasmodic pain, costiveness, from bronchial catarrh. CASES XVIII, XIX, and XX. Flatulence, heartburn, waterbrash, diarrhoea, from an attack of epidemic cholera. Adhesion of the poison to the locality. Evil of purgatives. CASE XXI. Indigestion from the depressing effects of rheumatic fever. Pain at epigastrium after food. CASE XXII. Flatulence and pain in abdomen after child-bearing. CASE XXIII. Weight at epigastrium and vertigo, flatulence and acidity, from climatic influences. CASE XXIV. The same producing hysteria. CASE XXV. The deleterious climatic influences are changes, rather than continued depressants. Resistance gained by use of Iron. CASE XXVI. The dependence of indigestion on change of weather a diag- nostic sign. CASE XXVII. Influence of locality. Flatulence, nausea, acidity, waterbrash, emaciation, when in a malarious district, and not elsewhere. CASE XXVIII, Soft air. CASK XXIX. Sea air and bathing. CASE XXX. Chronic flatulence after tropical dysentery. Remarks on digestion in hot countries. CASE XXXI. Effects on flatulence of abstinence from sugar. 2. Indigestion of albumen and fibrin. CASE XXXII. Pain in epigastrium after meat during the debility induced by an acute fever. CASE XXXIII. Pain, nausea, and diarrhoea after meat in an aphthous con- dition of mucous membrane. CASE XXXIV. Phthisis pulmonalis. Weight at the epigastrium after animal food, diarrhoea, emaciation, relieved by Quinine and Iron. CASE XXXV. Fatal consequence of a mental shock in a consumptive who could not digest meat. OASE XXXVI. Vomiting from oesophageal lesion alleviated by anaesthetics. CASE XXXVII. It is the form rather than the chemical constitution which makes meat difficult of digestion in cesophageal cases. Fish easier digested from its friability. CASE XXXVIII. Yet in some stomach cases even the softest animal food is rejected. ANALYSIS. 307 { 3. Indigestion of fat. CASE XXXIX. Consumption fatal from loss of power of assimilating fat, though the amount of tubercle moderate. CASE XL. Consumption, though advanced, relieved by great power of assimilating fat. CASE XLI. Moderate amount of consumption and moderate amount of assimilating power balancing one another. CASE XLII and XLI1I. Renewal of fat assimilation overcoming tubercular diarrlnra. CASE XLIV. Strumous dyspepsia consists in the non-assimilation of fat. CASE XLV. Disgust to fat joined to defective assimilation. The disease induced by starvation in childhood. XL VI. Importance of fat at the period of puberty in girls. \ I. VII. The disease induced by over-exertion of intellect. CASE XLVIII. Cutaneous symptoms of non-assimilation of fat. 2 4. Digestion of water. CASE XLIX. Osmosis of water through membranes defective from the watery condition of the blood in induced anaemia. L. Osmosis defective from retarded blood-stream in diseased heart. CASE LI. Osmosis defective from retarded blood-stream through emphy- sematous lungs. CASE LII. Illustrations of the variations in the specific gravity and alka- linity of the urine through the normal absorption of fluid. I 5. Treatment of indigestion based on the article of food not digested. CASE LIU. It must not consist in entire omission of the indigested article from the dietary. Scorbutus from leaving off vegetables by medical advice. CASE LIV. Purpnra from insufficient vegetable diet in a hard-working man. CASE LV. Pain at the epigastrium, costiveness and debility, from omitting meat. Amenorrha-a a stomach disease. HINTS ON DIETK $ C. Treatment based on general ]mth!o,ii.-(il condition of indigestion, as used tt< t/i> foregoing cases. _/*//;< r/yr'/j/ (Juinim n,, CHAPTER III. Habits of Social Life //(iy Valerian. Arrest of acute functional vomiting by withdrawal of all food, i VI. The same in a more chronic instance. ('('II. The same, Mood being also thrown up. 1 < VI 1 1. Kfl'i-rts of the shower-baths. Hereditary nature of this disease. CASE CCIV. Effects of strong mental imjires-ion in causing and curing the disease. < CCV. Association of functional vomiting with functional paralysis of Other parts illustrates the true physiology of the a-t. 1 (,'CVI. Throwing up of food from mechanical impediments to its descent. 314: ANALYSIS. * 8. Vomiting in Pulmonary Consumption. CASE CO VII. In slight degree. CASE CCVIII. The degree of dyspepsia and degree of tuberculosis are not proportioned to one another. CASE CCIX. Sickness dependent on debility. Use of Cod-oil and Hypo- phosphite of Lime compared. CASES CCX and CCXI. Early vomiting in consumption. Use of Opium in small doses. CASE CCXII. Use of Opium in large doses in the vomiting of advanced consumption. CASE CCXIII. Vomiting in advanced consumption from the nauseousness of the sputa difficult to be remedied. 9. Occasional Causes of Chronic Vomiting. CASE CCXIV. Uraemia and not dropsy is the cause of it in Bright's disease. CASE CCXV. Emphysema. CASE CCXVL Ditto. Vomiting at night. CASE CCXVII. Marsh malaria. CASE CCXVIIL Worms. CASE CCXIX. Shock. CASE CCXX. Alcoholism. Oxide of Zinc as a remedy. CASE CCXXI. Poisoning by Arsenic. CASE CCXXII. Repugnance to food, want of appetite. 10. Sea-sickness. CASE CCXXIII. The pathological condition does not always cease with its motive cause, but may induce acute illness afterwards. CASE CCXXIV. It may bring on chronic vomiting. CHAPTER VI. Flatulence. CASE CCXXV. Fatal impediments to diaphragm caused by flatulence. CASE CCXXVI. Impediment to motion of heart causing irregular pulse. CASE CCXXVII. Intestinal flatulence in fat women. CASE CCXXVIII. Flatulence cured by the direct renewal of digestive solvent. CASE CCXXIX. Direct relief of flatulence by absorption of the collected gas. CASE CCXXX. Cure by Strychnine and Iron. ANALYSIS. 315 CHAPTERS VII and VIII, on Diarrhoea, Constipation 'and CostivenesSj are not illustrated by Cases. CHAPTER IX. Nerve Disorders connected unth Indigestion. CASE CCXXXI. Sick-headache arising from mental causes cured by leaving off purgatives and taking Quinine and Taraxacum, in a gouty man. K XXII. Sick-headache in a weakly woman. 1 CCXXXIII. The same with erythema nodosum. CASE CCXXXIV. Headache causing alarm of apoplexy. CASE CCXXXV. Long-ingrained headache cured by Strychnine and Quinine. CASE CCXXXVI. Hemicrania in such cases an evidence of improvement. CASE CCXXXVII. Occupation of the whole head an evidence of the contrary. CASE CCXXXVIII. Purgatives aggravate the disease. CASES CCXXXIX and CC XL. Gastric vertigo also aggravated by purga- tives. CASES CCXLI and CCXLII. Difference of this vertigo and that produced by alcohol. CASE CCXLIII. Addled brain and addled stomach. CASK ('('X U V. Vertigo and mental helplessness. CASK CCXLV. Strong epileptic fit from undigested food in a healthy child. CASE CCXLVI. Mild chronic epilepsy from chronic morbid condition of alimentary canal. CASES CCXLVII and CCXLVIIL The same. Cure by dietetic discipline. CASE CCXLIX. Incurable epileptic fits preceded by flatulence and dis- tension. CASE CCL. Choreic spasms. CASK CCLI. Stomach cough in phlegmatic temperament. CASE CCLII. Stomach cough in a gouty diathesis, alternating with the pains. CASE CCLIII. The same coinciding with the pains. CASK O'l.I V. Anaesthesia. 1C ASK CCLV. Paralysis. CASE CCL VI. Atrophy of muscles. CASE CCLV 1 1. Flushing of face. * CCLVIII and CCLIX. Nottlorash. CCLX. Erythema circumscriptum from indigestion in a gouty person. ALPHABETICAL INDEX TO THE COMMENTARY. Acid and alkaline dyspepsia, 144 medicinal use of, 14<>, 147 physiological use of, 76, 136, 144 "Acidity," 144,211 Acute acid dyspepsia of Chomel, 148 Acute and chronic, their essential dif- ference, 22 Albumen, indigestion of, 53 Alcohol, abuse of, 121, 233, 279 Alkali, medicinal use of, 135, 140, 142, liil. 1>;2. 2-1 physiological use of, 73, 76 Alkaline fluid of waterbrash, 148 Anieiiorrlid'a due to stomach, 1'J An.-i-sthesia, 14', 298 Arsenic, injurious effect of, 233 Ascetism, 95 ilation the path of cure, 21, 56,63 Atrophy of muscles, 107, 2U9 Back, sensations in the, 177, 179, 189 Bathinir, cold, 120. I'M. 14.:. 22<>, 280 Beef-t ;or making, 84 , 258 .omitiiK of. ln<), 197 Bilious attacks, 198 diarrhnvi. Bilion- liisniutli. niedii-inal use of, 196, 224 Bloodleitin . vomiting, 109, 156, 201 in.-. :<"! 230 Carbonic acid, medicinal use of, 14". 142 physiological u-e of, 241 Catamenia, connection of, with diges- ti-i, ilHi. 217 Catarrh of the stomach, 171. J98, al, m.'diriiKil i; Cheese, toasted, 86 Cholera, chronic effects of, 44, 270 cramps in, 105 stools, 204 Chronic and acute, their essential dif- ference, 22 Classification of forms of indigestion, 27, 29, 77, 139, 149 Climate, effects of, 48, 174 Cod-liver oil, preparation for the use of, 89 " Coffee-ground" vomit, 206 Constipation, 190, 272 Contagiousness of hysteria, 223 Cookery, 82, 155, 169 Cooks, indiiiestion in, 155, 159 Constructive remedies, 90 Corpulence, 74. 80 Costiveness, 275 a consequence of purgation, . 278, 2b7 Cough, gastric, 296 Definition of constipation, 272 COStiVrllr- eczema, 71 (note) flatulence. SI, 211 heartburn hysteria, 34 indigestion, 18, 25 vital arts. I4.'i Deformities from pressure . li'l. In;) ui -live remedies, 42, 11'.'. 12" Miarrhu-a and emaciation, 17i> forms of. Dietetics, SI, li!2, 178, 268 Dilatation of stomach, 122 Dram-drinkim:. death from, 124 Dy-eutery, effects of, 158 X too little. much. !'7, 163, 171 Emaciation following excess, 101 318 ALPHABETICAL INDEX. Emphysema pulmonum as a cause of indigestion, 75, 230 Epilepsy, 71,292 Erythema nodosum, 284 circumscriptum, 303 Exercise, excess of, 38, 163 too little, 102 Fasting, 94 Fecal vomiting, 215 Female figure, proportions of, 106 Fermentation, 44, 48, 211, 252, 290 Fetor of sputa, nausea from, 227 Flatulence, 166, 241 Fluids, indigestion of, 90 Gastric catarrh. See Catarrh of the Stomach, Gluttony, 92, 163 Green vomit, (198, 206 Gripes, 167 Habits leading to indigestion, 92 Hce.matem.esis. See Bloody vomiting. Hsematoxylum, 170 Heartburn, 134 Heart disease, a cause of indigestion, 37, 74, 171, 174 as affected by indiges- tion, 99 Hemicrania, 286 Hereditary tendency to hysteria, 221 Homoeopathy, 23, 119 Hunger, 35, 138 Hydrocyanic acid, use of, 140, 174, 239 Hydropathy, 118, 162, 280 Hypochondriasis, 98, 162, 248, 277 Hysteria, 34, 98, 216, 291 Idleness, 113 Inanition, 31 Insanity, diagnosis of, 117 Insurance, selection of lives for, 125 Iodide of Potassium, 33, 91, 137 Iron, use of, 90, 141, 143, 161, 284 Kino, use of, 161 Lacing, tight, 103 Lead-poison, 68, 156, 157, 208 Lieutery, 168 Liquorice in heartburn, 141 Liver, action of reagents on, 256 Malaria productive of stomach-ache,! 66 vomiting, 231 Masturbation, 107, 111 Mercurials, 41, 90, 120, 174, 255 Milk, 83 Mind, action of digestion on, 98, 291 on digestion, 30, 31, 42, 70, 112, 237, 277, 283 Mineral waters, 142 Mucous diathesis, 48, 51 membranes, alternation of dis- eases of, 173 function of 51 (note) Muscular fibre, indigestion of, 58, 83 Mutton, encomium on, 86 Nerve disorders, 282 Nettle-rash, 287, 302 Oatmeal-eaters, waterbrash of, 154 (Esophagus, how affected by disease, 31, 58, 135, 148, 193, 222 ulcer of, 195, 196 Old age, 40 Oleaginous food, indigestion of, 52, 59 necessity for, 63, 80, 82 Oleaginous medicines, 63 Opium, pernicious effects of, 131, 248 medicinal use of, 133, 185, 227, 239, 267, 269 Osmosis, laws of, 73 Oxalate of lime in urine, 176 Oxide of zinc, 140, 233 Oysters, 87, 162 Pain necessarily joined to pleasure, 78 Pancreas, disease of, 66, 72 Pancreatic emulsion, 72, 90 Paralysis, 299 Pastry, anatomy of, 82 Pepsine, medicinal use of, 87, 235, 269 Periodicity of vomiting, 204 Phthisical indigestion, 5(J, 158, 168, 201, 225 Piles, 259, 274 Pregnancy, 234 Pressure, soreness on, 187 Puberty, influence of, on digestion, 67 Purgatives, 40, 46, 80, 119, 199, 267, 278, 286, 287 Pus, formation of, 171, 197 vomiting of, 195 Quinine, general use of, 90, 178, 253 given without acid, 167 Rest, easiest obtained in double organs, 22 importance of, in the treatment of disease, 55, 218, 300 Rheumatic fever, 55 Roasting, encomium on, 85 Saliva, physiological action of, 30 changes in, 91 Sarcina ventriculi, 171, 212 Schools, cautions respecting, 110, 119 Scurvy easily induced, 78 Sea-air and bathing, 50 ALPHABETICAL INDEX. 319 Sea-sickness, 235 Shoemakers' indigestion, 17 upright bench. Shoulders, paiu between, 177, 180 Sick-headache, 282 Skin affections, 71, 284, 287, 302, 303 Snuff. !_'; Solitude, 111 Spasm induced by atony, 162, 164 Spasmodic stomach-ache, 162, 237 Spermatorrhoea, 176, 24'J Stages of digestion, 27 ion of, 29 Starvation, 31, 92, 240 St ruinous indigestion, 65 iiiiiue, precautions in use of, 91 indigestion of, 30, 52 Sulphate of copper, 157, 169, 170 Tea, misuse of, 129 Temperature, as a remedy, 120, 143 Tobacco, 125 Treatment based on article indigested, 77 pathological con- dition, 90 Urine, aa affected by digestion, 76 Valerian, use of, 191, 218, 253 Vegetables, importance of, in diet, 78 Venereal excess, 110 Vertigo, 288 Violence as a cause of vomiting, 209, 231 Vital acts, 145 Vomiting, physiology of, 192 Waterbrash, 148, 209 Water, indigestion of, 73 medicinal use of, 143, 188, 256, 279 "Wearing" pain, 179 Weight at epigastrium interpreted, 171 HENRY C. (LATE LEA t BLANCHARD's) OF MEDICAL AND SURGICAL PUBLICATIONS, In asking the attention of the profession to the works contained in the following . tin- publisher would state that no pains are spared to secure a continuance of the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. The printed prices are those at which books can generally be supplied by booksellers throughout tin 1 L'uited States, who can readily procure for their customers any works not kept in stuck. Win-re access to bookstores is not convenient, books will be sent by mail post-paid on receipt of the price, but no risks are assumed either on the money or the books, and no publications but my own are supplied. Gentlemen will therefore in most cases find it more convenient to deal with the nearest bookseller. An ILLUSTRATED CATAI.OOCE, of 64 octavo pages, handsomely printed, will be for- warded bv mail, postpaid, on receipt of ten cents. HENRY C. LEA. Nog. 708 and 708 SASBOK ST., PHILADELPHIA, November, 1888. ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. THREE MEDICAL JOURNALS , containing over 2000 LARGE PAGES, Free of Postage, for SIX DOLLARS Per Annum. TERMS FOR 1809 -IN ADVANCE: THK AMERICAN JnrnxAi, OF THK MKIMCAT, SCIF.NCKS. and ) Five Dollars per annum, THE MKKH AI. NKWS ANT. LIBKAKY, both free of postage, ) in advance. OR. THK AMKKK-AX JnrnxAL OF THK MKDK'AL SCIKNCKS, published quar- } ,,. n n , six Dollars quarterly (1150 pa^es per annum), with THK MKI.I.'AI.'NKWS AND LIHKAKY. monthly C'.Sl pp. per annum), and J- per annum KAXKIX<:'S ABSTRACT OK THK MKIHCM. S< IK.M-KS. published half- . , . \varly (Gun pa -res per annum), all free of postage. > ; r.u.'.i n: s i i; sr /; inio.xs TO THK. AMKKK AX JOVKXAI. OK THK MKI-ICAI, HCIKM \ e wlu'ii m>t juinl for iu iidvanci-, J-'ivt- Hollars. THK M KDH'.-u. Ni:u> AM> I.n:i:.\i:v, froo <>f postnir 1 '. in :nlv;inrt\ Oi ]; \- B .i.v-VKAi:i.v AHSTRACT, Two Dollars and a Half pt-r anniini in a-lvaiu-o. le nnmlicrs One Dollar ami a Half. In thus offering at a price unpr^rcilt-ntcdly lew. this vist amount of valuable practical rn:ittt-r, the publisher felt that ho could only lie saved from li -- by a:; nt of circulation hitherto unknown in the nnnnls of medical journali>m. It is then^fure with much irratification that he is enabled to state that the marked appro- bation Of the pro ft- -vineed ill the steady inRF.N." " M AI.<;AI<;NK'S SURGERY," Tli-- work now appearing in its pages, Dr. HUDSON'S valuable "LECTURES o\ TMK Sri i>\ OK FKVF.R." will he completed in the number for December, 1868. "With .January. 1 *;'.>, another work of similar practical value will l>e begun, rendering this a very eliirible period for the commencement of new subscriptions. As stated above, tin- .-ul^cription price of the ' MKIUCAI. NKWS AND LIBRARY" is I 'ni.i.AK per annum in advance ; and it is furnished without charge to all advance paying subscribers to the A ^.v JOURNAL OK THK MKDICAL SCIENCES." III. KANKINr/S AI.STIiACT OF THK MHDICAL SCIENCES is issued in half-yearly volumes, which will be delivered to subscribers about the first of February, and tir.-t of August. Each volume contains about 300 closely printed taking about six hundred pages per annum. K LrenM'l ABSTRACT" has now been published in England regularly for more than twenty years, and has acquired the highest reputation for the ability and industry with which the essence of medical literature is condensed into its pages. It pur- /////< nt 'il Mulicine, and of the progress <>f M' .///,,- ,,/,,/ /;,, CoUateralJScit nee*," and it presents an abstract of all that is impor- tant or interesting in European Medical Literature. Kadi article is carefully con- dniM-d. so as to present its substance in the smallest possible compass, thus affording lor the very lartre amount of information laid before its readers. The volumes of 186^, fur instance, have thus contained FORTY-TWO ARTICLES o>- GENERAL QPE*TI<>NS IX MEDICINE. <>.\K lir.MiKKD A.VH T\V KNTY-NIN K ARTICLE* (>.\ SJ'EClAL QUESTIONS IN MEDICIKE. ShVKNTKKN ARTI-'I.KS u> F<>KKNS|C MKD1CIXE. !:!<;!! IV-KKiHT AKTI''I.K> K AKTI<-I.F.S ox I;KXKI:AL QUESTIONS IN SFROEHY. >NK IIUNDKEl) AM) FIFTY SIX AUTK L!> <>.\ ^I'ij'IAL QUESTIONS IN SURGERY. OM; iirxuKKK AND TWELVE ARTICLES UN MI DWIFEKY AND DISEASES OF WOMEN AM) CHILDKKN. sIX ARTICLES IN APPENDIX. Making in all nearly six hundred articles in a single year. Each volume, moreover, .tically arranged, witli an elaborate Table of Contents and a very full Index, thus facilitating the researches of the reader in pursuit of particular subjects, and enabling him to refer without loss of time to the vast amount of information con- tained in its pages. The subscription price of the "ABSTRACT," mailed free of postage, is Two DOLLARS AND A HALF per annum, payable in advance, single volumes, 1 50 each. As stated above, however, it will be supplied in conjunction with the "AMERICAN JOURNAL OF THK MKMI'.U. SI-IK.VCK*" and the "MKMICAL NKWS AND LIBRARY," the whole free <>f pi?t', t'ur Six DIIU.AKS PKK ANNUM IN ADVANCK. F"i- this small sum the subscriber will therefore receive three periodicals costing separately Ki^ht Dollars and a Half, each of tliem enjoying the highest reputation in its class, containing in all over TWO Tiioi- 1Sba - rs in this country, and we can certainly commend I It has the rare merit that it certainly ha* no rival this work to the renewed confidence and regard of ! in the English language for accuracy and extent of ur readers. Cincinnati Lancet, April, 1S65. I references. London Medical Gazette. fJOBLYN (RICHARD D.), M.D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition, revised, with numerous additions, by ISAAC HAYS, M. D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages; extra cloth, *1 50 ; leather, $2 00. It is the best book of definitions we have, and ought always to b upon the stadaut's table. Southern Med. and Surg. Journal. HENRY C. LEA'S PUBLICATIONS (Manual*). (JOHN), M.D., and (3M1TU (WiANClS than l.noo pages Is an Impossibility, but we think that bly the in. -t rlu*, n approaches as near to it - oiuitry Attempt* bTe be.-n nude in various , tble. Altogether, It U the be*t of UK clas*, and ban - juevxe Au- with a dei^rved success. A* an elementary text- its been useful, and will con- ia ttie, examination of private i'ily failed in ' all ap to t 1 . '! often be referred to by the f "Xeill and Smith :, try practitioner. Vn. MeA. Journal. a atr of the w'n AH a handbook for students tt Is Invaluahle, eon- .iirn and illuttrated, and ihi- 'uing in the raot condensed form th eslabllnhed J to the ^ I principled of medldne and ita collateral .1 of every elasn. *V. 0. Mea. and bury. hc i euco<(- 4 v. y/ Juurual qf MctJticiM. popnlar farorlte with the .Indent U so well \ ' *he rapid eonr* of leetoro., where work for the kn,.w n tl,!,. it r,nlr^ n mor* at the hands of T J". and renew peoMaary for an exa- tnediral editor than the annunciation of a new : '" 1: "' ' in no uort of compare . and any other on a -uu:lar )> 'bj-t-u*. y, , ./ .v SJ^IT.!::^: .r ts" There aro but few 8udent or practitioners of me- r . lverlM are explicitly, though coniely, laid befcra dicln. rlth the foi M-I- edition-, of |J , ,,- C( , ttr( !e it i nelw for us to recom- .mid though hinbly instrnctive work. TIIH .,](;; ..lonU. but tli.-re in a clans .ire been sifted, to wh,. m we rei |. hook 1 Dorado, and the pw- M W0 rth 1U weight In ilver that cUuw U Ue grdu- tiou- .11 tine little volume. A co . J- me dicine of more than ten years' xtauding. P'eiT " : who have not studied medicine blnce. Tl,- LMV nuK- u in.- c,.u>taut poekt companion. West- ' psr ha P find out from it that the ncience U not ex- m Lancet. \ ac ii y now what it was when they left it off. Th* T\> compress the whole science of medicine In less ' 8tetnoctry, M;teria Medic:i, Prnctical Medicine, In imc hirjxc rnynl 12mo. volume of nearly 1000 closely printed pager, with about 3()0 illustration? on wood. (Nearly Rf/>.'i/.) Tim nhility of the author, and hi* jaiu-tiiM! skill in condensation, give assnmnc* that thi- work will jirnvt- vnlualilo not unly t th- student jirej.jiring for examination, but also to the j.r:ii*- titiont-r de-irmi< ot" ,,\ .hiinini; within n ino.ler.at.> c"in|i.is-, a view of the existing condition of the It department* of science connected wilh medicine. TUDLO\V(J. L.). .)/. It., A MANTAL OF RXAMINATIOXS ujmn Anatorny, Pnrpery. Prnrtice of Medicine, Obstetric?, ' . I'liannacy, and Theni|-iitir--. To which is added a Medical Fortnuliiry. Third edition, thoroughly revised and greatly extended unr hi* final examination, durin.- "t uitlif ! y kind rnrnmi whom he i ' . IT f A It e>r ,-dical ntudien . it U neeemarily TO itaininp Klij large duodecimo page*. Afier a comewliat can-fn inform him- of it- i- ,nt.-nt-s w- )I:VH tunned a much more fcrornt' '. it than w. !. I. works. Although well adapted to meet t: nelf on oy aubject. and w: : Jfrt. Surg. Journal. rr. \\SKR (TllfMAS HA \\ A" />]. J/ f).. A M A\T LL OF CLINICAL MKhlciNK AND TUVSICAL DIAG- -IS. Third AmnriiMin, from the cecond enlarged and revised English edition. To which is added The Code of Ethics of the American Medical Association. In one huoa- some volume 12rao. (Preparing for ear{y publication.) HENRY C. LEA'S PUBLICATIONS {Anatomy}. QR AY (HENRY), F.R.S., Lecturer on Anatomy at St. Gnvrgda Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by II. V. CARTER, M. D., late Demonstrator on Anatomy at St. George's Hospital; the Dissec- tions jointly by the AUTHOR and DR. CARTER. Second American, from the second revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, with 388 large and elaborate engravings on wood. Price in extra cloth, $6 00 ; leather, raised bands, $7 00. The author has endeavored in this work to cover a more extended range of subjects than is cus- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding its exceedingly low price, the work will be found, in every detail of mechanical execution, one of the handsomest that has yet been offered to the American profession ; while the careful scrutiny of a competent anatomist has relieved it of whatever typographical errors existed in the English edition. Thus it is that book after book makes the labor of ' and with scarce a reference to the printed text. The the stndeat easier than before, and since we have , surgical application of the various regions is also pre- Eeen Blanchard & Lea's new edition of Gray's Ana- sented with force and clearness, impressing upon the toray, certainly the finest work of the kind now ex- i student at each step of his research all the important tant, we would fain hope that the bugbear of medical j relations of the structure demonstrated. Cincinnati students will lose half its horrors, and this necessary j Lancet. foundation of physiological science will be much fa- j This is, we believe, the handsomest hook on Aea- tomy as yet published in our language, and bids fair to become in a short time THE standard text-book of cilitated and advanced. N. 0. Jtled. Ifeios. The various points illustrated are marked directly on the structure ; that is, whether it be muscle, pro- cess, artery, nerve, valve, etc. etc. we say each point is distinctly marked by lettered engravings, so that the student perceives at once each point described as readily as if pointed out on the subject by the de- monstrator. Most of the illustrations are thus ren- our colleges and studies. Students and practitioners will alike appreciate this book. We predict for it a bright career, and are fully prepared to endorse the statement of the London Lancet, that "We are not acquainted with any work in any language which eu take equal rank with the one before us." Paper, printing, binding, all are excellent, and we feel that dered exceedingly satisfactory, and to the physician | a grateful profession will not allow the publishers to they serve to refresh the memory with great readiness; go unrewarded. Kashville lied, and Surg. Journal. s 'MITH (HENR Y H.}, M.D., and TJORNER ( WILL1A M E.), M.D., Pro/, of Surgery in the Univ. of Penna., &c. Late Prof, of Anatomy in the Univ. ofPenna.,Ac- AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $4 50. The plan of this Atlas, which renders it so pecu- liarly convenient for the student, and its superb ar- tistical execution, have been already pointed out. We must congratulate the student upon the completion of this Atlas, as it is the most convenient work of the kind that has yet appeared ; and we must add, the very beautiful manner in which it is "got up" is so creditable to the country as to be flattering to our national pride. American Medical Journal. TJDRNER (WILLIAM E.), M.D., SPECIAL ANATOMY AND HISTOLOGY. Eighth edition, exten- sively revised and modified. In two large octavo volumes of over 1000 pages, with more than 300 wood-cuts; extra cloth, $6 00. &HARPEY (WILLIAM], M.D., and Q VAIN (JONES RICHARD}. HUMAN ANATOMY. Revised, with Notes and Additions, by JOSEPH LBIDV, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. The very low price of this standard work, and its completeness in all departments of the subject, should command for it a place in the library of all anatomical students. A LLEN (J. if.), M.D. THE PRACTICAL ANATOMIST ; OR, THB STUDENT'S GUIDE IN THE DISSECTING ROOM. With 266 illustrations. In one very handsome royal 12mo. volume, of over 600 pages; extra cloth, $2 06. Oae of the most useful works upon the subject ever written. Hudical Examin* HF.NRY C. LEA'S PUBLICATIONS (Anatomy). (Eli A F.R.S. A SYSTEM or IM'MAN ANATOMY. Gfertttl *fed SpetiaL A new and revised Am.-i icun, from the last and en! -h edition. Kdited by W. H. Go- BRKniT. .Ml>. 1'r. it --or of Ueneral and Sin uy in the Medicxl College of Ohio. Illu.-trati-d with tin. hundred and ninety-seven engravings on wood. In one large and tavo volume, of over 600 large pages; extra cloth, $4 00; leather, $5 00. The publisher trust* that the well-earned reputation of this long-established favorite will be more than maintained l>y the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to in- troducing everything which increased experience in its use has suggested as desirable to render it a complete foe those seeking to obtain or to renew an acquaintance with Human Ana- tomy. The ,-1111011111 of additions which it has thus received may be estimated from the fact that the present edition contain* over one-fourth more matter than the last, rendering & smaller type and an enlarged page requisite to keep the volume within a convenient sire. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utim.-t caution to obtain entire accuracy in the text, and has largely increased the number of illutrati. n*. of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. JDY THE SAMK ATTJI'iR. THE DISSECTOR'S MANUAL; OR, PRACTICAL AXD SURGICAL ANA- TOUT. Third American, from the last revised and enlarged English edition. Modified and rearranged by WILLIAM HOST, M. D., late Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, of 582 pages, with 154 illu.-tr.it ions; extra cloth, $2 00. ETo/xv/vs. (RICHARD ^f.). M.D., * * Lsttr DfiHiiHttrntor >K. Surgeon. In one volume, very large imperial quarto; with fitf large and splendid plates, drawn in the best style ami beautifully colored, containing 190 figures, many of them the site of life; together with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. Price f 14 00. Ai no complete vv<.rk of the kind has heretofore been published in the English language, the ' volume will supply a want long felt in this country of an accurate and comprehensive- Atlas of Surgii-al Anatomy, to which the student and practitioner can at all times refer to ascer- tain the exact relative positions of the various portions of the human frame towards each other and to the surface, as well as their abnormal deviations. The importance of such a work t<> the student, in the absence of anatomical material, and to practitioners, either for consultation in emer<_- r r Uections of the dissecting room, is evident. Notwithstanding fhe large size, beauty anil finish of the very numerous illustrations, it will be observed that the i* so low as to place it within the reach of all members of the profession. We know of no work on Mirgical anatomy which r.-'t. -ti.-.i by tli"- clear an. I dltlnct tiuw>etions, an compete with it. hincet. winch every one ::. The work of Slaclim? on surgical anatomy 1* of the I ' '""I'*-" i'iv.> h..- j< :.. kixhnxt value. lu > publl- | ' (Ion of it- kind w . , U J in worthy of I * place In the libmry of any medical man, v '" u 'y of lite indent con ,k'e a better luvetin<>ut than . !oi" 1 X r >" :ineatloK Hi. rhan- M*.l%lW*timJ'o*ralafM*dicine""' " f ''" h ""'" body, are i.ivn,,t ( >, examine our iipecimen copy. IT anything will induce nar(<>oiui N nrh lithofrrmphic Illustration* of lurglral re- |ioo hare hitherto, wo think, bwn nien. While and Htndents to patronize a book >>f i>ucii IA and ev. r :.un-. (< ill. -in. it will be u the operator It bo' >! and nerre where of ihe rti-tic;i e u i >:ion in coateiupU;el. PEASI.KK (K. R.}. M.It.. rr< Anatumy, Pathology; for the use of medical students. With Tour hundred and tbir!y-fm:: .'.,* tious. la one handsome octavo volum* of rer tiOD pages, extra cloth. $3 75. 8 HENRY C. LEA'S PUBLICATIONS (Physiology). MARSHALL (JOHN], F. R. S. Professor of Surgery in University College, London, Ac. OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. With Additions by FRANCIS QDRSKV SMITH, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, Y THE SAME AUTHOR. THE MICROSCOPE ANT> ITS REVELATIONS. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very hand- some octavo volume, of 724 pages, extra cloth, $5 25. JT'IRKES (WILLIAM SENHOUSE), M.D., A MANUAL OF PHYSIOLOGY. A new American from the third and improved London edition With two hundred illustrations. In one large and hand- some royal 12nio. volume. Pp. 586. Extra cloth, $2 25 ; leather, $2 75. It is at once convenient In size, comprehensive in lent guide in the study of physiology in its most ad- design, and concise in statement, anil altogether well vanced and perfect form. The author has shown adapted for the purpose designed. St. Louis lied, himself capable of giving details sufficiently ample and Surg. Journal. in a condensed and concentrated shape, on a science in which it is necessary at once to be correct and not The physiological reader will find it a must excel- leugthoued. Edinburgh Med. and Surg. Journal. HENRY C. LEA'S PUBLICATIONS (Physiology). J)ALTON(A C.), M.D., U Profettor of Phytiultigy in the College of Phytician* and 8urffton, ltev> York, Ac. A TltKATISK ON 1M.MAN I'll VSKH.OGY, Desi^n-l for the use of Students and Practitioner? of Medicine. Fourth edition. re\i-ed. with nearly three hun- dred il!u-tr:ii i..iM on wood. In one very beautilul octavo volume, of about 700 pages, extra cloth, $5 25; leather, $6 25. (.Jntt t&ud.) ''ttfm. ! by Physiology and the kindred Science* during the last few years has r*- "nt edition (' -i thorough and extensive revision. This progress -i"tfd in :i: di-i-ovrrie*. nor in a ! hition in any of . the 'I !iiin been marked by great activity of investigation in a multitude of different directions, the combined result* of which have not failed to impress a new character on many of the feuluit "logical knowledge. ... In the revision mid correrti.iM of the present edition, the author baa endeavored to incorporate all sch improve- ments in physiological knowledge with the mass of the text in such a manner as no* essentially to alter the structure and plan of the work, so far as they have been found adapted to the wants and convenience of the reader. . . . Several new illuiUrations are introduced, some of them ag additions, others as improvements or - of the old. Although all parte of the book have received more or less complete revision, the greatest number of additions and changes were required in the Second Section, on the Physiology of the Nervous System." Advent of the first edition of Prof Pulton's i merits of clearness nd condensation, and being fully Phyrtologv, about eight year* ago, marked a new em brought np to the present level of Physiology, it i* In the study of ph\ : dly one of the most reliable text-book* iful ni:in:i. _ ,.tl upon thin science that could be placed in the hands science threw off the long, lo,,-. .rments ,,i the medic*! student. Am. Journal Jfed Sciences, biliiy and surmise, in which it had been ar- Oct. 107. rayed by ni'.-t arti-tn, and came among UK Minim.: and atiractive, in the beautifully tinted and clouely rr <>f- Dalton' work ha* such a well-established fitting di.-s of a demo:.- eputatton that it doe* not tand in need of any re- AS a result of erudition aud commendation. Ever iuc- its first appearance it baa if. Dalt.m to pnwent to tlie world become the highest authority iu tie English language; awur-. 'iry at once brief, pointed, aud com- a "J '' la: luaintain the enviable p iid which exhibited plainly in letter aud whirl, it ha> ui d exhaustion of the dif- drawingi the bai upon which the conclusions itr- ''"nt suci'e^ive editions U sufficient evidence. The riv.-d ai n-i. d It is no disparagement of the many present edition, which is the fourth, has been tho- excellent works on physiology, published prior to roughly revi.-.-d, and enlarged by the incorporation that of Dxlton, to say that none of them, either in phin of iirr.iii.'-iii-Mit or clearne of execution, could be compared with his for the use of students or gene- ral practitionerK of uiediriuo. For this purpose hi* book! nglish language. Wetltrn, Journal nf Jletiicin A capital toxt-book in every way. We are, there- it ID :t- fourth edltina. It has already been examined at full length iu th>>-e columns, go that we need not now further advert to it bevond reranrk- of M|! the many important advances which have lately been made in ihis rapidly progressing science. A. r. M.-l li; ir .l, Oct. l.\ 1867. As It stands, we esteem it the very best of the phy- siological text-books for the stndent. and the most concise reference and guide-book for the practitioner. .V r. Mett. Journal, Oct. 1867. The prcment edition of this now standard work f ally xu-taiiis the high reputation of iu accomplished au- thor. It in not merely a reprint, but has been fiiith- ing that In.th rerision and enlargement have been j f,,|| y revlied, an. I em ..-h additions an the us. London lied. Timet a*d Qatette, ,,, , ha* rendered deirible Taken -I r.-liableaod Wo Letter proof of the value of this admirable ' useful ti it hnn been issued work i lured than the fact that it ha 1- from the American pros*. Chicago Jted. Journal, ' ready reached a fourth edition in the short -; - : 1867. irs. Poei>iiing in an eminent degree the ' J)f\f;f./^>\ ROSLET), M. D., U Pr<-f- in Jffferffm Jf^Hml Oollrfff, PhHtut' 1 IM'.MAN I'lIVSloLOUV. Ki-hth .Million. Thoroughly revised and extensively modified and enlarged, with five hundred and thirty-two illustrations. In two and handsomely printed octavo volumes of about 1500 pages, extra cloth. $7 00. j /://.]/. i.vA'(c. G.) J I'll VSIOI.OCK'AL rilKMISTKV. TranslMli-l from tlu- second r.li- ti-n hv (IEOKOK K Dvv, M ! . K K S., A<-., edited l.y H. K. ROGERS, M 1> , I'n.te-nr ..f itry in the Medieal hejiMrnn.-nt ..('the I'liiver-ity ..t I'. : with il!u.-ti. in Fiuike's Atla- ..I 1'. Clieini-try. and IIM Appendix of plates. ( "in plete in t 'jontuining 12UU i>;i^, with nearly two hundred illu.-trution.-, extra clutli. $( I'll. nr TUK .s.rv/-: V. \\r\I. OF CHEMICAL I'll VSlOl.Oli V. Tr:in-l:i1.'.l from the liernmn, with \ : liiinn., l,y .1 Cut -I,,N M..KI;!-, M !> , with an Introdui-tory rn. JACK<'I\. M !>.. nf the I'ni . vnsyl- '^'ith iliu-trati..ii- 1.11 wi.ii.l. In une \ery hnn ! |'Uge extra cloth. ^ D (uor>i-:i;r r,^. M.H. /-.;;..<., a ,,,i j~>n \VMA.\- . }\:\. r.i: TI1K rUVSIOLocirAF, ANATOMY AND I'll VSK !,( > ; V OF M \N. With ahniit tli-eo hutnlrfd larjre nnd heaiitiful illustrations on wood. Complete in one large octavo volume of 'JaO page*, extra cloth. Price $4 H. 10 HENRY C. LEA'S PUBLICATIONS {Chemistry}. ( WM. T.), D. C.L., and BAYLOR (ALFRED ), M.D., F.R.S. CHEMISTRY. Second American edition, thoroughly revised by Dr. TAYLOR. In one handsome 8vo. volume of 764 pages, extra cloth, $5 00 ; leather, $6 00. (Just Issued.) FROM DR. TAYLOR'S PREFACE. "The revision of the second edition, in consequence of the death of my lamented colleague, has devolved entirely upon myself. Every chapter, and indeed every page, has been revised, and numerous additions made in all parts of the volume. These additions have been restricted chiefly to subjects having some practical interest, and they have been made as concise as possible, in order to keep the book within those limits which may retain for it the character of a Student's Manual "London, June 29, 1867. A book that has already so established a reputa- tion, as has Brande and Taylor's Chemistry, can hardly need a notice, save to mention the additions and improvements of the edition. Doubtless the work will long remain a favorite text-book in the schools, as well as a convenient book of reference for all. N. Y. Medical Gazette, Oct. 12, 1867. For this reason we hail with delight the republica- tion, in a form which will meet with general approval and command public attention, of this really valua- ble standard work on chemistry more particularly as it has been adapted with such care to the wants of the general public. The well known scholarship of its authors, and their extensive researches for many years in experimental chemistry, have been long ap- preciated in the scientific world, but in this work they have been careful to give the largest possible amount of information with the most sparing use of technical terms and phraseology, so as to furnish the reader, "whether a student of medicine, or a man of the world, with a plain introduction to the science and practice of chemistry." Journal of Applied Ohem- istry, Oct. 1S67. This second American edition of an excellent trea- tise on chemical science is not a mere repnblication from the English press, but is a revision and en- largement of the original, under the supervision of the surviving author, Dr. Taylor. The favorable opinion expressed on the publication of the former edition of this work is fully sustained by the present revision, in which Dr. T. has increased the size of the volume, by an addition of sixty-eight pages. Am. Journ. Aled. Sciences, Oct. 18t>7. THE HANDBOOK ix CHEMISTRY OP THE STUDENT. For clearness of language, accuracy of description, extent of information, and freedom from pedantry and mysticism, no other text-book comes into com- petition with it. The Lancet. The authors set out with the definite purpose of writing a book which shall be intelligible to any educated man. Thus conceived, and worked out in the most sturdy, common-sense method, this book gives in the clearest and most summary method possible all the facts and doctrines of chemistry. Medical Times. JftOWMAN (JOHN E.),M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. BLOXAM, Professor of Practical Chemistry in King's College, London. Fourth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. $2 25. The fourth edition of this invaluable text-book of Medical Chemistry was published in England in Octo- ber of the last year. The Editor has brought down the Handbook to that date, introducing, as far as was compatible with the necessary conciseness of such a work, all the valuable discoveries in the science which have come to light since the previous edition was printed. The work is indispensable to every student of medicine or enlightened practitioner. It is printed in clear type, and the illustrations are numerous and intelligible. Bo&ton Mud. and Surg. Journal. >r THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Fourth American, from the fifth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., extra cloth. $225. (Just Issued.) One of the most complete manuals that has for a long time been given to the .medical student. Athenceum. We regard it as realizing almost everything to be desired in an introduction to Practical Chemistry. It is by far the best adapted for the Chemical student of any that has yet fallen in our way. British and Foreign Medico-Chirurgical Review. The best introductory work on the subject with which we are acquainted. Edinburgh Monthly Juur. S7RA HA M ( THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applications of the Science in the Arts. New and much enlarged edition, by HENRY WATTS and ROBERT BRIDGES, M. D. Complete in one large and handsome octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $5 50. 'Part II., completing the work from p. 431 to end, with Index, Title Matter, /;>/. I'/tarmary, tr.). 1 1 (GEORGE), Ph. I>. A MANUAL ol-' KI. KM i:\TAKV ('Hi:. \IISTKY; Theorotioal and PraotioHl. With one hundred and ninety-seven illustration:". Edited by ROBERT BRIDORH, M I). In one large royal iL'mo. volume, of 600 pages, extra cloth, $2 00; leather, $2 50. We know of no treatise in the language so well I We know of none within the same limits which cn.lculat.-d to aid the -tndeni h familiar ' has higher claims to our confidence asa college elass- with the nninerovs facts in the Intrinsic - :. both for accuracy of detail and *ciuiiflc ar- whirli -d as a text- , rangement. Auyuita Medical Journal. fc ook : l "l lectures. * * * * We know of no text-book on chemistry that we The l.. il.ai has issued from wou i,j sooner recommend to the student than tliU our pr-- .-Am- ri'--in U> //>.// J-irti-tl. ,, f i. rof . F own es' work. Montreal Medical .rain most cheerfully recommend It as th- ,. A new and revised edition of one of the best elemen- hat we have yet examined. III. and I.il M-,l -ii,'l fiitry. Journal. A flrst-rate work upon a first-rate subject St. Louit Med. and Surg. Journal. No manual of Chemistry which we have met -.1 near meeting the wants of the beginner. Wutem Journal u/ Mtdicine and Surgery. and English student N. Y. Journal of Medical and Collateral Science. We unhesitatingly recommend It to medical In- dent*. If. W. Jfed. and Surg. Journal. This is a most excellent text-book for class Instruc- tion in chemistry, whether for school* or colleger Silliman't Journal. ABET, AND ni.oXAM'? HANDBOOK OF CHKM1S- TUV. I, Practical, and Technical Inone rol - -xtra cloth. $t 60. GARDNER'S MEDICAL CHEMISTRY. 1 vol. 12mo., with wood-cuts* pp. 396, extra cloth, $1 00. KNAPP'S TECHNOLOGY ; or Chemistry Applied to the Arts, and to Mannfactures. With American additions, by Prof. WALTER R. JORHSOK. In two very handsome octavo volumes, with 600 wood engravings, extra cloth, $6 00. Prnfejunr of Mattria Medlca in the Philadelphia College nf Pharmacy. A T II !: A T ISE OX PH A 1 1 M A Y. Designed as a Text-Book for the Student, and M a Guide for the Physician and Pharmaceutist. With many Formulae and nations. Third Edition, greatly improved. In one handsome octavo volume,. of 850 pages, with several hundred illustrations', extra cloth. $5 00. The immense amount of practical information condensed in this volume may be estimated from the fact that the Index contains about 4700 items. Under the head of Acida there are 312 refer- ences; under BmplMtiUffi, 36 ; Extracts, 159; Lozenges, 25; Mixtures, 55; Pills, 56; Syrups, I'M ; Tinctures, 138; Unguentum, 57, Ac. We have examined this large volume with a good deal of care, and find that the author has completely exhausted the imbjm upon which he treats ; a more complete work, we think, It would be impossible to find. To the student of pharmacy the work is indis- pensable; Indeed, so far as we know, U I* the only one of its kind in ^xi-t.-ur.-, and even to the physician or medical student who can spare five dollars to pur- chase it, we feel sure the practical information he will obtain will more than compensate him for the outlay. Caitada M*l. Jonrnnl, NOT. 1864. not been clearly and carefully discussed in this vol- ume. Want of space prevents oar enlarging further on this valuable work, and we must conclude by a Hituple expression of our hearty appreciation of its merits. DiMin Quarterly Jour, of Medical Science, August, 1364. We have in this able and elaborate work a fair ex- position of pharmaceutical science as it exists in the United States ; and it shows that our transatlantic friends have given the auhjeet most elaborate con- sideration, and have brought their art to a degree of The medical student and the practising physician perfection which, we believe, i scarcely to be snr- III find the volume of vr..itli for study paM-- r. !--rtood as very extravagant praise. In truth, it in not HO much the best M the only ! An attempt to furnish anything like an an Parrish's very valuable . Pratt we have at much a miittiT of r.'i difficult to think of a ly trivial, con clan; yet Mr. I'AHHISH h. matter In which tin- interested as the compou; cln-ion, we can only expre In < our huh opinion of the value of this work as a guide to the pharmaceutist, and in many to the |>hyician. not uiily in , but in other part- of the world. Britisk Mfd. Journiil. Xov. l-'th, 18W. of pharmaceutic sub-taur The fonii.T .l:tion have been snfflclently long i-;il puMir to rem|er tin- merit* of the >rk well known. It is certainly one of t!..- m : i- it would be complete and . practical pi with the ma i '! . irh, |S' i. ProffSMir nf In.-.' /, PhUadrl i GENERAL THEEAPEUTICS AND M \TKKIA Mi:ilf.\: :i.l:i|.tf.i for a Medical Text-Hook. With Iii'lrx.-- ol" llMii''. !!<< aii'l nf I>i--:i-i.-s and thi-ir H.-in.' li.'". Sixth editinn, re\ i.'ed und iinpm-, .-.1. \\ \:\\ one tmiidred .-ui'l niii.-ty thf-t- illustratinr,-. la two large and h&ndaomelj }>riiitt- II M I - \..\-. ! <>K TIIKIK I'll K PA II A- TION AN!' AI'.MINI-THATP'X. S.-vmth edition, with extensive additions. In on* very large octavo volume of 770 pages, extra cloth. $4 00. 12 HENRY C. LEA'S PUBLICATIONS (Mat. Med. and Therapeutics). VTILLE (ALFRED), M.D., A-3 Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AXD MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Third edition, revised and enlarged. In two large and handsome octavo volumes of about 1700 pages, extra cloth, $10 ; leather, $12. (Now Ready.) That two large editions of a work of such magnitude should be exhausted in a few years, is sufficient evidence that it has supplied a want genernlly felt by the profession, and the unani- mous commendation bestowed upon it by the medical press, abroad as well as at home, shows that the author has successfully accomplished his object in presenting to the profession a system- atic treatise suited to the wants of the practising physician, and unencumbered with details interesting only to the naturalist or the dealer. Notwithstanding its enlargement, the present edition has been kept at the former very moderate price. From the Preface to the Third Edition. Although the second edition of this work had for many months been out of print, the author preferred to delay a new issue of it, rather than omit anything which appeared to be substantially valuable among the recent advances of the science and art of Therapeutics. The subjects now treated of for the first time, are : CHROMIC ACID ; PERMANGANATE OF POTASSA ; THE SULPHITES OP SODA, ETC. ; CARBOLIC ACID; NITROUS OXIDE; RHIGOLENB ; and CALABAR BEAN. The article on BROMINE has been prepared entirely anew ; and that on ELECTRICITY very materially enlarged by an account of the most recent improvements in electrical apparatus, and in the appli- cation of this agent to the cure of disease. The additions which have been mentioned, with much new_matter besides, which will be found under the more important titles, occupy nearly one hundred pages. April, 1868. * A few notices of former editions are subjoined. We have placed first on the list Dr. Stille's great , hardly find a work written in a style more clear and work on Therapeutics. When the first edition of this simple, conveying forcibly the facts taught, and yet work made its appearance nearly five years ago, we j free from turgidity and redundancy. There is a fas- expressed our high sense of its value as containing a j cination in its pages that will insure to it a wide po- full and philosophical account of the exiting state | pularity and attentive perusal, and a degree of use- of Therapeutics. From the opinion expressed at that i fulness not often attained through the influence of a time we have nothing to retract; we have, on the single work. The author lias much enhanced the contrary, to state that the introduction of numerous practical utility of his book by passing briefly over additions has rendered the work even more complete ' the physical, botanical, and commercial history of than formerly. We can cordially recommend to those : medicines, and directing attention chiefly to their of our readers who are interested in Therapeutics a physiological action, and their application for the careful perusal of Dr. Still6's work. Edinburgh Med. amelioration or cure of disease. Chicago Med. Jour- Journal, 1865. An admirable digest of our present knowledge of Materia Medica and Therapeutics. Am. Journ. Med. Sciences, July, 1860. Dr. Stille's splendid work on therapeutics and ma- nal, March, IStiO. It has held from its appearance in 1860, the place it so well deserves, that of the best treatise on Thera- peutics in the English language A considerable amount of new matter has been added to this edition teria medica. London Med. Times, April 8, 1S65. j w ithout increasing its bulk, and its general appear- We think this work will do much to obviate the reluctance to a thorough investigation of this branch of scientific study, for In the whole range of medical literature treasured in the English tongue, we shall ance is all that could be desired of a work which should find a place in the hand library of every stu- dent and physician. Boston Med. and Sara. Jour- nal, Dec. 15, 1S04. riRIFFITH (ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods of Pre- paring and Administering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by ROBERT P. THOMAS, M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume of 650 pages, double-columns. Extra cloth, $4 00; leather, $5 00. In this volume, the Formulary proper occupies over 400 double-column pages, and contains about 5000 formulas, among which, besides those strictly medical, will be found numerous valuable receipts for the preparation of essences, perfumes, inks, soaps, varnishes, Ac. Ac. In addition to this, the work contains a vast amount of information indispensable for daily reference by the prac- tising physician and apothecary, embracing Tables of Weights and Measures, Specific Gravity, Temperature for Pharmaceutical Operations, Hydrometrical Equivalents, Specific Gravities of some of the Preparations of the Pharmacopeias, Relation between different Thermometrical Scales, Explanation of Abbreviations used in Formulas, Vocabulary of Words used in Prescriptions, Ob- servations on the Management of the Sick Room, Doses of Medicines, Rules for the Administration of Medicines, Management of Convalescence and Relapses, Dietetic Preparations not included in the Formulary, List of Incompatible*, Posological Table, Table of Pharmaceutical Names which differ in the Pharmacopoeias, Officinnl Preparations and Directions, and Poisons. Three complete and extended Indexes render the work especially adapted for immediate consul- tation. One, of DISEASES AND THEIR REMEDIES, presents under the head of each disease the remedial agents which have been usefully exhibited in it, with reference to the formulas containing them while another of PHARMACEUTICAL and BOTANICAL NAMES, and a very thorough GENERAL INDEX afford the means of obtaining at once any information desired. The Formulary itself is arranged alphabetically, under the heads of the leading constituents of the prescriptions. We know of none in our language, or any other, so This is one of the most useful books for the prac- tisins physician which has been issued from the press of late yi;ars, containing a vast variety of formulas for the safe and convenient administration of medi- cines, al 1 arranged upon scientific and rational prin- ciples, with tlie quantities stated in full, without signs or abbreviations. Memphis Med. Recorder. comprehensive in its details. London. Lancet. One of the most complete works of the kind in any language. Edinburgh Med. Journal. We are not cognizant of the existence of a parallel work. London Med. Gazette. , HENRY C. T.KA'S Pi ni.irATiONS (Mat. Med.and Therapeutics). 13 p ERE IRA (JONATHAN), M.D., F.R.S. and L.S. .MATKUIA MKDICA A NI> TIIF.K A PK.rTICS; lu-inr :n A3 ineiit of the late Hr. Pereira's Elements of M.iteria Me.liea, arranged in conformity with the British PharmacopoMa, nnd ud.ij.ted to the use of Medi-al Practitioners, Chemists and KriU".M-t-. Medical and Ph inn:iceiiti-al Student*, Ac. Hy F. J. PAI;. -enior Physi.-ian to Si. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; :KRT BKKTI.KI . M.K.r S . IV. .s r of Materia Medica and Botany to the Pharmaceutic.i: iireat Britain: and hy KIU:I:T U MMM.I. v F.R. 8., Chemical Operator to the Society of A|>otli irie.. With numerous additions and references to the United States Pharmacopoeia, hy HORATIO C. Woor>. M.D., Professor of Botany in the University of Pennsylvania. In one large and h indsome octavo volume of 1040 closely printed pages, with 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 04. (Just Issued.) The task of the American editor has evidently been no sinecure, fur not only has he given to us all that is contained ill th- , r pur- I pose*, but by a careful an > over a hundred new remedies has increased Ub&ldMl of the former work fully one-third, l.e-i.le- adding many new illustrnt > are original ' We in: - ty that by so doing he has pro- i portionateiy .lyof the con- | . but lis exvn.l.-d the applicability of ...t original, and has placed his medical coun- trymen un.l' r lasting obligations to him. The Ame- in now has all that is needed in the shape tr-ali>e on materia medica, and the medical student li*;t text-book which, for prac- tical utility and intrin-ic worth, stands unparalleled. Although of considerable *ij.e, it is none too large for the purposes for which It has been intended, and every medical man should, in justice to himself, spare a place for it upon his book-shelf, resting assured that the more he consult- it the better he will be satisfied of Us excellence. \ Y. M-d. K.< .//, X..v. is, 1886. It will fill a place which no other work can occupy in the library of the physician, student, and apothe- cary. Bstn Med.and Surg. Journal, Nov. 8, 1S66. Of the many works on Materia Medica which have appeared since the issuing of the British Pharmaco- prela, none will be more acceptable to the ntndent and practitioner than the present. Pereira's Materia >' (BENJAUIX), M.D. 'Till: MKniPAL FORMULARY: being a Collection of Prescriptions derived from the writings and practice of mnny of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations nnd Antidotes for Poisons. The whole accompanied with a few brief Pharmoceutic and Medical Observations. Twelfth edi- tion, carefully revised and much improved by ALBERT H. SMITH, M.D. In one volume 8vo. of :t7o |MgM, extra cloth, $3 00. (Now Ready.) frequently noticed in this Journal as the successive editions appeared, that it in Mitlcient, on the present occasion, to state that the editor has introduced into the eleventh edition a large amount of new matter, derived from the current medical and pharma. works well MS a number of valuable prescriptions furnished from private sources. A very comprehen- sive and extremely useful Index has also been np- We endorse the favorable opinion which the book haa so long e*tablihed for itself, and take this occa- niiiiiiend it to onr readers as one of the con- v.-ni.-nl handbooks of the office and library. Ciu- cinmiti Lnncet, Feb. 1861. The work has long been before the profession, and its merits are well known. The |T.'-.-iit il'.tion con- tainsmany valuable additions, and will bfltoundlo ,.,,_ wll|c|l fM . mut , >!( r ,. f ,, r ,, n( . p to the p 8rticn i ;ir h,.n exceedingly convenient , nine tor nr , ir , H , h( . , )r ^ M . ri |,.. r ,, 1;lv wiOl to a.lmiuUter ; and l practitioner. -CWeofifO t l, language of the Korn.ulary has been made to cor- i wiib the iioi,,,-n.-!.,tur.' of the new national The work is now so well known, and has tieen KO Pharmacopoeia. Am Sour. Mai. ScUnctt, Jan M.D.. ' : 'l'A \NI> IMl MIM M'V. delixered in the Tnivervity of IVnnsylvanin. With throe i'-diciiu-.s. Fourth and revised edition, extra clolh, $3 00. (Now RaJy.) ROTLE'S MATKKIA MKMU'A AND THK.i: Al'KI'- Tll ' 'i ninety-elf v.ilume of about 7cti pages, extra cloth, i CHRIS CAK1'! ' .'V T!Ii: exp!: VolllIT large M " Hi > jth. *i \ THE THREE KINMt<": .il and Th. r;ip.Mi: nnula lined in tii.' iiul.v of t(,e r. - i'i ir - : :>. la on- IJn;.' \ ..iiiiu- 14 HENRY C. LEA'S PUBLICATIONS (Pathology}. (7 ROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings ; extra cloth. $4 00. The very beautiful execution of this valuable work, and the exceedingly low price at which it is offered, should command for it a place in the library of every practitioner. the book-shelf of every American physician. Charles- To the student of medicine we would say that we know of no work which we can more heartily com- mend than Gross's Pathological Anatomy. Southern Med. and Surg. Journal. The volume commends itself to the medical student ; It will repay a careful perusal, and should be upon ton Med. Journal. It contains much new matter, and brings down our knowledge of pathology to the latest period. London Lancet. JONES (C. HANDFIELD], F.R.S., and SIEVEKING (ED..H.), M.D., U Assistant Physicians and Lecturers in St. Mary's Hospital. A MANUAL OF PATHOLOGICAL ANATOMY. First American edition, revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautifully printed octavo volume of nearly 750 pages, extra cloth, $3 50. Our limited space alone restrains us from noticing more at length the various subjects treated of in this interesting work ; presenting, as it does, an excel- lent summary of the existing state of knowledge in relation to pathological anatomy, we cannot too strongly urge upon the student the necessity of a tho- rough acquaintance with its contents. Medical Ex- aminer. We have long had need of a hand-book of patholo- gical anatomy which should thoroughly reflect the present state of that science. In the treatise before us this desideratum is supplied. Within the limits of a moderate octavo, we have the outlines of this great department of medical science accurately denned, and the most recent investigations presented in suffi- cient detail for the student of pathology. We cannot at this time undertake a formal analysis of this trea- tise, as it would involve a separate and lengthy consideration of nearly every subject discussed ; nor would such analysis be advantageous to the medical reader. The work is of such a character that every physician ought to obtain it, both for reference and study. N. Y. Journal of Medicine. Its importance to the physician cannot be too highly estimated, and we would recommend our readers to add it to their library as soon as they conveniently can. Montreal Med. Chronicle. ftOKITANSKY (CARL], M.D., Curator of the Imperial Pathological Mttseum, and Professor at the University of Vienna. A MANUAL OF PATHOLOGICAL ANATOMY. Translated by W. E. STVAINE, EDWARD SIEVEKING, C. H. MOORE, and G. E. DAY. Four volumes octavo, bound in two, of about 1200 pages, extra cloth. $7 50. GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by JOSEPH LEIDT, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored, extra cloth. ij> 00. SIMON'S GENERAL PATHOLOGY, as conducive to the Establishment of Rational Principles for the Prevention and Cure of Disease. In one octavo volume of 212 pages, extra cloth. $1 2.3. TyiLLIAMS (CHARLES J. B.}, M.D., Professor of Clinical Medicine in University College, London. PPvINCIPLES OF MEDICINE. An Elementary View of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the preservation of health. A new American, from the third and revised London edition. In one octavo volume of about 500 pages, extra cloth. $3 50. The unequivocal favor with which this work has | A text-book to which no other in our language is comparable. Charleston Med. Journal. The lengthened analysis we have given of Dr. Wil- been received by the profession, both in Europe and America, is one among the many gratifying.evidences which might be adduced as going to snow that there is LI steady progress taking place in the science as well as in the art of medicine. St. Louis Mad. and Surg. Journal. No work has ever achieved or maintained a more deserved' reputation. Virginia Med. and Surg. Journal. One of the best works on the subject of which it treats in our language. It has already commended itself to the high regard of the profession ; and we may well say that we know of no single volume that will afford the source of so thorough a drilling in the principles of practice liams's Principles of Medicine will, we trust, clearly prove to our readers his perfect competency for the task he has undertaken that of imparting to the student, as well as to the more experienced practi- tioner, a knowledge of those general principles of pathology on which alone a correct practice can be founded. The absolute necessity of such a work must be evident to all who pretend to more than mere empiricism. We must conclude by again ex- pressing our high sense of the immense benefit which Dr. Williams has conferred on medicine by the pub- lication of this work. We are certain that in the present state of our knowledge his Principles of Medi- cine could not possibly be surpassed. While we as this. Students and practitioners should make j regret the loss which many of the rising generation themselves ^intimately familiar^ witl^its teachings of praet itioners have sustained by his resignation of the Chair at University College, it is comforting to they will find their labor and study most amply repaid. Cincinnati Med. Observer. There is no work in medical literature which can fill the place of this one. It is the Primer of the young practitioner, the Koran of the scientific one. Stethoscope. feel that his writings must long continue to exert a powerful influence on the practice of that profession for the improvement of which he has so assiduously and successfully labored, and in which he holds so distinguished a position. London Jour, of Medicine HK.NKY C. LEA'S PUBLICATIONS (Practice of Medicine). 15 J^L/XT (AUSTIN), .!/-/>.. ' Pm/eMor / ,".- /Vi.-i>fe and Practice of Medicine in BcUrvue Med. Colltge, A ) A TKKATISK ON TI1K I'KI Nn, r.-\i-e.l Mint enlarge. I. In one large and closely printed octavo volume of 1002 pages : liamlsome extra cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Jint lit. nly.) t/if Prr fur* to tlif Tliirti Kililinn. Since the puMi'-ation, in December, 1860, of the second edition of this treatise, tnneh time has been devoted to its re\ision. It. < trui/ing in the favor with which it has been received a pro- portionate obligation to .strive constantly to inert-use it. worthiness, the author has introduced in the present edition additions, derived from his clinical studies, and from the latest contributions in medical literature, wlii.-h. it is tx-lieved, will enhance considerably the practical utility of the work. A slight modification in the typographical arrangement has accommodated these additions without materially increasing the bulk of the volume. NEW YOKK, October, 1868. At the very low price nffixed, the profession will find this to be one of the cheapest volumes within their reach. A few notices of former editions are subjoined. We are happy in being able once more to commend thin work to t hi- si udents and practitioners of im-.hr ne who seek fur accurate Information conveyed in lan- guage at once clear, precise, and expressive. Amer. .-es, April, 1867. Dr. Flint, who ban been known in this country for many years, both as an author and teacher, who lias discovered truth, and pointed it out clearly and dis- tinctly to other*, investigated the symptoms and na- tural history of disease aud recorded it- language and facts, and devoted a life of incestiant study and thought to the doubtful or obscure in bis profession, has at length, in his ripe scholarship, given this work to the profession an a crowning gift. I f w'e have spoken highly of its value to the proleiuiion and world ; if we have said, all considered, it is the very best work upon medical practice in any language; if we have spoken of its excellences in detail, and given points of special value, we hnve yet failed to express in any degree our iir.--.-nt -innate of its value as a guide in the practice of medicine. It does not contain toomnch or too . 'iibt should be T,. where truth is known. It is *ud --peculative where philosophy and peculation are all tli.-.t can at pr.----nt ! obtained, - admitted to th elevation ut established truth, without the ino-t thorough investigation. It remarkable with what evt-n lmtnl this work ', written, and how it all shows the mostcare- fnl thought and uniirinit Ktndy. We conclude that, th-Mich it may yet be susceptible of improvement, it Mill con-titu ted the very bunt which human knowledge can at present |>r rule of practice. Htifulo Med. and Surg. Journal, Feb. l-;7. Dr. Flint's book is the only one on the practice of medicine that c;in benefit the young practitioner. /. Journal, Aug. 18rt6. W- eoai .i.-r the 1 k, in all it essentials, as the hem S(l|>t.-'t to the -.indent of any of our num>-ni- kii on this subject. .V. 1' Med. Journ., Jan.'67. It terse conciseness fully redeem* It from being ranked among heavy and common-place works, while the unmistakable way in which Dr. Flint give* kit own views is quite refreshing, and far from common. It is a book of enormous research ; the writer is evi- dently a man of observation and large experience; his views are practically sound and theoretically moderate, and we have no hesitation In commending his magnum opus to our readers. Dublin Medical Press and Circular, May 16, 1866. In the plan of the work and the treatment of indi- vidual subjects there is a fresh ness and an originality which make it worthy of the study of practitioners as well as students. Ills, indeed, an admirable book, and highly creditable to American medicine. For clearness and conciseness in style, for careful reason- ing upon what is known, for lucid distinction between what we know and what we do not know, between what nature does in disease and what the physician can do and should, for richness in good clinical ob- servation, for independence of statement and opinion on great points of practice, and for general sagacity and good Judgment, the work is mo-t meritorious. It is singularly rich in good qualities, and free from faults. London Lancet, June 23, 1S66. In following out such a plan Dr. Flint has snc- ceeded most admirably, and gives to his readers a work that is not only very readable, interesting, and concise, but in every respect calculated to meet the requirements of professional men of every class. The student has presented to him, in the plainest possible manner, the symptoms of disease, the prin- ciples which should guide him In its treatment, and the difficulties which have to be surmounted in order to arrive at a correct diagnosis. The practitioner, besides baring such aids, has offered to him the con- clusion which the experience of the professor has enabled him to arrive at in reference to the relative merits of different therapeutical agents, and different methods of treatment. This new work will add not a little to the well-earned reputation of Prof. Flint as a medical teacher. .y. Y. Mad. Record, April 2, 1866. nr.NY7/,/>v).v. FO A- /;/>. yir/-: /;/>//:. A\n THE CYCLOIMCIHA OF I'UACTICAL MKPK'INF.: ooini.ri-iii.r Treatises on the Nature ami Treatment of '! it'-ria Medicn and Therapeutics, \\ '..in. n ami Children, Me.lical Jurisprudence, Ao. Ac. In four large super-royal .1 volumes. ni.'l-.'M ili.uljle-coluiuued pages, strongly and handsomely bound in leather, $15 ; extra cloth, $11. ** This work contain* no les* than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians. The most complete work on practical medicine extant, or at least iu our language. Buffalo Medical d.Tii Kni(M-h medicine is .-xhihit, d in the most ad- vantageous light. Mfdirn: BAKI.y I) F. < M.I). 1 vol. SA-O., pp. 000, cloth.' ;. H"U,AXIi-S MKDICAT, N"TK.s AND K From tliM third and enlarged Eugl;- tion. In one hand-oui. .uie of about 500 pages, extra cloth. |3 5U. 16 HENRY C. LEA'S PUBLICATIONS (Practice of Medicine}. TTARTSHORNE (HENRY], M.D., -*- -* Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. In one handsome royal 12mo. volume of 418 pages, clearly printed on small type, cloth, $2 38; half bound, $2 63. (Jnst Issued.) The very cordial reception with which this work has met shows that the author has fully suc- ceeded in his attempt to condense within a convenient compass the essential points of scientific and practical medicine, so as to meet the wants not only of the student, but also of the practi- tioner who desires to acquaint himself with the results of recent advances in medical science. As a strikingly terse, full, and comprehensive em- | nearly than any similar manual lately before us the bodiment in a condensed form of the essentials in , standard at which all such hooks should aim of medical science and art, we hazard nothing in saying teaching much, and suggesting more. To the student that it is incomparably in advance of any work of the we can heartily recommend ihe work of our transat- kind of the past, and will stand long in the future i lantic colleague,- and the busy practitioner, we are without a rival. A mere glance will, we think, iin- I sure, will find in it the means of solving many a press others with the correctness of our estimate. Nor do we believe there will be found many who, after the most cursory examination, will fail to possess it. How one could be able to crowd so much that is valu- able, especially to the student and young practitioner-, doubt, and will rise from the perusal of its pages, having gained clearer views to guide him in his daily struggle with disease. Z>M&. Mtd. Press, Oct. 2, 1807. Pocket handbooks of medicine are not desirable, even when they are as carefully and elaborately com- withiu the limits of so small a book, and yet embrace ] piled as thig) tne iatest> most comp i e , e , and most and present all that is important in a well-arranged, clear form, convenient, satisfactory for reference, with so full a table of contents, and extended general index, with nearly three hundred formulas and recipes, is a marvel. Western Journal of Medicine, Aug. 1807. The little book before us has this quality, and we can therefore say that all students will find it an in- valuable guide in their pursuit of clinical medicine. Dr. Hartshorne speaksofitas "an unambitious effort to make useful the experience of twenty years of pri- vate and hospital medical practice, with its attendant study and reflection." That the effort will prove suc- curate which we 'have seen. British Mtd. Journal, Sept. 21, 1S67. This work of Dr. Hartshorne must not be confound- ed with the medical manuals so generally to be found in the hands of students, serving them at best but us blind guides, better adapted to lead them astray than to any useful and reliable knowledge. The work be- fore us presents a careful synopsis of the essential elements of the theory of diseased action, its causes, phenomena c and results, and of the art of healing, as recognized by the most authoritative of our prufi->- sional writers and teachers. A very careful and can- cessful we have no doubt, and in his study, and at j did examination of the volume has convinced us that the bedside, the student will find Dr Hartshorne a j it will be generally recognized as one of the best man- safe and accomplished companion. We speak thus I nalsfor the use of the student that ha- yei appeared. highly of the volume, because it approaches more I American Journal Med. Sciences, Oct. Ibti7. (THOMAS], M. D., &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. FRANCIS CONDIE, M. D., author of "A Practical Treatise on the Diseases of Children." Ac. With one hundred and eighty- five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type; extra cloth, $6 50; strongly bound in leather, with raised bands, $7 50. Believing this to be a work which should lie on the table of every physician, and be in the hands of every student, every effort has been made to condense the vast amount of matter which it con- tains within a convenient compass, and at a very reasonable price, to place it within reach of all. In its present enlarged form, the work contains the matter of at least three ordinary octavos, rendering it one of the cheapest works now offered to the American profession, while its mechani- cal execution makes it an exceedingly attractive volume. DICKSON'S ELEMENTS OF MEDICINE; a Compen- dious View of Pathology and Therapeutics, or the History and Treatment of Diseases. Second edi- tion, revised. 1 vol. Svo. of 750 pages, extra cloth. .$t oo. WH ATTO OBSERVE AT THE BEDSIDE AND AFTER DEATH IN MEDICAL CASES. Published under the authority of the London Society for Aledical Obser- vation. From the second London edition. 1 vol. royal 12mo., extra cloth. $1 00. LAYCOCK'S LECTURES ON THE PRINCIPLES AND METHODS OP MEDICAL OBSERVATION AND RE- SEARCH. For the use of advanced students and junior practitioners. In one very neat royal 12m u. volume, extra cloth. $1 00. J^ARCLAY (A. W.}, M. D. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Signs and Symptoms of Disease. Third American from the second and revised London edition. In one neat octavo volume of 451 pages, extra cloth. *3 50. A work of immense practical utility. London I The book should be in the hands of every practical Med. Times and Gazette. \ man. Dublin Med. Press. PULLER (HEXRT WILLIAM], M. D., -*- Physician to St. George's Hvtpital, London. ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, ar r l Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. (Just Issued.) Dr. Fuller's work on diseases of the chest was so , accordingly we have what might be with perfect jus- favorably received, that to many who did not know i tice styled an entirely uew work from his pen, the the extent of his engagements, it was-a matter of won- portion of the work treating of the heart and great der that it should be allowed to remain three years j vessels being excluded. Nevertheless, this volume is out of print. Determined, however, to improve it, of almost equal size with the tirst. Luiidun JJedical Dr. Fuller would not consent to a mere reprint, and Times and Gazette, July 20, Ibo7. HENRY C. LEA'S PUBLICATIONS (Practice of Medicine). 17 Mrs77.v. ././>.. Prfet*or of the Principle ami P.--i--!iif. of Medicine In Bellev** Hospital Med. Cullffft, .V. T. PRACTICAL TKKATISK ON TIM-: PHYSICAL KXPI.oKA- Tl"\ OF T1IK CHKST AND TI1K DIAGNOSIS OP DISEASES AFKK- TIM} THE BB8PIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, extra cloth, $4 50. (Just Issued.) Premising this md prac 1S87. rach nted Ih il 111* i)f III.- i which IIP ran commit. The mericsn medlein. Atlanta Jftd. and Burg. Jwtr- nnl, Feb. 187. The chapter on Phthisis Is replete with Interest; and bis remark* on the diagnoni*. especially in the early stages, are remarkable for their acumen and , ct, and to alM concise, be: v . l!lliv ,, r M.-IK and uiirio- ny works i Medical Prtus, Feb. 6, ly i e i n ,i elegant, and the tone of freshness and originality which pervades his whole work lend an additional force to its thoroughly practical character, which cannot fail to obtain for it a place as a standard work ,ies of the respiratory system. London Lancet, Jan. 19, 1887. Thi* is an admirable hook. Excellent in detail and execution, nothing better conld he desired by the practitioner. Dr. Flint enriches Ms subject with much solid and not a little original observation. Ranking' i Abntract, Jan. 1867. III the invaluable work before n, we have a book If of nearly 600 page*, admirably arranged, clear, th. p.m.-!., a!, : -. without pro- lixity: t-xlit -.mi topic tonched ; a in .LID. :tinii'-l>ervation, which dues credit to its author, aud reflects honor on T TIIK SAVE Al'TUOR. A IMIACTK'AL TIIKATISE OX TIIK DIAGNOSIS, PATHOLOGY, AND TKKAT.MKNT OF DISEASES OF THE HEART. In one neat octavo volume of nearly 500 pages, with a plate ; extra cloth, $3 50. W >. :m'riran author u; ni.r.' e\t-a-ir>-ly known, "r ntry than Dr. I Flint. We willingly acknowledge his success, more , particularly iu the vuluuic on diseases of the heart, in makingan extended personal clinical study available for purpo-e* <>f illustration, in connection with case* which have linen reported by other trustworthy ob- servers. Brit,, and fur. Jfed.-Chir. KtoUto. SJHAXBERS (T. A'.), V.D., ' '.;, - . , H .,v-(7, Jjondiyn, Ac. TIIK INhKil-STloXS; or, Diseases of the Digestive Organs Functionally Treated. Second American, from the second and revised English Edition. In one hand- some octavo volume of over 300 pages, extra cloth, $3 00. (Now Ready.) most vivid and brilliant of living and practical skill that bis success as a teacher or diieal writers ; and here he aupplie*, in a graphic literary expositor of the medical art conMsts; and the .<, bright sketches fn>rn hi* w.-il- volume before us is a better illustration than its an- k, thor has yet produced of the rare degree in which ihes, original, brilliant, and iu- thoe combined qualities are at his command. Next .'. Everywhere he Is er.) !.;<. ;u,.| hj work to the diseases of children, there is no subject on A jert, and we have in th which '.n id. and we are e praise. .V J .IK of much value. irnn!, Nov. 187. e faculty which Tr. his sub- which the young practitioner is oftener consulted, or on which the public are more apt to form their opinions of his professional skill, than the various phenomena of indigestion. Dr. Chambers cornea most ... elements opportunely and effectively to bis assistance. In fact, 'make iTa modeT 'of its' sort' ~We'h a ve perused i toere are > ew situations in which the commencing 1'iiiiv: hiivi- Ktiulied every page' our interest practitioner can place himself in which Dr. Cham- . ,1 a we p, ..o.-.-d^.l. lt - r ' conclusions on digestion will not be of service. London Lancet, February 23, 1867. ay it down with unqualified ,r7. ]>I;I.\TO.\ (\\-II.U.\M\ M. //.. ;'. HJS, l.K( TU1KS ON TIN: IHSKASI-S OK TIIK STOMACH; with an Introduction on it.< Anatomy and Physiology. From the second and enlarged London edi- t, .n. With iMiistratiuns ..u .,..! In one handsome octavo volume of about 300 pages, (.///>/ /.., n he f tin f A m ^re f 11 t t,l I I T> t tn 1 t rk" In rat t nT i t> A t- I diagnos- tic*, -1m. J;ur >/ ttie Med. Science*, April, ltx. | 185. JjABERSffOff (.?. O.), M. />. PA TI lo L OCir A I. AND PRACTICAL o I 'Si: II V ATloNS ON DIS- THK AF.IMKN r \IIV CANAL, 'K-"|M1 \i TS. STu.MM'll. r.V'TM. AND INil.>IIM < With illu-tnitiong on wood. In one hand^utue octavo volume of 312 pages, extra cloth. $: TTUI L), M.D.. M. /.'. /. .1.. -*-* Ph>, ',,!. . Li-:cTri;i:s ON TIIK STUDY OF KKYKH. iu one vol. 8vo., extra cloth, (litaily *r.) 18 HENRY C. LEA'S PUBLICATIONS (Practice of Medicine). ROBERTS ( WILLIAM], M. D.. -*- ^ Lecturer on Medicine in the Manchester School of Medicine, &c. A PRACTICAL TREATISE OX URIXARY AND REXAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. In one very handsome octavo volume of 516 pp., extra cloth. $4 50. (Just Issued.) In carrying out this design, he has not only made > sive work on urinary and renal diseases, considered good use of his own practical knowledge, but has ; in their strictly practical aspect, that we possess in brought together from various sources a vast amount the English language. British M&lical Journal, of information, some of which is not generally pos- Dec. 9, 1865. sessed by the profession in this country. We must now bring our notice of this book to a close, re- gretting only that we are obliged to resist the temp- tation of giving further extracts from it. Dr. Roberts has already on several occasions placed before the profession the results of researches made by him on various points connected with the urine, and had thus led us to expect from him something good in which expectation we have been by no means disappointed. The book is, beyond question, the most comprehen- We have read this book with much satisfaction. It will take its place beside the bent treatises in our language upon urinary pathology and therapeutics. Not the least of its merits is that the author, unlike some other book-makers, is contented to withhold much that he is well qualified to discuss in order to impart to his volume such a strictly practical charac- ter as cannot fail to render it popular among British readers. London Med. Times and Gazette, MJtrch 17, 1866. % " Bird on Urinary Deposit?," being for the present out of print, gentlemen will find in the above work a trustworthy substitute. MORLAND ON RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRE- TION. 1 vol. 8vo., extra cloth. 75 cents. BLOOD AND URINE (MANUALS ON). By J. W. GRIFFTH, G. 0. REESE, and A. MARKWICK. 1 vol. 12mo., extra cloth, with plates, pp. 460. $1 25. BUDD ON DISEASES OF THE LIVER. Third edition. 1 vol. Svo. , extra cloth, with four beautifully colored plates, and numerous wood-cuts, pp. 500. $4 00. TONES (C. EANDFIELD), M. D., ^ Physician to St. Mary's Hosjiital, &c. CLIXICAL OBSERVATIONS DISORDERS. Second American Edition. extra cloth, $3 25. (Just Issued.) Taken as a whole, the work before us furnishes a ' short but reliable account of the pathology and treat- ment of a class of very common but certainly highly obscure disorders. The advanced student will fluid it a rich mine of valuable facts, while the medical prac- titioner will derive from it many a suggestive hint to , aid him in the diagnosis of "nervous cases," and in determining the true indications for their ameliora- tion or cure. Amer. Journ. Med. Set., Jan. 1S67. OX FUXCTIOX T AL XERYOUS In one handsome octavo volume of 348 pages, We must cordially recommend it to the profession of this country as supplying, in a great measure, a deficiency which exists in the medical literature of the English language. Xew York 3Itd. Journ., April, 1867. The volume is a most admirable one full of hints and practical suggestions. Canada Med. Journal, April, 1867. FA PRISON'S ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume of 292 pp. $1 50. SOLLY ON THE HUMAN BRAIN: its Structure, Phy- siology, and Diseases. From the Second and much enlarged London edition. In one octavo volume of 500 pages, with 120 wood-cuts; extra cloth. $250. BUCKNILL AND TUKE'S MANUAL OF PSYCHO- LOGICAL MEDICINE; containing the History, Nosology, Description, Statistics, Diagnosis, Patho- logy, and Treatment of Insanity. With a Plate, lu one handsome octavo volume, of 53ti pages, extra cloth. $1 25. 8 LADE (D. D.), M.D. DIPHTHERIA ; its X"ature and Treatment, with an account of the His- tory of its Prevalence in various Countries. Second and revised edition. In one neat royal 12mo. volume, extra cloth. $1 25. (Just issued.) SMITH OX CONSUMPTION ; ITS EARLY AND RE- MEDIABLE STAGES. In one neat octavo volume of 254 pages, extra cloth. $2 25. SALTER ON ASTHMA ; its Pathology, Causes, Con- sequences, and Treatment. In one volume octavo, extra cloth. $2 50. BUCKLER ON FIBRO-BRONCHITIS AND RHEU- MATIC PNEUMONIA. In one octavo vol., extra cloth, pp. 150. SI 25. FISKE FUND PRIZE ESSAYS. LEE ON THE EF- FECTS OF CLIMATE ON TUBERCULOUS DIS- EASE. AND WARREN ON THE INFLUENCE OF PREGNANCY ON THE DEVELOPMENT OF TU- BERCLES. Together in one neat octavo volume extra cloth, *1 00. HUGHES' CLINICAL INTRODUCTION TO AUS- CULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS. Second edition. One volume royal 12mo.. extra cloth, pp. 304. $1 25. WALSHE'S PRACTICAL TREATISE ON THE DIS- EASES OF THE HEART AND GREAT VESSELS. Third American, from the third revised and much enlarged London edition. In one handsome octavo volume of 420 pages, extra cloth. $3 00. (ROBERT D.}, K. C. C. A TREATISE OX FEVER; or, Selections from a Course of Lectures on Fever. Being part of a Course of Theory and Practice of Medicine. In one neat octavo volume, of 362 pages, extra cloth. $2 25. CLYMER ON FEVERS; THEIR DIAGNOSIS, PA- THOLOGY AND TREATMENT. In one octavo volume of 600 pages, leather *1 75. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat octavo volume, of 320 pages, extra cloth. *2 50 LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeu- tical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under thesame name in other parts of temperate as well as in tropical regions. In two large and handsome octav,o volumes, of nearly 1500 pages, extra cloth, $7 00. LA ROCHE ON P NEUMONIA ; its Supposed Connec- tion, Pathological, and Etiological. with Autumnal Fevi-rs, including an Inquiry into the Existencefcnd Morbid Agency of Malaria. In one handsome oc- tavo volume, extra cloth, of 500 pages. Price &3 00. HKNRY C. LEA'S PUBLICATIONS (Vcntn-al Diseases, etc.). 19 T> UM.< /7-:, \ /) ( /'/,' r.KMAN J.), At. D. t *-* Professor nf Venereal Diseases at the Col. of Phys. and Surg., Kete Tort. Ac. THE PATHOLOGY AND TKKATMKNT OF VKNKREAL DIS- I \- : 3. Including the results of recent investigations upon the subject. A new and re- vised eKraph on this abject in our language. British American J'.unml. s medicaj library. Pacijtc Jfed. j. J'l'irn-il. We have no doubt that It will supersede In America Terr nther treatise on Venereal. Sun Francisco . t-.on of Ml that 1* worth knowing e in general. It fllU up a gap 5liciiy. HiHttvii Mtdical and' Surgical Journal, an. 30, 1S64. The book Is one which every practitioner should have in his possession, and, we may further say, the fluty book upon the subject which he should acknow- ledge as competent authority. Buffalo Medical and Surgicul Journal, July, 1864. The best work with which we are acquainted, and the most convenient hand-book for the busy practi- tioner Cincinnati Lancet, July, 1S64. riULLERIER (A.}. and V tltt llopital dit Midi. J> I MSTEA D (FREE MA N J. ), *-* Profr*M>r <>f Venerea I Diseases In Hie College of Physicians and Surgeons, Jf. T. AN ATLAS OF VKNKIIKAL 1USKASKS. Translated and Edited by KAJ J. lie M STEAD. In one large imperial 4to. volume of 328 pages, double-columns, with 2 plates, containing about 150 figures, beautifully colored, many of them the size of troi :'\ i ..mill in extra cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at '. (Just Heady.) As the successor of Ricord in the great Venereal Hospital of Paris, M. Cullerier has enjoyed special ndviiuta<:-s for the present undertaking, and bis series of illustrations, though only recently tini-hf 1. is already recognized as tbe most complete and comprehensive that bus yet appeared on Uii.- .-nl jeft. In reproducing these plates every care has been had to preserve their artistic finish and nccurnry, and they are confidently presented as equal to anything that has yet been produced in tin? country. The reputation of Dr. Bum.'tead as a writer and syphilographer is too well known to require ntlirr guarantee for tbe fidelity of the translation or the value of the additions introduced. Antici|i:itin;_' a very larjrc .=:tle for this work, it is offered at the very low price of THREE DOL- . thus |.!:i--in^ it within the reach of all who are interested in this department of prac- tice, fit- ntlnnu-n desiring early impressions of the plates would do well to order it without delay. *#* A pecimen of the plates and text gent free by mail, on receipt of 25 cents. Thin |< a v.-ry hrtii'lsDiiu well-known and highly va That ! : the ant .41;. I : ' ::. Its rnmplu ophtlialmii cilte-i. h of th.- kiu.l dition in Ku-.-li-li of .. highly valued French publication. d. the an- -r the best and itise on venereal diseases in the !>.. iil.l think it proper to translate I peak* more highly In its favor than I It in a judgment ex at- ' -'.it:. in i< an excellent on*. The I 1 lilennorrhagia and rrhceal I 'are admirably and artistically ex- try. The I III' K1UII Ullll**l|lf f-A'^lll^ll IU lllls ItiliullJ. A UD y lir DMIII- tin- value of the work. 'I ttlnf-np of tbU pabltoation erned. . .I.M. Taiin- .if tlil.t ni.ivtiiflcent ' Work. The pUten in dimmo-ln liography urn most I admira: .ilily in diiitini riginals, as we know from personal examination. The appearance of the work in parts places it within tbe reach of all, and when completed it will be a mnt valuable accession to our literature. .V. 1". Mtd. Journal, April, 1868. This is probably the handsomest work of Its class ever published in this country. Eostun Med, and Surg. Journal, April 1.1, Tho two parts thus pablinhod are Illustrated by plates, than which none Kuperlor have been issued from the press; in fact, in this country, no more magnificent work has ever been published. Infinite - dne the publisher and translator that they should have placed before tbe profession, in Mich a style, so valuable a production. St. Louis Med. .Re- May, 1S6S. This in one of the most elegantly published and valuable works that have been lepriottxl and edited in this country, relating to the loathsome, though im- portant, class of vf uereal diseases. The author and iMitor are alike men of experience and eminent abi- lity ; and we freely com mm I tin- pr.nl net of thfir labon to the general patronage of the profession. /Vii.-iy,, M.,f May, 1868. ALLBMAND A\I> U7/,X".v. 'A PRACTICAL TI'J-ATISK ()\ T1IK OAtTSES, SYMPTOMS. ANI THKATMKXT <>F H'Ul.MAT- iliKIHK \. I'.v M L.u.LEMAsn. Tran.slnted and edited lir Hr!RV J. M' I'"' <: M t. Fifth Aniericnn e.lition. To which i* addril ">N -OFTHK VE8ICUL2B i>, M.I>. In one neat octavo volume, of about 400 pp., extra cloth, $2 75. LL (BE RKELET), S'lr . ON SVI'IIII.IS AND LOCAL CONTAGIOUS DISOIIPKILS. In one handsome octavo volume. (Nearly Ready.) 20 HENRY C. LEA'S PUBLICATIONS (Diseases of the Skin). WILSON (ERASMUS), F.R.S., ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. (Now Ready.) A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. From the Preface to the Sixth English Edition. The present edition has been carefully revised, in many parts rewritten, nnd our attention h;is been specially directed to the practical application and improvements of treatment. And, in conclusion, we venture to remark that if an acute and friendly critic should discover any differ- ence between our present opinions and those announced in former editions, we have only to ob serve that science and knowledge are progressive, and that we have done our best to move onward with the times. The industry and care with which the author has revised the present edition are shown by the fact that the volume has been enlarged by more than a hundred pages. In its present improved form it will therefore doubtless retain the position which it has acquired as a standard and classical authority, while at the same time it has additional claims on the attention of the profession as the latest and most complete work on the subject in the English language. Such a work as the one before us is a most capital and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his hook on diseases of the skin has long been re- garded as one of the best text-books extant on the subject. The present edition is carefully prepared, and brought up in its revision to the present time. In this edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases treated of in the body of the work. Cin- cinnati Lancet, June, 1863. No one treating skin diseases should be without a copy of this standard work. Canada Lancet. August, 1863. Y THE SAME AUTHOR. We can safely recommend it to the profession &8 the best work on the subject now in existence in the English language. Medical Times and Gazette. Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases ; it includes almost every fact or opinion of importance connected with the anatomy and pathology of the skin. British and Foreign Medical Review. These plates are very accurate, and are executed with an elegance and taste which are highly creditable to the artistic skill of the American artist who executed them. St. Louis Med. Journal. The drawings are very perfect, and the finish and coloring artistic and correct; the volume is an indis- pensable companion to the book it illustrates and completes. Charleston Medical Journal. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- EASES OF THE SKIN. In one very handsome royal 12mo. volume. $350. (Lately Issued.) Y THE SAME AUTHOR. - HEALTHY SKIN; a Popular Treatise on the Skin and Hair, their Preservation and Management. One vol. 12mo., pp. 291, with illustrations, cloth. $1 00. (J. MOORE), M.D., M.R.I. A., A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M. D. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. (Just Issued.) Of the remainder of the work we have nothing be- : This instructive little volume appears once more. yond unqualified commendation to offer. It is so far Since the death of its distinguished author, the study the most complete one of its size that has appeared, of skin diseases has been considerably advanced, and and for the student there can be none which can com- ' the results of these investigations have been added pare with it in practical value. All the late disco- by the present editor to the original work of Dr. Neli- veries in Dermatology have been duly noticed, and gan. This, however, has not so far increased its bulk their value justly estimated; in a word, the work is as to destroy its reputation as the most convenient fully up. to the times, and is thoroughly stocked with manual of disease* of the skin that can be procured most valuable information. New i'ork Med. Record, by the student. Chicago Med. Journal, Dec. 1S66. Jn. 15, 1867. i Y THE SAME AUTHOR. - ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, -.irh.>\ TIIK HFSKASESOF < HlI.l/KKN. In one large octavo volume of about 850 pages. (Nearly Ready.) The object of the author has been to present within a moderate compass a complete but concise account of the pathology and therapeutics of the diseases incident to infancy and childhood, M viewed from the standpoint of the most advanced condition of medical science. The unusual opportunities which he has enjoyed of clinical observation in public and private practice cannot fail to render the work one of great practical value. WEST ( CH.\ /,' /, />'), M. D~ Phytii-tnn to the ll<,*i>it'tlfnr Sick (Children, Ac. LKCTTIIKS ON TIIK IHSKASES OF INFANCY AND CHILD- HOOD. Fourth American from the fifth revised and enlarged English edition. In on large and handsome otavo volume of 650 closely-printed pages. Extra cloth, $4 50 ; leather, $5 50. (Just itfiied.) Of ill the EoKlinh writer* on the diHt-tn^s of cbll- 1 affording the readermnch pleasure, even Indepflndea dron, there in no one no entirely .,iiti-f;ici..rv I., n-* a of that - i roin the acquihition of valuable in we hav. i.iion as ; tm\b, Cincinnati Jour, of Medicine, March, ISM. r llm l,ih.-,t We hfcTe , ^^,-ded lt th( , mtni Dentine and lit ?! u^ ^ .1 ^TivTn wn II : P~c"> '"'^ " 'l,^a.. of children which has yet ' 1 bv a,d .raca. com ln tbl oantry.-fi/io Mtdic.il Journal. '-tf* book i.- tli.< l-.--t that has ever been in the Knqlixh IHIUUMI;** on the dieae of all a* am "' chlldhoo-l . i ' !H,H>IUI Rtvicto of Mtd. Maatoni when n< aBM rabjer :il to help u- uno part of the volume, no subject on which r:tl index, and a pecial li r- j| ir.-at, which does not exhibit the keen perception, rnnln- work. Botton Mtd. ( i,. ,,f the Dr. \\>t'K rolame Is, In onr opinion, locomi in hit management that - D E WEES (\\-II.I.L\M 1\ . M./>.. I ,,/ r. A TREATISE ON THK PHYSICAL AND MKDICAL TP.KAT- I "K i IHI.l'KKN. Eleventh edit! >n, with the author's last improvements and cor- rections. In one octavo volume of 54v s jmges. $2 80. 22 HENRY C. LEA'S PUBLICATIONS (Diseases of Women). ITHOMAS (T.GAILLARD\M.D., -*- Professor of Obstetrics, &c in the College of Physicians and Surgeons, N. Y., &c. A PRACTICAL TREATISE OX THE DISEASES OF WOMEN. In one large and handsome octavo volume of over 600 pages, with 219 illustrations, extra cloth, $5; leather, $6. (Now Ready.) From the, Preface. " This work was undertaken with the conviction that a treatise, such as that which the Author has aimed to prepare, was needed as a text-book for the American student, and as a book of reference for the busy practitioner. "No department of medicine has made greater advances within the last few years than Gyne- cology ; yet the record of its progress is, for the most part, to be found only in special monographs, journals, transactions of societies, &c., and is thus inaccessible to the mass of the profession in this country. It has, therefore, seemed to the author that a volume which should, within a limited space, present the latest aspect of the subject in a systematic form, could scarcely fail to prove useful, while his position for the last thirteen years as a teacher in this department has encouraged him, in the hope that his familiarity with the needs of the student may, to some extent, have fitted him to undertake the task." The best text-book for students, and a perfect wide completeness, a clearness and simplicity, to be found mecum to the gynecologist. 2f. Y. Journal of O'juttt- in no other book on the same subject within our rics, May, 1S68. knowledge ; its views on uterine pathology are, to We have recently been almost flooded by works our lnind . more consonant with reason and common from American sources on the allied subjects of ob- : 8en8e tban any other we have 8een - Enjoying fine stetricsandgynecoloey. Nor hasquantity alone been opportunities in an extensive field of observation Dr. the most noticeable feature connected with them, for Thomas, as an author, has fully sustained his high their quality has invariablv been of the highest. Dr. reputation as a teacher. We have no hesitation in great clinical experie illustrated by upwards of two hundred engravings, . In no work with which we are acquainted, is there some of them of great value. London lied. Times to be found so full and complete an exhibit of the im- and Oaz., April 25, 1868. ! proved means of diagnosis of the obscure subjects of The book of Prof. Thomas is well calculated to do gynecology, or of their more enlightened therapy, away with this latter objection, and to accomplish Dili our s P ace permit, we should be glad to go into an more towards the establishment of a rational system extended review of the work hefore us, giving not of uterine therapeutics than any other work of its merely an outline of the sul.jects treated of, but lull size in any language. We-have rarely read any trea- extracts from the text itselt. As it is, we can only Use upon a medical topic that has given us better recommend our readers to buy it, feeling convinced satisfaction, or impressed us with the fitness of an au- , he y win te amply repaid for the outlay. Z,ui>*n- thor for the proper performance of a most responsible WW Medical Herald, May, 1868. task Itisperhaps unnecessary for us to commend the Indee d, we do not know a better study in briefer work most heartily to every one who is or may be gpacei no ' t for medical students merely, but for prac- hable to treat uterine diseases. N. York Medical Be- t fa oners , who may re ally wish to have light upon an cord, April lo, 1868. . obscure pathway, to be 'trained in the thorough in- A work which will certainly add to the reputation vestigation of diseases peculiar to women, than is of its author, and come into general use in this coun- herein to be found. Western Journal / Medicine, try as a text-book. The style is exceedingly clear May, 1868. and concise, and the views expressed eminently prac- j tical and scientific. Quarterly Journ. of Psychul. It is a masterly resume of what is known by an Medicine April 1S6S experienced and honest observer. The Profession : is indebted to Prof. Thomas for thus tabulating the The work is concise and practical, avoiding the dis- much that has been accep ted as valuable and reliable cussion of unsettled questions but giving a judicious in gynec ology, but this is not by any means all the resume of known facts. Chicago Med. Journal, me *? t of th | work ; we have his ample experience, April, 186S. i gi ven j n jjj s opinions on pathology and treatment, We are led to believe that it is the best work that which carry conviction by the confidence we feel that has yet appeared on the diseases of women. There they are the candid opinions of an honest and compe- ls about it a precision and accuracy, a fulness and tent observer. Humboldt Med. Archives, April, 1863. HUE CHILL (FLEETWOOD), M. D., M. R. I. A. OX THE DISEASES OF WOMEN; including those of Pregnancy and Childbed. A new American edition, revised by the Author. With Notes and Additions, by D. FRANCIS COXDIE, M. D. , author of " A Practical Treatise on the Diseases of Chil- dren." With numerous illustrations. In one large and handsome octavo volume of 768 pages, extra cloth, $4 00; leather, $5 00. Y THE SAME A UTHOR. ESSAYS OX THE PUERPERAL FEVER, AXD OTHER DIS- EASES PECULIAR TO WOMEN. Selected from the writings of British Authors previ- ous to the close of the Eighteenth Century. In one neat octavo volume of about 450 pages, extra cloth. $2 50. BROWN OX SOME DISEASES OF WOMEN AD- MITTING OF SURGICAL TREATMENT. With handsome illustrations. One volume 8vo., extra cloth, pp. 276. $1 60. ASHWELL'S PRACTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised Lon- don edition. In one octavo volume, extra cloth, of 528 pages. $3 50. RIGBY ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. DEWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's last improvements and correc tions. In one octavo volume of 536 pages, with plates, extra cloth, $3 00. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES. Translated by C. D. MEIUS, M. D. Se- cond edition. In one vol. Svo, extra cloth, with numerous wood-cuts, pp. 720. $3 75. BENXEfT'S PRACTICAL TREATISE OX INFLAM- MATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uteriue Disease. Sixth American, from the fourth and re- vised English edition. 1 vol. Svo., of about ouO pages, extra cloth. $3 75. II I:\UY C. LEA'S PUBLICATIONS (Diseases of Women). 23 IJODKE (HUfiH L.). M.D. * * EmerU'ui Profcttor u/ (Metric*, tc., in the r*ivertity nf Ptnnylrr. prove acceptable to the pro- IM dUeaaes of women Dr. Hodge has e*tab- i ftchool of treatment that ban become world- . fame. '! ulife'n work i truly an original one beginning to end. eoawqnently race I me can pe- new. The lentofdis- believer iu : y of Inflammations of the (CHARLES), M.D. LECTURES )N THE DISEASES OF WOMEN. Third American, from the Third London edition. In one neat octavo volume of about 550 pages, extra cloth. $3 75 ; leather, $4 75. (Now Rtady.) The reputation which this volume has acquired as a standard book of reference in its depart- ment, render." it only necessary to say that the present edition has received a careful revision at the hands of the author, resulting in a considerable increase of size. A few notices of previous editions are subjoined. .inner of the author is excellent, hi* descrip- . .pliic ami perrpicuons, and his. treatment up te, and . common sense. Chicago lied. unot too highly recommend this, the second edition of Or UY-t excellent lecture* on the din- ettes of females. We know of no other book on this from which we have derived .-- much pleasure *ge given evidence of the .true.t. anJ diluent' iw.irctier after truth. He i. e mere coin; - ideas, but his ..i often years' patient invenllga- r women's disease* St. Bnrt'i ' in. - .1 ten.-h.-r, ! I earnest in his language, clear and com- iis, and logical in bin de- t, Jan. 1862. the author thanks for the ', >iint of instruction he has afford- d u. 11'.- 'ie needs no eulogy on our part. His n aud truthful j> -.me all 'jr them*elve*. M' ry. Review. i"d a standard work It beam evidence of having been carefully revised, and Is well worthy of the fine it has already obtained. i > an dnctl \\V ft'ir | As a writer. Dr. West stands, in our opinion, se- I cond only to Watson, the "Macaulay of Medicine;" ' he possesses that happy faculty of clothing instruc- tion in easy garments; combining pleasure with [ profit, he leads bis pupils, in spite of the ancient pro- verb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but It i* one that will please the great majority who are seeking trnth, and one that will convince the student that he has committed himself to a candid, safe, and valuable guide. AT. A. Meil.-Chirurg Review. We must now conclude this hastily written sketch with the confident assurance to oar readers that the work will well repay perusal. The conscientious, paiustaking. practical physician is apparent on every page. A'. 1". Journal of Mtdtcin*. We have to say of it, briefly and deeidedly, that it Is the best work on the subject In any language, and that it stamps Dr. West as the facile princept of British obstetric authors. Edinburgh. Jfed. Journal. We gladly recommend his lectures as in the highest degree instructive to all who are interested la ob- stetric practice. London. Lancnt. We know of no treatUe of the kind so complete, I and yet so compact. Chicago Jftd. Journal. Tin: KAMK AN EN<>EIKY INTO THE PATHOLOGICAL IMPORTANCE OF ULCERATION OF THK OS I'TKKI. In one neat octavo volume, extra cloth. $1 25. }TEIGS (CHAH/.KS />.), M. />.. LU. /,,,.<. .!-ff>r*:"\ WOMAN: HEi: JHSKASKS ANI> Til Kill K KM K I > I KS. A Series of Le-'tiire.j to his C!H.--.<. Fourth ami Itnjiroveil eY Till-: M My. ON THE NATURE, SIGNS, AND TREATMENT OE I'l VKR. In a Serie.< of Letters n }'.'. M./>. CLINH'AL LKCTTKES ON THE DISEASES OE W(MEN. With numerous illustrations. In one octavo volume of over 500 pages. Second edition, preparing. HENRY C. LEA'S PUBLICATIONS (Midwifery). jffODGE (HUGH L.), M.D., Emeritus Professor of Midwifery, &c. in the University of Pennsylvania, &c. THE PRINCIPLES AND PRACTICE OP OBSTETRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. (Lately published. ) The work of Dr. Hodge is something more than a simple presentation of his particular views in the de- partment of Obstetrics; it is something more than an ordinary treatise on midwifery ; it is, in fact, a cyclo- paedia of midwifery. He has aimed to embody in a single volume the whole science and art of Obstetrics. An elaborate text is combined with accurate and va- ried pictorial illustrations, so that no fact or principle is left unstated or unexplained. Am. Med. Times, Sept. 3, 1864. We should like to analyze the remainder of this excellent work, but already has this review extended beyond our limited space. We cannot conclude this notice without referring to the excellent finish of the work. In typography it is not to he excelled; the paper is superior to what is usually afforded by our American cousins, quite equal to the best of English books. The engravings and lithographs are most beautifully executed. The work recommends itself for its originality, and is in every way a most valu- able addition to those on the subject of obstetrics. Canada Med. Journal, Oct. 1864. It is very large, profusely and elegantly illustrated, and is fitted to take its place near the works of great obstetricians. Of the American works on the subject it is decidedly the best. Edinb. Med. Jour., Dec. '64. #** Specimens of the plates and letter-press on receipt of six cents in postage stamps. We have examined Professor Hodge's work with great satisfaction; every topic is elaborated most fully. The views of the author are comprehensive, and concisely stated. The rules of practice are judi- cious, and will enable the practitioner to meet every emergency of obstetric complication with confidence. Chicago Med. Journal, Aug. 18(34. More time than we have had at our disposal since we received the great work of Dr. Hodge is necessary to do it justice. It is undoubtedly by far the most original, complete, and carefully composed treatise on the principles and practice of Obstetrics which has ever been issued from the American press. Paciji* Med. and Surg. Journal, July, 1861. We have read Dr. Hodge's book with great plea- sure, and have much satisfaction in expressing our commendation of it as a whole. It is certainly highly instructive, and in the main, we believe, correct. "The great attention which the author has devoted to the mechanism of parturition, taken along with the con- clusions at which he has arrived, point, we think, conclusively to the fact that, in Britain at least, the doctrines of Naegele have been too blindly received. Glasgow Med. Journal, Oct. 1864. will be forwarded to any address, free by mail, BANNER (THOMAS H.), M. D., ON THE SIGNS AND DISEASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates and illustrations on wood. In one handsome octavo volume of about 500 pages, extra cloth, $4 25. (Just Issued.) The very thorough revision the work has undergone | state even, acceptable to the profession. We record - has added greatly to its practical value, and increased materially its efficiency as a guide to the student and to the young practitioner. Am. Journ. Med. Sci., April, 1S68. With the immense variety of subjects treated of and the ground which they are made to cover, the im- possibiliiy of giving an extended review of this truly single fault to find with it, and most heartily com- mend it to the careful study of every physician who would not only always be sure of his diagnosis of pregnancy, but always ready to treat all the nume- rous ailments that are, unfortunately for the civilized women of to-day, so commonly associated with the function. N. . Med. Record, March 16, 1868. our readers to the volume produced by Dr. Tanner, the second edition of a work that was, in its original mend obstetrical students, young and old, to have this volume in their collections. It contains not only a fair statement of the signs, symptoms, and diseases of pregnancy, but comprises in addition much inter- esting relative matter that is not to be found in any other work that we can name. Edinburgh Mtd. Journal, Jan. 1868. In its treatment of the signs and diseases of preg- nancy it is the most complete book we know of, abounding on every page with matter valuable to the general practitioner. Cincinnati Med. Repertory, March, 1868. This is a most excellent work, and should be on the table or in the library of every practitioner. Hum- boldt Med. Archives, Feb. 1868. A valuable compendium, enriched by his own la- bors, of all that is known on the signs and diseases of pregnancy. St. Louis Med. Reporter, Feb. lu, 1S6S. MONTGOMERY (w. p.), M.D., Professor of Midwifery in the King's and Queen's College of Physicians in Ireland. AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREG- NANCY. With some other Papers on Subjects connected with Midwifery. From the second and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts In one very handsome octavo volume of nearly 600 pages, extra cloth. $3 75. (HENRY], M.D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, &c.; including the Treatment of Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome octavo voluinfe of over 600 pages, extra cloth. $3 75. RIGBT'S SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American, edition. One volume octavo, extra cloth, 422 pages. $250. DEWEES'S COMPREHENSIVE SYSTEM OF MID- WIFERY. Twelfth edition, with the author's last improvements and corrections. In one octavo vol- ume, extra cloth, of 600 pages. $3 50. HENRY C. LEA'S PUBLICATIONS (Midwifery). 25 \CIIARLES D.), M.D., !.<>t. l,j r, -ttrio9, *c , in Out Jeferton, Medical OoUtyt, PhilatUlphia, OIISTKTKICS: Till: SCIKNCK AND T1IK A 11T. Fifth edition, revised. With one hundred and thirty illustrations. In one beautifully printed octavo volume of 760 large pages. F.xtra cloth, $5 50; leather, $6 60. (Just Itintti.) The original edition Is already so extensively and practitioner. The rapidity with whlcb the very large ... IKIWU to the profeiiMon that no recom- editions have been exhausted is the beet test of its endatlou i- nceary; it is sufficient to say, the true merit Besides, it is the prodnctlon of ao Ame- much extended, improved, rican wAo has probably had more experience in this Wlul-t the area i practical talents and I Tan eh than any other living practitioner of the coun- try. St. L<> nig Med. and Surg. Journal, Sept. 1867. He has also carefully endeavored to be minute and author render i: >u to the practitioner, it i- itute a most eligible and e\ -. lent. Southern Med. and Surg. Journal, .I'i!y, -indent that onr author has more par- .-,1 himself; hut to the practitioner tble as a book N > work that we have met with HO verything that falls to the lot of :r to perform. Every detail, no matter how ininme ,.r how trivial, him found a place. al Journal, July, 1867. This very excellent work on the science and art of obstetrics shonld be in the hands of every student and clear in his details, with as little reiteration a pomi- ble, and beautifully combines the relations of science to art, as far as the different classifications will admit. Detroit Review of Med. and Pharm., Ang. 1867. We now take leave of Dr. Melgs. There are many other and interesting points in bis book on which we would fain dwell, but are constrained to bring onr ob- ei vaiiou* to a clone. We again heartily express oar approbation of the labors of Dr. Meiga, extendingover many years, and culminating in the work before us, full of practical hints for the inexperienced, anil v.-u i'..r tho> whose experience has been considerable. Gflasguio Medical Journal, Sept. 1S67. DAMSBOTHAM (FRAXCIS If.), M.D. .1 1 Till: riUNCIPLES AND PRACTICE OF OBSTETRIC MEPI- l INK AND SURGERY, in reference to the Process of Parturition. A new and enlarged eiliti.'n. thoroughly revised by the autliiir. With additions by W. V. KEATING, M. D., Professor of Obstetrics, Ac., in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised b:inds; with sixty-tour beautiful plates, and numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. We will only add that the student will learn from To the physician's library it is indispensable, while it all he need to know, and the practitioner will find to the student, as a text-book, from which to extract it, ax a bonk of reference, surpassed by none other. the material for laying the foundation of an education >])?.. on obstetrical science, it baa no superior. Ohio Med. The character and merlin of Dr. Ramsbotham's i atld Sur ff- Journal. work .: .iown and thoroughly etahlUhed, When we call to mind the toil we underwent in - try and praise Mipertluous. acquiring a knowledge of this subject, we cannot bnt a-, which are numerous aud accurate, envy the student of the present day the aid which : in the highest style of art. We cannot this work will afford him. Am. Jour, of the Med. >d the work to our readers. tit. ti'-.lencet. j. Juu.riH.il. ftHURCHILL (Fl.KKTWnon), M. D., M.R.I. A. ON THE THE Fi: . K, M. D , author ot u l'r:ictii al Treatise on the Diseases of Chil- dren." Ac. With on* bandied and ninety-four illii.'trntions. In mie very handsome octavo volume of nearly Tun large pages. Extra cloth, $4 00; leather, $5 00. In adapting thi standard Iiivorite to the friints ol'the profession in the United States, the editor >ed t,, insert .MTythin^ that his f.xiierience IIIIH shown him wmild !.* desirable for the Ani'iii-an -;u i. -ni. including a lar^e niiiul.er <>l illu-i i at mns. With the sanction of the author. he ban nd.led, in the fnnu ot an ii|i|wiidix, some .'lupters from a little " .Manual for Midwives and .1 ly I"r. Cliun-liill, believing that the details there jire^enti-d can hardly tail to prove : advantage to the junior practitioner. The result of all tin se additions is that the work now contains fully one-half more matter than the last American edition, with nearly one- half in-. re illu-trations; so tlmt, notwithstanding the use of a smaller type, the volume contains mn."-t two hundred pages more than before. !-r the work Mill i tide tlmu ever ; and with lirh th- ' t'lmrrhill, we cn coniniund !! K profension with great cordiality and p Few work* on this branch of medical uriencn ar" eijMal t.. it. certainly none ixcel it, wh'-t!ier K. : . and in one re*|>eet it i> .uperior to all oilier-, vu.. In its statiMtical iiifornmtion, and jectsin all ti. even mure neoMM were cither of the ( .V. 1 1 . dded which could be well dispensed with. lullou of the tulile of > ws how y :!o> aim ,ud, and vxt to prexent the sub- v -..rk for . gathered from every source. it, ,.r lecturer, all of whom will Bud in it the information which they are seeking. Brit. AM. Journal. render I ill than of their . ilh which we v with this, in iterial which '< i Mxt. an/: .v JOHN *-' I',-'>ff.ar of Surgery In University College, TIIK SCIENCE AND ART OF SURGERY; l-in- a Treatise on Sur- Injuries. Disease?, and Operations. New and imjiroved American, from the Second enlarged and carefully revised London edition. Illustrated with over four hundred wood engravings. In one large and handsome octavo volume of 1000 closely printed pages; extra cloth, $6 ; leather, raised bands, $7. We *re bound to state, and we do BO without with- one of the very best, If not the best text-book of Iraw invidion* compari-on*. that Hie work of surgery with which we were acquainted, permits ns Mr. F.rrt, -[], in : -. sarpaRnes any that t<> give it but a passing notice totally unworthy of itt ha preceded it. Mr Krirhwn's is a practical work, merits. It may be confidently asserted, that DO work u< a doe proportion of the "Science and An on the science and art of surgery has erer received II ivii..- .It-rived no little instruction more uniTersal commendation or occupied a higher from it, iu many important branches of surgery, we position as a general text-book on surgery, than this can have no heMtation in recommending it a a valu- treatUeof Professor Krichsen. Savannah Journal of able book alike to the practitioner and the student. M> ewiuently d.dacUc, and eaaractafind '>' H in..-i admirable directness, The limited time we have to review this improved clearness, and compactness. Ohio Med. and Surg. fa work, the first issue of which we prized Jnurnal. nr THE SAME ACTIf>K. (Rtndy in June.) OX RAILWAY. ANI> OTHER INJURIES OF THE NERVOUS SYSTEM. In small octavo volume. Extra cloth, $1 00. Ic'ime thin a perha|>* thi^ ni"-t practically ueu for many a day. Medical . It will serve a a most useful and trustworthy guide to the profession In general, many of whom may be consulted in such cases; and it will, no doubt, take its place as a text-book on the subject of which it treat*. Medical Prett. M Il.LKR (JAMI' fsif> /Y"/Wv"r -!' Sirrgenj in the. University of Edinburgh, Ac. PRINCIPLES OF SURGERY. Fourth American, from the third and rr\ !-n. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth. $3 75. J]Y THE SAME AUTHOR. TIIK PRATTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the Americtin editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra cloth. $3 75. . tluit ttv volumes have ever mailf M.I I ri|iiir>-il. The author is an eminently sensible, prac- profound n impf -.hort a time a* tlie | tical, and well-Informed nmn, who knuwx exactly nn. I the " I'ruclire" of Snrt'i-ry l>y Mr. n K:ir | l( . IM talking about and exactly how to talk it. r no richly merited the reputation they have | A'"i/-/-Ay Medical Recorder. PI l!ll IK f \\'ILU.\ Vi. F. R.S. PI.. f .t TIIK rillNCHM.KS AND PRACTICE <>F STIICKRY. K.I it IM! by .J.Mix NKII.I., M. I'., Pruff-r-or nf Surpery in th- Penna. Medical College, Surgeon to the IVnn-yKaiiia lf>c|>ital, Ac. In one very handdouie octavo volume of TbO pages, with 31tt illu.xtrationo, extra cloth. $'' ~'t. G w.}. M.D. ON BANDAGING ANDOTHKR OPERATIONS OF MINOR SUR- :i|'tlf m-trnrt- M.my points which he may have forgotten. Brit. Am. Journal, May. Isvttli. U K IIV. New edition, with an a 1'Jtiio. volume, of nearly 400 page;, with Exceedingly convenient and valuable In all H..-MI- lofession. Oiicayi .!//. The very best manual of Minor Surgery we have IH'II. Ltuffulo Medicul Journal. MALOAIGXE'8 OPERATIVE 8UROKRT. With nn- I SK ; r.RT. In > Terr hand- nieron* lllii"ir.tion on W..IH!. ID one handme som octavo volume, extra cloth, of over 650 pig**, octavo volume, extra cloth, of nearly 600pp. *2 30. | with about 100 wood-cats. $3 iS. HENRY C. LEA'S PUBLICATIONS (Surgery). TJRUITT (ROBERT), M.R.C.S., frc. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illus- trated with four hundred and thirty -two wood-engravings. In one very handsome octavo volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00; leather, $5 00. Besides the careful revision of the author, this work has had the advantage of very thorough editing on the part of a competent surgeon to adapt it more completely to the wants of the Ameri- can student and practitioner. Many illustrations have been introduced, and every care has been taken to render the mechanical execution unexceptionable. At the very low price affixed, it will therefore be found one of the most attractive and useful volumes accessible to the American practitioner. All that the surgical student or practitioner could desire. Dublin Quarterly Journal. It is a most admirable book. We do not know when we have examined one with more pleasure. Boston lied, and Surg. Journal. In Mr. Druitt's book, though containing only some seven hundred pages, both the principles and the practice of surgery are treated, and so clearly and perspicuously, as to elucidate every important topic. The fact that twelve editions have already been called for, in these days of active competition, would of itself show it to possess marked superiority. We have examined the book most thoroughly, and can say that this success is well merited. His book, moreover, possesses the inestimable advantages of having the subjects perfectly well arranged and clas- sified, and of being written in a style at once clear and succinct. Am. Journal of Med. Sciences. Whether we view Druitt's Surgery as a guide to operative procedures, or as representing the latest theoretical surgical opinions, no work that we are at present acquainted with can at all compare \rith it. It is a compendium of surgical theory (if we may use the word) and practice in itself, and well deserve* the estimate placed upon it. Brit. Am. Journal. Thus enlarged and improved, it will continue to rank among onr best text-books on elementary sur- gery. Columbus Rev. of Med. and Surg. We must close this brief notice of an admirable work by recommending it to the earnest attention of every medical student. Charleston Medical Journal and Review. A text-book which the general voice of the profes- sion in both England and America has commended at- one of the most admirable "manuals," or, "vade mecum," as its English title runs, which can be placed in the hands of the student. The merits of Druitt's Surgery are too well known to every one to need any further eulogium from us. Nashville Med. 'Journal. TJAMILTON (FRANK H.), M.D., Professor of Fractures and Dislocations, &c. in Bellevue Hasp. 3fed. College, AVtc York. A PRACTICAL TREATISE OX FRACTURES AND DISLOCA- TIONS. Third edition, thoroughly revised. In one large and handsome octavo volume of 777 pages, with 294 illustrations, extra cloth, $5 75. (Jutt Issued.) The demand which has so speedily exhausted two large editions of this work shows that the author has succeeded in supplying a want, felt by the profession at large, of an exhaustive treatise on a frequent and troublesome class of accidents. The unanimous voice of the profession, abroad as well as at home, has pronounced it the most complete work to which the surgeon can refer for information respecting all details of the subject. In the preparation of this new edition, the author has sedulously endeavored to render it worthy a continuance of the favor which has been accorded to it, and the experience of the recent war has afforded a large amount of material which he has sought to turn to the best practical account. In fulness of detail, simplicity of arrangement, and accuracy of description, this work stands unrivalled. So far as we know, no other work on the subject in the English language can be compared with it. While congratulating our trans-Atlantic brethren on the European reputation which Dr. Hamilton, along with many other American surgeons, has attained, we also may be proud that, in the mother tongue, a classical work has been produced which need not fear compa- rison with the standard treatises of any other nation. Edinburgh Med. Journal, Dec. 1866. The credit of giving to the profession the only com plete practical treatise on fractures and dislocations in our language during the present ceiitury, belongs to the author of the work before us, a distinguished American professor of surgery; and his book adds one more to the list of excellent practical works which have emanated from his country, notices of which have appeared from time to time in our columns du- ring the last few months. London Lancet, Dec. 15, 1866. These additions make the work much more valua- ble, and it must be accepted as the most complete monograph on the subject, certainly in our own, if not even in any other language. American Journal Med. Sciences, Jan. 1867. This is the most complete \reatise on the subject in the English language. Ranking' s Abstract, Jan. 1867. I A mirror of all that is valuable in modern surgery. 1 Richmond Med. Journal, Nov. 1866. BRODIE'S CLINItAL LECTURES ON SURGERY. 1 vol. 8vo., 350 pp.; cloth, $1 25. HARWELL'S TREATISE ON DISEASES OF THE JOINTS. With illustrations. 1 vol. 8vo., of about 500 pages ; extra cloth, $3 00. COOPER'S LECTURES ON THE PRINCIPLES AND PBACTICB OF SURUERY. In one very large octavo volume, extra cloth, of 700 pages. $2 00. fiIBSON'8 INSTITUTES AND PRACTICE OF SUR- OBRT. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo vol- umes, about 1000 pages, leather, raised bands. $6 50 JONES' PRINCIPLES AND PRACTICE OF OPH- THALMIC MEDICINE AND SURGERY. With one hundred and seventeen illustrations. Third and revised American, with Additions from the second London edition In one handsome octavo 'volume of 455 pages, extra cloth. $3 25. MACKENZIE'S PRACTICAL TREATISE ON DIS- EASES AND INJURIES OF THE EYE. From the fourth revised and enlarged London edition. With Notes and Additions by ADDING M* HEWSOJC, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume of 1027 pages, extra cloth, with plate* and numerous wood-cuts. *<5 50. HK.NRY C. LEA'S PUBLICATIONS (Surgery). 29 rrOYNDEE (JOSEPH), F.R.S., * Aiirnl Surgeon to and Lecturer on Surgery at St. Jfary't Hospital. TIIK WSBA8E8 <>F THK K.\K: tlu-ir .Vumv, IMuirnosis, and Treat- ment. With one hundred engravings on wood. Second American edition. In one very handsomely printed o-ta\o \...ume of 4.40 pages; extra cloth, $4. The appearance of a volume ofMr. Toynbee'ii, there- fore, in which tin- -ul'ject of aural disease i- to the moHt -cientitlc manner, and oar knowledge in to it placed fully on a par with that which The work, a* WHS stated at the outset o'oar notice, Is a model of its kind, and every page and paragraph of it are worthy of the most thorough study. Con- sidered all in all as an original work, well written, Wt . p, ,,.,.,., ,. . -t o(hr organs of the body, philoophlcally elaborated, Mrf i.i. v U a matter for sincere congralui > and drawing!- it I* by far the abt*t mo- onably hope that henceforth ti _-r.ij,h that ha ever appeared on the anatomy and Use will cease to be uni.nu- the upprobria of medical diseases of the ear, and one of the most valuable con- science. London Medical Review. tributioos to the art and science of Burgeiy in the I nineteenth century. >'. Am. Med.-CHirurg. Review. T A r/.'A'.Vf '/; .;./'>//.y 7..\ /'. /.'. C. S., and MOON (ROBERT C.), J Review, Ac. "* 11 a '> ', Sur %*? toeSouthvark Op*- tliiiiniK- l/'Utptiril, Ac. A IIANDV-IJOOK OF OPHTHALMIC SURGERY, for the use of itioners. *With numerous illustrations. In one very handsome octavo volume, extra cloth. $2 50. (Just Issued.) No book ." -nrgery was more n ! I Not only, as Its modest title suggests, a "Handy- i- Book" ot ' Opliihalmic Surgery, but an excellent and It epito- well-digexled retttant of all that is of practical value ioural to t)if eye in a cle;ir n. y. Seio 1'urk Medical Journal, No- . enabling the practi- vmber, IWJti. . ance of proper ; Thts o hj pct the authors have accomplished in a " * 1 :' highly satisfactory manner, and we know no work '." w.- run more highly recommend to the "buy practi- '- (i ' ; tioner" who wi.hw to make himself acquainted with We < 1 this book to the notice of the r.-c.-nt improvements in ophthalmic science. Such our i < an excellent outline of a work as this- w ninth wanted at this time, and in.. .le: i. ophthalmic aorgerj. British Jfed. Journal, this want Messrs. Laurence and Moon have now well i supplied. Am. Journal Med. Science*, Jan. 1867. T A WSOX (GEORGE], F. R. C. &, 1 J J n t'i tli>- K'lyil Ismdon Ophtludwic Hospital, Xoorjtelds, Ac. IN.ITKIKS (>K THK KVK. OIIIJIT, AND KVKI.IDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In one very hand- some octavo volume, extra cloth, $3 50. (.\uu- llnl y.) This work will be found eminently fitted for the general practitioner. In cases of functional ir structural di<*as>es of the eye. the physician who has not made ophthalmic surgery a special tudy can, in tii'..*t instances, refer a patient to some competent practitioner. Cases of injury, however, supervene suddenly and usually require prompt assistance, and a work devoted espe- cially to them cannot but prove essentially u.-eful to those who may at any moment be calleff upon to treat such accident?. The present volume, as the work of a gentleman of large experience, may be considered as eminently worthy of confidence for reference in all such emergencies. It it an admirable practical book in the highest and fulne-s O f practical knowledge. We predict for Mr. best sense of the phrase, ('..piously illustrated by I.aw.son's work a great and well-merited success. nt wm>dcui, and with well-selected, well- We are confident that the profession, and especially, described canes, it is written in plain, simple Ian- ' as we have said, our country brethren, will feel guage, and in a style the transparent clearness and grateful t him fur having given them in It a guide iraukness, no tu spiMk, .if which, add greatly to its xnd cuiin^ellur fully up to the most advanced state of value and usefulness-. Ouly a master ui his subject ophthalmic Surgery, and of whom they ran make a -.write; every topic is handled with .-lyand lam - London Medical ~ .. and xtraightfurwardi, ..w the ami Uiiictte, May 18, 18<>7. skilful and highly educated surgeon writiug from / Clinical Surgery to Univertity Collrgt Hospital. LBCTtlKES ON i>isK.\si;s oi- TIIK i KI.NAKY o in JANS. With illustrations on wood. In one neat octavo volume. (Preparing for earl BORLAND (W. W.), M.D. DISKASKS OF THK URINAHV OIKJANS; a Comiu-ndium of thrir Diagnosis, Pathology, and Treatment. With illustrations. In one large and handsome octavo volume of about t>UO pages, extra cloth. $3 50. Taken as a whole, w.- cn reconiumnd Dr. Morlaud'n I of every medical or surgical practitioner. Brit, and compendium as a very deirable addition lo the library | >l/r Med.-Uhir. Rmtu>, April, 1M9. fji:i;u\f; (T. /?.), F.I: Surgam to thr Is>nN HISKASKS OK THK TKSTIS, SI'KKMATIC CORD, AND SCROTUM. Second American, from the second and enlarged tab, edition. In one handsome octavo volume, extra cloth, with numerous illustra- tions, pp. 420. $2 00 i 30 HENRY C. LEA'S PUBLICATIONS (Surgery). WALES (PHILIP S.), M. D., Surgeon U. S. N. MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations : embracing Minor Surgery, Band- aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred and fortv-two illustrations on wood. In one large and handsome octavo volume of about 700 pages: extra cloth, $5 75; leather, $6 75. (Just Issued.) A Naval Medical Board directed to examine and report upon the merits of this volume, officially states that " it should in our opinion become a standard work in the hands of every naval sur- geon;" and its adoption for use in both the Army and Navy of the United States is sufficient guarantee of its adaptation to the needs of every-day practice. The title of this book will give a reasonably good It is the completestbook on these subjects we know idea of Us scope, but its merits can only be appreci- of, and it cannot fail to be exceedingly useful to the ated by a careful perusal of its text. No" one who un- busy practitioner, especially to the busy country phy- dertakes such a task will have any reason to com- . sician who has thrown upon his care something of plain that the author has not performed his duty, and surgery in its various details, with all manner of gene- has not taken every pains to present every subject in ral practice, and, therefore, may often wish to refresh a clear, common-sense, and practical light. It is a himself as to the most convenient and elegant modes unique specimen of literature in its way, in that, : of dressings and manipulations. Cincinnati Lancet treating upou such a variety of subjects, it is as a and Observer, Jan. 1863. . whole so completely up to the wants of the student j We nave examined Dr. Wales' book with much and the general practitioner. We have never seen care> and believe that his labor will greatly benefit any work of its kind that can compete with it in real tne practitioner of surgery. It seems to us especially utility and extensive adaptability. Dr. Wales per- beneficial to the country medical practitioner who is fectly understands what may naturally be required surge on, physician, and obstetrician, as occasion re- of him in the premises, and in the work before us has q u i res . \v e commend the work to our readers as a bridged over a very wide gap which has always here- most use f u i one.Xashville Med. and Surg. Journal, tofore existed between the first rudiments of surgery j an jggg. and practical surgery proper. He has emphatically given us a comprehensive work for the beginner ; and ,. The title of the above work is sufficiently indica- when we sav of his labors, that in their particular tive of its contents We have not seen for a long sphere they leave nothing to be desired, we assert a lme < m the En g llsl1 language) a treatise equal to thu great deal to recommend the book to the attention of * extent nor one which is better adapted to the those specially concerned. In conclusion, we would wants . f the general student and practitioner. ers who, without any special pretensions to surgery, are occasionally liable to treat surgical cases. 2f. Y. Med. Record, March 2, 1S68. It is certainly the most complete and thorough work of its kind in the English language. Students and young practitioners of surgery will find it invaluable. It will prove especially useful to inexperienced coun- try practitioners, who are continually required to take charge of surgical cases, under circumstances precluding them from the aid of experienced surgeons. Pacific Med. and Surg. Journal, Feb. 1868. This is a most complete and elegant work of 673 pages, and is certainly well deserving of the com- mendation of every American surgeon. This work, besides its usefulness as a reference for practitioners, is most admirably adapted as a text-book for sludents. Its 642 illustrations in wood-cuts, represent every man- ner of surgical appliance, together with a minute de- scription of each, the name of its inventor, and its prac- tical utility in mechanical surgery. There is, perhaps, no work in the English language so complete in the description and detail of surgical apparatus and ap- pliances as this one. The entire work entitles the au- thor to great credit for his clear and distinct style as a writer, as well as for his accuracy of observation and great research in the field of surgery. We ear- nestly recommend every member of the profession to add a copy of it to his library, with the assurance that he will find some useful suggestion in the treat- ment of almost every surgical case that may come under his observation. Humboldt Med. Archives, Feb. 1S68. porter, Feb. 1868. A useful book is always a necessary one, and that this book is eminently one of that character, needs but a glance at its pages to show. It certainly de- serves a place in the library of every physician. Leauenworth Med. Herald, Feb. 18(38. The book seems to be complete in every respect, and is a welcome addition to our shelves. Boston lied, and Surg. Journal, Jan. 9, 186$. In our opinion it is a good book, and one which every student and practitioner needs in his library. Especially would its value be appreciated by the sur- geon whose field of practice is anywise remote from the larger cities. Chicago Med. Journal, Jan. 1S68. This volume will be a useful acquisition to a large number of the working members of the medical pro- fession in this country. Practitioners will find mate- rial aid and encouragement in its pages which they could nowhere else obtain, to the same extent, in so convenient a form. Am. Journal Med. Sciences,. Jan. 1868. He must be a blockhead indeed who, after study- ing this portion of the book before us, tails to adapt himself to the emergeny of any case, for we find here described pretty much every contrivance ever devised, and we can hardly conceive of that combi- nation of circumstances which would deprive us of all these means of assistance, and the absence of on or more of the usual aids would only stimulate the ingenuity to devise some other plan of relief. Alt-Mi York Med. Journal, May, 1868. A SET ON (T. J.) OX THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, from the fourth and enlarged London edition. With handsome illustrations. In one very beautifully printed octavo volume OT about 300 pages. $3 25. (Jitft Issued.) The short period which has elapsed since the ap- pearance of the former American reprint, and the numerous editions published in England, are the best We can recommend this volume of Mr. Ashton's in the strongest terms, as containing all the latest details of the pathology an-d treatment of diseases connected with the rectum. Canada Med. Journ., March, 1S66. One of the most valuable special treatises that the phvsician and surgeon can have in his library. Chicago Medical Examiner, Jan. 1S66. arguments we can offer of the merits, and of the use- lessness of any commendation on our part of a book already so favorably known to our readers. Boston Med. and Surg. Journal, Jan. '26, 1866. HENRY C. LEA'S Pt HI.ICATIONS (Medical Jurisprudence, ndon edition. With Notes and References to American Decisions, by CLB- JIE.NT B. PKNROSB, of the Philadelphia Bar. In one large octavo volume of 776 pages, extra cloth. $4 50 ; leather, $5 60. (Just It rued.) Considerable additions have been made by the editor to this edition, comprising some important sections from the author's larger work, " The Principles and Practice of Medical Jurisprudence,'' as well as references to American law and practice. The notes of the former editor, Dr. Harts- borne, have likewise been retained, and the whole is presented as fully worthy to maintain the distinguished position which the work hag acquired as a leading text-book and authority on the wbjeet. A new edl aril authon ilion of a work acknowledged as a stand- ity everywhere within the range of the Knelish language Considering the new matter intro- -hiniasis and other subjects, aud the plates representing the crystals of poisons, etc., it may fairly be regarded as the most compact, comprehen- sive, and practical work on medical jurisprudence which ha- i u.'. l from the press, and the one beat r students. Pacific Med. and Surg. Journal, Feb. ltt>7. The ixth In charge of a n-'W delphia bar, wl elaborate treatises. New York Medical Record, Feb. U, 187. The present edition of this valuable manual Is a great improvement on those which have preceded It Some admirable instruction on the subject of evidence and the duties and ^ppon*ibtlitiea of medical wit- nesses has been added by the distinguished author, and some fifty cuts, illustrating chiefly the crystalline forms and microscopic structure of substances used as poisons, inserted. The American editor baa also pnlar work comes to ns lntr e auc 8 t v nt ! chapters from Dr. Taylor's larger Mr Peurose of the Phila- wor k. "The Principles and Practice of Medical Jurig- much to render it useful, j prudence," relating to trichiniaals, sexual malforma- not only t., ,,ers of this country, | tion insanity as affecting civil responsibility, suicidal n. Wisely retaining ". and life Insurance Ac , which add considerably American editor. Dr. to its value. Beside* this be has introduced nnnie- .................... -..., .... has added many valuable notes of his rou references to cases which have occurred in this mmkM ****& far , the be , lit ttide - bwlt rtment of medicine for students and the ,* a a os : Ion of Dr. Taylor's work Is so well ? oun ' ry ; U mmkM **** far the belit ttide - bwlt ished. that it needs no recommendation. He is ln this depa own. n?i the blgheit iivTnVa"thorrty"on7li"marters"con- general practitioner In our language. Button Mtd. nected with forensic medicine, and every successive i and Sur lf- Journal, Dec. 27, 18W. edition of bis valuable work gives fresh assurance to Taylor's Medical Jurisprudence has been the text- hi many admirers that he will continue to maintain book in our colleges for years, and the present edi- bls well-earned position. No one should, in fact, be tlon, with the valuable additions made by the Ameri- without a t.-x'-t. ...k on the subject, as be does not | can editor, render it the most standard work of the day, on the peculiar province of medicine on which U treats. The American editor, Dr. Harts home, baa done his duty to the text, and, upon the whole, we and thoroughly practical work upon the subject, we cannot but consider this volume the best and richest w iuld :irn..- i 'y i . "iiinifiul this, as forming the best treatise on medical jurisprudence in our language. groundwork for all their future studies of the more i Brit. Am. Med. Journal. emergency for its ne. To those who are not the for- tunate possessor* of a reliable, readable, Interesting, ir (FORBES), 11. D., D. C.L., Ifc. ON OBSCURi: DISEASES OF THE BRAIN AND DISORDERS OF TMK MINI*: their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo volume of nearly 600' pages, extra cloth. $4 25. (Just Issued.) Of the merits of Dr. Winalow's treatise the profes- : our conviction that it is long since so Important and si. m has sufficiently judged. It has taken Its place in beautifully written a volume ban issued from the the front rank of the works npon the special depart- British medical press. The details of the manage- neut of practical medicine to which it pertains. ment of confirmed cases of insanity more nearly In- Cincinnati Journal of Medicine, March, 1866. It Is an interesting volume that will amply repay for a careful perusal by all intelligent reader*. inr.iy,, M'-t Ks'inti:irr Feb. 1886. A work which, like the present, will largely aid in r the first unl in-iitiil disease, is practical value, and demands earnest liligent *' ; .nt of all who 1 the medical profession, and have iu which the ippinesn <> . .- and famili.'* Iv.'il. Wu shall therefore i arily very imperfect not.' it and classical work by expressing u ad vi attention and I IV" "III I' I .'.' t,..r-i w- 1 fit re and I r" largely in bri-f .. Wmslow's gr terest those who have made mental diseases therr special study; but Dr. Winslow's masterly exposi- tion of the early symptoms, and his graphic descrip tlons of the insidious advances of incipient insanity, together with his judicious observations on the treat- ment of disorders of the mind, should, we repeat, be carefully studied by all who have undertaken the responsibilities of medical practice. Dublin Medical /')'. -V It is the moat interesting as well as valuable book that we have seen for a long time. It is truly fasci- nating. Am. Jmir. Mtd. Science*. l>r Winslow's work will nn.i . npr an unique position In the m.-.! tnre of this country. London Me il lil.-ia- J KA (RENRY C.) ^SUPERSTITION AM) roRCK: ESSAYS Ot TIfH WACK11 OF LAW, THK WAOER OF I'.ATII.K. TI1K i>l;l>KA I,. AND TORTURE. In one hand- some volume royal 12mo., of 406 pages; extra cloth, $2 5t*. Ttieropiotis r.'llr. , y wiiu-li Mr. !. h.- a humor so fine and good, that he makes us regret it HluMr ! -hows in the fullest mauucr lli.' wa- not within hi* intent, as it wa reitainly within it ronlticl and varying success, the advance* his power, to render the whole of h:- thorough work **i J defeats, by which the progress of humane Icginla- more popular in manner. Atlantic Mm, lion i has been and i, still marked. This work fills up | T 1J* i* a book of extraordinary research. Mr !.. with the fullest exemplification and detail the w.- ; ..,, |||s ,,,,,, ,.-,,, . and . ramarks which we have ,,,,,,1-d above. Aa a book of , lrikin , r ,,,.,, rd ,, f ,,, e rn , Hl MII ,.. r , mi . ins of our OB . ^Jr : lf h hl ne " 1 happy Middle Age. could ,,.,t poil,ly have been com- "" - p.,-V . . . A* a wurk of mrtOM iii ,.,u.r.v a When half in spite of himself, as It appears he i outlying point* of obsolete law, , and klch>'s a ir.'iic or character in the history of U-gali/- i one of the most remarkable books we4iv rrr and cruelty, he betrays so artlsllta feeling, and ! met with. London Athn Reese on Blood and Urine 18 Rigby on Female Diseases 22 Rigby's Midwifery 24 Rokitansky's Pathological Anatomy . . .14 Royle's Materia Medica and Therapeutics . . 13 Salter on Asthma . . 18 Sargent's Minor Surgery .... Sharpey and Quain's Anatomy, by Leidy . Simon's General Pathology .... Simpson on Females ..... Skey's Operative Surgery .... Slade on Diphtheria Smith (J. L.) on Children .... Smith (H. H.) and Horner's Anatomical Atlas Smith (Edward) on Consumption . Solly on Anatomy and Diseases of the Brain Still's Therapeutics Tanner's Manual of Clinical Medicine . Tanner on Pregnancy Taylor's Medical Jurisprudence . Thomas ou Diseases of Females . Thompson on Urinary Organs Todd and Bowman's Physiological Anatomy Todd on Acute Diseases Toynbee on the Ear Wales on Surgical Operations . . . WalsUe on the Heart Watson's Practice of Physic .... West on Diseases of Females West on Diseases of Children West on Ulceration of Os Uteri . . . What to Observe in Medical Cases Williams's Principles of Medicine Wilson's Human Anatomy . Wilson's Dissector Wilson on Diseases of the Skin . . . Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine Wilson on Healthy Skin .... Wilson on Sperrnatorrhosa .... Winslow on Brain and Mind 27 27 IS 21 t> 13 18 12 5 24 31 22 29 9 18 29 30 18 16 23 21 23 16 14 7 20 20 20 20 19 31 "55 DATE DUE PRINTED IN U S UC SOUTKHH REGOML UBRAB A 000 511 648 8 ons... WI 11*5 1868 Chambers, Thomas King. Indigestions.. WI 11*5 CU5i 1868 MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664