HX64132196 RC826 .B67 Dvspeosia RECAP ^c&ab 3!^ Columbia (initier^itp CoQese of ^f)^siimnsi anb burgeons: Hibrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/dyspepsiaOObowe DYSPEPSIA. BY SERANUS BOWEN, M. D., Harv. FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY, ETC., ETC. " There is no case of dyspepsia, unless it be accompanied by some necessarily fatal disease, but what can be perfectly and permanently cured.'''' LORING, PUBLISHER, Corner Bromfield and Washington Streets, BOSTON. Copyright, 1877, By SERANUS BOWEN- THE RIVERSIDE PRESS, CAMBRIDGE: PRINTED BY H, O. HOUGHTON AND COMPANY. I HAVE been led by the suggestions made to me by a number of my dyspeptic patients, to print the accompanying pages, in the hope that a more rational view of this disease may be aided thereby. Any one who reads this with the expectation of finding some universal panacea recommended for the cure of every case, will be disappointed. My aim has been to point out as clearly and concisely as I can what dyspepsia is, why it is such a complicated disease, and what the rational indications are for its treatment. I do not claim originality for all my views, but that they are the conclusions that any reasonable physician will come to, who makes a special study of dyspepsia. no East Thirtieth Street, New York, March, 1877. DYSPEPSIA. \^7'HILE Dyspepsia is, strictly speaking, a symptom of disease, rather than a disease, yet we find it convenient, in writing of the great variety of forms in which it is made manifest that digestion is being carried on slowly, imperfectly, or painfully, to class them all under this general head, for the symptom of this lack of nutrition that is most commonly present is dyspepsia^ — painful digestion. It is a fatal error to take it for granted that all forms of dyspepsia are the result of one and the same pathological condition. For that which is good treatment in one case, or series of cases, is infinitely worse than no treatment at all, in an- other. Digestion has been aptly defined as " the proc- ess by which food is reduced to a form in which it can be absorbed by the intestines, and taken up by the blood-vessels." Until this process is com- pleted, the necessary supply of that of which the 6 D YSPEPSIA. body is built up, cannot be used for its nutri- tion. It is not to be wondered at that a defect in any part of the alimentary canal may cause dyspepsia, for unless the required amount of the constituents of the body is properly assimilated, there is some- thing withheld, which will in time surely lead to disease. Disease should not be thought of as something added to life, but as something taken from it. It is not, as was formerly taught, something to be attacked and driven out of the body ; but it is a state in which something has already been taken from the body, and which it should be the aim of the physician to restore, namely, — health. Perfect health is that state of the body in which all its functions are performed, perfectly and pain- lessly. When one varies from that condition, he is just so far diseased. There is no single function on which all the others are so dependent, as that of the proper assimilation of the nutriment, which goes to build up the various parts of the body. Dyspepsia, the most common of all the diseases that afflict civilized man, is unfortunately apt to be looked upon, both by the physician and the patient, as being not worthy of much attention in its earlier stages ; neglected then, the disease DYSPEPSIA. 7 becomes fixed — life is one of misery, — and the patient is apt to seek relief, not from professional hands, but from the thousand and one nostrums advertised. The only rational treatment for dyspepsia is that which endeavors by care and skill to restore the digestive organs to such a condition, that the processes which they are called upon to perform, instead of being painful, shall bring a sense of comfort. There is no case of dyspepsia, unless it be ac- companied by some necessarily fatal disease, but what can be perfectly and permanently cured by careful and judicious treatment. The popular idea both with the public and a large number of the medical profession, that this can be brought about by simply starving the patient, is an erroneous one. One of the best writers on this subject says : " I do not think that we profit much from those off-hand advisers who suppose they accomplish everything by forbid- ding the use of the sort of food that produces the symptoms. On the contrary, as I have shown by examples which every one may cap, out of his own patients, if he will turn them over in his mind, an actual state of disease may arise from persistence in the remedy. " A partial repose for a time, and abstinence 8 D YSPEPSIA. 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 that 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 rest which is needed, may be gained often by a change in the mode of prepar- ing the articles which cause most inconvenience, often by the substitution of something else, not so agreeable, perhaps, or so common, but which will be more easily assimilated. In the physiological cure of diseases it is al- most impossible to exaggerate the importance of the digestive viscera. In every acute case, sur- gical or medical, the modification of the result produced by the efforts of the physician, rests almost entirely on how far, how wisely, or how foolishly, these organs are watched over ; whether they are well or ill-treated, either by the scientific guidance of the skilled physiologist, or by the em- pirical rules of the routine practitioner ; according to the traditions of the nurse, or the instinct of the patient. Each of these may be in its way a useful guide ; but the first is at least the most capable of improvement by labor. As regards chronic diseases, also, science ena- DYSPEPSIA. 9 bles us to trace them, by steps more or less dis- tinct, — many of them not manifested in the or- gans themselves, but affecting the whole body, to an abnormal state of the digestive viscera. It needs but to name gout, tubercle, anaemia, and some of the forms of Bright's disease, to engage our closest attention to their causes. The fact is, that indigestion, intervening be- tween the blood and the new matter with which it seeks to renew itself, perverts incipient life at its very source, and thus perverts all its future manifestations. It produces a great variety of morbid phenomena, as immediate or remote con- sequences, and affects more or less all the func- tions of the body. Whatever value may attach to the evidence of the dependence of disease on the digestive or- gans, it is very clear that we look to them for relief from disease. Out of the six or seven hundred forms of med- icines in habitual use, very i^-^ indeed are not occasionally offered to the stomach for accept- ance, and an overwhelming majority of them can only be used in this way. The great advantage of paying special attention to the digestive or- gans is that, as a rule, they are the most directly curable, and that by their means, distant parts, otherwise out of our control, may be favorably influenced. lO DYSPEPSIA. Watch a case of typhoid fever, and see what immediate improvement follows the shedding of the dead epithelium, with which the mucous membranes have been coated, a change which is announced 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 nerv- ous system begins again to renew its life, and delirium ceases, as new nervous matter fit for duty is generated. We must remember that it is of no use to em- ploy the best possible means of staying the mor- bid symptoms, unless the absorbents assimilate a sufficient quantity of new 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 the assimi- lation of food. And to insure the assimilation of food the stomach and its colleagues must be in working order. But 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 DYSPEPSIA. II to set down what is so common as inevitable. They neglect indigestion as unimportant, forget- ful that though its removal may not always lengthen lives, yet that it would at all events treble their value both to individuals and to so- ciety. The digestive tract all the more imperatively demands attention, because it has not the advan- tage enjoyed by the respiratory and by the upper part of the urinary apparatus, and other parts, of being double. Man has two lungs, two kidneys two hemispheres to the brain, two sides to his body generally; but only one stomach, and one intestinal canal. A reason for great caution in preserving their integrity, — 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 nei- ther 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 pro- duced ! 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 any one of its parts has not only over the whole tract, but over the whole body and 12 DYSPEPSIA. 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 impor- tance on the treatment. It is extremely difficult to obtain that rest which is so essential in the management of disease. If you have pneumonia you may give a holiday to the smitten lung and recover with the other; but if you have an equally acute inflammation of the oesophagus or stomach, the danger is great, because they are necessarily in constant use. In indigestion the cause of the trouble may be with any one of a great number of organs, and the particular organ which is at first diseased may be the subject of several diseases; but the common link which connects them all is a partial defect in the necessary supply of that of which the body is built up. This explains why deranged diges- tion affects more or less all the functions of the body. In the management of deranged digestion, whether existing alone or as a complication of other complaints, it is important to know what oreans are desfenerated, and to some extent the treatment must be modified by such knowledge. Even in many incurable diseases, life is much prolonged, made happier and more easy, by care- DYSPEPSIA. 13 ful and judicious attention to the digestive ap- paratus. In all diseases, but especially in those of a chronic character, the most important function for us to pay attention to is digestion. The effect of climate, for instance, in pulmonary consumption, is proportioned with extreme accuracy to the de- gree in which the absorption of food is improved or injured by it Take, for example, anaemia, a disease which is characterized by every sign of debility; the es- sential character of the blood in this disease is a diminution in the ratio of red corpuscles. If, as generally happens, iron improves the condition of the alimentary canal, so that the stools, from being scanty, and mucous, consisting mainly of wind and half digested food, become natural and regular, then the body is renewed by fresh nutri- ment, and the strength is rapidly reinstated ; but if it irritates the mucous membrane, so as to make the evacuations irregular, black, and slimy, the patient remains as anaemic as ever. Hence the importance of suiting to the case in hand the particular form in which the remedy shall be pre- sented. If ready solubility, and presentation to the absorbing surface, in such shape as to get an entrance of a large quantity quickly into the sys- tem, were the only thing to be considered, the 14 DYSPEPSIA. question as to which is the best preparation might be left to the chemist. Some preparations, both soluble and insoluble, are more or less astrin- gent, and have various qualities acting on various parts of the alimentary canal, which render them appropriate or not to individual cases. So that not the most elegant, not the most praised as in- genious by the druggist, is the oftenest selected by the judicious physician, to whom the cure of the patient, not the harmony of the prescription, is the object in view. And it is not only the general health that is benefited by attending to the functions of the stomach, but even organs as far as possible re- moved from the stomach, physiologically speak- ing. A patient who has an enlarged prostate gland, when digesting well, finds that his urine is quite transparent, and free from mucus, even when microscopically examined ; but if the stomach is disturbed by any imprudence or accidental ill- ness, there is a copious formation of pus in the bladder. My object, thus far, has been to lead you to rate aright the importance of the proper management of the digestive organs in disease. I mean dis- ease generally, and not that which specifically afiects these organs alone. I shall now endeavor as concisely as possible to DYSPEPSIA. 15 give a sketch of some of the principal modes in which the function of digestion is deranged, and to point out what rational indications for treat- ment they afford. The morbid phenomena accompanying these errors of the digestive function may be divided according as they occur during the first stage, — that is before the ahmentary mass has passed out of the stomach; in the second stage, — that is during its passage along the small intestines ; or in the third stage, — after the passage of the ileo- Ccecal valve, which divides the small from the large intestines. In the first stage, we may notice as common phenomena those generally known by the follow- ing names : Heartburn, Acidity, Weight, Tight- ness or Distention, Oppression, Wearing or Boring Pain, Cramp or Spasms, Eructation, Vomiting. Heartburn is a sense of heat at the cardiac orifice of the stomach ; that is, where the oesoph- agus (or gullet) enters the stomach. This may arise in three ways : — First. By over-sensitiveness of the nerves ; Second. By too long exposure to the acids of digestion ; Third. By too much acid being formed. That which arises from over-sensitiveness of the nerves, is frequently, though not always, ac- 1 6 DYSPEPSIA. companied by over-sensitiveness in other parts of the body, and is the form of heartburn which weak, nervous, and hysterical persons usually suffer from. It comes on almost immediately after eating, and if vomiting does not occur, remains until the acidity has been neutralized either by the abun- dant flow of the alkaline saliva down the gullet, or by taking some alkali. The worst of this neutralization, either natural or artificial, is that a good deal of albuminous food remains undigested. It is absolutely requi- site for the solution of albuminoid substances, by the gastric juice, that they should be acid while in the stomach ; and if this natural acidity is prevented because it happens to be painful to the over-sensitive nerves, the gastric juice cannot act. Thus digestion from being painful becomes defective also. This form of heartburn usually occurs in nerv- ous, sensitive persons, and may be caused by over-anxiety, watching, harassing mental emo- tions, or any external circumstances which pro- duce over-sensitiveness. In the female it is some- times caused by tumors of the uterus, or by pregnancy ; and in the male I have known it to be induced by piles, or by constipation. It is also not infrequently associated with head- ache, or some other form of neuralgia. D YSFEFSIA. 1 7 The indications in this form of heartburn are, first to deaden the over-sensibility of the nerves, and then to follow up this merely temporary re- lief with appropriate tonics which shall effect a permanent cure. The form of heartburn, which is produced by too long exposure of the food to the acids of di- gestion, never comes on immediately after eating, — usually not until from one to three hours after a meal. The long continuance of this is apt to bring on the first form after a time, and it fre- quently brings on nervous headache and occasion- ally a decided intermittent neuralgia, aggravated by the same causes and removable by the same remedies as that arising from marsh miasma. The persons in whom it most frequently occurs are active men of business, literary laborers, clerks, the over-thoughtful, and the over-careful. That form which is produced by too much acid being formed in the stomach, is the only one to which the name of " acidity " is applied with pro- priety, for it is only in this variety of heartburn that there is really an excess of acid. The pain is much less intense than in the other varieties, but the regurgitations are much greater; sometimes true vomiting occurs; some- times only a teaspoonful of intensely sour liquid comes up, roughening the teeth, and bringing the 3 1 8 DYSPEPSIA. tears into the eyes ; sometimes a gaseous acid is belched up spasmodically ; sometimes it oozes up gradually, and its presence is shown by the saliva and breath being sour to the taste and smell. A permanent cure of this disease can only be brought about by the use of such remedies as strengthen the local power of the gastric solvent, augment its quantity, and excite the peristaltic motions. In this, as in a great number of the varieties of dyspepsia, the patient is tempted to take some- thing in the form of a cathartic, which in some cases, gives him temporary relief, but which is certain to leave him in a worse condition than that in which he was at first. Weight, Tightness, Distention, sometimes a feeling expressed as being " blown out with wind," while on examination of the epigastrium, the stomach is found not to be more tumid than that of a healthy person while digesting, — are modifi- cations of a sensation produced in the nerves of the stomach itself. Where this sensation exists alone, unaccom- panied by soreness, or pain on pressure, or by decided pain immediately after eating, it is com- paratively easy to judge of the real meaning ot the phenomenon. Like all other mucous membranes, that of the DYSPEPSIA. 19 stomach may be affected acutely or chronically. The acute form may be called " gastric catarrh ; " the chronic form " mucous flux." Both are liable to be followed by vomiting, which relieves tempo- rarily the distress, and which in the acute variety constitutes the most ordinary form of " bilious attack," so called from the bile, which the action of the diaphragm in vomiting, causes to regurgi- tate along with the contents of the stomach. When not rejected by vomiting, the food which has been eaten is so enveloped in mucus that it cannot be acted upon by the gastric juice, and is passed, very little changed, into the bowels, where it is liable to ferment, and by its acidity, cause diarrhoea, flatulence, and sometimes a copious dis- charge of mucus from the bowels. This latter result is more common in acute, than in chronic cases, where the motions are often infrequent and irregular, and the faeces are unformed and lumpy. In acute cases this excess of mucus is often accompanied by very intense headache, but in chronic it seldom goes beyond a feeling of stu- pidity. Flushing of the face, and heat at the back of the eyes, are also nervous symptoms de- pendent upon the chronic condition. " Acute catarrh of the stomach," like all other catarrhs, is often excited by external and often by epidemic influences. 20 DYSPEPSIA. " Mucous flux " is more dependent on organic changes in either the stomach itself or some other organ. Tubercles in the lungs, chronic bronchitis, enlarged heart, oftenest produce it, and it is not infrequently associated with can- cerous, tubercular, and inflammatory affections of the neighboring parts. When this sensation of weight, tig]jtness, or distention is accompanied with soreness on press- ure, more especially if the soreness exist when the stomach is empty, or if accompanied by a decided pain arising from the indigestion of food, it denotes that the secretion of mucus depends upon some local inflammation or ulceration, of a chronic character, in the mucous membrane. When a tumor can be felt, the probability is, that it is of a cancerous nature. When there has been bloody vomiting, it is almost certain that there is an ulcer, either cancerous or non- cancerous. The excessive secretion of mucus in the stom- ach, from whatever cause it may arise, is indicated by the distention mentioned above. But the evil rarely stops here. The gastric juice that is poured out cannot penetrate the slimy layer that envel- opes, as in a bag, the food which has been eaten, and consequently it ferments, and produces all the evils arising from chemical decomposition in the DYSPEPSIA. 21 stomach. Hence acidity and heartburn arise as heretofore explained ; and hence, in some consti- tutions, vomiting, in others a passage of the fer- mentins: mass into the bowels, and diarrhoea. It must always be borne in mind that mucus is a substance that is absolutely indigestible. The indications for treatment derived from a mucous condition of the stomach are as follows : First, it must be remembered that it is not only an evidence of disease, but it is also a cause of further trouble, and therefore should be directly restrained by astringents. Secondly, the place of the patient's own gastric juice, which cannot get at the food, must be sup- plied by artificial solution of the aliments, and their decomposition must be prevented. Thirdly, alterative diet, and medicines, and local counter-irritants, must be used to relieve the con- gested or degenerated condition of the organ at fault, especially in those cases which are compli- cated with pain. It must be remembered that in these cases pur- gatives of whatever kind are sure to do harm. Oppression is often complained of at the same time with the weight, tightness, or distention of the epigastrium. But it means something more, and is by no means identical. Indeed, in those cases of mucus on the stomach, which relieve 2 2 DYSPEPSIA. themselves by vomiting, or rapidly passing on with the alimentary mass, there is no oppression at all. Oppression indicates a general feeling of mor- bid lassitude and physical incapacity throughout the whole body. There is a confusion of ideas, sometimes an unnatural sleep, sometimes faintness, irregular nervous action, such as flushings of the face, palpitations of the heart, fidgets, twitchings, or cramp. As I said before, these are often the accompa- niments of gastric mucous flux, but at the same time they may often exist without it, and, indeed, almost anybody may bring them on by getting very tired and then eating largely. If vomiting occurs, you see no mucus in the egesta, but sim- ply the food last taken, unaltered in quality or appearance. Digestion has completely stopped. Oppression shows an exhausted condition of the muscular and nervous system of the stomach. The causes are those which usually exhaust the nervous energies without stimulating the powers of life, such as prolonged and severe intellectual labor, annoyance of mind, and overstrained atten- tion. Temporarily and in persons previously dis- posed, mere corporeal exertion may bring it on. It is obvious that the treatment should be to re- store to the stomach its natural tone. DYSPEPSIA. 23 Wearing or Boring Pain is nearly always suffi- cient to arouse a suspicion of ulceration. The suspicion is strengthened if weight, and tightness of the epigastrium be present, to indicate the ex- cessive secretion of mucus which usually accom- panies chronic ulcer ; and the diagnosis is further confirmed by the occurrence of bloody vomiting. It is in these cases that the failing organ re- quires to be spared work. Liquid food should be given, such as milk with lime or soda water, in small quantities and as frequently as possible. The chief object of the lime water is to prevent the milk from forming a large curd, but it is also a sedative to the raw surface, just as it is to a blistered or burnt skin. Cramp or Spasmodic Pain in the epigastrium appears to arise from the pylorus, where the food passes from the stomach to the intestines. It oc- curs chiefly in old persons, and does not show any organic disorder of the part. A simple remedy, such as a thimbleful of brandy with two drops of laudanum, is as efficient as anything that can be administered. Flatulence. The intestines naturally contain a certain amount of atmospheric air and carbonic acid gas, and it is only when these gases are in excess that they are spoken of as " flatulence." Eructation. In health all the air that finds its 24 DYSPEPSIA. way into the stomach is readily absorbed, and many individuals never pass it away, either up- wards or downwards, 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, the abdomen of a perfectly healthy person is somewhat 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 func- tion most generally interfered with is absorption. The air collects, is swelled by heat, and expelled, although it may be present in no excessive quan- tity. Should the oesophagus be easily relaxed, there is eructation ; should it be contracted, there is intestinal flatulence. So far, we have spoken of the air as being in- creased only by heat and expansion. But in some cases it is further augmented by gases disengaged from decomposed food. Even alcoholic fermen- tation sometimes occurs in the stomach, as is proved by instances of vomiting in which the matters ejected are visibly undergoing this chem- ical change. In all these cases the treatment should aim at restoring the proper tone to the stomach. Intestinal Flatulence. In a state of health the gases formed in the intestines are reabsorbed DYSPEPSIA. 25 almost as soon as they are formed, so that the abdomen is puffy only for a short time after meals ; but, as explained before, lowered vitality promotes the collection of air by arresting ab- sorption. Lowered vitality also increases the extent of decomposition by diminishing the flow of bile. One of the chief functions of the bile is to act on the albuminous matters contained in the food, by preventing their decomposition, and preserving them safely, to be exposed to the absorbents of the intestines. Excess of gas in the small intestines is the most troublesome sort of wind. Should it escape up- wards through the pylorus into the stomach, it is apt to cause vomiting, or sometimes it causes a most nauseous eructation of sulphureted hydro- gen. There seems to be some difiEculty about the passage of the air downwards through the ileo- csecal valve, which separates the small from the large intestines. Hence, intestinal flatus often rolls about in the abdomen, causing the well- known and distressing " grumblings," and the ab- domen will sometimes be distended and painful for several days with it, without its being expelled or absorbed. There is often considerable pain on one side 4 26 DYSPJEVSIA. or the other, most generally just below the ribs on the right, and then patients are almost certain to complain that their "liver is out of order." When there is most pain in the side there is least " grumbling " of the abdomen, and it probably arises from the long continued, immovable, dis- tention of one part of the intestine. Flatulence of the intestines is troublesome dur- ing the day, but when it comes on at night it causes still more inconvenience by preventing sleep. In many cases there is not pain enough to account for it, yet a complete wakefulness pre- vails. It is also to be remarked that this sleep- lessness is, in most instances, made worse by opium. 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 aggra- vate than to relieve the feverish restlessness, and to cause headache. The persons most liable to this troublesome affection are women, especially those of a weak muscular fibre, and a tendency to form fat. In cases of this kind the treatment has to be DYSPEPSIA, 27 conducted with great care. Remedies which pro- mote the flow of bile are of course indicated, as well as those which arrest decomposition ; and above all, those which restore the intestinal mu- cous membranes to their normal tone. Mercury is certainly a powerful temporary re- lief, but it has to be resorted to again and again, until its habitual use gives rise to anaemia. And the patient should be warned that any remedies which are purgative will be certain to produce a bad effect. With regard to diet, the patient should have a full allowance of lean meat and water ; should avoid butter and fat, as well as rich sauces ; and if alcohol is allowed at all, it should only be in very small quantity. The most common affection of the nervous system, arising from imperfect digestion, is Head- ache. It occurs from a great variety of causes, as has already been stated, and the only rational means to take for its cure is to endeavor to remove the morbid condition of the organs that are affected. Without this the headache can be only tempora- rily relieved, and of course there will be a fre- quent recurrence of it. The same thing may be said of the great variety of other nervous symp- toms that arise from indigestion. 28 DYSPEPSIA. I have hardly alluded to Constipation as one of the results of indigestion. It is one of the most common affections, and one that needs care and skill to cure. Patients who are troubled in this way have usu- ally been dosed with all sorts of purgatives, from blue pill down through the whole list, not to mention the various patent medicines, *' aperi- ents," and " bitters." The result of all this is that the whole intes- tinal tract is worn out, and is not capable of healthy action. And the longer any chronic con- dition has remained, the more time and patience will be required for its cure. Indigestion does not prevent Corpulence. In fact, it is probable that one cause of that hyper- trophy, is the delay of the food, both animal and vegetable, in the stomach, and the setting up, in the carbonaceous material, of a fatty fermentation instead of digestion. This obesity of persons with weak gastric di- gestion is peculiarly distressing. The defect in muscular power prevents a sufficient amount of exercise to keep it from increasing, hence it be- comes a daily growing inconvenience. The encroachment, too, of the fatty upon the other tissues, and the dilute spread of the insuffi- cient blood, through an unnaturally large quan- DYSPEPSIA. 29 tity of minute blood-vessels, tend to produce de- fective nutrition of important parts ; and hence we find, as a consequence of corpulence, dilata- tions and degenerations of the heart, fatty depos- its on the same, Bright's disease of the kidneys, etc. The addition to the body of many pounds, in the shape of fat, requires certainly a very large addition of blood and blood-vessels to nourish it, and yet the same heart has still to undertake this labor. The balance, then, between the systemic and pulmonary circulation must be destroyed, and the lungs be unequal to the excretion of so much more carbon than they were intended to provide for ; hence the blood becomes more venous, more liable to form congestions, and to dilate the yield- ing walls of the heart, by its retarded pace. The effect of diminished circulation, in also producing degeneration of other parts, need not be enlarged upon. The Causes of Dyspepsia may be briefly stated as follows : — Excessive mental work and worry ; Inaction of the body, with over-action of the mind; Eating too much when either mind or body is exhausted ; Under-feeding, that is, not taking a sufficient 30 DYSPEPSIA. quantity of nutritious food, or not eating a suffi- cient variety ; The habitual abuse of alcohol, opium, tea, to- bacco, purgative medicines, " bitters," etc. Another cause that should be mentioned is a diseased state of the lungs or heart. It must not be forgotten, however, that while diseases of the lungs and heart are not unfrequently among the causes of dyspepsia, these diseases are in many cases the direct result of dyspepsia, or of the in- nutrition caused by it. I wish once more to repeat, there is no case of dyspepsia, unless it be accompanied by some nec- essarily fatal disease, but what can be perfectly and perma7iently cured, by careful and judicious treatment. To attain this end, the form of dyspepsia in each case must be made out, the proper remedies applied, and thus this disease, which is the most common, and which causes more suffering, both mentally and bodily, than any other one, become a comparative rarity. COLUMBIA UNIVERSITY This bqgk is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C2ei638)MS0 RC826 B67 Bowen Threne