COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64 132234 RC826 .F82 indigestion, Columbia ^inibergitp intfjeCitpotiSetogorfe COLLEGE OF PHYSICIANS AND SURGEONS \ •><-* ^.>A Reference Library Given by V -tl-7.325 -'^ 16.17) ^21.845 ^0.39) -t* G.43, with some 3 to 4 per cent, of water of crystallization (M. Foster), We can readily understand how the power to construct less complex bodies may be retained, yet the capacity to build up hemoglobin may be lost for a- time; and require medicinal treatment for its restoration. We see how certain blood-poisons, lead, mercury, malaria, gout, and syphilis, may render a person anoemic; yet their general nutrition may be little, if at all affected. We know that when there is such a toxic element pres- ent, iron will not cure the anaemia, however potent in simple anaemia, until the specific in each case be added; and then improvement sets in. With the two mineral poi- sons it is necessary to eliminate them from the system, to relieve it from their presence, ere blood-formation can proceed. In malaria we give quinine, in gout lithia and potash, in syphilis mercury or iodide of potassium, with iron; and then the iron is operative; without the specific, chalybeates are like an arrow without, a head. The clinical relations of anaemia teach us a valuable lesson as to the 76 TISSUE NUTRITION. [chap. v. loss of power in the system to construct the complex sub- stance, haemoglobin. Another lesson in the same direction is taught us by the nervous system; the loss of nervous energy, the prostra- tion, the unfitness for toil, necessitating a holiday, now so commonly experienced. Here, it would seem, there is impairment of the ability to construct lecithin. Lecithin is complex fat containing phosphorus and nitrogen. " Lecithin C^,, Hg^, NPOg, occurs widely spread through the body. Blood, gall, and serous fluids contain it in small quantities, while it is a conspicuous component of the brain, nerves, yolk of egg^ semen, pus, white blood, corpuscles, and the electrical organs of the ray." This is what Michael Foster says about lecithin. The well- known association betwixt a heavy seminal expenditure and the loss of nervous energy, upon which quacks and charlatans have traded so largely, is thus intelligible and comprehensible. Its presence in the electrical organs of the ray is not devoid of significance. This lecithin is a subject upon which we will have soon to know more than ■we do at the present time. Just as the complex hasmo- globin is a constitutent factor of red blood-corpuscles; so we will find this complex fat — lecithin — a constituent fac- tor of nerve-cell and fibres. We do not know enough of the subtle changes which lie at the foundation of the loss of nervous energy, so well, or intimately, as the associations of aucTsmia; but there is much pointing in this direction, viz., that it is linked with an insufficiency of lecithin. It is either used up too freely by overwork, or worry, which is still more exhausting; or it is formed imperfectly from CHAP, v.] TISSUE NUTRITION. 77 some impairment in the assimilative processes. It seems probable that this complex fat is the food^ar excellence oi the nervous svstem. That without it nervous enersrv can- not be manifested. Further we may not yet affirm. But it is perfectly legitimate to throw together a few clinical facts bearing on the matter, which speak with a not quite inarticulate sound. When the nervous system has been severely overtaxed for a considerable time, it may give out evidences of exhaustion; while the muscles are well-nourished, and the adipose tissue of the body is not diminished. It is clear that here- there is a localised mal- nutrition, restricted to the nervous svstem. The serous fluids, including the serum of the blood, contain lecithin in small quantities; therefore exhaustion of this substance in the nervous system would require time for its repair; and if the nervous system is still called u23on, it must furnish evi- dences of exhaustion and diminished capacity, until the normal proportion of lecithin is restored. Rest for the nervous system permits of the reaccumulation of this com- plex phosphorized fat. Then we find phosphorus advo- cated for nervous exhaustion and depression. " Ohne phosphor keine gedanke," was Moleschott's dictum now so widely known — (" Without phosphorus there is no thought "). But this phosphorus has to be formed. into a fat before it can be of service. Not onlv thouo;ht, but motor messages involve the oxidation of this complex fat. Lecithin, cerebrin, and neurin, are complex substances, found in the nervous system; though the two latter are simpler, not containing phosphorus. But the decomposi- tion of these complex bodies is essential to nervous energy. 78 TISSUE miTRITIOm [cH.iP. v. Neuralgia is like most pain, the prayer for healthy blood. *' Pain is the prayer of a nerve for healthy blood," wrote Romberg ; and most certainly this is true of neuralgic pain. Neuralgia is intimately linked with the presence of poisons in the blood — mineral, malarial, or produced within the body. Neuralgia is at other times the offspring of simple anaemia, mere bloodlessness. Neuralgic pain tells of unhealthy blood; blood either containing a positive poison, or itself deficient in nutrient material. The rest of the body may be fairly well nourished; but neuralgia, and a sense of lethargy or unfitness for work, may tell that the nervous system is underfed — that the organism is un- equal to the formation of those complex substances, the food of the nervous system. So far as we know it is in the preparation of these corrx- plex matters for the blood and the nervous system — neither of which exists in plant life — that animal synthesis exhibits itself. Bone is the infiltration of lime into ordinary car- tilage : but hemoglobin and lecithin are complex bodies, built up in the animal organism. Starch, sugar, fat, are built up from carbonic acid and water; albumen from these and free ammonia in the air. All are synthetically built up by vegetable life, and appropriated by animals. Animals evolve energy by the union of these substances with oxygen ; they pull to pieces and oxidise the construc- tions of plant life, and in doing so evolve heat and force. But the oxygen-carrying haemoglobin, the force-liberating lecithin, are essentially the creation of animals themselves; who build them up from less complex substances. The complexity of these nervine matters are associated CHAP, v.] TISSUE miTRITIOK. 79 somehow with the immense " liberating-power" that they possess. The respiratory centre occupies a little space in the medulla, but its rhythmic discharges set off a large series of muscles; and when its explosions are stimulated by the presence of carbonic acid in excess in the blood, all the muscles of the body may be more or less thrown into action. No wonder then that at times the system is un- equal to the construction of these elaborate compounds; when it can carry on successfully the digestion, assimila- tion, and transformation of ordinary materials — built up by vegetables originally, and appropriated by animals. Xo wonder either that when the power to build up these products of animal synthesis is lost, it may require somes time before the system can regain it. The conversion o\' spare hydrocarbons within the system into fat, and ever spare proteids, though this is rather fatty histolysis, and the development of adipose tissue is not to be compared tq the construction of hsemoo-lobin and lecithin, the two most complex products of the body; the two which must, and only can be built up by animal synthesis. So much then for the loss of power to construct complex bodies. At other times, there exists a loss of power to assimilate albuminoids, and then the muscles suffer chiefly; and espe- ciallv the two muscles in constant action, — the heart and the diaphragm. This is a practically important matter, as a heart so weakened is not uncommonly mistaken for a heart undergoing fatty degeneration. In the general evidence of loss of power in the heart, the two conditions are almost identical. There is this difference, however, " fatty degeneration " is a condition the gravity of which 80 TISSUE JSrU-TRITIOJV. [chap. v. it is impossible to underrate; while "heart starvation" is a condition carrying with it little cause for apprehension, except in those conditions of acute failure in pyretic states of blood poisoning, where the heart's action becomes ex- ceedingly rapid and fluttering; a condition fraught with extreme danger. But " heart starvation " as ordinarily seen is a condition of some permanency, and not a truly " acute " condition. When the digestion of albuminoids is defective, then the blood cannot furnish to the muscular, structures the pab- vdum required for the maintenance of their integrity; consequently they are ill-nourished and their functional activity is impaired. When the heart is so enfeebled, and the diaphragm also half-starved, then there are dis- turbances in the circulation which closely rese^/ible the symptoms of tlie fatty heart. The heart-sounds are ill- defined, and less audible than normal ; while the heart's imjDulse is lost, or nearly so. The pulse is feeble and compressible. There is a tendency to fainting, while the mental operations are confused, the brain being imper- fectly supplied with blood. There is a feeling of unsteadi- ness, or lack of self-reliance, which is very distressing. The patient sighs, and there are seizures when the respi- ration is arrested. Indeed, the symptoms and sensations are those given by Da Costa, in his admirable work "Medical Diagnosis," as some of the indications of the fatty heart. But " fatty degeneration " as a disease of advanced life, is distinctly senile in its aspect; while "heart starvation" is a malady of middle life. One pre- sents the toict ensemble of age, — of widespread senile de- CHAP, v.] TISSUE NUTRITIOir. 81 generative change; the other is rather an invalid, as a person pulled down with dysentery, or tropical fever. At a distance, the tottering gait, the unsteady stejD, the bowed fissure leanins: on a stick, mav belona: to each alike; but on nearer approach, the resemblance fades out, and the points of dissimilarity become obvious. Nevertheless, it is by no means rare to see cases in which " heart-starvation " has been mistaken for the "fatty heart." Indeed, the resem- blance is so close, and the general practitioner has so manv thino-s to attend to on the one hand; while on the other, our acquaintance with the heart " as a muscle " has not kept pace, or anything like it, with our acquaintance with the valvular diseases of the heart, of which the " mur- mur " is thQ \nd\Qaiiion i^ar excellence ; that such mistake does not always involve either carelessness or culpable ignorance. But in the absence of the significant mur- mur, the presence of distinct debility in the heart is mystifying to the ordinary practitioner, and calls up the fear of " fatty degeneration; " and not unnaturally so. The knowledge which one man acquires by the sweat of his brow, after years of patient toil and painstaking obser- vation, cannot be transferred in its entirety to another ; there is no " roval road " to knowleds-e. Individual acquired skill cannot be passed from brain to brain, any more than the juggler who can keep six balls in the air at once, can endow an onlooker with like capacity, by merely showing him *' how it is done." The muscles, and still more their representatives in the motor area of the brain-hemispheres, require a long training before this manual skill can be acquired. So it is in 82 TISSUE NUTRITIOm [chap. v. other matters. It is not difficult to say how the diag- nosis betwixt the "fatty heart" and "heart starvation" is to be made; but without individual toil to acquire the requisite capacity, the reader cannot attain it. There is no royal road to the discrimination betwixt two allied conditions, especially when the resemblance is so close as it is betwixt the fatty heart and its double, — heart starvation. There are in each the same signs on physical examina- tion of the heart; in each the same cold extremities, indica- ting want of blood in the arteries; in each the evidences of cerebral anaemia; in each the same incapacity for exer- tion and breathlessness on effort; a whole group of symp- toms, indeed, is found present in both. But in the fatty heart there are found evidences of senility all over the bod\^ The skin is degenerate, unnaturally smooth and greasy, or furred with myriads of wrinkles; the eye ex- hibits an arcus senilis (arcus is a " bow," not a " ring"), seen under the upper eyelid long before it is present in that portion of the eye which is seen, and which is exposed to light; while the temporal artery is seen tortuous and meandering like a brook in a flat meadow. He was a wise man, a keen observer, and an accurate thinker, who said " a man is no younger than his arteries " (S. Wilks): and it is the condition of the arteries which is our trustiest guide in making the diagnosis. In the fatty heart the arteries are usually atheromatous, rigid, and tortuous. In a well-marked case, the temporal artery may be seen to elonofate, as well as to widen on the ventricular svs- tole; the radial artery is felt to undergo the same tran- CHAP, v.] TISSUE NUTRITIOX. 83 sient change. The arteries feel like tendons, or even pipe-stems. If, at the same time, the pulse is irregular or intermittent, then the fatty heart is present almost to a positive certaint3\ But where evidences of age are want- ing, then in all probability the condition present is that of heart starvation : it not being- denied that fattv desrenera- tion is found in certain rare states even in comparatively young persons. But for once that fatty degeneration is so found, fifty times fatty degeneration is diagnosed when heart starvation is the actual state of matters. The disres- tion of albuminoids is defective and the capacity of the heart and diaphragm is impaired ; furnishing a group of symptoms closely resembling those manifested when the heart is the subject of that molecular decay, known as fatty degeneration, or necrosis. Even when there may be ground for the gravest suspicion as to the integrity of the fibres of the heart, the condition may still be one where '^ starvation " is also present ; that is, there is act- ual degeneration of some of the fibrillse, while there is starvation in those fibrillos remaining structurally sound. Such cases are met with from time to time (see "Heart Starvation/' H. K. Lewis ; reprinted from the Edinburgh Medical and Surgical Journal^ ^lay, 1881). Here it is most important to remember that a small quantity of albuminoids, properly and completely digested, will furnish more tissue-nutriment than a large meal, none of which is thorous^hlv digested. A dietarv of fish, white meat, eggs, milk-puddings, with fruit, will digest and feed up a starved heart and diaphragm; when liberal meals rich in meat fail to do so. It is not the amount swallowed, it 84 TISSUE NUTRITION. [chap. v. is the amount digested, which is to be the measure of the actual nutritive material in the blood ; and from it the nutrition of the starved tissues. In such cases, it is well to aid the feeble natural digestive powers by the addition of pepsin, or the pancreatic preparations. It is somewhat difficult to induce the friends of the patient to believe that such an apparently insufficient dietary is the one cal- culated to repair debilitated conditions of muscles ; but insistance can be accompanied by explanation, and the results convince the doubtful and convert them to con- viction. Tlie recognition of ill-fed muscles from impairment in the power of assimilating albuminoids, as a condition in- volving the heart and diaphragm, is a matter which must engage the attention of the profession in a little time ; indeed, when it is sated with nerve pathology and poison- germs, and can turn its attention to something else. In pernicious anaemia there is great muscular asthenia, and the heart is the subject of actual " fatty degeneration." There is a growing general malnutrition of the muscular system especially, though, as Addison observed, there may , be an increase in the amount of subcutaneous fat. In- deed, in anaemic states, fat is apt to be deposited. The farmer often bleeds his oxen to make them fatten, when they do not feed satisfactorily. Tissue-nutrition might not inappropriately be otherwise termed " protoplasmic metabolism or digestion." CHAPTER VI. SECONDARY INDIGESTION. . NE UR OSAL .—REFLEX. — CA RDIA C. — TOXEMIC. We now come to the consideration of those forms of indi- gestion and mal-assimilation which are secondary condi- tions, due to disturbances elsewhere, or to the presence of poisons in the body. These will be found to be a large wide-spread series. The first of this group of dyspepsiae is that due to dis- turbance of the nervous system, as overwork, worry, anxiety, suspense, or emotion; w^here the encephalic dis- turbance interferes with the digestive act. " How thin you are getting ! " we remark to an acquaintance. " Yes, I have been a good deal worried of late; I have a lot of work: and lately I have had a good deal on my mind;" is the common response. Such is the effect of mental dis- turbance persisting for some time. Acute indigestion is the result of sudden perturbation. " That the secretion of gastric juice is affected in a very marked manner by conditions of the nervous system, is indicated by the effect of the mental emotions in putting an immediate stop to the digestive process, when it is going on in full vigour" (Carpenter). We all are only too familiar with the con- sequences of bad news, or other " upset," when at m.eals. Unconscious previously of the possession of a stomach, or the process known as the digestive act, we suddenly feel a lump in the epigastrium, and an accompanying convic- 86 SECONDARY INDIGESTION. [chap. vi. tion that the meal is wasted. This is the effect upon perfectly healthy persons; more marked is the disturbance in those who suffer from indigestion. Vomiting may oc- cur, or diarrhoea; either clearing away the spoiled victuals, but by a process the reverse of pleasing. If neither occur, then the undigested material is the source of disturbance for some time afterwards. The reaction of this upon the nervous system is productive of great discomfort; indeed, in some, acute misery is induced thereby. Dr. Carpenter, F.R.S., the author of the well-known works on Physiology, has paid considerable attention to the effects of mental conditions upon the organic pro- cesses; and it may be well to make several quotations from his writings on the subject. By so doing, the reader will be put in possession of the views of the illustrious physiologist ; which may carry with them, too, more weight than my unsupported word. After giving the effects of emotion upon other secretions, he proceeds to speak of those connected with the digestive act. " The flow of saliva, again, is stimulated by the sight, the smell, the taste, or even by the thought of food; espe- cially of such as is of a savoury character. On the other hand, violent emotion may suspend the salivary secretion; as is shewn by the well-known test, often resorted to in India, for the discovery of a thief amongst the servants of a family — that of compelling all the parties to hold a certain quantity of rice in the mouth during a few minutes, the offender being generally distinguished by the comparative dryness of his mouthful at the end of the experiment. There is much reason to believe that the CHAT. VI.] SECONDARY INDIGESTION. 87 secretion of tlie gastric fluid is affected, in the same man- ner as that of the saliva, by the impressions made by food upon the senses ; for it has been ascertained by Bidder and Schmidt, that it is copiously effused into the stomach of dogs that have been kept fasting, when flesh or any other attractive food is placed before them. That the secretion, on the other hand, is entirely suspended by powerful mental emotion, seems almost certain, from the well-known influence which this has in dissipating the appetite for food, and in suspending the digestive pro- cess when in active operation. As a cheerful state of feeling, on the other hand, seems to be decidedly favor- able to the performance of the digestive function; it prob- ably exerts a beneficial influence, as to both quantity and quality, in the secretion of gastric fluid, of the influence of mental states, or other secretions concerned in the reduction and appropriation of the food (such as biliary, pancreatic, and intestinal fluids), neither observation nor experiment has as yet afforded any satisfactory informa- tion. It is a prevalent, and perhaps not an. ill-founded opinion, that melancholy and jealousy have a tendency to increase the quantity and to vitiate the quality, of the hiliary fluid. Perhaps the disorder of the organic func- tions is more commonly the source of the former emotion than its consequence: but it is certain that the indulgence of these feelings produces a decidedly morbific effect by disordering the digestive processes, and thus reacts upon the nervous system by impairing its healthy nutrition." This last is a very significant remark, and throws much light upon many cases where there are evidences of mal- 88 SECONDARY INDIGESTION. [chap. vt. nutrition of the nervous system, taking its origin in emo- tional disturbance. This transient disturbance perturbs the assimilative processes; and these, in turn, lead to per- sisting mal-nutrition of the nervous system. Again, "there is abundant evidence that a sudden and violent excitement, or some depressing emotion, especially terror, may produce a severe and even a fatal disturbance of the organic functions ; with general symptoms (as Guislain has remarked), so strongly resembling those of sedative poisoning, as to make it highly probable that the blood is directly affected by the emotional state, through nervous agency; and, in fact, the emotional alteration of various secretions, just alluded to,* seems much more prob- ably attributable to some such affection of the blood, than to a primary disturbance of the secreting process itself. Although there can be no doubt that the habitual state of the emotional sensibility, has an important influence upon the general activity and perfection of the nutritive processes as is shewn by the well-nourished appearance usually exhibited by those who are free from mental anxiety, as well as from bodily ailment, contrasted witli the "lean and hungry look " of those who are a prey to continued disquietude — yet it is not often that we have the opportunity of observing the production of change in the nutrition of any specific part, by strong emotional ex- citement. In the two following cases, the correspondence of the effects to their alleged causes may have been only casual ; and a much larger collection of facts would be * The urine, the sexual secretions, the sweat, and more than all, the milk — ^the secretion of the mammary gland. CHAP. VI.] SECONDARY INDIGESTIOK 89 needed to establish the rationale here advanced as probable. But so many analogous though less strongly-marked phe- nomena are presented in the records of medical experience, and the influence of the emotions upon the products of secretion is so confirmatory, that there does not seem any reasonable ground for hesitation, in admitting tliat the same explanation may apply here also. The first of these cases, cited by Guislain, from Ridard, is that of a woman, who, after seeing her daughter violently beaten, was seized with o-reat terror, and suddenly became affected with gangrenous erysipelas of the right breast. But a still more remarkable example of local disorder of nutrition, occasioned by powerful emotion, and determined as to its seat by the intense direction of the attention to a particu- lar part of the body, is narrated by Mr. Carter, " On the Pathology and Treatment of Hysteria." " A lady, who was watching her little child at play, saw a heavy window- sash fall uj^on its hand, cutting off three of its fing^ers; and she was so much overcome by fright and distress, as to be unable to render any assistance. A suro-eon was speedily obtained, who, having dressed the wounds, turned himself to the mother, whom he found seated, moaning and complaining of pain in the hand. On ex- amination, three fingers, corresponding to those injured in the child, were discovered to be swollen and inflamed, although they had ailed nothing prior to the accident. In four-and-twenty hours, incisions were made into them, and pus was evacuated; sloughs were afterwards discharged, and the wounds ultimately healed." The influence of the state of exj)ecta)it attention in modifying the processes of 90 SECONDARY INDIGESTION. [chap. vi. nutrition and secretion, is not less remarkable than we have already seen it to be in the production or modifica- tion of muscular movements. It seems certain that the simple direction of the consciousness to a part, indepen- dently of emotional excitement, but with the expectation that some change will take place in its organic activity, is often sufficient to induce such an alteration; and would probably always do so, if the concentration of the atten- tion was sufficient," This last matter will be referred to again in the consideration of hysterical dyspepsia, and hypochondriasis. It has certainly much to do with the occurrence, if not the production, of the '^ mother's marks'* so commonly met with. In considering the question of how emotion affects the digestive process. Dr. Carpenter says experiments have not led to agreement among observers. He writes " Bernard, with many others, considers that the division of these nerves (the pneumogastrics), instantaneously checks the secretion of the gastric fluid, and therefore, puts a stop to digestion; and he points to the pallor and flaccidity of the stomach which immediately succeed the operation, the slight and superficial digestion of the alimentary mass ■which takes place, and to the additional circumstance, that in the rabbit there is a sudden change in the reaction of the urine from alkaline to acid, the latter being the normal condition in the fasting state, and therefore, showing that all action on the food must have stopped. He further observes, that in galvanising the pneumogastrics, an abun- dant flow of gastric juice takes place. Longet, however, maintains, that division of the pneumogastrics operates chap: n.] SECONDARY INDIGESTION. 91 rather in paralysing- the muscular movements of the stomach, than in stopping the secretion of the gastric juice; for he states that if a small quantity of milk were given to the animal, 24 or even 48 hours after the section, and when, therefore, there could be no gastric juice re- maining in the stomach, it has invariably clotted after death, or upon making the animal vomit; and small quan- tities of meat or other food were dio^ested readilv enouofh, though large masses were only superficially digested, because the muscular power of the stomach being para- lysed, the food was not properly intermingled with the gastric juice." These interesting observations point to several matters of clinical moment. They tell that section of the pneu- mogastric nerves arrests the secretion of gastric juice with *' pallor and flaccidity of the stomach;" that is, the arterioles of the stomach dilate in the act of dig-es- tion, when the mucous lining at the same time is wet with the flow of the gastric juice. Thus we see that both (1) disintegration by the muscular movements; and (2) the production of the solvent gastric juice, are arrested; no wonder then that the digestion is hindered ! Such prob- ably is the effect of fear and depressing emotions. On the other hand, galvanising the pneumogastrics produces an abundant flow of gastric juice. This is analogous to pleasant emotions aiding digestion; and may throw some light upon the time-honoured practice of taking wine with food. Paul urged upon Timothy to " drink no longer water, but have a little wine for thy stomach's sake and thine often infirmities;" it seems probable that Timothy had indiges- 92 SECONDARY INDIGESTION: [chap. vi. tion among his " infirmities." Pleasurable emotions of a cheerful enlivening character, act like a stimulus through the pneumogastrics, and dilate the gastric arterioles, pro- moting the secretion of gastric juice; while increasing the energy of the muscular movements of the stomach. These observations are in perfect accord and harmony with our practice of giving agents, which so act upon the stomach when the digestive act is defective. Persist- ing emotions act in the same way but less potently, producing the same results through longer and slower operations. Thus worry, anxiety, " carking care," and other depressing influences, cause a persisting loss of flesh, even when no uncomfortable sensations are com- plained of; while exhilarating conditions lead to more per- fect and complete digestion and nutrition. Shakespere wrote. "Let me have men about me that are fat : sleek-headed men, and Buch as sleep o'nights. Yond' Cassius has a lean and hungry look ; he thinks too much : such men are dangerous. Would he were fatter ! But I fear him not : " — and we all know how persons emaciated by worry and anxiety, "pick up flesh," when their minds are once more at rest after much perturbation. The observation that " small quantities of meat or other food were digested readily enough, though large masses were only superficially digested " is one pregnant with instruction as to the dietetic requirements of many dyspep- tics. It shows that when the digestion is impaired small quantities of food are digested "readily enough; " while larger amounts were only digested on the surface, the CHAP. VI.] SECONDARY INDIGESTIOy. 93 interior being untouched. Not only is tlie secretion of gastric juice diminished notably, but the movements are abolished so that the disintegration is not accomplished, which fits the food for admixture with the bile and the pancreatic secretion, which is so large a part of the function of the stomach ; probably more important than even the digestion of albuminoids in an acid medium, because this last may be sui^jDlemented by the pancreatic digestion of albuminoids in an alkaline medium. It shows that in en- feebled assimilation to give small quantities of food is to secure complete digestion, while larger meals undergo little digestion, and have therefore little nutritive value ; as is insisted upon in the preceding chapter when speaking of the dietary in "heart starvation." Such then is a part of the aid which physiological research can give to practical medicine. Impaired nutrition is, then, often the direct outcome of mental disturbance. The most pronounced inveterate case of anEemia, I ever met with personally, occurred in a girl of splendid physique and magnificent family history. She was the type of health when her father fell down by her side at market, and died there and then. She imme- diately became ansemic and remained so, despite most varied treatment. Pernicious anagmia about which so much has been written lately, is probably a perversion of nutrition due to nervous disorder, rather than a local disease, " atrophy of the gastric glands ; " if atrophy of the gastric glands is ac- tually found after death, it is probably the consequence, rather than the cause of the anaemia ; instead of being a 94 SECONDARY INDIGESTION. [chap. vi. rational explanation, in the face of the powers of the pancreatic secretion, it seems rather like "putting the cart before the horse." It is a case of distinct loss of the power to assimilate albuminoids, a matter discussed in the pre- ceding chapter. It appears that " there is often a consider- able amount of subcutaneous fat ; " yet " almost without exception the heart is in a state of fatty degeneration ; its walls are pale, flaccid and friable ; the interior of the ven- tricles, and especially of the left ventricle, shows irregular whitish striiB running transversely across the muscular bundles, and especially the j^apillary muscles " (S. Coup- land). It is a disease only observed in recent times ; and is one of the increasing number of perversions of nutrition with which we are becoming familiar now-a-days. The mental associations of diabetes are very interesting in relation to this subject. Talking one day with Mr. Van Abbott, whose biscuits for diabetics have such a well- deserved renown, I asked him, — "Who are your diabetics mostly ? " The reply was very significant — " Business men comparatively old and grey for their years ; men who look as if they had a deal on their minds." This was the re- sponse. It stands in a suggestive relationship to the fact of acute diabetes being set up by shock or other mental perturbation ; or of its artificial production, by the puncture of the floor of the fourth ventricle. The direct nervous connection betwixt the brain and the liver has been shown by Cyon and Aladoff. It contrasts with the mere glyco- suria, so common in stout men, where the digestion of starch is perfect, and the liver only dehydrates enough into glycogen for the wants of the system ; the surjolusage CHAP. VI.] SECONDARY INDIGESTION. 95 running off by the kidneys. Here, if it were not for this " waste pipe," the individuals would become inordinately fat. Such glycosuria is a totally different matter from the diabetes, which leads to wasting; where either (1) the liver has lost the power of dehydrating the sugar, brought to it by the portal vein, the more probable hypothesis; or (2) the ferments in the liver hydrate the glycogen, or animal starch into suga-r again, too swiftly for the wants of the body; and the " fuel-food " escapes unburnt. In either case it becomes necessary to feed the patient on food which is not saccharine, and therefore liable to these perversions of dehydration, and secondary hydration. If food can be taken in sufficient quantity and assimilated, which underofoes no saccharine transformation, the dia- betic is preserved: if not he perishes. S. Haughton, F.R.S. tells of the diabetic patient dying of inanition, that in the delirium which precede.d the final change, he cried out " Fat ! roasted fat from the angels of heaven! " Such perversion of the assimilative processes which is so marked in its various forms at the present day, will be considered in relation to its rapid increase, and the pros- pects of the next generation and their successors, — if they have an}^ — in a succeeding chapter. The failure of the teeth it will be seen is but one part, one factor in a wide- spread deterioration of the digestive processes. The ter- rific demand upon the nervous system in the present " struggle for existence," and " fight for a competency " is telling with deadly effect upon the organic processes and their nutritive products. Not only do we recognize men- tal factors in the production of the disturbance of the 96 SECONDARY INDIGESTION. [chap. yi. digestion, in the digestive act in the stomach — ordinarily spoken of as if it were the whole of the digestive act; but we see the liver may be disordered by mental disquietude. Jaundice has been known to be produced by fright, and more chronic functional disturbance of the liver is linked with persisting mental perturbation. Diabetes is set up acutely by mental emotion; chronic overwork leads to a more lasting form of mental taxation. Recently Clifford Allbutt, F. R.S.J urged with his wonted able advocacy, the mental relationships of chronic renal disease. In his opinion enduring mental anxiety and worry over business difficulties, is a potent factor in the production of chronic Bright's disease with albuminuria. Indeed a huge mass of evidence is being collected to show that excessive toil in that portion of the brain which is devoted to intellectual processes, leads to deterioration of the functions of the viscera, which form part of the organic life. The viscera which provide the pabulum for the intellectual and motor processes, i.e. the brain and muscular system, become affected in time by the demand upon them, and give way under the strain. More pronounced is this effect when the posterior lobes, which are linked with our subjective states and our emo- tions, are involved. Loss of appetite, of the power of all digestion is the common outcome of acute grief. The production of new matters in the blood is shown by the hair turning grey suddenly; even in a single night, as was the case, it is said, with Marie Antoinette and the Prisoner of Chillon. It is quite common to see the hair acquire a distinct grey hue when a person is subject to acute severe CHAP. VI.] SECONDARY INDIGESTION. 97 mental trouble, a lawsuit, the death of a loved relative, intense suspense in speculation or business, indeed any cause of profound emotion; and to see it lose this tempo- rarily acquired hue, when the cause of the mental pertur- bation has either passed away, or the blow has been softened by time. The secretion of milk in woman is profoundly affected by mental emotion, indeed may become a deadly poison. Sir Astley Cooper observed two cases of arrest of the secretion from emotion and wrote — "Those passions which are generally sources of pleasure, and which, when moderately indulged, are conducive to health, when carried to excess, alter, and even entirely check, the secretion of milk." According to Dr. Carpenter, many observers have noticed fits of passion in a suckling mother followed by convulsions and death in the infant after being put to the breast. Thus, in one case a tumult arose between a soldier and a carpenter in whose house he was billeted ; the carpenter's wife rushed in, wrested the sword from the soldier, and broke it in pieces. " While in this strong excitement, the mother took up her child from the cradle, where it lay playing, and in the most perfect health, never having had a moment's illness; she gave it the breast, and in doing so sealed its fate. In a few minutes the infant left off sucking, became restless, panted, and sank dead upon its mother's breast." It is clear that the disorder in the secretion provoked by mental emotion produces some very active poison, acting rapidly upon the nervous system with deadly effect. Convulsions usually are provoked ; nor is this perversion of secretion in emotion confined to human beings, Carpenter writes, 98 SECONDARY mDIGESTION. [chap. vi. "Another case was that of a puppy, which was seized with epileptic convulsions, on sucking its mother after a fit of rage." Such are the acute perversions which produce toxic matters in the milk of a mother when she is emotionally excited. The mental disturbance sets up modifica,tions of secre- tion which result in the formation of a poison acting mainly, if not entirely, upon the nervous system. So in more chronic and persisting conditions. A men- tal upset disturbs the nutritive processes, and the changes so induced react upon the nervous system: consequently we can comprehend how persisting depraved nutrition can be traced to a particular period of mental disturbance by the sufferer, with a fair show of reason for what is stated. The most intractable case of dyspepsia with malaise, lethargy, inability for exertion, a disordered state of the bowels, with furred tongue, a hot bitter taste in the mouth on waking; all the evidences indeed of disordered diges- tion with the production of abnormal "by-products of digestion," which ever came under my notice, was that of a returned East Indian. This gentleman came of a healthy stock, was a well nourished person, took a very high place in the examination for the East Indian Civil Service; continued his labours; took one thing after another, far outstripping all his competitors: with what re- sult ? This! His digestive apparatus became so thoroughly disordered that he was compelled to retire from duty, to come home to England, to do nothing. A confirmed dyspeptic, his bodily comfort destroyed, his prospects CH.\p. Yi.] SECONDARY INDIGESTION. 99 clouded darkly, crippled in the race for life; he has to sit helplessly looking on, while his old competitors diminish the space betwixt him and them, and then overtake him ; after that, see them going onward leaving him hopelessly behind. If he were not a man of high moral principle he would be driven to suicide ! Another more ordinary case was that of a gentleman in a business house in South AYales. He had charo;-e of a branch of the business, was an energetic active man, in- dustrious, persevering, and painstaking. Feeling it would be an advantage to be acquainted with the French lan- guage, he sat up at nights to learn it. Under this additional strain his health broke down. He seemed rather surprised when told that he had been, from a medical point of view, guilty of a piece of consummate folly: for, from a business point of view his conduct merited the highest commendation. He omitted from his calculation the matter of his health. His dior-estion broke down, he began to sweat at nights, and his left lung w^as not above suspicion. Fortunately his employers, knowing his value, took alarm and sent him to me at once, before the mischief had gone any length. He was put upon tonics, and advised to go a trip into the Mediterranean in one of their vessels ; and then to go to France for a time, so as to acquire the language without overworking. The result of his overwork was a breakdown: a very common matter. He just lost the time which would have enabled him to have acquired French in a less violent hurry. He is now well and free from any chest ailment. Such then are examples of a class of case sadly too nu- 100 SECONDARY INDIGESTION. [chap. vi. merous at the present time. In this generation men will not be content to move at the leisurely pace of their grand- fathers. Mr. Deane, in " The Mill on the Floss," spoke to his nephew Tom Tulliver as follows:—" The world goes on at a smarter pace now than it did when I was a young fellow. ^A'hy, sir, forty years ago, when I was much a strapping youngster as you, a man expected to pull between the shafts the best part of his life, before he got the whip in his hand. The looms went slowish, and fashions didn't alter quite so fast; I'd a best suit that lasted me six years ! Every- thing was on a lower scale, sir, in point of expenditure, I mean. It's the stream, you see, that has made the dif- ference; it drives on every wheel double pace, and the wheel of fortune with 'em." And so men push, and strive, and struo:a:le, and attain their end, — or break down in trying. It is the old Anglo-Saxon plan to find out wdiat can be done by over-doing, and so learning the extreme limit. A butcher's boy was spokesman for his race, when summoned before the magistrates at Teddington, for furi- ous driving ; the constable stated the mare was going thirteen miles an hour, w^hen the boy triumphantly re- futed him by saying, — " She can't do it ; she has not got it in her ! " He evidently knew to a nicety what she could do, by noting what she could not do. So it is in the pres- ent pace of life. It is faster ! faster ! Our steeplechasers gallop faster than their old-fashioned half-bred predeces- sors ; our fox-hounds run faster than of yore, till our hunters have to be nearly thorough-bred to keep pace with them. It is the pace at which we live that over- taxes our organic processes, and the digestive processes CHAP. VI.] SECONDARY INDIGESTION. 101 breaking down under the strain. It is the early period at which the pace is put on which is telling. Our race- horses are trained so young, that they soon are unfit for the racecourse ; how few horses are there now who are good for anything at six years old. Old Forrester was racing long years after any horse is now put to the stud; but probably he never ran as a two-year old. Eclipse was five years old before he was trained. As with horses, so with men. A man used to be satisfied to have earned a compe- tency at 60; now he strains to retire at 45 with a fortune. As with men, so with the racehorses; the difficulty is to keep up their appetite and digestion. This it is which bothers the trainer. The young horses " go off their feed," and then the training is suspended. Quinine, with acids and gen- tian, is in vogue in trainers' establishments, to keep up the young scions of a famous stock. In the high-bred racer, the digestive organs give way under the demands upon them, made too early. As the trainer has to whip up the appetite of his two-year old, so the Lincolnshire grazier finds it pay him to cook a part of the food for his stall-fatted stock. Perhaps in a few years it may be necessary, or anyhow, profitable, to give these oxen tonics. To what then are we coming. Tonics, artificial digestive agents, or even artificially digested food, may be palliative as regards the individual: but they cannot be regarded as curative as to the race. For our successors something else is necessary ; and what that " something " must be will be seen in a subsequent chapter. There is another aspect of this subject, of the effect of mental attitudes upon the organic processes, which needs 102 SECONDARY INDIGESTION: [chap. vi. a little consideration, especially for those whom it con- cerns, viz., the hypochondriac ; and those who though not exactly belonging to the class " malade imaginaire," still give too much attention to their subjective sensations. It may be well again to quote Dr. Carpenter verbatim in this matter: — " The influence of the state of expectant attention in modifying the processes of nutrition and secretion, is not less remarkable than we have seen it to be in the produc- tion of muscular movements. The volitional direction of the co7isciousness to a part, independently of emotional ex- citement, suffices to call forth sensations in it, which seem to depend upon a change in its circulation ; and if this state be kept up automatically by the attraction of the attention, the change may become a source of modification, not only in the functional action, but in the nutrition of the part. Thus, there can be no doubt that real disease often supervenes upon fancied ailment, especially through the indulgence of what is known as the hypocliondriacal tendency to dwell upon uneasy sensations ; those sensa- tions being themselves, in many instances, purely ' sub- jective.' In many individuals (especially females), whose sympathies are strong, a pain in any part of the body may be produced by witnessing it in another, or even hearing described the sufferings occasioned by disease or injury of that part ; and if this pain be attended to, and be- lieved in, as an indication of serious mischief, injurious consequences are very likely to follow. So, again, the self-tormenting hypochondriac will imagine himself the victim of any malady that he may ' fancy ; ' and if this CH.u'. Yi.] SECONDARY mDIGESTIOIT. 103 fancy should be sufBciently persistent and engrossing, it is not unlikely to lead to real disease of the organ to which it relates. His persistent direction of the attention has a much greater potency, when combined with the expectation of a particular result; and thus it happens that the spells of pretenders to occult powers, in all ages and nations, often produce the predicted maladies in the subjects who are credulous enough to believe in their efficacy. Such was formerly the case among the negroes of the British West Indies, to such a degree, that it was found necessary to repress what was known as ^ Obeah practices,' by penal legislation; a slow pining away, ending in death^ being the not uncommon result of the fixed belief on the part of the victim, that ' obi ' have been put upon him by some old man or woman reported to possess the injurious power. So great, indeed, was the dread of these spells, that the mere threat of one party to a quarrel to ^put obi' upon the other, was often sufficient to terrify the latter into submission. And there is adequate ground for the asser- tion, that even amongst the better instructed classes of our own country, a fixed belief that a mortal disease had seized upon their frame, or that a particular operation or system of treatment would prove unsuccessful, has been in numerous instances, the real occasion of a fatal result." I introduce this paragraph verbatim, to put the dys- peptic on his guard about the study of his subjective sensations; as much as to warn the hypochondriac that it is well to try to put away his, or her morbid dwelling on ideal conditions. It is clear that it is desirable the dyspeptic be cured as soon as may he; not only fpr his, or 104 SECONDARY INDIGESTION. [chap. yi. her comfort or well being, but iii order to obviate the danger of disordered function leading to structural change from the direction of the attention thereto. This is no imaginary danger, as Dr. Carpenter shews. Even when the sensations of discomfort are present, it is well not to let them absorb the attention; the sufferers should turn their thoughts in other directions, or have them distracted for them. Certainly it is within my personal experience that persons who have long been troubled with indigestion, have died of cancer of the stomach. Nor do I regard these as accidental relationships, or mere coincidences. Long gastric trouble culminated in cancer of the pyloric ring, not that such is a common occurrence; but certainly in a number of cases either gastric cancer had a far reaching history of indigestion preceding it; or long-standing func- tional disorder led to structural change: whichever way the reader chooses to put it. It is most desirable then that such sensations as arise from disordered function, are put away as much as possible by actual sufferers; while those whose maladies are cen- tric, and due rather to disturbance within the posterior lobes of the cerebral hemispheres, than to actual disorder in the viscera, will be wise to attend as little as they can to their abnormal feelings. Dr. Hughlings Jackson, F.R.C.P., holds that the liver, indeed, each of the viscera, has its representative area in the brain, just as much as the arm or leg is represented in a distinct and localized area. The hypochondriac feels his sensations in the part to which he refers them; just as other sensations are ex- perienced which are unreal. The lunatic is not the only CHAP. VI.] SECONDARY INBIGESTIOX. 105 individual who has what others regard as hallucinations. What each one feels is known to himself. A patient of mine once felt hairs in liis mouth; there were no such hairs. But the impression lasted the remainder of his lifetime. Jn such a case, there must have been a centric disturbance referred to a peripheral cause, in accordance with our common experience. " Phantom limbs," are a not uncommon phenomena; and a man will feel the little finger ache with cold, in an arm amputated years before. So in hypochondriasis, probably the disturbance is the primitive sensation in the cerebral area, not the part to which it is referred; but the persistent direction of the at- tention to the said viscus, may in time lead to actual func- tional disorder; which in its turn may set up structural change in the course of time. The relations betwdxt the brain and the digestive organs are intimate and interesting. Disturbances in the viscera disorder the brain directly, as well as by the abnormal products which reach it through the blood. Disturbance in the posterior lobes, those portions of the hemispheres connected with our internal sensations, may lead in time to disorder in the viscera associated therewith. The direc- tion of the attention operates banefully upon the organs to which it is turned. There are actions and reactions within the complex microcosm; and the organic nervous system has not been denominated " the sympathetic " with- out good and sufficient reasons. This is an aspect of the subject which must be considered and reflected upon. Its consideration may be disturbing to sundry nervous per- sons; but that is simply unavoidable, however undesirable. 106 SECONDARY INDIGESTION. [chap. vi. It is all very well for certain enthusiastic individuals to deny themselves wine, which would do them good, in order to set an example of abstinence to those who yield to al- coholic temptation; but the bulk of humanity do not carry their " altruism " to such lengths. Such a way of regarding the linked intimacy of mental states and morbid digestive processes, may be alarming to sundry invalids and valetudinarians, but its consideration will be benefi- cial to a large class; and after all, Jeremy Bentham was right, when he insisted upon " the happiness of the greatest number" being the thing to be aimed at. For on the other hand, a mental state may operate beneficially. Dr. Carpenter continues — " But on the other hand, the same mental state may operate beneficially, in checking a morbid action and restoring the healthy state. That the confident expectation of a cure is the ipost potent means of bringing it about, doing that which no medical treatment can accomplish, may be affirmed as the generalized result of experiences of the most varied kind, extending- throuo^h a lono- series of ages." He then instances cases of "cures" ejBfected by faith, and says, — "For although there can be no doubt that in a great number of cases the patients have believed themselves to be cured, when no reed ameliorcition of their condition had taken place, yet there is a large body of trustworthy evidence, that permanent amendment of a kind perfectly obvious to others, has shown itself in a great variety of local maladies when the patients have been sufficiently possessed by the expectation of benefit, and h J faith in the efficacy of the means employed." It cH.\p. VI.] seco:n'dary indigestion: io7 is quite clear in this matter, that the confidence of the patients will rest upon the confidence with which they are told that they will be cured. If the curer, or tliauma- turgus, believe not in the cure, he cannot inspire the patient with faith. If the medical man speak to the patient with doubtful accents and hesitating utterances, he does not inspire confidence ; he really sows distrust. This is the explanation of the successful treatment of a case by one man, where another has failed; the remedial measures being much the same. The one carries the patient with him to the restoration of health ; the other intensifies a morbid state, and tends to make it permanent. This is a matter too little thought about. Just as a weak-willed medical man fails to do certain patients good ; and lack of decision of character unfits a medical man for dealing with emergencies, where the judgment must be prompt and the action energetic ; so the therapeutic ni- hilist, who doubts the eflBcacy of drugs, and leaves the patient to nature, disheartens many patients, and leaves them chronic valetudinarians, when in the hands of an enthusiast, the cases would soon move onward to a satisfac- tory termination. There are some men who are " doubt- inor Thomases :" there are others who decrv what thev do not understand, and depreciate remedies with whose po- tency they are unacquainted, who do infinite, immeasurable harm to their patients. An eclipse of faith in medicines has now existed some time ; but the darkness is beginning to move away, and a return of faith, stronger, firmer, more capable of giving a raison d'etre for its existence than in the past, is dawning, — the daybreak of happier times for 108 SECONDARY mDIGESTION. [chap. yi. those who are stjicken down with ilhiess, or crippled in their working power by incapacity in their digestive viscera. This therapeutic nihilism is a passing wave of opinion, a temporary mental state, the end of which is at hand; and the sooner it is over the better for all. The patient's pros- pects will be all the brighter, the medical man all the happier for feeling that the patient has got some " value received " in return for his outlay. A healthier condition of thought on matters medical will generally obtain ; for quacks, charlatans, and irregular practitioners of all kinds, are to a great extent fostered by the recent want of faith in the medical profession. When a man is sick, what he wishes is to get well ; the means is to him a matter of comparative indifference. If he gets his health again, he recks little whether it is by the means of a notorious quack, or by those of some one possessed of the " hall mark " of the venerable College of Physicians. This is a moral aspect of the question which that ancient institution has been rather nodding over for some years past ; and it is quite time that it awakened up to a proper consideration of the subject. The public will not rest patiently quiet till its slumbers are completed ; and the sooner the period of awakening arrives the better for all. Stronger faith in the profession as a body, will lead to more belief in the individual units of it ; and this in turn will inspire the public. Perhaps those acrid personages who have a distinct line of faith, or rather the want of it, those individuals who believe in Homoeopathy, and talk flippantly of "Allopaths," who deny the utility of the Contagious Diseases Act (Human), who are anti-vacci- CHAP. VI.] SECONDARY INDIGESTION. 109 iiators ; who are blended compounds of scepticism and credulousness ; those who are utterly unteachable from prejudice and ignorance " vaunting itself as knowledge," cannot be benefited ; not even if their chief diurnal in- structor, their *' guide, philosopher, and friend," the Daily JVews, was to modify its attitude, and shew a livelier in- terest in matters affecting the public health, and a little more decent respect for the observations of " the natural man," They are an unhopeful class, the obstructionists of all progress in matters sanitary and hygienic ; wdiose self-satisfaction in their ignorance on matters medical is simply as aggressive and impertinent as that ignorance is appalling. They are blinded guides in their self-ap- pointed mission of directing the opinions of mankind ; but their faith in themselv^es is unbounded ! Such then are the cerebral relations of disturbances in the digestive processes. They do not necessarily involve a disordered tongue, or constipation, or diarrhoea ; or manifest those evidences of dyspepsia, found when the indigestion is primary. There is another form of indis^estion due to nervous dis- turbance elsewhere, which also carries with it no obvious siofns of the dio-estive tract beino- the sole seat of trouble, as a bare, or raw^, or a foul, or furred tongue ; but w^iere con- stipation is commonly found. This is due to a tender ovary, mostly the left. This lies near the rectum, and the pas- sage of fasces causes pain ; the pain inhibits the movements of the bowel, and constipation is the result. The accu- mulated ffeces keep up the ovarian tenderness, and the voiding of them produces still more pain. And so the action 110 SECONDARY mDIGESTIOK [chap. vi. and reaction work in a downward direction. Such indi- gestion is properly termed " reflex." It is a very common malady which has been overlooked. It is mentioned by Negrier, Robert Barnes, and Lombe Atthill. I had to learn to decipher it for myself, and first described it in an article on " Ovarian Dyspepsia," in the American Journal of Obstetrics and Diseases of Women and Children^ Jan., 1878, though it may have been delineated elsewhere j but if so, I am not acquainted with the article. " The reproductive organs of woman are the source of most of her troubles during that period of her life when they are functionally active. Often will far-away irritation in the womb, or ovary, be found to be the cause of the moot prominent objective and subjective phenomena manifested elsewhere. Irritation is not always felt where it arises ; the pain is very commonly in the knee when the disease is in the hip-joint ; in the right shoulder when the liver is involved. We know that the pregnant uterus, especially in the early months before it has escaped from the pelvis, commonly produces very troublesome vomiting ; or it may produce a persistent cough, known in Scotland as ' a cradle cough.' Vomiting is a common outcome of injury to, or acute mischief in the testicle, as it is a pronounced symp- tom of a calculus in the kidney. The old term ' the sym- pathetic nerve ' was founded on the appreciation of the fact that one part was influenced by, or sympathized with, an- other through the fibrils of this nerve. Currents may arise in the ovary and be felt — not there when they arise — but at some far-distant point, where they run out. If a num- ber of ivory balls be suspended in a row, touching each CHAP. VI.] . SECONDARY IKDIGESTIOK. Ill other, and a tap be given to either terminal ball, it is the one at the otlier end which flies from its place. Conse- quently waves of nerve-perturbation, arising in the ovary, manifest themselves by disturbances elsewhere. The glit- tering flash which glances out from some female irides is the external indication of ovarian irritation, and ' the ovarian gleam ' has features quite its own. The most marked instance which ever came under my notice was due to irritation in the ovaries, which had been forced down in front of the uterus and been fixed there by adhesions. Here there was little sexual proclivity, but the eyes were very remarkable. They flashed and glittered unceasingly, and at times perfect lightning bolts shot from them. Usually there is a bright glittering sheen in them which contrasts with the dead look in the irides of sexual excess, or profuse uterine discharges. Cough, palpitation, face • ache, usually on the right side, inframammary pain, usually in the left sixth or seventh intercostal nerves, and gastric irritation are the ordinary outcomes of uterine flex- ion, or ovarian disturbance. The most important matters clinically are the gastric symptoms reflexly excited by pelvic irritation. " So important and so common are these maladies, and so utterly unsatisfactory their treatment under the usual remedies — as bismuth, hydrocyanic acid, oxide of silver, &c. — that they deserve to be treated at some length. In the first place the stomach has different nerve-fibrils — those from the vagus, and those from the sympathetic. Claude Bernard observed that the application of a galvanic stimulus to the vasrus fibres caused free secretion of the 112 SECONDARY INDIGESTION. [chap. ti. gastric juice ; while the same stimulus applied to the sympathetic fibrils issuing from the semi-lunar ganglia, caused a diminution and complete arrest of the secretion. The action of sympathetic nerve-fibrils is to excite con- traction in the arteries and arterioles ; that of the pneumo- gastric fibrils to dilate these vessels. Consequently we can readily understand how currents coming in by the sympa- thetic tracts from pelvic, or other irritation, may contract the gastric arterioles and arrest the flow of gastric juice. If the irritation be sufficiently powerful then vomiting is set up. In ordinary digestion the gastric blood-vessels are dilated and there is a free flow of gastric juice. The irritation coming in from without checks both these pro- cesses, and then imperfect digestion with pain, or nausea is the result. This may not proceed further than loss of appetite, dyspepsia, and nausea : or there may be severe persistent vomiting set up by the introduction of food into the stomach, till a very serious condition may be reached. In either case the tongue is clean, and there are no evi- dences of disturbance in the gastro-intestinal canal, as in primary gastric indigestion. Such is the dyspepsia so common in women. Primary dyspepsia is no more fre- quent in women than in men, and presents the same features in both sexes. But reflex dyspepsia has other and quite different associations. In both forms of dyspep- sia there may be constipation, or diarrhcBa, excited by the undio-ested food irritating the intestines, but these are incidental or coincident collaterals. In reflex dyspepsia there are usually the intercostal neuralgia, with the three tender spots of Valleix, one under the mamma, the second CHAP. Yi.] SECONDARY INDIGESTION. 113 at the base of the left scapula, the third at the exit of the posterior rootlet of the sixth or seventh intercostal nerve from the spinal column; and palpitation. Less commonly faceache or cough, and in middle-aged women flushings. Then there are the uterine out-comes of the ovarian mis- chief — leucorrhoea, with or without menorrhagia, while at times the menstrual flux is lost, or all but lost, in the j^ro- f use leucorrhoea. The o-enerative or^-ans of women become turgid with blood during sexual excitement, approaching the erectile condition of the male organ under excitement. Ovarian irritation sets up vascular turgescence in the fe- male parts which continues more or less persistingly. The consequence is that there is profuse secretion, often with ex- cessive catamenial losses. Frequently, too, there are erotic dreams, recurrent orgasms, during sleep, ' the period ^:)a;* €xcelle?ice of reflex excitability.' In more pronounced cases, these discharges take place in the waking state, without any reference to psychical conditions, being found alike in married women cohabiting with their husbands, and in spinsters and widows. That sexual excitement may be produced, or kept up by lewd thought may not be denied; but this is not necessarily the psychical attitude here. The uterine centres in- the cord and the centres presiding over the bladder lie in close proximity to each other. The irritable condition of the lumbar centres of the reproduc- tive organs is communicated to the vesical centres, and then a very distressing condition results, viz., a state of weakness and irritability in the bladder, and the call to make^water is sudden and imperative, and must be attended to at once, or a certain penalty be paid for non-attention. 114 SECONDARY INDIGESTION. [cHAr. vi. Such are the objective and subjective phenomena exhibited in a complete case of 'reflex dyspepsia' of ovarian origin: and it is by the study of such well-marked cases that the student will learn to recognize the less marked or imperfect cases. Nor does it necessarily follow that the symptoms shall stand in a definite proportion to each other in each and every case. Sometimes the chief disturbance is ute- rine, at other times mainly gastric. When the latter, the case often runs as follows — a girl, usually of the neurosal diathesis, betwixt nineteen and twenty -four years of age, becomes the subject of intractable vomiting. This goes on till such weakness is produced that the patient is confined to bed, and her life apparently endangered. The least particle of food is immediately rejected, more or less com- pletely. All sorts of combinations of drugs are tried, and fail to procure any alleviation of the condition. The medi- cal attendant is nearly worried out of his life, consultants are called in without avail; the friends of the patient are worked up to a state of feverish anxiety; the sufferings of the patient are not inconsiderable; and so the case wears on for weeks. Bismuth, hydroc^^anic acid, opium, effer- vescing mixtures, champage, milk and seltzer water, beef- tea, hot and cold, raw meat pounded, maltine, all are tried and fail; sometimes enough is retained to support life; at other times it becomes necessary to resort to nutritive ene- mata. All who have seen much practice are familiar with such cases, which are very trying to all parties concerned, and which are unaffected by the different remedial measures resorted to; and which seem at last to wear themselves out, and are followed by long and tedious convalescence. A CHAP. VI.] SECONDARY INDIGESTION. 115 year or two afterwards the patient is in good health, often a happy mother. Here the absence of local indications throws the medical man off the scent as to the real nature of the malady with which he is brought in contact, and the ovaries are unsuspected. All the remedies are futile and inoperative because not directed to the origin of the trou- ble. The case lingers on till it would seem the general mal-nutrition starves down the congested ovary into quietude, and then the reflex disturbances cease. Were the true origin of the case known or discovered, then the successful treatment would soon be forthcominof-. As a case in point, I may mention a girl who came under my care some time ago at the West London Hospital. For many months she had been under medical treatment for persisting retching and vomiting. The girl was pale and anasmic, with lack-lustre eyes, and a peculiar but charac- teristic expression, which may be observed but cannot be described, indicative of ovarian trouble. The left ovary was found congested and exquisitely tender, pressure over it almost producing syncope, and exciting acute nausea. The ovary was treated, and in ten days the girl left the Hospital — well, but I doubt if permanently cured. "What is the treatment of these cases? It consists of several factors each essential and complementary to the others. The bowels should be unloaded, so that there shall be no pelvic congestion. A small quantity of sul- phate of magnesia in each dose of medicine will usually attain this end. If not quite sufficient an aloetic pill at bed-time is indicated. In small doses, as said before, aloes excites the hremorrhoidal vessels; in fuller doses it depletes 116 SECONDARY INDIGESTION. [chap. vi. them. The bowels should be emptied at bed-time. A load in the bowels during sleep produces vascular turges- cence in females whose reproductive organs are out of health, just as it produces chordee in a man with gonor- rhoea. Then comes the other factor — the reflex manifesta- tions. Instead of treating the stomach an agent must be o:iven which will influence the nerve tracts over which the perturbatory waves travel. Bromide of potassium deadens the nerve-fibrils alike along their course and at their peri- pheral endings. Both at the ^periphery in the ovary and at the terminus, the stomach, is its influence felt. It blunts the nerve endings while it deadens the conductive power of nerve-fibrils. Consequently a combination like the following is useful' : — Mag. Sulph. 3 i. Potass. Bromidi 3i. Mist. Camphorse, | i., ter in die. If the stomach reject this a hypodermic injection of half, or a third, of a grain of morphia will usually produce such effects that the stomach will tolerate the medicines. Nutritive enemata may be needed for a day or two. As soon as the bromide is tolerated and retained, matters improve. Sometimes it is well to substitute infusions of gentian for the camphor mixture as a vehicle; it acts beneficially upon the stomach, as do all bitters, and ren- ders it more tolerant of the medicines. Local treatment in the shape of a blister over the tender ovary is of much value; not only does it produce a mental impression, but we have reason to suppose that nerve-waves can meet and CHAP. VI.] SEC Om) ART IXBIGESTIOy. Ill neutralize each other — like rays of light — under certain circumstances. The ordinary Emplastrum Cantharidis 2x2 applied over the offending ovary on going to bed will usually be found to produce vesication by the morning. Some slio:ht soreness follows, but the relief afforded to the internal pain far outweighs this. In some rare instances a crop of boils follows the blister; but so rarely as not to militate a2:ainst its use. By these measures combined, the reflex g-astric disturbance is effectually removed. " There remains the leucorrhceal loss to be considered. Hiofofinson's svrino-e, or the common enema svrinofe for infants, are preferable to the glass syringe, which is brit- tle, and accidents sometimes occur. First an injection of plain water to remove all discharge, and then of a little alum water, not stronger than an ounce to two quarts of water, will usually soon reduce the loss. If there also be menorrhagia the usual measures must be adopted." [T7ie Practitioner's JSandbooh of Treatment^ 2nd edition.) Another form of " secondary indigestion," is that due to venous fulness from valvular disease of the heart. Its chief indication is that "sense of fulness" experienced by the patient, even when the stomach is empty of food. This is rarely absent in cases of cardiac failure in elderly persons, indeed, it is in old persons that it is mainly felt; though it is not uncommon in young persons with severe mitral disease. It arises from obstruction to the circulation, due to some lesion in the heart — usually a valvular lesion; but at times occasioned bv the vieldino- of the muscular wall. This ob- struction causes a damming of the blood at the point, which works backwards into the veins and venules. 118 SECONDARY INDIGESTION: [chap. vi. " Sooner or later, the right heart yields, either by the tricuspid ostium becoming so large as the muscular "walls dilate, that the valves become insufficient; or by secondary implication of the tricuspid valves rendering them no longer equal to the closure of the normal ostium; or by a combina- tion of both. Then the venee cavse become distended, and the jugular veins are seen to pulsate. Some jugular pulsa- tion may be seen before the tricuspid becomes insufficient; it is caused by the reflux of blood through the tricuspid be- fore its flaps are driven together on the ventricular contrac- tion. All the branches of the venee cavas become distended ; and especially is this the case with the portal circulation, which is not provided with valves. Splitting up as it does in the liver, the portal vein is partially protected by minute divisions in the liver, otherwise great disturbance would be occasioned by the want of valves in it, on tricuspid regurgi- tation. But, in consequence of this sub-division in the liver, that viscus becomes gorged with blood in tricuspid regurgitation, and pulsates with the regurgitating current driven backwards by the hypertrophied right ventricle. Liver-pulsation is a distinct symptom of diagnostic value; while the venous fulness of the liver leads to a develop- ment of connective tissue corpuscles in the inter-lobular areolar tissue; first there is increase of bulk in the liver, then cirrhosis or atrophy as the connective tissue con- tracts; the liver tissue becoming much firmer and harder than normal. The liver is easily deranged by an excess of food when so affected, and great care in diet is requisite for the proper performance of its functions. There is serous effusion from the gorged venules into the bile- cmvp. VI.] SECONDARY INDIGESTION. 119 passages attending it, so that Oppolzer has given to this condition the term ' albuminicholi; ' and he further states that in this condition there is consrestion of the mucous lining of the bile ducts with jaundice, and that both these conditions are readily affected by a common cold. The disturbances and chan^-es in the liver are much more marked in some persons with tricuspid failure than in others. " The spleen is implicated in this congestion of the portal circulation; it becomes enlarged from the development of connective tissue in it, is larger than normal, and of firmer consistence, resembling a beefsteak in appearance when cut open. We know, as yet, nothing of the symptoms of dis- turbance of the functions of the spleen. " The stomach and intestinal canal are also deranged, and the disturbances set up in them by tricuspid failure are dis- tinct and pronounced. There is fulness of the venules of the stomach, and from that springs catarrh, with its patho- gnomonic indication, * sense of fulness,' even when the stomach is empty. The feeling of being constantly 'too full ' is a very common outcome of advanced cardiac failure. The secretion of gastric juice is impaired, and it is diluted with a serous fluid. Consequently its digestive power is impaired. The catarrhal mucus is readily folded over any solid food, which so covered cannot be acted upon by the solvent juices, themselves impaired in power. Dys- pepsia is the result of taking any but liquid food; and this condition of the stomach should ever be borne in mind in the treatment of cases where the tricuspid has begun to leak. In this condition of the mucous membrane, gas is 120 SECONDARY INDIGESTIOIT. [chap. vt. often disengaged very freely in many elderly persons, and the eructations are persistent, and often very loud. The patient's condition is very distressing; and the pressure on the diaphragm, and on the right ventricle, causes much disturbance of the respiration and dyspnoea, with very un- pleasant palpitation. This altered mucous membrane also causes morbid sensations and cravings for highly-spiced or unsuitable food; and this may lead to differences of opinion betwixt patient and doctor. "The intestinal canal is involved, and may be disturbed in two directions. There may be irregular and defective ac- tion of the bowels from imperfect nutrition of the muscular fibre of the bowels, calling for warm aperient medicines, — (for here the aperients must be warm and contain carmina- tives as much as in the case of the menopause) — enemata, or soap suppositories (Trousseau). Or the congestion of the venules of the intestinal canal may lead to diarrhoea, which often furnishes great relief, and should never be interfered with without good reason, nor until becoming unquestionably excessive. King Chambers says, that in conditions of gastric and intestinal catarrhs, the use of compound kino powder is indicated, and that under these circumstances, especially gastric catarrh, it rarely consti- pates. Alternations of constipation and of purging may occur. Bleeding piles, or hemorrhoids, are frequent in the subjects of cardiac failure. Hemorrhage from these piles often gives great relief, and should not be rashly checked. When no bleeding has occurred for some time, a flow of blood from some other organ may take place, as haemoptysis, for instance, and be followed by distinct relief. CHAP. VT.] SECONDARY mDIGESTION. 121 If there also be old-standing kidney disease, there may be found old, small, contracted granular casts alongside the dark recent casts; or, according to Basham, casts in a state of fatty degeneration. The kidneys are found enlarged, swollen, injected with blood, and from the venous congestion a growth of young connective-tissue corpuscles is set up in them. When attending the Pathological In- stitute at Vienna, it Avas quite common to see these recent chanor-es from heart failure alono:side the evidences of old standing renal mischief. The two were quite distinct. This subject will be treated more at length in the Chapter on the Gouty Heart. *' The genito-urinary system is disturbed by the venous congestion. There may be vesical catarrh, prostatic ful- ness, or urethral catarrh, or even hydrocele from conges- tion of the pampiniform plexus (Oppolzer). " In women, there are catarrhal and menorrhagic troubles from concrestion of the veins of the uterus and vagina. Oppolzer thought that profuse menses often accompanied the arterial fulness of aortic regurgitation, and regarded it as a symptom of some value in that form of cardiac disease. My own observations have not been numerous enough to enable me to corroborate this statement. '' Dr. Angus Macdonald has recently published a work on the 'Bearings of Chronic Disease of the Heart upon Preg- nancy, Parturition, and Childbed,' which is of the great- est interest; but unfortunately he does not discuss the questions of whether leucorrhoea is common in women with heart-disease, or what is the effect upon the amount of the menstrual flux. So far as my impressions go, for 122 SECONDARY INDIGESTION. [chap. yi. I have no exact data on the subject, these outcomes of fulness of the pelvic veins are not so influenced by disease of the heart as might d priori have been expected." When this condition of venous fulness is the cause of indigestion, it is obvious that the therapeutic measures must be directed to the improvement of the circulation. If the circulation can be relieved, the uncomfortable sen- sations will pass away along with the catarrh with which they are casually related. Astringents, as compound kino powder, are very efficacious in simple primary gastric catarrh; but in those cases where the circulation is the cause of the catarrh, they are also useful, but to a much less extent. It is better practice to put the patient in bed, so as to give the heart as little work as possible to do; to improve its condition by giving agents like digitalis and strychnia, which act directly upon the heart and increase the vigour of its contractions, so that the heart fills the arteries by emptying the veins — -rfor that is really the func- tion of this "blood-pump;" and to relieve the fulness of the venous radicles by evacuants, as hydragogue cathar- tics, and diaphoresis produced by the application of heat. When the blood is relieved of a quantity of water by these measures, then the venous fulness is relieved, and with it the catarrh which is its consequence. Strict dietary is in- dispensable to the relief of such cases. An error in diet is fraught with mischief which may persist for long. In- deed, the correct regulation of the dietary will tax the re- sources of the physician to the utmost. But the results to the patient are very grateful and agreeable, as well, too, as to the doctor's self-pride. CHAP. VI.] SECONDARY mBIGESTION. 123 There is still another form of " secondary indigestion " which remains to be described; and that is, the ** toxsemic " form. Mal-nutrition, the result of a poison in the blood, is far from an uncommon occurrence. The presence of the poison interferes with assimilation generally, and the for- mation of the complex body — haemoglobin, in particular. Consequently anosmia is a common feature in the case of mineral poisons, as mercury and lead; in miasmatic poisons like that of malaria; in poisons acquired or pro- duced, as syphilis and gout. These two latter poisons commonly interfere largely with the assimilative organs and their functions. As gout will be dealt with in extenso in the second part of this work, nothing more need be said about its effects upon nutrition here. But it is necessary to say something about syphilis. Young persons with con- genital syphilis often present conditions of mal-nutrition and ansemia, especially the latter, where the ordinary measures, including the administration of chalybeates, are impotent to initiate improvement; but where the addi- tion of mercury or iodide of potassium acts like a charm. The syphilitic infant is a sorry spectacle. Its puny limbs, the skin either hanging in folds, or dry, harsh, and dirty; its wasted muscles; its withered face, approaching the wrinkled face of age; its sore eyes, often with a discharge; the characteristic "snuffles; " its whining, moaning, feeble cry; the presence of a coppery-tinted blush upon its nates and around its anus, sometimes with condylomata, some- times with a general rash more or less developed. It is, indeed, an object in more senses than one. It is piti- 124 SECONDARY INDIGESTION'. [chap. yi. able for its own sake, from pure humanity; it is pitiable morally as an illustration that the sins of the father are ■undoubtedly visited upon the children; it is pitiable to see the fond mother's love given to so sorry a babe. Ordinary measures are impotent here to affect any good. Mercury is the specific. When this is added the child fattens, its little wasted limbs grow plump; the rash disappears; the '^ snuffles " vanish; the eyes recover their normal aspect; it is the difference betwixt a changeling, an elfish goblin, and a human baby. But it is not in children only that such ^' toxfemic " mal- assimilation is found. The following case illustrates this form of indigestion.. A friend of mine wrote to me in the spring of 1880 a most dolorous account of his sufferings from indigestion, which had proved most intractable, in- deed, had deiied all the resources of a careful painstaking provincial physician. I wrote to him sketching out a dietary to be strictly adhered to in addition to the medi- cinal treatment, which was all that could be desired. No improvement took place; the indigestion being as unpleas- ant as ever. Late in the autumn he presented himself with a local malady, a persistent pain, which was found to be due to a periosteal thickening, nipping a sensory nerve. I found out a history of syphilis long 3'ears ago, which had been forerotten, until cross-examination brousfht it to mind; so little indication of its presence had it given. In order to be quite sure about the diagnosis, on which hung both the prognosis and the treatment, I took him to Jonathan Hutchinson for his opinion. He quite coincided with the view taken. The patient was put upon iodide of CHAP. ^^.] SECONDARY INDIGESTION. 125 potassium with immediate improvement as to the pain; not only that, but the indigestion has disappeared. I had told him that it was possible it might be found to do so. That the underlying factor was the unrecognised syphilis, in all probabilit}^, and that the specific treatment might cure the indigestion as well as the pain. He improved much after this treatment was adopted. Doubtless there are many such cases if they were only recognised. We are beginning to be familiar with " vis- ceral syphilis," in the form of structural changes set up by it in the viscera; but as a cause of functional de- rangement, its influence has scarcely yet been recognised. In time, probably, this will generally be admitted. Such then are some of the relations of indigestion, which are not described in our ordinary text-books; but of which the practitioner must know something, in his own interests as well as those of his patients. They require for their recognition that careful interpretation of subjective phen- omena which has been largely lost sight of in recent years, in the too exclusive devotion to the signs furnished by physical examination. Indeed, it is the individual which must be studied; not a diseased entity, described by a word or a phrase, presenting certain objective indications. Further, the successful treatment of these secondary forms of indiofestion, involves somethins- more and outside mere dietary, however indispensable; and the administration of the usual remedial agents: it comprises attention to the exciting cause and measures strictly adapted thereto. When made thus comprehensive, the treatment contains the elements of success — at least potentially. CHAPTER VII. INDIGESTION AS AN INTERCURRENT AFFECTION. This is a very important matter for the patient, and not insignificant for the practitioner. The aspect of a case may suddenly be clouded, like a bright April day may suddenly alter with the swift oncome of a dark rain- cloud, racing up with the wind. It may shew at first '^ike a man's hand " arising out of the sea, as did that which caused Elijah to send word to Ahab, yet '' it came to pass in the meanwhile, that the heaven was black with clouds and wind, and there was a great rain." So the prospects of a case may be suddenly obscured; and almost 'before danger is scented, the aspect may be profoundly changed. A little nausea, the surface of the tongue alter- ing, a rise of temperature, and the case doing well, may be suddenly endangered ; as the Eurydice, sailing with her stun-sails set, was sunk bodily by a squall coming up unnoticed behind Shanklin Downs. The wary and experienced practitioner knows the im- port of such threatenings; a rise in the temperature is as significant, and ominous withal, as a sudden fall of the barometer tells of comins: storm. Just as the seaman furls his topsails, and puts the ship under bare poles, unless it be a storm-jib, when the barometer suddenly falls for a typhoon; so when the medical man sees the thermometer suddenly rise, he is on the alert as to the other indicia of coming storm. But there are other semeia of threatening CHAP, vn.] INDIGESTION. 127 danger even earlier than this palpable change; like the stormy petrel that precedes the gale, the tongue grows irritable, red, angry-looking, or abnormally bare and smooth; there is restlessness, some nausea, the appetite is lost or very capricious, the sleep is disturbed; such are the symptoms which immediately arrest our attention, or ought to do so. The rise of temperature converts sus- picion into certainty; but usually it- is well not to wait for this corroboration, but to act promptly on the first sus- picion. The case may be one of pneumonia, it may be of surgical operation, or of typhoid fever. No matter what the form of disease, when these indications of acute disturbance in the digestive tract shew themselves, it be- hooves the practitioner to put the hands on deck; the craft is in danger, more or less imminent. The coming risk must be faced. To use another simile, when a general sees that he is beins: threatened with a flank movement, he makes his disposition accordingly; he changes his front so as to face his new^ foe. So it must be with the medical practitioner. He must meet the new danger; and many a patient is needlessly lost for want of this rapid change of front. If the new intercurrent attack proceed to vomiting, then the prospect becomes vastly grave, indeed. If food cannot be retained, the patient will sink. Nutritive enemata may keep the case floating a while; but only a little while, not for long. In many cases, the change is due to pushing alcoholic stimulants too freely; in others, alcohol is urgently called for. All depends upon the precise facts of each case. The medicines previously given are often to be withheld; 128 INDIGESTION, [chap. vn. however strong the necessity for resort to them may seem. The usual mixture of bismuth and soda in calumba, with a drop or two of hydrocyanic acid, or a few grains of bromide of potassium, alone is permissible. The bland- est of food, a little white-wine whey, or milk and lime- water; if the milk is at all likely to be curdled, a few grains of prepared chalk, or light carbonate of magnesia, may be stirred into it, or a little baked flour to lessen the firmness of the curd. If beef-tea be given, let it con- tain some baked flour, to give it some more actual food value, compared to what it possesses alone. Let whatever be taken, be small in quantity at once: little and often ! If the outlook be very clouded, it may be well to resort to the partially digested milk, or milk- gruel of Dr. Wm. Roberts. If there be tympanitis, a turpentine stupes, or a liniment of chloroform on a few folds of lint, covered with an overlapping piece of oil-silk are good. If vomiting actually set in, give a hypodermic injection of morphia at once, sufficient to " quiet " the stomach. If there co-exist danger of paralysing the re- spiration or the heart by the dose of morphia, give with it a little sulphate of atropia (morphia gr. |-, liq. atropia sulph. gtt. ii.) ; this obviates any danger arising from the morphia. Before the days of the hypodermic injection, opium or morphia had to be given per rectum. In a case of intense vomiting seen when a youth, I remember my father giving a dram of laudanum in a starch enema, with excellent effects. In a couple of hours the stomach tolerated a morphia draught, which acted topically upon the stomach as well as systemically; after the crisis was CHAP, vn.] I^^DIGESTION: 129 passed, the management of the case was comparatively simple. Now the hypodermic syringe has diminished the difficulties materially; and in the hands of a man at once wary and courageous, is simply invaluable in emergencies. Sometimes when the symptoms are not quite so threaten- ing, or the case so urgent, it is sufficient to give a tiny mite of a pill, as a grain of the extract, opii at bedtime, or to add to it gr. \ of morphia. So small a thing does not irritate the stomach by its presence, a matter of the very highest importance. If there be great thirst, and the patient gulps fluid down eagerly, it will be up again im- mediately; having done no good, and only furthered the exhaustion: let a chip of ice slowly dissolve in the mouth and cool the fauces, the local seat of thirst. A little cream ice is at once cooling and nutritive; or iced milk may slowly be sipped, or sucked through a straw, or a glass tube. But a little at once: or it is an instance of "the more haste, the less speed." Patience and watchfulness must be combined with promptness of action, when the time for action arrives. Judicious nurses, whose muscles of expression are under complete control, so as not to betray their inward anxiet}'", are to be desired. All injudicious and emotional friends are to be banished, energetically and remorselessly; it is no time for folly, no matter how near the tie, how close the relationship! The link of blood does not justify culpable homicide in the interests of the individual dangerously ill. A darkened room; perfect quiet; no disturbing element must be allowed to enter by eye or ear. Brain and stomach alike must have ab- 130 imyiGESTION. [chap. vn. solute rest. A cool clear-headed pilot at the helm, and a capable crew tendering willing obedience, and the craft may be steered through the peril into smooth water. A wrong move at the critical moment, and all is swiftly over; and regret is unavailing. To meet a grave emergency coming on swiftly, taxes all the resources, all the capacity of the medical attendant; and is a sharp test of the man as well as the practitioner. Wealth of resource, fertility of thought, the moral courage to accept the responsibility of energetic action; all are required in these times of ex- treme peril. When the stomach is irritable, it must be compromised with; there is no alternative. So long as it is patient and tolerant, medicine to affect other parts may be given; but when the stomach itself is out of order, its moods must be met; it must be humoured and conciliated. It is no good to attempt to master it! Just as Mahomet had to go to the mountain when the mountain did not go to him; so when the stomach is in active revolt it must be com- promised with, and soothed. High-handed measures are out of the question. Conciliation alone is feasible; and it must be practised. The stomach is the suffering slave of humanity ordinarily, but when it is in revolt it must be compromised with, and coaxed into submission. Certainly the hypodermic syringe has worked a marvellous improve- ment in our measures of dealing with the stomach in emer- gencies; but the difficulties are quite great enough which still remain. We cannot be hio-h-handed with the stomach! In attacks of typhoid fever, when the tongue goes red and irritable, the aspect of the case grows dark like the CH.^. vn.] lyDIGESTIOy. 131 niorHt-fall "svith rain and a shrinkinor barometer. The dietary of the patient becomes everything, or almost every- thing; the medicinal part of the treatment being modified at the same time. The patient may have been under no treatment, or merely some hydrochloric, phosphoric, or, still better, hydrobromic acid may have been given in syrup and water every few hours ; but when the tongue chang'es, it is time to examine the stools for the curd of milk. This is far too little attended to by the practitioner, even if familiar with typhoid cases. At the Fever Hospi- tal, Islington, under Drs. Broadbent and Mahomet, such watchful inspection is constantly practised. AYhen the undigested curds tell that the assimilative powers are upset, then it is well at once to add some baked flour to the milk, or to mix it in equal quantities with lime- water ; or to give instead some rice-water, or thin arrow- root. The Americans are fond of a sliced lemon and two ounces of sugar being placed in a jug and a quart of boiling-water poured upon them ; after that to add the white of an egg, and froth it up. Such is a pleasant drink. Always be it remembered, that sugar requires very little digestion, it soon finds its way into the blood, and next to alcohol is the easiest digested food we have. (This matter will be referred to again in the ensuing chapter). A little beef-tea or white wine whey may be desirable, until the digestive tract is once more fit to as- similate milk : and then it is well to besrin ao-ain with milk in small quantities, and not alone, or unmixed with alkalies or diluents. Such must be the method of proce- dure — or disaster will not be far ahead. 132 indigestion: [chap. vn. Then again there are more persisting' disturbances of digestion which manifest themselves in the course of more chronic disorders. There is a weak spot in the organism, sa}^ a consolidated lung-apex, quiescent, doing no harm : strictly latent, merely impairing a little the thoracic capacity. Such a state is a very common occurrence. But let the digestion become disturbed and with it the nutrition : and what then ? When a regiment of soldiers do a long march, who falls out first ? Those who are not strong; those who have been enfeebled and thereby un- fitted for such demand upon them ! So it is with the body; when the nutrition is impaired it is the " weak spot " that feels it first, and most intensely. The lung-apex from a static condition, free from danger, commences to break down ; its nutrition is lowered beyond the point when it can maintain its existence, and it commences to die piece- meal by molecular necrosis. It undergoes fatty histolysis, it softens; around its periphery is a zone of ulceratioDj which sets up hectic fever; and in its death it may involve the fate of the organism. Comparatively unimportant, its existence is transformed into a grave matter when the tissue-nutrition is impaired by disturbance in the assimila- tive processes. In the quiescent static condition the area of lung which has undergone consolidation is a matter for little if any anxiety, further than as a potential element of danger; but when breaking down it is transformed into a very grave matter indeed, the danger is tangible and present ; the potential has been realised. In the same way we see individuals the subject of CH.^. ^Ti.] IXniGESTIOy. 133 chronic valvular disease of the heart. A certain injury of a permanent incurable character has been done to the val- vular mechanism ; this is compensated by muscular growth known as hypertrophy. As long as the compensatory growth is maintained the case goes on well. If the valvu- litis is of the progressive order then the muscular compen- sation must go on ^j>a;-i lyassu, else the compensating power becomes insufficient, and the case moves on down hill ; as too many do. But in many instances the injury to the valve is done and over ; it is like a mutilated hand, which is not what it was in its pristine integrity, it is crippled — but there is no tendency in the mutilation to proceed further. So in many cases of valvular disease of the heart, the mischief is done — the mutilation, such as it is, is worked ; but the condition is that of a cicatrix or scar, it is static and has no tendency to progression. In these cases, which are far from uncommon, so long as the muscular hypertrophy is maintained so long is the compen- sation perfect. But when the digestion fails, when the nutritive pabulum to this hypertrophied muscle is insuffi- cient, the prospect changes. From a static condition, downward progress is instituted ; which if not quickly stayed, will bring the organism to wreck and ruin. It is like progressing over a level plateau, and then coming to a precipitous declivity. Again the bright sky is suddenly clouded. A patient •with aortic regurgitation, a very clever artist, knows this as well as I do ; and speaks as feelingly. So long as his nutrition is good, he is unconscious of his heart, and feels well subjectively : but when indigestion is provoked then 134 INDIGESTION. [chap. vn. lie becomes acutely conscious of his heart, and of its impaired power. He realizes that if his digestion was to be greatly disturbed, his static heart condition would soon take an undesirable movement in a downward direction. This matter of possible loss of assimilation in an indivi- dual who has a weak spot, whose weakness renders perfect nutrition a necessity, is one which must have more atten- tion given to it in the future than it has had in the past. A consumptive man gets engrossed in business, for which he is quite fit physically, if and provided he takes proper care of himself ; but he gets carried away by overwork, cannot spare a sufficient time for his meals ; and what then ensues ? His digestion becomes impaired, and the blood is insufficiently fed. The tissues are ill-nourished by the poverty-stricken blood. The healthy tissues get on fairly well on these half-rations, but the weakened piece of lung breaks down ; and in its necrosis all but carries off the rest of the organism — indeed the individual swims for his life ; and survives with a cavity where that deteriorated piece of consolidated lung once was. It has been a very near thing, a close shave ! Or a woman has a static mitral lesion, which has lasted for years without progress of any kind. She marries, becomes pregnant, has a difficult par- turition, her health is further impaired by suckling ; this occurs once or oftener. The muscular hypertrophy which compensates the lesion begins to suffer from the general mal-nutrition ; the muscle yields, and a downward course swift and certain, is set up. It is just the company of soldiers over again ; under a severe demand the weakest break down first. Or in famine the liealthy members sur- CHAP, vn.] INDIGESTION. 135 vive, heaving been hardly tested ; but poor Tom ! whose lungs were bad to start with ; he succumbed. A tomb- stone tells of hiui ! Unfortunately in the body-family one member cannot die out, and leave the rest. He must live with them ; or they must die with him ! Hence the terrible necessity for seeing that the ** poor Tom " of the tissues does not die, when the evil day of famine allowances arrives. Many a person in apparent health, but really possessed of one of these latent sources of danger, is laid prostrate by severe disease as tyjDhoid fever, and ague ; he survives the storm, but a weak lung- apex breaks down in the mal-nutrition which follows in its wake. Or he undertakes a hard life — goes out to Manitoba, to farm, or to Colorado, New Mexico, or Texas, as a cattle stockman, turns consumptive and just lives to get home to die. Or he manifests some luno- mischief and is sent out to Australia, finds it suits him, and settles on a sheep-farm. The fresh-air and outdoor life agree with him : and for a while all is well. But the food taken at irreai-ular intervals and prepared anyhow, or nohow ; the resort to strong tea as an invio^oratino: beverasj'e is baneful ; after a while the assimilation becomes decidedly impaired, the blood is ill fed ; the weak bit of lunor ig starved and breaks down. And the individual goes down with it ; or survives a wreck, a dismantled hulk, fit for no more active service. . It is this relation pf the ^^ weak spot" to intercurrent indi2:estion which demands such careful consideration when determining upon a rough life abroad. CHAPTER VIII. DIET AND DRINK. These two practical matters require a few words to them- selves. Of course what is written here only admits of a general application to cases of indigestion ; each case requires to have the treatment fitted to it, just as a tailor fits a suit. Nevertheless some generalizations may be use- ful; chiefly in the direction of what is to be avoided. And first and foremost comes the question of the albumin- oids. Hydrocarbons once assimilated give no trouble in their metabolism within the body. Certain it is that gly- cosuria may be a disease, and a very serious one ; but it is not the appearance of the sugar in the urine which is the initial disturbance, it is the outcome thereof — the out- ward visible sign of inward disorder. It is not the origin of the thunder-cloud; it is the outcome of it, the thunder and the lightning. Fat may be deposited until it becomes a trouble, to say the least of it, impeding the heart's action when accumulated under the pericardium. Sugar and fat lead to biliousness, but not directly. A rich meal, in good old Saxon — a " surfeit," upsets the liver ; but it is the albu- minoids which are the real source of trouble. The hydro- carbons burn up readily ; to invert this, we may say that the respired oxygen is consumed or engaged with the easily oxidisable hydrocarbons ; leaving the less oxidisable albu- minoids, which unite unwillingly with oxygen, over, i.e. little affected, These, it is really, which are the source of CHAP. \iji.] DIET AND DRINK. 137 trouble. It is these albuminoid elements of our food which cause the disturbance after a "surfeit." It is the "luxus consumption" of albuminoids which is the initial cause of disturbance, whether in " biliousness " or in " gout." As to the latter, this is srenerallv admitted. It is the excess of albuminoid material beyond our tissue-requirements, which we eat that is the source of all our woes. In the present meat-eating wave of fashion this excess or '■' luxus consumption," is the cause of many maladies. We over- load the assimilative processes and they break down under the strain. None of the meal is properly digested ; but there is the waste to be got rid off. The excretory emunc- tories are taxed to eliminate the excessive amount of waste matter, and various maladies spring therefrom. To eat food and to dio-est it, are not one and the same thino-. Bulimia leads to mal-nutrition. The old expression, "the wolf at the stomach," was applied to cases where voracity was associated with leanness. The ill-fed blood causes the sensation of hunger to be felt acutely; and then the vora- city induced by the bulimia is great, but unsatisfying. This is often well seen after measles in children, they are hungry all day long. They eat and eat unceasingly to appease the pangs of hunger; but in vain. The more they eat the worse they thrive, because they digest little or none: and unless they are restricted to proper meals they virtually eat themselves to death. The}" die of hunger — of actual starvation — in the midst of unlimited food, and everlasting eating. To eat and to digest are not, then, one and the same thiner. Let me here quote a sentence from Dr. Lauder Brunton. 138 DIET AND DRINK. [chap, xui. He describes the man who is "run down" and needs a holiday. "Not only does the brain seem exhausted, but the whole system appears to be languid and weak; instead of the man being able for a twenty or thirty miles walk, one or two miles produce fatigue, and sometimes an in- tense languor is felt without any exertion at all. And yet all this time he may have been trying to keep up his strength. He takes butcher's meat three times a day, per- haps also strong soups, to say nothing of wine, or brandy and soda to pick him up. His tissues ought to be getting sufficient nourishment to enable them to do their work, and yet it is evident that they are not in a condition to do so. The man, and very likely his friends also, wonder at his condition, and when he goes to his medical attendant to describe his case he says — ' I take all sorts of strength- ening things, and yet I feel so weak.' If instead of using these words, he were to say, ' Because I take all sorts of strengthening things I feel so weak; ' he would express a part, at least, of the truth." Dr. Brunton holds that the mal-products of digestion are positive depressent poisons. The subject will be referred to again more at length fur- ther on. Enough here to shew that " strong food does not necessarily involve strength; " rather the opposite when the digestion is impaired. A little, well digested, feeds the blood, and from it again, the tissues, better than a large meal, none of which, or very little indeed, is prop- erly digested. Strong- beef-tea, made from almost fabulous amounts of beef, on which the housewife proudly dilates — well, it is the fashion, so it must be spoken of with circumspection — CHAP, vm.] DIET Am) JDRIXK 139 is a fraud I or something akin thereto. Its food value has yet to be demonstrated ! Not long ago calves-foot jelly was indispensable in conditions of debility; its day is now over, it is little heard of. Strong beef-tea, meat essences, meat juice, are pleasant; and certainly patients think they are proper things for the debilitated. Well they may be so; if and provided they take something else as well. But to give the starving patient, starving in the midst of plenty, these things to feed him, is giving him a stone when he asks for bread. A little lio-ht food which can be digested is infinitely better for him. This is something like what should be arrived at. Breakfast; porridge, oatmeal or hominy, with milk, to start with; to set the children a good example ! Then a little cold meat, or bacon, or fish; with a cup of coffee, tea, or cocoa. Some fruit. Lunch; some potatoes mashed with plenty of milk and butter, better still cream, peppered and salted, and browned before the fire. A little cold minced meat in a thin layer, not to be further cooked but only to be made hot, may be added. Some cold milk pudding, left over from the dinner of the day before, and some stev/ed fruit. A glass 0"f milk, a glass of carlowitz, claret, or sherry, may be permissible; with others only a little brandy, or whisky and water agrees. Let it be little. No glasses of wine betwixt meals to " whip one up." Such habit is bad, very bad ! Dinner; a little light soup, some boiled fish, very little joint, or some game, or entree like sweetbread, or spinach and a poached egg', some milk pudding, and stewed fruit. 140 DIET AND DRINK. [chap. vm. Wine, two glasses of the \vines mentioned, or a glass of Bucellas; or perhaps, if the patient be very sure that it does good, arid suits better than anything else — one glass of port wine; or a little spirits and water. Aerated waters are objectionable, they are too gaseous; while alkaline waters are not good at meal times, they reduce the acidity of the stomach, which is essential to the disfestive action in the said stomach. Xow as to dessert. Perhaps I am going to be heretical; perhaps only " a little advanced," Isuts are certainl}^ not to be advocated for the dyspeptic. Oranges, pomeloes and shaddocks, are like grapes, unobjectionable if the juico only be swallowed; apples, pears, plums, gooseberries}, cherries, strawberries, each and all are good. The salts, potash and others, of sub-acid fruits are good for " the blood." Often these fruits are forbidden unnecessarily. If they disagree let them be avoided; experience must be the sole judge of their admissibility. Only they need not be eschewed wholesale, as is too much the rule. Bananas, figs, pine-apples, raisins (Sir W. Gull, Bart., stated his partiality for raisins before a Royal Commission, therefore there can be no doubt about their value), pre- served peaches and apricots, when the fresh fruit cannot be obtained, are also good; candied fruits perhaps are not as a rule admissible. We eat far too little fruit in Great Britain to our meals. Supper; a draught of milk and an arrowroot biscuit is the best and lightest. It is rarely required except after an early dinner. Some persons, however, must take their food at short intervals, because they can only digest little at once. CHAP, vm.] DIET AND DRimC 141 When the fast betwixt supper and breakfast is too long, a little milk and a biscuit in the small hours of the morn- ing maybe taken; or a tumbler of milk with a teaspoonful of rum, or brandy in it may be taken on getting out of bed to dress. With some persons this enables them to take a fair breakfast. Some persons can eat no breakfast. Not uncommonly "they eat their breakfast before they go to bed;" they make a good supper; this is very common with business people who work hard all the day, and have no rest till supper time. The mistress of a business requiring much jDersonal attention, is apt to do this. She commonly be- comes a dyspeptic; if her digestion can stand this outrage, usually she ultimately becomes the subject of gout, in someone or other of its many forms. Some dyspeptics find that they must take no fluids with their food, and have to live on a very dry dietary, an Arab dietary. Others require more fluids than they allow them- selves. Others require a biscuit, or some light article of food " betwixt meals." When this is made an excuse for a glass of sherry, it is to be closely criticised as a question- able habit, " more honoured in the breach than the obser- vance." To take some fruit would be better in every way. Some succulent fruit would satisfy the craving '^ for some- thing," and would not require the beverage " to get it down." Such use of fruit ought to be more general than it is at present. In all households where the expense-does not forbid it, a large dish of picked fruit of various kinds, when the season permits of it, should be placed on the 142 DIET AND BRINK. [chap. vni. side-board every morning, with a label " Help yourself " on it (as is found in the waiting rooms of several London consultants). Children would soon cease to overeat them- selves, just as do the assistants in confectioners' shops, when they realise that it is to be a constant affair, not an occasional treat to be made the most of. Such an idea is well worthy of adoption. If the " temperance " section of society would set the example, it would soon be followed by others; to the benefit of the digestive organs of many: while it would be agreeable to all. Fresh gathered fruit out of the garden and orchard ought to be placed on the breakfast table every morning. For those who experience a bitter or hot taste in the morning on awakening, such addition to the breakfast table would be most acceptable. And now a few words as to the beverages to be taken, Americans are a dyspeptic people; they drink much iced Avater at meals, ergo, iced drinks at meal-times are bad ! They may be, when carried to excess; this is not denied. But iced drinks are not the cause of the widespread dys- pepsia in the U. S. A. There are other potent factors in action. Iced drinks are very grateful to the thirsty, but too much indulgence therein produces a torturing thirst; as the person who indulges in eating snow in the Arctic regions discovers quickl}^ Just as snowballing causes the hands, first to feel cold, and then to glow with heat if continued; so the constant application of an iced fluid to the fauces, at first grateful, becomes a source of intense discomfort : for the blood-vessels are first contracted and ultimately paralysed, and then the fauces glow with warm blood, like the skin of the snowballer's hands. CHAT, vm.] DIET AND DRimC 143 Iced fluids are not desirable for dyspeptics, to say the least of it. Ordinarily at dinner, the ice-pudding is fol- lowed by a glass of liquor — " to correct it." A certain temperature is requisite for digestion, and too much cold is undesirable. So too, the stomach is acid after a meal, for the gastric digestion is acid; therefore alkaline waters are contra-in- dicated at meal-times. They should be taken before meals, properly, when the stomach is alkaline. The milder effer- vescing waters are comparatively unobjectionable. Then as to the medicated "temperance" drinks. The 'zones and 'dones ! They mostly contain phosphorus and iron, and other medicinal matters; and therefore, may not be taken indiscriminately, or with impunity. For well-nour, ished persons, and still more, stout, florid, plethoric individ- uals, they are unsuited. For the pallid, " limp," listless be ings, they are well adapted. But too much fluid, even a " beverage free from alcohol," is not without its drawbacks. As to alcoholic beverages, they are good or harmful ac- cording to the use made of them. As to the mischievous- ness of alcoholic indulgence, all, " the total abstainer," and his less rigid brothers and sisters, are agreed. Ifc is bad physically, intellectually, and morally ! But what would be decided excess in one person is not "excess" in an- other. Also this varies in the individual. There are times of debility when generous wine may be freely drunk, not only without injury but with benefit: but the desire for them passes away as the indications for them disappear. (It is not forgotten that careless medical instructions to drink wine freely, have led to sorrowful results; nor that 144 DIET AND BRINK. [chap. vm. a patient may interpret medical instructions liberall}'', so as to make an excuse for alcoholic indulgence.) So long as alcoholic drinks improve the appetite, do not heat the patient, and do not disturb the tongue, it is impossible to say they are doing harm; and it is certain they are doing good and agreeing. The physician must speak out with a distinct utterance, ^^e., if his ideas are well-defined and chiselled-out. He must neither pander to a popular taste for alcoholic beverages; nor be afraid of the strictures of " The Temperance Record," or " The Alliance News; " and my friends, the editors of these two earnest publica- tions, must excuse me, if I thus take up a position dis- tasteful to them. They must allow for others what they claim for themselves, — i.e., " the courage of their convic- tions." There is a certain unstable temperament in cer- tain persons, perhaps a part of the neurosal tendency of the age which must be taken into consideration. Alike in rural Devonshire, in the manufacturing districts of Lan- cashire and Yorkshire, the magistrates are aghast at the amount of Asylum accommodation they are called upon nowadays to provide; so great is the spread of lunacy. All nervous affections are on the increase. Consequently there is a growing class for which it is more or less unde- sirable to advise stimulants, especially alcohol. We can- not now order a glass or two of wine daily with the care- lessness of yore. It is growing yearly more and more unsafe to do so. Each case must be the subject of con- scientious thought- in this matter. It is this " unstable temperament," against which the medical man must be on his guard when recommending alcoholic beverages. CHAP, vm.] DIET Am) DRIXK, 145 Remembering then that he is using an '' edged tool " that ma}' cut both ways, and in full consciousness of what he is doing, tlic medical man may order alcoholic bever- ages. And now I will saj^ what I personally think — dogmatism would be improper. The use of a light wine is not undesirable with many persons, from Timothy downward. " Wine which makelh glad the heart of man," sang the Psalmist, in a hymn of praise and thankfulness; and it is the use of wine, not the abuse of it, which is being considered here. The emo- tional temperament mav.be drunk with other excitement than that set up by alcohol. " They are drunken but not with wine; thev staofo-er but not with stronsr drink." Ex- cess, or indulgence in wine is bad, as is excess in anything else — medicated non-alcoholic beverages not excepted ! But it should be drunk with meals; " to eat," as they say in France and elsewhere. A little light white or red French wine is admissible; Hock is more apt to be a manufactured wine. Hungarian wine, white or " Carlowitz," and Australian wines are mak- ing good their claim to the confidence of the public; some Italian wines are very palatable; Greek wines also, for those who do not dislike the flavor of resin in them. The wines of Spain and Portugal are too potent for ordinary use, still a glass of sound sherry or port is often very good; albeit, more money, that can ill be spared, is thrown away upon port wine than is pleasant to think of. A glass of good ripe port, or of Bucellas, in season, and in the right time, toward the close of a meal, is not to be branded as a malefactor, and banished from society. Marsala is usu- 7 146 DIET AND DRINK. [chap. vm. ally a trustworthy wine, and its bitter flavor is in its favor as a wine for invalids. With others again, a little plain spirit, brandy or whisky — Scotch, Irish, or Bourbon, even "old rye," not absolutely forbidden, is their best beverage, diluted with some water. With others plain water — " Adam's ale " — is the best beverage. Malt liquors are scarcely suited to the dyspeptic; and a little sound bitter ale alone of the series may be permitted to the sufferer from indigestion. But for the dyspeptic no rule " absolute " can bo laid down in beverages any more than in food. Each case requires its own regimen all through. Man}^ cases of dyspepsia, especially when there is moaning sickness, some catarrh, excessive flatulence, a foul tongue, and an un- steady eye, are due to alcohol wholly and solely; and no reliance, whatever, can be placed on the word, statement, affirmation, or assertion corroborated by solemn oaths, of a drunkard; for "a drunkard is a liar ! " And this holds good of both sexes, and all ages; everywhere and ever. Moderation in food, especially albuminoids a little, prop- erly digested, is more nutritive than a feast, none of which is properly or completely digested. Moderation in drinks, especially alcoholic; the via media^ neither total abstinence nor excess. These are two grand rules to be observed. Whey, when it can be procured fresh, or skimmed milk, is a splendid beverage for dyspeptics. There is a quantity of nutritive sugar of milk in it, while it contains all the salts of milk. CHAP, vm.] DIET AND DRINK. 147 This leads up to a matter not altogether unimportant, yet rarely remembered; it is this, — sugar is a very easily digested hydrocarbon. Though it disagrees with many, with most dyspeptics it can be taken in greater or less quantity, in their tea or coffee; or with their spirit and water. When the appetite is very defective, if the alcohol be given with hot water and sugar, its food-value is greatly enhanced. Unfortunately, it cannot always be so taken; and alone with cold water, plain or aerated, must it be drunk. Finally, tea and coffee are more or less objectionable and disturbing to dyspeptics. Cocoa, not too full of fat, but thin, is better: or a glass of milk: or the tumblerful of syrup of the continent, for breakfast. The cup of tea before getting up is utterly uncalled for, and unmitigatedly bad. Kettledrum is as well let alone; while the cup of strong tea or coffee after dinner should be avoided scru- pulously. The incubus of fashion and conventionality is a heavy burden for most dyspeptics. They should not even bathe before breakfast, if they have sufi5cient strength of mind to brave the strictures of Mrs. Grundy. If they have not, I am sorry for them; nor do I think the position of their medical adviser one to be coveted. Neither the doctor nor the patient has then a fair field, if there be lack of courage moral, or other, on either side! CHAPTER IX. THE FUNCTIONS OF THE LIVER. The liver is the largest gland in the body; indeed, is facile pririceps among these organs, both as regards its size and the importance of its function. To many readers then, especially the junior members of the profession and stu- dents, to whom the works of M. Foster and other physiol- ogists are familiar, it will seem strange, that up to a recent period, the liver was spoken of as a mysterious terra incog- nita, a sort of Central Africa in the map of the organism. Much had been learned empirically as to disorders and disturbances of health referred, not inaccurately, to the liver; and their appropriate treatment had been deter- mined with much clinical acumen; still it was an em- piricism unilluminated by scientific knowledge. The shrewd practitioner shook his head sagaciously in certain cases, and oracularly pronounced the word "liver; " ordered slops and a light diet; the patient followed his in- structions, and felt the better for the treatment. The bulk ,of empirical testimony, so accumulated, was such as to carry with it conviction in most minds; to entitle it to respect from all ! But the wave of disbelief, which is now beginning to break, swept many minds away with it; and because infant physiology could not speak articulately as to the function of the liver, and could only lisp out a few limping utterances, the store of empirical lore had to be thrown aside as lumber, — without value or claim to any CHAP. IX.] FUNCTIONS OF THE LIVER. 149 consideration. To such a humiliating end then the ob- servations of centuries had to be relegated, accordinir to a scepticism as conceited as it was unwarranted. A few of the harder-hearted practitioners clung tenaciously to what experience had taught them ; and are now rewarded for their constancy, by seeing modern physiology testifying to the accuracy of the lessons of this experience of their own, and of observant predecessors. When the old practitioner classed "liver and kidney" together, when speaking of maladies where the urine was altered in its appearance and reaction, he spoke from an experience which dated back as far as Galen, at the least. That historic phj^sician knew that the urine solids came from the liver; how he knew, how he or some one else arrived at such a conclusion with the means they then possessed; it is simply impossible to say. They were keen observers these old physicians, and could sum up the evidence be- fore them with minds eminently judicial. When scientific knowledge did not exist in any form, such observations were all that medicine had to rely upon. When chemistry began to break a path for a truly scien- tific knowledge of the physiology of the body, the matters easiest to examine were taken first. The urine naturally tempted the curiosity of chemists, and the presence of nitrogen in the urine solids, disclosed their descent from the albuminoids of our food. The kidneys were exalted to honour. In old-standing gout, the kidneys were found to be extensively diseased. The imagination then bounded to the conclusion that the kidneys formed uric acid and urea, from pre-existing products of retrograde nitrogenised 150 FUNCTION'S OF THE LIVER. [chap. ix. metamorphosis in tlie blood. I can well remember when the statement that urea was formed in and by the liver, and only excreted by the kidneys, was received as the latest utterance of a school not entitled to the confidence of the student-mind. The promulgators of that view were regarded by the steady old-fashioned teachers, much as Melancthon and Luther were regarded by the court of Rome, viz., as unsound heretics. " There is no pain like the pain of a new idea," said the late Mr. Bagehot; and to many minds a new idea unsettling the old-established notions, is excessively painful. Unless, at the same time that it brings down the old edifice, it is prepared with a new erection to take its place, they will have none of it. They wilfully shut themselves up in a shell, and having once assumed this attitude, nothing can coax them out of it. The storms of controversy, the intense interest in the agonosphere, affect them not. In the language of the late Lord Beaconsfield, once applied to a political opponent about a measure he disapproved, they " passionately em- braced a corpse." They hugged their defunct impression till the odour of putrescence compelled them to cast it away. Such is the present position of the generation of medical men, who are beginning to pass from us. The Croonian Lectures of that accomplished physician the late Charles Murchison, delivered before the Royal Col- lege of Physicians in 1874, took the medical world by sur- prise. By those prepared for, and seeking a new faith, they were hailed with the utmost delight, as bringing within their reach the scientific knowledge they thirsted for; to such they were as welcome as a well to the traveller in the desert. CHAP. IX.] FUNCTIONS OF THE LIVER. 151 In the present and following chapters I shall avail my- self as largel}'' of the work of Murchison, as I did of that of W. Roberts, in the preceding section of the work ; and ac- cordingly do now make full acknowledgment of my in- debtedness to Dr. Murchison for all that he told us in these said lectures on " The Functional Derangements of the Liver." Not that Dr. Murchison did not owe much to others, as he himself readily and generously acknowledged; but the array and order into which he cast a huge series of isolated facts and observations, entitle him to be regarded as the preacher of the new faith to the medical profession in England. Of course there w^ere many others working in the same direction as Dr. Murchison, if less ably and less enthusias- tically, and to whom his work came as a perfect boon. Slowly something was being learned about the liver. Chemistry told us that the great condiment of our food, chloride of sodium, was split up in the body into hydro- chloric acid for the gastric juice, and soda for the bile. The utility of common salt in the organism and the uni- versal craving for it, were alike demonstrated. The long travel alike of African tribes and American buffaloes for salt "licks," became intelligible; and the wickedness of the salt tax in India dawned upon the mind. The liver secreted bile; that much was certain; and bile was not merely an excrementitious matter, but fulfilled a useful purpose. The liver then had a raison d'etre in scientific medicine. Perhaps to give the views of the late Dr. Kirkes as expressed in his well-known " Handbook of Physiology" in the very zenith of its fame, still edited by 152 FUNCTIONS OF THE LIVER. [chap. ix. the accomplished author and therefore representing the views of that erudite physician and physiologist; in the fourth edition published in 1860, will demonstrate most conclusively the advances made in very recent years. He places the secretion of bile first, as might be expected from that time of day. He recognised the presence of glycocholic and taurocholic acids in union with soda; but no account of their chemical composition is given to throw light upon their origin. He gives the process of secreting bile, which he regards as " constantly secreted for tlie purification of the blood ; " a vague phrase, in harmony with the general vagueness of the knowledge of that time. He recoo-nizes bile to be excrementitioics and digestive, and that, as the latter, — "bile is a light elaborated fluid, formed of materials which do not pre-exist in the same condition in the blood, and secreted by cells in a highly organised gland ; " nevertheless, he writes — " The general tendency, however, of modern observation is to the effect, that bile has very little influence on the process of diges- tion." He adds — "The bile, however, like the gastric fluid, has a strongly antiseptic power, and may serve to prevent decomposition of the food during the time of its sojourn in the intestines."- He says — "Respecting the nature of the influence exercised by the bile in digestion, there is, however, very little at present known. It is sup- posed by some, that the bile assists in converting the chyme into chyle, especially by emulsifying the fat, and thus rendering it capable of being absorbed by the lac- teals." So much for the bile. The light is little yet. He goes on—" The secretion of bile, as already ob- CHAP. IX.] FUXCTIONS OF THE LIVER. 153 served, is only one of the purposes fulfilled by the liver. Another very important function appears to be that of so acting upon certain constituents of the blood passing- through it, as to render some of them capable of assimila- tion with the blood generally, and to prepare others for being duly eliminated in the process of respiration. From the labours of M. Bernard, to whom we owe most of what we know on the subject, it appears that the low form of albuminous matter, or albuminose, conveyed from the ali- mentary canal by the blood of the portal vein, requires to be submitted to the influence of the liver before it can be assimilated by the blood." This is the beginning of a most important matter in physiology, or rather the beginning of the recognition of the matter, viz., that imperfectly assimi- lated albuminoid matter, the product of digestion in tlie gastro-intestinal canal, is further elaborated by the liver, so that the tissues may be fed therefrom. The liver was recoo^nized bv M. Claude Bernard as being connected with the higher elaboration of the albuminoid constituents of our food ; by it the peptones, produced by the digestive act in the stomach and small intestines, are further fitted to feed the blood, and from it, again, the tissues. So far ! so good ! Dr. Kirkes also recog-nized the relation of the liver to the saccharine materials of our food. "The saccharine principles of the food undergo, in their passage through the liver, some transformation necessary to the subsequent purpose they have to fulfil in relation to the respiratory process, and without which, such purpose could not be properly accomplished, and the substances themselves would 154 ■ FUNCTIONS OF THE LIVER. [chap, ix. be eliminated as foreign matters by the kidneys." Thanks again to M. Bernard, some light was breaking upon "gly- coo-en," or "hepatic," or "animal starch," as it was vari- ously termed ; and its utility in the economy of the body. They have also begun to note " that the liver possesses the remarkable property of forming sugar out of principles in the blood, which contain no traces of saccharine or amy- laceous matter." This was a step forward. It was seen that the liver in the Carnivora, constructs sugar out of the materials of their food. The utility of sugar as the respir- atory food is beginning to be seen ; as also its storage in the liver from intermittent meals for constant use. Like the granary into which we pour our corn after the annual harvest, and from which we take it again for our daily wants ! He says of the glycogen — " It manifests a remark- able tendency to pass into sugar in the presence of an animal ferment." He sums up thus — "The liver may be regarded as an organ engaged in forming two kinds of secretion, namely bile and sugar, or rather the glycogenic substance readily convertible into sugar. The experiments of Lehmann led him to believe that the liver-sugar is con- verted into lactic acid, previous to being finally disposed of in respiration." From this we see that in 1860 our ideas as to the func- tion of the liver were beginning to take shape ; that chaos was coming into some approach to . order. We will next see how Dr. Murchison arranged the order of the different functions of the liver ; and how much a few more years had taught us upon this subject. The gigantic stride made between 1860 and 1874 will tell in no indistinct CHAT. IX.] FUNCTIONS OF THE LIVER. 155 language the light modern physiology has thrown upon the digestive processes; and with that the service it has rendered to practical medicine. We see how the grand physiologist Claude Bernard was opening up for us, knowledge of incalculable value as to dio-estion; as one of the numerous subjects he was investi- gating. His range was a wide one; his grip was as tight as his grasp was extensive. He it was, above all others, who has forced nature to reveal some of her most impor- tant secrets; and we must all be grateful to him accord- ingly — grateful in proportion to what we have received from him. In a few more years his views were clearer, more precise, more advanced. Not only this: but they were accepted by the leading physiologists, especially by Ludwig of Leipsic, and the school of which he is the illus- trious and honoured head. "We may summarise the matter as standing in 1860, something near this. 1. The bile was not merely excrementitious as regards the blood; it was useful in the digestive act, emulsifying fat. 2. The crude albuminoid products of digestion in the gastro-intestinal canal were further elaborated in the liver, and fitted for the nutrition of the tissues of the organism. 3. The saccharine elements of our food underwent some change in the liver, being converted into glycogen, or ani- mal starch; and this again, in the presence of an animal ferment, was once more transformed into sugar, which was burnt in the blood. Further that the liver in the carnivora could form this glycogen from the albuminoid elements of their food. 156 FUNCTIONS OF THE LIVER. [chap. ix. The physiologist was on a scent which lie ran upon rapidly and swiftly, until in 1874, Dr. Murchison placed the matter as follows. We will note the day-break passing into morning light, in further acquaintance with the utility of bile; the relation of the Hver to albuminoid matters, both constructively and destructively: and in the matter of storage of glycogen. The importance of some knowledge on these subjects to the physician in his every day w^alk in life, it is simply impossible to over-estimate. The first thing to be noted is the change in the ar- rangement. Instead of the secretion of bile it is the " gly- cogenic function of the liver" which stands first. " The most valuable contributions towards our knowledge of this matter have been the researches of Claude Bernard and other observers, who have shown that the liver has the power of making and storing up for a time within its cells glycogen (Cg H^^ 0,) a substance resembling dextrine (Cg Hj^, OJ, in its chemical composition and reaction, and like it capable of conversion into sugar by the action of albuminoid ferments. This substance always exists in the liver in larger amounts during digestion, than during fast- ing, attaining its maximum usually about four or five hours after a meal." He then proceeds to show that gly- cogen when present in excess in the liver may be converted into fat. (We are all familiar with the huge fatty liver of the goose which furnishes pate de foie gras). Also that glycogen can be formed by the liver in a dog fed on albu- minoid matters alone, and that the decomposition of a peptone produces glycogen and the nitrogenous matters leucin (0^ H^3 NOJ and tyrosin (0, H,, NO3) which are CHAP. IX.] FUXCTIOXS OF THE LIVER. 157 ultimately resolved into urea (CH^ N^ O). Not only does this glycogenic function of the liver supply an easily oxidisable matter readilv converted into carbonic acid and water, producing heat ; but there are good grounds for believina^ that it assists in cell-fjrowth. Sug-ar is found in the cells of the placenta, in foetal tissues, in the inflam- matory products of pneumonia, and in new growth when- ever cell-formation is active. Nor is this confined to animals ; the same occurs in plant life." Further — '• In the early stages of foetal life the blood- cells multiply throughout the entire mass of blood ; but when the liver begins to be formed, this process ceases, and a very active formation of colorless blood-cells is set up in the liver, these colorless cells undergoing a gradual change by the development of coloring matter in their interior into red corpuscles. According to Kolliker, this new formation of blood-corpuscles in the liver continues during the whole of the foetal life of the mammalia. The observations quoted above make it probable that the liver in the adult continues to perform the functions which per- tain to manv different tissues of the foetus, the grlvcosren secreted in its cells combining" with nitroo^en and formino- an azotised protoplasm, which maintains the nutrition of the blood and tissues." Further — " The process of assimi- lation may soon go on to the production of fat in the liver, or it may stop short at the formation of another principle which escapes from the liver, and is elsewhere transformed into fat. Lastly, there are good grounds for thinking that both glycogen and sugar serve some purpose in muscular action ; at all events, it has been found that the quantity 158 FUN-CTIONS OF THE LIVER. [chap. ix. of sugar in the blood becomes greatly diminished in passing through the vessels of contracting muscles. According to Bernard this destruction of sugar in muscles is duie to lactic fermentation." It is as lactic acid that sugar is probably burnt in the organism. Galen held that the liver was eno^as^ed in sano-uification. Dr. Murchison holds that Galen was right; and proceeds — " But modern research has made it probable that the liver is endowed with a function not suspected by Galen, and which from a pathological point of view is even more im- portant than that which we have been considering. Many observations pathological as well physiological point to the conclusion that the liver is not only a blood-forming but a blood-destroying or purifying organ, and that it contri- butes in a great degree to the destruction of albuminous mat- ter derived from the food and textures, and the formation of urea and lithic acid, which are subsequently eliminated by the kidneys. First, there seems to be little doubt that the albumen and fibrin of the blood become largely disintegrated in the liver. Lehmann and Bernard have shown that while the portal blood contains much fibrin, blood from the he- patic vein contains little or none." Further he writes — *' Moreover there are grounds for believing that, while white blood-corpuscles take their origin in the liver, the red corpuscles are destroj'ed there, and that the nitro- genous coloring matters of the urine are partly the result of the destructive process." There is stronc: evidence of the destruction of albuminoid matters in the liver. It is the grave of the red blood- corpuscles ; further it is, in all probability, the furnace in CHAP. IX.] FUNCTIONS OF THE LIVER. 159 -vvhicli all forms of albuminoid waste are oxidised into the ultimate product urea, which is cast out by the kidneys. He then gives observations from various authorities, and writes : " It is important to add, that the formation of urea in the liver is always greatly increased after food. Lithic acid has also been found repeatedly in the liver of man and mammalia, but always in small quantity; whereas, in birds, in which lithic acid takes the place of urea, as the great eliminator of nitrogen, it also takes the place of urea in the liver, as it probably does in the human liver under certain pathological conditions. All these observations point to the liver as being largely concerned in the de- structive metamorphosis of albuminoid matter, the pro- ducts of which are eliminated by the kidneys ; although it is not improbable that other glandular organs, and even the corpuscles in the circulating blood, as believed by II. Ludwig and Fuhrer, may contribute to the process." A certain amount of body-heat is formed by these pro- cesses going on in the liver. Again, Galen is corroborated in his opinion, "that the liver is a great centre of animal heat." This second function of the liver, namely, the oxidation of waste and surplus nitrogenised material, is one of the g'reatest moment in the treatment of liver-derangements. It is in the metabolism of albuminoids that we iind the origin of many maladies. Dr. Murchison writes: " The third function of the liver is the secretion of bile. The composition of this substance is complex, and its uses are not yet sufficiently known." The colouring matter of bile is formed from hremoglobin "by 160 FUNCTIONS OF THE LIVER. [chap. ix. the hepatic cells, in the passage of the blood through the liver." Then again, " There are, on the other hand, grounds for believing that bile-pigment is in its turn converted into urinary pigment. It is also a well-known clinical fact, that nothing influences so much the charac- ters of the urinary pigment as functional or structural disease of the liver." Blood-pigment is first converted into bile-pigment, and finally into urinary pigment. The important matters of bile are the two bile-acids in union with soda. " The bile-acids in human bile are two — glycocholic acid (C^gH^gNO^) and taurocholic acid (CjgH^^NO^S). Both acids are derivatives of albumen and contain nitrogen ; and taurocholic acid, to which the bitter taste of the bile is due, contains all the sulphur of the bile. Both are in bile combined with soda, and both are what are called conjugate acids ; that is to say, they are com- posed of choiic acid (C^^H^^OJ, which contains neither ni- trogen nor sulphur, in combination with taurin (C„H^NO^S) which contains both nitrogen and sulphur, and glycocin (C2H5NO2) which contains nitrogen but no sulphur." In the bile is found also a fatty substance cholesterin (C^^H^^O), the main constituent of gall-stones. "The amount of bile secreted by the liver has been shown experimentally to increase suddenly after a meal, reach its maximum in about two hours, and then gradually decline ; while by abstinence it is greatly lessened." Of this, but a very small portion is expelled by the bowels. " A large propor- tion of the bile secreted by the liver is again absorbed, either by the biliary passages, or by the mucous membrane of the bowels. From what is now known of the diffusi- CHAP. IX.] FUNCTIONS OF THE LIVER. 161 bility of fluids through animal membranes, it is impossible to conceive bile long in contact with the lining membrane of the gall-blader, bile ducts, and intestines, without a large portion of it passing into the circulating blood. The constant secretion and re-absorption of bile is, in fact, merely part of that osmotic circulation constantly taking place between the fluid contents of the bowel and the blood, the existence of which is too little heeded in our pathological speculations, and in therapeutics." Further, " How many times this cycle of movement is repeated, before the bile is extruded from the system, we have no means of knowing; but in the course of the osmotic circu- lation, much of the bile appears to become transformed in- to products which are eliminated by the lungs and kidneys; while at the same time this circulation assists in the as- similation of the nutritive materials derived from the food. In the first place it assists in the absorption of fat. It is a well-knowu clinical fact that, when the common bile- duct becomes obstructed from any cause in man, the fat throughout the body wastes." It is also excrementitious in that it contains materials, which by conversion, are cast out of the body as excrementitious matter. Further, bile stimulates the peristaltic action of the bowel and prevents putrefaction in the intestines. Dr. Murchison sums up thus : " From what has been stated, it follows that the func- tions of the liver may be summed up under three heads, viz.: *' 1. The formation of gl^^cogen, which contributes to the maintenance of animal heat, and to the nutrition of the 162 FUNCTIONS OF THE LIVER. [chap. ix. blood and tissues; and the development of white blood- corpuscles. "2. The destructive metamorphosis of albuminoid matter, and the formation of urea and other nitrogenous products, which are subsequently eliminated by the kidneys, these chemical interchanges also contributing to the develop- ment of animal heat. " 3. The secretion of bile, the greater part of which is reabsorbed, assisting in the assimilation of fat and pep- tones, and probably in those chemical changes which go on in the liver and portal circulation; while part is excre- mentitious, and in passing along the bowel, stimulates peristalsis and arrests decomposition." Such is where Dr. Murchison leaves the subject in 1874. The advance made during these fourteen years from 1860 to 1874 was mainly due to the labours of Claude Bernard, whose death has, for a time, checked the enquiry. Others are makincr themselves certain .about the facts and then progressing. This summary throws much light upon many matters of great clinical interest. Certainly derangement in the gly- cogenic function of the liver gives us diabetes; but the derangements of the liver are mainly connected with the metabolism of albuminoids. And this fact is a matter the practical physician must keep clearly in his mind's eye, w^ell focussed and distinct, in his plan of treatment, in the interests alike of the patient and himself. Such summary brings us up pretty well to our time, and gives the reader the results of years of patient investiga- tion, in a condensed form, convenient for his use. We CHAP. IX.] FUNCTIONS OF THE LIVER. 163 recoo-nise then that the liver is the storehouse of our fuel food, in the form of glycogen. This is converted into sugar as is required for the wants of the organism, by a ferment in the liver itself. It is the same process in the body as in the plant. The plant digests its stpred starch as it requires, by first converting it into sugar. The liver takes from its store of glycogen as it requires for the wants of the body. By such means a regular supply of sugar is furnished to the blood. Upon this subject our information is fairly explicit. As to the second function of the liver we have much to learn. We recoo'nise its action in tlie destruction of waste and surplus albuminoids; we see that urea is formed by the liver, not by the kidneys; we begin to see that lithiasis, or lithsemia is primarily a derangement of the liver, and that the waste matter in the blood produces in time struc- tural changes in the kidney; we can see that when oxida- tion is imperfect the nitrogenous matters suffer most. All this we discern. But what we do sincerely desire to know more about is — the further elaboration of the proteid matters which have been converted into peptones in the diofestive canal. The liver has to do with this matter. A further elaboration goes on in the liver, and disturbance in the liver leads to malnutrition. Further it seems very probable that the huge gland is a filter, allowing certain nutritive matters to pass onward, while arresting other matters whose presence in the blood is deleterious. Dr. Lauder Brunton, F.R.S., wrote (Oct. 1880), "It seems not at all unlikely, then, that the liver has got another func- tion besides those usually assigned to it, viz., that of pre- 164 FUNCTIONS OF THE LIVER. [chap. e. venting the digestive ferments from reaching the general circulation so as to act upon the tissues." This is a very interesting subject — this capacity of the liver to confine the digestive ferments to their own proper domain where they are eminently useful; and preventing their emergence therefrom into the general circulation where they would in all probability be distinctly harmful. It would appear also that peptones when escaping into the general circulation are depressant agents. I will quote Dr. Brunton again — " Professor Albertoni has found that peptones have a most remarkable action upon the blood, completely destroying the coagulability in dogs, while they have little power in this respect over the blood OK rabbits and sheep. He and Dr. Schmidt-Mtihlheim independently made the discovery that peptones prevented the coagulation of the blood in dogs, and the latter, under Ludwig's direction, has also investigated their action upon the circulation. He finds that when injected into the veins, they greatly depress the circulation, so that the blood- pressure falls very considerably; and when the quantity injected is large, they produce a soporose condition, com- plete arrest of the secretion by the kidneys, convulsions and death. From these experiments it is evident that the normal products of digestion are poisons of no inconsider- able power, and that if they reach the general circulation in large quantities they may produce very alarming, if not- dangerous symptoms." It would appear that in certain conditions, as a consequence of disturbance in the working of the liver, the organism is not only ill-fed from the absence of normal products of assimilation, but is actually CHAP. IX.] FUNCTIONS OF THE LIVER. 165 poisoned by the presence of products which are positively huriiiful. Here there are blended the evidences of aniemia and toxaiinia. No wonder then that nervous depression is found along with indigestion. " The action of digestive ferments is just beginning to find a practical application in medicine, and sometimes undoubtedly they are of very great service; but unless their action is investigated more thoroughly than it has been up to the present, it is just possible that we may find that the digestive ferments, like all other powerful agents, may do much harm as well as good." This is a useful hint from Dr. Brunton to the effect that "children should not play with edged tools." The indiscriminate use of artificial digestive ferments may do for them what indis- criminative use has done for many a useful agent, viz., bring them into disrepute. ^Ye must use these agents with all the knowledge and skill we can bring to bear upon them —wielding them discreetly. It seems possible that in some cases and under certain conditions, they might act injurious- ly. But granting this, we must not be deterred from resort to them for the relief of evils we know, by the possible exist- ence of hypothetical drawbacks. It is well, however, to bear the matter in mind so far as not to forget such a possibility. But to return to the more strictly proper subject matter here, and follow Dr. Brunton a little further:— " And now comes the question. How is it that ni healthy conditions of the intestine, peptones do not pass into the general cir- culation, and are therefore unable to exert any poisonous action upon the nerve-centres? This question is one we cannot at present answer quite satisfactorily. Usually the 166 FUNCTION'S OF THE LIVER. [chap. ix. peptones disappear from the portal blood before it reaches the general circulation. Indeed Ludvvig and Schmidt- Muhlheim found that even in the portal blood, before it reaches the liver, very little if any peptone is to be found. They have not succeeded in discovering where the peptone undergoes change. Plosz and Gergyai, and also Drosdorff, have discovered peptone in the blood of the portal vein; and Plosz and Gergyai have been led by their experiments, to regard the liver as the seat of the transformation of pep- tones. In consideration of the more recent experiments of Ludwig and Schmidt-Miihlheim, we cannot entirely adopt the views of these authors, though it is nevertheless possi- ble that they are to a certain extent right, and that the liver, to some extent at least, serves the purpose of prevent- ilig any peptones from getting into the general circulation, which may have escaped transform.ation in the portal blood before reaching it." Such then is our very latest information on the n:iatter. There is digestion, there is also a filtering process in health. We may suffer that form of indigestion known as " biliousness," either from imperfection in the elaboration of the products of digestion in the gastro-intestinal canal, or from imperfection in the filtering process. In either case the system is ill-fed, and at the same time poisoned by the want of certain consti- tuents, and the presence of others in the blood. The liver then is a most important organ in the elaboration of the products of digestion, as well as in the destruction by oxi- dation of waste and surplus albuminoid material. Disor- der of the liver then will give us maladies, of which some account will be f urnislied in the ensuing chapter. CHAPTER X. THE PHENOMENA OF LIVER DISTURBANCE. BILIO USNESS. From what has been said in the preceding chapter as to the function of the liver, the reader will be prepared for an explanation of certain well-known, and equally well-marked clinical phenomena. It is quite a common experience, with children espe- cially, to see an acute " bilious attack " follow free indul- gence in rich food. Some children are " upset " by what are quite ordinary means with other children. Even a little rich cake is sufficient in some to disturb the dio-es- tive system, to produce nausea with headache, followed by actual vomiting, giving great relief, and sometimes by purging ; after which the child resumes its wonted state of health. Every medical man of any experience at all has seen this over and over a2:ain. About the clinical facts no doubt or difference of opinion obtains. But about the explanation a wide difference will be noted in the opinions founded upon these data. I mean the more re- mote, not the obvious explanation. The mother of the child will tell vou, with the most unhesitatino- confidence, that — " it was the sweets, and the rich cake. Anything too rich, either with sugar or butter, always upsets that child ! " The old family doctor nods his venerable head in complaisant harmony; and "that child" is carefully watched in the future as to its eating, especially with 168 LIVER BISTURBANCE. [chap. x. reference to saccharine and fatty food, in anything like excess. Yet this theory, however widely accepted, contains a fallacy; and it is important in the interest of that child, of other -children similarly circumstanced, and indeed in the interest of a number of adults, that this matter be thrashed out. The fallacy is one which only revealed itself when chemistry explained the composition of bile; previous to that epoch, the fallacy lay too well-concealed to be suspected to be a fallacy. The relations of cause and effect were too clear for a scintilla of doubt to suggest itself. Nevertheless a fallacy does underlie these familiar clinical phenomena. From what was said in the last chapter, it is abundantly clear that it is the metabolism of albuminoids in the liver which caused these disturbances. The readily oxidisable hydrocarbons burn up quickly without trouble, unless it is the heart-burn excited by some fatty acid in the stomach. As said before, Liebig pointed out that the union of nitro- gen with other elements, interfered with the ready oxida- tion of the compound so formed. The albuminoid tissues of the body do not themselves burn, while the fuel-food burns in them; just as the works of a steam engine do not burn with the coals burning in the furnace. It is the albuminoids, which in their underground hidden career, from peptones to bile acids and urine solids, which cause the troubles of the liver. The filtering of peptones, the elaboration of albuminoids, the construction of white cor- puscles, the relations of the liver to matters for histogenesis on the one hand; its relations to histolysis on the other; CHAP. X.] LIVER DISTURBANCE. 169 its being the fui-uace in wliich waste and surplus nitro- genized material, old elTeto blood- corpuscles, arc burnt ; and the luxus consumption of albuminoids which are split up into fat and urea ; these are the matters which cause those disturbances of health, which we recognize as asso- ciated with "the liver." In the form of the acute bilious attack here described, it is the second part of the function of the liver which is involved, viz., the oxidation of waste and surplus nitrogenized matters. The attack is the old- fashioned " surfeit," that is, a meal where the palate is followed regardless of the wants of the body ; in other words the individual eats more than is good for him, or her, as it is in delicate girls this trouble is most frequently seen ; while it is boys, rather, who are given to eating to excess. An excessive quantity of food is taken and the assimilative organs are upset thereby. Unless a portion of the inordinate meal be got rid of by vomiting, or by purging, it is by oxidation that it must be removed. All are familiar with the very sharp pyrexia, the sudden and marked rise of body temperature which accompanies acute indiofestion. The svstem is holdino; a bonfire to the o-reat discomfort of the child, the dismay of its mother and nurse, and the benefit of the family doctor ! An emetic, a dose of laxative medicine containing a mercurial, and the attack is, usually, soon over without any future consequences. In a few instances the liver remains irritable, and is easily upset b}'^ any error in diet for some time afterwards ; a con- dition to which the term " bilious fever " was applied by a past generation. Now this acute bilious attack is undoubtedly preceded by 170 LIVER DISTURBANCE. [chap. x. indulgence in rich food, by which is usually meant sugar and butter; but it will not do to overlook the eggs used in the preparation of *' good things " in which the youthful appetite delights. This view of the maternal parent and the family doctor is quite in harmony with the views held by persons more widely, and more specially informed than they were, or professed to be. Even Liebig thought that bile was formed from the hydrocarbonaceous elements of our food ; follow- ing the formula for cholic acid iS^^J^iS^h)- ^on Gorup- Bessanez held the same view ; " and it was a favorite theory, some five and thirty years ago, that the bile was derived chiefly from the decomposition of the fats; in fact, a return to a much older belief that the bile was a kind of soap." In 1852, in an article published hj Bidder and Schmidt, doubts were cast on this hypothesis. *' Bidder and Schmidt, however, noticed that upon an exclusive diet of fat, the secretion of bile at once fell to the level of that in an animal from whom all food was with- drawn ; so that they think that the nitrogenous elements of the food must be looked on as the chief source of the bile." To follow the subject further — ■''^ H. Nasse in his earlier work saw, however, a great increase of the secretion of bile, when with fat nitrogenous foods were also given. Ritter found that in a dog fed only on potatoes, or on po- tatoes and fat only, the amount of bile daily excreted fell very low." These are important observations pregnant with information as to the dietary which excites " bilious- ness." These quotations are made from the learned trea- tise of Dr. Wickham Legg on " Bile, Jaundice, and Bilious CHAP. X.] LIVER DISTURBANCE. 171 Diseases,"" 1880; a perfect storeliouse of iiifonnatiou and research, to wliicli reference will frequently be made in this chapter. One further quotation will illustrate even more clearly the point I am driving at, as to the source of the bile. *' The amount of nitrogen in glycocol, and of nitro- gen and sulphur in taurin would certainly seem to point to an origin in the albuminous bodies of the blood or food. Some part of these bodies is thought to be split up in the liver into taurin and glycocol, while another part goes to form leucin, tyrosin, xanthin and hypoxanthin-bodies con- taining nitrogen. Meisner would probably go a step further, and say that urea also was formed abundantly in the liver. Do the peptones at once furnish these nitrogenous bodies, or are they derived from the products of the decomposition of the tissues ? Karl \^oit would answer that the bile acids, are derived, like the urea, from the tissues, while the great dependence of the bile-making functions upon the glycogenetic function would seem rather to suggest that they come immediately from the splitting up of the pep- tones." We may make bricks without straw, but we cannot make them without mortar ! The nitrogenised elements in the bile-acids, to say nothing of the sulphur in taurin, point conclusively to their origin from the albuminoids of our food. There is no evading that conclusion; unless we assume that the animal body builds up, by sj^nthesis, com- plex substances containing nitrogen, from hydrocarbons; an hypothesis which will not hold water for one moment. The complex haemoglobin and lecithin are necessarily built up in the animal body; but as regards the ordinary mat- 172 LIVER DISTURBANCE. [chap. x. ters there is '^metabolism" not "construction;" and this metabolism results in destructive metamorphosis by oxida- tion. The explanation should stand so: — (1) There is an over- abundance of food taken; (2) the more readily oxidisable hydrocarbons burn first; (3) leaving the less readily com- bustible albuminoids to be burnt as best may be. It is this residuum of nitrogenised material which produces the excess of bile, with the general disturbances produced therefrom. The rich food is the cause of the bile, but not "directly," only "indirectly." The importance of this distinction is this, erroneous hypothesis leads to an impro- per dietary; the correct theory suggests the appropriate dietary. " Ritter found that in a dog only fed on potatoes, or on potatoes and fat only, the amount of bile daily secreted fell very low." Yes; that is it ! On a non-nitro- genised dietary, or one containing very little nitrogen indeed, the amount of bile produced was very small. This is the secret of the successful treatment of Biliousness. In the PMladelpliia 3IecUcal Times for June 23rd, 1877, isaii article on "Biliousness and its Management " by the writer. As a more extended experience merely corroborates what is there stated, it may be well to quote from this article, which shows that the views expounded here have not been hastily seized upon, but are the outcome of protracted thought; and are sustained by an experience extending over a number of years. "The next matter is to see what bearing the details given above have upon the right treatment of the condition of biliousness. I am of opinion that they throw a whole flood of light upon the treatment, CHAP. X.] LIVER DISTURBANCE. 173 both dietetic and medicinal. They lead to conclusions somewhat different from what are generally held, especially about the ordinary bilious attack — that is where the bile- acids are the chief matter. It has been held, and is yet too much held in reference to these persons, that: 'as a rule those articles of diet are most apt to disagree which con- tain much saccharine or oleaginous matter, and not, as might perhaps have been expected, nitrogenous food, plainly cooked.' On this matter I am at issue with Dr. Murchison. I have seen bilious individuals who asserted that they could only take a little lean meat, bread, and tea, getting no better, but worse, on this dietary; who were all the bet- ter for a dietary exclusively hydrocarbonaceous. Of course they commenced with the full expectation of being much worse, but were agreeably surprised to find themselves better. In realit}^ these people had worked in a wrong direction, and took the things they should have avoided, and avoided the things they should have taken. Of course it is true that anv indul^-ence in saccharine or oleaofinous food in addition to their ordinary food made them worse; but how that is brought about has been explained above. They never tried to do without their albuminoid food, and tliat is the point." What was written as my experience in 1877 remains my experience still in 1881. The chemical composition of the bile-acids points to their origin in the albuminoids ; the application of this to practical medicine gives satisfactory results. I discussed the matter with some of our best authorities, including- Dr. Murchison, who recognised the importance of the subject, at that time; and their agreement with my own 174 LIVER DISTURBANCE. [chap. x. view was almost complete. The lessons taught us by -the liver disorders of hot climates is eminently suggestive. To quote again from the article above: — " And again the subject of indulgence in nitrogenised food crops up. If in the tropics, fruit, vegetables, oils, and other hydrocar- bonaceous food alone be taken, the liver is not so dis- ordered as when meat is added. It is the second function of the liver which is so serious a matter in hot climates; and there and elsewhere the best way to give physiological rest to a disturbed liver, is to relieve it as far as possible from the labour of disintegrating albuminoid matter. It apparently taxes the liver little to store up glycogen and give it out again; but the breaking up of nitrogenised bodies is the labour which tests it most severely. In trop- ical climates, then, hydrocarbonaceous food should form the staple of diet; and that, too, only in stinted quantities by those whose livers are unequal to high functional ac- tivity." If this was made the rule, then, the amount of bile would be reduced, as in the case of Ritter's dog. There would just be that amount of bile which is required for the emul- sionising of the fat, enough, that is; and no surplusage to disorder the system. Those Europeans who follow the habits of the natives as to the avoidance of meat and alcohol, know comparatively little of bilious disorder; and do not develop that bronzed look which used to be asso- ciated with a Nabob, i.e., that individual of marvellous constitution and vitality, who survived an Indian experi- ence and returned to his native shores, a curiosity in every way. The returned East Indian now is not distinguishable CHAP. X.] LIVER DISTURBANCE. 175 from the ordinary Briton. What one man may do with impunity, is forbidden to others. Some persons can eat meat and drink bottled beer, to say nothing of " pegs " of brandy and soda, and yet live and work in Bengal; but they do not run thirteen to the dozen. "While most of those who try to do this are overtaken by a nemesis in the shape of liver disorder, which interferes most materi- alh' with their bodily comfort and their power of work. So it is at home: there are individuals, adults as well as children, who are upset by what would not be regarded as indulgence by others, and which can be taken by them with impunity. After reviewing the production of bilious attacks, the article proceeds: — "From this consideration of the production of an ordinary bilious attack in a fairly liealthy person, it is comparatively easy to proceed to the consideration of the production of allied bilious attacks in those who are abnormally liable to them. Dr. Murchison repeats the thoughtful suggestion that 'most persons have more liver, just as they have more lung, than is ab- solutely necessary for the due performance of its function. But in others, not unfrequently the offspring of gouty parents, the organ in its natural condition seems only just capable of performing its healthy functions under the most favourable circumstances, and functional derange- ment is at once induced bv articles of diet which most persons digest with facility.' In those persons with livers which if not abnormally small in size, are of limited func- tional power, bilious disturbances are readily produced; just as they are in persons whose livers are crippled by organic disease." All are familiar with instances of indi- 176 LIVJER DISTURBANCE. [chap. x. viduals who have suffered from bilious disturbance in India, who come home and are fairly well; but if they venture back to India with the disabled liver, they are quickly ill aofain. This is well seen in cases where liver-abscess has existed, and been survived. It is those individuals with the maimed liver of abnormally low functional activity, who must be so watchful about their dietary, so scrupulous to avoid any indulgence approaching excess. They must never forget what H. Nasse found," a great increase of the secretion of bile, when, with fat, nitrogenous foods were also given." It is " high tea," as well as dinners and suppers, which upset these beings w4th the congenitally incapable, or with maimed livers. Tea, with cream and sugar, tongue or potted meat with bread and butter, or buttered toast, or muffins; then these last with jam or marmalade, followed by cheese-cakes, jam-puffs, and a good slice of pound-cake, or plum cake to finish up with: this is the sort of meal to properly upset a child whose liver is not at all what it might be. Such a " feed " is well enough for healthy children, with an appetite of a polar bear, and the digestion of an ostrich; but for the bilious child, or adult, it is an instance that " one man's meat is another man's poison." After this "party-tea" the child goes home to bed, and awakens sick and feverish. It vomits freely, and gets relief. Or it is not so quickly relieved. It is in high fever, 105° or so in an hour or two; a cold is suspected, not a " surfeit," and it goes on until it vomits a quantity of pure bile, usually followed by purging; and then it gets relief. Or an emetic, accompanied by a purgative (some CHAP. X.] LIVER DISTURBANCE. 177 calomel and ipecacuan is the common compound) is given, and these processes instituted artificially, with the effect of procuring relief and a fall of the temperature. At other times, more usually in adults, the attack is less acute. There is headache, a foul tongue, with a bitter taste in the mouth, a vitiated state of the stools, and a loss of all appetite. Here the last, by leading to the rejection of all food, permits of the system recovering itself. The surplus of albuminoid material is burnt up by oxidation into urea; and so the system clears itself by this starvation. It is Dame Nature's plan of striking a new equilibrium ! And, as such, ought to be treated with respect, and not with recipes to restore the appetite; which, if successful, would only further embarrass the organism. Now it is the prevention, rather than the treatment of such cases that calls for our attention. The avoidance of the surfeit is too palpably called for, to need a word about it. But it is the fallacy as to the precise causation of the excess of bile, which renders it necessary to lay stress upon the form of food which produces bile. So long as the fat and the sugar are held to blame, so long will the child be erroneously fed. It will be allowed albuminoids, and be restricted in the matter of hydrocarbons ; and so the tendency to be bilious will be directly fostered. Adult or child, the ordinary dietary is a little lean meat, dry bread, and tea, or coffee without sugar or cream. You wdll be told, milk is "bilious," eggs are "bilious," butter is " bilious," porridge is distasteful ! Yes, this is a story with which one has long been familiar ; is familiar at the present time, and likely to be "acquainted" with for some 178 LIVER DISTURBANCE. [chat. x. time to come — probably the rest of one's life-time; as I do not belong to a family of centenarians, but only of fair longevity. The proper dietary is thus studiously avoided, and the evil perpetuated. What is the appropriate treatment dietetic and medicinal of this state of affairs ? Dietetically it is the avoidance of albuminoids (see p. 137) in all forms, in any quantity. The food should consist of farinaceous matters, fruit natural or stewed, vegetables, fish, or a little white meat. Butter, cream, oil, or fat are not forbidden ; if and provided nitro- genous material be not taken too freely therewith. Medici- nally, an hepatic stimulant of some kind, in a dinner-pill, or at bedtime with a vesretable laxative ; and next mornins^ a saline purgative. Many a chimney does not draw proper- ly because the flues are not well swept. So it is with the bilious; it is necessary "to sweep the flues," i.e., to keep the bowels open. When this is done certain desirable foods are no longer found to be " bilious." They agree, instead of disagreeing as before. Exercise, plenty of exercise to increase the oxidysing processes, is most desirable. By the union of these measures the "bilious" individual is usually much benefited. But infinite care is required, incessantly and unintermittingly. Occasional lapses upset the individual for some time afterwards. The congenitally inefficient liver is only equal to the most moderate demands upon it ; consequently it must be compromised with. It is a case of Mahomet and the Mountain; it would not come to him, so he had to go to it ! So the liver not being equal to what an ordinary normal liver can do, it becomes necessary to reduce the food taken to what it can dispose C3HAP. X.] LIVER DISTURBANCE. 179 of. There is no alternative. There is no getting another liver: the individual will have to remain content, or dis- content as the case may be, with the viscus dame Nature has given him; and he must just accommodate himself, or lierself, to the inevitable. It is no doubt very hard that such watchful care is imperatively necessary, and socially very irritating; but there it is. Other individuals there are who cannot take certain wines without suffering for their indiscretion. Some per- sons can get through a good dinner very fairly provided they are not tempted to taste the port wine. But if indis- creet enough "to try a glass of port," at the solicitation of their host, next day their liver resents the indiscretion. In others it is champagne which alone must not be touched on any consideration. While with others this is the only wine which they can take without consequential suffering. "Why one wine alone should disagree with certain livers is a refinement which physiology is not 3'et able to explain. The alcohol, the ethers, the salts are much the same; what is then the minute matter which constitutes the dif- ference ? We must answer that in the present state of our knowledge, we do not know. The clinical fact remaining all the same ! Now it is time to consider in some detail two kinds of '•'Liver Disturbance." (1) Biliousness proper; (2) Lithia- sis or Lithjemia, which takes the form of indigestion, rather than that which is known as gout. In the first, bile- acids are the offending matter. In the second, the forma- tion of lithates by the liver is the malady par excellence. 1. Biliousness (proper) is the form of hepatic disturb- 180 LIVER DISTURBANCE. [chap. x. ance found in persons naturally "bilious." Such persons are ordinarily dark, often swarthy; but by no • means necessarily so. The typical bilious individual is dark, with black hair. The skin is thick, wanting in trans- parency even if not actually " muddy," there is a large development of pigment. The eyes are dark, the con- junctivae have a distinctly yellow hue. When very marked the individual looks " steeped " in bile; the yellow stain showing itself everywhere. The dark skin not uncom- monly presents a number of freckles on the face. The hands are dark, and never white; indeed the hue is that of the lighter-coloured of the dark races. Why there should be this development of pigment, the black hair, the darkly pigmented irides, it is impossible to say; as we do not know the relations of pigment to the colouring matters of bile. But there is some association; that is clear enough. These bilious individuals may be active, ma}'' be lethar- gic; may be circumspect in their living, or may be care- less; but they suffer for their indiscretions ! Their digestive canal is their bane in life. Their appe- tite is capricious; and that is an advantage, as the loss of appetite lessens the amount of food taken, and, therewith the demand upon the liver. Their bowels are rarely regular; commonly they are constipated, ordinarily with diarrhoea when the " bilious attack " is passing away. They commonly have headache, and usually their temper is irritable. They are not as a rule lively people; rather they are gloomy, or morose. The dark swarthy Stuarts were a bilious people. After reproaching the Duke of CHAP. X.] LIVER DISTURBANCE. 181 Grafton on his descent from Charles the Second, Junius says — " There are some hereditary strokes of character, by which a family may be as clearly distinguished as by the blackest features of the human face. Sullen and severe without religion, profligate without gaiety you live like Charles the Second, without being an amiable compa- nion; and for aught I know, may die as his father did, without the reputation of a martyr." The swarthy skin, the peculiar turn of mind, are each a part of the bilious temperament; alike the outcome of something which is causal to both. The old Greeks used the word " Melan- cholia "for mental depression; " black-bile," as it means, was they held the physical cause of a state of mental de- pression. When under the influence of a bilious attack, this mental attitude is aggravated, and the irritability and depression are pronounced. The character of James the Second is in harmony with a persisting biliousness. Now the bile-acids and the colouring matter of bile, are not the same thing; just as the colouring matter of the urine and the urine solids (proper) are not the same thing. But a high-coloured urine is usually a urine of high speci- fic gravity. And an icteric hue is usually found with bili- ary disturbance. Both the colouring matters of bile are nitroo:enised matters. o Bilirubin C,H,,N,03. Biliverdin C,,H,„N,0,. tell of their derivation from albuminoid material orior-in- ally, if immediately the products of the destruction of haemoglobin. Glycogen which unites with cholic acid to 182 LIVER DISTURBANCE. [chap. x. form glycocholic acid, has the formula C2H5NO2; and taurin C,H,N03S. The bile colouring matter and the bile acids go together. Where the one is, the other is not far away. Taurocholic acid is the material which gives the bitter taste in the mouth in biliary disturbance; it does not give the yellow hue to the fur on the tongue, but the two go together clini- cally. The tongue is usually furred, the fur being yellow or even brown, first thing in the morning; if persisting all day, worst then. Along with this is experienced a bitter taste in the mouth. Sometimes the tongue looks quite clean when a bitter taste is complained of; but if the pa- tient be placed in the light and then the eye is brought near to a level with the tongue, so as to look along it, then the yellow, or brown hue is perceptible, which was unno- ticeable before; just as a dyer holds up a skein of silk, side- ways to the eye, when he wishes to be very certain about the shade of colour. Where there is co-existing old stand- ing debility, the tongue is swollen, pale, flabby, and show- ing the indentations of the teeth at its edges, while its surface is whitish, and its j^apillse are long. " If the liver be somewhat congested, with these appearances we may often observe the fungiform papillae on the tip and edges larger and redder than natural. In other cases, and espe- cially when there is at the same time, more or less gastric catarrh, the whole surface of the tongue is uniformly cov- ered with a thick fur, sometimes whitish, but occasion- ally of a yellowish or brownish tint. According to Sir James Paget, psoriasis of the tongue, difficult to distin- guish from syphilitic psoriasis, occasionally results from CHAP. X.] LIVER DISTURBANCE. 183 gout " (Murchison). Tlie tongue is worthy of careful study and minute inspection, in all cases of disturbance of the chylopoietic viscera. Disorder of the bowels is common. There is torpor often with flatulence. The bowels are irregular; either constipated always, or constipation alternates with loose- ness. Often acidity is complained of in the intestines, with a headache of its own. Prout, in his well-known work on " Stomach and Urinary Diseases," says of this trouble — "When acidity prevails in the lower portion of the intestinal canal, and particularly in the coecum, the treatment must be modified to meet the circumstances. The soluble antacids in this case have comparatively little effect, from their being neutralized and absorbed before they reach the seat of the affection ; hence the insoluble antacids, and particulary magnesia, will in general be found most useful in such cases. The shortest mode, however, of getting rid of the immediate inconvenience of acidity in the lower bowels, is usually to inject a pint or two of warm water (or of soap and water), and thus of re- moving the offending cause. By this simple remedy I have often seen the severe nervous headache, and other unplea- sant symptoms usually accompanying acidity in the lower bowels, immediately removed. Those who suffer from such causes usually require the aid of purgatives, which in gen- eral are better taken at bedtime. Purgatives of a mild but effectual kind, such as the Decoct. Aloes Comp. with magnesia often suit well; as do pills taken at a late dinner if duly adjusted to the circumstances of the case. Drastic purgatives in general should be avoided; for though they 184 LIVER DISTURBANCE. [chap. x. sometimes give immediate relief, they usually leave the patient more inveterately disposed to the disease. Neither this class of diseases, nor the remedies adopted to remove them, have been so carefully studied as they deserve to be." What Prout complains of in the concluding sentence, still continues to hold good. Matters requiring " careful study " never have been, never will be, properly attended to, un- less humanity undergoes some prepared modification af- fecting the multitude, and disposing it favorably to ear- nest thought; which will be about the advent of the Millennium ! The stools are sometimes pale, " wanting in bile," we say ; and this is common when there is a deposit of lithates in the urine. Commonly they possess a very offensive odor. At other times the stools are pale and putty-like, while the urine possesses a very offensive odor immediately when passed. This condition I have met with in elderly women with ansemia and large livers; it is common to hear them complain of the offensive charac- ter of their urine; ''I can't abide myself," is a frequent expression with them. It would seem that there is present in the urine some substance possessing the properties, to the nose at least, of skatol or indol. Certain it is there is some perversion of assimilation, or metabolism, or oxidation which shows how closely the liver and the urine are linked together. At other times they are lumpy, dark coloured, and offensive, as if too long in contact with the intestinal secretions. Such stools often alternate with diarrhoea, when the stools are charged with bile producing the sen- sation of scalding at the vent, as if the motion consisted CHAP. X.] LIVER DISTURBANCE. 185 of "red-hot sand; " leaving behind it a good deal of irrita- tion. Chronic conditions of anal itching are always the concomitant of biliary disturbance in persisting indigestion. These stools, black and offensive, have a term for them, viz., " vitiated," an expressive, old-fashioned phrase. The urine is usually high-colored, but clear ; at other times it contains a deposit, which may vary — may be white, fawn- colored, or "brick-dust " in hue. Indeed, the whole phe- nomena are those of excess of bile, poisoning the Avhole system, and chiefly disturbing the digestive canal. The bile-acids here are the disturbing agents, in all probability at least. The following is Murchison's summary. — " The symp- toms, usually associated with a deficient excretion of bile, are an irregular, usually costive state of the bowels, the stools being insufficiently colored with bile, and of a pale yellow, drab, or whitish color ; loss of appetite, a white or yellowish tongue ; a disagreeable, often bitter taste in the mouth, especially in the morning ; flatulence ; a yellow or muddy tint of skin (indicating, unless there be concurrent hyper£emia of the liver, ansemia rather than jaundice) ; dingy conjunctivae; languor and disinclination for exertion; frontal headache ; dulness and heaviness, drowsiness after meals ; great depression of spirits, and sometimes hypo- chondriasis ; and frequent deposit of lithates in the urine on cooling. These symptoms are very apt to be induced, especially toward middle life, by sedentary and indolent habits, the habitual use of rich or indierestible food, neo-lect of the bowels, great, or protracted anxiety of mind, or by a general want of vigor, consequent upon disease of the 186 LIVER DISTURBANCE. [chap. x. heart or of some other organ ; and the tendency to them is, in many cases, inherited. They are commonly, and perhaps correctly, ascribed to what is called " torpidity of the liver," but the non-excretion of bile may possibly be merely one of the symptoms, rather than the cause of the morbid state; the real cause being the retention in the sys- tem, not of bile, but of those products of disintegration which it is the purpose of the kidneys to eliminate. At the same time, it is very probable that engorgement of the liver with bile interferes with the normal processes of dis- integration of albumen which takes place in the gland." And it certainly is probable that there is a surplusage of bile in these cases. Useful in normal amount in the assi- milation of fat, freely poured out and freely absorbed more than once, a large quantity of bile may be accumulated, that portion normally cast out by the bowels being reab- sorbed ; why, we cannot tell in the present state of our knowledge, the clinical fact remaining all the same. The purgatives which are operative in such cases are those which act upon the upper part of the intestine, and sweep away a quantity of bile too swiftly for its absorption by the bowel lower down. Such are notably mercury, rhubarb, aloes (as well as acting on the colon), and podophyllin, or gamboge. The utter inability of purgatives like s,ulphate of magnesia and castor oil to relieve conditions of bilious- ness is well known. The patient with the furred tongue, bad taste in the mouth, and general languor and malaise, states that the bowels have been freely opened by these agents; yet no sense of relief is experienced therefrom. A laxative containing mercury brings away some bile-laden CHAP. X.] LIVER BI8TURBANGE. 187 stools, and the sense of relief is marked; while the tongue cleans, and the bitter taste in the mouth disappears. Such a remedial agent a by-past generation called an " altera- tive," a term justified by the clinical facts; but not to be explained satisfactorily otherwise in the present state of our knowledge. ^Yhen the surplusage of bile is swept away, the system feels relieved, the appetite returns, and assimilation is restored. It is clear from this that a certain amount of bile only is required for the purposes of diges- tion, and the overplus can truly be regarded as excremen- titious. In this matter we must still look to the utterances of clinical medicine, as physiology, just yet, is not in the position to speak authoritatively. Probablj'', ere many years have passed away, it will have much to tell us that we will be very glad to hear; as in the past so probably in the future, our clinical observations will be corroborated as well as explained by advancing physiological knowledge. At least there is every reason to believe so from the lessons of the past. In the meantime it is not unwarrantable, nor yet out of place, to throw together a few matters which will at least be suggestive in the aggregate; if nothing more can be claimed for them.. Ti\p bile is a fluid which passes very easily through animal membranes; not only that, but when such membranes are wetted with bile, oil easily passes through them. It is easy then to comprehend how bile may very readily escape out of the bowels into the portal venules, if allowed to remain in contact w^ith the bowel. It is secreted under a very low pressure, a fact, the importance of which we scarcely are yet in a position 188 LIVER mSTURBANGE. [chap. x. to fully realise. It is a fluid evidently which is freely poured out and readily absorbed, and may circulate in the chylopoietic viscera in abnormal quantities some time, be- fore being cast out of the system by the act of spontaneous purgation; sometimes accompanied by vomiting. When such an accumulation of bile exists, sooner or later the natural eliminating action comes into play, giv- ing relief. The diarrhoea, of which the patient complains, and asks for a remedy, is the natural means of restoring an equilibrium once more. It is the thunderstorm which clears the air : and therefore the patient should be grateful for it. But it is not in humanity, in its sublunary state anyhow, to be grateful for what is unpleasant. Now a very interesting question suggests itself, but does not bring with it a complete or satisfactory answer ; and it is this. Is it the excess of bile-acids which produces the lethargy, the depression, the " melancholy," of the bilious attack; or is it that in a bile-laden state the liver is im- paired in its filtering power, and allows peptones, or other crude matters of gastro-intestinal digestion, to pass through it into the general current of the blood ? The question is one which at least is worthy of con- sideration, even if a positive answer cannot be given to it. Such consideration will enlarge our acquaintance with the subject; and that is good, even if but imperfect good. One part of the subject is clear enough anyhow, and it is this. The normal products of digestion give us agreeable sensations, a part of which is a sense of energy. But this varies. A small meal is more apt to give the sense of energy and well-being; while a full meal gives a very CHAP. X.] LIVER DISTURBANCE, 189 pleasant sense of well-being combined with a feeling of dolce far niente, of disinclination to exertion. But that the mental associations of normal digestion are pleasant, there can bo no doubt. Charity dinners demonstrate the belief in the effects of a good meal ujDon the generous im- pulses. Young ladies talk to their papas after dinner about their lovers, when they know that some objections exist to them in the paternal mind. Mamas know this too. "A hungry man is an angry man;" when a man's stomach is full he is inclined to be amiable. That is a well recognised fact. But when the products of digestion are abnormal, then a very different mental state is pro- duced. There is depression, with irritability; no matter whether the state is one of ordinary "biliousness," or one of "lithasmia." Whether lithates or bile-salts are the of- fending matter, the mental state is not one of well-being-, but the opposite. Nor is it the posterior sensory lobes of the hemispheres alone which are involved. We know that Cyon and Aladoff have traced a direct nervous communica- tion betwixt the liver and the posterior lobes of the brain, that portion of the cerebrum, indeed, which is linked with our subjective sensations. There is this matter of nerve- communication by fibres of the sympathetic to be borne in mind; this '' sympath}^," as well as the direct effect upon the sensorium of the abnormal matters — abnormal in cha- racter or in amount, circulating in the blood. Such poisoned blood, too, produces modifications of sensation. There is the general cutaneous itching of jaundice, well- recognised; and the itching of lithiasis, the general pru- rigo of inefficient renal action, seen in the subjects of 190 LIVER DISTURBAN'GE. [chap. x. chronic Bright's disease. There are burning' or scalding patches, and sometimes " lightning flashes " of acute pain, and hyperresthesia in those who are the subjects of lithia- sis; as sudden sometimes as the pains of locomotor ataxy. There is neuralgia. Also severe cramps. While head- ache is almost invariably present. It may be " megrim," or it may be " frontal," through both temples ; or it may be " vertical," or " occipital," or even it may be general. Usually it is accompanied by a sense of nausea and ana3mici. Alterations of vision, dimness of sight, etc., or modifi- cations of hearing-, sounds in the ears, buzzing, or ringing, may be experienced. One eye may be more affected than the other, or one ear; or there may be vertigo, or a sense of dizziness, or swimming experienced. Even convulsions are not unknovv^n as the result of such toxaemia. More striking still is the cardiac disturbance set up by this poisoning by bile in the blood. Bile has been found experimentally to have " a direct paralysing action on muscles" by Ranke; and Wickham Legg agrees with him as to the action. Rohrig first clearly showed that it is the bile-acids, and not the bile-pigment or cholesterin, which causes the slow pulse. At other times, there is a lowering of the blood-pressure, with that rapidity of the pulse which is linked therewith; and this slow pulse, or rapid pulse depends upon the condition of the sympathetic system, according to Traube. It appears, too, that bile- acids in any quantity in the blood are destructive to the red corpuscles. There is then another factor in the depression produced CHAP. X.] LIVEE DISTURBANCE. 101 beyond that (1) of the direct action of the bile-laden blood upon the brain; and (2) the sympathy bet\A'ixt the liver and the posterior lobes, by their direct nerve-communica- tion; there is (3) the elfect upon the circulation, lowering the blood-pressure in the brain as well as elsewhere. No wonder then that there is depression linked with irrita- bility: the depression of brain actually ill-fed, with the irritability caused by the positive presence of a blood- poison. " The influence of the liver upon the animal spirits has been recognized by medical writers in all ages. To the belief in the existence of such an influence may be traced the origin of such terms as llypocliondriasis and ATelancholia. Although it is not contended that the morbid states of mind, to which at the present day we apply these terms, have their origin in the liver, they are unquestion- ably, in many instances, accompanied and aggravated by derangement of the organ; and it is equally true that, independently of either hypochondriasis or melancholia, persons with functional derangement or structural disease of the liver are subject to fits of great depression of spirits, and often groundless fears of impending danger, which cease when the liver is restored to its normal state. Irritability of temper is another common symptom of func- tional derang-ement of the liver, and is sometimes the first indication of anything wrong. A man who has previously borne the crosses of life with equanimity, and been amiable to those about him, gradually becomes disconcerted by trifles; his mind broods upon them; and he makes all around him unhappy, and himself the most miserable of all. His relatives perceiving no other sign of indisposition, 192 LIVER DISTURBANCE. [chap. x. and failing to recognize the true cause, too often put down the ebullitions of temper to something mentally or morally wrong; to moral depravity, or failure to make any mental effort, but remedial measures calculated to restore the liver to healthy action, if resorted to in time, will often remove the irritability, and either the patient's improvement under such treatment, or an attack of gout, reveals the cause of the patient's bad temper." So writes Dr. Murchison. And there is no doubt much of what Americans call " pure cursedness" is due to a toxsemic state of the blood, con- taining as it does " bile-poison." The subjective sensations of the individual are unenviable, to put it as mildly as possible. I remember a lady of very fine sentiments and strong religious feeling, who became quite alarmed at what she regarded as her own perversity and innate wickedness, and the inefficacy of prayer — who recovered her normal state of mind on a line of treatment which filled her brain with healthy blood. In some cases the second factor — the direct sympathy betwixt the liver and the posterior lobes of the brain, exercises a distinct influence; and the sensory portion of the brain is more affected than the rest of it, i.e., the posterior portion supplied by the vertebral arteries * which is related to tlie subjective sensations, is more af- fected than the intellectual or motor areas. Consequently we find a peculiar state of mind. There is perverted emotion wdth a distinct perception of the perversion. Thus Jean Jacques Rousseau wrote — "I feel bitterly my wrong * Not only is the blood-supply special, but the sympathetic nerve- supply to the vertebral arteries is derived from the lower cervical ganglia ; that of the internal carotids from the superior cervical ganglia. CHAT. X.] LIVER DISTUEBAN-CE. 193 conduct and tlie baseness of my suspicions; but if any- thing can excuse mc it is rny mournful state, my loneli- ness.'' The intellect here was perfectly conscious that there was a morbid condition of the emotions which it was evidently unable to control. The late Thomas Carlyle knew what this horrible feeling was — "The accursed hag dyspepsia had got me bitted and bridled, and was ever striving to make my living-day a thing of ghastly night- mares; I resisted what I could, never did yield or surrender to her; but she kept my heart right heavy, my battle being sore and hopeless." Yet he strove on under the infliction; his experience fully bearing out what is written in the in- itial sentence of this book. There is little real difference be- twixt the action of bile-acids or lithates in their toxic effect upon the brain-cells. Both act potently. It is scarcely, however, a complete consideration of the subject to leave it here. To revert to Dr. Brunton's paper, it would seem tliat there are gases evolved in certain states of disorder of the assimilative organs which are distinctly toxic in their effects. He follows Dumarquay as to the absorption of sulphuretted hydrogen from the intestine. "In cases of indigestion this gas seems to be not unfrequently found, because persons often complain of the taste of rotten eggs in the mouth, or in the eructations. Even in such small quantities it is not improbable that it may exert a deleteri- ous influence both upon the nervous system, and upon the blood, for it is a powerful poison, in its action somewhat resembling hydrocyanic acid, though not so strong." In some cases the production of sulphuretted liydrogen may be a factor in the nervous depression produced. 19J: LIVER DISTURBANCE. [chap. x. He writes : — "The greatest care appears to have been taken in the construction of the liver to prevent the bile from coming in contact with the blood ; the ultimate radicles of the bile-ducts or biliary capillaries being placed as far from the blood capillaries as the structure of the liver will allow. Notwithstanding this care, the distance between the blood and the bile capillaries is small, though it is sufficient under ordinary circumstances to prevent the absorption of bile into the blood. But, whenever an ob^ struction takes place to the exit of bile, and the pressure of bile in the biliary capillaries increases, an absorption of this secretion occurs. Bile is secreted under a very low pressure, and a very slight increase in this is sufficient to cause reabsorption." He goes on: — " But bile is not the only substance which produces a depressing effect upon the circulation, when absorbed into it from the portal circulation. In many cases of nervous depression we find a feeling of weakness and prostration coming on during digestion, and becoming so very marked about the second hour after a meal has been taken, and at the very time when absorption is going on, that we can hardly do otherwise than ascribe it to actual poisoning by digestive products absorbed into the circulation. From the observation of a number of cases I came to the conclusion that the languor and faintness of which many patients complained, and which occurred about eleven and four o'clock, was due to actual poisoning by the products of digestion of breakfast and lunch; but at the time when I arrived at this conclusion I had no experimental data to show that the products of digestion CHAP. X.] LIVER DISTURBANCE, 195 were actually poisonous in themselves, and only within the last few months have I seen the conclusions, to which I had arrived by clinical observations, confirmed by experi- ments made in the laboratory. Such experiments have been made by Professor Albertoni of Genoa, and by Dr. Schmidt-Miihlheim, in Professor Ludwig's laboratory at Leipsic." (What these observations were is given at p. 164). We thus see that there are many factors in the production of the nervous depression, and disturbance linked with abnormal action in the liver. If the nervous system strongly affects the liver when perturbed (Chap, ix.), it is also abundantly clear that the liver when disordered, produces a potent effect upon the cerebral hemispheres. These two halves of the subject are well worth keeping in mind and contrasting. So much for the consideration of the nervous phenomena provoked, or set up by disturbance of the function of the liver. We may now consider the effect of the bile-laden blood upon the heart. In using here the term "^bile-laden," it is intended it shall embrace these other products which may co-operate with the bile in producing nerve-disturb- ances. We saw at p. 190 that bile is a poison acting upon the heart. We saw further that its action was not alike in all cases; and that Traube held this difference to be due to the condition of the sympathetic system. What actually occurs in practice bears out the views, of Traube. At times patients present themselves with deep depression of the nervous sj^stem, while the heart's action is slow and feeble. Here there is direct action upon the cardiac ven- 196 LIVER DISTURBANCE. [chap. x. tricles through the inhibitory fibres of the vagus. The depressing effect of the bile-laden blood upon the cerebral hemispheres is intensified by the comparative anaemia of the brain, consequent upon the arrested action of the heart. The defective blood-supply produces the symptoms of cerebral anaemia, and blends them with those of biliary toxaemia. The pulse is slow, frequently unequal, corre- sponding to the stroke of the ventricle. This irregular action of the heart alarms the patient, already depressed by the effects of the bile upon the brain, and causes the impression of "something wrong with the heart'' to take possession of the patient's imagination, and to cause him, or her much needless alarm. But it is not easy to con- vince them that the alarm is needless, and without real foundation. Impressions founded on subjective sensations aie not easily laid at rest; they raise their hydra-headed front again and again, in spite of all the efforts made to keep them in subjection. The horrible sensations and the irregular action of the heart will range themselves together in a most suggestive manner. Just as the Hydra grew another head as fast as one was cut off, so the disordered imagination will yield to the suggestive associated facts, and put its own interpretation on the linked phenomena. Assure them that there is no actual disease of the heart, they depart comforted; for the time. But in a little while the impression comes back, with a rebound as it were* and the apprehensions of organic disease are as dominant and dominating as ever. Yet when the function of tlie liver is restored, and the blood is once more freed from bile, and its kith and kin, the mind escapes from the in- CHAP. X.] LIVER BISTURBANCE. 197 cubus which bestrode it; and tlie reason once more re- sumes its wonted sway. The condition passes away; like a bad dream leaving behind it for a time a painful feeling; which haunts the sufferer like the refrain of mournful Music — a melancholy symphony ! At other times, the symptoms are those of a low blood- pressure, with a rapid pulse. Here there is palpitation at times; often severe, and alarming the patient. It is well known that with a low blood-pressure in the arteries the heart's action is rapid. The roots of the vagus, are not freely supplied with blood, and then the accelerator fibres of "that rope of varied strands," the vagus are thrown into action. At times this leads to positive palpitation, the contractions of the ventricle being so quick and vigor- ous. It is indeed a true form of neurosal palpitation, not influenced by effort. It also disappears when the func- tional activity of the liver is regained under appropriate measures: the first step being to get rid of superfluous bile-products, and other albuminoid matters, and to so feed the patient as to give the liver but little to do. A dietary containino- little albuminoids is the one most suitable as taxing- the liver little in the metabolism of nitrogenised matters. Sleeplessness is another symptom much complained of by these bilious patients, and it is linked with the cardiac disturbances very closely. The patient complains of in- ability to sleep, in vain it is courted for hours; it will not be wooed. The sleepless hours are in themselves barely tolerable; but when in addition to this, the disturbed car- diac action is present, the condition becomes almost un- 198 LIVER DISTURBANCE. [chap. x. bearable. The sleejDless patient feels at times as if the heart really would stop, its pulsations become so slow and feeble. Dej^ressed before, this deepens the gloom; and a sense of misery is intensified by apprehensions of approach- ing dissolution. When there is palpitation, the case is different. In the silent watches of the night, the sufferer is suddenly wakened out of sleep by a violent paroxysm of palpitation. This is alarming enough; but when the vio- lent beats are succeeded by apparent sudden stoppage, then the dread indeed is acute. So long- as the heart is violently beating, the sufferer is comparatively easy in mind; but when the sense of stoppage comes, then the sensation is that of dying. The evil effects of this are not immediate only, the shock upsets the patient for some time afterwards, and is only slowly, and not rarely imperfectly recovered from. Dr. Murchison writes — " Sleeplessness may, of course, arise from many different causes, but one of its causes is that derangement of the liver, which pro- duces lithsemia. When this is the case, the patient is often heavy and drowsy after a full meal, and he may fall asleep at once on retiring to rest; but after one, two, three, or four hours, he awakes, and then he either lies awake for hours, or he is constantly falling asleep, dream- ing, or having the nightmare, and awaking — four or five times, or even oftener in the course of one hour — until the morning comes, when he drops into a quiet sleep of an hour or more, or he is obliged to get up tired and irritable. This sleeplessness, like the vertigo we have already consid- ered, is often induced by particular articles of diet, or by some unwholesome combination of them. What will ex- CHAP. X.] LIVER DISTURBANCE. 199 cite headache, giddiness, or disorders of the circulation in some patients, will in another cause sleeplessness. Some- times, however, this symptom will occur when the patient is most careful as to diet. What is important also to note is, that in most of these cases there are no obvious symp- toms of gastric dyspepsia; the appetite may be good, too good in fact; the bowels may be regular; and there may be no pain, flatulence, or other discomfort, after meals; but there will be found an unusual tendency to the deposit of lithates in the urine, and very often other phenomena of a so-called gouty diathesis." Such is a brief summary of the phenomena associated with sleeplessness, when the patient is not otherwise ill; in the less grave cases indeed. Such are then the disturbances of a neurosal nature, which belong alike to biliousness, and to lithtemia, or lithia- sis. Whether it is bile-acids, or lithates, which are the disturbing matter, the phenomena are much alike as re- gards the subjective sensations; instead of the buoyant sensations, the sense of energy given by the normal pro- ducts of digestion, there is depression and panphobia, the outcomes of a blood laden with abnormal products, or with natural products of albuminoid metabolism in excess. As they will be referred to in the next section, it will not be necessary to write them here. Such then is a bird's eye view of the symptoms produced, when the liver is embar- rassed or hindered in its working, either by too much to do from too many albuminoids being taken in the food, or by some cause of disturbance to its functional activity. It fails to elaborate the products of gastro-intestinal diges- tion as it ought uorrnally to do; while it produces bile- 200 LIVER DISTURBANCE. [chap. x. acids in excess, or it conducts the metabolism of the digested proteids on a downward course, splitting them up into uric acid and urates. It is a deeply entrancing sub- ject this, of how the liver acts upon the digested proteids, instead of further elaborating them, so as to furnish pabu- lum to the tissues; it arrests their further progress and sends them prematurely on a retrograde career, splitting them up into bile or urine solids. It is like a batch of bread spoiled in the baker's oven. The flour and water have been well mixed, the yeast incorporated therewith; the fermenting action of the yeast is operating on the starch granules; the dough is rising nicely; it is cut into loaves and placed in the oven. But the oven is too hot or too cold, and instead of wholesome nutritious bread, we get a sodden, or burnt mass, unfit for food, and only so much good material converted into waste; we all know the stout-hearted determination of the youth " to make a spoon or spoil a horn ! " In this case it is a promising horn spoiled and no spoon made ! The peptones are wasted; instead of tissue-pabulum, they are turned aside to under- go a retrograde metamorphosis by a jDremature oxidation. The aborted proteids only furnish so much waste matter, which the system must get rid of as excrementitious material. Instead of so much pabulum to the tissues, there is only so much waste matter to be eliminated. The management, medicinal and dietetic, of this condi- tion will be given in the next chapter. A less pronounced condition than this just described, has been very commonly seen in the recent east winds, which proved so disastrous to the late Lord Beaconsfield; and in CHAP. X.] LIVER DISTURBANCE. 201 the persistent north-east wind which prevailed throughout May, 1880. They found out every person who " had a liver," without respect to persons. Patient after patient at the hospital had to have the plan of treatment arrested for a time, in favor of one adapted to the intercurrent state of liver dis- turbance. Private patients required the same " change of front." Tlie east wind finds out tlie liver, albeit it lies snugly ensconced under the diaphragm and protected by the abdominal walls ; and the expression " a bilious chill," ex- tends from an acute condition, resembling a cold in dura- tion, to a more persisting state. Xor is the expression an "undesirable one ; though it has been sharply criticised by some. The patient complains of malaise, of incapacity for exertion, bodily toil is taxing, mental work is irksome ; they are unfitted too, for their usual occupation. The bowels are more or less disturbed, loose or constipated; there is a bad taste in the mouth, and the tongue has more or less a brown-hued fur upon it. The urine is either high-colored and dense, or laden with lithates, according as the liver is capable of converting the nitrogenized waste into urea, or only splitting up the peptones into uric acid and urates. Here again the nutrition was affected and the peptones diverted from their normal course, and turned to destruc- tion, — wrecked on the way, indeed. In all cases iron and tonics had to be withdrawn, and hepatic stimulants and laxatives, with a restricted dietary, substituted therefor. It was clear the liver was incapacitated for the time from taking any part in the elaboration of the crude products 202 LIVER DISTURBANCE. [chap. x. produced in the digestive canal. In some cases, but not in all, there was some pain and distention experienced in the region of the liver. In all, without exception, there was more or less of that cerebral irritation, that mental disquietude, which has been described earlier on as being the outcome of disturbance in the function of the liver. CHAPTER XI. PHENOMENA OF LIVER DISTURBANCE {Continued). LIVER INDIGESTION. Whex Dr, Murchison delivered his Croonian Lectures be- fore the Itoval Colleo-e of Physicians, and came to the subject of ^'Abnormal Disintegration," he said: — "I need not remind an audience such as that which I have the honour to address, that deposits in the urine of lithic acid, or lithates, are not due to any morbid condition of the kidneys. What I wish to insist is, that the frequent occurrence of these deposits in the urine ought always to be reofarded as a sis^n of functional derana^ement of the liver, arising from causes, sometimes temporary, at other times more or less permanent." This is a positive ex- pression of opinion, clear and decisive. These deposits in the urine are, then, significant of dis- ordered functions in the liver. Thev belono- to indigestion proper. They were held, are perhaps held still by some, to be the evidences of kidney disease. " Gravel" of course indicated kidney mischief, and "sand" was a form of gravel ! Diuretics and potash gave relief, and these agents acted upon the kidneys; could the evidence be more complete? Yes, it is true that to give potash is to give relief. With potash uric acid makes a most sol- uble salt, and in such combination uric acid is readily drained out of the blood. To illustrate the action of potash, it is enough to add 204 LIVER DISTURBANCE. [ch.aj'. xi. some liquor potassse to a specimen of urine turbid from litbates; it quickly clears. The stronger base potash ousts the soda and ammonia from their union witli the uric acid, forms with it a soluble salt; and the turbid urine becomes clear. Could anything be more delight- fully simple! But it is not the mere excretion of uric acid that we have to deal with; it is the more important as well as more remote matter, its formation in the system, which we wash to influence. To go back to our analogy of the thunder-storm, it is not enouo-h to study the lio-htnino- and the thunder; we must proceed to investigate the genesis of the storm, to consider the forces which brought it aboui;. To dissolve out the offending uric acid by potash, is like putting up a lightning conductor — -a very useful thing ia its way; the utility of which I have no wish to und-er-esti- mate. But no simile runs on all-fours: and though the administration of potash may be analogous to the light- ning-rod, we can influence the genesis of the lithiasis; if we cannot yet, in the present state of our knowledge, exercise any control over the production of the thunder- storm. A little while ago, we knew no more how to do this, than w-e yet know how to abort a thunder-storm. It has long been held that uric acid is the poison of gout; and Prof. Garrod has demonstrated that it is "gout poison," ^jx:/?* excellence. But while granting this, there is a form of indigestion of which the abnormal formation of lithic acid and lithates is a prominent symptom, which should rather be classed under the head of "liver indiges- tion," than that of "gout." The two overlap, and the CHAT. XI.] LIVER DISTURBANCE. 205 old phrase " liver and kidneys," if vague, was certainly not inaccurate. To formulate ''what is gout?" I should make the essay to this effect : — Gout is due primarily to functional derangement of the liver in the splitting up of albuminoids; the blood is surcharged with nitrogenised waste, and this in time leads to structural changes in the kidneys ! But there is a form of lithiasis, which is more properly to be considered a liver derangement than gout. " Gout " is a term which will be made to embrace a wide area in Part II.: and it need not be undulv extended bv includino- " liver indiofestion " under that headins*. "When gout is described, it will be necessary to revert to this matter; but it need not further engage our attention at the present stage of the enquiry. In speaking of uric acid, M. Foster says : — '' This, like urea, is a normal constituent of urine, and, like urea, has been found in the blood, and in the liver and spleen. By oxidation, a molecule of uric acid can be split up into two molecules of urea, and a molecule of mesoxalic acid. It may, therefore, be spoken of as a less oxidised form of a proteid metabolite than urea; but there is no evidence whatever to shew that the former is a necessary ante- cedent of the latter; on the contrary, all the facts known go to shew that the appearance of uric acid is the result of a metabolism slio-htlv divero-inor- from that leadino- to urea." It must, then, be regarded as the product of perverted metabolism in the liver. Prout held uric acid to have another source than urea, to be formed larofelv from the gelatinous forms of our albuminoid food, while urea was held to be derived from ordinary albuminoid matters. 206 LIVER DISTURBANCE. [chap. xi. This view was soon abandoned, and it was thought uric acid was a normal product, viz., a sort of nitrogenised waste preceding urea, and converted into urea by further oxida- tion; or by a splitting up into urea and oxalic acid. Now we regard it as a product of perverted metabolism in the liver. The appearance of lithates in abundance in the urine, about the time when the liver is actively engaged in the digestive process, renders it highly probable that certain peptones, instead of undergoing further elabora- tion, are turned aside, and broken up prematurely into lithic acid and lithates. That these lithates do not in any way represent tissue waste, for they have never been tissues ! They stand in the same relations to- the tissues that a still-born child bears to an estate it would have inherited, had it been born living and viable. So the material which forms uric acid might have been tissue under more favourable circumstances. Such is the posi- tion, to put it broadly. Now as to the clinical relations of these lithates, the outcomes of perverted metabolism in the liver, in other words, the products of " liver-indigestion." In the article on " Biliousness," referred to before in the earlier section of this article, is written: — "Biliousness may take one of two directions. In some persons there is the regular bilious attack, — headache, furred tongue, disturbance of the alimentary canal, vitiated stools, and fulness over the hepatic region, the urine being merely high coloured. In others, again, there is rather a dyspeptic condition, with the appearance of lithates in the water, especially two or three hours after a meal. There is no essential difference CHAT. XI.] LIVER DISTURBANCE. 207 betwixt the two; in each there is defective oxidation. But in the one tlie bile-acids seem to preponderate, while in the other the urinary products of nitrogenised waste take the leading place. The first is rather the condition of the congenitally bilious, the latter of the congenitally gouty." This division, further experience corroborates, and it seems really a fairly correct one. It may be questioned, how- ever, whether the expression — "in each there is defective oxidation " — does not require a little explanation. " Defec- tive oxidation" is found in both states, but the conditions do not depend for their production on defective oxidation solely; there is the perverted metabolism as well. But both ai% outcomes of liver disturbance, linked with defec- tive oxidation; and the offending matters are alike of albuminoid origin and descent. Uric acid, as has often been pointed out, is found alike in birds of a high temperature, and in cold-blooded rep- tiles; and, therefore, is not due to defective oxidation merel}". It is rather the form of excreted urine solids suited to '' solid " urine; while urea is the form found in "fluid" urine (M. Foster). Dr. Henry Bennett, in his valuable work on " Nutrition in Health and Disease," 2nd Edit., 1876, Avrites : — " I have repeatedly alluded to the presence of morbid salts in the urine as a result and an evidence of imperfect digestion. I believe their presence to be the most delicate and most easily recog- nised test that we can brino; to bear in the dias^nosis of defective digestion; and I am also of opinion tliat its value, though recognised, has not been fully appreciated by the profession. They consist principally of uric acid. 208 LIVER DISTURBANCE. [chap. xi. urate of ammonia, purpurine or colouring matter, oxalate of limej the triple phosphates, the neutral phosphate of lime, pus or blood globules, epithelial scales, and fibrinous casts of the uriniferous tubules of the kidnev." Thus we see uric, or lithic acid, alone, or combined with ammonia, stands first, and after that the phosphates. *' Phosphatic deposits are principally observed in those persons in whom the nervous system has been too greatly and too continu- ously used, and the general vitality thereby lowered. When this is the case, there is of course a more rapid disintegra- tion of the phosphatic salts which enter so largely into the structure of the brain, and of the nervous system generally. The acid phosphate, which, by its reaction on the triple phosphate and the phosphate of lime in the healthy urine, secures its solution, is no longer in sufficient quantity to prevent the precipitation of the abnormally abundant phos- phates, and they are thus more or less copiouslj^ de- posited." It is not yet possible to sa}^ very much on this subject, but the relation of phosphatic deposits to disturb- ance in the nervous system stands in a most suggestive relationship to the formation of lecithin; the phosphorus of which is normally derived from the phosphates of our food. Further than this may not be affirmed. He proceeds in this matter by making the observations: — " Sufficient time, also, must be allowed to pass for the processes of digestion to be accomplished, and for the chyle to reach the blood. As soon as the chyle has reached the circulation, the kidneys commence their function of filtra- tion and elimination, if it is unfit for assimilation. This elimination they continue until the blood is thoroughly CHAP. XT.] LIVER DISTURBANCE. 209 purified. Thus, for some hours after the ingestion of food by a dyspeptic patient, the urine will remain clear, because the ch^'le has not reached the circulating fluid. Then for a longer or shorter time it becomes turbid, and throws down in cooling a deposit of pinkish or pale hue owing to its beino- loaded with urate of ammonia. In the same specimen will constantly be found, on microscopical exam- ination, uric acid, oxalate of lime, or phosphatic salts. After this it again becomes clear, because the blood has been purified of the impure chyle, and the urine has reverted to its normal character." Here we see Dr. Bennett speak of the higher processes of digestion, viz., when the matters rendered soluble by the digestion in the alimentary canal have entered the blood as " chyle." A younger man would probably use a more modern nomen- clature. He goes on — " Such being the case, to test the digestion of food by the state of the urine; we must ex- amine that'whicli is secreted by the kidney during the hour or two which follows the completion of digestion, and the entrance of the chyle into the blood. This period varies of course, accordino- to the leno;th of time that the food in- gested takes to digest, which itself varies, as we have seen, according to the nature of the food, and according to indi- vidual peculiarities. Milk, eggs, vegetables, fish, etc., take about two hours; so the urine should be examined two or three hours after their ingestion. Fowl, game, beef, veal, etc., take from two to three or four hours. With some persons the stomachal and intestinal digestion is so slow that a much longer time elapses before the chyle reaches the blood, and is thus abnormally eliminated by the kid- 210 LIVER DISTURBANCE. [chap. xi. iieys. In others the digestive processes, on the contrary, are very rapid, and the morbid deposits must be sought for at an earlier period." It will now be clear and intelligible to the reader why I did not discuss the urine and its modifications earlier on under ordinary indigestion. Urine deposits belong to that part of the digestive act .which goes on after the soluble matters have entered the blood; not with that part which relates to rendering the food soluble. They have entered the blood, and here the digestive act in the alimentary canal has performed its part, and is over and past. It is with the metabolism after the products of digestion have entered the portal circulation that urinary deposits are concerned. Therefore they do not belong to the first forms of indio-estion, but to the latter, or "liver indigestion;" and must be considered in the section devoted to this last matter and its disturbances. Consequently, as Dr. Bennett insists, a certain time must be allowed to elapse after a meal before the urine is examined for the mal-products of disordered assimilation. He holds that, even in pyrexia, the. deposit of lithates, so well known at the breaking of a common cold, "is in a great measure owing to the imper- fect dio-estion and assimilation of the food given, and not to the retrograde metamorphosis of the nitrogenised tissues." A view which has much to recommend it to the attention of the profession. He proceeds — " Uric acid crystals are found more or less abundantly under the same circumstances as the double urates, and often in the same patients. I have in vain endeavored, in some cases, to find a distinct cause or CHAP. XI.] LIVER DISTURBANCE. 211 reason for their absence; as also their appearance and dis- appearance in tlie same person. Their constant existence undoubtedly indicates a more decidedly depraved state of tlie digestive functions, and a more debilitated, broken- down condition of the general health than is shown by the presence of urate of ammonia alone. It is frequently observed in persons presenting the gouty or rheumatic diathesis or constitution." "We will follow Dr. Bennett to his conclusion — "lam thus disposed to think that the presence of uric acid and of lithates in the urine in such abnormal quantities as to constitute a de]3osit, is very much more frequently the result of defective digestion than defective metamorphosis of tissue, especially in dyspeptic individuals. This is not the generally received opinion, but that it is really the case appears to me evident, from the circumstances that I am able, in the majority of such cases, to trace them to the food digested a few hours pre- viously, and that they disappear from the urine secreted after a prolonged fast." Dr. Bennett has made such careful study of the modifications produced in the urine by in- digestion, that I put his views before the reader at some leno-th, believinor them to be worthv of all attention. Dr. Murchison delivers himself as follows, as to the pro- duction of uric, or lithic acid, and lithates. " Excluding those cases in which deposits of lithic acid or lithates are thrown down in the urine not until twelve or twenty hours after its emission, as the result of spon- taneous changes, to which Scherer has given the name of acid urinary fermentation, and those which are due to a marked deficiency of urinary water, deposits of lithic acid, 212 LIVER DISTURBANCE. [chap. xi. lithates and abnormal pigments which appear in the urine as soon as it cools, are chiefly met with under the follow- ing conditions: — " 1. In febrile diseases, in which we know that the liver becomes enlarged and congested, and its gland-cells loaded with minute granules," and in which there always is an increased disintegration of albuminous matter. Every one, for example, is familiar with the copious deposits of lith- ates which are so common during an attack of ordinary febrile catarrh. " 2. In many structural diseases of the liver, and particu- larly in those which are characterised by an increased amount of blood in the organ, such as inflammation, cir- rhosis, cancer, and simple hypersemia, whether mechanical or active. "3. In functional derangement of the liver, either tem- 2:)orary or persistent. " Lithuria, like glycosuria, is very often due to a function- al disease of the liver. Although even glycosuria is still ranared in some text-books with albuminuria and diseases of the kidney. In other words, abnormal disintegration of albuminous matter in the liver may lead to a morbid condition of the blood and of the entire system, which often manifests itself in lithuria." Now a very well marked instance of the second division of Dr. Murchison, including "simple hyperaemia, whether mechanical or active," is seen in the urine in cardiac dropsy. As the heart fails in power the bulk of urine falls pari passu. The bulk of urine is in strict proportion to the CHAP. XI.] LIVER DISTURBANCE. 213 blood-j^rcssure in tlic arteries; and this, again, to the vigour with which the heart pumps the blood into the arterial system. "When the heart begins to fail the blood is less vigorously pumped into the arteries, the blood- pressure then falls, in the kidney as elsewhere, and with it the bulk of the urine, in other words the amount of water passed. This morbid change may proceed a con- siderable leno'th w^ithout the urine beins; otherwise altered than beins: scantv and dense, or concentrated. But when the liver becomes involved in the venous fulness, and begins to enlarge from passive congestion, then the urine chanofes. It now contains lithates in abundance, fawn- coloured, or pink, sometimes more than pink. The con- gestion of the liver interferes with its functional activit}'", and then lithates appear in the water, — the proof of the deranorement of the function of the liver. This is the more liable to happen when the plan of treat- ment adopted is a very " sustaining " one. The patient is encouraged to take the most strengthening " things," that is, albuminoids in as great quantity as possible, and then the crippled liver is unequal to carrying on the ordinary metabolism, and lithates make their appearance. The association of such lithates with the disablement (more or less) of the liver, ought to be made a point of impor- tance in the dietetic management of the case. In the face of such evidence it is of the most questionable utility to force albuminoids upon the patients, when the liver is thus evidently unequal to dealing with them; and the dietary should be modified, and made projDortionate to the reduced power of the liver, gorged with venous blood. 214 LIVER DISTURBANCE, [chap. xi. Of course a dense urine is apt to deposit urates after being passed some time, especially in cold weather. But still there is the difference betwixt the dense, high col- oured urine, which remains clear for a considerable time, and the urine which becomes turbid with urates shortly after being passed. The latter tells clearly of functional embarrassment of the liver. As reg-ards the colour of the urates thrown down much might be said. " The frequent or constant occurrence of a brownish or red urate deposit without or with only a feeble degree of pyrexia, is a circumstance to awaken sus- picions of some serious organic disease; but the indica- tion is more general than special. Organic disease of the lungs, heart, liver, spleen, or other part, attended with emaciation and waste of the tissues, is usually accom- panied with abundant deep-coloured urate deposit. Func- tional derangements of the digestive organs are also generally accompanied by pale urate deposits in the urine " (W. Roberts). This is an observation not without much clinical value. Many old j^ractitioners observe the colour of the urine deposits very carefully. There is a general consensus of oj)inion that the pale-coloured, chalky look- ing deposits are found along with indigestion; especially those deposits found from two to five hours after a meal, as described by Dr. Henry Bennett. On the other hand deep-coloured pink, or even crimson deposits are rather found usually in old gouty subjects; at least, in my ex- perience. Nor is the matter one to be dismissed as of little, or no practical importance. The production of bili- rubin, or the non-production of it may depend upon states CHAP. XI.] LIVER BISTURBAN'CE. 215 of the liver which differ considerably. AVhile not wishing to be too precise, it may be said that in acute liver- indi":estion there is little bilirubin found from which the urine colouring" matter is derived; in old gouty cases it is freely produced. This may indicate a difference in the metabolism going on in the liver. Again, we approach the border-lands, the frontier of the agonosphere, — the unknown which possesses so much interest for us. Uric acid is generally regarded as indicating another state of affairs, though Dr. Bennett thinks it a difference of de- gree, indicating a more pronounced morbid state; while Roberts remarks as follows : — " There is this difference between the conditions favourable to the deposit of free uric acid and the amorphous urates — that a high density (or concentration) favours the latter, and a low density (or dilution) favours the former." Thus making it largely a matter of solution or density. This difference of opinion illustrates that the subject is as yet far from being settled definitely. Connected with the relations of the urine to conditions of functional disorder of the liver, stands azoturia or baruria, as it has been termed by various writers; in. which there is an excess of urea in the urine. Prout first described it, and Willis followed him. Prout divided these cases into "excess of urea icithoiit diuresis, and excess of urea with diuresis.^'' In the first, though there is great susceptibility to derangement, as well as to actual disease of the assimilating and other functions, I am not aware that any one derangement of any one organ can with cer- tainty be pronounced to be characteristic of an excess of 216 LIVER DISTURBANCE. [chap. xi. urea in the urine. In the second, modifications of tlie disease, in which the quantity passed is excessive; besides most of the symptoms above enumerated in an aggravated form, there exists, in addition, more or less of thirst and morbid craving after food. The patient likewise complains of general coldness and great bodily weakness. In some in- stances also, there is considerable emaciation; though not to the same remarkable extent as in diabetes. The causes predisposing to an excess of urea in the urine seem to be nearly allied to those predisposing to diabetes. Most of the subjects of the disease in the forms above described, have been middle-aged men, of sj)are thin habit, with a sort of hollow-eyed anxiety of expression on their counte- nance; unusually nervous and susceptible, but by no means always hypochondriacal; and also free from gout, and, as far as could be ascertained, from structural disease of the urin- ary or any other organs. With respect to the ^Droximate cause or intimate nature of the disease, I have been long of the opinion that it depends upon derangements of the secondary assimilating processes, rather than the primary." Having related a case at some length, where the patient so largely recovered as to be practically well, he goes on: — • " The second case I shall recite is one that occurred to Dr. Elliotson, at St. Thomas's Hospital; who furnished me with the urine for examination every week, so as to enable me to ascertain the effects of the remedies employed. March 5th, 1819. Rodman, aged fifty-five. Symptoms resembling diabetes. There is a constant craving for food, a sense of cold over the whole body, and a frequent desire of passing urine, which in twent3^-four hours amounts to CHAP. XI.] LIVER DISTURBANCE. 217 sixteen pi Jits. The urine of this man was pale-coloured; its specific gravity was 1.020; and it contained a very larg-e proportion of urea ; but not the least particle of saccharine matter. On standing, it also deposited crys- tals of lithic acid. Ordered opii. gr. 1^ bis die (opium in this case was ordered by Dr. E., on the supposition the disease was diabetes). March 20th. — Feels much better. Urine reduced to two pints in twenty-four hours. Pergat. The urine was now somewhat deeper coloured ; and de- posited a copious sediment consisting partly of lithic acid crystals, and partly of lateritious sediment. Its sj^ecific gravity was increased to 1.0344; evidently from its having become more concentrated than natural. The quantity of urea was abundant, but not in the proportion in which the urine was concentrated. "The man became so well shortly after the above date, that he did not return to the hospital till August 19th. Disease returned six weeks ago. Feels as ill as ever — very weak. Bowels costive. Quantity of urine in twenty-four hours, about four pints. Ordered opium, as before. The urine was now transparent. Its specific gravity was 1.023, and urea was abundant. Under the above plan he speedily became better, and soon afterwards ceased to attend the hospital." — (" On the Xature and Treatment of Stomach and Urinary Diseases ; being an Enquiry into the Con- nection of Diabetes, Calculus, and other Affections of the Kidney and Bladder, with Indigestion," 3rd Edit., 1840). Wm. Roberts thinks, " precise facts in support of Front's view are wantins:; " but refers to a case recorded bv the late Dr. Parkes (" On the Composition of the Urine," p. 374), 10 218 LIVER DISTURBANCE. [chap. xi. where a man, on the ordinary diet of University College Hospital, passed 1130 grains of urea daily, and concludes thus: — ''In my own experience, I have usually found that cases which at first sight appeared to belong to this cate- gory — cases exhibiting a dense urine and a train of ner- vous symptoms, — turned out on more exact investigation, to want a special feature indicated by Prout as the es- sential one ; namely, an absolute increase in the daily discharge of urea. Nevertheless, some facts, rarely ob- served, have left an impression on my mind that Prout's description is not altogether fanciful." He then gives notes of a case, where more than 500 grains of urea were passed daily. In this case, as in Parkes', there was a trace of sugar present. As to the causation of these cases, Dr. Roberts says: — "In the case just related, the cause of the complaint was mental anxiety; and in all the instances which I have been inclined to place in this group, the origin of the disorder could always be traced to some kind of mental emotion." Perhaps Prout was not far astray in regarding such cases as pathologically related to diabetes ; and Roberts admits: — "That there is some relation between the two conditions seems not improbable." Dr. Handfield Jones has described six cases of like disease under the head of Baruria, Brit. 3fed. Jour., Oct. 12th, 18G1. While the late Dr. Fuller, without acquaintance with what had been done by Prout and others, brought before the Medico- Chirurgical Society, papers " On Excess of the Urea in the Urine as a Guide to Diagnosis and Treatment of Certain Forms of Dyspepsia " (Trans., Vol. 40, 42, and CHAT. XI.] LIVER DISTURBAN-CE. 219 51); in which he described simihir cases. Passing throug-li all of them was, then, a history of nervous trouble, which gave them a certain character and generic resemblance. They stand in an interesting and suggestive relationship to the excessive quantity of urea found in the urine in the early stages of chorea. In connection with this subject, closely linked thereto indeed, stands Albuminuria. The presence of albumen in the urine is usually regarded as the evidence of disease of the kidney. It is not necessary to discuss the whole subject here: it is enough to say that it is much easier to detect the presence of albumen in the urine, than to know what it means, or what its significance is, when it is found. The student is taught the various means by which a trace of albumen may be demonstrated in the urine; but he is not taught, and in the present state of our knowledge, there is no one who can teach him what its precise signi- ficance is when found. We know that in certain con- ditions its presence is of the most sinister omen; we have learned that at other times it is devoid of sio^nificance. I shall here review merely its relation to disturbance of the digestive organs. Such relation of albuminuria was entertained by the late Dr. Parkes, who " inclined to the opinion that the liver plays an important part in the devel- opment of albuminuria; he thinks, through some failure in preparation, either by the stomach or the liver, albumen enters the right side of the heart, still in a crude state, and in a condition similar to that introduced into the jugular vein in Bernard's experiment." (Claude Bernard found that crude albumen injected into the jugular vein. ^20 LIVER DTSTURBAJ^CE. [chap. xi. produced temporary albuminuria). It is well known, tliat if two or three raw eggs are eaten at once, albumen makes its appearance in the urine. It would seem that here the quantity of crude albumen passing from the alimentary canal into the blood, overruns the power of the liver to deal with it; and a certain portion passes through the liver in its crude state, and as such escapes througli the kidneys. The late Dr. Basham, in discussing the presence of albumen in the urine, wrote: " There is yet another subject of interest connected with the long continuance of albumen in the urine; associated as it universally is with a diminution of the urea, the lead- ing characteristic of healthy urine. Can it be said in these cases, that the albumen is the pathological substitute for urea ? The fact cannot here escape notice, that cases frequently occur in which the urine continues for months, and even years, persistently albuminous. I know two cases of near four years duration, the patients' health being fairly re-established; all the chief functions being performed with undeviating regularity, and with no ob- vious disorder, except in the composition of the urine. The character of this being the presence of albumen, with diminution of urea. Although we are as yet without proof, yet it has appeared to me probable, that the albumen in the urine (in these long-standing cases) must, in some way, take the place of urea, and become, as it were, its pathological substitute." The remarks of the late Dr. Murchison are so replete with knowledge, and given with such judgment, that it appears better to give them verbatim than to attempt to CHAP. XI.] LIVER DISTURBANCE. 221 condense them. " There are also reasons for believing that albuuiinuria may be induced by hepatic derangement independently of structural disease of the kidneys. It is now generally acknowledged that albuminuria, even when copious, and in the absence of any acute febrile disorder, does not necessarily indicate renal disease. Very often, in these cases, the albuminuria is intermittent or remittent, and the albumen has peculiar chemical characters; the previous addition, for example, of a few drops of mineral acid, preventing to an unusual extent the subsequent coagulability by heat. Errors in diet are one of the most common causes. In some persons, peculiarly constituted, temporary albuminuria is a constant result of certain arti- cles of food, such as uncooked eggs. In several instances I have known the urine passed at night to contain albu- men, often associated with lithates and a high specific gravity; whereas the morning urine was clear, of low spe- cific gravity, and contained no albumen. Again, in cer- tain cases of exophthalmic goitre the urine, at some hours of the day, usually after food, is loaded with albumen, whereas at others it contains none; and this state of mat- ters may last for many months, and then completely dis- appear. Now, it is not contended that in all these cases the liver is the organ primarily at fault, but certainly in some there is good reason for believing it to be so; the albuminuria being unattended by any other symptom of renal disease, varying greatly in quantity and sometimes absent; and the urine being of normal quantity, of high specific gravit^^, and habitually loaded with lithates, lithic acid, oxalates, and pigments; and there being very often 222 LIVER DISTURBANCE. [chap. xi. cutaneous eruptions, dyspepsia, and other evidence of he- patic derangement. I have met with several instances of this sort, where the jDatient was subject to severe attacks of what at first seemed to be hej)atic colic, but where there was no jaundice, and the paroxysm was followed by a temporary yet extraordinary increase of lithates and albumen in the urine. Lastly, so often have I observed albuminuria associated with hepatic disorder, which has disappeared completely and permanently when this has been set to rights, that I have little doubt that we have in the liver a cause of albuminuria, to which attention has not 3'et been sufficiently directed. The pathology of the albu- minuria in these cases, may be similar to that of cer- tain cases of diabetes already referred to, the liver having too much work to do, and permitting some albumen to pass through in a form which cannot be assimilated; or possi- bly there may be some defect in the destructive functions of the liver, in consequence of which the albuminous mat- ter, instead of being converted into urea, does not even reach the stage of lithic acid. It is possible that in many of the cases now referred to, the albuminuria may indicate an early stage, not yet described, of the contracted or gouty kidney; yet it is certain that the symptom may per- sist or recur, during many years, without any other symp- tom of renal disease and with but little impairment of the general health." What Dr. Murchison says here, should be well weighed by every practitioner, I entirely agree with what is said; and for some time jDast I have treated certain cases of al- buminuria by a farinaceous non-nitrogenised dietary, with CHAi^. XI.] LIVER DISTURBANCE. 223 the best effects; the patient feeling better, along with a corresponding diminution of the amount of albumen in the urine. It will not do in practice to run away with the idea that albuminuria is pathognomonic of renal disease; to do so is to alarm the patient unnecessarily, and when time has disproved the doctor's vaticinations, to bring him in- dividually, and the profession generally, into disrepute. Nor is it possible to plead that the present views of the infallibility of the test-tube, are justified by our experience; laziness "or indifference are too large factors in the present attitude of slothful satisfaction, and blind confidence in the chemical test, — to enable it to be said that the posi- tion is excusable. Having often elsewhere entered my opinion on this sub- ject in writing, and protesting against the abject attitude of the profession at large, to objecting to reason on the phenomena, but accepting the presence or absence of albu- minuria as full, ample, and complete proof of the state of the kidneys; of the presence or absence of disease in them; I feel it desirable, here, to transcribe the views of others — ■ men, whose ojDinions are entitled to the greatest respect. One word more: — "Usually the whole albuminous con- stituents of our food are so transformed in the stomach, intestines, and liver, that no albuminous substances of the kind, which can pass through the kidneys get into the general circulation. But if one takes such a quantity of eggs as to comj^letely overtask the digestive powers, the egg-albumen will pass unchanged into the blood and be excreted by the kidneys. Other albuminous substances, the products of intestinal digestion, and peptones also, 224 LIVER DISTURBANCE. [chap. xi. occasionally make their appearance in the urine as egg- albumen " (Lauder Brunton). From what has been said above, it will be abundantly clear to the reader that the perversions of the metabolism of albuminoids in the liver, are verv interestino- in relation to the presence of lithic acid and lithates, of excess of urea, and even of crude albumen in the urine. All, separate or combined, may be so produced, without kidney disease necessarily being present; or even being the consequential result for a very considerable time. (1.) Crude albumen may pass unchanged in the liver into the general circula- tion, and pass out by the kidneys. (2.) The metabolism may take the direction of an excess of urea. Or (3) the splitting up of albuminoids may result in the production of a large quantity of lithic acid, usually in combination with ammonia or soda. Such conditions may be tem- porary, as the result of *' acute liver-indigestion;" or they may be less pronounced but permanent, and then in the language of Geo. Johnson, " renal degeneration is a consequence of the long -continued elimination of products offaidty digestion, through the kidney s.'^'^ , Such then is the production of lithiasis. But in the full consideration of this subject, we must include the disturbances which this " waste-laden" blood produces in its wake. In Part II. the matter of consequential renal changes will be discussed at length; together with the changes in the heart, arteries, and other organs, i.e., the phenomena of gout, or lithiasis. Here it will be sufficient to review the symptoms and disturbances which belong to acute conditions of liathiasis, or lithfemia (Murchison's CH.\r. XI.] LIVER DISTURBANCE. 225 term), provoked by '' liver-indigestion; " or perversion of metabolism in the latter portion of the digestive act, as seen in persons "who are not the subjects of confimicd gout. Asthma. — This is one of the outcomes of nitrogenised waste being present in excess in the blood; especially nocturnal asthma. This is not to be confounded with the asthma which is set np by some irritation with swell- ing of the bronchial lining membrane, often the result of a cold. It comes on suddenly in sleep, after a late meal. Dr. Todd thouD-ht that there was a Qnateries morhi which acted through the pneumogastrics upon the respiratory centre in the medulla. Dr. H^'de Salter was of opinion that the attack was set up by " the actual presence in the vessels of the lungs of the materials taken up from the stomach and intestines." He pointed out how an attack provoked by a full meal taken late in the day, could be averted; if the sufferer would sit up instead of going to bed until the hour of attack was passed. By so doing, the res- piratory centre could better and more successfully resist the irritation set up by the irritant material. The fact that if a certain hour or period could be so passed, the attack did not come on, is suggestive. It was not post- poned; it was averted. Awake, the poison was inopera- tive; asleep, it certainly set up an asthmatic paroxysm. This certainly connects it with the latter portio-n of the di- gestive act; while its association with a full meal renders its connection with the digestive act all the more certain. Dr. Murchison says: — "Asthma, like gout, is an here- ditary disease; it is common among persons springing 10* 22G LIVER DISTURBANCE. [chap. xi. from a gouty stock; it is not unfrequently associated with gout, gall-stones, or other hepatic derangements in the same individual; and attacks of asthma have been known to alternate periodically with attacks of gout. Moreover, an asthmatic paroxysm, like an attack of gout, of vertigo, or of sleeplessness, is often excited by a fit of indigestion, and by the use of particular articles of diet." They are related to those attacks of what Basham called ** inexplicable dyspnoea," found in the subjects of chronic gouty kidneys. It may, however, be questioned whether any irritation is conveyed up the pneumogastric nerves to the medulla, — an hypothesis which has been violently stretched to explain a variety of respiratory affections; but rather by a direct action of the products of abnormal digestion in the blood, upon the respiratory centre. At other times, bronchitis seems to be induced; while chronic bronchitis is a very common occurrence in chronic gout; at times, not unfrequently, an attack of acute bronchitis takes the place of a gouty paroxysm. Disturbances i7i the Heart are very common. There is palpitation, which is not that form excited by gas in the stomach, or transverse colon, pressing up the thin dia- phragm against the heart, and by its "elastic pressure" interfering with the heart's movements; a well-known form of palpitation. The palpitation of lith£emia is not always felt along with flatulence, but irregularly, as re- gards its connection with meals. It is casually linked with imperfect assimilation and evidences of waste in the blood, with a high arterial tension, and, at times, with an ill-fed or half-starved heart; and its origin is the same as CHAP. XI.] LIVER DISTURBANCE. 227 that of the imperfect angina pectoris vaso-motoria, to be spoken of a little later on. Then there is irregularity in the heart's action, allied to that spoken of in p. 190, in which the heart's action is depressed: in other cases there is irregularity in the volume as well as the rhythm of the pulse; or there may be intermissions, with or without fluttering of the heart's action. In others, again, there is pulsation of the abdominal aorta. Dr. Baillie drew at- tention to this subject long ago, in a paper entitled "Upon a Stronw' Pulsation of the Aorta in the Episfastric Re- gion," and Sir Charles Scudamore in his work on " Gout and Gravel, and General Observations on Morbid States of the Digestive Organs," 4th Edit., 1823, wrote:— "The pulsation in the epigastric region, which is sometimes felt to an alarming degree, by dyspeptic persons, is seldom met with in persons who are subject to acute gout." It is frequently found during the time of the digestive act, mostly in persons of a highly developed nervous system; and is unaccompanied by any severe disturbance of the general health. "The undue pulsation in these cases is often subdued by treatment directed against the liver " (Murchison). Angina Pectoris. — This is quite a common malady with those who suffer from " liver indigestion," and is not un- frequently met with in the sons of fathers who have died of anmna; and who may themselves die of ang-ina in advanced life, when their heart-walls become the seat of fatty degeneration. From the researches and observations of Eulenberg, Nothnagel, Lauder Brunton and others, we have learned that angina pectoris is not a neuralgia of the 228 LIVJSR DISTURBANCE. [chap. xi. heart, as thought by Heberden and those who have fol- lowed him, so frequently as a vaso-motor affection. It is due to spasm of the small arteries, excited by the irritant presence of nitrogenised waste in the blood in excess. This causes a high blood-pressure in the arteries which may provoke an attack of palpitation, or of angina pectoris vaso-motoria, as the case may be. As chronic states, hypertrophy of the left ventricle and atheroma of the arteries are set up by this sjDasm. When the gouty heart passes into the stage of failing hypertrophy from fatty de- generation, these attacks become very serious. The rotten h-eart-walls fail, and angina is as grave then, as it is com- paratively free from danger while the heart-walls are struc- turally sound. If the reader wishes to pursue this matter further, he will find it discussed in a chapter of its own, in my work On the Heart and its Diseases (2nd edit., 1879). The tendency to arteriole spasm is evidenced by the hands "dying" at times, or the feet being painfully cold in the subjects of lithiasis. The tendency of vitiated states of the blood, when laden with lithic acid and lithates, to produce inflammation of the veins, is recognised by Sir James Paget (" On Gouty and some other Forms of Phlebitis"). It is, however, rather found in acute paroxysms in those who suffer from gout. When the urine is laden with these products of perverted metabolism, it possesses irritant qualities. Gouty urethritis simulating gonorrhoea, is no rare affection: or chordee, or even orchitis may be so excited. Stone in the kidne}^ or bladder is often found in persons generally well, entailing their own symptoms: or as Dr. Bennett writes — "I have CHAP. XI.] LIVER DISTURBANCE. 229 met with some patients so extremely sensitive in tliis re- spect that even in health, if the ingestion of food is fol- lowed by the formation of lithates, they become aware of their presence as soon as the urine reaches the bladder, owing to the sudden pain they occasion. I have attended many patients suiTering from irritable bladder from this cause, who have been erroneously thought to labour under stone, stricture of the urethra, or inflammation of the neck of the bladder." He says that fibrinous casts of the kidney tubules are sometimes found. "Their presence is gener- ally considered to indicate severe irritation or even disease of the kidney. Mere fibrinous casts, however, not contain- ing oil corpuscles or epithelial casts, are constantly present in simple cases of dyspepsia, in which the kidneys are evi- dently neither the seat of great irritation, nor of actual disease." He concludes — " When morbid deposits in the urine, the result of defective nutrition, are thus the cause of irritability of the urinary organs, it is vain to hope for relief until the digestive functions have been restored to a more healthy state, and until the urine has ceased to be loaded with the lithatic salts. The latter keep up constant irritation in the bladder and urinary passages, in the same way as sand constantly thrown into the eye would keep up, irritation or inflammation of the conjunctiva." Lithic acid teases the whole urinary tract from the tu- bules of the kidney, which are not rarely found blocked with small calculi of lithic acid, to the meatus itself. This irritant urine often excites pruritus vulvae, or even an ecze- matous. condition of the genitals. Such is the direct effect of the presence of lithic acid. 230 LIVER DISTURBANCE. [chap. xi. Skin Affections are common: and pruritus ani, with or without eczema, is sadly common in liver-indigestion. General pruritus, or itching, is found in jaundice, or in lithsemia, and is an outcome of blood-poisoning by the products of indigestion. Urticaria is so associated; as is eczema, some other skin affections, and also boils and carbuncles. Diabetes is also accompanied by phlegmonous or carbuncular inflammations. A suggestive relationship ! Nervous Symptoms. — Upon no tissue does the lithic acid exert a more irritant influence than upon the brain cells, and of this the most prominent is disturbance of temper. The most constant symptom, in my mind, is irritability of temper, in conditions of lith^mia. Even naturally good tempered persons get cross, irritable, peevish, and waspish, when their blood is so poisoned. With some who are in- dolent, this toxaemia may spur them into activity, if the blood is at the same time well-fed; and these are usually stout, well-nourished persons. But in others, where the brain is ill-fed, as well as poisoned by lithates, the results are far from pleasing. In the first edition of my work On the Diseases of the Heart (1872) is written—" It would often be satisfactory and agreeable to explain anomalous and •indefensible acts by this theory, and to lay some of human frailty to the charge of uric acid." To this is appended a foot-note, evidently inspired by some recent experiences, the memory of which yet remains sharply defined. " It may seem somewhat out of place to allude to impressions formed by the writer as to the effect of retained urine salts on mental processes here, even in a foot-note; but this excess of urine salts docs seem to have a stimulant effect CHAP. XI.] LIVER DISTURBANCE. 231 upon the -brain, and gouty people are usually possessed of some talent. The conclusions, so far, seem to indicate that nuiny persons of good brains, but lacking in energy and inclination to think, are stimulated by retained uric acid into excellent thinking, and attain a reputation late in life. While in others, with small, irritable, ' foxy ' brains, the disturbins: effect of these retained excreta makes the cares of business, etc., quite intolerable. Retirement from business at first gives relief; but soon this irritability ex- cites them to have something to do, and this too commonly is effected by becoming members of boards and committees, when this mental irritability takes the form of mischievous perversity, of ill-controlled interference Avith everything and everybody. In this condition they remind the writer of nothing so much as a cancerous gland — no longer ful- filling any useful purpose, but merely a source of irritation to everything around them," A further experience only endorses this opinion: and such persons are *' social nui- sances;" they " cannot agree with themselves," and of course, it is needless to say, they cannot agree with any- body else. A relative of the writer used to say that " she felt as if she could fight with a feather," when her brain was teased with these lithates. Irritability of temper is pro- nounced, and little things put the sufferer out to an extent quite disproportionate to the exciting cause; while the posi- tive mental suffering and annoyance is aggravated by the consciousness that there is unreasonableness in it, a some- thing wrong within themselves. Often there is a sleepless night, the patient not getting off to sleep till late in the morning ; he, or she, aAvakes not feeling refreshed, but 232 LIVER DISTURBANCE. [chap. xi. irritable and cross to a degree; ready to take offence at anything or nothing at times, the dread of the household if in authority. If the head of a business firm, the under- lings are apt to have a bad time of it; for however reason- able and considerate ordinarily, at these times he is simply unbearable. The ordinary explanation " he got out of the wrong side of the bed " is strictly applicable to these cases. Minutise are criticised or quarrelled with, and the objections raised certainly come often under the heading *' frivolous and vexatious." Nor is it only others who have to suffer; the subjective sensations of the individual are far from envi- able. They know they are misbehaving themselves, yet cannot exercise sufficient inhibition to control their morbid impulses. There is irritability blended with depression; that is the mental attitude. Life is a discord, not a musical note ! Yet they do not receive the sympathy and con- sideration fairly due to them. When the cripple halts in his walk, we do not blame him, we readily recognize his maimed condition ; but when individuals manifest impaired mental action, instead of recognising an infirmity we at once accuse them of " giving way to their temper," or " not exercising proper self-control," or in some other recog- nised phrase blame them morally. But to do so is to act without rational self-control on our own part. Perhaps they exercise all the control in their power; only it is un- equal to completely subduing the irascibility excited by the toxic matters in the blood circulating in the brain. They often merit a consideration and a sympathy which is not exhibited towards them by most persons. They have CHAP. XI.] LIVER DISTURBANCE. 233 claims to our charity, much stronger than they get credit for. The causes of such Functional Derangement of the Liver, may now be considered by the liglit of what has been said before. It is quite clear that first and foremost stands an ex- cess of albuminoid food. About this there can exist no scintilla of doubt, or question. When albuminoid food is taken in excess of the tissue needs, the surplusage, or luxus consumption, is split up in the liver; and it is in this function of the liver we find the disturbance which leads to the excessive production of lithic acid and lithates. It is not necessary to review the subject again here, but, to speak broadly, instead of urea we find the liver producing the less oxidised and less soluble uric, or lithic acid. There is a vicious habit formed which tends to perpetuate itself. The vice persists, until the gouty habit, or cachexia is ena^endered: and then this condition of the production of lithic by perverted metabolism in the liver is riveted on to it. Not only then must albuminoids be given in sparing quantities, but it does not seem a matter of in- difference which form of albuminoid material is taken as food. Clinical observations tend to point in the direction of the avoidance of meat-albuminoids; especially the flesh of beasts, as compared with that of birds and fishes. While caseine seems indicated as the form least liable to be split up into lithic acid; either as milk, the well recog- nised milk dietary; or as the vegetable legume, of which Revalenta Arabica is the best known type. We are not as yet in a position to be very dogmatic on this subject, but 234 LIVER DISTURBANCE. [chap. xi. such conclusion seems suggested; like the shadow of the comino- reality projected forward, in front of it. But to this we will revert in the next chapter. Here the great matter to insist upon is the avoidance of the too free indulo-ence in the toothsome and palatable albuminoids, especially flesh. The next matter is a sufficiency of oxygen, which in- volves fresh air and exercise. The liver-indigestion of the city-man is often the consequence of an insufficiency of oxygen to expedite the metabolism and splitting up of al- buminoids in the liver. The amount taken as food and di- gested by the gastric juice and trypsin of the pancreas may not be excessive; but from want of a sufficiency of oxygen the liver cannot deal efficiently with the proteids borne to it in the blood of the portal vein. Consequently we find the products of suboxidation, to use the language of the late Bence Jones, formed instead of the normal urea. The air of many business places is not calculated to provide the active oxygen required for the oxidation of albuminoids. The improvement which follows upon a day or two in the country tells at once its own tale, as to what is requisite in this class of case. Long ago Mr. Alexander Shaw pointed out {Medical Times and Gazette, July and September, 1842) how the movements of the diaphragm facilitate the flow of blood through the liver, brought to it by the valveless portal vein. A deep inspiration sucks the blood into the liver, while ex- piration expels it with a jet. Exercise, especially horse- back exercise, that time-honoured remedy, is then indica- ted in these cases of liver-indigestion due to an imperfect CH,ip. XI.] LIVER DISTURBANCE 235 supply of oxygen. In all cases where there is a tendency to the formation of the vicious habit of the production of lithic acid in excess, in persons much confined indoors in ill-ventilated chambers, it is desirable that fresh air in the country, aud best by the sea-side, should be obtained if possible. The deficiency of oxygen in tropical temperatures has a marked effect in the production of the bilious maladies, the disorders of the liver, so commonly seen in returned East Indians. Xo doubt their indulgence in animal food has much to do with it. Those races who live on rice and dahl (a legume) or other of the legunilnosce suffer little from biliarj^ derangement. Experimentation has corroborated' this view founded upon clinical observation, extending over centuries; and animals which are exposed to a high temper- ature are found to have degenerative changes instituted in their livers. This is a division of the subject which recom- mends itself to those who meditate a residence in tropical climates. Then there is no doubt about the effect of alcohol in pro- ducino- liver derano-ement. We all know how enlaro-ement of the liver, followed by subsequent contraction, is induced bvthe abuse of alcohol. About this no one entertains any doubt. But alcohol taken even sparingly disagrees with some persons whose livers are easily upset, and they have scrupulously to avoid it; for it is, indeed, a poison to them. Even the form of alcohol is not unimportant. "With one a glass of champagne, with another a single glass of port is sufficient to upset the liver; and a recurring ex- perience tells unmistakably the relations being those of 236 LIVER DISTURBANCE. [chap. xi. cause and effect, and not mere coincidence. To speak broadly, it would seem that alcohol stimulates the liver to give off some of its stored glycogen, and thus unlocks a quantity of heat-giving material, possibly, perhaps prob- ably, by increasing the amount of blood in the hepatic artery, a recognised cause of the liberation of glycogen or animal starch; and its conversion by the hepatic fer- ment into suo-ar. This is in accordance with the fact tliat a glass of wine, or its equivalent, will often excite a glow and a feelino' of warmth, not commensurate with the heat- producing capacity of the mere hydrocarbon of the alcohol itself. When the habit of taking alcohol to excess ha? been formed, and especially taking it in large quantitie:? on an empty stomach, the liver begins to enlarge; and soon a quantity of pathological connective tissue is formed, which gives it greater firmness and density of texture; at the same time, its functional capacity is impaired, espe- cially its power of dealing with albuminoids, as seen by the presence of lithates in the urine. The subjective phenomena of indigestion are commonly seen in drunk- ards. The addition of alcohol to a dietary rich in all material, especially albuminoids, is a fertile factor in the production of liver indigestion; and of all the alcoholic beverages, those prepared from malt act most jDotentlyfor evil. Before proceeding to discuss two matters of great, in- deed, cardinal importance, in this perverted metabolism in the liver, which leads to the production of lithic acid in abnormal quantities, it may be well to say a few words on some other factors. CHAP. XL] LIVER DISTURBA:S''CE. 237 Disease of the heart, and to a lesser extent disease of the lungs, may lead to embarrassment of the liver functionally, by gorging it with venous blood; as a consequence of the Q-ackwirkung, or " back-working," from the obstruction of- fered to the blood flow. When there is such a lesion as impedes the flow of blood through the lungs, the right ventricle becomes enlarged, and so the driving power is increased. But the enlargement usually entails a certain amount of reo-urgitation through the tricuspid valve, and then the veins from the liver become enlarged, and the flow through the liver is obstructed. The liver becomes enlarged in turn, and can be felt to pulsate with the impact of the venous blood driven backward through the insufficient tri- cuspid valve, each time the big right ventricle strikes. This " liver pulsation " is often a diagnostic sign of the greatest value in certain cases. The liver so engorged with this regurgating venous blood, is embarrassed, maimed, or crippled in its functional w^orking, and a free production of lithates is the consequence. In the consideration of this matter it must not be forgotten that, whether disease of heart or lung, the oxidizing processes are impaired by defective chemical interchanges in the thorax ; and so a deficiency of oxygen is an operating factor not to be overlooked. Then all structural disease of the liver mutilates the organ and limits its functional capacity. When an abscess of the liver has destroyed a great portion of the viscus, it leaves the remainder scarcely equal to the demand upon it. This is seen by the diminution in the amount of urea 238 LIVER DISTURBANCE. [chap. xi. formed when the liver is the seat of extensive disease. Dr. Parkes found in examining the urine of cases of liver- disease from India, the amount of urea varied greatly. When the injury was extensive, so as to have destroyed a large area of the liver structure, the amount was less- ened in a degree in strict proportion to the extent of the destruction worked : while in other cases, when there w^as no destruction of the liver structure but engorgement of it with blood, increasing the activity of the liver-cells, the amount of urea was increased, as was also that of lithic acid. In acute yellow atrophy the amount of urea is largely decreased, while that of leucin and tyrosin is largely increased. In cirrhosis also, the amount of urea is diminished; and the same occurs in cancer of the liver, as seen in cases quoted by several authorities. When the structure of the liver is destroyed, its functional power is lessened in a corresponding degree. Consequently, the causes which derange the liver usually are specially oper- ative upon persons whose livers are the seat of structural change. Derangements of the liver may be consequent upon primary and preceding disorder of the gastric or intes- tinal organs of digestion. Crude, or abnormal, or partially digested matters, absorbed into the blood of the portal vein from the alimentary canal, may, in the course of time, lead to secondary disorder of the liver. This, however, it must be admitted, is founded a good deal on <^ j^Hor/ reasoning; and though the features of cases often suggest this, it can scarcely be regarded as demonstrated to a conviction. There remain two matters connected with functional OHAP. XL] LIVER DISTURBANCE. 239 dcrang-ement of the liver, still to be considered, of the greatest interest. Tlie one is the effect of nervous in- fluences; and the other is that of what may be termed congenital insufficiency in the liver. As to nervous influences they have been very fully con- sidered in Chap, vi., pp. 86-109. It Avas there pointed out that mental disturbance exercises a profound influence over the digestive organs, and very specially the liver. The extent to which such influence affects the liver is almost inconceivable, until the literature of the subject is examined. For centuries we have been more or less famil- iar with the effects of indigestion and mal-nutrition upon the brain and nervous system: but the converse, the effect of nervous disturbance upon the liver and alimentary canal, is one wath which our acquaintance is more recent. Dr. Murchison sums up the matter very completely and tersely, and as his views wdll give corroboration to wdiat I have written elsewhere, I will give them verbatim. " Many facts show the great influence of the nervous system upon the secreting organs. Sudden fear, or other severe mental emotion, has been known to arrest the se- cretion of milk and saliva; and we have already seen how injuries and diseases of nerve-tissue may jDroduce diabetes by deranging the glycogenous function of the liver. But many other ailments of the liver besides diabetes have a nervous orio-in. Prolono^ed mental anxiety, worry, and in- cessant mental exertion, not only interfere with the j^ roper secretion of bile, but too often derange the processes of sang-uification and blood-change, in which the liver is so deeply concerned, and induce lith^emia, with many of the 240 LIVER DISTURBANCE. [chap. xi. symptoms already described. Gravel and g-out are ac- knowledged to be the frequent lot of those who live more by nerve- than by muscle-work. Such results are all the more likely to ensue if the diet has been such as favours hepatic derangement — if, for example, to drown grief, the patient has indulged in stimulants — and the habits have been sedentary. There is also good evidence that nervous agencies may not only cause functional derangement, but even structural disease, of the liver. Acute atrophy, in which the secreting cells are rapidly disintegrated, and the functions of the organ arrested, appears in many instances to have a purely nervous origin; very of ten the first symp- toms of the disease have occurred immediately after a severe fright, or an outburst of passion, in a person pre- viously healthy. An impression made upon the brain appears to be reflected to the liver and deranges its nutri- tion. Many observations have satisfied me that the extru- sion of gall-stones from the gall-bladder, as well as their formation, may be traced to nervous agency. Dr. Budd has also observed that mental anxiety or trouble has great influence in the production of gall-stones; and I have repeatedly known attacks of biliary colic from gall- stones, excited by some sudden emotion. Lastly* even cancer of the liver appears sometimes to result from the functional derangement induced in the first instance by mental trouble. I have been surprised at the frequency with which patients suffering from primary cancer of the liver have traced the commencement of their ill-health to indigestion, following protracted grief or anxiety. The cases have been far too numerous to be accounted for on CHAP. XI.] LIVER DISTURBANCE. 24=1 the supposition that the mental distress and the cancer have been mere coincidences. A similar observation has, I believe, been made by Sir Robert Christison, and by other eminent authorities." These are very definite and equally strong and decided expressions of opinion. Dr. Budd wrote : (" Diseases of the Liver," 3rd edit., 1857). — "Another condition that seems to me to have great influence on the production of .gall-stones, or at least of biliary gravel, is mental anxiety or trouble." It is indeed abundantly shewn that mental disquietude disturbs the functions of the liver, one and all, " stock, lock, and barrel;" and, not only that, but may set up even structural disease, to the extent of cancer itself. " Congenital Insufficiency " of the liver is, there is every reason to believe, the cause of much of the trouble to which *' bilious " persons are liable. Dr. Budd, a keen observer, one of a laro-e familv of medical men, all of whom were remarkable for their acumen and their incisive thought, expressed himself on this subject as follows: — " In most persons, perhaps, a portion of the liver may waste or become less active, without sensible derangement of health. They have more liver, as they have more lung, than is. absolutely necessary. In others, on the contrar}^, the liver, from natural conformation, seems only just capa- ble of effecting its purpose in favorable circumstances. They are born with a tendency to bilious derangements. This innate defect of power in the liver has its counterpart in the deficient respiratory power in persons with vesicular emphysema of the lungs, and, like the latter defect, and most other peculiarities of physical structure, is no doubt 11 242 LIV:ER disturbance. [chap. xi. frequently inherited. Persons who inherit this feebleness of the liver, if we may so term it, or in whom, in conse- quence of disease, a portion of the liver has atrophied, or the secreting element of the liver has been damaged, may suffer little inconvenience as long as they are placed in favorable circumstances, and observe those rules which such a condition requires; but whenever from any cause — - as a hot climate, gross living, indolent habits, constipation, — a more abundant secretion of bile is requisite to purify tlie blood, the liver is inadequate to its office, and they become bilious and sallow." Such then is a very shrewd observation, and explicit expression of opinion, in one of our most trustworthy authorities; none the less deserving of confidence because he used the phraseology of his day; and did not know that the liver was largely engaged with the albuminoid material of our food. Had he been aware of this, he would have employed a more comprehensive expression than that of "a more abundant secretion of bile is requisite to purify the blood." He would have grasped the subject more efficiently, as Dr. Murchison, possessed of more recent and more extended knowledge, has done. He quotes Dr. Budd, and adds: — "The person is born with a tendency to biliary derangements. Gout and diabetes, which we have found to originate in hepatic derangement, are hereditary diseases ; and the liver is always very readily disordered in persons who inherit a tendency to gout. This constitutional tendency to hepatic derangement, is too often lost sight of by patients, and per-- baps sometimes by their medical advisers. The habitual use of alcohol is often recommended for various ailments. CHAP. XI.] LIVER DISTURBANCE. 243 Avitliout due regard to the tendency of the individual to liepatic derangement, and thus serious consequences may ultimately arise from alcohol taken with a medicinal object. Again, a patient often argues that his liver-troubles can- not be due to what he eats or drinks, because he is most careful as compared with friends who indulge largely and suffer nothing-, for2:ettin2- the ada^re: 'one man's food is another man's poison.' One man, for instance, may drink a bottle of wine and be none the worse, whereas, another has his liver derano-ed bv a sino-le g-lass." Doubtless the explanation offered above is a reasonable one, and tells us fairly satisfactorily Avhy one man cannot eat and drink without suffering for it, what would be quite a moderate amount for another person; who can habitually take that much, and more, without any inconvenience supervening thereupon. The subject has not escaped the observation of other authorities and Dr. J. Henry Bennett writes : — '' The gouty diathesis, when it is the result of hereditarj^ taint, has proved in my experience the cause of some of the most intractable forms of d\'spepsia, both in male and female, that I have met with. Indeed, I believe that dyspepsia, recognising this cause, is in some instances, quite incurable, and can only be palliated. It is a sad legacy that the gout}^, from self-indulgence, often leave to their children, even when they themselves are free from it. Singularly enough, it does not show itself, necessarily, in all the children of a gouty father or mother, but only in one or more of the number. The children of gouty parents ought, more especially, to follow the hygienic and 244 LIVER DISTURBANCE. [chap. xi. dietetic laws laid down in these pages, if they wish to es- cape much suffering'. As a rule, they ought to be all but water-drinkers, throughout life; they have to pay the pen- alty of their progenitor's excesses, or dietetic errors. If the gouty diathesis is strongly marked, they should be most moderate and abstemious in their food habits, and lead as active and muscular a life as possible. Indeed, they should never lose sight of the fact, that a miserable gouty old age may be their fate, should their life be pro- longed, unless they make many sacrifices to ward off the impending danger." This relation of indigestion with the gouty diathesis, i.e., a constitution which is gouty by in- heritance, is one which is the more extensively recognised, as the subject is more investigated. There is a well- known story which may be quoted in proof thereof. An old clergyman once ejaculated, "I have been a dyspeptic for fifty years. Thank God, for it ! " The reason of his satisfaction, expressed so devoutly, was the fact that all his brothers were dead and buried, cut off by gouty affections; he alone remained of the family. Dyspepsia had saved him from the fate which overtook the rest. The dyspeptic then is, under certain circumstances, a better life, in insurance phrase, than those who are free therefrom. But is longevity worth the price, many will be tempted to ask ? Dr. Leared commences his little work " On Imperfect Digestion," as follows: — "The digestive power may be compared to the physical strength. Every individual can, without inconvenience, carry a certain weight, while any addition to it is accompanied by a proportionate sense of CHAP. XI.] LIVER DISTURBANCE. 245 oppression. In the same way, what is called indigestion, is often simply a result of excess. The amount of food which each man is capable of digesting with ease has al- ways a limit." Quoting Cicero's gratitude that his ad- vancing years had diminished his inclination to eat and drink, he points out that: — "At all stao-es of adult life, but particularly during its decline, the appetite is over- stimulated by condiments, and tempted to excess by culi- nary refinements. Dyspepsia is not the worst result of this. Gout, and still more serious maladies connected with an impure state of the blood, closely follow. In- fringements of the laws of digestion are constantly, and in many cases unconsciously, committed. One man di- gests with ease an amount of food, which would be fatal to another. Animal food is easily digested by some per- sons twice or even three times daily; while, if taken by others more than once, it is sure to induce suffering. Nevertheless, the diet of persons associated together is apt to be the same, and sufficient individuality in matters of eating and drinking is seldom observed." There is much force in the way in which Dr. Leared here points out the diversity of individuals in their diges- tive capacity, like any other capacity; and also that the power is not always the same in the same individual, but is diminished with age. That we are apt to eat alike, w^hatever our individual capacities, is certain; and the dyspeptic who moves much in society, or "goes out at all " is always being tempted, inveigled, or goaded by jeers and jibes, into eating a great deal infinitely better avoided; with the person who suffers from " liver-insuf- 246 LIVER DISTURBANCE. [chap. xi. ficiency," any indiscretion is swiftly punished, and suffer- ing follows closely on the heels of the offence. This congenital incapacity in the liver deserves an at- tention it does not receive either from the patients who suf- fer, or the medical men who advise them, as a rule. Just as we see poor wretches with flat narrow chests, and we recognise that in consequence of their badly developed chests they will readily succumb to disease of the respira- tory organs; because at the best they only possess as much lung as will barely carry them on in a makeshift way. So we should learn to recognise the other fact, — that of the congenitally incompetent liver. If such recognition were more general it would be well for those so born imperfect. They must eat in proportion to the capacity, or rather the want of it, in their livers; not according to their appetite or the habits of society, if they wish to exist in (compara- tive) comfort. I remember well a gentleman of good descent, in my early experience in Westmoreland when I took my father's practice, who was embarrassed by one of these incapable livers. Straitness of means and a waxing family compelled him to live very sparingly and economi- cally; and partly by that, partly by long hours every day in the open air, in the garden, or on the roads with a rake, a life of industry comparing favourably with that of many field-hands, he managed to keep himself in health and comfort. But the slightest omission or relaxation of his dietetic or hygienic arrangements was followed by retribu- tion, swift and sufficient to keep him at his round of self- denial and self-imposed toil for a considerable time to come afterwards; and occasionally, but rarely in fact, he went CHAP. XT.] LIVER DISTURBANCE. 247 away to visit a more afiluent brother for a week, with the invariable result of well-marked articular gout being estab- lished in him. For many long years this went on, and this poor gentleman taught me much about congenital im- pairment of the assimilative organs. Probably this is a well-marked instance, a very well defined instance indeed, of the influence of descent in impairing the digestive pro- cesses. The plebeian alderman eats (or is reputed to do so), vigorously with undiminished zest and appetite, free from gout or dyspepsia, into good old age; giving the lie to the statement that " of all carnal pleasures cometh satiety at the last.'' While the well descended gentleman gets gout on the slightest provocation; eats as daintily as a lady, when his means will permit it, drinks most abstemi- ously, and yet his enemy has him on the slightest provoca- tion. There must be a reason for this, surely ! And prob- ably the explanation lies, as Dr. Budd wisely suggested, in some congenital impairment in the functional capacity of the liver. The fact that the children of the alderman who could perform such gastronomic feats, do not possess their progenitor's capacity, is one well recognised. Indeed it is simply impossible to avoid the conclusion, that there exists a section of society who are hereditarily feeble in the liver, either actually bilious by bile-acids, or the sub- ject of lithiasis, from the liver being unequal to the nor- mal transformations of albuminoids. Such persons step into their inheritance, whether they like it or not. Some persons inherit unstable nervous systems, others weak lungs, while indubitably others inherit incapable livers ; and the sooner the fact of " liver-insufnciency," is gener- 248 LIVER DISTURBANCE. [chap. xi. ally recognised, the better for those who suffer (potentially) therefrom. After this rather lengthy consideration of " Biliousness " and "Liver Indigestion," we can approach all the more satisfactorily the subject of the treatment of these allied conditions; and comprehend all the more clearly the why and wherefore of what will be recommended in the ensu- ing chapter. CHAPTER XII. THE TREATMENT OF LIVER DISTURBANCE —MEDICINAL AND DIETETIC. The reader will now be fully prepared to enter upon the question of how to improve the condition of persons who labour under hepatic derangement. For a certain class of readers this section of the subject will possess little interest, and a languid curiosity is all it will arouse. But I venture to think there is a much larger class who will eagerly read this chapter; viz., that portion of the medical profession who not only are sincerely desirous of doing what good they can to their fellow creatures; but who feel that they would be glad to give their patients something like " value received " for their money. A valid excuse may be ten- dered for simply watching a case of uncomplicated pneu- monia, or typhoid fever, running its course; prepared to take the requisite active steps when the necessity for them arises. But such mere observation of cases of derange- ment of the liver is what no one would attempt in the pos- session of his reasoning faculties, be the same more or less; and if it were essayed, the patient would soon express his opinion on the subject — and emphatically, I suspect. And in doing so he would be held justified by all: when we think how important it is that a man be enabled to work in comfort, or an approach to it; and not only that, but also to have his health as long as possible. We all know how, as age advances, the digestiv^e and assimilative 11* 250 LIVER DISTURBANCE. [chap. xn. organs begin to fail. Gout is a disease of middle age and advanced life. The work which the liver has to do day by day tells upon it, and instead of the ordinary normal meta- bolism in it, disturbances and perversions arise. The arrangements which change grape-sugar into glycogen, and glycogen back again into grape-sugar, become dis- turbed, and then diabetes is the consequence. Or the splitting up of albuminoids is perverted, and then lithic acid is largely formed, instead and in lieu of urea, and then gout is the result. Now it behooves the medical man to keep well in view the future, as well as to recognise the present necessities, in cases of liver derangement. It is not only desirable to give relief at the time; but it is well to include the future in the therapeutic scheme. It is not only the immediate trouble of the patient, it is what is looming in the distance which must be calculated for in the estimate. This factor it was, which, being omitted from the calculation, ultimately brought such discredit on the " blue-pill and black-draught " treatment. Such means gave immediate relief; about that there can exist no ques- tion. But what was the consequence ? Possessing a ready means of procuring relief, our predecessors went on their way rejoicing — ate, drank and were merry, as in the day before the flood, " and knew not till the flood came and swept them all away." So it was with them. They set no bounds to their indulgence, and fell back on the blue- pill and black-draught when inclined, until an unremedi- able condition was established. Instead of righting itself, the system became accustomed to this artificial means of restoring the equilibrium, until the power of self-restoration CHAr. xn.] LIVER DISTURBANCE. 251 of the balance became irretrievably lost; and then a per- manent cachexia settled down upon the remainder of their days. So conspicuous did the evil become, that the stream set in in the opposite direction so effectually that now many persons, yes, and many medical men too, look upon a mer- curial pill as if it were " possessed of a devil." The reaction came and swept reason away in its current as it often does; and one extreme begat the. other. I remember well, not many months ago, reading a paper before a large suburban society upon the desirability of sweeping the accumulated nitrogenised waste out of the blood, in certain cases of dilated heart with enlarged liver; when, in the discussion which followed, several gentlemen of various ages asked if I thought a mercurial at times permissible in such cases; as timidly as if they felt themselves liable to be suspected of wishing to resuscitate the Druidical faith, or exhibiting a latent belief in the old notion that " nine live lice upon a piece of bread and butter" were the most appropriate and effectual treatment of an attack of jaundice. And on as- suring them that I not only thought such remedial agent permissible and lawful, but even approved thereof, they seemed immensely relieved ; while several and sundry others present interchanged a significant glance as if they thought I was the subject of incipient general paralysis; indicating, too, that my utterances in future would receive no regard or confidence from them. They clearly would have none of this renewal of an exploded doctrine; they would as soon think of reverting to the Pythagorean teach- ing of the transmigration of souls. But, perhaps, they will find after a while that a mercurial pill, succeeded by a 252 LIVER BISTURBANCK [chap. xn. smart purgative, is a very good plan of treatment in certain cases; provided that they follow it up by a rational dietary, so as to prevent future accumulation of waste matter in the blood. It was the nes:lect of this latter which brouo-ht the mer- curial remedy into disrepute. By attention to it in the future, the mercurial pill, followed by a saline laxative will have its day again; liable, however, to be again discarded if abused ! Colchicumhas been in and out of the Pharma- copoeia some half-dozen times at least, according to the ebb and flow of medical belief, and the fashion of the times. Unbounded faith is often the precursor of an equally blind, irrational unbelief, as history tells us. Such oscillations of belief simulate at first the overthrow of a superstition, and bv some are thousfht to be such a movement, until time disproves it. The trying for witchcraft, and the general belief in witches, their wholesale detection and cruel pun- ishment, culminated in a reaction as swift as it was com- plete; and the belief of one generation was the scoff and scorn of the next immediately succeeding it. Sir Thomas Browne, the renowned author of Heligio Medici, believed in witches, and once as a witness swore in court ''that ho was clearly of opinion that the persons were bewitched." Yet the men who believed in witches and the judicial pun- ishment of witchcraft were, as Lecky points out, quite as capable of forming an accurate opinion on other matters of life as other people have been. So the men who practised medicine with the use of the blue-pill and black-draught were in the possession of their senses; only abuse led to reaction. Now the dread and horror of a mercurial in any CH.1P. xn.] LIVER DISTURBANCE. 253 case, and under all circumstances, is leading a large section of men to the opposite extreme — of its avoidance in season and out of season; and that portion of my audience looked upon me as if I were a nineteenth century would-be imita-- tor of Julian ''the apostate." The heroic plan of treatment, the lancet and the blue pill, has been followed by a re- action which has extended to Nihilism with many as regards drugs; while an unbounded faith in beef-tea, and the sus- taining plan of treatment now generally obtains with them. Nevertheless, in many cases a mercurial and a saline after- wards form a very good plan of therapeutic attack in emer- gencies. Admitting, at the same time, that the natural loss of appetite leading to abstinence, is much better in many cases. Nor does this confession of faith in mercuri- als as a cholagogue involve a retrograde movement which will extend to a resuscitation of a belief in witchcraft, or the tenets of Druidism. To advocate the proper use of mercury as a cholagogue is not, then, the revival of an exploded superstition. Still it is now acknowledged that it is not well to resort to the habitual use of mercury as a cholagogue; for it is found that once accustomed thereto, the liver does not respond to other less potent stimulants; like the toper who, familiar with brandy and a split seltzer, ^lares little for a drau^-ht of hock and soda-water. The subject will be reverted to a little further on. But our choice of remedial agents should be pro- foundly influenced by the fact that as age proceeds, the assimilating organs lose some of their pristine energy. Nor does the mature organism require the material which is essential to the building of the tissues in growth, and in 254: LIVER DISTURBANCE. [chap. xn. that consolidation of the system which follows growth of stature. The energy of manhood will enable the system to burn up much food, perhaps not absolutely demanded, but which is, at least, not harmful. But when advancing years limit the energies, then such consumption becomes baneful; while a less liberal supply of oxygen renders the task of oxidizino- albuminoids more difficult than it once was. A natural failure of the appetite follows ; which should be respected, and not struggled with. There is then, in the first place, w^hat to avoid; when this spontane- ous anorexia, or loss of appetite manifests itself — its lesson is to leave it alone: lessened body-wants no longer require an active, keen appetite; and attempts to whip up the appe- tite by bitters are to be discouraged. The appetites vary with advancing years. The mistress gives way to the cook; and the skill of the latter, like the charms of the former, is frausrht with an element of dano-er to the owner. The temptations to eat more than either is required or good for him, to which the middle-aged man of means is ex- posed, the natural weakness or lack of strength to resist temptation, should induce him, if reason ruled the roost, to discharge his cook for one of less, instead of more skill, when the natural decay of the appetite begins to manifest itself. Such, however, is not the case, and is not likely to be the case for a long time to come. So the cook, the more skilful the more dangerous, is the first matter to be decided. He or she must, or ought to be, discharged ; or handed over to the possessor of a more youthful appetite and vigorous set of digestive organs. Then the family medical attendant should pledge himself, by solemn oath CHAT, xn.] LIVER DISTURBANCE. 255 and covenant, never to prescribe bitters when the appetite is defective, or capricious; the patient equally binding him- self never to whip or flog the jaded appetite by bitters, either hop bitters or Angostura with a little gin, or dry sherry before dinner. If such compact were made and kept faith- fully, many a liver would be able to hold its own, and fulfil its function fairly well, which, under the present arrange- ment, is prematurely worn out years before its potential exhaustion. It is but human to sacrifice the future to the present; and an ajDpetite which is waning ought to be conserved, its owner thinks! Certainly; the question is how best can it be conserved ? It is not preserved by stimulating the appetite and the stomach to consume more food than the liver can dispose of. Rather the judicious plan is to follow the indications of the appetite, and when it flags to eat accordingly. But whether this plan Avill obtain, or not, till the millennium is reached, is a subject which cannot be settled out of hand. It may safely be said, that it ought to obtain. Especially should such rule be observed by persons Avho have resided in tropical climates, or been the subject of hepatic disorders. Dr. Budd makes a remark which may profitably be quoted here, viz.: — "In persons Avho die of yellow fever, the liver presents various morbid appear- ances, which have been minutely described by Louis, that depend not on the products of inflammation, or on the state of the vessels, but on the condition of the cells. The damage done to the liver in this way may last for years. It is probable that the bilious disorders of many men on their return to this country from India, and other hot cli- 256 LIVER BISTURBANCE. [chap. xn. mates, are, in great measure, owing to permanent injury done to the secreting element of the liver." This remark is pregnant with suggestiveness, that in many cases the secreting cells of the liver, by which the metabolism and splitting up of albuminoids by oxidation are carried on, become impaired functionally; if not always structurally. Such modifications should be remembered when the pa- tient's dietary is being laid down: nor need such consid- eration be restricted to returned East Indians; it might quite well be extended to those who, though they may not have resided in tropical countries, nevertheless have suffered from biliary and hepatic disturbances. It may be well to proceed to the consideration of acute bilious congestion of the liver. In such cases in children, it may be well to administer an emetic of ipecacuanha, with a small dose of a mercurial, followed by a purgative. But this should not be resorted to habitually in consequence of unrestricted indulgence in food. It should only be a dernier resort in emergencies. Very often the loss of ap- petite and languor lead to spontaneous restoration of the health; and, even at the risk of shocking some anxious mothers, or impulsive practitioners, it may be said that such is, with delicate children, much better for them in every way; educating the system to take care of itself, and proving a very good lesson for future guidance. Still, the emetic and purgative may, at times, be indicated. In acute cono-estion of the liver of warm climates, I may quote Sir Joseph Fayrer, K.C.S.I., F.R.S.L. and E., written for me for my Practitioner^ s IlandhooJc of Treat- ment: — "In reference to the treatment of the functional CHAP, xn.] LIVER DISTURBANCE. 257 derangements of the liver which arise from cono-estion and I think more especially that form in which it is ac- companied by anaemia, such a condition, in short, as is so frequently seen in persons who have lived long in hot malarious climates like India, the West Indies, and the Coast of Africa, I may say this. Bevond mere swellino- of the liver from engorgement with blood, other chancres — fatty or amyloid— will no doubt supervene, and it is often difficult to determine how far the functional is due to the structural change. The treatment I generally find most effective, is attention to diet and drinks. Avoid much fatt}', sugary, and alcoholic fluids. No beer. Claret and water for drink. Warm clothing, so as to keep the skin moist. An occasional dose of colocynth and calomel, or blue pill, and every morning, or every other mornino-, a dose of saline aperient, such as sulphate of magnesia, with quinine and gentian, sufficient each time to produce two or three loose motions. Counter-irritation by tincture of iodine over the loins. WJieJi the portal circulation is relieved, some preparation of iron may be very useful. The urine is a good test of the hepatic condition; it will improve under the above treatment, but it is well to give the patient some alkaline waters — Vichy, Vals, or Carlsbad. Albuminuria will be present at times,, when the kidneys, like other abdominal viscera, are congested, or are irritated by lithic acid. In my opinion, too much importance is at- tached to this symptom in some cases. Indeed, I think the subject of albuminuria would bear rewritino-. Albu- minuria may be functional in such cases, and pass away like the other symptoms." Certainly, looked at by our 258 LIVER DISTURBANCE. [chap. xn. most recent light, such albuminuria may be but a part of tlie hepatic derangement, and pass away with it ac- cordingly. Now is it unfriendly criticism of Sir Joseph Fayrer's practice to say, that in his line of treatment, the matter of albuminoids is omitted ? Yet to withhold them is in all probability also very desirable, and would be ac- companied by improvement in the symptoms. The patient should be kept upon rice-water, or other simple starchy matter, which gives the liver the least labour. Or a little beef-tea with baked flour in some form might be taken sparingly; where procurable, a milk dietary might be substituted, or whey, where there is anorexia with much thirst. Probably a liberal supply of subacid fruit is ahvays desirable, as well as grateful to the patient. As regards permanent biliousness as seen in England, my practice has been modified by the light of advancing phj'^siology, with advantage, I firmly believe, to my pa- tients. I no longer allow them to consume albuminoids in any quantity; but instruct them in this, as in other elements of their food. But this is the dietetic manage- ment to be discussed further on. It is well to give them a pill containing a hepatic stimu- lant, to be followed by a mineral saline next morning Two copious motions, one before, the other after breakfast, furnish much sense of comfort in cases where the bowels are sluggish; that is in the bulk of cases. By such treat- ment, they are greatly improved; even in cases where " con- genital insufficiency of the liver " is presumably present. At this point it may be well to review those medicinal agents which act upon the liver. CHAT, xn.] LIVER DISTURBANCE. 259 Soda, and its salts, are found to act potently upon the liver. Consequently, while sulphate of magnesia is a capital purgative when the intestinal glands alone re- quire stimulating, this salt acts little if at all upon the liver; and when it is desirable to "rouse the liver," as the phrase runs, sulphate of soda, its bitter taste not- withstanding, should be prescribed. The experiments of Rutherford countenance and corroborate the conclusions at which clinical empiricism had arrived. Potash for the kidneys; ammonia for the lungs; soda for the liver: these are the bases of the salts to be used according- to the cir- curastances of cases. Sulphate of soda is best taken in the mornino; first thing- on o-etting- out of bed. Then some bicarbonate of soda, or Rochelle salts, must be added; with a carminative of some kind, in a bitter infusion, warm. Such a draught, first thing, is of the greatest service. The carminative not only covers the objectionable taste of the salts, but is itself useful. Dr. Budd wrote: — " Pep- per, ginger, and other hot spices, are also supposed, and perhaps justly, to render the liver more active, and increase the secretion of bile." It is well to bear this in mind, in prescribing for hepatic derangements under all circum- stances. Chloride of ammonium has always had warm advocates for its utility as a cholagogue. Mercury, in all its forms and preparations, has been in use for centuries in liver deranorements. Sad and disas- trous are the consequences of the abuse of this powerful medicine. The indiscriminate and inordinate resort to 260 LIVER DISTURBANCE. [chap. xn. mercury has brought the treatment of the Services into well-deserved disrepute. Potent for good, still more po- tent for evil, when abused; mercur}^ has fallen from its hio-h estate into comparative disgrace, or neglect. Its claims, however, must be considered rationally. Highly as it was once extolled, it is now equally abused, and de- preciated. Nor can we wonder at this, when we think how it has come about ! The terrible consequences of the administration of mercury till free salivation was produced, formed a lesson which many took to heart; in some cases too earnestly. The zealots who ordered patients to be S8.1ivated to so many pints a day, simply dethroned their idol in public opinion. Then followed the quack-salvers, with their patent medicines, who announced, with all the flourish of trumpets at their command, that their pills *' contained no mercury." The action actually extended to the point of abandoning mercury in the treatment of syphilis. Slowly the tide of indignation against the use of mercury has ebbed until its use in syphilis is once more universal. The late Prof. John Hughes Bennett hated mercury with a virulence scarcely conceivable by those who did not know him. He denounced it, he inveighed against it, he poured all the power of ridicule he possessed, and that was no slight amount, upon it; he shot every arrow of sarcasm in his quiver and it was a pretty full one, at the misguided, wicked persons who dared to advocate the administration of a single grain of calomel. Peace to his ashes; an iconoclast, he did a good service in his way. Still the crusader is an enthusiast; and an enthusiast is CHAP, xn.] LIVER DISTURBANCE. 261 not a person of a judicial frame of mind. The crusade against mercury is now passing- away; liaving played a useful part; the tendency at present is the other way, and the cautious and rational use of mercury is once more finding numerous advocates. In speaking of mercury Dr. Budd wrote: — "The marked temporary benefit often re- sulting^ from mercurv o-iven for this effect has, from the difficulty of distinguishing the various diseases of the liver, and the constant indiscriminate use of the drug, led to great evils. This medicine was at one time, by English practitioners, given almost indiscriminately, and long per- severed in, for disorders of digestion, many of which did not depend on fault of the liver at all, but on local disease of the stomach or intestines, or on faulty assimilation, the result of debility, which the prolonged use of the mercury but too often increased." This is a judicial expression of opinion by a man whose opinion is entitled to every re- spect. The way in which German writers have condemned the English use of mercury has done much to help on the growing disuse of the drug; their condemnation has been wholesale thorouoh-fjoinG: and indiscriminate itself: and has been sometimes the blatant utterance of iofnorance as well as, at times, genuine honest criticism. Dr. Murchison has put the position of mercury very pointedly. After giving the results of numerous experi- ments he proceeds: — "Mercury and allied purgatives pro- duce bilious stools by irritating the upper part of the bowel, and sweeping on the bile before there is time for its reab- sorption. The fault of mercury standing at the bottom of the scale of cholagogues in ROhrig's experiments is ac- 262 LIVER DISTURBANCE. [chap. xn. counted for by its surpassing otlier cholagogues in this property; for of course the larger the quantity of bile that is swept clown the bowel, the less is reabsorbed, and the less escapes from a biliary fistula. It would appear that mercury by increasing the elimination of bile, and lessening the amount of bile, and of other products of disintegrated albumen circulating with it in the portal blood, is after all a true cholagogue, relieving a loaded liver far more effec- tually than if it acted by merely stimulating the liver to increased secretion as was formally believed, and as some authorities yet maintain; for in this case it might be expected to increase instead of diminishing hepatic con- gestion." This is very judicial. But Dr. Murchison pro- pounds another view essentially his own. After describing that patients of undoubted intelligence are certain about the benefit they derive from mercurials, he writes: — "It is not impossible that the good effects of mercury on the liver, and in some forms of inflammation, may be due to its property of promoting disintegration. It seems not improbable that mercury, which we know from experi- ments to reach the liver, may under certain circumstances act beneficially by promoting, or in some way influencing the disintegration of albumen. The remarkable effect of mercury on constitutional syphilis perhaps admits of a similar explanation. But in whatever way it is to be ex- plained, the clinical proofs of efficacy of mercury in certain derangements of the liver are to my mind overwhelming. I say so the more advisedly, because I was taught to regard mercury as a remedy worse than useless, not only in he- patic diseases but in syphilis: it cannot, therefore, be said CHAP, xn.] LIVER DISTURBANCE. 263 that the convictions forced upon mc by experience are the result of preconceived opinion." Dr. Murchison was a pupii of the hite J. Hughes Bennett. So was I; and T can also plead that my belief in mercury has been " forced upon me by experience," for Bennett's thundering diatribes dominated my mind for a long time ; and the impression made by him upon my youthful mental processes was only ground out by the resistless action of au accumulating experience. When the kidneys are extensively diseased a marked in- tolerance of mercury is often manifested; and like opium i": must be given with much caution then ; though its utility with red and pink lithates is incontestable. In the white deposits of true liver-indigestion it is not indicated. A broad rule may be struck to this effect — when there is atony and asthenia mercury is contra-indicated; but when there is fair power, without anjemia, it may be given. Always bearing in mind tliat broad rules do not apply to every case; and where individual experience has demon- strated that mercury does not agree, scrupulously avoid it. The old fashioned plan of six or eight grains of calomel for acute indigestion may suit some strong persons; but it is within my own personal experience, not of my own pre- scribing it is almost needless 'to say, that such reckless practice has done immense harm to a delicate patient. Mercury is one of those " edged tools " which must be handled with care and judgment. When the patient has found opium to disagree, whether you find any albumen' in the urine or not, my youthful re^ders^ just hold your hand about merctiry ; it is not necessary tq insist upon 264 LIVER DISTURBANCE. [chap. xn. tliis for older readers — they have found it out for them- selves. Another broad rule may be put thus : persons of the gouty, sanguine, or arthritic diathesis bear mercury much better than do those of the strumous diathesis. With the first, the action of mercury in disintegrating albuminoids acts beneficially as a rule ; but upon the defective constitutions of the strumous with their imper- fect tissue-building (p. 72) mercury acts too energetically, and in a very undesirable manner. When to give a dose of mercury in conditions of lithiasis and albuminuria, where it will do good ; and when to avoid it as you would a Cobra-di-Capello, is a problem in each case to be solved, which will task the natural powers and the acquired skill of the practitioner to the utmost. Consequently I think it well to quote a passage from the second edition of the "Practitioner's Handbook," — "Dr. Broadbent informs me that in the numerous cases of albuminuria in the London Fever Hospital, towards the decline of the affection, when only small quantities of albumen remain, mercury in limited doses usually leads to the entire disappearance of the albumen. It is a remedy, however, which should be resorted to cautiously; while quite a safe measure in the hands of so careful a physician as Dr. Broadbent, it may be a very dangerous agent in the hands of some practitioners." So in certain cases of albuminuria, not consequent upon acute fever, a little mercurial may be very beneficial; but in every in- stance it should not be given until the case has been made the subject of patient thought. Given careless!}'', most de- plorable results may follow. A tense pulse is usually a CHAP, xn.] LIVEE DISTURBANCE. 265 fair iiidicalion for it. The wliole subject is one on wlilcli we all desire more precise in formation. Aloes is an agent long recognised as having an effect upon the liver. So is rhubarb. " Many persons have succeeded in warding off bilious attacks to which they are subject, by taking habitually, before dinner, a few grains of rhubarb. A rhubarb pill will often relieve a slight bilious disorder, even before it has purged" (Budd). Taraxacum is a reputed liver stimulant, much in vogue with the world at large, and with herbalists; but little used by regular medical practitioners. Jalap, colocynth, and senna, are also cholagogues of some potency. Ipecacuan is an hepatic stimulant, not only of time- honoured repute, but the observations of clinical medi- cine are borne out by the physiological experimentalist. Rutherford found it to be one of the most potent of chola- gogues. Personally, I am very fond of giving ipecacuan, especially in a '* dinner-pill;" in that, following a practice which has been all but obsolete for a long time, but which seems likely to be revived. It seems to obviate the action of opium upon the liver, when combined with that drug, as Dover's powder. To the same class of hepatic stimulants belong " Iridin," extracted from the root of the Iris Versicolor, now much in vogue. Still more popular is " Euonymin," derived from the bark of Euonymus Atro-purpureus; a drug now much used in the United States as well as in Great Britain. " Hydrastin," from the root of the Hydrastis Canadenis, possesses allied properties; and so does " Jug- 12 266 LIVER DISTURBANCE. [chap. xn. landin," a resin from the root of the butter-nut (Juglans Cinerea). It is officinal in the U. S. A. " Baptisin " from the root of the Wild Indigo (Baptisa Tincturia) also possesses a moderate stimulant action on the liver. Where a powerful cathartic is required, as well as a liver stimulant, then it is well to prescribe podophyllin; a drug entitled to be ranked as a potent cholagogue, as well as a purgative. Of allied character is croton oil, popular a generation ago for the treatment of lumbago connected with lithiasis. These agents are all useful according to the indications in each case in liver trouble, biliousness, or lithiasis; and may be used with advantage, as cholagogues and hepatic stimulants. Of a totally opposite character in its action is opium. We cannot separate one action of a drug from its otlier actions, except by blocking out the objectionable action, by combining an agent of antagonistic properties. Thus, I systematically use belladonna with opium in the severe cough of phthisis, to keep off the night-sweats induced by it. The co-administration of ipecacuan largely prevents the action of opium upon the liver; a laxative its action upon the bowels. But this action of opium is useful when the liver-ferment converts glycogen too freely into sugar; and so is useful in the treatment of diabetes. In azoturia, or baruria, where there is a neurosis of the liver splitting up the albuminoids into urea, and therewith a certain amount of bulima, opium also is useful. It puts a check upon the activity of the liver; and this, though it consti- tutes a drawback to its administration ordinarily, is useful in some cases of excessive action of the liver-cells. CHAP, xn.] LIVER DISTURBANCE. 267 In the liver disturbance clue to j^yrexia, quinine lessens the morbid activity of the viscera. Then there are mineral remedies to be considered. Nitro-muriatic acid taken by the mouth, is often useful when an attack of jaundice is passing away. Some like foot-baths containing it; others, a lotion of it upon lint over the liver. The free chlorine in this acid is generally regarded as the potent factor. Chloride of ammonium is often criven therewith. " It o^oes with either acids or alka- lies" (Murchison). Acids, Murchison thinks, may not act directly upon the liver, but may do good indirectly by improving gastric digestion. In some cases, he holds, both acids and alka- lies may be given advantageously — the alkalies before, the acids after a meal. This is in accordance with what Ringer advocates; tlie alkalies taken when the gastric mucous membrane is alkaline excite a better flow of gastric juice. The acids given during the period of gastric digestion probably aid -therein. Alkalies are more in favour as a rule than acids, in the treatment of hepatic affections. Where the alkaline bile is insufficient to counteract intestinal acidity, fixed alkalies are indicated as Prout held (p. 183). Soda is the alkali for the liver ^:)ar excellence. Of the common condiment of our food, the hydrochloric acid goes to the gastric juice; the soda to the bile. The alkalies are good, especially potash, in rendering lithates soluble. According to Bence Jones, alkalies are of great service in aiding the oxidising processes which go on in the body. Some persons, however, cannot take 268 LIVER DISTURBANCE. [chap. xn. alkalies without extreme depression. I know a stalwart Yorkshireman, who could not take a teaspoonful of effer- vescing citrate of potash for three mornings consecutively, without experiencing such prostration, produced thereby, that he was unfitted for business. Others aofain can take large quantities, not only with impunity, but Avith positive benefit. Murchison recommends that alkalies should be suspended for a time, as they may, when long-continued, hiterfere with gastric digestion. This must depend upon the evidences of each case. The acid bi-phosphate of soda is an excellent solvent of lithic acid, according to Ritter von Schroff, and might be substituted for the ordinary alkali. When alkalies, and especially potash, depress, it is well to give them with a tonic. Potash is a muscle poison, often acting powerfully upon the heart. It is easy to counteract this action, by giving with it an agent which increases the vigour of the cardiac contractions. When alkalies are indicated, they should not be taken with meals, or during the time of the gastric digestion. This is too obvious to require much insistance. Even alkaline waters, as Vichy, Vals, Seltzer, or Bath water, should not be drunk at meals; neither should potass, or lithia, or artificial seltzer water be taken with wine or milk then; as alkalies neutralise the acidity and there- with the activity of the gastric juice. The waters of Carlsbad, Marienbad, Tarasp, etc., may be drunk early in the morning; as may the piore potent waters of Piillna, Frieclrichshall, Hunyadi Janos, Estill (Ky.), or Bedford (Pa.) springs; all the more efficacious with a little warm water. CHAr. xn.] LIVER DISTURBANCE. 2G9 Sulphur springs are useful in some cases of biliousness, and the crowds at Harrogate, drinking the waters, and " clearing the system," as they term it, of the vestigia of persistent over-eating and drinking, tell how the inhabi- tants of the manufacturing towns which line each side of the slopes of the backbone of England, believe in periodi- cal purgation, as a means of warding off the evil conse- quences of over-indulgence of the palate. Homburg has a like story to tell; and so have other watering places. As the subject of mineral waters will be discussed fully in the succeeding Part II., when gout is being specially considered, it is unnecessary to go into the subject further here. Chalybeates, either as natural waters or in more strictly medicinal form, are contraindicated in all cases where the action of the liver is embarrassed; and never should be prescribed until the tongue is perfectly clean, and the digestion and assimilation restored by appropriate mea- sures. Iron may increase the activity of the oxidizing processes under certain circumstances; but when there are active symptom.s of hepatic disturbance present, it does harm and not good. About that I have long been certain. If the reader wish to know more about this matter, he can consult the article " When not to give Iron," The Practi- tioner, Sept., 1877, or the second edition of xnj Practitioner'^ s Ha^alhook. Murchison says: — " In simple lithaemia I have constantly known iron to increase the tendency to deposits of lithates in the urine, constipate the bowels, and aggra- vate any symptoms from which the patient may have pre- viously suffered." Dr. Garrod writes: — "It is important 270 LIVER DISTURBANCE. [chap. xn. that great attention should be paid to the condition of the bowels and liver during the exhibition of iron preparations; which he thinks " are for the most part contraindicated " in conditions of lithiasis. The wish to hasten the patient's convalescence is a laudable one; but to give iron prema- turely is often to illustrate the adage " the more haste the less speed." Tonics generally are of questionable value until their appropriate time has arrived, viz., after a certain progress has been made. The lighter bitters, as quassia, gentian, chiretta, or cascarilla, suit better than cinchona or quinine, as a rule, at first. Strychnia or nux vomica is a capital tonic, stimulating the liver as well as the peristaltic move- ments of the bowels, especially indicated where there is flatulence. Phosphorus was often of service in lithoemia according to Murchison. .Arsenic he thinks often useful where chalybeates disagree; a statement corroborated by my own experience. Now the junior section of my readers may feel as if they would like some more precise indications about the use of the agents just mentioned. Under what circumstances to prefer one' agent; and why at other times another should be selected. This is very natural, and as far as the sub- ject permits of such handling, I will try to tell them. But unfortunately, only very broad rules can be laid down, and each case requires its own individual treatment: just as each man requires his clothes to fit him, as differentiated from some one else. It may then be said that hepatic stimulants are indicated for permanent use, to "give a fillip" to the liver, as the common phrase runs. These CHAP, xn.] LIVER BISTURBANCE. 'Ill are, ipecacuan, hydrastin, euonymin, iridin, and baptisin, and their congeners, with aloes, rhubarb, colocyntli, jalajD, or senna, as laxatives, with carminatives in pill, combined as required; or the more potent podophyllin, croton oil, or gamboge, wliere there is stubborn constipation. To these may be added arsenic or strychnia, according to the phenomena exhibited by certain cases. Such may be termed the permanent treatment of the disorder; to be continued for some time. Then for conditions of aggravation, or acute disturbance, it is well to give a pill containing some mercurial at bed- time; and next morning some sulphate of soda with an alkali. Twice or thrice a week this may be done with de- cided advantao^e to the case: the dietarv at the same time being carefully regulated and adapted to the patient. In some cases warm baths seem to have an excellent effect both upon the liver and the skin; while at othe^ times a large hot poultice over the liver stimulates it most satisfactorily. A poultice is clearly indicated with those persons who either cannot take much medicine by the mouth, or who are disinclined to try. In cases of " bilious chill," such a measure, in addition to the medicine appro- priate thereto, is often of service. But "the acquired ex- perience of the individual," won by the sweat of his brow, can no more be transferred bodily to another, than can how to wield a stethoscope, or see correctly through a microscope; or the apparently simpler matter, alluded to before, of keeping six balls in tlie air at once, a common juggler's feat, or Mr. Maskelyne's skill in keeping his nu- merous plates spinning. The aspirant may be told " how 272 LIVER DISTURBANCE. [chap. xii. to do " each of these; but to ^' do " them he must learn for himself: there is no ^' royal road" to it, nor can a "cram- mer " do it for him. Beyond the medicinal treatment lies the dietary, on which it is not now necessary to be diffuse after what has been said in the two preceding chapters. The great fact there insisted upon, and reiterated, is that it is not the hydro- carbons of our food, but the albuminoids which are tlie source of trouble; alike in "biliousness" and in "liver- indigestion." The readily oxidisable hydrocarbons, when an excess of food is taken, are burnt up first; or in other words, upon the hydrocarbons the respired oxygen is ex- pended, leaving the less readily oxidisable albuminoids iiaperfectly acted upon. In such manner is a certain por- tion of disturbance in the metabolism of albuminoids brought about. This, indeed, is the explanation of the de- rangement set up by a " surfeit " by over-indulgence in food. This must be clearly differentiated from the perver- sion of metabolism which is a vicious habit, the albumin- oids being split up into uric acid rather than urea. The reader must distinguish betwixt these two forms of liepatic derangement, else his 2:)ractice and treatment will be un- satisfactory. For the first, more discretion is indicated in the future, especially with those who possess a congenitally incompetent liver. Nevertheless, with all children it is w^ell to avoid excess in eating. Probably the children of the present are no»t any more addicted to over-eating than their predecessors; but it is probable they cannot do it with the same impunity. The digestive organs are not in " these degenerate days " equal to those tremendous disjDlays of CHAP, xn.] LIVER DISTURBANCE. 273 capacity with which our ancestors, in their juvenile years, have been credited; on the other hand juvenile parties, the increasing use of sugar — due to its comparatively low price — and the prevalence of rich cakes at tlie present time, con- stitute a species of temptation to the present generation which they cannot always successfully resist. That a bil- ious attack is a corrective as well as a curative agent must be admitted; and the memory of the suffering helps the future resistance to temptation. Still, children are but children, and a superintendence by their seniors is re- quisite and necessary. Most children can be controlled ; but there are some unwholesome children who will, fully conscious of the consequences, gorge themselves when a supply of "good things" is available, and will not practice moderation. Such children are usually the offspring of foolish parents, who will not look ahead in the matter of consequences; and upon whom all warnings fail unheeded. Maudsley says that the difficulty of dealing with the in- sane lies chiefly in their half-cracked relatives. So with these foolish children the difficulty lies in their silly parents; who do not see, or will not be made to see, what the future consequences w^ll be, that the child wull grow up the sub- ject of biliary disorder which will cripple its working power and embitter its existence. For such children, some one interested in them, who has their welfare at heart, must exercise for them, and in their behalf, the control in w^hich they themselves are deficient. With adults the case is different; and they individually know better, if they only will try to exercise self-restraint. Yet often such persons are wilful, arguing that they ** may as well have a good . 13* 274 LIVER DISTURBANCE. [chap. xn. rue (regret) as a bad one," i.e., if they are going to make themselves ill they might as well do it thoroughly; balan- cing the enjoyment of the eating against the pains of the "bilious attack." In such cases little can be done; for there are some persons whom even experience cannot teach. Still, counsel and warning may do some good if persisted in. These are the persons who, instead of practising moderation when their Nemesis overtakes them, or even when they apprehend that punishment is in pursuit of indulgence, fly to the antibilious pill and the morning draught, either black-draught, Hunyadi Janos, or efferves- cent citrate of magnesia. By so doing they educate, or cultivate a vicious habit, and like other foolish people ''reap as they have sown," and become, in time, the^ub- jects of well-established hepatic derangement. Such " bil- ious " individuals, lacking in discretion, are usually to be found amongst the female sex, but not exclusively so; and are usually comparatively young. This brings up the matter of clinical observation that such "bilious" individuals become, in middle-age, dyspep- tic or gouty. This is a very interesting matter for con- sideration; the explanation, however, not 3^et being cleared up. The liver seems to become further disordered, and instead of an excess of bile-acids, produces an excess of lithates. It would aj^pear, for it would not be judicious to put the matter more strongly, that in the system, while young, any excess takes the direction of biliary disturb- ance, the bowels being chiefly implicated, and the urine being high-coloured, and of high specific gravity, but not otherwise altered in character; while in more advanced CHAP, xn.] LIVER DISTURBANCE. 275 life there is indigestion with the production of quantities of lithates, usually of pale color, when any indiscretion in diet has been committed. While the explanation is not vet forthcominof, still it is well to bear the association in mind as throwing a strong light upon the function of the liver, and the relations, clinical as well as chemical, be- twixt the bile-acids and the urine solids.* This matter tells very articulately that the dietary adapted to lithiasis is also that suited to biliousness, viz., a non-nitroo;enised dietarv. If I seem to insist on til is matter, usque ad nauseam, my apology must be that the impression that it is the hydrocarbons of our food which are at fault, is so universal, so deep-rooted, that it is necessarv to be explicit. It is not *' flooforino^ a dead horse " to speak dogmatically on this matter, for multitudes of persons are making themselves ill-, destroying their pros- pect of future comfort and physical well-being, by errone- ous imj^ressions leading to injurious practices. They live upon the lean of a chojD, some dry bread, and tea or coffee without sugar or cream, with much self-denial in the vain and delusive search after health, or an approach thereto: instead of a farinaceous dietary with stewed fruit. This is open heresy flaunting itself, I am quite aware, in their eyes. Further, I am also quite aware, that such a meal as has just been described, is more digestible at the time * It may be -well to contrast the chemical formulas : Taurin CoH.XO^S . Urea C0H4X2O2 Glycogin CQH5NO2 Uric Acid CioHiNiOc-MHO Bilirubin C6Hig;!Sr203 Biliverdin CisHooNsOi There is a generic resemblance, if nothing more or closer. 276 LIVER DISTURBANCE. [chap. xn. it is taken; will admit it is perhaps the only sort or kind of meal which can be taken without discomfort. Neverthe- less, it distinctly tends to perpetuate the trouble; while the other dietary, less attractive at first, perhaps even re- pulsive, and provocative of repugnance, is the one cal- culated to produce an improvement ultimately. It is the question of the future versus the present. Present comfort and future discomfort; or present self-denial with future improvement. It is the old, old story of resisting tempta- tion, or giving way to it, with future rewards and punish- ments meted out accordingly. In great matters so in small; to resist present tempta- tion is to secure future happiness — to merit a future reward; and in this case the certainty of the reward is such, while not too far distant, as to make it blind folly not to practice the present self-denial which is requisite for its ultimate attainment. As in theology, so in hygiene, the w^hole question is w^hether the faith is a living faith — vital, and capable of inspiring conduct — or not. A faith that is not equal to inspiring conduct is a hollow gourd, a delusion and a snare; if not, indeed, a sham. Another matter there is about which something may be appropriately said at this point, just as well as anywhere else, which is connected with the liver, on which an erroneous opinion is prevalent. We have seen that urea is a product of the liver. We know that the liver is the furnace in which effete blood-corpuscles and tissue-debris are burnt; there is no question about that. But while admitting and acknowledging all this, it does not follow that all the urea has once been tissue. That is an as- CHAP, xn.] LIVER DISTURBANCE. 'Til sumption not warranted by the facts. ^Ye know that the liver also disposes of the luxiis consumption of the albu- minoid materials of our food. Let us see what Prof. M. Foster says: — "In dealing with the statistics of nutrition, our attention will be drawn to the fact that the introduc- tion of proteid matter into the alimentary canal is foUoAved by a large and rapid excretion of urea, suggesting the idea that a certain part of the total quantity of urea normally secreted comes from a direct metabolism of the proteids of our food, without these really forming a part of the tissues of the body" (3rd edit., p. 404). Yet for some years back we have been told of the amount of urea passed by fever- patients, as representing so much tissue-waste. It was assumed, quite gratuitously^ it would appear, that urea was the final stage of what was once tissue, whether ordinary muscular fibre or blood-corpuscle; and on this hypothesis rested one side of the arch. The fact that in fever the muscles waste, and that at a high temperature the albu- minoid tissues melt down, constituted the base of the other half of the arch. The complete arch was this — the amount of urea found in the urine is the measure of the tissue- waste ! It is not necessary to refute this at length. If not a "dead horse," it certainlv ous^ht to be. Such an idea should be as extinct as the dodo. This is a digression, but not a waste of time, I venture to think. It helps to introduce what I am about to say as to the dietary in conditions of " biliousness " and of *' liver indio-estion." A certain portion of the albuminoid elements of our food passes into the albumen of the liquor sanguinis; another 278 LIVER DISTURBANCE. [chap. xii. portion passes into the bile-acids; while a third passes into urea. This is solid ground. The liver performs the work of elaboration in the first case; of destructive meta- morphosis in the second and third. Plas the liver a selec- tive function ? Does anything go on in the liver such as goes on in human manufactories, namely, a selection of the fit, with a rejection of the unfit ? In Messrs. Rodgers' Cutlery Establishment at Sheffield, bones and ivory are cut up for knife-handles: of these only some pieces are fit to be used. The fit pieces are passed on to the knife-handle maker, to be made into the hafts of knives: the rejected pieces are passed on to the refuse heap, to be ground up into bone- dust used to clean plate. Is there any analogous action in the liver; any selective choice by which certain proteid matter is selected for further elaboration; while other pro- teid matter is rejected, and either burned up into urea, or utilised in a lowlier form as the bile-acids ? We do not know; we may never know. It is not likely anyhow that this can be ascertained in the life-time of the present generation. We can only see through a glass darkly. Our successors may be able to see all in the bright light of noonday. Some such selective action seems probable. Is this the smoke which precedes the fiash; as is said on the Russian steppes ? Is this the shadow projected forward of a future solid something; of what physiology may some day in the far distance make solid ground for us? We cannot say. This much may be averred, that some such "notion" would make "a good working hypothesis," which would be a useful guide to us in our daily practice. It would help to clear our views, that of the proteid ele- CHAP, xn.] LIVER DISTURBANCE. 279 mcnts of our food, a portion only passes on into tissue. Tliat much of the remainder is either burnt as so much fuel, a fuel leaving a tremendous residuum of ash; or is utilised in a lowlier form. The ash is the urea. The low- lier form is the bile-acid, which emulsionises fats in the duodenum. The matter must be left here; and our curi- osity must pause unsatisfied, nay dissatisfied, led up to the gates of the promised land — and left there. From this vision, mirage, or reality, who can tell, w^e may now turn, and scrutinise the reality of clinical facts. These facts we know, recognise, and are familiar with in practice; albeit a bit muddled from erroneous explanation. The theory that bile comes from the hydrocarbons of our food, is an ignis fatuus, which led our predecessors into a morass. It underlay the dietary spoken of recently (p. 172), which though acceptable to the palate and perhaps to the alimentary canal, — the solvent portion of the digestive act, is nevertheless the perpetuating factor of the hepatic derangements. Such at least I hold it to be. Too exclu- sively albuminoid, it maintains and keej^s up the morbid condition. It throws too much work upon the liver, if easy of digestion in the alimentary canal. Starch may be hard of digestion as regards its solution and progress to grape-sugar in the portal vein; but then it gives no further trouble in its future history. The lean of a chop may neither cause pain nor flatulence, on its way to being con- verted into peptones; but its after history is less satis- factory. The advocates of raw meat for the treatment of indigestion may claim that it is acceptable to the stomach: but the liver may not be pleased therewith. Ayoungman 280 LIVER DISTURBANCE. [cilvp. xn. may find favour in a girl's eyes, but her parents may not be satisfied with him. Acceptable enough to her; the very qualities which weigh favourably with her, may be those on which her father especially founds his objections. That food which is acceptable to the stomach may be the very matter which disturbs the liver. Indeed it is these very alouminoids which are the subjects of gastric peptic diges- tion, and which sit easily upon the stomach, that we sus- pect as most readily " taking to evil ways " in the liver; and instead of proper metabolism or elaboration, proceed- ing downwards to bile-acids or urine solids. They are the suspected anyhow ! In practice it is necessary to discriminate betwixt the immediate present and that which lies outside and beyond it. A patient may truthfully affirm that the lean of a chop, a little dry bread, with a cup of tea without milk or sugar, is the meal which causes the least suffering, and agrees the best. But it does not follow, I assert, that this is the food therefore indicated for the patient, or really best suited to the requirements of the case. Physiology must be our guide and interpreter; and not the subjective sensations of the patient during the digestive act. Not that these latter are to be utterly dis- regarded: but they must not dominate us, or be allowed to silence all other voices in their own assertive tones. They must be listened to, but only so far; no further. Having thus differentiated clearly betwixt what is agree- able and what is good; what is acceptable at the time, and what is clearly desirable in the future interests of the patient: it may be well to lay down rules for the dietary in conformity with what physiology teaches. When the CHAP, xn.] LIVER DISTURBANCE. 281 patient is »idvised to make stewed fruit and cream, or a milk-pudding, a staple article of diet; to have it prepared always for dinner, and to have what is left over at dinner for breakfast next morning; dismay spreads over the fea- tures. There is something so utterly un-English in such a breakfast, that the patient looks horrified. Yet a great variety of fruit, and of dishes of milk and farinaceous mat- ters are available for the purpose; and this does not involve monotony, a thing most carefully to be avoided in all dietaries. Nothing prejudices a patient against a dietary more powerfully than poverty in the number of dishes available. A short list is distinctly deterrent. So it is well to point out that in addition to the fruits which are indiofenous, and which are readilv available each according to their season, there are a large variety now to be pro- cured at any time, put up in tins. For instance there are grapes, cherries, strawberries, raspberries, figs, peaches, apricots, pineapples, apples, pears, plums, pumpkins, mel- ons, cranberries, guavas, and others. Or the dried fruits, Normandy pippins, apple-rings, dried peaches, pruneilos, French plums, figs ; all of which are excellent stewed. Then the milk-pudding can be made with corn-flour, hominy, rice, tapioca, sago, crushed cereals, and other fari- naceous matter, so as to furnish variety. With a little exercise of her ingenuity, the housewife can make a num- ber of combinations rendering anything like monotony out of the question. That is if she will try I One thing it is well to bear in mind, that in these cases where it is desir- able to avoid albuminoids, it is well to make these milk- puddinsrs without e2-o:s. Thev -are almost as toothsome 282 LIVEE DISTURBANCE. [chap. xn. without, and suit much better. Then there are blanc- manges, made without isinglass, which may be utilised. Or there are various fruit creams, which can be had ac- cording to the season. Strawberries, gooseberries (goose- berry-fool is also good), black-currants, wine-currants, red and white, which may be made with creams, or eaten as they are. The dread of sweets which has obtained will- interfere to prevent the adoption of such a dietary; but I ask the patient to give it a fair trial. When tliis is done I venture to think the results will please them; as they have proved satisfactory to me. The salts in fruits may not be great in quantity but they are certainly operative, as we see in the prevention of scurvy. A recent expedition in the Arctic regions found under the snow a little sour red berry which they gathered and preserved in barrels for use in their sledge-expeditions, and so prevented scurvy; their conduct in this respect contrasting favorably with the contemptuous disregard of such well known facts as the efficacy of the sub-acid fruits, especially of all vegetables, in staving off scurvy, exhibited by the English under Captain Clements Markham. These salts are good: while the use of fruit regulates the bowels, a matter of impor- tance in all derangement of the liver; whether bile-acids or lithates are involved. In consequence of the amount of egg in it, custard is objectionable. The yolk of an egg added to the milk however is permissible. This combina- tion of fruit with milk and farinaceous matters, should be made one of the cardinal points of the dietary. If the patient feel " bilious " under this regimen, a morning laxa- tive once or twice a week will be found to carry off any superfluity which is disagreeing in the dietary. CHAP, xn.] LIVER DISTURBANCE. 283 Then there arc vegetables to be considered. Potatoes boiled, steamed, masiied, or passed through a sieve, eaten with milk and butter, are good for lunch or dinner: pro- vided always that they be thoroughly disintegrated. Few things offend a stomach more than a piece of hard un- chewed potato, upon which the stomach can exercise no influence whatever. The same applies to greens generally, brocoli, Brussels sprouts, cabbages, and cauliflowers; and holds good of vegetable marrow. This last, like cauliflower, may be cooked au gratin, but should be eaten with care and sparingly. Peas and beans, French beans, and scarlet-run- ners, all are admissible in limited quantities only; as con- taining a large proportion of albuminoid matter, caseine. Then there are, carrots, turnips, parsnips, beet, asparagus, sea-kale, boiled celery, onions, and leeks. All these are permissible as regards their chemical composition, and do not tax the liver; but there is the stomach to be consulted, and that is a matter not to be forgotten. In each case, therefore, it must be made a matter of experience, what agrees, and what does not; and this, and not any rule of thumb, must be made the guide for the future in the diet- ary. The same must be said of salads in their various forms. They are not to be prohibited provided they do not disaoree. Now of fishes, salmon certainly is objectionable, least so plain boiled, hot or cold, and it is well to avoid cucumber with it. Then fried sole is verv indi2:estible. Plain boiled, it is permissible. Mackerel and herring are undesirable, unless plain boiled. The flesh of the turbot, brill, halibut, skate, or plaice, is admissible, and so is that of the gur- 284 LIVER DISTURBANCE. [chap. xit. net, and John Dory, what there is of it. Cod-fish is very well suited, whether fried, boiled, or augratin, or as a fish- pudding with mashed potatoes. Ling is unobjectionable, so is the haddock. Whiting, "the chicken of the sea," is excellent. So is red mullet; less so gra^^ mullet. Trout are good in limited quantities. Eels are apt to disagree with the stomach. Shrimps and prawns and good; so are crayfish. The lobster and crab are apt to upset the stom- ach, otherwise they may be eaten in moderation. Oysters are good, and so are mussels, for those who like them. Of fowls, fair quantities may be taken; but their flesh is rich in albuminoids, be it remembered. First cgmes the chicken, boiled; cold, with or without salad, if the stomach approves. Then the pigeon, the pheasant, and the par- tridge, grouse, black-game, capercailzie, prairie-fowls, quails, snipe; all in limited quantities are permissible. The duck and the goose, and the turkey, unless it be a little of the breast, are to be avoided. Of " flesh-meat," pork is poison. Beef is less objection- able; and so is mutton. A little of either, cold, may be taken at lunch. Yeal is to be avoided; unless it be in the form of sweet-bread. Lamb's fry is permissible; or lamb's head boiled is often nice for a weak stomach. Of potted meats they offer no difficulties in the way of disintegration; any may be taken sparingly as sandwiches, made with thin slices of stale bread, with the butter rubbed well into the bread, and spread not too thick. Bread may be eaten, best stale, or as whole-meal bread; then biscuits are digestible. Toast tempts some. Farina- ceous matter may be cooked with milk, as oatmeal- CHAP, xn.] LIVER DISTURBANCE. 285 porridge, hominy, steam-crushed cereals, " Cerealine," a delightful combination, good in many ways. Boiled with milk and poured into a pie-dish to stand over-night; and, next morning, cut in slices and fried, it looks like the most tempting white fish, and is delicious. Hominy, so treated also, is good. Indeed, if farinaceous foods agree with the patient, a large variety of simple dishes can be prepared, especially with milk. Soups are contraindicated, unless it be a little gravy soup, the poorer the better. Pastry is objectionable on account of its indlgestibility in the stomach. But with those with whom it does not disagree, there is no objection to its use. For further information as to dishes and their prepara- tion, the reader is referred to Food for the Invalid, the Convalescent, the Dysjyejytic, and the Gouty, by the writer, published by Messrs. Macmillan & Co. (Each dish requiring such indication is marked with certain initials; the interpretation of which is given therein at pp. 26-27. It is well to follow what is written there, and all dishes containins: meat should be taken in moderation.) The sort of daily dietary to be arrived at has been sketched out in Chap. viii. p. 139, as suited for indiges- tion; and to this the reader may return, and peruse it, and reperuse it with advantage. Then as to drinks. Alcohol is undesirable except in limited quantities. Alcohol is a powerful stimulant to the liver. AYhen taken fasting, it often produces an amount of heat out of proportion to that evolved in its combustion. 28G LIVER DISTURBANCE. [chap. xn. It seems to liberate so much of the liver-glycogen, by dilating the branches of the hepatic artery; and so con- verting so much glycogen into grape-sugar. When this is carried beyond a certain amount, then the vascularity of the liver is increased, and it becomes enlarged in size; subsequent contraction follows, with ascites and dropsy in its wake. It is then to be taken sparingly. A little claret, Carlowitz, Graves, or hock, may be taken by those who feel that some such beverage is required to enable them to eat, and enjoy their food. Others find a little simple spirit, as brandy or whisky, in plain or aerated water, agree best with them. Potent wines, and all malt liquors, are to be avoided. Aerated waters alone, or with a little milk, or some syrup are also indicated. If also alkaline, it is well not to take them during gastric digestion at least. Beyond the dietetic and medicinal treatment of condi- tions of hepatic derangement, lie the matters of change of air, and mineral springs.' It may be laid down as an axiom that " bilious persons are always worse in a low-lying, and warm locality; and are the better for being in a fairly bracing atmosphere." For instance, to take London, such persons are never well in the basin of the Thames, and are always improved by getting to the hills that skirt the val- ley. In Brixton tliey feel good for nothing, and are always ailing. On the slopes of Hampstead and Highgate they are comparatively well; or on the Surrey hills around the Crystal Palace. This illustration will serve for other neighbourhoods. The oxidising processes are much favoured by a bracing locality. Consequently, they should not re- CHAP, xn.] LIVER DISTURBANCE. 287 turn to India, or the tropics if there be any reason to sup- pose that the secreting structures of the liver have received a;iy permanent damage. A liver which may suffice, with care, to carry on its function in Great Britain may be quite unfit for a life in India. The injury inflicted upon the liver by one residence in India, the West Indies, Guiana, or Guinea, incapacitates the organ for another such ex- perience; wliich, therefore, should not be adventured. And whatever applies to a liver unaltered in size, and free from any mutilation of structure, as that caused by an abscess, applies even more stringently to a liver which has been crippled by disease. To speak broadly then, in hepatic derangement it is well to avoid warm, damp, low-lying localities, either as temporary or jDermanent residences: unless it be when an east wind is blowing. This disturb- ing element upsets all ordinary calculations; and when in action must be allowed for. Consequently in summer the east coast is to be preferred to the south or west. Again, Ilfracombe is to be selected rather than Torquay orDawlish. The AYelsh resorts must be classed by the same rule; and so must all others over the face of the globe. For such as are fortunate enough to be able to afford it, it would be well to chano^e their residence in winter and summer. Then as regards watering-places, the same rule will obtain, viz., a bracing locality, except when the east' wind is blowing. Sulphur springs, with a laxative in the water, suit biliousness; alkaline waters are adapted for the treat- ment of lithiasis. But periodical excursions to such water- ing-places must not be made an excuse for indulgence in the interval; as is the case with ordinary individuals. The 288 LIVER DISTURBANCE. [chap. xn. patients "with a liver" will soon find that this is a prac- tice not adapted to their individual requirements; nor calculated to improve their condition. Abstinence and self-denial must rule them in their every-day walk in life. But all are human, and, as such, liable to err — to slip on the narrow path; and if a family festival, or an important celebration should lead to some departure from the beaten track, a mercurial pill and mineral laxative are permis- sible; but they should be resorted to with a distinct sense of failing, of weakness, like the conviction of sin ex- perienced by a penitent at the altar. When at the sea-side it is not advisable for persons who suffer from any form of hepatic derangement, to bathe much in the sea; especially in the early morning. The "dip" should be brief and far short of any chill. It should be taken about 11 a.ra., and be followed by a walk. The warm bath followed by an hour or two in bed to keep up the action of the skin, is a measure which has much to be said for it; and ao-rees with many verv well. But each case requires its own management adapted to the patient's wants, requirements and exigencies. The attempt has here been made to describe the digestive act in the alimentary canal first, and then after that the function of the liver; to give the readers the broad lines upon which to proceed. Sometimes the track is clear and distinct; sometimes broken and iixlistinct, despite the light which advancing physiology is throwing upon it. The liver is the largest of all glands — has a function proportioned to its size. Up to a recent period we knew nothing of its func- tions, except the production of bile. Now, however, we re- CHAP, xn.] LIVER DISTURBANCE. 289 cognise that it possesses a most important action on the one hand — (1) upon the further elaboration of the crude pro- ducts of digestion in the alimentary canal; and, on the other hand, (2) upon the destructive metamorphosis of al- buminoids. It is then intimately related on one side -with indigestion and mal-assimilation; and on the other with lithiasis,'or gout in its widest sense. Its relations with the first have been given: in Part 11. I will strive to describe its relations with the second; and, therewith, the disturb- ances and diseases to which such lithiasis gives rise in its turn. The fat of our food does not, as do sugar and albumin- oids, pass into the venules of the portal vein, and thence to the liver; but is taken up by the lacteals. The liver, then, takes no part in the assimilation of fats; except that its bile aids in the emulsionising of fat in the upper bowel. (While these sheets have been passing though the press, a copy of "Observations on the Constitutional Origin and Treatment of Local Diseases," by the famous John Abernethy, F.R.S., dated 1809, has been lent me by a patient, who was re-arranging his library; and coming upon the volume, opened it, read some of it, and was struck by what was written there, as being almost the very remarks made by myself about his regimen. It is gratifying to find myself in accord with so capable a man. Medicine has forgotten a good deal, as well as learnt much this century !) 13 APPENDIX. THE FAILURE OF THE DIGESTIVE ORGANS AT THE PRESENT TIME. The perusal of the foregoing chapters will have shown the reader that there actually exists, or at least 1 hold there exists, a strong tendency to failure in the organic processes at the present day. These organic processes furnish the elaborated pabulum for the organs of active life: — albumen for the tissues generally, haemoglobin for the red blood cor- puscles, and lecithin for the nervous system. The tre- mendous demands made upon the nervous system at the present time is believed, by others as well as myself, to be the cause of this failure. The effects of mental worry, and emotion upon the digestive and secretory functions is given in Chap, vi., pp. 85-106. The increased demand upon the nervous system, and especially the cerebral hemispheres in the present day, is telling upon the whole of the digestive organs, and especially upon the liver; which carries on the further elaboration of the crude products of digestion in the alimentary canal. As we saw, glycogen is stored by the dehydration of the grape sugar in the portal vein; and from these stores regular rations are given off by hydration, under the action of the liver ferment, to the blood for the production of body heat and force. Then the liver not only elaborates the products of the gastro-intestinal diges- tion of proteids, but it is the furnace in which e£Pete, waste, Ai'PENDix.] THE DIGESTIVE OROAKS. 291 and surplus albuminoids are burnt. The bile aids the pan- creatic secretion in the emulsifying of fats. Now it was abundantly shewn that mental states pro- foundly modify these processes, as temporary conditions. Not only that; but there is much pointing in the direction that the pace at which we live nowadays, is exercising a persisting effect upon the digestive organs, of a deteriorat- ing character. The dental caries, so prevalent, indeed universal at the present day, is but a part of the general widespread failure of the digestive organs. Our grand- parents hardly ever heard the word " dentist," but the present generation know him well; and if they do not regard him with affection, at least recognise his utility. The increase in the demand for laxative medicines is de- monstrated by the perpetual advertisements which meet the eye, from natural waters, through an almost endless series, to Holloway's pills. Constipation is not claimed to be a modern malady; what is asserted is, that it is on the increase. Up to the days of our parents, children had porridge and milk for breakfast, took them well, digested them (for "porridge" always requires the plural with it), and throve on them. The American on the boundless prairie is " raised upon hominy," and in his physique is a contrast to the product of the Eastern states — the advantage not lying with the New Englander. The diastase of the cerealia has only of late years been pressed into the service of man, to supplement the failure in the natural diastase of the sali- vary secretion. Our predecessors know as little of diastase and its functions, practically, as did the chemist, scientifi- cally. Pepsin derived from animals, or even a plant — the 292 FAILURE OF [appendix. papua, is also of recent date. The pancreatic secretion, scientifically and practically, is a matter strictly of our own times. Whence comes the profound modification of the organic processes, the commissariat of the active or animal part of the body ? It is the effect of modern demand upon the nervous system, it is believed ; and not w^ithout a good amount of evidence for the belief. We know that the body is influenced in the direction of deterioration by subtle forces. The inability of the Ano-lo-Saxon to in- habit India is a well-recognised fact. The children of Anglo-Saxon parents, born and reared in India, deteri- orate so markedly, that it is now quite usual to send the Younfr Ano'lo-Indian to Europe to be reared and educated. It is said that in the third generation the Anglo-Indian dies. Be this the exact truth, or only an approach to it, ii' is a fact of or-rim sio;nificance. The same fatality has been found to attach itself to the aborigines of large towns. It appears that without regular and repeated infusions of new blood by incomers from the country, the town- dweller would perish off the face of the earth. A deterioration is wrought by a protracted resi- dence in a large town. What said Lugol, the great French authority, about the inhabitants of Paris : — " Scrofula shews itself in the third generation of those whose an- cestors entered Paris full of health and vigour, and from the third generation the malady rages even to the utter extermination of the family name." This is a very frank statement, without reserve, by an eminent authority; and its frankness is quite equalled by its gravity. *^ To the utter extinction of the family name," i.e., to complete ex- APPENDIX.] THE DIGESTIVE ORGANS. 293 termination. From this it would seem town-dwellers are a doomed race. The population of towns is now in excess of the country in Great Britain. The food of town-dwellers is inferior to that of the jjeasant population; as all familiar with the subject only know too well. The revelations of the Fac- tory Commission, amidst the toilino- millions of our manu- facturing- towns, especially those where spinning mills are common, are as instructive as they are appalling. The evidence of Dr. Ferguson of Bolton, before the Commis- sion, told a terrible tale as to the infant mortality, and the deterioration of the physique of the young mill-hands when appearing to be certified for work in the mills. Dwarfing was on the increase in spite of the Factory iVcts. (x\nd the improvement which resulted from these beneficent Acts, is readily admitted by those who knew the mill- districts on each side of the slopes of the back-bone of England, before and after the passing of these Acts.) One bright spot alone was visible amidst the darkness and the gloom, and that was the good effects of a certain amount of milk in the dietary, in the improvement of the physique. Those w^ho feel interested in this matter can consult TJie Sanitary Record for July 17th and Sept. 25th, 1875. A. dietary of tea and bread and butter, was much im- proved when a certain amount of milk w^as added to it. Now the steady increase of the population of towns is a fact; that the increase will go on further and further is as certain as that to-morrow's sun will rise. The subject is one of the gravest importance to us ; of even graver importance to succeeding generations. Of course, for the toiling millions little can be done beyond the building of 294 FAILURE OF [appendix. airy and comparatively healthy suburbs, and the estab- lishment of workmen's trains, night and morning, into the larger towns; and the inculcation of broad principles about food and drink, fresh air, pure-water, and effective drainage. The poor have a hard lot indeed ! But for those whose means permit of their consulting the health of their little ones, something more may profit- ably be said. Unpalatable much of what is to be written will be to many. Impossible perhaps to a few. But as children ovi^e a duty to joarents ; so parents owe a duty to those children whom they call into being. The State now takes care that the children shall have at least the rudi- ments of an education; it protects them from small-pox by compulsory vaccination, one of the most beneficent of all discoveries. It guards their dietary by the Food Adul- teration Act. Then milk is brought in tins from the mountain pastures of Switzerland, in unlimited quantities; about the purity of "which no doubt can reasonably be en- tertained. The fat-containing maize is brought to us in numerous forms. There is no difficulty in providing milk and a farinaceous dietary for our town infants. Much can be done for them; but more must be done still. Artificial digestive agents may be given with suitable food, to aid in, and perfect the natural digestion. But something more is desirable. For our animals, and more especially valuable stock like racehorses, breeding stations in healthy localities are pro- vided. Surely the offspring of cultured human beings are as valuable, and worthy of as much care as the descendants of " Stockwell," and of " West Australian ! " Something simi- lar is desirable in the shape of institutions, placed in suitable APPENDIX.] THE DIGESTIVE ORGAN'S. 295 localities and under proper supervision; where town-born children could be received in tender years, and reared. Plenty of exercise, in the open air, would secure an appe- tite for simple food, as well as the perfect oxidation of all waste matter; and the child placed under such favourable circumstances, would be as free from deterioration as is the racehorse. For, thoug-h much has been said about the deterioration of the racehorse, it does not appear that any falling off actually exists. Certainly the practice of train- ins; them so earlv. as is now the fashion, is not o-ood for these immature scions of a noble race; but from personal enquiries made of Mr. John Day, the well-known trainer at Danebury, and his neighbour, Mr. Tom Cannon, the equally well-known jockey and trainer, no falling off is discernible in the racing stock of the present. Indeed, in the opinion of the latter authority, the young stock of the present is actually an improvement upon anything Avhich has preceded it. This came out casually during an en- quiry into the feeding of racehorses, and their training; which is very severe and trying. One of the greatest sources of anxiety to the trainer is the failure of the ap- petite. This entails the suspension of the training. It was said before, at (p. 101), that the use of tonics and bitters is not unknown amonsf the trainino- establishments for racehorses; but in neither of these Hampshire train- ing stables are these adjuvants adopted. Indeed, in Mr. Cannon's opinion, simple loss of appetite in a healthy young racehorse, never occurs; he holds that when the young horse is "off his feed," it indicates son^ething wrong with it elsewhere. The air of these Hampshire downs is very bracjng, anc^ whets the appetite of the 296 FAILURE OF [appendix. human beings as well as racehorses who reside on, or near them. My enquiries were directed to the matter of any possible failure of the digestive organs in the racehorses of the present due to the excitement and mental tension of their mode of life. This may seem somewhat whimsical to some readers; but the racehorse, I am credibly informed in the absence of any personal knowledge, lives a life of much excitement and full of incident. Some enjoy the race; others dislike and dread the event, or, to use the precise expression for it for which we have no equivalent in ordinary English, " funk " immensely when being got ready for the race. It seemed, therefore, desirable, in order to make my observations on the matter of the ner- vous relations of indigestion as complete as possible, to extend my enquiry to animals whose existence entails much demand upon the nervous system; as the life of a racehorse undoubtedly does. The results of my en- quiries were strictly negative; at least as regards these Hampshire training stables. But there is much analogy betwixt the existence of racehorses and human beings. Especially young racehorses, run as they now are so largelv at two and three years old. It seemed quite possible, that this early training and nervous tension might affect the young horse; just as life in a large town affects human infants in the way of failure of the digestive organs. But so far there is no evidence of any such cause and effect; and this I am inclined to attri- bute to the fact, of young racehorses being reared in the country, in the healthiest localities that can be seciir^d for the purpose. APPENDIX.] THE DIGESTIVE ORGANS, 297 When we consider the life of children of the present day in large towns, we become painfully aware of the truth underlying the old adage: — "You cannot both cat your cake and have your cake." The town-child is pro- vided with innumerable and many very elaborate complex toys in its nursery. It is constantly carried to sights which will please it, and, in doing so, excite it. Its little life is a round of gaiety, so far as its indulgent parents can manage it. It is taken to the circus, to the pan- tomime; it has its children's parties and balls; it is edu- cated to mimic the life of pleasure. Heaven save the mark ! of its seniors. Everything to " force " its bram is aggregated. And a forced product it is, in its precocity ! But precocity, the late Prof. Lay cock held to be an unde- sirable matter, as incompatible with a full and complete development in the adult; and those who have paid atten- tion to the matter agree with him. The little infant of the Lemuridce, a lowly form of monkey, will follow its mother the day it is born; but it is only a Lemur when its full potentiality is realised. The little Baboon baby rolls on its back, and gazes at its extremities in perplexity and wonder for about a month before it commences its perigrinations; but it develops into an anthropoid ape ultimately, capable of much that is im- possible to the Lemur. The human baby passes through a longer and more protracted period of helplessness, but it possesses the potentialities of a man in it; and may de- velop into an engineer who can span a river, throw an iron girdle over an estuary; or an astronomer who can weigh the stars in his balance, and calculate the perturbations of the planets, or the erratic path of a comet. 13* 298 FAILURE OF [appendix. Early development is not to be desired, and the forced products of town life can no more last well, than does the racehorse raced long before his period of growth is com- pleted. The promising two-year old, and the quick-witted town-child, neither possess much prospect for their later 3^ears. The comparatively dull, stupid, heavy country child has a far brighter future before it. It is keeping its cake, not eating it. It is building up a stalwart frame; its brain is comparatively inert ^' lying fallow;" its energies are not expended in a round of variety and excitement; it is slowly developing its utmost potentialities, not being exhausted prematurely. This is an aspect of the subject which cannot be overlooked in any scheme for the im- provement of future generations. Lugol found struma grovr up in town-bred children; and what is struma but an impaired protoplasmic digestion, a tissue deterioration ? Such children if born of country people and reared in the country would have been free from any such tissue degen- eration. ^ This subject is one which has long engaged my atten- tion, and in November, 1877, I delivered a lecture before " The London School- Mistresses' Association'''' upon "The Relations of Growth to Education " which was subsequently republished by them as a pamphlet. More recently the matter has been fully considered in a pamphlet "The Physiologist in the Household," Part L, Adolescence (pub- lished by Bailliere, Tindal & Cox, 1880); which I venture to believe is worth perusal by those specially interested in this subject. Oliver Wendell Holmes in his quaint, pithy way alludes to this subject in his " Autocrat at the Break- fast Table." He writes — "Men often remind one of pears APPENDIX,] THE DIGESTIVE ORGANS. 299 in tlieir "vvay of coming to maturity. Some are ripe at twenty, like human jargonelles, and must be made the most of, for their day is soon over. Some come into their perfect condition late, like the autumn kinds, and these last better than the summer fruit; and some like the win- ter helis, have been hard and uninviting until all the rest have had their season, get their glow and perfume long after the frost and snow have done their worst with the orchards. Beware of rash criticisms ; the rough and stringent fruit you condemn may be an autumn or a winter pear; and that you picked up beneath the same bougrh in Auo-ust, niav have been onlv its worm-eaten windfalls. Milton was a Saint-Germain with a graft of the roseate Early-Catharine. Rich, juicy, lively, frag-rant, russet-skinned old Chaucer, was an Easter-Beurre; the buds of a new summer were swelling when he ri]3ened." This is rather wandering from the exact subject matter, — pursuing a side-issue in legal phraseology, but it bears on what is being discussed here, viz., the development of a healthy physique, endowing its possessor with greater potentialities in the future. The child reared in the country has a brisker appetite and a better digestion than the town-child. If his o-pow-th is slower, he ulti- mately attains a larger stature. Quetelet '*' Sur I'Homme " proved this about the physical stature; it is equally true about the mental and intellectual stature. How far im- perfect digestion and assimilation is the cause of the ar- rested development, either wholly or in part, may scarcely be apportioned ; but it is a factor, be^'ond question. Girls develop more rapidly than boys; but their ulti- mate development is less than that of boys. This side- 300 FAILURE OF [A^PE^^)IX. issue is intimately linked with the exact raatter under discussion, viz., the rearing of town bred-and-born chil- dren in the countiy. Of course the objection will be raised, that it is impos- sible to send the children awav. Well ! The Ang-lo-Indian has to do it. And there is no evidence that Ano-lo-Indians are wanting in family affection, only they have learned to subordinate their own feelings to their children's welfare. And the town-resident at home, not in Great Britain alone, but wherever the Anglo-Saxon has raised his tent-pole over the face of the earth, must learn to do likewise. The ghost of the Red Indian flitting around the old burying places, and dreaming of the old wigwam stand- ing where a huge town now exists, has the sinister con- solation of thinkino- that the white man cannot live on the land he has usurped — without special precautions. The red man's grave is covered with the white man's buildings, solid, massive, immense ; but his first-born die in them. Colonel Pyncheon erected " The House of the Seven Gables," where Matthew Maule had built his rude hut, "shaggy with thatch;" but a Kemesis hunof around the land snatched from the murdered man. " God ! " said the poor man, on his way to the scaffold, innocent of the crime of witchcraft for which he was con- demned to die, — '' God Avill give him blood to drink." So ma}' say the ghost of the red man of the present possessor of his land, too. The Anglo-Saxon has ex- terminated the Red Indian, " Thou shalt want ere I want " has been his creed. The waning Indian had to vacate his possessions for the Yengees, that they might increase and multiply on the face of tlie earth. And now APPENDIX.] THE DIGESTIVE ORGANS. 301 what is the result? The Anglo-Saxon is a dying race, perishing beside the tomb of the red-man whom he slew. It is " Naboth's vineyard," in the nineteenth century ! What if this grim and terrible fact be an undoubted fact: and it seems that the threatened extinction of the old population, so immediate for Massachusetts, is being in- augurated in Ohio. The nutrition of the American-born woman is often unequal to feeding a second organism; or if that second organism has successfully struggled into an independent existence, it is unequal to its maintenance for long. The spectre of the exterminated Red man sees death reaping a rich harvest among the babes and suck- lings of his enemy; there are other graves being dug alongside those of his ancestors. The angel of death is smiting the usurper in turn. If this be so, the American has the sorry consolation of knowing that in his old home, in tlie cradle of his race, the same phenomenon is to be observed; only not yet to so distinct and terrible an ex- tent. The Anglo-Saxon exterminated the native British; there was no compromise; the conquered Briton did not become " a hewer of wood and a drawer of water " — the serf of his victorious assailant; he perished, died out abso- lutely. The Anglo-Saxon settled down on the vacated lands and increased and multiplied. For generations this process went on, successful and unchecked. Dirt, filth, the disregard of all hygienic laws, the neglect of the sani- tary arrangements of old Roman civilization; the crowd- ing, the narrow tenements; indeed, the necessity for regarding a town as a fortress in the interminable wars of the dark ages, and erecting the houses accordingly — brought plagues in their wake; often exterminating the in- 302 FAILURE OF [appendix. habitants, and causing the markets to be held in the open country at some distance. Now the scene is changed, but not the venue. Where the wattled huts of the ancient Briton once stood, amidst sacred groves devoted to Druid- ical rites; now we see the many-storied mill, the long chimney belching forth smoke, the endless rows of cottages inhabited by the toilers who work in the mill. The Angel of death i^ busy still. With the practical turn of his race the town-inhabitant protects himself and his young, so far as lies in his power; brings his water from long distances, constructs elaborate sewerag-e arrangements, thus copying the wisdom of the old heathen at last; further, he has appointed Medical Officers of Health and Analysts, still more to guard him and his. He has learned that poison- germs may lurk in his water, and still more in his milk- supply, since Dr. M. W. Taylor, of Penrith, first pointed out the danger hidden in the milk-can (1858); and re- peated outbreaks of scarlatina, following the milk-supply, have driven the lesson home. He has provided so far as in his power lies, against these fluid-borne diseases: and the tale of the dead so slain is but as a unit against myriads. For one victim to zymotic disease, a holocaust perish from failure in their digestive processes. For one infant lying in its last sleep from specific germ-carried pyrexia, a thousand wasted marasmatic atomies are to be found in their graves from improper food, and an imper- fect digestion. It is time then that some general united effort be made to arrest this slaughter of the Innocents; compared to which Herod's massacre was as nothing. It may be costly; it may entail many sacrifices; the parent may APPENDIX.] THE DIGESTIVE ORGANS. 303 liave to consent to separation from the child; children may have to grow up no longer under the parent's eye, except at intermittent periods; but under the skilled supervision of guardians bound to them by no tie of blood. All this may be very repulsive; but unfortunately it is unavoidable ! Some such practice, which will enable children to be reared in the country, must be adopted be- fore long. Food of the most digestible character may be supplemented by artificial digestive agents; but this is only palliative as regards the individual, — it is not cura- tive as regards the race ! The town-population in Great Britain now constitutes the majority of the people. The issue is a sharp one: and must ere long occupy the attention of our legislators. But it is to be feared that any such action must be pre^ ceded by much outside discussion of the question. How, and by what precise measures the evil has to be met, and, if possible, vanquished, it is not for me to say here. First the evil must be fully appraised before adequate measures for dealing with it can be formulated. My duty extends to pointing out the actual facts, and indicating the direc- tion the proposed measures must take; to go further would savour of impertinence, and overweening vanity. The actual solution of the problem will engage many minds, and exercise many intellects, before "Eureka" can be shouted. In order, however, to grapple with the difficulty in a practical form, and to do what can be done, until such arrangements can actually be made for the rearing of town-children in the country, I give some valuable re- marks by Prof. L. Duncan Bulkley, M.D., of New York, 304 FAILURE OF [appendix. the wearer of an honoured name. Dr. Bulkley and myself discussed most earnestly the question of the coming race — if there is to be one at all — on the banks of the Cam, at the Annual Meeting of the British Medical Association, 1880; and now by his courtesy, I am enabled to lay before the reader what he has found desirable in. the interests of the children in the U. S. A.; whose necessities are indeed greater than ours. ''ON THE FAILURE OF NUTRITION IN CHILDREN, WITH ITS TREATMENT, BY DR. BULKLEY. The nutrition of the body is dependent on very many dif- ferent factors, all of which must be perfect to constitute perfect health. Nutrition in children has to do with two quite different elements ; first the growth of the body, and second the repair of waste. Failure in nutrition to a greater or less extent must involve defect in one, or both of these respects; when the growth of the body is interfered with, the actions of life are deranged. Failure in nutrition in children has two great causes, which are hereditary or acquired. Far too much stress has ordinarily been placed upon the former, which, of course, is irremediable; whereas the latter, upon which in reality the greatest measure of the difficulty rests, is quite amenable to careful and judicious treatment. We will first, therefore, briefly dismiss the former, or hereditary causes of failure of nutrition, in order to devote more thought to the second or acquired causes, upon whose proper recognition and under- standing must rest much of success in medical practice. APPENDIX.] NUTRITION ly CfflLDFEy. 305 In regard to hereditary causes of imperfect nutrition in children, all cases may be divided into three great sub- divisions; first, those exhibiting the influence of the stru- mous habit; second, those showing the gouty; and third, those characterised by the nervous temperament or habit. There can be no doubt that as children manifest to a greater or less extent certain physical peculiarities of form and feature, and also certain mental idiosyncrasies; and as certain diseases, as syphilis, can undoubtedly be trans- mitted to offspring; and certain conditions of system, or tendencies thereto, such as phthisis, gout, rheumatism, and cancer, can likewise be transmitted; that the less pro- nounced states of physical constitution can in like manner be handed down, so that the individual with the strumous, gouty, or nervous habit or condition, transmits the same even to the child at its youngest period of life. Thus we may have developed and exhibited in the infant these stages to a greater or less degree, and they may act as sufficient causes in modifvino^ its nutrition. AVe therefore see a certain number of infants, or very small children, exhibiting signs of imperfect nutrition, which are intimately dependent upon the state or habit of body which they have acquired with birth. The strumous child speaks plainly by its light delicate hair, its pasty- white complexion, and its enlarged lymphatic glands and flabby muscles ; either with very light or very dark eyes, long eyelashes, large nose, thick upper lip; and if skin lesions form they will be characterised by the develop- ment of pus and a tendency to the formation of thick scabs, or crusts, not accounted for by the intensity of the inflam- 306 FAILURE OF [appendix. mation. Its. failure of nutrition Avill be exhibited rather by the great appetite, decayed teeth, swollen abdomen, often filled with wind; tendency to constipation and in- testinal worms. The gouty child will show a tendency to an acid stomach, as an infant will often vomit milk, will have occasional attacks of constipation, alternating with diarrhoea. Will very frequently be restless at night as a result of its indigestion; and if skin lesions manifest them- selves they will be characterized rather by a redness of surface, great itching, tendency to watery exudation, dry- ing into thinner scales or crusts, with much less tendency to pus formation. The child with the nervous habit or temperament will show its failure of nutrition by an ir- regular and fitful appetite, and easily deranged digestion, especially interfered with by nerve causes, as over-excite- ment, &c. It will be wakeful rather than restless at night, and irritable during the day. These states, or conditions which belong more or less markedly to infantile cases, are important to recognise. And there is undoubtedly no little truth in the old idea, in regard to the family physician understanding the con- stitution of the patient; and this is especially true with regard to children. But if a reasonable amount of care and judicious thought be given to the cases, these features may be understood and developed by one who has but recently met the person affected. And success in practice depends to a very large measure upon the grasp which the physician takes upon the idea as to the constitution, or state of the child he is to treat. But if the knowledge and appreciation of these features are valuable in the treatment of disease, or the restoration APPENDIX.] NUTRITION IN CHILDREN. 307 to health of tliose suffering from imperfect nutrition; a perfect comprehension of the elements next to be con- sidered is, if possible, yet more important. For the fea- tures which have been dwelt upon belong so completely to the constitution or state of the individual, that frequently they cannot be altered to any very great extent by the phy- sician; whereas the elements relating to the daily life of the patient, next to be treated of, are such as the physician can affect; and upon his proper management of them, will rest, to a large degree, the success. We come therefore to the second, or most important ele- ment, or factor of failure of nutrition in children, namely, the acquired causes of its beginning, and continuance. There is no one who has even the slightest knowledge of botany but recognizes that the plant-life is different, not only in various sections of the earth, but in different portions of the same tract of territory, according to the relations existing. Not only is there the vast difference between the products of the earth, of temperate and tropi- cal climates; but in the temperate zone we find the great- est varieties in nature, according to the soil, situation, moisture, and sunlight, &c. We would never expect to find the lily of the valley, or wood violet on the top of a mountain, nor the mountain shrub pine in the depths of the valley. Certain plants absolutely require a certain soil; if they are placed in any other, they wither and die. One will require a great amount of moisture; others but little, or none. The same is true of the animal creation; one animal thrives upon food on which another would perish. Therefore, upon the proper selection and adminis- 308 FAILURE OF [appendix. tration of food, or the proper regulation of the hygiene and surroundings of the patient, depends the measure of health which it is to enjoy. The cause of failure of nutrition in children, in by far the larger proportion of instances, has to do Avith external factors rather than with hereditary states. The diet and hygiene of the child require to be regulated with the utmost nicety, if we would secure per- fect nutrition.' Even as a hot-house in which delicate plants are being reared, requires careful skill and thought; ignorance in one will be followed by evil results, quite as surely as ignorance in the management of the other. Instinct is undoubtedly given to living beings for the purpose of the preservation of the species : and when allowed to operate undisturbed may be very largely and safely relied upon. In the lower animals instinct un- doubtedly is all sufficient for the maintenance of perfect nutrition in the young as well as in the adult ; provided that other causes do not operate in too great a degree. But animals and birds can readily be made sick by temptations offered to them in the way of food; also by deprivation of air, light, etc. The natural instinct of the young infant is for milk; and upon proper milk it thrives. Older children are quite satisfied with very simple food, provided they are not attracted by other things. It must be remembered, however, that instinct cannot be trusted to entirely in children because of the many perturbations to which life is subject, and of the many temptation^ which appear on all sides to transgress the rules of health. The child is then dependent upon the intelligence and knowledge of those older than itself; and it certainly does not answer to allow the tastes of the infant, or child, to be the guide in APPENDIX.] NUTRITION IN CHILDREN. 309 the matter of diet and hygiene. On unsuitable food, given in an improper manner perfect nutrition certainly will not be maintained. And for the perfect development of the child, care and thought should be exercised by its guardians. As failure in nutrition may be due to improper food, so it may also be due to imperfectly prepared food. Coming now to the actual facts, the food which the infant feeds upon, the mother's milk, may often be greatly impaired in its quality; and where there is failure of nutrition in the infant child at the breast, this should always be looked to. In nursing infants with eczema it will constantly be found, that the health of the mother is not perfect; and a careful investigation will always find elements to be corrected in it. It is very common to find that the mother is in the habit of consuming large quantities of tea, or perhaps beer, or ale, or takes wine pretty freely; or perhaps she is taking strong chocolate, or milk in order to promote lactation, and these disagree with her, causing dyspepsia. Or she is constipated, or in her urine she has disorders indicative of derang-ement of dio^estion and assimilation. Now if these elements exist, if the mother's secretions as from the bowels, kidneys, skin, liver, etc., are not healthy, certainly the secretion of milk is not healthy; and thus it cannot afford the proper nutriment for the child. In the case of nursing infants, therefore, exhibiting the signs of failure of nutrition, the attention should always be turned first to- wards the mother. And in a very large percentage of cases, errors of assimilation and integration will be found in the mother, w^hich must be corrected before we can hope for, or expect great and permanent benefit to the child. It 310 FAILURE OF [appendix. must never be forgotten that the mother may have exten- sive oxaluria, as ahnost the sole indication of mal-assimi- lation; or she may have simply a coated tongue, acid taste in the mouth, or other signs. Or she may have a general tired feeling, especially in the morning after sleep. The nursing mother should not be allowed, as a rule, to take fermented liquors; and generally the quantity drank should be diminished especially if it is used in excess. Milk an- swers best in the large proportion of instances for the mother; and if it is not well borne at first, the habit of taking it can be acquired; very frequently it is necessary to add a little alkali, and the liqua: potassse 10 or 15 ms. may be added to each tumbler-full of milk. In not a few instances the milk furnished by the mother is absolutely too weak to sustain the child properly; and the mother's health must be improved by such tonics as iron, bark, cod-liver oil, etc. The nursing child with mal-nutrition may also be bene- fitted by the exhibition of certain remedies; although in the main the proper supply of milk, with sun-light and fresh air, and absence of nervous excitement, will gene- rally be all-sufficient. Constipation is a far more common state even in infants, than is usually supposed; and many will be found who are dependent for their daily action of the bowels upon enemata, or suppositories of soap, etc. The occasional administration of a proper dose of calomel, will in some cases be of the very greatest service in pro- moting the nutrition of infants. This of course should not be persisted in to any great extent; but occasionally it may be given with advantage as often as every few days. Pepsin, or lacto-peptine may be used with very great ad- APPENDIX.] NUTRITION m CHILDREN. 311 vantage at times in even very small infants, exhibiting imperfect nutrition; either a little placed dry on the tongue, or held in suspension in flour-water, or the like, taken at each time of nursing. In many instances, especially in strumous children, cod- liver oil will be found to be of the greatest service, even in very small infants; although, their power of digestion of fats being small, it should be given in very small quanti- ties, and not too often. It may sometimes be used with great advantage in the way of inunction; and linseed oil, or sweet almond oil may be substituted for this purpose. Again, very many children, especially those of a " gouty stock " will have their nutrition very greatly benefited by the administration of a small quantity of alkali; for this purpose, perhaps, lime-water answers very well, having the additional advantage of supplying the elements necessary for the growth of the bones. But sometimes this is distaste- ful, and sometimes it seems to fail; we may then use the liquor potassas with advantage. Enquiry should always be made in regard to the urine of these little ones, and if it is found to stain the diaper much, an alkali should be used, with remedies calculated to act upon the kidneys. For this purpose the following prescription will often be found of very great value. ^. Potassse Acetatis 3i.— 3ii. Spiritus JEther. Nitrosi 3 i. — 3 ii. Liquor Ammon. Acetatis | ii. A teaspoonful three or four times daily, near the time of nursino-. If there is much restlessness at night, and any tendency 312 FAILURE OF [appendix. to feverishness, a little aconite may be added to this mix- ture with great advantage. Many infants receive, in addition to the parent's milk, or perhaps in place of it, diet which is entirely erroneous. A number of infants suffering from imperfect nutrition are found to be taking large quantities of starchy food, such as corn-starch, bran, etc.; and, in many instances, far too much sugar is given with the food. Sometimes, however, there are very great errors committed with regard to the diet of these little ones; and one finds constantly among the poor classes of children of the most tender years, those who are allowed to partake of anything eaten b}^ adults, for which they may crave. And it is not at all uncommon to find children, even less than a year old, who are allowed to partake of tea, and coffee perhaps, even more than once a day. And one may often see in the hands of very small children the most indigestible substances, to say nothing of crackers, candy, etc. It would seem almost, at first sight, as though these errors could not prevail among the upper classes, but we have only to remember that the nurses, to whom so much is often committed, all come from the lower ignorant classes; and unless they are watched and directed otherwise, they will tend to practice just what they have been brought up to, and taught at home. One sees a great many children in whom imperfect nu- trition has resulted from the continuance of nursing long after the suitable period has passed, or after the mother has ceased to secrete milk which is properly nutritious. The manner in which little infants so impoverished will pick up, when placed upon proper and suitable nutriment, APPENDIX.] NUTRITION IN CHILDREN. 313 is sometinies amazinc:. The greatest benefit mav be often derived from the addition of the yolk of an egg once or twice daily to the diet of very small children; this may be given either raw or lightly cooked, mingled with the milk, or taken separately. After children have passed from the breast, there is danger of ver}'' great errors being committed in regard to the nutrition of the child. Far too often it is allowed to select its own food indiscriminately from that used by adults. And even if it does not fail in securing the ele- ments required for the formation of its frame, it will very commonly be found that it has induced an indigestion •which may be kept up by the same means; and thus have its nutrition materially impaired. The weak, strumous, irritable child therefore, should have its diet looked to, and directed with even greater care than its lactation. Injuri- ous articles must be absolutely interdicted with a firm hand ; and the proper nutriment for the case must be insisted upon, at all hazards. Some of the elements of "indigestion, biliousness, or gout in its protean aspects," may be very commonly discovered ; ultimately to be developed elsewhere. These must be diligently sought for and remedied. It is useless, when called upon to improve the condition of a growing child, simply to give this or that remedy ; either one which has been recommended by some one or another, or one which has been found serviceable in what seems a similar case. These cases cannot be treated upon a written plan. The habit, or constitution of the child must be investigated; its diet and mode of life, powers of sleep and bathing, and also anything which can conduce in any 14 314 FAILURE OF [appendix. way to its health, must come under the scrutiny of the physician. When the child arrives at somewhat older years, the elements of schooling, and its intercourse with others, must be taken very carefully into consideration. Every child cannot be submitted to the same routine of life; every child cannot bear the same amount of schooling, or even of home instruction. Nor can every child be allowed the free exercise of its will in regard to its exercise, and many other matters of life; just as all adults, or even animals, can- not be submitted to the same work, confinement, nervous strain, etc., and yet maintain health. Far too little attention has been paid in past and recent times to the value of milk as a nutrient. This can be advantageously added to the diet of very many individuals — even of adults; and it can even be taken in the intervals between the meals, or made to supplem.ent them. Should it cause any of the elements recognised under the general term of "biliousness," this tendency may be more or less averted by the administration of an alkali at the same time, together with care in the regulation of the bowels, etc., etc. We have thus seen that failure of nutrition in children in a large number of instances, is not always one and the same, depending upon identical causes; but that there are many elements connected with it, each one of which may be of more or less importance in individual cases. And as the chain is only strong in the perfect integrity of each and every link, so health is only maintained at a perfect standard by the integrity of action of every organ; and ti\e proper supply of nutriment for the growth and repair of each portion of the body. The hereditary tendency of the APPENDIX.] miTRiTiOjsr m children: 315 child, must be to a greater or less extent recognised in each instance therapeutically; and the main general line of treatment must be more or less altered in accord there- with. But by far the largest share of causation of the failure of nutrition, is to be found in the surroundings of every day life; and only by careful study and acquaintance with these, can a case be guided into health. Internal medication can undoubtedly do a great deal to improve nutrition even in the youngest subjects; but it must be ever remembered that the action of the medicant is, and will be but temporary; while the erroneous diet or mode of life may go on long after the patient has ceased to take medicine. And as treatment cannot restore the patient to more than the condition of perfect health pre- viously enjoyed; so when the diseased state is removed, there will be naturally the tendency to return to it, if the same causes are continually at work, and in operation. In addition to the cod-liver oil so commonly required by strumous children, and the alkalies of service in the gouty state, we will find very great improvement in many instances from the use of arsenic. And when combined with iron, it forms one of the most powerful means of restoring nutrition and vitality. The following combina- tion will be found of great service in many instances. 1^ Liquor Potassse Arsenitis, 3 ss. — 3 i. Ferri Ammon. Cit., 3 ss. — 3 i. Potassse Citrat, 3 i- — 3 ii. Vini Ferri Dulcis (Malaga), J iii. Teaspoonful after eating. The syrup of the lacto-phosphate of lime is often very valuable in improving the nutrition of children, as also the 316 NUTRITIOIT IN CHILDREN. [appendix. syrup of the phosphates of lime, soda, and iron. Care must always be exercised, however, in administering these tonics, that the action of the bowels be as perfect as pos- sible, and that the kidneys do their work. Many cases will be found, where iron, cod-liver oil, and various tonics have been previously employed without effect, in which success was attained rapidly after very moderate attention to the emunctory organs of the body. The condition of the skin as an organ, should never be forgotten in connection with failure of nutrition in chil- dren. It is not very common that they are bathed too little, although this sometimes occurs. Probably they are more often bathed too frequently; and perhaps are too often chilled in the bath or afterwards, and the repulsion of the blood from the surface may result in internal dis- orders. Cold hands and feet are a very frequent indication of imperfect nutrition in children. These should be attended to; the children should not be allowed to go to bed with icy feet, which will often be the means of causing wakeful- ness for some lenofth of time aftei* retirins;-. The feet should be warmed either artificially by putting them in hot water, or by w^arm applications to them, and wearing of socks. Or if there is sufficient vigour, a reac- tion may be obtained by a quick plunge into cold water. Cold hands and feet are always an evidence of imperfect circulation; and this of itself does most frequently cause an indigestion. When the hands and feet are cold, the bath should be used in moderation. FINIS. IXDEX. Page A ction of Saliva . . ■ . 9 Action of Stomach, Imper- fect Solvent . . . 24 Actual Treatment of Children . 305 Acute Indigestion . . . 128 in Typhoid Fever 130 Affections of the Skin . . 230 Albuminoids, Digestion of . 13 " Effects of Cooking on 46 Albuminuria . . . .319 " Sir Joseph Fayrer on 219 Alcohol .... 143, 285 Angina Pectoris .... 227 Apex-Consolidation of Lung . 132 Appetite, Natural Failure of the 254 Artificial Digestion . . .55 Artificial Digestive Ferments . 41 Asthma 225 Attack, Bilious . . . .167 Attention, Influence of Expec- tant 102 Azoturia 215 "one, Effects of Dieb upon . 172 Bile, Effects of, upon the Heart .... 195 Bile, Effects of, upon the Xer- Tous System . . . 196 Bilious Attack .... 167 Biliousness 167 " Chronic . . .174 " Effects on the Mind . 191 " Symptoms of . .182 " Treatment of . . 178 Page Bladder SjTnptoms . . . 228 Brain and Digestive Organs, Reiations of , . . . 105 Brunton, Dr. Lauder, Views of . 163 /~>ancer. Gastric Caries, Dental 29 291 117 50 29 Cardiac Indigestion Caseine of Milk . Catarrh, Gastric Cause of Indigestion, S3'philis as a 123 Causes, Mental, of Diabetes, . 94 " " of Indigestion . 86 Causes of Decay in Children . 292 " Derangement of the Liver . . . 233 " Diabetes . . 18, 94 Children, Diseases of, Treatment of Actual .... 305 Children, Diseases of. Preven- tive 293 Children, Types of . . . 306 Climates, Hepatic Unfitness for Hot 25~^ Clinical Relations of Uric Acid 211 Colour of Tongue . . .182 " Urates . . .214 Confident Expectation, Effects of 106 Congenital Insufficiency of the Liver 241 Congestion of the Liver, Uric Acid in 213 318 INDEX, Page Consolidation of Lung Apex . 132 Cooking, Effects of, on Albumi- noids . . . . .46 Cooking, Effects of, on Fat . 51 '^ " Starch . 43 TPv ecay in children, Causes of . 290 -^ Dehydration ... 17 Derangement of the Liver, Causes of ... . 233 Diabetes . . . . 18, 94 " Mental Causes of 94 Diarrhoea . . . . • . 30 Diastase 42 Diet 136 " Effects of, upon Bile . 172 Dietary in Indigestion i;;9 Digebtion, Intestinal . 17 " Natural . 7 " of Albuminoids 13 *' " Fat . . . 15 " " Starch . 8 Digestive Artificial Ferments . 41 " Organs and Brain, Re- lations of 105 " Power, Failure of 290 " " Variety of . 244 Dilatation, Gastric . 30 Disintegration .... 11 " Imperfect . 21 Disorder, Functional, of Liver, Treatment of . . . 280 Disturbances in the Heart . 226 " Phenomena of Liver 167 Disturbance, Treatment of Liver- 249 Drinks 141 " Iced . . 14 " Temperance 143 Dr. Kirkes' Views 151 Dr. Lauder Brunton's Views 163 Dr. Murchison, Views of . 154 Fag-e "Epffect of Bile upon the Heart . 195 -^ '' " " Mind. 191 " Nerv- ous System . . 196 *' Confident Expectation 106 " Cooking on Albumi- noids 46 Effect of Cooking on Fats . 51 Starch . 43 " East Winds . . 200 Emigrant Life .... 135 Examine Urine, Time to . . 209 Expectant Attention, Influence of 1C2 TT'ailure of Digestive Organs . 290 Failure, Natural, of the Ap- petite .... 2.54 Fat, Digestion of . . 15, 59 " Effects of Cooking on . .51 Fayrer, Sir Joseph, on Albumin- uria 219 Ferments 8 " Artificial Digestive . 41 Fever, Indigestion in Typhoid . 130 Faeces 9 Food, Peptonised . . .63 Salt as . . . .19 Fulness, Venous, of Liver . . 237 Functional Disorder of the Liver, Treatment of . . 280 Function of Pancreatic Secretion 17 the Liver. . . 148 " " Dr. Brun- ton's Views .... 163 Function of the Liver, Dr. Kirkes' Views of . . . 151 Function of the Liver, Dr. Mur- chison's Views of . . 154 Furred Tongue . . . .33 f^ astric Cancer VJT Catarrh 29 29 INBEX. 319 Gastric Dilatation "■ Irritability "^ Stimulants *' Ulcer . Page . 30 . 31 . 26 . 29 TTaemoglobin . . . .15 -^^ Headache .... 38 Heart, Disturbance in . . 226 " Effects of Bile upon . 195 " Starvation . . .80 Hepatic Unfitness for Hot Cli- mates . , . . . 255 Hereditary Impairment of the Liver 246 Hydration 12 Hydrogen, Sulphuretted . . 193 Teed Drinks . . . .142 Impairment, Hereditary, of the Liver . . . .246 Imperfect Digestion . . .21 '' Solvent Action . . 24 Indigestion, Acute, . . . 128 Cardiac . . .117 " Dietary in . . 139 " Heart Hypertrophy 133 " in Emigrant Life . lo5 " in Lung Apex Con- sol'dation . . 132 " Intercurrent . . 126 " in Typhoid Fever . 130 " Liver . . .203 " Xeurosal . . 85 *' Ovarian. . . 110 " Reflex . . .109 *' Secondary . . 85 " Symptoms of . 34 " " Mental 40 *' Syphilis as a Cause of . . . 123 " Toxemic . . 123 Influence, Nervous . . , 239 *' of Expectant Atten- tion . . .102 Page Irritability, Gastric . . .31 Insufficiency, Congenital, of the Liver 241 Intestinal Digestion . . .17 "T ecithin . Life, Emigrant 20, 76 . 135 . 61 Liquor, Pancreaticus Liver, Causes of Derangement of . . . .233 ' ' Congenital Insufficiency of the. . . . 241 " Disturbance, Treatment of . . . . fi49 " Functional Disorder of the . . . . 167 " Functions of the . . 148 " Impairment, Hereditary, of the . . . 246 " Indigestion . . . 203 '* IS'ervous Influence on . 239 " Stimulants ... 28 " Treatment of . . 280 " Uric Acid in Congestion of the . . . 213 " Yenous, Fulness of . 237 ^X/Tastication . . . .48 '^ Mental Causes of Diabetes 94 Mental Symptoms of Indiges- tion 40 Mercar}', Use of ... 250 Metabolisms, Perversions of . 224 Milk. Casein e of . . . .50 Murchison, Dr., Vie-ws on the Functions of the Liv^er . 151 "VTatural Digestion ... 7 "^ Is'atural Failure of Appetite 254 ! Nervous Influence on Liver . 239 " Symptoms . . .230 " System, Effects of Bile upon . . . 196 Neurosal Indigestion . . .85 Nutrition Tissue . . .70 320 INDEX. /^varian Indigestion ^ Oysters Page . 110 . 44 "TDancreaticus Liquor . . 61 Pancreatic Secretion, Func- tion of . . . .17 Pancreatic Stimulants . . 27 Pectoris, Angina . . . 227 Pepsin. ..... 58 Peptones 18 Peptonised Food . . .63 Perversions of Metabolism . 224 Phenomena of Liver Disturb- ance ..... 167 Potash, Utility of . . . 203 Preventive Treatment of Degen- eration 292 Production of Uric Acid . . 205 Proteids 56 TDeflex Indigestion . Relations of Brain and Di- gestive Organs Qaliva, Action of Salivary Stimulants Salt as Food Secondary Indigestion Skin Affections . Sleeplessness Solvent Action, Imperfect . Starch, Digestion of . " Effects of Cooking on 109 . 105 . 9 . 25 . 19 . 85 . 230 . 197 . 24 . 10 . 43 Starvation, Heart . 80 Stimulants, Gastric . . 26 " Liver . 28 " Pancreatic . 27 Struma . 72, 298 Sulphuretted Hydrogen . 193 Pag:e Symptoms of Biliousness . .183 " Bladder . . . 228 " of Indigestion . . 34 " Mental, of Indiges- tion . . .40 " Nervous . . .230 Syphilis as a Cause of Indiges- tion 123 n^emperance Drinks Tissue Nutrition . . 143 . 70 Tongue, Colour of . . . 183 " Furred . • . . .33 Toxsemic Indigestion . . . 123 Treatment, Actual, of Children 305 " of Liver Disturbance 249 " Preventive, of Chil- dren 293 Tubercle ..... 74 Types of Children . . . 306 TTlcer, Gastric . . . .29 Unfitness, Hepatic, for Hot Climates . . . 255 Urates. Colour of . . . 214 Uric Acid, Clinical Relations of 211 " in Congestion of the Liver . . .218 '' Production of . . 205 Urine, Time to Examine . . 209 Use of Mercury . . . .250 XTariety of Digestive Power . 344 Venous Fulness of Liver . 237 Views of Dr. Lauder Brunton . 163 Dr. Duncan Bulkley . 305 '' Dr. Kirkes . . . 151 " Dr. Murchison . . 154 TTTater, Colour of ^^ Wines 214 145 T«V»\.t<'.j \ \ V \tu keok^^fCc^^*^ ^Crovti.K'^^ "Qroi