ON THE 
ORGANIC DISEASES AND FUNCTIONAL DISORDERS 
OP 
THE STOMACH. ON THE 
ORGANIC DISEASES 
AND 
FUNCTIONAL UISOEUEES 
OF 
THE STOMACH. 
GEORGE BUDD, M.1)., 
PROFESSOR OF MEDICINE IN KING’S COLLEGE, LONDON ; 
LATE FELLOW OF CAIUS COLLEGE, CAMEUIDGE. 
SAMUEL S. & WILLIAM WOOD, 
261 Pearl Street, New York. 
1856. Efc&mrti ©■ Urnfetna, -printer anti Stcrfotijptr. 
No. 26 Frankfort Street, N. T. ADVERTISEMENT. 
The following Lectures, with, the exception of Lecture XIV., 
have before appeared in a scattered manner in one of the 
weekly medical journals. Those on Self-digestion of the 
Stomach after Death and on Simple Ulcer were delivered at 
the College of Physicians, as the Croonian Lectures, in the 
spring of 1847, and were soon afterwards published in the 
“Medical Gazette.” The remaining Lectures on the Organic 
Diseases of the Stomach were published in the “ Medical Times 
and Gazette,” in 1858, and the Lectures on the Functional Dis- 
orders of the Stomach in the same journal in 1854. They 
are now republished with such additions and corrections as 
my subsequent experience has suggested. 
Dover Street, 
October, 1855. CONTENTS. 
LECTURE 1. 
PAGfi 
Introduction—Difficulties attending the study of stomach disorders—Self- 
digestion of the stomach; or changes that take place in the coats of 
the stomach after death from the action of the gastric juice, . • 3 
LECTURE 11. 
Softening of the coats of the stomach from the action of the gastric juice 
after death—Different circumstances under which it occurs, . . .26 
LECTURE 111. 
The organic diseases and functional disorders of the stomach—Arrangement 
of the subject—Congestion of the stomach resulting from an impedi- 
ment to the course of the blood through the liver or the chest—Con- 
gestion resulting from other causes, . - . . . . . 45 
LECTURE IV. 
Inflammation of the stomach—its various kinds or degrees: Ist, Inflamma- 
tion excited by undigested food, or alcoholic drinks ; 2ndly, Inflamma- 
tion caused by more powerful mechanical or chemical irritants; Srdly, 
Inflammation resulting from defective nutriment, or from the presence 
of noxious matter in the blood, . . . . . . 64 
LECTURE V. 
Inflammation of the stomach—continued, . . . . . .80 
Ulceration of the mucous membrane of the stomach—The perforating or 
simple ulcer, 95 
LECTURE VI. CONTENTS, 
LECTURE VII. 
Ist, Perforating or simple ulcer of the stomach—Treatment; 2nd, Perfo- 
rating ulcer of the duodenum; 3rd, Minute superficial ulcers of the 
PAGE 
stomach, . . . 115 
LECTURE VIII. 
Cancer of the stomach, . . .132 
LECTURE IX. 
Sympathetic disorders of the stomach from irritation elsewhere, . . 150 
LECTURE X. 
Deficient secretion of gastric juice—Slow and imperfect digestion, . .168 
Fermentation in the contents of the stomach, with development of sarcinse, 180 
LECTURE XL 
LECTURE XII. 
Indigestion arising from defective action of "one of the excreting organs, 
or from some fault in the nutritive processes in other parts of the body, 196 
LECTURE XIII. 
Forms of indigestion characterised by some peculiarity in the symptoms— 
Urticaria—Pyrosis—lndigestion of drunkards, 212 
LECTURE XIV. 
Symptoms of stomach disorders—Pain and soreness of the epigastrium— 
Vomiting—Excessive acidity—Flatulence, 233 
LECTURE XV. 
On some of the remedies for stomach disorders—lpecacuanha—Bismuth 
The vegetable astringents—Hydrocyanic acid—The alkalies, . . 258 
LECTURE XVI. 
On some of the remedies for stomach disorders—The mineral acids—The 
vegetable hitters—The preparations of steel—Purgatives—General 
rules of living, ON THE 
ORGANIC DISEASES AND FUNCTIONAL 
DISORDERS OF THE STOMACH. 
LECTURE I. 
Introduction—Difficulties attending the study of stomach disorders— 
Self-digestion of the stomach, or changes that take place in the coats 
of the stomach after death from the action of the gastric juice. 
The stomach, whose disorders we are about to consider, is the 
foundation or root of all the complex apparatus that ministers 
to the nutrition of the body. It is, as Shakspeare termed it, 
“the storehouse and the shop of the whole body;” but it is 
more than this, for it not only receives and holds in store the 
crude materials for the sustenance of the body, but, by the 
agency of its peculiar juice, helps to dissolve those materials and 
to prepare them for conversion into the living blood. Any 
serious disorder of its functions necessarily affects in some degree 
the after-processes, and tends to contaminate or divert the life- 
stream at its source. To ensure, then, the proper nutrition of 
the body, and, consequently, the due maintenance of its manifold 
powers, the functions of the stomach must be rightly performed. 
But in man, fundamental and important as they are, the func- 
tions of the stomach are liable to be disordered by various con- 
ditions and in various ways, so that derangements of the 
stomach constitute a large proportion of human ailments. 
Notwithstanding their frequency, however, and their obvious 
importance, and the great attention which has in consequence 
been paid to them by physicians in all times, our knowledge of 
them, it must be confessed, is still very scanty and vague. The 10 
INTRODUCTION. 
reason tliat onr knowledge is so defective is, that the study of 
these derangements is extremely difficult. Considering such of 
them only as are dependent on some appreciable change of 
structure, the physician has great impediments to encounter. 
Where the organic change is not such as to cause a palpable 
tumor, there are no direct means of ascertaining the physical 
condition of the organ, while the sick man is living. The 
stomach is not visible, like parts on the surface; it cannot be 
explored by the sense of hearing, like the organs within the 
chest; its outline can seldom be distinctly felt, like that of the 
liver or the spleen; and its secretions are not poured out sepa- 
rately and unmixed for our inspection, like those of the kidnev. 
The nature of its diseases must' be inferred almost wholly from 
the functional disturbance they occasion. But the functions of 
the stomach are more readily deranged than those of any other 
secreting organ, and by a greater variety of conditions. Irrita- 
tion of the brain, the passing of a gall-stone, obstruction of the 
bowels, disease of the kidney or of the uterus,—will cause 
vomiting as frequent and distressing as organic disease of the 
stomach itself. Any sudden emotion, a febrile condition how- 
ever induced, various unhealthy conditions of the blood,—will 
suspend or derange the secretion of its solvent juice. 
Again, the structural diseases of the stomach—at least, of its 
mucous membrane, which is the source of its digestive power, 
—have been less elucidated by morbid anatomy than those of 
most other organs. When inflammation, for example, occurs in 
solid organs, as the brain, the liver, or the kidney,—or in the 
closed sacs of the body, as the peritoneum, or the pleura,— 
where it does not immediately destroy life, it leaves, for the most 
part, some permanent traces. If the body be opened at any 
future time, these traces are seen, and to a certain extent under- 
stood. It is not so with mucous membranes. The effusions to 
which inflammation gives rise are in them poured out on an 
open surface, and discharged from the body; and often, even 
when the disease is of long continuance, no permanent changes 
of structure result,—at least, no changes which our senses can 
appreciate. 
This remark applies, indeed, to the mucous membrane of the 11 
INTRODUCTION, 
air-tubes or of the urinary bladder and urethra, as well as to 
that of the stomach. But when inflammation occurs in the air- 
tubes or in the urethra, the matters effused are thrown off un- 
mixed for our inspection, and from their varying characters the 
progress or decline of the malady may be traced. The secre- 
tions to which inflammation of the stomach gives rise are, on 
the contrary, mixed with various matters,—with whatever is 
taken as food, or drink, or physic; and with the different secre- 
tions which are poured into the stomach and intestines to work 
those important changes in the food in which digestion consists. 
But, in the study of these diseases, there is yet another diffi- 
culty. The stomach presents various appearances, independent 
of disease,—according to the condition of the person when death 
occurred, and the time of year, and the mode of death, and the 
time after death at which the body is examined; and several 
of these appearances are very like the products of disease, and 
have, indeed, been generally confounded with them. 
Before, then, we can discriminate the changes of structure 
which are due to disease, we must be able to recognize, and 
rightly to interpret, these other changes that occur without it. 
By far the most important of these is the change which the 
stomach undergoes after death from the solvent action of its own 
proper juice. This change exists in greater or less degree in a 
large proportion of the bodies we examine ; and unless we are 
familiar with its characters, it is impossible that we can distin- 
guish the effects of inflammation and other changes of nutri- 
tion of the mucous membrane. A study of this is not only a 
necessary preliminary to the study of the diseases of the mucous 
membrane, but it also throws light on the circumstances which 
promote the secretion of the gastric juice, and on various func- 
tional disorders to which the stomach is liable. 
It is to this change, therefore, that I shall first call your at- 
tention. 
I need hardly remind you that it was John Hunter who first 
announced that the stomach itself may be dissolved or digested 
after death, by its own proper juice. 
Eailier pathologists, from Morgagni downwards, had occa- 
sionally remarked extreme softness of the mucous membrane— 12 
SELF-DIGESTION 
indeed, of all the tissues in the splenic end of the stomach,— 
hut they had all regarded this change as the result of disease. 
Hunter was led to the discovery of its real nature by finding it 
in an extreme degree in some persons killed by accident, in the 
midst of health; in whom, therefore, it could not be thus ex- 
plained. He says:—“ The first time that I had occasion to ob- 
serve this appearance in such as died of violence, and suddenly, 
and in whom, therefore, I could not easily suppose it to be the 
effect of disease, was in a man who had his skull fractured, and 
was killed outright by one blow of a poker. Just before this 
accident he had been in perfect health, and had taken a hearty 
supper of cold meat, cheese, bread, and ale. Upon opening 
the abdomen, I found that the stomach, though it still contain- 
ed a good deal, was dissolved at its great end, and a considerable 
part of its contents lay loose in the general cavity of the belly. 
This appearance puzzled me much. 
“ The second time was at St. George’s Hospital, in a man who 
died a few hours after receiving a blow on his head, which frac- 
tured his skull. 
“From these two cases, among various conjectures about so 
strange an appearance, ! began to suspect it might be peculiar 
to cases of fractured skull; and therefore, whenever I had an 
opportunity, I examined the stomach of every person who died 
from that accident; but I found many of them which had not 
this appearance. 
“I afterwards met with the same appearance in a man who 
had been hanged.” 
In some of the cases that fell under the observation of Hunter, 
the digestive action had extended much further than through 
the stomach. After having dissolved the stomach at the usual 
place, it had partly dissolved the adjacent side of the spleen, 
and had dissolved the adjacent portion of the diaphragm quite 
through, so that the contents of the stomach were found in the 
cavity of the chest, and had even corroded, in a slight degree, 
the surface of the lung at that part. 
Hunter found softening of the stomach of the same kind in 
some of the animals that were the subjects of his experiments on 
digestion, when he did not open them immediately after death. OF THE STOMACH. 
13 
These animals, after having been fed with various kinds of food, 
were all killed at different stages in the process of digestion. 
He procured also the stomachs of a great variety of fish— 
which when they come into our hands have usually died from 
violence—in a state of perfect health, and with their stomachs 
full; and in many of these he found the-digesting part of the 
stomach in the same dissolved state as the digested part of the 
food. 
Hunter concluded that digestion of the stomach after death is 
most common, and takes place to the greatest extent, in persons 
who die violent deaths; but that it occurs very frequently, 
though then usually in less degree, where death arrives more 
slowly from disease. He says, indeed, “ There are few dead 
bodies in which the stomach at its great end is not in some 
degree digested; and one who is acquainted with dissections can 
easily trace these gradations.” 
These observations of Hunter excited great interest at the 
time, not only from their novelty and startling character, but 
also from the new views they unfolded of the process of diges- 
tion, which was then very imperfectly understood. They 
showed, indeed, conclusively, as the sagacious mind of Hunter 
at once perceived, that digestion depends essentially on some- 
thing secreted by the coats of the stomach and poured into its 
cavity; and that this solvent menstruum,—this gastric juice,— 
though indebted to the stomach for its secretion, is yet capable 
of acting independently of it. 
The experiments of Hunter were repeated and varied, among 
others by Spallanzani, who, when Hunter’s paper fell into his 
hands, was engaged with his experiments on digestion. Spall- 
anzani’s experiments, which were all made on the lower animals, 
and which were multiplied and varied with his characteristic 
patience, confirmed the main fact announced in Hunter’s paper, 
—that digestion goes on after death, and that the stomach itself 
may then be digested by its own proper juice. Spallanzani, 
probably from making his observations in winter, did not for 
some time, among a great number of stomachs which he ex- 
amined, find a single one which had its great end perforated from 
digestion of its coats. He found, he tells us, the mucous mem- 14 
SELF-DIGESTION 
brane dissolved more or less, and especially in fish, but never 
observed that entire destruction of all the coats of the stomach 
which had been noticed by Hunter. His observations, however, 
taught him a fact of which Hunter was not aware,—the fact, 
namely, that a certain degree of heat is required to develope the 
solvent power of the gastric juice. 
Soon after the publication of Hunter’s paper, observations on 
softening of the stomach in man were published by several phy- 
sicians. In these observations the appearances of the softened 
stomach are very faithfully described, but no one seems to have 
met with the change so frequently as Hunter. Most writers, 
from making their dissections chiefly in winter, or from only 
recognising the change when it existed in an extreme degree, 
inferred that digestion of the stomach after death occurs but 
seldom, and in cases that must be considered as exceptions to the 
general rule. 
At length, the interest which the subject at first excited died 
away; few observations on this remarkable change were pub- 
lished ; and when softening of the stomach was met with, it was 
regarded by most physicians, as it had been before the time of 
Hunter, as the result of disease. In France, indeed, where 
morbid anatomy was most assiduously cultivated, but where the 
writings of Hunter were less generally read than in this country, 
many of the most enlightened pathologists seemed never to have 
even suspected that it could have any other origin ; so that, in 
1830, when Hr. Carswell again mooted the subject in Paris, and 
exhibited softened stomachs of rabbits that were killed soon 
after feeding, and opened some hours after death, almost as 
much interest—l may say, indeed, surprise—seems to have been 
excited, as was caused by the first publication of the observa- 
tions of Hunter. 
From this time the renewed interest had its former effect, and, 
for a few years, essays on the subject frequently appeared. Ob- 
servations, indeed, of softening of the stomach, or of digestion of 
the stomach after death, have occasionally been published up to 
this time; some very admirable ones recently, by Mr, Wilkin- 
son King, in one of the late numbers of “ Guy’s Hospital Re- 
ports.” But pathologists, in general, seem not to be aware how 15 
OF THE STOMACH. 
frequently the stomach undergoes this change. It has been 
supposed by many to occur only after violent deaths; and when 
occurring, as it often does, in other circumstances, it has been 
either overlooked or has been regarded as the effect of disease. 
M. Louis, for instance, one of the most accurate observers of 
our time, has published a special essay on softening (with thin- 
ness) of the mucous membrane of the stomach; and in his elabo- 
rate work on Phthisis has given, in the statistical form usual with 
him, the exact proportions in which he found this change, after 
death by acute and by chronic diseases; but when these works 
were first published, he seems not to have suspected that such a 
change could take place except from disease. . To any one, 
however, who is familiar with the appearances produced by the 
gastric juice in cases like those which first arrested the attention 
of Hunter, where death happens suddenly in the midst of health, 
it will be evident enough, from the mere perusal of M. Louis’ 
descriptions, that in most of the instances to which he refers, the 
softening of the stomach occurred after death, and was the mere 
effect of the solvent power of the gastric juice. 
The question then arises—How is it that in this age of in- 
quiry, when morbid anatomy has been studied with a zeal and 
success incomparably greater than in any former time, the truth 
set forth by Hunter has been so slow to make its way ? 
The reason apparently is, that the change in question varies 
in frequency and degree with many circumstances,—with the 
time of year, with the heat of the room in wdiich the body is 
kept, with the circumstances of death, and with the previous 
state of health;—so that the observations of one man did not 
tally with those of another; what one found frequently, another, 
whose observations were made in different circumstances, found 
but seldom. The variable and disturbing circumstances were 
not considered, and each man naturally distrusted observations 
that appeared to be contradicted by his own, 
Ho one seems to have observed this change so frequently as 
Hunter; but the truthfulness of Hunter’s mind, and the sim- 
plicity and candour of his statements, prevent us from sup- 
posing that in this respect he was guilty of any exaggeration. 
The fact is, that the solvent powers of the gastric juice require 16 
SELF-DIGESTION 
a certain temperature, and increase as tire temperature rises from 
the lowest point at which they act at all to the temperature of 
the blood,—the temperature at which they act in the living 
body. Hunter’s observations were probably made during a hot 
summer, when, by reason of the high temperature, softening or 
digestion •of the stomach after death was unusually frequent. 
During the past summer, which was a very hot one, my atten- 
tion was casually drawn to this subject, and from the middle of 
May to the middle of August I carefully examined the stomach 
in all the bodies that were opened in the King’s College Hospi- 
tal. In several instances the mucous membrane in the great 
end of the stomach was completely destroyed, and in a very 
large proportion it had been clearly acted on, more or less, by 
the gastric juice. I renewed my observations in October, but 
the change, at least in a striking degree, was then much less 
frequent. 
Digestion of the stomach by the gastric juice is generally ob- 
served, as I have already intimated, in the big end of the 
stomach; where any liquid that may be in the stomach collects 
after death, and where the mucous membrane is thinner, and 
less firm, and usually less protected by mucus, than in other 
portions. 
The first effect of the gastric juice is to render the mucous 
membrane thinner and softer, so that it may be readily removed 
by the pressure of the fingers ; and at the same time to Uachen 
the Rood contained in its vessels. If the capillaries of the 
mucous membrane were full of blood when the action of the 
juice commenced, the softened membrane gets a greyish or brown- 
ish cast, and is paste-like and opaque. If, on the contrary, the 
capillaries of the mucous membrane were empty, the softened 
tissue is rendered somewhat gelatinous and transparent; and 
should the larger branching vessels in the submucous cellular 
tissue be full, these are blackened, and thus rendered conspicu- 
ous, and, in consequence, are plainly seen through the thin and 
softened and gelatinized membrane. 
Precisely similar changes take place in albuminous tissues 
out of the stomach, when they are submitted to the action of the 
gastric juice at the temperature required for digestion. If the OF THE STOMACH. 
17 
substance contains little blood or fat, like white of egg or lean 
boiled meat, it is rendered more or less transparent or gelatinous, 
as it softens; if, on the contrary, it contains much blood and fat, 
like raw or roasted flesb, it is transformed into a brownish paste. 
In a still higher degree of this post-mortem digestion of the 
stomach, the mucous membrane most acted upon has the form 
and appearance of a thin layer of mucus or paste. The under- 
lying tissues are next dissolved and removed, until, as in the 
instances which first attracted the attention of Hunter, all the 
coats are eaten through and the contents of the stomach escape 
into the general sac of the peritoneum. The edges of the open- 
ing thus made, to borrow the description of Hunter, “appear 
to be half dissolved, very much like that kind of dissolution 
which fleshy parts undergo when half-digested in a living 
stomach, or when dissolved by a caustic alkali,—viz., pulpy, 
tender, and ragged.” 
In some instances, the portion of the diaphragm which lies in 
contact with the dissolved end of the stomach gets dissolved in 
its turn, and the contents of the stomach pass into the cavity of 
the chest. The spleen, the lungs, and other organs with which 
the solvent juice is thus brought into contact, are in such cases 
more or less corroded by it. 
Digestion of the stomach occurs, as I have before remarked, 
in the highest degree in its big end; and it is only in this part, 
where the liquid contained in the stomach chiefly collects after 
death and where the mucous membrane is thin, that perforation 
from this cause ever takes place: but when this end of the 
stomach is perforated, or its mucous membrane much softened, 
other portions of the organ exhibit in less degree the action of 
the same agent. The edges of the folds, which the organ, when 
contracted, always exhibits in its pyloric portion, are the parts 
that here become softened the first. If the mucous membrane 
was empty of blood, these folds appear as whitish semi-trans- 
parent lines, or rather narrow bands, in which the mucous mem- 
brane is palpably thinner and softer than in their intervals, 
where it is more protected—partly perhaps by the mucus which 
lodges in the furrows—from the action of the dissolving agent. 
If, on the contrary, the mucous membrane was congested, 18 
SELF-DIGESTION 
the softened bands have a brownish tint, which contrasts still 
more strongly with the pink uninjured membrane around 
them. 
It sometimes happens, as was shown by Mr. King, in a paper 
published in the 7th volume of “ Guy’s Hospital Reports,” that, 
after death, some of the liquid in the stomach regurgitates 
through the cardiac orifice (mainly, perhaps, through the con- 
traction of the abdominal muscles in the rigor mortis), and 
lodges in, and dissolves, the lower end of the oesophagus. 
Here, as towards the pyloric end of the stomach, the projecting 
edges of the folds are acted upon first. The coats of the oeso- 
phagus may be completely dissolved, one after another, like 
those of the stomach; and in this way, also, some of the con- 
tents of the stomach may pass into the cavity of the pleura. A 
case of this kind occurred to Sir A. Cooper, who related the 
particulars of it to Mr. King. “ The oesophagus,” he said, 
“ was dissolved, atid the bread and cheese was found extrava- 
sated in the chest.” 
The under or back part of the oesophagus, on which the sol- 
vent fluid rests, is the part that is most acted on in such cases; 
and from the lower end of the oesophagus lying to the left of the 
vertebral column, it follows that where perforation takes place 
the opening leads into the left pleural sac. 
When the oesophagus is thus dissolved or corroded by the 
gastric juice, the great end of the stomach is always dissolved 
or corroded also. 
As digestion of the stomach after death does not occur in all 
cases, and as, when it does take place, it occurs in very different 
degrees in different cases, the question arises—On what condi- 
tions does this digestion depend ? 
Two conditions obviously necessary are,—Ist, that the 
stomach at the time of death should contain a certain quantity 
of active gastric juice, or, at least, of muriatic or lactic acid, which 
make with the coats of the stomach a digestive mixture; and 
2ndly, that the stomach should be kept for some hours after 
death at the temperature required for artificial digestion. 
The first condition is very generally fulfilled in persons who 
are killed by accident, in the midst of health, and soon after a OF THE STOMACH. 
19 
meal. The instances, before related, which so strongly arrested 
the attention of Hunter, were of this kind. 
It was early remarked by Hunter, that softening of the stom- 
ach does not occur in all cases of violent death; and it was infer- 
red from his observations, and the inference was strengthened 
by the experiments of Hr. AY. Philip and Dr. Carswell, that it 
only takes place when death happens soon after a meal • that 
is, while the process of digestion in the stomach is actively 
going on. 
It is, indeed, only at such times that the stomach, under 
ordinary circumstances, contains any gastric juice. AYhile the 
stomach is empty of food, the fluid which moistens its surface is 
not acid, and has no peculiar solvent power. This point was 
conclusively established by the observations of Dr. Beaumont 
on the stomach of St. Alartin, which could be seen and examined 
through a large fistulous opening in the wall of the belly; and 
one of the most interesting circumstances witnessed by Dr. 
Beaumont in his long-continued observations was the out-pouring 
of the gastric juice -on mechanical irritation of the inner surface 
of the stomach, and especially on the introduction of food. The 
following is the account he gives of one of his experiments. 
(Exp. 63.) 
“Jan. 19th.—At 9 o’clock A.M., coats of stomach perfectly 
healthy and clean. No appearance of morbid action; tongue 
clean, and every appearance of perfect health. There was no 
free fluid in the gastric cavity until after the elastic tube was 
introduced, when it began slowly to distil from the end of the 
tube, drop by drop, perfectly transparent and distinctly acid. 
I obtained about one drachm of this kind, and then gave him a 
mouthful of bread to eat. No sooner had he swallowed it than 
the fluid commenced flowing more freely from the tube, and I 
obtained two drachms, less pure, however, with saliva and 
mucus mixed with it, and slightly tinged with yellow bile. The 
surface of the protruded portion of the villous coat at this time 
ecanre covered with a limpid fluid, unforrnly spread over its 
w.o 6 Slu’face, distilling from myriads of very fine papillary 
points, and trickling down the sides. After letting him rise and 
u a v a mit two or three minutes, I again introduced the tube, 20 
SELF-DIGE STICK 
and obtained about two drachms more of very pure gastric 
juice, making in the whole five drachms.” 
Dr. Beaumont states, that in more than two hundred observa- 
tions he never found any gastric juice in the empty stomach; 
and he considered mechanical irritation of the mucous mem- 
brane, or the more natural and more efficient irritation by food, 
to be necessary for the secretion of it. 
The secretion of the gastric juice is, to use a word much in 
vogue, a reflex function, whose ordinary excitant is the impress- 
sion of food on the mucous membrane of the stomach. The 
nervous influence, so excited, causes the sudden and rapid out- 
pouring of the gastric juice, just as the nervous influence called 
into action by mechanical irritation of the conjunctiva causes a 
flow of tears. Now the flow of tears may be excited, not only 
by mechanical irritation of the conjunctiva, but by mechanical 
irritation of the mucous membrane of the nostril, or of the 
mouth ; and by certain medicines, like iodide of potassium, which 
are excreted at those surfaces; and by mental emotion. The 
flow of urine, again—an instance in some degree analogous,— 
may be increased by emotion, as well as by direct irritation of 
the kidney itself. 
The question then arises—May not the same thing happen for 
the gastric juice ? May not the outporing of this be occasionally 
determined by other influences than the presence of food in the 
stomach ; or, at least, by nervous impressions on other parts ? 
Many considerations lead to the inference that it may. 
Spallanzani obtained some gastric juice from his own stomach 
by tickling the fauces, and thus exciting vomiting, in the morn- 
ing before breakfast, when the stomach, we may presume, was 
empty of food. By exciting vomiting twice in succession, he 
obtained in this way juice enough to undertake some experi- 
ments, of which he has given an account. That the fluid was 
actually the peculiar solvent juice of the stomach was shown by 
its dissolving and preventing the putrefaction of meat. 
A case having great interest as regards this question was 
brought under my notice last summer. 
A gentleman, forty years of age, while riding in the Park at 
six o’clock in the afternoon of the 21st of May, was thrown from OF THE STOMACH. 
21 
his horse and, by the fall, fractured bis skull. He was taken to 
bis bouse, where be lay motionless and insensible till half-past 
one p. M. on the following day, when be died. 
On examination of the body, which was made eighteen hours 
after death, by my colleague, Mr. Fergusson, the great end of 
the stomach was found to be completely dissolved, and oilier 
portions of the organ exhibited in less degree the usual appear- 
ances caused by the solvent action of the gastric juice. The 
portion of the diaphragm in contact with the great end of the 
stomach was likewise dissolved quite through, so that there was 
a large opening from the stomach into the cavity of the left 
pleura. This cavity contained about a pint and a half of dark 
grumous fluid, not unlike coffee-grounds, consisting chiefly, I 
presume, of partially digested or altered blood. 
Now the accident happened, as far as I could learn, and I 
made many inquiries on this point, before dinner, when the 
stomach was probably quite empty; and according to the state- 
ment of Mr. Fergusson and others in attendance upon the 
patient, it completely destroyed the power of swallowing, so that 
nothing whatever was taken into the stomach from the time of 
the accident to his death. 
Here, then, was digestion of the stomach in the highest degree, 
after a violent death, which did not occur, however, suddenly 
and soon after a meal, as in the instances of similar destruction 
of the stomach recorded by Hunter and others, but, on the con- 
trary, at the end of nearly twenty hours passed in a state of 
coma, and after an unusually prolonged fast. 
The question, then, naturally arises, was the secretion of the 
large quantity of gastric juice which must have existed in the 
stomach at the time of death determined by the shock of the 
accident, or by the subsequent irritation of the brain which the 
accident occasioned ? And is there not still some ground for the 
suspicion which Hunter early entertained and then abandoned, 
t iat digestion of the stomach is especially apt to occur after 
. oa^l rom fracture of the skull ? It is clear that if gastric 
juice should be secreted under such circumstances, and in an 
empty stomach, its action on the coats of the stomach after death 
would be unusually great, because it would not then be absorbed 22 
SELF-DIGESTION 
and neutralized by food, and would liave nothing but the unpro- 
tected stomach to dissolve. 
But, as I have already stated, it is not only after violent death 
in the midst of health that digestion of the stomach takes place : 
it also, and not unfrequently, though then usually in 
much less degree, in persons who die of disease. The reasons 
of this difference of degree are obvious. In a state of health, 
the secretion of gastric juice is determined by the presence of 
food in the stomach, and the quantity of juice secreted varies 
with the quantity of food which it has to dissolve. At the end 
of two or three hours after a meal, the stomach is either empty 
or the solvent power of its juice has been in a great measure 
expended in digesting the food. Hence it is that digestion of 
the stomach is usually found in the highest degree when death 
happens suddenly, soon after a full meal. 
How, in most diseases the appetite is impaired, and much less 
food is usually taken than in health, more especially as their 
fatal termination approaches. In most diseases, too, the power 
of digestion suffers—the gastric juice secreted, after a given 
quantity of food, is less in quantity, and has less solvent power, 
than in health. On both accounts, the digestion of the stomach 
itself after death occurs less frequently, and usually in much less 
degree. 
There are, however, some striking exceptions to this general 
rule. In persons who die of phthisis, and after death from some 
other diseases, the mucous membrane of the stomach, in its great 
end, is frequently found much softened by the gastric juice ; and 
now and then all the coats of the stomach are destroyed at that 
part in almost as great extent as when death happens suddenly, 
in the midst of health, sdon after a meal. 
A consideration of these cases raises some interesting ques- 
tions, but I have not time to enter on it to-day. I shall, there- 
fore, reserve whpt I have to say on this subject until I have the 
honour of addressing you again, and shall now proceed to speak 
of the other conditions necessary for 'post-mortem digestion of 
the stomach. 
One requisite for this, as was clearly shown by the experi- 
ments of Spallanzani, is a certain temperature. Spallanzani OF THE STOMACH. 
found that the gastric juice, which acts strongly at the tempera- 
ture of the living body, loses its solvent powers, and is no 
longer antiseptic, when the temperature falls below a certain 
degree,—a conclusion which has since been fully confirmed by 
the experiments of Dr. Beaumont. Digestion is probably most 
rapid at the temperature of the living body, about 100° Fahren- 
heit ; it goes on briskly at the temperature of the atmosphere in 
summer ; but at the temperature of 60° Fahrenheit, (to judge by 
an experiment of Spallanzani,) it becomes very slow and feeble. 
This accounts for the circumstance that digestion of the stomach 
after death is most commonly met with in summer. Much, 
however, must depend on the temperature of the body at the 
time of death, and on the rapidity of cooling which takes place 
afterwards, which must of course vary, whatever be the season, 
v ith the place in which the body is kept, and with the nature of 
the material, whether woollen or otherwise, in which it is 
wrapped. 
Another condition necessary for artificial digestion, and there- 
foie lequired for the digestion of the stomach after death, is that 
the digestive fluid should be acid. It was proved by Schwann, 
m his experiments on artificial digestion with rennet, that the 
digestive fluid is inert when neutralised by carbonate of potash, 
but recovers its solvent power on the addition of the proper 
quantity of hydrochloric acid. 
flhe digestion of the stomach after death may be occasionally 
prevented by ammonia given just before death to relieve the 
sense of sinking. If the juice be in small quantity, it may be 
neutralized, and thus rendered inert after death, by the transu- 
dation of the alkaline serum of the blood. 
Alcohol, again, renders the digestive principle inert; and if 
this be given freely just before death, as it often is in this coun- 
be absorbed before the circulation ceases, and may prevent 
° subsequent solution of the stomach, which the gastric juice 
otherwise occasion, A great number of medicines also 
suspen or much diminish the solvent powers of the gastric 
juice, ant, if given just before death, may prevent or retard the 
subsequent digestion of the stomach. 24 
SELF-PROTECTIVE POWER 
The influence of medicines in retarding digestion, which may 
now be clearly ascertained by artificial digestion with rennet, has 
not yet been sufficiently studied. The importance of knowledge 
on this point is very obvious, when we consider how frequently 
medicines of different kinds, many of which are slowly absorbed, 
are given when there is food in the stomach, and when digestion 
is still going on. 
Digestion of the stomach after death is especially interesting, 
because it exhibits to us in a very striking manner the self-pro- 
tective power possessed by living tissues. While the food we 
take into the stomach is rapidly dissolved by the mere chemical 
action of the fluid which is there secreted, the coats of the 
stomach itself, which in composition are nearly the same as the 
food which is thus dissolved, suffer no damage. The chemical 
action of the gastric juice, as regards the stomach itself, and no 
doubt the chemical action of various articles of food as well, is 
counteracted by the forces which the nutrition of the organ 
developes. We have, indeed, the protective influence of these 
forces always presented to us in the resistance which the tissues 
of living bodies offer to the chemical affinity of the matter by 
which they are surrounded. Even air and moisture, which are 
so necessary to the continuance of life, destroy by their chemical 
action, and resolve into simpler chemical combinations, all the 
tissues of both animals and plants when life is extinct. But the 
instance we have been considering is perhaps more likely to fix 
attention, from the circumstance that the destructive agent is 
formed by the very tissues which it subsequently serves to 
destroy. We see an analogous instance in plants. The leaves 
of a living plant, under the influence of light, are 
evolving oxygen ; yet they yield readily to the chemical action 
of the oxygen of the air when the vital principle is extinct. 
The protective influence of the forces developed in the pro- 
cesses of nutrition has not been sufficiently considered in patho- 
logy. It is through the resistance which they offer to destruc- 
tive chemical changes that the tissues of living bodies remain 
unhurt amidst the many causes of disturbance to which they are 
ever exposed. This vital resistance, if we may so term it, exists 
in different degrees in different persons. Men of feeble consti- 
tution have frequently recurring ailments, the effect of external 25 
OF TISSUES. 
agencies, which they have not strength enough to resist; others, 
by nature more robust, exposed to these same agencies, pass 
through life without ever suffering sickness. 
The vital resistance varies in intensity at different periods of 
life, and becomes very feeble in old age, when the tissues suffer 
damage, and when the current even of life may be stopped by 
slight disturbing influences. The way to prolong life in old 
age is carefully to protect the body from cold and from all other 
avoidable causes of disturbance: above all things to abstain 
from lowering remedies in the treatment of the ailments that are 
incident to it. 
But, at any period of life, the vital resistance varies in degree 
according to the circumstances in which the person is placed. 
It requires for its support the proper nutrition of the tissues. 
"Vv hatever promotes this—as pure air, good food, the natural 
stimulus of the nerves, the healthy play of the different organs 
serves to maintain and increase it. Whatever lowers the nu- 
trition of any part, renders that part more liable to disease from 
chemical disturbing influences from without. So it is with the 
whole body. Whatever exhausts the body—as insufficient food, 
prolonged cold, excessive bodily fatigue, the depressing passions 
leaves it without its proper protection. Its tissues suffer 
damage from external agencies which in other conditions of the 
body would have been without injurious effect. 
Disease always comes in the train of exhausting or depressing 
influences of whatever kind. Fever attacks the poor in prefer- 
ence to the rich,—the new-comers to towns, those of our medical 
students who are exhausted by work. Erysipelas infects those 
who are weakened by other diseases. Consumption is especially 
frequent among the inmates of prisons. It has long been a 
popular notion, and is probably a true one, that the dread of 
cllolcra predisposes to it. After devastating wars, and in seasons 
°f scarcity, when a whole population is depressed, pestilence 
mvariably comes in the form of infectious fever or malarious 
isease. This has long been known to the historian and the 
statesman, as the result of experience. The physician looks 
deepei, and sees in it the effect of the diminished vital resistance 
which all exhausting or depressing influences occasion. LECTURE 11. 
Softening of the coats of the stomach from the action of the. gastric juice- 
after death—Different circumstances under which it occurs—lnferences 
to he drawn from them. 
Softening of the stomach having the same characters as that 
which was found by Hunter in the bodies of persons who had 
been killed by accident in the midst of health, and soon after a 
full meal,—that is, while digestion was actively going on— 
occurs also, and not unfrequently, in other and very different 
circumstances. 
Cruveilhier has distinguished two kinds of softenings of the 
stomach, both occurring principally in its big end, and has called 
them the pulpy softening and the gelatinous softening, from the 
appearance respectively presented by the softened tissues. The 
pulpy softening he supposes to occur after death, from the action 
of the gastric juice; the gelatinous softening, during life, from a 
peculiar morbid process. Rokitanski distinguishes three varie- 
ties of softening in this portion of the stomach, according to the 
color of the softened tissues; and two of these he supposes to 
occur during life, as the effect of disease.' 
An attentive examination of these so-called varieties leaves no 
doubt in my mind that they are all produced after death, and 
by the same agent,—namely, the gastric juice; and that the 
differences of transparency and color in the softened tissues, to 
which so much importance has been attached, result mainly 
from variations in the quantity of blood in these tissues at the 
time of death. 
In illustration of this, I may call your attention to a stomach 
on the table, which I obtained, two days ago, from a man who 
died of phthisis in King’s College Hospital. The stomach was 
much congested at the time of death, and towards its pyloric SELF-DIGESTION, 
27 
portion tlie edges of the folds, which are the only parts where 
the mucous membrane is softened, appear as brown lines or 
bands. The change is exactly like that represented in this plate 
of Cruveilhier, which he gives as an illustration of the gdatini- 
fovTTi softening, except in the darker colour and in the want of 
transparency of the softened tissues; which are perfectly ex- 
plained by the greater quantity of blood which the tissues con- 
tained at the time of death. 
The essential characters of the change are:— 
Ist. A softening of the mucous membrane, usually over a 
considerable space in the great end of the stomach, and along 
the edges of the folds extending from this towards the pyloric end; 
parts which, for reasons I have already assigned, are most ex- 
posed to the action of the dissolving agent. 
2nd. A blackening of the blood in the tissues so acted upon, 
giving various shades of brown to the softened tissues when 
much blood was contained in them at the time of death. 
A third character of the change is, that the softened or digest- 
ed tissues have an acid reaction; and that they putrify less 
readily than other parts, in consequence of the antiseptic prop- 
erties of the gastric juice. 
These characters will serve in most cases to distinguish the 
digestion of the stomach that occurs after death, even in its 
slighter degrees, from every other change. If the coats of the 
stomach at the time of death were empty of blood, they are ren- 
der ed, in the process of softening, more or less transparent or 
gelatmifoi m, as all albuminous tissues are when acted upon by 
the gastric juice or by acetic acid: if, on the contrary, the soft- 
ened tissues contained much blood or fat, they became brown 
and opaque or paste-like. 
As the digestion proceeds, the mucous membrane is rendered 
thinner and softer, until it resembles a thin layer of mucus or 
paste. The other coats of the stomach are next dissolved and 
removed, in succession, from within outwards, until a ragged 
aperture is made, through which the contents of the stomach 
escape into the peritoneal sac. The process of digestion may 
.:ti bo on, so that the side of the spleen contiguous to the stom- 
ac r may be dissolved, or the diaphragm at that part may be 28 
SELF-DIGESTION 
eaten through, and the contents of the stomach pass into the 
cavity of the chest. 
It occasionally happens, as I have before remarked, that some 
liquid from the stomach regurgitates, after death, through the 
cardiac orifice, and causes similar changes in the lower end of 
the oesophagus. 
The conditions necessary for this post mortem digestion of the 
coats of the stomach are, first, that the stomach at the time of 
death should contain some gastric juice, or at least some mu- 
riatic or lactic acid; and second, that it should be kept for 
some hours after death at the temperature required for artificial 
digestion. 
The first condition is very generally fulfilled in persons 
who are killed by accident, in the midst of health, and soon af- 
ter a meal; and up to this time it has been commonly supposed 
that digestion of the stomach after death occurs in a high degree 
only under such circumstances. 
It has, indeed, been generally taught that gastric juice is only 
secreted while food is in the stomach, and that it only exists in 
the stomach for a few hours after a meal,—and this is, no doubt, 
true for persons in health. Dr. Beaumont, during the long time 
that he made St. Martin the subject of experiment, invariably 
found that when the stomach was empty of food, the fluid which 
moistened its surface was not acid and had no peculiar solvent 
power. 
But in certain diseases gastric juice is secreted when the stom- 
ach is empty, and exists in the stomach unmixed with food and 
long after food has been taken. 
Again, in certain catarrhal states of the stomach, the lactic 
fermentation is apt to occur in the saccharine principles of the 
food in the stomach, and the result is, the generation of a large 
quantity of lactic acid, which forms with the mucous membrane 
of the stomach a digesting mixture. 
In persons who die of the diseases and disorders in question, 
digestion of the stomach is often found in as high a degree as in 
persons killed by accident in the midst of health and soon after 
a meal: and not unfrequently the softening of the stomach may 
be predicted with tolerable certainty by a peculiar train of symp- 29 
Toms, which result, I imagine, from the presence of free gastric 
juice, or of a digesting acid, in the otherwise empty stomach. 
This occasionally happens in cases of simple nicer of the stom- 
ach. On the table are two preparations exhibiting this disease 
in conjunction with entire destruction of the mucous membrane 
in the great end of the stomach, doubtless produced by the gas- 
tric juice. One of these preparations has been long in the Mu- 
seum of King’s College ; the other is that of a stomach which I 
obtained in the month of January, in very cold weather, from a 
man who died under my care in King’s College Hospital, from 
perforation of the stomach, caused by the ulcer. 
OF THE STOMACH. 
In simple ulcer of the stomach, pain at the epigastrium is 
sometimes felt when the stomach is empty of food; and, to- 
gether with thirst and an impaired appetite, there are frequently 
sour eructations and occasional vomiting of a sour fluid. These 
symptoms seem to depend mainly on the presence of gastric 
juice, or its acid, in the otherwise empty stomach. It is easy to 
conceive that the flow of the juice may be excited in the empty 
stomach by the irritation of the ulcer or its secretions, just as 
it was in the experiments of Spallanzani by the mechanical irri- 
tation of pebbles or of bits of sponge or glass. 
Digestion of the stomach in a High degree is found much more 
frequently in persons—and especially in women—who die of 
phthisis. On the table are two preparations in which this is 
well exhibited:—the mucous membrane in the great end of the 
stomach is completetely destroyed, and the branching vessels in 
the submucous cellular tissue are exposed, and are very con- 
spicuous, from the blackening of the blood they contain. These 
stomachs were obtained from men who died of phthisis in King’s 
College Hospital; one of them last summer, the other about two 
months ago. It now and then happens that in persons who die 
of this disease, the muscular and serous coats in the great end 
of the stomach are found dissolved, as well as the mucous coat; 
and the stomach, when removed, exhibits an aperture on its 
great end, with ragged flocculent edges, as when death happens 
suddenly after a full meal; and, as in these latter cases, the ab- 
sence of any marks of inflammation of the peritoneum or of the 
coats of the stomach, as well as the peculiar characters of the 30 
SELF-DIGESTIOIST 
change itself, show clearly that the softening takes place after 
death, from the action of the gastric juice. 
This softening of the stomach has been well described by M. 
Louis, who was not, however, aware of its real cause. In his 
elaborate work on phthisis, he states that he observed it in about 
one-fifth of the subjects he examined, who had died of this 
disease. 
Tire individuals in whom it is found have generally had for 
some weeks, and often for several months before death, much 
disorder of the stomach: pain and tenderness at the epigastrium, 
loss of appetite, thirst, frequent vomiting, (the matters vomited 
being slightly acid), or frequent nausea. 
This gastric disorder, which is extremely common in the ad- 
vanced stages of phthisis, exhausts the strength, and sometimes 
attracts more of the patient’s attention than the primary disease 
of the lung. The frequent occurrence of the peculiar softening 
of the coats of the stomach caused by the gastric juice after 
death, in the persons in whom it has existed, shows that this 
disorder is associated with increased secretion of gastric juice, or 
with the presence of gastric juice, or of a digesting acid, in the 
otherwise empty stomach. It is not improbable that, in these 
cases, the flow of gastric juice in the empty stomach is excited 
by irritation of the lung, just as it was excited by Spallanzani, 
in his own person, by voluntary irritation of the fauces. 
3rd. Digestion of the stomach after death frequently takes 
place, also, in persons who die of inflammatory diseases of the 
brain. These diseases give rise to the same kind of secondary 
gastric disorder as tuberculous disease of the lung—viz., frequent 
vomiting or nausea; together with pain at the stomach, thirst, 
and loss of appetite, unless the latter symptoms are masked by 
delirium or blunted sensation. The frequent occurrence of 
softening of the stomach after death in inflammatory diseases of 
the brain shows, as in cases of phthisis, that this gastric disorder 
is associated with increased secretion of gastric juice, or with 
the presence of gastric juice, or its acid, in the otherwise empty 
stomach. 
The cases are strictly analogous in this respect to the instance 
which I related in my last lecture, in which the highest degree OF THE STOMACH. 
31 
of digestion of the stomach and diaphragm was found in a man 
who died from fracture of the skull after an unusually pro- 
longed fast. 
4th. Softening of the stomach of the same kind is also often 
met with in persons who die of typhoid fever, especially, I be- 
lieve, where death has been preceded by delirium or other 
serious disorder of the functions of the brain. 
In some instances in which this happens there has been pain 
and soreness of the stomach, and vomiting, for some days before 
death; but generally the gastric disorder is masked by the 
delirium or the blunted state of sensation which usually exists 
in severe forms of fever. 
When softening of the stomach occurs in persons who have 
died of fever, the softened tissues have generally a rust-colour, 
or brownish tint, from the circumstance of the blood remaining 
fluid and gravitating to the lowermost parts of the stomach, 
where the softening takes place. 
sth. The same change is occasionally met with in persons who 
die of cancer of the uterus, or of peritonitis, or of other diseases 
of the abdominal viscera, which lead to secondary functional 
disorder of the stomach. Where it occurs in conjunction with 
chronic diseases, as phthisis or cancer of the uterus, which do 
not cause delirium or coma, it has generally been preceded for 
some time before death by the peculiar gastric disorder which I 
have described. When it occurs in conjunction with inflamma- 
tory disease of the brain or fever, which destroy or pervert 
sensation and which kill quickly, the symptoms of gastric dis- 
order are, of course, less marked, and are often altogether 
absent. 
In any case, the degree of the softening bears no necessary 
relation to the severity or duration of the gastric disorder. The 
gastric disorder may have existed for months, but the stomach 
may chance to be empty at the time of death, and no softening 
of its coats occurs. And, on the other hand, where there has 
been no gastric disorder, or only a slight degree of it, a consid- 
erable quantity of gastric juice may be poured out just before 
death, and the highest degree of softening take place. 
Ihese facts have been noticed by Louis, Cruveilhier, and SELF-DIGESTION 
others, whose attention has been directed to this subject; and, 
as they supposed the softening to be the result of disease and 
to occur during life, they could only explain them by supposing 
that at times this disease runs a very rapid course, or that it is 
latent: in other words, that it gives rise to no appreciable 
symptoms. 
All these difficulties are removed by the explanation which I 
have offered: namely, that the softening occurs, in all cases, 
after death; and that the degree of it depends, if the conditions 
of temperature, &c., be alike, on the quantity of the solvent 
juice in the stomach at the time of death, and not at all on the 
duration or extent of the gastric disorder. 
The same kind of gastric disorder not unfrequently occurs, 
especially in nervous women, from disordered menstruation, the 
irritation of gall-stones, or some other cause of disturbance, and 
after continuing in a severe form for weeks, or even for months, 
subsides, on the removal of its exciting cause or on improve- 
ment of the general health, and the power of the stomach is 
perfectly restored. No weakness of digestion or other symptom 
remains to show that the organ has been damaged in its struc- 
ture. 
But it is in infants who die from the age of three or four 
months to two years that softening of the stomach in a high 
degree occurs most frequently. In them, different portions of 
the intestines are frequently found softened as well as the 
stomach; and the softened tissues, from the state of anaemia in 
which infants usually die, are generally semitransparent, or 
gelatiniform. 
The change is found very commonly in infants who die from 
hydrocephalus or phthisis, and occasionally, unconnected with 
any structural disease, in infants who die of exhaustion conse- 
quent on the eruptive fevers or on improper diet after weaning. 
The children in whom it takes place have generally had for 
some time before death severe disorder of the stomach of the 
same kind as occurs in adults: frequent vomiting, loss of appe- 
tite, great thirst, and crying, as if from pain; and with these 
symptoms there is often diarrhoea, the discharges from the 
bowels being green, like spinach, from the presence, I imagine, OF THE STOMACH. 
of bile acted on by muriatic acid which bas passed down from 
tbe stornacb, or of lactic acid winch has passed down from the 
stomach or been formed in the bowel, and has not been neutral- 
ized by the various secretions of the intestinal canal. 
In infants the softening of the stomach is found unconnected 
with organic diseases of other organs much more frequently than 
in adults, because in them the functional gastric disorder, which 
may be excited hj teething or other causes of disturbance, rapidly 
exhausts the strength, causing a state of collapse, and thus prov- 
ing fatal of itself. 
In infants, the softening is usually more extensive than in 
adults, and in higher degree; more frequently leading to perfo- 
ration of the stomach and to softening or corrosion of contiguous 
organs. As in adults, however, the degree of softening bears no 
necessary relation to the severity or duration of the gastric symp- 
toms ; and this circumstance, together with the absence of any 
marks of inflammation in the peritoneum, even when the dia- 
phragm, as well as the stomach, has been dissolved quite through, 
shows that the changes have taken place after death. 
This softening of the stomach is usually found, then, in per- 
sons who die of disease in some other organ, and of those diseases 
especially which have long heen known to lead to secondary functional 
disorder of the stomach. How this peculiar softening of the coats 
of the stomach is, in any case, a clear proof that there was active 
gastric juice, or its acid, in the stomach at the time of death. Its 
frequent occurrence, therefore, in persons who die of the diseases 
I have mentioned, shows us that the functional disorder of the 
stomach, so common in those diseases, is associated with increased 
secretion of gastric juice, or its acid; or with secretion of gastric 
juice, or its acid, when there is no food in the stomach ; or with 
undue retention of it in the stomach; so that at the time of death 
active gastric juice is contained in the stomach, which subsequently 
dissolves or digests its coats. 
The question then arises—How is this functional disorder 
brought about in these several diseases, and what is its real 
nature ? 
A' hen disease of any one organ causes secondary disease of 
another and distant organ, it must be either through the circulating 34 
SELF-DIGESTION 
fluids, or through the nervous system. It is only by the circu- 
lating fluids, or through the nerves, that disease of an organ can 
cause secondary disorder of a different organ remote from it. 
But, in the cases in question, this secondary disorder of the 
stomach can hardly arise through the blood. Tubercular disease 
of the lung, continued fevers, inflammatory diseases of the brain, 
cancer of the uterus, and. mere functional disorder of this organ, 
lead to no common change in the blood by which this peculiar 
functional disorder of the stomach can be explained. 
We are driven then, to the inference, that the secondary dis- 
order of the stomach in these diseases is produced through the 
intervention of the nervous system. And this inference is con- 
firmed by the fact, that in phthisis the softening of the coats of 
the stomach after death, like the functional disorder that usually 
precedes it, is more common in women than in men; and that 
when it results from inflammatory disease of the brain, it is much 
more common in young children than in grown-up persons. For 
the same primary disease, whether it be of the brain or of the 
lung, the change is most common in those persons who, by their 
sex and age, are most liable to sympathetic disorders. 
Considering, then, this functional disorder as a sympathetic 
disorder excited through the nervous system, the further question 
arises—What is its real nature ? Does this sympathetic disorder 
affect the secreting apparatus of the stomach, or merely its mus- 
cular coat? 
In my last lecture I mentioned the circumstances which led 
me to infer that the outpouring of the gastric juice, which has 
been supposed to result from direct irritation of the stomach 
alone, might also be excited, through reflex nervous influence, 
by irritation of other parts; that as the flow of urine may be 
increased by emotion as well as by direct irritation of the kidney 
through the blood; or as the secretion of tears may be excited 
by irritation of the nostril or the mouth, or by emotion, as well 
as by irritation of the surface of the eyeball: so might the out- 
pouring of the gastric juice be excited by irritation of the fauces, 
and, therefore, probably of the lung, or by irritation of the brain, 
as well as by mechanical or other irritation of the inner surface 
of the stomach itself. OF THE STOMACH. 
35 
The circumstances which. I have brought under your notice to- 
day confirm this inference, and afford additional grounds for sup- 
posing that in many of the cases we have been considering, it is 
to the secretion of gastric juice excited in this way in an empty 
stomach that the symptoms referable to the stomach, and the diges- 
tion of its coats after death, are mainly owing; that the secon- 
dary disorder of the stomach which occurs in inflammatory 
diseases of the brain, in phthisis, and in various diseases of the 
abdominal viscera, affects the secreting apparatus of the stomach, 
as well as its muscular coat. 
The secretion of gastric juice when the stomach is empty of 
food is, of course, a waste of digestive power, and necessarily 
leaves the stomach more or less exhausted for a time. If, after 
the wasted juice has passed away, more food be taken than the 
exhausted stomach can readily dissolve, it frets the mucous mem- 
brane, and may cause it to secrete an unhealthy mucus, which, 
acting as a ferment, may lead to the frequent and abundant gene- 
ration of lactic acid from the saccharine elements of the food. 
In some of the cases to which I have alluded, the softening of 
the coats of the stomach may, however, be accounted for in 
another way; namely, by supposing that an impediment existed 
to the free action of the muscular fibres, so that the stomach 
could not be completely emptied, and that the acid thus remain- 
ing in the stomach after digestion was over, dissolved its coats 
after death. 
Softening of the stomach, which maybe satisfactorily accounted 
for in this way, is now and then found in conjunction with cancer 
of the pylorus, and in some cases of simple ulcer of the stomach, 
when the ulcer is near the pylorus, or when it is of long stand- 
ing and partially cicatrized, so that it has altered the shape of 
the stomach and prevents the proper action of the muscular 
fibres. 
The explanation applies also to those cases of phthisis in which 
the stomach is found much enlarged as well as softened. It was 
particularly remarked by M. Louis, and has been long known, 
that the stomach often becomes much enlarged in the course of 
phthisis, being not unfrequently found after death three or four 
times its usual size. No satisfactory explanation of this enlarge- 36 
SELF-DIGESTION 
ment of the stomach has, that I am aware of, been jet given. 
M. Lords ascribes it to the frequent cough; but, if it were so pro- 
duced, it would be observed in conjunction with mere chronic 
catarrh as frequently as with phthisis. The real cause of it is, 
I believe, enlargement of the liver from fatty degeneration, which 
always exists in those cases of phthisis in which the stomach is 
found much enlarged after death. The large liver compresses 
the pyloric division of the stomach, and prevents the stomach 
from bring emptied through the pylorus by the wasted and 
weakened muscular fibres. When this happens, some of the acid 
products of digestion must remain in the stomach, and may be 
the cause of the softening of its coats found after death. 
In many cases of phthisis, and in most of the cases of other 
diseases in which the stomach is found softened, the change can- 
not be thus explained, and can only be accounted for by the 
supposition I have before advanced. 
I have hitherto described the most common form of softening 
by the gastric juice; namely, where the great end of the stom- 
ach and the lower and back part of the oesophagus—parts on 
which the gastric juice usually lodges after death—are the parts 
softened. But, occasionally, softening of the same kind occurs 
in other situations. Cruveilhier remarked that the' gelatiniform 
softening is sometimes found on the anterior wall of the stomach, 
when the stomach is empty, and when there is no softening on 
the posterior wall or in the great end, where the softening or 
digestion after death usually takes place; and that in some 
instances the same kind of softening occurs also in the intes- 
tines ; and he considers these facts conclusive evidence that the 
softening could not in such cases be the effect of the gastric 
juice, and that it must have resulted from disease, and during 
life. lie says—•“ The gelatiniform softening is generally met 
with in the splenic end of the stomach; but it occurs also in its 
anterior wall, and in various parts of the small and of the large 
intestine, and in the lower end of the oesophagus. The softening 
always proceeds from within outwards, and in the intestines, as 
in the stomach, may lead to perforation. The parts thus trans- 
formed are colourless, transparent, completely deprived of 
vessels, and of a sour smell, without any marks of inflammation, OF THE STOMACH. 
and without the odour of gangrene. The softened parts, indeed, 
Undergo putrefaction less readily than others.” This kind 
of softening, he adds, occurs occasionally in adults, but it is 
much more common in infants. 
Soon after the publication of Hunter’s paper, by which the 
attention of the profession was first called to the digestion of the 
stomach after death, instances of this kind were noticed ; and in 
the sixth yoI. of the “Edinburgh Medical and Surgical Jour- 
nal,” there is a paper by Mr. Adam Burns, containing observa- 
tions exactly like those of Cruveilhier, Burns met with three 
cases in which the fore part of the stomach was dissolved; and 
four cases (apparently including these three) in which every part 
of the alimentary canal, from the cardiac orifice of the stomach 
to the beginning of the rectum, was dissolved into a pulpy, glu- 
tinous mass, transparent, and bearing some resemblance to thick 
starch. Not a single point of either the stomach or intestinal 
tube but was so much acted upon, that it tore whenever it was 
even gently touched. The other viscera presented no peculiar 
changes. The subjects were young children, fat, and free from 
putrefaction. In all of them the abdomen, when opened, emit- 
ted a sour smell. Burns did not know the history of these per- 
sons, and could tell nothing of their condition during life. 
As in instances like those I have just cited, the softening oc- 
curs in parts with which the gastric juice does not generally 
come into contact, the question naturally arises—may not the soft- 
ening in such instances have been brought about in some other 
way ? It is important to bear in mind that ordinary putrefac- 
tion does not produce these effects. The changes which putre- 
faction causes in the firmness and texture of the mucous mem- 
brane of the stomach occur very slowly. For several days after 
death, when most of the viscera are softened by putrefaction, the 
mucous membrane of the stomach often retains almost the firm- 
ness which it had at the time of death. Gas forms in the sub- 
mucous cellular tissue, causing an emphysematous condition of 
the coats of the stomach; the blood decomposes, and filters 
through the vessels, and stains its different coats ; the stomach 
becomes further discoloured by the gases that permeate its tis- 
sues ; but the mucous membrane retains its firmness, sometimes, SELF-DIGESTION 
as was observed by Andral, for eight or ten days after death. 
From this the inference may be drawn that unnatural softness of 
the mucous membrane of the stomach cannot be ascribed to ordi- 
nary putrefaction unless many days have elapsed since death, or 
uidess putrefaction has far advanced in other parts of the body. 
But, setting putrefaction aside, might not the softening of the 
stomach and intestines have occurred during life, from defective 
nutrition, or so.me other morbid process ? The stomach and in- 
testines, it is expressly stated by both Cruveilhier and Burns, 
exhibited no traces of inflammation; and the same remark has 
been made by other pathologists who have described similar ap- 
pearances in these organs ; but we not unfrequently find soften- 
ing of other tissues, occurring from some obscure fault of nutri- 
tion, without any process to which the term inflammation can 
be rightly applied. This sometimes happens, in organs that are 
much exercised, from mere defective nourishment. The more 
an organ is exercised, the greater is the waste of its constituents, 
and the sooner, therefore, it suffers, when, from defective supply 
of food or from any fault in the assimilating processes, the repair 
of its waste is prevented. 
The cornea, from being of delicate texture and much exposed, 
suffers from defective nourishment, and becomes ulcerated, when 
firmer and more protected and more vascular tissues, into the 
composition of which nearly the same elements enter, present no 
such marks of destruction. The muscles of the heart are in con- 
tinual action, and in low fevers (in which the fibrine of the blood 
becomes much diminished, and the nutrition of the muscles is 
prevented) they undergo a softening that does not occur in the 
voluntary muscles, which, from the commencement of these fe- 
vers, are in comparative repose. But in the secreting glands, 
which have many points in common with the mucous mem- 
branes, as regards both structure and function, a similar soften- 
ing is now and then met with, without any trace of inflammation, 
the result, seemingly, of some obscure defect of nutrition. 
A change of this kind is occasionally met with in the liver, in 
those cases of jaundice that prove fatal speedily from disorder 
of the functions of the brain. All the tissues of the liver, in 
certain parts of the organ, are found softened, or disorganized; OF THE STOMACH. 
and in these parts, on microscopic examination, none of the 
hepatic cells, which serve to secrete the bile, can be seen. 
The question, then, very naturally arises,—Might not the 
softening of the stomach and intestines in the cases to which I 
have referred, have resulted from some obscure fault of nutri- 
tion ? A consideration of the particulars of these cases will, I 
think, show conclusively that it did not so originate, but that, 
as in the ordinary cases of stomach digestion, the change occur- 
red after death, and was the effect of a chemical solvent. 
Cruveilhier has given the particulars of a case in which he 
found the fore part of the stomach softened, and a drawing, rep- 
resenting the appearance of the stomach in question. The person 
in whom this occurred was a man-servant, twenty-two years of 
age, who died of fever, in the latter stages of which there was 
severe disorder of the brain. The stomach was found empty, 
and was only softened in this spot on its anterior surface. The 
mucous and muscular coats were here destroyed and removed, 
so that perforation was only prevented by the peritoneum, which 
was spread as a thin gauze over the part. 
But there is another circumstance noticed by Cruveilhier, 
which to my mind is quite conclusive that the softening resulted 
from the gastric juice after death. In the lower and back part 
of the oesophagus there were two perforations leading into the 
left pleural sac, just as are found occasionally in conjunction 
with softening of the great end of the stomach in persons killed 
by an accident, in the midst of health, and soon after a meal; 
and, as happens in these latter cases, the edges of the perfora- 
tions were soft and ragged, and the bloodvessels surrounding 
them were of a jet blade. Cruveilhier notices, moreover, that at 
a spot corresponding to these apertures, the pleura covering the 
rung had also undergone the gelatiniform softening, and that the 
tissue of the lung was laid bare; and with all this, he expressly 
states, there were no marks of inflammation, either in the pleura 
or in the lung. 
But if any doubt still remains of the nature of these changes, 
it will be removed by a case, which I will next cite, recorded 
by Adam Burns in the paper to which I have already referred. 40 
SELF-DIGESTION 
The following are the particulars of the case, as given by 
Burns:— 
“About ten months ago, I had occasion, two days after death, 
to open the body of a very emaciated and anasarcous young 
girl, who had died from scrofulous enlargement of the mesen- 
teric glands. On raising the coverings of the abdomen, the 
stomach, which was empty, presented itself to view, with its 
front dissolved. The aperture was of an oblong .shape, about 
two inches in its long diameter, and an inch in its short, with 
tender, flocculent, and pulpy edges. This I demonstrated to 
the pupils attending my class; and I especially called their 
attention to the fact, that the liver, which was in contact with 
the hole, had no impression made on it. Having proceeded 
thus far, I placed all the parts as they had been, stitched up the 
abdomen, and laid the body aside in a cold situation for two 
days. Then I opened it again, in presence of the same gentle- 
men, and we found that now the liver, where it lay over the 
dissolved part of the stomach, was pulpy; its peritoneal coat 
was completely dissolved, and its substance was tender to a con- 
siderable depth. At this time the other parts of the liver were 
equally solid as before ; and as yet every part of the subject was 
free from putrefaction. The posterior face of the stomach, oppo- 
posite to the hole, was dissolved, all except the peritoneal coat; 
at least, the internal coats were rendered pulpy and glutinous.” 
“ The dissolved part,” he goes on to observe, “ was seated at the 
fore part of the stomach, about an inch distant from the pylorus, 
and midway between the smaller and greater curvatures of this 
viscus, at a part of the stomach with which the gastric juice 
could not have come into contact, as the body had constantly 
been in the supine posture.” 
How, it will naturally be asked,—If the softening of the 
stomach in these cases was the effect of the gastric juice acting 
after death, how did it happen that the fore part of the stomach 
•was dissolved, while the hinder and lowermost parts, where 
fluids in the stomach tend to collect, were not dissolved ? 
The following is, I have little doubt, the right explanation of 
the fact. In the case related by Cruveilhier, the stomach is 41 
OF THE STOMACH. 
stated to have been empty; that is, its surface was moistened 
merely by the gastric juice. Now the man died of fever, and, as 
happens in the severe forms of this disease, the blood, we may 
infer, was unusually fluid after death, and gravitated to the low- 
ermost parts of the stomach; and the transudation of the alka- 
line serum of the blood through the coats of the vessels in these 
parts neutralized the acid of the small quantity of gastric juice 
contained therein, and destroyed its solvent power. 
In Burns’s case, the fact that the stomach was softened in its 
fore part only, may be explained in the same way. The 
stomach, here also, was empty, and the girl was dropsical. The 
alkaline dropsical fluid, transuding through the coats of the 
stomach at its hinder or lowermost part, neutralized the acid of 
the small quantity of gastric juice that moistened its coats, and 
prevented any digestive action from taking place there. 
It may be predicted with tolerable safety that it will be only 
in such cases, and where the stomach is empty, that softening of 
the upper or fore part will occur, without there being at the 
same time softening of the lower and hinder parts. 
If it be established by the circumstances I have mentioned 
that the softening of the stomach in these cases was the effect of 
the gastric juice after death, the presumption is very strong that 
the so-called gelatiniform softening of the intestines, which is 
met with in the same 'class of cases as the softening of the 
stomach, and very generally (as seems to have happened in three 
of the cases related by Burns) in the same persons ;—the pre- 
sumption, I say, is very strong that the softening of the intes- 
tines is of the same nature, and produced by the same agent. 
But, without reference to the stomach or to the circumstances 
m which the softening occurs, and considering merely the char- 
acters of the change in the intestines, we are led to the same 
conclusion. 
The change, like that produced by the gastric juice, affects the 
different coats of the bowel in succession, from within outwards, 
leading at length to perforation. 
The decomposition, like that in digestion, is unattended by 
evolution of gas. 
The parts softened, when they did not contain much blood at 42 
SELF-DIGESTION 
the time of death, have a semi-transparency, or a gelatinous 
appearance, like albuminous tissues in process of softening by 
the gastric juice. 
Again, from the observations of Burns, we may infer that the 
change in question, like digestion of the stomach after death, is 
most common in summer. Burns, indeed, tells us that he never 
met with it except in the summer months. 
Digestion after death requires the presence of a free acid, and, 
as digestion goes on, the acidity of the gastric fluids increases. 
Now, both Cruveilhier and Burns particularly remarked, and 
their observations appear to be quite independent, that the 
softened intestines in the cases in question had a sour smell. 
Another very important property of the gastric juice is, that 
it prevents putrefaction. Now it is stated by Cruveilhier, and 
the same may be inferred from the remarks of Burns, that the 
softened parts had no odour of gangrene. Cruveilhier expressly 
says, indeed, that they undergo putrefaction less readily than 
others. 
All the circumstances I have mentioned—the circmstances, 
namely, that the softening of the coats of the intestines occurs 
in the same class of cases, and sometimes in the same person, as 
softening of the stomach; that it occurs especially in summer; 
that it involves the different coats of the bowels in succession, 
from within outwards; that it is unattended by the evolution of 
gas; that the softened tissues have a semi-transparency, and a 
sour smell; and that they exhibit no marks of inflammation, 
and are free from any odour of gangrene:—all these circumstances 
leave, I think, no doubt that the change in question is a diges- 
tion of the tissues, and that it occurs after death. 
The softening of the intestines is most commonly found in in- 
fants who have died of hydrocephalus, or of tuberculous disease 
of the lung, or with functional disorder of the brain; and in 
whom, together with the peculiar gastric disorder that so often 
exists in the cases in which softening of the stomach is found, 
there has been severe diarrhoea, with green, spinach-like stools: 
the green colour being the effect of uncombined acid on the bile. 
Softening of the intestines, like softening of the stomach, is 
also found occasionally in grown-up persons who have died of OF THE STOMACH. 
43 
phthisis, or of typhoid fever; especially where diarrhoea has 
existed, with the peculiar gastric symptoms to which I have so 
often referred. 
There can be little doubt that in the cases in which this hap- 
pens the gastric juice passes, in its active state, from the stomach 
into the intestines; and that not meeting there with alkali enough 
to neutralize its acid, and thus destroy its solvent powers, it dis- 
solves or digests the coats of the intestine after death. 
The result, then, at which I arrive is, that the softening, with 
thinness, of the coats of the alimentary canal, described by Louis, 
the pasty or pulpy and the gelatiniform softening of Cruveilhier, 
and the other varieties, described by other authors, distinguished 
by the color of the softened tissues, are essentially the same 
change; and that this change, whether it exists in the lower end 
of the oesophagus, or in the great end of the stomach, or in the 
fore part of the stomach only, or in any part of the small or the 
large intestine, is the result of digestion after death,* like the 
softening of the great end of the stomach, remarked by Hunter, 
that occurs after sudden and violent death, in the midst of health, 
and soon after a meal. 
I have occupied much of your time in considering the change, 
because I consider the subject is one of great importance. It is 
obviously important with reference to medico-legal inquiries; 
and it is important, also, with reference to the attainment of a 
right knowledge of the pathology of the digestive organs. Every 
one who has studied the diseases of these organs by means of 
morbid anatomy must have had his mind perplexed, as mine has 
often been, and his progress stayed, by the continually recurring 
question, What do these striking changes mean ? 
But the subject is important, too, with immediate reference to 
practice, because the study of it leads us to a more intimate 
knowledge of a peculiar form of indigestion, which is of frequent 
occurrence. In the class of cases, indeed, in which this form of 
softening of the stomach and intestines is found after death, there 
generally exists for some time previous to death a peculiar form 
* The intestines are probably sometimes digested by their own proper juices, 
which, although alkaline, have been lately found to possess, like the gastric 
juice, a digestive power over albuminous tissues. SELF-DIGESTION. 
of indigestion, attended with various distressing symptoms re- 
ferable to the stomach and bowels,—the result mainly of the 
presence of free, nncombined digestive acid in them; and the 
efficacy of liquor potass* and other alkalies in relieving this 
gastric disorder, and the like efficacy of chalk mixture (which 
furnishes an insoluble antacid which is not absorbed in the 
stomach, but passes down into the intestines,) in relieving the 
diarrhoea and the griping pain that attends it;—the efficacy of 
these medicines results from their neutralizing this acid, and thus 
preventing the gastric juice, which loses its solvent power when 
thus neutralized, from exerting any chemical action on the 
tissues or calling for the expenditure of their vital force of 
resistance. LECTURE 111. 
The organic diseases and functional disorders of the stomach—Arrange- 
ment of the subject—Congestion of the stomach resulting from an im- 
pediment to the course of the blood through the liver or the chest—Con- 
gestion resulting from other causes. 
In passing under review the disorders of the stomach, I shall 
speak first of those which depend on organic disease, or on some 
visible or palpable change in the coats of the stomach; and 
afterwards of those, the so-called functional disorders, which re- 
sult from derangement of the general health, or from disease 
originating in some other part of the body. 
Of organic changes in the coats of the stomach, one of the 
simplest is congestion—that is, a plethora of the bloodvessels— 
which is a very common morbid condition, and a very import- 
ant one with reference to the medical treatment of various dis- 
eases. 
Congestion of the stomach, as of the other organs which have 
an active function, may result from very different conditions. 
A congestion, or oyer-fulness of the bloodvessels of the stomach, 
may obviously result from any mechanical impediment to the 
return of blood from the stomach to the heart. The congestion 
thus arising is of the simplest kind—the kind most intelligible 
to us—and we may, therefore, fitly consider its effects first. 
A striking instance, showing some of these effects, is recorded 
m an admirable paper on this subject by Dr. Yellowly, in the 
fourth volume of the “ Medico-Chirurgical Transactions.” 
Philip Nicholson, a man about thirty years of age, was hanged 
on Penenden Heath, near Maidstone, on the 28rd of August, 
1813. He was greatly convulsed while hanging, and died unu- 
sually hard. The body was opened the following day at three 46 
CONGESTION 
o’clock in presence of Dr. Yellowly, who thus describes the state 
of the stomach; 
“The whole of the abdominal viscera were deeply congested 
with dark-colored blood. 
“ The external vessels of the stomach were very turgid, and 
its inner surface was everywhere coated by dark-colored, clotted 
blood. This adhered pretty firmly to the mucous membrane, 
but came off, though with some difficulty, when the stomach was 
put into water. Much of it, however, continued to hang about 
the folds in the great end, though the other parts were freed. 
When the blood was washed off, the whole surface of the mucous 
coat was red.” 
In this instance, great congestion of the stomach was rapidly 
brought on by strangulation; and its most striking effects, as 
seen in the dead body, were uniform redness of the mucous 
membrane and the extravasation of clotted blood upon it. This 
clotted blood coated the whole inner surface of the stomach, and 
adhered firmly to it, and had evidently escaped, not at one spot 
from a large ruptured vessel, but by exhalation from every part 
of the free surface of the membrane. 
A near approach to the sudden strangulation which the hang- 
man inflicts is presented to us in severe epileptic fits, which are 
not unfrequently followed by vomiting of blood and by the dis- 
charge of blackened and altered blood from the bowel. To take 
one instance among several such which my hospital case-books 
contain;—On the 18th of November, 1854, Joseph Parish, a 
well-nourished man, thirty-six years of age, was admitted into 
the hospital with partial paralysis of the left arm and leg and of 
the right side of the face, which occurred during a severe epilep- 
tic fit a fortnight before. His appetite and digestion were good, 
and there wTas no symptom to indicate that anything was amiss 
with the stomach. On the 30th of November, about eight in the 
evening, he was seized with another epileptic paroxysm, in 
which rigid contraction of the muscles of one side alternated with 
terrible convulsions, “ as if,” to use the words of the physician’s 
assistant, “ powerful electric currents were being passed through 
the different portions of the frame.” During the convulsions, 
the face and neck became highly congested, and every now and OF THE STOMACH. 
47 
tlien a good deal of frothy saliva was forced from the mouth. 
The convulsions were at times succeeded by a state of profound 
stertor, which continued three or four minutes, when the convul- 
sions would recur again. 
The epileptic paroxysm lasted nearly four hours, when the 
convulsions entirely ceased, and soon after this, a faint gleam of 
intelligence beginning to dawn, he was seized with vomiting, 
and threw up about half a pint of dark brown, almost black, 
coffee-ground-looking matter, which owed its colour, as the 
microscope showed, to the presence of altered blood. The fol- 
lowing night, when the bowels moved for the first time after the 
fit, the discharges from them were reported to be black, like 
pitch. The vomiting did not recur. 
The day after the fit he was very much exhausted, but quite 
conscious, and answered pretty readily questions addressed to 
him. He expressed himself as not desiring food, but feeling 
very thirsty. He was placed on milk diet, and desired nothing 
more till the sth of December, five days after the occurrence of 
the fit, when the appetite for meat and the power to digest it 
returned. On the Bth of December, and for some days after- 
wards, the appetite was ravenous, and the meat diet of the hos- 
pital appeared to be digested with ease. 
On the 14th of January, he was again seized with horrible 
epileptic convulsions, during which he vomited blackened and 
altered blood, as on the 30th of November. The convulsions 
lasted many hours, and were succeeded by a state of coma, in 
which he died at 7A. M., on the 15th, When the body was 
opened, there were found scattered over the surface of the brain 
a great number of small cysts containing the cysticercus ccllu- 
losa, which were doubtless the cause of the epileptic convulsions. 
The stomach contained from two to three ounces of a dark 
grumous fluid like that vomited during the fits. On washing it, 
a dark ecchymosed patch was found near the lesser curvature, 
but no sign of ulceration was anywhere to be detected. In this 
instance the blood was vomited in minute shreds or flakes, 
because it oozed drop by drop, and coagulated as it oozed, from 
the open surface of the mucous membrane. The appetite and 
the power of digestion quickly returned, after the vomiting of 48 
CONGESTION 
blood on the SOtli of November, because no great injury was 
done to the membrane. 
Congestion of the stomach of the same kind, but more gradual 
in its occurrence, and generally less in degree, always exists in 
persons with the “ hob-nail,” or gin-drinker’s liver. In this dis- 
ease, the current of blood through the liver is impeded, and the 
stomach and intestines, which send all their blood to the portal 
vein, are consequently kept in a state of congestion. This fre- 
quently leads to an oozing of blood from the mucous membrane, 
and it now and then happens that the haemorrhage is abundant, 
so that a great quantity of blood is brought up by vomiting, I 
have met with several instances of cirrhosis, in which death 
was caused, or at least was very much hastened, by haemorrhage 
from this source, and in which the sound state of the stomach 
after death showed that the blood had exhaled from the unbroken 
surface of the mucous membrane. An abundant hremorrhage 
is, however, comparatively rare. The congestion is slowly pro- 
duced, and the minute vessels most probably grow gradually 
stronger, so as to bear the additional stress upon them. Far 
more commonly, the oozing of blood is slight in degree, but in a}' 
continue for many days, or even weeks. During this time the 
patient has constant pain at the epigastrium, and may vomit 
daily a small quantity of blackened blood, which is generally 
mixed with mucus, or is in very small distinct coagula, that 
consist of the colouring matter of the blood, and also of its albu- 
men, which is coagulated as it exudes from the vessels by the 
acid secretions of the stomach. Occasionally, the stools also are 
stained with blood, which may have come from the stomach or 
from some part of the bowel itself. 
But it often happens in such cases that the extravasated blood 
passes out of the body unnoticed. Too little is poured out at a 
time to cause vomiting. It is voided, therefore, by the bowels, 
and in its passage through them gets mixed with other matters, 
and is, besides, so much altered that it is no longer recognised as 
blood. 
The same thing may happen in organic diseases of the heart, 
and in diseases of the lung, where the passage of the blood 
through the chest is much impeded. In consequence of the im- OF THE STOMACH. 
49 
pediment to the onward course of the blood the stomach is kept 
in a state of congestion, and an oozing of blood from its mucous 
niembrane now and then takes place. The blood extravasated 
at any one time is generally so small in quantity that it does not 
excite vomiting, and may thus pass out of the body unnoticed. 
Now and then, however, especially where the impediment to 
the*circulation attains a high degree in a person not reduced by 
previous illness, the haemorrhage is abundant and blood is 
brought up in large quantities by vomiting. A few years ago 
I witnessed profuse vomiting of blood, clearly brought on in 
this way, in a young man who was dying of rheumatic peri- 
carditis, and who had for some days been suffering from the 
distressing fits of suffocation which largo effusion into the peri- 
cardium occasions. 
In the spring of the present year the same thing happened 
in a poor girl, seventeen years of age, named Emma Garrett, 
who died in King’s College Hospital of valvular disease of the 
heart, the result of rheumatic fever which she had twelve 
months before. She was brought into the hospital on the 4th 
of November, 1851, suffering much from pain at the prsecordia, 
palpitation, and difficulty of breathing. On examination it was 
found that the heart was much enlarged, and that there wras a 
systolic bellows-sound, which was loudest at the apex of the 
heart and along its left edge and on the left side of the chest 
behind—indicating a backward current of the blood through the 
mitral orifice. On the 27th of November, acute pericarditis 
came on, and a “ to-and fro” sound was heard. Erom this time 
the breathing was much embarrassed, and there was constant 
catarrh, and now and then, for a time, solidification of the lower 
lobe of one of the lungs. 
On the 2nd of March, she began to spit blood, and continued 
to do so until her death, which happened on the morning of the 
9th. For two days before her death she had repeated vomiting 
of blood, which was clearly effused in consequence of the con- 
gestion of the stomach produced by the great impediment to the 
passage of the blood through the chest; for when the body was 
examined after death no ulcer, or even abrasion, of the mucous 
membrane of the stomach was found. 50 
CONGESTION 
Thus, when congestion of the stomach arises from hindrance 
to the return of its venous blood, whether the impediment be in 
the liver or in the chest, one of its most striking effects is an 
oozing of blood from the free surface of the mucous membrane. 
When the blood is poured out in large quantity it causes sick- 
ness and is thrown up—or most of it is thrown up—by vomit- 
ing. When it is poured out little at a time, it passes through 
the bowels, and is frequently, perhaps generally, unnoticed. 
The effects of congestion of the stomach are, however, some- 
what different, as I have already hinted, according to the cir- 
cumstances under which it occurs. When a great impediment 
to the passage of the blood through the liver or the chest is 
created rapidly, it is much more apt to cause haemorrhage from 
the stomach than when it is created gradually and slowly— 
doubtless because in the latter case the bloodvessels of the 
stomach grow stronger, so as to better bear the additional stress 
upon them, which they must do by virtue of the power which 
bloodvessels everywhere have of becoming hypertrophied readily 
—that is, of growing rapidly stronger, or larger—when by an 
altered condition of the circulation, tubes of greater strength or 
volume are required. 
An impediment to the passage of blood through the liver or 
the chest, if it be created rapidly, usually causes haemorrhage 
from the stomach before it causes ascites : an equal impediment 
created slowly, causes ascites before it causes haemorrhage. 
It has long been remarked, that mucous membranes are the 
only tissues in which blood escapes readily from the vessels. 
Haemorrhage never occurs in consequence of mere congestion, 
however it be brought on, in the serous or in the synovial mem- 
branes ; hardly ever in the brain, in the substance of the liver, 
or in some other of the viscera. 
The different mucous membranes vary much in their liability 
to haemorrhage from congestion. As a general rule, the liability 
to haemorrhage is greater the more active the function of the 
membrane. Some mucous membranes, as those of the oesophagus, 
the urethra, the urinary bladder, serve as a mere lining, and are 
little disposed to bleed, except from some direct injury done to 
their surface. Others, as those of the stomach, of the intestines, OF THE STOMACH. 
of the uterus, which, having a more active function and furnish- 
ing abundant secretions, are naturally more vascular, bleed readily 
from mere passive congestion or fulness of their vessels. 
No tissue in the body is so prone to haemorrhage at all times 
and at all ages as the mucous membrane of the stomach. But, 
in all mucous membranes alike, it is only on the free surface of 
the membrane that the blood escapes in any quantity. In cases 
of the gin-drinker’s liver, where blood has been oozing almost 
constantly for several days, or even weeks, from the open surface 
of the membrane, hardly a drop filters into the cellular tissue 
beneath; and after death the stomach often exhibits no stain or' 
trace of the haemorrhage of which it had been lately the seat. 
It has not yet, that I know of, been shown what is the peculi- 
arity of structure in mucous membranes that allows the ready 
issue of blood from their vessels; or why it is that the blood issues 
only on the open surface of the membrane—why it is not poured 
out also on its under surface, so as to collect in the loose cellular 
tissue in which the vessels run. 
Late researches on those structures have shown that mucous 
membranes consist of a layer of epithelium spread like a pave- 
ment on a thin and structureless membrane, which serves to sup- 
port it; and that the blood-vessels run and ramify in the cellular 
tissue behind. From this it might have been expected that blood 
would be more apt to filter into the cellular tissue between the 
coats of the stomach than to exude from the open surface of the 
mucous membrane. 
The cause of the blood’s escaping only on the open surface of 
the membrane is clearly some mechanical condition. However 
the congestion be brought on, whether it be by impediment to 
the return of blood from the stomach or not, it is only on the 
open surface of the mucous membrane that the blood issues in 
any quantity. Again, if the stomach be injected with coloured 
size in the dead body, the size will ooze readily from the open 
surface of the mucous membrane, but seldom gets extravasated 
m any quantity on its under or attached surface, so as to collect 
between the mucous membrane and the coats beneath. 
Another circumstance of much interest and importance is, 
that although mucous membranes, and that of the stomach in 52 
GENERAL EFFECTS 
particular, allow blood to issue readily from them, they do not, 
in states of mere congestion, however brought on, allow the 
serum of the blood, or the w'ater of the blood, to escape without 
the red corpuscles. 
In examining the bodies of men who have died with the gin- 
drinker’s liver, I have often been surprised that while the belly 
was enormously distended by a dropsical fluid in the peritoneal 
sac, and while the coats, even of the intestines, or of some parts 
of them, were oedematous, there should have been no flux, no 
drain of fluids from the bowel itself, beyond the scanty oozing of 
blood of which I have already spoken. 
When the stomach and intestines are long kept in a state of 
congestion from a bar to the passage of the blood through the 
liver or the chest, the nutrition of the mucous membrane is less 
active than in health, its peculiar and solvent juices are more 
sparingly secreted, and, in consequence, digestion is slower and 
more feeble; and unless an inflammatory condition of their 
lining membrane be caused by the irritation of imperfectly 
digested food, the bow'els are apt to be costive. 
Analogous effects are produced by a state of passive conges- 
tion in every other organ. The unnatural fulness of the vessels, 
and the slowness of the current through them, lessen the activity 
of the nutritive processes, limit the supply of oxygen which is 
essential to the development of every living force, and thus 
diminish the power of the organ, of whatever kind that power 
may be. 
If, from organic disease of the heart, the brain be kept in a 
state of congestion, the evolution of the nervous force is hin- 
dered—the feelings and sensations are blunted, the will is less 
energetic, the muscular movements are less vigorous and precise, 
and the intellectual power is diminished—and all this to a 
certain extent independently of the increased pressure on the 
nervous substance which a state of congestion occasions. 
Again, if the vessels of the lungs be kept congested, dropsical 
fluid may collect in the sac of the pleura, or even in the spongy 
tissue of the lung itself, which will, of course, clog the lung and 
shorten, the breath; but, quite independently of this, the mere 
state of congestion the distension, that is, of the capillary ves- OF CONGESTION. 
sels and tlie slowness of the current through them—hinders the 
proper function of the lung, lessens the absorption of oxygen 
and the exhalation of carbonic acid, and, if the congestion be 
great, causes distress, or difficulty, in breathing. 
So, again, if the kidney be kept in a state of congestion, some 
of the albumen and of the red corpuscles of the blood may 
escape with the urine; but the excretion of water and of the 
proper saline constituents of the urine is diminished. 
Analogous effects are produced in the muscles. In cases of 
organic disease of the heart, where the current of blood through 
the chest is greatly impeded, the muscles are inadequately 
nourished, and, in consequence, they soon tire and only slowly 
recover their fatigue. If the congestion be long kept up, the 
muscles waste. In diseases of the heart the blood returns less 
freely from the legs than from other parts, and when the oedema 
of the legs, which is so common in these diseases, goes off for a 
time, the muscles are always found flabby and small, much more 
shrunk than the muscles of the arms and of other parts of the 
body. 
The effect of impeded circulation in everywhere hindering 
the processes of nutrition, is, perhaps, best seen when disease of 
the valves of the heart comes on in childhood. 
From that time, if the disease should much impede the course 
of the blood through the chest, the child is checked in its growth 
and dwarfed, and the age of puberty is much deferred. 
It is then in accordance with a general law, that when the 
stomach is kept in a state of passive congestion from a bar to 
the current of the blood through the liver or the chest, the 
secretion of the gastric juice is diminished, the stomach can 
digest less food, and requires longer intervals of rest.* 
It is another fundamental effect of these conditions, that, in 
the same measure in which the proper nutrition of the texture 
* Recent researches have led to the inference that the amount of the gastric 
juice, and therefore the amount of materials needed for its supply, is much 
greater than has been hitherto imagined. Lehmann estimates that not less 
than four pounds of gastric juice is secreted daily by a man in health. 
■—Lehmann’s “Physiological Chemistry.” Translation by Dr. Day, vol. ii. 
p. 53, 54 
GENERAL EFFECTS 
is hindered, is its power enfeebled to resist an injurious influence 
of any kind. 
If, under these circumstances, food is taken which is difficult 
of digestion or more food is taken than the stomach can master, 
some of it remains long undigested in the stomach, and irritates, 
and at length inflames the mucous membrane. The congestion 
of the stomach is thus increased; the afflux of blood and the 
more complex changes caused by inflammation are added to the 
pre-existing passive congestion; and the digestive power, if not 
entirely suspended, is rendered very much weaker than it was 
before. 
Again, if alcoholic drinks be taken in undue quantity, as they 
often are in the hope of supporting the strength, or if irritating 
medicines be given, they are only slowly absorbed into the 
general circulation, and are thus especially apt to exert an injuri- 
ous action on the coats of the stomach itself. 
In the treatment of all diseases which cause much impediment 
to the passage of the blood through the liver or the chest, it is 
very important that the congestion of the stomach and the feeble- 
ness of digestion that necessarily results from it should be borne 
in mind. The congestion of the stomach is, indeed, secondary, 
and is relieved by whatever lessens the impediment to the circu- 
lation on which it depends; but, while it lasts, both food and 
physic should be regulated with reference to it. A sparing and 
easily digestible diet, and, when the nervous system can bear it, 
total abstinence from fermented drinks, is the regimen best 
suited to such cases. When alcohol is necessary, it should be 
given sufficiently diluted; and when mercury and diuretics are 
deemed expedient for the object of relieving the embarrassed 
circulation, their action on the stomach should be carefully 
watched. 
Unless, indeed, the diet be properly regulated and care be 
taken not to fret the stomach by irritating drugs, a persistent 
congestion of the stomach leads to an inflammatory condition of 
its mucous membrane almost as surely as a persistent congestion 
of the lung leads to bronchitis. 
Hitherto I have spoken only of the simplest kind of conges- OF CONGESTION. 
55 
tion—the mere turgescence of the vessels of the stomach, which 
results from a mechanical impediment to the passage of the blood 
through the liver or the chest. But a plethora, or fulness of the 
vessels, may result from very different conditions. The purpose 
of the blood is to supply materials for the nutrition of the vari- 
ous tissues of the body and for those secretions by which the 
purity of the blood itself is maintained; and the quantity of 
blood which flows to any part, and the freedom with which the 
stream traverses its capillary vessels, depend very much on the 
affinity or mutual action between the elements of the part and 
the blood. The natural affinity between the blood and the 
tissues, (varying in degree according to the state of action or 
repose,) which is requisite for healthy nutrition, may be modi- 
fied, and the circulation, in consequence, deranged by changes 
originating either in the tissues or in the blood. Thus, when 
inflammation of the mucous membrane of the stomach is set up 
by undigested or irritating food, or when any other injury is done 
to it which nature has to repair, more blood flows to the 
stomach, and more is retained in its vessels, while the inflamma- 
tion or the reparative process exists. So again, if the coats of 
the stomach be the seat of a cancer, the wonderful powers of 
growth in the new tissues draw an additional quantity of blood 
to the stomach and cause an unnatural fulness of its vessels. 
After a time, indeed, in consequence of the increase in the 
volume of the current, the arteries and veins which serve as its 
channel grow larger. 
The congestion of the stomach that results from inflammation, 
or from the growth of a cancer, or from other structural changes, 
will be considered when these several conditions come under our 
notice, and therefore need not detain us now. But, as I have just 
stated, congestion may originate not only in an unnatural condi- 
tion of the tissues which the blood nourishes, but also in an un- 
natural condition of the blood itself, A change in the relative 
proportion of the constituents of the blood, or the presence of 
some foreign matter in it, by changing the consistence of the 
blood and thus rendering its propulsion more difficult, or by 
modifying the chemical relation which naturally exists between 
the blood and the tissues, may cause the blood to pass less freely 56 
CONGESTION 
than natural through the capillary vessels, and so to accumulate 
in them. 
In every secreting organ, the circulation is especially modified 
by those unhealthy states of the blood which especially influence 
the secretion. The secreting organs are the outlets through 
which noxious or effete matters are removed from the body. 
Some matters are removed principally by one secreting organ, 
some by another. Every kind of matter is removed in greatest 
quantity by the organ which has the greatest affinity for it. The 
very act of secretion implies a special affinity between the secre- 
ting structure and those elements of the blood which go to form 
the secretion; and the exercise of this affinity, as a matter of 
necessity, influences the current of blood. Its first effect is to 
draw an increased quantity of blood to the part, to cause? an in- 
creased quantity to pass through it in a given time, and, generally, 
to render the nutrition of the part more active. If, however, the 
matter to be eliminated is more than the organ power to 
cast off, the blood is unduly detained there, the minute vessels 
of the organ become gorged, and all those effects ensue which 
result from the simpler kind of congestion we have before 
considered. 
The vascular plethora of the stomach, for example, that results 
from an unnatural condition of the blood, like the congestion that 
is caused by an impediment to the return of the venous blood, 
lessens the secretion of the gastric juice, renders the mucous mem- 
brane more disposed to be inflamed by the irritation of undigested 
or unwholesome food, and, if the congestion attain a certain de- 
gree, causes an oozing of blood from the open surface of the 
membrane. 
Yomiting of blood, especially when it is in small blackish 
coagula, which show that the blood escaped by oozing, and that 
it was coagulated before it had time to collect in a mass, is, per- 
haps, the most distinct and conclusive evidence of congestion of 
the coats of the stomach. 
There are probably many morbid states of the blood that lead 
to congestion of the stomach, and to the consequent exhalation 
of blood from the open surface of its mucous membrane. 
Haemorrhage from the stomach, arising in this way, now and OF THE STOMACH, 
57 
then occurs in women, from a stoppage of their monthly courses, 
A very striking instance of this is related by Dr. Watson, on 
the authority of Dr. Latham:—“A young woman became the 
subject of hasmatemesis, recurring at monthly periods, about the 
age of fourteen. She had never menstruated. This continued 
until she married, and in due time fell with child. Thereupon 
the Inematemesis ceased. She brought forth and suckled her 
infant. During lactation the haemorrhage did not recur. It 
came on again soon after she ceased to nurse the child, no re- 
gular menstruation by the uterus having ever happened. This 
was the woman’s own account, and there appeared no reason to 
question its accuracy.” 
Haemorrhage of the stomach, arising from suppressed men- 
struation, generally occurs, as it did in this instance, at the ap- 
pointed time, or near the appointed time, of the natural monthly 
discharge. While it lasts, the power of digestion is suspended, 
and the stomach is painful and tender. It was rightly remarked 
by Cullen, that this kind of gastric haemorrhage hardly ever 
proves fatal. The blood generally escapes by oozing from the 
open surface of the mucous membrane, and, when a certain 
quantity is lost, the system is relieved, as by natural menstrua- 
tion, and the disposition to haemorrhage ceases. 
Even when this vicarious haemorrhage takes place from an 
ulcer in the stomach, as I believe it not infrequently does, the 
blood does not issue from a vessel of considerable size laid open 
by the process of ulceration,—the usual source of haemorrhage 
in cases of the simple or perforating ulcer,—but oozes from the 
minute vessels of the raw surface. 
Haemorrhage vicarious of menstruation usually takes place 
from an ulcerated surface or from the open surface of those 
mucous membranes which are most disposed to bleed. It takes 
place more frequently from the mucous membrane of the stomach 
than from any other mucous membrane, because the mucous 
membrane of the stomach is frequently, like the mucous mem- 
brane of the uterus at the time of menstruation, the source of an 
abundant secretion, and, in adaptation to this more active secret- 
ing function, is more vascular and more readily allows an exu- 58 
CONGESTION” 
dation of blood from its surface than the mucous membrane in 
other parts. 
Yomiting of blood resulting from suppressed menstruation is 
distinguished from that which results from other causes, by its 
occurring at the time and in place of the natural menstrual dis- 
charge ; by the absence of other conditions, such as an impedi- 
ment to the passage of the blood through the liver or the chest, 
or great enlargement of the spleen, which are known to lead to 
congestion of the stomach; and, when the haemorrhage does not 
take place from an ulcer, by the circumstance that the disorder 
of the stomach is of short continuance—that the vomiting of 
blood is not long preceded, or long followed, by pain, vomiting, 
or other symptoms that denote organic disease of this organ. 
The means most effectual in arresting the vomiting of blood 
that results from suppressed menstruation, are—the abstraction 
of a small quantity of blood from the arm ; the application of a 
blister to the epigastrium; cold and slightly astringent drinks; 
unloading the bowels by a purgative injection; and complete 
abstinence from food. When the haemorrhage has ceased, the 
remedies most likely to prevent its recurrence, are'—some bitter 
astringent, to brace the coats of the stomach; sulphate of mag- 
nesia, or sorge other saline purgative, in sufficient quantity to 
promote a free action of the bowels, and thus to prevent the 
congestion of the stomach which a loaded state of the large intes- 
tine occasions; and, in conjunction with these remedies, the em- 
ployment of all available means which tend to promote the nat- 
ural monthly courses. 
In the various diseases which are attended with an abundant 
and morbid secretion from the coats of the stomach, whether 
this secretion results from a poisoned state of the blood or from 
a poison in the stomach irritating the surface of the mucous 
membrane, haemorrhage from the stomach not unfrequently 
takes place. 
In malignant cholera, for example, it sometimes happens that, 
after the discharges have continued some time and while they 
are still profuse, the matter ejected from the stomach, instead of 
having its usual appearance, which has caused it to be compared OF THE STOMACH. 
59 
to “ whey ” or “ rice-wrater,” is brown, or blackish, from the 
presence in the whey-like fluid of brown or black flakes, suffi- 
ciently numerous to impart their colour to the whole mass. 
When the matter is poured on a filter, the colourless liquid trans- 
udes, and the brown or black flakes are left on the filter. These 
brown or black flakes consist of minute coagula of blood, which 
has exuded from the mucous membrane of the stomach, and has 
been coagulated and blackened before it has had time to collect 
in a mass. In cases in which this black vomit occurs, the 
matter discharged from the bowels has often a reddish or plum, 
colour from the presence of blood which has exuded from the 
mucous membrane in some part of the small or large intestine, 
where it is not exposed to the action of an acid, and, conse- 
quently, is not clotted and blackened, as it is in the stomach. 
After death from cholera, the vessels of the stomach and intes- 
tines are found congested, and in those cases in which haemor- 
rhage has occurred some ecchymosed spots may usually be seen 
on the mucous membrane, marking, no doubt, the chief sources 
of the effused blood. 
It is very important, in the treatment of cholera, to consider 
the nature of the process of which the stomach is the seat. • The 
abundant flux from the mucous membrane, which results not 
from mere passive congestion, but from an active process of 
secretion ; the burning heat which is usually felt there; the 
craving for cold drinks; and the great vascularity of the stomach 
which may be seen after death—all speak the same language 
and forbid the use of alcoholic drinks and of acrid and stimulat- 
ing drugs, which have been often resorted to in cholera with the 
view of keeping up the temperature of the body and supporting 
the strength, but which, unless they have some specific action, 
must, by irritating the coats of the stomach, tend still further to 
increase the flux, and thus to hasten the collapse which they are 
given to prevent. 
In yellow fever, again, haemorrhage from the stomach (which 
appears to be the cause of the characteristic black vomit*) takes 
* Dr. Hassall has recently thrown doubt on the generally received opinion 
that “ the black vomit” of yellow fever owes its colour to the presence of blood. 
In a specimen which he examined under the microscope he found, among other 60 
CONGESTION 
place by oozing from the mucous membrane; and the blood, as 
it exudes, is blackened by the acid secretions with which it is 
mixed. It seems that in the yellow fever, as in cholera, the 
haemorrhage from the stomach is preceded by an abundant secre- 
tion from the mucous membrane. Sir William Pym, describing 
the symptoms of one of the forms of yellow fever, says:—“ In 
many cases, the patient in a few hours begins to be troubled 
with flatus of the stomach, and distressing hiccough, and is sud- 
denly and unexpectedly seized with faintness, sickness, and 
painful retchings, followed by vomiting at first of whatever had 
been taken as food or drink, and very soon after by a brownish 
fluid, resembling dirty water, mixed with a dark-coloured flaky 
matter, which floats upon its surface; and, at last, by a matter 
resembling coffee-grounds. . . . The quantity of fluid ejected, 
in most cases, wonderfully exceeds the quantity drunk; indeed, 
all the fluids in the body seem to be pouring into the cavity of 
the stomach; for when it has, to all appearance, been emptied 
several times, and the patient thinks himself relieved from any 
further painful straining, he is, in the course of a few minutes, 
without having tasted drink, under the necessity of again having 
recourse to the basin. The vomiting, in the latter hours of the 
disease, is attended with a peculiar loud and hollow noise, which 
is heard at a great distance, and is a most painful and distressing 
sound (particularly in camp) to those who are aware of the suf- 
ferings of the patient.” 
Every one who has had charge of a cholera hospital will be 
struck with the strong resemblance which the gastric disorder in 
some cases of cholera bears to that which is so graphically 
described in the preceding passage. 
Haemorrhage from the stomach, produced in the same way, 
occurs now and then, though very rarely, in the course of 
objects, a vast number of irregular bodies, frequently brown, and some- 
what resembling blood-discs, shrivelled and discolored, but insoluble in acetic 
acid. These bodies constituted the most peculiar matter of the “vomit.” 
From their insolubility in acetic acid, he thinks it improbable that they are 
altered blood-discs, and conjectures that they may be sporules of a fungus, 
and that they may be important agents in keeping up the vomiting.—Lancet, 
Feb, 12,1853.' OF THE STOMACH. 
61 
typhoid fever. In the month of July, 1853, a fatal case of this 
kind fell under my notice. A young man, twenty-one years of 
age, previously healthy, had been ill of typhoid fever, with occa- 
sional vomiting, but no severe general symptoms, for three 
weeks, when black vomit came on. The vomiting of black mat- 
ter (blood coagulated in small portions and blackened) recurred 
frequently, and he died of exhaustion three or four days after 
the first occurrence of haemorrhage. 
Another cause of congestion of the stomach, often leading to 
an oozing of blood from its mucous membrane, is arrest of 
secretion in the liver. 
The blood is drawn to the liver, and its passage through the 
liver is promoted, by the forces which are there at work separa- 
ting and elaborating the principles of the bile and effecting those 
reparative changes in the blood which the agency of the liver 
causes. When the action of these forces is suspended the blood 
does not pass through the liver with its usual freedom, and the 
stomach and intestines become congested, just as when a palpable 
mechanical bar is opposed to the free return of the venous blood. 
In those terrible cases in which jaundice, followed by fatal dis- 
order of the brain, results from suppressed secretion of bile, 
haemorrhage from the stomach and bowels is a common event. 
Again, in cases of jaundice from permanent closure of the 
common gall-duct, which prove fatal by gradually exhausting 
the strength, it not unfrequently happens that after the jaundice 
has lasted many months, and when the secreting cells of the liver 
are destroyed, death is hastened by the occurrence of haemorrhage 
in the stomach and bowels. 
In either class of cases the haemorrhage occurs without ulcer- 
ation of the mucous membrane of the stomach or intestines, and 
is best explained by supposing that it results from congestion of 
the stomach and intestines, caused by the complete arrest of se- 
cretion in the liver. 
Haemorrhage from the stomach now and then occurs also in 
persons in whom the spleen has for some time been greatly en- 
larged. Numerous instances of this have been recorded, from 
the time of Morgagni downwards; but the true relation of the 
facts has not been made out. A very important circumstance in 62 
CONGESTION 
the history of such case is, that the vomiting of blood is preceded 
or attended by ascites, by enlargement of the superficial veins of 
the belly, and by other symptoms which show that the passage 
of the blood through the liver is greatly obstructed; and the 
question arises, On what does this obstructed circulation depend? 
The most natural supposition is, that the obstructed circulation 
results, not from the disease of the spleen, but from obstruction 
of branches of the portal vein, or some other organic changes in 
the liver; and that it is caused, as is cirrhosis, by a mechanical 
bar to the passage of the blood. 
A circumstance somewhat against this supposition is, that ob- 
structed circulation through the liver does not commonly cause 
great enlargement of the spleen; and that, in most of the recorded 
cases in which vomiting of blood has been associated with enor- 
mous enlargement of the spleen, the enlargement of the spleen 
has been the effect of ague, which does not often lead to obliter- 
ation of the veins of the liver or to other organic changes which 
impede the passage of blood through it. It is for morbid anatomy 
to settle this point. Only one opportunity of elucidating the sub- 
ject by dissection has fallen to me ; and, in that instance, I failed 
to discover any mechanical impediment to the passage of the 
blood through the liver. 
The question then occurs, Does not some degree of impediment 
to the passage of blood through the liver, in such cases, result 
from an unnatural condition of the blood itself, in consequence 
of suspended action of the spleen? There can be little doubt 
that the spleen contributes, like the liver, to the reparation of 
the blood. If either of those organs be much diseased, a state 
of lasting amemia results. It seems not unlikely, from the ana- 
tomical relation of the two organs, that the changes effected by 
the spleen are preparatory to those effected by the liver; and 
that, if the former changes' be prevented, the blood that flows to 
the liver may not be in healthy relation to its secreting cells; 
and, in consequence, its course through the capillary net-work of 
the lobules may be in some degree hindered and a disposition to 
ascites and gastric haemorrhage result. 
As I have before observed, it is for morbid anatomy to decide 
if this supposition be true. 63 
OF THE STOMACH. 
It now and then happens that haemorrhage of the stomach 
from overfulness of its bloodvessels, instead of being the effect 
of a single condition, is attributable partly to obstruction to the 
current of blood through the liver, rendered more effective, it 
may be, by feeble propulsive power in the heart, and partly to 
an unhealthy condition of the blood itself disposing to haemor- 
rhage, which is sometimes brought on by watching, mental anx- 
iety, or other depressing influences. 
If time permitted, I could cite more than one instance in which 
excessive vomiting of blood seemed to have been thus produced. 
With respect to haemorrhage of the stomach from congestion, 
it is important to bear in mind that dark shreds are sometimes 
vomited, which are hardly to be distinguished by the naked eye 
from shreds of coagulated and darkened blood, but which con- 
sist of flakes of gastric mucus coloured by tea, or by some other 
dark coloured liquid recently swallowed. In such cases the 
microscope enables us to ascertain readily that the dark matter 
does not oavo its colour to the presence of blood. LECTURE IV. 
Inflammation of the, Stomach—its various kinds or degrees: 1 st. Inflam- 
mation excited by Undigested Food, or Alcoholic Drinks ; Indly. In- 
flammation caused by more powerful Mechanical or Chemical Irritants; 
Zrdly. Inflammation resulting from Defective Nutriment, or from the 
presence of Noxious Matter in the Blood. 
Having- spoken of the effects of congestion of the stomach, I 
have now to call your attention to those of inflammation of its 
lining membrane. 
The term, inflammation, is generic, and, in the latitude now given 
to it, comprehends processes which, although they have many 
points in common, differ in very important particulars. Taking 
the case of the synovial membranes,—the inflammatory process 
may lead to the effusion of a watery fluid, which may be com- 
pletely absorbed; or to the effusion of coagulating lymph ; or to 
the secretion of pus: and it is observed, that the result in any 
individual case is mainly determined by the nature of the agent 
by which the inflammation is kindled. The inflammation of 
rheumatism leads to the effusion of a serous fluid, which, at 
least, does not undergo coagulation in the synovial capsule. 
The inflammation that results from a penetrating wound, or 
from the presence of pus in the blood, generally leads to the 
secretion of pus. But, in either case, there are many common 
phenomena. There is increased flow of blood to the part and a 
plethora or fulness of its bloodvessels ; increased heat from the 
increased oxidation and other chemical changes which are there 
going on ; and unnatural swelling from the effusion of fluids if 
the effused fluids cannot readily escape. Again, whatever be 
the cause or the result of the process, the blood undergoes the 
same fundamental change in its physical properties,—a change 
which, as M. Andral has shown, is mainly dependent on an INFLAMMATION". 
65 
increase in the proportion of its coagnlable element. It is to 
these constant phenomena, that the generic term u inflammation ” 
is properly applied. But, whenever the term is used, it must be 
recollected that it is a generic term, and that, in speaking of any 
individual case, it is not enough to say that the disease is inflam- 
mation of this or that part. To convey an exact notion of the 
changes that are taking place it is necessary to specify, in some 
way or other, the kind of inflammation, either by reference to 
the cause of the inflammation, as by saying that it is rheumatic 
inflammation or gouty inflammation or syphilitic inflammation or 
erysipelatous inflammation; or, if the cause be unknown, by ref- 
erence to the nature of the fluids effused, as by saying that the 
inflammation is suppurative or adhesive. 
The matters effused in inflammation vary not only with the 
nature of the agent by which the inflammation is kindled, but 
also according to the tissues inflamed. The inflammation of the 
joints which occurs in rheumatic fever leads to the effusion of a 
fluid which does not coagulate, and which is in most cases 
readily absorbed, so that no permanent damage results. The 
inflammation of the pericardium and of the valves of the heart, 
which so frequently co-exists with the inflammation of the joints 
and which is doubtless excited by the same agent, leads to the 
effusion of coagnlable lymph, and produces lasting, and often 
fatal, changes of structure. 
The inflammation of a mucous membrane may lead, accord- 
ing to the kind of inflammation—lst. To the secretion of viscid, 
or opaque, or otherwise altered mucus ; 2nd. To the effusion of 
plastic lymph, which forms a coating, like a layer of coagulated 
albumen, on the membrane ; 3rd. To the formation of pus ; but, 
whatever be the character of the matter effused, no permanent 
mischief need follow. The morbid product is poured out on the 
open surface of the membrane, and is cast off; and when the 
process of inflammation is ended, the membrane may be restored 
to its original condition. 
The various results of inflammation in mucous membranes are 
best studied in the air-tubes, because the several kinds or degrees 
’of inflammation I have just referred to are common in them and 
are readily distinguished from the circumstance that the secre- 66 
VARIOUS KINDS 
tions from the inflamed membrane are spit up, unmixed with 
other matter, and may likewise be found, unchanged, choking 
the tubes in the dead body. But with regard to the stomacli 
the case is widely different. If any part of the mucous mem- 
brane of the stomach be inflamed, the matters secreted by this 
part are mingled with the secretions of other parts and also with 
the food which the stomach contains; and they must, besides, 
be speedily changed by the chemical action of the gastric juice. 
If, therefore, they are thrown up by vomiting, it must, in most 
cases, be difficult to distinguish their primary form; but if, 
instead of being thrown up, they pass downwards through the 
bowel, they must be still further altered by admixture with the 
bile, the pancreatic juice, and the fluids poured out by the coats 
of the(bowel itself, as well as by the chemical changes which are 
there going on. It cannot, then, excite much surprise that but 
little has been learned respecting the inflammatory diseases of 
the mucous membrane of the stomach from an inspection of the 
matters which the inflamed membrane secretes. 
But there is another difficulty in the study of these diseases— 
they seldom prove fatal; so that opportunities of examining the 
inflamed membrane itself seldom occur. Inflammation of the 
air-tubes not unfrequently destroys life, not by the constitutional 
disturbance which the process of inflammation excites, but by 
the mere mechanical effect of the secretion, which blocks up the 
smaller tubes and thus suffocates the patient. 
Secretions from the mucous membrane of the stomach cause 
no mechanical obstruction of this kind, so that inflammation of 
it seldom proves fatal. After a time the inflammation subsides 
and leaves no trace behind. 
Again, when death does occur during the active stage of the 
process, the marks of this process are much less certain than in 
inflammatory diseases of the air-tubes. The secretions are 
changed by mixture with what else there may happen to be in 
the stomach; and a softening or destruction of the mucous mem- 
brane, which, in the air-tubes, would at once be ascribed to 
disease, may here have occurred after death from the chemical 
action of the gastric juice or of the other matters which the sto- 
mach contains. 67 
OF INFLAMMATION. 
For all these reasons, our knowledge of the inflammatory 
diseases of the mucous membrane of the stomach is extremely 
vague. 
One of the simplest forms of inflammation of the mucous mem- 
brane of the stomach, as well as one of the most frequent, is 
that brought on by excess in eating or drinking. Much has 
been added to our knowledge on this subject by the observations 
of Dr. Beaumont on Alexis St. Martin, who, in consequence of 
a gun shot wound, had a permanent fistulous opening through 
the abdominal parietes into the stomach, thus affording Dr. 
Beaumont the rare opportunity of seeing much of what took 
place in the stomach during the process of digestion. 
Dr. Beaumont found that whenever St. Martin ate heartily of 
substances hard of digestion for some days in succession, an 
inflammatory state of the mucous membrane of the stomach 
resulted. The membrane exhibited aphthous patches and red 
spots, from which small drops of blood sometimes exuded. It 
secreted very little proper gastric juice, but a considerable quan- 
tity of ropy mucus, which became yellowish, or muco-purulent, 
when the inflammation was more than commonly severe. 
This condition of the stomach caused slowness of digestion, 
so that food sometimes remained in the stomach undigested for 
twenty-four or forty-eight hours or even longer. It caused, also, 
slight tenderness at the pit of the stomach and a thin white coat 
on the tongue, but very little constitutional disturbance. Under 
the influence of low diet and cooling drinks, the inflammation 
very speedily subsided and the membrane regained the appear- 
ance of health. 
These effects are illustrated by the following experiments by 
Dr. Beaumont, on Alexis:— 
On the 7th of December, Alexis had some symptoms of gastric 
derangement, and the mucous membrane of the stomach ex- 
hibited small aphthous patches. 
At 9 o’clock in the morning of the Bth of December, he finished 
breakfasting on fried sausage, dry toast, and a pint of coffee. At 
half-past 10, the stomach was full of fluids, and its mucous coat 
was red and irritable, inclining to dryness. There was a thin 
whitish coat on the tongue, and a similar appearance on the 68 
INFLAMMATION 
protruded portion of the stomach. At a quarter before 12,— 
that is, at the end of nearly three hours,—the stomach was still 
full, and rancid oil floated on the top of its contents. 
At a quarter before three on the same day, Dr. Beaumont 
placed in the stomach, suspended on a string, a roasted oyster, 
that weighed, when raw, four drachms ; and Alexis ate twelve 
others of about the same size. * 
At half-past four, the oyster on the string was not half- 
digested, and Alexis complained of headache, lassitude, dull 
pains in the left side and across the breast. The tongue was 
furred with a thin yellowish coat, and inclined to dryness. The 
eves were heavy and the countenance was sallow. The mucous 
membrane of the protruded portions of the stomach, according 
to Dr. Beaumont, very much resembled the appearance of the 
tongue, with small aphthous patches in several places,' quite irri- 
table and tender. 
Dr. Beaumont then suspended his observations and, at night, 
dropped into the aperture six grains of blue pill and four com- 
mon-sized aloetic pills, and sprinkled on the exposed surface of 
the stomach five or six grains of calomel. 
The medicine operated early the next morning, relieved the 
symptoms of indisposition, changed the appearance of the 
stomach and tongue, and removed the aphthae. 
On the 9th, that is, the day after the experiments were made, 
Alexis felt quite well and the coats of the stomach looked 
healthy again. 
The rapid recovery in such cases is owing to the active nutri- 
tion of the mucous membrane. In consequence of this active 
nutrition, the effects of inflammation of the mucous membrane 
of the stomach are much more transient than those of inflamma- 
tion of the mucous membrane of the air-tubes, or of the urinary 
bladder, or of the urethra, or even of the intestines. 
The mucous membrane of the air-tubes, or of the urethra, or 
of the urinary bladder wastes but little and is slowly renewed. 
If it be much injured, the process of repair is long. 
The mucous membrane of the stomach, on the contrary, has 
an active function. Its epithelium is frequently shed to effect 
digestion, and is rapidly renewed; and, in consequence, the OF THE STOMACH. 
superficial inflammation of it we are considering is very 
transient. 
The erythematous inflammation of the stomach, in the in- 
stance I have just cited from Dr. Beaumont, was brought on by 
eating fried sausages and roasted oysters. The effect which 
these or any other unwholesome articles of food have on the 
stomach, of course depends greatly on the previous state of the 
stomach and of the general health. What at one time is readily 
digested and does no harm, at another time is digested very 
slowly and frets and inflames the stomach. Food which under 
ordinary circumstances is most wholesome may thus inflame the 
stomach, if, by an impediment to the passage of the blood 
through the liver or the chest, or by a state of fever, or by ner- 
vous exhaustion, or by previous excesses, the gastric juice is, 
for the time, diminished. 
The stomach may be inflamed by alcoholic drinks, just as it is 
by unwholesome food. This was repeatedly seen by Dr. Beau- 
mont in his observations on St. Martin. The following pas- 
sages are very instructive on this point;— 
“July 28th, 9 o’clock, a.m.—Weather clear; wind FT. W., 
brisk; thermometer 66°. Stomach empty; not healthy; some 
erythema and aphthous patches on the mucous surface. St. 
Martin has been drinking ardent spirits, pretty freely, for eight or 
tea days past; complains of no pain, nor shows symptoms of 
any general indisposition; says he feels well, and has a good 
appetite. 
“ August Ist, 8 o’clock, a.m.—Examined stomach before eat- 
ing anything; inner membrane morbid; considerable erythema, 
and some apthous patches on the exposed surface; secretions 
vitiated. Extracted about half an ounce of gastric juice; not 
clear and pure as in health; quite viscid. 
“ 2nd, 8 o’clock, a.m.—Circumstances and appearances very 
similar to those of yesterday morning. Extracted one ounce of 
gastric fluids, consisting of unusual proportions of vitiated mucus, 
saliva, and some bile, tinged slightly with blood, appearing to 
exude from the surface of the erythema and aphthous patches, 
which were tenderer and more irritable than usual. St. Martin 70 
INFLAMMATION 
complains of no sense of pain, symptoms of indisposition, or 
even of impaired appetite. Temperature of stomach. 101°. 
“ 3rd, 7 o’clock, a.m.—Inner membrane of stomach unusually 
morbid; the erythematous appearance more extensive, and spots 
more livid than usual, from the surface of some of which exuded 
small drops of grumous blood; the aphthous patches larger, and 
more numerous; the mucous covering thicker than common, 
and the gastric secretions much more vitiated. The gastric 
fluids extracted this morning were mixed with a large propor- 
tion of thick ropy mucus, and considerable muco-purulent mat- 
ter, slightly tinged with blood, resembling the discharge from 
the bowels in some cases of chronic dysentery. Notwithstand- 
ing this diseased appearance of the stomach, no very essential 
aberration of its functions was manifested. St. Martin complains 
of no symptoms indicating any general derangement of the sys- 
tem, except an uneasy sensation, and a tenderness at the pit of 
the stomach, and some vertigo, with dimness and yellowness of 
vision on stooping down and rising again; has a thin, yellowish- 
brown coat on his tongue, and his countenance is rather sallow; 
pulse uniform and regular; appetite good; rests quietly, and 
sleeps as well as usual. 
“4th, 8 o’clock, a.m.—Stomach empty; less of those aphthous 
patches than yesterday; erythematous appearance more exten- 
sively diffused over the inner coats, and the surface inclined to 
bleed ; secretions vitiated. Extracted about an ounce of gastric 
fluids, consisting of ropy mucus, some bile, and less of the 
rauco-purulent matter than yesterday; flavour peculiarly fetid 
and disagreeable; alkalescent and insipid; no perceptible acid; 
appetite good ; rests well, and no indications of general disease 
or indisposition. 
“ sth, 8 o’clock, a.m.—Stomach empty ; coats less morbid 
than yesterday; aphthous patches mostly disappeared; mucous 
surface more uniform, soft, and nearly of the natural healthy 
colour; secretions less vitiated. Extracted two ounces of gastric 
juice, more clear and pure than that taken for four or five days 
last past, and slightly acid; but containing a larger proportion 
of mucus, and more opaque than usual in a healthy condition. 
“ 6th, 8 o’clock, a.m,—Stomach empty; coats clean and OF THE STOMACH. 
71 
healthy as usual; secretions less vitiated. Extracted two ounces 
of gastric juice, of more natural and healthy appearance, with 
the usual gastric acid flavour; complains of no uneasy sensa- 
tions, or the slightest symptom of indisposition; says he feels 
perfectly well, and has a voracious appetite; hut not permitted 
to indulge it to satiety. He has been restricted from full, and 
confined to low diet and simple diluent drinks for the last few 
days, and has not been allowed-to taste any stimulating liquors, 
or to indulge in excesses of any kind.” 
In this instance, the inflammation of the stomach was caused 
by ardent spirits. The effect which these have on the stomach 
depends greatly on their state of dilution. The more they are 
diluted, the less apt are they to irritate and inflame the stomach. 
It has long been known that spirit-drinkers are the especial victims 
of cirrhosis, which has, in consequence, been called, in this city, 
“ the gin-drinker’s liverand it has been very generally supposed 
that distilled or ardent spirits hurt the stomach more than fer- 
mented liquors, even when the spirits are diluted with water so 
as to be of the same strength. But in wine and malt liquors the 
alcohol exists in a state of mere admixture with their other con- 
stituents, and there can be little doubt, therefore, that the more 
injurious effects of ardent spirits depend mainly on the circum- 
stance that the victims of spirit-drinking not only drink large 
quantities of spirits, but often drink them “ neat” and on an 
empty stomach. In wine and beer the alcohol is already largely 
diluted, and the beverages, when drunk to excess, are usually 
drunk at, or soon after, meals, when the alcohol is still further 
diluted by admixture with the contents of the stomach. 
The effect of spirits on the coats of the stomach, like that of 
food which is hard of digestion, depends greatly on the previous 
state of the stomach and of the general health, as well as on 
season and climate. Spirits hurt the stomach more when its 
mucous coat is already inflamed, or when, from an impediment 
to tbe passage of the blood through the liver or the chest, or from 
any other cause, the vessels of the stomach are congested, so that 
liquids are slowly absorbed from it; and in hot seasons or hot 
climates. Lnder these circumstances, small quantities of fer- 
mented drinks may do much mischief. 72 
INFLAMMATION 
In tlie observations I have cited from Dr. Beaumont, nothing is 
more striking than the rapidity with which the stomach recov- 
ered under the influence of low diet and cooling drinks. With- 
out this power of rapid recovery the stomach would be unfit for 
its office. If the erythematous inflammation which is excited by 
unwholesome food or by excess in eating or drinking took long 
to subside, the absence required for recovery could hardly be 
borne. • 
The inflammation, instead of subsiding rapidly, is, however, 
often long kept up and is sometimes aggravated, from the cir- 
cumstance that the disorder causes but slight constitutional dis- 
turbance, and that the appetite is less impaired than the digestive 
power. The usual diet is in consequence taken, and the tender 
surface fretted. Quantities of solid food or of fermented drinks, 
which at other times would do no harm, are sufficient to keep up 
a soreness that already exists. 
The chronic inflammation so excited is attended with an in- 
creased secretion of mucus, and causes a thickening, and the so- 
called “ mammillated” appearance, and occasionally, I believe, 
minute superficial ulcers of the mucous membrane. Its most 
characteristic symptoms are—constant slight tenderness at the 
epigastrium; slowness of digestion; pain or uneasiness in the 
stomach, and occasional vomiting, after meals, especially after 
meals of solid food; and a white and furred tongue. The 
matter vomited contains viscid mucus, which, now and then, pre- 
sents a few streaks of blood, more or less altered. The disorder, 
even after it has lasted a considerable time, generally disappears 
readily if the stomach be allowed sufficient intervals of rest, or 
the patient be restricted to cooling drinks and a diet consisting 
entirely of farinaceous substances and milk. 
A superficial, or erythematous, inflammation of this kind 
occurs, not only as a disease by itself in persons otherwise 
healthy, but also very frequently in the course of various other 
inflammatory or febrile diseases, when the food has not been 
brought down to the diminished power of the stomach. Under 
such circumstances the inflammation of the stomach is more 
difficult to recognise, from its symptoms being complicated, or 
masked, by those of the primary disease. It is thus often over- OF THE STOMACH. 
looked, and muck mischief is in consequence done by the un- 
seasonable use of stimulants. 
Chronic inflammation of the kind we are now considering 
sometimes results, not from the digestive powers of the stomach 
being overtaxed, but from the existence of some impediment to 
the passage of the digested food from the stomach into the in- 
testine. When, for example, a simple deep ulcer exists near the 
pyloric end of the stomach, interfering with the action of its 
muscular fibres, or when the pyloric orifice is slightly strictured, 
or is pressed upon by a large liver, the stomach cannot always 
completely empty itself, and what remains in it after digestion is 
over, frets and inflames its mucous coat. As the inflammation 
in such cases results from an abiding condition, it is difficult to 
remedy, and thus, occasionally, leads to habitual vomiting of 
ropy mucus. This happened in a woman who died, a few years 
ago, in King’s College Hospital, from the effects of a large simple 
ulcer near the pyloric end of the stomach. Much ropy mucus 
was vomited for a long time before death, leading to the suspi- 
cion of cancer of the stomach, and, after death, ropy mucus of 
the same kind, hard to detach, was found coating almost the 
whole surface of the mucous membrane. 
In the same way, if the urinary bladder or the gall-bladder 
cannot completely empty itself, the retained urine or bile decom- 
poses, or becomes too highly concentrated, and consequently 
frets and inflames the mucous membrane. Inflammation of the 
mucous membrane of the stomach would be caused in this way 
much more frequently, if it were not for the circumstance that 
the stomach has two outlets, and that when the pyloric outlet is 
stopped, any irritating matters it may happen to contain can be 
cast off by the mouth. 
A higher degree of inflammation, brought on in the same 
way—by direct irritation of the stomach—is seen in persons 
who have swallowed some hard and insoluble substance which 
lacerates and frets the mucous membrane, or some poison whose 
action on the membrane is corrosive. The immediate effects of 
this are—pain in the stomach, with a sense of heat there, and 
occasional vomiting, the matters vomited being tinged with 
blood. If the injury done to the stomach be very great, or the 74 
INFLAMMATION 
pain, be very severe, the heart’s action is much depressed, as in 
severe forms of peritonitis—the pulse becomes small and rapid, 
the skin cold and clammy, and the countenance shrunk. When 
this state of depression passes away, a slight degree of fever 
comes on; but, unless the inflammation of the stomach be ex- 
cited by some agent which has become absorbed into the blood, 
and has thus affected other organs, the constitutional disturbance 
is but slight. Some years ago a theory was promulgated which 
ascribed the terrible constitutional disorder that exists in con- 
tinued fever to inflammation of the mucous membrane of the 
stomach, or of the stomach and intestines; and, according to 
this theory, the different forms of continued fever were spoken 
of as gastritis and gastro-enteritis. In the most elaborate essay 
on typhoid fever yet published, the disease is designated “ gastro- 
enteritis,” But among the stores of medical literature are many 
remarkable cases, which show that simple inflammation of the 
stomach, however severe, does not, after the first shock of the 
injury has passed away, cause great nervous or constitutional 
disorder. 'The stomach—the common receptacle of all that is 
eaten and drunk—liable to receive a great number of substances 
which are mechanically or chemically irritating to it, and des- 
tined to exert its wonderful power imperceptibly, is so organized 
and in such relation to other parts of the system, that great and 
continuous irritation of its mucous membrane sometimes exists 
unattended by alarming constitutional disorder. 
The most remarkable instance on record of long-continued 
mechanical irritation of the stomach is that of a sailor who died 
in Guy’s Hospital in 1809, from having, in imitation of a juggler, 
foolishly swallowed fourteen clasp knives, most of which were 
nearly four inches long and full an inch in their extreme 
breadth. 
In this instance, the mechanical irritation of the stomach, and 
the inflammation it set up, caused severe pain in the stomach, 
frequent vomiting, and loss of flesh, and together with injury 
done to the bowels by some fragments of the knives that passed 
into them, eventually destroyed life; but, from the first, it seems 
not to have excited much fever or any marked disturbance of 
the nervous system. The knives were swallowed on the sth OF THE STOMACH. 
75 
and 6th of December, 1805, and the man lived between three 
and four years afterwards—till March, 1809, It is stated that 
towards the close of January, 1806—that is, in less than two 
months after he swallowed-the knives,—he moved about and at 
intervals performed the duty of a sweeper; and that in the 
course of the following autumn, though still having pain in the 
stomach when standing erect, and occasional vomiting, he 
gathered strength and flesh, ate and drank voraciously, and per- 
formed various easy duties in his ship.* 
Another case, which is historically interesting, and still in- 
structive on the point before us, is that of the man who swal- 
lowed molten lead during the fire which consumed the Eddy- 
stone Lighthouse, near Plymouth, in the winter of 1756. This 
man, Henry Hall, who was 94 years of age, but remarkably 
active for his time of life, had, with two other men, the charge 
of the Eddystone Lighthouse. About two o’clock in the morn- 
ing of the 2nd of December, the fire which consumed the light- 
house broke out in the lantern. Hall, who was at the time the 
only man upon the watch, attempted to extinguish the fire, and, 
in order to reach it, had to throw water four yards higher than 
his head. As he was looking upwards to see the direction and 
success of some water he had thrown, a quantity of molten lead 
fell in a torrent from the roof upon his head and face and over 
his clothes, and part of it made its way through his shirt-collar 
and very much burnt his neck and shoulders. From that mo- 
ment he had a violent internal sensation and imagined that a 
quantity of the lead had passed down his throat into his body. 
As the rage of the flames increased, he, with his companions, 
had to retire downwards, from room to room; and at ten o’clock, 
after the fire had been burning eight hours, some boatmen, who 
had come to their assistance, found them almost in a state of 
stupefaction, in a cave on the east side of the rock, to which 
they had retreated to avoid the falling of the timber, red-hot 
bolts, &c., upon them. The boatmen being unable, on account 
* n account of this remarkable case, drawn up by Dr. Marcet, is con- 
tained in the 12th volume of the “ Medico-Chi rurgical Transactions.” Nu- 
merous corroded blades, and other fragments of the knives, found in the 
stomach after death, are preserved in the museum of Guy’s Hospital. 76 
INFLAMMATION 
of the surf, to land upon the rock, threw a coil of small rope 
upon it. The lighthouse men laid hold of the rope, and having 
fastened it, one by one, round their waists, jumped into the sea 
and were towed into the boat. They were immediately taken 
by sea to Plymouth, a distance of about fourteen miles, where 
Hall was attended by Dr. Spry. He invariably told Dr, Spry 
(who constantly administered the proper remedies to such burns 
and hurts as could be perceived) that if he would do anything 
effectual towards his recovery he must relieve his stomach from 
the lead which he was sure was within him; and this he not only 
told Dr. Spry, but those about him, though in a very hoarse 
voice; and he also said the same thing to Mr. Jessop (the sur- 
veyor), who went to see him several times during his illness. 
The reality of the assertion seemed, however, then incredible to 
Dr, Spry, who could scarcely suppose it possible that any human 
being could exist after receiving molten lead into the stomach, 
much less that he should afterwards be able to bear towing 
through the sea from the rock, and also the fatigue and incon ' 
venience from the length of time he was in getting on shore be- 
fore any remedies could be applied. The man did not show 
any symptoms, however, of being either much worse or of 
amendment till the sixth day after the accident, when he was 
thought to be better. He constantly took his medicines, and 
swallowed many things, both liquid and solid, till the tenth or 
eleventh day, after which he suddenly grew worse; and on the 
twelfth day, being seized with cold sweats and spasms, he soon 
afterwards expired. 
The following is the account given by Dr. Spry of the condi- 
tion of the stomach:— 
“Examining the body, and making an incision through 
the left abdomen, I found the diaphragmatic upper mouth 
of the stomach greatly inflamed and ulcerated, and the tunica 
in the lower part of the stomach burnt; and from the great 
cavity of it took out a great piece of lead,” weighing 7 oz. 5 drs. 
8 grs. 
On the 19th of December, 1755, Dr. Spry transmitted an ac- 
count of the case to the Eoyal Society; “ but that learned body 
thinking the circumstance very unlikely and extraordinary, and 77 
OF THE STOMACH. 
doubting tbe truth of it, the reading of the paper was deferred 
until a further elucidation was received.” 
Dr. Spry, when his word was thus doubted, made various ex- 
periments on dogs and fowls, for the sake of re-establishing his 
character for veracity. • 
He poured molten lead, by means of a funnel, down the throat 
of a small dog which had eaten nothing for twenty-four hours, 
and kept the dog afterwards without food or drink. The next 
day the dog was very brisk, and, on being killed, six drachms 
and one scruple of lead were found in its stomach. The stomach, 
Dr. Spry says, was much corrugated, but its internal coat was 
not excoriated. 
In another experiment he gave a large dog half-a-pint of milk, 
and very soon afterwards poured, in the same way, molten lead 
down its throat. Yery soon after swallowing the lead, the dog, 
according to Dr. Spry, ate freely of milk, as if nothing ailed 
him ; and continued to do so daily for three days, when it was 
killed, being at that time very lively. Six ounces and two 
drachms of lead were taken from the stomach. “The pharynx 
and cardiac orifice of the stomach were a little inflamed and 
excoriated, but the oesophagus and stomach seemed in no man- 
ner affected.” 
Dr. Spry performed similar experiments on fowls, with a like 
result. 
Having transmitted to the President of the Eoyal Society an 
account of these experiments, and having offered further to 
establish, by the oaths of himself and others, the truth of the 
facts stated in his paper, the paper was read to the Society, and 
afterwards published in the Society’s “ Transactions.” 
A few years ago these experiments of Dr. Spry were confirm- 
ed by other experiments made in France by M. Bretonneau. 
In one of M. Bretonneau’s experiments, three ounces of boil- 
ing water were poured into the stomach of a young dog. The 
dog immediately uttered frightful cries and vomited violently 
several times. The next day it appeared languid and oppressed, 
drank with avidity, but refused food. The third day convales- 
cence commenced, and made progress up to the seventh day, 
when the dog was killed. The evening before its death, it 78 
INFLAMMATION 
caressed its master and rolled at Iris feet in play. When the 
body was opened, the mncons membrane, the underlying cellu- 
lar tissue, and oyer a large space, the muscular coat of the 
stomach, were found in a state of gangrene. 
In another four dogs had, each of them, eight 
ounces of boiling water injected into the stohlach in such a way 
as not to injure the oesophagus. Three days afterwards, they 
played together and snatched from each other food that was 
thrown them. They were then killed ; and, in their stomachs, 
were marks of injury like those observed in the former experi- 
ment. 
Among the stores of medical literature, there are also many 
remarkable cases in which great destruction of the lining mem- 
brane of the stomach resulted from poisoning by the mineral 
acids; and in which, although life continued many days, or even 
weeks, after the acid was swallowed, no striking disorder of the 
intellect resulted. 
Some years ago, an instance of this kind was brought under 
my notice by Mr. Miller, of King-street, St. James’s, in which 
entire destruction of the lining membrane of the oesophagus, and 
charring of a small portion of the lining membrane of the 
stomach, resulted from swallowing sulphuric acid. In this 
instance, although a large portion of the lining membrane of the 
oesophagus, which is now in the museum of the College, was 
brought up entire, like the finger of a glove, the man lived many 
months, and at length died from the combined effects of strict- 
ure of the oesophagus and tuberculous disease of the lung. 
In the “Medical Gazette” for September 11th, 1846, a very 
remarkable case of this kind is recorded, in which the patient 
lived twenty-three days after swallowing nitric acid, and in which 
the lining membrane of the stomach was found after death to be 
almost entirely destroyed. 
Such cases may be classed with the cases I have before related, 
for the ill effects of strong mineral acids taken into the stomach 
are mainly due to their local action. The acid chars the tissue 
with which it comes in contact, coagulates the blood in its mi- 
nute vessels, and consequently, while it is sufficiently concen- 
trated to have this chemical effect, although it may continue to OF THE STOMACH. 
79 
permeate the tissues as it would permeate dead membranes, it 
does not become absorbed into the general mass of circulating 
blood. 
Thus, when severe inflammation of the stomach results from 
direct local injury, whether this be caused by mere mechanical 
irritation or by the action of heat or strong acids, severe local 
symptoms—commonly excruciating pain and frequent vomiting 
—result; and, for a time, the heart’s action may be much de- 
pressed ; the depression which immediately follows the injury, 
or the exhaustion consequent on the inability to eat or digest, 
may, indeed, destroy life; but there is not, necessarily, any high 
degree of fever, or any serious disorder of the functions of the 
brain. 
These cases confirm, then, the conclusion we had before arrived 
at,—viz., that a slight inflammation of the stomach, resulting 
from the irritation of undigested food, or from excessive or un- 
seasonable indulgence in alcoholic drinks, or from the ill-advised 
use of irritating drugs, excites but little constitutional disorder, 
and from the slightness of this disorder and the power of rapid 
recovery which the stomach possesses, is but little heeded and 
often overlooked. 
The effects of any injury to the stomach must depend very 
much on the previous state of the stomach and of the nervous 
system, and on the muscular power of the heart. An injury of 
the stomach which in one person would do no harm, in another 
may cause terrible irritability of the stomach or excessive pain 
and collapse, just as an injury of the hand or foot, which in one 
person has no serious result, in another causes agonizing pain, or 
the fatal spasms of tetanus. 
Many instances are on record in which a person previously in 
good health has died very speedily and unexpectedly after a 
gluttonous meal of some indigestible substance, and apparently 
in consequence of the pain which the over-distension and irri- 
tation of the stomach occasioned. In such instances the imme- 
diate cause of death is faintness or stoppage of the heart’s ac- 
tion, under the influence of the pain: and I believe that in most 
of them the heart was previously unsound, or the poAver to bear 
up under pain or other depressing sensations had been weakened 
by intemperate habits. LECTURE Y. 
Inflammation of the. stomach—continued. 
The mucous membrane of the stomach may be fretted and in- 
flamed by various conditions besides excesses in eating or drink- 
ing and the swallowing of substances which are hard of digestion 
or which exert an injurious chemical action upon it. Among 
these conditions may be ranked severe or long-continued absti- 
nence. The stomach is an organ whose action, like the actions 
of the voluntary muscles and the brain, is destined to be inter- 
mittent ; and when the digestive power is exhausted, a certain 
period of abstinence, or rest, is required in order to restore it. 
The first effect of abstinence is, then, to strengthen the stomach 
and enable it to digest a greater quantity of food; but if the 
abstinence be complete and exceed a certain limit, the nutrition 
of the mucous membrane becomes impaired; digestion then grows 
feeble, and changes in the texture of the membrane take place, 
which, in appearance at least, are very like those which inflam- 
mation produces. 
This fact, which has been indistinctly perceived since the time 
of Hunter, was noticed a few years ago by MM. Andral and 
Gavarret during a course of experiments to ascertain the in- 
fluence of various conditions on the composition of the blood. 
M. Andral says:— 
“ In some experiments which I undertook with M. Gavarret 
for the purpose of determining the composition of the blood in 
animals deprived of food, one circumstance particularly struck 
me,—-namely, a notable augmentation in the proportion of the 
fibrin. My astonishment ceased when, on opening the bodies of 
these animals, I found in their stomachs evident signs of inflam- INFLAMMATION. 
81 
mation, such as bright redness, softening, and numerous ulcera- 
tions of the mucous membrane.” 
He then gives the following details of one of the experiments 
in question:—Three dogs, in good health, were bled on the same 
day, the 21st December, 1841, in order to ascertain the composi- 
tion of their blood, and were then subjected to different degrees 
of abstinence until they died. 
The first was entirely deprived of food and drink, and lived 
twenty-one days. Some blood was drawn for analysis, at the 
end of the first week, and again at the end of the second week, 
and it was found that the fibrin had increased in the intervals of 
the successive bleedings from 2-3 parts in 1000 to 3'9 and 4*5 parts. 
The second dog was deprived of food, but allowed to drink 
water, and lived twenty-five days. Like the former, it was bled 
at the end of the first and second weeks, and the proportion of 
fibrin wras found to have increased in the intervals of the bleed- 
ings, from 2‘2 parts to 2-9 and 4'o parts. 
The third dog was allowed a small quantity of soup every 
morning, and lived thirty-three days. Blood drawn at the end 
of the first and second weeks had very little more fibrin than 
that drawn at the commencement of the experiment, but, at the 
end of the third week, when some blood wras again taken, the 
fibrin was found to have increased from I‘6 parts to 3’3 parts. 
M. Andral says that this dog, which was not completely de- 
prived of food, was the only one in which the stomach was 
not ulcerated, and that in it the redness of mucous membrane of 
the stomach was less general and less vivid than in the others. 
The last instance shows, that even a small quantity of food, 
if it contained all the elements requisite for nutrition, may pro- 
tect the stomach and prevent those destructive changes which 
total abstinence causes; and this accords with the well-known 
fact, that persons who, from a scanty diet, are much wasted, can 
sometimes, like persons wasted by fever, digest great quantities 
of food. 
The case is very different if a person be long restricted to 
food, which, whatever be its quantity, is not sufficiently varied 
for healthy nutrition. If such a diet be persisted in beyond a 
certain time, the nutrition of the mucous membrane of the 82 
INFLAMMATION 
stomach is impaired as by total abstinence, and, in consequence, 
the appetite fails and digestion is greatly enfeebled. 
This was well shown by experiments first performed by 
Magendie, and subsequently repeated and varied by a Commit- 
tee appointed by the French Institute with Magendie at its 
head, to determine the nutritive properties of different kinds of 
food. The experiments proved that dogs kept exclusively on 
water, with the addition of oil, sugar, fat, or even of albumen, 
fibrin, or gelatine, in their pure state, soon die of starvation, 
just as when kept on water only. 
The subject is further illustrated by the disorders of health 
that have been observed to occur in prisoners kept on a diet of 
bread and water. 
A good account of these disorders has been given by Mr. 
Malcolmson, in a letter he addressed, in 1887, to Sir Henry 
(now Lord) Hardinge, on the effects of solitary confinement and 
a bread and water diet on the health of prisoners in India. He 
says, “ Many men, particularly those of indolent habits, endure 
a confinement of four or six weeks on bread and water without 
injury to their health; but, in some instances, a shorter period 
is sufficient to cause a total loss of appetite / the bread is hardly 
touched, and on other food being allowed, the patient is unable to 
eat or digest it. The stomach becomes weak; there is uneasiness 
across the stomach, spleen, and liver; the latter is torpid. The 
bowels are confined, or they are relaxed, with slimy discharges, 
unaccompanied with pain; yet the swollen red tongue indicates 
the existence of irritation of the mucous membrane of the diges- 
tive canal. The pulse is quick and feeble; and the clammy 
skin, vertigo, debility, headache, and sleeplessness, show how 
much the constitution suffers from diminished nervous power. 
The convalescence is slow, and the treatment requires to be 
adapted to the enfeebled state of the system.” 
It appears, from the instances given by Mr. Malcolmson, that 
when a man is long kept on such a diet, the health is irretrieva- 
bly ruined; the subsequent allowance of food sufficient for the 
maintenance of health does not restore him. 
These observations of Mr. Malcomson are confirmed by the 
early Reports of the Inspectors of Prisons. 83 
OF THE STOMACH. 
The irreparable injury to the health produced by long con- 
tinuance on a diet deficient in some of the principles requisite 
for nutrition is also well shown in the curious and painful his- 
tory of Dr. Stark, who, in 1769, when he was pursuing his 
his medical studies at St. George’s Hospital, heroically made 
himself the subject of experiment. 
His experiments were commenced on the 12th of June ; and, 
from this time until the 26th of July,—that is for more than six 
weeks,—he lived on bread and water only; increasing from time 
to time the daily allowance of bread from twenty ounces, which 
he took at first, to thirty-eight ounces. For the next fortnight— 
from the 26th of July to the 9th of August—he varied the diet 
by subtracting, first four, and then eight ounces, from the thirty- 
eight ounces of bread, and adding an equal quantity of sugar. 
The person upon whom these experiments were made was, to 
use his own words, “ a healthy man, about twenty-nine years of 
age, six feet high, stoutly made, but not corpulent, of a florid 
complexion, with red hair.” 
Once, during the course of these experiments, he yielded to his 
craving for food of other kind, and ate four ounces of meat, and 
drank two or three glasses of wine; but otherwise he adhered 
rigidly to the diet. On the 9th of August, that is, at the end of 
eight weeks and two days, he was only 2lbs. less in weight than 
when he commenced his experiments, but scurvy was making 
its appearance. The entries made in his journal about this time 
show that the nutrition of the lining membrane of the stomach 
and bowels had become greatly impaired. He states, on different 
occasions, that he had little appetite,—that he ate the latter part 
of the allowance of sugar with great abhorrence,—that he had 
pains in the bowels, and frequent liquid stools, which contained 
some clear, gelatinous substance. 
His experiments were pursued, with some slight variation, and 
the scorbutic symptoms made progress. Subsequently, there occurs 
the following entry in his journal:—- 
“ On the Bth of September, I was so weak and low that I almost 
fainted in walking across my room. Had four or five loose stools 
in the course of the day; was sick; and my tongue was foul.” 
The experiments were still continued, and the narrative goes 84 
INFLAMMATION 
on till tlie month of February, when the Doctor, reduced 
to the most deplorable condition, fell a victim to his love of 
science. 
It will be seen, that in Dr. Stark, as in the prisoners that fell 
under the observation of Mr. Malcolmson, the loss of appetite 
and enfeebled digestion that resulted from the defective diet were 
attended by frequent slimy discharges from the bowels. A simi- 
lar disorder of the bowels was noticed by Magendie in his ex- 
periments on dogs and continually recurs in the early Reports of 
the Inspectors of Prisons. The insufficient diet leads, in the 
bowels as in the stomach, to impaired nutrition, and often to an 
inflammatory state of the mucous membrane. 
Happily, severe disorders of the digestive organs, resulting 
from insufficient food, are, in this country, extremely rare ; but 
it is probable that there is some truth in the popular notion, that 
in persons whose digestion is weak the stomach is frequently in- 
jured by too long fasting. It has often seemed to me that a rigid 
diet, too long persisted in, in the early stage of continued fever, 
has been productive of much mischief in this way. 
Inflammation of the mucous membrane of the stomach may be 
excited in another way still—namely, by some noxious matter 
in the blood. 
This has been strikingly shown by experiments that have been 
made on the lower animals for the sake of ascertaining the effects 
of arsenic. Mr. (now Sir Benjamin) Brodie, in a paper on this 
subject published in the “Philosophical Transactions” for 1812, 
says:— 
“ Mr. Home informed me, that in an experiment made by Mr. 
Hunter and himself, in which arsenic was applied to a wound 
in a dog, the animal died in twenty-four hours, and the stomach 
was found to be considerably inflamed. 
“ I repeated this experiment several times, taking the precau- 
tion always of applying a bandage to prevent the animal licking 
the wound. The result was, that the inflammation of the sto- 
mach was commonly more violent and more immediate than 
when the poison was administered internally, and that it pre- 
ceded any appearance of inflammation of the wound.” After 85 
OF THE STOMACH. 
detailing some of his experiments, Mr. Brodie thus sums np the 
effects of the poison— 
“ These experiments were repeated, and the results, in all es- 
sential circumstances were the same. The symptoms produced 
were,—1. Paralysis of the hind legs, and afterwards of the other 
parts of the body; convulsions; dilatation of the pupils of the 
eyes; insensibility; all of which indicate disturbance of the 
functions of the brain. 2. A feeble, slow, intermitting pulse, 
indicating disturbance of the functions of the heart 
3. Pain in the region of the abdomen ; preternatural secretion 
of mucus from the alimentary canal; sickness and vomiting in 
those animals which are capable of vomiting;—symptoms which 
arise from the action of the poison on the stomach and intes- 
tines.” 
The following is the account he gives of the appearance ob- 
served on dissection:— 
“ In animals killed by arsenic, the blood is usually found fluid 
in the heart and vessels after death ; but otherwise, all the mor- 
bid appearances met with on dissection are confined to the sto- 
mach and intestines. . . . 
“In many cases where death takes place, there is only a very 
slight degree of inflammation of the alimentary canal; in other 
cases, the inflammation is considerable. It generally begins very 
soon after the poison is administered, and appears greater or 
less according to the time which elapses before the animal dies. 
Under the same circumstances, it is less in graminivorous than in 
carnivorous animals. The inflammation is greatest in the sto- 
mach ; but it usually extends also over the whole intestine. I 
have never observed inflammation of the oesophagus. The in- 
flammation is greater in degree, and more speedy in taking place, 
when arsenic is applied to a wound, than when it is taken into 
the stomach. The inflamed parts are in general universally red; 
at other times they are red only in spots. The principal vessels 
leading to the stomach and intestines are turgid with blood; but 
the inflammation is usually confined to the mucous membrane of 
these viscera, which assumes a florid red color, becomes soft and 
pulpy, and is separable without much difficulty from the cellu- 
lar coat, which has its natural appearance. In some instances 86 
INFLAMMATION 
there are small spots of extravasated blood on the inner surface 
of the mucous membrane, or between it and the cellular coat, 
and this occurs independently of vomiting, I have never, in 
any of my experiments, found ulceration or sloughing of the 
stomach or intestine; but, if the animal survives for a certain 
length of time after the inflammation has begun, it is reasonable 
to conclude it may terminate in one or other of these ways.” 
“ The inflammation from arsenic, occupying in general the 
whole of the stomach and intestine, is more extensive than that 
from any other poison with which I am acquainted. It does 
not affect the pharynx or oesophagus, and this circumstance dis- 
tinguishes it from the inflammation which is occasioned by the 
actual contact of irritating applications.” 
In another paragraph, he says;— 
These experiments of Sir B. Brodie have been repeated by 
others with the same results, and have been further confirmed 
by numerous cases in which arsenic applied to a sore, or to a 
large surface even of sound skin, or inhaled in the form of 
vapour, has proved fatal in man. In such cases, unless death 
occur early from the action of the poison on the nervous system 
or the heart, pain in the belly, with vomiting and the discharge 
of mucus from the bowels, almost always comes on; and after 
death, marks of extensive inflammation of the mucous mem- 
brane of the stomach and intestines exist. 
It seems probable that this inflammation results from some of 
the poisons being eliminated at the mucous membrane of the 
stomach and intestines—a membrane which must be regarded, 
not as a mere lining of the tube, as the mucous membrane of 
oesophagus is, but, also, as an expanded gland, destined to fur- 
nish abundant secretions, and, by virtue of its active secreting 
power, occasionally instrumental in eliminating noxious princi- 
ples from the blood. 
Many other substances, when absorbed into the blood from 
the surface of the body, have, like arsenic, an especial action on 
the stomach and intestines. Jalap, for example, purges, and 
lead excites colic, when applied to a wound. There can be 
little doubt that some of the noxious principles that may be 87 
OF THE STOMACH. 
bred in the body act in a like special manner on these organs, 
and may excite inflammation or functional disorder of them. 
When arsenic is given medicinally, it should be given largely 
diluted, in order that it may exert no direct injurious influence 
on the stomach; but when this precaution is adopted, it often 
happens, after the medicine has been taken some time, even in 
moderate or small doses, that nausea comes on, with pain and a 
sense of burning heat in the stomach. These symptoms are 
usually the earliest distinct indications that the arsenic has been 
given in too large quantity, and it is very important to bear in 
mind that they depend on inflammation of the mucous mem- 
brane of the stomach. On the occurrence of these symptoms, 
the arsenic should not only be left off, but the patient should be 
kept on a sparing farinaceous and milk diet. The disorder of 
the stomach will then quickly subside. 
If, after the occurrence of the gastric disorder, the use of the 
arsenic be continued, the sufferings referable to the stomach in- 
crease, and an inflammatory state of the bowels likewise comes 
on, causing griping pains of the belly, with diarrhoea and the 
discharge of slimy mucus. The inflammation of the stomach 
and bowels thus excited seems often not to depend on the direct 
local action of the arsenic on the coats of the stomach, but on 
the accumulation of it in the system. The pain in the stomach 
and nausea seldom come on till the arsenic has been taken for 
some time; and if, under proper management, they subside 
speedily and the arsenic be then taken again, the disorder in 
most cases soon recurs. 
Whenever inflammation of the stomach is excited by some 
noxious matter in the blood, which must necessarily be convey- 
ed to every part of the mucous membrane, and be carried in 
the blood to every other part of the body, we may expect the 
inflammation, like that which results from the absorption of 
arsenic, to be more extensive than that caused by the mere out- 
ward application of an irritating agent, and to be attended by 
symptoms of inflammation or irritation of the bowels, and by 
some disturbance of the functions of other organs, w'hich the 
inflammation of the stomach itself cannot explain. 
The gastric disorder in yellow fever and in cholera, which is 88 
INFLAMMATION 
attended by great congestion of the stomach and by effusion of 
fluids from the mucous membrane, which has many characters 
in common with those states which we designate inflammation, 
is probably brought on in this way, by the influence of some 
poison acting through the blood. 
Another instance of inflammation of the stomach arising from 
an unhealthy condition of the blood is that which sometimes 
occurs in gouty states of the system, when the gout does not fix 
itself in the limbs or when it suddenly leaves them. 
The stomach is more apt to suffer from the sudden retroces- 
sion of gout than any other organ ; and two kinds of gastric 
disorder arising in this way have been recognised. 
The first and most common kind usually occurs in chronic 
gout, and is chiefly marked by a feeling of weakness or sinking 
in the stomach, with griping pain and a sense of cramp. The 
pain is relieved by pressure, and is seldom attended with vomit- 
ing, fever, or other symptoms indicative of active inflammation. 
When the disorder has these characters, it is best treated by 
warm alcoholic stimulants, and by sinapisms, applied for the 
purpose of recalling the gout to the joints that have been recently 
or oftenest affected with it. 
The second kind of gastric disorder succeeds active inflamma- 
tory gout in the joints, and is marked by severe pain in the 
stomach, a high degree of fever, and frequent vomiting or retch- 
ing, often attended by profuse diarrhoea. If the disorder be not 
controlled, the active febrile symptoms are early followed by a 
state of alarming and sometimes fatal collapse. 
This affection of the stomach is, now-a-days, of rare occur- 
rence, and has not been sufficiently studied. There can be little 
doubt that the disorder is inflammatory, but that, like gout, in 
other parts, it has characters which may serve to distinguish it 
from common inflammation. 
One of the most striking characters of gouty inflammation of 
the limbs is an abundant effusion of fluid into the synovial cap- 
sules, or into the cellular tissue surrounding the inflamed joints. 
In gouty inflammation of the stomach, an effusion of the same 
kind sometimes takes place into the cellular tissue under the 
mucous coat, causing great thickening of the walls of the OF THE STOMACH. 
89 
stomach. In illustration of this I here show yon a remarkable 
preparation which I have found in the museum of the College. 
It exhibits a considerable portion of the pyloric end of a stomach, 
the walls of which are enormously thickened by what seems to 
have been coagulable lymph effused into the cellular tissue 
under the mucous coat. The preparation was left to the College 
by Dr. Hooper, and is thus described in his catalogue:— 
u A Portion of an Adult Stomach.—There is considerable depo- 
sition of albumen between the coats—between the muscular and 
villous coats. The subject was labouring under acute rheumatic 
fever, with swelling of all the limbs, which suddenly disap- 
peared, and his stomach seized with pain. He became delirious, 
and lived two days. Mr. Guthrie’s stomach had the same 
appearance.” 
What is here termed “acute rheumatic fever,” was, in all 
probability, acute gout affecting a great number of joints at 
once. 
This peculiar form of inflammation of the stomach exemplifies 
a fact which must ever be borne in mind in the consideration of 
inflammatory diseases—namely, that the course and character, 
and, in great measure, the event, of inflammation, in any tissue, 
depend on the nature of the influence by which the inflamma- 
tion is caused. 
When the gouty disorder of the stomach succeeds active 
gouty inflammation of the joints, and has itself the characters of 
active inflammatory disease, the most efficient remedies are 
leeches, or a blister, applied to the epigastrium; abstinence from 
all stimulating food; effervescing potash-water, in small quan- 
tities at a time, to allay thirst; and opium, to alleviate the severe 
pain and to support the action of the heart. In conjunction 
with these remedies, sinapisms or other stimulants should be 
used, for the purpose of recalling the gout to the joints which it 
has recently left. 
I have hitherto spoken only of inflammation of the mucous 
membrane of the stomach. 
Another form of inflammation of the stomach is now and 
then, met with, in which coagulable lymph becomes effused into 
the cellular tissue under the mucous coat, which coagulable 90 
lymph, if not soon absorbed, hardens and contracts, forming a 
dense gristly tissue, binding the mucous membrane to the coats 
beneath. Inflammation having this result, frequently occurs at 
the margin of an old ulcer of the stomach, as at that of an old 
ulcer of the skin; but it often exists also, especially in the neigh- 
bourhood of the pylorus, independently of ulceration or any 
other permanent change of texture in the mucous membrane. 
In such cases, the lymph is generally effused pretty evenly in 
the entire circumference of the pylorus and leads to the forma- 
tion of a gristly ring or band, which, by its contraction, perma- 
nently narrows or strictures the orifice. This form of disease 
seldom occurs till near the age of 40, and is, I believe, almost 
invariably the effect of spirit-drinking. It is usually found in 
conjunction with marks of adhesive inflammation of the liver, 
spleen, and other organs, which spirit-drinking so frequently 
causes. 
INFLAMMATION 
The inflammation most probably involves the mucous mem- 
brane, as well as the cellular tissue beneath; at its onset, 
causes, like other forms of inflammation, pain and tenderness of 
the stomach, and vomiting. The inflammatory symptoms sub- 
side as the mucous membrane recovers; but gradually the lymph 
in the cellular tissue contracts, and those disorders ensue which 
a narrowing of the pyloric orifice of the stomach occasions. The 
food is retained in the stomach longer than it should be; the 
stomach consequently grows larger, and the patient has an unu- 
sual facility of vomiting. Some years ago, I made a 'post-mortem 
examination of a gentleman who died of granular disease of the 
kidney, in whom narrowing of the pyloric orifice of the stomach, 
from adhesive inflammation of the cellular tissue, likewise 
existed. The only indication of this latter disease was an extra- 
ordinary facility of vomiting, which he had long had. He could 
empty his stomach almost when he-pleased; but he sometimes 
vomited involuntarily, especially after having indulged more 
than usual in eating and drinking; and, on such occasions, it 
almost invariably happened that the liquids he had taken were 
rejected, while the solids were retained. 
When the narrowing of the orifice is greater, and the action 
of the muscular fibres near the pylorus is impeded, the stomach OF THE STOMACH. 
91 
seldom completely empties itself, and the acid residue of diges- 
tion in it ferments, causing heart-burn, sour eructations, and 
flatulence, and now and then excites inflammation of the mucous 
membrane. The stomach continues to grow larger, and, as its 
capacity augments, the vomiting may become less frequent, but 
more is thrown up at a time, and at length the disease destroys 
life by impeding the passage of the food into the intestine. 
The same symptoms of obstruction are produced by cancer of 
the pylorus, which occurs at the same age, and from which the 
disease we are considering is distinguished by its slower pro- 
gress ; by the absence of haemorrhage, which frequently occurs 
in cancer; by the absence of any perceptible tumour; and by 
the circumstance, that it occurs almost exclusively in spirit- 
drinkers. 
In some cases, the disease, instead of being limited to the 
pylorus, extends some distance in front of it, and the morbid 
changes, as well as the symptoms, are very djfficult to distin- 
guish from those of cancer. 
During the inflammatory process, the disease, like adhesive 
inflammation of the liver, is probably much under the influence 
of treatment. Leeches, and blisters, and diet, would lessen the 
inflammatory action, and no doubt favour the absorption of the 
effused lymph. When the inflammatory process is over, and 
the lymph has become hard and contracted, the treatment can 
only be palliative. The evils resulting from undue acidity and 
flatulence may be mitigated by remedies suited to these condi- 
tions : vomiting and other gastric disorder may be lessened by 
proper regulation of the diet: but the most important point is, 
to make the patient give up his habit of drinking, and thus to 
prevent recurrence of the inflammation and other addition to the 
mischief already done, than that which time of itself brings. 
In the treatment of inflammation of the mucous membrane of 
the stomach, the fundamental point is to give the stomach suffi- 
cient intervals of rest, and to avoid irritating it by physic or 
food. For inflammation brought on by alcholic drinks, or by 
undigested or irritating food, nothing more is generally necessary 
than cooling drinks and restriction for a few days to a sparing 
diet, consisting of light broths, farinaceous substances, and milk. 92 
INFLAMMATION 
If the inflammation be very severe, causing much pain and ten- 
derness, with a sense of heat at the stomach and frequent vomit- 
ing on the contact of food, leeches may be applied to the epigas- 
trium; the stomach may be cooled, and its irritability much 
lessened, by sipping from time to time iced water, or by holding 
pieces of ice in the mouth, and swallowing the water as the ice 
dissolves; and the diet may be still further restricted. Broths 
may be interdicted, and, for a few days, nothing more be allowed 
than the simplest drinks, and those farinaceous substances that 
are principally composed of starch. In active inflammation of 
the entire stomach, or when, from any cause, the digestive power 
is very feeble, there is usually dislike of animal food, and, 
by a natural instinct, arrowroot, gruel, etc., are substituted for 
it. Even farinaceous substances, when they contain much 
gluten, are found to be heavy and oppressive. The peculiar 
business of the stomach is to dissolve the albuminous constitu- 
ents of the food. The gastric juice has comparatively little 
action on the stomach, which, consequently, taxes the stomach 
less, most probably passes out of the stomach more quickly, and 
is certainly found, when the digestive power is suspended, to be 
less oppressive to it. As I have before observed, the restoration 
of the stomach to its healthy condition is greatly promoted by 
the active nutrition of its lining membrane. 
It may here be not an unfitting place to speak of an appear- 
ance of the inner surface of the stomach, to which attention was, 
I believe, first called by M. Louis, who described it as the uetat 
mammelonne,” “the mammillated state,” of the mucous mem- 
brane. The mucous membrane in some parts of the stomach, 
instead of having an even velvety surface, presents prominences 
not unlike the granulations of a wound, separated by superficial 
furrows. 
The mucous membrane which exhibits this mammillated ap- 
pearance varies in colour in different cases, being sometimes 
rosy, but more commonly greyish. It is always manifestly 
thickened, and is usually covered by a thicker layer of mucus, and 
by more viscid mucus than other portions of the stomach. By 
some pathologists, the mammillated state has been ascribed to OF THE STOMACH. 
93 
contraction of the muscular fibres of the stomach. The muscu- 
lar fibres of the stomach, as of other parts, contract after death 
by the rigor mortis, and contract in greater degree than the 
mucous membrane. The tendency of this contraction must be 
to throw the mucous membrane into folds, or, if the mucous 
membrane be adherent along certain lines to the tissues beneath, 
to raise or throw out the intermediate spaces, and thus, if the 
adherent lines be fitly placed, to produce prominences like those 
in question. 
But it was rightly remarked by M. Louis, that the mammil- 
lated appearance of the stomach cannot be attributed to contrac- 
tion of the muscular fibres, because it is often found in stomachs 
which are considerably distended, and sometimes does not exist 
at all when the stomach is much contracted. It really depends 
on actual thickening of the mucous membrane at the projecting 
spots, and this may arise from various causes. 
It sometimes arises from mere increased secretion, or retained 
secretion; and in that case, by strong pressure of the finger, the 
retained mucus may be squeezed out, and the mammillated 
appearance be destroyed. The appearance is most common in 
those parts of the stomach where the mucous membrane is thick- 
est, and furnishes the most viscid mucus. In the big end of the 
stomach, where the membrane is thinner and its secretion more 
liquid, it is less frequently seen, and, when it does exist there, 
is less in degree. 
It is sometimes found, as a consequence of retained secretion, 
in persons who had fasted for some hours before death. 
In persons who die speedily of malignant cholera, where the 
stomach pours out in extraordinary abundance a gruel-like fluid, 
the mucous membrane in a large portion of the organ always 
presents in a striking degree this mammillated appearance. By 
pressure between the fingers, a thick, gruelly fluid may be 
squeezed out, and the membrane be at once rendered smooth 
and even. 
The appearance is also often seen in persons dead of yellow 
fever, which resembles cholera in being attended by an abundant 
secretion from the mucous membrane of the stomach. 
The mammillated state was attributed by M. Louis to inflam- 94 
INFLAMMATION, 
mation of the mucous membrane, and may doubtless result from 
the thickening of the mucous membrane which inflammation 
causes; but it may equally arise from any other vital process 
which increases the secreting activity of the cells and favours 
the retention of the secreted fluids within them. That it is not 
generally a serious pathological change is sufficiently shown by 
the observation of M. Louis himself—that often it is not denoted 
by any symptoms of gastric disturbance, and that it is always 
found in conjunction with some other disease. Another circum- 
stance which shows that it cannot be considered in all cases a 
morbid state is, that it is sometimes found in persons killed by 
accident in the midst of health. 
On the 15th of May, 1846, at eleven, a.m., a robust labourer 
fell from a scaffolding at the British Museum, and fractured 
several of his ribs. He was taken to King’s College Hospital, 
where he died about an hour after the accident. The following 
day, twenty-six hours after death, when the body was opened, 
the stomach was found empty, and the mucous membrane to- 
wards the pyloric end was of a greyish colour, thickened, mam- 
millated, and covered with ropy mucus. The mammillated ap- 
pearance probably resulted here from the circumstance, that 
death occurred just before the time of the principal meal, and 
when the stomach had been for some hours empty. LECTURE YL 
Ulceration of the mucous membrane of the stomach. The ‘perforating or 
simple uloer. 
I shall call your attention to-day to an affection of tire 
stomach, which is often brought under our notice in the hospital, 
and which has been yariously termed simple ulcer, or chronic 
ulcer, or perforating ulcer, of the stomach. The series of pre- 
parations which I have placed on the table afford good illustra- 
tions of its various forms and results. 
In most cases, the stomach presents no marks of disease, 
except a single deep ulcer on its inner surface. This ulcer is 
seldom larger than a shilling, but sometimes, especially when it 
is situated on the posterior wall of the stomach, grows to the 
size of a crown-piece, or larger even than this. It is generally 
circular or oval, and in all cases extends through the mucous 
membrane, the edges of which are clean-cut, as if a portion of 
the membrane had been punched out. Sometimes, the mucous 
membrane only is destroyed, and the ulcer has then an even 
base, formed of the submucous cellular tissue. In other cases, 
after a time, the process of ulceration eats through the other 
coats of the stomach in succession, so that perforation takes 
place and some of the contents of the stomach escape into the 
sac of the peritoneum. 
The outer coats of the stomach are always destroyed in less 
extent than the mucous coat, so that, when perforation occurs, 
the aperture seen from without is much smaller than the cor- 
responding ulcer of the mucous membrane. 
At first, and often for a long time after the formation of the 
ulcer, the coats of the stomach at its margin present no change 
of structure; but in cases of long standing the margin of the 96 
PERFORATING ULCER. 
ulcer, like tliat of an old ulcer of the skin, is frequently hard 
and tkick, from the contraction of lymph that has been effused 
into the submucous cellular tissue. This hardness and thicken- 
ing seldom, however, extend more than a line or two from the 
edge of the ulcer. 
It frequently happens that, before all the coats of the stomach 
are eaten through, adhesive inflammation of the peritoneum over 
the ulcer is set up, and lymph is poured out, which glues the 
portion of the stomach covering the ulcer to the pancreas, or to 
the left lobe of the liver, or to some other organ with which it 
happens to be in contact. The adhesions formed in this way 
often prolong the life of the patient by closing the aperture made 
by the ulcer, and thus preventing extravasation of the contents 
of the stomach into the peritoneal sac. 
When the ulcer extends deeper than the mucous membrane, it 
frequently opens a branch of one of the arteries with which the 
stomach is supplied, and thus causes sudden and profuse, and, it 
may be, fatal haemorrhage. 
The ulcer is generally situated along the lesser curvature of 
the stomach, or near it; usually nearer the pyloric orifice than 
the cardiac ; and much more frequently on the posterior wall of 
the stomach than on the anterior. It is hardly ever found in 
the splenic or big end of the stomach, where the softening of 
the mucous membrane caused by the gastric juice is most apt to 
occur. 
An ulcer is now and then met with in the first or upper part 
of the duodenum, having precisely the same characters as the 
simple ulcer of the stomach, and doubtless formed in the same 
way. 
In most cases of simple ulcer of the stomach the ulcer is soli- 
tary, and, as I have before observed, the stomach presents no 
other marks of disease, except such as are clearly traceable to it. 
Now and then, however, more than one ulcer exists. Of seventy- 
nine cases collected by Eokitansky the ulcer was solitary in 
sixty-two. Of the remaining seventeen cases there were twelve 
in which two ulcers existed; four in which there were three 
ulcers; and one in which there were five. Of the preparations 
which I have placed on the table there are three in which two 97 
ulcers exist in tlie same stomach. Now and then an ulcer in 
the duodenum is found in conjunction with one in the stomach. 
PERFORATING ULCER. 
A simple ulcer of the stomach is sometimes met with cica- 
trised. The ulcer heals just like an nicer of the skin. The 
portion of the mucous membrane destroyed is replaced by a 
dense fibrous tissue, which contracts, and thus draws toward the 
centre of the ulcer, and consequently puckers, the mucous mem- 
brane around it. The newly-formed fibrous tissue has a very 
different appearance from the mucous membrane of which it 
takes the place, and never fills up the cavity or depression 
formed by the ulcer,—so that the scar of the ulcer is readily 
discernible by the deep permanent depression which is thus left, 
as well as by the puckering of the mucous membrane around it. 
If, however, the ulcer be small, its edges may be drawn together 
and unite, and a mere stellar cicatrice be left, without any per- 
manent depression. 
When the ulcer is large and situated across the lesser curva- 
ture of the stomach, the process of healing, by the contraction 
that attends it, often permanently alters the shape of the stomach, 
diminishing its breadth at that part. This change of shape is 
very striking in these two preparations from the King’s College 
museum, in each of which the stomach is divided into two 
pouches, as if by a string passed transversely round it, looping 
up the greater curvature towards the lesser. 
Such are the facts respecting the simple ulcer of the stomach 
that have been learned from dissection, and from some of these 
facts—from the circumstance, namely, that the ulcer always 
extends through the mucous membrane, and that, when first 
formed, it has always a definite circular or slightly oval shape 
and clean-cut edges—there can be little doubt that it is formed 
by sloughing of the mucous membrane, and not by a process of 
ulceration commencing at the surface. 
The important question now naturally arises,—Under what 
circumstances does the ulcer occur, and by what agency is it 
produced ? On these points our knowledge is very defective. 
The disease is met with in both sexes, but as it appears, more 
frequently in women than in men. In the 79 cases I have 
before referred to, of which an analysis has been given by llokit- 98 
CAUSES. 
ansky, 46 occurred in women, 88 in men. It hardly ever occurs 
under the age of 16,* but is found in persons of all ages from 
this to 60 and upwards. According to Rokitansky, it is met 
with more frequently in persons beyond 50 than in persons 
under 30. 
It occurs in tbe different countries of Europe in wbicb morbid 
anatomy is cultivated; in agricultural districts and in large 
cities; and, though not with equal frequency, in the various 
classes of society. It seems to be much more frequent, even 
considering their relative numbers, among the poor than among 
the rich, and, in this country, is generally supposed, and I believe 
rightly, to be most frequent in the class of maid-servants, between 
the age of 18 and that of 25. Lastly, the ulcer has not been 
found in conjunction with, or in sequel to, any other disease, 
with such frequency as to lead us to conclude that it has any 
intimate connexion with it. 
It is clear that these facts have not yet given us the clue to the 
real cause of the disease. The circumstance, if it be true, that 
the disease is more frequent, relatively to their numbers, among 
the poor than among the rich, and that it is more frequent 
among unmarried maid-servants than in other classes, would 
favour the inference, that a state of anaemia disposes to it. But 
it is almost idle, at present, to speculate further. The observa- 
tions yet made do not enable us to explain how it is that the 
ulcer hardly ever occurs under the age of 16; how or why it is 
that the ulcer is always situated in what has been termed the 
pyloric division of the stomach or in the first part of the duode- 
num ; how it is, again, that the ulcer is generally single, and 
that it is so much more frequent along the lesser curvature of 
the stomach, or near it, than in any other part. 
Peculiarities in the structure or function of the pyloric division 
of the stomach, or some physiological relation between the 
stomach and other parts not yet suspected, may, by-and-by, be 
brought in evidence, and may perhaps furnish satisfactory an- 
swers to these important questions. That there are such phy- 
siological relations as I have here suggested is rendered ex- 
* I have met with one instance in which it occurred, in a girl, at the age of 
fourteen and a half. 99 
EFFECTS. 
tremely probable by the remarkable discovery, made a few 
years ago by Mr, Curling, that severe burns are frequently fol- 
lowed, at least in young persons, by a sloughing ulcer of the 
middle portion of the duodenum, which, like the ulcer of the 
stomach of which I am speaking, frequently destroys life by 
eating into an artery, and thus causing sudden and profuse hge- 
morrhage, or by leading to fatal perforation. 
Waiving, then, any further speculation on the cause of the 
ulcer, let us turn our attention to its effects and to the circum- 
stances which promote or hinder its healing. 
An ulcer in the stomach, however produced, which has ex- 
tended through the mucous membrane, is clearly very difficult 
to heal; and when cicatrization does take place, the lost sub- 
stance is very imperfectly restored, and, unless the ulcer be a 
very small one, a deep depression, or pit, is left. 
The contrast which the stomach presents in this particular 
with the small and with the large intestine is very striking. 
The ulcers which form in the small intestine in typhoid fever ge- 
nerally heal in a few weeks, when the force of the fever is past. 
The ulcers which form in the large intestine in dysentery often 
heal rapidly, if proper care in diet be taken; and in those cases 
in which they remain open, or in which some of them remain 
open, for years, no perforation of the intestine takes place. At 
the bottom of the ulcer lymph is effused, which becomes firm 
and resisting and effectually protects the coats beneath. 
Several circumstances conspire to prevent the same thing from 
happening in the stomach. 
The first of these is the great change of volume to which the 
stomach is liable two or three times a day. Directly after a 
meal it is full and large, and at the enofc of three or four hours it 
is again empty and contracted. 
The healing of an ulcer must also be retarded by the constant 
churning motion that takes place in the stomach during digestion. 
Dr. Beaumont observed that, in the stomach of St. Martin, as 
long as digestion was going on, the food was regularly carried 
round and round, in from one to three minutes, from left to 
right along the great curvature of the stomach, and from right 
to left along the lesser curvature. 100 
PERFORATING ULCER. 
The sagacity of Hunter had already led him to infer that re- 
gular movements take place in the stomach, from the circum- 
stance that-in the hair-balls found in the stomachs of cows and 
some other animals the hairs have a regular direction. 
In a state of health, we are happily unconscious of these 
movements of the stomach, as we are of the stronger contrac- 
tions and movements of our hearts ; but when an ulcer exists 
in the stomach they must fret its surface and be an obstacle to 
its healing. 
The process of healing is doubtless hindered also by the irri- 
tation of the sore caused by the various substances which are 
taken as food. 
The mucous membrane of the stomach is so organized as to 
bear with impunity, when healthy, the contact of substances 
differing widely in their qualities. The stomach is intended to 
be the common receptacle of the various matters from which the 
nutriment of the body is derived : and its mucous membrane, 
with which all these matters are brought into contact, is so or- 
ganised as not to be injured or painfully affected by them. But 
when a portion of the mucous membrane is destroyed, the mild- 
est articles of food cause pain—a change of temperature even, by 
the drinking of water too hot or too cold, causes pain—and the 
surface of the sore is constantly fretted, and its healing retarded, 
by the contact of those substances which are the natural and ap- 
propriate stimulus of the mucous membrane. 
The healing of an ulcer in the stomach is probably retarded 
also by the action of the gastric juice. The solvent power of this 
juice has, indeed, no injurious effect on the living mucous mem- 
brane, but it probably dissolves and removes the lymph which 
is poured out on the bottom of the ulcer, and it is only by means 
of this plastic lymph that the lost substance can be repaired and 
the ulcer heal. 
All these circumstances explain how it is that a small ulcer, 
which causes no constitutional disturbance, which may not even 
much impair the nutrition of the body, and which, if situated in 
a lower portion of the same canal, might soon heal, becomes so 
serious a disease,—how it leads so frequently to long-continued 
suffering and death. 101 
SYMPTOMS. 
It is now time that we should consider the symptoms of ulcer 
of the stomach and the circumstances by which it may be dis- 
tinguished from other affections of this organ. 
We have already seen that the disease is one of considerable 
danger—that it may at any time destroy life, almost suddenly, 
by causing perforation of the stomach or profuse haemorrhage. 
We have seen, too, that it is a curable disease—that the ulcer, 
even when of long standing, may heal, and the health of the 
patient be restored—and there can be no doubt that the healing 
of the ulcer and the recovery of the patient may be brought 
about or be much promoted by judicious treatment. The health 
and life of the patient may depend, then, on our ascertaining the 
real cause of his ailments. But, at an early period of the disease 
it is not easy to do this. We are not aided in detecting the 
disease by knowledge of its causes or of any peculiar circum- 
stances under which it is apt to arise ; and when the disease is 
recent, the symptoms are of doubtful character, and often the 
sufferings of the patient and the derangement of his health are 
so slight as not to alarm either himself or his friends. Sometimes 
he follows his usual occupations, and seeks no advice, till perfo- 
ration of the stomach takes place. He does not even regard him- 
self as an invalid, and is considered by his friends in good health, 
when he is seized suddenly with agonizing pain at the epigas- 
trium and with the other symptoms of peritonitis from perfora- 
tion, falls rapidly into collapse, and dies within twenty-four or 
thirty-six hours. 
In such cases, the character of the symptoms—especially the 
great suffering referred to the stomach and the suddenness with 
which life is cut short in the midst of apparent health—often 
lead to a suspicion of poisoning. One instance of this kind, 
which gave rise to a coroner’s inquest, has fallen under my own 
observation, and many others are related in the systematic works 
on forensic medicine. A perusal of these works might, indeed, 
lead to the belief that the symptoms which precede perforation 
are generally trivial; but such is by no means the case. In a 
great majority of instances the symptoms are distressing, and, 
when the disease has lasted some months, they are generally 
significant enough. 102 
PERFORATING ULCER. 
The most constant symptom is pain in the stomach, which is 
generally referred to a small spot, and is more severe after meals, 
when the stomach is distended and when its vermicular move- 
ments are going on. The pain usually abates as the stomach 
gets empty, to be renewed again by the next meal, blow and 
then, however, pain is also felt when the stomach is empty. 
Together with this pain, there is some degree of tenderness, or 
soreness, at the epigastrium; but this is often slight, and, like 
the pain, is generally referred to a small spot. Besides the pain 
at the epigastrium, pain is very commonly felt in a small space 
in the corresponding part of the back. There is also occasional 
eructation of a sour fluid, and now and then, perhaps only once 
or twice in a month, the patient vomits his food. 
The disease causes very little constitutional disturbance. 
Unless the ulcer be large, there is complete absence of fever 
and of thirst, the appetite is commonly but little impaired, and 
the patient does not fall away perceptibly in flesh or in strength. 
The pain at the stomach after meals, and the sour eructations, 
and, it may be, the occasional vomiting, are the only symptoms 
of disease. These symptoms persist, and the patient may go on 
for months, heeding them but little, and following his ordinary 
course of life. At times, however, the pain at the stomach gets 
more severe, and the vomiting more frequent, and the appetite 
fails. Now and then there is slight diarrhoea. These exacer- 
bations render a restricted diet necessary; and, under the influ- 
ence of this, the symptoms soon return to their former degree, 
and the patient goes on as before. 
After a time, the ulcer may begin to heal and the pain of the 
stomach to abate. The process of healing may go on uninter- 
ruptedly and the health be permanently restored; but more 
generally the amendment is only temporary, and, after an inter- 
val of comparative ease, the former pain and uneasiness of the 
stomach return. 
But, as dissection has already disclosed, the ill effects of ulcer 
of the stomach do not end here: the patient is liable to accidents 
which may at any moment place his life in jeopardy. The most 
common of these is profuse haemorrhage, in consequence of the 
ulcer eating into one of the arteries of the submucous cellular 103 
SYMPTOMS. 
tissue. The haemorrhage is often preceded for a day or two by 
an increase of pain, which may, perhaps, be taken as evidence 
that the ulcer is spreading; but, in other cases, it occurs without 
any aggravation of the usual symptoms. 
If the blood be poured out in small quantity or slowly, it may 
pass off by the bowel, without causing vomiting. The patient 
grows rapidly weak and listless, has a slight diarrhoea, without 
tenderness of the belly or fever, and the discharges from the 
bowels are copious and black. More frequently the blood is 
poured out in large quantities at a time, and acts as an emetic. 
The patient has a sense of weight at the epigastrium and a feel- 
ing of faintness and nausea, soon succeeded by vomiting of a 
large quantity—from one to three pints—of black, clotted blood. 
The vomiting is followed by a state of faintness, and the haemor- 
rhage ceases. Frequently, the vomiting recurs on the same or 
the following day, and a large quantity of blood is again brought 
up. Some blood also passes downwards, and the discharges 
from the bowels are copious and black. 
At the end of a day or two the haemorrhage ceases entirely, 
and the patient is left blanched and weak. In addition to the 
sufferings which belong properly to the disease of the stomach, 
he has now those which result from the loss of blood. Slowly, 
and by degrees, the loss of blood is repaired, and the symptoms 
directly referable to the stomach alone remain. 
In the majority of instances, after the lapse of some months, 
or, it may be, of two or three years, haemorrhage comes on again. 
The patient, after a day or two’s increase of pain, but sometimes 
without this and quite suddenly and unexpectedly, is taken, as 
before, with faintness and nausea, which is followed by vomiting 
of black, clotted blood. The circumstances of the former attack 
are repeated, and, at the end of a day or two, at most, the hae- 
morrhage again ceases. 
The occurrence of haemorrhage is an accident, and may take 
place soon after the formation of the ulcer, or years after, or not 
at all. It may result from a small ulcer, and not from a large 
one. It has, therefore, no constant relation to the severity of 
the other symptoms. When haemorrhage has once occurred it is 
very apt to occur again. I have known an abundant hemor- 104 
PERFORATING ULCER. 
rhage do good by inducing an early resort to proper treatment, 
and by thus preventing a small ulcer from growing large. 
In cases wbicb are very protracted—where tbe ulcer remains 
open, as it sometimes does, for many years—it happens not un- 
frequently, that an outpouring of blood, such as I have described, 
occurs four or live times, at unequal, and, it may be, long inter- 
vals. Notwithstanding that the haemorrhage is generally abun- 
dant, it seldom proves immediately fatal. Among a large num- 
ber of cases of this kind that have fallen under my own observa- 
tion, there have been only two or three in which this happened. 
In one of these cases, the patient, who was master of the 
parish school of St. Clement’s, lived in the immediate vicinity 
of the hospital, and a complete history of his illness was taken. 
Symptoms of ulcer of the stomach first appeared in June, 1842, 
when he was forty-eight years of age: and from this time till 
his death, which happened in December, 1844, he was frequently 
under my care on account of it. He had an abundant hasmor- 
rhage from the stomach in October, 1848, which ceased at the 
end of two or three days, and did not recur till the 20th of De- 
cember, 1844. On the evening of that day, he grew faint and 
vomited blood. The loss of blood was not, however, sufficient 
to prevent his attending his school as usual. On the evening of 
the 23d he grew faint again, and felt sick, but did not vomit. 
He complained of griping pains in the belly, but was not purged. 
About an hour afterwards he fell down in a fainting lit and ex- 
pired. 
The stomach and the whole of the intestinal canal down to 
the descending colon were distended with dark, clotted blood. 
The ulcer from which the blood came was situated on the pos- 
terior wall of the stomach, about two inches to the right of the 
cardiac orifice, and was as large as half-a-crown. It had de- 
stroyed all the coats of the stomach down to the pancreas, which 
was there adherent to it, and had eaten through a large artery, 
which I took to be the splenic, from which the haemorrhage 
doubtless proceeded. Nearer the cardiac orifice was the de- 
pressed scar, about the breadth ol a shilling, of another ulcer 
which had healed. 
On the table is a preparation showing an ulcer on the posterior SYMPTOMS. 
105 
wall of the stomach, which caused fatal haemorrhage by eating 
into the splenic artery; and another preparation showing an 
ulcer on the lesser curvature which led to the same event by 
laying open the gastric or coronary artery. 
Simple ulcer of the stomach, as I have already remarked, 
seldom proves fatal by haemorrhage. Cruveilhier states, that, 
of the cases which he had collected, the only ones that proved 
fatal in this way were those in which the ulcer had eaten (as in 
the preparations to which I have just pointed) into the gastric 
or the splenic artery. These ulcers form most commonly, as we 
have seen, along the lesser curvature of the stomach, or on its 
posterior wall; so that the gastric artery, which runs along the 
lesser curvature, and the splenic artery, which crosses the pos- 
terior surface, are liable to be involved in the ulcer. 
But death results much more frequently from another acci- 
dent to which persons with this kind of ulcer are liable—namely, 
perforation of the stomach, and the escape of its contents into the 
sac of the peritoneum. When this happens, the patient is seized 
.suddenly, with agonizing pain at the epigastrium, soon followed 
by the other symptoms of peritonitis from perforation, and 
usually dies in from eighteen to thirty hours. 
As I have already remarked, the occurrence of death in this 
sudden way, in a person who, up to the time of the perforation, 
had been following his usual course of life, and had seemed in 
good health, has often led to a suspicion of poisoning. All the 
concomitant circumstances have, in consequence, been often 
noticed and recorded with extreme care and minuteness. Mr. 
Alfred Taylor, who has published an excellent paper on this 
subject it its medico-legal relations, (in the fourth volume of 
“ Guy’s Hospital Reports,”) states, that the perforation generally 
occurs soon after a meal. Its more frequent occurrence at that 
time is, no doubt, chiefly attributable to the distention of the 
stomach which then exists, and to the vermicular movements of 
its coats, which are then taking place; but it may possibly also 
be owing, in some degree, to the solvent action of the gastric 
juice. When the ulcer has eaten down to the peritoneal coat, 
and has, perhaps, impaired the vitality even of this, the gastric 106 
PERFORATING ULCER. 
juice may exert its solvent action upon it, and immediately 
cause tlie catastrophe. 
In some cases the process of ulceration is rapid, and perfora- 
tion occurs early, without having been preceded by any severe 
or alarming symptoms, and within a few weeks (it may be) of 
the formation of the ulcer. In other cases the ulcer remains 
open for many years, giving rise to its ordinary symptoms, and 
now and then to an alarming haemorrhage; and, at last, leads 
to the fatal perforation. A remarkable instance of this kind fell 
under my care in King’s College Hospital, in October, 184-3. A 
house-carpenter, sixty-three years of age, who had had the usual 
symptoms of ulcer of the stomach for fifteen years, was brought 
into the hospital on the 3rd of October, in a state of extreme 
exhaustion from vomiting of blood, which came on some days 
before. The haemorrhage had then ceased, and did not again 
recur. Two days after his admission to the hospital, perforation 
of the stomach occurred, and he died twenty hours afterwards. 
The ulcer, which was not larger than a shilling, was situated on 
the lesser curvature of the stomach, about half an inch from the 
pylorus, and had a hard and thickened edge. The rest of the 
stomach and the intestines throughout were perfectly sound. 
Occasionally perforation takes place, but the contents of the 
stomach are not effused over the wdiole surface of the peritoneum, 
so as to excite general peritonitis. The diffusion of the contents 
of the stomach, and of the consequent inflammation, is prevented 
by adhesions which have already taken place; and the result is 
a circumscribed abscess in the sac of the peritoneum, behind the 
ulcer. One instance of this has fallen under my own notice, 
and two others are recorded by Dr. Seymour, in a paper pub- 
lished in the u Medical Gazette” for 1844. When this happens, 
and when the abscess is of considerable size, there is, of course, 
constant suffering, with loss of appetite and hectic fever, which 
soon wears out the strength of the patient. 
Fatal perforation is, I believe, most common when the ulcer 
is situated on the anterior wall of the stomach or along its lesser 
curvature. It would take place much oftener than it does, were 
it not for adhesions which are apt to form between the peritoneum SYMPTOMS. 
107 
covering the nicer and some other organ which this part of the 
stomach may happen to touch. Before all the coats of the sto- 
mach are eaten through, adhesive inflammation is set up in the 
portion of peritoneum covering the ulcer, and coagulable lymph 
is poured out, which serves, in some degree of itself, as a safe- 
guard against perforation, and which glues the stomach at this 
part to the organ with which it happens to be there in contact. 
By this means the aperture which the process of ulceration 
would otherwise cause is stopped. The pancreas is, from its 
situation, the organ by which fatal perforation is most commonly 
prevented. The symptoms which denote this partial adhesive 
inflammation of the peritoneum are an aggravation of pain and 
of tenderness, (which are still confined to the region of the sto- 
mach,) more frequent vomiting and a certain degree of fever. 
It happens now and then, that, without perforation taking 
place, or at least without extravasation of the contents of the 
stomach taking place, the adhesive inflammation of the peri- 
toneum set up above the ulcer, instead of being confined to the 
immediate vicinity of the ulcer and leading to the effusion of 
only a small quantity of lymph, is much more extensive—lymph 
is poured out in considerable quantity, the stomach becomes 
united to all the adjacent viscera, and some coils of intestine, it 
may be, become united to each other,—so that after the inflam- 
mation has subsided, besides the symptoms which properly be- 
long to ulcer of the stomach, the patient is liable to obstruction 
of the bowels and other evils which result from the natural 
movements of these organs being restrained. 
All this happened to a man from whom the stomach forming 
this preparation was taken, who died under my care in March,. 
1845. The stomach was much altered in shape, being length- 
ened at the expense of its breadth, and was united to all the 
adjacent organs—the liver, the spleen, the pancreas, the colon— 
so firmly, that it could only be separated from them by dissec- 
tion, The coils of intestine in the upper half of the belly were 
glued together in the same way. 
The ulcer which was the source of all this mischief was, at the 
time of death, of the size of a fourpenny piece, nearly circular, 
and situated midway between the orifices, along the lesser cur- 108 
PERFORATING ULCER. 
vature of the stomach. The edges of the ulcer are indurated, 
and the mucous membrane for some distance around is puckered 
by the contraction which the ulcer has undergone. 
In this instance, death resulted from exhaustion, which was 
occasioned, not merely by the ulcer in the stomach, but also by 
the adhesions of the stomach and bowels which resulted from 
it. These adhesions, by causing obstruction, led to frequent 
vomiting, and doubtless prevented in other ways the proper 
action of the digestive organs. 
It now and then happens, when the ulcer attains a large size, 
that death results from exhaustion, without any such extrane- 
ous mischief. 
When the ulcer is situated near the pylorus and is of large 
size or has a thick and hardened edge, the action of the muscular 
fibres near the pylorus is hindered, and, in addition to the symp- 
toms properly belonging to an ulcer of the stomach, there are 
those which result from obstruction of the pyloric orifice. The 
stomach does not completely empty itself, and the residue of 
digestion in it ferments, causing sour eructations, and flatulent 
distension of the stomachy which is an additional source of pain. 
The matters vomited in such cases are often extremely sour, and 
after death the stomach very commonly contains some muriatic 
or lactic acid, which dissolves, or digests, the mucous membrane 
in its big end, where the liquids that are in it collect. The 
same thing happens when an ulcer situated some distance from 
the pylorus along the lesser curvature, in the process of healing, 
contracts in a direction transverse to the curvature, and thus 
loops up the stomach at this part and divides it into two 
pouches. In that case the pouch at the big end does not com- 
pletely empty itself; some of the acid residue of digestion re- 
mains in it, and the mucous membrane in this portion of the 
stomach is found dissolved after death. One of the prepara- 
tions on the table affords a striking illustration of these effects. 
The stomach is divided into two distinct pouches by the con- 
traction of an ulcer situated on the small curvature of the 
stomach, midway between the cardiac and pyloric orifices; and 
the mucous membrane in the left, or cardiac, pouch has been 
completely destroyed by the action of the gastric juice after 109 
SYMPTOMS. 
death. This peculiar destruction of the coats of the stomach 
shows that the stomach contained a digesting acid at the time of 
death, and affords a clue to much of the gastric disorder that 
exists in such cases. 
A remarkable instance of a large simple ulcer of the stomach 
proving fatal by mere exhaustion has been lately under our ob- 
servation at the Hospital. 
On the 17th of March, Sarah White, a poor woman 56 years 
of age, was brought into the Hospital in a frightful state of 
emaciation—the bones almost starting through the skin. She 
was, of course, extremely feeble, and was, besides, so listless 
that no connected history of her illness could be taken. As far 
as could be gathered from her statements, she had always been, 
weakly, but had no serious illness till the preceding autumn— 
about six months before—when she became troubled with indi- 
gestion and occasional vomiting. This continued to increase, 
and about December she began to suffer very severe pain at the 
stomach, accompanied with frequent vomiting of what she de- 
scribed as a sour and offensive phlegm. She did not, she said, 
reject her food, although she was only able to take it in small 
quantities at a time, owing to the pain and uneasiness it gave 
her. In January she had got so weak that she was obliged to 
take to her bed, and then had a great loathing of food and 
rapidly fell away in flesh. She continued to vomit sour fluid 
and occasionally her food, and became very costive—the 
bowels not being relieved sometimes for a week or a fortnight 
together, and then never without medicine. She had also offen- 
sive eructations, and in the fortnight preceding her admis- 
sion to the Hospital, several times vomited a matter like coffee- 
grounds. 
When she was brought into the Hospital, her belly was much 
drawn in—so that the iliac arteries could be readily felt—and 
between the ensiform cartilage and the umbilicus a firm tumour 
was noticed, that turned out to be the spine, which was much 
curved forwards in this region. She had frequent vomiting of 
coffee-ground matter and eructations of sulphuretted hydrogen. 
Her loathing of food of all kinds was such that it was with great 
difficulty she could be made to take any. • The little she did eat 110 
PERFORATING ULCER. 
the stomach retained. She died on the 3rd of March, six days 
after she was brought to the Hospital. 
On examination after death, the stomach was found to be 
greatly enlarged, so that it reached the pubis and was there in 
contact with the urinary bladder. It contained a large quantity 
of dark grumous matter, consisting partly of altered blood. On 
its posterior surface it was adherent to the transverse colon and 
to the omentum, and in attempting to detach it from these parts, 
a large simple ulcer was discovered, which had eaten through all 
but the peritoneal coat of the stomach. This ulcer, which was 
situated across the lesser curvature of the stomach, midway be- 
tween the orifices, was almost a perfect circle, 2- inches in diame- 
ter, and had a clean cut margin, without any induration about 
it. The liver was somewhat enlarged and fatty, and the gall- 
bladder contained an oval calculus of cholesterine. There was 
no other disease of any importance in the body. 
From the account I have given of the symptoms and effects 
of the perforating ulcer of the stomach, it will be seen that 
the disease becomes more easy of detection the longer it has 
lasted. 
Early in the disease the symptoms are few and equivocal. 
Pain and soreness at the epigastrium felt after meals, occasional 
sour eructations, and occasional vomiting—which are often the 
only symptoms then present—may result from various other 
causes, and even from mere functional disorder. 
After these symptoms have lasted some weeks or months, their 
very continuance becomes significant—it renders it highly pro- 
bable that they depend on organic disease: while the seat of the 
pain, and the circumstance that it is always increased by eating 
and usually abates as the stomach gets empty, lead to the infer- 
ence that this organic disease is in the stomach. 
After a time the symptoms I have mentioned are often suc- 
ceeded by the sudden occurrence of profuse vomiting of blood. 
When this has happened, the detection of the disease becomes 
much easier. 
Vomiting of blood may, indeed, result from various other con- 
ditions ; but these may generally be distinguished from ulcer by the nature of the illness and by the circumstances under which 
it occurs. 
DIAGNOSIS. 
Ist. Vomiting of blood may result from a general tendency to 
haemorrhage, in consequence of a general fault of nutrition or a 
faulty condition of the blood, as in scurvy or purpura; but in 
such cases the haemorrhage is not confined to the stomach— 
blood issues from other mucous surfaces, and purpuric spots 
appear on the skin. 
2ndly. Again, vomiting of blood may result, as we have seen, 
from mechanical congestion of the stomach, in consequence of 
some impediment to the free passage of the blood through the 
liver or the chest. In such cases, the quantity of blood lost is 
usually small, and the cause of the haemorrhage is generally ob- 
vious enough from the co-existence of other symptoms, which 
reveal the primary disease and which show that the passage of 
the blood through the liver or the chest is greatly impeded. 
Srdly. Vomiting of blood sometimes occurs, without any 
organic disease of the stomach itself, in persons who, in conse- 
quence of repeated attacks of ague, or other causes, have great 
enlargement of the spleen. Here, also, the previous history of 
the patient, his cachectic condition, and the palpable enlarge- 
ment of the spleen, readily lead us to the original cause of the 
haemorrhage. 
4thly. Lastly, the haemorrhage may be vicarious of the cata- 
menia ; and this is especially liable to happen in young unmar- 
ried women,—the class of persons supposed to be most subject 
to ulcer of the stomach. But, in such cases, the haemorrhage 
usually occurs at the monthly period, and the natural discharge 
is suppressed or has previously been irregular; and, if no ulcer 
of the stomach exist, the vomiting of blood, although it may be 
attended with severe pain at the time, has not been preceded, 
and is not followed, by the long-continued pain and soreness 
produced by ulcer. 
In a large proportion, however, of cases even of this periodi- 
cal vomiting of blood, an ulcer of the stomach does exist, and is 
the chief, if not the sole, source of the haemorrhage; but the 
blood, instead of issuing from a vessel of considerable size laid 
open by the process of ulceration, as in ordinary cases of simple 112 
PERFORATING- ULCER. 
ulcer, oozes from the minute vessels of the raw surface, in con- 
sequence of a congestion of the stomach, which takes the place 
of the appointed monthly congestion of the uterus. Symptoms 
of ulcer of the stomach are then present in the intervals of the 
vomitings of blood; and the haemorrhage is traced to a periodi- 
cal congestion of the stomach only from its occurring at the 
appointed time, and from its taking the place of the natural 
monthly courses. 
sthly. The vomiting of blood from the simple ulcer of the 
stomach may also be distinguished from that arising from other 
conditions by the characters of the blood vomited. 
When the haemorrhage consists in a mere oozing of blood, as 
it does in congestion of the stomach and sometimes in cancer, 
the blood is coagulated as it escapes, and is vomited in minute 
clots or shreds. In simple ulcer of the stomach the blood 
usually issues from a vessel of considerable size laid open by 
the ulcer; it is poured out rapidly and abundantly, coagulates 
in a mass, and large clots are often thrown up. 
When vomiting of blood does not depend on any of the con- 
ditions which I have just mentioned, it results almost invariably 
(except in the case of malignant fevers) from organic disease of 
the stomach itself. 
When, therefore, profuse vomiting of blood occurs in a per- 
son who exhibits no general tendency to haemorrhage; who 
has no disease of the liver, or in the chest, which greatly im- 
pedes the passage of the blood ; who has no great enlargement 
of the spleen; and in whom the haemorrhage cannot, from the 
time of its occurrence and other circumstances, be referred to 
disorder of the menstrual function;—we are driven, in reason- 
ing by the method of exclusion, to ascribe it to disease of the 
stomach itself. When such is the case, and when, moreover, 
the vomiting of blood has been preceded for some weeks or 
months by pain and soreness at the stomach, always brought 
on or increased by meals, hardly a doubt can remain that it 
actually depends on organic disease of this organ. But, in per- 
sons under the age of thirty, the only organic disease of the 
stomach that gives rise to profuse haemorrhage, with very few 
exceptions, is ulcer. DIAGNOSIS. 
113 
It follows, therefore, that, from the peculiar train of symptoms 
winch I have mentioned,—namely, pain and soreness of the 
stomach, always brought on or increased by meals, continuing 
for many weeks or months, with occasional sour eructations 
and occasional vomiting, but without much fever or constitu- 
tional disturbance, and succeeded, at the end of that time, by 
profuse vomiting of blood,—it follows that, from this peculiar 
train of symptoms, we may occasionally, in persons between 
eighteen and thirty, infer the existence of ulcer of the stomach 
with almost as much certainty as that of any inward disease. 
In persons above the age of thirty, vomiting of blood, pre- 
ceded by disordered and painful digestion, may likewise occur 
from cancer of the stomach. For persons, therefore, who have 
reached this age, the question will arise,—Is the organic disease 
of the stomach, which we have inferred to exist, simple ulcer, 
or is it cancer ? When the disease has lasted some months, it 
is usually not difficult to answer this question. 
Cancer of the stomach, in most cases, originates at the pyloric 
or the cardiac orifice, and in some degree narrows or obstructs 
it. It also gives rise to a tumour, which, at the end of some 
months, is generally palpable enough; and it ahvays interferes 
greatly with nutrition, causing progressive, and, after a time, 
extreme wasting. 
Simple ulcer seldom produces any of these effects. When, 
therefore, from the train of symptoms I have mentioned, we 
have inferred that organic disease of the stomach exists, we may 
often proceed a step further, and conclude that this disease does 
not obstruct either the cardiac or the pyloric orifice; and from 
the circumstance that the power of digestion remains and that 
there is no great wasting, we may conclude, also, that the dis- 
ease involves only a small portion of the stomach. 
We are thus led to the conclusion that there is organic disease 
of the stomach of such kind as to cause haemorrhage,—that this 
disease involves only a small portion of the stomach,—that it 
does not obstruct the orifices,—and that it does not form a 
tumour large enough to be felt. The probability, in such a case, 
will be very great, that the disease is simple ulcer, and not 
cancer. The probability is the greater, the longer the previous 114 
PERFORATING ULCER, 
duration of the disease. A simple ulcer may continue almost 
stationary—at any rate, with little change in the symptoms—for 
twenty years. Cancerous disease, on the contrary, constantly 
and steadily progresses; the symptoms become, week after week, 
more marked; and, although life may be protracted, especially 
in colloid cancer, for four or five years, the patient generally 
dies, much emaciated, within twelve months. 
If, then, the disease has lasted this time, presenting the peculiar 
train of symptoms I have mentioned, and there is still no great 
wasting, and no evidence that the orifices of the stomach are 
obstructed, and no tumour to be felt, hardly a doubt can remain 
that the disease is simple ulcer of the stomach. The evidence is 
as complete and decisive as we can well have for any inward 
disease. Although, then, it may be difficult, or even impossi- 
ble, soon after an ulcer of the stomach has formed, to distinguish 
it from some other diseases, the distinction may generally be 
made surely enough when the ulcer has existed many months. 
It is often possible to go a step further than this, and to form 
some opinion respecting the size and the site of the ulcer. 
The size of the ulcer may be judged of by the constancy of 
the pain and the severity of the other symptoms. If the pain be 
slight and of short duration, and the appetite be good, and vom- 
iting occur seldom, and there be no wasting,—the ulcer is small. 
The site of the ulcer is determined by the spot in which the 
pain is felt. If there be much tenderness at the epigastrium, and 
no pain in the bade,—the ulcer is most probably on the anterior 
face of the stomach. LECTURE YIL 
Ist. Perforating or simple ulcer of the stomach—Treatment; 2nd. Per- 
forating ulcer of the duodenum ; 3rd. Minute superficial ulcers of the 
stomach. 
We have considered the symptoms and effects of a simple 
nicer of the stomach, and the circumstances by which, after it 
has existed some time, it may generally be distinguished from 
other diseases. 
Supposing the existence of the ulcer to be thus made out, the 
question arises,—How can we best alleviate the sufferings to 
which it gives rise, and obviate its dangers, and promote its 
healing ? 
We have seen that there are several circumstances which, 
impede the healing of an ulcer in the stomach, and which cause 
the repair of the lost substance, when healing does take place, to 
be less perfect there than in lower portions of the alimentary 
canal. These circumstances are,—the great and frequent 
changes of volume to which the stomach is subject; the writhing 
movements that are constantly going on in its coats while diges- 
tion continues; the mass of crude substances that are put into it, 
which, being constantly driven round and round, must contin- 
ually irritate and fret the ulcer; and, as regards the ulcer and 
the secretion from its surface, the irritating and solvent action of 
the gastric juice. It is by lessening as much as possible the 
unfavourable influence of these circumstances that the recovery 
of the patient is best promoted. The chief means of effecting 
this is by proper regulation of the diet. The patient should 
prevent the ill effects of distention of the stomach, and, as much 
as possible, of change of volume of the stomach, by eating little 
at a time ] and the food taken should be of the least irritating 116 
PERFORATING- ULCER. 
kind. Whatever would irritate an ulcer on tlie skin will irri- 
tate an ulcer in the stomach. 
Milk, and compounds of milk with farinaceous substances— 
which would make a soothing poultice for an ulcer of the skin— 
are the articles of food which are the most soothing, or, rather, 
which cause the least pain, in ulcer of the stomach, and are, 
therefore, those on which the patient should mainly subsist. As 
a diet of this simple kind requires to be persevered in for a con- 
siderable time, especially when the ulcer is large or of long 
standing, care should be taken that the milk is of good quality, 
and the farinaceous substances given with it should be of the 
most nutritious kind. Bread, maccaroni, semolina, biscuit-pow- 
der, and other substances made of flour; Indian-meal, where 
there is no repugnance to it; and oatmeal,—are preferable to 
arrowroot, and those other farinaceous substances which mainly 
consist of starch. If the milk be good and the farinaceous sub- 
stances be properly selected, a person may be kept for a long- 
time on such a diet, in conjunction with sugar and tea, without 
any impairment of strength. 
When the irritability of the stomach is not great, finely-mash- 
ed potatoes, mashed turnips or carrots, and other soft and well- 
cooked vegetables, in small quantity, may likewise be given; 
and there will then be little danger that the general health of 
the patient will suffer from the restriction of the diet, unless he 
has previously been of intemperate habits' and his nervous system 
requires the stimulus of alcoholic drinks. 
Many persons find that they cannot readily digest milk—that, 
if they take much' of it with their ordinary diet, it lies heavy on 
the stomach, and causes biliousness and headache. It very sel- 
dom happens, however, that milk has this effect when the diet 
is sufficiently restricted, and when the animal food and fermented 
drinks commonly consumed by persons in health are excluded 
from it, and when the milk, instead of being taken alone, is inti- 
mately mixed with farinaceous substances. When milk, by 
itself, is rapidly swallowed in considerable quantity, it is apt to 
coagulate in the stomach in solid masses, through which the 
gastric juice does not readily filter, and which are, consequently, 
hard of digestion; whereas, if it be sipped slowly, or be inti- 117 
TREATMENT. 
mately mixed with, farinaceous substances before it is eaten, the 
casein it contains coagulates in small flakes, which are exposed 
on every side to the action of the gastric juice, and which are, 
consequently, soon dissolved. 
As the condition of the stomach improves, a little jelly or 
beef-tea, or the yolk of a soft boiled egg, may be allowed; and 
at length, a small quantity of fish, or of tender and easily digest- 
ed flesh, when this can be taken without inducing pain. 
Medicines are of secondary importance to a properly regulated 
diet. 
Where there are sour eructations, or where, in case of vomit- 
ing, the matters vomited are very sour,—that is, where the 
stomach does not completely empty itself or where the irritation 
of the ulcer causes an outpouring of acid in the empty stomach, 
from five to ten grains of trisnitrate of bismuth, suspended in 
water by means of compound tragacanth powder and syrup, 
may be given with advantage, two or three times a day, a quar- 
ter of an hour before meals, and a dose of magnesia at night. 
These medicines will tend to prevent undue acidity of the 
stomach,—the bismuth by lessening the secretion of the mucous 
membrane, the magnesia by neutralizing any excess of acid 
when digestion is over—and they do not, of themselves, irritate 
the surface of an ulcer. For correcting undue acidity, magnesia 
is, perhaps, better than potash or soda, as the latter medicines, 
if given in quantity more than enough to neutralize the acid, 
irritate the ulcer, and have a tendency to occasion hemorrhage 
from it. 
If the stomach be very irritable, the patient may often derive 
benefit from swallowing now and then a small lump of ice, 
which will allay the sense of heat in the stomach and render the 
vomiting less frequent. 
When the pain at the stomach is harassing and the nights are 
restless, much relief may be afforded by opium, which is best 
given in its crude form and in pills. 
When the bowels are much confined, an aloetic, or a com- 
pound colocynth pill should be given. These medicines irri- 
tate the stomach less than castor-oil, rhubarb, or the saline pur- 
gatives. They exert their chief action on the large intestine, 118 
PERFORATING ULCER. 
and may generally be given in cases of nicer of the stomach, 
without bringing on or increasing the pain. When ulcers exist 
in the intestines, on the contrary, and a purgative is necessary 
—as sometimes happens during convalescence from typhoid 
fever and in dysentery,—the purgative that is safest and best is 
castor-oil, and of this small doses are then always sufficient. A 
drachm, or two drachms, will act as surely as two or three times 
the quantity, and with much less offence to the stomach and 
much less irritation to the bowels. 
In these diseases, as in ulcer of the stomach, great care should 
be taken in diet until there is reason to believe that the ulcers 
have healed. Many a case of typhoid fever has terminated 
fatally, from perforation of the bowel during seeming conval- 
escence, and many a case of dysentery has become chronic, from 
want of attention to this point. The appetite has been indulged 
without stint and the raw surface of the ulcers continually 
fretted. 
If vomiting of blood should occur, the means most likely to 
restrain the haemorrhage are, ice swallowed in small quantity or 
applied to the epigastrium, rest in the horizontal posture, pro- 
longed fasting, and medicines which have an astringent or styp- 
tic action,—such as oil of turpentine, acetate of lead, in conjunc- 
tion with opium, alum, and tannin. 
The oil of turpentine, the most efficient, perhaps, of these 
medicines, was, I believe, first employed as a remedy for haem- 
orrhage in the stomach, by John Hunter, in a case of which he 
has left the following account:— 
“A young man applied a strong solution of corrosive subli- 
mate for the cure of an itching of the pubes; by this application 
a violent inflammation was produced, I ordered a wash of 
lime-water, to decompose any part of the sublimate still adher- 
ing, and a poultice of oatmeal and lime-water to cover the parts, 
with tinctura thebaica sprinkled over it, which gave him much 
relief. This was continued two days, when I ordered him the 
bark, to diminish irritability; but the apothecary chose to give 
him an emetic first, which brought up a great deal of blood 
from the stomach, for which Dr. Ileberden, who was called in, 
ordered tincture of roses ; but this proved ineffectual. Seeing 119 
TREATMENT. 
the patient dying, and well knowing the good effects of turpen- 
tine in stopping bleeding externally, I gave him two spoonfuls 
every two hours of an emulsion made with chio turpentine; 
cold water clysters being also used. He continued for some 
time very low, and had scarcely any pulse, having lost so much 
blood ; but he recovered, and grew strong and fat.” 
Of late years, the oil of turpentine has been highly spoken 
of, as a remedy for haemorrhage from the stomach, by Dr. 
Graves, Dr. Seymour, and other physicians. The turpentine is 
best given, as recommended by Dr. Graves, in cold water, in 
doses varying from ten to twenty minims, repeated more or less 
frequently according to the urgency of the symptoms. 
It is, however, more effectual where the blood escapes by 
exhalation from the mucous membrane or from the minute ves- 
sels of a raw surface than in cases like those we are considering, 
where it issues from a vessel of considerable size laid open by 
the spreading of the ulcer, and where the patient usually gets 
rapidly faint and brings up at once an enormous quantity of 
black, clotted blood. 
After the occurrence of profuse haemorrhage, (and often with- 
out this in young unmarried women, who seem to be especially 
liable to ulcer of the stomach), a state of great anaemia exists, 
and, from the irritability of the stomach and the disordered 
digestion, the reparation of the blood is more than commonly 
difficult. In such cases, two or three grains of citrate of iron 
may be given three times a-day, immediately after meals, as soon 
as food fit for persons in this condition has ceased to cause pain, 
Ilhe citrate of iron does not then irritate the ulcer, and it not 
only tends to invigorate the body and to remedy the nervous 
and other disorders which a state of anaemia causes, but most 
probably, by rendering the nutritive processes more active and 
healthy, also promotes the healing of the ulcer. 
When, in the course of the malady, feverish symptoms arise, 
with much tenderness at the epigastrium, indicating a spreading 
of the ulcer or the occurrence of inflammation in the portion of 
peritoneum above it, the most efficient remedies are, abstinence 
from food as long as it can be well borne, opium, and rest. We 
have seen that perforation and haemorrhage are often preceded 120 
PERFORATING ULCER. 
for a day or two by increased pain and soreness of the stomacli. 
Aggravation of the pain betokens a spreading of the nicer, and 
should always be promptly opposed by restricted diet. Pro- 
longed fasting is, doubtless, the most efficient remedy for any 
aggravation of the symptoms, and the surest means of obviating 
the danger which such aggravation threatens. 
The plan of treatment just described naturally suggests itself 
when it is clearly seen that an ulcer of the stomach exists ; and, 
in most of the cases in which it is tried, its good effects are soon 
apparent. After the patient has been kept for a few days on a 
diet consisting exclusively of farinaceous substances and milk, 
the pain has generally much abated, and the vomiting, if any 
existed, has ceased. Sometimes the amendment is progressive; 
and, if the plan be persevered in for a few weeks, the ulcer 
heals, and the patient recovers. In other cases, on the contrary, 
the pain and soreness, though much lessened, continue to be 
felt; and, if the ulcer heal at all, it is only after the lapse of 
many months. As a general rule, the ulcer is slower to heal, 
the longer it has lasted. Old ulcers are generally larger and 
deeper than recent ones; and they often have a raised and hard 
margin, which prevents, or very much retards, the process of 
healing. 
At the hospital I have had positive proof, in several instances, 
that an ulcer of the stomach has healed under treatment such as 
I described. The first instance of the kind I met with occurred 
six or seven years ago. The patient, who was a labouring man, 
was long in the hospital with symptoms of ulcer of the stomach, 
and was an object of much attention. He left the hospital ap- 
parently well, and afterwards went to live in the country, where, 
sometime subsequently, he died under the observation of Mr. 
Tudor, who was a student at the hospital while he was an inmate 
of it, Mr. Tudor, recollecting the man’s former history, had the 
curiosity to open the body, and found in the stomach the cicatrice 
of a former ulcer. 
Another case occurred in a man named Joseph Marshall, who 
came to the hospital five or six years ago, on account of vomiting 
of blood and other symptoms of ulcer of the stomach. He was 
kept on a milk and farinaceous diet for many weeks, and the 121 
TREATMENT. 
gastric disorder ceased. In the beginning of March, 1851, he 
became an ont-patient of the hospital on account of erysipelas of 
the head, of which he died. His wife, knowing the interest I 
had previously taken in the condition of his stomach, informed 
me of his death. I obtained permission for an examination of 
the body, which was made by Dr. Beale. The stomach, which 
is now in the museum of the College, presented in its big end, 
about two inches from the cardiac orifice, a scar, or rather seam, 
of an ulcer, which by its contraction had very much puckered 
the adjacent portion of the mucous membrane. 
Another case occurred in the hospital in the winter of 1850. 
Benjamin Brown, a man sixty-four years of age, who had led a 
very intemperate life, and drunk great quantities of gin, was ad- 
mitted into the hospital on the 28th of October, 1850, with 
jaundice and ascites, and complaining much of pain in the 
stomach and vomiting. 
He stated that his health was good until six weeks before his 
admission to the hospital, when he was taken with vomiting, 
purging, and severe pain in the epigastric region. The pain con- 
tinued, the stomach rejected almost everything he ate, and, a 
fortnight after the commencement of his illness, he vomited more 
than a pint of dark-coloured, clotted blood. A week after the 
vomiting of blood, jaundice came on, and he subsequently 
noticed that his belly was swelled. After his admission to the 
hospital, the irritability of the stomach abated; but the jaundice 
persisted, the dropsy increased, and he died from the effects of 
cirrhosis on the 3rd of January, between nine and ten weeks after 
his admission to the hospital and nearly four months from the 
commencement of the gastric symptoms. When the body was 
opened, two ulcers, freshly skinned over, were found in the 
stomach. The liver was in a high degree of cirrhosis, and the 
pylorus was slightly strictured by a narrow ring of white fibrous 
tissue under the mucous coat. The healing of the ulcers, which 
must have been impeded by these conditions, was probably due 
to the strict diet enforced soon after their formation before their 
edges had become thick and hard. 
In most cases, perhaps, the chief impediment to the cure ol 
these ulcers, when they are not large or of long standing, arises 122 
PERFORATING- ULCER 
from the difficulty of making the patient submit long enough at 
a time to the restricted diet that is necessary for it. The pain 
may not be sufficiently severe, or the general symptoms suffi- 
ciently alarming, to furnish an adequate motive for so much 
self-denial. The ulcers consequently persist until they cause 
perforation, or until, from their edges having become thick and 
hard, they are very difficult to heal. 
When an ulcer of the stomach has healed, the cicatrice is 
exposed to be irritated by the food, and by the acids secreted 
by the stomach and formed from the food, and is apt, after a 
time, to open again. In that case the symptoms, after having 
ceased for a time, recur. In some instances in which the ulcer 
is not large and heals without much difficulty, such an alterna- 
tion may take place more than once. I presume that this has 
happened in a poor woman of the name of McCann, who has 
been lately an inmate of the hospital. In 1851, after having- 
suffered for three weeks pain in the stomach after food, she had 
sudden, and profuse vomiting of blood, and was brought to the 
hospital greatly blanched. Under a rigid diet of milk and fari- 
naceous substances the gastric disorder subsided, and she left 
the hospital well. She continued well for two years when pain 
in the stomach recurred, soon followed, as before, by profuse 
vomiting of blood. She was brought to the hospital again, 
recovered again under the former treatment, and remained well 
till the middle of January, 1854. The stomach disorder then 
returned, and on the Ist of March she was brought to the hospi- 
tal for the third time. Under the influence of diet she soon 
recovered, as before. 
It is almost unnecessary to observe that many of the effects 
of simple ulcer of the stomach, except perforation and haemorr- 
hage, may result from a fistulous opening into the stomach, 
caused by the discharge of an hydatid tumour or an abscess of 
the liver through it. If the tumour or the abscess was large, 
the opening is generally slow to close up, so that the pain in the 
stomach after food is of long continuance, and the unnatural 
adhesions of the stomach at the seat of disease restrain its move- 
ments, prevent perhaps its completely emptying itself, and thus 
give rise to other and more serious disorders of digestion. OF THE DUODENUM. 
An ulcer in the duodenum causes less severe and less signifi- 
cant symptoms than an ulcer in the stomach. The duodenum is 
not liable to the same changes of volume as the stomach, and 
its contents do not undergo the same churning from the move- 
ment of its coats, and the surface of a sore in it is not fretted 
in the same degree by the crude substances taken as food. 
The chief symptom of ulcer in the duodenum is pain in the 
situation of the ulcer, which is seldom constant, and which, in 
most cases, is felt only two or three hours after a meal, when 
the food is passing from the stomach into the duodenum. After 
this has continued for some time, the ulcer may heal; but occa- 
sionally, like a simple ulcer of the stomach, it burrows deeper 
than the mucous membrane, and eats into an artery in the sub- 
mucous cellular tissue, causing sudden and profuse haemorrhage, 
or perforates the bowel, and thus sets up inflammation of the 
peritoneum that proves speedily fatal. 
From the symptoms being usually much less severe than in 
ulcer of the stomach, the fatal perforation usually occurs with 
still less warning. 
In the summer of 1851, Dr. Johnson brought me the stomach 
and duodenum of a man who had died very unexpectedly from 
this cause. He was a carman, thirty-five years of age, and about 
eleven o’clock on the 21st of July, left his home, apparently in 
good health. About an hour afterwards, while talking in the 
stable, he was seized with agonizing pain in the belly, soon fol- 
lowed by faintness, retching, and other symptoms of peritonitis 
from perforation of the bowel; and died at four o’clock in the 
afternoon of the 25th. 
On the anterior surface of the upper part of the duodenum 
was a single perforating ulcer, which on the inside of the bowel 
was nearly as large as a shilling, and had soft edges. The lin- 
ing membrane of the stomach was sound. 
The man was moderately muscular and well-nourished, and 
was stated to have enjoyed almost uninterrupted good health. 
On inquiry it was ascertained that he was occasionally bilious, 
as was supposed, from drinking beer; and that he sometimes 
complained of pain at the pit of the stomach after turning the 
mangle, but never after eating or at any other time. These tri- 124 
PERFORATING ULCER 
fling ailments were tlie only discoverable effects of the malady 
till the fatal perforation occurred. 
During the last few years, some striking cases of the same kind 
have been published in the weekly medical journals. The fol- 
lowing instance is recorded in the “Lancet” for the 18th of 
July, 1846. 
A gentleman, who had previously enjoyed excellent and un- 
interrupted health, had for three days slight uneasiness in the 
stomach and bowels, which induced him to take a dose of castor- 
oil, but did not prevent his entering fully into his occupations 
and amusements. On Friday, the 29th of May,, he had spent 
several hours on horseback on the downs of Epsom, and was 
returning home, when he was seized, at a short distance from 
Epsom, at six o’clock in the evening, with violent pain in the 
stomach and bowels, which obliged him to alight and seek a 
place to lie down.. He entered a farm-house, and threw himself 
on his belly, apparently in great agony, and seeking relief from 
pressure. Half an hour afterwards he was found by Mr. Stil- 
well, the surgeon who was called to him, lying on his back on a 
sofa, in a state of collapse, and complaining of severe pain in the 
region of the stomach. He was placed in bed, and died there, 
in the farm-house, the next day, about eighteen hours from the 
time of his unexpected and terrible seizure. Other interesting 
particulars of the case, which I have no time to mention, are re- 
corded by Mr. Stilwell. The perforating ulcer was on the ante- 
rior surface of the duodenum, near the pylorus. 
A case still more impressive, with the details of which some 
of you are perhaps familiar, occurred in the summer of 1845, 
and is related by Dr. Little in the “ Lancet.” I allude to the 
case of Mr. Somes, the great shipowner and the late Member 
of Parliament for Dartmouth, in whom perforation of the 
duodenum occurred while he was engaged in the House of 
Commons. 
He was a man of firm and vigorous constitution, fifty-seven 
years of age, and, although he seems to have suffered for some 
time occasional pain at the epigastrium, considered himself in 
good health. The perforation occurred at a quarter-past one 
p.M,, causing great agony and speedy collapse, which ended in 125 
OF THE DUODENUM. 
his death shortly after one p.m., on the following day, just 
twenty-four hours from the time of his unexpected seizure. 
The ulcer, as in former case, was near the pylorus. 
I have already alluded to the remarkable discovery made some 
years ago by Mr. Curling, that a sloughing ulcer sometimes 
forms in the upper part of the duodenum within a few days after 
a severe burn, and undoubtedly in consequence of it: and that 
in such cases the ulcer, like that which is related to the simple 
ulcer of the stomach, now and then destroys life speedily and 
unexpectedly by haemorrhage or perforation. This discovery 
gives a new interest to perforating ulcers of the duodenum, and 
renders it not improbable that in other cases it may arise from 
some condition hitherto unsuspected. It is, therefore, desirable 
that the instances in which it occurs with any unusual complica- 
tion should be placed on record. The only instance of this sort 
that I can call to mind as having fallen within my own obser- 
vation, is that of a young woman, Ann Purke, twenty-two 
years of age, who was brought into the hospital on the 25th of 
November, 1850, on account of an enormous compound ovarian 
cyst, which sprang from the right ovary and seemed to have 
been growing about twelve months. On the 9th of May fol- 
lowing there was so much distress from the great distension of 
the belly and the resulting shortness of breath, that the tumour 
was tapped, and about a gallon of highly albuminous fluid 
drawn off. Some relief resulted from the operation, but the 
poor woman died on the 18th. She was constantly under ob- 
servation in the hospital from the time of her admission in No- 
vember, but no particular intestinal disturbance was remarked 
until the 2nd of May, when a note was made that for a few days 
preceding she had suffered from vomiting. From that time un- 
til her death, vomiting was frequent and distressing, and there 
was occasional purging. On examination of the body, the lining 
membrane of the intestinal canal was found to be sound, except 
in the duodenum, in which there were two large ragged ulcers. 
The appearance of the ulcers, as well as the recent occurrence ot 
the intestinal disorder, indicated that the ulcers were of recent 
formation, and thus raised the suspicion that the tumour had in 
some way or other been instrumental in causing them. 126 
PERFORATING ULCER. 
SMALL SCATTERED ULCERS. 
Another kind of ulceration, not unfrequent in the stomach, 
and of great practical importance, is that which has been des- 
cribed by Cruveilhier and Rokitansky as “ haemorrhagic ero- 
sions” of the mucous membrane. When the stomach is opened, 
a number of roundish, dirty brown or soot-black spots are seen, 
from the breadth of a pin’s head to that of a small pea, which 
owe their colour to blood blackened by the acid secretions of the 
stomach. Sometimes, instead of roundish spots, there are nar- 
row streaks of the same colour. When the minute blood-clot 
is washed away, there is a slight depression, the result of a su- 
perficial ulceration, or “erosion,” of the mucous membrane and 
the adjacent portion of the mucous membrane is often swollen 
and soft. 
These superficial erosions of the mucous membrane are found 
in all parts of the stomach, but are most common in the pyloric 
end; and now and then, with them, erosions of the same cha- 
racter, and having doubtless a similar origin, are found in the 
upper part of the duodenum. 
The erosions are attended by a catarrhal state of the mem- 
brane, and the stomach usually contains a considerable quan- 
tity of mucus, often mixed with brownish flakes, like coffee- 
grounds, which consist of coagulated and blackened blood. 
They form at all ages, and in the course of various diseases, 
but occur especially in active inflammatory diseases, in con- 
tinued fevers, in persons in whom an impediment exists to the 
passage of the blood through the liver or the chest, and at the 
close of lingering diseases, when the power of digestion fails,— 
in diseases, that is, in which, from a state of fever, or from an 
impediment to the passage of the blood through the liver or the 
chest, or from nervous exhaustion, there is a scanty secretion of 
gastric juice. The “ erosions,” as I have before remarked, are 
attended by a catarrhal state of the mucous membrane, and 
seem to arise from superficial irritation of the membrane by 
food, when that protection is wanting which the stomach natu- 
rally derives from an active nutrition and a plentiful secretion 
of gastric juice. They occur not unfrequently in drunkards, 127 
CAUSES. 
and in persons in whom, from any of the conditions I have just 
mentioned, the natural secretions of the stomach are scanty, and 
they are occasionally brought on in the course of other diseases, 
by the untimely or excessive use of ardent spirits, of ether, of 
calomel, corrosive sublimate, or other medicines which have a 
corrosive action on the mucous membrane. 
I have several times had reason to ascribe if to an excessive 
use of stimulants, given in the hope of remedying the sense of 
sinking in the last days of life, especially when this has been cut 
short by cirrhosis or by organic disease of the heart. 
Some years ago I met with a rude plate, giving a good general 
idea of this form of ulceration of the stomach, in a publication 
called the “ Teetotaler’s Companion.” The plate professed to be 
a representation of the “ulcerated stomach of a drunkard.” 
A clue to the explanation of these minute superficial bleeding 
ulcers is given by the observations of Dr. Beaumont, on the 
effects which excess in eating or drinking had on. the stomach of 
St. Martin. 
On the 80th of December, 1832, the stomach of St. Martin 
was found to be clean and healthy: the gastric juice was pure, 
and distilled more freely than common. At half-past one P.M., 
it was examined again, and found to be empty and clean. 
In the afternoon St. Martin became intoxicated, and the con- 
dition of the stomach on the following morning is thus des- 
cribed : 
“ Dec. 31.—At seven o’clock A.M,, weather cloudy ; atmos- 
phere damp And chilly; wind S.; thermometer 30Q ; tempera- 
ture of the stomach 100|° ; colour darker red than natural, and 
arid. Mucous coat abraded in spots, and rolled in small shreds; 
more irritable than usual.” 
Dr. Beaumont states, as the result of his observations on the 
subject, that whenever a feverish state existed, or St. Martin had 
eaten more than the stomach could digest, or had drunk ardent 
spirits or other intoxicating liquors to excess for some days in 
succession, the mucous membrane of the stomach lost its smooth 
and healthy appearance, and its secretions became vitiated and 
greatly diminished or entirely suppressed. 
And he further observes, that, under such circumstances, 128 
SUPERFICIAL ULCERS. 
“ there are sometimes found, on the internal coat of the stomach, 
eruptions, or deep red pimples, not numerous, but distributed 
here and there upon the villous membrane, rising above the 
surface of the mucous coat. These are at first sharp-pointed 
and red, but frequently become filled with white purulent 
matter. At other times, irregular, circumscribed red patches, 
varying in size or extent from half an inch to an inch and a-half 
in circumference, are found on the internal coat. . . . There 
are also seen, at times, small aphthous crusts in connexion with 
these red patches. Abrasion of the lining membrane, like the 
rolling up of the mucous coat into small shreds or strings, leav- 
ing the papillae bare for an indefinite space, is not an uncommon 
appearance.” 
We almost seem here to be witnesses of the formation of the 
minute superficial ulcers, or erosions, in question. 
Minute superficial ulcers are apt to form also, more especially 
in women, when there is some permanent source of irritation 
elsewhere, deranging the stomach by nervous sympathy. They 
form, for example, not unfrequently, in women with tuberculous 
disease of the lung, and occasionally in hysterical or nervous girls 
with some source of irritation in the uterine system. In such 
cases it is probable that the immediate cause of the ulceration is 
still food which the stomach cannot digest. The sympathetic 
disorder causes waste of power, and so weakness of the stomach : 
this leads to slow and imperfect digestion: and imperfectly 
digested food may, by fretting the mucous membrane, give rise 
to the ulcers in question. 
There are probably other conditions, unfavourable to healthy 
nutrition, which may lead to the formation of these minute 
ulcers. The singular fact discovered by Mr. Curling, that burns 
often cause sloughing ulcers of the duodenum, shows that this 
portion of the intestinal canal has, with the skin, a physiological 
relation, of the nature of which we are yet ignorant. 
From the cases yet recorded, it would seem that those ulcers 
result from burns more frequently in children than in grown-up 
persons,—a circumstance which affords a presumption that the 
nervous system furnishes the connecting links. 
Some years ago, Mr. Simon discovered that bleeding ulcers EFFECTS. 
129 
of the stomach may be caused in cats, irrespective, seemingly, 
of the nature of their diet, by keeping them for some weeks 
in close confinement in a dark place. In the spring of 1846, 
through the kindness of Mr. Simon, I had an opportunity of 
examining the stomach and duodenum of a cat which had been 
kept for three weeks in a rabbit-hutch in a dark cellar, and dur- 
ing this time had been fed entirely on cat’s-meat and water. The 
creature was much emaciated, and the stomach and upper part of 
the duodenum presented several irregular linear abrasions of the 
mucous membrane, which were of a dark-brown colour from 
the presence of altered blood, and resembled the linear hemorr- 
hagic erosions of the human stomach. It is possible, therefore, 
that confinement, with insufficient light and other conditions 
unfavourable to nutrition, may occasionally have the same result 
in man. 
These minute superficial ulcers usually cause pain in the 
stomach after solid food; | frequent vomiting, excited by the 
presence of food; and haemorrhage. The effects are so far like 
those of common simple ulcer; but there are several circum- 
stances which may serve to distinguish the two forms of disease. 
1. The haemorrhage which results from the minute scattered 
ulcers consists of an oozing of blood from the capillary vessels 
of the abraded surface. It occurs as soon as the ulceration 
takes place, and may continue, day after day, while the ulcers 
exist, but is usually small in amount at any one time. The 
haemorrhage in simple ulcer arises from the ulcer eating into 
one of the vessels of considerable size which run in the cellular 
tissue under the mucous coat. It usually occurs suddenly after 
the other symptoms of simple ulcer have existed for some time, 
and is profuse; and,, where it does not prove fatal, seldom con- 
tinues more than two or three days. 
2. When these superficial ulcers exist there is usually a 
catarrhal or inflammatory condition of the mucous membrane 
in great extent, and as a consequence probably of this, there is 
often a thin white coat on the tongue, and there is a more dif- 
fused soreness and much greater irritability of the stomach, and 
the appetite and power of digestion are very much more im- 
paired, than in cases of simple ulcer, in which the stomach is 130 
SUPERFICIAL ULCERS. 
usually healthy, except at the ulcerated spot. For the same 
reason, the matter vomited in cases of haemorrhagic erosion often 
contains much mucus, tinged with blood, which seldom happens 
in cases of simple ulcer. 
3. The two forms of diseases may be further distinguished by 
the different circumstances in which they respectively occur. 
The minute superficial ulcers, like the deep ulcer, may con- 
tinue long, if the stomach be constantly irritated by food which 
it cannot digest, or by alcoholic drinks or irritating medicines : 
they may perhaps, by such means, be fretted into deep ulcers : 
but as long as they remain superficial, they may, in most cases, 
be readily healed, and the stomach be restored to its healthy 
condition. A few leeches, or a blister, or the daily application 
of a large mustard poultice to the epigastrium; the frequent 
sipping of iced water, which tends greatly to allay the vomit- 
ing ; and a diet restricted to the lighter farinaceous substances 
and milk, to be taken cold and in small quantities at a time,— 
are all the means that are generally necessary. As the stomach 
becomes less irritable, the diet may be improved; but as long 
as food has a tendency to cause pain or vomiting, it should be 
given in the form of pulp, so as not to irritate the stomach 
mechanically or needlessly tax the power of digestion. Alco- 
holic stimulants, and aromatics of all kinds, greatly irritate the 
stomach, and should be strictly forbidden. If, in spite of these 
means, there be much pain in the stomach, or frequent vomit- 
ing excited by food, powdered opium, with small doses of nitrate 
of silver, in pills, may be given with advantage. Powdered 
opium is less irritating to a raw surface and has better effect 
than tincture of opium or the salts of morphia, especially when 
these salts are given in solution. 
If constipation exist in such a degree as to increase the dispo- 
sition to vomiting or cause unpleasant distension of the belly, 
it may be remedied by enemas, or, as in cases of perforating 
ulcer, by an aloetic, or the compound colocynth pill. 
When the disorder is thus treated at its first occurrence, the 
irritability of the stomach in most cases, as I have already 
stated, soon subsides, unless the digestive power has been much 
impaired by spirit-drinking, or unless there be any permanent EFFECTS, 
131 
source of irritation elsewhere, which has bought on and keeps 
up the gastric disorder. In such cases the malady may bo 
almost of as long continuance, and be as difficult of cure, as a 
simple ulcer of moderate size. I have known a disorder, which 
I have taken to be of this kind, in an hysterical girl, continue 
for months in spite of the most careful diet—reducing the pa- 
tient almost to death’s door, and leading to the suspicion of 
incurable organic disease. LECTURE YIII. 
Cancer of the Stomach. 
Cancer originates in the stomach more frequently than in any 
other organ, with the single exception of the uterus. 
The organs in which cancer most frequently originates are, 
the uterus, the stomach, and the female breast. Out of 9,118 
cases of death from cancer, recorded in the Mortuary Registers 
of Paris from 1837 to 1840, M. Touchon found that the disease 
was seated in the uterus in 2996 cases ; in the stomach in 2308; 
and in the breast in 1147 ;* or, taking the proportionate round 
numbers, in the uterus, in about one-third of the cases; in the 
stomach, in about one-fourth; and in the breast, in about one- 
eighth. 
The stomach now and then becomes involved in cancerous 
disease commencing in the subjacent cluster of lymphatic 
glands; but, almost always, cancer of the stomach is primary 
—that is, the stomach is the part first affected with cancfr. 
All the principal varieties , of cancer—schirrus, medullary 
cancer, and areolar or colloid cancer—occur, separately and in 
combination, in this organ; and the last-named variety, areolar 
or colloid cancer, though much less common than the other 
varieties, is more frequent in the stomach than anywhere else. 
The different parts of the stomach are not equally liable to 
cancer. The pyloric end is by far the most frequent seat of it; 
next after this, perhaps, the cardiac orifice; then, the space 
along the smaller curvature between the two orifices. The part 
least liable to caneer, as to the perforating ulcer, is the big or 
splenic end. 
Sometimes the cancer, at the time of death, is of small ex- 
* See Walshe “On Cancer,” in which this table is given. CANCER 
tent; but occasionally, and especially in colloid cancer, the 
disease spreads until the greater portion, or even the whole of 
the stomach, is involved. 
When cancer originates at the pyloric ring, it spreads towards 
the big end of the stomach, but not in the opposite direction 
along the duodenum. This singular circumstance is' probably 
owing in great measure to the closeness of the cellular tissue in 
the duodenum, which must impede the extension of the disease 
along it. Cancer does not spread readily along a mucous mem- 
brane, except it be through the intervention of the sub-mucous 
cellular tissue, into which the cancerous matter filters; and if 
cancer of the stomach has generally a greater superficial extent 
than cancer of the bowel, it is owing to the greater looseness of 
the cellular tissue in the stomach, which the extensive and rapid 
variations in its volume require. 
The changes which the stomach undergoes, and the course of 
the disease, vary with the kind of cancer. 
Schirrous or fibrous cancer, which is the most common 
variety, appears first as a thickening and induration of the sub- 
mucous cellular tissue, difficult to be distinguished from the 
thickening and induration caused by the contraction of effused 
lymph, except by the circumstance, that it is less uniform and 
that the mucous and muscular coats soon become adherent to 
the hal’d tissue between them. From the part first affected, the 
disease spreads into the cellular tissue beyond, and gradually in- 
volves the muscular coat on one side and the mucous coat on the 
other. 
The muscular layer becomes affected early, and in an even, 
uniform manner. The cancerous matter, which develops itself 
between the muscular fibres, causes great apparent thickening 
of the muscular coat, and, if a transverse section of the coats of 
the stomach be made in the earlier stages of the disease, gives 
to the cut edge a very peculiar appearance, which is seen in all 
the varieties of cancer, and which consists of whitish or bluish- 
white lines perpendicular to the surface of the mucous coat and 
in striking contrast with the red muscular fibres. After a time, 
the muscular fibres waste and degenerate—that is, cancer-cells 
form within their sheaths, and take the place of the original CANCER, 
organic constituents of the muscle—and what remains of them 
gets blended with the surrounding cancerous mass, so that this 
peculiar appearance is lost. 
In the sub-mucous cellular tissue the cancerous matter like- 
wise spreads as, by infiltration, but much less evenly than in the 
muscular coat; often forming lobular masses, which project into 
the cavity of the stomach. 
The mucous membrane, from the invasion of the cancer, un- 
dergoes various changes, which have been well described by 
Rokitansky, in nearly the following terms 
“Sometimes it degenerates into an areolar cancerous tissue, 
which discharges large quantities of gelatinous fluid: sometimes 
it is converted into a medullary tissue, and sprouts into fungoid 
or medullary masses, which suppurate, and thus partially expose 
the schirrous cellular tissue; but, most frequently, it becomes 
the seat of a sloe-black softening, with haemorrhage, and the 
schirrous sub-mucous cellular tissue is at length found invested 
by a thin, gauze-like, black remnant of the mucous membrane, 
or quite denuded, merely retaining here and there on its surface 
a few black, convoluted vessels. 
“ The schirrus, too, undergoes various metamorphoses. It may, 
after it has been denuded of the mucous membrane, become 
gangrenous in large patches, or in round circumscribed spots, the 
tissue exfoliating by layers, so as to give rise to deep, smooth ex- 
cavations in the crude cancer; or it may become developed into 
a more highly organized cancerous growth, such as medullary 
sarcoma, accompanied by bleeding fungoid tissue ; this soon be- 
comes destroyed by a suppurative process, leaving an ulcer which 
is surrounded by an elevated lardaceous margin.” 
The diseased mass constitutes a hard irregular tumour, which 
can often be felt through the walls of the belly. 
Medullary cancer, when primary, may originate in the mucous 
membrane or in the sub-mucous cellular tissue. The chief points 
in which it differs, in course and effects, from the varieties of hard 
cancer, are, that it grows more rapidly, becomes sooner and more 
widely disseminated, and sprouts into exuberant medullary or 
fungoid masses, which undergo rapid transformation. 
Areolar or colloid cancer appears first as an infiltration of the EFFECTS. 
135 
peculiar jelly-like matter of this variety of cancer into the sub- 
mucous cellular tissue, and between the muscular fibres and into 
the interstices of the mucous coat. This infiltration renders the 
walls of the stomach much thicker than natural, and gives to a 
section of the muscular coat the striated appearance I just now 
described. The infiltration into the cellular tissue and between 
the muscular fibres is very even; but the diseased mucous mem- 
brane is apt to sprout here and there into roundish spongy masses, 
the cells of which are filled by the jelly-like matter. After a 
time, the exposed surface of these projecting spongy masses wears 
away; • the whole inner surface of the diseased mass becomes 
eroded; all traces of muscular fibres and of mucous membrane 
disappear; and the walls of the stomach are converted into a 
gelatiniform tissue, an inch or two thick, in which no traces of 
the muscular or of the mucous coat are seen. 
The disease, like the other varieties of cancer, is most common 
at the pyloric end, which it usually encircles evenly. From this 
end the cancer spreads continuously and evenly towards the 
splenic end, but very seldom extends in the opposite direction, 
along the duodenum. In some cases, the entire stomach is at 
length involved; but generally death occurs before this happens, 
and the diseased portion then often terminates abruptly, forming 
a funnel, of which the pyloric ring is the small aperture. The 
outer surface of the diseased mass is covered by the peritoneum, 
and, when the disease has extended far, is roughened by the 
partial projection of unequal semi-transparent cancerous cells. 
Whatever be the kind of cancer, the ulcer resulting from it 
has seldom, if ever, the repulsive smell which is so common in 
open cancer of other parts, and which is here doubtless prevented 
by the antiseptic and solvent action of the gastric juice on the 
sloughing surface of the sore. 
The size of a stomach affected with cancer varies greatly, ac- 
cording to the site and extent of the diseased portion. When 
the disease is limited to the pyloric end, and, by obstructing or 
narrowing the pyloric orifice or by preventing the free action of 
the muscular fibres, greatly impedes the passage of food into the 
duodenum, the stomach generally gets much enlarged,—in some 
protracted cases so much so that the pylorus falls into the right CANCER 
iliac fossa and the great curvature of the stomach reaches almost 
down to the pubis. When, on the contrary, the pyloric orifice is 
not obstructed or narrowed and a large portion of the body of 
the stomach is invaded by the cancer, the stomach sometimes 
becomes much contracted. 
In those cases in which the pyloric orifice is obstructed and 
the stomach has grown large, the muscular fibres of the stomach 
are hypertrophied, and the mucous membrane in its big end is 
frequently found much softened or digested after death. This 
latter change, which gives a clue to the cause of some part of the 
gastric disorder, arises, I need hardly say, from the circumstance 
that the stomach, in consequence of not readily emptying itself, 
frequently contains at the time of death some muriatic or lactic 
acid. 
When cancer of the stomach has existed for some time, and 
reached the surface of the organ, the diseased mass often be- 
comes agglutinated to the liver, or to a cluster of enlarged can- 
cerous glands behind it. 
The disease frequently proves fatal without extending beyond 
the stomach; but, like cancer, originating elsewhere, it is apt, 
after a time, to become disseminated, and thus to give rise to se- 
condary cancerous tumours in other parts of the body. 
These secondary or remote effects of the disease vary with 
the kind of cancer. 
In medullary cancer, and in schirrus, the mesenteric glands in 
the neighbourhood of the primary disease or to which the lym- 
phatics of the stomach run, become first tainted with the cancer, 
and after a time numerous scattered cancerous tumours form in 
the liver. This extension of the disease is effected by the trans- 
fer of cancerous germs from the primary seat of disease through 
the lymphatics and the veins. It seldom happens that the dis- 
ease becomes disseminated more widely. The wide diffusion of 
cancer is everywhere effected mainly through the veins, which 
serve as channels for the transfer of the cancerous germs ; but 
the veins of the stomach all run to the liver, and the cancer 
germs conveyed to this organ seem all to be stopped in the 
plexus of capillary vessels which goes to make up its lobular 
substance. None of them pass through the liver with the blood, CAUSES. 
to form cancerous tumours in the lungs or other organs. When 
a further extension of the disease takes place from the liver, it 
is generally, first to the lymphatic glands to which the lympha- 
tic vessels of the liver run, and thence through the lymphatic 
vessels up the chest, until the cancerous matter enters the blood, 
and so becomes diffused over the rest of the body. In the great 
majority of cases the local disease of the stomach destroys life 
before this wide diffusion of the cancer takes place, so that 
when an opportunity is afforded of examining the body, the 
only parts affected with cancer are the coats of the stomach, the 
liver, and the lymphatic glands to which the lymphatic vessels 
of the stomach or the liver run. 
In colloid cancer, dissemination does not take place in the 
same way. The germs of the disease are too large to be trans- 
mitted by the veins, and cancerous tumours do not form in the 
liver, as in other varieties of cancer. But occasionally small 
scattered tumours, or even considerable masses of colloid cancer, 
are found in the omentum and mesentery, and on the intestines, 
especially near their mesenteric attachment. These small tumours 
are sometimes under the peritoneum, and spring probably from 
germs transmitted through the lymphatics; in other cases they 
grow on the outer surface of the serous membrane, and seem to 
result from the mere transplantation of germs detached from the 
surface of the original cancer. JSTow and then, in cases of cancer 
of the stomach, the uterus, or ovary, or rectum, is found affected 
with cancerous disease, which, as these parts are common seats 
of primary cancer, most probably arose, not from cancer-germs 
transmitted from the stomach, but from the constitutional dispo- 
sition to cancer leading to cancerous degeneration of these several 
organs independently of each other. 
In almost all cases, the cancerous disease that co-exists with 
cancer of the stomach is limited to the abdominal cavity. 
Of the causes of cancer of the stomach no more is known than 
of those of cancer of other parts. 
An instance is now and then met with in which a tendency to 
the disease was clearly inherited. I was told a short time ago 
ky a physician now living that he has lost one brother and two 
sisters of cancer, out of a family of nine. The brother died at 138 
CANCER, 
sixty-one, from cancer of the stomach ; one sister at fifty-seven, 
also from cancer of the stomach ; one sister at fifty, from cancer 
of the uterus. A few years ago, a man died under my care in 
the hospital of cancer of the stomach, while I was attending his 
father out of the hospital with the same disease. The most 
striking instance of this kind on record is perhaps that of the 
Napoleon family. The first Emperor Napoleon, his father, and 
his sister Caroline, are stated to have all died of cancer of the 
stomach. In the great majority of cases, however, no inherited 
tendency can be traced—the victim is the first of his family 
afflicted with cancer. 
The disease is rather more common in men than in women, 
and, like primary cancer of the liver, hardly ever occurs before 
the age of thirty-five. Cases are indeed now and then met with 
in which it occurs much earlier in life, I have met with an 
instance of its occurrence in a woman at the age of twenty-six. 
A case is related by Andral in which a woman died of it at the 
age of twenty-two, and in which the disease seems to have 
begun before the age of twenty; but such instances are extremely 
rare. In nine cases out of ten,—probably in a much larger pro- 
portion,—it comes on after the age of thirty-five. 
The disease occurs in all classes of society, from the emperor 
to the beggar; in the sober as well as in the dissipated; in 
people who live in the country, as well as in those who live in 
towns. Indeed, no habits or conditions of life have as yet been 
shown to have any powerful influence in bringing it on. 
The symptoms of cancer of the stomach have seldom any char- 
acters that are peculiar or especially significant, until the disease 
has existed a considerable time. 
The first complaint is generally of a dull pain, or a sense of 
uneasiness at the pit of the stomach, which comes on gradually, 
without fever or other illness, and is always aggravated by 
taking food. This pain or uneasiness is attended with impair- 
ment of appetite, and with flatulence, heartburn, and other 
results of disordered digestion. 
As the disease makes progress, the disorder of digestion in- 
creases. The patient usually loses all relish for food, is troubled SYMPTOMS. 
139 
with occasional eructation of a sour fluid, occurring at various 
hours of the day, and now and then, soon after meals, brings 
up, in the same manner, small quantities of food. He loses 
flesh, and in most cases becomes much depressed in spirits. 
Still he is free from fever; the pulse is no quicker than it should 
be; the tongue is clean or only slightly furred; and there is 
no unnatural heat of skin, and no thirst. 
The uneasiness at the epigastrium and the disorder of di- 
gestion continue, but the symptoms vary in some degree 
according to the seat and extent of the disease. When the can- 
cer involves the body of the stomach and the orifices are un- 
obstructed, vomiting, if it occur at all, occurs soon after meals, 
and what is brought up at a time is moderate in quantity, and 
consists of the secretions of the stomach and the food, or por- 
tions of the food, recently swallowed. 
When, as happens much more frequently, the disease is con- 
fined to the pyloric end of the stomach, the pyloric orifice 
usually becomes obstructed or narrowed, or the passage of the 
food through it is impeded by the restrained action of the mus- 
cular fibres. In such cases vomiting is a necessary result, but 
it takes place later after meals than in the former class of cases, 
niore is brought up at a time, and the matters vomited are very 
sour. 
Several conditions,—undue retention of the food, a scanty 
supply of gastric juice, and the presence of unhealthy and de- 
composing secretions furnished by the cancerous surface,—con- 
spire to promote in the contents of the stomach some unnatural 
fermentation, which leads to the formation of enormous quanti- 
ties of acid, and often to an abundant evolution of gas. The 
acid frets the stomach, and much additional suffering results 
from its flatulent distension. Occasionally, and especially when 
a cancerous ulcer exists in the stomach, the food unduely detain- 
ed there undergoes the butyric fermentation or common putre- 
factive changes, and thus gives rise to fetid eructations and the 
other symptoms of “ surfeit,” which, from their infrequency in 
other chronic diseases of the stomach, are often important evi- 
dence of the existence of cancer. In many cases, perhaps in all 
those in which the body of the stomach remains sound, the 140 
CANCER 
obstruction of tire pyloric orifice leads, after a time, to great 
enlargement of the stomach. When this has taken place, 
vomiting occurs more rarely—at the end of each day, of every 
two or three days, or at still longer intervals—and a great 
quantity is brought up at once; the matter ejected comprising 
the accumulated secretions of the stomach and all the food not 
capable of absorption in the stomach that had been eaten since 
the last vomiting. 
When, on the other hand, the disease involves the cardiac 
orifice, the entrance of food into the stomach is impeded. The 
act of swallowing causes pain, or a sense of uneasiness, at the 
epigastrium, passing through to the back ; and very commonly 
a small portion of what is swallowed lodges in the lower end of 
the oesophagus, and is immediately or speedily brought up again 
by an effort of eructation rather than of vomiting. The patient 
himself is aware that the food does not readily enter the stomach. 
In all cases where much is rejected by vomiting, and but little 
consequently passes into the duodenum, the bowels become con- 
fined ; but where the pylorus is not obstructed, the costiveness 
is interrupted now and then by a transient diarrhoea, produced 
by the irritating matters which pass from the stomach into the 
bowel. 
When the cancer involves the body of the stomach or the 
pylorus, the matters brought up from the stomach, besides the 
natural secretions of the stomach and portions of the food more 
or less digested or otherwise altered by some fermentative pro- 
cess, often contain a considerable quantity of glairy mucus, 
secreted, for the most part, by the diseased portion of the mucous 
membrane. It sometimes happens, early even in the disease, 
that this mucus is mixed with black or brown flakes, consisting 
of blackened and altered blood. At a later period, and especi- 
ally after ulceration has occurred, an abundant haemorrhage not 
unfrequently takes place. A sense of weight or oppression at 
the epigastrium is then felt, with faintness and nausea, and a 
large quantity of matter is vomited, which, according to the 
time the blood remained in the stomach and the quantity of free 
acid the stomach contained, is of a soot-black, or of a dirty red- 
dish brown, justifying its familiar comparison with coffee-grounds. SYMPTOMS. 
141 
This matter owes its peculiar colour to black or brown flakes, 
formed of blood that oozed from the diseased surface, and as it 
issued from the vessels was clotted and blackened by the acid 
secretions of the stomach. 
But, before the disease has advanced thus far, the patient has 
generally lost much of his flesh and strength, and has the pallid 
and faded look so constantly seen in the latter stages of malig- 
nant disease. By careful examination of the belly, we may now 
generally feel an irregular tumour formed by the cancerous mass. 
The situation of this tumour of course varies with the site of the 
disease as regards the stomach itself, and also, when the pyloric 
end is the part diseased, with the degree of displacement which 
the stomach has undergone. 
When the disease involves the cardiac orifice, which does not 
admit of displacement, or when it occupies the body of the 
stomach without obstructing the pylorus, the tumour is neces- 
sarily in the place which the diseased portion of the stomach 
naturally occupies. 
Most commonly, as we have seen, the disease involves the 
pyloric end of the stomach. In that case also the tumour is 
usually felt about the place wrhich the diseased portion naturally 
occupies; but when the stomach grows large, and the diseased 
portion has not contracted unnatural adhesions to the contiguous 
fixed parts, the pylorus falls in the belly, and the tumour may be 
felt much lower down in the right side, and even in the iliac fossa. 
The tumour is felt more or less readily and distinctly, according 
to the part it occupies. A tumour at the cardiac orifice of the 
stomach which lies deep, directly behind the lower end of the 
sternum, so that the hand cannot be pushed against it, is much 
more difficult to define or to feel than one which is somewhat 
lower down the belly. Deep-seated tumours can indeed, in all 
cases, be most readily and distinctly felt when they are near the 
middle of the belly, for the reason that the hand can there be 
pushed to a greater depth. If the linea alba be considered as a 
cord attached to two fixed points,—the lower end of the sternum 
and the pubes,—it will be plain that the middle of it is the place 
at which this can be pushed to the greatest depth from the 
straight line joining the two points. 142 
CANCER, 
Great enlargement of the stomach, which so constantly results 
from strictured pylorus, may be generally ascertained by an 
unusual resonance on percussion. Often, too, on looking at the 
belly, the outline, or part of the lower outline, of the distended 
stomach may be seen, and if such examination be made day 
after day, this outline will be found to vary according to the 
degree of distension of the stomach at the time. When the 
pylorus is completely strictured, the vermicular movements even 
of the stomach can sometimes be plainly seen through the walls 
of the belly. This happened in a very striking degree in a poor 
man who died in the hospital in the spring of 1855. In this 
instance the mere handling of the belly excited strong move- 
ments of the stomach—the stomach seemed to roll, and a wave 
of contraction passed along it, which was most distinctly seen 
about the cardiac end. 
The tumour can be the more readily felt, and the outline of 
the stomach be the more distinctly traced, in consequence of the 
thinness of the walls of the belly, which results from the general 
wasting, and in consequence also of the bowels being generally 
empty and contracted. When the aperture of the pylorus is 
much obstructed, and but little consequently passes from the 
stomach into the duodenum, the belly, except where it may be 
raised by the tumour or by the distended stomach, is almost 
always sunk or hollowed. The intestines contain but little fsecal 
matter, and, notwithstanding the costiveness, are seldom dis- 
tended with gas. 
The course of the disease is in some degree further modified 
by the development of secondary cancerous tumours in other 
organs. 
When the primary cancer is either scirrhous or medullary, 
the lymphatic glands near the stomach, and to which the lym- 
phatics of the stomach run, become tainted, and secondary can- 
cerous tumours sometimes form in the liver, leading to enlarge- 
ment of the liver, and now and then to an unevenness of its 
surface, which, from the empty state of the bowels and the gen- 
eral wasting, can in most cases be readily felt. 
The dissemination of gelatiniform or colloid cancer usually 
leads, as we have seen, to scattered masses of gelatiniform cancer SYMPTOMS. 
over the peritoneum and omentum, and its most striking results 
are distension of the belly and ascites. 
While these organic changes are taking place, and revealing 
themselves more and more distinctly to our senses, there is a 
gradual diminution of flesh and strength, and the pain or uneasi- 
ness at the epigastrium continues, attended frequently with pain 
or uneasiness in the corresponding part of the back and in the 
loins, which is probably owing to the lymphatic glands behind 
the stomach, and to which the lymphatics of the stomach or the 
liver run, becoming tainted with the cancer. The temper like- 
wise grows more irritable and morose, and the nights are rest- 
less. The loss of appetite is generally complete : but even now, 
unless the cancer be in rapid growth, there is seldom fever—the 
skin is cool, the pulse not much quicker than it should be, and 
the tongue clean or only slightly furred. 
After a time, usually varying from six months to two years, 
but occasionally, especially in colloid cancer, extending to seve- 
ral years, the patient, worn-out by want of nourishment, by pain 
and broken rest, and it may be by loss of blood, dies of exhaus- 
tion—the mental faculties and the senses remaining in most 
cases unimpaired, almost to the last. 
Such is the usual course of cancer of the stomach. Cases 
however are now and then met with in which some of the most 
characteristic symptoms are wanting. Thus, in a person ad- 
vanced in life, and where the cancer grows slowly, the pain, 
instead of being severe or harassing, as it usually is, may be so 
slight that it is little if at all complained of; or the tumour, 
from being small and at the back of the stomach, or from being- 
overlapped by an enlarged liver, may not be felt; or again the 
disease may not obstruct the pylorus and may involve only a 
small portion of the stomach, and vomiting may not be frequent 
enough to attract much notice. 
The cases most difficult to distinguish as cancer are those in 
which the disease involves only a small portion of the hinder 
part of the stomach, and does not obstruct either of its openings. 
There are then, as in other cases, loss of appetite, more or less 
complete, progressive waste of flesh, and after a time the cachec- 
tic condition which cancerous disease so commonly causes, but 144 
CANCER. 
in other respects the symptoms, even when ulceration has occur- 
red, may differ but little from those of simple ulcer. The pain 
after food may indeed be less severe and the vomiting less fre- 
quent than in cases where there is a simple ulcer of equal size, 
because the raw surface is often less tender and irritable in a 
cancerous ulcer than in one occurring in healthy tissues. 
Instances of this kind are however comparatively rare, and in 
the great majority of cases the disease follows more or less 
closely the course I have described. 
The existence of cancer of the stomach is the more difficult 
to ascertain, from our not knowing its causes or any circum- 
stances in which it is especially apt to occur. It does not, 
indeed, often occur before the age of thirty-five; but in persons 
beyond this age it is met with, and with no observed differences 
as to frequency, in all conditions of society. Eokitansky has 
remarked that tubercle and cancer are seldom developed together, 
and seldom arise in succession in the same person; and infers 
that the constitutional states which favour the occurrence of the 
one disease oppose the development of the other. It is not 
impossible that future observation may disclose some unsuspected 
relations between cancer and other forms of disease, and that it 
may point out even some more direct indications of the cancerous 
diathesis; but at present we have no light of this kind to guide 
us. In persons therefore beyond the age of thirty-five, there are 
no circumstances that give unusual significance to symptoms; 
and until the disease has lasted some time the symptoms, as we 
have seen, have seldom any characters that are peculiar or 
especially significant. Pain or uneasiness referred to the stom- 
ach and increased by food, sour eructations, occasional vomiting, 
and lowness of spirits,—which are often the only symptoms 
noticed for some weeks, or even months,—may all arise from 
simple ulcer of the stomach, and from many other conditions. 
After some time, the disease is easier to detect. The circum- 
stance. that the symptoms have continued, or rather that they 
have got gradually worse—that the pain has become more har- 
assing, or the vomiting more frequent, and the loss of appetite 
more complete—in spite, it may be, of a restricted diet, and of 
other means which usually relieve such symptoms when they 145 
DIAGNOSIS. 
are the effect of superficial inflammation of the mucous mem- 
brane or of mere functional disorder,—the circumstance, I repeat, 
of bthis continuance, or rather of this aggravation of the symp- 
toms, leads to the inference that they result from organic dis- 
ease; while the progressive loss of flesh, and the faded look, and 
often a morbid moroseness or despondency, must excite a strong 
suspicion that this disease is cancer. Such a suspicion will be 
confirmed if much mucus, especially mucus mixed with brown 
or black flakes, should be thrown up from the stomach. When 
the mucous membrane is invaded by cancer in considerable 
extent, this frequently happens; but in simple ulcer of the 
stomach, the disease most likely at this time to be taken for 
cancer, it happens but rarely. In cases of simple ulcer, indeed, 
the disease is limited to the ulcerated spot—the mucous mem- 
brane in other parts of the stomach, even up to the edge of the 
ulcer, being usually healthy. 
After the disease has existed for some months, and the patient 
is much wasted, a tumour may, in most instances, be felt in the 
region of the stomach. When such is the case, and when the 
discovery of the tumour has been preceded by the symptoms I 
have mentioned and the patient is of an age when cancer of the 
stomach is common, little doubt can remain that the disease is 
cancer. Vomiting of a large quantity of matter of a soot-black 
or dark brown, like coffee-grounds, which, as I have already 
observed, often happens in advanced stages of cancer, would, of 
course, render this inference still more sure. 
In a person who has led a temperate life, the same inference 
may be drawn when, without any palpable tumour, the symp- 
toms show clearly that the pylorus is much obstructed. Stric- 
ture of the pylorus sometimes results, as we have seen, from the 
hardening and contraction of lymph, poured out in consequence 
of inflammation, in the cellular tissue under the mucous coat; 
but this disease, like cirrhosis of the liver, which is likewise 
caused by the interstitial deposit of co'agulable lymph, is almost 
always the effect of spirit-drinking. Stricture of the pylorus 
may be caused, too, by the cicatrisation of a simple ulcer at the 
pyloric end of the stomach, or in the upper part of the duo- 
denum ; but such an event is extremely rare, compared with 146 
CANCER 
stricture of the pylorus from cancer, and, when it does occur, 
the symptoms which preceded those of stricture, and sometimes 
the age of the patient, help us to distinguish the disease from 
cancer. 
In distinguishing cancer of the stomach, it is also very im- 
portant to consider the time the disease has already lasted, and 
the actual condition of the patient with reference to it. In cancer, 
the disease makes continual progress, the patient grows gradually 
thinner, and, in three cases out of four, dies of exhaustion within 
twelve months; in a very large proportion of cases, within two 
years. Simple ulcer of the stomach, the organic disease most 
likely to be confounded with cancer, may, on the contrary, exist 
for many years, causing almost constant, and even severe suf- 
fering, but without destroying the appetite or causing much 
waste of flesh. If the disease, therefore, has existed for several 
years, or even for many months, without much loss of flesh, the 
chances are greatly against its being cancer. 
In some cases it is possible, after a time, not only to tell 
that the disease is cancer, but also to specify the particular kind 
of cancer. 
The different kinds of cancer differ in their rate of progress. 
Medullary cancer grows much more rapidly, and becomes sooner 
and more widely disseminated than schirrous and colloid cancer. 
They differ, also, as regards the direction in which dissemi- 
nation of the cancer takes place. Schirrous and medullary 
cancer, when they become disseminated from the stomach, 
usually give rise to cancerous tumours in the liver, and thus cause 
enlargement of the liver and other symptoms of primary cancer 
of this organ. Colloid cancer, on the contrary, when it becomes 
disseminated, leads to secondary cancerous tumours in the mesen- 
tery, but very seldom to the formation of any similar tumours 
in the liver. 
The different kinds of cancer differ, moreover in the degree 
of pain and constitutional disturbance they occasion. Medullary 
cancer and schirrous cause much more pain and constitutional 
disturbance than colloid cancer, which, when it involves the 
pylorus, generally causes death by its mere mechanical effect 
in obstructing the passage of food. DIAGNOSIS. 
147 
If, therefore, after the disease has lasted some months, the 
liver grows large and there are other symptoms indicating the 
existence of cancerous tumours in it, the inference may be 
drawn that the cancer is medullary or schirrous; if the disease 
made very rapid progress, that it is medullary rather than 
schirrous. 
If, on the contrary, the disease progresses slowly, and causes 
little pain that is not fairly attributable to distension of the 
stomach, and little constitutional disturbance, and if, at the end 
of twelve months, there is no enlargement of the liver, the 
inference will be, that colloid is the variety of cancer. This 
inference will be confirmed if ascites or any other symptoms 
should render it probable that there are secondary cancerous 
growths in the peritoneum or omentum. 
In cancer of the stomach, the chief object of treatment is to 
lessen the sufferings of the patient. 
One of the most effectual means of doing this is by properly 
regulating the diet. In this disease there are, as we have seen, 
many conditions—the destruction of a portion of the digesting 
membrane by the cancer, the decomposing or unhealthy secre- 
tions furnished by the cancerous surface, the impediment to the 
natural movements of the stomach which the disease causes, and 
very frequently, obstruction of the pyloric orifice—which tend 
to prevent the healthy action of the stomach, and give rise to 
various disorders of digestion that terribly aggravate the suffer- 
ings that are directly attributable to the cancer itself. 
It is obvious, when such impediments to healthy digestion 
exist, that the digestive power should never be over-taxed, and 
that great care should be taken that the food required to nourish 
the body is reduced to its most easily-digestible form. 
When the pylorus is obstructed, the solid food should be re- 
duced to a state of pulp, so that, if not dissolved in the stomach, 
it may pass with the least possible difficulty into the duodenum. 
In advanced stages of the disease, when a large portion of the 
stomach is involved in the cancer and its digestive power is 
greatly impaired, the food should be such as will pass readily 
through the pylorus and can undergo some kind of digestion 148 
CANCER. 
afterwards. Arrowroot, and other light farinaceous food; beef- 
tea or nicely prepared soup; the yolks of eggs beaten up with 
sugar and with cold arrowroot that has been boiled in water, 
and then mixed with water and wine; and a small quantity of 
the cooked pulp of some fruit,—are the substances of which 
the diet should mainly consist. 
Much of the suffering in cancer of the stomach is at all times 
caused by food which the stomach cannot digest: and in the 
final stage of the disease in some instances—when a digesting 
fluid is no longer secreted, or the pyloric orifice is closed: when, 
consequently, food distends and oppresses the stomach without 
supporting the body—marked relief from pain and other dis- 
comfort will result from the patient almost entirely ceasing to 
eat—eating only an occasional spoonful of milk—and support- 
ing the body as much as possible by nourishing enemas. 
Much alleviation of suffering may also result from the judi- 
cious use of medicines. 
When, for example, much mucus is secreted in the stomach, 
or when, as seems sometimes to happen, the irritation of the 
cancer causes an excessive secretion of gastric acid, benefit often 
results from the astringent action of bismuth, which is best 
given a short time before meals. 
When there is an excess of acid, much relief is obtained from 
neutralizing this by lime water and magnesia. While there is 
a great excess of acid in the stomach, there is usually a repug- 
nance to food; but the disposition to take food and some power 
of digestion often return when the excess of acid has been neu- 
tralized by a dose of magnesia. The excess of acid commonly 
results from a process of fermentation in the stomach, which 
leads also to the generation of carbonic acid, or some other gas; 
and the acid and the gas together bring on vomiting. The fer- 
mentation may be impeded, and the evils resulting from undue 
acidity and flatulence be to a certain extent prevented by brandy, 
and by dill-water and other aromatics, which may be combined 
with bismuth, or with alkalies, when these are necessary. 
When there are fetid eructations, indicating the development 
of sulphuretted hydrogen, pills, containing small doses (from 
one quarter to one half minim) of creosote may be given with TREATMENT. 
149 
advantage at each meal; or a few grains of the bisulphite of 
soda; or some finely-powdered wood-charcoal. 
It is requisite, also, to obviate constipation, which is a very 
common effect of cancer of the stomach, and which almost 
always renders the patient more irritable and uneasy than he 
otherwise would be. The best way to obviate constipation is to 
give occasionally an aloetic, or a compound colocynth pill. The 
pill does not oppress the stomach by its bulk; and aloes and 
colocynth, which exert their chief action on the large intestine, 
are less apt to offend the stomach than most other purgatives. 
Again, cancer of the stomach, especially when far advanced, 
causes loss of sleep, harassing pain in the stomach and back, 
and much nervous irritability ; and, to mitigate these evils, re- 
course must be had to sedatives and narcotics. These may be 
given singly, or in various combination, according to the par- 
ticular object in view, or the effects which they are found to 
have on trial. To procure sleep, no other sedative is so efficient 
as opium. To alleviate pain, and to allay general nervous irri- 
tability, the medicines most in repute, and probably the best, 
are conium and belladonna, which have the additional advantage 
of not confining the bowels and checking the secretions, as 
opium does. 
Proper regulation of the diet, the well-timed use of alkalies 
and sedatives, prevention of constipation by pills of colocynth 
or aloes, and avoidance, as much as is possible, of conditions 
which exhaust the strength, are the principal means we have to 
alleviate suffering and prolong life. In many cases, the relief, 
even from the most judicious employment of these means, is 
comparatively small. The cancer gradually spreads, everywhere 
changing the coats of the stomach as it creeps on, and blending 
them with its own mass; and, at length, by blocking up the 
pylorus, or by greatly impairing digestion, and also, in many 
cases, by causing haemorrhage, exhausts the strength of its victim. 
It is clear that such results (and it is not in our power to pre- 
vent them) cannot be produced without much suffering of various 
kinds. LECTURE IX. 
Sympathetic Disorders of the Stomach from irritation elsewhere. 
HAYING passed in review the organic diseases of the stomach, 
we have next to consider its functional disorders, which are far 
more frequently presented to our notice. 
Functional disorders of the stomach, of some kind or other, 
must, indeed, result from organic disease. To do its work well, 
the stomach must be sound and be properly nourished. 
When, from the blood being impeded in its course through 
the liver or the chest, the stomach is kept congested, the nutri- 
tion of its mucous membrane is impaired, gastric juice is secreted 
in small quantity, and digestion is consequently slow and feeble. 
In high degrees of congestion, the secretion of gastric juice is 
almost suspended, and blood oozes from the open surface of the 
mucous membrane. 
When the mucous membrane of the stomach is inflamed, the 
secretion of gastric juice is arrested or very much lessened, and 
an unhealthy mucus, prone to pass into decomposition, is cast off 
from the membrane. The results of the disease are—loss of ap- 
petite, thirst, pain and a sense of heat in the stomach after food 
has been taken, and, it may be vomiting. If, under the influence 
of decomposing mucus in the stomach, some unnatural fermen- 
tation is set up in the food, much other disorder is superadded to 
this. 
When a simple ulcer of the stomach exists, gastric juice may 
be secreted to digest the food and nourish the bodybut the pre- 
sence of food in the stomach, unless it be in small quantity and 
of the least irritating kind, frets the sore and causes pain; the 
natural movements of the stomach are often hindered, so that it 151 
SYMPATHETIC DISORDER. 
cannot be completely emptied; from the surface of the sore 
there is a discharge, which is offensive to the rest of the stomach; 
the sore itself, being a constant source of irritation, is apt to ex- 
cite disordered action of the muscular coat, and to cause an out- 
pouring of gastric acid when there is no food in the stomach to 
dissolve ; and from these causes, separate or combined, there is 
occasional vomiting. 
When the stomach is the seat of cancer, there is usually, 
again, pain or a sense of oppression after food, and various dis- 
orders resulting from the morbid secretions of the diseased mu- 
cous membrane and from the narrowing of the orifices or the 
impediment to the proper movements of the stomach which the 
disease occasions. 
Functional disorder of the stomach may result not from 
organic disease of the stomach merely, but from organic disease 
of other organs; and that, not by the constitutional disturb- 
ance which this disease sets up or by any change it may cause 
in the state of the blood, but by an influence transmitted through 
the nerves. 
All this has been fully considered in the preceding lectures. 
An illustration and a type of disorder of the stomach so pro- 
duced, is seen in an experiment long ago performed by Spallan- 
zani. 
Spallanzani excited vomiting in himself by tickling the fau- 
ces, in the morning before breakfast, when the stomach was 
empty of food, and when, as we may infer from the recent ob- 
servations of Dr, Beaumont, it contained no gastric juice. By 
the act of vomiting, more than an ounce of fluid was thrown up, 
and by then exciting vomiting again in the same waff he ob- 
tained a still larger quantity. He then tested the digestive 
properties of this fluid, and found that it dissolved meat and 
prevented its putrefaction. The fluid consisted, therefore, at 
least in part, of gastric juice. 
Here, then, mechanical irritation of the fauces not only ex- 
cited reflex action of the muscles to produce vomiting, but also 
excited, in the same way,—by reflected nervous influence,—a 
secretion of gastric juice. 
Irritation of the lung, or of the brain, or of the liver, or of the 152 
SYMPATHETIC DISORDER 
uterus, from certain kinds of organic disease, frequently leads, 
as is well known, to sympathetic vomiting—that is, to vomiting 
caused by nervous influence reflected from the seat of dis- 
ease upon the muscles which, perform this act. The matter 
vomited in such cases is frequently acid, even when digestion is 
not going on; and, as we have already seen, the stomach ex- 
hibits the action of the gastric juice after death, more frequently 
in persons who die of diseases that cause this sympathetic gas- 
tric disorder, than in others. Whence we may safely infer, that 
the reflex nervous influence excites, not merely the act of vom- 
iting, but also, in many cases, as in the experiment of Spallan- 
zani, a secretion of gastric acid. 
A familiar instance of this gastric disorder is seen in phthisis. 
In most cases of phthisis, indeed, vomiting occurs sooner or 
later, and the functions of the stomach are otherwise disordered; 
and not unfrequently, in certain stages of the disease, there is 
more suffering from the stomach disorder, than from symptoms 
immediately referrible to the lung. 
In phthisis, vomiting may be brought on in several ways. 
Sometimes, especially at an early stage of the disease, when 
the cough is dry and hard, vomiting results from the mere 
violence of the cough; occurring, as in hooping cough, only at 
the end of hard fits of coughing, and without much loss of appe- 
tite or of digestive power, and with little or no pain in the 
stomach. 
When brought on in this way, it is most effectually controlled 
by sedatives, which lessen the frequency and the violence of the 
cough, on which the vomiting depends. Three minims of dilute 
hy dr cranio acid, with from a twelfth to a twentieth of a grain 
of muriate of morphia, three times a-day, generally succeeds 
in mitigating, if not entirely removing, this variety of gastric 
disorder. 
More commonly, vomiting occurs later in the disease, usually 
attended by loss of appetite and by pain, and a sense of heat at 
the stomach, and the matter vomited is usually sour. These 
symptoms, unless proper means be taken to prevent them, con- 
tinue many weeks or months—in fact, often till death—and 
after death, in such cases, the mucous membrane of the stomach OF THE STOMACH. 
in the big end is very commonly found thin and soft. Now and 
then all the coats are completely dissolved. 
These facts have been accurately noted by M. Louis, in his 
elaborate work on Phthisis, in which the changes of structure 
found in the stomach after death are supposed to have occurred 
during life, and to account for the gastric disorder. 
One circumstance incompatible with this supposition is noticed 
by M. Louis—it is, that the changes of structure found after 
death do not correspond in degree with the severity or duration 
of the gastric symptoms. The change of structure is sometimes 
great where the gastric disorder has been slight; and where the 
symptoms have been severe and prolonged, the stomach is some- 
times found perfectly uninjured. 
I have endeavoured to show in a former lecture that the 
gastric symptoms in such cases originate, not in structural dis- 
ease of the stomach, but in undue and untimely secretion of 
gastric juice, and other functional disorder excited by reflex 
nervous influence. The functional disorder may, after a time, 
lead to an inflammatory or a catarrhal state of the mucous mem- 
brane, which will be an additional cause of disordered digestion; 
but the softening of the stomach that so commonly occurs takes 
place after death, from the action of the gastric acids, and cannot 
bp expected, therefore, to have a constant relation to the symp- 
toms in degree, since the extent of softening depends merely on 
the quantity of gastric acid which the stomach happens to con- 
tain at the time of death, on the temperature at which the dead 
body is kept, and on the time after death at which it is ex- 
amined. * 
The best remedies for this gastric disorder are alkalfos, to 
neutralize the excess of acid in the stomach, and astringents, 
which tend to restrain undue secretion by the mucous mem- 
brane. 
Fifteen grains of bicarbonate of potash, or fifteen minims of 
liquor potassse, or an ounce and a half of chalk mixture, three 
times a-day; or, better still, the vegetable astringents,—logwood, 
krameria, catechu, kino—will generally stop the vomiting for a 
time, and alleviate the other symptoms of this gastric disorder. 154 
SYMPATHETIC DISORDER 
Astringents should be given a short time before meals: 
alkalies, two or three hours after meals. 
In the advanced stages of phthisis there is often, especially in 
women, another cause of gastric disorder. The liver grows fatty 
and large, and overlaps and compresses the pyloric end of the 
stomach; leading to that enlargement of the stomach so com- 
monly found in persons dead of phthisis, and, in a slight degree, 
to the various evils of obstructed pylorus. For these evils, as 
we cannot remove the cause on which they depend, we have no 
effectual remedy. 
Disorder of the stomach of the same kind sometimes originates 
in the liver, especially from the irritation caused by an abscess 
or from the passage of gall-stones. 
I shall only speak here of the effects of the passage of gall- 
stones, which, in this country, is by far the more common condi- 
tion. 
The illness in such cases generally comes on suddenly, two or 
three hours after eating, with severe pain, like that of colic, in 
the region of the gall bladder. The pain abates, and recurs 
again in paroxysms, attended by a sense of constriction at the 
lower part of the chest, and commonly by distressing nausea 
and frequent vomiting. The matters vomited are often very 
sour, even when the stomach has been previously completely 
emptied of food. 
Now and then, after the stomach has been completely emptied 
of food, and when nothing more is eaten, enormous quantities of 
acid are brought up by the repeated efforts of vomiting. This 
acid, which is obviously secreted by the coats of the stomach, 
was found by Front to be the muriatic. 
After the symptoms have continued some time they generally 
cease suddenly, as the stone passes out of the gall-duct into the 
bowel. 
The sequence of events, in such cases, is as clear as if it 
resulted from direct experiment. The gall-stone passes into the 
common duct, and immediately causes severe pain, with vomit- 
ing and the outpouring of an acid fluid from the stomach. The 
.stone escapes from the duct into the duodenum, and the pain, 155 
OF THE STOMACH, 
the vomiting, and the undue secretion of acid in the stomach, 
cease at once. 
There is no mistaking the relation of the facts. The mechan- 
ical irritation of the stone in its passage through the gall-duct 
causes vomiting by nervous influence reflected on the muscles 
that perform that act, and causes untimely secretion of acid in 
the stomach, by nervous influence reflected on the secreting 
structure in its mucous coat. 
The muriatic acid must be derived from the decomposition of 
common salt in the secreting apparatus of the stomach ; so that 
mere mechanical irritation of the lining membrane of the gall- 
duct, by means of an influence transmitted by the nerve, sets in 
action, in a distant part, a muscular power and a chemical 
power,—a muscular power that empties the stomach by almost 
convulsive efforts of vomiting, and a chemical power that causes, 
in the coats of the stomach, the rapid decomposition of common 
salt. 
The facts, as mere objects of scientific interest, are very 
remarkable, and important inferences regarding the actions of 
the body in health as well as in disease, are deducible from 
them. It has, for example, long been a disputed question— 
What is the proper acid of the gastric juice ? And the question 
has proved difficult of solution, because the stomach generally 
contains no acid when it is empty of food; and, if vomiting be 
excited and the contents of the stomach be analysed, while 
digestion is going on, any acids that may be formed from the 
food in the process of digestion are mixed with the acid secreted 
by the coats of the stomach itself. During the passage of a gall- 
stone, on the contrary, acid is sometimes abundantly secreted by 
the coats of the stomach, and is thrown up, unmixed with acid 
from other sources; so that, if the acid vomited in such cases be 
the muriatic, we are led to the conclusion which was formed by 
Dr. Prout, and which recent researches have confirmed, that 
muriatic acid is the proper acid of the gastric juice. The irrita- 
tion caused by the passage of a gall-stone is probably reflected 
on the muscles that cause vomiting, and on the secreting appa- 
ratus of the stomach, in different .relative degrees in different 
cases, In some cases the muscles may be chiefly excited, and 156 
SYMPATHETIC DISORDER 
there may be severe and frequent vomiting, without much 
increased secretion; in others, there may be greatly increased 
secretion, while the vomiting is slight. 
The same difference is observed in different cases, in the gas- 
tric disorder in phthisis. 
The passage of a gall-stone, which produces this secondary dis- 
order in the stomach, causes severe pain in the injured gall-duct; 
and, as a general rule the gastric disorder is doubtless greater the 
more severe the pain. We must bear in mind, however, that 
the irritation of the internal parts may cause severe sympathetic 
disorder, without causing any pain. A worm in the bowel, 
which causes no pain there, may be the exciting cause of spas- 
modic disorder. An old abscess in the liver, not painful in it- 
self, may occasion frequent vomiting. An injury in the hand 
or foot, attended with little pain, may give rise to the fatal 
spasms of tetanus. 
It is not, therefore, a valid objection to the explanation given 
above of the gastric disorder in phthisis, that in some of the 
cases in which this disorder is great there is little or no pain in 
the chest. The irritation is transmitted to the central organs of 
the nervous system, and there reflected so as to cause the sym- 
pathetic disorder of motion or of secretion, though it be not of 
such kind as to cause pain. 
During the passage of gall-stones, considerable and speedy re- 
lief to the gastric disorder may often be given by alkaline medi- 
cines. Dr. Front especially recommended frequent draughts of 
hot waiter, containing carbonate of soda in solution—from one to 
two drachms of the soda to a pint of wrater. “ The alkali,” he 
says, “ counteracts the distressing symptoms produced by the 
acidity of the stomach, while the hot water acts as a fomenta- 
tion to the seat of pain. • The first portions of water are com- 
monly rejected almost immediately ; but others may be repeat- 
edly taken ; and, after some time, it will be usually found that 
the pain will become less, and the water be retained.” 
Bismuth and chalk combined, which, when there is free acid 
in the stomach, acts both as an alkali and an astringent, is often 
of still greater efficacy in the vomiting sympathetic of hepatic 
disease. From five to ten grains of prepared chalk, and as much 157 
OF THE STOMACH. 
of the trisnitrate of bismuth, may be suspended in water by 
the mucilage of tragacanth, and given, together with minute 
doses of morphia, as often as the symptoms require. 
The passage of a renal calculus along the ureter affects the 
stomach in the same way, and often just as much, as the passage 
of a gall-stone along the common duct. 
The same kind of gastric disorder may result from disease of 
the brain, especially from inflammation of the brain or its mem- 
branes. It has been long known, that vomiting is a frequent 
and often a prominent symptom of such disease; and the cir- 
cumstance to which I have before referred, that in persons 
who have died of it the mucous membrane of the stomach in its 
big end is frequently found more or less dissolved or digested 
by the gastric juice, shows that the irritation of the brain does 
not excite merely the mechanical act of vomiting, but that it 
excites also, at least in many cases, untimely secretion of gastric 
acid. 
It is in inflammatory diseases of the brain, more than in other 
diseases, that this gastric disorder is seen; and it occurs especi- 
ally in the early stage of those diseases, when the symptoms beto- 
ken irritation of the brain, rather than compression. Andral, 
who has investigated this subject with much care, says:— 
“Vomiting, or at least nausea, very frequently attends acute 
inflammation of the membranes of the brain. These symptoms 
show themselves almost exclusively in an early stage of the dis- 
ease, and they often mark its onset. In some cases, they are not 
often repeated, and excite little attention, and cease to recur at 
the end of twenty-four hours. In other cases, on the contrary, 
they continue many days, and sometimes even during the entire 
course of the disease.” 
This circumstance explains how it happens, that when death 
results from inflammatory disease of the brain, the stomach is, 
in some cases, found perfectly sound ; while in other cases, which 
are comparatively few in number, it exhibits in high degree the 
changes which are produced after death by the solvent action of 
the gastric juice. 
These changes cannot take place unless there be a good deal 
of free acid in the stomach at the time of death; which is seldom 158 
SYMPATHETIC DISORDER 
the case, unless the gastric disorder have continued to the time 
of death, and which may not be the case even then. 
The gastric disorder varies very much in different cases, not 
merely in duration, but in severity while it continues; and prob- 
ably in the relative degree in which the muscles and the secret- 
ing function are affected. Andral says, “ Some patients vomit 
only two or three times a-day; others at much shorter intervals— 
■every hour, for instance, or every quarter of an hour. Many 
patients throw up in this way, in a short time, an enormous 
quantity of yellow, or greenish bile; others,' in the midst of 
painful efforts, only expel a little mucus. There are some who 
cannot take a spoonful of drink without bringing on vomiting.” 
This gastric disorder, like other sympathetic nervous disor- 
ders, occurs more frequently, and in higher degree, in women 
than in men, and in children than in grown-up persons. 
The vomiting or nausea is sometimes attended by pain at the 
epigastrium and some degree of tenderness, especially, I believe, 
where the secreting function is especially disordered; but these 
symptoms are less frequently noticed than in phthisis—in con- 
sequence, probably, of the shorter duration of the gastric disor- 
der in most cases, and of the severe pain of the head which 
usually attends inflammatory diseases of the brain, and which 
prevents the patient from feeling, or regarding, a slighter pain 
in the stomach. 
Where the gastric disorder is attended with secretion of much 
acid, soda and magnesia, chalk, and bismuth, are the remedies 
which most allay it. 
Gastric disorder of the kind we are considering results more 
frequently still from organic disease of the uterus. 
The effect of irritation of the uterus in causing vomiting was 
shown with the distinctness of direct experiment in the follow- 
ing case related by Dr. Gooch. 
“ Dr. Denman passed a ligature round a polypus of the fun- 
dus of the uterus ; as soon as he tightened it he produced pain 
and vomiting. As soon as the ligature was slackened these 
symptoms ceased, but whenever he attempted to tighten it the 
pain and vomiting returned. The ligature was left on, but 
loose. The patient died about six weeks afterwards, and, on 159 
. OP THE STOMACH, 
opening the body, it was found that the uterus was inverted 
and that the ligature had included the inverted portion.” 
Frequent and distressing vomiting now and then occurs, as is 
well known, in women afflicted with cancer of the uterus: an 
effect, no doubt, of reflex nervous influence: and the circum- 
stances that, in such cases, the vomiting is often attended by 
pain at the stomach and thirst, and that the coats of the stomach 
are occasionally found much softened or digested after death, 
show, as in the instances I have before cited, that in many cases, 
at least, this reflected nervous influence disorders the secreting 
function of the stomach, as well as the muscles. 
Disorder of the stomach of the same kind now and then 
occurs when miscarriage is about to take place, and also in con- 
junction with chronic ulcer of the neck of the womb. In the 
latter class of cases, the sufferings referrible to the stomach may 
be so severe and long-continued, and the pain in the womb so 
slight, that both the patient and her medical attendants may 
have their attention more fixed on the secondary functional 
disorder than on the primary disease. 
In these diseases of the uterus, indeed, as in tuberculous 
disease of the lung, the degree of disorder of the stomach has 
no constant relation to the degree of pain in the primary seat 
of disease. 
The same kind of gastric disorder now and then results from 
what might seem to be very trifling causes of disturbance. In 
nervous women, particularly in those whose sensibility has been 
exalted by losses of blood or by a state of anaemia brought on 
in any other way and in whom digestion is habitually feeble, 
the direct irritation of the coats of the stomach by an unwhole- 
some or undigested morsel of food may excite the disorder, 
which, if any other disturbing influence exist, may subsequently 
be kept up for weeks, or even months together, unless great 
care be taken not to irritate the coats of the stomach by physic 
or food. 
When the disorder originates in this way, it usually comes on 
in the evening, or at night, and especially after fatigue. The 
illness commences with vomiting or nausea, which is followed 
by pain or uneasiness at the pit of the stomach, and, if the dis- 160 
SYMPATHETIC DISORDER 
order continue long, by loss or great impairment of appetite, 
and by thirst. The stomach sometimes becomes extremely 
irritable, so that vomiting recurs frequently, and is at once 
brought on by swallowing any food or even the simplest drinks. 
There is then severe pain at the pit of the stomach, and the 
matters vomited are usually bitter. When the stomach is less 
irritable, food is retained for a time, and the matters rejected 
from the stomach are intensely sour. The acid thrown up in 
such cases is probably not all secreted by the coats of the 
stomach. The continued disturbance of the secreting function 
of the stomach seems to lead to an inflammatory, or a catarrhal 
state of the mucous membrane. The digestive power is greatly 
weakened, and under the influence of unhealthy or decomposing 
mucus the starchy principles of the food undergo fermentation 
in the stomach, by which large quantities of lactic acid are form- 
ed. The undue acidity of the stomach, or the great disturbance 
of its secreting function, lessens the secretion of the liver, and 
after the disorder has continued some days the countenance 
sometimes becomes slightly sallow. The symptoms are then 
not unlike those produced by the passage of gall-stones, and are 
almost as severe. The sallowness, however, when it occurs, 
never attains a high degree, and is generally transient, while the 
gastric symptoms are often of much longer continuance than 
those usually are which result from the passage of gall-stones. 
In some cases they continue with slight intermissions for months 
together, and lead to the suspicion of serious organic disease. 
This happened in the case of a lady fifty-seven years of age, 
who came under my care in the summer of 1845. She had then 
been subject for many years to attacks such as I have described, 
of most distressing vomiting, attended by severe pain at the epi- 
gastrium. The matters vomited were always sour, and, when 
the vomiting was frequently repeated, were bitter. In some at- 
tacks, after these symptoms had continued a day or two, the coun- 
tenance became sallow. 
It was supposed that the attacks might be owing to the pas- 
sage of gall-stones ; but, though diligent search was often made 
for them in the matters discharged from the bowels, none were 
ever found there. OF THE STOMACH. 
161 
The attacks generally came on in the evening, and were 
brought on, as she supposed, by fatigue, or by something un- 
wholesome she had eaten. They occurred especially when she 
had been weakened by haemorrhage from internal piles, to which 
she was subject. 
The piles were cauterized by nitric acid, and the haemorrhage 
ceased to recur. Upon this her general health improved, and 
the attacks became less frequent and severe. 
I had heard nothing of her for three years, when, in the month 
of June, she called on me looking stouter and healthier than four 
years before. 
She told me that nine months before that time the stomach 
disorder came on again, and was so severe that she was confined 
to bed four months, vomiting almost everything she took. After 
trying various medicines in vain, she was speedily and per- 
fectly cured by taking ten grains of bismuth and ten of mag- 
nesia every four hours, and a Jose of soda, rhubarb, and calumba, 
at the hour of dinner. 
The symptoms had recurred in a slight degree since, but were 
immediately stopped by the bismuth and magnesia mixture, 
which she believed to be a perfect remedy for these attacks. 
I could cite to you many other instances where stomach dis- 
order of this kind, seemingly induced in the way I have des- 
cribed, was so severe and long-continued as to lead to the belief 
of serious organic disease. The disorder is, as I have stated, 
most common in women, especially in those whose nervous sus- 
ceptibility has been exalted by losses of blood or otherwise, but 
it also occurs in men who have excitable nervous systems and 
whose digestion is habitually feeble. 
The means I have found most effectual in mitigating and sub- 
duing the disorder are—bismuth, Avhich be given in doses 
of ten grains a short time before meals; an occasional dose of 
magnesia or chalk, to neutralize any excess of acid which the 
stomach may contain ; regulation of the bowels by pills of colo- 
cynth or aloes; total abstinence from alcoholic drinks, which 
generally aggravate the disorder; and a diet composed of liquid 
and pultaceous food of the least irritating kind. 
When the stomach lias become tranquil, it is requisite, with 162 
SYMPATHETIC DISORDER 
the view of preventing a recurrence of the disorder, to stop any 
exhausting drain that may exist, and, by a course of steel medi- 
cines, by a nourishing but easily digestible diet, and by other 
means available for this purpose, to remedy the state of anaemia 
or the irritability of the nervous system from which the disorder 
springs. 
The gastric disorder we are considering occurs, as I have 
before remarked, more frequently in women than in men. It 
occurs still more frequently, from a given cause of disturbance, 
in young children, in whom the secreting function of the stom- 
ach is very active, and who are especially liable to reflex func- 
tional disorders of other kinds. 
Young children with tuberculous disease of the lung or 
inflammation of the brain, have this secondary gastric disorder 
more frequently than grown-up persons suffering from the same 
diseases, and their stomachs are more frequently acted on, and 
in higher degree, by the gastric juice after death. 
They are not liable, like grown-up persons, to disorder origi- 
nating in the liver or the uterus; but they have, at a certain 
period, a constant source of disorder in the irritation of teething, 
which frequently causes gastric disturbance, as it does some of 
the convulsive disorders to which young children are so subject. 
The stomach disorder, like disorder of the muscles, occurs 
most frequently during the first dentition, in children weakened 
by the eruptive fevers, or by purgative medicines, improper 
food, or impure air. It is especially apt to occur on weaning, 
when the health of the child often suffers, not only from sudden 
change of food, but from the improper food often substituted for 
the mother’s milk. Occurring under these circumstances, it has 
been popularly known as the “ weaning brash,” and has been 
described in medical works as the “ atrophia ablactatorum.” 
The early symptoms are frequent vomiting, with thirst and 
fretfulness, and occasional writhing of the body and plaintive 
cries, expressive of pain. The matters vomited are sour and 
bilious, and are thrown up with more effort than attends the 
common “puking” of healthy children. These symptoms are 
sometimes attended with looseness of the bowels, the matters 
discharged from them being greenish, from the presence of bile OF THE STOMACH. 
rendered green by the free acid secreted by the stomach or 
formed by fermentation from the food, and which has not been 
neutralized in its rapid passage through the bowels. 
If the disorder continues, the child wastes rapidly and grows 
feeble and soon exhibits the well-known signs of exhaustion,— 
coldness of the surface, irregular pulse, sighing, and slight stu- 
por,—signs which have been described by Dr. Marshall Hall as 
marking what he has termed the “ hydrocephaloid disease” of 
infants. 
In this state the child may die, and on examination of the 
body after death there may be no discoverable change of struc- 
ture in any organ, or there may be found, in greater or less de- 
gree, that peculiar softening of the coats of the stomach, and 
sometimes (in cases in which there has been diarrhoea,) of por- 
tions of the bowels also, that is produced after death by the 
solvent action of the gastric juice. 
The disorder is to be controlled in infants much in the same 
manner as in grown-up persons. The gums should, if needful, 
be lanced, to lessen the irritation from which the disorder 
springs. The child should be fed with good milk, or milk and 
baked flour, or better still, if it.be not more than twelve months 
old, with the milk of a healthy nurse, at short intervals and in 
small quantities at a time, and should have given to it, in doses 
suited to its age, chalk or magnesia or bismuth, or, if it can be 
got to take them, one of the less nauseous of the vegetable 
astringents, as krameria or logwood. If the disorder have 
already produced much exhaustion, a few drops of aromatic 
spirits of ammonia may be given occasionally with the milk, or 
with one of the medicines I have just mentioned. 
We are now in a condition to take a general view of this 
peculiar gastric disorder. 
It occurs, as we have seen, in grown-up persons and in chil- 
dren, in the male and in the female sex, but is most frequent, for 
the same cause of disturbance, in susceptible women and in 
children, especially in children ill-fed or reduced by previous 
disorders, persons whose nervous systems are highly excitable, 
an’d who are very prone to sympathetic nervous disorders of 
other kinds. 164 
SYMPATHETIC DISORDER 
It seldom exists unless there be some cause of disturbance 
elsewhere in the body, and occurs with especial frequency in 
conjunction with tuberculous disease of the lung, inflammation 
of the membranes of the brain, cancer and some other forms of 
disease of the uterus, the passage of gall-stones through the 
ducts, and, in children, while the gums are irritated and inflamed 
by teething. It occurs also in cases of simple ulcer of the 
stomach, and in cancer of the stomach: irritation at the diseased 
part of the stomach causing, in these cases, undue and untimely 
secretion in the sound part. 
When the exciting cause is of long continuance, or when a 
proper plan of treatment has not been followed, the gastric dis- 
order in grown-up persons may continue in high degree, with 
occasional slight intermissions, for months together. In young 
children this cannot happen: the stomach disorder impedes 
nutrition, and brings on a state of exhaustion soon fatal of itself. 
When the disorder has lasted some time, it is not always en- 
tirely functional. The continued functional disorder exhausts 
and weakens the stomach and sometimes induces an inflamma- 
tory or catarrhal state of the mucous membrane. The diges- 
tive power is further weakened, and the stomach secretes an un- 
healthy mucus, which promotes undue fermentation in the 
starchy principles of the food, and thus leads to the formation 
of large quantities of lactic acid, or some other acid of the same 
group, which are an additional cause of disturbance in the 
stomach and bowels. 
Whether death has been occasioned by the gastric disorder or 
by the concomitant disease, the degree of change found in the 
stomach after death does not usually correspond with the severity 
or the duration of the gastric symptoms. The softening of the 
stomach, which is usually the most striking change observed in 
such cases, takes place, as we have seen, after death ; and does 
not depend, therefore, on the severity or duration of the disor- 
der, but mainly on the quantity of free gastric (muriatic or 
lactic) acid which the stomach happened to contain at the time 
of death. The disorder may have been severe and have lasted 
long, but the stomach may contain no free muriatic or lactic acid 
at the time of death, and may be found perfectly uninjured; 165 
while, on the other hand, the gastric disorder may have been 
very slight; so slight, even, as to have escaped notice ; and yet 
muriatic or lactic acid may have been poured out, ojr lactic acid 
may have formed in the stomach in considerable quantity, just 
before death, and the stomach be found much dissolved. 
OF THE STOMACH. 
This disorder has been very commonly attributed to inflam- 
mation : and the vomiting, the pain and tenderness at the epi- 
gastrium, the thirst, and, in fatal cases, the softening of the mu- 
cous membrane of the stomach often seen when the body was 
opened, have seemed to many conclusive evidence in favour of 
this opinion. Inflammation causes, indeed, vomiting, pain, and 
tenderness at the epigastrium and thirst; but these symptoms 
inay result from other conditions,—vomiting from irritation else- 
where ; pain and soreness at the epigastrium, from the presence 
of free acid in the empty stomach; thirst, from this, and from 
the increased'secretion which the disorder causes; and the pecu- 
liar softening of the stomach that has been observed in such 
cases, is not caused by inflammation, and can be explained only 
from the action of a free digesting acid in the stomach after 
death. The disorder may, as I have already observed, lead, 
after a time, to an inflammatory or catarrhal condition of the 
mucous membrane of the stomach ; but, at its origin, and often 
long after, the disorder of the stomach is entirely functional, and 
is more allied to the excited and disordered state of the intellect 
in delirium tremens, or to the involuntary and disordered, and 
often violent movements of the voluntary muscles in chorea, 
than to inflammation. 
The power inherent in the voluntary muscle accumulates by 
rest to be discharged at the will of the animal for its own pur- 
poses. The chemical power of digestion inherent in the stomach 
accumulates in the same'way, to be discharged to serve an im- 
portant purpose when food is placed in the stomach. Every 
kind of power which an animal can generate,—the mechanical 
power of the muscles, the chemical (digestive) power of the sto- 
mach, the intellectual power of the brain, the electrical power of 
the torpedo, accumulates through the nutrition of the organ 
on which it depends. The accumulated power is discharged by 
an influence transmitted through the nerves; and, in a state of 166 
SYMPATHETIC DISORDER 
health, it is discharged in a degree regulated by the will or by 
the physical wants of the animal. 
Power is expended only to the extent which the emergency 
requires. When, for example, food is placed in the stomach, 
whatever may be the capabilities of the stomach at the time, 
only so much gastric juice is secreted as is required for proper 
and speedy digestion. But, in states of disease, the power is 
sometimes expended in undue measure and by nervous influ- 
ence transmitted from unusual sources, without control of the 
will and without reference to the physical wants.' 
The disorder we have been considering is, at its onset, an in- 
stance of this kind. 
The most effectual remedies for the disorder are,— 
1. Sedatives, and other means which lesson the irritation 
from which the gastric disorder springs. 
2. Alkalies and astringents. 
Alkalies sometimes give immediate relief by neutralizing the 
acid which the stomach contains: astringents alleviate the dis- 
order rather more slowly, but for longer time, by restraining 
the undue and untimely secretion. 
The insoluble antacids—magnesia and chalk—are well suited 
to this disorder. They serve to neutralize any excess of acid 
that may be in the stomach, and, given under these circum- 
stances, have an astringent action on the surface besides. 
Bismuth, of which I have more than once spoken, has a re- 
markable effect in restraining undue secretion in the mucous 
membrane, and may often be given with advantage—alone, or 
in conjunction with magnesia or chalk. 
While the disorder continues, the diet should consist chiefly 
of milk and farinaceous food, and little should be eaten at a 
time. Alcoholic drinks, and all stimulating articles of food, sel- 
dom fail to aggravate the disorder, and should be strictly for- 
bidden. 
If symptoms indicating an inflammatory state of the stomach 
should occur, namely; & sense of heat in the stomach, and pain 
excited by food, tenderness at the epigastrium, and a white coat 
on the tongue,—a blister or mustard-poultices may be applied 
to the epigastrium; and the stomach may be cooled, and be OF THE STOMACH, 
167 
rendered less irritable, by swallowing occasionally, and espe- 
cially after meals, a small lump of ice. 
If constipation exist, it may be remedied by medicines, sncli 
as pills of colocynth or aloes, wbicb do not mncb offend or 
oppress tbe stomacb. 
In some cases of this sympathetic disorder all these means are 
unavailing: nothing will stop the vomiting while the original 
irritation exists. LECTURE X. 
Deficient secretion of gastric juice—Slow and imperfect digestion. 
The subject of the last lecture was the disorderly secretion of 
gastric acid, which may result from disease in some other organ 
unduly exciting, by means of reflex nervous influence, the 
secreting function of the stomach. 
In a state of health the stomach contains no gastric juice 
while it is empty of food; but the contact of food with the 
mucous membrane immediately causes the juice to flow from it 
in quantity sufficient for complete and easy digestion. The for- 
mation of gastric juice depends on the proper nutrition of the 
mucous membrane—just as the power of a muscle depends on 
the proper nutrition of the muscular fibre—but the outpouring 
of the juice when food touched the mucous membrane, like the 
outpouring of saliva from the presence of food in the mouth, is 
excited by reflex nervous influence; that is, the impression of 
the food on the surface is transmitted by the nerves to some 
central part of the nervous system, and thence reflected to excite 
the action of the secreting apparatus. 
This reflex nervous influence, which causes the outpouring of 
gastric acid on the contact of food with the mucous membrane 
of the stomach, may be excessive; or it may be excited by other 
impressions on the mucous membrane of the stomach than those 
arising from the presence of food; or, lastly, it may be excited 
by irritation in other organs—producing in these several ways 
the disorders we considered at our last meeting: and, on the 
contrary, when there is food in the stomach and gastric juice is 
required, the nervous influence exciting the secretion may be 
deficient in energy, and the juice may be poured put in too 
small quantity for complete and easy digestion. 
Dr, Wilson Philip showed, by various experiments on rabbits 169 
GASTRIC JUICE. 
and other animals, that if the eighth pair of nerves be divided 
in the neck, any food which the creatures may afterwards eat 
usually remains in the stomach undigested; and, after death, 
the coats of the stomach are not found dissolved by the gastric 
juice, however long the animal may have lain dead. 
The experiments did not warrant the conclusion that Dr. W. 
Philip drew from them,—that the secretion of gastric juice is 
entirely dependent on an influence transmitted through these 
nerves; but they proved that the division of the nerves and the 
injury and shock of the operation arrested the secretion for a 
time. 
It is well known that long-continued watchfulness, or exces- 
sive fatigue, or great mental excitement, will prevent or take 
away the feeling of hunger, and destroy for a time the power of 
digestion. 
A man in the wild excitement of delirium tremens has a 
repugnance for food of every kind. When the delirium sub- 
sides and the nervous system has been refreshed by a few hours’ 
sleep, the appetite and the power of digestion return. 
In the case of St. Martin, to which I have before referred, Dr. 
Beaumont had ocular proof that the depressing passions of fear 
and anger lessen the secretion of the gastric juice. Feebleness 
of digestive power, arising from this cause, is often seen in men 
of excitable temperament who sutler anxiety, or who overstrain 
their minds in the pursuit of wealth or other objects of ambition. 
A scanty secretion of gastric juice may result from many 
other conditions. If the stomach be kept in a state of conges- 
tion, or if its mucous membrane be inflamed, the secretion of 
gastric juice is, as we have seen, arrested or diminished. The 
same thing happens, as is well known, in inflammation of other 
organs attended with fever, and in states of active fever, how- 
ever induced. 
A deficient secretion of gastric juice results also, indepen- 
dently of these conditions, from indolent and sedentary habits 
and the habitual consumption of more food than the system with 
such habits requires. The purpose of digestion is to supply the 
waste of the body; and it has been wisely ordered that the 
power of digestion shall increase with the waste. The day- 170 
DEFICIENT SECRETION 
labourer, who toils from sunrise to sunset in the fields, has gene- 
rally some compensation for the hardships of his lot in the com- 
fort of a strong and easy digestion. A man convalescent from 
fever or any other lingering and wasting disease requires, and 
can easily digest, much more food than when in established 
health; a woman suckling her child, much more than when she 
has no such drain. Where the increased need of food is of long 
continuance, the power of digestion is permanently increased, 
and the mucous membrane of the stomach becomes hypertro- 
phied. This happens, as Dr. Todd has shown, in cases of dia- 
betes. In this disease, a large part of the food, when dissolved 
in the stomach, does not undergo those other and ulterior changes 
which fit it to form part of the living blood, but, instead of this, 
becomes converted into a low form of sugar, which passes off in 
the urine without contributing to nourish the body. There is 
consequently an unnatural craving for food; food in large quan- 
tity is rapidly dissolved in the stomach; and, as is seen on dis- 
section, the mucous membrane of the stomach acquires unusual 
development. 
It often happens in the middle and upper classes of society 
that the secretion of gastric juice is only relatively deficient. 
The stomach can digest food enough to nourish the body, but 
not enough to satisfy the pampered appetite. 
It has been clearly shown by the experiments of Spallanzani 
and Dr. Beaumont, that the quantity of juice required for diges- 
tion is proportioned to the quantity of food. When gastric juice 
has dissolved a certain quantity of food, it is saturated, and can 
dissolve no more. The digestive power may, indeed, be restored, 
in a certain degree, by the addition of water, or by the addition 
of muriatic or lactic acid; but to carry digestion much further 
there must be a fresh quantity of the juice. If, then, a man eats 
too frequently or too much, the gastric juice may be inadequate 
for the proper and easy digestion of the food, without any fault 
fairly attributable to the stomach. The organ is simply over- 
taxed. Indigestion brought on in this way is the natural pen- 
alty for the violation of a natural law, or, as a humorous writer 
has termed it, “the remorse of a guilty stomach.” 
Again, the secretion of gastric juice is not unfrequently scanty, OF GASTRIC JUICE. 
171 
in consequence of a permanent defect in the secreting apparatus 
of the stomach, when there is no disease elsewhere impairing its 
action, and when there is no great fault to be found with the 
habits of life. The stomach is sometimes weak from its original 
constitution; and when it is naturally powerful it has sometimes 
its gland-structure injured, and is permanently weakened, by 
hard-drinking, or by the long-continued use of irritating drugs, 
or by diseases that much affect its secreting apparatus. I have 
met with many instances in which feebleness of digestion that 
seemed to be irremediable and permanent resulted from an 
attack of cholera, which, probably does permanent injury in 
some cases to the glandular structure of the stomach.* 
From any of these causes it may happen that gastric juice is 
secreted in insufficient quantity for the purpose of digestion. 
We may next consider the form of indigestion thus resulting. 
A necessary effect of an insufficient secretion of gastric juice 
is, of course, slowness of digestion. The food, instead of being 
completely digested and passing out of the stomach in two or 
three hours, remains undigested, or only partially digested, for a 
much longer time,—it may be, for twelve, or even twenty-four 
hours. The undigested portions of food remain in the stomach, 
and during the slow process of digestion there comes on a sense 
of weight or uneasiness at the pit of the stomach, which gradu- 
ally lessens, and at length ceases, as the food gets dissolved and 
passes out of the stomach. If any portions of the food remain 
solid, there is often, at the end of some hours, when the stomach 
is getting empty, a distressing feeling of spasm, or cramp, at the 
pit of the stomach. 
Some experiments made by Dr. Beaumont on St. Martin seem 
to show that this feeling of cramp is owing to the undigested 
portions of the food getting into the pyloric orifice of the stomach. 
Wishing to ascertain the temperature of the stomach during 
digestion, Dr. Beaumont passed a small thermometer into the 
* The various forms of atrophy of the gland-structure of the stomach have 
been lately made the subject of careful microscopic examination by Dr. Hand- 
held Jones; and I have much pleasure in referring the reader to his recently 
published work on the morbid conditions of the stomach, in which the results 
of his investigations are embodied. 172 
DEFICIENT SECRETION 
stomach, of St. Martin, When the bulb of the thermometer got 
into the narrow or pyloric end of the stomach, there was a forci- 
ble contraction of the stomach upon it, attended by severe pain 
and distress, like the cramp or the sensation frequently described 
as cramp by persons suffering from undigested food in the 
stomach. When the experiment was repeated several times in 
quick succession, it left a sense of soreness which was sometimes 
felt the following day. 
If portions of food remain undigested many hours, they irritate 
the lining membrane of the stomach, and cause headache, a 
slightly furred tongue, and feelings of general disorder. 
Hot unfrequently this irritation of the stomach checks secre- 
tion in the liver, so as to render the complexion somewhat sal- 
low ; and in nervous persons who dine late it greatly disturbs 
the sleep. 
When, from permanent weakness of the stomach, the digestion 
is habitually feeble, the body after a time is imperfectly nourished 
—the blood is poor in globules, the circulation is feeble, the ex- 
tremities are apt to be cold, the spirits are depressed, and the 
various powers of the body decline. For great continued exer- 
tion, whether of body or mind, there must be a strong stomach 
and a large consumption of food. 
The remedies for habitual slow digestion, in persons otherwise 
healthy, are to be sought in proper regulation of the diet and 
habits of life, and in medicines which tend to increase the secre- 
tion of gastric juice. 
The diet should consist of food easily soluble, the stomach 
should never be overloaded, and there should be a suffi- 
cient interval between meals. Care should especially be taken 
to avoid new bread and tough meat, and not to oppress the 
stomach by malt liquors, or to indulge in fermented drinks of 
any kind beyond the point which, from habit or otherwise, the 
state of the nervous system may require. Bodily fatigue and 
nervous exhaustion should be avoided, as these states lessen the 
secretion of gastric juice; but mind and body should be suffi- 
ciently exercised. We were intended to be active creatures, 
and a life of indolence is the infraction of a natural law, which 
always brings a penalty of some kind or other. A certain OF GASTRIC JUICE, 
173 
amount of bodily exercise and agreeable occupation of the mind 
promote digestion and improve in various ways the general 
health, and contribute greatly to the preservation of both the 
bodily and the mental powers. 
Various medicines,—ipecacuanha, rhubarb, cayenne pepper— 
taken in small doses, stimulate the lining membrane of the stom- 
ach and cause a more abundant out-pouring of gastric juice, and 
may often be taken with advantage just before the principal 
meals by persons who are troubled with slowness of digestion. 
For example, from half a grain to two grains of ipecacuanha 
and three or four grains of rhubarb, or a grain of capsicum with 
three or four grains of rhubarb, in a pill, may be taken before 
dinner, or before breakfast and before dinner. 
Salt and mustard have an action on the coats of the stomach 
of the same kind. A large quantity of salt taken at breakfast 
will sometimes relieve the headache and much of the other dis- 
comfort that follows a debauch. Mustard, as is well known, 
promotes, with most people, the digestion of beef and other rich 
meats; and its habitual use will occasional!}7- be found greatly to 
mitigate the discomfort that results from an habitual slow diges- 
tion. White mustard-seed, swallowed whole, was indeed, some 
years ago, one of the popular remedies for indigestion; and I 
have met with more than one instance of aggravated indiges- 
tion in which much benefit was attributed to its use. It was 
given in the dose of a table-spoonful two or three times a day. 
These stimulants for the stomach—ipecacuanha, salt, mustard— 
when taken in considerable doses, are all of them powerful 
emetics. As a remedy for frequently recurring slowness of 
digestion, ipecacuanha seems to me to be more effectual than 
any of the others. The dose of it should, of course, be too small 
to cause a feeling of nausea. 
The uneasiness at the stomach that arises from slow digestion, 
may often be mitigated by drinking a small glass of water, or 
by eating a lump of sugar, an hour or two after meals or when 
the uneasiness begins to be felt. 
Where digestion is habitually slow and feeble, much benefit 
of more lasting kind may frequently be derived from the muri- 
atic or the nitro-muriatic acid, taken for some weeks together, 174 
FERMENTATION 
half an hour or three parts of an hour before the principal 
meals. 
I need hardly say that, when digestion is slow and feeble, 
care should be taken not to give at the time of meals, or while 
digestion is going on, alkalies, the alkaline salts, or other medi- 
cines that suspend or enfeeble the action of the gastric juice. 
When weakness of the stomach is congenital, and when it 
arises from an irreparable injury done to its gland-structure, the 
chief relief from the ills it causes is to be found in suiting the 
diet to the power of digestion, and in measures that tend to im- 
prove the general health. 
But mere slowness of digestion is not the only ill effect of a 
scanty or depraved secretion of gastric juice. It often happens 
when the stomach is weak and disordered, or when more food is 
eaten than the healthy stomach can readily master, and espe- 
cially when at the same time it secretes an unhealthy mucus 
prone to ferment, that the undigested food in the stomach under- 
goes putrefactive changes or some unnatural fermentative pro- 
cess instead of proper digestion. 
One of the most remarkable properties of the gastric juice is 
that of preventing the putrefaction of meat, Spallanzani first 
ascertained the fact, that gastric juice not only prevents the 
putrefaction of meat, but has the power to arrest the process of 
putrefaction already begun, and even to correct the fetor of meat 
already tainted. Later physiologists have ascertained that it 
likewise hinders the lactic, acetic, and alcoholic fermentations, 
which consequently do not occur in the stomach during healthy 
digestion. i 
But if the gastric juice be insufficient in quantity, or faulty in 
composition, this controlling power may be inadequate to its 
purpose, and the food in the stomach may undergo some fer- 
mentative changes that ought not to take place. 
The precise nature and the products of these changes depend 
on the quality of the food and on the state of the substance that 
acts as a ferment. If this substance be decomposing mucus, as 
Lehmann has suggested that it commonly is, the kind of fer- 
mentation will very much depend on the stage of decomposition 
which this has reached. 175 
IN THE STOMACH-CONTENTS, 
In some cases, the food undergoes common putrefactive 
changes, and sulphuretted hydrogen is evolved. Distension and 
uneasiness of the stomach come on, with frequent eructation of 
sulphuretted hydrogen,—belchings as of rotten eggs. This is 
attended with severe frontal headache—often with a feeling of 
chilliness—and the other disorder familiarly known as the effects 
of surfeit. All this disorder is speedily removed when the 
stomach is emptied by a vomit. 
This kind of indigestion is a common effect of over-eating, 
even in young and healthy persons, and hence is popularly 
known as “a surfeit.” Delicate and growing boys often eat 
largely from a sense of exhaustion, and soon afterwards engage 
in active play ; the food is undigested, and surfeit occurs. It is 
more prone to occur in persons with carious teeth, when offen- 
sive saliva passes into the stomach. 
It frequently occurs, too, as we have seen, in cancer of the 
stomach, where offensive secretions are poured into the stomach, 
while the food, in consequence of an obstacle at the pyloric 
orifice of the stomach or of some impediment to the free action 
of its muscular fibres, is unduly detained there. 
When “ a surfeit ” occurs in a young and healthy person, the 
quickest and best way of removing the disorder is to give an 
emetic, and so free the stomach from the putrefying matter; and 
afterwards, if need be, to empty the bowels by some quickly- 
acting purge. 
In malignant disease of the stomach, in which this kind of 
disorder is especially apt to occur, emetics, which irritate the 
lining membrane of the stomach and may cause violent efforts of 
vomiting, are unsafe, and an attempt should rather be made to 
prevent the disorder by proper regulation of the diet. As char- 
coal has antiseptic properties, toasted bread may be taken instead 
of plain bread, toast and water instead of plain water, and a 
small quantity of freshly burnt and powdered charcoal may be- 
given with each of the principal meals. This may be conveni- 
ently prepared by pounding bread thoroughly charred; and as 
it is quite tasteless, may be taken suspended in tea*, water, or 
any other liquid. 
Should the disorder occur in spitd of precautions such as these, 176 
FERMENTATION 
the progress of the putrefactive changes may sometimes he 
stayed, and the further evolution of gas he prevented, by small 
doses of creosote. From half a minim to a minim of creosote 
is sufficient, and may be given in a pill at the time of meals, or 
as soon afterwards as the putrefactive changes begin. 
It much more commonly happens, when digestion is feeble, 
that the contents of the stomach undergo some other kind of 
fermentative process. 
If the food have consisted chiefly of vegetables, fruits, new 
bread, ill-fermented malt liquors, new wines, it has a tendency 
to pass into a fermentation by which carbonic acid is freely 
evolved. This causes great distension of the stomach, and a 
distressing sense of uneasiness, frequently relieved for the mo- 
ment by the eructation of inodorous gas—chiefly, carbonic acid 
gas. 
If the stomach be emptied by a vomit, the rejected matter is 
seen to be in a state of active fermentation. 
In the case of St. Martin, Dr. Beaumont had an opportunity 
of witnessing this process in the stomach itself. St. Martin had 
been in the woods all day, picking wortleberries, and had 
eaten no other food from seven in the morning to eight in the 
evening. Dr. Beaumont then looked into the stomach, and found 
it, to use his own expression, “full of berries and chemi- 
fying aliment, frothing and foaming, like fermenting beer or 
cider.” 
If food be eaten which is already in a state of fermentation, the 
fermentative process may continue in the stomach itself. When, 
for example, new wine is drunk,—wine that is in a state of fermen- 
tation,—the fermentation sometimes continues ; is, perhaps, even 
increased by the heat of the stomach; and carbonic acid is evolv- 
ed very rapidly. The stomach becomes greatly distended, and 
it is stated that the consequent disorder is sometimes so great a*s 
to destroy life. Cattle, when first placed in a field of fresh clover 
or other rich pasture, frequently eat more than their stomachs 
can digest. The vegetable mass ferments in the stomach, as it 
would at the same temperature out of the body, and carbonic 
acid and hydrogen (and sometimes hydrogen and sulphuretted 
hydrogen) are evolved in great quantity. In consequence of the 177 
IN THE STOMACH-CONTENTS, 
peculiar structure of the stomach in cattle, these gases cannot 
escape through the oesophagus, and the stomach becomes enor- 
mously distended—in some cases even to bursting. 
In man the gas escapes readily through the oesophagus, so 
that, even when much of it is evolved, the immediate ill effects 
of this kind of indigestion are very rarely serious. In the course 
of a few hours the fermentative process is at an end, and the dis- 
tension of the stomach subsides. 
The cases in which medical advice is most frequently sought 
are, however, not those where distressing distension iand flatu- 
lence result from mere over-feeding in healthy persons, but 
where this kind of indigestion in less degree is habitual, so that 
uneasiness of the stomach and flatulence are commonly felt an 
hour or two after the principal meals. 
Tire ill effects of the disorder are, then, not confined to disten- 
sion and uneasiness of the stomach. The fermentative processes 
in the stomach give rise to products which, when absorbed into 
the blood, have an injurious influence on the general health, and 
the frequent repetition of the indigestion prevents the proper 
nutrition of the body. The patient is usually depressed in 
spirits, is less capable than in health of mental exertion, and has 
lost some gf his customary energy and strength. It often hap- 
pens that oxalic acid is one of the products of the unhealthy 
digestion, and that crystals of oxalate of lime may be found in 
the urine. In many such cases the indigestion itself results from 
a faulty state of the general health, or from overwork or depress- 
ing influences of other kinds, and the disorder belongs to a class 
to which I shall call your attention in a future lecture. 
When thus arising, the flatulent distension of the stomach 
may sometimes be prevented by the pills composed of ipecacu- 
anha and rhubarb, or capsicum and rhubarb, of which I have 
before spoken; but a remedy which succeeds more frequently 
is the nitro-muriatic acid—ten minims of each of the dilute acids 
twice a-day,—taken half an hour, or three quarters of an hour, 
before the principal meals. 
Much good will result also from horse-exercise,' change of 
air, and other influences which tend to improve the general 
health. 178 
FERMENTATION 
The diet should be light and nourishing, and the patient 
should eat sparingly of succulent vegetables, fruits, and saccha- 
rine substances in general, and should carefully abstain from ill- 
fermented malt liquors.. 
A more common kind of gastric disorder is one which seems 
to be owing to the lactic fermentation, by which the starchy 
principles of the food are rapidly converted in the stomach into 
lactic acid. This disorder is most common in nervous persons 
with feeble digestion, in whom it not unfrequently happens that 
acid collects in great quantity in the stomach after meals. They 
often familiarly tell us, that almost everything they eat turns to 
an acid. If vomiting occur an hour or two after meals, the 
matter thrown up is very acid, and, on analysis, the acidity has 
been often found to be mainly due to lactic acid. 
It was supposed by Dr. Front that much of the lactic-acid 
which collects in the stomach in such cases is derived from the 
blood, and that it is secreted by the coats of the stomach. 
Whether this be so or not, there can be little doubt that it is 
often formed in great quantity in the stomach from the starchy 
principles of the food. It is possible that the secretion of lactic 
acid by the coats of the stomach may promote the conversion 
of the saccharine principles of the food into this substance. 
rm • i i • n . , • • • i n i • n n n w . . • 
This lactic fermentation is not, like the kinds of fermentation 
of which I have before spoken, attended with evolution of gas. 
It causes, therefore, not flatulence, but heartburn and pain in 
the stomach, which is often very severe, and which is sometimes 
attended with a feeling of constriction or cramp. 
The uneasiness that results from undue acidity thus arising 
may be relieved for the time by alkalies, and may often be pre- 
vented by giving, before meals, medicines which have an astrin- 
gent or bracing effect on the coats of the stomach—bismuth and 
magnesia, or, better still, the mineral acids, especially the sul- 
phuric acid. 
Lactic acid, out of the body, is apt to undergo another kind 
of fermentation, which causes the slow evolution of hydrogen 
and carbonic acid, and which leads to the formation of butyric 
acid. 
There can be little doubt that the same changes occasionally IN THE STOMACH-CONTENTS. 
179 
take place within the intestinal canal. Hydrogen is one of the 
gases that have been found in the intestines, and now and then 
the matter vomited by persons of weak digestion has the sour 
rancid smell of butyric acid. 
I have spoken of several kinds of fermentation as if they ex- 
isted separately; but it very commonly happens, although one 
kind may predominate and give a character to the disorder, that 
these several kinds, and others of which little is known, go on 
simultaneously, or rather perhaps in quick succession, in the 
stomach, and that various gases, carbonic acid, hydrogen, and 
sulphuretted hydrogen, and various acids, lactic, butyric, etc., 
are formed. The consequent disorder is not confined to the 
stomach. The acid and unnatural products of digestion may 
pass into the bowels, fret their lining membrane, and excite 
griping pain and purging; some noxious matters may be ab- 
sorbed, and cause headache and other disorder; and, if the indi- 
gestion recur frequently, the general health must suffer. 
Severe attacks of vomiting and purging, commonly designated 
English cholera, seem often the result of fermentation or putre- 
faction of food in the stomach, by which some highly-irritating 
matter is formed. If I may judge from my own experience, 
such attacks generally come on in the evening, soon after dinner, 
or at night, soon after supper, and are much more frequently con- 
sequent on a meal of meat or cheese, than on the eating of 
fruits, to which, perhaps from the greater frequency of the dis- 
order in autumn, they are generally ascribed. I have found no 
remedy so effectual in checking the disorder as pills composed 
of creosote and opium. 
Our knowledge of the various kinds of fermentation is still 
very imperfect. As it becomes more extensive and exact, our 
knowledge of various forms of indigestion will, doubtless, be- 
come more precise, and our power of relieving them greater 
than it now is. LECTURE XI. 
Fermentation in the contents of the stomach, with development of 
sarance. 
The consideration of the preceding kinds of fermentation 
leads us naturally to that particular kind in which those curious 
bodies, the sarcirm ventriculi, are formed in the stomach. 
These bodies were first discovered by Mr. John Goodsir, in 
1842, in a case of which he has given the following account:— 
u Mr. , aged nineteen, consulted me about a stomach 
complaint, under which he had been labouring for four months, 
and which had more or less resisted every attempt made for its 
removal. He informed me that he considered it to be water- 
brash ; that it attacked him on awaking in the morning with a 
feeling of distension of the stomach; that, without any effort of 
vomiting, a quantity of fluid, varying in volume from two- 
thirds to a whole wash-hand basinful, passed up from his 
stomach; that, after this, he was quite relieved, and experienced 
no further inconvenience till the evening of the same day, when, 
without decided distension, sounds as of a fluid boiling or bub- 
bling, and proceeding from the region of his stomach, were per- 
ceptible to himself, and to those around him; that he slept well 
enough, but was generally attacked in the usual manner next 
morning. Such was my patient’s own account of his case. 
“ On examining more particularly into the symptoms, I could 
ascertain nothing positive. His tongue and pulse were natural; 
he had no headache, nausea, or thirst; no tumour could be 
detected in the epigastrium, and no pain on pressure was com- 
plained of in the region of the stomach. The bowels were 
moved daily, and the stools were normal. His appetite was 
not affected, and the usual articles of diet appeared to agree FERMENTATION". 
181 
with him. He was thin, but had a good complexion, and his 
flesh was firm. He stated that he had been very fat, but that 
this had left him before the accession of his stomach complaint.”'25. 
' The fluid thrown up from the stomach smelt, Mr. Goodsir 
adds, like fermenting wort, with a faint acid odour; and, after 
it had stood a few hours, was covered with a mass of froth, like 
the head of a pot of porter. The fluid itself was then mode- 
rately transparent, and of a light brown colour, and had 
deposited on the bottom of the basin a ropy matter of granular 
appearance. 
Mr. Goodsir proceeded to examine the fluid under the micros- 
cope, expecting, from the signs of fermentation which the 
matter presented, to see some of the globular or moniliform 
algae, which are the usual concomitants of certain fermentations. 
“ What,” he says, “ was my astonishment then to find, in the 
first drop I examined, not the vegetables I was led to expect, but 
numerous individuals of a form with allies of which the zoolo- 
gist is familiar! Drop after drop exhibited the same specific 
form, with a precision which convinced me that I had now to 
deal with an organism which, whether animal or vegetable, was 
closely allied to certain genera of bacillarice, and much more 
closely to the genus gonium among the volvocince.” 
plates, the thickness of which is about one-eighth 
of the length of one of the sides. rThey are di vid- 
ed into four equal squares by lines, which join 
the middle points of opposite sides and cross at 
right angles in the centre of the face, so as to re- 
These organisms—the sarcinae—are square or slightly oblong 
semble a packet bound with cords which cross at right angles. 
Each of the four secondary squares is again divided into four 
ternary squares, which are similarly arranged, but more faintly 
marked. 
Perfect individuals vary from the 800 th to the 1000 th of an 
inch in the length of their sides, and under a high power appear 
slightly brown or yellow. 
After discovering the sarcinae, Mr. Goodsir submitted some of 
* “Edinburgh Medical and Surgical Journal,” vol. Ivii. p. 430. 182 
FERMENTATION 
the fluid to Dr. George Wilson, who made an elaborate analysis 
of it, and found that it contained a large quantity of acetic acid, 
some acid which he inferred to be the lactic, and a minute quan- 
tity of hydrochloric acid. 
The patient was under Mr. Goodsir’s observation nearly two 
months, at the end of which the disorder still continued, but had 
been much mitigated by the remedies employed. 
Soon after the observations of Mr. Goodsir were published, 
sarcinae were found by Mr. Busk in three cases in quick suc- 
cession. 
The first case was that of a young man who was admitted into 
the Seamen’s Hospital for severe injuries, and who, previously to 
the infliction of these injuries, had been in perfect health. He 
jaad sustained rupture of the diaphragm, in consequence of 
which the whole of the stomach and parts of other abdominal 
viscera had passed into the cavity of the left pleura. After his 
admission to the hospital, he lived about eight days, during 
which time everything he swallowed was brought up again by 
a kind of regurgitation, apparently without having entered the 
stomach at all. Besides the mere ingesta, a peculiar-looking 
brown fluid was occasionally thrown up in large quantity,—to 
the amount, in the course of twenty-four hours, of several pints. 
On being allowed to stand for twenty-four hours, this fluid under- 
went fermentation, had a faint odour, something like that of fer- 
menting wort, and was covered with a yeasty froth. 
On examining the brown matter through the microscope, Mr. 
Busk found that it was composed almost wholly of sarcinm and 
of small bodies like the toruhe of yeast. 
The second case was that of a young man with fracture of the 
spine, and as was supposed, rupture of the diaphragm,-—the re- 
sult of a fall into the hold of a vessel. About twelve hours after 
the accident he vomited once, and once only; and the matter re- 
jected consisted of a small quantity of brownish fluid, mixed 
with food. The brown colour, as in the former case, was found 
to depend upon the presence of coloured flakes, composed in the 
greater part of sarcinm. 
This man never vomited afterwards, and at the end of several 
months was in perfect health, excepting the paralysis and other IN THE STOMACH-CONTENTS. 
effects of the injury done to the spine. His appetite and diges- 
tion were very good. 
The third case related by Mr. Busk was that of a boy, about 
fifteen years of age, who was much reduced by disease of the 
hip-joint, from which he had long suffered, A short time before 
his death, he was seized with acute pleurisy, which was attended 
with frequent vomiting, and in the matter thus rejected, and 
consisting of little more than mucus, were observed many brown- 
ish flakes, which were found to be composed principally of 
sarcinse. 
Nothing peculiar was observable in the mucous membrane 
of the stomach in this or in the first of the cases related by Mr. 
Busk; nor were any of the sarcinse to be detected, on the most 
careful examination, in any other part of the alimentary canal 
than the stomach. (“Microscopical Journal,” vol. ii., p. 321.) 
In the winter of 1850, two men having this peculiar form of 
indigestion were in the hospital together, and were long under 
my observation. 
One of them, James Lane, was a labourer, forty-four years of 
age, and the stomach disorder, as in two of the cases recorded 
by Mr. Busk, seemed to have resulted from an injury. He told 
us that he had led a temperate life in the country and that his 
health was good until two years before, when, while he was at 
work on a railroad, a large quantity of earth fell upon him, 
throwing him with violence across some pieces of thick board. 
He was completely buried in the earth for half an hour, at the 
end of which he was dug out insensible, and was found to have 
received some severe injuries of the head and face. Ever since 
this accident he had experienced palpitation and shortness of 
breath on exertion, so that he had been unable to work hard, 
and his stomach had been disordered in the following way. As 
soon as he recovered from the immediate shock of the injury, 
he began to suffer pain at the stomach. The pain continued, 
and from that time he had occasional vomiting; but the vomit- 
ing did not trouble him much until the last four months, during 
which it had occurred, on an average, two or three times in 
twenty-four hours. The vomiting occurred most frequently in 
the evening or at night after he had gone to bed. 184 
FERMENTATION 
On his admission to the hospital, on the 11th of December, he 
was thin, and much out of condition. His appetite was good, 
but a few minutes after every meal he had pain and a sense of 
burning at the pit of the stomach, soon followed by much flatu- 
lence and distension of the stomach, which continued until he 
vomited, when the stomach got slack and the heartburn ceased. 
The matter vomited varied in quantity, from a teacupful to a 
quart or more. It was always sour, and, after it was vomited, 
fermented and frothed like wort. When it had stood some 
hours in the vessel in which it was received, it consisted of a 
clear liquid, which had a brownish sediment and was covered 
by a light-brownish frothy matter that looked and smelt like 
yeast. He stated that the stomach was usually emptied by four 
or five efforts of vomiting—that a clear liquid like water came 
first; a thicker and brownish matter last. 
On microscopic examination," the brownish matter was found 
to contain great numbers of the yeast-fungus and sarcinse. 
Lane complained of pain at the right of the epigastrium, and 
was unable to lie on the right side, as this posture increased the 
pain and uneasiness at the stomach and the flatulence. On 
account of this pain, several blisters had been applied between 
the right mamma and the epigastrium. At a small spot under 
the cartilage of the tenth rib on the right side there was constant 
tenderness, but no tumour could be felt there. The stomach 
appeared to be somewhat enlarged, and the bowels were habitu- 
ally costive. It seemed probable that the diaphragm had been 
injured, and that the movements of the stomach were impeded 
by unnatural adhesions of the stomach near its pyloric end. 
Lane was quite free from fever, but his nights were often rest- 
less from the uneasiness and distension of the stomach, which 
were usually most troublesome in the evening and at night. 
He was kept on a diet of lean meat and bread, and was ordered 
to take two minims of creosote in pills three times a day. Under 
this treatment the symptoms abated; and on the 15th of Janu- 
ary, five weeks after he came under our notice, he left the hospi- 
tal much improved in condition, but still suffering from pain at 
the epigastrium, flatulence, and the occasional vomiting or eruc- 
tation of a sour fermenting liquid. IN THE STOMACH-CONTENTS. 
185 
I sent tlie liquid vomited on two different occasions to the 
Laboratory of the College, and requested Mr. Hardwick,to ana- 
lyse it for me, and to ascertain especially what acids were in it, 
and whether it contained alcohol. He complied with my request, 
and the result of his analysis was, that the first specimen con- 
tained acetic acid and a trace of hydrochloric acid, but no alco- 
hol ; the second specimen, acetic acid, but neither hydrochloric 
acid nor alcohol. 
The result of the analysis confirmed, therefore, that made by 
Dr. Wilson, that the acid generated by the fermentative process 
is acetic acid. 
In the “ Medical Times ” for the 23rd of August, 1851, Dr. 
Jenner has published some very valuable and interesting obser- 
vations on the case of a man who had suffered terribly for many 
years from the kind of stomach disorder we are considering. In 
this instance, an analysis of the matter vomited was once made 
by Professor Graham, who found that “it contained a large 
excess of free hydrochloric acid, a little acetic acid, alcohol, and 
sugar. The gas disengaged was carbonic acid.” 
Similar results seem to have been obtained by Dr. Bence 
Jones, from analyses of fluid containing sarcinse vomited by a 
man in St. George’s Hospital. 
It is probable', therefore, that in the fluid vomited by Lane 
and analysed by Mr. Hardwick, alcohol was present at an earlier 
stage of the fermentative process, but that by the time the anal- 
ysis was commenced this had all passed into acetic acid. 
It occurred to me, that it might be possible to generate the 
sarcinse from some materials of the food out of the body; and 
with the assistance of Dr. Jordan, the physician’s assistant at the 
hospital, I made the following experiment:— 
A small quantity of the brownish matter containing toruke 
and sarcinse, vomited by Lane, was added, in separate glasses, 
Ist. To sugar and water. 
2ndly. To starch and water. 
Srdly. To albumen (white of egg) and water. 
4thly. To a mixture of the contents of the three preceding 
glasses. 
The fluid in these several glasses was kept for two or three 186 
FERMENTATION 
days at the temperature of the body; but in not one of them 
were the sarcinse multiplied. I did not then know that an acid 
condition of the fluid is essential to their development, as M. 
Andral and Dr, Hassall have shown that it is to the develop- 
ment of some other fungi. 
On the 14th of December, 1850, three days after the admis- 
sion of Lane to the hospital, another man, Joseph Burraston, 
was admitted, thin and out of condition, like Lane, and having 
a stomach disorder of the same kind. 
Burraston, who was forty years of age, was a pot-cleaner at a 
public-house in London, and had drunk very hard of beer and 
spirits. He had suffered in years gone by from syphilis and 
gonorrhoea; but, with the exception of these diseases, his health 
seems to have been good, considering his habits, until about 
twelve months before his admission to the hospital, when he 
began to have occasional sickness, especially after drinking beer 
or spirits. 
Six months before his admission the vomiting became more fre- 
quent ; and since that time he had sometimes vomited twice or 
thrice in a day. The appetite was always very good. He suffered 
no positive pain in the stomach, but soon after meals had a burn- 
ing heat there, and the stomach became blown out with wind. 
O 7 • 
The uneasy sensations continued until vomiting occurred, when 
they ceased, to be excited again, in greater or less degree, after 
the next meal. The matter vomited often amounted to a pint 
and a-half, and sometimes to two or three pints. It usually con- 
sisted of a sour clear liquid, having a light brownish stringy sed- 
iment. It fermented, and after a time became covered with a 
brownish froth, like that on the top of fermenting wort. The 
brown matter, both in the sediment and at the surface of the 
liquid, contained abundance of the yeast-fungus and sarcinse. 
Ho tumour could be felt at the epigastrium, but the bowels 
were habitually costive and the stomach appeared to be larger 
than natural. 
The long duration of the malady, the habitual constipation, 
and the apparent enlargement of the stomach, led me to infer, 
that the pyloric orifice of the stomach was somewhat strictured; 
and it seemed probable, from there being no tumour and no IJST THE STOMACH- CONTENTS, 
187 
positive pain—from there being, in fact, no indications of can- 
cer of the stomach or of simple ulcer—that the cause of the 
stricture was that induration of the cellular tissue in the pyloric 
ring which spirit-drinking causes. 
Burraston remained in the hospital till the 29th of March— 
between three and four months. During all that time he was 
quite free from fever ; the pulse usually ranging from 56 to 80 
a minute. The appetite was constantly good, sometimes more 
craving than natural. The condition of the stomach varied 
according to the remedies employed. Sometimes, although 
there was more or less flatulent distension and sense of burning 
in the stomach after meals, there was no vomiting for many days 
together. At other times, vomiting occurred two or three times 
a-day. The distension and uneasiness of the stomach were 
usually greater, and the vomiting was more frequent in the eve- 
ning and at night, than in earlier parts of the day. The mat- 
ter vomited was always the same kind of glairy fluid, and was 
almost always acid and fermenting. On two or three occasions, 
however, the fluid was alkaline; and it was observed, that when 
such was the case, no sarcime could be found in it. The same 
fact was noticed in a man who was some months before in the 
hospital under the care of Dr. Todd.* 
The sleep seemed to depend mainly on the state of the sto- 
mach ; being sound when the stomach was empty, and disturbed 
and broken when the stomach was distended and uneasy. The 
urine was always clear, and usually very acid. The quantity of 
it passed daily varied from a pint and a-half to three pints and a- 
half in twenty-four hours, and the specific gravity ranged from 
1022 to 1011: the larger quantities within this range and the 
lower specific gravities being by far the more common condition. 
The urine contained no albumen, but often exhibited under the 
* On one occasion, in 1849, I found sarcinoe in a fluid which was neutral. 
The fluid, which had been vomited by a man in King’s College Hospital, had a 
light-brown foam on the surface and a light-brown viscid matter at the bot- 
tom—both containing sarcinse. The liquid did not redden litmus-paper ; but 
when this paper was pressed on some of the light-brown matter from the top 
or bottom, it was distinctly reddened. 188 
FERMENTATION 
microscope crystals of oxalate of lime. It was frequently no* 
ticed that the saliva had an acid reaction. 
Various plans of treatment were tried in succession. 
At first, two minims of creosote were given three times a-day, 
in pills, as in the former case; and, in order to obviate constipa- 
tion, five grains of the compound aloetic pill at night. 
Under these remedies considerable amendment took place, 
so that three or four days were sometimes passed without vo- 
miting ; but the peculiar disorder of digestion always existed in 
greater or less degree, and, at times, the distension of the sto- 
mach was as great, and, if vomiting occurred, the matter thrown 
up was in as large quantity, and had the same characters as be- 
fore. 
On the 16th of January the creosote was left off, and, on ac- 
count of the frequent presence of oxalate of lime in the urine, 
twenty minims of the dilute nitro-muriatic acid were given twice 
a-day, half-an-hour before the principal meals. 
At the end of a week, no benefit having resulted from the 
acids, the creosote was again given instead, and a diet was or- 
dered from which saccharine substances were excluded, and 
which comprised a pound of lean meat, eighteen ounces of glu- 
ten bread, and two pints of coffee. The disorder again abated. 
On the sth of February it is noted that he had gained S~lbs, 
in weight in the previous week. On the evening of that day, 
however, he vomited three pints of matter, which was as sour 
as the matter vomited before, and fermented as much. From 
this time, though there was always more or less distension and 
uneasiness of the stomach after meals, he did not vomit till the 
19th, when he again brought up three pints, having the same 
characters as before. On this day his weight was 8 stone lOlbs,, 
exactly as it was on the sth of February, a fortnight before. 
It then occurred to me, that as the disorder seemed to be 
kept up by some obstruction at the pyloric end of the stomach, 
good might possibly result from occasionally emptying the sto- 
mach completely, and thus getting rid of the ferment by means 
of emetics; and, in consequence, I ordered him to take occa- 
sionally one scruple of sulphate of zinc. The emetics acted very 
powerfully, but no essential benefit resulted from them. 189 
IN THE STOMACH-CONTENTS. 
The medicines he had hitherto been taking were now left off, 
and five grains of nux vomica were given in pills three times a- 
day. These pills were taken more than a week without appa- 
rent benefit. On the 10th of March they were discontinued; 
and having learned from a man who was some time before in 
the hospital vomiting sarcinse that he had derived much benefit 
from eating large quantities of common salt, I prescribed this as 
a medicine, to Burraston. 
From the 10th of March to the 19th he took two tea-spoonfuls, 
and after the 19th two table-spoonfuls of common salt in half a 
pint of water, twice a-day. Together with the salt, he occa- 
sionally took, as before, compound aloetic pills, to regulate the 
bowels. 
This remedy proved much more successful than any previ- 
ously tried. After he took the large doses of salt, he had occa- 
sionally a sense of burning in the stomach and more or less of 
distension; but did not vomit and had very little nausea ; and 
on the 29th of March, three weeks after the salt was ordered, 
he left the hospital much relieved. 
On the Bth of October of the same year, the nurse at the 
hospital under whose charge he was, showed me a letter she had 
just received from him, in which he stated that ever since he 
left the hospital he had continued to take the salt, and that for 
some time he had also taken habitually cascarilla tea. His 
stomach disorder, he stated, was very much less troublesome 
than when he was in the hospital, and he attributed the amend- 
ment mainly to the salt. 
In the autumn of 1851, I was consulted at my own house by 
a man who had suffered from this kind of stomach disorder for 
ten years, and who had derived great relief from enormous 
doses of carbonate (bicarbonate?) of soda. He was a carpenter, 
forty years of age, who lived in the country, and had always, as 
he stated, been of temperate habits. The stomach disorder came 
on without assignable cause, and slowly but gradually increased. 
He told me that four years before I saw him a chemist had 
recommended him to take carbonate of soda, and that he soon 
got to take enormous quantities of it; for months together as 
much as three-quarters of a pound a week—on his bread, and 190 
FERMENTATION 
in liis tea and beer—and sometimes, for a short time, as much 
as a pound a week. For the last four months his allowance had 
been a quarter of a pound a week, and he had found that a 
larger quantity of it gave him pain in the back. He stated that 
at first he derived great benefit from these large doses of soda, 
and that they enabled him to resume his work, which he had 
been obliged to discontinue before. His strength, however, had 
gradually declined, and when I saw him he was much emaciated, 
and had the look of a man with malignant disease. No tumour 
could be felt in the region of the stomach, but the stomach was 
much distended; the bowels were habitually very costive; 
the cutaneous veins of the belly were large; vomiting occurred 
frequently, sometimes as often as two or three times a day, 
and several times within the preceding two years he had 
vomited matter like coffee-grounds. His symptoms differed 
from those of the patients of whom I have before spoken, in the 
circumstances, that solid food gave him pain in the stomach, so 
that he had been induced to refrain almost entirely from its use- 
It was plain that at the time I saw him there was obstruction 
of the pyloric orifice, and it seemed probable that this was the 
effect of slowly-growing malignant disease. 
I prescribed at first large doses of salt, but no benefit resulted 
from them ; and I subsequently ordered, I know not with what 
effect, bismuth, magnesia, and opium. 
He lived till towards the end of 1858, and on post-mortem 
examination of the body it was ascertained, as was subsequently 
reported to me, that the malady consisted in simple stricture of 
the pylorus—so complete that a probe could scarcely be passed 
through. There was no thickening nor any other indication of 
malignant disease, and every other organ of the body was 
sound. 
It appears from the preceding cases, and many similar ones on 
record, that the peculiarity of the disorder we are considering 
consists in this, that the secretions of the stomach, which seem 
to be usually more abundant than natural, undergo or excite in 
the food, in the stomach and after they have been thrown up 
from it, a fermentation which is attended with the evolution of 
carbonic acid and with the production of torulse and sarcinge, 
and which leads to the formation of acetic acid. IN THE STOMACH-CONTENTS. 
191 
The production of the disorder seems to require that there 
shall be some condition which prevents the stomach from com- 
pletely or readily emptying itself. 
The disorder may occur in young persons, and exist for a 
short time, as in one of the cases related by Mr. Busk, and in a 
case that has been recorded by Dr. Bence Jones, in which it was 
noticed a short time before death in a boy of fourteen, who died 
of peritonitis and granular disease of the kidney; but it has 
been most frequently noticed in men who have reached middle 
age,—persons more liable than any others to simple stricture 
and cancer of the pylorus and to other diseases which prevent 
the stomach from completely emptying itself,—and in such per- 
sons the malady is usually of long duration and may, indeed, 
continue to the end of life. 
The appetite is generally good, but the indulgence of it is 
followed by flatulent distension of the stomach, attended by a 
sense of burning or other uneasiness, which, when an ulcer of 
the stomach exists, sometimes amounts to almost agonizing pain. 
When the disorder is slight, the heartburn or uneasiness at the 
stomach continues for some hours, and then gradually subsides, 
as—in one way and another, by the absorption and discharge of 
its contents,—the stomach gets empty. When the disorder is 
in higher degree, the uneasiness persists until it is relieved by 
the vomiting or eructation of a clear, sour, fermenting liquid. 
The quantity of this liquid ejected at once varies in different 
cases and at different times; and when an obstruction at the 
pyloric orifice has long existed _ and the stomach has become 
much enlarged, sometimes amounts to two quarts or more. 
When much is thrown up from the stomach, the bowels, as in 
ordinary cases of stricture of the pylorus, are usually costive. 
There is, in most cases, complete absence of fever, but sleep is 
often much disturbed by the distension and uneasiness of the 
stomach, which, as they result from eating, are more distressing 
in the evening and at night than in earlier parts of the day. 
The disorder of digestion, the pain, the disturbance of sleep, 
cause loss of flesh, and, after the malady has lasted long in high 
degree, the patient is usually emaciated, has a dry skin, a slow 
pulse, and the look of a person with serious organic disease of 192 
FERMENTATION 
the stomach. The disorder is readily recognized when it is in 
such degree as to cause vomiting, by the circumstance, that the 
matter thrown up from the stomach ferments, and that both the 
foam which collects on its surface and the sediment it throws 
down contain abundance of sarcinae and torulse. 
It would seem, from the evolution of carbonic acid, from the 
development of torulse, and from the fact, that alcohol was de- 
tected by Professor Graham in the matter vomited in a case of 
this kind, that common alcoholic fermentation is the first step 
in the process of transformation ; but the alcohol appears to be 
rapidly transformed, and the process ends in the production of 
a large quantity of acetic acid. ISTo symptoms of intoxication 
have been noticed in cases of this kind. 
As the production of acetic acid from alcohol requires a large 
quantity of oxygen, there can be little doubt, that where, as in 
the analysis published by Mr. Goodsir, a very large quantity of 
acetic acid has been found in the matter vomited, much of this 
acetic acid has been formed after the matter has been ejected 
from the stomach. We know that fermentation goes on actively 
in the matter ejected, and the conditions for the acetification of 
alcohol would seem to be much more favourable when the 
matter is exposed to the air than when it is shut up, excluded 
from the direct influence of the air, in the body. 
It must not be supposed, however, that this peculiar fermen- 
tation constitutes the whole disease. The disease consists pri- 
marily and essentially of some organic change which prevents 
the stomach from completely or readily emptying itself, and 
which causes a secretion from the coats of the stomach which, 
when mixed with the food, is prone to undergo or to excite the 
fermentative process in question. The fermentation may be 
stopped for a time; the matter thrown up from the stomach may 
be alkaline, and contain no sarcinae, as happened to Burraston 
during his stay in the hospital; but the patient, instead of being 
then well, has the more common kind of disorder which an 
impediment to the emptying of the stomach causes. The ques- 
tion then arises,—How is it that an impediment to the emptying 
of the stomach leads to this kind of fermentation in some cases 
and not in others? Is there any peculiarity in the organic 193 
IN THE STOMACH-CONTENTS. 
change in the particular cases in which the fermentation occurs ? 
It is curious that, in two of the cases related bj Mr. Busk, the 
disorder resulted from hernia of the stomach through the dia- 
phragm, the coats of the stomach itself being sound. 
The development of the sarcinse has probably the same rela- 
tion to the fermentative process, or to some stage of the fermen- 
tative process, as the development of toruhe has to simple alco- 
holic fermentation. It is worthy of note that sarcinse are not 
peculiar to the stomach. They have been found in other animal 
secretions in a state of decomposition. In a review of Leh- 
mann’s “ Physiological Chemistry,” in the British and Foreign 
Medico-Chirurgical Review for 1851, it is stated that sarcinse 
have been once detected in the urine by Heller; and Dr. Beale 
tells me that he has discovered them once in urine and once in 
decomposing bile. 
But, although the development of torulae and sarcinas cannot 
be considered the primary cause of the stomach disorder, the 
fermentation that attends it, by leading to the evolution of gas 
and the fermentation of acetic acid, and thus distending and 
fretting the stomach, terribly aggravates the sufferings which 
the impediment to the emptying of the stomach, which is the 
origin of the mischief, would otherwise produce. 
The heartburn and uneasiness of the stomach may be lessened 
by neutralizing the excess of acid by carbonate of soda or some 
other alkali; but the readiest, perhaps, in most cases, the chief 
means we have of relieving the disorder, are the agents which 
tend to prevent the fermentative process. The fermentative 
process may be checked by creosote, which has a remarkable 
influence in checking fermentation of various kinds, and which 
was given with benefit in three of the cases noticed above and in 
several others of which accounts have been published in the 
medical journals. A small dose—a minim or half a minim—in 
the form of pill, might prove sufficient if taken, as it should be, 
at every meal.* 
If we may judge by the case of Burraston, the fermentation 
* In the new mode of preparing vinegar from alcohol, by making the alcoholic 
liquid frequently strain through twigs or shavings, it is found that any charring 
of the twigs or shavings entirely prevents the acetilication of the liquid. 194 
FERMENTATION 
may also be checked, and the disorder, in some cases, be ranch 
mitigated by large quantities of common salt. 
A more effectual remedy still is the bisulphite of soda, which 
is a powerful antiseptic, and has been of late years much used 
in some anatomical schools to preserve bodies for dissection. It 
has also been used to prevent the fermentation of vegetable 
juices. It owes its virtues to the circumstance, that it is decom- 
posed by almost any vegetable acid, and that its decomposition 
liberates sulphurous acid, which has great power to prevent 
alcoholic and acetous fermentation.* 
The merit of suggesting it as a remedy for the disorder we 
are considering belongs, I believe, to Dr. Jenner, who gave it 
with much success in the case to which I have before referred. 
I have myself given it with great benefit in several cases in 
which the symptoms were like those that attend the vomiting of 
sarcinte, and in many other cases in which much discomfort re- 
sulted from the development of gas in the stomach. From fif- 
teen grains to a drachm of it may be given, dissolved in water, 
two ar three times a day; and with proper care as to the time 
of giving it, smaller doses will often prove sufficient. It is very 
soluble, and as it is not kept by all druggists, my custom is to 
prescribe a solution of it of the strength of two drachms of the 
salt in an ounce of water, and to order a teaspoonful of this to 
be taken in a wineglass of water soon after meals, or when the 
fermentative process in the stomach is about to commence. I 
have given it in these doses without intermission for a consider- 
able time, with much benefit to the stomach disorder and with- 
out any apparent ill effects. 
There, perhaps, many other agents having power to prevent 
fermentation, that might prove beneficial in the same way. 
In chronic cases of the disorder, the drain from the coats of 
the stomach, and the frequent throwing up of part of its con- 
tents, causes constipation, and it is requisite to obviate this con- 
dition, since any undue accumulation in the bowels aggravates 
the stomach-disorder. The best aperients are probably aloetic 
or colocynth pills. 
*ln some parts ol Devonshire, sulphurous acid generated by the burning of 
sulphur, is used to arrest fermentation and prevent acetification in cider. IN THE STOMACH-CONTENTS. 
195 
When the disorder is severe and the patient reduced in flesh, 
opiates, timely administered, are of much service in lessening 
the uneasiness of the stomach and promoting sleep. 
It now and then happens, that the disorder co-exists with 
chronic ulcer of the stomach, and that eating solid food causes 
pain in the stomach, which is different from the uneasiness that 
results from distension of the stomach, and pain also in the cor- 
responding part of the back. In such cases, as in ordinary cases 
of simple ulcer, the diet should be of the least irritating kind. 
By the various means which I have now enumerated, the dis- 
order may be greatly mitigated, the strength of the patient kept 
up, and his life prolonged—which is as much as can be promised 
for any disorder which originates, as this usually does, in irre- 
movable organic changes. LECTURE XII. 
Indigestion arising from defective action of one of the excreting organs, 
or from some fault in the nutritive processes in other parts of the 
body. 
The stomacli is influenced in its action not merely by the state 
of the nervous system, but also by the state of the blood, and so, 
indirectly, by the various conditions that affect the nutritive 
processes in the body. 
If the blood be rendered impure by defective action of one 
of the excreting organs, or by improper food, or by any fault in 
the assimilating processes, the secretions of the stomach are gen- 
erally insufficient or unhealthy, and indigestion, in some form 
or other results. 
I shall speak first of the disorders of digestion that result 
from defective action of the excreting organs. 
The stomach is in more direct relation with the liver than 
with any other important excreting gland. The stomach and the 
liver are parts of the same great apparatus, whose office it is to 
supply, from the crude matters taken as food, fit material for the 
sustenance of the body. The action of the one organ is in some 
degree complemental to that of the other. Dr. Front long ago 
advanced the opinion, that the muriatic acid of the gastric juice 
is furnished by the decomposition of chloride of sodium or com- 
mon salt, and that the soda thus set free in the blood is eliminat- 
ed with the bile. He was early led to the opinion which the 
researches of Matteucci, Liebig, and others, tend in some meas- 
ure to support, that the principal digestive organs constitute a 
kind of galvanic apparatus, of which the mucous membrane of 
the stomach may be considered the acid, or positive pole, and 
the hepatic system the alkaline, or negative pole. 
Dr. Bence Jones has lately shown, that soon after meals, INDIGESTION. 
197 
when the stomach secretes a large quantity of muriatic acid, the 
urine has a tendency to become alkaline; and that the soda set 
free on the decomposition of the chloride of sodium which fur* 
nishes the muriatic acid of the gastric juice, instead of being all 
eliminated by the liver, as Front seems to have supposed, is in 
part eliminated by the kidneys. Other observers have shown 
that, when the stomach is pouring out a large quantity of acid, 
the alkalinity of the saliva likewise increases; and, since the 
increased alkalinity of the urine and saliva at such times results 
from the increased quantity of free soda in the blood, it is pro- 
bable that the same law holds for all other secretions of which 
soda is an essential constituent. But still there is reason to 
believe that the opinion advanced by Prout is in part true, and 
that an intimate relation—and one, probably, of the kind which 
Prout supposed—exists between the secreting functions of the 
stomach and the liver. 
If the secretion of the liver be defective in consequence of 
deficient power in the organ, or in consequence of the congestion 
of it that results from high living and indolent habits, the func- 
tions of the stomach are almost invariably disordered, and, in 
conjunction with a slight yellow tinge in the conjunctiva and 
skin, there is a coated tongue, an impaired appetite, nausea and 
especial disrelish of rich dishes, constipation; and often, with 
this defective action of the stomach and liver, there is disturbed 
or unrefreshing sleep, and great depression of spirits. 
The remedies for this condition are, a light and simple diet, 
with water fi?r drink; fresh air; exercise, to promote perspira- 
tion, without fatigue; and medicines that increase the secretions 
of the liver, bowels, and kidney. A moderate dose of blue pill, 
repeated two or three times on alternate nights, and a drachm 
of sulphate of magnesia in infusion of senna every morning, 
answers well for persons strong enough to bear it. To others, 
fifteen grains of bicarbonate of soda twice a-day, with enough 
of the potassio-tartrate of soda to act gently on the bowels, or 
some other medicine of similar action, may generally be given 
with advantage. 
Again, when the kidneys imperfectly perform their office, so 
that urea and other constituents of the urine contaminate the 198 
INDIGESTION 
blood, tbe functions of the stomach are generally more or less 
disordered. 
This is especially seen in advanced stages of Bright’s disease, 
when the kidneys are atrophied. The prominent symptom of 
the stomach-disorder in such cases is nausea or vomiting. The 
vomiting is sometimes so frequent as greatly to interfere with 
nutrition, and is the only disorder of stomach complained of. 
In other cases, the ordinary effects of slow and feeble digestion— 
a sense of weight and oppression after meals, with flatulent dis- 
tension of the stomach or undue acidity—co-exist with the 
nausea or vomiting; and sometimes these effects of slow and 
feeble digestion exist alone. 
In chronic granular disease of the kidneys there are several 
conditions which tend to disorder the functions of the stomach. 
First, there is, perhaps, in many cases, as when the kidney is 
irritated by a calculus, a purely nervous influence starting from 
the kidney, which is reflected upon the stomach and tends to 
derange it. 
In the next place, the gastric juice becomes vitiated by ad- 
mixture with urea, and probably with other hurtful excxemen- 
titious matters. The mucous membrane of the stomach must, 
as I have before observed, be regarded as an expanded gland, 
destined to furnish abundant secretions, and, by virtue of its 
active secreting function, occasionally instrumental in eliminat" 
ing noxious principles from the blood. It has been found, 
indeed, on chemical analysis, that, in malignant cholera, and in 
those diseases of the kidneys in which the secretion of urine is 
very defective, the matters vomited contain urea, or the muriate 
or carbonate of ammonia derived from the decomposition of it. 
The elimination of these foreign matters, or the reflex nerv- 
ous influence, may, moreover, excite the secretion of gastric 
acid where there is no food in the stomach to dissolve; or may 
cause congestion of the stomach, and thus lessen the supply of 
gastric juice: or may lead, directly or indirectly, to an inflam- 
matory condition of its lining membrane, and so not only lessen 
the supply of gastric juice, but also cause a secretion of un- 
healthy mucus, which, from its proneness to ferment, is an addi- 
tional source of gastric disorder. FROM IMPURITY OP BLOOD, 
199 
I have already observed, when speaking of the effects of 
arsenic, that a stomach disorder caused by some noxious matter 
in the blood is apt, if it exceed certain limits, to be followed by 
an analogous disorder of the bowels. The cause of disturbance 
acts alike, though in different degrees, on the different parts of 
the intestinal canal. An illustration of this is seen in the gran- 
ular disease of the kidney, in which diarrhoea not unfrequently 
co-exists or alternates with the gastric disorder, and in which 
the matters voided by the bowels, as well as those ejected from 
the stomach, have been found to contain urea. 
In granular disease of the kidney, the blood is alwayfe im- 
poverished, and there is a source of further exhaustion in the 
abiding drainage of albumen from the system. It is very im- 
portant, therefore, to remedy the disorder of digestion, and so, 
in the greatest possible extent, to supply the waste. Hot unfre- 
quently, indeed, more relief can be given by remedying the 
stomach disorder than by any measures in our power that directly 
affect the kidney itself. 
The vomiting or nausea may generally be controlled by the 
dilute hydrocyanic acid, which may be given in doses of four or 
five minims three times a-day, and which may be conjoined 
with small doses of potash or soda, if any indications of undue 
acidity likewise exist. 
Another remedy, very effectual in controlling the vomiting, 
is creosote, of which a minim or less may be given, in a bread- 
pill, three times a-day, before meals. 
If these means should fail, the vomiting and much of the 
associated gastric disorder may often be stopped for a time by 
a few purgative doses of cream of tartar and jalap, which 
probably relieve the stomach by causing a more abundant eli- 
mination of the noxious matter by the bowels. This medicine 
is best given, as are most others of similar action, in a single 
dose sufficient for the desired object, in the morning before 
breakfast, since it will then, in addition to the drain it causes 
from the mucous membrane, only sweep away the refuse of 
digestion, whereas if it be given at other times or in repeated 
doses during the day, it sweeps away food that has been more 200 
INDIGESTION 
or less digested, but the nutritious elements of which have not 
been absorbed. 
I need hardly remark, that when such impediments to healthy 
digestion exist, very great care should be taken in diet. If the 
food be hard of digestion, or if more be eaten than the stomach 
can easily dissolve, it not only oppresses the stomach and causes 
much temporary discomfort, but may excite an inflammatory 
condition of the Tnucous membrane, and thus still further weaken 
the digestive power. 
The blood may be rendered impure and the stomach be 
deranged, not only by defective action of the great excreting 
organs, but also from fault in the processes concerned in the 
waste and repair of the tissues in other parts of the body. The 
blood is the storehouse from which the different textures of the 
body draw the materials for their nourishment and growth. 
Physiology teaches us that the organic constituents of most of 
the textures of the body are being constantly renewed—that, as 
time flows on, although the form remains nearly the same, the 
matter is changed. Every exercise of power causes an expen- 
diture of the substance of the organ that ministers to it. Some 
constituent of the organ is resolved into simpler chemical com- 
pounds, which are then given back to the blood, and the blood 
furnishes to the organ fresh materials to supply the waste. 
There is thus a constant interchange between the blood and the 
tissues 5 the organic constituents of the tissues waste—are 
resolved, that is, into simpler chemical combinations,—and are 
then absorbed into the blood, and thrown off by the different 
excreting organs; and the elements of the tissues thus taken 
away are reconstructed out of fresh materials supplied by the 
blood. These processes of waste and repair are what have been 
termed the processes of secondary assimilation. It is essential 
to the purity of the blood that they be rightly performed. There 
are several ways in which they may be deranged. The expen- 
diture of power may be too great, the tissues may waste too 
rapidly, and thus more effete matter may pass into the blood 
than the excreting organs can remove; or, without this, either 
in the waste or in the reconstruction of the tissues, some sub- 201 
FROM IMPURITY OF BLOOD. 
stances may be formed, and may pass into the blood, which are 
difficult of excretion, or which disorder the action of other 
organs. 
It was Dr. Front who fixed onr attention on this great class of 
disorders—disorders not depending on any visible structural 
change, but on some fault in those subtle processes that minister 
to nutrition. There are, doubtless, more disorders of this class 
than we have yet distinguished. They all lead to an unnatural 
state of the blood, from the excess of effete matter or from the 
presence of some unnatural and injurious principle in it; and 
often this leads again to an unnatural state of the urine—the 
great drain through which the soluble effete matters of the body 
are cast off. 
These states of faulty assimilation are then, in some instances, 
revealed to us by the condition of the urine. 
One of the most important of them, as far as digestion is con- 
cerned, is that characterized by the formation of lithic acid in 
undue quantity, and in which an excess of this substance exists 
habitually or frequently in the urine. 
This particular derangement of the nutritive processes often 
has its origin, as you know, in a peculiarity of constitution—the 
so-called lithic diathesis,—which is permanent, and which is 
especially frequent in the members of gouty families and in per- 
sons of middle age who lead the kind of life that conduces to 
gout,—who eat, that is, large quantities of animal food, and 
drink freely of malt liquors. 
In such persons, occasional indigestion is very common— 
indigestion marked chiefly by excessive acidity of the stomach 
and heartburn, and by the condition of the urine, which con- 
tains a sediment of lithate of ammonia or lithic acid gravel, or 
which, without this, is high coloured and more than commonly 
acid. With this acid indigestion there is often insufficient 
action of the liver, a bilious tinge in the complexion, costive 
bowels, a coated tongue, which sometimes dries at night, and 
heavy or disturbed and unrefreshing sleep. 
In this form of indigestion, much relief is given by alkalies, 
which neutralize the excess of acid in the stomach when diges- 
tion is over, and thus stop or prevent the uneasy sensations to 202 
INDIGESTION 
which it gives rise. The soluble alkalies do good also, and 
more permanent good, by promoting the secretion of the liver 
and the kidneys. The bicarbonate of soda and the bicarbonate 
of potash are, in most instances, the best forms in which these 
can be given, and the best time for giving them, as was pointed 
out by Dr. Front, is two or three hours after the principal meals. 
Fifteen grains of either, two or three times a-day, is, in most 
cases, a sufficient dose; and, if there be a sense of heat in the 
stomach, this may be conjoined, as Front recommended, with a 
few grains of nitre. 
At the same time, a few doses of bine pill may be given on 
alternate nights, further to promote the secretion of the liver, 
and colocynth, or colocynth with henbane, to keep np free 
action of the bowels. 
The use of the alkalies should be continued for some weeks, 
and, if any gouty symptoms exist, a grain of acetous extract of 
of colchicum may be given at night. 
Fersons who suffer from this kind of indigestion should en- 
deavour to promote the action of the lungs and the skin, and, 
with this object, should take active exercise, be much in open 
air, and sleep in an airy bed-room; and they should live on a 
simple and abstemious diet—not eating too largely of animal 
food, and carefully avoiding ill-fermented malt liquors, rich 
dishes, heavy pastry, and cheese. Where total abstinence is not 
feasible, the alcoholic drinks best suited to them are pale sherry, 
in small quantity, or brandy, largely diluted with water. 
By such means the indigestion may often be stopped, the exces- 
sive acidity of the urine corrected, and the general health greatly 
improved; but the disorders have their origin in a peculiarity 
which is constitutional and abiding, and they are, therefore, very 
liable to recur. 
Another faulty state of the general health, attended with 
indigestion, is now and then met with, in which the urine is apt 
to contain oxalic acid in considerable quantity, and to precipi- 
tate, on standing,‘the well-known octohedral crystals of oxalate 
of lime. 
Dr. Front supposed that a more than common disposition to 
the formation of oxalic acid in the system is indicative of a FROM IMPURITY OF BLOOD. 
peculiarity of constitution: and lie expressed this supposed 
peculiarity by the term oxalic diathesis. 
Oxalic acid, which is composed of only carbon and oxygen, 
with the elements of water, and which exists in many plants, 
and may be readily formed by the oxidation of various animal 
and vegetable substances, may come to be present in the urine 
in several ways. 
Ist. It may be taken in the food; may escape conversion in 
the stomach, and after its absorption into the blood; and may 
thus pass off in the urine, in combination with lime. 
Many vegetables contain oxalic acid in combination with 
alkalies or with lime. The stalks of rhubarb, which in the? 
spring are largely eaten in this countay in tarts, and sorrel, 
which is much used abroad as salad, contain it in considerable 
quantity in combination with alkalies. In some persons, the 
oxalic acid taken in these articles of food is changed in the 
process of digestion, or undergoes conversion in the blood by 
the influence of oxygen, and, consequently, does not pass off, as 
oxalic acid, in the urine. In others, whose power of digestion 
is weaker or in whom respiration is less active, the oxalic acid 
escapes conversion and passes off in the urine in combination 
with lime. 
This may happen in persons who are in perfect health and 
who have no marked tendency to the formation of oxalic acid in 
the system. With this occasional, and, if we may so term it, 
accidental presence of oxalic acid in the urine, we have nothing 
here to do. It may lead to the formation of a small calculus of 
oxalate of lime, and so have very serious results; but it does 
not denote any abiding disorder of digestion or nutrition. 
2nd. Oxalic acid may be formed in the body, and, as Dr. Gar- 
rod has shown, its presence may be detected in the blood when 
none of it is taken in the food. 
The oxalic acid which is formed in the body may, possibly, 
be derived immediately from the saccharine elements of the 
food, or from lithic acid and other substances that result from 
the waste of the tissues, or from both these sources at once. 
We know, indeed, that, out of the body, oxalic acid may be 
readily formed, under the influence of oxidizing agents, from 204 
INDIGESTION 
sugar, starch, and their chemical equivalents; and Liebig and 
Wohler have shown that it may also be readily formed from 
lithic acid. 
Dr. Prout long ago inferred that oxalic acid might be derived 
from the waste of the tissues, from the fact that its habitual or 
frequent presence in considerable quantity in the urine is often 
associated with an unhealthy condition of the skin, and also from 
the fact, that, in rheumatic and in hectic fever, large quantities 
of another non-nitrogenous acid—lactic acid—which must, he 
imagined, have their source in waste of the tissues, are formed 
or set free in the body. 
Oxalic acid is said to be constantly present in the urine of 
herbivorous animals; and, according to Lehmann, it often exists 
in the urine of men in perfect health, but in such minute quan- 
tity that it is not readily discovered. It may then, he says, be 
sometimes made apparent by freezing the urine. When urine 
is frozen, a great part of the water crystallizes in a compara- 
tively pure state, and, if this be removed, the concentrated urine 
that remains deposits crystals of oxalate of lime. 
The quantity of oxalic acid is found to be increased, so that 
the urine, without any such concentration, deposits numerous 
crystals of oxalate of lime, under many circumstances;— 
1. It is increased, according to Lehmann, by emphysema of 
the lungs, by the diminished elasticity of the lungs that results 
from repeated attacks of catarrh, and by other conditions that 
impede respiration, and thus prevent perfect oxidation of the 
carbon, which passes off in the urine as oxalic acid, instead of 
escaping in the form of carbonic acid by the lungs. 
It is also increased, according to him, by drinks that contain 
much carbonic acid, and by the alkaline bicarbonates and vege- 
table salts; and he accounts for this increase by supposing that 
the superfluous carbonic acid which has entered the blood or been 
generated there from the salts of the vegetable acids, must ob- 
struct the absorption of oxygen and impede the perfect oxidation 
of those substances in the blood which support respiration. 
2. The quantity of oxalic acid in the urine is often increased, 
as Dr, Walshe has shown, during convalescence from typhus 
fever, rheumatic fever, and other acute diseases, in states of 205 
FROM IMPURITY OF BLOOD. 
anaemia, and in the course of many chronic diseases that inter- 
fere with nutrition. 
8. A considerable deposit of oxalate of lime often exists in the 
urine of persons who have no appreciable disease of the lung or 
other organs, and who have had no positive illness, but who have- 
disordered digestion and look and feel out of condition. As the 
general health improves, the oxalate of lime disappears from the 
urine; but under the influence of fatigue and many other condi- 
tions unfavourable to health, the indigestion and other ailments 
recur and the oxalate of lime appears again. 
Dr. Front, observing an especial tendency to this kind of dis- 
order in certain persons and certain families, and believing that 
diabetes, which he considered on chemical grounds to be a kin- 
dred malady, was constitutional, and to a certain extent heredi- 
tary, was led to suppose that the especial tendency to the formation 
of oxalic acid and the concomitant disorder of health had its origin 
in a peculiarity of constitution, and, as I have already mentioned, 
he designated this supposed peculiar constitution the oxalic dia- 
thesis. There is, however, no constant connexion between the 
disordered state of health and the presence of oxalate of lime in 
the urine. A copious deposit of oxalate of lime may result from 
other conditions, and the ailments we are considering may exist 
without the oxalate. Very often, however, the ailments and the 
oxalate co-exist, and constitute and define a disorder which it is 
very important to recognize, because experience has shown that 
it can generally be controlled or much mitigated by a particular 
plan of treatment. 
To the patient nothing seems amiss in the urine. He complains 
only of his indigestion and its accompanying ailments. It is the 
form of this indigestion that we have now to consider. 
It presents no striking or distinctive characters. The appetite 
is often good, sometimes more craving than in health; digestion 
is not slower than it should be; there is no pain, no sense of op- 
pression or weight at the stomach immediately after meals ; there 
is seldom vomiting or heartburn. But much discomfort is caused 
by flatulent distension of the stomach, especially two or three hours 
after a meal, when the stomach is getting empty, and sometimes 
there is pain in the stomach at that time. With this flatulent 206 
INDIGESTION 
distension of tlie stomach there are often uneasy sensations in 
the belly that seem to result from flatulent distension of the duo- 
denum or colon. 
This disorder of digestion is usually associated with other symp- 
toms of constitutional disorder, and especially with nervous symp- 
toms. The patient in most cases grows somewhat thinner, is 
weak and readily fatigued, sleeps badly, is troubled with palpi- 
tation, is irritable in temper, and depressed in spirits, and often 
hypochondriacal in a high degree, and has, or fancies he has, defi- 
ciency of sexual power. Frequently, too, he has a wearing pain, 
or a sense of uneasiness across the loins, and empties his bladder 
more frequently than in health,—symptoms resulting probably 
from irritation of the urinary organs by the passage of the oxalic 
acid through them. 
In some cases there is evidence of defective or faulty nutri- 
tion of the skin in a scaly eruption or a succession of boils. 
These ailments vary greatly in degree in different cases. In 
some, they are very trifling; in others the restlessness at night 
and the mental depression unfit the patient for his usual occu- 
pations and render his life miserable. They are none of them 
peculiar to the disorder we are considering. Taken together, 
indeed, they often form a group that is tolerably significant; but 
the only sure evidence that oxalic acid is in excess is the pre- 
sence of numerous crystals of oxalate of lime in the urine. 
The urine is then always acid, generally more acid than in 
health; in most cases of an amber-colour and transparent, and of 
moderate or rather high specific gravity. If allowed to stand in 
a conical glass vessel, a light cloud of mucus may form at the 
bottom, but there is often no other deposit. 
In some cases, however, together with oxalate of lime, the 
urine contains an excess of urea, and is of higher specific grav- 
ity than in health; or it contains an excess of lithic acid or 
of lithate of ammonia, and these substances are deposited at the 
bottom of the glass. 
The crystals of oxalate of lime are not visible to the naked 
eye, except when many of them are entangled in a dense cloud 
of mucus at the bottom of the glass, in which case they can 
sometimes be seen as minute glistening points j but they may, FROM IMPURITY OF BLOOD. 
207 
as Dr. Golding Bird first showed ns, be in all cases readily dis- 
covered by the help of the microscope. The detection of them 
is important, because it throws light on the nature of the dis- 
order and may determine the plan of treatment. 
A disposition to such recurring derangements of the general 
health and to the formation of oxalic acid in the system, may— 
like the disposition to gout, diabetes, and other kinds of faulty 
assimilation—either be inherited, or be induced, where no inhe- 
rited tendency to it exists, by certain external conditions or ha- 
bits of life. 
The conditions which Dr. Front assigned as most conducive 
to it, are—residence in a damp or malarious district, the too 
abundant consumption of sugar, the depressing emotions of 
anxiety and grief, exhausting bodily or mental labour, long 
courses of mercury, excessive smoking, and, indeed, all other 
circumstances that seriously depress the vital powers. 
Among the inhabitants of this great city, there are, I believe, 
no circumstances that conduce to it so much as the foulness of 
the air we are always breathing, and the anxiety and exhausting 
labour of mind and body that are almost inseparable from the 
pursuit of wealth or distinction. 
Now, all these conditions, by their action on the nervous sys- 
tem, enfeeble respiration ; and it seems probable that, as Leh- 
mann has suggested, the formation of oxalic acid may be imme- 
diately owing to the defective oxidation of those materials in 
the blood by which respiration is supported: but, in the cases we 
are considering, it is not the less dependent on derangement of 
the general health, which is apt to recur, and which constitutes 
a definite object of medical treatment. In some cases it seems, 
from the high specific gravity of the urine and from the large 
quantity of the urea that co-exists with the oxalate of lime, that 
there is a more rapid waste of the tissues than is natural, and 
that the respiration is not'absolutely, but only relatively defec- 
tive,—insufficient, that is, for the complete oxidation of the large 
quantity of combustible materials on which the inspired oxygen 
acts. 
The indigestion and the various other ailments that result 208 
INDIGESTION 
from this general derangement of health are much under 
control. 
The remedy of most efficacy, where the urine is free from a 
red deposit, is the nitro-muriatic acid, which often prevents the 
formation of oxalic acid after a few days, lessens the flatulence 
and the palpitation, and makes the sleep quiet and the spirits 
more cheerful. From eight to twenty minims of each of the 
dilute acids may be given twice a-day in a glass of water, half 
an hour before breakfast and half an hour before dinner. 
It was long ago known that nitric acid, or the nitric and 
muriatic acids, have occasionally great efficacy in indigestion; 
but it was Dr. Prout who rendered our knowledge on this point 
precise, and showed that it is in the particular form of indiges- 
tion we are considering, and in persons in whom there is a dis- 
position to the formation of oxalate of lime in the urine, that 
they are especially of service. 
The mineral acids have a tendency to cause a deposit of lithic 
acid, or of lithate of ammonia, in the urine, and when such a 
deposit exists, it is seldom advisable to give them longer. Dr. 
Prout tells us, that when his patient lived at a distance in 
the Country, he commonly advised him to take the acids for a 
month or until lithic acid or lithate of ammonia appeared in the 
urine. 
All ailments that result from faulty assimilation and that 
depend primarily on peculiarity of frame or constitution arc 
very liable to recur. If, therefore, the mineral acids should 
prove of service, they may be had recourse to again and again, 
on each recurrence of the same disorder. 
If the tongue be clean, some of the light bitter tonics may be 
given with advantage in conjunction with the mineral acids. 
When the urine from the first has a deposit of lithic acid or 
of lithate of ammonia, the mineral acids should not be given, 
and the best substitute for them that I know of is the carbonate 
or the aromatic spirit of ammonia. 
Where there is want of sleep, and great nervous irritability, 
and much flatulence and palpitation, the tincture of henbane, or 
the dilute hydrocyanic acid, or some other sedative, may bo FROM IMPURITY OF BLOOD. 
209 
given with advantage in conjunction with either of the medicines 
I have just mentioned. 
So much for remedies which the Pharmacopoeia supplies. 
The proper regulation of the diet is equally important. Dr. 
Front, considering the excessive use of sugar as one of the 
causes of this disorder of health, laid it down as a rule, that sac- 
charine articles of food, and particularly sugar, should, as much 
as possible, be avoided; and that the diet should consist chiefly 
of animal food and the stronger farinaceous matters. 
He advised, also, that the patient should abstain as much as 
possible from alcoholic drinks, and that, when he cannot abstain 
entirely, he should select in preference to others, sherry, or 
brandy properly diluted with water. In some cases, however, 
these are too heating, and sound malt liquor, or hock, or claret, 
may be substituted for them. 
Many years have elapsed since these injunctions were made, 
and the wisdom of them, as general rules, has been fully estab- 
lished. 
It is very important, also, that the patient should change for 
a time his habits of life. If he is an inhabitant of a large city, 
and exhausts himself with mental or bodily labour, country air, 
rest, and recreation, are often sufficient of themselves to restore 
the health. 
Long continued and severe functional disorder of the stomach 
—so long continued and severe even as to destroy life—now 
and then occurs without our being able to discover the original 
cause of disturbance. An instance of this has lately fallen under 
our notice in King’s College Hospital, in a man named Peter 
Brisbane, who was admitted into the hospital on the 25th of 
April, 1855, with what was supposed to be fatal organic disease 
of the stomach, in its last stage, and died there on the 7th of 
May. He was a Scotchman, 42 years of age, of moderate height 
and well formed, and had been employed as a baker in London 
for twenty years. He stated that his habits had always been 
temperate, and that his health was good until two years and a 
half before, when lie began to be troubled with pain at the epi- 
gastrium and vomiting. The pain came on after food, and he 
was free from it as long as the stomach was empty. It was 210 
INDIGESTION 
more severe after solid than after liquid food, and lie was soon 
unable to take the heavier kinds of meat, as beef and veal, at all. 
The articles of food that seemed to agree best with him were 
rice, custard, and other light puddings. As a rule, the pain did 
not come on until an hour after meals, and after lasting some- 
where about an hour, it ended in vomiting. He was also at this 
time troubled with heartburn and waterbrash, and occasionally, 
even when the stomach 'was empty, would vomit small quanti- 
ties of bile. He did not lose the desire for food, but ate little at 
a time for fear of bringing on the pain. He could not point to 
any particular spot as having been the seat of this pain, but 
referred it to the whole surface of the stomach. From the begin- 
ning of his illness he became languid and out of spirits, and lost 
flesh; but the loss of flesh did not proceed beyond a certain 
point. 
The condition just described continued with little variation 
for eight or nine months, when the stomach-disorder abated and 
he gained flesh. He did not, however, recover completely. 
Every four or five days pain in the stomach recurred, and he 
did not regain his spirits or lose entirely the feeling of languor. 
Six or eight months before his admission to the hospital, the 
disorder returned in an aggravated degree—the pain coming on 
almost immediately after eating, being very severe, and ending 
soon (generally, in half an hour) in a lit of vomiting. He now 
also had eructations of a very disagreeable taste, not, however, 
particularly resembling that of rotten eggs. 
These symptoms continued, he began again to lose flesh, and 
this the more rapidly than before, and soon became very pallid. 
On his admission to the hospital he was extremely pallid, had 
an anxious look, and was thin, but not wasted in a great degree. 
On auscultation at the base of the heart and root of the neck, 
those murmurs were heard which extreme anaemia causes. All 
his ailments were referred to the stomach. He complained of a 
diffused pain in the stomach after meals, frequently vomited 
soon after eating, and now and then vomited some bile when 
the stomach was empty. He was troubled also with heartburn 
and often with eructations which he described as being some- 
times nauseous and once as tasting sweet. He had no desire for FROM IMPURITY OF BLOOD. 
food—uating, as lie said, only because lie felt exhausted: and 
bis nights were restless. The tongue was clean, but very pale; 
the skin generally hotter than natural; the pulse rapid—the 
numbers counted after his admission to the hospital ranging from 
105 to 124. The urine was tested for albumen and found to be 
free from it, and there was no discoverable disease in any other 
part of the body. He was ordered a farinaceous and milk diet, 
with eggs, and small doses of steel. On the 80th of April, five 
days after he entered the hospital, diarrhoea set in, and he died 
of sheer debility and bloodlessness on the 7th of May. 
Who would not have supposed after this that the stomach 
would have been found much diseased ? On examination, how- 
ever, it was found to be of its natural size and shape, and its lin- 
ing membrane was quite sound, and had undergone no apparent 
change of texture. There was a suspicion of some thickening 
about the pyloric ring, but the reality of this, as a morbid change, 
was extremely doubtful. No disease was discovered in the liver, 
spleen, lungs, bowels, or kidneys. The kidneys, on the suspicion 
that there might be some degeneration of their gland-structure, 
were examined under the microscope and found to be sound. 
The terrible gastric disorder was evidently functional, for there 
was no change in the stomach to account for it, but the cause of 
the disorder, even when every part of the body was laid open to 
examination, eluded our search. The extreme pallidness leads 
to the inference that the cause of disturbance was in the blood- 
making organs. LECTURE XIII. 
Forms of indigestion characterized by some peculiarity in the symptoms— 
Urticaria—Pyrosis. 
WE have lately considered some forms of indigestion connected 
with, derangement of the general health, and characterized by an 
unusual tendency to the formation of certain principles in the 
system; which principles pass off, and may be detected, in the 
urine. I come now to speak of other forms of indigestion, which 
probably lead to the formation of unnatural matters in the sys- 
tem ; but these matters have not been distinguished, and the 
disorder is defined by some peculiarity in the symptoms. 
The disorder of this class that I shall speak of first, is one 
characterized by an eruption of nettle-rash. 
Nettle-rash may be produced in various ways. It may be 
produced by the direct application of a sting-nettle or some other 
irritating substance to the skin itself; and it occasionally occurs 
without this—probably from some irritating matter formed in 
the system and conveyed to the skin with the blood,—in ague, 
in jaundice, in rheumatic fever, and in disordered states of the 
menstrual function. Its most frequent cause, however, is indi- 
gestion, or, rather, imperfect digestion of particular articles of 
food. 
When brought on in this way, it occasionally occurs in per- 
sons whose digestion is not generally weak, from eating some 
particularly unwholesome or indigestible substance. The sub- 
stances that have been observed to bring it on most frequently 
are, shell-fish, especially crabs and muscles, other fish of various 
kinds when tainted or out of season, honey, various vegetable 
substances, especially mushrooms, cucumbers, almonds, oatmeal. 
I have lately met with an extensive nettle-rash which was NETTLE-RASH. 
ascribed to a pork-pie, and once suffered from it myself' in com- 
mon with two other persons, from eating mackerel. 
In such cases, the eruption generally comes on within an hour 
or two after the unwholesome substance has been eaten; and, 
when it is extensive, is generally attended with nausea and 
uneasiness at the stomach, a sense of constriction at the chest, 
restlessness, confusion of the head, and heat, swelling, and flush- 
ing, first of the face, and soon afterwards of the entire surface. 
These symptoms are sometimes soon followed by pain or uneasi- 
ness of the bowels and diarrhoea. 
The object of treatment should, of course, be to expel, as soon 
as possible, the offending matter from the intestinal canal. The 
stomach may be first emptied by an emetic of ipecacuanha or 
sulphate of zinc, and the bowels afterwards cleared by some- 
warm but quickly acting purge. 
When the offending matter is thus got rid of, the eruption in 
most cases soon disappears, and some degree of debility is the 
only effect of the disorder that remains. 
Nettle-rash may, as I have said, be brought on by eating some 
substance particularly unwholesome, in persons who have no 
permanent weakness of digestion. The fault is not so much in 
the stomach as in the food; but the disorder is much more apt 
to occur, even in this way, in persons whose digestion is habitu- 
ally weak. 
Some persons, on the contrary, have frequently recurring 
nettle-rash from eating substances which others readily digest. 
With them it is the stomach that is chiefly at fault, and its 
weakness is shown by general slowness of digestion and by 
inability to digest particular articles of food. The eruption in 
such cases is seldom extensive, but recurs very frequently, gene- 
rally an hour or two after dinner—which is the heaviest and 
most complex meal of the day—or in the evening. Jt harasses 
the patient for two or three hours, or during the greater part of 
the night, and then disappears until the imperfect digestion of 
another meal brings it on again. In some persons it is caused 
by common articles of food, and recurs almost daily for years 
together: in others, it is caused only by some particular sub- 
stance. 214 
INDIGESTION. 
One of my former pupils at the College was affected in this 
way only from eating oatmeal. In a letter which I received 
from him in 1842, he says,—“ The peculiarity of my constitu- 
tion in reference to the action of oatmeal upon it first mani- 
fested itself about four years ago. Prior to this time the singular 
susceptibility did not exist, I believe, for I can recollect that in 
my boyhood I could take oatmeal gruel as well as most persons. 
But about four years ago, having a cold, I took, according to 
custom, a cupful of gruel on going to bed. 
“ I had taken nothing before or with it, and with the excep- 
tion of a common slight cold, was perfectly well. I lay down, 
but felt no inclination to sleep. I soon became very restless, 
and my skin hot and irritable; a violent sneezing came on; my 
eyes felt hot and painful; they soon discharged. The sneezing 
became unceasing, accompanied also with discharge; I was very 
feverish and thirsty; my head was swollen, hot, and painful. 
This extended to my whole body; it became swollen, and cover- 
ed with wheals accompanied with intolerable itching. The 
combination of all the symptoms produced in me the most 
wretched state of mind, amounting to perfect misery. I tried 
walking about in the cool air, but without any relief. A medical 
friend with whom I was residing gave me a saline effervescing 
draught, with a few drops of the wine of colchicum. Whether 
by the aid of this pr that the irritation had worn itself out I 
know not, but as nearly as I can recollect, in about two hours from 
the accession of the horrors, they began to abate. I again went 
to bed, this time exhausted, fell asleep, and found myself the 
next day not much the worse for the illness; a slight feeling of 
debility was the only sensible effect of it. 
“ Some time after this I suffered in the same way, but less 
severely, from eating soup that contained some oatmeal. 
“A more remarkable instance occurred in the summer of 
1839. I was in the country, and having occasion to go into the 
stable just before taking a walk, I put two or three oats into 
my mouth. X had not walked above a mile before I began to 
sneeze, and the symptoms above described quickly came on, 
but much milder. I soon recognized my old enemy, and recol- 
lected eating the oats. I was glad to get home as quickly as NETTLE-RASH. 
215 
possible. The irritation soon left me this time, and I have not 
since repeated the experiment.” 
An account very like the one I have read to you is given by 
Willan in his work on “ Cutaneous Diseases,” in the words of 
Dr. Winterbottom, who twice had an extensive nettle-rash from 
eating a few sweet almonds ; and another similar account drawn 
up by Dr. Gregory, who once had an illness of this kind from 
eating almonds, and once from eating an unpeeled green cu- 
cumber. 
When brought on in this way, the duration of the disorder is 
very various. Dr. Winterbottorn states, that in his first attack 
the illness came on within a few hours after eating the almonds, 
and continued during the greater part of the night. It gradu- 
ally abated towards morning, and the next day not the least 
vestige of the complaint remained. In his second attack, the 
illness came on a few hours later, and lasted the greater part of 
the ensuing day. 
Dr. Gregory states, that in him the disorder brought on by the 
sweet almonds, went off the next day; that brought on by the 
cucumber continued four days, and was at length removed by a 
cathartic. 
I have known a nettle-rash that seemed to be accidentally 
brought on by eating tainted fish, last for months. 
Willan tells us that he has known an extensive nettle-rash 
proving very troublesome for a length of time induced, in per- 
sons otherwise healthy, by rubbing oatmeal on the hands and 
wrists. 
It would seem from this, that, with respect to oatmeal, the 
irritating matter that causes the eruption is not developed in the 
stomach, but exists, ready formed, in the oats, and merely 
escapes transformation in the process of digestion. 
It is well known that the principles to which many substances 
owe their smell and flavour are not changed by the gastric juice. 
The odoriferous principle of asparagus passes off in the urine 
without any diminution of its aroma; oysters and many other 
substances are often tasted again, with a heightened flavour, 
hours after they were eaten, and when they are perfectly dis- 
solved in the juices of the stomach. 216 
INDIGESTION. 
When nettle-rash is brought on by eating some substance in 
common use, and recurs frequently, the offending substance may 
sometimes be detected by the plan followed by Willan. He 
says,—“I have desired several persons affected with chronic 
urticaria, to omit first one and then another accustomed article 
of food or drink, and have thus been frequently able to trace 
the cause of the symptoms. This appeared to be very different 
in different persons. In some, it was malt liquor; in others 
spirit, or spirit and water; in some white wine, in others vine- 
gar ; in some fruit, in others sugar; in some fish, in others un- 
prepared vegetables. I must, however, confess, that several 
cases have occurred to me where a total alteration of diet did 
not produce the least alleviation of the complaint,” 
It sometimes happens that a nettle-rash resulting from defec- 
tive digestion is brought on not merely by some one substance, 
but by several substances in common use; and it is then very 
difficult to detect the offending substances, or to prevent the dis- 
order by any restriction of diet to which the patient will submit. 
In such cases, the disorder may sometimes be prevented by 
giving daily, immediately before dinner, or before breakfiist and 
before dinner, a pill containing three or four grains of rhubarb; 
or, what is still more effectual, three or four grains of rhubarb 
and from half a grain to a grain and a-half of the powder of 
ipecacuanha. 
I several years ago learnt the occasional efficacy of rhubarb 
given at such times from a lady, who told me that she was har- 
assed by frequently recurring nettle-rash for many years, and 
consulted many physicians and tried various remedies in vain, 
until some person who had suffered in the same way advised 
her to eat a few grains of rhubarb every day, just before break- 
fast and just before dinner. She followed the advice, and was 
freed from the nettle-rash. After some time she left off the rhu- 
barb, and the nettle-rash returned. She took the rhubarb again, 
and the nettle-rash again disappeared. This experiment she often 
repeated at distant intervals, and always with the same result. 
When she gave me this account she had continued the practice 
of thus eating rhubarb for several years, with the occasional in- 
termission of a few days, by way of experiment. She had a per- NETTLE-RASH. 
217 
suasion that if she then left off the rhubarb the nettle-rash would 
recur. 
Small doses of rhubarb and ipecacuanha are, as I have before 
observed, often of service, where from slowness of digestion, a 
sense of weight and oppression at the stomach is felt for some 
hours after meals, and seem to quicken and strengthen digestion 
bj increasing the flow of the gastric juice. 
While taking these medicines, the patient should endeavour to 
strengthen digestion by exercise and fresh air ; should be care- 
ful not to eat too much at a time, or too often ; and should live 
on a very simple diet—avoiding spirits, and cheese, and pastry, 
and uncooked vegetables, and, in particular, those substances 
which have an especial tendency to bring on nettle-rash. 
It sometimes happens, especially in that the nettle-rash, 
though depending immediately on the stomach, occurs only when 
digestion is weakened by over-fatigue, of by anxiety or some 
other mental emotion, or by profuse monthly discharges, and that 
remedies of a different class are availing. 
In some such cases, where all the means I have before spoken 
of had failed, I have known the eruption disappear under the 
use of carbonate of ammonia, alone or in conjunction with tinc- 
ture of gentian. 
Serpentaria is another remedy that has obtained some repute 
in the treatment of this disorder, but I have never made trial 
of it. 
I may as well observe here, that the irritation of nettle-rash, 
whatever be its cause, may be much allayed by a lotion made by 
mixing half a drachm of acetate of lead and half an ounce of tinc- 
ture of opium with eight ounces of water. 
Another variety of stomach-disorder, well defined by its symp- 
toms, is pyrosis or water-brash. 
What serves to distinguish water-brash are fits of heartburn— 
that is, of a burning sensation at the pit of the stomach, or ex- 
tending from the stomach to the fauces—-followed by the rejec- 
tion of a liquid, thin and colourless like water, which seems to 
be forced into the mouth by a kind of ruminating action of the 
stomach and oesophagus. 218 
INDIGESTION. 
The term pyrosis expresses merely the sensation of burning; 
the popular terms, “water-brash,” and “ water-pang,” are meant 
to express the combination of the two symptoms that distinguish 
the disorder—the sensation of burning, and the rejection of the 
liquid. 
Water-brash sometimes results from a palpable source of irri- 
tation in the stomach itself, or in some organ that can much 
affect the stomach by sympathy. 
It now and then occurs in organic diseases of the stomach, 
especially cancer and simple ulcer. 
It occasionally results from pregnancy, in which case the dis- 
order often continues till the womb delivers its burden. 
Dr. Watson has spoken of a case in which it seemed to be 
owing to an enormous lb%r which pressed upon the stomach. 
But it often occurs when there is no serious disease of the 
stomach, nor any palpable cause of disturbance elsewhere, and 
constitutes the most characteristic symptom of a gastric disorder 
which has always been very common among the poor in the 
northern countries of Europe, where its prevalence seems to 
have been mainly attributable to unwholesome diet. 
It is stated, on the authority of Linnaeus, that it was very 
prevalent in Lapland when the great botanist travelled there in 
1732. 
Cullen tells us that it was a frequent disorder among the poor 
of Scotland in his time, and that it also occurred there, though 
more rarely, in people of better condition. 
Dr. West, writing in 1841, states that it was then endemic 
among the poor in North Wales. 
A few years ago it was common in the North of England, 
and also, as I can myself testify, in some parts of the West of 
England, among the peasantry, who then subsisted almost en- 
tirely on coarse farinaceous and other vegetable food. 
It is less frequent in towns than in rural districts, but still is 
not uncommon among the dispensary patients in London, espe- 
cially the women, who have bad and insufficient food, and at 
the same time live much in-doors and are subject to many other 
,depressing influences. WATER-BRASH. 
219 
A good description of this endemic water-brash has been left 
us bj Cullen, who saw much of it in Scotland. He says: 
“ The tits of this disease usually come on in the morning and 
forenoon, when the stomach is empty. The first symptom of it 
is a pain at the pit of the stomach, with a sense of constriction, 
as if the stomach was drawn towards the back. The pain is in- 
creased by raising the body into an erect posture, and therefore 
the body is bended forwards. This pain is often very severe; 
and, after continuing for some time, it brings on an eructation of 
a thin, watery fluid in considerable quantity. This fluid has 
sometimes an acid taste, but is very often absolutely insipid. 
The eructation is for some time frequently repeated, and does 
not immediately give relief to the pain which preceded it, but 
does so at length, and puts an end to the fit.” 
In the next paragraph Cullen says: “It is often without any 
symptoms of dyspepsia.” This statement, however, is not per- 
fectly correct. The water-pang is often the only ailment com- 
plained of, and the disorder is popularly known by this name; 
but generally flatulence and other evils of feeble digestion co- 
exist with it. 
The disorder varies very much in duration and degree. In 
some cases it occurs only occasionally and for a short time ; in 
others, it continues, with occasional intermissions, for months or 
years. In some, oiily an ounce or two of fluid is ejected in the 
day, and this seems to be secreted in the mouth only; in others, 
for months together, as much as a pint or more is ejected daily, 
by distinct efforts of rumination, which sometimes pass into 
vomiting. 
The disorder most frequently occurs in states of anaemia, and 
by impairing digestion and causing a drain from the system, 
tends to produce further debility, so that when it is severe, and 
has lasted long, the patient is usually pale, and thin, and weak, 
and out of spirits. 
The fluid is, as I have said, thin and colourless, looking very 
like saliva. It is generally slightly alkaline and almost tasteless, 
but sometimes, even in persons in whom it is commonly insipid, 
it is sour. When alkaline or insipid, it has the characters of 
saliva: when sour, it contains some of the gastric acids. The 220 
WATER-BRASH. 
character of the fluid depends very much on the time of its 
ejection. The fluid ejected soon after a meal is commonly alka- 
line, and probably consists chiefly of saliva, the alkalinity of 
which increases during the process of digestion; the fluid ejected 
towards the completion of digestion is frequently sour. 
It has often been a question—What is the source of the fluid 
in pyrosis ? Does it come from the stomach, or from the pha- 
rynx and mouth, or from both these sources at once ? 
Some persons have, indeed, supposed, from the resemblance 
which the fluid has to saliva, and from the effort of vomiting or 
rumination that attends its rejection, that it might come from 
the duodenum or the pancreas. But such a supposition is 
scarcely admissible. As Dr. West, who has published an 
admirable treatise on pyrosis, has well observed, fluid could 
hardly be forced up from the duodenum into the mouth without 
more violent efforts than attend the rejection of the fluid in 
pyrosis; and if the fluid secreted by the pancreas were so forced 
up by an inverted action of the bowel, the fluid secreted by the 
liver, which is poured into the intestine at the same spot, must 
be forced up as well. But the fluid of pyrosis, though often 
sour from containing some of the gastric acids, is never bitter 
and never tinged with bile. 
The fluid must, then, come either from the stomach, or from 
the oesophagus and mouth, or from both these sources at once. 
There can be little doubt, that when the fluid is acid, it consists, 
at least in part, of acids secreted or formed in the stomach ; but 
there is reason to believe, that when it is alkaline it is derived 
chiefly, if not exclusively, from the salivary and other glands in 
the mouth and pharynx, and that it is secreted under the influ- 
ence of an uneasy sensation in the stomach, which is especially 
felt when the stomach is empty of food. 
In a former lecture I remarked, that irritation of the fauces 
may excite the secretion of gastric juice, and that Spallanzani, 
by tickling his own fauces in the morning before breakfast, 
when the stomach was doubtless empty, obtained gastric juice 
enough to perform some experiments on digestion, of which he 
has given an account. There can be little doubt that certain 221 
CAUSES. 
kinds of irritation of the stomach may excite the action of the 
secreting follicles in the fauces. 
M. Velpeau, at one of the meetings of the Academie de Mede- 
cine in 1849, related the case of an agricultural labourer, thirty- 
two years of age, who had swallowed a large iron fork, with 
which he had attempted to extract or force downwards a veal 
hone which had stuck in his throat. The attempt bringing on 
vomiting, he let go the fork, which, after some movements of 
deglutition, fell into the stomach. The account states, that at 
first he did not suffer much pain, but that after a while his suf- 
ferings became almost intolerable, especially after he had taken 
food or a little drink. From time to time he had the desire to 
vomit. Water often came in abundance in his mouth. The fork 
lay at first in the big end of the stomach, with its prongs turned 
towards the left side. It remained in this position a fortnight, 
and then approached the pylorus, where it remained nearly four 
months. During all this time vomiting of black matters occur- 
red several times a-day; the mouth was continually filled with a 
watery liquid; his sufferings were excessive and unceasing ; and 
he could not support the least nourishment. The fork then 
passed through the pylorus, and, twenty months after he had 
swallowed it, was discharged by the bowel. 
All authorities on the endemic water-brash agree with Cullen, 
that it is much more frequent in women than in men, and much 
more frequent in grown-up persons than in children. 
It does not prevail equally at all seasons, but is much less fre- 
quent in summer than in winter and spring. 
In Scotland, it has long been generally ascribed to the diet of 
the poor consisting too exclusively of farinaceous food. The 
supposition that the disorder is so produced explains its preva- 
lence among the poor in the rural districts in Scotland, in North 
Wales, and in the North and West of England, where oatmeal or 
barley-bread is—or rather was until lately—for some months in 
the year*one of the chief articles of subsistence with the poor. It 
explains the general exemption of the rich, who have a more 
nutritious and a more varied diet. It explains the fact, that, 
even among the poor, the disorder has been much more frequent 
in rural districts than in London and other large cities, where 222 
WATER-BRASH. 
the poor have eaten wheaten bread and consumed larger quanti- 
ties of animal food. 
The circumstance that the disorder has prevailed chiefly in 
the northern countries of Europe, where spirits are plentifully 
drunk, has led to the belief expressed by most writers on the 
subject, that spirit-drinking has had great influence in bringing 
it on. There can be little doubt that the intemperate use of 
spirits, by causing a catarrhal condition of the stomach and 
uneasy sensations in the stomach when it is empty, occasionally 
produces water-brash ; but the supposition that the water-brash 
that has been endemic in the northern countries is attributable to 
this condition is hardly reconcilable with the fact, that the dis- 
order has always been very much more common in women than 
in men, while men have been doubtless the chief consumers of 
spirits. 
The circumstance that the disorder has prevailed chiefly in the 
northern countries of Europe and that it has been there less fre- 
quent in summer than in winter and spring, has also led to the 
supposition that cold and wet have great influence in bringing 
it on. The supposition is most probably true. The combined 
influence of cold and wet, by deranging the chemistry of the 
body and by checking the action of the skin, is often instrumen- 
tal in rendering the secretions of the stomach unhealthy; and 
when a catarrhal or a very acid state of the stomach exists, it is 
very important, with the view of removing it, to keep up the 
action of the skin. But the greater prevalence of the disorder 
in the northern countries and in cold seasons is probably attri- 
butable in much greater degree to the influence of diet. In 
warmer countries, the poor inhabitants live, indeed, on vegetable 
food, but not so exclusively on coarse farinaceous food as the 
agricultural poor in the north of Europe. The fact that in Scot- 
land, and in the north of Europe generally, the disorder gets 
less frequent as summer advances, may be in great measure 
owing to the circumstance, that milk is then more abuifdant and 
more largely consumed by the poor. It has been shown of late, 
that milk has great efficacy in preventing and curing scurvy. 
Milk, the sole food of the young of mammalia, contains all that 
is requisite for the growth and nutrition of the body, and will CAUSES. 
doubtless remedy many disorders engendered by a diet wanting 
in some of the elements required for healthy nutrition. 
It would seem, then, most probable that the disorder, in coun- 
tries in which it is endemic, is mainly owing to the influence of 
climate and to the diet of the poor not being sufficiently varied, 
and consisting too much of coarse and innutritions farinaceous 
food. 
But if such be the main causes of the disorder, there are 
doubtless, various other conditions that assist in bringing it on. 
Most of these may be classed under two heads:— 
1. Excessive labour, insufficient clothing, loss of blood, and 
all other conditions that tend to exhaust the body. 
2. Pregnancy, constipation, anxiety, and other conditions that 
tend to disorder the functions of the stomach. 
We have already seen that water-brash occasionally occurs 
in a high degree in the wealthy classes, especially in women, 
where it cannot be ascribed to any peculiarity in diet, and seems 
to be owing solely to such conditions as these. 
Pryosis, then, considered with reference to its remote causes, 
is of two kinds : 
1. That which has been termed by some writers symptomatic 
pyrosis, which is brought on (without any peculiarity in diet) 
by pregnancy, or some other condition that disturbs the func- 
tions of the stomach. 
2. That which has been termed, in contradistinction to the 
former, idiopathic pyrosis, which prevails chiefly among the 
agricultural poor in rural districts, and which seems, in most 
cases, to be mainly owing to defective diet. 
In either case the disorder appears to be immediately depen- 
dent on a catarrhal condition of the stomach, or on some other 
condition that renders the secretions of the stomach unhealthy 
and irritating. 
Many conditions conspire to render it much more frequent in 
women than in men. Women are much more frequently in 
states of debility, from the nature of their constitutions and from 
their having in suckling and in excessive or unnatural uterine 
discharges, causes of exhaustion from which men are exempt; 
they have also more excitable nervous systems, and, in conse- 224 
WATER-BRASH. 
quence, the functions of the stomach in them are more apt to 
he deranged by mental influences and by disease in other parts 
of the body; and, among the lower classes, they have generally 
a less nutritious diet. 
In the treatment of water-brash, our first endeavour should, 
of course, be to remove the conditions that may seem to have 
brought it on or to maintain it. 
If the disorder should seem to have been mainly caused by a 
diet not sufficiently nutritious, or consisting too much of farina- 
ceous substances, the remedy most likely to be effectual will be 
a wholesome nourishing diet containing a proper quantity of 
animal food in its most digestible form. Little permanent benefit 
can, indeed, be expected from medicine unless the diet is im- 
proved. 
If the' disorder should seem to have been induced, or to be 
kept up, wholly or in part, by fatigue, it is very essential that 
the patient should rest; if by constipation, that this condition 
should be removed by purgatives, such as aloes or colocynth, 
that do not offend the stomach. 
After these points have been attended to, much further good 
may be done by medicines. 
The medicines that have been found most useful in pyrosis 
are— 
Ist. Medicines which have an astringent action on the coats 
of the stomach. Among these may be classed bismuth, lime- 
water, and the vegetable astringents—kino, catechu, krameria, 
logwood. 
2nd. Sedatives, especially opium and the salts of morphia, 
which probably also tend to restrain undue secretion by the 
mucous membrane, but which are chiefly of use in allaying the 
gastralgia that attends pyrosis. 1 
Medicines from these two classes may often be combined with 
advantage. Five grains of bismuth with a twelfth of a grain of 
the muriate of morphia, or five grains of the compound kino 
powder, or an efficient dose of catechu, krameria, or logwood, 
with opium, may be given before meals two or three times 
a-day. 
3rd. Some other medicines have obtained repute in pyrosis 225 
TREATMENT. 
which cannot be classed with the preceding. They have most of 
them an astringent action on the coats of the stomach, but act, 
directly or indirectly, on the nervous system as well. The chief 
of these are, nitrate of silver, which may be given in pills, in 
doses of half a grain, three times a-day; mix vomica, which may 
also be given in pill, in the dose of from three to five grains, 
three times a-day; quinine; and the mineral acids. 
Some of the medicines I have mentioned have been popular 
remedies for pyrosis in districts in which the malady has pre- 
vailed. 
It is stated that nux vomica is a popular remedy among the 
Laplanders, to whom it was recommended by Linmeus, and that 
lime-water was some years ago a popular remedy among the 
rural population of North Wales. 
4th. The disorder is often connected with anaemia, and steel 
is of great service both in removing it and in preventing its 
recurrence. 
The medicines of which I had most experience in disorders 
of this class, and which are probably as efficacious as any, 
are bismuth, with morphia; krameria and logwood, with opium; 
and steel. 
There is another kind of gastric disorder which is closely 
allied to water-brash, and which is characterized by paroxysms 
of violent pain at the stomach, often described as spasm, that 
come on when the stomach is empty. While the pain lasts the 
epigastrium is tender to the touch, and the pulse gets slow and 
the surface of the body cold. The pain is generally relieved by 
taking food, no matter what, and by lying down. 
The disorder is often unattended with vomiting or nausea, 
but now and then, when the pain is very severe, vomiting oc- 
curs, especially on any movement of the body. There may be 
few other symptoms of dyspepsia. The appetite, in the intervals 
of the pain, is not unfrequently good, and digestion is tolerably 
quick and without uneasiness, unless the disorder is very severe, 
when but little can be eaten or digested. The tongue is usually 
pale and flabby, but clean. In most cases the patient is weak 
and sleeps soundly. 226 
GASTEALGIA. 
This disorder is not very uncommon in men and women in 
the middle ranks, but seldom, if ever, occurs in children. 
In men, it seems to be brought on by family cares, or anxiety 
in business, or over-fatigue, and is, I believe, most frequent be- 
tween the ages of thirty-five and fifty. In women, it is most 
frequently the effect of profuse monthly discharges. 
The disorder may continue for two or three months ; and, in 
persons who have once had it, is very liable to be brought on 
again by trouble, over-fatigue, losses of blood, want of rest, or 
any other cause of exhaustion. 
In the summer of 1846, the following notes were sent me re- 
specting a medical man, practising in a country town, who was 
then between thirty-five and forty years of age:— 
“ About three hours after each meal—or perhaps about four or 
five hours are nearer the mark—and, as soon as digestion appears 
to be over, he is seized all at once with severe pain in the stomach, 
which soon becomes so intense as to depress the circulation in 
a very remarkable way. The pulse falls to 35 in a minute; he 
becomes deadly pale; his hands and feet grow cold; and all his 
strength appears to have left him. This state of things contin- 
ues until he gets something to take in. But the very moment 
he swallows anything—and what is remarkable is, that the effect 
seems to be quite independent of the nature of the aliment,—he 
gets complete relief until the period comes round when the sto- 
mach is again empty. In the absence of food, the pain is much 
assuaged by his assuming the recumbent posture. 
“For the rest, his appetite is perfectly good ; he does not suf- 
fer at all from thirst; and his bowels are regular as the day. 
The evacuations perfectly healthy in appearance. At times the 
stomach becomes enormously distended with wind, but this is 
not generally the case at the time of the paroxysm. He never 
vomits; never has nausea, water-brash, or heart-burn. Sleeps well. 
He is a good deal alarmed about himself, but still not nearly par- 
ticular enough, either in his diet or in his way of life generally.” 
Since the time when this letter was written the gentleman to 
whom it relates has had several illnesses of the same kind, most 
of them brought on by fatigue. GASTRALGIA. 
227 
This disorder, like other functional disorders, occurs in various 
degrees. In some cases so slight as to be little complained of; 
in other cases causing as much suffering for a time as the worst 
kinds of organic disease. 
It may generally be distinguished readily, even when most 
severe, from organic diseases of the stomach, by the circumstance, 
that the pain and tenderness exist only, or are greatest, when 
the stomach is empty of food, and that they are removed or less- 
ened by eating or by lying down. 
In cancer of the stomach and in simple ulcer—the. painful or- 
ganic diseases of the stomach—there is generally constant uneas- 
iness in the stomach, and the pain and tenderness are almost 
always greatest when the stomach is distended by food. This 
disorder is, as I have stated, closely allied to water-brash. Like 
water-brash, it occurs, I believe, chiefly in grown-up persons who 
have been exposed to exhausting influences; and, as happens in 
water-brash, the pain comes on in paroxysms wheTi the stomach 
is empty; and in the intervals of the paroxysms the patient 
may both eat and digest. 
Its affinity with water-brash is shown more clearly by the 
occasional occurrence of vomiting or of the eructation of a thin 
fluid from the stomach during the paroxysm of pain. 
The disorder differs from water-brash in the circumstance 
that there is seldom any liquid rejected from the stomach, and 
that the pain is more severe, and attended with more depression 
than the water-pang usually is. 
The pain is probably caused by unhealthy and irritating se- 
cretions from the mucous membrane. 
The medicine I have found of most use in this disorder is 
hydrocyanic acid, given in full doses. Opium is likewise of 
service, but is, I believe, generally less effectual than hydro- 
cyanic acid. 
Much benefit often results also from preparations of iron, 
especially citrate of iron, of which from three to five grains may 
be given, dissolved in water, immediately after meals. 
The disorder may sometimes be mitigated by alkalies and 
other medicines that increase and modify the secretions. On 228 
INDIGESTION 
more than one occasion I have known it speedily remedied by 
small doses of the grey powder. 
Bismuth, nitrate of silver, and other medicines that have an 
astringent influence on the coats of the stomach, are of much 
less service than in water-brash. 
The patient should live on a light but nutritious diet, have 
regular meals and plenty of sleep, and should avoid fatigue, and, 
as much as possible, other causes of exhaustion. 
When the paroxysms of pain have ceased to recur, quinine 
and other tonic medicines may generally be given with much 
advantage. 
Among the dispensary patients in London, there is a common 
form of dyspepsia, closely allied to those we have just considered, 
the result of exhaustion, and brought on by deficient food, ex- 
cessive labour, want of sleep, and trouble. It is much benefited 
by small doses of opium, and by steel. 
Another variety of indigestion that may be classed with those 
we have lately considered is the indigestion of drunkards. 
The chief characters of this are want of appetite, and vomit- 
ing, or dry retching, in the morning, with a white or furred 
tongue, and a slow pulse. The power of digestion is much 
enfeebled, and if the patient eat at any time what for others 
would be a very moderate meal, he is apt to vomit soon after- 
wards, and to be troubled by pain in the stomach and flatu- 
lence. 
This disorder, like the vice from which it springs, is most fre- 
quently in men of middle age, and is generally associated with 
more or less of that strange and peculiar disturbance of the 
nervous system which hard drinking brings on, and of which 
the most striking effects are, inability to sleep, or sleep broken 
by frightful dreams, despondency in the morning, and tremu- 
lousness of the hands and tongue. 
The vomiting, at first, may occur only in the morning; but 
after a time the health gets broken, and vomiting may occur fre- 
quently at other times of the day. 
Spirit-drinking often induces an inflammatory or catarrhal OF DRUNKARDS. 
229 
condition of the mucous membrane of the stomach, which may 
give rise to flatulence and other disorders of digestion; and it 
now and then causes, as I have before stated, minute superficial 
ulcers of the mucous membrane of the stomach, which may 
account for the pain that is sometimes felt after meals, as well as 
for the fact that the morning vomit of the drunkard sometimes 
contains small clots or streaks of blood. 
It now and then causes also adhesive inflammation of the 
submucous cellular tissue of the stomach, especially near the 
pylorus, which leads to stricture or narrowing of the pyloric 
orifice, and to all the evils that result from that condition. 
But the gastric disorder we are considering may occur with- 
out either of these events, and when the stomach, in case of 
death, may exhibit no striking marks of disease. 
The disorder may, in most cases, be readily distinguished by 
the peculiarity of its symptoms, when the habits of the patient 
are known ; but it is sometimes much more severe than I have 
represented it, and may then lead for a time to the suspicion of 
incurable organic disease. For months together the patient 
may have no desire to eat, and may vomit any time of the day 
after food has been taken, an'd of course falls away greatly in 
flesh and strength. In such cases, it is requisite to watch the 
progress of the disorder and the effect of remedies upon it, to 
say positively what its nature is. 
The same form of indigestion, like the peculiar nervous dis- 
order with which it is associated, now and then occurs in persons 
who do not drink to excess, but whose nervous systems are ex- 
hausted by mental anxiety, fatigue, or want of food. Anxiety 
and over-fatigue take away the appetite, impair digestion, and 
often prevent sleep. If the influence of either of these condi- 
tions be continued, and there be no sleep for several successive 
nights, and no solid food be eaten for several successive days, a 
state bordering on delirium tremens often comes on. The nights 
are disturbed by spectral illusions, the hands and tongue tremble, 
the appetite is quite gone, and vomiting is apt to occur in the 
morning, or at other times of the day if food be taken. 
The exhaustion from want of food sometimes leads to similar 
results. 230 
INDIGESTION 
TMs kind of disorder is very common among the poor in 
London, especially among tlie women—among those even who 
do not drink largely. It is brought on by the conditions I have 
just specified, aided, no doubt, in very many cases, by the use 
of stimulating drinks. 
Like delirium tremens, it may also be brought on by exces- 
sive depletion, or by the shock of severe injuries or operations. 
I have known it caused by fright. 
The most efficient remedies for this disorder are bitters, opium, 
and solid food. 
In all the public-houses for drinking bitter tinctures are kept, 
and the drunkard takes a glass of these “ bitters” as his mov- 
ing dram. He finds that it strengthens and settles his stomach 
and gives some little appetite for the morning meal. 
Gentian, quassia, and calumba are the bitters most com- 
monly used, and they may be taken, singly or combined, two or 
three times a-day, an hour before the principal meals. They 
are generally taken, and are most relished, in the form of tinc- 
ture. 
Opium is of still greater benefit. It tranquillizes the nervous 
system, procures sleep, and, by so doing, settles and strengthens 
the stomach. 
The weakness of the stomach is in great measure the result of 
the general disorder of the nervous system. 
This is more strikingly seen in that higher degree of nervous 
disorder that constitute delirium tremens. While the delirium 
exists, and the nights are passed without sleep or in sleep that is 
broken by frightful dreams, there is total inability to eat; but 
the appetite generally returns when the nervous system has been 
refreshed by sleep. Opium, by giving this refreshing sleep, 
remedies, indirectly perhaps, but more surely than any other 
medicine, the gastric disorder. 
In the cases we are considering, where the more prominent 
symptoms are those of the gastric disorder, small doses of opium, 
or of morphia, may be usefully combined with the bitters. In 
most cases small doses of opium so given are sufficient, if the 
patient give up the destructive habit of drinking, to restore, after 
a time, the tone and power of the stomach. But it now and then OF DRUNKARDS, 
happens where the gastric disorder is severe, that very large doses 
of opium are required to control it. 
In January, 1849, a man, fifty-two years of age, was brought 
into King’s College Hospital in this condition. He had long 
been of very intemperate habits, and, for some time before his 
admission to the hospital had vomited a portion of almost every 
meal. He was weak, and generally out of condition, and had 
very little appetite, and a white flabby tongue, and a pulse gene- 
rally under sixty, sometimes under fifty in a minute, and slept 
badly. After taking food of any kind he had a sense of nausea, 
followed in about ten minutes or a quarter of an hour by the re- 
jection of part of the food. He had occasionally severe pain in 
the stomach, and water-brash; but the stomach was not generally 
either painful or tender. 
Bismuth, nitrate of silver, and hydrocyanic acid, were tried 
'without benefit. The symptoms were somewhat mitigated by 
quassia and gentian, and by small doses of the liquor opii 
sedativus; but no decided amendment took place until the 
middle of May, when the physician’s assistant at the hospital, 
in my absence, prescribed for him half a grain of muriate of 
morphia, and five minims of dilute hydrocyanic acid, every four 
hours. This soon stopped the vomiting and gave him a full 
measure of sleep, and the appetite returned. He continued to 
take the morphia in very large doses, in conjunction with hydro- 
cyanic acid ; steadily grew stouter and stronger; and, at the end 
of some weeks, left the hospital to resume his accustomed 
labour. 
In all cases of this kind, as well as in delirium tremens, it is 
essential that the patient should eat as soon as possible some 
solid nourishing food. Ho medicines produce lasting benefit 
until solid nourishing food can be eaten. 
When there is pain or soreness in the stomach after meals, and * 
when what is vomited contains small specks or streaks of blood 
—leading to the inference that inflammation or minute ulcers of 
the mucous membrane exist, strict diet and effervescing draughts, 
with opium, are the proper remedies. 
The kind of disorder we are considering is now seldom met 
with, except in the lower ranks of life. Half a century ago hard- 232 
INDIGESTION. 
drinking was common in the upper classes, and men of fortune 
were often sent to Bath to restore the tone of their stomachs by 
drinking its waters. Heberden classed these waters among the 
specific remedies. He says,—“ The honour of this title (of spe- 
cific) may be justly claimed by the Peruvian bark for the cure 
of agues; quicksilver for venereal disorders; sulphur for the 
itch; and perhaps opium, for some spasms; and Bath waters for 
the injury done to the stomach by drinking.”* 
The most common gastric disorders among the poor in Lon- 
don are water-brash, and want of appetite and feeble digestion, 
the result of exhaustion and drink. 
Now and then another peculiar gastric disorder is met with, 
in which digestion is tolerably good in the morning, so that a 
substantial breakfast causes no discomfort; but if a hearty meal 
be eaten in the after-part of the day, it is followed by distressing 
flatulence and pain at the stomach, which sometimes ends in 
vomiting, and sometimes, after continuing several hours, gradu- 
ally subsides, without vomiting, as the stomach gets empty of 
gas. This variety of gastric disorder occurs most frequently in 
the decline of life, or in persons whose circulation is languid 
and who are readily fatigued ; and the weakness of digestion is 
in great measure owing to debility or exhaustion. 
In such cases, half a drachm of aromatic spirits of ammonia, 
or five grains of carbonate of ammonia, may be given with ad- 
vantage three times a day; and from five to ten grains of 
bismuth, just before dinner. 
The patient should, of course, take his most substantial meal 
in the morning, when digestion is strongest; should be at rest in 
the recumbent posture for a couple of hours in the middle of 
the day ; and should carefully avoid fatigue. 
* “ Commentaries,” p. 6. Third Edition. LECTURE XIV. 
Symptoms of stomach disorders—-pain and soreness at the epigastrium— 
vomiting—excessive acidity—-flatulence. 
We have now considered the principal diseases and derange- 
ments of the stomach that have been yet distinguished. 
It appears that many of the most striking symptoms pre- 
sented to our notice—namely, pain and soreness at the epigas- 
trium, vomiting, excessive acidity of the stomach, flatulence— 
may result from very different conditions. It may, therefore, 
be not uninstructive to pass these symptoms in review for the 
purpose of discovering what peculiarities they present in the 
different circumstances under which they occur. 
Pain and soreness at the epigastrium exist in most of the organic 
diseases of the stomach—in cancer, in simple ulcer, and in all 
active inflammatory states of the mucous membrane,—but they 
often exist in as high and even in higher degree in disorders 
that are not dependent on any striking organic changes, and 
that are usually regarded as merely functional: for instance, in 
the sympathetic disorder of the stomach that occurs in phthisis 
and other diseases, and in water-brash and the kindred disorders 
we have lately been considering. 
When the pain and soreness depend on the organic diseases I 
have mentioned, they are almost always more severe soon after 
meals or when the stomach is full, than at other times, and are 
usually much more severe after a heavy meal of animal food 
and fermented drinks than after a light one of farinaceous sub- 
stances and milk. 
When the pain and tenderness are the result of functional 
disorder, they sometimes occur only when the stomach is empty, 
and are relieved by food, no matter what. The pain seems to 234 
SYMPTOMS ; 
be excited by unhealthy secretions from the mucous membrane, 
or by some irritating products of digestion, and abates when 
these are diluted by food. 
The distinction between pain that is most severe soon after 
meals, and pain that is only felt or is most severe when the 
stomach is empty, is of great importance in practice. 
When pain occurs soon after meals, or when the stomach is 
full, the greatest relief is usually given by a light, that is, an 
easily digestible diet. When pain is felt only when the stomach 
is empty, it is most effectually controlled by sedatives, and, if 
the pain be attended by undue secretion from the mucous mem- 
brane, by bismuth and other medicines which act immediately 
on the secreting surface, and by avoidance of fatigue and other 
causes of exhaustion, by proper regulation of the time of meals, 
and by steel. 
The pain of organic disease cannot be distinguished by its 
character from that which results from functional disorder, but 
in certain circumstances uneasy sensations of peculiar character, 
and different from ordinary pain, are often felt in the stomach. 
When the secretion of gastric juice is scanty, and digestion in 
consequence slow, there is an uncomfortable feeling in the 
stomach, which is generally described as a sense of weight and 
oppression. 
The uneasy sensation in pyrosis, when the fluid eructated is 
alkaline, is generally described as pain with a sense of constric- 
tion at the stomach. 
A similar feeling of constriction is sometimes felt in cases of 
flatulent distension of the stomach, and especially, according to 
Dr. Front, when the gas distending the stomach is nitrogen. 
A solid morsel of undigested food, in passing through the 
pylorus, excites a distressing sensation generally described, and 
perhaps rightly described, as cramp in the stomach. 
The feelings of constriction and of cramp seem to result from 
strong spasmodic contraction of the muscular fibres of the 
stomach, especially of those near the pyloric outlet. 
Vomiting is a more frequent disorder than pain and soreness at 
the stomach, and is brought on by a far greater number of con- 235 
VOMITIJSTG. 
ditions. Pain and soreness seldom exist unless there is some- 
thing amiss in the coats of the stomach itself or in its secretions, 
but vomiting occurs in numberless instances where the stomach 
is nowise in fault. 
Magcnclic long ago proved that if the pylorus be closed, vomit- 
ing may be brought on by sudden pressure on the stomach, 
without any muscular action of the stomach itself. He found, 
indeed, that vomiting could be excited in dogs, by injecting 
tartar-emetic into their veins, when the stomach had been 
removed and a pig’s bladder connected with the oesophagus had 
been substituted for it. 
The conditions under which vomiting occurs may be ranged 
in the following classes:— 
1. Organic diseases of the stomach itself. 
2. Some mechanical impediment to the passage of the food 
out of the stomach, or in its subsequent course through the 
bowel. 
3. A source of irritation in some other organ affecting the 
stomach by nervous sympathy. 
4. Morbid states of the blood. 
When vomiting results from organic disease of the stomach,— 
from cancer, from simple ulcer, or from inflammatory states of 
the mucous membrane—it usually co-exists with pain in the 
stomach; and the vomiting is generally rendered much less 
frequent, and the pain less severe, by eating little at a time and 
by abstaining from food which, from its quality or form, is irri- 
tating or oppressive to the stomach. 
When vomiting is brought on by food, and occurs constantly 
soon after food is swallowed, and especially if the vomiting be 
attended with pain, nothing usually gives so much relief as 
allowing the patient to eat only food of the lightest kind and in 
very small quantity at a time. Benefit may likewise result from 
a blister applied to the epigastrium, and from some absorbent 
powder—as bismuth, magnesia, or charcoal—taken a short time 
before meals; but when there is any ulceration or abrasion of 
the mucous membrane, hydrocyanic acid and creosote, which 
have great efficacy in some other kinds of vomiting, generally 236 
SYMPTOMS ; 
do harm. As I have before intimated, proper regulation of the 
diet is usually the most effectual means of relief. In some cases 
when its mucous membrane is inflamed or the seat of numerous 
minute superficial ulcers, the stomach is intolerant of food of 
any kind, and vomiting can only be arrested by a long fast. 
An intolerance of food arising from a state of inflammation of 
the mucous membrane, or from the presence of minute super- 
ficial ulcers, sometimes exists for a long time, the stomach being 
continually fretted, and the morbid state kept up, by food which 
it cannot digest. 
In children and in young unmarried women cases now and 
then occur, in which much of what is eaten is very soon vom- 
ited, for weeks or months together, so that great wasting and 
debility ensues, without there being any discoverable source of 
irritation in any organ apt to affect the stomach by sympathy, 
or any unhealthy condition of the blood. The vomiting ap- 
pears to arise from an irritable condition of the stomach itself, 
and the disorder may sometimes be speedily cured by allowing 
the patient to eat only milk, with some farinaceous substance, 
in very small quantities at a time. 
In the fifth volume of “The Medical Observations and En- 
quiries,” published in 1784, there is an interesting paper on this 
subject, which brings before us two of the most distinguished 
members of our profession of that time. The paper is by Dr. 
William Hunter, and entitled “ The Successful Cure of a Severe 
Disorder of the Stomach, by Milk, taken in Small Quantities at 
Once.” It gives a graphic account, apparently from memory, 
of a case that fell, many years before, under Dr. Hunter’s obser- 
vation. 
“ Many years ago,” Dr. Hunter says, “ a gentleman came to 
me from the eastern part of the city, with his son, about eight 
or nine years old, to ask my advice for him. The complaint 
was of great pain in the stomach, frequent and violent vomit- 
ings, great weakness and wasting of flesh. I think I hardly 
ever saw a human creature more emaciated, or with a look more 
expressive of being near the end of all the miseries of life. The 
disorder was of some months’ standing, and, from the beginning 
to that time, had been daily growing more desperate. He was VOMITING. 
237 
at school when first taken ill, and concealed his disorder for 
some time; but growing much worse, he was obliged to com- 
plain, and was brought home to be more carefully attended. 
From his sickly look, his total loss of appetite, besides what he 
said of the pain which he suffered, but especially from his vom- 
iting up almost everything which he swallowed, it was evident 
that his disorder was very serious. 
“ Three of the most eminent physicians of that time attended 
him in succession, and tried a variety of medicines without the 
least good effect. They had all, as the father told me, given 
the patient up, having nothing further to propose.” . . . . “He 
was stripped before the fire, and examined with attention in 
various situations and postures; but no fulness, hardness, or 
tumour whatever could be discovered: on the contrary, he ap- 
peared everywhere like a skeleton covered with a mere skin; 
and the abdomen was as flat, or rather as much drawn inwards, 
as if it had not contained half the usual quantity of bowels.” 
The advice which Dr. Hunter gave to the father was this:— 
“Take your son home, and as soon as he has rested a little, 
give him one spoonful of milk. If he keeps it some time with- 
out sickness or vomiting, repeat the meal; and so on. If he 
vomits it, after a little rest try him with a smaller quantity, viz., 
with a dessert or even a teaspoonful. If he can but bear the 
smallest quantity, you will be sure of being able to give him 
nourishment. Let it be the sole business of one person to feed 
him. If you succeed in the beginning, persevere with great 
caution, and proceed very gradually to a greater quantity, and 
to other fluid food, especially to what his own fancy may invite 
him; such as smooth gruel or panada, milk boiled with a little 
flour of wheat or rice, thin chocolate and milk, any broth with- 
out fat, or with a little jelly of rice or barley in it, &c.” 
Dr. Hunter further adds;—“I heard nothing of the case till, 
I believe, between two or three months after. His father came 
to me with a most joyful countenance, and with kind expressions 
of gratitude told me that the plan had been pursued with scru- 
pulous exactness, and with astonishing success—that his son had 
never vomited since I had seen him—that he was daily gaining 
flesh and strength, and colour and spirits, and now grown very 238 
SYMPTOMS ; 
importunate to have more substantial food. I recommended * 
the change to be made by degrees. He recovered completely; 
and many years ago he was a healthy and very strong young 
man.” 
In an appendix to this paper is a letter from Mr. William 
Hey, of Leeds, giving a short account of four other cases, in 
which, for periods varying in the different cases from ten days to 
twelve months, vomiting had constantly occurred after meals, 
and which, acting on a hint given him by Dr. Hunter, Mr. Hey 
had treated with much success by a diet consisting solely of 
milk and bread, in small quantities at a time. 
The subjects of these cases were all young; The first was a 
girl of eleven, the second a girl of eighteen, the third and fourth 
schoolboys, whose ages are not stated. In none of these cases 
is there any mention of pain in the stomach, which was a prom- 
inent symptom in Dr. Hunter’s case, but there are other cir- 
cumstances that point to the stomach itself as being most 
probably the original source of disorder. In the first case, for 
example, it is stated that after an emetic, consisting of four 
grains of powdered ipecacuanha, there was vomiting of blood, 
which continued at intervals the whole day: in the second 
case that vomiting, though always occurring after meals, fre- 
quently occurred at other times, and that then mucus was 
brought up: in all the cases, that rapid amendment followed the 
restriction of the diet. 
I have met with several cases similar to those which thus ex- 
cited the attention of Dr. Hunter and Mr. Hey—cases, that is, 
in which vomiting almost constantly occurred after meals, for a 
long time, in young persons, in whom I could discover no con- 
dition apt to affect the stomach by sympathy; and in which 
cases, consequently, I have been led to attribute the vomiting to 
a morbid condition of the stomach itself. The chief disorder is 
an intolerance of food, and this may continue for a long time 
without much pain in the stomach, without fever, and even 
without impairment of appetite. In a case of this kind, recently 
under my care, a small quantity of blood had been vomited more 
than once. 
The only active morbid conditions of the mucous membrane VOMITING. 
239 
of the stomach in young persons that we know of, is that state, 
or those states that we designate inflammation; the simple, or 
perforating ulcer ; and superficial ulcerations, or erosions of the 
mucous membrane. The disorder cannot depend on the simple 
or perforating ulcer, for this kind of ulcer causes less frequent 
vomiting and greater and more circumscribed pain than usually 
exists in such cases, is much more difficult of cure, and has 
not hitherto been found in persons so young as some of the sub- 
jects of this disorder are. The most probable supposition is, 
that the disorder depends on a catarrhal state, combined per- 
haps in some cases with small superficial ulcerations, or erosions 
of the mucous membrane. These may result from irritation of 
the membrane by hard or indigestible substances, or from in- 
flammation of it excited in other ways, and may be long pre- 
vented from healing by continual irritation from food. This 
supposition accounts for the great length of time the disorder 
may continue, and the rapid amendment that commonly takes 
place when the patient is allowed to eat nothing but milk, with 
some farinaceous substance, in very small quantities at a time. 
Whenever the stomach is very intolerant of food, in conse- 
quence of a morbid state of its mucous membrane, the food should 
always be liquid, or pulpy, since a solid morsel of any kind may, 
by mere mechanical irritation, bring on a recurrence of the vom- 
iting. During convalescence from cholera, and in many other 
states, an unnatural irritability of the stomach may be kept up 
for some time by want of attention to this point. 
So much for the vomiting that results from morbid states of 
the stomach itself. 
The vomiting that results from a mechanical impediment to 
the passage of the food out of the stomach or in its subsequent 
course through the bowel, may often be distinguished by the 
time of its occurrence, or by the quantity or character of the 
matters vomited, and by the co-existence of the vomiting with 
other significant symptoms. 
When, for example, the pylorus is strictured, or there is any 
other abiding impediment to the passage of food through it, the 
stomach gets permanently enlarged, and part of its lower out- 
line may sometimes be seen through the wasted walls of the 240 
SYMPTOMS ; 
belly. Vomiting occurs, for the most part, wlien the stomach 
is full, and the quantity then vomited is large. The vomiting 
often occurs in the evening, and nearly as much is thrown up as 
the patient has eaten in the day. When the stomach is greatly 
enlarged, two or three days may pass without vomiting, and then 
an enormous quantity be rejected at once. 
There are no means of preventing vomiting of this kind if the 
pylorus be very much narrowed. When the impediment to the 
passage of food out of the stomach is slight, much good may be 
done by proper regulation of the diet, which should consist 
chiefly of liquids that can be absorbed in the stomach, and of 
substances that are easily dissolved or softened, and may so 
pass readily through the narrowed outlet. 
When there is an impediment in the small or in the large in- 
testine, what has been described as an antiperistaltic motion 
takes place, and the contents of the intestine are returned into 
the stomach and then rejected. It would be unwise to attempt 
to restrain this vomiting until the obstruction that caused it is 
removed. 
When efforts of vomiting are straining and frequently repeat- 
ed, without any obstruction in the course of the bowel, the con- 
tents of the duodenum are forced into the stomach and rejected. 
What is thrown up has the colour and the bitter taste of bile. 
The bile is not forced into the stomach by pressure on the duo- 
denum from without—which would tend to force the bile down- 
wards as well as upwards, and could hardly empty the duode- 
num—but by the action of the muscular fibres of the duodenum 
itself. It sometimes happens that after hard efforts of vomiting, 
when the stomach is empty, a small quantity of liquid is thrown 
up, consisting almost entirely of bile. No external pressure that 
can be produced by the diaphragm and abdominal muscles could 
effect this without the aid of muscular action in the intestinal 
canal itself. It would seem, then, that in hard and straining 
efforts to vomit, the so-called antiperistaltic action extends from 
the stomach to the portion of intestine immediately below it. 
Vomiting of bile generally indicates that the efforts of vomiting 
have been hard and straining, but seldom signifies anything 
more. VOMITING. 
241 
When vomiting results from a source of irritation in some 
other organ affecting the stomach by nervous sympathy, it is 
immediately excited by a sense of nausea, and is usually unat- 
tended by pain at the stomach, unless the irritation that causes 
the vomiting, causes. also an untimely or excessive secretion of 
gastric acid. 
This kind of vomiting is sometimes more distressing and more 
uncontrollable than any other. A feeling of nausea that is un- 
ceasing, and vomiting that nothing will stop, occurring imme- 
diately after anything, the simplest drink even, is swallowed, 
and continuing day after day till the patient nearly dies of ex- 
haustion—seldom depends on organic disease of the stomach, 
but may arise from the strangulation of a portion of omentum, 
from a calculus sticking in the ureter or the common gall-duct, 
from pregnancy or some uterine irritation, from inflammation 
within the head, and even as most travellers know, from the 
mere movement of a ship at sea. 
This terrible disorder may continue a considerable time with- 
out any serious damage to the stomach itself. When its excit- 
ing cause is removed, the vomiting, before uncontrollable, may 
cease at once, and the full power of the stomach be speedily 
restored. 
This kind of vomiting may often be distinguished by the 
knowledge that some condition that is apt to cause such disorder 
of the stomach exists, and by the absence of pain and soreness 
at the epigastrium, or, if there be pain, by the rejection of a 
large quantity of acid, which may account for the soreness and 
pain. In some cases, the very urgency of the vomiting, and the 
unceasing feeling of nausea, may lead to the inference that the 
disorder does not originate in the stomach itself. 
If, in such cases, there be no undue secretion by the mucous 
membrane, the vomiting may sometimes be alleviated by seda- 
tives. If there be an untimely or excessive secretion of gastric 
acid, by far the best remedies are alkalies, bismuth, and the veg- 
etable astringents. I need hardly observe that whatever lessens 
the original irritation will mitigate the gastric symptoms. The 
gastric disorder in phthisis, for example, is usually much miti- 
o-ated by whatever lessens the violence and frequency of the 242 
SYMPTOMS ; 
cough. In some cases of this sympathetic disorder, as I have 
already observed, nothing will stop the vomiting while the con- 
dition that excites it continues to act. 
The vomiting that arises from unhealthy states of the blood is 
likewise attended with a feeling of nausea. It is associated with 
a depraved secretion from the mucous membrane—most proba- 
bly with the elimination of some noxious matter through it,— 
and when the food is not rejected the digestion is commonly 
slow and imperfect, and flatulence and other evils of slow and 
imperfect digestion exist. When the gastric disorder exceeds a 
certain limit it is apt to be followed by an analogous disorder of 
the bowels, which is probably excited in the same way—namely, 
by the elimination of the same noxious matter through their 
mucous membrane. 
Disorder of the stomach, seemingly arising in this manner, 
very often occurs in granular disease of the kidney. In such 
cases, the clue that guides to its source is the unnatural condition 
of the urine, and the disorder may often be much alleviated— 
1. By measures directed to the stomach itself,—by suiting the 
diet to the power of digestion, and by hydrocyanic acid, or small 
doses of creosote, given just before meals ; 
2. By the horizontal posture, and other measure that favour 
the action of the kidney ; 
8. By keeping up a free action of the skin where it is possible 
to do so; and 
4. If these means should fail, by giving a few purgative doses 
of the compound jalap powder, or some other medicine of simi- 
lar action, which, as I have before observed, most probably 
relieve the gastric disorder by ridding the system of noxious 
matter through the drain it causes from the intestinal canal. 
A disposition to vomiting is always much increased by a cos- 
tive state of the bowels, and in almost all cases in which obsti- 
nate vomiting does not originate in a morbid condition of the 
stomach itself and anything approaching to constipation exists, 
good will result from keeping the bowels freely open by such 
purgatives as do not offend the stomach. No medicine is so 
generally useful for this purpose as small doses of sulphate of 
magnesia, or, if there be an excess of acid in the stomach, of 243 
EXCESSIVE ACIDITY. 
sulphate of magnesia and carbonate of magnesia together, which, 
under the circumstances I have just mentioned, is one of the 
best anti-emetics we possess. 
Excessive acidity of the stomach is another very common effect 
of the organic diseases and functional disorders of this organ. 
It has been shown by the experiments of Dr. Beaumont and 
others, that when the stomach is empty the fluid that moistens 
its surface is slightly alkaline or neutral. The gastric juice, 
which is secreted by the coats of the stomach on the contact of 
food, seems to consist mainly of a peculiar organic principle de- 
rived from the coats of the stomach, to which the name “pepsin” 
has been given, together with muriatic acid, or with muriatic 
acid in conjunction with a certain quantity of lactic acid. 
This acid fluid, the gastric juice, is nature’s solvent for the 
nitrogenous constituents of the food, and the acid it contains is 
an essential constituent of it. It has been shown that the juice 
loses its solvent power if its acid be neutralized by carbonate of 
potash, but recovers it again on the addition of a proper quantity 
of muriatic or of lactic acid, which, in the experiments on arti- 
ficial digestion, are the only acids that have been found to make 
with the mucous membrane of the stomach an energetic diges- 
tive fluid. 
■ The gastric juice gradually dissolves the food, and in so doing 
loses its solvent power; but it does not lose its acidity in the 
stomach. On the contrary, as the food becomes more and more 
digested, the acidfly of the gastric fluids increases. The acid 
passes out of the stomach with the chyme, and the portion of it 
that is not absorbed is then neutralized by the alkaline secre- 
tions of the liver, the pancreas, and the intestine itself. Re- 
peated observations have shown that the contents of the small 
intestine some way down are generally slightly alkaline or 
neutral. 
It is right, then, that while the stomach is empty of food, it 
should contain no free acid; and that the acid which is requisite 
for digestion and which is secreted by the glands of the stomach 
on the contact of food, should, after performing its office, pass 
into the duodenum, and in its course through the intestine be 244 
SYMPTOMS ; 
either directly absorbed or be neutralized by the alkaline fluids 
with which it is then mixed. But in various derangements of 
the stomach the gastric acid is often secreted at unseasonable 
times, or in too great abundance; or other acids are formed in 
considerable quantity in the stomach from the food, and the con- 
tents of the stomach are, in consequence, unduly acid. 
Acid may get into the stomach in three ways:— 
1, It may be poured out by the glands of the stomach. 
2. It may be taken in the food. 
3. It may be generated from the food in the stomach by some 
fermentative process. 
The glands of the stomach only secrete, as far as we know, 
muriatic acid,* perhaps lactic acid, and, in certain circumstances, 
carbonic acid. There may be generated in the stomach by differ- 
ent fermentative processes,—lactic acid, acetic acid, oxalic acid, 
butyric acid, carbonic acid, and probably many others. 
The acids that cause excessive acidity of the stomach are the 
muriatic and the lactic, singly or combined. Acetic acid is 
formed more rarely; oxalic and butyric acids in too small quan- 
tity to produce this effect; and carbonic acid seems to be only 
troublesome or injurious from the flatulent distension it occa- 
sions. 
We have seen that there are many conditions which lead to 
an excessive or untimely secretion of gastric acid. 
Spallanzani and Dr. Beaumont collected gastric juice for some 
of their experiments by mere mechanical irritation of the inner 
surface of the stomach; and there can be little doubt that the 
irritation resulting from a simple ulcer, or from cancer affecting 
a small portion of the stomach, or from the presence of some 
hard or indigestible substance when the stomach is sound, often 
causes an excessive secretion of gastric acid, or the secretion of 
gastric acid when there is no food in the stomach to dissolve. 
* Bidder and Schmidt appear to have finally proved that muriatic acid is 
the essential acid of the gastric juice, as Prout, and more recently Liebig, 
maintained. Lactic acid is often present, but is not essential, and is probably 
in most cases developed from the food. The way to settle this point is to 
analyse the acid fluid that is sometimes repeatedly thrown up during the pas- 
sage of a biliary or renal calculus, and in other circumstances, long after the 
stomach has been completely emptied of food and of the products of digestion. EXCESSIVE ACIDITY. 
245 
A source of irritation in some other organ that can affect the 
stomach by a reflex nervous influence, like direct irritation of 
the stomach itself, may cause an outpouring of gastric acid, 
when the stomach is empty of food. Proof of this may often 
be had during the passage of gall-stones through the gall-ducts; 
in the gastric disorder so common in organic diseases of the brain 
and in tubercular disease of the lung; and in various other 
conditions. . . 
Again, excessive secretion of gastric acid may result from 
some fault, either inherited or acquired, in what have been 
termed the secondary assimilating processes, leading to certain 
unhealthy conditions of the blood. This is seen most distinctly 
in gouty persons and in men of middle age who have led the life 
that disposes to gout. The excessive acidity of the stomach to 
which such persons are prone seems to result, for the most part, 
from excessive secretion of gastric acid; and according to Front 
the predominating acid in them is the muriatic. It is possible 
that in certain other morbid states of the general health, lactic 
acid, which we know to be a constituent of the muscles, and 
which is eliminated by the kidneys, may be secreted by the 
stomach in great quantity: but no proof has been given that 
such is the case. We have no ready means of distinguishing 
lactic acid, and when much lactic acid has been found by analy- 
sis in matters vomited, it must, except under peculiar circum- 
stances, be very difficult to say that this acid was secreted by 
the coats of the stomach, and not formed in the stomach, as we 
know it may be in large quantity, from the saccharine elements 
of the food. 
Acids are, as we have seen, often formed from the food in the 
stomach, by some fermentative process. This does not happen 
in healthy digestion, since healthy gastric juice, in sufficient 
quantity for digestion, prevents lactic and other acid fermenta- 
tions of the food. But if the gastric juice be unhealthy or be 
secreted too sparingly, or if from obstruction of the pylorus or 
otherwise the food be too long detained in the stomach, it often 
happens that digestion is disordered and that there is set up in 
the stomach some fermentative process by which great quanti- 
ties of acid are generated. This is especially the case, as 246 
SYMPTOMS ; 
Lehmann has asserted, in catarrhal states of the stomach; when, 
while the solvent juice is poured out sparingly, an unhealthy 
mucus is secreted, which rapidly decomposes and acts as a fer- 
ment for the food. 
In cancer of the stomach all these conditions not unfrequently 
conspire; and when, in this disease, vomiting occurs some time 
after meals, enormous quantities of acid are brought up that are 
probably formed, for the most part, by the lactic or some other 
acid fermentation of the food. 
The kind of fermentation set up in the stomach depends on 
the nature of the food, and on the quality or stage of decompo- 
sition of the gastric mucus, so that in different cases different 
acids* and other products are formed. 
When acidity of the stomach arises in this way, it frequently 
happens that some gases are likewise formed, and flatulence 
co-exists with undue acidity. 
An excess of free acid, as Lehmann has shown, suspends or 
weakens the solvent power of the gastric juice, and thus puts a 
stop to stomach-digestion, or renders it slow and feeble. In the 
intensely sour matter that is sometimes thrown up in cancer of 
the stomach, may often be seen shreds of meat, eaten many 
hours before, still undigested. 
When much acid exists in the empty stomach, or when, dur- 
ing digestion, acid is secreted or formed in excess, it causes a 
sensation of heat about the cardia, and sometimes along the 
oesophagus, which is familiarly known to gouty and dyspeptic 
persons as heartburn. This unpleasant sensation is not known 
only to those who are habitually dyspeptic. There are probably 
few grown-up persons in the middle and upper ranks of society, 
who have not occasionally felt it. That the sensation is caused 
by the acid is proved by the well-known fact, that magnesia, or 
* “ Fresh animal membranes, such as bladder and the lining membrane of 
the stomach, immersed in water in an open vessel, pass through certain succes- 
sive stages of decomposition, and accordingly, in the first phase of their decom- 
position, bring a solution of sugar into the state of lactic fermentation; in the 
second, into mucous fermentation; and in the third, into vinous fermentation.” 
—“Handbook of Chemistry,” by L. Cmelin, published by the Cavendish 
Society, vol. vii., p. 99. EXCESSIVE ACIDITY. 
247 
soda, or any other alkali, taken in sufficient quantity to neutral- 
ize the free acid in the stomach, will at once remove it. In 
some cases free acid in the stomach causes not the sensation of 
heartburn, but pain in the stomach, more or less severe, often 
attended with flatulence and with a feeling of constriction or 
cramp. Gastralgia produced in this way is generally felt when 
the stomach is empty, or nearly empty, of food: and, according 
to Dr. Front, the predominating acid in such cases is generally 
the lactic. 
But the ill effects of excessive or untimely formation of acid 
in the stomach are not always confined to the stomach itself. 
The acid which passes out of the stomach into the duodenum 
may be more than the alkaline fluids with which it is mixed in 
its course down the small intestine can neutralize, and the free 
acid thus existing in the bowel may fret its mucous membrane 
so as to cause griping pain and purging. It is probable that 
chalk owes its well known power of checking some forms of 
diarrhoea, not merely to its astringent action on the coats of the 
intestinal canal, but also to its being an insoluble substance, 
which passes onwards and combines until it is completely neu- 
tralized with any free acid it may meet in its course. 
It was observed by Dr. Prout that this disorder of the bowel 
is most frequently set up when the predominating acid in the 
stomach is the lactic: and he offered an ingenious explanation 
of the fact. “The muriatic acid,” he says, “is derived from the 
decomposition of common salt in the blood. The acid is poured 
out at the inner surface of the stomach, and the soda that is set 
free passes to the liver and is there excreted in the bile. When, 
therefore, the muriatic acid has performed its part in digestion, 
and passed into the duodenum, it meets and combines again 
with its equivalent alkali contained in the bile. But when lactic 
acid is generated in the stomach, in excess, it does not meet 
with an equivalent alkali in the duodenum, and so frets and 
disorders the bowel.” 
This ingenious explanation has recently lost much of its force, 
since observations that seem trustworthy have led to the infer- 
ence that the soda set free by the decomposition of common salt 
in the coats of the stomach is not all eliminated with the bile, 248 
SYMPTOMS ; 
as Prout supposed, but is in part cast off by the kidneys and 
other secreting glands, where it cannot again meet with its 
muriatic acid. 
The fact that there is more frequently disorder of the bowel, 
with undue acidity of the stomach, when the predominating acid 
in the stomach is the lactic, probably depends in great measure 
on the circumstance, that the excess of lactic acid is commonly, 
if not always, owing to excessive lactic fermentation of the sac- 
charine elements of the food, which still goes on or is succeeded 
by some other fermentative process in the bowel itself. 
But the mischief resulting from excessive or unseasonable 
formation of acid in the stomach does not always end here. In 
grown-up persons excessive acidity of the stomach and bowels 
often causes severe frontal headache. If the excessive acidity 
continue long, it lessons the secretion of the liver and of the skin, 
rendering the complexion sallow, and the skin harsh and dry; 
and causes, or at least is attended with, languor and disinclina- 
tion for mental exertion, and, now and then, rheumatic pains in 
the limbs, in persons disposed to them, and various other un- 
comfortable feelings. All these remote disorders are doubtless 
attributable to noxious matters of some kind or other in the 
blood. 
An excessive formation of lactic acid in the stomach may lead 
to impurity of the blood in various ways. The derangement of 
digestion that attends the excessive formation of acid, may give 
rise to the formation of other hurtful matters in the stomach 
itself, and also during the subsequent passage of the vitiated 
products of digestion through the bowels; and these hurtful 
matters and part of the uncombined acid may be directly ab- 
sorbed by the bloodvessels, or possibly, as Dr. Prout suggested, 
they may be absorbed by the lacteals, and cause additional 
impurity of the blood by preventing the proper completion of 
the chyle. Again, as I have just stated, excessive acidity of the 
stomach frequently causes or co-exists with defective action of 
the liver, kidneys, and skin; and defective action of these im- 
portant excreting organs may obviously lead to further contam- 
ination of the blood. 
Knowing, then, that an excessive formation of acid in the EXCESSIVE ACIDITY. 
249 
stomach may lead to impurity of the blood in so many ways, 
we can hardly wonder at the general or remote disorders which 
this condition sometimes induces. 
The remedies for excessive acidity of the stomach will depend 
in some measure on its cause. 
The excessive acidity of the stomach that results from a gouty 
condition of the system, like other manifestations of the gouty 
habit, is much more common in men than in women; and is 
most common in middle age, and in men of gouty families, or 
who have lived the life that disposes to gout—that is, who have 
eaten largely of animal food and drunk freely of malt liquors. 
The acid in excess in such cases, if Prout was right, is the 
muriatic. It seldom causes much pain in the stomach, or dis- 
order of the bowels, and the result of it chiefly complained of is 
a sense of heat in the stomach, or heartburn. This uncomfort- 
able feeling may be alleviated for the time by soda, magnesia, 
or any other antacid; but it is apt to recur, for months or years 
together, on any indiscretion in diet. 
The proper remedies for this condition are those of the kin- 
dred disorders of gout: an occasional dose of blue pill and colo- 
cynth, to keep up free action of the liver and bowels; alkalies, 
to neutralize the excess of acid in the stomach, and to increase 
the secretions of the liver and the kidneys; colchicum; but, 
above all, habitual exercise in the open air, and spare living. 
In many cases great benefit will accrue from total abstinence 
from alcoholic drinks, which often cause undue acidity in irrita- 
ble stomachs, and thus, and probably in other ways, render 
gouty disorders more frequent and severe. Where beverages 
of this class cannot be altogether dispensed with, those should 
be chosen which, like brandy and sherry, contain no free acid ; 
and they should be taken sufficiently diluted, since the more 
concentrated they are, the more, as a general rule, they create 
acidity, and the greater is the direct injury they do to the sto- 
mach itself. 
The excessive acidity that results from organic disease of the 
stomach, such as simple ulcer or cancer, is distinguished by the 250 
SYMPTOMS ; 
other symptoms that belong to those diseases, and is most effec- 
tually controlled by proper regulation of the diet, and by mag- 
nesia and bismuth, which will neutralize the excess of acid in 
the stomach and tend to restrain undue secretion, without frett- 
ing, as the soluble alkalies might do, the surface of an ulcer 
should any exist. 
The undue acidity of the stomach that results from irritation 
elsewhere, is very commonly associated with vomiting, and may 
generally be distinguished by the symptoms that reveal the 
primary disease. The immediate effects of the excess of acid may 
be controlled by the proper administration of .alkalies; but the 
most efficient remedies are those which act on the secreting sur- 
face—bismuth, the vegetable astringents, and in some cases the 
sulphuric acid. Alcoholic drinks generally aggravate the dis- 
order and increase the acidity, and when taken at all should be 
largely diluted. Port wine, from being more astringent, often 
suits better than sherry. 
Our treatment of acid indigestion would be much more un- 
erring, if we had any ready and sure means of ascertaining whe- 
ther the excess of acid in the stomach has resulted from a too 
abundant or an unseasonable secretion of the gastric acid, or 
whether it has been formed from the food in the stomach by 
the lactic or some other acid fermentation. The lactic and other 
acid fermentations result from feebleness of the digestive power, 
or from some obstruction at the pylorus or near it; and, as 
Lehmann has pointed out, are doubtless often promoted by a 
catarrhal condition of the mucous membrane, leading to a secre- 
tion of unhealthy mucus, which, when the gastric juice is insuffi- 
cient, soon decomposes and acts as a ferment. The disorder, 
when there is no obstruction at the pylorus or elsewhere, is in 
delicate people of habitually feeble digestion often of long con- 
tinuance. It is generally much aggravated by alcoholic drinks. 
The most effectual remedies for it, are, as I have already stated, 
a diet suited to the feeble power of digestion; warm clothing; 
mustard poultices frequently applied to the epigastrium; and 
bismuth and other medicines which exert an astringent action 
on the mucous membrane. FLATULENCE. 
251 
Another symptom that attends indigestion in its various forms 
is flatulence. 
In healthy digestion no gas is generated in the stomach; but 
in some forms of indigestion gases of different kinds are evolved 
there, sometimes in great abundance, and give rise, according to 
their kind and amount, and the previous condition of the sto- 
mach and chest, to various uncomfortable feelings. 
There are three possible sources of flatulence:— 
1. Air swallowed. 
2. Gas generated from the food or secretions in the intestinal 
canal by some fermentative process. 
3. Gas secreted or evolved by the coats of the intestinal canal 
from the blood. 
When gases have got into the intestinal canal in either of the 
first two ways, an interchange of these with the gases of the 
blood may take place by endosmosis. 
The air swallowed can only furnish, directly, oxygen and 
nitrogen, in the proportion in which they are contained in atmos- 
pheric air; namely, one volume of oxygen to about four of 
nitrogen. The only interchange of any amount that can take 
place in a moderate time between these gases and those of the 
blood, by endosmosis, is the interchange that takes place when 
atmospheric air is brought into contact with the capillaries of 
the lungs—that is, the exchange of a certain portion of its oxygen 
for about an equal volume of carbonic acid. The nitrogen of 
atmospheric air, which undergoes little change in amount even 
in respiration, must under ordinary circumstances remain almost 
unaltered, as far as any interchange by endosmosis is concerned. 
The blood is, indeed, always saturated with nitrogen, because 
nitrogen is constantly brought in contact with it in the lungs, 
and is not expended, as the absorbed oxygen incessantly is, in 
the system. It may be inferred, therefore, that the gases in the 
stomach resulting from air swallowed and changed only in this 
way, are one volume of oxygen and carbonic acid, combined, to 
about four volumes of nitrogen. 
The only gases the blood contains are those of the inspired 
and expired air—oxygen, nitrogen, and carbonic acid,—and it 
is clear that oxygen, which is constantly needed in the blood,. 252 
SYMPTOMS ; 
and which it is the business of respiration to supply, cannot be 
exhaled; so that the only gases that can pass directly from the 
blood into the intestinal canal, are nitrogen and carbonic acid. 
It follows, therefore, that the only gases that can get into the 
intestinal canal from these two sources, are, oxygen, nitrogen, 
and carbonic acid: that oxygen can only be derived from air 
swallowed, and that its amount cannot be greater than in atmos- 
pheric air; namely, than one volume to four of other gases. 
The gases furnished by fermentative processes in the intestinal 
canal, are carbonic acid, hydrogen, different compounds of hy- 
drogen, and nitrogen. Lactic and the viscous fermentation may 
occur without any evolution of gas. Vinous fermentation 
evolves carbonic acid: butyric fermentation, carbonic acid and 
hydrogen; common putrefactive changes generate these gases, 
nitrogen, and various compounds of hydrogen, such as sulphur- 
etted hydrogen, carburetted hydrogen, and ammonia. While 
these gases are being evolved, the quantity of oxygen in the 
intestinal canal, derived from the air swallowed, is gradually 
lessened by some of it entering into combination with other sub- 
stances and some of it passing directly, without change, into the 
blood. 
Stinking putrifactive changes—leading to the evolution of 
sulphuretted and carburetted hydrogen—require some time for 
their production, and are retarded by the acids of digestion, so 
that they seldom take place in the stomach, but are very common 
in the large intestine. When they do take place in the stomach, 
they are recognized by the eructation of the fetid sulphuretted 
hydrogen gas—the belching as of rotten eggs. 
The gases evolved by the ordinary fermentative processes in 
the stomach, consist of carbonic acid and hydrogen, and of car- 
bonic acid in greater amount than hydrogen. 
The ordinary gases of the stomach are, therefore, oxygen, 
nitrogen, carbonic acid, and hydrogen. The oxygen is derived 
solely from the air swallowed, and its proportion to the other 
gases can never be greater, and must generally be very much 
less, than its proportion in atmospheric air. The hydrogen 
must be derived from some fermentative process, and must be 
much less in volume than the carbonic acid. So that when dis- FLATULENCE. 
253 
tension of the stomacli occurs, it must be chiefly from nitrogen 
or carbonic acid : and if from carbonic acid, this must be derived 
for the most part from some fermentative process. 
Magendie and Chevreul found in the stomach of a man, soon 
after execution, a gaseous mixture, consisting of 11 volumes of 
oxygen, 71*45 of nitrogen, 14 of carbonic acid, and 3*55 of 
hydrogen. As all the oxygen must have been derived from air 
swallowed, this accounts for about 44 volumes of nitrogen, and 
shows that at least 55 volumes in the 100 of the gaseous mixture 
consisted of atmospheric air that had been swallowed. If all the 
nitrogen was derived from air swallowed (as is probable), it 
must have been mixed originally with about 17*86 volumes of 
oxygen, and supposing that the 6*86 missing volumes of this 
oxygen had been exchanged for the equal volume of carbonic 
acid, nearly nine-tenths of the gaseous mixture (71*45 of nitro- 
gen, and about 17*86 of oxygen and carbonic acid combined) 
must have resulted from air swallowed. Of the remainder of 
the gaseous mixture, amounting to rather more than one-tenth 
by volume (7*14 of carbonic acid and 3*55 of hydrogen), the 
hydrogen was certainly, and the carbonic acid most probably, 
derived from some fermentative process. 
When the gaseous mixture in the stomach is chiefly derived 
from some fermentative process, it consists, for the most part, of 
carbonic acid and hydrogen, or of these gases with nitrogen and 
some of the compounds of hydrogen. 
The gases that are found in the intestines contain very little 
oxygen, and consist of nitrogen, carbonic acid, hydrogen, and 
the compounds of hydrogen, in varying proportions. 
The effects of gases in the stomach depend, as I have said, on 
their kind and amount, and on the previous state of the stomach 
and chest. 
A certain quantity of atmospheric air always passes into the 
stomach with the food and saliva, and there can be little doubt 
that it serves there some useful purpose. It is only when at- 
mospheric air is swallowed in large quantity, or at unseasonable 
times, that it is productive of mischief; and it is probable that the 254 
SYMPTOMS ; 
mischief it does then results from its mere mechanical effect in 
distending the stomach and impeding its movements. 
Carbonic acid, when it results from a fermentative process, is 
a proof of unhealthy digestion. It co-exists with other unna- 
tural products, but probably of itself only does harm, like at- 
mospheric air, from its mere mechanical effect in distending the 
stomach. 
When gas exists in certain amount in the stomach, it always 
causes an unpleasant feeling of distension, and sometimes a dis- 
tressing sense of constriction or cramp. If the distension of the 
stomach be great, or if the stomach be the seat of simple ulcer 
or cancer, it often causes severe pain. How and then, when the 
stomach is full, the eructation of the gas excites vomiting ; the 
gas, in its explosion, seemed to bring up with it some of the li- 
quid and solid contents of the stomach. 
The symptoms are, of course, often attended with other evils 
arising from disordered digestion. 
In persons who are asthmatic or who have a diseased or irri- 
table heart, flatulent distension of the stomach often embarrasses 
the breathing or causes palpitation; and in bad sleepers, or 
when the quantity of gas is large, it greatly disturbs the sleep. 
I have already stated that flatulent distension of the sto- 
mach generally arises chiefly from nitrogen or from carbonic 
acid. Dr, Front assigned somewhat different effects to these two 
gases. He says, “From whatever source this gaseous principle 
(nitrogen) is derived, it usually gives much annoyance: for while 
the carbonic acid gas, on account of its stimulating qualities, ge- 
nerally escapes from the stomach, the passive character of the 
azote, and the peculiar spasmodic constriction which usually ac- 
companies its development, cause it to be retained there, and 
thus to add greatly to the miseries of the patient.” 
I do not know whether Dr. Front had any more direct evi- 
dence in favour of this opinion than the well known fact, that 
the large quantities of carbonic acid swallowed in soda water 
and other effervescing drinks, instead of oppressing the stomach 
are sometimes very grateful to it. 
Hydrogen and its compounds always result from an unnatu- 
ral fermentative process, and when they are formed, other hurt- FLATULENCE, 
fal products of unhealthy digestion are formed as well. They 
not only act mechanically, like atmospheric air and carbonic 
acid, in distending the stomach and impeding its movements, 
but may be absorbed into the blood, and exert an injurious in- 
fluence upon it. The development of sulphuretted hydrogen 
in the stomach is almost always attended with headache and 
other symptoms of general disorder. 
Gases, of whatever kind they may be, seem to become gra- 
dually absorbed in the intestinal canal. The flatulent distension 
gradually lessens, and often disappears entirely after some hours, 
when the intestinal canal has its natural contractility, although 
there may be no eructation or direct expulsion of gas. The ab- 
sorption of the gases is favoured by the contractility of the in- 
testinal canal, in consequence of which they are subject to pres- 
sure in addition to the common atmospheric pressure to which 
the whole body and the fluids within it are exposed; and the 
absorption of the gases must also be promoted by the secretions 
which are poured into the intestinal canal, and which, after 
serving their purpose, are again absorbed, carrying with them 
into the blood such proportions of the intestinal gases as they 
are able to dissolve. 
Late researches lead to the inference that the amount of the 
secretions poured into the intestinal canal is much greater than 
has hitherto been supposed. Lehmann obtained a certain quan- 
tity of gastric juice from the stomach of a dog, and ascertained 
by experiment how much coagulated albumen it was capable of 
dissolving. From this experiment he calculates that to digest 
the food ordinarily consumed by a healthy man, something like 
four pounds of gastric juice must be secreted daily. Bidder and 
Schmidt, from their very elaborate researches, infer that the 
whole mass of fluids poured into the intestinal canal from the 
blood in twenty-four hours, is equal to one-sixth of the weight 
of the whole animal, and that it far exceeds in quantity the 
whole mass of the blood itself. The fluids thus poured into the 
intestinal canal are, for the most part, again absorbed, and if 
their quantity at all approaches the estimate of these distin- 
guished physiologists, and if the fluids at the time, of them secre- 
tion are not much charged-with gases, they must be capable of 256 
SYMPTOMS ; 
dissolving and carrying into the blood a large quantity of gas, 
should it happen to be present in the intestinal canal. This may 
account for the disappearance of nitrogen, which, since the blood 
is saturated with it, is only sparingly and under certain circum- 
stances, absorbed directly from the air in the lungs. 
It is often difficult in practice to tell the source of flatulent 
distension of the stomach, since the gases which the stomach 
commonly contains (oxygen, nitrogen, carbonic acid, and hydro- 
gen), and which are brought up by eructation, are inodorous, 
and cannot be distinguished by the taste. The source of the gas 
may be best ascertained by considering the circumstances under 
which the flatulence occurs. 
One of the sources of flatulent distension of the stomach is, as 
we have seen, air swallowed. In addition to the quantity of air 
which necessarily finds its way into the stomach with the food 
and saliva, air is sometimes gulped into the stomach by certain 
spasmodic respiratory movements, and some persons have the 
power of swallowing great quantities of it at will. The opinion 
has been lately advanced, that the flatulent distension of the 
stomach so common in hysterical and hypochondriacal persons, 
which comes on suddenly from mental emotion, and gives rise 
to explosive bursts, originates in this way. 
When there is no disorder of respiration or of the nervous 
system that can thus account for the flatulence, it no doubt 
arises in most cases, if not in all, from some unnatural fermenta- 
tive process in the stomach. It then occurs some time after 
meals, and is often associated with undue acidity or other evi- 
dence of disordered digestion. 
Gras may be formed not only from the food, but also from 
mucous and other secretions of the stomach, when these are 
unhealthy or remain in the stomach too long; and this may 
account for the flatulence from which some persons suffer when 
the stomach is empty of food. Frerichs found butyric acid in 
the stomachs of a fasting horse and a fasting sheep. 
Various aromatics the so-called carminatives—have great 
effect in relieving flatulence, which they probably do chiefly by 
stimulating the stomach to contract, and thus expelling the 
wind. 257 
FLATULENCE. 
When the flatulence is habitual and arises from some fermen- 
tative process in the stomach, more lasting relief is obtained by 
excluding from the diet, which should be suited to the power of 
digestion, all substances especially prone to ferment; by pre- 
venting constipation, when a disposition to it exists, by the occa- 
sional use of some warm purgative; by the adoption of a healthy 
mode of life; and by medicines calculated to improve digestion. 
Great and immediate relief will sometimes result from small 
doses of creosote, taken at meal times, or from the bisulphite of 
soda, taken an hour or two after meals or as soon as the evolu- 
tion of gas in the stomach begins to be felt. LECTURE XY. 
On some of the remedies for stomach disorders—ipecacuanha—bismuth 
—the vegetable astringents—hydrocyanic acid—the alkalies. 
HAYING now considered the various diseases and disorders of 
the stomach, it may perhaps be instructive to pass in review 
some of the means we have to remedy or relieve them. 
I have before observed that we have greater power over the 
disorders of the stomach than over those of any other organ of 
equal importance. 
In the first place, we can, for a time, lessen its work, and so 
lessen its vascularity, more than that of most other organs. The 
action of the lungs must go on without ceasing. The blood that 
has ministered to nutrition is returned from every part of the 
body to the lungs, and must there evolve the carbonic acid with 
which it is charged. Interruption of the process, even for a few 
minutes, is death. In the liver and in the kidney, an active 
process of secretion is always going on, and we have no power 
to arrest it, for however short a time. But, if needful, the 
stomach may be kept entirely without food for twelve or twenty- 
four hours, or longer still, and its work may be greatly lessened 
for a considerable time. 
This power to give the stomach entire rest for many hours, 
and to lessen its work, and so lessen its vascularity, for a con- 
siderable time, is of great avail in subduing or mitigating the 
inflammatory diseases to which it is subject. 
Again, we can act by medicines more directly and more va- 
riously on the stomach than on any other organ. Our medi- 
cines are applied directly to it, and have, many of them, a direct 
local action upon its coats. Ipecacuanha, rhubarb, and ginger, 
increase its secretion, and bismuth, lime, and the vegetable 259 
REMEDIES. 
astringents, restrain undue secretion, by their direct action on 
the secreting membrane. Opium, prussic acid, and carbonic 
acid allay pain and check vomiting, not only by their influence 
on the system at large, but also by their direct action on the 
nerves of the stomach itself. Ice-water, which is another pow- 
erful agent in controlling vomiting when this depends on an in- 
flammatory condition of the coats of the stomach, acts directly 
by lowering the temperature of the stomach itself. Acids and 
alkalies, which are very efficient remedies in some kinds of gas- 
tric disorder, in addition to their more remote effects, have a 
direct action on the lining membrane of the stomach and on the 
fluids secreted by it. Carminatives, again, probably owe their 
efficacy chiefly to the immediate action they exert on the coats 
of the stomach. 
We cannot exert such various direct action on any other 
organ. Medicines that are destined to act on most other organs 
can reach them only through the blood. They must, therefore, 
first be absorbed into the blood, and become diffused through 
it, and can only reach their proper destination little at a time. 
Indeed, much of what is administered may never reach its pro- 
per destination at all: it may be decomposed in the system, or 
be eliminated through other organs. If, for example, iodide of 
potassium be given to reduce the size of an enlarged gland, 
much of it may be decomposed in the stomach, or be eliminated 
by the kidneys and other secreting organs, before it has ever 
reached the diseased gland. But medicines that act directly on 
the stomach cannot miss their destination, and may be applied 
to it at once, in full measure, and without change. Some medi- 
cines even which are almost insoluble, such as bismuth and 
lime, act powerfully upon it. 
There are several other circumstances that render the disor- 
ders of the stomach more remediable than those of many other 
organs. 
The stomach owes its wonderful power to its mucous mem- 
brane, and when inflammation of this membrane occurs, the pro- 
ducts of the inflammation, as happens with other mucous mem- 
branes, are poured out on its free surface, and seldom cause per- 
manent change of its texture. Again, the matters so effused 260 
REMEDIES; 
have a ready outlet. They are not long pent up; they do not 
long remain in contact with the mucous membrane to irritate its 
surface, and thus to perpetuate the disorder from which they 
resulted—as I believe morbid secretions often do in the minute 
mucous tubes of the liver and the lung. 
Again, the mucous membrane of the stomach, from having a 
more active secreting function, is more vascular, and has a more 
active nutrition than most other mucous membranes, so that in- 
juries of its free surface are more readily repaired. 
Another circumstance more favourable still is, that the stomach 
does not decay or suffer irreparable changes in structure, in the 
same degree as many other organs, by the mere effect of age. 
All these circumstances serve to render the disorders of the 
stomach more remediable than those of any other organ of equal 
importance. But to remedy the disorders of the stomach we 
must distinguish their several forms, and know the kind of action 
which our medicines exert. Unless we do this, we , shall often, 
by the wrong application of our means, aggravate the disorder 
which it is our object to remove. The number and the various 
action of our remedies will but render our practice the more 
uncertain. 
I shall therefore say a few words on the action, and on the 
right application, of some of the more common' remedies for 
the various forms of gastric disorder; and first, of ipecacuanha. 
Ipecacuanha increases the secretions of the stomach in greater 
degree, probably, than any other medicine we possess. It in- 
creases, as is well known, the secretion of the skin, and the 
secretion of the mucous membrane of the air-tubes; but it in- 
creases in much greater degree the secretion of the lining mem- 
brane of the stomach, to which it is directly applied. An emetic 
dose of ipecacuanha causes a copious secretion of mucus and of 
gastric acid, which is rejected by vomiting. Doses too small to 
excite vomiting or nausea increase the secretion of the gastric 
juice, and in so doing render digestion quicker and stronger. 
Its right application, therefore, is where digestion is slow, or 
where, through slow and feeble digestion, nettle-rash or other 
secondary disorders are bred. 
Small doses of ipecacuanha were, I believe, first recommended IPECACUANHA. 
261 
as a remedy for indigestion in a tract published in 1785, by a 
French naturalist, M. Daubenton, well known from the aid he 
afforded Buflfon in the production of his splendid work on natu- 
ral history. Daubenton was educated for medicine, but left the 
practice of it for his favourite study of natural history. In the 
tract in which he recommends small doses of ipecacuanha in 
indigestion, he says, “I have repeatedly experienced beneficial 
effects from it in my own person that surpassed my expectations, 
and I have prescribed it to many others, with whom it has had 
similar success. # I consider it, therefore, a duty to publish the 
observations on the utility of this simple remedy, for the benefit 
of those persons who have delicate stomachs, and as particularly 
useful in that form of indigestion which is so frequently found 
to attend the turn of life.” 
Daubenton is careful in stating that the cases in which ipeca- 
cuanha is useful are where digestion is slow,—where the food 
lies heavy on the stomach and there is an inability for mental or 
bodily exertion for some time after meals,—a kind of disorder 
which is, he states, especially common in men of middle age, or 
beyond it, who lead sedentary lives. 
He believed that ipecacuanha owes its efficacy in such cases 
to its exciting peristaltic action in the stomach, and imparting 
an energy to its glands. 
He recommends that it should be given in the morning fast- 
ing, and in quantity sufficient to occasion a slight feeling of 
vermiculating motion in the stomach, but without causing any 
sensation of pain or nausea. The quantity requisite to produce 
this effect varies in different persons from a quarter of a grain 
to two grains. He advises, therefore, that very small doses be 
given at first, which may be gradually increased till a sensible 
effect is produced. 
In the beginning of this century, an English translation of 
Daubenton’s tract was published by Dr, H. P. Buchan, and 
rapidly sold. 
In the Preface to this translation, Dr, Buchan says: “ The 
translator of this little tract can truly declare, that since he be- 
came acquainted with the information contained in it, his prac- 
tice in the complaints here enumerated has been more successful 262 
REMEDIES ; 
and than it was previously, and liis sole motive for 
publishing the translation, which was originally made for his 
own private use, is to extend the knowledge of what he con- 
ceives to be a practical improvement in the art of medicine.” 
Ipecacuanha, as a remedy for indigestion, being thus highly 
commended, was for a time much employed in this country, and 
then fell into disuse, in consequence, I believe, of its having 
been employed indiscriminately in various kinds of indigestion, 
and often, therefore, in kinds to which it is not suited, and which 
it would tend to aggravate rather than remedy. 
It is clearly impossible that any medicine having a definite 
mode of action—whether it be to increase secretion or to restrain 
it—can be used successfully in stomach disorders, unless the 
various kinds of stomach disorder be distinguished, and the 
medicine be given only in that kind, or in those kinds, to which 
it is suited. Here, as in other departments of medicine, we must 
rightly distinguish kindred disorders before we can learn the 
right use and the power of remedies. 
I have used ipecacuanha as a remedy for indigestion for several 
years, and am satisfied that it often has much efficacy in re- 
moving the uneasiness and sense of oppression after meals and 
the various other evils that result from slow digestion. 
Small doses of rhubarb, ginger, and pepper, have a similar 
kind of action, and may be given singly or together for the 
same purpose, I generally prescribe ipecacuanha, from half a 
grain to a grain, in a pill, with three or four grains of rhubarb. 
With many, a favourite remedy for the discomfort resulting 
from slow digestion is a grain of cayenne pepper, with three or 
four grains of rhubarb. The best time for giving medicines for 
the purpose in question is just before dinner, and before any 
other meal after which a sense of oppression is usually felt. 
Another remedy more frequently used for indigestion than 
ipecacuanha, and of great efficacy in certain forms of it, but still 
given by many practitioners with uncertainty and doubt, is 
bismuth. 
Bismuth was, I believe, first employed as a remedy for 
stomach disorders towards the close of last century, by Dr. 263 
BISMUTH. 
Odier, Professor of Physic, in Geneva, who made known its 
virtues in a paper published in the “ Journal de Medecine,” in 
1786, and entitled, “ Sur les Effets du Magistere de Bismuth, 
donne interieurement, comme Antispasmodique.” In this paper 
Odier says, “ Most of the patients who were cured by it were 
affected with cramp or violent pain in the stomach after meals. 
It is especially in such cases that I have found bismuth supe- 
rior to all other remedies.” And he adds, “It has also much 
success in stopping palpitations, pains in the stomach, and other 
nervous ailments in pregnant women.” “It fails where the 
cramps in the stomach and other nervous ailments depend on 
some organic disease rather than on simple excess of irrita- 
bility.” 
In 1801, a paper on the effects of bismuth was read to the 
Medical Society of London by Dr. Marcet, at that time one of 
the physicians of Guy’s Hospital, who tells us that he learnt 
the use of the medicine the year before at Geneva, from Dr. 
Odier. 
Dr. Odier, in a note to Dr. Marcet, says: “ I use this remedy 
with success in doses of six grains, four times a-day, in all cases 
of spasms of stomach, brought on by any kind of aliment, and 
proceeding only from the irritability of that organ. This com- 
plaint is extremely frequent at Geneva, particularly among ser- 
vant-maids, who are in the habit of carrying water on their 
heads and make great use of their arms.” 
Dr. Odier assured Dr. Marcet that he had tried the medicine 
in much larger doses, and that he had never observed it to pro- 
duce any ill effects ; while, on the contrary, he had hardly ever 
known it to fail when used in the circumstances that have just 
been mentioned. 
Dr. Marcet made trial of the medicine in London, and his ex- 
perience confirmed the previous observation of Dr. Odier, that 
bismuth is a remarkably successful medicine in what were then 
vaguely termed spasmodic affections of the stomach. 
Since that time it has been extensively used, often with very in- 
definite notions as to what it is capable of affecting, and, of 
course, with very various results. Amid the conflicting testimony 
respecting it, there is, however, ample evidence that it has real 264 
REMEDIES j 
and great efficacy in some forms of gastric and intestinal disor- 
der. 
It is often of signal service, as Odier remarked, in tlic func- 
tional disorders of the stomach that are so common in women 
who are ill-fed and over-worked, or exhausted in any other way, 
and especially where the stomach is very irritable, so that pain 
and vomiting occur soon after meals. 
It is an efficient remedy when pain in the stomach, with in- 
creased secretion of gastric acid, occur from tuberculous disease 
of the lung or from some irritation elsewhere ; and in infants, 
where this kind of disorder, with exhausting diarrhoea, results 
from the irritation of teething, or from improper food, or from 
the change of diet on weaning. 
Against the pain in the stomach and vomiting that result from 
simple ulcer and other forms of organic disease, it is only of use 
occasionally, when the stomach secretes an unhealthy mucus, 
or when there is an excessive or untimely secretion of gastric 
acid. 
It is of little use in the indigestion that depends on gout, 
and that occurs in well-fed and plethoric men. 
It is of no use in the uneasiness of the stomach, of which I have 
before spoken, that results from slowness of digestion or a scanty 
secretion of gastric juice. 
Bismuth, as applied to the stomach, was considered by Odier 
an antispasmodic. The action it exerts seems to be confined to 
the mucous membrane with which it is brought into contact, and 
to be a surface-iioXiovi. It restrains undue secretion, and has a 
sedative influence on the stomach, probably by its direct action 
on the coats of the stomach, as well as by preventing the out- 
pouring of irritating secretions. 
It is best given, suspended in water, a short time before meals. 
Ten grains, three times a-day, is, in most cases, an efficient dose; 
but it may be given, as Odier discovered, in much larger quan- 
tity, without any ill effects. It is soothing, rather than irritating, 
to the mucous membrane over which it passes ; and, from being 
of such sparing solubility, has little effect elsewhere, except 
what it has indirectly from the action it exerts on the stomach. THE VEGETABLE ASTRINGENTS. 
265 
It has, indeed, of late, been recommended by more than one 
writer to be given by drachms rather than grains. 
Bismuth may often be given with advantage with other medi- 
cines,—with opium, or magnesia, or chalk,—which allay pain, 
or neutralize an excess of acid, or restrain undue secretion. 
Chalk, and the vegetable astringents,—kino, catechu, krame- 
ria, and logwood,—-are generally given to restrain diarrhoea. It 
does not seem to be generally known that they are just as effect- 
ual, perhaps more effectual, in restraining undue secretion from 
the stomach. 
Chalk, like bismuth, from its sparing solubility, has little 
direct action, except on the mucous membrane over which it 
passes. The vegetable astringents have a more remote astrin- 
gent influence. This is clearly seen in the colliquative stage of 
phthisis; where, besides restraining the diarrhoea and stopping 
the vomiting with increased secretion of gastric acid that often 
occurs in this state, they restrain, often in a very striking degree, 
the profuse sweating. 
They seem all to have much the same effect. I generally 
give the preference to krameria and logwood. Kino is not con- 
veniently given in solution; and catechu is not only very nau- 
seous, but, from being much used in the arts, is often of inferior 
quality. The most grateful to the taste is krameria; the most 
effectual, I believe, is logwood. Logwood has a mawkish taste, 
which is best corrected by cinnamon. 
An ounce of logwood shavings, and a drachm and a-half of 
powdered cinnamon, may be infused for four hours in ten ounces 
of boiling water, and then strained. An ounce and a-half of the 
strained infusion may be given two or three times a-day, a short 
time before meals. 
Another medicine of great use in the treatment of stomach 
disorders is hydrocyanic acid. 
The bitter almond and the cherry-laurel, which owe their 
efficacy to the hydrocyanic acid they contain, have been long 
used in medicine. Hydrocyanic acid, which was first separated 
by Scheele, in 1782, seems to have been first employed in its 
separate state, in Italy, about 1810, by Drs. Borda and Brera. 
It was little used elsewhere till 1817, when it was recommended 266 
REMEDIES ; 
by Majendie, (in a paper presented to the Academic des Sciences, 
Nov. 17, 1817,) as a remedy in diseases of the chest, especially 
consumption. 
In this paper, Majendie arrives at the conclusion, fully justi- 
fied by subsequent experience, that dilute hydrocyanic acid may 
be employed with advantage to restrain nervous and chronic 
coughs; and that it is useful in the palliative treatment of 
phthisis, in diminishing the hardness and frequency of the cough, 
in moderating the expectoration, and in favouring sleep. 
It was first recommended as a remedy for stomach disorders 
in 1820, by Dr. Elliotson, in a paper entitled “ Numerous Cases 
Illustrative of the Efficacy of the Hydrocyanic or Prussic Acid, 
in Affections of the Stomach; with a Eeport upon its Powers 
in Pectoral and other Diseases in which it has been already 
recommended.” 
In this paper, Dr. Elliotson gave brief notes of a series of 
cases in which pain in the stomach or vomiting was speedily 
removed by this medicine. It was soon tried by others with 
the same effect, and is now one of the medicines most in repute 
for the relief of pain in the stomach and vomiting. 
It is not, however, in all cases of gastralgia, or in all cases of 
vomiting, that hydrocyanic acid can be given with advantage. 
In some cases, it aggravates pain in the stomach, or increases 
vomiting, or even brings it on when it did not previously exist. 
It is of most service in the gastralgia, and in the sympathetic 
vomiting that occur in nervous persons from irritation elsewhere, 
without inflammation or ulceration of the coats of the stomach, 
and without undue secretion of gastric acid. 
Given alone, or in conjunction with soda, it is the most 
effectual remedy we know of for the gastralgia that is apt to 
occur when the stomach is empty of food in nervous persons 
who have been subjected to exhausting influences; and for the 
vomiting that results from granular disease of the kidney. 
It is of no use when pain or vomiting result from an inflam- 
matory condition of the stomach. 
It aggravates pain and vomiting when these symptoms are 
caused by an ulcer, or when they depend on excessive or un- 
timely secretion of gastric acid. It often, for example, increases 267 
HYDROCYANIC ACID. 
the vomiting that occurs in phthisis, which alkalies and the 
vegetable astringents will prevent. 
When there is undue acidity of the stomach it may, however, 
often be given with advantage in conjunction with soda or 
potash, when it would not be of service if given alone. The 
alkalies neutralize the excess of acid, and the sedative influence 
of the hydrocyanic acid is then exerted. 
I have little to add to what I have already said respecting the 
other sedatives of the stomach. 
Opium is especially useful in the vomiting that results from 
intemperance, or that occurs, with sleeplessness or troubled 
sleep, in persons exhausted by want of solid food, or by over- 
work, pain, or other depressing influences,—a kind of disorder 
that is not uncommon among the poor in our large cities. 
When vomiting results from an inflammatory condition of 
the stomach, the most effectual sedatives arc leeches, carbonic 
acid, and iced water. 
Other medicines of great service in stomach disorders are the 
alkalies and the mineral acids. 
The different alkalies have been long employed to correct 
undue acidity of the stomach; and when given in stomach dis- 
orders, it has been chiefly for the purpose of neutralizing a sup- 
posed excess of acid in the stomach. This seems to have been 
the purpose for which they were chiefly given, in cases of indi- 
gestion, by Front. He says:—“ It should be constantly borne 
in mind, that alkaline remedies have no effect in preventing 
acidity: their effects are solely confined to neutralizing the acids 
already formed.” He recommends, therefore, that they should 
be given three or four hours after a meal. In a subsequent 
chapter, he adds:—“If the proper time for taking alkaline 
remedies be attended to, it will oe found, that a very small pro- 
portion of the remedy will, in all instances, be sufficient to ac- 
complish the purpose; that is to say, from ten to twenty grains 
of the carbonate of potash will, in almost every case, be suffi- 
cient to counteract the acid residuum of the meal, which, in fact, 
is all the real good that can possibly be expected from the use 
of this remedy.” 
Dr. Holland expresses the same opinion. He says:—“As 268 
REMEDIES; 
they (the alkalies) cannot fitly be termed a remedy for dyspep- 
sia, but a relief merely to one symptom of the disorder, there is 
reason for closely conjoining their use with that part of digestion 
which it is the object to alter.” 
The soluble alkalies, potash and soda, have, however, more 
remote effects, by increasing the secretions of the liver and the 
kidney, and, perhaps, by otherwise modifying the processes of 
nutrition. Their general or constitutional influence is well shpwn 
by their curing eruptions, and by their efficacy in rheumatic 
fever and in gout. 
The effect of soda is different from that of potash. 
The salts of potash act more especially on the kidney. They 
have, I believe, little direct effect on the liver; but they are all 
of them—acetate of potash, nitre, bitartrate of potash—active 
diuretics. The very readiness with which they are eliminated 
by the kidney tends, no doubt, to lessen their direct action on 
other secreting organs. 
The salts of soda, on the contrary, act more especially on the 
liver, increasing the secretion of bile, of which soda is a natural 
constituent, and are little esteemed as diuretics. The salts of 
soda exist in larger quantity than the salts of potash in the blood 
and in the animal fluids, and modify more directly morbid secre- 
tions from the mucous membrane of the air-tubes, and hence are 
of more general use as expectorants. 
The salts of ammonia, again,—the sesquicarbonate, the acetate, 
the citrate,—act more especially on the skin. They have little 
direct action on the liver or the kidney, but are our most 
esteemed sudorifics. 
In indigestion, soda is more generally useful than potash, 
probably from its more direct effect on the liver. The bicar- 
bonate of soda alone, or in conjunction with rhubarb, or 
calumba, or gentian, has long been a favourite remedy in 
the stomach disorders of persons in the middle and in the up- 
per classes of society who take too little exercise and live 
freely. 
It is taken occasionally some hours after meals by most per- 
sons prone to acidity of the stomach and heartburn, for the mere 
purpose of neutralizing an excess of acid in the stomach, and, 269 
THE ALKALIES. 
in tlie form of soda-water, is generally resorted to for the pur- 
pose of settling the stomach after a debauch. 
In the hind of indigestion common enough in persons who 
take little exercise and live freely, that consists in impairment of 
appetite and nausea and disrelish for rich dishes, with a furred 
tongue, and defective action of the liver, and costive bowels, no 
remedy is more effectual than the bicarbonate of soda, in doses 
of fifteen grains, three times a-day, before meals, in conjunction 
with an occasional small dose of blue-pill to increase further the 
secretion*of the liver, and with colocynth or aloes to keep up 
regular action of the large intestine. 
If there be a sense of heat in the stomach, or if the secretion 
of urine be scanty, a few grains of nitre may be added to the 
soda. 
Soda may be given at any time to neutralize an excess of acid 
in the stomach; but, as Dr. Prout remarked, it will not always 
prevent an excessive formation of acid; on the contrary, if it 
be given at improper times, it may, by weakening the digestive 
power, promote those fermentative changes in the food which 
lead to the abundant formation of lactic and other acids, and 
may thus cause an undue acidity of the stomach that would not 
otherwise exist. The gastric juice is, and ought to be, an acid 
liquid, and if its acidity be destroyed by an alkali its digestive 
power is suspended. It has been clearly shown in experiments 
on artificial digestion, that if the infusion of the mucous mem- 
brane of the stomach employed in these experiments be used 
with too little acid, digestion is slow and feeble; if it be used 
without any acid, no digestion takes place, and putrefactive 
changes ensue. 
If, then, alkalies be given at the time of meals, or just before 
or soon after, to persons whose digestion is habitually slow and 
feeble, or to persons whose digestion has been weakened by the 
sympathetic disorder of the stomach that often results from a 
source of irritation elsewhere, the alkalies may still further 
weaken digestion, and do much mischief. 
The fact that alkalies, improperly given, injure the stomach 
and weaken digestion, was emphatically noticed by Prout. He 
says: “The injudicious use and abuse of alkaline remedies in 270 
REMEDIES. 
acidity of the stomach, is often a source of great mischief.” 
“ When taken in large doses, and at improper times, the effect 
of alkalies is to cause an absolute increase of acid. Thus, when 
a large quantity of alkali is taken into an empty stomach, the 
immediate effect is, that the stomach, in endeavouring to resume 
its natural condition, throws out an additional quantity of acid 
to neutralize the redundant alkali. When alkaline remedies, 
therefore, are injudiciously persisted in, a daily contest arises 
between the stomach and the doctor. If the .constitution be 
sound, the stomach, in spite of the doctor, usually gains the 
ascendency, but at the expense of extraordinary labour in the 
secretion of a greater quantity of acid. If, on the contrary, the 
vital powers of the stomach be weak, the doctor may conquer, 
but at the risk of still further enfeebling the vital powers of that 
organ; and, in both instances, the general result will be, that 
the diseased functions of the stomach, producing acidity, will be 
augmented rather than improved.” 
It is difficult, in the present state of our knowledge, to lay 
down more precise rules for the employment of alkalies. It 
may perhaps, be adopted as a maxim, that alkalies, given to 
exert their constitutional effect, are most frequently useful to 
persons who have dry skins and perspire little, and eat largely 
of animal food and live in towns; that acids are most frequently 
useful to persons who live in the country, eat largely of vegeta- 
ble food, and perspire much. 
If there be one symptom more than another that suggests and 
justifies the use of soda, it is a furred or coated tongue. LECTURE XYI. 
On some of the remedies for stomach disorders—the mineral acids—the 
vegetable hitters—the preparations of steel—purgatives—general rules 
of living. 
The mineral acids, especially the nitric and the muriatic, have 
of late years come much into vogue as remedies in certain forms 
of indigestion. 
It was remarked by Heberden, that persons suffering from 
excessive acidity of the stomach are not always injured, and are 
sometimes even benefited, by acid drinks. He says;— 
“ Potus acidi non semper nocent aegris acore ventriculi labo- 
rantibus, nonnunquam etiam auxilio sunt.” 
The good effects of acids were pointed out more distinctly by 
Pemberton, Speaking of the administration of alkalies, he says: 
—“This” (the giving alkalies) “is one method, and that the 
more common one, of endeavouring to destroy the abundant 
quantity of gastric acid. Sometimes, however, it abounds so 
much, that a greater quantity of alkali may be required to ren- 
der it inert than can with propriety be administered internally; 
in which case complete relief is frequently obtained from the 
very opposite treatment, namely, by a more powerful acid.” 
The acid which Pemberton was in the habit of using is the 
nitric ; which he gave in doses of five drops, every four hours, 
in cold water. 
The good effects of acids in the treatment of some kinds of 
stomach disorder was subsequently fully established by Dr. 
Prout, who did more than any one else to bring these medicines 
into fashion. 
Prout found them of especial efficacy in the gastric disorder 
that occurs in what he termed “the oxalic diathesis,” and that 272 
REMEDIES ; 
is marked chiefly by distressing flatulence and palpitation or 
irregular action of the heart, occurring some time after meals, 
and by the presence of oxalate of lime in the urine. 
The mineral acids are often useful to persons in whom diges- 
tion is habitually slow and feeble, from a scanty secretion of 
gastric juice, and who have a sense of weight or oppression at 
the stomach after meals. 
They are often useful, also, as Pemberton showed, in the indi- 
gestion attended with excessive formation of lactic acid that 
occurs in weak and nervous persons, and when the stomach has 
been for some time disordered and weakened by a source of irri- 
tation elsewhere. 
In other forms of indigestion, they are seldom ‘of benefit. 
They do positive harm in the indigestion that results from 
organic disease of the stomach, or from an inflammatory condi- 
tion of its mucous membrane, and generally do harm in the 
indigestion of gouty persons, and wherever the urine throws 
down a sediment of red lithate of ammonia or of lithic acid. 
The mineral acids have a tendency to cause deposits of lithic 
acid in the urine, and can seldom be given with advantage when 
such deposits exist. 
The injunctions of Dr. Prout on this point are very positive. 
Speaking of the remedies adapted to the ailments that result 
from the oxalic diathesis, he says:—“ The effects of the mineral 
acids must be watched; and when they begin to produce a 
deposition of the lithate of ammonia, or of lithic acid, their use 
must be suspended. Indeed, in all instances, the mineral acids 
require to be left off after a time, as, when too long persisted in, 
they not only cease to do good, but in most instances do harm. 
In cases of this diathesis, where the patient lives at a distance 
in the country, I commonly recommend the use of the muriatic 
acid, (or nitro-muriatio acid, as the case may be,) to be persisted 
in till the lithate of ammonia, or the lithic acid, begins to appear 
in the urine, or for a month; and by adopting such a course of 
acids three or four times in the year, and by a carefully regu- 
lated diet, I have seen the diathesis gradually subdued, and at 
length removed altogether.” 
The mineral acids produce their effect, partly, perhaps, from TONICS, 
273 
tlieir direct action on tlie coats of the stomach, and partly from 
their general tonic influence on the system at large. 
The best time for giving them is half an hour or three-quar- 
ters of an hour before meals. 
Another class of medicines often of use in dyspepsia is that 
which includes the vegetable and mineral tonics. 
The most important medicines of this class are the vegetable 
bitters,—quinine, gentian, calumba, strychnine,—and the differ- 
ent preparations of iron. 
Quinine, and the bitters generally, are especially grateful to 
persons who have injured their stomachs by hard drinking. 
"With such persons they improve the appetite and strengthen di- 
gestion, and have a bracing effect upon the system at large. 
In persons exhausted by over-work, or wherever weakness of 
the stomach is the result of general debility from other causes, 
they often do much good in the same way—hy improving the ap- 
petite and strengthening digestion. 
They do harm in organic diseases of the stomach; in pletho- 
ric states of the system; and generally where there is a furred 
tongue, or where the urine throws down a sediment of lithic 
acid, or lithate of ammonia. Their most striking effect is to im- 
prove the appetite, when this has been impaired from hard 
drinking, or from over-work, or from nervous exhaustion from 
other causes; and the best time for giving them is from half an 
hour to an hour before meals. 
The different bitters have not precisely the same effect. Calum- 
ba has a sedative influence not possessed by the others, and pro- 
bably on this account has had a wider reputation as a remedy 
for mere indigestion. Gentian and chiretta (which is of the gen- 
tian tribe, and is much employed by practitioners in India) tend 
to increase the secretion of the liver, or at any rate do not im- 
pede the secretion of the liver, which quinine and quassia seem 
often to do. They are, therefore, better suited to bilious per- 
sons, and to those cases of indigestion where the secretions of the 
liver are defective. 
The different preparations of steel are especially useful in the 274 
REMEDIES; 
indigestion that occurs in chlorosis, and generally where weak- 
ness of the stomach results from anaemia. 
They do harm in plethoric states of the system, and generally 
where there is a furred tongue, or where the urine throws down 
a sediment of lithate of ammonia or of lithic acid. 
The citrate, or ammonio-citrate, is the most agreeable prepa- 
ration to the taste, and generally the most grateful to the sto- 
mach. If there be any disposition to sickness or nausea, or any 
tendency to furring of the tongue, it may be given in conjunc- 
tion with the bicarbonate of soda or potash. This makes a mix- 
ture haying much the same effect as Griffith’s 'mixture,—the 
mistura ferri composita,—and far more agreeable. 
The miniated tincture of iron is more astringent than the 
other preparations, and may be given in conjunction with dilute 
muriatic acid, in the forms of indigestion suited to this latter 
medicine, when these exist in states of anaemia. 
The sulphate of iron, like the other metallic sulphates, has a 
tendency to cause sickness, and should not be given in cases 
where a disposition to sickness exists. 
Steel medicines do good by improving the quality of the 
blood rather than by their immediate action on the coats of the 
stomach, and are best given at meal-times. They then are 
mixed with the food, and gradually absorbed with the products 
of digestion, and are less apt to offend the stomach and to cause 
headache than at other times. 
Whenever steel medicines are given, it is essential that a 
regular action of the bowels be kept up. These medicines tend 
to confine the bowels and to cause evolution of sulphuretted 
hydrogen in them; and, unless this tendency be counteracted, 
they are apt to fur the tongue and cause headache. 
The choice of purgatives is a very important matter in stomach 
disorders. The different purgatives exert their chief action on 
different portions of the intestinal canal: some excite the secre- 
tion or the peristaltic movement of one part, some of another. 
In disorders of the stomach and bowels, where a purgative is 
required, care should, therefore, be taken to select that which is 
least prone to irritate the injured or disordered part. 
Castor-oil, for example, offends the stomach, but acts very PURGATIVES. 
275 
mildly on the large intestine. It should not be used in stomach 
disorders, or where, from any cause, a tendency to vomiting 
exists; but is better than any other purgative in dysentery or 
during convalescence from typhoid fever, when the intestines 
are ulcerated, and in various other conditions where a speedy 
and sure purgative, and one not apt to irritate the large intestine, 
is required. 
Senna acts chiefly on the small intestine, and, besides exciting 
its peristaltic action, increases the secretion from its mucous 
membrane. It acts, also, on the liver, increasing the secretion 
of bile. In conjunction with a few grains of calomel or blue 
pill, it is, as every one knows, one of the best purgatives" in 
bilious states of the system, or where an evacuant is required; 
but in mere disorders of the stomach, it is often objectionable, 
from the tendency it has to cause sickness. 
The best purgatives in stomach disorders are aloes and colo- 
cynth, which exert their chief action on the large intestine. 
These medicines may do much harm when the large intestine is 
ulcerated or inflamed; but in simple ulcer of the stomach, and 
in the most severe functional disorders of the stomach, they may 
generally be given without causing either pain of the stomach or 
sickness. In some kinds of functional disorder of the stomach, 
aloes seems, indeed, like other bitters, to improve the appetite 
and strengthen digestion. 
Aloes appears to act more exclusively on the large intestine, 
and to irritate the stomach less than colocynth, and hence, in 
stomach disorders, is generally preferable to it. 
Where, from the existence of piles, or from pregnancy or 
some other condition, these medicines are objectionable, the best 
substitutes for them in stomach disorders are the saline purga- 
tives, which exert their chief action on the small intestine, and 
have little tendency to cause pain in the stomach or sickness. 
But if much may be done to remedy the disorders of digestion 
by medicines suited to particular emergencies, still more may 
often be done to strengthen and improve digestion, especially 
with the overworked inhabitants of this great city, by horse- 
exercise; by occasional change of air and scene; by sea and 276 
EEMEDIES ; 
other bathing; by rest and early hoursby all conditions, in 
fact, which tend to invigorate the body, and which increase the 
power of digestion, as they often do the exhausted mental or 
muscular power, by improving the nutrition of the organ on 
which it depends. 
Independently of such conditions as these, much may also be 
done to strengthen and improve digestion by certain general 
rules of living. 
All writers on indigestion, from the time of Celsus, have, 
indeed, laid down general rules or maxims, the observance of 
which is calculated to render digestion more easy and perfect. 
According to Sir Henry Holland, one of the best as well as 
latest writers on this subject, the most important of these max- 
ims are the following;— 
1. That the food should be well masticated. 
2. That the stomach should never be filled to a sense of 
uneasy repletion. 
8. That there should be no urgent exercise, either of body or 
mind, immediately after a full meal. 
The importance of proper mastication has been long generally 
recognized, and might have been inferred from the existence of 
special organs for this purpose in some form or other, in all 
animals that eat solid food. 
By mastication, the food is ground down and intimately 
mixed with saliva. The triturition of the food allows the gastric 
juice to act speedily on every particle of it on all sides, and so 
hastens that solution of it in the stomach in which stomach- 
digestion essentially consists. The chemist imitates the pro- 
cess when he grinds down in his mortar any hard and sparingly - 
soluble substance which he wishes to dissolve. The bird that 
feeds on hard grains, by an instinct more unerring than man’s 
reason, swallows pebbles to increase the grinding power of its 
crop. 
If the food be tough, and so escape proper triturition, or if it 
be swallowed in large morsels, through which the gastric juice 
cannot readily filter, it is dissolved in the stomach much more 
slowly, and tends to cause uneasiness of the stomach and all the 
other evils that result from slow and imperfect digestion. 277 
GENERAL RULES. 
There has been much difference of opinion respecting the uses 
of saliva. The first and most obvious use of it is, to lubricate 
the mass of food in the mouth, and so make it more easy to 
swallow. The quantity of saliva is in great measure determined 
by the need of it for this purpose. The more liquid the food, 
the less, cceteris paribus, is the secretion of saliva The saliva 
must also serve to keep separate the particles of the triturated 
food, and thus expose them more fully to the action of the 
gastric juice. 
Liebig, considering the great disposition which saliva has to 
froth, has rightly remarked, that it must convey into the stomach 
atmospheric air, and has suggested that a certain quantity of air, 
or rather of the oxygen it contains, may contribute to set in 
action, or promote the digestive process. 
Besides these mechanical uses, saliva has a chemical action on 
the starchy principles of the food. It has no solvent or digestive 
action on albuminous substances, but, like the pancreatic juice, 
it promotes the tranformation of starch into sugar,—the first step 
in the series of changes which starch can undergo in the animal 
body. 
Seeing that proper mastication may contribute to digestion in 
various ways, it is obviously important, as regards digestion, 
that the organs of mastication be in a sound condition. If many 
of the teeth be wanting, the food may escape proper triturition. 
If the teeth be filthy, or be much decayed, the saliva, always 
prone to decomposition, very readily becomes foetid; and the 
food intimately mixed with this saliva, like food tainted in other 
ways, is apt, in persons of weak digestion, to offend the stomach, 
and to undergo in the stomach common putrefactive changes, 
thus causing all the discomfort that arises from surfeit. 
The second maxim, “not to fill the stomach to a sense of un- 
easy repletion,” is more important than the maxim we have just 
considered, and more frequently broken. In the middle and 
upper classes of society, indigestion is too often, as a humorous 
writer termed it, “ the remorse of a guilty stomach.” The appe- 
tite is indulged, and more is habitually eaten than is required to 
nourish the body, or than the stomach can long continue to di- 
gest. The consequence is, that the stomach suffers, and that 278 
GENERAL RULES 
superfluous matters, including tire hurtful products of imperfect 
digestion, pass into the blood, disorder the processes of nutrition 
in various parts of the body by polluting the nourishing stream, 
and often cause permanent change of structure in the arteries, 
and in the liver and the kidney, which serve to eliminate the su- 
perfluous matters from the system. 
The sufferings of the stomach itself are but a small part of the 
ailments that habitual over-indulgence of the appetite brings on* 
Not unfrequently a vigorous stomach digests much superfluous 
food for a long time without pain or uneasiness, and the penalty 
of the indulgence is paid in occasional fits of the gout, or, more 
remotely still, in the various ailments that result from those per- 
manent changes of structure that high living tends to bring on. 
Experience has shown, that uneasy digestion more frequently 
results from excess in the quantity of food than from any fault 
in its quality,—a circumstance which our present knowledge of 
the process of digestion enables us fully to explain. 
The gastric juice, out of the body, will dissolve the various 
kinds of food; but, as Spallanzani long ago remarked, it will 
dissolve only a limited quantity of any kind. When this limit 
is attained, the solvent power is expended. The digestive power 
may be restored to a certain extent by the addition of water or 
of free acid; but, to dissolve much more of the food, there must 
be a fresh quantity of the juice. 
The stomach at any time can furnish only a certain quantity 
of gastric juice. If more food be eaten than this can dissolve, 
part of the food is imperfectly digested, and causes uneasiness of 
the stomach; and often the undigested food, as Dr. Beaumont 
has shown, excites in the mucous membrane an erythematous 
inflammation, which prevents the proper nutrition of the mem- 
brane and the restoration of the expended power. 
Eating too frequently is equivalent to eating too much. When 
the power of the stomach is expended, it is gradually restored, 
like the intellectual power of the mind or the mechanical power 
of the muscles, by the nutrition of the organ on which it de- 
pends. For this restoration of power, whatever be its kind, an 
interval of rest is necessary. 
The absolute quantity of food required to nourish the body OF LIVING. 
279 
varies greatly in different persons,—partly from inherited pecu- 
liarity of constitution, partly from habits of life and other con- 
ditions. The supply must equal the demand, so that no positive 
rules as to quantity can be laid down. In some persons, without 
any peculiarity that constitutes actual disease, the waste of the 
body is much greater, and what is eaten is less perfectly assimi- 
lated, and more food is consequently required than in others. 
The rule, therefore, laid down by Dr. Holland, not to fill the 
stomach to a sense of uneasy repletion, is much better than any 
positive rules as to the quantity of food. The quantity of food 
should clearly never be greater than the stomach can easily 
digest. 
The third maxim, “that there should be no urgent exercise, 
either of body or mind, immediately after a full meal,” merely 
enjoins obedience to a natural tendency, which man has in com- 
mon with other animals. All alike have a disposition to rest 
when the stomach is full. Digestion requires an additional flow 
of blood to the stomach and an expenditure of nervous power, 
and goes on more slowly when the means of its support—the 
nervous influence and the blood—are needed elsewhere. Men 
who earn their living by bodily labour, and have digestive 
power to spare, may often violate this rule with impunity, but 
studious men, and men of feeble digestion, can seldom do so 
without aggravating their ailments. The work of digestion is 
quite as much as the system can well do at a time. 
It is also important to easy digestion that the meals should be 
taken at proper times. With regard to the absolute time of 
meals, much depends on habit; and this again is often deter- 
mined by the custom of society or the needs of business. The 
man of business, to avoid working immediately after dinner, 
must dine late; the idle man must often dine alone, or he must 
dine late. Our legislators, who do their work at night, and 
people of fashion, who visit at night, must have little sleep, or 
they must breakfast late, and consequently, dine late. They 
are hardly free agents in the matter as long as they follow the 
business, or enter into the social amusements, of their class. 
The following rules are, I think, the best that can be laid down 
on this point;— 280 
GENERAL RULES 
1. That the substantial repasts should be separated by an in- 
terval sufficient to allow the stomach to recruit its power. 
2. That abstinence from food should never be so protracted as 
to induce a sense of exhaustion. Exhaustion from fasting, as 
from other causes, weakens the digestive power. If, then, the 
interval between breakfast and dinner be long, a light luncheon 
should be taken; if the dinner be in the middle of the day, a 
light supper should be taken. 
8. A third rule is, that the last heavy meal should be some 
hours before bed-time. 
The process of digestion, when it is easy and the food was 
required, favours sleep. But sleep renders digestion slower, and 
thus prolongs the irritation which uneasy digestion sets up; and 
the digestion of a heavy meal, by causing uneasiness in the 
stomach, and by furnishing superfluous or noxious matters to the 
blood, when from the greater slowness of respiration and secre- 
tion these are less readily consumed or excreted, often disturbs 
the sleep. 
As Dr. Holland has remarked, much harm is done in this way 
by the lateness of the present fashionable hour of dinner. This 
is well suited to persons who are to spend great part of the night 
in the House of Commons or at a ball, in whom it prevents the 
exhaustion that would otherwise result from many hours of ex- 
citement ; but it is a source of much mischief to persons whose 
occupations call them up in good time in the morning, and who 
must, consequently, spend their nights in sleep. 
'The food allowed to dyspeptics should not be too much re- 
stricted as to kind. The body requires a great number of prin- 
ciples for its healthy nutrition, and, unless these are furnished, 
the incessant waste of the body cannot be repaired. If the diet 
be too much restricted, some principle or principles may be 
wanting, which, although entering only in extremely small 
quantity into the composition of certain tissues, may yet be re- 
quired for healthy nutrition. 
The error most commonly committed on this point is to debar 
the patient from vegetable food. Persons who eat freely of 
milk, which seems to contain all the nourishing principles of 
both animal and vegetable food, may abstain with impunity OF LIVING. 
281 
from fresh succulent vegetables and fruits; but persons who eat 
sparingly of milk, as dyspeptic persons often do, from inability 
to digest it, cannot long abstain from succulent vegetables, or 
their preserved juices, without falling, in some degree, into that 
faulty state of nutrition that constitutes scurvy. 
The best diet is, generally, a mixed diet of animal and vege- 
table food; and this may be sufficiently varied, without in- 
cluding the more unwholesome articles of the two classes. 
Persons of weak digestion should abstain from veal and pork, 
and from all salted, dried, or smoked meats, which experience 
has shown to be particularly hard of digestion. 
They should also abstain from new bread, which is apt to 
ferment and expand in the stomach : and from peas, beans, and 
other vegetables which are hard to digest and have an especial 
tendency to cause flatulence. With such restrictions as to the 
kind of food, and with the restrictions as to quantity which I 
have before mentioned, the patient may generally be allowed to 
follow his own desires. 
On the question of drinks it is still more difficult to lay down 
positive rules. Much has been written of late respecting the 
effects of alcoholic drinks, and opinion is still divided on the 
use and abuse of them. The following points seem, however, to 
admit of no reasonable doubt. 
Ist. That alcoholic drinks, by the stimulus and support they 
furnish, are of great service in various diseases attended with 
exhaustion or depression; or in which there is inability to digest 
solid food. 
2nd, That the habitual use of them in moderate quantity is 
often beneficial to persons whose occupations are exhausting or 
depressing; or who have long been accustomed to such stimulus. 
3rd. That by the mass of mankind, high and low, they are 
drunk to injurious excess. 
In persons who suffer from indigestion, if taken at all, they 
should be taken in very moderate quantity, and only at the time 
of meals, or soon after. If taken when the stomach is empty, 
they stimulate the stomach when it has no work to perform, and 
are absorbed more rapidly, and are consequently more apt to 
cause disorder in the head and elsewhere than at other times. 282 
GENERAL RULES 
Tlie quantity tliat can be taken with advantage, or without 
injury, varies greatly in different persons, according to the con- 
stitution, the size of the body, the mode of life, and the previous 
habits. Any quantity is hurtful that oppresses the head, or 
makes the skin hot, or disturbs the sleep. 
The effect of the different fermented drinks, when taken to 
excess, differs greatly. 
The distilled spirits do the greatest direct injury to the stomach 
and the liver. The victims of spirit-drinking frequently die of or- 
ganic disease of the stomach, or of that disease of the liver 
which is here fitly called the gin-drinker’s liver; but they suffer 
little from gout. 
The heavy malt liquors, probably from the greater dilution of 
the spirit, have little disposition to inflame the stomach or the 
liver, but have an especial tendency to bring on gout. No men 
are such melancholy victims of gout as men of the lower classes 
in London, who make their hard work an excuse for drinking 
enormous quantities of porter. 
Wines are free from the strongest objections to both these 
classes of drinks. They have much less tendency than spirits 
to damage the liver, and much less tendency than malt liquors 
t© bring on gout. 
All seem to be intoxicating in proportion to the quantity of 
spirit they contain. All, therefore, if taken to excess, injuriously 
affect .the brain. 
These leading facts respecting the different effects of alcoholic 
liquors may serve, in some degree, to guide us in prescribing 
one or the other of them. 
Spirits, and the drier wines, are the best suited to gouty per- 
sons, or to men in the middle of life who are of gouty families, or 
whose mode of living disposes to gout,—persons who would do 
well always to abstain from heavy malt liquors. 
Malt liquors, from containing more of the elements of nutri- 
tion, are especially suited to agricultural labourers and others 
whose work is hard, and whose diet is scanty and not sufficiently 
varied. 
The liquor that is most generally wholesome is wine. 
Tea and coffee are not open to the same objections as fermented OF LIVING. 
283 
drinks, but they are doubtless commonly taken to very inju- 
rious excess by nervous or excitable persons in the upper and 
middle classes, who do not counteract their influence by bodily 
labour. 
If harm be done by irrtproper food and drink, harm may also 
be done by improper physic, or by physic taken at improper 
times. 
On this point, much good advice may be given by a medical 
man who knows the nature of the disorder he is called on to 
treat, and the kind and degree of influence which his remedies 
exert. 
We have now considered at some length the various disorders 
of digestion. It may be some comfort to persons who suffer 
from them that a stomach easily disordered may be the means of 
preserving them from more serious ills. Persons in the middle 
and upper classes of society who have strong stomachs gene- 
rally abuse the gift,—eat and drink more than the system re- 
quires ; go on doing this for a time with seeming impunity ; but 
pay, at length, the full penalty of their over-indulgence, in gout, 
or in some of the more serious ailments that result from the 
changes of structure in the different tissues which over-indul- 
gence at table tends to bring on. The man whose stomach is 
easily upset is early taught to avoid such excesses, and so es- 
capes the penalty. I believe it would be found that, in the 
middle and upper classes of society, a large proportion of those 
who attain an advanced age are in some degree dyspeptic. 
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publication of this volume, an acceptable service to the profession. The work is full 
of practical precepts, presented in language at once intelligible and chaste. For the 
practitioner of medicine, it is invaluable. The student will find it a vade mecum full 
of instructive lessons.”—Charleston Medical Journal and Review. “ Many important facts are forcibly impressed, and the author’s luminous exhorta- 
tions, even on subjects comparatively insignificant in themselves, are generally calcu- 
lated to impress correct rules of practice.”— Western Lancet. 
“No one can read this book without becoming convinced that it contains much 
valuable instruction, and is the result of a large experience in this specialty.”—New 
Hampshire Journal of Medicine. 
“The work contains graphic descriptions of the diseases of women and children, 
with judicious advice as to treatment.”—Boston Medical and Surgical Journal. 
“We greatly admire the author’s independent course, and the principles on which 
he bases his practice. We consider the work a very useful one, which will be read 
with much interest and profit by the profession generally.”—Cincinnati Medical 
Journal. 
“ In the teachings* of Dr. Bedford, in reference to the class of cases which present 
themselves at the Clinic, there is far more to praise than to condemn. His pre- 
lections are in general sound.”—American Journal of the Medical Sciences, Phila- 
delphia. 
“ It is full of practical precepts, and discusses with the ability of a master the 
various diseases incident to women and children.”—N. Y. Evening Post. 
“ A treasury of knowledge for the student and the practitioner of medicine, while 
the mother, anxious for her own health and that of her daughters, will find it re- 
plete with judicious counsel.”—N. T. Commercial Advertiser. 
“A publication of the first importance. We can not see how any student may 
well dispense with it, or any practitioner, however eminent, overlook it.”—N. York 
Morning Express. 
“ The book abounds with sage counsels to the physician, and is full of important 
instruction to those not of the profession. The style is agreeable oftentimes touch- 
ingly eloquent, with occasional dashes of humor, and the work is remarkable for the 
great variety of subjects discussed in its pages.”—N. Y. Chronicle. 
“It is remarkable for the accuracy of language, depth of thought, and felicity of 
expression with which the practical precepts to be found in almost every page arc* 
presented to the reader.”—N. Y. Spectator. 
“An examination of the pages of this book has satisfied us that it is one full of 
interest and instruction, not alone for the practitioner of medicine, but for the com- 
munity at large; for, independently of the valuable information it contains with re- 
spect to almost every disease incident to women and children, it is replete with 
sound practical precepts for parents in regard to the present system of female edu- 
cation. There is here and there a severe but just hit at the fashions and follies of 
the day; and all in a style and manner not only captivating and convincing, but oc- 
casionally truly eloquent.”—N. Y. Observer. 
“ This book supplies a desideratum in medical literature. Clinical teaching is of 
immense value to the medical student, and Professor Bedford is eminently fitted to 
impart such instruction. His mode of procedure, showing the successive inquiries 
by which he obtains a knowledge of the disease, and the treatment applicable to 
each case, is finely illustrated in this volume. It will be consulted with profit by the 
practitioner, and prove a rich store-house to the medical student.”—Norton’s Literary 
Gazette. 
“ The author of this work is well known as the Professor of Obstetrics in the 
University of New York, and a medical writer of great experience and eminent 
ability. The volume reproduces, in a very attractive form, a vast amount of observ- 
ation and experience, and must prove highly acceptable to the medical profession, 
and abounds in passages well worthy the attention of the general reader.”—N. York 
Courier and Enquirer. 
“ The work displays a great deal of research, and embodies a large amount of 
practical knowledge upon the subjects to which it refers.”—New York Journal of 
Commerce. HOW TO NURSE SICK CHILDREN. 
Intended especially as a help to the Nurses at the Hospital for Sick Children; but 
containing directions which may be found of service to all who have the charg< 
of the young. 
“ The young mother, or the still younger nurse, is commonly supposed to under 
stand the child’s wants and habits intuitively, and the consequence of such intuitive 
knowledge is, we fear to say how often, the source of a debilitated constitution or 
death to the child, anguish, and a murmuring spirit to the parent. Nor is the blame 
to be laid solely .at the door of the young mother or the child, but rather at the door 
of those who, with knowledge at their command, have failed to communicate it. 
“ The author brings to his task the two great qualifications—a thorough love of 
children, and a thorough knowledge of their habits in health and disease. It is a 
simple but feeling account of the wants of the sick child, and of the duties required 
of its attendant.”—Brit. & For. Med. Chir. Review. 
ON RHEUMATISM, RHEUMATIC GOUT, AND 
SCIATICA; 
HENRY WILLIAM PULLER, M.D., CANTAB., 
Their Pathology, Symptoms, and Treatment. 
Fellow of the Royal College of Physicians, London; Assistant Physician to St 
George’s Hospital, etc., etc. 
“One of the best practical works of modern times.”—Winslow's Journal of Psycho- 
logical Medicine. . 
DISEASES OP MENSTRUATION AND OVARIAN 
INFLAMMATION, 
In connection with Sterility, Pelvic Tumors, and Affections of the Womb. 
EDWARD JOHN TILT, M.D., 
Physician to the Harrington General Dispensary, and to the Paddington Free 1 
“ The best publication on the subject.”—Boston Med. and Surg. Journal. 
pensary for the Diseases of Women and Children. 
MICROSCOPIC ANATOMY OF THE HUMAN BODY, 
IN HEALTH AND DISEASE. 
Illustrated with numerous drawings in color, by Arthur Hill Hassal, M.8., Mem- 
ber of Royal College of Surgeons of England, etc., etc. With additions to the Text 
and Plates, and an Introduction, containing Instructions in Microscopic Manipula- 
tion, by 
HENRY YAN ARSDALB, M.D. 
2 vols. Bvo. 79 plates. 
MANUAL OP DISEASES OP THE SKIN. 
Translated from the French, with Notes and Additions, by T. H. Burgess, M.D. Re- 
vised and corrected, with additional Notes, by H. D. Bulklby, M.D., Physician of 
the New York Hospital, etc., etc. Second American Edition. 
MM. GAZENAYE AND SCHEDEL. 
“ One of the most concise, complete, and practical treatises with which we are 
acquainted.”—Northern Lancet. 
“It is direct, full, and explicit in its descriptions.”—N. H. Journal of Medicine. PRINCIPLES OF PHYSIOLOGY, 
Designed for the use of Schools, Academies, Colleges, and the General Deader. 
Comprising a familiar explanation of the Structure and Functions of the Organs of 
Man, illustrated by comparative reference to those of the Inferior Animals. Also, 
AN ESSAY ON THE PRESERVATION OF HEALTH, 
With fourteen quarto plates, and over eighty engravings on wood, making in all 
nearly two hundred figures. 
“ Nothing could be more appropriate. It is a fascinating book for man, woman, 
or child. We hope the trustees of institutions will give an early attention to this 
valuable and unexceptionable treatise on human organism.”—Boston Medical and 
Surgical Journal. 
J. COMSTOCK & B. M. COMINGS, M.D. 
LECTURES ON NATURAL AND DIFFICULT 
PARTURITION. 
Professor of Midwifery, University College London; Obstetric Physician, University 
College Hospital; and formerly Assistant-Physician to Dublin Lying-in Hospital 
Illustrated by seventy engravings. 
EDWARD WILLIAM MURPHY, A.M., M.D., 
“This is a very excellent treatise on Obstetrics.”—Am. Journal of Medical Science. 
“An excellent book. It is commended to us by the position and rich practical 
experience of the author.”—Boston Medical and Surgical Journal. 
“We earnestly recommend it to the learner as the monograph, par excellence, on 
the subject.”—Annalist. 
“ As a text-book for students, we are of opinion that Dr. Murphy’s Lectures should 
rank very high.”— Western Lancet. 
A SERIES OF ANATOMICAL PLATES; 
With References and Physiological Comments, illustrating the structure of the differ- 
ent parts of the Human Body; with two hundred plates. 4to. 
Professor of Anatomy and Physiology in the University of London, and W. J. B. 
WILSON, M.D., Lecturer an Practical and Surgical Anatomy and Physiology. 
Third edition, revised, with additional notes, by Joseph Pancoast, M.D., Professor 
of General, Descriptive, and Surgical Anatomy, in Jefferson Medical College of 
Philadelphia; Lecturer on Clinical Surgery at the Philadelphia Hospital, etc., etc. 
“ Much superior as a system to any that have been hitherto published in this 
country.”—Medico- Chirurgical Review. 
JONES QUAIN, M.D., 
THE ANATOMY, PHYSIOLOGY, AND PATHOLOGY 
OF THE HUMAN TEETH, 
With the most approved Methods of Treatment, including Operations, and the 
method of making and setting Artificial Teeth. With 30 Plates. 
PAUL B. GODDARD, M.D., M.A.N.S., M.A.P.S., 
Demonstrator of Anatomy in the University of Pennsylvania. Aided in the practical 
part by Joseph E. Parker, Dentist. 
“ The account of the structure of the Teeth is a very valuable one, and is illus- 
trated by some remarkably well executed views of their microscopic structure.”— 
Am. Jour, of Med. Science.