NATIONAL LIBRARY OF MEDICINE NLM DD13flm 1 :vr LTV^nn^ ,; ;■■■■ ,. ✓^'W *' Surgeon General's Office C/ecaon,. Toxr ft**. "^OQO^QTO.re^ * *TTWWW«W **££■£ *^ ■vm^,. " ff A' ' A AA*AA^AAA.:aa,/V*'V^ NLM001381999 vw^VV>a i'VAA.A/ i&j*^^ 'Sllsss^^i^^-?'; yi^ vW^^^^S^ ^AAA' * 5' s£*£**,AA Sa'Sa' '^ \rAA* ^';^'-1^«% ^A *AA, ^'VPs«/irs*l^.\. . *a^aa>;A'>A$hA ;^- -^'-•> ^^ *^v VwvSnS tyV#*YVWV^ A . «/ ^^ Sta?'c/i. Starch is a hydro-carbonaceous material found in the seeds of plants, especially the cerealia, in palm-pith as sago, as tapioca from the cassava, and as arrowroot from other tubers, or as potato starch. Its chemical formula is Cl2H20O10. It is the material upon which the young plant feeds until it can get its own nutriment ; except as sago. Like animals, vegetables have an early infant period, when the food is found for them by their parents. Just as chap, n.] NATURAL DIGESTION. 11 the chick in the egg lives upon the material stored up within the shell; so the seed lives upon the starch and the fat, also stored up within the husk. These stores of ma- terial for the life of the young plant are garnered for human food. The digestion of starch within the body is allied in nature to that process by which the infant plant feeds upon the starch within the husk. The seed undoes the material built up by the adult parent plant, by means of a ferment contained within its tissues. In malting barley the ferment within the grain of barley changes the starch in the transformation into malt, just as it does in germination within the earth. When the subject of arti- ficial digestion is considered, we shall see how this ferment of barley, diastase, is utilized to transform the starchy matter of our food, when the natural digestion of starch is defective. The plant pulls the starch granules to pieces and renders the insoluble starch soluble ; and that is just what happens in human digestion. For digestion is solution ; disintegration precedes solu- tion ; the insoluble starch must be converted into soluble grape sugar, to pass from the digestive canal into the blood. While the teeth are crushing the food, and the tongue is rolling the mass over and over, it is being mixed and inter-penetrated with saliva. Saliva contains a fer- ment identical in its properties with the diastase of barley. • The saliva of man possesses more of this diastatic power than any other animal. For long centuries now man has cooked the starchy material of his food ; and so the sali- vary glands of man have become functionally very active. In the form of the ground cereals, we find the action of the 12 NATURAL DIGESTION. [chap. n. teeth supplemented. Disintegration is largely performed for us. Then "by cooking, the starch granule is prepared by the action of the digestive ferment, by having its cap- sule ruptured. When bread, a biscuit, or pastry is chewed, the saliva is mixed with the farinaceous particles, and the transformation of starch into grape-sugar is instituted. The insoluble starch is liquefied by hydration, that is by the addition of a molecule of water, into dextrine and grape-sugar. The formulas for these are : Dextrine C6 H10 06 Grape-sugar C8 Hl9 06. Food could not be stored in a soluble form ; it would be washed away. So the digestive act is the dissolving of food, till, in fluid form, it can pass through the walls of the diges- tive canal into the blood. There it is turned back de hydrated by the removal of the added molecule of water, and stored up in the body. When the digested starch in the form of dextrine, the soluble or grape-sugar, is taken into the blood of the portal vein, and reaches the liver, it is dehydrated back into glycogen or "animal starch." As rapidly as the starch is liquefied into soluble sugar it passes through the walls of the stomach ; and so does not interfere with the digestion of albuminoids going on there- in. The diastatic action can only go on in an alkaline or neutral medium ; as soon as the contents of the stomach become acid the diastatic digestion of starch is arrested. What starch is left over from the salivary digestion, re- mains unaffected by the gastric digestion. When the food passes the pyloric ring, and is mixed with the alkaline bile, chap, n.] NATURAL DIGESTION. 13 then the digestion of starch is once more resumed under the influence of the amylolytic ferment in the pancreatic secretion. Albuminoids. From the albumen in the ^gg, the tissues of the embryonic chick are formed. From the albumen in the see'd of the plant, the tissues of the germinating seed- ling are fashioned. Tissues are formed from albuminoids, with some auxiliary assistance from hydrocarbons. Liebig long ago pointed out how the presence of nitrogen in com- bination with hydrogen and carbon, interfered with their ready union with oxygen. Albumen has the formula ac- cording to Hoppe-Seyler, quoted by M. Foster : '-'SO. 9 -H-6.9 -^ 15.4 ^52.7 ^0.8 to S3.5 to T.3 to 16.5 to 54.5 to 2.0 Containing nitrogen, albuminoids do not readily oxidize; and thus the body tissues are formed of albuminoid mate- rials. The hydrocarbons, or fuel food essentially, burn by oxidation in the system, while the tissues themselves do not burn. It is like the coal burning in the steam-engine, while the iron-work does not burn. Nevertheless the iron- work wears out by a slower process of oxidation, known as " rusting." So it is with the albuminoid tissues of the body; they do not burn properly, but they slowly oxidize, or rust as they wear away. Albuminoids are not affected by the saliva; the gastric juice is their solvent. On the digestion of starch the gas- tric juice exercises no effect, except to arrest the action of the saliva upon it. " When digestion is proceeding com- fortably and normally, a certain interval elapses before the acidity of the stomach becomes considerable, and during 14 NATURAL DIGESTION. [chap. n. the interval, the salivary diastase continues active, and has time to accomplish a good deal of work." It is upon albu- minoids that "pepsin," the gastric ferment, exercises its sole action. The gastric juice contains pepsin and hydrochloric acid. "In one important respect pepsin, the ferment of gastric juice, differs from ptyalin, the ferment of saliva. Though saliva is most active in a faintly alkaline medicine, there seems to be no special connection between the fer- ment and any alkali. In gastric juice, however, there is a strong tie between the acid and the ferment, so strong that some writers speak of pepsin and hydrochloric acid as forming together a compound pepto-hydrochloric acid." (M. Foster.) Before digestion an albuminoid is termed a "proteid;" the digested proteids are termed "peptones." As peptones, albuminoids readily pass through the walls of the digestive canal into the blood. The change is caused by adding a molecule of water ; "judging from the ana- logy with the action of saliva on starch, we may fairly suppose that the process is at the bottom one of hydra- tion" (M. Foster). The solvent action of the gastric juice is greatly aided by the muscular movements of the stomach; as the contents are rolled over and overtherebv, they are brought into immediate contact with the digestive pepsin and the acid. Muscular fibres fall asunder, and gradually disappear in the stomach as the digestive act progresses; so other proteids are rendered soluble in this acid solvent medium. The whole of the proteids are not digested in the stomach, but are passed through the pyloric ring, when it relaxes towards the termination of gastric digestion. The two rings, the one at the foot of the gullet, chap, n.] NATURAL DIGESTION. 15 the cardiac orifice, as well as the pyloric ring at the intes- tinal outgoing orifice of the stomach, are contracted dur< ing the time of its activity ; and as the contents become disintegrated, the pyloric ring relaxes. The food has fallen to pieces in the stomach, such of it as will, little bits, of gristle and vegetable fibre being left en masse/ and so is prepared for further intestinal digestion. The fat is stored in the body in areolar tissue, in the connective tissue, or packing material, and as such consists of fat in an albu- minous envelope. In normal digestion that envelope is dissolved, and the fat set free. But fat itself hitherto has undergone no change whatever. "On fats gastric juice is powerless. They undergo by reason of it, no change what- ever in themselves when adipose tissue is eaten, all that happens is that the proteid and gelatinigenous envelopes of the fat-cells are dissolved, and the fats set free ; the fat itself undergoes no change except the very slightest emul- sion." At times the liberation of fat interferes with gas- tric digestion. Fat. It is only after the food has passed the pyloric ring that the digestion of fat commences. Some decomposition at times takes place, and a fatty acid is formed, which irri- tates the stomach, and constitutes one form of dyspepsia. "The digestive change undergone by fatty matters in the small intestine, consists mainly in their reduction into a state of emulsion, or division into infinitely minute particles. In addition to this purely physical change, a small portion undergoes a chemical change whereby the glycerine and fatty acids are dissociated. The fatty acids thus liberated then combine with the alkaline bases of the bile and pan- 16 NATURAL DIGESTION. [chap. n. creatic juice, and form soaps. The main or principal change is undoubtedly an emulsifying process, and nearly all the fat taken up by the lacteals is simply in a state of emulsion, and not of saponification." Bile exercises some influence upon fats. " It has a slight but only slight emulsifying power. A mixture of oil and bile separate after shaking, less rapidly than a mixture of oil and water ; this action is probably due to the alkaline nature of bile. Oil passes with considerable ease through a filter- paper kept wet with a solution of bile salts in company with one kept constantly wet with distilled water. Bile therefore must be said to have a slight action even on fats. It is probable, however, that it is more useful when com- bined with pancreatic juice than when acting by itself " (M. Foster). A fat is a hydro-carbon, containing a small poportion of oxygen. It is formed Avhen the assimilation of hydro-car- bon is in excess of the body needs ; the surplusage is stored as fat or adipose tissue. This reserve is consumed when the food is insufficient in supply, and disappears on starvation. This is the formula of stearin, the firmest of the fats. (C„H„0),) O.H. \°> The others, oleine and margarine, are much the same che- mically. Oleine is the most fluid and then comes margarine. Speaking broadly the digestibility of a fat is in proportion to its stiffness when cold. The best cod-liver oil is frozen at a low temperature, to freeze out the margarine and stearine, and is nearly pure oleine. Cod-liver oil is most chap, n.] NATURAL DIGESTION. 17 digestible on account of its fluidity, as well some bile in it. Then comes the fluid fat of bacon, butter, and then cream, oils and animal fats. Intestinal digestion. When the food, now known as chyme, rendered fluid or semi-fluid in the stomach, passes the pyloric ring, it meets the alkaline bile and becomes alkaline. Then the digestion of pepsin stops. Just as the acid gastric juice arrests the salivary digestion of starch; so- the alkaline bile kills the action of pepsine. To this alkaline mass is poured out the secretion of the pancreas. This is a most potent solvent fluid. It con- tains (1), a diastase, digesting starch ; (2), trypsin, a fer- ment digesting proteids in an alkaline medium; and (3), an emulsive ferment which acts upon fats. Like the gas- tric secretion it contains a ferment which curdles milk—an action necessary to the digestion of milk. Under its influ- ence the digestion of the starch left in the stomach after the salivary action is arrested, is resumed. The proteids are converted by the trypsin into peptones. The fat is emul- sionised in the presence of bile. The soluble sugar, and the soluble peptones pass into the blood of the portal vein. The fat is taken up by the lacteals in the intestinal villi and carried into the thoracic duct. The waste is passed on to be voided ; being still acted on to some extent by the succus entericus, or intestinal juice. Such, then, is the digestive act. After being made soluble, to pass through the walls of the digestive canal, sugar and peptones are turned back by dehydration, into starch and proteids. They have been dissolved so as to pass readily through organic membranes; 18 NATURAL DIGESTION. [chap. n. now they are to be stored up, so they are changed back; otherwise they would escape out of the blood as easily aa they got into it. When the liver is unequal to dehydrating the sugar of the portal vein into glycogen as rapidly as the sugar is formed, the sugar passes out by the kidneys, con- stituting glycosuria. This may be produced in any one by excess of sugar, at once. When the disturbance is pronounced, it constitutes " Diabetes." As glycogen or animal starch, the amyloids of our food, are stored for the needs of the body, and given off as required. The after history of peptones is very interesting, as far as it is known. They disappear in the blood, and are not found in it, " neither in the portal blood, nor in the chyle, nor in the general blood during digestion, is there any ap- preciable quantity of peptones." (M. Foster.) In a recent article, " The Practitioner," October and November, 1880, Dr. Lauder Brunton, F.R.S., discusses the possibility of peptones escaping the dehydrating process, and thinks " that the liver, to some extent at least, serves the purpose of preventing any peptones from getting into the general circulation, which may have escaped transformation in the portal blood before meeting it." Indeed, from the time t he peptones disappear, to the time of their final change and appearance as excreta, as bile acids and urine solids, we, as yet, do not know their history; yet it is what we would most certainly like to know. From the albumen in the liquor sanguinis the tissues are fed. This is termed "In- terstitial Nutrition." Finally, there are the salts of the blood to be considered. We do not know of any digestion of the salts of the body beyond mere solution of them in the fluids. Conditions of spanasmia are produced from their chap, n.] NATURAL DIGESTION. 19 deficiency, either from the food not containing a sufficiency of them, or their disappearance, as in profuse night-sweats. They are useful in digestion somehow; for I have noticed again and again at the City of London Hospital for Dis- eases of the Chest, how the appetite of the consumptive patient improves within two or three days of the arrest of severe night-sweats. Prof. M. Foster, F.R.S., writes— " The effects of salts as food. All food contains, be- sides the potential substances which we have just studied, certain saline matters, organic and inorganic, having in themselves little latent energy, but yet either absolutely necessary, or highly beneficial to the body. These must have important functions in directing the metabolism of the body; the striking distribution of them in the tissues, the preponderance of sodium and chlorides in blood-serum, and of potassium, and phosphates in the red corpuscles, for instance, must have some meaning; but at present we are in the dark concerning it. The element phosphorus seems no less important, from a biological point of view, than carbon or nitrogen. It is as absolutely essential for the growth of a living beinar like Penicillum as for man himself. We find it probably playing an important part as the conspicuous constituent of lecithin, we find it pecu- liarly associated with proteids, apparently in the form of phosphates; but we cannot explain its role. The element sulphur, again, is only second to phosphorus, and we find it as a constituent of nearly all proteids; but we cannot tell what exactly would happen to the economy, if all the sulphur of the food were withdrawn. We know that the various saline matters are essential to health; that when they are not present in proper proportions nutrition is af- 20 NATURAL DIGESTION. [ohap. n. fected, as is shown by certain forms of scurvy : we are aware of the peculiar dependence of proteid qualities on the presence of salines ; but beyond this we know very little." Lecithin is a "complex nitrogenised fat, with the for- mula, C44H9N.P09 occurs widely spread throughout the body. Blood, gall, and serous fluids contain it in small quantities, while it is a conspicuous component of the brain, nerves, yolk of egg, semen, pus, white blood-cor- puscles, and the electrical organs of the ray " (M. Foster). Iron is a necessary component of haemoglobin, a most complex substance, containing—C.53H7N16021S.4F. . " Haemoglobin is a so-called ozone carrier " (M. Foster). Here is a very complex body in the red corpuscles, upon which depends the giving off of carbonic acid, and the taking up of oxygen. Lecithin is a phosphorized fat which seems to be the food of the nervous system par excellence. AY here these infinitely complex bodies are formed we do not know. Yet we clinically recognise that there is anae- mia in which the absence of iron in the food plays a part. It seems possible that the imperfect formation of " lecithin " may be the cause of much lack of nervous energy associated with impaired nutrition. The failure of the assimilative processes to build up these complex bodies may co-exist with power to form the ordinary products of digestion. We are beginning to see, albeit " through a glass darkly," the clinical value of a good knowledge of digestion, in its power to aid us in the treatment of many maladies, which take their origin in failure of the digestive processes. CHAPTER III. PRIMARY INDIGESTION. All digestion, then, is a process of solution for which previous disintegration is essential. Indigestion then may be due to, (1) imperfect disintegration; and (2) defective solvent power. Of course, if the food taken be of an un- suitable nature, be indigestible in itself, then indigestion follows; for which the digestive processes are not to blame. Imperfect disintegration. This is mainh^ due to insuffi- cient mastication. Certainly, when uncooked seeds are eaten the disintegration is never sufficient ; but most of our food requiring thorough disintegration, is prepared for us by first grinding, and then cooking. The defect lies either in the bad practice of eating hurriedly; or, in a growing cause of indigestion, bad teeth. As to the practice of eating too hastily it is to be condemned without exten- uating circumstances. The habit of eating in company and chatting, is conducive to good digestion, by prolong- ing the meals; and allowing the disintegrating action of mastication to go on efficiently. It is not merely that the effect of saliva upon starch is lost, or largely so (that might be made up for and compensated by the later diges- tion of pancreatic diastase), but the food is insufficiently chew,ed; and is therefore swallowed in an unprepared state for the disintegrating action of the stomach. To grudge time for the proper mastication of food is as irrational as was the revolt of the members against the belly. If the 22 PRIMARY INDIGESTION. [chap. m. digestion be not perfect, then the rest of the body will suffer from want of pabulum. The food should be slowly taken and thoroughly chewed : if the teeth will permit. Even when a glass of milk is swallowed, or a cup of beef- tea, containing some baked flour, it is ^all the better for being taken slowly, and being to some extent mixed with saliva previous to being swallowed. When farmers' wives and daughters fed calves " off the finger," so that they got their milk slowly; they did better and had less diarrhoea than now when the calves are allowed to take their milk , greedily, so that it curdles too firmly in the stomach. The admixture of some form of ground farina to prevent the formation of too firm a curd would be desirable; if the demands of modern agricultural life can no longer afford the time for feeding calves " off the finger." Too firm curdling of milk is a common cause of diarrhoea both in human and bovine infants. The curd is indigestible, so it is got rid of as readily as possible by ejection from the bowels. In all cases where a milk diet is required, this too firm curdling should be looked to; it is the equivalent of imperfect disintegration. Bad teeth are a fertile cause of indigestion. They not only forbid perfect mastication, but the pain of mastication often causes the food to be bolted; even when the individuals know full well they will have to suffer for it. The present grave increase in the spread of dental caries is matter for the most serious thought, as regards the next and ensuino* generations. If this spreads as it is doing at the present time, such a thing as a natural tooth will scarcely ever be seen. As soon as the crowns protrude from the gum they chap, m.] PRIMARY INDIGESTION. 23 will require the care of the dentist; maybe it will become necessary to nip off the crowns almost as soon as fully developed, in hopeless despair of their remaining fairly sound. Bad teeth lead to impaired digestion in two ways, (1) they interfere with the proper admixture of saliva with the starchy matters of the food, by which the amylolytic action of salivary diastase is lost or thrown away; and (2) by im- perfect mastication the food is not prepared for the further disintegrating action of the stomach, and so great and abnormal muscular movements of that viscus are required in order to carry on the disintegration of the unchewed, or imperfectly chewed food. In all cases of indigestion then, the teeth ought to be critically examined, and if found defective put in working order; after which the trouble- some symptoms may pass away without requiring further medical attention. Imperfect disintegration may be due to defective action in the stomach. There the atrophy of the muscular coat impairs the energy of the movements of the stomach; as is notably seen in gastric dilatation; or there may be an abnormal quantity of gastric mucus thrown off, in which the food is rolled over and over, until a thick mucous layer is formed which most effectually resists the solvent action of the gastric juice, so that the action of the salivary dias- tase alone goes on, and the food is passed into the intes- tines in no way advanced by gastric digestion; or an ulcer on the walls of the stomach may arrest the muscular move- ments of this viscus, and so lead' to impaired disintegra- tion. In all these cases there is lessened disintegrating power in the stomach, and consequent indigestion. 24 PRIMARY INDIGESTION. [chap. in. Now in all cases of indigestion due to impaired disin- tegrating action, the sole remedy is to modify the diet accordingly; if the cause of the impaired disintegration be not, as is often the case, removable. Bolting the food may be remedied ; bad teeth may be supplemented by the skill of the dentist; imperfect muscular movements in the stomach may be improved by the administration of strych- nine. But in the bulk of cases the treatment lies in suita- ble food. It must be prepared so as not to require disintegration. In mild cases it is sufficient to avoid pastry, veal, pork and other things which are not easily disintegrated; and to adopt a dietary of fish, white meat, milk puddings, and stewed fruit. But when the case is one of gastric catarrh, ulcer, dilatation, or cancer, then a strict regimen is absolutely necessary. The food must be in fluid, or semi-fluid form; and consist of such materials as require neither mastication nor the exercise of much muscular movement in the stomach ; if there be gastric catarrh such as cannot well be rolled up into a mass, and covered with tenacious mucus. It does not matter what the gastric lesion, the digestive act is the same; and re- quires identical management. It must then consist of milk, or milk-gruel; or beef-tea, or mutton broth with some baked flour added. Such then briefly is the management of indigestion due to imperfect disintegration. Imperfect solvent action. This may be due to impairment in the saliva, the gastric juice, or the pancreatic secretion. The first will give us impaired digestion of all amyloid materials; the second impaired digestion of albuminoids; while the third will render the assimilation of fat imperfect. chap, in.] PRIMARY INDIGESTION. 25 Deficiency in the two first may be met by increasing the activity of the last by appropriate measures. But defi- ciency of fat-digestion by impaired pancreatic secretion cannot be compensated. In each case before us, it is necessary to arrive at clear views as to what it is we wish to remedy, ft will not be found either successful, or satis- factory to prescribe at a venture either medicine or arti- ficial digestive agents, in a hap-hazard way. To give bit- ters, hydrochloric acid, or even pepsin wine, when it is the digestion of starch and fat which is defective. Nor prepa- rations of malt diastase when it is the digestion of albu- minoids which is impaired. There must be a precision in diagnosis preceding the therapeutic efforts, guiding and giving aim to them, for the latter to be successful. Pre- cision in diagnosis as to anatomical change lias been insisted upon usque ad nauseam, considering the barren- ness of results attained thereby. But precision in diag- nosis from observation of physiological function, and its disturbances, has yet to be attained ; but when attained it will be most fertile in result. For the stimulation of the salivary glands we possess few agents, little if ever resorted to for the purpose of stimulating the salivary glands. The chief of these are mercury, jaborandi, and pellitory. Some persons chew ginger, or cinchona bark; but such measures are of com- paratively little service, contrasted with the resort to vegetable diastase to supplement the digestion of starch by the salivary diastase. This matter will receive attention in the next chapter, devoted to the consideration of the Artificial Digestive Ferments. 26 PRIMARY INDIGESTION. [chap, nx For the stimulation of the gastric secretion we possess several agents. There are a number of articles of our pharmacopoeia which increase the flow of gastric juice. Among them are agents which produce severe inflamma- tory symptoms in the stomach if taken in larger quantity, of which arsenic is the type. Alcohol possesses the same power. In small doses both these agents produce a flow of blood to the lining membrane of the stomach, which in- creases the flow of juice. When empty the mucous coat of the stomach is pale and bloodless. When food is taken it becomes red, turgid with blood, and bedewed with secre- tion exuding from the orifices of the gastric tubules. Con- sequently the glass of sherry, or even gin and bitters, is not out of place, or out of time, in all cases. Where it is undesirable to resort to alcoholic stimulants the old-fash- ioned dinner-pill of ipecacuanha, cinchona, and aloes and myrrh pill is indicated. Ipecacuanha in small doses ex- cites the mucous membrane of the stomach; in larger doses it excites vomiting. Further, it is a powerful stimulant to the liver. Consequently it is indicated as a constituent of primary importance in the dinner-pill. Then there are bitters of world-wide reputation both to whip the appe- tite, and to increase the digestive power of the stomach. Ringer has found that the contact of an alkali to the lining membrane of the stomach induces a subsequent flow of gastric juice if taken before a meal. By the judi- cious fitting of such measures to each case, good results may often be obtained without further measures being required. These other measures are the utilizing of the gastric secretion of our omnivorous congener the pig, to help to do the digestion for us. chap, nx] PRIMARY INDIGESTION. 27 So long as the stomach was supposed to be the sole, or almost sole seat of the digestive act, measures intended to act upon it were alone sought for, and enquired after. But when physiological research discovered that the sto- mach only played a part, a comparatively subordinate part in the digestive act, other means were searched for, and found; viz., measures which stimulate the secretion of the pancreas and the liver. How the action of this last large viscus has so long remained shrouded in Stygian darkness, it is impossible to say. Practical medicine has gleaned a scrap or two of empirical lore about it. But science was dumb, or scarcely articulate, until this sneer was justifi- able, " it was taught by physiologists, sixteen hundred }Tears ago, that the urine was formed by the liver and separated by the kidneys; and those who come after us may judge whether the nineteenth century have made any real progress in this matter compared with Galen." Cer- tainly it wras not till late in the nineteenth century that any real advance was made in our knowledge of the phys- iology of the liver and pancreas; such as is of practical use to us in our essays to aid, or remedy disturbed assimi- lation. For the stimulation of the pancreas we possess only one agent of whose properties we are at all assured; and that is sulphuric aether. Dr. Balthazar Foster, of Birmingham, first used aether to stimulate the pancreas to increased se- cretion in cases where cod-liver oil, taken alone, disagreed, or was not assimilated. The addition of tether led to satis- factory results. Dr. Fosters expressions of opinion and practice led to a Commission being formed in the United 28 PRIMARY INDIGESTION. [chap. m. States to investigate the subject. Their results corrobo- rated Dr. Foster's views. Instead, however, of stimulating the pancreas in some cases, it is more convenient to employ a preparation con- taining the different pancreatic ferments, as the Liquor Pancreaticus, giving it according to the directions fur- nished in the next chapter. For the stimulation of the liver we can use a variety of agents whose actions have been much elucidated by the work of Prof. Rutherford of Edinburgh, who investigated the action of drugs upon the liver. These agents are ipe- cacuanha, iridin, and euouymin, as vegetables; and the sulphate of soda as a saline laxative or purgative, accord- ing to the dose. By the use of these agents the liver is stimulated; a fact quite corroborated by clinical observa- tion. Sulphate of magnesia is a stimulant to the intes- tinal glands and a purgative; but it will not clean the tongue and unload the -liver like the sulphate of soda. It is this fact which led me to substitute " Sodae Sulphat." for " Mag. Sulphat." in so many prescriptions in the second edition of my " Practitioner's Handbook of Treat- ment, or the Principles of Therapeutics" (1880). Espe- cially when there are deposits in the urine, and pale stools, with a furred tongue, and a bad taste in the mouth in the morning, is the use of these hepatic stimulants to be re- sorted to: and the results so attained are satisfactory when a proper dietary is added thereto. As to the efficacy of hepatic stimulants there can be no more doubt than that these are stimulants to other glands. Mercury is especially indicated in some cases; chiefly when the blood ohap. ra.J PRIMARY INDIGESTION. 29 is surcharged with nitrogenised waste, whether bile acids or urine solids. Some concomitants of Indigestion. It may be well now to consider some concomitant states which require atten- tion, before proceeding to review the matter of the inabil- ity to digest fats; often a very grave affair, especially when found with profuse night sweats. In gastric catarrh not only must the food be fluid or semi-fluid, and utterly free from perceptible particles, such as may be rolled into a ball and enveloped in a covering or catarrhal mucus; but means must be used to check the catarrh. Compound kino powder is a great favourite in the treatment of gastric catarrh; the pill of sulphate of copper and opium is often useful. Other combinations of opium and astringents may be used. T. King Chambers has pointed out that in gastric catarrh these combinations do not produce constipation to the extent that might be anticipated; their astringent action apparently being spent upon the morbid mucous lining of the stomach. In gastric ulcer it is well to give an opiate an hour before food is taken. This lessens the pain, and diminishes the movements of the stomach, so that vomiting is prevented to a great extent. It allows the food to pass through the stomach into the duodenum, especially when it consists of milk-gruel already partially digested. Bismuth is also very useful. In gastric cancer an opiate is equally indicated. Both in ulcer and in cancer, when the surface is raw, the acid of the gastric juice causes acute pain, so the food should be " sheathed with an alkali." 30 PRIMARY INDIGESTION. [chap. m. In gastric dilatation, it is desirable to empty the stom- ach artificially from time to time, and then wash it out with a solution of the sulphites. The diet always to be most carefully attended to in each case. In diarrhoea, especially when it comes on immediately after food, the contents of the small intestine are swept along too rapidly for absorption to go on properly; and therefore the system is badly nourished. Here opium and bismuth are especially indicated, together with a strict milk dietary. Often there is acidity, especially with in- fants, and then lime water, prepared chalk, or light mag- nesia—some or other of the fixed alkalies, should be added to the milk. Astringents containing tannin, or the mineral astrin- gents, as sulphate of copper, and opium are indicated in true ordinary diarrhoea. Sometimes larger doses are re- quired than those in ordinary use. When the diarrhoea is frequent, teasing, and the amount passed small in quantity and no relief is obtained, then it is well to give a full dose of castor oil, or rhubarb. If it persist after this the rec- tum should be explored, for a mass will probably be found in the colon, preventing the passage of solid faeces. In constipation it is well to give a pill at bedtime, and if necessary a saline purgative next morning. The pill may consist of Pil. Al. et Myrrh., Pil. Col. Co., according as a mild, or a more powerful laxative is required. Then next morning a dose of effervescing citrate of magnesia, or a purgative water, or some black draught; or, better still some soda sulphate with Rochelle salts in a bitter infusion containing a carminative, taken warm. A morning laxa- chap, m.] PRIMARY INDIGESTION. 31 tive taken warm acts at once, more promptly (a great matter for business men), and more efficiently. At other times Trousseau's plan of a suppository of hardened honey, or soap may be tried; or it may be enough to resort to an enema. In very severe constipation it is well to give potent cathartics, scammony, podophyllin, or gamboge at night, and a saline purgative in the morning. But the case must be followed up actively, and the constipation relieved somehow; else the indigestion cannot be remedied. (Dys- peptics with confirmed constipation are very difficult pa- tients to manage, and require a medical adviser of deter- mined will, as well as considerable skill in the wielding of remedial agents.) When there is pruritus ani (itching of the fundament) also present, then hepatic stimulants are required for relief. This may be due, however, to the presence of " Seat Worms," which require sharp cathartics, and injec- tions of infusion of quassia. Anal fissures, ulcers, piles, fistulae, &c, require treat- ment that cannot be described here. The regulation of the bowels by. an appropriate dietary will be given in Chap. VIII. But laxatives are commonly required as well in cases. At other times there is gastric irritability to be dealt with. Then the tongue, our only index of the state of the intes- tinal canal, is raw and denuded of epithelium, either in'a broad furrow up the middle, or over the surface generally. When this condition obtains, whether alone, or along Avith pulmonary consumption, or other malady, it claims our attention exclusively; at least all other matters must only 32 PRIMARY INDIGESTION. [chap. m. be subordinate. This imperativeness is too commonly not fully recognized, with disastrous results. But experience tells that it must be the chief object of our solicitude. " Needs must when the devil drives," and this condition of denuded, or but partially grown epithelium cannot be re- legated to a second place in our remedial measures, with due regard to the patient's safety. As a skilful general changes his front according to his enemies' tactics, so the wary physician, when he sees this change coming on, changes his line, when the malady puts on this new aspect. Bismuth and alkalies, a milk diet, with the alkaline sheath; firmness, patience, and perseverance, are all required to see the patient safely through " the valley of the shadow of death;" when aphthae appear the efforts must be re- doubled. When the tongue recovers its normal aspect, and the epithelium is no longer half-grown, but quite ma- tured, then the treatment may advance to mineral acids; but so long as' the bareness remains, so long must the treatment be directed, if not exclusively, still mainlv, to the state of the lining membrane of the digestive tract. Then there is " the furred tongue" where there is a perfect layer of debris of food and dead epithelial scales, indicative of the state of the lining membrane of the digestive canal. Not uncommonly purgatives have been taken by the pa- tient, once or oftener, to remove it. If mercury have been no part of the remedies employed no effect has followed, as regards improvement in the condition of the tongue. A mercurial will usually make the desired alteration; but not always. In some cases, however, the relief is not so readily furnished; and the mercurial must be repeated tJHAP. in.] PRIMARY INDIGESTION. 33 and a mixture containing nitro-hydrochloric acid and smal' doses of sulphate of soda, is requisite for a week or even more, before the digestive organs are restored to their normal working condition. In some cases the tongue looks normal till placed in a side light, and then by looking across the tongue a brown shade can be observed. Here the same line of treatment is required; and, however anaemic the patient may be, it is useless, worse than useless to give chalybeates: for when the liver is disturbed, iron never agrees. There are certain states of the digestive organs when the patient complains that the sight of fat produces repugnance and loathing; but where there are no decided objective symptoms. But they cannot digest fat, at least in its ordinary forms. Whether it is the fat interferes with gastric digestion, and is intolerable to the stomach; or there is also some inability to digest the albuminous capsule of the fat granules in adipose tissue; or what the particular ob- jection is, is not yet known; the fact remains that fat is most objectionable to them. What to do with these cases as regards their dietetic management will be given in the next chapter, in the section devoted to the practical measures to be adopted when the assimilation of fat is disturbed. It is clear from what has so far been written that the old impression of the stomach being the sole seat of the diges- tive act must be abandoned in favour of views more sound, and in accordance with the teachings of modern physio- logy ; if we are to be exact in our treatment of the disturb- ances of the assimilative processes. 2* 34 SYMPTOMS. [chap. m. SYMPTOMS. A few of the prominent symptoms produced by indigestion may now be given briefly. One of the frequent outcomes of indigestion is the production of an acrid acid in the stomach. This seems to be* one of the fatty acids, prob- ably butyric, and is very acrid in its properties. It is usually not produced early, but rather late on in the diges- tive act. It causes a bitter pungent taste felt at the foot of the gullet. This sensation is termed " cardialgia " or "heart-burn." Another is "pyrosis" or "water-brash." This consists in the eructation of a fluid into the fauces, sometimes acid, sometimes alkaline; at other times acrid, or even feeling " cold." Certain articles of food, notably oatmeal, are arTt to produce it. A third is " regurgitation " of the food; sometimes sour, sometimes sweet. With some persons, this act, analogous to " chewing the cud," is habitual; a certain number say it is not disagreeable to them. Allied to this is the " eructation of wind " or " belching," to many persons a great source of annoyance. When highly-flavoured articles of food are eaten, the taste is often very pronounced in the eructated wind. The cock- ney phrase for this is an expressive one—their food " re- peats," they say. " Flatulency" is another outcome of disordered digestion, and often creates a most uncom- fortable sense of distension. Frequently the pressure of this elastic gas in the stomach produces " palpitation." Betwixt the heart and the stomach lies the thin dia- chap, m.] SYMPTOMS. 35 phragm only ; and gas in the stomach, or transverse colon, presses upon the heart and interferes with its movements; producing either "palpitation" or "inter- mittency " in its stroke, as the case may be. " Vomit- ing " is not very common except in acute indigestion; and gives immediate relief, as it does in gastric ulcer. It is most frequent in "gastric catarrh " in the morning; es- pecially where too much alcohol has been taken the previous evening. In acute dyspepsia it is the natural form of attaining reiief. It is often followed by sharp diarrhoea, sweeping away such part of the contents of the stomach as have passed into the intestinal tube. At other times " diarrhoea " is provoked by each meal. " Itching at the seat " is found in other cases, and it is a most torturing, distressing affection. When it is due to seat- worms it is readily amenable to treatment in most in- stances; but not in all. Then there is " pain " at the pit of the stomach. When due to "gastric ulcer" it is provoked as soon as the stomach has become acid, and is aggravated by the muscular movements dragging on the base of the ulcer; thus vomiting gives immediate relief. So long as the stomach is at rest, and in its alkaline state of quiescence there is no pain. In " gastric cancer " there is also sharp pain not always relieved by vomiting; nor alone provoked by food, but felt at other times at first, and ultimately continuous and persistent. Pain is commonly found along with other evidences of indigestion, and may occur imme- diately after a meal; or at a later period when the contents of the stomach are passing the pyloric ring; when felt at 36 SYMPTOMS. [chap. m. this time it is duodenal. " Nausea," or a sense of sick- ness, is a very common symptom either found along with pain, or alone. It may be present almost habitually; but be accompanied by actual vomiting only when the disturb- ance of the digestive act is unusually great. " Constipation " is a common concomitant of dyspepsia; not rarely its exciting cause. So long as constipation is permitted to continue, so long will dyspepsia persist. By perseverance, patience, and determination, the most ob- stinate constipation may be overcome. Too frequently, however, the patient grows indifferent, or tires of the treat- ment, and as a consequence relapses into the habitual condition. It is the bane of their lives to many persons; still it is much more amenable to treatment than is gener- ally supposed. The throat often feels sore, or uncomfortable; at other times there is a tendency to " hawk up phlegm," which gathers on the fauces. In some cases there is a turgid state of the fauces, little dendritic vascular twigs being very visible. Less frequently, there are " purple-like ekv vations of the mucous membrane," at times even " folli- cular ulceration; " or the uvula is relaxed and elongated, tickling the throat and producing troublesome couch. "Aphthae" are not usual except in children, or adults the subjects of severe advanced exhaustion. The tongue should always be carefully inspected. Some- times it is " swollen," " relaxed," and " indented with the teeth;" at other times it is " raw " or " irritable," being denuded of its epithelium. In other cases it is " foul" or "loaded;" and this "fur" may be yellow, or brown, chap. m\] SYMPTOMS. 37 especially when the liver is disordered. Or there may be a " strawberry" tongue: sometimes like a red strawberry with the papillae like the red seeds; more commonly it resembles a white strawberry, the tongue being generally white with red papillae protruding through the fur, closely resembling the red seeds upon a white strawberry. Less commonly the papillae are enlarged, looking like small in- flamed warts; these are the large papillae, fifteen to twenty in number, near the root of the tongue. At times a foul streak is seen along the mesial line of the tongue, the edges being very clean; at other times this is reversed, a clean streak running up the middle of the tongue. Some- times one side of the tongue is fouler than the other; here there is a local cause. " Fissures " of the tongue are not rare; most commonly associated with the practice of drinking hot fluids, especially tea. " Deep sulci" are usually syphilitic, especially when the tongue generally is smooth as if the papillae were shaven cleanly off with a razor. Such a sign is of great importance, as some cases of indigestion have been incurable fill an anti-syphilitic treatment has been adopted for some other ailment; and then, presto, the indigestion has disappeared. " Psoriasis " is also significant. There seems some evi- dence that the stomach is sometimes the seat of analogues to skin affections; as it certainly is the seat of an erup- tion in some cases of small-pox. " Skin eruptions " are very frequently linked with diges- tive disturbances, and only curable by putting the diges- tive organs in order. Eczema with pruritus of the geni- tals, or anus, is always associated with dyspepsia in some part of the digestive tract. 38 SYMPTOMS. [chap. m. In some cases there is a "taste in the mouth," especially a hot burning taste on awaking in the morning. This is due to some abnormal products of the later part of the digestive act, and is often a troublesome symptom. In certain cases there is a sour taste in the mouth, less com- monly a sweet taste, or the saliva may be clammy with a sensation of heat in the mouth; this is commonly found along with constipation. " Headache " is a very common outcome of dyspepsia. It varies in character from a dull weight to acute agony. It may be confined to the temples, the forehead, or the occiput; or it may be general. It may be accompanied by "swimming" in the head, or "intolerance" of light or of sound. At times the slightest sound is simply unbear- able; in other cases (comparative) ease can only be secured by lying in a dark room like the Rev. Mr. Irwine's sister Anne, in "Adam Bede." Miss Kate was sponging the aching head with fresh vinegar when he went into the room so darkened by blinds and curtains that Miss Kate could not knit at the best. " It was a small face, that of the poor sufferer; perhaps it had once been pretty, but now it was worn and sallow. Miss Kate came towards her brother and whispered—'Don't speak to her; she can't bear to be spoken to to-day.' Anne's eyes were closed, and her brow contracted as if from intense pain." Miss Anne Irwine's headaches were those of indigestion evidently; and very bad headaches they were ! They belonged to that variety which comes on the day after the meal which has provoked them; where there are some noxious pro- ducts of late digestion poisoning the half-starved brain. chap, m.] SYMPTOMS. 33 In such cases the duodenum is found to be the seat of morbid change, when the patient passes into the dead- house. In most cases the headache accompanies other evidences of gastric disturbance, and is felt early, or after a meal. The face is often flushed, and the hands and feet are cold. In many cases the hea*larhe is distinctly that of anaemia,—the blood being drawn to the abdominal viscera by the digestive act. There is often a sensation of " swimming in the head " felt along with the pain, or "dizziness." The pain in the vertex often experienced is symptomatic of cerebral anaemia. More distressing than the actual physical pain, is the sense of misery experienced by many. The mental dis- comfort, the sense of wretchedness, of utter unfitness for work, and inability to collect the thoughts, is to many dyspeptics their greatest trouble. The brain is disabled for the time, no matter what its capacity under favorable circumstances; and the sense of intellectual paralysis is very distressing. Here there is positive toxaemia, from abnormal products of digestion findino- their way into the blood ; as well as an insuffi- cient supply of blood to the brain. To brain-workers this is a o-reat drawback; indeed, the dyspeptic is handicapped very heavily in the race of competition to gain a living, or amass a fortune. The dyspeptic can earn less, and must spend more on (suitable) food than others do; and where the income is a small one, the dyspeptic is really to be pitied. Indigestion cuts down the individual far more than is generally credited. In the modern keen struggle for existence, the dyspeptic is like a man fighting with *>ne hand tied. 40 SYMPTOMS. [chap. m. This mental attitude of gloom, apprehension, distrust, and incapacity intensifies the physical discomfort, and tends to cause the sufferer to have misgivings that the malady is something more than mere indigestion. A haunting fear that the brain is the seat of disease where there is headache, the heart where there is palpitation or irregular action, tortures the unhappy sufferer. The remembrance of this impression hangs like a dark cloud over the intervals of comparative health; while the antici- pation of another attack is projected like a shadow thrown in front of it, indeed " coming events cast their shadows before." When there is great pulsation of the abdominal aorta the dyspeptic is worried with the apprehension that there may be an aneurysm present. There is, indeed, a panphobia, a general sense of dread, of impending evil which embitters the sufferer's existence, and every un- comfortable sensation is interpreted as an indication of structural disease somewhere. The physical suffering is aggravated by mental misery, compared with which it is as nothing: for peace of mind is rendered absolutely im- possible to the unfortunate dyspeptic; he, or she lives with the sword of Damocles hanging overhead. CHAPTER IV. SUITABLE FORMS OF FOOD. ARTIFICIAL DIGESTIVE FERMENTS. Having described the various disturbances of the digestive tract, interfering with the proper and ordinary assimilation of the main constituents of our dietary, starch, albuminoids, and fat ; it may be well to review the means of preparing the various forms of our food. Starch in its natural state, raw and uncooked, is scarcely digestible by man. In ani- mals, probably starch is mostly digested by the pancreatic diastase. But in man starch is largety digested by the salivary diastase. " It has been noted that the saliva of man possesses more diastatic power than that of almost any other animal. Among the herbivora, which are such large consumers of starch, the saliva has comparatively little diastatic power ; and in some, as the horse, it is almost altogether wanting. I apprehend that this is due to the fact that man alone has learnt to cook his starchy food, and that the diastatic power of his saliva has become developed with the opportunity for its exercise. Diastatic power would be thrown away in the saliva of the horse, because he eats his food in the raw or uncooked state, and saliva is almost without action on raw starch." This is a very interesting observation by Wm. Roberts, and as re- gards the horse, no attempt has been made to cook his food for him. But with the animals the farmer wishes to fatten for market, especially oxen, the cooking of their 42 SUITABLE FORMS OF FOOD. [chap. rv. food is regularly performed by our most advanced agri- culturist. Starch is prepared by cooking cereals previous •to their being given to cattle ; as it is found cheaper to so prepare the starch for fatting cattle, than to leave them to do the whole of their digestion for themselves. The Lincolnshire farmer has solved, in part at least, the prob- lem of the conversion of starch into sugar, or approaches thereto ; as well as the scientific physiologist. And one of the most instructive conversations on the means of prepar- ing starch for food, I ever remember listening to, was down in the Fens one evening, when some farmers were discuss- ing the subject of the cheapest means of fattening stock. It was soon cleaily apparent that they were working in precisely the same direction as the physiological physician moves, when he comes to diet a child with a weak digestion; with this difference—the physician desires to feed the child little regardless of the cost; while the farmer's aim is to produce so much fat at the least cost. When inspecting the measures adopted by Collinson Hall, at his large dairy farm in Essex, my attention was arrested by a huge heap in one of the rooms, where crushed oats and partially malted barley, were fermenting the starch into dextrine and maltose. In cooking starch the granule is cracked, and the starch largely gelatinised, so that the salivary diastase readily liquefies it, and converts it into soluble sugar. Durino- baking, starch, or part of it, is undoubtedly converted into dextrine. The action of yeast converts part of the starch into sugar, and this again into " alcohol and car- bonic acid gas ; the latter, in its efforts to escape from the chap, rv.] SUITABLE FORMS OF FOOD. 43 dough with which it is mixed, distends it, forming vesi- cular spaces in its interior, and so causing it to become porous and light. Much of the alcohol is dissipated in the process of baking " (A. Hill Hassall). Consequently we see that intuitively and without the light of science, man has commenced the artificial digestion of starch, when only a savage, and long- before the dawn of his- tory. We at the present are emerging out of the early darkness, and stepping forward by the morning light on the path to the artificial digestion of starch ; by so doing economising the body-energy which would otherwise be consumed in the conversion of insoluble starch into a soluble saccharoid, otherwise diastatic digestion. Conse- quently farinaceous materials are first ground and then cooked ; this constitutes the first part of the digestive act. Now it is a matter of no little hrTportance to understand intelligently how cooking may affect the digestibilitv of prepared starch. When farina is simply boiled or baked with milk, the preparation is at once simple and digestible, and the saliva is rapidly mixed therewith in the mouth. But when eggs are added, then the disintegration in the mouth is not nearly so perfect, and much more chew- ing is required ; because the coagulated albumen holds the starch granules together. .Consequently milk puddings for invalids are better made without eggs. Then again, everybody, medical and lay, knows how in- digestible is pastry of all kinds. When the farina and fat are closely mixed together in the act of "kneading the dough," the adhesive property of the gluten of flour is somehow so increased, that the act of mastication is 44 SUITABLE FORMS OF FOOD. [chap. iv. rarely equal to efficient disinteg-ration in those whose digestion is feeble. The stomach is incited to active muscular movements to continue the disintegration, and acute pain is experienced. A piece of pie-crust is rank poison to many dyspeptics. So is toasted cheese, which also resists the disintegrating action of the dyspeptic's stomach very effectually. Some persons cannot eat suet pudding, as ordinarily made, without a severe penalty from dyspepsia : but if the cook adds to the flour a cer- tain quantity of bread-crumbs, then the digestion of the pudding is painless. Gluten once cooked remains non- adhesive ; so the bread-crumbs cause the masses of pud- ding to readily fall to pieces in the stomach. Probably some baked flour would do just as well, if added to the ordinary flour. Maize flour is not nearly so adhe- sive, as its albuminoids are not in the form of tenacious gluten ; so much so, that without some wheaten flour it will not make leavened bread. Consequently, for the preparation of puddings, and still more for pastry for deli- cate children and dyspeptics, it would be well to add some maize flour to the ordinary flour. In precisely the same way we try to prevent milk forming too firm a curd in the stomach, by mixing with it some starch. The presence of the starch granules interferes with the solidity of the curd, and causes it to fall to pieces readily in the stomach. On the other hand, oysters are spoiled in cooking. "Our practice in regard to the oyster is exceptional, and furnishes a striking example of the general correctness of the popular judgment on dietetic questions. The oyster is almost the only animal sub- chap, iv.] SUITABLE FORMS OF FOOD. 45 stance which we eat habitually and by preference, in the raw or uncooked state; and it is interesting to know that there is a sound physiological reason at the bottom of this preference. The fawn-coloured mass which consti- tutes the dainty of the oyster is its liver, and this is little less than a mass of glycogen; associated with the glycogen, but withheld from actual contact with it dur- ing life, is its appropriate digestive ferment—the hepatic diastase. The mere crushing of the dainty between the teeth brings these two bodies together, and the glycogen is at once digested, without other help, by its own diastase. The oyster, in the uncooked state, or merely warmed, is, in fact, self-digestive. But the advantage of this provi- sion is wholly lost by cooking, for the heat employed im- mediately destroys the associated ferment, and a cooked oyster has to be digested, like airy other food, by the eater's own digestive power." This graphic description by Dr. Roberts tells us how it is that oysters au naturel are so much in vogue for invalids, as they deservedly are. Also, why oysters should not be cooked in oyster sauce, but put into the prepared sauce just as it comes to table. Why, as King Chambers insists, in a beef-steak pudding, the oysters should not be cooked, but a flap of the paste raised, and the oysters popped in, just as the pudding is served. In making oyster pates,, the paste is cooked in bread-crumbs, which is then taken out and the oysters put in; after which, the pates are just warmed, and no more, and then brought up to the dinner table. The idea that long cooking increases the digestibility of food, is not always correct. 46 SUITABLE FORMS OF FOOD. [chap. rv. But "cooking" is essentially a part of the digestive pro- cess, not only in man, but in some domesticated animals as well. The products vary according to the skill of the cook, and the adjustment of the process to what physiolo- gical knowledge tells us is correct and sound. When the cook makes a hash of meat already cooked, instead of making the gravy first, and when fully prepared then putting in the slices of meat, and just warming them before serving—the only way by which a hash is tolerable to a delicate stomach—she too often stews it well in the gravy, believing that thereby she increases its digestibility. But ask dyspeptics about meat so cooked a second time, and their tale of woe is most instructive. Now as to the effects of cooking upon the proteid ele. ments of our food. " It is this well-established fact, the easier digestibility of loosely-aggregated tissue, that has led me to repudiate raw meat in the diet of invalids. Cooking, the action of heat, disassociates organic tissues, destroys the cohesion of muscular fibres, and must, there- fore, render all kinds of meat easier to dissolve, to digest. To give meat raw, however finely chopped, is to forego all the advantages gained by judicious cooking, and to force on the digestive organs double work. Moreover, raw, uncooked meat may contain the ova of human entozoa, of the various species of tape-worms, and of the trichina" (James Henry Bennett, " Nutrition in Health and Dis- ease "). Again, Dr. Roberts writes: " With regard to the staple articles of our food, the practice of cooking it before- hand is universal. In the case of farinaceous articles, cooking is indispensable. When men under the stress of chap, iv.] SUITABLE FORMS OF FOOD. 47 circumstances have been compelled to subsist on the un- cooked grain of the cereals, they have soon fallen into a state of inanition and disease. By the process of cooking, starch is not merely liberated from its protecting enve- lopes, but it suffers a chemical change, by which it is transformed into a gelatinous condition, and this enor- mously facilitates the attack of the diastatic ferments. A change of equal importance seems to be induced in the proteid matter of the grain. I found that the gluten of wheat was incomparably more digestible, by both artificial gastric juice and by pancreatic extract, in the cooked than in the uncooked state. In regard to flesh meat the advan- tage of cooking consists chiefly in its effects on the connec- tive-tissue, and the tendinous and aponeurotic structures^ associated with muscular fibre. These are not merely softened and disintegrated by cooking, but are chemically converted into the soluble and easily digested form of gela- tin. I made some instructive observations on the effects of cooking on the contents of the egg. The change in- duced by cooking on egg-albumin is very striking. For the purpose of testing this point I employed a solution of egg-albumin, made by mixing white-of-egg with nine times its volume of water. This solution when boiled in the water-bath does not coagulate nor sensibly change its ap- pearance, but its behaviour with the digestive ferments is completely altered. In the raw state this solution is at- tacked very slowly by pepsin and acid, and pancreatic ex- tract has no effect on it; but after being cooked in the water-bath, the albumin is rapidly and entirely digested by artificial gastric juice and a moiety of it is rapidly di< 48 SUITABLE FORMS OF FOOD. [chap. rv. gested by pancreatic extract." The employment of raw meat pounded is therefore not an advantage though advo- cated by some medical men. Personally I have never seen a case in which raw meat seemed to be indicated. The connective-tissue which binds the fibrillae of muscle to- gether, is so acted upon by heat, in cooking, that the fibres fall readily to pieces in the stomach; and so are easily acted upon by the solvent gastric juice. Mastication or chewing breaks down the masses of meat, and their dis- integration is completed by the gastric movements. Mastication, as a disintegrating matter, is separable from the admixture of starch with saliva in the act of chewing. So is the disintegrating action of the stomach 'separable from the solvent action of the gastric saliva. Mastication exerts no influence upon albuminous matters, of a solvent character; nor does the action of the stomach affect fats, except by the solution of the albuminous enve- lopes which surround fat as found in the bodies of animals. There is a digestive act in mastication, viz., the conversion of starch into sugar by the salivary diastase: and a pre- paration of albuminoids, for the action of the gastric juice. In the stomach there is the digestion of proteids, and the preparation of fats for the action of the bile and the pan- creatic secretion, by the digestion and solution of the albuminous envelope of animal fat—the. connective-tissue in which the fat globules are stored in the body. There is then preparation for coming acts, as well as actual solvent action in mastication, and the gastric portion of digestion. Now, meats differ in their digestibility according to their closeness of fibre, and the firmness with which the fibres chap, rv.] SUITABLE FORMS OF FOOD. 49 are bound together. Pork, veal, beef, mutton, lamb, stand in the inverse order of their digestibility as regards the readiness with which their fibres fall asunder. The effects of cooking upon the fibre itself probably being much the same, viz., the effect of heat upon albumen in rendering it more easily acted upon by pepsin and trypsin. The hare and rabbit are fairly digestible as to disintegration. Then come the flesh of fowls of all kinds; the finer fibre of game being specially digestible. Then comes the flesh of fish; for reptiles are not a part of an ordinary diet. But fish varies—the Tunny fish tribe are hard of digestion. Salmon is often digested with difficulty, and so is fried sole. It is not merely the question of the firmness or looseness of fibre only, there is the method of cooking; where the fibres are soaked in fat, a weak stomach cannot digest them com- fortably ; there is dyspepsia often with the eructation of a fatty acid. Then, all kinds of white fish are most digesti- ble, especially when boiled. The disintegration of muscu- lar fibre in the preparation of meats for potting is complete; with them the solvent part of the digestive act is alone required. On thin stale bread with the butter in limited quantities and well rubbed into the tiny holes and inter- stices of (stale) bread, and then a little potted meat spread over, a very digestible little meal is obtained. Such sand- wiches with a cupful of beef tea are specially indicated where the patient cannot take milk. Then there are the vegetable albuminoids especially the pulse tribe, or legumes, which are capitally disintegrated by cooking, and best by boiling or baking. Thus beans, hari- cots and broad, peas, lentils, dahl, &c, are all well broken 3 50 SUITABLE FOUMS OF FOOD. [chap. rv. up by heat. The disintegrated flour can easily be passed through a sieve, and then the disintegration factor of the digestive act is disposed of. There can be no question about the fact that with some persons vegetable albu- minoids are much more easily digested than animal albu- minoids; and I quite agree with Sir Henry Thompson in his remarks upon this subject. Besides too, fat spreads easily over the disintegrated particles of cooked vegetable albuminoids, as is well seen in the baked beans and fat pork of New England. Indeed by such means fat can often be taken without offence to a stomach, that cannot other- wise tolerate it; and much of the digestibility of fat de- pends upon the fineness of the particles into which it is sub-divided. Haricot beans well boiled passed through a sieve, and then the floury part mixed with milk makes an excellent soup ; quite equal in food value to any made with meat stock. The ordinary lentil soup is at once a most economical and a most valuable soup for ordinary persons; though scarcely perhaps quite adapted for persons with in- digestion. But " the proof of the pudding is in the eating thereof,"—if it does not disagree, there is certainly no ob- jection to its use. " Now a few words as to the digestion of milk caseine. As milk it is the most digestible of proteids, i.e., with those with whom it agrees. It differs in its digestion from other forms of albumen. "Milk is much more easily digested by pancreatic extract than by artificial gastric juice; but in the case of egg-albumen the advantage lies decidedly with the gastric juice." Using the one part in ten of water solution of egg-albumen and boiling it in the water bath, chap, iv.] SUITABLE FORMS OF FOOD. 51 Dr. Roberts found with pepsin and hydrochloric acid the transformation went on swiftly and without interruption to its close. Whilst the pancreatic ferment was only able to convert a part of the albumen into peptone. There is one point of the greatest practical moment about the obser- vation, and it is this—When meat or egg digestion is to be artificially aided it is well to use pepsin and hydrochloric acid. But when the digestion of milk is to be practically assisted by a digestive ferment, it is desirable to use trypsin; the pancreatic secretion in an alkaline vehicle. " Tryptic digestion of milk is rapid and leaves only a very slight resi- due—whereas peptic digestion of milk is slow, and leaves a large residue." In order to secure exact results it is therefore essential to use precise means, guided by the light physiological ob- servation is throwing upon this hitherto obscure subject of digestion. And now to the consideration of the third division of the subject, the digestion of fats. We do not know as yet any change exercised upon fat by heat, by the act of cooking, except that of rendering it fluid. Certainly cooking renders fat more toothsome, and in the case of fat exposed directly to great heat, as in the case of the fat of a beef steak, or a mutton chop, the action of the heat upon the albuminous capsule of the adipose tissue, is to make it decidedly tasty. But heat does liquefy fat, and separates (we believe) olein, from stearin and mar- garin. The liquid portion of fried bacon is digested by many who cannot digest the solid portion of bacon fat. This is a well-known fact. The fluid is the olein. Fats 52 SUITABLE FORMS OF FOOD. [chap. rv. vary in their digestibility. The late Dr. John Hughes Bennett said: "The main causes of tuberculosis were the dearness of butter and the abundance of pastrycooks; the poor not getting sufficient fat, and the upper classes dis- ordering their digestion by puff paste." Now butter con- sists of the fat globules of milk removed from their envelopes of caseine by the act of churning ; thus getting rid of the albuminous envelope which is one of the difficul- ties in the digestion of animal fat. How far it is this en- velope; how far it is the presence of firm stearin which constitutes the difficulty in the digestion of animal fats, in each case; we can not always say. Then again to speak broadly, the lower the temperature at which fat ceases to be liquid the easier its digestion. In the best cod-liver oils, the stearin and margarin are taken out by freezing; the liquid olein being poured off. Beef fat and mutton suet are less digestible than lard, bacon dripping, and butter; the latter only becoming firm at a much lower temperature than is sufficient to render beef and mutton suet hard. Cod-liver oil is the most easily digestible of all forms of fat. In that lies its great utility. It can be digested when other fats are beyond the reach of the diges- tive processes. Some have thought this due to the basyle with which the fatty acids are in union, being propvline, instead of glycerine, like other fats. " Others, again, have attributed it to the minute quantities of iodine; and others to the biliary matters found in the oil ; the last seems far the most reasonable supposition " (Lauder Brunton). In addition to this there seems to be something in the pre- sence of a little free fatty acid, as found in certain cod* chap, rv.] SUITABLE FORMS OF FOOD. 53 liver oils. " The different behavior of two specimens of the same oil, one perfectly neutral, and the other containing a little free fatty acid, is exceedingly striking. I have here before me two specimens of cod-liver oil—one of them is a fine and pure pale oil, such as is usually dispensed by the better class of chemists ; the other is the brown oil sent out under the name of De Jongh. I put a few drops of each of these into these two beakers, and pour on them some of this solution, which contains two per cent, of bicarbonate of soda. The pale oil you see is not in the least emulsi- fied ; it rises to the top of the water in large clear globules: the brown oil on the contrary yields at once a milky emul- sion. The pale oil is a neutral oil, and yields no acid to . water when agitated with it—in other words it is quite free from rancidity; but the brown oil when treated in the same way causes the water with which it is shaken to redden litmus paper." (When the inhabitant of Arctic regions prefers his fat rancid, probably he is only following out what experience has taught him is good in his liberal con- sumption of fat). " The bearing of these observations on the digestion of fat is plain. When the contents of the stomach pass the pylorus they encounter the bile and pan- creatic juice, which are alkaline, from the presence in them of carbonate of soda. So that the fatty ingredients of the chyme, if they only contain a small admixture of free fatty acids, are at once placed under favourable circum- stances for the production of an emulsion without the help of any soluble ferment, the mere agitation of the contents of the bowels by the peristaltic action being sufficient for the purpose " (Roberts). Possibly some fats containing a 54 SUITABLE FORMS OF FOOD. [chap. rv. large proportion of oleine emulsionise more readily than others. But the whole subject is in its infancy so far as our acquaintance with it is concerned. Certainly in some cases of imperfect digestion of fats it seems that a pill con- taining some dried oxgall and castile soap, taken an hour or so after food, is indicated as likely to be of service. After this review of the digestion of the different ingre- dients of our food, we can see the digestion of, Starch by saliva and pancreatic diastase ; Proteids by pepsin and trypsin ; Fat by pancreatic secretion ; will lead us to the proper and exact use of artificial diges- tive agents : about which at present the wildest confusion obtains both by the manufacturing chemists and the pro- fession generally. The chemists may take umbrage at this statement, but they will find a difficulty in disposing of it. When malt preparations are directed to be taken after food when the stomach is acid, that is at the time when the sali- vary diastase, or its vegetable substitute is at once rendered inert ; when malt extract is added to cod-liver oil directed to be taken " during or immediately after a meal," an ad- mixture which is certainly palatable ; but the vegetable diastase is little likely to be operative in the acid stomach, while the oil is taken too soon to be acted upon : a com- bination which is certainly not physiological ; and when an emulsion of cod-liver oil and pepsin is commended by the British Medical Journal in a recent review, dead in the teeth of all that physiology teaches us (March 19th, 1881).* * "Peptodyn, a combination of the whole of the digestive secretions— pepsine, pancreatine, diastase or ptyalin, etc., forming a valuable remedy chap, rv.] SUITABLE FORMS OF FOOD. 55 It may now be well to consider the use of Artificial Digestive Agents in practice. First it may be desirable to consider their use as addi- tions to the natural digestive ferments ; and then to pro- ceed to the use of artificially digested food. Starch is digested by the salivary diastase while the food is being chewed, and in the stomach before, and until its contents are acid ; and afterwards by the diastase of the pancreatic secretion. The latter can best be discussed when artificial pancreatic secretion is spoken of ; the sali- vary diastatic action alone will be reviewed now. Starch is converted into sugar, is transferred from an in- soluble to a soluble matter by the action of diastase of the saliva. It is equally well acted upon by the diastase pre- pared from cereals, i.e., the digestive diastase of the embryo- plant. Such preparations under different names as " malt extract," "maltine," &c, are now placed upon the market by enterprising manufacturing chemists. They are mainly given to children ; though there exists no reason why they should not be more largely given to adults. In their adop- tion it must be borne in mind they act upon starch solely and exclusively, and have no effect upon other articles of our food. Sugar does not require them ; it is soluble in the treatment of dyspepsia, and diseases arising from imperfect nutri- tion—dose, 3 to 5 grains." This compound, or rather "jumble," to be taken apparently any time the patient prefers, is a marked illustration of what is written above as to disregard of time and place of the portions of the digestive act. (This is advertised in the " British Medical Journal," April 22nd, 1881.) 56 SUITABLE FORMS OF FOOD. [chap. rv. without a ferment. But for starch, liquefaction precedes saccharification. Consequently "malt diastase " should be given so that it may be operative before the contents of the stomach become acid. It should then be added to milk- gruel, and milk puddings, before they are taken ; or at latest immediately after they are swallowed, and before the other articles of a meal are eaten. Thus with children, their milk porridge, made with oatmeal, hominy, or crushed cereals, should be taken first for breakfast with the malt with them, or immediately afterwards ; after an interval a little fat bacon or cold meat, (ham is to be preferred), may be added, with bread and a little cocoa, or coffee with cream in it. Such would be a scientific and physiological use of vegetable diastase ; which is a treacly-looking thinsr as usually seen, of sweet taste, and therefore well adapted to admixture with milk porridge immediately before being supped; or by itself immediately afterwards. While chil- dren are suckling there is little natural diastase found, and it is not till the sixth or seventh month that it is found in the saliva in sufficient quantity to be operative. "Until this period it is therefore not advisable to administer fari- naceous food to infants." It would seem the irritation set up by the teeth excites more efficient secretion in the salivary glands. If malt diastase cannot be given as recommended above, it will be well to continue the digestion of starch by resort to artificial pancreatic secretion. At least, that is the con- clusion warranted by the present state of our knowledge. Proteids, or albuminoids, are the matters speciallydi- gested in the stomach. "Proteids are attacked bv the chap, rv.] SUITABLE FORMS OF FOOD. 57 digestive ferments at two points in the alimentary canal; by pepsin in the stomach, and by trypsin in the small in- testine. Between these two acts of digestion there is a complete break in the duodenum, owing to the abrupt change of reaction, from acid to alkaline, which occurs at that point. Gastric digestion is, in all creatures, an essen- tially acid digestion." At the present the acid gastric digestion of proteids by pepsin is being considered exclu- sively. The observations of Dr. Beaumont upon Alexis St. Martin, who had the front wall'of the stomach and abdo- men blown away by a gunshot wound, were made at a time when our physiological knowledge was too imperfect to be much guide to him. More recentlv C. Richet had an opportunity of examining the act of g-astric digestion in a young man whose stomach was artificially opened for a stricture of the gullet. Thus our knowledge is not con- fined exclusively to the observations made upon animals. " Richet found that the acidity of the contents of the sto- mach during digestion, although it varied through con- siderable limits, had a marked tendency to maintain the normal average. If acid or alkali were added to the di- gesting mass the mean was presently restored automati- cally—the stomach in the former case ceasing to secrete acid, and in the latter case secreting an increased quantity of acid." Gastric juice contains a digestive ferment only active in an acid medium. "The reaction is distinctly acid, and the acidity is normally due to free hydrochloric acid. This is proved by the fact that the amount of hydro- chloric acid is more than can be neutralised by the bases 3* 58 SUITABLE FORMS OF FOOD. [chap. rv. present. Lactic acid and butyric and other acids when present are secondary products, arising either by their re- spective fermentations from articles of food, or from de- composition of their alkaline or other salts" (M. Foster). To aid this portion of the digestive act when defective we give pepsin, with or without an acid—usually with hydrochloric acid. Pepsin is precipitated by alcohol in great quantity. It is sold as a wine, but it is better prepared with glycerine. It is sold by chemists in various preparations. It is com- monly sold or prescribed along with hydrochloric acid. " In gastric juice there is a strong tie between the acid and the ferment, so strong that some writers speak of pepsin and hydrochloric acid as forming a compound pepto-hydro- chloric acid" (M. Foster). "The essential property of gastric juice is the power of dissolving proteid matters, and of converting them into peptones " {Ibid.). When then we resort to the use of pepsin as an artificial digestive agent, we must clearly bear in mind that it is the digestion of albuminoids solely, that we can assist by its means. It should be given after a meal has been taken, when the natural gastric solvent is being poured out, in order to assist that solvent in its digestive action. It is then useless to add it to cod-liver oil; if it be desir- able to administer both these agents, let the pepsin be given early after a meal, when it will be serviceable; and then afterwards the oil, when its time arrives. But to combine them is simply to set the lessons of physiology at defiance; to ignore the place and time of the different factors in the digestive act. chap, rv.] SUITABLE FORMS OF FOOD. 59 We now come at last to the digestion of fat. Hitherto, neither in the diastatic digestion of starch, nor in the gastro-pepsin digestion of albuminoids, has fat been acted upon. The fat of adipose tissue is liberated from its albu- minoid envelope in the stomach—that is all.* But when the contents of the stomach pass the pyloric ring into the duodenum, and are mixed with the bile, then fat com- mences to undergo a transformation. It is not digested by any change, or metabolism in its chemical composition, any hydration by the addition of a molecule of water, as is the case when starch is converted into sugar, and pro- teids into peptones; it is, so far as we yet know, merely emulsionised. This emulsionising of fat, by the reduction of it to minute globules, renders it small enough to be taken up bv the intestinal villi; without such emulsionis' ino- fat could not enter the tiny terminal endings of the lacteals in the villi of the intestine. For such emulsifica- tion, an alkaline medium is essential. The bile renders the food acid in the stomach, alkaline in the intestines. In an alkaline medium the pancreatic secretion is active; and in an alkaline medium only. In this alkaline medium * Probably even the digestion of the albuminous envelope goes on in the stomach to a limited extent only. As the envelope is digested, the free fat remains, and so prevents the acid gastric juice from acting upon the centre of the piece of adipose tissue. Thus the periphery only is digested in the stomach. In the alkaline medium, so soon as trypsin dis- solves the albuminous corpuscles, the fat, so freed, is emulsionised. and thus the trypsin can act upon the internal portion. Thus the digestion of fat, even as adipose tissue, is mainly the work of the pancreas aided by the bile. 60 SUITABLE FORMS OF FOOD. [chap. rv. the pancreatic diastase resumes the digestion of starch; trypsin converts proteids into peptones; and fat is further emulsionised. So we see that when fat assimilation is de- fective, the use of an artificial pancreatic secretion aids the further digestion of starch and albuminoids, as well as acting upon fat. Consequently when we resort to an arti- ficial pancreatic secretion, we must take care to see that it is not killed, or rendered inoperative for ever by some gastric acid remaining in the stomach. It is this " acid gulf " in the stomach which we have to guard against, else our artificial pancreatic secretion is useless, of no earthly avail. It is necessary then to protect the artificial pan- creatic secretion by a solution of soda; and soda is un- palatable, to put it mildly. Dr. Roberts therefore advo- cates ten or fifteen grains of bicarbonate of soda, to be taken with the dose of Liquor Pancreaticus at " the tail of the digestive act." This passes it safely through the stomach: just as a guard of soldiers sees a merchant con- veyed over an unsettled frontier infested by robbers. What- ever preparation of pancreatine be adopted there seems nothing for it but the alkaline guard to see it through the stomach. An oil emulsionised by the admixture of a small quantity of bile and a small amount of pancreatic secretion would, in all probability, aid the natural pan- creatic digestion. On this matter, however, we can only speculate in theory; clinical facts alone can positively de- termine the matter. The proper time to administer the artificial pancreatic secretion, is when the contents of the stomach are finally escaping through the pyloric rino-, at least an hour and a half after an ordinary meal. The chap, rv.] SUITABLE FORMS OF FOOD. 61 time varies in different individuals, and how to determine this we do not yet know. But when the gastric digestion is over no more juice is secreted, and what has been se- creted has probably spent itself upon the food-contents of the stomach. The alkali neutralises any remaining acid, and so protects the trypsin from the deadly effects of an acid upon it. Soda is the natural alkali in bile ; and therefore the alkaline guard of the trypsin should be a solution of soda. So used and guarded artificial pancreatic secretion con- tains the greatest promise in dyspeptic cases. A four- ounce bottle of Liquor Pancreaticus contains 32 doses of one teaspoonful (that is an old-fashioned small teaspoon) or rather one drachm each. To give 32 doses of bicarbo- nate of soda (fifteen grains), involves a solution of one ounce of the soda in sixteen ounces of water ; dose, one tablespoonful with each teaspoonful of Liquor Pancreati- cus. In many cases the administration of Liquor Pancreaticus causes the most satisfactory improvement in the patient's condition. The muscles become plump; the subcutaneous fat once more fills out the wrinkled skin; the brain is fed; and with this comes back the lost sense of energy,of fitness for work. In some cases the disablement of the digestive organs is such that it becomes imperatively necessary to resort to artificially digested food. This is much better than feed- in o- by the bowel, which soon becomes so painful that it is impossible to continue it. Feeding by enemata is a last resource, only to be adopted in critical emergencies, when 62 SUITABLE FORMS OF FOOD. [chap. rv. it is invaluable; but it can only be resorted to for a brief period. In acute gastric disturbance, in catarrh, ulcer, and cancer, it is well to do away with the necessity for movement in the stomach as far as lies in our power, by giving the food already digested to a great extent. Milk and milk-gruel can readily be digested by the methods advocated by Dr. Roberts, to be given shortly. Partially digested foods can be purchased; but person- ally, I have never prescribed them. But milk and milk- gruel digested by the Liquor Pancreaticus, have done me Veoman service in many an intractable case. They are prepared as follows, and the enema appended is worthy of careful consideration; when an enema has to be resorted to, it is highly important that it have as high a food value as can be given to it. In thus giving Dr. Roberts' directions verbatim, I am hopeful that the perusal of them will incline many readers to order the liquor pancreaticus for their patients, who, without the formulae, might not see the practical forms in which it may be made useful. If, in doing so, I can in- cline some to try this preparation who might otherwise have remained unacquainted with it, it will be gratifving; and will make some amends for the loan of them to me for my book. Here the reader will see a great manv forms of food which can be peptonised with advantage, and with- out destroying their toothsomeness. For the purposes of general indigestion, the liq. pan- creaticus is mainly indicated, and will be found to be of much advantage. In those cases of imperfect assimilation of albuminoids, chap, rv.] PEPTONISED FOOD. 63 where there is a plentiful supply of fat in the body, but the muscles are flabby and ill-nourished; or in those cases where there is pain and discomfort immediately after food, —the cases in which the late Dr. Arthur Leared said there was dyspepsia from "insufficiency of gastric juice;" it may be well to give the liquor pepticus. i.—For the Preparation op Peptonised Food. In peptonising or partially-digesting food by means of "Liquor Pancreaticus (Benger)," it is important to remem- ber that the liquor must not be added to food of any kind at a higher temperature than 140° Fah. This temperature can be estimated with sufficient accuracy, should no suit- able thermometer be at hand, by tasting. If too hot to sip without burning the mouth, it would entirely destroy the activity of the liquor pancreaticus, and must be al- lowed to cool before such addition is made. Peptonised Milk.—A pint of milk is diluted with a quarter of a pint of water, and heated to a temperature of about 140° F. (60° C), (or the diluted milk may be divided into two equal portions, one of which may be heated to the boiling point and then added to the cold portion, the mix- ture will then be of the required temperature.) Two or three tea-spoonfuls of liquor pancreaticus, together with ten or twenty grains of bicarbonate of soda (about half a small tea-spoonful) are then mixed therewith. The mix- ture is then poured into a covered jug, and the jug is placed in a warm situation under a cosey, in order to keep up the heat. At the end of an hour, or an hour and a half 64 PEPTONISED FOOD. [chap. rv. the product is boiled for two or three minutes. It can then be used like ordinary milk. The object of diluting the milk is to prevent the curdling which would otherwise occur and greatly delay the peptonising process. The addition of bicarbonate of soda prevents coagulation during the final boiling, and also hastens the process. The pur- pose of the final boiling is to put a stop to the ferment action when this has reached the desired degree, and there- by to prevent certain ulterior changes which would render the product less palatable. The degree to which the pep- tonising change has advanced is best judged of by the development of the bitter flavour. The point aimed at is to carry the change so far that the bitter taste is distinctly perceived, but is not unpleasantly pronounced. The ex- tent of the peptonising action can be regulated either by increasing or diminishing the dose of the liquor pancreaticus or by increasing or diminishing the time during which it is allowed to operate. By skimming the milk beforehand, and restoring the cream after the final boiling, the pro- duct is rendered more palatable and more milk-like in ap- pearance. Peptonised Gruel.—Gruel may be prepared from any of the numerous farinaceous articles which are in common use—wheaten flour, oatmeal, arrowroot, sago, pearl barley, pea or lentil flour. The gruel should be very well boiled, and made thick and strong. It is then poured into a covered jug, and allowed to cool to a temperature of about 140° F. Liquor pancreaticus is then added in the propor- tion of a table-spoonful to the pint of gruel, and the jug is kept warm under a cosey, as before. At the end of a chap, iv.] PEPTONISED FOOD. 65 couple of hours, the product is boiled, and finally strained. The action of the pancreatic extract on gruel is two-fold: the starch of the meal is converted into sugar, and the albuminoid matters are peptonised. The conversion of the starch causes the gruel, however thick it may have been at starting, to become quite thin and watery. Peptonised gruel is not generally, by itself, acceptable food for in- valids, but in conjunction with peptonised milk (pepton- ised milk-gruel), or as a basis for peptonised soups, jellies, and blanc-manges it is likely to prove valuable. Peptonised Milk-Gruel.—This is the preparation of which I have had the most experience in the treatment of the sick, and with which I have obtained the most satis- factory results. It may be regarded as an artificially di- gested bread and milk, and as forming by itself a complete and highly nutritious food for weak digestions. It is very readily made, and does not require the thermometer. First, a good thick gruel is prepared from any of the farinaceous articles above mentioned. The gruel, while still boiling hot, is added to an equal quantity of cold milk. The mixture will have a temperature of about 125° F. (52° C). To each pint of this mixture, •two or three tea- spoonfuls of liquor pancreaticus and twenty grains of bi-, carbonate of soda (half a small tea-spoonful) are added. It is then kept warm in a covered jug under a 'cosey,' for a couple of hours, and then boiled for a few minutes, and strained. The bitterness of the digested milk is almost completely covered in the peptonised milk-gruel ; and in- valids take this compound, if not with relish, without the least objection. 66 PEPTONISED FOOD. [chap. iv. Peptonised Soups, Jellies, and Blanc-M/<.s.—I have sought to give variety to peptonised dishes by preparing soups, jellies, and blanc-manges containing peptonised aliments. In this endeavor I have been assisted by a member of my family, who has succeeded beyond my ex- pectations. She has been able to place on my table soups, jellies, and blanc-manges, containing a large amount of di- gested starch and digested proteids, possessing excellent flavor; and which the most delicate palate could not accuse of having been tampered with. Soups were pre- pared in two ways. The first way was to add what cooks call ' stock ' to an equal quantity of peptonised gruel or peptonised milk-gruel. A second and better way was to use peptonised gruel, which is quite thin and watery, in- stead of simple water, for the purpose of extracting shins of beef and other materials employed for the preparation of soup. Jellies were prepared simply by adding the due quantity of gelatine or isinglass to hot peptonised gruel, and flavoring the mixture according to taste. Blanc- manges were made by treating peptonised milk in the same way, and then adding- cream. In preparing all these dishes, it is absolutely necessary to complete the operation of peptonising the gruel or the milk, even to the final boiling, before adding the stiffening ingredient. For, if liquor pancreaticus be allowed to act on the gelatin, the gelatin itself undergoes a process of digestion, and its power of setting on cooling is utterly abolished. Peptonised Beef-Tea.—Half a pound of finely minced lean beef is mixed with a pint of water and twenty grains (half a small tea-spoonful) of bicarbonate of soda. This is chap, rv.] PEPTONISED FOOD. 67 simmered for an hour and a half. When it is cooled down to about 140° Fahr. (60° C.) a table-spoonful of the liquor pancreaticus is added. The mixture is then kept warm under a cosey for two hours, and occasionally shaken. At the end of this time, the liquid portions are decanted and boiled for five minutes. Beef-tea prepared in this way is rich in peptone. It contains about 4.5 per cent, of organic residue, of which more than three-fourths consist of pep- tone ; so that its nutritive value in regard to nitrogenised materials is about equivalent to that of milk. When sea- soned with salt, it is scarcely distinguishable in taste from ordinary beef-tea. Another way.—One pound of finely minced lean beef is mixed with a pint of water, and simmered for an hour and a half. The resulting beef-tea is then decanted off into a covered jug. The undissolved beef-residue is beaten with a spoon into a pulp or paste, and added to the beef-tea in the covered jug. When the mixture has cooled down to 140° Fahr. (or when it is cool enough to be tolerated in the mouth), a table-spoonful of the liquor pancreaticus is added, and the whole well stirred together. The covered jug is then kept warm under a cosey for two hours ; at the end of this time the contents of the jug are boiled briskly for two or three minutes and finally strained ; it is then ready for use. The extreme solubility of digested products, whether of starch or of proteids, detracts from their acceptability to the healthy. To them they appear thin and watery; they miss the sense of substance and solidity which is charac- teristic of their ordinary food. But to the weak invalid without appetite, this sense of substance or thickening is 68 PEPTONISED FOOD. [chap. rv. generally an objection, and they take with more ease an aliment which they can drink like water. The jellies and blanc-manges, on the other hand, give to invalids of more power that sense of resistance and solidity which is desired by those of stronger appetite. The greater variety which can now be given to this form of food will obviate the monotony sometimes complained of under the continuous use of peptonised milk-gruel. The Use of liquor Pancreaticus as an Addition to Food shortly before it is Eaten.—Certain dishes commonly used ,by invalids—farinaceous gruels, milk, bread and milk, milk flavoured with tea, or coffee or cocoa, and soups strengthened with farinaceous matters or with milk—are suitable for this mode of treatment. A tea-spoonful or two of the liquor pancreaticus should be stirred up with the warm food as soon as it comes to table. And such is the activity of the preparation that, even as the invalid is engaged in eating—if he eat leisurely, as an invalid should—a change comes over the contents of the cup or basin ; the gruel becomes thinner ; the milk alters a shade in colour, or perhaps curdles softly; and the pieces of bread soften. The transformation thus begun goes on for a time in the stomach ; and one may believe that, before the gastric acid puts a stop to the process, the work of digestion is already far advanced. This mode of administering liquor pancreaticus is simple and convenient. No addition of alkali is required, and of course no final boiling. The only precaution to be observed is that the temperature of the food, when the extract is added, should not exceed 150° F. (65° C). This point is very easily ascertained ; for no liquid can chap, rv.] PEPTONISED FOOD. 69 be tolerated in the mouth, even when taken in sips, which has a temperature above 140° (60° C). If, therefore, the food is sufficiently cool to be borne in the mouth, the liquor pancreaticus may be added to it without any risk of injur- ing the activity of the ferments. 2.—For Medicinal Administration. When given with a view of aiding the digestion of starch}'- food, one or two teaspoonfuls should be admin- istered in a little water with meals. Taken in this way it acts in the same manner as Malt Extract, but much more powerfully. When liquor pancreaticus is given with a view of aid- ing intestinal digestion, one or two tea-spoonfuls, with a pinch of bicarbonate of soda, dissolved in half a wine-glass of water, should be taken two or three hours after a meal. 3.—Liquor Pancreaticus as an Addition to Nutritive * Enemata. Liquor pancreaticus is peculiarly adapted for adminis- tration with nutritive enemata. The enema may be pre- pared in the usual way with milk-gruel and beef-tea ; and a dessert-spoonful of liquor pancreaticus should be added to it just before administration. In the warm temperature of the bowel, the ferments find a favorable medium for their action on the nutritive materials with which they are mixed; and there is no acid secretion to interfere with the comple- tion of the digestive process, or the preparations of pepsin, or of the vegetable papuan, which is a most potent agent in the digestion of albuminoids—vegetable though it be. CHAPTER V. TISSUE NUTRITION. " From the food the blood is fed ; from the blood tho tissues are fed." In the first place, then, we must have healthy blood for the formation and maintenance of healthy tissues. The blood in its ceaseless round carries pabulum to the tissues of the body. The little artery, with its vitalizing fluid, carries a supply of albu- minoid material to the tissues in excess of their wants. A large quantity flows on through the capillaries into the corresponding venule, and soon rejoins the bulk of the circulating fluid. A portion of the serum passes through the capillary walls and feeds the tissue ; the surplusage being taken up by the lymphatics, and so preserved for future use. It is desirable to have clear views about this matter of tissue-nutrition. The whole of the serum does not flow through the capillaries into the small veins, a part passes into the tissues. In order to maintain a balance betwixt the parts and their supply of pabulum, there is the lymphatic vessel. The surplusage is taken up by this lymphatic, and returned to the blood by the thoracic duct. Thus the surplusage is removed from the tissue and saved from waste, or even being positively harmful. If the surplusage were not removed, there would be over-nutrition of the part with hypertrophy. Thus, when John Hunter placed a cock's spur in a cleft made in the bird's comb, the spur grew to a most abnor- chap, v.] TISSUE NUTRITION. 71 mal extent. When there is a disturbance in this natural balance betwixt supply and demand, then hypertrophy is the result. The son of a friend of mine wore a high shoe on one foot. But the high shoe was on the sound leg. He had a great enlargement of the other leg from obstruction in the lymphatics, and it grew disproportion- ately from the excess of nutritive fluid in the tissues; so much so, that he had to wear a high shoe on the foot of the normal limb. Such elongation of limbs from chronic inflammation in their joints, is a not-uncommon phenomenon. Wc know that when the venous system is engorged from valvular disease of the heart, we get a development of pathological connective-tissue in the different viscera, especially the liver, spleen, and kidneys; though the lungs, the brain, and the uterus, may be enlarged, or rendered of denser texture, or both. Around a chronic ulcer there is a vas- cular zone, which produces epidermal scales in excess, and on which the hairs grow to a gigantic size. Some diseases tend to produce local disturbances of nutrition, notably syphilis, and struma. Syphilis produces nodes under the periosteum, and gummata elsewhere,—active proliferation of connective-tissue corpuscles. Cancer is the production of histological elements out of place or out of time. Scirrhus is cartilage where no cartilage should be. Colloid, so often found in the ovaries, is only the sarcode of the umbilical cord. Osteocephaloma is a growth of cells from the bone identical with the cells of the mar- row of the foetal bones. It is then not truly heteromorphic; it is normal tissue, out of place, or out of time. Colloid 72 TISSUE NUTRITION. [chap. v. m the ovaries, marrow cells in the cancer springing from bone; these tell of an association which is certainly not accidental. Struma is essentially a disease of hyperplasia of connec- tive-tissue; a growth, in excess, of cells of inferior quality. The enlarged glands, the thickened epiphyses of the lon;^ bones; what are they but hyperplasia of elements found there normally ? The neoplasm is an inferior or degraded form of cell-life; nothing strictly new. In tubercle, there is a growth of lowly cells along the course of the tiny arteries. These imperfect cells crowd upon each other; and if this crowding goes so far as to press upon the nutrient arterioles, then there is danger of their death, of molecular necrosis. Thus tubercle softens, breaks down, and is expectorated. If the crowding* of these imperfect cells in a gland passes a certain point, the gland structure breaks down into a scrofulous abscess. It is the same method of procedure, viz., the development of cell ele- ments about the nutrient vessels, which causes the ripe apple to drop off; which fills up two of the three holes in a cocoa-nut, and then gradually fills up the third, till the fibres can no longer bear the weight, the nut drops off from its attachment, and comes to the ground. So when the abnormal cell elements accumulate till thev press on the nutrient arteriole, the part so cut off from its pabulum, dies. Thus we find we have disturbances of tissue—nutrition in the direction of excess—of excess of quantity with deterioration of quality. Then there is atrophy from mal-nutrition, local or general. Phthisis, consumption, or a "wearino-," the chap, v.] TISSUE NUTRITION. 73 old vulgar term for wasting disease, is general mal-nu- trition from impairment of the digestive and assimilative processes. Then we see persons, at other times, with flabby ill-fed muscles, yet well clad with fat. Their adipose tissue is sufficiently fed, but npt their muscles. Here there is de- fective assimilation of albuminoids, while the digestion of starch and fat is normal and unaffected. Indeed, as is well seen in chlorotic girls, there is an inverse proportion established, the muscles are flabby, while there is a posi- tive accumulation of fat. They are breathless ; partly because they are anaemic, partly because their heart and diaphragm are half-starved. The assimilation of albu- minoids is impaired, and especially is the formation of that complex body haemoglobin interfered with. The red corpuscles are deficient, and oxidation is impaired. When improvement is inaugurated, the red corpuscles are in- creased in number ; the muscles fill out, while the fat in the body is diminished. Such are the various steps in the process of the restoration of health. Then at other times there is a distinct deficiency in the assimilation of fat. One of the difficulties of modern, or rather recent times, is the growing inability to take fat ; children now, in a great many instances, simply loathe fat, especially a lump of adipose tissue. They can take cod-liver oil, even like it, they can take the fluid fat of fried bacon, they can take butter; but animal fat en masse they turn from with repulsion. Granting that in many instances, the objection has no better foundation than a silly notion that it is "vulgar" to eat fat; still, there 4 74 TISSUE NUTRITION. [chap. v< remains an unpleasantly large proportion in whom the repugnance to fat is genuine and unaffected. When this rejection of fat has proceeded a certain length, then phthi- sis looms up. A certain amount of fat is apparently es- sential to the formation of perfectly healthy tissue ; and when the system is imperfectly supplied with fat, then tissue deterioration is apt to shew itself. This holds good of animals as well as man. Tubercle is common in the lungs of sheep and oxen ; and it is quite a frequent occurrence to find withering tubercular masses in the ani- mals when fatted—a recovery after the starvation of a previous hard winter. When starved, or partially so, these inferior cell-elements are formed; when the nutri- tion is improved then normal tissues are formed, healthy and sound,—and the lowly histological elements wither. With the consumptive, we try to get them to take fat, the easily assimilable cod-liver oil being the fat mainly used ; but, in some cases, other oils or cream will do very well; if they can take it and assimilate it, then recovery takes place. Fat is so furnished for histological elements, and then the tubercular process is stayed; and the patient's life is saved. It is not asserted that this is all, the complete whole, of the production and cure of tubercle; but it is an important part of the subject, this inability to assimilate fat. With- out a sufficiency of fat the cell-elements are imperfect, they are produced in excess with deterioration of quality. In the present state of our knowledge, we are unacquainted with any agents which act directly upon tissue-nutrition. The tissues are fed from the blood ; and " deteriorated chap, v.] TISSUE NUTRITION. 75 tissues need for their regeneration the baptism of healthy blood; " to improve the blood is the way to the regenera- tion of the tissues. We can only feed the body through the blood; the blood is fed from the food we eat. If we can improve the blood, we can feed the tissues. We know that we may have anaemia with fair, indeed good general tissue-nutrition. The assimilative and con- structive processes are equal to the commoner tissues; but they cannot build up haemoglobin. Haemoglobin has this formidable looking formula, C53.80) -tl7.32> -^16.175 ^21.S4* ^0.39J " e-43? with some 3 to 4 per cent, of water of crystallization (M. Foster). We can readily understand how the power to construct less complex bodies may be retained, yet the capacity to build up haemoglobin may be lost for a time; and require medicinal treatment for its restoration. We see how certain blood-poisons, lead, mercury, malaria, gout, and syphilis, may render a person anaemic; yet their general nutrition may be little, if at all affected. We know that when there is such a toxic element pres- ent, iron will not cure the anaemia, however potent in simple anaemia, until the specific in each case be added; and then improvement sets in. With the two mineral poi- sons it is necessary to elirrjinate them from the system, to relieve it from their presence, ere blood-f#rmation can proceed. In malaria we give quinine, in gout lithia and potash, in syphilis mercury or iodide of potassium, with iron; and then the iron is operative; without the specific, chalybeates are like an arrow Avithout a head. The clinical relations of anaemia teach us a valuable lesson as to the 76 TISSUE NUTRITION. [chap. v. loss of power in the system to construct the complex sub- stance, haemoglobin. Another lesson in the same direction is taught us by the nervous system; the loss of nervous energy, the prostra- tion, the unfitness for toil, necessitating a holiday, now so commonly experienced. Here, it would seem, there is impairment of the ability to construct lecithin. Lecithin is complex fat containing phosphorus and nitrogen. " Lecithin C44, Hao, NPO0, occurs widely spread through the body. Blood, gall, and serous fluids contain it in small quantities, while it is a conspicuous component of the brain, nerves, yolk of egg, semen, pus, white blood- corpuscles, and the electrical organs of the ray." Thia is what Michael Foster says about lecithin. The welU known association betwixt a heavy seminal expenditure and the loss of nervous energy, upon which quacks and charlatans have traded so largely, is thus intelligible and comprehensible. Its presence in the electrical organs of the ray is not devoid of significance. This lecithin is a subject upon which we will have soon to know more than we do at the present time. Just as the complex haemo- globin is a constitutent factor of red blood-corpuscles; so we will find this complex fat—lecithin—a constituent fac- tor of nerve-cell and fibres. We. do not know enough of the subtle chan^tes which lie at the foundation of the loss of nervous energy, so well, or intimately, as the associations of anaemia; but there is much pointing in this direction, viz., that it is linked with an insufficiency of lecithin. It is either used up too freely by overwork, or worry, which is still more exhausting; or it is formed imperfectly from chap, v.] TISSUE NUTRITION. 71 sjome impairment in the assimilative processes. It seems probable that this complex fat is the food^?ar excellence of the nervous system. That without it nervous energy, can- not be manifested. Further we may not yet affirm. But it is perfectly legitimate to throw together a few clinical facts bearing on the matter, which speak with a not quite inarticulate sound. When the nervous system has been severely overtaxed for a considerable time, it may give out evidences of exhaustion; while the muscles are well-nourished, and the adipose tissue of the body is not diminished. It is clear that here there is a localised mal- nutrition, restricted to the nervous system. The serous fluids, including the serum of the blood, contain lecithin in small quantities; therefore exhaustion of this substance in the nervous system would require time for its repair; and if the nervous system is still called upon, it must furnish evi- dences of exhaustion and diminished capacity, until the normal proportion of lecithin is restored. Rest for the nervous system permits of the reaccumulation of this com- plex phosphorized fat. Then we find phosphorus advo- cated for nervous exhaustion and depression. "Ohne phosphor keine gedanke," was Moleschott's dictum now so widely known—(" Without phosphorus there is no thought"). But this phosphorus has to be formed into a fat before it can be of service. Not only thought, but motor messages involve the oxidation of this complex fat. Lecithin, cerebrin, and neurin, are complex substances, found in the nervous system; though the two latter are simpler, not containing phosphorus. But the decomposi- tion of these complex bodies is essential to nervous energy 78 TISSUE NUTRITION. [chap. v. Neuralgia is like most pain, the prayer for healthy blood. " Pain is the prayer of a nerve for healthy blood," wrote Romberg ; and most certainly this is true of neuralgic pain. Neuralgia is intimately linked with the presence ■of poisons in the blood—mineral, malarial, or produced within the body. Neuralgia is at other times the offspring of simple anaemia, mere bloodlessness. Neuralgic pain tells of unhealthy blood; blood either containing a positive poison, or itself deficient in nutrient material. The rest of the body may be fairly well nourished; but neuralgia, and a sense of lethargy or unfitness for work, may tell that the nervous system is underfed—that the organism is un- equal to the formation of those complex substances, the food of the nervous system. So far as we know it is in the preparation of these com- plex matters for the blood and the nervous system—neither of which exists in plant life—that animal synthesis exhibits itself. Bone is the infiltration of lime into ordinary car- tilage : but haemoglobin and lecithin are complex bodies, built up in the animal organism. Starch, sugar, fat, are built up from carbonic acid and water; albumen from these and free ammonia in the air. All are synthetically built 'up by vegetable life, and appropriated by animals. Animals evolve energy by the union of these substances with oxygen ; they pull to pieces and oxidise the construe* tions of plant life, and in doing so evolve heat and force. But the oxygen-carrying haemoglobin, the force-liberating lecithin, are essentially the creation of animals themselves; who build them up from less complex substances. The complexity of these nervine matters are associated chap. v.J TISSUE NUTRITION. 79 somehow with the immense " liberating-power " that they possess. The respiratory centre occupies a little space in the medulla, but its rhythmic discharges set off a large series of muscles; and when its explosions are stimulated by the presence of carbonic acid in excess in the blood, all the muscles of the body may be more or less thrown into action. No wonder then that at times the system is un- equal to the construction of these elaborate compounds; when it can carry on successfully the digestion, assimila- tion, and transformation of ordinary materials—built up by vegetables originally, and appropriated by animals. No wonder either that when the power to build up these products of animal synthesis is lost, it may require some time before the system can regain it. The conversion o;' spare hydrocarbons within the system into fat, and ever spare proteids, though this is rather fatty histolysis, and the development of adipose tissue is not to be compared tc the construction of haemoglobin and lecithin, the two most complex products of the body; the two which must, and only can be built up by animal synthesis. So much then for the loss of power to construct complex bodies. At other times, there exists a loss of power to assimilate albuminoids, and then the muscles suffer chiefly; and espe- cially the two muscles in constant action,—the heart and the diaphragm. This is a practically important matter, as a heart so weakened is not uncommonly mistaken for a heart undergoing fatty degeneration. In the general evidence of loss of power in the heart, the two conditions are almost identical. There is this difference, however, "fatty degeneration " is a condition the gravity of which 80 TISSUE NUTRITION. [chap. v. it is impossible to underrate; while "heart starvation" is a condition carrying with it little cause for apprehension, except in those conditions of acute failure in pyretic states of blood poisoning, where the heart's action becomes ex- ceedingly rapid and fluttering; a condition fraught with extreme danger. But " heart starvation" as ordinarily seen is a condition of some permanency, and not a truly " acute " condition. When the digestion of albuminoids is defective, then the blood cannot furnish to the muscular structures the pab- ulum required for the maintenance of their integrity; consequently they are ill-nourished and their functional activity is impaired. When the heart is so enfeebled, and the diaphragm also half-starved, then there are dis- turbances in the circulation which closely resemble the symptoms of the fatty heart. The heart-sounds are ill- defined, and less audible than normal; while the heart's impulse is lost, or nearly so. The pulse is feeble and compressible. There is a tendency to fainting, while the mental operations are confused, the brain being imper- fectly supplied with blood. There is a feeling of unsteadi- ness, or lack of self-reliance, which is very distressing The patient sighs, and there are seizures when the respi- ration is arrested. Indeed, the symptoms and sensations are those given by Da Costa, in his admirable work "Medical Diagnosis," as some of the indications of the fatty heart. But " fatty degeneration " as a disease of advanced life, is distinctly senile in its aspect; while "heart starvation" is a malady of middle life. One pre- sents the tout ensemble of age,—of widespread senile de« chap, v.] , TISSUE NUTRITION. 81 generative change; the other is rather an invalid, as a person pulled down with dysentery, or tropical fever. At a distance, the tottering gait, the unsteady step, the bowed figure leaning on a stick, may belong to each alike; but on nearer approach, the resemblance fades out, and thepoints of dissimilarity become obvious. Nevertheless, it is by no means rare to see cases in which " heart-starvation " has been mistaken for the " fatty heart." Indeed, the resem- blance is so close, and the general practitioner has so many things to attend to on the one hand; while on the other, our acquaintance with the heart " as a muscle " has not kept pace, or anything like it, with our acquaintance with the valvular diseases of the heart, of which the " mur- mur " is the indication par excellence; that such mistake does not always involve either carelessness or culpable ignorance. But in the absence of the significant mur- mur, the presence of distinct debility in the heart is mystifying to the ordinary practitioner, and calls up the fear of " fatty degeneration; " and not unnaturally so. The knowledge which one man acquires by the sweat of his brow, after years of patient toil and painstaking obser- vation, cannot be transferred in its entirety to another ; there is no " royal road " to knowledge. Individual acquired skill cannot be passed from brain to brain, any more than the juggler who can keep six balls in the air at once, can endow an onlooker with like capacity, by merely showing him " how it is done." The muscles, and still more their representatives in the motor area of the brain-hemispheres, require a long training before this manual skill can be acquired. So it is in 4* 82 TISSUE NUTRITION. [chap. v. other matters. It is not difficult to say how the diag- nosis betwixt the " fatty heart " and " heart starvation " is to be made; but without individual toil to acquire the requisite capacity, the reader cannot attain it. There is no royal road to the discrimination betwixt two allied conditions, especially when the resemblance is so close as it is betwixt the fatty heart and its double,—heart starvation. There are in each the same signs on physical examina- tion of the heart; in each the same cold extremities, indica- ting want of blood in the arteries; in each the evidences of cerebral anaemia; in each the same incapacity for exer- tion and breathlessness on effort; a whole group of symp- toms, indeed, is found present in both. But in the fatty heart there are found evidences of senility all over the body. The skin is degenerate, unnaturally smooth and greasy, or furred with myriads of wrinkles; the eye ex- hibits an arcus senilis (arcus is a " bow," not a "ring"), seen under the upper eyelid long before it is present in that portion of the eye which is seen, and which is exposed to light; while the temporal artery is seen tortuous and meandering like a brook in a flat meadow. He was a wise man, a keen observer, and an accurate thinker, who said " a man is no younger than his arteries " (S. Wilks): and it is the condition of the arteries which is our trustiest guide in making the diagnosis. In the fatty heart the arteries are usually atheromatous, rigid, and tortuous. In a well-marked case, the temporal artery may be seen to elongate, as well as to widen on the ventricular sys- tole; the radial artery is felt to undergo the same tran- chap, v.] TISSUE NUTRITION. 83 sient change. The arteries feel like tendons, or even pipe-stems. If, at the same time, the pulse is irregular or intermittent, then the fatty heart is present almost to a positive certainty. But where evidences of age are want- ing, then in all probability the condition present is that of heart starvation ; it not being denied that fatty degenera- tion is found in certain rare states even in comparatively young persons. But for once that fatty degeneration is so found, fifty times fatty degeneration is diagnosed when heart starvation is the actual state of matters. The diges- tion of albuminoids is defective and the capacity of the heart and diaphragm is impaired ; furnishing a group of symptoms closely resembling those manifested when the heart is the subject of that molecular decay, known as fatty degeneration, or necrosis. Even when there may be Ground for the gravest suspicion as to the integrity of the fibres of the heart, the condition may still be one where " starvation " is also present ; that is, there is act- ual degeneration of some of the fibrillae, while there is starvation in those fibrillae remaining structurally sound. Such cases are met with from time to time (see "Heart Starvation," H. K. Lewis ; reprinted from the Edinburgh Medical and Surgical Journal, May, 1881). Here it is most important to remember that a small quantity of albuminoids, properly and completely digested, will furnish more tissue-nutriment than a large meal, none of which is thoroughly digested. A dietary of fish, white meat, eggs, milk-puddings, with fruit, will digest and feed up a starved heart and diaphragm; when liberal meals rich in meat fail to do so. It is not the amount swallowed, it 84 TISSUE NUTRITION. [chap. v. is the amount digested, which is to be the measure of the actual nutritive material in the blood ; and from it the nutrition of the starved tissues. In such cases, it is well to aid the feeble natural digestive powers'by the addition of pepsin, or the pancreatic preparations. It is somewhat difficult to induce the friends of the patient to believe that such an apparently insufficient dietary is the one cal- culated to repair debilitated conditions of muscles ; but insistance can be accompanied by explanation, and the results convince the doubtful and convert them to con- viction. The recognition of ill-fed muscles from impairment in the power of assimilating albuminoids, as a condition in- volving the heart and diaphragm, is a matter which must engage the attention of the profession in a little time ; indeed, when it is sated with nerve pathology and poison- germs, and can turn its attention to something else. In pernicious anaemia there is great muscular asthenia, « and the heart is the subject of actual " fatty degeneration." There is a growing general malnutrition of the muscular system especially, though, as Addison observed, there may be an increase in the amount of subcutaneous fat. In- deed, in anaemic, states, fat is apt to be deposited. The farmer often bleeds his oxen to make them fatten, when they do not feed satisfactorily. Tissue-nutrition might not inappropriately be otherwise termed " protoplasmic metabolism or digestion." CHAPTER VI. SECONDARY INDIGESTION. NE UR OSAL.—REFLEX.—CARDIA C.—TOXMMIC. We now come to the consideration of those forms of indi- gestion and mal-assimilation which are secondary condi- tions, due to disturbances elsewhere, or to the presence of poisons in the body. These will be found to be a large wide-spread series. The first of this group of dyspepsiae is that due to dis- turbance of the nervous system, as overwork, worry, anxietv, suspense, or emotion; where the encephalic dis- turbance interferes with the digestive act. " How thin you are getting ! " we remark to an acquaintance. " \ es, I have been a good deal worried of late; I have a lot of work: and lately I have had a good deal on my mind;" is the common response. Such is the effect of mental dis- turbance persisting for some time. Acute indigestion is the result of sudden perturbation. " That the secretion of gastric juice is affected in a very marked manner by conditions of the nervous system, is indicated by the effect of the mental emotions in putting an immediate stop to the digestive process, when it is going on in full vigour " (Carpenter). We all are only too familiar with the con- sequences of bad news, or other " upset," when at meals. Unconscious previously of the possession of a stomach, or the process known as the digestive act, we suddenly feel a lump in the epigastrium, and an accompanying convic- B6 SECONDARY INDIGESTION. [chap. vi. tion that the meal is wasted. This is the effect upon perfectly healthy persons; more marked is the disturbance in those who suffer from indigestion. Vomiting may oc- cur, or diarrhoea; either clearing away the spoiled victuals, but by a process the reverse of pleasing. If neither occur, then the undigested material is the source of disturbance for some time afterwards. The reaction of this upon the nervous system is productive of great discomfort; indeed, in some, acute misery is induced thereby. Dr. Carpenter, F.R.S., the author of the well-known works on Physiology, has paid considerable attention to the effects of mental conditions upon the organic pro- cesses; and it may be well to make several quotations from his writings on the subject. By so doing, the reader will be put in possession of the views of the illustrious physiologist ; which may carry with them, too, more weight than my unsupported word. After giving the effects of emotion upon other secretions, he proceeds to speak of those connected with the digestive act. " The flow of saliva, again, is stimulated by the sight, the smell, the taste, or even by the thought of food; espe- cially of such as is of a savoury character. On the other hand, violent emotion may suspend the salivary secretion; as is shewn by the well-known test, often resorted to in India, for the discovery of a thief amongst the servants of a family—that of compelling all the parties to hold a certain quantity of rice in the mouth during a few minutes, the offender being generally distinguished by the comparative dryness of his mouthful at the end of the experiment. There is much reason to believe that the chat, vi.] SECONDARY INDIGESTION. 87 secretion of the gastric fluid is affected, in the same man- ner as that of the saliva, by the impressions made by food upon the senses ; for it has been ascertained by Bidder and Schmidt, that it is copiously effused into the stomach of dogs that have been kept fasting, when flesh or any other attractive food is placed before them. That the secretion, on the other hand, is entirely suspended by powerful mental emotion, seems almost certain, from the well-known influence which this has in dissipating the appetite for food, and in suspending the digestive pro- cess when in active operation. As a cheerful state of feeling, on the other hand, seems to be decidedly favor- able to the performance of the digestive function; it prob- ably exerts a beneficial influence, as to both quantity and quality, in the secretion of gastric fluid, of the influence of mental states, or other secretions concerned in the reduction and appropriation of the food (such as biliary, pancreatic, and intestinal fluids), neither observation nor experiment has as yet afforded any satisfactory informa- tion. It is a prevalent, and perhaps not an ill-founded opinion, that melancholy and jealousy have a tendency to increase the quantity and to vitiate the quality, of the biliary fluid. Perhaps the disorder of the organic func- tions is more commonly the source of the" former emotion than its consequence: but it is certain that the indulgence of these feelings produces a decidedly morbific effect by disordering the digestive processes, and thus reacts upon the nervous system by impairing its healthy nutrition/' This last is a very significant remark, and throws much light upon many cases where there are evidences of mal- 88 SECONDARY INDIGESTION. [chap. vi. nutrition of the nervous system, taking its origin in emo- tional disturbance. This transient disturbance perturbs the assimilative processes; and these, in turn, lead to per- sisting mal-nutrition of the nervous system. Again, "there is abundant evidence that a sudden and violent excitement, or some depressing emotion, especially terror, may produce a severe and even a fatal disturbance of the organic functions ; with general symptoms (as Guislain has remarked), so strongly resembling those of sedative poisoning, as to make it highly probable that the blood is directly affected by the emotional state, through nervous agency; and, in fact, the emotional alteration of various secretions, just alluded to,* seems much more prob- ably attributable to some such affection of the blood, than to a primary disturbance of the secreting process itself. Although there can be no doubt that the habitual state of the emotional sensibility, has an important influence upon the general activity and perfection of the nutritive processes as is shewn by the well-nourished appearance usually exhibited by those who are free from mental anxiety, as well as from bodily ailment, contrasted with the "lean and hungry look" of those who are a prey to continued disquietude—yet it is not often that we have the opportunity'of observing the production of change in the nutrition of any specific part,fcby strong emotional ex- citement. In the two following cases, the correspondence of the effects to their alleged causes may have been only casual; and a much larger collection of facts would be * The urine, the sexual secretions, the sweat, and more than all, the milk—the secretion of the mammary gland. chap, vi.] SECONDARY INDIGESTION. 89 needed to establish the rationale here advanced as probable. But so many analogous though less strongly-marked phe- nomena are presented in the records of medical experience, and the ipfluence of the emotions upon the products of secretion is so confirmatory, that there does not se'em any reasonable ground for hesitation, in admitting that the same explanation may apply here also. The first of these cases, cited by Guislain, from Ridard, is that of a woman, who, after seeing her daughter violently beaten, was seized with great terror, and suddenly became affected with gangrenous erysipelas of the right breast. But a still more remarkable example of local disorder of nutrition, occasioned by powerful emotion, and determined as to its seat by the intense direction of the attention to a particu- lar part of the body, is narrated by Mr. Carter, " On the Pathology and Treatment of Hysteria." " A lady, who was watching her little child at play, saw a heavy window- sash fall upon its hand, cutting off three of its fingers; and she was so much overcome by fright and distress, as to be unable to render any assistance. A surgeon was speedily obtained, who, having dressed the wounds, turned himself to the mother, whom he found seated, moaning and complaining of pain in the hand. On ex- amination, three fingers, corresponding to those injured in the child, were discovered to be swollen and inflamed, although they had ailed nothing prior to the accident. In four-and-twenty hours, incisions were made into them, and pus was evacuated; sloughs were afterwards discharged, and the wounds ultimately healed." The influence of the etate of expectant attention in modifying the processes of 90 SECONDARY INDIGESTION. [chap. vi. nutrition and secretion, is not less remarkable than we have already seen it to be in the production or modifica- tion of muscular movements. It seems certain that the simple direction of the consciousness to a part, indepen- dently of emotional excitement, but with the expectation that some change will take place in its organic activity, is often sufficient to induce such an alteration; and would probably always do so, if the concentration of the atten- tion was sufficient." This last matter will be referred to again in the consideration of hysterical dyspepsia, and hypochondriasis. It has certainly much to do with the occurrence, if not the production, of the " mother's marks " so commonly met with. In considering the question of how emotion affects the digestive process, Dr. Carpenter says experiments have not led to agreement among observers. He writes " Bernard, with many others, considers that the division of these nerves (the pneumogastrics), instantaneously checks the secretion of the gastric fluid, and therefore, puts a stop to digestion; and he points to the pallor and flaccidity of the stomach which immediately succeed the operation, the slight and superficial digestion of the alimentary mass which takes place, and to the additional circumstance, that in the rabbit there is a sudden change in the reaction of the urine from alkaline to acid, the latter being the normal condition in the fasting state, and therefore, showing that all action on the food must have stopped. He further observes, that in galvanising the pneumogastrics, an abun- dant flow of gastric juice takes place. Longet, however, maintains, that division of the pneumogastrics operates chap, vi.] SECONDARY INDIGESTION. 91 rather in paralysing the muscular movements of the stomach, than in stopping the secretion of the gastric juice; for he states that if a small quantity of milk were given to the animal, 24 or even 48 hours after the section, and when, therefore, there could be no gastric juice re- maining in the stomach, it has invariably clotted after death, or upon making the animal vomit; and small quan- tities of meat or other food were digested readily enough, though large masses were only superficially digested, because the muscular power of the stomach being para- lysed, the food was not properly intermingled with the gastric juice." These interesting observations point to several matters of clinical moment. They tell that section of the pneu- mogastric nerves arrests the secretion of gastric juice with "pallor and flaccidity of the stomach;" that is, the arterioles of the stomach dilate in the act of diges- tion, when the mucous lining at the same time is wet with the flow of the gastric juice. Thus we see that both (1) disintegration by the muscular movements; and (2) the production of the solvent gastric juice, are arrested; no wonder then that the digestion is hindered ! Such prob- ably is the effect of fear and depressing emotions. On the other hand, galvanising the pneumogastrics produces an abundant flow of gastric juice. This is analogous to pleasant emotions aiding digestion; and may throw some light upon the time-honoured practice of taking wine with food. Paul urged upon Timothy to " drink no longer water, but have a little wine for thy stomach's sake and thine often infirmities;" it seems probable that Timothy had indiges* 92 SECONDARY INDIGESTION. [chap. vi. tion among his " infirmities." Pleasurable emotions of a cheerful enlivening character, act like a stimulus through / the pneumogastrics, and dilate the gastric arterioles, pro- moting the secretion of gastric juice; while increasing the energy of the muscular movements of the stomach. These observations are in perfect accord and harmony with our practice of giving agents, which so act upon the stomach when the digestive act is defective. Persist- ing emotions act in the same way but less potently, producing the same results through longer and slower operations. Thus worry, anxiety, " carking care," and other depressing influences, cause a persisting loss of flesh, even when no uncomfortable sensations are com- plained of; while exhilarating conditions lead to more per- fect and complete digestion and nutrition. Shakespere wrote. "Let me have men about me that are fat : sleek-headed men, and such as sleep o'nights. Yond' Cassius has a lean and hungry look; he thinks too much : such men are dangerous. Would he were fatter! But I fear him not: "— and we all know how persons emaciated by worry and anxiety, " pick up flesh," when their minds are once more at rest after much perturbation. The observation that " small quantities of meat or other food were digested readily enough, though large masses were only superficially digested" is one pregnant with instruction as to the dietetic requirements of many dyspep- tics. It shows that when the digestion is impaired small quantities of food are digested "readily enough;" while larger amounts were only digested on the surface, the chap, vi.] SECONDARY INDIGESTION. 93 interior being untouched. Not only is the secretion of gastric juice diminished notably, but the movements are abolished so that the disintegration is not accomplished, which fits the food for admixture with the bile and the pancreatic secretion, which is so large a part of the function of the stomach ; probably more important than even the digestion of albuminoUs in an acid medium, because this last may be supplemented by the pancreatic digestion of albuminoids in an alkaline medium. It shows that in en- feebled assimilation to give small quantities of food is to secure complete digestion, while larger meals undergo little digestion, and have therefore little nutritive value ; as is insisted upon in the preceding chapter when speaking of the dietary in " heart starvation." Such then is a part of the aid which physiological research can give to practical medicine. Impaired nutrition is, then, often the direct outcome of mental disturbance. The most pronounced inveterate case of anaemia, I ever met with personally, occurred in a girl of splendid physique and magnificent family history. She was the type of health when her father fell down by her side at market, and died there and then. She imme- diately became anaemic and remained so, despite most varied treatment. Pernicious anaemia about which so much has been written lately, is probably a perversion of nutrition due to nervous disorder, rather than a local disease, " atrophy of the gastric glands ;" if atrophy of the gastric glands is ac- tually found after death, it is probably the consequence, rather than the cause of the anaemia ; instead bf being a 94 SECONDARY INDIGESTION. [chap, vi rational explanation, in the face of the powers of the pancreatic secretion, it seems rather like "putting the cart before the horse." It is a case of distinct loss of the power to assimilate albuminoids, a matter discussed in the pre- ceding chapter. It appears that " there is often a consider- able amount of subcutaneous fat ;" yet " almost without exception the heart is in a state of fatty degeneration ; its walls are pale, flaccid and friable ; the interior of the ven- tricles, and especially of the left ventricle, shows irregular whitish striae running transversely across the muscular bundles, and especially the papillary muscles " (S. Coup- land). It is a disease only observed in recent times ; and is one of the increasing number of perversions of nutrition with which we are becoming familiar now-a-days. The mental associations of diabetes are very interesting in relation to this subject. Talking one day with Mr. Van Abbott, whose biscuits for diabetics have such a well- deserved renown, I "asked him,—"Who are your diabetics mostly ? " The reply was very significant—" Business men comparatively old and grey for their years ; men who look as if they had a deal on their minds." This was the re- sponse. It stands in a suggestive relationship to the fact of acute diabetes being set up by shock or other mental perturbation ; or of its artificial production, by the puncture of the floor of the fourth ventricle. The direct nervous connection betwixt the brain and the liver has been shown by Cyon and Aladoff. It contrasts with the mere glyco- suria, so common in stout men, where the dio-estion of starch is perfect, and the liver only dehydrates enough into glycogen for the wants of the system ; the surplusage chap, vi.] SECONDARY INDIGESTION. 95 running off by the kidneys. Here, if it were not for this " waste pipe," the individuals would become inordinately fat. Such glycosuria is a totally different matter from the diabetes, which leads to wasting; where either (1) the liver has lost the power of dehydrating the sugar, brought to it by the portal vein, the more probable hypothesis; or (2) the ferments in the liver hydrate the glycogen, or animal starch into sugar again, too swiftly for the wants of the body; and the " fuel-food " escapes unburnt. In either case it becomes necessary to feed the patient on food which is not saccharine, and therefore liable to these perversions of dehydration, and secondary hydration. If food can be taken in sufficient quantity and assimilated, which undergoes no saccharine transformation, the dia- betic is preserved: if not he perishes. S. Haughton, F.R.S. tells of the diabetic patient dying of inanition, that in the delirium which preceded the final change, he cried out " Fat! roasted fat from the angels of heaven! " Such perversion of the assimilative processes which is so marked in its various forms at the present day, will be considered in relation to its rapid increase, and the pros- pects of the next generation and their successors,—if they have any—in a succeeding chapter. The failure of the teeth it will be seen is but one part, one factor in a wide- spread deterioration of the digestive processes. The ter- rific demand upon the nervous system in the present " struggle for existence," and " fight for a competency " is telling with deadly effect upon the organic processes and their nutritive products. Not only do we recognize men- tal factors in the production of the disturbance of the 96 SECONDARY INDIGESTION. [chap. vi. digestion, in the digestive act in the stomach—ordinarily spoken of as if it were the whole of the digestive act; but we see the liver may be disordered by mental disquietude. Jaundice has been known to be produced by fright, and more chronic functional disturbance of the liver is linked with persisting mental perturbation. Diabetes is set up acutely by mental emotion; chronic overwork leads to a more lasting form of mental taxation. Recently Clifford Allbutt, F.R.S., urged with his wonted able advocacy, the mental relationships of chronic renal disease. In his opinion enduring mental anxiety and worrv over business difficulties, is a potent factor in the production of chronic Bright's disease with albuminuria. Indeed a huge mass of evidence is being collected to show that excessive toil in that portion of the brain which is devoted to intellectual processes, leads to deterioration of the functions of the viscera, which form part of the organic life. The viscera which provide the pabulum for the intellectual and motor processes, i.e. the brain and muscular system, become affected in time by the demand upon them, and give way under the strain. More pronounced is this effect when the posterior lobes, which are linked with our subjective states and our emo- tions, are involved. Loss of appetite, of the power of all digestion is the common outcome of acute grief. The production of new matters in the blood is shown by the hair turning grey suddenly; even in a single night, as was the case, it is said, with Marie Antoinette and the Prisoner of Chillon. It is quite common to see the hair acquire a distinct grey hue when a person is subject to acute severe chap, vi.] SECONDARY INDIGESTION. 97 mental trouble, a lawsuit, the death of a loved relative, intense suspense in speculation or business, indeed any cause of profound emotion; and to see it lose this tempo- rarily acquired hue, when the cause of the mental pertur- bation has either passed away, or the blow has been softened by time. The secretion of milk in woman is profoundly affected by mental emotion, indeed may become a deadly poison. Sir Astley Cooper observed two cases of arrest of the secretion from emotion and wrote"—"Those passions which are generally sources of pleasure, and which, when moderately indulged, are conducive to health, when carried to excess, alter, and even entirely check, the secretion of milk." According to Dr. Carpenter, many observers have noticed fits of passion in a suckling mother followed by convulsions and death in the infant after being put to the breast. Thus, in one case a tumult arose between a soldier and a carpenter in whose house he was billeted ; the carpenter's wife rushed in, wrested the sword from the soldier, and broke it in pieces. " While in this strong excitement, the mother took up her child from the cradle, where it lay playing, and in the most perfect health, never having had a moment's illness; she gave it the breast, and in doing so sealed its fate. In a few minutes the infant left off sucking, became restless, panted, and sank dead upon its mother's breast." It is clear that the disorder in the secretion provoked by mental emotion produces some very active poison, acting rapidly upon the nervous system with deadly effect. Convulsions usually are provoked ; nor is this perversion of secretion in emotion confined to human beings, Carpenter writes, 5 98 SECONDARY INDIGESTION. [chap. vi. " Another case was that "of a puppy, which was seized with epileptic convulsions, on sucking its mother after a fit of rage." Such are the acute perversions which produce toxic matters in the milk of a mother when she is emotionally excited. The mental disturbance sets up modifications of secre- tion which result in the formation of a poison actin" mainly, if not entirely, upon the nervous system. w So in more chronic and persisting conditions. A men- tal upset disturbs the nutritive processes, and the changes so induced react upon the nervous system: consequently we can comprehend how persisting depraved nutrition can be traced to a particular period of mental disturbance by the sufferer, with a fair show of reason for what is stated. The most intractable case of dyspepsia with malaise, lethargy, inability for exertion, a disordered state of the bowels, with furred tongue, a hot bitter taste in the mouth on waking; all the evidences indeed of disordered diges- tion with the production of abnormal "by-products of digestion," which ever came under my notice, was that of a returned East Indian. This gentleman came of a healthy stock, was a well nourished person, took a very high place in the examination for the East Indian Civil Service; continued his labours; took one thing after another, far outstripping all his competitors: with what re- sult ? This! His digestive apparatus became so thoroughly disordered that he was compelled to retire from duty, to come home to England, to do nothing. A confirmed dyspeptic, his bodily comfort destroyed, his prospects chap, vi.] SECONDARY INDIGESTION. 99 clouded darkly, crippled in the race for life; he has to sit helplessly looking on, while his old competitors diminish the space betwixt him and them, and then overtake him ; after that, see them going onward leaving him hopelessly behind. If he were not a man of high moral principle he would be driven to suicide! Another more ordinary case was that of a gentleman in aJmsiness house in South Wales. He had charge of a branch of the business, was an energetic active man, in- dustrious, persevering, and painstaking. Feeling it would be an advantage to be acquainted with the French lan- guage, he sat up at nights to learn it. Under this additional strain his health broke down. He seemed rather surprised when told that he had been, from a medical point of view, guilty of a piece of consummate folly: for, from a business point of view his conduct merited the highest commendation. He omitted from his calculation the matter of his health. His digestion broke clown, he began to sweat at nights, and his left lung was not above suspicion. Fortunately his employers, knowing: his value, took alarm and sent him to me at once, a v before the mischief had gone any length. He was put upon tonics, and advised to go a trip into the Mediterranean in one of their vessels ; and then to go to France for a time, so as to acquire the language without overworking. The result of his overwork was a breakdown: a very common matter. He just lost the time which would have enabled him to have acquired French in a less violent hurry. He is now well and free from any chest ailment. Such then are examples of a class of case sadly too nu- 100 SECONDARY INDIGESTION. [chap. vi. merous at the present time. In this generation men will not be content to move at the leisurely pace of their grand- fathers. Mr. Deane, in " The Mill on the Floss," spoke to his nephew Tom Tulliver as follows:—" The world goes on at a smarter pace now than it did when I was a young fellow. Why, sir, forty years ago, when I was much a strapping youngster as you, a man expected to pull between the shafts the best part of his life, before he got the whip in his hand. The looms went slowish, and fashions didn't alter quite so fast; I'd a best suit that lasted me six years ! Every- thing was on a lower scale, sir, in point of expenditure, I mean. It's the stream, you see, that has made the dif- ference; it drives on every wheel double pace, and the wheel of fortune with 'em." And so men push, and strive, and struggle, and attain their end,—or break down in trying. It is the old Anglo-Saxon plan to find out what can be done by over-doing, and so learning the extreme limit. A butcher's boy was spokesman for his race, when summoned before the magistrates at Teddington, for furi- ous driving ; the constable stated the mare was going thirteen miles an hour, when the boy triumphantly re- futed him Try saying,—" She can't do it ; she has not got it in her ! " He evidently knew to a nicety what she could do, by noting what she could not do. So it is in the pres- ent pace of life. It is faster ! faster ! Our steeplechasers gallop faster than their old-fashioned half-bred predeces« sors ; our fox-hounds run faster than of yore, till our hunters have to be nearly thorough-bred to keep pace with them. It is the pace at which we live that over- taxes our organic processes, and the digestive processes chap, vi.] SECONDARY INDIGESTION. 101 breaking down under the strain. It is the early period at which the pace is put on which is telling. Our race- horses are trained so young, that they soon are unfit for the racecourse ; how few horses are there now who are good for anything at six years old. Old Forrester was racing long years after any horse is now put to the stud; but probably he never ran as a two-year old. Eclipse was five years old before he was trained. As with horses, so with men. A man used to be satisfied to have earned a compe- tency at 60; now he strains to retire at 45 with a fortune. As with men, so with the racehorses; the difficulty is to keep up their appetite and digestion. This it is which bothers the trainer. The young horses " go off their feed," and then the training is suspended. Quinine, with acids and gen- tian, is in vogue in trainers' establishments, to keep up the young scions of a famous stock. In the high-bred racer, the digestive organs give way under the demands upon them, made too early. As the trainer has to whip up the appetite of his two-year old, so the Lincolnshire grazier finds it pay him to cook a part of the food for his stall-fatted stock. Perhaps in a few years it may be necessary, or anyhow, profitable, to give these oxen tonics. To what then are we coming. Tonics, artificial digestive agents, or even artificially digested food, may be palliative as regards the individual: but they cannot be regarded as curative as to the race. For our successors something else is necessary ; and what that "something" must be will be seen in a subsequent chapter. There is another aspect of this subject, of the effect of mental attitudes upon the organic processes, which needs 102 SECONDARY INDIGESTION. [chap. vi. a little consideration, especially for those whom it con- cerns, viz., the hypochondriac ; and those who though not exactly belonging to the class " malade imaginaire," still give too much attention to their subjective sensations. It may be well again to quote Dr. Carpenter verbatim in this matter:—■ " The influence of the state of expectant attention in modifying the processes of nutrition and secretion, is not less remarkable than we have seen it to be in the produc- tion of muscular movements. The volitional direction of the consciousness to a part, independently of emotional ex- citement, suffices to call forth sensations in it, which seem to depend upon a change in its circulation ; and if this state be kept up automatically by the attraction of the attention, the change may become a source of modification, not only in the functional action, but in the nutrition of the part. Thus, there can be no doubt that real disease often supervenes upon fancied ailment, especially through the indulgence of what is known as the hypochondriacal tendency to dwell upon uneasy sensations ; those sensa- tions being themselves, in many instances, purely 'sub- jective.' In many individuals (especially females), whose sympathies are strong, a pain in any part of the body may be produced by witnessing it in another, or even hearing described the sufferings occasioned by disease or injury of that part ; and if this pain he attended to, and be- lieved in, as an indication of serious mischief, injurious consequences are very likely to follow. So, again, the self-tormenting hypochondriac will imagine himself the victim of any malady that he may < fancy ; ' and if this chap, vi.] SECONDARY INDIGESTION. 103 fancy should be sufficiently persistent and engrossing it is not unlikely to lead to real disease of the organ to which it relates. His persistent direction of the attention has a much greater potency, when combined with the expectation of a particular result; and thus it happens that the spells of pretenders to occult powers, in all ages and nations, often produce the predicted maladies in the subjects who are credulous enough to believe in their efficacy. Such was formerly the case among the negroes of the British West Indies, to such a degree, that it was found necessarv to repress what was known as ' Obeah practices,' by penal legislation; a slow pining away, ending in death, beino- the not uncommon result of the fixed belief on the part of the victim, that 'obi' have been put upon him by some old man or woman reported to possess the injurious power. So great, indeed, was the dread of these spells, that the mere threat of one party to a quarrel to ' put obi' upon the other, was often sufficient to terrify the latter into submission. And there is adequate ground for the asser- tion, that even amongst the better instructed classes of our own country, a fixed belief that a mortal disease had seized upon their frame, or that a particular operation or system of treatment would prove unsuccessful, has been in numerous instances, the real occasion of a fatal result." I introduce this paragraph verbatim, to put the dys- peptic on his guard about the study of his subjective sensations; as much as to warn the hypochondriac that it is well to try to put away his, or her morbid dwelling on ideal conditions. It is clear that it is desirable the dyspeptic be cured as soon as may be; not only for his, 01 104 SECONDARY INDIGESTION [chap. vi. her comfort or well being, but in order to obviate the danger of disordered function leading to structural change from the direction of the attention thereto. This is no imaginary danger, as Dr. Carpenter shews. Even when the sensations of discomfort are present, it is well not to let them absorb the attention; the sufferers should turn their thoughts in other directions, or have them distract* d for them. Certainly it is within my personal experience that persons who have long been troubled with indigestion, have died of cancer of the stomach. Nor do I regard these as accidental relationships, or mere coincidences. Long gastric trouble culminated in cancer of the pyloric ring, not that such is a common occurrence; but certainly in a number of cases either gastric cancer had a far reachi!!."" history of indigestion preceding it; or long-standing func- tional disorder led to structural change: whichever way the reader chooses to put it. It is most desirable then that such sensations as arise from disordered function, are put away as much as possible by actual sufferers; while those whose maladies are cen- tric, and due rather to disturbance within the posterior lobes of the cerebral hemispheres, than to actual disorder in the viscera, will be wise to attend as little as they can to their abnormal feelings. Dr. Hughlings Jackson, F.R.C.P., holds that the liver, indeed, each of the viscera, has its representative area in the brain, just as much as the arm or leg is represented in a distinct and localized area. The hypochondriac feels his sensations in the part to which he refers them; just as other sensations are ex- perienced which are unreal. The lunatic is not the only chap, vi,] SECONDARY INDIGESTION. 105 individual who has what others regard as hallucinations. What each one feels is known to himself. A patient of mine once felt hairs in his mouth; there were no such hairs. But the impression lasted the remainder of his lifetime. In such a case, there must have been a centric disturbance referred to a peripheral cause, in accordance with our common experience. " Phantom limbs," are a not uncommon phenomena; and a man will feel the little finger ache with cold, in an arm amputated years before. So in hypochondriasis, probably the disturbance is the primitive sensation in the cerebral area, not the part to which it is referred; but the persistent direction of the at- tention to the said viscus, may in time lead to actual func- tional disorder; which in its turn may set up structural change in the course of time. The relations betwixt the brain and the digestive organs are intimate and interesting. Disturbances in the viscera disorder the brain directly, as well as by the abnormal products which reach it through the blood. Disturbance in the posterior lobes, those portions of the hemispheres connected with our internal sensations, may lead in time to disorder in the viscera associated therewith. The direc- tion of the attention operates banefully upon the organs to which it is turned. There are actions and reactions within the complex microcosm; and the organic nervous system has not been denominated " the sympathetic " with- out good and sufficient reasons. This is an aspect of the subject which must be considered and reflected upon. Its consideration may be disturbing to sundry nervous per- sons; but that is simply unavoidable, however undesirable. 5* 106 SECONDARY INDIGESTION. [chat. vi. It is all very well for certain enthusiastic individuals to deny themselves wine, which would do them good, in order to set an example of abstinence to those who yield to al- coholic temptation; but the bulk of humanity do not carry their " altruism " to such lengths. Such a way of regarding the linked intimacy of mental states and morbid digestive processes, may be alarming to sundry invalids and valetudinarians, but its consideration will be benefi- cial to a large class; and after all, Jeremy Bentham was right, when he insisted upon " the happiness of the greatest number" being the thing to be aimed at. For on the other hand, a mental state may operate beneficially. Dr. Carpenter continues— " But on the other hand, the same mental state may operate beneficially, in checking a morbid action and restoring the healthy state. That the confident expectation of a cure is the most potent means of bringing it about, doing that which no medical treatment can accomplish, may be affirmed as the generalized result of experiences of the most varied kind, extending through a long series of ages." He then instances cases of "cures" effected by faith, and says,—" For although there can be no doubt that in a great number of cases the patients have believed themselves to be cured, wdien no reed amelioration of their condition had taken place, yet there is a large body of trustworthy evidence, that, permanent amendment of a kind perfectly obvious to others, has shown itself in a great variety of local maladies when the patients have been sufficiently possessed by the expectation of benefit, and by faith in the efficacy of the means employed." It chap, vi.] SECONDARY INDIGESTION. 101 is quite clear in this matter, that the confidence of the patients will rest upon the confidence with which they are told that they will be cured. If the curer, or thauma- turgus, believe not in the cure, he cannot inspire thu patient with faith. If the medical man speak to the patient with doubtful accents and hesitating utterances, he does not inspire confidence ; he really sows distrust. This is the explanation of the successful treatment of a case by one man, where another has failed; the remedial measures being much the same. The one carries the patient with him to the restoration of health ; the other intensifies a morbid state, and tends to make it permanent. This is a matter too little thought about. Just as a weak-willed medical man fails to do certain patients good ; aT;;d lack of decision of character unfits a medical man for dealing with emergencies, where the judgment must be prompt and the action energetic ; so the therapeutic ni- hilist, who doubts the efficacy of drugs, and leaves the patient to nature, disheartens many patients, and leaves them chronic valetudinarians, when in the hands of an enthusiast, the cases would soon move onward to a satisfac- tory termination. There are some men who are " doubt- ing Thomases ;" there are others who decry what they do not understand, and depreciate remedies with whose po- tency they are unacquainted, who do infinite, immeasurable harm to their patients. An eclipse of faith in medicines has now existed some time ; but the darkness is beginning to move away, and a return of faith, stronger, firmer, more capable of giving a raison d'etre for its existence than in the past, is dawning,—the daybreak of happier times foi 108 SECONDARY INDIGESTION [chap. vi. those who are stricken down with illness, or crippled in their working power by incapacity in their digestive visiera This therapeutic nihilism is a passing wave of opinion, a temporary mental state, the end of which is at hand; and the sooner it is over the better for all. The patient's pros- pects will be all the brighter, the medical man all the happier for feeling that the patient has got some "value received" in return for his outlay. A healthier condition of thought On matters medical will generally obtain ; for quacks, charlatans, and irregular practitioners of all kinds, are to a great extent fostered by the recent want of faith in the medical profession. When a man is sick, what he wishes is to get well ; the means is to him a matter of comparative indifference. If he gets his health again, he recks little whether it is by the means of a notorious quack, or by those of some one possessed of the " hall mark " of the venerable College of Physicians. This is a moral aspect of the question which that ancient institution has been rather nodding over for some years past ; and it is quite time that it awakened up to a proper consideration of the subject. The public will not rest patiently quiet till its slumbers are completed ; and the sooner the period of awakening arrives the better for all. Stronger faith in the profession as a body, will lead to more belief in the individual units of it ; and this in turn will inspire the public. Perhaps those acrid personages who have a distinct line of faith, or rather the want of it, those individuals who believe in Homoeopathy, and talk flippantly of "Allopaths," who deny the utility of the Contagious Diseases Act (Human), who are anti-vacci- chap, vi.] SECONDARY INDIGESTION. 109 nators ; who are blended compounds of scepticism and credulousness ; those who are utterly unreachable from prejudice and ignorance "vaunting itself as knowledge,' cannot be benefited ; not even if their chief diurnal in- structor, their "guide, philosopher, and friend," the Daily News, was to modify its attitude, and shew a livelier in- terest in matters affecting the public health, and a little more decent respect for the observations of " the natural man." They are an unhopeful class, the obstructionists of all progress in matters sanitary and hygienic ; whose self-satisfaction in their ignorance on matters medical is simply as aggressive and impertinent as that ignorance is appalling. They are blinded guides in their self-ap- pointed mission of directing the opinions of mankind ; but their faith in themselves is unbounded ! Such then are the cerebral relations of disturbances in the digestive processes. They do not necessarily involve a disordered tongue, or constipation, or diarrhoea ; or manifest those evidences of dyspepsia, found when the indigestion is primary. There is another form of indigestion due to nervous dis- turbance elsewhere, which also carries with it no obvious signs of the digestive tract being the sole seat of trouble, as a bare, or raw, or a foul, or furred tongue ; but where con- stipation is commonly found. This is due to a tender ovary, mostly the left. This lies near the rectum, and the pas- sage of faeces causes pain ; the pain inhibits the movements of the bowel, and constipation is the result. The accu- mulated faeces keep up the ovarian tenderness, and the Voiding of them produces still more pain. And so the action 110 SECONDARY INDIGESTION [chap. vi. and reaction work in a downward direction. Such indi- gestion is properly termed "reflex." It is a very common malady which has been overlooked. It is mentioned by Negrier, Robert Barnes, and Lombe Atthill. I had to learn to decipher it for myself, and first described it in an article on " Ovarian Dyspepsia," in the American Journal of Obstetrics and Diseases of Women and Children, Jan., 1878, though it may have been delineated elsewhere ; but if so, I am not acquainted with the article. " The reproductive organs of woman are the source of most of her troubles during that period of her life when they are functionally active. Often will far-away irritation in the womb, or ovary, be found to be the cause of the moot prominent objective and subjective phenomena manifested elsewhere. Irritation is not always felt where it arises ; the pain is very commonly in the knee when the disease is in the hip-joint ; in the right shoulder when the liver is involved. We know that the pregnant uterus, especially in the early months before it has escaped from the pelvis, commonly produces very troublesome vomiting ; or it may produce a persistent cough, known in Scotland as ' a cradle cough.' Vomiting is a common outcome of injury to, or acute mischief in the testicle, as it is a pronounced symp- tom of a calculus in the kidney. The old term ' the sym- pathetic nerve ' was founded on the appreciation of the fact that one part was influenced by, or sympathized with, an- other through the fibrils of this nerve. Currents may arise in the ovary and be felt—not there when they arise—but at some far-distant point, where they run out. If a num- ber of ivory balls be suspended in a row, touching each chap, vi.] SECONDARY INDIGESTION. Ill other, and a tap be given to either terminal ball, it is the one at the other end which flies from its place. Conse- quently waves of nerve-perturbation, arising in the ovary, manifest themselves by disturbances elsewhere. The glit- tering flash which glances out from some female irides is the external indication of ovarian irritation, and ' the ovarian gleam' has features quite its own. The most marked instance which ever came under my notice was due to irritation in the ovaries, which had been forced down in front of the uterus and been fixed there by adhesions. Here there was little sexual proclivity, but the eyes were "ery remarkable. They flashed and glittered unceasingly, snd at times perfect lightning bolts shot from them, Jsually there is a bright glittering sheen in them which contrasts with the dead look in the irides of sexual excess, or profuse uterine discharges. Cough, palpitation, face ache, usually on the right side, inframammary pain, isually in the left sixth or seventh intercostal nerves, and gastric irritation are the ordinary outcomes of uterine flex- ion, or ovarian disturbance. The most important matters clinically are the gastric symptoms reflexly excited by pelvic irritation. " So important and so common are these maladies, and si) utterly unsatisfactory their treatment under the usual remedies—as bismuth, hydrocyanic acid, oxide of silver, £c.—that they deserve to be treated at some length. In the first place the stomach has different nerve-fibrils—■ {hose from the vagus, and those from the sympathetic. Claude Bernard observed that the application of a galvanic stimulus to the vagus fibres caused free secretion of the 112 SECONDARY INDIGESTION. [chap, tl gastric juice ; while the same stimulus applied to the sympathetic fibrils issuing from the semi-lunar ganglia, caused a diminution and complete arrest of the secretion. The action of sympathetic nerve-fibrils is to excite con- traction in the arteries and arterioles ; that of the pneumo- gastric fibrils to dilate these vessels. Consequently we can readily understand how currents coming in by the sympa- thetic tracts from pelvic, or other irritation, may contract the gastric arterioles and arrest the flow of gastric juice. If the irritation be sufficiently powerful then vomiting is set up. In ordinary digestion the gastric blood-vessels are dilated and there is a free flow of gastric juice. The irritation coming in from without checks both these pro- cesses, and then imperfect digestion with pain, or nausea is the result. This may not proceed further than loss of appetite, dyspepsia, and nausea : or there may be severo persistent vomiting set up by the introduction of food intc the stomach, till a very serious condition may be reached In either case the tongue is clean, and there are no evi- dences of disturbance in the gastro-intestinal canal, as ii primary gastric indigestion. Such is the dyspepsia s