operative, and of these errors excess of food is doubtless the most
common. The influence of this as an etiological factor in derangement
of digestion can scarcely be exaggerated. In very many instances more
food is taken into the stomach than is actually required to restore
tissue-waste, and the effects of such excess upon the organism are as
numerous as they are hurtful. Indeed, few elements of disease are more
constantly operative in a great variety of ailments. In the first
place, if food be introduced into the stomach beyond
tissue-requirements, symptoms of indigestion at once manifest
themselves. The natural balance betwixt {443} supply and demand is
disturbed; the general nutrition of the body is interfered with; local
disturbances of nutrition follow; and mal-products of digestion find
their way into the blood. Especially is this the case when the
excessive amount of food contains a disproportionate amount of
nitrogenous matter. All proteid principles require a considerable
amount of chemical alteration before they are fitted for the metabolic
changes of the organism; the processes of assimilative conversion are
more complex than those undergone by fats and amyloids; and it follows
that there is proportional danger of disturbance of these processes
from overwork. Moreover, if nitrogenous food is in excess of
tissue-requirement, it undergoes certain oxidation changes in the blood
without becoming previously woven into tissue, with resulting compounds
which become positive poisons in the economy. The kidneys and skin are
largely concerned in the elimination of these compounds, and the
frequency with which these organs become diseased is largely due, no
doubt, to the excessive use of unassimilated nitrogenous food. Then,
again, if food be introduced in excess of the digestive capacity, the
undigested portion acts directly upon the stomach as a foreign body,
and in undergoing decomposition and putrefying changes frets and
irritates the mucous membrane. It can scarcely be a matter of doubt
that large groups of diseases have for their principal causes excess of
alimentation beyond the actual requirements of the system. All such
patients suffer from symptoms of catarrhal indigestion, such as gastric
uneasiness, headache, vertigo, a general feeling of lassitude,
constipation, and high-colored urine with abundant urates, together
with varied skin eruptions. Such cases are greatly relieved by reducing
the amount of food taken, especially nitrogenous food, and by a
systematic and somewhat prolonged course of purgative mineral waters.
Europe is especially rich in these springs. The waters of Carlsbad,
Ems, Seltzer, Friedrichshall, and Marienbad, and many of the alkaline
purgative waters of our own country, not unfrequently prove valuable to
those who can afford to try them, and their value shows how often
deranged primary assimilation is at the foundation of many human
ailments. The absurd height to which so-called restorative medicine has
attained within the last twenty years or more has contributed largely
to the production of inflammatory forms of indigestion, with all the
evil consequences growing out of general deranged nutrition.
The use of indigestible and unwholesome food entails somewhat the same
consequences. This may consist in the use of food essentially unhealthy
or indigestible, or made so by imperfect preparation (cooking, etc.).
Certain substances taken as food cannot be dissolved by the gastric or
intestinal secretions: the seeds, the skins, and rinds of fruit, the
husks of corn and bran, and gristle and elastic tissue, as well as
hairs in animal food, are thrown off as they are swallowed, and if
taken in excess they mechanically irritate the gastro-intestinal mucous
membrane and excite symptoms of acute dyspepsia, and not unfrequently
give rise to pain of a griping character accompanied by diarrhoea.
Symptoms of acute dyspepsia also frequently follow the ingestion of
special kinds of food, such as mushrooms, shellfish, or indeed fish of
any kind; and food not adapted to the individual organism is apt to
excite dyspeptic symptoms. Appetite and digestion are also very much
influenced by the life and {444} habits of the individual. The diet,
for instance, of bodily labor should consist largely of digestible
nitrogenous food, and meat, par excellence, should be increased in
proportion as muscular exercise is increased. For all sorts of muscular
laborers a mixed diet is best in which animal food enters as a
prominent ingredient. Thus, it has been found, according to the
researches of Chambers, that in forced military marches meat extract
has greater sustaining properties than any other kind of food. But with
those who do not take much outdoor exercise the error is apt to be, as
already pointed out, in the direction of over-feeding. It cannot be
doubted at the present time that over-eating (gluttony) is one of our
popular vices. Hufeland says: "In general we find that men who live
sparingly attain to the greatest age." While preventive medicine in the
way of improved hygiene--better drainage, better ventilation, etc.--is
contributing largely to the longevity of the race, we unfortunately
encounter in more recent times an antagonizing influence in the elegant
art of cookery. Every conceivable ingenuity is resorted to to tempt men
to eat more than their stomachs can properly or easily digest or
tissue-changes require. The injurious consequences of such over-feeding
may finally correct itself by destroying the capacity of the stomach to
digest the food.
But, on the other hand, in many nervous forms of dyspepsia the weak
stomach is not unfrequently made weaker by severely restricted regimen,
and especially is this the case with mental workers. Theoretical and
fanciful considerations sometimes lead to physical starvation. This is
apt to be the case with dyspeptics. Men who toil with their brain
rather than their muscles, whether dyspeptic or not, require good,
easily-digested mixed diet. It is a popular error to suppose that drugs
can take the place of such food, especially drugs which are supposed to
have a reconstructive influence over the nervous system, such as iron
and phosphorus. The expression of Büchner, "No thinking without
phosphorus," captivating to theoretical minds, has gained much
notoriety, and has doubtless led to the excessive use of that drug in
nervous forms of indigestion. There never was a period when phosphorus
was so universally prescribed as the present. It enters into endless
combinations with so-called nerve-tonics. Of the injurious influence of
the drug in many cases of functional indigestion there can be no doubt;
and the statement itself, so often quoted, that "the amount of
phosphorus in the blood passing through the brain bears an exact
proportion to the intensity of thought," is calculated to mislead. T.
K. Chambers, author of the excellent _Manual of Diet_, makes the
statement that "a captive lion, tiger, leopard, or hare assimilates and
parts with a greater amount of phosphorus than a hard-thinking man;
while the beaver, noted for its power of contrivance, excretes so
little phosphorus that chemical analysis cannot find it in its
excreta." In the wonderful adaptations and regulative mechanisms of
nature we may trust largely to the natural law of supply and demand in
maintaining a proper equilibrium. It may be doubted, indeed, whether we
require at any time more phosphorus for brain- and nerve-tissue than
can be found in such food as contains digestible phosphatic salts. The
natural demand for food grows out of healthy tissue-change. An appetite
to be healthy should commence in processes outside of the stomach.
Food may also be introduced into the stomach in an undigestible form
{445} from defects of cookery. The process of cooking food produces
certain well-known chemical changes in alimentary substances which
render them more digestible than in the uncooked state. By the use of
fire in cooking his food new sources of strength have been opened up to
man which have doubtless contributed immeasurably to his physical
development, and has led to his classification as the cooking animal.
With regard to most articles the practice of cooking his food
beforehand is wellnigh universal; and especially is this the case with
all farinaceous articles of food. The gluten of wheat is almost
indigestible in the uncooked state. By the process of cooking the
starchy matter of the grain is not only liberated from its protecting
envelopes, but it is converted into a gelatinous condition which
readily yields to the diastasic ferments. Roberts, in his lectures on
the _Digestive Ferments_, points out the fact that when men under the
stress of circumstances have been compelled to subsist on uncooked
grains of the cereals, they soon fell into a state of inanition and
disease.
Animal diet is also more easily digested in the cooked than in the raw
state. The advantage consists chiefly in the effects of heat on the
connective tissue and in the separation of the muscular fibre. In this
respect cooking aids the digestive process. The gastric juice cannot
get at the albumen-containing fibrillæ until the connective tissue is
broken up, removed, or dissolved. Hot water softens and removes this
connective tissue. Hence raw meat is less easily digestible.
Carnivorous animals, that get their food at long intervals, digest it
slowly. By cutting, bruising, and scraping meat we to a certain extent
imitate the process of cooking. In many cases, indeed, ill-nourished
children and dyspeptics digest raw beef thus comminuted better than
cooked, and it is a matter of observation that steamed and underdone
roast meats are more digestible than when submitted to greater heat.
Some interesting observations have been made by Roberts on the effects
of the digestive ferments on cooked and uncooked albuminoids. He
employed in his experiments a solution of egg albumen made by mixing
white of egg with nine times its volume of water. "This solution," says
Roberts, "when boiled in the water-bath does not coagulate nor sensibly
change its appearance, but its behavior with the digestive ferments is
completely altered. In the raw state this solution is attacked very
slowly by pepsin and acid, and pancreatic extract has no effect on it;
but after being cooked in the water-bath the albumen is rapidly and
entirely digested by artificial gastric juice, and a moiety of it is
rapidly digested by pancreatic extract."
It is a mistake, however, to suppose that cooking is equally necessary
for all kinds of albuminoids. The oyster, at least, is quite
exceptional, for it contains a digestive ferment--the hepatic
diastase--which is wholly destroyed by cooking. Milk may be
indifferently used either in the cooked or uncooked state, and fruits,
which owe their value chiefly to sugar, are not altered by cooking.
The object in introducing here these remarks on cooking food is to show
that it forms an important integral part of the work of digestion, and
has a direct bearing on the management of all forms of dyspepsia.
Haste in eating, with imperfect mastication, is a common cause of
indigestion in this country. Mastication is the first step in the
digestive {446} process. It is important, therefore, that we have good
teeth and that we take time to thoroughly masticate our food, for by so
doing we prepare it for being acted upon by the juices of the stomach.
Time is also necessary in order that the salivary secretion may be
incorporated with the alimentary substances. By the salivary diastase
starch is converted into sugar and albuminoids are prepared for the
action of the gastric juice. If these changes take place imperfectly,
the stomach can scarcely regain in gastric digestion what was lost in
imperfect mastication and insalivation. Haste in eating is one of the
American vices. It grows out of the temperament of our people. We are
jealous of lost time, and unfortunately this time is too often taken
from the stomach. We bolt our food with unseemly haste, and pay the
penalty in ruined stomachs. Many cases of indigestion are greatly
relieved, if not permanently cured, by simply doubling or quadrupling
the time occupied in eating.
Irregularity in the intervals between meals, such as taking one meal
only in twenty-four hours or taking food before the preceding supply
has been digested, is another fruitful source of indigestion. The
digestive process, in the natural order of change, is confused; changes
which should take place are delayed; and the results are such as arise
from excessive eating. Moreover, the stomach lacks the rest so
essential to digestion. The necessary interval, however, between meals
varies with the nature of the food taken. "Between the extremes of the
carnivoræ," says Ewald, "which feed once in twenty-four hours, and the
herbivoræ, which never have done with the business of feeding, man
holds a middle place, but not without permitting the recognition in the
course of his life of a sort of transition from the herbivora to the
carnivora. Infants should have the breast during the first three weeks
as often as they wake; after that every two hours to the third month;
then up to dentition every three hours; and later there should be five
meals in twenty-four hours." But to this general statement there are,
of course, many exceptions. Under certain pathological conditions food
should be taken in small quantities at short intervals. This is
especially the case in chronic gastric catarrh and in feeble digestion
of nervous subjects. Such patients are not unfrequently improved by
becoming again infants or herbivoræ. By the use of an exclusive milk
diet or peptonized milk gruels, given in small quantities at
comparatively short intervals of time, the stomach may be so
accommodated that it will digest without discomfort a large amount of
nourishment within a given time. To S. Weir Mitchell of Philadelphia we
are indebted for some valuable observations bearing upon this point of
forced alimentation.
To the causes of indigestion already alluded to may be added the habit
of spirit-drinking, especially the habit of taking alcohol undiluted on
an empty stomach, which rarely fails after a time to engender dyspeptic
symptoms. It is a prominent factor in the production of chronic gastric
catarrh--a condition more frequently present in painful indigestion
than any that have been named. It is one of the most common diseases
met with in practice. Indeed, all causes already alluded to involve,
sooner or later, if they are constantly operative, irritative and
catarrhal conditions of the mucous membrane of the stomach, so that we
find it difficult at times--indeed impossible--to separate purely
functional from subacute inflammatory forms of dyspepsia. Practically,
we simply study the {447} subject in the relative degrees of prominence
of the one condition or the other.
But, in a still more comprehensive sense, indigestion is caused by
disturbance of organs directly associated with the stomach in the
digestive process. All organs closely associated with each other in
their physiological functions are apt to become associated in morbid
action. The clinical recognition of this is a matter of great
importance in the management of gastric affections. And first in the
order of importance in such association is the liver. So closely,
indeed, are the liver and stomach functionally associated in the
process of primary assimilation that they may be considered parts of
the same great digestive apparatus. Hence disturbance of the
liver--either in the formation of glycogen, the destruction of
albuminoid matter, or the secretion of bile--is immediately
communicated to the stomach. It may be difficult to say which of these
separate and distinct functions of the liver is most at fault; that can
only be a matter of physiological inference. In the one case, for
instance, the dyspeptic may be fairly well nourished, yet his
elimination may be bad. In the other there is no failure of the
destructive and excreting functions, but those concerned in the
assimilation of fat and peptones are disordered, so that the patient is
not well nourished, so far as the fatty element is concerned. This is
the more common form, and a form not unfrequently associated with
pulmonary consumption. The liver finally becomes fatty--a condition
usually found associated with the constitutional forms of phthisis.
The pancreas is also closely associated with the stomach, and its
secretion is of essential value in the digestive process. It is to be
regretted that our precise knowledge of its diseases is in such
striking contrast with its importance in the animal economy, and yet it
can scarcely be doubted that in dyspeptic symptoms associated with
failure of digestion of starchy, albuminous, and fatty elements of food
there is disorder of the secretion of the pancreas. Hence in the
treatment of the early stages of pulmonary consumption and other
disorders associated with deficient digestion and assimilation of fatty
substances the importance of directing our attention to the condition
of the liver and pancreas, as well as to the stomach.
That morbid states of the intestinal track occupy a prominent place in
the etiology of dyspepsia is also a well-recognized clinical fact.
Indeed, constipation of the bowels is an almost universal accompaniment
of deranged digestion, and when persistent for years it is apt to lead
to the most disastrous consequences. These are mainly in the direction
of lessened elimination from the intestinal glandulæ. The general
symptomatology of deficient excretion from these glandulæ is closely
analogous to the same condition of the liver: there is impairment of
the general health; the clear florid complexion disappears; the patient
becomes of a greenish or sallow hue; the blood is altered in quality;
fatigue is experienced after the slightest exertion; the nights are
restless; and there is great tendency to mental despondency. Moreover,
constipation often precedes the gastric symptoms. The diminished
muscular activity of the intestinal track extends to the stomach; its
movements are diminished; food is not properly mixed with the gastric
juice, and by being too long retained in the stomach in a comparatively
undigested state acetous fermentation in the saccharine and starchy
articles of diet is set {448} up, acid eructations and a sour taste in
the mouth being commonly complained of. Dyspepsia associated with this
condition of the intestinal track cannot be relieved until the
constipation is relieved, and by overcoming the constipation the
dyspeptic symptoms often disappear.
Mention has been made of the baneful influence of certain mental states
in the production of dyspeptic symptoms. But there are forms of
indigestion due to local nervous disturbance existing elsewhere than in
the nerve-centres. This was ascribed by the older writers to what they
termed consensus nervorum, or sympathy, by which "the operation of a
stimulus is not limited to the nerves immediately irritated, but is
extended to distant parts in known or unknown connection with the
irritated nerves." An intimate acquaintance with this law of sympathy
is of the utmost importance in the study of the functional forms of
dyspepsia, for no other organ of the body is subjected to such a wide
range of reflected nervous disturbance as the stomach. Morbid
sympathetic impressions are transmitted mainly through branches of the
vaso-motor nerve of the semilunar ganglia of the abdomen, and from the
pneumogastric to the stomach. Thus, a pregnant uterus not unfrequently
produces very troublesome vomiting; some females suffer from nausea and
indigestion during each menstrual period; and the more chronic forms of
pelvic irritation, such as a flexed uterus, and endometritis,
cervicitis, or tender ovary, may be the continuous exciting cause of
most troublesome forms of nervous dyspepsia. There is also close
sympathy of the stomach with the lungs and heart through the
distribution of the pneumogastric. So also may fixed points of
irritation in any part of the nervous system be reflexly transmitted to
the stomach, giving rise to most pronounced symptoms of indigestion.
And it is evident that in all such cases but little can be accomplished
in the way of relieving the dyspeptic symptoms until the cause upon
which they depend is removed. The treatment must have reference mainly
to the removal of such cause.
Lastly, all the causes mentioned finally concur in producing
irregularities of the mechanism of digestion; and this may be done by
disturbing either the muscular movements of the stomach or in
suspending or perverting the gastric solvents, or in these two
conditions combined.
SYMPTOMS.--1st. Referable to the Stomach.--The symptoms which attend
and indicate the presence of functional dyspepsia are such as accompany
in a greater or less degree almost all cases of chronic gastritis.
Clinically, so far as the direct gastric symptoms are concerned, it is
difficult to separate them. The more prominent of the local symptoms
are--a sense of fulness and distension after meals, discomfort during
the digestive process, derangement of appetite, acid eructations,
flatulence, regurgitations of food, and sometimes nausea and vomiting.
There is seldom severe pain; the sensation is rather that of
uneasiness. Exceptionally, however, there may be pain, which radiates
from the stomach to the shoulders, and may pass down the left arm so as
to simulate angina pectoris. But it may be readily distinguished from
that complaint by coming on after food, and not after exertion. In
other cases a sense of constriction may be accompanied by dyspnoea,
arising from impeded movements of the diaphragm from being pushed
upward by the distended stomach, or there may be heartburn, with an
ill-defined sense of burning felt in the epigastrium; {449} but thirst,
so frequently present in chronic gastritis, is, as a rule, absent in
functional dyspepsia. These symptoms are manifested in varying degrees
of prominence in individual cases, and some of them are rarely found
present. Thus, nausea and vomiting are not characteristic features of
the chronic forms of functional dyspepsia, and as a rule epigastric
tenderness is entirely absent. In markedly hysterical subjects or in
persons whose nervous system has been unduly excited by alcohol there
may be shrinking from the slightest touch upon pressure; but in these
cases the tenderness is not confined to the stomach, nor is it
increased by deep pressure. In some cases there is an unnatural craving
for food--a symptom rarely if ever observed in structural lesions of
the stomach--and now and then it happens that the appetite becomes
depraved, especially with hysterical patients. They crave indigestible
and unnatural substances, such as earth, chalk, and substances wholly
devoid of alimentary properties. Impairment of appetite, however, is
the more common feature of this form of indigestion.
Flatulence and eructations are generally complained of, the flatulence
being accompanied by a painful sense of fulness, affecting in equal
degree the stomach and small intestines. It is derived principally from
putrefactive or fermentative changes of the ingesta, which are
imperfectly elaborated in the stomach. The gases consist of carbonic
acid, sulphuretted hydrogen, hydrogen, nitrogen, and the hydrocarbons,
the butyric and acetic fermentations furnishing the hydrogen and
carbonic acid gas. In addition to these marsh gas is formed by a
special fermentation, the basis of which exists in the cellulose taken
with vegetable food. In excessive meteorism from paralysis of the
intestines the gas is principally nitrogen; the marsh-gas fermentation
results from the ingestion of certain easily-fermentable vegetables,
such as cabbage, cauliflower, etc.
In a certain proportion of cases regurgitation occurs from the stomach.
The liquor regurgitated may be intensely acid from the presence of some
of the fatty acids, probably butyric, lactic, or acetic. Exceptionally,
it may be insipid or brackish, constituting what is known as pyrosis,
or water-brash. The fluid is usually tasteless and without smell, and
in reaction it is neutral to test-paper. It contains sulphocyanuret of
potassium, and it has been supposed therefore to be only saliva. The
quantity thrown up may vary from a spoonful to a pint or more. It
affects females more than males, and especially those who subsist upon
coarse and indigestible food. It is best treated by astringents--such
as kino, krameria, logwood, or tannin--administered in the intervals
between digestion, so that they may act directly on the mucous
membrane. The oxide and nitrate of silver are thought by some to be
superior to the vegetable astringents.
Cardialgia is a painful condition of the stomach, usually referred to
its cardiac orifice, and is popularly known as heartburn. It is met
with in both functional and organic disease of the stomach. It is very
constantly present in chronic catarrhal gastritis, and evidently
depends upon the presence of an acid, for it is usually promptly
relieved by alkalies, such as chalk, magnesia, soda, or alkaline saline
waters. Food containing much fat, starch, or sugar should be avoided.