ON DISEASES OF THE STOMACH. CHAPTER I. INTRODUCTION. THE function of digestion is essentially connected with life and health; and slight deviations from its normal performance produce suffering in a greater or less degree. He is, indeed, fortunate who can pass through his daily duties without having the thoughts and attention directed to those operations for the solution, absorption, and assimilation of nourishment, which in health are completed unconsciously, without attention, or sense of pain. If there be severe derangement of the digestive functions, not only is the attention directed to them, and discomfort entailed, but there is reaction upon the higher capabilities of man's nature: the energies of the brain are enfeebled, the memory is defective, the will vacillates, and the intellectual powers are less free to guide in daily duty, avocation, and research. The strength and muscular movements are diminished, and the pleasure of life changes to daily suffering and anxiety. Contrast the vigour of mind and body during health, with the enfeebled energy of the dyspeptic and hypochondriac. In the former state there is no impediment to the exercise of deep thought and labour, in any sphere to which the mind may be directed; the whole attention in the latter is absorbed by those functions, which are at best only subservient to the manly exercise of mind and will. If the digestive process be altogether checked, and no new supply of nourishment be absorbed and assimilated; if no restoration be made to the waste entailed by the exercise of every function, life must sooner or later cease; and disease, in its ravages, presents few spectacles more distressing to witness, than the gradual wasting of the frame, and cessation of life itself, from the non-supply of food. Thus the whole system sympathises with disorder of the alimentary canal. A knowledge of the structure and functions of each part of the digestive apparatus, is necessary for the right comprehension of its diseases. The structures of the alimentary canal are various, and their sympathies universal; but in health these are so combined as to form a beautiful and harmonious whole: thus, 1st, we find a mucous membrane richly supplied with glands, lining the alimentary canal throughout its course; these glands are for secretion and excretion; the secretions from these act physically or chemically in the digestive process, whilst the excretory glands separate noxious or effete principles from the blood. 2nd. Beneath the mucous is the muscular coat, essential for the execution of the required movements, and for the propulsion of the contents of the canal. 3rd. The peritoneal or serous covering, which by its smoothness permits of the movement of one portion of the intestine upon another, and allows distension to take place. 4th. The binding tissues, which are found between these previously mentioned tunics, and which support other equally essential parts, namely, 5th. The bloodvessels and lymphatics; and, 6th, the nervous supply from the sympathetic and cerebro-spinal nerve. As Abercrombie has remarked, in reference to diseases of the stomach, so also, it may be added, in reference to every part of the alimentary canal; for the proper performance of the function of digestion, the mucous membrane must be in health, the secretions normal, the supply of blood and nervous energy such as required, and the movements free. It must, however, be borne in mind, that the alimentary canal contains substances which are, strictly speaking, external to the living agency and control of animal life; and that those chemical forces, which we find in operation external to the body, act in the same manner within the stomach and small and large intestines the food becomes dissolved when the same solvents are provided, and other circumstances adapted, as to temperature, movements, &c., equally in a phial as in the stomach. The fermentation of its contents takes place in the stomach and canal, as well as in any chemical receiver; and these facts have to be remembered in the study, as well as in the treatment, of disease. Chemical force is in operation throughout the whole animal economy; it is modified and controlled by the living power, or it is free to act alone. Each of the parts which have been mentioned, may be alone diseased, or all conjointly; the symptoms arising from each are in some cases distinct, in others we cannot separate the one from the other. 1st. Mucous membrane and its secretions. The derangement of these constitute, perhaps, the greater part of the milder ailments of the alimentary canal. The symptoms vary according to the part affected: in the stomach, producing some of the forms of dyspepsia; in the intestines, constipation, diarrhoea, &c. But, when the mucous membrane alone is affected, it appears probable that pain is not produced, and this circumstance we must regard as a merciful arrangement. The lining membrane is exposed to varied causes of irritation, but we do not experience pain; if such were the case, every portion of undigested food might produce suffering; in some cases severe pain is found in indigestion, but this arises from an extreme sensibility of the sympathetic and other nervous supply of the stomach, &c., and, is not due to the mucous membrane alone. Dr. Beaumont, in his observations on the stomach of Alexis, sometimes observed the mucous membrane dry, injected, and much irritated without the production of pain; so, also, I have observed actual inflammation of the stomach, as found in cases of poisoning by oxalic acid, by chloride of zinc, and even by arsenic, without pain from first to last. 2nd. The muscular coat we find so stimulated, that it rapidly contracts, and impels onwards its contents; or, it is so enfeebled as to retain them; sometimes it is spasmodically contracted, or again, dilated, as in the forms of colic and flatulent distension, &c. These conditions appear to be productive of pain, sometimes of a very intense form, as we find in the griping of colic, and in enteritis, &c. As long as the peristaltic action is uniform, regular, and healthy, we are unconscious of the movement; but as soon as it becomes irregular or tumultuous, retarded or spasmodic, we are sensible of uneasiness, or even of severe pain; the muscular coat of the intestine is probably excited to contraction by the direct stimulus of its contents, but the harmony of its movements is due to the supply of nervous influence which it receives. 3rd. The peritoneal or serous investment also manifests its derangement by pain; and here, again, is a wise provision, for as its disorders require rest, or rather an absence of movement of the coils of intestine one upon another, and the pain of peritoneal disease is increased by muscular exertion, so the patient becomes prompted to assume that position, and to retain that state, which is the best suited for the restoration from disease. The observant pathologist and physician know, practically, the importance of rest in the recumbent position, and they follow the teaching of nature in their stringent directions: by this means inflammation is localized, and when perforations of the intestine have taken place, the injury is limited and life may be prolonged. 4th. The state of the investing or binding tissues; and, 5th, the supply of blood, are important considerations in the study of these diseases of the intestine. The former, in some cases, appears to be the seat of fatal malady, as in the forms of constriction of the pylorus, and in cancer. Still more does the latter, the supply of blood, call for attention: it may be in excess, as in active or passive hyperæmia; in pulmonary, cardiac, and hepatic diseases the engorgement of the mucous membrane leads to peculiar and characteristic symptoms; the rupture of vessels, or ulceration into them, causes hæmorrhage into the canal; and again, a scanty supply or depraved condition of blood prevents the proper performance of digestion, as after great hæmorrhage, in over-lactation, in purpura, scurvy, or starvation. The appearance of the blood discharged into the several portions of the canal greatly differs; thus, in disease of the stomach, it is generally ejected as dark semi-coagulated blood; sometimes, as in the latter stages of cancer, as coffee ground substance; or, in the acute disease of the stomach and duodenum, according to Dr. Fraser and others, as a green fluid. If, however, blood be passed into the duodenum, and discharged per rectum, it has a black and tarry character; and in proportion as the source of the discharge is near or more distant from the rectum, a sanguineous appearance is retained. 6th. The state of the nervous supply is often lost sight of; this is a most complicate system of nervous fibrils and ganglia, which are intimately connected with the cerebro-spinal centres, and with the ganglionic centres of other parts, as of the lungs, the heart, and the urino-genital organs. Many of the signs of intestinal disease arise from this cause, and they have been dwelt upon by various authors. In the Guy's Hospital Reports of 1856, I have described some dissections and observations on this supply of nerves; they surround the vessels, are distributed with them, and reach every part of the intestine. The sympathy of abdominal disease with other organs is due to this supply. In indigestion, we find cephalalgia, depression of spirits, impaired mental energy, disordered sensations of general or special sense; and all these arise from the connexion of the sympathetic and the cerebro-spinal nerve. So again, the throbbing of the vessels, the excited or irregular action of the heart in dyspepsia, proceed from the union of the cardiac ganglia with the solar plexus of nerves. With the lungs, the kidneys, the uterus, we notice similar sympathetic disturbance; and oftentimes, in a most marked manner, the skin is observed in close connexion with the internal mucous membrane; this disorder of the alimentary canal induces many forms of cutaneous eruption, as urticaria from partaking of mussels; or the more chronic diseases of lepra, eczema, &c. These sympathies may, however, be due to the vascular condition, as well as to the nervous relation, of one structure with another. This relationship of parts, however, sometimes acts in a reverse direction; the alimentary canal is affected, secondarily, from disease of other structures, for example, vomiting is a symptom of disease of the brain, of the kidney, and of the uterus. beside these, there appear to be symptoms of primary disease of the alimentary canal, which are due directly to the sympathetic nerve. 1. A remarkable depression of the pulse, which we often find in these diseases of the abdomen, when the pulse becomes soft and compressible, and often irregular. 2. A sense But |