Part 71

Exhaustion of the nerves of organic life strongly predisposes to the atonic forms of dyspepsia. We have already seen how markedly the digestive process is influenced by certain mental states, and it is a well-recognized fact that the sympathetic system of nerves is intimately associated with all the vegetative functions of the body. Without a certain amount of nervous energy derived from this portion of the nervous system, there is failure of the two most important conditions of digestion--viz. muscular movements of the stomach and healthy secretion of gastric juice. This form of indigestion is peculiar to {441} the ill-fed and badly-nourished. It follows in the wake of privation and want, and is often seen in the peculiarly careworn and sallow classes who throng our public dispensaries. In this dyspepsia of exhaustion the solvent power of the stomach is so diminished that if food is forced upon the patient it is apt to be followed by flatulence, headache, uneasy or painful sensations in the stomach, and sometimes by nausea and diarrhoea. It is best treated by improving in every possible way the general system of nutrition, and by adapting the food, both in quantity and quality, to the enfeebled condition of the digestive powers. Hygienic measures are also of great importance in the management of this form of dyspepsia, and especially such as restore the lost energy of the nervous system. If it occur in badly-nourished persons who take little outdoor exercise, the food should be adapted to the feeble digestive power. It should consist for a time largely of milk and eggs, oatmeal, peptonized milk gruels, stale bread; to which should be added digestible nitrogenous meat diet in proportion to increased muscular exercise. Systematic outdoor exercise should be insisted upon as a sine quâ non. Much benefit may be derived from the employment of electric currents, and hydrotherapy has also given excellent results. If the indigestion occur in the badly-fed outdoor day-laborer, his food should be more generous and mixed. It should consist largely, however, of digestible nitrogenous food, and meat, par excellence, should be increased in proportion to the exercise taken. Medicinally, such cases should be treated on general principles. Benefit may be derived from the mineral acids added to simple bitters, or in cases of extreme nervous prostration small doses of nux vomica are a valuable addition to dilute hydrochloric acid. The not unfrequent resort to phosphorus in such cases is of more than doubtful utility. Some interesting contributions have been recently made to this subject of gastric neuroses by Buchard, Sée, and Mathieu. Buchard claims that atonic dilatation of the stomach is a very frequent result of an adynamic state of the general system. He compares it to certain forms of cardiac dilatation--both expressions of myasthenia. It may result from profound anæmia or from psychical causes. Mathieu regards mental depression as only second in frequency. Much stress is laid upon poisons generated by fermenting food in the stomach in such cases. It may cause a true toxæmia, just as renal diseases give rise to uræmia. Of course treatment in such cases must be addressed principally to the general constitution.

But of all predisposing causes of dyspepsia, deficient gastric secretion, with resulting fermentation of food, is perhaps the most prevalent. It is true this deficient secretion may be, and often is, a secondary condition; many causes contribute to its production; but still, the practical fact remains that the immediate cause of the indigestion is disproportion between the quantity of gastric juice secreted and the amount of food taken into the stomach. In all such cases we have what is popularly known as torpidity of digestion, and the condition described is that of atony of the stomach. The two main constituents of gastric juice--namely, acid and pepsin--may be deficient in quantity or disturbed in their relative proportions. A certain amount of acid is absolutely essential to the digestive process, while a small amount of pepsin may be sufficient to digest a large amount of albuminoid food. {442} Pure unmixed gastric juice was first analyzed by Bidder and Schmidt. The mean analyses of ten specimens free from saliva, procured from dogs, gave the following results:

Gastric Juice of a Dog. Water 973.06 Solids 26.94 Containing--Peptone and pepsin 17.19 Free hydrochloric acid 3.05 Alkaline chlorides 4.26 Ammonium chloride 0.47 Chlorine 5.06 | Lime 1.73 Phosphates | Magnesia 0.23 | Iron 0.08

They proved by the most careful analyses that fresh gastric juice contains only one mineral acid--namely, hydrochloric; since which time Richet has been able to prove that "this acid does not exist in a free state, but in loose combination with an organic substance known as lucin," the chloride of lucin. And just here the curious and puzzling question arises as to the secretion of a mineral acid from alkaline blood. Ewald, the distinguished lecturer in the Royal University of Berlin, tells us that "a brilliant experiment of Maly's has thrown unexpected light upon this. There are fluids of alkaline reaction which may contain two acid and alkaline mutually inoffensive salts, but still have an alkaline reaction, because the acid reaction is to a certain extent eclipsed; for instance, a solution of neutral phosphate of soda (Na{2}HPO{4}) and acid phosphate of soda (NaH{2}PO{4}) is alkaline. Such a solution placed in a dialyzer after a short time gives up its acid salt to the surrounding distilled water, and one has in the dialyzer an alkaline fluid outside an acid fluid." He thus proved that the acid phosphate of sodium is present in the blood in spite of its alkaline reaction.

Lack of the normal amount of the gastric secretion must be met by restoring the physiological conditions upon which the secretion depends. In the mean time, hydrochloric and lactic acids may be tried for the purpose of strengthening the solvent powers of the gastric secretion.

EXCITING CAUSES.--The immediate causes of dyspepsia are such as act more directly on the stomach. They embrace all causes which produce conditions of gastric catarrh, such as excess in eating and drinking, imperfect mastication and insalivation, the use of indigestible or unwholesome food and of alcohol, the imperfect arrangement of meals, over-drugging, etc.

Of exciting causes, errors of diet are amongst the most constantly 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.

Nausea and vomiting are only occasional symptoms of functional dyspepsia. When vomiting does occur it may take place at different times {450} and with varying degrees of severity, differing in this respect from the nausea and vomiting of subacute gastritis, which takes place, if at all, soon after the ingestion of food. The time of vomiting and the character of the matter ejected are liable to great variation in functional dyspepsia. It may be the result of direct irritation of morbidly sensitive gastric nerves, or it may be a reflex phenomenon; it may follow soon after the ingestion of food, or it may come on when the stomach is empty; the material vomited may be simply food but little altered or an alkaline ropy mucus; it may consist in the acid juices of the stomach or in a neutral watery fluid; or the ingesta may have undergone fermentative and putrefactive changes from either insufficient amount of the gastric solvent or from narrowing (constriction) of the pyloric extremity, in which case the yeast fungus (Torula cerevisiæ) or the Sarcina ventriculi may be found in great abundance in the vomited matter. Vomiting of this kind usually occurs some time after eating. The gastric juice itself checks putrefaction; so also does the admixture of bile. In the absence of these natural antiseptics fermentation takes place. But it would be erroneous to suppose that the fermentative dyspepsia is the primary disease; it is a symptom which can be permanently corrected only by correcting the condition upon which it depends.

Among the most noticeable of the phenomena referable to other organs than the stomach are those connected with the liver and the alimentary canal. The tongue in dyspeptic troubles varies much in character. In reflex sympathetic indigestion it is not unfrequently clean; in hepatic dyspepsia it is generally thickly coated with a white or yellow fur. The symptoms are such as pertain more especially to chronic gastro-duodenal catarrh, such as nausea, epigastric oppression, furred tongue, heartburn, acid eructations, flatulent distension of the stomach and bowels, unpleasant taste in the mouth, offensive breath, loaded urine, frontal headache, irritability, and hypochondriasis.