The American Quarterly Review, No. 17, March 1831

by Various

Then again, our author has been told by a sufferer, that he felt as if a number of wires passed up from the stomach to the brain, and there ramifying into small branches, communicated a sort of jarring or vibrating sensation to each particular nerve. This is a perfect musical case of a dyspeptic, who has a sort of piano-forte stomach; we might fancy him exclaiming in the language of Shakspeare,—

"This music mads me; let it sound no more;
For though it have help'd madmen to their wits,
In me, it seems, it will make wise men mad."

Then come "pains between the shoulders and in the small of the back, cramps, stitches, pains in joints, with universal soreness and weariness." This is as bad as the plague, a very wilderness of agonies. Heaven guard us from them! To crown all, the sufferings of Caliban under the magical touches of Prospero are applied to the wretched dyspeptic, who has "cramps by night, and side-stitches to pen his breath up; old cramps (one attack is not sufficient) shall rack him and fill his bones with aches, making him roar so loud, that beasts shall tremble at his din;" this is the very climax of bodily suffering—long may we all be preserved from the Halsted Dyspepsia!

Error in diet, and want of proper exercise, are correctly assigned as two great causes of this disease; the former as respects the quantity, quality, time and manner of taking food, and the latter as it affects persons of a sedentary habit. These causes lead to actual dyspepsia, or a bad concoction of the food in the stomach, from whence the evils described arise; and which are sufficient of themselves, without adding to the list those affections, dependant upon diseases of other organs, although occupying the stomach as their seat, and all of which our author has indiscriminately classed under his sweeping term, dyspepsia. A very common error of diet, as respects the time and manner of taking food, is not treated of with sufficient force, when its baneful tendency is considered:—the custom that prevails, of dining within a very short period, sometimes only a few minutes, and returning immediately to the avocations of the day; the food is sent to the stomach only half masticated, and the system directly subjected to exertion, during which, the process of digestion cannot take place. If we make a hearty meal, and at once proceed to labour of any kind, the food remains for hours in an unaltered state; whereas, if we give a short repose to our bodies, by assuming an easy posture, and partially dismissing the remembrance of past, and the prospect of future cares, allowing, in fact, the whole business of life a short rest, as far as may be, the stomach will perform its office with ease and certainty. Mr. Halsted devotes one section to the consideration "of the particular condition of the stomach in dyspepsia;" and as he confesses that doctors differ on this subject, he kindly lends his assistance to relieve their indecision, by roundly asserting "that it consists mainly, in a debility or loss of power of action, in the muscular coat of the stomach." That a feebleness of the system may affect the muscular coat of the stomach, is far from a novel doctrine; but the idea that dyspepsia mainly depends upon this cause, is certainly as new as it is startling: the very meaning of the word would dispose us to consider that any want of action in the stomach, preventing the due concoction, or the breaking down of aliment for the purposes of nourishment to the frame, would apply to it, and, strictly speaking, it would; not that the muscular coat is alone, or the most powerful agent, in reducing the food to pulp or chyme; it is one of the many forces in the service of nature. It must be remembered that digestion, however well commenced in the stomach, is not perfected there; that, in the words of Dr. Mason Good, "it ranges through a wide spread of organs closely sympathizing with each other, and each, when disordered, giving rise to dyspepsia." After the formation of chyme, and the food has passed the pyloric orifice of the stomach, it undergoes a new process in the duodenum, when it is converted into chyle, probably by the action of the bile, although this is a point not absolutely determined by physiological experiment; even now, digestion is only half finished, the lacteals (a class of absorbing vessels particularly numerous in the duodenum, and also existing in the larger intestines) take up this fluid, for the purpose of conveying it into the thoracic duct, which terminates in the left subclavian vein, nor is the total process of digestion completed, until, in the language of the author above quoted, "it has been exposed to the action of the atmosphere, travelling, for this purpose, through the lungs, when it becomes completely assimilated with the vital fluids." Hence, although the meaning of dyspepsia must be restricted, as its derivations demand; the term, digestion, bears a much more extensive signification than it generally receives, and any error in its process may be properly denominated indigestion; however, Mr. Halsted regards the term dyspepsia as equivalent to indigestion, and we may, for once, adopt the same phraseology. Now, as digestion is of so complicated a nature, how will Mr. H. explain his reference to the muscular coat of the stomach as a chief cause of its derangement? Is he so admirable a pathologist as to discriminate, when called to a case of dyspepsia, whether, to use his own words, "it consists in a diminished quantity or vitiated state of the gastric fluid, in a morbid secretion from the inner coats of the stomach, or from a peculiar acid generated there; whether chronic inflammation of the mucous membrane of that organ, or a torpid state of the liver and a deficient secretion of the bile occasion it: it would appear that such conditions may exist, and then produce their different symptoms, requiring a modified treatment;" but it frequently happens that these cases, slight in themselves, determine principally to the stomach, and are not apparent to the keenest eye in any other organ upon the first attack. Besides, it is the practice of Mr. Halsted, when he discovers that the digestive apparatus is not originally in fault, but that a chronic inflammation of the stomach, or a torpor of the liver, prevails, to modify his treatment; this, at all events, is new doctrine, to treat inflammation and torpor upon modified principles. If, however, diagnosis is so slight an affair in his hands, let him, without delay, inform his countrymen at what college he studied, and what were his plans of improvement.—Pathology is a difficult science, and needs mentors to point out the best paths for its attainment.

The muscular coat of the stomach has undoubtedly its proper office to perform, and, failing in its functions, it may, in conjunction with other causes, lead to dyspepsia; but to fix upon this, in particular, is to negative the effects of other organs, and to deceive both your patient and yourself.

One of the most important discoveries in this work appears under the title of "the state of the abdominal muscles during dyspepsia;" which is pronounced to be a very characteristic feature of the disease, never yet noticed by writers on the subject, or particularly attended to by physicians. It would certainly have been somewhat strange for medical writers to enlarge upon a symptom of one disease, which absolutely belongs to another; or for physicians to attend to what they could not detect; and it is equally singular, that this very characteristic feature should only have favoured Mr. Halsted and his patients with a visitation. Whenever the muscles of the abdomen are in a state of constriction, as described by him, the usual cause is spasm of some part of the intestinal canal, produced by colic, either of an accidental nature, arising from some acrid ingesta, which irritate the bowels without producing diarrhœa, attended with griping pains and distention, and spasmodic contraction of the abdominal muscles, with costiveness; or of a bilious form, closely allied to bilious diarrhœa and cholera (Gregory.) These are the varieties of colic which have been confounded with dyspepsia, particularly the first described; the symptom alluded to has little or nothing to do with the office of the stomach, but depends chiefly upon acrid substances, which have passed from that organ, to exercise their pernicious qualities upon the intestines; the sufferings of Mr. Halsted, so pathetically described, may at once be referred to a fit of the colic, which a due want of care rendered very frequent.

Pass we now to the treatment, premising that a ride in a stage-coach led to the discovery of its advantages, and taking care, at the same time, of our abdominal muscles, lest the exertion of laughter should occasion one of the muscular spasms so much dreaded by our author. The plan is divided into four compartments; tickling, pickling, ironing, and throwing up the bowels. The tickling is performed by gentle taps and slight pushes in the pit of the stomach. (Who could bear it? It would throw nine patients out of ten into convulsions!) The pickling, by wrapping up the patient from the chest to the hips with flannel cloths, wrung out in a mixture of equal parts of hot vinegar and water. (This at all events tends to keep him.) The ironing, by spreading a coarse dry towel on the bowels, and passing over them "a bottle filled with boiling water, or, what is better, a common flat-iron, such as is used in smoothing linen, heated as warm as can well be borne, for fifteen or twenty minutes." Make an ironing-board of a patient's bowels! This is worse than all: a man might consent to be tickled and pickled—but to iron him for twenty minutes—mercy on us! the very thought is sudorific.

The throwing up of the bowels comes the last: fancy Mr. Halsted seated on the right side of his patient, and facing him; then placing his right hand upon the lower part of the abdomen, in such a manner, as to effect a lodgment (we quote his words) as it were, under the bowels, suffering them to rest directly upon the edge of the extended palm, and then, by a quick but not violent motion of the hand, in an upward direction, the bowels are thrown up much in the same manner as in riding on horseback, a sensation being communicated like that produced by a slight blow. (It is difficult to imagine who is entitled to the greatest admiration, the practitioner or the patient.) This treatment, it is said, will generally effect an increase in the strength of the pulse, a warmth in the extremities, and a gentle perspiration. So we should imagine: if such a mode of riding, with one's bowels in another man's hands, will not produce perspiration, what will? The position of the sufferer, during the last most remarkable process, may be occasionally altered, the practitioner taking his station behind him; or he may be placed with his back against the wall, whilst all these freedoms are taken with his bowels. Nay, more,—he may be instructed to perform the operation on his own person.

"Wer't not for laughing, I should pity him."

This, then, is the Halstedian treatment!