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one who has not left ample room and verge enough for a new and enlarged consideration of the subject. The single topic of hypochondriasis and its connexion with gastric symptoms would of itself form material for a chapter of some length. Yet so little have our recent authorities on diseases of the stomach found it to be within the somewhat narrow range they have prescribed to themselves, that there is hardly a hint to be found in any of them upon the subject. So important a morbid relation should not be given over to the quacks.

And here we are tempted to make one remark tending to a less inglorious view of the connexion of dyspepsia with an advancing civilization than that we have put forth, half in jest, at the beginning of this article. May it not be that, with the growth of man in intelligence and moral elevation-in proportion as spirit rises supreme over matter the sensibility of the whole nervous system is exalted, and its diseases, or functional derangements, are rendered proportionately important? It is the characteristic of an intellectual age to suffer the penalties of an over-worked or ill-worked brain. But among these penalties a restricted digestive faculty is perhaps first in rank and in frequency. It is the inexorable fate which binds the intellectual workman to the earth, and reminds him that he must not follow his aspirations to the neglect of the machinery that controls the very power of thought. The lowest of his appetites holds him in check, as if to remind him that true wisdom is not in rising above human nature, but in submitting gracefully to all its limitations.

But we must not linger on this subject. Suffice it to say that the entive sketch of dyspepsia, considering it only as a sketch, is excellent; the analysis of its multiform symptoms and of their combinations being at once simple and comprehensive, and the treatment equally judicious and clearly stated. In the general description of the symptoms of gastric disease, the author is not less successful in producing a trustworthy picture of a difficult subject; and the ideas, even if not absolutely novel, are often so strikingly enunciated as to have the effect of novelty. The following passage on gastric pain is important. After showing that a high degree of tactile sensibility is unnecessary" (he might say "would be positively injurious") to the stomach in the discharge of its function, and that therefore no such sensibility has been accorded, the author proceeds:

"But we are not, therefore, to imagine this important organ really insensible to stimulation, or to suppose that, because it is not every moment arousing the brain of its master, and demanding his forethought or exertion, it remains unimpressed and inactive. On the contrary, we must rather conclude that it has a special sensibility of its own, not one whit less marvellous (but surely more so) for possessing a certain independence of the cerebro-spinal centre. Closely related to this centre by the feelings of hunger and satietynay more, dictating to it (so to speak) those exertions which the proper alternative of these two states imperiously demands from the mass of mankind-it has a sphere of action altogether its own. And the study of digestion has shown us how admirably and silently the stomach fulfils its various and complex tasks; and how, incidentally to these, the unfelt particle of food no sooner touches its mucous surface than it excites the flow of a variety of secre

tions, both far and near, and provokes movements in the muscular substance of its walls and vessels, as well as in the analogous structures of neighbouring parts. To these acts, which respectively constitute the sensation and motion of the healthy stomach, its morbid states afford an instructive parallel. And just as the kind of sensibility specific to a healthy muscle-the feeling of its strength, its equilibrium, its measurable force-seems to be traceable by gradual modifications, through healthy fatigue to the feverish soreness of overexertion, and through this to the universal muscular pain and prostration of various grave general ailments, so the indistinct sensation of the healthy stomach affords us the best clue to the acute sensibility of the diseased one, and allows us to trace a scale of a similar kind-from satiety to repletion; from repletion to distension and weight in the epigastrium; and from hence to the dull heavy aching of dyspepsia, the gnawing or burning pain of ulcer, and the sharp agony of cancer of the stomach." (pp. 48, 49.)

Again, a few pages further on, we find the following:

"The pain of gastric disease is grave in proportion not only to its severity, but also to its concentration and fixedness. In other words, a severe and continuous pain, confined to a single spot of small size, is a more serious indication than one which at times of equal (or nearly equal) severity, fluctuates in its different attacks, and ranges the epigastrium, of which it habitually occupies a wide area. Pain is graver in or near the median line, not only because (for many reasons which will readily suggest themselves) it is, cæteris paribus, more certainly gastric here than elsewhere, but because this situation (at least, such is my opinion) indicates a more serious derangement of the innervation of the organ than when the pain has a less exact correspondence with the solar plexus. Lastly, of all situations, a median and dorsal one (in anatomical language rachidian, and ranging from interscapular to lumbar), which is usually an addition and complication to a previous epigastric pain, is the most serious-so much so, that it will rarely be found associated with any but the graver gastric dyspepsias, and belongs chiefly to deep ulcers, or to cancerous lesions of the stomach, involving all its coats." (p. 53.)

There is excellent matter for thought in all this; and it suggests, as does the whole book, the idea that more has been thought than is written. We would, however, interpose a caution which arises to our minds in copying these passages. Let the author jealously guard against his besetting sin, which is the over-use, sometimes amounting to abuse, of parentheses, commas, dashes, and all the other means invented by modern typography, for presenting sentences to the eye in the highest state of literary perfection. The necessity for employing to the utmost these arts of the intellectual cuisine is not always consistent with that robustness and vigour of style which is to be cultivated as the highest type of health; it rather indicates a kind of mental dyspepsia, not seriously affecting the vitality of the author, but interfering somewhat with his comfort and with the satisfaction of his readers. Let him take in good part this hint from a fellow-sufferer, who has had to make great exertions, perhaps only in part successful, towards overcoming this malady. It is only a "danger-signal," and possibly prophylactic of graver evils; but it requires watching.

In speaking of vomiting, the author advances the view that it is essentially an act of the cerebro-spinal centre, whether produced by reflex transmission of nervous influence, or by direct irritation. Even


when the cause of irritation is introduced into the stomach, he holds that it operates not always through the special nervous systems of the abdomen, but (at least in the case of tartar-emetic) through a multitude of disturbed functions connected with the absorption of the poison into the blood, and telling their tale of distress upon the cerebro-spinal centre. This view is no doubt correct, at least as regards those poisons which, like tartar-emetic, produce the same results when introduced into the stomach and into the blood. We think that an important distinction is to be drawn, in this point of view, between different kinds of emetic substances. Some, like mustard, and, perhaps, sulphate of zinc, appear to act by direct irritation. Their operation is sudden, quick, complete as regards evacuation, but attended by little nausea, and no more permanent result than emptying the viscus. Others, like arsenic and antimony, are really very uncertain in their emetic effect (dose for dose), as compared with the preceding; but they produce grave constitutional disturbance, and the nausea, prostration, and death, which is their maximum result, are induced fully more readily by moderate than by large doses, because the latter tend at once to emesis, and, therefore, to removal of the poison. In connexion with this elimination of irritant poisons by vomiting, Dr. Brinton has performed a remarkable experiment, which seems to assign to the stomach a higher office than that of merely resenting the presence of a deleterious substance. It would appear probable that the stomach is really an excretory organ of the first importance, as regards tartar emetic; for that poison, when injected into the blood of a dog, is soon found in the stomach "in a state of concentration much exceeding that in which it must have been mingled with the mass of the blood."* This is a very important doctrine in relation to general pathology. Dr. Brinton points out that vomiting in disease must probably often be considered as an eliminative act; and he refers, in illustration, to the vomiting at the commencement of fever. It is certainly a remarkable fact, that among the various means which have been proposed for cutting short the attack of contagious fevers, the only one which, to our mind, has any good authority, or any considerable amount of evidence in its favour, is that of an emetic administered during the first few days; and it is worthy of notice, that the class of emetics always recommended for this purpose consists of those which in all probability enter into the blood, and shake the nervous system to its foundations previous to their action on the stomach. These facts are strongly corroborative of the author's ingenious theory; which, moreover, derives additional interest, if not strictly scientific support, from the evident manner in which it would demonstrate the "final cause" of that kind of vomiting which accompanies poisoning by arsenic and antimony, when introduced into the system by other channels than the stomach. There is a purpose, too clear to demand explanation, in the selection of the stomach as the leading channel for the elimination of injurious substances, which find by that organ their usual entrance into the economy.

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See p. 61 of this work, and the author's article, Stomach, in the Cyclopædia of Anatomy; also the Lancet' for 1858, vol. ii. p. 599.

In regard to hemorrhage, Dr. Brinton of course repudiates the old doctrine of hæmatemesis "by exhalation." It is certainly true that some cases of fatal gastric hemorrhage are very puzzling to the morbid anatomist; but, as the author remarks, it is not surprising that "amongst the myriads of these minute tubes present (in the mucous membrane), the eye often fails to detect the exact vessel or vessels involved in the lesion." Dr. Brinton believes, and we think correctly, that the inter-tubular vessels are rarely the seat of hæmorrhage as compared with the superficial, or supra-tubular network. We believe, in fact, that the majority of what are called the " hæmorrhagic erosions" of the gastric mucous membrane are the result of direct irritation, acting perhaps upon a mucous membrane accidentally denuded of its protective covering. And, if we mistake not, a very considerable proportion of the minute microscopic lesions described by recent authors are, in like manner, mechanical or chemical in their origin, whatever their importance or insignificance in regard to gastric pathology. This is evidently Dr. Brinton's view in so far as he goes into detail. Though he has apparently not been inclined to make a very pointed critical analysis of the observations of Dr. Handfield Jones on this subject, we gather from a few hints his opinion that an exaggerated importance has been assigned by that able pathological anatomist to appearances, the result, in many instances, of decomposition and manipulation of the mucous membrane. The recent researches of Dr. Wilson Fox will probably bring the subject once more under consideration, but we cannot stop here to enter upon it; nor, indeed, do we feel that we have a right to assume a tone of authority in relation to a matter depending on such delicate investigation. Certain it is that no intelligible relation has as yet been pointed out between the multitude of post-mortem changes, and the functional state of the organ during life; and, till this is done, we must decline to admit into the rank of diseases what are, at best, only problematical appearances of disease.

Dr. Brinton's doctrines on flatulence and on the symptoms connected therewith, are in some respects peculiar; and here we shall not say that he absolutely carries our convictions, but unquestionably he makes good show of weighty argument in favour of his own views. He entirely rejects the idea of secretion of air into the intestinal canal as a cause of this symptom; pointing out that the gas of flatulent intestines, even when not containing elements which cannot be procured from the blood in appreciable quantity, differs altogether in composition from the usual gaseous products of the system as evolved in expiration. "It contains," he remarks, "ten times the quantity of carbonic acid, and two hundred times the quantity of nitrogen found in expired air; and he argues, not without force, that gas of this composition is much more likely to be evolved from the food than from the process called "secretion," which has only been hypothetically called into existence to account for cases of enormous flatulent distension occurring within a very short period of time. Still, this is only, after all, a question of probability, and it does not appear impossible

that the gas of secretion may, when separately procured, present a different composition from that which has hitherto been analysed as intestinal flatus. Dr. Brinton lays great stress on the fact that in sudden and complete starvation the gases disappear from a great part of the canal; but the stoutest advocate for secretion will not deny, now-adays, that gases are evolved in large quantity from the food; and, further, that the absence of food from the system diminishes, as respects the blood and the tissues, the sources from which waste gaseous matters are to be drawn, according to the hypothesis. The experiments of Magendie and Girardin (incidentally repeated by Frerichs), according to which gas is found in a coil of intestine for some time isolated by ligatures, and previously emptied by pressure, is objected to by Dr. Brinton on the ground that it is impossible by pressure entirely to empty the intestine of its contents; and that a single grain of starch or sugar remaining would, under decomposition, evolve gases equivalent to eight cubic inches of space. Surely this experiment is important enough to justify its repetition with additional precautions. There could be no difficulty, one would think, in washing out every particle of starch or of sugar from a coil of intestine, previously to the application of ligatures; besides, the character of the gases evolved would, in this case at least, be ascertainable, and would be of great importance to the inquiry. This experiment is really crucial as respects the doctrine of secretion; and we cannot consider the negative of Dr. Brinton as carried until it has been thus tested.

Dr. Brinton insists much on the pressure to which the intestinal gases are subjected, as modifying their bulk, and believes that many of the cases of apparently sudden evolution of gas are really due to the expansion of the gas already in the intestinal canal by the temporary paralysis or at least relaxation of part of the wall. He explains the tympanitic distension of peritonitis in this way, and also that gastric flatulence which is the rapid result of taking a few mouthfuls of improper food. In the latter case, he believes that the irritation induces,-1st, an abnormal sensation, sometimes amounting to pain, or at all events to an impression on the nerves of the part, which causes, 2nd, a relaxation in the coats of the stomach, and thereby, 3rd, expansion and rarefaction of its contained air; 4th, a secondary rush of air from the duodenum through the relaxed pylorus; 5th, increased sense of pain or uneasiness by over-fulness of the stomach; 6th, expulsive efforts of eructation. This view, which undoubtedly is favoured by many facts in the symptomatic history of colic and other flatulent affections, will bring to the mind of the reader the late Dr. Abercrombie's observations on ileus, which led him to the doctrine that spasm, commonly so called, was no part of the pathology of that affection, but rather a paralytic relaxation leading to over-distension of the bowel and undue retention of its contents. The most important novelty, perhaps, of Dr. Brinton's view is the idea that the pain of such attacks is not the effect of the accumulation so much as its cause, or at least its antecedent. The pain is the expression of an outraged sensibility, so to speak, of the mucous membrane; the paralysis and

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