has been losing flesh previously or not, which arises from the organs of waste being the first to regain their due action.' We were at first somewhat surprised at this observation, and could not recollect any instance in our own practice where such an occurrence had had place. On reading, however, a little further, we discovered that Dr. Philip alludes to that bloated and unhealthy bulkiness of the body in which the system is rather puffed up and bloated than really overnourished. The secretions in these cases appear imperfect throughout the whole animal economy, and the fat thrown out is of a medium consistency between actual health and edema. The countenance exhibits in fact that appearance which has been termed leucophlegmatic. The loss of blood, therefore, in this case, is not, we apprehend, a true loss of flesh, but rather of this unhealthy secretion, arising perhaps not so much from the organs of waste being first to regain their due action, as from the secerning vessels regaining theirs, whence fat more perfectly elaborated, but smaller in quantity, is laid down. The immediate consequence of this is a diminution in bulk, because even should the absorbents exert no more than their usual energy, the supply being less than before, the size of the body must decrease, though the muscular system is actually at the very same time on the increase. Under these circumstances, therefore, the loss of bulk must certainly be regarded as a favorable symptom. The explanation we have offered of this phenomenon may appear superfluous, because the fact being allowed, the indi cations of treatment remain the same. It is, however, more consonant to our general knowledge of the absorbent system; for hitherto no proof has ever been adduced of its energy being diminished in disease. On the contrary, it acts with apparently increasing energy as the general system becomes weaker, and even remains active when all the other functions of life have ceased. The loss of bulk can only be considered favorable, as we have stated, when it is attended with increase of strength, or at least without its diminution. But when an opposite progress has place, and the strength diminishes, the disease will generally prove extremely difficult to cure. Philip, justly considering this symptom as one of much importance, enters into an examination of its causes, some part of which we extract. Dr. 'It evidently arises from several causes, but I believe chiefly. from the following. All causes of irritation tend more or less to excite a feverish state. Hence the tight pulse, and frequent occurrence of some feverishness, particularly towards evening, in the second stage of indigestion, one of the most severe and obstinate causes of irritation. The tight pulse, indeed, which is always present in a greater or less degree at this period, constitutes itself a certain degree of feverishness, and, when considerable, is accompanied with all its essential symptoms. The vessels, in consequence of the continued irritation of the most sensible nerves of our frame, are excited to embrace the blood more strongly than in health; hence the tight pulse. Now this state, though a morbid one, tends for the present to support the strength, and we know, when in the extreme, will even give a preternatural degree of strength. I have repeatedly been consulted by dyspeptics, who said that the most unaccountable peculiarity of their case was, that they never felt tired, but felt as if they could walk forever. This, so contrary to what is usual in indigestion, arises from peculiarity of habit; but strikingly illustrates a point of great importance in the nature of the disease. In such patients, the nerves are so braced by the tightened circulation, as not only to obviate the usual debilitating effects of the irritating cause, but even to give a preternatural vigor. 'Could we suddenly relieve the dyspeptic from the causes of irritation to which he has been so long subject, by at once removing the disease, he would feel a depression of strength, till the nerves had accommodated themselves to the change. The tightened state of the circulation would be relaxed, and the effect of this would be increased by the secreting surfaces, which were bound up, beginning to separate more freely their various fluids, and also by the alimentary canal being less distended with flatulence, and a collection of undigested food, which, however injurious, for the time gives tension, and therefore tone.' The direct inference from this reasoning is precisely that which has been long confirmed by experience, namely, that dyspeptic patients very ill bear any sudden change in their habits. However injurious may be the tendency of stimulants, to withdraw them suddenly is even more prejudicial. It has not unfrequently occurred to ourselves to see patients who had been thus treated. All stimuli had been forbidden to individuals who had been accustomed to take them in great excess. The result was so quick and complete a prostration of strength, as really to deserve the epithet of frightful. Every function seemed about to cease at once, and the patient passed rapidly from one fainting fit into another. We are the more inclined to press this circumstance on our readers, because, if we recollect rightly, Mr. Howship has inculcated a contrary practice, and maintains that he has never seen any ill effects to proceed from a sudden change from a highly stimulating to a mild diet. That he may have met with such instances, is not improbable; but they are certainly exceptions to the general rule. Another cause of depression in the commencing treatment of dyspepsia, is the impossibility of relieving cases of long standing, without some of those measures which more directly soften and relax the secreting surfaces.' These measures are of an antiphlogistic kind, but require extreme caution and sagacity in employing them. Without recurring more or less to their employment, it will be often found impossible to make any impression on the disorder, and yet a very slight excess in depletion will induce the most obstinate hysterical affection. It is also no unusual consequence of bleeding, especially if it be general, to induce an increased flatulence, but which is usually very transitory; and if the inflammatory tendency be sufficiently overcome to admit their administration, readily yields to the use of tonics. The following remarks of Dr. Philip so perfectly coincide with the result of our experience, that we would particularly recommend them to the attention of our readers. The difference in the manner in which different individuals bear the changes necessary to recovery, in advanced states of the disease, is very remarkable. In some, the habit may be quickly altered, with but little depression of strength; while in others, it requires all the attention of the physician to prevent a considerable degree of it-such is the difference of constitution. The treatment should be regulated accordingly, and any great degree of depression prevented. The physician may overlook the essential change which takes place in the progress of indigestion, and constitutes the difference between what I have called the first and second stages; but it is impossible for the patient himself to overlook it. We constantly find dyspeptics declaring that the stimulants which used to relieve them seem now to do harm; and that they cannot continue their use for many days together, though the sense of depression which they feel on abstaining from them, still impels them to return to, and even to increase them, by which they never fail to aggravate the disease. They are taking a course exactly the reverse of the only one which leads to health. In this disease, it is common to recommend change of scene, a mild and nutritive diet, mineral waters, and no inore medicine than the patient finds absolutely necessary; and there is a great deal of good in all this; but in a very large majority of such cases these means prove ineffectual. The cure is then said to be hopeless, and the patient must use the means which his experience tells him suit him best, and make himself as comfortable as he can. In such cases, a permanent cure can generally be effected by no other means than simply removing the tight pulse and bound state of the secreting surfaces, by gradually weaning the patient from his stimulants, at first rejecting the more powerful, and combining the milder with those means which, without acting as stimulants to the stomach, already too much stimulated, both by the disease and the means employed for its relief, excite the organs, to which the debility, originally confined to the stomach, has now spread; in consequence of which the system is neither receiving what it ought to receive, nor throwing off what it ought to get rid of; and thus the disease, in one of its most distressing, and in by far its most obstinate form, is prolonged. When this necessary change of measure produces depression, the remedy is simply to make it by slower degrees, to make the dose of the alteratives extremely small, and to retain as much of the tonics as will not materially interfere with the only means of restoring health.' Excess in diet is yet another source of this depression; and,' excepting where very highseasoned dishes are eaten, we believe the quantity to have much more effect than the quality of food on dyspeptic patients. In the treatise to which the present small volume is only an appendix, Dr. Philip has entered at consi derable length into the different qualities of dietetic articles. It is not, however, the part of the volume which is in our opinion the most useful; and it is quite impossible that it can be founded on data universally applicable: for, in the first place, no two stomachs will digest the same food with equal ease,-nor will the same stomach, even in apparent health, at all times enjoy the same digestive energy. In the second place, by some delicate stomachs the less digestible food will be more readily assimilated than food more generally digestible. Thus many instances have fallen under our observation, in which lobsters and other shellfish have been commonly eaten without inconvenience, though the same individuals have been easily disordered by common aliment, though taken moderately. We do not certainly mean to contend, that there is no difference in aliments themselves; or that there are no general rules by which medical practitioners may direct their patients; but that our know ledge of the various kinds of food is not so precise as to enable us to distinguish accurately between articles of the same nature. To say the truth, we do not believe that mutton is more digestible than beef, or venison than mutton. We scarcely care whether our patients take turkey or common barndoor fowl; and we are not very anxious that they should prefer partridges to pheasants, or Woodcocks to wild ducks. Neither do we believe, that there is much difference in the digestibility of fish, provided they are eaten simply, and without their usual accompaniments of butter and rich sauces. But we do be lieve, that one and all of these are capable of doing great injury to the digestive organs and to the constitutional vigor, if taken in excess; and this excess is to be calculated not by the actual quantity, but by the energies of the stomach. Consequently, whenever there is uneasiness after eating, the stomach has been overloaded, whether much or little has been taken. With respect to the difference in the digestibility of food, the experiments of Gmelin and Tiedeman have amply proved, what common observation had taught before, namely, that the most easily divisible is also the most digestible aliment; but that the degree of nutritiveness is generally in an inverse ratio to that of digestibility: the most nutritive food is the least easily least easily assimilated. Again; we do not believe in the opinion of those who interdict either animal or vegetable food under all circumstances of indigestion: either one or other may be perhaps properly prohibited, where either the habit is too inflammatory, or experience has shown that vegetables disagree; but in general both animal and vegetable food may be taken, as well when the powers of digestion have been impaired, as when they enjoy a perfect state of health. Only we would give this caution, that vegetables be thoroughly cooked, and not brought, as sometimes they are, half raw to the table. In the latter part of this essay, Dr. Philip has stated more definitely his doctrine of indigestion, directly asserting it to be a state of fever. With the qualification he has added, it would be difficult to refute the opinion; but we doubt not that most readers will be aware how very little, in many circumstances, a state of indigestion agrees with fever. The description in the latter part of the following extract is accurately drawn ; but whether it be a species of indigestion or not, it is for the most part quite incurable by medicine, and will generally take its own time. Stimulants materially increase the disease, and depletion weakens without relieving. 'They will also see clearly that, however it may be modified in particular instances, this disease of the whole system is exactly of the same nature as other affections of the whole system arising from other causes of irritation; that is, that it is a state of fever; a disease which admits of infinite variety, from a degree hardly perceptible, to that which destroys life. 'In longprotracted nervous fever, we sometimes find the functions only deviating a little from the healthy state. The patient, when he is still, feels very well; his appetite is moderate, he digests pretty well. The pulse is a little tight, but not more frequent perhaps than natural; the secreting surfaces are less free than usual, but their function is but little deranged. The patient is listless, less capable of exertion, perhaps subject to occasional fits of heat, particularly of the hands and feet, but can hardly be said to be ill, and wonders he does not get quite well. There is no physician who has not seen those, in protracted cases of the milder forms of nervous fever, in such a state as is here described.' In the essay on the Principles of the Medicinal Treatment in the more Protracted Cases of Indigestion,' we do not find anything very particularly worthy of remark, or which has not been noticed in the work itself. Dr. P. most judiciously, however, dilates on the necessity of considering every secreting surface in the treatment of indigestion, and not confining the attention to any one singly. The skin is as important an organ in supporting or relieving this complaint as the mucous coat of the stomach and intestines. The medicines which the author prefers for the purpose of correcting these surfaces are the nitrate of potash, tartarised antimony, and ammonia. The following extract from the Appendix points out the circumstances under which the nitrate of potash may be employed: "The nitrate of potash is chiefly indicated when there is a tendency to an increase of heat in the evening, or during the night, and particularly to a burning in the hands and feet; and in such cases its good effects are both greatest and most quickly apparent; but they are not confined to such cases. When there is no increase of heat, and even when the temperature is below the healthy standard, if this be not the case in a considerable degree, I still find this medicine to add to the good effects of the alterative course, provided there is an evident tightness of pulse, when examined in the way pointed out in my Treatise on Indigestion: but in such cases it is generally proper to combine it with some warm medicine. Small doses of tincture of orangepeel, or the compound tincture of cardamoms, are those I have generally employed.' |