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CHAPTER IX.

HEPATIC DYSPEPSIA.

THE liver is frequently blamed for disturbance with which it has no connection; but, there can be no doubt, that in some forms of dyspepsia the liver shares in the disorder of the stomach, and that this unhealthy state perpetuates the gastric symptoms.

The veins of the stomach pass into the vena portæ, and thus directly to the liver; and any irritating ingredient or stimulant, after exciting the mucous membrane of the stomach, in an equally direct manner creates similar abnormal action in the liver. Thus ardent spirits exert their action at once upon the liver; and although the erythematous inflammation of the stomach thus produced very quickly subsides, less readily does that of the liver, for the secretion of the bile is changed, it is diminished in quantity, or of an unusually irritating character; the elements of bile are thereby retained in the blood, and thus the balance of the whole economy is upset. If the offending cause is only temporary, then the irritation it has excited soon diminishes, and the attack is what is so often

called a "bilious attack;" but if, on the contrary, the irritation is renewed day by day, then the congestion of the stomach becomes persistent, its secretions are disordered, its mucous membrane thickened, its submucous coats infiltrated, and the liver still more seriously suffers. There is inflammatory effusion into Glisson's capsule, leading to enlargement and afterwards to contraction of the gland; the serous surface becomes thickened and inflamed, the secreting cells atrophied, and the bile ducts changed in their character. The depuration of the blood is hindered, effête materials are retained, engorgement of the portal system is consequent, and the disease thus leads to organic change in the liver and to dropsy. Hepatic dyspepsia is the first step in this most serious downward course of disease; and what are its symptoms? Many of them are referred directly to the stomach, others to the liver. The former is irritated and irritable, and vomiting is a common symptom, sometimes only sufficient to empty the viscus, but more generally severe and leading to regurgitation of bile into the stomach. This also is rejected, and the patient regards it as proof of excess of biliary secretion. Still more severe is vomiting in some instances; and the stomach remains so irritable that for many days it will not bear the presence of any food, however bland its character. This irritability of the stomach is preceded by foul and furred tongue, by bitter or unpleasant taste in the mouth, ar ften

accompanied with severe headache, with vertigo and disturbed vision, and it may be, with noises in the ears. The headache is often very severe in acute temporary disturbance of the stomach of this kind, and is experienced across the eye-brows, at the forehead, or at the back of the head; sometimes the whole head is felt to throb with each pulsation of the heart. The countenance is sallow and the mind depressed; sleep is greatly disturbed, and everything is seen mentally through a distorted medium; the physical strength is apparently lessened, and the patient complains of exhaustion, a weakness the result of impeded action, rather than of actual loss of power. The kidneys act imperfectly, and the urine is scanty and loaded with lithates; the bowels are often confined, but sometimes irregularly purged, with accompanying pain; the motions are mottled and clay-coloured, or of very dark and offensive character, and as an additional discomfort, hæmorrhoids distress the patient.

Another class of cases are those in which, without any gastric irritant whatever, bilious vomiting comes on, and is connected with extreme irritability of the stomach. Languor and headache often precede the attack, and tenderness at the scrobiculus cordis follows.

These symptoms closely resemble those of inflammatory dyspepsia.

The condition thus described is an easily remediable one, but the first and essential means of relief is to

avoid perpetuating the disturbance by fresh excitement, by indigestible or rich viands, by fermented liquors or ardent spirits. The most manifest treatment is to allow the stomach to rest, having first removed irritating matters from it, if need be, by an emetic; and at the same time, it is well to unload the bowels and the portal system by a free purgative; thus the congestion of the liver is lessened, and the first step towards relief obtained. After a time, saline drinks, soda water, or more correctly carbonic acid water, with or without milk, may be taken. Soda water is very often resorted to, and its benefit is partly due to the sedative action of the carbonic acid, and to the diluent action of the water; in fact, free potions of cold water are a very serviceable remedy in this condition, it cleanses away offending excreta by acting on the bowels, on the kidneys, and in fact, on all the abdominal glands.

A free mercurial purge is often productive of great benefit; as four or five grains of calomel, blue pill or grey powder, followed by a saline purge.

If the stomach continue irritable, bismuth may be given, with magnesia or its carbonate.

Still the most bland nourishment only should be allowed as arrowroot made with water, mutton broth, thin gruel, &c.

If the dyspepsia be of a chronic kind, and the secretions have been already acted upon, we have found great benefit from the use of the nitro-muriatic acid with

taraxacum; and as a purgative, small doses of the resin of podophyllum with rhubarb, capsicum, and henbane. If the secretion from the stomach be defective in quantity, ipecacuanha is an excellent addition. Another form of treatment is the combination of dried rhubarb with dried carbonate of soda, the bowels are thereby gently acted upon, and the tonic effect of the rhubarb strengthens, whilst the alkali diminishes the irritability of the membrane; these medicines in a fluid state, although less palatable, can be given in more effective doses.

Still, too often some fresh indiscretion renews the complaint, or the patient cannot be persuaded to discontinue ardent spirits, or wine in excess, or large draughts of malt liquors, and the physician is expected to remove the effect, whilst the cause is allowed to remain. The vigorous diet, and strict regime of the hydropathic establishments often prove of signal service in these cases; for it is found to be easier to go from one extreme to another, than to observe rules of hygiene commensurate with the wants of the system and the healthy activity of its functions.

When the stomach has become weakened by attacks of this kind, extreme regularity as to the time of meals should be observed; sufficient time should be allowed for thorough mastication, and the articles of diet, although of a proper character, should not be unwisely mixed together.

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