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Another question, however, between these authors, (and this manifestly not a mere question of words,) is, whether that tenderness which is experienced in the epigastrium, after dyspepsia shall have lasted some time, be a mark or not of inflammatory condition. Let us first hear what Drs. Philip, Paris, and Johnson, successively say on this head, and then we must be indulged in drawing our own inference from the whole. We may state by the way, that the tract whose title-page is placed at the commencement of the present division of our paper, is a sort of vindication by Dr. Philip of his own doctrines in reference to this particular, which having been published while the subject of digestion has been passing under our review, could not have found a place among the works first enumerated.
• The second stage of indigestion,' says Dr. Philip, “ is marked by a permanent tenderness on pressure, sometimes but slight, of the soft parts close to the edge of the cartilages of the false ribs on the right side, after they have turned upwards to be joined to the sternum. This spot is often very circumscribed, and always lies about half-way between the end of the sternum and the place at which the lowest of the cartilages begins to ascend; and the cartilage itself, near the tender part, often becomes very tender, not unfrequently, indeed, much more so than the soft parts. The patient, in general, is not aware of this tenderness till it is pointed out by the physician.
• This symptom never exists long, nor to any considerable degree, without the pulse becoming hard, and it often, at the same time, becomes rather more frequent than in health. There is no other symptom of the disease before us to which I am so anxious to call the reader's attention as to what I have here termed a hard pulse, because on it much of the proper treatment seems to depend.'
After having introduced some further remarks respecting the necessity of recognizing this hardness of the pulse by a particular mode of feeling it; viz. by a steady pressure gradually decreased. Dr. Philip goes on to state, that he considers the tender epigastrium and hard pulse to be the marks by which the disorder called dyspepsia is to be divided from its first into its second stage ; because, he adds, from the time of their appearance, at whatever period this happens, we shall find its nature, and, consequently, the plan of treatment suited to it, changed.
• This arrangement,' says Dr. Paris, is wholly artificial. Nature does not acknowledge it, nor will she submitto it. If then any advantage is to be derived from it, it must be received and considered only as an attempt to class together those symptoms wbich may arise from functional aberration, and those which are more usually associated with organic change. We must renounce all rigid adherence
to definite stages and arbitrary divisions, which nature disclaims. Every practitioner of any experience, must well know, that the hard pulse and tenderness of the epigastrium are likely to occur in a temporary attack of indigestion ; and I have frequently witnessed extensive mischief, with change of structure, without the occurrence of such indications.'
And Dr. Johnson more boldly and emphatically states, that this same tendernesss exists in every stage of indigestion. 'I ' will go,' he adds,' one step further, for I have no hesitation • in avowing that, if a whole regiment of soldiers were turned 'out and their epigastria pressed with the pointed fingers, and ' with the force that Dr. Philip uses, they would all wince, ' from the general downwards. Then, again, with respect to the hardness of the pulse, on which, as we have seen, Dr. Philip lays so much stress, as characterizing mainly the assumed change; Dr. Johnson, having quoted the words of his opponent in reference to the manner of detecting this hardness, expatiates both on the symptom itself, and the manner of detecting it, with the following freedom of stricture.
• I appeal to the experience of every practitioner, whether such a refinement as the above can be entitled to much confidence in the examination of a phenomenon like the pulse, which varies with almost every emotion or thought that crosses the mind of a dyspeptic invalid. Is it to be assented to, that by such a criterion as this we shall be enabled to distinguish irritation from inflammation, or functional from organic disease? The fact is, that in irritation of the stomach or bowels, the pulse is often as hard and as quick as in in. flammation of those parts. The heart is so much under the influence of the stomach, in functional derangement of the latter organ, that no dependence can be placed on the state of the pulse, whether as regards hardness, frequency, or irregularity. In general, however, it will be found in dyspepsia, that the pulse is much quicker, not only while the food is digesting in the stomach, but during the whole time that chyme is passing along the intestines, than after these processes are finished. The pulse, through the day, will often be up to nearly 80, and fall by nine or ten at night to 60. Indeed, the dyspeptic invalid is never so well as just before bed-time, when all irritation is removed from the organs of digestion ; and this often leads him to take for supper such food and drink as render him miserable all the next forenoon.
• In fine,' adds Dr. J., I am compelled to differ from Dr. Philip respecting tenderness of the epigastrium and hardness of the pulse, as pathognomic signs of a particular change in indigestion from irritation to inflammation from functional to incipient organic disease. These symptoms are present in the earliest as well as in the latest stage of indigestion; nor do I believe that there is any regular order or succession of phenomena in this Protean malady, by which the abovementioned change can be ascertained. At the same time, I have no doubt that, even in the earliest periods of indigestion, there is occasionally inflammatory action mixed up with irritation, when excesses are committed or improper stimulants have been exhibited. But, on the other hand, I am satisfied from what I have personally experienced, and seen in others, that all the phenomena of what is calied the second stage of indigestion, including tenderness in the epigastrium and sharpness of pulse, may, and do very generally depend on irritation ; or, in other words, on functional disorder of the stomach and bowels.
We may not, perhaps, quite approve of the temper and spirit, or rather, we should say, of the manner in which the statements and allegations of Dr. Wilson Philip are met on the part of his able opponents, Dr. Paris and Dr. Johnson; we should have been more pleased with a little less of dogmatic and dictatorial opposition to an individual who has done so much for pathology; but at the same time we cannot help conceding, that there is a great deal of justice in these Philipics (were we inclined to pun) we might call them Anti-Philipics to which we now advert, and specimens of which we have quoted. Divisions into stages, we hold to be for the most part mere delusions: the transitions of morbid condition are neither so regular nor so abrupt as the statements of systematizers would lead the student to infer. Although we grant to Dr. Philip. that an inflammatory condition of a part produces a pervading erithism of the whole frame, which is usually marked by more or less wiryness, or, if you please, hardness of the pulsations, yet, we must confess ourselves deficient in that kind of tact which shall enable us immediately to pronounce with precision on structural condition by the criterion proposed. That a great deal also of tenderness may be present, independent even of a small degree of inflammation, we hold to be fact. Indeed, it is a curious circumstance, that there is no part of the body less obnoxious to inflammatory irritation than the stomach; the final cause of which should seem to be, that the
is so constantly exposed to the influence of irritants. It is true, that a chronic species of inflammation is not seldom engendered in the internal membrane of the stomach and its appendages; but then, this is for the most part connected with specific susceptibility, as of cancerous tendency; or it has been produced by the gradual and repeated operation of spirituous liquors, not by food, nor as the result of mere dyspepsia.
Upon the whole, we may conclude, that indigestion, for the most part, is primarily a disease merely of muscular spasm and membranous disorder; that the ingesta irregularly propelled to the pylorus by the former, and not duly acted on in consequence of the latter, becomes in a greater degree than is natural, subject to the laws which regulate the action of matter destitute of vitality;---that hence fermentations take place, and that these fermentations produce distension, flatulent eructations, and mechanical impediments to orderly function ;—that pains are produced partly by the spasmodic condition of the fires which compose the coats of the stomach, partly in consequence of the acrimonious secretion of the disordered membrane, the surface itself being already in a state of diseased sensibility, partly from the distension of fatus, and altogether from that law of the vital system which inexplicably, but invariably, brings uneasiness when the harmony of organic movements is broken in upon. This, then, seems the simple rationale of indigestion abstractedly considered ; and when congestions and inflammations have place, they occur in those localities, and are regulated, both as to time and mode, by those constitutional susceptibilities and periods of life, some of the most prominent of which we have above hinted at; and thus maladies are induced, which, had we space, or rather, were this the proper opportunity, we might stretch out into a much more lengthened and formidable list, both of acute and chronic affections.
At the same time, let us not run into the mischievous, the practically mischievous error, of looking upon all derangements in the light of mere debility and spasm; and of supposing that excitants are the only remedies for disordered conditions of the stomach. Much, as we shall immediately see, is often done by those medicinal agents whose modus operandi, as far as we canat all understand it, seeros referrible to a principle quite opposite to that of stimulation. But, before we proceed to the consideration of its cure, we must turn our attention to the exciting causes of indigestion.
That over-feeding is the main circumstance by which dyspeptic conditions are engendered, no one will for a moment dispute; but the question will then be, In what does this consist ? Now, the reader, by looking over what we have written in the second part of the present article, will perceive that we are not of that school of dietetic severity and abstemious prudery which demands that the scales shall regulate the quantum of ingesta, and which holds, that even moderately to satisfy the demands of the appetite is to open the flood-gates of disease upon our devoted frames. We then and there further said, that scarcely any rule but the rule of sensation can be relied on as one of abstract correctness or universal application. It is, however, of much consequence to attend to this rule ; and let not him, especially, who is conscious of constitutional predisposition to plethoric disease, take occasion to convert our liberty into license. Fast eating is another pregnant source of dyspeptic mischief, as we have also before intimated. That bad, or, in other words, confined air is injurious to the digestive function, is shewn, not only by all experience, but has been proved by direct experiments instituted for the purpose of demonstrating the connexion of the stomach with the lungs. It has, indeed, been propounded as an axiom, that digestion of the food is in the ratio of air consumed by the lungs. Hence, in part, the keen appetite, and facile digestion, and vermillion cheek of the labouring rustic, compared with the little desire for food and little capacity for digesting it, that is manifested by the pale artist who plies the sickly
trade' of the metropolis ;-in part, we say, for muscular and mental, as well as pulmonary varieties, must be taken into the account; and it must also be recollected, that the surface of the body, which is very differently circumstanced in the two individuals, has a very material influence in regulating the interior movements of the system, more especially of the stomach. How intimate this association is, we have already pointed out. And it should also be remembered, that the condition of the skin, as to temperature, as well as in reference to other exterior circumstances, is of great moment in modifying stomach action. While digestion is much promoted by a certain kind and degree of cold applied to the body's surface, indigestion, on the other hand, is frequently aggravated, nay, is not seldom produced by an undue reduction of exterior heat; and partial or irregular application of cold, is more particularly calculated to impair the energy of the stomach. There is no country, perhaps, in which so little attention is paid to this particular as in Britain. Even the hardy Russian, who rolls his naked body in snow while reeking from the hot bath, is abundantly more careful in this respect, than the most delicate female of our own country. So influential is this exposure in the production of stomach maladies, that dyspepsia in females of the more respectable classes, is quite as frequent as it is among the other sex, on account, partly, of the thin clothing and exposed habits of the former proving equally noxious, in the long run, with the more free practices of the latter in reference to meats and drinks.
That mental affections are productive of stomach maladies needs scarcely be noticed, the fact is so constantly obtruding itself on the view of the observer; and although lowness of spirts may consist with regularity of appetite and digestion, you still, for the most part, see, that hypochondriasis becomes dyspepsia, as dyspepsia falls into bypochondriasis.
A hent position of the body is another fruitful source of stomach weakness and irregularity ; this is so conspicuously