In dyspepsia, as in hysteria, when the pathology of the disturb ance is so little understood, the only safe principle of diagnosis is that of exclusion. The possible conditions of the brain, of the lungs, and of the heart must be duly weighed, and attention must also be paid to the condition of other abdominal viscera.
§ 1. The (Esophagus presents only one form of disease—a cer tain degree of closure either from stricture or from spasm. The complaint of the patient is of difficulty in swallowing, a sensation of the food stopping somewhere in its course, and its being again brought up. The distinctive feature of this state is that the re turn of the food is immediate ; very few mouthfuls can be swal lowed, perhaps no more than one, before the pain and discomfort become such that the patient cannot proceed till that has been rejected ; and the difficulty is always proportioned to the solidity of the food, fluids continuing to pass when no solid matter is re ceived. into the stomach at all. The rejected matter is simply masticated food, and has no smell of acidity, nor does the patient perceive any taste of bile.
True stricture comes on very gradually and insidiously, is ac companied by marked emaciation, and generally attended with a sense of hunger which cannot be relieved in consequence of the impossibility of filling the stomach with food: if necessary, the diagnosis may be made still more clear by introducing the pro bang. The closure from spasm is generally more suddenly de veloped, and is not attended by the same constitutional effects. In stricture, the condition is permanent, and the only perceptible difference in the power of swallowing is due to the quality of the food. ; in spasm, the difficulty varies in consequence of circum stances for the most part inappreciable. The remote cause of spasm would appear sometimes to be mere nervous irritability ; in other e,ases it is due to local irritation of some portion of the mucous membrane, or to the pressure of a tumor on the case phagus. In spasmodic stricture the probang can be passed, although it meets with some resistance when any local e,ause of irritation exists. The circumstances here referred t,o apply equally to disease of the cardiac opening of the stomach, which produces an exactly analogous effect, in regard to the introduction of food, as that of closure of the cesophagus, and therefore need not be considered separately.
In seeking for characters by which these diseases may be distinfaished, we observe that any evidence of " exaltation." or of nervous initability in other organs, prepares us for the existence of a similar condition in the cesophagus ; if we learn that anything liable to irritate the membrane has been swallowed, or if we find any redness or spots of ulceration on the fauces, we suspect the coexistence of spasm with local irritation : if a tumor exist, we should have concomitant evidence of pressure on the trachea.
It further deserves notice, that occasionally ulceration of the epiglottis and imperfect closure of the entrance of the windpipe excite coughing, so imme diately upon the act of swallowing, that grmt part of each mouthful is returned before it can pass the irritable spot. Here there is not necessarily any spasm of the cesophagus ; and if, along with the known existence of cough, and pro bably also of hoarseness or mucous breathing, the act of deglutition be watched, its cause will be at once revealed.
§ 2. Organic Diaeases of the Stomach.—The two most important lesions found in the stomach are stricture of the pylorus, which is very often cancerous, and simple ulceration of the mucous mem brane. Gastritis is a disease of very rare occurrence in its acute form ; dilatation is most commonly the result of partial closure of the pylorus, but possibly also commences as an idiopathic disorder.
a. Stricture of the Pykruo in its earlier stage, cannot be dis tinguished from mere functional derangement; and when, as very commonly happens, dyspepsia is conjoined with it, the patient may appear t,o recover under treatment while yet the disease pro- ceeds unchecked. The most constant symptom of stricture of the pylorus is vomiting: but I have seen the disease run on to a fatal termination, in which, during a long period, that symptom vras absent in consequence of an ulcerated opening communicating with the duodenum. When accompanied by ulceration, there is usually, at some period or other, grumous vomiting, which owes its appearanoe to a small quantity of blood, altered by the secre tion of the stomach; sometime,s there is more copious hemorrhage. The stomach may become enormously distended : indeed dilata tion probably always exists, more or less; but it is much greater in simple thickening than in scirrhus of the pylorus, when the stomach is more irritable, and its contents more speedily rejected. Several meals, or even the food of three or four days, may be, in great part, accumulated before it is rejected, or, on the other hand, the vomiting may occur after every meal ; the longer interval proves the existence of dilatation, if anything like the whole quantity of food be rejected ; the constant recurrence of the vomiting after food shows that there is a condition of irritability. The absence of signs of dilatation when the vomiting occurs at longer intervals, and the return of the food after every meal, are each of them more favorable indications as being more likely to depend on dyspepsia than a certain degree of dilatation with vomiting at intervals of one or two days.