It is very important to remember, with reference to the stomach and its disorders, that almost every patient, no matter how ignorant or ill-informed, frames to himself, according to his amount of knowledge or prejudice, a theory of his ailments : one attributes to indigestion all his sufferings, another con stantly alleges that he is bilious, a third is not satisfied unless he is well purged, and a fourth, who relishes the pleasures of the table, is slow to admit that his stomach is overtaxed or unequal to the demands made upon it. No cause more frequently leads to wrong diagnosis than forgetting to separate between the true narration of symptoms and sensations, which are our only guide in this class of disorders, and the construction of a theory which no patient is able to form correctly in his own case. Social progress would stand still for ever if nothing were to pass current but bare description ; yet, in the history of a case, everything else should be rigidly excluded ; and it is better to trace out the disease as we do in childhood, by our unaided observation, than to admit into our conception the statement of the patient that he is " bilious." No more expressive term exists for a certain condition of body than this, it is as true, strictly and legitimately true, as " fever," " rheumatism," &c.: but it theorizes—it is a compendious expression of certain symptoms ; and it is the duty of the physician, not of the patient, to determine whether this implied theory properly express the category of symptoms or not. In the present day, no organ is more hardly dealt with than the stomach, whether we con sider the starvation and improper food of the poor, the irregular hours of the man of business, the pampering and overfeeding of the rich, or the still more pernicious disregard of the proper evacuation of the effete contents of the alimentary canal, which false delicacy, sedentary habits, and sheer inattention produce. The habits of the patient, therefore, afford a further help to diag nosis, as one of the elements in the history of the case. • The symptoms of dyspepsia may be referred to three distinct heads—pain, or nervous irritation, impaired muscular action, and faulty secretion. In their analysis, it is to be remembered that while pain is an evidence of irritability, and thus, perhaps, simply of faulty innervation, it may also depend on the condition of the mucous membrane, and the character of its secretion, or on over distension and spasmodic contraction of the muscular fibre. Simi larly, though distension be essentially the fault of the muscular structure, which has become relaxed, weak, and ineffective, yet this very weakness may be a symptom of nervous debility, or may be simply caused by distension with gas, generated because the secretion is imperfect. In the same way, faulty secretion may be directly traceable to the condition of the mucous layer and fol licles, but may also result from imperfect nervous or vascular action, or follow on the detention of food in the viscus from defi cient muscular power. Nothing, indeed, can be more erroneous than the limitation of each of these effects to that particular struc ture which is directly concerned in their production. But we are not on this account to disregard the information thus conveyed ; on the contrary, pretty nearly all the complex cases that come before us may be resolved into these three simpler elements— irritability, distension, and faulty secretion : caution is chiefly to be exercised in theorizing that this or that particular function is the one primarily deranged.
a. Irritability presents a great variety of phases, which receive from patients as many different appellations. It is often mani fested in extreme intolerance of food; beginning by slow degrees, it at length becomes such that every meal is rejected, and some times the quantity of food must be reduced to a mere spoonful, and its quality be the very simplest and blandest possible, to prevent its rejection. Such a form of irritability may be pro
duced by ulceration, but is certainly not limited to it. Pain, referred so often by the hysterical to the left side, or described as passing through the chest and being felt between the shoulders, or perceived in the centre of the sternum as well as over the epi gastric region ; a feeling of emptiness or craving, which, relieved for a short time by food, returns in its full extent before the sto mach can by possibility be emptied; sensations of fulness, weight, dragging, &c.; gnawing, cutting, tearing pains, &c.,—must all be regarded as evidences of irritability. It is manifestly impossible to assign to all of these their true pathological import, or even to guess why they are so differently described ; but it is of service to consider their relation to the ingestion of food, as tending to show in some measure their exciting cause. Thus, if the disa greeable or painful sensation be observed shortly after food is taken, if some kinds of food produce it at once, and others not at all, especially if bland fluids do not excite pain, as they gene rally do in ulceration, we should have strong reason for believing that the symptom was chiefly nervous, that the irritability of the stomach was the primary affection. Whereas, if a longer interval must elapse before the sensation be aroused, if it be accompanied by acidity or eructation, or if it exist when the stomach is empty, being rather relieved by the presence of food, we shall probably be right in regarding it as symptomatic of faulty secretion. If a sense of weight or dragging be the form assumed, and it be expe rienced at a still later period, we may assume that there is some delay in the process of emptying the stomach, either as a conse quence of torpidity of muscle, or more commonly as the effect of over-distension : still more, if the pain be of a spasmodic charac ter, and very late in its occurrence, it may be referred to the in effective contractions of the muscular fibre distended beyond its proper limits, and vainly attempting to expel crude and half digested aliments to which the pylorus refuses egress.
b. Distension.—Dilatation, in its minor and less important sig nification—more properly distension or relaxation of muscle, in dicated by the pain just referred to, and by the existence of un usual resonance—is more likely to be primary in persons of lax, flabby muscular structure, than in those who have firm resilient flesh. Such a condition is more probable if there be coexisting constipation and want of intestinal peristaltic action, if the appe tite be unaffected, and the first stage of digestion easy; but it can scarcely persist without reacting on the mucous membrane, through the delay of food in the stomach : and hence it becomes compli cated by evidence of faulty secretion. On the other hand, one of the most constant effects of imperfect digestion is the generation of flatulence, which must necessarily distend the stomach till it find an outlet; crude and ill-digested food must also necessarily be delayed in passing the pylorus, whether the muscular action be at fault or not ; and it is therefore by no means easy to say how much is due to the imperfection of the muscle, and how mach to the defect of the secretions. More easily recognized are those cases in which the distension, the discomfort., and the delay of the digestive process are all of them caused by overloading the sto mach, which sooner or later rebels against the habitual overtax ing of its powers. It may still be capable of disposing readily, of a moderate meal, but it refuses to propel a large mass of hete rogeneous contents; in such cases, probably, the actual over stretching of the fibre is a more efficient cause of the distension than the character or quantity of the secretion.