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and render it persistent. The symptoms referable to the mind are, doubtless, in part secondary to the dyspepsia; but I have long held the opinion that the mind plays an important part in the ætiology of the affection.
In 1841, I contributed to the "American Journal of the Medical Sciences" a paper entitled "Dyspepsia as connected with the Mind." In that paper, I described the mental disorders often associated with difficult or labored digestion, and I expressed the opinion that these disorders are not entirely effects of dyspepsia and that the causes of this affection may be mental. This view of the etiology was at the time novel, and, even at the present time, is by no means fully recognized either in theory or practice.
I had been led to regard dyspepsia as, in many instances, referable to the mind, by personal experience. Notable distress attending the process of digestion and accompanied with great mental depression, despondency, and apprehensions, followed a change from college excitements and pleasures to a comparatively solitary life in the country and the beginning of the study of medicine. Instantly, however, on beginning to attend medical lectures in the city of Boston, and coincident with exuberant spirits, dyspepsia disappeared.
At the time when the paper to which I have referred was written, dyspepsia, in New England, prevailed very generally among the classes of society which may be distinguished as educated, or, perhaps, as may be better said, the reading and thinking classes. Exemption from this affection was an exception to the rule. The contrast between that time and the present in this regard is striking. How is this contrast to be explained? The explanation partly relates to the mind as involved in the causation of dyspepsia and partly to dietetics.
A half-century ago, most maladies were supposed to originate in the prima via, as the digestive organs were significantly called. It was enjoined upon all who desired to preserve health to watch closely these organs, and to make a constant and careful study of diet with reference to digestion. Dietetics and digestion, next to the weather and politics, furnished the topics
for common conversation. The evils of the gratification of the appetite for food furnished themes for writers and preachers outside of the medical profession. Moral as well as physical ills were referred to errors in diet, for which the sufferers were held responsible. There are a few at the present day who entertain those ideas which were so common fifty years ago. Within a few months, I have received a sermon by a clergyman, in which a strictly regulated and spare diet is recommended as indispensable, not only to health, but to good morals and religious faith.
The views generally entertained, at the time to which I have referred, largely by physicians and almost universally by nonmedical sanitarians, may be summed up in a few maxims as follows: Eat only at stated periods, twice or thrice daily, and never between meals, no matter how great may be the desire for food. Never eat late in the evening or shortly before bedtime. In the choice of articles of diet, carefully select those which reason and personal experience have shown to be best digested; and never yield to the weakness of eating any article of food simply because it is acceptable to the palate. In order to avoid the temptation of overeating, let the articles of food be coarse rather than attractive, and eschew all the devices of the cuisine. Always leave the table hungry. Study personal idiosyncrasies, and never indulge in kinds of food which, although wholesome for most persons, are injurious to a few who are peculiarly organized. With reference to this last maxim, bear in mind that "what is one man's meat is another man's poison." In order to secure, as effectually as possible, a proper restriction in the quantity of food, it was recommended by some physicians, and to some extent practiced, that every article be carefully weighed at meal-times, and that a certain quantity by weight be never exceeded. Vegetarianism, or Grahamism was advocated and practiced by many. Total abstinence from drink was considered by a few as a good sanitary measure, compelling the body to derive the needed fluids exclusively from fruits, vegetables, and other solid articles of diet. Restriction in the amount of drink, as far as practicable with regard to the power of en
durance, was very generally deemed important, so as not to dilute the gastric juice.
Dyspepsia formerly prevailed chiefly among those who adopted, to a greater or less extent, the foregoing maxims. It was comparatively rare among those who did not live in accordance with dietetic rules. The affection is much less prevalent now than heretofore, because these maxims are much less in vogue. The dyspeptics of the present day are chiefly those who undertake to exemplify more or less of these maxims. It seems to me, therefore, a fair inference that dyspepsia may result from an attempt to regulate diet by rules which have for their object the prevention of the affection which they actually produce. It is to be added that an important causative element involved in the practical adoption of these rules is the attention thereby given to digestion. It is by introspection and constant watchfulness of the functions of the stomach, that the mind exerts a direct influence in the causation of this affection.
The foregoing views of the etiology of dyspepsia foreshadow the dietetic treatment. Considering the limits to which this paper must be restricted, I can, perhaps, best submit the general plan of treatment which I have for many years pursued, by supposing a hypothetical case.
A patient presents the symptoms which denote difficult or labored digestion, with more or less of the associated symptoms which have been enumerated. We shall assume the diagnosis to have been made positive by excluding gastric ulcer, gastritis, carcinoma, and other lesions of the digestive organs. Renal and cerebral diseases have also been excluded.
I am accustomed then to ask the patient, "Do you regulate your diet?" The answer is generally in the affirmative, and it is often given promptly and emphatically. Then I say: "This is a good reason for your having dyspepsia; I never knew a dyspeptic get well who undertook to regulate diet." The patient is usually not a little surprised at these assertions, and he may take issue upon them. The success of the treatment will depend on the willingness and confidence with which the patient enters upon a reform in dietetic habits. "What system
of diet do you advise?" is a question which is naturally asked. The answer is, that I have no rigid system of diet to advise, but that food must be taken in sufficient quantity and sufficiently varied to satisfy the requirements of assimilation and nutrition, and that this is not to be done by adopting any fixed rules regulating the amount and the kind of diet. "How am I to be guided?" is a question which naturally follows. The reply is: "Not by theoretical views of alimentation and digestion, no matter how much they may appear to be in accord with physiological and pathological doctrines, but by the appetite, the palate, and by common sense." The patient, if intelligent (as dyspeptics usually are), may be reminded of the fact that nature has provided appetite and the gustatory sense for the regulation of diet as regards quantity and variety. To oppose these natural regulations is to do violence to nature. If the patient be a clergyman, he may be taxed with a want of sufficient reliance on Providence. Providence or nature takes care of digestion, leaving only the claims of appetite and the palate for human oversight.
"But," the patient will be likely to say, "am I not to be guided by my own experience and avoid articles of food which I have found to disagree with my digestion?" The answer is, that personal experience in dietetics is extremely fallacious. An article of diet which may cause inconvenience or indigestion to-day may be followed by a sense of comfort and be well digested to-morrow. A variety of circumstances may render the digestion of any article of food taken at a particular meal labored or imperfect. As a rule, articles which agree with most persons do not disagree with any, except from casual or accidental circumstances, and from the expectation, in the mind of the patient, that they will disagree. Without denying that there are dietetic idiosyncrasies, they are vastly fewer than is generally supposed; and, in general, it is fair to regard supposed idiosyncrasies as purely fanciful. Patients not infrequently cherish supposed idiosyncrasies with gratification. The idea is gratifying to egotism, as evidence that Providence has distinguished them from the common herd by certain peculiarities of constitution.
Dyspeptics generally have many questions to be answered. They are proverbially "long-winded" in giving a history of their experiences, and inquisitive as regards information from their physicians. Supposing our patient to be a type of this class, a full account of the matters discussed in a consultation would extend this paper to too great length. Suffice it to say that the maxims which have been enumerated as causative of dyspepsia are to be reversed in pursuing the plan of treatment which it is the purpose of this paper to submit. The instructions, abbreviated, will then be as follows:
Do not adopt the rule of eating only at stated periods, twice or thrice daily. Be governed in this respect by appetite; and eat whenever there is a desire for food. Eat in the evening or at bedtime, if food be desired. Insomnia is often attributable to hunger. In the choice of articles of diet, be distrustful of past personal experience, and consider it to be a trustworthy rule that those articles will be most likely to be digested without inconvenience which are most acceptable to the palate. As far as practicable, let the articles of diet be made acceptable by good cooking. As a rule, the better articles of food are cooked, the greater the comfort during digestion. Never leave the table with an unsatisfied appetite. Be in no haste to suppose that you are separated from the rest of mankind by dietetic idiosyncrasies, and be distrustful of the dogma that another man's meat is a poison to you. Do not undertake to estimate the amount of food which you take. In this respect different persons differ very widely, and there is no fixed standard of quantity, which is not to be exceeded. Take animal and vegetable articles of diet in relative proportions as indicated by instinct. In the quantity of drink, follow nature's indication; namely, thirst. Experience shows abundantly that, with a view to comfortable digestion, there need be no restriction in the ingestion of liquids.
It is perhaps needless to say, but in justice to my subject it should be considered, that in these few remarks I have given but a rough outline of the dietetic treatment of dyspepsia, according to the general plan which for a long time I have advo