Popular Science Monthly/Volume 18/January 1881/Indigestion as a Cause of Nervous Depression II
By T. LAUDER BRUNTON, M. D., F. R. S.
BUT bile is not the only substance which produces a depressing effect upon the circulation when absorbed into it from the portal system. I have already mentioned that certain albuminous products of intestinal digestion and peptones occasionally make their appearance in the urine. Among the former is an albuminous substance, not precipitated by boiling, but by nitric acid in the cold. This constance I have observed in the urine of a healthy man after he had drunk a large quantity of strong beef-tea at a draught upon an empty stomach. My attention was drawn to the urine by the froth remaining upon it for a somewhat unusual time. On examination, this substance was discovered in it. On examining the beef-tea which the person had taken, a similar albuminous substance was found in it, so that there can be little doubt that in this case the albumen was simply absorbed so rapidly from the stomach or intestines that it passed without change through the portal system into the general circulation, and thus reached the kidneys, where it was excreted in much the same way as sugar would have been under similar circumstances. We find only too frequently that both doctors and patients think that the strength is sure to be kept up if a sufficient quantity of beef-tea can only be got down; but this observation, I think, raises the question whether beef-tea may not very frequently be actually injurious, and whether the products of muscular waste which constitute the chief portion of beef-tea or beef essence may not under certain circumstances be actually poisonous. For although there can be no doubt that beef-tea is in many cases a most useful stimulant, one which we find it very hard indeed to do without, and which could hardly be replaced by any other, yet sometimes the administration of beef-tea, like that of alcoholic stimulants, may be overdone, and the patient weakened instead of strengthened. In many cases of nervous depression we find a feeling of weakness and prostration coming on during digestion, and becoming so very marked about the second hour after a meal has been taken, and at the very time when absorption is going on, that we can hardly do otherwise than ascribe it to actual poisoning by digestive products absorbed into the circulation. From the observation of a number of cases I came to the conclusion that the languor and faintness of which many patients complained, and which occurred about eleven and four o'clock, was due to actual poisoning by the products of digestion of breakfast and lunch; but at the time when I arrived at this conclusion I had no experimental data to show that the products of digestion were actually poisonous in themselves, and only within the last few months have I seen the conclusions to which I had arrived by clinical observation confirmed by experiments made in the laboratory. Such experiments have been made by Professor Albertoni, of Genoa, and by Dr. Schmidt-Mühlheim, in Professor Ludwig's laboratory at Leipsic.
Professor Albertoni has found that peptones have a most remarkable action upon the blood, completely destroying its coagulability in dogs, while they have little power in this respect over the blood of rabbits or sheep. The number of species upon which he experimented is limited, so that he can not as yet draw the conclusion with certainty that peptones prevent the coagulation of the blood in carnivora and not in herbivora, although, so far as experiments go, this conclusion seems probable. He and Dr. Schmidt-Mühlheim independently made the discovery that peptones prevented the coagulation of the blood in dogs, and the latter, under Ludwig's direction, has also investigated their action upon the circulation. He finds that, when injected into a vein, they greatly depress the circulation, so that the blood-pressure falls very considerably; and when the quantity injected is large, they produce a soporose condition, complete arrest of the secretion by the kidneys, convulsions, and death. From these experiments it is evident that the normal products of digestion are poisons of no inconsiderable power, and that if they reach the general circulation in large quantities they may produce very alarming, if not dangerous, symptoms.
Such experiments as this open up a new and very wide field of inquiry, which is likely to prove of very great practical importance. We have hitherto been accustomed to reckon all peptones as identical, by whatever digestive ferment they were formed, and to look upon it as a matter of slight moment whether albuminous foods introduced into the digestive canal were dissolved by the stomach or by the pancreas, although it is quite possible that the peptones differ as much from each other as different kinds of sugars. It is a matter of wonder, also, that at the present moment, although the digestive processes have been so carefully investigated, we know very little of the uses of the succus entericus. Notwithstanding the great extent and evident importance of the intestine, and the large quantity of fluid which it is able to secrete, all that we find regarding the action of this secretion in such a book as Foster's "Physiology" is that "the statements with reference to its action are conflicting. Probably it has no direct action on either fats or proteids, but is amylolitic in some animals, though not in all." Succus entericus has also been said to change cane-into grape-sugar, and by a fermentative action to convert cane-sugar into lactic acid, and this again into butyric acid, with an evolution of carbonic acid and free hydrogen. The reason why experiments on the action of intestinal juice have given such an apparently unsatisfactory result is that they have been chiefly tried on such kinds of food as we are accustomed to put into our mouths. Now, the intestinal juice is not intended to act upon such substances: its place is to finish the digestion begun by the other juices; and when experiments with intestinal juice are tried upon foods which have previously been subjected to the action of the other digestive fluids, positive and not negative results are obtained. Thus, for example, it was stated by Kühne, in his lectures at Amsterdam in 1868-'69, that though intestinal juice would dissolve raw albumen and fibrine, it would not act at all upon them if boiled; but if the boiled albumen or fibrine were first subjected to the action of pancreatic juice for a short time, the intestinal juice would afterward dissolve them much more quickly than it would even in a raw condition. The action of digestive ferments is just beginning to find a practical application in medicine, and sometimes, undoubtedly, they are of very great service; but unless their action is investigated more thoroughly than it has been up to the present, it is just possible that we may by and by find that the digestive ferments, like all other powerful agents, may do much harm as well as much good. Hitherto we have been accustomed to regard the phases of digestion, gastric digestion, pancreatic digestion, and intestinal digestion, as almost separate processes, any of which we might increase indefinitely without doing any harm to the patient. We forget the relation which each bears to the other; and yet such a relation undoubtedly exists, for we find that when pepsin is mixed with bile it is precipitated and rendered inert. Further transformation of foods by the gastric juice is thus arrested as soon as the chyme leaves the stomach. And well it is that this should be so, for if the pepsin were not rendered inert it would destroy that pancreatic ferment (trypsin) which acts on albuminous substances, and thus interfere with digestion by it. How far this prolonged peptic digestion and impaired pancreatic digestion of albuminous substances has to do with the production of poisonous digestive products in cases where the quantity of bile poured into the intestine is deficient it is at present impossible to say, but it is a condition which ought to be kept in mind in all cases where there is deficiency of bile in the intestine, and the advisability of nourishing the patient by farinaceous food is constantly considered in these cases.
And now comes the question, How is it that in healthy conditions of the intestine peptones do not pass into the general circulation, and are therefore unable to exert any poisonous action upon the nerve-centers? This question is one which we can not at present answer quite satisfactorily.
Usually the peptones disappear from the portal blood before it reaches the general circulation. Indeed, Ludwig and Schmidt-Mühlheim found that even in the portal blood, before it reaches the liver, very little if any peptone is to be found. They have not succeeded in discovering where the peptone undergoes change. Plósz and Gergyai, and also Drosdorff, have discovered peptone in the blood of the portal vein, and Plósz and Gergyai have been led, by their experiments, to regard the liver as the seat of the transformation of peptones. In consideration of the more recent experiments of Ludwig and Schmidt-Mühlheim, we can not entirely adopt the view of these authors, though it is nevertheless possible that they are to a certain extent right, and that the liver, to some extent at least, serves the purpose of preventing any peptones from getting into the general circulation, which may have escaped transformation in the portal blood before reaching it.
And now, having run over in this cursory manner some points connected with digestion and with the functions of the liver, we come back to the question of why it is that the mental worker becomes depressed, irritable, melancholy, and, it may be, stupid and forgetful, after a few months' work, although every part of his body may be organically healthy, and a month's holiday may be sufficient to restore every organ to perfect functional activity? One reason, no doubt, may be that his systematic overwork may produce a diminution in the energy-yielding substance of his nerve-centers, just as we see that a certain amount of atrophy occasionally occurs in overworked muscles. But this does not seem very probable. It seems much more likely that they cease to act in the normal way because, during each day's activity, a certain amount of waste product is formed which is not perfectly removed during the hours of rest.
All throughout the body we have most elaborate arrangements for removing waste products. In the muscles, for example, we find that the fascia which surrounds them forms a regular pumping arrangement, the two layers of which it consists being separated from each other at each muscular relaxation, and pressed together at each contraction. The lymph and the waste products which it contains are thereby actually pumped out of the muscle at each contraction, and sent onward into the larger lymph-channels, so that the muscular action itself removes the waste products. At the same time we find that the movement of the muscles of the leg, for example, will also pump out the blood from the veins, sending it upward from the feet, and pressing it upward to the body.
Again, we find that in the abdomen and thorax we have pumping arrangements, whereby any excess of the serous fluid which bathes the intestines and lungs is pumped out of the peritoneal pleural cavities by the action of respiration. The two layers of the central tendon of the diaphragm and of the pleura here form pumping arrangements similar to the fascia in the leg.
The brain and spinal cord, being inclosed in rigid cases, have no pumping arrangements in immediate connection with them, but the circulation of the cerebro-spinal fluid in them is probably affected also by the movements of the thorax and abdomen. The cavity of the arachnoid and of the cerebral ventricles is not only continuous with similar cavities in the spinal cord, but also with the lymph-space surrounding the choroid, with the interior chamber of the eye, and even with the lumbar lymphatics; and Professor Schwalbe has succeeded in injecting these parts by a single insertion of the nozzle of his injecting syringe into the arachnoid. His observations have been confirmed and extended by Althann. The experiments of Quincke have shown that during life a current exists in the cerebro-spinal fluid, both from above downward and from below upward. The cause of this current is, in all probability, the respiratory movements. We have, indeed, in the brain and spinal cord, a condition not unlike that which exists in the fascia covering muscles, where the muscular substance during its contraction presses flexibly the inner against the unyielding outer layer of the fascia, and thus produces, in the space between them, a pumping action. The skull and vertebral canal would correspond to the hard outer layer or fascia; and the brain and cord, which, as we know, expand and retract during the movements of respiration, when a part of their bony case is removed, will have a similar pumping action upon the cerebral spinal fluid to that of the muscle upon the lymph in the fascia.
In the case of the brain and the cord there will be, in addition, a pumping action produced by the very circulation of the blood in them, the alternate expansion and dilatation corresponding to the heart's beats, having a similar effect to that produced by the respiratory movements. As stimulation of the brain causes dilatation of its vessels, and increases the flow of blood through them, mental action of itself not only attracts more blood to the brain, but provides to some extent for the removal of waste products. The movements induced by the cardiac pulsations are not so extensive as those caused by the respiratory movements or by muscular exertion, and therefore, when the brain is overworked, and the respiration and muscular movements are underworked, the cerebral nutrition will be diminished by the imperfect removal of waste from its substance. But if, in addition to this, the cerebral cells and fibers are actually poisoned by the circulation within the vessels which supply them, of noxious substances due to imperfect digestion or assimilation, matters will become very much worse,
We have already seen how much the liver has to do with such a condition. Now, while the brain is being taxed to its utmost, the worker generally gets but very little exercise. The consequence of this is, that although the respiratory movements still go on with regularity, and the pressure of the diaphragm upon the liver at each respiration presses the bile more or less out of the liver, yet the pressure thus exerted is very much less than would be the case if the individual were making occasional vigorous efforts during which the breath was held, and the muscles of the abdomen put into action, as, for instance, in springing from bowlder to bowlder on the moraine of a Swiss glacier. So long as the brain-worker is exceedingly careful what he eats, so that no excess of bile is formed, and is fortunate enough to escape duodenal catarrh, so that no impediment, however slight, prevents the flow of bile into the intestine, he may get along perfectly well; but if he be unfortunate enough to get what is commonly known as cold in
the stomach, or unwary enough to irritate the mucous membrane of his stomach or duodenum by wines or spirits, the case is at once altered, for now the swollen mucous membrane of the duodenum tends to close the orifice of the bile-duct, or the congestion may even extend up the duct itself. Thus an impediment, however slight it may be, is opposed to the exit of bile from the liver. The pressure under which the bile is secreted, as I have already said, is very small, and there being no extra pressure put upon the liver by the diaphragm and abdominal muscles, instead of the bile being at once forced out of the bile-capillaries it will remain in them, causing more or less congestion, and now follows a whole series of disagreeable results. The bile, which may be looked upon as a waste product of the liver, not being removed, the other functions of the liver are disturbed. Assimilation becomes imperfect, we find lithates appearing in the urine; the circulation in the liver itself may be altered, and thereby the whole circulation in the stomach and intestines may be impeded, for it must be remembered that all the blood from the stomach and intestines has to pass through the liver before it again reaches the general circulation. Thus the individual becomes troubled with hæmorrhoids, secretion and vermicular movement in the bowels are impaired, so that constipation results; congestion of the stomach, with loss of appetite, impaired digestion, and flatulent eructations ensue, and the brain and nervous system begin to suffer from the accumulation in them of their own waste, or the absorption of abnormal products of assimilation.
Feeling weak, dull, and melancholy, the sufferer now thinks he ought to take meat three times a day, and perhaps, during the intervals of his meals, to take strong beef-tea, or perhaps a glass of wine or a nip of brandy. Yet, in spite of all this, he becomes weaker, more stupid, and more melancholy; and no wonder. He is simply further overtaxing his already overworked digestive organs. He is piling up fuel, instead of removing ash, and choking the vital processes both in his digestive and nervous systems. What he wants is not more nutriment, but a more rapid removal of waste, and the change upon the adoption of a proper system of treatment is in many cases most marked and satisfactory, both to the physician and the patient.
The first thing to be done is to clear out the liver. This may seem to be an unscientific expression, one adapted rather to popular notions than in accordance with ascertained facts. But this is not the case. In a former paper on the action of purgative medicines, I have explained the way in which certain purgatives may be said to have the effect of clearing out the liver, and first among those we must reckon mercurials. In the case which we have just been describing, five grains of blue-pill may be taken every night, or two or three grains of calomel either alone or combined with extract of hyoscyamus or conium, and this should be followed next morning by a saline draught. As a saline we may use sulphate of magnesia, or Friedrichshall, Pullna, Hunyadi Janos, or Carlsbad water; but, whichever saline we may choose, the use of one or other of them should on no account be omitted. One of the best salines is half a drachm of crystallized Carlsbad salts dissolved in a tumbler of hot water and drunk immediately after rising in the morning, and this may be used not merely in the morning after the mercurial, but it may also be employed every morning in cases where the bowels are constipated. The quantity of water is of considerable importance. Half a teaspoonful dissolved in a full tumbler is more efficacious than double the quantity of salt in half the quantity of water. Nor is this to be wondered at, for not only has the larger quantity of liquid greater power to wash out the intestine, but the increased amount of the water tends to increase the quantity of bile secreted, and this increase in bile is especially marked when the water is taken frequently in small quantities, as it is by persons undergoing the cure at Carlsbad, or who take the solution of Carlsbad salts at home by sipping it at intervals while dressing, instead of drinking it all off at once.
Zawilski found that when liquids were taken in this way not only was the bile secreted in greater quantity, but under a greater pressure, so much so that secretion still occurred when such an obstruction was opposed to its exit as would usually have caused the bile which had already been excreted to be reabsorbed.
When the Carlsbad salts are employed after the mercurial, it is, I think, best to take them in single large draughts immediately on rising, but when used by themselves the solution should be sipped at intervals during dressing. When used alone, the Carlsbad water, warmed by standing the tumbler in a basin of hot water or in an ætna, is perhaps even better than the salts, which represent only a part of the normal constituents of the water. After the liver has been thoroughly cleared out in this manner by a mercurial purgative followed by a saline, vegetable cholagogues, such as iridin and euonymin, may be employed to assist the action of the Carlsbad salts, when these are found to be insufficient, even although they are taken with regularity. These cholagogues, the introduction of which into medicine, in this country at least, we owe to Professor Rutherford, are sometimes as useful, perhaps even more so than mercury, but, as a rule, I think the mercurial purgative is the best to begin with. Euonymin is the cholagogue most usually employed, but iridin is really the most powerful one, and is specially recommended by Dr. Rutherford.
Instead of trying to keep up the strength, as it is termed, by loading the stomach with food, the exhausted brain-worker should rather lean toward abstinence from food, and especially toward abstinence from alcoholic liquors. The feeling of muscular weakness and lassitude, which I have already had occasion to mention as frequently coming on about two hours after meals, is not uncommonly met with in persons belonging to the upper classes who are well fed and have little exercise. It is perhaps seen in its most marked form in young women or girls who have left school, and who, having no definite occupation in life, are indisposed to any exercise, either bodily or mental. I am led to look upon this condition as one of poisoning, both on account of the time of its occurrence, during the absorption of digestive products, and by reason of the peculiar symptoms—viz., a curious weight in the legs and arms, the patient describing them as feeling like lumps of lead. These symptoms so much resemble the effect which would be produced by a poison like curare, that one could hardly help attributing them to the action of a depressant or paralyzer of motor nerves or centers. The recent researches of Ludwig and Schmidt-Mühlheim render it exceedingly probable that peptones are the poisonous agents in these cases, and an observation which I have made seems to confirm this conclusion, for I found that the weakness and languor were apparently less after meals consisting of farinaceous food only. My observations, however, are not sufficiently extensive to absolutely convince me that they are entirely absent after meals of this sort, so that possibly the poisoning by peptones, although one cause of the languor, is not to be looked upon as the only cause. A glass of soda water, with or without the juice of a lemon squeezed into it, may be slowly sipped when the feeling of weakness comes on, and a biscuit may be eaten along with it if desired. This will sometimes relieve languor, but if it be found insufficient, a small cup of warm but weak tea or cocoa with a biscuit will act as an efficient stimulant, although they may be less unobjectionable than the soda-water. Heat is one of the most powerful of all cardiac stimulants, and any warm fluid in the stomach will increase its action; a cup of warm water alone will do this, but it is unpleasant to take, and so something must be added to flavor it: a little claret may be used if tea disagrees, or tincture of ginger and sugar, or even some Liebig's extract. It is the local action of the warmth that we want, and in order to obtain it we may sometimes have to put up with the inconvenience of giving substances which will be to some extent injurious after their absorption, such as beef-extract or even whisky. The advice that I have given here, in recommending a glass of cold soda-water or a cup of hot tea, may remind one of the countryman in one of Æsop's Fables who fell into disgrace because he blew upon the fire to heat it, and blew upon his porridge to cool it. And yet the countryman was right, for experience had taught him that the desired result would follow his actions, even though he might not be able to explain the reason why. So we find that a draught of cold water will revive a fainting person, and hot water will have a somewhat similar effect. Both of them give relief by stimulating the circulation, but their modus operandi is different. In the case of the hot water the circulation is stimulated through the heart, which is excited to increased contraction, and thus the tension within the vessels is raised. In the case of the cold, the pressure is also raised, not by stimulation of the heart, but by the contraction of the vessels, especially those of the stomach and intestine. In the case of warmth, more blood is poured into the aorta by the excited heart, and where we apply cold less blood flows out of the aorta into the veins through the intestinal vessels, and thus it is that in both cases the tension is raised and the faintness removed.
At each meal it is well for the patient to begin with the solids before he proceeds to the fluids, and at breakfast, instead of beginning the meal with a cup of tea or coffee, he should finish a slice of dry toast and a piece of fish, egg, or bacon, before he takes any liquid at all. The same rule should be observed at lunch and dinner. The effect of this course is that the patient is less troubled with weight and flatulence after meals. The explanation of the fact probably is that the solids, entering the stomach first, stimulate it to secretion and movement; whereas, if it already contained a quantity of liquid at the time they were ingested, they would not have this effect, and imperfect digestion would be the result. At dinner, wine or beer may be taken if the patient finds them agree, but in all probability he will be better without them. There are some brain-workers who require them and must have them, but it is better for a good many others to avoid either wine or beer, and to take some effervescing water instead. Not unfrequently we hear the complaint that effervescing water is too cold, and where this is felt to be the case ginger ale or zoedone may be substituted, the color of these beverages and their more pungent taste rendering them more grateful both to the eye and the palate of many persons. In some cases weak claret and-water may be used, and if the water be somewhat warm the mixture will be better for the patients, and will not cause the feeling of coldness in the stomach of which they sometimes complain.
A medicine which has long enjoyed a great reputation in disorder of the liver is nitro-muriatic acid, and I think this reputation well deserved. We do not know how it acts, but in some way or another it does tend to improve the digestion. Ten minims of the dilute nitro-hydrochloric acid, either before or immediately after meals, combined with some aromatic and carminative, such as chloroform and cardamoms or orange, and from five to ten minims of tincture of nux vomica, where the nervous depression is great, is a most efficient remedy.
But, even with all this care in food and drink, with all this attention to what is to be taken and what avoided, with medicine morning, noon, and night, how are we to keep the liver in order without exercise? Sometimes the patient may be able to take walking exercise, but when he does it is generally only for a short time during the day, and of so gentle a character that the respiratory movements are but very slightly increased, and the liver is hardly more stimulated by the pressure of the diaphragm and abdominal walls during the walk than it would have been had the patient remained quietly at home. Time is an important element in many cases. Many a hard-worked man has his day so fully occupied that he can not give up more than a quarter or half an hour to exercise, and it is of importance that in this limited period he should get as much exercise as possible, and the best way to employ this brief time is by taking horse-exercise. I believe it is to the late Lord Palmerston that we owe the saying that "the outside of a horse is the best thing for the inside of a man," and it is very near the truth. A brisk trot for fifteen minutes will cause more pressure upon, and stimulation of, the liver than a lazy lounge of an hour or more. The time for this will depend in a great measure upon the engagements of the patient. It should not be taken immediately after a meal, and for most men whose days are fully occupied almost the only time to take it is before breakfast. A cup of milk, or a small cup of tea or coffee, with a piece of bread and butter or a biscuit, may be taken just before starting, and then the regular breakfast will be taken with greater appetite and better digestion after the exercise is over.
By careful attention to the removal of waste products, and to the prevention of absorption of poisonous substances from the intestine, by regulation of the diet, regulation of the bowels, and exercise, in the ways just mentioned, I believe that the nervous exhaustion and depression from which brain-workers suffer may be greatly diminished, even although it may not be entirely prevented.—Practitioner.