Reading Salisbury, Part 8: Starving on a Full Stomach

The disease of the camps

Before the lungs, Salisbury says, the bowels. Four chapters of his book are given to what he calls consumption of the bowels, the chronic diarrhoea that in his lifetime was less a symptom than a plague. In the American Civil War it was the single largest killer in uniform. Roughly two soldiers died of disease for every one killed in battle, and diarrhoea and dysentery led the list, emptying regiments that never saw a fight. Walt Whitman, who spent those years at the bedsides of dying soldiers in the Washington hospitals, wrote afterward that “the real war will never get in the books,” and a great part of the war he meant was men dying slowly of their bowels in long rows of cots.

Salisbury had examined those men. He writes of “a careful and extensive examination” of soldiers on the march, and his conclusion about the cause is in Chapter XVIII: they lived on “dry bread or biscuit, with sweetened coffee or tea,” because “they can only carry cooked meats for a few days’ rations and cannot usually carry the means for cooking on the way.” Hardtack and sugar, day after day. “This dry, amylaceous diet produces a constipated state of the bowels,” the retained starch ferments, the gas builds, and at length “the constipated condition gives way” to profuse discharge, which, once the gut lining has been damaged, does not stop.

He was wrong about the agent. Camp diarrhoea was infectious, carried by contaminated water and the latrines dug too close to it, and the organisms that caused it were found within a generation of his book. But the soldiers who died of it were, almost to a man, soldiers who had been living on biscuit, and the ones who could cook meat fared better, and he noticed that where the army did not. The seed was in the water. The soil was in the haversack.

Constipated first

Chapter XVI stages the disease, and the first stage will be familiar to anyone who read Part 7. It is overlooked. “In all cases uncomplicated by dysentery,” he writes, “the diarrhoea is preceded by a constipated condition of the bowels. This, however, is overlooked by the patient.” By the time he seeks help, “he only remembers that his bowels have been loose for some time,” and only careful questioning turns up “a preliminary constipated period” of several weeks.

During those weeks the signs are the usual ones, the ones nobody counts. Gas, “often distending these organs so as to excite pain through from one side to the other.” Legs that prickle and “get asleep.” “A mixed up, numb feeling in the head,” ringing in the ears at night, floaters before the eyes, “defective or dulled memory.” A cough toward morning. Palpitation on slight exertion. A voice gone husky. And, in the middle of it: “Appetite good and often ravenous for fermenting foods.”

Ravenous for the thing that is doing the damage. He has said it before, in the Introductory Remarks, as theory. Here it is as a clinical finding, in a list between a hoarse voice and tired muscles.

The body gives up complaining

Then the adaptation.

In many people, Salisbury says, the first stage simply fades. “After a short time, in such cases, it frequently passes away, the alimentary canal adapting itself to the dry amylaceous and saccharine food, so that digestion goes on quite passably to all appearances, and the passages become quite natural.” The patient is no longer troubled. He can live on biscuit now. And: “the patients are now disposed to become more plethoric than usual. They feel, however, less tonicity of the system; they are frequently troubled with palpitations, hurried and often oppressed breathing after any short, severe exertion, and readily tire.”

Plethoric is a nineteenth-century word for fleshy and full-blooded. The body has stopped objecting to the diet, has adapted to it, and the adaptation is that the man gets heavier, softer, shorter of breath, and quicker to tire, while reporting that his digestion is fine. Salisbury thought this was a dangerous state, because if any fever or shock came along, the diarrhoea returned “and becomes chronic and more difficult to control,” and because in people with strong digestion who never developed diarrhoea at all, the trouble went instead to the heart and the lungs.

Strip his mechanism and what he is describing is the ordinary course of a modern adult. The young man’s body protests the diet, with bloating and discomfort and a few years of being told it is nothing. Then the protests stop. He can eat anything. He also weighs thirty pounds more than he did, loses his breath on one flight of stairs, and considers himself in reasonable health, because the one organ that used to complain has gone quiet. The quiet was not health. It was the body ceasing to fight a battle it had lost, and shifting the cost somewhere less noticeable.

Starving to death

The chronic stage is the one he saw kill people.

“The appetite is generally good, sometimes unusually so, there being no difficulty in retaining food on the stomach. Often the patients are hungry most of the time, and in some instances they desire to eat constantly, the food running through them almost as fast as taken, fermenting but undigested. Really the patients are starving to death, the alimentary canal being more a yeast pot than an apparatus for digesting food.”

And a page later, in the list of symptoms: “There is often an increased craving for food and drinks, but the food, notwithstanding the amount consumed, produces no increase of flesh. On the contrary, a steadily increasing emaciation is almost always noticed, with gradual enervation of body and mind.”

Hungry most of the time. Eating constantly. Starving. The patient dies, he says at the end of the chapter, “apparently exhausted from want of nourishment, which, although taken freely, is not appropriated.”

In his patients the food ran out the far end before the body could use it. In the modern version the food is absorbed perfectly well and stored where it does no good, and the person is at once overfed and undernourished, carrying a surplus and starved at the cellular level, and hungry, always, because the body is asking for what it needs and getting what it does not. The direction is reversed, wasting then and gaining now. The condition is the same: a person who eats all day and whose tissues are not being fed. Salisbury put the two facts side by side, constant hunger and steady decline, and did not let the appetite fool him into thinking the man was nourished. That is a harder thing to do than it sounds, in a culture where eating is taken as proof of being fed.

Do not suppress it

The acute stage, when the diarrhoea first breaks, is the one place he claims an easy cure, and his warning about how it is usually mishandled is a warning about medicine in general. Caught early, he says, the disease “yields readily” to a single purgative dose of salts, some mineral tonics, and “a rigid diet of broiled lean beef, with one cup of clear tea at each meal.” But “if neglected, or if attempts are made to suppress it with opium and astringents, and with light farinaceous diet, the abnormal alimentary conditions invariably become worse, and the diarrhoea reappears with aggravated symptoms, and soon becomes chronic.”

Opium to stop the diarrhoea; crackers and gruel because the patient is weak. That was the standard treatment, and in Salisbury’s telling it was the thing that turned a week’s illness into a lifelong one, because it quieted the symptom and fed the cause. He states the rule in the pathology section as a general law: “Every and all remedial means that have a tendency to produce an astringent, soporific or congestive influence, aggravate the disease.” Anything that silences the body’s complaint while leaving the complaint’s cause in place makes the disease worse.

The opium is gone. The principle is not. Every chronic condition in a modern clinic has a drug that quiets its symptom, and the patient leaves with the symptom quieted and the biscuit still in the haversack.

Sugar in the stool

Chapter XVII is what he found with the microscope, and it is more careful than his critics would expect. He lists yeast, of course, and the “colloid” jelly he found in every case. He found fat globules, and crystals, and “beautiful hexagonal prisms of crystalline sugar,” sugar passing straight through a body that could not use it, which is as plain an image of malnourishment in the midst of plenty as the book offers.

He also does something here that he could not do with his own central theory. The colloid matter, he concludes, “is not the cause of the diarrhoea, but is merely the consequence” of the fermentation; it is “present in direct proportion to the severity of the case” and it disappears when the diet changes. A passenger, correctly identified as a passenger, by the same man who mistook the yeast for the driver. He had the discipline. He applied it selectively, which is how most people apply it.

And then the sentence that was his real evidence, the one that kept him from revising anything: “As soon as patients are put upon an exclusive diet of the pulp of lean beef, the yeast plants are killed or cleaned out, the fermentative changes cease, and the thickened state together with the attendant catarrhal condition gradually pass away, and a healthy state is restored.” He fed them beef and they got better. Whatever was wrong with his explanation, that observation was his to make, and he made it over and over.

On the table

Chapter XVIII is the autopsies, and most of it is for a stronger stomach than this series assumes. Thickened colon, enlarged glands, a spleen full of blood, an omentum “entirely deprived of adipose,” the body having burned its own fat stores while its owner ate all day. Clots in the heart, which he attributes, with a nod to Virchow, to the fermentative state of the blood. The liver, interestingly, “as a general rule quite healthy and firm,” which fits a wasting disease and not a modern one.

One passage is about method rather than pathology. The lining of the stomach and colon, he found, was studded with enlarged, swollen follicles, “fungoid elevations, wider above and constricted below.” When the organs were cleaned for examination, these were “liable to be brushed or torn off, leaving ragged or clean edged depressions, resembling the bed of ulcers. In this way many stomachs which have been examined only after cleaning, seem to have been ulcerated, when really no such lesions existed.”

Other physicians had been opening these bodies, washing out the gut, finding what looked like ulcers, and recording an ulcerative disease. The ulcers were made by the washing. Salisbury caught it because he looked before he cleaned, and he says twice in the chapter that ulceration “is not as frequent in this disease as is generally supposed.” Whatever else is true of his microscope, he knew the difference between what the disease had done and what the examiner had done, and that distinction is rarer in every field than it should be. Before concluding that something is damaged, it is worth asking who handled it last.

Yeast pots

Chapter XIX is a page, and it restates the thesis in the flattest language he has: “In consumption, the stomach and bowels are ‘yeast pots.’” The lining, he says, loses “those beautiful and wisely bestowed selective powers found in healthy states, by virtue of which only such products as are required to nourish and maintain the tissues are taken up,” and begins “to ‘gobble’ up the good and the bad together.”

The yeast is wrong. The selective power is real, and so is its loss. A healthy gut is a filter with judgment, and a gut that has been fed the wrong things for long enough stops judging and starts passing everything through. That the lining of the intestine can be damaged into letting through what it should hold back is now an active field of research with its own vocabulary. Salisbury had the picture in 1867 and the wrong name for what was damaging it.

What survives

Four chapters on a disease that, in its infectious form, has largely left the countries where this will be read. What is left standing is not small.

That the quiet phase comes first and is overlooked. That the body adapts to a bad diet by ceasing to complain, and that the adaptation shows up as weight, breathlessness, and fatigue reported as health. That a person can be hungry all the time, eat constantly, and be starving, and that appetite is no evidence of nourishment. That the cure for a cause is not the suppression of its symptom, and that the usual treatment, then and now, does exactly the suppressing. That the thing to look at is what runs through the body unused, the sugar in the stool, the surplus on the frame, as the mark of a body that is being fed but not nourished. And that a careful man checks whether the damage he is looking at was done by the disease or by his own hands.

The soldiers died of their water, and of their biscuit, and no change of diet alone would have saved the ones the water had already reached. But the biscuit is still in the haversack, in a form the quartermaster would not recognize, and the men carrying it are still hungry most of the time, and still, in the only sense that matters to their tissues, starving.

Read along

The book is in the public domain, and the Internet Archive has the complete scan free of charge, in PDF, EPUB, and plain text:

The Relation of Alimentation and Disease (Internet Archive)

Part 9 compresses Chapters XX through XXX, the pathology of consumption in the diaphragm, heart, air passages, and lungs, into one short post, keeping the handful of passages that still land and leaving the rest on the table where Salisbury found it.