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A  TREATISE
y^fjtf
LM fe
AND ITS CONSEQUENCES,
CALLED
NERVOUS AND BILIOUS COMPLAINTS
OBSERVATIONS
THE ORGANIC DISEASES,
IX WHICH THEY SOMETIMES TERMINATE.
BY A. P. W. PHILIP, M. D., F. R. S. Ed., &c.  /
 /
-, (
       SECOND EDITION,     -*""gSF?


  \?1TH SOME ADDITIONAL OBSERVATIONS^ I Q ^ *J I *


       ^fePARY~OT THE     V" ^-~.


       WASHINGTf           ----. \


      ^ PHILADELPHIA:

II. C. CAREY & I. LEA—CHESNUT STREET.

  kVV H. r. f'APEY & CO, NO. 157, BROADWAY, NEW YOIIK.
    i       ..............

            •1822. 

^

WX
U„ -'O 
TO THE
        PRESIDENT,
FELLOWS AND LICENTIATES,
OF THE
               OF LONDON,

     THE FOLLOWING TREATISE

          IS RESPECTFULLY DEDICATED

              BY A MEMBER,

 WHO IS DEEPLY IMPRESSED WITH THE ADVANTAGES WHICH THE
       PROFESSION OF MEDICINE HAS DERIVED FROM
          THE INSTITUTIONS, AS WELL AS THE
            SCIENCE, OF THAT COLLEGE.


5, Hanoyeh Square,}
 November, 1821. j 
C9
• 
                                                Page.
Preface      ...     .     -     _     -     -v
Preface to the first edition      -     -     -     -    vii

A TREATISE, &c.      -----   l

                    CHAPTER I.

Of the symptoms  of Indigestion.       -      -   4
    Of  tkft flymptoms of the firat ateg^ of Indigestion  lb.
    Of the symptoms of the second stage of Indigestion 16
    Some observations on the third stage of Indigestion  22
    Of the various forms and comparative duration of
      the different stages of Indigestion     -     -  24

                   CHAPTER II.

Of the causes of Indigestion    -     -     -  29
                     Section i.
    Of  the process  of digestion     -      -     -  ib.

                     Section ii.
    Of  the remote causes of Indigestion     -.    -  39
                     Section hi.
    Of  the immediate causes of Indigestion    -    -  47

                   CHAPTER III.

Of the treatment of Indigestion    -       -  66
                     Section i.
    Of  the treatment of the first stage of  Indigestion    ib
4 
                  CONTENTS.
                                              I'p^-e.
Of the diet in Indigestion     -                  6&
Of exercise  in Indigestion      -     -     -     -   8/
Of the medicinal treatment in the first stage  of
   Indigestion     -      -      -               -   95
Of the preparative means     -           -    -  to
Of the treatment when  the disease is confined to
   the stomach and bowels    ...      -   99
Of the treatment when the disease has spread far-
   ther than the stomach and bowels    -      -   109
                 Section ii.
Of the treatment of the second stage of Indiges-
   tion    -      -    -    -      -      -     -   117
Of certain trains of symptoms, whnsp treatment
   does not fall under the general plan  of rure     141
Of the concurrence of the second stage of Indiges-
   tion and fever    -     -      -     -         158
Recapitulation     -       -       -     -      -   163

               CHAPTER IV.

the third  stage of indigestion    -     -   163
                  Section i.
Qf dyspeptic phthisis     -    - ■   -    -    -   168
Of the symptoms of dyspeptic phthisis    -    -   169
Of the causes of  dyspeptic phthisis      -         174
Of the. appearances  on  dissection  in  dyspeptic
   phthisis.....-    -175
Of the nature of dyspeptic phthisis      -      -   176
Of the treatment of dyspeptic phthisis     -    -   182
                 Section ii.
Of habitual  asthma     -     -     ...   jgj
Of the employment of  galvanism in habitual
   asthma.......192
• 
P R E F A C E
      TO THE

SECOND EDITION.
   In revising the following Treatise, the author's only ob-
ject has been to render it more useful to the practitioner.
   As  hardly  h.df a year has elapsed since its publication,
any considerable  enlargement of it is  not to be expected;
but he hopes that the present edition will be found in several
respects improved.  Many observations have been added,
and an  attempt has been made,  in several passages, to ex-
plain  more fully  the  principles  which led to the treatment
recommended  in it, the  author's  confidence in which, he
is happy to say, has been strengthened since the appearance
of the first edition, by communications from several physi-
 cians, to some of whom  he  has  not the honour of being
 personally known.
    For the  sake of histy readers, who seldom see arrange-
 ment  in a work where  the  subject is  at all  complicated,
 without numerous divisions and references, the author has
introduced a greater number of these, which, to the diligent
 who bear in mind the plan laid down and  feel no difficulty
 in perceiving how the different parts of the subject arrange
 themselves under it, are often  superfluous, and therefore
 unwelcome interruptions. 
-se* 
PREFACE
     TO THE

FIRST EDITION.
  My chief objects in the followine_Treatise have been to
give arrangement to the various affections which have been
termed  nervous and bilious; to ascertain the nature  of the
disease  on which they depend; to trace the causes  which
determine them to assume the various forms in which they
are presented to us, and to determine the appropriate treat-
ment of each of these forms.
  In enumerating the symptoms, I have been led to enter
more fully than, I believe,  has hitherto been done, into the
manner in which the sympathy of parts influences the phe-
nomena and  treatment of  diseases, and thus to endeavour
to ascertain some of the laws by which it is regulated.
  An attempt  has been made to distinguish  the symptoms
which are the more immediate effects of the remote causes,
from those which arise from the continuance of the disease
itself, and to shew, that on a correct knowledge and  conse-
quent discrimination of these two classes of symptoms, the
successful treatment, in a great degree depends.
  My attention has been particularly directed to the  latter,
by  which the  changes which take place in the progress of
the disease are  indicated.   I  have endeavoured to ascertain
the nature of these changes, and the manner in which they 
VITI                   PREFACE.

influence the various functions, and at length,  in  many in-
stances, destroy the organization of some vital part.
  The adaptation  of the  means  of cure to  the changing
nature of the disease, has been constantly kept in view; for
similar trains of  symptoms,  at  its different  periods,  we
shall  find,  require different, and sometimes even opposite,
means' of cure.
  I  have attempted to point out the influence of regimen,
and  to dertermine  the  rules  by  which the employment of
mercury, which, we have  reason to  believe, has become
too indiscriminate in this disease, should be regulated, and
the limits  at which its beneficial, no longer counterbalance
its injurious, effects.
  In  the composition  «f  the  following  Treatise, recourse
has not been had tc the works of others.   It cannot there-
fore  be regarded as an attempt to present to the reader the
sum of our .knowledge on the subject.   I offrr it simply as
the result of my observations,  and the reflections suggested
by them, during a space of twenty-five years. 
*■..
                                                        *



   IT is a remarkable fact, that there is hardly any disease
 less understood than that which is most frequently present*
 ed to us,- and known under the vague denominations of bil-
 ious, nervous, and stomach  complaints; which  seems the
 more  extraordinary, because there is none of greater im-
 portance, whether we  regard its variety,  its consequences,
 or its connexion with other diseases.
   This irises,  I  believe, from two  circumstances.   The
 first^elates to .the nature of the disease itself.  In its early
• stages, in which  other fatal diseases sometimes give us an
 opportunity of examining the  organs chiefly affected, the
 cause of derangement is in parts too minute for observation;
 and before  its  fatal termination, it is so changed, that the
 inspection of those who fall a  sacrifice to it, throws little
 light on its  origin.  Who, for example,  can learn from the
 appearances in the body of a drunkard, what particular state
 of the  parts concerned caused  the dyspeptic symptoms,
 which preceded the indurated liver, and distended abdo-
• men? The second circumstance to which I allude, relatesto
                           B 
 a                   ON INDIGESTION   .

 the  causes of the disease.   We kno.w that the. digestive
 power of the stomaoi, depends on a'fluid secreted in it, and
 consequently, that a deranged state of this fluid must be the
 cause of the symptoms  of Indigestion; but-we cam make
 little practical  use  of this knowledge, unless  we know the.
 immediate causes of its derangement, and the  particular
 manner in which the derangement, operates in producing '
 the symptoms of the disease.  These are-the questions which
 chiefly interest the physician; and yet, as far as I know, no
 attempt has been made to answer them; and the practice in
 this  disease remains uncertain and ill defined.
   My attention has  frequently been  arrested by finding,
 that  cases, in. which the usual means, in many instances
successful; had failed, and  indeed often  aggravated 'the
 symptoms, yielded readily to an opposite  plan.  Cases  re-
 lieved by opposite plans of treatment,  it  is evident,  cannot
 be of the  same  nature, however similar their causes and
 symptoms<   They are either different diseases, or different
 stages of a disease, whose nature undergoes some  change
 in its progress.
   I  have arranged the various cases, of which  I  am about
 to treat, under the denomination of Indigestion, because the
 symptoms of this derangement from a more or less promi-
nent  feature in  all, and all begin with these  symptoms.   I
prefer this term to dyspepsia, which has been employed bv
 medical writers to express a disease much less varied,- and
 of much less extent than that I am about treat of.  Indiges-
 tion, therefore, in the sense in  which I shall use this term
 is not synonymous with dyspepsia, but includes it.
  The following Treatise may be divided into four parts:—
 In the first, I shall present to the. reader, a  review  of the
symptoms of Indigestion, and  its more immediate  conse-
 quences;1 in  the second,  consider the remote causes of this
disease, the manner  in which they excite it,  and the  nature
 of the changes which take place irf its progress; in the third
 detail the plans of treatment  which bave appeared  to me 
           AND ITS CONSEQUENCES.            '  3

most successful in it; and in the last, make some observa-
tions on the symptoms and treatment  of the organic de-
rangements, in which it often termites.
  By a disease we mean,  not only that collection of symp-
toms which are present at  any  otik time, but also  those
which appear'in succession,  arising from the same source.
We shall  find Indigestion the most varied of all diseases.
Beginning  from  simple "and  apparently unimportant devia-
tions from health, it gradually becomes so complicated, and
often, at length,  so undermines every power of the system,
that it is difficult to give a view of its symptoms, which shall
be at once  sufficiently full and distinct;   It is an affection
of the central  part of a most complicated structure, capable
of influencing  even its remotest parts,  and each, through
many channels; and in* various ways. 
/
OF THE SYMPTOMS
                   CHAPTER  I.


     *   OF THE SYMPTOMS OF INDIGESTION.

                              * •
   I shall divide  the symptoms of Indigestion into three
 stages.   While  this  division renders,  the actount of them
 more distinct, it  at the same time answers a more important
 purpose, for we shall find the disease in these stages varying
 in its nature, as well as in its symptoms.


    Of  the S$irt\>toms \>f the  Tirat Stage.
    • ■                                  ■ •

   The first; symptoms of  Indigestion are either such as* im-
 mediately arise  from the undigested  food itself; or from
 the state of the  stomach and bowels which causes the dis-
 ease, and the  irritation of their nerves,  occasioned by the
 undigested food, or  their own vitiated  secretions.
   The  symptoms which immediately.arise from the* undi-
 gested food are flatulence,  distention  of the 'stomach and
 bowels, and acid, oily and putrescent eructations.
   From the debility of the stomach and bowels, and irrita-
 tion of the nerves, a greater variety of symptoms  spring.
 Organs  of such  importance  in the animal economy cannot
 long be  so def&nged  as to produce vitiated secretions, with-
out at the same time, giving rise to other disturbance in the
 system.   The debility of stomach, which  prevents .a due
 secretion of healthy gastric fluid, must at length, pro^Jtice
 some of those other effects which we witness, when the pow-
 ers of the stomach are disordered by any offending cause. 
                   OF  INDIGESTION.                 5

   An emetic, while it remains on the stomach, destroys the
 appetite, occasions  nausea, sometimes pain, and produces,
 in consequence of  the sympathy which exists between the
 stomach and every other part of  the system, a general state
 of debility, now  and then almost approaching to syncope.
 The surface  is  pale, cold,-and  shrunk,  and the action of
 the heart is impaired,  the pulse becoming small and feeble.
 The limbs .perhaps tremble, and  are always unequal  to
 their usual exertions,  and  the mind is  anxious and sub-
 dued.   These symptoms, however,  disappear as soon  as
 the act of vomiting relieves the stomach from the offending
. cause.
   When we  consider  that  the  causes which disorder the
 powers  of the stomach in Indigestion are  of a  mote per-
 manent  nature, and that the contents which irritate its sur-
 face, although often removed, as in the case of the emetic,
 are soon reproduced, we shall find little difficulty in perceiv-
 ing the  general rationale  of the symptons of this disease.
 But, in order more particularly to ascertain the state of the
 stomach and bowels in its various  stages, it will be necessary
 to take a closer view of its symptoms, and attempt a more
 minute investigation of their immediate causes.
   The symptoms which arise immediately from undigested
 food, exist in various degrees in  different-cases.  In the ve-
 ry  commencement  of the  disease, they  are often the only
 symptoms which occasion  much  uneasiness, from which it
 appears, that the functions of the stomach may, for a cer-
 tain time, be so disordered as to  produce a feeble, or other-
 wise vitiated "secretion, without in any other way very sen-
' sibly affecting the functions  of  the system.  People fre-
 quently complain of a-sense of distentfon after eating, and
 flatulent and  acid eructations, who, notwithstanding, enjoy
 •good gene^t health;  and find  that even these  symptoms
 may be prevented by taking less food, and that  of a more
. digestible quality; and, if they are prudent in this respect,
' and the constitution is otherwise  soand,  and not exposed to 
g                OF THE SYMPTOMS

ihe "effects of indolence, and  other  causes weakening  the
nervous system, the stomach wili often recover its powers
without further mean's.
   In the majority of cases, however, either front neglect on
the part of the patient, or  a greater degree of obstinacy in
the* cause, the  above symptoms  continue to  recur.  This
never happens  for any  great  length,of  time,  without  the
other parts of the-alimentary canal partaking of • the disease.
Their  secretions also begin to suffer sortie deviation  from
the healthy  state.   Those  of the intestines,  for  the most
part, are impaired in quantity, and,  at the same time, prob-
ably altered in quality.   The bowels do  not  act so readily •
as  usual, and they are occasionally distended and  tense,
especially sometime  after eating.  The mouth is clammy,
and the.tongue more or less furred, particularly in the morn-
ing.
   But these symptoms,  the  patient finds, yield to some
mild  aperient,  which, at the  same  time, promotes the ac-
tion of the  stomach,  and his feelings on the  whole,  differ
but little from those of health. He is more apt to be thirsty,
his appetite  is generally more or less impaired and variable,
he complains of his feet  being cold, but still  nis strength,
and general appearance,  are  but  little affected, and he  sel-
dom thinks it necessary to pay particular attention to symp-
toms which  appear so slight,  and  for the time yield so read-
ily;
   By degrees, however, they recur  more frequently, and
begin to be attended with some depression of strength which
at first  is only  occasional.   This,  in  generaV,.is the firsf
thing which seriously calls his attention to the disease. The
mind, if the disease proceed,  partakes  of these returns of
langour, and the patient  at length  finds it difficult  at  all
times to command  his.attention,  and upon th%whole, that
he is not capable of his usual  mental efforts.   His' sleep is
disturbed by perplexing  dreams, and  sometimes by  fits of .
night mare. In a  large  proportion of cases, however,  he 
                  OF INDIGESTION.   ,              y

 ePJoys g°°d nights, and even  those who are troubled with
 dreaming  and restlessness, often  feel more drowsy than.
 usual.                                       .
   He now becomes  alarmed, and occasionally  feels a de-
 gree  of despondency.   Instead  of thinking too .lightly of
 his complaint, he often regards  it in the most serious point
 of view, and cannot be persuaded that any thing less than
 some important derangement, can produce the anxiety  and
 depression by which his attention gradually becomes wholly
 engrossed; for none but an  attentive physician can know-
 how slight a derangement of the alimentary Canal, especial-
 ly after the habit of disease is formed, is  capable of essen-'
 tially influencing every function of the system.
   While  the symptoms thus proceed, a change,  sooner or
 later, taljes  place, which, marks  an  important step iti the ■
 progress of  the  malady.  The alvine discharge  begins to
 deviate from the healthy appearance: i{  sometimes contains
 uncombined bile, sometimes  it  chiefly consists of bile; its
 colour at  other times is too light,  more frequently too dark;
 and  occasionally, at length, almost black;  at different, times'
 it assumes  various  hues,  sometimes inclining  to  green,
 sometimes to blue, and sometimes it is mixed with, and now
 and  then  almost wholly consists of,  undigested bits of food.
 When there is much straining, it often  contains mucus in
 distinct masses, and not unfrequently,  substances resemb-
 ling bits of membrane.  It  frequently  separates from the
 canal with more  flifficulty than  usual,  and leaves a feeling
' of the bowels not having been completely emptied.
    We have reason to believe that the above change and Va-
 riety of colour arise  chiefly from the  state of the  bile, to
.. which  the  alvine discharge owes  its natural tinge, being
  quite white, when no bile flows into the bowels.  It would
  appear that the properties of  the bile are sometimes  changed
  without change of colour; but this is comparatively so rare,
  that if the colour of the alvine discharge be natural, we may

                                           *  4 '  ■ 
g               OF THE SYMPTOMS

generally infer that the function of the liver  is duly per-

^m'disease has hitherto been  what  is called stomach
complaints.   It. is now, from the various appearances of
the vitiated  bile,  and the various  symptoms which arise
from the irritation it occasions in the alimentary canal, what
is called bilious and nervous  complaints.  The former of
the two last appellations has also arisen from the  bile, of
which there is sometimes a superabundant secretion, being,
occasionally, in consequence of the inverted action of the
duodenum,  thrown into the  stomach; and  there  exciting
nausea, headache, and bilious  vomiting.
  Many conceive that the changes  of-colour in the alvine
discharge are often to be ascribed, more to circumstances
in diet, and changes which the contents of the bowels un-
dergo in their passage  through this canal, than to the state
of the  bile;  and,  I have no doubt, these causes operate to
a greater  or less  extent.  The long delay of their contents
in the bowels generally darkens the  colour;, a miik diet'pro-
duces a  discharge of a lighter colour than  one  consisting
chiefly of. animal  food, and some vegetables and medicines
communicate a certain tinge to the  discharge.  According
to my experience, however, these causes on the whole, pro-
duce less effect than  might be expected^ and,  with  a little
attention on the part of the practitioner, will seldom mis-
lead him.   It must always be  kept in view, that the  ap-
pearance of the discharge often changes* when it has  re?
mained for some time out of the body.
  The urine also  deviates from  the healthy state.   In its
most  healthy state,  it is perfectly tansparent when  passed,
and remains so after it cools,  its colour being  more or less
deep in proportion to the degree in which its contents are
diluted.  It is, however,  liable  to some deviations from
this state under circumstances which can hardly be said to
affect the general health.
  It appears  from some experiments  which I made many
years ago for tfce purpose of ascertaining the effects of vari- 
                   OF INDIGESTION.                 9

ous circumstances in diet, &c, on the state of the urine, an
account- of which  the College  of  Physicians  of London
did. me the  honour to publish in the last volume of their
Transactions, that  when  acid greatly prevails  in the stom-
ach and bowels, or, the skin becomes more inactive than
usual,  so that it does not freely throw off the acid, which it
appears from these experiments always passes by this organ,
a red deposition, which consists of lithic acid, takes place
from  the  urine after it has stood for some time,  this fluid
still remaining clear; and on the other hand, that,  when the
skin has, been unusually excited, or an alkalescent state of
the stomach and bowels prevails, it  becomes turbid, and
deposits a white sediment, which has  been ascertained, by
the experiments of Dr. Wollaston,  to consist of  the phos-
phates of  the urine.
  Both these states, particularly the former, are  more  apt
to appear  in Indigestion than in ordinary health; and the
urine in this disease is sometimes covered with a  very thin-
oily film,  which appears' to arise from an imperfect state of
the assimilating  process..  Sometimes  also  it is limpid,
and passed  in unusually large quantities,  more frequently
scanty and too high coloured.  It is  thej most  apt, as we
should a priori expect, to deposite the above sediments  un-
less some  degree of fever prevail, when it often either de
posites nothing, or  a little of the red sediment.
  A remarkable sympathy between  the state of the kidneys
and intestines is often observed in Indigestion, the urine re-
maining scanty and high-coloured, when the bowels  are
constipated;  and flowing  freely, and  of a paler colour, as
soon as a free discharge  from  them has been  obtained.
Even  in those dropsical affections which supervene on this
disease, it is common for all diuretics  to fail when the bow-
els are constipated, and for the operation of cathartics alon<n
to be followed by a  free discharge from the kidneys,.
                           C
• 
 10              OF THE SYMPTOMS

  The copious flow of urine which sometimes attend Indi-
gestion seems frequently to arise from a failure in the action
of the skin, as appears from some of the experiments just.
referred to.   The kidneys and skin separate the same fluid
from  the  blood,  and  a failure of secretion from the latter
is often compensated by an increase of that from the former,
if they have not by sympathy partaken too much of the state
of the skin.   Thus in dyspeptics  an  unsual application of
cold to the surface,  when the powers of the system are not
able so to re-act as to support the due action  of the skin
under it, frequently occasions an increased flow  of urine.
  The same cause often occasions a greater discharge from
the bowels.  It particularly demands attention in this dis-
ease,  that, although the increased.discharge from the bow-
els in  the instance before us  is of a watery nature, when the
skin has, from the state of that disease, become uniformly
languid, the increase is often in the solid,  as well as liquid,
contents of the bowels.   On  the same principle, the quantity
which passes from the bowels of delicate children when the
skin has become dry and shrivelled, is often astonishing, and
that even when little nourishment is received, as if not only
what  ought to have passed by the skin, but a great deal of
what  has  been inhaled by  this organ were deposited in a
solid form in the  alimentary canal.   Some facts  would lead
us to suppose that in such a  state of  the skin, the inhalation
by  it  is often  very great.   I have  seen several gallons of
water drawn off from a child ten or twelve years  old  la-
bouring under extensive abdominal disease,  and apparently
recollected in eight or ten days,  although but little fluid had
been taken.
  What is here said  is well  illustrated by an opposite state
of the system.  In very great  eaters,  the ajvine discharge
is often no greater than in other people, but the secretion by
the skin is found  much more. free.   Even  in a remarkable
case of this kind, an account of which appeared in the journ-
als  of the jlay (1797.) in which an individual could  eat 
                   OF INDIGESTION.               it
daily twelve or fifteen pounds of raw meat, and would have
starved if confined to the allowance of two or three ordinary
men, the alvine discharge  was little, if at all, greater than
usual,  yet  he continued thin,  and the superfluous quantity
of food ran off by'profuse night-sweats.
  The sensible change in the appearance of the alvine secre-
tions in Indigestion, is generally attended  with some change
in the other symptoms.   The  stomach  is more apt to be
oppressed after eating, the  patient  often  observing that he  •
feels as if there were not room for what he had taken.  The
bowels are frequently variable, diarrhoea  often supervening-
without any evident cause, almost uniformly followed by fits
of constipation.   These, the patient finds, cannot now be re-
moved by the simple medicines which at first restored due
action  to the bowels,  larger doses or more active medicines
are necessarv, and their effect corresponds with the previous
state of the bowels.   The discharge is generally unsatisfac-
tory, something seeming to be  retained.  It is  very often
waterv, or  frequent small semi-fluid, teasing, mixed with
mucus, and  sometimes streaked with blood, and after it
has been  repeated, often chiefly consists  of mucus  and a
little blood, the passage  of which  is attended with  much
griping and bearing down, and followed by a constant desire
of further evacuation.   The  patient takes more medicine,
with the hopes of a freer effect, but he thus often increases
the straining more than the discharge.
  • After this state of irritation has continued to recur for
a great  length of time,  a  degree of permanent spasmodic
stricture sometimes appears to take place in the rectum.
This I have known happen to such a degree as to give a tape-
like appearence to the alvine discharge for many months with-
out intermission, and suggest the idea of organic stricture, till
an examination of trie part proved its real nature.  A more
temporary contraction of the rectum, occasionally giving this
appearance to the discharge, is not an uncommon symptom.
• 
  lg             OF THE  SYMPTOMS

    In the meantime the patient is harrassed with a variety of
  other symptoms, arising from the irritation occasioned by
  the morbid contents of the alimentary canal, increasing lan-
  guor pains of the stomach,  more frequently of the bowels,
  and particularly of the lower part of the bowels,  sometimes
  continued, generally of the griping kind, a sense  of  heat,
  or, as  the patient often  calls it,  burning,  referred to the
  stomach,  and now  and then extending  to  the  bowels,
• which  sometimes proves  the most obstinate and distressing
  symptom of the disease, or of weight in the- right hypochon-
  drium  or lower part of  the  abdomen, with  unusual  dis-
  tention of the former, sometimes disappearing in a day or
  two, particularly after freer evacuations, and returning again,
  at  other  times more  stationary, a more foul and  clammy
  tongue, nausea,   more rarely vomiting, a depression of
  strength,  which  sometimes,  pnrticularly after'the  unsatis-
  factory operation of cathartics, almost amounts to syncope,
  and  a  despondency that is  hardly equalled in any other
  disease.
    As these symptoms proceed, otrlers the consequence of
  the sympathy which exists between the stomach and other
  parts of the system, gradually shew  themselves.   These
  are different in different cases,  pain of different parts,  and
  other complaints, of the.head, affections  of the sight, the
  hearing, smell, or taste.  More or less habitual inflammationj
  and even ulceration, of the throat are  by no means uncom-
  mon, and the  voice  and articlilation  are sometimes  vari-
  ously affected.   The patient  is distressed with spasms of
  the trunk or limbs, numbness, and even temporary loss of
  power in  the latter; and feelings of endless variety are des-
  cribed as sometimes  in one part of the  body and sometimes
  in  another.                        •
    By constant recurrence of such attacks without being uni-
  formly ill, for the rapidity with which the patient rallies is often
  as  great as that with which he  is subdued,  he  is gradually
  rendered'unfit for the active duties of life.   This preys on 
                  OF INDIGESTION.               4 3

his mind, increasing the despondency which makes a part
of his disease, and which in its turn, by further debilitating
the digestive organs, aggravates all the symptoms..
   These organs being no longer in a proper state to supply due
nourishment, the body becomes emaciated,  and more per-
manently feeble, the strength by degrees rallying less readily
and less perfectly after the frequent returns, and what was
at first only a temporary depression from a debilitating cause
affecting the  nerves of the  alimentary  canal, is gradually
changed into real debility, trie countenance, which  is almost
always a sure index of what is passing internally, becoming
pale and haggard.
   It  is of great importance in judging  of the  state  of
this disease to distinguish between debility and what may be
ealltrd depression of strength.  In  the latter the  actjon of
the vit.d powers is only impeded, in the  former their vigor
is impaired.  The  one  may  supervene in a moment, and
may  be as instantly relieved; the other,, unless the cause be
very  powerful,  comes on more slowly, and is in  all  cases
slowly  removed.  We  have an instance  of depression of
strength in the effects'of an offending cause in the stomach
and bowels, which cease as soon as thecause ceases to ope-
rate; of debility in the effects of repeated irritation of these
organs, which continue  after the cause of irritation no long-
 er exists.   Thus  the  debility,  which ar/pears suddenly at
the commencement as well as at other periods of Indigestion,
 is of trifling importance^ compared with that more  perma-
 nent debility which supervenes gradually,  the symptoms of
 which  are often slight  compared4 with those of temporary
 depression of strength, but which is always more difficult of
 cure.  The one is chiefly important as  it indicates  what is
 passing internally;  the  other proves  that the powers of the
 constitution are yielding to the disease.  Either mistaken for
 the other leads to serious errors in practice.
    The patient,  often from-an early  period of Indigestion,
 feels some uneasiness on lying on the left side, more rarely 
 14              OF THE SYMPTOMS

 this is the case with respect to the right side.   In the pro-
 gress of the disease, lying on either side becomes uncom-
 fortable, and, in its advanced stages, the only easy position
 is on the back, with the  shoulders a little raised, and gene-
 rally inclined to the right side.
   Such is the general course of the disease we  are consid-
 ering.   Those who are acquainted with the laws of sympa-
 thy  which in so striking a manner  modify the phenomena
 of disease, will expect, that in  the parts  which most sympa-
 thize with the stomach and  bewels, and consequently par-
 take most of their affections, the symptoms  of this disease
 will be found most varied.  Thus it is  that the  tongue and
 other parts of the mouth are variously affected from the com.
 mencement.  Their secretions become more and  more thick
 and clammy, the former being covered with a white or brown-
 ish mucus, which also more or less adheres to, and irritates the.
 fauces; sometimes all these  parts are more or less parched
 and stiff, at other times the saliva is morbidly thin and copi-
 ous, the tongue  being cleaner but often of a whitish and
 sodden  appearance.   In protracted  cases  when  the  symp-
 toms have been  rather obstinate than severe, and conside-
 rable debility has come on, this symptom is often very trou-
 blesome, the saliva frequently running from the mouth.
  In the advanced stages of the more severe  cases, there is
 often a viscid frothy  secretion from the fauces, while  the
 mouth in general is drier than usual, which forms  a very
 prominent feature of the disease.  The patient is constantly
hawking up  this matter, particularly  after  eating, and will
tell you that all his food turns to phlegm.   This discharge
is sometimes so  great and harassing as to prove the most
distressing symptom,  and seems not  a little  to  add  to the
debility.   In some  cases the tongue, in  the more advanced
stages becomes clean,  shining, and morbidly smooth,  and at
length affected with aphthae.   .This state of it is seldom ob-
served except when a considerable degree of fever has su-
pervened, which is not uncommon at these periods. 
                   OF  INDIGESTION.                45

  The skin, in protracted cages, often becomes dry, shrivelled,
and sometimes,  at length, almost scaly, and the hair is par-
ched  and  inclined to stand on end, the whole surface is
cold,  the patient,  is  constantly hanging  over the  fire, and
even  experiences frequent fits of chilliness approaching to
shivering; he bears all extremes of temperature  ill,  being as
. much oppressed by a very high temperature as he is chilled
by a  low one; wounds heal less readily than usual, and the
skin is n©t unfrequently affected with a troublesome itching,
which often shifts its seat, or with nettle rash, herpes, and
other species of eruptions, and even ulceration sometimes
supervenes without any evident cause.
   Besides the more transitory symptoms in the head, which
 h.ave been mentioned, there  are often marks of an habitual
 undue  determination of blood to the brain, producing lan-
 guid inflammation of the  eyelids, tinnitus aurium,' and occa-
 sionally  throbbing of the temples.  Some  are oppressed
 with drowsiness, sometimes  almost approaching to stupor,
 others  with almost constant pain more or less severe, some-
 times in the back of the  head, more frequently in the fore
 part, others are subject to giddiness, and some even to sud-
 den  fits of insensibility.
    The thoracic viscera are often particularly affected, occa-:
 sional, and  not unfrequently, more or less permanent, dys-
 pnoea supervenes, and#the patient is sometimes harassed by
 a dry and irritating  cough, or with fits of palpitation.  .
    When expectoration ^attends the cough,  it is  generally
 difficult, but brings considerable temporary  relief.  It de-
 serves notice, that in this stage of the disease, he  more fre-
 quently  complains of pain in the left than in the right side;
 but  the seat of the pain is very  various, not unfrequently,
 i,t is chiefly in the  back, about the  shoulders, sometimes
 attended with  itching', and in the limbs, more frequently in
 the  legs than the arms. . Irregularity of pulse and syncope
 are not unusual symptoms.  The former I have repeatedly-
  known  continue for years,  even  attended  with  the  more 
 6              OF THE SYMPTOMS

characteristic symptoms of angina pectoris without organic
affection of the heart  having supervened, although  under
such circumstances it is always to be dreaded.   It  is not
uncommon for the muscles of the chest to become painful
on motion, and even to the  touch.  The abdominal muscles
also  are sometimes affected in the same way.   This  affec-
tion is apt to be worse at night, so that the patient turns him-
self in bed with difficulty and pain.


   Of the  Symptoms of the  Seconn Stage
                 of Indigestion.

  At various periods of the disease, for the most part after
repeated derangement of the hepatic function, comes on a
permanent tenderness  on pressure, sometimes but slight, of
the soft parts close to the edge of the  cartilages of the false
ribs on the right side, after they have  turned upwards to be
joined to the sternum.  This spot is often very circumscri-
bed, and always lies about  half way between the end  of the
sternum and the place at which the lowest of the cartilages be-
gins to ascend; and the cartilage itself near the tender part off-
en becomes very tender, not unfrequently indeed much more
so than the soft parts.  The  patient in general is not  aware
of this tenderness till it is pointed ou^t by the physician.
   This symptom never exists-long and to any considerabfe
degree without the pulse becoming hard,  and it often  at the
same time becomes rather more frequent  than in health.
   There   is  no other  symptom of the disease before us to
which  I  am so  anxious to call the reader's attention as to
what I have termed a hard pulse, because on it much  of the
proper treatment seems to depend.  It sometimes happens,
especially when the tenderness in the epigastrium is consid-
erable, that the pulse  becomes such as would on all occa-
sions obtain  the  name of hard; but more frequently the 
                   OF INDIGESTION.               ±y

 hardness is only to be distinctly perceived by examining the
 pulse in a particular way.
   Those who have been much in the habit of examining the
 different states of the pulse must be aware, that its hardness
 is most  perceptible when a slight degree of pressure is em-
 ployed.  A certain degree, by greatly compressing the ves-
 sel, will give some feeling of softness to the hardest  pulse,
 and a slight degree of  hardness is not perceptible  with the
 pressure generally employed in feeling the pulse.   If the
 pressure be gradually lessened till it comts to nothing, it
 often happens that a distinct  hardness of pulse  is felt before
 the pulse wholly vanishes under the finger, when no hard-
ness can be distinguished in the usual way of feeling it.
   This is in no degree the case in a healthy pulse, nor even
 in the first stage of the disease we are considering.   But
 when the tenderness of the epigastrium is at all-a prominent
 feature,  it may always be  perceived, that is, there is then a
 certain  degree of pressure,  sometimes very slight,  under
 which the pulse gives a decidedly wiry sensation to the fin-
 ger, the  degree of pressure, under which  the hardness may
 be perceived, denoting its degree.  It is  most  sensible im-
 mediately after the patient has been using exercise.
  I consider the occurence of the tenderness  of the  epigas-
trium and  hard pulse as denoting the second stage of the
disease, because from the time of their appearance, at what-
ever period this happens, we shall find its nature, and con-
sequently the plan of treatment suited to it, changed.
  These symptoms are generally accompanied with others,
indicating some degree of feverishness.   The  chilliness of
which the  patient has long.complained is now sometimes,
and independently of any change of temperature in  the sur-
rounding medium,  interrupted  by  languid  and oppressive
fits of heat; and the hands and feet instead of being uni-
formly cold, as in the earlier stages, often  burn, particularly
during the first part of the night, while at other times they 
18                OF THE SYMPTOMS

are more obstinately cold.  The thirst also often increases,
and sometimes there is a tendency to partial swe:ii3 in the
morning, especially if the patient lie longer than rsual; and
these symptoms are generally attended with au  increase  in
som.  of those of the first stage.
   When the tenderness of the epigastrium and hard pulse
are consideraole, there is.generally, more  or less  iin inability
of exercise, except of the passive kind,  much active exer-
cise producing an insupportable languor; hut slight degrees of
the above symptoms are gent-rally unattended by this inability.
   The tenderness of the  epigastrium, after it has lasted for
som-Jtime, generally begins to be attended with some degree
of fulness in the part, and to extend downwards along the
edep  of the  cartilages,  till at  length, there is  a degree  of
fulness, and sometimes  tenderness, throughout the right
hypochondr'mm; which  feels firmer  than  the left; but the
tenderness • is seldom so  great as in  the part of the epigas-
trium above described.  Sometimes the pressure, both there
and in the hypochondrium, rather produces a sense of op-
pression aff.aing the breathing than pain.   Sometimes, par-
ticularly in the epigastrium, it.occasions pain passing through
the body  towards  the back, sometimes  quite to the back,
at other times ri fixed pain or sense of oppression under the
sternum, anJ, in some cases, a pain extending to the  left
side.
   There is often,  we have seen,  a degree  of fulness in the
right hypochondiium at earlier periods; but it is then more
transitory, being generally relieved and sometimes removed
by the effects of cathartics, and not unfrequently, spoptane-
ouslv disappearing and returning again.
   Such is the regular course of what I have called the first
and second stages  of Indigestion; but there is a  class of
symptoms, or rather, a  modification of certain  symptoms,
which, ahhough not forming an essential, constitutes, when
it does appear, the most important part  of  the  diease, 
                  OF INDIGESTION.                19

W*  have seen that even from the commencement,  distant
parts of the system, particularly those which sympathize
most with the stomach, suffer.  When any part has suffer-
ed more  frequently th.'.n the rest, its powers are gradually
weakened, and as the second stage proceeds its affections
assume in some degree a different and more prominent cha-
racter.  Thus headach, affections of the chest, of the lower
bowels, &c, often at length become the chief disease.
  It particularly deserves attention that the secondary affec-
tions undergo the  same change with the disease from which
they spring.  In the first stage they are merely nervous affec-
tions, disappearing as soon as the cause which produced them
ceases to operate.   In the second stage they assume an inflam-
matory character, become  more and more of a permanent
nature, and  in the  same proportion,  more independent of
the original disease,  till at-  length they  cannot be removed
without an  appropriate  mode of treatment directed to the
part secondarily affected.   This circumstance renders a par-
ticular consideration of them necessary  in  laving  down the
means  of cure: it will therefore  tax the  reader's memory
less  and save repetition to defer  any further account of them
till we come to this part of the subject. I shall then also, for the
same' reasons, lay before him such observations relating to
the  nature  of these affections as exclusively apply to them.
After this  explanation- I hope  I  shall  not be accused of a
neglect of order  in what I shall say  on  this part of the
subject..
   In reviewing  the symptoms of the  disease which forms
the  subject  of this  Treatise, it particularly  deserves atten-
tion that all the diseases which are called, and strictly speak-
ing are, nervous,  are apt to run into febrile diseases; injury
ensuing if  at  the period when this change takes place, a
corresponding change  is not made in  the means  of cure.
Many facts point out,  that long  continued nervous irritation
at length terminates in inflammation of the organ affected.
 Even an affection,  which  in the  first  instance,  is wholly 
 so               OF THE SYMPTOMS

 sympathetic, arising from irritation applied to a distant part,
 will, if severe or long continued, terminate in inflammation
 of the organ sympathetically affected.
   In the 43d, 44th  and 45th Sections of MorgagnVs 2\st
 Epistle, the reader will  find the pleuritis verminosa treated
 of at some length;  he  mentions one case in which all the
 symptoms  of pleurisy  were well  marked that terminated
 favourably by  bloody vomiting which brought up a worm.
 We  might in this instance attribute the relief obtained rath-
 er to the loss of blood than the expulsion of the worm; but he
 refers  to  a paper of Pediatto on  the pleuritis verminosa,
 where the relief obtained by the expulsion of worms fiom
 the stomach and intestines, particularly from the former, is
 unequivocally proved.
   It there appears that all who vomited the worms, or pass-
 ed them bv the bowels, recovered, while  those who did not,
 died.  All the common means of treatment in inflamma-
 tion  of the lungs failed; medicines which destroyed  the
 worms  alone were successful.   While their expulsion im-
 mediately removed the disease, it is impossible for us to be-
 lieve that  real inflammation of the lungs had existed;  yet
 in those in whom the disease had  been  allowed to take its
 course, the same appearances were found  in the thoi acic vis-
 cera  as in  those who die of other forms of pneumonia.
   We  often see the  same principle strikingly illustrated in
 the diseases of children.   We find it obtaining indeed in every
 instance.  When affections of  the liver produce p'ain in the
 shoulder, there is no disease in this part.   The pain is merely
 sympathetic.   If we press or rub the shoulder, the patient
 feels no more uneasiness from it than he would in the other
 shoulder; but after the pain has continued for a considerable
time the shoulder itself often becomes affected, he cannot then
bear to have it pressed, and sometimes cannot lie upon it.
   When inflammation spreads from the intercostal muscles
to the lungs, it does not traverse the pleura, reaching the lungs
by the  fold by which this membrane is reflected over them.
It passes at once from  the  pleura of the ribs to that of the 
                   OF  INDIGESTION                g|

lungs, between  which  there is no  direct communication,
for this  often happens previously to any adhesion having
,taken place.   Why is  inflammation of the  bowels as «pt
to spread to the  contiguous  parts  with which they  have
no  other, immediate  connexion, as  to those  which are in
continuation  with  the  diseased part?  Why does  loss of
blopd  by the applicataon  of leeches to the  skin over an
inflamed organ  often give more  relief than  loss  of many
times as much blood from a distant part?  It  is needless
to  multiply  instances,  whoever observes with attention the
phenomena  of disease will find  them numberless.  I have
just had occasion to mention a striking one  in which the
tenderness on  pressure of the internal  parts of the  epi-
gastrium is communicated to the neighbouring cartilage.
   These  facts teach an  important lesson in the prevention
of disease, that the first beginnings of many sympathetic
affections however  trivial  should be  watched with  care.
The hea-diich frequently occurring from disordered stomach,
may  at length  become a disease of the  head, itself; and
there is "no organ, we have reason to  believe,  in which  dis-
ease may not arise in the same  way.   They  teach a lesson
of'equal  importance in  the treatment of diseases,  the ne-'
cessity of being minutely  acquainted  with  the history of
the case, in order to ascertain, whether sympathy with other
parts had contributed to produce disease in those now most
prominently  affected; for if this has been the case, and the
affection of the former still continues, we shall attempt in
vain to restore-health by means directed only to the latter.
   It will Appear,  I 'think, from  what I am about  to  say,
that  it is  of the last  importance in  the treatment of  Indi-
gestion, to observe the period at which the above-mentioned
change in its nature takes place, at which the  disease ceases
to be a case of mere nervous irritation, producing a disor-
dered secretion; and begins to affect the sanguiferous, as well
as  the nervous system* which in many cases happens long
before  organic  disease* has taken place, but which, if not
counteracted, is generally its precursor. 
 *9               OF THE SYMPTOMS
 <*&
   Indigestion thus comes to be divided into three stagesr
 the first, characterized by the various symptoms a'.ove enu-
 merated, arising from the undigested food, from the  state*
 of" the stomach  and bowels, which is the cause of  the Ciis-
 ease,  and from  its necessary consequence, the additional
 irritation to  which these cavities are subjected by the undi-
 gested food and vitiated secretions; t^sccond,  characteriz-
 ed by tenderness,  or  other  uneasiness on pressure in the
 part of the  epig'astric region above pointed out, and a de-
 gree of hardness  in the pulse, often  accompanied by other
 febrile symptoms; and the third,  by the symptoms of organ-
 ic disease iri the abdomen,  chest, or head.


      Of the third stage  of Indigestion.]

   It appears, from what  has been  said, that in  the loeal af-
 fections of the second stage of  Indigestion, the sanguifer-
 ous as  well as nervous power of the part affected, is involved
 in the disease.  This  state pf general derangement* of the
 powers of iife cannot long continue without change of struc-
 ture.    The  symptoms  indicative of such  derangement,
 therefore, are the immediate forerunners of organic  disease.
 If they cannot be arrested they usher in the last stage of Indi-
 gestion.. It is a curious  fact, and one of the   greatest im-
 portance in the treatment, that the organic affection rarely
 takes  place in the  original seat of  the disease,  but in other
 organs  with  which the stomach- sympathizes, the  liver
 pancreas, spleen,  mesenteric glands, lower bowels, heart
 lungs, brain,  &c.
   Thus,.when the  body is examined after death, the patient
 is said to have died of disease  of some-of  these  parts, and
 there is nothing in the appearance  of  the organs to" distin-
 guish such affections from diseases which originate in the
organs themselves.  It is only by a careful attention to the
history of the particular case, and to the known  laws of the 
                  OF INDIGESTION.                g3

animal economy, that, we  are enabled to- distinguish  the
sympathetic from the primary disease.
  With respect to those cases in  which  the lungs become
diseased,  I attempted some years ago,  in  a paper which the
Modicochirurgical Society did me the honour to publish in
the seventh volume of  their  Transactions,, to point out the
means of  distinguishing them from primary diseases of the
lungs, and the peculiar treatment which the sympathetic dis-
ease requires to prevent  its proving as fatal as that whose
original seat is in the lungs.   In the  present publication I
am about  to enter into the subject more fully, and endeavor,
as far as  a  long-continued and  anxious attention to  the
phenomena of the  cases in question, and the laws of the an-
imal economy will enable me, to trace the nature  and the
consequences of that affection of the centre of  the system,
for so much the stomach mayjustly be called, which, if ne-
glected, produces a general tendency to disease; that often,
if I may so  speak,  fixes on some vital organ, and wholly
destroys its  organization.                         •      (
   It is one of the curious  circumstances of the  progress of
the disease we are considering, which  particularly demands
attention,  that  when it  fixes decidedly on one organ,  the
others are, to a certain degree, and some  times wholly,  re-
lieved._ The establishment of the secondary-affections gen-
erally relieves  the  dyspeptic  symptoms; and  even  a se-
condary disease may be relieved by another supervening on
it.
  Thus, it is not uncommon in Indigestion for the liver  to
suffer in such  a manner, that it shall become  enlarged and
tender on pressure: and  when the disease is destroying  the
texture of the lungs, having spread from  the liver to them,
for the former to recover, or nearly recover, its healthy state.
Sympathetic disease, when completely  established, seems to
act on that which excites  it, in the same way,  though much
more effectually, in which  artificial drains are found to  do,
while the sympathetic affection which precedes the establish- 
 g4,              OF THE SYMPTOMS

 ment of actual disease, tends to increase the original derange %
 ment. Thus an extensive external disease, as 1 have witness-
 ed, occurring in such cases, will often save the vital organ,
 even after the disease has made considerable progress in it.
   Why the spontaneous  occurrence of external disease in
 these cases produces an effect which we can  so feebly imi-
 tate by exciting such a disease,  we can no more explain than
 why  a spontaneous sweat carries off fever, while one pro-
 duced by art,  and even by means  which themselves  relieve
 fever, often brings little or but partial relief;  or,  why a
 spontaneous fit of shivering is often followed by a hot fit and
 perspiration which puts a period to the fever,  while  a shiv-
 ering produced by art, would  hardly ever fail to increase
 it.
   To enter fully on what I have called the third stage of In-
 digestion, that in which it has produced organic affections,
 would be foreign to my purpose, and would lead to  a con-
 sideration of a' large proportion of. all the most serious dis-
 eases to which we are subject; for organic affections not only
 vary according to their degrees  and the organ they affect,.
 but according  to the consequences resulting.from them, ab-
 scess, atrophy, dropsy, &c.
   I shall in the last chapter, treat of this stage  of the dis-
 ease at such length as the nature of the present treatise ad-
 mits of.   On account of the extensive nature and great va-
 riety of Indigestion, according to the sense  in which I use
 this term, it will be the most distinct plan to lay before the
 reader the causes and treatment  of the first and second sta-
 ges, the symptoms  of which have been detailed, before I
 enter on a more particular consideration of the last stage.

 Of the various forms and comparative du-
   ration of the different stages of Indiges-
   tion.
  The relative duration of the different stages, as well as
the severity and nature of their  symptoms, is  very various
in different cases.   In  some the  first stage is'  very slowly, 
                      OF INDIGESTION.                25

    ev^n when  the occasional causes of the disease have been
    long and repeatedly applied,  changed into the second.  Thus
    we see men of the most  irregular habits, and others whose
    habits are good, but whose  digestive organs are naturally
    weak, for many years laboring under the symptoms of the
    first stage of Indigestion, without the  disease, it  I may be
    allowed the expression,  fixing on  them.  The former are
    greatly indebted to a  natural  vigor of constitution, and in
    the latter, the  stomach alone is weak.   In the former, p^r-
♦    ticul arly when  the above  symptoms have been severe, when
    at length any considerable degree  of  inflammatory  action
    supervenes, change of structure often very quickly ensues; the
    the organs, from long continued irritation, being, as it were,
    prepared for the change.
      In others, on the contrary, particularly those of a more
    feeble constitution, the second stage soon shews itself.   Be-
    fore the symptoms of the first stage have long attracted no-
    tice, tenderness in  the  epigastrium supervenes, and  the
    pulse becomes contracted.   In such cases the second is gen-
    erally the  protracted stage of the disease, and the patient
    often continues to be  much harassed, and occasionally  seri-
    ously ill, for a long time  before organic disease is establish-
    ed.
      After this has taken place, the duration of  the disease, in
    different cases, is also very various, the change proceeding
    more or less rapidly according to the strength of the con-
    stitution, and  other  causes,  some of which seem involved
    in great obscurity.   But it may in general be observed, that
    the longer  and to the  greater degree the causes have been
    applied  previous to  the  occurrence of organic disease,  the
    more rapid is its progress.
      The proportional prevalence of the different symptoms of
    Indigestion is  as various  as the duration of its stages.
      In the  first  stage,  pains and other affections of the head
    in some, in others, fits of palpitation, cough, and dyspnoea,
    or distention and pains of the stomach, or flatulence and
                              E 
s6              OF THE SYMPTOMS

irregularity of  the bowels are the most troublesome symp-
toms.   The symptoms of the second stage in like  manner,
which are both more varied and more strongly marked than
those of the first  stage, in some, are chiefly confined to the
abdomen; in others affect the other cavities, and  the different
symptoms are variously modified in different cases.
   Thus Indigestion  presents itself  in various forms, which
in its progress assume more decided characters;  and no ca-
ses can differ more from each other than those which  form
the last stage  of this  disease; which necessarily varies ac-
cording to the organ in which the change of structure  takes
place; and  it tends  still further  to perplex the symptoms,
that  in some cases the disease proceeds in more than one or-
gan at the same time, the affection of the one not arresting
that of the  other, as we have seen often  happens.
   In  every stage of the disease, indeed,  there is  endless
variety, and the more nearly it approaches to its fatal termi-
nation, the more its  different cases assume the appearance of
diseases which  have nothing in common.
   With regard to the circumstances which dispose the sym-
pathetic disease to affect one part in  preference to another,
we have reason to believe that this  is chiefly determined by
different parts in different individuals  being more  liable to
disease than others, and  therefore feeling more the cause
of irritation which affects the whole system.  Thus in chil-
dren,  who are disposed to inflammation  and subsequent ef-
fusion in the ventricles of the brain.  Indigestion often ter-
minates in hydrencephalus internus.  From about fifteen to
thirty-five years of age, the disposition to  affections of  the
lungs is greatest, and it often produces phthisis.   At a more
advanced period,  a  tendency to disease of the rectum  pre-
vails, and in old age to affections of the heart and head,  the
latter however of a  different nature from  those to  which
children are subject; and we still observe  the tendency of
Indigestion to  produce the disease to which the system is
disposed, whatever be its seat. 
                   OF  INDIGESTION.                 gy

  These observations  seem particularly  applicable to the
inflammation and consequent organic affection of the  fee
in gout.   When a tendency to this disease exists, °it may be
induced by any cause that produces, and for a certain time
keeps up,  Indigestion.   In some the disposition to  gout is
so great, that  it appears without being  preceded by symp-
toms of derangement in the first passages; but in  the  ma-
jority of cases it is preceded  by these symptoms,  and the
tendency to them seems to constitute a considerable part of
the hereditary  disposition to gout.
  The  regular forms  of this  disease not affecting a vit
part, tend  less  to derange  the  system in general and give
more relief to the  primary 'disease  than most of the other
symptomatic  affections  which  have been  enumerated, the
patient often remaning well for some time after; and the more
cautious,he is in preserving the vigour of the digestive or-
gans, the  longer interval he enjoys.  Hence appears the
danger which attends interrupting  the regular fits of gout,
the  sympathetic disease being prevented from  taking the
course  which the disposition to affection  of the extremities
gives it, seizes on the part, generally an internal one, which
next to these is most liable  to  disease; and  on  the  other
hand, if any thing  so affects any of  the vital parts during a
fit of gout as  to render  it  considerably  the  weakest part,
the  sympathetic disease  sometimes  leaves the joints  and
seizes on the internal part,  producing what is called retro-
cedent gout.   It is evident that the risk of both these acci-
dents will  be greatest,  where the powers  of the system are
most impaired.
   The connexion of Indigestion and urinary gravel partic-
ularly deserves attention, as it differs from the connexion of
the  former with the preceding diseases.   It is not by sym-
pathy alone that the Indigestion appears to excite it.  I have
already had occasion to make some observations on the states
of the urine  in Indigestion.  In most cases of this disease,
we have seen, there is  a considerable production of acid in 
g8              OF THE SYMPTOMS

the first passages.   This acid,  as appears from the  experi-
ments above  referred to, enters the mass of  blood, and is
thrown out of the s\stem by the skin and kidneys.   As all
other acids occasion  a  precipitation of  lithic acid from the
urine, when the action  of the skin  is impaired, the acid we
are speaking of often passes in  such quantity by the kidneys
as to cause  a  deposition of lithic acid,  before  the  urine
leaves these organs, which there,  probably in consequence
of being agglutinated bv a secretion from  the  internal sur-
face of the kidnev, excited by the irritation of the fine sand,
frequently concretes into small masses  occasioning fits of
gravel.
   We have seen that a precipitation of lithic acid, after the
urine  has. stood  for some  time,  is a  frequent symptom of
Indigestion.    The gravel which often  attends this disease
is only a greater  degree of this  symptom, for  it appears
from  the observations  of the best writers  on calculous dis-
eases, that the calculi formed in  the  kidney are almost al-
ways concretions of lithic acid.*   Thus it seems to  be, that
in old age,  gout and gravel often alternate, as  it is in the in-
tervals of the gout  that Indigestion  chi- fly  prevails, the
affection of the joints relieving the stomach during its con-
tinuance.  The duration of this  relief, after the fit, becomes
less in proportion  as the constitution has been enfeebled by
repeated  attacks.

  *See the  paper above referred to in the last volume of the Transactions
of the College of Physicians. 
OF  INDIGESTION.
89
CHAPTER  II.
            OF THE CAUSES OF INDIGESTION.

     The causes of a disease are divided into immediate and
.   remote,  the changes in the body which more or less direct-
   ly excite the symptoms, and the causes which produce these
   changes..
     As it is impossible to understand the operation of the re-
   mote causes of Indigestion, without  a knowledge of the
   digestive process, our attention must, in the first instance,
   be directed  to this subject.

                        SECTION I.


            Of the "Process  of Bigestion.

     It has been ascertained by the experiments of Spallanza-
   ni and others,  that the stomach secretes  a fluid  capable,
   even out of the body, of converting the food into such a
   mass as that into which it  is changed in the stomach, imme-
   diately before  it  is  sent  into  the duodenum.  This fact
   leaves no room to doubt,  that  it is by  the agency of the
   above fluid that the food undergoes the change which is ef-
   fected on it in  the stomach; and it appears from the obser-
   vations of Mr.  Hunter, that such is the power of  this flu-
   id, that it often corrodes* the  stomach  itself when deprived
   of the vital principle by which it is enabled to resist its ac- 
30                 OF THE CAUSES

tion.   When to these facts we add, that by  means of the
muscular power of the stomach, the f od, when duly pre-
pared by the action of the gastric fluid, is propelled into the
duodenum, we state the sum of our knowledge on this sub-
ject.   These facts, however, are far from affording an ex-
planation of the  process which, takes place in  the stomach.
It does  not appear  from the observations of any of the au-.
thors here referred to,  by what means the  fluid which is
secreted by it  is  uniformly  applied to the food, nor upon
what principle the food which is prepared for the duodenum
is separated from the rest.
   Mr.   Hunter found that even when  part of the  stomach
itself had  been dissolved by the gastric  fluid, the food last  •
taken remained  wholly unchanged.  This fact alone is suf-
ficient to militate  against the  idea assumed  by some, that
by the muscular power of the stomach its contents are so
moved   as to be continually in the act of being mixed toge-
ther and with the gastric fluid,  by which their uniform solu-
tion is effected.  According to  this  view of the subject also,
it would be difficult to account for the  gradual discharge of
the contents of the stomach into the duodenum.  This in-
testine must either for a long time cease to receive any food
from the stomach  after  every  addition made to the con-
tents of  the latter.,  or receive  food in every  different stage
of solution, an imperfection in a natural process which is
in opposition to every thing we know of the  animal econ-
omy.
   My attention  was particularly directed  to this subject by
finding from many trials, that when the eighth pair of nerves
is divided in the neck of a rabbit, and one portion  of each
nerve folded back,* immediately after the  animal has taken
   •It has been found  by repeated experiments, that  if neither of the
divided ends be displaced, some nervous influence still  passes by the di-
vided nerve, and that, although the divided ends be separated by a space
of even a quarter of an inch  See the Journal of the Royal Institution,
No. 23, page 17, et seq. It was this circumstance which gave to Mr.
Brodie and Mr.  Broughton results different from those which Dr.  Hast-
mgs and myscli had obtained. 
                   OF INDIGESTION.                gl

a full meal, after a fast of whatever continuance; none but
undigested  food is found  in  its stomach,  provided it has
been allowed to live for a certain number of hours after the
operation.   Now,  if,  without the division of these nerves,
the rabbit be  killed after  a fast  of however many hours,
some food is always found  in its stomach, reduced apparent-
ly to the same state as that which, during the ordinary period
of digestion, is sent to the pyloric portion except that from
the continued  secretion of the  fluids of the  stomach it is
mixed with a greater proportion of them.   It would  seem
indeed" that the stomach of this animal is not able so to con-
tract as to expel the last part of its contents.
  When the foregoing experiment is considered it will appear,
either that the food, last received into the stomach,  is never
mixed with that already there, and which has more or less
undergone the  action  of  the  gastric fluid,  or if they  be
mixed together, that  the  stomach  has the  power of again
separating them, retaining the one and propelling the other
into the intestine.   These facts induced me to make some
experiments on a large scale, for the purpose of ascertaining
with  great  accuracy the  process  which takes place  in the
stomach,  without  which it is impossible  to  understand the
nature of the symptoms which arise from its defects.
  With  this view  I   examined the stomachs  of about a
hundred and thirty rabbits immediately after they had been
killed in the usual way, which is by a blow on the back part
of the head, at various periods of digestion.  The follow-
ing were the results.*
  The first thing that strikes the eye on examining the stom-
achs  of rabbits which have lately eaten  is,  that the new is
never mixed with the old food.   The former is always found
in the centre, surronded on all sides by the old food, except
  *  Inquiry into the Laios of the Vital Functions. It is hoped that the rea-
der  will excuse the frequent references to this Treatise in this and the
last Sections of this Chapter, because it is by facts, which appear  to  be
ascertained in it, that I shall attempt some parts of the pathology of
indigestion. 
 3£                OF THE CAUSES

 that on the upper part between the new food and the small-
 er curvature of the stomach there  is sometimes little or no
 old food.   If, as we ascertained  by more than twenty trials,
 the old and  the  new  food be of different kinds, and the
 animal killed  before a great length of time has elapsed after
 taking the latter, the line of separation is perfectly evident,
 so that all the old may  be  removed without disturbing the
 new food.  To ascertain  this  point we fed rabbits on o;.ts,
 and after  making them fast for sixteen or seventeen hours^
 allowed  them  to  eat  as much cabbage as they chose, and
 killed  them at different periods, from one to eight hour,
 after they  had  eaten it.
   On  opening the stomachs of rabbits three or four weeks
 old,' who both  sucked  and ate green food, we alwavs found
 the curdled milk unmix-d  with  the green food.  Before
 the stomach  was opened  we could, from its transparency,
 see where  the green food and wh<-re the rhilk iay.
   If the old  and new  food be of the  same kind, and the
 animal be allowed to live for a considerable time after taking
 the latter,  the gastric fluid passing from the old to the  new
 food  and  changing, as  it pervades  it,  renders the line of
 separation indistinct.  So that on a cursory view we should
 suppose the old and new food mixed together, but towards the
 small  curvature of the  stomach and  still more towards the
 centre  of the  new food, we find it,  unless it has been very
 long in  the stomach, undisturbed and comparatively  fresh.
 All around, the nearer  the  food lies to th  surface of the
 stomach the more it is digested.   This is true even with re-
 gard to the food in the small curvature,  compared with that
 nearer the  centre, and the food which touches the surface of
 the stomach is more  digested than any other found in the
 same  part  of the  stomach; but,  unless the animal has not
 eaten  for a grej*t length of time, the food in contact with
the surface of the  stomach  is in very diff rent stages  of
digestion in different parts of this organ.  It is least digest-
ed  in the small curvature,  more in  the large end  and still
more in the middle ol the great curvature. 
                  OF INDIGESTION.               33

  The foregoing observations apply to the cardiac portion
of the stomach, the food  in the pyloric portion, is always
found in a state very different from that just described.   It
is more equally digested, the central parts differing less from
those which lie near the surface  of the stomach.  It is evi-
dent, however, that all  the change effected in the stomach
is  not completed when the food  enters this  portion of  it,
because we find it the more digested the nearer it approach-
es to the  pylorus,  where, being ready  to  pass  into the
intestine, it has undergone all that part of digestion which
is performed in the stomach.
  It appears, that  in  proportion as the food is digested it
is moved along the great curvature,  where the change in it
is rendered more perfect to the pyloric portion.  Thus the
layer of food  lying next the surface of the stomach is first
digested, and  in proportion as  this. undergoes the proper
change, and is moved  on by  the muscular  action of the
stomach, that  next  in turn succeeds to undergo the same
change.
   As the gastric fluid, to a certain extent, pervades the con-
tents of the stomach, though  apparently  in no  other  way
than  by simple juxtaposition, for the arrangement of the
food, above described, we never found disturbed; the change
in each part, which in its turn comes in contact with the
stomach, is far advanced before it is in actual contact with
it; and consequently is soon after this in a proper state to
be moved on towards the pyloric end.
  Thus a continual motion is going on, that part of the food
which lies  next the surface of the stomach passing towards
the pylorus,  and the  more central  parts  approaching the
surface; whether food is ever so digested in the small curva-
ture as to be sent to the pyloric portion without having tra-
versed the. large curvature, I have not been able to ascertain.
When rabbits have fasted sixteen  or eighteen hours, the
whole food found in the cardiac portion, which is in small
quantity compared to what is found in it after a fast of short 
3 A                OF THE CAUSES
duration, seems to be all nearly in the same state with that
next the  surface  of the  large  curvature, the gastric fluid
having pervaded  and acted upon the whole, and is  conse-
quently,  as far as we can judge, prepared to be sent to the
pyloric end.
   It is in the great end of the stomach, where the digestion
appears to  go on so rapidly, that  Mr.  Hunter  found the
stomach  itself dissolved, and by  the most  satisfactory ar-
guments  showed, that this is the effect of the gastric fluid
after death.  His observations on this subject confirm the
foregoing view of digestion, and  show that the  same  pro-
cess, observed in the stomach of the rabbit,  takes place in
the human stomach; for he found part of the stomach dis-
solved, while the  recent food it contained remained  wholly
undigested, in the case of a man who happened to be killed
immediately after a full meal.
   This I have often observed  in rabbits  when  they have
been killed immediately after eating,  and allowed to  lie un-
disturbed for  some  time.   On opening  the abdomen, we
have found the great end of the  stomach soft, eaten through,
sometimes altogether consumed, the food being only  cover-
ed by the peritoneum, or lying quite bare for the space of
an inch and a half in diameter, and part of the  contiguous
intestines in the last case also consumed,  while the cabbage,
which the  animal had just  taken, lay in the centre of the
stomach unchanged, if  we except the alteration which had
taken place in the external parts of  the mass it had formed,
in consequence of imbibing  gastric  fluid  from the  half-di-
gested food in contact with it.
   We sometimes found the great end of the stomach dissolv-
 ed within an hour and a  half after death.  It was more fre-
 quently found so when the animal had lain dead  for many
hours.   This effect does not always ensue, however long it
 has lain  dead.  It seems only to take place when there hap-
 pens to be a greater than usual supply of gastric fluid, for
# 
                  OF INDIGESTION.                35

we always observed it most apt to happen when the animal
had eaten voraciously.
   Why it should take place without the food being digested
is evident from what has been said.   Soon  after death, the
motions of the stomach, which are constantly carrying  on
towards the pylorus the most digested food, cease.   Thus
the food which lies next to the surface of the  stomach, be-
coming fully  saturated with  gastric  fluid, neutralizes  no
more,  and no new food being presented to it, it necessarily
acts on the stomach itself, now deprived of life, and on this
account, as Mr.  Hunter justly observes, equally subject to
its action  with other dead animal matter.   It  is remarkable
that the gastric, fluid of the rabbit, which lives wholly on vege-
table food, should so completely digest its own stomach as
not to  leave a trace of the  parts acted on.*   I never saw
the stomach eaten through except in the large.end, in other
parts its internal membrane is sometimes injured.
   Although the  food is in the most digested  state in the
pyloric end, it appears both from  the fact  just mentioned,
and several other circumstances,  that the change  is chiefly
effected in the great end of the stomach.  The food found
in the  pyloric  end is comparatively dry, while that found
in the  great end,  if digestion is much advanced,  is mixed
copiously with the fluids  of the  stomach, and  there  is  a
more evident  difference in the state of the food,  before it
comes  into this part, and when it is about to leave it, than in
any other part of the stomach.   Dr.  Hastings, on examin-
ing the stomach of a woman, who had died under his care,
found  it every where in a state of ulceration, except in the
great end, where it was healthy.   The  stomach  had  per-
formed its functions to the last, and  the state of the alvine
discharge proved, that the food had been properly  digested.
   If we keep  in view the foregoing account  if the process
of digestion in the rabbit,  it will be interesting to  trace the

  'The  rabbit will often, when hungry,  eat animal food very readily. 
   36                OF THE CAUSES

   effect  produced  on it by depriving the stomach of a great
   p.rt of its nervous influence, by dividing the eighth pair of
   nerves in the neck.
     The division of this pair of nerves is one  of the  oldest
   physiological experiments of which we  have any account.
•  It was performed by several of the ancients, and  has been
   repeated  by a great  many physiologists in modern  times.
   Valsalva  is among the first who gave any distinct account of
   its effect on the stomach.  Haller, and many others, repeated
   it and describe its effects on this organ.*
     If the  animal be  allowed to live for a considerable time
   after these nerves are divided  in the neck  and one  portion
   of  each folded back,  the food remaining  in the stomach we
   have seen, if the animal has lately  taken a  full meal, is al-
   ways found undigested, and nearly in the same  staic  in all
   parts of the  stomach, a circumstance which  I was at first
   greatly nt a loss to explain.  This effect  is uniform, I  never
   saw it otherwise.   Yet we must conceive,  that  at the time
   the animal la?t eats,  there is some food more or less digest-
   ed in its stomach, and some  gastric fluid  to act  on purt of
   that just received into it.   The foregoing statements explain
   the difficulty.   The  division of the eighth pair  of nerves
   prevents the due formation of the gastric  fluid; but the an-
   imal still living: and the motions of the alimentary canal be-
   ing independent of the nervous influence,! the usual motions
   of the stomach continue and  send onwards  into the duode-
   num, all the food which is digested, and consequently ca-
   pable of applying to the stomach  that stimulus,  which ex-
   cites its natural motions.
    Thus it is evident, that the  undigested food must at
   length come into contact with it.   As soon as this -happens
   the usual secretions not being supplied to produce the prop-

    •S.2e a paper by Dr. Hastings,  in the 21st number of the Journal of
   the Royal Institution, on  the effects  of dividing the eighth  pair of
   nerves.
                  fExperimental Inquiry, Chap. 6. 
                  OF INDIGESTION.                %y

er change in the food, an unnatural motion is excited; hence
the efforts to vomit, which generally ensue in about an hour,
an hour  and a half, or two  hours, after the division of the
nerves,  marking the time when the  stomach  having sent
towards  the pylorus its digested contents, begins to feel the
effects of undigested food coming into contact with it.  To
these efforts to vomit we must ascribe the  circumstance of
food h-ing generally found in the oesophagus when an animal
dies from the division  of the eighth pair of nerves, for food
is found there althtmgh it is not allowed to eat after the op-
eration.   If the animal be allowed to eat after the operation,
the efforts to vomit almost  immediately  ensue, the food,
as is evident from the  way in which h enters the stomach,
directly coming  in contact with some  part of the small cur-
vature.
   Thus we see the cause of the efforts to vomit which  fol-
low the division of the eighth pair of nerves; and  why, if
the animal be allowed to live for a certain time after the op-
eration,  nothing but undigested  food is  found  in  the sto-
mach.  It also appears from the same  circumstances, why
the stomach is generally more distended than usual after the
eighth pair of nerves have been  divided, particularly if the
animal had been allowed to eat  after the operation, all the
food not digested by the gastric fluid present before the di-
vision of the nerves,  remaining in the stomach, and swell-
ing from the heat and moisture.*
   From all that has been  said  it appears,  that the process
which the food  undergoes  in the stomach is that of being
formed into a mass, in appearance nearly homogeneous; that
this process takes  place only  on or near the surface of  the
stomach, and that, in proportion as the food there situated
undergoes the necessary change, it is by the muscular power
of the stomach moved onwards towards he  pylorus, mak-

  I have sometimes, but very rarely, seen a small quantity of undigested
food in the duodenum. 
 3g                 OF THE CAUSES
 ing  room for that which next succeeds till  the whole con-
 tents of the stomach Have undergone this  process,  the  di-
 gested contents being regularly  discharged into the duode-
 num, as they arrive at  the  pylorus, till most, and in some
 animals  all the contents of the stomach are thus removed
 into that intestine;  from  which, after  they  have  for some
 time been detained there, and mixed with  the bile and pan-
 creatic fluid, they are  continually  passing into the  adjoin-
 ing parts of the canal.
   When the gastric fluid has not a  constant supply of fresh
 food to neutralize it, it  is capable, as appears  from what has
 been said,  of corroding the stomach  itself,  alter the vital
 principle of this  organ  is  extinct;  from which it appears
 probable, that  the uncombined  gastric fluid may produce
 some effect on the coats of the stomach during life, and va-
 rious facts would lead  us to suppose that  the  sensation of
 hunger  arises from the action of this fluid.   A supposition
 which seems to  be confirmed  by  the  following experi-
 ment.
   A person in good  health was prevailed upon to abstain
 from eating for more than  twenty  hours, and  further to
 increase the appetite by  more exercise than usual.  At the
 end of this time he was  very hungry, but instead of  eating,
 excited vomiting  by drinking  warm water,  and irritating
 the fauces.   The water returned mixed only with  a ropy
 fluid such as  the gastric fluid is described to  be by Spallan-
 zani, or as I have myself obtained  from the stomach of  a
 crow.  After this operation  not  only all desire to eat was
 removed, but  a degree  of disgust  was  excited by  seeing
 others eat.    He, however,  was prevailed  upon to  take  a
 little milk and bread, which, in a very short  time, ran into
 the acetous fermentation, indicated by flatulence  and  acid
 eructations.
  It seems an inference from this experiment, that the pains
caused by  hunger may  be prevented by constantly exciting
vomiting; and the death, which arises from it, converted 
                   OF  INDIGESTION.               gg

 into that from inanition, which only proves fatal after the
 lapse of  some weeks.  People  live for weeks  without food
 in fevers,  where there  is  no secretion of gastric fluid.
   It would appear then that one of the uses of the gastric
 fluid  is, by the  action on the coats of the stomach, to re-
 mind us when a supply  of food is necessary.
   We have  reason  to  believe from the result of the fore-
 going experiment, as well as from other circumstances, that
 in man the stomach is capable of propelling the whole of its
 contents  into  the duodenum.  In a case of Indigestion, I
 saw  orange juice which had remained on the stomach for
 twenty-four hours, brought up by vomiting, unmixed with
 any thing, and apparently little, if  at all, changed.   In this
 case there was no appetite, and no secretion of gastric fluid.
   Having traced  the different steps of the process of  diges-
tion in the healthy stomach, we are better prepared to under-
 stand the operation of the causes which disturb it.

                     SECTION  II,


   Of the remote  causes  of Indigestion.

   In considering the remote causes of this disease,  the  at-
 tention, we  shall find,  must be as  much  directed  to the
sympathy of the  alimentary  canal with other  parts of the
system, as  in  enumerating its symptoms;  for as the whole
system is essentially influenced by  the affections  of that
canal, and  some  parts peculiarly  so; in  like  manner it is
influenced by  affections of the system in general, and par-
ticularly  of those  parts.   The remote causes of Indigestion,
therefore  may be divided into those which act directly on
the stomach and intestines, those  which act on other  parts,
and those which affect the whole system.
   It may be  proper  here to call the reader's attention to a
circumstance  which  greatly  influences the phenomena of 
 40                 OF THE CAUSES

 diseases, and, in particular, tends to render them protracted
 and difficult of cure.  The affections,  whether primary or
 secondary, of parts which sympathize,  influence the state of
 each other.   Thus  sympathetic  affections, provided  they
 have not been converted into  actual disease of the part, in
 which case, we have seen, they relieve the original disease,
 become causes which support and aggravate it.   The debil-
 ity of the skin, for an example,  occasioned by  Indigestion,
 so reacts on the digestive  organs,  as   to increase  the
 disease  of the  stomach.   Similar observations  apply to
 the  sympathetic affections  of the  liver,   the  brah>,  &c,
 produced  by  the diseased  state  of the stomach; and the
 disease is farther aggravated by the increase of  general  de-
 bility caused  by these affections.  It  is thus that the evil
 increasing, if  I may be allowed the expression, in a geomet-
 rical ratio, and not by simple  addition,  the whole powers of
 the system, in severe attacks of disease, often sink  with a
 rapidity which  at  first  view appears unaccountable.   We
 shall  find  these facts  strikingly  illustrated in  considering
 the causes and treatment of Indigestion.
   It is evident from  what has been said of the  function of
 the stomach,  that it may be deranged  in two ways; either
 by causes affecting  its secreting power, so that the proper
 chemical  change is  no longer effected in  the food;  or by
 such as  debilitate its  muscular  power, so that the  food
 though properly  prepared as far as it is  brought into contact
 with proper parts of the stomach, is neither duly  so brought,
 nor regularly propelled into the duodenum.
   It appears  from  the  experiments related in the  Inquiry
 into  the  Laws of the  Vital Functions  above referred   to
 that the muscular fibre, though independent of the nervous
system, may be influenced through it.  It follows, therefore,
that the  muscular fibres of the  stomach may not only be
affected  by causes acting directly on them, but  by  such as
act through the medium of their nerves. 
                                                    ■ 0
                    OF INDIGESTION.                4|

   Among the chief causes of Indigestion, which act directly
 en the muscular fiures of the stomach, are narcotic  and
 other  offensive substances received into it.   I have found,
 that although opium applied to the external surface of the
 alimentary canal and  heart, produces  no sensible effect on
 their  muscular power,  applied  to their  internal surface it
 produces the same  effect as  when  directly applied to the
 muscular fibres them elves;* impairing their power, unless
 the quantity Be extremely minute, and  instantly destroying
 it if the quantity be considerable.
   It. may be questioned  whether the opium  pervades the
 fine internal m-mbranes of these organs  and  acts directly on
 their muscular  fibres, or  affects these  fibres through  the
 nervous extremities distributed on this membrane.  This  is
 a question of little importance.  I consider it as acting im-
 mediately on the  muscular  fibres, because its effect is the
 same  as  when directly applied to.them, and different from
 what it.is when it acts  evidently on  the nerves themselves;
 and  we know that the bile is capable  of  transuding through
 the coats both of the gall  bladder arid intestines.
   It is probable that other offensive substances received
 into  the stomach, tohacco, distilled spirits,.strong peppers,
 those of an acid or putrid  nature generated in the stomach
 itself, &c, may also in the same way  immediately affect the
 muscular fibres.   AH these  substances,  however,  as  will
 presently appear, otherwise influence the state of the stomach.
 We have reason to believe that the reception of large quanti-
 ties  of very warm  or very cold fluids  also directly affect'
 these fibres.   It is not uncommon for a fit of Indigestion to
 be induced by  taking  suddenly considerable quantities of
 iced  fluids.   Violent and repeated vomiting also debilitates
the muscular fibres of the  stomach.  But  of  the  causes
which  immediately  affect them,  the most frequent and pow-

  ,  Inquiry intn the La-ws of ttie  Vital Functions.  Page  133, et seq.
 Second edition.          *
                            O 
4g                OF T1TF, CAUSES

erful  is  morbid  distention.   We  know that  the  muscular
power of the stomach, rectum, and bhdder, and we h.ive
reason to believe thatthe sime observation  applies to the
heart and other similar cavities, m-iy for the time be wholly
destroved bv over distention.   The stomach m*y be so dis-
tended that  the most powerful emetics will not tx ite vom-
iting,* notwithstanding r.h? muscles sympathetically  excited
in this operation, those of the abdomen  and diaphargm, are
thrown into  strong and  repeated action; one  among many
proofs, thu  howeve-r necessary the yctioiiof these muscles  in
vom-ting, it is by thatof the stomach itself thatits contents are
rejected. Trie  abdominal  muscles excite the action of the
stomach in  this operation,  in the same way that the same
action of these  muscles,  though sudden and powerful, ex-
cites the bladder and rectum.   So perfectly the sume indeed
are these actions, that if  the  bladder and rectum  are  suffi-
ciently  disteiided at  the'time of  vomiting to be effectually
excited, their contents also are discharged, unless retained
by a voluntary  act  exciting their sphincters.  In all these
instances the action of die hollow muscle is excited by being
pressed  against  its contents by  the abdominal muscles and
diaphragm.
   The   most common cause  of morbid  disteption of  the
stomach is  eating to  fast; for the appetite only subsiding  in
 proportion  as the food  combines with and neutralizes the
 gastric  fluid, previously  in  the stomach, when we eat too
 fast, time  is not  given for it to  combine with that part of
 the food which is presented to it,  till so much is  taken that
 the whole  gastric fluid, which the stomach is  capable of
 supplying  during the digestive process, is not sufficient to
 eff ct the due  alteration on the food; whereas when we eat
  * The reader will find some good observations on this subject, and
cases illustr.it:' e of them, under the head of Gastritis,  in EUefs Work
De cog. et -Cur. Morbis.  I also beg leave to refer fum to my treatise on
Symptomatic Fevers, page 231.  Fourth edition. 
                   OF  INDIGESTION.               43

slowly,  so that a proper time is given for the above combi-
nation to take place, the appetite abates before the stomich
is overcharged:  for whikj digestion goes on, and the gastric.
fluid is  only supplied in proportion as fresh  food  comes  in
contact  with the coats' of the stomach, it combines with the
food as it is formed and never excites the appetite.
  Every  one has occasionally observed that ii  his meal is
interrupted for ten or fifteen minutes after he has eaten per-
haps  not  more than  a  third of the usual quantity, he finds
that he  is  satisfied.   The gastric fluid whicn had accumula-
ted has  had time to combine with,  and be neutralized by, the
food he had taken. It is for the same reason that a few mouth-
fuls taken a little before dinner will often wholly destroy the
appetite,  especially  in  delicate people, in whom the gastric
fluid is  secreted in small quantity, or of a less active quality.
Frequent interruptions  in eating would be injurious, because
we^iould thus be pervented taking the proper quantity of
food, for digestion  seems  chiefly' performed by  the fluid
which is secreted, as fresh food comes in contact  with the
stomach; *and the time, which that which has accumulated
requires for its  neutralization, which of  course  must be
more or less according  to the accumulation which has taken
place, that  is, generally  speaking, according to the length
of our  fast,  is the proper  measure  of the  quantity  which
ought to be taken, provided we qotinue to eat, without de-
vouring, our  food.
  Another  frequent cause of over-distention of the stomach
is high  seasoning and great variety of food,  or such as par-
ticularly pleases the palate,  by which we are induced to eat
after the appetite is satisfied; or by the stimulus, of the high
seasoning a greater supply of gastric fluid than the food calls
for is excited, and thus the appetite prolonged.  This seems
in  particular  to be  an effect  of wine drank during dinner.
This  practice, although it  occasions less immediate incon-
venience  than eating to fast, often,  if carried very far, by 
 44                 OF  THE CAUSES

 the preternatural excitement of the stomach, at length im-
 pairs  its vigor.   It is  not  uncommon  in  those who have
*greatlv  indulged  in  the pleasures of the table, to find the
 stomach enlarged, and its fiores sensibly relaxed.
   The  degree of  distention which the  stomach undergoes
 also  depends  much on  the kind of aliment.   All food ap-
 pears to swell  more  or less, after  it is receivtd  into the
 stomach; some kinds  more than  others, and of  course that
 which  is most  difficult  of digestion  cet. par. swells most;
 both because  it is digested and removed from the stomach
 most slowly,*  and because that which most resists the action
 of the  gastric  fluid is  most apt  to  run into fermentation.
 In considering the treatment,  I shall have occasion partic-
 ularly to point out the diet most easy of digestion.
   It is not by its effects on  the muscular  fibres of the
 stomach alone, however, whether acting directly on those
 fibres,  or through the  intervention  of their  rterves,^^hat
 over-distention tends to produce Indigestion.   Its operation
 on the  nerves of  the stomach  themselves is equally inju-
 rious.   It is by this effect that it produces that peculiar pain,
 restlessness, and sense of oppression, which attend an over-
 distended stomach.  «Such  irritation of the'  nerves  of  a
 secreting surface cannot exist Without affecting its  secreting
 power.f  The gastric fluid becomes  less fitted for its func-
 tions, and thus the distention is increased, and other  evils
 induced.   The contents of the  stomach- not  being  duly
 changed,  acquire  morbid properties,  and the various symp-
 toms detailed  in the first chapter supervene.

   * See what was-said in the last Section of the Nature of the Digestive
 Process.                     . .                         i
   f It appears from experiments detailed in Jin Inquiry  into the Laius of
 the Vital Functions, to which  I have frequently had occasion to refer, and
 ill The Journal of the Royal Institution, that the nervous influence is im-
 mediately essential to the changes which constitute secretion,  I beg leave
 to refer the reader to  papers  on this subject, which the Editor of the
 above Journal did me the honour to publish in  the eighteenth,  twenty-
 first, and twenty-third numbers of that work. 
                   OF INDIGESTION.               4g

  Wheh morbid distention of the stomach and its conse-
quences  frequently recur,  the powers  of this  organ are
weakened, and the debility, sooner or later, extends to the
other organs concerned in the digestive process.
  But morbid distention  is  only one among many causes
which may derange the nervous power of the stomach, and
thus vitiate its secretion.  It is probably in this way, in part,
that many of the causes which have been mentioned operate.
Others appear to make their impression wholly on the nervous
system, onlv secondarily affecting the muscular fibres of the
stomach; violent  passions, particularly  grief and  anxiety;
too long application to business, severe  study, and exces-
sive  venery.   Strong impressions of the mind often instant-
ly  destroy the appetite by occasioning such a secretion of
gastric fluid, as, not possessing healthy properties,  at  once
itself fails to apply, the due stimulus to  the stomach, and
tends to vitiate the effect of that which had been previously
 secreted.
   Indigestion sometimes arises  from mechanical pressure,
either of the stomach itself, or other parts of the alimentary
 canal from tumors  or indurations  of neighbouring  parts,
 or  from extraneous bodies lodged in any part of the  canal.
 These pauses are comparatively" rare, and consequently not
 to  be inferred,  except from circumstances which  unequivo-
 cally point out their existence.
   Other causes have a more complicated operation, not only
 directly affecting the powers of the stomach, but influencing
 it at the same time by their operation on other organs, with
 which it particularly  sympathizes.   In  intoxication, the
 stomach not only suffers from the  morbid stimulus  of the,
 intoxicating fluid,, hut in consequence  of its eftVcts  on the
 brain.  Similar observations apply to a moist, cold, and va-
 riable atmosphere."  The  stomach  not  only suffers  by the
 general debility and relaxation induced on the nervous, and,
 through  it,  on  the muscular system; but  also by the peculiar
 effects  of such an  atmosphere  on the  office of the skin. 
 4g                OF THE CAUSES

 Thus, too free a use of calomel and other medicines which
 powerfully affect the-abdominal  secretions, not only injures
 the stomach by their direct effect on  this organ,  but by the
 disorder excited in.parts with which it immediately sympa-
 thizes.
   Some causes of Indigestion affect the  stomach chiefly by
 sympathy.  The principal of these are various affections of
 the bowels, the  most common long-continued constipation.
 We find instances of  the same kind  in the Indigestion pro-
 duced by diseases, and even accidents affecting the head;  by
 stone in the bladder,  &c.
   So extensive, indeed, are the sympathies of the stomach,
 that whatever greatly disorders  the function of any  impor-
 tant organ may be ranked among the causes of Indigestion;
 its tendency to produce this disease being proportioned to its
 degree,  and the degree of sympathy  which exists between
 the stomach and the part  primarily affected.
   It seems chiefly by their effects on the system in general,
 that indolence, and debility * arising from long disease and
 other causes,  not unfrequently prove the exciting cause of
 Indigestion.
   All the exciting .causes  of this disease, applied in a less
 degree,  act as pre-disposing causes.
   Among its predisposing causes must  be ranked variable
 weather.  The influence of the  spring, indeed, seems often
 to act as the exciting cause in  the pre-disposed, and, from
 its tendency to induce the  inflammatory diathesis,  particu-
 larly disposes  to the symptoms of the second stage,-in those
 who  have for  some time laboured under  the disease.  The
 latter may also be said of  taking cold, and all  other causes
•of inflammation.
   The period of life from puberty to about thirty- and old
 age, and in some an hereditary disposition, atsopre-dispose
 to indigestion.   It is common to  find  the descendants of
 those who have suffered much from Indigestion  labouring
 under this disease.   Much has  been  said of the  nature of 
                  OF INDIGESTION.               4y

hereditary disease; all that is necessary for us to know, is the
fact, which  cannot be  disputed, that  those parts  which
were most liable to disease in the parent, are  likewise found
so in the children; but neither is this universally the case,
nor does the disease necessarily take place when the disposi-
tion to it exists.


                     SECTION III.


  Of the immediate  causes  of Indigestion.
                 ♦
   The immediate causes of a disease are the states of body
 induced by the remote  causes, and from  which  all  the
 symptoms more or less directly arise.  A knowledge of these
 causes is of the greatest importance in conducting the treat-
 ment  of the disease.  Where  we are altogether ignorant of
 them, the treatment is founded either on  the simple  princi-
 ple  of employing the same  means  Which have formerly
 proved useful, or on our general knowledge of the  laws of            g
 the animal economy. ' It is only*  in  proportion  as  we are
 acquainted with the immediate causes  of  a  disease, that
 our endeavours can be directed to restore the due functions
 of the parts affected; and in the instances, in which, after
 having long treated diseases on the vague principles, which
  are our only guides when the immediate causes are wholly
  unknown-, we have at length arrived at a knowledge  of these
  causes; we perceive that many parts of our former  plans
  were  superfluous, and not a few,  although  affording  some
  present relief, injurious.
    In  angina pectoris,  for example, before' it was known to
  depend on an obstructed circulation  through the heart, the
  stomach was oppressed with  a constant succession  of anti-
  spasmodic medicines," because the symptoms* are similar to
  those, which we know, from the  general laws  of  the ani-
• 
4g                OF THE CAUSES
mal economy, spasm of certain parts necessarily produces;
and the disease was increased by warm stimulating medi-
cines,  which the debility, necesfcsfrily attendant on  the state
of the circulation, seemed to call. for.
   As soon as dissection unfolded .the  nature  of this  dis-
ease,'it was evident  that  anti-spasmodics, however  they
might  relieve certain symptoms, and consequently be proper
for immediate relief, could do little towards preventing the
recurrence of the  attack;  and that  all powerful stimulants,.
by increasing the flow of blood to the heart* already incapa-
ble of duly transmitting the usual  quantity, serve  only to
hasten the fatal termination.                      •
  In endeavouring to trace the immediate causes of a dis-
ease, there  are two objects w.hich  demand attention; the
change produced  in the  seat of the disease by its  remote
causes, and the manner in  which this change  produces the
symptoms.   Without  a  knowledge  of   the  first of these,
our principles of treatment  must be vague; without that of
the other, they cannot  be adapted  to the  particular cases
under  treatment..  To  recur to the disease just mentioned;
till we knew that  angina pectoris  arises  from the difficulty
with Which the blood is transmitted  through  the heart,  our
only principle of treatment was to relieve the most urgent
symptoms;  and* now that  we  are. acquainted  with  this
cause,  if We could not distinguish what symptoms immedi-
ately depend upon it, and what are secondary, arising from
sympathy  and peculiarity of constitution, our plans' of treat-
ment,  it is evident, could not be suited ta individual cases.
  The  first part, of the  subject has already been considered.
It is evident, from what has been said in the first  and se-
cond sections of this  chapter, on the one  hand, that  the
causes  of Indigestion must  necessarily affect either the mus-
cular or nervous power of the stomach,  or both, on which
we have seen its function  aepends; and, on the other, that
all  the causes, above  enumerated  are   evidently  such as
influence them.   In considering   the remaining part of the 
                   OF INDIGESTION.                4o

 subject, the manner in which debility of the  muscular and
 nervous powers of the stomach  produce the symptoms of
 Indigestion,  I shall in the first place, consider those of the
 first, and afterwards  those of the second   stage  o£  this
 disease.
   Little need be added to what I have already had occasion
 to say of the symptoms which are confined to the stomach
 itself.   As the food can  only  be regularly  propelled into
 the duodenum by  the  due action of muscular fibres of the
 stomach, it is evident  that, if this fails, oppression  and dis-
 tention must ensue; and if the due secretion of the gastric
 fluid depend  on the healthy state of the nervous influence of
 the stomach,  its properties must  be affected  by any cause
 disordering this  influence, and it will consequently fail to
 produce the due change on the food.
   As it appeared from what was  said above,  that the causes
 affecting the muscular power of the stomach by the derange-
 ment which every  morbid  affection of this power occasions
 in the digestive process, soon  affects the nerves  of  that or-
 gan; it may now  be observed,  that all causes affecting  the
 nervous power of the stomach, independently of the direct
 action of the  nervous on the muscular  power, by prevent-
 ing the food from Ijeing formed into that substance which is
 the natural stimulus to the muscular fibres of the stomach,
 enfeebles  their action;  which we have seen is wholly  pre-
 vented, if the cause effecting the nerves  be so powerful as
 entirely to  prevent  the due change on the food, as happens
 when the eighth pair of nerves is divided, and one  portion
of each folded back.  The morbid distention and undigested
food thus constantly applied to the surface of the stomach,
still  increase  the  debility  of both nervous  and muscular
powers.  So  complicated  is  the  operation  even of those
causes  of disease, which   at first view  appear the  most
simple.
  The manner in which a morbid  affection of the muscular
or nervous power of the stomach  produces the symptoms of
                           H 
0O                OF THE CAUSES

Indigestion affecting distant parts, is by no means so evident.
The first question which arises  is, Why does the influence
of affections of the  stomach, and other vital organs, extend
through all  parts of the system, while  the powers of the
organs of sense, parts of equal sensibility, may  not  only
be deranged, but wholly  destroyed,  without  affecting the
function of any  other  part?  It way  be said,  because the
latter are not organs  essential  to  life.  This reply,  it  is
evident,  relates to the final,  not the efficient, cause; and on-
lv suggests other terms in which  the  question  may be put.
I need h >.rdly observe, that  I here speak of the function of
the organs of sense, not of  the powers which  sustain them.
These are as much vital  powers as those of  the  stomach.
If the sentient extremities ot the nerves  of the eye or ear
be deranged  by electricity, for  example, sight or hearing
are lost,  but there the evil ends.   If  those  of the stomach
be so deranged, with  the  function of the  stomach  every
other function of the system is lost;  not in   consequence
of  the failure  of the  digestive  process,  but instantly.  If,
instead of a  chemical,  we employ a mechanical  agent,—a
sudden blow, for example, the same  difference  of effect is
observed.  On  the cause of this difference, whatever  it be,
it is evident that many of the symptoms of Indigestion de-
pend, for the effects of the. various states of the stomach,
in the different  stages of this disease, are instantly propa-
gated to  the most distant parts of the  system.  We see the
extremities become  hot or cold,  moist or dry;  the  functions
of the brain or  heart immediately fail, and as quickly re-
vive; according to the changes  which  are going on in the
stomach, and the degree in  which the  nerves of this organ
are affected by them.
   So great is the power of  the  sympathy which exists be-
tween different parts  of the system, not only in "modifying,
but in producing the symptoms of disease, that it is a  point
of no small consequence to ascertain  by what  laws it is
regulated. 
                  OF INDIGESTION.                gJ

  It has been an opinion from  the time of Willis,  that the
sympathy which exists  between different parts,  depends
on the connexions in the course  of  their nerves; and ttiis
Opinion  is still maintained by some of trie best writers;  but
when we consider to  what inferences it leads, we shall pause,
I think, before  we give it our assent.   It is known  that the
nerves convey impressions to and from the brain, to which
we  owe feeling and voluntary power.  If we  compress  or
divide the nerves of  a  limb,  so  as to cut off  its  communi-
cation through the.m with this organ,  its sensation  and vol-
untary power are lost. •  But we have no  reason  to believe,
from the usual phenomena of the  nervous system,  that  an
impression made on the extremities  of a nerve  will, in its
progress to the brain, so affect any other nerve, with which
it may communicate, as  to influence its extremities.
  The first objection which presents itself to this explanation
is, that it is an unnecessary one.  All nerves convey impres-
sions to the source of nervous  influence, and every nerve
is capable of being influenced by  this source.   These are
acknowledged facts, and they are capable of explaining the
phenomena in question.  It is possible, however, that some
collateral facts may  prove, that the former is the  just expla-
nation.   Is it found  that parts never  sympathize unless their.
nerves  are connected  in their progress?   Do parts, whose
nerves are most connected, most sympathize?  A crowd of
facts reply to these questions.  What connexion of nerves
exists between a vital  organ  and the skin  which covers it,
between the  liver  and the ligaments of the  shoulder, be-
tween the viscera of  the abdomen and its parietes, the sto-
mach and  the cartilages of the ribs,  &c? Why does inflam-
mation of the pleura of the ribs spread as readily, or nearly so,
to that of the lungs,  which is only in contact  with it, as to
that in continuation with  it, which is supplied from the same
branches both of nerves  and vessels?   Why is inflammation
of the parietes of the abdomen, or of any part of the bow-
els,  in like manner,  as readily communicated to  the part in 
 5g                  OF THE CAUSES

 contact with it, however little their nervous communications,
 as to that with whose  nerves the nerves  of the affected part
 most freely communicate?     *#*
   These and  various similar facts, as far  as I can judge,
 leave no room to doubt that nerves  sympathize only from
 their connexion  in their common source," and that the nu-
 merous  connexion? we observe in  their course are  only
 useful  in the  same way  with the  ganglions  and plexuses,
 which  may be proved by direct experiment to enable the in-
 fluence,  descending  from  that  source, to pass from  one
 nerve to another, so that one may partake of  that whifth  is
 conveyed by many, a power  which,  it may also be shewn,
 is necessary to the continuance of life.*   That the phenom-
 ena of  sympathy depend on changes in the source of nervous
 influence,!  would appear,  I think from the fact alone, that
 sympathetic  feelings  still continue to be  referred to a limb

  * Experimental Inquiry, Part. II Chapters 4, 5, 7. Sect.  2; and Chap-
 ter 9.
  f I am happy in being able, in  confirmation of the, above position,  to
 refer to a very able paper by Mr. Charles  Cell, in  the  Philosophical
 Transactions of this year, entitled,  "On the Nerves; giving an account
 of some experiments on their structure and functions, -which lead to a new
 arrangement of the system," which has appeared since the publication of
 the first edition of this treatise.  In the above paper Mr. Bell has point-
 ed out the interesting fact, that some of the  nerves  which supply those
 muscles of voluntary  motion, which sympathize with  affections  of the
 lungs, have their or.gin near that of the eighth pair:  thus readily  ac-
 counting for sympathies which have been very generally ascribed  to the
 connexions of the great sympathetic with other nerves; an explanation
 which wholly fails to account for those  sympathies affecting only certain
 muscles.
  I would take the liberty of suggesting that the above nerves,  on the
functions of which Mr.  Bell has thrown so much light, should be named
pnemo-gasttic, instead of respiratory, for I think  Mr.  Bell will, on far-
ther consideration, admit that the  muscles in question equally sympa-
thize with the stomach, and  other abdominal viscera, as with the lungs;
and we know  that the eighth pair of nerves bestows its influence on the
latter as well as the former organs. 
                   OF INDIGESTION.                 53

which is lost;,because this  seems to be  a law of general
application, at whatever part the separation takes place.
   If  we compare the foregoing facts with the result of ex-
periments which prove, that the  vital organs are  supplied
with nervous  influence from  every  p^rt of the brain  and
spinal marrow,* while the org .as of sense  derive theirs
only from  particular parts of them;  it  seems a  necessary
consequence*' that the one set of  organs cannot be injured
without influencing every part of the sysum, while in in?
juries of the other, onlv  those  part-s of the general source
of nervous influence, from  which their  own nerves arise
being affected, the evil extends no farther.
   It  appears from what has been said, that juxta-position
is one of the  most powerful  causes  of parts partaking of
the affections of each other.  We see textures of the  most
dissimilar  nature, receiving tneir nerves  and vessels  from
the most  distant  sources, immediately partaking of  each
other's affections if they lie together.   Inflammation of the
skin  of the chest often spreads  to the intercostal muscles, to
the pleura of the  ribs, to. that  of the lungs, to  the lungs
themselves.*  The same observations apply to the other ca-
vities, for the interposition of bone  itself  does not always
prevent this progress. This well-known fact is often of great
consequence, in tracing the causes and explaining the  phe-
nomena of diseases.   We s.hall find it so in the disease be-
fore us.
   When the cause of injury applied  to the vital  organs  is
very great, as in the cases above  mentioned, all parts of the
system are equally affected, the power of  all being immedi-
ately  destroyed.   But when  the cause  is  comparatively
slight, the effect on the parts, which most  sympathize  with
these organs, may be considerable; while  on others   it  is
hardly to be observed.   Thus the effects of irritation of the
stomach appear in the liver,  the  skin, the  head, when they
 are not  to be perceived in other  parts; but as the  disease
* Experimental Inquiry. Part II, Chap. 9. 
 54                 OF THE  CAUSES

 increases, as we  find  from  the above enumeration of its
 symptoms, they become sensible in every part.
   It  appears  from the experiments related in the  seventh
 chapter of the above  Experimental  Inquiry, that  any di-
 minution of the«extent of the organs which supply the nerv-
 ous  influence, affects  the state of. secreting surfaces, and
 impairs the temperature: and Mr. Brodie observed similar
 effects, particularly with respect to  the temperature from
 powerfully debilitating causes  affecting  these organs.    It
 cannot, therefore,  seem'surprizing, in derangement of the
 digestive organs,  which so greatly debilitates  the powers  of
 the nervous system, and which when excessive, we have
 seen,  is even  capable of destroying those powers, that dis-
 eases of  other  parts of the body, and particularly of the
 skin,   which so eminently sympathizes with  those  organs,
 should frequently arise, and be  difficult of cure.   It  appears
 from  the progress  of  Indigestion  that,  wherever  sympa-
 thetic affections are long continued, or frequently renewed,
 actual disease ensues.
   All that is here  said  is  well  illustrated  by, and  readily
 explains,  Mr. Abernethy's  valuable  observations  on the
 constitutional  origin  of Local Diseases.   He  found  that
 many wounds,  which resisted all the  means which the  sur-
 geon could employ, were attended with a disordered  state of
 the digestive organs, and yielded readily when the due  per-
 formance of their  functions .was restored; nay, that many
 wounds and other local diseases had no other origin than the
 states of health which attend irritation of the stomach  and
 bowels.
   It is also to be observed that the failure of nervous power
 appears more readily in some of the nervous functions than
in others.  In Indigestion, before the other  functions of the
surface are much  impaired, the  patient complains of  a
sense of cold;  and when, by degrees, the  failure of these
becomes apparent, the  sensation of cold, an actual  reduc-
tion of temperature, and a less  than natural  ability to resist 
OF INDIGESTION.
55
its extremes,  still continue to form a predominant feature of
the disease; for we have seen that dyspeptics are as unable
to bear extreme heat as cold.
 All this we still find strikingly illustrated by the operations of
nature in other cases.  It appears from  the observations of
Mr. Guthrie, in his work on Gun Shot Wounds,  that when
the nerves of a limb are injured, all its functions are impair-
ed.   It is more liable to ulceration than a sound  part.  In-
flammation does not take its usual course in it,  and wounds
in it heal with greater difficulty than usual.   A  diminution
of temperature, however, and an  inability to resist changes
of temperature,  he observes are,  from  the first, the most
striking features;  and  the limb remains below the  natural
degree for months, or  even  years, if  the nervous influence
is not perfectly restored.
   The  preceding  observations shew, not only  that those
symptoms  of Indigestion which  affect'parts at  a  distance
from the stomach,  may arise from any other cause lessening
the  power of the nerves, whether acting as affections of the
stomach do,  on the  whole  nervous system, or only  on
the  nerves of the parts chiefly affected; but  that the order
and general character of the symptoms, thus produced, are
the same as when they arise from Indigestion;  pointing out,
in a striking manner, the similarity of their cause.
   When the whole of  the facts which have been laid  before
the  reader, in this and  the preceding sections, are  kept in
View  it seems easy to point out in  what way the remote
causes of  Indigestion operate in producing all the symptoms
of what I  have called  the first stage  of this  disease.  The
debility induced by these causes on the muscular and nerv*
ous powers  of the alimentary canal, on the one hand, by
preventing the due change on the food, and its clue discharge
into the duodenum, and progress  throughout the rest of the
 canal,  produces  the  symptoms which  immediately  arise
 from undigested food;  and on the other, either by its direct
 effects in the stomach  and bowels, or through the irritation 
 gfl                OF THE CAUSES
 of the undigested food  and  vitiated secretions,  excites the
 nervous derangements which affect these cavities themselves,
 or other parts with which they sympathize.
   But in  the second stage of the  disease  we  see a change
 which cannot be referred to  either of these heads, I mean,
 the occurrence of  tenderness in a certain part of  the epigas-
 tric  region abov ■  described,  which hardly ever fails to  su-
 pervene in protracted cases:  and  when considerable, to  be
 accompanied with a pulse  which  will  be found more  or
 less  hard, if ex imined in.the way above pointed out,* and
 some of the other indications of fever which have been en-
 umerated.  I am  now to lay before the reader  such facts as
 seem to throw light en the more immediate cause  and nature
 of those symptoms, which we shall find greatly influence the
 treatment of  this  disease.
   I have  had occasion to call the reader's attention to many
 facts which prove, that  irritation is often  felt in a put at a
 distance from that to which the irritating causes  are appli-
 ed.   Now, whatever may  be said of the way in  which any
 cause of irritation affects the part to which it is  applied, it
 is evident, that it  can only affect a distant  part through  the
 medium of its nerves. Thus, when worms in the intestines    i
 produce  pain of  the chest,  dyspuce3, &c, we know  that
 these symptoms arise through the medium of the nerves,
 and by watching their effects  we are enabled to determine,
 what the effects of mere irritation  of the nerves are.
   It appears, from what  was said above, that this irrita-
tion,  in the first  instance,  produces no sensible  change in
 the part sympathetically affected.  If the worms  are  re-
 moved  from the  intestines  within  a few  hours after the
pain, the dyspncei, and  other  pectoral symptoms  have su-
pervened, they  immediately  disappear, and the  lungs per-
form  all their functions  as w>ell  as if no symptom of dis-
ease  had existed.   But  we  have  also  seen, that if these

                   * Chap. I, page 17, et seq. 
OF INDIGESTION.
51
sympathetic symptoms remain  for a certain  time, inflam-
mation of the lungs takes place, and they exhibit, on dissec-
tion, all the  marks of this  disease, suppuration and its oth-
er consequences not excepted.  Other instances of the same
kind were adduced, and it would be easy to multiply them.*
  Thus it appears  that  irritation of the  nerves  of  a part
may exist for some time without any change taking place in
the state of its  circulation; and when the cause of irritation
is not severe, and the part little  disposed to  disease, this
may be the case for a longtime.  Pain of the  shoulder often
continues  for  months  in  chronic affections  of  the  livery
without the shoulder becoming stiff or  tender to the touch;
but,  it also  appears, that the continuance  of  the nervous
affection,  sooner or later, according to  its degree, and the
tendency  to  disease  in  the  part  sympathetically  affected^

  * Since the publication of the first edition of this  Treatise, Mr. Bro-
die has favoured me with the following letter, containing an account of
an important experiment which he made many years  ago, and some
valuable observations, which seem  strikingly to illustrate this  part of
the subject, and which he has had the goodness,  at my request,  to  per-
mit me to make public.
  "My deal* Sir,—The following are the particulars of the experiment td
which you have alluded:
  "On the 29th of June,  1814, I exposed the nerves of  the eighth pair hi
the  neck of a rabbit, and by  means of a fine  needle, I passed a  silk
thread transversely through the  substance of each nerve, in the manner
of a small seton.  The extremities of the threads were left hanging out
of the external wound.  This operation did not produce any immediate
effect on the respiration: but at the end of twenty-four hours the  animal
was observed to breathe in a laborious and difficult manner, twenty-eight
times in a minute.  The threads were  withdrawn, but the removal of
them occasioned no relief, and fourteen hours afterwards the rabbit was
found dead.  On dissection both lungs were seen loaded  with blood and
inflamed.  The left lung was  inflamed in the greatest degree, the sur-
face of it being encrusted with coagulated lymph, and lymph being effused
also in several places in the intertubular substance and auricles.   There:
was a considerable quantity of serum in the cavity of each pleura.-
  "The stomach and intestines were in a natural state,  presenting no ap-
pearance of inflammation.  The  gall-bladder was  nearly emptied.  A
                         *I 
38                  OF THE  CAUSES

influences the state of its vessels.   The effect,  which thus
takes place  in  a distant  part,  must,  of course, uke  place
more readily in that to  which tne cause of irritation is  ap-
plied. .
   Now it appears from what was said in the  second section
of this chapter, that all the  causes of  Indigestion act either
dinctly or indirectly, on the nerves of the digestive organs.
This irritation of  the  nerves  must sooner or later  produce
the same  effects here,  as in'other parts, and  the vessels at
length partaking of the disease some tendency to inflamma-
tion must ensue.   This is indicated by the symptoms above
mentioned,  a tenderness on  pressure  in  the part affected,
hardness of the  pulse  and  other febrile symptoms, which
under all circumstances indicate  inflammation or a state  ap-
proaching to it.

slight degree of inflammation existed in each nerve; but only at the part
where the seton had been introduced.
 "It appeared tome that, in this experiment, the inflammation of the lungs
might reasonably  be attributed to the irritation produced by the threads
on the nerves, by which they were supplied.  A multitude of other cir -
cumstances might be  adduced in proof of  the doctrine, that simple
nervous irritation is capable of producing local  inflammation, even at a
distance from the part in which the source of the irritation  exists.  A
calculus passing down the ureter occasions pain in the testicle; and if a
certain length of time elapses before the calculus escapes into the blad-
der, this symptomatic pain is followed  by swelling, tenderness, and no
small degree of inflammation in  the testicle.  In like manner, in some
Cases of disease in the hip, the symptomatic pain in the knee is attended
at last by tenderness and puffy swelling of the  latter articulation;  and
in many instances, in which suppuration takes place slowly on  the mem-
brane of the brain,  after an injury of the head,  the patient becomes af-
fected with inflammation and abscesses  of the lungs, liver, or some other
organ remote from the seat of the original malady
   "I have much pleasure in being  able to communicate to yr>u  these ob-
servations,  in confirmation of the  opinions which you have expressed and
published  on these subjects; and  I am, dear Sir, yours,  very truly,
                                              B.  C. Biiodie/'
     "Saville-row, Oct. 26, 1821." 
                   OF INDIGESTION.                gg

   As the tenderness of the epigastrium is always the first
of these symptoms,  and the others  are proportioned  to  it,
and yield, as we shall find, to the means which relieve it; it
is evident that these symptoms arise  from the same cause
which produces  it.  It is a  point  of considerable  impor-
tance in the  treatment, therefore, to  ascertain the  nature
and  seat  of  the affection,  which occasions this tender-
ness.
   It is evident that of the different parts of  the stomach  the
pylorus is the one most exposed to the causes of irritation.
Other parts  experience  the irritating effects of different
portions of its morbid  contents,  but the  pylorus is neces-
sarily exposed to those of all.  All must pass by this orifice.
When therefore we  see that,' after Indigestion has continu-
ed for some time, a certain  part of the region of the sto-
mach becomes tender on  pressure, we  cannot help turning
our attention to this part.  Now in  the natural situation of
the viscera, exactly  in  the tender part  of the  epigastrium,
the pylorus lies,  with the thin  edge of the  liver  upon and
in contact with it; as I have ascertained  with  the kind as-
sistance of Mr. Brooks, whose anatomical  skill is so gener-
ally acknowledged.
   When  all  these  circumstances  are considered, can we
doubt  that it is the irritated  pylorus assuming a low degree
of inflammation  which occasions the  tenderness on  pres-
sure above described; and when we  consider what has just,
been said  of the influence of juxtaposition in the  spreading
of this disease, can we doubt,  when we find the tenderness
with  some  degree  of  fulness  gradually extending down-
wards, along  the soft parts on  the edge of  the cartilages of
the right side of  the epigastrium,  as we find it to  do in the
progress of Indigestion, and at length ending in evident
enlargement and  tenderness of the liver, that the  affection
of the pylorus is  communicated to  the  thin  edge of this
organ, with which it is in contact,  thence  by degrees ex-
tending to its other parts?  Thus it is that of all the neigh- 
g0                 OF  THE CAUSES
bouring parts no other so frequently partakes of this affec-
tion of the stomach.   It is doubtless in the same way, that
the habit of drinking spirits, which  must  apply so  great a
degree of irritation to the pylorus,  seldom fails to produce
affections of the liver.
   We have reason to believe that it is  from its greater ex-
posure to  causes of  irritation, that the pylorus  itself is
more subject to organic disease  than any other  part of the
stomach;  but the wise Author  of our  being seems to have
given to a part  necessarily so much  exposed,  a great power
of resisting disease;  so  that  the first  deviations  from the
healthy state, which are  communicated from it to the liver,
more readily take root there, if I may be  allowed  the ex-
pression;  and the structure of this organ  yields to the affec-
tion which that of the part, from which it receives it, gen-
erally resists.   The liver indeed is here already disposed to
disease,  its action we have seen  from an earlier period, hav-
ing by sympathy, been influenced by the state of the  sto-
mach; and  the continuance  of  diseased action,  we know,
disposes  to disease of structure.
   I am well aware that  the fulness  of  the right hvpochon-
drium in  Indigestion, even when  combined  with  tender-
ness on pressure,  does not always indicate an affection of the
liver.  It often, I believe, arises from  the state of the  du-
odenum, which frequently expels its contents with difficulty
in this disease,  and  my experience corresponds with many
of the observations made by Dr. Yeats in  his excellent pa-
per on this intestine, in the last  volume of the  Transactions
of the College of  Physicians.
   It has been stated in enumerating the symptoms,  that the
fulness and tenderness of the right  hypochondrium  in the
early stages of Indigestion  are often  temporary.   I have
repeatedly seen them, even  when they were  considerable,
disappear  after the operation of a  brisk  cathartic.   They
must then  arise cither  from  a distended and oppressed
state of the duodenum, or temporary distention of  the va- 
                   OF INDIGESTION.             •  6l

rious vessels of the liver.   To  which of these causes we
should  ascribe  them,  the  accompanying symptoms  will
generally enable us to determine    Tt,« feeling given to the
hand bv the distended duodenum is different from that pro-
duced  by the gorged liver, and in the lormer osc- the chief
fulness is generally lower down,  and does not seem  to pro-
ceed so immediately from under the edge of the thorax as
general fulness of the liver does; so that even where,  from
more permanent  debility of the duodenum,  its morbid dis-
tention is a more constant symptom, the two casts may gen-
erally  be distinguished.   The more  temporary  narure of
both  these affections,  with the history and general symp-
toms of the case, for the most part readily enable us to dis-
tinguish them  from fulness and tenderness of the same  re-
gion arising from organic disease of tht liver, which comes
on slowly  and  uniformly, and the commencement of which,
when  it arises  from Indigestion,  may generally be traced to
 the epigastrium.
   The observations which have  been laid before the reader,
 as far as I am capable of judging,  leave no room to doubt,
 that an inflammatory  affection  of the  pylorus,  excited by
 the passage of the irritating  contents of  the stomach for a
 longer  or  shorter  time, according  to  the  nature  of these
 contents,  and  the  greater  or less degree of inflammatory
 tendency  in the  part, is  the cause of the tenderness observ-
 ed in  the  epigastrium, and which at first is generally  con-
 fined  to a space  not larger than a shilling;  an inference con-
 firmed by  dissection,   which often exhibits  the internal
 membrane of the pylorus thickened in those who  have suf-
 fered  much from the disease of the digestive organs.
    It appears  from many experiments detailed in the intro-
 duction to my Treatise  on Symptomatic Fevers, and which
 have been carefully repeated  by  Dr. Hastings*  with the
 same results,  that all the  causes of inflammation act by de-
*Dr. Hastings's Treatise on Broncldtis. 
 63  t              OF THE CAUSES

 bilitating the capillary  vessels  of the part,  and thus allow.-
 ing them to be distended by the vis a tergo, from which, as
 appears from what is said  in the treatise just  referred to,
 and  last part  of the Inquiry  into the  Laws of the  Vital
 Functions,  all the phenomena of inflammation seem neces-
 sarily to  arise.
   It  is  this debility  of the finer  vessels  of the  pylorus,
 therefore, produced by long continued irritation of its nerves,
 from which arise, in the second stage  of Indigestion, the
 hard  pulse  and other symptoms of feverishness above enu-
 merated, and by which, we shall find the successful treat-
 ment of this stage essentially influenced.
   It is  a point of great importance  in the progress of dis-
 ease,  that febrile disease begins with inflammatory  action,
 that is,  debility  and distention of the finer vessels, and their
 constant effect  increased action of the larger ones, and  at
 length necessarily produces debility  of the nerves; while
 nervous disease  begins with the latter, and as certainly ends
 in debility and distention of the finer  vessels.   It seems to
 be  this  which renders the chronic  inflammation of organs
 so much more difficult of cure, and apt to run to derange-
 ment  of  structure, than  the acute form of the disease.   In
 the former,  the functions of the part are more generally in-
jured.  Its  nervous power  is debilitated before  its vessels
 begin to be  distended.   Besides, the debility of  the nerves,
 and that of  the extreme  vessels tend to increase each other;
 and unless  the chain of. diseased  action can be broken by
 means which enable the vessels  to recover their healthy di-
 ameter, it goes on more or less quickly, sometimes, if the
 symptoms are mild, very slowly,  till  the structure  of  the
orgm is destroyed.
  The inflammatory action  in Indigestion, partaking of the
 chronic  nature of the disease it belongs to, often  in the first
instance attracts  so little attention,  that the stimulating plan,
which we shall  find  suited  to the first  stage, is  sometimes
pursued till  organic derangement  at once announces to the 
                  OF INDIGESTION.                fl3

practitioner the danger of the patient, and  the necessity of
adopting other principles of  treatment.   But as  such an
inflammatory  state as that  we have  been considering may
always, I believe, be observed to precede organic derange-
ment of vital  organs; and, both on  this account, and  for
other reasons, appears to be  its  immediate  cause;  it is  of
the utmost consequence, in  preventing that derangement, to
watch the first appearance of inflammatory action, for it  is
at the beginning alone that it can  be effectually counteracted.
The period at which  it shows itself,  we have seen,  is very
various, a circumstance which has doubtless contributed  to
obscure this part of  the disease.
   While the  foregoing changes  are going on in the solids,
the fluids of the body must necessarily undergo correspond-
ing deviations from the healthy state.  In proportion as the
flow of nutriment into the blood  is lessenefj, the chyle itself
probably more or less  vitiated,  and  as  the different secre-
tions fail,  the circulating fluids must  be subject to various
changes.   What these are the present state of our  knowl-
edge makes it impossible to ascertain.
   In those who have long laboured under Indigestion in its
more  severe  forms, the blood is sensibly altered  in some
of its  properties.   The proportion both of red globules and
lymph is less than in health.   This state of the blood must
necessarily affect that of the fluids supplied  to secreting
surfaces, and  from  this  cause  also, the secretions of the  .
 digestive  organs must further  deviate from  the  healthy
 state.
   In considering the mutual  action  of one part of the sys-
 tem on another, the  state of  the mind  deserves  particular.
 attention  in  Indigestion.  The  disease itself we have seen
 seldom  fails to render it anxious,  irritable, and apprehen-
 sive;  and this state of mind, which we have found ranked
 among its causes, cannot fail to  influence its symptoms.
    When the reader  reviews the  various facts  which  have
 been laid  before him relating to the operation  of the  re- 
 (54                 OF THE CAUSES
 mote causes of Indigestion, and  particu^irly takes into the
 account  what I have  frequently had occasion to recall  to
 his recollection, that the  morbid states  of all those  parts
 svmpathetically affected,  till  actual  disease takes place  in
 them, operate as secondary causes of the primary affection,
 both  by sympathy,  and by their farther weakening the  gen-
 eral powers of the  system,  he will perceive how  complicat-
 ed the operation of its remote causes must be; and indeed,
 by reflecting on thJ nature of the  animal body,  the  great
 variety of  parts of  which it consists, the  different nature of
 these parts,  the variety of functions necessary  to produce
 each individual result, and the variety of  causes which  may
 influence  each org.in in this complicated  structure, we are
 prepared for such a conclusion.
   When the motions  of"  a clock  are suspended,  we find a
 wheel clogged,  and readily  perceive how this cause of de-
 rangement has destroyed  the  action of  the  machine; be-
 cause its action depends wholly on  one principle,  and con-
 sequently all  causes  impeding  its motion  must  nffect  this
 principle.  But did the nature of the clock  include many
 principles of action, and were the cause  of disorder such,
 as might influence several or all of them,  we should seldom
 find its effect confined  to the derangement of one p.irt;  yet,
 even then the  effects of the offending cause  would be simple
 compared to those  of a cause of disease,  for to bring the
 machine  into a state  analogous to that of the animal body,
 and render the effect of its off. tiding causes equally  com-
 plicated, its different principles of action must not only have
 some of  them a direct, and all an indirect, dependence on
 each other; but beside this dependence for their  actual ex-
 istence, each must  in a greater or less degree be capable of
 influencing every other, and in such  a way,  that the second-
 ary affection re-acts  on the part  first impressed  by the of-
 fending cause.
   In  a machine so constituted, until  we  could trace the
manner in  which the different principles of action depend 
                    OF INDIGESTION.                gg

  upon and affect each other,  what possibility would there be
  of ascertaining the change which any cause of derangement
t.had occasioned in it,  and there could surely be no expec-
  tation of finding  it in the disorder  of any one part.  How
  vain then was the humoral pathology,  and how  vain that of
  the simple, or even of the living solid,  although the last,
  which we.owe chiefly .to the labours of Hoffman and Cullen,
  must be regarded as an important step towards  a true view
  of the nature of  disease.
    All the parts of a living  body  are concerned in its dis-
  eases, and it is only as we advance  in a knowledge of those
  various parts, and their relations to  each other, that the  na-
  ture of its deviations from a state of health  can  be under-"
  stood.
K 
60            OF THE TREATMENT
CHAPTER III.
      OF THE TREATMENT OF INDIGESTION.

   The treatment of Indigestion, like its symptoms, may be
divided into three parts,  that of the first, second, and third
stages of the disease.  The two  first  only,  for  reasons
already given, we are here to consider.


                     SECTION I.


Of  the  treatment  of  the  first   stage  of
                   Indigestion.

  The first object in the cure of all diseases is to remove
the remote causes as  far as they still continue to operate.
Among those of Indigestion, we have seen, that whatever
occasions morbid distention of the  stomach or irritates its
surface holds a chief place.   It unfortunately happens, that,
there is a  continual tendency  in  this disease  to  produce
those causes.  However  well, therefore,  we may succeed
in removing them, it requires constant attention to prevent
theirrecurrence.   It also appears from what has been said,
thu these  observations  apply  with  almost equal  force to
some of  the  other  causes  of this disease,  particularly t« 
                    OF INDIGESTION.                Qy

  that inactivity of body and irritable, anxious and  despond-
  ing state of mind,  which so frequently cause,  and are caus-
- ed by, Indigestion.
    The  first part of the treatment, therefore, which falls un-
  der our attention, relates to diet and exercise both of mind
.• and body; and  in the slighter and more recent cases a strict
  attention to these alone, or at most  with the assistance of an
  occasional mild aperient, will  often  be  found  sufficient to
  effect the cure; and the  neglect of  them  will, in  all cases,
  tend to counteract  whatever other means we employ.


            Of  t\ve diet in Indigestion.

    The objects  to be kept in view   in regulating the diet in
  this disease,  as appears from what has just been  said, are
  that it shall tend as little as possible to produce either mor-
  bid  distention  or morbid irritation  of  the  surface of the
  stomach.                  »
    Many of the regulations, belonging to the  first  of these
  heads arise out of  what was said in the  section on the  im-
  mediate causes of Indigestion.  It would appear from the
  observations  there  made,  that the appetite continues till the
  first food neutralizes the gastric fluid  which had accumulat-
  ed in the stomach  and caused the  sensation of hunger.  If
  the patient eats with great rapidity, he will, during the time
  required for this combination,  put  such a quantity of food
  on the stomach as to occasion some degree of morbid dis-
  tention, which  will be greatly increased  by the  swelling of
  the food, in  consequence of digestion  being impeded  by
  the  distention; while  the stomach, at the same  time, for
  reasons  above  explained,  does not, with the  usual facility,
  propel it  into the intestine.  Thus it is that the feeling of
  distention  often increases for some time after too full a meal,
  and,  at length, is  frequently  accompanied with actual
  pain. 
 gg              of THE  TREATMFNT

    The food, when we eat too fast, is not only received into
 the stomach in too great quantity, but is swallowed without
 being duly masticated and mixed with saliva,  and therefore
 without properly undergoing what may  be considered the
 first process of digestion.  It is thus  presented to  the sto-
 mach in a  state, in  which the  gastric fluid pervades, and .
 consequently acts upon it with more difficulty.   In this way
 eating too fast is injurious even when  the patient abstains
 from taking too much. For these reasons, to eat moderately
 and slowly, is often  found of greater consequence than any
 other rule of diet.   The dyspeptic,  in eating, should care-
. fully attend to the first feeling of satiety.   There is a  mo-
 ment  when the relish given by the appetite ceases;  a single
 mouthful, taken after this,  oppresses  a weak stomach.  If
 he eats slowly, and attends carefully to this feeling, he will
 never overload the stomach.
   Morbid  distention of  the  stomach, however, may  take
 place although there  be no error in either of these respects,
 if the food be  of such a nature, that  the  fluids of a weak
 stomach are unable to effect thevecessary  change on  it,  in
 consequence of which it runs into fermentation.
   It is evident that morbid distention, from whatever cause,
 cannot exist without, at the same time, occasioning morbid
 irritation of the surface of the stomach.  The distention it-
 self has this effect, but as deranged digestion is the conse-
 quence of  this degree of  distention, it can  never stop here.
 All undigested food, however small.the quantity, is a cause
 of irritation.
   Tncis the whole train of symptoms, which constitute a fit
 of Indigestion, miy arise either from too large a quantity of
 food,  particularly if  carelessly masticated, or from food of
 difficult digestion, most readily of course  from a  combina-
 tion of these causes.   It is, therefore, of great consequence,
 in  regulating  the  treatment of this  disease,  to  ascertain.
 wh  t kirn's  f  food are most easily  changed  by the gastric
 fluid.  This is sometimes influenced by peculiarities of con-
c 
                   OF INDIGESTION.                gg

 stitution, to which no general  rules will apply, but it is not
 difficult to perceive, what kind of diet  is usually best suited
 to a weak stomach.
   Tough, acescent, and oily  articles of food, with a large
 proportion of liquid, compose the diet most difficult of di-
 gestion.   It would appear that a  feeble gastric flui;!,  ns in-
 deed we might a priori suppose, does not admit of being
 greatly diluted without having its powers much impaired.
 The diet opposite to this, then,  is that which agrees best
 with dyspeptics.   In the  first  stage of  Indigestion, a  ciitt,
 composed pretty  much of animal food and stale bread,  is the
 best.
   If we  except beef and veal, the flesh of old, in general,
 is more easy of digestion  than that of young animals, on
 account of the greater quantity of mucilage in the latter.  All
 mucilages are of  difficult digestion.   Evt-n the vegetable
 mucilages,  which in small quantity are generally grateful to
 the stomach, will  oppress.it,  if taken  very  freely.   They
 are among the things  which, in vulgar language, are called
 sating, or phlegmy.   Whatever produces the feeling known
 by these terms disagrees with the stomach.
  The stronger kinds of animal  food, of  which beef may
 be  considered the  strongest,  are most apt to excite fever.
 On this account we often allow those,  recovering  from fe-
 ver or otherwise disposed to it, to eat the animal mucilages,
 or those  meats which  contain  a great  proportion  of  them,
 when even mutton for example is forbidden.   Thus animal
jellies and young  meats have  obtained the name  of light,
 but this only relates to the tendency to  produce fever, for as'
 far as digestion is concerned they are heavier than mutton,
 and to many  stomachs than beef.  A  similar observation
 applies  to the vegetable,  compared with  the  animal king-
 dom; the former are less  apt to excite fever,  and are there-
 fore called lighter, but they are in general  more difficult of
 digestion. 
 70          ■      OF THE TREATMENT
   From what it arises that mutton is to most  stomachs so
 much more easy of digestion than beef, it would be difficult
 to say.  Most kinds of game are of  easy digestion.   Fishi
 independently of the heavy sauce with which it is eaten,  is,
 for the most part, less easily digested than the flesh of land
 animals; and as  it at the same  time  affords less nutriment,
 it is in both respects less proper for  the  food of dyspeptics;
 although  from the white kinds beiqg less apt to excite fever,
 they,  like  the animal mucilages, have  obtained the  name
 of  light, a  term which so  often deceives  with respect to
 what is most easy of digestion, that it is necessary to keep
 this explanation of it in  view.
   The meat most mixed with fat, is, cet. par., most op-
 pressive.   It is on  this account that pork and the tongues
 of  many animals are of difficult digestion.    For the  same
 reasOn, geese and ducks are  the most  oppressive kinds of
 poultry.  Turkey is more  so than  fowl,  which, next  to
 mutton, is,  perhaps, upon the  whole, the  lightest animal
 food  in common use, if the skin be-avoided.   Of the dif-
 ferent kinds of game, pheasant is least easy of digestion.
 The lean part of venison is, perhaps, the most digestible ar-
 ticle of diet.   Hare ar.d partridge appear to  be as  much so
 as mutton,
  Eggs, as  far as relates  to a tendency  to produce  fever,
 may be regarded as of  a middle  nature between animal and
 vegetable food.   It is a common  opinion that they  disagree
 with bilious  people, that is, people labouring under  Indi-
 gestion, in whom the aisease has extended to the -function
 of the liver.   This opinion,  in  general, I  believe, is ill-
 founded, if  they are eaten soft boiled with stale bread.  In
 this  state, although  offensive to a few stomachs, they, for
the  most part, are easy of digestion,  if the patient c mfines
himself to  one, or  at  most  two, and  are  an agreeable
change.
  Few things are of more difficult digestion than new bread.
This obseryation applies to every thing which by mastication 
                    ©F  INDIGESTION.                 *4

  forms a tenacious  paste, which is not easily pervaded  by
  the gastric fluid.  So  difficult of digestion is such a paste,
  that I have known more than one dyspeptic, whose stomach
  could only digest new  bread, when it was  soak^cl  in melted
 ' butter.   Here one of the articles most difficult of digestion,
  was more easily digested than the tenacious pa'ste which its
  presence prevented.   Even bread sufficiently old is oppres-
  sive if taken alone, and in large quantity,  it still forms a
3 mass not very readily pervaded.
    On the same  principle,  food is often rendered more in^
  digestible by processes employed with a view to assist the
  stomach.   All articles composed of strong jellies, and food
  carefully  mashed  are oppressive.    The  coarser division
  which our food undergoes  in mastication is better suited to
  assist digestion.  Most  dyspeptics find, that potatoes, for
  example,  finely  mashed, although  without any admixture
  are more difficult of  digestion than when properly masticat-
  ed.  During  mastication  the  saliva  is freely  mixed with
  them,  and a mass is formed easily pervaded.  When they
  are mashed, they resist admixture with the  saliva, as well
  as the gastric fluid.
   Our food is rendered more easy of digestion by simple roast-
  ing or boiling, provided  it is not too much done.   Beyond
  this, the art of cookery is nothing,  but that of pleasing the
  palate  at  the expense  of the  stomach.  There  are  a few
  circumstances under which it is proper to bribe  a patient to
  eat; under  all others, the  refinements  of  the  cook  are at
  variance  with the. objects of the  physician.  However im-
  posing the plans of  concentrating  much nutriment in small
  compass may at first view appear, we may  be well assured,
  that in such concentration something is taken  away from
  what nature designed for our food, which is useful to us.
     It is not generally known, that the most  concentrated de-
  coction of beef, so far from affording much  nourishment,
  will not,  if unmixed  with  something solid,  even allay the
  appetite.   A  person under my care was  attacked  with a 
 yg            OF  THE TREATMENT

 severe pain  of the face when  even the  smallest.quantity of
 anv solid food  was  put on the stomach,  a  single mouthful
 of bread never failing to bring on  the attack; and, as he at
 length refused  all  solid  food, he  was confined  for  some
 weeks to a strong decoction of beef;  but, however strong,
 and in whatever quantity it was taken, it never relieved  the
 calls of hunger,  and he rapidly emaciated.
   Fresh vegetables, on account  of their  tendency  to fer-
 ment,  are,  on the whole, injurious in  Indigestion.   Some
 vegetables, however, are more so than others.   Peas, beans,
 cabbage and  waxy potatoes, 1  have  found  the worst. Mealy
 potatoes, turnips, and  broccoli,   among  the  best.    They
 should always  be  boiled till they  are soft;  raw vegetables
 of all  kinds are oppressive:  lettuce appears to be  the least
 so.  The tough, thready, and membraneous parts of vege-
 tables  are of most difficult digestion.
   Fruits are also difficult of digestion, particularly the cold
 fruits,  melons, cucumbers,  &c;  next to these, the mucila-
 g'nous fruits, gooseberries, pears,  &c.  Apples and straw-
 berries I  have found,  on  the  whole lightest;  but we  more
 frequently find peculiarities in the stomach with  respect to
 fruits than other articles of diet.   To many stomachs the
 most accessant  fruits,  currants,  mulberries, &c, are par-
 ticularly offensive.   All preserved fruits are oppressive,—
 the large proportion  of  sugar adding much to their indiges-
 tible quality.  To some dyspeptics  sugar is so oppressive,
 that I have known several who  were obliged  to abstain even
 from the small quantity used  in  tea.  Most stomachs bear
 acids better than acescents.
  Bread is not the worse for being hard, provided it is pro-
 perly masticated.  All hard and tough animal food, partic-
ularly if it be salted,  which  adds to its hardness, is of dif-
ficult digestion.  It seems to  be  from  its hardness that smok-
ed meat is oppressive.  Hard and tough animal food cannot,
by  mastication,  be reduced to the  loose  pultacious  form
which  hard bread assumes. 
                    OF  INDIGESTION.                *£

   There are few things in common use so oppressive as but-
 ter.  It appears to be more  so than the fat of meat.   The
 fat of mutton  is less difficult of digestion than' that of beef,
 and the fat of venison less so than either.  The same  may
 be said of the  fat of turtle, but all kinds  of fat  are oppres-
 sive to a weak stomach, and that of which we are inclined
 to eat  the most, is generally,  on this account,   the worst;
 We have  little experience of oil in  this country.  Could I
 trust the result of  a few instances, I should  say  that olive
 oil,  to  a stomach accustomed to it, is less oppressive   than
 butter, probably than most kinds of fat.
   All oily substances are rendered more oppressive by be-
 ing fried,  as in many of our dishes; yet, such is the pecu-
 liarity  observed  in  particular  cases, that I have known a
 dyspeptic digest fried bacon pretty well, who could not di-
 gest mutton; as if the strong stimulus of the  former  excit-
ed a secretion  of gastric fluid,  where the  milder  stimulus
 of the mutton failed.   It seems to be on this principle  that
 the  stomach will often digest a little of any thing for which
the  patient greatly longs, and  that the appetite  sometimes
 increases after we begin to  eat.
   Cheese  is, in  general, still  more difficult of digestion
than either butter or fat.  With their  oily nature, it com-
bines the hardness and toughness of the dry  and compress-
ed curd, which  is very difficult of  minute division.  Milk
and  cream,  with their  preparations, are generally oppres-
 sive  in proportion  to  their richness: but the  same propor-
tion of. cream  mixed with  water  is more  digestible  than
milk.
   Much seasoning is injurious, both by the  unnatural ex-
citement which  it occasions, by  which it, for the time,  in-
creases the power of the stomach, at the expense of subse-
quent debility;  and  by inducing us to eat too much.  It also,
like other strong stimulants, has a more direct tendency to
induce the second stage of the disease,
                           L

                                      e 
 74             OF THE TREATMENT
    With respect to fluids,  water is evidently intended  for
 the proper dilution of our food.   As, on the one hand,  we
 have seen the food may be so watery  that  it too much di-
 lutes the  gastric fluid; so, on the  other, it may be  so dry,
 that this fluid cannot easily  pervade it, and its necessary
 motions in the process of digestion are effected  with diffi-
 culty.*
   But these are not the only, nor  do they appear indeed to
 be the principal,  purpose for which we arc induced to drink,
 which seems generally to  be,  to  supply the waste of mois-
 ture occasioned by the various secreting surfaces, and par-
 ticularly  by the skin, which  is  the most extensive; hence
 every thing which  promotes  perspiration  increases thirst.
 For a similar  reason  diarrhoea, and the  operation of a  ca-
 thartic have the  same effect; and it appears from many facts,
 that there is often a rapid absorption of fluid  from  the sto-
 mach.
   In health, when the various functions are  in due propor-
 tion, little liquid is  required  with  the food, the  inhalation
 by one set of vessels nearly compensating for the exhalation
 by others.   Thus it is that the most healthy are little trou-
 bled with thirst.   In' Indigestion, we have seen it is a fre-
 quent symptom.   It seems sometimes to arise from a gener-
 al failure  of the secretions  of the  alimentary  canal,  from
 the mouth downwards,  more  frequently  from  irritation of
 the stomach, excited  by the undigested food; for there is a
 false thirst, as  well as a false  appetite.   As  that irritation
 frequently  induces the patient  to eat when there are no flu-
 ids in the stomach adapted to the office of digestion, it ex-
 cites him to drink when there  is no want of fluidity  in the
various  juices of the body; and when, so far from there

  * Besides the gastric  fluid, properly so called, we  have reason  to
believe that the stomach, like other  secreting surfaces, forms  a bland
fluid for the purpose of defending itself to a certain degree against the
irritation of its contents.  This fluid may  also  be of use in promoting
the necessary motions of the food.
'  vt 
                   OF INDIGESTION.               75

being a want of liquid in the stomach, it is surcharged with
vitiated fluids.
  The drink,  under such circumstances, only giving relief
in proportion  as it  dilutes  the  irritating  matter, the thirst
returns as  soon as its irritating  properties  again increase by
its continued fermentation, or perhaps merely as soon as the
stomach has become  accustomed  to the  dtgree^f  relief
which the  last draught procured.   In  this way  dyspeptics
often drink Vast quantities, greatly distending the stomach
and increasing their disease.
  There is some difference  of opinion  respecting the* pro-
priety of drinking at meals.  It is evident from what has
been said,  that the  necessity of drinking  must be different
under different circumstances;  but in general  it  is best
shewn by the  degree of thirst,  and there cannot  perhaps be
a more erroneous idea than that,  which induces some peo-
ple to drink during meals, for the  purpose,  as they say, of
assisting digestion, when they feel no desire for it.
   Drinking water can in no other way assist digestion than
by affording the proper degree of moisture to the food.  If
there  be no thirst,  we may be  assured  that it already pos-
sesses  this degree of moisture, and  that any  addition to it
will only dilute the gastric fluid, and consequently enfeeble
its solvent  power.  I have often observed, that  eating too
fast causes thirst, the food being swallowed  without a due
admixture of saliva, the mass formed in the stomach is too
drv-   It is  almost  unnecessary to observe, that the liquid
taken after food must but imperfectly answer the purposes
of that mixed with it during mastication.
  The best rules, I believe, which  a, dyspeptic can follow,
are not to yield to every slight sensation of thirst, and  when
the sensation is considerable, to take but a moderate quan-
tity, and that  deliberately,  for it is with  drinking as with
eating,  if he swallow  with too  great rapidity, he will take
too much. 
76              OF THE TREATMENT

   Such'appear to be the regulations respecting liquids most
consistent  with the nature  of Indigestion, when the fluid
possesses no other properties but those of quenching the
thirst.  If it possess other properties, other circumstance:,
demand  consideration.   Both nutritive articles of diet and
stimulants mav be received in the liquid form.
   I have^ust had occasion to observe, that the most nutri-
tive  fluid alone will neither satisfy  the appetite  nor afford
due nourishment.   When we reflect on the facts above stat-
ed relating to the  manner in  which digestion  is  performed
in man and the animals  most similar to him, we shall easily
perceive why liquids alone are incapable of affording suffi-
cient  nourishment.  We  have seen, that that part of the
food  which  lies  next the stomach  having duly  undergone
the action of  the gastric fluid, is  moved onwards  towards
the pylorus, while that  next  in succession is in its  turn ap-
plied to the surface of the stomach,  where it excites a fur-
ther secretion of gastric fluid, undergoes its action, and in
like manner is moved onwards towards the pylorus.
   That the motions necessary  for these purposes  may be
readily performed, a certain  degree of moisture  is necessa-
ry; but if the contents of the stomach be wholly  fluid, it is
evidently impossible that such a process can go on with any
degree of precision.  The fluid cannot be so changed as to
present a constant and regular succession of food,  compar-
atively fresh,  to the surface of the stomach; there  will not
therefore, be the same stimulus to excite to a continued se-
cretion of gastric fluid, and  what  is secreted  will be too
easily diffused  through the liquid contents  of the stomach
to make the proper impression on any one part; the same
must necessarily happen to the  more  digested  part in  its
passage  to the pylorus; it must  be  more or  less  diffused
through  the  other contents  of the  stomach;  in  short,  no
part will be  duly digested.  The  gastric fluid, being tco
much diluted for  its function, is rather diffused through the
contents of the stomach than neutralized by  them, hence 
                   OF INDIGESTION.                ^

the appetite is never perfectly-allayed, and little nourishment
afforded.   Thus  the effects of liquid  food  tend  to coi.firm
the view of digestion afforded  by  the  facts, which  have
been laid before the reader.
  When nutritive fluids,  however, are mixed with solids,
although  of a  less  nutritious  quality,  they  afford  suffi-
cient  nourishment.   Strong  broth,  mixed  With  bread, or
any other solid article of  food, is sufficiently nutritious; but
it is by no  means the form,  as appears from what has been
said,  in which  nutriment  should  be presented  to  a  weak
stomach, unless the appetite or irritability  of the stomach,
as sometimes happen,  be such  that  solid  food cannot be
taken.  The proportion  of  liquid is too great,  if there be
much  broth in the mixture; ana  if not> it approaches too
much to the nature of the mucilaginous paste,  to permit
the digestive fluids to pervade* it with ease.  Thus all  kinds
of broth are apt to become sour on a weak  stomach, and to
cause other things to  run  into fermentation.  When  liquid
nutriment is taken, as soups  and broths  usually are, before
other food, it has the additional bad effect of inducing us to
eat too much.  •
  The diet of the dyspeptic should not only be well chosen,
but simple.  Variety is always an inducement  to overload
the stomach, and indeed so intermixed are the  feelings pro-
duced by  the  calls of hunger, and by  the  means  which
please the palate, that,  when the desire to eat is constantly
renewed by  a succession of different  kimls  of agreeable
food, it  is impossible to judge when we  have received the
proper supply.
   We have reason to believe that by such  means an actual
increase of secretion is produced in  the digestive organs,
and.thus an artificial  appetite, if I  may  use the expression,
excited at the  expanse of subsequent debility;  which,  al-
though it may not immediately show itself  by symptoms of
Indigestion,  which also is common, at  length, in the ma-
jority of people,  weakens the digestive powers. 
 78            OF THE TREATMENT
   With respect to stimulating fluids, the operations  of the
 most innocent of these seems to be confined to the digestive
 organs.   The various aromatic  waters,  ginger-tea,  &c,
 seem only to  be objectionable in  the same way that other
 kinds of seasoning are, and we shall  find,  that in certain
 states of Indigestion  they are  useful,  in  giving temporary
 tone to the stomach and bowels.
   The most pernicious fluid of this class, it is well known,
 are those which owe their stimulating property to the pre-
 sence  of alcohol.   When  taken in  considerable  quantity,
 they not only  more, perhaps,  than any other stimulants, in-
 jure the digestive  organs; but extend their pernicious  effects
 to other parts of the  system,  to.which, we have  reason to
 believe,  they are immediately applied  by means of the  ab-
 sorbents.
   Like most substances capable of powerfully affecting the
 animal  frame, they possess  valuable as well as pernicious
 qualities; and, were the former of these less eminent than
 they really are, so general is their use in one form or  other;
 and in  most people the habit, which requires their continued
 use, so  fixed,  that they seldom can be  wholly  withdrawn,
 except in very early life,  without  doing  more  harm than
 good.
   All will agree that alcohol  in every shape  is unnecessary
 to those who are in health,  and have never been accustomed
 to the  use of  it; and that had  no  beverage but water ever
 been known, however we might feel the want of a stimu-
 lus, in many cases, doubtless, the most valuable we possess,
 a great number of  the most fatal diseases we are subject to
 would have been less frequent; but these are not the  ques-
 tions before us.  Our object is, to  inquire what is the best
for dyspeptics, as  we find  them  in the  habits of society
which prevail in this country.
  As these habits are  such, that more or less alcohol  is ne-
cessary to support the usual vigour of the greater numher of
people, even in health, nothing could be more injudicious 
                  OF INDIGESTION.                73

than wholly to deprive them of this support, when they are
already weakened by disease, unless it could be shewn that
even a moderate use of it essentially  adds to their disease;
which, in  the  instance  before  us, we shall  find, is by no
means the  case  with respect to all the forms in which this
stimulus may be taken.
  As dyspeptics then, who have been accustomed to its use,
cannot be  deprived  of it,  and as,  under certain  circum-
stances, it  is even a useful remedy, we are here to inquire
how far it is found so in Indigestion,  and how we can best
secure its beneficial and  avert its evil  effects.
  There appears to be an essential difference in the effects
of alcohol, such as it exists in fermented liquors, and after
it has been  distilled from them.  Both have their inconve-
niences.  So apt is the latter to  injure the tone of the sto-
mach, that, were it not  that  it is necessary for the solution
of certain  medicines,  frequently  beneficial in Indigestion,
we might,  without hesitation, banish it from the treatment
of this disease;  with the exception of  those cases, in  which
all kinds of fermented liquors, which have not been distill-
ed, increase  the symptoms,  and the patient's habits render
the use of  alcohol in some form indispensable*
  In the fermented liquors which have not been  distilled,
on  the other hand, the alcohol is often combined with sub-
stances of  difficult digestion,  which are particularly felt by
the dyspeptic.   This is most remarkably the case with malt
liquor, of  which even the weakest kinds often increase the
symptoms of Indigestion, and the strongest are among the
most Indigestible articles  of diet.   The  same  objection,
though in  a  less degree, exists  with  respect to the other
fermented  liquors of this country.  Of these, cider  is the
best,  provided the acetous fermentation has not commenced
in it.  Perry usually contains too much mucilage, and some
kinds are very oppressive to  the stomach,  apparently  from
this cause.   The home-made wines are still more objection- 
g0             OF THE TREATMENT

able  being still more apt to run into the acetous  fermenta-
tion.
   The form in which alcohol is  most beneficial, and in gen-
era: does least harm, is that of foreign  vines.  TU pro-
perties of these  are various, and different kinds suit differ-
ed stomachs.   The astringent property of  port wine stems
to give it  a peculiar tonic power;  and, if it do not consti-
pate,  there is, perhaps, no  other wine so well suited to oys-
peptics.   It  should  not  be  drank till  of a certain age, the
tartar of new port-wine  benig  offensive to the  stomach.
Sjiyi: dyspeptics find it,  as well as the other stronger, wines*
agree better with them,  when diluted;  and  others find the
lighter wmes, particularly claret, better;  while  with others*
all  the  lighter  wines, and  even port-wine, are  acescent.
Even in these cases, however,  the effects of the stronger
wines are often improved by diluting  them.  Of this and
many other circumstances  in  diet,  each  individual must
judge  for  himself, as there is no  rule of general applica--
tion.
   Many stomachs seem to feel  the bad effects of the distill-
ed spirits,  which,  it issaiJ,  are added to the stronger wines;
for even the most objectionable  of all the fermented liquors*
which have not been distilled, appears to be less pernicious
than anv of those  which have  undergone  this process.   I
have  known dyspeptics  so  sensible to the bad effects of the
latter,  that they have felt an increase of debility for sever-
al days  after drinking  a single glass  of spirits and water.
This does not arise from its oppressing the stomach, it even
for the time assists digestion, and that, if the quantity taken
be not too great,  to  a considerable degree, a  property in-
deed which belongs  more or less to all fermented liquors,
though not in the same degree to those which have not been
distilled.   It is this unnatural, excitement that feems to do
harm.  It is followed by a corresponding debility; and  what-
ever be the change induced by distillation, there are no facts.,
I believe, better ascertained, than  that  the same  quantitv
• 
                    OF INDIGESTION.                8i

 bf alcohol in the form of distilled spirits, although equally
 diluted, both by its  immediate operation gives more tempo-
 rary assistance to the stomach, and by its secondary effects,
 hurts it more, than  in that of any fermented liquor which
 has not been distilled.
   It is thus that many dyspeptics, whose digestion, is disor-
 dered by  all kinds of wine, can drink djjuted  spirits.  But
 it is impossible by any addition to make their permanent ef-
 fects  similar to  those of wine.   Those addicted  to  wine
 seem often to be destroyed by excess of nutriment.  They
 become  full, often ruddy, at least for a certain time  even
 robust, and not unfrequently die of sanguineous  apoplexy.
 Those addicted to  spirits, on -the  Contrary, generally be-
 come  pale,  often emaciated, and more or less paralytic; and
 although  both are subject to debility of stomach, obstructed
 liver, and dropsical affections;  the latter soonest  fall into
 those diseases,  and in them they make the  most rapid pro-
 gress.
   A very moderate  use of wine can hardly be said to be in-
jurious; we see those who use it  in this way, live as long,
 and enjoy as good health, as those  who wholly  abstain from
 it; and to somt constitutions,  independently of the effects
 of habit,  it  may  be useful.  I believe neither of these ob-
 servations apply to "distilled spirits, although as  already
 hinted, when, the  stomach has  been greatly  weakened by
 excess, so that it cannot digest any fermented liquor which
has not been distilled; the effects of diluted spirits are often
 less injurious, than the total  collapse  of the system which
ensues on wholly withdrawing the accustomed stimulant.
   The best thing to be done in such cases is,* to give no more
than is necessary, and that in the most diluted form which
is consistent with the debilitated state of the stomach.   The
usual additions of lemon and sugar which are  supposed by
many to bring the spirit into something like its state previous
to distillation, according to my  experience,  only  increase
the evil, by adding to the hurtful stiiriulant. articles of  dif-
                         M 
 82            OF  THE TREATMENT

 ficult digestion, without  at  all ameliorating  its properties.*
 When it is necessary to use  distilled spirits, I have f ;und it
 the best plan to let it be as pure as possible, and mix it with
 nothing but water.   I have known  more than one instance,
 in which the stomach was even sensible to the difference be-
 tween coloured and  colourless  brandy.
   Tea  and coffee are injurious in another  way; they pos-
 sess a narcotic power, which, we have seen, when consider-
 able, is  capable of producing  Indigestion.  By ma"ny they
 are regarded as a fruitful cause of this disease, but their ef-
 fects on  the whole  have, perhaps, been over-rated. Green
 tea, and  a very strong infusion of black tea  or coffee, are
 injurious to many stonmchs.  I have repeatedly  seen severe
 fits of Indigestion induced  by them, always  characterized
 by a greater than usual  degree of nervous affection.  To
 many, however,  even these, and to most  people,  a weak
 infusion  of  black tea and coffee, seem to be  innocent. They
 produce  no  present bad effects, and, where  this is the case,
 I have never been able to perceive any proof  of their con"
 tinued use, doing harm.  It is remarkable that their peculiarly
 refreshing sedative effect is generally,  in the first instance,
 felt even by those with whom they most disagree.  If drank
 very hot, they, of course, produce the effects of other hot
 fluids, which we are presently  to consider.
   It is by no means a fair inference,  that what produces ve-
 ry  injurious consequences in some,  miftt do  more  or less
 harm in all.  We frequently  see articles of  diet, and still
 moi*e frequently, medicines,  which cannot be  borne  by one
 stomach,  perfectly innocent to another.
   The tendency of tea and coffee to prevent sleep in many
people, for even this effect is by  no  means universal, must
 be injurious as far as the want of  sleep is so. It is generally
 in those in whom they produce  most  of this effect, that their
 other injurious effects are most apt to appear.
   There has been some  difference of opinion respecting the
 proper temperature of the drink of dyspeptics.   Some, from 
                   OF INDIGESTION.                33

 the present relief obtained from fluids  drank very  warm,
 have recommended a high temperature; but the relief thus
 obtained is, like that obtained from distilled spirits, general-
 ly compensated by subsequent  debility.    When fluids  of
 the usual  temperature of the air,  are too  cold for a weak
 stoinach, which is frequently the case, there is no objection
 to raising them to any degree that does not *xceed  that-of
 the body;  although, when the stomach  bears it Well, fluids
 of the common temperature  seem rather to have  a tonic
 effect in Indigestion.  A very low temperature is objection-
 able.  I have already had occasion to observe that  fits of
 Indigestion may be induced in  weak stomachs by iced
 fluids.
   I have had occasion, in the preceding  observations, to
 point out  the impropriety of dyspeptics eating too  fast or
 too much, or using too liquid a diet;  the due repetition of
 their meals also deserves particular attention.
   It is evident from  what has been  said of the  process of
 digestion,  that a considerable time must elapse after a toler-
 ably full meal, before the more central parts of the food un-
 dergo the  action of  the gastric  fluid;  but, as we are  not
 prompted to eat,  till there is some uncombined gastric fluid
 in the stomach, it is evident, that it is the intention of nature,
 that we should abstain till some time after all the food alrea-
 dy taken has undergone the action of this fluid.    The accu-
 mulating gastric fluid  having then no more  undigested food
 presented to it, begins so to affect the stomach as to occasion
 the sensation of hunger.  The recurrence of this  sensation,
 therefore,  must be the proper indication, that a due time has
 elapsed since the  last meal.
  Now this will  be  different under different circumstances,
 so that it is impossible to lay down any rule of general ap-
plication; but  it can  never be very soon after an ordinary
 meal, except where the digestion is more rapid than natural,
 which sometimes happens.   The patient must be careful to
 distinguish between a real appetite, and a desire to eat what 
 §4,          OF THE TREATMENT

 is agreeable,  a mistake by which we often see the stomach
 oppressed.  On  the other hand, it  is injurious to a weak
 stomach long to bear the calls of hunger.
   It has appeared  to me that,  with  the generality of dys-
.peptics, to take  three moderate meals  in  the  twenty-four
 hours is the best rule.   A  few, particularly those who" are
 much trOubleoVwith a sense of depression and sinking, find
 four meals better.  The last meal should alwavs be taken a
 little before bed-time, and  should  never, particularly after
 the  disease has>  continued for some time,  consist of ani-
 mal food.   The dvspeptic should eat nothing in the intervals
 of these, meals.   There is no greater  mistake  than that he
 should constantly be taking something.   This disturbs  the
 natural process, and  entirely prevents the recurrence of  ap-
 petite,  a certain degree of  which is a wholesome stimulant
 to the stomach.  The stomach  by  this  constant eating  be-
coming more  and more debilitated, and  every part by sym-
pathy  partiking  of the  debility, the patient wholly misap-
prehends the cause; and with a view to increase his strength,
still  increases  the  frequency of his meals,  till  he hardly
passes a couple of hours without eating.  By such a prac-
tice, pursued for  years, I have  repeatedly  seen debility of
the stomach and a  morbid irritability of the whole system
established.
  It is not, however, to  be overlooked,  that there are  ca-
ses of urgent debility, both in this and  other diseases,  in
which it is for  the  time necessary that  the  patient should
take little and often.   Sometimes the stomach can bear  so
little  food  at  one  time, that  were the  usual  intervals   of
meals observed, due  nourishment  would not be received.
But  it is not sufficiently attended to,  that in such states,  in
proportion  as the  quantity of nutriment received is lessened,
the waste is lessened at the same time.   The langour of the
digestive firgans is  communicated to other parts of  the sys-
tem,  and, if the  organs of supply  are   inactive,  those  of
 waste are affected in a similar way.   A due attention to this
* 
                   OF INDIGESTION.                gg

fact would often prevent the  friends of the invalid urging
him to .take food  against the  appetite,  whidi  seldom an-
swers any other purpose but that of oppressing the stomach..
When it is necessary  to eat ver) often, every  cafe shoul4
be taken,  by recurring, as soon as possible,  to a better plan
of  diet, to prevent the habit of very frequent eating,  being
formed.
  Among the other evils of this practice,  an artificial want
arises, and if the patient is not continually taking food, he
feels a sense of sinking, which  persuades him that its  con-
stant, reception is necessary  to  his existence.  Such patients
can only be restored to regular meals by very gradually in-
creasing the intervals of eating.  An argument is adduced
from the general good condition  of cooks,  for eating little
and very often;  but, it is forgotten that a healthy stomach
and robust frame  will bear  many irregularities, which over-
whelm a less-healthy or more feeble one.   We might  as
well adduce the fact of healthy people being  most nourished
by  oily food,  as an argument for feeding the dyspeptic with
butter and fat.   No doubt by this constant  eating, a great
deal of food  may be taken, and a strong  and  healthy sto-
mach, notwithstanding the way in which it is taken, may di-
gest it; but we are here inquiring into the means of best as-
sisting a weak stomach.
   I have dwelt the longer on this  and other similar points, be-
cause  I have found them essential  to the proper treatment
of  the dyspeptic ; and, like the process of digestion  itself,
they have not perhaps obtained all  the  attention  they  de-
serve.  The  study of the two subjects, indeed, must go
hand  in hand ;  without a correct knowledge of the healthy
function,  it is evidently  impossible  to  perceive the princi-
ples, on which this part of the treatment of  its deviations
from the healthy  state should  be founded.
    In the .foregoing observations on  diet the -AUenron has
been  chiefly confined  to its effects on the  stom~.cn, but its
influence on the bowels of the dyspeptic  ought  not  to  be
• 
 86              OF THE TREATMENT
 overlooked.  Indigestion, we have seen, is generally attend-
 ed with languid bowels; and, as far as the stomach admits
 of it, it is proper to make the diet such, as tends to counter-
 act this  state of them.  A vegetable diet  is less  astringent
 than one composed chiefly of animal food, and fresh vege-
 tables are  more aperient than bread.  But this must not be
 carried too far ; it is better to take  aperient medicines than
 disorder digestion by an improper diet.   I have in several
 instances seen advantage from eating household bread, mix-
 ed with.a  certain  proportion of rice, previously softened by
 boiling.   This admixture, contrary to what might be expect-
 ed, renders the bread aperient, but it also, in  general, ren-
 ders it more difficult of digestion.   It is also  for the most
 part rendered more aperient by allowing part of the bran
 to remain  in the flour.
   When there  is much irritation of the  bowels mucilagi-
 nous fluids, in such quantity as does not oppress the stomach,
 are  useful,, even  butter and fat are occasionally  useful  in
 this way ;  but, in general, any considerable quantity of them
 so disorders digestion, as more than  to compensate for their
 effects in the  bowels; and  not unfrequently the disorder
 they produce in the secreting power  is such, that the  con-
 tents of the bowels become more irritating than they were.
 I have known many dyspeptics, in whom the use  of butter
 always had this effect.
   When diarrhoea seems rather  to arise from a degree of
 relaxation  of the bowels  than from the nature  of their con-
 tents, it is proper to use articles  of an astringent kind, such
 as rice seasoned with cinnamon.  B  it it is a great error in
 the treatment of this disease, immediately to check diarrhoea
 for it generally arises from irritating  matter, the retention of
 which would be injurious.
  Upon  the whole, however,  it is to be observed, that the
diet best suited to the  stomach is generally found, best for
the bowels  also ; their disorders in this disease,  if we  ex^
cept a degree of languor, generally arising from the vitiated
secretions, which attend disorder of the former.
• 
OF  INDIGESTION.
          ^f exercise in Indigestion.

  The exercise both of mind and body demands particular
attention in the dyspeptic.
  The different kinds of bodily exercise  may  be  arranged
tinder three heads; that  in which the body is moved by its
own powers; that in which it is moved by other powers, ag
in the various modes  of gestation;  and that in which the
circulation is promoted without moving the body, by friction
for  example, or merely by pressure.
  The dyspeptic  may  be so  weak, that friction is the only
kind of exercise which he can bear without fatigue. Where-
ver the  strength is much reduced, indeed, although a little
of some rougher exercise may be borne, friction  is always
useful.  It is the principal exercise among the higher ranks of
some Asiatic nations, and it was used both by the Greeks and
Romans after they become luxurious. It would not  be proper
in Indigestion to confine  the  friction to the abdomen, when
it is the  only mode of exercise, although in such cases it
should be carefully applied to this part.  To  dyspeptics in
general, whatever be their other modes of exercise, friction
of the abdomen  is always useful.
  Mere pressure is a mode of exercise inferior to friction;
but, if generally applied to the limbs  in an* interrupted man-
ner, from the valvular  structure of their veins, it has a con-
siderable effect in promoting the circulation.
  As the  total want of exercise is hot more pernicious than
that which occasions fatigue, and no exercise is very benefi-
cial •which cannot be continued for a considerable time, the
different kinds of gestation, even after the patient  has reco-
vered a moderate degree  of strength, are often found prefer-
able to those exercises, in which the  body is moved by  its
own powers,
« 
 yg            OF THE TREATMENT

   The gentlest kind of  gestation is sailing,  which is ser-
 viceable in almost all cases of debility, and has been found
 particularly so in debility of the stomach and bowels.
   Next to sailing, the gentlest exercise in  common  use, is
 the motion of a carriage ;  but in such climates  as our own,
 unless the patient has been accustomed to an open carriage,
 he  must either be confined to a close one, or run the risk of
 taking cold.   As substitutes for a carriage, but  inferior to
 it,  swings and spring-chairs are used.
  No::j of these mxles of exercise is equal to  horseback,
 when the  patient is strong  enough not to be soon fatigued
 by it.   From the stimulus given to the alimentary canal by
 the shaking in riding, it appears to be particularly well adap-
 ted to Indigestion : and  every physician has seen instances
 of this disease, in which it has been more beneficial than any
 other exercise.
  Any rough exercise, however, particularly  riding  on
 horseback, soon after meals, disturbs the stomach.   If the
 reader  will reflect on what has been said of the  process  of
 digestion, the cause of  this will readily appiar.  We have
 seen that, in  healthy digestion, no admixture of the new
 food, with that which may yet remain in the stomach from
 the  last meal, rmd which, if due  tim? have been afforded,
has  already undergone the action of the gastric fluid, nor  in-
deed of the different parts of the new food, ever takes place.
 We must, .therefore, infer, that any such admixture is unfa-
 vorable to this process; and it is evident,  from the way in
which digestion is performed, that, did this happen, some
part of the food would again be presented to the surface of
the  stomach,  after it had undergone the digestive process ;
and, consequently, a  corresponding portion of  undigested
food prevented from approaching it in  due  time. *     •
  The mixing of the different parts of  the food by any jolt-
ing  exercise will be most apt to take place in the  dyspeptic.
If we fill a closed vessel with such contents as those of th-; 
                   OF  INDIGESTION.               gy

stomach,'we shall find that but little relative change of place
will happen among its different parts by shaking the vessel.
But if, instead  of these contents wholly  filling the vessel,
any space  be  occupied by air, their  relative  situation  will
be readily disturbed.  Now, the stomach always, more or
less firmly, embraces its contents; but, in  Indigestion, air
is generally extricated from the food, and  we have  reason
to believe, indeed, is often secreted by the surface both of
the stomach and bowels, and thus room is given for a ready
change in the relative position  of their contents.   The  dys-
peptic is   often warned against any jolting  exercise after
meals, by the uneasiness it occasions.  It is a good general
rule,  therefore, for  him to avoid  exercise  jf all  kinds for
an hour and a half after eating.   This affords an addition-
al reason for not eating too often.  We still find the dictates
of  nature pointing out what is  best; for all animals  are in-
clined to  repose, and even to sleep, after eating.
   Walking, when it can be borne for an hour or  two with-
out fatigue, is, of all exercises,  the  best.  It is that which
nature intends for us.  There  is no other accompanied with
such  a uniform and regular  exercise of the muscles and
joints; and from the valvular  structure of the veins of the
extremities, it  is better fitted  than  any  other  to promote
the circulation, and consequently  all the functions  of the
system.   It  is  also  the most  agreeable  mode of exercise.
Our desire for it when  it has been long  withheld, becomes
excessive.
   But in Indigestion, from the peculiar effect on  the abdo-
minal viscera  of  riding  on horseback, it is generally of
service to combine  it with  this exercise.   I have  known
some dyspeptics, however, to  whom horseback was  always
more or less  irksome,  when it occasioned any  degree of
shaking.   To such,  the slowest riding alone  can  be  useful,
and that only when  they are unable  to walk for a sufficient
length of time, and when the weather admits of  such  gen- 
 90              OF THE TREATMENT
 tie exercise without a risk of  being  chilled,  to  which  we
 have seen they are.peculiarly liable.
   Those exercises in the  open air, in which the bodily ex-
 ercise is combined with a moderate and pleasurable exer-
 cise of mind,  particularly gardening, are well  adapted  to
 this disease, provide J the patient can  avoid fatigue, which
 is not always easily done when the mind  is occupied.
   A proper exercise of the mind, indeed, is almost of as
 much consequence  to the  dyspeptic  as that  of  the  bo-
 dy.   When the latter is debilitated and  ill at ease, the for-
 mer is generally languid and  listless.  This state of mind
 is more or less counteracted by a due degree of bodily ex-
 ercise, but the occupation  of the mind itself is necessary to
 its cure.
   The maxims by which the exercise of the body is  regu-
 lated,  are also  applicable  to that of  the  mind.   The  great
 rule is, to exercise without fatiguing it.  Any study which
 fatigues, is injurious, and  a mind  wholly unoccupied is no
 less so.  When the debility is considerable, the mind should
 be occupied  by amusement  alone, and even  those amuse-
 ments which greatly interest the  feelings,  or occasion any
 considerable effort  of mind, are hurtful.  When, on the
 other hand, the patient has recovered a considerable degree
 of strength, a  moderate attention even to  business is ser-
 viceable.   However  varied our  occupations, if   they  tend
 only to present gratification, they soou become insipid.  The
 mind must have something in  view,  some  plan  of  increas-
 ing its enjoyments, to interest it agreeably for  any  length
 of time.  There are  few things of greater advantage  than
 the*1 conversation of friends,  who constantly present to the
patient the fairest side of his future prospects.
  The time  of day, at  which either  the mind  or  body
is exercised, is  also  a matter  of  importance.   Towards
 evening every kind of exertion becomes  irksome, and con-
sequendy hurtful.   In the debilitated, a degree of fever  or
something  resembling it, probably the consequence of the 
                   OF INDIGESTION.               . 91

unavoidable  irritations  of the day, comes  on at this time,
which is only to be relieved by repose : going early to bed,
therefore, is of great consequence  to  them.  It seems to
be for the same reason that animal food is hurtful at a late
hour.
  Exposure to the night air  appears to be more pernicious
than we can easily account for.  I am inclined to ascribe its
effects to the damp, which prevails  in the  early part of the
night from the condensation  of the watery  vapour raised
during the  day, being applied to the skin,  at a time when,
from the state just mentioned,  its. function is most apt to
fail.  In sultry climates, where the evening dews are heavy,
the effects of the night air are often fatal, even to those in
health.   It is well known, both in the East  and  West In-
dies, that people are often attacked with  agues, from pass-
ing a single night abroad in  the woods,  where the vapour
is most confined.  Of the baneful effects of the night air at
Batavia, Dr.  Lind relates a striking proof in his account of
the fevers of India;  ''During the sickly  season,  a boat be-
longing to the  Medway man-of-war,  which attended  on
shore every night to bring fresh  provisions,  was three times
Successively  manned; not one  of  her crews having sur-
vived that  service.''
  The bad effects of the night air,  even of this country, to
invalids, I had.often remarked, before I began to consider
to what it might be ascribed.   Whatever may be said of the
above explanation, which it would be difficult to verify,—of
the fact I have no doubt.   It may be observed, that the ef-
fects experienced from the night air by dyspeptics, are  simi-
lar  to those produced on  them  by  a damp  air from other
causes.
  It  is chiefly to the greater dampness of the air of  large
towns, I believe, that  we should  ascribe their often disa-
greeing with dyspeptics.  Dr. Hutton has shewn, that when
two portions-of air, of  different  temperatures,  saturated
with water, are mixed, the mean temperature will not ena- 
 92                 OF THE TREATMENT
 ble them to hold in solution the same  quantity of water. 1
 have, from an eminence, observed a wind, highly  charged
 with moisture,  passing over a great extent of country, which
 contained several small towns, and occasioning a deposition
 of moisture, wherever it mixed with the air of the towns;
 so that from each of them  a streak of  mist extended in the
 direction of the wind, the air every where  else remaining
 perfectly clear.  To the  same  cause we must ascribe the
 thick fogs of London.  They occur  when  the  air  is  most
 charged with moisture, and in cold weather, when the num-
 ber of  fires being greatest, there  is the  greatest difference
 of temperature between the  air of the country  and that qf
 the metropolis.  A damp air feels colder than a dry one of
 the same temperature, not only because it abstracts the heat
 of our bodies more  rapidly, but because it tends to debili-
 tate the functions of the nerves of the surface.
  Although  it is  of consequence for  the debilitated to go
 early  to  bed, there are  few things  more hurtful  than re-
 maining in it too long.  After the degree of strength, of
which  the  state, of the system is capable, is  restored by
sleep, any longer continuance in bed, unless the tlebility be
 such as to render  the mere effort of sitting  up too much,
tends only to relax.  Getting up an hour  or two earlier, of-
ten gives a degree of vigour which nothing else can procure.
 I have known people whose feet constantly became  cold and
damp if they remained in bed a few hours longer than usual.
 For  those who  are  not much  debilitated,  and  sleep  well,
 the best rule is to get out  of bed soon afyer  waking in the
morning.  This,, at first, may be too early, for the debilitat-
ed require more^ sleep than the healthy; but rising early, will
gradually prolong the sleep on the succeeding night, till the
 quantity  which the  patient enjoys is equal to  his  demand
 for it.
  Lying  late is not only hurtful by the relaxation  it  occa-
 sions, but also by occupying  that time of the day at which
 exercise is most beneficial. 
                      OF INDIGESTION.               93

      If the dyspeptic be much debilitated, he should take his
   first meal as soon as he is dressed.   He will often find him-
   self hurt, and always  less benefited  by exercise, either  of
   mind or body, with the stomach  and upper bowels empty,
   as they necessarily are, in the morning.
      When  the debility is less, he will often experience benefit
   from a walk or ride before breakfast.   This observation is
   particularly applicable to those in whom Indigestion has pro-
   duced too great a determination of  blood to the head, which
■«  is, for the time,  increased by the recumbent posture during
   the night.
   *  We are most vigorous when the first process of digestion
   is so far advanced,  that the vessels which  receive the nutri-
   ment from the intestines  are pouring it into the'blood; and
   then it is that a free circulation is most useful for mixing the
   new juices with this fluid, and promoting its passage through
   the lungs, where they are perfected into blood.
      Some light and  agreeable occupation of the mind,  with
   perfect rest of body, is  best for an hour  and  a half  after'
   breakfast.  From  this period to  the  time of  the second
   meal,  which should be  about  the micldie hour between
   breakfast and bed time,  is the proper  one  for ail the  more
   powerful exercises either of mind or  body.  The corres-
   ponding  interval between the second and third  meal, is bet-
   ter spent in the gentler employments of both; and after the
   last meal, which should  be light,  the invalid can hardly  go
   to bed too soon.
       The objection to going to bed after too full a meal is, that
    the sleep will be disturbed,  and consequently less refreshing.
    Going to bed immediately, even after a light meal, in those
    unaccustomed to it, will  have  some degree of this effect, at.
    first, but this inconvenience will soon  cease.  However ar-
    tificial  our habits may be, the system is generally soon re-
    conciled  to a return to what is natural.   When four meals
    in the day are necessary, the interval between the first and 
 94             OF THE TREATMENT

 the last should be  divided into three,  instead of two equal
 parts.
   Under all circumstances of course, in regulating both di-
 et and exercise,  attention must be paid to the age and habits
 of the patient.   It is seldom  proper all at once  to attempt
 the correction of  the  most  injurious habits; the change
 should be made with caution and judgment.   This is  par-
 ticularly the case with respect to the use of fermented liquors
 and active exercise, because there are  no means that  more
 essentially influence the constitution; and were we suddenly
 to withdraw the  accustomed stimulants, or urge  to efforts
 beyond the strength, irreparable injury might  be  done.  The
 more advanced the  age, habits are corrected with the great-
 er difficulty, both because all habits are strengthened by con-
 tinuance, and because  the less vigorous the constitution is,
 it is the less able to bear the change.
   At advanced periods of  life, a  change of habits  must not
 only be  attempted  more  cautiously, but  it must not be at-
 tempted  in the same degree.  It is  to  be recollected,  that
 in old age repose is more necessary,  and exertions  of every
 kind less beneficial  and more apt to  be  injurious; and  that
 powerful stimulants are less hurtful, both because old age
 requires excitements more, and there is less space left for them
 to produce their pernicious effects.   Under  all circumstan-
 ces, however, and at all times of life, the principles which
 have been laid down must, I believe, be kept in view.
   Such are themeans of  preventing the re-application of
 the causes of Indigestion most apt to arise from the disease
 itself.  Some  others will occur  to the mind  of  every one
 conversant with the disease.  Frequent vomiting, diarrhoea
 and fits of constipation,  are among  the chief  of  these.  It
is  almost unnecessnry to say that they must  be corrected as
soon as the  circumstances of the case admit  of it.   The
means proper for these purposes  will appear in considering
what may be called  the medicinal part of the treatment. 
OF INDIGESTION.
93
Of tive Medicinal TYeatment in t\ve ftcst
             stage  of Indigestion.


  It appears, from what has been said of the nature of the
first stage of Indigestion, that it arises from the debility of
the muscular fibres and nervous influence of the stomach
and bowels. . While we are,  by a proper regulation of diet
and exercise, endeavoring to prevent every cause which may
increase their debility, it is  necessary, by the aids which
medicine affords, to endeavor more directly to restore .their
vigor.
  The medicinal treatment of this stage may be divided into
that indicated while the disease is  confined  to the stomach
and bowels,  and that which becomes necessary in conse-
quence of its having  spread  to other parts.
  But, besides the means which alone deserve the name of
curative, others to be regarded as preparatory, must occa-
sionally be employed.   To give the curative plan  the best
chance of success, it is not only necessary to remove the
remote causes and prevent their re application; but, as far
as we can, to remove the more immediate effects of these
causes, and thus bring the digestive organs into the circum-
stances most favorable to the operation of that plan.


          Of the YYe^arative Cleans.


  When we are consulted by those laboring under Indiges-
tion  we generally find the stomach and bowels loaded.  It
is necessary in  the first  place, to relieve them from some
part of this load, and, as far  as we can, to correct the proper-
ties of that which remains.   On this account we  frequently 
 yg              OF THE TREATMENT

 find it advisable to 'commence the treatment by an emetic,
 followed bv some mild aperient, It should be our endeavour
 by an attention to the proper  rules of diet,  to  prevent the
 necessity  of repeating the former of these ;  and the latter,
 we shall find, only makes part of the general plan, as far as
 it is necessary for the regular and free action of the bowels.
   An emetic, in the early stages of the disease, seems some-
 times beneficial by the excitement, as well as the evacuation,
 it occasions.   Its frequent repetition, however, is injurious.
 Frequent vomiting, we have  seen, ranked among the causes
 of the disease ; yet the temporary relief, obtained by eme-
 tics, not only often induces the  patient to repeat them, but
 has persuaded some physicians,  that the  cure of the disease
 may be attempted by them alone.
   If the first emetic, however, does not remove it, as some-
 times happens, when it is slight, and of  recent  occurrence,
 rather deserving the name of  disordered stomach than the
 disease  we are considering;  its repetition  generally  does
 more harm than good.   If emetics are repeated at all,  it
 should only be for the purpose  of removing  urgent symp-
 toms.   Their continued use  not only occasions a great de-
 gree of morbid  excitement, but inverts the natural action of
 the stomach, and frequently  of the first intestine also,  and
 consequently tends to debilitate both, and break the habit of
 their natural functions.
   When it appears that  offensive matter still exists in the
 stomach and bowels, after the operation  of the  emetic and
 aperient, Which may be known by a sense of oppression and
 distention of these cavities, and  by eructation  of wind  and
 ill-digested food, or  of an acid  matter which is sometimes
so acrid as almost  to excoriate  the  fauces ; we must, by
 gentle stimulants, particularly the distilled waters occasion-
ally mixed with a  small  proportion of some  aromatic tinc-
ture, endeavour to excite  them to  a better secretion ; and
at the same time, by the use of correctives, more directly to
 dter the morbid properties of their contents. 
                   OF INDIGESTION.                g7

   When  the eructations are  acid, the alkalis,  magnesia*
lime-water, and prepared chalk,  are the  best correctives.
If the foregoing symptoms are attended with much debility*
a cold surface, and sense of sinking, carbonate of ammonia
is the best.   When  the  bowels are too languid, magnesia,
which forms  an aperient salt, with the acid of the  first pas-
sages, may be used ; and when diarrhoea prevails, lime-water,
and the prepared chalk, which are astringents.  In this case
also,  combining the chalk with  some mucilaginous  sub-
stance, which defends the surface of the stomach and  bow-
els, as in the mistura cretse, is generally of use.  When none
of the latter symptoms prevail, the  fixed alkalis, particularly
soda, from its greater power, is the best antacid.
   Although  morbid acidity may be lessened,  it cannot be
wholly prevented by a diet consisting chiefly of animal food;
and I have repeatedly had occasion to observe, that when a
person is  wholly confined to animal food, the contents of the
stomach and the breath become very acid as soon as he be-
gins to feel disgusted with it;
   As the pains, which  arise from irritating  matter in the
stomach and bowels, proceed either directly from irritation
of  their surface, or from spasms excited by the  irritation;
they are generally  allayed  by the means just  pointed  out.
In  the latter case, which is distinguished by the severity
and intermitting nature of the  pain, unaccompanied by the
symptoms  which indicate inflammation, the aromatic  tinc-
tures  may occasionally be used in larger doses than would
be proper  in their habitual employment.
  If the foregoing means  fail, an opiate must be given, care
being taken by the subsequent exhibition of an aperient, to
counteract its constipating tendency.  The  exhibition of the
aperient with fhe opiate tends to prevent the effect  of  the
latter.
  Spasm of a more permanent  nature  seems sometimes to
attend and  oppose a powerful obstacle to the action of  the
                           O 
 98             OF THE TREATMENT
 bowels.  In such cases the  combination of an  opiate with
 the aperient,  seems often to promote  its operation.  The
 repetition of the opiate, under such circumstances, however,
 requires great circumspection.   It  may,  by  counteracting
 the peristaltic  motion  of the intestines, prove a more obsti-
 nate cause of constipation than the spasm  which it removes.
   When  the diarrhoea, excited by the irritating contents oi
 the  bowels, continues  after we have reason to  believe that
 its cause has been expelled ; mucilage of  acacia, with small
 doses of opium, or  if these alone do not succeed, combined
 with astringents, are the proper  means.
   When vomiting is obstinate, it is often  allayed by the  sa-
 line  draught taken in a state of  effervescence, or  a  mixture
 of sulphuric acid, conserve of roses,  and peppermint-water,
 carefully strained.   If these fail, the most effectual means,
 according  to my experience,  is a  pill,  composed of opium
 and  camphor, and blistering the region  of the stomach^.
   Such are the  means, by a judicious employment of which
the stomach and bowels are brought, as nearly as their de-
bilitated functions admit of, into the natural state ; the more
nearly this can  be  done, the better is the chance of relief
from the  means  v/e are  now to consider, namely, those
 which more directly tend to restore tone to  the stomach and
bowels.
  * When, in the second stage of Indigestion, along' with the vomiting",
there is considerable tenderness on pressure in the epigastrium,  the
means which take off the inflammatory action, particularly loss of blood
from the part, with subsequent blistering, are the  most effectual.
  In the affection of the stomach, called the water-brash, there is  a fre-
quent rejection, rather resembling eructation than vomiting, of a watery
fluid from the stomach.  I  cannot help agreeing in opinion with  Jtr
Cullen,  that this is a peculiar affection of the stomach, not depending on
the state of  that organ which produces the disease wc are considering,
It is not necessarily accompanied by .the symptoms of indigestion. 
OF  INDIGESTION.
99
Of the Treatment when the "Disease is con-
     fined to the Stomach and Sow els.


    We have seen that,  although the causes  of  Indigestion
seem, some to act  on the muscular fibres of the stomach,
and some on  its nerves, yet these powers are so connected
in  their functions,  that whatever debilitates  the one, in a
greater or less degree,  necessarily  affects the other.  We
shall find that a similar observation applies to the means of
relief.  Whatever tends to restore a healthy  nervous power
to the stomach, tends to form the food into  that substance
which is best fitted to excite  the  muscular fibres  of this
organ ;  and whatever  excites the  natural action of these
fibres, tends to relieve the nerves from  their load, and in
the most favorable way, to bring into contact with their ex-
tremities the food on which, through the intervention of the
gastric fluid, their powers are to be exerted.
  Although some of the remedies  seem to operate  more in
the one of these ways than in the  other, as I wish to avoid
nice distinctions, it  will be better to include  the whole un-
der one head, in  an inquiry respecting the  use  of tonic
remedies in  this disease; and I shall  attempt no other  di-
vision than the simple one of the  means which act directly
on the stomach and  bowels, and those which  influence them
through other parts.
  The former may be divided into two classes, those which
tend to excite, for the time, the particular function of these
organs, or allay the irritation  of  their nerves ; and those
which seem to act less by any immediate effect, than by be-
stowing on them some degree of permanent vigour.
  The medicines of one class have  been termed stimulants
and anodynes.  The most  powerful of the  other consist of 
 100           0F THK  TREATMENT
 bitters, astringents, and those medicines which tend  to sup-
 port a due activity of the bowels.
   I have already had occasion to observe, that simple dis-
 tilled spirits, and still more the aromatic tinctures, tend for
 the time to promote the action of the stomach ; and to warn
 against too free a use of them ; because the increased vigour
 thus procured, especially if they  have been  frequently re-
 peated,  is generally  succeeded  by corresponding debility.
 By  very small  doses of such medicines,  however, particu-
 larly when combined  with those whose effects are more per-
 manent, advantage  on the whole arises.   We find that bit-
 ters and astringents not  only  produce their  good effects
 more speedily,  but,  for the most part, more  permanently
 also, if combined with small doses of those medicines, which
 are more purely stimulant; and, indeed,  the action of the
 latter seems often necessary to enable the stomach  to  bear
 the former without oppression.
   Thus it has become an universal practice  to combine  a
 small quantity of distilled spirits  and aromatics, with other
 stomachic  medicines.   The quantity of distilled spirits  in
 such mixtures should always be small, a twelfth, at most an
 eighth, of the whole.  The choice of the aromatic is of less
 consequence ;  the properties of all are similar.  Some suit
 the stomach and the taste of  individuals better than others.
 There  is, upon the whole, however, some  difference in their
 properties.  Ginger  may  be used when cardamoms would
 heat too much, and cardamoms will  relieve  flatulence and
 spasmodic  pains,  when ginger would fail.
   Similar in their operation to this class  of  medicines are,
 ammonia and its carbonate, which have not,   perhaps  ob-
tained  all the attention they deserve in this disease.  They
are more apt to heat than aromatics, and,  in  the same pro-
portion, more beneficial  in that languor and coldness, which
 are often such prominent features of  Indigestion.  Their
 greater tendency to heat seems to arise from  their acting as
 a more general stimulant.   They  are more apt to strengthen 
                   OF  INDIGESTION.              101

and quicken the pulse, and, probably, act on the sanguifer-
ous system after they are  taken up  by the absorbents ; I
have found them decidedly serviceable when aromatics had
failed.  They are best adapted to those cases where a con-
tinuance of the  disease has  produced much debility, and
consequent languid circulation, without much tenderness of
the epigastrium, or hard pulse,  or any sensation of burning
in the hands or feet at. night.
   Cfimphor possesses some of the properties of ammonia in
a slighter degree.   Its sedative property renders the mistura
camphorse a good vehicle for  other medicines.
 • Among  the means of temporary  relief  in  Indigestion,
very warm water holds a higher place perhaps than is gen-
erally supposed.  To its frequent use we have seen there are
the same objections as to other powerful stimulants.   It de-
serves mentioning,  although it is difficult to explain  it,  that
a considerable degree of heat,  I  mean nearly as much as the
patient can bear without complaiut, applied extern dly to the
region of the  stomach is more effectual, provided it  be con-
tinued for a sufficient length of time, in relieving that kind
of pain of the stomach which  most frequently attends  Indi-
gestion, than any  application of heat we can make internal-
ly.   It is also frequently relieved by heat applied to the feet.
  Opium  belongs to  the head  of remedies employed for
temporary relief.    Large doses of this medicine have no
place in the treatment of Indigestion, except for the purpose
of relieving severe pain. The other symptoms are increased
by  them.   Very small doses, however, two or three miliums
of tincture  of  opium  for example, repeated two  or three
times a day, often prove highly serviceable in allaying  mor-
bid irritation, and their  constipating effect is generally easily
counteracted.   They sometimes indeed have  very  little of
this effect.
  I have found the pulvis ipecacuanha? compositus the  most
beneficial form in which small doses of opium can be given
in this disease.   From two to four grains of  this prepara- 
102           0F THE TREATMENT
tion, given every six or eight hours, appear to have a pecu-
liar effect in allaying the irritations attending Indigestion,
which probably arises from its action on the  skin.   It ap-
pears to be best adapted to those cases in which that combi-
nation of languor and  restlessness, often so  remarkable  in
this disease, prevails.   It is  better from  time  to time  to
discontinue and renew its use, than to exhibit it for a great
length of time, without interruption ; which, even when the
dose is very small,  is apt  to occasion some  confusion  or
other uneasiness of the head.
  The effect of opiates in Indigestion explains an observa-
tion sometimes made by dispeptics, that they find their din-
ner digested with less flatulence and acidity, when they  go
to sleep after it.  The composure produced by sleep, in some
degree, answers the purpose of the opiate.   In  many  dys-
peptics a small dose of opium,  taken after dinner,  gives
more relief, and, for the time, more effectually promotes di-
gestion,  than any other means.  It is almost  unnecessary  to
add, that the habit of having recourse to it for this purpose
would be very objectionable.  It is probably on account of
its anodyne quality, that lettuce, as I  have had occasion  to
observe  above, appears to be less indigestible than other raw
vegetables.
  In  considering the causes  of Indigestion, we have  seen
how readily the disease is increased by every  thing which
occasions morbid irritation of the nerves  of the stomach.
It is, in  a great degree, in this  way that the  undigested
contents  of a weak stomuch aggravate  the symptoms.   By
lessening the sensibility  of  the  nerves, and thus allaying
that irritation,  an opiate seems to check the progress of In-
digestion, as well as to render us less sensible  to the irrita-
ting matter already formed.
  The medicines called nervous are also often  useful in al-
laying irritation of the nerves in Indigestion, especially when
it chiefly  affects parts  at a distance  from the stomach.
Myrrh, camphor, castor, and valerian,  I have found most 
                    OF INDIGESTION.              10g

  beneficial, except when the disease inclines to hysteria, and
  then a combination  of some  of  these, and  asafcetida, is a
  means of temporary  relief, second, perhaps, to none  but ei-
  ther, which approaches too nearly to the nature of distilled
  spirits, to admit of its free and frequent employment. This
  class  of medicines, and  particularly the combination just
  mentioned, that especially of asafcetida  and castor,  seldom
  fail to give relief in palpitation arising  from Indigestion, if
  no inflammatory disposition have supervened.   It also,  in
  general, gives more  or less temporary relief to the dyspnoea,
  which we have found sometimes so obstinate a symptom of
*  this disease.  Of  the various medicines of this class, how-
  ever, those best suited to some cases are not always most
  effectual in others ; and when such as are on the whole most
  successful fail, others  often succeed.
     But it is of much less consequence to give relief in fits of
  Indigestion than to  prevent their recurrence.  We are now
  to inquire how far medicine can assist the due regulation of
   diet and exercise  in effecting this object.
     The small doses of opium which I have just had occasion
   to mention, are calculated to effect more than temporary re-
 lief in Indigestion.   I have  found them, or rather  still
   smaller doses, one or two grains, for example, of the pulvis
   ipecacuanha? compositus, of  essential  use,  combined with
   the  medicines we are  about to consider.
     It has already been observed, that  of the tonics whose
   effect is most permanent, bitters and  astringents are those
   on which we chiefly rely,* and that their effect is increased
   by combining them with small doses of some of the stimu-
   lants we have been considering.
     Bitters have been long known to possess a power of in-
   vigorating the digestive organs.  There is a great variety
   of them, but I believe they may all be divided  into simple
   bitters, and those which  at the same time possess a  stimula-
   ting quality.  Of those in common use, camomile, bitter
   %r,ange-peel, and wormwood, seem to be the most free from
4 
 104l            OF THE TREATMENT

this quality*.  Calumba possesses  it  in  a greater  degree"
than gentian and cascarilla,  and  the  Peruvian baik  in a
greater degree than any other.   1 speak not at present of
the ^stringency of  the  last, which  renders it a medicine of
different properties.  It is particularly to  be observed that
the stimulant property of bitters, although less immediately
powerful, is  of a more permanent nature  than that of the
stimulants which we have been considering ;  and the latter
may often be used for the purpose of occasional relief, when
the inflammatory tendency  is too great to admit of the more
permanent stimulant.
   All  the foregoing bitters, if we except the bark, which is   •
often oppressive to the stomach, are well  suited to the first
stage of Indigestion ; but in proportion as the  second stage
approaches, we find the less stimulating bitters answer bet-
ter ; and  in  this stage, even the  gentian,  which,  of those
that deserve  the name of stimulating, possesses, perhaps, the
least of this property, is often too heating, and the bark in
general cannot be borne, even for a few days;  while in the
earliest periods of the disease, when it supervenes on debili-
tated states of the constitution, and the stomach still  retains
considerable  comparative vigour, a cold infusion of the bark^
is often the most beneficial of all bitters. It has by many been
banished from  the  treatment of Indigestion, but this, I  be-
lieve, has  arisen from its having  been employed indiscrimi-
nately  in all cases and periods of the disease.
   It is remarkable that certain stomachs cannot  bear any
species of bitter.   I have known some who constantly suffer
from even a  few spoonfuls of camomile tea ; so that in them
we are wholly precluded from the use of this class  of medi-
cines.
  * By stimulating quality of bitters, I mean the power by which  some
of them increase the force of the circulation, and consequently are ren-
dered improper where the inflammatory diathesis prevails  It seems not
to be generally known, that this property bears little relation to the
quantity of "essential oil which they contain. 
                   OF INDIGESTION.              ^0«

   Many object to the long-continued use of bitters and aro-
matics.  There are strong objections to the long-continued
use of every medicine.   If it is one of great  power, it ex-
hausts the strength ; if not, it seems to become almost wholly
inert.   When the disease is obstinate,  it is  better, after a
certain degree of relief is obtained, to discontinue  such
medicines, and, sooner or later, recu* to them, as the symp-
toms  may require.
   I believe, however, the apprehensions  from their  long-
continued use have chiefly arisen from  their effects in gouty
cases.  It prevents the regular returns of this disease, as has
been proved by the effects of what was called the  Portland
Powder, and some other specifics •. but  it appears, I think,
from  the facts stated in the last Chapter, thatthe bad effects
which ensue should rather be ascribed to the prevention  of
the regular gout,  than any direct operation of the medicine.
The same effects follow, when the  return of  regular fits  is
prevented merely by applications to  the joints, which we
know, independently of this consequence, could have no se-
rious  effect.
   Astringents are less generally adapted to cases of Indiges-
tion than bitters, on account of their tendency to increase the
inactivity of the bowels, which so generally prevails in this
disease.  Some of them, however, are medicines  of such
value, that we often find it advisable to  employ them, al-
though at the expense of correcting this  effect.  Nor are
they in all cases equally apt to produce it.
   All vegetable astringents seem to fc:;ve more or less tonic
effect  on the stomach, as well as on other parts of the  sys-
tem ;  and  to this we must,  in  some degree, ascribe the
good effects of the bark in the cases above pointed out; but
the mineral kingdom affords the  most beneficial medicines
of this description.  Of these, iron deserves  the first place.
In chlorotic Indigestion, combined with stimulants, it is the
most powerful medicine  we. possess,  because  it is the most 
 106               OF  THE TREATMENT
 powerful in removing the obstruction whence the  Indiges*
 tiOn by sympathy arises, so that in this case it belongs rather
 to the cluss of remedies which we are next to consider ; but
 there are few cases of Indigestion in  which it  is not found
 more or less useful at an early period, if no tendency to the
 second stage of the disease has shewn itself.   Its good effects
 are increased by  combining it with bitters  and aromatics;
 and,  in  idiopathic Indigestion,  the carbonate has appeared
 to me its best preparation, provided it can be taken in rather
 large doses, without oppressing the stomach.
   Next  to  iron,  the  sulphuric  acid seems to be the best
 stomachic astringent, and it may  be used in later stages of
 the disease than iron.  It is particularly serviceable in  those
 cases,  where sweating, which is not  unusual, is too easily
 induced  by  exercise; for much tendency to  sweating  indi-
 cates relaxation, not vigour  of the skin.   It appears  from
 the experiments relating to the circumstances which influ-
ence the state of the urine, above  referred to, that the saline
 matter, secreted  by the skin, is not so certainly thrown off
 even  by profuse  sweating, as by  a free insensible perspira-
 tion.
  In the  opinion  of many, the sulphate of zinc  given  in
 very small doses, also holds a distinguished place among
 the astringents  suited to Indigestion.  It may be  given at
later periods than iron, but it requires caution; and  if  its
 good effects do not soon appear, should be laid aside.  It is
one of those powerful agents, which  must always  be em-
 ployed with some degre^ of  suspicion.
  Other  medicines  beside bitters and astringents,  seem to
act in a similar way on the alimentary canal.   All the mine-
 ral acids possess more or less of a tonic  power.  The white
 oxide of bismuth has lately been much celebrated.   It seems
 best adapted to those c?.ses in which there is frequent recur-
 rence of pain referred to  the stomach.
  To enumerate r.ll the medicines which have been employed
 with  a view to  restore  vigour to the stomach and bowels 
                   OF INDIGESTION.               107

would be a difficult task,  and not a very  useful one ; for
few, with the  exception  of the foregoing,  possess much
power.   The  acrid  vegetables, particularly horse-radish
and mustard-seed, are indicated in the same cases in which
ammonia and aromatics are most beneficial.   Their infusion
often forms a good vehicle for ammonia and its carbonate.
  Sarsaparilla appears to me to hold a much higher place
among  the  remedies of this  disease than is generally sup-
posed, but it is not to its early stages that it  is best suited,
and  from its mucilaginous property, it is apt to oppress the
stomach.   It is in protracted cases, where general languor
of the secreting surfaces  has become  permanent,  and the
stomach is  consequently in some degree relieved, that it  is
most useful.   I shall have occasion to make some observa-
tions upon  it in speaking of such cases.
  It has become common to employ mercury in some  form
or other in all cases of Indigestion;  but, I believe its use is
always injurious in the  period of the disease we are now
considering; that  is, while  the  derangement is confined to
the alimentary canal.  I  shall have  occasion to treat fully
of what appears to me the  proper  use of  this medicine in
the other stages of the disease.   Instances have frequently
occurred, in which the disease seemed to be confirmed  by
its  unnecessary and improper employment.  I believe we
may say, without  hesitation, that it  is never to  be used in
any  stage for the mere purposes of an aperient.
  The proper use of aperients is a subject of great impor-
tance at all periods, and in all states of Indigestion.  In the
period under consideration, their object is merely to support
a regular  action of the bowels, which as  the secretions of
the  whole  canal  are inclined to  fail, and  the stomach and
upper bowels do not discharge their contents so readily as
they ought to do, should  be rather freer than in  health.  It
often has an  excellent effect to combine  bitters with gentle
aperients in the early stages of the disease.   Epsom  salts
are frequently employed in  this  way with great  advantage. 
 108            OF THE TREATMENT

 If they are too cold, or occasion too  watery a discharge,
 small doses of sulphate of potash and rhubarb often answer
 better.                       ,
   Different aperients suit different constitutions.  I have
 found none employed merely for the purpose of supporting
 a regular action of the bowels, so generally  useful as  pills
 composed of ipecacuanha, compound extract of colocynth,
 and soap, with the addition  of a little  gamboge, when  they
 are not sufficiently active, occasionally taken at bed-time.
 In many  senna has  appeared to me  a medicine  of great
 value.   It seems more directly to promote digestion, at the
 same time that it excites the  bowels;  a property also of the
 pills just  mentioned.
   With  respect to those remedies which act on other parts,
 and  only by sympathy influence  the" alimentary canal,  the
 most powerful and,  indeed, the only ones  which appear to
 have much effect, are such as make their impression on the
 uterus and the skin.  I have already had occasion to mention
 one'of the most powerful of the means tending to restore the
 functions of the uterus.  All this class of course are beneficial
 in Indigestion, as far  as it depends on a failure  of those
 functions.  With respect to  the  means which  make  their
 impression on the skin, the cold  bath, where there is con-
siderable general vigour, and the  warm salt bath in almost
all cases, the  shower bath, particularly where there is  too
much determination of the blood to the head, and spunging
 the body with salt water, or water and vinegar, especially
when this practice is followed by friction  of some continu-
 ance, often aid other means, and sometimes.appear to  be
 powerful  remedies.   Among these means might also  be
 ranked blistering the epigastric  region, were not so severe
 a remedy hardly allowable in  the earlier periods of the dis-
 ease, where gentler means generally succeed.   Covering the
 epigastric region with stimulating and anodyne  plasters is
 sometimes of use. 
                  OF INDIGESTION.              10U
  The gastric fiui<* of other aninvds has been proposed as a
remedy  in Indigestion. . If the vi-vv which has been taker.
of this disease be correct, it could answer no other purpose
but that of temporary relief.  1 have known the inspissated
bile  of  the ox used as a cathartic in  Indigestion with good
effect.  It appears to  deserve attention,  particularly in  the
state  of the disease  we are now to consider.


Of the  Treatment  w\\en the disease  A\as
   s\vreaa; fvtfthei!  than the Stomach  and
   lionets.

   It is .observed in the first Chapter, that,  sooner or later
after the first symptoms of this disease have  shewn them-
selves,  the  alvine discharge begins  to deviate from  the
healthy state ; in different cases, and sometimes in the same
case at  different times, assuming various appearances.   The
treatment then becomes more complicated.
   When the alvine discharge assumes an unnatural colour,
we  may  be assured  that the disease has spread further
than the alimentary canal.  The secreting power of the liver,
and, probably of the  pancreas, partakes  of it.   As  these
organs  pour their secretions into the  first intestine, the state
of which  seems greatly  to influence the symptoms  of  the
different stages of Indigestion, they  immediately  affect the
 greater part of the canal, and, by sympathy,  greatly influence
 the state of the stomach.  From the  size, structure, and po-
 sition of the duodenum, it is evidently the  intention of  na-
 ture to  detain its contents for some time, that they may be
 intimately mixed with those secretions;  and we have reason
 to believe, that the process which takes place in this intes-
 tine, is essential to the due formation of chyle.  The bene-
 ficial effect of purgatives in Indigestion seems greatly to de-
 pend on their assisting its motions.  It appears,  from  the 
 HO           OF  THE TREATMENT
 enumeration of the symptoms, that they aTe much influenced
 by the state of the duodenum;  and I have,  from several
 cases, had reason  to believe, that  the  peculiarly beneficial
 effects which  I have witnessed from the senna in  Indiges-
 tion, arise from its being well fitted to  promote the action
 of this intestine.   It has appeared  more  effectually  to  re-
 move the fulness of  the right hypochondrium, when it de-
 pends on  morbid distention of the duodenum, than any other
 medicine equally mild in its operation.
   The change in the appearance of  the  alvine discharge,
 we have  seen, occurs at Various  periods  of the disease ; in
 some cases,  almost as soon as the symptoms of Indigestion
 begin to  attract notice;  so that it is difficult to say, except
 from  considering  the nature  of the  remote causes, where
 the disease  originated.   It is more common,  however, for
 it to take  place after  various symptoms  of disordered diges-
 tion have lasted for  some weeks,  and  the slighter  symp-
 toms, we  have seen,  may continue for years  without any
 material alteration in the appearance  of this discharge.
   Of the  particular state of the pancreatic fluid, we have no
 means of  judging.   The alvine discharge,  it appears from
 what  was said above, generally owes its colour to the bile.
 By the degree of colour, therefore, we may judge  of the
 quantity of bile poured into the intestines, and by  its  hue
 of the state of this fluid.   An admixture of blood, when it
flows from a high part of the canal, so that it is mixed with
the other contents,  and has had time to assume a dark co-
lour, before  it is discharged,  sometimes  gives to the  dis-
charge an appearance similar to that given by certain states
of the bile.  They may be distinguished, however, by dilu-
tion with  water; if the  change  of colour arise from  bile, a
greenish  or  yellowish  shade  will  be produced;  if from
blood, a dark brown one.
  When the change  in  the alvine  discharge  takes  place,
then,  we  are  assured,  that in addition to the original  dis-
ease, we have to contend with derangement in the  function 
                   OF INDIGESTION.              41i

bf the  liver.   The  case is now not only more complicated,
but more difficult  of  cure ;  the diseased action of parts
which sympathize,  while there is no degree of structural de-
rangement tending  to confirm each other.
  The  principle  of the  treatment is to combine with the
means, which tend to restore vigour to the alimentary canal,
which we have just been  considering, those  which correct
the morbid state of the  liver.   It is  generally  admitted
that we possess no  medicine of equal  power with mercury
in correcting the morbid states of this  organ, but it unfortu-
nately happens that its continued use  is generally injurious
to other organs, and particularly to the stomach and bowels;
and the  chief object to be kept in view in  its employment
in this stage of  Indigestion is, so to manage its exhibition,
that it shall produce the desired effect on the liver, with as
little injury as possible to other parts of the system.
  The first observation which presents itself on the employ-
ment of mercury at this period of the disease is, that  it is
not to be so given as to  be received  into  the  circulating
system.   Mercury, when thus introduced, has the property
of more or less exciting all the secreting surfaces, but their
excitement is supported by it at great expense to the con-
stitution,  and when long continued, seldom fails to impair
its powers.  No practice  can be   worse than that which
unnecessarily risks  this effect.  In  the  first stage of Indi-
gestion, there  is no occasion  to  clSnge  by  such powerful
means the state of the general habif*to  which the diseased
action  has  but  imperfectly  extended, and in  which it is
still so purely sympathetic, that it  immediately  disappears
as soon as the disease of the central parts is removed; and
experience has amply proved, that the  deranged action  of
the liver can, in consequence of the sympathy which exists
between this organ  and the alimentary canal, be corrected by
the local effect alone of the mercury on the latter.
   Another observation of importance respecting the use of
mercury at this period is, that its long-continued use is 
  112            OF THE TREATMENT
 seldom necessary.  The practice of  giving  it every second
 day, or tv-cii d oly, and almost indiscriminately, in cases of
 Indigestion for a considerable length of time without at-
 tending to  the state of the alvine discharge, although its re-
 ception into the system be prevented by the regular use of
 pu.^iuives, is, as far as I can judge, in opposition to every
 thing which we  know of the nature of the disease, and the
 effects of this medirine.
   What are the  effects which  we expect  from the  use  of
 mercury, in  the first stage of Indigestion after  a healthy
 secretion of bile  is restored, which  is often effected by two
 or three doses, sometimes by one ?   h is true that a recur-
 rence to  it is generally  necessary, but in the first instance
• we should 'wait till we see whether this necessity will be in-
 dicated by a return of the morbid state of the  bile.   The
 effect of  its  first exhibition  is more or  less permanent in
 different cases, and the most favourable cases, when we have
 obtained a healthy flow of bile, yield to the other means we
 have been considering.
   In the more obstinate cases, indeed, where the disordered
 state of the liver constantly recurs at short intervals,  it  is
 better for a certain time to give a moderate dose at stated
 intervals,  by which the alimentary canal will suffer less, as a
 smaller dose is  required for  the prevention of this state
 than for its  removal.   Biit even in these cases, this practice
 should not  be long purfued, without trying from time to
 time how far  the powers of the constitution are sufficient
 without its aid.   By these means we ascertain the  extent
 to which it  is necessary to carry the  use  of this medicine.
   The form in which it  should be exhibited is  also a point
 of great importance.  It ought never, we may safely affirm,
 in the case  before us, to be used externally ; for we have
 no reason to believe, that its action on the skin  can materi-
 ally  affect the liver by sympathy ; and we often  find that,
 when exhibited in this way, it  produces little effect on  that
 organ, till the state of the gums shows its presence in the
• 
                   OF INDIGESTION.              113

constitution, which  I have already had occasion to observe,
is at this period unnecessary.
  All that is here wanted is something that may speedily
correct the disordered function of the liver.  To produce
this  effect quickly,  without being more generally applied
to the  system than is necessary, mercury must be given
internally.   The sympathetic effect on the  liver,  during its
passage through the alimentary canal, we have seen, is suffi-
cient for the purpose.
  There are two forms in which it is usually given, calomel
and  blue  pill.  The former being the  most aperient, it is  a
good general rule to give it when the bowels are most lan-
guid," and the blue  pill when they are more easily excited.
But  this is not the only property in which these preparations
differ.   The blue pill is  generally most  oppressive  to  the
stomach; the calomel most irritating to  the  bowels; al-
though in some  cases, I  have seen the former, in very deli-
cate subjects, from  its being less cathartic, and consequently,
for a longer time, hanging  about the bowels, if I may use
the expression, more irritating than calomel.
  For the same reason,  small  doses of calomel, a quarter,
or half a grain, are often more irritating than two or three
grains, which more quickly pass off;  and the  irritation of
the bowels is most  effectually prevented  by taking an open-
ing  draught some hours  afcer the calomel.   With most
people, this is not necessary when the blue pill  is taken^
its continuance in the bowels generally giving  less  uneasi-
ness.
   From these properties of the two preparations, the reader^
will readily perceive the circumstances which should influ-
ence our choice of them.   In the most  recent cases, calo-
mel taken at night, and  carried off by an aperient draught
in the morning, generally  answers best.    Here  we want
only the most transitory  action of the medicine.
                           Q 
 H4,            OF  THE  TREATMENT
   On  the other hand, when the disease has lasted longer?1
 or the firsf few doses of calomel have failed  to produce a
 permanent flow of healthy  bile,  we feel the necessity of em-
 ploying a preparation which may remain longer in the ali-
 mentary canal with less irritation than calomel would pro-
 duce were it  retained there.
   Hence  the  great success which often attends giving four
 or five grains of the  blue pill  every second or third night,
 as recommended  by Mr.-Aberntthy,  particularly in  those
 cases where the affection of the  liver has supervened early,
 and where, consequently, it  is  the principal  cause  which
 supports and  aggravates  the disease.   This observation, it
 is evident, applies  with still greater force,  when it is the
 original disease, and the alimentary canal suffers  oiily by
 sympathy and the irritation of the vitiated secretion of the
liver.  It is always to be recollected, however, that in  Indi-
gestion it is  an  unhealthy  secretion  of bile  alone which
renders mercury necessary in the  first stage, that the  time
 in which  it produces the  necessary  effect  is  different  in
different cases, and  that all that is taken after this is inju-
rious.
   In some, the blue  pill is so oppressive, that I have seen
several  who  could not take  it even in much smaller do-
ses*.  To  them  it  is  necessary  to  give small  doses  of
calomel, and if it irritates, to combine it with anodynes.
   It nlso deserves particular attention in the choice of  these
means, that the most beneficial  use of calomel necessarily
occasions brisk purging,  on which the benefit derived  from
it often greatly depends ; while,  by its peculiar  effect on the
first passages, it excites a better action of the liver; by  its

  * It is remarkable that the  blue pill is so offensive to some constitu-
tions, that I have seen several instances, in which it disordered the se-
cretion of bile, even when it was healthy at the time of  its exhibition ;
and in such cases, as far as I have observed, the disordered state of the
 bile continues as long as  it is used.  This effect is similar to that which
 we sometimes observe from repeated doses of calomel in children. 
                   OF  INDIGESTION.              ng

purgative effect, as well as by that of the draught  which
its exhibition renders expedient, it tends further to emulge
the gall-ducts, and relieve the distended state of the liver.
   Its operation then is  most wanted  where  this distention
is greatest,  which  may be known, we have seen, by  the
state of the right hypocnondrium, and will be least injuri-
ous where the strength is most able to bear so considerable
a call upon  it.   When there is little distention of the liver,
and the strength is much reduced, the operation of the blue
pill, provided it agrees tolerably well with the stomach, is
preferable.   The relief obtained from it may be less speedy,
but it will be obtained at less expense to the constitution.
Instances frequently occur of the  bad effects of not attend-
ing to this distinction.   What  is  only  a salutary evacua-
tion in one case, is an overpowering cause  of  debility in
another.
   Where the symptoms  are  rather  obstinate than severe,
and where they yield readily, but  continually show  a ten-
dency to return; covering the  parts, to which the tender-
ness and fulness  have extended,  with a warm mercurial
plaster, often, in the former instances, tends to remove the
disease ; and in the latter, to prevent its recurrence.  I have
known such a plaster worn for  months, and  even years, the
symptoms constantly recurring  when it was  laid aside.
   When  mercury  occasions much irritation of the bowels,
its  continued use  brings on a degree of  the  dysentary.
Calomel, we have seen is most irritating, it is, therefore,
most apt to produce this  effect.  The patient is tormented
with griping and tenesmus, and at length passes little more
than mucus, often mixed with  a  small quantity of blood.
If, in such cases, we increase the dose of mercury,  in  hopes
of freer  evacuations,  we only  increase the  evil.  Discon-
tinuing its use  for a little is the best remedy  ; and  when we
find, as sometimes happens in such cases, that on returning
to it  the same symptoms constantly  recur,  and  cannot be
prevented by  changing  the  preparation,  or the use of 
116             OF THE TREATMENT

anodynes and  mucilages, it must for the  time be laid
aside.
  Both because mercury seldom  produces the  effect  here
mentioned, except when its use has been continued for some
time, and because the effect  is most apt to ensue when  the
bowels have been long exposed to 9thtr causes of irritation ;
we less frequently have to contend  with it in the first stage
of Indigestion,  which is the more fortunate, because the few
substitutes for this medicine, which we possess, are less suited
to the early than  the more advanced stages, in which it ap-
pears from what is said above, the  disease is not only es-
sentially altered in its nature, but affects the system  more
generally.
  Some  of  the mineral acids are  the best substitutes for
mercury.   A combination of the muriatic  and  nitric acids
has appeared to me  the  most  successful, whether  taken
internally or  used externally  in the way  recommended by
Dr. Scott.
  This  class of medicines are otherwise useful,  we have
seen, in the first stage of Indigestion ; and if they maintain
a due action  of the liver, there is no occasion for the use of
mercury.   They seldom,  however, have this effect for any
length of time  when  its action has once been disordered  ;
and they are much less calculated than mercury  for quickly
restoring it,  and hardly at all for suddenly  emulging  the
biliary ducts, the effects which we look for  from mercury
in the first stage of Indigestion.   I shall have occasion to
make some further observations  on the use of the  mineral
acids,  in speaking of the treatment of the second stage.
  In some cases we shall find the dandelion an  assistant to
mercury, and under certain circumstances  capable of  being
substituted for it.  It is defective in the  same respects  as
the acids, and has the  additional  disadvantage of often be-
ing oppressive  to the  stomach in considerable  doses, and
in small doses it is of little or no use. 
                 OF INDIGESTION.               117

  From a  want of attention  to the circumstances under
which medicines should be  employed, many fall into dis-
repute, which are capable  of excellent  effects  when  used
more judiciously.  We are too apt to fall into  the practice
of viewing a certain set of medicines as calculated to remove
a certain disease, and, as one fails, to use another, without
much attention  to the  properties peculiar to each, or the
circumstances of the disease to which these peculiar proper-
ties are adapted.   If we have recourse to the  acids or the
dandelion,  wherever mercury does not afford the usu;d re-
lief, we shall often be  disappointed.   If we  employ them in
the cases I shall soon have occasion to point out,  they will
seldom, as  far as experience enables me to judge, fail to  be
useful.
   The treatment of the first stage of Indigestion, then, con-
sists in promoting the due  action of the stomach and bow-
els, by the various means  which have been detailed ; and
correcting  the secretion of the liver, if it deviates from the
healthy state,  by the  occasional use of mercury, care being
taken neither to employ it in greater quantity, nor for a
longer time, than is necessary for this purpose, as its effects
on the stomach and bowels are evidently in opposition  to
the other parts of the treatment.


                      SECTION II.

 Of the Treatment of the Second Stage  of
                   Indigestion.

    It  appears  from what was said  of the symptoms of  In-
 digestion, that they are liable,  after the disease has  lasted
 some time, to undergo a considerable change; the epigas-
 trium  becoming  tender  on pressure,  the pulse hard, and
 some tendency to fever supervening. These symptoms char-
 acterize what I have called the second  stage of the disease. 
 U8          OF THE  TREATMENT
   The period at which this change happens, we have seen,
 is nearly as various as that at which the deranged function
 of the liver shews itself,  which it sometimes accompanies
 from its first appearance, but  hardly  ever precedes.   In
 most cases, the above symptoms do not supervene  till  the
 function  of this organ  has been disordered for some time,
 or its  disordered  state has repeatedly  occurred.   It  may
 also be observed, that, like the disordered state of that func-
 tion, they are apt to come and  go for some  time  before
 they are  established.   This  is true, even of the tenderness
 in the epigastrium.  On one day it shall be  considerable,
 and, even on the next, without the use of medicine, it shall
 have  disappeared.  In most cases, however, it is more sta-
 tionary from the  first,  and,  if the disease  lasts, it always
 becomes so.
   As soon as the symptoms characterizing the second stage
 are established, we find that bitters and aromatics cease to
 give any effectual relief; and in many cases, the most stim-
 ulating in particular, increase the feverish restlessness that
 occasionally assails the  patient, and that languor and unea-
 siness which seldom wholly leave him.  If, in consequence
 of his increasing complaints  of debility, his medicines  are
 changed  for others of  a  more  strengthening nature,  the
 effects are still worse;  and he often thinks that his  disease
 admits of no  relief, but  from aperients, and particularly
 mercurial aperients, of the good effects of which he  is  al-
 ways sensible, and, consequently, is very apt to  fall into an
 excessive use  of them : and many medical men appear  to
have arrived at nearly the same conclusion, for it is not un-
usual to find them declaring, that they see little good done
in such cases except by purgatives and  mercurials, a prin-
 ciple which has sometimes been applied even to the earlier
stages.
  Unless I have been deceived by a pretty extensive expe-
rience of the  phenomena of  this disease, there  is no stage
of it to which this conclusion is applicable.   We have seen 
                   OF INDIGESTION,              lig

 that  purgatives  and mercurials,  properly  employed, are
 valuable medicines in the first stage.   We shall also find
 them so in that we are about to consider.   But  in  both
 they are only part of the means, and, if employed  too free-
 ly, and to the  neglect of others, will  in all cases do mis-
 chief.
   The inflammatory symptom^ of the second stage of Indi-
 gestion, led me  to adopt a practice founded on them, and
 the immediate relief obtained confirmed the views which had
 suggested it.
   The stimulating plan, which is proper while the fault is
 in the muscular and nervous powers of the stomach  alone,
 is no longer applicable.  The  disease,  however, still so
 far partakes of its original nature, that, were we to regulate
 the treatment  by  an attention to  the  inflammatory symp-
 toms alone, the powers of the system would soon sink un-
 der it.
   The more powerful anti-inflammatory  measures, there-
 fore, a very low diet,  general blood-letting, &c, are rarely
 proper,  unless,  as sometimes happens,  the inflammatory
symptoms increase to  those of active  inflammation.  The
disease is then  of a different nature,  and must be treated
on  the  same  principles,  although with  more than usual
caution, as other phlegmasiae.  The less stimulating of the
tonic means employed in  the first stage, on the other hand,
 are still indicated ; the extent to which the one or other set
of means should be carried, being regulated by the greater
 or less degree of the inflammatory tendency.
   In two other respects,  the principles of the treatment in
 the first and second stages of Indigestion differ.   In the
enumeration of their symptoms, we have seen, that although
 various other functions suffer more or less by sympathy with
those of the digestive organs, almost from the  commence-
 ment of the disease ; it is in the  second  stage, both  from
the longer continuance of the  derangement  of the  central
 parts, and from the greater  severity and more complicated 
 Iso             OF THE TREATMENT
nature of that derangement,  that they suffer most.  Their
affections, therefore, here influence  the  indications of  < tire
more  than  in the first stage ; and as the strength is  more
impaired in the second stage, while the means of relief, at
the same time, are  of a more debilitating  nature ; an uni-
form endeavour to preserve, as much as possible, that which
remains is  here  more indispensable.  Evacuations, which,
while the vigour of the system  is comparatively  entire, and
the patient can be supported by stimulating diet and medi-
cines,  have the best effects ;  at  a  later period, and where
less stimulating means alone are applicable, may be attended
with serious injury.  The system not  rallying now, as  in
the first stage, the  effect of one debilitating measure is still
felt, when we  are called  upon for another;  and,  if our
plans  are not regulated with caution, and so directed  as  at
no great  distance of time  to restore the proper  functions,
and thus render a continuance of  such measures  unnecessa-
ry, the patient sinks equally under his  disease and the means
employed to relieve it.
  Such then are the principles on which, as far as I am ca-
pable  of  judging from  repeated experience of the various
plans  which have been pursued in  this  disease,  the proper
treatment of the second stage is founded.  An inflamma-
tory tendency  is superadded to the derangements which
constitute the first stage ;  stimulating  measures  are there-
fore to be employed with more  caution,  and anti-inflamma-
tory measures become  more  6r*ess  necessary.   The dis-
eased action has spread farther, and the strength  is more re-
duced; our measures must therefore  embrace a  wider  field
of practice, and the strength must be husbanded with greater
care.
  We are now to consider more in  detail the means, to the
employment of which these principles  lead.   I shall, in  the
first place, lay before the reader that  part of the treatment,
which forms the characteristic  difference between it, and
that we have been considering;  and  then point out how those 
                   OF INDIGESTION.              lgl

 means, which are common to both stages, should be modi^
 fied in the one before us.  We  shall next  consider such
 additional  means  as do  not belong to the treatment of the
 first stage, but cannot, like the anti-inflammatory means, be
 regarded as in opposition to the plans there  pursued ; and
 in the last  place, take a  view of the treatment of the sym-
 pathetic  affections which attend  the second stage,  and  re-
 quire means directed to the organs  they affect.   These we
 have seen  immediately  lead to change  of  structure, and
 may, therefore, be  regarded as the  link, which connects the
 second and third stages of this  varied disease.
   The first thing, which appeared to me to throw much light
 on the nature and treatment of the  second stage  of Indiges-
 tion, was the effect of applying leeches to the tender part of
 the epigastrium.  It was not, I found, merely that the ten-
 derness was relieved, and the pulse softened ;  but that the
 patient breathed and walked better,  that  the  bowels  were
 more  easily moved,  and the skin appeared  more relaxed,
 the feverish tendency which frequently shews itself in  the
 evening,  being in the same degree  lessened.
   From  these observations it appeared, that the effect of the
 leeches was not that of mitigating any particular symptoms,
 but of relieving  the cause of the whole ; because it is only
 on this supposition that such general relief could be afforded.
   But even these, I found, were not the whole effect of the
 local, blood-letting.   On resuming the plan of treatment, it
 soon appeared, that the patient bore the use of tonics much
 better than before ;  and in some instances, a recurrence to
 the treatment of- the first stage, under such circumstances,
 removed the  disease.  It seemed  to have been the slight
inflammatory action, which the leeches relieved, that alone
had prevented the beneficial effects of these means.   I have
 thus had  many opportunities of seeing the patient, after the
 use of the leeches, quickly restored to health by a plan, little
different  from that which had previously  been employed in
vain, and sometimes with an aggravation  of the symptoms.
                          R 
m
OF  THE TREATMENT
   But so  fortunate an issue, I soon found, was only to be
expected where the second stage had been of very short du-
ration, or the constitution was particularly favourable.   On
the tonic plan being resumed, the tenderness of the epigas-
trium  was generally soon renewed, and a repetition of the
leeches became necessary.  Each  repetition  to the same
extent generally, produced  less relief than the preceding,
and  if a larger quantity of blood was taken, the relief was
obtained at too great an expense of strfhgth.
   The application of a blister  to the part from which the
blood was taken, immediately after its abstraction, tended
both  to increase the effect  of the  leeches,  and render it
more permanent; but, even with this aid,  their repetition
in the more inflammatory cases soon became necessary.  In
those  less inflammatory, blisters  sometimes  relieved the
symptoms  without the aid of leeches,  but like the leeches
they often failed to give permanent relief.
   Other measures, therefore, were  requisite.  The  first
that occurred was to abandon, in such  cases, the more stim-
ulating  parts  of the  treatment, and  although  the patient
generally  felt a degree  of sinking  and debility from this
change,  particularly  if made too suddenly;  these  symp-
toms were less  permanent than when  repeated bleedings
were employed, and  the constitution  gradually accommo-
dated itself to the change.
   The lighter bitters and those stimulants whose effects, are
comparatively more exerted on the nervous than the  san-
guiferous system, could in general still be borne.  Among
many  hundreds,  I have seen but few who could not  bear
the occasional, though not the regular use of aromatics,  or
even of ammonia and  some of its preparations;  and all could
take the infusion of camomile flowers or bitter orange-peel,
with the exception of  those whose peculiarity of constitution
did  not admit of the use  of bitters at any  time: and  with
regard to diet, although in the more  confirmed cases few
could  bear well the most stimulating  kinds of meat,  par- 
OF INDIGESTION.
123
ricuiarly beef, a little chicken  daily, or once in two days,
was generally borne without inconvenience, and supported
the strength more, and agreed  better with the stomach, than
a diet composed wholly of vegetable food.
   Nor have  I found  it  necessary  in  such cases wholly to
abstain  from the  use of wine, although  it has generally
been adviseable  to lessen  its quantity, and often to take it
diluted.   It  is seldom, I believe, proper to reduce  the diet
more than this, unless  active  inflammation be threatened.
In a few, particularly when a  considerable degree of hard-
ness of  pulse, notwithstanding the use of the above means,
continued, I have seen a diet wholly vegetable and even a
total abstinence  from wine, which is much less permanently
stimulating than animal food, strikingly  beneficial.   It is
common for  the appetite  to improve on lessening the quan-
tity of animal food.   This depends in part on other food
affording a less proportion of nourishment, but very much,
I believe on the tendency  to  fever being  lessened by the
change.
  The state of the bowels in such cases is often influenced by
the diet in a very remarkable manner. They are not only torpid
under the use of animal food, but purgatives act imperfectly,
and with great  irritation.  On using a vegetable diet, they
are frequently  relaxed without the  aid of medicine; and if
purgatives are  still necessary, they act in much  smaller
doses, and without irritation.   It has generally been found
better, however, to obviate the inflammatory tendency by
other means, than to adopt so  low a diet as very essentially
to reduce the strength.
   Of all the medicines which  I have  employed with  this
view, I  have found none equal to  nitrate of potash  taken in
a considerable quantity of water, in which a little gum had
been dissolved.  The gum seems by defending, in some de-
gree, the stomach and bowels from the irritation  of  their
contents, which tends to counteract the cooling property of
the nitrate, to add sensibly to its effect.  If much be added, 
 Ig4           0F THE TREATMENT.
 however, it  is  apt to oppress  the stomach.   Eight or ten
 grains of nitre  in an  ounce  and  a half of water, with a
 twelfth or sixteenth part of mucilage of acacia,  have  been
 given three times a day, and repeated every hour or  hour
 and half, when the skin became  hot generally, or the hands
 and feet began  to burn.   Two or three  doses thus taken
 seldom  fail  to reduce the  increased  temperature, and re-
 lieve the restlessness which it occasions; and thus simple as
 these means  are, they often procure good nights, when the
 want of  sleep, as frequently happens in  this  stage  of the
 disease,  is the effect of feverishness.   The common saline
 draught, the sulphate of  potash  and other medicines of this
 description have similar effects,  but none of  them appear to
me equal to the  above nitrate.*
  'It is not to be  overlooked, however,  that all  medicines
 of this description are debilitating.  I have  known injury
 done by  two free a use of them,  the powers  of the stomach
being farther enfeebled, and a state of greater general  ner-
 vous debility supervening.   In general it is only when  they
 are used incautiously, that these  effects are to be apprehend-
ed.  I have met with a few, in  whom even  small doses of
 the nitrate of potash occasioned  irritation and debility.
   In addition to the foregoing means,  rather a freer use of
aperients than in the first stage has been found useful. Ape-
 rients not  only promote the action  of the bowels  in expell-
ing their contents, but occasion a freer flow into them of the
 bile and  pancreatic  fluid, and of  the fluids  of the various
 glands of the canal itself.   We have also, indeed, reason to
 believe that  they stimulate the absorbent,  as  well as ex-
  *The carbonic acid gas, disengaged when the saline draught is taken in
 a state of effervescence, is grateful to many stomachs; to others it is
 oppressive, and the draught seems  to agree better  with  the stomach
 When the  effervescence has been allowed to  subside.  I may here ob-
 serve by-the-by, that both from the extraction of air  being apt to op-
 press, and because they more readily combine with the acid of the first
 passages,  the pure alkalis are sometimes found better correctors of  acid-
 ity than their carbonates, 
                   OF INDIGESTION.              ±25

creting vessels, a languid state  of the bowels being unfa-
vourable to nutrition.
   The disease, however, partakes too much of the  chronic
nature to admit of great evacutions  of  any  kind; and, al-
though the free action of the  bowels is  indicated here, not
only as a'means of exciting the  various functions of the ca-
nal, but  of  allaying inflammatory  action, I  have  seldom
found more than three evacuations in the twenty-four hours
proper;  and  even  this  degree  of catharsis  should not be
continued for many days together,  for although the call for
it is greater than in the first stage, the strength is often less
able to bear it.  Constipation, on the other hand, should be
very carefully avoided, both from the direct injury it does,
and because  it is difficult to remove it without means, which
risk too  great an effect.  Purgatives on the whole, can hardly
be here regarded as among the  means employed for the
purpose  of relieving inflammatory  action.    They must be
used chiefly for the same purposes as in the first stage,  and
consequently belong rather to the means we are next to con-
sider.
   When the inflammatory symptoms continue to recur af-
ter  the temporary relief obtained by the preceding means,
a perpetual drain, established  in the most  tender  part, is
often  followed with the best effects.  I  have seen many ca-
ses, »with this aid, yield to the  means which they had  long
resisted  without it.
   With  regard to the  modification,  in  the second stage, of
the means common to both stages,  in considering the anti-
inflammatory measures suited  to that  stage, I have neces-
sarily been led to  make such observations on diet, aperients,
and the  use of stimulants and other tonics, as apply to it.
   When the first  stage  of Indigestion,  we have seen, has
continued  for some time, the  function of the  liver becomes
disordered.   A greater or less  tendency to disorder in this
organ, after it once appears, always continues throughout
 the disease, so that it is a constant attendant on the second 
 12.6            OF THE TREATMENT.
stage;  and those medicines which influence the secretion of
this organ, therefore, always form part  of its  treatment.
Of these  we still find mercury by far the most efficacious.
   Several circumstances render  caution, in the use of this
medicine, even more necessary in the second  than  in the
first stage.   Not  only has the greater continuance  of the
disease occasioned a greater loss of strength; but its increase
and the change which has taken place in its nature, renders
it necessary to employ this medicine for a longer  time, and
often in a way that more directly  influences the state  of the
constitution.
   In the first stage,  we have seen, we want only the local
effect of the medicine on the stomach and bowels;  and in
the earlier periods of the second stage,  and in mild cases,
even after the disease has continued for along time, we still
find that this effect of it, particularly of the blue  pill, re-
peated for a longer time, is often  sufficient,  especially when
the anti-inflammatory measures we have  been considering
are duly employed.
  When  it is sufficient,  no other  should be  attempted.
But in many  cases, and in  a large proportion of those of
long standing,  it fails.   The relief afforded by the occasion-
al  doses of mercury gradually  becomes less, and they at
length  cease to be of any essential use.
  When it is given in such doses, indeed, as to  produce a
considerable effect upon the bowels, partial relief is still of-'
ten obtained,  but  the  strength  rapidly  fails under  this
employment of it; and  the relief afforded does not extend
to  the  most essential part of the disease.  While the pa-
tient is relieved for  the moment,  we find the slow change
which  leads to the disorganization of some vital part going
on, and constantly occasioning a renewal of the symptoms;
which  are thus relieved at an expense of strength,  that ac-
celerates the fatal termination; and,  beneficial as  occasional
4oses of  mercury usually are in the earlier periods  and 
                  OF INDIGESTION.               i8y

milder  forms of the  disease, it  may often be  questioned
whether in confirmed cases they do more good or harm.
  Finding so little advantage from the usual mode of giving
mercury,  in the second stage of  Indigestion, when it does
not soon shew a tendency to yield; and that all means are so
generally  unsuccessful in the last stage, which, in such  cases,
is always  at  hand;  it occurred to  me to try the effect of
more frequently repeated doses of  this  medicine, so small,
that  if they did little good, nothing, at least, was to be ap-
prehended from them.
  I  have  generally given a grain  of the bifce pill, sometimes
only half  a grain,  twice or three times in twenty-four hours,
till the secretion of bile appeared  to be  healthy, repeating
these doses when it was again  disordered; and by such do-
ses,  which may appear to many little better than trifling, I
have seen the  bile  gradually restored to a healthy  state,
when larger doses had been employed in vain.  They not
only often succeed where larger doses fail, but the  change,
in proportion as it takes place more slowly, seems generally
to be more permanent.
   The correction  of  the state of the  bile, however,  is but
one of the effects of such a plan.   Along  with its improve-
ment, the skin  generally  becomes relaxed, and of a proper
temperature, the pulse more dilated, the colour and expres-
sion of the countenance better; and, in particular,  that ex-
pression  of langour, so peculiar  to the advanced stages of
the  disease,  abates.  As  all  these changes  depend on a
common  cause, and consequently  take place together, the
state of the bile, which should from time to time be ascer-
tained, is a good indication of  the general effects of the
medicine. *
   It is true that the most  transitory  effects  of mercury,
 when they correct the state of the liver, at the same time
produce  many  of the foregoing  effects in other organs, the
 diseased  state of which is supported by sympathy with  that
 of the  alimentary canal.   But this is chiefly observed in the 
 128            0F THE TREATMENT
 first, or the  milder cases of the second, stage; while in the
 more  serious cases, the affection  of these organs,  we have
 seen from its frequent  recurrence and longer  continuance,
 becoming more obstinate and less immediately dependent on
 the original disease, resists the occasional exhibition of the
 medicine.
   On  this the good effects of the plan, I am here consider-
 ing, seem chiefly  to depend.   By the mercury being given in
 such minute  doses, it enters the system, and acts directly on
 the various organs, now too much implicated in the disease
 to yield to it% syripathetic effect, yet, by the smallness of the
 quantity, it is unattended by the bad consequences of what is
 called  a course of mercury,
   The beneficial effects  of this plan appearing slowly at first,
 discourages the hopes of the physician,  and, as 1 know, in
 many instances, has caused  it to be  laid  aside.   It is diffi-
 cult besides to persuade the patient that  any plan which
 produces  no  immediate sensible effect,  can be much relied
 on ;  for  I have always  made it a rule to discontinue  the
 mercury even in this stage of the disease, when the slightest
 affection of the mouth appeared,  and any degree of saliva-
 tion  has generally seemed to me to do more harm than good.
  It is nearly twenty years since  I first adopted this mode
 of using mercury in the case before us, and I have  now
 great satisfaction in stating ; that several men of experience,
 in our profession,  who, at first, believing that no good could
 result from such minute doses, viewed the practice  as little
 better  than a  waste of time, have since confessed,  that it
gave a degree of relief which  could  not  be procured  by
larger doses.   This, and my own repeated experience of its
effects, enable me to speak of them with confidence.
  Although we do not thus obtain the sudden benefit which
results from a more vigorous practice,  we avoid the mis-
chief it often  does;  and whatever good effect is produced,
is allowed, if  I may use the expression,  to  accumulate in
the constitution.   We  are not undoing on  the one hand, 
                   OF INDIGESTION.              jgg

 what is done on the other, which, with all the care that can
 be taken, is  very often the case when larger doses are em-
 ployed.
   It is almost unnecessary to observe,  after what has been
 said, that to  render the plan most successful, the various ob-
 servations respecting diet and exercise, and the  occasional
 aids of cathartics, local blood-letting,  blisters and cooling
 medicines, must constantly be kept in view ; and if the blue
 pill occasion  any irritation of  the  bowels, which sometimes
 arises  even from the doses here recommended, it must  be
 obviated by  anodynes.
   For this purpose I have found the  extract of poppies,
 conium, and  hyoscyamus, the best means; and,  I  have, fpr
 the last eight or  ten years, been in  the habit of combining
 equal quantities of the  last  of these with the blue pill, as a
 preventive ;  and have experienced from it not only this ad-
 vantage, but  some good from its general sedative effect on
 the system ; and it will easily be believed, that  the extract
 of hyoscyamus in doses not exceeding a grain, given two or
 three times a day, never produces inconvenience of any kind.
   If the irritation,  occasioned by the internal  use of the
 mercury, cannot be allayed, its external use may here  be
 tried, the dose  being proportioned  to  that recommended
 internally.   From a  scruple to half a  drachm of the weak
 mercurial ointment may be rubbed into the skin every even-
 ing.  This way  of employing  it, however, is objectionable
 in the case before us; by it the medicine is less effectually
 applied to the chief seat of the disease, and the quantity re-
 ceived is much less easily ascertained.    I have already had
 occasion to observe, indeed, that the external use of mercury
 seldom has much effect in correcting the state of the bile,
till it produces some effect on  the mouth.
  If even this use of  it irritate the bowels, which may  hap-
pen, particularly in the advanced  stages when  they  have
already suffered  much from the medicine, and  we cannot
                            S 
 130            0F THE TREATMENT
 obviate  that effect, it must be discontinued ;  and only re
 newed at intervals, for the  time that the bowels can bear
 it without irritation.   Beyond this even the smallest doses
 do more harm than  good.
   In the few constitutions, in which no dose of the blue pill
 can be taken without disordering the stomach, I have sub-
 stituted for it, with good effect, a  sixth or  eighth part of a
 grain of calomel,  combined  with some anodyne, but this
 preparation is not so  well suited to the objects in view.
   It is not uncommon in all  constitutions, for a few grains
 of the blue  pill to  occasion  a slight pain  referred  to the
 stomach soon after it is taken, which continues lor half  an
 hour or more,  and this symptom sometimes arises from
 smaller doses; but it is seldom of much importance, and
 often ceases to recur after a  few doses have been taken.
   I have not found it necessary to confine the  patient under
 the foregoing plan, while his strength is equal to the exertion
 of going abroad ;  except at night and in bad weather ; and
 this degree of confinement his disease requires independent-
 ly of medicine.
   I have had occasion to observe that it is to the second,
 rather than the first,  stage, that the substitutes for mercury
 are best adapted, and that the mineral acids, particularly  a
 combination of the muriatic  and nitric  acids, and the dan-
 delion appear to be the best.
   Much has of late been  said of the external use of these
 acids.   Both  their internal  and external use  has appeared
 to me best adapted to cases of some continuance, where the
 inflammatory tendency has been to a great degree subdued
and small doses  of mercury  have  been  employed without
the usual benefit.  In  such cases, I believe, the use  of the
acids will almost always be  found better, than  increasing
the quantity of mercury beyond what produces the slightest
indication of its presence in  the gums.   If the habit  bear
the mercury well, the acid may be used in aid of it ; if not,
or if the  use  of the acid, as  sometimes  happens, causes the 
                  OF INDIGESTION.               131

mercury to irritate the bowels, the latter should be discon-
tinued under the use of the acid.
  When the  mercury, either on account of its effects on the
bowels, or the debilitated state of the patient,  can only be
used  at  intervals; the intermediate use of the acids is gen-
erally of considerable service.  They tend at once to restore
the strength and  prolong the effects  of the mercury.  Ac-
cording  to  my experience,  the  external use of the  acids,
recomended  by  Dr.  Scott, is more powerful, both  as a
substitute for  mercury, and  a means of correcting its de-
bilitating effects, than  internal use.  It consequently requires
more  caution,  where  there  are  any  considerable  remains
of the inflammatory  diathesis;  I have known it produce an
alarming increase  of  the infl immatory symptoms.
   The dandelion  appears to possess greater powers in this
disease that are usually ascribed to it, but  it requires to be
taken  in very large doses.  It is best adapted  to those ca-
ses, in which the bile is deficient or much disordered, while
the power of  the stomach is  still considerable.   In such
cases, I  have seen the patient restored by a  strong decoc-
tion of dandelion  used for common drink,  without the  aid
of any other medicine.  In addition to its effect on the liver,
it tends  to  cool, and consequently allay the inflammatory
diathesis, and often  excites both the bowels and kidneys.
The latter effect, which is best counteracted by alum, when
the stomach bears it well, is frequently such as to make it
necessary to discontinue the dandelion.   The former is sel-
dom  considerable, and can always be restrained.  It is of-
ten given with great advantage in aid of the small doses of
mercury when the stomach bears it  well,  and enables us
further to diminish the quantity of  this medicine.  I shall
have  occasion  to  make  some  additional observations on it
in speaking of the treatment in the third stage of  Indiges-
tion.
   Besides the means, the  more prominent effect of  which
is, that of  correcting the secretion of bile,  there are  others 
 I33          OF THE  TREATMENT
 often  useful, particularly after  the  general  inflammatory
 tendency has been subdued, and  debility becomes the most
 urgent symptom ;  which seem to act more uniformly on all
 the secreting surfaces.  For this we are prepared by what
 has already been said.
   We have seen  the secondary  affections in this disease
 gradually gaining importance in its progress, and, that if no
 vital organ is so much weaker than the rest,  that the dis-
 ease fixes on it, producing effects  which we are presently to
 consider, the various organs  which have from the first suf-
 fered by sympathy,  have their powers  more permanently
 impaired ; and the disease gradually assumes the form rather
 of a case of general,  and for  the most part obstinate, debil-
ity, than a  disease of any one set of organs.
   This form it assumes the more readily, in consequence of a
law of the animal econemy which has often attracted our at-
 tention; namely, that although the sympathetic affections pro-
duced by a disease, tend to  increase the original  affection,
in proportion as the secondary affection begins to be changed
into actual disease of the part, it tends to relieve the disease
from  which it sprung.   Hence it  is, that in the case we are
 speaking of,  in proportion  as  debility of other  parts  be-
 comes permanent and independent of the cause which pro-
 duced it, the digestive  organs are frequently relieved.   It
 is not uncommon for patients in the state I am speaking of
 to express their surprise, that they should be so weak, when
 the stomach  performs  its office so much better than when
 they felt comparatively little  of this general debility.
   The state of the disease before us necessarily supervenes
 more readily in  some  than  in  others; according as the or-
 gans  secondarily affVcted are more liable to disease,  and no
 particular organ so much weaker than the rest as to induce
 the disease to fix particular in it.
   We have now, in  some degree, a new disease to contend
 with.   The general sympathetic disease has become  that of
 most importance,   Even in this  case, however,  the pulse 
                   OF INDIGESTION.               133

is still more or less contracted, and a degree of hardness
will be readily perceived in it, if it be examined; in the way
which has  been pointed out; a circumstance,  which, with
the  history  of  the disease,  and some uneasiness being still
caused by pressure  in the above-mentioned part of the epi-
gastrium, readily distinguishes this state from other cases
of debility.
   The remains  of  the  original disease to be observed in
such cases, together with the good effects which often, for
the time,  result from every  thing  which generally excites
the  secreting surfaces, frequently induce physicians still to
look to mercury, given in what is called an alterative course,
that is, in doses taken at considerable intervals, as the chief
means of relief in  such  cases; the propriety  of which  I
think many  circumstances  must lead us to question.
  Before the disease arrives at  this  period, every power  of
the constitution  has  been strained by it, and not unfrequently
by  the means employed  for  its relief.  From mercury in
particular, it has generally  suffered much;  and  the bad
effects of  medicine, like all other morbid  affections, gaining
force by habit,  we  see those of mercury now appear from
doses, which, at an earlier* period, would have produced no
sensible derangement.
  There is also another point of importance to be consid-
ered  in  such  cases.  The  general debility produced by
mercury, when it is given for the removal of a local disease,
is, particularly  if it  has  been  successful in removing it,
more  or less readily corrected, the  functions  in  general
being  healthy.  But in the  case before us, where they are
in a  state of disease, it is corrected, if  it be corrected, at
all, with great difficulty.  •
  If to the forgoing circumstances  we add,  that, powerful
as mercury often is in exciting the due action of the secret-
ing surfaces in  general, it is by no means so powerful a
remedy in  this  respect as  in  correcting disorder of the
hepatic system, the skin and other  secreting surfaces often 
 134        OF THE  TREATMENT

remaining  obstinately inactive under its use; and that if it
fail  to excite the secreting surfaces,  its general effects on
the svstem must add their debility:  we shalll admit, I think,
not  only that little is to be expected from it  in the  case be-
fore us, but, as far as we can judge from the known tffocts
of this  medicine, and the nature  of  the  disease, there  is
great risk of its increasing the evil.   This inference, how-
ever, is not alone the result of reasoning.  If we carefully
watch  its effects, according to  any experience I have had
in such  cases, they  will be found to correspond with it.
However it  may  relieve for a little, when resumed after a
long interval, its  good effects soon disappear,  and the only
consequences of  continuing its  employment seem  then to
be, to  add  to  the debility  and hasten the progress of the
disease.
   Although  the state I am speaking of may be considered
as comparatively  rare, for it is much more common for the
diseased action, which has long existed in  obstinate cases
of Indigestion, to fix principally on one organ,  than to pro-
duce the general  state of debility  I am here  considering;
yet  we  very frequently meet with a state resembling this,
before  the  disease finally fixes an  one organ;  and particu-
larly in the intervals between the attacks of disease,  which
that organ generally  suffers, before  actual change of struc-
ture commences in it.  To this state,  the observations just
made, and those I am about to make, equally  apply as to that
where no organ suffers in particular; except that in the form-
er, the  means  which influence the whole system,  must be
combined with those directed to the organ chiefly affected
which we are presently to consider.
   I  have found the debility most-obstinate when least com-
plicated with the determination to particular parts, provided
change  of  structure had  not taken place in the latter case.
The inflammatory tendency, we have se«m, is still shewn by
the hard pulse, which is relieved  with difficulty ;  because
not depending on the affection of any one part, local evacu- 
                  OF INDIGESTION.              135

ations influence  it but little, nor are they at all the appro-
priate remedy ;  and the general state of debility admits of
but a very cautious use of those which produce their effect
on the whole system.
  Blood-letting  is here out of the question.   The pulse
must be softened by a  mild  diet and  medicines which  ex-
cite the secreting surfaces, but mercury, we have just seen,
is objectionable.   The moderate use of saline  medicines is
among  the  best means in such cases.   It  would  surprise
any one whose attention  had  not been particularly directed
to them, to observe the effects which a diet, composed wholly
of vegetable substances and milk, if the stomach can bear it,
combined with small doses of such medicines, often produ-
ces in those labouring  under this form of the disease ; who
have been vainly endeavouring to support their strength by
a large  proportion of animal food and tonic medicines.  It
has long been admitted, indeed, that such a diet is  some-
times useful incases of debility.  By this change, the pulse
is more or  less softened, and the bowels and  the  skin are
relaxed.
  It  unfortunately  happens that the debility  is  generally
such that some portion of animal food is necessary,  and a
diet wholly composed  of vegetable matter is often apt to
renew the symptoms of Indigestion.  A little of the milder
kinds of animal food, therefore, is for the most part  neces-
sary,  but  I  have  generally  seen the best  effects from ab-
staining from it every  second or third day.
   Great advantage has appeared to me to arise, in the  case
before us, from sarsaparilla, the continued use of which of-
ten seems to give a general tendency to  greater freedom in
the secreting surfaces.   I have repeatedly seen it, by its mild
stimulant and tonic  powers,  succeed where every thing else
had failed.
   I have also seen strikingly good effects, when the pulse
was much contracted,  and the skin shrunk  and cold, from
very small doses of colchicum ; but, like other medicines of 
13(.             OF THE TREATMENT

this description, it must be used with caution,  and no fur-
ther th:m is necessary to soften the skin and the  pulse.   An-
timonhd medicines, in  alterative doses, are sometimes use-
ful, but  in  general  they  debilitate  too much to  be long
continued, and their effects soon cease when they are laid
aside.  The effects of both these meoicines, particularly the
former, are often improved by  combining  them with  the
small doses of opium above mentioned.
  We may infer, from what was said of the effect of a damp
air in speaking of the causes of Indigestion, that a clear and
fresh  air  is often of the greatest  use  to  the dyspeptic, and
the states we are now considering require it more than those
of an  earlier period.
  A very sharp air, however, is unfavourable.  It too much
promotes the inflammatory tendency  and all sudden changes
of weather, on  this account, are injurious.  It is thus that
the spring is  the  most unfavourable season for invalids of
this description ; but a heavy  still air never fails to depress
their spirits and increase the whole train of nervous symp-
toms.
  I have often, during a long residence  in a  town where
the air is too close, both from its low situation and the flat
and wooded state  of the  country, seen these  observations
strikingly illustrated.  Patients of this description drooped
in the town, but, on being removed to  the  neighbouring
hills of Malvern, immediately revived ; and those who at
Malvern enjoyed good health, often had a renewal of their
nervous and billious complaints on coming to the closer air.
   A free and mild air, a  mild  and easily digestible diet,
regular exercise proportioned to the  strength, a regular state
of the bowels,  a moder te use of saline  medicines  at the
times  when the gen-ral temperature  is increased, or there is
a sensation of burning in the hands and feet, and the  use of
sarsaparilla when it  does not oppress the stomach, and such
other  medicines as  excite the secreting  surfaces generally
without  materially  impairing the strength, I would  say, 
                    OF INDIGESTION.               13^

 constitute, according to my experience, the outlines of the
 best plan in such cases ;  and I believe mischief is always
 done by powerful measures.
   It is necessary to make the patient sufficiently acquainted
 with his case to  be satisfied with  very  gradual amendment.
 I believe mercury should now make no other part  of the
 treatment than in the first stage of the disease.   It should
 only be employed for restoring due action to the liver when
 this considerably deviates from the healthy state, and then
 in  as small quantity, for  as short a time, and with  as  little
 impression  on the general system as possible.
   When other means fail, a voyage and change of climate
 are often of service ; and I  believe the waters  of  Buxton
 are sometimes useful.
   What is called change  of air indeed,  although in the same
 climate, is almost always  beneficial in  Indigestion, and par-
 ticularly  in the advanced stages.   I  shall take the present
 opportunity to lay before  the reader the observations which
 have occurred to me on  this subject.
   There has been much difference of opinion respecting the
 cause to which the  benefit derived from change  of place is
 to  be ascribed.   We  have reason to believe that it arises
 from various circumstances, but least of all, in  most instan-
 ces, from mere change of air.   It is evident that  the air
 is effectually changed by  the wind,  and far more  rapidly
 than it can be by  any change of place.   Yet it is only when
 the temperature  or  degree of moisture is changed  by the
 wind, that we can perceive it produce  any  change  in the
health,  if we except  that a certain degree of wind is useful
by  preventing absolute stillness  of the- air, which  always
becomes oppressive when long  continued, and that, inde-
pendently of any  impregnation of  the air,  for  it is  felt by
those who inhabit single houses in the country, as  well as by
the inhabitants of towns.   A free circulation of air  is par-
ticularly grateful  to the feelings, and, as we might from this
alone infer, favourable to health.
                             T 
 138            OF THE TREATMENT
   The truth is, that the air is essentially the same in all pla-
 ces.   It  has been found by correct experiments, that in
 the closest parts  of London  and on the top of the  M.dvern
 Hills,  it possesses the  same proportion  of  the  principle
 which suppoets animal life, and  is itself, indeed, in all re-
 spects the same ; but  it  is capable of being variously im-
 pregnated.   The sense of smell at once informs  those from
 the country, that.the  air of large towns  is less unmixed
 than th.it which they have been  accustomed to  breathe.
   All impregnation of this kind  must, we should  at  first
 view  suppose, be more or less injurious, and  to a certain
 degree it may be  so ; but we  have reason to believe, I think,
 that it is  much less so  than the occasional greater dampness
 and dullness of the air of large towns, produced  in the way
 pointed, out  in  the second chapter, and the usual  greater
 stillness of the air in  them from confinement by the build-
 ings.
   The  chief impregnation of the  air of large towns seems
 to be from smoke, which  does not appear to be particularly
 unwholesome.  It has  on the contrary indeed been supposed
 to preserve from disease, and has often been employed  with
 this view.  The  other effluvia of such towns  are in too
 small  quantity to  produce much impregnation of the exter-
 nal air.
   I have just had occasion to observe, that the change of
 air by  the wind seems  only to affect the health by the  mo-
 tion of the air it occasions, and by its influencing its tempe-
 rature  and degree  of  moisture.   I am inclined to think
that it  is merely in these  ways, which  are doubtless in many
cases very important, that change of place, as far as the air
is concerned, ;«ffects us.  The air  itself, I  have just  had
occasion to observe, is always the same; and its impregnations,
unless it be confined, are never, perhaps, such as  sensibly to
influence the health, if we  except those  states connected with
the production of contagious  diseases, which are very little 
                    OF INDIGESTION.                13g

 understood*.   But there are many other things in  change
 of place capable of essentially influencing it, of which, I be-
 lieve, the  most powerful is  the excitement given  by the
 change  itself.  How often  do we find continual change ne-
 cessary, the new place being no better th,m the old, as soon
 as the novelty of the change is worn  away.
   To the  mere exercise  of body occasioned by the travel-
 ling, or to which  a new  situation  naturally  incites,  much
 must often be ascribed ; but,  I believe, we must look to the
 occupation and cheerfulness  of mind  occasioned by the
 change for its chief effects.  The feelings of sickness on the
 one hand,  like all other feelings, are soon associated with
 every thing around us ; and on the other, the mind, if not
 forcibly abstracted, fixes intensely on any object, which for
 a long time chiefly occupies the attention. In long continued
 sickness, we want something  to  break that association, and
 something to divide our attention.  What can so powerfully
 produce these effects as a total change of place ?  The poor
 in some parts of  this  country, who cannot aff >rd to send
 their children to a distance  in the decline of hooping-cough,
 in which change of place is so powerful  a remedy, confine
 them daily for a certain time close  to the machinery  of a
 mill, and this often answers the  purpose as well.
   Let me add, those who ascribe to fancy all diseases which
 may be  cured by change, know little of the nature of disease
 or the laws of the  animal econemy.    Will they ascribe the
 hooping-cough to  fancy, or eruptions and sores of  the sur-

  * Some  have been inclined to doubt whether the air is ever so changed
 as to produce .disease, independently of the presence of contagion and
the changes of its temperature and degree of moisturg, but there are
some well-ascertained facts  which it is difficult to explain on any other
 supposition   We see contagious diseases, particularly the plague, ap-
pearing and declining  in different parts of a country, perhaps, hundreds
of miles distant from each other, at the same time and  without any evi-
dent cause, which it would be difficult to account for by any of the known
 properties of contagion.  I have elsewhere had occasion to consider this
 subject at some length —Treatise on Fevers, p. 158, et seq. fourth edition. 
 140             0F THK TREATMENT.
face, pains and stiffness  of the joints, and a thousand other
ailments,  which  are often  cured  by change alone ?  We
have seen how extensive the trains of diseases are, which in
many cases depend on affections of the digestive organs ;
and how much these affections are influenced by the state of
the mind, which is very  nearly as much the subject  of  ex-
ternal circumstances as the body.
   In the cases, we have last been considering, the patient is
not  always  much  emaciated, and  is  sometimes full and
bloated.   This seems to  arise from  the waste  being  much
lessened by a general failure  of  the  secreting  powers, and
it is  not  uncommon for loss  of  flesh to be among the first
symptoms of recovery.   The increasing power  of the or-
gans of supply, if the recovery  goes on, soon  of  course
begins to  counteract this effect.
   As these cases  have seldom been  accurately distinguish-
ed,  their  treatment must be regarded  as in its  infancy*.
They are sometimes treated  merely as  cases of obstinate
debility, and thus by the  tonic means employed, the lurking
inflammatory tendency is  called into action ;  and  often,  at
length, shows itself by some  of  the trains  of  symptoms,
which now demand our attention, the particular considera-
tion of which has, for reasons above stated, been referred to
this  place.
  * The green jaundice, of which Dr. Baillie gives so valuable an account
in the fifth volume of the  Transactions of the  College of Physicians, is
different from these cases, incurable organic disease of the liver having
almost always taken place in it.  In other respects the tw^o states are
similar, and it is particularly satisfactory to me, that the observations
he makes on the .treatment so nearly correspond with the result of my
experience.  I have also seen his observations on the prognosis, as well
as the treatment of green jaundice strikingly confirmed. 
OF  INDIGESTION.
Ill
Of  certain  T^ins of  Symptoms  wnose
   Treatment does  not fall nn&ei: t\ie gen-
   eral Pian of Cmee.


   It appears, from what I have already had occasion to say,
that the symptoms which arise, when "the sympathetic affec-
tions begin to have an  existence, independent of the cause
which  produced them,  and consequently to require a  plan
of treatment  directed to the parts they  affect, show them-
selves  at earlier periods, as well as  at the period which we
have just been considering.  The earlier they show them-
selves, the inflammatory uction generally rises the  higher,
the later they appear they  are the more  obstinate,  and the
more apt to occasion change of structure.   This  is at all
times their tendency,  and it is therefore, as I have already
has occasion  to  remark, that they may be regarded as the
link  which connects  what I have termed  the second  and
third stages  of  Indigestion ; the former characterized by
the presence of  the inflammatory tendency ;  the latter by
the usual consequence of its continuance, change of struc-
ture in some  vital part.          •
  The class of symptoms, of which I  am speaking, more
than any other, tends to render the'disease complicated, and
consequently, at first view, obscure ; but a careful study of
them unfolds  its true nature, the manner in which it extends
its influence throughout the system,  and the steps by which
it is  capable of disorganizing any part of it.
  Some of its most striking features, we have seen,  arise
from the manner in which  distant parts sympathize with the
stomach.  The nature of the affection of these parts, it  was
observed, corresponds with that of the  stomach  itself.   In
the first stage they are mere nervous affections, ceasing as 
 14S              OF THE TREATMENT
 soon as the cause of irritation from which they arise ceases.
 In  the  second stage they become inflammatory  affections,
 which have an existence independent of that cause ; for the
 occurrence  of the inflammatory  tendency in the stomach,
 immediately produces the same tendency throughout the
 system, to  such  a degree  indeed, that Inflammation readily
 arises in those  parts of it which most  sympathize with the
 stomach, even from causes not connected  with the disease.
  The secondary symptoms of Indigestion are most easily
 excited  in infancy, and least so in advanced periods of life.
 In infancy  too they are most  speedily fatal; but  it is from
 puberty to about forty years of age that they  are most fre-
 quent, because  at this period, their causes are  most fre-
 quently applied, and the susceptibility of the constitution is
not yet greatly impaired.   Besides, after forty,  we have seen,
the  disposition to Indigestion  is less.
  It appears from the  enumeration of  the symptoms' of In-
digestion, that the liver is the first organ which partakes of
the  disease of the alimentary  canal.   In  the first stage, we
have seen that its function is generally der mged at an early
period ; and in the second, that the inflammatory tendency
of the pylorus in  most  cases, soon extends to  it.   It is also
the  organ which  is most frequently the seat of those trains
 of symptoms, which we are now about to consider,
  It is  not uncommon in the second  stage of Indigestion,
when the patient takes cold,  or is exposed to  other causes
of inflammation, or, indeed, without any  evident cause, for
the  greater part of the  right hypochondrium to become full
and  tender on pressure, with a sense of oppression and an
increased hardness of  pulse,  often accompanied  with some
degree of dyspnoea and a dry teasing cough.  He sometimes
 complains of pain in the right, not unfrequently in the left,
hypochondrium, or in the pit of the stomach, or in the right,
or sometimes the left,  shoulder, and experiences some un-
 easiness in lying  on either side, particularly on the left, a
 greater than usual derangement of the biliary secretion ac- 
                  OF INDIGESTION.               14g

eompanying these symptoms.  In short, he evidently labours
under inflammation of the  liver.
  It is seldom, however, of the most active kind, requiring
general blood-letting, which is fortunate, as patients of this
description rarely bear loss of blood well.  I have seen many
who had long laboured under Indigestion unable to bear the
necessary loss of blood, when attacked with acute inflamma-
tion.   They  are, however, comparatively, little liable  to it.
Their inflammatory attacks generally partake of the chronic
nature of the habitual disease, and for the most part  yield
to local blood-letting and blisters, with the aid of a mild di-
et and saline and aperient medicines.
  This treatment, combined  with  the small doses of blue
pill, given in the way above pointed out,  never  fails to re-
lieve the affection of the liver we are here considering, till
its frequent recurrence h;is rendered it obstinate, and produ-
ced some tendency to change of structure.
  The pain,  it has been just observed, is often felt in the left
side, while the tenderness on pressure is wholly confined fb
the right; but, after the  affection of the  right  side is re-
lieved by evacuations from the tender part, it is  not uncom-
mon for the left side to become both full and tender, the in-
flammatory affection appearing to attack the spleen  as  soon
as the liver is relieved from it; and it will,  sometimes, on
the fulness and tenderness of the left side being relieved by
the same  means, return to the liver.  This alteration I  have
seen happen  more than  once before the  disease subsided,
in those who had long laboured under the second stage of
Indigestion.
  Sometimes, though much  more  rarely, the fulness and
tenderness appear in the left side alone.   The pain is  then
more confined to the seat of the tenderness.   The  same
means are here  proper, with the exception of the blue pill,
which seldom seems to be of  much service in this affection;
and  the  employment of which must therefore be regulated
by the state of the other symptoms. 
  I44           OF THE TREATMENT.

    The chief seat of such attacks, however, is often in  or-
  gans at a greater distance from that of the original disease.
  I shall, in the first place, mention the lower bowels, because
  these are more  immediately connected  with  the disease,
  and are  injured, not only by sympathy with the higher parts
  of the canal, but more directly influenced by their vitiated
  secretior.s and the undigested food.
    The irritation of bowels, which attends the first stage, is
  for the most part easily relieved by purgatives and anodynes.
  In  the   second stage it often becomes obstinate, and shews
  the  same inflammatory  tendency which now characterizes
  the primary disease.   The  hypogastrium becomes full and
  tender  on  pressure,  and the irritation  which  exists  there
  increases the general tendency to fever.
    We should a priori expect that the lower bowels would
  suffer more than other parts  of the  canal, especially  when
  the disease  is of long continuance,  the morbid  contents  of
  all  the rest  passing by them.  The sigmoid  flexure of  the
  colon appears  to  be the part most liable  to  be affected,
  probably from the contents  lodging there longer than  in
  other parts  of the large intestines.   It is not uncommon in
  protracted cases, to find a considerable  degree of  tender-
  ness in  the  seat of this part, which  is sometimes at length
  affected  with  ulceration.   It is  also,  probably  for  similar
  reasons, common, though not so much so, to find tenderness
  on pressure in the seat of the ccecum.  In other instances it
 . is more  general.
    Opening  medicine, in such cases, seldom gives  much re-
  lief, and  often increases the irritation ; nor have  I  found
  any means effectual without those which lessen the  inflam-
  matory  state of  the parts.  The application of leeches to the
  part most tender on  pressure, and  the use of mucilaginous
  and anodyne  clysters seldom fail  to give relief,  and then
  mild aperients generally succeed in procuring a free action
  of tne bowels.   It is  sometimes  necessary  to repeat  these
^ means,   and when the symptoms are obstinate their  good 
                    OF INDIGESTION.              145

  effects may be  promoted by the tepid bath; but I have sel-
  dom  found fomentations of  the abdomen of  much use,
  although  a large poultice applied over the lower part of it
  sometimes appears to be of service.
    Both  from the  passage  of the vitiated  contents of the
  bowels, and from the return  of the blood through the hepatic
  system being rendered less  free, those who have long  la-
  boured under Indigestion,  are particularly  subject to piles;
  great relief is generally obtained in the affection of the bow-
  els, we are considering, when they bleed freely; and when
  they  exist  to  a considerable degree without bleeding, the
  application of leeches  to them is sometimes the best mode
  Of letting blood  in that affection.   I have repeatedly ohserv-
  ed, even  where  it had  not  gone the length of producing
  decided inflammatory  symptoms, but the  patient had  for
  some  days been teased by  scanty, irritating and unsatisfac-
  tory  evacuations,  that after  a small spontaneous discharge
  of blood from the piles, the  bowels have emptied themselves
  with freedom and ease.  Foreign, particularly French, phy-
  sicians,  place great  reliance  on bleeding from the seat of
  the piles, even  where no  degree of  this disease exists, in
  all inflammatory affections of the bowels.   Dyspeptics we
  have seen are often subject to more or less  permanent spas-
  modic stricture of the rectum, this  is most apt to occur
  when  some degree of  inflammatory tendency in the bowels
  has supervened, and we  have reason to believe that when
  frequently  renewed it may end in organic stricture.   This^
  however,  is certainly  not  a  frequent occurrence.   When
  Indigestion  is  complicated with organic  stricture of  the
  rectum, it will  generally be found, I believe, that the stric-
  ture is the primary disease.
»    Every cause  of irritation of the alimentary canal is apt to
  renew the inflammatory tendency in the bowels, particularly
  the repeated use  of mercurial  medicines.  It is  also fre-
  quently renewed by cold or other causes of  inflammation* 
 146            OF THE  TREATMENT
 The best means of prevention are a very mild and rather
 mucilaginous diet and a free state  of  the canal.
   The  chest frequently suffers in  the second stage of Indi-
 gestion, the dyspncei, which we  have seen  an  occasional
 attendant at all periods of  the disease, becomes more per-
 manent, with  a sense of oppression  and difficulty of lying
 in the horizontal posture, and an increase of the tenderness
 of the epigastrium, the hardness of the pulse, and  burning
 of the hands and feet.  The feeling of oppression is  greater
 than seems to  belong to the degree of the dyspnoea, and is
 much increased by all active exercise.   A short dry cough
 sometimes attends,  but is by no means a constant symptom;
 a circumstance  which, with the absence of any  thing that
 deserves  the name of fever, often deceives respecting  the
 inflammatory nature  of the affection.   Blisters  generally
give relief,  but we  still  find local blood-letting the most
certain and expeditious  means.
  The  increase of  the tenderness  of the epigastrium, hard
pulse, and feverish symptoms distinguish this affection from
another species  of permanent dyspnoea, which we found a fre-
 quent attendant on Indigestion, and which I shall  soon have
occasion more particularly to consider.   It seems to be wholly
a nervous affection, and frequently to be the effect of repeated
attacks of the inflammatory dyspncea, which is still apt to be
renewed,  and  consequently  to become complicated  with  it,
when the patient is exposed to taking cold or  any other
cause of inflammation.
  Palpitation we have seen is sometimes  a symptom  of
Indigestion, and  is, for the most  part, readily relieved by
means already pointed out; but in  some instances  the affec-
tion  of  the  heart becomes so obstinate, that I have repeat-
edly known  it  assume the form of angina pectoris,  and be *
treated in vain as such, for several years; yielding, at length,
to means which restored due  power to the digestive organs.
 All affections of the heart becoming obstinate in the  second 
                  OF INDIGESTION.              147

stage of Indigestion  with an increased  hardness of pulse,
are relieved  by  loss of blood; and  I have seen  decided
carditis supervene under sucn circumstances, requiring the
frequent repetition of copious general blood letting.
  It is a common observation that carditis is apt to super-
vene after repeated attacks of rheumatic pains of the limbs.
I believe  from many cases which'have  fallen  under.my
observation, that it will generally be found in such instances,
that the rheumatic pains had been combined with, and in a
greater or less degree dependant on disorder of the digestive
organs.
  The pains  of the limbs arising from this cause, will often'
completely assume the  form  of rheumatism,  and become
very  obstinate, if .the cause  which supports them be over-
looked; which  is the more likely to happen, because here,
as in other cases, cold is very often their immediate excit-
ing  cause.   I have seen  severe pains of the limbs which
had long resisted the means usually successful in rheumatic
cases,  wholly  removed, by  combining  with these  means,
the treatment adapted to the second stage of Indigestion.
  But of all the sympathetic affections of distant parts in Indi-
gestion, none are so frequent as those of the head.  In the
second  stage,  they usually assume the same inflammatory
character  with  the other affections belonging to this stage.
From the function and situation cf the brain, however, the
nervous  affections  of this organ connected with a diseased
state of the stomach,  assume a more formidable appearance
than those of other parts,  and consequently  demand more
attention.  After considering the former, therefore, I shall
lay before the  reader the observations which my experience
of tl>e latter  has suggested.
   Head-ach,  we have  seen, is one of  the most common
symptoms, both of the first and second stage of the disease,
sometimes,  indeed, Indigestion shews  itself only by  this
symptom.  In the milder cases this is by no means uncom- 
 148           0F THE TREATMENT
 mon, and it now and then happens in the most severe.  I
 was one of  many physicians  who  were  consulted in a case
 where violent pains of the head had resisted  every  means
 which could be thought of.   The  disease proved fatal, and
 we expected to find great disorganization in the  head, to
which all the formidable symptoms had been referred.   No
 trace  of disease, however, could be found in it, and the or-
ganization of the liver seemed to be wholly destroyed.
   In the first stage head-ach is generally  a mere temporary
affection of the nervous system, and, indeed  frequently  su-
pervenes on other nervous  symptoms, which it  relieves.
It is particularly apt to be preceded by affections of the sight,
and may often be removed by emetics and cathartics,  which
remove the  immediate cause of irritation.  When severe,
indeed, it is frequently relieved by spontaneous vomiting.
The head-ach of the second  stage is often more obstinate.
 Emetics  and cathartics, indeed, also frequently relieve it,
because these  not  only remove the cause of irritation, but
occasion  depletion of the vessels of the head.  The most
 effectual  remedy, however, is blood-letting from the head.
The head-ach of the first and second stages  of Indigestion,
besides the accompanying symptoms may generally be dis-
tinguished by  the latter being greatly increased by stooping,
or when the patient holds his breath, and forces the blood
towards the  head, while this is rarely the case with the head-
ach of the first stage, and never to the same degree, a cir-
cumstance very characteristic  of the nature of these affec-
tions.
   The head-ach  of the  second stage  sometimes becomes
very formidable when its inflammatory nature  has not been
understood,  occasioning the most agonizing pain, and even
delirium.   No case of it has occurred to me in which  bleed-
 ing from the head did not give immediate relief.  Blister-
 ing the nape of the neck is often of service, but as it often
 fails,  and the relief is never so speedy, and seldom so com- 
                    OF INDIGESTION.              149

pjete as from local blood-letting, the latrer, unless the strength
is much reduced, is  preferable; to saj nothing of its effect on
the habit in general,  which, when the head ach has frequent-
ly returned, is beneficial, for local of course is  also general
blood-letting as far as it  goes;  and from the nature of the
circulation in  the encephalon, the blood being returned from.
it  by inanimate canals which  cannot  partake of the excite-
ment, there is no  other inflammatory  affection to  which a
generally  increased  action of the  sanguiferous system so
much disposes as  to that of the brain.  Blisters are a pow-
erful means of preventing the return of the pain.
   It often happensT apparently for the reason just mention-
ed, that this inflammatory state of the head requires a lower
diet, and  more frequent repetition of the blood-letting, than
the other affections  we have been considering.
   Here, as in  all cases of inflammation, however little general
blood-letting  may seem to be indicated in the first instance;
when local blood letting has been frequently repeated, with-'
out subduing  the hardness of the pulse, or preventing the re-
currence of the symptoms, the greatest advantage often ari-
ses from  letting blood generally.   In  such  cases, indeed, it
becomes indispensable.   The strength may  be exhausted by
the constant repetition of the local blood-letting, without the
tendency to the disease being subdued.
   From the  blood being taken  more  slowly, local, even to
the same extent, never produces the whole  effect of general
blood-letting.  I  have repeatedly  seen the pulse  softened,
and the recurrence of the disease prevented, by one general
blood-letting, and that to no great extent,  when frequently
repeated local blood-lettings had had little effect beyond the
 present relief they afforded.
   General and local blood-letting relieve inflammation in dif-
 ferent ways.   The former, by lessening the vis a tergo, tends
 to prevent farther congestion in the inflamed part; the other,
 by lessening  the  quantity of  blood in the part, to relieve 
150
OF  THE TREATMENT
 more directly that which has already  taken place.   Now,
 although the quantity of blood in the inflamed part is repea-
 tedly lessened, and thus the inflammation for the time reliev-
 ed;  the  general inflammatory action continuing, the vessels
 again suffer distention,  till this action is subdued by general
 loss of blood.
   On the other hand, I have seen many cases where repeat-
 ed general blood-letting had failed to subdue inflammation,
 in which it has ceased on the local abstraction of blood.
   Here the generally increased force of the circulation had
 been sufficiently subdued, the vis a tergo sufficiently lessened;
 but the long debilitated vessels could not recover their usual
 diameter, till more directly relieved from the blood which had
 distended them beyond it. It is evident that it is in protracted
 cases that both  these states  must occur; but their existence
 seems sufficiently to evince the propriety of combining  local
 and general blood-letting in  all cases of active inflammation.
   If the  foregoing observations  be correct, little advantage
 is to be expected from  general  blood-letting, when there is
 no general increased excitement of the circulation.   This in-
 ference seems fully warranted by experience, for under such
 circumstances, the loss of two ounces of blood from the part
 affected often  gives more relief than that of a pound from a
 distant part.
   Blood-letting seldom does much good in the  head-ach of
 the first stage  of indigestion.  If it is not relieved by clear-
 ing the stomach and bowels, and the use of what are called
 nervous medicines, a pretty large blister applied to the nape
 of the neck, or behind the ears," is the most effectual reme-
 dy.
   The effect of nervous medicines in relieving it, is often con-
siderable, but  very uncertain.  In many cases they seem to
do little or no  good.  Valerian and conium appear to be the
most frequently successful.   Opium is ill adapted  to  this
head-ach, any  relief obtained from it being  generally more 
                  OF INDIGESTION.               i5i

than compensated by its effects on the stomach and bowels.
Opium  in the head-ach of the second stage is  out  of the
question; but I have found that after the hardness of the
pulse is to a certain degree subdued, such a use of the com-
pound powder of ipecacuanha as supports a general tenden-
cy to moisture on the surface, provided means are employed
at the same time, to keep the bowels free, is very useful in
preventing its returns.   The  effects of this  medicine seem
sometimes improved  by combining an  antimonial with it.
In many cases, particularly in the early period of the second
stage, and when its characteristic  symptoms are not very
prominent, the head-ach seems to  partake  of the nature of
both  stages, and is  best relieved by a combination  of the
above means.
   It sometimes happens in the second stage that the head-
ach assumes  a chronic form, continuing for weeks or even
months, without being very severe.  Both local and general
blood-letting then very frequently fail to give permanent re-
lief.   The best means are those which support an habitually
free  action of the bowels and  skin,  and most effectually cor-
rect  the disease  of the digestive  organs;  and  permanent
drains from the neighbourhood of the head.
   Alarming as some of the  inflammatory affections  of the
head are, its  nervous affections connected with  irritation of
the digestive organs, contrary to what we see in other parts,
are  often still more so; arid  when they occur in the second
stage, supersede the inflammatory  tendency.  They  appear
to be of two  kinds; the one arising from long-continued
irritation of the nerves of so  important a part of the system
as the digestive organs, directly debilitating and sometimes
wholly destroying the source  of nervous influence; the other
from this  irritation affecting the state of the vessels of the
brain, and consequently the  distribution of that portion of
the blood which is sent to the head.
   The  former of these is only a greater degree of the affec-
tion which is usual at all periods  of  Indigestion.  Giddiness 
 133           OF THE TREATMENT

 and temporary loss  of power or vitiated feeling in vanoin
 parts of the body, we have seen, are not uncommon symp-
 toms even from the commencement.   But it is in those cases
 where powerful and repeated causes of irritation on the one
 hand, and,  on the  other, the debility  occasioned by long-
 continued indigestion, which every where affects the secret-
 ing  power,  and consequently the state  of every part,  have
 gradually enfeebled the functions on  which the supply of
 nervous influence  depends; that  these  symptoms  become
 formidable.   It is  not very unusual, under such circumstan-
 ces, to see the patient, after more severe attacks than usual,
 and sometimes  without this  warning,  suddenly fall down,
 and in a few hours, and in some cases, almost immediately,
 expire.
   In such cases the aids of medicine are vain.  The powers
 of the constitution are not oppressed by disease, but worn
 out by its contiuuance.   This  is  what  in contradistinction
 to apoplexy  arising chiefly from the state of the  vessels, is
 properly  termed nervous apoplexy, the  most fatal of all its
 forms;  and  it  has been remarked that in some cases, no
 morbid appearance presents itself on dissection.   The  fatal
 derangement is in the nervous system alone, whose struc-
 ture is too  minute for  our observation.  If the usual plan
 of bleeding  in  all cases of  sudden insensibilty be here re-
 sorted to, the disease is only the more suddenly fatal.
  The state  of the brain in such cases resembles that which
 surgeons call concussion.  Its mechanism is deranged.  The
 difference is, that  in the one this mechanism is deranged
 by a sudden and violent cause, applied while the powers of
 the system are entire; and which,  consequently, if the little
 strength  which remains be carefully husbanded, may often
repair the injury: the other is the effect of a succession of
 slight causes gradually changing the mechanism of the brain,
 and at the same time exhausting the powers of every other
part, so that the constitution possesses no means of repairing
the injury. 
                   OF INDIGESTION.              igg

   The pure nervous apoplexy, however,  as here described,
 is necessarily an extremely rare  disease; because it very
 seldom happens that the causes continue  long enough so to
 derange the finer mechanism of the brain  as to produce loss
 of function,  without influencing the state of the  circulation
 in it  in such a  manner  as to produce a  fatal  effect in this
 way.
   There is something at first view very inexplicable  in the
 phenomena of apoplexy, such as  it often  appears in those
 who have  long laboured tinder the  more severe forms of
 Indigestion.   Dissection has not only  shewn that sanguine-
 ous apoplexy, which  is generally  attended with  a flushed
 countenance  and strong beating  of the  temporal arteries,
 sometimes occurs,  when from the paleness  of the counte-
 nance and  the previous symptoms, as  well as nervous habit
 of the patient, we should have expected  to  find the  blood
 in the brain rather below  than above the  due quantity; but
 that such is often the state of  the circulation in this organ,
 when  the  countenance, on the attack  of  the apoplexy, be-
 comes much paler than before, and the beating of the tem-
 poral arteries, hardly  perceptible.  Nay, such  cases  will
 often be relieved by  blood-letting, although  it  is always
 prudent to  employ  it with  the greatest caution;  for, inde-
 pendently  of other considerations,  we  have  no certain
 means of distinguishing  them from the case we  have just
 been considering, in which blood-letting always hastens the
 fatal termination.  If the case admits  of relief from blood-
 letting,  the smallest loss of blood from the head,  is imme-
 diately attended with a diminution of the  insensibility.
  When we consider the free  communications which exist
 between the vessels of the brain and those  of the external
 parts of the head,  and that both are supplied from the same
 trunks,  great turgescence and  fulness of the former appear,
 at first view,  altogether incompatible with a shrunk and
 comparatively empty  state of the latter;  yet  no physician
has practised long without having proofs of the  existence of 
154            OF THE TREATMENT
the state here described.   I have repeatedly seen, in an ex-
hausted constitution, the face become suddenly pale,  and all
poweulost, the  patient  falling down  insensible,  and  the
countenance continuing to increase in paleness till it assumed
a cadaverous hue; and yet  this patient has been immediately
restored to the use of his faculties; the  paleness of  his
countenance at the same time abating, by the loss of blood;
and  there is every reason to believe would have died with-
out it.
  The brain,  we have  seen,  is one of those parts which  are
most apt to sympathize with the digestive organs; even in
slight attacks  of Indigestion, its powers are not unfrequent-
ly so enfeebled,  that  all its functions  are impaired.   This
debility extends to,  and indeed seems  sometimes chiefly to
take place  in, its vessels.*  We know,  from the evidence
of dissection, that in such  cases they suffer themselves, and
that  often very suddenly, to be morbidly distended by the
usual vis a tergo, and thus to  receive a greater  than usual
share of the blood sent to  the  head.   The external vessels
consequently  receive a smaller quantity; hence the paleness
of countenance on the attack  of this species  of apoplexy,
and  the increasing paleness  in proportion as the blood  ac-
cumulates  in the encephalon, owing to the increasing debil-
ity of the vessels of the whole, or some particular part of it.
   When the minute vessels  are distended,  inflammation is
the consequence; when the larger vessels, congestion, which
in the head  occasions  apoplexy.   In  inflammation of  the
brain, the  parts  affected are found  uniformly red.  In  ap-
oplexy  there is little of this uniform redness, but the larger
vessels are preternaturally  distended.f   I speak not here of
the more common case of  rupture of the vessels.

  *It appears, from direct experiment, that  affections of the nervous
system are capable of instantly depriving the  vessels of their power.—
Inquiry into the laws of the vital functions, Exper. 27, 28, 29.
  fSee Inquiry into the laws of the  vital functions.  Second edit. p. 301,
et seq. 
                   OF INDIGESTION.              ±55

   Thus it is that, in such cases  as that before us, the in-
flammatory tendency in the brain is superseded. The trunks
of the  vessels themselves being debilitated  and distended,
can  no longer  supply the  vis a tergo 'which  supports  the
preternatural distention  of the capillaries, which therefore
retain their usual diameter, and consequently, as far as
they are supplied with blood, their functions.
   The loss  of blood takes off the state  of extreme  disten-
tion,  which supports and increases the debility of  the ves-
sels,  the immediate cause of which is often of a transitory
nature, and thus enables them to recover their usual diam-
eter;  in consequence of which  the external  vessels again
receive their due proportion of  blood.  Thus, at the same
time  that the sensibility is restored, the countenance  re-
gains its colour.
   It is  probable that this state of disease sometimes origin-
ates from causes acting directly  on the brain  itself; but in
most instances we have  reason to believe, that it originates
from  irritation of the stomach and other digestive  organs.
It is most apt to  supervene in exhausted states of the con-
stitution,  or in what are called very nervous habits, and is
evidently of a different  nature  from  distention of the ves-
sels of the encephalon arising from general fulness, aggra-
vated in the head by any occasional cause,  a  distended state
of the stomach, for example, pressing  on  the descending
aorta, a common cause of apoplexy in the plethoric.
   It is  evident, that in  the apoplexy we are considering
loss of blood from the head, and that only to such an extent
as relieves  the symptoms, is alone proper; although  as  I
have  witnessed, the incautious use of general  blood letting
in such a case is followed by immediate relief;  but it is also
followed by a degree of debility which  further disposes to
returns of the attack, as well as to other diseases.
   Slight irritations of the stomach often debilitate the ex-
ternal capillary  vessels of the head,  where  they are  most
delicate, in consequence of  which they for  the time suffer 
 106           OF THE  TREATMENT
 morbid  distention, particularly  if the late  reception of a
 meal  gives  more than  usual vigour  to  the  vis  a tergo*
 Hence the flushing of the face of dyspeptics after dinner,
 especially when they have taken any thing which  disagrees
 with the stomach.  There can be little doubt, I think, that
 this tendency in irritation of the stomach to debilitate,  and
 consequently occasion distention of,  the  vessels  of  the
 head, concurs with the pressure on the  descending aorta to
 produce the apoplexy which is so apt to arise  after a full
 meal.  In the advanced  stages of Indigestion this effect is
 determined  to the internal, more readily than the external,
 vessels of the head, by the debility induced on  the former,
 in consequence  of their greater  sympathy with  the long-
 continued irritation of the digestive organs.
   I had occasion  to  obsery.e, in  speaking  of the  relation
 which subsists between the sympathetic affections which at-
 tend Indigestion and the original disease, that the relation
between the latter and urinary gravel, depends  less on any
 sympathy which exists between  the stomach and kidneys,
 than  on the generation of acid in'the  alimentary canal in
 Indigestion.   We find this observation further illustrated by
 the symptoms we  have just been considering.
   We have  seen, that the internal organs, sympathetically
 affected in this disease, are peculiarly liable to inflammatory
 affections in the second stage, producing the different trains
 of symptoms which have been laid before the reader.  The
kidnevs, however, seldom shew any tendency of this kind;
although it  is not uncommon  in  Indigestion, for  the acrid
 state of the  urine,  arising  from the superabundance of acid
and its other saline contents, occasioned by the greater gen-
 eration of acid in  the alimentary canal, and the inactivity of
 the skin, so to irritate the urinary passages as to occasion
frequent micturition, and a sense  of burning, and other
painful sensations in these passages,  even when no deposi-
 tion of lithic acid* takes  place in them.
  *As it is an acknowledged fact that the excessive use of distilled spi-
 rits, and other fluids containing alcohol, tends to produce urinary gravel; 
                  .   OF INDIGESTION.                ^y

   Such symptoms  may  generally be relieved by diluting
 and mucilaginous fluids,  but they can only be germane miy
 removed by preventing the morbid generation of acid in the
 alimentary  canal, and restoring due action  to the. skin.
   It is almost unnecessary to observe, that in all  the  fore-
 going cases we must keep in view the origin of  the disease'.
 The debility of the digestive  organs, however  relieved by
 the  secondary disease,  is easily renewed by any  cause de-
 ranging  their  functions,  and  always  has  the worst effect.
 All  the regulations respecting regimen,  then, and even the
 occasional use of stomachic medicines are  proper,  as far as
 the symptoms of that disease admit of them.*
   I shall  not prolong   this part of the treatise  by observa-
 tions on the connexion of Indigestion with  hydrencephalus
 internus,  epilepsy,  affections  of  the  mind, and  other dis-
 eases of the head, respecting which  many  valuable  obser-
 vations have been made  by several  writers; but  close my
 observations on the second stage  of  Indigestion  with some
 remarks on the  manner in which  it influences  the  phenom-

 I was induced to make some experiments for the purpose of ascertaining
 haw far  the addition of alcohol to the urine, after it is out of the body,
 tends to promote a deposition  of lithic acid  from this  fluid.  I found,
however, from repeated trials, that it had a contrary tendency, both re-
tarding the deposition of this acid and greatly lessening the quantity de-
 posited, which, probably  in consequence of its  being deposited more
 slowly, appeared in larger  and more distinct  crystals when  the alcohol
was added .to the urine.  This  combines with other circumstances in
proving, that, contrary to the opinion of M.  Majendie,  it is by  the de-
 bility its incautious use induces on the digestive organs, and not by any
 direct influence on the urine, that alcohol disposes, to  urinary gravel.  To
what cause can we ascribe the  diminished tendency  of the urine to de-
 posits lithic acid, when the common spirit of wine of the shops, or rum,
 the forms in which I used the alcohol, are added to it?
  *I have during the last five or six years recommended  galvinism  in
certain protracted cases of Indigestion.  I shall  have occasion, in the
 last chapter of this treatise, to point out the circumstances which led
 to its employment,  the mode of using it, and the effects to be expected
from it. 
 138           OF THE TREATMENT,

 ena and treatment of the fevers of this country.  By the
 second  stage  of Indigestion, we have seen, is meant such
 disorder of the stomach  as has,  by continued  irritation,
 occasioned in the pylorus a state, if not of inflammation,
 inclining to it, accompanied with an inflammatory tendency
 throughout the system which is apt to shew itself chiefly in
 those parts which most sympathize with the stomach.


 On the eoncwTYence  of t\\e  second  stage
          of  Indigestion and Yeveir.

  The concurrence of the second stage of Indigestion and
 fever is perhaps the .most common combination of disease
 which is  presented to us.  It arises either from fever at-
 tacking those labouring under this stage of  Indigestion, or
 from the  latter supervening in the course of the fever.
  From the attention of physicians having lately been much
 directed to the local affections, which, although not essen-
 tial to, often attended, fever, has arisen one of  the greatest
 improvements in its treatment; for these local affections  be-
 ing all of an inflammatory nature, support and aggravate
 the general disease.
  I shall here beg leave to quote what is said of the nature
 of fever in the preface to  the fourth edition of my Treatise
 on simple and eruptive fevers.  The more I have considered
the subject, and observed  the course of febrile diseases, the
more  it appears to. me, that  the view there taken of it is
consistent  with the phenomena of those diseases, and leads
 to the proper treatment  under their various forms.   But
my reason for troubling the reader with it here is, that it
seems to explain  the relation which  subsists  between them
and the disease which forms the subject of this  treatise.
  ''It is impossible to subject the whole system to sufficient-
ly minute  observation, to make the immediate cause of fe- 
                   OF  INDIGESTION.              i5y

ver the subject of experiment; but we know that there are
local diseases capable of exciting fever, and it may be pos-
sible  to  ascertain by experiment  the  state of the  part  on
which these local diseases  depend, and thus  to arrive at a
knowledge of one or more changes in the vital  organs ca-
pable of producing fever, and by comparing the phenomena
of these diseases  with those  of simple fever, to ascertain
how far the same changes  which we observe in the part ob-
tain throughout the system, as soon as the irritation  occa-
sioned  by the state of that part, or any other  cause, pro-
duces fever.
  "It appears,  from some  experiments made with the assis-
tance of the microscope, related  in the introduction to my
treatise on symptomatic fevers, to which I have already had
Occasion to allude,  that inflammation arises from debility of
the capillary vessels, and their consequent distention by the
vis a tergo, and that we can at will  produce inflammation
by debilitating the capillaries, and relieve it by increasing
their action.   Wherever, therefore, the  symptoms of  in-
flammation, increased temperature, redness and swelling ap-
pear, the capillary vessels are debilitated, and preternatural-
ly distended.
  "Now, in the hot  stage  of fever,  all the surfaces are af-
fected with  increased  temperature,  redness, and swelling;
and as the debility and consequent distention of the capil-
laries of a  part, as appears from direct observation, pro-
duce  increased action of the larger arteries of the part, this
general  debility and distention,  of the capillaries produce
increased action of the whole arterial system.  In  inflam-
mation the debilitated vessels being comparatively few, the
vis a tergo quickly, and to a great degree, distends them.
In fever, the debilitated  vessels being very numerous,  it
produces its  effect more  slowly, and to  a  less degree,  in
proportion as the resistance  is greater.
   ''If in any part the vessels are weaker than  in others,
they  suffer a greater degree of morbid distention, particu- 
   160             OF THE TREATMENT.
.  larlv after the increased action of the heart and large vessels
  has been excited.  Hence arise the congestions and inflam-
  mations so frequent in fever.   These act as,  we have seen,
  inflammation does in other cases, in supporting the morbid
  excitement of the  heart  and  larger arteries.  Thus, it is
  that  the treatment of such  affections is of the first impor-
  tance in determining the course of the fever.''
   It is  unnecessary here to pursue  this  subject  farther.
  The cause of the  cold,  preceding  the hot, stage of fever;
  and the modus operandi of the causes of this disease  are con-
  sidered in the above Treatise.
   Now, in those  who labour under the  second stage of In-
  digestion, we have seen that  some of those  parts  which
  greatly sympathize with the stomach, generally suffer most.
  These therefore, are the week parts which most feel the ef-
  fect of the morbidly increased force of circulation in fever.
  Their vessels are most  apt to  suffer distention, producing
  congestion or inflammation, according as the  distention is
  in the larger or smaller vessels.
   The liver, it appears from what has been  said, is  the part
  which most frequently  suffers  by  sympathy in the second
  stage of Indigestion. It therefore  often happens that, when
  those labouring under this stage are attacked  with  fever a
  train of symptoms similar to that detailed in page 142, super-
  venes, the proper treatment of which is essential to that of
  the fever.
   The principle of the treatment of these symptoms, when
 they occur in fever, is precisely the same as where they su-
  pervene without  it,  but the actual  practice is not altogether
  so.   The fever, in its early stages, by adding to the severi-
' ty of the  inflammatory  symptoms, renders  more active
  means necessary.   Hence, if the general symptoms do not
 indicate general loss of blood, a greater local abstraction of
  it is usually proper, than when no fever but that occasioned
  by the local affection attends. 
OF INDIGESTION.
161
  The same  observation  applies  to  the  use of cathartics.
At the commencement of fever the free action of the bowels
is particularly beneficial, and by  such a state of the liver is
rendered  doubly so.   It is thus that brisk doses of calomel
at this period are generally more beneficial than other mer-
curials.
  In the latter stages of fever, on the contrary, if this affec-
tion of the liver still continue, which is not uncommon, eith-
er from its having been neglected  in the early stage, or from
its proving more obstinate than usual, I have always found
the minute doses of blue pill  above specified,  given  every
six  or  eight hours,  most  beneficial.  Combined, indeed,
with moderate evacuations of blood from the part, or (when
the tenderness  is inconsiderable, and the affection  of the liv-
er rather betrays itself by a vitiated secretion of  bile, than
by inflammatory symptoms,) blisters applied to the region of
this organ, they rarely fail to restore due  action  to it,  un-
less the nature of the fever, or constitution of the patient,
be very unfavourable;  and thus  often remove the fever,
which, when its symptoms have become mild, isfrequently
at this period prolonged by  the local affection alone.
  When the sympathetic disease, previous to the attack of
fever, has chiefly affected other parts, the bowels,  the lungs,
the brain,  &c,  we still find the  part most affected by that
disease, suffering most in the  fever; and  the same plan  of
treatment, mutatis mutandis,  is applicable, except that  the
same benefit is not to be expected from  the  specific opera*
tion of mercury.
  When Indigestion  has not arrived at its  second stage  at
the time  the fever makes  its attack,  the  accession of this
disease, by increasing the inflammatory tendency,  often in-
duces that stage.  The vessels, although  they had not been
sufficiently weakened to yield to the usual force of the cir-
culation,  yield to its increased  force; and it particularly de-
serves attention, that an  attack of fever, as  I have repeat-
edly witnessed, is often the means of permanently convert- 
 162           OF THE  TREATMENT
 ing the first into the second stage of Indigestion; so that the
 fever  leaves behind it tenderness  of the epigastrium, and
 more or less hardness of the pulse,  where they had not pre-
 viously existed.
   When this is the case to any considerable degree, the pa-
 tient generally  becomes liable to a renewal of fever from
 slight causes; and if the morbid state of the digestive organs
 is not  removed,  he is  often exhausted by repeated attacks
 of fever, which, as  the  debility  increases,  assume  a more
 chronic form, and often at length terminate in  typhus, or
 the  more-severe species of what  has been called nervous
 fever.
   Local congestion or inflammation,  as might be expected,
 although none of the symptoms of Indigestion have preced-
 ed, sometimes  takes place in  fever, that is, when the force
 of the circulation is morbidly increased.  This is most  apt
 to happen in the brain  or liver.
  The principle treatment, as far as I have been able to ob-
 serve, is still the same.  In the latter case,  however,  the
 means  of relief are  generally sooner successful, and the pa-
 tient bears them better.  The treatment of fever, in  those
 who have long laboured under  the symptoms of  Indiges-
 tion, requires great  circumspection.   It is surprising after
 how moderate a degree of fever symptoms of  danger often
 arise in them, and indeed death itself actually ensues.  Both
 the vascular and  nervous systems of  some organ necessary
to life have been previously enfeebled, and  it wholly loses
its pov/er before the fever produces any  very great general
effect.   The  patient dies  as much  of  the disease under
which he has so long laboured,  as of  the fever which has
supervened on it, and that at a time perhaps when his physi-
cian's mind is fatally abstracted  from  the former.    These
observations  have been so often impressed on me in  the
course  of practice, that I cannot help, in a particular man-
ner, calling the attention of others to them.  The more we
see of disease, we shall, I think,  be the  more ready to ad- 
                  OF INDIGESTION.               1(53

mit that the digestive organs form  so important a part  of
the animal system, and are so  intimately connected with
every  other part of it, that there is no case in which their
state can with safety be disregarded.


                 T^ecanitnYation.

   We have now traced Indigestion  from its commence-
ment to the moment at which  it is about  to  terminate  in
organic disease; for a repetition of the  local affections  we
have been  considering almost  always terminates in change
of structure, which when«thus produced, seems in no degree
to differ from organic disease  of the same parts, arising
from other causes.
   It may  be useful here  to present to the  reader  a  short
recapitulation of the different  parts of the subject which
have engaged our attention.
   In the commencement of the disease, we have seen, that
the muscular and  nervous  powers of the stomach  are en-
feebled, and that the debility gradually extends to the  other
parts  of the alimentary canal,  to the  liver,  and at length,
more or less, to every part of the system.
   The irritation caused  by the contents  of the stomach,
which, from  the debilitated state of the nervous and  mus-
cular powers of this organ, have acquired morbid properties,
at length produces a degree of inflammatory action,  that is,
debility of the capillary vessels, and  its  immediate conse-
quences, in the part of the stomach most exposed to it, the
symptoms  of which I have regarded as  characterizing the
second stage of the disease ; and, as  in the first stage, the
deranged  function of the stomach produces a tendency to
deranged function  in every other part; in  the second stage,
every other part, in like  manner, partakes of  this  inflam-
matory tendency.  The pulse becomes hard, and inflamma-
tion is every where readily excited, particularly in the parts 
 1G4            OF THE TREATMENT
 which most sympathize with the stomach, or are from other
 causes most liable to disease.
   In the first stage, the debility of the nervous and muscu-
 lar powers of the stomach is to be counteracted by attention
 to diet and exercise, and a  proper use of aperient, stimulant,
 and  tonic medicines; and, in proportion as it is relieved, the
 sympathetic affections, which depend on it, disappear.
   In the second stage,  it is necessary to  obviate the in-
 flammatory tendency, and only to employ the means suited
 to the first stage, as  far  as  they  are compatible with this
 object;  while our attention  must now at the same time be
 directed to the parts sympathetically affect^ in which, from
 the longer continuance of deranged function, and the inflam-
matory tendency prevailing throughout the system, the sym-
pathetic begins to be changed into real disease.
   The affection of these parts, we have seen, like that of the
stomach, from which it  arises, now consists in a debility of
the vascular, as well as  nervous,  power.   On these powers
depend the secreting and absorbing processes, which are as
necessary to the continuance of the healthy structure as the
healthy function of the part; except that, from the nature
 of the function  it  is immediately affected, from that of the
 structure, its changes take place more slowly.
   When Indigestion has produced change of structure, it
 constitutes, we have  seen, what I have called the third stage.
 of this disease, which we are  now to  consider mpre particu-
 larly. 
OF  INDIGESTION.
165
                  CHAPTER IV.


      OF THE THIRD STAGE OF INDIGESTION.

   The stomach is  less liable to change of structure than
most other organs.  This change, therefore, although some-
times taking place in it, is much more  frequent, as I have
already had occasion to observe, in the parts with  which it
sympathizes.
   The diseases, which thus arise from  neglected  Indiges-
tion, are so  various, and so different from the  disease from
which they spring, as  well as from each other, that to give
any thing like a satisfactory account of them would require
a treatise of greater extent than the whole of that now pre-
sented to the public, and a  superficial account  would be
worse than  none.   I shall  therefore consider only those
cases, to which, from their great frequency in  this country,
my attention has been particularly directed, I mean the pul-
monary affections produced by a disordered state  of the  di-
gestive organs;  and the principles, which I shall have oc-
casion to illustrate in  treating of those diseases, will  be
found applicable to others arising from the same source.
   Organic disease, in  the common acceptation of the term,
is disease attended with such change of structure, as is appa-
rent on dissection after death.   This involves  a change of
structure in all the parts of the diseased organ.   We cannot
doubt, however, that there is a change of structure in the
finer parts of our mechanism, which leaves no traces to be
detected after death.   Thus we have seen, that in those who
have long been exposed to causes of great nervous irritation,
the function of the brain and spinal marrow sometimes fails8 
 166            OF THE  THIRD  STAGE

 The usual stimulants cease  to produce their accustomed ef-
 fects.   This at first is only  occasional, and the organs soon
 resume their usual functions; pointing out that,  however
 their action has been oppressed, their mechanism is still en-
 tire; and  has, if disordered at  all,  only been temporarily
 so: but, by decrees, the diseased state becomes more per-
 manent; and, at length,  sometimes  ends in that species  of
 palsy,  or  apoplexy,  in which, although the permanent ina-
 bility  proves, dissection cannot  always detect, change  of
 structure.
   I have  often had occasion to call the reader's attention  to
 a fact, which is at once evident to all in the least degree
 acquainted vvith the structure  and  functions of the animal
 boay,  that it must, except  under particular  circumstances,
 he through the nervous system, that  any  organ can  be influ-
 enced  by  a distant  part.  We have  also seen  an  intimate
 connexion between the function of the nerves and that of the
 vesseis in  those  processes,  on which the constant  changes
 going on in the body depend.  The   nerves  of a secreting
 organ are  n  -er disordered without influencing the  secreted
fluids;  and, consequently without tending to influence the
vessels which supply the fluids, from which those are form-
 ed.  Thuo it is, in the common course of things, that soon-
er or later, in cases  of  long-continued nervous  irritation,
the vessels either of the part to which the irritating  cause
is applied, or some  part  which  sympathizes with it, devi-
ate from the healthy state.   This we have seen,  constitutes
 the difference etween the first and second  stages  of Indi-
 gestion.   In the former, the nerves  and  secreted fluids
rlone are  affected; in the latter, the  vessels  partake of the
disease.
  The facts just stated,  however, prove, that in some cases,
where either the nerves are more liable to disease than  usu-
al, or the vessels less so,  a permanent change in the former
takes place before the vessels become affected, this  change
cither occurring  in  the nerves  of particular organs, or in 
                   OF INDIGESTION.              l6y

the general  source of nervous  influence; producing i^ the
one instance permanent loss of power in a part, in the oth-
er,  in the whole system.
  This permanent change, if the animal be capable of sur-
viving it, operates as all other  established disease does  in
tending to prevent disease of other parts; and thus the vas-
cular system of the organs affected, notwithstanding the vi-
tiated state  of their secretions, often  for a long time, re-
tains  its healthy functions.  In such cases, however,  there
is necessarily a tendency to affection of the vessels which is
indicated by a degree of sharpness of pulse, which may al-
most always be observed in them.
  Thus we find on inquiry, that the permanent diseases of
distant parts produced by sympathy, with the state of the
stomach in  Indigestion,  are of these two kinds, namely,
that in which  the nerves alone,  and that  in which both the
nerves and vessels are affected.  Of these the one in which
the vessels as  well as the  nerves are involved, is by far the
most frequent.
  Of those two kinds, then, are the sympathetic affections
of the lungs which we are about to consider.  In the one,
the disease has extended to all  the vital powers of this or-
gan; in the other, to its nerves alone.
  Some years ago  I  presented  to the Medico-Chirurgical
Society, an account of the former of  these under the name
of Dyspeptic Phthisis, which,  as I have  already had occa-
sion to observe, the society did  me the honour to publish
in the seventh volume of their transactions.   This account
I am here about to present to the reader,  with the addition-
al observations which I have since made on that disease.
  'The disease produced by a permanent derangement of the
nervous power alone of the lungs, for want of a more ap-
propriate name,  I  called  habitual  asthma.  My  attention
was first attracted to it   by finding, that the difficulty of
breathing produced by Indigestion, when it had lasted for
a considerable time, often did not yield with the other symp- 
 168           OF  THE THIRD STAGE

 toms of this disease; and then generally resisted the effects
 of medicine.
  This affection, in many  instances,  gradually increases,
 notwithstanding every effort to relieve it, till it unfits the
 sufferer for all the active duties of life.   It was with peculi-
 ar satisfaction,  therefore, that I found  galvanism an almost
 uniform  means  of relief in  it,  and  not unfrequently of
 cure.
  This induced me,  in 1816, to present some  observations
on this effect of galvanism, and my reasons  for believing
that habitual asthma  depends wjiolly on an  affection of the
nerves of the lungs, to the Royal Society; which did me the
honour to publish them in the  philosophical  transactions of
the  following year.   I shall, after considering dyspeptic
phthisis,  lay before  the reader the observations there pub-
lished, with such additions as have since occurred to me.
                      SECTION I.


              Of Dys^e^tic Yhthisis.


   It is very common for the different species of pulmona^-
ry consumption  to be  regarded as the  same  disease  and
treated  in  the same way; yet it will be evident, I think,
from the following observations,  that the nature of that spe-
cies which I am about to consider is peculiar; and that while
under the common treatment,  it is nearly as  fatal as the
other forms of the disease, under that which is suited to.it,
its progress may generally in the earlier, and sometimes in
the more advanced, stages be arrested.
  I shall in the first place, point out the symptoms by which
this  species of pulmonary consumption is distinguished;
then  make some observations on its causes,  and the appear- 
                   OF INDIGESTION.              jgg

ances discovered by dissection after death; and, in the last
place,  I shall detail the plan  of treatment  which  I have
found most successful  in it.


                 Of the Symptoms.

   I had occasion about sixteen years ago, to mention thid
species of  consumption and the plan of treatment which ap-
peared to me best adapted to it, in my Treatise on febrile
diseases.   Since  that time it has particularly attracted my at-
tention:   It  cannot, therefore, I think, fail  to be of some
use to those whose attention has also been directed to it,  to
see the observations I have been  led to make in  so many
years experience of it; for there are few diseases  so fre-
quent in the part of England  in which  I have resided, and
indeed, I believe in most parts of Great Britain.  To those
whose attention has not yet been particularly  directed to  it,
any observations on it  must be useful.
   It is not my  intention to give a detailed account  of the
symptoms  of this species of phthisis.   I shall only mention
the symptoms  and modifications of symptoms by which it
is distinguished.
   It is generally preceded, as appears  from what has been
said, by symptoms of  Indigestion, and  particularly by those
which indicate some disorder in the secretion of bile. Con-
trary  to what is usual in other species  of the disease, the
spirits from the beginning are generally more or  less de-
pressed, and the countenance is sallow.
   The cough at first is usually dry,  or  the patient brings up
a little mucus after a severe,  and often long-continued, fit
of coughing, which seems to be rather the effect of  the ir-
ritation of coughing  than any thing  which had previously
existed in  the  lungs;  for the  cough in this species of con-
sumption,  particularly  in its early stages, frequently  comes
in violent fits, in tire intervals of which the patient is often
                            Z 
 170           OF THE THIRD  STAGE
but little troubled with it.  These  fits are particularly apt to
occur after he  has  eaten, especially if he has eaten  a great
deal,  or any thing by which the digestion is disturbed; and
on lying down.
  In many instances they are most apt to  come on when
he lies on the left side, sometimes when he lies on the right.
I think  in almost all cases, the)' are least  apt to occur  in
the recumbent  position,  when the patient lies  on the back
rather inclining to the right with the shoulders a little raised;
and it  generally happens in the more advanced stages, and
often  before the strength  is much exhausted, that this is  the
only position in which he can lie without inconvenience.   It
is common in this form of phthisis,  as  indeed in all others,
for the cough to be  troublesome for some time after awaking
in the morning.  As the  disease  proceeds, the cough  be-
comes more frequent, returns less decidedly by fits, and is
attended with a more copious expectoration.   In all these
respects there is of course considerable  variety in different
cases, but in almost all the general  character here pointed
out may be observed.
  The matter expectorated is  at first limpid  and glairy;  by
degrees we see  intermixed with it small portions of an opake
pus-like substance,  the proportion  of which  in the progress
of the disease increases;  and in some cases  the quantity ex-
pectorated is astonishing, often much greater in proportion
to the severity of the other symptoms, than  in other species
of phthisis.   I  have seen  half a  pint  or more of  pus-like
matter mixed with  tough phlegm expectorated daily, when
the other symptoms were comparatively  mild.
  In  other species of phthisis, very copious and long con-
tinued expectoration of pus like matter is less common.  In
them  such copious  expectoration generally  arises from the
bursting of an  abscess.   The matter  it contained,  if not
sufficient  to occasion suffocation,   being brought  up, the-
quantity expectorated is  again reduced  till  another abscess
bursts. 
                   OF INDIGESTION.              171

  Bloody expectoration is by  no means  uncommon in  this
species  of phthisis.   Blood often appears early in the  dis-
ease mixed with  the colourless phlegm.  After the pus  like
expectoration commences, if  blood has not  previously ap-
peared, it is  much less apt to appear than in other forms of
the disease.   If  it appear even in small  quantity  after this
stage commences, the case generally proves fatal.
  While  the blood is mixed  only with a transparent fluid,
there may be good hopes of recovery,  certainly better than
under  the same circumstances  in  any other species of
phthisis.   A similar observation applies to the pus like  ex-
pectoration.   If  there be no admixture of blood, there may
be  good  hopes of recovery,  if the disease  has not lasted
long; and certainly much better than under the same  cir-
cumstances in other species of the disease.
  The expectorated matter is less apt than in these, to as-
sume a sanious appearance;  but when this  occurs,  it seems
to indicate nearly as much danger as in them.   If it happen
under the proper treatment, there is no hope.   Nearly the
same may be said of every admixture of pus-like matter
and blood occurring under these circumstances.
  I here wave all discussion respecting  the means of  dis-
tinguishing pus and mucus.   In my treatise on symptomatic
fevers*  I have  considered  the question at  length.  It is
necessary  in  practice to have  means of judging independent
of nice  experiments.  Whether the matter I call pus-like, be
pus or not, is not here the question;  it is that to which  the
observations, which I am  about to  lay before the  reader,
apply.  The  only criteria, which I have  found necessary
in practice, are  its  pus-like  appearance,  and  its  sinking
when so agitated in water  as to separate it from the tough
mucus, with which it is mixed.  I am inclined to think  that

  •Page 30, et seq., fourth edition.   The criterion of pus, proposed by
Dr. Young,  in  his work on consumptive diseases, p. 27, if its certainty
be admitted, appears to me the best, as it is the most easy of applica-
tion. 
 17S           OF THE THIRD STAGE
 this substance is almost always real pus.  Dut if we know
 what states of disease are connected with what appearances
 in the expectorated matter, it is of comparatively little con-
 sequence whether what we see be pus or not.
   The  breathing in  the  earlier stages of this  species  of
 phthisis, is'sometimes more oppressed by the  recumbent
 posture, than  in other forms of the  disease; and  is more
 frequently attended with a sense of tightness across the  pit
 of the stomach.  The same observations which apply to the
 cough in the recumbent position, and after eating,  apply  to
 the dyspnoea; but it often happens  in the early stages, that
 there is little or no dyspnoea:  and there is  very rarely, ex-
 cept in the advanced  stages,  that marked dyspnoea on exer-
 cise,  which so frequently attends even  the commencement
 of other species of phthisis.
  There is often little or no pain. In many cases the patient
is subject to a dull pain in the pit of the stomach, or pretty
low down in  the left side of the chest; more rarely the pain
is in the same part in the  right side.  There is hardly ever
a fixed  pain  high in the chest, except about the shoulders.
There, it is not uncommon,  and there is frequently an un-
easy sensation and a sense of  oppression under the sternum.
  The patient sometimes  complains of  darting pains in va-
rious parts of the chest,  and  frequently  in more  distant
parts, particularly in  the back  and shoulders,  and in the
legs;  and is often subject  to head-ach.
  The hectic fever is hardly ever completely formed  at so
 early a period  as  in  other species of phthisis, and  some-
times there is a copious  purulent  expectoration with but
 slight fever,  and that not at all assuming the form of hectic,
 the skin remaining dry in the  morning, and there being lit-
 tle or no evening exacerbation; a state  of the  symptoms
 hardly ever observed  in other forms of the disease.
  The emaciation is seldom so rapid as in other species of
 phthisis, but seems  to keep pace with  the  state  of the
 fever. 
                  OF INDIGESTION.                173

  Such is the manner in which the symptoms common to all
forms of phthisis  are  modified in this species of it, but a
diagnosis  resting merely on  the  modification of symptoms
must always be  fallacious; it is therefore fortunate, that in
the present instance, there is superadded to the usual symp-
toms of phthisis, others peculiar to this species, by which,
with very little  attention, it  may  always  be distinguished;
symptoms indicating a deranged state of the digestive  or-
gans.
  The  patient  is often distressed  with flatulence,  acidity,
and irregular bowels; the tongue is furred,  the appetite, for
the most  part, contrary to what is usual in other forms of
the disease, much impaired.   The variety in  this  respect,
however, is considerable.    Sometimes there is  a false ap-
petite  which fails after a few mouthfuls, and a sense of- op-
pression  after  eating,  as if there  were not room for what
had been taken.
   The alvine discharge is  seldom well  coloured,  and  the
epigastric region, at the part above pointed out, is  more or
less full and tender on pressure.
   In many  cases, particularly in those of some continuance,
there is a greater degree of fulness and firmness in the right
hypochondric region than in the  left, often attended with
tenderness  on pressure.   Much  less frequently  there is
some  preternatural  fulness,  and a degree  of tenderness in
the left hypochondric   region  also.  In  health, the feeling
given  to the hand in examining the  two sides, is perfectly
similar, as  I have ascertained by repeated trials.  The liver
lying under the ribs,  we press on  nothing  but  the  muscles
and soft bowels on either side.
   The above symptoms vary much at different times,  but
the patient  is hardly ever free from them.  The connexion
between them and the pulmonary symptoms is rendered evi-
dent by the latter increasing with  the former,  so that when
 the epigastric region is very full and tender, and the flatu-
 lence and acidity more troublesome  than usual, the cough 
  174.          OF THE THIRD STAGE
 and dyspnoea are so also; and on the former symptoms sub-
 siding, the latter likewise abate.  Even the rising of wind
 from the stomach,  often for the time, removes the tendency
 to cough.
   The foregoing are the symptoms of the more early stages
 of this species of phthisis.  In  its advanced stages,  it ap-
 proaches more and  more to other forms of the disease.  All
 the  symptoms, which  more particularly  indicate a tubercu-
 lar state  of the lungs, shew themselves; the cough is more
 constant,  and partakes  more  of the hacking kind,  the
 breathing is more affected by  exercise, and the hectic  is
 more completely formed.
   According  to a law of sympathy, to which   I  have had
 frequent occasion to refer, the fulness and tenderness  of the
 epigastric and hypochondric regions,  with the various other
 symptoms indicating derangement of  the alimentary  canal,
 now, that the disease is fixed in the lungs, are often lessened,
 and  sometimes wholly disappear; which, if the  pulmonary
 symptoms continue unabated, always, I  believe, affords  a
 fatal  prognosis.
   The patient at length sinks with precisely the same symp^
 toms as in other species of phthisis.
   In addition to these, some other of the more prominent
 consequences  of  severe  affection of the  digestive organs
 sometimes shew themselves, particularly dropsy of the bel-
 ly, which I never knew  to supervene in  other  species of
 phthisis.  A degree of anasarca,  the  effect of debility is
 not uncommon in the latter stages of all its species.


                 Of the Causes.


   The species of  phthisis which I am considering  arises
from all the causes of the other forms of this disease  with
the exception of those whose operation is confined to the
lungs themselves; the  inhaling of dust,  other  diseases of 
                  OF INDIGESTION.              175

the lungs, the bones  pressing unequally on them, &c.   To
compensate for the want of the causes immediately affecting
the lungs,  we have  a numerous  set of causes affecting the
digestive organs.  Drunkards, in particular, at that time of
life which  disposes to phthisis, frequently fall a sacrifice to
this form of  the disease.  In short, we perceive  equally in
its causes,  as in its symptoms,  its connexion with the  state
of the digestive organs; from which it may be justly termed
dyspeptic phthisis.
   It particularly deserves attention, that in many families,
this form of  the disease alone appears.  Its fatal effects may
generally,  I believe, be prevented by carefully avoiding the
causes which tend to debilitate  the digestive  organs;  and
watching the approach of the symptoms enumerated in the
first chapter.


       Of  the appearances on dissection.

   The appearances  of the  lungs are generally  much the
same as  in other  cases of phthisis; but we almost always
find at the same time, either a diseased state  of the liver,
or traces of disease  having  existed in it.  In cases where
the disease of  the liver has  been severe,  and  the  patient
has died as much of this disease,  as  that  of the lungs;  I
have seen  those parts of the lungs in the neighbourhood of
the liver alone affected,  the  left side  appearing sound or
nearly so.
   In  general, however, the affection of the liver seems to
have little  immediate share  in the cause of death; and the
patient lives, as  in  other cases of phthisis, till  almost the
whole lungs  are rendered incapable of  their function. Here,
as in many other cases, we often  have occasion to remark to
what extent  change  of  structure, even in the vital organs,
may  go  without  destroying  life, when.'the change is very
slowly effected; a circumstance which, perhaps,  more than 
 176            OF THE THIRD STAGE

 any  other, shews the extent of the resources, by which we* >
 are enabled to counteract the more immediate effects of dis-
 ease.
   It is not at all uncommon  in dyspeptic  phthisis to find
 the spleen as well as the liver  diseased.  As the  coeliac ar-
 tery dividing into three branches supplies the liver, stomach,
 and  spleen, may we not suppose that the pain so frequently
 felt  in  the left side and in the epigastrium in this form of
 phthisis, arises from  more than the  due quantity of  blood
 being thrown  into the arteries of the two  latter  organs, in
 consequence of the obstructed state of  the liver?   Is it ow-
 ing to  their being supplied by the same artery,  that we so
 frequently find a diseased  state of the  liver  and spleen  in
 the same subject, and that inflammations of these organs so
 frequently alternate with each other?

    Of the nature of dys\*e\>tic phthisis.

  It is impossible to observe even in a cursory manner the
 symptoms of this disease, without remarking that the state
of the lungs is connected with that of the digestive organs.
 Its causes, we have seen, afford the same inference; and in
those who  die of it, I have  just  had  occasion to remark,
we very frequently find a diseased state, or  proofs of a dis-
eased state having existed, in one of the organs of diges-
 tion.
  A question of the first importance in the treatment of
 this disease here arises.   What is the nature of the relation
 observed between the affection, of the lungs and that of the
 digestive organs in this  species of  phthisis?  Is the one a
 consequence of the  other, or are they simultaneous affec-
tions arising from a common cause?  They  are not simulta-
neous affections,  for  the one almost always evidently pre-
cedes the other.
  In by far the majority of cases in which both the lungs
and  digestive organs  are affected,  the  affection  of the di- 
                   OF INDIGESTION.              177

gestive organs precedes that of the lungs.   In some instan-
ces we find the affection of the lungs the primary  disease.
But in these,  the case does not assume the form above de-
scribed, but that of simple phthisis; and  the hepatic affec-
tion, which is always the most prominent feature of the de-
rangement in the digestive organs when it  is  complicated
with phthisis, does not show itself till  a late period  of the
disease; and then seems only to influence the symptoms by
increasing the oppression and irritation, and hastening the
fatal termination.
   We often observe  the first of these forms of the disease
arise from causes evidently acting on the digestive  organs,
and as far as we can perceive,  in  no degree on the lungs;
and the last,  from causes evidently acting on the lungs, and
in no degree on the digestive organs.
   It seems  to be a necessary inference  from the  preceding
facts, that a diseased state of either set of organs may pro-
duce that of the other.   But the tendency of disease  to
spread from the digestive organs to the lungs is much great-
er, than that to spread from the latter to the former.  We
often see  a slight degree of derangement in the digestive
organs prodvice cough and other pulmonary symptoms, and
derangement seldom exists in all  the digestive organs with-
out producing more or less of  these symptoms; whereas  it
is only after  disease has advanced very far in the  lungs,
that it is apt to spread to the digestive organs, and in the
greater number of instances it proves fatal  without spread-
ing to them.
   When to these circumstances we add/that all  the pecu-
liarities of those cases of phthisis, which are from the com-
mencement accompanied with  disease of the digestive or-
gans,  may  be easily explained  by the  existence of this
disease; and that, as I shall presently have occasion to point
out more at  length, every  thing which relieves  it, at  the
same time relieves the pulmonary symptoms that attend it,
                           Aa 
 178            OF THE  THIRD  STAGE
 the inference appears to be  unavoidable;  that in the spe-
 cies of phthisis, which we  are  considering, the  pulmonary
 disease arises from that of the digestive organs.
   It is not to be overlooked,  however, that it  is  in  those
 most disposed to pulmonary disease that affections of  the
 digestive organs most frequently  produce  it.   We conse-
 quently see this species of phthisis most apt to occur in the
 same habit which disposes to other forms  of that disease.
 This would be more uniformly  the  case, were it  not that
 those who have weak lungs, often have strong digestive or-
 gans ; an observation as old as Hippocrates.  On the  other
 hand, when the digestive organs are naturally weak, or pow-
 erful causes of disease in them  have  existed, particularly
 the free use of spiritous liquors, we  often see it  occurring
 in habits apparently least disposed to pulmonary  disease.
   It will place in a clearer light what has been said of the
 nature of the disease before us, and tend farther to illustrate
 the observations which.have been  made on  the first and se-
 cond stages of Indigestion,  to take  a cursory view of the
 sympathy which exists between the.  state of the  digestive
 organs, and the principal seat  of derangement in some other
 diseases.   I have already had. occasion to refer to a work,
 which no physician,  whatever may be the extent of his ex-
 perience and the  accuracy of  his  observation,  can  peruse
 without advantage, although the  modesty of its author has
 induced him to address it only to those belonging to his own
 branch of the  profession; I  mean  the work  of  Mr. Aber-
 nethy, entitled " Surgical Observations en the Constitutional
 Origin and Treatment of Local Diseases.11
  I believe that  experience has led many others  to similar
 views, but  no other person  has laid them before the public
in the.way  in which Mr.  Abernethy has done,  and those
physicians whose attention has been  directed  to  the same
object, must be happy to see in Mr. Abernethy's  work, a
confirmation of their own observations; and such a  confirma-
 tion as they were not  likely to receive from the work of a 
                   OF INDIGESTION.               179

physician.   The physician's attention is directed to internal
disease ; there his inquiries  naturally begin.   Mr.  Aber-
nethy's, for a similar reason, began with external disease ;
and I believe every physician, circumstanced as I was,  will
feel as I felt on reading his work.  I unexpectedly met him
on a road  where  I did not expect to meet  a surgeon, but
where the assistance of a surgeon was  of greater  conse-
quence than that of any physician could  have been.   From
local, he was unavoidably carrying on his  observations  to
general,  diseases.  The sympathies in question so connect
them that it was impossible for him to do otherwise.   From
general,  I  was,  for the same reason, carrying mine on  to
local, diseases.  In the case of dyspeptic  phthisis which Mr.
Abernethy relates, the reader will find  the principle of the
treatment which  I have  employed in that disease for more
than sixteen years, as appears from what is said in the last
volume of  the  edition of my Treatise on Febrile Diseases
published in 1804; and the following cases, which occurred
to me before I read his work, or  was  acquainted  with his
opinions, and which I shall relate as concisely as I can, will
afford a confirmation of these opinions and  of  the  practice
founded on them in local diseases.
  I mention these cases, because, like Mr. Abernethy's case
of phthisis, they tend to confirm the accuracy  both  of his
observations and  mine; for surely no stronger confirmation
can be required of any  opinion,  than two observers wholly
unconnected, setting out  from the most opposite quarters,
and meeting in the same point.   My plans of practice are
not precisely the same as Mr. Abernethy's, and in particular
the mode of giving mercury  in  internal disease,  which  I
found most successful, is different from his, but the general
principle's the same.
  I have already had occasion to allude to the case of a gen-
tleman who laboured under severe pains  of the legs,  which
had been treated unsuccessfully for two years.   The digest
tive organs were deranged, and the epigastric region tender 
 lg0           OF THE THIRD STAGE
 on pressure.  A grain of blue pill combined with stomachic
 and opening medicines was given mree or four times a day;
 and the pains, with his  other symptoms, disappeared in a
 few weeks.  A gentleman  had sores  continually breaking
 out in various  parts of the body, which  had proved  obsti-
 nate, for which he had been advised  to go through a regular
 course of mercury.  The digestion was  deranged, and the
 epigastrium tender.   He took stomachic and opening medi-
 cines, with a grain of calomel every second or third night,
 and his symptoms disappeared in about a fortnight.  A lady,
 after repeated attacks of illness, remained very weak; glan-
 dular swellings appeared in  different parts of the body, and
 it was feared  that  what is called a general breaking up of
 the constitution was about  to  take  place.   The  appetite
 failed, the bowels were disordered, and the epigastrium was
 tender.  She took sometimes a grain of  blue  pill two  or
 three times a  day, with stomachic and opening medicines,
 and af other times either a few grains  of blue pill, or one
 grain of calomel, according to the state of the bowels every
 second or third night; no application  being made to  the
 glandular swellings, but occasionally two  or three leeches
 when they were tender on pressure.  In about three months
 her complaints disappeared  under this  plan of treatment,
 nothing but a depression of spirits remaining, which was
 removed by change of place.
   In one respect Mr. Abernethy's mode  of giving mercury
 in the cases above alluded to, and that to  which I have been
 led in internal disease, arising from the sympathy  of  other
 parts with the digestive  organs, agree.   It  is from  small
 and undebilitating quantities that good effects are to be ex-
 pected in such cases; given otherwise k weakens the diges-
 tive organs, and often thus increases the disease,
   Mr. Abernethy mentions other internal diseases, particu-
larly those  of the head and  heart,  caused by the deranged
state  of  the  digestive organs.   I have repeatedly seen his
observations on those diseases confirmed; and could relate 
OF INDIGESTION.
181
several cases, to which I have already had occasion to allude,
in which  the patient had for  years  laboured  under symp-
toms of angina pectoris,  and had been treated for this dis-
ease, in which the  case yielded in a few weeks to minute
doses of blue pill combined with stomachic  and opening
medicines,   in  such instances  we must, of course, suppose,
that no organic  disease of the heart  had  yet supervened.
   His  observations on the brain are well illustrated by two
excellent treatises,  by Dr. Cheyne*,  and Dr. Yeatesf, on
the Hydrencephalus Internus.   It seems surprising that the
immediate connexion of this disease, with the state of the
digestive  organs should so long have escaped physicians.
   It is not  meant that hydrencephalus internus, or any  of
the other diseases  to which I allude, always  arises from
affections of these organs.   In many instances they evidently
arise from causes acting on the parts in which  they have
their seat; but were I to  speak from my own experience,  I
should say,  that in at least five  cases of six,  this disease
arises  from the  former cause;  and  that, in  all cases, pre-
serving  a proper  state  of the digestive organs is the«best
means of prevention;  for even where it arises from other
causes, their tendency to produce it  will be greater or less
according to the state  of these organs.
   It is well known that nervous affections will, if I may use
the expression,  mimic the symptoms of almost every disease,
but it  does  not seem  to be generally admitted, although I
think we  have sufficient proof of the fact, that, if this mimic
disease be kept up for  a certain  length of time,  it  will be
converted into the  real disease, let the cause which produced
it be  what it may.  The observations  made in the second
and third chapters, seem sufficiently to illustrate this part of
the subject.
   * A  Second Essay on Hydrocephalus Jlcutus, or Dropsy in the brain, by
 J. Cheyne,  M. D., Dublin, 1815.
   •j- A statement of the Early Symptoms which lead to the Disease termed
 Water  in the Brain, &c, in a Letter to Martin Wall, Esq. M. D., &c, by
 G. D. Yeates, M. D„ &c, London, 1815. 
182
OF  THE THIRD STAGE
 Of the Treatment of Dys\>e^tic Yiithisis.

   In speaking of the treatment  of this form of phthisis, I
 shall follow the same  plan which was adopted  in  speaking
 of its symptoms, confining myself to those circumstances in
 which  it differs from the other  species of the disease.
   As  it  appears, both from the symptoms and  causes of
 dyspeptic phthisis, that  the affection of the lungs is influ-
 enced by the state of the digestive organs, it is reasonable to
 suppose that the means which tend to improve their func-
 tions,  will here  be  a useful auxiliary to those  usually em-
 ployed  in phthisis.   In Indigestion we have seen  that  the
 function of the liver becomes disordered,  and  at length,
 some degree of fulness, and sometimes tenderness on pres-
 sure, of the  right hypochondrium  supervene.  It is after
 these symptoms have supervened, as appears from what has
 been said, that disorder  of the digestive organs  is  apt  to
 affect the lungs; and it is in proportion as we relieve them,
 that we find the affections of  the lungs relieved.
   This  species of phthisis may be divided into three stages,
 in which the  prognosis and mode of treatment are different.
   In the first, the affection of the  lungs  is merely sympa-
 thetic, so that when the cause which produces it is removed
 it ceases of course.   This stage is distinguished by the
 short time which the disease has lasted, by the general mild-
 ness of the symptoms, the fever  in particular being very
 slight, and by there generally being no  expectoration but
 what the cough itself seems to  occasion,  consisting  of a
 colourless phleghm, and for the most part in small quantity.
  Sometimes what is expectorated is in masses of  a  tough
 glairy appearance, and of a blackish  hue, as if mixed with a
 small portion of carbon, which seem  to have lain some time
 in the lungs; the expectoration of which relieves the cough
 which, in this case, is seldom very troublesome.  This last
appearance of the expectorated matter generally indicates
the very mildest  form of  the disease.  It is when there is 
                   •OF INDIGESTION.              18g

U6 expectoration, or when it is thin,  scanty, and  difficult,
that the disease is  most apt to degenerate  into the  more
alarming forms.
  In the second stage of dyspeptic phthisis, the continuance
of the sympathetic affection has produced actual disease in
the lungs.
  There are two ways in which this disease  indicates itself.
The most frequent  is by  some  degree of inflammation su-
pervening  on the surface of some  part of the bronchia,  or
air  cells, in consequence of which  the expectorated matter
begins to be mixed with small portions of a pus-like sub-
stance,  which  gradually increases  as the inflammation ex-
tends, till the quantity, we have seen, is often astonishingly
great.*  Sir Everard  Home, in a treatise on the properties
of pus, has shewn how readily irritation of secreting sur-
faces produces it, independently of any breach of substance.
L?ss  frequently small  vessels,  in consequence of  their be-
ing debilitated by sympathy with the  state of  the  stomach,
analogous  to what  we  have seen sometimes happens in the
vessels  of the  brain,  now and then give way,  which pre-
vents  the  inflammatory  action, so  that  the  expectorated
matter presents no degree of the purulent appearance,  but
is occasionally mixed with blood.
  The symptoms now assume a moie formidable character,
the tendency to fever in particular is greater; but it seldom,
we  have seen, completely'puts on the form of hectic.   In
this stage there is either no breach of substance in the lungs,
or the little vessels which from time to time  give way, soon
heal.  It seems to  be  at this period that tubercles generally
form.   These going on  to suppuration and ulceration,  or
the irritated surface of the  bronchia and air-cells becoming
ulcerated,  the last  stage commences, in  which dyspeptic
phthisis  is nearly  as  fatal,  as any other form  of the dis-
ease.

  •The reader will find many good observations on the tendencies of inflam-
mation of the bronchial membrane in Dr. Hastings late work on this sub-
ject. 
 !g^            OF THE THIRD STAGE

   This stage is indicated by the aggravation of all the symp-
 toms; particularly  by the fever assuming more perfectly the
 form  of hectic,  and the expectorated matter occasionally
 containing both a pus-like  matter and  blood;  although  it
 more frequently happens than in other forms of the disease
 that, where there h.is been no expectoration of blood at an
 early period, none  appears  afterwards.  The expectorated
 matter in different cases, however, assumes  all the various
 appearances observed in the  last stage  of other  forms of
 phthisis.
   In the first stage the disease generally yields readily, ex-
 cept  the  dyspeptic  symptoms are peculiarly obstinate (in
 which case some degree of them has generally been of long
 standing,  or the patient has suffered from former attacks of
 the disease,)  or there  is  such a  tendency to a tubercular
 state of the lungs,  that the hepatic  affection which I have
 had occasion to observe always shews  itself before  Indiges-
 tion produces phthisis, and this state of the lungs occur al-
 most at the same time.
 Such appear to me  to be the chief circumstances which some-
 times render the disease fatal, even when properly treated at
 this early period; but so generally successful is a proper treat*
 ment  at this period, that it required many years' observa-
 tion to convince me that  it will not always succeed, and to
 satisfy my mind respecting the causes of its failure.  The last
 of the causes just mentioned, I'am convinced, is the most
 frequent of them.  It is  evident that when the tendency to
 tubercles of the  lungs is very great,  the case approaches to
 the nature of that form of  phthisis which  originates in the
 lungs themselves, whose fatal  tendency no mode of treat-
 ment, however early adopted, will always prevent.
  It often adds much to the unfavourable  prognosis, to find
 that the patient has scrophulous enlargement  of the more
external glands, which is  frequently such as cannot be seen,
but only felt.   It will be generally admitted,  I believe, that
external glandular swellings and suppurations often tend to 
                  OF INDIGESTION.               ^gj

prevent internal disease.  We see in the same family some
fall a sacrifice  to phthisis,  while  others, labouring under'
these swellings, escape it.   I have seen  a person in the last
stage of phthisis, saved by the glands of the neck suddenly
swelling and suppurating.   But that slight enlargement of
the external "glands, which  may rather be felt  than  seen
while it indicates, is not of  sufficient importance to obviate,
the tendency toainternal disease.
   Provided  there  be  no great  tendency to tubercles, and
the hepatic affection  is not  unusually  obstinate, the  first
stage  of dyspeptic  phthisis generally yields  to  the  usual
means  of  relieving the cough  and  tendency  to  fever;
combined  with  the- milder parts  of  the  treatment of
the  second  stage  of Indigestion,  particularly such art
attention  to diet  as   prevents  the  stomach   being  op-
pressed, and counteracts the inflammatory tendency, keep-
ing up rather a freer action of the bowels than is necessary
in health, and  taking care,  by occasional doses of blue pill
dr calomel, according as the bowels are more or less easily
acted on,  to preserve a sufficiently copious and healthy se*
cretion of  bile.
   I have generally given the mercurial, for  the  most part
one grain of calomel combined  with  the compound extract
of  colocynth, when the bowels  were languid, in other cases
three or four grains of the blue  pill, every second or third
night, desiring the patient  not  to go out the next day, till
it shall have passed off, and if it does not pass off in a cou-
ple of hours after rising, to assist it by an aperient draught.
This part of the plan must be pursued  till the secretion of
bile becomes  healthy.  It  ought then  to be discontinued,
and resumed,  if rendered necessary by  the disordered state
of this secretion recurring.
   By waiting a couple of hours in the morning previous to
giving  the opening draught,  too great an  effect is avoided,
and the effect of the mercurial on the liver better secured;
both of which is more necessary here, than in the first stage
of Indigestion; where  we  have seen it  is  often  more our
                             Bb 
 186        '      OF THE THIRD STAGE
 object to obtain a very  free evacuation, and only the most
 transitory effect of the mercurial.
   The less stimulating stomachic  medicines have generally
 been used,  particularly  when the  appetite  was  much  im-
 paired.
   All of this class of  medicines which possess* any heating
 quality,  have appeared  objectionable.   Even  gentian,  so
 useful in the first stage of Indigestion,  seems  often  to  in-
 crease the cough and the tenderness of  the epigastrium.  I
 have found  extract of  camomile  flowers,  combined with
 small quantities of the powder or  oil of carraway, among
 the best  stomachics in  such  cases; and, unless  the strength
 be much reduced, Epsom salts have appeared to be the best
 assistant to the cathartic effects of  the mercurial.
  The latter I have given, as appears from what has just
 been said* not for the  purpose of moving the bowels,  but
 improving the state of the bile, and therefore only in small
 doses.  The tendency  to phthisis  is a strong additional ar-
 gument for avoiding as much as possible every thing  which
 tends to  impair the vigour of the stomach and  bowels.
  The second stage of dyspeptic phthisis, requires a plan of
 treatment essentially different  from the foregoing.  When
 the disease has been n. glected  till this stage  commences
 which is  not unfrequently the case, or we find that notwith-
 standing the employment  of the above means,  the  sputa
 begin to  assume a purulent appearance, or to  be mixed with
 blood, the  tenderness  of the  epigastrium  continuing and
 an unhealthy secretion  of bile constantly recurring, we may
 be assured that the foregoing means will probably be ineffec-
 tual;  and that if time be lost with  them  till the third stage
 supervenes,  the termination will prove fatal.
  The following is  the plan  which,  under such  circumstan-
 ces,  I have for many  years adopted,  and the  efficacy  of
which originally induced me to offer  my observations on
this#su! ject to the attention  of  the  public.  It consists of a
 combiuauon of the most decisive  treatment ol the second 
                   OF  INDIGESTION.              137

stage of Indigestion with that of phthisis.   We are here to
recollect,  that while it is even of greater importance than in
simple Indigestion  to save the strength, it is  of still greater
importance  to  expedite the cure.  The most to be appre-
hended from delay in the former case is an  increase  in the
severity and obstinacy  of the  dyspeptic symptoms;  but in
the latter the structure of the lungs is threatened, and,  if
the cause of injury cannot  be removed,  will  soon be de-
stroyed.
   One  grain of the blue pill,  combined  with  some mild
stomachic,  was given two or three  times  in the course of
twenty-four hours, and continued either till the  tenderness
of the epigastric region yielded,  and a proper  stcretion of
bile was restored;  or the gums appeared a little  redder and
fuller than natural.
   I have already had occasion to make some observations
on the advantages  arising from mercury given in minute do-
ses.  There is no case in which they are more  conspicuous
than in  that before us.  As  the tenderness  of  the right
hypochondrium abates, and the  state of the alvine discharge
improves, in by  far the majority of  cases  the pulmonary
symptoms gradually disappear.
   With the foregoing  plan I have always combined  means
for  tht purpose of more directly relieving the tenderness of
the hypochondrium.   If it be slight, a succession of small
blisters applied over the tender part is oftm sufficient.   If
 considerable, the blisters should be preceded by. the  loss of
 from  two  to  four ounces  of blood from this  part, from
 which if there be  much  hardness of pulse, although the
 tenderness   be  not considerable,  great advantage  generally
 arises.   When  the  disease is obstinate, or has repeatedly
 recurred, a permanent discharge from the  tender part, es-
 pecially  that  by  a seton, often essentially promotes the
 cure.
    By  these means the quantity of  mercury  required  is
 much lessened.   If the tenderness be very great indeed, no 
 lg8            OF THE THIRD STAGE

 quantity will  succeed unless  we reduce  the  inflammatory
 action. ,
   For the purpose of lessening  the quantity of  mercury, I
 have also combined with it such other means as tend to pro-
 mote a regular and healthy secretion of bile.
   The external use of the mineral acids too much disposes
 to inflammation to be employed in the case before us.  Sa-
line aperients, more or less, promote a due action of the
liver,  and are, therefore, preferable to other cathartics, pro-
yided they are equally suitable in other respects; but of the
means which I have employed  with this  view in dyspeptic
phthisis, none has  appeared equal to the dandelion.   It
ought  always,  perhaps,  to be given  in some form or other
in this disease, if the stomach can bear it in large doses.
   When the patient can take a decoction of it poured upon
camomile flowers for his  common drink;  or,  what  I have
found  better,  can gradually increase the dose of the fresh
expressed juice to two or  three table  spoonfuls, taken  in
camomile tea, three times a day; its beneficial  effects are
frequently very striking.   If it tends to oppress the stomach,
advantage often arises from  infusing  a few cloves with the
camomile flowers.   When the dandelion could be given in
either  of  these ways, I have often given  only half a*grain«
of the blue pill twice or three times a day, and I thijt'k have
generally found as much advantage from this dose, as from
a whole gcain  without the dandelion.
   I have also, particularly where the pulse was  very hard,
seen great advantage from  giving with the mercurial very
small doses, four or five minums, of the tincture of  colchi-
cum repeated  three or four times a day- and it  is of great
Use in  all cases to allay the feverish heat by nitrate of pot-
ash or saline draughts.
   If neither the tenderness of  the epigastrium be removed;
nor the gums a little affected  by the above plan in about a
fortnight,  I have gradually  increased the  quantity  of the
blue pill till one of these  effects  took place.    If  either 
                           OF  INDIGESTION.               Igg

        take place without  relieving the pulmonary symptoms, the
        prognosis is bad.   If the tenderness of the epigastrium con-
        tinue,  the hepatic affection is unusually obstinate:  if this be
        wholly removed without materially relieving the pulmonary
        symptoms, we  have reason to .believe that the  disease has
        made  great progress in the lungs.
           It is surprising from  what states the lungs will sometimes
        recover, when  relieved from  the irritation of the hepatic
        affection.   I  have seen  many   recover, not only  whose
        friends,  but whose physicians, had lost hope of them.  But
        in these  cases  the proper means had not been tried; if these
        have failed,  the hope is no  better  than in other species
        of phthisis.
          AVhere the failure of relief proceeds from the obstinacy
        of the hepatic affection,  some  hope arises from a  fuller
        mercurial  course,  but  it is often fallacious; for, although
        such a plan as  I have recommended may be pursued without
        any diminution of strength, and is generally, by  relieving
•       the  disease, attended  with an improvement of  it;,  a freer
        use  of this medicine, if its advantage be not immediately
        apparent, will generally be found hurtful.
           It sometimes happens that the tenderness of the epigas-
        trium is wholly, but the  pulmonary symptoms  only  par-
        tially, relieved by  the above plan.  In this case the hepatic
        affection  is apt to recur,  always bringing with  it  an in-
        crease of the pulmonary  symptoms,  till the structure of the
        lungs is  at length destroyed.   Here, if the recurrence of
        the  hepatic affection be neglected, the  fatal  termination is
        rapid.  If it be carefully watched and relieved as soon as it
        appears, the case is  protracted, and  the decline  of the pa-
        tient  gradual.  I  have known  cases, where the progress
         of the disease had by such means been  so  retarded, that
         there was little increase in it in the space of several months,
         prove rapidly  fatal on the adoption of another plan.
           But the most fatal case is when the hepatic affection finally
         disappears, the seat of the disease being wholly transferred 
 190              OF THE  THIRD STAGE

 to the lungs, as happens frequently  in the last stage of this
 species of phthisis.   In this  case there is no  hope;  while
 the  hepatic  affection  continues  to recur, there is always
 some  hope, however small, that on its final removal, the
 lungs may recover.
   With respect to  the' parts  of the treatment which are
 common to dyspeptic  and other  forms of phthisis, I have
 little to offer in speaking of the  former.   The  various
 means found useful in other cases of this disease are appli-
 cable here, as far as they do not  tend to renew or increase
 the affection of the digestive organs.  I think I have found
 a  combination  of the extracts of white poppy  and  conium,
 the best anodyne in this form  of phthisis.   Opium is more
 inclined to constipate the bowels  and retard the due flow* of
 bili, and the anodyne power  of the  hyoscyamus  in such
 doses as are  safe, is  not  to be depended  on.   When the
 epigastrium is very  tender,  animal  food and fermented
 liquors  are peculiarly injurious.
   Some suppose th:u mercury is often useful in  phthisis ori-
 gin .1 ting in the lungs.  I have  never found  it so, but I
 think when  it has been employed in such cases on  account
 of other diseases being complicated with them, it has al-
 most always proved hurtful.   I have remarked that in this
 form of the disease it never seems to improve the strength,
 as it generally does in dyspeptic phthisis, by improving the
 digestion.  In  them  the  digestion   is generally good, and
 we have nothing to compensate for the debilitating effects of
 the mercury.
   If there be any case of idiopathic  phthisis in which mer-
 cury is proper, it is one which  I have already had occasion
 to mention, in  which the pulmonary disease  produces dis-
 ease  of  the digestive organs; of which we  still  find  hepatic
 affection the prominent feature, and  which always tends to
 aggravate the original disease.   I have not,  however, found
 it useful in  such cases, which I think may be easily ex-
plained.   In them the pulmonary affection is far advanced 
                  OF INDIGESTION.               iQi
before the affection of the digestive organs appears, and both
on this account and  because  the  former is the original dis-
ease, it cannot be removed by removing the latter.  Btsides,
it is not likely that small doses of mercury will remove the
hepatic  disease, while  the  cause which  produced it still
continues to operate;,and large  doses, if they are capable
of removing it, are  here out of the question.
  If what has been  said in the foregoing observations  on
dyspeptic phthisis be correct, the  principle of  treatment in
other organic  diseases which have a similar  origin may
easily be inferred. r
  We must combine the treatment of Indigestion with that
necessary in the disease which has supervened on it, in such
a way as  never tofose  sight  of  the former; for, however
much the affection of the digestive organs may be relieved
by the  establishment of another disease, it is always apt to
recur; and as far as  I have observed, the recurrence of the
primary,  rarely tends to relieve, and  generally aggravates
the symptomatic, disease.


                      SECTION II.


             Of HabitnaV Asthma.


  I have already had occasion to make some observations
on this disease, and to mention generally the means of  relief
which I have found most effectual.
  We have seen that Indigestion sometimes so affects the
nervous system, or some particular part of it, that perma-
nent debility, either general or partial,  and that with little
or no affection of the sanguiferous system, ensues.
   This is particularly apt to happen in the lungs when Indi-
gestion has been long attended with a considerable degree 
     loo             OF THE THIRD   STAGE

     Of dyspnoea.   In such  cases, I have already had  occasion1
     to observe, the dyspnoea with a tendency to cough sometimes
     remains after all  the  other symptoms  have disappeared,
     and is often but little influenced by medicine.
       It appears from experiments related in an Inquiry into the
     Laws  of the  Vital functions, to which  I have frequently
     had occasion to refer, that after the nervous influence of the
     lungs  and stomach has  been greatly impaired by  dividing
     the eighth pair of nerves, and folding back one of  their di-
     vided ends, in consequence of which digestion is suspended,
     and the breathing rendered difficult; the animal can  be made
     to breathe  with freedom and digest his food by sending  the
     galvanic influence through the lungs and stomach.*

      * See an account  of a repetition of the  above experiments,  with  a
     confirmation of their results,  in the Medical and Physical Journal for
     Mew, 1820; by Clarke Abel, M. D., F. R. S., &c.
      Since the publication of the first edition of this Treatise these experi-
    ments  have again been repeated,  in consequence of several gentlemen
    still thinking that their results required further confirmation.  The fol-
    lowing  is the very candid account of the results given by one of these
    gentlemen, .Mr. Broughtoii, in the twenty-second number of the  Journal
    of the Royal Institution,  pp  326, 7.
     Having stated that  the eighth pair of nerves had been divided in the
    neck of three rabits, pains having been taken to keep  their  divided
    extremities asunder,  and one of the rabbits subjected  to  the  influence
    of the voltaic battery in the way above pointed out, he observes:
     "The galvanised rabbit had remained singularly quiet the whole time,
    breathing freely, and with no  more apparent distress than the twitches
    usually  produced  by the galvanic influence, which in this case was un-
    interruptedly kept up.  The other rabbits laboured strongly in their
    breathing.  They  were  all three killed  at  the same period,  and their
    stomachs successively opened.  In the two non-galvanised rabbits, diges-
    tion had scarcely made any progress, but in that galvanised, it was perfect
    irt'the  manner, to all appearance,  avowed by Dr. Wilson Philip and his
#   supporters.  However we  may differ in opinion, as to the real state of
    the food in the notvgalvanised rabbits, as to Dr. Wilson Philip's  theory,
    or, as  to the cause of the formation of chyme and chyle being found
    under the influence of a galvanic battery, Dr. Wilson Philip cannot be
    denied the merit of correctness in his assertions  (hitherto almost univer-
    sally distrusted,) relative to the simple fact of a certain power of galvanism 
                    OF INDIGESTION.               193

   It is an inference from my own experiments and observa-
tions^  aa well as those  of others, particuferly5 of M. le
 Gallois, that what is called the nervous system, comprehends
two distinct systems, the sensorial,  and the nervous system
properly  so called.   Now,  we  have no reason to  believe •
that  galvanism can  perform any of the functions of  the
sensorial  system; yet,  in  the greater  number of instances
in which it has been used in medicine,  it has been expected
to  restore the sensorial power.   It  has been  expected to
restore hearing, and sight, and voluntary  power.   It  mayf
now  and  then happen  in  favourable  cases, from the  con-
nexion  which  subsists between  the sensorial and nervous
systems, that bv  rousing the energy of the latter, we  may
excite ^the former; or  the sensorial power  may be entire,
and the  fault »in  the nerves which convey its influence.
From our experience of such ca'ses, however, there seems
little reason to hope  that galvanism will often be successful
in them.  We have reason to believe, from the experiments
related  in  the Inquiry just referred to, that galvanism has
no  other  power over  the muscular system than that  of a

producing digestion, after dividing the eighth pair of nerves, under cir^
cumstances in which it is impeded without the galvanism.
  "It ^s proper to state that the President and several members of the
Royal Society, and of the colleges of physicians and surgeous, among
whom were Mr. Brodie  and myself, inspected the progress of these
experiments, which were carried on under the constant superintendance
of Dr, Wilson Philip."
  Mr. Broughton also admits that the experiments afforded reason to
believe that the  nervous  influence  passed by nerves after they had been
divided; and it has from experiments since made been admitted by Mr.
Brodie and Mr. Cutler the gentleman who wtfs so good  as to assist me in
these experiments, that this may happen although the divided ends be
separated by the distance of a quarter of an inch, provided the nerves
be not otherwise displaced.—See a paper relating to this subject in the
twenty-third number of the Journal of the Royal Institution.
  *  See Experimental Inquiry, chap. X.,  and the experiments there re-
ferred to.
                            Cc
0 
 194           OF THE THIRD STAGE
 stimulus;* we are, therefore, to  expect little more  advan-
 tage from it irf diseases depending chiefly  on faults of the
 sanguiferous, system,  than from other stimuli,  &c.   But I
 cannot help regarding it as almost ascertained, that in those
• diseases in which  the original cause of derangement is in the
 nervous  system  properly so  called, where the sensorial
 functions are entire, and the vessels healthy, and the power
 of secrection, which  seems immediately to depend  on the
 nervous system,  is  alone  in fault,  galvarfism will often
 prove a valuable means of relief.
   As soon as the foregoing view of the subject presented it-
 self, I   as led to  inquire  what diseases depend on  a  fail-
 ure of  nervous  influence.  The effect or the stomach and
lungs, of dividing the*.eighth pair of nerves.f answered the
 qaestion respecting two of the  most  important diseases of
 thi- ckss.    We have seen, 'that withdrawing a considerable
 p <rt of the nervous influence from the stomach and lungs
 suspends the digestive powers,  and produces great difficulty
 of breathing.  The following observations relate chiefly  to
 aff ctions of the lungs.   Of the effects of galvanism  in dis-
 ordered digestion, the  principal experience which  I have
 had  has been in cases where it was complicated with asth-
 matic breathing.
   When the effect of depriving the lungs of a considerable
 part of their nervous  influence is carefully attended to, it
 will.be found, I think, in all respects,  similar to the dyspnoea
 which often attends Indigestion, and which, when it remains
 after the other  symptoms have disappeared,  I have called
 habitual asthma.   In this disease the breathing is constantly
 oppressed, better  and worse  at  different  times, but never
 free, and often, we have  seen, continues to  get  worse  in
 defi<nc<*nf every means *.>-• can employ.

   *Comr:vre the experiments related  in the  first and  second chapters
 of this nurt  of the Inquiry with Exp. '70, 71, 72, 73, and the observa-
 tions vviucu foiio'.v  them.
               ■\Exp. Inq. Exp. 44, 45.
m 
                   OF INDIGESTION.              195
  It appeared from repeated trials,  that both the oppressed
breathing,  and the collection of phlegm, caused by the di-
vision of the  eighth pair of nerves, may be  prevented by
sending the galvanic  influence through the  lungs.*   That
this may be done with safety in the human  body we  know
from numberless instances, in which galvanism has been ap-
plied to it in every possible way.
  Such ace the circumstances which led me to expect relief
from galvanism in habitual asthma.   'Although its effects in
this  disease have been witnessed  by other  medical men, I
shall mention nothing in the following pages  which did not
come under my own observation.                ".
  I  have employed  galvanism in  many  cases of habitual
asthma, and  almost uniformly with relief;  and have  found
the affection of the breathing as readily relieved when it ap-
peared  as a primary disease, as when it succeeded to Indi-
gestion.
   The time, during which the galvanism was applied before
the patient said that his breathing was easy; has varied from
five minutes to a  quarter of an hour.   1 speak of its appli-
cation in as great  a degree as the  patient could bear without
complaint.   For  this effect 1 latterly found from eight to
sixteen  four-inch plates of zinc and  copper, the .fluid em-
ployed being one  part of muriatic acid, arid  a hundred and
twenty of water,  sufficient.^  Some require  more than six-
teen.plates,  and a few cannot bear so  many as eight? for the
sensibility of different individuals to galvanism is very dif-
ferent.  It is curious and not easily accounted for,  that a
considerable  power,  that, perhaps, of  twenty-five or thirty
plates, is often necessary on first applying the galvanism, in
order to excite anv sensation;  yet, after the sensation is  once
 excited, the patient shall  not, perhaps, particularly at  first,
 be able to bear more than six or eight plates.
   The stronger the sensation excited, the  more speedy  in
 general is the relief-  I have  known the breathing instantly

                  *Exp. 70, 71,  72,  72. 
 196            OF THE THIRD STAGE
 relieved by a very strong  power.   It  has  generally been
 made a rule to begin with a very weak one, and  increase it
 gradually  at the  patient's  request, by moving one  of the
 wires from one division of the trough to another, and mov-
 ing it back again when he complained of the "sensation being
 too strong.   It is  convenient  for this  purpose  to  charge
 with the fluid about thirty plates.
   The galvanism was applied in the following maimer.  Two
 thin plates of metal, about two or three indues in diameter,
 dipped in water, were applied, one to the nape of the neck,
 the.other, to the .lower part of the epigastric region.   The
 wires,  from the different ends of  the trough,* were brought
 into contact  with these  plates, and as  observed  above, as
 great a galvanic power maintained, as the patient could bear
 without complaint.   In  this way the galvanic influence was
 sent through the lungs  as much as  possible,  in the direction
 of  their  nerves.  It is proper, constantly to move the wirep

  •I found a trough, of the old construction, more effectual in restoring
 the due  action of the lungs than the improved pile.  I was at first at
 a loss to account for this circumstance:  from  many observations, I have
 now reason to believe,  that it arises from such effects of galvanism, like
 its other effects on the animal body, being  proportioned  less to the
 quantity of electricity  supplied by the trough, than to the intensity of
 its electrical and quantity of its chemical power, both of which are pro-
 portioned rather to the number of plates, than to the extent of surface.
  I have repeatedly tried the effects of a powerful electrical machine, in
 habitual asthma.  They are considerable, but inferior to  those of the
 voltaic trough: which I would ascribe to the former possessing much less.
 chemical power, in proportion to the intensity of its electricity, than
 the latter.   The most powerful electrical battery will not readily decom-
pose water without the ingenious arrangement suggested by Dr. Wollas-
ton, for concentrating, as much as possible, its electrical power; while
the power of a few voltaic plates is,  without any precaution, sufficient
for  this purpose.
  I have latterly found a trough, composed  of plates two inches  by
three, nearly, or altogether,  as effectual as one  of plates  four inches
 square.
  There is reason to believe that plates of an inch and half or two inches
 square, would answer medical purposes nearly as well as larger ones. 
•
                   OF INDIGESTION.             197

upon the metal plates, particularly the negative wire, oth-
erwise the  cuticle is injured in the places on  which they
rest.  The relief seemed much  the same, whether the pos-
itive wire was applied to the nape of the neck,  or the pit of
the  stomach.   The negative  wire  generally  excites the
strongest sensation.   Some patients thought, that the relief
was most speedy, when it was applied to the epigastric re-
gion.
   The galvanism was discontinued  as soon as the  petient
said that his breathing was easy.  In the first cases in which
I used it, I sometimes prolonged its' application for- a quar-
ter of an hour,  or twenty  minutes, after the patient said he
was perfectly relieved, in the hope of preventing the early
recurrence of the dyspnoea; but I did  not find that it had
this effect.
   It is remarkable,  that in several who had laboured under
oppressed  breathing for from ten to twenty years, it gave
relief quite as readily as in more recent cases;  which proves,
that  this habitual difficulty of  breathing, even in the most
protracted cases,  is  not  ascribable to any change having ta-
ken place in the more evident mechanism of the lungs.
   With regard to that form-of  asthma which returns in vi-
olent paroxysms, with intervals of perfectly free breathing,
I  should expect  little advantage from galvanism in  it;1 be-
cause as I have just observed,  I found that the peculiar dif-
ficulty of breathing, which occurs in this species of asthma,
Cannot  be induced in animals,  by diminishing the nervous
influence of the lungs.   It is probable, that in the human
 subject  the cause of this disease is spasm, from which, in-
 deed, it takes its name; and  we have no reason to  believe,
 from what we know of the nature of galvanism, that it will
 prove the means of  "relieving  any affection of this kind.
    Galvanism  is  sometimes  useful in  protracted  cases  of
 spasmodic asthma,  when  the fits have become less severe
 and more or less difficulty of breathing is almost constantly
 present; in  short, when the spasmodic has assumed a good 
•
   198            OF THE THIRD STAGE
   deal of the form of habitual asthma.   Even  in these cases,
   however, as  far as my  experience has  gone,  the  relief af-
   forded  by it is very imperfect,  and of short duration.  It
   is often such, however,  as  very  sensibly aids other means.
    The spasmodic  asthma is comparatively a  rare disease,
   not o.ie case of it occuring for at least fifty of habitual asth-
   ma.
    Of the first cases of habitual asthma, which I saw, mar
   ny'occurred in  work-people of the city where I then  resid-
   ed, who had  been obliged to  abandon their employments in
   consequence of it, and some of them, from its long contin-
   uance,  without any hope  of returning to  regular  work.
   Most of them  had tried the usual means in vain.  By the
   use of galvanism they were  relieved  in different  degrees,
  bu: all sufficiently to be restored to their employments.  I
  afterwards saw sever&l  of them, who, although  they had
  not used galvanism for many months,  said they had contin-
  ued to work  without inconvenience.   Some,  in whom the
  disease had been wholly removed, remained quite  free from
  it? some  had had  a return of it, and derived  the same ad-
  vantage from galvanism as at first.
    The application of galvanism  was confined to  asthmatic
  dyspnoea.  In all inflammatory cases  it would  be injurious;
  and, in cases  arising from dropsy, or any other mechanical
  impediment, little or nothing, it is evident, is to be expected
.  from it.
    If the  secretion of bile  continue  to  be disordered, and
  there is tenderness on pressure in the hvpochondric  region
  the  means, which have been pointed out in the third chapter
  must be employed for the purpose of relieving these  symp-
  toms  previous  to  the use of   galvanism;  and  to  these
  means  alone the  dyspnoea  sometimes •yields; but I  have
  learned  from a prett)  extensive  experience,  that in a large
  majority  of such cases it will resist them, yet readily admit
  of relief  from galvanism. 
                   OF  INDIGESTION.              199

  If there be little tendency to  inflammation,  galvanism is
also a  means of relieving the affection of the digestive  or-
gans.   In all the cases where habitual asthma was compli-
cated  with symptoms of Indigestion, the latter  as  well as
the former were relieved by it.   I  have repeatedly seen .
from it the  same effect  on the  biliary system  which arises
from calomel, a copious bilious  discharge from  the bowels
coming on within a few hours after its employment.   This#
seldom happens except where there appears to have  been a
failure in the secreting  power  of the liver, or  a defective
action in the gall tubes.
   I have not found that the presence even of a severe cough,
which is common in habitual asthma, in which there  is al-
ways  more or less cough,  counter-indicates  the  use of gal-
vanism.   The cough, under its u^e, generally becomes less
frequent in proportion as the accumulation of phlegm in the
lungs is prevented;  but it seems to have no direct effect in
allaying it.   During the  application of the galvanism the
patient is often  excited to cough up  the phlegm, which is
oppressing  the  lungs.   It frequently,  however, disappears
without being coughed up.
   In some cas.es the cough continued troublesome after  the
dyspnoei  had disappeared.  Galvanism never  appeared to
increase   it,  except  when the inflammatory  diathesis  was
considerable.  In the most chronic forms of phthisis, where
the symptoms had lasted for several years and habitual asth-
ma had  supervened, I have  seen  the relief obtained from
galvanism Very  great, notwithstanding some admixture of
a pus-like substance in  what was  expectorated.  In these
cases it  relieves the breathing,  leaving the other symptoms
little  changed.  I need hardly add, after what has been said,
that in ordinary cases of phthisis nothing could be more im-
proper than the use of galvanism.
   The dyspnoei arising from phthisis and that from habitual
 asthma are easily distinguished.  The former  is less vari-
 able.  It is  generally increased by the exacerbations of the 
 *o00           OF THE THIRD STAGE
 fever, and always by exercise.   When  the  patient  is still
 and cool, except in the last stages of phthisis, bis breathing
 is-generally pretty easy; and is seldom much influenced  by
 changes of the weather, except they increase the inflamma-
 tory tendency.  The latter is worst  at particular, times  of
 the day, and frequently  becomes  better and worse without
 any evident cause.   At the times when  it is better the pa-
 ticut can  often  use  exercise without  materially increasing
 it.   Its exacerbations are unaccompanied by any increase of
 fever.  Changes of the  weather influence it much.   It is
 particularly apt to be increased  by close and foggy weather.
   When there is a  considerable  tendency to  inflammation
 in-habitual asthma, the repeated application of  galvanism
 sometimes increases it sO much, that the  use of  this influ-
 ence no longer gives relief till  the  infl-«mmatory tendency
 is subdued by  local blood-letting.   It  always gives relief
 most readily, and the  relief is generally most permanent in
 those cases which  are  most free from inflammatory ten-
 dency, and least complicated with other diseases,  the chief
 complaint being a sense of tightness  across the  region  or
 the stomach, impeding the breathing.  The patients re-
 marked that the sense of tightness gradually abated, while
 they were under the influence of  the galvanism, and that  as
 this happened their  breathing  became  free.   The  abate-
 ment of the tightness is often attended with a sense of warmth
 in the stomach, which seems  to come in its place.   This
 sensation is most frequently felt  when the negative wire  is
 applied near the pit of the stomach, but the relief does not
 seem  less when it is not felt.
  With respect  to the continuance of the  relief obtained by
 galvanism, it is different  in different cases; in the most se-
 vere cases it does not Ust so long as  in  those  where  the
symptoms are  slighter, though of equal continuance.  This
observation, however,  does  not  universally apply.   When
the patient is galvanised in the morning, he generally feels
its good effects more or less till next morning.   In  almost 
OF INDIGESTION,
20 i
all, the repetition of the  galvanism gradually increases the
degree of permanent relief, but  its increase is much more
rapid in some cases than in others.
  The permanency of its good effect in the disease  before
us, has  appeared very  remarkahly in several cases where
the  symptoms, after having been removed by  it, were re-
newed after intervals of different duration, by cold or other
causes.  In these cases,  means which  previous to  the use
of galvanism, had failed to give relief, were now success-
ful without its aid; or with few applications of it compared
with those which had been necessary in  the first instance.
I have not yet seen any case, in  which galvanism had been
of considerable  advantage, where its good effects appeared
to have been  wholly lost.   Taking  cold  and the excessive
use of fermented liquors have been the principal causes  of
relapse.
   The galvanism has seldom been used  more  than  once a
day.   In some of the more severe cases it  was  used mor-
ning and  evening.   About a sixth part of those who have
used it  appear,  as  far as I yet know, to have obtained a
radical cure.   It in no case failed to  give more or less  re-
lief provided  there was little  inflammatory tendency.  It
failed to give  considerable relief only in about one-tenth;
 I may add, that  were it  only  the means of present relief,
 we  have reason  to  believe that, being  more  innocent, it
would  be found preferable  to the heating, spiritous,  and
 soporific medicines, which, are  so constantly  employed in
 this disease.
   As a very  small galvanic power,  that of not more than
 from four to  six  three-inch double  pl.ites, often relieved
 the dyspnoea,  may we not hope that  a  galvanic apparatus
 may be constructed, which can  be worn by the patient, of
 sufficient  power to prevent  its recurrence in  some of  the
 cases in which  the occasional  use of the remedy does  not
 produce a radical cure ?
                            Dd 
202             OF THE THIRD STAGE
   I wished to try if the impression on the mind,  in the
employment of galvanism, has any share in the  relief ob-
tained from it.   I found that by scratching  the  skin  with
the sharp  end of a wire, I could produce a  sensation so
similar to that excited^bv galvanism, that those  who had
most  frequently  been  subjected to this influence were de-
ceived by  it:  By this method, and arranging the trough,
pieces of  metal,  &c, as usual,  I deceived several who had
formerly received  relief from galvanism, and  also several
who had not  yet used it.  All of them said  that they ex-
perienced  no  relief from what was done.
   Without allowing them to rise, I substituted for this pro-
cess the real application of galvanism, merely by immersing
in the trough without their knowledge, one end of the
wire  with which I had scratched the nape of the neck, the
wire  at the pit of the stomach having been all  the  time
applied as usual  by the  patients  themselves.  Before the
application of the galvanism had  been continued as  long
as the previous  process, they all said they were relieved,
I relate the particulars of the two  following experiments,
because they point out two circumstances of importance, in
the application of galvanism in asthmatic  cases, and in
judging of its modus operandi.
   The  first  was made  on  an intelligent lady,  of*about
thirty-five years of age, who had for many  years laboured
under habitual  asthma.   Her  breathing was very much
oppressed at the  time  that she  first used galvanism.   The
immediate effect  was,  that  she breathed with ease.   She
said she had  not breathed so well for many years.  Part of
the relief  she obtained proved permanent,  and  when she
was galvanised once a day for about ten minutes she suf-
fered little dyspnoea at any time.   After she had been gal-
vanised for eight or ten days, I deceived her in the manner
just mentioned.   The  deception was complete.   She  told
me to increase or lessen the  force of the galvanism, as she
was accustomed  to do, according to the sensation it produ- 
                   OB  INDIGESTION.              203
 ced.   I obeyed her directions by increasing or lessening the
 force with which I scratched the neck with the wire.  After
 I had done this for five minutes, she said the galvanism
 did not relieve her as usual, and that she felt the state of
 her  breathing the  same as when the operation was begun.
 I then allowed the galvanism to pass through the chest, but
 only through the upper part of it, the  wire in front  being
 applied about the middle of the  sternum.  She  soon said
•that  she felt a  little relief;  but  although it was continued
 in this way for  ten minutes, the relief was imperfect.   I
 then directed her to apply the  wire in  front  to the  usual
 place, so that the influence 'might  pass through  the whole
 extent of the chest; and, in a minute and a half, she said
 her breathing was  easy, and that  she now  experienced the
 whole of the effect of the  former applications of the rem-
 edy.
   To try how far the effect of galvanism  in asthma  arises
 merely  from its stimulating the  spinal  marrow, in a young
 woman  who had been several times galvanised in the  usual
 way  the wires were  applied to the nape  of the neck and
 small of the back, and  thus the galvanic influence was sent
 along the spine fof nearly a quarter of an hour.  She said
 her  breathing was  easier, but not so  much  so as  on the
 former applications of  the galvanism; and on  attempting to
 walk up stairs  she began to pant,  and found her breathing,
 when she had gone about half way, as difficult as before the
 galvanism was  applied.  She was then  galvanised  in the
 usual way for five minutes: she now said her  breathing was   *
  quite easy, and she  walked up  the whole  of the   stairs
  without bringing ort any degree  of panting, or feeling any
  dyspnoea.  The above  experiment  was made in the presence
 of  four medical gentlemen.   This patient, after remaining
  free from her disease for about half a year, returned to the
  Infirmary, labouring under a slighter degree of it, and ex-
 perienced immediate relief  from galvanism.   The disease
 seemed to have been  renewed  by cold, which had at the
■N 
 g04<         •  OF THE THIRD  STAGE
 same time  produced other complaints.  This is one of the
 cases above alluded to in speaking of the  permanency of
 the good effects  of galvanism.  On the return of this pa-
 tient to the Infirmary,  two or  three applications  of gal-
 vanism, combined with  means which  had given no perma-
 nent relief to the dyspnoea previous to her first using gal-
 vanism, now soon removed  it.  When she first used this
 remedy, it required its constant employment once or twice
 a day for several weeks  to produce  the same effect.
   Many  medical gentlemen,  I  have already had occasion
 to observe,  have frequently witnessed the relief afforded by
 galvanism in habitual asthma;  and Mr. Cole, the house sur-
 geon of  the  Worcester  Infirmary, authorizes me to say,
 that no other means there employed have been equally effi-
 cacious in relieving this  disease.
   In the foregoing account of  habitual asthma,  I have en-
 tered more fully than would otherwise have been necessary,
 into the diagnostic symptoms of this disease; because it has
not, in  general, been particularly distinguished from other
 species of dyspnoea; nor indeed considered as a distinct dis-
 ease, although  it often appears as such.
  Observations similar to the  foregoing respecting the  use
 of galvanism,  there  is reason  to believe, will be found to
 apply to other cases of  Indigestion;  but,  as  I observed
 above, 1 cannot speak with the same certainty  of its effects
 in these cases,  having made but few trials of galvanism in
this disease, except where it was complicated with habitual
asthma, the  removal of which, by enabling the patient to use
exercise*, no doubt' contributed  to  a  more healthy  action
 of the digestive  organs,  which  always ensued when these
 organs  had been deranged, which was generally the case
 this  disease  much more  rarely appearing as  an idiopathic
 affection, than as the consequence of Indigestion.

  * The effect of indolence, in painful diseases, is often much less inju.
 rious than in health.   Pain, if not so great as to overpower, in some de-
 gree, comes in place of exercise, in preserving the  general activity of
 the functions. 
                 OF INDIGESTION.               go 5
  In some, galvanism, at the time  of its  application, occa-
sions a tendency to sighing; and in  some, in whom it  re-
moved the dyspnoea, it seemed to occasion a permanent
sense of sinking referred to the pit of  the stomach.  This
was easily relieved by small doses of carbonate of iron and
bitters, without any return of the  dyspnoea.  It generally
gave a great degree of relief to the dyspnoea, when it pro-
duced this effect.
  In the  Inquiry into the Laws of the Vital Functions, to
which I have frequently referred, the reader will find cases
related, in which habitual asthma  was relieved by galva-
nism, and some in which it wholly removed this disease.  ,
THE END. 
I ^"HARRISBURG
PRINTED BY WILLIAM GREER
:1
 GR1 
 
NLM032772594