f *%-* * - * -if? ** £v Xs . ,2yQczy%&c^aozzzozyzyz6ao(z®Q>o$ .; Surgeon General's Office \\ j&&£w^ ^ZZZ ZQZQZCZCZDZDZQZQZO'OOZm 0 K V TREATISE ON AND ITS CONSEQUENCES, CALLED NERVOUS AND BILIOUS WITH OBSERVATIONS ON THE ORGANIC DISEASES, IN WHICH T1IET SOMETIMES TERMINATE. BY A. P. W. PHILIP, M. D. F. R. S. Ed. &c. THIRD EDITION, WITH SOME ADDITIONAL OBSERVATIONS. PHILADELPHIA: ■ v '/ H. C. CARET AND I. LEA, CORNER OF CHESTNUT AND.FOURTH STREET, AND J. CRISST, NO. 177, CHESTNUT 6TREET. • J. Crissy & G. Goodman, printers. 1823. ©©STEffiSTS Page Preface - vii Preface to the first edition i - - - ■> i* A TREATISE, &c ------ n CHAPTER I. Of THE SYMPTOMS OF INDIGESTION - - - "14 Of the symptoms of the first stage of Indigestion - ib. Of the symptoms of the second stage of Indigestion - 25 Some observations on the third stage of Indigestion 30 Of the various forms and comparative duration of the different stages of Indigestion 33 CHAPTER II. Of THE CAUSES OF INDIGESTION 37 Section i. Of the process of digestion .....ib. Section ii. Of the remote causes of Indigestion . * - - 46 Section hi. Of the immediate causes of Indigestion - - 53 CHAPTER III. Of the treatment of Indigestion - 7fl VI contents. Section i. Page Of the treatment of the first stage of Indigestion - 70 Of the diet in Indigestion - - - - - 71 Of exercise in Indigestion ----- 88 Of the medicinal treatment in the first stage of Indiges- tion ........96 Of the preparative means - - - - - ib. Of the treatment when the disease is confined to the stomach and bowels ----- 99 Of the treatment when the disease has spread farther than the stomach and bowels - - - - 109 Section ii. Of the treatment of the second stage of Indigestion 116 Of certain trains of symptoms, whose treatment does not fall under the general plan of cure - - 137 Of the concurrence of the second stage of Indigestion and fever - *•-/ - - 152 *, Recapitulation - - - - - -157 CHAPTER IV. ♦ Of the third stage of Indigestion. - - - 159 Section i. Of dyspeptic phthisis - - - - - 162 Of the symptoms of dyspeptic phthisis - ib. Of the causes of dyspeptic phthisis - - - 167 Of the appearances on dissection in dyspeptic phthisis 168 Of the nature of dyspeptic phthisis - - - 169 Of the treatment of dyspeptic phthisis - - . 174 Section ii. Of habitual asthma ------ ]83 Of the employment of galvanism in habitual asthma ib. PREFACE TO THE FIRST EDITION. My chief objects in the following 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 Jhem to assume the various forms in which they are presented to us, and to deter- mine the appropriate treatment 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 phenomena and treat- ment 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 show, that on a correct knowledge and consequent 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 dis- ease are indicated. 1 have endeavoured to ascertain the nature of these changes, and the manner in which they influence the va- rious functions, and at length, in many instances, destroy the or- ganization of some vital part. Viii prefacl. 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 determine 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 ol the following Treatise, recourse has not been had to the works of others. It can not, therefore, be regard- ed as an attempt to present to the reader the sum of our know- ledge on the subject. I offer it simply as the result of my obser- vations, and the reflections suggested by them, during a space of twenty-five years. PREFACE TO THE SECOND EDITION. In revising the following Treatise, the author's only object has been to render it more useful to the practitioner. As hardly half a year has elapsed since its publication, any con- siderable enlargement of it is not to be expected; but he. hopes that the present edition wjtl be found in several respects improved. Many observations have been added, and an attempt has been made, in several passages, to explain more fully the principles which led to the treatment recommended in it, the author's con- fidence in which, he is happy to say, has been strengthened since the appearance of the first edition, by communications from seve- ral physicians, to some of whom he has not the honour of being personally known. For the sake of hasty readers, who seldom see arrangement in a work where the subject is at all complicated, without numerous divisions and references, the author has introduced a greater num- ber of these, which, to the diligent who bear in mind the plan laid down and feel no difficulty in perceiving how the different p^rts of the subject arrange themselves under it, are often super- fluous, and therefore unwelcome interruptions. o & J>: A TREATISE ON INDIGESTION, &c. It is a remarkable fact, that there is hardly any disease less understood than that which is most frequently presented to us, and known under the vague denominations of bilious, nervous, and stomach complaints; which seems the more extraordinary because there is none of greater importance, whether we regard its variety, its consequences, or its connexion with other diseases. This arises, I believe, from two circumstances. The first re- lates 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 termi- nation, 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 symp- toms, which preceded the indurated liver, and distended abdo- men? The second circumstance to which I allude, relates to the causes of the disease. We know that the digestive power of the stomach, depends on a fluid secreted in it, and consequently, that a deranged state of this fluid must be the cause of the symp- toms of Indigestion; hut we can make little practical use of this knowledge, unless we know the immediate causes of its derange- 12 ©N indigestion ment, 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 relieved by opposite plans of treatment, it is evident, can not 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 form a more or less prominent feature in all, and all begin with these symptoms. I prefer this term to dyspep- sia, which has been employed by medical writers to express a dis- ease much less varied, and of much less extent than that I am about to treat of. Indigestion, therefore, in the sense in which I shall use this term, is not synonymous with dyspepsia, but in- cludes 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 consequences; in the se- cond, consider the remote causes of this disease, the manner in which they excite it, and the nature of the changes which take place in its progress; in the third, detail the plans of treatment which have appeared to me most successful in it; and in the last, make sqme observations on the symptoms and treatment of the organic derangements, in which it often terminates. By a disease we mean, not only that collection of symptoms which are present at any one time, but also those which appear in succession, arising from the same source. We shall find In- digestion the most varied of all diseases. Beginning from simple and apparently unimportant deviations from health, it gradually AND its consequences: 13 becomes so complicated, and often, at length, so undermines every power of the system, that it is difficult to give a view of its symp- toms, which shall be at once sufficiently full and distinct. It is an affection of the central part of a most complicated structure, ca- pable of influencing even its remotest parts, and each, through many channels, and in various ways. 14 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 account 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 Symptoms of the First Stage. The first symptoms of Indigestion are either such as immedi- ately arise from the undigested food itself; or from the state of the stomach and bowels, which causes the disease, and the irritation of their nerves, occasioned by the undigested food, or their own vitiated secretions. The symptoms which immediately arise from the undigested food are flatulence, distention of the stomach and bowels, and acid, oily and putrescent eructations. From the debility of the stomach and bowels, and irritation of the nerves, a greater variety of symptoms spring. Organs of such importance in the animal economy can not long be so deranged as to produce vitiated secretions, without 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, produce some of those other effects which we witness, when the powers of the stomach are disordered by any offending cause. op indigestion. 15 An emetic, while it remains on the stomach, destroys the ap- petite, occasions nausea, sometimes pain, and produces, in conse- quence 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 subdued. 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 more permanent nature, and that the contents which irritate its surface, although often remov- ed, as in the case of the emetic, are soon reproduced, we shall find little difficulty in perceiving the general rationale of the symp- toms of this disease. But, in order more particularly to ascertain the state of the stomach and bowels in its various stages, it will be necesssary 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 very commence- ment of the disease, they are often the only symptoms which oc- casion much uneasiness, from which it appears, that the functions of the stomach may, for a certain time, be so disordered as to pro- duce a feeble, or otherwise vitiated secretion, without in any other way very sensibly affecting the functions of the system. People frequently complain of a sense of distention after eating, and flatulent and acid eructations, who notwithstanding, enjoy good general health; and find that even these symptoms may be pre- vented by taking less food, and that of a more digestible quality; and, if they are prudent in this respect, and the constitution is otherwise sound, and not exposed to the effects of indolence, and other causes weakening the nervous system, the stomach will often recover its powers without further means. In the majority of cases, however, either from neglect on the part of the patient, or a greater degree of obstinacy in the cause,. 16 of the symptoms the above symptoms continue to recur. This never happens for anv great length of time, without the other parts of the alimentary canal partaking of the disease. Their secretions also begin to sufftr some deviation from the healthy state. Those of the intes- tines, for the most part, are impaired in quantity, and, at the same time, probably altered in quality. The bowels do not act so readily as usual, and they are occasionally distended and tense, especially some time after eating. The mouth is clammy, and the tongue more or less furred, particularly in the morning. But these symptoms, the patient finds, yield to some mild ape- rient, which, at the same time, promotes the action of the stomach, and his feelings on the whole, differ bat 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 bis feet being cold but still his strength, and general appearance, are but little affected, and he seldom thinks it necessary to pay particular attention to symptoms which appear so slight, and for the time yield so readily. 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 general, is the first thing which seriously calls his attention to the disease. The mind, if the disease pro- ceed, partakes of these returns of languor, and the patient at length finds it difficult at all times to command his attention, and upon the whole, that he is not capable of his usual mental efforts. His sleep is disturbed by perplexing dreams, and sometimes by fits of nightmare. In a large proportion of cases, however, he enjoys good nights, and even those who are troubled with dream* ing and restlessness, often feel more drowsy'than usual. He now becomes alarmed, and occasionally feels a degree of despondency. Instead of thinking too lightly of his complaint, he often regards it in the most serious point of view, and can not be persuaded that any thing less than some important derange- ment, can produce the anxiety arid depression by which his atten- tion gradually becomes wholly engrossed; for none but an atten- tive physician can know how slight a derangement of the alimen- ON INDICESTION. 17 tary canal, especially after the habit of disease is formed, is ca- pable of essentially influencing every function of the system. While the symptoms thus proceed, a change, sooner or later, takes place, which marks an important step in the progress of the malady The alvine discharge begins to deviate from the healthy appearance: it 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 theu almost wholly.consists of undigested bits of food. When there is much straining, it often contains mucus in distinct masses, and not unfrequently, substances resembling bits of mem- brane. It frequently separates from the canal with more difficulty than usual, and leaves a feeling of the bowels not having been completely emptied. We have reason to believe that the above change and variety of colour arise chiefly from the state of the bile, to which the al- vine 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 generally infer that the function of the liver is duly performed. The disease has hitherto been what is called stomach com- plaints. 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 ner- vous complaints. The former of the two last appellations has also arisen from the bile, of which there is sometimes a super- abundant secretion, being, occasionally, in consequence of the inverted action of the duodenum, thrown into the stomach; and (here exciting nausea, headache, and bilious vomiting. Many conceive that the changes of colour in the alvine dis- charge are often to be ascribed more to circumstances in diet, ind changes which the contents of the bowels undergo in their 3 18 OP THE SYMPTOMS 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 milk diet pro luces 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 mv experience, however, these causes, on the whole, produce less effect than might be expected, and with a little at- tention on the part of the practitioner, will seldom mislead'him. It must always be kept in view, that the appearand of the dis- charge often changes, when it has remained for soaie time out of the body. The urine also deviates from the healthy state. In its most healthy state, it is perfectly transparent 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 the purpose of ascertaining the effects of various circum- stances in diet, &c , on the state of the urine, an account of which the College of Physicians of London did me the honour to pub- lish in the last volume of their Transactions^ that when acid greatly prevails in the stomach 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 wheB the skin has been unusually excited, or an alkalescent state of the stomach and bowels prevails, it becomes turbid, and deposites a white se- diment, whieh has been ascertained, by the experiments of Dr. Wollaston, to consist of the phosphates of the urine. Both these states, particularly the former, are more apt to ap- pear in Indigestion than in ordinary health; and the urine in this disease is sometimes co ered with a very thin oily film, which OF INDIGESTION. 19 appears to arise from an imperfect state of the assimilating pro- cess. Sometimes also it is limpid, and passed in unusually large quantities, more frequently scanty and too high coloured. It is then most apt, as we should a priori expect, to deposite the above sediments unless some degree of fever prevail, when it often either deposites 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 remaining scanty and high coloured, wheu the bowels are constipated; and flowing freely, and of a paler colour, as soon as a free dis- charge 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 bowels are constipated, and for the operation of cathartics alone to be followed by a free discharge from the kidneys, The copious flow of urine which sometimes attend Indigestion 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 in- crease of that from the former, if they have not by sympathy partaken too much of the state of the skin. Thus in dyspeptics an unusual application of cold to the surface, when the powers of* the systtm 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 disease, that, although the increased discharge from the bowels 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 wtien 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 20 OF THE SYMPTOMS 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, labouring under extensive abdominal disease, and apparently re-collected 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 alvine 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 journals of the day (1797) in which an individual could eat 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 super- fluous quantity of food ran off by profuse night-sweats. The sensible change in the appearance of the alvine secretions 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 va- ' Tiable, diarrhcea often supervening without any evident cause, almost uniformly followed by fits of constipation. These, the pa- tient finds, can not now be removed by the simple medicines which at first restored due action to the bowels, larger doses or more active medicines are necessary, and their effect corresponds with the previous state of the bowels. The discharge is generally unsatisfactory, something seeming to be retained. It is very often watery, or frequeDt 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 fol- lowed 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,. OF INDIGESTION. 21 After this state of irritation has continued to recur for a great length of time, a degree of permanent spasmodic stricture some- times appears to take place in the rectum. This I have known happen to such a degree as to give a tape-like appearance to the alvine discharge for many months without intermission, and sug- gest the idea of organic stricture, till an examination of the part proved its real nature. A more temporary contraction of the rec- tum, occasionally giving this appearance to the discharge, is not an uncommon symptom. In the meantime the patient is harassed with a variety of other symptoms, arising from the irritation occasioned by the morbid contents of the alimentary canal, increasing languor, 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 dis- tressing symptom of the disease, or of weight in the right hypo- chondrium or lower part of the abdomen, with unusual disten- tion of the former, sometimes disappearing in a day or two, par- ticularly 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, particularly after the unsatisfactory operation of cathartics, al- most amounts to syncope, and a despondency that is hardly equal- led in any other disease. As these symptoms proceed, others, the consequence of the sym- pathy which exists between the stomach and other parts of the system, gradually show themselves. These are different in dif- ferent parts, and other complaints, of the head, affections of the sight, and hearing, smell, or taste. More or less habitual in- flammation, and even ulceration of the throat are by no means uncommon, and the voice and articulation are sometimes various- ly affected. The patient is distressed with spasms of the trunk or limbs, numbness, and even temporary loss of power in the Iat- 22 OF THE SYMPTOMS ter; and feelings of endless variety are described as sometimes in one part of the body and sometimes in another. By constant recurrence of such attacks without being uniformly 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 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 bo ly becomes emaciated, and more permanently feeble, the strength by degrees rallying less readily and less per- fectly after the frequent returns, and what was at first only a tem- porary depression from a debilitating cause affecting the nerves of the alimentary canal, is gradually changed into real debility, the 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 called depres- sion of strength. In the latter the action of the vital powers is only impeded, in the former their vigour 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 slow- ly, and in all cases slowly removed. We have an instance of depres- sion of strength in the effects of an offending cause in the stomach and bowels, which cease as soon as the cause ceases to operate; of debility in the effects of repeated irritation of these organs, which continue after the cause of irritation no longer exists. Thus the de- bility, which appears suddenly at the commencement as well as at otherperiods of Indigestion, is of trifling importance, compared with that more permanent debility which supervenes gradually, the symp- toms of which are often slight compared 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 inter- nally; the other proves that the powers of the constitution are OF INDIGESTION. 23 yielding to the disease, -g'lelltl 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 this is the case with respect to the right side. In the progress of the dis- ease, lying on either side becomes uncomfortable, and, in its ad- vanced stages, the only easy position is on the back, with the shoulders a little raised, and generally inclined to the right side. Such is the general course of the disease we are considering. Those who are acquainted with the laws of sympathy, which in so striking a manner modify the phenomena of disease, will expect, that in the parts which most sympathize with the stomach and bowels, and consequently partake 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 affect- ed from the commencement. Their secretions become more and more thick and clammy, the former being covered with a white or brownish mucus, which also more or less adheres to, and irri- tates the fauces; sometimes all these parts are more or less parch- ed and stiff, at other times the saliva is morbidly thin and copious, the tongue being cleaner but often of a whitish and sodden appear- ance. In protracted cases when the symptoms* have been rather ' obstinate than severe, and considerable debility has come on, this I* symtom is often very troublesome, the saliva frequently running from the mouth. In the advanced stage of the more severe cases, there is often • a viscid frothy secretion from the fauces, while the mouth in gen- eral 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 aphtha:. This stale of it is seldom 3-4 OF THE SYMPTOMS observed except when a considerable degree of fever has super- vened, which is not uncommon at these periods. The skin, in protracted cases, often becomes dry, shrivelled, and sometimes, at length, almost scaly, and the hair is parched 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 tem- perature as he is chilled by a low one; wounds heal less readily than usual, and the skin is not unfrequently affected with a trouble- some itching, which often sjiifts its seat, or with nettle rash, herpes, and other species of eruptions, and even ulceration some- times supervenes without any evident cause. Besides the more transitory symptoms in the head, which have been mentioned, there are often marks of an habitual undue de- termination of'blood to the brain, producing languid inflammation of the eye lids, tinnitus aurium, and occasionally throbbing of the temples. Some are oppressed with drowsiness, sometimes almost approaching to stupor, others with almost constant pain more or less severe, sometimes in the back of the head, more frequently in the fore part, others are subject to giddiness, and some even to sudden fits of insensibility. The thoracic viscera are often particularly affected, occasional, • and not unfrequently, more or less permanent, dyspnoea super- , venes, and the patient is sometimes harassed by a dry and ifrita- ' . ting cough, or with fits of palpitation. When expectoration attends the cough, it is generally difficult, but brings considerable temporary relief. It deserves notice, thai. in this stage of the disease, he more frequently complains of pair. in the left than in the right side; but the seat of the pain is very- various, not unfrequently, it 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 re- .peatedly known continue for years, even attended with the more characteristic symptoms of angina pectoris without organic affec- OF INDIGESTION. 25 tion of the heart having supervened, although under such circum- stances 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 affection is apt to be worse at night, so that the patient turns himself in bed with difficulty and pain. Of the Symptoms of the Second Stage of Indigestion. At various periods of the disease, for the most part after repeat- ed 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 circumscribed, and always lies about half way between the end of the sternum and the place at which the lowest of the cartilages begins to ascend; and the cartilage itself near the tender part often 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 out by the physician. This symptom never exists long and to any considerable 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 considerable, that the pulse be- comes such as would on all occasions obtain the name of hard; but more frequently the hardness is only to be distinctly perceiv- ed by examining the pulse in a particular way. Those who have been much in the habit of examining the dif- ferent states of the pulse must be aware, that its hardness is most perceptible when a slight degree of pressure is employed. A cer* 4 26 OF THE SYMPTOMS tain degree, by greatly compressing the vessel, will give some feeling of softness to the hardest pulse, and a slight degree of hard- ness is not perceptible with the pressure generally employed in feeling the pulse. If the pressure be gradually lessened till it comes to nothing, it often happens that a distinct hardness of pulse is felt before the pulse wholly vanishes under the finger, when no hardness can be distinguished in the usual way of feel- ing 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 finger, the degree of pressure, un- der which the hardness may be perceived, denoting its degree. It is most sensible immediately after the patient has been using exercise. I consider the occurrence of the tenderness of the epigastrium and hard pulse as denoting the second stage of the disease, be- cause from the time of their appearance, at whatever period this happens, we shall find its nature, and consequently the plan of treatment suited to it, changed. These symptoms are generally accompanied with others, indi- cating some degree of feverishness. The chilliness of which the patient has long complained is now sometimes, and independent- ly of any change of temperature in the surrounding medium, in- terrupted by languid and oppressive fits of heat; and the hands and feet, instead of being uniformly cold, as in the earlier stages, often burn, particularly during the first part of the night, while at other times they are more obstinately cold. The thirst also often increases, and sometimes there is a tendency to partial sweats in the morning, especially if the patient lie longer than usual; and ihese symptoms are generally attended with an increase in some of those of the first stage. Whevi the tenderness of the epigastrium and hard pulse are considerable, there is generally, more or less an inability of ex- OF INDIGESTION. 27 ercise, except of the passive kind, much active exercise producing an insupportable languor; but slight degrees of the above symp- toms are generally unattended by this inability. The tenderness of the epigastrium, after it has lasted for some time, generally begins to be attended with some degree of fulness in the part, and to extend downwards along the edge of the car- tilages, till at length there is a degree of fulness, and sometimes tenderness, throughout the right hypochondrium; which feels firm- er than the left; but the tenderness is seldom so great as in the part of the epigastrium above described. Sometimes the pressure, both there and in the hypochondrium, rather produces a sense of oppression affecting the breathing than pain. Sometimes, parti- cularly in the epigastrium, it occasions pain passing through the body towards the back, sometimes quite to the back, at other times a fixed pain or sense of oppression under the sternum, and, in some cases, a pain extending to the left side. There is often, we have seen, a degree of fulness in the right hypochondrium at earlier periods; but it is then more transitory, being generally relieved, and sometimes removed by the effects of cathartics, and not unfrequently, spontaneously 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, although not forming an essential, constitutes, when it does appear, the most important part of the disease. We 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 suffered more frequently than the rest, its powers are gradual- ly weakened, and as the second stage proceeds its affections as- sume in some degree a different and more prominent character. 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 affections undergo the same change with the disease from which they spring. In the first stage they are merely nervous affections, disappearing 28 OF THE SYMPTOMS as soon as the cause which produced them ceases to operate. In the second stage they assume an inflammatory character, become more and more of a permanent nature, and in the same proportion, more independent of the original disease, till at length they can not be removed without an appropriate mode of treatment directed to the part secondarily affected. This circumstance renders a particu- lar consideration of them necessary in laying down the means of cure: it will therefore tax the reader's memory less and save re- petition 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 .'.flec- tions 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 sub- ject of this Treatise, it particularly deserves attention that all the diseases which are called, and strictly speaking are, nervous, are apt to run into febrile diseases; injury ensuing if at the pe- riod when this change takes place, a corresponding change is not made in the means of cure. Many facts point out, that long con- tinued nervous irritation at length terminates in inflammation of the organ affected. Even an affection, which in the first instance, is wholly 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 33d, 44th and 45th Sections of MorgagnVs2\st Epistle, the reader will find the pleuritis venninosa treated of at some length; he mentions one case in which all the symptoms of pleu- risy were well marked that terminated favourably by bloody vo- miting which brought up a worm. We might in this instance attribute the relief obtained rather to the loss of blood than the worm; but he refers to a paper of Pedratto on the pleuritis ver- minosa, where the relief obtained by the expulsion of worms from the stomach and intestines, particularly from the former, is un- equivocally proved. It there appears that all who vomited the worms, or passed OF INDIGESTION. 29 them by the bowels, recovered, while those who did not, died. All the common means of treatment in inflammation of the lungs failed; medicines which destroyed the worms alone were suc- cessful. While their expulsion immediately removed the disease, it is impossible for us to believe that real inflammation of the lungs had existed; yet in those in whom the disease had been al- lowed to take its course, the same appearances were found in the thoracic viscera 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 in- stance. When affections of the liver produce pain in the shoul- der, there is no disease in this pirt. The pain is merely sympa- thetic. 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 can not then bear to have it pressed, and sometimes can not 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 lungs, between which there is no direct communication, for this often happens previously to any adhesion having taken place. Why is inflam- mation of the bowels as apt 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 blood by the application 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. 1 have just had occasion to mention a striking one in which the tenderness on pressure of the internal parts of the epigastrium is communicated to the neighbouring cartilage. These facts teach an important lesson in the prevention of dis- ease, that the first beginnings of many sympathetic affections, however trivial, should be watched with care. The headache fre- 30 OF THE SYMPTOMS quently occurring from disordered stomach, may at length become a disease of the head, itself; and there is no organ, we have rea- son to believe, in which disease may not arise in the same way- They teach a lesson of equal importance in the treatment of dis- eases, the necessity 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 pro- minently 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 Indigestion, 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 disordered 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. Indigestion thus comes to be divided into three stages: the first, characterized by the various symptoms above enumerated, arising from the undigested food, from the state of the stomach and bow- els, which is the cause of the disease, and from its necessary con- sequence, the additional irritation to which these cavities are sub- jected by the undigested food and vitiated secretions; the second, characterized by tenderness, or other uneasiness on pressure in the part of the epigastric region above pointed out, and a degree of hardness in the pulse, often accompanied by other febrile symptoms; and the third, by the symptoms of organic disease in the abdomen, chest, or head. Of the third stage of Indigestion. It appears from what has been said, that in the local affections of the second stage of Indigestion, the sanguiferous as well as ner- vous power of the part affected is involved in the disease. This OF INDIGESTION. 31 state of general derangement of the powers of life can not long continue without change of structure. The symptoms indicative of such derangement, therefore, are the immediate forerunners of organic disease. If they can not be arrested they usher in the last stage of Indigestion. It is a curious fact, and one of the greatest importance 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 distinguish such af- fections 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 animal economy, that we are enabled to distinguish the sympathetic from the primary disease. With respect to those cases in which the lungs become diseas- ed, I attempted some year ago, in a paper which the Medico- chirurgical Society did me the honour to publish in the seventh volume of their Transactions, to point out the means of distin- guishing them from primary diseases of the lungs, and the pecu- liar treatment which the sympathetic disease 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 endeavour, as far as a long continued and anxious at- tention to the phenomena of the cases in question, and the laws of the animal 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 may justly be called, which, if neglected, pro- duces 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 decidcly on one organ, the others are to a cer- tain degree, and some times wholly, relieved. The establishment of the secondary affections generally relieves the dyspeptic symp- ■32 OF THE SYMPTOMS toms; and even a secondary 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 re- cover, 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 arti- ficial drains are found to do, while the sympathetic affection which precedes the establishment of actual disease, tends to increase the original derangement. Thus an extensive external disease, as I have witnessed, 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 imitate by excit- ing such a disease, we can no more explain than why a spontane- ous sweat carries off fever, while one produced 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 fol- lowed by a hot fit and perspiration which puts a period to the fever, while a shivering produced by art, would hardly ever fail to increase it. To enter fully on what I have called the third stage of Indiges- tion, that in which it has produced organic affections, would be foreign to my purpose, and would lead to a consideration of a large proportion of all the most serious diseases 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, abscess, atrophy, dropsy, &c. I shall in the last chapter, treat of this stage of the disease at such length as the nature of the present treatise admits of. On account of the extensive nature and great variety 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 treat- ment of the first and second stages, the symptoms of which have OF INDIGESTION. 33 been detailed, before I enter on a more particular consideration of the last stage. Of the various forms and comparative duration of the different stages of Indigestion. The relative duration of the different stages, as well as the se- verity and nature of their symptoms, is very various in different cases. In some the first stage is very slowly, even when the oc- casional causes of the disease have been long and repeatedly ap- plied, changed into the second. Thus we see men of the most irregular habits, and others whose habits are good, but whose di- gestive organs are naturally weak, for many years labouring un- der the symptoms of the first stage of Indigestion, without the disease, if I may be allowed the expression, fixing on them. The former are greatly indebted to a natural vigour of constitution, and in the latter, the stomach alone is weak. In the former, parti- cularly 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 organs, from long con- tinued 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 shows itself. Before the symptoms of the first stage have long attracted notice, tenderness in the epigastrium supervenes, and the pulse becomes contracted. In such cases the second is generally the protracted stage of the disease, and the patient often continues to be much harassed, and occasionally seriously ill, for a long time before organic disease is established. After this has taken plam the duration of the disease, in dif- ferent cases, is also very vaTWus, the change proceeding more or less rapidly according to the strength of the constitution, 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 de- gree the causes have been applied previous to the occurrence of organic disease, the more rapid is its progress. 34 OF THE SYMPTOMS The proportional prevalence of the different symptoms of Indi- gestion 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 irregularity of the bowels are the most troublesome symptoms. 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 cases can differ more from each other than those which form the last stage of this disease; which necessarily varies according 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 th in one organ 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 termination, the more its different cases assume the appearance of disease which have nothing in common. With regard to the circumstances, which dispose the sympa- thetic 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 children, who are disposed to inflam- mation and subsequent effusion in theventricles of the brain. In- digestion often terminates in hydrocephalus 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 prevails and in old age to affections of the heart and head, the latter how- ever of a different nature from those to which children are sub- OF INDIGESTION. 35 ject; and we still observe the tendency of Indigestion to produce the disease to which the system is disposed, whatever be its seat. These observations seem particularly applicable to the inflam- mation and consequent organic affection of the feet 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 symptoms of derangement in the first passages; but in the majority 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 vital 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 remaining well for some time after, and the more cautious he is in preserving the vigour of the digestive organs, 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 ren- der it considerably the weakest part, the sympathetic disease sometimes leaves the joints and seizes on the internal part, pro- ducing what is called retrocedent gout. It is evident that the risk of both these accidents will be greatest, where the powers of the system are most impaired. The connexion of Indigestion and ilrinary gravel particularly deserves attention, as it differs from the connexion of the former with the preceding diseases. It is not by sympathy 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 considera- ble production of acid in the first passages. This acid, as ap- pears from the experiments above referred to, enters the mass of 36 OF THE SYMPTOMS blood, and is thrown out of the system 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-or- gans, which there, probably in consequence of being agglutinated by a secretion from the internal surface of the kidney, 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 de- gree of this symptom, for it appears from the observations of the best writers on calculous diseases, that the calculi formed in the kidney are almost always concretions of lithic acid.* Thus it seems to be, that in old age, gout and gravel often alternate, as it is in the intervals of the gout that Indigestion chiefly prevails, the affection of the joints relieving the stomach during its continu- ance. The duration of this relief, after the fit, becomes less in proportion as the constitution has been enfeebled by repeated at- tacks. * See the paper above referred to in the last volume of the Tarnsactiom of the College of Physicians. OF INDIGESTION. 37 CHAPTER II. OF THE CAUSES OF INDIGESTION. The causes of a disease are divided into immediate and re- mote, the changes in the body which more or less directly excite the symptoms, and the causes which produce these changes. As it is impossible to understand the operation of the remote causes of Indigestion, without a knowledge of the digestive pro- cess, our attention must, in the first instance, be directed to this subject. SECTION I. Of the Process of Digestion. It has been ascertained by the experiments of Spallanzani 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, immediately 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 effected on it in the stomach; and it appears from the observa- tions of Mr. Hunter, that such is the power of this fluid, that it often corrodes the stomach itself when deprived of the vital prin- ciple by which it is enabled to resist its action. When to these facts we add, that by means of the muscular power of the sto- mach, the food, when duly prepared by the action of the gastric 38 OF THE CAUSES fluid, is propelled into the duodenum, we state the sum of our knowledge on this subject. These facts, however, are far from affording an explanation of the process which takes place in the stomach. It does not appear from the observations of any of the authors here referred to, by what means the fluid which is secre- ted 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 remain- ed wholly unchanged. This fact alone is sufficient 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 together and with the gastric fluid, by which their uniform solution is effected. According to this view of the subject also, it would be difficult to account for the gradual dis- charge of the contents of the stomach into the duodenum. This intestine must either for a long time cease to receive any food from the stomach after every addition made to the contents of the latter, or receive food in every different stage of solution, an im- perfection in a natural process which is in opposition to every thing we know of the animal economy. My attention was particularly directed to this subject by find- ing from many trials, that when the eighth pair of nerves is di- vided in the neck of a rabit, and one portion of each nerve folded back,* immediately after the animal has taken 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 divi- sion of these nerves, the rabbit be killed after a fast of however * It has been found by repeated experiments, that if neither of the di- vided ends be displaced, some nervous influence still passes by the divided 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. Hastings and myself hrul obtained. OF INDIGESTION. 39 many hours, some food is always found in its stomach, reduced apparently to the same state as that which, during the ordinary period of digestion, is sent to thepiloric 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 contract 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 mix- ed 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 in- duced me to make some experiments on a large scale, for the pur- pose 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 m the usual way, which is by a blow on the back part of the head, at various periods of digestion. The following were the results.* The first thing that strikes the eye on examining the stomachs 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, surrounded on all sides by the old food, except that on the upper part between the new food and the smaller curvature of the sto- mach there is some times little or no old food. If, as we ascertain- ed 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 per- fectly evident, so that all the old may be removed without disturb- ing the View food. To ascertain this point we fed rabbits on oats, * Inquiry into the Laws of the Vital Functions. It is hoped that the reader will excuse the frequent references to this Treatise in this and the last Stc lions 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 Indigestionv 40 OF THE CAUSES 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 hours, after they had eaten it. On opening the stomachs of rabbits three or four weeks old, who both sucked and ate green food, we always found the curdled milk unmixed with the green food. Before the stomach was opened we could, from its transparency, see where the green food and where the milk lay. 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, un- less it has been very long in the stomach, undisturbed and com- paratively fresh. All around, the nearer the food lies to the sur- face of the stomach the more it is digested. This is true even with regard 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 great length of time, the food in contact with the surface of the stomach is in very different stages of digestion in different parts of this or- gan. It is least digested in the small curvature, more in the large end, and still more in the middle of the great curvature. 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 digest- ed, the central parts differing less from those which lie near the surface of the stomach. It is evident, 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 approaches to the pylorus, where, being ready to pass into the intestine, it has undergone all that part of digestion which is per- formed in the stomach. OF INDIGESTION. s 41 It appears, that in proportion as the food is digested it is mov- ed 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 mus- cular action of the stomach, that next in turn succeeds to undergo the same change. As the gastric fluid, to a certain extent, pervades the contents 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 curvature as to be sent to the pyloric portion without having traversed the large cur- vature, 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 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 consequently, 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 ap- pears to go on so rapidly, that Mr. Hunter found the stomach it- self dissolved, and by the most satisfactory arguments showed, that this is the effect of the gastric fluid after death. His obser* vations on this subject confirm the foregoing view of digestion, and show that the same process, observed in the stomach of the rabbit, takes place in the human stomach; for he found part of the stomach dissolved, while the re-ent feed it contained remained 6 42 OF THE CAUSES 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 undisturbed 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 covered by the peritoneum, or ly- ing quite bare for the space of an inch and a half in diameter, and part of the contiguous intestines in the last case also consum- ed, 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 dissolved within an hour and a half after death. It was more frequently 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 happens to be a greater than usual supply of gastric fluid, for 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 towjards the py- lorus the most digested food, cease. Thus the food which lies next to the surface of the stomach, becoming fully saturated with gastric fluid, neutralizes no more, and no new food being pre- sented to it, it necessarily acts on the stomach itself, now depri- ved 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 vegetable 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. * The rabbit will often, when hungry, eat animal food very readily. OF INDIGESTION. 48 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 sto- mach 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 ex- amining 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 performed its func- tions 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 of the process of di- gestion, in the rabbit, it will be interesting to trace the effect pro- duced on it by depriving the stomach of a great part of its ner- vous influence, by dividing the eighth pair of nerves in the neck. The division of this pair of nerves is one of the oldest physio- logical experiments of which we have any account. It was per- formed 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 fold- ed back, the food remaining in the stomach we have seen, if the animal has lately taken a full meal, is always found undigested, and nearly in the same state in all parts of the stomach, a circum- stance which I was at first greatly at a loss to explain. This ef- fect is uniform, I never saw it otherwise. Yet we must conceive, that at the time the animal last eats, there is some food more or * See a paper by Dr. Hastings, in the 21 st number of the Journal of the Royal Institution, on the effects of dividing the eighth pair of nerves. 44 OF THE CAUSES less digested in its stomach, and some gastric fluid to act on part 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 animal still living, and the motions of the alimentary canal being independent of the nervous influence,* the usual motions of the stomach continue and send onwards into the duodenum, all the food which is digested, and consequently capable of applying to the stomach that stimu- lus, which excites 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 proper 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 circum- stance of food being generally found in the oesophagus when an/ animal dies from the division of the eighth pair of nerves, for food is found there although it is not allowed to eat after the operation. 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 it enters the stomach, directly coming in contact with some part of the small curvature. Thus we see the cause of the efforts to vomit which follow the division of the eighth pair of nerves; and why, if the animal be allowed to live for a certain time after the operation, nothing but .undigested food is found in the stomach. It also appears from the same circumstances, why the stomach is generally more dis- tended than usual after the eighth pair of nerves have been di- vided, particularly if the animal had been allowed to eat after the operation, all the food not digested by the gastric fluid present * Experimental Inquiry, Chap. 6. OF INDIGESTION. 45 before the division of the nerves, remaining in the stomach, and swelling 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 fobd there situated undergoes the necessary change, it is by the muscular power of the stomach moved on- wards towards the pylorus, making room for that which next suc- ceeds, till the whole contents of the stomach have undergone this process, the digested contents being regularly discharged into the duodenum, 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 detain- ed there, and mixed with the bile and pancreatic fluid, they are continually passing into the adjoining 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, after the vital principle of this organ is extinct; from which it appears probablef that the uncombined gastric fluid may produce some effect on the coats of the stomach during life, and various facts would lead us to suppose that the sensation of hunger arises from the action of this fluid. A sup- position which seems to be confirmed by the following experiment. A person in good health was prevailed upon to abstain from eating for more than twenty hours, and further to increase the ap- petite by more exercise than usual. At the end of this time he - was very hungry, but instead of eating, excited vomiting by drink- ing 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 Spallanzani, or as I have myself obtained from the sto- mach 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 • I have sometimes, but very rarely, seen a small quantity of undigested food in the duodenum. 46 OF THE CAUSES bread, which, in a very short time, ran into the acetous fermenta- tion, 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 vomit- ing; and the death which arises from it, converted 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 remind us when a supply of food is necessary. We have reason to believe from the result of the foregoing 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 se- cretion of gastric fluid. Having traced the different steps of the process of digestion in the healthy stomach, we are better prepared to understand 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 attention, we shall find, must be as much directed to the sympathy of the alimentary canal with other parts of the system, as in enumerat- ing 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 particularly of those parts. The remote causes of Indiges- tion, therefore, may be divided into those which act directly on OF INDIGESTION. 4V tlie 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 circum- stance which greatly influences the phenomena of 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 dis- ease of the part, in which case, we have seen, they relieve the original disease, become causes which support and aggravate it. The debility of the skin, for an example, occasioned by Indiges- tion, 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 brain, &c, produced by the diseased state of the stomach; and the disease is farther aggravated by the increase of general debility caused by these affections. It is thus that the evil increasing, if I may be allowed the expression, in a geometrical ratio, and not by simple addition, the whole powers of the system, in severe attacks of disease, often sink with a ra- pidity 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 mus- cular power, so that the food, though properly prepared, as far as . it is brought into contact with proper parts of the stomach, is nei- ther 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 influ- enced 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. Among the chief causes of Indigestion, which act directly on 48 OF THE CAUSES the muscular fibres of the stomach, are narcotic and other offen- sive 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, appli- ed to their internal surface it produces the same effect as when directly applied to the muscular fibres themselves;* impairing their power, unless the quantity be extremely minute, and instant- ly destroying it if the quantity be considerable. It may be questioned whether the opium pervades the fine in- ternal membranes of these organs and acts directly on their mus- cular fibres, or affects these fibres through the nervous extremi- ties distributed on this membrane. This is a question of little importance. I consider it as acting immediately on the muscu- lar 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 and intes- tines. It is probable that other offensive substances received into the stomach, tobacco, 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. All these substances, however, as will presently appear, otherwise influence the state of the stomach. We have reason to believe «th*at the reception of large quantities of very warm or very cold fluids also directly affect these fibres. It is not uncommon for a fit of Indigestion to be iuduced by taking suddenly considerable quan- tities of iced fluids. Violent and repeated vomiting also debili- tates the muscular fibres of the stomach. But of the causes which immediately affect them, the most frequent and powerful is morbid distention. We know that the muscular power of the stomach, rectum, and bladder, and we have reason to believe that the same observation applies to the heart and other similar * Inquiry into the Laws of the Vital Functions. Page 133, ct sea. Secottf edition. OF INDIGESTION. 49 cavities, may for the time be wholly destroyed by over distention, The stomach may be so distended that the most powerful emetics •■- will not excite vomiting,* notwithstanding the muscles sympa- thetically excited in this operation, those of the abdomen and diaphragm, are thrown into strong and repeated action; one among many proofs, that however necessary the action of these muscles in vomiting, it is by that of the stomach itself that its contents are rejected. The 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, excites the bladder and rectum. So perfectly the same indeed are these ac- tions, that if the bladder and rectum are sufficiently distended 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 the hollow mus- cle is excited by being pressed against its contents by the abdo- minal muscles and diaphragm. The most common cause of morbid distention of the stomach is eating too fast; for the appetite only subsiding in proportion as the food combines with and neutralizes the gastric fluid, previ- ously 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 sto- mach is capable of supplying during the digestive process, is not sufficient to effect the due alteration on the food; whereas when we eat slowly, so that a proper time is given for the a'bove com- bination to take place, the appetite abates before the stomach is overcharged: for while 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 if his meal is inter- * The reader will find some good observations on this subject, and cases illustrative of them, under the head of Gastritis, in Eller'a Work De cog, et Cur. Morbis. 1 also beg leave to refer him to my treatise on Symptomatic l\rt>, page I"1 i. Fourth edi'io'n. 5D OF THE CAUSES rupted for ten or fifteen minutes after he has eaten perhaps not more than a third of the usual quantity, he finds that he is satisfi- ed. The gastric fluid which had accumulated has had time to combine with, and be neutralized by, the food he had taken. It is for the same reason that a few mouthfuls taken a little before dinner will often wholly destroy the appetite, especially in deli- cate people, in whom the gastric fluid is secreted in small quan- tity, or of a less active quality. Frequent interruptions in eating would be injurious, because we should thus be prevented 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, provid- ed we continue to eat, without devouring, our food. Another frequent cause of over-distention of the stomach is high seasoning and great variety of food, or such as particularly pleases the palate, by which we are induced to eat after the appe- tite 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 occa- sions less immediate inconvenience than eating too fast, often, if carried very far, by the preternatural excitement of the stomach, at length impairs its vigour. It is not uncommon in those who have greatly indulged in the pleasures of the table, to find the sto- mach enlarged, and its fibres sensibly relaxed. The degree of distention which the stomach undergoes also de- pends much on the kind of aliment. All food appears to swell more or less aft^r it is received into the stomach; some kinds more than others, and of course that which is most difficult of diges tion cet. par. swells most; both because it is digested and remov- ed from the stomach most slowly,* and because that which most * See what was said in the last Section of the Nature of the Digestive ** Process, OF INDIGESTION. 51 resists the action of the gastric fluid is most apt to run into fer- mentation. In considering the treatment, I shall have occasion particularly 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 nerves, that over-distention tends to pro- duce Indigestion. Its operation on the nerves of the stomach them- selves is equally injurious. 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 j of a secreting surface can not exist without affecting its secreting \ power.* The gastric fluid becomes less fitted for its functions, 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 symptoms detailed in the first chapter supervene. When morbid distention of the stomach and its consequen- ces 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, only se- condarily affecting the muscular fibres of the stomach; violent passions, particularly grief and anxiety; too long application to business, severe study, and excessive venery. Strong impressions of the mind often instantly destroy the appetite by occasioning such a secretion of gastric fluid, as, not possessing healthy pro- perties, at once itself fails to apply the due stimulus to the stomach, * It appears from experiments detailed in Jin Inquiry into the Laws of the Vital Functions, to which 1 have frequently had occasion to refer, and in The Journul of the Royal Institution, that the nervous influence is immedi- ately essential to the changes which constitute secretion. 1 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. 52 OF THE CAUSES 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 tumours or indurations of neighbouring parts, or from extraneous bodies lodged in any part of the canal. These causes are com- paratively rare, and consequently not to be inferred, except from circumstances which unequivocally point out their existence. Other causes have a more complicated operation, not only di- rectly 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, but in consequence of its effects on the brain. Similar observations apply to a moist, cold, and variable 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. Thus, too free a use of calomel and other medicines which pow- erfully affect the abdominal secretions, not only injures the sto- mach by their direct effect on this organ, but by the disorder ex- cited in parts with which it immediately sympathizes. Some causes of Indigestion affect the stomach chiefly by sym- pathy. The principal of these are various affections of the bowels, the most common long-continued constipation. We find instan- ces of the same kind in the Indigestion produced by diseases, and even accidents affecting the head; by stone rn the bladder, &c. So extensive, indeed, are the sympathies of the stomach, that whatever greatly disorders the function of any important orgau may be ranked among the causes of Indigestion; its tendency to produce this disease being proportioned to its degree, and the de- gree of sympathy which exists between the stomach and the par4 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. OF INDIGESTION. 53 All the exciting causes of this disease, applied in a less degree, act as pre-disposing causes. Among its pre-disposing causes must be ranked variable wea- ther. 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, particularly 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 tak- ing 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, also pre-dispose to indiges- tion. 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 hereditary disease; all that is necessary for us to know, is the fact, which.can not be disput- ed, that those parts which were most liable to disease in the pa- rent, are likewise found so in the children; but neither is this uni- versally the case, nor does the disease necessarily take place when the disposition to it exists. SECTION III. Of tJw immediate causes of Indigestion. The immediate causes of a disease are the states of body in- duced 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 treatment of the disease. WThere we are altogether ignorant of them, the treatment is found- ed either on the simple principle of employing the same means which have formerly proved useful, or on our general knowledge of the laws of 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 54 OF THE causes 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 animal economy, spasm of certain parts necessarily produces; and the disease was increased by warm stimulating medicines which the debility, necessarily attendant on the state of the circulation, seemed to call for. As soon as dissection unfolded the nature of this disease, 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 incapable of duly transmitting the usual quantity, serve only to hasten the fatal termination. In endeavouring to trace the immediate causes of a disease, there are two objects which demand attention, the change produc- ed in the seat of the disease by its remote causes, and the manner in which this change produces the symptoms. Without a know- ledge of the first of these, our principles of treatment must be vague; without that* of the other, they can not be adapted to the particular cases under treatment. To recur to the disease just mentioned; till we knew that angina pectoris from the difficulty , with which the blood is transmited 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 immediately depend upon it, and what are secondary, arising from sympathy and peculiarity of constitu- tion, our plans of treatment, it is evident, could not be suited to individual cases. The first part of the subject has already been considered. It is evident, from what has been said in the first and second sec- OF INDIGESTION. 55 tions of this chapter, on the one hand, that the causes of Indiges- tion must necessarily affect either the muscular or nervous power of the stomach, or botb^ on which we have seen its function de- pends; and, on the other, that all the causes above enumerated are evidently such as influence them. In considering the remain- ing part of the subject, the manner in which debility of the mus- cular 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 of 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 distention 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 af- fected by any cause disordering this influence, and it will conse- quently fail to produce the due change on the food. As it appeared from what was said above, that the causes af- fecting the muscular power of the stomach by the derangement which every morbid affection of this power occasions in thediges- tive process, soon affects the nerves of that organ; it may now be observed, that all causes affecting the nervous power of the sto- mach, independently of the direct action of the nervous on the muscular power, by preventing the food from being 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 prevented, if the cause affecting 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 atfirst view appear the most simple. The manner in which a morbid affection of the muscular ©r 56 OF THE CAUSES nervous power of the stomach produces the symptoms of Indiges- tion 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 may 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 only suggests other terms in which the question may be put. I need hardly 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 of the nerves of the eye or ear be deranged by electricity, for ex- ample, 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 depend, for the effects of the various states of the stomach, in the different stages of this disease, are instantly propagated to the most distant parts of the system. We see the extremities become hot or cold, moist or dry; the func- tions of the. brain or heart immediately fail, and as quickly revive; 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 between different parts of the system, not only in modifying, but in produc- ing the symptoms of disease, that it is a point of no smali conse- quence to ascertain by what laws it is regulated. It has been an opinion from the time of Willis, that the sympa-. thy which exists between different parts, depends on the connex- ions in the course of their nerves; and this opinion is still main- tained by some of the best writers; but when we consider to what OF INDIGESTION. 57 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 commupication through them with this organ, its sensation and voluntary power are lost. But we have no reason to believe, from the usual phenomena of the nervous system, that an impres- sion 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 impressions 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 explanation. 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, between the viscera of the abdomen and its parietes, the stomach and the cartilages of the ribs, &c. ? Why does inflammation 0/ 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 ves- sels? Why is inflammation of the parietes of the abdomen, or of any part of the bowels, in like manner, as readily communicated to the part in contact with it, however little their nervous com- munications, as to that with whose nerves the nerves of the af- fected 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 numerous connexions we observe in their course are onlv useful in the same wav with the 8 58 OF THE CAUSES ganglions and plexuses, which may be proved by direct experiment to enable the influence; descending from that source, to pass from one nerve to another, so that one may partake of that which is conveyed by many, a power which, it may also be shown, is ne- cessary to the continuance of life.* That the phenomena of sym- pathy depend on changes in the source of nervous influence,! would appear, I think from the fact alone, that sympathetic feel- ings still continue to be referred to a limb 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 experiments which prove, that the vital organs are supplied with nervous in- fluence from every part of the brain and spinal marrow,}: while the organs of sense derive theiis only from particular parts of them, it seems a necessary consequence, that the one set of organs can not be injured without influencing every part of the system, while in injuries of the other, only those parts of the general source of nervous influence, from which their own nerves arise being af- fected, 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, * Experimental Inquiry, Part II, Chapters 4, 5, 7. Sect. 2; and Chapter 9. f y am happy in being able, in confirmation of the above position, to re- fer to a very able paper by Mr. Charles Bell, in the Philosophical Transac- tions of this year, entitled, " On the Nerves; giving an account of some expe- riments 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. I.i the above paper, Mr. Bell has pointed out the interesting fact, that some of the nerves which supply those muscles of voluntary motion, which sympathized with affections of the lungs, have their origin near that of the eighth pair: thus readily accounting for sympathies which have been 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-gastric, instead of respiratory, for I think Mr. Bell will, on farther consideration, admit that the muscles in question equally sympathize 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. \ Experimental Inquiry. Part II, Chap. 9. OF INDIGESTION. 59 receiving their 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 inter- costal muscles, to the pleura of the ribs, to that of the lungs, to the lungs themselves. The same observations apply to the other cavities, 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 phenomena of diseases. We shall find it so in the disease before 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 immediately 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 dis- ease increases, as we find from the above enumeration of its symp- toms, they become sensible in every part. It appears from the experiments related in the seventh chapter of the above Experimental Inquiry, that any diminution of the ex- tent of the organs which supply the nervous influence, affects the state of secreting surfaces, and impairs the temperature: and Mr. Brodie observed similar effects, particularly with respect to the tem- perature from powerfully debilitating causes affecting these organs. It can not, therefore, seem surprising, in derangement of the di- gestive 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 diseases of other parts of the body, and particularly of the skin, which so eminently sym- pathizes with those organs, should frequently arise, and be diffi- cult of cure. It appears from the progress of Indigestion that, wherever sympathetic 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 60 OF THE CAUSES of Local Diseases. He found that many wounds, which resisted ail the means which the surgeon could employ, were attended with a disordered state of the digestive organs, and yielded readily i\hen the due performace 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 an 1 bowels. It is also to be observed, that the failure of nervous power ap- pears more reauily 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 reduction* of temperature, and a less than natural ability to resist 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 co ed, reason to believe that they stimulate the absorbent, es well as excreting vessels, a languid state of the bowels being unfavourable to nutrition. The disease, "however, partakes too much of the chronic nature to admit of great evacuations of any kind; and, although the free action of the bowels is indicated here, not only as a means of ex- citing the various functions of the canal, but of allaying inflam- matory 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 reliev- ing inflammatory action. They must be used chiefly for the same purposes as in the first stage, and consequently belong rather to the me*ans we are next to consider. When the inflammatory symptoms continue to recur after 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 cases, 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-inflamma- tory measures suited to that stage, I have necessarily been led to make such observations on diet, aperients, and the use of stimu- lants and other tonics, as apply to it. When the first stage of Indigestion, we have seen, has continu- ed 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 124 OF THE TREATMENT constant attendant on the second stage; and those medicines which influence the secretion of this organ, therefore, alwa)s 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 medi* cine, 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 direct- ly 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 peri- ods of the second stage, and in mild cases, even after the disease has continued for a long time, we still find that this effect of it, particularly of the blue pill, repeated for a longer time, is often sufficient, especially when the anti-inflitmmatory 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 tails. The relief afforded by the occasional doses of mercury gradually becomes less, and they at length cease to be oT any es- sential use. When it is given in such doses, indeed, as to produce a con- siderable effect upon the bowels, partial relief is still often obtain- ed, 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 patient 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 symp- toms; which are thus relieved at an expense of strength, that ac- celerates the fatal termination; and, beneficial as occasional doses of mercury usually are in the earlier periods and 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 mer- OF INDIGESTION. iJ5 cury, in the second stage of Indigestion, when it does not soon show 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 repeat- ed doses of this medicine, so small, that if they did little good, no- thing, at least, was to be apprehended from them. I have generally given a grain of the blue 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 doses, which may ap- pear to many little better than trifling, I have seen the bile gradu- ally restored to a healthy state, when larger doses had been em- ployed 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 improvement, the skin generally becomes relaxed, and of a proper lenipcrature, the pulse more dilated, the colour and expression of the countenance better; and, in particular, that expression of languor, so peculiar to the advanced stages of the disease, abates. As all these changes depend on a common cause, and consequently take place toge- ther, 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 slate of the liver, at the same time produce man\ 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 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 immediate- ly dependent on the original disease, resists the occasional exhi- bition of the medicine. On this the good effects of the planjJP^am here considering seem chiefly to depend. By the mercury being given in such 126 OF THE TREATMENT minute doses, it enters the system, and acts directly on the various organs, now too much implicated in the disease to yield to its sympathetic 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, dis- courages the hopes of the physician, and, as I know, in many in- stances, has caused it to be laid aside. It is difficult 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 de- gree of salivation 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 con- fidence. Although we do not thus obtain the sudden benefit which re- sults from a more vigorous practice, we avoid the mischief it of- ten 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, what is done on the other, which with all the care that can be taken, is very often the case when larger doses are employed. It is almost unnecessary to observe, after what has been said, that to render the plan most successful, the various observations respecting diet and exercise, and the occasional aids of cathartics, local blood-letting, blisters and cooling medicines, must constant- ly be kept in view; a^fttf the blue pill occasion any irritation of the bowels, which sometimes arises even from the doses here re- commended, it must be obviated by anodynes. OF INDIGESTION. 127 For this purpose I have found the extract of poppies, conium, and hyoscyamus, the best means; and I have, for the last eight or ten years, been in the habit of combining equal quantities of ca;ion, being brought up, the quantity expectorated is ag;iin reduced till another abscess hursts. Bloody expectoration is by no means uncommon in this species of phthisis. Biood often appears early in the disease mixed with the colourless phlegm.. After the pus-like expectoration com- mences, if blood has not previously, appeared, it is much less apt to ap$par than in othtr forms of the disease. If it appear even in small quantity after this stage commences, the case .generally proves f tal. While the+»lood is mixed only wilh^ 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 expectoration. If there be no admixture of blood, there may be good hopes of recovery, if the- disease has not lasted long; and certtinly much better than under the same circumstances in other species of the disease. The expectorated matter is less apt than in these, to assume a sanious appearance, but when this occurs, it seems to indicate nearly as much danger as in them. If it happen under the pro- per 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 distinguish- ing pus and mucus. In my treatise on symptomatic fevers* I * 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 admit- ted, appears to me the best, as it is the most easy of application. • OF INDIGESTION. • 165 have considered the question at length. It is necessary in prac- tice 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 this substance is almost always.real pus. -But if we know what-states of disease are connected with these ippcarances in the expecto- rated matter, it is of comparatively little consequence 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 Dbservations which apply to the cough in the recumbent portion, . and after eating apply to the dyspnoea; but it ofton happens in the early stages, that there is little or no dyspnoea: and there fs very rarely, except in the advanced stages, that marked dyspnoea on exercise which so frequenty 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 ciiest; 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 uneasy sensation and a sense of oppression»under the sternum. The patient sometimes complains of darting pains in various parts of the chest, and frequently in more distant parts, particu- larly in the back and shoulders, and in the legs; and is often sub- j ect to head-ach. The hectic fever is hardly ever completely formed at so early a period as in other species of phthisis, and sometimes there is a copious purulent expectoration with but slight fever, and that npt 166 OF THE THIRD STAGE at all assuming the form of hectic, the skin remaining dry in the morning, and there being little 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 phthi- sis, but seems to keep pace with the state of the fever. Such is the manner in which the symptoms common to all forms of phthisis are modified in this species of it, but a diagnosis rest- ing merely on the modification of symptoms must always be fal-. lacious; it is therefore fortunate, that in tne present instance, there is superadded to the usual symptoms 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 di- gestive organs. The patient is often distressed with flatulence, acidity* and ir- regular 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. m Sometimes there is a false appetite which fails after a few mouthfuls, and a sense of oppression after eating, as if there were not room for what had been taken. The alvine discharge is seldom well coloured, and the epigas- tric 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 hypochon- dric region than in the left, often attended with tenderness on pressure. Much less frequently there is some preternatural ful- ness, and a degree of tenderness in the left Jivpochondric 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 evident by the OF INDIGESTION. 167 latter increasing with the former, so that when the epigastric re- gion is very full and tender, and the flatulence aud acidity more troublesome than usual, the cough and dyspnoea are so also; and on the former symptoms subsiding, 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 sfages of this species of phthisis. In its advanced stages, it approaches more and more to other forms of the disease. All the symptoms, which more particularly indicate a tubercular state of the lungs, show 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 fix- ed in the lungs, are often lessened, and sometimes wholly disap- pear; which, if the pulmonary symptoms continue unabated, al- ways, I believe, affords a fatal prognosis. The patient at length sinks with precisely the same symptoms as in other species of phthisis. In addition to these, some other of the more prominent conse- * quences of severe affection of the digestive organs sometimes show themselves, particularly dropsy of the belly, 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 the lungs, the bones pressing 163 OF THE THIRD STAGE uwqinlly on them, &c To compensate for the want of the cau- ses in nediately affecting the lungs, we have a numerous set of causes itffectin? 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 equal- ly in its causes, as in its symptoms, its connexion with the state of the digestive organs; from Which it may be justly termed dys- peptic phthisis. It particularly deserves attention, that in many families, this form of tbe disease alone appears. Its fatal effects may general- ly, I believe, be prevented by carefully avoiding the causes which tend to debilitate the digestive organs; and watching Jthe approach of the symptoms enumerated in the first chapter. Of the appearances on dissection. The appearances of the lungs are generally much tbe same as in other case's 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 ren- dered incapable of their functions. Here, as in manvother cases, we often have occasion to remark to what extent chalbge of struc- ture, even in the vital organs, may go without destroying life, when the change is very slowly effected; a circumstance which, perhaps, more than any other, shows the extent of the resources, by which we are enabled to counteract the more immediate effects of disease. It is not at all uncommon in dyspeptic' phthisis to find the spleen as well as the liver diseased. As the cceiiac artery divi- OF INDIGESTION. 169 ding 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 arte- . ries of the two latter organs, in consequence of the obstructed state of the liver? Is it owing 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 dyspeptic 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 diseased state having existed, in one of the organs of digestion. A question of the first importance in the treatment of this dis- ease here arises. What is the nature of the relation observed between the affection of the lungs and that of the digestive or- gans in this species of phthisis? Is the one a consequence of the other, or are they simultaneous affections arising from a common cause? They are not simultaneous affections, for the one almost always evidently precedes the other. In by far the majority of cases in which both the lungs and digestive organs are affected, the affection of the digestive organs precedes that of the lungs. In some instances we find the af- fection of the lungs the primary disease. But in these, the case does not assume the form above described, but that of simple phthisis; and the hepatic affection, which is always the most prominent feature of the derangement 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 22 no OF THE THIRD STAGE symptoms by increasing the oppression and irritation and hasten- ing 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 di- gestive organs. It seems to be a necessary inference from the preceding facts, that a diseased state of either set of organs may produce that of the other. But the tendency of disease to spread from the diges- tive organs to the lungs is much greater, than that to spread from the latter to the former. We often see a slight degree of derange- ment in the digest-ve organs produce cough and other pulmonary Symptoms, and derangement seldom exists in all the digestive or- gans without 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 num- ber of instances it proves fatal without spreading to them. When to these circumstances we add, that all the peculiarities of those cases of phthisis, which are from the commencement accompanied with disease of the digestive organs, 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 symp- toms that attend it, the inference appears to be unavoidable, that in the species of phthisis, which w'e are considering, the pulmo- nary disease arises from that of the digestive organs. It is not to be overlooked, however, that it is in those most dis- posed to pulmonary disease that affections of the digestive organs most frequently produce it. We consequently 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, organs; an observation as old as Hippocrates. On the other hand, when the digestive organs are naturally weak, or powerful causes of disease in them have existed, particularly OF INDIGESTION. 1^1 tbe free use of spirituous liquors, we often see it occurring in ha- bits apparently least disposed to pulmonary disease. It will place in a clearer light what has been said of the na- ture of the disease before us, and tend farther to illustrate the ob- servations which have been made on the first and second stages of Iudigestion, 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 ex- tent of his experience 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. Abernethy, entitled " Surgical Observations on the Constitutional Origin and Treatment of Local Diseases." I believe that experience has led many others to similar views, but no other person has laid them before the puolic 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 obser- vations; and such a confirmation as they were not likely to re- ceive from the work of a physician. The physician's attention is directed to internal disease; there his inquiries naturally begin. Mr. Abernethy's, for a similar reason, began with external dis- ease; 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 as- sistance of a surgeon was of greater consequence than that of any physician could have been. From local, he was unavoida- bly carrying on his observations to general, diseases. The sympa- thies in question so connect them that it was impossible for him to do otherwise. From general, I was, for the same reason, car- rying 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 172 ©F THE THIRD STAGE of the edition of my Treatise, on Febrile1* 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 observa- tions 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, ^d in particular the mode, of giving mercury in in- ternal disease, which I found most successful, is different from his, but thf general principle is the same. I have already had occasion to allude to the case of a gentle- man who laboured under severe pains of the legs, which had been treated unsuccessfully for two ye :rs. The digestive organs were deranged, and the epigastric region tender on pressure. * A grain of blue pill combined with stomachic and opening medicines was given three 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 obstinate, for which he had been advised to go through a regular course of mercury. The digestion was de- ranged, and the epigastrium tender. He took stomachic and open'ng medicines, 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 oT the body, and it was feared that what is called a general breaking up of the constitu- tion 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 at other times either a few grains of blue pill, or one grain of calomel, according to the state OF INDIGESTION. 173 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 remov- ed 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 in- ternal disease, arising from the sympathy of other parts with the digestive organs, agree. It is from small and undebilitating quanti- ties that good effects are to be expected in such cases; given other- wise it weakens the digestive organs, and often thus increases the disease. Mr. Abernethy mentions other internal diseases, particularly those of the head and heart, caused by the derangefl state of the digestive organs. I have repeatedly seen his observations on those diseases confirmed; and could relate several cases, to which I have already had occasion to allude, in which the patient had for years laboured under symptoms of angina pectoris, and had been treated for this disease, in which the case vielded in a few weeks to minute doses of blue pill combined with stomachic and opening medicines. In such instances we must, of course, sup- pose, that no organic disease of the heart had yet supervened. His observations on the brain are well illustrated by two excel- lent treatises, by Dr. Cheyne,* and Dr. Yeates,f on the Hy- drencephalus 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 act- ing on the parts in which they have their seat; but were 1 to • A Second Essay on Hydrocephalus Acutus, or Dropsy in the brain, by J. Cheyne, M. D., Dublin, 1815. # f A statement of the Early Symptoms which lead to the Disease termed Water in tlte Brain, &c, in a Letter to Martin Wall, Esq. M. D., &c, by G. D. Yeates, fcc.; London, 1815. • 1^4 •* THE TniRD STAGE 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, preserving a proper state of the digestive or- gans is the best means of prevention; for even where it arises from other causes, tbeir tendency to produce it will be greater or less according to the slate 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 dis- ease, let the cause which produced it be what it may. The ob^, servations made in tbe second and third chapters, seem sufficient- ly to illustrate this part of the subject. ■ Of the Treatment of Dyspeptic Phthisis. In speaking of the treatment of this form of phthisis, I shall follow the same plan which was adopted in speaking of its symp- toms, confining myself to those circumstances in which it differs from the other species of the disease. As it app< ars, both from the symptoms and causes of dyspeptic phthisis, that the affection of the lungs is influenced by the state of the digestive organs, it is reasonable to suppose that the means which tend to improve their functions, will here be a useful aux- iliary to those usually employed 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 pressure, 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 sympathetic, so OF INDIGESTION. 175 that when the cause whieh produces it is removed, it ceases of course. This stage is disti.iguislie.l by the short time which the disease has lasted, by the general mildu ss 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 phlegm, 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 por- tion of carbon, which seem to have I tin some time in the lungs; the expectoration of which relieves the cough, which, in th S case, is seldom very troublesome. This last appearance of the expec- torated matter generally indicates the very mildest form of the disease. It is when there is no 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 superven- ing on the surface of some part of the bronchia, or air cells, in consequence of which the expectorated matter begins to ue mixed With small portions of a pus-like substance, which gradually in- creases as the inflammation extends, till the quantity, we have seen, is often astonishingly great.* Sir Evcrard Home, in a treatise on the properties of pus, has shown how readily irritation •f secreting surfaces produces it, independently of any breach of substance. Less frequently small vessels, in consequence of their being debilitated by sympathy with the state of the stomach, an- alogous to what we have seen sometimes happens in the vessels of the brain, now and then give way, which prevents the inflam- matory action, so that the expectorated matter presents no degree §f the purulent appearance, but is occasionally mixed with blood. * The reader will find many good observations on the tendencies of in- flammation of the bronchial membrane in Dr. Hastings late work on this subject. 176 OF THE THIRD STAGE The symptoms now assume a more 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 sup- puration 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 disease. This stage is indicated by the aggravation of all the symptoms; 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 has 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, except 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 shows itself before Indigestion produces phthisis, and this state of the lungs occur almost at tbe 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 treatment at this period, that it required many years' observation to convince me that it will not always succeed, and to satisfy my mind respect- ing the causes of its failure. The last of the causes just mention- ed, 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 ease approaches to the nature of that form of phthisis which ori- OF INDIGESTION. 177 ginates on the lungs'themselves. whose fatal tendency no mode of treatment, 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 can not be seen, but only felt. It will be generally admitted, I believe, that external glandular, swellings and suppurations often tend to prevent internal disease. We see in the same family some fall a sacrifice to phthisis, while others, labouring under these sw Uings 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 enlarge- ment of the external glands, which may rather be felt than seen, while it indicates, is not of sufficient importance to obviate, the tendency to internal disease. Provided there he no great tendency to tubercles, and the he- patic 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 an attention to diet as prevents the stomach being oppressed, and counteracts the inflammatory tendency, keeping up rather a freer action of the bowels than is necessary in health, and taking care, by occasional doses ofblue pill or calomel, according as the bowels are more or less easily acted on, to preserve a sufficiently copious and healthy secretion 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 doe's not pass off in a couple 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 discon- tinued, 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 23 178 OF THE THIRD STAGE the opening draught, too great an effect is avoided, and the effect of the mecurial 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 object to obtain a very free eva- cuation, and only the most transitory effect of the mercurial. The less stimulating stomachic medicines have generally been used, particularly when the appetite was much impaired. 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 increase 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 carroway, 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 argument 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 treat- ment essentially different from the foregoing. When the disease has been neglected till this stage commences, which is not unfre- quently the case, orwe find that notwithstanding 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 con- tinuing, and an unhealthy seceretion of bile constantly recurring, we may be assured that the foregoing means will probably be ineffectual; 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 circumstances, I have for many years adopted, and the efficacy of which originally induced me to offer my observations on this subject to the attention of the public. It consists of a combination of the most decisive treatment of the second stage of Indigestion with that of phthisis. OF INDIGESTION. 179 We are here to recollect, that while it is even of greater impor- tance 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 seve- rity and obstinacy of the dyspeptic symptoms; but in the latter, the structure of the lungs is threatened, and, if the cause of in- jury can not be removed, will soon be destroyed. 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 secretion 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 doses. There is no case in which they are more conspicuous than in that be- fore us. As the tenderness of the right hypochondrium abates, and the state of the alvine discharge improves, in by far the majo- rity of cases the pulmonary symptoms gradually disappear. With the foregoing plan I have always combined means for the purpose of more directly relieving the tenderness of the hy- pochondrium. If it be slight, a succession of small blisters ap- plied over the tender part is often 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 ad- vantage generally arises. When the disease is obstinate, or has repeatedly recurred, a permanent discharge from the tender part, especially that by a seton, often essentially promotes the cure. By these means the quantity of mercury required is much les- sened. If the tenderness be very great indeed, no 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 promote a re- gular and healthy secretion of bile. The external use of the mineral acids too much disposes to in- flammation to be employed in the case before us. Saline aperi- 180 OF THE THIRD STAGE ents, more or less, promote a due action of the liver, and are, therefore, preferable to other cathartics, provided they are equal- ly suitable in other respects; but of the means which I have em- ployed 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 iu large doses. When the patient can take a decoction of it poured upon camo- mile 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, advmtage often arises from infusing a few cloves with the camomile flowers. When the dandelion could be given in either of these ways, 1 have often given only half a grain of the blue pill twice or three times a day, and I think have generally found as much advantage from this dose, as from a whole grain 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 colchicum repeated three or four times a day: and it is of great use in all cases to allay the feverish heat by nitrate of potash 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 take place without relieving the pulmonary symptoms, the prognosis is bad. If the tenderness of the epigastrium continue, the hepatic affection is unusually ob- stinate: if this be wholly removed without materially relieving the pulmonary symptoms, we have reason to believe that the dis- ease has made great progress in the lungs. It is surprising from what states the lungs will sometimes re- cover, when relieved from the irritation of the hepatic affection. I have seen many recover not only whose friends, but whose phy- sicians, had lost hope of them. But iu these cases the proper OF INDIGESTION. 181 means had not been tried; if these have failed, the hope is no bet- ter than in other species of phthisis. Where the failure of relief proceeds from the obstinacy of the hepatic affection, some hope arisestrom a fuller mercurial course, but it is often fallacious; for, although such a plan as I have re- comijiended may be pursued without any diminution of strength, and is generally, by relieving the disease, attended with an im- provement 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 epigastrium is wholly, but the pulmonary symptoms only partially, rel-eved by the above plan. In this case the hepatic affection is apt to recur, always bringing with it an increase 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 termi- nation is rapid. If it be carefully watched and relieved as soon as it appears, the case is protracted', and the decline of the patient 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 disippears, the seat of the disease being wholly transferred 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 affec- tion 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 applicable 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 bile, and the anodyne power of the hyoscyamus in such doses 182 OF THE THIRD STAGE as are safe, is not to be depended on. When the epigastrium is very tender, animal food and fermented liquors are peculiarly in- jurious. Some suppose that mercury is often useful in phthisis originat- ing 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 almost always proved hurt- ful. 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 de- bilitating effects of the mercury. If there be any case of idiopathic phthisis in which mercury is proper, it is one which I have already had occasion to mention, in which the pulmonary disease produces disease of the digestive organs; of which we still find hepatic affection the prominent fea- ture, 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 explained. In them the pulmonary affection is far advanced before the affection of the digestive organs appears, and both on this account and because the former is the original dis- ease, it can not be removed by removing the latter. Besides, it is not likely that small doses of mercury will remove the hepatic disease, while the cause which produced it still continues to ope- rate; 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 dyspep- tic phthisis be correct, the principle of treatment in other organic diseases which have a similar origin may easily be inferred. We must combine the treatment of Indigestion with that ne- cessary in the disease which has supervened on it, in such a way as never to lose sight of the former; for, however much the af- fection of the digestive organs may be relieved by the establish- ment 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. OF INDIGESTION. 183 SECTION II. Of Habitual 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 permanent 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 Indigestion has been long attended with a considerable degree of dyspnoea. In such cases, I have already had occasion to observe, the dysp- noea with a tendency to cough sometimes remains after all the other symptoms have disappeared, and is often but little influ- enced 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 divided ends, in consequence of which digestion is suspended, and the breathing rendered diffi- cult, 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 con- firmation of their results, in the Medical and Physical Journal for May, 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 following is the very candid account given by one of these gentlemen, Mr. Brough- ton, 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 rabbits, 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, 184 OF THE THIRD STAGE It is an inference from my own experiments and observations,' as w<-|| ;is those oi others, particularly of M. le G.illois, that wh;.t is called the nervous system, comprehends two distinct sys- tems, the sensorial, and the nervous system properly so called. Now, we have no re ison to believe that galvanism can perform any of the functions of the sensorial system; yet, in the grc.it'.r number of instances in which it has been used in med-.:ine, it has been expected to restore the sensorial power. It his been expected to restore hearing, and sight, and voluntary power. It may now and then happen in favourable cases, from the con • nexion which subsists between the sensorial and nervous systems; that by rousing the energy of the latter, we may excite tiie former, or the sensorial power may be entire, and the fault in the nerves which convey its influence. From our experience of such c ses, however, there seems little reason to hope that galvanism will often be successful in them. We have reason to believe, from breathing freely, and with no more apparent distress than the twitches • usually produced by the galvanic influence, which in this case was uninter- ruptedly kept up. The otherrabbits laboured strongly in their-breathing. They were all three killed at the sy Dr. Wilson Philip and his supporters. However we may differ in opinion, as to the real state of the food in the non gal- vanised rabbits, as to Dr. Wilson Philip'-, theory, or, as to the cause, of the formation of chyme and chyle being foind under the influence of a galvanic battery, Dr. Wilson Philip can not be denied the merit of correctness in his assertions (hitherto almost universally distrusted,) relative to the simple fact of a certain power ol galvanism producing digestion, after dividing the eighth pair of nerves, under circumstances in winch it is impeded without the galvanism. " It is proper to state that the President and several members of the Royal Society, and of the colleges of physicians and surgeons, among whom were Mr. Brodie and myself, inspected the progress of these experiments, which were carried on under the constant superintendance of l)r. Wilson Philip." Mr. Broughton also admits that the experiments afforded reason to be- lieve 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 was so good as to assist me in these experiments, that this may happen although the divided ends be sepa- rated by the distance of a quarter of an inch, provided the nerves b< not otherwise displaced.—See a naper 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 refer- red to. OP INDIGESTION. 185 the experiments related in the Inquiry just referred to, that gal- vanism has no other power over the muscular system than that of a stimulus;* we are, therefore, to expect little more advantage from it in diseases depending chiefly on faults of the sanguiferous system, than from other stimuli, &c. But I can not help regard- ing it as almost ascertained, that in those diseases in which the original cause of derangement is in the nervous system proper- ly so called, where the sensorial functions are entire, and the ves- sels healthy, and the power of secretion, which seems immediately to depend on the nervous system, is alone in fault, galvanism will often prove a valuable means of relief. As soon as the foregoing view of the subject presented itself, I was led to inquire what diseases depend on a failure of nervous influence. The effect on the stomach and lungs, of dividing the eighth pair of nerves,! answered the question respecting two of the most important diseases of this class. We have seen, that withdrawing a considerable part of the nervous influence from the stomach and lungs suspends the digestive powers, and pro- duces great difficulty of breathing. The following observations relate chiefly to affections of the lungs. Of the effects of gal- vanism in disordered 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 of- ten 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 defiance of every means we can employ. * Compare the experiments related in the first and second chapters of this part of the Inquiry with Exp. 70, 71, 72, 73, and the observations which follow them. fExp. Inq.Esp. 44, 43 24 186 OF THE THIRD STAR* It appeared from repeated trials, that both the oppressed breath- ing, and the collection of phlegm, caused by the division 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 applied to it in every possible way. Such are the circumstances which led me to expect relief from galvanism in habitual asthma. Although its effects in this dis- ease 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 appeared as a primary disease, as when it succeeded to indigestion. 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. I speak of its application in as great a degree as the patient could bear without complaint. For this effect I latterly found from eight to sixteen four-inch plates of zinc and copper, the fluid employed being one part of muriatic acid, and a hundred and twenty of water, sufficient. Some require more than sixteen plates, and a few can not bear so many as eight; for the sensibility of different individuals to gal- vanism is very different, 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 any 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 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 * Exp. 70,71, 72, 73. OP INDIGESTION. 187 request, by moving one of the wires from one division of the trough to another, and moving it back again when he complained of the sensation being too strong. It is convenient for this pur- pose to charge with the fluid about thirty plates. The galvanism was applied in the following manner. Two thin plates of metal, about two or three inches in diameter, dip- ped 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, con- stantly to move the wires upon the metal plates, particularly the negative wire, otherwise the cuticle is injured in the places on which they rest. The relief seemed much the same, whether the positive 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 region. The galvanism was discontinued as soon as the patient said that his breathing was easy. In the first cases in which I used it, I sometimes prolonged its application for a quarter of an hour, * I found a trough, of the old construction, more effectual in restoring the due action of the lungs than the improved pile. 1 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 proportioned 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 chemi- cal power, in proportion to the intensity of its electricity, than the latter. The most powerful electrical battery will not readily decompose water with- out the ingenious arrangement suggested by Dr. Wollasion, for concen- trating, 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 a half or two inches square, would answer medical purposes nearly as well as larger ones. 188 " OF THE THIRD STAGE or twenty minutes, after the patient said he was perfectly reliev- ed, 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 op- pressed 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 taken place in the more evident mechanism of the lungs. With regard to that form of asthma which returns in violent paroxysms, with intervals of perfectly free breathing, I should ex- pect little advantage from galvanism in it, because as I have just observed, I found that the peculiar difficulty of breathing, which occurs in this species of asthma, can not 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, indeed, it takes its name; and we have no reason to be- lieve, 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 spasmo- dic asthma, when the fits have become less severe and more or less difficulty of breathing is almost constantly present; in short, when the sp tsinodic has assumed a good deal of the form of ha- bitual asthma. Even in these cases, however, as far as my ex- perience has gone, the relief afforded 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 one case of it occurring for at least fifty of habitual asthma. Of the first cases of habitual asthma, which I saw, many oc- curred in work-people of the city where I then resided, who had been obliged to abandon their employments in consequence of it, and some of them, from its long continuance, 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, but all sufficiently to be restored to their em- OF INDIGESTION. 189 ployments. I afterwards saw several of them, who although they had not used galvanism for many months, said they had con- tinued to work without inconvenience. Some, in whom the dis- ease had been wholly removed, remained quite free from it; some had had a return of it, and derived the same advantage from gal- vanism as jt first. The application of galvanism was confined to asthmatic dysp- noea. 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 hypochondric region, the means which have been pointed out in the third chapter must be em- ployed for the purpose of relieving these symptoms previous to the use of galvanis n; and to these means alone the dyspnoea sometimes yields; but I have learned from a pretty extensive experience, that in a large majority of such cases it will resist them, yet readily admit of relief from galvanism. If there be little tendency to inflammation, galvanism is also a means of relieving the affection of the digestive organs. In all the cases where habitual asthma was complicated 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 employ- ment. 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 always more or less cough, counter-indicates the use of galvanism, The cough, under its use, generally becomes less frequent in pro- portion 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. 190 OF THE THIRD STAGE In some cases the cough continued troublesome after the dysp- noea 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 asthma had supervened, I have seen the relief obtained from galvanism very great, notwith- standing some admixture of a pus-like substance in what was ex- pectorated. In these cases it relieves the breathing, leavii g the other symptoms little changed. I need hardly add, after what has been said, that in ordinary cases of phthisis nothing could be more improper than the use of galvanism. The dyspnoea arising from phthisis and that from habitual asthma are easily distinguished. The former is less variable. It is generally increased by the exacerbations of the fever, and always by exercise. When the patient is still and cool, except in the last stages of phthisis, his breathing is generally pretty ea- sy; and is seldom much influenced by changes of the weather, ex- cept they increase the inflammatory tendency. The latter is worst at particular times of the day, and frequently becomes bet- ter and worse without any evident cause. At the times when it is better the patient can often use exercise without materially in- creasing it. Its exacerbations are unaccompanied by any increase of fever. Changes of the weather influence it much. It is par- ticularly apt to be increased by close and foggy weather. When there is a considerable tendency to inflammation in ha- bitual asthma, the repeated application of galvanism sometimes increases it so much, that the use of this influence no longer gives relief, till the inflammatory 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 tendency, and least complicated with other dis- eases, the chief complaint being a sense of tightness across the region of 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 hap- pened their breathing became free. The abatement of the tight- OF INDIGESTION. 191 ness is often attended with a sense of warmth in the stomach, which seems to come in its place. This sensation is most fre- quently 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 continuince of the relief obtain d by gal- vanism, it is different in different cases; in the most severe cases it does not last so long as in those where the symptoms are slight- er, though of equal continuance. Tnis observation, however, does not universally apply. \Vheu the patient is galvanise! in the morning, he generally feels its good effects more or less till next morning. In almost all, the repetition of the galvanism gradually increases the degree of permanent relief, but its increase is much more rapid in sone cases than in others. The permanency of its good effect in the disease before us, has appeared very remarkable in several cases wh re the symptoms, after having been removed by it, were renewed 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 successful without its aid; or with few applications of it compared with those which had been necessary in the first in- stance. 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 ferment ed liquors having been the principal causes of relapse. The galvanis n has seldom been used more than once a day. In some of the more severe cases it was used morning 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 cases failed to give more or less relief, 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 inno- cent, 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 192 OF THE THIRD STAGE four to six three-inch double plates, 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? I wished to try if the impression on the mind, in the employ- ment of galvanism, has any sh ire in the relief obtained 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 by galvanism, that those who had most frequently been subjected to this influ- ence were deceived by it. By this method, and arranging the trough, pieces of metal, &c, as useful, 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 experienced no relief from w!iat was done. Without allowing them to rise, I substituted for this process 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 nap° 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. Irelate the particulars of the two following experi- ments, because they point out two circumstances of importance, in the application of galvanism in asthmatic cases, and in judg- ing 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 perma- nent, and when she was galvanised once a day for about ten minutes, she suffered little dyspnoea at any time. After she had been galvanised for tight or ten days, I deceived her in the man- ner just mentioned. The deception was complete. She told OF INDIGESTION. 1 193 me to increase or lessen the force of the galvanism, as she was accustomed to do, according to the sensation it produced. I obey- ed 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 di- rected 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 ap- plications of the remedy. To try how far the effect of galvanism in asthma arises merely in 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 for nearly a quar- ter of an hour. She said her breathing was easier, but not so much so as on the former application of the galvanism; and on attempting to walk up stairs she began to pant, and found her breathing, when she had gone about halfway, 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 on any degree of panting, or feeling any dyspnoea. The above experi- ment was made in the presence of four medical gentlemen. This patient, after remaining free from her disease for about half a vear, returned to the Infirmary, labouring under a slighter degree of it, and experienced immediate relief from galvanism. The disease seemed to have been renewed by cold, which had at the same time produced other complaints. This is one of the cases above alluded to in speaking of the permanenrv of the good effects 25 194 OF THE THIRD STAGE of galvanism. On the return of this patient to the Infirmary, two or three applications of galvanism, combined with means which had given no permanent relief to the dsypnoea previous to her first using galvanism, 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 ob- serve, have frequently witnessed the relief afforded by galvanism in habitual asthma; and Mr. Cole, the house surgeon of the Wor- cester Infirmary, authorizes me to say, that no other means there employed have been equally efficacious in relieving this disease. In the foregoing account of habitual asthma, I have entered 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 disease, although it often ap- pears as such. Observations similar to the foregoing respecting the use of gal- vanism, there is reason to believe, will be found to apply to other cases of Indigestion; but as I observed above, I can not 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. In some, galvanism, at the time of it's application, occasions a tendency to sighing; and in some, in whom it removed 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. * The effect of indolence, in painful diseases, is often much less injurious than in health. Pain, if not so great as to overpower, in some degree, comes in place of exercise, in preserving the general activity of the functions OF INDIGESTION. 195 it generally gave a great degree of relief to the dyspnoea, when it produced 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 galvanism, and some in which it wholly removed this disease. THE END. jBTj *.» 4, *r -. • * * •