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A TREATISE
ON
BSTIDHOaBVB®:



  AND ITS CONSEQUENCES,
CALLED
NERVOUS AND BILIOUS COMPLAINTS;
WITH
OBSERVATIONS
ON
THE ORGANIC DISEASES,
IN WHICH THET SOMETIMEartfERMINATE.
BY A. P. W. PHILIP, M. D. F. R. S. Ed. &c.
      FOURTH EDITION, fT7;VT r^^~



WITH SOME ADDITIONAlj 0®8^aflIQN>,:. tf AL'S OFFlCc I



                    JAN.-12-1902    !
JAMES CUISSY, NO. 177, CHESTNUT


      OPPOSITE THE STATE HOUSE.


   J. Crissy 8t G. Goodman, printers.



           1824.      V
Hi n
r 8TOEET.
PHILADELPHIA; M X 7 «£ V  . 
WJ.


W24-
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i 
TO THE
             PRESIDENT,

      FELLOWS AND LICENTIATES,

                   OF THE

 ROYAL COLLEGE  OF PHYSICIANS

                OF LONDON,

      THE FOLLOWING TREATISE

           IS RESPECTFULLY DEDICATED

               BY A MEMBER,

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

5, IIanoveh Sq.uatoO
 November, 1821. \ 
 
©©iriEairais
                                               Page.
Preface     -    -------   vii
Preface to the first edition......ix
A TREATISE, &c      -     -    -    -    -     -11

                    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 forins 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      - %* -    -    "70 
uONTENTS.
                     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 h.
 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.

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 11.
 Of habitual asthma......183
 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 them 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.   I 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
preface.
  The adaptation of the means of cure to tbe 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 of 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 with 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
parts of the subject arrange themselves under it, are often super-
fluous,  and therefore  unwelcome interruptions.
                             2 
 
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; but we  can make  little  practical use of this
knowledge,  unless we know the immediate causes of its derange- 
12
ON 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 lias 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 some 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 tlie  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 ©f stomachj
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. 
OF 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
any great length of time, without the other parts of the alimentary
canal partaking of  the disease.  Their secretions also  begin  to
suffer 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,
especia'ly 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 but little from those of health.
He is more apt to be thirsty, his appetite is generally more or less
impaired and  variable, be  complains of his 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 and 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 INDIGESTION.
17
iary 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 then almost wholly consists of  undigested  bits of food.
When there is much straining, it often contains mucus in  distinct
masses, and not unfrequently, substances  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
there 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,
and changes which the eontents of the bowels undergo in their 
18
OF 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 produces-a discharge of  a  lighter colour
than one consisting  elm fly of animal food,  and some vegetables
and  medicines communicate  a certain  tinge to the discharge.
According to my experience, however, these causes, on the whole,
produce less  effect  than might be expected, and with a little at-
tention on the part of the praptitioner, will seldom mislead him.
It must always be kept in view, that the appearance of the dis-
charge often changes, when  it has remained for some 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
ptece from the urine after,it has stood  for some time, this fluid
still remaining clear; and on the other  hand,  that when the skin
has been unusually  excited, or an alkalescent state of the stomach
and bowels prevails, it becomes turbid, and 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 coNered with a very thin oily  film, which 
OP 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 depos«te 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, when 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 wien the  skin has become  dry and shrivelled, is often
astonishing,  and that even wheo 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-
riable, diarrhoea 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 frequent small semi-fluid, teasing, mixed  with  mucus,
and sometimes streaked with blood, and after it has been repeated,
often chiefly consists of  mucus  and a little blood, the passage of
which is attended with much griping and bearing down, and 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 lat- 
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 body 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
other periods 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.   Either mistaken  for the other leads to
serious errors in practice.
  The patient, often from an  early period of Indigestion, feels
some uneasiness on lying on the left side,  more rarely 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 lormer 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
ebstinate  than severe, and considerable debility has come on, this
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 aphthae.   This state ©f it is seldom 
24
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  shifts  its  seat,  or  with nettle rash,
 herpes, and other species of eruptions, and even ulceration some-
 times supervenes yvithout 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 irrita-
ting cough, or yvith fits of palpitation.
   When expectoration attends the cough, it is generally difficult,
 but brings considerable temporary relief. It deserves notice, that
 in this stage of the disease, he more frequently complains of pain
 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 yvith  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 yvith the more
 characteristic symptoms of angina pectoris without organic affec 
OF INDIGESTION.                   &5
tion of the heart having supervened, although under such circum-
stances  it is ahvays to be dreaded.  It is not uncommon for the
mus les 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 yvhen  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 yvho 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
 these  symptoms are generally attended yvith an increase in some
 of those of the first stage.
   When  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, constitiftes, 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 yveakened, 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.  1  shall then also,  for the  same reasons, lay
before him such observations relating  to the nature of these affec-
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 JWorgagnVs2lst Epistle,
the reader  will  find the  pleuritis  verminosa  treated of at some
length; he mentions one case in which all the symptoms of pleu-
risy yvere 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  yvho  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 part.   The pain  is merely sympa-
thetic.   If  we press  or rub the shoulder, the patient feels no
more uneasiness from it than he yvould 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  yvhich 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 yvhich 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 yvhich, 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 yvhich 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 decidely 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,
yvhen 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,  yvill 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 yvhich  puts a period to the
fever, while a shivering produced by art, would hardly ever  fail
to increase it.
   To enter fully on yvhat 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 yvhich I use this  term,  it  will be tht
most distinct plan to lay before the reader  the causes  and treat-
ment of the first and second stages, the symptoms of yvhich 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 yvhen 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 yvere, 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 place, the duration of the disease, in dif-
ferent cases, is also very  various, the change proceeding more or
less rapidly according to  the strength of the constitution, and other
causes, some of yvhich seem involved in  great obscurity.  But it
may in general  be observed, that the longer and to the greater de-
gree the causes hare been applied previous to the  occurrence of
 M^anic disease, the more rapid is its progress 
34
OF THE bOIPTOMS
  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 o! 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 yvhich form the last stage of this
disease; which necessarily varies according to the organ in yvhich
the change of structure takes place; and  it tei.ds slill  further to
perplex the symptoms, that  in some cases the disease proceeds in
more than 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, yvhich dispose the sympa-
thetic disease to affect one part in preference to another, yve 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  the ventricles of the brain.  In-
digestion  often  terminates in  hydrencephalus internus.  From
about-fifteen to thirty-five years of age, the disposition to affections
of the lungs is greatest, and it often produces phthisis.   At a more
advanced period, a tendency to disease of the rectum 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  yvhich 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 urinary 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 
S6
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 Tarnsacti<ms
vf the College  of Physicians. 
OF INDIGESTION.
                    CHAPTER II


         OF THE CAUSES OF INDIGESTION.


  The causes of a disease are divided into immediate  and re-
mote, the changes in the body yvhich 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.

              Oftlie 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 yvhich 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  yvhich
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 had
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 the piloric portion, except that from
the continued secretion of the fluids  of the stomach it is mixed
yvith 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  yvill appear
either that the food, last received into the stomach, is never mix-
ed yvith that already there, and yvhich 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 yvhich takes
place in the stomach, without yvhich it is impossible*) understand
the nature of the symptoms yvhich arise from its defects.
   With this view I examined the stomachs of about a hundred and
thirty rabbits immediately after  they had been killed in the usual
way, which is by a blotv 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
o*f 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 neyv 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 neyv 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 Sec-
tions of this Chapter, because it is by facts, which appear to be ascertained
in it, that 1 shall attempt some parts of the pathology of Indigestion., 
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,
yvho both sucked and ate green food, we always found the curdled
milk unmixed with  the  green  food.   Before the stomach  yvas
opened yve could, from its transparency, see where the green food
and where the milk Jay.
   If the old and neyv 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, yve find it, un-
less it has been very long in the stomach, undisturbed and  com-
paratively fresh.  AH 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 yvith 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 yvhich lie near the
surface of the stomach. It is evident, hoyvever, 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.
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,
yve 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 yvhole, 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 partof the
'fomach dissolved, while the recent food  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 yvhen 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  yve 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 yvas 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 towards  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
sayv  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.
43
  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 yvith 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-
aminjng'the stomach of a woman,  who had diet1 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 sayv  it otherwise.  Yet yve must conceive,
that at the time the animal  last eats,  there is some food more or

  *  See a paper by Dr. Hastings, in the 2]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 pome
 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 tyvo
 hours after the division of the nerves, marking the time when the
 stomach  having sent toyvards  the pylorus  its digested contents,
 begins to feel the  effects of undigested food coming  into contact
 yvith it.   To these efforts to vomit yve must ascribe the circum-
 stance of food being generally found in the oesophagus yvhen 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 allotved 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 beat and moisture.*
   From all that has been said it appears, that the process which
the food undergoes in the stomach is that of being formed into a
mass, in appearance nearly homogeneous; that this process takes
place only on or near the surface of the stomach, and that,  in
proportion as the food there situated  undergoes the necessary
change, it is by the muscular power of the  stomach moved on-
wards toyvards the pylorus, making room for that yvhich next suc-
ceeds, till the yvhole 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 yvith 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 probable, 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 yvhich 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
yvas 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 crovy.  After this operation  not only all desire to eat
yvas removed, but a degree of disgust yvas 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, yve are better prepared to understand the
operation of the causes yvhich 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.
47
the stomach and intestines, those which act on other parts, and
those yvhich 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,  yve have seen, they relieve the
original disease,  become causes which  support and aggravate it.
The debility of the skin, for an example, occasioned by Iudiges-
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 geueral 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 yvith 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 poyver, 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 tfo
 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 ©n 
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  yve 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, otheryvise influence
the state of the stomach.  We have  reason to believe that 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 induced 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 yve have  reason to believe
that the same observation applies to the  heart and other similar

  •Inquiry into the Laws oftlie Vital Functions.  Page 133, et sea.  Second 
OF INDIGESTION.
49
cavities, may for the time be yvholly 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 throyvn  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 yvith 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  above 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 Filer's Work De cog. et
Cur. Morbis. I also beg leave to  refer him to my treutise on itgtnptomdfn:
I'cr-prs. page 131.  Fourth edition.
              7 
50
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 yve 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 after 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

 Process6 *''* W" "^ '" tHe ,Mt SeCli°" °f the Nalure of the festive 
                        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
of a secreting surface can  not exist  yvithout 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  An  Inquiry into the Laws of
the Vital Function*, to which 1 have  frequency had occasion  to refer, and in
The Journal of the Royal Institution, that the nervous influence is immedi-
ately essential to the changes which constitute secretion.  I beg leave to
refer the  reader to papers on this subject, wlriclTthe Editor of the above
Journal did me the honour to publish iff the eighteenth, twenty-first, and
twenty-third numbers of that work.     «
\ 
 52                    OF THE CAUSES

 and tends to vitiate the effect of that yvhich 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 in the bladder, &c.
   So extensive, indeed, are the  sympathies of the  stomach, that
whatever greatly disorders the  function of any important organ
 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 yvhich exists between the stomach and the par1
 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 tJie  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.
 Where yve 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, yvhich 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 knoyv, from
the general laws of the animal economy, spasm of certain  parts
necessarily produces; and the disease was in..Teased 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 yvas
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 tyvo  objects which demand attention, the change produc-
ed in  the seat of the disease by its  remote causes, and the manner
in yvhich 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
yvith 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 yvhat 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 both, 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  &re  confined to the stomach  itself.
As the food can only he 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 the  diges-
tive process, soon affects the  nerves of that organ;  it may now be
observed, that all causes affecting, the nervous potver of the sto-
 mach, independently of the  direct action of the nervous on the
 muscular powrr, 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, yvhich at first view
 appear the most simple.
   The manner in yvhich a  morbid affection of the muscular  or 
56
OF THE CAUSES
 nervous poyver 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 yvhich  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, yve 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 yvhich 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 yvhich 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 small  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 yvhen yve  consider to what 
OF INDIGESTION.
57
inferences it leads, we shall pause, I think, before we give it our
assent.   It  is knoyvn that the nerves convey  impressions to and
from the brain, to which we owe feeling and voluntary  power.
If yve compress or divide the nerves of a limb, so as to cut off its
communication through them with  this organ, its sensation and
voluntary power are lost.  But  yve 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.   AM  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 of the pleura
of the ribs  spread  as readily, or nearly so,  to that of the lungs,
yvhich is only in contact with it, as to that in continuation yvith it,
yvhich 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  yvith  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 connexion?  we
observe  in their course arc only useful in the same way with the
              8 
58
OF THE CAUSES
 ganglions and plexuses, yvhich 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 vve 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 theirs 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 oftthe most dissimilar nature,

  * Experimental Inquiry, Part II, Chapters  4, 5, 7. Sect. 2; and Chapter 9.
  f I 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 \ ear, 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 Ins appeared since the publication of the first edition of this
treatise.  In 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  yvell-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,
yvhich 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, yvhich so greatly debilitates the powers  of the
nervous system, and which when excessive, yve have seen, is even
capable of destroying those powers, that diseases of other  parts of
the body, and particularly of the skin, yvhich 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
UP THE CAUSES
of Local Diseases.  He found that many yvounds, yvhich resisted
all  the  means  which the surgeon could  employ, were  attended
yvith ;> disordered state of the digestive organs, and yielded readily
wbtn the due  performace of  their functions was restored;  nay,
that many  yvounds and other local diseases had no other origin
than the states of health which attend irritation of the stomach
and bowels.
   It is also to be observed, that the failure of nervous power ap-
pears  more readily in some of the nervous functions than in others.
In Indigestion,  before the other functions of the surface are much
impaired, the patient complains of a sense of cold;  and  when by.
degrees, the failure of these becomes apparent,  the sensation of
cold,  an actual 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*d.
   All this we still find strikingly illustrated by the  operations of
nature in other cases.  It appears from the observations of Mr.
Guthrie, in his work on Gun Shot Wounds, that when the uerves
of a limb are injured, all its functions are impaired.  It is more
liable to ulceration than the sound part.  Inflammation  does not
take its usual course in it, and yvounds in it  heal with greater dif-
ficulty than usual.  A diminution of temperature,  however, and
an inability to resist changes of temperature, he observes are, from
the first, the most striking features; and the limb remains below
the natural degree for months, or even years, if the nervous influ-
ence  is  not perfectly restored.
   The preceding observations  show, not only  that those symp-
toms  of Indigestion  yvhich affect parts at  a distance  from the sto-
mach, may arise from any other cause  lessening the power of the
nerves, yvhether acting as affections of the stomach  do, on  the
yvhole nervous  system, or only on the nerves of the parts chiefly
affected; but that the order and general character of the symptoms.
thus produced,  are the same as yvhen they arise from Indigestion;
pointing out, in a striking manner, the similarity of their cause.
   When  the yvhole of the facts yvhich have been laid before tfcp 
OF INDIGESTION.
61
reader,  in this  and the  preceding sections, are  kept in view,  it
seems easy to point out in  what way the remote causes of Indi-
gestion operate in producing all  the symptoms of what 1  have
called the first stage of this disease.   The  debility induced  by
these causes on the muscular and nervous potvers of the alimen-
tary canal, on  the one hand, by preventing the due  change on the
food,  and its  due discharge  into  the  duodenum,   and  progress
throughout the  rest of the canal,  produces  the  symptoms which
immediately arise from undigested food; and on the other, either
by its direct effects in the stomach and  bowels, or through the ir-
ritation  of the  undigested food and vitiated secretions, excites the
nervous derangements which affect  these cavities themselves,  or
other parts with yvhich they sympathize.
   But in the second stage of the disease we see a  change which
can not be referred to either of these heads, I mean, the occurrence
of tenderness in a certain part of the epigastric  region above de-
scribed, which hardly ever fails to supervene in protracted casts;
and  when  considerable, to be accompanied with a  pulse yvhich
yvill be found  more or less hard, if examined  in the way above
pointed out,* and some of the other indications of fever which
have been enumerated.   I am now to lay before the reader such
facts as seem  to  throw light on  the more immediate cause and
nature of  those symptoms, which we shall  find greatly influence
the treatment of this disease.
   I have had occasion to call the  reader's attention to many facts
yvhich prove,  that irritation is often felt in a part at a distance
from  that  to  yvhich the  irritating  causes  are applied.  Now,
whatever  may be said of the way in yvhich  any cause of irrita-
tion affects the part to which it is applied, it is evident, that it
can only affect a distant part through  the medium of its nerves.
Thus, when worms in the intestines produce pain of the chest,
dyspnoea, &c, we know that these symptoms arise through the me-
dium of the nerves, and by yvatching their effects yve are enabled
'.o determine, what the effects of mere irritation  of the nerves are.
* Chap I, page 17, el seq. 
62
OF THE CAUSES
   It appears, from what was said above, that this irritation,  in

the'first instance, produces  no sensible change in the  part sym-

pathetically affected.  If the yvorms are removed from the intes-

tines  within a  few hours after the pain, the dyspnoea, and other

pectoral symptoms have supervened, they immediately disappear,

and the lungs perform all their functions as well as if no  symp-

tom of disease had existed.    But we have also seen, that if these

sympathetic  symptoms remain for a certain time, inflammation

of the lungs takes place, and they exhibit, on dissection, all the

marks of this disease, suppuration and its other consequences not

excepted.  Other instances of the same kind were adduced, and

it  would be easy to multiply  them.*


  * Since  the publication of the first edition of this Treatise,  Mr. Brodie
has favoured me with the following letter, containing an account of an im-
portant experiment which he  made many  years ago, and some valuable
observations, which seem strikingly to illustrate  this part of the subject,
and which he has had the goodness, at my request, to permit me to make
public.
  " My dear Sir,—The following are the particulars of the experiment  to
which you have alluded:
  " On the 29th of June, 1814, I exposed the nerves of the eighth pair  in
the neck of a rabbit, and by means of a fine needle, I passed a silk thread
transversely through the substance of  each nerve, in the manner of a small
seton.  The extremities of the threads were left hanging out of the exter-
nal wound.  This operation did not produce any immediate effect on the
respiration: but at the end of twenty-four hours the animal was observed to
breathe in a laborious and difficult manner, twenty-eight times in a minute.
The threads were withdrawn, but the removal of them occasioned no relief,
and fourteen hours afterwards  the rabbit was found dead.  On dissection
botli lungs were seen loaded with blood and inflamed.  The left lung was
inflamed in the greatest degree, the surface of it being encrusted with coa-
gulated lymph, and lymph being effused also in several places in the inter-
tubular substance and auricles.  There was a considerable quantity of serum
in  the cavity of each pleura.
  " The stomach and intestines were in a natural state, presenting no ap-
pearance of inflammation.  The gall-bladder was nearly emptied.  A slight
degree of inflammation existed in each nerve; but only at the  part  where
the seton had  been introduced.
  " it appeared to me that, in this experiment, the inflammation of the lungs
might reasonably be attributed  to the irritation produced by the threads on
the nerves, by which they were supplied.  A multitude of *pther circum-
stances might be adduced in proof of the doctrine, that simple nervous irrita-
tion is capable of producing local inflammation, even at a distance from the
part in which the source of the  irritation exists. A calculus passing down the
ureter occasions pain in the testicle; and if a certain length of time elapses
before the calculus escapes into the bladder,  this symptomatic pain is fol-
lowed by swelling, tenderness,  and no small degree of inflammation in the
testicle.  In like manner, in some cases of disease in the hip, the sympto-
matic pain in the knee  is attended at last by tenderness and puffy swelling 
OF INDIGESTION.
63
   Thus it appears that irritation of the nerves of a part may ex-
ist for some time without any change taking place in the state of
its circulation; and yvhen the cause of irritation is not severe, and
the part little disposed to disease, this may  be the case for a long
time.   Pain of the shoulder often continues for months in chronic
affections of the liver, without the shoulder becoming stiff or ten-
der to the touch; but, it also appears, that the continuance of the
nervous affection, sooner or later, according to its degree, and the
tendency to disease in the part  sympathetically affected,  influen-
ces the state of its vessels.   The effect, which thus takes  place
in a distant part, must, of course, take place more readily in that
to which the cause of irritation is applied.
   Now it appears from what was said in  the  second section of
this chapter, that all the causes of Indigestion act either  directly
or indirectly, on the  nerves of the digestive organs.
   This irritation of the  nerves must sooner or later produce the
same effects here, as in other parts, and the vessels at length par-
taking of the disease, some tendency to inflammation must ensue.
This is indicated by the symptoms above mentioned, a tenderness
on pressure in  the  part affected, hardness of the pulse and  other
febrile symptoms, which under  all circumstances indicate inflam-
mation  or a state approaching to it.
   As the tenderness  of the epigastrium is always the first of these
symptoms, and the others are proportioned to it, and yield, as we
shall find, to the means which  relieve it, it is evident that  these
symptoms arise from the same cause yvhich produces it. It is a point
of considerable importance in the treatment,  therefore, to ascertain
the nature and seat of the affection, which occasions this  tender-
ness.

of the latter articulation; and in many instances in which suppuration takes
place slowly on the membrane of the brain, after an injury of the head, the
patient becomes affected with inflammation and abscesses of the lungs, liver,
or some  other organ remote from the seat of the original malady.
  "I have much pleasure in being able to communicate to you these obser-
vations, in confirmation of the opinions which you have expressed and pub-
lished on these subjects; and I am, dear Sir, yours,  verv truly,
                                                 B C. Bkqbit: "
    Saville-row, Oct. 26, 1821." 
64
OF THE  CAUSES
    It is evident that of the different parts of the stomach, the pylo-
 rus is the one most exposed  to  the causes of irritation.  Other
 parts experience  the  irritating effects of different portions of its
 morbid contents, but the pylorus  is necessarily exposed to those of
 all.  All must pass  by this orifice.  When therefore we see that,
 after Indigestion  has continued for some time,  a certain part of
 the region of the stomach becomes tender on pressure, we can not
 help turning our attention to this part   Now in the natural situa-
 tion of the viscera, exactly in  the tender part of the epigastrium,
 the pylorus lies, yvith the thin edge of the liver upon and in con-
 tact with it; as (  have  ascertained with the kind assistance of Mr.
 Brooks,  whose anatomical  skill is so generally acknowledged.
   When all these circumstances are  considered, can  yve doubt
 that it is the irritated  pylorus  assuming a loyv degree of inflam-
 mation which occasions the tenderness on pressure above describ-
 ed; and yvhen yve consider what  has just been said of  the influ-
 ence  of  juxta-position in the  spreading of this  disease, can  we
 doubt, when we find the tenderness with some degree of fulness
 gradually extending  downwards,  along the soft parts on the edge
 of the cartilages of the  right side of the epigastrium, as we find it
 to do in the progress of Indigestion, and at length ending in evi-
 dent enlargement and tenderness of the liver, that the affection of
 this organ, with which  it is in  contact, thence by degrees extend-
 ing to its other parts?   Thus  it is that  of all the neighbouring
parts no other so  frequently partakes of this affection of the sto-
mach.   It is doubtless  in the same way, that the hahit of drink-
ing spirits,  uhich must apply  so great a degree of irritation to
the pylorus, seldom fails to produce affections of the liver.
  We have reason to believe that it is from its greater  exposure
to causes of irritation, that the pylorus itself is more subject  to
organic disease than  any other part of the stomach; but the yvise
Author of our being  seems to have given to a part necessarily so
much exposed, a great power of resisting  disease; so that the first
deviations from the healthy state, yvhich are communicated from
it to the liver, more readily take root there, if I may be allowed
the expression; and the structure of this organ yields to the affec- 
OF INDIGESTION.
65
tion which that of the  part, from which it receives it, generally
resists.   The liver indeed is here already disposed to disease, its
action we have seen from an earlier period, having by sympathy,
been influenced by the  state of the stomach, and the continuance
of diseased action, yve know, disposes to disease of structure.
  I am  well aware that the fulness of the right hypochondrium
in Indigestion, even when combined with tenderness on pressure,
does not alyvays  indicate  an  affection  of the  liver.   It  often,
I believe,  arises  from the  state of the duodenum,  which  fre-
quently  expels its contents with difficulty in this disease, and my
experience corresponds with  many of the observations made by
Dr. Yeats  in bis excellent paper on this intestine, in  the last vo-
lume of the Transactions of the College of Physicians.
  It has been stated, in enumerating the symptoms, that the ful-
ness and tenderness of the right hypochondrium in the early stages
of Indigestion are often temporary.  I have repeatedly seen them,
even yvhen they were considerable, disappear after the operation
of a brisk cathartic.  They must then arise either from a distend-
ed and oppressed  state  of the duodenum, or temporary distention
of the various  vessels of the liver.  To which of these causes we
should ascribe them, the accompanying symptoms will generally
enable  us  to determine.  The feeling given to the hand by the
distended duodenum is different from that produced by the gorged
liver,  and in the former case the chief fulness is generally lower
down, and does not seem to proceed  so immediately from under
the edge of the thorax as general fulness of the  liver does; so that
even where, from more permanent debility of the  deodenum, its
morbid  distention is a more  constant symptom, the two  cases
may generally by distinguished.   The more temporary nature of
both these  affections,  with  the  historv and general symptoms of
the case, for the most part readily enable us to distinguish them
from fulness and tenderness of the same region arising from or-
ganic  disease of the liver, which comes on slowly and uniformly,
and the commencement of which, when it arises from  Indigestion,
may generally be traced to  the epigastrium.
  The observations yvhich  have been 1 iid before the reader, a?
              9 
66
OF THE CAUSES
 far as I am capable of judging, leave no room  to doubt, that an
 inflammatory  affection of the pylorus, excited by the  passage  of
 the irritating contents of the stomach for a longer or shorter time
 according to the nature of these contents, and the greater or less
 degree of inflammatory tendency in the part, is the cause of the
 tenderness observed in the epigastrium, and which at first is gen-
 erally confined to a space not larger than a shilling; an inference
 confirmed by dissection, which often exhibits the  internal mem-
 brane of the pylorus thickened in those yvho have suffered much
 from  the disease of the  digestive organs.
   It appears from many experiments detailed in the introduction
 to my Treatise on Symptomatic Fevers, and which have been care-
 fully  repeated by Dr.  Hastings* with the same  results,  that all
the causes  of  inflammation act by debilitating the  capillary ves-
 sels of the part, and thus  allotving  them to be  distended by the
 vis a tergo, from which, as appears from what is said in the trea-
 tise just referred to, and last part of the Inquiry into the Laws of
 the Vital Functions, all the phenomena of inflammation seem ne-
 cessarily to arise.
   It is this debility of  the finer vessels of the pylorus, therefore,
 produced by long continued irritation  of its nerves, from which
arise, in the second stage of Indigestion, the hard pulse and  other
symptoms of feverishness above enumerated, and by which, yve
 shall  find the successful  treatment of this stage essentially influ-
 enced.
   It is a point of great importance in the progress of disease, that
febrile disease begins with inflammatory action, that is,  debility
and distention  of the finer vessels,  and their  constant effect in-
 creased action of the larger ones, and  at  length necessarily pro-
 duces debility  of the nerves; while nervous disease  begins  with
the latter, and as certainly  ends in debility and distention of the
finer vessels.   It seems to be this which renders the chronic in-
flammation of organs so much more difficult of cure,  and apt to
run to derangement of structure, than the acute form of  the dis-
 ease.   In the  former, the functions of the  part are more generally
* Dr. Hastings's Treatise on Bronchitis. 
OF INDIGESTION.
67
Injured.   Its nervous power  is debilitated  before its  vessels be-
gin to be distended.   Besides, the debility of the nerves, and that
of the extreme vessels tend to increase each other; and unless the
chain of diseased action can be broken by means which enable
the vessels to recover their healthy diameter,  it goes on  more or
less quickly, sometimes, if the  symptoms  are mild, very slowly,
till the structure of the organ is  destroyed.
   The  inflammatory  action  in Indigestion, partaking of the
chronic nature of the disease it belongs to, often, in  the first in-
stance, attracts so little attention, that the stimulating plan, which
yve shall find suited to the first stage, is sometimes  pursued till
organic derangement at once announces to  the  practitioner the
danger of the patient, and  the necessity of adopting other princi-
ples of treatment.  But as such an inflammatory state as that yve
have been  considering  may ahvays,  I believe, be  observed to
precede organic  derangement of vital organs; and,  both on this
account, and for other reasons, appears to be its immediate cause;
it is of the utmost consequence, in preventing that derangement,
to watch the first appearance of inflammatory action, for it is at
the beginning alone  that it can be effectually counteracted.   The
period at which it shows itself,  yve have seen, is very various,  a
circumstance yvhich has doubtless contributed to obscure this part
of the disease.
   While the foregoing  changes are going on in the solids, the
fluids of the body must necessarily undergo corresponding devia-
tions from the healthy state.  In proportion as the flow of nutri-
ment into the  blood is  lessened, the  chyle  itself probably  more
or less vitiated, and as the different secretions fail, the circulating
fluids must be subject to  various changes.   What these are the
present state of our  knowledge  makes it impossible to ascertain.
   In those who have long laboured under Indigestion in its  more
severe forms, the blood is sensibly altered in some of its properties.
The  proportion  both of red globules  and lymph is less than in
health.   This state of  the blood must necessarily affect that of
the fluids supplied to secreting  surfaces, and from this cause also, 
68
OF THE CAUSES
the secretions  of the  digestive  organs must further deviate from
the healthy state.
   In considering the mutual action of one part of the system on
another, the state of the mind deserves particular attention in In-
digestion.  The disease itself we have seen  seldom fails to render
it  anxious, irritable, and  apprehensive;  and this state of mind,
yvhich yve have found ranked among its causes, can not fail to in-
fluence its symptoms.
   When the reader reviews the various  facts which  have been
laid before him relating to the operation  of the remote causes of
Indigestion, and particularly takes into the account what I have
frequently had occasion to recal to his  recollection, that the mor-
bid states of all those  parts sympathetically affected, till actual
disease takes place  in  them,  operate as secondary causes of the
primary affection, both by sympathy, and by their  farther weak-
ening the general powers  of the system, he will  perceive how
complicated the operation of its remote causes must be;  and in-
deed  by reflecting on  the nature of the  animal  body, the great
variety of parts of which it consists,  the different nature of these
parts, the variety of functions necessary  to produce each  indivi-
dual result,  and the  variety of causes which may influence each
organ in this  complicated structure, we  are prepared for such a
conclusion.
   When the motions of a clock are  suspended, yve find  a wheel
clogged, and readily perceive how this cause of derangement has
destroyed the action of the machine; because its action  depends
yvholly  on one principle,  and consequently all causes impeding
its motion must affect this principle.    But  did the nature of the
clock include  many principles  of action, and were the cause of
disorder such, as might influence several or  all of them, yve should
seldom finds its effect  confined to  the  derangement of one part:
yet, even  then the effects of the offending cause would be simple
compared to those of a cause of disease,  for to bring the machine
into a state  analogous to that of the  animal body, and render the
effect of  its offending causes equally complicated,  its  different
principles of action must not only have some of them a direct, and 
OF INDIGESTION.
69
all an indirect, dependence on each other; but besides this depen-
dence for their actual existence,  each must in a greater or less
degree be Capable of influencing every other,  and in such a way,
that the secondary affection re-acts on the part first impressed by
the offending cause.
   In a machine so constituted, until we could trace the manner
in which the different principles of action depend upon and  af-
fect each other, what possibility would  there be of ascertaining
the change which any cause of derangement had occasioned in it,
and there could surely be no  expectation of finding  it in the dis-
order of any one part.  How vain then was  the humoral patho-
logy, and hoyv vain that of the simple, or even of the living solid,
although the last, wnich we  owe chiefly to the  labours of Hoff-
man and Cullen,  must be regarded  as an important step toyvards
a true view of the nature of disease.
   All the parts of a living body are  concerned in its diseases, and
it is  only as  we advance in  a knowledge of those various parts,
and their relations to each other, that  the nature of its deviations
from a state of health can be  understood. 
70
OF THE TREATMENT
                    CHAPTER HI.


      OF THE TREATMENT OF  INDIGESTION.


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

                       SECTION I.

  Of the treatment of the first stage of Indigestion.

  The first object  in the cure of all diseases is to remove the re-
mote causes as far as they still continue to operate.  Among those
of Indigestion, we have seen, that whatever occasions morbid dis-
tention of the stomach, or irritates, its surface, holds a chief place.
ft unfortunately happens,  that there is  a continual tendency in
this disease to produce those causes.  However well, therefore,
yve  may suceeed in removing them, it requires constant attention
to prevent their recurrence.  It also appears from what has been
said,  that these observations  apply  yvith almost equal  force to
some  of the other causes of this disease, particularly to that inac-
tivity  of body and irritable, anxious and desponding state of mind,
yvhich so frequently cause, and are caused by, Indigestion.
  The first part of the treatment, therefore, which falls under our
attention, relates to diet and exercise both of mind and body; and
in the slighter  and more recent cases a strict attention to these
alone, or at most with the assistance of an occasional mild ape-
rient, will often be found sufficient to  effect the cure; and the 
OF INDIGESTION.
11
neglect of them will, in all cases, tend to counteract whatever
other means we employ.

                Of the diet in Indigestion.

  The objects«to be kept  in view in regulating the diet in  this
disease, as appears from yvhat has just been said, are that it shall
tend as  little as possible to produce either morbid distention or
morbid irritation of the surface of the stomach.
  Many  of the regulations belonging  to the first of these heads
arise out  of what was said  in the section on the immediate causes
of Indigestion. It yvould appear from the observations there made,
that the appetite  continues till the first food neutralizes  the gas-
tric  fluid  which had accumulated in the stomach and caused the
sensation of hunger.   If the patient eats  with great rapidity, he
will, during the time  required  for this combination, put such a
quantity  of food  on the stomach as to occasion some degree of
morbid distention, which will be greatly  increased by the swel-
ling of the  food, in consequence of-digestion being impeded by the
distention; while the stomach, at the same time, for reasons above
explained, does not, with the usual facility, propel it into the intes-
tine. Thus it is that the feeling of distention often increases for
some time after too full a meal, and, at length, is frequently accom-
panied with actual pain.
   The food, when  yve eat too fast,  is not only received   into the
stomach  in too great quantity,  but is swallowed without being
duly masticated and mixed with saliva, and  therefore  yvithout
properly undergoing what  may  be  considered the first process of
digestion.  It is thus presented to the stomach in a state, in which
the  gastric fluid pervades,  and  consequently acts upon  it yvith
more difficulty.  In this   way  eating  too  fast is injurious even
yvhen the patient abstains from taking too much.  For these rea-
sons, to eat moderately and slowly, is often found of greater con-
sequence that any other rule of diet.   The dyspeptic, in eating,
should carefully attend to the first feeling of satiety.  There is a 
72                   OF THE TREATMENT
moment when the relish given by the appetite  ceases;  a single
mouthful, taken after  this,  oppresses  a weak stomach.  If he
eats  slowly, and attends carefully to this feeling, he will  never
overload the stomach.
  Morbid distention of the  stomach, hotvever,  may take place,
although there be no error in either of these respects, if  the food
be of such a nature that the fluids of a weak stomach are unable
to effect the necessary  change on it, in consequence of  which it
runs into fermentation.
  It is  evident  that  morbid  distention,  from  whatever cause,
can not exist without, at the same time, occasioning morbid irri-
tation of the surface of the stomach.  The  distention itself has
this effect, but  as deranged  digestion is the consequence of this
degree of distention, it can never stop here.   All undigested food,
however small the quantity, is a  cause of irritation.
  Thus the  yvhole train of  symptoms, which constitute a fit  of
Indigestion,  may arise either from too large a quantity  of  food,
particularly  if carelessly masticated, or from food of difficult di-
gestion, most readily of course from a combination of these cau-
ses.   It  is,  therefore, of great  consequence, in regulating the
treatment of this disease, to  ascertain what kinds of food are  most
easily changed by the gastric fluid.  This is sometimes influenced
by peculiarities of  constitution, to which no general  rules  will
apply, but it is not difficult to perceive, what kind of  diet is usu-
ally  best suited to a weak stomach.
   Tough, acescent, and oily articles of food, with a large propor-
tion  of liquid, compose the diet most difficult of digestion.   It
would appear that a feeble gastric fluid, as indeed we might a priori
suppose, does not admit of being greatly diluted yvithout having its
powers much impaired.  The diet opposite  to this, then, is that
which agrees best with dyspeptics.   In the first stage of Indiges-
tion, a diet,  composed pretty much of animal  food and stale bread,
is the best.
   It yve except beef and veal, the flesh of old, in general, is more
easy of digestion than that of young animals, on account of the
greater quantity of mucilage in  the latter.  All mucilages are of 
OF INDIGESTION.
73
difficult digestion.   Even the vegetable mucilages, which in small
quantity are generally  grateful to the stomach,  will oppress it, if
taken very freely.   They are among the things which, in  vulgar
language, are called  sating, or  phlegmy.   Whatever produces
the feeling known  by these terms disagrees with the stomach.
   The stronger kinds of animal  food, of yvhich beef may be con-
sidered  the strongest, are most apt to excite fever.  On this ac-
count we often  allow those, recovering  from fever or  otherwise
disposed to it, to eat the animal  mucilages, or those meats which
contain  a great proportion of them,  yvhen even  mutton  for  exam-
ple is forbidden.   Thus animal jellies and young  meats have ob-
tained the name of light, but this only relates to the tendency  to
produce  fever, for  as  far as digestion is concerned they are hea-
vier than mutton,  and to many  stomachs than beef.   A similar
observation applies to  the  vegetable,  compared with  the animal
kingdom; the former are less apt to excite fever, and  are there-
fore called lighter, but they are in general more difficult of diges-
tion.
   From what it arises that mutton is to  most stomachs so  much
more  easy of digestition than beef, it  would be difficult to say.
Most  kinds of game are of easy digestion.  Fish,  independent-
ly of the heavy sauce with which it  is eaten, is  for the most
part,  less easily digested than the flesh of land animals; and as it
at the same time affords less nutriment, it is in  both respects less
proper for the food of dyspeptics; although from the white  kinds
being less apt to  extite lever, they,  like the animal mucilages,
have  obtained tne  name of light, a term  which so often deceives
yvith  respect  to what is  most easy of digestion, that it is  neces-
sary to keep this explanation of  it in view.
   The  meat  most  mixed yvith fat, is, eel. par., most  oppressive.
It is  on  this account that pork and the tongues of many animals
are of difficult digestion.   For the same reason, geese  and  ducks
are the  most oppressive kinds  of poultry.   Turkey  is more  so
than  fowl, which, next to  mutton,  is,  perhaps, upon  the  yvhole,
the lightest animal food in common use, if the skin be avoided.
Of the  different kinds of game, pheasant  is least easy of  digest
               10 
74
OF THE TREATMENT
tion.   The lean  part of venison is, perhaps, the most digestible
article ol diet.   Hare and partridge appear to be as much so as
mutton.
   Eggs, as far as relates to a tendency to produce fever, may  be
regarded as of a middle nature  between animal and  vegetable
food.  It is a common opinion  that they disagree  with bilious
people, that is people labouring under  Indigestion, in whom  the
disease has extended to the function of the  liver.   This opinion,
in general, I believe,  is ill-founded, if they are eaten soft boiled
with stale bread.  In this  state, although offensive to a few sto-
machs, they, for  the most  part, are easy of digestion, if the pa-
tient confines himself to one, or at most two, and are an agreea-
ble change.
   Few things  are of more  difficult digestion than  new bread.
This  observation  applies to every  thing which by  mastication
forms a tenacious paste, which is not easily pervaded by the gas-
tric fluid.   So difficult of digestion is such a paste,  that I have
known  more than one dyspeptic, yvhose stomach  could only  di-
gest neyv bread, when it yvas soaked in melted  butter.   Here
one of the  articles most difficult of digestion was more easily
digested  than the tenacious paste yvhich its presence prevented.
Even bread sufficiently old is oppressive  if taken alone, and  in
large quantity, it still  forms a mass not very readily  pervaded.
   On the same principle, food is often rendered more indigestible
by processes employed yvith a view to assist the  stomach.   All
articles composed of strong jellies, and food  carefully  mashed are
oppressive.   The  coarser division  yvhich our food undergoes  in
mastication  is better suited to assist digestion.   Most dyspeptics
find, that potatoes, for example, finely mashed, although yvithout
any admixture, are more difficult of digestion than yvhen properly
masticated.   During mastication the saliva is freely  mixed yvith
them,  and a mass is  formed  easily pervaded.   When they are
mashed,  they resist admixture with the saliva,  as  well as the
gastric fluid.
  Our food is rendered more  easy of digestion by simple roasting
or boiling, provided it is not  too much done.  Beyond this, the 
OF INDIGESTION.
75
art of cookery is nothing, but that of pleasing the palate at the
expense of the stomach.   There are a few circumstances under
yvhich it is proper to bribe a patient to eat; under all others, the
refinements of the cook are at variance yvith the objects of the
physician.   However imposing the plans of concentrating much
nutriment in small compass may at first  view appear, yve may be
well assured, that in such concentration  something is taken away
from what nature designed for our food,  yvhich is useful to us.
  It is not generally known, that the most concentrated decoction
of beef,  so  far from  affording much  nourishment, will not,  if un-
mixed with something solid, even allay  the  appetite.   A person
under my care yvas attacked with a severe pain of the face when
even the smallest quantity of any  solid  food yvas  put on the sto-
mach, a single mouthful of bread never  failing to bring on the at-
tack; and, as he at length refused  all solid food, he  was confined
for  some weeks to a strong decoction of beef; but, however strong,
and in whatever quantity it yvas taken,  it never relieved the calls
of hunger, and  he rapidly  emaciated.
  Fresh vegetables, on account of their  tendency to ferment, are,
on  the  whole, injurious in Indigestion.  Some vegetables, how-
ever, are more so than others.   Peas, beans, cabbage and waxy
potatoes, I have found the worst.   Mealy potatoes, turnips and
broccoli, among  the best.  They  should always be boiled till
they are soft; raw vegetables of all kinds are oppressive; lettuce
appears to be the least so.   The tough, thready,  and membrane-
ous parts of vegetables are of most difficult digestion.
  Fruits are also difficult of digestion, particularly the cold fruits,
melons, cucumbers, &c; next to  these, the  mucilaginous fruits,
gooseberries, pears, &c.   Apples and strawberries  I have found,
on  the whole, lightest; but we more frequently  find peculiarities
in the stomach yvith respect to fruits than other articles of diet.
To many  stomachs the most  acescent  fruits, currants, mulber-
ries, &c, are  particularly offensive.   All  preserved fruits are
oppressive,—the large proportion  of sugar adding much to their
indigestible quality.   To some dyspeptics sugar  is  so oppressive,
that I  have  known several  yvho  were  obliged  to abstain  even 
76
OF THE TREATMENT
 from the small quantity used  in tea.   Most stomachs* bear acids
 better than actscents.
   Bread is not the worse for  being hard,  provided it is properly
 masticated.   All  hard  and tough  animal  lood, particularly if it
 be salted, which adds to its hardness, is of difficult digestion.   It
 se< nis to be from its  hardness that smoked meat is oppressive.
 Hard and tough animal  food can not, by mastication, be reduced
 to the loose pultacious form which  hard bread assumes.
   There are few things in common use so oppressive as butter.
 It appears  to be more so than the fat of meat.  The fat of mut-
 ton is less  difficult of  digestion than that of beef, and the fat of
 venison less so than either.   The same may be said of the fat. of
 turtle, but all kinds of fat are oppressive to a weak stomach, and
 that of  which yve  are inclined  to  eat the   most is generally, on
 this account, the worst.  We  have  little experience of oil in this
 country.  Could I trust the result of a few  instances, I should say
 that olive oil, to  a  stomach accustomed to  it, is less oppressive
 than butter, probably than most kinds of fat.
   All oily substances are rendered more oppressive by being fried,
 as in many of our dishes; yet, such is the peculiarity observed in
 particular cases,  that I have known a dyspeptic digest fried  ba-
 con pretty  well, who  could not digest  mutton; as if the  strong
 stimulus of the former excited a secretion  of gastric fluid, where
 the milder  stimulus of the mutton failed.   It seems to be on this
 principle that the stomach will  often digest a little of  any thing
 for yvhich the patient greatly  longs, and  that the  appetite some-
 times increases after we begin to eat.
   Cheese is,  in  general, still more difficult of  digestion  than
 either butter or fat.   With  their  oily nature, it combines the
hardness and toughness of the dry and  compressed curd, which
is very difficult of minute division.   Milk  and cream, with their
preparations, are generally oppressive in proportion to their rich-
ness: but the same proportion of cream mixed yvith water is more
digestible than milk
  Much seasoning is injurious, both by the unnatural  excitement
yvhich it occasions, by which it,  for the time, increases the power 
OF INDIGESTION.
77
of the stomach, at the expense of subsequent debility; and by in-
ducing us to eat too much.   It also, like other strong stimulants,
has a more  direct tendency to induce the second stage of the dis-
ease.
  With respect to  fluids, water is evidently intended for the pro-
per dilution of our  food.   As, on the one hand, we have seen the
food may be so watery that it too much  dilutes the gastric  fluid;
so, on the other,  it  may be so dry, that  this fluid  can not easily
pervade it,  and its necessary motions in the process of digestion
are affected yvith difficulty.*
  But these are not the only, nor do they appear indeed to be the
principal, purposes for which  we are induced  to drink, which
seems generally to  be, to supply the waste of moisture occasioned
by the various secreting surfaces, and particularly  by the  skin,
which is the  most  extensive; hence every thing which promotes
perspiration increases thirst.   For a similar reason diarrhoea, and
the operation of a  cathartic have the same effect; and it appears
from many facts, that there is often a rapid absorption of fluid from
the stomach.
  In health,  when the various functions are  in due proportion,
little liquid  is required with the food, the inhalation  by one  set of
vessels nearly compensating for the exhalation by  others.   Thus
it is  that the most healthy  are little troubled with  thirst.  In In-
digestion, we have seen it is a frequent symptom.   It seems some-
times to arise from a general failure of the  secretions of the ali-
mentary  canal, from  the  mouth downwards, more  frequently
from irritation of the stomach,  excited  by the undigested  food;
for  there is a false  thirst, as yvell as  a false  appetite.   As that
irritation frequently induces the patient to eat  when  there are no
fluids in the stomach adapted to the office of digestion, it excites
him  to drink yvhen  there is no want of fluidity in the various juices
of the body; and when so far from there being a  want of liquid
in the stomach,  it is surcharged  yvith vitiated fluids.

  *  Besides the gastric fluid, properly so called, we  have reason to believe
that the stomach, like other secreting surfaces, forms a bland fluid for the
purpose of defending itself to a certain degree against the irritation  of  its
contents.  This fluid may also be of use in promoting the necessary motion?
'jf the food. 
^8
OF THE TREATMENT
   The  drink, under such circumstances, only giving relict  in
proportion as it dilutes the irritating matter, the thirst returns as
soon as its irritating properties again, increase  by its continued
fermentation, or perhaps  merely as soon as the stomach  has be-
come accustomed  to the degree of relief yvhich the last  draught
procured.  In this  way dyspeptics  often drink  vast  quantities,
greatly  distending the stomach and increasing their disease.
   There is some difference of opinion respecting the propriety of
drinking at meals.   It is evident from what  has been said, that
the necessity of drinking must be different  under different cir-
cumstances; but in  general  it  is best  shown by the degree  of
thirst, and there can not perhaps be a  more erroneous idea than
that, which induces  some  people to drink during meals, for the
purpose, as they say, of assisting digestion, when they feel no de-
sire for  it.
   Drinking water can  in no other way assist  digestion than by
affording the proper  degree of moisture to the food.  If there be
no thirst, we may be assured that it already possesses this degree
of moisture, and that any  addition to it yvill  only  dilute  the gas-
tric fluid, and consequently enfeeble its solvent power.   I have
often observed, that eating too fast causes thirst,  the food  being
swallowed without a due admixture of saliva, the  mass formed in
the stomach is too dry.   It is almost unnecessary  to observe, that
the liquid taken after food must but  imperfectly answer the  pur-
poses of that mixed with it during mastication.
   The  best rules, I believe,  yvhich a dyspeptic can follow, are
not to yield to every slight sensation of thirst, and when  the sen-
sation is considerable, to take but a moderate quantity, and that
deliberately, for it is yvith drinking as yvith eating, if he swallow
yvith too great rapidity,  he will take too much.
   Such appear to be the regulations respecting liquids most con-
sistent with the nature of indigestion, yvhen the  fluid possesses no
other properties but those of quenching the thirst.   If it possesses
other properties, other circumstances demand consideration. Both
nutritive articles of  diet and stimulants  may be  received in the
liquid form. 
OF INDIGESTION.
79
  I have just had occasion to observe,  that the most nutritive
fluid alone will neither satisfy the appetite nor afford due nour-
ishment.  When we  reflect on the facts above stated relating to
the manner in yvhich  digestion is performed in man and the ani-
mals most similar to him,  we shall easily  perceive yvhy  liquids
alone are incapable of affording sufficient nourishment.  We have
seen, that that part of the food yvhich lies next the.stomach having
duly undergone the action of the gastric fluid, is moved onwards
towards the pylorus, while that  next in succession is in  its turn
applied to the surface  of the stomach, where  it excites a further
secretion of gastric fluid, undergoes its action, and in  like man-
ner is moved onwards towards the pylorus.
   That the motions necessary for these purposes may be  readily
performed,  a certain degree of moisture is necessary; but if the
contents of the stomach be wholly fluid, it is evidently impossible
that such a process can go on with any degree of precision. The
fluid can not be so changed as to present  a constant and regular
succession of food, comparatively fresh, to the surface of the sto-
mach; there will not, therefore, be the same stimulus to  excite to
a continued  secretion of gastric fluid,  and what is secreted will be
too easily diffused through the liquid  contents of the stomach, to
 make the proper impression on any one part; the same  must ne-
 cessarily happen  to the more digested part in its passage to  the
 pylorus; it must be more or less diffused through the other contents
 of the stomach; in short, no part will be duly digested.   The
 gastric fluid, being too much diluted for its function, is rather dif-
 fused through the contents of the stomach than  neutralized  by
 them, hence the appetite  is never perfectly  allayed, and little
 nourishment afforded.  Thus the effects  of  liquid  food tend to
 confirm the  view of digestion afforded by the  facts,  which have
 been  laid before the reader.
    When nutritive  fluids,  however,  are  mixed with solids,  al-
 though of a less nutritious quality, they afford sufficient  nourish-
 ment.  Strong broth, mixed with bread,  or any other solid arti-
 cle of food, is sufficiently nutritious; but it  is by no means  the
 form, as appears from yvhat has been  said,  in which nutriment 
80                   OF THE TREATMENT

should be presented to a weak stomach, unless the appetite or ir-
ritability of the stomach, as sometimes happen, be such that solid
food can not be taken.  The proportion of liquid is too great, if
there be much broth in the mixture; and if not, it approaches too
much to the nature of the mucilaginous paste, to permit the di-
gestive fluids to pervade it yvith ease.   Thus all  kinds of broth
are  apt to become sour on a weak stomach,  and to cause other
things to run into fermentation.   When liquid nutriment is taken,
as soups and broths usually are, before  other food, it has the ad-
ditional bad effect of inducing us to eat too much.
  The diet of the dyspeptic should not only be well chosen, but
simple.  Variety is always an inducement to overload the stomach,
and indeed so intermixed  are the feelings produced by the calls
of hunger, and by the  means which please the  palate, that, when
the  desire to eat is constantly renewed by a succession of differ-
ent  kinds of agreeable food, it  is impossible to judge when we
have received  the proper supply.
  We have reason to believe that by such means an actual in-
crease of secretion is  produced  in the digestive organs, and thus
an artificial appetite, if I may use the  expression, excited at the
expense of subsequent debility;  which, although  it may  not  im-
mediately show itself  by symptoms of Indigestion, which  also  is
common, at length, in  the majority of people, weakens the diges-
tive powers.
  With respect to stimulating fluids, the operations of the most
innocent o( these seems to  be  confined to the digestive organs.
The various aromatic  waters, ginger-tea, &c, seem only to be ob-
jectionable in the same way that other kinds of seasoning are, and
we shall find, that in   certain states of  Indigestion they are use-
ful, in giving temporary tone to  the stomach and  bowels.
  The  most pernicious fluid of this  class, it is well  known, are
those which owe their stimulating property to the presence of al-
cohol.  When  taken   in considerable  quantity,  they  not  only
more, perhaps, than any other stimulants, injure the digestive or-
gans; but extend their pernicious effects to other parts of the sys- 
OF INDIGESTION.
81
tern,  to which we  have reason to believe, they are  immediately
applied by means of the absorbents.
   Like most substances capable  of powerfully affecting the ani-
mal frame, they possess valuable as well as pernicious qualities,
and, were the former of these less eminent than they really are,
so general is their use in one form  or  other,  and in most people
the habit which requires their continued use, so fixed, that they
seldom can  be wholly withdrawn, except in very early life, with-
out doing more harm than good.
   All  will  agree that  alcohol in every shape is unnecessary  to
those  who are in health, and have never been accustomed to the
use of it; and that had no beverage but water ever been known,
however we might feel the want of a stimulus, in  many cases,
doubtless, the most valuable we  possess, a great number of the
most  fatal diseases  we are subject to, would  have been  less fre-
quent; but these are not the questions before us.  Our object is,
to inquire what  is the best for dyspeptics, as we find them in the
habits of society which prevail in this  country.
   As these habits are such, that  more or less  alcohol is necessary
to support the usual viguor of the greater number of people, even
in health, nothing  could be more injudicious than wholly to de-
prive  them of this support, when they are already weakened  by
disease, unless it could be shown that  even a moderate  use of it
essentially adds to their disease; which in the instance before us,
yve shall find, is by no me^ns the case  with  respect to all the
forms  in which this stimulus may be taken.
   As dyspeptics then, who have been  accustomed to its use, can
not be deprived of  it, and as, under certain  circumstances, it is
even a useful remedy, we are here  to inquire how far it  is found
so in  Indigestion, and how yve can  best secure its beneficial and
avert  its evil effects.
   There appears to be an essential difference in the effects of al-
cohol, such  as it exists in fermented liquors, and after it has been
distilled from them.   Both have their inconveniences.   So apt is
the latter to  injure the tone of the stomach, that, were it not that
;t  is necessary for the solution of certain  medicines, frequently
               n 
8i
OF THE TREATMENT
beneficial in  Indigestion,  yve might, without hesitation, banish it
from the  treatment of this disease; with the exception  of  those
cases  in  which all kinds of fermented liquors, which have not
been distilled,  increase the symptoms, and  the patient's habits
render the use of alcohol in some form indispensable.
   In the fermented liquors which  have not been distilled, on the
other hand, the alcohol is often combined with substances of dif-
ficult digestion, which are  particularly felt by  the dyspeptic.  This
is most remarkably the case with malt liquor, of which  even the
weakest  kinds often increase the  symptoms  of Indigestion, and
the strongest are among the most Indigestible articles  of  diet.
The same objection, though in  a less degree, exists with respect
to the other fermented liquors of this country.  Of these cider  is
the best, provided the acetous  fermentation  has not commenced
in it.   Perry  usually contains too much mucilage,  and some kinds
are very oppressive to the stomach, apparently from  this cause.
The home-made wines  are still more objectionable, being still
more apt  to run  into the acetous fermentation.
   The form in  which alcohol is most beneficial,  and in  general
does least harm, is that of foreign  wines.  The properties of  these
are various,  and different kinds suit  different stomachs.   The
astringent property  of port  wine  seems to  give it  a  peculiar
tonic power;  and, if it do not constipate, there is, perhaps, no  other
wine so yvell  suited to dyspeptics.   It should not be drank till of
a certain  age, the tartar of neyv port-wine being  offensive to the
stomach.   Some dyspeptics find it, as well as the other  stronger
wines, agree  better yvith them, when diluted; and  others find the
lighter wines, particularly claret,  better; while with others, all
the lighter wines, and even  port-wine, are  acescent.   Even in
these cases, however, the effects of the stronger wines are  often
improved by  diluting them.   Of this and many other circumstan-
ces in  diet, each individual must judge for himself, as there is no
rule of general  application.
   Many  stomachs seem  to feel the bad effects of the  distilled
spirits, which, it is said, are added to the stronger yvines; for even
the most objectionable of all the  fermented liquors,  which .have 
OF INDIGESTION.
83
not been distilled, appears to be less pernicious than any of those
which have undergone this process.   I have  known dyspeptics
so sensible to the bad effects of the latter, that they have felt an
increase  of debility for several days after drinking a single glass
of spirits and yvater.  This does not arise from its oppressing the
stomach,  it even for the  time  assists  digestion,  and that, if the
quantity  taken  be not too  great, to a considerable degree, a pro-
perty indeed which belongs more or less to all  fermented liquors,
though not in the same  degree  to those which have not been dis-
tilled.  It is this  unnatural excitement that seems to do harm.
It is followed by a corresponding debility;  and yvhatever  be the
change induced by distillation, there are no facts, I believe, bet-
ter ascertained, than that  the same quantity of alcohol in the form
of distilled spirits, although equally diluted, both by its immediate
operation, gives more temporary assistance to the stomach, and by
its secondary effects, hurts  it more, than in that  of any ferment-
ed liquor which has not been distilled.
   It is thus that many  dyspeptics, whose digestion is disordered
by all kinds of yvine, can  drink diluted spirits.   But it is impos-
sible by any addition to make  their permanent effects similar to
those of yvine.   Those addicted to wine seem often to be destroy-
ed by excess of nutriment.  They become full, often  ruddy,  at
least  for  a certain time  even robust, and not  unfrequently die of
sanguineous apoplexy.  Those addicted to spirits, on the  contra-
ry, generally become pale, often emaciated, and more or less pa-
ralytic; and although both are subject  to debility of stomach, ob-
structed liver, and dropsical affections, the latter soonest fall into
those diseases,  and in them they make the most rapid progress.
   A very moderate use of wine can hardly be said to be injuri-
ous; we see those who use it in this yvay, live  as long, and enjoy
as good health, as those who wholly abstain from it;  and to some
constitutions, independently of the effects of habit, it  may be use-
ful.   I  believe neither of these observations  apply to distilled
spirits, although  as already hinted, when  the  stumach has been
greatly  weakened by  excess,  so that  it can not  digest any fer-
mented liquor which has  not been distilled, the effects of diluted 
84                   OF THE TREATMENT
spirits are often less injurious, than the total collapse of the sys-
tem which ensues on wholly withdrawing the accustomed stimu-
lant.
   The best thing to be done in  such cases is, to give no  more
than is necessary, and  that  in the most  diluted  tbrm  which  is
consistent with the debilitated  state of the stomach.  The  usual
additions of lemon  and sugar which are supposed by many  to
bring the spirit into something like its state  previous to distilla-
tion, according to my experience, only increase the evil, by add-
ing to the hurtful stimulant, articles of difficult digestion, without
at all  ameliorating its  properties.   When  it is necessary to use
distilled spirits, I have  found it the best plan to let it be as pure
as possible, and  mix it with nothing  but water.   I have  known
more than one instance, in which the stomach was even sensible
to the difference between coloured and colourless brandy.
   Tea  and coffee are injurious in another  way; they possess a
narcotic power, which, we have seen, when considerable, is ca-
pable of producing Indigestion.  By many they are regarded as a
fruitful cause of this disease, but their effects on the whole have,
perhaps, been over-rated.   Green tea, and a very  strong infusion
of black tea or coffee, are  injurious to many stomachs.  I have
repeatedly seen  severe  fits of Indigestion  induced by them, al-
yvays characterized  by a greater than usual degree  of nervous
affection.  To many, however, even these, and to most people, a
yveak infusion of black  tea and coffee, seem to be innocent. They
produce no present bad  effects, and, where this is the case, I have
never  been able to perceive any proof of  their  continued use
doing harm.   It  is remarkable that their peculiarly refreshing se-
dative effect is generally, in the first instance,  felt even by those
yvith whom  they most disagree.   If drank very hot, they,  of
course, produce the effects of other hot fluids, yvhich yve are pre-
sently  to consider.
   It is by no means a fair  inference,  that what produces very in-
jurious consequences in some, must do more or less harm in ali.
We  frequently see articles of diet, and still more frequently, me 
OF INDIGESTION.
85
dicines, which can not be borne by one stomach, perfectly inno-
cent to  another.
  The tendency of tea and coffee to prevent sleep in many peo-
ple, for even this effect is by no means universal, must be injuri-
ous as far  as the want of sleep is so.  It is generally in those in
whom they produce most of this effect, that their other injurious
effects are  most apt to appear.
   There has been some  difference of opinion respecting the pro-
per  temperature of the drink of dyspeptics.   Some, from  the
present relief obtained  from  fluids  drank very warm, have re-
commended a high temperature; but the relief thus obtained is,
like that obtained  from distilled spirits, generally compensated
by subsequent debility.  When fluids of the usual temperature of
 the air, are too cold for  a weak stomach; yvhich is frequently the
 case, there is no objection to raising  them to any degree that does
 not exceed that of the body; although, when the stomach bears it
 yvell,  fluids of the common temperature seem rather to  have a
 tonic effect in Indigestion. A very low temperature is objectiona-
 ble.  I have already had occasion to observe that fits of Indiges-
 tion may be induced in  weak stomachs  by iced fluids.
    I have  had occasion,  in the preceding observations, to point out
 the impropriety of dyspeptics eating too fast or too much, or using
 too liquid a diet, the due repetition  of  their meals also deserves
 particular attention.
    It is evident from what has been said of the process of diges-
 tion that a considerable time must  elapse  after a tolerably  full
 meal, before the more central parts of the food undergo the action
 of the gastric fluid; but, as we are not prompted to eat, till there
 is  some  uncombined gastric fluid  in the stomach, it  is evident,
 that it is the intention of nature, that we should abstain till  some
 time after all  the  food already taken  has undergone the action of
 this fluid.  The accumulating gastric  fluid having then no  more
 undigested food presented to  it, begins so to affect the stomach as
 to  occasion the sensation  of hunger.   The recurrence  of this
 sensation, therefore, must  be the   proper indication,  that a due
 time has  elapsed since  the last meal. 
86
OF THE TREATMENT
   Now this  will be different under different  circumstances,  so
that it is impossible to lay down any rule of general application;
but it can never be very soon after an ordinary meal, except where
the digestion is more rapid than  natural, which sometimes  hap-
pens.  The patient must be careful to distinguish between a real
appetite, and a desire  to  eat  what is  agreeable,  a mistake  by
which we often see the stomach oppressed.  On the other hand,
it  is injurious to a tveak stomach long to bear the calls of hunger.
   It has appeared to me that, with the  generality  of dyspeptics,
to  take three moderate meals in the twenty-four hours is the best
rule.   A few,  particularly those  yvho are much troubled  with a
sense of depression and sinking, find four meals better.  The last
meal should always be taken a little before bed-time, and should
never, particularly after the disease has continued  for some time,
consist of animal  food.  The dyspeptic  should eat nothing in the
intervals of these  meals.   There is no  greater mistake than that
he should constantly be taking something.  This disturbs the na-
tural process, and entirely prevents the  recurrence of appetite, a
certain degree of which is a wholesome  stimulant to the stomach.
The stomach by  this constant eating  becoming more  and more
debilitated, and every part by sympathy partaking of the debility,
the patient wholly misapprehends the cause; and yvith a view to
increase  his strength, still  increases the frequency of his meals.
till he hardly passes a couple of hours without eating.   By such a
practice, pursued  for years, I have repeatedly seen  debility of the
stomach and a morbid irritability of the whole system established.
   It is not, however, to be overlooked, that there are cases of ur-
gent debility, both in this and other diseases, in which it is for the
time necessary that the patient should take little and often.  Some-
times the stomach can bear so little food at one time, that were
the usual intervals of meals observed, due nourishment would not
be received.   But it is not sufficiently attended to, that in  such
states, in proportion as the quantity of nutriment received is les-
sened, the  yvaste  is lessened at the same time.  The languor of
the digestive organs is communicated toother parts of the system,
and, if the organs of supply are inactive, those of yvaste are affect 
OF INDIGESTION.
87
ed in a similar way.   A due  attention to this  fact would often
prevent the friends of the invalid urging him to take food against
the appetite, which seldom answers any other purpose but that of
oppressing the stomach.   When it is necessary to eat very often,
every care should be  taken, by  recurring, as soon as possible, to
a better plan of diet, to prevent  the habit  of very frequent eatiug,
being formed.
   Among the other evils of this practice, an artificial want arises,
and if the patient is not continually taking food, he feels a  sense
of sinking, which persuades  him that its constant reception is
necessary to his existence.  Such patients can  only be restored
to  regular meals by very  gradually increasing the intervals of
eating.  An argument is adduced from  the general good con-
dition of cooks, for eating little and very often, but, it is  forgotten
that a healthy stomach and robust frame will bear  many irregu-
larities, yvhich overwhelm a less healthy or more feeble one. We
might  as  well  adduce  the fact of  healthy  people being most
nourished by oily food, as an  argument for feeding the dyspeptic
yvith butter and fat.   No doubt by this constant eating, a great
deal  of food may be  taken, and a strong and healthy  stomach,
notwithstanding the way in yvhich it is taken, may  digest it;  but
we are here inquiring into the means of best assisting a  weak
stomach.
   I have dwelt the longer on this  and other similar points,  be-
cause I have found them  essential to the  proper treatment of  the
dyspeptic; and, like the process of digestion itself, they have  not
perhaps obtained all  the attention  they  deserve.   The  study of
the two subjects, indeed, must go hand in hand; yvithout a correct
knowledge of the healthy function,  it is  evidently impossible to
perceive the principles, on which this part of the treatment of its
deviations from the healthy state should be founded.
   In  the foregoing observations on diet, the  attention  has been
chiefly confined to its effects on the stomach; but its influence on
the bowels of the dyspeptic  ought not to be overlooked.   Indiges-
tion, we  have seen,  is generally attended yvith  languid bowels;
and, as far as the  stomach admits of it, it is proper to make  the 
88
OF THE TREATMENT
diet such, as tends to counteract this state of them.   A vegetable
diet is less astringent than one composed chiefly of animal  food,
and fresh vegetables are more aperient than bread.  But this
must not be carried too far; it is better to take aperient medicines
than disorder digestion by an improper  diet.  I have in several
instances  seen  advantage  from eating  household  bread, mixed
yvith a certain proportion of rice, previously softened by boiling.
This admixture, contrary to what might be expected, renders the
bread aperient, but it also, in general, renders it more difficult of
digestion.   It is also for the most part rendered more aperient by
allowing part of the bran to remain in the flour.
  When there is  much irritation of the bowels, mucilaginous
fluids  in such quantity as does not opbress the stomach, are use-
ful, even butter and fat are occasionally useful in this  way; but, in
general, any considerable quantity of them so disorders digestion,
as more  than compensate  for  their  effects in the bowels;  and
not unfrequently the disorder they produce in the secreting power
is such, that the contents of the bowels  become more irritating
than they were.  I have  known many dyspectics, in whom the use
of butter always had tihs effect.
  When diarrhoea seems rather to arise from a degree of relaxa-
tion of the bowels than from the nature of their contents,  it is
proper to use articles of an astringent kind, such as rice seasoned
with cinnamon.   But it is a great error in the  treatment of this
disease, immediately to check  diarrhoea, for it generally arises
from irritating matter, the retention of yvhich would be injurious.
  Upon  the whole, however; it is to be observed, that the diet
best suited to the stomach is generally found best  for the bowels
also; their disorders in this disease, it we except a degree of lan-
guor,  generally arising from the vitiated secretions, which attend
disorder of the  former.

                Of exercise in Indigestion.

   The exereise both of mind and body demands particular at-
tention in the dyspeptic. 
OF INDIGESTION.
89
The different kinds of bodily exercise  may  be arranged  under
three heads;  that in which the body is moved by its own powers;
that in which it is  moved by other powers, as in  the various
modes of gestation; and that in which the circulation is promoted
without moving the  body,  by friction for example, or  merely by
pressure.
   The dyspeptic may be so yveak,  that friction is the only kind
of exercise which he can  bear without fatigue.   Wherever the
strength is much reduced, indeed, although a little of some rough-
er exercise may be borne, friction is always useful. It is the prin-
cipal exercise among the higher ranks of some Asiatic nations, and
it was used both by the Greeks and Romans after they became
luxurious.   It would not be proper in Indigestion to confine the
friction to the abdomen, when it is the only mode of exercise,
although in such cases it should be carefully  applied to this part.
To dyspeptics in general, whatever be their other modes of exer-
cise, friction of the abdomen is always useful.
   Mere pressure is a mode of exercise inferior to friction; but, if
generally applied to the limbs in an interrupted manner, from the
valvular  structure of their veins, it has a considerable effect  in
promoting the circulation.
   As the total want of exercise is not more pernicious than that
which occasions fatigue, and no  exercise is very beneficial which
can  not be continued for a  considerable time,  the different kinds
of gestation,  even after the patient has recovered a moderate de-
gree of strength, are often  found preferable to those exercises, in
which the body  is  moved by its own potvers.
   The gentlest kind of gestation is sailing, which is serviceable
in almost all  cases of debility, and has been found particularly so
in debility of the stomach and botvels.  Next to sailing, the gen-
tlest exercise in  common use, is the motion of a carriage; but in
such climates as our oyvn, unless the patient has been accustomed
to an open carriage, be must either be confined to a close one, or
run the risk of taking cold.   As substitutes  for a carriage,  but
inferior to it, swings and spring-chairs are used.
   None of these modes of exercise is equal  to horseback, yvhen
               12 
90
OF THE TREATMENT
the patient is strong enough not to be soon fatigued by it.   From
the stimulus given to the alimentary canal by the shaking in rid-
ing, it appears to be particularly well  adapted to Indigestion; and
every physician has seen instances of this disease, in which it has
been more beneficial than any  other exercise.
   Any rough exercise, however, particularly riding on horseback,
soon after meals,  disturbs the  stomach.   If the reader  will re-
flect on what has been said of the process of digestion, the cause
of this will readily appear.   We have seen  that,  in healthy di-
gestion, no admixture of the new food,  with that which may yet
remain in the stomach from the last meal, and yvhich, if due time
have been afforded, has already undergone the action of the gas-
tric fluid,  nor indeed of the different  parts of the new food, ever
takes  place.   We must, therefore, infer,  any such admixture is
unfavourable to this process; and it is evident, from the way  in
which digestion is performed, that, did this happen, some part of
the food would again be presented  to the surface of the stomach,
after it had undergone the  digestive process, and, consequently, a
corresponding portion of undigested food prevented from approach-
ing it in  due time.
    The mixing of the different parts of the food by any jolting ex-
ercise yvill be most apt to take place  in the dyspeptic.   If we fill
 a closed  vessel with such  contents as those of the stomach, we
 shall find that  but little relative  change of place will happen
 among its different parts by shaking the vessel.  But if, instead
 of these contents wholly filling the vessel, any space be occupied
 by air, their relative situation will be readily disturbed.   Now,
 the stomach always, more or less firmly, embraces its  contents;
 but, in Indigestion, air is generally extricated from the food, and
 yve have reason to believe,  indeed,  is often secreted by the surface
 both of the stomach and bowels, and thus room is given for a rea-
 dy change in the relative   position of their  contents.   The dys-
 peptic is often warned against any jolting  exercise after meals,
 by the uneasiness it occasions.   It is a good general rule,  there-
 fore, for him to  avoid exercise of all kinds for an hour and a half
 after eating.   This affords an  additional reason for not eating too 
OF INDIGESTION.
91
often.   We still  find the dictates of nature  pointing out what is
best; for all animals are inclined to repose, and even to sleep, af-
ter eating.
   Walking, when  it can  be borne  for an hour  or  two yvithout
fatigue, is,  of all  exercises, the best.   It is that which nature in-
tends for us.   There is no other accompanied with  such a uni-
form and regular exercise of  the muscles  and joints; and  from
the valvular structure of the veins of the extremities, it is  better
fitted than  any other to promote the circulation, and consequently
all the functions  of the system.   It is also the  most agreeable
mode of exercise.  Our desire for it when it has  been long with-
held, becomes excessive.
   But in Indigestion, from the peculiar effect on the abdominal
viscera of riding  on horseback, it is  generally of service to com-
bine it with this exercise.   I have knoyvn some dyspeptics, how-
ever, to whom horseback was always more or less irksome, yvhen
it occasioned any degree of shaking.   To such, the slowest riding
alone can be useful, and that only yvhen they are unable to walk
for a sufficient length of time,  and when the weather admits of
such gentle exercise without a risk of being chilled, to which we
have seen they are peculiarly  liable.
   Those exercises  in the open air,  in which the bodily exercise
is  combined  with a moderate and pleasurable exercise of mind,
particularly gardening, are well adapted to this disease, provided
the patient can  avoid fatigue, which is not always easily  done
when the mind is occupied.
   A proper exercise of the mind, indeed, is almost  of as much
consequence  to  the dyspeptic as that of the body.   When the
latter is debilitated and ill at ease, the former is generally lan-
guid  and  listless.   This state of mind is more or less  coun-
teracted by a due degree of bodily exercise, but the occupation of
the mind itself is necessary to  its cure.
   The maxims by which the exercise of the body is regulated,
are also applicable to that  of the mind.  The  great rule is, to
exercise yvithout  fatiguing it.   Any study which fatigues, is  inju-
rious, and a mind wholly unoccupied is no less  so.  When the 
02
OF THE TREATMENT
 debility is considerable, the mind should be  occupied by amuse-
 ment alone, and even those amusements which greatly  interest
 the feelings, or occasion any considerable effort of mind, are hurt-
 ful.  When, on the other hand, the patient has recovered a con-
 siderable degree of strength, a moderate attention even to business
 is serviceable.   However varied  our occupations,  if they tend
 only to present gratification, they  soon  become insipid.  The
 mind must have something in vietv, some plan of increasing its
 enjoyments,  to interest it agreeably for any length of time. There
 are few things  of  greater advantage than  the conversation  of
 friends, who constantly present to the patient the fairest  side of
 his future prospects.
   The  time  of day,  at which either the mind or body is exercised,
 is also  a matter of importance.  Towards evening every  kind of
 exertion becomes irksome, and consequently hurtful.   In  the de-
 bilitated, a degree of fever,  or something  resembling it, probably
 the consequence of the unavoidable irritations of the day, comes
 on  at this time, which is only to be relieved by repose: going ear-
 ly to bed, therefore,  is of great consequence  to them.   It seems
 to be for the same reason that animal  food  is hurtful at a late
 hour.
   Exposure  to the night air appears to be more  pernicious than
 yve can  easily account for.   I  am inclined to ascribe its effects to
 the damp which prevails in the early part of the night from the
 condensation of the watery vapour raised during the day, being
 applied  to the skin, at a time when, from the state just mentioned,
 its function  is  most  apt to fail.   In sultry climates, where  the
evening dews are heavy, the effects of the night air are often fa-
tal, even to those in health.   It is  well known, both in the East
an West Indies, that people are often attacked with agues, from
passing  a single night abroad in the woods, where the vapour is
most confined.   Of the baneful effects of the night air at Batavia,
Dr. Lind relates a striking proof in  his  account of the fevers of
 India. ** During the sickly season, a  boat  belonging to the Med-
 way man-of-war, which attended  on  shore every night to bring 
OF INDIGESTION.
93
fresh provisions, was three times successively manned; not one of
her creyvs having survived that service."
   The bad effects of the night air, even of this country, to inva-
lids, I had often remarked, before I began to consider to what it
might be ascribed.  Whatever may be said of the above explana-
tion, which it would be difficult to verify,—of the fact I have no
dpubt.   It may be observed, that the effects experienced from
the night air by dyspeptics, are similar to those produced on them
by a damp air'ffbm other causes.
   It is chiefly to the greater dampness of the air of large towns, I
believe, that  we should ascribe their often disagreeing yvith dys-
peptics.   Dr. Hutton has shown,  that when two portions of air,
of different temperatures, saturated with water,  are mixed,  the
mean temperature will  not enable them to hold in solution  the
same quantity of water.   I have, from an eminence, observed a
yvind, highly charged with moisture, passing over a great extent
of country, yvhich contained several small towns, and occasion-
ing a deposition of moisture, wherever it mixed  with the air of
the towns; so that from  each of them  a streak of mist extended
in the  direction of the wind, the air every where else remaining
perfectly clear.   To the same  cause yve must ascribe the thick
fogs of London.   They occur when the air is most charged with
moisture, and in cold weather, yvhen the number of fires being
greatest, there is the greatest difference of temperature between
the air of the country and that of the metropolis.  A damp air
feels colder than a dry one of the same temperature, not only be-
cause it abstracts the beat  of our bodies more rapidly, but be-
cause  it tends to debilitate  the  functions of the nerves of the
surface.
   Although it is of consequence for the debilitated to go early to
bed, there are few things more hurtful than remaining in it too
long.  After  the  degree of strength,  of yvhich the  state of the
system is capable, is restored by sleep, any longer continuance in
bed, unless the debility be  such as to render the mere  effort of
sitting up too much, tends only to relax.   Getting up an hour or
two earlier, often  gives a degree of vigour which nothing else can 
94
OF THE TREATMENT
procure.  I have known  people  whose  feet constantly  became
cold and damp if they remained in '?ed a few hours longer than
usuil.   For those who are not much debilitated, and sleep well,
the best rule is to get out of bed soon after waking in the morning.
This, at first, may  be too early, for the debilitated  require more
sleep than the healthy; but  rising early, will gradually prolong
the sleep on the succeeding night,  till the quantity which the pa-
tient enjoys is  equal to his demand for it.
   Lying late is  not only hurtful by the  relaxation it  occasions,
but also by occupying that time of the day at which exercise is
most beneficial.
   If the dyspeptic be  much debilitated, he should take his first
meal as soon as he is  dressed.  He will  often find himself hurt,
and  always less benefited by exercise, either of  mind or body,
yvith the stomach  and upper bowels  empty, as they necessarily
are, in the morning.
   When the debility is less,  he will often experience benefit from
a walk or ride before breakfast.   This observation is particularly
applicable to those in whom Indigestion has produced too great a
determination of blood to the head, which  is, for the time, in-
creased by the  recumbent posture  during the night.
   We are most vigorous when the first process of digestion  is so
far advanced, that the vessels  which receive the  nutriment from
the intestines are pouring it into the blood; and  then it is that a
free circulation is most useful for  mixing the new juices yvith this
fluid, and  promoting  its passage  through the lungs, yvhere  they
are perfected into blood.
   Some light and agreeable occupation of the  mind,  with  per-
fect  rest of body,  is  best for an hour and a half after breakfast.
From this period to the time of the second  meal, which should
be about the middle hour between breakfast and bed-time, is the
proper one for all the more powerful exercises  either of mind or
body.  The corresponding interval between the  second and third
meal, is better spent in the gentler employments of both; and after
the last meal,  yvhich should be light, the invalid can hardly go to
bed too soon. 
                      OF INDIGESTION.                    95

  The objection to going to bed after tpo full a meal is, that the
sleep will be disturbed, and consequently less refreshing.  Going
to bed immediately, even after a light meal, in those unaccustom-
ed to it, will have some  degree of this effect, at first, but this in-
convenience will soon cease.   However artificial our habits may
be,  the system is  generally soon reconciled to a return to what is
natural.   When four meals in the day are necessary, the interval
between the  first  and the last should be divided into three, instead
of two equal parts.
  Under all  circumstances of course, in regulating both diet and
exercise, attention must be paid to  the age and habits of the pa-
tient.  It is seldom  proper all at once to attempt the  correction
of the most injurious habits; the change should be made with cau-
tion and judgment.  This is particularly the case with respect to
the use of fermented liquors and active exercise, because there
are no means that more essentially  influence the constitution; and
yvere we suddenly to withdraw the accustomed stimulants, or
urge to efforts beyond the strength, irreparable  injury might be
done.  The  more advanced the age,  habits  are corrected with
the greater difficulty, both because  all habits are strengthened by
continuance, and because the less vigorous the constitution is,
it is the less  able to bear the change.
  At advanced periods  of life, a change of habits must not only
be attempted more cautiously, but it must not be attempted in the
same degree. It is to^be  recollected, that in old age repose is more
necessary, and exertions of every kind less beneficial and more apt
to be injurious; and that powerful stimulants are less hurtful, both
because old age requires excitements more, and there is less space
left  for them to produce their pernicious effects.   Under all cir-
cumstances,  however, and  at all  times of life, the principles
yvhich have been laid down  must,  I believe, be kept in vietv.
  Such  are  the  means  of  preventing  the re-application of the
causes of Indigestion most apt to  arise from the  disease  itself.
Some others will occur to the mind of every one conversant with
the disease.  Frequent vomiting, diarrhoea, and fits of constipa-
tion, are among the chief of these.  It is almost  unnecessary to
say that they must be corrected as soon as the circumstances of 
96
OF THE TREATMENT
the case admit of it.   The means proper for these purposes  will
appear in considering  what may  be called the medicinal part of
the treatment.

  Of the  Medicinal  Treatment in  tlie  first  stage  of
                       Indigestion.

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

               Of the Preparative Means.

   When we are consulted  by those labouring under Indigestion^
we generally find the stomach and boyvels  loaded.  It is neces-
sary  in the first place, to relieve them from some part of this  load,
and, as far as yve can, to correct the properties of that which re-
mains.  On this account yve frequently find it advisable  to com-
mence the treatment by an emetic, followed by some mild aperi-
ent.   It should be our endeavour, by an  attention to the proper 
OF INDIGESTION.
97
 rules  of diet, to prevent the necessity of repeating the former of
 these; and the latter, we shall  find, only makes part of the gene-
 ral plan, as far as it  is necessary for the regular and  free action
 of the bowels.
   An emetic, in the early stages of the disease, seems sometimes
 beneficial by the excitement, as well as the evacuation, it occa-
 sions.  Its frequent repetition, however, is injurious.   Frequent
 vomiting, we have seen, ranked among the causes of the disease;
 yet the  temporary relief, obtained by emetics, not only often in-
 duces the patient'to repeat them, but has persuaded some physi-
 cians, that the cure of the disease  may be attempted  by them
 alone.
   If the first emetic, however, does not remove it, as sometimes
 happens when it is slight, and of recent occurrence,  rather  de-
 serving the name of disordered stomach than the  disease we are
 considering,  its repetition generally does more harm  than good.
 If emetics are repeated at  all, it should only be for the purpose of
 removing urgent symptoms.  Their continued use not  only occa-
 sions a great degree of morbid excitement, but inverts the natu-
 ral action of the stomach, and frequently  of  the  first intestine
 also,  and consequently teuds to  debilitate both, and  break  the
 habit of their natural functions.
   When it appears that offensive matter still exists in the stomach
 and bowels, after the operation of  the emetic and aperient, yvhich
 may be  known by  a  sense of oppression and distention of these
 cavities, and by eructation of wind  and ill-digested  food, or of
 an acid matter, which is sometimes so acrid as almost to  excori-
 ate the fauces,  we must, by gentle stimulants,  particularly  the
 distilled  waters occasionally mixed  yvith a small proportion of
 some aromatic tincture, endeavour to excite them  to a better se-
 cretion; and at the  same time,  by the use  of correctives, more
 directly to alter the morbid properties of their contents.
  When the eructations are acid, the alkalis,  magnesia, lime-
water, and prepared chalk, are  the best correctives.  If the fore-
going symptoms are attended with much debility, a cold surface,
and sense of sinking, carbonate of ammonia is the best.   When
               13 
98
OF THE TREATMENT
the bowels  are too languid,  magnesia, which forms an  ape-
rient salt, with the acid of the first passages,  may be used;  and
when  diarrhoea prevails,  lime-water,  and the prepared chalk,
which are  astringents.   In this case also, combining the chalk
with some mucilaginous substance, which  defends the surface of
the stomach and bowels, as in the mistura cretae,  is generally of
use.  When none of the latter symptoms prevail,  the fixed alka-
lis, particularly soda, from its greater power, is the best antacid.
   Although morbid acidity may be lessened, it  can not be wholly
prevented by a diet consisting chiefly of animal food; and I have
repeatedly had occasion to observe, that when  a person is wholly
confined to  animal food, the contents  of  the  stomach and the
breath become  very acid as soon as he begins to  feel  disgusted
Wi'b  it.
   A- the pains, which arise from irritating matter  in the stomach
ant bowels, proceed  either directly  from irritation  of their sur-
face, or from spasms excited by the irritation,  they are generally
allayed by the means just pointed out.   In  the latter case, which
is distinguished by the severity and intermitting nature of the pain,
unaccompanied  by  the  symptoms which indicate  inflammation,
the aromatic tinctures may occasionally be used in larger doses
than vvculd be  proper in their habitual employment.
   If the foregoing means fail, an opiate must be given, care being
taken by the subsequent exhibition  of an aperient, to counteract
its constipating tendency.   The exhibition of  the aperient with
the opiate tends to prevent the eflect of the latter,  i
   Spasm of a more permanent uaiure seems sometimes to attend
and oppose a powerful obstacle to the action of the bowels.   In
such cases the combination of an opiate with the aperient, seems
often to promote its operation.   The repetition  of the opiate, un-
der such circumstances, however, requires  great circumspection.
It  may, by counteracting the  peristaltic motion of the intestines,
prove a more obstinate cause of constipation than the spasm
which it removes.
   When the diarrhoea, excited by the irritating contents of the
botvels, continues after we have reason to  believe that its cause 
OF INDIGESTION.
99
has been expelled; mucilage of acacia, with small doses of opium,
or if these  alone do not succeed, combined with astringents, are
the proper means.
   When vomiting is obstinate, it is often  allayed  by the saline
draught taken in a state of effervescence, or a mixture of sulphu-
ric acid, conserve of roses, and peppermint-water, carefully strain-
ed.   If these fail, the most effectual means, according to my ex-
perience, is a pill, composed of opium and camphor, and blister-
ing the region of the stomach.*
   Such are the  means, by a judicious employment of which the
stomach and bowels are  brought, as nearly as their debilitated
functions admit of, into the natural state; the more nearly this can
be done, the better  is the chance of relief from the means we are
noyv  to consider, namely, those yvhich more directly tend to  re-
store tone to the stomach and  bowels.

 Of  the  Treatment when the Disease is confined to the
                    Stomach and Bowels.

   We have seen that although the causes of Indigestion seem,
 some to act on  the  muscular fibres or  the stomach, and some on
 its nerves, yet  these  powers are so connected in thtir  functions,
 that  whatever debilitates the one, in a greater or less degree, ne-
 cessarily affects the other.   We shall find that a similar observa-
 tion  applies to  the  means of relief.   Whatever tends to restore a
 healthy nervous power to the stomach, tends to  form the food
 into that substance which is best fitted to excite the muscular fi-
 bres of this organ; and whatever excites the natural action of these
 fibres, tends to  relieve the nerves from their load, and in the most

   * When in the second stage of Indigestion, along with the vomiting
 there is consUlerable  tendernefs on pressure in the epigastru.m the^means
 whkh take oft'the inflammatory action, particularly loss of blood from the

 reject  rather resembling eructation, than vomiting, rf » watery^ fluid
 from the stomach. I  can not help agreeing in opinion with D.. Cullen, that
 th°s  s a peculiar affection of the stomach, not  depending on  he state of
  Sat  organ which produces the disease we  are considering. It is not ne-
 ressurily accompanied by the symptoms of Ind.gest.on. 
100
OF THE TREATMENT
 favourable way, to bring  into contact with their extremities the
 food on yvhich, through the intervention of the gastric fluid, their
 powers are to be exerted.
   Although some of the remedies seem to operate more  in  the
 one of these ways  than in the other as I  wish to avoid nice dis-
 tinctions, it will be better to include the whole  under one head,
 in an inquiry respecting the use of tonic remedies in this disease;
 and I  shall attempt no other division than the simple one of the
 means which  act directly on the stomach  and bowels, and those
 which influence them through  other parts.
   The former may be divided  into two classes, those which tend
 to excite, for the time, the particular function of these organs, or
 allay the  irritation of their nerves; and those which seem to act
 less by any immediate t fleet, than by. bestowing on them some
 degree of permanent vigour.
   The medicines of one class have been termed stimulants and
 anodynes.   The most powerful of the other consist of bitters, as-
 tringents, and those  medicines which tend to support a due ac-
 tivity of the bowels.
   I have  already had occasion to observe, that  simple  distilled
 spirits, and still more the aromatic tinctures, tend for the time to
 promote the action of the stomach; and to warn against too free
 a use of them; because the increased vigour thus procured, espe-
 cially if they have been frequently repeated, is generally succeed-
 ed  by  corresponding debility.  By very  small   doses  of such
 medicines, however,   particularly when  combined with those
yvhose effects are more permanent, advantage on the yvhole  arises.
We find that bitters and astringents not only produced their good
 effects more speedily, but, for  the most part, more permanently
 also if combined with small doses of those medicines, which are
 more purely stimulant; and, indeed, the action of the latter seems
often necessary to enable the stomach to bear the former without
 oppression.
   Thus  it has become an universal practice to combine a small
 quantity  of distilled spirits and aromatics, with other stomachic 
OF INDIGESTION.
101
medicines.  The quantity of distilled spirits  in  such mixtures
should always be small, a twelfth, at most an eighth, of the whole.
The choice of the aromatic is of less consequence; the properties
of all are similar.   Some suit the stomach and the taste of indi-
viduals better than others.   There is, upon the whole, hotvever,
some difference in their properties.  Ginger  may be  us«-d when
cardamoms  would  heat too much, and cardamoms will relieve
flatulence and.spasmodic pains, when ginger would fail.
   Similar in their  operation to this class of medicines are,  am-
monia and its carbonate, which have not, perhaps, obtained all
the attention  they deserve in this disease.   They  are more apt to
heat than aromatics, and, in the same proportion,  more beneficial
in that languor and coldness, which are often such prominent fea-
tures of  Indigestion.   Their greater  tendency to heat seems to
arise from their acting as a more general stimulant.   They are
more apt to strengthen and  quicken the pulse, and, probably, act
on the sanguiferous system  after they are taken up by  the absorb-
 ents;  I have found them decidedly serviceable when aromatics
 had failed.   They are best adapted to those  cases  where a con-
 tinuance of  the disease  has produced much debility, and conse-
 quent languid circulation, without much tenderness of the epigas-
 trium, or hard pulse, or any sensation of burning in the hands or
 feet at night.
    Camphor possesses some of the  properties of ammonia in a
 slighter degree.  Its sedative  property renders the mistura  cam-
 phorae a good vehicle for other medicines.
    Among the  means of temporary  relief in Indigestion, very
 warm water holds a higher place perhaps than is generally sup-
 posed.  To its frequent use we have seen there  are the same ob-
 jections as to other powerful stimulants.   It deserves mentioning,
 although it is difficult to explain it, that a considerable degree of
 heat, I  mean  nearly  as  much as  the patient can bear without
 complaint, applied externally to the region of the stomach, is more
 effectual, provided it be continued for a sufficient length of time,
 in relieving that kind of pain of the stomach yvhich most frequent-
 ly attends Indigestion, than any application of heat we can make 
102
OF THE TREATMENT
 internally.   It is also frequently  relieved by beat applied to the
 feet.
   Opium belongs to the head of remedies employed for tempo-
 rary relief.   Large  doses of this medicine have no place in the
 treatment of Indigestion, except for the purpose of relieving se-
 vere pain.   The other symptoms pre increased by them.   Very
 small doses, however, tyvo or three minums of tincture of opium
 for example, repeattd two or three times a day, often prove highly
 serviceable  in allaying morbid  irritation, and  their constipating
 effect is generally easily counteracted.  They sometimes indeed
 have very little of this effect.
   I have found the pulvis  ipecacuanha? compositus  the  most
 beneficial form in which small doses of opium can be  given in
 this disease.  From two to four grains of this  preparation, given
 every six or eight hours,  appear  to have a peculiar effect in al-
 laying the irritations attending Indigestion, which probably arises
 from  its action on the skin.   It appears to be best adapted to
 those cases in yvhich that combination of languor and restlessness,
 often so remarkable in this  disease, prevails.   It is better  from
 time to time to discontinue and renew its use, than to exhibit it
 for a great  length  of time, without interruption;  which,  even
 when the dose is very small, is apt to occasion confusion or other
 uneasiness of the head.
   The effect of opiates  in Indigestion  explains  an observation
 sometimes made by dyspeptics, that they find their dinner digest-
 ed with less flatulence and acidity,  when they go to sleep  after
 it.  The composure produced by  sleep, in some degree answers
 the purpose of the opiate.   In many dyspeptics a small dose of
 opium, taken after  dinner, gives  more relief,  and, for the time,
 more effectually promotes digestion  than any other means.   It is
 almost unnecessary  to add, that the habit of having recourse to it
 for this purpose would be very objectionable.   It is probable, on
 account of its anodyne quality,  that  lettuce, as I have had occa-
 sion to observe above, appears to be less indigestible  than other
raw vegetables.
   In considering the causes of Indigestion, we  have  seen  how 
OF INDIGESTION.
103
readily the disease is increased by every thing  which  occasions
morbid irritation of the nerves of the stomach.  It is, in a great de-
gree, in this way that the undigested contents of a  weak stomach
aggravate the  symptoms.   By  lessening the sensibility of the
nerves, and thus allaying that irritation, an opiate seems to check
the progress of Indigestion, as yvell as  to render us less sensible
to the irritating matter already formed.
   The medicines called nervous are also often useful in allaying
irritation of the nerves in Indigestion, especially when it chiefly
affects parts at a distance  from the stomach.  Myrrh, camphor,
castor, and valerian, I have found  most beneficial, except when
the disease inclines to hysteria, and then a combination of some
of these, and  asafoetida, is a  means of  temporary relief, second,
perhaps, to none but either, which approaches too  nearly to the
nature of distilled spirits,  to  admit of its free and frequent em-
ployment.   This class  of medicines, and particularly the combi-
nation  just  mentioned, that  especially  of  asafoetida and castor,
seldom fail to give relief in palpitation arising from Indigestion,
if no  inflammatory disposition have supervened.   It also, in gen-
eral,  gives more or less temporary relief to the  dyspnoea, which
we have found sometimes  so obstinate a symptom of this disease.
Of the various medicines of this class, however, those best suited
to some cases are  not always  most  effectual in others; and when
such  as are on the whole  most successful fail, others often suc-
ceed.
   But it is of much less consequence to give relief in fits  of In-
digestion than to prevent their recurrence.   We are now  to in-
quire how  far medicine can assist  the due regulation of diet and
exercise in effecting this object.
  The small  doses of opium  which I have  just had  occasion to
mention, are calculated  to effect more  than temporary relief in
Indigestion.   I have  found them,  or rather still smaller doses,
one or two grains, for example, of  the pulvis ipecacuanha? com-
positus, of essential use, combined  yvith the  medicines we  are
about to consider.
  It has already been observed, that of the tonics whose effect is 
104
OF THE TREATMENT
 most permanent, bitters and  astringents are those on which we
 chiefly rely, and that their effect is increased by combining them
 with small doses  of some of the stimulants we have been consid-
 ering.
   Bitters have been long known to possess a power of invigorat-
 ing  the digestive organs.   There is a great variety of them, but, I
 believe they  may all be  divided into  simple bitters, and those
 which at the same time possess a stimulating quality.  Of those
 in common  use, camomile, bitter  orange-peel, and wormwood,
 seem to be the most free from this  quality*.   Columba  possesses
 it in a greater degree than  gentian and cascarilla, and the  Peru-
 vian bark  in a greater degree than any other.   I speak not at
 present of the astringency of the last, which renders it a medicine
 of different properties.   It  is  particularly to be observed that the
 stimulant property of bitters,  although less immediately powerful,
 is of a more permanent nature than that of the stimulants which
 we have been considering; and  the latter may often be used for
 the purpose of occasional relief, when the inflammatory  tendency
 is too great to admit of the more permanent stimulant.
   All the foregoing bitters, if we except the  bark, which is often
 oppressive to the stomach, are well suited to the first stage of In-
 digestion;  but in proportion as the second stage approaches, yve
 find  the less stimulating bitters  answer better; and in this stage,
 even the gentian,  yvhich of those that deserve the name of stim-
 ulating, possesses, perhaps, the least of this property, is  often too
 heating, and the bark in general can not be borne, even  for a few
 days; while in the earliest periods of the disease,  when  it super-
 venes on debilitated states  of the  constitution, and the stomach
 still  retains considerable comparative vigour, a cold  infusion of
 the bark is often  the most beneficial of all bitters.  It has by
 many been banished from  the treatment of Indigestion,  but this,

  * By stimulating quality of bitters, I mean the power  by which some of
them increase the force of the circulation, and consequently are rendered
improper where the  inflammatory diathesis prevails. It seems  not to be
generally known, that this property bears little relation to the quantity of
essential oil which they contain. 
OF INDIGESTION.
105
I believe, has arisen  from its having been employed indiscrimi-
nately in all cases and periods of the disease.
   It is remarkable that certain  stomachs can not bear any spe-
cies of bitter. I have known some who constantly  suffer  from
even a few  spoonfuls of camomile tea; so that in them we are
wholly precluded  from the use of this class of medicines.
.   Many object to the long continued use of bitters  and aroma-
tics.   There are  strong objections to the long continued use of
every  medicine.   If it  is one of great power,  it exhausts the
strength; if not, it seems to become almost wholly inert.  When
the disease  is obstinate, it is  better, after a certain degree of re-
lief is obtained, to discontinue such medicines, and, sooner or
later, recur to them, as the symptoms  may require.
   I believe, however, the apprehensions from their long-continu-
ed  use have chiefly arisen from their effects in  gouty cases.  It
prevents the regular returns of this disease,  as has been  proved
by the effects of what was called  the Portland Powder, and some
other specifics: but it appears, I tbink, from the facts stated in
the last chapter, that the bad eflVcts yvhich  ensue should rather
be  ascribed to the prevention of the regular gout, than any direct
operation of the medicine.  The same effects follow, when the
return  of regular fits is  prevented merely by applications to the
joints,  yvhich we know, independently  of this consequence, could
have  no serious effect.
   Astringents are less  generally  adapted to  cases of Indigestion
than bitters, on account of their tendency to increase the inactivity
of the  bowels, yvhich so generally prevails in this disease. Some
of them, however, are medicines of such value, that yve often find
it advisable to employ them,  although at the  expense of correct-
ing this effect. Nor are  they in all cases equally apt to produce it.
  All  vegetable astringents seem to have more or less tonic effect
on the stomach, as yvell  as on other parts of the system;  and to
this yve must, in some degree, ascribe the good effects of the  bark
in the'cases above pointed out; but the mineral  kingdom affords
the most beneficial medicines of this description.   Of these, iron
deserves the first place.   In chlorotic Indigestion, combined yvith
               14 
106
OF THE TREATMEiNT
stimulants, it is the most powerful medicine we possess, because
it is the most powerful  in  removing the obstruction whence the
Indigestion by  sympathy  arises, so that in  this case it belongs
rather to the class of  remedies which we are next to consider;
but there are few cases  of  Indigestion  in which  it is not found
more or less useful at an early period, if no tendency to the  second
stage  of the disease  has shown  itself.   Its  good effects  are in-
creased  by combining  it  with bitters  and aromatics;  and, in
idiopathic Indigestion, the carbonate has appeared to me  its best
preparation, provided it can be taken in rather large doses, with-
out oppressing the stomach.
  Next to iron, the sulphuric acid seems to be the best stomachic
astringent,  and it may be used in later stages of the disease than
iron.   It is particularly serviceable in those cases, where  sweat-
ing, yvhich is not unusual,  is too easily  induced by  exercise; for
much tendency to sweating indicates relaxation, not vigour of the
skin.   It appears from  the experiments  relating to the circum-
stances which influence the state of the urine, above referred to,
that the saline  matter, secreted by the  skin; is  not so  certainly
thrown off, even by profuse sweating, as by a free insensible per-
spiration.
  In the opinion of many, the sulphate of zinc, given in very small
doses,  also  holds a distinguished place among  the  astringents
suited to Indigestion.  It may be given at later periods than iron,
but it requires caution; and if its good effects do not soon appear,
should be laid aside.  It is one of those powerful agents, which
must always be employed with some degree of suspicion.
  Other medicines beside bitters  and astringents, seem to act in
a similar way on the alimentary canal.  All the mineral acids
possess more or less of a tonic  power.   The white oxide of bis-
muth  has lately been  much celebrated.   It seems best adapted
to those cases in which  there is frequent recurrence of pain re-
ferred  to the stomach.
  To  enumerate all  the  medicines yvhich have  been employed
with a view to restore vigour to the stomach and bowels would be
a difficult task, and not  a very useful one; for fetv, with the excep- 
OF INDIGESTION.
107
tion of the foregoing, possess much power. The acrid vegetables,
particularly horse radish and mustard-seed, are indicated in the
same Cases in which ammonia and aromatics are most beneficial.
Their infusion often  forms a good vehicle for ammonia and its
carbonate.
   Sarsaparilla appears to me to hold a much higher place among
the remedies of this disease than is generally  supposed, but it is
not to its early stages that it is best  suited,  and from its mucila-
ginous property, it is apt to oppress the stomach.   It  is in  pro-
tracted cases,  yvhere general languor of the secreting surfaces has
become permanent, and  the stomach is conseqOently in  some
degree relieved, that it is most useful.   I shall have occasion to
make some observations upon it in speaking ol such cases.
   It has become common to employ  mercury in  some form or
other in all cases of Indigestion; but,  I believe its use is always
injurious  in the  period of the disease yve are notv  considering;
that is, while the derangement is confined to the alimentary canal.
I  shall have  occasion  to treat fully of what  appears  to me the
proper use of  this medicine in the other stages of  the disease.
Instances have frequently occurred, in which the disease seemed
to be confirmed by its unnecessary  and improper employment.
I believe we may say,  without hesitation, that it is never to be
used in any stage for the mere purpose of an aperient.
   The proper use of aperients is a subject of great importance at
all periods, and in all states of Indigestion.  In the period under
consideration, their object is merely to support a regular action of
the bowels, which as the secretions of the whole canal are inclin-
ed to fail, and the stomach and  upper bowels do not  discharge
their contents  so readily as  they ought to do, should  be rather
freer than in health.   It often has an excellent effect to combine
bitters with gentle aperients in the  early stages of  the disease.
Epsom salts are frequently employed in this way with great ad-
vantage.   If they are too cold, or occasion too watery a discharge,
small doses of sulphate of potash and rhubarb often answer  bet-
ter.
.   Different aperients suit different constitutions.  I have found 
108                 OF THE TREATMENT

none employed merely for the purpose of supporting a regular ac-
tion of the bowels, so generally as pills composed of ipecacuanha,
coupound extract of colocynth, and soap, with the addition of a
litt e gamboge, when they are not sufficiently active, occasionally
taken at bed-time.   In many senna has appeared to me a medi-
cine of great value.    It seems more directly to promote digestion,
at the same time that it excites the  bowels; a property also  of
the pills just mentioned.
   With respect to those remedies yvhich act on other parts, and
only by sympithy influence the alimentary canal, the most pow-
erful and, ii deed, the only ones which appear to have much efftct,
are such as make their impression  on the uterus and the 6kin.
I have already had occasion to mention one of the most powerful
of the means tending to restore the functions of the uterus.  All
this class of course are  beneficial in Indigestion, as far as it de-
pends on a failure of those functions. With respect to the means
yvhich make their impression on the skin,  the cold bath, yvhere
there is considerable general vigour,  and the warm salt bath  in
almost all cases, the  shower bath, particularly yvhere there is too
much determination of the  blood to the  head, and spunging the
body with salt water, or water and vinegar, especially when this
practice  is followed  by friction of some continuance,  often aid
other  means,  and sometimes appear to be powerful  remedies.
Among these means might also be ranked  blistering the  epigas-
tric region, were  not so severe a remedy hardly allowable in the
earlier periods of the  disease, yvhere gentler means generally
succeed.  Covering  the epigastric region yvith stimulating and
anodyne plasters is sometimes of use.
   The gastric fluid of other animals has  been proposed as a re-
medy  in Indigestion.   If the view which has  been taken of this
disease  be correct, it could answer no other purpose but that  of
temporary  relief.  I have  known  the  inspissated bile of the ox
used as  a cathartic in iudigestion with good effect.   It appears to
deserve attention, particularly in the state of the disease yve are
notv to consider. 
OF INDIGESTION.
109
Of the Treatment  when  the Disease has  spread fur*
           ther than the Stomach and Boivels.

  It is  observed in the first chapter, that, sooner or later after
the first symptoms of this disease have shown themselves, the
alvine discharge begins to deviate from the healthy state, in dif-
ferent cases, and sometimes  in the same case at different times,
assuming  various  appearances.   The  treatment  then  becomes
more complicated.
  When the  alvine  discharge assumes an unnatural colour, we
may be assured  that the disease  has spread further than the ali-
mentary canal.  The secreting power of the liver, and, probably
of the pancreas, partakes of it.  As  these organs  pour  their se-
cretions into the first intestine, the state of which  seems  greatly
to influence the  symptoms of the different  stages  of Indigestion
they immediately affect  the greater part  of the  canal, and,  by
sympathy greatly influence the state of the stomach.  From the
size, structure, and position  of the duodenum, it is evidently the
intention of nature to detain its contents for some  time, that they
may be intimately mixed with those  secretions; and  yve have rea-
son to believe, that the process which  takes place in this intes-
tine, is essential to the due formation of chyle.   The beneficial
effect of purgatives  in Indigestion seems greatly to depend  on
their assisting its motions.   It appears, from the  enumeration of
the symptoms, that they are much influenced by the state of the
 duodenum; and I have, from several cases, had reason to believe,
 that the peculiarly beneficial effects which I have witnessed from
 the senna in Indigestion,  arise from its being well  fitted to pro-
 mote the action of this intestine.  It has appeared more  effectu-
 ally to remove  the fulness of the right hypochondrium,  when it
 depends on morbid distention of the duodenum,  than any  other
 medicine equally mild in its operation.
   The change in  the  appearance of the alvine discharge, we
 have seen, occurs at various periods of the disease; in some cases,
 almost as soon as the symptoms of Indigestion begin  to attract 
 110                  OF THE TREATMENT

 notice; so that it is difficult to say, except from  considering the
 nature  of the  remote  causes, where the disease originated.  It
 is more common, however, for it to take place after various symp-
 toms of disordered digestion have lasted for some weeks, and the
 slighter symptoms, we have seen, may continue for years yvithout
 any material alteration in the appearance of this discharge.
   Of the particular state  of the pancreatic fluid, we  have  no
 means of judging.  The alvine discharge,  it appears from  what
 yvas said  above, generally  owes its  colour to the bile.   By the
 degree of colour,  therefore, we  may judge of the quantity of bile
poured into  the intestines, and by its  hue, of the state of this fluid.
 An admixture of  blood, when it flows from a high part of the ca-
 nal, so that it is mixed with the other contents, and has  had time
to assume a dark  colour, before it is discharged,  sometimes gives
to the  discharge an appearance similar to  that given by certain
states of the bile.   They may be distinguished, however, by dilu-
tion with  water; if the change of colour arise from bile, a green-
ish or yellowish shade  will be  produced; if from blood, a  dark
brown one.
   When the change in the alvine discharge takes place, then, we
 are assured, that  in addition to  the original disease, yve have to
contend yvith derangement in the function of the liver.   The case
is now not only more complicated, but more difficult of cure: the
diseased action of parts which sympathize, while there is  no de-
gree of structural  derangement tending to confirm each other.
   The principle of the treatment is to combine yvith the means,
yvhich tend  to restore vigour to the alimentary canal, which we
have just  been considering, those which correct the morbid  state
of the liver.  It is generally admitted that we possess no medicine
of equal poyver yvith mercury in correcting  the morbid  states of
this organ, but  it  unfortunately  happens that its  continued use is
generally injurious to other organs, and particularly to the stomach
and boyvels; and the chief object to be kept in view in its employ-
 ment  in this stage of  Indigestion is, so to manage its exhibition,
that it shall  produce the desired effect on the liver, with as  little
injury as  possible to other parts of the system. 
OF INDIGESTION.
Ill
  The first observation which presents itself on the  employment
of mercury at this period of the disease is, that it is  not to be so
given as to be received into the circulating system.  Mercury,
yvhen thus introduced, has the property of more or less  exciting
all the secreting surfaces, but their excitement is supported by it
at great expense to the constitution, and when long continued,
seldom  fails to impair its powers.  No practice can be worse than
that which unnecessarily risks this effect.   In the  first stage of
Indigestion, there is no occasion to change by such powerful means
the state of the general habit to which the diseased action has but
imperfectly extended, and in which it  is still  so  purely  sympa-
thetic, that it immediately  disappears as soon as the disease of
the central parts is  removed; and  experience has amply  proved,
that the deranged action of the liver can, in consequent of the
sympathy  yvhich exists  between  this organ and  the alimentary
canal, be  corrected by  the local effect alone of the  mercury  on
the latter.
   Another observation of importance respecting the use of mer-
cury at this  period is, that its long-continued use is seldom neces-
sary.   The practice of giving it every second  day, or even daily,
and almost indiscriminately, in cases of Indigestion for a consid-
erable length of time yvithout attending to the state of the alvine
discharge, although  its reception into the system be prevented by
the regular use of purgatives, is, as far as I can judge, in opposi-
tion to every thing  which yve know of the nature of the disease.
 and the effects of this medicine.
   What are the  effects yvhich we expect  from the use of mercury,
 in the first stage  of Indigestion after a healthy secretion of bile is
 restored, which is often effected by two or three doses, sometimes
 bv one?   It is true that a recurrence to  it is generally necessary,
 but in*he first instance yve should wait till we see  yvhetherthjs
 necessity  will be indicated by a return of the  morbid state of the
 bile.   The effect of its  first exhibition is more or less permanent
 in different  cases, and the most favourable  cases, when we have
 obtained a healthy flow of bile, yield to the  other means we have
 been considering. 
112
OF THE TREATMENT
   In the more obstinate cases, indeed, where the disordered state
of the liver constantly  recurs at short intervals, it is better for a
certain time to give a moderate dose at stated intervals, by which
the alimentary canal will  suffer less,  as a smaller dose is requir-
ed for the prevention of this state, than for its removal.  But  even
in these cases,  this practice should not be long pursued, without
trying from time  to time how  far the powers of the constitution
are sufficient yvithout its aid.   By these  means we ascertain the
extent to which it is necessary to carry the use of this medicine.
   The form in which it should be exhibited is also a point of great
importance.   It  ought never, we may safely  affirm, in  the case
before us, to be used externally; for we have no reason to believe,
that its  action on the skin can materially affect the liver  by  sym-
pathy; and we often find that, when exhibited in this way, it pro-
duces little effect on that organ, till the state of the gums shotvs its
presence in the constitution, which I  have already had occasion
to observe, is at this  period unnecessary.
   All that is  here wanted  is something that may speedily correct
the disordered  function  of the liver.  To  produce this effect
quickly, yvithout being more generally applied  to the system than
is necessary,  mercury must be given internally.   The sympathetic
effect on the  liver, during its passage  through the alimentary ca-
nal, we have  seen, is sufficient for the purpose.
   There are  tyvo forms in which it is usually given,  calomel and
blue pill.  The former being the most aperient, it is a good gen-
eral rule  to give it when  the  bowels are most languid,  and the
blue pill yvhen they are more easily excited.   But this is not the
only property in yvhich these  preparations differ.   The blue pill
is generally most oppressive to the stomach; the calomel  most ir-
ritating to the bowels; although in  some  cases, 1 have seen the
former, in very delicate subjects, from its being less cathartic,
and consequently, for a longer time, hanging about the bowels, if
I  may use the expression, more iiritating than calomel.
   For the same reason, small  doses of calomel, a quarter, or half
a grain, are often more irritating than two or three grains, which
more quickly pass off; and the irritation of the bowels is most effect- 
OF INDIGESTION.
its
 ually prevented by taking an  opening draught some hours after
 the calomel.   With most people, this is not necessary when the
 blue pill is taken, its continuance in the bowels  generally giving
 less uneasiness.
   From these properties of the two  preparations, the reader will
 readily  perceive  the circumstances  which  should  influence  our
 choice of them.   In the most recent cases, calomel take at night,
 and carried off by an aperient draught in the morning, generally
 answers best.   Here we want only  the  most transitory action of
 the medicine.
   On the other hand, yvhen the disease has lasted  longer, or the
 first feyv doses of calomel  have  failed to produce a permanent
 flow of healthy bile, yve feel the necessity of employing a  prepa-
 ration which  may remain  longer in the alimentary canal with
 less irritation than colomel would produce were it retained there.
   Hence the  great success which often attends giving four or five
 grains of the  blue pill every second or third night, as recommend-
 ed by Mr. Abernethy, particularly in those cases  where the affec-
 tion of the  liver has supervened early, and where consequently, it
 is the principal cause which supports and aggravates the disease.
 This observation, it is evident,  applies with still greater force,
 when  it is  the original  disease, and the alimentary canal  suffers
 only by  sympathy and the irritation of the  vitiated secretion  of
 the liver.   It is always  to be recollected, however, that in Indi-
 gestion it is an unhealthy secretion  of bile  alone yvhich renders
 mercury necessary in the first stage, that the time in  yvhich  it
 produces the necessary effect is different in different cases,  and
 that all that is taken after this is injurious.
   In some, the blue pill is so oppresive, that I have seen several
 Who could not take it even in much smaller  doses.*   To them it

  * It is remarkable that the blue pill is so offensive to some constitutions,
that I have seen several instances, in which it disordered the secretion qf
bile, even when  it was healthy at the time of its exhibition; and in such cases,
as far as I have observed, the disordered state of the bile continues as long
as it is used. This effect is similar to that  which we sometimes observe
from repeated doses  of calomel in children.
               15 
114
OF THE TREATMENT
is necessary to give small doses of calomel,  and if it irritates, to
combine it with anodynes.
   It also  deserves particular  attention  in  the choice  of these
means, that the most beneficial  use of calomel necessarily occa-
sions brisk  purging, on which the  benefit derived from it often
greatly depends; while, by its peculiar effect  on  the first passages,
it excites a  better action of the liver; by its purgative effect, as
well as by that of the draught which its  exhibition renders  ex-
pedient, it tends further to emulge the gall-ducts, and relieve the
distended state of the liver.
   Its operation then is most wanted where this distention is great-
est, which may be  known, we have seen, by  the state of the right
hypochondrium, and will be least injurious yvhere the strength is
most able to bear so considerable a call upon it.  When there is
little distention of the liver, and the  strength is much reduced,
the operation of the blue  pill, provided  it agrees tolerably  well
yvith the stomach, is preferable.   The relief  obtained from it may
be less speedy, but it will be obtained at less expense to the con-
stitution.   Instances frequently occur of the bad effects of not at-
tending to this distinction.   What is only a salutary evacuation in
one case, is  an  overpowering cause of debility in another.
   Where the symptoms are  rather  obstinate than severe,  and
yvhere they  yield readily,  but continually show  a tendency to re-
turn, covering the parts, to which the tenderness and fulness have
extended, with a warm mercurial plaster, often,  in the former in-
stances, tends to remove the disease;  and in the latter, to prevent
its recurrence.   I  have known such a plaster worn for months,
and even years, the symptoms constantly recurring yvhen  it yvas
laid  aside.
   When mercury occasions  much irritation of  the bowels, its
continued use brings on a degree of the dysentery.   Calomel, we
have seen, is most  irritating; it is, therefore,  most apt to produce
this  effect.   The patient is tormented with griping and tenesmus,
and  at length passes little more  than  mucus, often mixed with a
small quantity of blood.  If in such cases, we increase the dose
of mercury, in  hopes of freer evacuations, we only  increase  the 
OF INDIGESTION.
115
evil.  Discontinuing its use for a  little is the best remedy; and
when yve find, as sometimes happens  in such cases, that on re-
turning to it the same symptoms constantly recur, and can not be
prevented by changing the  preparation, or the use of anodynes
and mucilages, it must for the time be laid aside.
  Both  because mercury seldom produces the  effect here  men-
tioned, except when its  use has been continued for some time
and because the effect is most  apt to ensue when the bowels have
been long exposed to other causes of irritation, we less frequent-
ly have  to contend with it in the first stage of Indigestion which
is the more fortunate, because the few substitutes for this medi-
cine, which we possess, are less suited to the early than the more
advanced stages in which it appears.  From what is said above, the
disease is  not only essentially altered in its nature, but affects the
system more generally.
  Some of the mineral acids are the best substitutes for mefcury.
A combination of the muriatic and nitric acids  has appeared  to
me the most successful, whether taken internally or  used exter-
nally in the way recommended by Dr. Scott.
  This class of medicines are  otherwise useful, we have seen, in
the first stage of Indigestion; and if they maintain a due action of
the liver, there is no occasion  for the use of mercury.   They sel-
dom, however, have this effect for any length of time when its
action has once been disordered; and they are much less calcu-
lated than mercury for quickly restoring it, and hardly at all for
suddenly emulging the biliary ducts, the effects which yve  look for
from mercury in  the first stage of Indigestion.   I shall have oc-
casion to make some further observations on the use of the mine-
ral acids,  in speaking of the treatment of the second stage.
  In some cases we  shall find the  dandelion an assistant  to mer-
cury, and under certain circumstances  capable of being substi-
tuted for it.   It is defective in  the same respects as the acids, and
has the additional  disadvantage of often being oppressive to the
stomach in considerable doses, and in small doses it is of  little or
no use.
  From a want  of attention to the circumstances under which 
116
OF THE TREATMENT
 medicines should  be employed, many foil into disrepute, yvhich
 are capable of excellent effects when used more judiciously.  We
 are too apt to fall into the practice of viewing  a certain set  of
 medicines as calculated to remove a certain disease, and, as one
 fails, to use another, without much  attention to the properties pe-
 culiar to each, or the circumstances of the disease to which these
 peculiar properties are adapted.   If we have recourse to the acids
 or the dandelion, wherever mercury does  not afford the usual  re-
 lief, yve shall often be disappointed.   If yve employ them in the
 cases I shall soon have occasion to point out, they will seldom, as
 far as experience enables  me to judge, fail to be useful.
   The treatment of the first stage of Indigestion, then, consists in
 promoting the due action  of the stomach and bowels, by the va-
 rious means which have been detailed; and correcting the secre-
 tion of the liver, if it deviates from  the healthy state, by  the oc-
 casional use of mercury, care being taken neither to employ it  in
 greater quantity, nor for a longer time, than is necessary for this
 purpose, as its effects on the stomach and  bowels are evidently in
 opposition to the other parts of the treatment.

                       SECTION II.

 Of the  Treatment of ilie Second Stage of Indigestion.

  It appears from yvhat yvas said of the symptoms of Indigestion,
that they are liable, after the disease has lasted some time, to un-
dergo a considerable  change; the epigastrium  becoming  tender
on pressure, the  pulse hard, and some tendency to  fever super-
vening.  These  symptoms characterize what I have  called the
second stage of the disease.
  The period  at which this change  happens, we have seen,  is
nearly as various as that at yvhich the deranged  function of the
 liver shows itself, yvhich it sometimes accompanies from  its first
appearance, but hardly ever precedes.  In most cases, the above
symptoms do not supervene  till the function  of  the  organ has
been disordered for some time, or its disordered state has repeat- 
W INDIGESTION.
117
edly occurred.   It may also be observed, that, like the disorder-
ed state of that function, they are apt to come and go for some
time before they are established.   This is true, even of the ten-
derness in the epigastrium.  On one day it shall be considerable,
and, even on the next, yvithout the use of medicine, it  shall have
disappeared.  In most cases, however, it is more stationary from
the first, and, if the disease lasts, it always becomes so.
  As soon as the symptoms characterizing the second stage are
established, we find that bitters and aromatics cease to give any
effectual  relief; and in many cases, the most  stimulating in  par*
ticular, increase the feverish restlessness that occasionally assails
the patient, and that languor and  uneasiness which seldom whol-
ly leave him.   If, in consequence of his increasing complaints of
debility, his medicines are  changed for others of a more strength-
ening nature, the effects are still  worse; and he often thinks that
his  disease admits of no relief, but from  aperients and particu-
larly mercurial aperients, of the good effects  of which he  is al-
yvays sensible, and, consequently, is very apt to fall into an  ex-
cessive use of them: and many medical  men appear to have ar-
rived at  nearly the same conclusion, for it is  not unusual in find
them declaring, that they see  little good  done in such cases ex-
cept by purgatives and mercurials,  a principle which  has some-
times been applied even to the earlier stages.
  Unless I have been deceived by a pretty extensive  experience
of the phenomena of this disease, there is no  stage of it to yvhich
this conclusion is applicable.   We have seen that purgatives and
mercurials, properly employed, are valuable medicines to the first
stage.   We shall also find  them so in that yve are about to consi-
der.  But in both  they  are only part of the  means, and, if em-
ployed too freely, and  to the neglect of others, yvill in all  cases
do mischief.
  The inflammatory symptoms of the second stage of Indigestion,
led  me to adopt a  practice founded on them, and the immediate
relief obtained, confirmed the views which had suggested it.
  The stimulating plan, which is proper while the fault is in the
muscular and nervous powers of the stomach  alone, is no longer 
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OF THE TREATMENT
applicable.  The disease, however, still so far partakes of its ori-
ginal nature, that, were yve to regulate the treatment by an atten-
tion to the inflammatory symptoms alone, the powers of the sys-
tem would soon sink under it.
  The  more powerful anti-inflammatory measures, therefore, a
very low diet, general blood-letting, &c, are rarely proper, un-
less, as sometimes happens, the inflammatory symptoms increase
to those of active inflammation.  The disease is then of a differ-
ent nature, and must be treated on the same principles, although
yvith more than usual caution, as other phlegmasia?.  The less sti-
mulating of  the tonic means employed in the first stage, on the
other hand, are still indicated; the extent to which the one or
other set of means should be carried, being regulated by the great-
er or less degree of the inflammatory  tendency.
  In two other respects, the principles of the treatment in the
first and second stages of Indigestion differ.   In the enumeration
of their  symptoms, we have seen, that although various  other
functions suffer more or less  by sympathy with those of the di-
gestive organs, almost  from the commencement of the disease,
it is in the second stage, both from the longer continuance of the
derangement of the central parts, and from  the greater severity
and more complicated nature of that derangement, that they suf-
fer most.  Their affections, therefore, here influence the indica-
tions of cure more than in the first stage; and as the strength is
more impaired in the second stage, while the means of relief, at
the same time, are of a more debilitating nature, an uniform en-
deavour to preserve, as much as possible, that which remains, is
here more indispensable.  Evacuations, yvhich, while the vigour
of the system is comparatively entire,  and the patient can be sup-
ported by stimulating diet and  medicines, have the  best ef-
fects; at  a later period, and where less  stimulating  means alone
are applicable, may be attended with serious injury.   The sys-
tem  not rallying now, as in the first  stage, the effect of one de-
bilitating  measure  is still  felt, when  we  are called  upon for
another;  and, if our plans are  not regulated  with caution, and so
directed  as  at no great  distance of time to restore the proper 
OF INDIGESTION.
119
functions, and thus render a continuance of such measures unne-
cessary, the patient sinks equally under his disease and the means
employed to relieve it.
   Such then are the  principles on yvhich, as far as I am capa-
ble of judging from  repeated  experience of the  various plans
which have been  pursued in this disease, the proper treatment
of the second stage is founded.  An inflammatory tendency ia
superadded to the derangements which constitute the first stage;
stimulating measures  are therefore to be employed yvith  more
caution,  and anti-inflammatory measures become more  or less
necessary.  The  diseased action  has  spread farther,  and  the
strength  is more reduced; our  measures must therefore embrace
a wider  field  of practice, and  the strength must be husbanded
yvith greater care.
   We are now to  consider mace in detail the means, to the  em-
ployment of which these  principles lead.   I shall, in the  first
place, lay before  the reader that part of the treatment, which
forms the characteristic difference between it, and that we have
been  considering;  and then  point out how  those means, which
are common to both stages, should be modified in the one before
us.  We shall next consider  such additional means as do not be-
long to the treatment of the first stage, but can not, like the anti-
inflammatory means,  be regarded  as  in opposition to 'the plans
there pursued; and in the last place, take a vieyv of the treatment
of the sympathetic affections  which attend the second stage, and
require means directed to the organs they affect.   These we have
seen immediately lead to change of structure, and may, therefore,
be regarded as the link, yvhich connects the second and  third
stages  of this varied disease.
   The first thing,  which appeared to  me to throw  much light on
the nature and treatment of the second stage of Indigestion, was
the effect of applying leeches  to the tender part of the epigastrium.
It yvas not, I found, merely that the tenderness yvas relieved, and
the pulse  softened; but that the patient breathed and walked  bet-
ter, that the botvels were more easily moved, and the skin ap-
peared more relaxed,  the  feverish tendency yvhich frequently
shows  itself in the evening, being in the fame degree lessened, 
120
OF THE TREATMENT
   From these observations it appeared,  that the  effect of the
leeches was  not that of mitigating any particular symptoms, but
of relieving the cause of the whole; because it is only on this sup-
position that such general relief could be afforded.          \
   But even these, I found, were not the whole effect of the local
blood-letting.  On resuming the plan  of treatment,  it soon ap-
peared, that  the patient bore the use of tonics much better  than
before; and in some instances, a recurrence to the treatment of
the first stage,  under  such circumstances, removed the  disease.
It seemed to  have been the slight inflammatory action, which the
leeches relieved,  that  alone had prevented the beneficial effects
of these means.  I have thus had  many opportunities of seeing
the patient, after the use of the leeches, quickly restored to health
by a  plan, little  different from that which  had previously been
employed in  vain, and  sometime* with  an aggravation of the
symptoms.
   But so fortunate an issue, I  soon found,  was only to be expect
ed yvhere  the second stage had been of very short duration, or the
constitution was particularly favourable.   On the tonic plan being
resumed, the tenderness of the  epigastrium was generally soon re-
newed, and a repetition of leeches became necessary.   Each re-
petition to the same extent generally produced less  relief than the
preceding, and if a larger quantity of blood was taken, the relief
yvas obtained at too great an expense of strength.
   The  application of  a blister to the part from which the blood
was taken, immediately after its abstraction, tended both to  in-
crease the effect of the leeches, and render it more permanent;
but, even  yvith this aid, their repetition in the more inflammatory
cases  soon became necessary.   In those less  inflammatory, blis-
ters sometimes relieved the symptoms without the aid of leeches,
but like the leeches they often fail to give permanent relief.
  Other measures, therefore, were  requisite.  The first that oc-
curred yvas to abandon, in such cases, the more stimulating parts
of the treatment, and although the patient generally felt  a degree
of sinking and debility from this change, particularly if made  too
suddenly, these symptoms were less permanent than when  re- 
OF INDIGESTION.
121
peated bleedings  were employed, and the constitution gradually
accommodated itself to the change.
   The lighter bitters  and those stimulants yvhose effects are com-
paratively more exerted on the nervous than the sanguiferous sys-
tem  could in  general still be  borne.   Among  many hundreds, I
have seen but few who could not bear the occasional, though not
the regular use of  aromatics, or even  of ammonia  and some of
its preparations;  and all could take the infusion  of camomile
flowers or bitter orange-peel, with the exception of those whose
peculiarity of constitution did  not admit of the use of bitters at
any time: and with  regard to diet, although in the more confirmed
cases feyv could bear well the most  stimulating kinds of meat,
particularly beef, a little chicken daily, or once in tyvo days, was
generally borne yvithout inconvenience, and supported the strength
more, and agreed better with the stomach, than a diet composed
yvholly of vegetable food.
   Nor have I found it necessary  in such cases  wholly to abstain
from the use of yvine, although it has generally  been advisable
to lessen its quantity, and often to take it diluted.  It is seldom,
I  believe, proper to reduce the diet more than  this, unless active
inflammation  be threatened.  In a few, particularly when a con-
siderable degree of hardness of pulse, notwithstanding  the use of
the above means, continued, I have seen a diet wholly vegetable
and even a total abstinence from wine,  which is much less per-
manently stimulating than animal food, strikingly beneficial.  It
is common for the appetite to improve on lessening the quantity of
animal food.  This depends in part on other food affording a less
proportion of nourishment, but very much, I believe, on the ten-
dency to fever being lessened by the  change.
   The state of the bowels in such cases is often influenced by the
diet in a very remarkable manner.  They are not only torpid un-
der the  use of animal food, but purgatives  act imperfectly, and
yvith great irritation.   On using a vegetable diet,  they  are  fre-
quently relaxed without  the aid of medicine;  and if  purgatives
are still necessary, they act in much smaller  doses, and without
 irritation   It has generally been found better, however, to obvi-
               16 
122
OF THE TREATMENT
ate the inflammatory tendency by other means, li;an  to adopt so
low a diet as very essentially to reduce the strength.
   Of all the mediciues which I have employed with this view, I
have found none equal to nitrate of potash taken in a considerable
quantity of water,  in  which a  little gum  had been dissolved.
The gum seems by defending, in some  degree, the stomach and
bowels from the irritation of their contents, yvhich tends to coun-
teract  the cooling property of the nitrate, to add  sensibly to its
effect.   It much be added, however, it is  apt to oppress the sto-
mach.   Eight or ten grains of  nitre in an  ounce  and a  half of
water, yvith a  twelfth or sixteenth  part of  mucilage of acacia,
have  been given three times a day,  and repeated every hour or
hour and half, when the skin became hot generally, or the hands
and feet began to  burn.  Two  or three doses thus taken seldom
fail to reduce the increased temperature, and telieve the restless-
ness yvhich it occasions; and  thus  simple as the means  are,
they often procure good nights, when the want of sleep, as fre-
quently happens in this stage of the  disease, is the effect of fever-
ishness.   The common saline draught, the sulphate of potash and
other medicines of this  description have  similar effects, but none
of them appear to me equal to the above nitrate.*
   It is not to be overlooked, however, that all medicines of this
description are debilitating.   1 have known injury done by two
free a use of them, the  powers of the stomach  being farther en-
feebled, and a state of greater general, nervous debility superven-
ing.   In general,  it is only when they are used incautiously, that
these effects are to be apprehended.   I have met with a  few, in
whom even small  doses of the nitrate of potash occasioned irri-
tation and debility.
   In addition  to the foregoing means, rather a freer use of aperi-
ents thau in the first stage has been found  useful.   Aperients not

  *-The carbonic acid gas, disengaged when the saline draught is taken in
a state of effervescence, is graieful to many stomachs; to others it is op-
pressive, and the draught seems to agree better with the stomach when the
effervescence has been allowed to subside. I may here observe, by the by,
that both from the extraction of air-being apt to oppress, and because they
more readily combine with the acid of the first passages, the pure alcali*
are sometimes found  better correctors of acidity than their carbonate-. 
OF INDIGESTION.
123
 only promote the action of the bowels in expelling their contents,
 but occasion  a freer flow into them  of the bile and pancreatic
 fluid, and of  the fluids of the various glands.of the canal itself.
 We have also, indeed, reason to believe  that  they stimulate the
 absorbent, as yvell 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, tor 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  yvhole,  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 means  we are next to consider.
   WThen  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, yve 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, always form part
of its treatment.   Of these we still find mercury by far the most
efficacious.                     •
   Several circumstances render caution, in the use of this medi-
cine, pven 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, yve still find  that this effect of it,
particularly  of the blue pill, repeated for a longer time, is often
sufficient, especially when the anti-inflammatory measures we
have been considering are duly employed.
   When it  is sufficient,  no other should  be  attempted.   But in
many cases, and  in a large proportion of  those of long standing,
it tails.  The relief afforded  by the occasional doses of mercury
gradually becomes less, and they at length cease to be of 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; yvhich 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.
125
cury, in  the second stage of Indigestion, yvhen  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
yvhen it  yvas 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, yvhen larger doses had  been em-
ployed in vain.   They not only often succeed yvhere 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 temperature, 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, yvhen they
correct the state of the  liver, at the same time  produce  many of
the foregoing effects in other organs, the diseased state of yvhich 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  plan, I am here  considering,
seem chiefly to  depend.   By the mercury being given in  such 
120'
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,
 yvhen 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
 instating, 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, yvhich
 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; and if the blue pill occasion any irritation of
the bowels, yvhich 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
the last of these yvith the blue pill, as a preventive; and have ex-
perienced from it not only this advantage, but some good from its
general sedative effect  on the system; and it yvill easily be believ-
ed, that the extract of hyoscyamus in doses not exceeding a grain,
given two or three times a  day, never produces inconvenience of
any kind.
  If the irritation, occasioned by the internal use of the mercury,
can not be allayed, its  external use may here be tried, the dose
being  proportioned to that recommended  internally.  From  a
scruple to half a drachm of the yveak mercurial ointment may be
rubbed into the skin every evening.   This  way of employing it,
however, is objectionable in the case  before us; by it the medicine
is less effectually applied to the chief seat of the disease,  and the
quantity reoeived is much less easily ascertained. I have  already
had occasion to observe,  indeed, that the external use of mercury
seldom has much  effect  in correcting the state  of the bile, till it
produces some  effect on the mouth.
  If even this use of it irritate  the  bowels, which may happen,
particularly in  the advanced stages, yvhen they have already suf-
fered much from the medicine; and  we can not obviate that ef-
fect, it must be discontinued; and only  renewed at intervals, for
the time that the bowels  can  bear it without irritation.  Beyond
this even the smallest doses do more harm  than good.
  In the few constitutions, in which no dose of the blue pill can
be taken yvithout disordering the stomach,  I have substituted for
it, with good effect, a sixth or eighth  part of a grain of calomel,
combined with some anodyne, but this preparation is not so well
suited to the objects in view.
  It is not uncommon in  all constitutions, for a few grains of the
blue pill to occasion a slight pain referred to the stomach soon af-
ter it is taken,  which continues for half an hour or more, and this
symptom sometimes arises from smaller doses; but it is seldom of
much importance, and often ceases to recur after a few doses have
been taken. 
128                  OF THE  TREATMENT
   I have not found it necessary to confine the patient under the
foregoing plan, while his strength is equal to the exertion of going
abroad, except at night and in bad weather; and this degree of
confinement his disease requires independently of medicine.
   I have had occasion to observe  that it is to the second, rather
than the first,  stag , that  the substitutes  for mercury are best
adapted, and that the mineral acids, particularly a combination of
the muriatic and nitric acids, and the dandelion appears  to  be
the best.
   Much has of late been said of the external use of these acids.
Both their internal and external  use  has appeared to me best
adapted to cases of some continuance, where the inflammatory
tendency has been to a great degree subdued, and small doses of
mercury have been  employed  without  the usual  benefit.   In
such cases, I believe, the use of the acids'will almost always be
found better than increasing the quantity of mercury beyond what
produces the slightest indication of its presence in the gums.   If
the habit bear the mercury yvell,  the acid may be used in aid of
it; if not, or if the use of the acid, as sometimes happens, causes
the mercury to  irritate  the  bowels, the latter  should  be discon-
tinued  under the use of the acid.
   Whtn the mercury, either on account of its effects on the bow-
els, or  the  debilitated  state of the patient, can only be used at
intervals, the  intermediate use of the acids is generally of con-
siderable service.  They tend at once to  restore the strength and
prolong the effects of the mercury.  According to my experience,
the external use of the  acids, recommended, by Dr. Scott, is more
powerful, both  as a substitute for mercury, and a means of cor-
recting its debilitating effects, than internal use.   It consequent-
ly requires more caution,  where  there are any considerable re-
mains of the inflammatory diathesis; I have known it produce an
alarming increase of the inflammatory symptoms.
   The dandelion appears to possess greater powers in this disease
than are usually ascribed to it, but  it requires to be taken in very
large doses.   It  is best adapted to  those cases, in which the bile
is deficient or much disordered, yvhile the  power of the stomach 
OF INDIGESTION.
129
is still considerable.   In  such cases, I hive seen the patient re-
stored by a strong decoction of dandelion used for common drink,
yvithout the aid of any other medicine.  In addition  to its effects
on the liver, it tends to cool, and consequently allay  the inflam-
matory diathesis, and often excites both the bowels and kidneys.
The latter effect, which is best counteracted by alum, when  the
stomach bears it well, is frequently such as to make  it necessary
to discontinue the dandelion.   The former  is seldom considera-
ble, and can always be restrained.  It is  often given with great
advantage in aid of the small doses of mercury when  the stomach
bears it well, and enables  us further to diminish the  quantity of
this medicine.   I  shall have occasion to  make some additional
observations on it in sneaking of the treatment in the third stage
of Indigestion.
  Besides the  means, the more prominent effect of yvhich is, that
of correcting the secretion of bile,  there are others  often  useful,
particularly  after  the general  inflammatory  tendency has been
subdued,  and  debility becomes the most urgent symptom, which
seem to  act more uniformly on all the secreting surfaces.  For
this we are prepared by what has  already been  said.
  We have seen the secondary affections in this disease gradually
gaining importance in its  progress, and that if no vital organ is
so much weaker than the  rest, that the disease fixes on it, produ-
cing effects which we are  presently to consider, the various  or-
gans which have from the  first suffered by sympathy, have their
powers more  permanently impaired; and the disease gradually
assumes the form rather of a case of general, and for the most
part oostinate, debility, than a disease of any one set of organs.
  This form it assumes the  more readily, in consequence of a
law of the animal  economy which  has often  attracted our atten-
tion;  namely,  that  although  the sympathetic affections produced
by a disease, tend to increase the original  affection, in proportion
as the secondary affection  begins to  be changed into actual dis-
ease  of the  part, it tends  to relieve the  disease from  which it
sprung.   Hence it is, that in the case we are speaking of, in pro-
portion as debility of other parts becomes permanent and  inde-
               17 
130                  OF THE TREATMENT
pendent of the cause yvhich produced it,  the digestive organs are
frequently relieved.  It is not uncommon for  patients in the state
I am speaking of to express their surprise, that they should he so
weak, when the stomach performs its office so much better than
yvhen  they felt  comparatively little  of this general debility.
   The state of the disease before us necessarily supervenes more
readily in  some than in others; according as the organs seconda-
rily affected are more liable to  disease,  and no particul; r organ
so much yveaker than the  rest as to induce the disease to  fix par-
ticularly in it.
   We have now, in  some degree, a neyv  disease to  contend with.
The general sympathetic disease has become  that of most im-
portance.  Even in this case, however, Hie pulse is still more or
less contracted, and  a degree of  hardness will  be readily perceiv-
ed in it, if it be examined in the  way yvhich has  been pointed
out; a  circumstance, which, with the history of the  disease,  and
some  uneasiness being still caused by pressure in the above men-
tioned part of the  epigastrium, readily  distinguishes this  state
from other cases of debility.
   The remains  of the  original  disease to be observed  in  such
cases,  together yvith  the good effects which often,  for the time,
result  from every thing yvhich generally excites the  secreting sur-
faces,  frequently induce physicians still to look to mercury, given
in what  is called an alterative course, that is, in doses taken at
considerable intervals, as the chief means of relief in such cases;
the propriety of which 1 think many  circumstances must  lead us
to question.
   Before the disease arrives at  this  period,  every  poyver of the
constitution has been strained by it, and not unfrequently by the
means employed for its relief.   From mercury  in  particular,  it
lias generally suffered much; and the bad effects  of medicine,
like all  other morbid affections, gaining force by  habit,  we see
those of mercury now  appear from doses, which, at an earlier pe-
riod, would have produced no sensible derangement.
   There is also another point of importance to  be  considered in
such cases.  The general debility produced by mercury, when it 
OF INDIGESTION.
131
is given  for the removal of a local disease, is, particularly  if it
has been successful in removing it, more or less readily corrected,
the functions in general being healthy.   But in the case before
us, where  they are  in a state of disease, it is corrected, if it be
corrected at all, with great difficulty.
   If to  the foregoing circumstances  we  add, that, poyverful  as
mercury often  is in exciting the due action of the secreting sur-
faces in general, it is by no means so poyverful a  remedy  in this
respect  as  in correcting disorder of the hepatic system, the skin
and other secreting surfaces otten remaining  obstinately inactive
under its use; and that if it fail to  excite  the secreting surfaces,
its general  effects on the system must add to their debility: yve shall
admit, I think, not only that little is to be expected from  it in
the case before us, but,  as  far as yve can judge from the knoyvn
effects of this medicine, and the nature of the  disease, there is
great risk of its increasing the  evil.  This inference, however, is
not alone the result of reasoning.   If yve carefully watch its ef-
fects, according to any experience I have had in such cases, they
will be  found to correspond yvith it.  Hotvever it may relieve for
a little,  yvhen resulted after a long interval, its  good effects soon
disappear,  and  the only consequences of  continuing its employ-
ment seem then to be, to add to the debility and hasten the pro-
gress of the disease.
   Although  the state I am speaking of  may be  considered  as
comparatively  rare,  lor it is much more common for the diseased
action,  which has long existed in obstinate cases of indigestion,
to fix principally on one organ, than to produce the general state
of debility I am here considering; yet we very frequently meet
with a state resembling this, before  the disease finally fixes  on
one organ; and particularly in the  intervals between the attacks
of disease,  which  that  organ generally  suffers, before  actual
change of structure  commences in it.  To this state, the obser-
vations  just made, and  those I am  about to make, equally apply
as to that where no organ suffers in particular; except that in the
former, the means which influence the whole system,  must  be
combined  with those directed to the organ chiefly affected, which
we are  presently to  consider. 
132
OF THE TREATMENT
   I have found the debility most obstinate when least complica-
 ted  with the  determination to particular parts,  provided change
 of structure had not taken place in the latter case.   The inflam-
 matory tendency, yve have seen, is still shown by the hard pulse,
 yvhich is  relieved with difficulty,  because, not depending on the
 affection of any one part, local evacuations influence it but little,
 nor  are they at ail the appropriate remedy; and the general state
 of debility admits of but a very cautious use of those which pro-
 duce their effect on the whole system.
   Blood letting is here out of the  question.  The pulse must be
 softened by a  mild diet and medicines which excite the secreting
 surfaces, but mercury, we have just seen, is objectionable.   The
 moderate use of saline medicines is among the best means in such
 cases.  It  would surprise any one whose attention  had not been
 particularly directed to them, to observe the effects  which a diet,
 composed  wholly  of vegetable  substances and  milk, if the sto-
 mach can bear it, combined yvith  small doses of such medicines,
 often produces in those labouring  under this form of the disease;
 who have been vainly  endeavouring to support  their strength by
 a large proportion of animal food  and tonic medicines.   It has
long been admitted, indeed, that such a diet is sometimes  useful
 in cases of debility.   By this change, the pulse is more or less
softened, and the boyvels and the skin are relaxed.
   It unfortunately happens that the debility is generally such that
some portion of animal  food is necessary, and a diet wholly com-
posed of vegetable matter is often  apt to renew  the symptoms of
Indigestion.  A little of the milder kinds of animal food, there-
fore, is for  the most part necessary, but I have generally seen the
best  effects from abstaining from it every second or third day.
   Great advantage has appeared  to  me to arise,  in  the case
before us, from  sarsaparilla, the continued  use of yvhich often
seems to give a  general tendency to  greater freedom in the  se-
creting surfaces.  I have repeatedly  seen it, by its mild stimulant
and tonic powers, succeed yvhere every thing else had failed.
   I have also  seen strikingly good effects,  when the pulse was
much contracted, and the skin shrunk and cold,  from very  small 
                       OF INDIGESTION.                   133

doses of colchicum; but, like other medicines of this description,
it must be used with caution, and no further than is necessary to
soften the skin and the pulse.  Antimonial  medicines, in altera-
tive doses, are sometimes useful, but in general they debilitate too
much to be  long continued, and their effects  soon cease yvhen
tbey are laid aside.  The effects of both these medicines, parti-
cularly the former, are often improved by combining them yvith
the small doses of opium above mentioned.
  We may  infer, from what was said  of the effect of a damp air
in speaking of  the  causes of Indigestion, that a clear and fresh
air is often of the greatest use to the dyspeptic, and the states we
are noyv considering  require it more  than  those of an  earlier
period.
  A very sharp  air, however, is unfavourable.  It too  much pro-
motes  the  inflammatory  tendency,  and  all sudden  changes of
weather, on this account, are injurious.  It is thus that the spring
is the most  unfavourable season for invalids of this description;
but a heavy still air never fails to depress  their  spirits  and in-
crease the whole train of nervous symptoms.
  I  have often, during a long residence in a town yvhere the air
is too  close, both from its low situation and  the flat and  wooded
state of the country, seen these observations strikingly  illustrated,
Patients of this description drooped in  the town, but on being re-
moved to the neighbouring hills of Malvern, immediately  revived;
and  those who at Malvern  enjoyed  good health, often had a re-
newal of their nervous  and  bilious  complaints on coming to the
closer  air.
  A free and mild air, a mild and easily  digestible diet,  regular
exercise proportioned to the  strength, a regular state of the bowels,
a moderate use of saline medicines at  the times yvhen the general
temperature is increased, or there is  a  sensation of burning in the
hands and feet, and the use of sarsaparilla yvhen it does not op-
pess the stomach, and such other medicines  as excite the secret-
ing surfaces generally without  materially impairing the strength,
I would say, constitute, according  to my experience, the outlines
of the best plan in  such cases: and I believe mischief is always
done by powerful measures. 
134
OF THE TREATMENT
   It is necessary to make the patient sufficiently acquainted yvith
his case to be satisfied with very gradual amendment.   I believe
mercury should now make no other put of the treatment than in
the first stage of the  disease.  It should only be employed for
restoring  due action to the liver when this considerably deviates
from the healthy state, and then in as small quantity, for as  short
a  time, and  yvith as little impression on the general system as
possible.
   When other means fail, a voyage and change of climate are of-
ten of service; and I believe the waters of Buxton are sometimes
useful.
   What is called change of air, indeed, although in the same cli-
mate, is almost always beneficial in Indigestion, and particularly
in the advanced stages.   I shall take the present opportunity to
lay before the reader the observations which have occurred to
me on this subject.
   There has been much difference of opinion respecting the cause
to which the benefit derived from change of place is to be ascrib-
ed.  We  have reason to believe that it arises from various  cir-
cumstances, but least of all, in  most instances, from mere change
of air.   It is evident  that the air is effectually changed by the
wind, and far more rapidly than it can be by any change of place.
Yet it is only when  the  temperature or degree of moisture is
changed by the wind, that we can perceive it produce any change
in the health, if yve except that a certain degree of wind is use-
ful by preventing absolute stillness of the air, which always be-
comes oppressive yvhen long  continued, and  that, independently
of any impregnation of the air, for it is felt by those who inhabit
single houses in  the country, as yvell as by  the inhabitants of
towns.  A free circulation of air is particularly grateful  to the
feelings, and, as yve might from this alone infer, favourable to
health.
   The truth  is, that the  air is essentially  the same in all places.
It has been tound by correct experiments, that in the closest  parts
of London and on  the  top of the Malvern Hills,  it possesses the
same proportion of the principle yvhich supports  animal life, and 
OF INDIGESTION.
135
is itself, indeed, in all respects the same; but it is capable of being
variously  impregnated.   The  sense  of smell at once  informs
those from the country, that the air of large towns is less unmix-
ed than that yvhich they have been  accustomed to breathe.
  All impregnation of this kind must,  we should at first view sup-
pose, be more or less injurious, and to a certain degree it may be
so;  but yve  have reason to believe, I think,  that it  is much less
so than the occasional greater dampness and dullness of the air
of large toyvns, produced in the way  pointed out in the second
chapter, and the usual greater stillness of the air in them  from
confinement by the buildings.
  The chief impregnation of  the air of large towns seems to be
from smoke, which  does not appear to  be particularly unwhole-
some.  It has on the contrary indeed been supposed to  preserve
from disease, and has often been employed with this view..   The
other effluvia of such toyvns are in too small  quantity to  produce
much impregnation of the  external air.
   I have just had occasion  to observe,  that the  change of air by
the yvind seems only to affect the health by the  motion of the air
it occasions, and by its influencing its temperature and degree  of
moisture.   I am inclined  to think that it is merely in these ways,
yvhich are doubtless in many coses very  important, that change
of place,  as  far as the  air is concerned, affects  us.   The  air it-
self, I have just had occasion to observe, is always the same; and
its  impregnations, unless it be confined, are never, perhaps, such
2s sensibly to influence the health,  if we except those states con-
nected with the production of contagious diseases, which are very
little understood.*  But there are  many other  things in change
of place capable of essentially influencing it, of which, I believe,

  * Some have been inclined to doubt whether the air is ever so changed
as to produce disease, independently of the presence of contagion and the
changes of its temperature and degree  of moisture, but there  are  some
well-ascertained  facts which it is difficult to explain on any  other supposi-
tion.  We see contagious diseases, particularly a plague, appearing and
declining in different parts of the country, ptrhaps, hundreds of miks dis-
tant  from  each other,  at the same time and without  any evident aUse,
which it would be difficult to account for by any of the known properties
of contagion. I have  elsewhere had occasion to consider this subject at
some length.—Treatise on Fevers, p. 158, etseq. fourth  edition. 
136
OF THE TREATMENT
 the most poyverful is  the excitement given by the change itself.
 How often do we find continual change necessary,.the neyv place
 being no better than the old, as soon as the novelty of the change
 is  yvorn away.
    To the mere exercise of body occasioned by the travelling, or
 to  yvhich a  new situation naturally incites, much  must often be
 ascribed; but, I believe, we must look to the occupation  and
 cheerfulness of mind  occasioned by  the change  for its chief ef-
 fects.   The feelings of sickness on the one hand, like all other
 feelings, are soon associated with every thing  around  us; and on
 the other, the mind, if not forcibly  abstracted, fixes intensely on
 any object, which  for a long time chiefly occupies the attention.
 In  long continued sickness,  we want something to  break that as-
 sociation, and something to divide  our attention.   What can so
 powerfully produce these  effects as  a total change  of place?  The
 poor in some parts of this country, who can not afford to send their
 children to a distance  in the decline of hooping-cough, in which
 change of place is  so powerful a remedy, confine them daily for
 a  certain time close to the  machinery  of  a mill,  and this often
 answers the purpose as well.
   Let me add, those who ascribe to fancy all diseases which may
 be  cured  by change,  know little of the  nature of disease or the
 laws  of the  animal economy.  Will  they ascribe the hooping-
 cough to fancy, or eruptions and sores of the surface, pains and stiff-
 ness of the joints, and a thousand other ailments, which are often
 cured by change alone?  We have  seen how extensive the trains
 of diseases are, yvhich  in many cases depend  on affections of the
digestive organs; and how much these affections are influenced by
 the state of  the mind,  which is very nearly as much the subject
 of external circumstances as the body.
  In the cases  we have last been considering, the patient is  not
 always much emaciated, and is sometimes full and bloated.  This
 seems to rise from the yvaste being  much lessened by a general
 failure of the secreting powers, and it  is not uncommon for loss
of flesh  to be among the  first  symptoms of recovery.   The  in-
creasing poyver of the organs of supply, if the recovery goes on.
soon of course begins to counteract this effect. 
OF INDIGESTION.
137
   As these cases have seldom been  accurately  distinguished,
their treatment  must be regarded as in its infancy.*   They are
sometimes  treated  merely  as  cases  of obstinate debility, and
thus by the tonic means employed, the  lurking inflammatory ten-
dency is called into  action; and often,  at length, shows itself by
some of the trains of symptoms, yvhich now demand our attention,
the particular consideration of yvhich has, for reasons above stated,
been referred to this place.

Of certain Trains of Symptoms whose Treatment does
        not fall under the general  Plan of Cure.

   It appears, from what I have already had occasion to say, that
the symptoms which arise, when the sympathetic affections  begin
to have an  existence,  independent of the  cause  which produced
them, and consequently to require a plan of treatment directed to
the parts they affect, show themselves at earlier periods,  as well
as at the period which we have just been considering.   The ear-
lier they show themselves, the inflammatory action generally rises
the higher, the later  they appear they are the more obstinate, and
the more apt to occasion change of structure.  This is at all  times
their tendency, and it is therefore, as I have already had occasion to
remark, that  they may be regarded as the link which connects
what I  have termed the second  and third  stages of Indigestion;
the former  characterized  by the  presence of the inflammatory
tendency; the latter  by the usual consequence of its continuance,
change of structure  in some  vital part.
   The class of symptoms,  of which I am speaking,  more  than
any  other, tends to render the  disease  complicated,  and conse-
quently, at first view, obscure;  but a careful study of them un-

  * The green jaundice, of which Dr. Baillie gives so valuable an account in
the fifth volume of the Transactions of the College of Physicians, is different
from these cases, incurable organic disease of the liver having almost always
taken'place in it.  In other respects the two states are similar, and it is par-
ticularly satisfactory to me, that the observations he makes on the treat-
ment so nearly correspond with the result of my experience.  I have also
seen his observations on the prognosis, a» well as the treatment of the greeo
jaundice strikingly confirmed.
            18 
138
OF THE TREATMENT
 folds its true nature, the manner in which it extends its influence
 throughout  the  system, and the steps by  which it is capable of
 disorganizing any part of it.
   Some of  its most striking features, we  have seen, arise from
 the manner in which distant parts sympathize yvith the stomach.
 The nature  of the affection of these parts, it was observed, cor-
 responds with that  of the stomach itself.   In  the first stage they
 are mere nervous affections, ceasing as soon as the cause of irri-
 tation from  which they arise ceases.  In the second stige they
 become  inflammatory affections, yvhich have an existence inde-
 pendent of that  cause; for the occurrence of the inflammatory
 tendency in the  stomach, immediately producestbe sime tenden-
 cy throughout the  system,  to such a degree indeed, that inflam-
 mation  readily arises in those  parts of it yvhich most sympathize
 with  the stomach, even  from causes  not  connected  with  the
 disease.
   The secondary symptoms of Indigestion are most easily excit-
 ed in infancy, and least so in advanced periods of life.  In infan-
 cy  too  they  are most speedily  fatal; but  it is from puberty to
 about forty  years of age that  they are  most  frequent, because
 at this period, their causes  are most frequently applied, and  the
 susceptibility of  the constitution is  not yet greatly impaired.  Be-
 sides, after forty, we have seen,  the disposition  to Indigestion is
 less.
   It appears from the enumeration of the symptoms of Indigestion,
 that the liver is the first organ  which  partakes of the  disease of
 the alimentary canal.  In the  first stage,  we  have seen that its
function is generally deranged  at an  early  period; and in the  se-
 cond, that the inflammatory tendency of the pylorus in most cases,
 soon extends to it.  It is also the orgin which is most frequently
 the seat of those trains of symptoms, which we are now about to
 consider.
   It is not uncommon in the second stage  of  Indigestion, when
 the patient takes cold, or is  exposed to  other  causes of inflam-
 mation, or, indeed, without any evident cause,  for  the greater
 part of  the right hypochondrium to become full and  tender on 
OF INDIGESTION
139
 pressure, yvith a sense of oppression and an  increased hardness
 of pulse, often accompanied  with some degree of dyspnoea and a
 dry teasing cough.  He sometimes complains of pain in the right,
 not unfrequently in the left,  hypochondrium, or in the pit of the
 stomach, or in the right, or sometimes the left shoulder,  and ex-
 periences some uneasiness in lying on either side, particularly on
 the left, a greater than usual  derangement of the biliary secretion
 accompanying these symptoms.   In short, he evidently labours
 under inflammation of the liver.
   It is seldom, however, of the most active kind, requiring gene-
 ral blood-letting, which is fortunate, as patients of this description
 rarely bear loss of blood well.   I have  seen many who had long
 laboured under Indigestion unable to bear  the necessary  loss of
 blood, yvhen attacked with acute inflammation.  They are, how-
 ever, comparatively, little liable to  it.   Their inflammatory at-
 tacks  generally  partake  of  the chronic nature of the habitual
 disease,  and  for the most part yield to local blood-letting and
 blisters with the aid of a mild diet and saline and aperient medi-
 cines.
   This treatment, combined  with the snnll  doses of blue pill,
 given in the way above pointed out, never fails to relieve the af-
 fection of the liver yve are here considering, till its frequent re-
 currence has  rendered it obstinate, and produced some tendency
 to change of structure.
   The pain, it has been just  observed, is often felt in the left side,
 while the tenderness on pressure is wholly  confined to the right;
 but, after the  affection of the  right side is relieved by evacuations
from the tender  part, it  is not uncommon for the left  side to be-
come both full and  tender, the inflammatory affection appearing
to attack the spleen as soon as the liver is relieved from it; and it
will, sometimes, on the  fulness  and tenderness  of the left  side
being relieved by the same means, return to the liver.   This al-
teration I have seen happen more than once  before the disease
subsided, in those who had long laboured under the second stage
of Indigestion.
  Sometimes, though much more rarely, the fulness and tender- 
140
OF THE TREATMENT
ness appear in the left side alone.  The pain is then more confined
to the seat of the  tenderness.   The same means are here proper,
with the exception of the blue pill, which seldom seems  to be of
much service  in  this affection;  and the  employment of which
must therefore be regulated by the state of the other symptoms.
   The chief seat of such attacks, however, is often in organs at
a greater distance from that of the original disease.  I shall, in
the first place, mention the lower bowels, because these are more
immediately connected with the disease, and  are injured, not only
by sympathy with the higher parts of the canal, but more direct-
ly influenced by their vitiated secretions and the  undigested food.
   The irritation of  the bowels, which attends the first stage, is for
the most part easily relieved by purgatives and anodynes.  In the
second stage it often becomes obstinate, and shows the same in-
flammatory  tendency yvhich  now characterizes the primary dis-
ease.   The hypogastrium becomes full and tender on pressure,
and the irritation which exists there increases the general tenden-
cy to fever.
   We should  a priori expect that the lower bowels would suffer
more than other parts of the canal, especially  when the  disease
is of long continuance, the morbid contents of all the rest passing
by them.   The sigmoid flexure of the colon  appears to be  the
part most  liable to be affected,  probably from the  contents
lodging there longer than in other parts of the  large  intestines.
It is not  uncommon in protracted cases, to find a considerable de-
gree of tenderness in the seat of this part, which is sometimes at
length  affected with ulceration.   It is also, probably for similar
reasons,  common, though not so  much so, to find  tenderness on
pressure  in the seat of the coecum.. In other instan«es it is more
general.
   Opening  medicine, in such cases, seldom gives much relief,
and often increases  the irritation;  nor have I  found any means
effectual  without those which  lessen the inflammatory state of the
parts.   The application of leeches to  the part most tender on
pressure, and  the use of mucilaginous and anodyne clysters  sel-
dom fail to give relief, and then mild aperients generally succeed 
OF INDIGESTION.
141
in procuring  a free action of the bowels.   It is sometimes ne-
cessary to repeat these means, and when the symptoms are obsti-
nate their good effects may be promoted by the tepid bath; but I
have seldom  found fomentations  of the abdomen of  much  use,
although a large poultice applied over the  lower part of  it some-
times appears to be of service.
   Both from the passage of the vitiated contents of the bowels,
and  from the return of the blood through the  hepatic system
being rendered less free, those yvho have long laboured under In-
digestion, are particularly subject to piles; great relief is  general-
ly obtained in the affection of the  bowels,  we  are considering,
when they bleed freely; and yvhen they exist to a considerable
degree without bleeding,  the application  of leeches  to them  is
sometimes the best mode rff letting blood in that affection.  I
have repeatedly observed, even where it had not gone the length
of producing  decided inflammatory symptoms, but the patient had
for some days been teased by scanty, irritating and unsatisfacto-
ry evacuations, that after  a small  spontaneous discharge  of blood
from the piles, the bowels have emptied themselves with freedom
and ease.  Foreign, particularly French,  physicians,  place great
reliance on bleeding  from the  seat of the piles, even where no
degree of this disease exists, in all inflammatory affections of the
bowels.   Dyspeptics we  have seen are often subject to more  or
less  permanent  spasmodic stricture  of  the  rectum,  this is  most
apt to  occur when some degree of inflammatory tendency in the
bowels have  supervened, and yve have  reason  to believe that
when frequently renewed it may end in organic stricture.   This,
however, is certainly not a frequent occurrence.   When Indiges-
tion is complicated yvith  organic stricture of the rectum, it will
generally be found, I believe,  that the stricture is the primary
disease.
   Every cause of irritation of the alimentary canal is apt to re-
new the  inflammatory  tendency  in the bowels, particularly the
repeated  use of mercurial medicines.   It is also frequently re-
newed by cold or other causes of  inflammation.'   The best means
of prevention are  a very  mild  and rather mucilaginous  diet and
a free  state of the canal. 
142
OF THE TREATMENT
   The chest frequently suffrs in the second stage of Indigestion,
the dyspnoea, which yve have seen an occasional attendant  at all
periods of the disease,  becomes more permanent, with a sense of
oppression and difficulty of lying in the horizontal posture, and an
increase  of  the  tenderness of the epigastrium, the  hardness of
the pulse, and  burning of the  hands  and feet.  The feeling of
oppression  is greater than seems  to  belong to the degree of the
dyspnoea, and is much  increased by all active exercise.  A short
dry  cough  sometimes  attends, but is by  no  means  a  constant
symptom; a  circumstance yvhich,  yvith the  absence of any  thing
that deserves the name of fever, often  deceives respecting the in-
flammatory nature of the affection.  Blisters generally give relief,
but  yve still find local blood-letting the most certain and expedi-
tious means.                      '     ,
   The increase of the  tenderness of the epigastrium, hard pulse,
and  feverish symptoms distinguish  this affection from another
species of permanent dyspnoea, which yve found  a frequent at-
tendant on  Indigestion, and which I shall soon  have occasion
more particularly  to consider.  It seems to be wholly a nervous
affection, and frequently to be the effect of repeated attacks of
the inflammatory dyspnoea, which is still  apt to be renewed, and
consequently to become complicated yvith it, when the patient is
exposed to taking cold or any other cause of inflammation.
   Palpitation we have  seen is sometimes a  symptom of  Indiges-
tion, and is, for the most part, readily relieved by means already
pointed out; but in some instances the affection of the heart be-
comes so obstinate, that 1 have repeatedly  known  it assume the
form of angina pectoris, and be treated in vain as such, for seve-
ral years; yielding, at length, to means which restored due power
to the digestive organs.  All affections of the heart becoming ob-
stinate in the second stage of Indigestion with an increased hard-
ness of pulse, are relieved by loss of blood; and I have seen de-
cided carditis supervene under such circumstances, requiring the
frequent repetition of copious  general blood-letting.
   It is a common observation that carditis is  apt to supervene after
repeated  attacks of rheumatic pains of the limbs.   I believe from 
OF INDIGESTION.
143
many cases which have fallen under my observation, that it will
generally be found  in such instances, that  the  rheumatic pains
had  been combined yvith, and in a greater or less degree  depen-
dent on, disorder of the  digestive organs.
   The pains of the limbs arising from this cause, yvill often com-
pletely assume  the form of rheumatism, and become very obsti-
nate, if the cause which supports  them be overlooked;  which is
the more likely to happen, because here, as in  other cases, cold
is very often their immediate exciting cause.  I  have seen severe
pains of the limbs which bad long resisted the means usually suc-
cessful in rheumatic cases, wholly removed, by  combining with
these means, the treatment adapted to the second stage  of Indi-
gestion.
   But of all the sympathetic  affections of  distant  parts in Indi-
gestion, none are so frequent as those of the  head.   In the second
stage, they usually assume the same inflammatory character with
the other affections belonging to this stage.  From the function
and situation of the brain, however, the nervous affections of this
organ connected with a diseased state of the stomach,  assume a
more formidable appearance than those of other parts,  and con-
sequently demand more  attention.   After considering the  former,
there%e, I shall lay before the reader the observations which my
experience%f the latter has suggested.
   Head-ach, yve have seen,  is one of the  most  common  symp-
toms, both of the first and second stage of the disease, sometimes,
indeed, Indigestion shows itself only by  this symptom.  In the
milder cases this is by no means uncommon, and it now and then
happens in the most severe.   I yvas one of many physicians yvho
were consulted in a case where violent pains of the head had re-
sisted every means which could be thought of.  The disease prov-
ed fatal,and we expected to find great disorganization in  the head,
to which all  the formidable  symptoms had been referred.  No
trace of disease, however, could be  found in it, and the  organiza-
tion of the liver seemed to be wholly destroyed.
   In the first stage, head-ach is generally  a mere temporary affec-
tion of the nervous system, and, indeed frequently supervenes on 
144
OF THE TREATMENT
 other nervous symptoms, yvhich it relieves.  It is particularly apt
 to be preceded by affections of the  sight, and  may  often  be re-
 moved by emetics and cathartics, yvhich remove the immediate
 cause of irritation.   When severe, indeed, it is  frequently relieved
 by spontaneous vomiting.  The head-ach of the second stage is
 often more obstinate.   Emetics and  cathartics, indeed, also fre-
 quently relieve  it,  because these not only remove  the  cause  of
 irritation, but occasion depletion of the vessels of the head.   The
 most effectual remedy, however, is  blood-letting from  the head.
 The head-ach of the first and second stages of Indigestion, besides
 the accompanying* symptoms may generally be distinguished by the
 latter being greatly  increased by stooping or when the patient holds
 his breath, and forces the blood towards the head, while this  is
 rarely the case with  the head-ach of the  first stage, and never to
 the same degree, a circumstance very characteristic of the nature
 of these affections.
   The head-ach of the second  stage sometimes becomes very for-
 midable when its inflammatory  nature has  not  been understood,
 occasioning the most agonizing pain, and even delirium.   No case
 of it has occurred to m< in which bleeding from the head did not
 give immediate  relief.   Blistering the nape of the neck is often
 of service, but as it often fails,  and the relief is never so sjpeedy,
 and seldom so complete as from local blood-letting," th* latter, un-
 less the strength is much reduced, is preferable; to say nothing of
 its effect on the habit in general, yvhich, when  the head-ach has
 frequently returned, is beneficial, for local of course is also general
 blood-letting as far as it goes; and from the nature of the circu-
 lation in  the  encephalon, the blood being  returned from it by in-
 animate canals which can not partake of the excitement, there is
 no other inflammatory affection to which a generally  increased
 action of the  sanguiferous system so much disposes as to that of
the brain.  Blisters are a powerful means of preventing the return
of the pain.
   It often happens, apparently for the reason just mentioned, that
this inflammatory state of the  head requires a  lower diet, and
more frequent repetition of the blood-letting, than the other affec*
fions we have been  considering. 
                       OF INDIGESTION.                   J45

   Here, as in all cases of inflammation,  however little general
blood letting may seem to be indicated in the first instance, when
local blood letting has been frequently repeated, without subdu-
ing the hardness  of the pulse, or preventing the recurrence of the
symptoms, the greatest advantage often  arises  from  letting blood
generally.  In such cases, indeed, it becomes indispensable  The
strength may be exhausted by the constant repetition of the local
blood-letting, without the tendency to the disease being subdued.
   From the blood being taken more  slowty,  local, even  to the
same extent, never produoes the yvhole effect of general blood-let-
ting.   I have repeatedly seen the pulse  softened, and the recur-
rence of the disease prevented, by one general blood-letting, and
that to  no great extent, when frequently repeated local blood-let-
tings had had little effect beyond the present relief they afforded.
   General and local blood letting relieve  inflammation in  differ-
ent  ways.   The former, by lessening the vis a tergo, tends to
prevent farther congestion in the inflamed part; the  other by les-
sening the  quantity of blood in the part, to relieve more directly
that which  has already taken place.  Now, although the quantity
of blood in the inflamed part is repeatedly lessened, and thus the
inflammation for the time relieved, the general inflammatory ac-
tion continuing, the  vessels again suffer distention, till this action
is subdued by general loss of blood.
   On  the  other  hand, I have seen many cases  yvhere repeated
general blood-letting had failed to subdue inflammation, in which
it has  ceased on  the local abstraction of blood.
   Here the generally  increased force of the circulation had been
sufficiently subdued, the vis a tergo sufficiently lessened; but the
long debilitated vessels could not recover their usual  diameter, till
more directly relieved from the blood  which had distended them
beyond it.   It is evident that it is in  protracted cases that both
these states must occur; but their  existence seems sufficiently to
evince the propriety of combining local and general  blood-letting
in all cases of active inflammation.
   If the foregoing observations be correct, little advantage is to
be expected from general blood-letting, when there  is no general
             19 
146
OP THE TREATMENT
increased  excitement of the circulation.  This  inference seems
fully warranted by experience, for under such circumstances, the
loss of two ounces of blood from the part affected often gives more
relief than that of a pound from a distant part.
   Blood-letting seldom  does much good in  the head-ach of the
first  stage of Indigestion.   If it  is not relieved by  clearing the
stomach and bowels, and  the  use of what are called nervous
medicines, a pretty large blister applied to the nape  of the neck,
or behind  the ears, is the most effectual remedy.
   The effect of nervous medicines  in relieving it,  is often  con-
siderable,  but very uncertain.  In  many  cases they seem to do
little  or no  good.  Valerian and conium appear to  be  the  most
frequently successful.   Opium  is  ill  adapted  to this head-ach,
any relief  obtained from it being generally more than  compensated
by its effects on  the stomach and bowels.   Opium  in the head-
ach of the second stage is out of the question; but  I have found
that  after  the hardness of the pulse is to a certain degree subdued,
such a use of the compound powder of ipecacuanha as supports a
general tendency to moisture on the surface, provided means are
employed  at the same time, to keep the bowels free, is very use-
ful in preventing its return.  The effects of this medicine seem
sometimes improved by combining an antimonial  with it.   In
many cases, particularly in the early period of the second  stage,
and  yvhen its characteristic symptoms are not very prominent, the
head-ach  seems to partake of the  nature of both  stages, and  is
best relieved by a combination of the  above means.
   It sometimes  happens in  the second stage that the  head-ach
assumes  a chronic form, continuing for weeks or even months,
without being very severe.   Both local and general  bloodletting
then very frequently  fail to give  permanent  relief.   The  best
means are those yvhich support an habitually free action of the
bowels and  skin, and most effectually correct the disease of the
digestive  organs; and permanent  drains from the neighbourhood
of the head.
   Alarming as some of the inflammatory affections of the head
are, its nervous affections connected with irritation  of the diges- 
OF INDIGESTION.
147
live organs, contrary to what yve see in other parts, are often stii
more so; and when they occur in the second stage, supersede the
inflammatory tendency.  They appear to be of two kinds; the one
arising  from long-continued irritation of the nerves of so im-
portant a part of the system as the  digestive organs, directly de-
bilitating and sometimes wholly destroying the source of nervous
influence, the other from this irritation affecting the  state of the
vessels of the brain, and consequently the distribution of that por-
tion of the  blood which is sent to the head.
   The former of these is only a greater degree of the affection
which is usual at all periods of Indigestion.   Giddiness and tem-
porary loss of power or vitiated feeling in various parts of the
body, we  have  seen,  are  not  uncommon  symptoms even  from
the commencement.   But it is  in  those cases where powerful
and  repeated causes of irritation on the one hand, and, on the
other, the  debility occasioned by long-continued indigestion,
yvhich every where affects the secreting  power, and consequently
the state of every part, have  gradually enfeebled the functions on
yvhich the  supply of nervous influence depends, that these symp-
toms  become  formidable.   It  is not  very unusual, under such
circumstances, to see the  patient, after more severe attacks than
usual, and sometimes without this warning, suddenly fall down,
and  in  a few hours,  and  in some cases, almost immediately,
expire.
   In such cases the aids of  medicine  are vain.   The powers of
the constitution  are not oppressed by disease, but worn out by its
continuance.  This is what in contradistinction to apoplexy aris-
ing chiefly from the state of the vessels, is properly termed ner-
vous apoplexy,  the most fatal of all  its forms; and it has been
remarked  that in some cases, no morbid appearance presents it-
self on dissection.  The fatal derangement is in the nervous sys-
tem alone, yvhose structure is too minute for our observation.  If
the usual plan of  bleeding in all cases of sudden insensibility be
here resorted to, the disease is only the  more  suddenly fatal.
   The state of  the brain in such cases resembles that which sur-
geons call concussion.  Its mechanism is deranged.  The differ- 
148
OF THE TREATMENT
ence is, that in the one this mechanism is deranged by a sudden
and violent cause, applied while the powers of the system are entire;
and  which consequently, if the  little strength which remains be
carefully husbanded, may often repair the injury: the other is the
effect of a succession of slight causes gradually changing the me-
chanism of the brain, and  at the same time exhausting the powers
of every other part, so that the constition possesses no means  of
repairing the injury.
   The pure nervous apoplexy, however, as here  described,  is ne-
cessarily an extremely rare disease; because it very seldom hap-
pens that the causes continue long enough so to derange the finer
mechanism of the brain as to produce  loss of function,  without
influencing the state of the circulation in it in such a manner as
to produce a fatal  effect in this way.
   There is something at first view very  inexplicable in the phe-
nomena of apoplexy, such as it often appears in those  who have
long laboured under the more severe forms of Indigestion.  Dis-
section has not only shown  that sanguineous  apoplexy,  which is
generally attended with a flushed countenance and strong beating
of the temporal arteries, sometimes occurs, when from the pale-
ness of the countenance and the previous symptoms, as well  as
nervous habit of the patient, we should have expected to find the
blood in the drain  rather below than above the due quantity; but
that such is often the state of the circulation in this organ,  when
the countenance, on the attack of the apoplexy, becomes  much
paler th «n before,  and the beating of the temporal arteries, hardly
perceptible.  Nay, such cases will often be relieved by blood-let-
ting, although it is always prudent to employ  it with the greatest
caution; for, independently of other  considerations, we have no
certain means of distinguishing them from the case  yve have just
been considering, in which blood-letting always  hastens the fatal
termination*   If the case admits of relief from blood letting, the
smallest loss of blood from the head, is immediately attended with
a diminution  of the insensibility.
   When we  consider the free communications  which exist be-
tween the vessels of  the brain and those of the external parts of 
OF INDIGESTION.
149
the head, and that both are supplied from the same trunks, great
turgescence and fulness of the former appear, at first view, alto-
gether incompatible with  a shrunk and comparatively empty state
of the latter;  yet no physician has practised long without h wing
proofs of the existence of the state here described.   I  nave repeat-
edly seen, in an exhausted constitution, the face become suddeuly
pale, and all power lost,  the patient falling down insensible,  and
the countenance continuing to increase in paleness till it assumed
a cadaverous hue; and yet this patient has been  immediately re-
stored to the use of his faculties; the paleness of his  countenance
at the same time abating, by  the loss of blood, and there is every
reason to believe would have  died without it.
  The brain, we have seen, is one of those parts which are most apt
to sympathize yvith the digestive organs; even in slight attacks of
Indigestion, its powers are not unfrequently so enfeebled, that all
its functions are impaired.  This debility extends to, and indeed
seems sometimes chiefly to take place in, its vessels.*  We know,
from the  evidence  of dissection,  that in  such  cases they suffer
themselves, and that often very suddenly, to be morbidly  distended
by the usual vis a tergo, and thus to receive a greater than usual
share of the blood sent to the head.   The external vessels conse-
quently receive a smaller  quantity;  hence the paleness of counte-
nance on the attack of this species of apoplexy, and the increasing
paleness in  proportion as the blood accumulates in  the encephalon,
owing to the increasing debility of the vessels of the yvhole, or
some particular part of it.
  When the minute vessels are distended, inflammation is the
consequence;  when the  larger vessels, congestion, yvhich in the
head occasions apoplexy.   In inflammation of the brain, the parts
affected  are found uniformly  red.   In apoplexy there is little of
this uniform redness, but the larger vessels are  preternaturally
distended .f  I speak not  here of the more common  case of rup-
ture of the vessels.
  * It appears,  from direct experiment, that affections of the nervous sys-
tem art- capable of instantly depriving the vessels of their power.—Inquiry
into the laws of the vital functions, Exp< r.  27, 28  29.
  f See Inquiry into the laws of the vital functions.  Second  edit. p. 301, et
teg. 
150
OF THE TREATMENT
   Thus it is that, in such cases as that before us, the inflamma-
tory tendency in the brain is superseded.   The trunks of the ves-
sels themselves being debilitated and  distended, can no  longer
supply the vis a tergo yvhich supports the preternatural distention
of the capillaries, yvhich therefore retain their  usual diameter,
and consequently, as far as they are supplied with blood, their
functions.
   The loss of blood takes off the state of extreme distention,
which supports and increases the debility of the  vessels, the im-
mediate cause  of which is often of a transitory nature,  and thus
enables  them to recover their usual diameter;  in consequence of
yvhichthe external vessels  again receive  their due proportion  of
blood.  Thus,  at the same  time that the sensibility  is restored,
the countenance regains its  colour.
   It is probable that this slate of disease sometimes originates from
causes acting directly on the brain itself; but in most instances
we have reason to believe, that it originates from irritation of the
stomach  and other digestive organs.   It is most apt to supervene
in exhausted stales of the constitution, or in what are called very
nervous habits, and is evidently of  a different nature from disten-
tion of the vessels of the encephalon arising from general fulness,
aggravated in the head  by any occasional cause, a distended state
of the stomach, for example, pressing on the descending aorta, a
common cause  of apoplexy in the plethoric.
   It is evident, that  in the  apoplexy we  are considering,  loss of
blood from  the head, and that only to such an extent as relieves
the symptoms,  is  alone  proper; although as I have witnessed, the
incautious use of general blood-letting in such a  case is followed
by immediate relief; but it is also followed by a degree of  debili-
ty which  further disposes to returns of the attack,  as yvell as to
other diseases.
   Slight  irritations of the stomach often debilitate the exernal
capillary vessels of the  head,  where  they are most delicate, in
consequence of which they for the time suffer morbid distention,
particularly if the late reception of a meal gives more than usual
vigour to  the vis a tergo.  Hence the flushing of the face  of dys- 
                       OF INDIGESTION.                    151

peptics after dinner, especially when they have taken  any thing
which disagrees yvith the stomach.   There can be little doubt, I
think, that this tendency in irritation of the stomach to  debilitate,
and consequently occasion distention of, the vessels of  the  head,
concurs with the pressure on the descending aorta to produce the
apoplexy which is so apt to arise after a full meal.   In the ad-
vanced stages  of Indigestion this effect is determined  to the in-
ternal, more readily than the external, vessels of the head, by the
debility induced on the  former,  in consequence of  their greater
sympathy with the long-continued irritation of the digestive organs.
   I had occasion to observe, in  speaking of the relation which
subsists between the sympathetic affections which attend Indiges-
tion and  the original disease, that the relation between the latter
and urinary gravel,  depends less on  any sympathy which  exists
between the stomach and kidneys, than on the generation of acid
in the alimentary canal in Indigestion.   We find this observation
further  illustrated by the symptoms we  have just been  consi-
dering.
   We have seen, that the internal organs, sympathetically affect-
ed in this disease, are peculiarly liable to  inflammatory affections
in  the second stage,  producing the  different trains  of symptoms
yvhich have been laid before the reader.   The kidneys, however,
seldom  show  any tendency of this  kind; although  it  is not un-
common in Indigestion, for  the acrid state of the  urine, arising
from  the superabundance of acid and its other  saline contents,
occasioned  by the greater generation of  acid in the  alimentary
canal, and  the inactivity of the skin, so to irritate the urinary pas-
sages as to occasion  frequent micturition, and a  sense of burn-
ing, and other painful sensations in these passages,  even when no
deposition of lithic  acid* takes place in them.

   * As it is an acknowledged fact that the excessive use of distilled spirits,
and other fluids containing alcohol, tends to produce urinary gravel, I was
induced to make some experiments for the purpose of ascertaining how far
the addition of alcohol to the urine, after it is out of the body, tends to pro-
 mote a deposition of lithic acid from this fluid.  I found, however, from re-
 peated trials, that it had a contrary tendency, both retarding the deposition
 of this acid and greatly lessening the quantity deposited, which, probably
 in consequence of its being deposited more slowly, appeared in larger and
 mere distinct chrystals when the alcohol was added to the urine. This com- 
 152                  OF THE TREATMENT

   Such symptoms may generally be relieved by diluting and mu-
 cilaginous fluids, but they can only be permanently removed by
 preventing the morbid generation of acid in the alimentary canal,
 and restoring due action  to the skin.
   It  is nlmost unnecessary to observe, that  in all  the foregoing
 cases we must keep  in vieyv the origin of the disease.   The de-
 bility of the digestive organs, hoyvever relieved by  the secondary
 disease, is easily renewed by any cause deranging their functions,
 and always has the worst effect.   All the regulations respecting
 regimen, then,  and even the occasional use  of stomachic medi-
 cines arc proper, as far as the  symptoms of that disease  admit of
 them.'*
   I shall not prolong this part of the treatise by observations on
 the connexion of Indigestion with hydrencephalus  internus, epi-
 lepsy, affections of the   mind, and  other diseases of the head,
 respecting yvhich many valuable observations have been made by
 several yvriters;  but close my observations on the second stage of
 Indigestion yvith some remarks on  the manner in which  it influ-
 ences the phenomena and treatment of the fevers of this  country.
 By the second stage of Indigestion, yve have  seen, is meant such
 disorder of the stomach as has, by  continued  irritation, occasion-
 ed in the pylorus a state, if not of inflammation, inclining to it,
 accompanied yvith an inflammatory tendency  throughout the  sys-
 tem, yvhich is apt to show itself chiefly in those parts which most
 sympathize yvith the  stomach.
 On  the concurrence of the second stage of  Indigestion
                         and Fever.
   The concurrence of the second stage of Indigestion and fever
 is  perhaps the most common combination of disease  which is pre-
 bines with otht circumstances in proving, that, contrary to the opinion of
 M. Majendie,  it is by the debility its incautious use induces on the diges-
tive organs, and not by  any direct influence on the urine, that alcohol dis-
 poses to the urinary gravel   To what cause can we describe the diminished
tendency of the urine to deposite lithic acid, when the common spirit of wine
of the shops, or rum, the forins in which I used the alcohol, are added to it?
  * I have, during the last five or six years, recommended galvanism in cer-
tain protracted cases of Indigestion. I shall have occasion, in the last chap-
ter of  this treatise, to point out the circumstances which led to its employ-
ment,  the mode of using it, and the effects to be expected  from it. 
OF INDIGESTION.
153
sented to us.  It arises either from fever attacking those labouring
under this stage of Indigestion, or from the latter supervening in
the course of the  fever.
   From the attention of physicians having lately been much di-
rected to the local affections, which,  although  not essential to,
often attended fever, has arisen one of the greatest improvements
in its treatment; for  these local affections  being all of an inflam-
matory nature, support and aggravate the general disease,
   I shall here beg  leave to quote yvhat is said of the nature of
fever in the preface of the fourth edition of my Treatise on simple
and eruptive fevers.  The more I  have considered the subject, and
observed the course of febrile diseases, the more it appears to me,
that the view there  taken of it is consistent with the phenomena
of those diseases, and leads  to  the proper treatment under  their
various forms.  But my reason for troubling the reader yvith it
here is, that it seems to explain  the relation yvhich subsists be-
tween them and the disease which forms the subject of this treatise.
   " It is impossible to  subject the whole system to sufficiently
minute observation, to make the immediate cause of  fever the
subject of experiment; but  yve know that there are  local diseases
capable of exciting fever, and it may be possible to ascertain by
experiment the state of the part on which  these local diseases de-
pend, and thus to arrive at a knowledge of one or  more changes
in the  vital organs capable  of producing fever, and  by comparing
the phenomena of these diseases with those of simple fever, to as-
certain how far the same changes which we observe in the part
obtain throughout the system, as soon as the irritation occasioned
by the state of that part, or any  other cause, produces fever.
   " It appears, from some  experiments made with  the assistance
of the microscope, related  in the  introduction  to my treatise on
symptomatic fevers, to which I have already had occasion to allude,
that inflammation arises from debility of the capillary vessels, and
their  consequent  distention  by  the vis  a tergo,  and  that yve can
at will produce inflammation by debilitating the capillaries, and
relieve it by  increasing their action.  Wherever, therefore, the
svmptomp of inflammation, increased  temperature, redness an4 
154
OF THE TREATMENT
 swelling appeared, the capillary vessels are debilitated, and pre-
 ternaturally distended.
   " Now, in the hot stage of fever, all the surfaces  are affected
 with increased  temperature,  redness,  and swelling; and as the
 debility and  consequent distention of the capillaries of a part, as
 appears from direct observation, produce increased action of the
 larger arteries of the part, this  general debility and distention of
 the capillaries produce  increased action of the whole  arterial sys-
 tem. In inflammation, the debilitated vessels being comparatively
 few, the vis a tergo quickly, and to a great degree, distends them.
 In fever, the debilitated vessels  being very numerous, it produces
 its effect more slowly, and to a less degree, in proportion as the
 resistance is greater.
   " If in any part the vessels are weaker than in others, they suf-
 fer a greater degree of morbid  distention, particularly after the
 increased action of the heart and large vessels has been excited.
 Hence arise  the congestions  and  inflammations so frequent in
 fever.   These act as,  yve have  seen, inflammation does in other
 cases, in supporting the morbid excitement of the heart and larger
 arteries.  Thus, it is that the treatment  of such affections is of
 the first importance in determining the course  of the fever."
  It is'unnecessary  here to pursue  this subject farther.   The
 cause of the  cold preceding the  hot, stage of fever: and the modm
 operandi of the  causes of this disease are considered in the above
 Treatise.
  Now, in those yvho labour under the second stage  of Indiges-
tion, we have seen that some of  those parts which greatly sympa-
thize with the stomach, generally suffer most.    These, therefore,
are the yveak parts yvhich most feel the effect of the morbidly in-
creased force of circulation in fever.   Their vessels are most apt
to suffer distention, producing congestion or inflammation, accord-
ing as the distention is in the larger or smaller vessels.
  The  liver, it appears, from  what  has been said, is the part
which most frequently suffers by sympathy in the second stage of
Indigestion.   It therefore often happens that, yvhen those labour-
 ng  under this stage are  attacked with fever, a train of symptoms 
OF INDIGESTION.
155
similar to that detailed in page 138, supervenes, the proper treat-
ment of which is essential to that of the fever.
   The principle of the treatment of these symptoms, when they
occur in  fever, is precisely the  same  as  where  they supervene
without it, but the actual practice is not altogether so.   The fe-
ver,  in its  early stages, by adding  to  the severity of the inflam-
matory symptoms, renders more active means necessary. Hence,
if the general symptoms  do not indicate general  loss of blood, a
greater  local abstraction of it  is usually proper, than yvhen  no
fever but that occasioned  by the  local affection attends.
   The same observation  applies to the use of cathartics.  At the
commencement  of fever,  the free action of the bowels is particu-
larly beneficial,  and by such a state of the  liver is rendered doubly
so.  It is thus that brisk  doses of calomel at this  period are ge-
nerally more beneficial than  other mercurials.
   In the latter stages of fever, on the contrary, if this affection of
the liver still continue, which is not  uncommon, either from its
having been neglected in  the early stage,  or from its proving more
obstinate than usual, I have  always found  the minute  doses of
blue pill above specified,  given every six or eight  hours, most be-
neficial.   Combined, indeed, with moderate evacuations ef blood
from the part, or (when the tenderness is  inconsiderable, and the
affection of the liver rather betrays  itself by a vitiated secretion
of bile, than by  inflammatory symptoms,) blisters applied to the
region of this organ, they  rarely  fail to restore due action to it, un-
less  the nature of the fever, or constitution of the  patient, be very
unfavourable; and  thus often remove  the fever, yvhich, when its
symptoms have  become mild is  frequently at this period prolong-
ed by the local affection  alone.
   When the sympathetic disease, previous to the attack of fever,
has  chiefly  affected other parts, the  bowels, the lungs, the  brain,
&c, we still find the part most affected by that disease, suffering
most in the fever; and the same plan of treatment, mutatis mutan-
dis,  is applicable, except that the same benefit is not to be expect-
ed from the specific operation of mercury.
   When  Indigestion has not  arrived at its second stage at the 
156
OF THE  TREATMENT
time the fever makes its attack, the accession of this disease, by
increasing the inflammatory tendency,  often induces  that stage.
The vessels, although they had not been sufficiently weakened to
yield to the  usual force of the circulation, yield to its increased
force; and it particularly deserves attention, that an attack of fe-
ver, as I have repeatedly witnessed, is  often the means of perma-
nently converting the first into the second stage of Indigestion; so
that the fever leaves behind it tenderness of the epigastrium, and
more or less hardness of the pulse, where they had  not previously
existed.
  When this is the case to any considerable  degree, the patient
generally becomes liable to a renewal of fever  from slight causes;
and if the morbid state of the digestive  organs is not removed, he
is often  exhausted by repeated attacks of fever, which, as the de-
bility increases, assume a more chronic form, and often at length
terminate in typhus, or the more severe species  of what has been
called nervous fever.
  Local congestion  or inflammation, as might be expected, al-
though  none of the symptoms of Indigestion have preceded, some-
times takes place in fever, that is, when the force of the circula-
tion is morbidly increased.  This is most apt to  happen in the
brain or liver.
  The principal treatment, as far as I have been able to observe,
is still the same.   In the latter case, however, the means of relief
are generally sooner successful, and  the patient bears  them bet-
ter.  The treatment of fever, in those who have long laboured
under the symptoms of Indigestion, requires great circumspection.
It is surprising after how  moderate a degree of fever symptoms of
danger  often  arise in them, and indeed death itself actually en-
sues.   Both the vascular and nervous systems  of some  organ ne-
cessary  to life have been previously enfeebled,  and  it wholly loses
its power before the fever  produces any very great general effect.
The patient dies as much  of the disease under which  he has so
long laboured, as of the  fever yvhich  has supervened  on it, and
that at  a time perhaps when his physician's mind is fatally ab-
stracted from the former   These observations have been so often 
OF INDIGESTION.
157
impressed on me in the course of practice, that I can not help, in
a particular manner calling the attention of others to them.   The
.more yve see of disease, yve shall, 1 think, be the more ready to
admit that the digestive organs  form so important a part of the
animal aystem, and are so intimately connected with every other
part of  it, that  there  is no case in yvhich their state can with
safety be disregarded.
                      Recapitulation.
   We have now traced Indigestion from its commencement to
the moment at yvhich it is about to terminate in organic disease;
for a repetition of the  local affections  we have been considering
almost always terminates in change of structure which when thus
produced, seems in no degree to differ from organic  disease of
the same parts,  arising from other causes.
   It may be useful here to present to  the reader a short recapi-
tulation of the different parts of the subject which have engaged
our attention.
   In the commencement of the disease, we have seen, that the
muscular and nervous powers of the stomach are enfeebled, and
that the  debility gradually extends to the other parts of the ali-
mentary canal, to the liver, and at length, more or less, to every
part of the system.
   The irritation caused by the contents of  the stomach, yvhich,
from the debilitated state of the nervous  and muscular  powers of
this organ, have acquired morbid properties, at length produces a
degree of inflammatory action, that is, debility of the capillary
vessels, and  its  immediate  consequences, in the part of the sto-
mach most exposed to  it, the symptoms of which I have regarded
as  characterizing the second stage of the disease; and, as in the
first stage, the deranged function of the stomach produces a ten-
dency to deranged function  in every other part,  in  the second
stage, every  other part,In like  manner, partakes of this inflam-
matory tendency.  The pulse becomes hard, and inflammation is
every yvhere readily excited, particularly in  the parts yvhich most
sympathize yvith the stomach, or are from other causes most liable
to disease. 
158
OF THE TREATMENT
   In the first stage,  the  debility of the nervous  and muscular
powers of the stomach is to be counteracted by attention  to diet
and  exercise, and a proper use of aperiment, stimulant, and tonic.
medicines; and in proportion  as it  is  relieved, the sympathetic
affections, yvhich depend  on it, disappear.
   In the second stage, it is necessary to obviate the inflammatory
tendency, and only to employ the means suited to the first stage,
as far as they  are compatible yvith  this object; yvhile our atten-
tion  must now at the same time be directed to the part sympa-
thetically affected, in which, from the  longer continuance of de-
ranged  function,  and  the inflammatory  tendency  prevailing
throughout the system, the sympathetic begins to be changed into
real  disease.
   The affection of these parts, yve have seen, like that of the sto- •
mach,  from which it arises, now consists in a debility of the vas-
cular, as well  as  nervous  power.  On these powers depend the
secreting and absorbing processes, which are as necessary to the
continuance of the healthy structure as the healthy function of
the part; except that, from the nature of the function it is imme-
diately affected, from that of the structure, its changes take place
more slowly.
   When Indigestion has produced change of structure, it consti-
tutes, yve have seen, what I have called the third stage  of this
disease, which we are now to consider  more particularly. 
OF INDIGESTION.
159
                     CHAPTER  IV,

      OF THE THIRD STAGE OF  INDIGESTION.

   The stomach is less liable to  change  of structure than  most
other organs.   This change therefore, although sometimes taking
place in it, is much more frequent, as I have already had  occa-
sion to observe, in the parts  with which it sympathizes.
   The  diseases;  which thus arise  from  neglected Indigestion.
are so various, and so different from the disease from which thev
spring, as yvell as from each other,  that  to give any thing  like a
satisfactory account of them would require a treatise of greater
extent than the whole of that noyv presented to the public,  and a
superficial account would be worse than none.  I shall therefore
consider only those cases, to  which, from their great frequency in
this country, my attention has been particularly  directed, I mean
the pulmonary  affections produced by a disordered  state of the
digestive organs; and the principles, yvhich I shall have occasion
to illustrate in treating of those diseases, will be found applicable
to others arising from the same source.
   Organic disease,  in  the  common acceptation of the term, is
disease  attended yvith such change of structure, as is apparent on
dissection after death.   This involves  a  change of structure in
all the parts of the diseased organ.   We can not doubt, however,
that there is a change of structure in  the finer parts of  our me-
chanism, yvhich leaves no traces to be detected after death. Thus
we have seen, that in those yvho have long been exposed to causes
of great nervous irritation, the function of the brain and spinal
marrow sometimes fails.  The usual stimulants  cease to  produce
their accustomed effects.  This at first is only occasional,  and
the organs soon resume  their usual functions; pointing  out that,
hoyvever their action has been oppressed, their mechanism is still 
160
OF THE THIRD STAGE
entire; and has, if disordered at all, only been temporarily so: but,
by degrees, the diseased state becomes more permanent; and, at
length, sometimes ends in that species of palsy, or  apoplexy, in
which, although the permanent inability proves, dissection can not
always detect, change of structure.
   I have often had occasion to call the reader's attention to a fact,
yvhich is at once  evident to all in the least degree acquainted yvith
the structure  and functions of the animal body, that it must, ex-
cept  under  particular  circumstances, be through  the  nervous
system, that any organ can be influenced by a distant part. We
have also seen an intimate connexion between the function of the
nerves and that of the vessels  in those processes, on which the
constant changes  going on in the body depend.  The nerves of a
secreting organ  are  never  disordered without influencing the
secreted  fluids; and,  consequently, without tending to influence
the vessels which  supply the fluids, from yvhich those are formed.
Thus it is, in the common  course of things, that sooner  or later,
in cases of long-continued nervous irritation, the vessels  either of
the part to which the irritating cause  is applied, or some part
which sympathizes with it, deviate from the healthy state.  This
yve have seen, constitutes  the  difference between  the  first and
second stages of Indigestion.  In the former, the nerves and se-
creted fluids  alone are affected; in the latter, the vessels partake
of the disease.
  The facts just stated, however, prove, that in some cases, yvhere
either the  nerves are  more  liable  to disease than  usual, or the
vessels less so, a  permanent change in the former takes place be-
fore the vessels become affected, this change either  occurring in
the nerves of particular organs,  or in the  general source of ner-
vous influence; producing in the one instance permanent loss of
power in a part, in the other, in  the whole system.
  This permanent change, if  the animal be capable of surviving
it, operates as all other established disease does in tending to pre-
vent disease of other parts; and thus the vascular system of the
organs affected, notwithstanding the vitiated state of their  secre-
tions, often for a long time, retains its healthy functions.  In such 
OF INDIGESTION.                   161
oases, however, there is necessarily a tendency to affection of the
vessels which is indicated by  a degrfce of sharpness of pulse,
which  may almost always be observed in them.
  Tius we fi id on inquiry, that the pirmnnent diseases of distant
parts produced by  symp ithy, with the state  of  the  stomach  in
Indigestion, are  of these  two  kinds, namely, th.it in which the
nerves alone, and that in yvhich both the nerves and vessels are af-
fected.   Of these the one in which the vessels  as well as  the
nerves are involved, is by far the most frequent.
  Of those two kinds, then, are the sympathetic affections of the
lungs which we  are about to consider.   In throne, the disease
has extended to all  the vital powers'of this  organ; in the other, to
its nerves alone.
  Some years ago I presented to the Medico-Chirurgical Society,
an account of the former of these under  the  name of  Dyspeptic
Phthisis, which, as I have already had occasion to  observe, the
society did me the honour to  publish in the seventh volume of
their transactions.   This account I am  here  about to  present to
the reader, with the additional observations yvhich I have since
made on that disease.
  The disease produced by a permanent derangement of the ner-
vous power alone  of the lungs, for  want of  a more appropriate
name, I  called habitual asthma.   My attention  was first attract-
ed to  it by finding, that the 'difficulty of breathing produced by
Indigestion, when it had lasted for a considerable time, often did
not yield yvith the other symptoms of this disease; and then gen-
erally resisted the effects of medicine.
   This affection, in many instances, gradually increases, notwith-
standing every effort to relieve it, till it unfits the sufferer for all
the active duties of life.   It yvas yvith peculiar satisfaction, there-
fore, that I found galvanism an almost uniform means of relief in
it, and not unfrequently of cure.
   This  induced  me, in 1816,  to present some observations on
this effect of galvanism, and my reasons for believing that habit-
ual asthma depends wholly on an  affection of  the nerves  of the
lungs, to the Royal Society; which did me the honour to publish 
162
OF THE THIRD STAGE
them in the philosophical transactions of the following year.   1
shall, after considering dyspeptic phthisis, lay before the reader
the observations there published, with such additions as have since
occurred to me.

                        SECTION I.

                  Of Dyspeptic Phthisis.

   It is very common for the different species of pulmonary con-
sumption to  be regarded  as the same disease, and treated in the
same way; yet it will  be  evident, I think, from the following ob-
servations, that the nature of that species which I am about to con-
sider is peculiar; and  that while  under the common treatment, it
is  nearly as fatal  as the  other forms of the disease,  under that
which is suited to it, its progress may generally in  the earlier,
and sometimes in the  more advanced stages, be arrested.
   I shall in the first place, point out the symptoms by which this
species of pulmonary consumption is  distinguished; then make
some observations  on  its  causes,  and  the appearances discovered
by dissection after death; and, in the last place, I shall detail the
plan of treatment yvhich I have found most successful in it.

                     Of the Symptoms.

   1  had occasion about sixteen years ago, to mention this species
of consumption and the plan of treatment which appeared to  me
best adapted to it, in my Treatise on Febrile Diseases.   Since that
time it has particularly attracted my attention: It can not, there-
fore, I think, fail  to be of some use to  those whose attention has
also been directed to it, to see the observations I have been led to
make in so many years experience of it; for  there are few diseases
so frequent  in the  part of England in yvhich I have resided, and
indeed, I believe in most parts of Great Britain.  To those whose
attention has not yet been particularly  directed to  it, any  obser-
vations on it must be useful. 
OF INDIGESTION.
163
   It is not my intention to give a detailed account of the symptoms
of this species of phthisis.  I shall only mention  the  symptoms
and modifications of symptons by which it is distinguished.
   It is generally preceded, as appears from what  has been said,
by symptoms of Indigestion, and particularly by those  which in-
dicate some disorder in the secretion of bile.   Contrary to what
is usual in other species of the disease, the spirits from the begin-
ning are generally more oc less depressed,  and  the countenance
is sallow.
  The cough at first is usually dry, or the patient brings up a little
mucusftifter a severe,  rind often long-continued, fit of coughing,
which seems to be rather  the effect of the irritation  of coughing
than anything which had previously  existed in the lungs; for the
cough in this species of consumption,  particularly in its  early
stages, frequently comes  in violent fits, in  the intervals of which
the patient is  often but little troubled with it.  These fits are par-
ticularly apt to occur after he  has eaten, especially if he has eaten
a great  deal, or any thing by which the digestion is disturbed, and
on lying down.
   In many  instances they are most apt to come on when he lies
on the left side, sometimes when  he lies on the right.   I think in
almost all cases, they are  least apt to occur in the recumbent po-
sition, when  the patient  lies  on the back rather inclining to the
right with the shoulders a little raised; and it generally  happens
in the more advanced stages, and  often before the strength is much
exhausted, that  this is the only position in yvhich he can  lie with-
out inconvenience.   It is  common in this form of phthisis, as in-
deed in  all others, for the cough to be troublesome for some time
after awaking in the morning.  As the disease proceeds, the cough
becomes more frequent, returns  less  decidedly  by fits, and is at-
tended  with a more copious expectoration.   In all these respects
there is of course considerable variety in different cases,  but  in
almost  all the general  character here pointed out may be observed.
   The matter expectorated is at first limpid and glairy;  by de-
grees we see intermixed  with it  small portions of an opake pus-
like  substance, the proportion of which in  the  progress of the 
164
OF THE THIRD STAGE
 disease increases; and in some cases the quantity expectorated is
 astonishing,  often much greater in  proportion to the  severity of
 the other symptoms, than in other species of phthisis.  I have seen
 half a pint or more of pus-like matter mixed  with tough phlegm
 expectorated daily, when the other symptoms yvere comparative-
 ly mild.
   In other species of phthisis, very  copious and long  continued
 expectoration of pus-like matter is less common.  In them such
 copious expectoration generally  arises from  the bursting  of an
 abscess.  The  matter it contained,  if not sufficient to occasion
 suffocation, being brought up, the quantity expectorated y>  again
 reduced till another abscess bursts.
   Bloody expectoration  is by no means uncommon in this species
 of phthisis.   Blood often appears early in  the disease mixed yvith
 the colourless phlegm.   After the  pus-like expectoration  com-
 mences, if blood has not previously appeared, it is much less apt
 to apepar than in other forms of the disease.  If it appear even
 in small quantity after this stage commences, the case generally
 proves fatal.
   While the blood is mixed only yvith a transparent  fluid,  there
 may be good  hopes of recovery, certainly better than  under the
 same circumstances in any other species of phthisis.    A similar
observation applies to the pus-like expectoration.  If there be no
admixture of blood, there may be good hopes  of  recovery, if the
disease has not lasted long; and certainly much better than under
the same 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.
Youig,  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. 
                       OP 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, yvhich 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 yvhen so agitated in water as to separate it from the tough
mucus, yvith yvhich 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 appearances in the expecto-
rated matter, it is of comparatively little consequence  whether
what yve see be pus or not.
   The breathing in the earlier stages of this species of phthisis,
is sometimes more oppressed  by the recumbent posture, than in
other forms of the disease; and is more frequently  attended with
a sense of tightness across the pit of the stomach.   The  same
observations which apply to the cough in the recumbent position,
and after eating apply to  the dyspnoea;  but it often happens in
the early stages, that there is  little  or no dyspnoea: and there is
very rarely, except in the advanced stages, that marked dyspnoea
on exercise yvhich 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 chest; more rarely the  pain is in the
same part  in the right side.    There is hardly ever a fixed pain
high in the chest, except about the shoulders.  There,  it is not
uncommon,  and there  is frequently an 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-
ject 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 yvith but slight fever, and that not 
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 yvith 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 the 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.   T^he variety in  this respect, however, is considerable.
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 yvell 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  yvith tenderness on
pressure.  Much less frequently there  is  some preternatural ful-
ness, and a degree of tenderness in the left  hypochondric region
also.   In health, the feeling given to the hand in examining the
tyvo 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 thit when the epigastric re-
gion is very full and tender, and the flatulence and acidity more
troublesome than usual; the cough and dyspnoea are so also; and
on  the  former symptoms  subsiding, the latter likewise abnte.
Even the rising of wind from  the stomach, often for the time,
removes the tendency to cough.
  The  foregoing are the symptoms of the more  early stages of
this species of phthisis.  In its advanced  stages, it approaches
more and more to other forms of the disease.   All the symptoms,
yvhich 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; yvhich, 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, yvith the exception
of those whose operation is confined to the lungs  themselves: the
inhaling of dust, other  diseases of the lungs, the bones pressing 
168
OF THE THIRD STAGE
unequally on them, &c.   To compensate for the yvant of the cau-
ses immediately affecting the lungs, yve  have a numerous set of
causes affecting the digestive organs.   Drunkards, in particular,
at that time of life which disposes to  phthisis, frequently fall  a
sacrifice to this form of the disease.   In short, we perceive 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 the 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 the approach
of the  symptoms enumerated in the first chapter.

           Of the appearances on  dissection.

   The appearances of the lungs are generally much the same as
in other cases of pht'iisis; 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 yvhere the  disease of the liver has
btcn 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 yvhole lungs are  ren-
dered incapable of their functions. Here, as in many other cases,
we often have occasion to remark to yvhat extent change 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 cceliac 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 yvhich both the lungs and
digestive organs are affected, the affection of the digestive organs
precedes  that of the lungs.   In some instances yve 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,  yvhich  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 
170
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 digestive  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
yvhich 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 we are considering, the pulmo-
nary  disease arises from that of  the digestive organs.
   It is not to be overlooked, however, tbat 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 uot 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.
171
the 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
Indigestion, to take a cursory vieyv 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, yvhich 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 public in the way
in which  Mr. Abernethy has done, and those  physicians whose
attention has been directed to the same  object,  must be happy to
see in Mr. Abernethy's work, a confirmation of their own 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 yvhere 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 yvhich I have  employed in that disease for more
than sixteen years,  as appears from what is said  in the last volume 
172
OF THE THIRD STAGE
 of the edition of my Treatise, on Febrile Diseases, published in
 1804; and  the  following  cases, which  occurred to me before I
 read his work, or yvas acquainted with his opinions, and yvhich 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 tyvo observers wholly unconnected, setting
 out from the most opposite quarters,  and meeting in  the  same
 point.  My plans of practice are not precisely the same as Mr.
 Abernethy's, and in particular the mode of giving mercury in in-
 ternal disease, which I found most successful, is  different  from
 his, but the general principle is the snme.
  I have already had occasion to allude to the case of a gentle-
 man who laboured under severe pains of the legs, yvhich had  been
 treated unsuccessfully for two years.  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, yvhich
 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
 opening 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 of the body, and it yvas
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 ef 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  yvhen  they yvere  tender on  pressure.  In about  three
months her complaints disappeared under this plan of treatment,
nothing but a depression of spirits remaining, which yvas 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 yvith 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 yveakens 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 deranged 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 yvhich  the case yielded in a few
weeks  to minute dose.s 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 yvell 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  I to
  •  A  Second  Essay on  Hydrocephalus Acutus^r Dropsy in the brain, by.
J. Cheyne, M. D., Dublin, 1815.             5
  | A statement of the Early Symptoms which lead to the Disease termed Water hi
the Brain, &c, in a Letter to Martin Wall, Esq. M. D., &c, by G. D. Yeates,
fee.; Lendon, 1815. 
174
OF THE THIRD STA8E
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, their tendency to produce it will  be greater or
less according to the state of these organs.
   It is yvell 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 yvill be converted into the real  dis-
ease, let the cause which produced it be  what it may.   The ob-
servations made in the  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 appears, 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
yvhich tend to improve  their functions, yvill 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 yve relieve them, that we find the affections
of the lungs relieved.
   This species of phth^is may be divided into  three stages, in
yvhich the prognosis and mode of treatment are different.
   Tn the first the affection of the lungs is merely sympathetic, so 
OF INDIGESTION.
175
that when the cause yvhich  produces it is  removed, it ceases of
course.   This stage is distinguished by the short time which the
disease has lasted, by the general  mildness 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 lain some time in the  lungs;
the expectoration of which relieves the cough, which, in this case,
is seldom very troublesome.   This last appearance of the 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 tyvo ways in  yvhich  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 yvhich the expectorated matter begins to be 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 Everard  Home, in a
treatise on the properties of pus, has shown how readily irritation
of 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 yve 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. Hasting's 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, yve 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
yvhich 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 vaiious 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
shoyvs  itself before Indigestion produces phthisis,  and this state of
the lungs occur almost at the same time.
  Such appear to me to be the chief circumstances which some-
times render the disease fatal, even yvhen 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 yvill 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
case 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 he 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-tilings 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 thejmternal 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 be  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  yvith 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 occr^sional doses ofblue pill or calomel, according as the bowels
are more orless  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,
yvhen the bowels were languid; in other cases three or four  grains
of the blue pill,  every second or third night, desiring the patient
not to go out the next day, till it shall have passed off, and  if it
 does not pass off in a 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; yvhere we
have  seen it is often  more our object  to obtain a very free eva-
cuation,and only the most transitory eff ct of the mercurial.
   The less stimulating stomachic medicines have generally been
used, particularly yvhen the appetite was much impaired.
   AH of this cl iss  of medicines which  possess any heating quality,
have appeared objectionable. Even gentian, so useful  in the first
stage of Indigestion,  seems oftgi 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 1 have given, as appears from what his 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, or we find that  notwithstanding the employment of
the above menus, the sputa begin  tr^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 yvill 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 yvith 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 epig istric  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 yvith 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
ehts,  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 yvhich 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 in
large  doses.                 ^  ' *  *  '  -2'
   When the patient can take a decoction of jt 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, advantage often arises from infusing
a feyv cloves with the camomile  flowers.   When the dandelion
could be given in  either of these  ways, 1 have often  given onhy
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 miliums, 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 beat 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 abo,ut a fortnight,
I have gradually increased the quantity of theblue pill till one of
these  effects took place.   If cither take place without relieving
thejpulmonary 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,  yve have  reason to believe that thejdis-
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 in these cases the  proper 
                       OF INDIGESTION.                   181

 means had not been tried;if these jjjave failed^the hope is no bet-
 ter than in other species .of phthisis.  .$«•.* .\V?
   Where  the failure*of relief proceeds tfom the obstinacy.of the
 hepatic affection, some hope, arises irom« feller mercurial course,
 but  it is often falfacious^for, although such a'plan as I  have re-
 commended may be pursued, without any diminution of strength,
 and is generally, by relieving the  disease, attended yvith an im-
 provement of it, a freer use  of this medicine, if Us advantage be
 not  immediately apparent, yvill  generally be found hurtful.
   It,sometimes happens that the tenderness of the epigastrium is
 wholly, but the.aplmouary  symptoms only partially, relieved by
 the  ahove  plan.   -In this case the hepatic affection is apt to recur,
 ahvays bringing with, it a.n'increase of the pulmonary symptoms,
 ^ill the structure of the lungs is  at length destroyed.   He^re^ifihe
 recurrence of. the. hepatic affection be neglected, the fetal termi-
 nation, is rapid.r, If ifebe c^refully-.WHtched and relieved as soon
 as it appears,^Jie case is  protracted, andkt,he deqliae. of the patient
 gradual.  , I have known ca§es, where the progress of the disease
 had by such mean&>been so retarded, that there was little increase
 in it in  jthe space of  several months, prove rapidly fatal  on the
 adoption of-angthejr plan.                „. .
   But the/most, fatal case  is when the hepatic affection  finally
 disappears, the  seat of the djseate being wholly transferred to the
 lungs, as  happens frequently in the.lagt stage of this species of
 phthisis.   In tbis^, case there is  no hope; wlyle«the hepatic affec-
tion continues to recur, there is always.some hope, however small,
 that on its final removal, the lu.igs 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
OP 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
i 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, yvhile 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 musUcombine 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 t«
  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 yvith little or no affection of the
sanguiferous system,  ensues.
   This is particularly apt to happen in the lungs when Indigestion
has been long attended yvith 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 cxpermjj^kfc. and observations,*

 as well as those of others,  particularly  0/ M  'le  Gdlois,  that

 what,is called the  nervous sy.&eja, comprehends two d stinct sys-

 tems, the .sensorial, and the  nervous system properly so cttUed*

 Now, vve^aa^ no  rertsou «t»  believe ".'(^at  galvanism  cfcn perform

 any of-^le fauctioiis/of the sensorial;sysfcfcni; yet,  in .the greater •

 number of iast^ces in jwhiclv  it has  been ^aed in medicine, it

 has  been expected  to .restore, t^ ■ senjpri^poyver.   Jktjpa&i)fen

 expected-ito restore hearing,  and,sight,  and.'^Auitary power.   It t'*<-

 may uow and.tbe,n "happen in favourable cases, from  the con-

;neiion which subsists be^vee© the sensorial and  nervous systems;

 that by rousing the energy of the latter, we mayexc}te the former,

 or the sensorial power  may be entire,  and tbe^fault  in,-the nerves

 yvhjch convey its influence.   From our experience ofsucb; cr.ses,

 however, there seems. fj^tle  reason  to hope that galvanism yvill

 often  be successful in  them.   We have reason to  believe, from


 breathing freely^and with no more ap^pareffi;  distress than -.then twttf-hj^
 usually producecTby the galvanic influence, which in "his case w.is uninter-
 ruptedly kept up.  Tin- other ribbits l»boured;stroiiglt  in. I heir breathing.
 They were all three kill<iJ at the snme  perjod',  and tlieir.stom.achs succes-
 sively.opened.  In the two  non-galvanised raobits, digestion had« scarcely'
 made any progress t but in that galvanised, it was perfect,, in  tbe maimer, "to
 all appearance, avowed,')' 13.r. W ilson Philip'and his supporters.  However
 we nwy differ in opifjfowy as to the/i*e;d state of" the food- in »the' non-gal-
 vanised rabbits, as to  Dr. YVilsQp Philip5-,  theory, or,"*as tq the cause of the
 formation* of chymejind chyle being.found under the influence of a galvanic
 battery, Dr.  Wilson PhUipVeun not be deni >l  the  merit of  correctness in
 his1 assertions (niftieirlo almost universally dktrusted,)4relative 10 the simnie
 fact of-a certain power.of gdvauism producing  digestion, after dividing'lhe
 eighth pair .of nerves, undejr circumstances in. which it  is impeded without,
 the galvanism.'   .,*'                          ,              *
   "It is proper torslate that the  President  and sevpral members of the
 Royal Society, and of the colleges of physicians.uud sturgeons, among whom
 were Mr. Brodie and myself, inspected thVprogt'tjss of-these experiments,
 which  were carried on under .the constant superintendance of Dr. Wilson
 Plrilip."   .                     "  -^                        "■
   Mr. Bronghtoni 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, tliatthis may happen altiiough the divided ends be sepa-  /
 rated by the distance of a quarter o}' an'inch, provided the nerves be not
 otherwise displaced.—'See a paper relating  to this subject  in the twenty-
 third number of the Journal of the Royal Institution.
   * See Experimental Inquiry, chap.  X., and the experiments there 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
origin >l 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,f 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 yvhich of-
ten attends  Indigestion,  and yvhich,  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.
                     t Exp. h\q. Exp. 44, 45.
             24 
186
OP THE THIRD STAGE
   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 yvith 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
Dothingin 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 yvires  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,  yvere 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
yvay 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 yvas  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
tobelieve, 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.
  1 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. Wollaston,  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
6quare,  would answer medical purposes nearly as well as larger ones. 
138
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, tiiat 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  suhject  the cause of this disease is spasm, from
which, indeed, it takes its name; and we have no reason to be-
lieve, fro.n what we know of the nature of galvanism, that it yvill
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 spasmodic his 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 meaus.
   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- 
©F INDISESTION.
189
ploytnents.   I afterwards saw  several of them, who although
they had not used galvanism for many months, said they h*d 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 at 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 galvanism; 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 affectiop 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 seCn from it the same effect on the biliary
 system yvhich arises from calomel, a  copious bilious discharge
 from the boyvels coming on within a feyv 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 forins 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, leaving the
other symptoms little changed.  I need  hardly  add,  after what
has been said, that in ordinary cases of phthisis nothing  could be
more 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.   A\ 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  thp 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 continuance of the  relief obtained 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.  Tiiis  observation, however,
does not universally apply.  Wheu the patient is galvanised in
the morning, he gener illy 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 some cases than in others.
  The permanency of its good effect in the disease before us, has
appeared very remarkable  in several cases where 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.
  Tiie  galvanisn  has sel bin 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 yvho  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 yvas 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  yvhich 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 gdvanism, has any share 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 what 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 nape of the neck, the wire at the  pit of  the
stomach  having been all the time applied as usual by the patients
themselves.   Before the application  of the galvanism  had been
continued as  long as the previous process, they all said they were
relieved.  I relate the particulars of  the  tyvo 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,  yvho had for many years  laboured under habitual
asthma.   Her breathing yvas 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 yvhen she was  galvanised  once a day  for about ten
minutes, she suffered little dyspnoea at any time.  After she had
been galvanised  for eight or ten days,  I deceived her in  the man-
ner just  mentioned.   The deception  was complete.   She told 
OF INDIGESTION.
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 yvith  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 yvhen the
operation  yvas  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.  1  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 yvhole 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 yvas 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 half way, as difficult as before
the galvanism was  applied.   She yvas then galvanised in  the  usual
way  for five minutes: she now said her  breathing yvas quite easy,
and she yvalked up the whole of the stairs without bringing on any
degree of panting,  or feeling any  dyspnoea.   The above experi-
ment yvas made in  the presence of four medical gentlemen.   This
patient, after remaining free from her disease  for about  half a
\ear, 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, yvhich had at the
same time produced other complaints.   This is one  of the cases
above alluded to in speaking of the permanency of the  good effects
               25 
194 £*             OF THE THIRD STACK
of galvanism.   On the return of this patient to the Infirmary, tyvo
or three applications of galvanism, combined yvith  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  yvhere it yvas
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, yvhich always ensued
when these organs had been deranged, which yvas  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 its 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  yvas easily relieved by small  doses
of carbonate of iron and bitters, without any return of the dyspnoea.

  * The. effect of indolence, in pai nful 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  yvas relieved by galvanism, and some in
yvhich it wholly removed this disease.
THE END. 
["j-ys  s.«?
 
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