A TREATISE DIET: WITH A VIEW TO ESTABLISH, ON PRACTICAL GROUNDS, & Sgsttm of Mult* FOR THE PREVENTION AND CURE OF THE DISEASES INCIDENT TO A DISORDERED STATE OP THE • '0;: ' J. A. PARIS, M.D. F.R^//||^ FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, ETC. ETC. " Some Physiologists will have it that the Stomach is a Mill ;—others, that it is a fermenting Vat ;—others, again, that it is a Stew-pan:—but in my view of the matter, it is neither a Mill, a fermenting Vat, nor a Stew-pan—but a Stomach, Gentlemen, a Stomach.'''' Manuscript Notefrom Hunter's Lectures. PHILADELPHIA: ROBERT H. SMALL, 165 CHESNUT STREET. Clark & Jtaser, Printer*, 33 Carter's Alley. 1826. W0P . ? CONTENTS. PART I. PART II. Different Varieties of Bread .115 Birds ¦ % . .*'¦ . '^.^^M- Farinaceous Aliments .115 Fish .* : V v 100 Milk . .105 An Estimate of the Nutritive and Digestible Qualities of several species of Aliment, as derived from the application of the Physiological and Chemical Principles established in the preceding pages . . 105 Wines, &c. H . . , . 94 Fermented Liquors . 93 Tea, Coffee, Chocolate, &c 90 Barley Water, Gruel, &c 89 Water .'¦ • . . . 84: Of Drinks . . . ' 81 Of Condiments 76 Cookery 74 The Classification of Aliments . . 70 Effects of Animal and Vegetable Food compared . . . . . 65 Introductory Observations 63 The Materia Alimentaria 63 PART II. Instinctive desire for Exercise . • . . . . 59 Thirst * •"' . • 56 Hunger iSH 54 Relations of the Digestive Functions with our Sensations ... 54 PhyFiological History of Digestion .' 34 VI. The Skin 32 V. The Kidneys .31 IV. The Lungs » 31 III. Vessels for carrying the Nutritive Product to the Circulation 30 II. The various Glands which are subservient to the Secretion of the different Fluids intended to act on the Alimentary Matter 15 Sect. I. The Alimentary Canal . 9 Anatomical View of the Digestive Organs 8 PAGJE Introduction 1 IV CONTENTS. PAGE dulses ' • :# *• W 121 Ndts ic . . . . .122 Esculent Roots 123 Esculent Herbs . ..!*.. 125 Fruits . . ... . " . . .126 On the Intermixture of Aliments . . ... 128 On the Periods best adapted for Meals, and on the Intervals which should elapse between each .... ..... 130 Breakfast . . . . .132 Dinner . • . . 133 #k . . . . .134 Supper . . . .134 On the Quantity of Food that ought to be taken at different Meals 135 Conduct to be pursued previous and subsequent to Meals . . . 139 On the Influence of different Aliments in modifying the appearances of the Alvine Discharges . . 143 PART III. Of Indigestion . . 147 Imperfect Chymification 149 Imperfect Digestion in the Duodenum 155 Of Headachs which arise from Indigestion 156 Indigestion from Biliary Derangement 159 A Tabular Scheme for investigating the Causes, Nature, and Seat of Indigestion . . . .. , . . . . . . .;'. . 168 A Commentary upon the Preceding Table . . . . . 169 Of the Cure of Indigestion 178 Practical Rules for the Guidance of Dyspeptic Patients . ... 180 Acidity of Stomach, Flatulence, &c. . . . ... . 181 Recapitulation ........... 195 On the Diet best adapted for Persons labouring under Tabes Mesenterica, &c. ............ 198 Conclusion 200 Illustrative Cases 201 A TREATISE ON DIET, Sfc. Sec. INTRODUCTION. Apology for the Work. — Popular interest of the Subject. — Works on Dietetics, numerous, but not satisfactory. — Contrariety of Qpinion begets Scepticism. — The fate of a Patient who consults too many Physicians. — The quantity of Food, and the circumstances under which it is taken, more important than its quality.—Dietetic Precepts should not savour of ascetic austerities. — Absurdity of the supposition that Nature can direct us in the selection of Food.—' Man has no natural Food. — The qualities of Vegetables completely changed by Cultivation. — Cookery. — The folly of denying the influence of Regimen in the cure and prevention of Disease.—Digestion, comprehensive Signification of the Term. In these days of literary fecundity, an author who ventures to add a new work upon a subject which has already given birth to so many volumes, must be able to satisfy the public tribunal, that he is either prepared to extend the general stock of information, or to correct the errors into which preceding writers have been betrayed. I shall certainly, upon the present occasion, rely with greater confidence upon this latter plan of defence. It will be readily admitted that few subjects, connected with the medical art, have excited more popular interest, or occasioned more sedulous inquiry, than that of which I propose to treat in the following pages; and yet, were the numerous works on dietetics subjected to a healthy digestion, how meagre would be the proportion of real aliment extracted from their bulky materials. Upon this occasion, at least, we may, with Diderot, ridicule the popular adage, " the more heads the better counsel — because nothing is more common than heads, and nothing so unusual as good advice." Suppose an unprejudiced reader, my assumption I admit is violent, were to Wade through the discordant mass to which I allude, would he not inevitably arrive at the mortifying conclusion, that nothing is known upon B 2 Introduction. the subject in question; or rather, that there does not exist any necessity for such knowledge? Nothing cherishes the public scepticism, with regard to the efficacy of the medical art, so much, as the publication of the adverse and contradictory opinions of its professors, upon points so apparently simple and obvious, that every superficially informed person constitutes himself a judge of their merits. If a reader is informed by one class of authors, that a weak stomach is unable to convert liquid food into aliment, and by another, that solid food is injurious to feeble stomachs, he at once infers that the question is one of perfect indifference; and he ultimately arrives, by a very simple process of reasoning, at the sweeping conclusion, that the stomach, ever kind and accommodating, indiscriminately converts every species of food into nourishment and that he has therefore only to consult his own inclination in its selection. On the valetudinarian, incapable of healthy reflection, and ever seeking for causes of fear and anxiety when they do not choose to come uncalled, such works may have a contrary tendency, and lead him to suspect the seeds of disease in every dish, and poison in every cup. 2. To make the case still stronger, let us suppose that the unprejudiced person, whom we have chosen to represent on this occasion, instead of a reader becomes a patient, and submits his complaints to the judgment of these discordant authors; might he not, like the Emperor Adrian, prepare an inscription* for his tomb-stone? This is not an imaginary case, but one of daily occurrence in this metropolis. A dyspeptic invalid, restless and impatient from the nature of his complaints, wanders from physician to physician, and from surgeon to surgeon, in the eager expectation of procuring some relief from his sufferings: under the direction of one, he takes the blue pill, and, like Sanctorius, measures, with scrupulous accuracy the prescribed quantity of his ingesta; but, disappointed in the promised benefit, he solicits other advice, and is mortified by hearing that mercury, in every form of combination, must aggravate the evils he seeks to cure, and that a generous diet, and bitter stomachics, are alone calculated to meet the exigencies of his case; a trial is given to the plan, but with no better success: the unhappy patient at length determines to leave his case to nature; but at this critical juncture he meets a sympathising friend, by whom he is earnestly entreated to apply to a skilful physician, who had succeeded in curing a similar complaint, under which he had himself severely laboured: the anxious sufferer, with renewed confidence, sends for this long sought for doctor, and he hears, with a mixture of horror and astonishment, that his disorder has been entirely mistaken, and that he must submit to the mortifications of a hermit, * " It was the great number of physicians that killed the Emperor." introduction. 3 or his cure is hopeless. It is unnecessary to pursue the history; but I appeal to the candid and enlightened members of the profession to say, whether I have caricatured the portrait. No one can believe that I intend to cast the slightest reproach upon any practitioner by these observations; it is to the unsettled state of professional opinion upon the subject of diet, and to the obscurity which involves the theory of digestion, that all these evils are to be solely attributed. But to return to the subject of dietetic works; it appears to me that their authors have laid far too great stress upon the quality of the different species of food, and have condemned particular aliments for those effects which should be attributed to the quantity, and circumstances under which they were taken; their dietetic precepts have frequently assumed the air of ascetic austerities, and they have thus represented the cure far more formidable than the disease. It has been sarcastically observed by a popular writer, more remarkable for the playfulness of his style than the soundness of his arguments, that there exists a more intimate connexion between the doctrine of Tertullian and that of many a dietetic'practitioner, than is generally supposed—that he is the ascetic intrenched in gallipots and blisters, preaching against beef and porter; terrifying his audience with fire and brimstone in one age, and in the other, with gout and apoplexy. Now, while we must all deeply lament that the severity of this sarcasm should have been, in some measure, sanctioned by the theoretical absurdities of many of our minor writers, it is impossible that any reasonable person can seriously contend, that numerous diseases do not arise from an improper management of diet; much less, that a judicious regulation of it cannot be rendered subservient to their cure. 3. It has been affirmed with an air of much confidence, that the management of our diet requires not the aid of reason or philosophy, since Nature has implanted in us instincts sufficiently strong and intelligible to direct us to what is salutary, and to warn us from such aliments as are injurious. We may here observe, that man has so long forsaken the simple laws which Nature had instituted for his direction, that it is to be feared she has abandoned her charge, and left him under the control of that faithless guide and usurper, to which civilization has given dominion. Appetite, which expresses the true wants of the system, can no longer be distinguished from that feeling which induces us to prefer one species of food to another, and which entirely depends on habit, and certain associations. That the natural relations which subsist between the qualities of food and the impressions made by them on the senses, are changed or destroyed by the refinements of artificial life, is a fact supported by too many powerful arguments to refute: how many kinds of aliments, originally disagreeable, become pleasant by habit; and 4 Introduction. how many substances, naturally agreeable, become disgusting from the creation of certain prejudices! I am acquainted with a lady who is constantly made sick by eating a green oyster; the cause of which may be traced to an erroneous impression she received with respect to the nature of the colouring matter being cupreous. It has also been frequently observed, that persons in social life have acquired a preternatural sensibility to vegetable odours, while the savage has a keener sense for the exhalations of animal bodies: we are, for instance, assured by Captain Cook, that the people of Kamschatka did not smell a vegetable essence placed near them, but that they discovered, by their olfactory sense, a rotten fish, or a stranded whale, at a considerable distance. 4. Dr. George Fordyce has urged a still more serious and conclusive objection to that hackneyed maxim—" that we ought to live naturally, and on such food as is presented to us by nature ;" viz. that man has no natural food. It is decreed that he shall earn his bread by the sweat of his brow; or in other words, that he shall, by his industry, discover substances from whence he is to procure subsistence ; and that if he cannot find such, he must cultivate and alter them from their natural state. There is scarcely a vegetable which we at present employ, that can be found growing naturally : Buffon states that our wheat is a factitious production, raised to its present condition by the art of agriculture. Rice, rye, barley, or even oats, are not to be found wild; that is to say, growing naturally in any part of the earth, but have been altered, by the industry of mankind', from plants not now resembling them even in such a degree as to enable us to recognise *heir relations. The acrid and disagreeable apium graveolens has been thus transformed into delicious celery; and the colewort, a plant of scanty leaves, not weighing altogether half an ounce, has been improved into cabbage, whose leaves alone weigh many pounds, or into a cauliflower of considerable dimensions, being only the embryo of a few buds, which, in their natural state, would not have weighed many grains. The potato, again, whose introduction has added many millions to our population, derives its origin from a small and bitter root, which grows wild in Chili and at Monte Video.* These few instances may suffice to answer the object for which they were introduced : the reader will find many others in the Introduction to my Pharmacologia.t 5. If cultivation can ever be said to have left the transformation of vegetables imperfect, the genius of cookery is certainly entitled to the merit of having completed it; for, whatever traces of natural qualities may have remained, they are undoubtedly obliterated during their passage through her potent alem- * See Pharmacologia, edit. 6, vol. i. p. 147. f Ibid. p. 114. f Introduction. 5 bic. It has been observed that the useful object of cookery is to render aliments agreeable to the senses, and of easy digestion; in short, to spare the stomach a drudgery which can be more easily performed by a spit or a stewpan, —that of loosening the texture, or softening the fibres of the food; and which are essential preliminaries to its digestion. A no less important effect is produced by rendering it more palatable; for it is a fact, which I shall have to consider on a future occasion, that the gratification which attends a favourite meal is, in itself, a specific stimulus to the organs of digestion, especially in weak and debilitated habits. 6. Experience can alone supply the want of instinct; and unless we assume this as the basis of all our inquiries upon the subject of diet, our theories, however refined, and supported by chemical and physiological researches, will prove but Will-o'th'-wisps, to lead us astray into numerous difficulties and embarrassments. Experience, for instance, dearly bought experience, has taught us that headache, flatulency, hypochondriasis, and a thousand nameless ills, have arisen from the too prevailing fjashion of loading our tables with that host of French entremets, and hors-dceuvres, which have so Unfortunately usurped the roast beef of old England. The theorists, in the true spirit of philosophical refinement, laugh at our terrors; they admit, to be sure, that the man who eats round the table, " ab ovo usque ad mala" is a terrific glutton, but that, after all, he has only eaten words ; for, eat as he may, he can only eat animal matter, vegetable matter, and condiment, either cooked by the heat of water or by that of fire, figure or disfigure, serve, arrange, flavour, or adorn them as you please. There is no physician of any practical knowledge who cannot, at once, refute such a doctrine; every nurse knows, from experience, that certain mixtures produce deleterious compounds in the stomach, although the chemist may perhaps fail in explaining their nature, or the theory of their formation. What would such a reasoner say, if he were invited to a repast, and were presented only with charcoal and water? would he be reconciled to his fare by being told that his discontent was founded on a mere delusion? that the difference between them and the richest vegetable viands was merely ideal, an affair of words, as in either case he would only swallow oxygen, hydrogen, and carbon? and yet the presumption in such a case would not be more violent, nor would the argument be less tenable, than that by which the chemist attempts to defend the innocence of a practice which converts our refreshments into burdens, and our food into poison. To those who question the value of dietetic regulations in the cure of disease, I have only to observe, that they may as well deny the utility of the medical art altogether, and assert that in all disorders of function, Nature is sufficiently powerful to rectify and cure Introduction. 6 them, without the intervention of art: unless this be granted, it is absurd to say that beneficial impressions may not be made as well through the medium of the materia alimentaria, as through that of the materia medica ; or, to borrow the language of Dr. Arbuthnot, that what we take daily by pounds must be, at least, as important as what we take seldom, and only by grains or tea-spoonsful. 7. Those who have read my work on Pharmacology, will easily discover the train of research by which my mind has been led, from the study of the operation of medicines, to that of the digestion of aliment; while those who are acquainted with the various works on dietetics will readily admit, that an ample apology may be found for giving to the public another volume on that subject. Upon this point, however, T wish to be distinctly understood; for I should be seriously concerned at being identified with a school, which uniformly depresses the opinions and writings of others, in order that those of their own immediate disciples may rise in relative importance. It would be worse than foolish to assert that, upon the subject of dietetics, we have no works of merit; the valuable treatise of Dr. Fordyce would, singly, be sufficient to repel with triumph a charge so illiberal and unjust: at the same time, it cannot be denied, that since the periods in which many excellent works were composed, physiology, as well as chemistry, has advanced with rapid strides; pathology has thrown off the mystic veil with which the humoral doctrine had invested her, and the views, as well as the language of medical science, have undergone corresponding revolutions. Facts alone remain unchanged; but those are so buried in the ruins of the fallen fabric, that, unless they be rescued from the confused mass, their intrinsic value must be entirely lost: any work, therefore, carefully collated, with the view of accomplishing such an object, even should it present but little novelty, must prove an acceptable offering to the intelligent part of the community. 8. Before the subject of dietetics can be systematically considered, or the principles upon which disease may be prevented or cured by an appropriate diet, can be properly understood, or profitably applied, the reader must be made acquainted with the complicated machinery by which Nature extracts blood from food. The various processes engaged in this wonderful transmutation are expressed by the comprehensive term digestion, although this word is sometimes employed in a more limited sense, to denote only those preparatory changes which the food undergoes in the stomach. Mr. Abernethy would appear to use the term according to this latter acceptation, for he says,— "Digestion takes place in the stomach, chylification in the small intestines, and a third process, hitherto undenominated, is performed in the large intestines." The relation of a tale which Introduction. 7 has been so often told, may, perhaps, appear to many as not only superfluous but reprehensible; I must, however, remark, that every author is conventionally allowed to state the theme of his discussion in his own language, and the advantages which have hitherto attended the indulgence sufficiently sanction its continuance. 8 Of the Digestive Organs. ANATOMICAL VIEW OF THE DIGESTIVE ORGANS, Their elaborate Machinery.—Their Structure varies according to the Food of the Animal to which they belong. — Enumeration of the several digestive Organs. — Their extraordinary sympathetic relations — The alimentary Canal :— its peristaltic Motion.' — The Stomach: — its Figure, Dimensions, Situation, and Structure. — Small Intestines. — The Duodenum: — Peculiarities of its Functions entitle it to be considered as a second Stomach: — Provisions to limit its Motions. — Jejunum. — Ilium.—charge Intestines. — Cmcum. — Colon. — Rectum. — The various Glands, or secreting Organs, for the preparation of the digestive fluids.— The Salivary Glands. — Glands of the Stomach and Intestines. — The Liver. — The Pancreas. — Observations on the supposed Use of the Spleen. —Vessels for carrying the nutritive Product to the current of the Circulation.— The Lacteals. — Mesenteric Glands.—'The Thoracic Duct. — The Lungs.— The Kidneys.— The Skin. 9. No function in the animal economy presents such elaborate machinery as that of digestion; but its complexity and extent have been found to vary according to the nature of the food upon which it is designed to act. If it greatly differ in composition from the matter of which the animal is constituted, the changes it has to undergo before it can be adapted for the support and reparation of the body which receives it, must necessarily be more considerable, and the organs are accordingly more extensive and elaborate in herbivorous than in carnivorous animals; while man, who derives his supplies of nourishment from both the kingdoms of nature, possesses an intermediate organization. His digestive organs may be said to consist of a long canal, extending from the mouth to the anus, varying in the diameter of its different parts, according to the distinct duties which each is destined to perform ; and which are also capable of contracting or enlarging their dimensions according to the circumstances under which they act; —of various glands, or secreting organs, for the preparation of the liquids which are required for acting on the alimentary matters; —of vessels for conveying to the current of the circulation the nutritive product of the operation;—of the lungs which complete its assimilation with the blood; —and of the kidneys, which carry off the remaining portion as excrementitious. These different organs are not only intimately connected with each other, but they display an extraordinary sympathetic relation with the sanguiferous and cerebral systems: there is, for instance, no organ of the body which is not directly or indirectly affected by the operations of The Alimentary Canal. 9 the stomach: we shall therefore cease to wonder that an impression made upon it by a medicinal agent, or by an alimentary substance, should afford the means of exciting an action in the most distant parts of the machinenor can we be surprised that the aberrations of this central organ should give origin to the greater number of maladies with which the body is afflicted ; or, that those should be so effective which are directed, for their cure, through the medium of its sympathies. But that we may not, like the members in the ancient fable, wage an unjust war against the stomach for the maladies which it may thus inflict, it is necessary to state, that the stomach suffers equally, in its turn, from the derangement of distant organs. What practitioner has not witnessed the sudden sickness produced by the sprains of tendinous and ligamentous structures, or by blows on the head or other parts? To distinguish between the sympathetic and primary affections of the digestive organs, is a problem of the greatest practical importance; and the profession is much indebted to Mr. Abernethy for his endeavours to show how the stomach and bowels may become affected from local disorder. 10. Although it would be obviously foreign to the plan and objects of this work to enter into minute anatomical investigations, yet as there are certain facts, connected with the structure and locality of the alimentary organs, which it is essential for the practitioner to bear in mind, I shall here offer such a description of them as may appear necessary for his guidance, or for the maintenance of that perspicuity which I am anxious to bestow upon the following pages. In the performance of this task, I shall preserve the order of arrangement already noticed (9), viz.— I. The Alimentary Canal. 11. Although, in strict language, the alimentary canal includes the whole passage from the mouth to the anus, the term is more usually employed to express only the stomach and intestinal tube. It may be represented as a long canal, commonly calculated as being five or six times the length of the adult, differently twisted upon itself, and of different dimensions in various parts of its extent. Anatomists describe it as composed of several distinct tunics, or coats, the existence of which may be traced throughout its whole extent, although their structure undergoes variation in the different divisions of the canal; but this will be better understood when we come to speak of its individual parts. The intestinal canal is susceptible of a peculiar motion, which arises from the successive or simultaneous contraction of its longitudinal or circular fibres, and has been differently denominated by authors; some have named it vermicular, others peristaltic. C 10 The Alimentary Canal; its Peristaltic Motion. This contraction always takes place slowly, and in an irregular manner; it is, however, capable of being accelerated by the action of certain stimulants. It does not seem to be sensibly controlled by the will; nor indeed, does it appear to be much influenced by the nervous system, for it proceeds in the stomach after the section of the eighth pair of nerves, and it even continues, though the intestinal canal be entirely separated from the body: at the same time it appears, from the experiments related by Dr. W. Phillip, that, although these muscular fibres be independent of the nervous system, they may in every instance be influenced through it; a fact of very great pathological importance, since it follows that the muscular fibres of the canal may not only be affected by eauses acting directly on them, but by such as act through the medium of their nerves. M. Majendie observes, that the peristaltic motion becomes more active by the weakness of animals, and even by their death; and that in some, by this cause, it becomes considerably accelerated. The object of this motion is to propel forward the contents of the canal, and to favour those changes which it is destined to undergo. The intestinal canal is never in a state of complete collapse, it always contains gas or vapour, which prevents its sides from coming into contact. It has been stated that this canal is of different dimensions in various parts of its extent, and it is principally from this diversity of magnitude that anatomists have established those divisions which we have next to consider. 12. The stomach is a membranous bag, very much resembling in shape that of the pouch of a bag-pipe, or, more strictly speaking, that of a conoid bent upon itself. It is Hot easy to determine its exact capacity in the living body, nor is it a fact of much practical importance: in various states of disease, we have reason to believe that it is considerably augmented in size. It has two orifices; the one termed the cardia, which is a termination of the tube we call the oesophagus; the other, which communicates with the small intestine, and to which the term pylorus has been given. The pylorus is raised up, being nearly, but not quite level with the cardia, so that its upper and lower surfaces form, as it were, two concentric circles, one on the upper side, which is called the small curvature, and one on the lower, which is termed the great curvature. The stomach is situated immediately below the diaphragm, the cardia being nearly opposite to the middle of the vertebras. From thence it bulges out to the left side, the great curvature coming forward and downward; it then passes on to the right side, rising upwards, so that the pylorus is not much farther from the diaphragm than the cardia; when, therefore, a man is in an erect posture, substances must ascend to pass through the pylorus. It is, however, evident that its situation, and relation with Coats of the Stomach. 11 the neighbouring organs, will always suffer variations according to its degree of distention; the following observations will therefore deserve the attention of the pathologist:—in its flaccid state, it occupies the epigastrium and part of the left hypochondrium; whilst, when distended, it exchanges its flattened, for a rounded form, and fills almost completely the left hypochondrium; the greater curvature descends towards the umbilicus, particularly on the left side: on account of the resistance that the vertebral column presents, the posterior surface of the stomach cannot distend itself in that direction; this viscus is therefore wholly carried forward. This dilatation of the stomach produces very important changes in the abdomen: the total volume of the cavity augments; the belly juts out; the abdominal viscera are compressed with greater force; and the necessity of passing urine or faeces is frequently experienced. At the same time, the diaphragm is pressed towards the breast, and it descends with some difficulty; whence the respiratory motions are impeded. The stomach, although a single bag, must be considered as divisible into two distinct cavities, to which different offices are evidently assigned. The left half has always larger dimensions than the right; and M. Majendie calls the one the splenic part, because it is supported on the spleen, and the other the pyloric part, since it is supported on the pylorus. 13. The stomach has been described as composed of several membranes, viz., the peritonaeal, muscular, nervous, and villous coats. The nervous coat, however, of Haller and the old anatomists, is now acknowledged to be nothing more than cellular membrane; and we might with equal propriety dismiss the two former from the number. The peritonaeal covering, being common to* all the contents of the abdomen, can scarcely be recognised as one of the proper coats of the stomach; while it has been very justly observed, that the muscular fibres, arranged between the peritonaeum and the villous membrane, cannot maintain the name of a coat with propriety, since the term signifies a containing membrane, whereas the muscular fibres owe their connexion with each other to interposed cellular membrane. There remains, then, only the villous membrane; and this, in fact, is the only proper intestinal coat, or containing membrane of the aliment. The same observations will apply to the structure of the alimentary canal generally. 14. The villous, or mucous membrane, has a whitish-red appearance, and presents a singular velvet-like appearance, from which it has derived its name; not being elastic, it has numerous folds, or rugae, which supply this deficiency, and serve to accommodate the capacity of the stomach to the bulk of its contents; and, at the same time, to retain the aliment until it is duly elaborated. It is usually lined with a mucous matter, especially in its splenic extremity; it also contains many follicles: Duodenum; its Structure and Situation. 12 and near the pylorus are to be seen several glands, to which is assigned a peculiar office, to be hereafter described. The stomach is abundantly vascular; indeed it may be observed that few structures receive so much blood as this organ; four arteries, three of which are considerable, are exclusively devoted to its service; and their several branches communicate most freely with each other in all directions, by innumerable anastomoses; and, being tortuous, they can thus accommodate themselves to the full and empty states of the cavity. Nor are its nerves less numerous; they are composed of the eighth pair, and a great many filaments proceeding from the solar plexus of the great sympathetic. At the pylorus the mucous membrane thickens, and forms a circular fold, which performs the office of a valve; a fibrous dense tissue is also here found, which some authors have called the pyloric muscle. 15. The duodenum comprehends that range of small intestine which commences at the pylorus, and extends for about twelve inches; and so important are the changes which the aliment undergoes in its cavity, that many authors have regarded it as entitled to the appellation of a second stomach; and I shall, hereafter, have occasion to state, that many diseases which have been erroneously attributed to the stomach, derive their origin from the functional aberrations of this intestine; a fact which renders a knowledge of its structure and situation of great importance to the pathologist. Unlike the stomach, which may be said to be comparatively loose and floating in the abdominal cavity, it is secured in its position by various attachments, and the manner it is protected strongly evinces the importance of its functions. The practitioner should ever keep in mind the position and bearings of this intestine; for, as Dr. Yeats has justly observed, and the fact has been confirmed by my own experience, that patients, directed by their own uneasy feelings, will frequently trace, with most anatomical accuracy, the course of the duodenum with their finger, from the stomach to the loins on the right side, and back again across the abdomen to the umbilicus. The duodenum, at its commencement, turns backwards and downwards for a short way; it then turns towards the right kidney, to the capsule of which it is more or less attached; it here forms a sacculated angle, and in this depending part, the ducts for conveying the pancreatic and biliary secretions enter the intestine; it now ascends from the right to the left, just before the aorta and the last vertebras of the back; it continues this direction from thence obliquely forward by a slight curvature, and makes its exit through the ring in the mesentery. Its mucous membrane, which presents many villi, and a great number of follicles for the secretion of its own peculiar fluid, forms irregular circular folds, termed " Valvulse Conniventes" which increase the surface of the intestine, while Jejunum — Ilium. 13 they prevent the too rapid passage of its contents. It is furnished with nerves from the ganglions of the great sympathetic; and it is also abundantly supplied with blood-vessels. It is impossible to view all the arrangements of this organ, without being satisfied that Nature was anxious to limit its motions; and a little reflection will convince us of the great importance of such a provision: Dr. Yeats, in his valuable paper on the duodenum,* which is published in the sixth volume of the Transactions of the College, has alluded to this fact in a very pointed manner. It is evident that, had this intestine been loose and floating, the food might have passed too rapidly through it; it might also have drawn the small end of the stomach out of its proper situation; and there would have been a constant disposition in the food to pass out of the stomach into the duodenum, upon every relaxation of the pylorus; besides which, had it been less confined, and consequently subject to greater distention, a regurgitation might have taken place into the ductus communis, from an alteration in that obliquity of its direction, which now so securely guards against such an occurrence. Dr. Fordyce, in noticing the fact of the peritonaeum being wanting on the back of the duodenum, most erroneously concludes that this was ordained with a view of allowing a greater distention than can take place in the lower intestines; had such been the design of Nature, she certainly would not have discarded so highly elastic a membrane, and attached the back of the duodenum to the vertebrae. 16. The Jejunum. The precise point at which the duodenum terminates, and the jejunum commences, cannot perhaps be accurately denned; but this latter intestine is generally considered as beginning where the mesentery takes its rise. It appears to have derived its name from the fact of its usually being found empty; probably from its more rapid powers of absorption. 17. The Ilium is the continuation of the jejunum, and is the last division of the small intestine; it is said to have derived its name from the manner in which it is coiled up by the mesentery. Its parietes are thinner than those of the preceding portion of the canal, and this circumstance, together with the deep yellow colour of its contents, impart to it an appearance very distinct from that of the duodenum. 18. The large intestines exceed the others in diameter, but are less considerable in length; in structure they also differ considerably from the small intestines; their mucous membrane does not present that villous appearance of which we have spoken; but is, on the contrary, smooth: the number of folli- * Some Observations on the Duodenum; with plates descriptive of its situation and connexions. Extracted from the Gulstonian Lectures, by G. D. Yeats, M, D., &c. 14 Caecum — Colon; how divided. cles is also less, and it is supplied with much fewer arteries, veins, and nerves. 19. The Caecum constitutes the first division of this portion of the intestinal canal, although some anatomists consider it as merely the head of the colon, and restrict the term caecum to a small gut which is usually described under the title of Appendix. Vermiformis, and which takes its rise from the posterior part of the caecum; it is about the size of a quill, resembling, in figure and diameter, a common earth worm: its coats contain numerous mucous glands, and its cavity, which communicates freely with that of the caecum, is usually filled with a thick mucous fluid: its use is not well understood, but it is evidently designed to supply a fluid of some kind; and as the essential parts of the digestion are completed before the aliment arrives at this part, we may fairly conclude that the object of such fluid is to lubricate the intestinal passage, and thus to facilitate the expulsion of the faeces. At its junction with the ilium, the eaecum, or, according to some anatomists, the colon, exhibits a valve, formed by the production of the interior coat of the intestine, evidently disposed to permit matters to pass forwards, but to prevent their return into the ilium. 20. The Colon constitutes the principal tract of the large intestines, and exceeds them all in diameter: as accumulations in its cavity frequently produce various ill effects from their pressure, it becomes essential for the practitioner to know its direction and bearings. It commences in the cavity of the os ilium, on the right side; from thence, ascending by the kidney on the same side, it passes under the concave side of the liver, to which it is sometimes tied, as also to the gall bladder, which tinges it yellow in that place;* it then runs under the bottom of the stomach to the spleen, in the left side, to which it is also affixed; and thence, passing in the form of the Greek letter 2, it terminates in the upper part of the os sacrum in the rectum. It appears, therefore, to be contiguous to all the digestive organs, and may consequently produce much disturbance by its morbid distention; its connexion with the duodenum is also a circumstance of much pathological importance: whatever motion takes place in the former intestine, will be communicated, more, or less, to the latter; and should it become unnaturally distended, it will press immediately upon the ascending part of the duodenum, and retard the progress of the alimentary matter, which has always to rise against gravity, when the body is in an erect position, or recumbent on the right side. The colon has been divided into the ascending portion, which extends from the caecum to the right hypochondrium; into the transverse portion, * At least such is its appearance in the dead subject; whether a similar transudation takes place during life, is very doubtful. Chylypoietic Glands. 15 or what is termed its great arch; and into the descending portion, including what has been called its sigmoid flexure. The coats of this intestine are much stronger than those of the others; its muscular layer has also a peculiar disposition; its longitudinal fibres form three straight bundles or bands, far separated from each other when the intestine is dilated; at the same time, its circular fibres form bands, equally separated from each other, but more numerous: from which arrangement, it follows, that in a great number of places, the intestine only consists of the peritonaeum and its mucous membrane; these places are generally formed into distinct cavities, which have been termed the cells of the colon; they serve .to promote a gradual descent of the excrement; but, when the action of the canal is torpid, they give origin to much mischief, by unduly retaining its contents. 21. Several physiologists have supposed that the colon performs some other function than that of a mere recipient. Sir E. Home imagined that it formed fat; an hypothesis, which would have received some slight support from the fact that the fattest animals have generally the largest colons, did we not know that persons have lived, and enjoyed good health, for many years, with an artificial anus formed by the cecal extremity of the small intestines, which sufficiently proves that the large intestines are not essential to perfect digestion, nor to the maintenance of life. 22. The Rectum is the last portion of the intestinal canal; it begins at the upper part of the os sacrum, where the colon ends, and going straight down (whence its name), it is tied to the extremities of the coccyx by the peritonaeum behind, and to the neck of the bladder in men, but in women to the vagina uteri before; whence arises the sympathy between those parts. The coats of the rectum are more thick and fleshy than those of any other of the intestines: it has in general no valves, but several rugae; had the former existed, the expulsion of the faeces would have suffered inconvenient delay. The figure of the rectum varies, as it is full or empty; when empty, it is regularly cylindrical, and contracts in transverse folds: it is capable of very great distention, and may even be extended to the size of a large bladder; the quantity of faeces that sometimes accumulates is prodigious, and cannot be removed except by mechanical means. II. The various Glands which are subservient to the Secretion of the different Fluids intended to act on the Alimentary Matter. 23. There is nothing more mysterious in the digestive process than the great variety of the different fluids which appear essential for its completion; each of which has appropriate glands for its secretion. These fluids are, the saliva, which is The Saliva ; its chemical Composition. 16 formed by glands whose secretory ducts open into the mouth; and mucous matter, which results from the action of numerous follicles situated in the interior of the cheeks and palate, upon the back of the tongue, on the anterior aspect of the velum and on the uvula; —the gastric juice, formed by glands in the stomach ; and the mucus secreted by its membrane; —the " succus intestinalis," or proper juice of the duodenum and small intestines ;—-the bile, which being secreted in the liver, and rendered more stimulating in the gall-bladder, is afterwards carried into the duodenum ; —the pancreatic juice, which is secreted in the pancreas, and carried into the duodenum along with the bile; to which may, perhaps, be added the watery liquids thrown into the intestines by the exhalants. Were I to describe the intimate structure of the several glands and vessels which furnish these fluids, we should be led into anatomical details of tedious length, and which would be wholly unattended by practical utility. It is, however, essential for the physiologist, as well as the practitioner, to become acquainted with the most recent account of the chemical history of these several secreted fluids. 24. The Saliva. The mixture under this name is probably variable in its physical and chemical properties, according to circumstances which have not hitherto been examined. When first discharged from the mouth, it always holds suspended a mucus, which is not dissolved, but imparts to it a frothy quality, by enabling it to retain the air which it absorbs from the atmosphere. It is readily separated by merely diluting the saliva as it flows from the mouth, with distilled water, when it will gradually subside, and may be collected on a filter. It is a curious circumstance that, although no traces of phosphate of lime can be detected in this mucus by the application of reagents, yet, after incineration, a considerable proportion appears in the ash.* It has been doubted whether this mucus be secreted by the salivary glands, or is the common mucus of the mouth; the latter appears more probable. The saliva, deprived of this mucus, consists, according to the analysis by Berzelius, of Water 992.9 A peculiar animal matter 2.9 Alkaline muriates --- 1.7 Lactate of soda and animal matter - 0.9 Pure soda 0.9 * It is this mucus that produces the tartar of the teeth, which, at first, is only mucus precipitated on the surface of the enamel; but it soon begins to decompose ; its colour changes, by the influence of the air, from white to yellow; the warmth and moisture of the mouth contribute to complete the decomposition, and the same earthy phosphates, which are produced by oxidation and combustion in open fire, are here formed, and slowly deposited on the surface of the tooth by a slower but a similar process. The tartar is therefore, as it were, the ash of mucus crystallized on the tooth. The Furred Tongue. 17 The peculiar matter of the saliva is soluble in water, but not in alcohol; and the solution is not precipitated either by alkalies or acids, or sub-acetate of lead, or muriate of mercury, or tannin; neither is it rendered turbid by boiling. The saliva derives its name from the saline qualities which it possesses; and although, under ordinary circumstances, we are not conscious of them, yet when the stomach has been long empty, and the nervous system acquires increased sensibility, the saline taste is frequently perceptible. The same effect is produced by disease; and the disagreeable taste of which invalids complain, often depends upon chemical changes having been produced in this secreted fluid. The common furred tongue would appear to arise from an increased quantity of vitiated mucus. The peculiar milky tongue* which appears in certain states of the system, occasionally derives its appearance from an innumerable number of microscopic bubbles of air, as I have ascertained by observation: in such cases, the quantity, rather than the quality of the mucus, appears to be affected. The black tongue of typhus, on the other hand, is indebted for its character to a decomposed state of the mucus; while a deficiency in the true salivary secretion will explain its dryness. It must at the same time be confessed, that there are certain morbid conditions of the tongue which cannot be explained upon these principles, much Jess can we discover the nature of their connexion with those diseases which are known to produce them. I am, for instance, at a loss to understand why the tongue should be clean in certain stages of hectic fever, at the very time that the stomach is palpably deranged: and thus again, although experience has established the fact, how are we to explain why an unnaturally red tongue, of a cherry colour, when accompanied with tenderness in the epigastric region, should denote organic mischief in the alimentary organs? I am so perfectly satisfied of the truth of this statement, from experience, that if a patient applies to me with aggravated symptoms of dyspepsia, and I perceive his tongue to be bright, I form an unfavorable diagnosis of his case. I state this as a general proposition, to which of course there will be many exceptions. When we consider the size of the salivary glands, which altogether cannot weigh more than four ounces, the quantity of fluid which they continually secrete is truly astonishing. It would be a difficult matter to ascertain, with accuracy, the proportion of saliva which these glands can separate in a given time; but we know, that a person unaccustomed to smoking, will discharge half a pint in a very short period. In the case of a felon, who cut his throat in prison, and so completely divided both the * I am induced to consider the milky tongue as rather indicating a sympathetic, than primary derangement of the stomach. It is thus constantly produced by mental anxiety. D The Gastric Juice. 18 larynx, a little above the cricoid cartilage, and the oesophagus at the same point, that whatever was introduced into the mouth escaped by the external wound; it was found that, during each meal, there was a discharge of saliva from the mouth, amounting to from five or six, to eight ounces, or even more. This is sufficient to disprove the opinion of Dr. Fordyce, who says, " as far as I can judge, the secretion during a meal can hardly exceed an ounce or two; and I should think that it serves only to lubricate the passages through which the food is to pass." With respect to this latter assumption, I shall have to offer some observations in a future part of the work. 25. The Gastric Juice. Great difference of opinion has existed with regard to the qualities and composition of this fluid; it would, however, appear that other secretions of a mucous nature take place in the stomach, with which it may be mixed: this circumstance, together with the difficulty of obtaining it in an isolated form, are sufficient to explain the contradictory results which different chemists have obtained. It is, moreover, by no means improbable that this liquor may vary in different stomachs, or even in the same stomach under different circumstances. M. Majendie observes, that the contact of different sorts of food upon the mucous membrane, may possibly influence its composition: it is, at least, certain that the gastric juice varies in different animals; for example, that of man is incapable of acting on bones, while that of the dog digests these substances perfectly. From the best authorities upon this subject, the true gastric juice would seem to be a glairy fluid, not very diffusible in water, and possessing the power of coagulating certain fluids in a very eminent degree. Dr. Fordyce states, that six or seven grains of the inner coat of the stomach, infused in water, gave a liquor which coagulated more than a hundred ounces of milk. Some authors have regarded it as colourless, and without taste or smell, while others have described it as being acidulous.* Dr. Young, of Edinburgh, is stated to have found that an infusion of the inner coat of the stomach, which had been previously washed with water, and afterwards with a dilute solution of sub-carbonate of potass, still retained the power of coagulating milk very readily. We see, therefore, how unfounded that opinion is which attributes to the potation of water, the mischief of diluting the gastric fluid, and thus of weakening the digestive process. The coagulating arid efficient principle, whatever it may be, is evidently not diffusible in that liquid. After one fit of vomiting, should another take place after a short interval, the matter brought up will be little more than water, with a slight saline impregnation,and some mucus; it will not be * Dr. Prout has lately read a paper before the Royal Society, in order to prove that the stomach always contains muriatic acid. I shall have occasion to advert to this fact in a subsequent part of the work. The Intestinal Juice — The Liver. 19 found to possess any power of coagulation; which, Dr. Fordyce observes, evidently shows that even water flowing from the exhalants, and which we should therefore expect would throw off the whole of any substance from the surface of the stomach, is incapable of detaching the gastric juice. 26. The mucous membrane of the small intestines secretes also a peculiar liquid, to which Haller gave the name of intestinal juice; the quantity that is formed in twenty-four hours, he estimated at eight pounds: and M. Majendie states, that if this mucous membrane be laid bare in a dog, and the layer of mucus absorbed by a sponge, it is renewed in a minute; and he says, that this observation may be repeated as often as we please, until the intestine becomes inflamed by the contact of the air, and foreign bodies. It has never been submitted to an accurate analysis; it appears, however, to be viscous, thready, of a salt taste, and capable of reddening paper tinged with turnsol. 27. The Liver is, by far, the largest gland in the human body, and is so disproportionate to the quantity of liquid secreted, that the bile must require a very extensive apparatus for its elaboration; and this inference is strengthened by an examination$, i. e. horse and bull, when prefixed to any word, were used to express its comparative greatness. We have thus, Aorse-radish, or the greater radish ; horse-mint; bull-rush, &c. The great Dock is called /ftp/>o-lapathum, and the horse of Alexander, from the size of its head, Bucephalus. Esculent Herbs. 125 stimulant; it is. perhaps, the best of all condiments for the prevention of flatulence. Esculent Herbs. .221. In this class are arranged the leaves and stalks of such vegetables as are eaten at table in the form of "greens and salads." Some ancient nations, we are told, were accustomed to range over fields and woods in search of food, devouring, like animals, any wild herb they could find likely to satisfy their hunger: "Quae sol atque imbres dederant, quod terra crearat Sponte sua, satis id placabat pectora donum." Lucret. lib. v. Some herbs are still eaten in a raw state; but they are far less digestible than when cooked. During the heats of summer they are refreshing, and are well calculated to* assuage that febrile state which full meals of animal food are known to occasion. Of all these herbs, the Water-cress is the most beneficial; for, by operating in some degree as an aromatic, it promotes digestion, and corrects that tendency to flatulency which other raw vegetables are apt to produce. According to Xenophon, the ancient Persians lived upon water-cresses, which they considered the most wholesome of vegetable productions. The Lettuce is generally eaten with other herbs, in the form of a salad, dressed with oil and vinegar. S,ome difference of opinion has arisen with respect to the propriety of such additions. Gosse, of Geneva, found that vinegar retarded its solution in the stomach; and oil has been stated by others to render it less digestible; I have generally found such condiments useful, and that dressed lettuce is less likely to ferment in the stomach than that which is eaten without them. Oil is known to have such an effect in checking fermentation, and the vinegar is not found to promote it. The lettuce contains a narcotic* principle; and the effect of this is, in a great measure, obviated by a vegetable acid. Those persons, therefore, who eat lettuce with a view to obtain such effects, ought to take it without vinegar. Whatever difference of opinion may exist with regard to lettuce, there is none with regard to celery, the digestibility of which is greatly Increased by maceration in vinegar. Cucumbers are by far the most unwholesome of all raw vegetables, and should be avoided as poison by dyspeptics. The vegetables which require to be boiled are the different species and varieties of colewort; the value of which does not depend so much upon their nutri- * We are told that Galen, in the decline of life, suffered much from morbid vigilance, until he had recourse to eating a lettuce every evening, which cured him. Fruits. 126 tive quality as the tenderness of their texture. On this account, the cauliflower and brocoli are the species to be preferred, particularly the younger sprigs of the former. Of the kinds where the leaves only are employed, the Savoy is of a sweeter and more tender texture than the others, particularly its central and upper leaves. The cabbage tribe appear to contain a peculiar essential oil, whence the peculiar odour of cabbage water; this matter is liable to produce offensive effects on the stomach. The vegetable should therefore be boiled in two successive waters, in order to free it entirely from the noxious ingredient, and at the same time to render its texture soft and digestible. Asparagus is quickly dissolved in the stomach, and, when sufficiently boiled, is not disposed to create flatulence or acidity: along with its mucilage it frequently contains some sweetness, which affords a proof of its nutritive quality. From the peculiar odour which it imparts to the urine of those who eat it, it appears to possess some active matter distinct from its mucilage; and it is generally considered diuretic." I have, however, prepared a strong infusion, as well as extract, from it, in order to ascertain this point, and I have not been able to discover any diuretic effects from its' administration in large doses. Asparagus is only wholesome when in an intermediate state, between root and plant. When older than this, it is remarkably acrid. Fruits. 222. These are generally regarded as articles rather of luxury than of food; and were we to form our opinion of their value from their abuse, we should certainly be rather disposed to class them under the head of poisons than of aliments, Nothing can be more mischievous to the invalid than large quantities of apples, pears, and plums, in the form of dessert, after the stomach has been already loaded, and its good nature taxed to the utmost by its Epicurean master. But, when taken under other circumstances, they contribute to health, and appear to be providentially sent at a season when the body requires that cooling and antiseptic aliment which they are so well calculated to afford. It is not my intention to enter into a minute history of the several kinds; but it will be useful to take a general view of the qualities which distinguish each division, and to state the circumstances which render them useful or objectionable. 223. Fruits may be arranged under the following heads: stone fruits, the apple species, small-seeded fruits, small berries, and farinaceous fruits. 224. The stone fruits have been denounced as the least digestible species by popular acclamation, and I am inclined to acquiesce in the truth of the assertion as a general proposition; but much of the mischief that has been attributed to their use Different Fruits. 127 has arisen from the unripe state in which they were eaten. They are, however, certainly less digestible than other species, and more liable to undergo fermentation in the stomach. The hard pulp of certain plums remain also in the alimentary canal for a long time, and are frequently passed without having been materially changed. The ripe peach is the most delicious, as well as one of the most digestible of the stone fruits: the apricot is equally wholesome; but the nectarine is liable to disagree with some stomachs. Cherries are far less digestible: their pulpy texture and skins are not easily disposed of by the stomach; and as the sweetest species contain a considerable excess of acid, they may be objectionable in some cases, and desirable in others. The apple species is not so dilute and watery as the foregoing fruits, and is less apt to pass into a state of noxious fermentation; but its texture is firmer, and on that account it is retained longer in the stomach, and often proves indigestible. The same observations apply to pears, except that their texture being in general less firm, they are less objectionable. The orange, when perfectly ripe, may be allowed to the most fastidious dyspeptic; but the white, or inner skin, should be scrupulously rejected, for it is not more digestible than leather. The small-seeded fruits are, by far, the most wholesome. Of these, the ripe strawberry and raspberry deserve the first rank. The grape is also cooling and antiseptic, but the husks and seeds should be rejected. The gooseberry is less wholesome, on account of the indigestibility of .the skin, which is too frequently swallowed. The fruits to be classed under the head of small berries, are the cranberry, the bilberry, and the red whortleberry. These are seldom eaten, except when baked, and in that state their acescency seldom proves injurious. The farinaceous fruits are universally unwholesome. The melon, which is the principal one, is very apt to disagree with weak stomachs, and should never be eaten after dinner, without a plentiful supply of salt ancl pepper. 225. The most proper periods for indulgence in fruit appear to be the morning and evening. On some occasions it may be taken with advantage at breakfast, or three hours before dinner, and it affords a light and agreeable repast if taken an hour before bed-time; but these regulations are to be influenced by circumstances which no general rule can possibly embrace. 226. By cookery, fruit, otherwise unwholesome, may be converted into a safe and useful aliment. Apples, when baked, afford a pleasant repast; and from their laxative properties are well adapted to certain cases of dyspepsia. Fruit pies, if the pastry be entirely rejected, may be considered valuable articles of diet. Dried fruits are by no means so useful or safe as is generally imagined; the quantity of sugar which enters into their composition disposes them to fermentation. 128 l Intermixture of Aliments. 227. Having offered some general rules with respect to the circumstances which re'nder food salutary -or noxious, and illustrated these principles by an examination of the several classes and species of aliments, it remains for me to say a few words upon the subject of their intermixture. I have already, in the introduction of this work (6), alluded to the mischief which arises from the too-prevailing fashion of introducing at our meals an almost indefinite succession of incompatible dishes. The stomach being distended with soup, the digestion of which, from the very nature of the operations which are necessary for its completion (81), would in itself be a sufficient labour for that organ, is next tempted with fish, rendered indigestible from its sauces; then with flesh and fowl; the vegetable world, as an intelligent reviewer* has observed, is ransacked from the cryptogamia upwards; and to this miscellaneous aggregate is added the pernicious pasticcios of the pastry-cook, and the complex combinations of the confectioner. All these evils, and many more, have those who move in the ordinary society of the present day to contend, with. It is' not to one or two good dishes, even abundantly indulged in, but to the overloading the stomach, that such strong objections are to be urged ; nine persons in ten eat as much soup and fish as would amply suffice for a meal, and as far as soup and fish are concerned, would rise from the table, not only satisfied but saturated. A new stimulus appears in the form of stewed beef, or cotelettes a la supreme: then comes a Bayonne or Westphalia ham, or a pickled tongue, or some analogous salted, but proportionately indigestible dish, and of each of these enough for a single meal. But this is not all; game follows; and to this again succeeds the sweets, and a quantity of cheese. The whole is crowned with a variety of flatulent fruits and indigestible knick-knacks, included under the name of dessert, in which we must not forget to notice a mountain of sponge cake.t Thus, then, it js, that the stomach is made to receive, not one full meal, but a succession of meals rapidly following each other, and vying in their miscellaneous and pernicious nature with the ingredients of Macbeth's caldron. Need the philosopher, then, any longer wonder at the increasing number and severity of dyspeptic complaints, with their long train of maladies, amongst the higher classes of * See the review of ray Pharmacologia, in the Journal of Science and the Arts, No. xxviii. f The custom of introducing cake after a rich entertainment is very ancient; but the cakes or " mustacea" of the Romans were very different compositions. They consisted of meal, aniseed, cummin, and several other aromatics: their object was to remove or prevent the indigestion which might occur after a feast. A cake was therefore constantly introduced, for such a purpose, after a marriage entertainment; and hence the origin of the "BhideCakk," which in modern times is an excellent invention for producing, instead of curing, indigestion. Plurality of Food. 129 society ? " Innumerabiles morbos non miraberis, coquos numera." But it may be said, that this is a mere tirade against quantity; against over-distention of the stomach: that it argues" nothing against variety of food, provided the sum of all the dishes does not exceed that which might be taken of any single one. Without availing myself of the argument so usually applied against plurality of food, that " it induces us to eat too much," I will meet the question upon fair grounds. It is evident that the different varieties of food require very different exertions of the stomach for their digestion; it may be that the gastric juice varies in composition, according to the specific nature of the stimulus which excites the vessels to secrete it; but of this we are uncertain, nor is it essential to the argument: it is sufficient to know, that one species of food is passed into the duodenum in a chymified state in half the time which is required to effect the same change in another. Where, then, the stomach is charged with contents which do not harmonize with each other in this respect, we shall have the several parts of the mixed mass at the same time in different stages of digestion: one part will therefore be retained beyond the period destined for its expulsion, while another will be hurried forward before its change has been sufficiently completed. It is then highly expedient, particularly for those with weak stomachs, to eat but one species of food, so that it may be all digested and expelled at nearly thersame period of time; that when the duodenal digestion has been fully established, the operations of the stomach shall have ceased. I have, on a former occasion (98), insisted upon the importance of such a regulation, and it now leads me to make some remarks upon the periods best adapted for our meals, and upon the intervals which should be allowed between them. S 130 ON THE PERIODS BEST ADAPTED FOR MEALS, AND ON THE INTERVALS WHICH SHOULD ELAPSE BETWEEN EACH. 228. It is not extraordinary that a discrepancy of opinion should exist upon a question which involves so many fluctuating circumstances. Controversy upon this, as upon many other subjects of diet, has engendered a disbelief in its importance; and this scepticism has given a plausible pretext for indulgence on the one hand, and protracted fasting on the other, as the wishes or habits of mankind may have rendered most agreeable. It will therefore be difficult to convince the public of the necessity of those regulations which are so essential for the maintenance of health or for the cure of disease. We have been told that the best time for dining is, 11 for a rich man, when he can get an appetite, and for a poor one, when he can get food." But appetite in health is regulated by habit, and in disease it acts but as an imperfect monitor. Certain general principles, therefore, deduced from observation and experience, must be laid down for our guidance; and these again in their application must be modified and adapted to the circumstances of every particular case. 229. All physicians concur in advocating the importance of regularity, both as it regards the number of meals and the periods at which they are taken. Those who have weak stomachs will, by such a system, not only digest more food, but will be less liable to those affections which arise from its imperfect assimilation, because, as Dr. Darwin has justly observed, they have, in such a case, both the stimulus of the aliment they take, and the periodical habit, to assist the process. The periods of hunger and thirst are undoubtedly catenated with certain portions of time, or degrees of exhaustion, or other diurnal habits of life; and if the pain of hunger be not relieved by taking food at the usual time, it is liable to cease till the next period of time or other habits recur. As these' periods must vary in every individual, according to the powers of digestion, the degree of exercise taken, and the quality of the food, it frequently becomes necessary, in civilized life, to have recourse to intermediate meals, or luncheons, in order to support the powers of the stomach during the long interval which may occur between the conventional periods of repast. But to the dyspeptic patient, in search of health, such indulgencies are rarely to be permitted; unless, indeed, the circumstances under which he is placed leave him no option between long fasting and supplementary refection. I am more anxious to impress this precept upon the minds of invalids, as the anxiety of friends, and the popular errors which exist The Number of Meals. 131 upon the subject of diet, are too apt to establish the mischievous belief, that "a little and often" will be more likely to restore the languid stomach to its healthy tone than moderate meals at more protracted intervals. The specious aphorism of Dr. Temple, that "the stomach of an invalid is like a schoolboy, always at mischief unless it be employed," has occasioned more dyspeptic disease than that respectable physician could ever have cured, had his practice been as successful as that of and his life as long as that of an antediluvian. The theory upon which this objection rests has already been explained (98). The natural process of digestion is thus disturbed, and the healthy action of the stomach, as evinced by the return of moderate appetite, is entirely prevented. In answer to this reasoning, the patient will sometimes tell you, that frequent refreshment is essential to his comfort; that a sensation of faintness obliges him to fly to such a resource, in order to rescue himself from the distress which it occasions. This, in general, is an artificial want, created by habit, and must be cured by restoring the patient to regular meals, which is to be effected by gradually lengthening the intervals of eating. But, since no general rule is without its exceptions, so it may be observed, that there are cases of disease, in which the stomach is unable to bear any considerable quantity of aliment at one time, whence it becomes indispensable to repeat it at short intervals, in order to afford a sufficient proportion of nutriment; but as the patient acquires strength, such a system should be gradually abandoned. 230. But, though the advantage of regular meals at stated periods is desirable, it has been much disputed how many should be allowed in the day: some physicians have considered one, others two, three, or even five necessary. It is, perhaps, impossible to lay down a general rule that shall apply to every particular case. In some persons, the food rarely remains longer than three hours in the stomach; in others four, five, or even six hours. It is evident, that the repetition of the meals ought to be regulated by this circumstance, always avoiding the extremes of long fasting and repletion. Some nations have been satisfied with one meal a day; but the stomach would thus be oppressed with too large a quantity, and in the interval would suffer from the want of some nourishment in it. Such a plan, therefore, is neither calculated for persons of robust health, and who are engaged in much bodily exertion, and consequently require large supplies, nor for those of a weak habit, who are not able either to take or to digest such a quantity of aliment in a single meal as will be sufficient to supply the waste of the body during twenty-four hours. Celsus recommends the healthy to take food rather twice in the day than once; and Sanctorius says, that "the body becomes more heavy and uneasy after six pounds taken at one meal, than after eight taken at three; and that he 132 The Quality of the different Meals? who makes but one meal in the day, let him eat much or little, is pursuing a system that must ultimately injure him." In my opinion, an invalid may safely take three frugal meals; or, on some occasions, even four, provided a certain quantity of exercise be insisted upon. It is reported, that when Alexander the Great turned away his cooks, on proceeding upon a march, he observed that he had no further occasion for such assistants, as he carried with him superior cooks; —a long morning's journey to create an appetite for his dinner, and a frugal dinner to give a relish to his supper. 231. I shall now consider the nature of the different meals, and the periods at which they can be taken with the greatest advantage; repeating, however, that all general rules must be modified in their application according to particular circumstances. 232. Breakfast. This is, perhaps, the most natural, and not the least important of our meals; for, since many hours must have intervened since the last meal, the stomach ought to be in a condition to receive a fresh supply of aliment. As all the food in the body has, during the night, been digested, we might presume, that a person in the morning ought to feel an appetite on rising. This, however, is not always the fact; the gastric juice does not appear to be secreted in any quantity during sleep, while the muscular energies of the stomach, although invigorated by repose, are not immediately called into action: it is therefore advisable to allow an interval to pass before we commence the meal of breakfast. We seem to depart more from the custom of our hardy ancestors, with regard to breakfast, than any other meal. A maid of honour in the court of Elizabeth breakfasted upon beef, and drank ale after it; while the sportsman, and even the day labourer of the present day frequently breakfast upon tea. The periods of their meals, however, were so generally different from those of modern times, that we cannot establish any useful comparison between them, without taking into consideration the collateral circumstances which must have influenced their operation. The solidity of our breakfast should be regulated by the labour and exercise to be taken, and to the time of dining. Where the dinner hour is late, we should recommend a more nutritious meal, in order to supersede the necessity of luncheon, or what the French call un d&jeuner d la fourchette. At the same time it must be remembered, that dyspeptic invalids are frequently incommoded by such a repast, if it be copious. Heartburn is a common effect of a heavy breakfast, especially if it be accompanied with much diluting liquid; and a question has consequently arisen as to the propriety of taking much fluid on these occasions. Some have recommended a dry breakfast, as peculiarly wholesome; and we have been told, that the celebrated Marcus Antoninus made 133 Breakfast. — Dinner. a rule to eat a hard biscuit the moment he got up. I think it will not be difficult to show the reasons why liquids are essentially necessary at this meal. To say nothing gf the instinctive desire which we all feel for them, it is evident that there is a certain acrimony and rankness in all our secretions at that time; the breath has frequently a peculiar taint in the morning, which is not perceptible at subsequent periods of the day. This may be explained by the loss which the fluids of the body have sustained by perspiration, as wejl as by the quality of newly-elaborated matter introduced into the circulation during sleep. The experiments of Sanctorius have fully demonstrated the superior power of sleep in promoting the perspiration; insomuch, that a person sleeping healthfully, and without any unnatural means to promote it, will, in a given space of time, perspire insensibly twice as much as when awake. This fact is sufficient to prove the necessity of a liquid breakfast. Every physician, in the course of his practice, must have been consulted upon the propriety of taking meat, tea, or coffee, at breakfast. I shall, therefore, offer to the profession the results of my experience upon this subject; and I am encouraged in this duty by a conviction of the advantages which have arisen from my views of the question. A person who has not strong powers of digestion, is frequently distressed by the usual association of tea with bread and butter, or, what is more injurious, with hot buttered toast, or muffin; the oily part of which is separated by the heat of the liquid, and remains in the stomach, producing, on its cardiac orifice, an irritation which produces the sensation of heartburn. On such occasions I always recommend dry toast, without any addition. New bread, or spongy rolls, should be carefully avoided. Tea, to many persons, is a beverage which contains tod little nutriment: I have therefore found barley water, or a thin gruel, a very useful substitute. A gentleman some time since applied to me, in consequence of an acidity which constantly tormented him during the interval between breakfast and dinner, but at no other period of the day: he had tried the effects of milk, tea, coffee, and cocoa, but uniformly without success. I advised him to eat toasted bread, with a slice of the lean part of cold mutton, and to drink a large cup of warm barley water, for the purpose of dilution. Since the adoption of this plan he has entirely lost his complaint, and continues to enjoy his morning diversions without molestation. Hard eggs, although they require a long period for their digestion, are not generally offensive to the stomach; they may therefore be taken with propriety, whenever, from necessity or choice, the dinner is appointed at a late season. 233. Dinner. Among the Romans this was rather considered as a refreshment to prevent faintness, than as a meal to convey nourishment. It consisted principally of some light repast, 134 Tea. — Supper. without animal food or wine; but in modern times it is considered the principal meal, at which every species of luxurious gratification is indulged in. With regard to the proper period at which invalids should dine, physicians entertain but one opinion ; it should be in the middle of the day, or at about two or three o'clock. Sir A. Carlisle has justly observed, that it is thus best adapted to the decline of animal vigour, because it affords a timely replenishment before the evening waning of the vital powers, and which naturally precedes the hour of rest; besides which, the custom tends to prevent intemperance; while late hours, and a consequent state of exhaustion demand, or seem to justify an excessive indulgence in strong drinks, and in variety of food. The exact period, however, of dinner must be directed by the physician with reference to the necessary habits of his patient, the nature and time of his breakfast, and, above all, to the rapidity or slowness of his digestion. I will illustrate the importance of this precept by the relation of a case which lately fell under my immediate notice and care, A gentleman, resident in a distant part of the country, applied for my advice under the following circumstances. His health was generally good, but he had lost all appetite for his dinner, and constantly experienced a sensation of weight and uneasiness after that meal: I prescribed some laxative and bitter medicines, and after a fortnight had elapsed 1 again saw him. He then told me that he had not experienced the sensations of which he had complained for some time; but that the circumstance afforded him but little encouragement, as he had uniformly found the same beneficial change whenever he resided in London, which he was at a loss to explain, as he took the same exercise in the country. I then inquired whether the hour at which he dined was the same in both situations? when it appeared, that in the country he dined at three, and in London at about six. I immediately suspected the origin of the complaint, and fortunately touched the spring which unfolded the whole secret: his digestion was remarkably slow, and the dinner in the country was served up before the breakfast had been duly digested. By my advice this evil was remedied; and he has never since had any reason to complain of want of appetite, or of the weight and oppression which had so long distressed him. 234. Tea. I have already stated my reasons (146) for considering this repast as salutary; and where it is practicable, exercise should follow it. 235. Supper. In the time of Elizabeth, the nobility and gentry were accustomed to dine at eleven, to sup between five and six, and to go to bed at ten. It is therefore evident, that any argument, in favour of this meal, founded upon the healthy condition of our ancestors, must be fallacious. By supper, in modern times, we understand a late meal just before bed-time. But On the Quantity of Food to be taken at Meals. 135 as sleep is not favourable to every stage of digestion, it is very questionable whether retiring to rest with a full stomach can, under any circumstances, be salutary. During the first part of the process, or that of chymification, a person so situated may perhaps sleep quietly, unless indeed the morbid distention of the stomach should impede respiration, and occasion distress; but when the food has passed out of the stomach, and the processes of chylification and sanguification have been established, the natural propensity of the body is for activity, and the invalid awakes at this period, and remains in a feverish state for some hours. Upon this general principle, then, suppers are to be avoided; that is to say, hearty suppers, which require the active powers of the stomach for their digestion. The same objection cannot be urged against a light repast, which is generally useful to dyspeptics; and it has been truly and facetiously observed, that " some invalids need not put on their night-caps, if they do not first bribe their stomachs to good behaviour." An egg lightly boiled, or a piece of dry toast, with a small quantity of white wine negus, will often secure a tranquil night, which would otherwise be passed with restlessness. Amongst the intellectual part of the community, there has ever existed a strong predilection in favour of suppers; the labour of the day has been performed; the hour is sacred to conviviality, and the period is one which is not likely to be interrupted by the calls of business. To those in health, such indulgencies may be occasionally allowed; but the physician should be cautious how he gives his sanction to their wholesomeness. The hilarity* which is felt at this period of the day must not be received as a signal for repairing to the banquet, but, as an indication of the sanguification of the previous meal (105). On the Quantity of Food that ought to be taken at different Meals. 236. There is no circumstance connected with diet, which popular writers have raised into greater importance; and some medical practitioners have even deemed it necessary to direct that the quantity of food, appropriated to each meal, should be accurately estimated by the balance. Mr. Abernethy says, that "it would be well if the public would follow the advice of Mr. Addison, given in the Spectator, of reading the writings of L. Cornaro; who, having naturally a weak constitution, which he seemed to have ruined by intemperance, so that he was expected to die at the age of thirty-five, did at that period adopt a strict regimen, allowing himself only twelve ounces of food daily." * Breakfast has been considered the meal of friendship : Dixnbk that of etiquette! and Suppeb the feast of n>it. On the Quantity of Food to be taken at Meals. 136 When I see the habits of Cornaro so incessantly introduced as an example for imitation, and as the standard of dietetic perfection, I am really inclined to ask with Feyjoo,—did God create Lewis Cornaro to be a rule for all mankind, in what they were to eat and drink? Nothing can be more absurd than to establish a rule of weight and measure upon such occasions. Individuals differ from each other so widely in their capacities for food that to attempt the construction of a universal standard, is little less absurd than the practice of the philosophical tailors of Laputa, who wrought by mathematical calculation, and entertained a supreme contempt for those humble and illiterate fashioners who went to work by measuring the person of their customer; but Gulliver tells us, that the worst clothes he ever wore were constructed on abstract principles. How then, it may be asked, shall we be able to direct the proportion of food which it may be proper for an invalid to take? I shall answer this question in the words of Dr. Philip, whose opinion so exactly coincides with my own experience, that it would be difficult to discover a more appropriate manner of expressing it. " The dyspeptic should carefully attend to the first feeling of satiety. There is a moment when the relish given by the appetite ceases; a single mouthful taken after this, oppresses a weak stomach. If he eats slowly, and carefully attends to this feeling, he will never overload the stomach." But that such an indication may not deceive him, let him remember to eat slowly. This is an important condition; for when we eat too fast, we introduce a greater quantity of food in the stomach than the gastric juice can at once combine with; the consequence of which is, that hunger may continue for some time after the stomach has received more than would be sufficient, under other circumstances, to induce satiety. The advantage of such a rule over every artificial method by weight and measure, must be obvious; for it will equally apply to every person, under whatever condition or circumstances he may be placed. If he be of sedentary habits, the feeling of satiety will be sooner induced: and if a concurrence of circumstances should have invigorated his digestive powers, he will find no difficulty in apportioning the increase of his food, so as to meet the exigencies of the occasion. 237. Although it must be admitted, that we all take more solid food in health than may be necessary for supporting the body in its healthy state; yet it is important to know, that too great a degree of abstinence will also tend to weaken and distress both mind and body. Men who in the earlier ages, from a mistaken notion of religion, confined their diet to a few figs, or a crust of bread and water, were so many visionary enthusiasts; and the excessive abstinence to which some religious orders are subjected, has proved one of the greatest sources of modern superstition. The effects of feeding below the healthy Caution against over-feeding. 137 standard, are also obvious in the diseases of the poor and ill-fed classes in many parts of England and Ireland; and these are still more striking in those districts where the food is chiefly or entirely vegetable, and therefore less nutritious. It is also well known, that the obstinate fasting of maniacs often occasion a disease resembling the sea scurvy. 238. Those who are induced from their situation in life constantly to exceed the proper standard of diet, will preserve their health by occasionally abstaining from food, or rather, by reducing the usual quantity, and living low, or maigre, as the French call it. A poached egg, or a basin of broth, may on such occasions be substituted for the grosser solids. The advantage of such a practice has not only been sanctioned by experience, but demonstrated by experiment. The history of the art of " train* ing" will furnish us with some curious facts upon this subject. It is well known that race-horses and fighting-cocks, as well as men, cannot be preserved at their athletic weight, or at the " top of their condition/' for any length of time; and that every attempt to force its continuance is followed by disease. A person, therefore, in robust health, should diminish the proportion of his food, in order that he may not attempt to force it beyond the athletic standard. I am particularly anxious to impress this important precept upon the mind of the junior practitioner, as I have, in the course of my professional experience, seen much mischief arise from a neglect of it. A person after an attack of acute disease, when his appetite returns, is in the condition of a pugilist who is about to enter upon a system of training; with this difference, that he is more obnoxious to those evils which are likely to accrue from over-feeding. In a state of debility and emaciation, without any disease, with a voracious appetite, he is prompted to eat largely and frequently ; and he is exhorted by those not initiated in the mysteries of the medical art, to neglect no opportunity to "get up his strength." The plan succeeds for a certain time, his strength increases daily, and all goes on well; but, suddenly, his appetite fails, he becomes again unwell, and fever or some other mischief assails him. To the medical practitioner the cause of the relapse is obvious: he has attempted to force his strength too suddenly and violently beyond that athletic standard which corresponds with the vital condition of his constitution. * 239. Any sudden transition from established (habits, both with regard to the quantity and quality of food, is injudicious. This precept is the more important, as persons who have too freely indulged, and begin to feel the bad effects of their excesses, are disposed to alter their habits without the preliminary preparations. They leap at once from the situation which gives them pain or fills them with alarm, instead of quietly de- T 138 Influence of the Mind scending by the steps which would secure the safety of their retreat. 240. After long fasting, we ought also to be careful how far we indulge ; this is a caution given to us by Avicenna, and practical physicians must be well aware of the penalty which attends a disobedience of it. When a famine occurred in the city of Bocara, those who had lived on roots and herbs, on their return to bread and flesh, filled themselves greedily, and died. But we need not search the annals of former times for an illustration : persons who have been enclosed in coal mines for several days without food, in consequence of the accidental falling in of the surrounding strata, have not unfrequently lost their lives from the too assiduous administration of food after their extrication. During the period of my studentship at Cambridge, Elizabeth Woodcock was buried under the snow for the space of eight days: on her being found, she was visited by those to whom so extraordinary an adventure presented any interest; and I can state, from my personal knowledge of the fact, that she died in consequence of the large quantity of sustenance with which she was supplied. In the first volume of the Memoirs of the Philosophical Society of Manchester, the case of a miner is recorded, who after remaining for eight days without food, was killed by being placed in a warm bed, and fed with chicken broth. 241. The advantages which are produced by rendering food grateful to invalids are so striking, that the most digestible aliment, if it excite aversion, is more injurious than that which, though in other respects objectionable, gratifies the palate. If feelings of disgust or aversion are excited, the stomach will never act with healthy energy on the ingesta; and in cases of extreme dislike, they are either returned, or they pass through the alimentary canal almost unchanged. On the other hand, the gratification which attends a favourite meal is, in itself, a specific stimulus to Ihe organs of digestion, especially in weak and debilitated habits. In the sixth edition of my Pharmacologia, 1 published a case which was related to me by Dr. Merriman, highly illustrative of the powerful influence of the mind upon these organs. A lady of rank, labouring under a severe monorrhagia, suffered with that irritable and unrelenting state of stomach which so commonly attends uterine affections, and to such a degree, that every kind of aliment and medicine was alike rejected. After the total failure of the usual expedients to procure relief, and the exhaustion of the resources of the regular practitioner, she applied to the celebrated Miss Prescott, and was magnetised by the mysterious spells of this modern Circe. She immediately, to the astonishment of all her friends, ate a beefsteak, with a plentiful accompaniment of strong ale; and she continued to repeat the meal every day for six weeks, without upon the Digestion. 139 the least inconvenience! But the disease itself, notwithstanding this treacherous amnesty of the stomach, continued with unabated violence, and shortly afterwards terminated her life. On the other hand, I could cite several cases to show, that the most nutritive and digestible aliment may be rejected by the stomach, if any impression against its salubrity be produced. I remember a case in which, from some groundless suspicion, the idea of the food having been poisoned by copper was introduced, the persons at table became sick, one or two absolutely vomited, and the remainder complained of distress in the stomach and bowels. Conduct to be pursued previous and subsequent to Meals. 242. As dietetic regulations are intended for the use of those who are either suffering under disease, \r are compelled, from the precarious state of their health, to attend to every circumstance which may be likely to preserve it, it is scarcely necessary, in a professional work, to apologise-for the introduction of advice which, to the robust and healthy, may appear frivolous and unnecessary. It is admitted, that nature never contemplated the necessity of confining men to a certain routine of habit; nor did she contemplate, as far as we can learn, the existence of those diseases which may render such discipline necessary. We have in this place only to inquire into the habits which are most favourable or hostile to the process of digestion, and then to form a code for the direction of those who stand in need of such artificial assistance. 243. Exercise in the open air is essential to the well-being of every person ; but its degree must be regulated by the circumstances under which the individual is placed. The interval between breakfast and dinner is the period for active exertion ; and the enjoyment of it, when not attended with severe fatigue, will strengthen and invigorate all the functions of the bod}'. This, too, is the period when the mind may direct its energies with the greatest chance of success; but it is important to remark, that the valetudinarian and dyspeptic ought never to take his principal meal in a state of fatigue: and yet I would ask, whether there is a habit more generally pursued, or more tenaciously defended? Ay,and defended too upon principle; — the invalid merchant, the banker, the attorney, the government clerk, are all impressed with the same belief, that after the sedentary occupations of the day, to walk several miles to their villas, or to fatigue themselves with exercise before their dinner, or rather early supper, will sharpen their tardy stomachs, and invigorate their feeble organs of digestion. The consequence is obvious : instead of curing, such a practice is calculated to per- 140 Exercise without Fatigue. petuate, and even aggravate the malady under which they may suffer, by calling upon the powers of digestion at a period when the body is in a state of exhaustion from fatigue. Often have I, in the course of my practice in this town, cured the dyspeptic invalid, by merely pointing out the error of this prevailing opinion, and inducing him to abandon the mischievous, habit which has been founded upon it. Do not let me be understood as decrying the use of moderate exercise before dinner; it is the abuse of it that I am anxious to prevent. No person should sit down to a full meal, unless he has had the opportunity of previously inhaling the open air, and taken a quantity of exercise, proportionate to his power of sustaining it without fatigue. Upon this point I agree with Mr. Abernethy, who says, " I do not allow the state of the weather to be urged as an objection to the prosecution of measures so essential to health, since it is in the power of every one to protect himself from cold by clothing; and the exercise may be taken in a chamber with the windows thrown open, by walking actively backwards and forwards, as sailors do on shipboard." Horse exercise is undoubtedly salutary, but it should not supersede the necessity of walking; where the two modes can be conveniently combined, the greatest advantage will arise. I have heard that a physician of eminence has declared, that "equitation is more beneficial to the horse than to his rider:" my own experience on this subject will not allow me to concede to such a proposition; nor to that which maintains that " riding is the best exercise for regaining health, and walking for retaining it." It must be admitted that the shaking which attends horse exercise, is salutary to the stomach and intestines; it is also less fatiguing to the inferior limbs ; so that persons in a weak state can use it with less pain or difficulty. There is also another circumstance connected with this subject, upon which I am inclined to think that sufficient stress has not been laid, the rapidity with which we change the air. I am not aware that any theory has been proposed to explain the fact; but I am perfectly well satisfied, that rapid motion through the air is highly beneficial. As this is a gymnastic age, I may be allowed to offer some further observations upon the importance of exercising the body. The occupation of digging is more beneficial than is usually supposed; and to dyspeptic patients it proves useful, by the agitation thus occasioned in the abdominal region. Patients who have suffered from visceral congestion, have experienced the greatest benefit from it. I am induced to believe, that the general discontinuance of those manly exercises, which were so commonly resorted to by our ancestors in the metropolis, has contributed to multiply our catalogue of dyspeptic diseases; and I cannot but express my satisfaction at the prospect of the establishment of a society for their re-introduction. Stow, in his Survey of London, laments the retrench- Banger of introducing Gas into our Apartments. 141 merits of the grounds appropriated for pastimes, which had begun to take place even in his day: what would he say, could he now revisit the metropolis? It has been truly observed, that had it not been for the effect of bodily exercise, Cicero* would never have triumphed at the bar, nor Julius Caesar in the field. 244. One of the great evils arising from too sedentary habits, is constipation of the bowels. This, however, may to a certain degree be remedied, by standing for a certain period; and I have repeatedly known the greatest benefit to arise from the student or clerk introducing a high desk into his office, by which he is enabled to pursue his occupation in a standing posture. 245. I have already explained the necessity of exercise at that period of the digestive process, when the chyle enters the circulation (105); and it is, perhaps, not the least of the evils which attend the modern fashion of late dinners, that it should preclude the possibility of such .a regulation. The utility of dancing may certainly be deduced from these views, and its propriety sanctioned on just principles; but the latenesst of the hour at which these recreations commence, and, what is worse, the excessive heat and ill-ventilation of the apartments in which they are usually carried on, must counteract any benefit which might otherwise attend an indulgence in them. If exercise be useful during the period of sanguification, pure air is no less so; and I shall take this opportunity of entering my protest against the introduction of gas into the interior of our houses. Carbu* retted hydrogen is a deadly poison.; and even in a state of great dilution, it is capable of exerting a very baneful effect upon the nervous system. I have been consulted on several occasions for pains in the head, nausea, and distressing languor, which evidently had been produced by the persons inhaling the unburnt gas in the boxes of our theatres. In order to afford additional support to the objections which I have urged upon this occasion, I shall quote an account of the effects produced upon Sir Humphry Davy by the inspiration of carburetted hydrogen gas. He introduced into a silk bag four quarts of this gas nearly pure, which had been carefully produced from the decomposition of water by charcoal, an hour before the experiment, and which had a very strong and disagreeable smell. " After a forced exhaustion of my lungs," says he, " the nose being accurately closed, I made three inspirations and expirations of the gas. The first inspiration produced a sort of numbness and loss of feeling in the chest and about the pectoral muscles. After the second inspiration, I lost all power of perceiving external things, and had no distinct sensation, except a terrible oppression on the chest. During the third expiration this feeling disappeared, I * See Plutarch's life of Cicero. f In former times the ball commenced at six, and terminated at eleven; but now it begins at eleven and ends at six. Sir H. Davy's Experiment. 142 seemed sinking into annihilation, and had just power enough to drop the mouth-piece from my unclosed lips. A short interval must have elapsed, during which I respired common air, before the objects about me were distinguishable. On recollecting myself, I faintly articulated, *1 do not think I shall die.' Putting my finger on the wrist I found my pulse thread-like, and beating with excessive quickness. In less than a minute I was able to walk; and the painful oppression on the chest directed me to open air. After making a few steps, which carried me to the garden, my head became giddy, my knees trembled, and I had just sufficient voluntary power to throw myself on the grass. Here the painful feeling of the chest increased with such violence as to threaten suffocation. At this moment, I asked for some nitrous oxide.* Mr. Dwyer brought me a mixture of oxygen and nitrous oxide, which I breathed for a minute, and believed myself relieved. In five minutes, the painful feelings began gradually to diminish. In an hour they had nearly disappeared, and I felt only excessive weakness and a slight swimming of the head. My voice was very feeble and indistinct: this was at two o'clock in the afternoon. I afterwards walked slowly for about half an hour; and on my return was so much stronger and better, as to believe that the effects of the gas had disappeared, though my pulse was 120, and very feeble. I-continued without pain for nearly three quarters of an hour, when the giddiness returned with such violence as to oblige me to lie on the bed; it was accompanied with nausea, loss of memory, and deficient sensation. In about- an hour and a half the giddiness went off, and was succeeded by an excruciating pain in the forehead, and between the eyes, with transient pains in the chest and extremities. Towards night these affections gradually diminished ; at ten, no disagreeable feeling except weakness remained. I slept sound; and awoke in the morning very feeble and very hungry. I have," adds Sir H. Davy, " been minute in the account of this experiment; because it proves, that carburetted hydrogen acts as a sedative, i. e. that it produces diminution of vital action, and debility without previously exciting. There is every reason to believe, that if I had taken four or five inspirations, instead of three, they would have destroyed life immediately, without producing any painful sensation, "t After this proof of the poisonous nature of carburetted hydrogen,—after the cases of sickness and headach which have occurred, in consequence of its inhalation at the theatre, am I not borne out in my opinion, that its introduction into our apartments is fraught with danger ? * Sir H. Davy had previously inspired this gas, and found it capable of producing an excitement resembling that of incipient intoxication. f " Researches, Chemical and Philosophical, chiefly concerning Nitrous Oxide, and its Respiration, by Humphry Davy." Certain Aliments colour the Excrements. 143 246. Sleeping after dinner is a practice of very questionable propriety ; it is true, that the inhabitants of many southern climates indulge it with impunity : but it does not appear essential in our country, where animal food is used in such considerable quantities. In states of disease it may occasionally be useful, and the recumbent posture ma3%expedite the passage of the aliment out of the stomach into the intestines; but the person who lies down for the accomplishment of such an object, should be careful to remove all ligatures from his body. On the Influence of different Aliments in Modifying the Appearances of the Discharges of the Body. 247. The external characters of the feculent discharges of the body, may be said to announce the healthy or diseased state of the digestive functions, with as much certainty as the pulse does that of the sanguiferous system. But, in order that we may deduce safe conclusions from such data, we must be acquainted with the nature and extent of the changes which are produced on these discharges by the operation of different aliments and medicines. The air has also the effect of changing the colour of the fasces; they should therefore be examined before such an alteration is likely to be produced. This observation applies with great force to the stools of infants, which, although perfectly yellow when voided, speedily assume a green appearance; a fact which would seem to arise from the spontaneous decomposition of the bile. 248. Certain green vegetables, especially spinach, impart to the fasces a green hue, which may be mistaken for vitiated bile. Beet-root will also give a colour to the alimentary discharge, which it is necessary to distinguish. Persons who take a considerable quantity of milk, will pass pale-coloured evacuations, as if the bile were imperfectly secreted.. Where the aliment has been of a very complicated description, the faeces will generally assume a crude and diversified character, owing, probably, to the several parts not having undergone the same degree of digestion, as already explained (227). Where much stimulant drink has been used, and the person has been subjected to long fasting, or much labour, or has perspired profusely, the fasces acquire a hardened character. It is essential for the practitioner to know, that certain parts, both of animal and vegetable substances, pass through the body without undergoing any change: this is the case with the skin and seeds of fruits, &c. Cheese is also very apt to pass in an undigested state. Dr. Marcet records an instance of this kind, in which the substance was at first mis- taken for an intestinal concretion ; but it proved to be either a piece of cheese formed into a ball by the action of the intestines, or a portion of caseous matter actually formed in the intestines, from milk taken as nourishment by the patient, and coagulated Conclusion of Part IT. 144 by the gastric juices into an undigestible mass. This latter-supposition is the more probable, as Dr. Wollaston, a few years afterwards, had several concretions of the same kind brought to him for examination by a medical practitioner, and which proved of the same nature, and had been discharged by a patient whilst using a milk diet. It has also beenPstated by Dr. Marcet, that concretions of oat seeds are not unusually passed by the inhabitants of Scotland and Lancashire, where the oat-cake is in common use as an article of food amongst the lower classes. The spawn of lobsters, a very indigestible substance, has also occasioned similar deception. Magnesia, when repeatedly taken, will, by the assistance of a little animal mucus, become consolidated into masses of formidable magnitude. Mr. E. Brande has recorded an interesting case of this kind in the first volume of the Journal of the Royal Institution. The influence produced by certain medicines upon the colour of the fasces, is equally striking; iron has the property of tinging them black, and magnesia, of giving a white appearance. We see, therefore, the importance of attending to such circumstances, where it is an object to ascertain the state of the biliary secretion from the colour of the stools; and it would be judicious, on such occasions, to restrict patients to a diet that is not likely to colour the fasces. 249. I have now brought to a conclusion the history of Alimentary Substances. It will be readily perceived, that the terms digestible and indigestible, as applied to particular species of food, are but relative in their import, depending upon circumstances which I have endeavoured to investigate: with what degree of success I have performed this task, it will be for the public to decide; but I may be allowed to observe, that the importance which I have bestowed upon some, perhaps, apparently trivial circumstances, has arisen from a belief, founded on practical grounds, in the influence which they exert on the human body; while, if I have passed over others with less notice than they may appear to deserve, it has arisen from a conviction that they have either been overrated in importance, by those writers who have indulged in discussions upon them, or are so involved in doubt and uncertainty, that I have despaired in throwing any additional light upon their nature and bearings. The theory of Digestion, and the history of Alimentary Substances, are so intimately connected with the diseases to which our organs are exposed, that without a thorough knowledge of the former, we cannot expect to understand the phenomena of the latter; nor to establish a rational and successful system of treatment for the prevention and cure of Dyspepsia. I shall now proceed to the third division of the work, which will embrace the history of Indigestion in all its forms and stages; in which I shall hope to turn the principles, already developed, to a practical advantage. PART ZZX. OF INDIGESTION. u 2?« m. OF INDIGESTION. 250. It has been already observed (8) that authors have differed in their acceptation of the term Digestion. Some regarding it as merely denoting that preparatory process which the food undergoes in the stomach; while others have received it in a more extensive latitude, as comprehending the whole of that elaborate and complicated series of actions, by which nature converts bread into blood. We cannot, therefore, be surprised to rind that pathologists should as widely have differed in their definition of the disease termed Dyspepsia, or Indigestion. Notwithstanding the distinction which Dr. Philip is disposed to establish between these terms, by considering " Dyspepsia" as expressing a disease much less varied, and of much less extent, than that which he comprehends under the denomination of " Indigestion I am still disposed to regard them as synonymous; and when they occur in the following pages, I must beg the reader to receive them with that impression. The term Indigestion is evidently nothing more than a literal English translation of the Greek compound Dyspepsia. 251. I define Indigestion to be a primary disease, in which one or more of the several processes by which food is converted into blood, are imperfectly or improperly performed, in consequence either of functional aberration, or organic lesion. This definition may, perhaps, be opposed, on the ground of its too comprehensive signification; but I may observe, that however extensive may be the series of symptoms which are thus included under one general head, they will afford, when viewed collectively, sufficient evidence of their relation with the digestive process; although, on a loose and hasty observation, they may not present any general principle of dependency and connexion : if they appear disunited, let the practitioner suspect 148 Sympathies of the Stomach. that he has never viewed them with sufficient reference to that physiological harmony which subsists between the organs in which they arise Acidity of stomach and urinary depositions are equally indicative of deranged digestion; but the mind that is not acquainted with the relations of the stomach and kidneys, or with the connexion which subsists between the formation of perfect chyle and the discharge of natural urine, will not be disposed to arrange symptoms, so .apparently remote in their alliance, under one common head. There are many sympathies subsisting between different functions which are not perceptible as long as the general balance of health is preserved: this is remarkably the case with the skin and stomach; but the moment this healthy equilibrium is destroyed, the sympathies become apparent. The physiologist, therefore, without, an acquaintance with the body in its morbid states, must remain ignorant of some of the more important circumstances of the animal economy. The same reasoning applies to the study of natural philosophy: the discovery of the existence of an electric fluid could never have been made, had the natural conditions of matter, with regard to this agent, remained unchanged; the basis of all chemical research is founded upon the same principle; decomposition, and the development of the elements of bodies, are effected by overturning the affinities by which they are naturally combined. These observations are introduced in order to warn the practitioner not to deduce any conclusion against the existence of certain sympathies, on the ground of their not being apparent in a state of health. In a practical point of view, I consider the classifications of the nosologist as of very little utility; they have no solid foundation in nature, but are entirely the work of human reason; artificial contrivances, for the purpose of assisting us in the acquirement and retention of knowledge. Such an- avowal will sufficiently explain the motive which has induced me to throw off the trammels to which I might have been expected to conform. 252. From the universal sympathy which the stomach entertains for every part of the living body, its functions may become impeded or perverted from the existence of diseases which originate in organs with which it has no immediate connexion; an affection of the head, or even a disease in the urethra, may create sickness, loss of appetite, or a suspension in the digestive process; but such phenomena are not to be confounded with the primary symptoms of Dyspepsia; the) 7 are affections of sympathy or induction, and will require very different treatment. In distinguishing between such effects, consists the skill of the practitioner; and it requires a comprehension of mind, a freedom from prejudice, a clearness of judgment, and a patience of minute inquiry, that do not fall to the lot of every member of our profession. I am strongly inclined to think that physicians Imperfect Chymifcation. 149 of the present day are too apt to accuse the alimentary functions of offences which should be charged on other organs. It is, perhaps, natural in those who have devoted much time and attention to one particular subject, to fall into an error of this kind; they have a favourite child of their own to support, and they prefer it with the blind partiality of a parent. As connected with this opinion, I beg to direct the reader's attention to the first case which I have introduced, in my "practical illustrations," at the end of the present volume. I. Imperfect Chymification. 253. The symptoms which arise from the food undergoing its appointed changes in the stomach with difficulty, or in an imperfect manner, are generally those which first indicate the approach of indigestion, and frequently recur at intervals, for a considerable period, without occasioning any constitutional disturbance, or even a degree of local distress sufficient to awaken the alarm of the patient. In some cases, indeed, they are only produced by the use of particular aliments-, or under the operation of peculiar circumstances; but in others, they follow the ingestion of every species of food, although their violence is usually influenced by the quality and quantity of the meal. In this latter case, a morbid state of the stomach exists, which ought to be remedied without delay. In investigating the circumstances of an indigestion, produced only by some particular aliment, we shall soon discover whether it is to be attributed to a peculiar idiosyncrasy of the stomach, which cannot be said to amount to disease, or to a debilitated condition of that organ, which renders it unable to«ligest any food that requires considerable powers for its chymification. The mucous membranes of the stomachs of certain persons, appear to be irritated by particular aliments, as the skin is known to be by particular coverings: I am acquainted with a person who can never wear cotton stockings without suffering from considerable cutaneous irritation; and I also know a gentleman who is incapable of eating the smallest quantity of mackerel without experiencing uneasiness in the stomach, and yet he digests every other species of food with facility: this is not disease, but idiosyncrasy, and it is very essential to distinguish them from each other. If, on the other hand, a person informs me that, as long as he lives upon mutton, or beef, that his digestion goes on well, but that if he cats pork, veal, or fried meat, he suffers from heartburn, and other unpleasant feelings in his stomach, I deduce a different conclusion, and infer that his general powers of digestion are feeble, and easily depressed ; and that he is consequently unable to convert into healthy chyme those aliments which require a higher degree of exertion. 150 Symptoms of a Fit of Indigestion. 254. There is no fact better understood, than that the living principle of our organs possesses the power of preventing the chemical changes to which their contents would, under other circumstances, be exposed. The blood does not coagulate or putrefy in the vessels; this urine does not undergo decomposition in the healthy bladder: nor does the food ferment in the stomach, unless that organ be in a state of disease; but if its vital powers fail, the chemical affinities gain the ascendency, and, after a certain interval, various symptoms arise, which clearly evince the change which has been produced. This is the philosophy of an ordinary attack of indigestion, when, either from the quantity or quality of the food, the stomach is inadequate to perform its necessary duties. An uneasiness and sensation of weight and distention is experienced in the region of the" stomach, acidity prevails, and eructations of disengaged air distress the patient; a sensation of nausea is felt, arising from an effort of the stomach to eject that which it is unable to digest. Chilliness is perceived, and a general lassitude arises from the sympathy which is produced on the nervous and sanguiferous systems. These effects are felt particularly towards the end of chymification, and, after a certain period, pass off, and the remaining parts of the process are apparently conducted with regularity. But this is a statement of the symptoms which attend a casual fit of dyspepsia, as it may occur to persons in health, from the influence of various circumstances, such as an overloaded stomach, indigestible food, a too hearty meal after long fasting or fatigue, obstructed bowels, or any other cause which may occasion a temporary debility of the stomach. It is only necessary, in such a case, to avoid in future the exciting causes, and to clear the bowels of ;»oy superfluous and crude matter which may be supposed to lodge in them. But lightly as we may, in general, treat a casual indigestion of this kind, cases are on record which should awaken us to a sense of its possible mischief, especially if the subject of it be a person advanced in life. If a patient retires to rest before the stomach is relieved from its load, he may pass into a comatose state, accompanied with apoplectic stertor, from which it is not unfrequently difficult to rouse him; and which arises from the sympathy of the brain with the oppressed stomach. It is of great importance to distinguish such an affection from genuine apoplexy, since, if the stomach be not relieved, the stupor increases, and the patient is lost. We should carefully examine the epigastrium, in order to ascertain whether any considerable fulness can be felt in that region, and inquire into the history of the patient: if he can be awakened, no time should be lost in administering an emetic, and it will be a safe practice to abstract a quantity of blood from the arm, which will have the additional advantage of accelerat- Its Causes. 151 ing the operation of any medicine that may have been administered for his relief. 255. It must, however, be allowed that such attacks from an overloaded stomach are not frequent; and are unlikely 1o occur, except the muscular powers of that viscus be so impaired as to prevent the usual efforts which nature employs to throw off an unmanageable burthen. 256. Should indigestion in the stomach continue to recur, the paroxysm will assume a more troublesome character; its symptoms will increase in number and extent, and the mischief will speedily involve other functions : but before I proceed to follow the course which it usually runs, it will be useful to examine the causes to which the origin of the disease in the stomach is to be attributed. 257. It has been stated (65) that, in every change which the aliment undergoes, we shall discover the combined operation of mechanical and chemical agents: when the food, therefore, is introduced into the stomach, it owes its conversion into chyme to such combined actions, viz. the chemical power of the gastric juice, and the mechanical movements of the stomach. It is to the failure or imperfect operation of the one or the other of these necessary actions that the indigestion is to be attributed. However perfectly the gastric juice may be secreted, if the mass be not sufficiently churned in the stomach, it cannot become perfect chyme; and the most active motions of the stomach will not compensate for a deficiency in the alimentary solvent. It signifies very little whether the paucity of the gastric liquor be absolute or relative; that is to say, whether it be originally secreted in less than a natural proportion, or the quantity of food taken be so great that the usual proportion of the solvent is insufficient for its solution; in either case, an indigestion must follow; although there appears to exist an accommodating power in the healthy stomach, which enables it to regulate its supply according to the call which may be made for it. 258. The quality and quantity of the gastric fluid, secreted by the stomach, may be influenced by causes immediately acting upon that organ, or by those which affect it through the medium of sympathy. < Under the first class of causes may be noticed those which produce a direct influence upon the nerves of the stomach, without whose healthy action no secreting surface can perform its functions with regularity. Amongst these, the injudicious ingestion of narcotic substances, or of alcohol, deserve a distinguished notice. The languor arising from inanition also brings on what Mr. Abernethy calls a " discontented state of the stomach;" in which case, the gastric juice is not secreted in a healthy manner. But the causes which act locally on the secreting powers of the stomach are few in number, and perhaps small in importance, when compared with 152 Indigestion excited by Mental Emotion, those which act through the medium of sympathy. During the periods at which the posterior stages of digestion are performed, the healthy secretion of gastric juice is not easily excited; and if, therefore, food be presented at these times, it will be apt to occasion indigestion. An overloaded state of the bowels will be attended with the same consequence; exercise, when accompanied with fatigue, or indolence, may, by producing general debility, occasion a corresponding state of collapse in the stomach. Passions of the mind, fear, anxiety, and rage, are also well known to affect the nervous system, and through that medium, the stomach; and so immediately are its consequences experienced, that a person receiving unpleasant intelligence at the hour of a repast, is incapable of eating a morsel, whatever might have been his appetite before such a communication. ¦"Read o'er this; And after this; and then to breakfast With -what appetite you have." 259. The sympathy subsisting between the skin is another source, and often an unexpected cause of gastric debility. If the cutaneous vessels be unusually excited, and this excitation be continued for any length of time, they will at length fall into a state of indirect debility, whence a sense of faintness, loss of appetite, and inability of digesting solid food, will be experienced; This fact explains the diminished appetite of which persons complain in hot weather, and that universal custom in tropical climates of combining the food with large quantities of aromatic stimulants. One of the most striking instances indicative of this-consent between the skin and stomach, is, where cold or wet is applied to the lower extremities, exciting pain in that organ and indigestion. Violent spasms, and in persons predisposed to gout, an attack of that disease in the stomach, have been occasioned by remaining for some time with the feet thoroughly wet. The custom of pouring spirit into the shoes or boots upon such occasions, from the mistaken idea of counteracting the evil, increases the mischief, from the additional cold produced by its evaporation. The first object, under such circumstances, is to prevent evaporation; and the chance of taking cold is greatly diminished, if not entirely prevented, by covering the wet clothes with some dry garment. It has been said, and perhaps with some reason, that the thin shoes and light dress render delicate females, notwithstanding their temperance, more subject to the whole tribe of dyspeptic complaints, particularly flatulence and want of appetite. 260. As the skin acts upon the stomach, so does the stomach, in its turn, re-act upon the skin; for all sympathies are reciprocal. A physician who is conversant with affections of the stomach, well knows how to appreciate the indications which the and by several other Causes. 153 appearance of the countenance affords; there is a peculiar pallor and relaxed condition of the skin, which is truly indicative of a deranged state of the digestive organs, and which gradually disappears under a successful treatment. The want of appetite for breakfast, which is complained of by invalids, is frequently to be attributed, amongst other causes, to the atony produced on the surface of the body, and consequently on the stomach, by sympathy, by the relaxing influence of a warm bed; and hence arises the utility of restoring a reaction, by fresh air and exercise, before we attempt to sit down to our morning repast. The warm bath, if not at too high a temperature, or indulged in for such a length of time as to induce indirect debility, will be found, by its stimulant operation on the skin, to place the stomach in a condition to digest the dinner when employed a few hours before that meal. I shall have to refer to these facts when I come to consider the modes of curing indigestion. 261. The influence of a healthy condition of the digestive organs upon the skin, is so well understood by those that direct the art of training, that the clearness of the complexion is considered the best criterion of a man being in good condition, to which is added the appearance of the under-lip, " which is plump and rosy, in proportion to the health of the constitution." 262. The stomach also sympathises, in a remarkable degree, with the urinary organs; nephritic complaints are invariably attended with nausea. I lately had a very troublesome case of dyspepsia under my care, which was aggravated, if not originally produced, by a troublesome stricture in the urethra, which kept up a constant irritation. 263. I have next to consider the causes which may operate in depressing or paralysing the muscular powers of the stomach, by which the mechanical process, essential to chymification, is imperfectly performed. Of these, undue distention is perhaps the most common, and, at the same time, the most powerful. This may be proved, not only from ample observation on the stomach, but by the analogy of other cavities: if the bladder be distended for some time with urine, its muscular powers are paralysed; it has often happened that where a person has, from necessity, retained his urine for a considerable time, on attempting to void it, he has found himself incapable of expelling a single drop, although the bladder has been ready to burst from over-distention. The same fact occurs with respect to the rectum : if this observation be applied to the stomach, we shall easily perceive why, in an over-distended state of that viscus, vomiting can scarcely be produced by the most violent emetic; and we shall readily understand from the same train of argument, how greatly the muscular fibres may become permanently debilitated by the repetition of such an excess. This X 154 Loss of Muscular Power in the Stomach. over-distention is particularly apt to occur in cases where the food has a tendency to swell, from the heat and moisture of the stomach ; for a person may not be aware of the quantity he has taken from any sensation of fulness at the time he ceases to eat, and yet, in the space of an hour, he may experience the greatest uneasiness from such a cause. This generally happens where much new bread has been taken; nuts have also this property in a remarkable degree, and ought, for such a reason, to be prohibited, where such an effect is to be apprehended. A draught of soda water, or any beverage which contains fixed air, may be visited with the same penalty. There are certain postures of the body, which, by preventing the necessary egress of the contents of the stomach, favour an accumulation in its cavity; this occurs in the occupation of the shoemaker, tailor, engraver, from stooping on the last, or desk, by which their thoracic and abdominal viscera are compressed together for many hours; the margin of their ribs is pressed upwards, so as to force the stomach against the diaphragm, and to impede the passage through the pylorus: it is evident, that if such a habit be continued after a full meal, that all the train of dyspeptic terrors must be produced; and we have all witnessed too many practical illustrations of the fact, to require farther evidence of its truth. The profession is much indebted to Dr. W. Philip, for having proved by experiments, related in his Inquiry into the Laws of the Vital Functions, that the muscular fibre, though independent-of the nervous system may, in every instance, be influenced through it; from which it follows, as a corollary, 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 the nerves. Hence, the presence of offensive matter in the stomach, whether arising from noxious aliment, or vitiated secretion, will have the effect of diminishing its muscular energy. It is in this way that a draught of cold water, or a quantity of ice, may at once paralyse the stomach. In cases, therefore, of protracted indigestion, it is evident that both the chemical and mechanical functions of the stomach will be injured; neither the one nor the other can long remain alone affected. Irritation of the nerves will occasion vitiated secretion, and vitiated secretion will become a source of irritation to the nerves. 264. We have seen the manner in which indigestion may take place in the stomach ; but there are cases in which the secretions of that organ are perfectly performed, and in which the muscular contractions of the stomach are carried on with healthy vigour and regularity. The chyme is, therefore, duly elaborated, and the paroxysm of dyspepsia may not commence until the food has entered the duodenum. Duodenal Indigestion. 155 Imperfect Digestion in the Duodenum. 265. In the earlier part of this work, the structure, position, and functions of this " second stomach," have been fully described, and the practitioner must bear in mind the peculiar circumstances which relate to its anatomy and physiology, in order to .understand the nature and extent of those aberrations to which it is liable. The chyme certainly undergoes some change in this organ, independent of that which is produced on it by its admixture with the bile and pancreatic juice, and which would appear to be effected by the agency of its own peculiar secretion ; this secretion may become insufficient in quantity to answer its intended purpose, or its quality may be occasionally vitiated ; but there exists no direct evidence upon this point, and we can only maintain the probability of such an occurrence on the ground of analogy. As far as the pathology of this organ is concerned, I consider the contributions of Dr. Yeats, in his paper published in the Medical Transactions, as truly valuable ; and I have great pleasure in bearing testimony of its importance. The hints which I have derived from it, have not only been useful to me, in the execution of my present task, but in the prosecution of my duties as a private practitioner. I am quite satisfied, that many morbid affections which have been usually attributed to the stomach, ought to be solely referred to the functional aberrations of the duodenum; and when we consider the situation of this intestine, with respeet to the colon, and the pressure which it must suffer whenever this latter gut is loaded with fasces; when we reflect upon the elaborate manner in which it is constructed; the connexion of its nerves with other organs; its limited capacity and motion; its tortuous course; the distress which must arise from its distention, and the irritation which, from such a cause, must be immediately propagated through its nerves to very important parts; when we remember that the pancreatic and biliary ducts may be obstructed by its repletion, and the necessary flow of the bile prevented ; and, lastly, when we consider that the vena cava inferior may be thus pressed upon, and the circulation of its blood obstructed, —we shall not have much hesitation in admitting that a morbid condition of the duodenum must prove a pregnant source of local as well as of general distress. It is also necessary to state that, from the confinement which this intestine suffers at its termination within the ring, at the mesentery, the propulsion of its contents is liable to be retarded or obstructed ; and, should any hard or indigestible matter have escaped the action of the stomach, it may, by lodging, occasion a temporary stoppage in this part of the canal. 266. The symptoms, which arise from duodenal indigestion, are easily distinguishable from those which depend upon an 156 Symptomatic Hcadach. affection of the stomach. In a casual paroxysm of this kind, the distress is not felt until some time has elapsed after the indigestible meal, and then no oppression is felt at the pit of the stomach, but on the right side, and a puffiness is frequently perceptible in the region occupied by the intestine. In some cases a severe pain is felt in the back, especially in the region of the right kidney ; and Dr. Yeats states a symptom, which I have also noticed on such occasions—a faint and fluttering pulse, occasioned by the pressure of the vena cava against the spine by the distended intestine. Emetics in such a case are safer remedies than purgatives; by their action, the offending substance is regurgitated into the stomach, and thus at once eliminated ; whereas a purgative may increase the distress, and even produce farther mischief. Glysters, however, will be always advisable, in order to remove any pressure which the colon may occasion by its indurated contents. 267. I believe that where indigestion in the stomach has remained for any considerable length of time, that the duodenum rarely escapes corresponding mischief; it is difficult to imagine a case in which the fluids of the stomach are constantly in a vitiated, and those of the duodenum in a healthy condition. The very circumstance of half-concocted chyme being repeatedly urged forward into the cavity of the intestine, will be sufficient to derange its functions. When, therefore, we take a general view of the symptoms which mark confirmed indigestion, we must take into consideration the effects produced by the derangement of this important organ. In some cases the evidence of such an affection will be more striking than in others, but in most we shall find some proof of its existence. 268. A casual indigestion in the duodenum may be produced by various causes; in addition to those already enumerated as capable of occasioning such an affection in the stomach, we may mention mechanical obstruction, arising from the presence of nuts, cherry-stones, &c.; a vitiated state of the bile, or a temporary suspension of its flow from the liver, by which the chyme will be prevented from undergoing its destined changes, and thus, remaining in the duodenum, may ferment, and distend the intestine with air; accumulations also in the colon, which, by diminishing the diameter of the duodenum, will necessarily impede its functions. Of Headachs which arise from Indigestion. 269. From the intimate sympathy which subsists between the nerves of the stomach and the brain, it is not extraordinary that any casual derangement of the digestive process should communicate its influence to the head. Dr. Warren* has described * Medical Transactions, vol. iv. p. 233. Symptomatic Headach. 157 this complaint with an accuracy which, as far as description goes, leaves nothing to be desired. He states that there are two forms of dyspeptic headach; the one he refers to a fault in the stomach, the other to a defective action of the upper bowels. The former is distinguished by a languid and feeble, but not an unnaturally frequent pulse; the tongue is whitish and slightlycoated ; the edges are of a pale red colour. The patient perceives a sensation of mistiness before the eyes, and general indistinctness of vision ; he feels a dull pain or weight in the head, attended with some confusion, is slightly giddy, and fearful of falling. These symptoms are attended with slight nausea, or an uneasiness and sense of irritation in the stomach ; and often also by a feeling of constriction about the fauces, accompanied with a watery secretion from the posterior part of the mouth. Coldness, slight stiffness or numbness of the fingers, are sometimes present; and the other parts of the system are, in general, affected with a great degree of nervous sensibility. The second species of headach, or that depending upon irritation in the bowels, probably in the duodenum, is remarkable for the appearance of brilliant ocular spectra which distress the patient; there is chilliness of the body, and coldness and dampness of. the hands and feet; the pain in the head is very severe, attended with a sensation of coldness and tightness of the scalp, slight giddiness, weight, distention and stiffness of the eye-balls. In some cases, as these symptoms increase, they are accompanied by tingling and numbness of the fingers and hand. The tongue, in this disorder, is usually covered with a yellowish white fur, and is often very considerably coated with it. The pulse is of the natural frequency, but languid; nausea is often present, but seldom in so great a degree as to produce vomiting. There is usually flatulency, and a sensation of dryness and inactivity of the bowels. This last symptom I consider as pathognomonic; the patient feels as if his bowels had lost their sensibility, and were unable to propel their contents, which occasions a peculiar sensation of weight and stoppage. Dr. Warren observes', that the appearances of the stools vary so much, that a general rule cannot be drawn from them; but he believes, that in all cases of headach of this description, they will be found of an unhealthy quality. The most frequent appearance in them is bile in too large quantity; sometimes of various colours, and of different degrees of viscidity; occasionally the evacuations have a natural appearance, but contain portions, of undigested food. At other times, the stools are of a faint yellow colour, and float upon water, giving out an odour like that of saliva : a very common appearance, especially where there has been great dejection of spirits, is a loose stool, of a dark greenish-brown colour, in smell resembling that of the grounds of sour beer. 270. The stomach headach generally occurs in the earlier Headach and Plethora. 158 stage of digestion; that which may be termed the duodenal headach, takes place when the food has passed into the intestine. The former is relieved by an emetic, the latter receives no mitigation from such a remedy; this is consonant with our theory of its origin; whereas, a purgative, as we should expect, generally cuts short the paroxysm, by hastening the expulsion of the offending cause. 271. From the symptoms above related, the practitioner will not be at a loss to discriminate between these two species of headach; but pain in the head may arise from causes distinct from the alimentary canal; as from congestion of the brain, from its internal disorganization, from diseased bones of the skull, or from a deranged state of the nervous system. It will be useful to point out the diagnostic symptoms by which each of these affections may be distinguished. Dr. Warren observes, that headachs which arise from congestion of the brain, are distinguished from those of dyspeptic origin, by the presence of plethoric symptoms, by a full and oppressed pulse, by a difference in the character of the pain, which, in the headach arising from fulness of blood, is accompanied with throbbing, and a sense of action in the system,,which alarms the feelings; while the pain of dyspeptic headach is described as being either a dull aching, or else a racking pain, often moving from one part of the head to another, and attended with soreness of the scalp. In the first, the eyes look red and full; in the second, they have a depressed and languid appearance. Those which arise from internal disorganization, the same eminent physician considers to be marked by an acute fixed pain, by a quick, irritable, and sometimes irregular pulse; but should pressure on the brain have taken place, the pulse is full and slow, but is not attended with the steady violent heat which accompanies sudden congestion of blood in that organ. When headach is caused by chronic disease of the bones of the skull, it is distinguished by the constancy of the pain, which is confined to one spot, whence violent shoootings proceed to some fixed point. As the disorder advances, slight symptoms of pressure on the brain ensue; and on examination, a tenderness of the bone is observed. The nervous headach is distinguished by the absence of constitutional disorder, and by the smallness of the space on the surface of the head which the pain occupies. 272. There sometimes occurs a soreness of the scalp, with shooting pains, which are produced by the slightest touch. This affection, I believe, always depends upon some derangement of the biliary system. 273. There is a species of headach which would appear to depend upon a languid circulation through the brain; it occurs after an excess of wine; or, in women, during the catamenial discharge. It is described as rather resembling numbness than Biliary Derangement* 159 pain, or that sensation which is produced by intense cold. The languor of the circulation, pallor of the countenance, and other symptoms of debility, will offer sufficient means for distinguishing it. 274. If the dyspeptic headach be allowed to take its course, it will generally terminate in a few hours; but when it has become habitual, it is often protracted through one, two, or more days. Its cure is to be effected by those means which we have afterwards to consider, as the best modes of rectifying the errors of the digestive organs. 275. Cutaneous eruptions are not unfrequently produced by a fit of indigestion; such affections are popularly denominated surfeits; they are generally of short duration, and disappear on the removal of the offending cause; although severe and inveterate diseases of the skin are sometimes established, and continued by a chronic disease of the stomach or other digestive organs. The best mode of treating such affections, and the diet which should be employed for their cure, will form a subject for future consideration. Indigestion from Biliary Derangement. 276. It .is evident that a regular and healthy secretion of bile is indispensable to the act of chylification, and to the proper action of the intestines, and that a deficiency, redundancy, or a vitiated condition of this fluid, may act as an exciting cause of indigestion. If it be deficient, the chyme cannot undergo that decomposition in the duodenum by which chyle is formed and separated; and as the bowels are, at the same time, deprived of their natural stimulus, the undigested mass is not protruded, but is left to undergo various morbid changes; air is extricated, the alimentary secretions become depraved, and the whole series of the digestive functions are thus suspended, or deranged. If the bile be too copiously secreted, it is poured out in large quantities into the intestine, producing temporary diarrhoea, and part of it being regurgitated into the stomach, during the act of vomiting, which, in the first instance, is excited by the sympathy of the stomach with the duodenum and hepatic system, occasions a train of symptoms of greater or less severity, according to the circumstances of each particular case. If the bile be vitiated in quality, it will not only be incapable of accomplishing the alimentary change which it is destined to fulfil, but it will irritate and fret the mucous membrane by its contact. It is evident that the violence and extent of the symptoms produced by such causes will be liable to vary; and the practitioner must not imagine, that the absence of diarrhoea, colic, and other violent feeli ngs, affords evidence of the healthy state of the biliary secretions. Derangements in these functions often proceed insi- 160 Biliary AJfeclions. diously, and lay the foundation for a serious disease, which, although latent for a period, will ultimately be kindled into activity, whenever an exciting cause shall fire the train. 277. To explain the origin of biliary irregularities, we have to consider the sympathies by which the liver may be influenced. The investigation of the diseases of warm climates, and the corrected views, with regard to the autumnal complaints of our climate, have sufficiently established the existence of a sympathy between the skin and the liver. Whenever an organ has been in a state of over-excitement, it is liable to fall into a corresponding state of torpor. The perspiration is, therefore, more apt to be checked after the continuance of hot weather, than at any other season of the year; and since the same observation may be extended to the liver, we shall readily perceive the cause of those biliary affections which so generally occur in this country during the autumnal season. The application of cold to the feet, or whatever contributes to check the perspiratory functions, may create, in those predisposed to such complaints, a bilious attack. The sympathy which subsists between the stomach and liver, has already been adverted to. It seems a wise provision, that the biliary functions should be connected, by a close sympathy, with that of the stomach, in order that the food, converted into chyme, may meet with a necessary quantity of bile in the duodenum. In consequence'of such a sympathy, irritation in the stomach is generally attended with an increased secretion of bilej the action of nausea is usually followed by such an effect. Hence, melted butter, every thing fried, pastry, and other indigestible materials, are popularly denominated bilious; and although such a term countenances a latitude of expression, which is inconsistent with the more definite notions of strict pathology, yet it cannot be said to be erroneous. As the varied and increased action of a gland has much influence in determining the nature of the fluid secreted, we cannot be at a loss to explain the vitiated condition in which the bile is secreted under such circumstances; indeed, it is frequently on such occasions of a degenerated colour, extremely acrid, and scarcely possessing the qualities of bile. Dr. Saunders considers it probable, that from the quantity secreted, and the rapid manner in which it is poured into the duodenum, there is not time sufficient for a perfect secretion. 278. We may therefore agree with Dr. Saunders, that whenever, either from an irregular distribution of nervous energy, or from the operation of indigestible and acescent food, the tone of the stomach falls below the degree necessary to the digestive process, the liver immediately sympathises with it, and bile is no longer emulged into the duodenum, until a reaction takes place, when its quantity is morbidly increased in proportion to the degree of previous atony. If this occur to such an extent^ Symptoms of Chronic Indigestion. 161 that its free admission into the intestine be impeded, it will accumulate in the excretory ducts of the liver, ahd either regurgitate into the system by the hepatic veins, or be absorbed by the lymphatic system, and a yellow suffusion of the skin will follow. 279. The abuse of spirituous liquors, from their operation on the stomach and brain, is a fertile cause of biliary derangement, and from the between the sensorium and the liver, the effects of strong and sudden mental emotions, in occasioning an irregular secretion of bile, will also admit of satisfactory explanation. ' • . Progress and Symptoms of Chronic Indigestion. 280. From considering a fit of indigestion in the stomach or duodenum, let us now proceed to trace its consequences, when it is frequently repeated or protracted. In this case, other organs become successively involved in the mischief, and a train of distressing and complicated symptoms arise. Dr. Wilson Philip has considered indigestion as divisible into three distinct stages. Under the first, he arranges those symptoms which merely announce a disturbed and unhealthy condition of the digestive functions. The second stage he considers as denoted by the tenderness of the epigastrium, and the hardness of the pulse. The third stage includes those diseases which he supposes to arise from the change of structure, which is ultimately produced by long-continued functional derangement. I have no great objection to a conventional division of this kind, if it can in any way assist the memory of the practitioner, and contribute to the perspicuity of the description, by presenting the symptoms in well-defined groups, rather than in a separate and. unconnected form. But the arrangement is wholly artificial. Nature does not acknowledge it, nor will she submit to it; if, then, any advantage is to be derived from it, it must be received and considered only as an attempt to class together those symptoms which may arise from functional aberration, and those which are more usually associated with organic change. We must renounce all rigid adherence to definite stages, and arbitrary divisions, which nature disclaims/ Every practitioner of any experience must well know that the hard pulse and tenderness of the epigastrium are likely to occur in even a temporary attack of indigestion; and I have frequently witnessed extensive mischief, with change of structure, without the occurrence of such indications. With regard to the "third stage," I would observe, that if the diseases therein stated as the results of indigestion, be purely such, we may as well, at once; refer all organic disease to the same source, and, like the ancient physicians of Egypt, confine our prescriptions to vomits, purgatives, and ab- Y 162 Dyspeptic Phthisis; Doubts respecting. stinence. I am well aware how unpopular must be any doctrine that opposes such'a belief, for I have practised too much in the western part of Cornwall, not to know the consolation which phthisical patients derive from being assured that their complaints owe their origin to a disordered stomach ; but although the physician may reconcile his conscience thus piously to deceive his patient, let him be aware how he deceives himself. I make these observations in the pure spirit of philosophic candour; I respect and duly appreciate the talents of Dr. Philip; I give him every possible credit for the good intention -and integrity with which he advances his opinions, and I feel well assured that he will extend the same charity to me; but I differ with him. Indigestion, or, in other words, derangement of the stomach, is a frequent companion of pulmonary disease, and what is the disease in which the stomach does not sympathise? but I am sceptical as to the existence of. any malady which is entitled to the specific appellation of " dyspeptic phthisis " A person having tubercles in the lungs may have his life protracted for many years, by judicious management, and by avoiding every exciting cause which might kindle the spark into flame, by keeping the circulation in check, and promoting the healthy action of the secretions. On the contrary, the fatal termination may be equally accelerated by want of care, and, above all, by creating a permanent disturbance in the digestive functions. If Dr. Philip designates a latent disease, thus kindled into activity, " dyspeptic phthisis ," I have no objection to the term; we are no longer at issue, our difference of opinion is not essential; it is an affair of words, and of words only. But to return from this digression to the subject more immediately before us, viz. the complicated train of symptoms which successively present themselves in cases of protracted dyspepsia. 281. It has been seen that indigestion may originate in the stomach, or intestines, either from vitiated secretion, muscular imbecility, nervous derangement, or biliary and pancreatic disturbance; but, from whatever cause the disease may primarily originate, after it has remained for some time in operation, the different organs, directly or sympathetically connected with the chylopoietic apparatus, will participate in the mischief, and it will not be easy to distinguish between primary symptoms, and those of mere induction. There is, perhaps, not any disease which is more protiform in its aspects than dyspepsia: we shall rarely find any two cases precisely similar in the origin and progress of their symptoms, although to an experienced judge they will present such a general similitude, as to leave no doubt of their nature and causes. 282. The dyspeptic patient having, for some time, suffered from those feelings of uneasiness, which have been already de-i scribed (254), experiences some diminution in his strength. Netv Symptoms successively developed. 163 This, at first, is only occasional, and is for a while attributed by him to some accidental circumstance; he had felt it before, and the readiness with which his elasticity and strength returned, naturally inspires a hope that his present depression may be removed; but it has endured longer than usual, and he ultimately becomes alarmed. It is in this stage of the malady, that the patient frequently introduces himself, for the first time, to a physician. It is of great importance, upon such an occasion, to distinguish between that feeling of transient depression, which as Tissot observes, is invariably associated with alimentary disturbance, and that debility which announces a general diminution of constitutional energy. In the former case, there are periods in which the patient feels perfectly well and strong; but in the latter, although his spirits may vary, he never rises to the healthy standard of vigour. He tells you. that " he begins to feel his usual avocations irksome, and too laborious; that he has long suffered from a bad digestion" which by care and management he had been hitherto enabled to control; but that he has now little or no appetite, that his strength fails-him, and that he fears he is " getting into a bad way." He finds that the slightest exercise occasions fatigue, and deluges him with perspiration. On examining the tongue, it will' be usually found coated on the posterior part, and on its centre, with a brownishyellow fur; his bowels are, by turns, costive, and too much relaxed; the pulse at this period is generally slow and small; although it is sometimes hard; his countenance is more pallid than usual; the eyes appear sunken, and the eye-lids swollen, and the eye-halls are occasionally injected with yellow streaks. In some cases, heatburn and a sense of oppression are experienced after meals; but in others, the patient only complains •f languor and extreme listlessness. On some occasions, a sense of constriction is felt about the fauces, and a of swallowing is experienced, as if the oesophagus presented some mechanical obstruction to the passage of food. Dizziness; unusual drowsiness; pains in the head; ringing in the ears; a disagreeable taste in the mouth ; an altered state of the salivary secretion, being sometimes limpid like water, and at others thick and ropy; palpitation and a sense of faintness are symptoms which, also, in a greater or less degree, usually distress the dyspeptic sufferer. His hands are alternately hot and cold; in the former state they are dry, in the latter more usually damp. His nights are sometimes, but not generally, disturbed by restlessness and uneasy dreams. He wakes in the morning without that feeling of refreshment which follows repose in health, and is unwilling to rise from his bed, or indeed to move; his limbs ache, the muscles of the trunk are even sore to the touch; and any change of position is attended with inconvenience. Every alteration in the weather is felt as a serious evil; if it becomes a degree or Symptoms of Indigestion. 164 two colder, he creeps to the fire, and inveighs, in terms of bitterness and sarcasm, against the variableness of the climate; if its temperature be raised, he is oppressed with heat. His bowels become more and more untractable; the usual purgative* ceases to produce its accustomed effect; he increases the dose, and when it does operate, the action is too powerful, and its effects are not easily checked ; a diarrhoea is established; and this again, in its turn, is superseded by still more obstinate constipation. If I could but obtain a medicine, cries the invalid to his physician, that would keep my bowels in a regular state, I should soon become convalescent: there lies the difficulty; the evil arises from the inconstant and unsettled state of the alimentary secretions, and it is not easy to graduate an artificial stimulant so that it shall always correspond with the varying state of the organs upon which it is to operate. The depression of his spirits increases as the disease advances; he gives his case up as lost; loses flesh, suffers a thousand distressing sensations, and fancies the existence of a thousand more. Wandering pains are felt in the bowels and side; a tenderness in the epigastrium is experienced on pressure; the abdomen is often preternaturally tense; his breathing is occasionally oppressed; a short dry cough distresses him, and expectoration is extremely difficult. If, under such circumstances, the alvine discharges be inspected, they may present every variety of morbid appearance; they may be unnatural in colour, odour, consistence, figure, or quantity. I shall, hereafter, have occasion to speak more fully»upon this subject, as well as upon the morbid appearances which the urine presents under such circumstances. 283. The patient, in this stage of his complaint, will sometimes complain of being disturbed, on first falling asleep, by fearful startings, and catching of the limbs, uneasiness in the region of the chest, attended with difficulty of breathing, so as to resemble angina pectoris; and it is not unusual for him on such occasions to perceive flashes of fire, like lightning, with a numbness in his hands; this numbness is sometimes only felt in one or two fingers. Sore throat, occasioned by relaxation, is also a very usual symptom; the skin is frequently dry, and even scaly; the tongue also becomes drier, and sometimes clean, and of a brighter colour than usual. Harassed by such feelings, the unhappy invalid anxiously proposes a trial of change of air, and his friends acquiesce in the belief that such a plan will tend to his recovery. He quits his residence, but to no purpose, his emaciation increases; his ankles swell; and the general debility thus produced sooner or later calls some other disease into activity, the nature and locality of which will necessarily vary in different cases. If the spring of a«piece of machinery snaps, and all its different parts are hurried into violent motion, the wheel upon which the greatest strain is made, Symptoms of Indigestion. 165 or that which is of the weakest construction, will be the first to give way. Just so is it with the human body. Those organs more immediately connected with the digestive function will more readily undergo a change of structure, on account of the protracted irritation they must have sustained. Then, in succession, those which are connected by the ties of sympathy; while the general loss of balance, thus occasioned, will render any organ, originally weak, very liable to disease. This view of the subject is supported by experience; the history of those complaints which terminate the life of the dyspeptic patient, will sufficiently explain the manner in which they were produced. Unless they take their origin in a viscus immediately connected with the digestive functions, as in the stomach, intestines, mesenteric glands, liver, &c. dyspepsia can only be considered in the light of a general debilitating cause ; and it is a circumstance no less extraordinary than important, that when any new disease is permanently established, the original symptoms are mitigated, and sometimes wholly suspended; whereas, if the new affection be only symptomatic, instead of relieving, it often aggravates them. 284. Dr. Philip lays great stress upon the hardness of the pulse, as indicative of approaching mischief; I confess that my experience does not confirm the importance he has ascribed to it. The permanent tenderness of the epigastrium, and a clean bright tongue, always excite a greater apprehension in my mind. The pulse is very treacherous in its indications: I have found it to be soft and undulating in cases where no doubt could exist as to the presence of organic mischief. It is just, however, to state that Dr. Philip acknowledges that its hardness is sometimes only perceptible when examined in a particular way. He says that those who have been much in the habit of examining the different states of the pulse, must be aware, that its hardness is most perceptible when a slight degree of pressure is employed. A certain degree, by greatly compressing the vessel, will give some feeling of softness to the hardest pulse, and a slight degree of hardness is not perceptible with the pressure generally employed in feeling the pulse. If the pressure be gradually lessened till it comes to nothing, it often happens that a hardness of pulse is felt before the pulse wholly vanishes under the finger, when no hardness can be perceived in the usual way of feeling it. 285. I consider the train of reasoning by which Dr. Philip establishes the important fact, that long-continued irritation at length terminates in inflammation and organic derangement in the part affected, —as constituting a very valuable part of his work. The idea is certainly not new, but the.cases which he has adduced in illustration of its truth, are apposite 166 Organic changes in the Bowels. and very satisfactory. The practical mischief which arises from a neglect of the fact is, I am satisfied, very extensive. 286. After indigestion has continued to harass the stomach for some time, its villous coat becomes affected, and as the pylorus, from the peculiar nature of its office, is more exposed to the continued source of irritation than other parts of the stomach, it is certainly, as Dr. Philip justly states, very liable to become inflamed, and the tenderness in the epigastrium may perhaps in some cases be thus explained ; but it must be remembered that, in internal diseases, the pain is frequently referred to a part at some distance from the real source of it; a morbid distention of the liver, an irritated state of duodenum, and a gorged condition of the colon, are not uncommonly attended with the same feeling. It is, at the same time, difficult to imagine, how serious mischief can be inflicted upon the pylorus without the occurrence of vomiting. 287. When the bowels have been long in a state of disorder, the villous coat becomes tumid, turgid with blood, and sometimes ulcerated; and Mr. Abernethy states that these appearances have been most manifest in the large intestines. He says, that he has repeatedly observed, in dissections of these cases, the large intestines to be more diseased than the smaller ones, and he accounts for this fact in the following manner. If digestion is incomplete, the undigested food must be liable to chemical changes, and the products resulting from this cause are likely to be most stimulating to the large intestines. Indeed, he adds, in advanced stages of this disorder, mucus and jelly tinged with blood are discharged, and it seems probable that a kind of chronic dysentery may be thus induced. In my own practice, I have witnessed several cases of this kind ; but I confess that I cannot perceive why the duodenum and smaller intestines should not be equally exposed to such a source of irritation. 288. It is not extraordinary that protracted dyspepsia should sometimes terminate in a disease of the mesenteric glands; it is only surprising that such a state of irritation and imperfect development of chyle should continue for so long a period, as they are in many cases known to do, without occasioning such an effect. We must suppose that the selecting tact with which the lacteals are endowed, enables them for a considerable time to reject imperfectly formed or vitiated chyle, and that it is not until this is destroyed, that the irritating matter finds its way to the glands. The circulating fluids of the body are for the same reason not materially deteriorated until the dyspeptic disease has continued for some time; the blood then undergoes some, important change, but animal chemistry is not yet sufficiently advanced to demonstrate its nature. I have examined the blood of a patient who had long laboured under a disease of Organic changes in the Bowels. 167 the digestive organs, and the most remarkable character which it presented was the loose texture of its crassamentum, and a deficiency in its red globules. In some cases the serum assumes an opaline appearance. 289. When we consider the connexion which subsists between the function of the kidneys and that of the chylopoietic organs, we shall easily explain the disturbed appearance of the urine, and the occurrence of calculous disorders in cases of dyspepsia. 290. Before I proceed to consider the medical treatment and dietetic regulations most appropriate for the cure of the several forms of indigestion, it will be necessary to inquire into the remote and immediate causes of that disease. In fulfilling this part of my duty, I shall deviate from the usual plan of such investigations, and arrange my observations in an order that may, in some degree, correspond with that which should be adopted by every physician who undertakes to examine a patient with a view to detect the cause, nature, and seat of his disease. I shall first present the reader with a tabular arrangement of the objects of such an inquiry, and then comment upon the relative importance of each. 168 A SCHEME FOR INVESTIGATING THE CAUSES, NATURE, AND SEAT OF INDIGESTION. I. LEADING QUESTIONS, concerning rl. Their Nature; Intensity; Duration; Permanence and Lo- I cality. 2. Their Accession; Concourse; and Order of Succession. Specific J Whether increased or Mitigated by any particular Posture or Motion , Ca. The Patient's own belief, \A. Assignable Causes. < b. Preceding Ailments. £c. Hereditary Predisposition. Strength and Regularity of Voluntary Motions. " Animal J 2. —— Sensations. Functions. ] 3. ¦ Intellectual Operations. Ya. Strength, ft, Pulse, -with respect to 1 *' Vital j Itf- Order. Genebal J Functions. 1 2. Respiration. StmptomM C a. Its Degree. \3. Animal Heat, < b. — Uniformity. (_c. Equable Diffusion. {1. Appetite and.Thirst. 2. State of the Tongue." 3. State of tbe Secretions. f^ (_b. Cutaneous. 4. — Excretions. $ a a-f™™(_b. Urinary. ft Age. Ca. Whether sedentary or active. j b. ————- conducted in any particular 2. Occupation. -( posture. _, I c. 1 i7t heated rooms, or in the open Pabtictjlar j [air Circumstances. fa. With respect to 3. Former Habits and Customs. 1 b of Mnd V. ' and Body. t_4. Residence. Climate. II. OCCASIONAL QUESTIONS, concerning CI. State of Menstrual Discharge.. Females. <. 2. Married or Unmarried State. (_3. Impregnation. Lactation. Number of Children. Children. 1. Dentition. 2. Former Diseases. 3. Diet, &c. III. GENERAL OBSERVATIONS, upon CI. Bulk and Stature. 2. Particular Conformation. Physical )n Complexion and Physiognomy. 4. Mobility and Ifritft- Chabacteb. £ bility. IV. COLLATERAL CIRCUMSTANCES. 1. Season of the Year. 2. Nature of Prevailing Epidemics. Ca. Moisture and Dryness. 3. Weather. < b. Prevailing Winds. C.c. Abundance and quality of Fruits. v? Commentary upon the preceding Scheme. 169 A COMMENTARY UPON THE PRECEDING TABLE. 291. In order to illustrate the relative importance of the several subjects which are embraced in the preceding tabular scheme, as well as to direct the practitioner into the more direct path of pathological inquiry, let us suppose a person, labouring under some one of the forms of dyspepsia, to present himself for examination. We first learn, from his own report, the general nature of the symptoms by which' he is distressed; and we then proceed to make such farther inquiries as may enable us to form an opinion respecting their origin and mode of cure. 292. The intensity of the symptoms cannot be always inferred from the patient's own report, but must be deduced from our experience in such cases. The dyspeptic is too apt to depict his feelings in extravagant language, and to become unnecessarily anxious and apprehensive. An inquiry into the duration of his complaints is of much importance; for it has been already stated (283) that the intervals of comfort are abridged as the disease progresses, until at length he becomes harassed by an uninterrupted series of sufferings. It is, however, from the locality of the symptoms that we are to form our. opinion with respect to their seat and origin; and for ascertaining this fact we must be particular in our inquiry, and minute in our examination. Is the stomach affected ? If a sense of weight or burning after the ingestion of food, acid, or putrescent eructations be present, we may conclude such to be the case. If there exist any uneasiness or fulness in the epigastric and right hypochondric regions, produced or increased by pressure, we may infer that there exists some diseased condition of the liver, duodenum, or, perhaps, of the pyloric orifice of the stomach; and that we may be enabled, under such circumstances, to form a diagnosis, the patient must be submitted to a manual examination. For this purpose, every ligature must be removed from the abdomen, and he must be .placed on a sofa, reclining on his back, with his legs drawn up, so as to throw the abdominal muscles into a state of relaxation. Where the fulness and tenderness arise from a distended state of duodenum, the sensation given to the hand is very different from that which is produced by organic disease of the liver; the tumor in the former case is more diffused and less defined. Dr. Yeats also justly observes, that, by pressure on the region of the liver, no uneasiness will be complained of, but if the pressure be made with the edge of the open hand under the ribs, with the palm of it flat upon the abdomen, considerable uneasiness will be felt up towards the liver, and down towards the right kidney; a soreness is likewise felt an inch or two to the right, just above the navel.. In such cases also, the anatomical accuracy with which the patient will trace the course of the duodenum with his finger, from the stomach to the loins on the Z 170 A Commentary upon the Scheme right side, and back again across the to the umbilicus, will greatly assist the diagnosis. There are, besides, other sympr toms to be hereafter enumerated which will enable us to arrive at a still more positive conclusion. It is of the greatest importance to distinguish between a morbid state of the duodenum and that of the liver: I have frequently, in the course of my own practice, seen patients who have undergone salivation, from a belief in the existence of hepatic disease, but who were merely suffering under duodenal irritation; and my friend Dr. Yeats has stated the same conviction upon the subject. On the other hand, I am equally satisfied that chronic inflammation of the liver has been repeatedly mistaken for a dyspeptic state of the stomach. Dr. Saunders says, that he has seen many cases of this kind, which have been supposed to arise from indigestion. The patient generally complains of pain, which he falsely attributes to the stomach; and its continuance is so short, and the degree of it frequently so inconsiderable, that no alarm respecting the future health of the patient is produced. The relief obtained by eructation and discharge of air, tends to confirm the opinion that the seat of the disease is in the stomach; but this relief may be explained on the principle of removing the distention of the stomach, and so taking off the pressure of this organ from that which is the seat of the complaint. 293. Where the tenderness in the epigastrium is extremely circumscribed, not occupying a space larger than a shilling, Dr. Philip infers the presence of an inflammatory affection, or a state approaching to it, of the pylorus, excited by the passage of the irritating contents of the stomach. I have already expressed some doubt upon this subject; I cannot conceive such a state of pylorus, as to occasion pain on pressure, to be unattended with vomiting. 294. The accession, concourse, and order of succession of the different symptoms, are calculated to throw considerable light upon the nature of a dyspeptic disease; indeed, in protracted cases, it is only by a careful examination of these circumstances that we shall be able to separate primary from secondary affections. The stomach cannot long err without communicating its vice to the other chylopoietic organs; the liver may become affected from mere irritation, and every part of the body, from sympathetic influence, may put on the appearance of disease. How are we then, except by a careful examination into the history of the case, to ascertain the organ in which the mischief originated ? 295. Whether the symptoms are mitigated, or increased by any particular posture or motion. This is an important question. Where the disease is confined to the stomach, the patient appears capable of lying with equal ease on either side: but if the duodenum or liver be affected, he will experience some un- for investigating Dyspeptic Disease. 171 easiness on lying on the left side. Where the disease has become complicated, lying on either side is irksome, and the easiest position is found to be that of lying on the back, with the shoulders a little raised, and inclined to the right side. The muscles of the chest are, on such occasions, not unfrequently sore, and the patient finds it difficult to turn even in his bed without pain. 296. Assignable causes. It will be always right to inquire of the patient whether he can account for the accession of his disease. He will tell you whether he has exposed himself to the operation of any of those causes which are known to be active in producing it. His previous state of health should also be investigated, for we may be thus enabled to explain the occurrence of symptoms, and to connect them with the derangements of distant organs. An affection of the stomach may, for instance, be traced to some sympathetic action, which might otherwise be mistaken for a primary disease. 297. Hereditary susceptibility. So many vague notions are entertained upon this subject, that it will be necessary for me to define the latitude in which the term is to be received. Dyspepsia, depending upon peculiarity of stomach, is certainly hereditary, but it is only hereditary in predisposition, always requiring the influence of some cause to produce it, and consequently always to be prevented, and often relieved, by avoiding the exciting cause. In cases of great obscurity, a knowledge of the disease to which the patient's parent is particularly obnoxious, must, for reasons sufficiently obvious, assist our judgment. 298. Having acquired all the information which is to be obtained by questioning the patient upon the subject of his "specific symptoms," we are next to investigate the "general symptoms," connected with the animal, vital, and natural functions. In this line of inquiry, the judgment which we have been able to form will be confirmed or modified; we shall, at the same time, be enabled to discover the influence which the local affection has produced upon the general system. 299. It has been already observed (283) that the strength of the patient, both as it regards the voluntary motions, and intellectual operations, does not suffer until the dyspeptic disease has acquired a considerable influence over the system. The condition, therefore, of these functions will serve as a measure of the severity of the complaint; but in forming such an estimate we must be careful to avoid the fallacies with which it is surrounded (283). 300. The pulse only affords indications of questionable value; when taken in conjunction with other symptoms it may serve to fortify our conclusions; but I am anxious to impress my strong conviction upon the mind of the practitioner, that when 172 A Commentary upon the Scheme received as an isolated testimony, it will be liable to lead him into error. Its strength, when other evidences concur, will undoubtedly throw some light upon the general state of the vital powers; its frequency may indicate a state of morbid excitement, its hardness must excite the suspicion of organic mischief, and its irregularity will denote a disturbed state of the circulation, the cause of which must be deduced from other symptoms. 301. The state of the respiration is a" circumstance worthy of attention; for it may concur, with other symptoms, to indicate a state of congestion in the abdominal viscera, by which the descent of the diaphragm is impeded. It will also suggest other states of primary or secondary disease, the nature of which the reader will easily understand from the various observations which are interspersed through the preceding pages of this work. 302. Animal heat. The degree, uniformity, and equable diffusion of heat are circumstances of some importance: they will enable us to form some estimate of the state of the vital powers generally; and when we consider what an intimate connexion subsists between the temperature of the body and the different stages of digestion, it will throw some light upon the comparative energy with which they are performed. 303. With regard to the indications afforded by the state of the appetite for solids or liquids, I have already delivered my opinions. 304. The appearance of the tongue has also been noticed in the preceding pages of this work; it is natural to expect that a part, which is so immediately connected with the functions of the stomach, should be the first to exhibit a deranged condition in dyspepsia, and we accordingly find this to be the case. Baglivi has said that the pulse may deceive you, but that the indication afforded «by the tongue is infallible. It greatly varies, however, in appearance, in different cases, and in different stages of the same case. When white and milky, it announces general irritation. When brown or dark coloured, foul congestions in the prima? viae, or the presence of vitiated secretion; and when unusually bright and shining, a morbid condition of the villous coat of the stomach or intestines, which is usually associated with, or is the precursor of, organic mischief; for it indicates the presence of a degree of fever not commonly excited by the simple functional aberrations of the digestive organs. In some Cases the tongue is comparativel) 7 clean, but its cuticle loses its natural hue and transparency, and presents a sodden appearance: this generally depends upon the secretions having been for a considerable length of time in an unnatural state. 305. The salivary secretion is susceptible of various morbid conditions, to which the labours of the animal-chemist have not hitherto been directed (24); it is sometimes unnaturally ropy or for investigating Dyspeptic Disease. 173 viscid, so as to occasion an incessant hawking; at other times it is so preternaturally thin and copious, as to be discharged from the mouth in considerable quantities. I have lately seen a dyspeptic patient who declares, that his pillow is thoroughly wet in the morning with the discharge which takes place during the night: and yet dryness of the mouth, and a parched tongue, are amongst the most disagreeable of his symptoms, as if the secretion had lost the power of lubricating the parts to which it is applied. Frank states that he has known the saliva, when secreted in unnatural quantities, to have become saccharine. 306. The state of the cutaneous discharge is a circumstance of more importance than physicians usually assign to it. The reciprocal connexion which subsists between the functions of the skin and stomach is so obvious, that if the latter be deranged, the former is immediately infected, and vice versfi. It is the change produced upon the skin which assists in bestowing that peculiar physiognomy so characteristic of protracted indigestion; and amongst the most useful remedies in this disease, will be found those which are calculated to restore the healthy action of the cutaneous organs. When we remember that a person in health who takes eight pounds of aliment during the twentyfour hours, will discharge five of them by perspiration, we shall readily perceive how greatly the suspension or derangement of such a function must burthen the digestive organs. 307. The condition of the excretions, as to quantity and quality, is another object of important inquiry. I shall first describe the different appearances which the faeces may present in the various states of chylopoietic disturbance. On some occasions they will contain an excessive quantity of bile, on others they will not be sufficiently tinged with that secretion, and will therefore assume a light yellow, or a clay-brown colour. They will sometimes more particularly indicate by their appearance the presence of vitiated secretion, and have a dark olive, or a blackish-brown hue. In some cases they have so far degenerated as to resemble pitch. Where the biliary secretion has been irregularly supplied, the fasces may assume a partially coloured appearance. It is not unusual to notice mucous and gelatinous matter, accompanying, but not mixed with the fasces, and which have been sometimes mistaken for worms. It must have derived its origin from the alimentary membranes, or from the glands situated in the canal. There is a very peculiar morbid evacuation which I have occasionally witnessed, and which has been described as resembling yeast in colour and consistence. This frequently comes on suddenly, and as suddenly departs; it is generally very profuse in quantity, and is usually preceded by uneasy sensations in the alimentary canal. It would appear to be a morbid secretion of the intestinal juices during a torpid state of the liver: although in one case in which I witnessed its 174 A Commentary, 8?c. occurrence, it was evidently connected with a diseased state of the pancreas. I may, in this place, take notice of the appearance of fat-like lumps of matter which are sometimes passed from the intestines, f suspect that they are inspissated portions of mucus from the coscum; I have, at least, observed such evacuations to be accompanied by pain in that region. In most cases of dyspepsia, the stools will contain portions of undigested food, showing at once the failure of the assimilating powers. The odour of the discharge is a circumstance of importance; a foetid stool indicates less permanent or extensive change, than one which is deficient in the characteristic odour, and yields a faint smell. The consistence of the faeces will likewise be found to afford some useful signs. It has been generally supposed that their dryness affords a proof that the nutritive part of the aliment has been duly absorbed : and there can be no doubt that such motions, if their colour be natural, should be considered as favourable in cases of indigestion. Boerhaave has remarked, that "people who complain of going too seldom to stool, and of voiding hard and dry faeces, complain without reason, because this proves the strength of their constitution." The least favourable consistence is that of a soft pudding, especially if the discharge-of the motion be unattended with a feeling of relief corresponding with the quantity evacuated; a sensation of something being retained, accompanied with that of a bearing down in the lower portions of the intestines, is not unusual upon such occasions. There is a peculiar appearance connected with this species of evacuation, which, I believe, has never been described in any work, nor indeed is it easy to convey by words its exact nature. It was first pointed out to me by Dr. Baillie, and I have since noticed it in numerous instances, and become satisfied of its immediate connexion with diseased secretion. The consistence of the motion is that of a pudding, but it is of unequal density in its different parts, and exhibits a surface as if it had been rasped by a file. I have still another form of faeces to describe, which would seem to depend upon a contraction of the intestine; the excrement is hard, but having a diameter not much exceeding that of a tobacco-pipe. In protracted cases of dyspepsia, the occurrence of this appearance has given origin to a belief in the existence of stricture in the rectum: but I believe its cause is always seated in the higher portions of the large intestines. Some of my readers may perhaps consider the observations which I have been induced to offer upon the appearances of the feculent discharge as unnecessarily minute: but I am anxious to urge upon every practitioner the absolute necessity of such inspections. No one can successfully conduct the treatment of a severe dyspeptic complaint unless he submits to the performance of such a duty. All the great physicians of antiquity relied upon such a source of information for their guidance. Hippocrates carried the practice to such an extent as to have The Examination of the Urine. 175 acquired from some of the wits of his age the appellation of f, as Aristophanes had before named Escufapius. Some modern practitioners have, from the same scrupulous attention, been obnoxious to a similar charge ; but I trust that no physician will be induced to swerve from the performance of a paramount duty by such intimidation.* 308. The examination of the urine is also a matter of considerable i mportance. Its appearance will not only assist us in forming a judgment respecting the seat, of the dyspeptic disease; but, if carefully watched from day to day, will point out the beneficial changes which our plan of diet and medicine may have produced. It will also instruct us in the species of food which best agrees with the patient; for slight errors of diet, although imperceptible in other respects, are generally announced by obvious changes'in the urinary deposits. 309. Without entering, with chemical minuteness, into the history of the changes which the urine undergoes under different conditions of the body, there are certain phenomena with which every practitioner ought to be well acquainted : these I shall briefly enumerate, and endeavour to point out the indications which they severally afford. The quantity evacuated during a given interval is the first question which presents itself; a diminished flow of deep coloured urine is invariably associated with febrile action; while an increased quantity of pale urine more generally indicates a peculiar state of nervous irritability, unattended with fever. In estimating, however, this circumstance, the practitioner will see the importance of inquiring into the vicarious excretion of the skin. Much has been written upon the subject of albuminous urine, or that in which a coagulum is produced by the application of heat; Dr. Blackall has maintained that it is connected with too great an action in some part of the system, and he considers that its occurrence in dropsy should be received as an indication of the necessity of blood-letting. I have met with several cases of dyspepsia, in which such a state of urine occurred, and I am disposed to believe with Dr. Prout that it is derived from the chyle. I have, at this time, two patients under my care, who have long suffered from the effects of tubereulated lungs; and during the progress of the present work, I examined their urine, and found in both cases that it was albuminous. We have, probably, foo few data to lead us to a safe conclusion with regard to the cause of the phenomenon: but I am, at present, impressed with a belief that it arises from imperfect sanguification; the chyle not undergoing the necessa- * A patient may be so circumstanced, that the preservation of the fxces, for inspection, is attended with inconvenience. It is, therefore, worthy of notice, that a table-spoonful of sweet oil poured over them, by investing the surface vith a film, effectually prevents evaporation, and the consequent stench they might otherwise occasion. This precaution should always be adopted in the wards of hospitals. 176 The Examination of the Urine. ry changes to convert it into perfect blood, is eliminated by the kidneys, it is essential in every case of protracted dyspepsia, to inquire into the state of the urinary secretion, in order to ascertain whether the patient may not be labouring under diabetes. So many valuable works have appeared upon this subject, that I consider it unnnecessary to enter upon its history : but I should not discharge my duty to the professional reader, were I to omit noticing the concise but luminous chapter with which Dr. Prout has favoured us in his truly valuable work on the diseases of the urine. 310. But of all the changes of which the urine is susceptible, none perhaps are less equivocal, or more indicative of a deranged state of the alimentary functions, than the deposit of lithic acid, either in an amorphous or crystalline form. Dr. Prout states that this acid, when in the former condition, is always in some state of combination, generally with ammonia; but when in the latter, it is nearly pure. He observes, that in healthy urine the lithic salt exists in such a proportion, as to be held in permanent solution at all ordinary temperatures; but that from particular causes affecting the health, its quantity is preternaturally increased, and the excess is deposited as the urine cools. Dr. Philip is inclined to account for its appearance in the urine from an increased quantity of acid passing through the urinary organs: from this view of the subject the lithic acid deposited must be considered as arising, not from the excess of that substance in the urine, but from a decomposition of the compounds into which it enters by the agency of a free acid. He considers that, in a healthy state of the system, the precipitating acid is thrown off by the skin, and he supposes that even when generated in excess, it may be diverted to the surface of the body by merely increasing the insensible perspiration. But, from whatever cause the precipitation may take place, its occurrence must' be considered as a very delicate test of alimentary disturbance. By watching the occurrence and disappearance of these deposits, we are enabled to form a very just conclusion as to the efficacy of any plan of medicine or diet that may have been prescribed. I am acquainted with a gentleman who can never eat bread without discovering a change in his urine. He told me that he had entirely overcome the lithic diathesis by substituting biscuits. 'To those who are not acquainted with the influence which the slightest error in diet possesses over the urine, this may appear a refinement scarcely within the bounds of credibility: Dr. Prout, however, has stated a parallel case. The variety of colour, also, exhibited by the lithic sediments, is deserving of some attention, and the profession is under deep obligations to Dr. Prout for the able manner in which he has described such modifications. He arranges them under three divisions, viz. 1. Yellowish or nut-brown sediment; 2. Reddish-brown or Lateritious sediments; and 3. Pink sediment. Age and Occupation of the Patient considered. 177 The first variety indicates a strong tendency to the lithic acid diathesis : although in some cases an opposite state of system prevails, and an alkalescent condition of the stomach and bowels may be supposed to exist, in general, the nearer such spdiments approach to white, the more of the phosphates they contain. Dr. Prout says, that the second variety of sediment varies in tint from nearly white, in which state it is with difficulty distinguished from the last variety, to a deep brick-red or brown. It is to be considered as a symptom indicative of phlogistic fever, or very frequently of local inflammatory action. The thi rd variety of sediment owes its colour principally to the Purpurate of Ammonia: its presence indicates the existence of certain chronic visceral affections, especially of the liver. 311. These observations are sufficient to impress upon the practitioner the necessity of inspecting the urine of his patient; the indications it affords are not to be received without due cau- tion. If taken alone, they may not be worthy of any considerable degree of credit, but when viewed in conjunction with other symptoms, they will undoubtedly assist his diagnosis. 312. We come now to consider the " Particular Circumstances" of the patient under examination. His age, for obvious reasons, is a fact of importance. By learning the nature of his occupation, we shall be enabled to form some judgment with respect to the causes that may have excited his disease. The posture in which some persons are accustomed to sit, is a frequent source of affections of the stomach and bowels. Literary people and clerks from bending to the desk or table are frequently thus affected. Tailors and shoemakers are notoriously obnoxious to.serious obstructions from such a cause: by the position in which these tradesmen pass a considerable portion of the day, the margin of their ribs is pressed upwards so as to force the stomach against the diaphragm, and to impede the passage through the pylorus. It is equally essential to inquire into the former habits and customs of the patient; we thus become acquainted with his dietetic irregularities, the degree of exercise to which he has been accustomed, and various other circumstances which may have contributed to produce the disease under which he labours. If he has resided in a warm climate, we shall be led to suspect the existence of hepatic affection. The " Occasional Questions" which I have introduced, as necessary for the examination of females and children, are too obvious in their importance to require any farther comment. With respect to the value of " General Observations" upon the physical character of the individual, I have only to state, that those accustomed to medical physiognomy will derive much information from such an inspection; although the evidence is of such a nature that it cannot be described; it is to be learnt only from experience. 2 A 178 OF THE CURE OF INDIGESTION, as it relates to dlet, exercise, and medicinal Treatment. 313. The previous habits of the patient, and the origin and seat of the disorder, are the circumstances from which the physician is to derive his indications of cure. If the disease has not extended its influence beyond the stomach and bowels, the means to be adopted will be more simple, and, at the same time, more prompt in their salutary operation, than where it has involved the functions of remote organs; but in this latter case, the symptoms are so frequently those of mere sympathy, that the practitioner has often the satisfaction of witnessing their removal by remedies that can only have acted on the prima? via?. 314. It has been stated (257) that the stomach may fail in the performance of its duties, either from a deficiency in the secretion of its menstruum, or from a loss of power in its muscular fibres; but in either case we must refer the disease to a loss of nervous energy. Some persons, predisposed to indigestion, and who inherit the temperament most fayourable to its production, would seem to have less than an ordinary ratio of nervous energy supplied to their muscular structures. In such cases, there is an unusual torpor in the bowels, even during health. An attention to this fact has frequently led me to adopt measures which might have proved less successful under other circumstances. As a general proposition it may be stated, that the secretion of gastric juice, and the muscular power of the stomach, are so intimately associated with each other, that the one cannot long be deficient without the other partaking in the torpor; and the practitioner, who has had much experience in the treatment of dyspeptic disease, will readily concur with Dr. Philip in believing, that whatever tends to restore a healthy nervous power to the stomach, tends to form the food into that substance which is best fitted to excite the muscular fibres of this organ; and that whatever excites the natural action of these fibres, tends to relieve the nerves from their load, and, in the most favourable way, to bring into contact with their extremities the food on which, through the intervention of the gastric fluid, their powers are to be exerted. Pathology of the Stomach. 179 315. The pathology of the stomach may, therefore, be greatly simplified by referring it to a defect of nervous action; and our first duty is to inquire into the causes that may have occasioned it, and which, in general, may be identified with errors of diet, affections of the mind, or irregularity of exercise. 316. The nature and influence of such remote causes have been fully discussed in the preceding pages; and by carefully appreciating their operation, the practitioner will obtain a clue for his guidance. He must lay down a system of rules for his patient, by which the remote causes of his complaints may be removed; but, in his attempts to reform bad habits, he must be careful to avoid all abrupt transitions, except in those circumstances which have no direct influence upon the vital powers of the body. I should, for instance, be very cautious "how I withdrew spirituous stimulants, although I might be well satisfied that the indulgence of such potations had given origin to the disease; but I should not feel any hesitation in at once withholding every species of pastry, or other indigestible matter, without reserve. Upon the same principle, we should gradually diminish the number of meals, where they have exceeded the proper limit, adopting them with skill and caution to the fluctuating circumstances of the patient. The same observation applies to exercise: nothing would be more injudicious than to expose the invalid, debilitated by sedentary habits, to the effects of sudden and protracted exercise; nor should the person, whose habits have been laboriously active, be abruptly restricted to an irksome state of indolence. The discipline, in such cases, must be graduated according to the previous habits of the patient; to his age, strength, and the nature of his disease. Exercise can never prove salubrious, if it be followed by fatigue. Mr. Abernethy has prescribed to his patient a set of rules, which I shall take the liberty of quoting in this place, in order that I may offer such observations upon their value, as my own experience has Suggested. " They should rise early when their powers have been refreshed by sleep, and actively exercise themselves in the open air till they feel a slight degree of fatigue." Upon this first rule, I am disposed to make the following comment. Although we must all agree in the advantages of early rising, yet, in dyspeptic cases, I have frequently known the disease greatly aggravated by the patient suddenly changing his habit, with regard to the hour of rising; and that if he becomes the least fatigued, before his morning repast, he remains languid and uncomfortable during the rest of the day. A long walk before breakfast, unless the person has been accustomed to the practice, will frequently produce a fit of indigestion. I have already observed, that it is advisable to allow an interval to pass before we commence the meal of breakfast; and where the weather and circumstances will permit Practical Rules. 180 it, this interval should be passed in the open air, but the bodyshould not suffer the least fatigue. Mr. Abernethy then proceeds to say, " they should rest one hour, then breakfast, and rest three hours, in order that the energies of the constitution should be concentrated in the work of digestion." It appears, then, that the patient is to rise early, to take exercise until he feels slightly fatigued, and then to rest an hour before he is allowed to take any refreshment. This plan might succeed very well in preserving a robust and healthy man in vigour; but where we have to deal with a person whose energies are languid, and whose feeble powers are easily exhausted, I fear that such discipline would be ill-calculated to afford assistance. It is notorious that all dyspeptic persons are especially languid in the morning, and they accordingly require a regimen the very reverse to that which Mr. Abernethy recommends. Such, at least, is the conviction of my mind. To the practice of resting three hours after breakfast there can be no objection; it is the period best adapted for intellectual business. He then recommends " active exercise again for two hours, rest one; then taking their dinner, they should rest for three hours, exercise two, rest one, and take their third slight meal." 317. It is impossible to frame any general rule that shall apply to every case, but I will offer a sketch of the plan I have usually recommended: the practitioner will readily modify its application to meet the circumstances of any particular case. The dyspeptic patient should rise from his bed as soon as he wakes in the morning: for as Mr. Abernethy justly states, that "many persons upon first waking feel alert and disposed to rise, when, upon taking a second sleep, they become lethargic, can scarcely be awakened, and feel oppressed and indisposed to exertion for some time after they have risen." He should then walk, or rather saunter for some time in the open air, previous to taking his breakfast, the material of which is to be selected according to the principles already discussed (232). He is now in a condition to follow his usual avocations; but it is a circumstance of no slight importance to procure an evacuation at this period, which is easily effected by habit (79); a person who accustoms himself to the act at a certain hour of the day, will generally feel an inclination at the appointed season. The invalid should not. allow his occupations, if sedentary, to engage him for more than three hours, after which exercise on horseback, or by walking, should be uniformly taken. I have already observed, that the state of the weather ought not to be urged as an objection to the prosecution of measures so essential to health. Where the season of the year, and the situation of the patient, will allow the exercise, I strongly urge the advantages to be derived from digging: the stimulus thus given to the abdominal regions is highly salutary in dyspeptic affections. The hour of Acidity of Stomach. 181 dinner should not be later than three o'clock (233), and the patient should rest for an hour before he sits down to the meal (243). It should consist but of few articles (227), should be carefully masticated (236), and the invalid should rise from the table at the moment he perceives that the relish given by the appetite ceases. The manner in which he should regulate his potations, at and subsequent to this meal, has been already considered (146). With respect to the allowance of wine, every practitioner must use his discretion, and be guided by the former habits and present condition of his patient (167). It is essential that the invalid should enjoy rest for at least two hours after dinner (106), that is to say, he should not enter upon any occupation or diversion that may occasion the slightest fatigue; to a gentle walk, or saunter in the garden, there can be no rational objection, especially at that season of the year when such a pastime is the most invitipg. At six er seven o'clock, he may take some diluting liquid, as tea; after which, exercise will be highly useful, to assist the sanguification of his previous meal: in the summer season there will be no difficulty in accomplishing this object; and if the strength of the patient will allow the exertion, some active game, as bowls, will be attended with advantage. At ten o'clock he may take some toasted bread, or a lightly boiled egg, with a glass of wine and water, should his previous habits render such an indulgence necessary, and at eleven he may retire to rest. The bed-room should be well ventilated, and its temperature should, as nearly as possible, be that of the apartment from 'which the patient retires. A wellstuffed mattress is to be preferred to a bed of down, and the curtains should not be so drawn as to exclude the free circulation of air. The invalid should be careful in not retiring to rest with cold feet: nothing contributes more readily to disturbed sleep, and uneasy dreams, than the unequal circulation which takes place on such occasions. ? "318. Such are the general rules which-1 should enforce for the protection of those invalids who are liable to dyspeptic attacks. There are particular features in the history of every case which will require appropriate treatment, and I shall now proceed to their consideration. Acidity of Stomach, Flatulence, &c. 319. It has been a question often discussed, whether the acidity which occurs in the stomachs of dyspeptic invalids, arises from the fermentation of the food, or from a vitiated state of the gastric secretion ? It appears to me that it may occasionally depend upon either of these causes. In cases of imperfect chymification, it would appear more, generally to depend upon the matter generated by the food; for it is instantly relieved by a Flatulence. Methods of Cure. 182 dose of carbonate of soda: but where it is symptomatic of some disease in a distant organ, as in that of the uterus, it would seem to be connected with an acid state of the gastric juice, and is not relieved by the administration of alkalies. I am not aware that this distinction has ever been established, but I am so well satisfied of its truth, that I have, in several cases, been led, from this circumstance alone, to distinguish between primary and symptomatic affections of the stomach. Unrelenting and continued cardialgia ought to lead us to suspect disease in some other organ; although I am not prepared to state that it is never the effect of a primary affection of the stomach. 320. In ordinary cases of acidity, the procuring evacuations from the bowels is the first measure to which we are to resort. We have afterwards to adopt such treatment as may prevent its recurrence. This indication is to be fulfilled by bringing the digestive organs into healthy action by a well-regulated regimen, and by such medicines as may give tone to the stomach, and increase that pulsatory action of the bowels, by which they are enabled to pass off the undigested portions of food. It is also probable that the bile may be unduly secreted in quantity or quality, for cardialgia is a common symptom of hepatic obstructions. Emetics have been recommended by some authors; but I suspect that such remedies, however quickly they may remove the present paroxysm, are calculated to favour its return. I am therefore disposed to prefer purgatives, especially as the disease is generally complicated with foecal congestions in the colon. Five grains of the compound extract of colocynth, or of the compound camboge pill, combined with two of calomel, afford a very efficient remedy upon such an occasion. When the bowels have been thus relieved of their load, their peristaltic motion may be kept in a state of gentle excitement by the following draught, which I have found to be singularly efficacious in such cases: R Sodee-Tartarizatee, ij. Sodee Carbonatis, 9ij. Aquae Anethi, f gj. Tinct. Calumbse, f 5j. Fiat haust. cum Acidi Tartarici granis quindecem in aquae semi-fluid-uncia solutis, in impetu effervescentite sumendus. 321. The exhibition of alkalies and absorbent earths will remove the present evil, but it will not produce any beneficial influence in averting the cause by which it was produced. Carbonate of ammonia is, perhaps, the most efficacious of the antacids, for it neutralises a portion of the acid matter which appears to exist in a gaseous state in the stomach, and which, on that account, eludes the action of the fixed salts. It is, moreover, calculated to relieve the debility which so frequently attends an attack of this nature. I have known very small doses of opium Treatment of Cardialgia. 183 relieve this affection after the bowels have been thoroughly evacuated; and in cases where there is reason to refer its origin to asymptomatic affection of the stomach, nitric acid has been found useful. Diarrhoea is not an unusual attendant of this disease, in consequence of the irritation which the bowels receive from the contact of the acrid matter: small doses of magnesia, combined with a few drops of laudanum, and made into a draught with some mucilage, will generally be found to relieve the complaint. 322. We are, however, to look for permanent relief to a change in the food; all the vegetables should be withdrawn, and a diet of animal food substituted: but if such a change should excite the disgust of the patient, we must relax in our commands, for the stomach will never digest that against which the inclination rebels. The substances which are found, by experience, more particularly liable to create this disorder, are all fried articles, butter and greasy viands, pastry and crude vegetables; in short, whatever is indigestible may act as its exciting cause. Astringent wines, as port, are very apt to favour its occurrence. I have before observed, that the stomach is frequently sensible to very minute portions of astringent matter (171). Dr. Philip says, that he has known more than one instance in which the stomach was even sensible to the difference between coloured and colourless brandy. Broths of every description, but especially those made of the meat of young animals, are a fruitful source of heartburn. Veal contains a saccharine principle which is very susceptible of acetincation. The medicines best calculated to invigorate the alimentary canal, are those composed of pure vegetable bitters, with the addition of some aperient salt. The infusion of quassia, in the dose of half a fluid-ounce, with two fluid-drachms of the infusion of senna, and a drachm of tartrate of potass, warmed with some aromatic tincture, is an excellent compound in such cases. I have also found the infusion of rhubarb, quickened with a small proportion of the compound tincture of aloes, a very useful remedy. 323. Flatulence is often a very distressing disease; it sometimes is associated with acidity, but frequently is the only symptom which indicates an imperfect digestion. Whether the gas, with which the intestines are inflated, be a product of fermentation, or a secretion from their vessels, is a question which has given origin to some discussion. It may probably arise from either of these causes, although it is generally attributable to the former. In some cases, it appears to contain sulphuretted hydrogen gas, and eructations take place which are characterized by the smell of rotten eggs. Where this Occurs, we may infer the existence of great alimentary disturbance; the natural affinities, by which the digestive changes are produced, appear to be subverted, and a new chain of compositions and decompositions 184 Flatulence may arise from different Causes. established. The albumen would seem to be the substance from which this compound is generated; and in several cases which have fallen under my notice, relief has been obtained by confining the patient to a strictly farinaceous diet. Ordinary cases of flatus, however, are of a different nature; the air appears to. be the product of.fermentation, and, by avoiding such vegetables as are known to be susceptible of it, the disease has been removed. In certain states of the alimentary canal, a sense of distention may be felt, without any morbid increase in the quantity of intestinal gas; an undue sensibility or irritability of the bowels may occasion such a feeling. This fact has been well illustrated by Dr. Parry :* he observes, that " there is often considerable variation in the degree of inconvenience resulting from the use of food or drinks which disagree." " Sometimes," says he, ** if I take acids, as considerable quantities of fruit, and immediately afterwards eight or ten scruples of kali at a dose, in saturated aqua kali carb., I feel no distention of the stomach, and bring up no carbonic acid gas: several hours afterwards there is a great uneasiness in the colon, which is not relieved till a great quantity of wind passes downwards. In this case it was absolutely necessary that the wind should have existed in the stomach, because an acid and an aerated kali were mixed there. But no dyspepsia, or what is called wind, was produced by it, because the stomach itself was not thrown into a spasmodic state from being over-irritable. Afterwards, however, when the same wind passed into the colon, that bowel being in a state of morbid irritability, the uneasiness from the wind was produced there till the wind was expelled." Although the terms in which this fact is expressed may not be consonant with those of modern science, the fact itself, as well as the explanation of it, are of great practical value. It is not the presence of gas in the intestinal canal, but the irritability of the intestines, which renders them impatient of the slightest stimulus of distention, that occasions the distress so common to dyspeptic invalids. A person in robust health may, from various accidental circumstances connected with the nature of his food, experience an unusual intestinal distention; but it will not occasion distress, for the reasons above stated. The practice to be founded upon such observations is evident: we shall obtain more advantage from calming the irritability of the bowels, than by dispelling the flatus by carminatives. I have found small doses of the extract of hyoscyamus, combined with two grains of ipecacuan, produce relief in attacks of-flatulence which have resisted the ordinary methods of cure.. Dr. Parry considers that dyspepsia consists in such a state of the villous coat of the stomach or in- * Collections from the Unpublished Medical Writings of the late Caleb Hillier Parry, 1825. Irritability of the Intestines. 185 testines, or both, as subjects them, to be morbidly susceptible of irritation from certain kinds of food, or certain changes of the food, which are not perceived, or produce no uneasiness in healthy stomachs; and that this affection of the villous coat, throughout all its degrees, up to inflammation itself, is apt to be followed by sympathetic or symptomatic affections of the secretory arteries or glands seated in it, and often of the muscular coat of the alimentary canal itself. I believe that such an affection is the general consequence, although not the cause of dyspepsia. In the treatment, therefore, of this complaint, we may frequently interpose sedatives with advantage. Protracted dyspepsia not unfrequently depends upon a morbid condition of the alimentary surfaces; the mucous membrane becomes affected, and the disorder is not removed until measures have been adopted to restore its healthy secretions. A fretful state of the intestinal discharges is generally associated with such a disturbance, and I have found the administration of a lenient purge every morning, with small doses of the vinum colchici, repeated twice a day, eminently successful in such cases. 324. Where the dyspeptic disease is connected with duodenal irritation, I. know of no medicine more useful than the vinum colchici; taking care to accompany its exhibition with that of occasional laxatives. Purgatives that act „with violence are always followed with an aggravation of the symptoms. Dr. Yeats speaks in high terms of commendation of the sulphate of potass : " It appears to me," says he, " to have a more specific effect upon the duodenum than the sulphate of magnesia. I give 9j. of it twice a day, in the infusion of quassia, and gr. iij. of the pilula hydrargyri, with or without two grains of extract, aloes, according to the state of the bowels. If much feverish irritation prevails, arising, as I imagine, from some slight inflammatory action in the duodenum, the saline draught, in a state of effervescence, is substituted, with the sulphate of potass, for the bitter infusion, with the happiest effects, and the pil. hydrarg. is given without the aloes." This is very excellent practice: I am satisfied that nothing is more mischievous than active purgation in every stage of dyspepsia. Drastic doses of calomel, to which some practitioners resort, are calculated to increase the morbid irritability by which the disease is kept alive. In cases even of loaded bowels, it will be more prudent to excite their peristaltic action by a gentle but continued stimulant, than to irritate by active purges. Where the biliary discharges are faulty, small doses of mercury are useful; and I prefer the hydrargyrum cum creta, cn such occasions, in doses of four grains, and combined with two or three grains of pulvis ipecacuanhse, to every other, form of combination. 325. Mr. Abernethy has offered some very valuable observations upon the subject of purgatives: he says that persons may 2 B 186 Active Purgation injurious. be purged without having their bowels cleared of the (cecal matter which may be detained in them; we should therefore- endeavour to ascertain what kind or combination of purgative medicines will excite a healthy action of the bovyels, without teasing them, or producing discharges from the organs themselves. The best mode of proportioning the degree of excitement to the end designed, is to take a dose of a suitable medicine at night, but short of that which may prove irritating; if it fail sufficiently to excite the organs, a similar dose may be taken in the morning; which also failing, it may be repeated at regular intervals during the day. The principle that should govern our conduct in the administration of purgatives, may be briefly stated— the excitement is to be repeated till the requisite action is induced, yet no single excitement, being such as may prove an irritant to the organ. 326. The mischief which may be produced by too active purgation seems to have been well understood by the ancients; but the modern practitioner has too frequently rejected the advice which the sages of our profession have recorded for his instruction. " He who takes a rough purge," says Plutarch, " to re lieve his body from too great a load of food, may be compared to the Athenian, who finding the multitude of citizens troublesome to him, contrived to drive them out by filling the city with Scythians and wild Arabs." I do not wish to invest the Grecian historian with the attributes of a medical oracle; but we may be allowed to borrow from him a figurative allusion to illustrate the importance of a precept which cannot be too frequently or too forcibly impressed upon the mind of the medical practitioner. 327. We may obtain the best form of a purgative from an infusion of senna, graduated in strength according to the circumstances of each particular case, and combined with small doses of some neutral salt. Where accumulations may be supposed to have taken place in the colon, a dose of the pilula cambogiae composita is an effectual remedy. 328. Where the symptoms of dyspepsia are accompanied with an evident spasmodic affection of the alimentary canal, as indicated by its inverted and convulsive movement, the malady may be inferred to exist more particularly in the muscular structure. Dr. Parry is inclined to regard such cases as distinct from those of dyspepsia, and to class them under the head of nervous irritability of the stomach; but they evidently constitute a link in the same chain, and are so intimately connected with the series that they cannot be practically separated from it. In such cases the symptoms of flatus are prominently distressing: the air which exists in the canal, and which should pass insensibly downwards, inviscating itself with the food, is thus arrested in its course, producing borborigmi and eructations from the sto- Stimulants. White Mustard Seed. 187 mach. In such cases, the medicines most likely to afford relief are aloetic stimulants : I have found the decoctum aloes compositum a truly valuable remedy in all affections connected with a torpid or irregular action of the muscular coats of the intestines. On some occasions, I have subjoined the infusumarmoracisR compositum with evident advantage. 329. The administration of the white mustard seed, which has been lately revived with all the confidence which attaches to a newly discovered remedy, is certainly a useful medicine in several morbid states of the intestinal canal; but, according to my experience, it is serviceable only in such cases as are marked by alimentary torpor. In affections attended with muscular inirritability, or in those associated with a diseased state of the mucous surfaces, it is unquestionably useful. I have known it to ensure a regular alvine discharge in persons of costive habits ; and I have also found it to correct that species of diarrhoea which attends a diseased condition of the mucous membrane of the intestines. These unbruised seeds were much commended by Dr. Mead in ascites, and by -Bergius in intermittents, and numerous writers have extolled their virtues in stimulating the stomach and intestines. Dr. Cullen, however, observed that the seeds given in this form are never broken down or dissolved in the stomach, but pass away entire by stool; and he therefore inferred that they were incapable of producing any beneficial effect. This statement appears to have thrown so much discredit upon their value, that they fell into disuse, and they have only lately regained the confidence of the profession. I confess myself to have been amongst those who were disposed to consider the unbruised see'ds as perfectly inert; but experience has taught me that such an opinion is incorrect. The seeds consist of fecula, mucilage, an acrid volatile oil, on which their Virtues depend, and which on standing, deposits a quantity of sulphur, a bland fixed oil, which considerably obtunds the acrimony of the former constituent, and an ammoniacal salt. The fixed and volatile oils may be obtained by expression, and if the mixture be submitted to the action of alcohol, the latter will be dissolved, and be thus separated from the former. It has been lately discovered, by some experiments conducted in France, that if the alcoholic solution be evaporated, a solid and crystallizahle substance, distinguished by acid properties, may be obtained ; and as sulphur is said to enter into its composition, it has been termed " sulpho-sinapic acid." If the whole seeds be macerated in boiling water, we shall at first obtain an insipid mucilage, which, like that of linseed, resides in the skin ; but if the maceration be long continued, the water will become impregnated with matter yielding the odour of sulphuretted hydrogen; a sufficient proof that a portion of the volatile oil may be thus extracted ; and it is probable that this process may even proceed more rapidly in the 188 Bitter Stimulants. — Blisters. digestive canal. In administering them, however, as a remedy, we should be cautious to prevent their accumulation in the bowels. A patient, to whom I lately recommended their use, informed me that his evacuations became extremely offensive, so that it is not improbable that a portion of sulphuretted hydrogen may be disengaged during their passage. Their administration evidently requires caution: if any inflammatory irritation exists, they must prove injurious: where, however, there is a sluggish or deficient secretion of the alimentary juices, I have no doubt respecting their utility. 330. The practitioner is well acquainted with the doctrines of Broussais: he maintains, that almost every disease arises from an inflammatory affection of the digestive canal;-and, although the absurdity of so general a proposition must be admitted, we shall act wisely in suspecting the existence of such a state of disease in protracted dyspepsia: tenderness upon pressure, and the appearance of the discharges from the bowels, will generally announce such a condition; and lenient purges, the application of leeches, and a low diet, will furnish the best methods of treatment. 331. The utility of bitters, in the treatment of dyspepsia, is a very questionable and often a dangerous practice. It is, however, the popular resource of those who suffer from deficient appetite; and I am satisfied that many serious evils have arisen from its indiscriminate application. Where the disease arises from a mere want of tone, and is not complicated with intestinal irritation, such medicines are, of all others, the most effectual; a truth which will be readily deduced from the observations which 1 have already offered upon the operation of these agents (135). 332. Blisters are of eminent service in cases of intestinal irri-* tation, accompanied with tenderness on pressure; they will frequently also' put a stop to obstinate vomiting, when other methods have failed of success. 333. The external application of heat to the region of the stomach will often allay gastric irritation that depends upon the presence of indigestible matter. The process of chymification is thus promoted by a species of contiguous sympathy that is not well understood. 334. The application of heat to the feet will be attended with the same beneficial consequences; this connexion is still less apparent, but it is a fact, no less remarkable than true, that the digestion of a person in health may be arrested by the sudden application of cold to the lower extremities. 335. The use of frictions, when applied by means of the fleshbrush to the abdominal region, deserves a distinguished place in the catalogue of dyspeptic remedies. I have usually directed its application for a few minutes, night and morning, and the most Use of Flannel. — The Cold Bath. 189 obvious benefit has arisen from it. The ancients are well known to have held friction in high estimation, not only in the cure, but for the prevention of disease. The moderns have unwisely suffered the practice to fall into disuse. If it were necessary to illustrate the utility of friction, we have only to adduce the well known effects which are produced on horses by the operation of currying; .and which can alone depend upon freeing the surface from the recrementitious part of the perspirable matter, and promoting a due circulation in the skin. In thus making them sleek, they become more gay, lively, and active, and will preserve their strength with half the quantity of food, than when it is given to them without Such assistance. In cases where the application of cold may be considered useful, the brush may be immersed in equal quantities of vinegar and Water. 336. With respect to the utility of wearing flannel next the skin, some diversity.of opinion has existed. Its advantages consist in gently stimulating the surface, promoting perspiration, and conveying away the moisture as it may be deposited. When worn only in the day it does not appear objectionable, but is, on the contrary, salutary to those whose skin may be supposed to require such a stimulant; but I agree with Dr. Beddoes in believing that no good reason can be assigned why any one, who is the master of a comfortable bed, should wear it during the night. In that state of increased sensibility of the skin which sleep induces, it is more likely to be injurious than at any other time, by the stimulating effects of its piles, and by the warmth it keeps collected round the body. There is also another objection to its use, under such circumstances: the perspirable matter, by accumulation, undergoes a chemical change, and the skin is thus, as it were, immersed in a noxious atmosphere. For the same reason, the flannel should be frequently changed. I have generally preferred, in dyspeptic cases, the use of a flannel stomacher, or a piece of loose flannel worn over the stomach and bowels during the day, and which may be thrown off at bedtime. 337. The use of cold and warm bathing offers another subject for consideration. The advantages arising from it, in the treatment of dyspepsia, are indisputable; but its application requires skill and prudence. When we consider the functions of the sk in, in their relations to the digestive process, we cannot be surprised that an improvement in the state of the former should confer a corresponding benefit on the latter. The cold bath appears eminently serviceable to those who are suffering from dyspepsia, induced by the enervating modes of life peculiar to great towns, or by great mental exertion. Where, however, there exists considerable biliary disturbance, it generally does harm. It is also a matter of great consequence to ascertain the strength of the patient, and whether his vital energies are sufficient to Practical Directions for Bathing. 190 produce that re-action, without which the cold bath must ever prove a source of mischief. This circumstance must likewise direct us in appointing an appropriate period for the operation. The robust and healthy may bathe early in the morning, or before breakfast, without the least hesitation; but the dyspeptic invalid should never venture into the water until his stomach has been stimulated by a slight meal. The period best, calculated for immersion is about two hours after breakfast, which will enable him to take some previous exercise; he ought never to feel any degree of chilliness, but should be rather Warm than cool, before he attempts to bathe. Dr. Currie has justly observed, "that persons ought not to wait on the edge of a bath, or of the sea, until they are perfectly coot, for if they plunge into the water in that state, a sudden and alarming chilliness may be expected, which would not have been the case had they been moderately warm when they went into the water." There exists a popular belief that, unless a person plunges head foremost, an accumulation of blood may take place in the brain. There is no truth in this observation. A sudden plunge is a violent and unnatural exertion, and if the patient has not strong powers of reaction, it may be followed by unpleasant consequences. The shock thus given to the nervous system may, like a blow on the head, produce syncope. A case occurred at Brighton in which a person, in a state of debility, died suddenly from the shock of a shower-bath. 33S. An invalid should never remain longer than two minutes in the water, and the body should be kept during the whole time under the surface. If, instead of a genial glow, chilliness, languor, and headach follow, we may conclude that the vigour of the system is not equal to create and sustain that re-action upon which the be'nefits of bathing must depend, and the practice should be immediately abandoned. It is, I think, generally advisable for invalids to bathe only on alternate days, until they find their strength so much increased as to allow them, without risk, to indulge it daily. 339. The patient generally inquires whether, before bathing in the sea, it may not be proper to prepare himself by the use of a warm bath. I.generally recommend a previous immersion in the tepid bath, at a temperature commencing at 90° Fah., lowering five degrees each time, and terminating at 65°. Some laxative should be taken a few days before the course of bathing is commenced ; but all violent purges must be cautiously avoided. I have known persons who, from a popular notion of the safety of purgation on such occasions, have taken violent doses of medicine, and been rendered extremely ill by their first immer- sion. 340. The warm bath is better calculated for those invalids whose re-action is not sufficient to sustain the shock of cold The Warm Bath.—Shower Baths. 191 water. In such cases it will augment rather than diminish their natural strength and vigour; it will regulate the functions of the skin, promote the digestive powers, and concur with other measures to re-establish their health. To ensure objects so desirable> there are several precautions which it may be necessary to enumerate. As our purpose is not to induce profuse sweating, the temperature should not, on the first going into the bath, exceed 94° or 95°, but it may be gradually increased to 98°. In ascertaining its heat, we should never trust to our sensations; the thermometer is the only indication upon which we should rely. The most proper period for using the warm bath is an hour or two before dinner. If it be used during any of the ulterior stages of digestion, as in the evening, it will be liable to accelerate the circulation, and to produce disturbance. I have known persons, troubled with indigestion, to suffer considerable restlessness and irritation, by going into a warm bath just before bed-time. The patient ought not to remain immersed longer than twenty minutes; and upon coming out, he may walk in the open air, but should be cautious not to occasion fatigue. Count Rumford has published an interesting essay on the subject of warm bathing, in which he observes that "a person may gain fresh health, activity, and spirits, by bathing every day at two o'clock in the afternoon, at the temperature of 96° or 97° Fah., and remaining in the bath half an hour. He continued that plan for thirty-five days, and derived from it permanent advantage;" and he adds, "that the idea of going into bed after a warm bath, in order to prevent taking cold, is erroneous; that no alteration should be made in the clothing, and that the body, on exposure to the air, is not more susceptible of catching cold than it was before going into the bath." This coincides so perfectly with my own experience, that I feel it unnecessary to offer any farther remarks upon the subject. Count Rumford also justly reprobates the idea of any advantage being derived from temperate baths of from 55° to 60°. The animal temperature, he observes, is 98°; in those temperate baths, therefore, we lie motionless in a temperature inferior to that of our own bodies, and consequently must lose instead of acquiring heat, or even retaining that which we possessed. 341. Shower-baths have been supposed to be more efficacious, in certain diseases, than baths of less partial application. In stating the result of my own experience upon this subject, I have to observe, that in debilitated habits they are not unattended with danger. I have certainly seen that species of indigestion whLh would seem to arise from, or be intimately connected with nervous irritability, greatly alleviated by the use of such partial baths, but I have generally recommended that the temperature of the water should be raised to 50°. Persons of a 192 Change of Air strong habit, who have been exhausted by intellectual exertion, are greatly resuscitated by such means. 342. Change of air is one of the most efficacious methods of curing dyspeptic complaints. The chemist has proved that the essential constituent parts of the atmosphere are the same in all places and situations; it has been collected in cities and in the country, on mountains and in plains, and even at the height of 7250 yards above the level of the sea, by Gay Lussac, in his aerial voyage in September, 1805; but it has never been found perceptibly different in composition. From the latest and most accurate experiments, the proportions of oxygen and azot are 21 and 79. It is indeed true, that various foreign bodies may be present, such as an increased quantity of carbonic acid, animal exhalations, smoke, &c. The quantity of aqueous vapour is also liable to constant variation. What then renders the air of some places so much more salubrious than that of others? or, whence arise the advantages which the invalid so constantly experiences from change of place ? The proposition itself may perhaps be denied ; and any attempt to establish an explanatory theory upon such a subject, may be compared to the attempt made by the Royal Society, at the command of king Charles,- to explain " why, if a vessel is filled brimful of water, and a large live fish be plunged therein, that it shall nevertheless not overflow."—. Is it a fact ? Is one situation more salubrious than another? and do dyspeptic patients actually derive any benefit from mere change of air? I do not imagine that any physician, who has practised a few years, will require any evidence of these facts beyond that which his own experience must have supplied. It is notorious that children, who may be regarded in the light of sensible instruments, become unhealthy, if constantly confined to the air of large cities; robust and healthy persons are not so affected; but the delicate, and above all, the dyspeptic invalid, is notoriously injured by it. Let him retire only for a few days into the country, and the effect which is produced by the change is too apparent to admit of any question. Some have supposed that the insalubrity of the air of a large city may depend upon the greater dampness and stagnation of the air, occasioned by its numerous buildings: I am not disposed to assert that such causes may not have a share in producing the effect; but the animal effluvia, and the carbonaceous matter so abundantly floating in the atmosphere, must also be taken into consideration. How does it happen that plants wither and die in a short time after they are brought from the nursery-grounds into the more capacious streets of the metropolis? Why should iron rust with so much greater celerity in London than in the country ? These, observations, however, merely go to prove that the air of a city is less pure than that of the country. Is there any evidence to show that the air of different places, remote from towns, varies Meteorological Remarks. 193 in its salubrity in different places, or in the same place at different times ? I apprehend that most of the beneficial or evil effects of different air maybe ultimately referred to its relations to moisture and dryness. That such changes are considerable and striking, under certain circumstances, have been rendered apparent by the admirable researches of Mr. Daniel, who, by the invention of a simple and correct hygrometer, has been enabled to throw very considerable light upon this hitherto obscure subject. That the cutaneous discharge is very materially affected by the degree of moisture in the atmosphere is evident; and that the digestive organs may therefore be thus influenced, through its medium, is a corollary which no one will refuse to admit. When the air is very moist, it is a bad conductor of the perspirable matter, which, therefore, instead of being carried off in an insensible form, is condensed upon the surface; hence we appear to perspire greatly upon the slightest exercise, whereas the cuticular discharge is, at that time, absolutely less. We have all experienced the sensation of heat, and disposition to sweating, during the moist weather which so frequently occurs in this country in April and May, the wind being at the time stationary at south-west or south. On the contrary, during the prevalence of an east-wind, the most violent exercise will scarcely prove diaphoretic, and yet the quantity of cutaneous exhalation is far greater than during that state of atmosphere when the slightest exercise deluges us with perspirable matter. Dr. Schmidtmeyer says, that in Chili, notwithstanding the high temperature which would have been intolerable in Europe, and deluged the inhabitants with perspiration, so rapidly does evaporation proceed, that it might even be doubted whether, after considerable exercise, any perspiration was occasioned by it.* It is scarcely necessary to observe that the atmosphere of Chili is remarkable for its dryness. The functions of the lungs are no less influenced by the state of the atmosphere than those of the skin. The former organs are constantly giving off water, and if it be not carried off, with equal rapidity, it is reasonable to suppose that some influence will be produced upon them, beneficial or otherwise, according to the peculiar condition of the patient, as I have endeavoured to explain in the last edition of my Pharmacologia, under the history of Expectorants. How is the cure of hooping-cough, by change of air, to be explained, unless we adopt the belief Which I have endeavoured to enforce? 343. The advantages which attend " change of air," in the treatment of various diseases, has been ascribed by many physicians to the exhilarating impressions thus produced upon the mind, and to the simultaneous change of habits which usually takes place upon such occasions. I am willing to admit the ex- * Travels into Chili. 20 194 Change of Scene and Habits. tensive and powerful operation of such causes in the treatment of diseases in general, but more particularly in those cases in which the digestive organs constitute the source of the derangement; for such affections are influenced by the state of the mind to an extent to which it would be difficult to assign a limit. It therefore follows that, in the recommendation of a place of resort for invalids, various circumstances are to be taken into consideration : it is no less important to furnish amusement for the mind, than to provide salubrious air and wholesome food for the body. A continual change of residence is, perhaps, better adapted for ensuring our object, than a protracted stay in any one place. The genial excitement, which a succession of novelties produces on the mind, to say nothing of the advantages which necessarily arise from the exercise of the body, is more likely to ensure exhilaration and cheerfulness, and to break down the associations which continued disease will always engender, than a monotonous residence in a watering place, where, after the first few days, the patient becomes familiarized with the objects around him, the spell by which he is to be cured is broken, and his mind is watching every pulsation, in order to discover some indication of that returning health which he so anxiously anticipates. This truth is beautifully illustrated by an anecdote related by Sydenham, and will go farther in establishing the importance of the principle I. am desirous of enforcing, than any argument which it is in my power to adduce. This great physician having long attended a gentleman of fortune with little or no advantage, frankly avowed his inability to render him any farther service, adding, at the same time, that there was a physician of the name of Robinson, at Inverness, who had distinguished himself by the performance of many remarkable cures of the same complaint as that under which his patient laboured, and expressing a conviction that, if he applied to him, he would come back cured. This was too encouraging a proposal to be rejected: the gentleman received from Sydenham a statement of his case, with the necessary letter of introduction, and proceeded without delay to the place in question. On arriving at Inverness, and anxiously inquiring for the residence of Dr. Robinson, he found, to his utter dismay and disappointment, that there was no physician of that name in the place, nor ever had been in the memory of any person there. The gentleman returned, vowing eternal hostility against the peace of Sydenham; and on his arrival at home, instantly expressed his indignation, in not very measured terms, at having been sent so many hundred miles for no purpose. "Well," replies Sydenham, "are you better in health?"— " Yes; I am now perfectly well, but no thanks to you." " No ?" says Sydenham, " but you may thank Dr. Robinson for curing you. I wished to send you a journey with some object of interest in view; I knew it would be of service to you: in going Recapitulation. 195 you had Dr. Robinson and his wonderful cures in contemplation, and in returning you were equally engaged in thinking of scolding me." There was more wisdom and address in such a scheme than in that which is said to have been practised by Hippocrates, who sent his patients from Athens with no other object than to touch the walls of Megara, and then to return. 344. I have thus endeavoured to investigate the principles upon which the treatment of indigestion is to be conducted. I might have descended into fuller detail, but the art of selecting remedies, of graduating their strength, and of modyfying their powers by combination, constitutes a subject to which I have directed the attention of the practitioner in a distinct work, the extensive sale of which convinces me that it must be already in the hands of every professional reader, and will render any farther observations in this place unnecessary. After all, more benefit will arise in dyspeptic diseases, from a judicious regulation of the diet and habits of the patient, than from large quantities of medicines; although I do not intend by this observation, to undervalue the importance of such agents, when directed by the skilful hand of the physician. The unhappy invalid, who seeks for relief from the nervous cordials, and stomachic mixtures of the empiric, may occasionally derive the feeling of temporary relief, from the operation of stimulants to which the regular practitioner will never resort. Let him remember that such relief, if obtained, must be at the expense of his future welfare. Such expedients have been aptly enough said to be drafts upon the constitution, payable with compound interest a few months after date. 345. I shall now recapitulate some of the more prominent doctrines which have been established in the preceding pages; a plan which will not only have the advantage of placing the subject in a simple and perspicuous point of view, but of affording the reader with a convenient index to the practical parts of the work. Recapitulation. 1. The first object is to discover the origin and seat of the disease (290). 2. If it arise from a debilitated state of the stomach, in which either the secretions are deficient or depraved, or the muscular powers of that organ have lost their vigour, we have first to remove, as far as we are able, the remote causes which may have produced the disorder. The alimentary canal must be cleared of all foul congestions, and their future accumulation prevented, first, by a strict adherence to a diet most likely to ensure the digestion of the food; and, secondly, by the careful exhibition of laxatives, which may carry off the superfluous parts. The func* 196 Recapitulation. tions of the skin must be restored, and a general vigour imparted to the body, by remedies which are calculated to strengthen the nervous system. 3. If the dyspeptic disease has continued so long as to produce an inflammatory state of the gastric membranes, we must employ antiphlogistic means for its* cure (330). 4. If the duodenum be the seat of the disorder (265), we must carefully ensure, by appropriate diet, the complete chymification of the food, so that it shall not be irritated by the contact of half digested food; the secretions which enter its cavity must be regulated and improved, by small doses of mercury; and colchicum may be administered in the manner above directed (324). Above all, the colon must be carefully preserved from feculent accumulations. 5. If the bowels be distressed with flatus, we must ascertain whether the feeling arises from an increased quantity of air present in the canal, or a morbid sensibility of the membranes, which renders the ordinary quantity of elastic matter burthensome. In the former case the treatment must be regulated by such measures as may prevent fermentation (323), in the latter, the irritability of the intestines must be appeased by sedatives. 6. If acidity prevails, we have to inquire whether it arises from the nature of the food, or the morbid state of gastric juice, and regulate our measures accordingly (319). 7. Where disease exists in the bowels, and the appearance of the stools indicates a dysenteric affection, we may infer that the mucous membrane is in a state of disease. 8. The administration of tonics and aromatic stimulants will always be attended with mischief, where a phlogistic condition of the mucous membranes exists: mild aperients and light diet are to be prescribed under such circumstances. 9. Where there exists a languor in the muscular powers of the alimentary canai, and a torpor in the secreting membranes, bitters, aromatics, and other stimulants, such as mustard-seed, &c. may be safely administered. 10. The dietetic code of the dyspeptic patient may be summarily included under the following precepts: — A. Precepts in relation to the Quality of Food. a. Animal food is more digestible, but at the same time more stimulant and less flatulent, than vegetable diet. A dyspeptic invalid may be restricted to meat and bread with advantage, until his digestive powers have gained sufficient energy to enable him to convert vegetable matter into healthy chyle (110, 111), after which a due mixture of both species of aliment will be essential (112). b. The wholesome quality of food depends as much, or even more, upon its mechanical condition, than upon its chemi- Recapitulation. 197 cal composition (123 —125); and as this is influenced by various circumstances under our own control, we may render food, naturally indigestible, of easy digestion (126 —128). The digestibility of any species of aliment, as well as its nutritive qualities, are influenced by the different modes of cookery (129 —134). The addition of condiments is also capable of producing the same effects (135 —• 142). The practitioner will be enabled to direct that species of food, which is best calculated to fulfil the indications of the case, by an attentive perusal of those remarks which are introduced in the body of this work, (189 —227). And he will also find ample directions for his guidance in the selection of liquids for drink (143 —186). B. Precepts in to the Quantity of Food. a. This must, in every case, be regulated by the feelings of the patient: let him eat slowly, masticate thoroughly, and, on the first feeling of satiety, dismiss his plate, and he will not have occasion for any artificial standard of weight and measure. But he must, in such a case, restrict himself to one dish; an indulgence in variety provokes an artificial appetite which he may not readily distinguish from that natural feeling which is the only true indication (236-241). C. Precepts, with regard to the Periods best adapted for meals, and on the Intervals which should elapse between each. I have, upon every occasion, endeavoured to impress upon, the practitioner the high importance of these considerations. In every situation of life, we too frequently pass, unheeded, objects of real importance, in an over-anxiety to pursue others of more apparent but of far less intrinsic value; so is it with the dyspeptic invalid in search of health : What shall I eat? Is this, or that species of food digestible? are the constant queries which he addresses to his physician. He will religiously abstain from whatever medical opinion, or even popular prejudice has decried as unwholsesome; and yet the period at which he takes his meal is a matter of comparative indifference with him : although he will refuse to taste a dish that contains an atom of vinegar with as much pertinacity as if it held arsenic in solution, he will allow the most trifling engagement to postpone his dinner for an hour. So important and serious V an error do I consider such irregularities, that I have frequently said to a patient labouring under indigestion, "/ will wave all my objections to the quality and quantity of your food, if I were sure that such a sacrifice of opinion would ensure regularity in the periods of your meals." Diet to be used in Mesenteric 198 a. The principal solid meal should be taken in the middle of the day (233). b. Four hours after which a liquid meal should be indulged in (234). c. The digestion of one meal should be always completed before fresh labour is imposed upon the stomach (98). d. The intervals at which food is to be taken must be regulated by the digestive powers of the individual, and the rapidity with which they are performed (233). c. The patient should never take his meal in a state of fatigue (243). f. Exercise should always taken three or four hours after dinner (105, 245). On the Diet best adapted for Persons labouring under Tabes Mesenterica We know nothing of the operation of the mesenteric glands, nor of the part they perform in the scheme of digestion; but we are assured, by experience, that w ciation and atrophy follow. Ti to propose in such cases, was m that it can be successfully sup] although, if it were my object hen they become diseased, emaie dietetic plan which I am about either suggested, nor am I aware aorted, by physiological theory; to adduce an hypothesis, I think I might be able to give it the air of plausibility. My conviction of the utility of the treatihent, however, rests exclusively upon the basis of experience. I have uniformly found a vegetable diet injurious in such cases, while one entirely composed of animal matter has proved beneficial; but in order to ensure such a result, the meals should be scanty, and in quantity short of what the appetite may require; the intervals, also, between the repasts should be lengthened. In this way are the unwilling absorbents induced to perform their duty with greater promptitude and activity; but it is a practice which, from the extreme anxiety of friends and relatives, the feelings of craving and hunger expressed by the patient, and the mistaken but universal prejudice respecting diet, it is always painful to propose, and generally difficult to enforce: where, however, circumstances have given me a full and unreserved control, the advantage of the plan has been most decisive. In affections of this kind, the stomach rarely loses its powers; and it is less an object to provide easily digestible, than highly nutritive food. I have a patient of this description, who has derived much advantage from a diet composed principally of animal fat; and I have frequently noticed a sort of instinctive desire for rich and concentrated nourishment, which has not produced the ill effects which it undoubtedly would have occasioned in a simple dyspeptic disease. Diet of Pulmonary Invalids. 199 Of the Diet oe Pulmonary Invalids. In tubercular affections of the lungs, it has been often disputed whether the low diet, so universally prescribed in such cases, is that which is best calculated to arrest the progress of the disease. From my residence at Penzance, and from the various cases which have fallen under my care, in consequence of having there practised, I may, without the risk of incurring the charge of presumption, assert that few physicians have possessed greater opportunities of experience in this complaint than myself. The conclusions to which this has led me may be expressed in a very few words. Where there exists, in the earlier stages, great lassitude, coldness of the extremities, a quick but weak pulse, a tightness across the chest, as if it were confined by cords, but unaccompanied with acute pain in the side, a strictly vegetable diet is injurious. I have in such cases prescribed a regimen similar to that which I have above proposed for the cure of mesenteric affections; and I have certainly found it to be useful. To assert that I have cured an organic disease in the lungs would be more than foolish; but I have certainly arrested its progress in some cases, and I have restored others to perfect health, who had been gradually declining under a different treatment. Where a permanent cure has been effected, the presumption is, that the lungs were never actually deranged in structure; but the symptoms were of a nature to have justified such a conclusion. The medicine upon which I place the greatest reliance in such cases, is the extract of hemlock; and were I to express the extent of my own confidence in its powers, I might, perhaps, fall into the dangerous error, against which I have so strongly protested in my Pharmacologia—that of bestowing such extravagant praise upon a remedy as to detract from its reputation. I shall, therefore, only observe, that this remedy tranquillizes the irritation of the lungs to a greater degree than any other medicine with which I am acquainted; but in order to insure so desirable an effect, it must be given in much larger doses than those in which it is usually administered. I usually commence with a dose of five grains three times a day, which I gradually increase to 9j, or even more: it will generally produce a slight giddiness, nausea, and a tremor of the body ; a peculiar heavy sensation is also experienced about the eyes, and a tightness across the forehead; and the bowels frequently become relaxed; unless some of these sensations are produced, I consider that the remedy has not had a fair trial. The following is the formula for the preparation of the mixture which I have found to be so highly serviceable. If I am required to explain the modus operandi of each ingredient, I might, perhaps, fail in inspiring that confidence in its utility, to which I am convinced it is entitled. The practitioner must 200 Conclusion. therefore rest satisfied with the results of experience, and accept facts in the place of theory. B Extract. Conii, et Extract. Hyoscyami, aa Mucilaginis Acaciee, f 5 ij - Tere simul, et adde Liquorts Ammonias Acetatis, f |j. Aquae purse, ffivss. Vini Ipecacuanha?, f3j. Syrupi Rhseados, f"3Vl* Fiat mistura, de qua sumantur cochlearia duo ampla ter quotidie. I have now fulfilled the objects which I proposed to myself in the composition of the present Work. I have attempted to establish the principles upon which the digestibility and nutritive powers of different aliments depend; and 1 have endeavoured to point out the circumstances which may render any species of food indigestible and noxious. I have shown the causes upon which dyspepsia depends, and enumerated the remedies which may be applied for its cure. It only remains for me to relate a few Cases in illustration of the views I have offered, and in confirmation of the utility of that medicinal and dietetic treatment which has been developed in the preceding pages. 201 CASES IN ILLUSTRATION OF THE PRECEDING VIEWS CASE I. A. B., a gentleman of rank and fortune, of the age of twentyfour years, had suffered for several months with occasional headach in the evening, which, at first, was generally relieved by a cup of strong coffee, and it therefore excited little or no attention. The pain, however, became more severe, and returned at shorter intervals; it sometimes attacked him during the morning, and was accompanied with sickness, by which a quantity of strong acid was ejected from the stomach, and the paroxysm was thus terminated. His person was strong and athletic, his countenance florid, and he underwent considerable exercise during the pursuit of the field amusements to which he /was devoted: his appetite was therefore considerable, and the quantity of food which he was in the daily habit of taking, exceeded that which is generally sufficient for the most robust. He had never been in the habit of restricting his diet, because he had hitherto never felt any inconvenience from its excess. In the use of wine, however, he was temperate. The first professional communication which I received from him was in April, 1824; he had then for some weeks been suffering from headach. and sickness, and distressing symptoms of acidity. I shall quote that part of his letter in which he describes the treatment he had received. "My medical attendant ordered me aloes and blue pill, and a potion made of gentian, bark, cascarilla, and liquor potassae. I found the prescriptions, word for word, in your Pharmacologia. I cannot, however, say much for them, although the draught certainly does me some little good: he also ordered me lime-water, which is worth all the other put together: as for magnesia, I might as well eat powdered glass. What do you recommend next ? 1 am regularly feeding on mutton, beef, &c, to the utter disgrace of vegetable diet." From this period he gradually grew worse; his attacks of headach increased in severity and frequency, and were rarely relieved until a great quantity of bile and intensely acid matter were thrown off the stomach: he grew rather thinner, but was 2D 202 Cases in Illustration of the Preceding Views. by no means emaciated. I ordered him doses of carbonate of ammonia an hour after his dinner, and desired him to confine himself to an animal diet. He was well purged, and the action of the bowels kept up by small portions of a neutral salt. The stools were always natural in appearance. He now found the slightest deviation from the prescribed diet to produce a headach; and when he prognosticated its approach from the presence of acid eructations, he was frequently enabled to avert it by a dose of ginger and carbonate of soda, which I had also prescribed for him. He says, "I have found it necessary to take your prescription once or twice a day, which has averted many a vile headach, as I always take it if I feel any symptom of the generation of acid, such as heartburn, or an acid taste in my mouth. Having thus converted 'my stew-pan, vat, mill, &c.' into an apothecary's shop, I am much better than I have been, and have been nearly free from headach for the last fortnight, until yesterday, when I was in dock all day, and shall be so to-morrow. There is still, however, remaining to plague ine, a sort of languor and laziness which perhaps Dr. C.'s bitter prescription is intended to obviate, though it scarcely has such an effect. I wish the shooting season had arrived." I have introduced the relation of his feelings in his own words, because they will serve to convey a good idea of their nature and intensity, as well as of that hilarity and natural flow of spirits which constantly accompanied the progress of the disease of this highly gifted and amiable young man. In November I received from him a letter, of which the following is an abstract: " I find that the perpetual recurrence of my old headaches leaves me nothing for it but to turn them into a subject of amusement. I have been reading some speculations about muriatic acid in the human stomach, and would like very much to know what acid is in mine; and I wish you would put me in the way of testing it, fori can obtain any quantity. If it is a vegetable acid, how does it get into giblet soup or salt beef, or fresh butter, cum multis aliis ? if it is an animal acid, I know of none except the phosphoric, and I have no idea of making a match-box out of my viscera, so I vote at once it is not that; if it is a vegetable acid, how comes it that I may eat a dozen ripe peaches, and be none the worse for them ? but wo to me if 1 eat a buttered muffin; ergo, I infer that it is not wholly the acetic acid; and if not, what else can make sweet tea, or any thing like ale, beer, or porter, perfect poison to me? As for an animal acid, there is no poison for me like strong broth, or soup; ergo, there must be some villany in that. I was told, the other day, that baked meat would disagree with me, and I find this to be the case. Now, for the muriatic acid, which I strongly suspect to be the one under which I suffer, for the action on my teeth, when I am sick, is too sharp for any thing less pungent; I find that if I eat salt meat, an acid is immediately formed Cases in Illustration of the Preceding Views. 203 in my stomach, and yet I can take any quantity of salt with my meat, without being the worse for it: how can this happen? I am so often almost frantic with these headaches, that I am quite willing to devote myself to any experiment which you may choose to institute. The next curious, and to me unaccountable fact is, that if I eat any thing, even a mutton chop, between breakfast and dinner, I am sure to suffer from it, and that severely. About a week ago I went to Dublin, to transact some important business, and, lo, when the day came, my head felt as if it were nailed to my pillow. They sent for Mr. Crampton, the surgeon general, who greatly approves of the carbonate of soda and ginger, and added to it five grains of rhubarb. This very day I have taken, at three times, thirty grains of the soda, which gives a very temporary relief. I am particular in my diet, and take no drink but water; still, in spite of these precautions, I have a very bad headach once a week, and a moderate one or two besides. It is very odd that I never had two of my severe headaches on two successive days; that they never make me look the least pale or yellow. Their progress is exactly similar: I am at first heavy and dull, then a headach comes; then I feel sick, then I am sick: the produce of the operation is very acid, or very bitter; then I get better, and go to sleep, but in a quarter of an hour I wake worse, and so oh, every half hour until about four in the morning, when I gradually get better, and invariably wake quite well." By.a steady perseverance in the plan of diet and medicines prescribed for him, he found considerable alleviation, until April, 1825, when he complained of having a return of his old headaches with their usual severity ; but he had relaxed in the strictness of his diet; and he adds: " I think, by more care in future, I shall be able to keep them in check; but I ought to state that I now suffer from a sense of weight and oppression, chiefly after meals." On the 18th of May he had a most violent attack, owing to having eaten a mince pie, and his subsequent letters complain of a listlessness and want of energy, which rendered him incapable of the slightest exertion. I expressed a wish to see him, and he arrived from Ireland on the first of June; the journey had been of service to him, and I found him much thinner, but better than I had expected. His numerous friends in London, anxious to pay that respect which his talents and urbanity so justly commanded, poured in their invitations, so that to expect obedience to any plan of regimen was not to be calculated upon. He left London, and proceeded to Leamington, where he unfortunately, by the explosion of his fowling-piece, lacerated his little finger, and was compelled to suffer its amputation. His health declined under this operation; he lost flesh, experienced increased headaches, and was so ill as to induce his friends to call in the aid of a popular practitioner in that neigh- 204 Cases in Illustration of the Preceding Views. bourhood, under whose superintendance he took drastic doses of scammony, not only without relief, but with an evident aggravation of the symptoms. He became thinner, and more than proportionally reduced in strength; so much so, that he found himself incapable of horse exercise: he suffered severely from constant nausea and oppression. In this state he continued, until his bowels, for the first time since the commencement of the disease, exhibited signs of torpor. " From a daily pill of camboge, scammony, aloes, and colocynth," says he, " I was obliged to increase the dose to four, and at last to discontinue them as entirely inefficient; and medicine having become as necessary to me as food, my medical attendant in Ireland has contrived a more active combination, which I take daily, but 1 fear that I shall be obliged either to increase its dose, or supersede it by one still more powerful, as I find that this is even losing its effect." His bowels at length became so torpid, that the most powerful drastics failed in their operation; his strength was daily declining; scarcely a day passed without headach and sickness: he suffered, during the night, from most violent cramps in his legs. In the middle of December I received a letter from him, which was nearly illegible; and he states that he can scarcely see his hand, not from dizziness, but from an indistinctness of vision, which continues without any amendment during the day. His vision at length became so imperfect, that he could no longer correspond with me: I then urged the necessity of his once more coming to town; a proposal which he eagerly embraced ; but such was his weakness, and so severe his sickness, vomiting without any cessation for forty-eight hours, that he was many days on the road. His face, hands, body, and legs, swelled to a considerable degree, and he experienced great difficulty in breathing. As soon as he arrived in town I immediately proposed a consultation. His bowels had not been moved for ten days, and every medicine given for that object had failed in its effects: this circumstance, connected with the fact of his deficient vision, which now rendered him incapable of recognising his friends, or even of distinguishing the windowframes, induced me to suspect that all the symptoms of this unfortunate case were to be referred to some disease in the brain. Sir H. Halford, Dr. Maton, and Dr. Warren, met me in consultation. The first great indication to be fulfilled was the evacuation of the bowels; he had already, by my direction, taken ten drops of the oil of the Croton Tiglium without effect. He was now directed to take twenty grains of calomel, with five grains of scammony; and a dose of the infusion of senna, with jalap and a neutral salt, every hour, until an evacuation was procured. After some hours the bowels answered, and a perfectly healthy and figured motion was obtained. The vomiting was appeased by effervescing draughts; and a trial of the hydrocyanic acid Cases in Illustration of the Preceding Views. 205 was proposed. He was cupped, and blistered on the back of the head; but his vision grew daily more obscure; his headach was relieved, but he constantly experienced a sense of weight and uneasiness in the region of his stomach; his pulse was regular, but hard, and rarely less than a hundred beats in a minute. In this distressing state he remained for ten days; when I was suddenly called to him in the middle of the night, in consequence of a violent dyspnoea which had seized him. I found him in a state of apparent suffocation, and immediately requested the attendance of Mr. Keate, in order that some blood might be abstracted from the arm. He lost sixteen ounces, but no relief was afforded by the operation. Dr. Maton saw him shortly afterwards with me: haemorrhage had taken place from the lungs, and he died at two o'clock, after the failure of the methods usually adopted in such an exigency. What was the nature of his disease ? I confess that I had long considered the brain as its seat; and I explained the dyspnoea from a deficient supply of nervous energy, his symptoms bearing a striking analogy to those which were produced by a division of the eighth pair of nerves. The result, however, of the dissection will throw some light upon this obscure and interesting case. Upon inspecting the abdominal viscera, not the slightest trace of disease could be discovered; the stomach was larger, and the diameter of the intestines smaller than usual, but there was no other appearance worthy of notice. On opening the thorax, the lungs appeared so gorged with blood, as almost to resemble the spleen in texture; they were emphysematous in several places. The heart was apparently healthy in external appearance, but of a large size; upon making an opening into the right auricle and ventricle, these cavities were morbidly dilated, so as to constitute what has been termed passive aneurism: their panetes were not thickened. The left ventricle was also unusually large: the valves were in a healthy condition. Upon opening the head, the structure of the brain and its membranes were found in a perfectly healthy state, but without the usual presence of blood. The substance of the brain itself was perfectly blanched, and, upon cutting into it, the usual spots of blood were not produced. This organ, therefore, although not injured in structure, must have been unfitted for the performance of its functions from a deficiency of blood; in consequence, probably, of the feeble action of the heart. The history of this extraordinary case will admit of much physiological speculation. That the heart was the primary seat of* the disease, appears to be the most probable conjecture; the loss of vision must have arisen * I have learnt, since his death, that the pulsations of his heart frequently produced a considerable noise in bed, but he was himself unconscious of it, and never experienced the least unpleasant feeling in the chest; nor did the pulse, or any other symptom, indicate disease in that organ. Cases in Illustration of the Preceding Views. 206 from a deficient circulation through the brain; and to this also we are to attribute the obstinate state of the bowels. The derangements of the stomach may be referred to its sympathetic relations to the brain. The gorged state of the lungs may be accounted for, either by the imperfect action of the heart, or by the deficiency of nervous energy; for a similar appearance is observed in cases of narcotic poisoning, where the death of the animal takes place from the destruction of the powers of the brain. I have lately met with a case of diseased heart, in which the patient complained of a similar imperfection in his vision; and he died in consequence of pulmonary haemorrhage. I had no opportunity of examining the body. CASE II. C. D., a gentleman resident in the country, and far advanced in life, was seized with a violent pain in the gastric region at two o'clock in the morning: he arose from his bed, walked for some time about his room; and at length, the pain having left him, he again retired to rest, and awoke in the morning, perfectly well. This paroxysm returned every morning, at about the same hour, for several weeks: his medical attendant administered large doses of calomel, from a conviction that the disease arose from some hardened faeces in the colon; but this treatment aggravated the complaint! He afterwards gave him five grains of pil. hydrargyri every night, and a dose of neutral salt in the morning; but the disease continued to harass him with more or less violence every successive morning. Under these circumstances, he proceeded to London for advice, and placed himself under the care of a physician of celebrity, who decided at once that the liver was the seat of the disease. The patient was accordingly subjected to a course of mercury; his gums were affected, but still no alleviation of the pain was experienced. It was several weeks after this event that I first saw him, and the effects of the mercury had subsided. My first object was to inquire into the state of his digestive functions, with a view to ascertain the length of time which his organs required for the completion of their operations. It appeared that his digestion was unusually slow, and that one meal in the day was amply sufficient to satisfy his wants. He dined at six o'clock, and I therefore thought it probable, that at the period when he was usually awoke out of his sleep by pain, the food might be undergoing its ulterior changes in the duodenum. I carefully examined the seat of this complaint; there was evidently a puffiness in the region of the duodenum, and, by pressure, he experienced a slight p$in, which extended into the lumbar region. I directed him to change his dinner hour from Cases in Illustration of the Preceding Views. 207 six to three o'clock, and I laid down for his guidance such a plan of diet and exercise as would be best calculated to ensure a perfect digestion. I also prescribed the following mixture :— R Mist. Camphoree, Vini Colchici, fjij. Magnesias Carbonatis, 5j« Spir. Juniper, Co. f3ij. Fiat mistura, de qua sumantur cochlearia duo ampla, mane nocteque. I saw him after the interval of a week: he informed me that he had entirely lost the pain, and thst his bowels had been gently relaxed by the medicine. His tongue, which was previously furred, had become clean, and no pain was now produced on pressure. He called upon me several times, and left London perfectly cured. CASE III. E. F., a young man, twenty-six years of age, and a clerk in one of the public offices, applied to me under the following circumstances. Previous to the attack of which he complained, he had enjoyed very good health, although his bowels were constitutionally sluggish, and he had been in the habit of taking, occasionally, a purgative pill to excite them into action. He was attacked with a sense of oppression in the region of the stomach, accompanied with an uneasiness in his head, and great depression of spirits. His skin was harsh and dry, his tongue furred on the back part, and his appetite was greatly impaired. * He awoke in the morning with a parched mouth, and a feeling of lassitude which he had never before experienced. His urine deposited large quantities of lithic acid: he was unable to give me any satisfactory account of the appearance of his alvine evacuations; I however desired that measures might be taken in order to obtain the necessary information. I directed him to take a pill composed of five grains of the compound extract of colocynth, and two grains of calomel, at night, and a draught of senna, with sulphate of magnesia, in the morning. It produced four copious evacuations of highly offensive matter, of a greenish hue, and mixed with a quantity of undigested matter, like soft soap. He experienced a feeling of relief, but still his uncomfortable sensations were not removed. After an interval of three days the dose was repeated; the evacuations were more healthy in appearance, but his symptoms were rather aggravated by the medicine, His head felt heavy, and his ideas were confused. His pulse was perfectly natural. I directed him to take three grains of the pil. hydrargyria with two grains of the powder of ipecacuan, every night, and to take each morning a Cases in Illustration of the Preceding Views. 208 draught composed of three fluid-drachms of the infusion of senna, six fluid-drachms of mint-water, and a drachm of tartrate of potass. His diet and habits he had told me were perfectly regular, and that his occupation would not allow him to alter the hour at which he took his dinner. At this period I lost sight of him for several weeks; his friends had persuaded him to apply to some other practitioner, who, as I afterwards learnt, had directed a very proper plan of medicine for his cure; but he daily became worse, lost flesh, and suffered much from uneasiness in his head: he had, at his own desire, been cupped, but the operation afforded no relief. On his return to me, I found him labouring under all the symptoms of protracted dyspepsia, and the greatest depression of spirits. I told him that nothing short of a complete revolution in his habits would cure him; that it was in vain to expect relief from medicine, unless its administration was associated with a strict adherence to such a plan of regimen as I should propose. He reluctantly consented to obey my injunctions. I learnt from him that his usual habit was to breakfast at nine o'clock, to proceed to his office at ten, where he continued till five o'clock, after which he walked for two hours, and dined at seven, or sometimes later. I was satisfied that this plan had gradually debilitated his digestive organs, and rendered them inadequate to the healthy performance of their functions. His mind had been exhausted by the duties of the morning, and his body by the fatigue consequent upon exercise at so unfavourable a period. I desired him to dine at three o'clock, to take some tea at six, and to walk for an hour afterwards: the only medicine which was directed for him was a draught of a saline aperient every morning. He continued this plan of diet for six weeks, and was perfectly restored to health. CASE IV G. H., the active partner in an extensive firm in the west end of the town, applied to me for advice, in order that he might be relieved from a severe attack of heartburn and flatulence, which invariably assailed him every evening. He informed me that he had tried every species of food for his dinner; sometimes restricting himself entirely to animal food, and at others to a vegetable diet; that he had taken water, and drank wine, but that no perceptible difference was experienced. His usual hour for retiring to rest was eleven o'clock; but, although fatigued by the labours of the day, he was unable to close his eyes before two or three o'clock in the morning. I told him that I suspected the error was not in the quantity or quality of his food, but in the periods at which it was taken, and requested that I might be informed as to his general habits in this respect. He told me, Cases in Illustration of the Preceding Views. 209 that such was the nature of the business in which he was engaged that it was impossible for him to leave the counting-house before' six o'clock, and that he could not therefore dine before seven; but, as he commenced business at an early hour, he was compelled to take a luncheon at three or four o'clock. I immediately discovered the origin of his complaint; and told him, that he must either abandon his meat luncheon, or convert it into a regular dinner: for the simple fact was this, that the digestive organs were thus rendered unable to dispose of the second meal, since the stomach was called into action before the food, of which the luncheon consisted, was converted into chyle. I ordered him no medicine, but he called upon me after the interval of a fortnight, and informed me that he had entirely lost all his unpleasant symptoms, having made an arrangement which enabled him to dine at his house of business at five o'clock, and to return home to tea at eight. CASE V. K. L., a gentleman of forty-five years of age, who had long indulged in the luxuries of the table, and sacrificed liberally to Bacchus, was attacked, about six months before I saw him, with severe symptoms of dyspepsia; loss of appetite, pain and distention after eating, depression of spirits, loss of strength, restless nights, and various other symptoms, which it is unnecessary to enumerate, were sufficient to mark the nature and intensity of his complaint. He had been under the care of different practitioners, but the treatment suggested for his relief had been unsuccessful. When I first saw him, there was considerable tenderness in the epigastric region, his tongue was furred, his bowels extremely irregular, being sometimes relaxed, and at other times obstinately costive; he had occasionally passed stools loaded with mucous matter, and tinged with blood. His pulse was quick and small. He complained particularly of attacks of fever, which occasionally assailed him in the evening; they were preceded by nausea, and a slight shiver; he then became ex. tremely hot, and his head throbbed: this feeling continued for I three or four hours, and left him extremely languid and dejected. I He was unable to account for these paroxysms: sometimes he fancied that they might have been induced by exposure to cold, at other times he referred them to some indigestible food which he had taken. I frankly told him, that, unless he would strictly conform to the plan of diet and medicine that I should propose, | I considered him in a hazardous situation. I directed him to be cupped on the epigastric region, and to take two grains of ipecacuan, with five' grains of the extract of hyoscyamus, every night. I I prescribed a kxative draught, composed of tartrate of soda, with a small quantity of manna, in a vehicle of mint-water, to o Cases in Illustration of the Preceding Vienna. be taken twice a day. His diet was directed to consist of the most digestible and least stimulant species of animal food, to be taken but once in the twenty-four hours, at about three o'clock. I advised him to take thin gruel with dry toast for, his breakfast, and to use a tepid shower-bath on alternate mornings. I saw him again in the following week. There was less tenderness in the epigastrium, his bowels had been slightly relaxed, and he thought himself rather better, but there was no material improvement in his general health. I impressed upon him the importance of persevering in the plan, and allowed him to take two glasses of claret, diluted with ah equal.bulk of water. I did not see him again until after the expiration of ajprtnight. He was then evidently improved, and told me that he felt confident that the plan Upon which he was proceeding was the right one. He had already experienced less uneasiness after his dinner, and slept better. I found his pulse fuller, and at the same time slower. I now prescribed for him doses of the vinum colchici, with magnesia, in mint-water, and desired that the pills of ipecacuan and hyoscyamus might be continued. At this time he went into the country, and I lost sight of him for two months; but he returned very much better: his tongue was now clean, his bowels regularly acting twice a day, but he had still no appetite; I therefore ventured to prescribe an infusion of calumba, adding to each five ounces an ounce of the infusion of senna, and two drachms of tartrate of soda. He continued this medicine regularly twice a day, for three weeks, and is at this time so far recovered, as to be able to take two mutton chops for dinner, without experiencing any unpleasant feelings after the meal. I consider this simple plan to have succeeded in correcting the alimentary secretions, and imparting tone to the digestive organs; and I have introduced the relation of the case, merely to show that the most aggravated case of dyspepsia may be cured by a strict adherence to a judicious diet, with scarcely any other medical remedies than such as are calculated to keep up a gently increased action of the bowels. I could adduce many similar cases; but my object is to avoid prolixity. I trust that, in the preceding pages, I have succeeded in demonstrating the great importance of a well-regulated diet, and in establishing the principles upon which the digestibility and indigestibility of various aliments depend. THE END. 210