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,-Jrkv  f>yv)0^vtv4^i
A  TREATISE
?^J
ON
INDIGESTION.
WITH
OBSERVATIONS
SOME PAINFUL COMPLAINTS ORIGINATING IN INDIGESTION,
     AS TIC DOULOUREUX, NERVOUS DISORDER, &c.
                      BY

           THOMAS J.  GRAHAM,
 OF THE UNIVERSITY OF GLASGOW ; AND THE ROYAL COLLEGE OF SURGEONS,
                    LONDON, &C.

                                                    /

                iFCrst ^merfcan,                  .  /

FROM THE LAST LONDON EDITION REVISED AND ENLARGED:  V

                     WITH

           NOTES; AND AN APPENDIX,
 Containing Observations relative to the mode of treating Dyspepsia lately adopted
       and recommended by Dr Avery, Mr Halstead, and others;

          BY AN AMERICAN PHYSICIAN.
            Pulatreljmfa:

KEY AND MIELKE, 181 MARKET STREET.
       Printed by James Kay, Jun. 4* Co*.
                1831.
L 

                             vvx









  " He wanted no other recommendation for any one article of science, than
the recommendation of evidence—and, with this recommendation, he  opened
to it the  chamber of his mind, though authority  scowled  upon it,  and taste
was disgusted by it, and fashion was ashamed of it."
                 Br Chalmers—On the Merits of Newton's Philosophy.
\
Entered according to the act of congress, in the year 1831, by Key and Mielke,
  in the Clerk's office of the District Court of the Eastern District of Penn-
  sylvania. 
PREFACE
               TO


THE  FIRST  EDITION.
The liver is a gland of  waste;  the stomach and
small intestines are organs of supply—(a supply of
the most  important  and imperious nature): the
former  is  an insensible  viscus,  comparatively
speaking,  loosely connected  with the other  abdo-
minal viscera, and  with the general habit; the lat-
ter are  organs of  elevated  sensibility,  not  only
intimately associated with every part of the system,
but themselves forming  the chief  viscera of the
abdomen ; and with their blood-vessels, nerves and
membranes making up the great bulk of this cavity.
From this,  I believe, we rightly infer, that the
liver is  an organ in the animal economy of far in-
ferior importance  to  the  digestive tube; and  I
maintain,  that its  disorders are by no means to be
compared  with those of the  extensive  surface  of
this canal, either in frequency, or severity, or con-
sequence  to  the welfare of the constitution.  A 
«s
 IV                 PREFACE.
 principaLobject of the following observations is to
 enquire into the evidences of this fact, and to show,
 that the organization, vital properties,  functions,
 and sympathies, of this canal, when contrasted with
 those of the liver, tend  to prove, that what  are
 commonly called  "liver and bilious  complaints"
 are, nine times out of ten, in reality affections  of
 the stomach or bowels,—and, that combined with
 a consideration of the symptoms, and effects of re-
 medies, the above circumstances become irresisti-
 bly convincing of the truth  of this assertion.
   My attention was early  excited towards ascer-
 taining the correct pathology of those maladies, so
 generally named "liver complaints"  from  a per-
 suasion, that, in the nature of things, disordered  or
 diseased liver is not likely to be, in any degree,  so
 often met with, or of such consequence, as disorder
 of the functions of the  alimentary canal,__that
 centre of sympathies, to which we are incessantly
|and immediately applying stimulants and irritants,
; so numerous and dissimilar; and from finding, that
 when  these evils were treated in the too  common
 way, with active mercurials, they never failed to
 increase instead of  disappearing, being not  seldom
 confirmed, so that the parts  affected  ever after re-
 mained debilitated, and subject to frequent disor-
 der : whereas, a different treatment directed, in the
 first instance, towards restoring the impaired ener- 
PREFACE.
V
gies, and healthy secretions of the  digestive tube,
rarely failed to remove all complaint.  It is not a
little singular, that the sentiments of Mr Abernethy
and Dr Hamilton, in regard to the paramount fre-
quency  of disorders of the stomach and bowels,
and the effectual relief to be obtained in them from
the exhibition  of mild aperients and alteratives,
should have gained  such general confidence among
medical men, when their practice is so seldom and
imperfectly followed, especially that of the former
writer;  the liver still being harped  upon continu-
ally, as bearing the onus of disease, and calomel ac-
cordingly administered with an unsparing hand.
  The light thrown upon  the subject of the  first
part of  this treatise by morbid anatomy has been
drawn exclusively from the records of dissections,
contained in the writings  of  men of professional
eminence, rather than from any cases and exami-
nations of my own; because those records are be-
fore the public, and as the dissections they describe
were not instituted  to serve my purpose, they will
with justice be received as more satisfactory  and
conclusive than any I might produce from my own
practice.
  Though I consider that  mercurial preparations
are  extensively exhibited in such doses, and for so
great a length of time,  as  constitute them active
poisons rather than remedies; yet, let it be remem-
     B 
vi
PREFACE.
 bered, that I do not here inveigh against their pro-
 per use, but only against their abuse.  This is an
 evil of some magnitude in Great Britain;  and it
 appears  to me imperative upon the profession, to
 take a closer and more impartial view of the  pro-
 perties and operation  of mercury, particularly of
 calomel, than has yet been witnessed; seeing, as we
 do, that scrophula,  hydrencephalus,  consumption,
 and indigestion,  are  fast increasing  upon  us.
 These are all diseases of  debility,  and the  last,
 though not the most formidable, is perhaps now the
 most frequent.  In  its treatment, it  has been too
 general to disregard altogether the important prin-
 ciple, that " the relief of irritation is  the great ob-
ject of medicine;" and it appears evident, that in
 endeavouring  to remove supposed  disease  of the
 liver, our  violent  and  deleterious  measures have
 greatly multiplied  real disorder and weakness of
 the digestive  canal. 
PREFACE
                       TO

      THE  SECOND  EDITION.


I would  take the opportunity presented by the
publication of a second  edition of this volume  to
say, that its contents are solely the result of personal
observation  and experience, and I  therefore must
hold myself responsible for the correctness of the
opinions herein  advanced.  Many of these senti-
ments are at variance with those widely received
on  the same subjects, and  some of  them lead
directly to the adoption of a treatment the very re-
verse of what is too commonly, perhaps I ought to
say generally, followed; but when our conclusions
are drawn from close observation of the course  of
a disorder, and the operation of different remedial
measures  upon it, no difference from general senti-
ments, however great,  ought to deter an author
from the  statement of his opinions.  On the con-
trary, the greater this difference, on points involving
practical consequences, the more desirable is it that 
viii
PREFACE.
 the conclusions should be fully stated, and I have
 here therefore  proceeded on this conviction.
   If it is lawful to judge  from the effects of reme-
 dies on my own dyspeptic system, on  that of a
 near relative who is always in my house, and on
 the constitutions of the many patients I have seen,
 I must infer that the principles on which indiges-
 tion is generally treated admit of great and mani-
 fest improvement.  It appears to me that we may
 come  to the same conclusion, in regard to the  in-
 dications which regulate the treatment of chronic
 disease in general, and I think, notwithstanding the
 multitude of medical books now in being, that a
 Treatise describing at length the nature and correct
 principles of treatment of chronic disease in gene-
 ral, is a work much wanted, and, from the greatly
 increased and increasing number of chronic mala-
 dies, capable of being made of more real service to
 the public, than any other single medical publica-
 tion that has been, or could be written.   In the
 absence of such a book, the young medical practi-
 tioner  cannot  too sedulously yield himself to the
 study of the principles of management described in
 the fourth chapter of this volume, which will  be
 found to be those of the greatest importance in all
chronic disorders.
Croyden, Surrey. 
CONTENTS.
Preface           ....          hi

                       CHAPTER  I.
Nature and symptoms of Indigestion        .         .      13
Prominent evils in the Medical practice of the present day   13
Origin of the terms nervous and bilious  .         .          15
Frequency of liver  conplaints questioned    .         .      16
The acute sensibility, nervous connexions and  superior im-
  portance of the stomach and intestines          .          18
Influence of the sympathetic nerves         .         .      19
Inferior sensibility  and importance of the liver     .          20
Extensive influence of the assimilating viscera over the other
  organs of the economy           .        .         .23
Principal causes of the prevailing idea respecting the uncom-
  mon frequency of bilious and liver complaints   .          26
Swelling and pain in the pit of the stomach and right side    28
Mr Abernethy's treatment of such cases contrasted with the
  ordinary mode        .        .        .         .28
Means of distinguishing affections of the liver from those of
  the digestive tube          ...          30
Symptoms indicating irritation of the mucous membrane  of
  the stomach, duodenum and colon        .         .      30
Remarks upon the situation and affections of the duodenum   32
The colon and its affections   .        .         •          34
Dr Curry's opinions     .         .        •         .39
The nature and origin  of discoloured stools, commonly
  called bilious     .        •        •         •          41
Origin of bloody discharges by the mouth, &c.         .      45
------of black vomit and bilious discharges      .          50
Superior value of Dr Jackson's works on fever         .      51
Opinions of Portal and  Howship relative to the nature of
  black evacuations ....          53 
X
CONTENTS.
Erroneous opinions of Dr Ayre respecting the source of the
  blood discharged by vomiting    .         •         .54
Refutation of these opinions by Andral, Abernethy, &c.       56
Dr Ayre's pathological opinions relative to hepatic influence
  in marasmus condemned     ...          57
Dr Pemberton's views on marasmus         .         •      61
Yeasty discharges, with a case by Dr Blackall     •          63
Dr Good, too fond of making the liver a vortex of disease      66
Remarks of M.  Andral, Jun., relative  to the  pathology of
  diarrhoea, dysentery and lientery         .         .      68
The stomach and bowels the true seats of disorders popularly
  termed bilious    ....          72
Effects of mercurials     .         .         .         .72
Mr Abernethy not one of those who consider the liver to be
  the root of all evil in diseases of the chylopoietic viscera     76
The investigations of Broussais, Andral and other continental
  authorities, show that the liver  is much less frequently
  effected than the English physicians generally suppose      80
Dr Curry's erroneous  opinion of his own case      .          81
Powerful influence of  climate in modifying the operation of
  remedies    .          .         .                   .84
Large doses of calomel prescribed in  the Indies and some
  parts of the United States   ...          85
Yellowness of the eyes not necessarily  connected with dis-
  ease of the liver       .         .         .         .88
Intermittent pulse and fluttering at the pit of the stomach     94
Increased mortality in Great Britain from apoplexy and palsy  97

                      CHAPTER  II.
Varieties of Indigestion        ...          qo
Situated in the stomach  .                                  ftn
                                                    •      yy
------------small intestines         .         .         100
------------biliary organs      .         .              101
------------ large intestines         .                    202
Diagnostic symptoms of the different forms of dyspepsia      104
Character of the  pulse    .                                 -
Forms of dyspepsia which are most common and intractable   106
The bowels the seat of those internal disorders which prevail
  in autumn, as well  as the source of gout, tic-douloureux,
  scrophula, &c.       .
States of the general system  in dyspepsia     .              108 
CONTENTS.
XI
                      CHAPTER  III.
Causes of Indigestion         .         .         .          110
Sedentary living and mental anxiety the principal      .     112
Repletion          .         .         .         .          113

                      CHAPTER  IV.
Treatment of Indigestion          .         .          .116
General principles  .          .         .         .          117
     1. To restore healthy secretions        •          •     117"
     2. To augment the strength      '  .         .          117
     3. To relieve irritation       .         .          .117
Debility a frequent source of depraved secretions            119
The relief of irritation a grand principle           •          121
Particular remedies     .          .         .          .123
     1. Medicine  .         .          .         .          123
         Mercury to be used with caution   .          .125
         Different effects from  the same preparation given
          in large and in small doses   .         .          126
         Testimonials against salivation      .          .127
         The admirable effects produced by mercurials in
          some cases has led to its abuse         .          131
         Effects of mercurials upon the nervous system      134
         Opinions of Drs Hamilton, Alley, &c. relative to the
          poisonous qualities of mercury    .          .135
         Permanency of its deleterious effects     .          137
         The mercurial  combinations most useful in dyspep-
          tic complaints          .         .         .139
         Valuable qualities of rhubarb and ipecacuanha       139
         -----------------tartarized antimony       .     144
         -----------------nitric acid           .          145
     "^-----------------alkaline solution               148
         Proper aperients for dyspeptics      .         .     158
         Nitro-muriatic  acid bath       .         .          158
        Indigestion depending upon a  contraction of the
          rectum      .         .         .         .158
         Treatment of  local pain  and uneasiness occurring
          in Indigestion     .         .          .          160
        Treatment of the inflammatory or excited form of
          dyspepsia    .         .         .         .161
    2.  Diet                                               162 
xii
CONTENTS.
          When\his should consist of vegetable substances   163
          When of animal, with the best kinds         .     163
          Nature of fish       .         .         .          164
          Comparative digestibility of fluids and solids        164
          Most suitable drinks    .       -  .         .165
          Opinion of malt liquor        .         .          168
     3.  Regimen       .         .          .         .168
 Useful auxiliaries            .        .         .          172

                      CHAPTER  V.
 Of tic douloureux, gout, and fulness of blood in the head, as
   dependent on indigestion        .          .         .174

                       APPENDIX.
Notice of the "Dyspeptic's Monitor"    .         .         183
--------Dr Abercrombie's treatise on diseases of the sto-
            mach, &c.   .         .          .        .192
--------Mr Halstead's "new method of curing dyspep-
            sia"            ...          194
          Professor  Hitchcock's " Dyspepsia forestalled and
            resisted"      -  .         .         .         206 
A
TREATISE
                 ON

INDIGESTION.
                  CHAPTER  I.

ON  THE NATURE  AND SYMPTOMS  OF INDIGESTION, AND
  WHAT ARE USUALLY CALLED, BILIOUS OR LIVER COM-
  PLAINTS.

There appear  to me to be two prominent errors
in the medical practice of the  present day: one, is
the mistaking severe disorders of the stomach, and
intestinal canal, for disease in  the liver; the other,
is the employment of large doses of mercury, for
the  cure  of  these  supposed "liver complaints"
The mischief that arises from  these errors is incal-
culable.    They are wide spreading evils, whose
destructive influence is unhappily felt  by persons
of every age, rank,  and condition, and  which call
aloud for a remedy.*

  *The evils here adverted to, though exceedingly prevalent
throughout the United States, are more especially so in those situ-
ated towards the south and west, where they exert an  almost
universal influence over the practice of medicine.—Edit.
     C 
14
NATURE AND SYMPTOMS
   The term  " liver complaint" is now in the mouth
of every one ; and it is well known, that mercury'
in some form, generally the most injudicious, is the
universal medicine for all kinds  and degrees of dis-
order in the digestive  organs.  A patient suffering
from such disorder, which is usually denoted by
oppression at the stomach after eating, want of ap-
petite, weakness, depression of spirits, irregularity
of the bowels, discoloured motions, &c,  can at this
time hardly consult his  physician  or apothecary,
without being told he has a "liver complaint"  and,
as a necessary consequence, being soon loaded with
calomel or blue pill.  Indeed, it is a fact, of which
I am convinced  from ample experience, that even
the slighter forms of derangement in the assimilat-
ing viscera  are  often  designated  by  the above
fashionable term, and treated accordingly.*
   It is much to be regretted, that there-is a fashion
in medicine,  as well as  in the other affairs of life.
A few years  ago, the majority  of  ordinary com-
plaints were said to be on the nerves : now,  they
all depend upon, and  centre in the liver.  On this
subject, a modern writer has well observed, " the
princess, afterwards Queen Anne,  was subject to
hypochondriacal attacks, which her physicians pro-
nounced to be spleen, vapours, or hyp, and recom-
mended Rawleigh's confection,  and pearl cordial,
for its cure;  this circumstance was sufficient to
render the disease and remedy fashionable, and no
the valuable little work of Dr Hall on the Mimoses. 
OF INDIGESTION.
15
other complaint was ever heard of in the precincts
of the court but that of the vapours.   Some years
afterwards, in consequence  of Dr Whytt's publi- '
cation on ' Nervous Diseases,' a lady of fashion was
pronounced to be nervous—the term became gene-
ral, and the disease fashionable; and spleen, vapours
and hyp, were consigned to oblivion.   The reign
of nervous diseases, however,  did  not long  con-
tinue, for a popular work appeared on Biliary Con-
cretions, and all the world became bilious."*  It
is an  unhappy circumstance, that the  world  still
continues in this state, and that both  the  disease
and  its remedy  have taken so  deep a root in the
professional mind, that there is yet no appearance
of a change to another ideal fashionable malady,
whose favorite remedy, we might hope, would be
a medicine more like  pearl cordial or Rawleigh's
confection than  calomel, and therefore more con-
genial to the human constitution, and which, if it
were  n6*t attended with any sensible benefit, would
possess, at least,  the advantage of being innocent.
  Those disorders, which are, in common language,
called bilious and liver complaints, are denoted by
some or all of the following symptoms,  viz. a sense
of distention and oppression after eating, with flat-
ulent, acid eructations;  diarrhoea, or constipation
and uneasiness of the bowels; furred tongue  ; im-
paired appetite and strength ; discoloured motions,
they being either  green, dark-coloured, black, or
* Paris's Pharmacologia, vol, i. 
 16          NATURE AND SYMPTOMS

 much too light;  nausea,  headach, and  bilious
 vomiting; palpitation of the heart,  with or with-
 out  occasional pain in that organ;  pain in the pit
 of the stomach and towards the right side;" sallow-
 ness of complexion; and depression of  the spirits:
 —and if the chief, or the whole of these symptoms
 are present,  especially if in a severe  degree,  it is
 usually considered sufficient to justify the opinion,
 that a liver disease exists.  But according to  my
 experience, a very large  majority  of those mala-
 dies are not liver complaints, but properly disorders
 of the stomach, and intestinal canal; and this fact
 will form the subject of consideration  in  the first
 part of this book.
   It is acknowledged, that in every severe disor-
 der of these viscera, the liver participates, and its
secretions are consequently vitiated; but this is  a
secondary  affection, and very different from  the
state in which that organ is usually considered to
be  found.  They are not, as is erroneYju&ly ima-
gined, primarily and chiefly liver diseases, in which
there is, at least,  incipient disorganization of that
viscus, or  a  condition nearly approaching  to it,
which is the idea  commonly  intended  to  be con-
veyed to patients, and generally received by them,
from  the use of the term liver complaint; but are
functional derangements of the stomach and intes-
tines, the liver being affected secondarily and sym-
pathetically ; and  so far from requiring large  and
repeated doses  of mercury, for  the restoration of
its healthy functions, that they can be permanent- 
OF INDIGESTION.
17
ly re-established only by the use of means directed
to correct the original morbid affection.   Among
these  means, we  shall  see  that  mercury is not
always admissible, even in minute doses, and that
in large ones it is invariably pernicious.
   So vast  a sink of  disease has  the  liver  been
thought of  late, that it is considered by some men,
of no small professional  eminence, as amongst the
greatest improvements of modern medicine, that
the attention of the practitioner is duly awakened
to the  "remarkable sympathy" which it exerts in
its functions with all the other viscera!   This sen-
timent appears to me utterly inconsistent with our
physiological knowledge, and with the light thrown
on the  pathology of abdominal disease  by morbid
anatomy: it seems invalidated by established facts.
When  we remember the dull sensibility of the liv-
er, and the loose* connexion it has with the other
viscera of the abdomen, and with those of the chest,
by reason of the small number of its  nerves, we
are at  a  loss to conceive how  this  "remarkable

  ■* I wish the reader to bear in mind, that throughout this book,
when contrasting the abdominarconnexions and general sympathies
of the liver with those of the  stomach and intestines, I speak rela-
tively.  It cannot be my desire to endeavour to show that the
liver is really slightly connected with the other abdominal viscera
and general system, but that this  connexion is much inferior to
that of the stomach and bowels.  It is on this inferiority of con-
nexion and sensation, that I  found my opinions of its inferior im-'
portance to the well-being of the whole frame, which if I succeed
in proving, is all I require to show that other language, and more
lenient  treatment, than is  commonly employed,  ought  to  be
adopted. 
18          NATURE AND SYMPTOMS

sympathy" can  exist  between  them;  and if our
judgments are unbiassed by theory—unwarped by
bile, surely we are naturally led to question it; but
if it be transferred, as it  ought to be,  to  the ali-
mentary canal,  we are so far from being unable
to perceive the source of that intimate  and impor-
tant sympathy  subsisting  between this and  every
other organ, and indeed with the remotest parts of
the body,  that we are  surprised it has so long es-
caped due attention.   For whilst  the anatomist
notes the comparative paucity of nerves distributed
to the hepatic viscus, he is struck with the number
and variety of them,  almost innumerable, which
ramify and subdivide  upon the alimentary  canal
and mesentery, especially upon the upper part of
the former.  These, by their connexions with each
other,  with the nerves  of the  spinal marrow
throughout, and  with those of the chest and  head,
establish such an intimate intercourse of sensations
and affections between themselves, and every  other
part of  the body,  as readily explain the marked
and  powerful  influence they  exercise over  the
functions  of every organ, even the most  distant,
and of both the external and internal surfaces.  In
these nervous connexions,  and in the elevated sen-
sibility  arising  from and dependent upon them,
we  at once recognise the foundation of  the consti-
tutional origin of local diseases, and the source of
those wandering pains, and indescribable sensations
as well as  of that  great nervous  depression, and
general disorder and debility, invariably accompany- 
OF INDIGESTION.
19
  ing an unhealthy state of these assimilating viscera.
  By reason of these extensive and diversified  asso-
  ciations, the stomach and bowels become a centre
  of sympathies, and disorder, originating here, rapid-  .
  ly propagates itself to every  other part.  Thus we
  see the propriety and necessity of attending closely
  to the state of these  internal viscera, in diseases of
  every class and degree, whether original or  sym-
  pathetic.
     Though  I do not consider the nerves as the ex- r
  elusive instruments of sympathy, they are unques-^
  tionably the chief sources of it;  and, therefore, it
  is a natural inquiry, where this "remarkable  sym-
  pathy" clearly appears  from disordered  liver, and
  how does it arise, situated as this viscus is, so much
  without the  nervous   connexions established be-
  tween the  remaining assimilating viscera, and all
  other parts of  the body, by the important system
  of the great sympathetics, and the par  vagum?
  These sympathetic nerves are the principal  links
  which  unite the internal   nutritive  functions,  to
  those which keep  up the relation of the animal
*■ with external objects;  and  it is by this  bond of
  union that the derangement of their important func-
  tions, whether by acute or chronic disease, is neces-
  sarily attended with proportionate changes in all
  the acts of the animal economy, in the same man-
   ner as the  defects of one wheel interrupt or dis-
   turb the mechanism of a whole machine.  But,
   as was  observed above,  so imperfect are  the  sensi-
   bilities of the liver, that though acute inflammation 
20
NATURE AND  SYMPT031S
 of any portion of the alimentary canal is invariably
 marked  by  the  acutest suffering, and  the most
 alarming  symptoms,   which,  if  not  checked,
 speedily terminate fatally, inflammation  of the liver
 will be making destructive progress when  the pa-
 tient slightly complains only of a  flux,—frequent
 inclination to stool,—gripings and watery motions;
 the heat of the surface being but little increased,
 and the pulse neither hard nor quick ; and thus  he-
 patitis  generally appears,  even  under the burning
 sun of  the east.   Morgagni mentions several  in-
 stances of inflammation of the liver, marked by no
 peculiar symptoms, an occurrence with which our
 naval and military surgeons, who have served long
 in tropical climates,  are  very familiar.*   In the


   * Dr Archibald Robertson, in his Medical Topography of New
 Orleans,  in describing the frightful march of dysentery,  which
 " knew neither pause nor hindrance, but, like the fabled vulture of
 ancient mythology, pursued its cruel task from day to day" amongst
 the British troops before that place, observes:—" Oftener the com-
 plaint would make its attack with the common introductory symp-
 toms, and no pain in tlrs right hypochondrium was felt through-
 out the disease, either on inspiration, or strong pressure under the
false ribs.  In whatever garb of disguise it made its appearance,
 disease of the liver (as I have before stated,) and, consequently,
 a vitiated state of its secretions, were undoubtedly the primary
 cause  of  the mischief. Dissection of the  fatal cases  showed
 structural derangement,—a soft friable condition, and generally
 suppuration of that gland.  I have often found two  separate  ab-
 scesses in the parenchyma of its large lobe, the one generally less
 deep-seated than the other, and containing, in some instances, a
 quart of pus, similar in colour and consistence to what is usually
 found in psoas abscesses.  How such extensive  disorganization-
 and formation of matter could take place, without any preceding
palpable indication of local mischief, is to me still a mystery: 
OF INDIGESTION.                21
ordinary chronic affections, also, of this viscus, oc-
curring  in  this country, so great is its insensibility,
so  indistinctly do the other  viscera of  the  abdo-
men, and the general system  sympathize  with it,
that extensive organic mischief has often been de-
tected in   it  by the   knife of the anatomist after
death, when  the  patient during  life was uncon-


But such  was the fact."   In noticing the appearances on opening
the abdomen of a naval officer, who fell a martyr to dysentery off
New Orleans, he says,—" After the liver had been removed, and
laid out for minute inspection, I found an abscess of such extent
and so lined in its inner surface with a thick, fretted, and irregular
exudation of coagulable lymph, that it resembled a  familiar and
homely object, viz. a large  winter glove, lined with worsted!  On
accurate examination, a second abscess was found, lower down
in the large lobe, containing a pint of pus."
   " This  officer had never, at any period of the disease, felt any
■pain in his side:  From his general intelligence, and from the
accurate descriptions he gave me daily of his minutest sensations,
I am convinced he would  have mentioned that pain, had it exist-
ed, even  to  the extent of a 'sensus molestiae.'  Besides,  he
was one of the last men in  the world that one would have suspect-
ed  of hepatic affection, being florid in complexion; and having
previously enjoyed the best health all his life."
  " Instructed by this insidious case, I had my eye to the liver
ever afterwards; but pain  of side, or pain on pressure under the
ribs, was  by no means often felt, though  dissection after death
brought to light  hepatic disorganization, equally  extensive as in
the above  case."—Dr Johnson on Tropical Climates, page 438.
   Though I cannot agree  with Dr Robertson, that this  hepatic
disease should be considered as the chief and primary cause of
dysentery, it  being regarded by me as one only, and most certain-
ly not the principal, in a series of morbid causes ; yet these ex-
tracts tend irresistibly to  convince us of the truth of what I here
advance, and which it is material for the profession and the public
to reflect  upon,—the natural and  conspicuous insensibility of the
liver, and the inferior importance of its functions.
D 
22          NATURE AND SYMPTOMS
scious of any thing wrong in that region.  These
persons, when alive, had shown no yellowness or
sallowness of complexion, had complained of no
pain in the  right side, or shoulder, nor  suffered
under any perceptible weakness, or any other symp-
tom which could lead their friends or physician to
suppose, that so large a viscus  was actually in a
state of irremediable disease.  Are not these facts
irreconcileable with  the hypothesis, of an impor-
tant and remarkable sympathy  existing between
hepatic derangements,  and all the other acts of the
animal economy {  Do they not, on the  contrary,
forcibly convince us how comparatively imperfect
the relation of the liver is, how inferior its sympa-
thy, with other parts ;  proving most satisfactorily
the error and folly of calling the prevailing disor-
ders of the digestive  organs,  bilious complaints ?
And when we  reflect  upon the extensive nervous
influence,  the exalted sensibilities,  and  the great
importance  of the functions of  the stomach and
bowels, do not the probability and rationality of
considering these affections as centering  here, and
not in the liver, become apparent ?
  The fact of positive disease frequently taking
possession of the liver, without the constitution, or
any single viscus sympathizing with it, and, there-
fore, without its being discovered  during the life of
the patient,  cannot  be  denied.  In order  to over-
come  the  powerful argument   thence  derived,
against the supposition of so "remarkable a sym-
pathy" being exerted by this viscus,  in its functions 
OF INDIGESTION.
23
with all the remaining viscera, will it be asserted,
that it is not the organic injury, but the simple de-
rangement of function in the liver, that is attend-
ed  by effects so extensive and pernicious ?  This
follows of course:   But it is, at least unreasonable,
and contrary to what takes place in any other
organ;  having for* its support, merely the disco-
loured appearance  of the alvine discharges, and the
power of mercury in restoring them to their natu-
ral colour, which we shall presently see is a weak
prop.  Those who maintain this opinion have the
cause of an improbable anomaly to explain, for we
meet with nothing similar in the lungs, the head,
the digestive tube, or elsewhere.   Here the favor-
able prognosis of the physician is in proportion to
the freedom of the affected viscus from structural
disease, and the degree in which the remaining vis-
cera sympathize with it, and in which the general
habit emaciates and sinks, is also  generally in the
same proportion.  This  accords with all we know
respecting the  laws of organic life ; and before it
can be admitted, that these laws are reversed in
favour of hepatic derangements, we must assuredly
possess some clearer and better reasons for it than
have hitherto been attempted.
   The stomach, and first intestines, unquestionably
perform the most  important offices in the  frame,
and are the grand sympathizers with all the local
and constitutional derangements of the system, the
cause of which has been  pointed out as  arising
chiefly from the enlarged and  varied communica- 
24           NATURE AND SYMPTOMS

tions  of those nervous apparatus,  known  by the
name of the great sympathetics, and  par vagum.
These assimilating viscera carry with them in their
action all the other organs of the economy;  " they
summon to their aid the whole system of the vital
powers; and this sort of derivation is the more con-
spicuous as the  organization  is more delicate,  the
sensibility  more lively, the susceptibility greater.''
In short, it may be truly remarked, that they are
the great arbiters  of health and disease, of life and
death.  Yet, in the modern fashionable  system of
the pathology and  treatment of abdominal disease,
these are considered parts of far  inferior  conse-
quence to the liver ; this is regarded as the fruitful
"fons malorum"  and  thus we retrograde  in  our
knowledge of diseases, and in  our acquaintance
with  the means of cure.
  In the adult,* the alimentary tube  is at least six
times the  length  of the body: so  delicate is its
organization, so  important its functions, that, as we
have seen,  it possesses  a distinct system  of  nerves,
remarkable for their acute sensibility,! and  for the
fineness, as well as the number, and the connexions
of  their filaments.   It is the  grand medium of
sympathy; and there is  an  immediate  connexion

  * In children it is a great deal more extensive  than even this,
the extent of surface which it unfolds, being always proportionate
to the assimilating exigencies of the constitution. Since the growth
of the body is most rapid in the earlier periods of life, this impor-
tant tube is therefore then proportionally longer.
  t It is true that this sensibility is sui generis. 
OF INDIGESTION.
25
between it and the centre of all nervous influence,
the brain, for there is an union in the stomach of
the cerebral and sympathetic nerves: in it, the food
we take is converted into a homogeneous nutritive
fluid, which now nearly resembles, and is soon ac-
tually to  become blood, the substance that gives
life and energy to every part.   This  canal is the
distinguishing characteristic that separates the ani-
mal from the vegetable  creation, and is  therefore
essential to every animal, from the zoophyte, eter-
nally fixed  in his rocky habitation,  up  to man,
whose restless activity carries him to the very ends
of the  earth.  It is the  part to which the proper-
ties of life seem to  adhere with the greatest tena-
city, for whatever is the kind of death the animal
dies, this is the last  organ in  which the traces of
life may be  discovered.   Moreover, it  is the most
irritable part of the human  body; and such are its
connexions and sympathies, that the  morbid phe-
nomena, resulting from irritation  of  its internal
membrane, are infinitely more numerous and dis-
tressing than all the rest of the catalogue of human
diseases collectively.   It may be safely  asserted,
that seven-eighths of human afflictions originate in,
this cause.  No bounds can be  placed to the various
maladies it stimulates, and to  which it gives rise.
At one time it will produce all the phenomena of
typhus fever, of the most malignant grade, and the
patient will be as completely delirious as in phre-
nitis itself: at another, the interruption to digestion, 
26
NATURE AND SYMPTOMS
conjoined with the sympathetic disorder of various
other functions of the system, resulting from sim-
ple irritation of  this extended surface, will termi-
nate in actual dissolution, no traces of disease being
discoverable in it, or in any other part after death.
Then, surely, the man who can  compare  the  im-
portance of the hepatic functions  with those of
this tube,—who can regard the  disorders of  the
former as those which should engage our chief at-
tention  in abdominal derangements, and  in  the
diversified, local, and general  maladies, to which
the human body is subject, takes a lengthened stride
backwards in physiological and pathological science,
which every benevolent mind must regret, on ac-
count of its  consequences, and in  which no  one
will follow him who attains to correct views,  and
to a successful practice in medicine.
  There are  several circumstances which have
concurred to render hepatic disorders and diseases,
and their remedy, calomel, fashionable in Great
Britain.   The five  following  have  probably  had
the greatest weight, and we shall, therefore, con-
fine our attention principally to them.
  They are,—1st.  A fulness, and  tenderness on
pressure, and.pain, being often present at the pit of
the stomach, extending a little to the right side.
  2d. The alvine discharges being  almost always
discoloured in  bowel complaints, and not unfre-
quently green or black, like  pitch,  from which
they have been called bilious; and  the power of 
OF INDIGESTION.              27
small doses of mercury, in correcting this appear-
ance.*
   3d. Organic disease  being  sometimes  found in
the  liver  after  death,  in cases of  intestinal, and
other disorders, when  no  traces  of such  mischief
are detected  in any other viscus.
   4th. A great number of our countrymen annu-
ally return from the  East and West Indies  with
biliary and intestinal disorders, arising  from their
residence  within the  tropics, where the liver is
the  organ the  most  obnoxious  to disease,  and
where  calomel  is  the  sovereign remedy  for all
bodily ills: these, on their return to England^ are
ready to pronounce the maladies of their friends to
be liver complaints, and cannot, of course, conceive
any other medicine equal to calomel.
   5th. The  sensible influence which the opinions
and practice  of  professional men from India have

  * In almost every  instance where from  a  diseased action in
some part of the intestinal canal, more particularly in the colon
and lower portion, the ordinary secretions of its surface become
changed and the  appearance of the stools correspondingly altered,
a liver affection is supposed to be at the bottom of the case. Should
the stools be darker than ordinary, or green, the bile is pronounced
vitiated, and nothing will serve to correct it but a course of mer-
cury.  If on the contrary the colour appears lighter than usual,
the bilious secretion is deficient, the liver torpid or its ducts ob-
structed. Under all these circumstances the real seat of the disease
is generally overlooked, and an erroneous practice adopted. The
true causes of the diversified appearances produced  by the most
frequent disorders of the first passages will be found very happily
explained in a subsequent page of this treatise.—Edit. 
28
NATURE AND SYMPTOMS
 had and still continue to have, over medical prac-
 tice at home.*
    1st.  The  fulness  and  tenderness  here  referred
 to must not be confounded  with the enlarged  and
 indurated state of the liver, occasionally to be  felt
 by manual  examination.   This is  generally  too
 sure an indication of organic injury in that viscus,
 while the former, for the most part,  affords  us no
 grounds for such a suspicion.f
    This fulness  and soreness  at  the pit  of  the

   * The prejudices which prevail  in our southern  and western
 states  exert no less influence over the practice of this country,
 than those of the physicians from India over that of England.—
 Edit.
   t Mr Abernethy (at page 88 of his Observations on the Consti-
 tutional Treatment of local Diseases) has related the case of a
 young lady, in  whose hepatic region an incipient enlargement
 and hardness of this kind was felt externally. While reading it,
 I could not help contrasting the gentle means this gentleman used
 with perfect success for the cure of this affection,  consisting of
 " mild mercurials and aperients," with the active stimulant mea-
 sures too commonly resorted to in similar instances, where calomel
in large and oft-repeated doses is forced upon the unhappy patient.
 He says,  «I found, upon inquiry, that the chief seat of her pains
was in the posterior edge of the liver.  Indeed, that viscus was en-
larged, so as to be felt in the epigastric region, and was so tender
as to cause much pain on being compressed, at any part along
the cartilages of the ribs.   Her tongue was furred; her appetite
deficient; digestion bad; bowels  costive; and stools black, or else
untinged with bile.  I had no hesitation in advising that attention
should be chiefly directed to rectify the disorder  of the chylo-
poietic viscera.  Mild mercurials and aperients were given, by
which, with other means, she got materially better in health, and
was able to walk about as well as ever.  The gentleman, who at-
tended this patient, met me accidentally two  months afterwards,
and informed me that she  was quite well."
                                                      tt 
OF INDIGESTION.             29
stomach, and in the right side, I believe usually to
depend upon irritation and debility of the internal
surface of the stomach, duodenum, or colon; and I
think that the situation,  and acute sensibility of
these parts,—the frequently rapid development of
the symptoms,—the character of the swelling,—
the effects of remedies,—the insensibility of the
liver, and the appearances,  on dissection,  of fatal
cases, sufficiently prove the correctness of this idea.
   At first view, it is evident that we must often
be liable  to  mistake the nature  and seat of the
swelling and pain we are considering, if great at-
tention be not paid to the case, since the stomach
and duodenum, as well as the colon, are situated
in the immediate region of the affection, close upon
the  biliary organs.   The  ensiform  cartilage, or
what in common language is called the end of the
breast-bone, will be  found to present commonly to
the middle  of  the stomach, and  the lower orifice
of this organ, when in its natural state, is opposite
to the fossa umbilicalis of the liver:—The duode-
num, or first intestine, on  quitting  the  stomach,
goes in a direction downward; then it passes up-
ward till it touches the gall-bladder; then making
a sudden turn, it descends directly near to the right
kidney, and is involved in the lamina of the mesoco-
lon ; it then takes a sweep towards the right side, ob-
liquely across the spine:—the colon ascends on the
right side of the small intestines, before the kidney;
passes across the upper part of the belly, under the
margin of the liver (in contact with the gall-blad-
      E 
30
NATURE AND SYMPTOMS
der),  and before or under the stomach.   Such
being the situation of these viscera, and of the liver,
we cannot be surprised if  their derangements are
often  confounded, and that swelling and tenderness,
existing  either in the stomach, or duodenum, or
colon, should, for want of strict examination,  and
from  the superior attention paid of late to the liver,
be ascribed to  disorder or  disease of this part.
   Tenderness  and swelling on the upper and fore
part of  the abdomen, is frequent in disorders of
the digestive tube, but they are in general different
from  those arising from enlarged liver, both in seat
and character; the  fulness not being  situated so
much towards the right,  or so  low  as the latter,
an<J being not  a hard, but a puffy, elastic swelling.
The tenderness also  differs in its seat,  from that
produced by hepatic affection, in the same way as
the enlargement, and it is not, like the latter, felt
only on pressure of the hand, but is almost always
present, more  or less, until removed by the appli-
cation of remedies, and is  sometimes very trouble-
some when no  pressure  whatever exists on the
part.   The fulness  consequent upon chronic he-
patitis is very generally quite on the right  side,
and felt lower than the epigastric region; but when
it arises from irritation of the mucous membrane
of the stomach, it is  found mostly at the very end
of the breast-bone:—when it is the consequence of
a similar state of the  duodenum,  a little  to the
right, and somewhat lower than the termination of
this bone.  When it is still lower, and  seemingly 
                 OF INDIGESTION.              31

across the upper part of the belly,  the colon  is
generally its seat.*
   These symptoms often supervene in two or three
weeks, or even a shorter time, after the patient is
first conscious of indigestion, which is  extremely
unfavourable  to the  supposition of  existing liver
disease, as  organic derangement takes  a  much
longer time to develope itself in chronic disorders.
From the acute sensibility of the alimentary canal,
we are not at  a loss to account  for. the rapid
development of these phenomena, while the faint
sensibility of  the  liver  becomes  an  additional
reason for our considering pain and swelling, in its
texture, to be  rare when compared  with a similar
condition of  the  digestive  tube.    The different
effects which follow local blood-letting in the two
complaints, likewise point out a real difference in
their nature.   In this puffiness  which I consider
symptomatic  of disorder in the  alimentary canal,
the application of leeches is indicated, and is almost
immediately  followed   by  striking,  permanent
benefit:  in chronic  disease of the liver, the  local
abstraction of blood is rarely indicated, and, when
resorted to, is attended with very little and transi-
tory relief.  Besides these well-marked distinctions

  * The special attention of the reader is requested to the de-
scriptions, contained in the preceding and following paragraphs,
of the relative situation of the parts in the abdomen, most com-
monly the seats of disease.  A thorough acquaintance with this
subject is of the first importance towards arriving at a correct
diagnosis.—Edit. 
32
NATURE AND SYMPTOMS
between the  two maladies, it  will  be found, if I
mistake not, that the pain changes its place a little,
and the patient gains some relief, on the expulsion
of wind, in this affection of the stomach or bowels,
which change and relief do not occur in diseased
liver.*
   The duodenum, or first intestine, is  fixed by a
rather loose cellular tissue to the posterior side of
the abdomen, and dissection has proved, that it is
susceptible of  such  dilatation, as  occasionally to
equal even the stomach in size.   The existence of
pain in this part may frequently be detected by its
being felt under the seventh or eighth rib, passing
deep, seeming to be in the seat of the gall-bladder,
and stretching towards the right hypochondrium,
and to the kidney, and again appearing as  if on  the
loins.   From the course of  the duodenum,  we
should expect pain in it to take this direction, and
we readily perceive how liable it is, in our day, to
be  confounded  with that arising from hepatic
affection.  Dr James Hamilton, Jun. remarks, that
 when along  with the usual symptoms,  there  is a
 milky white appearance of the urine, as if it were
 mixed with chalk, he never has any doubt on the
 subject of its being a disorder of the first intestine,
 because  he  has invariably found the duodenum
 affected under  such  circumstances, and  he  never
 observed  the  same appearance  of the urine in
* Ferriar's Medical Histories, vol. ii, page 28. 
OF INDIGESTION.              33
diseased liver.*   I am sorry that I have not been
able to ascertain what importance is to be attached
to this  symptom.   If  future observation  should
prove it to be generally present in the  disorders
of the first intestine, while it is as often  absent in
cases of disorganized liver, of course it will materi-
ally assist us in forming a correct diagnosis in these
diseases.  It is  nearly certain,  that in disease of
the biliary organs, the urine seldom fails constantly
to deposit a pink sediment, which kind of deposition
very rarely  appears, for any length  of time, in
disorder of the digestive canal.
   The  duodenum is  more glandular, and more
vascular than any other part of the small intestines ;
it is the part which receives the biliary and pan-
creatjf fluids, where  the peristaltic motion is begun
in the natural action of the bowels, and  in which
a kind of second stage of digestion takes place;
and it is  to be regretted that its disorders do not
gain greater attention among us, as it  is more than
probable that they  constitute some of  the  most
painful and severe within the abdomen,  and form
no mean  proportion of those maladies commonly
treated as  liver complaints.  Hoffman, Sylvius,
and a few others, have treated  of them in  their
works, in an  instructive way;  and Mr John Bell
correctly observes, that it has been the opinion of
the most respectable  old physicians, those whose
knowledge of diseases has been  drawn from an
* Observations on the use and abuse of Mercury, page 110. 
34
NATURE AND SYMPTOMS
 acquaintance with anatomy, from the frequent in-
 spection of dead bodies, and the observation of the
 symptoms during life, that the study of the diseases,
 connected with the duodenum, is the most impor-
 tant  which can occupy the attention of the medi-
 cal inquirer.*
   The intestine colon seems  especially liable to
 excessive irritation and disease, and that tenderness
 and swelling in  the  right side is often  owing to
 such a condition of this part, I  am persuaded from
 observation, and  the  fact is corroborated by the
 testimony of respectable writers.  In the records
 of  dissections  of protracted and fatal  cases of
 abdominal affection, to be found in different medical
 works, the colon is noted as having  presented, in
 the majority of instances, particular marks of organic
 lesion.   This is observable in the writings of Mr
 Abernethy, M. Louis, M. Broussais and Dr Black-
 all.   Out of  fifty-three  cases of disease in the
 alimentary canal examined by M.  Andral, Jun.,
 twenty-eight presented remarkable disorganization
 only in the caecum and colon, and the greater part
 of the remaining number shewed an analogous state
 of  the lower portion  of the ileum, immediately
joining the colon.   In five out of six fatal cases of
 abdominal disease alluded to by Mr Howship, the
 disorganization  was almost confined to this part of
 the canal.
   The following  case, for which I am obliged to
* Bell's Anatomy, vol. iv, page 70.  1804. 
OF INDIGESTION.
35
Mr Howship, strikingly exemplifies the mistakes
sometimes  made  in  practice, in considering an
affection of this bowel as disease of the liver; and
it is hoped that it will prove an useful illustration
of the correctness of  the opinions above delivered
on this point.

   " The subject of this case was a lady, whose
complaints had,  by various practitioners, been at-
tributed to disease in the liver; upon which  pre-
sumption she had, in  the early part of her illness,
been repeatedly subjected to the influence of mer-
cury, without benefit.  Of several who had seen
and attended her, Dr Hooper was the only physi-
cian who could never be persuaded  to believe her
complaints hepatic, notwithstanding  constant local
uneasiness, frequently severe pain, and a degree of
tumour below the cartilages of the ribs  on the
right side, with occasional  pain at  the shoulders.
The action of the bowels was irregular; sometimes
there were twenty-four  stools in as many hours;
at others, strong purgatives  were required to be
frequently given for days together, without effect."
   A variety of medicines were given, but in vain,
arid she died in February 1820.
   " On examination,  in presence of Dr Hooper,
1 found a thickened, discoloured, soft and  elastic
tumour, lying across  the upper part of the abdo-
men, a circumscribed portion of which tumour had
visibly raised the external  parietes,  previous to
their being laid aside.  From the right extremity 
36           NATURE AND SYMPTOMS

of this tumour several strong adhesions passed off
to the adjacent surface of the parietes; from its
anterior  part also, several  short thick cords, the
result of effusion,  were  firmly attached to the
peritoneum,  just within the  scrobiculus cordis.
The tumour itself  turned out to be the  stomach
and transverse arch of the colon, closely and  com-
pletely adherent to  each  other; the former viscus
much  discoloured, the latter  much  diseased,  so
altered in texture, and so much thickened,  as  to
have entirely lost its natural characters."
  " The adhesions just mentioned were exceedingly
strong, and all proceeded  from  the colon, which
had evidently been the seat of the primary inflam-
mation.   The  bands attached to the scrobiculus
cordis clearly  explained the  distressing  sense  of
gnawing, or  burning, or glowing heat, with the
occasional sense of pulling, or  drawing at that part,
from which she was never altogether free."
  At the latter period of her illness, the patient
had  dropsy,  and Mr Howship adds, " The  ascites
proved  to have been merely the consequence of
the derangement in the function of  absorption, re-
sulting from the first inflammation; for  the liver
was healthy  in structure, although its peritoneal
covering was somewhat thickened."*

   Hard  drinkers are thought to be  particularly
obnoxious to disease of the liver, which is unques-
                                               ■*
  * Howship on Diseases of the Lower Intestines,  page 80.—
 3d edition. 
OF INDIGESTION.
37
tionably true; but now that the  diseases  of the
intestine colon are considered, I ought not to pass
over unnoticed the fact, that in many such instances
the hepatic viscus has been found after death quite
healthy in its  structure,  while the only or  chief
disease has been in  the  colon.   Mr Howship, at
pages 123 and 125 of the work just referred to,
has noticed two cases of  this description, and Dr
Blackall, in his work on dropsy,  mentions others.
Mr Howship's first case  (page  103) was that of a
gentleman, who, after many years of hard drinking,
died from a blood-vessel  in the lungs bursting into
the cavity of  the chest;  " the liver, stomach, and
bowels, were  apparently healthy,  except the head
of the colon  which felt thickened.   I therefore
dissected this part out, secured its vessels, and the
same evening injected it.  In this operation, scarce-
ly any resistance was felt from the arteries; and,
on cutting open the bowels, I found this was owing
to a broad band of ulceration, by which the villous
membrane surrounding the head of the colon and
cavity of the caecum  was  destroyed,  the vessels
upon the ulcerated surface allowing the injection
to flow freely into the gut."
   With regard to positive  pain at the pit of the
stomach, and in the sides, I think it is so common,
that  few cases of derangement  of the digestive
organs occur  without some degree of it, and there-
lore it is not an indication of disease,  or disorder
in the liver.   Dr Marshall Hall is of the same
opinion.   "Sometimes,"  he observes,  page  75,
      F 
38
NATURE AND SYMPTOMS
 " there is  extreme pain extending across the false
 ribs, leading to  the suspicion of  inflammation of
 the pleura, or, together with the affection of the
 complexion, it leads to the suspicion  of inflamma-
 tion or disease of  the liver."—" It is distinguished
 by being liable to recede and to recur, by varying its
 situation,  frequently  by being unattended by
 tenderness on pressure, when the examination is
 made  with proper care."  This author  is fully
 sensible how often pain in the sides leads to a sup-
 position of a " liver complaint:" in referring to the
 means of distinguishing those affections of the di-
 gestive organs, which are attended by a sallowness
 of complexion, and occasional pain in the side, and
 which are therefore often confounded in practice
 with disease of the liver, he remarks:  "By these
 means, the list of chronic diseases of the liver would
 be  considerably curtailed, for I  could  recall, at
 this moment, numerous instances of  this error in
 diagnosis."*
  I have known several patients, in whom, together
with the usual dyspeptic feelings,  there was swell-
ing and frequent darting pains  in the epigastric
region, and sides, who have been under  the com-
mon course of treatment for  a  "liver complaint"
for several weeks, or months,  without  deriving
benefit, but rather growing worse; and who have
had this pain almost directly removed, the enlarge-

  * Essay on the Mimoses (2d edition), page 144.  See also the
Cases at page 76 of the same work. 
                OF INDIGESTION.              39

ment also  gradually disappearing, under  the use
of means directed to restore the digestive tube to
a healthy state.   In some cases of this description,
there has existed so great a degree of tumefaction,
and occasional pain, in the side, as would  have  led
me, at first view, if I were not aware how fallacious
these symptoms are, to pronounce them as certain
indications of disease in the liver.  When,  how-
ever, the other appearances denoting disorganization
were absent, it has been my practice to reject such
an opinion, and the effects of  remedies have inva-
riably proved its propriety.
   The late  Dr James Curry (de mortuis nil nisi
verum), whose book on biliary concretions, together
with  his mode of practice,  operated greatly in
making  diseased liver, and its  supposed  remedy,
calomel, so  very fashionable and  fatal, was so
wedded  to his notions on this subject, that in  his
patients, invariably,  the liver was  considered  the
real  source of all  their  ailments;  and  if, when
labouring under stomachic irritation and  disorder,
they complained of pain  in  the left side, in  the
region of the stomach, he would endeavour to per-
suade them they were mistaken, and that it certainly
was  in the right!   If he could not bring  them
over to this belief, it was his custom to say—Ah,
I shall bring it there then!   What  value can  be
attached to the opinions, or what good could attend
the practice of a man whose judgment was  so
amazingly perverted ?   That this unfortunate phy-
sician  did  often  bring the pain to the right side 
40          NATURE AND SYMPTOMS

there is no question, for he took a sure and speedy
method of  doing it, by administering his panacea
(calomel), in large, oft-repeated doses, which, by be-
ing excessively stimulating, and debilitating the se-
creting vessels of the liver, and of all the other diges-
tive organs, provoked disorder, and paved the way for
a rapid supervention of disease.   It  is well known,
that Dr Curry was in the habit  of  salivating peo-
ple twice and even thrice during a single attendance,
and it is to be feared, that  the patients he  has left
behind, with broken, ruined health, " the remnant
of their former selves,"  from  the excessive use of
calomel, are  very  numerous.    The professional
man, who allows his judgment  to be so  far  per-
verted by a favorite hypothesis, or notion, as to lead
him, without scruple or care, to institute measures
that are  inimical and poisonous to the constitutions
of his patients, may be  truly called  unfortunate,
and his  errors ought to be pointed out,  that the
public  may be  sensible of  the   danger of  such
means,  and young practitioners  also  put upon
their guard.*

  * I should not allude in this  way to Dr  Curry's opinions and
practice, if it were not, in my opinion, necessary to bear the most
pointed testimony against them.
  [Prototypes of Dr Curry are by no means uncommon in  Ame-
rica, and the  number cannot be expected to diminish whilst the
pathology of abdominal diseases remains in its present obscurity,
and the prevailing prejudices in favour of  hepatic predominance,
and the indispensableness of mercury continue.  Nothing but the
establishment of the most positive data can arrest the progress of
vague speculation, and free the judgment from perversion___
Edit.~\ 
OF INDIGESTION.             41
  2d.  When the stomach  and  other- digestive
organs are  weakened,  it is certain that they are
often unable to exert that power over the matters
they contain, which in a state of perfect health
prevents their acting  chemically on each other,
and occasioning decompositions and forming new
combinations.  This power, which  the healthy
stomach exercises over its contents, was appropri-
ately called  by Dr Fordyce, its governing power.
Under disorder, when this governing  power is lost
or  impaired, an acid is  generated in the stomach
and bowels, which decomposes the bile and pro-
duces a green precipitate, and  green stools are the
consequence; in other instances, the acid combines
with the  soda of the  bile, and  there  is a  thick,
viscid, bitter precipitate, and  the stools look like
pitch.  In some  diseases, a green bile is brought
up by vomiting.  It is .common to call such dis-
charges as these bilious, and to refer their unnatu-
ral appearance to  a morbid action in the liver; but
the fact is, that the bile itself, in such cases, under-
goes a chemical change in the stomach and intes-
tines, in consequence of the  energies of these or-
 gans being impaired by disorder, and  the idea of
 these  discoloured evacuations being owing to an
 unhealthy secretion of  bile, receives therefore little
 countenance from their existence.  In some in-
 stances  they appear to depend purely upon  this
 decomposition of healthy bile ; in others, upon that
 change  united with diseased secretions from the
 alimentary canal  itself:  this last state  is the most 
42
NATURE AND SYMPTOMS
common, and is  almost always  present when  the
stools are  very copious and fetid.  That bile does
undergo this  decomposition, is proved by some
circumstances which are  observed  to  take place
out of the body.   It is known, for  instance, that
the faeces  of infants, although yellow when voided,
frequently become green after some time; and the
urine of a jaundiced patient, which is of a deep
yellow when  voided, becomes  after a few hours
green.  It is not easy to account for this change
of colour, but by supposing that an acid is gener-
ated by the reaction of the elements of which the
bile consists.   Besides, we are  aware that the in-
testinal juice in a healthy state has a brackish taste,
and turns turnsol paper of a deep red, shewing that
it possesses acid  properties; it is more than proba-
ble then, that under disorder, this acidity  is much
increased; and  that it should, in that condition,
from its  operation on  the biliary  and pancreatic
fluids, give rise to green or black, viscid discharges,
is no more than we might anticipate.
   That the black, pitchy, or yeasty, and fetid na-
ture of the motions, are owing much more to an un-
healthy condition of the mucous membrane of the
bowels, than to  a wrong action of the liver, is ren-
dered more than probable by the large quantity of
these  matters often voided under disorder,—by
 the mucous and bloody  fluids wTith which they
are frequently mixed, evidently vitiated secretions
from the  intestines,—and  by the  organic lesions
and marks of inflammation, not seldom found after 
OF INDIGESTION.
43
death, in the large or small intestines in these cases,
when the liver shews no appearances of disease, or
excessive disorder.
  It is not likely, that the immense  quantity of
discoloured, offensive matter, sometimes discharged
under severe  disorder of the assimilative viscera, is
poured forth  entirely  or chiefly from the liver, be-
cause its secerning vessels bear  no  proportion in
point of number, activity, or importance to those
opening upon the vast line of  bowel contained in
the abdomen.   Patients  sometimes void, in the
course of twenty-four  hours, many quarts, and some
even gallons, of various coloured liquids.  Morgag-
ni has cited the example of a woman, who, in one
day only, passed, per anum, forty pints of a limpid
fluid.   Does it consist with our  knowledge of
physiology, to suppose that this is derived princi-
pally from any other  part than the mucous coat
of the bowels, which  only, from being of great ex-
tent, seems fully adequate to such prodigious eva-
cuations?   Highly stimulating  agents, such  as
large doses of calomel, excessive eating and  drink-
ing, and other similar practices, act directly on the
mucous coat  of the alimentary canal;  they irritate
and disorder  it, the first effect of which is to occa-
sion an augmented flow of blood into it, and its
natural secretions become,  in consequence, often
increased,  and almost  invariably faulty.    Some-
times diarrhoea follows, and proves a salutary crisis
to the existing irritation.   The quantity of  liquid 
44
NATURE AND SYMPTOMS
occasionally exhaled by this coat under such  cir-
cumstances is astonishingly great.*
  The slimy mucus, frequently found mixed with
the faeces of persons  labouring under aggravated
disorder of the digestive organs, is certainly indi-
cative of a highly disordered state  of the functions
of the bowels.   The quantity of this  is sometimes
excessive, and now and then appears like a purulent
secretion.  In  adults,  it is generally considered an
indication of long standing disorder in the bowels.f
It would appear, that  there are not many  cases of
severe bilious disorder, where this  slime is not re-
markable, and we are  assured it cannot come from
the liver.  It is particularly frequent in children,
whose greater susceptibility and irritability render
them very subject to bowel complaints: at which
we cannot be surprised, when we  recollect the
close connexion  subsisting between  the  alimen-
tary tube, and  every other part of the body, by its
nerves and blood-vessels.  In  this association,  we
perceive the  reason why painful dentition, indi-
gestible food, or cold  followed by  fever, invariably
produces disordered bowels, and unnatural  stools.
Indeed, let irritation of the nervous system be exci-
ted from whatever cause, it is commonly followed

  * It is  probable, that the quantity of healthy intestinal juke,
formed in twenty-four hours, amounts to eight  pints.  This was
Baron Haller's calculation from experiment.  We know how
very small a proportion the  quantity of bile, secreted in the same
time, bears to this.
          t Scudamore on Gout, &c. 4th edition. 
OF INDIGESTION.              45
by derangement of the digestive tube; its secre-
tions become vitiated, and  either deficient, or in
excess.   Whether the irritating cause be at the be-
ginning local, as from an injury, or general, as from
fever, it is soon propagated to this highly sensitive
part.
  Vague observation has  considered the  black,
bloody stools, as morbid discharges from the liver;
but an attentive consideration of the phenomena,
and of the attending circumstances, inclines one to
look upon them as diseased secretions from the in-
ternal surface of the digestive canal;  and this opi-
nion  gains   confirmation  from the  appearances
presented on dissection.  Bloody motions,  says Dr
Marshall Hall, are "affections of much more fre-
quent  occurrence, than is generally  imagined, in
abdominal derangements."   He speaks of vomiting
of blood, as being not unfrequently combined with
it; and adds, " the two diseases appear to be similar
affections of  different  parts of the alimentary
canal."  " In several cases, the patient has awoke
in the morning with blood in the mouth."*  This
last symptom, which must have occurred to every
medical man of much practice, in cases of deranged
general health, does in no small degree strengthen
the conviction, that such black evacuations are de-
rived from the bowels, and not from the liver.
When the digestive tube  is much deranged, the
irritation extends throughout,  from   the  mouth

         * Essay on the Mimoses, 2d edition, page 74.
     G 
 46          NATURE AND SYMPTOMS

 even to the anus :—the mouth is parched and hot,
 and the tongue coated with an unnatural secretion;
 at the other extremity of the canal, there is heat,
 uneasiness, and  piles; both, though situated at so
 great a distance from each other, are consequences
 of the same cause.   In like manner,  irritation of
 the internal membrane of the intestines  acid sto-
 mach, accompanied with  evacuations of blood, is
 carried by continuity of surface to the  same mem-
 brane, lining the mouth; and the bloody state  of
 this visible  part of the  organ becomes a  pretty
 sure criterion, in what way  the internal parts also
 are affected.   We cannot be surprised, if a simila-
 rity of action pervades the  whole surface, and a
 haemorrhagic tendency appears throughout.  "If
 pains of the abdomen are observed, if the skin  is
 burning hot, the pulse frequent;  if the dejections
 are slimy, membraniform, or bloody, we may be
satisfied that the intestine is the seat  of  more or
less intense inflammation."  Sometimes, however
 "sanguineous  evacuations have been observed to
take place per anum'm individuals, whose intestinal
mucous coat was found sound after death.   These
passive haemorrhages are analogous to those which
take place in many dropsical individuals, at the inter-
nal surface of the serous membranes of the chest and
abdomen; they are similar to the haemorrhages, of
which the skin, the cellular  tissue, and the syno-
vial membranes, become the seat  in scorbutics."*

  * M. Andral, Jun. on the Pathological Anatomy of the Diges-
tive Tube.                                     s
4 
OF INDIGESTION.
47
" It seems probable, that the stools, which resemble
pitch, are principally composed of diseased secre-
tions from the internal surface of  the  intestines,
since they do not seem like the residue of the food,
or discharges from the liver.*"
   Mr Abernethy, in referring to cases  in which
there were discharges  downwards of black blood,
together with other morbid  matter,  says, "I ex-
amined the bodies of several persons who died un-
der attacks of this  nature, and  found the  villous
coat of the alimentary canal highly inflamed, swoln,
and  pulpy.   Bloody specks zeere observed in vari-
ous parts; and sphacelation had actually taken place
in one instance.  The liver was  healthy in some
cases, and diseased in  others."f   Again he writes
(page  47),  "where the  disordered  state  of  the
bowels had been of longer duration, I have found
the  villous coat of the  intestines  swoln, pulpy,
tinged with  blood  and apparently  inflamed,  and
sometimes ulcerated;  and these appearances have
been most manifest  in the large intestines."
   In the Medical  Repository for 1823, there is
a  case  of  diseased  peritoneum and  intestines,
where the stools, in the  beginning of  the com-
plaint, resembled ink,  and towards its termination
were of a light colour, purulent, and very offen-
sive.  As  it  shows the  connexion  which black,

   * Abernethy's Observations on the Constitutional Treatment
of Local Diseases.
   t Observations on the Constitutional Treatment of Local Dis-
eases. 
48          NATURE AND SYMPTOMS
fetid stools have with intestinal irritation  and dis-
ease, I have inserted an abstract of it here:—

   "Michael Slater, aetat. 31, was admitted into St
Gile's Parochial Infirmary, October 22, 1822, hav-
ing a tumour of considerable magnitude  situated
on the right side of the abdomen, attended  with
frequent pain  and vomiting,  extreme emaciation
and hectic symptoms.   He stated that he had been
ill five months; that his symptoms were occasional
pain about the navel, which he considered  of a
colicky  nature;  vomiting, and dark-coloured eva-
cuations, the latter  of which he described as  re-
sembling ink; and that about a month after these
symptoms had come on, he  discovered a small
tumour  on  the right side of the abdomen, which,
with his other symptoms, had continued gradually
to increase."—"He died December 13th.—About
three weeks previous to  his death,  a distressing
diarrhoea came  on; his  evacuations, which had
hitherto been scanty, and not procured without the
aid of medicine, now became copious, of a  light
colour,purulent,and very offensive."—"Dissection.
—The  peritoneum  lining the abdominal muscles
was found remarkably thickened  (the thickening
varying from one and a half to two  inches) by a
substance somewhat  resembling  fat, but much
more firm.   On exposing the  intestines, an  ap-
pearance presented  itself, which  at first seemed
difficult to unravel: on more minute examination,
however,  it was evident that the  tumour was 
OF INDIGESTION.
49
formed  by the same  thickening or organized de-
position already described, and  which extended
more or less over the whole surface of the perito-
neum.  The parts, more immediately forming the
tumour, were the lower portion of the ileum and
ascending colon, which, having become agglutinated
by coagulated  lymph, formed an immense and
compact mass.    On  the  anterior  part  of this
tumour, was an  opening formed  by  ulceration,
through which a large quantity of matter had escap-
ed into the cavity  of the abdomen,  which, in all
probability, was the  immediate cause  of death.
On following the course of the outer opening,  a
cavity was laid open, occupying  its central  part,
and extending about eight inches from side to side,
through which all excremental matter must have
passed for some time  previous to death, the struc-
ture of the intestines being at this part totally de-
stroyed by ulceration; consequently, there were four
openings communicating with the cavity,  formed
by  the  ascending colon  on one side, and the in-
ferior part of the ileum on the  other.   The in-
testines, through the  greater part of their course,
were considerably  constricted.   The ureter  and
pelvis of the right kidney were greatly distended
with urine.  The lungs were free from tubercles,
and appeared perfectly healthy.   The remaining
viscera were natural."

   The black vomit, so often present in fatal  cases
of the yellow fever of tropical climates, was form- 
50
NATURE AND SYMPTOMS
erly thought to be a morbid secretion from  the
liver, and the black stools common in that disease
were also considered bilious;  indeed, many of  the
incorrigible sticklers for liver complaints may still
regard them  as such: but close observation, and
repeated dissection, have clearly demonstrated  the
former to be a diseased secretion from the stomach,
and the latter vitiated discharges from the bowels.
They are unquestionably of  similar character  to
the melaena, and hematemesis, of temperate climes,
differing from them only  in intensity.  In  the
severer examples of this frightful fever, "the vomit-
ed matter is rarely bilious; it is a pituitous or ropy
liquor,  with numerous  darker coloured flakes:
sometimes clots of blood entangled in mucus,  ap-
parently portions of the inner coat of the stomach,
are brought  up in gulping;—if the body be open,
the stools are black, smooth  like tar  or molasses,
and offensive;—blood, sometimes, without mixture,
discharges itself gradually by the anus, sometimes,
mixed with connected portions of mucus—the inner
coat of the alimentary canal—it passes  off at in-
tervals in large evacuations."   In  the aggravated
form of this malady, " haemorrhage from the nose,
oozings of blood from the ears, gums, and in short,
from the whole track of the alimentary canal,yrom
the mouth downwards,  are observed  on manv oc-
casions."  On examining the bodies of  those who
die of yellow fever, " the blood  vessels of the sto-
mach and intestines are found much distended, but
actual  inflammation is rarely apparent; the  ap- 
OF INDIGESTION.               51
pearance of the inner surface is seldom  uniform
through the whole,—the veins are  generally dis-
tended ; but besides this, the inner  surface of the
stomach often exhibits large spots,  or circles of a
bright red, resembling actual inflammation; in the
centre of which, are frequently seen small  points,
like beginning gangrene; the villous coat  is also
loose, in the act of separation, and actually separa-
ted in some places.   In  the second form of this
fever, more frequently than in the other, the colour
of  the inner  coat of the intestinal  canal is like
brick-dust, the coat hanging loose, and almost  se-
parated.   Sometimes  this  takes  place  uniformly
through the whole track; sometimes it is confined
to particular places, or  a  congeries of  distended
blood-vessels,  entangled in the mucous membrane,
appear in clusters, to  bespangle  the surface with
bloody spots; the cavity is  sometimes also lined or
filled with  black  grumous blood.''*  It  is true,

  * Jackson's Outline of the History and Cure of Fever, page
187, et seq. (1798).  I cannot But remark here, that in this? ex-
cellent work we find the more correct pathology of fever, both
endemic and contagious, and its rational treatment, precisely the
same as they have been lately recognized and established among us,
and which are now the very reverse of what were entertained and
followed by the great body of  medical men in the year ninety-
eight. The different modifications of fever, of late so ably illustra-
ted by Dr Armstrong, and other recent authors, were clearly point-
ed out by Dr Jackson in the last century; and these writers add little
to the means of cure that were then described and used by him.
He has distinctly and correctly noticed the simple, inflammatory
and congestive forms of febrile diseases; and, regardless of opposi-
tion and reproach, blood letting, purgatives, and aperients, cold 
52
NATURE AND SYMPTOMS
that in the more aggravated forms of yellow fever,
the  liver  appears sometimes  uncommonly large,
black and distended,  as  if suffocated  with  blood;
but this is no more than what takes place  in the
head, lungs and other viscera.
   In the second volume of Les  Memoires de la
Societe Medicale d'Emulation, there  is a valuable
case, in which blood  first passed from the stomach
by vomiting, and then downwards from the bowels,
attended by distention,  constant  distress, failing,
irregular pulse, and cold sweats; the bowels obsti-
nately  refusing  all impression from  purging  and
injections; the mechanical irritation of the rectum,
by the  introduction  of  a  large gum catheter its
whole length, was followed  by  the evacuation of
three large pots full of black, bilious  matter; the
abdomen was thus unloaded, and the patient, to all
appearance expiring,  gradually revived, and eventu-
ally  recovered.    The same  thing  happened a  se-
cond time, and was relieved by the same means.

and warm affusion, with free ventilation, and exposure to the air,
were his chief remedies.  Thus we see, that above five-and-twenty
years ago, when the phantoms, debility and putrescency, occupied
the minds of all other physicians, and worse than paralized their
energies, the enlightened Jackson alone possessed clear, compre-
hensive, and correct views  respecting the pathology of fever, and
was pursuing a line of practice at once rational  and successful.
These are unequivocal marks of transcendent genius and talent, of
which few can boast. Indeed, all the writings of this amiable
man evince a philanthropy, and an extent  and  accuracy of ac-
quaintance with medical philosophy, that entitle them to univer-
sal attention and admiration, and which rank their author among
the best of men, and the most useful  and distinguished of medi-
cal writers. 
OF INDIGESTION.
53
  The  distinguished M. Portal has lately  turned
his attention towards the  investigation of the na-
ture  of  these black evacuations, and has published
a memoir on the  subject.  He believes that the
black matter is not bile, having no trace of bitter-
ness, nor dissolving, like bile in cold water, nor giv-
ing any  green colour to the water; but that it is pure
blood, which, in the bodies of those examined after
death, may be seen to transude from the blood-
vessels of the stomach and intestines.
  Mr Howship has  attended  several individuals,
labouring under severe pains and relaxation in the
bowels, with  bloody stools; and after considerable
attention to these  complaints, he  is  persuaded of
their being essentially  a  morbid  affection of the
villous  coat of the  bowels.   In one  case, which
terminated fatally at the second attack,  he had an
opportunity of ascertaining this fact, by dissection;
and  the examination shows, that such  discharges
take place from functional disorder as well as from
actual disease, which is agreeable to the  extensive
experience of M.  Andral, Jun.:—"The bleeding
had  taken  place  from the capillary or exhalent
vessels, upon the internal surface of the  great  in-
testine, and although  it was  evident that every
part of  the bowel had been a  bleeding surface, no
part had suffered ulceration, nor was  any part  in-
flamed, though the whole was red."*

  * Observations on the Diseases of the Lower Intestines, page
99 (3d edition).
      11 
54          NATURE AND SYMPTOMS

  The darker fluids, passed in cases of  abdominal
disorder, sometimes resemble thick, black, bilious
stools; at others, they look like grumous, unhealthy
blood.   As  these  different  appearances alternate
in the same individual,  under a single attack of
disorder;  and  I  have  here  produced sufficient
evidence to prove, that the bloody motions are, for
the most part, entirely discharged from the intes-
tines; this fact becomes an  additional and power-
ful  support  to the opinion, that the  black, tar-
like evacuations, are  likewise  derived from  the
same source.
  Dr Ayre, in some  observations  on disorders of
the liver, considers the blood discharged by vomit-
ing and purging,  to  be  poured  forth  from the
liver; but his arguments  in favour of this origin
of the complaints are very inconclusive and un-
satisfactory, and are totally uncorroborated by any
facts.   He relates the appearances, on  dissection,
of two fatal cases of melaena; but so far from being
conclusive, they throw little or no  light upon the
subject.  If any thing is to be gathered from them,
it is that the bleeding took place from the intes-
tines.   The first is  a case  of a  girl  of  thirteen
years  of age:—the liver,  on being cut into, had a
blanched appearance,  and scarcely any blood issued
from  it,  or  from  the vessels leading  to it; and
from  this  circumstance  it  is  assumed, that the
blood  discharged, per anum, must have come  from
that viscus.   This will be allowed  to be very in-
firm ground for such a supposition;  besides patho- 
OF INDIGESTION.
55
 logy can receive no assistance from the appearances
 in a single case.   The liver was quite natural in
 its texture and bulk, and it is stated that the con-
 tents of the abdomen were perfectly healthy.  I
 confess, I feel inclined to inquire, whether the in-
 ternal surface of the bowels was examined through-
 out? as there is reason to fear, that in such exam-
 inations, this minute inspection of the internal sur-
face of the whole of the  bowels  is too  often  neg-
 lected.  In  the  second  case, which occurred in a
 woman aged seventy-five, it  is said, " the same
 appearances  were exhibited as  in the former case."
 Here, however, we are informed, that the intestines
 appeared equally blanched with the liver.   Indeed,
 nothing remarkable presented itself, but the general
 deficiency of blood in the thoracic and abdominal
 viscera; but from this Dr Ayre concludes, that
 the  haemorrhage  certainly  took  place from  the
 liver!—"This organ was completely  emptied of
 its blood, as well as the right auricle and ventricle
 of the heart, and the large veins leading to it.
 The structure of the liver, and all the other organs,
 notwithstanding her age, appeared healthy.  Both
the liver and intestines had a blanched appearance.
 The  latter  were  lined throughout with  a dark-
coloured slimy matter, similar to what was passed
after the hemorrhage stopped."*   Is not  the last
sentence unfavourable to the author's hypothesis ?

  * Practical Observations on Disorders of the Liver, by Dr Ayre,
page 29, et seq. 
56
NATURE AND SYMPTOMS
Does it not afford  evidence of the disordered, and
highly excited state of the internal surface of the
intestines, and  strengthen the probability of the
bleeding having been derived from them ?
   I  believe  these  cases  of Dr  Ayre, and his
reasoning, will  generally be considered very mea-
gre support to his  opinions on  this subject,  after
the facts brought forward above in confirmation of
the reality of a quite  contrary  sentiment.  We
have seen, that  frequently in these affections, blood
is  discharged from the  mucous membrane of the
mouth, affording presumptive  proof of the  same
membrane lining  the stomach and bowels being
the true seat  of the disorder, which  gives  rise to
vomiting and purging of blood ; since a variety of
facts show that this membrane, from its continuity
of surface, is  liable to be similarly affected through
its whole extent, and  therefore  the  affection of
the mouth becomes an  index  to the  state of the
stomach  and bowels.   We have likewise  found
that the results  of  M. Andral's indefatigable atten-
tion to disorders and disease of  the abdominal vis-
cera, and of  his extensive experience  therein, is,
that when the  dejections  are bloody,  we may be
satisfied the intestines are, for the most part, the
seat of more  or less  intense inflammation.   That
Mr Abernethy  has almost invariably found disease
in the large  intestines after death, under such cir-
cumstances, in  the numerous examinations he has
made; their villous coat being swollen, pulpy, and
tinged with blood.   That in the concentrated en- 
OF INDIGESTION.
57
demic fever of warm climates, where vomiting and
purging of blood are so frequent and alarming, and
the stools look like tar or molasses, the proofs of the
exceeding severity of the intestinal disease are incon-
trovertible.   And  that the protracted experience of
M. Portal convinces him, that the blood may be seen
in such states transuding from the blood-vessels  of
the alimentary canal, after death, which perfectly ac-
cords with the observations of Mr Howship. These
are multiplied proofs of the paramount intensity of
intestinal irritation; and in their number and weight,
they form a striking contrast to the scanty testi-
monies, and gratuitous assumptions of those, who
will still harp on the insensible liver, and who can
see little else than  an affection of this organ in all
abdominal disorders.
   Dr Ayre's book on marasmus, in assigning that
state of body as possessing its common origin chief-
ly or exclusively in liver  disorder, appears to  me
to carry  us far backward  in pathology.   The chief
feature of  it is a distorted one; and if it has met
with that favourable reception from the profession,
which some  seem to assert  it has, I cannot but
consider it as another proof of the false light which
overhangs this part of medicine in our  country.
Marasmus is much oftener met with as  consecu-
tive to intestinal irritation and disease, than to he-
patic affection; and it is to the first of these evils
we are to look for the most exquisite examples of
this species of consumption.    The following case
exhibits  the principal features of this malady, as it 
58          NATURE AND SYMPTOMS
 commonly occurs, with the most usual appearances
 on dissection.   We  are here presented with  a
 series of phenomena,  which, Dr Ayre would have
 said, had their origin  in  the disordered action of
 the liver;  but which the knife  of the  anatomist
 proves to be dependant upon intestinal lesion alone;
 and I appeal to familiar experience to verify what
 I advance,  that the symptoms  and morbid appear-
 ances of this case may be safely received, as exhibit-
 ing those which accompany and constitute ordinary
 marasmus, when it terminates fatally.  The  diar-
 rhoea, and the light clay-colour of the stools at one
 period, would no doubt have been considered by
 the abettors of  the bilious theory, as  conclusive on
 the subject of the disorder's being chiefly,  or  alto-
 gether, one of the  liver; but we find  this organ to
 be healthy, and that the morbid phenomena  were
 confined to the bowels.

   "Master M., a child of three years old, was at
 school in good health  till January  1810, when he
 became poorly, and was supposed to have taken
 cold.   His appetite was impaired, and his bowels
 were relaxed.   This, however, was scarcely noticed
 for some time.   He enjoyed his usual amusements,
 and it was expected his complaints would wear off
 again.   After some weeks, however, the child was
 sent home  with a  severe diarrhoea, the  abdomen
 much swelled, and at times very painful.  When
sent to  school he  was a very hearty and strong
child, but on his return was  much altered, weak, 
                OF INDIGESTION.             59
                  i
and emaciated.   As the disorder continued to in-
crease, he became heated in the skin."
  During the existence of these symptoms, the child
was improperly treated,  by  a very ignorant  apo-
thecary,  being  stuffed with mutton chops,  beef
steaks, and porter—the apothecary declaring  that
he would  soon  recover: but instead of  this, he
grew worse and worse,  till  his  case  was  pro-
nounced by the  same man to be hopeless.  " He
still continued to grow thinner, and the fever, which
was at first occasional, now became constant.   The
diarrhoea, however, was apparently on the  decline,
and this seemed to afford a ray of hope.  The mo-
tions were, on some days, not more  frequent than
natural, but every now and then violent fits of rest-
lessness and crying came  on,  and  he complained
of the s belly-ache.'
   "The abdomen  was exceedingly tumid and hard,
and excessively painful whenever in the slightest
degree pressed.   His  water was  observed to be
becoming high-coloured;  it was also rendered in
diminished quantity.  The appearance of his stools
had changed; they were  of a  light clay-colour, as
usually observed in disorders where the bile is
prevented  from flowing into the  intestine.   He
had once, about this period,  a sickness at  the sto-
mach, with vomiting; on which occasion the mat-
ter thrown up was found exactly to resemble, in
smell and appearance,  that which was  passed by
stool.
   " At this time,  I  was first desired to  see  the 
60
NATURE AND SYMPTOMS
 child.  The body was reduced almost to a shadow,
 the belly much swollen, very tense, and extremely
 painful.   There was an obscure fluctuation in the
 abdomen.   The motions were at this time less fre-
 quent than in  health.   The child  was perfectly
 sensible, and always called for his chair, when
 necessary.   The pulse was  pretty good, and  beat
 120 in a minute, but the little remaining  appetite
 had now failed, so that he took nothing."

   A  suitable treatment was now  instituted, but,
 after  languishing a few days, he expired.

                " Examination.

   " The body was inconceivably emaciated.   On
 laying open the abdomen, the peritoneum was found
 in many parts adherent to the viscera.  The omen-
 tum was considerably  thickened  by inflammation
 and disease.   The whole bundle of  intestines was
 found involved in one confused mass of adhesions.
 This  had been consequent to a very extensive ef-
 fusion of coagulable lymph into the cavity of the
 abdomen, in which was  also a  quantity of serous
 fluid,  that was removed in the course of the exami-
 nation.
   "This mass of coagulated  lymph was next  cut
into, when a quantity of brownish red fluid gushed
forth, and'with it the skins of some raisins.  This
circumstance proved, that some parts of the coats
of the intestines had  given way.   The  incision
was then extended, so as to expose more perfectly 
OF INDIGESTION.
61
the cavity'of this preternatural cyst; by this means,
a circular hole, about a quarter of an inch in diame-
ter, was discovered in the side of  the small intes-
tine.   From this, the  contents of  the bowels had,
in the first instance, escaped,  and  by it the fluids
still ran freely out."
           ******
   " On closer examination, the villous coat of the
small intestines was in several places found to be
destroyed  by ulceration;  but in  no  part, except
where the opening had been already detected, was
the ulceration deeper than the muscular coat of the
bowel."*

   Dr Pemberton called the marasmus of children,
the infantile remittent fever,f and considered it de-
pendant upon derangement  of  the  bowels.  He,
however, professed himself ignorant of the patho-
logical anatomy of the abdominal viscera, in this
disorder, from not having enjoyed sufficient oppor-
tunities of examining the bodies of those who died
of the complaint; but  he has noticed one fatal case
of this description, at the examination of which he
was present.  Here all the solid viscera of the ab-
domen were healthy, and the bowels were  evident-
ly the chief seat of the  affection.   Still,  nothing

  * Howship's Observations in Surgery  and Morbid  Anatomy,
page 264.
  t Treatise on the Diseases of the Abdominal Viscera, page 158.
     I 
62
NATURE AND SYMPTOMS
 is said by him of the state of the  internal surface
 of the intestines; probably, they were not examin-
 ed, at least, with the care and attention that is de-
 sirable, in every such affection, as the phenomena
 immediately visible  on removing the abdominal
 muscles, &c. render it probable, that inflammation,
 or some organic lesion, would have been discovered
 in their mucous membrane, had it been so examin-
 ed.   The subject of  the case was a child of four
 years old; and Dr Pemberton remarks, " the belly
 was swelled to a very large size, but there was not
 the least appearance of  inflammation on the peri-
 toneum, or upon any of the viscera of the abdomen,
 or any fluid in the  cavity.  The liver, pancreas,
 spleen, and kidneys, were natural; the maesenteric
 glands were in a small degree enlarged:—The in-
 testines were distended to an enormous size, so that
 the colon measured &even  inches in circumference,
 and all the other intestines were, in like manner,
 greatly distended."*
  When the stools are white, the secretion of bile
 is unquestionably suppressed; or, if secreted, it  is
 prevented passing into  the duodenum;  but the
 copious, frothy stools, which look like a  quantity
 of  yeast,  or  resembling  soft  pudding,   seem
 essentially connected with a very disordered or
diseased condition of the  bowels,  especially the
larger bowels; and the appearances presented, on

  * Treatise on the Diseases of the Abdominal Viscera, page 167. 
                 OF INDIGESTION.              63

dissection  of several fatal  cases,  set  this  ques-
tion quite at rest.*
   Dr Blackall  has favoured  us with  a very  in-
teresting  case, where the patient  voided, during
life, large quantities of a matter resembling yeast,
in colour, fluidity, and  effervescence.   The man
was supposed to have a liver complaint, and mer-
cury was accordingly given to him; by its effect
on the internal surface of the  bowels,  he mended
a little under its use, but afterwards relapsed, and
died; when dissection showed, that the mischief
had its seat in  the  bowels  only,  the  liver  being
healthy.   He suffered altogether more  from flatu-
lency, dyspepsia, and dejection of spirits, than from
any  precise  pain:  sometimes, however,   when
questioned, he would acknowledge an obscure un-
easiness  and  fulness towards  the lower  part of
the abdomen, on the right  side.  " The liver was
natural,  both in size and structure, and the gall-
bladder  full  of a yellow  healthy bile;  but  on
tracing the intestines, we found the caecum, and its
appendix with  some of the  neighbouring  parts,
involved in a mass of scrofulous adhesions, which,
when taken out, and dissected at leisure, presented
the  following  appearance:—The  disease  began

   * A very dangerous and not unfrequent error, is that of re-
ferring to  a disordered  liver to explain  the cause of those
mucous and gelatinous discharges  from the bowels, proceeding
solely from disease seated in the tract of the large intestine con-
sisting ordinarily of high irritation or inflammation in one or more
of the tissues.—Edit. 
K4
NATURE AND SYMPTOMS
about  two inches above  the termination of the
ileum.  Its inner membrane was, to the extent of
a crown-piece, covered with spots of lymph,  and
there were two or three small ulcers.   The whole
of the inner membrane of the caecum was com-
pletely destroyed by ulceration, and its other coats
much  thickened ;  the beginning of the colon  was
in the same  state,  for  five or  six inches further
nearly healthy, and then  again, for a short space,
thickened and ulcerated, in a spot where, by a sort
of unusual course of the intestine,  it had doubled
down  upon the  caecum."  Dr Blackall adds, "I
apprehend a slight degree of this disease to be not
unusual.  I have seen four cases of it to an extra-
ordinary extent, where the discharges, by stool,
greatly resembled  yeast in their appearance, and,
in one instance,  were nearly raised  by their
effervescence over the sides of the vessel.   All the
patients had this in  common, that they  died  ex-
tremely emaciated, and after a most tedious linger-
ing.   In all  there  was much  flatulencv, and in
some, a croaking noise of air, apparently, seated in
the ascending arch of  the colon, and sometimes
producing such a  projection there, as almost to
give  suspicion of a ventral hernia:" symptoms, I
presume, strongly indicative  of intestinal disease.
It is  very  correctly observed  by  this judicious
physician:—"Writers  describe  this  remarkable
complaint imperfectly, and, when they notice  the
occurrence  of yeasty discharges, they  generally
seem to refer them to an obstruction of the liver 
OF INDIGESTION.
65
exclusively.   But   many  circumstances,  parti-
cularly  the preceding dissection, prove the large
intestines to be much engaged in this disorder."*
  In  the Medical Repository for  October 1822,
there  is the following:—" We had, last year, an op-
portunity of inspecting the body of a naval officer,
who  had  served  long in the West Indies, and
who died, at an advanced period of life, of diarrhoea
gypsata.  On dissection, the liver was found tuber-
culated, the spleen  enlarged,  and  condensed in
structure; the pancreas  was much  enlarged, and
presented the appearance of incipient schirrus, in
more than one part.   The mucous coat of the di-
gestive  canal, from  the  mouth  to  the anus, pre-
sented  marks of disease, which  were  greater in
some  situations than in  others.   It was generally
more vascular than  natural, and, in many places,
was  inflamed  and  ulcerated.    The inflamed
parts  surrounding  the  ulcerations  were much
thickened.  The muciferous, or follicular glands,
possessed a dirty-grey colour,  and were enlarged
to various sizes, so  as to give,  in  some places,  a
granulated appearance to the mucous surface; in
others,  a number of small  ulcers were dispersed
through it, apparently in the situation of the orifices
of the mucous  glands.  These ulcers penetrated
deeply  into the villous coat, and were in some parts,
distinct; in others, they coalesced, and gave rise to

  * Dr Blackall's valuable Observations on Dropsy, page 108,
et seq. (1813). 
66
NATURE AND SYMPTOMS
 extensive ulcerations, with thickened and inverted
 edges, or to a foul, dark and rugged condition of
 the internal tunic.   These  lesions were more  ex-
 tensive in the rectum, colon,  lower part  of the
 ileum, duodenum, in the vicinity of the pylorus,
 in the pharynx, and more slightly in the jejunum,
 and commencement of the ileum.  The florid,
 thickened, ulcerated states of the palate and fauces,
 were apparent for some time before the death of
 the patient."
   The editors of the above journal have been led
 to take the same view of  the  pathology of this
 peculiar kind of diarrhoea, as is here maintained.
 On this subject, they wisely differ from DrGood*
 (who is evidently too fond of making the liver a
 capacious vortex of disease), observing, that from
 the character of these derangements, as well as from
 other circumstances, they have  concluded the dis-
 ease to be essentially one  of the follicular  glands
 of the intestines, from its  commencement, which
 terminates in their enlargement and ulceration;
 and  that the  alvine dejections  are  characterized
 by  the copious, and vitiated secretion to which
 their disorder gives rise.   They had  two  cases of
 this disorder under treatment, when this case was
 written, neither of which had received any bene-
 fit from the active remedies  prescribed.
  Not only does an impartial consideration of the
attending phenomena, and of the economy of the
* See his " Study of Medicine," vol. i. 
OF INDIGESTION.
67
 digestive  tube, contrasted with that of the liver,
 lead to the conclusion, that, for the  most part, all
 the cases of abdominal disorder, in which copious
 stools of either black, yeasty, bloody, or any other
 coloured  matter  are conspicuous, are essentially
 connected with a permanent excess of irritability
 in the intestines, wholly  independent  of  the state
 of the liver; but I believe  the dissections of  the
 many fatal examples on record more than bear me
 out in the assertion.   In a  considerable  majority
 of these instances, the liver presented no traces of
 disease or inflammation, while the organic lesions
 of the intestines  were  almost invariably  present;
 —■either simple  inflammation, of  various shades;
 thickening or softening of one or more of the coats;
 tubercles; or ulcerations, being conspicuous, and
 not seldom  unaccompanied  by disorganization in
 any other of the  abdominal  viscera.   The causes,
 symptoms, and post mortem  appearances  of ordi-
 nary diarrhoea, dysentery and  lientery, I  consider
 as clearly pointing them out to be  originally dis-
 eases of  the mucous  surface of the  bowels;  the
 liver,  if disordered,  being  affected  secondarily.
 The same may be  affirmed  of cholera morbus.*
These being complaints remarkable for the  quan-

  * The following quotation from my Treatise, entitled "Modern
Domestic Medicine," third  edition, page 265, fully explains my
sentiments in respect to the real seat and character of cholera.
  "It has been usual with medical writers to consider severe
affection of the liver,  or of the bile ducts, to be the immediate
cause of cholera (in other words, in what the disease essentially 
68
NATURE AND SYMPTOMS
tity of the intestinal discharges that take place un-
der them, they lend important proof from analogy,
of the correctness of the pathology  here advanced,
of the disorders which form the subject  of  consi-
deration in these pages.
   M.  Andral Jun., whose laborious and  extensive
researches on the pathological anatomy of the di-
gestive tube, entitle his sentiments on this point
to much deference and attention,   remarks,  that

consists), but the present author is  convinced, that it is really
owing to high irritation  and  spasm of the stomach and small in-
testines, for nothing can explain the severity  of the symptoms in
this disease, the extensive chain of influence excited, and the com-
plete exhaustion of the living principle, which sometimes occurs
with astonishing rapidity, but the supposition  of such a condition
of these very  sensible  and  important organs.  The imperfect
organization of the liver and  bile ducts, their dull sensibility, and
their confined sympathies, are so apparent, as to render it im-
possible for us satisfactorily to account for these phenomena by any
imagined spasm centered in  them."
  In regard to the nature of cholera,  Dr Good observes (Study
of Medicine, vol. i, page 268), " The general battery of symptoms
appears, therefore, to have been opened by a spasmodic constric-
tion of the bile ducts."   Further on (page 273) he is,  however,
compelled to add, " It still remains to be ascertained why an affec-
tion of the liver, or of the bile ducts, should be capable of excit-
ing so extensive a chain of influence on the nervous, rather  than
on any other system." In the copy which I possess of Dr Good's
work, I  find on referring to it at this  time, that I had pencilled
in the margin opposite to the former quotation, the following ob-
servations, which I would transcribe into these pages.  u If we
reverse  what is here said of the relative condition  of the biliary
organs,  and  the  alimentary  canal, and  consider the < general
battery of symptoms' to have been opened by high irritation and
spasm of the latter, the former participating in it, and therefore be-
coming obstructed, we shall certainly approach much nearer the
truth." 
OF INDIGESTION.             69
diarrhoea,  dysentery, and lientery, have been for a
long time looked upon as diseases entirely  inde-
pendent of intestinal inflammation; but it is in-
dubitable, that in a very large majority  of cases,
the intestines of individuals labouring  under diar-
rhoea, whether complicated or not, with dysenteric
symptoms, present evident marks  of  phlegmasia.
And he further judiciously observes,  that dissec-
tion establishes the fact that the same kind of
organic lesions in the intestines will in  some per-
sons produce dysentery; in others, diarrhoea.
   An objection has been raised to the idea of the
yeasty, dark, black motions,  frequently  voided in
the prevailing disorders of the digestive organs, be-
ing vitiated secretions from the bowels; because
all the secretions  poured into the intestines, or
supplied by them, except the bile, are for the most
part colourless: and it has therefore  been urged,
that any change from the natural appearance which
takes place in the  faeces, must result from a change
of the bile.   The former assertion is true, if it be
confined to a state of health; but how completely
is it invalidated by familiar experience, if  it be
meant to apply also to a diseased condition.   The
urethra of  a healthy  man secretes  a colourless,
limpid fluid; but when irritated and disordered,
its secretions  become  white, yellow,  or green,
opaque and stinking.   The same change takes place
under disorder in the serous membrane  lining the
chest, whose healthy secretions  are without  col-
our; and so it is with the secreting membrane of
     K 
70
NATURE AND SYMPTOMS
the bowels, and of  every other part.  In health,
their secretions are for the most part colourless, but
no bounds can be set to the change they may un-
dergo when exposed to irritation: then they are,
at different times, found of all  colours, from the
pure inodorous white to the concentrated offensive
black.   It is not a little surprising, therefore, that
the colour of the secretions of a healthy part should
be brought forward to prove that the  same appear-
ances are exhibited by them under  disorder and
disease.
  We have enumerated the power which mercury
possesses,  in restoring unnatural  stools to  their
healthy appearance,  among the causes of the sup-
posed frequency of liver complaints.   The opinion
which has much prevailed of late in the profession,
that this mineral exercises a specific action on the
liver, far more  immediate and efficient than it ex-
ercises on any  other secreting organ, is an  error
that is  grown  out of the striking change  often
produced  by it in discoloured, offensive motions,
and  from its almost exclusive  influence over the
acute bilious disorders of India.  If it is shown in
these pages, that such unnatural alvine evacuations
are  much more closely connected with  an  un-
healthy state of the internal membrane of the  bow-
els than with disorder of the hepatic  viscus, it has
been proved, that the notion that mercury exerts a
greater power over the secretions of the latter, than
it does over those of the former, derives no founda-
tion or strength from  the signal change in the 
OF INDIGESTION.
71
 stools just alluded to.   In the acute bilious  dis-
 orders of India (as they  are called), calomel is un-
 questionably superior to every other remedy.   In
 them it certainly seems  to originate specific effects
 and requires to be employed in large, quickly re-
 peated doses ; but nothing satisfactory can be de-
 duced from this  circumstance, in regard to  its
 having a more direct and powerful influence on the
 liver, than on the intestines and mesentery, in the
 ordinary chronic maladies of the abdominal viscera
 met with in this country; for  independent of the
 sensible and great difference  in  the complexion
 and severity of these affections of the two climates,
 my researches  lead me  naturally to   question,
 whether this unequalled  efficacy of calomel, in the
 diseases of the East, is owing to any such superior op-
 eration on the liver.  Its use  in acute hepatitis is
 certainly dependent upon an operation of this kind,
 but cholera morbus and dysentery, two of the most
 frequent and dangerous diseases  of that region, and
 in which the powers of mercury are equally con-
 spicuous, are affections  of the  alimentary canal;
 and it appears incontrovertible, that in the endemic
 fevers also of India, which may likewise be affirm-
 ed of the fevers of the West Indies, it is disease of
 the mucous surface of the digestive tube, that is
 principally concerned in producing the symptoms
visible under the attacks, since  the epigastric  and
umbilical regions are the principal foci of uneasi-
ness and  irritation, and this tube generally presents,
 on dissection, the most intense  appearances  of  or- 
72
NATURE AND SYMPTOMS
ganic lesion, and sometimes  none  are  found else-
where.   I think  it will not  be said  by medical
men of correct observation, after due reflection on
the results which have followed their employment
of mercury in different abdominal maladies, that, in
actual practice,  they  have  found  it possess a
greater curative power over unequivocal  disorder
or disease of the biliary organs, than  it has in a
similar condition  of  the  intestines.    The dis-
orders, popularly  termed bilious, in reality have
their seat in the stomach and bowels; and if  the
mercurial oxides are commonly of imperfect  use
in intestinal disease,*  it should  be remembered
also,  that in disease of the liver, it is no longer a
doubt whether they are of much or little service.
   The real fact is, that this mineral generally pos-
sesses, in a higher degree than any other known me-
dicine, the power of changing the condition of ac-
tion in the extreme vessels of the circulating system
throughout; it is for this reason, that  it is so  im-
portant an instrument in the hands of the physi-
cian in so many and apparently  dissimilar com-
plaints ; and it is proved by experience, to exert no
greater influence over the secreting vessels of the
liver, than it does over those of the intestines  and
mesentery.!

   * It should be remarked, that I here speak of positive or or-
ganic disease.
   t It would appear, that the rationale of the operation of calomel
is so imperfectly understood, as to occasion much apparent in-
consistency in regard  to its use.  We find it denounced by our 
OF INDIGESTION.
73
   3.  Of all our organs, the stomach is that which
in general  the most effectually resists  positive  dis-
ease.   It will sustain  considerable irritation  and
disorder for a long series of years, without under-
going any  alteration in its structure; but, from the

author in one place as a "highly stimulating agent," whilst here
it is held up as unquestionably superior to every other remedy in
the acute bilious disorders of India, when  " employed in large,
quickly repeated doses."
  So far as our observation  extends, calomel is the only article
in the class of purgatives which may be advantageously adminis-
tered in acute diseases where the  first passages are the  seats of
irritation and even inflammation.  In such cases instead of aggra-
vating the symptoms, as every other cathartic with which we are
acquainted would do, its immediate effect,  when given alone, is
generally to reduce diseased action  and allay irritation.  Ap-
plied  externally to  irritated  and  inflamed surfaces, calomel of-
ten exerts the most positive soothing  effects.   We have  often
witnessed these in hepatic and other cutaneous affections, and
when employed as an injection in  gonorrhoea.  We are  sensible
that in the present condition of our knowledge of the modus ope-
randi of medicines, the facts here  adduced must appear  at vari-
ance with  the new medical doctrines, for which  we profess  a
high  regard, but as we  never  can be persuaded to abandon well
demonstrated facts, we shall trust to further illumination from
physiological sources to clear away the mystery.
  Our remarks are intended to  apply  more particularly to the
medicine when administered with  a view to its immediate advan-
tages in acute diseases, and not to its operation when prescribed
as an alterative, the rationale of which we conceive  to be of  a
totally different kind.   The secondary effects of this medicine,
such for example  as the general irritation and salivation, so apt
to ensue upon the subsidence of the disease for which it may have
been administered, constitute a most formidable objection to its
common employment.   Happily, its use in all ordinary cases can
be dispensed  with, and  physiological medicine supplies  us with
resources, which make it seldom requisite to resort to a  remedy
that may ultimately prove dangerous.—Edit.
-V 
74
NATURE AND SYMPTOMS
liver possessing only very inferior vital properties,
it is much less able to resist the  disorganizing in-
fluence of irregular or violent action;  and as it
participates in the disorders of the first and second
stomach, disease from this cause frequently fastens
upon it alone, and the existing complication of evils
sometimes terminates in death.   Upon the dissec-
tion of bodies thus affected, the liver will present
appearances of disease, when there are no traces of
it in the stomach or duodenum, and very few and
slight ones in the other abdominal viscera.  This
occurrence, particularly when the patient's symp-
toms during life did not clearly denote  the  exist-
ence of hepatic mischief,  which not unfrequently
happens, has confirmed many of the profession  in
the popular notion of the exceeding prevalence of
liver complaints,  and  has been another cause  of
increasing and perpetuating the error.   The diffi-
culty with which disorganization is  induced  in
one, and the  greater facility with which it  origi-
nates in the other organ is forgotten; and, therefore,
the relation which the above  mentioned circum-
stances bear to each other, as  cause and effect, is
unperceived and reversed.  Instead of the organic
injury  of the liver being considered a consequence
of long continued  and  severe  derangement of the
stomachic functions, it is  regarded as an original,
independent affection, and sometimes,  even as the
sole complaint, notwithstanding that the stomachic
irritation may almost always be recognized during
life, as  the  primary malady, existing long before
* 
OF INDIGESTION.
75
symptoms  supervene,  which  decidedly  denote
hepatic mischief:—thus, liver complaint still  en-
grosses the attention of the practitioner, and pre-
sents itself to his imagination  on all such occasions
in the  living subject; and this reversion of causes,
drawn  with  confidence  from actual dissection,
stands  as a humiliating memento of the fallibility
of medical evidence, when the physician has a fa-
vourite hypothesis to support.
   I think there can be no difficulty in conceiving
that disorder, or disease, may and  does often exist
for some time  in the  liver, without the stomach
participating, and without the bowels being very
sensibly affected; but it does not consist with  our
physiological knowledge, or with  observation, to
suppose that the reverse of this ever occurs.  The
insensibility, and the natural functions of the  for-
mer organ, encourage this conclusion ; besides, it is
admitted, that we are  not unfrequently surprised
in finding marked disease in the liver after death,
when the patient during life  manifested no symp-
toms of such complaint: this gland is one of waste
rather  than of  supply; and  it is  reasonable  to
infer, therefore, that a partial interruption or ir-
regularity in its healthy actions may be borne, for
no short period, with little injury, and without its sen-
sibly influencing the functions of the other assimila-
ting viscera.  Not so with the stomach, and small in-
testines.  They are  organs of remarkable supply,
of the  most delicate and extensive connexions, and
are the most irritable parts  of the  body; in conse- 
76
NATURE AND SYMPTOMS
 quence of  which,   they cannot  be  disordered
 without involving the liver in the same morbid
 association; and it is particularly worthy of atten-
 tion in our day, that this is  ordinarily the natural
 course of invasions in the disorders under review.
   Mr Abernethy, whose great improvemnts in his
 profession, demand and engage general attention,
 with all his attachment to affections of the chylo-
 poietic viscera, and  partiality for blue pill,  is not
 one of those who consider the  liver to be the root
 of the evil in these disorders.   If I understand him
 right, instead  of considering this organ to be  the
 chief and  primary seat of invasion,  as  is generally
 done, he takes that view of the subject which  I
 would urge upon public  attention,  regarding  the
 stomach as commonly the first affected, then the
 intestinal  canal, and lastly the liver.   He remarks,
 "when digestion is imperfectly performed,  the
functions  of the intestinal canal will soon partici-
 pate in the disorder of the stomach.   Under these
 circumstances, the secretion  of  bile will also pro-
 bably become irregular."  Again,  "It is fair to
 infer, that where general  disorder of the digestive
organs takes place, those fluids  which  produce the
changes which  the  food  undergoes in them,  are
deficient or depraved; and  consequently,  that di-
gestion and tha subsequent processes must be im-
perfectly performed.   The liver is likely to  parti-
cipate in the disorder, and the biliary  secretion to
be diminished or vitiated.  This circumstance ad-
mits of ocular  demonstration: and I have, therefore,
r 
OF INDIGESTION.              77
considered it  as  an evidence  of a more or  less
general disorder of the digestive organs.   A very
reasonable objection  may, however, be  made to
considering the  derangement of the  function of
the liver as a  criterion of those of the stomach and
intestines; since  the  liver is independent of the
latter organs,  and may be the subject of a disorder
confined to itself.  In some cases, also, the alimen-
tary canal may be affected without disturbing the  -
liver.   Such circumstances may happen occasion-
ally ; but they are not ordinary  occurrences,  and
should  be  considered  as  exceptions  to general
rules,which do not militate against their common
operation.  In general, affections of the former in-
fluence the functions of the latter."*
   There is reason to fear,  from  the almost ex-
clusive attention paid of  late to  the  liver, that,
in  conducting the dissections in  such cases, the
state of the  digestive tube  has been  very often
either partially or wholly disregarded.   These ex-
aminations have  been made  in  a way  likely to
propagate the belief of the universal spread  of dis-
ordered and  diseased liver, but not calculated to
show the real state of the whole of the organs con-
cerned, and the relative frequency of intestinal dis-
ease.   If  the  biliary organs have  been  found
injured in their structure, it has been too frequently
considered sufficient to account for every symptom

  * Observations on the Constitutional Origin of Local Diseases,
page 42.
L 
78
NATURE AND SYMPTOMS
that occurred during life;  nothing was  thought
worthy of  particular notice in  the abdominal
cavity after this, and the dissection has accordingly
been hastily  concluded.   Had less attention been
directed to these parts and more to the intestines,
in examining the bodies of individuals  who have
died from a  diseased condition of the assimilating
viscera, the  relative state of the latter would  be
better  known,  and have  gained  due attention.
"It has frequently happened to  us, to find  the
mucous membrane evidently inflamed, disorganiz-
ed, and  ulcerated, in portions  of the intestines
which, when seen  and examined  externally, had
been regarded  as  healthy.   An  important error
may therefore  be  committed, if, as is sometimes
done, we pretend to judge of the  healthy  or
morbid condition of the  intestine by the appearance
of its external surface."*
   From what has  now been said  respecting the
appearance of organic injury of the liver, in pro-
tracted disorders of the digestive organs, it must
not be supposed that this is a common occurrence,
in  the examples  we daily meet with of these
multiform complaints,  the  great  proportion  of
which are of recent origin.   I could not pass  by
the fact of disorganization being sometimes found
in this viscus in these cases, when there is no such
thing elsewhere in  the abdomen, without adverting
to it as a cause of increasing,  among the profession,
* M. Andral, Jun. 
OF INDIGESTION.
79
the idea of the great frequency of this disease; but
as I believe it may be safely asserted, that fifteen
cases out of sixteen, of what are popularly termed
bilious complaints, are disorders of the  digestive
canal;  so I think it  indisputable, that in  four
cases out  of five, of what are  usually  designat-
ed  confirmed  liver  diseases,  there is no  positive
disease in the hepatic region,  the affections be-
ing  examples  either  of  aggravated functional
disorder  of the  stomach  and  intestines,  or  of
disease  in some  part  or parts of their course.
When chronic inflammation, induration, ulcera-
tion,  or  any   other  organic  lesion,  does super-
vene an unhealthy condition of these parts, I think
morbid anatomy proves, that such consequences are
much more frequently recognized in the bowels,
than in the gland secreting the bile.   Among the
several persons examined by Mr Abernethy, and re-
ferred to at page the fifty-fourth of this  Essay, it
was only  in  some cases  the liver was  diseased,
whereas such a condition occurred in every instance
in the intestinal canal, and was there of great extent
and severity.   In other instances, alluded  to  at
page the  forty-seventh of his Observations,  there
existed intense disorganization  in  the intestines,
but no mention is made of any unhealthy state of
the liver.  It  is more than probable that Dr Black-
all's five cases (see page  the  seventy-ninth) were
all of this character.   We are certain one of them
was so (and  in  this  mercury  was administered
under the idea of liver disease), and we are autho- 
80
NATURE AND SYMPTOMS
rized to conclude the rest were of the same nature,
from the  exact similarity of their  symptoms and
termination.   In Mr Howship's observations* on
disorders of the lower bowels, five  cases are re-
lated, in which abdominal pain and  uneasiness,
anorexia, debility, emaciation, and frequent copious
stools of bilious, dark, offensive matter, were the
prominent symptoms.   They are correct speci-
mens of what are now very frequently considered
liver complaints;  but on dissection,  disease  was
ascertained to be confined to the bowels, the liver
being unaffected.
   The  best  continental  writers  on abdominal
derangements are  unable  to embrace the English
notion of the paramount frequency and importance
of  liver disorder  or disease.   The  laborious  ob-
servations of Broussais, Andral, and  others, have
made them acquainted with the frequency of in-
testinal lesions; but the  liver has  comparatively
seldom been  found by them thus invaded.  They
have uniformly been struck with the severe, com-
plex, and  extensive morbid actions, constantly aris-
ing from  gastric  and  bowel disorder;  but  they
have yet to learn, that actions, still more intense
and complicated,  unfailingly attend upon hepatic
derangement.  In this  point, I think  that  the
French and  German practitioners, as a body, are
superior to us, and the reason is obvious.  In their
practice and  researches,  they  are  not misled  by
bilious theories, and notions  of the omnipotent
powers of calomel, and consequently they have not 
                OF INDIGESTION.              81

fallen into those misconceptions which, from the
present fashionable opinions  in  England,  prevail
among us.*
  The  late  Dr  James  Curry,  who,  regarding
almc3t every patient  with "jaundiced eye,'' could
see  little  affecting them but  liver  disease, was in
the habit  of putting his hand  to his right side, and
saying, he was assured there was a very  small por-
tion of liver left there.   Some might think it was
not wise in him to make so frequent a confession of
this kind, since, if a man could live for years in
tolerable health (which was his case), with only a
very small portion of liver, and that probably in a
state far  from healthy,  the  conclusion generally
drawn from thence would be in no small degree
unfavourable to the doctor's opinion, of the supreme
importance of the healthful actions of this  viscus,
and of  the absolute  necessity of restoring to the
free use of calomel in its derangements.   How-
ever, he was totally mistaken in his own case, for
after death the liver was found to be quite sound!
—a circumstance not much  in  favour  of his  dis-
criminating powers.  Yet authors are not wanting,
who speak of the practical success of this physician,
attributing  it to his  superior acquaintance with
hepatic disorders.   To me, this success and dis-
cernment appear  equally problematical.  I know
of more than a few who have fallen victims to his

  *  A most magnanimous avowal, showing a mind divested of
prejudice and capable of receiving opinions if well sustained, even
when these proceed from successful rivals.—Edit. 
82
NATURE AND SYMPTOMS
 practice,  but am not  informed of any who have
 been restored to health by its effects.*
   Dr James Hamilton, Jun. in his very useful ob-
 servations on the use and abuse of mercury, observes,
 " As it  is the object of the author to  improve  the
 science of medicine, and not to expose the errors
 of individuals who practice it,  he avoids mention-
 ing  many instances  which have fallen under  his
 observation, where patients were pronounced to be
 labouring under an affection of the liver upon  the
 most superficial inquiry into the symptoms.  One
 old lady, nearly seventy years of age,  was actually
 put  upon a  severe course of mercury by a physi-
 cian, who declared that he felt her liver to be  en-
 larged,  though the examination was  made while
 she  lay on  her left  side  in bed,  and without  re-
 moving her dress, which consisted of a thick flannel
 shift, besides the ordinary linen one.   In this case,
 however,  the liver proved to  be quite sound."   I
 have lately  seen an  instance almost  precisely
 similar, and my experience painfully convinces me,
 that the occurrence referred to  in the former part
 of this extract  is sufficiently  common.   Dr  Hall
 remarks, " I  have this day had  the opportunity of
 ascertaining,  by a careful dissection, that in a case
of mimosis  decolor,  long considered a  case  of
 'liver complaint,' there was no  perceptible disease
of that or any other viscus."f

  * We could here introduce the case of at least  one other
eminent physician who fell a victim to the hepatic prejudices
entertained by himself and  medical advisers.—Edit.
  t Essay on the Mimoses, page 142. 
OF INDIGESTION.
83
  Mr  Abernethy and  Dr Hamilton, Sen.  have
given to the intestinal canal, their full share of ef-
fect  in the prevailing  bilious disorders, and  their
treatment is rationally directed towards obtaining
healthy secretions from them.  They believe, that
the unhealthy colour of the faeces, and all the pro-
minent symptoms of indigestion, are intimately
connected with an unhealthy condition of the ali-
mentary secretions; and their mode of cute rests
upon the principle, that "the state of the bowels
has an important and  remarkable influence  over
that of the stomach, of the internal mouth, of the
external surface, of the circulation, and of almost
every organ of the human frame."*   How far re-
moved is this view of the nature of those disorders
of the general health, now so very prevalent, from
that commonly taken,  in  which the  liver has an
unreasonable degree of importance attached to it.
And how different this principle of cure from that
too generally acted upon,  in which large and re-
iterated doses of a debilitating, and highly stimu-
lant mercurial, are resorted to!—a means, it is con-
ceived, not very well adapted to restore  the im-
paired energies, and  natural  secretions of any or-
gan.
   4. The great number of  our countrymen  who

  * Hall on diagnosis, first part, page 129. This sensible and
accurate writer justly observes, " A deranged state of the bowels
may be deemed the fertile and immediate source of most  disor-
ders of function, and the more remote cause of many organic dis-
eases." 
84
NATURE AND SYMPTOMS
  annually return from the East  and West Indies
  with disorder, or disease, in the biliary organs, and
  the exclusive influence of mercury over the acute
. diseases of India,  have likewise operated, in  no
  mean degree, as causes in the spread of what may
  very properly be termed the bilious mania.   Man
  is prone, especially in medicine,  to form erroneous
  associations.   Persons returning from India are
  naturally led to talk of the universal  nature and
  great fatality of liver diseases in  that country, and
  to extol the inestimable value of calomel;  hence,
  they readily imagine every  considerable disorder
  of  the  digestive organs, which  they  meet with
  among  their friends and acquaintances in England,
  to be no other than a liver complaint; and suppose,
  that the medicine from which they have so often
  derived immediate and striking relief under an al-
  most vertical sun,  must  prove  the most suitable
  and powerful remedy also to their friends at home.
  The valetudinary are  not seldom prevailed upon
  to receive these crude notions, and to pursue the
  practice to which they  directly  lead.  The indi-
  viduals, giving and receiving this information, for-
  get the  vast difference existing  between the cli-
  mate of Great Britain and that  of India, and are
  ignorant of the powerful  impression produced by
  climate, on animal  as well as vegetable life.  They
  are not  aware how widely the ordinary diseases of
  the two countries differ from each other in charac-
  ter; those of tropical regions being  for the most
  part extremely acute, and demanding the prompt 
                  OF INDIGESTION.              85

 and vigorous employment of very active measures;
 while  those under view,  in  temperate climates,
 are generally rather chronic than acute, indicating
 no immediate  danger.   This  applies especially to
 the biliary organs.  Reiterated experience evinces,
 that  those who reside within the tropics bear and
 sometimes, indeed,  require much larger doses  of
 mercury  than can be administered with safety to
 those, who inhabit cold or temperate latitudes; and
 that  much more striking benefit attaches to so free
 a use of it in the diseases of the former, than can
 be obtained from the most judicious administration
 of it  in those of the latter.   The blue pill, which
 we find so valuable at  home, is useless in the East
 Indies;  whereas,  twenty-grain doses of calomel,
 which no  English practitioner would be justified
 in  prescribing, unless  in urgent cases, and under
 peculiar circumstances that very rarely  occur, are
 often ordered in India, twice, or thrice, or even of-
 tener in the twenty-four hours, and with admirable
 effect*.

  * In the United States, and especially in those states situated
 towards the south and west, a physician often rises in celebrity in
 proportion to the magnitude of the doses of calomel, which he
 ordinarily prescribes.  Notwithstanding the temerity of such a
practice, the patients often recover from the diseases with which
they were attacked, and the calomel  so skilfully administered
gets the credit of the cure.  Should the patient subsequently
suffer the horrors of a mercurial fever, and a salivation which per-
haps causes the palate and gums to slough, and the teeth to become
loose or even drop out, the chance is that the physician will get
more praise than censure, since it will be  inferred that in all
probability death would have ensued but  for the salivation.
M 
86
NATURE AND SYMPTOMS
   As an instance of the  powerful  influence  of
climate, in modifying the operation of remedies, it
will not be  improper to notice  the  fact, that the
doses of medicines given in England, excite uni-
versal astonishment  among the  faculty in  Italy.
The  extract of henbane  is usually  administered
among us in doses of five grains, three times a day,
or oftener; yet Dr Harrison in a letter to Dr Paris
observes, that when he gave it in Italy to the ex-
tent of three grains thrice  a day, it  produced, in
two patients, a temporary  amaurosis,  or  loss  of
sight, " which disappeared, and again  recurred,  on
the alternate suspension and administration of this
medicine: and it deserves particular  notice, that
these very patients had been in the habit of taking
similar  doses of the  same  remedy  in England,
without any unpleasant result.  Now, that this
depended upon  an increased susceptibility of  the
patient  in the warmer climate, rather than an in-
creased  power in  the remedy, is unquestionable,
since the extract which was administered in Italy
had been procured from London."*
   5.  For several years past, there have  been medical
men  of talent and character, both physicians and
surgeons, who after a residence of  some years in the

From the appearances of some of the living monuments of that
practice which are by no means rare, we think that they purchas-
ed existence at a dear rate.  Of this much we are certain, that
the very kind of cases in which calomel  in large doses would by
many be regarded as indispensable, yield to  a more rational
treatment where there is.no risk of subsequent danger.—Edit.
  * Paris's Pharmacologia, vol. i. 
OF INDIGESTION.              87
East and West Indies, have returned to practice in
their native country.  They have had to encounter,
almost daily, the most formidable affections of the
liver,  and  alimentary  canal, abroad;  and  have
grown much attached to calomel, from its excellent
and unequalled powers in those diseases.   Upon
returning to England, they have unfortunately con-
sidered the  liver to be the root of the mischief, in
the greater  number   of  the  disorders of  this
country, as well as in those of India,  and have
therefore used calomel with great freedom, in their
subsequent practice at home; and, by their writings
and  representations, have prevailed upon a large
proportion  of us to embrace their opinions, and
adopt their mode of treatment.  These opinions and
the manner of cure have been indefinitely  and in-
judiciously  described,  and still  more vaguely im-
bibed.   In regard to the seat of the evil, what ap-
plies, in truth, to the alimentary canal,  has been
from   plausible,  though  insufficient  reasoning,
assigned to the liver; and, in point  of treatment,
that which is  suitable, with any  force, only to
acute invasions, has likewise been extended un-
happily to chronic  affections.  This is a principal
cause  of bilious   disorders, and their  remedy,
calomel, becoming so  highly fashionable in this
country.
   These gentlemen have fallen into the same error
as their unprofessional brethren  from India, in dis-
regarding the great difference in the two climates,
and in the effects of remedies uniformly resulting 
88          NATURE AND SYMPTOMS
therefrom.  It is strange  and surprising how pro-
fessional men of ability should imagine, that be-
cause chronic hepatitis is a prominent disease in the
East  and West Indies, it must be so likewise in
England.  With as much reason might it be sup-
posed, that  pulmonary  consumption, which is so
pre-eminently destructive  throughout  Europe, is
also a wide-spreading and fatal complaint within
the tropics.
   Yellowness of the eyes  has often been consider-
ed a certain sign of diseased  liver, and  the same
may be said of a sallow or yellow hue of the com-
plexion ; but these  symptoms are very frequently
seen, when functional disorder exists in the stomach
and bowels only.   That  they are  not to be de-
pended upon, as proofs of positive disease in the
liver,  is certain from such cases having been seen,
where neither yellowness  of the eyes or skin were
present,—instances  of which  are related  in  the
writings of Dr Farre  and Dr Blackall.  It ap-
pears  to me, that these symptoms have  been too
hastily supposed  to indicate, at least, considerable
disorder in the biliary organs, with more or less of
obstruction there; for where such symptoms were
observable, dissection has failed, in many instances,
to discover vestiges of these  irregularities, while
marks of great  disorder have been  visible in the
intestines, and appearances of the absorption of bile
from  that canal were decisive.  Hence we are led
to  believe,  that jaundice  and  ydHowness  of the
eyes are not unfrequently consequences  of bowel 
OF INDIGESTION.
89
derangement, unaccompanied with any alteration in
the  qualities of the  bile:—under such circum-
stances,  this  fluid is secreted in a healthy state,
but  from an unnatural  condition of the  bowels,
they do  not effect that change in it  which takes
place in health; and it would appear,  that they are
moreover so affected as to absorb it from their
surface,  and thus it enters with the chyle into  the
mass of  circulating  blood.*  Dr Scudamore enu-
merates  a  general  sallowness,  or partial  stains
of yellow in the skin, as the occasional symptoms
of indigestion in the intestinal canal ;f and Dr Hall
is persuaded, that jaundice,  and a continued though
variable state  of sallowness—of yellowness   or
jaundiced hue, very frequently accompanies both
the  acute and chronic form of the disorders of the
digestive organs.^
   In  the  Medical  Repository for March  1824,
there are two  cases related by  Dr  Chisholm of
Canterbury, in which yellowness of  the eyes  and
skin, and other symptoms that I consider to denote
derangement of the digestive tube were prominent

  *  It is worthy of observation, however, that this sallowness is
often owing to a peculiar condition of the cutaneous circulation,
and  is wholly independent of the state of the bile.  In many
Europeans who have been long resident in India, we witness  a
sallowness of this description; and it is a yellowish hue, arising
from the same cause, which often imparts a distinctive character
to the yellow fever of the West Indies.  Dr Good represents the
yellowness in this fever to arise from the absorption of bile, but
it has nothing to do with such a cause.
   t  Treatise  on Gout, page 85 (4th edition).
  t  Essay on the Mimoses, page 78, and 116. 
 90          NATURE AND SYMPTOMS

 features;  during life, they were considered as  ex-
 amples of liver disease, and treated accordingly,
 but dissection proved the biliary organs to be per-
 fectly healthy.  These cases afford additional and
 unequivocal evidence of the truth of many of  the
 opinions advanced in this  essay,  and  as the first
 case is particularly interesting, I have  transcribed
 it at length.
   "Richard Sutton, aetatis 25,  servant in husband-
 ry, was admitted  into  the Canterbury Hospital,
 April  18th.   This poor fellow was in a very  de-
 bilitated state, and could not give  any account of
 himself.   From a person,  however, who  accom-
 panied him,  I learned that his symptoms were,
 ' sickness, inability to retain any thing on the sto-
 mach, very  obstinate constipation,' and that he
 had some  time before laboured under fever and in-
 flammation.—Habeat  quam   primum  hydrarg:
 subm: gr. x. Extr:  hyoscyami gr. v.  Inj. enema
 purgans.   Pil. hydrarg: gr. v. P.  Ipecac:  comp.
 gr. x. hora somni.  On visiting him next morning,
 I had leisure to make a closer examination.   Skin
 of a yellowish green hue, as were  the  conjunctivae
 (as described  by Dr  Baillie,  in green jaundice).
 Great prostration of strength, and  flatness of the
 abdomen.   Pulse scarcely perceptible at the wrist.
 No fulness of either hypochondrium.   On apply-
 ing pretty severe pressure to the right lobe of the
 liver,  he  appeared to  wince.   Urine  natural in
 quantity, but rather highly coloured.   The calomel
has procured several dark, offensive stools.   Sick- 
OF INDIGESTION.
91
ness only after eating.   Retained the Dover's pow-
der, which, with the blue pill, is to be  continued
every night.   Cathartic mixture every  morning,
and the effervescing mixture occasionally.
  " This plan was persevered in until  the 25th,
during which time I had several opportunities of
shewing this case to my professional friends, who
agreed with  me in thinking (though the case was
obscure), that the seat of the disease was the liver.
  "25th. Omitt:  Pulv: Ipecac: Co.—Cont  Pil:
Hydrarg: Illin. Semi-drachma Ung. Hydrarg. Fort.
Sup. reg. Hypochon dextr. quaque nocte.
  " The greatest attention was paid to the different
symptoms.   The bowels became more regular in
their action, and the dejections more natural; the
sickness, too, was less  distressing.   Nourishing
food, with wine, was given; as  well as  bark, aro-
matic confection, &c. &c.   The treatment, how-
ever, was of no avail: he died on the 20th of May.
  "Dissection.—I examined the body 24 hours
after death, when  I found the liver perfectly natu-
ral in size and structure; the gall bladder about
one-third full of healthy bile; the stomach smaller,
and more flabby than common; no disease of the
cardia or pylorus; pancreas,  spleen,  kidneys, and
urinary  bladder, natural.   The intestines  had a
contracted appearance,  and their villous coat (as
did that of the stomach) readily yielded to the ap-
plication,  though slight, of the  finger-nail.   The
lungs were studded with tubercles  in  different
stages, and very firmly  attached to the pleura cos- 
92
NATURE AND SYMPTOMS
talis, on both  sides,  requiring very great force  to
separate the adhesions.   The  pericardium  con-
tained about an  ounce of fluid, and was here and
there spotted with coagulable lymph on the inter-
nal membrane.   I thought the heart was smaller
and  softer than natural, but could not discover any
disease in the mitral, semi-lunar, or tricuspid valves;
neither was there any communication between the
ventricles; the foramen ovale was closed.   On re-
moving the scull-cap, I was astonished to find the
vessels,  even the most minute, gorged with blood.
The ventricles contained more fluid than usual,
and  there was evidently a softening of the centri-
cal and medullary substances."

   This extract would have been perhaps still more
useful, had  the  alimentary canal been more mi-
nutely  examined, and the  morbid appearances
there more fully noted; however,  as the descrip-
tion stands, it proves thaMhe chief disease was in
that  canal,  and it is most probable, that all the un-
healthy phenomena,  found in the  head and chest,
derived their origin from  the intestinal  affection.
Dr Chisholm considers this " a very vexatious  and
unsatisfactory case;" but would  it have  appeared
so, had liver disease been a less frequent subject of
consideration with the physician, and the digestive
tube obtained  that attention, which its more deli-
cate  organization, and its more important  offices
demand ?
   This relation proves what I  have already ob- 
OF INDIGESTION.
93
served  (page 43), that so far as  the  colour and
fetor of the stools are concerned, it  matters  little
how healthy the bile is, if the digestive tube  is se-
verely disordered, or diseased; for we  perceive in
this instance, that the liver was sound,  and its  se-
cretion apparently neither faulty nor deficient,  for
the gall-bladder was one-third full of healthy bile,
yet the bowels  were  obstinately constipated, and
the motions, produced by the aperients administer-
ed, dark and offensive.  Precisely the same pheno-
mena have Jieen discovered in other  similar  cases
of intestinal disease.
   The second  case, alluded  to above, was  one of
haemoptysis, which terminated fatally,  and where
the face, during life, " was generally of a cadaver-
ous hue;  and the conjunctivae much tinged  with
bile."   Dr Chisholm observes, " Having heard that
this patient had been in the hospital (I believe  more
than once) before, and that his complaint had been
considered an affection of the liver, and  treated as
such, I proceeded to  examine that viscus very mi-
nutely ; its size and structure were  natural, but  of
a deeper colour than  usual;  the  other  abdominal
viscera were likewise  healthy."   It  is  evident,
therefore, that the yellowness of  the  eyes  in this
patient also, which the physician  regarded as de-
pendant upon hepatic mischief, was  really owing
to functional disorder of the  digestive tube.
   A sensation of fluttering at the pit  of  the sto-
mach has also been enumerated by Dr  Pemberton
and others, among the signs  characteristic of chro-
     N 
94
NATURE AND SYMPTOMS
nic disease of the liver; but my experience  con-
vinces me, that it is rather a symptom of indiges-
tion in the stomach or bowels; and I have known
Brandish's alkaline solution remove it,  after mer-
cury and other means had been resorted to in vain.
The same may be said of an intermitting  pulse.
It has  been wisely remarked, that " a sense of flut-
tering about  the heart, or at the scrobiculus cordis,
is the universal symptom of disorders of the diges-
tive organs, and of nervous affections; whilst it sel-
dom or never occurs in organic diseases."*  And
that "in organic diseases, the pulse is generally
frequent and small, but regular.   In disorders  of
function, it is usually of the natural size  and fre-
quency, but  often  intermittent  and  irregular."f
From  the nature of the symptoms, we cannot  be
surprised if this fluttering and intermittent pulse
(particularly the latter)  should be the  cause  of
much  uneasiness to the subjects of them,  and such
they almost always are.  Therefore, it is gratify-
ing to be able to dissipate the fears arising from
this source, by assuring the individuals thus afflict-
ed,  that  there  are few facts in medicine better
established, than that these  are symptoms of irri-
tation  and disorder, but not  of disease.   "Some
books  speak  of  intermitting pulses, as dangerous
signs, but, I think,  without  reason; for such trivial
causes will occasion them, that they are not worth
* Hall on Diagnosis, first part, page 105.
t Ibid (page 125). 
OF INDIGESTION.
95
regarding in any illness, unless joined  with other
bad signs of more moment."*
  Judging  from the  frequency with  which we
hear of our neighbours being afflicted with "liver
complaints," it would seem that this disease is more
common than even consumption.  It is accurately
calculated,  that this affection of the  lungs carries
off prematurely one-fourth  of the inhabitants of
Europe, and that above five thousand  persons die
of it annually, in London alone!   Yet, I appeal to
any unprejudiced person of respectability, who has
an extensive acquaintance, and especially to those
whose custom it has been to mix at Bath, Chelten-
ham, Brighton, &c. among the valetudinary  and
convalescent visitors to those favorite resorts, wheth-
er, so far as report  goes, disease does  not appear
at least as frequent in the liver, as in the lungs?
Notwithstanding, if the bills of mortality be exa-
mined, it will be  found that hundreds  of deaths
from  consumption  are  recorded every quarter,
whilst there is hardly a trace to be found in them
of those who have died from diseased liver.  It is
acknowledged, that disease of the liver is in gene-
ral by no means so certainly, or  rapidly fatal as
that of the lungs, and that it not unfrequently ori-
ginates other complaints, which prove fatal (as
dropsy), from which  cause  the hepatic  disease is
not recognized as the original source of all the sub-
sequent mischief;  but if it were half so common
* Heberden's Commentaries, page 510. 
96
NATURE AND SYMPTOMS
as is conjectured, there is no doubt we should find
at least fifty cases of death from this disease noted
in the  quarterly returns of the hills of mortality,
where  there is now in fact no more than one.
  Formerly, disorganization of the liver was rare-
ly found but in  middle-aged and elderly persons;
now, it seems to be considered almost as common
in the  young as in the old, and is not unfrequently
recognized even  in  children.   I  am  acquainted
with a physician who has gained great credit with
a family of some distinction, by curing one of the
little  children  of a " liver complaint."   Yet Dr
Baillie remarks, in his work on Morbid Anatomy,
that this disease is hardly ever met with in a very
young  person; an opinion that does not admit of
just contradiction.  Notwithstanding, I have known
several young persons who were pronounced to
have  this fashionable disease, and  who  rapidly
emaciated and  grew worse under an active course
of mercury, some of them dying in a state of sali-
vation  !  Who can say that these were  cases that
would not have done well, if a rational and suitable
mode of treatment had been instituted ?
  It were well, if the idea of the  universality of
bilious and liver disease had  been the  only error
in this point, introduced among us. from  abroad.
Were  this the case, it would have hardly  been
worth  the trouble  of refutation; but a practical
evil has  resulted from this error in language, and
the active  mercurial oxides  are  improperly re-
presented to be the sure and only remedies for the 
                 OF INDIGESTION.               97

major part of the prevailing disorders of the diges-
tive organs.   Thus,  the constitutions of the  in-
habitants of this island have been, within the last
twenty years,  mercuralized  without mercy, and,
consequently, scrophula, consumption,  palsy* and
indigestion,  all  diseases of  debility,  have rapidly
and greatly multiplied; and as long as this mineral
is so freely and indiscriminately administered, they
will continue to increase both in number and  ob-
stinacy. Not only are " bilious and liver complaints"
much less frequent than many suppose, but when
disease has really  inVaded the structure of the bili-
ary organ, it is very questionable whether an  ac-
tive use of  any mercurial  preparation  is the best
treatment that  can  be adopted.   This point  we
shall  consider presently.

  * That scrophula and consumption have much increased in
frequency in Great Britain,  within the last thirty years, is
generally admitted; that it is the case with  stomach complaints
is notorious.  The following authentic record of the number of
deaths from apoplexy and palsy, that occurred in London in the
four last years of the seventeenth and eighteenth centuries, shows
how alarmingly these diseases also are increasing upon us.
Years.	Died of Jlpoplexy Died of		Total
	and suddenly.	Palsy.	Mortality.
1696 . .	. . 109	. . . 17 ... .	18,638
1697 .	. . . Ill	. . . 27 ...	20,970
1698 .	. . . 116	. . . 21 ...	20,183
1699 .	. . 106	. . . 24 ...	. 20,795
1796 . .	. . 225	. . . 73 ...	19,288
1797 .	. . . 214	. . . 99 ...	17,014
1798 . .	. . 224	. . . 86 ...	18,155
1799 . .	. . 249	. . . 105 ...	18,134
	See\^	"illan's Reports, edited by	A. Smith.
 
98
          CHAPTER  IL


OF THE DIFFERENT KINDS OF INDIGESTION.
Indigestion, like most other complaints, differs in
its seat and character in different patients.   There
are four different kinds of disorders of the diges-
tive organs, each having its seat principally, if not
exclusively, in a particular organ, though one spe-
cies or variety seldom exists, for any length of time,
without producing an unfavourable change in  the
neighbouring parts, and therefore, in some degree,
occasioning  the  other varieties.   Among  these
multiplied affections, we accordingly meet with
some  whose  immediate seat is in the  stomach;
others, in which the small intestines are chiefly or
almost entirely concerned;  a  third  description,
where a faulty or  deficient biliary secretion is the
principal, if  not the sole complaint; and a fourth,
in which the large intestines are most affected, the
derangement existing there  being sometimes  the
single  cause of much local and general disturbance
and distress.  All these  being cases  of disorder
situated in some part of the assimilating apparatus,
may with propriety be classed  under the head of 
OF INDIGESTION.
99
Indigestion, or Dyspepsia, because their immediate
tendency is to prevent the regular and perfect  di-
gestion and assimilation of the food.
  In the severer forms of this malady, it is mani-
festly of no small moment to the patient, or assist-
ance to  the medical attendant, that the kind of af-
fection present be correctly distinguished, since on
this foundation alone  can the former reasonably
hope to derive from professional exertion, that ef-
ficient and gratifying relief which it is, in general,
so well  calculated to afford; and as it respects the
physician,  it is equally evident that this knowledge
is not only of consequence to him, but also that it
must, if his efforts are usually  successful, be the
very first which he must obtain.   I shall therefore
endeavour  briefly to point out here, the discriminat-
ing symptoms of the varieties of  indigestion now
referred to, so far as  my leisure and experience
enable me.
   1.  In the first modification, furred tongue, clam-
my mouth, want of appetite, heart-burn, oppression
at the pit of the stomach after  meals, or sinking
after a short abstinence, with nausea and rejection
of food, are generally the most prominent symp-
toms.   The  mouth  is parched and  dry in  the
morning, thirst prevails through the day, and  the
breath is more or less fetid.   The bowels are of-
ten tolerably  regular, sometimes quite so, and  the
colour of the motions little changed from a natu-
ral appearance.   In some cases, there is a tendency
to constipation, although the  colour  of  the  faeces 
100
DIFFERENT KINDS
 remains the same as they were  when the patient
 was quite well.   The drinking of  much liquid is
 particularly distressing.  There is  tenderness on
 pressure, and pain at the pit of the stomach, and
 sometimes towards the leftside.  A puffy swelling
 also is occasionally to be felt at the  former part,
 and, in protracted and severe cases,  soreness may
 exist there, and a burning sensation, more or less
 constant, and extending to the right side.  Morbid
 acidity in the stomach is very common, and like-
 wise a simple returning of the food soon after it is
 taken, especially  of the dinner meal.  The urine,
 in general, soon becomes turbid, and deposits, on
 standing, a yellowish, or yellowish  red sediment
 It is not seldom small in quantity.   The complex-
 ion sometimes becomes  pale, but  is very  rarely
 sallow.
   2. When the  small intestines (parts  of  great
 extent and importance) are the organs most affect-
 ed, the tongue is  usually furred, although not so
 greatly as in the first variety, and perhaps the fur
 has not so white an appearance.   Here the thirst
 is less than in the former modification; the mouth
 not so  parched or dry; the appetite  not so sensibly
 impaired, nor the breath so much tainted.  There
 is little oppression, or sense of sinking at the pit of
the stomach, except after an immoderate or  im-
 proper gratification of the palate, nor is there  any
 nausea or  vomiting; but the bowels are various-
ly and  much disordered, being either very con-
fined or too much relaxed.   The stools are highly 
OF INDIGESTION.
101
 unnatural and offensive, being either of  a light
 brown colour, or green, or dark and black, pitchy,
 and frequently slimy.   Occasional  or  frequent
 diarrhoea is often a troublesome symptom of this
 form of the complaint, and sometimes exists  from
 the commencement.   As thirst is not urgent, fluids
 are not indulged in, and when they are,  they do
 not oppress and injure the individual so greatly as
 when the stomach is principally affected.   In the
 first modification, there may be considerable extri-
 cation of gas from the  stomach; in  this, the patient
 is annoyed with offensive flatulence in the bowels.
 When pain is present,  it  is felt in the bowels, most
 commonly in the right side, and about the umbili-
 cus ; and as,  where the stomach is  the part  most
 affected, we have heat  and viscid secretion in the
 mouth, so when the disorder exists chiefly in the
 bowels, the heat and irritation is most sensible and
 troublesome at the other extremity of the digestive
 tube, and the patient is often afflicted with piles,
 and sometimes with tenesmus, after a visit to the
 water closet.   In general, I think the colour of the
 urine is high, and it deposits a highly coloured red
 sediment.   The complexion is pale  and [sallow,
 sometimes yellow, which last  colour often tinges
 the conjunctivae also.
   3. Should  the biliary organs be chiefly involved
in the existing disorder, the prominent symptoms
are in general pain or uneasiness in the right side,
constipation of the bowels, unhealthy alvine dis-
charges, in which the white and dark perhaps pre-
     o 
102           DIFFERENT KINDS

dominate, a yellow thick fur on the tongue, and a
high pink coloured turbid urine.   The appetite is
usually more impaired than in the  second form,
but not so much so as in the first.  The  pulse va-
ries, in a small degree only, from the healthy stand-
ard.  In this, as well as in the second modification,
digestion appears to take place with tolerable faci-
lity and perfection in the stomach; but indigestion
occurs below this organ, yet not, I think, to so great
and uncomfortable a degree as when  the  bowels
are more under the influence of  disorder than the
liver.   Upon the whole, it may be questioned
whether the sallowness and jaundiced hue of the
countenance and eyes are more frequent and visible
here, than they are in the second form;  but they
are, in some cases, of a more steady character.   In
cases of some standing, there is generally a palpa-
ble enlargement and hardness in the right side,
close to the margin of the ribs.
   4. The true seat  of  indigestion originating in
disorder of the large intestines, often remains a long
time undiscovered, the reason of which appears, to
me to be the frequency with which the generality
of dyspeptics labour under  some irritation about
the rectum or anus,  such as  piles, occasional dis-
charge of blood, heat and pain there on going to
stool, &c.  When patients complain of these symp-
toms, professional men usually think they are only
indications of the existence of disorder in  the  su-
perior portions of the canal, which do incidentally
happen to almost all such patients, and which  are 
OF INDIGESTION.
103
only to be removed by the remedies calculated to re-
move the chief and original affection.   As a general
opinion, this is no doubt a correct one, but cases of
dyspepsia not  unfrequently occur in which the
chief seat of all the patient's distressing symptoms
is in the rectum and colon.   These cases may very
generally be distinguished by the presence of pretty
constant uneasiness  about  the anus  on going to
stool, with frequent discharges of blood; occasional
pain in the rectum; obstinate costiveness,  which
nothing but medicine is capable, for any length of
time, of obviating; and uncommon flatulence.   On
close examination, it will commonly be found that
the diameter of the faeces, when consistent, is less
than usual, and flattened or figured; and sometimes
there is a slight prolapsus of the skin of the anus
on  one side.   Occasionally  the  patient  labouring
under this form  of  the complaint, will be daily
much  annoyed by frequent calls to the water closet,
which are only partially effectual.  The most fre-
quent  cause of this modification of dyspepsia, is the
existence of a permanent contraction, or stricture
in the rectum, or lower part of  the colon; but I
believe an excessive irritability of those parts, un-
attended with any permanent contraction, does now
and then exist, and form the real seat  of  all  the
distress which is  suffered under the general appear-
ance of indigestion.
   In this last modification  of the  disorder now
treated of, I have uniformly observed that the  pa-
tients  are greatly distressed with bilious headaches, 
104            DIFFERENT KINDS
  if the bowels are permitted to remain in a confined
  state beyond a certain period.  But, if the patient
  is tolerably attentive to his diet, his appetite is uni-
  formly good, and the tongue  but little furred; the
  strength however, is often much impaired, and in
  the advanced periods of the  malady, the nervous
  depression and irritability are at certain  times ex-
  cessive and peculiarly harassing.
   ^ Amongst the multitude of the complaints under
  view, which we are every year called upon to wit-
  ness and to treat,  there will ever be many, in which
  some of  the above symptoms will  be found,  that
  are noticed as denoting a different form of the com-
  plaint, while others may  be absent that properly
  belong to them; yet,  according to my observation,
  it but seldom occurs, that the characteristic  signs
  do not exist in such number, and with sufficient evi-
 dence, to enable us, upon proper consideration, to
 discover the particular kind of derangement which
 we are requested to prescribe  for.  In stomach
 disorder, the want of appetite, the oppression after
 eating, and the  occasional pain  in the  epigastric
 region and left side, the very furred white tongue,
 the frequent rejection of food, and the distress oc-
 casioned by drinking freely of liquids, will usually
 point to the seat of disorder pretty distinctly   In
 intestinal  irritation, the highly disordered state of
 the bowels,  the unnatural appearance and offensive-
 ness of the motions, the intestinal pain and flatulence,
the partial wasting and debility, while the appetite
is good and  the  tongue but little furred, clearly 
OF INDIGESTION.
105
show, that the bowels are subject to the most sen-
sible and greatest disorder.  The affection of the
liver is denoted by the greater degree of pain in the
right side, up under the ribs, of tenderness on press-
ure there, which is sometimes  attended with en-
largement and hardness, by the pulse being almost
unaffected, the urine pink-coloured, and sometimes
by the whiteness and tenacity of the motions.   In
this last form of the disorder, from the insensibility
of the organ concerned,  the  symptoms are often
obscure, and seldom point with great exactness to
the nature of the malady.  The  disorder of the
large  intestines  may always be  ascertained  by
passing a bougie.
  I have observed that in cases  of indigestion de-
pending on  great irritation in the  large intestines,
patients  have often an unimpaired appetite  and
relish for food,  with a clean tongue, and they will
also digest their food well, provided they are  care-
ful in respect to  the two points of quantity and
quality; and this state of the stomach and tongue
will often be present, when they are greatly harass-
ed by general nervous depression, and local uneasi-
ness about the rectum.
  There is  seldom much difference in the pulse of
the various classes of dyspepsia.  It is mostly small,
weak,  slower than  natural, but regular.  Under
an aggravation  of the symptoms  it may become
quicker than natural, and sometimes intermitting.
If there exists an inflammatory action or tendency,
it is more or less hard. 
106           DIFFERENT KINDS

  The  second form  of abdominal  derangements
above noticed, appears to me to be the most com-
mon, and it is also, in general, the most painful
and obstinate,—that which is more extensive in its
effects than any other, and which gives rise to more
dangerous and intractable diseases.   Next to it are
the disorders of the  stomach; then those  of the
liver;  and lastly, those of  the large intestines.
The disorders of the biliary organs,  notwithstand-
ing what is generally asserted to the contrary, I am
constrained, after considerable reflection upon the
subject, and an impartial and strict examination of
it, to consider as very inferior to the varieties pre-
ceding it in the foregoing division,  in frequency,
intensity, and  importance.
  In the bowels we recognise the seat of those in-
ternal disorders of the abdomen, which so generally
prevail  in  autumn,  and  at  other seasons of  the
year, and which are, for the most part, readily cured
by aperients and alteratives.   Here  especially  ori-
ginate  gout, scrophula, tic douloureux, and other
frequent and painful chronic maladies, which we
have to combat, at every stage of professional ex-
ertion;  and it is likewise here  that those more
alarming and  fatal  complaints—acute  diarrhoea,
dysentery,  cholera  morbus,  hydrencephalus,  and
perhaps fever, have their chief and primary seat
and origin.  The organization and offices of the in-
testines,  clearly explain the reason why they are so
pre-eminently susceptible of  irritation and disease,
and serve at the same time to corroborate the fact. 
OF INDIGESTION.
107
Their internal surface is of immense  extent, and
exquisite sensibility; it is an absorbing and secret-
ing surface of the first importance  in  the animal
economy; since the chymous pulp prepared in the
stomach from the food, is here converted into chyle,
absorbed, and carried into the circulating system,
to nourish, sustain, and invigorate the whole, while
the gross, innutritious parts are carried downwards
for the purpose of being expelled.   Here  are  re-
tained, for a longer or shorter time, the bland and
nourishing, as well as all the harsh  and irritating
liquids and solids which we take in  the  form of
food, or medicine,  or as a gratification to the palate.
They are applied immediately to its  surface, and
considering how unremittingly this  is done, both
in excess of quantity, and without regard to quali-
ty ; how numerous are its blood-vessels and nerves,
and therefore how highly sensitive it is, and how
extensive its  connexions; we may be surprised that
disorder of the stomach and intestinal canal is not
more frequent and inveterate, rather than it is so
general.   Besides, there is no other organ which is
so much affected by the never ceasing changes and
vicissitudes in the  atmosphere,  to which we are
constantly exposed, and from which we so greatly
suffer in  this climate; neither  is there any one
(except the stomach), that so immediately and in-
tensely participates in mental affections, or irregu-
lar morbid action of any part of the nervous system.
  Hitherto we have considered  only  the  varieties
of indigestion arising  froi  the difference  of their 
108
DIFFERENT KINDS
 situation, but there is likewise a manifest  differ-
 ence in dyspeptic cases founded on the general con-
 dition of the constitution, without any reference
 whatever to the particular seat  of affection, and
 which distinction it is at  least of as  great  conse-
 quence to understand, as the varieties  already no-
 ticed.
   We meet then, in practice, with  two different
 states of the general system in this disease;  one is
 a condition of simple debility, the other is a state
 of debility associated with inflammatory action, or
 a strong tendency thereto.   The latter case  is de-
 noted by a  uniformly dry state of the  skin, with
 more or less local pain, a tendency to inflammatory
 congestion in the head, side, lungs, or other  parts,
 being frequently present, with a  hardness in the
 pulse.   There   exists also much  feverish  heat,
 which stimulant remedies are very apt to augment
 greatly.   In the former case, the skin it is true is
 sometimes dry, but it is also often moist, and that
 for days or weeks together; and  there may like-
 wise be local pain, but it is  manifestly rather the
 pain  of weakness and disorder than that of inflam-
 mation, and the same may be said of any appearance
 of congestion in the head, &c.  The pulse here is
 small and feeble, without any tension; and the fe-
 verish heat or flushes, which almost all dyspeptics
 are occasionally more or less subject to, is such as is
generally relieved by mild tonics and stimulants.
  Many cases of indigestion with inflammatory ap-
pearances occur, whicl  .equire the exercise of 
OF INDIGESTION.
109
much caution and discrimination, in order to ascer-
tain whether these appearances are owing to  de-
bility, or to  inflammation, and  many grievous  er-
rors  have  been committed  in this respect  from
want of attention.*   Yet I  think a  physician of
observation can rarely fail to discover the  real  na-
ture  of  the case before him, if  he duly considers
the condition of the pulse and skin, with the con-
stitutional  tendency of  the patient, and  does  not
overlook the  fact  that debility alone, when con-
siderable, will  often  produce in persons not dis-
posed to inflammation, such  an irregular and  ap-
parently  excited state of the local circulation, as
simulates true inflammatory action.  This subject
will be further illustrated in the fourth  chapter.
   The inflammatory action above adverted  to is,
of course, not that  of  acute  inflammation, but  of
an  inflammation of a subdued and imperfect  char-
acter, which is  usually termed chronic.

  * Some years since, a surgeon at a fashionable watering place
attended a  patient,  above fifty years of age, well known to  the
author, who laboured under considerable  weakness and much sto-
machic disorder, and had always been weakly.  The surgeon  allud-
ed to was called in to attend her for a great increase of internal
disorder, accompanied with pain and uneasiness about the fore-
head and eyes; the  latter symptoms led  him to bleed  her from
the arm, and an increase of pain being the consequence, he bled
her again: the result was lamentable indeed, for  it produced so
much exhaustion that the next day she suddenly lost her  sight,
which has never returned.  This was a case in which tonic  re-
medies were indicated, and would probably have done the patient
much service, whereas the debilitating measures so improperly re-
sorted to, inflicted an injury from which it is very unlikely  she
will ever recover.
P 
110
                 CHAPTER III.


           OF THE CAUSES OF INDIGESTION.


Almost every observant person is now struck with
the frequency of Indigestion among the inhabitants
of Great Britain, and it is a common and interesting
question, what is the cause of the uncommon fre-
quency of this complaint among us ?   It is seldom
that I have met  with a correct answer to this en-
quiry, either in conversation with professional men,
or in their writings; some attribute it to one thing
and others to another, but most certainly the cause
is not one, it is not single, but is for the most part M
dependent on changes which have  of late years
gradually taken  place in the general pursuits  and
mode of living  in  this country, and  since these
changes are undisputed, and are, I think, equal to
the production of the effect, the  real sources of the
malady appear to me sufficiently manifest.
   It is a general sentiment  that a grand cause, if
not the chief one, is inordinate  repletion, and  its
necessary concomitants  morbid  distention of the
stomach, &c. ;* but many circumstances  concur to
* Some authors on Indigestion appear to lay great stress on 
OF INDIGESTION.
Ill
prove the fallacy of this opinion.   It  is  fully as-
certained that the old  English ate  and drank as
much (some think more, and I am of that opinion)
as we do in the  present day, yet they were com-
paratively exempt from indigestion.   In the reign
of Henry the eighth, for example, both wine and
ale were commonly drank  at  breakfast, the quan-
tity served being a pint to  each person; and maids
of  honour in  the court of Queen  Elizabeth ate
beef steaks for breakfast, and  drank ale  after it;
while at present we can hardly take a small quan-
tity of ale after dinner, without its occasioning much
inconvenience.   Again, it is well known, that in the
majority of cases,  if a dyspeptic will give  ease to
his mind, and free exercise  in the  open country
to his body, he digests his food easily and perfectly,
which before sat very uneasy on the stomach, and


morbid distention from over-feeding, as a cause of indigestion,
and also on eating too fast as a  source of morbid distention;
but  is not this mere trifling, when causes of greater frequency
and weight are  at the  same time  overlooked?   Did not our
fore-fathers distend their stomachs as much as we do, or more,
and did they not eat as fast ?  Yet where was  their indiges-
tion?   This  view of  the subject, although  countenanced  by
some whose writings on this complaint are valuable, is very un-
satisfactory and erroneous. A knowledge of the causes of a dis-
ease is of great consequence towards a correct employment of
the most efficient means of recovery; and this view has a direct
tendency to lead patients to lay the greatest stress, on what is
in reality of inferior importance.   It cannot be my wish to un-
dervalue the effects of attention to diet, but, as I have had occa-
sion to remark elsewhere (Treatise on the Jirt of Prolonging
Life), in all sciences we must learn to distinguish the relative value
of different agents, if we would apply them with the best effects. 
112
CAUSES
often excited perhaps what are termed fits of dys-
pepsia.   It cannot be correctly said, that  in these
instances the diet is the cause  of  indigestion.   It
is true it proves the incidental occasion of uncom-
fortable sensations and disorder, because there pre-
viously existed a weakened  and depraved condi-
tion of the assimilating organs, from the influence
of moral or physical causes (or both) of a charac-
ter very different from excessive repletion; the sto-
mach here being rebellious and fastidious, simply
from its debility, and  not because  the  food is  of
inferior quality, or in improper quantity.
   I consider the principal causes of indigestion  to
be  1st.  A sedentary mode of living, that is, one in
which bodily exercise is  deficient; 2dly.  Anxiety
of mind;  3dly.  The inhabiting populous cities or
places.   Among the chief  minor  causes we  may
probably reckon, light dressing;  late hours;  and
an  unrestricted  indulgence of the appetite.   In
the latter we may include the influence of impro-
per quality,  as well as undue quantity of food.
  After muci} consideration of this subject, I am ful-
ly persuaded that deficient exercise and mental anx-
iety are by far the most common  and most pow-
erful sources of dyspepsia, and when  considered
in conjunction with the common practice of crowd-
ing into towns and cities, to  the neglect  of those
rural pursuits, which necessarily carry men abroad
continually  into  the open  country, they will  be
found quite  equal to  the  production of  that re-
markable and general  change  in  the vigour and 
OF INDIGESTION.
113
energies of the digestive apparatus, which is now so
conspicuous among us, and which is the immediate
cause of indigestion, that is, in what the disorder
essentially consists.   It does, not consist with  my
present planrto enter at length into this subject,
and it must suffice for  me to remark that it is very
evident, that individual wealth has accumulated in
this kingdom within the last thirty or forty years
beyond all  precedent, the acquisition of which has
been attended (as the history of the world  proves
it ever has been, and  ever will be) with unusual
anxiety, and  diminished bodily exercise  of  a salu-
tary kind.   It is plain that  in the present state of
things, men's minds are too much engaged,  and
their bodies too little, and here  lies the root  of the
bodily mischief so much complained of.  It must
not be forgotten, that independently of the anxiety
attending an eager pursuit of business, the uniform
result of success is a greater style of living, which
invariably  brings with it  an increase   of  care, and
multiplies the sources not of enjoyment, but of dis-
quietude.*   So far as deficient exercise is concern-

   * The influence of success in our worldly pursuits here alluded
to, when become frequent, is much greater than perhaps the ge-
nerality of men  are wont to think it.  It works extensively in va-
rious ways, and produces marvellous changes on the moral and
physical condition of a people.  With this success, the "prideof
life" increases; every man is struggling to compete in style with
his neighbour, and in the struggle, whether successful or not, he
necessarily exposes himself to numberless anxieties and disqui-
etudes, which do not cease even with the consummation of his
 wishes, but are too often thereby much augmented. 
114
CAUSES
ed  as a cause  in the present case, I  have already
given it as my opinion (in the book  just quoted),
that it is "the  debauchery of inaction," and not of
repletion,  that has spread  itself so extensively
throughout this nation, and engendered so alarming
an increase of dyspepsia, and other chronic mala-
dies.
  Among  the  minor causes,  no  doubt  excess  in
eating and drinking has great effect  in  multiply-
ing cases of indigestion;  which effect is augmented
by the inferior and  base quality of many articles
of diet of general  consumption,  such as baker's
bread and  brewer's  beer.  It is  not many years
since it was as common  for families to make their
own bread, and brew their own beer, as  it is now
for them to have these articles from  their trades-
men.  My readers  will perceive that I do not wish
to represent these changes as principal  causes  of
the present malady, but  they are  causes, and pro-
bably have greater  effect than is  commonly sup-
posed. It must be recollected that these are articles
of daily consumption, and therefore, if  injurious,
their deleterious  operation, although in the be-
ginning silent,  yet is sure, and annually accumu-
lating.
  If what  is now said be true, it  follows that the
cause of indigestion is not single, but  that  its  ori-
gin must in general be sought for  in  many injuri-
ous habits; deficient bodily exercise, and  mental 
OF INDIGESTION.
115
anxiety, being those causes  which have by far  the
most powerful influence in its production.*

  * The circumstance of the Parisians and inhabitants of French
towns generally, being less subject to the various forms of dys-
pepsia (the very name of which is unknown to them), than those
of the large towns of England and America, furnishes a curious
subject for enquiry.   Are the French more  exempt from any
or  all the causes enumerated  by our author than the  English
and ourselves ?   Let us view some of these separately.  To the
first, namely, a sedentary life  and deficiency of bodily exercise,
the inhabitants  of the Gallic towns perhaps  plead as guilty as
the others we have mentioned, if we except their  well known
saltatory propensities, which however  are not generally indulg-
ed by les gens des lettres of different orders.   In regard however
to the second cause, namely, mental anxiety, we certainly think
ourselves justified in speaking with less hesitation, and disposed
to join all the world  against the declaration of the facetious Yo-
rick, that if the  French have a fault" they are  too serious."  The
happy moral constitution with which they are  endowed by nature
enables them to rid themselves almost at pleasure of those cares
and inquietudes that sink deep into others and poison the foun-
tains of their health and happiness.  Their capacities for social
intercourse and keen relish for amusement, let this come in what-
soever form  or shape it  may, unquestionably tend  in  a high de-
gree to diminish one of the most abundant sources of dyspepsia.
In the French character we observe far less of what our author
calls by a borrowed expression, the "pride of  life," than is appa-
rent in the English and, unfortunately, but too strongly manifested
among ourselves.  They seem too much disposed for the immedi-
ate enjoyment  of their  worldly goods, to hoard them up  with
ceaseless anxiety in the  sordid hope of becoming one day richer
than their neighbours, and able to outvie them in style.
   A view of the considerations, embraced in our author's third di-
vision  of causes, would require much more space than is  allotted
to a marginal note.   One of the topics involved, namely,  the pe-
culiarities of French diet, and notions relating to eating and drink--
ing, would alone furnish  matter for a formidable volume, and pos-
sibly for  two or three.  We shall  therefore dismiss  it with the
remark, that we regard  the free use made of  animal food in this
country,  together with the despatch and little discrimination ge- 
116
        CHAPTER IV.


OF THE TREATMENT OF INDIGESTION.
In adverting  to  the treatment of this  disorder, I
think  it desirable to notice first, the general prin-
ciples  of that treatment, and afterwards, the em-
ployment of individual remedies.
  It is proper to notice  the general principles of
management  first, because they obviously, suppos-
ing them correct, form the foundation  on which
alone any physician can practice successfully.   To
these principles, when his practice is considerable,
he finds himself  compelled continually to refer, and
in obstinate or obscure cases, they frequently prove
as a light to guide him in  the darkness  that  may
surround the  malady of his patient, and thus pre-
serve him from  being led astray  by  incidental
symptoms or circumstances of an untoward char-

nerally manifested in eating, as contributing greatly to multiply
dyspeptic ailments.  This remark we think applies with peculiar
force to the very young and aged, or such as have passed the mid-
dle of life.  No fact  can be more self-evident than that feeble
powers of digestion require particular attention both to the quality
and quantity of the food.—Edit. 
OF INDIGESTION.            117
acter, and likewise from the  mazes of error into
which many fall who have either no principles at
all, or only those which are erroneous.
   There are two general principles, which are of
paramount importance  and universal  application.
They are,  1st. That the secretions generally are
to be restored  to  as healthy  a  state as possible;
2d. That while we are aiming at this, the strength
of the patient must be maintained and augmented
also to the utmost.  A third  general indication I
shall notice presently.
   It has certainly been too much the practice in
this complaint, as well as in  other chronic mala-
dies, to overlook or disregard  the latter  principle,
while aiming to accomplish the object  described
in the former, from  which circumstance many pa-
tients have necessarily suffered greatly for a time,
and some permanently, as the  mischief  done by
active lowering measures, could never after be per-
fectly surmounted.  At this we cannot be reason-
ably surprised,  because if the  physical  strength of
an individual is reduced  below a certain point, it
is  often found impossible  entirely to recover  the
injury thus  inflicted, at  least by the  use of any
means within the  individual's reach.  I think it
is frequently not  sufficiently considered, that this
disorder has, for the  most  part,  its  origin in  de-
bility,  and  also  that local or  general  weakness
is  a common  cause, indeed  the chief cause of
unhealthy  and depraved  secretions.   It  follows
from  this,  that   when  lowering measures  are 
118
TREATMENT
used, or permitted to operate, although the  most
efficient alterative medicines may at the same time
be given, the secretions remain unimproved, and
the patient instead of getting better, grows worse,
and for this obvious reason, that we are, by having
recourse  to enervating means,  strengthening the
foundation  of depraved secretions, which is debili-
ty, and thereby rendering the most efficacious  al-
teratives of no  service whatever.   This  applies
equally to  a lowering  treatment  employed only
for a few days or hours, and to that pursued  for
weeks; and these circumstances lead me to believe
that the  very general practice among Surgeons, of
giving a  patient a calomel or blue pill at night, and
a brisk purging draught in the  morning, defeats its
own object of restoring more healthy secretions by
the weakness which it occasions.   In  this case, if
the pill be given, in  combination with antimony,
and without the purgative, it will seldom fail ulti-
mately to accomplish the object desired, which I
believe is frequently unattained when  purgation is
connected  with it.
   In indigestion, and all chronic maladies, it may
be safely laid down as a maxim, that the secretions
will often  be restored to a healthy character by
tonic  remedies, simply used as such, while they
can never  be perfectly and permanently improved
by the most efficient alteratives, whether simple or
combined, which have an enervating effect, that is,
which are so administered as  to have this result.
In reference to the  treatment of  the  complaints
alluded to, there is no general principle of greater 
OF INDIGESTION.
119
 importance than this,  and it has its foundation in
 the cause of morbid secretions, which are uniform-
 ly either so  entirely dependent on debility, or so
 closely associated with it, as was  above remarked,
 that to augment this weakness, is necessarily to ag-
 gravate the unhealthy  state of the secreting surfa-
 ces.   That debility  is the fruitful source of de-
 praved secretions* may be inferred from various
 characteristic circumstances,  indeed, from the ordi-
 nary symptoms and progress of all chronic diseases.
 Whenever we meet with a weakly man, who per-
 haps  may nevertheless not complain of any posi-
 tive indisposition,  do we not always find the se-
 cretions much deranged,  and  often in an exact pro-
 portion to his debility,  the condition of the former
 ever varying with  that of the latter, so that if the
 strength be increased, the secreting surfaces are im-
 mediately and evidently  improved, while  they are
 as directly injured  by the reduction of the general
 strength ?  If  it be inquired  what is  the kind  of
 habit in which we  witness severe and  protracted
 ulcerations, or  pimples, or swellings, or  inordinate
 discharges, and other evidences of a morbid action
of the  secretory vessels, is not the ready answer,—
in that which  is either originally weak, or which
has become so  from the influence of bad habits, or
deleterious agents ?   Again, in susceptible consti-

  *  Under the term secretions, I  include all the excretions  as
well as those discharges  which are by  physiologists more strictly
termed secretions. 
120
TREATMENT
tutions, where we fear the possible occurrence of
tubercles or ulceration in the lungs, or of enlarge-
ment and ulceration of the joints or glands, &c.
(such as is so frequently seen  in  strumous habits,
or those disposed to  scrophula), is not the  correct
advice of the physician invariably to  this effect—
if you can maintain  the patient's  general strength,
you place her in a state of security, but mark well,
whatever tends  to lower  the  general vigour of the
frame will  threaten her  very existence.   The or-
dinary operation of the most useful remedies con-
curs to prove the correctness of the assertion now
advanced, for how frequently does it  happen that
the physician seeks in  vain, even by the most pow-
erful alterative medicines judiciously prescribed, to
correct the  unhealthy condition of the vessels just
referred to, if he  neglects to  recommend, at the
same time,  means which have what may be term-
ed a direct  tonic effect.  Thus it is   that quinine,
iron, and other  tonics, given in conjunction  with
calomel or blue pill, often accomplish such objects
as are now  spoken of, which the  latter  could not
do alone, even under favourable circumstances in
other points of  view.*

  * For the same reason the professional man appear^ to me of-
ten to defeat his own intentions, when he advises in chronic dis-
orders the use of mercurial alteratives, for example,  but likewise
recommends at the same time local, or general blood-letting.  In
this way, he is frequently  employing, in the same day, antagonist
forces  and may be seen really, though unwittingly, creating great-
er disturbance than  he was called to cure. 
OF INDIGESTION. .           121
   These facts show the utter folly of a sentiment
common among a certain class  of persons, that in
severe  chronic diseases, the constitution  must in
the beginning suffer under the operation of  active
remedies, in order to the cure of the existing ma-
lady.   This  is a  sentiment which has  been the
source of innumerable evils, and whether express-
ed in words, or only by the practice of those who
embrace it, ought never to meet with any quarter.
It points to a  way the very reverse of that dictated
by Nature, and therefore  the  reverse of what is
right,  for the  moment she commences the cure of
any disease, in the same moment does she begin to
restore a comfortable feeling to the afflicted,  which,
in the main, increases and keeps pace with his grad-
ual recovery.
   A third grand indication in the general manage-
ment  of disorders of the digestive  functions, is the
relief of irritation.   Keeping this principle in view,
may assist us very much in the correct application
of the other principles just noticed,  for if the mea-
sures  taken  to restore healthy secretions, or aug-
ment  the strength, are productive  of irritating or
uncomfortable sensations, we may almost  always
conclude that those means are either inappropriate
in themselves, or employed in an unsuitable manner.
The results of attention to it likewise tends  greatly
to strengthen the evidence in favor of  the senti-
ments here  advanced, respecting  the  necessity of
increasing the general energies of the body as far
 as possible, for we invariably find that irritability, 
122
TREATMENT
 pain, and irritation are closely connected with de-
 bility, so much so, that whatever augments the lat-
 ter aggravates the former,  and,  on the  contrary,
 we cannot take  a  more  certain  way of  lessening
 the former, than by resorting  to those  means
 which have the greatest influence in removing the   %
 latter.*
   Acting on this  principle  of relieving  irritation
 to the utmost is also very frequently of eminent
 service in directing us to such measures, as prove
 of  great value in  aggravated cases,  which, at least
 in the beginning, do not  admit of remedies tend-
 ing directly either to improve the secretions, or in-
 crease the strength.   It must be remembered that
 I now  advert to  protracted or extreme cases, in
 which we so commonly find excessive  uneasiness
 and irritation, under various forms;  and in which
 we are unable, with propriety, to do more than en-
 deavour to soothe  the malady of  the sick, until  a
 favourable change takes place, and  permits us to
 advise measures capable of exercising a  beneficial
 influence of a positive  character.   Here we have it
 always in  our power to recommend the use of mild
 soothing means, calculated to relieve irritation, and

  *  Indeed, we may take an extended view of the subject, and
justly affirm that, as Mr Abernethy expresses it, the relief of irri-
 tation is the great object of medicine.  For in proportion as we
 succeed in delivering our patient from all that is debilitating and
annoying, so do we enable the constitution, or Nature, as some
 would say, to perfect the work of restoration.  This sentiment is
equally applicable to acute and chronic diseases. 
OF INDIGESTION.
123
thus to pave the way for the more speedy and more
effectual application of remedies designed  to fulfil
the preceding indications, and thereby permanently
to restore the patient's health.
   We have now to speak of the application of indi-
vidual remedies to the  fulfilment of the  general
principles or indications above proposed, and this
will terminate what I have to say respecting the treat-
ment of the present disorder, for in proportion as
we succeed in allaying irritation, and ^establishing
the physical energies of our patient, and improving
his secretions, so do we succeed in restoring him to
health.
   The remedies  for indigestion  naturally divide
themselves into three great  classes, viz:—Medi-
cine, Diet and Regimen.  Under the head of Regi-
men, I include air, exercise, bathing, and the like.
   The medicines which I have  found to possess
the greatest efficacy in fulfilling  the  objects just
noticed, as  being those which we should ever chief-
ly keep in  view in the treatment  of the present
complaint, are mercurial preparations, rhubarb, ipe-
cacuan, nitric acid, the  alkaline solution, and cer-
tain metallic oxides, with quinine, sarsaparilla, and
mild aperient medicine.
   In the treatment both of the slighter and  more
severe disorders of  the  digestive  organs, at this
time so prevalent  in every part of Great  Britain,
mercury, in general practice,  holds the first  place,
and  certainly its  administration  is very often at-
tended with admirable effects, and sometimes such 
124
TREATMENT
 as cannot be obtained by any other known remedy.
 But though frequently an eligible  medicine, it  is
 not always the best, even in small quantities;  and
 has certainly been injurious in the common way
 of administering it, which I consider injudicious in
 regard to the mode, and deleterious in point of dose
 and repetition.
   Calomel is, on the  whole, the  favorite form of
 this mineral, but as it has a strong tendency, when
 given alon*, to weaken and  irritate  the stomach
 and bowels, it ought  always in chronic diseases to
 be conjoined with  other alteratives, which  are of
 milder operation, and capable of aiding its salutary
 effects.  Therefore, the frequent practice of order-
 ing a grain or two  of calomel alone  in  a pill at
 night, with an  aperient in the morning, cannot be
 too severely reprobated.   The proper practije is
 to combine it with tartarized antimony or James's
 powder, and guiacum, with or without  a  minute
 dose of opium,  as circumstances indicate.*
  In many cases, the milder preparations of quick-

  * The following formula for alterative pills may be convenient
 to some, disposed to try the practice here recommended.
  Take of calomel, twenty grains; tartar emetic,  four grains;
pulverized gum guiacum, two scruples.  Rub these intimately to-
gether in a mortar, and with the addition of a sufficient quantity
of conserve of roses, or syrup of any kind, form into a mass and
divide into twenty pills.
  The above prescription may be advantageously varied on some
occasions by leaving out the tartar emetic and substituting twenty
grains of James's powder.  It is also sometimes useful to combine
with the mass a small portion, say two or three grains of opium or
its extract.—Edit. 
OF INDIGESTION.
125
silver, as the blue pill, or hydrargyrus cum creta,
being less irritating than calomel, are found to agree
much better, and to be very useful when the latter
fails of any beneficial effect.  This appears to take
place chiefly when great debility is present, or the
system is unusually irritable.   I believe, however,
that in numerous  severe examples, the combina-
tion of  calomel and antimony above referred  to,
excites a greater curative, power than the blue pill,
or any other mercurial compound.
   Since all mercurial preparations are very active,
the subjects of  dose and repetition are worthy of
great regard, and this applies  more  especially  to
calomel, because it  is  the most energetic  of those
preparations in  ordinary  use,  and also from the
doses in which  it is too commonly given, being, in
my  opinion, improperly large, and more  likely to
produce  and increase disorder than to  remove  it.
   Some cautious practitioners look upon any quan-
tity  of calomel above four grains to be  large; but
I think the same of half  that dose.   Three, four,
five  grains, and  even more, once or  twice  a day,
for days or  weeks,  are doses now frequently order-
ed,* when hajf a grain at bed time, or a grain thre'e
or four times a week, where  this  article  agrees,
will effectually  promote healthy secretions in some
very bad  states of the assimilating viscera.   Then,

  * Since the  publication of the former  edition of this book, I
have had  reason to hope that this medicine is not  now  given so
incautiously as formerly; the above remarks, however, appear to
me still quite appropriate.
     It 
126
TREATMENT
  surely, fifteen or twenty times that  quantity of a
  substance which operates as a powerful  stimulant
  to all the digestive organs, and to every part of the
  body, cannot fail to be extremely injurious.   For-
  merly, a grain or two of calomel taken occasionally
  was considered sufficient to accomplish the ends for
  which, quantities,  so  excessive,  are  now recom-
  mended for a  long continuance.  This unhappy
 increase has arisen  from a common and  natural er-
 ror,  that of expecting an increased advantage from
 an augmented dose; it being either overlooked, or
 disregarded, that all medicinal substances are, for
 the most part, only relative agents  in the cure  of
 disease, and that it  is the dose which  almost inva-
 riably  determines  their specific  effect;  so that,
 though half a grain, or a grain of calomel, carefully
 repeated, is often powerfully curative, three, four,
 and more grains, administered at the same or short-
 er intervals, may be, and actually is, under ordinary
 circumstances, truly poisonous.*
   Perhaps it will be urged, that though a grain, or

  * It appears to us that the effects of no two medicines, having
the least resemblance to each other, can differ more than those of
calomel when given in large and in small doses.  In a large dose,
its operation is for the most part limited to  the alimentary canal,
where it acts as a prompt evacuant; but when  administered in
minute and often repeated doses, its chief impression is made up-
on other tissues than those with which it comes first in  contact,
and a general irritation is roused throughout the system, which
frequently proceeds to inflammation in the fibrous, cutaneous and
glandular structures.  Such a distinction we think of the highest
importance m a practical view___Edit. 
OF INDIGESTION.
127
 half a grain of calomel, administered three or "four
 times a week, will correct some  bad  disorders of
 the abdominal viscera, it requires much more ac-
 tive doses, or at least that the grain  should be fre-
 quently repeated, and longer continued, to remove
 a true liver complaint, that is, positive disease there.
 But this assertion is contrary to  daily  experience,
 and opposed to the opinions of some of the  most
 esteemed practitioners of .the present day.   I have
 seen the constitutions of such persons irrecoverably
 ruined by active mercurial courses;  but, in no in-
 stance, did I  ever witness  a cure effected by this
 treatment,   It is painful to recollect, that in  dis-
 organized livers,  mercury carried to  the extent of
 salivation  is  commonly regarded as  the sheet an-
 chor, the  fit  and only remedy;  for  I will venture
 to affirm, that the far greater number of such cases
 grow  materially  worse, rather than  better, from
 such use of it;  and  that this aggravation consists
 not merely in an increase of the patient's weakness
 and morbid irritability; but  that the existing  dis-
 ease in the liver  becomes more extensive and inve-
 terate.  Among  others, Mr Abernethy, Dr Black-
 all, Dr Farre and Dr James Hamilton, Jun., bear
 a strong and weighty  testimony against salivation
 under such circumstances, which it is highly desi-
 rable should  be universally attended to.*

  * If the opinions here set forth with so much force be correct,
 and that they are so we have not the least doubt, what incalcula-
ble mischief must result from a practice, founded upon the com-
 mon notion of the absolute necessity of a mercurial salivation for 
128
TREATMENT
  The first Of these able  writers  observes, "Per-
sons who are  salivated have, as far as I have re-
marked, the functions  of the liver and digestive or-
gans constantly disturbed by that process.  1  can-
not, therefore, but think that it is wrong to use
mercury in hepatic affections to  that extent which
would disorder the functions of the liver, if they
were previously healthy.  In the majority of cases,
the disorder has existed for a long time, and has be-
come habitual; therefore it is not likely to be cur-
ed  suddenly.   For this  reason, we should adapt
our treatment to the more  rational  expectation of
effecting a gradual recovery, than a sudden cure."*
  Dr. Blackall's general  habits  of discrimination
entitle his  sentiments, on a question like the  pre-
sent, to considerable  attention.    In speaking of
mercury, he says, "On the scirrhusortuberculated
state of the liver, a frequent cause of dropsy in this
country, I have seldom seen it make any impress-
ion.  It would be somewhat in  its favour to add,
that it is universally safe.   I dare not  assert  this,
since I have seen, in such instances, the mercurial
habit superadded by continued salivation, and then
the disorder become more complicated  and  more
speedily fatal."f
  Dr Farre, when treating of chronic enlargements
of the liver, observes, "Patients suffering under the

the  cure of what may be properly or improperly named liver com-'
plaint.—Edit.
  *  Surgical Observations, before cited, page 77.
  t  Observations on Dropsies, page 70. 
OF INDIGESTION.            129
      diseases above described, are not, as  far as I have
      observed, benefited  by the operation of mercury.
      Few medical men now attempt to cure, by these
      means, tumours, in the restricted sense of the word,
      at or near the surface of the body; but it is more
      especially true, that such efforts prove altogether
      fruitless, when directed to Ihe cure either  of  the
      tubera circumscripta, or dnrlsa;  for by  the time
      that the most careful examiner can distinguish them,
      the progress of the disease has  been already so con-
      siderable, that the mercurial action tends only to
      exhaust powers,  which art  will subsequently in
      vain attempt to restore."*
        Dr James Hamilton, Jun., also, has remarked it
      to be his  experience, that "the ordinary mode of
      exhibiting mercury for the cure of chronic hepati-
      tis, in this  country, not  unfrequently hurries on
      the disease, or, by  impairing the constitution, lays
      the foundation for paralytic affections;  and it may
      be truly affirmed, that-it thus often shortens life."f
■        There are even some Indian practitioners of re-
      putation, who, desirous of keeping in view the great
      difference existing between acute and chronic disease
      of the  liver, have objected to the free use of mer-
      cury in the latter, though none are more sensible
      of its superior efficacy in the former state of disease.
      Dr Dick, whom Dr  Saunders  calls "a gentleman
      high in the medical profession, in Bengal, and of
* Morbid anatomy of the Liver, page 21.
t Observations on the Use and Abuse of Mercury, page 79. 
 130               TREATMENT
                                                9
 much practice in Calcutta," says, " In recent attacks
 of liver complaints, after early bleeding, blistering,
 and the free use of laxatives, I never saw a case
 where  suppuration came on, if mercury were free-
 ly used, and continued till the  mouth was sore;
 and, if  I be not much mistaken, it is in such cases
 that it  has the best effects.  In chronic cases, there
 is no fever, but only<4rn obtuse pain in the side and
 shoulder, with a fulness in the side, and about the
 pit of the stomach, keeping up a  constant uneasi-
 ness,  mercury seems to me to have but  little good
 effects; when used freely, it removes the symp-
 toms  at the time, but they generally return as soon
 as the mercury is left  off."*
   Where an  alteration exists  in the structure  of
 the liver,  it appears to me, that if mercury is capa-
 ble of making any impression on the disease, it is
 when exhibited in small doses, at distant intervals.
 If a four-grain compound  calomel  pill, or five  or
 six grains of the blue  pill, given  every night for
 some  time, is not  able to reach the  complaint,
 this mineral will generally be  ineffectual, and  in
augmenting the quantity till salivation is  induced,
we shall only be distressing and weakening the pa-
tient,  without at all gaining upon his disease.  Per-
sons,  in such a case,  derive real advantage only
from small  undebilitating doses of mercury, that
do not very sensibly affect the general system; and
not from active, enervating courses, which disturb
* Saunders on the Liver. 
OF INDIGESTION.
131
every  healthy process.  "Though  mercury be  a
remedy of signal benefit in altering the condition of
action in the  extreme vessels, it requires  a very
cautious and  circumspect management.   It re-
quires to be slowly and gradually introduced  into
the system; for the foundation of change, and the
renewal of structure, depend upon a gradual, uni-
form, and extensive action  upon diseased parts ; ac-
tion, violent,  irregular, and partial, deranges gene-
ral health, but does not ordinarily affect the seat of
the disease."*
   Having considered it my  duty, in the former
part of this essay, to controvert some of Dr  Ayre's
opinions on the pathology of the prevailing " bilious"
disorders, it is with pleasure I remark, that  his ob-
scured pathological views do not lead to  error in
his practice; for  no  one  can administer calomel
more judiciously than he does.   He condemns its
use as an active purgative, and considers  that one
grain, or less, in twenty-four hours, is sufficient in
ordinary cases; and therefore I may now quote his
authority in support of the  rules here laid down for
the cautious exhibition of that medicine.
   Mercury must be considered an admirable me-
dicine on very many  occasions;  it has enjoyed the
confidence of the profession above three  hundred
years, and  Mr Pearson has justly remarked, that
"not one medicine  besides, derived from the ani-

  * Jackson's Outline of the History and Cure of Fever, paee
314.  (1798.)                                    & 
132
TREATMENT
mal, vegetable, or mineral kingdoms, has maintain-
ed its credit with men, actually employed in ex-
tensive practice,during a tenth part of that period;"
which is a sufficient proof  of its value.  But the
remarkable efficacy of this mineral in some cases
has led to its abuse; and this abuse seems to me so
general, and is ordinarily  followed  by effects so
permanent and destructive, as to call aloud for cor-
rection.   Indeed, it may with propriety be ques-
tioned, whether mercury, notwithstanding  its val-
uable curative  powers, has not been a source of
more real injury to the constitution of Englishmen,
than it  has, or can  be for  years to come, of good.
When I recall to recollection, the numerous  cases
of ruined health, from the excessive employment
of calomel, that has come  to my knowledge; and
reflect upon  the  additional proofs  of  its N ruinous
operation, which are still  daily presenting  them-
selves ; I cannot forbear regarding it, as commonly ex-
hibited, as a minute instrument of mighty mischief,
Which, instead  of conveying health and strength
to the diseased  and  enervated, is  made to scatter
widely  the seeds  of debility and  disease of the
worst kind, among persons of every age and condi-
tion.
  Perhaps it is not exceeding the truth to say that
the mercurial  oxides, especially calomel, are now
daily given for  the cure of  disorders and diseases of
every character, at every stage,  and under every
variety of circumstances; and,*vhatis fraught with
the weightiest evil, without care or discrimination. 
OF INDIGESTION.              133
It is not only the learned physician,  or the well-
educated  apothecary,  that  is   so extravagantly
fond of this substance; but if the surgeon's dispen-
ser,  or apprentice boy, is  called upon to take or to
prescribe medicine, it is calomel;  if the  country-
man wants physic, he, who  formerly found jalap
or salts to answer his purpose well, must now have
calomel; if the delicate  young lady needs a pill,
she  sends for  blue pill or calomel;—and  mothers,
whether  high or low, rich or poor, think  nothing
so good for their infants, as  calomel, which  they
pour in with as little consideration as rhubarb or
magnesia !*
   That so powerful  an article, taken  or adminis-
tered by all descriptions of persons, without care
or discrimination, as  to the  dose or disease, must
be attended with the most lamentable consequen-
ces,  no one can with truth deny; for this medicine
is not only a poison in excessive  doses, but, as  was
     »
  * Dr Blackall, of Exeter, also expresses himself very strongly
on this subject.  " Parents," says he, " have something to regret,
who are so perpetually giving calomel to  their children, without
any distinction or  care, as  a common domestic remedy.   And
it is difficult to conceive on what view of the subject even prac-
titioners proceed, who indulge in its  use with less scruple than
ever, with less attention as to dose, with less caution as to man-
agement, whilst they are observing and lamenting the daily in-
creasing  ravages  of hereditary  scrophulous disorders.  It can
hardly be, in the present day, from want of calomel, that such a
taint is propagated."  Indeed, the powerful and depressing effects
of calomel on  the whole nervous and  vascular systems, unequivo-
cally prove its poisonous qualities, and raise insuperable objections
to its frequent employment in free doses.
S 
134               TREATMENT
remarked above, even  in the ordinary doses of
two  and three  grains, it is an active stimulant to
the organs of digestion, and to the whole constitu-
tion.   There is not another article in the materia
medica,  in common use, which, so immediately
and permanently,  and to so great a degree, debili-
tates the stomach and bowels, as  calomel; yet this
is  the medicine which is sent for, and prescribed
on every occasion; the most trifling, as well as the
most urgent!
  Its  action on the nervous system  is demonstra-
tive of its being an article in its nature, inimical to
the human constitution: since what medicine be-
sides,  in frequent use, will excite feelings so  hor-
rible  and indescribable  as  calomel, and  other
preparations of mercury.   An excessively peevish,
irritable,  and despondent state of  mind, is a  well-
known consequence of a single  dose of this  sub-
stance.  Dr Falconer, of Bath, in a paper  where
he  forcibly animadverts  on its   abuse, observes,
" Among other ill  effects, it tends to produce tre-
mors,  paralysis, and  not unfrequently  incurable
mania.  I have myself seen  repeatedly, from this
cause, a kind of approximation to these maladies,
that embittered  life  to  such a degree, with a
shocking depression of spirits, and other nervous
agitations with which  it was accompanied, as to
make it more than commonly probable, that many
of the suicides which disgrace our country, were 
OF INDIGESTION.            135
occasioned  by the intolerable feelings that result
from such a state of the nervous system."*
  To set the poisonous qualities of mercury in  a
still clearer light, I would  here insert an extract
from Dr Hamilton's work on the abuse of mercu-
ry,  and also from Dr Alley's observations on the
hydrargyria, an eruptive disease which is some-
times  produced  by this mineral.  The former
gentleman says (page 24), " In  a lady (whom the
author attended some  years ago,  along with his
intelligent  friend Dr Farquharson), who had had
such  small doses of the blue pill, combined  with
opium, for three nights successively, that the whole
quantity amounted to  no more than five grains of
the mass;  salivation began  on the fifth day,  and
notwithstanding every  attention,  the tongue and
gums  became  swelled to  an  enormous degree;
bleeding ulcers  of the  mouth and fauces  took
place, and  such excessive irritability and debility
followed,  that for nearly a  whole month her life
was in the utmost jeopardy."  Dr Alley observes
(page 40),  that he has  seen the mercurial eruption
appear  over the entire body of a boy about seven
years old,  for whom but three  grains of calomel
had been prescribed, ineffectually, as a purgative.
  Some may think, that these instances prove only
idiosyncrasy in the individuals  affected, rendering
them in an extraordinary degree obnoxious to the

  * Transactions of the Medical Society of  London, vol. i. page
110. 
136
TREATMENT
pernicious  effects  of this single substance; that
such  peculiar dispositions, in respect of a variety
of really innocent  medicines, are every day met
with;  and, therefore, that  the  conclusions here
drawn, touching the deleterious properties of mer-
cury, are inconclusive.  But this cannot be consis-
tently affirmed, because the above instances of the
poisonous operation of mercury are not, like the
others alluded to, of rare occurrence; on the con-
trary, they are common, and are only  two out of
a vast number (not all equally bad)  that  have
been, and are still daily witnessed, many of which
are on record.
   Dr Hamilton, Jun. observes, "In several cases,
the author has decidedly  ascertained, that  ulcera-
tions of the villous coat of the intestines of infants
and  young children have  been induced  by the
frequent repetitions  of doses of calomel."   Does
not this fact call upon the mother to abandon its
use altogether in the disorders of her child, and to
leave the  administration of so dangerous a sub-
stance to  the medical  practitioner alone?  And
does it not demand more care and attention on our
part,  in prescribing this  oxide, than has been of
late observed?
   There is a circumstance  in  the operation of
mercury, which has hitherto been only hinted at
in these sheets, but which is of no small moment,
and ought  to engage the serious and attentive con-
sideration of the professionj as well as of all unpro-
fessional persons, who are in the habit of taking 
OF INDIGESTION.
137
mercury themselves, or of giving it to their chil-
dren,—I mean the  permanency of its  deleterious
effects.   An improper  or excessive use of the ge-
nerality  of medicines  is recovered  from without
difficulty; but it is  not so when the same error is
fallen into with the mercurial oxides.  They affect
the human constitution in a peculiar manner, tak-
ing, so to speak, an iron grasp of all its systems,
and penetrating even  to the  bones, when incau-
tiously  employed, by which they not only change
the healthy action of its vessels, and general struc-
ture,  but greatly impair and destroy its  energies;
so  that  their  abuse   is very  rarely overcome.
When the tone of the stomach, intestines, or ner-
vous  system generally, has been once injured by
this mineral, according to my  experience,  and I
have  paid considerable attention to the subject, it-
could afterwards seldom be restored.  I have seen
many persons  to whom it has been largely given
for the removal of  different complaints,  who, be-
fore they took it, knew what indigestion and ner-
vous depression meant, only by the description of
others ; but since they  have become experimentally
acquainted with both, for  they now constantly
complain of weakness  and irritability of the diges-
tive organs, of frequent lowness of spirits, and  im-
paired strength; of all which,  it appears  to  me,
they  will ever be sensible.   Instances of this de-
scription abound.  Many  of  the victims  to the
practice are aware of this origin of their permanent
indisposition, and many more, who  are at present 
138               TREATMENT
 unconscious of it, might here find, upon investiga-
 tion, a sufficient cause for their sleepless nights, and
 miserable days.
   It is to be lamented, that in our day, in severe
 cases, whether of disordered function,  or actual
 disease, which resist the usual remedies prescribed
 under clear indications, salivation is frequently re-
 sorted to from some vague  notion of  its exerting
 an admirable,  though  inexplicable  effect, when
 previous expedients fail; and thus, we have  often
 every benevolent feeling of  the mind  called into
 painful exercise, upon viewing patients already ex-
 hausted  by protracted  illness,   and whose  only
 chance of recovery depended upon great care, and
 a soothing tonic plan of treatment, groaning under
 the  accumulated miseries of an  active  course  of
 mercury, and by this for ever deprived of perfect
 restoration.  A  barbarous practice, the  inconsist-
 ency, folly, and injury of which, no words can suf-
 ficiently describe.   I will venture to  affirm  that
 the  man, who undergoes strong salivation  in a
 chronic complaint, is never the same person, as  to
strength and bodily feelings,  after it, as he was be-
fore*.
   Let it not be thought that  I am insensible to the
value of calomel, and other mercurial preparations,

  * Except in cases of  syphilis, to talk of the cure of a chronic
disease by salivation would be approaching to the  absurd; but it
is proper for me to remark, that it is  quite different if it be exci-
ted to check an acute disease, especially in warm climates ; here
it is often the only and the effectual remedy. 
OF INDIGESTION.
139
 or that it is my desire  to undervalue them.   By
 no  means.  I have already said sufficient respect-
 ing them, to prove the contrary; but it is too often
 forgotten  in medical practice,  that they are of a
 nature unfriendly to our bodies,  which is  a  well
 established fact;  and is, therefore, singly a proof
 that they  ought to be exhibited sparingly, and with
 great caution.  So  far from being  adapted to do-
 mestic use, calomel is a medicine which an unpro-
 fessional person should never presume to touch on
 his own opinion.  When administered with care
 and  judgment, it is  sometimes invaluable,  being
 capable of accomplishing the most desirable pur-
 poses ; but in the hands of the uneducated and un-
 skilful, it  becomes a deadly weapon.
  The combinations of mercury which my obser-
 vation leads me to regard as most useful in indiges-
 tion,  are  calomel,  with  tartarized antimony or
 James's powder, guaiacum, and opium ;  or  the
 blue pill,  with  James's powder, or  the compound
 powder of ipecacuanha.  A small pill of this de-
 scription may be  given every night, or every other
 night,  in  conjunction with any  other  medicine,
 excepting the mineral acids.
  Rhubarb and ipecacuanha are both of great ser-
 vice  in this complaint, especially in stomach affec-
 tions, or where the  biliary secretion is faulty or
 deficient.  They  are most efficacious  stomachics
and  aperients, and have appeared  to me to  render
altogether unnecessary any of the ordinary bitters
 and  aromatics,  as gentian,  cascarilla, &c.  in  the 
140
TREATMENT
  treatment of the great majority of the disorders of
  the assimilating organs.   Rhubarb is inferior only
  to mercury in its power of changing to a natural
  colour,  the very  discoloured evacuations so com-
  mon to such disorders—a change  which is always
  considered most desirable.   If it is not alone equal
  to this effect, a small dose of ipecacuanha, or tar-
 tarized antimony, added to it, will rarely fail so to
 increase the efficiency of the rhubarb, as to render
 it fully effectual.   The  value  of this  drug as a
 stomachic, and corrector of unhealthy motions,  is
 not sufficiently known and appreciated.   Mercury
 will often disappoint our  expectations in the  chro-
 nic affections of the liver and duodenum, in this
 country, when rhubarb is perfectly successful; the
 reason of which seems to  be, that we often require
 a medicine, which combines a tonic  or  stomachic
 property,  with  that of exerting a direct salutary
 action on the duodenum, and  the  biliary  ducts
 which terminate in  it.   Now mercury possesses
 only the latter power; but rhubarb unites the two.
 It has been judiciously observed,  that as "when a
 disordered state of the stomach is induced by the
 bile" (a circumstance seldom occurring), "no bit-
 ters will be useful; so, if an unhealthy  condition
 of the bile is induced by the stomach, no blue pill
 will avail;"*  but we then order  such bitters as
 rhubarb with great effect.

  * Abernethy:—Manuscript of Lectures delivered at Bartholo-
mew's Hospital. 
OF INDIGESTION              141
   If the virtues of rhubarb were duly prized, cal-
 omel and the blue pill would be in less use in the
 bilious  disorders  (as they  are called),  both  of
 adults and  infants.   In the intestinal irritations to
 which the  latter are subject, it is undoubtedly  far
 superior to calomel as a common  remedy.  The
 frequency of bowel complaints, among young chil-
 dren, is  evidently  connected with the weakness of
 the  intestinal canal at their early age ;* there is
 then a  deficiency of that  tone of energy in the
 bowels,  which, in  persons of  mature years, pre-
 vents the matters  received  into them from so soon
 suffering decomposition, and forming new and  vi-
 cious  combinations  that   irritate  and  disorder.
 Therefore,  we might  reasonably  suppose, that a
 medicine which readily promotes a healthy flow
 of bile,  and strengthens at the same  time that it
 evacuates, would be much better suited to the ten-
 der organs of a child than calomel, which, though
 often a valuable remedy, is of  a very debilitating,
 enervating nature.   It has  frequently been assert-
 ed, that children require large doses  of calomel,

  * A sentiment, quite opposite to this, has prevailed too much
 among some medical men; but the opinions of Magendie has
 every support  that can be desired  from reason, observation and
experiment; and now that we see active mercurials so constantly
and fearlessly  given to  infants, it may not be without effect  to
quote his words. " Instead," he says, " of considering the diges-
tive organs of a new-born child, or even those of one very young,
as being gifted with an  overplus of strength, we must view them
as much weaker than they will thence forward become."
                     Magendie's Physiology, vol. ii. p. 117.
T 
142
TREATMENT
 and bear them better than adults, which appears to
 me an erroneous and dangerous  sentiment.   The
 mucus and slime, that so thickly line their  intes-
 tines, may frequently render a moderate dose,  or
 doses, ineffectual, if uncombined with any  other
 aperient; but those  who, on this  account, augment
 the quantity, and repeat it, until it operates power-
 fully, pursue, to say the least, an  unsafe and  inju-
 dicious practice.   I repeat it, that there is no  truth
 in the practice of medicine more  apparent and cer-
 tain, than that the exhibition of large and repeated
 doses of mercury, for the cure of chronic maladies,
 is highly inimical to the constitution of all persons:
 they  ought, therefore,  to be  carefully avoided.
 None but cases of emergency justify their use in
 the bowel complaints of  children, the well known
 but neglected formula, that combines rhubarb with
 the sulphate of potash, being fully equal to the re-
 moval of most of the ordinary  disorders of  this
 class.*
   So  excellent a corrector is rhubarb of vitiated
 biliary secretions, and so  efficient a deobstruent,
 that I have known five grains taken once a day for
 a month, to cause nearly the entire absorption of a
 large sarcocele, dependent upon great constitution-
 al disorder.   The  bowels were always confined,
 the  motions discoloured,  the digestion  bad,  the

  *  About ten  or twelve  grains of rhubarb with eight or ten
grains of the super-sulphate of potash or sal polychrest form  a
mild and, generally, sufficiently efficient purgative for females and
persons in delicate health___Edit. 
OF INDIGESTION.
143
flesh reduced, the strength  greatly impaired; but
this small  quantity  of rhubarb, dissolved in water,
and taken  daily an hour before dinner, produced a
healthy flow of bile, with a sufficient and consist-
ent alvine  evacuation every day; relieving the pa-
tient, in every respect,  in a very unexpected and
gratifying  manner.   Within four  weeks, by  this
simple  means, the general strength was much re-
cruited, the appetite and flesh increased, the coun-
tenance  was   recovering  fast its wonted healthy
look, the local complaint  appeared one-third of its
former size, and had the  patient persevered  in the
use of the  rhubarb,  I am persuaded he would have
perfectly recovered  ; but, feeling himself so  much
better, he  neglected to  continue the remedy, and
consequently suffered a  relapse.  The blue pill
had been  previously given  in this case, for  some
weeks, by a distinguished  surgeon, but with results
far inferior to what was afterwards obtained by
the employment of the  rhubarb.*
   Ipecacuanha is another  article which operates di-
rectly, and in a very salutary way, on the internal
surface of  the stomach  and bowels, and through
them on the skin and biliary secretion, and which

  * Dr Marshall Hall thinks very favourably of the virtues of
rhubarb in the mimoses.  He  observes (page 94  of the second
edition of his  Essay), that he has found rhubarb and magnesia of
great use,  when there was "diarrhoea, with scanty, fetid, and
dark-coloured motions."—" Indeed, in all cases where the more
active purgative medicines have been employed in the commence-
ment, rhubarb appears to be particularly adapted,  from its tonic
properties, to complete the cure." 
144
TREATMENT
may be advantageously given to dyspeptics, either
alone, or combined with  rhubarb.  An excellent
tonic pill is made by uniting one grain of ipecac-
uanha with two grains of powdered rhubarb, and
two grains of soap;  to be taken, twice or thrice a
day.
   The tartarized antimony has an operation some-
what similar to that of ipecacuanha, and may often
be  used with  good effect, as an alterative.  This
medicine is very much used on the continent in
bilious and gastric disorders, and is there considered
fully capable of fulfilling the indications for which
mercury is so commonly ordered in this  country.
It will be  universally  acknowledged, I presume,
that this antimonial preparation is a remedy of no
mean power, in cleansing the primae viae, and pro-
moting  a soluble state of the bowels, while it ex-
erts a very salutary action on the whole cutaneous
surface; if, therefore, the properties of rhubarb, ei-
ther singly, or  combined with the emetic tartar,'
are really what they are  now described, we  may
conclude that they  may be often advantageously
employed as substitutes for mercury.
   The experiments of M. Magendie, and the usual
effects of emetic tartar upon the animal economy,
prove that this substance exerts a specific influence
on the  mucous  membranes of the alimentary canal
and lungs, by which we are frequently able to ac-
complish very desirable objects in morbid invasions
of these parts.   A similar influence over these or-
gans is possessed by ipecacuanha.   They both em- 
OF INDIGESTION.
145
inently promote expectoration, determine to the
skin, and  increase  the  peristaltic  action  of the
bowels; and if an animal is killed by an over-dose
of the former substance, death, in every instance,
is  found to be produced by violent inflammation
of the substance of the lungs, and of the mucous
membrane of the alimentary canal, extending from
the upper orifice of the stomach to the anus.  The
result  is still the same, if  the active principle of
the tartarized antimony be  thrown into the jugular
vein, or be simply absorbed from any part of the
body.* These phenomena account for the remark-
able power often  possessed by ipecacuanha  and
tartarized antimony over severe dysentery, and oth-
er unhealthy states of the bowels, which are too
generally  looked upon as  bilious: and they corro-
borate, at the  same time, the truth of the opinions
given in this essay respecting the nature of dysen-
tery, and of the other disorders which I believe to
be erroneously considered as essentially connected
with hepatic affection.  Dr Balfour's Illustrations
of the power  of Emetic Tartar  afford additional
evidence in favour of my views.
   In treating  those morbid affections of the diges-
tive organs which centre in the stomach, there are
two medicines which appear to me of great value.
One is, the nitric acid, which, though it made a
great noise at  one time in the cure df certain dis-

  * See M. Magendie's paper on the influence of Emetic Tartar
on man  and on animals. 
146
TREATMENT
eases, and not without reason,  seems now almost
entirely laid aside as an internal remedy; the other
is Brandish's caustic  alkali, a  medicine  but little
known,  even for what it was originally recom-
mended  (scrophula), and not at all in the maladies
under review.
   With  me, the nitric acid has repeatedly succeed-
ed in restoring the assimilating viscera to the per-
formance of their healthy functions, when mercu-
ry, in every form, was  either useless or  injurious,
and  where no benefit accrued from the employ-
ment of  other medicines.  It acts as a tonic and
alterative to the stomach and general habit, and is
best adapted to the  cure of that modification of in-
digestion in which  the stomach and duodenum
are chiefly concerned; where,  along with a  great
deal of debility, there is heat and pain in the epi-
gastric region, vomiting of food, want of appetite,
burning  in the  hands and feet, or  of the  general
surface, and especially when, with the existence of
these symptoms, mercury has been   freely thrown
in, under  the idea of there being a "liver com-
plaint."  It strengthens the stomach and duode-
num, and at the same time promotes their healthy
secretions; and from being powerfully refrigerant,
it proves a grateful, as well as an effectual  medicine,
when morbid heat, either partial or general, inter-
nal,  or external, is a troublesome  symptom.  In
slight and recent cases, it is of little  or no service;
the  severe and  tedious being those in  which its 
OF INDIGESTION.
147
powers are the most conspicuous, which renders it
the more valuable.
   It is too common a practice, in this form of the
complaint, to give large and frequent doses of cal-
omel as a purgative, and otherwise, when it never
fails to sink the strength, and to  excite the most
horrible  nervous sensations; here this acid will be
found strikingly restorative.   In the beginning, it
may be  taken in doses of six drops three times a
day, in a large wine-glassful  of distilled  water,
sweetened with sugar, if agreeable, and gradually
increased to eight or ten drops.
   The mineral acids are considered by competent
judges, as very useful in the advanced stages of in-
digestion ; and the nitric acid has also been praised
for its effects in chronic inflammation of the liver,
occurring in India; but it has never gained that
confidence among medical men, in the treatment
of these complaints, that it merits, though its ac-
tion on  the  skin, and  its combining  within itself
the properties of a tonic, alterative, and refrigerant,
clearly point it out as  a valuable  remedy.   Dr
Scott considered it, in most instances, far superior
to mercury in  the chronic hepatitis  of the East.
Its power in  correcting general  and local morbid
action is apparent, from  its effects in restoring the
constitution to a measure of its former health  and
strength, after it has been impaired by protracted
or severe courses of mercury; and in healing the
frightful ulcerations, so  often  the consequence of
such courses,  in which its  efficacy is scarcely 
148               TREATMENT
 equalled by any known medicine.  The proofs  of
 its value which were elicited during the controver-
 sy that took place some years since respecting its
 antisyphilitic powers, are sufficient to convince us,
 that it demands a greater share of attention  from
 the profession; and, from recent investigations into
 the nature of the ordinary syphilitic diseases, it  is
 no longer doubtful whether mercury, or the nitric
 acid, is in general the  safest and  best remedy in
 many of these disreputable complaints.
   I have known this acid, within a  week, to re-
 store,  in a  great measure, the  skin of dyspeptics
 from the dark, sallow hue, so common in such ca:
 ses, to its natural appearance.  In these patients,
 mercury had failed to  produce this, or any other
 beneficial change; but the alteration from the use
 of the acid  has  been so striking, as to excite the
 attention of their friends, and to be hailed by them
 as a certain sign of returning  health,  in  which
 they were not disappointed.
   The'alkali recommended by Mr Brandish, for
 the cure of  scrophula, is often of signal service in
 stomachic weakness  and disorder.  It is decidedly
 tonic to this part, and to the whole of the alimen-
 tary canal, and operates  as a permanent stimulus to
 the whole  system,  increasing  the appetite  and
 strength,  and exhilarating the spirits  in a remar-
 kable manner.   All the  alkalies are  occasionally
 found  of excellent use in these maladies; they are
efficacious correctors of morbid  acidity and have
other  effects on  the  stomach and bowels that are 
OF INDIGESTION,
149
very grateful and beneficial.   Reasoning from the
healthy changes wrought by it, I should say, the
alkaline solution of Brandish possesses every good
quality of the most powerful alkalies, and alkaline
earths, in common use, without  their objections;
as it possesses no deleterious property, and may be
continued for several  months in succession, not
only  without injury,  which  cannot always  be
avoided in prescribing the former, but with increas-
ed advantage, both  as a tonic and alterative.
   Like the  foregoing acid, it is of  most service
where the stomach is  the  chief seat of disorder;
but instead of being applicable to the cases where
heat is  a troublesome feeling, it is in those in
which coldness of  the feet, chilness of the general
surface, languor, fluttering at  the pit of the sto-
mach, and morbid acidity,  are the most prominent
symptoms, that it  displays its full  powers.  The
acid cools while it strengthens; this  gently stimu-
lates, and imparts an agreeable glow to the whole
frame.  It is likewise often of as much use in re-
cent, as in old and bad cases; and it favours the
natural action of the bowels.
   Some persons, who suffer from intestinal weak-
ness and disorder, or the second modification of in-
digestion, derive much and lasting advantage  from
this alkali; and, if I mistake not, it is much  more
exhilarating to the spirits, where it agrees,  more
strengthening also, and a more effectual alterative
than the acid.
   Every one will  acknowledge how requisite it i>
r 
150               TREATMENT

to preserve and increase the strength, in  advanced
stages of  these disorders,  for  which purpose it is
common to prescribe light bitters and aromatics,
in conjunction with other more efficient  measures;
on this account, the nitric acid, and the caustic al-
kali, lay strong  claim to general confidence, from
their being at once eminently tonic and alterative,
supporting the strength more  permanently, and in
a way far superior to bitters and  aromatics, at the
same time that they are capable of removing the
cause of the complaint.
  Many ladies in the higher circles,  who pass a
great part of their time in large  towns and cities,
in overheated rooms, and  who take little exercise,
from these causes become pale and weak, lose their
appetite, and are distressed with constipation of the
bowels, and many uncomfortable sensations about
the region of the stomach, particularly after eating;
to such, the alkaline solution will prove a mild,
but exhilarating and excellent tonic, that tends ef-
fectually to remove constipation, and to restore the
energies both of body and mind.
  At the commencement,  it should be given in
doses of a tea-spoonful  morning and evening, and
gradually increased to  two tea-spoonfuls.  Fresh
beer, and milk  and water, cover its taste  the best;
and whatever it is taken in,  not less than three-
fourths  of a tea-cupful should be used as  a vehicle,
since  the nature of the remedy requires  it to be
diluted  with a considerable quantity of some fluid.
If beer  be employed for this purpose, it should be 
OF INDIGESTION.
151
 quite fresh; and acids of every kind, with all sub-
 acid fruits, must be altogether  avoided, while tak-
 ing this alkali.*
   I would recommend this  alkali to the attention
 of persons who suffer from  a long residence in a
 warm  climate.  The chief  complaint of these in-
 valids is, a deficient and irregular action of the sto-
 mach and bowels, which they will find the  alka-
 line solution well adapted to remove.
   The employment of metallic tonics, and indeed
 of many other strengthening medicines, appears to
 be much feared by  some  late writers on indiges-
 tion,  but  without  sufficient  reason.   No  doubt
 many practitioners have done harm by their prema-
 ture  or  otherwise improper exhibition,  but  this
 does not in any degree militate against their utility.
 Their  use is frequently contraindicated  in the in-
 flammatory kind of habit or condition, mentioned
 at page 108, but in that of simple debility, describ-
 ed before it, they are generally  very useful,  and
 sometimes of more service than any other descrip-

  * As this alkaline solution is not generally sold by druggists,
 I have thought it advisable to mention, that it may be procured
 from Mr Watts, chemist, &c. 478, in the Strand.
  [An excellent alkaline solution may be conveniently prepared
 in the following manner.—Take, of hickory ashes,  one quart,
 soot about a tea-cupful; Pour on these a gallon of boiling water,
 and after it has stood  a day or two decant  or filter for use.  As
 this is probably  a much less concentrated  preparation than the
 one recommended in  the text, the dose may be at first a table-
 spoonful, and subsequently increased gradually to a  wine-glass
or tea-cupful three times a day, always diluted with at least an
equal quantity of water.—Edit.~] 
152
TREATMENT
 tion of medicines.   Of course there is a great dif-
 ference in cases, with respect to  the effect  result-
 ing  from the administration of particular metals.
 In some cases, iron will prove the most  available;
 in others, bismuth, and in a third class,  nitrate  of
 silver, or sulphate of zinc.   A recent author* has
 represented the nitrate of silver as being capable of
 superseding all the other metallic tonics, but in this,
 he is, in my opinion, quite mistaken.   I  believe it
 is a most serviceable remedy in many  cases of in-
 digestion, whose chief seat is in  the stomach, but
 in at least as many, both iron and bismuth  singly
 are more appropriate and useful.   It will not be
 expected that I should here  particularize the in-
 stances to which they  are most applicable, as they
 hardly admit of description;  it is sufficient for me
 to  say that they are those  of debility, unaccompa-
 nied with inflammatory action.   Bismuth is well
 known to be of superior value where pain in the
 stomach is a prominent symptom; and  I  have rea-
 son to think it is of equal service in many cases of
 dyspepsia, where there is  not much pain in that
 organ, but great local and general weakness.   The
 sub-carbonate of iron appears to me to be the best
 preparation of that  mineral,  and rhubarb, or  ipe-
 cacuan, with a minute dose  of aloes, may be ad-
 vantageously joined with it.f

  * Dr Johnson, on Morbid Sensibility of the Stomach. ■
  1  We have witnessed most admirable effects from  the nitrate
of silver in dyspeptic cases attended with great irritability of the 
OF INDIGESTION.             153
   I have not used the  quinine much in  dyspeptic
cases, but, nevertheless, consider it a very servicea-
able medicine.   Its efficacy is increased by uniting
it with rhubarb.
   The daily,  or almost  daily, exoneration of the
bowels is of essential importance in all disorders of
the  digestive viscera, but this  object must be ac-
complished by very mild aperient medicine, assist-
ed  by a diet of  a laxative nature.   Purging, espe-
cially with calomel, deserves severe reprobation for
the  reasons already advanced at  page   117.  It
commonly excites  the most distressing sensations
in the patient, and provokes every bad symptom.
As a gentle aperient, the  following pills may be
recommended for  their  mildness  and  efficacy.
Aperients,  given in the form  of pills, are  almost
always by far the most proper in indigestion.

     R  Extr: Colocynth: conip:
        Pil: Rhei comp: aa 9j
        Pulv: Ipecac: gr. vj
        01: Carui, gr. iv.
        Saponis Duri gr. xiv. M. ut fiant Pil: xij,  equibus
        suinantur una vel altera, omni nocte, hora decubitus.
stomach manifested by pain after eating, &c.  We have used it
after the following fornfula:
           Nitrate of Silver           gr.  x
           Pulv. Gum Aloes
                Ipecacuanha, of each     xvi
           Denarcotized Opium           iv.
  To be made into a mass by means of conserve, or other conve-
nient substance, and divided into twenty pills, one of which may
be taken two or three times a day.   Edit. 
154               TREATMENT
   Or these,
     R  Aloes Spicat: Bj
        Scammoniae Pulv: gr. xv.
        Extr: Rhei 3ss
        Bacc: Capsici pulv: gr. vj
        01: Caryophill: gtt. v. Ft. pilulae xv. quarum sumat una
        vel altera, hora somni, pro re nata.

   Common saline purgatives are almost altogether
 inadmissible in these complaints.   The natural sa-
 line waters of Cheltenham and Leamington  are,
 however, unquestionably of great utility in many
 of the disorders now treated of, but I have reason
 to coincide in the truth of the opinions long since
 delivered,  by Dr Saunders,  that the valetudinary
 visitors to  those places may  usefully  be divided
 into three classes, viz.  those who gain  unequalled
 benefit from the waters; those who obtain neither
 good nor harm; and those who suffer injury.  The
 latter class are composed, principally, of persons
 who labour under stomach  disorder, in every  in-
 stance of  which we may with certainty predict,
 that active aperients will be found extremely  in-
jurious ; and this is, for obvious reasons, especially
 the case, if the medicine be suspended in a large
 quantity of water.   Therefore, those suffering from
 abdominal disorder, who resort in search of health
 to the wells of those elegant and delightful towns,
 should be careful to ascertain the nature of their
 symptoms  before they  venture on drinking  the
 purging waters, lest they return worse than they
 went. 
               OF  INDIGESTION.            155

  As active purging has been so general a practice
in these maladies, and large doses of calomel are
thought particularly efficacious, I would here re-
mark, how contrary this mode of proceeding is to
that of Mr Abernethy, and Dr Hamilton,  Sen.
whose writings are so much admired by the profes-
sion.   Dr  Hamilton  prescribes  purgative  medi-
cines to excite, but  not to stimulate the bowels, and
he  combines  with them,  generally,  unirritating
doses of mercury.   Mr Abernethy's practice is still
more gentle; he says—"As I have found the leni-
ent plan of treatment (that of  exciting the peris-
taltic action of the bowels,  so as to induce them to
clear out  the  whole of the residue of the food,
without irritating them, so as to  produce what is
ordinarily called purging),  particularly successful,
I have rarely deviated from it."  (page 70).
  In respect to the adaptation of the foregoing re-
medies  to the particular forms of indigestion de-
scribed in the second chapter, I would observe, that
in stomach affections, the pills of rhubarb and ipe-
cacuan, with soap;  iron in some form; bismuth;
the alkaline solution; and nitric acid, have appear-
ed to me the most efficacious medicines to be used
in the day, with which, a mild mercurial alterative
may sometimes  be  given  at night  with no small
advantage.  Mercury however, in any form, is less
called for in this modification of the malady  than
in the second  and third varieties (page 100); and
often cannot here be borne at all.  When required,
the blue pill, combined  with compound powder of 
156
TREYTMENT
ipecacuan, or rhubarb, is the best  mode of  giving
it.   I have witnessed the most satisfactory changes
from using  the rhubarb pill,  mentioned at page
144, during  the day, with the following pill every
night, or every second night :*—

     R  Pil: Hydrargyri, gr. iv.
       Pulv: Ipecac:  Comp: gr. i. M. ft.
     Pilula.

   When the small intestines seem greatly affected,
mercurial preparations are generally very servicea-
ble,  and the  following has appeared to me the most
efficacious  combination.   If much pain be present,
the  quantity of opium  ought  to be increased a
little, and should the symptoms be urgent, the pill
may be ordered twice a day in the commencement
and  afterwards  once a day, or once in two days:—

     R  Hydrarg:  Submuriatis, gr. xij.
       Antimon:  Tartariz: gr. i.
       Guaiaci Gum:  Pulv: gr. xxiv.
       Pulv: Opii, gr. i.
       Conf: Aromat: q.  s. ft. Pil: xij.

   Together with the  mercurial, the tartarized an-
timony in solution; the rhubarb pills; quinine; or
compound  decoction  of sarsaparilla, may be  given
during the day.  The alkaline infusion  01* sarsapa-

  * Combined,  of  course, with a  proper diet  and regimen.
These points I do not advert to here, as I shall presently notice
them  somewhat at length. 
                 OF  INDIGESTION.              157

rilla, as well as the ordinary  decoction, I have
known of great service in this form of the com-
plaint.*  The  former  preparation  appears most
applicable and useful when considerable debility is
present, or where  the stomach, as well as the in-
testines, are much weakened and disordered,  and
especially if morbid acidity of the stomach is a pro-
minent symptom.   Sarsaparilla is a medicine of
superior utility in  plethoric habits, and where  the
excited form of indigestion (page 109) appears.
   In the present variety of dyspepsia, aperients are
generally indicated,  on account of the  constipated
state of the bowels usually existing.   The object
in employing aperient medicine should be to gain
a comfortable exoneration of the bowels daily, or
nearly so, with as  little irritation as possible, as al-
ready remarked.  In every respect  we  ought to
imitate the healthy operations of nature; and, as in
this particular,  they  are at the same  time efficient,
and not only unirritating, but accompanied with
great relief, so should the discharges procured by
medicine be  as nearly as may be attended with
similar results.   But these results can never be in-
sured, in  chronic diseases, by  purging.  Patients

  •* This alkaline  solution may be prepared  in  the following
manner:
  Take of sarsaparilla root sliced and bruised, four or six ounces;
liquorice root sliced, one ounce; lime water, four pints.  Let
these digest together in a  covered vessel for twenty-four hours,
during which time they should be frequently stirred and shaken.
When strained it is fit for use.  About a pint of this, divided into
three equal doses, may be taken daily.— Edit.
     V 
158
TREATMENT
can hardly have a milder aperient pill than  that
prescribed at page 153.   If they do  not suit the
patient's habit, the compound decoction of aloes, or
a seidlitz power in warm water, may perhaps be
found suitable.  These are mild aperients of the
very best description.
  It is  in derangement of the biliary organs,  that
such mild aperients as are presented in the natural
saline waters of Cheltenham and Leamington of-
ten prove of the utmost service; and with these,
which are taken every morning, or  every other
morning, a mercurial pill at night is conjoined with
the best effects.  It must not  be forgotten, how-
ever,  that tonics are  in this  form of  the disorder
also very generally indicated; the most appropriate
are rhubarb, alkaline  solution and quinine.
  The nitro-muriatic acid bath, recommended by
the late Dr Scott, is,  in  my opinion, of no small
advantage in some severe affections of  the liver and
small intestines.  Sometime ago I met with a most
severe case, that demonstrated its usefulness in a
very gratifying manner, for the patient quite reco-
vered from a most lamentable condition by its em-
ployment alone.  In this  example, ulceration, or a
state  nearly approaching  to it, seemed  to have
taken place  in the alimentary canal, for the patient
had ulceration in the  throat, with extreme tender-
ness and pain in particular parts of the abdomen,
and occasional discharges of blood and pus.
  When indigestion depends on the existence of a
contraction in the rectum, the principal means of 
                  OF INDIGESTION.             159

relief is the passing of a rectum bougie every other
day.*   An alterative pill every other night may,
perhaps, be indicated at the same time, and some-
times the tonic pill of  rhubarb and ipecacuan,  or
the alkaline infusion of sarsaparilla.   To procure a
free evacuation of the bowels in this modification
of the disorder, the use of the clyster machine is
often of eminent service.   The patient may throw
up a pint of thin gruel, or linseed tea, every morn-
ing, or four times a  week, with the view of evacu-
ating the lower bowels, without irritation.   If there
exists much irritability in the  rectum,  this injec-
tion will be found  very soothing and useful.   In
strictures of the rectum, some surgeons recommend
the  bowels to be rather freely acted on by mild
aperients, during the process of cure, but accord-
ing to my observation, this is not an eligible plan,
on account of the irritation it occasions.f

  * For the management of this part of the cure, I must refer to
books on Surgery.   Some useful hints connected with this point
will, however, be found in my volume on Domestic Medicine al-
ready referred to.
  t I ought to have remarked in the second  chapter, that wfyen
stricture in the rectum has existed for a long time, and the con-
traction has become very  considerable, the patient generally  la-
bours under peculiar nervous depression and agitation, recurring
in paroxysms, or fits, so that he will be for a little while tolerably
free from any unusual degree  of nervousness, and  then it will
suddenly attack him with great, and sometimes an overwhelming
force.  I have lately met with two or three patients in which this
distressing feature of the disease was very strongly marked, and
that it entirely depended on the existence of a close  contraction
of the lower intestine was evident, from its having been quite re-
moved by the use of the bougie alone.  One of these patients used 
160
TREATMENT
    In regard to the treatment of local pain and un-
 easiness, so common in indigestion, I would observe
 that  in my practice, general remedies directed  to
 the  fulfilment of the indications, noticed at page
 117, have almost uniformly been far the most ef-
 fectual.   When pain and soreness exist at the  pit
 of the stomach,  or in  the side,  or chest, &c. it is
 very common to recommend  the  application  of
 leeches, or the cupping glasses,  with or without a
 blister; and in rather full habits, bleeding from the
 arm is not unfrequently practised for the removal
 of these symptoms; but I am firmly persuaded that
 such  measures  are  not  generally the best,  even
 when this kind  of inconvenience is  considerable,
 and also that they are very often attended with in-
 jurious consequences.   My reasons for this opinion
 will  be given in the next chapter, when  referring
 to  the treatment of  indigestion  associated with  a
 fulness of blood in the head.  Very  often have  I
 seen such symptoms  quite removed, even in full
 habits, by the proper employment of the foregoing
 remedies, after blood-letting and blistering, in va-
 rious forms, had been used with  only a partial and
 temporary benefit at the best, always followed by

 to be attacked by these nervous fits at night, generally after the
 candle was put out in his bed-chamber, when they would come
 on accompanied with so great a sense of oppression about the
chest,  and of suffocation, as would compel him instantly to rise
from his bed and seek for a light, which would have the effect of
relieving him more  or less completely.  Before these attacks
commenced, this person was freer than most men from a sense of
nervousness. 
OF  INDIGESTION.
161
some  degree of  injury.*   The  local applications
I  would advise  in such  cases are warm  fomenta-
tions two or three times a day, and  when the ten-
derness of the part will admit of it, frequent gen-
tle friction with the soap liniment.
   In regard to the particular treatment applicable
to  the inflammatory or excited form of dyspepsia,
mentioned at page 108, and to that in which  sim-
ple debility is manifested,  1 have only to remark
here,  that in  the former case, we must not  in the
beginning attempt the  use  of  direct tonics,  but
trust  to the efficacy of mercurial alteratives  with
sarsaparilla, tartarized antimony, and rhubarb and
ipecacuanha,  joined with  a  very mild  diet,  and
much exposure  to country air, to improve the pa-

  * The superior value of the proper employment of alterative
medicine, with a correct diet and regimen, in  these cases, was
particularly exemplified in the case of a dissenting clergyman,
whom  I lately visited.  This gentleman is  decidedly of a full
habit, and has been  labouring under indigestion for three or four
years, accompanied with almost constant pain across the stomach,
which frequently attacked also the side and chest during the win-
ter months.  He had been often  bled, leeched  and blistered, at
intervals, for the removal of these symptoms, without any satis-
factory or permanent benefit, although  medicines were  likewise
given internally at  the same time.  It appeared to  me  that the
principles of preserving the strength unimpaired, and of soothing
local irritation, had not been sufficiently attended to in this case,
and therefore  the patient gained  no real and lasting advantage
from the treatment pursued under more than two or three differ-
ent practitioners ; and if the results of another mode of proceeding,
founded on the principles above inculcated, may be considered as
 conclusive on the subject, this was a correct view of the state of
the case, for the patient perfectly recovered in three months from
the adoption of this  method. 
162
TREATMENT
 tient's  condition, and so to augment his strength
 that he may be able to bear quinine, bismuth, iron,
 &c. and have his recovery thereby established.*
   Diet has always been considered a subject of no
 small moment in the treatment of the present com-
 plaint.   The grand maxim with regard to it is, to
 eat and drink sparingly, at stated intervals, and of
 food the most digestible, and that agrees best with
 the individual.   No bilious  or  dyspeptic  person
 should  eat more than four times a day, and those
 periods ought to be, as near as possible, at regular
 intervals of four or five  hours;  say eight, twelve,
 four, and nine o'clock.  It is a common, but very
 erroneous and injurious supposition, that such pa-
 tients  ought  to  eat little and often; because by
 taking food in this way,  scarcely two hours elapse
 throughout the whole day  without something be-
 ing swallowed, by which means the stomach has
 no  time for the perfect digestion of the previous
 meal, and is  kept in a constant  state of irritation
 and disorder.   No rest is given to it, and therefore
 instead  of gaining strength, it loses it.   It may be
 safely received as a general rule, that food  should
 not be taken in the intervals of meals, and a want
 of this kind will seldom  be felt by those who ad-
here to  the hours just'mentioned.f

  * See the directions at page 406 of  my Modern Domestic Me-
 dicine.
  t This testimony is at direct variance with the opinion express-
ed in the  often repeated saying of the late Dr Rush, that " the
stomach, like a school boy, was always in mischief when idle.—
Edit. 
OF INDIGESTION.
163
   Where a considerable degree of  hardness exists
in the pulse, with much feverish heat generally,
an  inflammatory  tendency exists  in the system,
when a diet wholly vegetable, and even a total ab-
stinence from wine, must, for the most part, be ob-
served, and is strikingly beneficial.   The best ve-
getables are, turnips, brocoli, French beans, aspara-
gus, and potatoes; no other should be taken.   In
this state of the complaint, light, plain puddings
are allowable, but pastry is altogether inadmissible
in every description of case.
   In the greater number of instances, however,
the hardness of pulse just noticed is not present,
and then an animal diet is the best.  Mutton, ve-
nison, lamb, and tender beef, are the most whole-
some and digestible of  meats; and  next to these
come partridge, pheasant, fowl, chicken, and hare.
Of either of these, a small quantity roasted  and
little done may be taken at dinner, it being seldom
proper for a dyspeptic to eat animal food more  than
once a day.  The flesh  of full grown animals  is to
be preferred to that of young ones, and  I know no
exception to this rule.  Some medical men, how-
ever, have gone so  far,  and erred so widely, as to
assert the reverse of this to be the truth, but they
are blind leaders.  Preference  has, indeed, been
given to veal  over beef, by some physicians of great
judgment, who agree as to the superior digestibi-
lity of  the flesh of full  grown animals in general;
but, according to my experience, it is a preference
that ought not to be maintained, for I have found 
 164               TREATMENT
               i
 few articles of diet more indigestible and irritating
 than veal, and, therefore, in my practice, it is uni-
 versally forbidden to those of weak digestive  pow-
 ers.   Full grown tender mutton and venison are
 unquestionably the most digestible, and best of all
 meats.  All salted and dried meats is inadmissible,
 and  boiled fresh meat of any kind is not quite free
 from objection in  severe indigestion.   Excepting
 oysters in their natural  state, every sort of fish  is
 bad  in the present disorder, and must be altogether
 avoided, at least in the beginning.
   In common language, fish  is called a light arti-
 cle of  diet, but it is an error to suppose  it to be
 easy of digestion.   It is  given to patients convales-
 cent from acute diseases, in preference to flesh, not
because it admits of  a more ready solution in the
stomach,  but on account of its exciting less heat
and  fever.  Both vegetable and animal food done
a second time is very objectionable, and, therefore,
hashes, harricoes, stews, and the like, must make
no part of the dyspeptic's cookery.  In all cases,
plain biscuit is preferable to white bread, but well-
made brown bread is better than either, when the
bowels are confined, and there is strength of sto-
mach sufficient to take it.
   Generally speaking, all slop fluids are much more
difficult of digestion  than solids, and a  weakened
stomach is quite incapable of digesting even the
ordinary  quantity which is taken in health  with
satisfaction and benefit.  It is for this reason that
broths and soups are  injurious to most  dyspeptics, 
N
                OF INDIGESTION.             165

and that drinking too freely of soup, tea, and the
like, will sometimes  throw such  persons  almost
into agonies.  They should therefore be abstained
from as much as possible.
  Port wine  is almost invariably hurtful,  but a
little  foreign white wine  taken after  dinner, is
sometimes useful.   The best  wine is old sherry,
but with some  patients good  claret answers very
well.   If wine cannot be taken, a little weak bran-
dy  and water may sometimes  be tried, but it is
what I should seldom recommend, and ought in
all cases to be changed for wine or beer, as soon "as
possible.  Mild home-brewed beer generally agrees
better  than  wine or brandy.   It ought not to be
strong ale, which is at all times difficult of  diges-
tion ; neither should it be poor weak beer, but that
of a moderate strength or  body.  There exists a
general prejudice  against the use of beer in indi-
gestion and bilious complaints, but I cannot help
thinking it is, in the majority of instances, without
substantial  foundation.  If patients are properly
treated, they will,  in  general,  find good beer to
agree very well.   To  quench  thirst  in the  inter-
vals of meals, nothing can be found equal to soda
water: it is  exceedingly grateful and effectual, and
that made with  the soda powders appears to me to
be much better  than the bottled water.*  For the

  * The best soda water is made with toast and water, instead
of plain water.  The toast has so much of a softening  quality,
that it imparts an additional spirit to the soda water prepared in
     W 
166
TREATMENT
partial  or general heat  and feverishness so often
present in this malady, it is an appropriate and effi-
cient draught, and  in the  summer is particularly
useful.   It should then be constantly drank in  pre-
ference to any other liquid.  Well made toast and
water is likewise a proper drink, and so is lemon
or orange tea, that is, lemon or orange-peel infused
in boiling water;  The latter possesses a stimulus
which is very useful  to some disordered stomachs.
   Tea, cocoa, or thin chocolate, made with water,
may be taken for breakfast, and at tea-time; with
biscuit, bread and butter, or dry toast.   Rolls, and
all  other spongy bread,  are bad; and coffee must
be wholly forsaken.   One fresh lightly-boiled egg
may be taken at breakfast, if it agrees.   Whatever
liquid is taken in the morning and evening, the pa-
tient  should not exceed a common breakfast-cupful
at each time.
   The  supper should be very light, and small in
quantity, consisting of a roasted apple, or potatoe,
or an egg lightly boiled, with a biscuit, or some
bread and butter.   In summer, a little good ripe
fruit in season will make a very wholesome supper.
A small tumbler full of mild beer may likewise be
allowed if it agrees, and the portion of food  then
taken be solid.   Some dyspeptics find well-made
grit or oatmeal gruel, with or without milk, to
form  an agreeable and wholesome supper.

this manner, and renders it  both more agreeable to the palate, and
more grateful to the stomach.  In winter, the water  should be
lukewarm. 
OF INDIGESTION.
167
   The food should be well masticated, and quiet-
 ness, with rest, observed for at least half an hour
 after each meal.  Digestion almost invariably pro-
 ceeds much better in a sitting, than in a recumbent
 position.
   The Scotch oat-cake is wholesome, and very easy
 of digestion, and many dyspeptics will find great
 advantage from frequently eating it (when they can
 get it) instead of bread.  Its aperient qualities are
 an additional recommendation.
   Dr Johnson has strongly  recommended (in his
 Essay  on  Morbid Sensibility  of the Stomach)
 water gruel as a very nutritious unirritating species
 of food for dyspeptics, and he seems to think it uni-
 versally of superior value in such cases.  In this
 advice it appears to me that he has not sufficiently
 considered  the difference existing between that
 form of indigestion (see page 108) in which a state
 of general excitement or inflammatory tendency is
 conspicuous, and that where debility exists without
 this tendency.   In the former cases, no doubt such
 gruel is a most useful food, but in the latter, which
 are by far the most  common  examples, it is not
 found suitable, on  account of its speedily acidify-
 ing,  and  thus proving oppressive and irritating.
 In these latter cases, gruel made  with a large pro-
 portion of good beer, instead of water, will be found
particularly  easy of digestion, and very nutritious.
For the majority of dyspeptics, it forms the most
wholesome article for supper that I am acquainted
 with. 
168
TREATMENT
   As, contrary it would seem to the sentiments of
professional men in general, I consider good malt
liquor the most friendly to the human constitution
of all fermented liquors,  perhaps I ought here  to
remark farther on  this point, that it is the base
quality of that article, as  now generally or univer-
sally sold, that has brought it into so much disre-
pute.   No man  can answer for  the effects of the
stuff usually sold as beer; but good home-brewed
beer of a moderate strength will be found to  suit
the majority of dyspeptics uncommonly well, agree-
ing better than wine, since it is far less disposed to
acescency, and better fitted  to act as a stomachic,
and therefore to invigorate both the digestive organs,
and the constitution at large.*
   If malt liquor will not agree,  I  recommend the
use of soda water, or toast and water, made as above
directed.
   A correct Regimen is of the utmost consequence,
and a strict and constant attention  to it is absolute-
ly necessary in order to obtain a perfect cure.  All
sedentary occupations must be forsaken as much
as possible, and if they can be entirely given up,
the prospect of complete relief will be far greater.
Indeed, considerable and permanent advantage can
only be obtained, in the majority of instances, by
relinquishing in a very great measure  all such en-

  * The infusion of hop, contained  in all good beer, is a very
useful bitter tonic, that tends to strengthen the stomach, and in-
vigorate the whole frame. 
OF INDIGESTION.
169
gagements,  and quitting the confined atmosphere
and  late hours of the crowded city, for the pure,
dry, bracing air of the country, with its early ris-
ing,  and active  exercises.   It is the common neg-
lect  of such a regimen that makes indigestion so
rarely and  imperfectly cured; for  where  a high
state of chronic debility,  and nervous  irritability,
has  been induced by long continued exposure to
the  depressing effects of confinement, and  intense
application  to business, literary pursuits, or plea-
sure, no medicine, nor even diet, can be employed
with much effect as a substitute  for country air,
daily active exercises, cheerful company, and early
rising.   The patient should quit his bed  by six
o'clock in the morning in the summer, and by se-
ven  in the winter;  and after  partaking of  a light
breakfast, take exercise freely for two or  three
hours  before dinner.  After  dinner, gentle  exer-
cise should be again taken for an hour or two.  Of
all exercises, those of walking and riding on horse-
back  are the most  beneficial, and, where  the  pa-
tient's means and strength allow, they should be
used alternately; but when the strength is much
reduced, horse  exercise is almost  invariably  to be
preferred.
   The power of daily active exercise* in the open

   * The following observations respecting  the value of exercise,
 in my  Treatise on  the Art of Prolonging Life, refer to a point
 which appears to me so worthy of attention, both from the public
 and  profession at large,  that I would beg leave to insert them
 here.__" I  would here bespeak the reader's attention to the dif- 
170
TREATMENT
 air in curing indigestion is very great, indeed such
 as would appear to the  majority of persons  almost
 incredible;  and, therefore, it  cannot  be too  much

 ferent sections of this chapter, and more especially to that which
 adverts to the excellent and various uses of exercise; being con-
 vinced that while all these subjects are but too little attended to
 and their value too imperfectly known, that of exercise demands
 particular regard, on account of its remarkable  effects on health
 and longevity.  To all invalids it is a subject of the highest mo-
 ment.   None will accuse me of undervaluing the advantages re-
 sulting from attention  to diet,  in the  cure of disease; but it is
 proper for me to state, that there appears to me one grand point
 of superiority which exercise in the open air possesses, in this res-
 pect, over even diet, which is, that it is capable of exerting a direct
 and positive curative effect, whileithe  effects of diet, in the same
 circumstances, are rather negative than positive.   In using pro-
 per food, when  afflicted with any corporeal malady, we cut off a
 principal source of irritation, and take  an effectual means of nour-
 ishing and strengthening the body, and thereby of assisting nature
 in its  efforts to free  the constitution from an unwelcome and op-
 pressive visitor; but beyond this the virtues of suitable food can
 scarcely be said to extend.  On the other hand, exercise has often
 a direct and powerfully curative effect, from its accelerating and
 equalizing the circulation, when tardy and irregular, from its also
 strengthening the vessels and nerves, facilitating the excretions
 and greatly improving the tone of the digestive organs.   From a
 consideration of these facts, we see the reason why a correct diet
 should often fail to do little  more than  preserve the  patient from
 getting worse, and that an efficient regimen is found absolutely
 necessary to produce much  positive amendment, or to perform a
 sound and lasting cure.   To illustrate this subject still further,
 we may advert to the case of a person suffering under severe chro-
 nic gout, or an  aggravated attack of indigestion, and we shall of-
ten find, that if such patients attentively observe a suitable diet,
they gain much advantage : but if they go  a little  beyond this at-
tention  to diet, supposing it is even combined with  skilful medi-
cal treatment, the gouty man, in numerous instances, is still very
liable  to frequent  fits of his  tormenting disease, and will not
unfrequently find himself getting more feeble, and the fits to gain 
OF  INDIGESTION.
171
insisted upon by the physician, as an indispensable
requisite to  insure perfect freedom from this com-
plaint.   Many medical men lay great stress upon
attention to  diet, as necessary in the treatment  of
this and other chronic diseases, and so it is; no one
acquainted with my writings will  suspect me  of
undervaluing it, but I am fully persuaded that  re-
gimen  is of still greater moment, and experience
proves,  that exercise is the most essential  branch
of  the athletic  regimen.  1* am disposed to think
that exercise is  not so strenuously recommended as
it ought to be, or its virtues so fully known  as they
deserve.
   Cheerful  company and enlivening conversation,

an  increasing power over him; while the dyspeptic experiences
weakness of stomach,  and general debility  remaining, with a
liability to a renewal of his disorder, on the  operation of slight
causes.   But should these patients become convinced of the value
of regimen, in  the sense now attached to it, and  enter into its
adoption  with spirit and perseverance, they very soon discover
that they are using means which have a superior and remarkable
power in  resolving obstructions, and in so facilitating and regulat-
ing all the secretions, and imparting an increase of tone to every
function of the  body, as to afford them a most flattering prospect
of being at length enabled entirely to conquer their disease.   Un-
der the operation of this regimen, the gouty sufferer  finds his
crippled limbs to become free and strong, his digestive powers to
be augmented,  and  his spirits  surprisingly exhilarated; and the
dyspeptic bilious subject experiences an equally beneficial change
in  the increased tone of his  stomach and bowels,  in the  more
healthy secretion of bile, the keenness of his appetite, and the
greater quantity of food  he can take, not only with a relish, but
without the uneasiness he before felt severely from indulging in a
much smaller quantity; effects which both  have found diet and
medicine could only partially produce." 
172              TREATMENT
with  proper clothing, are also  subjects of  impor-
tance.  The feet and chest should be kept especi-
ally warm, and if the debility be great, with a con-
siderable reduction of the natural heat of the body,
a flannel waistcoat worn next the skin during the
colder months will  be very  proper.   The  bed
clothes should be no  more than sufficient to  keep
the patient comfortably warm, and a mattress is
always preferable to a feather-bed.
   The value of a pure air in dyspeptic cases being
universally known, need  not be insisted on.  A
dry bracing air is generally required.
   As an auxiliary remedy, the  tepid bath merits
attention.  Some people suppose the warm bath to
be relaxing, but when properly used in the present
disorder, it generally proves very refreshing and
strengthening.  From 90 to 95 degrees is the best
range of heat for  dyspeptics, and the proper time
for resorting to the bath is in the morning, between
breakfast and dinner; the patient using it three or
four times a week, and remaining in it from twenty
to thirty minutes, according to his feelings, which
ought to be comfortable on his  coming out.  A
gentle walk or ride  should  follow  it  when the
weather permits.
   Where the warm bath cannot be conveniently
obtained, or it fails to be beneficial, tepid sponging
should be substituted.  The whole surface of the
body  should be sponged regularly every morning
with tepid water, the patient rubbing himself dry 
OF INDIGESTION.
173
after it with a coarse towel.  This is a very re-
freshing and salutary practice.
   The internal use of the warm waters of Buxton
and Bath are occasionally of great service.   They
relieve  pain and uneasiness in the stomach, and
often eminently promote digestion.  The late Dr
Saunders of London thought highly of tepid  water
as a remedy in this  complaint, and  questioned
whether drinking  the  water  at the celebrated
springs  of Buxton would, upon  trial, be  found
more efficacious in  these complaints, than the re-
gular use of the same quantity of any pure  water
heated to the same temperature.   Those who wish
to try it may take a small tumbler-full after dinner
and supper.  For pain  or uneasiness in the sto-
mach,  occurring after dinner, or any other solid
meal, the addition of a tea-spoonful or a tea-spoon-
ful and  a half of strong tincture of ginger to the
tepid water will prove of great benefit.
x 
174
                  CHAPTER V.

 OF TIC DOULOUREUX, NERVOUS DISORDER, &c. AS CONNECTED
                 WITH INDIGESTION.


 No  enlightened practitioner  can long attentively
 pursue the study and practice of medicine, without
 being impressed with the great and extensive influ-
 ence exercised by the digestive functions over other
 parts of the human frame; indeed, so marked and
 important is this influence, that there is scarcely a
 disease, not originating in mechanical injury, which
 does not own derangement of these functions as its
 foundation,  either in its origin  or continuance.
 Commonly it is the sole  foundation both of acute
 and chronic complaints; while the smaller number
 which have had another origin, are still so greatly
 dependent on the integrity of these functions  for
 their perfect removal, that when this fact is over-
looked, it often becomes the source of a protracted
cure.  If therefore we were  about  to  treat, as a
late  author  (Dr Uwins) has proposed to himself,
of the diseases either directly or indirectly con-
nected with indigestion, we should be proposing to
ourselves  a most arduous  task, as  it would in re-
ality be to treat of almost  all the maladies incident 
OF TIC DOULOUREUX.
175
to the body.   It is consequently not my intention
to enter here on any such undertaking, but I have
a few remarks to offer on the subjects of tic dou-
loureux, nervous disorder, gout, and fulness of blood
in the head,  which it is hoped may not be unac-
ceptable to my readers.
   Fifty years ago tic douloureux was almost un-
known ; now it is frequently met with.   I do not
see how there can consistently be more than one
opinion, on the subject of its nature and origin, for
it is to me  evident, that it has grown with the
growth of stomachic and intestinal irritation, and
strengthened with their strength.   Yet some phy-
sicians appear disposed to regard it almost as an
independent  affection, founded  in' some peculiar
disease of the teeth, or nerves.   Opinions lead  to
practice, and they are no further deserving of no-
tice than  as they tend to practical results, good  or
bad.   Now if a practitioner considers this malady
to  be, for the most part, depending on the irrita-
tion of a diseased tooth or gum, or of the nerve af-
fected, it  necessarily follows that his practice will
correspond with  his sentiments, and thus, in my
opinion, his  patient will greatly suffer from the
employment of inappropriate and inefficient means.
That local irritation of  a nerve may occasionally
be the cause of tic douloureux, no  one will  deny,
but that it is internal disorder, which is the ordi-
nary cause of the malady, is equally certain.  All
the cases of  tic douloureux which I have seen  or 
 176        NATURE AND TREATMENT

 heard of, had great disorder of the general health
 most evident.
   Therefore, local means of relief will in this dis-
 order be very generally altogether unavailing, and
 those only can succeed which are calculated to ful-
 fil the general indications noticed in  the last chap-
 ter, as those which directly tend perfectly and per-
 manently  to  restore  the patient's general health,
 when the morbid sensibility of the nervous system,
 giving  rise to this peculiar affection  will cease.
 Although  the influence of  severe derangement in
 the digestive organs,  in producing excessive nerv-
 ous irritation and  pain  is  so  evident,  yet I  have
 been  frequently greatly surprised at the slight con-
 sideration given to this fact, by respectable profes-
 sional men.   They  have  taken different views
 respecting the origin  and proper  treatment of the
 cases  of tic douloureux on  which they were con-
 sulted,  but all (to whom I  refer) have tacitly
 agreed on the point, in the rejection of which alone,
 they assuredly ought  not to have differed—that of
 overlooking the fact  just mentioned.  It is  from
 this cause that so many of such patients fail to gain
 the relief which medical aid is capable  of affording
 them, for although iron, quinine,  &c. are very val-
 uable remedies in  many instances of the present
 affection,  they cannot reasonably be expected to
 succeed in all, or even the majority, any more than
 that they should be attended with success in the
 majority of dyspeptic  affections.  There is likewise
a middle path taken by many persons, in reference 
              OF TIC DOULOUREUX.          177

to the management of this disease, in which it is
treated as in a measure  dependent on the internal
derangement explained above, the  treatment being
partially conducted on this principle.  The relief
gained is consequently also partial.  The reason of
this is, that in aggravated cases (and this remark is
applicable to all diseases), we often find that it is
only  by a corresponding close attention to  the
foundation of the malady, and by following up un-
deviatingly  the advantages gained by such  atten-
tion, that we can succeed in their perfect removal.
This is a point worthy of much regard, for I have
seen many patients suffer long  and severely, from
a neglect of it.
  I have no intention of offering here any particu-
lar treatment for this very painful malady.  Cases
of tic douloureux differ much  from one another,
perhaps as greatly as cases of indigestion, and in its
details the treatment must ever be left to the judg-
ment of  the practitioner, guided by the principles
I have endeavoured to lay down.
  The preceding remarks are equally applicable to
the nature and treatment of Nervous Disorder and
Gout.   They are both founded in derangement and
weakness, or oppression of the assimilating organs,
and therefore the most effectual mode of treatment
is invariably that which most  speedily and per-
fectly removes this disorder and oppression.   I now
notice these complaints solely  with the view of
impressing on the reader's mind, the absolute ne-
cessity of an unreserved and continued attention to 
178                   OF GOUT.
the principles above described,  in order to  their
perfect cure.   It is surprising what gratifying and
unexpected  changes are  often  wrought  in  the
gouty man's condition,  by such  a  cordial and  un-
reserved attention.   For want of it many become
martyrs to gout or nervousness, who  really have
the  means  of  perfect  restoration   within  their
reach.*

  * I yesterday heard of an elderly gentleman, who had received
the most gratifying relief in gout, from taking soda, by the advice
of a surgeon in the country.   This gentleman had started on a
journey, but finding the gout coming on, he returned home, and
sent for his surgeon.   He was advised to take soda freely (in
what way I dont know), with the view of improving the state  of
the stomach; which most unexpectedly put an end to the gout
and be was almost immediately enabled to proceed on his journey.
The patient thought it marvellous, and is so publishing the extra-
ordinary virtues of soda wherever he  goes, that some think the
surgeon may make his fortune by the patients flocking to him from
this recommendation.  The circumstances  connected  with this
affair clearly illustrate an  error too common among both patients
and practitioners, and which it  has been my  endeavour in the
preceding pages to guard them against—namely, that of overlook-
ing principles, and dwelling on insulated facts.  Soda is no doubt
sometimes a valuable medicine in gout, and the old gentleman re-
ferred to happened to find it peculiarly efficacious at  the time he
took it; but certainly the generality of patients will not find it so
useful, and he himself may probably be disappointed in its opera-
tion the next time he takes it.  It is natural for the patient, who
has received signal benefit from a particular medicine, to extol it
above its merits, but the practitioner ought not to be tlras deceiv-
ed.  He ought to  be influenced  only by principle, and then he
will find himself capable of being generally useful to his patients;
while those, who lie at the mercy of insulated facts, only  happen
occasionally to strike the mark they aim at.
  [We  cannot withhold an expression of our most cordial assent
to the views and opinions  embraced in this most valuable note.—
Edit.] 
             FULNESS IN THE HEAD.         179

  Fulness of blood in  the head is a  symptom
which is often found in persons suffering from in-
digestion, especially in the young and  plethoric,
and  it is one liable  to  prove very  troublesome.
That the circulation should often be disturbed by
disorder  of the  assimilating functions, cannot ap-
pear  at  all  surprising,  when we recollect  how
marked  an  influence these functions  have  over
every other part of the frame; and that  an undue
influx of blood to  the head particularly should re-
sult from this disorder, is no more  than  we might
reasonably expect, from the close connexion exist-
ing  between that part and the stomach,  and the
very large proportion of blood sent constantly to
the brain, by the internal carotid and vertebral ar-
teries,—a quantity perhaps correctly calculated at
nearly one-tenth of the whole mass.*
  This symptom not unfrequently proves very in-
corrigible, but I am constrained to say, that this is
a state which ought not to be, provided the patient
will adopt the use of proper measures.   It has al-
ways appeared  to me, that the reason why  it so
commonly  proves difficult of cure  is,  because
blood-letting, blistering, and  purging, the means
usually  employed for  its  removal, are  unsuitable
and inefficient.  Indeed,  they are  not only inap-
propriate and ineffectual, but they too often increase
the  evil they were designed to remove, an  effect
                                       •
  * Some physiologists reckon it at one-eighth of the whole mass
of blood. 
180
FULNESS OF BLOOD
that might be anticipated, if the general principles
of treatment explained in the last chapter are cor-
rect.  For they teach us not only studiously to avoid
every expedient which is either directly  or indi-
rectly debilitating, but also as  constantly to employ
measures  of an opposite character, that is, those
which are capable of imparting strength generally
and locally.   Now it is certain  that blood-letting and
purging cannot ordinarily augment the strength of
an  individual.   Then why, it may be asked,  are
they commonly  resorted to in the present case?
The source of this  error has  been pointed out at
the 108th, and following pages.   It lies in the foun-
dation, or cause of this symptom, which is debility,
being disregarded.
   Since debility and disorder is the cause of this,
and almost all other undue determinations of blood
to particular structures, I therefore strongly object
to the abstraction of this fluid for their cure, and
also to the use of purgatives.  The principles on
which they are used appear to me erroneous, and
the results of the practice are, according to my ob-
servation, almost uniformly bad.   I have repeatedly
seen such local congestions of blood removed, by
acting on the invigorating principles  already so
often adverted to, which were scarcely relieved for
a  time, by  the  measures above  objected against.
This  is equally true of the symptom  as occurring
in young plethoric habits, and in those where debi-
lity was well marked.   Nevertheless, I do not wish
it to be understood,  that I  object to cautious local 
IN THE HEAD.
181
bleeding in such cases under all circumstances; on
the contrary, I believe there may be instances, in
which a small bleeding  or two may be practised
with advantage.  These cases are, however, com-
paratively rare.
   In weakly persons I would recommend  for the
cure of this symptom, tonics, especially mineral to-
nics, and very mild aperients, with the general diet
and regimen  detailed in the fourth  chapter.  For
young full habits, mercurial alteratives,, combined
with a full dose of tartarized antimony, a correct
diet, and daily active exercise.   Mineral tonics will
sometimes be very useful here also; even arsenic
may occasionally  be given  with admirable effect.
The curative  power of exercise is very great, but
it requires to  be followed up with energy.  A man
under the active exercises of  the  training  system,
soon loses all  giddiness and fulness in the head.
Y 
 
183
                 APPENDIX

        BY THE AMERICAN EDITOR.


  For a few years past, medical and even popular
writers have found so fruitful atopic in dyspepsia,
that we have been greeted with something new upon
it almost daily.  A treatise on the subject over which
but a few months may have  passed, must there-
fore appear somewhat in the back ground, unless
special means have been applied to bring it forward.
Regarding  the preceding  publication  as  peculi-
arly valuable, more especially so to  our medical
brethren, we design to remedy in some degree the
deficiency alluded to by superadding to it the latest
intelligence upon the subject, such at least as ap-
pears to us most interesting either from its  novelty
or intrinsic value.  We shall  begin by noticing a
little volume lately published by Dr Avery  of New
York with the title of the Dyspeptic's Monitor,
which recommends itself by many sensible views,
especially those relating to regimen.
  The writer appears to have had  very ample op-
portunities of  acquiring  information upon  the
subject of which he treats, for he tells us that hav-
ing long been  a prey to distressing symptoms of 
184
APPENDIX
 dyspepsia, over which medicine seemed to  possess
 little or no control, he left an extensive country
 practice, crossed the Atlantic, and spent some time
 in visiting different parts  of Great Britain and  the
 Continent,  collecting all the information  in his
 power in regard to the ailments with which he was
 afflicted.
   Dr Avery divides dyspepsia into three  species,
 though stages, we think, would have been the most
 proper  designation, as the symptoms  which mark
 them follow each other  in train as  the  morbid
 irritation extends  itself  from its primitive seat
 to involve other  parts.  The first derangement
 ordinarily observed, is confined to the gastric func-
 tions proper, without any material disturbance in
 those of the other abdominal viscera:  The  second
 includes affections of other portions of the intesti-
 nal canal, accompanied by what are often denomi-
 nated bilious symptoms:  The third, a  morbid sen-
 sibility or irritability of the lining membrane of
 the stomach and bowels, attended with sympathetic
derangements of  the liver, nervous  system, &c.
 Now all these we regard as consecutive stages, the
 last being necessarily attendant on the  second, and
 this  again upon the first.   We of course  except
 those cases of  disorder of the  digestive functions
 consequent upon lesions of other organs, such  for
instance as those of the liver and spleen.
   Dr Avery refers  the symptoms of  his  second
species to a vitiated condition of the bile without,
as we think, sufficient grounds.  Either the effect 
           BY THE AMERICAN EDITOR.       ] 85

may be mistaken by  him for the cause, or, what is
still  more probable,  that  which  he denominates
"tenacious, ropy bile," is more properly what the
pathologists of the physiological school would con-
sider an altered secretion from a mucous membrane
in a state of disease.
   The pages which  treat of the causes of indiges-
tion contain many sensible though not very novel
remarks.   Some of  these  are particularly  applica-
ble to patients  in this  country.   He strongly re-
probates the mode of living common in the United
States, and ascribes  the greater prevalence of dys-
pepsia here than in Europe chiefly to our very
variable climate and the inordinate consumption of
animal food.   He inveighs particularly against our
hearty mode  of breakfasting, which he  says is
equivalent to dining in England, and expresses his
conviction that it  occasions more weak stomachs
than can  be  well imagined.  The labourer who
has risen early and spent some three or four hours
in active employment, may feel no inconvenience
from the practice, but  with those who lead seden-
tary or inactive lives,  early and full  breakfasting
cannot be long continued  with impunity.   He ar-
gues that there is no necessity for nourishment un-
til the energy accumulated during sleep is partially
exhausted by exercise, and considers the feeling of
appetite as the criterion by which the stomach is
known to be in a condition to discharge its func-
tions properly.   The doctor's sketch of an Ameri-
can breakfast was doubtless  intended as a carica- 
186
APPENDIX
ture.   It  must be  confessed that in steam boats,
public inns and boarding houses, the a lafourchette
system is carried pretty far, but the tables of res-
pectable private families exhibit much more mode-
ration and good taste.   We are moreover somewhat
heterodox in regard to the doctor's notions of the
sad effects of breakfasting.   It  is well known, that
in the good olden time, before dyspepsia came into
fashion, even  the court ladies breakfasted upon beef,
ale and such  like substantial fare.   We would not
however be understood as advocating unlimited in-
dulgence in breakfasting, being in favour of mode-
rate meals on all occasions.
   Dr Avery  inveighs also, and we think very pro-
perly, against the habitual use of spirituous liquors
and their usual accompaniment, tobacco, as fruitful
sources of indigestion.  We are almost ashamed to
acknowledge that we are the only civilized nation
who do not regard the practice of chewing tobacco
as exceedingly vulgar.   If, however,  we  are not
greatly deceived, the use of tobacco is  rapidly de-
clining among those  who  pay the least regard  to
the proprieties of life.   Cigars are now scarcely
ever introduced at private dinner parties after the
ladies have retired, as was the common practice but
a few years since.
   The transient vigour  imparted to the stomach
by alcoholic drinks when  taken  after  a meal, has
often  led to their  habitual use  by persons with
weak powers of digestion.  This is indeed a very
prevalent vice, and  cannot be too  strongly reproba- 
           BY THE AMERICAN EDITOR.       187

ted.   The frequent application of all  unnatural
stimulants necessarily leads to derangements of the
natural  functions, and  we entirely agree with Dr
Avery in the opinion that,  though the stomach
may at first be goaded on by them to vigorous ex-
ertions, it must finally be wearied out and  sink
into languor and torpidity, and we may add, what is
still  worse, driven into inflammation which  may
terminate in disorganization.   The effects of spir-
ituous liquors taken when the stomach is empty,
are even more immediately  injurious than when
taken with the food.
   As to the treatment of dyspepsia, the author of
the "Monitor" agrees with Dr Graham, and we
believe all others who have had much to do  with
the disease, in regarding the  exhibition of medi-
cines as but a secondary consideration, since, with-
out a proper diet, no permanent advantage is to be
looked  for.  The impaired tone of the stomach
cannot be recovered unless by the  removal of one
of the most frequent causes leading to it, namely,
the habit  of overloading it.   Food should never be
taken without a natural appetite, and the stomach
is never to be forced when it shows no voluntary
inclination.  Great care must at the same time be
observed,  to restrain that morbid  craving for  food
which so frequently proceeds from corroding  aci-
dity or other causes, and constitutes a great annoy-
ance to the dyspeptic.
   In cases attended with great acidity, many au-
thorities  have united  in  recommending  a diet 
188
APPENDIX
composed almost exclusively of animal food.   " All
vegetables," says Dr Paris, "should be withdrawn
and a diet of animal food substituted."  This re-
commendation, which has always appeared to us
highly inconsistent  and injudicious,  we are very
glad  to  find  condemned by  Dr  Avery,  whose
conclusion, that the stomach bears that kind of food
best which excites it least and requires the shortest
time for its digestion, accords altogether with our
own observation.  Bread, milk, rice and such like
articles, will, we are confident, be generally found
to check the redundancy of acidity which would
most  probably be kept up by  a diet of the most
tender and digestible animal food.  The bread taken
with milk or any other fluid nourishment, should be
plain  and stale.   It must not be broken into the
liquid, but chewed  separately  in its  dry state, so
that it shall be well mixed with the saliva.  We
have been long in the practice  of laying particular
stress upon this last direction.   In the early stages
of dyspepsia a  milk  diet will  generally be  found
extremely beneficial, and those who cannot  take it
at first  without, considerable inconvenience, will,
after  a few days' perseverance, find it not only to
suit their stomachs, but become agreeable  to the
taste.  About half a pint will do for breakfast, and,
should the appetite call  for it,  a similar quantity
for supper.  At dinner it may  generally be eaten
as freely as desired, provided the stomach be not
oppressed or feel  too much  distended.   Both tea
and coffee should, if possible, be avoided.  If weak, 
BY THE AMERICAN EDITOR.        189
Dr Avery  thinks  that, like all hot drinks, they
prove debilitating to the stomach, whereas if strong,
they irritate its nerves, and give rise to a secretion
of thin mucous and subsequent acidity.
   In cases  not  so aggravated as  to render animal
food altogether improper, a small piece of boiled
mutton, roast beef, or boiled fowl may be eaten at
dinner.   Mutton is thought to be  most easily di-
gested when  taken cold.  The fatty parts should
always be avoided.   Boiled rice or stale bread  are
the most  suitable  accompaniments, and  no  more
drink should be taken than  is actually  required,
water or milk being  the most proper, and those in
small quantities at a time.  This  plan should  be
persisted in until the stomach will  bear a  more
liberal allowance without unpleasant feelings.   In-
dulgence in fruits is  very properly proscribed by
Dr Avery.   Such  dyspeptics as can partake of
them at all, must limit themselves to a very mod-
erate quantity of such as are ripe and most whole-
some.
   For the purpose of neutralizing the acid, which
is  often  a very troublesome accompaniment of this
stage, Dr Avery recommends, in addition to a well
regulated diet,  the employment of magnesia, pre-
pared chalk and the alkalies, and more especially
the carbonate of soda.  Whenever there  is a sen-
sation of gnawing at  the stomach, a copious flow of
saliva, flatulency and other symptoms of acidity
about a teaspoonful of the carbonate of soda may
be taken, dissolved in half a tumbler full  of water,
     z 
190
APT END IX
and repeated as frequently as the symptoms  shall
render it necessary.  From a trial of both articles,
we should  prefer the alkaline solution mentioned
in the preceding  part of this treatise.   Neverthe-
less we have known good effects from the carbonate
and  bicarbonate  of  soda.   They  are far more
agreeable to the palate than the carbonates of potash.
The lozenges  prepared  of  the bicarbonate of soda
constitute a very  convenient and agreeable form of
employing  the   medicine.   Those sold  in  the
French shops under the  name of D'Arcet's alkaline
digestive pastils, have long enjoyed very high celeb-
rity.   They contain about five per cent of the bi-
carbonate, to ninety  five of sugar, united by means
of mucilage of gum tragacanth and flavoured with
a very minute quantity of essence of mint.
   For the  relief  of certain symptoms  supposed to
proceed from  biliary derangement, such as restless-
ness at night,  disposition to doze through the day,
weariness in the back and limbs, Dr Avery recom-
mends a perseverance in the use of cathartics till the
symptoms shall have disappeared.   As these symp-
toms occur so frequently  without being associated
with any such derangements, this  and other rea-
sons that could be assigned, induce  us to think the
advice injudicious.   That it is at variance with the
views maintained in the preceding  treatise, is very
evident.
   In the treatment of the second species, or, as we
would call it,  stage of dyspepsia, which, as we have
already  said,  is  characterized by  a long train of
symptoms  ordinarily denominated  bilious, such as 
           BY THE AMERICAN EDITOR.       191

yellowness of the tongue in the morning,  bitter
taste, sallowness of complexion, &c. &c, his efforts
are not only directed to  the regulation of the sto-
mach, but likewise of the bowels and liver.   The
diet which he considers best suited to the stomach
and  least likely to promote irritation  in the liver,
is that already mentioned, consisting of one or other
of the farinacea, but more especially oat meal gruel,
which  may in general be taken without dislike for
a longer time  than  any thing  else of the kind.
From half a pint to a pint of this, seasoned with a
little salt, or sugar, and sometimes a very little nut-
meg, may be taken three times a day.  Should the
too frequent use of this occasion any dislike, it may
occasionally be omitted, and arrow root, rice water,
or Indian meal gruel substituted.  The patient is
exhorted not to be alarmed at the apparently scan-
ty allowance proposed, since it may be strictly per-
severed in for weeks with none but the happiest ef-
fects.  A little milk may be sometimes added to the
gruel,  but  this is only admissible  under peculiar
circumstances,  as for example,  where exercise is
taken in the open air.  Individuals who can avail
themselves of these last  advantages may dine on
oatmeal gruel, and  if they choose, breakfast and
sup upon a piece of stale bread, toasted or not, as
they like,  with a cup of  very weak black tea.
Among the means recommended by Dr Avery for
obviating or correcting a  confined state of the bow-
els, an inconvenience so commonly complained of
by dyspeptics and most persons who lead sedentary 
192
APPENDIX
lives, is the bread of unbolted flour, or what he re-
gards as still better, rye bread.  But the article
which he thinks will  least frequently disappoint
expectation is a thin mush made of rye flour, to be
eaten once or twice a dav with molasses.   He like-
wise recommends an  injection of half  a pint of
cold water to be used every day just before visiting
the water closet.   We think the quantity of  fluid
here mentioned rather larger than necessary,  one
or two ounces thrown  up by means of a small sy-
ringe generally answering every purpose.  Observa-
tion has taught us to regard this as one of the most
convenient and best means that can be resorted to
for obviating costiveness arising from a sedentary life.
It is especially adapted to cases attended with those
sensations of itching and crawling at the extremity
of the bowel which are sometimes so annoying.
   In a treatise under the title of " Pathological and
Practical  Researches on Diseases of the  Stomach,
the Intestinal Canal, the Liver, and other Viscera
of the Abdomen," by Dr John Abercrombie of
Edinburgh,* we find, among much other valuable
matter, some sensible remarks  in  relation to  dys-
peptic  complaints.   Of these he recognizes as the
least conjectural, first, a form originating from defi-
ciency of action in the muscular coat, occasioning
too long a detention of the alimentary matters fol-
lowed  by  imperfect changes and chemical decom-
positions :  Secondly, a form arising from an  irrita-
* Edinburgh, 1828, pp. S96, 8vo. 
           BY THE AMERICAN EDITOR.       193

ble state of the mucous membrane, leading to ex-
citement of the muscular coat, and producing  an
evil  precisely the reverse of that  just mentioned,
namely, either speedy rejection of the food by vom-
iting, or its propulsion downwards in  an  imper-
fectly digested state:  And thirdly, a form in which
there is deficiency in  the quantity, or alteration in
the qualities of the fluids of the stomach.
   Among the most important views presented  by
Dr Abercrombie on this topic are the  following:
Considering the muscular action of the stomach as
more vigorous when the contents of this organ are
in smaller quantity than where there is much dis-
tention, and supposing that the secretions are regu-
lated by the quantity of ingesta they have to act
upon, he lays it down as a first and great principle
in the treatment of indigestion, that the quantity
of food should be so restricted that no more be ta-
ken than the stomach is found capable of digesting
in a healthy manner.   If it  is found that the  di-
gestive process is carried on slowly, particular care
should be observed not to take additional food until
full  time has been allowed for the solution of the
former.  For example, if the healthy period be as-
certained to be four  or five  hours, the dyspeptic
should allow six or seven.  This is one  of our au-
thor's golden rules, by no means to be infringed
upon, and  it  perfectly accords  with  the  views
maintained in the preceding treatise.   The quan-
tity of the articles taken as food, though usually re-
garded as the most essential  consideration in the 
194
APPENDIX
 treatment of dyspepsia, Dr Abercrombie thinks  of
 minor importance  when  compared  to quantity.
 He believes, in  fact, that the dyspeptic might be
 almost regardless of any attention to the quality  of
 his diet, if he rigidly observed the necessary  res-
 trictions as to quantity.   He at the same time dis-
 approves of a mixed diet.  " It is often remarkable,"
 says he, " how articles which cannot be borne as a
 part of mixed diet, agree  perfectly when taken
 alone; how a person, for example, who fancies that
 milk disagrees with him, will enjoy sound digestion
 upon a milk diet, and how  another, who cannot
 taste vegetables without being tormented with aci-
 dity, will be entirely free from acidity on a vege-
table diet."
   As one of the chief objects we contemplated in
 referring to Dr Abercrombie's treatise was to show
 his pathological views, we shall say nothing of his
 medical treatment of dyspeptic complaints.   We
 have taken it for granted, here as well as elsewhere,
 that nearly every thing essential upon this  last
head, has been anticipated in Dr Graham's treatise.
 It has appeared  to  us  that  the  frequent  success
which has attended the Halsteadean  practice of
 champooing and succussation of the abdomen, tends
 to support Dr Abercrombie's views  in relation to
 the deficient action of  the muscular coat of the
 stomach and bowels.  We do not mean to say that
 these views furnish a rationale of this lately so fa-
 mous process, completely satisfactory, but that they
go further to elucidate its effects than any others 
BY THE AMERICAN EDITOR.       195
we have met with in books.  It is evident that we
are not of the number of those disposed to ridicule
and contemn the practice of Mr Halstead, now no
longer a secret.   On  the contrary, we think this
gentleman has conferred an obligation  upon his
countrymen  by making them  acquainted with an
agent known, for the most part, to people of other
nations from time immemorial, and the advantages
of which, under proper circumstances,  it might
argue great prejudice or dullness to deny.
   The treatment  recommended by Dr Graham in
dyspeptic cases, attended with pain and soreness of
the pit of the stomach, consisting of warm  fomen-
tations over that region,  with frequent gentle fric-
tion, corresponds strikingly with a part of the plan
introduced by Mr Halstead.
   Dr Graham, as we have seen, conducts, his treat-
 ment of dyspepsia upon the principle of studiously
 avoiding  every  expedient calculated to be either
 directly or  indirectly debilitating, such as blood-
 letting, purging, &c, and the employment  of mea^
 sures of an opposite character capable of imparting
 strength  both generally and  locally.  The same
 view seems to be maintained by Mr Halstead, who
 never restricted  his patients  in  diet, or enjoined
 forbearance in any case.  On the contrary, the sto-
 mach was urged  on every day to some new trial of
 its strength, and the boastful reports made by pa-
 tients of their gormandizing experiments were list-
 ened to with silent approbation.  This last  prac-
 tice so contrary  to the dictates  of common sense, 
196
APPENDIX
and differing so widely from the judicious course
of regimen recommended by Dr  Graham, must
have  proved highly injurious  to the cause of Mr
Halstead, inasmuch as it doubtless often prevented
recoveries,  aggravated symptoms, and produced re-
lapses.   We are speaking of his  early practice,
when he was in the full tide of experiment, and
before the publication of  his book, in which we are
glad to find  a reference  made to "the dictates of
common sense," and an  acknowledgment  that
hardly any case can be relieved  without some at-
tention to diet.  He has  even gone so far as to lay
down three dietetic rules, the first of which is, to
eat slowly; the second, to eat moderately; and the
third,  to eat  at  regular periods.   He  dispenses
altogether with  the  employment of internal re-
medies.
   In  the preface to his publication, Mr  Halstead
professes to give a full narrative of the  manner in
which he was led to adopt his  "new  method of
curing  dyspepsia."   We would observe, by  the
way, that this preface of some half dozen pages, is
perhaps the only portion  of the duodecimo which
came from  Mr Halstead's pen.   The rest, exclusive
of the description of the organs and process of di-
gestion, which is acknowledged to be taken from
the Library of Useful Knowledge, has undoubtedly
been  prepared by a professional  hand.   We shall
not of course be suspected of mentioning this in
disparagement.  The narrative alluded to repre-
sents, that having for more than twenty years suf- 
BY THE AMERICAN EDITOR.        197
 fered all the evils of dyspepsia in its most  aggra-
 vated  forms, and  exhausted every  means of cure
 he had heard of,  without success,  he finally  had
 his attention specially directed to the state of ex-
 treme hardness and unnatural rigidity of his abdo-
 men, with  the increased  tension and spasmodic
 contractions in the abdominal muscles during the
 paroxysms of the disease.  Convinced that a great
 deal of his distress was somehow or other connect-
 ed with these conditions, and struck  with the re-
 lief always obtained  from travelling day and night
 in stages, in which he often slept, he says that he
 came to the conclusion that  during the time he
 was asleep the abdominal muscles became relaxed
 and  the agitation  was  communicated to his  sto-
 mach  and bowels in the  manner  which nature
 seemed to require for their relief.   Satisfied with
 this  reasoning, he next  set about  devising some
 means by which he might  procure a relaxation of
 the rigid muscles and give a jolting  sort of motion
 to the stomach and  bowels.   In accordance with
 these views,  he was led to relax the abdominal
 muscles during exercise  by an exertion of the will,
 and  says that  he was thus enabled  to derive  the
full benefit of those exercises which had previously
failed in affording any relief.   From this it may
be inferred that the chances of obtaining advantage
 from  either walking or riding are greatly dimin-
 ished or entirely lost if the person be  maintained
in an erect position, in which  the abdominal mus-
     2a 
198
APPENDIX
cles are necessarily in a state of what Mr Halstead
denominates, involuntary contraction.  That the
stomach may receive the agitation so indispensably
necessary, a perfect relaxation must be procured,
which can only be effected by stooping forward or
settling down.  How this accords with the notions
of those who,  in the pursuit  of  healthy exercise,
would not abandon all pretensions to grace, we leave
to be determined by the persons whom it may coi-
cern.  Mr Halstead tells us, however, that after this
discovery he soon found that every one had not the
same voluntary control over  the muscles of  the
abdomen that he himself had.  That these muscles
are subject to the will  in some but not in others,
we must confess sounds to our ears as rather equi-
vocal, since we, and we believe all our professional
brethren, have  been taught  to regard them as  ap-
pertaining most decidedly to  the voluntary class.
This discovery, it must be observed, is related  in
the  preface.    For the reasons  already  given, it
could not have  been expected in any other portion
of the book.
   After this sketch of the deductive philosophy by
which, according to his printed account, Mr Hal-
stead was led   to adopt his  new mode of curing
dyspepsia, we shall attempt to convey some idea of
his process.   We have alluded to his book account,
because we had heard  a very  different story of  its
origin previously to his publication.
   It has been already stated that  Mr Halstead lays
particular stress upon the outward condition of the 
           BY THE AMERICAN EDITOR.       199

abdomen.  For the purpose of producing relaxa-
tion in  the  abdominal muscles, without which
there can be no hope, he advises  the external ap-
plication of warm fomentations, poultices, steam-
ing, &c, to be repeated two or  three times a day.
He particularly recommends the application, on
going to bed, of flannel cloths wrung out of a mix-
ture of equal parts  of  hot vinegar  and water.
These should be several times folded so as to retain
the warmth and moisture, and sufficiently large to
extend  from the chest to  the hips.   Upon this a
coarse dry towel may be spread, and then a bottle
filled with hot water,  or what is still more conve-
nient, a warm flat-iron, passed  gently  over  the
whole  abdomen for  fifteen or  twenty  minutes.
After the removal of the wet  cloths, a  piece of
warm,  dry  flannel should be substituted.  This
process  may be repeated two or three times a day,
and the best time  is when the stomach is empty.
In this way we are assured the  abdomen  may ge-
nerally in a  few days, be rendered soft and yield-
ing, the sense of constriction removed, the respira-
tion rendered more free and easy, and the patient
made altogether more comfortable.   Sometimes,
however, a much longer persistence is requisite to
produce  the desired effects.  Should this plan of
fomentation be found to  occasion exhaustion, it
ought to be omitted for a day or two, and  on being
resumed not continued  so  long each  time.   We
have read the letter of an American gentleman,
detailing the manner in which he was relieved in 
200               APPENDIX

Paris from a most inveterate case of dyspepsia.
It was  of course  written  prior to Mr Halstead's
"discovery."  "The only  medication employed,"
says the writer, " was external, by means  of hot
sulphurous baths every other day, continued from
three-quarters  of an  hour  to  an hour;  jets or
douches of steam, or hot water, upon the stomach
and bowels on alternate days, and a cataplasm of
flaxseed or bread,  applied to the  bowels every
night."*
   The application of poultices, fomentations, &c. in
diseased states of  the abdominal viscera is  in fact
as old as the practice of medicine; and in France,
especially where the doctrines  of  Broussais have
any influence, it  is resorted to in almost every
case of dyspepsia.   The rationale of this  plan of
treatment  is much more satisfactory as explained
by the French authorities than by  the one  whom
we are  now considering.   The effect produced on
the rigid muscles of the abdomen is but partial,
and that from which the  least  benefit is derived.
It is by its relaxing  effects generally and more par-
ticularly by its influence on  the skin that it is use-
ful in dyspeptic  cases.  The intimate connexion
subsisting  between  the functions  of the skin and
those of the chylopoietic apparatus is well  under-
stood by physicians.
   The next step  in the plan of cure is the com-
munication of a  certain mechanical action  to the
* Professor Hitchcock's Lectures, Appendix. 
BY THE AMERICAN EDITOR.       201
stomach, which process comprises the pith and mar-
row of the " new method."  In this operation the
patient is usually placed with his back to the wall,
having his waistbands loosened and his abdomen
without any other covering than a shirt or  other
thin garment.   The operator seated immediately
before him, places his hands on the lower margin
of the ribs, and  with  his thumbs or index fingers
presses just beneath the breastbone in the pit of the
stomach, so as to cover the spot usually possessing
the most sensibility.  The pressure is to be gradu-
ally increased, and should it occasion more uneasi-
ness  than  can  be conveniently borne,  may be
suspended.  Sometimes however there is so much
insensibility, that the strongest pressure which can
be made by a stout man using all his force gives
no pain or uneasiness.
  When this is  the case recourse is had to sudden
tapping or punching  with the finger and thumb
over the point indicated.  This part of the process
has  received  the  technical  appellation of "the
shock"  It is to be commenced gently and repeat-
ed  once or oftener every day until the sensibility
be  restored.   A sudden sensation of  pain darting
upwards towards the throat or in other parts, as the
back and limbs, is often perceived to  follow these
strokes upon the stomach, and when this happens,
it is regarded as a good omen.   The  more tender
the  spot pressed upon  or punched becomes,  the
more  rapid the cure,  and the  sensibility once
awakened must not be suffered to subside entirely, 
202
APPENDIX
 but kept up by the patient, who with his finger or
 thumb is to press upon it with sufficient force and
 frequency.
   As tenderness in  epigastrio is one of the most
 characteristic symptoms of acute inflammation of
 the stomach, it is easy to conceive  that the effects
 of punching for the purpose of  promoting this
 condition  might be attended  with  very disastrous
 consequences.   This part of the practice we think
 ought never to be resorted to without the  advice
 of a physician.
   The next step in the process is to communicate
 an impulse to the stomach of a jolting kind, which
 in the Halsteadean phraseology is called  "the ac-
tion"  This is done either  by the  patient himself
or an operator.  The last is  generally to be pre-
ferred, and is effected most conveniently in the fol-
lowing manner.   The operator seated on the right
 of the patient places his right hand firmly upon
the lower part of the bowels in such a manner as
apparently to get below them, and hold them rest-
ing upon the upper edge of his hand.   Then by a
succession  of upward movements  he produces a
kind of succussation very much like  that  which
takes place on horseback  or in a jolting vehicle.
This action on being kept up  for a minute or two
commonly produces  a sensation of warmth and
 general excitement, with a  feeling  at the stomach
which has been compared to a  slight electric shock.
Among the good effects resulting from  this process
is relief from flatulency when this has been a trou- 
BY THE AMERICAN EDITOR.       203
blesome symptom.  The flatus is expelled by ac-
tual mechanical force dexterously applied to each
hypochondriac region, which is certainly far better
than the common mode of correcting it by inter-
nal means, the subsequent effects of which are
often highly detrimental.  Though the  operation
may create slight uneasiness or pain at first, it be-
comes rather pleasant after a few repetitions.
   Another method, by which nearly the same ef-
fects may  be  produced,  is to place the  patient
against a wall with his body so inclined as to relax
the abdominal muscles, in which position the ope-
rator seated before him places his hands upon the
abdomen,  and pressing  firmly makes a quick suc-
cession of rubbing motions upwards.   In doing this
the ends  of the fingers  are  frequently punched
under the stomach, so as to give rise to that tender
and peculiar sensation which  has been  mentioned
as desirable to produce  and  promote.   This opera-
tion may be carried on  so that by moving the hands
gradually  downwards,  the succession  of   small
shocks may be imparted to the stomach by  impul-
ses made on the lower parts of the abdomen.1
   When  the patient is to  operate on himself,  he
must incline his  body  forwards so as to favour as
much as possible  the  relaxation of the abdominal
muscles.   Then placing his hands in a  horizontal
position in such a manner  as that the ends of the
fingers may meet just below the pit of the stomach,
he inclines the palms upwards, so as to get them, as
it were, beneath the stomach, and makes the same 
204
APPENDIX
 kind of quick upward movement which has been
 already described.   The hands may be  applied
 lower  and lower until, as before  mentioned,  the
 succussion is communicated to the stomach from
 the  lowermost parts of the abdomen.  These se-
 veral operations are recommended to be continued
 from one to five minutes each time, and  repeated
 frequently during the day; sometimes indeed, where
 there is a great degree of torpor, as often as every
 half hour.  It would, we think, be improper to
 employ these mechanical means immediately after
 eating, as Dr Avery recommends, and the best time
 for resorting to them is in general about an hour
 or two after a meal.  The intervals between  the
 applications should be gradually lengthened, so that
 two  or three applications a day  may be sufficient,
 and  finally the process may be superseded by other
 kinds of exercise.
   It cannot be denied, that by the means just  de-
 scribed, the most salutary effects  have been pro-
 duced  in  cases of  dyspepsia.   Those who have
 undergone or witnessed  the process must be satis-
 fied  that  the agent is   one of a  most positive
 character.  One who has not had such an exhibi-
 tion  could scarcely  believe it possible for the  ab-
 dominal viscera to bear the mechanical violence, to
 which  they are frequently subjected under the
 Halsteadean discipline.   We have heard of cases
 where  the utmost  strength of  an uncommonly
sturdy  man was applied in sudden punches over
 the pit of  the stomach.   Some patients in despair 
            BY THE AMERICAN EDITOR.        205

 of rousing the sensibilities of their torpid stomachs
 by the ordinary  methods, have even  resorted  to
 pushing  themselves violently  against  canes and
 sticks  posted against the wall.  And yet we are
 informed' that  out of  many hundred cases there
i has not been an instance of injurious effects ensu-
 ing.  This experience  is, we  think, calculated  to
 perplex in no small degree the ordinary reasoning
 of pathologists.  That  operators possessing no pro-
 fessional knowledge should  have gone on so long
 without  encountering cases of  supposed dyspepsia
 depending  upon acute  inflammation, scirrhous  or
 other organic affections,  where these mechanical
 applications must have inevitably proved detrimen-
 tal and dangerous, is to be ascribed to nothing short
 of the  most unexampled good fortune.
    The influence, which this practice is  calculated
 to produce upon the muscular, nervous, sanguine-
 ous and lymphatic capillary systems involved  in
 the various organs of the abdominal cavity, offers a
 subject for interesting enquiry.   As the manual
 exercise exacted is neither suited to the taste nor
 leisure of most physicians, it  is  not at all  likely
 that they will contest the field with the  Halstea-
 dean operators, who, should the  practice gain a
 permanent footing, will perhaps be  referred to  in
 the same manner as  the  bleeders, leechers  and
 other subsidiaries of the profession.
    We  shall conclude our notice of  Mr Halstead's
 practice with some remarks of Dr Avery, in which
 we entirely concur.  " Let not the professed gour-
      2b 
206
APPENDIX.
 mand, the idle epicure, nor even the book worm,
 the accountant, or delicate female,  who never  ex-
 ceed  one twenty-fourth of their time in active  ex-
 ercise in  the  open  air,  flatter themselves that
■shampooing will enable them to eat with impunity
 the hearty food  that is proper for  the  labourer
 only.   It may be usefully added to a proper regi-
 men, but is good for nothing without it.   In this
 respect it stands in the same light with every other
 remedy.   To suppose it applicable to all cases of
 dyspepsia is as absurd as to imagine that any one
 medicine will cure all diseases.   Mustard seed and
 brandy have both in their turn been considered as
 specifics.   The first is now and then  useful,  the
 second never."
   During the last year, a work  under the title of
 Dyspepsia Forestalled and Resisted has been pub-
 lished by Professor Hitchcock of Amherst College.
 It consists of a series of lectures on diet, regimen and
 employment, delivered to the students of that in-
 stitution, and embraces a very large fund of infor-
 mation upon those subjects, the result of much ob-
 servation and  extensive research.   As  might  be
 expected, it will be found more interesting to the
 general reader than to  the physician,  and the  ad-
 vocates  of moderation and  temperance have a
 zealous and very able advocate in Professor Hitch-
 cock. 
 
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