ii)Mi:;:;;:-:i"!:i;;-]^ ' Oft-: iU'i'lK'" ' • ,«i*?»?' iiii«1i l!i «ir»»ik'WWh'I1- ' :lt;;- •■ niwMvrM*]<}■■?Z[--K. W'i-<->>< : ■ ,-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 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. NATIONAL LIBRARY OF MEDICINE NLM D3Efl^E10 A NLM032892108