In every case where nausea, loss of appetite, and occasional retching, mark the progress of indigestion, the matters ejected from the stomach should be carefully examined; as upon the appearances which they exhibit, we are enabled to draw most important inferences respecting the extent to which disorder has proceeded, either in the stomach itself or in the adjoining viscera.

During the progress and advanced stages of indigestion, the sensibility of the whole nervous system is increased, the frame is more sensible of changes of temperature, and more susceptible of the impression of cold. The skin generally becomes dry and harsh when the temperature is at all lower than that of the surface of the body; and slight exposure to chills, or to a colder or moister air than usual, are productive of bowel complaints. Headach frequently occurs, the sleep is often disturbed, and the spirits generally dejected.

The Causes of Indigestion are, first, those which act upon the stomach indirectly, or by intermediate effects produced upon the body; and, secondly, such as directly invade the stomach itself, and are actually present in the viscus which they disorder.

The functions of the stomach are injured, not only by those causes which act directly on it, but by those influences also which impair the energy of the whole system. Of these latter, the most generally and continually operating are terrestrial exhalations. The depressing passions and anxieties of mind, also, although less general in their operation, are yet most efficient in the production of dyspeptic as well as of hepatic disorder; and when the former is the result of this cause, the latter disease is generally a concomitant.

In warm climates, and more particularly in the East, the supervention of biliary derangements upon disorders of the digestive function, is a consequence to which almost every experienced practitioner is alive; but still the subject is not the less deserving notice. The disorder of the stomach, which usually accompanies hepatic complaints, and often indeed produces them, is, however, too frequently overlooked, and the connexion disregarded, both in our speculations and practice. A similar remark may also be made respecting the origin of several disorders of the bowels.

A torpid state of the liver usually accompanies the imperfect performance of the digestive function, especially early in the complaint. This is in a great measure owing to the existence of a similar state of deficient energy of the vital actions of the liver to that which characterises indigestion. During this state of torpid function, the ingesta are retained longer in the stomach than in the

ease.

healthy condition of the organ, in order that they may undergo the necessary changes; at the same time, the bile is secreted in less quantity, or if it be secreted as abundantly as usual, it is frequently retained longer in the ducts and gall-bladder; hence it accumulates in these situations, and flows more sparingly into the duodenum. The result of this must necessarily be, that the chyme is slowly or imperfectly converted into chyle, and that the digestive process is retarded throughout the whole alimentary canal. A torpid state, however, of the liver, in warm climates generally, and in the East Indies more particularly, can be only a state of temporary disorder; but it is one necessarily tending to the production of ulterior disFor, as the elements of which bile is formed abound in the blood, the secretion of this fluid will generally proceed sufficiently fast to load the gall-ducts and bladder to a degree which will either occasion its expulsion into the duodenum, or will irritate and excite the vascular actions of the liver itself; and the frequent production of these effects will necessarily occasion inflammatory disorder of the organ. But it is not only the simple accumulation of bile which is hurtful, when the energy of this viscus is insufficient to rid itself of its load; it is chiefly the morbid change which the constitution of the bile undergoes when thus retained which is productive of disorder, both of the liver itself and of the bowels into which it is poured. During the remora of the bile in the biliary ducts and gall-bladder, it becomes inspissated, darker in colour, and more acrid as respects its effects upon sensible structures. Hence the tendency to the supervention of inflammation upon torpid states of this viscus, both in the liver itself and in the mucous coat of the intestines, after the acrid bile has been let loose into them. Thus it will be perceived that functional disorders of the stomach are not only important in themselves, but also most deserving regard, as inducing disorder of the liver, tending to inflammatory disease of this viscus and of the mucous surface of the bowels.

SECT. II. On the Treatment and Regimen of the Functional Derangements of the Stomach in Warm Climates.

In warm as well as in temperate climates, the first object of the practitioner is, to ascertain, as closely as is in his power, the causes productive of disorder, and the extent of derangement, as respects both the stomach itself and the adjoining viscera, which these causes have induced. The next point to which he should direct his views is, to remove these causes as far as he possibly can, and

to institute such a course of medical treatment and regimen as the circumstances of the case require. The causes which have been chiefly noticed as productive of stomach disorder, are those which should be especially removed; and this object having been insisted upon, with due decision on the part of the medical man, the following indications ought to be kept in view, in the exhibition of medicinal means,-namely, to remove the more urgent symptoms and complications which each case presents; to restore the impaired energy of the digestive functions; and to prevent a recurrence of the disorder.

The first indication can never be entered upon with any hopes of permament success, whilst the patient is allowed to indulge in those habits and courses from which the disorder springs. So long as he is allowed to overload and over-stimulate his stomach, the practitioner will prescribe the most efficacious remedies in vain. A light, low, and a bland diet ought therefore to be adopted before any medicine is taken; and this should be particularly and decidedly laid down by the practitioner, and a regular plan of diet and regimen entered upon by the patient previously to, or at least contemporaneously with the exhibition of medicine. This being premised, the various urgent symptoms and morbid associations which have supervened, should next be combated by suitable means. The acid and acrid eructations, which often prove hurtful after meals, will generally disappear as soon as a mild diet is adopted, and the quantity of the food reduced, so as to be in relation to the digestive energy of the stomach. If however, this symptom should still continue, gentle tonics may be combined with antacids and aperients, and a pill, consisting of a grain and a half of bluepill and two grains of aloes, or of the aloes and myrrh pill, may be taken every night. The functions of the liver are very seldom unimpaired in the dyspepsia of warm climates; the treatment, therefore, should always be directed with some reference to the presumed condition of that organ. If it be in a torpid state as is frequently the case, and still more especially if there seem to be a loaded condition of the biliary apparatus, unattended with an inflammatory state of the mucous coat of the stomach, then the treatment may be advantageously commenced by the exhibition of an ipecacuanha emetic; for great benefit will be derived from the influence of retching, in procuring the expulsion of the bile from the loaded gall-bladder and biliary ducts, and in favouring a free circulation through the substance of the liver. Whatever means may be pursued in order to remove the dyspeptic condition, but

little progress will be made towards effecting a cure, as long as the functions of the liver and bowels are allowed to remain in a dis ordered condition. When the bile is secreted in an insufficient quantity, then small doses of the blue-pill, in combination with aloes, may be given nightly, gentle tonics and aperients being exhibited throughout the day; and this plan should be persisted in for a considerable time, and until all disorder is removed. In such cases as are characterised by irregularity of the alvine excretions, and by a morbid state of the biliary secretions, ten or fifteen grains of bluepill may be exhibited with advantage every second or third night, and an aperient draught, consisting of equal parts of the compound infusions of senna and of gentian, with a little of the compound tinctures of aloes and of cardamoms, may be taken every morning; and when the secretions and stools are much disordered, a drachm or two of one of the neutral salts may be added to this draught, with great advantage. It will be generally observed, that this class of cases is most frequently met with amongst those who live upon much animal food and rich dishes: attention should, therefore, be paid to the diet of the patient. The institution of a regular course of aperients, and, in many cases, even of active purgation, should always be kept in view; and, in order that the functions of the stomach may not be disordered by the exhibition of such cathartics as possess acrid or irritating properties, the operation of those which are less offensive to the energies of the digestive organs should be promoted, by the use of injections. In cases of dyspepsia, attended with greater disorder of the functions of the liver and bowels than that which has been now considered, ten, fifteen, or twenty grains of calomel may be substituted for the blue-pill, recommended for the foregoing cases; and, in addition to the other means, a large blister may be placed upon the epigastric and right hypochondriac regions. Where the functions of the liver and bowels are much disordered, and especially when such disorder is characterised by an increased as well as a morbid state of the bile, the diet should then chiefly consist of farinaceous substances; little or no animal food ought to be taken; and active purgation should be resorted to, until the secretions contained in the stools assume a healthy character. As long as they present the appearances previously described, a deobstruent mercurial pill may be given with advantage every night, and an active purging draught the following morning; and this plan should be continued until all disorder ceases. We should not be led astray by the appearance of the motions voided on the first or second day of the purgative course;

for it very frequently happens, that the purges at first given accomplish no more, during that period, than the unloading of the colon and ileum of a part of their contents, and that part may not betray much disorder; and yet, after persisting in the use of purgatives for a day or two longer, the accumulated secretions, which have long remained locked up in the gall-bladder and biliary ducts, and adherent to the mucous surface of the alimentary canal, and the fæces and morbid secretions which have been long lodged in the cæcum and colon, are at last let loose; and I have often found, that measures necessary for the removal of them must be pursued even for a long series of days before the healthy state of function is restored.

Much mischief has arisen from the mistaken notion, that the very disordered state of the stools which is frequently present in the advanced stages of disorders of the digestive organs, is often the effect of the medicines which have been exhibited. But although the purgatives employed may change the colour of the motions, they by no means occasion the other morbid appearances they frequently present. Indeed, the colour, even when most opposite to the healthy tinge, if it arises at all from the operation of the medicine, can only result from its action upon secretions already of a very morbid condition. Their odour, putty-like consistence, variegated or marbled colour, dark-brown, greenish-brown, and inky appearances, and their viscid, tenacious, gelatinous, and often scybalous conditions, are by no means the result of the medicines employed. These various characteristics to which the practitioner cannot too closely attend, generally proceed from a vitiated state of the biliary and other secretions poured into the alimentary canal; and this arises from their long retention and accumulation upon the mucous surface; so that when they mix and combine with the fæcal matters passing through the colon, states of disorder, such as those to which I have alluded, are produced.

It not unfrequently happens, that states of congestion in the liver, and of inflammatory irritation of the mucous surface of the stomach, supervene in the advanced stage of indigestion. When such is the case, purgatives and enemas may be exhibited, a low and bland diet adopted, and leeches applied near the situation where fulness, weight, distention, and soreness indicate the existence of those forms of disorder. After these means have been adopted, and the urgent symptoms have been removed recourse should be had to such medicines as are likely to restore healthy action in the chylopoietic viscera, always keeping in view a free state of the