347. The previous habits of the patient, and the origin and seat of the disorder, are the circumstances from which the physician is to derive his indications of cure. If the disease has not extended its influence beyond the stomach and bowels, the means to be adopted will be more simple, and, at the same time, more prompt in their salutary operation, than where it has involved the functions of remote organs; but in this latter case, the symptoms are so frequently those of mere sympathy, that the practitioner has often the satisfaction of witnessing their removal by remedies that can only have acted on the primae viae.

348. It has been stated, that the stomach may fail in the performance of its duties, either from a deficiency in the secretion of its menstruum, or from a loss of power in its muscular fibres; but in either case we must refer the disease to a loss of nervous energy. Some persons, predisposed to indigestion, and who inherit the temperament most favourable to its production, would seem to have less than an ordinary ratio of nervous energy supplied to their muscular structures. In such cases, there is an unusual torpor in the bowels, even during health. An attention to this fact has frequently led me to adopt measures which might have proved less successful under other circumstances. As a general proposition it may be stated, that the secretion of gastric juice, and the muscular power of the stomach, are so intimately associated with each other, that the one cannot long be deficient without the other partaking in the torpor; and the practitioner, who has had much experience in the treatment of dyspeptic disease, will readily believe that whatever tends to restore a healthy nervous power to the stomach, tends to form the food into that substance which is best fitted to excite the muscular fibres of this organ; and that whatever excites the natural action of these fibres, tends to relieve the nerves from their load, and, in the most favourable way, to bring into contact with their extremities the food on which, through the intervention of the gastric fluid, their powers are to be exerted.

349. The pathology of the stomach may, therefore, be greatly simplified by referring it to a defect of nervous action; and our first duty is to inquire into the causes that may have occasioned it, and which, in general, may be identified with errors of diet, affections of the mind, or irregularity of exercise.

350. The nature and influence of such remote causes have been fully discussed in the preceding pages; and by carefully appreciating their operation, the practitioner will obtain a clue for his guidance. He must lay down a system of rules for his patient, by which the remote causes of his complaints may be removed; but, in his attempts to reform bad habits, he must be careful to avoid all abrupt transitions, except in those circumstances which have no direct influence upon the vital powers of the body. I should, for instance, be very cautious how I withdrew spirituous stimulants, although I might be well satisfied that the indulgence of such potations had given origin to the disease; but I should not feel any hesitation in at once withholding every species of pastry, or other indigestible matter, without reserve. Upon the same principle, we should gradually diminish the number of meals, where they have exceeded the proper limit, adapting them with skill and caution to the fluctuating circumstances of the patient.

The same observation applies to exercise; nothing would be more injudicious than to expose the invalid, debilitated by sedentary habits, to the effects of sudden and protracted exercise; nor should the person, whose habits have been laboriously active, be abruptly restricted to an irksome state of indolence. The discipline, in such cases, must be graduated according to the previous habits of the patient; to his age, strength, and the nature of his disease. Exercise can never prove salubrious, if it be followed by fatigue. Mr. Abernethy has prescribed to his patients a set of rules, which I shall take the liberty of quoting in this place, in order that I may offer such observations upon their value, as my own experience has suggested. "They should rise early when their powers have been refreshed by sleep, and actively exercise themselves in the open air till they feel a slight degree of fatigue" Upon this first rule, I am disposed to make the following comment. Although we must all agree in the advantages of early rising, yet, in dyspeptic cases, I have frequently known the disease greatly aggravated by the patient suddenly changing his habit, with regard to the hour of rising; and that if he becomes the least fatigued, before his morning repast, he remains languid and uncomfortable during the rest of the day.

A long walk before breakfast, unless the person has been accustomed to the practice, will frequently produce a fit of indigestion. I have already observed, that it is advisable to allow an interval to pass before we commence the meal of breakfast; and where the weather and circumstances will permit it, this interval may be passed in the open air, but the body should not suffer the least fatigue. Mr. Abernethy then proceeds to say, "They should rest one hour, then breakfast, and rest three hours, in order that the energies of the constitution should he concentrated in the work of digestion." It appears, then, that the patient is to rise early, to take exercise until he feels slightly fatigued, and then to rest an hour before he is allowed to take any refreshment. This plan might succeed very well in preserving a robust and healthy man in vigour; but where we have to deal with a person whose energies are languid, and whose feeble powers are easily exhausted, I fear that such discipline would be ill-calculated to afford assistance. It is notorious that all dyspeptic persons are especially languid in the morning, and they accordingly require a regimen the very reverse of that which Mr. Abernethy recommends. Such, at least, is the conviction of my mind.

To the practice of resting three hours after breakfast there can be no objection; it is the period best adapted for intellectual business. He then recommends "active exercise again for two hours, rest one; then taking their dinner, they should rest for three hours, exercise two, rest one, and take their third slight meal".

351. It is impossible to frame any general rule that shall apply to every case, but I will offer a sketch of the plan I have usually recommended: the practitioner will readily modify its application to meet the circumstances of any particular case. The dyspeptic patient should rise from his bed as soon as he awakes in the morning: for, as Mr. Abernethy justly states, "many persons upon first waking feel alert and disposed to rise, when, upon taking a second sleep, they become lethargic, can scarcely be awakened, and feel oppressed and indisposed to exertion for some time after they have risen." This is undoubtedly true. He should then walk, or rather saunter for some time in the open air, previously to taking his breakfast, the material of which is to be selected according to the principles already discussed (132). He is now in a condition to follow his usual avocations; but it is a circumstance of no slight importance to procure an evacuation at this period, which is easily effected by habit (92); a person who accustoms himself to the act at a certain hour of the day, will generally feel an inclination at the appointed season.

The invalid should not allow his occupations, if sedentary, to engage him for more than three hours, after which, exercise on horseback, or by walking, should be uniformly taken. I have already observed, that the state of the weather ought not to be urged as an objection to the prosecution of measures so essential to health. Where the season of the year, and the situation of the patient, will allow the exercise, I strongly urge the advantages to be derived from digging: the stimulus thus given to the abdominal regions is highly salutary in dyspeptic affections. The hour of dinner should not be later than three o'clock (134), and the patient should rest for an hour before he sits down to the meal. It should consist but of few articles, should be carefully masticated1, and the invalid should rise from the table at the moment he perceives that the relish given by the appetite ceases. The manner in which he should regulate his potations, at and subsequent to this meal, has been already considered (146). With respect to the allowance of wine, every practitioner must use his discretion, and be guided by the former habits and recent condition of his patient (254). It is essential that the invalid should enjoy rest for at least two hours after dinner (121), that is to say, he should not enter upon any occupation or diversion that may occasion the slightest fatigue; to a gentle walk, or saunter in the garden, there can be no rational objection, especially at that season of the year when such a pastime is the most inviting.

At six or seven o'clock, he may take some diluting liquid, as tea; after which, exercise will be highly useful, to assist the sanguification of his previous meal: in the summer season there will be no difficulty in accomplishing this object; and if the strength of the patient will allow the exertion, some active game, as bowls, will be attended with advantage. At ten o'clock he may take some toasted bread, or a lightly boiled egg, with a glass of wine and water, should his previous habits render such an indulgence necessary, and at eleven he may retire to rest. The bed-room should be well ventilated, and its temperature should, as nearly as possible, be that of the apartment from which the patient retires. A well-stuffed mattress is to be preferred to a bed of down, and the curtains should not be so drawn as to exclude the free circulation of air. The invalid should be careful in not retiring to rest with cold feet: nothing contributes more readily to disturbed sleep, and uneasy dreams, than the unequal circulation which takes place on such occasions.

1 Too much stress cannot be laid upon this circumstance; and, since a person who dines alone generally hurries his meals, I have generally advised the dyspeptic to dine in company with his friends.

352. Such are the general rules which I should enforce for the protection of those invalids who are liable to dyspeptic attacks. There are particular features in the history of every case which will require appropriate treatment, and I shall now proceed to their consideration.