Indigestion is the characteristic disease of our time. There are few men or women over thirty who have not suffered from it. The working classes are spared the most, but with the frequent suggestions in the newspapers and the introspection which has become so common, indigestion is often complained of even among them. Sedentary occupations, involving mental work and little physical effort, seem especially to predispose to some form of indigestion. Few of those who live what is called the intellectual life escape suffering from some of its symptoms. Not infrequently men have been hale and hearty specimens of muscular manhood when they took up some profession which compels them to be indoors, yet before long, they begin to complain of discomfort after eating, of tendencies to constipation, of headaches, of depression, of incapacity for mental effort after meals, and all these symptoms are attributed to the almost universal disease, indigestion.

It is possible for the general attitude of mind to have a great effect on digestive processes, and the symptom-complex which is called indigestion, or dyspepsia, is probably much more dependent on the mind than on any other factor. In many cases it is primarily due to over-concentration of attention on digestion. In others it is due to over-occupation with business, worry, or serious thought at times when the digestive processes need all the energy. In many cases so-called dyspepsia is due to an unfavorable state of mind toward digestive processes in general, because of unfavorable auto-suggestion. Normally, stomachic sensations reach our consciousness only under special circumstances. When, however, much attention is paid to them, even the slight sensations that occur with normal digestion may rise above the threshold of consciousness and become subjects of solicitude. If they do so, then the increased attention likely to be paid to them surely interferes with function and changes what may be merely physiological into pathological processes.

Disease Suggestions.—An unfortunate state of the public mind with regard to indigestion in general has been cultivated by many publications on the subject. People dread its occurrence, and fear that the first sign of discomfort in their gastric region is a signal of the beginning of a progressive affection. They fear the worst, and the consequence is a reaction quite out of proportion to the gravity of the ailment. So much has been said particularly of mistakes in diet that just as soon as they feel, or often rather think they feel, the first symptom of beginning dyspepsia they begin to study how to modify their diet so as to prevent its progress. They begin to eliminate various supposedly indigestible foods. Usually among the first things that are greatly reduced in quantity, or are entirely eliminated, are the fats and certain of the starchy vegetables. Because of expressions heard and read as to its harmfulness, the fearful ones also are usually timorous about taking fluid at meal times. As this is about the only time when they are likely to take fluid, unless it be summer, they soon suffer for lack of it. Eating only food that {251} leaves little residue and taking insufficient fluid leads to constipation. This reacts still further to disturb digestion, and to interfere with appetite.

This leads to further reduction in the amount and variety of food, with the consequence that insufficient nutrition to supply energy for bodily needs is taken. The digestive system gives up to the body as much as it possibly can, not only of the food materials to be consumed, but of its own substance. Thus it weakens its own vitality, with a lessening of appetite and of digestive power. Hence, a vicious circle of change is instituted, the consequences of which are easy to see. After a time the patient is taking only the blandest foods, constipation has become an important element in the case, and the mind is constantly occupied with solicitude over the digestion and the choice of materials at meals.

Contrary Suggestion and Digestion.—Hudson, in "The Law of Mental Medicine," insisted on the necessity for not suggesting to children the possibility of indigestion of various substances, for that is almost sure to disturb digestive functions. Children sometimes hear the remark that father or mother cannot take a certain article of food because it disagrees with them. The imitative faculty of the child is sure to be aroused, with the consequence that this particular food is not eaten with relish nor given a fair show for digestion, and will be the source of some stomach disturbance. Not infrequently substances thus spoken of are among those that are especially likely to do children good, such as milk or eggs, or occasionally butter. The harm done by the remark may, therefore, even be serious, for these foods should constitute a large proportion of the child's diet. Indeed, an excellent prophylactic in the matter of indigestion is to prevent as far as possible all conversation at table about the indigestibility of food. Unfortunately, this has, in late years particularly, become a favorite subject of table conversation.

Transferred Feelings.—Professor Cohnheim called attention to the fact that many uncomfortable feelings are likely to be mistranslated because they are referred to organs with which there is nothing wrong. Whenever this function is hampered in any way, there are many uncomfortable feelings associated with the digestion of food. The custom has been to refer the origin of all these to the stomach. Cohnheim thinks that it is much more likely that they really originate in the intestines, though the rule has been to take the patient's feelings as an indication and to treat the stomach. It is not an unreasonable thing for patients to be deceived as to the exact location of discomfort. Even in so acute a process as toothache it is possible to mistake the particular tooth that is giving trouble, and, as dentists know, a perfectly quiescent tooth is sometimes blamed for pain that is coming from another. Fillings have been removed, teeth have been treated, good teeth have been extracted, because patients insisted on the significance of their feelings in such cases. The stomach must not always be blamed. Sometimes the only source of supposed gastric discomfort is the constipation present which is usually easy to relieve.

Gastric Reflexes.—While the mind may serve to disturb digestion and produce gastric discomfort by over-attention, there are many reflexes that center in the digestive tract, the origin of which may be in distant organs. Fright often produces a sensation as of cold at the pit of the stomach. Looking down from a height has the same effect in some persons. Discordant noises {252} have the same effect on people of sensitive hearing and certain reactions to touch may be similarly reflected. There are a number of affections which produce uncomfortable reflex sensations in the gastric region. This is the hypochondrium of the olden time. Whenever feelings were complained of, for which there was no actual basis in the hypochondriac region, it came to be spoken of as hypochondriasis, a word that has an innuendo of imaginativeness about it. Dr. Head's studies with regard to the transfer of sensations from one portion of the body to the other, show us that there is a good physical reason in reflexes for many of these complaints. An explanation of this to patients will often relieve their minds greatly and make their discomfort seem much less serious. Dr. Head said:

With orchitis or prostatitis, we also occasionally find that the patient complains of a pain at the epigastrium, representing the stomach area. This is put down to hypochondriasis and if it occurs in a woman as a consequence of ovaritis, she is said to be hysterical. But this phenomena is no more "hysterical," whatever that may mean, than is the reference of the pain and the tenderness of an aching tooth to the back of the head or the shoulder. [Transfers which have been observed actually to take place.]
This is the phenomenon I have been accustomed to call "generalization" of visceral pain and tenderness, and is of such common occurrence as to form a very important factor in the clinical picture of many diseases.
The order in which generalization takes place, leads one to speak of the relative "specific resistance" of the centers for the sensory impulses from various organs. No very definite rule can be laid down to govern every case, but each case must be considered on its merits. However, the area which appears most easily on a woman, as a secondary affection, is the tenth dorsal; then, perhaps the sixth dorsal, or inframammary, and then the various gastric areas, beginning first with the ensiform or seventh dorsal. In a man the tenth dorsal appears rather less readily while the ensiform appears with great ease.

Affections of other organs within the abdomen may produce like reflexes. A chronic appendicitis, for instance, will often be reflected in the stomach area. So will the presence of gallstones, or of disturbances of the biliary mucosa. Loose kidney often produces stomach reflexes. Any disturbance of the intestinal function will produce gastric irritation and inhibition of digestion. Most of the other primary conditions are more serious. Often the patient is aware of their existence, and it is a relief to him to find that the stomach symptoms are not the index of further pathological development, but only reflex conditions. This of itself does much to make the condition more bearable.

Patients who are suffering from symptoms of indigestion often have areas of their skin surface that are at least very sensitive, if not actually tender. They feel the pressure of their clothing over a particular portion of the body, usually on the left side of the abdomen somewhat above, though at times also below the umbilicus. Though not painful, as a rule, it is decidedly uncomfortable and produces a constant desire to loosen the clothing, or lift it from the part. Mere loosening, it is soon found, does no good, because the clothing continues to touch the skin and it is not the constriction or pressure but the contact that produces the discomfort. Sometimes there is a distinct lesion of the stomach. This cutaneous hyperasthesia may, indeed, rise to the height of extreme tenderness in cases of gastric ulcer, or the like. But there is no {253} doubt that a certain amount of this sensation is present with all functional disturbances of the stomach and that the reflex sensitiveness of superficial nerves is only what might be expected from what we now know of this subject.

Discomfort and Digestion.—Just as certain food materials disagree because of the state of mind, so certain feelings in the gastric region, even in the skin surface, sometimes disturb digestion and lead to changes of the diet unwarranted by the condition. Patients conclude that, if the skin is so tender, then the underlying organs, the disturbance of which causes this tenderness, must be in a serious condition. For these patients the explanation of the present state of our knowledge as to reflex disturbance of sensory nerves will be of therapeutic value. They must be taught that pain is reflected from one nerve branch to another, and is not communicated by continuity of tissue, or by sympathetic affection from the stomach mucous membrane through the stomach wall, and then from the abdominal wall to the skin surface. This knowledge will prove reassuring.

Division of Energy.—After this mental occupation with digestion itself, which by consuming nervous energy lessens the amount available for digestive purposes, probably the most common factor in the production of indigestion is the concentration of mind on serious subjects, while digestion is proceeding. An old English maxim is that some people have not enough brains to run their liver and their business. The liver in old-time pathology was considered the most important of the abdominal organs and was taken by metathesis for them all. Most of us have only a limited amount of vital energy and, usually, we can accomplish only one thing well at a time. If we try to do intellectual work while digestion is going on, both the intellectual work and the digestion suffer. If we persist in attempting to do both, we will surely disturb the digestive organs and we may bring about grave neurotic disturbances in the central nervous system. We may be able for a time to accomplish the two things at the same time, but it will not be long before evil results will be seen. Nervous, high-strung people should be reminded of Lincoln's anecdote of the little steamboat on the Mississippi which had not steam enough to blow its whistle and run its paddle wheels at the same time, so that whenever the engineer wanted to blow the whistle he stopped the boat.

Indeed, much of the indigestion that we see is due to this dissipation of energy through the attempt to do two things at the same time. Those who live the intellectual life are the most frequent sufferers. Worries and anxieties that are allowed to trouble the mind during digestion time are sure to disturb digestion eventually because they use up energy that is needed for physical purposes.

A change of environment that takes us away from the ordinary cares of life, is often sufficient to make all the difference between ease of digestion and extremely uncomfortable dyspepsia. By worry the mind apparently becomes short-circuited on itself and uses up a large amount of the available energy in nervous impulses that do not find their way outside the central nervous system at all, but are used in disturbing associated nerve cells. Just as soon as a change of scene and occupation calls for a different set of thoughts and other feelings, energy is released for work outside the central nervous system itself, digestion begins to improve, and in a comparatively short time what seemed to be a serious gastric disturbance, disappears almost completely.{254}

Lack of Sleep Repair.—In my own experience one of the most characteristic stigmata of these cases of indigestion which are due to exhaustion through other channels of vital energy, is that they feel much better in the evening than in the morning. They are, therefore, tempted to stay up late and so do not get the necessary rest. Their excuse for late hours is that they need recreation. To that excuse I have no objection. They do need more recreation; they need more hours during which their minds are absolutely free from business cares; but these hours must not be taken from their sleep, for they need rest even more than recreation.

Worries and Irritations During Meals.—The presence of worries or irritation during meals or shortly after, as well as unfavorable states of mind towards digestion itself, and occupation of mind with serious affairs during digestion, are likely to be sources of serious disturbance of digestion. A fright, a fit of anger, nagging, irritation, or any disturbing emotions, may hamper digestion. An experiment that is sometimes performed in the physiological laboratory on the cat nicely illustrates this. If the laboratory cat is fed some dainty that it likes, mixed with bismuth in order that its stomach and intestines may be made opaque to the x-rays, and then be examined by means of the fluoroscope, the peristaltic processes of digestion by which food is mixed in the stomach, passed out into the intestines, and by which intestinal digestion is stimulated, may be seen to go on very interestingly. If, now, the cat is made to arch its back, and manifest the usual signs of extreme irritation, the process of digestion is interrupted, and will not be resumed till some time after the cat quiets down. The lesson is obvious.