m I mm 41 5 ■ Hi Hi HI ■ V* ++ V* ^^ ^ ,^ .,,• / AN ^ ON MORBID SENSIBILITY OF THE STOMACH AND ^OWEIiS, AS THE PROXIMATE CAUSE, OR CHARACTERISTIC CONDITION OP NERVOUS IRRITABILITY, IVIENTAL DESPONDENCY, HYPOCHONDRIASIS, &c. &c. TO WHICH ARE PREFIXED, OBSERVATIONS ON THE DISEASES AND REGIMEN OF INVAL- IDS, ON THEIR RETURN FROM HOT AND UNHEALTHY CLIMATES. BY JAMES JOHNSON, M. D. OF THE ROYAL COLLEGE OF PHYSICIANS, &C. , PUBLISHED BY BENJAMIN & THOMAS KITE, SOLD BY THEM, J. GRIGGS, & J. G. AUNER, AKD BY S. WOOD & SONS NEW-YORK. 1827. * *» \ K PREFACE. The following Essay is re-printed from the Fourth Edition (just published) of my Work on the " Influence of Tropical* Climates on European Constitu- tions," for the convenience of those who may be in possession of former Editions, or who may not be inclined to possess the present one. The subject of this Essay has occupied the pens of so many able writers, of late, that some excuse may seem necessary for another tax on the Public. The present, however, is not a very heavy tax on the purse or patience of the reader ; for if it he a bad, it is, at all events, not a large book. I shall not therefore offer an apology, since no apology will procure a favourable reception for him who obtrudes himself unnecessarily on the time and attention of his professional brethren. The materials of this Essay have been drawn entirely from personal observation, and not a few of them from personal suf- fering ; and if I have questioned certain popular doctrines, and insisted on a more rigorous system of self-control than may A IV PREFACE. suit the ideas of many people, both in and out of the Profession, I have done so on the sure ground of experience. Those who disrelish the precepts I have laid down — •or who may think the promised advantages too dearly purchased by the proposed sac- rifices, have only to go on, till time and ill health induce them to think more seri- ously on the work of reformation. I have not preached Utopian doctrines on the subject of diet — I have proposed nothing but what has been practised by many others as well as by myself with advan- tage — and I am confident that he who fives the plan a fair trial, will never con- emn it, even if he have not fortitude to pursue it. In this Essay I have endeavoured to in- vestigate the operation of moral causes on the digestive organs, more minutely than has generally been done ; and to trace, with more care, the reaction of these or- gans on the mental faculties. The amount of suffering which is inflicted on the body through the agency of the mind, is only equalled by the retributive misery reflec- ted on the mind through the medium of the body. The play of affinities and re- ciprocity of sympathies between the intel- lectual and material portions of our nature, have not been sufficiently attended to in the investigation and management of dis- PREFACE. eases ; and I am not without hope that this Essay may be instrumental in lessen- ing the extent of human maladies by in- creasing our knowledge of their moral as well as physical causes. In the treatment, I have ventured to ex- pose the injury which is done to the stom- ach by a farrago of tonics and stimulants, as well as by violent purgation — while I have shewn the efficacy of some simple remedies when judiciously employed. — But, above all, I nave endeavoured to de- monstrate the true principles on which the plan of diet and regimen should be con- structed, not only in indigestion, but in a host of mental and corporeal discomforts which are little suspected of having their origin in the stomach. Having long suf- fered from this class of complaints, in my own person, my attention has been strong- ly drawn to it in others. The result of my experience is here given, in as small a space as possible, and the Public will de- cide whether or not my observations have been correct, and the deductions from them legitimate. JAMES JOHNSON. Suffolk Place, Pall Mall East, 1st Nov. 1S26, vi CONTENTS PART I. DISEASES AND REGIMEN OF INVALIDS FROM HOT CLIMATES. Page The Youth setting out, and the Invalid returning home, con- trasted -------..8 Dangers on returning to a Cold from a Hot Climate - - 10 The lungs liable to take on Disease - - . - - 11 Conduct on the Voyage Home from India - - - 19 Necessity of strict Abstemiousness on Embarking for Europe 13 The Danger of Hypochondriasis after returning 14 Debility on the Voyage Home ------ 15 Great Danger from too much Food - - - - - 16 Rules for Food and Medicine 17 Bowel Complaints on the Passage Home 22 Dietetic and Medicinal Treatment of - - 23 Sympathetic Affection of the Chest, on the Voyage Home - 32 Observations on Dyspeptic Consumption, as it is improperly called ----------33 Stages — Diagnosis by Auscultation — Treatment - - 35 Organic Disease of the Liver 39 Deceptive Methods of ascertaining Organic Disease of this Viseus ---_._-_-40 Diagnosis of Disease in the Liver ----- 42 Different Kinds of Organic Disease of the Liver 43 Wasting of the Flesh a characteristic Symptom - 45 Treatment of Organic Disease of the Liver 47 PARTE. on morbid Sensibility of the stomach and bowels, &c. &c. Prevalence of this Disease among all Classes of Society - 52 Various Designations by which it is known 53 Indigestion, Dyspepsia, Hypochondriasis, Bilious Disorder, all only forms or features of the disease 54 Distinction between the Ganglionic and Cerebro-spinal Nerves - - -- - - - - ib. Different Kinds of Sensibility in different Nerves ib. Illustrations of this Difference of kind, in the Sensibility of Nerves ---------55 Organic and common Sensibilities of the Stomach ib. Danger of exciting common Feeling or Sensibility in the Stomach --------57 Food and Drink ought to produce no Sensation in the Stomach - - - - - - ib. excite Sensations of Comfort during Health in dis- tant Parts of the Body - - - - - - ib. Irritation of the Stomach produces unpleasant Sensations in distant Parts of the Body, with or without Pain in the Stomach itself -- ------ 5S Two Classes of Sympathetic Effects from Irritation in the Stomach 59 Class I, — Morbid Sensibility of the Stomach and Bowels, with obvious Disorder of those Organs - - - - 63 CONTENTS. Vii Page Symptoms of a Fit of Intemperance ----- 64 The Manner in whicn Morbid Sensibility is formed, and the Foundation of Indigestion established 66 Strictures on Dr. Philip's Stages of Indigestion - - ib. •* Indigestion " a Conventional Term — the Author's Rea- sons for using the Term tw Morbid Sensibility " of the Gastric and Intestinal Nerves ----- 67 Symptoms of Liver and Stomach Affection combined - 68 Distressing Effects of vitiated Bile on the Digestive Organs, and through them, on the Mental Functions - - 69 Effects of Biliary Irritation on the Tongue, Eyes, Kidneys, and other Parts of the Body - ' - - - - 71 Distressing Sense of Debility, varying with the State of the Stomach 73 Tenderness of the Pit of the Stomach, a deceptive Symptom 74 Strictures on Dr. Philip ? s Remarks on this Subject, and on the Organic Diseases to which Indigestion is said to lead ib. Pain in the Region of the Stomach, Remarks on - - 78 Hardness of the Pulse, Remarks on - - - - - 79 Febrile Symptoms, Remarks on- - - - - -82 Changes produced in the Mucous Membrane of the Stom- ach by a long Continuance of Irritation there - - ib. Sympathetic Affections of various Parts of the Body from Irritation of the Digestive Organs 83 Sympathetic Affections of the Brain - - - - 85 of the Nerves of Sense, as of Sight and Hearing ib. of the Heart - - - - - - -86 of the Lungs ------- 87 of various other Parts of the Body - - - 88 Class 11. — On Morbid Sensibility of the Stomach and Boiveb, . without any obvious Disorder in those Organs themselves 89 Physical Causes of this Morbid Sensibility - - - ib. ' bad Air — want of Exercise — late Hours - - 90 Diet, the chief Physical Cause - - - 91 Criteria of the injurious Effects of Diet 99 Drink, a powerful Physical Cause - - - 93 Moral Causes of Morbid Sensibility, as Anxiety of Mind ■ &c. &c. - - 94 — Modes in which they act on the Stomach - - 96 Effects on Moral Causes exasperated by Food and Drink --------- tb, Hypochondriasis, Remarks on the Doctrines which have been broached respecting this distressing Malady - 97 Doctrines of Cullen, Broussais, Falret, and of the Ancients ---------98 Hypochondriasis, Doctrine of Villermay, appears the near- est to truth — namely, Change in the Organic Sensibili- ties of the Visceral Nerves ------ 99 Graphic Sketch of this Disease - - - - 100 People most liable to it - - - - - - 103 Symptoms of its early approach - - - - 104 Exasperated and mitigated by Diet " - - - 105 Vlll CONTENTS. TREATMENT OF MORBID SENSIBILITY OF THE STOMACH AND BOWELS, DIETETIC AND MEDICINAL. DIETETIC TREATMENT. Page Simplification of the Indications to be pursued - - - 107 Chief Indication, the Removal of the Sources of Irritation - 108 Regulation of Diet, the first object - - - - - ib. Danger of prescribing Medicines in this Disease, without first establishing a System of unirritating Diet ib. Rules for establishing a Regimen adapted to the Degree of Morbid Sensibility, or to the Digestive Power of the Stomach 109 Criteria respecting the Quantity and Quality of Food that may be taken without injury - - - - -110 Observations on Drink - - - - - - -114 Necessity of Firmness and Resolution in pursuing proper Regimen --------- \\Q MEDICINAL TREATMENT. State of the Secretions to be first ascertained - - - 116 Hints for ascertaining the State of the Secretions - - 117 Danger of irritating Purgatives in Dyspeptic Complaints - 118 Various FormulfE for Aperients ------ 119 Cases where Mercury may be necessary, or not - - - lril Observations on White Mustard Seed - 122 Means for reducing the Morbid Sensibility of the Gastric Nerves --------- ib. Counter-irritation externally ------ if,. Anodynes, with Blue Pill and Ipecacuan - 123 Hyosciamus with Blue Pill, a valuable Sedative - - - ib. Vegetable Bitters and Tonics - - - - - - 124 Danger of their too early Administration - %b. Nitrate of Silver, an important Sedative in Morbid Sensibility of the Gastric and Intestiual Nerves - 125 -Cases in Illustration of its Utility ib. Sulphate of Quinine, the best, and almost the only Bitter Tonic that is necessary - . - - - - - log Rules for administering this remedy in Dyspepsia - - 129 Treatment of Sympathetic Affections of various Parts of the Body 130 MORAL AND PHYSICAL REMEDIES COMBINED. Rules for the Management of Exercise - - - - 134 MORAL AND PHYSICAL EFFECTS OF TRAVELLING. Plan of a three months' Tour for the Restoration of Health 137 Amount of Active Exercise taken by the Author on a Tour 139 Routine of Exercise, Diet and Rest - - - - 140 Investigation of the Moral Effects of Travelling - - 1 42 Investigation of the Physical Effects of Travelling - - 145 Effects on the Sensibility of the Body to external impressions of the Atmosphere - - - - 146 Effects of the Lungs of Phthisical People - - 148 Effects on the Organs of Digestion - 149 Effects on the Absorbent System and Secretions 150 Effects on Dropsical Dispositions - _ - ib. Effects on the Heart and Circulating System - L*2 Effects on the Blood itself - - - - 153 PART I. OHST&RVATI0X& ON THE DISE&SES HMD HBGIMEH OF ON THEIR RETURN FROM HOT AND UNHEALTHY CLIMATES. The English youth leaves his native shores, with vigorous health and buoyant spirits, for a foreign land of promise, where he is to meet with adven- tures, acquire fame, and realize a fortune. All the happy events, real or ideal, of his future journey through life, are painted by his ardent imagination, in prominent characters, on the foreground of the scene; while reverses, sickness, disappointments — death itself, are all thrown into the shade, or, if suffered to intrude, only serve as incentives to the pursuit which has been commenced. During the short span of existence to which man is doomed on earth, it is a merciful dispensation that youth anticipates no misfortune; and that, when the evil day arrives in after life, Hope comes, on glittering wing, and gilds the scene even till the last ray of our setting sun is extinguished ! B 9 ON THE DISEASES AND REGIMEN I have already pourtrayed, in another place, the dangers which the tropical sojourner runs, the dis- eases to which he is subject, the remedies which experience has found most effectual, and the regi- men which appears to me most appropriate in the Torrid Zone. A task remains, which I have not hitherto undertaken ; but which the experience and observation of twenty years may now enable me to accomplish. The nature of that task is explained in the title of this part of my work. An epoch, sooner or later, arrives (and most wel- come it generally is) when the completion of a pe- riod of service; the acquisition of competent for- tune ; or, what is more frequent than any other, the loss of health, points to a return to our native land — a land which the more constantly engrosses our daily thoughts and nightly dreams, the farther we are distant and the longer we are absent from it ! None but those who have sojourned for years on foreign shores, can appreciate the feelings of the European, who wastes the prime of life beneath a tropical sun, languishing in body, and pining in thought to revisit the scenes of his youth, While every form that Fancy can repair From dull Oblivion glows divinely there I If he crossed the seas, in early life, full of antici- pations, that can, alas ! be but rarely realised ; he shapes his course back again across the same path- less deep, with chastened but scarcely less ardent hopes of health and happiness on the soil which gave him birth. — Here, too, he is destined to en- counter dangers as well as disappointments. The powers of the constitution, however plastic, cannot immediately accommodate themselves to great and len changes of climate, even when the transition Froifi a bad to a good one: and the tropical inva- OF INVALIDS FROM HOT CLIMATES. 1C lid requires full as much caution and prudence in approaching the shores of England, as he did in landing at a former period, on the banks of the Ganges. When the European has become much debilitat- ed by liver affection, dysentery, or fever and its consequences, his main hope of recovery rests on change of climate, and under such circumstances, the sea voyage will often effect the cure. Indeed the instances are not few where more benefit is oh-- tained by the voyage home, than by subsequent residence in England. The voyage, though not totally free from inconvenience, presents not the thousand temptations to deviate from regular habits and regimen, which afterwards assail the tropical invalid, when he mingles with society in his native country. Besides, the uniformity and salubrity of the sea-air, aided by the mental exhilaration of a homeward voyage, produce surprising effects on the animal economy. During this voyage the ef- fects or sequelae of fevers generally disappear, and both appetite and strength return. But chronic dysentery and hepatitis are not so easily removed, and these the tropical invalid most commonly brings with him to Europe — sometimes considerably miti- gated, but at others, rather exasperated, especially if stormy wet weather is experienced off the Cape, or if the ship arrives in the channel at an unfavour- able period of the year. By residence in a hot cli- mate, the constitution becomes assimilated to it, and, in some measure changed. The return, there- fore, to a cold, though more healthy latitude, is liable to produce, if great care be not taken, a de- termination to those organs which have been wea- kened by previous disease; and thus a more or less acute inflammation is often set up in the mucous membrane of the bowels ; or they are rendered more irritable than before the invalid left India. A 11 OP THE DISEASES AND REGIMEN subacute inflammation of the liver is sometimes thus superinduced on a chronic disease or torpid state of that organ, requiring not only the subduction of the stimulus of food and drink, but even local abstrac- tions of blood from the region of the liver. But the most serious consequence of a return to Europe, after long residence in a tropical climate, is the aggravation or even production of disease in the chest. The mucous membrane of the lungs sympathises readily with that of the stomach, and thus produces what is called a stomach cough. Chronic diseaseof theliver produces the same thing, whether by means of sympathy, or simply by con- tiguity with the diaphragm, which is so intimately connected with the organ of respiration. Now, in a great majority of instances, these affections of the chest are only symptomatic, even when the inva- lid has returned to Europe, and will subside in pro- portion as the functions of the stomach and of the liver are restored. But, on the other hand, there are many cases where the symptomatic affection of the chest has continued so long as to induce actual disease there ; which disease will not be removed, nor even materially relieved by the remedies pre- scribed for the liver or stomach complaint. In this country, the symptomatic aflection of the lungs in chronic hepatitis and indigestion, has ex- cited much attention, and has been treated of under the names of ' f hepatic phthisis, " dyspeptic phthis- is," and " stomach cough." Where there is evi- dently derangement of the liver or stomach, and the patient is lately from a hot climate, the English practitioner sets down any pulmonary affection that may be complained of, as symptomatic, of course, of the abdominal disorder ; and thus, that time is lost in abortive attempts to remove both classes of complaints by striking at the original one, which might have saved the lungs from irremediable dis- OP INVALIDS FROM HOT CLIMATES. 12 organization. Many are the instances I have seen, and continue to see, where patients have been pro- nounced to be labouring under symptomatic disease only, while a few minutes' examination of the chest by percussion and auscultation detected organic chan ges in the lungs or heart which had passed the pe- riod when any chance of recovery could be expect- ed. This, in fact, is one of the greatest dangers which the tropical invalid runs, when he embarks for his native climate, where pulmonary complaints are the prevailing diseases. On this account, he should, from the moment he goes on ship-board, pay the utmost attention to his dress, and most cau- tiously avoid all exposure to wet and cold on the voyage homewards. This caution is not le*ss neces- sary for the invalid affected with the usual conse- quences of tropical diseases only, and where the chest is free at the time he embarks. As he ap- proaches the Cape, and afterwards the Channel, he is much more liable to pulmonary affection than a person who has never suffered from hepatic or stom- ach disorder; and, if the chest once becomes affect- ed, he is much more exposed to fixed and danger- ous disease there. If the pulmonary affection, even of the mildest kind, and purely symptomatic, has manifested itself between the tropics, he is in still more danger; and if the English practitioner faiis to make the most rigid examination of the chest, on his arrival, he becomes morally responsible iox all the serious consequences which may subsequent- ly result from this neglect. In short, I have no hesi- tation in asserting, that the disorder of the chest, even if purely symptomatic, demands more atten- tion, and is really of more importance than the ab- dominal disorder from which it arose. There is lit- tle or no organic disease of the liver in one case out of the twenty of those who return to this country labouring under " liver complaint" — and this re~ B 2 13 ON THE DISEASES AND REGIMEN mark is still more applicable to the stomach — con- sequently j there is but little risk of life. But if the lungs once become affected in structure; if symp- tomatic be confounded with organic derangement, or suffered by neglect to pass into that state, the case will rarely be otherwise than fatal. The surgeon of the ship, therefore, should take an early opportunity of examining the chests of all invalids complaining of cough, or who are easily put out of breath on ascending ladders, &c. If they cannot lie low in bed, or take in a deep inspiration without exciting cough ; and still more, if they feel uneasiness in any part of the chest, the case should be immediately attended to before the patient gets into the high latitudes, where the malady will cer- tainly be increased. A blister, a few leeches, or a crop of pustules excited by tartar-emetic, aided by warm dress, abstinence from stimulating drink, and some gentle diaphoretic to act on the skin, would save many a day's sufferings afterwards — nay, many a valuable life. But of this more here- after. It is on the voyage to England, where there are many circumstances favourable to the object in view, that the invalid should seriously think of adopting a system of diet and regimen that might not only obviate any injurious effects of a sudden transition from a hot to a cold climate, but contribute mate- rially to the removal of those complaints contracted by residence in the former. It cannot, indeed, be too strongly impressed on the mind of the tropical invalid, that without a firm resolution to coerce his appetites into complete subjection, and make them subservient to the restoration of his health, he will gain little by a return to his native skies ; but, on the contrary, he will either confirm those maladies under which he already labours, or, what perhaps is worse, convert them into forms less formidable OP INVALIDS FROM HOT CLIMATES. 14 indeed in appearance, but effectually subversive of every enjoyment, mental or coporeal, which can render life desirable. Of all the miseries to which man is liable, by the frailties of his nature, there is none more terrible to endure, or difficult to remove, than that hypochondricaal despondency which is sure to settle on the tropical invalid, in his own country, in the midst of his friends, and in the pos- session of wealth, unless he succeeds, by timely and proper measures, in correcting those morbid condi- tions of the digestive organs, from which this dae- mon draws a gigantic power and influence, that ty- ranize over all fortitude, philosophy, and even re- ligion itself! The extent of this evil is so great in these isles, that it has been suspected, and not with- out probability, that our tropical colonization has introduced and propagated, by hereditary descent, a strong disposition to stomach and liver affections beyond that which is observed in any other coun- try. Be this as it may, the instances of insanity and suicide, from this cause, are not exceedingly rare; while the number of hypochondriacs, cursed, I might almost say, in the possession of reason, but driven to despair by the torture of their own mor- bid feelings and nervous irritation, which may be seen in all parts of the British dominions, but espe- cially at watering places, is truly astonishing! Of these, our tropical invalids form no inconsiderable portion ; and although the wretchedness of their sensation is only known to themselves, their medi- cal attendants, and some of their intimate acquaint- ances, the amount of it is great beyond all calculation. That this unhappy winding up of a life spent un- der a burning sun, in the acquisition of wealth, and in the vain expectation of enjoyment in declining years, cannot always be prevented, is but too true; yet, at the same time, I know from repeated exam- ples and multiplied observation, that a rigid system 15 ON THE DISEASES AND REGIMEN of self-control adopted as soon as the individual withdraws himself from under the deleterious in- fluence of a hot climate, and persisted in for a cer- tain time after his arrival in Europe, would, in nine cases out of ten, be fallowed, not only by restora- tion of health, but by an equilibrium of spirits and mental serenity which none but the temperate, the abstemious, and the prudent, can possibly appreci- ate. This system will be detailed farther on. The principal states of indisposition under which an invalid embarks for Europe, are debility from long-continued disease of the liver, or the remedies unavoidably employed for that complaint ; debility from fever, or a continuance of regular or irregular paroxysms of the disease ; and bowel-complaints. Debility can only be removed, of course, by the introduction of nutriment into the system; but this does not always follow the introduction of food into the stomach, even when taken with considerable relish. One of the first effects of the sea-air is an increase of appetite, and the invalid hails this as a favourable omen, and indulges the propensity to eat. The debility of the various organs, however, and their previous desuetude to much nourishment, seldom permit this new propensity to be satisfied, without subsequent detriment. Indigestion, fever- ishness, or irritation of the bowels is almost sure to follow too free an indulgence of the appetite, and consequently there is no increase of strength from this temporary return of desire for food. Jlppetite, indeed, is a bad criterion for taking food; digestion - — easy digestion, is the only sure guide. If we feel uneasy after four ounces of food, but comforta- ble after the ingestion of two ounces, we shall de- rive more support from the latter than from the former. The quantity and the quality of the food must be both carefully regulated ; and, in general, the invalid's own feelings will warn him when he OF INVALIDS FROM HOT CLIMATES. Id has erred on either point. But this is not always the case. There is no effect of indigestion more common than dejection of mind, when no corpo- real inconvenience appears to follow. The nerves of the stomach and upper bowels will be irritated, and this irritation will be propagated to the whole nervous system, and all its moral and intellectual at- tributes, by quantities and qualities of food which excite no sensible uneasiness in the organs of diges- tion, and produce no change in the secretions or ex- cretions by which the evil might be detected. A want of attention to this circumstance — or rather a want of knowledge of it, has led, and leads daily, in numerous instances, to states of mental desponden- cy, ending ultimately in complete hypochondria- cism. In insanity, the morbid condition of the mind is invariably dependent on a morbid condi- tion of the body, (whether indu#ed by moral or physical causes,) although the latter is rarely cog- nizable by external corporeal symptoms. This holds equally good in hypochondriacism. The mental despondency is invariably dependent on some disorder of the body, and, in nine cases out of ten, it is immediately dependent on a morbid or ir- ritable slate of the nerves of the stomach and bow- els. Of the truth of this I have had such multiplied proofs, that not a doubt remains on my own mind respecting it. It is as useless to attempt the remo- val of this mental despondency by moral means or mere persuasion, as to try to remove a fever or an inflamation by argument. The attempt, indeed, be- trays a great ignorance of the real nature of the com- plaint in the physician. Moral means may certain- ly contribute to improvement of the general health, and this will much improve the state of the diges- tive organs, on which the mental despondency de- pends. It is only in this way that moral means can 17 ON THE DISEASES AND REGIMEN have any influence on hypochondriacism. But of this, more hereafter.* If the invalid only labours under that debility pro- duced by fever and the remedies used for it, the sea-air and the gradual increase of tone in the di- gestive organs will generally be sufficient to renew the strength, under the caution above-mentioned respecting diet. In such cases it can rarely be pru- dent to exhibit direct tonics at the beginning of the voyage. A warm bitter is quite sufficient, as equal parts of infusion of ginger and gentian, with four or five grains of carbonate of soda, and a drachm or two of any bitter tincture in each dose. The bowels should be regulated by mild aperients that do not produce thin or watery discharges — an operation which should be avoided, but which, I am sorry to say, continues to do infinite mischief. Many prac- titioners and patJlnts are absolutely infatuated with the benefit to be derived from the blue pill at night, and the black dose in the morning. This medicine certainly sweeps away abundance of thin, fetid, and unhealthy secretions, and the patient feels lighter and more comfortable for a time; but a repetition of the practice produces the very secretions which it is designed to carry off or prevent. After clear- ing the bowels in this way, the great object is to procure formed motions, if possible, and that not oftener than once in the 24 hours. That medicine which goes slowly and without irritation along the intestinal canal, permitting the nutriment to be ta- ken up by the absorbents, and gently stimulating the large intestines to discharge the useless residue, is the one to which we should have recourse. Aloes is the basis of such medicine; but as, in the class of patients now under consideration, there is generally * The functional and organic diseases of the liver will be treated of presently, in conjunction with dyspepsia, from which they are rarely free, in tropical invalids. OP INVALIDS FROM HOT CLIMATES. 18 a defective or vitiated condition of the billiary se- cretion, and an irritable state of the gastric and in- testinal nerves, together with a torpid skin, it is necessary to combine other medicines with the aloes. A grain of blue pill, three or four grains of extract of hyosciamus, and a quarter of a grain of ipecacuan, combined with as much aloes as is suffi- cient to move the bowels once daily, will be found a valuable form of aperient for the invalid on the voyage home. The hyosciamus allays the morbid irritability of the nerves of the digestive tube; the blue pill gently excites the hepatic secretion as well as the pancreatic .and gastric ; the ipecacuan acts mildly on the skin ; while the aloes carries the whole slowly along the canal, and finally expels the faecal remains in the course of the ensuing day. Some little time may be necessary to ascertain the proportions of these medicines that may suit indi- vidual cases; but there can be little difficulty in ob- taining the proper result in the end. It is supposed that a disposition to haemorrhoids is an insuperable objection to aloes, or the compound extract of colo- cynth. This has been proved to be an error, and aloes is now commonly given by some of the best London practitioners for haemorrhoids. It is too much purging that increases and irritates piles rather than the kind of purgative. Where it is desirable to procure one free and copious operation in the morning, a common seidlitz powder taken at 7 o'clock, and before breakfast, will pretty certain- ly have this effect. If the tropical invalid continues to be teased with regular or irregular paroxysms of fever, in spite of the above means, the sea-air, and strict regimen; then we must have recourse to certain specifics, and above all to the sulphate of quinine, a medicine which is indeed of singular efficacy, when properly managed, in many of those morbid conditions of 19 ON THE DISEASES AND REGIMEN the digestive organs, resulting from the influence of tropical climates. The doses, however, should be small in the cases now under consideration, where there is generally some obstruction or congestion in the liver or spleen. The surgeon should atten- tively examine the state of these viscera, and by lo- cal detractions of blood and counter-irritation, re- move or lessen those affections on which the re- turns of the febrile paroxysm depend. When these organs are secured by such means, then from one to three grains of the quinine should be given every six hours, during the intermissions, in an infusion of bark, quassia, or gentian: and neither the sur- geon nor patient should be over anxious to stop at once these paroxysms by larger doses of the medi- cine. It is far better gradually to give tone to the whole digestive apparatus, while the secretions of the glandular viscera are slowly improved by the mild aperient above-mentioned. The attacks, at first mitigated and ultimately stopped, in this slow manner, will be far less liable to recur, than when overwhelmed suddenly by such powerful tonics as the quinine and arsenic in large doses. The inval- id, however, ought to continue the use of quinine, in conjunction with bitters and aperients, for a con- siderable time after all periodical accessions have ceased, since changes of weather, irregularities in diet, and many other causes are very apt to repro- duce the paroxysms. Although the subject of diet will be particularly considered farther on, yet it may not be improper to glance at it in this place. A ship cannot be sup- posed the best place for adopting a systematic course of diet, but as, from the pharmacopoeia, we select a very small number of medicines for practical use, so from the interminable list of culinary substances, a very few, indeed, will suffice for the necessary nutriment of man, especially when he is in a vale- OP INVALIDS PROM HOT CLIMATES. 20 tudinary state. In health, we may pamper the sen- ses ; as invalids, we must consult the organic sen- sibility of the stomach and bowels, without any re- ference to the palate. If we do not, we pay the penalty most severely. The tropical invalid then, returning for debility, resulting from liver complaint, long courses of mer- cury, or protracted fevers of whatever type, should breakfast on ship-biscuit or stale bread, without butter, and black tea, or coffee, with very little milk and sugar. A slice of cold meat is better than but- ter for breakfast. As dinner is at an early hour, he should rarely give the stomach any more to do till that period. He should then dine on from one to six ounces of plain animal food, according to his digestive powers, without vegetables of any descrip- tion, unless stale bread or ship-biscuit be classed un- der that head. This will seem a most terrible rule ! It is so in appearance, after the luxuries and provo- catives of an oriental table. But let the invalid pur- sue it only till he passes the Cape of Good Hope, and then he has permission to change it, and adopt what system he pleases. If he will not adopt so rigid an abstinence from vegetable matter at dinner, the best thing next to biscuit or stale bread is well boiled rice, rice or bread-pudding, or a dry, mealy yam. In England a mealy potatoe may be tried, but even this is apt to irritate the disordered nerves of a dyspeptic invalid. In respect to drink, a table-spoonful of good bran- dy to two wine-glassfuls of water, is a mixture pre- ferable to wine of every kind. If a sense of thirst prevail while masticating well and slowly his food, he must take some of this drink : if not, let him fin- ish before he drinks. The above potation should be made to suffice if possible ; and double the quan- tity should hardly ever be exceeded. It will be said that constitutions differ, and what will agree C 21 ON THE DISEASES AND REGIMEN with one stomach will not agree with another. This may be true; but we cannot make rules for excep- tions. There will not be one individual in fifty with whom the above plan will be found to disa- gree. We know, indeed, that some people will rather indulge the senses than improve the health, and these will aver that such a rigid system of diet entirely disagrees with them. They have truth laid before them here ; they may adopt it or neglect it as they think proper. The penalty will fall on themselves, not on the prescriber. It is hardly ne- cessary to say, that no other dessert than biscuit is at all to be thought of. Tea or coffee, with biscuit, at 6 o'clock, and half a pint of good gruel, sago, or arrow root, with a table-spoonful of brandy, for supper, should close the day, at ten o'clock in the evening. The inva- lid should then go to bed ; and if he has been ac- customed to more stimulation than the above scale affords, he will pass some sleepless nights, and be often tempted to break the vile system of abstemi- ousness which the doctor has prescribed. Let him persevere. Sleep will come — and that, too, of a more refreshing quality than ever followed the stu- pefying influence of wine or spirits. We da : ly hear it remarked, that long established habits of in- temperance cannot be safely interrupted at once. Of the truth of this I have much doubt, because I have seen a few — alas ! a very few instances, where downrighthabitual intoxication was suddenly check- ed, without any bad consequence resulting. But this is not the point under consideration. I am speaking of habits which are looked upon as far within the limits of temperance; for instance, the habit of drinking a pint of wine after dinner, and a glass or two of brandy and water in the evening, over a cigar. This habit may be easily broken, and what is of still more consequence, the habit of 07 INVALIDS FROM HOT CLIMATES. 22 eating a great deal too much through the day, may be readily and salutarily changed into strict abstemiousness. Bowel-complaint is one of the most common dis- eases under which an invalid labours when embark- ing for Europe. It is one, too, which is seldom cured on the voyage home. After repeated attacks of dysentery or hepatitis, the mucous membrane of the colon and rectum is actually altered in struc- ture, while that of the small intestines continues highly irritable for a long time. A large quantity of mucus and of very morbid secretions is constant- ly poured out from these surfaces, and their irrita- bility will not permit the presence of food or faeces, as in a healthy condition of the alimentary canal. In those who die of dysentery, we find ulcerations in the colon and rectum, with thickening and other lesions of the coats of these tubes. In those, there- fore, who have presented the same symptoms, but who have been fortunate enough to survive, there is every reason to believe that ulcerations had ex- isted, or do exist, as, indeed, has been proved by dissection. Ulceration of the intestines may take place without any discharge from the bowels, or particular pain that would indicate such a serious malady, as is proved by finding extensive ulcers in the mucous membrane, where death has been occa- sioned by fever — and that, too, without any tender- ness on pressure of the belly being evinced during life. Where there is discharge of mucus, blood, and puriform fluid, we may pretty certainly prog- nosticate that there is ulceration and other organic mischief in the coats of the lower bowels. This state will, of itself, keep up chronic diarrhoea or dysentery till the parts are restored to a sound con- dition — and, even after the structure, becomes sound, the function, from long habit, will remain deranged, or easily rendered so by very slight causes. 23 ON THE DISEASES AND REGIMEN But anotherand still more-fertile source of chronic bowel-complaint is disordered function, or diseased structure of the liver; one effect of which is very commonly relaxation and irritability of the bowels, especially in a tropical climate, and for some time after returning to Europe. It is not necessary, in this place, to enquire into the reason why the func- tion of the bowels should be so generally disturbed by disorder of the liver. The fact is well known to all who have practised in tropical climates, and that is sufficient for the purpose, at present. If the bowel-complaint be unaccompanied by he- patic affection, and merely kept up by disease or disorder in the bowels themselves, the treatment is less complicated, both on the passage home and subsequently in Europe, than where chronic hepa- titis is present. In the former case, or simple bowel-complaint, the invalid has three-fourths of the treatment, in his own hands, or in his own power. Have we any remedy to cure a chronic irritation, inflammation, or ulceration of the internal surface of the bowels ? I believe not. Nature must do this. But we can withdraw those things which obstruct nature and keep up the disease. If any portion of external surface were in the above-mentioned condition, what would we do ? The answer is plain. We would protect the part from extraneous irritation, and give it rest. Nature would do the remainder. This rule is equally applicable to bowel-complaints. The passage of the remains of our food over the irri- table or diseased membranes, lining the bowels, causes pain, throws the intestines into increased action, and, in fact, produces the phenomena of chronic dysentery or diarrhoea. We cannot, it is true, prevent this entirely ; but we can live upon that kind of food which affords not only the least quantity of residue, but the least irritating kind OP INVALIDS PROM HOT CLIMATES. 24 of residue. This object is obtained by living as much as possible On farinaceous food, as sago, ar- row-root, gruel, tapioca, rice, panada, with animal jellies. It is evident that every thing that passes the stomach undigested must add to the complaint, and, therefore, the quantity of nourishment taken in should always be as small as is compatible with the support of life. Indeed, as was observed before, the less that is taken into the stomach, the more will be extracted from it by the digestive apparatus, and the more strength we will derive from it. As the organs of digestion are, in this complaint, great- ly weakened, those substances'which have any ten- dency to turn acid are particularly injurious and irritating, since the vital powers of the stomach and intestines are not sufficient to overrule the chemical laws that produce the fermentative pro- cess. Hence vegetables and fruit are poison to the dysenteric invalid. The drink is also a matter of great importance. Wine is almost always injuri- ous, and very weak brandy and water is the only stimulating potation that should be indulged in. The less of this, too, the better. Rice water, with some spice, is the best drink ; and as little fluid of any kind as possible should be taken into the stomach. There is one important item in the management of bowel-complaints which is too often overlooked. This is, the necessity of 'quietude. It is difficult to account for the circumstance, but it is an absolute fact, that rest and the horizontal posture are of more benefit in dysenteric affections, whether acute or chronic, than in many of those spinal diseases for which the patient is confined to a hard mattress or an inclined plane. The action of the abdominal and other muscles sets in motion and augments the peristaltic action of the intestines, already in excess, and thus hurries along the remains of food, and pro- duces many more evacuations than would otherwise C 2 25 ON THE DISEASES AND REGIMEN take place in a state of quietude. The tropical in- valid, therefore, should not be gadding about the decks on the voyage home, but confine himself a good deal to his cot or his cabin, and, in wet or blowing weather, he should not attempt to go from below, unless compelled by unavoidable circum- stances. As the temperature of the ocean is, at all times, much below that of the land, in the hot season, the invalid should guard the skin most scrupulously from all assaults of moisture or cold air. If this be not attended to, the bowel-complaint will be exas- perated instead of amended on the homeward voy- age. The belly should be bandaged pretty tightly with a very long flannel roller, which will prove not only a defence from cold and humidity, but it will curb the action of the abdominal muscles, and tend to keep the intestines quieter. Food and drink should not be taken either very hot or very cold. The former excites the bowels almost im- mediately ; and the latter causes pain in the sto- mach and colic in the intestines. But is there nothing to be done in the way of medicine? Yes, provided the medicinal treatment be aided by the strictest attention to diet and regi- men, as sketched out here. We cannot by direct remedies heal chronic ulcerations, thickenings, or other morbid affections of the intestines ; but we can greatly assist nature in preventing and remov- ing various sources of irritation ; and we can lessen the morbid sensibility or irritability of the bowels themselves, and thus check the increased discharges from them. The two principal sources of irritation are, the remains of food passing along an irritable or actually diseased surface, and acrid or morbid secretions, coming from the liver, the pancreas, and the glands and follicles of the intestines themselves. I have OF INVALIDS FROM HOT CLIMATES. 26 already hinted at the means of lessening the irrita- tion of faecal matters, by strict attention to the quan- tity and quality of food taken into the stomach. If this point be attended to, much of the inconve- nience from morbid secretions will be prevented; for there is not a more certain method of rendering the secretions acrid and diseased, than by eating and drinking more in quantity than can be well di- gested and disposed of; or things of a quality known to disagree with irritable bowels. For the improvement of the biliary secretion, much may be done by medicinal treatment. As there is generally some degree of low inflamation or congestion about the liver, a few ounces of blood taken from the neighbourhood of that organ, once in a fortnight or three weeks, will be of essential benefit — especially if there be pain or tenderness on pressure under the false ribs. The counter-irrita- tion of an occasional blister, or, what is better, a tarter-emetic plaster to the region of the liver, will be found a useful item in the treatment. Very mi- nute doses of the mildest mercurial, particularly the hpdrargyrum cum creta, or the blue pill, combined with a small quantity of ipecacuan, and a drop or two of essential oil, every night, will be necessary, even if long and repeated courses of mercury have been previously endured. For it is to be recollect- ed, that the same remedy which fails, or only parti- ally succeeds, where the causes of hepatitis are in constant operation, will be often successful when the individual is withdrawn from the sphere of these causes, and enjoys the pure air of the ocean, or the genial influence of his native skies. But a mild mercurial is necessary, as an alterative, and to keep up some degree of healthy action in an organ that has been long stimulated by the heat of India, and by large doses of the same medicine, unavoidably exhibited to prevent destruction of the biliary ap- paratus. 27 ON THE DISEASES AND REGIMEN As ascidity is a common symtom in chronic bowel-complaints, so alkaline and absorbent medi- cines are daily and almost hourly necessary, till the digestive organs have acquired more power over the food taken in. Three to five grains of the car- bonate of soda, with an equal quantity of the com- pound cinnamon powder, three or four times a day, will be a useful antacid, and will cut off one source of irritation. On the other hand, rancidity is apt to prevail where oily or fat substances are taken into the sto- mach. We cannot qualify this so readily as acidi- ty. We should avoid the cause. A bitter spiritu- ous tincture is the best thing to check rancidity when it has taken place. Acrid, acid, and rancid matters, however, are so quickly and so constantly generated in the bowels, that we are forced to expel them by aperient medi- cines, even at the time when the intestines are re- ally too often acted on. The relief that follows this forcible expulsion of morbid secretions has induced both patients and practioners to have too much re- course to purgative, both in acute and chronic bow- el-complaints. They give relief in two ways — by removing irritating matters, and by lessening, for a time, irritability itself. Any strongly acting pur- gative will, as it were, exhaust the irritability of the nerves of the mucous membrane, and a tempo- rary insusceptibility to impressions is the natural consequence. But this method should be cauti- ously employed, and other means are preferable. Castor oil, rhubarb, and the milder aperients, not too often repeated, are much better than doses of calomel and ; black-draught, whatever may be the degree of comfort experienced after these last medi- cines. Thin injections of gruel and oil, with some laudanum, are very useful, not only in allaying ir- ritability of the rectum and colon, but of washing OF INVALIDS FROM HOT CLIMATES. 28 away the remains of irritating secretions from these parts. Whenever we exhibit purgatives in this complaint, we should combine with them some slight anodyne — especially the extract of hyoscia- mus or lettuce. This is a precaution too little at- tended to. So much for the correction of irritation resulting from diseased secretions. But we must remember that there is a morbid irritability of the mucous surfaces of the stomach, and especially of the bow- els, in consequence of which, things that, in health, would produce no sensation, much less inconve- nience, cannot now be borne without great, discom- fort. This state often obtains where no inflamation, no ulceration, no organic or perceptible change of structure in the parts themselves, has yet taken place, or remains after having one existed. Such condition appertains to the nerves of the digestive organs, and can only be remedied through the ner- vous system. There are many ways of diminishing morbid nervous irritability — I say morbid, because those things which decrease morbid irritability or sensibility, will not always decrease natural or healthy irritability. I have remarked on one of the classes of means we are to use — the subduction of irritating food, and the correction or removal of irri- tating secretions. The direct reduction of morbid sensibility in the intestines is generally attempted by direct sedatives or anodynes — of which opium stands at the head. Without this valuable medicine, we can seldom succeed in the bowel-complaints of hot climates; but its use is attended with much in- convenience in many constitutions, and we should endeavour to make as little as possible serve the pur- pose of quieting the bowels, and lulling the sensi- bilities of their nerves. From half a grain to a grain of opium, combined with two or three of hyo- 29 ON THE DISEASES AND REGINEN sciamus, a grain of blue pill, and half a grain of ipe- cacuan, will be found very beneficial every night at bed time, continued for a considerable time, while, every second or third day, a small dose of castor oil may be advantageously taken to remove any hard- ened faeces, or diseased secretions from the cells of the colon, in which they occasionally lurk, and keep up irritation in the whole line of the bowels. When the invalid is harrassed through the day with frequent motions, consisting principally of sli- my mucus, and attended with straining and tenes- mus, he should keep as quiet and horizontal as pos- sible, and take a spoonful of the following medicine after every relaxed motion. J& Pulv. Cretan comb. 3j. Confect. Aromat. . 3j. Tinct. Rhei, . . gij. Opii, . . 3j. Mucilaginis Acacias, gss. Syr. Zingib. . . gij Aquae Cinnamomi. ^iv. Misce, fiat mistura, capiat coch. j. mag. post singu- lam sedem liquidam. If the opium disagree, the tincture of hyosciamus may be substituted ; but it is not so efficacious in restraining the discharges from the bowels. There are many other medicinal substances which lessen morbid sensibility of the bowels besides those of the anodyne or narcotic class. It has long been known that debility is the parent of irrita- bility. This is obvious to the most superficial ob- server. A familiar example is seen after all acute or inflammatory diseases. During the height of the fever or inflammation, for instance, the general ex- citement of the system prevents the feeling of weak- ness; but as soon as the excitement subsides, the OF INVALIDS FROM HOT CLIMATES. 30 patient is then sensible of his exhaustion, and be- comes proverbially irritable. Nurses and other at- tendants on the sick, are aware that this irritability is a sign that the disease is subsiding or subsided, and always consider it as a favourable symptom. Now what applies to the whole, applies also to a part. Wherever local disease has been established, and the structure or functions injured, there will be debility and irritability. By removing the/br??zer, we shall generally mitigate the latter. Tonics, therefore, when they can be borne, and where they do not induce too much excitement, are valuable means of blunting the morbid sensibility of the nerves. But their bulk often proves a source of ir- ritation to the stomach and bowels, hence the sul- phate of quinine, properly managed, is superior to all others, on account of its vast efficacy in so small a form. It is generally given in doses too large, by which an excitement is produced that renders it necessary to discontinue the medicine. The follow- ing form will be found an admirable mode of ad- ministering this remedy in chronic dysentary and diarrhoea. Jk Tinct. Gentianae c. . . ^iss. Zingiberis . . . Camphorae Comp. aa gij. Sulphatis Quininae . gr. x. ft. solutio, capiat coch. j minut. ter die, ex pauxillo aquae tostae. The principal inconvenience that I have found to result from this remedy, is the increase of appetite, which soon follows, and which may induce the pa- tient to indulge too freely in food. He ought to be put on his guard against this danger. The improve- ment in the state of digestion that results from the operation of this preparation on the stomach, will 31 ON THE DISEASES AND REGIMEN greatly conduce to the removal of irritation from the bowels, of which undigested food is a common source. Independent of this, the quinine will be found, thus managed, to give tone to the whole line of the mucous membrane — to restrain the mucous discharges, and thus to directly lessen morbid sensi- bility in the nerves of these parts. I am not a friend to common astringents in the bowel-complaints which follow diseases and resi- dence in hot climates. The mucous discharges are thus rudely stopped, and a sub-acute inflammation of the membrane from whence it issued, or of the liver itself, is not an unusual consequence. It is far better to withdraw irritation and reduce morbid sensibility — the causes of the increased discharges — than to strike at the branches while the root remains untouched. The farrago of astringent substances that have been employed to restrain dysenteric and hepatic flux, are worse than useless, and the prac- tice of applying them, is built on an erroneous foun- dation.* If the means which I have pointed out should fail, it is highly probable that a gentle mer- curial course will be necessary, either on the voy- age home, or soon after gaining the shores of Eu- rope. This course, as I have hinted before, will often effect a cure, where long and repeated courses of mercury, beneath a tropical sun, and in a land that produces the causes of the disease, may fail, or give only temporary relief. The mouth, however should not be made sore while rounding the Cape, especially if that part of the voyage be made in June, July, or August, when wet and cold weather * Within these two or three years, I have seen some extraordi- nary good effects, in chronic irritability of the bowels, from small doses of the lunar caustic taken internally — namely, half a grain to a grain twice a day. We know the efficacy of this application externally, in lessening the irritability of sores, and I conceive that it acts in the same manner internally. OP INVALIDS FROM HOT CLIMATES. 32 may be expected. Advantage should be taken of the milder and lower latitudes, near the Equator, if it be deemed indispensable to impregnate the system with mercury. But, however this may be, as the tropical invalid approaches the shores of England, he should protect the skin, by all possible care, from chills or damp. The atmospheric influence will reach him in spite of all precautions ; but if he rashly exposes himself to the skies of this country, after a long residence in the torrid zones, especially if labouring under bowel or pulmonic complaint, he will be in danger of serious aggravation of his malady. Before quitting the subject of the homeward- bound voyage, I cannot help saying a few words more on a topic which has been already touched on — namely, those affections of the chest which are originally induced by disease of the liver, or of the digestive organs generally, and which have been called "dyspeptic phthisis/' " stomach-cough," &c. Many valuable lives are annually lost by treating these complaints as purely symptomatic, when they have actually become fixed diseases in the lungs or other parts within the chest. When the disease has passed the boundary, and become independent of its original cause, which it not unfrequently does, then I maintain, from the most unquestionable evi- dence, that it is aggravated rather than alleviated by the remedies employed for the cure of the origi- nal complaint. Modern investigations (ausculta- tion and percussion) have now given us the means of ascertaining with the greatest accuracy, whether there be or be not organic affection of the lungs or heart. The medical practitioner, therefore, who has the charge of the invalid on the voyage, or who first sees him on his reaching Europe, should not neglect to examine the chest most scrupulously, wherever there is cough, difficulty of breathing, or D 33 ON THE DISEASES AND REGIMEN irregularity in the circulation; and, if any disease be detected there, the hepatic or stomach affection should be made quite a secondary consideration, and every effort should be used to remedy the more dangerous malady that has supervened. A few days exposure to a cold or variable atmosphere may render the latter incurable, and therefore, seclusion in a regulated temperature should be enjoined, while local bleeding, blistering, and antimonials, are sub- stituted for mercurials and other measures pursued for the cure of the abdominal disorder. The inva- lid should be recommended to confine himself to his cabin, if on the voyage; or within doors, if land- ed, in the most sheltered situation which the coun- try can present. It is really lamentable to see men returned from a tropical climate, walking about the streets of London, or going to places of amusement in the cold raw evenings of winter, while the hack- ing cough, emaciated figure, and variegated coun- tenance, proclaim a condition of the lungs which ill comports with this exposure to the vicissitudes of a northern climate. The pulmonic affection which is caused by and su- pervenes on derangement of the liver and digestive organs, may occasionally be discriminated, especially in the early stage, from that which commences origi- nally in the chest, and proceeds from scrofula, or phthisical disposition of the constitution. The cough is at first dry, or only accompanied by a trifling expec- toration of mucus ; the spirits are more depressed ; the countenance more sallow than in the idiopathic forms of pulmonary disease. The paroxysms of cough are generally after eating, and early in the morning; and lying over on the left side is apt to excite cough when in bed. In the progress of the disease, the expectoration becomes more copious, and, from being limpid or glairy, begins to exhibit some suspicious points of a OF INVALIDS PROM HOT CLIMATES. 34 Eurulent character. This last character gradually ecomes more predominant, as the disease advances, and occasionally some streaks of blood are seen. In the commencement of the disease, and consequently where the cough and other phenomena are merely symptomatic of disorder in another quarter, the pa- tient can expand his chest, and go up an ascent with much less breathlessness than in cases where phthis- is is advancing in consequence of a previously tu- berculated state of the lungs. In the dyspeptic pulmonary affection, in short, it is the mucous mem- brane which is generally engaged, especially at the begining, and, therefore, the pulmonary structure Is previous to the air. In the more advanced sta- ges, the parenchymatous tissue of the lungs becomes condensed, or hepatized ; and the mucous mem- brane of the trachea and bronchia organically chang- ed, so as to throw out puriform matter. If there be any disposition to scrofula or tubercles, this dis- position is likely to be excited into action by the sympathetic irritation, and then phthisis, of the com- mon and fatal kind, will soon be developed. In this insidious and dangerous symptomatic dis- order of the chest, there is often little or no pain in any fixed point; but there is not unfrequently an uneasy sensation under the sternum ; or a dull pain at the pit of the stomach ; or fugitive pains, appa- rently of a muscular character, m various parts of the thorax, or even in the limbs, the spine, &c. It is probable that these are referrible to the disorder of the digestive organs rather than to the affection of the respiratory apparatus. The feyer does not take on the regular hectic form so early in the dys- peptic as in the idiopathic phthisis ; nor is the ema- ciation so rapid. It will he evident to the medical practitioner that these are only modified symptoms of idiopathic pulmonary disease, and consequently offer no cer- 35 ON THE DISEASES AND REGIMEN tain criterion that the disease is symptomatic of derangement of the digestive organs. The presence of this last derangement, however, as indicated by flatulence, irregularity of bowels, diseased secre- tions, furred tongue, loss of appetite, tenderness and fullness of the epigastrium, and a host of nervous and hypochondriacal phenomena, will strengthen the diagnosis. But the grand object is to determine the period when symptomatic disorder is passing into the state of actual disease ; and this, I main- tain, cannot be done by any investigation of symp- toms, however minute, short of exploration of the chest by means of auscultation and percussion. Yet, on this distinction between the two states, the whole question of treatment hinges. Dr. Philip has divided this disease into four sta- ges, in which, he acknowledges, the prognosis and mode of treatment are different. I mo - The pulmo- nic affection is merely sympathetic, and ceases with the removal of its cause. This stage is short in du- ration, mild in symptoms, and accompanied by no expectoration, except some phlegm with the cough. 2ndo. The sympathetic has .produced actual disease in the lungs, indicated by some degree of inflamma- tion in the bronchia, and admixture of pus-like sub- stance in the expectoration, somtimes blood. The tendency to fever is now greater, yet seldom in the hectic form. It is at this period, Dr. Philip thinks, that tubercles begin to form. But,-at the time Dr. P. wrote, we had not the means of ascertaining this circumstance, or, in fact, of knowing what were the organic changes that might be commencing or mak- ing progress in the lungs ; nay, we had not the means of saying whether organic change had actual- ly begun. Hence the diagnosis was mere guess- work. The ulterior stages are the same as in idio- pathic phthisis, and on these it is unnecessary to remark. Dr. Philip says, that it is after fulness OP INVALIDS FROM HOT CLIMATES. 36 and tenderness have taken place in the epigastric region, that the derangement of the digestive organs affects the pulmonary function. ButTiow long after, or when it begins to affect the pulmonary structure, neither he nor any man can tell without the means alluded to, which is only a discovery of very recent date. Without this investigation then, we may be too early in our treatment of the pulmonic affection, or too late. The former error is dangerous ; but the latter is fatal to the patient. If auscultation were attended with no other advantage than this discrimination of the two stages of dyspeptic phthis- is, (a disease so very prevalent in this country,) it would be the most valuable discovery of the pre- sent century. The treatment of the first stage of this disorder will be almost entirely directed against the hepatic and gastric affection on which it depends, and which will be fully detailed farther on. But even in this stage, much may be done by regimen, attention to dress, and regulation of temperature, in saving the organs of the chest from any increase of disorder in their function, or risk of change in their structure. This attention cannot injure the dyspeptic disorder, but, on the contrary, contribute to its removal ; while a neglect on this point may allow a sympto- matic to change into an organic disease, when the chance of recovery must be small indeed. So few opportunities are afforded of ascertaining the state of the lungs, by dissection, in the early stage of stomach cough, or dyspeptic phthisis, (as it has been improperly called, for in the early stage it is not phthisis at all,) that we have no other means of knowing what is passing, than by auscultation and percussion. In those cases where the cough is purely symptomatic, and where there is no other disease of the chest, the sound will be clear in all parts, and the air will be heard permeating the pa- D 2 37 ON THE DISEASES AND REGIMEN renchyma of the lungs in every direction. In se- veral instances where I have lately examined the chest, and where there were only the phenomena of sympathetic affection, I have found some por- tions of lung, especially in the left side, where no respiration could be heard, and where the sound was quite dull. By blistering, antimonials, colchi- cum, and seclusion, these points have regained their integrity of function, and the sound has returned. Hence I am led to conclude, that one of the first changes that take place, where symptomatic is pas- sing into structural disease, is a condensation of the parenchymatous substance of the lungs, by no means incompatible with restoration. It is probable, how- ever, that the very first change is that of irritation of the mucous membrane of the trachea and bron- chia into a low kind of inflammation, with a cor- responding change from a dry cough to one with some slight expectoration. Condensation or hepa- tization, as it is called, is probably the next change, and this supposition is, I think, strengthened by the fact, as ascertained by the stethoscope, that hepati- zation is the most common of all organic affections which we find in the lungs of people somewhat ad- vanced in dyspeptic phthisis. In the ulterior sta- ges, the lungs present, of course, on dissection and auscultation, the same phenomena as in regular idiopathic phthisis, so widely prevalent and so des- tructive in this country. I shall adduce no more reasons than are pointed out above, why the medical attendant should minute- ly examine the state of the chest, where cough has supervened on disorder of the digestive organs. A deiusive hope that the former may be safely over- looked, and that its removal will follow, as a matter of course, the improvement of the hepatic and di- gestive functions, may very often cause the practi- tioner a world of chagrin afterwards, when he finds OP INVALIDS FROM HOT CLIMATES. 38 his patient getting worse, and when an alteration in the treatment and prognosis will betray an error in the first diagnosis which was formed. Whereas, by careful examination of the chest, in the first in- stance, he will be enabled to form a more correct opinion, and consequently to give a more guarded prognosis ; circumstances that will be very useful to him, should the disease take a serious turn in the sequel. Should an examination of the thoracic organs shew the existence of organic disease in the lungs, no time should be lost in sending the patient to the most beneficial atmosphere, where the temperature should be regulated, and every possible means em- ployed to arrest the progress of disease in the lungs. So much difference of opinion prevails respecting the climates of France and Italy, that it is difficult to say where the patient should go. If other things were equal, Nice or Naples would appear to afford a fairer prospect than the gloomy skies of England; at least before any purulent expectoration appears. When a breach of structure is once made in the lungs, a warm climate can do no good, but rather increases the evil. When puriform matter begins to issue from the lungs, whether from broken-down tubercles, a com- mon vomica, or a diseased surface of mucous mem- brane, I apprehend a great revolution is about to take place in the general treatment. From several cases which have lately been under my own care, I am confident that the tonic plan, combind with lo- cal depletion and counter-irritation, is infinitely su- perior to the asses milk and hermit's diet on which the phthisical patients are usually kept. In exter- nal scrofulous sores, our great object is to improve the general health, and increase the general strength, and why should not the same plan be pursued when there is an internal abscess ? I fear we have too 39 ON THE DISEASES AND REGIMEN often confounded the fever of irritation, or, in other words, the phenomena of hectic, with inflammation, and that the means used to subdue this fever have too often increased it. Three cases lately fell under my notice, where the expectoration was purulent — the pulse ranging from 110 to 140 — with hectic fever and perspirations, and, in short, all the symp- toms of established phthisis; and yet where the whole of these phenomena disappeared under the administration of the sulphate of quinine in well acidulated infusion of roses, aided by light animal food ; sponging the chest twice a day, with tepid vinegar and water; and obviating pain in the chest by blisters, antimonial ointment, and occasional leeching. This, too, was done without any other air than that of London, Pentonville, and Bromp- ton.* But it would be out of place to pursue the subject of pulmonary disease any further, as another class of human maladies, to which the tropical in- valid is peculiarly prone in his native climate, is now to be considered. Before entering on this ex- tensive and difficult subject, however, I must dwell a little on — ORGANIC DISEASE ON THE LIVER. I may venture to assert, from pretty ample ex- perience, that not one in ten of those who are sup- posed to labour under "chronic liver disease," * The air of Brompton, by the way, is peculiarly mild and agreea- ble in pulmonic affections, as the Londoners well know, who send their children out there when labouring under whooping-cough; and who resort thither themselves, when affected with pulmonary complaints. It is protected from the easterly and northerly winds by London itself, and by the hills of Pentonville, Highgate, and Hampstead. It is open to the South and West ; and is, upon the whole, the mildest air in the vicinity of the metropolis. OF INVALIDS FROM HOT CLIMATES. 40 as it is termed, on their return from hot climates, have any organic affection of that viscus, which can be detected by the most minute examination. It is really astonishing how many people are deceived — medical men as well as their patientsre — specting enlargements and indurations of the organ in ques- tion. There are very few who labour under de- rangement of function in the liver or digestive ap- paratus, who have not tenderness on pressure, and an apparent fulness iu the epigastric region, and under the false ribs of the right side. These symp- toms alone are quite enough, in some men's minds, to entitle a tropical invalid, in particular, to the honour of having "chronic hepatitis," with en- largement of the organ. Yet, in nine instances out of ten, there is no such thing as organic disease in the case. The tenderness in pressure, is infinitely more common where there can be no suspicion of organic disease of the liver, than where this last is palpable to every eye. It is very common in the lighter shades, as well as in the higher decrees of dyspepsia, ana arises from morbid sensibility in the nerves of the stomach and bowels, far more fre- quently than from change of structure either in the liver or other contiguous organs. It is very often present even where there is no functional affection of the above-mentioned viscera ; but where there is an irritable state of the mucous membrane of the colon, where it sweeps round under the liver and false ribs: nay, I affirm that this tenderness of the epigastrium, to which so much undue importance is attached, may, at any time, be induced by a dose of purgative medicine that irritates the mucous membrane of the colon. There is, in fact, at all times, and in all people, even in the highest health, a greater or less degree of tenderness on pressure at the pit of the stomach, most probably owing to the vicinity of the great semilunar ganglion, or 41 ON THE DISEASES AND REGIMEN solar plexus, the sensorium of the abdominal vis- oera. What school-boy does not know how easily he may be what is called " hearted" by a slight blow in that region ? I repeat it, then, that tender- ness, in epigastrio, is an exceedingly fallacious sign, and no criterion at all of organic disease in the parts underneath. This natural tenderness at the pit of the stomach leads to another error very commonly committed — namely, the belief that an enlargement of the liver exists. The moment that the fingers of the physician or surgeon are thrust against the parietes in this region, the abdominal muscles are thrown into action, and one of the rigid bellies of the rec- tus, on the right side, is every day mistaken for the edge of the liver. Of this mistake I have seen nu- merous examples. No accurate judgment can be formed till the patient is placed in such a position as entirely relaxes the abdominal muscles. In some people, indeed, it is almost impossible to get these muscles relaxed in any position, while under examination ; m iney a7G voluntarily or involuntari- ly thrown into action the moment the fingers are applied to these parts. And, after this relaxation is obtained, a loaded state of the colon, no uncommon occurrence, will often deceive the incautious prac- titioner, and lead him to think he has discovered an indurated liver, which, in a few days, disappears under the use of aperient medicines. In respect to fulness of the epigastrium, there is much misconception. In corpulent people, no de- pendence can be placed in this symptom; while, in lean people, and especially in people who have be- come emaciated, as is often the case, the fulness in more apparent than real. In fact, in almost all people who are naturally thin, or emaciated by ill health, there is an apparent fulness in the epigas- trium while in the erect posture, produced by the OP INVALIDS FROM HOT CLIMATES. 42 shrunk state of the abdomen. In some individuals the stomach is much larger than in others, and any distention of this organ, by food or flatus, will give an unnatural appearance of fulness to this region. Pain in the region of the liver, or, indeed, in the " right side," is another symptom which leads many astray. The biliary organ occupies a large space, and is surrounded by other organs and struc- tures much more susceptible of pain than itself. The intercostal and other muscles, the stomach, the duodenum, and different contiguous parts, are far oftener the seat of pain than the liver itself ; and even when the seat of pain is in the biliary appara- tus, it is more frequently in the gall-bladder or ducts than in the substance of the organ. But pain is no proof of organic disease in any part of the body. The most painful disease to which the hu- man fabric is subject, tic douloureux, is unaccompan- ied by any visible change in the part, and often has its cause at a great distance from its apparent seat In respect to a symptom which has been, time immemorial, considered as pathognomonic of liver disease — pain at the tip of the right shoulder — I acknowledge that it does, in a certain proportion of cases, exist. But'from what I have myself seen, and from an examination of the records of cases where dissection proved the existence of organic disease in the liver, I am confident that this symp- tom does not accompany one twentieth of the dis- eases in question ; and that, when it does obtain, it is far more frequently an accompaniment of disor- dered function than disease of structure. Neither is this pain so generally in the tip of the shoulder as is supposed. It is very often seated in the in- ferior angle of the scapula, nay, still lower down among the long muscles of the back. I have known it to continue long and troublesome, where the functions of the liver were but little affected, and 43 OF THE DISEASES AND REGIMEN where the case was evidently dyspepsia, .dependent on irritability of the nerves of the stomach and up- per bowels ; and it has disappeared under the use of medicines directed entirely to the dyspepsia. Why this part should be more frequently the seat of this sympathetic pain than other parts of the body, is by no means accounted for by any particular distribu- tion of nerves. True it is, that there is no spot on the surface of the body, the nerves of which do not communicate, directly or indirectly, with the nerves of all other parts ; but this does not account for the peculiar courses and directions in which sympathies run. Thus, tic douloureux, when de- pendent on irritation in the digestive organs, takes its seat very generally on one side of the face — for which no satisfactory reason can possibly be given. Pain, then, whether in the region of the biliary apparatus, in the shoulder, or in the back, is no criterion of organic disease of the liver. It is more frequently absent than present in such diseases, and, when present, it is more commonly dependent on disordered function of the liver or stomach, than on changes of structure in either of these organs. This symptom, by the way, is rather a sense of burning or aching, than actual pain. It is more felt when exercise is taken than when the indivi- dual is quiet, and is very generally increased when the stomach is more than usually out of order, or when any temporary irritation of mind is kindled up. These are some of the principal sources of fallacy in regard to organic diseases of the liver, and ofte#. lead to unnecessary courses of mercury and other medicines, that, at least, do no good, but sometimes much harm. What evidence, then, it may be asked, have we of change of structure in the biliary apparatus ? If this organ can be felt protruding below the ribs, we can say it is enlarged, but of what that enlargement OP INVALIDS FROM HOT CLIMATES. 44 consists no pathologist can tell, unless he speak by- guess. It may be tubercles, it may be interstitial deposit sin the parenchymatous structure, of various kinds and consistencies, or hypertrophy of the pa- renchyma itself, it may be hydatids, &c. but the scalpel alone can unravel the true nature of the dis- ease, and then it is little consolation to the owner of the organ, even should its portrait form a beautiful and expensive plate, or the diseased mass be pre- served in that fluid which destroyed its original texture, and life itself. Of the various changes of structure which dis- section has shewn in the livers of those who have sojourned in hot and unhealthy climates, an en largement, generally with induration, of the paren- chymatous structure of the organ, is by far the most common. Whether this increase of volume be owing to simple increase of the natural structure (hyperthrophia or reproduction, as it is called by some foreign writers) or to an interstitial deposit of fatty, albuminous, or other animal material, admits of some doubt. That the liver, like the heart, may become magnified by multiplication, as it were, of its own natural substance, is by no means im- probable ; since we every day see livers of immense size, but of apparently healthy, or at least homoge- neous structure, in the bodies of those who betrayed no symptoms of the liver disease during life. But, in the great majority of those who have evinced derangement of function and increase of size in the biliary organ, we find a variegated appearance in the structure after death, proving an interstitial de- posit, which I conceive to be the most common cause of the enlargement. To the other morbid growths, as tubercles, hydatids, &c. the tropical in- valid is not more subject than his countrymen at home. There is yet another organic disease of the liver, E 45 ON THE DISEASES AND REGIMEN more common in this country than in hot climates ; which consists of a diminution and condensation of the parenchymatous structure with a corresponding inefficiency of function, and a long train of symp- toms which will be noticed farther on. The above are the principal changes which the biliary apparatus undergoes during life, and which can only be ascertained by the knife after death. But, it will be asked, " can we not tell by the symptoms what is the organic change going on?" I venture to assert that we cannot. Since little can be learnt from external examination, in respect to the kindoi structural disease in the liver, we have only the disorder of function, and its consequences on the constitution, to guide us, and I unhesitat- ingly aver, that disorder of function in the biliary apparatus is often more considerable where there is no change of structure, than where there is organic disease of great and irremediable magnitude. This is so much the case, that, when I find much functional disturbance in the biliary secretion, and much constitutional derangement resulting thence, I conclude (unless there be tangible enlargement) that the structure of the liver is unaffected in any material degree. The symptoms which afford the greatest proba- bility of organic disease in the liver, (supposing that no tangible enlargement is present, for then the ease is unequivocal,) are wasting of the body, a peculiar sallow and unhealthy aspect of counte- nance, permanent yellowness of the skin, derange- ment of the stomach and bowels, and dropsical ef- fusions. None of these symptoms are certain cri- teria, nor even the whole of them combined, they merely afford presumptive proof. They may all, even the permanent jaundice, exist, where the scal- pel can detect no material change of structure.* * Cases of permanent jaundice are on record, where no organie disease of the liver or obstruction of its ducts could be found after OP INVALIDS FROM HOT CLIMATES. 46 The morbid condition of the bile, or, in other words, disordered function of the liver, is, as I observed before, much more conspicuous and se- vere in many cases where there is no change of structure, than in cases where the enlargement of the liver is unequivocal, and the whole organ full of tubercles or other morbid growths. This is hard- ly credible; but it is a fact. I have seen motions, day after day, and week after week, containing the most healthy-looking bile, where the liver reached as low as the umbilicus, and was found after death a mass of disease ; while, on the other hand, every practitioner must have seen patients passing, for months in succession, or rather for years, the most depraved biliary secretion, ceranging the functions of all the abdominal organs and powerfully disturb- ing the health, where no organic disease could have existed, 6ince all these symptoms have been found to vanish suddenly, under the influence of proper medicine, diet, and pure air. In fine, we have no eertain mark of organic dis- ease of the liver, but tangible enlargement of its substance, and then, no certainty of the precise na- ture of the morbid structure — all the disorders of its function, and the consequences of these disor- ders on the general health, being found infinitely more often without than with any cognizable change in the organization of the biliary apparatus. This investigation or analysis of diagnostic symp- toms, is of the utmost importance in a practical point of view, for it narrows the treatment into two principal indications — that which is designed for the death. Such cases, however, are very rare ; and permanent jaun- dice may generally be set down as dependent on some tumour in the liver pressing on the bile ducts, and causing regurgitation, or absorption of the bile into the circulationo 47 ON THE DISEASES AND REGIMEN reparation of diseased structure, and that which is directed to the correction of disordered function.* Diseased Structure. As I have already shewn that we have no certain proof of diseased structure in the liver, except by its tangible enlargement, so it is to this state that I confine myself on the pres- ent occasion ; for this criterion being absent, all we can aim at is the improvement of disordered June* Hon, which will be fully treated of afterwards. Have we any, and what methods of removing en- largement of the liver, including various kinds of morbid growth ? That simple enlargement of this organ is often removed by proper means, there can ,be no doubt ; but that we have much power over tubercular or hydatid growths, is very ques- tionable. In all kinds of enlargement, however, one great object is to cut off as much of the supply by which the morbid growth is fed, as possible, and the next is to promote the absorption of what has already taken place. There can be very little doubt that, in most morbid growths, both in the liver and elsewhere, there is more or less increased ac- tivity of the blood-vessels of the part, or, in other words, inflammation, generally of the chronic kind. This slow or chronic hepatitis, by which the biliary organ is ultimately changed in structure, with in- duration and enlargement, shews itself more by de- rangement of function in the organ itself, and in those organs with which it is associated in office, * Inflammation, acute or chronic, and irritation, are rather to be considered the morbid processes by which structure is changed, and function disordered, than the organic and functional affections themselves. It would uot be proper to say that a man labours un- der organic disease of the lungs because ne is affected with pneu- monia, though the pulmonic inflammation may terminate in or produce disorganization, And, on the same principle, I do not class hepatitis, acute or chronic, among the organic changes in the liver, though it leads to those changes. OF INVALIDS PROM HOT CLIMATES. 48 together with a number of anomalous symptoms in the constitution at large, than by those symptoms which are common to slow inflammation in other structures of the body. We must not expect to find quickness of pulse, heat of skin, thirst, and other inflammatory phenomena, attending this slow process of disorganization, though these are more easily excited by slight causes than where there is no local disease. The constitutional disturbance will be found to be more proportioned to the de- rangement of the biliary secretion than to the change of structure or increase of bulk in the organ itself. Every practitioner must have seen instances where the liver descended low in the abdomen with little apparent inconvenience to the constitution, while, in other cases, where the same organ could scarcely be felt, the great deterioration of its func- tion has produced the utmost distress of mind and body, and led to dropsical effusions, fevers, and oth- er diseases destructive of life. From this it will be evident that one great object in the treatment of structural disease of the liver, is to correct or im- prove its function ^ and, as an inflammatory irrita- tion is at least a main cause both of the organic change that is going forward, and the disordered se- cretion that obtains, the removal of all agents that increase or keep up this irritation or inflammation, is a sine qua non in the treatment. As my object in this Essay is rather to render the indications sim- ple and clear, than to enter into minute details of therapeutical management, I need only observe that, in the organic disease of which we are treat- ing, our main chance of success lies in dietetic dis- cipline. If the patient will not consent to abandon the luxuries of the table and the stimulation of wine and all fermented liquors, his fate is cast, and bloated dropsy, with all its horrors, will soon over- take him. E 2 49 ON THE DISEASES AND REGIMEN Rigid abstinence in respect to food, and a total abandonment of every kind of vinous and spiritu- ous potation, act in a triply beneficial manner. This system diminishes the supply of nutriment to the morbid growth ; withdaws stimulation from an al- ready irritated or inflamed organ ; and powerfully promotes the absorption of any interstitial deposit or other preternatural growth in the biliary appara- tus. The result is an improvement in the function of the organ, and a general amelioration of the health, if at all within the reach of amelioration. This is the fundamental principle of treatment in organic, as well as in functional disease. All the others are subordinate, but many of them very im- portant. There are medicines which experience has proved to be capable of increasing the power of the absorbents in the removal of morbid growths. The principal one is mercury ; but it must be very carefully managed in organic diseases. Mercurial frictions over the region of the liver should be pre- ceded by several repetitions of a smaller or greater number of leeches, according to the exigency of the case, and the strength of the patient After ten days or a fortnight, the leeches should be re-appli- ed ; then a crop of pustules brought out by tartariz- ed antimony ; and then again, the original mea- sures renewed. A succession of changes in this way, do a great deal more than a long continued course of any one remedial process.* In the mean time, the secretions should be strictly attended to. Gentle bitter aperients, as rhubarb combined with extract of chamomile or gentian, may be given, and *The propriety of a course of mercury, so as to affect the consti- tution, in tangible enlargements of the liver, must depend on the circumstances of the individual case ; for it would be very danger- ous to recommend it as a general rule, though nothing is more com- mon than the association, in the mind, of an enlarged liver and a course of mercury. It is known, however, that mercury is more beneficial in functional, than in structuial diseases of this organ. 0? INVALIDS FROM HOT CLIMATES. 50 even the sulphate of quinine, when the appetite and digestive powers are weak. These means will ena- ble the patient to take in and digest a sufficient quantity of light and unirritating nutriment to sus- tain the constitution, while attempts are made to reduce the unnatural structure in the liver. In organic as well as functional disease of the biliary- apparatus there is generally great derangement in the functions of the skin and the kidneys. Colchi- cum and Ine taraxacum are very useful auxiliaries in suchesoes, while the greatest attention is to be paid to dress, and to avoiding night air and moisture. The saline aperient waters of Cheltenham, with the combined advantage of country air and mental amusement, will much contribute to improve the function of the liver, and, through that process, the structure. Too little attention is paid to the urina- ry secretion in hepatic diseases, though it is of the utmost importance, for dropsical effusions are the consequences which are most to be dreaded in all organic affections of the biliary apparatus, and they generally become the ultimate cause of the fatal termination. The taraxacum, in the form of ex- pressed juice, or decoction of the root, with super- tartrate of potass and spices, is a very valuable me- dicine, as it improves the biliary secretion, and acts both on the bowels and kidneys. It may be used as a good substitute for mercury, or, at all events, to lessen the quantity that might otherwise be con- sidered necessary, of that active mineral. How far iodine may possess the power of reducing morbid growths in the liver, has not yet been ascertained ; but it seems worthy of trial. In India, the actual cautery is much used by the native doctors, in en- largements both of the liver and spleen, especially of the latter; and often with benefit Europeans do not like to submit to this apparently but not really formidable operation. The moxa might also be of some service. 51 ON THE DISEASES AND REGINEN, &C. These very brief observations are all that I deem necessary to offer in respect to that organic disease of the liver which is ascertained by tangible en- largement. Without this criterion we have no positive proof of organic disease at all, and conse- quently our whole system of treatment hinges on regulating and improving the hepatic function — an indication which it is of infinite importance to pur- sue, and which would save many lives that are an- nually lost under the impression of organic disease, and under the system of treatment which is consid- ered suitable to such a condition of the biliary ap- paratus. I have endeavoured to reduce the diagno- sis within its proper, or at all events, its practical limits, and to restrain the vague notions respecting " liver disease," which are so prevalent and so de- trimental. Indeed, I am convinced that, were the term and the idea of " organic disease" of the liver obliterated, not only from the nosological chart, but from the minds of practitioners, it would be much better for their patients. No possible danger can accrue from mistaking an organic disease of the liver for a functional one ; but much mischief may result from the contrary mistake. 'This will appear a strange position to be maintained, and is the re- Verse of that commonly laid down ; but it is not stated without mature reflexion. More diseases of structure in the liver would be cured by careful at- tention to its function, than by all the other means put together. In quitting this subject, it is hardly necessary for me to say, that acute inflammation of this organ is passed over as not properly coming within the com- mon acceptation of structural or functional disease. It is to be treated like any other acute inflamma- tion, but with more attention to mercurial purga- tives. PART II. ON MORBID SENSIBXSXTir OF THE STOMACH AND DOWI^S. We now come to a class of complaints of most extensive bearing, and of paramount importance, not only to the valetudinarian, but to almost every individual in civilized life ; a class which so much disturbs our moral, as well as our physical nature, that it is hard to say which is the greater sufferer, the mind or the body ! This malady, or rather ab- stract of all maladies, is, in itself such a Proteus ; arises from so many different causes ; assumes so many different shapes ; produces so many strange and contrary effects, that it is almost as difficult to give it a name as to describe its ever-varying fea- tures. It knocks at the door of every gradation of society, from the cabinet minister, planning the rise and fall of empires, to the squalid inhabitant of St. Giles or Saffron Hill, whose exterior exhales the effluvia of filth, and interior those of inebriating potations. No moral attributes, no extent of power, no amount of wealth, are proofs against this wide- spreading evil. The philosopher, the divine, the 53 ON MORBID SENSIBILITY OP general, the judge, the merchant, the miser, and the spendthrift, are all, and in no very unequal degree, a prey to the Proteian enemy. If this statement be correct; if, under such a variety of circumstan- ces, and excited by such a variety of causes, the same malady, or class of maladies, should be found to assail such different characters, and give rise to such an endless variety of phenomena, there must surely be some connecting link, some prevailing error, common to all, which can thus place the phi- losopher and the peasant, the affluent and the indi- gent, the virtuous and the vicious, on one common level in regard to a particular affliction of body and mind. The designations which have been applied to this disease are numerous. *nA «r»«- ™~ «** **----• .. } ~w»^ ...iwc ono yjt uiem expressive of the real nature of the malady, but only of some of its multiform symptoms. Of all these designations, indigestion has been the most hacknied title, and it is, in my opinion, the most erroneous. The very worst forms of the disease ; forms, in which the body is tortured for years, and the mind ultimately wrecked, often exhibit no sign or proof of indigestion ; the appetite being good, the digestion complete, and the alvine evacuations natural. Nearly the same objection lies against the term dyspepsia, or difficult digestion. The train of symptoms exhibited in indigestion or dyspepsia, is only one feature, (a very common one I grant,) of the Proteian malady under consideration ; and by no means the most distressing one. The term hypochondriasis conveys no just idea of the na- ture of the disease, though a group of some of its more prominent phenomena is usually understood by that term. Cullen was very wrong in defining hypochondriasis to be "indigestion, with languor, sadness, and fear, from uncertain causes, in a melan- cholic temperament." Many of the most exquisite specimens of hypochondriacism are unattended with THE STOMACH AND BOWELS. 54 indigestion. Neither is Falret correct in making the brain the seat of hypochondriacism. The mind is affected, no doubt ; but only in a secondary man- ner. "Bilious disorder" is a term equally vague and equally erroneous as the others. Derangement of the biliary secretion is a frequent concomitant, perhaps a frequent cause or consequence of the ma- lady, but it is by no means always present, and when present, it is only one feature of the disease, and does not constitute its nature or essence. Of the various other designations, as spleen, vapours, melancholy, nervousness, irritability, mental des- pondency, &c. I need only say that they are forms or features of a disorder that assumes almost all forms. Hence my sagacious friend, Dr. Marshall Hall, not inaptly applied to this class the generic name mimoses, or imitators ; an appellation which is very significant, but which, of course, conveys no idea of the nature of the malady. It would, there- fore, be of great advantage to society at large, as well as to the profession, could we ascertain the leading causes by which this disorder is produced, the link by which its proteiform features are con- nected, and the means by which so complicated an affliction may be averted or removed. In order to clear the way for this investigation, the importance of which will be presently seen, it is necessary to make a few physiological and pathological observa- tions. In the nervous system we distinguish two great classes of nerves ; those which take their origin from the brain and spinal marrow; and those which are called the ganglionic nerves. The former trans- mit sensations to the sensorium, and nervous influ- ence to the voluntary muscles ; the latter regulate the functions of various vital and other organs, as those of the stomach, liver, heart, &c. It is in the first class of nerves that we find the common sensi- 6S ON MORBID SENSIBILITY OF bility of touch, and also the nerves of the other senses, as sight, hearing, smelling, and tasting. These nerves of sense teach us at once, that particu- lar kinds of sensibility only are possessed by par- ticular nerves. The optic nerve is only sensible to light, and will not convey the sense of touch, hear- ing, tasting, or smelling :* — and, on the other hand, the auditory nerve receives no impression from light, or any thing but sound. The nerves distri- buted over the body for touch, will not convey any other impression than that which is peculiar to their office. Whenever the proper stimulus is applied to any of these nerves, we are conscious of the impression, at least while we are awake. Now the ganglionic nerves have their peculiar offices and stimuli, as well as the cerebro-spinal nerves ; but with this great difference, that we are quite uncon- scious of the impressions made on them, as long as the impression is within the range of salutary ac- tion. The stomach is as sensible to the stimulus of food as the retina is to light, but we feel nothing of the impression. Let any one attentively observe when he eats plain food, or swallows plain drink. He feels both of these in his mouth and palate ; but the moment that either of them passes down the oesophagus, he is quite unconscious of its presence in the stomach. It is so with all the internal or- gans. The lungs feel the air, but we are not con- scious of its presence in the air-cells ; the heart feels * The eye, for instance, in a state of health, may be touched by the finger, and hardly a sensation "will be excited ; but let the same organ be inflamed, and then the most painful sensation will he produced by the slightest touch. In the same way, the cartilagi- nons surfaces and the synovial membranes of the joints are endu- ed with a peculiar, and not a common sensibility. They feel not the friction produced by even violent motion ; but let inflammation take place in these parts, and then the peculiar or unconscious sen- sibility will be raised or changed into common or morbid sensibili- ty, and the slightest motion will be attended with exquisite pain. THE STOMACH AND BOWELS. 56 the stimulus of blood, without our knowledge ; the gall-bladder is sensible to the presence of bile ; the intestines to chyle and to faeces; the urinary blad- der to urine, and so on ; while the intellectual sys- tem is quite unconscious of all these sensibilities. But let us go a step farther. Swallow a tea-spoon- ful of tincture of capsicum, or a wine-glassful of brandy, and then we feel not only a burning sensa- tion in the mouth and throat, but a certain degree of the same sensation in the stomach.* Simple as this experiment may appear, and unimportant any conclusion thence resulting, it nevertheless unfolds one of the most fundamental views in pathology, * We hear it commonly laid down by lecturers and others, that there is greater sensibility at the extremities of tubes and passages in the body, as the oesophagus, urethra, rectum, &c. than in the other portions of the same conduis. This is not a very clear view of the subject. There is more common or cutaneous sensibility at these extremities of passages, but less of the organic sensibility pe- culiar to these structures. When warm water is thrown up by a syringe into the rectum and colon, the heat is only felt in the an- us, unless the temperature be so high as to greatly offend the or- ganic sensibility of the mucous membrane, when a sense of pain rather than heat is felt in the bowels. It is the same with cold wa- ter injected into the intestines. It produces the sensation of cold in the rectum, but no sensation at all in the intestines, unless it be of very low temperature, when it occasions a dull colicky pain in the bowels. It is highly probable that different portions of the alimentary canal are endued with different kinds of sensibility. The sensibility of the stomach is in consonance with the presence of undigested food, which would occasion much inconvenience in the duodenum and other intestines ; while we know that the presence of bile in the duodenum produces no unpleasant effect there, whereas, if it re- gurgitate into the stomach, it disorders the whole system. The organic sensibility of the large intestines is very different in kind from that of the small. The presence of fajces in the colon and rectum produces no sensation ; but if matters pass down undigested from the stomach, the whole line of the intestines is irritated and annoyed ; although the effects are not felt there, but in various other parts of the body from sympathy. Onions, chesnuts, and a hundred other things, eaten in the evening, will disturb the organic sensibility of the stomach and bowels, producing what is called the fidgets, restlessness, incubes, and sundry other disagreeable sensa- tions, in parts of the body far remote from the actual seat of the irritation. F 57 ON MORBID SENSIBILITY OF and one of the most useful precepts in the art of pre- serving health. The moment we call forth con- scious sensation in the stomach, whether that be of a pleasurable or a painful kind, we offer a violence to that organ, however slight may be the degree; Whenever the conscious sensibility of the stomach (or indeed of any other internal organ) is excited by any thing we introduce into it — by any thing generated in it; or by any influence exercised on it, through the medium of any other organ, we rouse one of Nature's sentinels, who gives us warn ing that her salutary laws are violated, or on the point of being violated,. Let us view the matter closer. We take an abstemious meal of plam food, without any stimulating drink. Is there any con- scious sensation produced thereby in the stomach? I say no. We feel a slight degree of pleasant sensa- tion throughout the whole frame, especially if we have fasted for some time previously, but no distinct sensation in the stomach. There is not — there ought not to be, any conscious sensibility excited in this organ by the presence of food or drink, in a state of health; so true is the observation that, to feel that we have a stomach at all is no good sign. The physiological action of food and drink on the stomach is shewn more on other organs and parts than in the stomach itself. When the quanti- ty is moderate and the quality simple, there is noth- ing more experienced than a general sense of refresh- ment ; aud the restitution of vigour, if some degree of exhaustion were previously induced. We are then fit for either mental or corporeal exertion. But let a full meal be made, and let some wine or other stimulating liquor be taken ; we still feel no distinct sensation in the stomach ; but we experience a de- gree of general excitement or exhilaration ; the cir- culation is quickened ; the face shews an increase of colour ; the countenance becomes more animated THE STOMACH AttD BOWEXS. 58 be ideas more fluent. This excitement From food and drink, however, is not only transient, but it is moreover partial. In proportion as we have excit- ed the ganglionic system of nerves, or, in other words, the involuntary or vital organs, (stomach, heart, &e.) we disqualify the voluntary muscles for action, and the intellectual system for deep thought and other mental operations, In fact, we are then only fit to sit and talk very comfortably over our wine ; and ultimately to go to sleep. Whether this habit, which is that of civilized life in general^ be that which is best adapted for preserving or re- gaining health, is a question which I shall presently discuss; but, in the mean time, it will be sufficient- ly evident that pleasurable sensations are diffused over mind and body, by the presence of food and wine in the stomach, without the existence of any distinct sensation in the stomach itself. This is an obvious truth, and it is of great importance to re- member it. For if the nerves of the stomach, in a state of health, be capable of exciting pleasurable emotions in the mind, and comfortable sensations in the body, on the application of good food and generous wine, we shall find that the same nerves, when in a disordered state, are equally capable of exciting the most gloomy thoughts in the mind, and the most painful sensations in the body, on the application of the very same species of refection, either with or without an unpleasant sensation in the stomach itself. When the stomach is in a heal- thy condition, the application of certain agents will irritate its nerves, and produce a train of phenome- na bearing considerable analogy to those resulting from the application of common food in a disordered state of the gastric nerves. Thus, let some tartar emetic be secretly introduced with the wine which a man drinks after dinner. Instead of the pleasant sensations usually produced by this beverage, he 59 ON MORBID SENSIBILITY OP soon begins to perceive a languor of mind and body; the face grows pale instead of red ; the mind is un- steady and depressed ; the muscular power is dimin- ished ; the head aches or becomes confused ; the heart beats slow or intermits — in short, there is a prostration of all the corporeal and intellectual pow- ers ; and all this, in many cases, before any disa- greeable sensation is felt in the stomach. At length, nausea and vomiting take place if the dose be con- siderable enough ; the contents of the stomach are rejected; re-action succeeds; and the mental and cor- poreal energy is once more restored. — If tincture, or any other preparation of digitalis be introduced into the stomach, a train of the most distressing symptoms is induced throughout the whole system. The head becomes giddy ; the sight imperfect; strange noises are heard in the ears ; dreadful de- pression of spirits is experienced, with a feeling or fear of dying; irregular action of the heart; sense of sinking at the pit of the stomach, &c. &c. These phenomena will often go to a great height, without any distinct or disagreeable sensation in the stom- ach. Sometimes, however, and especially if the deleterious agent be introduced abruptly and in large quantity, nausea and sickness of stomach are among the first phenomena, (though never the very first,) and then the other symptoms above enumer- ated follow. A thousand examples might be adduced where certain articles both of food and physic act in this manner on the nerves of the stomach, in the midst of health, and from thence diffuse their baleful influ- ence over mind and body. These examples are familiar to the medical practitioner, and there is scarcely an individual who has not experienced, in his own person, a sample, more or less impressive, of the above kind. These facts authorise us to conclude, first, that, THE STOMACH AND BOWELS. 60 from the stomach, a diffusive energy and pleasurable feeling may be extended to all other parts of the body, and also to the mind, or at least to the organ of the mind, without any distinct pleasurable sensation in the stomach itself. Secondly, that from the stomach may be diffused over the whole system, intellectual and corporeal, a train of morbid feelings and phenomena of the most distressing kind, with or without any distinct sensation of pain or uneasiness in the organs of digestion. This view of the subject will be found of great importance in the investigation of diseases. It leads us to divide into two great classes, those sympto- matic or sympathetic affections of various organs in the body, dependent on a morbid condition of the stomach and bowels — viz. into that which is accom- panied by conscious sensation, irritation, pain, or disordered function of the organs of digestion ; and into that which is not accompanied by any sensible disorder of the said organs or their functions. Con- trary to the general opinion, I do maintain, from very long and attentive observation of phenomena, in others as well as in my own person, that this lat- ter class o£ human afflictions is infinitely more pre- valent, more distressing, and more obstinate, than the former. It is a class of disorders, the source, seat, and nature of which are, in nine cases out of ten, overlooked ; and for very obvious reasons, — because the morbid phenomena present themselves any where and every where, except in the spot where they have their origin. But it may be ask- ed, what are the proofs that various disorders, men- tal and corporeal, have their origin in gastric or in- testinal irritation, that irritation not being sensible to the individual? I answer, that the proofs will be found in the observation of cases every hour pre- senting themselves in practice. I ask for no assent to propositions or assertions, unless they accord F 2 61 ON MORBID SENSIBILITY OP with the experience of the practitioner himself. There are great numbers of dyspeptics in the pro- fession as well as out of it. Let these observe, in their own persons, the phenomena which I shall point out as proofs of the positions I have laid down, and decide according to the evidence of their own senses. I have already shewn, in the examples of antimo- ny and digitalis, (and the list might be increased ad infinitum,) that the remotest parts of the system may be disordered through the medium of the stomach, before any sensible effect is produced on the stomach itself. This, however, is in a state of health. But let the nerves of the stomach and bow- els acquire a morbid sensibility or irritability from any of the various causes which I shall hereafter de- tail, and then it will require no such applications as antimony or digitalis to induce a host of affections in remote parts of the body. Such food and drink as, in health, would only nourish or agreeably stimu- late, will then act like a poison on the system, de- ranging the mental, and disordering the corporeal functions, often without the slightest sensible incon- venience in the stomach and bowels themselves. How is this ascertained ? By simple observation. Let a person labouring under any of those multi- form symptoms included in the terms dyspepsia, hypochondriasis, &c. and more especially under mental despondency, brought on, for example, by moral afflictions, but who feels no inconvenience in the stomach itself, take food and wine in rather too great a quantity, or of a certain quality, and the symptoms will be aggravated, not perhaps im- mediately upon ingestion, but after a short lapse of time, often without any of the phenomena of indi- gestion. Let the same person considerably reduce the quantity of even the mildest food, or abstain a whole day from any stongfood; and let him take THE STOMACH AND BOWELS. 62 no wine or vegetable substance; — and he will find the symptoms mitigated. Let him return again to pretty full meals of mixed animal and vegetable diet, with his usual allowance of wine; again will the corporeal, and especially the mental disorder be exasperated. Let him adhere rigidly to a very ab- stemious proportion of the simplest and most unirri- tating species of food and drink, and take such med- icine as may be calculated to restore the natural, or obtund the morbid sensibility of the stomach and bowels; and then, if he does not experience, in a reasonable period of time, the most marked and sur- prising change for the better, I will grant that all my observations are mere creatures of the imagina- tion. I have seen so many instances proving in- contestibly the truth of these positions, that I am convinced, the great majority of those complaints which are considered purely mental, such as irrita- tability and irascibility of temper, gloomy melan- choly, timidity and irresolution, despondency, &c. might be speedily remedied and entirely removed by a rigid system of abstinence, and a very little medicine. On this account, medical men often have it in their power to confer an immense boon of hap- piness on many valuable members of society, whose lives are rendered wretched by morbid sensitive- ness of the mind, having its unsuspected source in morbid sensibility of the stomach and bowels. But more of this hereafter. ON MORBID SENSIBILITY OF THE STOMACH AND BOWKLS, ATTENDED WITH OBVIOUS DISORDER IN THE DIGESTIVE ORGANS.* I have stated that morbid sensibility of the gastric and intestinal nerves may be divided into two or- ders, viz. that in which there is sensible pain, ir- *h * It may appear an incongruity to consider the organic sensibili- of the stomach and bowels as morbidly increased at a time when e latter (the bowels) are generally supposed to be in a state of torpor, as evinced by constipation. But the organic sensibility of the bowels may be greatly perverted and exalted, and yet the mus- cular or peristaltic action irregular or even torpid. Besides, it is a law of the animal economy, that when nervous sensibility is too much excited in one part, it is too little so in some other. Thus, we often see the stomach and upper bowels in a state of great irri- tability, while the lower bowels are quite torpid, and will not pro- pel forward their^contents. Gastric irritability and vomiting are usually accompanied by constipation. Finally, I may observe, that the functions of the stomach, liver, and intestines, may be tor- pid, while the organic sensibility of their nerves may be in a state of morbid excitement. We see the functions of most organs suspended when they are in a state of inflammation, which must be a state of excitement of their nerves, and the same may be said of irritation. Very often, however, constipation is not an accompani- ment of morbid sensibility of the stomach and upper bowels. The large intestines are not unfrequently in a state of irritation as well as the small. THE STOMACH AND BOWELS. 64 ritation, or other disorder in these organs, as well as various sympathetic affections, mental and cor- poreal, dependent on them ; and that in which the morbid sensibility of the digestive apparatus is, as it were, masked, and only shews itself in a variety of morbid feelings and conditions of other organs and parts, as well as in the intellectual functions. The first class or order has been much more accu- rately investigated than the second — and, therefore, I shall content myself with a very brief view of the prominent features of the first order. SYMPTOMS. The phenomena which supervene on the introduc- tion of too large a quantity of food into the sto- mach, or of some particular kind of food, which, from peculiarity of constitution, disagrees with the stomach, have been set down rather incautiously as symptoms of indigestion. Thus, a man in perfect health, and with an excellent appetite, is allured by variety of dishes, agreeable company, provocative liquors, and pressing invitations, to take in food more in accordance with the relish of appetite than the power of digestion. No inconvenience occurs for an hour or two ; but then the food appears to, and actually does, swell in the stomach, occasion- ing a sense of distention there, not quite so pleasant as the sensations attendant on the various changes of dishes, and bumpers of Burgundy. He unbut- tons his waistcoat, to give more room to the labour- ing organ ; but that affords only temporary relief. There is a struggle in the stomach between the vital and the chemical laws, and eructations of air and acid proclaim the victory of the latter. The nerves 65 ON MORBID SENSIBILITY OP of the stomach are irritated by the new and injurious compounds or extrications, and the digestive power still farther weakened. The food, instead of being changed into bland and healthy chyme in a couple of hours, and thus passed into the duodenum, or second stomach, is retained for several hours in the stomach, occasioning a train of the most uneasy sen- sations, which I need not describe, but which amply punish the transgression of the laws of nature and temperance. Instead of sound sleep, the gourmand experiences perpetual restlessness through the night; or, if he sleeps, alarms his neighbours with the stifled groans of the night-mare. In the morn- ing we perceive some of those sympathetic effects on other parts of the system, which, at a later peri- od of the career of intemperance, play a more im- portant part in the drama. The head aches ; the intellect is not clear or energetic; the" nerves are unstrung; the tongue is furred ; there is more in- clination for drink than food ; the urinary secretion is turbid; and the bowels very frequently disorder- ed, in consequence of the irritating materials which have passed along the intestinal canal. This can hardly be called a fit of indigestion, though, even here, we find many of the leading phenomena which afterwards harrass the individual without such pro- vocation. It is a fit of intemperance, and repeti- tion seldom fails, in the end, to induce that morbid sensibility of the stomach and bowels which forms the characteristic feature of indigestion. I have called the above a fit of intemperance, and, of course, it is rather an extreme case, though by no means very uncommon. Nine-tenths of men in civilized society, however, commit more or less of this intemperance every day. If, when in health, we experience any degree of the foregoing symp- toms after our principal meal ; if we have a sense of distention, eructations, disturbed sleep, with sub- THE STOMACH AND BOWELS. 66 sequent languor, there was intemperance in our re- past, if that repast did not amount to two ounces of food, or two glasses of wine. But established indigestion is not so much indu- ced by this violence habitually offered to the stom- ach, as by the reaction of other organs (whose func- tions have been disturbed sympathetically) on the organ of digestion, The nervous system and the liver repay with interest, after a time, the injuries they sustain from the stomach. The gastric fluid, so much under the influence of the nerves, becomes impaired; the hepatic secretion vitiated; and then the phenomena of indigestion gradually acquire a higher degree of intensity, by the additional sources of irritation, and the corresponding augmentation of morbid organic sensibility. This progressive march of the disorder has been artificially divided into stages, and considerable im- portance attached to the division. The marks by which the stages are supposed to be cognizable do not appear satisfactory to me, or accord with my own observations. Dr. Philip lays down a deviation from healthy appearance in the motions as marking " an important step in the progress of the malady." "It (the alvine discharge) sometimes contains," says Dr. Philip, "uncombined bile; sometimes it chiefly consists of bile ; its colour, at other times, is too light, more frequently too dark, at length al- most black; at different times it assumes various hues, sometimes inclining to green, sometimes to blue, and sometimes it is mixed with, and now and then wholly consists of, undigested bits of food." If these be marks of an important step in the pro- gress of indigestion, I can only say, that the above conditions of the biliary secretion may often be seen where there is no indigestion at all, and that they are very frequently absent, when there is the high- est degree of indigestion, or at least of dyspepsia. 67 ON MOKBID SENSIBILITY OF That they mark a disturbance in the hepatic func- tion, there can be no doubt; but that they are ne- cessary attendants on any particular stage of indi- gestion, I cannot admit, consistently with my own observations. The functions of the liver, indeed, and the stomach are so intimately linked, that a de- rangement of one organ, and especially of the liver, is very commonly productive of derangement in the other, and it is difficult to say, in many cases, which has the priority. The appearance of the al- vine discharge is, unquestionably, one of the best indications of the state of the hepatic function, but I cannot admit that it is so good an index of that train of nervous and general dyspeptic symptoms as Dr. Philip seems to consider it. When this combination of gastric and hepatic dis- order obtains, whichever may have had the priority, the term " indigestion" is merely a conventional one, which is meant to designate a complication in which indigestion forms at most but a part, a very small part, and sometimes no part at all. I own that it is very hard for any one bnt a German to give such a name to this complication as may con- vey a clear idea of its nature. By the term " mor- bid sensibility of the stomach and bowels," I mean a disordered condition of the gastric and intestinal nerves, in which their natural sensibility is chang- ed, being morbidly acute, morbidly obtuse, (torpid) or perverted. By this term, I merely designate a fact or condition which, in my opinion, obtains much more generally in this class of maladies than the state called indigestion — indeed, I think I may aver, that it is never absent in the functional disor- ders of the digestive apparatus now under review, and that it forms the connecting link between these disorders and the various sympathetic affections of other and distant parts of the system. This is my apology for the term. THE STOMACH AND BOWELS. 68 When the combination of liver and stomach af- fection is established, we have a train of well-mark- ed phenomena indicative of their co-existence. The appetite is fickle, being sometimes ravenous, at oth- ers almost annihilated, and sometimes whimsical. Whatever is eaten produces more or less of disten- tion, discomfort, or even of pain in the stomach, or in some portion of the alimentary canal, till the fae- cal remains have been evacuated. On this account, the bilious'and dyspeptic invalid is very anxious to take aperient medicine, as temporary relief is generally experienced by free evacuations. I say temporary relief; for purgation will not remove the cause of the disease, it only dislodges irritating secretions, soon to be replaced by others equally offensive. Indeed the usual routine of calomel at night and black draught in the morning, if too often repeated, will keep up rather than allay irritation in the bowels, and produce, as long as they are con- tinued, morbid secretions from the liver and whole intestinal canal. It is astonishing how long scybala and irritating undigested matter will lurk in the cells of the colon, notwithstanding daily purgation. Many instances have come to my knowledge, where portions of substances, eaten two, three, and four months previously, have at length come away in little round balls enveloped with layers of inspissat- ed secretions. These scybala keep up an irritation^ generally without any pain, in the bowels, and the effects of this irritation are manifested in distant parts by the most strange and anomalous sensations that appear to have no connexion with the original cause. The practitioner is thrown off his guard by the belief that, after repeated cathartics which scour the bowels, there cannot be any thing left there. But this is a great mistake. It is not the most energetic purgative that clears the bowels most ef- fectually. If irritation be first allayed by hyoseia- G 69 OW MORBID SENSIBILITY OF mus or even opium, and then a mild cathartic ex- hibited, the evacuations will be much more copious than if the most drastic medicines were exhibited without previous preparation. In addition to the various appearances of the mo- tions, as described by Dr. Philip, I may add that, although the liver is often very torpid in this dis- ease, and conseqently the faeces of a clay-colour and devoid of natural smell, yet there is, in many cases, a copious secretion of viscid bile, which appears either distinct in the motions, or, when incorporat- ed with them, renders them as tenacious as bird- lime. It is exceedingly difficult to separate these motions from the bottom of the utensil by affusions of water. It is this tenacious ropy bile which hangs so long in the bowels of some people, and, by keep- ing up a constant irritation of the intestinal nerves, produces a host of uneasy sensations in various parts of the body, as well as fits of irritability in the mind. In some cases, where this poisonous secretion lurks long in the upper bowels, whose nerves are so nu- merous and sympathies so extensive, there is indu- ced a state of mental despondency and perturbation which it is impossible to describe, and which no one can form a just idea of, but he who has felt it in person. The term " blue devils" is not half expressive enough of this state; and, if my excel- lent friend, Dr. Marshall Hall, meant to describe itunder the head"mimosis inquieta," he never ex perienced it in propria persona ! This poison acts in different ways on different individuals. In some, whose nervous systems are not very susceptible, it produces a violent fit of what is called bilious colick, with excruciating pains and spasms in the stomach and bowels, generally with vomiting or purging, and often succeeded by a yellow suffusion in the eyes, or even on the skin. Severe as this paroxysm is, the patient may thank his stars that the poison TEE STOMACH AND BOWELS. 70 vented its fury on the body instead of the mind. Where the intellectual faculties have been much harrassed, and the nervous system weakened, the morbid secretion acts in that direction, and little or no inconvenience is felt in the real seat of the ene- my. The mind becomes suddenly overcast, as it were, with a eloud ; some dreadful imaginary evil seems impending, or some real evil, of trifling im- portance in itself, is quickly magnified into a terri- fic form, attended apparently with a train of disas- trous consequences, from which the mental eye turns in dismay. The sufferer cannot keep in one position, but paces the room in agitation, giving vent to his fears in doleful soliloquies, or pouring forth his apprehensions in the ears of his friends. If he is from home, when this fit comes on, he has- tens back ; but soon sets out again, in the vain hope of running from his own wretched feelings. If he happen to labour under any chronic complaint at the time, it is immediately converted into an incu- rable disease, and the distresses of a ruined and orphaned family rush upon his mind and heighten his agonies. He feels his pulse, and finds it inter- mitting ; disease of the heart is threatened, and the doctor is summoned. If he ventures to go to bed, and falls into a slumber, he awakes in the midst of a frightful dream, and dares not again lay his head on the pillow. This state of misery may continue for 24, 36, or 46 hours ; when a discharge of viscid, acrid bile, in a motion of horrible fetor, dissolves at once the spell by which the strongest mind may be bowed down to the earth, for a time, through the agency of a poisonous secretion on the intestinal nerves 1 I believe such a train of symptoms seldom obtains except where there has been a predisposi- tion to morbid sensibility, occasioned by mental anxiety, vicissitudes of fortune, disappointments in business, failure of speculations, domestic afflictions, 71 ON MORBID SENSIBILITY OP or some of those thonsand moral ills which render both mind and body so susceptible of disorder. It is under the influence of such paroxysms as these, I am thoroughly convinced, that nine-tenths of those melancholy instances of suicide, which shock the ears of the public, take place. Nothing is more common than to hear of these catastrophes, where no ostensible cause could be assigned for the dread- ful act. There might be no real moral cause ; but there was a real physical cause for the momentary hallucination of the judgment, in the irritation of the organ of the mind, through sympathy with the organs of digestion. Such is the intimacy of con- nexion, and reciprocity of dependence between the intellectual and corporeal functions ! The foregoing is a sketch of a high degree of bi- liary irritation acting on the mental faculties through the medium of the intestinal nerves. But there are a thousand shades of this irritation dis- playing themselves more in the temper or moral character, than in the corporeal functions. These I cannot at present stop to delineate. In the complicated disease under consideration, there are various functions disturbed, and phenome- na produced, which are all referrible to one com- mon source. The tongue is furred, especially in the middle and at the root, and, when there is much irritation in the stomach or duodenum, the papillae are elevated, and the edges and tip red. There is, in some people, a peculiar sense of constriction at the root of the tongue and about the fauces, which cannot be accounted for on any other principle than that of sympathy with the stomach. The mouth feels clammy, and there is a heavy odour on the breath. The clean red tongue, whether moist or dry, is indicative of serious mischief in the lining membrane of the stomach or bowels. It resembles a beef-steak, or cleanly dissected muscle. THE STOMACH AND BOWELS. 72 The eye may or may not be tinged yellow ; but there is a peculiar muddiness or lack-lustre in the coats of that organ, with an expression of languor or irritability in the countenance, especially about noon, which are singularly characteristic of the malady, and indicate, with unerring certainty, its existence to the experienced physician. In people beyond the age of 45, there is usually a greater de- fect of vision, particularly by candle-light, when the digestive organs are disordered, that when the functions of the stomach and liver are in good con- dition. The urinary secretion is generally disturb- ed ; being either turbid, or high-coloured, with more or less of pink or white sediment. It is, for the most part, rather scanty than otherwise, with occasional irritation in passing it. Sometimes, when the individual is in a state of nervous irrita- tion, it is as limpid as pump-water, made every half- hour, and in large quantity in the aggregate. It is curious that this clear and tasteless water should be more irritating to the bladder than the most con- centrated and highly saline urine. The individual cannot retain more than a few spoonfuls at a time, without great inconvenience. The skin and its functions are very much affected in bilio-dyspeptic complaints. It is either dry and constricted, or partially perspirable, with feelings of alternate dullness and unpleasant heat, especially about the hands and feet. The skin, indeed, in these complaints, is remarkably altered from its na- tural condition; and the complexions of both males and females are so completely changed, that the pa- tients themselves are constantly reminded by their mirrors of the derangement in the digestive organs. The intimate sympathy between the external sur- face of the body and the stomach, liver, and alimen- tary canal, is now universally admitted, and ex- plains the reciprocal influence of the one on the G 2 73 ON MORBID SENSIBILITY OP other. Many of the remote causes, indeed, of in- digestion and liver affection will be found to have made their way through the cutaneous surface. One of the most striking phenomena attendant on derangement of function in the liver and alimen- tary canal, is loss of flesh and of muscular power, The emaciation is easily accounted for, by the defi- cient supply of nutriment from an imperfect appa- ratus; and, it is not a little remarkable, that the liver-affection accelerates the loss of flesh much more than the stomach-complaint. The symptoms of dyspepsia may be very severe indeed, and yet emaciation will be very trifling; but let the function of the liver be much disturbed, and the flesh disap- pears with great rapidity. This is a strong proof that the bile is essential to the change of our food into healthy chyle. But the loss of strength, in this complaint, is out of all proportion to the waste of flesh. This is one of the most characteristic features of the disease, and is much more connected with nervous irritation in the stomach and bowels than with disorder of the liver. I have seen this prostration of strength in the highest degree where the biliary secretion was perfectly healthy, but where the nerves of the primae viae were extremely irritable. It is a sense of debility rather than actual debility. It is infi- nitely more distressing than real weakness. The least exertion, even that of stooping to take up a book, or stretching out the arm to take hold of any object, will cause such a feeling of inability for mus- cular action as quite depresses the spirits of the individual. Yet, perhaps, in less than three hours after this, when the food has passed from the sto- mach, or its remains from the bowels, the same in- dividual will be capable of walking a mile with comparatively little fatigue. This is a point which should be particularly inquired into, when ques- THE STOMACH AND BOWELS. 74 tioning the patient; for the state above described is not one of actual debility, but of irritation. The patient may, it is true, be much weaker than when in health: but this debility is uniform, and propor- tioned to the decrease of muscular fibre ; whereas, the distressing sense of debility, now under consi- deration, is out of all proportion to the emaciation, is not uniformly the same, and is always greater when there is food in the stomach, or bad secretions in the bowels, than when both are empty. It is, in fact, a sympathetic debility, from nervous irritation in the alimentary canal. The distinction between these two kinds of debility is the more necessary, as the treatment is somewhat different. Bark, wine, rich food, and tonics, are not the remedies for debility arising from gastric and intestinal irri- tation. The wretched feeling from this source is exasperated rather than relieved by tonics and stimulants, unless very carefully employed in com- bination with soothing medicine, and diet of very easy digestion. In respect to a symptom on which much stress has been laid by Dr. Philip, as marking an impor- tant stage of indigestion, namely, tenderness at the epigastrium, on pressure, I have already made some observations. That it exists in every stage of. indigestion, I venture to affirm — and I will go one step farther, for I have no hesitation in averring that, if a whole regiment of soldiers were turned out and their epigastria pressed with the pointed fingers, and with the force which Dr. Philip uses, they would all wince, from the General downards. With the following observation of Dr. Philip, I most cordially agree: — "The patient, in general, is not aware of this tenderness till it is pointed out by the physician." As for its being any criterion of organic disease in the liver, I have already express- ed my conviction in the negative, and that it is 75 ON MORBID SENSIBILITY OF characteristic of an inflammatory state, or incipient organic disease of the pyloric orifice of the stomach, I cannot, for several reasons, admit. One of these reasons is, that there is often much more tenderness in the epigastrium, in functional disorder, than in actual and unequivocal organic disease, as in scirr- hus of the pylorus, for example. Another reason is, that this tenderness in the epigastrium is fre- quently, if not generally, relieved by bitters and mild tonics, with light animal food, which would not be the case if it depended on inflammatory ac- tion or incipient change of structure. A third rea- son is, that the dyspeptic patient, in whom this ten- derness is so conspicuous, is proverbial for long life, and dies at last without any organic disease of the stomach. Let Dr. Philip himself bear wit- ness. " It is a curious fact," says he, " and one of the greatest importance in the treatment, that the organic affection rarely takes place in the origi- nal seat of the disease, but in other organs with which the stomach sympathises." This is a Pro- teian doctrine ; for it must ever elude the proofs af- forded by the scalpel. If the patient die of tuber- cles in the lungs, abscess in the brain, aneurism of the heart, enlargement of the liver and its conse- quences, or any other organic disease, dyspepsy having previously existed, we have only to say that the inflammatory action and change of structure began in the stomach, but shifted its seat, and ended in a distant part. " Thus," says Dr. Philip, " when the body is examined after death, the patient is said to have died of disease of some of these parts, and there is nothing in the appearance of the organs to distinguish such affections from disease which or- iginate in the organs themselves." It would be very easy to turn the arms of this doctrine against itself. Organic disease of the brain, for example, very frequently shews itself more, especially at an THE STOMACH AND BOWELS. 76 early stage, in disordered function of the stomach, than in disordered function of the intellect, and, at such period, the patient would be said to labour under indigestion. But, as them alady advances, the functions of the brain and nervous system become unequivocally disturbed, and then it might be said the disease was extending itself sympathetically to the organ of the mind. At length, on death taking place, the brain would be found disorganized, and tho stomach sound; when Dr. Philip would ingeni- ously explain the matter by the above mode of rea- soning. Again, if sympathetic affections end so frequently as Dr. Philip imagines in organic disease, ho\¥ is it that, in fatal affections of the brain from chronic disorganization, where the functions of the stomach are proverbially deranged from sympathy with the sensorium, (all. sympathies being recipro- cal,) we so rarely find any organic change in the stomach ? Illustrations of this remark are innume- rable. I may only just allude to a remarkable in- stance published by Dr. Chambers, where a large tubercle growing in the brain shewed all, or almost all, its bad effects on the stomach for a great length of time, and yet, on dissection, the stomach was found healthy, and the seat of disease in the brain. In short, while I agree with Dr. Philip, that every part of the body sympathises readily with the sto- mach, whether in health or in disease, I do con- tend, from attentive observation and long experi- ence, that these sympathetic affections of distant parts end, comparatively speaking, but rarely in organic disease, and consequently, that Dr. Philip's doctrine is calculated to excite a great deal too much of alarm in the mind of the patient, as well as in that of the inexperienced practioner. As Dr. Philip contends for inflammation as the pathog- nomonic character of indigestion in its second stage, it was incumbent on him to shew all the proof of 77 ON MORBID SENSIBILITY OP which the case is susceptible. He acknowledges that when the patient dies, it is of the organic dis- ease in a remote part, which was originally only sympathetic of the disease in the digestive appara- tus, the latter being no longer the seat of disease, and, consequently, exhibiting no alteration of struc- ture on dissection. So far, so good. But as indi- gestion, in all its stages, is one of the most common diseases which we meet, and as numbers of people are daily dying suddenly of other diseases or accidents, during the second stage of indigestion, why does not Dr. Philip bring forward proofs of inflamma- tion and insipient organic disease of the digestive apparatus, existing in that stage, as developed »by dissection ? This is the way in which we arrive at the knowledge of incipient changes of structure in other diseases not mortal in their early stages. But Dr. Philip offers us no such proof, and the conclu- sion is, that he could not. It will hardly be consi- dered an answer to this objection, that the pyloric orifice of the stomach is often found indurated in dram-drinkers. No one can deny that disease of the stomach may be brought on by such practices, but these cases have little analogy with the common dyspepsia so prevalent in civilized life, where in- temperance is on a very moderate scale. I have admitted more than some physicians will admit,* that sympathetic affection of the chest, from disor- der of the liver aud digestive organs, may and does end occasionally in organic disease. But we must recollect that disease of the lungs destroys nearly a fourth of the population, and that it is highly pro- bable that latent tubercles existed previously to the disorder of the stomach in almost all those who die of dyspeptic phthisis. The disease is, therefore, * See Dr. Paris, for example, who stoutly denies that there is, or can be, any such tiling as dyspeptic phthisis. THE STOMACH AND BOWELS. 75 called into action rather than produced by the disorder of the digestive organs. Perhaps, the same observation may partly apply to the other or- ganic diseases sympathetically called forth. But to return to the subject of tenderness at the epigastrium. I contend, for the reason already sta- ted, and for many others which I could adduce, that it is owing to irritation rather than inflammation, in the great majority of cases, and, consequently, that it is no criterion of the latter disease in this class of complaints. The indiscriminate application of leeches for its removal, has, to my knowledge, very often aggravated the disease. The counter- irritation of a blister or tartar-emetic plaster is far more effectual, and harmonizes with the true nature of the tenderness- — morbid sensibility of the gastric and duodenal nerves. In my own person, and those of many others, I clearly ascertained this point, and found that tonics and bitters more effect- ually relieved this tenderness than leeches and blue pill. The same may be said of pain in the stomach, independent of pressure, of which, by the bye, Dr. Philip takes no notice, in the second stage of indi- gestion. This is a very common feature of the dis- ease; but affords no criterion of the existence of in- flammation. On the contrary, it is far more severe in functional disorder than in unequivocal inflam- mation of the stomach, and is relieved, as every one knows, by tonics and even stimulants, rather than by leeches or depletion. It is not a little remarka- ble, that Dr. P. should bring forward pain on strong pressure as indicative of inflammation, while he passes over severe pain, which is so very common- ly complained of, independent of pressure. But the fact is, that neither tenderness nor pain in the Btomach of a dyspeptic patient affords any proof of inflammation in that organ. 79 ON MORBID SENSIBILITY OP Of fthe fulness at the epigastrium I have already spoken, and shewn that it is often more apparent than real, being produced by the emaciation so common in this class of complaints. That it is usually noticeable in indigestion I admit; but that it marks any particular period or stage of the dis- ease I never could discover. It is, I believe, much more frequently the effect of flatus than of organic disease. If the liver be enlarged, so as to cause this fulness, there will then be hardness of the part, as well as fulness, and the edge of the organ will be felt through the parietes. The cause will then be unequivocal. The observations which I have made, on tender- ness of the epigastrium will equally apply to what Dr. Phillip has advanced respecting a peculiar hard- ness of the pulse, as indicating a change in the na- ture of the disease from irritation to inflammation. The longer a practitioner lives, and the more he sees of disease, the more he will be convinced that the pulse is a " res fallaeissima" in indiges- tion as well as in other complaints. On this sub- ject, I must take the liberty of saying, that Dr. Philip appears to have refined to an excessive degree of minuteness. If a physician's whole sense was concentrated in the point of his fore-fin- ger, he would hardly be able to follow Dr. Philip in his diagnostic of hardness in a dyspeptic .pulse. This hardness is often to be recognized only by " a particular way" of feeling the pulse. "If the pressure be gradually lessened till it comes to noth- ing, it often happens that a distinct hardness of the pulse is felt before the pulse wholly vanishes under the finger, when no hardness can be felt in the usual way of feeling it." I appeal to the ex- perience of every practitioner, whether such a re- finement as the above can be entitled to much con- fidence in the examination of a phenomenon like THE STOMACH AND BOWELS. 80 the pulse, which varies with almost every emotion or thought that crosses the mind of a dyspeptic invalid. Is it to be assented to, that, by such a criterion as this, we shall be enabled to distinguish irritation from inflammation ; or functional from organic disease ? The fact is, that, in irritation of the stomach or bowels, the pulse is often as hard and as quick as in inflammation of those parts.* The heart is so much under the influence of the stom- ach, in functional derangement of the latter organ, that no dependence can be placed on the state of the pulse, whether as regards hardness, frequency, or irregularity. In general, however, it will be found in dyspepsia, that the pulse is much quicker not only while the food is digesting in the stomach, but during the whole time that chyme is passing along the intestines, than after these processes are finished. The pulse through the day will often be up to nearly 80, and fall, by nine or ten o'clock at night, to 60. Indeed, the dyspeptic invalid is ne- ver so well as just before bed-time, when all irrita- tion is removed from the organs of digestion; and this often leads him to take (or supper such food and drink as render him miserable all the, next fore- noon. In fine, I am compelled to differ from Dr. Philip respecting tenderness of the epigastrium and hard- ness of the pulse, as pathognomonic signs of a par- ticular change in indigestion, from irritation to in- flammation; from functional to incipient organic disease. These symptoms are present in the earli- est as well as in the latest stages of indigestion ; nor do I believe that there is any regular order or succession of phenomena in this Proteian malady, by which the above-mentioned change can be as- * See Dr. Marshall Hall's excellent Essays on Intestinal Irrita- tion. See also the Memoir of M. Barras, on Gastralgia mistaken for Gastritis, in the Medico- Chirurgical Review for October, 1826. H 81 ON MORBID SENSIBILITY OV certained. At the same time, I have no doubt that, even in the earliest periods of indigestion, there is occasionally inflammatory action mixed up with irritation, when excesses are committed, or impro- per stimulants have been exhibited. But, on the other hand, I am satisfied, from what I have person- ally experienced and seen in others, that all the phenomena of what is called the second st ge of indigestion, including tenderness at theepigas .rium and sharpness of the pulse, may and do very gen- erally depend on irritation ; or, in other words, on functional disorder of the stomach and bowels. No proof to the contrary has ever been given by the scalpel ; while the long lives and frequent recove- ries of dyspeptics, after years of suffering, afford strong presumptive proofs that no permanent in- flammation or organic disease had supervened on disordered function. This doctrine, while it is less disheartening than that of Dr. Philip, is equally prudent in point of practice. It lulls into no false security ; for if there be any one maxim in thera- peutics which is better established than others, it is that which teaches us to remove (if removable) as well as prevent disease of structure, by correcting disorder of function. If, in examining a case of in- digestion, we cannot determine whether or not in- flammation or organic change has commenced, (and I have shewn the difficulty, if not the impossibility of this discrimination by the marks which have been laid down by authors,) what can we do better than aim at improving the functions of the organs of digestion? Nay, we may go farther. Allowing that the tenderness in the epigastrium and hardness of the pulse did offer proof that inflammation or even organic change had commenced, I should be glad to know how we are to remedy the evil but by withdrawing the causes of all irritation from the organs themselves, which I shall shew is the funda- THE STOMACH AND BOWELS. 82 mental indication in the treatment of mere func- tional disorder. Frebile symptoms, as evinced by alternate heats and chills, or by evening heat and dryness of skin, some degree of thirst, dryness of the tongue, defec- tive secretions, high-coloured urine, and more than usual colour in the face, with quickness of pulse, are certainly more characteristic of inflammatory action going on in some part of the system, than tenderness of the epigastrium; and, when conjoined with this last symptom, I have no objection to pro- per precautions, as leeching the epigastrium, and cooling saline aperients. But whoever has atten- tively watched or felt the phenomena of gastric and intestinal irritation, will acknowledge that even these, nay a very strong paroxysm of fever, may be produced by irritation alone, and where there is not a particle of inflammation present. This is eve- ry day seen in children, who will shew high fever and excitement, when irritating matters are lodged in the prirmB viae, and who will be cured of these symptoms in a few hours by a brisk cathartic. This faet should be %orne in mind, when the dys- peptic patient evinces febrile phenomena, and the means of removing irritation should always be em- ployed before we have recourse to those which are calculated for the reduction of inflammation.* * The younger Andral has recently published an interesting Memoir on Chronic Gastritis, in which he labours to shew, and with some success, that a peculiar disorganization of the mu- cous membrane of the stomach, which he terms ramollissement, or softening, is often found where no other symptoms had presented themselves, during life, than those which are common to the very lightest shades of indigestion. " There may have been," says he "no vomiting— no loss of appetite— no pain— no thirst— no dis- turbance of the circulation. The patient merely complains that the digestion is more or less uneasy and imperfect— and that he loses flesh and strength." This diseased condition of the mucous membrane shews itself in three grades or degrees. In the .first degree, the membrane- 83 ON MORBID SENSIBILITY OF We are now to notice the more prominent sym- pathetic affections which depend on this combina- tion of gastric, hepatic, and intestinal disorder. It is difficult to say which is the organ or part that is most intimately linked in sympathy with the stom- ach and liver. I should say, however, that the brain, as the sensorium commune, to which all sen- sations are ultimately referred, is the first to sym- pathise with disorder of the abdominal viscera. Pain in some part of the head is a very common symptom in this class of disorders, but the func- tions of the brain are affected in a great variety of ways; especially its intellectual functions. Con- fusion of thought, unsteadiness of the mind, irrita- bility of the temper, defect of the memory, fickle- though softened and easily reduced to a pulp between the fingers, still preserves some degree of consistence before it is scraped off by the scalpel. In the second grade, we find only a layer of pulpy or gelatinous substance, of a white, grey, or reddish colour, which might be readily mistaken for a coat of mucus spread over the cel- lular membrane beneath. In the third degree, this semi-fluid pulp has disappeared, and the subjacent cellular tissue is left naked, in spaces of greater or lesser extent. M. Andral labours to prove that this softening is the legitimate product of chronic inflammation; but in this he is not quite satis- factory. He has, however, unequivocally proved that the above state of the mucous membrane takes place under the influence of irritating substances long applied to the stomach — in short, that it is intimately connected with a state of irritation, if not actual in- flammation. It is aggravated by the imprudent exhibition of stimulants and irritants — and it is soothed, or even cured, by an opposite system. M. Andral has described other morbid appear- ances in the stomachs of dyspeptics, as discolorations, morbid thickenings of the coats of the organ, &c. which shew that indi- gestion, though seldom fatal, may, if improperly treated by tonics and stimulants, end in disorganization of the coats of the stomach. Speaking of the nerves of the stomach, M. Andral remarks : — " Neither can we doubt that, among the various disturbances of function which the stomach undergoes, there are many which imitate, more or less completely, acute and chronic gastritis, but which are, in reality, owing to a morbid state of the gastric nerves or the centres of the ganglionic system. Hence, in some individu~ als, we have disordered digestion ; in others vomitings ; and in others still, epigastric tenderness and pain," &c. &c. &c. — In thia I entirely agree with M. Andral. THE STOMACH AHD BOWELS. 84 ness of disposition, and many other phenomena which are little suspected of corporeal origin, shew themselves infinitely more often than pain, deaf- ness, vertigo, defect of vision, or affections of mere sensation. The former gradually rise into gusts of passion, fits of despondency, brooding melancholy, permanent irascibility, and still higher grades of intellectual disturbance, till, as sometimes happens, the point of temporary alienation is reaehed, and suicide terminates the scene. Those functional dis- turbances of the brain, however, which are evinced in the form of mental phenomena, are very com- mon in morbid sensibility of the gastric and intes- tinal nerves, where the usual symptoms of indiges- tion and hepatic derangement are almost entirely wanting. In unequivocal disorder of the digestive organs, the affections of sensation about the head most engage the patient's attention. Pains of vari- ous kinds, not seldom remittent or intermittent, are felt in different parts of the scalp, about the face, or deep in the head. When purely sympathetic of stomach disorder, they are more frequently in some particular part, than in the head generally, and as- similate in their nature to tic douloureux. Indeed, I have no doubt that this dreadful disease is, in nine cases out often, caused by irritation of the ganglio- nic nerves; and the cures which have been per- formed by alterative and aperient medicines, and especially by the carbonate ofirdn, (which removes the morbid sensibility of the nerves,) confirm this opinion. In conformity with these views, it is fairly to be persumed, that many eases of epilepsy, are to be re- ferred to morbid sensibility and irritation of the gastric and intestinal nerves, else how should pur- gation and lunar caustic cure the complaint ? The former removes the sources of irritation, and the H 2 85 ON MOBBID SENSIBILITY OP latter the morbid nervous sensibility. But more of this anon. If sympathetic disorder of the brain or its mem- branes be long continued, it is believed, and it can- not be positively denied, that inflammation first, and change of structure afterwards, will be the re- sult. When these processes are once set up, they become, of course, in a great measure indepen- dent of the original cause that produced the sympa- thetic disorder, whether of function or sensation; and they are then not to be distinguished from idiopathic disease of the same parts. Nor would the discrimination, if practicable; be of any use, as respects the treatment. In what proportion of ca- ses these sympathetic affections of the head change into inflammatory and organic diseases, it is impos- sible to say, since few cases indeed have been so ac- curately watched through all their stages as to afford any satisfactory proof, if the thing is at all suscepti- ble of proof, which is very doubtful. As far as my own observation extends, this conversion into or- ganic disease is not so frequent as is imagined. Head-aches of great intensity, and even epilepsy go on for years, and leave no traces of their exist- ence, when death happens from other diseases. On the other hand, we see organic changes of immense extent take place in the brain, with but little pain or disturbance of the intellectual functions, even till the last. These facts should teach us caution in pronouncing on such a difEcult subject, and dis- trust of all theories or preconceived opinions. None of the senses are more frequently affected sympathetically than those of hearing and sight, Noise in the ears, and partial deafness are very common where the function of digestion is disor- dered, and may often lead us to suspect the latter, when very few of the common symptoms of indi- gestion are present. It is not uncommon for deaf- THE STOMACH AND BOWELS. 8(5 ness, noise in the ears, and sense of confusion in the head to disappear, for a time, after tea, coffee, dinner, or a glass or two of wine, and again to return when the stomach is empty. When this is the case, we may be assured that the cause is in the stomach, and that the affections of the head and or- gan of hearing are purely symptomatic. When these symptoms are aggravated by eating or drink- ing, there is then some reason to dread that a more permanent state of disorder, if not actual disease, is establishing itself in the head, and remedies should be directed to that quarter without delay. The same observations apply to affections of the organ of vision, as muscae volitantes, indistinctness of sight, uneasiness in the eyes when reading, or when exposed to a glaring light. These phenomena should not be treated too lightly. They may be precursors, or rather indications of a complaint more formidable than that in the stomach from whence they originally sprung. Next to the brain, I would say that the heart and mucous membrane of the lungs sympathise most readily with disorder of the liver and digestive ap- paratus. The irrregularity of action in the heart, consequent on disorder of the liver and stomach, is much more common than is generally suspected, being often passed unnoticed by either patient or practitioner. The intermission of the pulse, and the sense of tumult in the region of the heart are sometimes very alarming to the hypochondriac or dyspeptic invalid, and also to the young practi- tioner; but they are really of little importance.* * In a very few instances, I have seen most of those symptoms which appertain to real angina pectoris, produced by disordered function of the stomach, and give way to a radical change of regimen and diet. But in general it is in the form of palpitation, and intermissions of the ventricular action, that the sympathetic disorder of the heart shews itself, and is then not very distressing, unless the patient's mind be alarmed by the irregularity of the 87 ON MORBID SENSIBILITY OP That diseased structure of the heart does occasion- ally result from long-continued disturbance of its function, occasioned by bilio-gastric affection, I know is the case ; but the instances are so compara- tively rare, that this very circumstance affords ground for the belief that the same may be said of other sympathetic affections. I am acquainted at this time with one case where the action of the heart has been greatly disturbed for more than ten years, by dyspepsia, and yet when attention is paid to diet and the state of the bowels, the action of the heart becomes perfectly regular. Disease of the liver, however, is much more apt seriously to en- danger the heart than mere dyspepsia. In propor- tion, therefore, as the hepatic affection predominates over the gastric, so will be the risk of sympathetic disorder of the heart changing into disease of its structure. In all dyspeptic cases, therefore, the practitioner should bear this in mind, and be gui- ded in his prognosis accordingly. But he should also not fail to examine the heart by means of aus- cultation, which will afford him the most certain means of diagnosis between functional and structu- ral disease of this organ. Of the sympathetic affection of the lungs ending occasionally in phthisis, I have already spoken. I think Dr. Paris has been thrown off his guard in treating what is called "dyspeptic phthisis" as a creature of the imagination. Nothing is more common than a cough from irritation of the sto- mach, and it is surely unsafe to aver, that long-con- tinued disorder of function can never end in disor- ganization. But, however this may be, it is no longer a matter of doubt that chronic inflammation and other organic disease of the liver does very fre- pulse. In most cases of disordered digestion there is an irritability of the heart, which causes it to be excited into quick action by very trifling agitations of mind or exertions of body. THE STOMACH AND BOWELS. 88 quently affect the contiguous lung, which becomes hepatized, and, if there be any tubercular disposi- tion in the respiratory apparatus, phthisis is sooner or later developed. This is more particularly the case on the return of an invalid from a hot to a cold climate with hepatitis. But on this subject I need not add to what I have formerly adduced. Of the sympathies between the digestive appara- tus and various other parts of the body, as the kid- neys, bladder, urethra, rectum, organs of sense, skin,&c. it would be difficult to give a description. The urinary secretion is particularly under the in- fluence of biliary and gastric disorder, and, I believe, nine-tenths of those who are affected with the grav- el and calculous complaints would get cured (unless the stone was of some size) by a particular regimen, which will be presently described. The sympa- thies established between the cutaneous nerves and those of the digestive organs are very numerous, and tend to puzzle the practitioner exceedingly^ The shoulders, the back, the limbs, the face, are all very subject to painful and indescribable sensa- tions from irritation in the primae viae, and the ner- vous connexions do not afford satisfactory expla- nation of these phenomena, since the sympathetic association is generally strongest where the nervous communications are least numerous. Whenever these unaccountable feelings are complained of, they should lead us to suspect chylopoietic irrita- tion, and this irritation will often be found to exist, and to be the cause of the phenomena when there are very few of the common symptoms of indiges- tion or of derangement of the biliary secretion pre- sent. This brings us to the second division of this curious subject, ON MORBID SEH SIBIMTlf OF THE STosvyuya &xd howi^s, WITHOUT ANV OBVIOUS OR WELL MARKED SYMPTOM OP DISORDER IN THOSE ORGANS THEMSELVES. This is a subject which has been little treated of by writers on this class of diseases, and yet it is one of very great importance. It is necessary, in the out- set, to take a short review of the causes of morbid sensibility in the stomach and bowels, whether ac- companied or not by the ordinary symptoms of disorder in the organs of digestion. These may be divided into two classes; physical and moral. Nu- merous and powerful as are those of the first class, the moral causes are still more predominant and effective. PHYSICAL CAUSES. These are very numerous, the surface of applica- tion being that of the whole body, external and in- ternal. The stomach may be considered, not even excepting the brain, as the greatest centre of sympa- THE STOMACH AND BOWELS. 90 thies. Every impression on the skin, whether of cold or of heat, of humidity or of drought, influen- ces, more or less, the functions of the stomach. This must have been experienced by every indi- vidual. In a climate like ours, therefore, where atmospheric changes areso perpetually occurring, not only as to temperature, but as to humidity, den- sity, rarity, &c. we need not wonder that the func- tions of the alimentary canal should be so frequent- ly disturbed. Among those who live in the pure and open air of the country, these atmospheric changes have comparatively little effect ; but in cities and large towns, where the whole constitution is effeminated; where the external surface of the body is not ha- bituated to the vicissitudes of the skies ; where moral causes are constantly operating injuriously on the digestive organs; and where air, imbued with millions of miasmata, exhaled from every thing in the animal, vegetable, and mineral king- doms, is breathed, swallowed, and kept in contact with the skin, the effects are conspicuous, in the sal- low complexions, puny or capricious appetites, and imperfect digestion of the inhabitants. This state of the appetite and digestion, resulting from sedentary habits, impure air, late hours, and mental perturbations, leads to an aggravation of the evil, by the recourse which is had to high-seasoned dishes and stimulating drink, indulged in, more or less, by all classes of society. The nerves of the tomach are daily irritated by what is ingested ; while the nerves of the bowels are irritated by what is undigested. To these causes may be added the -itiated secretions themselves, not only of the sto- mach, but of the liver, pancreas, and all the innum- rable glands that stud the surface of the alimentary canal. These circumstances produce all the phe- nomena of indigestion detailed in the preceding 91 ON MORBID SENSIBILITY OF section, not only as regards the disorder in the or- gans of digestion themselves, but as respects the innumerable affections of distant parts, from sympa- thy with the stomach, and other internal viscera. The qualities and quantities of food and drink, which produce or keep up irritation and morbid sensibility in the digestive organs, are but little sus- pected of mischief, because they are in general use, and because many individuals are daily seen to take far greater liberties with the luxuries of the table, without any very apparent bad effects resulting. The evil day, however, arrives at last, and it is found that the same food and drink which had been so long taken with impunity, now begin to be fol- lowed by uncomfortable sensations, and, at length, with actual disorder in the digestive apparatus. Still this is considered as an accidental occurrence, not connected with previous habits of diet, but ow- ing to other and unknown causes. This last is very often true, in part. The previous habits may only have produced a predisposition to indigestion ; and, then, when any other cause is applied, especi- ally of a moral nature, the explosion takes place. The fact appears to me that, in civilized life, the host of and moral physical causes of disease that are always in operation keep the powers of the digestive organs below the standard of health ; while the quantity and quality of our usual food and drink are calculated to impair these same organs, even if they were in a state of the most perfect integrity of function. If this position be true, and I believe it to be so, it is easy to see the reason why so many labour under indigestion, even in its obvious or open forms. Among the leading physical causes of indigestion, then, I place our daily food and drink. I have shewn that neither the one nor the other ought to produce any sensation in the stom- ach, if taken in the proper quantity, and of the THE STOMACH AND BOWELS. 92 proper quality. But, whenever our drink induces sensible excitement in the system, or our food is followed by an inaptitude for mental or corporeal exertion, we have transgressed the rules of health, and are laying the foundation for disease. When food produces any sensation of discomfort in the stomach, as sense of distention, &c. attended or not with some degree of depression of spirits or irrita- bility of temper, indigestion, (or rather morbid sen- sibility,) has actually commenced ; and the height to which it may be carried, if the irritation of food and drink be continued. I need not now describe. As, of all the physical causes of indigestion, our diet is the chief; so over this cause we fortunately have the greatest control. But sensuality and con- viviality are perpetually seducing us from the paths of temperance, and seldom permit us to think of preserving health till we have lost it. It is quite needless to describe the kinds and quantities of food and drink that are injurious. I have shewn the rule by which each individual is to judge of this matter : — any discomfort of body, any irritabili- ty or despondency of mind, succeeding food and drink, at the distance of an hour, a day, or even two or three days, may be regarded (other evi- dent causes being absent) as a presu?nptive proof that the quantity has been too much, or the qua- lity injurious. It is, however, far more frequently by the quan- tity of our food that the stomach is irritated and its nerves rendered morbidly sensible, than by the quality. In respect to this last, the vegetable world (however lauded by hermits and philoso- phers) is infinitely more prolific of irritation, and its consequence, morbid sensibility, than the animal kingdom. Farinaceous food, however, as gruel, for example, is an exception. Perhaps, of all spe- I 93 ON MORBID SENSIBILITY OF eies of food, this is the least irritating, and where a high degree of morbid sensibility prevails, it is of- ten the only thing that can be borne. Tender ani- mal food is next, in point of unirritating qualities, with the advantage of being more nutritious and less bulky. We see whole nations, as the Hindoos and Scotch, live and thrive on food almost exclu- sively farinaceous ; while others, as in some parts of South America, live well upon animal food, and that almost alone. In respect to drink, water is the only fluid which does not possess irritating, or at least, stimulating qualities ; and in proportion as we rise on the scale of potation, from table beer to ardent spirits, in the same ratio we educate the stomach and bowels for that state of morbid sensibility, which, in civilized life, will sooner or later supervene. The physical causes, then, of morbid sensibility of the nerves of the digestive organs are, atmos- pheric impressions on the external surface of the body ; cutaneous disorders and their sudden retro- pulsion ; disordered functions and diseased struc- tures in other parts of the body, as in the brain, li- ver, &c. acting through the medium of sympathy on the organs of digestion ; food and drink in too large a quantity, or of too stimulating or indigesti- ble a quality, acrid substances, as drastic purga- tives, &c. taken into the stomach, or generated in the alimentary apparatus. Under these heads all, or almost all, the physical causes may be ranged. They are very numerous, and act through two prin- cipal channels ; sympathy and direct application. If it be asked how food, which is the natural stimulus of the nerves of the stomach and bowels, should render them morbidly sensible? I might answer, by asking another question ; how does light, which is the natural stimulus of the optic nerve, render it morbidly sensible, if too brilliant THE STOMACH AND BOWELS. 94 and too long applied ? The parallel, I think, is per- fectly just. The same reasoning is applicable to drink. If for water we substitute beer, wine, or spirits, we stimulate the nerves of the stomach, though some stomachs will bear this stimulation for many years, in succession, with little apparent injury. But not so in civilized life. By this stimulus the nerves are excited, and, in due time, irritated, so as to set up an habitual state of morbid sensibility. The doctrine of Brown, indeed, teaches us that this con- stant stimulation will ultimately wear out the exci- tability of the nerves, and render them less sensi- ble than at first, to the same stimuli. It may be so ; but I much doubt whether, in the last sad years of the confirmed drunkard, the morbid sensibility of the stomach and howels is not still his unhappy lot. His appetite and powers of digestion are nearly ex- tinguished, I grant; but the stomaeh becomes more irritable, in proportion as intemperance has been long-continued ; till, at length, the presence of food cannot be borne without pain or sickness, and a very small quantity of that burning potation which he used to swallow so freely, now makes him quick- ly inebriated. These are facts which we see every day, and they strongly support the position I have laid down. MORAL CAUSES. There is but one path along whieh these causes can travel from the organ of thought to the organs of digestion : but the number of airy sprites, and the velocity with which they glide along the silve- 95 ON MORBID SENSIBILITT OF ry pneumo-gastric conductors, baffle alt calculation f The intellectual operations of man, in a state of high civilization, as compared with man in a state of nature, are as much more numerous as the me- chanical arts of Europe out-number the simple con- trivances of Otaheite. In such proportion, also, his susceptibility to moral impressions is augment- ed to an incalculable extent; and these impressions, though first received by the sensorium, are all re- flected on the organs of digestion, with more or less force, according to the state of predisposition ia these organs. In this country, where man's rela- tions with the world around him are multiplied be- yond all example in any other country, in conse- quence of the intensity of interest attached to poll- tics, religion, commerce, literature, and the > arts; where the temporal concerns of an immense pro- portion of the population are in a state of perpetual vacillation ; where spiritual affairs excite great anxiety in the minds of many; and where specu- lative risks are daily run by all classes, from the disposers of empires in Leadenhail Street, down to the potatoe-merchant of Co vent Garden, it is really astonishing to observe the deleterious influence of these mental perturbations on the functions of the digestive organs. The operation of physical caus* es, numerous as these are, dwindles into complete insignificance, when compared with that of anxiety or tribulation of mind. These causes very often escape the investigation of the physician, unless ho is very much on his guard. The patient is prodi- gal of description, as far as regards his corporeal feelings ; and he is often very candid as to the physical causes which may be enquired after by the practitioner ; but he seldom reveals (for obvious reasons) the real origin of the evil, when it is of a moral nature, unless it be dexterously drawn from him by artful cross-questioning. The disorder of TfiE STOMACH AWD BOWELS. 96 the digestive apparatus, however, induced through mental emotions, is very generally of a different cast from that resulting from physical causes, such as in- temperance, &c but the slightest physical causes, in addition, exasperate the complaint exceedingly. It is hardly worth while to attempt any physio- logical explanation of the mode in which the men- tal discomfort effects the corporeal disorder. The fact has not escaped the notice of even the most heedless observer, and is pointedly alluded to by poets as well as physicians. A single look, and a very few words from the tyrant monarch, gave the ambitious Wolsey a fit of indigestion, which termi- nated the Cardinal's life! The function of digestion, as indeed every function, is so completely under the nervous influence, that there can be no doubt of the channel through which the mischief is pro- duced. MentaV anxiety not only arrests or disturbs the digestive process in the stomach, by interrupt- ing or weakening the nervous influence on which it depends, and thereby leaving the materials of food open to the chemieal laws that would act on them out of the body ; but, in a remarkable man- ner, vitiates or impairs the biliary secretion, there- by adding a new and powerful source of irritation to the delicate nerves of the duodenum and small intestines. The consequence is, that the whole line of the alimentar}'- canal, from the cardie orifice to the valve of the colon, is kept in a state of irri- tation, from the time the food is taken in, till its remains pass into the great intestine. This is dis- tinctly felt by the individual, who has no ease either in mind or body, till the process of digestion, such as it is, and of chylifieation is over, when he feels comparative comfort. The mind and body then seem relieved from a burthen, and a most sig- nificant remark is often made hy people in this con- I 2 97 ON MORBID SENSIBILITY OF dition, that, if they could live without food they would be well. Whenever this observation is made, we may rest assured that there is a morbid sensibility established in the nerves of the alimen- tary canal ; and it is two to one that this has been induced by mental anxiety, or, in other words, by moral causes. But, m a great proportion of cases, the effects of this morbid sensibility of the stomach and bowels are not distinctly recognized by the in- dividual by pain or uneasiness in the parts them- selves, nor by any very morbid state of the evacua- tions, but in the re-action of the gastric and intesti- nal irritation on the mental faculties. They notice, therefore, the exasperation of these mental mise- ries, at certain times, but do not suspect the food and drink as the cause of these exasperations. Hence arises a whole class of maladies, which, as being unattended by any evident disorder of the body, are attributed to the imagination, and the un- happy individual is put down by his friends, and too often by his physician, as adecided Hypochon- driac. HYPOCHONDRIASIS. This curse of civilization is not confined to any age or any nation. Wherever the mind has been cultiva- ted at the expense of the body, there hypochondria- cism has prevailed. Aristotle informs us that all the great men of his time were hypochondriacs, and the disease, in its more marked forms, has been des- cribed by physicians and even poets, from Hippo- crates down to the present time. In respect to the nature of this disease, I am con- vinced that juster notions were entertained of it some hundreds of years back than at the present THE STOMACH AND BOWELS. 98 moment, with all the advantage of pathological in- vestigations. Cullen defines it to be " indigestion, with languor, sadness, and fear, from uncertaiu cau- ses." Now, 1 do maintain that, although hypo- chondriacal symptoms often attend indigestion, as in deed I have abundantly shewn, yet, indigestion is by no means essential to hypochondriasis. In two patients whom I am now attending, and who are perfect models of hypochondriacism,the appetite is good, the evacuations perfectly natural, and no pain, flatulence, or other symptom of indigestion in the stomach, is complained of. In both these in- stances, however, the hypochondriasis may, at plea- sure, be exasperated or mitigated by free or by ab- stemious living — shewing that the nerves of the stomach and bowels are concerned in the mental phenomena. The Cullenian doctrine, I believe, is the prevailing one in this country; while two dif- ferent theories of the disease obtain on the Conti- nent, especially in France. The disciples of Brous- sais consider hypochondriasis as depending mainly on a state of chronic gastro-enteritis, while an able author, M. Falret, has laboured to prove that the seat of the disease is in the brain. The doctrine of Broussais is, indeed, pretty nearly the same as that of Dr. Philip ; but it is surely untenable, see- ing the lengthened age which hypochondriacs at- tain, and the frequent absence of all symptoms or proofs of gastro-enteritis. In respect to M. Fal- ret's doctrine, I think it is evident that the affection of the brain is more often secondary than primary, though it is very reasonable to believe that, in pro- cess of time, the brain does actually become affected, in the same way as we see long-continued disturb- ance of function in any other organ, end ultimately in change ofstructure. But these are consequences, not causes of the orginal malady. Thus, we see hypochondriasis occasionally terminate in mon- 99 ON MORBID SENSIBILITF OP omania, or insanity on a single point, and then it is probable that actual lesion of the brain or its mem- branes has taken place. None of the modern doc- trines, however, are new. Hippocrates, Galen, and Areteus, attributed hypochondriasis to black bile — the hepatic doctrine of our own time. Diodes placed the seat of the disease in the stomach, oth- ers in the liver, mesentery, and spleen. Willis con- sidered it an affection of the brain and nervous sys- tem, (the doctrine of Falret,) while Sydenham made it to depend on debility, and on irregularity of the animal spirits. Boerhaave believed in the existence of a tenacious matter obstructing the ves- sels of the hypochondria. Lower accused the state of the blood, and Hoffman believed that the disease often depended on chronic inflammation of the mucous membrane of the intestines — the present doctrine of Broussais.* The following opinion of Villermay, precisely accords with my own observation and experience. " Ce n'est pas dans l'alteration du tissu nerveux lui- meme, que reside la cause immediate de cette ne- vrose; c'est dans une affection des proprieties vi- tales des nerfs de la nutrition; aussi l'on recon- nait generalement pour siege primitif de Phypoch- ondrie, les visceres abdominaux, specialement Pes- tomac afectes dans leurs sensibilite organique." This appears to me the true state of the case. I have already observed, that mental anxiety, too much exercise of the intellect, and too little exer- cise of the body, were the chief causes, in this, and, indeed, in all other countries, of the various phenomena of hypochondriasis; and that a morbid sensibility of the nerves of the stomach and bowels, with or without the usual symptoms of disordered digestion, was the leading feature of the disease, * See Louyer- Villermay, Trait surles Maladies Nerveuses. — 1816 THE STOMACH AND BOWEL3. 100 and the cause of the varied and endless train of symptoms which develope themselves in the mind and in distant parts of the body. Hypochondriasis is generally represented as com- mencing with some unequivocal affections of the sto- mach, as sense of uneasiness and distention after eating, slow and difficult digestion, eructations of air, acid, or portions of the food, flatulence in the bowels some hours ofter eating, fur on the tongue, especially in the morning, with a pasty disagreeable taste in the mouth, occasional nausea or even sick- ness of stomach, appetite either defective, irregular, or voracious, disagreeable odour on the breath, ir- regularity, but generally constipation of the bow- els, &c. — in short, the usual symptoms of indiges- tion. This may be the case, especially when ari- sing from physical causes, as intemperance and the like ; but at this early period, the extensive morbid sympathies are not established, the mental phenom- ena are not developed, and the individual, in short, is not hypochondriacal. But let this state of the di- gestive organs continue, for a certain period, and become aggravated, or let the causes be of a moral rather than a physical nature, as losses in business, crosses in love, disappointed ambition, or a thou- sand other mental afflictions, and then we shall find that the original train of corporeal disorders in the digestive organs is masked, or almost entirely dis- appears, under the complicated sympathetic affec- tions of remote parts. These sympathetic affec- tions are of a mixed character, corporeal and men- tal. In proportion as the causes were of a physical nature, so will be the predominance of the sympa- thies : — and, on the other hand, in proportion as they were of a moral nature, so will the sympa- thetic disorders be of a predominant intellectual character. In general, however, they are mixed. There will be palpitation and irregular action of 101 ON MORBID SENSIBILITY OP the heart, cough, or other affection of the lungs — pain, heat, confusion, giddiness, noise, and a thou- sand other sensations about the head, uneasiness or pain in the region of the kidneys, the bladder, the rectum, or other parts of the body. In short, there is not an organ or spot of the whole human fabric which is not liable to become the seat of some mor- bid feeling, more tormenting than the most dan- gerous organic disease : so true is the expression of Mangetus : — " Signorum maximus est numerus, nix enim ulla pars corporis est quoz vim hvjus morbi effugit, prozcipue si morbus radices alte egerit." In the more advanced, or rather in the higher grades of hypochondriasis, especially if the morbid sensibility of the nerves of the digestive apparatus has been induced by moral affections of a trying na- ture, then the intellectual functions, the sensations, the perceptions, the meditations, are singularly dis- ordered. The nerves of sense, under these condi- tions, are morbidly susceptible to an astonishing de- gree. Thus, any sudden noise will make such an impression as if the organ of hearing was distribu- ted over the whole surface of the body. It is said of the hypochondriac that he exaggerates every feeling: but the truth is, that every sensation is ex- aggerated, not by his voluntary act, but by the morbid sensibility of his nerves, which he cannot, by any exertion of the mind, prevent. Hence his imagination is perpetually placing these morbid feelings in different parts of the body to the ac- count of some serious organic disease. The nerves of the hypochondriac are so painfully susceptible of every impression, and the mind is so harrassed by these distressing appeals from the senses, that the individual endeavours to avoid society, from the fear of collisions; or if the ties of friendship or other motive draw him into conversation, he is perpetu THE STOMACH AND BOWELS. 102 ally describing his complaints, or dwelling on their fatal tendency. Finding but little relief from medi- cine, and indeed seldom giving any medicine a fair trial, while the consolation of friends generallly in- creases his miseries, as consisting of raillery, or at- tempts to persuade him that his complaints are ima- ginary, he flies from one medical man to another, and not unfrequently becomes the dupe or the vic- tim of quacks, who humour his ideas ; confirm him in the belief of the reality of the evil he appre- hends ; and delude him by unequivocal assurances of cure. It is no wonder that, tired out with dis- appointed expectations, and tortured with wretched feelings, his life should become burthensome to him, and that he should look upon death as the only deliverer from complicated and incurable ills. It is not one of the least curious anomalies in this strange malady, that the individual who appears so solicitous about every symptom of his complaint; and consequently about life, should not very rarely be the one to commit suicide. The fact is, that hypochondraicism, in its highest degree, passes into monomania — and it is despair of relief that drives the sufferer to fly into the arms of death to escape the miseries of existence. I shall, therefore, pass over those aggravated cases of hypochondriasis as- similating with insanity, in which, for instance, the patient fancies the existence of something quite im- possible, as that his legs are made of glass or the like, in order to make a few observations on far lower but far more frequent grades of the disorder, characterized by mental despondency, fits of pas- sion, irritability of temper, gloomy anticipations, melancholy moods, alternate sallies of good and bad spirits, &c. &c. which meet the eye every hour of the physician's life. In civilized life, indeed, what 103 ON MORBID SENSIBILITY OP with ennui and dissipation in the higher ranks* — anxiety of mind, arising from business, in the mid- dling classes — and poverty, bad food, bad air, bad drink, and bad occupations, among the lower clas- ses, there is scarcely an individual in this land of liberty and prosperity — in this kingdom of " ships, colonies, and commerce," who does not experience more or less of the "English malady" — that is to say, a preternaturally irritable state of the nervous system, connected with, or dependent on, morbid sensibility of the stomach and bowels. As it is more easy to remove disorders in the be- ginning than when they have taken deep root, so it is very important, both to the patient and practi- tioner, to detect the lighter shades of what may go on in the end to confirmed hypochondriacism, of which there is not a more terrible or more untract- able malady incident to man. It is fortunate for the patient when unequivocal disorder of the sto- mach and digestive organs is an early feature of the disease, for then his attention is directed to the root of the evil. It is, also, a sign that physical causes are operating deleteriously, and these can always be more readily combated than moral causes. But when the disorder in the digestive organs is not * There are but few, who have led a very active life, whether in the army, the navy, the colonies, or in commercial pursuits at home, who are capable of enjoying the anticipated pleasures of re- tirement afterwards. We, therefore, find a great proportion of these in a state of hypochondriacism, more or less prominent. — Exercise, whether of body or mind, is the great antidote, when in moderation, to this state ; but few will take regular exercise, men- tal or corporeal, without some distinct pursuit, which those who are retired have not. Besides, as it is only the wealthy who volunta- rily retire, they think one great object of their remaining days is to live well ; and this very indulgence leads to more misery than they ever experienced in the pursuit after riches. Thus the physique j poisons their morale. Those, on the other hand, who are forced to j retire from military service, in consequence of their services being I no longer wanted, become discontented as well as idle, and a state > ! of hypochondriacism very generally succeeds. Of these we see daily instances, in these piping times of peace. THE STOMACH AND BOWELS. 104 very prominent, or is wanting, and the malady- shews its first approaches through the medium of the mind, or of distant sympathies in the body, the real state of the case is seldom ascertained till seri- ous mischief is done. Whenever, therefore, a man finds any alteration in his temper or moral feelings, there being no adequate moral cause, he should suspect some phy- sical cause. Let him then narrowly watch the state of these deviations from natural temper or feelings, after free living and after abstinence ; af- ter complicated dishes and after plain food ; after wine and after water. If he does not find an in- crease or diminution of his mental or corporeal ailments, according as he leans to the one side or to the other of those points of regimen, then I am no observer. But I am confident that he will readily recognize the correspondence between cause and effect ; and if so, how can we have a better test for the nature of the complaint, or a firmer basis for the treatment? Even if the original causes be purely of a moral nature ; as, for instance, severe losses in business, — still the mental despondency is aggravated by the morbid sensibility of the stom- ach; and this morbid sensibility is mitigated or exasperated by the quality and quantity of our food and drink. The physician cannot cure the moral cause that preys upon the mind, and through that medium injures the body ; but he can, in a great measure, prevent the re-action of the body on the mind, by which re-action the moral affliction is rendered infinitely more difficult to bear. Thus a man loses by speculation a certain sum of money, which makes a considerable impression on his mind, and depresses his spirits. After a while he finds that time, instead of healing the wound which misfortune had inflicted, has increased it; and that K 105 ON MORBID SENSIBILITY OF what he could look upon with some degree of for* ti-tude, in the beginning, is now become such a source of despondency that it haunts him by day and by night, and is for ever uppermost ia his thoughts, and even his dreams. He finds, moreo- ver, that some days he can view the misfortune with courage, and spurn the idea of giving way un- der it ; while, on other days, it presents itself in the most frightful colours, and he seems complete- ly deprived of all fortitude to resist its overwhelm- ing influence. This is a true copy, of which I have seen many originals, during the late commercial distresses, and ruinous speculations. What does ife teach us ? Why, that the moral affliction was borne with comparative ease till the digestive organs were impaired through the agency of the mind,, when re-action took place, and impaired, in turn,- the mental energies. But how are we to account for the fact that, one day the individual will evince fortitude, and the next despair; all the attendant circumstances of the moral evil remaining precisely as they were? It can be clearly accounted for by the occasional irritation of food or drink exasperat- ins: the morbid sensibility of the stomach, and thereby re-acting on the mind. This temporary irritation over, the mind again recovers a degree of its former serenity, till the cause is re-applied. I was led to this solution of the enigma some years ago, by observing that a very aged hypochondriac was every second day affected with such an exaspe- ration of his melancholy forebodings, that he did nothing but walk about his room wringing his hands, and assuring his servants that the hand of death was upon him, and that he could not possibly survive more than a few hours. Under these gloo- my impressions he would refuse food and drink, and, in fact, give himself up for lost. The succeed- ing sun,- however,- would find him quite an altered THE STOMACH AND BOWELS. 106 man. The cloud had broken away ; hope was re- kindled ; and the appetite for food and drink was indulged ad libitum. Next morning, all tfould again -be despair, and nothing but death could be thought of. So he went on, aa regular as light and darkness. But if, on the good day, he could be kept on a very small portion of food, and the bottle unopened, the next would be good also. This, however, could seldom be done 5 for as soon as he felt a respite from his miseries, procured by one da}^'s abstinence, he returned to his usual indulgen- ces and again irritated his stomach and bowels, and through them reproduced the blue devils in the mind. Another curious phenomenon was observed m this case, and, indeed, I have -seen the same in many others : — namely, that any purgative medi- cine, which operated at all briskly, brought on an exasperation of the mental depression. He was al- ways better when the bowels were constipated ; clearly shewing that whatever irritated the nerves of the alimentary canal, whether as food or as phy- sick, increased the mental malady. Indeed, the abuse of irritating purgatives is one of' the common physical causes of this morbid "sensibility, and should be carefully avoided in the treatment of the disease. I have known many instances where individuals., having this morbid sensibility of the gastro-intesti- aal nerves, experienced, after eating certain arti- cles of difficult digestion, such a state of irritability of temper, that they were conscious of the danger they ran, by the slightest collision or contradiction from even the nearest relations, and, therefore, avoided society till the fit went off. One gentleman in this state always caused liis servants to tie his two hands together, lest in the paroxysm of irrita- tion (without any ostensible cause) he should cut his throat er -otherwise commit suicide. .There tt)7 ON MORBID SENSIBILITY OP was great difficulty in keeping this gentleman front wine in excess. Tartar-emetic was, therefore, put into it unknown to him, and produced vomiting every time he took it. He persevered for a day or two, and then took such a disgust to his usual be- verage that he could not bear the sight of it. This also effectually checked his appetite for food ; and, for a time, there was almost a total cessation of the irritability of temper and paroxysms of agitation, till he got back to excesses of the table. In fine, it is impossible to enumerate the thou- sand ways in which different people are affected in their tempers and dispositions from this morbid sensibility of nerves ; and, that without any mate- rial feeling of discomfort in the very parts where the morbid sensibility exists. They cannot, there- fore, point out the causes of their wretched feeling, nor can their medical attendant often detect it Their complaints are considered imaginary, and pass unpitied ; and the unhappy victim of a real physical malady, which preys on his vitals, is thus set down as a hypochondriac, and so bantered and ridiculed by his friends, that the world is to him a purgatory, from which he has little regret in party- ing ! TREATMENT. The pains which I have taken to investigate the causes and the nature of the class of diseases which has passed under review will greatly abridge what I have to say as to the treatment The real and efficient remedies are very few in number, and, in this respect, they form a striking contrast with the innumerable forms and phenomena of the disease THE STOMACH ASTD BOWELS. 108 which they are prescribed. Speaking general- ly, I verily believe there is more harm than good done by the farrago of medicines which are thrown into the stomach of a dyspeptic patient, at a time, too, when that organ will scarcely digest the lightest food. I think I have proved that, whether there be os- tensible disorder of the digestive function, or only the manifestation of morbid sympathies at a dis- tance, or both at the same time, there is a morbid sensibility of the gastric and intestinal nerves: and hence, the first and most important indication is to lessen that sensibility, by withdrawing the causes of irritation, and applying such remedies as have the effect of diminishing irritability. If the sour- ces of irritation eould be completely withdrawn, Nature would generally effect a cure, without the assistance of medicine. But as these are sometimes of a moral, as well as a physical nature, we have but little power over the former, and are, therefore, on- ly able to mitigate the symptoms. As it Is on the regulation of diet that oar chief hopes of cure 'must rest, and as the system which I must insist on is rather rigid, I have endeavoured to shew the reason why this apparently severe discipline is absolutely necessary, in order to stimulate the practitioner to fearlessly prescribe, and the patient to implicitly adopt It There Is a great error committed every day, in flying to medicine at once, when the functions of the stomach and liver are disordered., the secre- tions unnatural, and the food Imperfectly digested. Instead of exhibiting purgatives day after day to carry off diseased secretions, we should lessen and simplify the food, in order to prevent the forma- tion of these bad secretions. In doing this we have K 2 109 ON MORBID SENSIBILITY OP great prejudices to overcome. The patient feels himself getting weaker and thinner; and he looks to nourishing food and tonics for a cure. But he will generally be disappointed in the end by this plan. From four ounces of gruel every six hours, he will, under many states of indigestion, derive more nutriment and strength than from half a pound of animal food and a pint of wine. Whenever he feels any additional uneasiness or discomfort in mind or in body after eating, he has erred in the quantity or quality of his food, however restricted the one, or select the other. If the food and drink irritate the nerves of the stomach, it must be redu- ced and simplified, down even to the gruel diet above alluded to. I have known dyspeptic patients gain flesh and strength on half a pint of good gruel thrice in the 24 hours ; and gradually bring the stomach, step by step, up to the point of digesting plain animal food and biscuit. On six ounces of animal food, a biscuit, and a glass of water, I have known invalids dine for months in succession, and attain, on this regimen, a degree of strength and a serenity of mind beyond their most sanguine hopes. In all or any of the various forms of dyspepsia which have been described, then, the diet is the first thing to Deregulated. But it is quite prepos* terous to prescribe a certain quantity, or even qua- lity of food/nd drink, till the power of the diges- tive organs' is ascertained. I have repeatedly point- ed out the criteria by which the patient, as well as the practitioner, may easily determine this impor- tant point. I care not if the dyspeptic invalid be- gins with a pound of beef-steaks, and a bottle of Port wine for his dinner. If he feel as comforta- ble at the end of two, four, six, eight, or 12 hours after this repast, as he did between breakfast and dinner of the preceding day, he had better continue his regimen, and throw physic to the dogs. But THE STOMACH AND BOWELS. 110 if, a few hours after his dinner, he feel a sense of distention in the stomach and bowels, or any of those symptoms of indigestion which have been pointed out ; if he feel a languor of body, or a clou- diness of the mind ; if he have a restless night; if he experience a depression of spirits, or irritability of temper next morning, his repast has been too much, or improper in kind, and he must reduce and simplify till he come to that quantity & quality of food and drinkfor dinner, which will produce little or no alteration in his feelings, whether of exhilaration immediately after dinner, or of discomfort some hours after this meal. This is the criterion by which the patient must judge for himself. The scale of diet must be lowered and simplified down to water gruel, if necessary ; otherwise a cure can never be expected. Speaking generally, the dys- peptic invalid may commence the trial with from four to eight ounces of plain and tender animal food, with stale bread, and few or no vegetables, at two o'clock, or as near that hour as possible, drinking, after the meal, a table-spoonful of brandy to two or three wine-glassfuls of water. If, after this, he feels light, and rather inclined to exercise or amusement than to take a nap on the sofa, he has hit the point; and to that system he should rigidly adhere. If he feel oppressed in body, or discomfit- ed in mind, he must reduce the quantity gradually ; if he feel a sense of emptiness, or faintness, he must increase the quantity of his food ; but this will very seldom be necessary. If the weak brandy and wa ter will not be taken, sherry and water, (a wine- glassful to the tumbler) may be allowed ; but it is not so salutary as the former. Every thing that is taken beyond this, at dinner, is at the patient's own peril ; and if he prefer wretched health of body and mind to a relinquishmentof the momentary gratifica- tion of sensual indulgence at table, let not thephysi- ^11 ON MORBID SENSIBILITY 05? cian give his sanction to such self-destruction. I have distinctly said that the invalid may eat and drink as much as he pleases ; provided he experience no increase of his morbid feelings from food and drink, within the 24 succeeding hours. If he do feel an increase of these, the necessity of the restriction which I propose is self-evident, and so far from be- ing the imposition of a penance, it is, in reality, the removal of one. Let it be remembered that I am speaking of the dyspeptic stomach, and not of that which is in the enjoyment of ail its healthy powers and of all its natural sensibilities. But the invalid may ask — "Can I not have my ailments re- moved without abridging my appetites?" No! And the practitioner, who undertakes the treat- ment under such conditions, betrays either a want of principle or a want of judgment. Well, then, the patient adopts such a simple and abstemious plan of diet that he feels no augmen- tation of his sufferings after food ; but still he is far from well. He escapes those periodical aggra- vations of his complaint, but the medium ratio re- mains as before. There must be time for all things. Effects do not always cease when their causes are removed. It may have taken a long application of noxious agents to produce the morbid sensibility of the nerves, and it will require some time to rein- state them in their natural tone of feeling. Besides, the causes that originally produced the disorder may have been of amoral nature, and may still con- tinue to operate. In this case we can only prevent the aggravation by proper diet, and mitigate the symptoms by proper remedies. The rest must be left to time, and to moral means. Although there is much peculiarity of disposi- tion, in regard to diet, observable in different indi- viduals, and therefore some latitude to be allowed on this account ; yet experience has shewn that, THE STOMACH AND BOWELS. 112 however the proper quantity of food may differ in different constitutions, there is one broad rule as to quality, which is seldom inapplicable to one in a hundred dyspeptics. The least irritating, and the most easily digested aliment is unquestionably farinaceous food, at the head of which we may place good grit gruel. I have known many who could digest only this, with- out unpleasant sensations in the stomach or other part of the body. When such is the case, the nerves of the stomach are in a high degree of mor- bid sensibility, and great caution should be taken not to irritate them by attempts at more nutritious food. No person is in danger of starvation who can take a pint — nay, only half a pint of good gruel in the 24 hours. Arrow-root, sago, tapioca, rice, salep, are all in the same class; but few of them will bear repetition so well as gruel. A little sugar, and a tea-spoonful of brandy in each cup of the gruel may be permitted ; but the brandy may be safely dispensed with in general. When the nerves have been kept free from irri- tation for a certain time by this mild regimen ; when the tongue cleans ; the sleep becomes more refreshing; and the intellectual feelings and func- tions more tranquil ; beef-tea may be mixed with the gruel ; then half an ounce or an ounce of chicken ventured on, and gradually increased. Whenever any uneasy sensations, of mind or body, occur, within the 24 hours after this trial of animal aliment, it should be decreased; or, if that will not do, wholly omitted, and the farinaceous food re- sumed. If no bad effects follow, the quantity of chicken may be progressively increased to six or eight ounces, with stale bread — but not too much of that. No particle of any other vegetable matter should yet be ventured on. While the farinaceous regimen is necessary, no drink should be taken, 113 ON MORBID SENSIBILITY OP unless thirst be urgent, when barley water or toast and water in small quantity may be allowed. When the chicken can be borne, the drink should vary in quantity, according to the feelings of thirst, and the number of ounces of the animal diet which can be tolerated. Thus, if the patient can- not take more than an ounce of animal aliment, a wine-glassful of water, with a tea-spoonful of brandy in it, is as much as should be taken after the re- past, unless thirst should urge, when some toast and water without brandy may be taken. If eight ounces of chicken can be borne with impunity, a tumbler of water, with a table-spoonful of brandy, is a fair allowance. From poultry, the dyspeptic should cautiously ascend to mutton or game, dressed in the simplest manner, and still with stale bread or biscuit. I would strongly advise that the quantity should never exceed half a pound in weight, even when that can be borne without a single unpleasant sensa- tion succeeding. It is quite enough, and generally too much. The invalid will acquire a degree of strength and firmness, not fulness, of muscle on this quantity, which will, in time, surprise his friends, as well as himself. When arrived at the power of digesting six or eight ounces of mutton, he may vary the kind of animal matter considera- bly. Lamb, hare, tender beef, tripe ; nay, venison may be taken, provided the golden rule be obser- ved of always keeping to the quantity which pro- duces no languor after eating ; no unpleasant sensation of mind or body during digestion.* * It may seem strange that I have not included fish in the list of edible matters for the dyspeptic. But, in truth, it is a very precari ous, if not dangerous species of food in weak stomachs. {Salmon is extremely improper, and even the white fish is very apt to turnrancid and greatly irritate the gastric and intestinal nerves. I would advise the invalid to abjure fish. Without butter or other sauces it is in- sipid ; and with these additions it is poison. I have known very TK£ STOMACH AND BOWELS. U4 I cannot urge this rule too strenuously on dyspep- tics ! Their happiness ; perhaps their welfare; and the happiness and welfare of many who are connec- ted with them, depend on its strict observance. It is needless to dwell on the endless catalogue of improper dishes. All are improper for the dy- speptic, or at least dangerous, that are not included in the above. Even a mealy potatoe will often ir- ritate the nerves of the stomach (without any per- ceptible sensation there) and pass undigested, after producing a great deal of wretched feeling in dis- tant parts of the body. The same may be said of every kind of fruit and vegetable. There is such a tendency to form acidity in the weak and irritable stomach ; vegetable matters are so prone to acidify ; and acid is so peculiarly offensive to the morbidly sensible nerves of the primae viae, that the dyspep- tic invalid cannot be too much on his guard against fruit and vegetables of every description, however innocent they may seem to be, as connected with disagreeable feelings in the stomach itself. As for cheese, pickles, nuts, onions, and a variety of pro- vocatives, they are rank poison in dyspepsia, and as such should be religiously avoided. In respect to drink, my firm conviction is that water is the best ; and till the habit of water-drink- ing can be acquired, the dilute mixture of brandy and water is the next best beverage. Still I have no objection to a glass or two of sherry, under the guidance of the criteria which I have so often laid down. The sooner, however, that every species of stimulating drink can be laid aside the better. A serious attacks of indigestion, in its febrile form, produced by tur- bot and even cod. Shell-fish, as crab, lobster, and oysters, are, in general, much less injurious, and can be borne without detriment by the dyspeptic stomach, when the irritability of its nerves has been a good deal subdued by a proper course of diet and medicine previously. |15 ON MORBID SENSIBILITY OP ctip of coffee after dinner is far preferable to wine. Malt liquors are quite out of the question. The other meals are of some consequence to be attended to by the'dyspeptic invalid. In the morn- ing, if the nervous irritability is not in the highest degree, (necessitating the use of gruel,) coffee or Bohea tea, with well toasted bread, cold, and very little butter ; or what is better, a little cold meat, may be taken ; and nothing more till dinner, if at two o'clock. Where tyrant custom compels to dine late, a slice of cold meat and biscuit should be taken at one o'clock. The tea should be the same as the breakfast, but without animal food.— And a cup of gruel is the best supper. Where farinaceous food call be relished for breakfast, it is certainly better than tea j and the milk or cream should be sparingly used. By adherence to the foregoing plan, varying the quantity according to the feelings subsequently ex- perienced, the surest foundation is laid, not only for health, but for happiness. Upon a regimen of this kind, the body will be brought to the greatest degree of permanent muscular strength, of which the individual constitution is susceptible ; and the intellectual powers will be raised in proportion. Equanimity of mind will be attained, if attainable at all • and where moral causes of irritation ot affliction cannot be avoided, they will be greatly neutralized. Under such a system of diet, the corporeal frame will be rendered more capable of undergoing fatigue; and the mind more able to resist misfortune, than by the richest dishes and most luxurious wines.* * Captain Head states that, when he commenced his travels m South America, he was quite unable to undergo the necessary ex- ertion, till he adopted the plan of living on plain animal food and water only. He could then, in a short time, tire out horses in bia pedestrian marches. THE STOMACH AND BOWELS. 116 The rigid system which I have proposed is not the creature of speculation, engendered in the closet. It is that which many, to my knowledge, have adopted with the most perfect success ; it is that by which I have conquered the most intense degree of dyspepsia in my own person. Those who have courage and perseverance to reap the fruits of such a system, will hardly be induced to change it, how- ever strongly they may be tempted by the luxuries of the table, and the seductions of convivial society. It would be well for those in the enjoyment of pre- sent health, if they employed it as a preservative of that invaluable blessing ! But this I do not ex- pect. I am addressing those who have tasted the bitter cup of sickness ; and especially those who have experienced the horrors of dyspepsia. The latter alone can appreciate the luxury of immunity from the terrible feelings of mind and body engen- dered by that worst of human afflictions. When a man has escaped the miseries of dyspep- tic feelings, and brought the sensibilities of his stomach to a natural state, by great attention to diet, he should be careful how he deviates from the rigid regimen by which he was restored to health. Nothing is so liable to relapse as dyspepsia ; and indulgence in variety of dishes, or vegetables and fruit, will be almost certain of making the indi- vidual pay dear for the experiment. But it is of still more importance to keep to a low quantity of food. The least over-exertion of the stomach in mastering a larger proportion than it can easily di- gest, will be sure to re-kindle the morbid sympa- thies of the body, and the wretched feelings of the mind. MEDICINAL TREATMENT. The foregoing rules of diet will apply to almost all cases and stages of dyspepsia, whether consis- L 117 ON MORBID SENSIBILITY OF ting in morbid sensibility of the gastric nerves, without apparent disorder of function ; or accom- panied by the various symptoms of indigestion and biliary derangement. This dietetic regulation is the basis of the treatment. Without it, no effectual cure can be accomplished ; and by it alone, nine cases in ten of common indigestion, in its earlier stages, might be removed. But much auxiliary as- sistance may be derived from a judicious application of medicine. After adjusting the subject of diet, our attention should next be directed to the state of the secre- tions. The mode of ascertaining their habitual condition is too often erroneous. Thus, a brisk purgative is given, and then the secretions are ex- amined. But the same medicine, if given to a per- son in health, would very frequently evacuate mat- ters that would be considered morbid. Besides, the action of purgatives will often rouse the liver and other glands to pour forth secretions very dif- ferent in quantity as well as quality from what are habitually secreted. The secretions cannot, in fact, be ascertained by one or two inspections. They should be examined when medicine has been taken, and when no medicine has been taken. They should also be examined after the operation of dif- ferent kinds of medicine. Mercurial aperients will bring down bile that is habitually defective. — Rhu- barb will tinge the secretions yellow that were pre- viously pale ; magnesia will render the motions pale that were formerly dark-coloured ; salts will expel watery motions ; aloes, solid evacuations. From this it will be seen, how necessary it is to think a little before a plan of medicine is determin- ed upon. When there is unequivocal disorder of function in the liver and digestive organs, as ascertained by the symptoms formerly described, it will generally THE STOMACH AND BOWELS. 118 be found that the secretions are unhealthy. The change of diet will, in itself, greatly correct this morbid condition of the secretions; but, in the mean time, they must be daily removed from the^ alimentary canal, in order to take away one source of irritation. In doing this, there is much caution necessary. Infinite mischief, as I have stated before, is daily occasioned by the indiscriminate employment of purgative medicine, in dyspeptic complaints. Bad secretions may be thus removed, but their repro- duction will never be thus prevented. It is by withdrawing the sources of irritation, and gradually improving the functions of the liver, the stomach, and the intestinal canal, that the formation of mor- bid secretions can be arrested. Purgation, there- fore, should be rarely employed. It may be pro- per, just at the beginning, to clear the alimentary canal of all its lurking contents ; but, after this, I do maintain that the main object is to produce but one evacuation daily, and that of a solid, rather than a liquid consistence. If practitioners knew the misery that is often produced by an irritating ca- thartic medicine in dyspeptie and hypochondriacal complaints, in this country, they would be more sparing than they are of their calomel at night and black draught in the morning. Experience has shewn, that there are some medi- cines which produce little irritation in the stomach and upper bowels, and act principally on the colon and rectum, as, for instance, aloes and sulphur. Jalap, calomel, salts, senna, antimony, and many other purgatives, produce a good deal of disorder in the stomach and along the whole eourse of the alimentary canal, causing a copious secretion from the glands and secreting surfaces of these parts, as well as of the liver. They are very useful, upon occasions, to remove all offending matters, but 119 ON MORBID SENSIBILITY OF should not be often employed. A combination of several different kinds of aperient medicine, that will act mildly, but gradually, along the whole line of the digestive apparatus, is far preferable to any one medicinal substance. Simplicity of prescrip- tion is very generally, on this point, accompanied by inefficiency of the effect designed. In dyspep- tic cases, and especially where there is morbid sen- sibility, in any considerable degree, in the stomach and bowels, it is of great consequence to join hyosciamus, or some gentle anodyne, with the aperient. When the morbid sensibility is not in great degree, the anodyne may be left out. The following formulas may be found pretty generally applicable as habitual aperients. (No. 1.) Jfc. Ext. Aloes . . . 9ss. Jalapii, (resinos) gr. vj. Col. compos. . gr. x. Pil. Hydrarg. . . gr. vj. Ipecac. Pulv. « . gr. j. 01. Cassias . . . gt. iij. M. ft. Pil. x. Capiat j. ij. vel iij. horasomni. These pills should be taken according to the ef- fects they produce. If one be sufficient to procure one easy evacuation the succeeding morning, well and good. If not, two, three, or any number may be taken, so as to effect the purpose desired. If much irritation prevail, from three to five grains of extract of hyosciamus should be taken at night with the pills. Of the two following forms, the first (No. 2) is a brisk purgative, that may sometimes be necessary, where considerable torpor of the lower bowels pre- vails. THE STOMACH AND BOWELS. 120 (No. 2.) Jfc. Extracti Colocynth. comp. £j. Jalapii . . . . gr. vj. Pulv. Scammon. compos, gr. x. Sub. Hydrargyri . . . gr. x. Antimon. Tart. . . . gr. j. Sapon. Venet gr. v. 01. Cassiae gt. iv. M. ft Pil. xv. quarum capiat j. ij. vel iij. hora somni. But as the stomach and bowels of some dyspep- tics are extremely tender, it is necessary to have a milder form of aperient than any of the above. (No. 3.) Jt. Ext. Rhei . . 9j. Aloes . . gr. v. Pil. Hydrarg. . gr. v. 01. Cassiae . . gt. iij. M. ft. Pil. x. Capiat i. vel. ij. pro dosi. There will be many cases where the irritability of the stomach and bowels will not bear more than a few grains of rhubarb and magnesia, without pro- ducing much distress. Where acidity prevails much, with disposition to pain and flatulence in the stomach, the following will be found a useful form of medicine. (No. 4.) J£. Magnes. Carbonat. . 3ss. Sulphatis . 3 iij. Spir. Ammon. Aromat. 3j. Tinct. Rhei . . . gss. Hyosciam. . Sss. Aquae Menth. Sativae §iv. Misce ft. Mistura, cujus capiat coch. i. mag. bis terve in die. L 2 121 ON MORBID SENSIBILITY OF . But, in fact, there is great difficulty in adjust- ing the aperient to the state of the case, so as to fulfil the essential indication — that of moving the bowels once daily, and always with as little irrita- tion as possible. Whenever thin or watery mo- tions are produced, more harm than good will be done. In proportion as the biliary secretion is derang- ed, the proportion of the mercurial must be increas- ed ;* but where there is no appearance of the liver being in fault, the less mercurial the better, espe- cially where the nerves of the stomach exhibit symptoms of much sensibility. In such cases, the following form of exhibiting the taraxacum (dande- lion) will be found very advantageous. (No. 5.) JL Infusi Taraxaci . . giv. Extracti Taraxaci, . gij. Carb. Sodae . . %sp. Tart. Potassae . . siij. Tinct. Rhei . . 3iij. Hyosciam. . n^xx. Misce, fiat Mistura, capiat tertiam partem ter die, * It may, in some cases, be prudent to touch the mouth with mercury ; but then the disease is hepatitis rather than dyspepsia. When this course is necessary, the patient snould be apprised of the circumstance, and warned to keep himself confined to the house, till the medicine is no longer reqnired. Where dyspepsia attends the hepatitis, as is almost always the case, the blue pill is preferable, in this country, to calomel, and should be gradually, steadily introduced till the mouth becomes sore, or the evacua- tions yellow and feculent. When this takes place, the symptoms of hepatitis generally vanish.- It is in such cases, that the nitro- muriatic acid bath, applied to the feet, legs, and arms, is often of very considerable benefit. This remedy, like most others, was overrated on its first introduction, and has, consequently, fallen al- most entirely into disuse — unmeritedly so. Its application is at- tended with too much trouble for patients and practitioners in general ; and this is one cause of the infi equency of its employ- ment. It ie not so well calculated for the morbid sensibility of the THE STOMACH AND BOWELS. 122 Before taking leave of the subject of aperients, I may add, that the use of injections, as auxiliaries, should not be neglected. In high grades of gastric and intestinal irritability, it is hardly possible to give any aperient by the mouth — even castor oil — 'without producing disagreeable effects ; and here the employment of injections is of great advantage. The rigid system of diet is our sheet anchor, till the morbid sensibility of the nerves is lessened or removed, and then aperients may be used with greater safety and greater latitude.* But are we possessed of no means of reducing this morbid sensibility of the nerves, in addition to the plan of unirritating diet? We certainly can great- ly assist the dietetic regimen by other means. The effect of counter-irritation is often very conspicu- ously beneficial. A small plaster of tartar emetic and Burgundy pitch applied to the pit of the sto- mach is one of the most powerful cOunter-irritants we possess, and is far superior to blisters. A scru- ple of the tartrate of antimony to each drachm of the Burgundy pitch, will, in two or three days, produce a copious crop of pustules, that will con- tinue to discharge for a week afterwards, and af- stomach and bowels, of wbieh I have been treating, as for a torpid state of the liver, a paucity of bile, and a constipated state of the bowels. * The white mustard-seed has lately attracted considerable at- tention ; and 1 have known a great number of dyspeptic invalids take it ; some with advantage, others without much effect: and. in a very few instances, it appeared to do harm. It certainly is not calculated for a very irritable state of the gastric aud intestinal nerves; since all spicy or hot aromatic substances are injurious in such cases. It is where the bowels are very torpid, the appetite bad, and the whole system languid and sluggish, that the white mustard-seed promises to be serviceable. If it keep the bowels open, and produce no unpleasant feeling in the stomach, alimen- tary canal, or nervous system, it may be taken with safety. If it do not produce an aperient operation it can do little good, and may, perchance, do miscluef. 123 ON MORBID SENSIBILITY OP ford much relief. I have no objection to a few leeches being previously applied to the part, espe- cially if much tenderness is complained of on pres- sure: for although irritation and inflammation are two very different conditions, and require different treatment, yet the former sometimes leads to the latter, and we occasionally see the two combined. On this account the application of a few leeches is a safe predecessor to the counter-irritation. Where irritation of the whole nervous system depends, as it often does, on irritation of the sto- mach, it will sometimes be necessary to keep up a steady soothing effect on the gastric nerves, by ano- dynes, combined with small doses of blue pill. The biliary secretion is sometimes so acrid that the patient is sensible of its descent into the duodenum, and experiences the most indescribably disagreea- ble sensations at the time, producing a kind of shud- der through the whole frame, and a radiation of morbid feelings from the region of the duodenum in every direction. This I experienced myself, and was qnite satisfied that it proceeded from the contact of the bile with the morbidly sensible nerves of the duodenum. In such cases, two or three grains of hyosciamus, one grain of blue pill, and two of the compound powder of ipecacuanha, every six hours, will keep the irritation in check, and help to correct the vitiated state of the biliary secretion. With these medicines, a little rhubarb at night, merely to ensure one action of the bowels daily, is all that should be taken, and this only when the bowels will not act spontaneously. Bearing in mind the intimate sympathy between the external surface of the body and the internal surface of the alimentary canal, the tepid bath is an important remedy, as a soother of irritability. The forenoon or the evening is the time to be selected, and the subsequent feelings of the individual will be the best criterion for its repetition. THE STOMACH AND BOWELS. 124 I now come to an important class of remedies for the lessening of morbid sensibility of the nervous system — namely, the vegetable bitters and tonics. The state of the appetite being a pretty fair index of the state of digestion, experience, in all ages, has confirmed the benefit to be derived from this class of medicinal substances in dyspepsia, when carefully managed. It is a well known truth that debility is the parent of irritability, and it is on this principle that tonics can be safely employed. But when irritability is great, tonics do more harm than good, and, in fact, increase instead of dimin- ishing the morbid sensibility of the stomach and bowels. On this account they cannot be safely employed till the irritability is reduced to a cer- tain point by mild diet and by soothing medicines, when they may be applied with the most decided and indeed surprising good effects. If they are given before this reduction of morbid sensibility, they produce great disturbance in the system, and I am confident they frequently change irritation into inflammation. In this case, as in the case of food, the feelings of the individual are unerring criteria of the salutary or noxious effects of bitters and tonics, and these should be scrupuously atten- ded to by the patient and practitioner. Many hy- pochondriacs have been driven into a state of in- sanity by the stimulation of wine and tonics, when the morbid sensibility of the stomach was in a high degree. Wine and tonics, like opium, will over- power the sensibility of the nerves for a few hours, in these cases, and some sleep may follow, but the terrible exasperation of irritability which succeeds, when the first effects of stimulation are over, has produced many an act of suicide, besides the thou- sand lower grades of mental misery, to which the unfortunate dyspeptic and hypochondriacal invalid is subjected by injudicious treatment. The dread- 125 ON MORBID SENSIBILITY OP ful depression of spirits and despondency of mind, resulting from this temporary exhilaration and ex- citement, are so much the more dangerous, as they too often lead to a repetition of the baneful causes that produced them. There is no point in practice which requires so much caution and skill in the practitioner as the exhibition of this class of reme- dies in dyspepsia and hypochondriasis. The mode of administering bitter tonics will be presently de- scribed, after premising a few observations on a preparation which I have sometimes employed with success in irritable states of the mucous mem- brane lining the stomach and bowels. I have now to draw the attention of the profes- sion to a medicine which I believe has never been employed in this class of diseases, but which, I ap- prehend, from what I have already seen, will be found a very valuable remedy. It is well known to surgeons that the nitrate of silver is one of the most powerful allay ers of irritability, when applied externally to painful and irritable sores. It is also well known that this medicine may be given inter- nally to the extent of several grains daily, for months in succession, in cases of epilepsy, and that without ever producing any bad effect. Indeed, it is now almost the only remedy on which any de- pendence is placed in the above-mentioned formida- ble complaint. My attention was first exeited to- wards its e,fFects on the stomach and bowels, some years ago, while exhibiting it to a young gentle- man employed in a public office of this metropolis, who laboured under epilepsy, and who, at the same time, had the usual symptoms of dyspepsia, and great irritability of the stomach and bowels. Considering the latter complaint as one of minor consequence, I gave the nitrate of silver alone, beginning with half a grain thrice a day, in crumb of bread, and gradually increasing it to two grains THE STOMACH AND BOWELS. 126 thrice in the 24 hours, beyond which I did not car- ry the dose. After the first month, he had no re- turn of the epilepsy ; but the medicine was contin- ued till the expiration of three months, when it was finally left off. He took no other medicine what- ever ; and in the course of the three months he was completely cured of all his dyspeptic symptoms. I was a good deal surprised at this event, and was at a loss to account for the result. But several ca- ses have since occurred, which lead me to think, Jirst, that epilepsy very often depends on morbid sensibility of the gastric and intestinal nerves, and, secondly ', that it is by removing this morbid irrita- bility of the alimentary canal, that the nitrate of silver sometimes cures epilepsy. We know, for in- stance, that convulsions and epilepsy are frequently produced by worms in the first passages, although no symptom of sensible irritation or pain may exist there at the time, the worms producing the phe- nomena above-mentioned by their action on the spe- cial or organic sensibility of the parts, and thence, by sympathy, on the brain and spinal system of nerves. The removal of the worms cures the con- vulsions and epilepsy, by removing the cause of ir- ritation, and the nitrate of silver very probably acts, in other cases, by lessening the sensibility of the nerves, and thereby rendering them unsuscepti- ble of irritation. On this principle I have adminis- tered the nitrate of silver, of late, in cases where the morbid sensibility of the gastric and intestinal nerves was produced by other causes than worms, and gave rise to other phenomena than epilepsy, and hitherto with marked advantage. In one case, that of a lady near Greenwich, the effects of the ni- trate of silver exceeded my most sanguine expecta- tions. She had been, for years, harrassed with con- vulsive twitching, faintings, and a host of the most strange and anomalous symptoms, almost daily, 127 ON MORBID SENSIBILITY OP which rendered her life miserable, and resisted every remedy that could be thought of by several eminent practitioners. Of the real nature of the disease, or the precise cause of it, I could form no rational conjecture ; but, among the numerous phe- nomena present in her case, there was evident de- rangement of the stomach and bowels. To this point several of her medical attendants had directed their attention, and all the usual means had been employ- ed to correct this part of the complaint, but without success. Purgatives almost invariably increased her sufferings, and she so dreaded the operation of a cathartic, that she sometimes allowed her bowels to be long constipated rather than take aperient medi- cine. Not knowing what else to do, I gave her the nitrate of silver, at first in doses of half a grain twice a day, gradually increasing it to four grains per diem, and that continued for the space of three months. At the same time I gave her a very small proportion of sulphate of quinine, not more than one, two, or three grains daily, and a common ape- rient pill to take when the bowels were confined. Long before the expiration of three months, she lost almost the whole of her complaints, and I saw her a few weeks ago, in the enjoyment of good health. Whether the disease may return, I cannot tell ; but the change that was wrought by this plan, was equally surprising to the patient and to my-' self. I am now exhibiting the same medicine, in combination with small doses of quinine, to some patients affected with obstinate dyspepsia, in that form which is more marked by the morbid sympa- thies of distant parts than by apparent disorder in the stomach and bowels themselves, and I have reason to believe, that the effects will be most bene- ficial. In one case, indeed, that of an elderly cler- gyman in Sussex, who has, for some years, laboured under a number of anomalous symptoms of a very THE STOMACH AND BOWELS. 125 distressing nature, especially affecting the head, the organs of sense, and the powers of the mind, but in whom the stomach and bowels exhibited marks of morbid sensibility, the nitrate of silver and sul- phate of quinine have been productive of the great- est relief, and I may say that he is on the point of being completely cured. I know too well the fallacies of medicine to hold this remedy up as a specific for removing morbid irritability of the primai viae ; but I think I may safely recommend it to the notice of my professional brethren, as an auxiliary in such cases, which it may be worth their while to try. It may be exhi- bited in the form of a pill at night, combined with any bitter or aperient extract. It will not inter- fere with the operation of almost any other medi- cine with which it is administered. Thus, half a grain of nitrate of silver, and two, three, or four, of extract of rhubarb, or, if the bowels require no as- sistance, extract of camomile or gentian, may be given every night at bed-time, and the dose gradu- ally increased to two or three grains daily. No inconvenience can possibly result from the adminis- tration of the medicine, if not continued beyond three months at a time. But I must remark on this, as on almost every other medicine, that unless the strictest attention be paid to diet, all medicines will fail. I particularly wish to be understood as recom- mending the nitrate of silver only as an auxiliary in a complaint which often baffles the practitioner, and where all auxiliaries are occasionally needful. The quinine may generally be given at the same time, not in pills, but in solution. In respect to bitters, as a class of remedies calcu- lated to lessen morbid sensibility, and improve the function of digestion, there can be no doubt as to their utility, when given at the proper period. Of late years, I have found in the sulphate of quinine, M 129 ON MORBID SENSIBILITY OF all the good properties of the other bitters, devoid of their bulk and other nauseating qualities. It is, in fact, the only bitter which we need in general and must ultimately supersede all others. In smali doses, as half a grain, thrice a day, dissolved in a tea-spoonful of any bitter tincture, as the compounc tincture of gentian, and diluted with a little toast and water, or any other fluid, it has an excellent ef- fect on the stomach, soothing its nerves, cleaning the tongue, improving the appetite, strengthening the digestion, and imparting tone and tranquillity to mind and body. If given in larger doses, espe- cially at the beginning, it stimulates too powerfully, and may do harm. It should, therefore, not be ex- hibited, till irritation is lessened by the subduction of improper food and the administration of proper medicines, and then it should be commenced in small doses, very gradually increased, and its ef- fects on the feelings watched as in respect to food, Managed in this way, it acts with surprising effica- cy, and it is not unusual for it to produce such a change in the appearance of invalids in a month or two, that the same person is hardly known. It should not be given in pills, as it is apt to pass un- digested in such forms, and thus disappoint the practitioner. Its effects are wanted on the sto- mach rather than on the bowels, and when medi cines are designed to operate on the former organ they should always be given in a liquid, or in i very soluble form, which is not the case with pills unless made soft and used the day they are com- pounded.* * The disease termed chorea is generally admitted as dependen' on irritation of the prims vise, and hence the practice of Dr. Hamilton, which consisted almost entirely in purgation. But ex- perience has now shewn that this plan will not always, perhaps not generally succeed. By it, we clear away irritating matters,»it | is true ; but the morbid sensibility remains, and our work is only half done. Hence the superior success which has attended the THE STOMACH AND BOWELS. 130 It is useless, as indeed it would be endless, to enter into an examination of the farrago of bitters, tonics, stomachics, and other remedies which have been recommended in the various forms and shades of indigestion and hypochondriasis. All the indi- cations which they are capable of fulfilling may be fulfilled by the few which I have pointed out, and why need we have recourse to subordinate agents, when the principals are at command ? But as I have taken great pains to explain the nature of this class of diseases and the objects which it is desirable to obtain, so it would be waste of time to dwell on the minor means of effecting these objects. They will suggest themselves to every medical practitioner, and none but medical practi- tioners should attempt the treatment of a class of maladies which requires the utmost skill to man- age. The dietetic regimen, indeed, may be put in force by any invalid, under the guidance of the rules I have laid down ; but let him beware how he meddles with the medical management of his com- plaint. If the indications to be fulfilled demand the minutest attention of the medical practitioner, how is it possible that the patient can judge of such difficult matters? The subject of exercise, though, strictly speaking, a physical remedy, and one of great importance in this class of disorders, especially in hypochondria- sis, will be glanced at presently under the head of moral remedies, with which it usually is associated. As to the host of symptomatic affections of dif- ferent parts of the body, originating in disordered conditions of the digestive organs, it is unnecessary to dwell on their treatment in this place. While they are merely sympathetic, (as they generally practice of following up the purgative plan by bitters and tonics. The former removes the irritants — the latter the susceptibility to the action of future irritants. 131 ON MORBID SENSIBILITY" OP are,)" they require no other treatment than that which is necessary for the removal of the disorder on which they depend, and when they become or- ganic affections, and independent of the cause which first produced them, their treatment will not differ from that employed for original or idiopathic affec- tions of the same organs or parts. The symptoma- tic disease of the lungs has been sufficiently consi- dered in a former part of this Essay, and I shall only glance at some of the others. The palpitation, or irregular action of the heart, which so often attends disorder of the stomach, is the most alarming of all. Headach, giddiness, noise in the ears, pains over the eye-brows, confu- sion of thought, loss of memory and other symp- toms about the head, are known, even to a pro- verb, to depend so often on the state of the stomach, that their existence seldom occasions much anxiety in either patient or practitioner ; but when the pulse begins to intermit, and the heart to beat irregularly against the ribs, great danger is usually apprehend- ed by the invalid, and the medical practitioner, who is not well versed in this class of complaints, is not un frequently thrown off his guard, and forms a more melancholy prognosis than the case gene- rally deserves. In these symptomatic affections of the organ of the circulation, however irregular may be the action of the heart and the pulse, they are not accompanied by the other usual attendants on- organic disease. The breathing is but little dis- turbed, the countenance has not the look of dis- tress, the lips are not blue, there is no oedema of the limbs, and the irregular action subsides when the stomach and bowels are empty, and the mind of the patient tranquil. But, as the surest proof of sympathetic disorder, the examination of the heart by auscultation, in the intervals, will shew that there is no enlargement, valvular imperfection, or THE STOMACH AND BOWELS. 132 other change of structure present. In such instan- ces, by confining the patient to a rigid diet for a day or two, and gently clearing the bowels, it may be proved to his own satisfaction that there is no dis- ease, nor even permanent disorder of function in the case. It is quite useless to prescribe any medi- cine for such sympathetic affection — " sublata causa, tollitur effectus." The sympathetic disorders about the kidneys, bladder, urethra, and rectum, are far more puzzling, and difficult to ascertain. Strictures of the rectum and urethra will be so completely imitated in dis- ordered states of the digestive organs, that both the urine and faeces will be expelled with considerable pain and difficulty, the former in a small twisted stream, the latter in flattened and spiral cylinders of very diminutive calibre, while both passages will resolutely resist the introduction of a bougie, there- by confirming the inexperienced practitioner in the belief of permanent organic stricture. It is very common, in these cases, for patients to complain, not only of irritation in making water, but of a sense of pain and smarting in the rectum for some minutes after each discharge of urine. The blad- der, too, will often be so irritable, that not more than half a pint of water can be retained. This last will generally deposit a sediment when cold, un- less there be much nervous irritability of the mind, when it will be as pale as distilled water. When these symptoms are present, the prognosis should be suspended till the disorder of the digestive or- gans is removed, or mitigated as there can be no hurry for the treatment of stricture, even if it be actually of an organic nature. In nine cases out of ten, these symptoms about the two passages will subside, pari passu, with the disorder that pro- duced them. In fact, where there is real perma- nent stricture of either of the canals, there is sel- M 2 133 ON MORBID SENSIBILITY OF dom half so much inconvenience felt, as where the stricture is temporary and sympathetic. — Such ca- ses afford a fine harvest for the unprincipled char- latan, who has little difficulty in persuading the pa- tient that he labours under a disease requiring con- stant mechanical treatment. This very treatment not unfrequently produces the very disease which it is pretended to remove, by the officious inter- ference of bougies, without proper attention to the constitutional disorder on which it depends. In what way, besides through the inscrutable channel of morbid sympathy, these affections of the kidneys, bladder, rectum, and urethra, are produced it is dif- ficult to say, but it is not improbable that the acri- monious secretions themselves may contribute much to the setting up of these local irritations imitating organic diseases of the parts thus irritated. MORAL REMEDIES. The moral causes of indigestion and hypochon- driasis are very numerous, but not so the remedies. The physician sees and deplores the operation of these causes, but he can do little more than combat their physical effects, and thus prevent, as much as possible, their re-action on the mind, through, the medium of which they were first directed to cer- tain organs of the body. What power can he exert over the thousand sources of mental anguish re- sulting from disappointed ambition, blighted hopes, ruined prospects, reverses of fortune, mercantile losses, domestic affliction, crosses in love, and all the varied ills to which the spirit as well as the flesh is heir ?— None have such opportunities of ob- serving the devastations committed on the body by THE STOMACH AND BOWELS. 134 the workings of the mind, as the medical philoso- pher. None can see the intimate connexion be- tween mind and matter, so clearly as he can. If metaphysicians had been physicians, they would not have issued into the world so many absurd specu- lations on the nature of the mental faculties, which they descant upon as independent of the corporeal organs through which they are manifested. Be this as it may, we find that men, labouring under moral afflictions, derive but little benefit from the moral lectures of the philosopher, or even the di- vine, on the virtues of patience, resignation, and calm submission to the dispensations of Providence and vicissitudes of fortune ! — Time, it is true, ef- fects a mitigation of our sorrows, and the mind, like the body, becomes accustomed to painful im- pressions, and ceases, at length, to feel them with much poignancy. But, as certain conditions of our corporeal functions greatly aggravate the mental af- fliction ; so other, and opposite conditions of the same functions do more to fortify the mind, than all the lectures of the moralist, the philosopher, or the divine. At all events, the physician can only work through physical agency, leaving to others, if such can be found, the pleasing task of curing the wounds of our spiritural nature by the balm of friendship and the consolations of religion. COMBINATION OF MORAL AND PHYSL CAL REMEDIES, AND ESPECIALLY EXERCISE. It is well known that one impression, whether mental or corporeal, will often supersede, or at least weaken another. This principle is sometimes 135 ON MORBID SENSIBILITY OP available in the cure of dyspepsia and hypochon- driasis, especially when resulting from moral cau- ses. If the patient's circumstances will permit him to engage in any pursuit that can occupy his at- tention and exercise his body, it will prove one of the most powerful means of counteracting the ori- ginal cause, as well as of removing its effects. Un- fortunately there are but few, comparatively speak- ing, whose circumstances will permit of the em- barkation in any new pursuit. Yet it is in the power of a great many to engage in a systematic exercise of the body, in some mode or other, if they will only summon resolution to make the experi- ment. The languor and listlessness attendant on the disorder are great obstacles to this plan, but they should be urged to it by all the eloquence of their medical attendants. Some caution, however, is necessary here. The debility and exhaustion which supervene on the most trifling exertion deter most people from persevering, and, therefore, the corporeal exercise must be commenced on the low- est possible scale, and very gradually increased. Thus, a person whose sedentary occupations con- fine him to the house, might begin by going once to the top of the stairs the first day, twice the se- cond day, and so on, till he could run up and down the same path some hundreds of times each day. It is wonderful what may be accomplished in this way by perseverance. I have known people, who could not go up a flight of steps without palpitation and breathlessness, acquire, in one month, the pow- er of running up to the top of the house one hun- dred times in the space of an hour, with scarcely any acceleration of the pulse or respiration. If the exercise can be taken in the open air, it will be still better, and the quantum gradually increased, by twenty or thirty steps daily. This task, which should be represented as an infallible remedy in THE STOMACH AND BOWELS. 136 the end, must be performed at first when the sto mach is nearly empty ; and when an increase of muscular power is acquired, it may be performed at any time> even immediately after dinner. Those who can engage in any of the lighter gymnastic exercises, now becoming so common, should be urged to it by every kind of persuasion, especially in the cool seasons of the year. These are means within the reach of almost all, and the advantages to be derived from such a system are incalculable* By this systematic exertion of the body, with very spare diet, most cases of dyspepsia might be com- pletely cured among the middling and lower clas- ses of society.* But there is a large class whose morale has been too far spoiled ; whose education has been too re- fined ; and whose senses have been too much pam- pered, to benefit by such simple means. There must be some incentive to corporeal exertion stronger than the foregoing plan presents; and moral excitement must be combined with physical agency, if we hope to carry our projects into beneficial ope- ration. That the long catalogue of dyspeptic and hypochondriacal complaints is much more frequent- ly the inheritance of the affluent than, of the indi gent, there can he no doubt ; and yet the former class have a remedy in their power which is infi- * It is very doubtful which is the more salutary kind of exercise — pedestrian or equestrian. I am inclined to agree with Dr. Parry,, in giving the preference to the former, as the more natural of the two. But as weakly persons will be induced to ride who would not walk, the horse-exercise is one of our most valuable remedies, in dyspepsia, as well as m many other diseases. If the individual* however, could be enticed to commence, and gradually increase* the active or pedestrian species, of exercise, it would certainly be far more efficacious in the removal of indigestion and hypochon- driacism than the passive, or comparatively passive exercise of ri- ding. There are some complaints, however, as of the heart and lungs, where passive is safer than active exercise, on account of the- temporary excitement of the circulation and respiration occasioned" by the latter. 137 ON MORBID SENSIBILITY OP nitely more efficacious than all the other moral and physical means put together, but which they rarely take advantage of — or, when they do embrace it, they seldom go the proper way to work. This is TRAVELLING. Since the Continent has been open to the En- glish, there has been no lack of this species of exer- cise ; but there are different kinds of travelling now, as there were different kinds of travellers in the days of Sterne. It is one thing to travel for health, and quite another thing to travel for the sake of studying architectural ruins, viewing pictures, ran- sacking libraries, or collecting antiquities. It is entirely with the first kind of travelling that I have to do — namely, that mode which conduces most to the restoration of health, leaving every other con- sideration entirely out of the question, with the exception of amusement, which I consider as es- sentially connected with the subject of health. In the course of a wandering life, I have had many op- portunities of studying the effects of travelling on different diseases ; but more recently I made one of a party whose sole object was the trial of a plan which I had devised for recruiting the health of three invalids, including myself. It may not be wholly uninteresting to the medical practitioner or the invalid, if I preface the remarks which I have to offer on the effects of travelling, by a concise sketch of the plan which was pursued in the present instance. Six individuals, three in health (domestics) and three valetudinarians, (one a lady,) travelled, in the months of August, September, and October, 1823, about 2500 miles, through France, Switzerland, Germany, and Belgium, for the sole purpose of health, and such amusement as was considered most compatible with the attainment of that object. The experiment was tried, whether a constant THE STOMACH AND BOWELS. 138 change of scene and air, combined with almost un- interrupted exercise, active and passive, during the day, principally in the open air, might not insure a greater stock of health than slow journies and long sojourns on the road. The result will be seen presently. But, in order to give the reader some idea of what may be done in a three months' tour of this kind, I shall enumerate the daily journies, omitting the excursions from those places at which we halted for the night, or for a few days. Our lon- gest sojourn was that of a week, and that only thrice; at Paris, Geneva, and Brussels. In a majority of places we only stopped a night and part of a day ; or one or two days, according to local interest. But I may remark that, as far as I was concerned, more exe: cise was taken during the days of sojourn at each place, than during the days occupied in tra- velling from one point to another. The conse- quence was, that a quarter of a year was spent in one uninterrupted system of exercise, change of air, and change of scene, together with the mental excitement and amusement produced by the per- petual presentation of new objects; many of them the most interesting on the face of this globe. The following were the regular journeys, and the points of nightly repose : — 1, Sittingbourn — 2, Dover — 3, Calais — 4, Boulogne — 5, Abbeville — 6, Rouen — 7, Along the banks of the Seine to Mantes — 8, Paris, with various excursions and perambulations— 9, Fontainbleau — 10, Auxerre — 1 1 , Vitteaux — 1 2, Di- jon, with excursions — 13, Champagnole, in the Jura Mountains — 14, Geneva, with various excursions — 15, Salenche — 16, Chamouni, with various excur- sions to the Mere de Glace, Jardin, Buet, &c. — 17, Across the Col de Balme to Martigny, with excur- sions up the Vallais — 18, By the Valley of Entre- ment, &c. to the Great St Bernard, with excur- sions — 19, Back to Martigny — 20, Vivian, on the 139 ON MORBID SENSIBILITY OF Lake of Geneva, with excursions — 21, Geneva — 22, Lausanne, with excursions — 23, La Sarna — 24, Neuf-chatel — 25, Berne, with excursions and per- ambulations — 26, Thoun — 27, Valley of Lauter- brunen, with various circuits — 28, Grindewalde, with excursions to the Glaeiers, &c. — 29, Over the Grand Scheidec to Meyrengen, with excursions to waterfalls j &c. — 30, By Brienz, Lake of Brienz, Interlaken, and Lake of Thoun, with various ex- cursions, to the Giesbach and other waterfalls, back to Thoun — 31, Berne — 32, Zoffengen — 33, Lu- cerne, with various excursions — 34, Zoug and Zu- rich — 33, Chaufhausen and Falls of the Rhine — 36, Neustad, in the Black Forest— 37, By the Val - lee d'Enfer to Offenburgh — 38, Carlshrue, with ex- cursions — 39, Heidelbergh — 40, Darmstadt — 41, Frankfort on the Maine, with excursions — 42, Mayence, with excursions — 43, Coblentz, Bingen, Bonn, &c. — 44, Cologne — 45, Aix La Chapelle, w 7 ith excursions — 46, Liege — 47, Brussels, with a week's excursions — 48, Ghent and Courtray — 49, Dunkirk — 50, Calais — 51, Dover — 52, London. Thus, there were 52 regular journeys during the tour, and 32 days spent in excursions and perambu- lations. And as there never was so much exercise or fatigue during the journeys as during the days of sojourn and excursions, it follows that the whole of this tour might be made with great ease, and the utmost advantage to health, in two months. As far as natural scenery is concerned, it would, per- haps, be difficult to select a track, which could offer such a succession of the most beautiful and sublime views, and such a variety of interesting objects, as the line which the above route presents. It would be better, however, to dedicate three months to the tour, if the time and other circumstances permitted, than to make it in two months ; though, if only two months could be spared, I would recommend the EFFECTS OF TRAVELLING. 140 same line of travel, where health was the object. Perhaps, it would be better, however, to reverse the order of the route, and to commence with the Rhine, by which plan the majesty of the scenery would be gradually and progressively increasing, till the traveller reached the summit of the Great St. Bernard. The foregoing circuit was made, as far as the writer is concerned, entirely in the open air, that is to say, in an open carriage ; in char-a-bancs; on mules; and on foot. The exercise was always a combination, or quick succession of the active and passive kinds, as advantage was always taken of hills and mountains, on the regular journeys, to get down and walk ; while a great part of each excur- sion was pedestrian, with the char-a-banc or mule at hand, when fatigue was experienced.* This plan possesses many advantages for the invalid, over the purely active or purely passive modes of tra- velling. The constant alternation of the two, se- cures the benefits of both, without the inconveni- ence of either. As the season for travelling in Switzerland, is the hottest of the year, and as, in the valleys, the temperature is excessive, so, great danger would be incurred by the invalid's attempt- ing pedestrian exercise in the middle of the day. But, by travelling passively in the hot valleys, and walking whenever the temperature is moderate or the ground elevated, he derives all the advantage which exercise of both kinds can possibly confer, without any risk to his health. The journeys on this tour varied from 20 to 50 or 60 miles in the day, and was always concluded by sunset — often much before that period. The * The writer of this has little hesitation in averring, that he walked full half of the whole distance which was traversed in this tour, that is, that in a quarter of a year, he walked twelve or thir- teen hundred miles. N i 141 ON MORBID SENSIBILITY OF THE STOMACH, &C. usual routine of meals was, some coffee at sunrise, and then exercise, either in perambulations, excur- sions, or on the first stage of the day's journey. At noon, a dejenne a la fourchette, and then imme- diately to exercise or to travel ; concluding the journey and the exercise of the day by dinner at the 8 o'clock table d'hote, where the company, of all nations, varying from 10 to 50 or 60 were sure to assemble, with appetites of tygers rather than of men. By ten, or half-past ten, all were in bed, and there was seldom a waking interval from that time till six in the morning, the punctual hour of rising. In this circuit we experienced great and sometimes very abrupt vicissitudes of temperature, as well as other atmospheric changes, but, as will be presently seen, without any bad consequences. Before I give any exposition of the moral and physi- cal effects of this kind of exercise, I may be per- mitted to premise, that I made it one of my prin- cipal studies, during the whole course of the tour, not only to investigate its physiological effects on my own person and those of the party, six in num- ber; but to make constant enquiries among the nu- merous and often intelligent travellers with whom I journeyed or sojourned on the road. Many of these were invalids — many affected with actual dis- eases — a considerable proportion had had dyspep- tic complaints previously, — and all were capable of describing the influence of travelling exercise on their mental and corporeal functions. What I am going to say on this subject, therefore, is the re- sult of direct experience and observation, unbiassed by any preconceived opinions derived from books or men. I am not without hope that my observa- tions will be of some service to the physician as well as to the invalid, by putting them in posses- sion of facts, which cannot be ascertained under any EFFECTS OF TRAVELLING. 142 other circumstances than those under which they were investigated in the present instance. 1. Moral Effects. If abstraction from the cares and anxieties of life, from the perplexities of busi- ness, and, in short, from the operation of those con- flicting passions which harrass the mind and wear the body, be possible under any circumstances, it is likely to be on such a journey as this, for which previous arrangements are made, and where a con- stant succession of new and interesting objects is presented to the eye and understanding, which pow- erfully arrests the attention and absorbs other feel- ings, leaving little time for reflexions on the past, or gloomy anticipations of the future. To this may be added, the hope of returning health, in- creased, as it generally will be, by the daily acqui- sition of that invaluable blessing, as we proceed. One of the first perceptible consequences of this state of things, is a greater degree of serenity or evenness of temper, than was previously possessed. There is something in the daily intercourse with strangers, on the road, and at the tables d'hote, which checks irritability of temper. We are not long enough in each other's society to get into ar- gumentation, or those collisions of sentiment which a more familiar acquaintance produces, and too of- ten raises into altercations and even irascibility, where the mind and body are previously irritable. These short periods of intercourse are the honey- moons of society, where only good humour and politeness prevail. We change our company be- fore we are intimate enough to contradict each other, and thus excite warm blood. Besides, the conversation generally turns on scenes and subjects with which we are pleased and interested on the road, while political and religious discussions are studiously avoided by all travellers, as if by a tacit 143 ON MORBID SENSIBILITY OF THE STOMACH, &C. but universal compact. One of the best remedies, then, for irritability of temper, is a tour of this kind. A few hundred pounds would be well ex- pended by many of our rich countrymen, in ap- plying this pleasant remedy to the mind, when soured and unpoised by the struggle after wealth, rank, or power ! I have already pourtrayed the influence of bad health, and especially of disordered states of the digestive organs, in producing depressions of spir- its, or mental despondency, far worse to bear than corporeal pain. For the "removal of this kind of melancholy, there is no other moral or physical remedy of half so much efficacy as a tour conducted on the plan which I have pointed out. It strikes at once at the root of the evil, (as I shall presently shew, when speaking of the physical effects of travelling,) by removing the causes on which this sombre state of mind depends. It is true that, in some cases of confirmed hypochondriacism, no earthly amusement, no change of scene, no mental impressions or excitement, no exercise of the body, can cheer the gloom that spreads itself oyer every object presented to their eye or their imagination I With them, change of place is only variety of woe — coslum non animum mutant. Yet, from two or three instances which have come within my know- ledge, of the most inveterate and incurable hypoch- ondriacism being mitigated by travelling, (though the mode of conducting the journey was far from good,) I have little doubt but that many cases of this kind, which ultimately end in insanity, or at least in monomania, might be greatly ameliorated, if not completely cured, by a system of exercise constructed on the foregoing plan, and urged into operation, by powerful persuasion, or even by force, if necessary. The change for the better, in such cases, is not perceptible at the beginning of EFFECTS OF TRAVELLING. 144 the tour ; but when the functions of the body have once begun to feel the salutary influence of the journey, the mind soon participates, and the gloom is gradually, though slowly dispelled. Where the mental despondency is clearly dependent on disor- der of the digestive organs, and has not yet indu- ced an)' permanent disease of the brain, an almost certain cure will be found in a journey of this kind, for both classes of complaints. It is hardly neces- sary to observe that beneficial effects, though not, perhaps, to the same extent, will be experienced in other sombre and triste conditions of the soul, re- sulting from moral causes, as sorrow, grief, disap- pointments, crosses in love, &c. by a tour conduct- ed in such a manner as strongly to exercise the body, and cheerfully to excite the mind. I have already shewn the powerful influence of moral causes in deranging the functions of the body through the medium of the intellectual functions. The same functions may be made the medium of a salutary influence. In most nervous and hypo- chondriacal complaints, the attention of the patient is kept so steadily fixed on his own morbid feel- ings as to require strong and unusual impressions to divert it from that point. The monotony of do- mestic scenes and circumstances is quite inadequate to this object, and arguments not only fail, but ab- solutely increase the malady by exciting irritation in the mind of the sufferer, who thinks his coun- sellors are either unfeeling or incredulous towards his complaints. In such cases, the majestic scene- ry of* Switzerland, or the picturesque and beautiful views in Italy or the Rhingau, combined with the novelty, variety, and succession of manners and customs of the countries through which he passes, abstract the attention of the hypochondriacal trav- eller (if any thing can) from the hourly habit of N 2 145 ON MORBID SENSIBILITY OF THE STOMACH, &C* exaggerating his own real or imaginary sensations, and thus help to break the chain of morbid associa- tion by which he is bound to the never-ending de- tail of his own sufferings. This is a paramount ob- ject in the treatment of these melancholy com- plaints; and I am convinced that a journey of this kind, in which mental excitement and bodily ex- ercise were skilfully combined, would not only ren- der many a miserable life comparatively happy, but prevent many a hypochondriac from lifting his hand against his own existence. It would unques- tionably preserve many an individual from mental derangement. This principle was well understood long before medicine was established as a science. At the ex- tremities of Egypt were two temples dedicated to Saturn, and to these the melancholies or hypochon- driacs of ancient days were sent in great numbers. There the priests worked on the body as well as the mind by the pretended influence of supernatural, and the real influence of medicinal agents. The consequence was, that miracles, or at least miracu- lous cures were daily performed. The Romans sent their invalids to Egypt for change of scene, and Hippocrates has distinctly recommended those afflicted with chronic diseases, to change the air and soil — " In morbis longis solum mutare." It would be going out of my province to speak of the benefits of travelling in any other moral point of view than that which is connected with the restora- tion of health. I shall, therefore, proceed to a consideration of the effects of this combination of mental and corporeal exercise on our bodily func- tions. —II. Physical Effects, The first beneficial influ- ence of travelling is perceptible in the state of our corporeal feelings. If they were previously in a EFFECTS OF TRAVELLING. 146 state of morbid acuteness, as they generally are in ill health, they are rendered less sensible. The eye, which was before annoyed by a strong light, soon becomes capable of bearing it without inconveni- ence; and so of hearing and the other senses. In short, morbid sensibility of the nervous system gen- erally is obtunded, or reduced. This is brought about by more regular and free exposure to all at- mospheric impressions and changes than before, and that under a condition of body, from exercise, which renders these impressions innocuous. Of this we see the most striking examples in those who travel among the Alps. Delicate females and sensitive invalids, who, at home, were highly susceptible of every change of temperature and other states of the atmosphere, will undergo extreme vicissitudes among the mountains, without the smallest inconve- nience. I will offer an example or two in illustra- tion. In the month of August, 1823, the heat was excessive at Geneva and all the way among the de- files of the mountains till we got toChamouni, where we were, all at once, among the ice and snow, with a fall of 40 or more degrees of the thermometer, experienced in the course of a few hours, from mid- day at Salenche, to the evening at the foot of the Glaciers in Chamouni. There were upwards of 50 travellers here, many of whom were females and invalids; yet none suffered any inconvenience from this rapid transition. This was still more remark- able in the journey from Martigny to the Great St. Bernard. On our way up, through the deep vallies, we had the thermometer at 92° for three hours. I never felt it hotter in the East Indies. At nine o'clock that night, while wandering about the Hos- pice of the St. Bernard, the thermometer fell to six degrees below the freezing point, and we were all nearly frozen in the cheerless apartments of the mon- astery. There were upwards of 40 travellers there — 147 ON MORBID SENSIBILITY OP THE STOMACH, &C. some of them in very delicate health, and yet not a single cold was caught, nor any diminution of the usual symptom of a good appetite for breakfast next morning. This was like a change from Calcutta to Melville Island in one short day! So much for the ability to bear heat and cold by journeying among the Alps. Let us see how hygrometrical and ba- rometrical changes are borne. A very large con- course of travellers started at day-break from the village of Chamouni to ascend the Montanvert and Mere de Glace. The morning was beautiful; but before we got two-thirds up the Montanvert, a tre- mendous storm of wind and rain came on us without a quarter of an hour's notice, and we were drenched to the skin in a very few minutes. Some of the party certainly turned tail, and one Hypochondriac nearly threw me over a precipice, while rushing past me in his precipitate retreat to the village. The majority, however, persevered, and reached the Chalet, dripping wet, with the thermometer below the freezing point. There was no possibili- ty of warming or drying ourselves here, and there- fore many of us proceeded on to the Mere de Glace, and then wandered on the ice till our clothes were dried by the natural heat of our bodies. The next morning's muster for the passage over the Col de Balme shewed no damage from the Montanvert expedition. Even the Hypochondriac above-men- tioned regained his courage over a bottle of Cham- pagne in the evening at the comfortable " Union," and mounted his mule next morning to cross the Col de Balme. This day's journey shewed, in a most striking manner, the acquisition of strength which travelling confers on the invalid. The as- cent to the summit of this mountain is extremely fatiguing, but the labour is compensated by one of the sublimest views from its highest ridge, which the eye of man ever beheld. The descent, on the EFFECTS OF TRAVELLING. 14S Martigny side, was the hardest day's labour I ever endured in my life, yet there were three or four in- valids with us, whose lives were scarcely worth a year's purchase when they left England, and who went through this laborious, and somewhat hazard- ous descent, sliding, tumbling, and rolling over rocks and through mud, without the slightest ulti- mate injury. When we got to the goat-herds' sheds in the valley below, the heat was tropical, and we all threw ourselves on the ground and slept soundly for two hours, rising refreshed to pursue our journey. Now these and many other facts which 1 could adduce, offer incontestible proof how much the morbid susceptibility to transitions from heat to cold — from drought to drenchings — is reduced by travelling. The vicissitudes and exer- tions which I have described would lay up half the effeminate invalids of London, and kill, or almost frighten to death, many of those who cannot expose themselves to a breath of cold or damp air, without coughs or rheumatisms, in this country. These facts may suggest some important indications to the physician who has charge of patients [labouring un- der, or threatened with, certain affections of the chest. I am strongly inclined to believe that many cases of incipient phthisis might be cured of the disposition to that terrible disease, by timely and cautious removal of morbid susceptibility to atmospheric impressions, by means of travelling in proper seasons, in proper countries, and in a proper manner. A young gentleman from Paris, was one of the party to the Montanvert, over the Col de Balme, and afterwards to the Great St. Bernard. He had strongly marked characters of incipient phthisis, and was travelling for his health. His breath was so short in ascending the mountains, and he coughed so violently, that I fully expected he would burst a blood-vessel in the lungs by his 149 ON MORBID SENSIBILITY OP THE STOMACH, &C. exertions. I had some difficulty in persuading him to mount my mule, of which I made no use, in getting up the Col be Balme, and I had much con- versation with him during our peregrinations to- gether. He informed me that he had had haemop- tysis several times in France; but that he had got much better and stronger since he had travelled in Switzerland. He had entirely lost all feverishness lately, and only experienced shortness of breath and cough on going up steep ascents. He had never caught cold from the time he set out on his journey, and felt no alarm at exposure to atmos- pheric vicissitudes in his perambulations among the mountains. I fell in with him nearly a month after this, in a more northern direction, and he was greatly improved in appearance. Several other travellers, with whom I had conversation, informed me they had entirely lost habitual coughs and great susceptibility to cold, while travelling in Switzer- land. These things do not harmonize with the doctrines of the schools, but facts are facts, and I leave them to the consideration of my professional brethren. The next effect of travelling which I shall notice, is its influence on the organs of digest- ion. This is so decided and obvious, that I shall not dwell long on the subject. The appetite is not only increased ; but the powers of digestion and assimilation are greatly augmented. A man may eat and drink things, while travelling, which would make him quite ill previously. A strong proof of its effects on assimilation is afforded by the univer- sal remark that, although much more food is taken in while travelling, much less faecal remains are discharged, and costiveness is a very general symp- tom among those who make long and repeated jour- neys, especially in a carriage or on horseback. The motions which were previously of bad colour and consistence, soon become formed or even solid, and EFFECTS OF TRAVELLING. 150 of a perfectly healthy appearance. The constipa- tion, which attends passive or mixed exercise, on these occasions, is hardly ever attended with any inconvenience; and travellers will go two or three days without a motion, and experience no uncom- furtable sensation, although the same degree of con- finement of the bowels, at other* times, would ren- der them ill, or at least very uncomfortable. These unequivocally good effects of travelling on the digestive organs, account satisfactorily for the various other beneficial influences on the constitu- tion at large. Hence dyspepsia, and the thousand wretched sensations and nervous affections thereon dependent, vanish before persevering exercise in travelling, and new life is imparted to the whole system, mental and corporeal. In short, I am quite positive that the most inveterate dyspepsia (where no organic disease has taken place) would be com- pletely removed, with all its multiform sympathe- tic torments, by a journey of two thousand miles through Switzerland and Germany, conducted on the principle of combining active with passive ex- ercise in the open air, in such proportions as would suit the individual constitution and the previous habits of life. This, it is true, is the rich man's remedy. But what is the expenditure of time and money, necessary for its accomplishment, compar- ed with the inestimable blessing of restored health ? How many thousand opulent invalids saunter away their time and their wealth, at watering places in this country, during the summer and autumn, with little or no improvement of constitution, when a three months' course of constant exercise in the open air, would cure them of ali their mala- dies ! The fact is, the power of this remedy is little known, and the manner in which it is applied by many invalids, is not calculated to shew its worth. 151 ON MORBID SENSIBILITY OF THE STOMACH, &C The kind of exercise under consideration has a marked influence on the absorbent system. It ex- cites this class of vessels into great activity. The fluids, even from the bowels, are rapidly taken up into the circulation, and thrown off by the skin, which is one cause of the constipation to which travellers are subject. This increase of activity in the function of the skin, exerts a very salutary in- fluence on the functions of various internal organs, with which the surface is sympathetically associat- ed. The secretion of bile is thus greatly improved, and this is of no mean consequence in many com- plaints* To the tropical invalid, with torpid liver and torpid skin, this remedy presents the highest advantages ; and I hope the present remarks will induce him not to neglect such an agreeable and useful remedy. The effects of travelling, on the absorbents, point at once to the benefits which may be derived from it, in cases where there is a dropsical tendency. In one gentleman whom I knew on this tour, there had been an cedematous state of the lower extremi- ties for many years, but whose legs became as small as ever they had been, in the course of one month's travelling. This activity of the absorbents causes the fat and flabby parts of the body to be rapidly reduced, while the exercise and the improved di- gestion increase the force and firmness of the mus- cular system. Hence corpulent people become thinner on the journey, but their muscles are in- creased in size; and what they lose in weight they* gain in strength. This salutary change of propor- tion between the muscular and the adipose systems of the body gives greater freedom to the functions of many important organs, especially to the heart and the lungs. Hence people who are easily put out of breath by exercise, or by going up an ascent, EFFECTS OF TRAVELLING. 152 soon acquire power to do both, without inconve- nience. The increased activity of the absorbents, during the combination of active and passive exercise in travelling, offers a powerful agency for the remo- val of morbid growths in the body, such as tu- mours, scrofulous swellings, &c. and this is one reason why I think great advantage might be de- rived from travelling, in cases where there is a ten- dency to consumption — a disposition so much con- nected with scrofulous affection both internally and externally. The effects of travelling on the circulation are peculiar. Active exercise unquestionably quickens the pulse; while passive exercise in a carriage renders it slower. In those diseases of the heart, therefore, where there is enlargement of the organ, with increase of force in the circulation, I think there can be little doubt that travelling, with com- bined active and passive exercise, would be dan- gerous, and would be likely to augment the disease. In such cases, the exercise should be completely passive, and then the effects would be beneficial. But there are many eases where there is a morbid irritability of the heart, from sympathy with other organs, as the stomach, liver, &c. In these, travel- ling offers a powerfully salutary remedy, not only by lessening the irritability of the heart, but by im- proving the functions of those organs with which the heart sympathises. The travelling exercise, in these instances, should be at first entirely pas- sive, and, as the irritability of the organ decreases, active exercise might be gradually ventured on, and progressively augmented. The exercise of travelling, whether active, passive, or both com- bined, has a very marked influence in producing an equal distribution of the blood to all parts of the body. This important effect must render it a pow- M 153 ON MORBID SENSIBILITY OP THE STOMACH, &C. erful agent in correcting undue determinations of blood to any particular organ or part — a phenome- non, which plays a conspicuous part in many of the most dangerous diseases to which the human fabric is liable. Hence, the utility of travelling, in many affections of the head and other parts to which an unequal distribution of blood may be habitually di- rected. There is but one other effect of travelling to which I shall allude, before I close this Essay, but I think it is a very important one, if not the most important of all. It is the influence which constant change of air exerts on the blood itself. Every one knows the benefits which are derived from change of air, in many diseases, when that change is only from one part to another, a few miles sepa- rated. Nay, it is proved, beyond all possibility of doubt, that the change from what is considered a good, to what is thought a bad air, is often attended with marked good effects. Hence it is very rea- sonable to conclude, that the mere change of one kind of air for another has an exhilarating or saluta- ry effect on the animal economy. It is true, that we have no instruments to ascertain in what con- sists this difference of one air from another, since the composition of the atmosphere appears to be nearly the same on all points of earth and sea. But we know from observation that there are great differences in air, as far as its effects on the human body are concerned. Hence, it would appear that the human body, confined to one particular air be it ever so pure, languishes at length, and is better- ed by a change. This idea is supported by analogy. The stomach, if confined to one species of food, however wholesome, will, in time, languish, and fail to derive that nutriment from it, which it would do, if the species of food were occasionally changed. The ruddy complexion then of travel- EFFECTS OF TBAVELLING. 154 lers, and of those who are constantly moving from place to place, as stage-coachmen, does not, I think, solely depend on the mere action of the open air on the face ; but also on the influence which change of air exerts on the blood itself in the lungs. I con- ceive, then, that what Boerhaave says of exercise, may be safely applied to change of air. " Eo ma- gis et densam, etpurpuream sanguinem esse, quo validius homo se exercuerit motu musculorum." It is to this constant change of air, as well as to the constant exercise of the muscles, that I attribute the superiority of the plan of travelling which I have pro- posed, over that which is usually adopted — where health is the entire object. On this account, I would recommend some of my fair country-wo- men, who have leisure as well as means, to improve the languid states of their circulation, and the deli- cacy of their complexions, by a system of exercise in the open air, which will give colour to their cheeks, firmness to their muscles, tone to their nerves, and energy to their minds. FINIS. % °* - ./ % v^ v 0c> vV V c*% y A c*-_ $**%., . . .