the cooling and refreshing qualities of the air, even in the finest
seasons, when every thing which pure and simple nature can offer,
invites them abroad, they do every thing they can, as Dr. Beddoes
observes, to add to the overstimulating operation of a full and
hearty dinner. After taking strong wine with their food, they sit in
rooms rendered progressively warmer, all the afternoon, by the
presence of company, by the increase of fires, and for more than half
the year, by the early closing of the shutters, and letting down of
the window curtains. After a short interval, tea and coffee succeed;
liquors stimulating both by their inherent qualities, and by virtue
of the temperature at which they are often drank. And that nothing
may be wanting to their pernicious effect, they are frequently taken
in the very stew and squeeze of a fashionable mob. The season of
sleep succeeds, and to crown the adventures of the evening, the bed
room is fastened close, and made stifling by a fire: and though the
robust may not quickly feel the effects of this mode of life, with
the feeble it is quite otherwise. These, as they usually manage,
rarely pass a few hours of sleep without feverishness and uneasy
dreams; both of which contribute to their finding themselves by far
more spent and spiritless in the morning, than after their evening
fit of forced excitement, instead of having their spirits and
strength recruited by the "chief nourisher in life's feast," Perhaps
they drink tea before rising, and indulge in a morning nap; this
weakens much more than the greatest muscular exertion they would be
capable of supporting for an equal time. For the sleep at this time
is almost invariably disturbed, and attended by a heat of the skin.
The reason of this must be evident to every one who has attended
these lectures.
The effect of sleep is to accumulate the excitability, or render it
more sensible to the effects of any stimulants applied. This takes
place in every constitution, and much more in the more delicate:
hence the heat of the bed, and of the tea, acts so powerfully on the
surface, as, in general, to produce great perspiration, or, at any
rate, great languor and debility.
Let me ask, can any one, who lives in this manner, expect to enjoy
good health? With as great probability might we expect, that when we
plunged a thermometer into hot water, the mercury would not rise, or
when we applied a lighted match to gunpowder, it would not explode.
The laws of nature are constant and uniform, and the same, or similar
causes, both in the animate and inanimate world, are always
productive of the same, or similar effects.
The cure of these complaints is at least obvious, if not easy. It
consists in deserting crowded and heated rooms, at least for part of
the time they have been usually occupied; in abstaining from strong
wines; in keeping the bed rooms moderately cool; and retiring to rest
at a proper hour.
With respect to the effects of nutriment, in producing asthenic
diseases, we may observe, that all watery vegetable food, too sparing
a use of animal food, as also meat which is too salt, and deprived of
its nutritious juices by keeping, when more nutritious matter is at
the same time withheld, constantly weaken, and thereby tend to
produce asthenic diseases. Hence would appear to arise that
remarkable imbecility of body and mind which distinguishes the
Gentoos. Hence arise the diseases with which the poor are every where
afflicted; hence scrofula, epilepsy, and the whole band of asthenic
diseases.
But intemperance in eating and drinking, or taking nutritious and
highly stimulant substances too freely, will, infallibly, bring on
asthenic disease, or a state of indirect debility, by exhausting the
excitability; and it must be observed, that this species of debility
is much worse to cure than the direct kind; for in the latter we have
abundance of excitability, and a variety of stimuli, by which we can
exhaust it to the proper degree, and thus bring about the healthy
state; whereas, in indirect debility, the vital principle or
excitability is deficient; and we have not the means of reproducing
it, at pleasure, absolutely under our command. Besides, the
subtraction of stimulants, which is one of the most certain means we
have of accumulating excitability, if carried to a great extent, in
diseases of indirect debility, would produce death, before the system
had power to reproduce the lost or exhausted excitability. Hence the
cure, in these two kinds of debility, must be very different: in
cases of direct debility, as in epilepsy, we must begin with gentle
stimulants, and increase them with the greatest caution, till the
healthy state is established: we must, however, guard most carefully
against over doing it; for, if we should once overstep the bounds of
excitement, and convert the direct into indirect debility, we shall
have a disease to combat, in which we have both a want of excitement
and of exciting power.
In cases of violent indirect debility, as, for instance, in gout,
when it affects the stomach: it would be wrong to withdraw the
stimulus, for the excitability is in such an exhausted state as to
produce no action, or very imperfect and diseased, from the effect of
the common exciting powers; we must, therefore, here apply a stimulus
greater than natural, to bring on a vigorous and healthy action, and
this stimulus we should gradually diminish, in order to allow the
excitability to accumulate, by which the healthy state will be
gradually restored.
This method was very judiciously recommended, by a very eminent
physician, in the case of a Highland chieftain, who had brought on
dreadful symptoms of indigestion by the use of whisky, of which he
drank a large silver cup full five or six times in the day. The
doctor did not merely say, diminish the quantity of spirits
gradually, for that simple advice would not have been followed; but
he advised him to drink the cup the same number of times full, but
each morning to melt into it as much wax as would receive the
impression of the family seal. This direction, which had something
magical in it in the mind of the chieftain, was punctually obeyed. In
a few months the cup was filled with wax, and would hold no more
spirits; but it had thus been gradually diminished, and the patient
was cured.
This reminds me of a number of cases, which had been brought on by
drinking porter, and other stimulant liquors, without knowing the
taste of water. In many of these cases if a moderate quantity of
water were drank every day they would be cured; but you would find
few who would follow such plain and simple directions. How then must
a physician proceed? Why, as is generally done by the most judicious:
they direct their patients to Bath or Buxton, and there advise them
to swallow a certain quantity of water every day, which they do most
scrupulously, and, of course, return home cured.
As causes of asthenic disease, we must not omit the undue exercise of
the intellectual functions. Thinking is a powerful exciting cause,
and produces effects similar to those of intoxication. None of the
exciting powers have more influence upon our activity, than the
exercise of the intellectual powers, as well as passion and emotion.
Homer, the great observer and copyist of nature, observes of the
hero, whom he gives for a pattern of eloquence, that, upon his first
address, before he had got into his train of thought, he was awkward
in every motion, and in his whole attitude; he looked down upon the
ground, and his hands hung straight along his sides, as if they had
lost the power of motion; and his whole appearance was a picture of
torpidity. But when he had once fairly entered upon his subject, his
eyes were all on fire, his limbs all motion, grace, and energy.
Hence, as the exercise of the intellectual functions evidently
stimulates, an excess of thinking must bring on indirect debility, by
exhausting the excitability. But though we do meet with instances of
indirect debility arising from this source, it must be confessed that
they much oftener arise from the use of very different stimulants.
As excessive exercise of the intellectual powers will bring on
indirect debility, so the deficient, weak, or vacant state of mind,
which is unable to carry on a train of thinking, will produce direct
debility. Indeed this debility often occurs to those whose minds have
been all their life actively engaged in business, but who have at
last retired to enjoy themselves, without having a cultivated mind
fit for retirement. They become languid, inert, and low spirited, for
want of the stimulus of mental exertion; and in many cases cannot be
completely restored to health, till they are again engaged in their
usual occupations.
Violent passions of the mind, such as great anger, keen grief, or
immoderate joy, often go to such an extent as to exhaust the
excitability, and bring on diseases of indirect debility. Hence both
epilepsy and apoplexy have been the consequences of violent passion.
On the contrary, when there is a deficiency of exciting passion, as
in melancholy, fear, despair, &c. which are only lower degrees or
diminutions of joy, assurance, and hope, in the same way that cold is
a diminution of heat, this produces a state of direct debility. The
immediate consequences observable are, loss of appetite, loathing of
food, sickness of the stomach, vomiting, pain of the stomach, colic,
and even low fevers.
The effect of impure air, or air containing too small a proportion of
oxygen, is likewise a very powerful cause of debility.
In short, when any or several of these causes, which have been
mentioned, act upon the body, asthenic diseases are the consequence.
Asthenic diseases, as has frequently been hinted, may be divided into
two classes, those of direct debility, and those of indirect
debility.
Among the diseases of direct debility may be enumerated dyspepsia,
hypochondriasis, hysteric complaints, epilepsy, bleeding of the nose,
spitting and other effusions of blood, cholera morbus, chorea,
rickets, scrofula, scurvy, diabetes, dropsy, worms, diarrhoea,
asthma, cramp, intermittent fevers.
Among those of indirect debility, or which are produced by over
stimulating, which exhausts the excitability, may be enumerated,
gout, apoplexy, palsy, jaundice, and chronic inflammation of the
liver, violent indigestion, confluent small pox, typhous fever, and
probably the plague, dysentery, putrid sore throat, tetanus.
Diseases, therefore, according to this system, may be divided into
two classes. First, general diseases, which commence with an
affection of the whole system, and which must be accounted general,
though some part may be more affected than the rest. Secondly, local
diseases, which originate in a part, and which are to be regarded as
local, though they may sometimes in their progress affect the whole
system, like universal diseases: still however they are to be cured
by remedies, applied not to the whole system, but to the part
affected only.
A pleurisy or peripneumony, for instance, is a general disease,
though the chief seat of the symptoms seems confined to a portion of
the thorax: but the affection of this part, though it may be somewhat
greater than that of any other equal part, is vastly less than the
affection or diathesis diffused over the whole body. The exciting or
hurtful causes which produce these diseases, by no means exert their
whole power upon a small portion of the superficial vessels of the
lungs, and leave the rest untouched; on the contrary, they affect
exery part of the system, and the whole body partakes of the morbid
change. Indeed the general or universal affection; viz. a sense of
heaviness and fullness, uneasy sleep, and other symptoms of increased
excitement, are commonly perceived some time before the pain of the
thorax becomes sensible. The remedies which remove the disease; viz.
venesection, abstaining from animal food, and every mode of
debilitating, do not exert their whole efficacy on an inflamed
portion of the lungs; for by removing the affection of the lungs we
should go but a little way towards removing the disease.
Among local diseases we may enumerate wounds, or solutions of the
continuity of the part, bruises, fractures, inflammations from local
irritation, &c. Hence it is evident that the treatment of general
diseases is the province of the physician; and of local ones of the
surgeon. But there are some general diseases which are apt to
degenerate into local, and therefore require the attention both of
the physician and the surgeon. Among these we may reckon suppuration
and gangrene, sphacelus, and some others.
The first class, or general diseases, may be divided into two orders;
sthenic, and asthenic. The asthenic order may be subdivided into two
genera; viz. diseases of direct debility, and diseases of indirect
debility; for debility, according to the system I am explaining, is
that relaxed or atonic state of the system which accompanies a
deficient action of the stimulant or exciting powers; and this
deficient action may arise immediately from the partial or too
sparing application of the exciting powers; the excitability or
capacity of the system to receive their actions, being unaffected or
sufficiently abundant; or it may arise from the excitability being
exhausted, by the violent or long continued action of the exciting
powers.
This arrangement of diseases, which naturally follows from the
fundamental principles of the doctrine, and which is guided by the
state and degree of excitement, is widely different from that of
former nosologists, who have arranged or classed them according to
symptoms, which have already been shown to be fallacious; and which
method of arrangement brings together diseases the most opposite in
their nature, and separates those most nearly allied. This is evident
in every part of the nosology of Sauvages and Cullen. In the genus
cynanche of the latter, are placed the common sthenic or inflammatory
sore throat, or cynanche tonsillaris, and the putrid or gangrenous
sore throat, the cynanche maligna: the former is a sthenic disease;
the latter one of the greatest debility; yet they have the same
generic name.
The mode of classing diseases which I have adopted, after the example
of Dr. Brown, is the consequence of first taking a view of the nature
of life, and the manner in which it is supported; and from thence
observing how those variations from the healthy state, called
diseases, are produced; and this is certainly the proper plan; for,
as every effect will be produced with more accuracy, whilst its cause
is acting in a proper degree, it is certainly right to begin by
drawing our general propositions from the healthy state; by which
means we avoid being misled by those false appearances which the
living system puts on, during a morbid state; and though the contrary
has been the general practice of nosologists and pathologists, I must
confess it appears to me like beginning where the end should be; for
to lay down rules for restoring health, and begin by observing the
phenomena of disease, is like building a house, and beginning with
the roof.
In the last lecture I pointed out the general method of curing
sthenic diseases; I shall now proceed to the cure of asthenic, and
shall begin with those depending on direct debility, as in these
diseases the excitability is morbidly accumulated, and consequently
more liable to be overpowered by the action of a stimulus, we must,
therefore, at first, apply very gentle stimulants, increasing them by
degrees, till the excitement be arrived at the healthy state.
In cases of indirect debility, the excitability is so far exhausted
as not to be sufficiently acted on by the ordinary powers which
support life; we must therefore employ, at first, pretty strong
stimulants, to keep up such a degree of action as is necessary to
preserve life; we should, however, be careful not to overdo it; for
our intention here, in giving these stimuli, is only to keep up life,
while the cure must depend upon the accumulation of the excitability.
That this may take place, therefore, we must gradually lessen the
quantity of stimulus, till the excitability become capable of being
sufficiently acted on by the exciting powers, when the cure will be
affected.
There is, however, an important point, with respect to the cure of
diseases of exhausted excitability, which could not be known to Dr.
Brown; and this depends on the fact which was formerly pointed out;
viz. that the degree of excitability was in proportion to the
oxydation of the system. On this account I have given the oxygenated
muriate of potash in typhus, which is a disease of diminished
excitability, in more than one hundred cases, without the loss of
one, a success which has attended no other mode of practice in this
disease, if we except, perhaps, the affusion of cold water, as
described by Dr. Currie, the effects of which are wonderful, but
which can only be applied at the commencement of the disease. In all
diseases of indirect debility, therefore, it is proper to attempt the
introduction of oxygen into the system, by the oxygenated muriate of
potash, acid fruits, nitre, &c. I do not think that the inhaling of
oxygen gas for a few minutes in the day can do much good; but free
ventilation of apartments, and gentle exercise in the open air, are
highly useful.
In either case of debility, we should by no means rely on the action
of medicines alone; for though there are a variety of stimulants
which will produce excitement, yet this is only temporary, we must
therefore endeavour, by nutritious substances, to fill the vessels
with blood, and employ all the natural exciting powers in due
proportion as soon as possible.
But in the cure of either sthenic or asthenic diseases we shall
seldom succeed by the use of one remedy only: for since no stimulus
exerts its effects equally on all parts of the body, but always acts
more powerfully on some part than on others, we cannot by the use of
one remedy alone obtain an equal increase or diminution of
excitement.
There are few diseases however in which the excitement is equally
increased or diminished over the body; some part being generally more
affected than the rest; and this inequality produces the various
phenomena or forms of disease; indeed no disease but increase or
diminution of strength would take place, on the supposition that an
equal increase or diminution of excitement all over the body, were
produced by the hurtful powers causing the disease.
From what has been said, it necessarily follows, that every stimulus
will not be equally efficacious in curing every form of disease;
which is sufficiently confirmed by experience. Hence there may be
some ground for the appellation of specifics, as some medicines may
act more powerfully upon the part which is the principal seat of the
disease, than others do.
In the cure of diseases we ought always to attend to two things most
carefully: first, to employ the proper kinds of powers, and then not
to overdo them, so as to convert either diathesis into the other; and
by passing over the line of health, instead of the intended cure, to
substitute one disease instead of another, and thereby bring life
itself into danger.
LECTURE XIII.
ON THE GOUT.
There is no disease, with which the human race is afflicted, whose
nature has been more mistaken than that which is to form the subject
of our present consideration. It has been regarded by most
practitioners as a salutary effort of the body to expel some hurtful
cause, and restore health; and therefore has been looked upon as
desirable to the patient. To attempt to cure it, therefore, would
have been wrong, had it been curable; but it has likewise been looked
upon as beyond the reach of medicine, or perfectly incurable; and, on
both these accounts, after having tried a variety of drugs, without
any good effect, the physicians have at last abandoned their
patients, to the care of patience and flannel, which, if the
constitution be not very much shattered, will often see them through
the disease.
But that it is a salutary disease I deny; and I affirm, that it
restores health in no other way, than the indigestion of a habitual
dram drinker would be relieved by a disease in the throat, which
would, for a time, prevent his swallowing any more liquor; the
consequence would be, that his digestive powers would recover their
tone, and he would, after a few weeks, feel himself better.
In the same way the pain and fever, which attend gout, and at the
same time the inability to move, with the weakened stomach, and bad
appetite, prevent the continuance of the mode of life which brought
on the disease; and thus, a truce being obtained, the exhausted
excitability of the body is allowed to accumulate, and the
constitution, of course, feels itself renovated.
Were the disease to be viewed in this light, it is probable that many
patients might in future desist from their former mode of life, which
brought on the disease; and we might venture to promise them, if they
did, that they would have no return of the complaint. But the
misfortune is, they think the gout has restored their constitution,
and that therefore they may return to their old mode of living with
impunity; in consequence of which, after a few months more, the
excitability is again exhausted; symptoms of indigestion come on, and
the stimulant mode of living is increased, with a view to bring on
the disease, which is to cure these symptoms. In this way, each time,
a greater and greater degree of indirect debility is induced, and at
last the system becomes so enfeebled, that the asthenic inflammation
is not confined to the extremities, but attacks the head, the
stomach, the lungs, and often puts a period to the existence of the
patient, which has for some time been miserable.
Besides, the idea, that the gout is incurable, is a false, and a very
dangerous doctrine; this is very far from being the case, and I am
firmly persuaded, not only from the nature of the disease, but from
experience, that it may always be cured, if taken in time, and proper
directions be followed. If, by the cure of gout be meant the
administration of some pill, some powder, or some potion, which shall
drive away the complaint, I firmly believe, that it never was, nor
ever will be cured. Indeed, it is astonishing that such an idea
should have ever entered the mind of any person, who has any
knowledge of nature, or particularly of the human frame; for, if the
gout is a disease of indirect debility, and the effect of
intemperance, as will be shown by and by, then a medicine to cure it
must be something to enable a man to bear the daily effects of
intemperance, during his future life, unhurt by the gout, or any
other disease; that is, it must be something given now, that will
take away the effects of a future cause; as well might a medicine be
given to prevent a man breaking his leg, or his arm, seven years
hence.
But no rational physician, or surgeon, would give a medicine with
this view, in such a case as I have supposed; on the contrary, he
would caution his patient against mounting precipices, scaling walls,
or bringing himself again into a situation, such as produced the
accident; and if he took his advice, he would, in all probability,
escape a broken limb in future.
In the same way a rational physician would advise a person recovering
from gout, to abstain totally and entirely from the course of life
which brought it on; and this being complied with, we might venture
to predict, with as much certainty in the one case as in the other,
that he would in future escape it.
What I have frequently endeavoured to inculcate in the course of
these lectures, always appears to me of the utmost importance: I
mean, the general diffusion of physiological knowledge, or a
knowledge of the human frame; this knowledge ought to form a part of
general education, and is, in my opinion, as necessary for a person
to learn as writing, or accounts, or any other branch of education;
for if it is necessary that a young man should learn these, that he
may be able to take care of his affairs, it surely can be no less
necessary, that he should learn to take care of his health; for to
enjoy good health, as a celebrated practical philosopher observes, is
better than to command the world.