By a continuance of this plan, the inflammation again appears; but the system having become more torpid, the inflammatory action is by no means so great as it was before: if it has power to restore the equilibrium between the resistance and propelling force, and thus cure itself, this effect is entirely confined to the inflamed part. The other foot labouring under similar torpor, or debility, now feels the effects of the propelling force, and an inflammation takes place in it, which having cured itself in the same manner, and the torpor of the foot first affected being returned, or even greater than it was before, on account of the previous excitement; the inflammation again attacks this foot, and thus the gout is supposed to emigrate from one limb to another. The gout, as a disease of general debility, however, remains the same; and it is only these symptoms, which form but a small part of the disease, that vary according to circumstances.
If, during an asthenic inflammation of the lower, or upper extremities, the torpor and debility of the whole system increase, then the force of the circulation, or propelling force, being diminished, the symptoms of inflammation will suddenly disappear; but as great debility now prevails, the stomach will be apt to be affected with cramps or convulsions, or an asthenic inflammation of some internal part will take place: for, though the propelling force is not sufficient to overdistend the debilitated vessels of the extremities, it will distend those of the internal parts nearer the heart, which are now debilitated.
In this case, it has been generally, but absurdly imagined, that the gout is translated, or recedes from the extremities to some internal part: the term of retrocedent gout has therefore been applied to occurrences of this nature. From the explanation which has been given, it is evident, that this term is improper. The general debility being increased, the propelling force becomes unable to produce an inflammation of the extremities, and this is the reason why it disappears. The disease, however, is not at all altered in its nature by this variation of symptoms. It is still the same, by whatever name it may be called.
It sometimes happens, that after full living, the stomach becomes particularly affected, and the patient is troubled with flatulency, indigestion, loss of appetite, eructations, nausea, and vomiting, with great dejection of spirits, pain and giddiness of the head, disturbed recollection, or muddiness of intellect, as it is termed, with all the symptoms, which usually precede a regular fit of the gout, yet no inflammatory affection of the joints is produced. This state has been absurdly enough called the atonic gout, as if there were a gout accompanied with vigour and sthenic diathesis: but the absence of inflammation in the extremities may depend on two causes. First, the powers producing the disease, may have debilitated the stomach and first passages, while the vessels of the extremities are not particularly debilitated, and the resisting force is able to counterbalance the propelling force: in this case, no morbid degree of distention or inflammation of the extreme vessels can take place. Secondly, the general debility may be such, and the power of the circulation so much diminished, that, though the extreme vessels may be debilitated, no inflammation, or preternatural distention will take place.
Hence, we see, that this is still the same disease; but that physicians have erred in their explanation of the symptoms, by regarding that as the principal part of the disease, which is only a symptom.
We have seen then, that by the theory which has been unfolded, all the symptoms of this hitherto mysterious disease are plainly and naturally explained. We shall next see if the only method of cure which experience warrants, cannot be explained upon the same principles.
If, on entering this part of the subject, any one should expect that I should furnish him with a receipt, consisting of certain drugs, which swallowed, will cause this terrible disease to disappear, and health to take its place, he would be very much mistaken; for, can any person in his senses suppose that a disease, which he has been almost his whole life in contracting, and an exhausted state of the excitability, which has been gradually brought on by years of intemperance, can be dispersed by a pill, a powder, or a julep? Or, if the symptoms could be relieved by medicine, which they often may, can he suppose, that they will not return, if the same mode of living, which first brought them on, be continued?
I shall, however, proceed to give some directions, which if rigidly persevered in, will not only afford relief in the fit, but will prevent its return with such violence, and at last totally eradicate it, provided the constitution be not completely exhausted, and almost every joint stiffened with calcarious concretions.
The inflammation of the extremities may at any time be relieved by means of electricity, or by stimulant embrocations applied to the part, and this without any danger whatever of throwing the complaint on some more vital part, as has generally been imagined. If I were to apply any debilitating means to the part, I should then probably relieve the pain; but, by debilitating the whole system, should cause an attack of the stomach, or some other internal part, as has been already explained; but by a stimulant application to the inflamed part I run no such risk. The inflammation is of the asthenic kind, depending upon a debility of the small vessels, whereby they do not afford sufficient resistance to the propelling force, and therefore become morbidly distended, or inflamed, as it is termed, though this term is certainly improper, even in a metaphorical view: but a stimulant application to the part excites the debilitated vessels to action; their contraction diminishes the morbid quantity of blood; and the balance between the propelling and resisting forces being restored, the inflammation of course ceases. This is not a mere deduction, a priori, from the theory of inflammation, which I have delivered; it is the result of repeated experience. I have seen several very violent gouty inflammations very speedily removed by electricity. Small sparks should be drawn from the part affected, at first through flannel, and increased as the patient can bear them: sparks alone are necessary; recourse need never be had to shocks. But though we thus remove a very painful part of the disease, yet still a formidable debility remains, and unless this be removed, the inflammation will be apt to return. In endeavouring to remove this general debility, we must recollect, that it is of the indirect kind, or depends upon an exhausted state of the excitability; our great object therefore, is to allow the excitability to accumulate. But this accumulation depends as well upon the proper action of the different functions, as upon the withdrawing of stimulants: we ought therefore to guard carefully against costiveness, by which the proper action of the stomach and bowels is very much injured: but we must use warm laxatives. An infusion of senna and rhubarb in proof spirits, made still stronger by aromatics, has always seemed to me to answer the purpose best, and this should be taken of a temperature rather above blood warm; for instance, about 100 degrees. This is particularly necessary, when the gout attacks the stomach, and I have several times seen a severe attack of it removed in half an hour, by a tincture of this kind. Indeed, the most violent attacks of the stomach may be relieved; and are only to be relieved by spirits, ether, and opium.
It is on this organ, that the hurtful powers have produced their greatest effect; for to it they are immediately applied. It is by no means surprising, that the constant application of highly seasoned foods, with fermented and spirituous liquors, should at last wear out the vital principle of this organ. Indeed it is often so far exhausted, that the most terrible cramps and convulsions take place, which would soon end in its total extinction, unless it were roused to somewhat like a proper action by the most powerful stimulants. Still, however, their effect is but temporary.
With respect to a regular fit, after the inflammation of the extremities has been subdued by the means I have mentioned, a generous, but not full diet should be used. A person who has been for a long time accustomed to wine, cannot easily be deprived of it at once; but he should drink Madeira, and those wines, which neither contain much carbonic acid, nor deposite much tartar. His food should be of the plainest kind, and generally boiled, instead of roast. The great thing is to keep the spirits and excitement rather under par, but not to let the patient sink too low. In this way, the exhausted excitability will gradually accumulate, and the healthy state be reestablished. When this is once effected, the gout may be prevented in future with the greatest certainty, if the patient will have resolution. The whole secret consists in abstaining, in toto, from alcohol, in every form, however disguised, or however diluted. He must not take it, either in the form of liqueurs, cordials, wine, or even small beer.
I believe there never was an instance of a person having the gout, who totally abstained from every form of alcohol, however he might live in other respects: and I doubt very much, if ever the gout returned after a person had abstained from fermented or spirituous liquors for two years.
Temperance in eating, and exercise, are, no doubt, powerful auxiliaries, and tend very much to promote health; but still they will not secure a person from a return of the gout, without this precaution. There seems something in alcohol, which peculiarly brings on this state of the constitution, and without it, it would seem that gout could not be produced. Here then is an effectual method of curing the gout, which will no more return, if this method be strictly persevered in, than the smallpox will attack the constitution after inoculation.
During the fit therefore, I would say, nearly in the words of Dr. Darwin, Drink no malt liquor on any account. Let the beverage at dinner consist of two glasses of Madeira, diluted with three half pints of water; on no account whatever drink any more wine or spirituous liquors in the course of the day. Eat meat constantly at dinner, without any seasoning, but with any kind of tender vegetables, that are found to agree. When the fit is removed, use the warm bath twice a week, an hour before going to bed, at about 93 degrees, or 94 degrees of heat. Keep the body open by means of lenitive electuary and rhubarb; for there is an objection to the tincture I mentioned, as containing alcohol. Use constant, gentle exercise; but never so violent as to bring on great fatigue. The grand secret, however, in the cure, as has been already observed, but which cannot be too often inculcated, is to abstain, in toto, from every thing that contains alcohol.
In short, though in acute diseases medicines are highly useful, a chronic disease can never be cured, and the healthy state reestablished, by them alone. To effect a cure in such cases, we must reform our mode of life, change our bad habits into good ones; and then, if we have patience to wait the slow operations of nature, we shall have no reason to regret our former luxuries.
LECTURE XIV. NERVOUS COMPLAINTS, &c
In this lecture I propose to take a view of some of those affections, which have been commonly, but improperly known by the appellation of nervous complaints, because it has been supposed by many that they are owing to a deranged state of the nerves, which, however, is by no means the case; for I hope to be able to make it appear, that these symptoms arise from a general affection of the excitement of the system. In short, by far the greater number of these complaints, arise from such a state of the excitement as approaches predisposition, or perhaps ranges between predisposition and disease, but does not in general actually reach disease; or rather, it is a state of the excitement, so far departing from the point of perfect health, that the functions are not performed with that alacrity, or vigour, which ought to take place; but labour under that disturbed and uneasy action, which, though it cannot be called actual disease, yet deviates considerably from the point of perfect health.
This is a new view of these diseases, but the more I have examined it, the more I am convinced that it is just. Indeed, the name, nervous, has generally been given to an assemblage of symptoms, which the physicians did not understand; and when the patient relates a history of symptoms, and expects that his physician shall inform him of the name, and nature of his complaint, he generally receives for answer, that his complaints are nervous, or bilious; terms which convey no distinct ideas, but which serve to satisfy the patient, and to conceal the ignorance of the physician, or spare him the labour of thinking.
Indeed, the idea of nervous diseases, which I have already pointed at, is not only new, but could only have arisen from such a view as we have been taking of the states of excitement and excitability. This view will not only lead us to form a more just idea of the manner in which these diseases originate, but will point out a distinction of them into two classes, of the utmost use in practice, but which distinction has totally escaped the attention of practitioners; for though these complaints have been generally thought to arise from a lowness of the nervous energy, or some kind of debility, or weakness of the nervous system, and, on this account, the stimulant and cordial plan of cure has been recommended, I am convinced, from observation, that nearly one half of them, if not more, originate from a state of the excitement verging towards sthenic disease; and in these cases, this general mode of treatment must be highly improper.
It has been already shown, that when the common exciting powers which support life, act in such a manner, that a middle degree of exciting power, acts upon a middle degree of excitability, the most perfect state of the system, or a state of perfect health, takes place: it is, however, seldom in our power so to proportion the state of excitement and excitability to each other. The action of the exciting powers is continually varying in strength; and the excitability, from a variety of stimulants, and other circumstances, which are not entirely under our direction, is sometimes more, and sometimes less abundant, than this middle degree. There is, however, a considerable latitude, on each side the point of health, within which the excitement may vary, and yet no disease, nor any disturbance of the functions may take place: but this has its limits, beyond which if the excitement be brought, on either side, it is evident that an uneasy or unpleasant exercise of the functions must take place. There is not, however, any precise line or boundary between this state, and that in which the functions begin to be disturbed; on the contrary, the law of continuity and gradation seems to extend throughout every part of nature. This departure from the healthy state, and approach to disease, in which what has been called the nervous state consists, is gradual and scarcely perceptible; but is apt to be produced by any circumstances, which lead the excitement beyond its proper limits.
Nervous complaints may therefore be divided, like all other diseases, into two classes. First, those in which the excitement is increased, or in which it verges to, or has actually reached, the point of predisposition to sthenic disease; Secondly, those in which the excitement is diminished, or in which it verges towards asthenic disease. This last class, as has been done before, may be subdivided into two orders. The first will comprise those diseases in which the excitability is sufficiently abundant, or even accumulated, but where the excitement is deficient from a want of energy in the exciting powers. In the second, there has been no deficiency in the action of the exciting powers; but on the contrary, probably for a considerable time, some of the diffusible stimuli not natural to life have been applied; in this case, the excitability has become exhausted, and a proper degree of excitement cannot be produced by the action of the common exciting powers.
No diseases show so clearly the fallacy of trusting to symptoms, as those of the former class. I have met with innumerable cases of this kind, in which, if you were to trust to the patients own description, they laboured under considerable debility; and had it not been for the particular attention I paid to my own case, I should not probably have suspected that a directly opposite state of the system may produce these symptoms.
From inheriting a good constitution, and being brought up in the country in a hardy manner, I am so much predisposed to the sthenic state, that I may consider the state of my excitement, as generally, indeed almost always, above the point of health: and unless I live in the most temperate, and even abstemious manner, the excitement is extremely liable to overstep the bounds of predisposition, and fall into sthenic disease. I have had several attacks of this kind of disease; and indeed, I never remember to have laboured under any disease of debility, or diminished excitement.
Health, according to the view we have taken of it, may be compared to a musical string, tuned to a certain pitch, or note; and though perhaps in the great bulk of mankind, either from the manner of living, or from other circumstances, the excitement is a little below, and requires to be screwed up to the healthy pitch, yet there are others where it is apt to get constantly above, and where it requires letting down to this pitch; my constitution is one of these: but I have this consolation, that if I can for a few years ward off the fatal effects of some acute sthenic diseases, this tendency to sthenic diathesis will gradually wear off, and I may probably enjoy a state of good health, at a time, when most constitutions of an opposite cast begin to give way. Whenever I have for some time lived rather fully, though by no means intemperately, after having for some days, or perhaps some weeks experienced an unusually good flow of spirits, and taken exercise with pleasure, I begin, first of all, to have disturbed sleep, I find myself inclined to sleep in the morning, as if I had not been refreshed by the night's sleep; my spirits become low, and I am apt to look upon the gloomy side of every thing I undertake or do. I feel a general sense of languor and debility, and am ready, as I have heard many patients labouring under the same state exclaim, to sink into the earth. From the slightest causes, I am apt to apprehend the most serious evils, and my temper becomes irritable, and scarcely to be pleased with any thing. If in this state, I take exercise, I soon feel myself fatigued; a disagreeable stupor comes on, without, however, the least degree of perspiration, and I feel an inability to move.
At first, I used to imagine these to be symptoms of debility, or diminished excitement, nor was it till after several ineffectual trials to relieve them by the tonic, or stimulant plan, that I was convinced of my mistake. This plan always caused an aggravation of every symptom, and if I persevered in it, an inflammatory disease was sure to be the consequence. Indeed, I might have suspected this, from considering, that these symptoms had been brought on by full living, and preceded by good spirits; but my mind had received such a prejudice from the writings of medical men, who had uniformly described these as a train of nervous symptoms, as they called them, depending on a debilitated state of the nervous system, that I was blind to conviction, till repeated disappointment from the stimulating plan, convinced me I must be wrong. The only alternative therefore, was a contrary plan, and the immediate relief I experienced, was a proof that I had detected the real nature of the complaint. Since that time, I can at any time prevent these unpleasant symptoms, by an abstemious course of life, and remove them, when they have come on, by the debilitating plan; which, instead of weakening, gives additional elasticity and strength to the fibres, and alacrity to the spirits. I have described the symptoms in one case, as this will serve as a general description. We may add, that persons labouring under this kind of predisposition, are particularly attentive to the state of their own health, and to every change of feeling in their bodies; and from every uneasy sensation, perhaps of the slightest kind, they apprehend great danger, and even death itself. In cases of this kind, the bowels are generally costive, and the spirits of the patient are very apt to be affected by changes in the weather, particularly by a fall of the barometer. How the diminution of atmospheric pressure acts in increasing the symptoms, we perhaps do not know; but its effects are experienced almost universally.
It is evident, that the only mode of cure in cases of this kind is extreme temperance: animal food should be taken sparingly, and wine and spirits in general totally abstained from. The bowels should be kept open by any mild neutral salt. I have generally found magnesia and lemonade to agree remarkably well in such cases. Exercise on horseback, is also particularly useful; bark, bitters, and the fetid and antispasmodic medicines, which are generally prescribed in such cases, are extremely hurtful.
This view of nervous complaints is, I may venture to say, as new as it is just. It has never been imagined, that any of them depended upon too great excitement; on the contrary, they have been universally considered as originating in debility, and of course, tonics were prescribed, which, though they produced the greatest benefit in the other class of nervous complaints, in these they occasioned the most serious evils, and often brought on real inflammatory diseases, or even diseases of indirect debility, as I have repeatedly seen.
These cases cannot at first sight, however, be easily distinguished from those of the opposite class; the symptoms being nearly alike, and the patient complaining of languor, debility, and extreme depression of spirits in both. But by attending carefully to the effects produced by the exciting powers, they may in general be distinguished. A patient of this kind will tell you, that he does not feel pleasant effects from wine, or spirituous liquors; instead of exhilaration, his spirits become depressed by them; whereas, in the contrary state, he finds almost instant relief. By attending to circumstances of this kind, the nature of the complaint may in general be ascertained.
Highly seasoned, and strongly stimulant foods should in the sthenic hypochondriasis, if it may be so called, be avoided; but the most mischievous agent of all, and which contributes to bring on the greater number of these complaints, is wine. This, I believe, produces more diseases, than all other causes put together. Every person is ready to allow, that wine taken to excess is hurtful, because he sees immediate evils follow; but the distant effects, which require more attentive observation to perceive, very few see, and believe; and, judging from pleasant and agreeable feelings, they say that a little wine is wholesome, and good for every one; and accordingly take it every day, and even give it to their children; thus debauching their natural taste in the earliest infancy, and teaching them to relish what will injure their constitutions; but which, if properly abstained from, would prove one of the most valuable cordial medicines we possess.
The idea that wine or spirituous liquors assist digestion, is false. Those who are acquainted with chemistry, know that food is hardened, and rendered less digestible by these means; and the stimulus, which wine gives to the stomach, is not necessary, excepting to those who have exhausted the excitability of that organ, by the excessive use of strong liquors. In these, the stomach can scarcely be excited to action, without the assistance of such a stimulus. If the food wants diluting, water is the best diluent. Water is the only liquor that nature knows, or has provided for animals; and whatever nature gives us, is, we may depend upon it, the best, and safest for us. Wine ought to be reserved as a cordial in sickness, and in old age; and a most salutary remedy would it prove, did we not exhaust its power by daily use.
I am sensible that I am treading on delicate ground, but I am determined to speak my sentiments with plainness and sincerity, since the health and welfare of thousands are concerned. Most persons have so indulged themselves in this pernicious habit of drinking wine, that they imagine they cannot live without a little every day; they think that their very existence depends upon it, and that their stomachs require it. Similar arguments may be brought in favour of every other bad habit. Though, at first, the violence we do to nature makes her revolt; in a little time she submits, and is not only reconciled, but grows fond of the habit; and we think it necessary to our existence: neither the flavour of wine, of opium, of snuff, or of tobacco, are naturally agreeable to us: on the contrary, they are highly unpleasant at first; but by the force of habit they become pleasant.
It is, however, the business of rational beings to distinguish carefully, between the real wants of nature, and the artificial calls of habit; and when we find that the last begin to injure us, we ought to use the most persevering efforts to break the enchantment of bad customs; and though it cost us some uneasy sensations at first, we must learn to bear them patiently; a little time will reward us for our forbearance, by a reestablishment of health and spirits.
I shall now proceed to examine the opposite class of nervous complaints: or such as do really depend on debility, or an asthenic state of the system. These may be divided into two orders; viz. those of direct, and those of indirect debility. I shall first consider those of direct debility.
Though these complaints originate from a deficiency of stimulus, yet it is very seldom from a deficiency of the common stimulant powers. The only people, who in general labour under this deficiency of the common stimulants, are the poor; they are seldom troubled with nervous complaints; their daily exercise, and constant attention to procure common necessaries, prevent their feeling what so grievously afflicts the rich and luxurious. These complaints arise chiefly from a deficiency of mental stimuli. The most common cause of them, and whose effects are the most difficult to remove, is to be looked for in the mind.
The passions and emotions, when exercised with moderation, and kept within proper bounds, are the sources of life and activity; without these precious affections, we should be reduced to a kind of vegetation, equally removed from pleasure and from pain. For want of these elastic springs, the animal spirits lose their regularity and play; life becomes a lethargic sleep, and we fall into indifference and languor.
If then the passions are so necessary to the support of the health of the body, when in a proper degree, can we expect, that when they are inordinate or excessive, or even deficient, we shall escape with impunity? tumultuous passions are like torrents, which overflow their bounds, and tear up every thing before them; and mournful experience convinces us, that these effects of the mind are easily communicated to the body. We ought, therefore, to be particularly on our guard against their seduction.
"'Tis the great art of life to manage well
The restless mind."
It is particularly in their infancy, if it may be so called, that we ought to be upon our guard against their seduction; they are then soothing and insidious; but if we suffer them to gain strength, and establish their empire, reason, obscured and overcome, rests in a shameful dependence upon the senses; her light becomes too faint to be seen, and her voice too feeble to be heard; and the soul, hurried on by an impulse to which no obstacle is presented, communicates to the body its languor and debility. The passions, by which the body is chiefly affected, are, joy, grief, hope, fear, love, hatred, and anger. Any others may be reduced to some of these, or are compounded of them. The pleasurable passions produce strong excitement of the body, while the depressing passions diminish the excitement; indeed it would seem that grief is only a diminution of joy, as cold is of heat; when this passion exists in a proper degree, then we feel no particular exhilarating sensation, but our spirits and health are good: we cannot doubt, however, that we are excited by a pleasant sensation, though we are unable to perceive it. In the same manner, when heat acts moderately, or is about the degree we call temperate, we do not perceive its effects on the body, though there can be no doubt, that the body is under the influence of its stimulus, and powerfully excited by it; for when it is diminished, or cold applied, we feel a deficiency of excitement, and become afterwards more sensible of heat afterwards applied.
The same takes place with respect to joy and grief, and proves, I think, clearly, that the one is only a diminution of the other, and that they are not different passions. When the body has been exposed to severe cold, the excitability becomes so much accumulated with respect to heat, that if it be afterwards applied too powerfully, a violent action, with a rapid exhaustion of the excitability, which ends in mortification, or death of the part, will take place. We should therefore apply heat in the gentlest manner possible, and gradually exhaust the morbidly accumulated excitability.