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.

If knowledge of this kind were generally diffused, people would cease to imagine that the human constitution was so badly contrived, that a state of general health could be overset by every trifle; for instance, by a little cold; or that the recovery of it lay concealed in a few drops, or a pill. Did they better understand the nature of chronic diseases, and the causes which produce them, they could not be so unreasonable as to think, that they might live as they chose with impunity; or did they know any thing of medicine, they would soon be convinced, that though fits of pain have been relieved, and sickness cured, for a time, the reestablishment of health depends on very different powers and principles. Those who are acquainted with the nature and functions of the living body, well know, that health is not to be established by drugs; but that if it can be restored, it must be by nicely adjusting the action of the exciting powers to the state of the constitution, and the excitability; and thus gently and gradually calling forth the powers of the body to act for themselves. And though I believe that most general diseases will admit of a cure, yet I am confident, that no invalid was ever made a healthy man by the mere power of drugs. If this is a truth, should it not be universally known? If it were, there would undoubtedly be an end of quackery, for all quack medicines, from the balm of Gilead, to the botanical syrup, are supposed to cure diseases, or at least asserted to do so, in this mysterious manner.

Dr. Cullen, in his Nosology, gives us the following definition of the gout.

"Morbus haereditarius, oriens sine causa externa evidente; sed praeeunte plerumque ventriculi affectione insolita; pyrexia; dolor ad articulum, et plerumque pedis pollici, certe pedum et manuum juncturis, potissimum infestus; per intervalla revertens, et saepe cum ventriculi et internarum partium affectionibus alternans."

Now, though this definition comprises a tolerably good general character of the disease, it contains some notions, depending on the prejudice of hypothesis, which, on a careful examination, ought not, I think, to be admitted.

In the first place, I would deny, that the gout, considered as a diseased state of the system, is hereditary. This may perhaps excite some degree of surprise; and, "I had it from my father," is in the mouth of a great majority of gouty patients.

If the diseased state of the system, which occurs in gout, were hereditary, it would necessarily be transmitted from father to son; and no man, whose father had it, could possibly be free from it. There are, however, many instances to the contrary. Our parents undoubtedly give us constitutions similar to their own, and there is no doubt, that if we live in the same manner in which they did, we shall have the same diseases. This, however, by no means proves the disease to be hereditary.

We shall hereafter see, that the gout is a disease of indirect debility, brought on by a long continued use of high seasoned food and fermented liquors. There is no doubt that particular constitutions are more liable to be affected by this mode of living than others; and if my father's constitution be such, I, who probably resemble him in constitution, shall in all probability be like him, subject to the gout, provided I live in the same way; this however by no means proves the disease to be hereditary. The sons of the rich, indeed, who succeed to their fathers estate, generally succeed also to his gout, while those who are excluded from the former, are also exempted from the latter, and for very obvious reasons, unless they acquire it by their own merit.

So that though the son of a gouty parent may have a constitution predisposing to the gout; that is, more liable to be affected by causes, which produce this disease, still, if he regulate the stimuli to the state of his excitability, he will remain exempt from it.

This distinction is of much greater importance than is generally imagined; for if a person firmly believes that the gout, as a disease, is hereditary, what will be his conduct? My father had the gout, says he, therefore I must have it; well, what cannot be avoided, must be endured; let me then enjoy a short life, but a merry one: he therefore abandons himself to a luxurious mode of life, and, if the gout be the consequence, which most probably it will, he accuses his stars, and his ancestors, instead of his own misconduct.

On the contrary, if a person be convinced that he has received from his ancestors a constitution liable to be overpowered by the use of high seasoned food, and fermented liquors, and excited into gouty action, what will be his conduct? Surely, if he reason at all, it must be in this way: my father was dreadfully afflicted with the gout; I have frequently witnessed his sufferings with the deepest concern. But is not my constitution, which resembles his, liable to be affected in the same manner, by similar causes? To avoid his sufferings, therefore, I must be very temperate; more so than those who have not the hereditary propensity; for the exciting powers, which would only keep them in health, would, if applied to me, infallibly bring on the gout. In consequence of this reasoning, he adopts a temperate mode of living, and avoids the disease.

From this you must be convinced, that it is not a matter of small moment to determine, whether the gout is hereditary, and consequently unavoidable, or not. The next part of Dr. Cullen's definition is "oriens sine causa evidente". This too, I can have little hesitation to pronounce erroneous. The cause of gout, namely, the use of highly seasoned food, and the use of fermented liquors, with, in general, a luxurious, and indolent mode of living, are quite evident enough in most gouty cases, and are amply sufficient to produce the disease.

There is another part of the definition, likewise, to which I would object, as it gives a false idea of the nature of the disease, and therefore causes the preventative plan to be pursued with less confidence. I mean that part where he says "per intervalla revertens."

That the gout, when once cured, is apt to return, if the mode of life which brought it on be not abandoned, no one will deny; nay, the fits will increase in violence, because the constitution gets more and more debilitated. This, however, is not peculiar to the gout, but common to most diseases.

In describing a broken leg, it would surely be wrong to say, that it is a disease which returns at intervals, after being cured; yet, it will return as infallibly as the gout, if a person take the same kind of leap, or expose himself to the same accidents as those which brought it on. Let those, therefore, who wish to avoid a return of the gout, totally change their mode of living: otherwise, if the attacks return, let them blame themselves, and not the nature of the complaint.

These observations were thought necessary, with a view to do away some prejudices, which very much retarded our inquiries into the nature and cure of this disease. I shall now proceed to give an account of the symptoms by which it is usually attended.

The gout generally attacks the male sex; but it sometimes, though more rarely, attacks also the female, particularly those of robust and full habits. It does not generally make its appearance, till the period of greatest strength and vigour is past; for instance, about the fortieth year; but, in some cases, where the exciting causes have been powerfully applied, or where the hereditary predisposition is very strong, it attacks much earlier; such cases are, however, comparatively rare, and can, in general, be easily accounted for.

This disease is seldom known to attack persons employed in constant bodily labour, and who live temperately; and is totally unknown to those who use no wine or other fermented liquors.

If then a person of a full strong habit have for several years accustomed himself to full diet of animal food, and a regular use of wine, and malt liquor, though he may for a long time find that he can perform all the functions with vigour, his strength will at last fail: the mind and body become affected with a degree of torpor and languor for which he cannot account, and the functions of the stomach become more or less disturbed. The appetite becomes diminished, and flatulency, and other symptoms of indigestion are felt. These symptoms take place for several days, and sometimes for several weeks before the fit comes on; but often, on the day immediately preceding it, the appetite becomes greater than usual.

In this state, if the person have fatigued himself by violent exercise, or if he have exposed the extremities to cold, or if his mind have been particularly affected by any anxiety, or distressing event; or in short, if any directly debilitating cause have been applied, the fit will often follow. It sometimes comes on in the evening, but more commonly, about two or three o'clock in the morning; the pain is felt in one foot, most commonly in the ball or first joint of the great toe; but sometimes in the instep, or other parts of the foot. With the coming on of this pain there is generally more or less of a cold shivering, which as the pain increases, gradually ceases, and is succeeded by heat, which often continues as long as the pain; from the first attack the pain becomes by degrees more violent, and continues in this state, with great restlessness of the whole body, till next midnight, after which it gradually remits, and after the disease has continued for twenty four hours from the commencement of the first attack, it often ceases, and with the coming on of a gentle perspiration allows the patient to fall asleep. The patient on coming out of this sleep in the morning finds the part affected with some degree of redness and swelling, which, after having continued for some days, gradually abate.

Still however, after a fit has come on in this manner, although the violence of the pain after twenty four hours, by the excitement that it produces, cures itself, and is considerably abated, the patient is seldom entirely relieved from it. For several days he has every evening a return of considerable pain and fever, which continue with more or less violence till morning. This return is owing to the exhaustion of the excitability by the stimuli of the day, and its remission is caused by the accumulation of the excitability, by sleep.

After having continued in this manner for several days, the disease often goes off, and generally leaves the person in much better health, and enjoying greater alacrity in the functions of both body and mind, than he had for some time experienced. This is owing to the general excitement produced by the pain, which removes the great torpor and debility which preceded the fit; and from the inability to take exercise or food, the excitability accumulates again. This is the true explanation: it does not depend on any morbid matter, which the gout hunts from its lurking places, drives to a joint, and thence out of the body, as has been imagined by many.

At first the attacks of the disease are confined to one foot only: afterwards both feet become affected, though seldom at the same time; but when the inflammation appears in one, it generally disappears in the other, and as the disease continues to recur, it not only affects both feet at once, but is felt in the other joints, especially those in the upper and lower extremities, so that there is scarcely a joint in the body that is not on one occasion or other affected. After frequent attacks, the pains are commonly less violent than they were at first, the joints lose their strength and flexibility, and often become so stiff as to be deprived of all motion.

Concretions of a chalky or calcarious nature are likewise formed upon the outside of the joints. This arises from an inability of the capillary vessels, which ought to secrete the calcarious matter, and deposite it in the bones, to perform their office, from debility: hence by sympathy other vessels ta ke up the matter and deposite it in the wrong place. These concretions, though at first fluid, become at last dry, and firm: they effervesce with acids, and are totally, or in a great measure, soluble in them.

After this short description of the gout, when it occurs in its regular form, as it is called, I shall now proceed to inquire how the exciting causes produce this disease, and what is the state of the body under which it occurs.

The gout seldom occurs but in those who have for several years lived upon a full diet of animal food, often highly seasoned, and at the same time been in the habit of taking daily, or at least very constantly, a greater or less quantity of fermented liquors, either in the form of wine, or malt liquor, or both. The affection of the limb has all the appearance of an active inflammation: the part becomes swelled, hot, red, and intolerably painful. It is this circumstance which has misled practitioners, who have supposed it a case of sthenic, or active inflammation: not only the appearance, but the causes which produced it, induced them to think so; hence they were naturally led to employ the debilitating plan: a little time and observation would, however, be sufficient to convince them of its inefficacy. They would find that the application of leeches to the part, and of the lancet to the arm, instead of subduing the inflammation, would increase it: or if it did not, that the pain often attacked some internal part, which was ascribed to a translation of the morbific matter from one part to another, but which is merely owing to an increased debility: a little attentive observation would convince practitioners, however mysterious it might seem to them, that this violent inflammation was not to be cured by debilitating: on the contrary, they would see cases, in which the patient, though contrarily to the strict orders of his physicians, could not forego his old habits; but would take his wine as usual, or in greater quantity, after a few days abstinence; and this abstinence having in some degree accumulated the excitability, he would find himself much relieved by wine, and would exultingly tell them, that they were mistaken. Circumstances of this kind seem to have staggered their faith a little, but still the idea of active inflammation which they believed was visible, and almost palpable, dwelt so upon their minds, that they were but half convinced. The favourite idea of increased action of the vessels of the part had so interwoven itself with every other, that we find it never lost sight of, in the indications of cure. Hence, though bleeding is not now generally practised with the lancet, yet leeches are often applied; but the most usual plan is to consign the patient to patience and flannel; strictly forbidding wine, or fermented liquors. As an exception to this general mode, it is however observed, by some practitioners, that when the stomach is weak, and when the patient has been much accustomed to the use of strong liquors, a little animal food, and even wine, may be allowable, and even necessary.

Thus has an erroneous view of the disease been the cause of an inert practice, which wavers between the suggestions of a favourite hypothesis, and the conviction of facts.

On inquiry, however, we shall find none of the increased vigour in the system, which has been suspected, nor increased action in the part more particularly affected; on the contrary, the whole body is in a state of indirect debility, or exhausted excitability, and the part more particularly affected, in a state of asthenic inflammation.

If the gout were of a sthenic or inflammatory nature, might we not ask, why the causes which produce it, do not produce it in the meridian of life, when they produce their greatest effect, and when real sthenic diseases are most apt to occur? or, why the symptoms of the inflammation, like all other real sthenic inflammations, are not relieved by the debilitating plan? The contrary, however, points out to us clearly the nature of the disease: the gout is not a sthenic disease, or a disease of strength: it does not depend upon increased vigour of the constitution, and plethora, but is manifestly asthenic, like all the rest of the asthenic diseases. The mode of living is such as brings on indirect debility, or exhaustion of the excitability, such as the use of rich and highly seasoned food, and a daily use of fermented liquors. These at first certainly produce vigour, or strength, and will be the cause of sthenic diseases; but they are generally taken in such a manner, that, though they produce a degree of excitement above the point of health, still they only approach the line of sthenic disease, without in general falling into it. They continue, however, to exhaust the excitability, and by the time that the vigour of the body begins naturally to decline, the system of a person who has lived in this manner is unusually torpid; all the blood vessels, which have hitherto been distended with rich blood, begin to lose their tone, from their excitability having been exhausted by the use of these powerful stimulants; but this torpor is particularly and first experienced in those parts which have been more immediately subject to the action of the exciting causes; viz. the stomach and bowels: symptoms of indigestion occur, and the excitability of these organs having been almost entirely exhausted by the violent action of the stimulants applied, cannot now be roused to any healthy action; the food is not properly digested, but runs into a kind of fermentation, which causes an extrication of gas: this distends the stomach and bowels, and produces pains, uneasy eructations, and all the distressing symptoms of indigestion. Nor is this in the least surprising, when we consider that many people who have brought on complaints of this kind, have been in the habit of eating heartily of rich and highly seasoned animal food, and of drinking from a pint to a bottle of wine, and perhaps a quantity of malt liquor, almost every day of their lives for years. This mode is sufficient to wear out the powers of the stomach, were it three times as capacious as it is, and of the constitution, were it ten times as strong.

When a torpor, or state of exhausted excitability, of the whole system, has been induced in this manner, and symptoms of indigestion produced, any directly debilitating cause applied to the extremities, adding to the indirect debility, causes a total torpor, or inactivity of the minute vessels of the part, and thus totally destroys the balance between the propelling and resisting force; hence the vessels will be morbidly distended with blood, a swelling and redness will take place, and an asthenic inflammation, produced in the way which I fully pointed out in the last lecture, will be established. Hence the pain, and other symptoms, which accompany a fit of the gout. Hence likewise we see, why debilitating powers applied to the part will not reduce the inflammation; and why a warmth, which aggravates every really sthenic inflammatory affection, is so comfortable in this.

Almost any debilitating cause, when the system has been brought by intemperance to the torpid state, which I have described, will bring on a fit of the gout, but nothing more certainly than cold or moisture: hence if a person have his feet chilled or wet, he will be almost certain to have an attack.

Hence we see that the asthenic inflammation is not the disease, but merely a symptom of it; and like other symptoms, fallacious in its appearance; the disease is a state of indirect debility, to which our attention ought to be directed.

When this inflammation is violent, and accompanied with great pain, after several hours continuance, it excites the action of the minute vessels, enables them to propel the blood, by which they are morbidly distended, and restores the balance between the resisting and the propelling force; and thus the inflammatory appearances will for a time subside, but the torpor of the whole system remaining, and the debility of the vessels returning, when their excitement, which was the consequence of their action, has ceased, another asthenic inflammation will take place, which will again cure itself as before; so that during a paroxysm, several remissions will take place, as was mentioned in the description of the disease. As, during the paroxysm, the pain causes a considerable degree of excitement over the whole system, the action of the stomach and other parts is roused by it; during the fit likewise, little nutriment is taken, so that by the action of the stomach and bowels, they get rid of their load; rest likewise assists to accumulate the excitability, so that from all these causes together, the body becomes restored to a state of vigour, which, compared with its former torpidity, makes the patient imagine that this friendly disease has restored him to a state of unusual health, and even renovated the powers of his constitution. Under this mistaken idea, he does not, when the fit leaves him, abandon the mode of life, which brought on the disease; highly seasoned food, and the usual quantity of wine, are again resorted to: after a time the torpor of the system, and symptoms of indigestion return, and he again hopes that his friend the gout will come and cure him.

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.

In the same manner, when the body has been under the influence of violent grief, any sudden joy has been known to overpower the system, and even produce instant death. We have an instance in history, of a mother being plunged into the extreme of grief, on being informed that her son was slain in battle; but when news was brought her, that he was alive, and well, the effect upon her spirits was such, as to bring on instant death. This event ought to have been unfolded to her in the most gradual manner; she should have been told, for instance, that he was severely wounded; but that it was not certain he was dead; then that there was a report he was living, which should have been gradually confirmed, as she could bear it. The same observations may be made, with respect to hope and fear, or despair; the former is an exciting passion, the latter, a depressing one; but the one is only a lower degree of the other; for a moderate degree of hope produces a pleasant state of serenity of the mind, and contributes to the health of the body; but a diminution of it weakens; and a great degree of despair so accumulates the excitability of the system, as to render it liable to be overpowered by any sudden hope or joy afterwards applied. What proves that joy and hope act by stimulating, and grief and despair by withdrawing stimulant action from the body, is, that the former exhaust excitability, while the latter accumulate it. Joy, for instance, does not render the system more liable to be affected by hope, but the reverse; and the same may be said of hope. In the same way, heat does not render the body more liable to be affected by food, but the reverse. Both these are stimulants, and exhaust the excitability. But after heat has been applied, if it be followed by cold, a great degree of languor or weakness will take place; because we have here a direct debility, added to indirect debility. In the same way, grief succeeding joy, or despair succeeding hope, produce a greater degree of dejection, both of mind and body, than if they had not been preceded by these stimulant passions; because here, direct debility is added to indirect. The excitability is first exhausted, and then the stimulus is withdrawn.

We see then, that the passions of the mind act as stimulants to the body, that, when in a proper degree, they tend to preserve it in health; but when their action is either too powerful, or too small, they produce the same effects as the other powers. We should therefore naturally expect, that when there is a deficient action of this kind of mental stimulus, or when the mind is under the influence of the depressing passions, a predisposition to diseases of direct debility would take place, and even these diseases be produced. Accordingly we find a numerous class of nervous complaints originating from these causes. Indeed, the undue action of the mental stimulants, produces more quick alterations in the state of the excitement, than that of the other exciting powers. Violent grief, or vexation, will immediately suspend the powers of the stomach. If we suppose a person in the best health, and highest good humour, sitting down to dinner with his friends, if he suddenly receives any afflicting news, his appetite is instantly gone, he cannot swallow a morsel. If the same thing happens after he has made a hearty dinner, the action of the stomach is suddenly suspended, and the whole process of digestion stopped, and what he has eaten, lies a most oppressive load. But this is not all: the whole circulation of the blood becomes disturbed; the contraction and dilatation of the heart become irregular; it flutters, and palpitates; hence all the secretions become irregular, some of the glands acting too powerfully, others not at all; hence the increased action of the kidneys, and hence a burst of tears; hysterical affections, epilepsy, and syncope, frequently succeed, in which every muscle of the body becomes convulsed. Indeed, many terrible diseases originate from this source, which were formerly ascribed to witchcraft, and the possession of devils.

In slower, more silent, but longer continued grief, the effects are similar, but not so violent. The functions of the stomach are more gently disturbed, its juices vitiated; and acidity, and other symptoms of indigestion, will show themselves. Hence no bland and nutritive chyle is conveyed into the blood; whence emaciation and general debility must follow; and the patient will at last die, as it is said, of a broken heart.

Besides the disturbed state of the stomach, and bad digestion, there can be no sleep in this state of mind; for,

"Sleep, like the world, his ready visit pays, Where fortune smiles; the wretched he forsakes; Swift on his downy pinion flies from woe, And lights on lids unsullied with a tear."

Hence the animal spirits will not be recruited, nor the worn out organs restored to vigour.

The minds of patients labouring under this division of nervous diseases, are likewise in general filled with over anxiety concerning their health; attentive to every feeling, they find, in trifles light as air, strong confirmations of their apprehensions.

It is evident, that in these cases, a state of direct debility prevails, attended with a morbidly accumulated excitability; hence, those remedies afford relief, which produce a quick exhaustion of this principle, and thus blunt the feelings, and lull the mind into some degree of forgetfulness of its woes. Hence opium, tobacco, and the fetid gums are often resorted to; and in the hands of a judicious practitioner, they will afford great relief, provided he carefully watch the patient, and prevent their abuse; for, if left to the discretion of the patient, he finds that kind of relief which he has long wished for; his moderation knows no bounds, and he is apt to take them in such a manner, as to add indirect debility, to direct, and thus bring on a state of exhausted excitability, while there is still a diminished state of mental stimulants. This will cause his spirits to be more depressed than ever; he will therefore increase the dose, whether it be of opium, tobacco, or spirituous liquors, and thus he will be hurried on, adding fuel to the flame, till his exhausted excitability becomes irrecoverable, and he ends his days in a miserable state of imbecility, if not by suicide. Hence, though some of these narcotic stimulants, which exhaust the excitability, and blunt the feelings, may be employed with advantage, in order to prepare the mind for those changes, which the physician wishes to produce, they should be used with the greatest caution, and never left in any degree to the discretion of the patient. The cure, however, depends chiefly on regulating the state of the mind, or interrupting the attention of the patient; and diverting it, if possible, to other objects than his own feeling.

Whatever aversion to application of any kind we may meet with in patients of this class, we may be assured that nothing is more pernicious to them than absolute idleness, or a vacancy from all earnest pursuit.

The occupations of business suitable to their circumstances, and situations in life, if neither attended with emotion, anxiety, nor fatigue, are always to be advised to such patients; but occupations which are objects of anxiety, and more particularly such as are exposed to accidental interruptions, disappointments, and failures, are very improper for patients of this class.

To such patients exercise in the open air is of the utmost consequence. Of all the various methods of preserving health and preventing diseases, which nature has suggested, there is none more efficacious than exercise. It puts the fluids all in motion, strengthens the solids, promotes digestion, and perspiration, and occasions the decomposition of a larger quantity of air in the lungs, and thus not only more heat, but more vital energy is supplied to the body; and of all the various modes of exercise, none conduces so much to the health of the body, as riding on horseback: it is not attended with the fatigue of walking, and the free air is more enjoyed in this way, than by any other mode of exercise. The system of the vena portarum, which collects the blood from the abdominal viscera, and circulates it through the liver, is likewise rendered more active, by this kind of exercise, than by any other, and thus a torpid state, not only of the bowels, but of this system of vessels, and the biliary system, is prevented.

When a patient of this class, however, goes out for the sake of exercise only, it does not in general produce so good an effect, as might be expected; for he is continually brooding over the state of his health: there is no new object to arrest his attention, and he is constantly reminded of the cause of his riding. Exercise will therefore be most effectual when employed in the pursuit of a journey, where a succession of pleasant scenes are likely to present themselves, and new objects arise, which call forth his attention. A journey likewise withdraws the patient from many objects of uneasiness and care, which might present themselves at home.

With respect to medicines, costiveness, which often attends these diseases, ought to be carefully avoided, by some mild laxative. Calcined magnesia, and lemonade, have always seemed to me to answer the purpose; but the most effectual method is to acquire a regular habit, which may be done by perseverance, and strict attention.

Chalybeate waters have been frequently tried, and may in general be recommended with success, particularly, as the amusement and exercise generally accompanying the use of these waters, aid the tonic powers of the iron. The bark may likewise be exhibited with advantage.

There is yet another class of nervous diseases which we have to notice, which are by no means uncommon; yet they have, like the first class, escaped the attention of writers on this subject, and of medical practitioners in general: I mean those where the system is in a state of torpor, or exhausted excitability.

This state of the system may be brought on by various causes, but principally by the long continued use of opium, tobacco, or fermented liquors.

When these substances, which are powerful stimulants, have been taken for some time, they bring on a state of the system so torpid, that the usual exciting powers, and the usual occurrences, which in general produce pleasant sensations, do not occasion a sufficient degree of excitement, in those whose excitability is thus exhausted. They therefore feel continual languor and listlessness, unless when under the influence of the stimulus which brought on the exhaustion. Every scene, however beautiful, is beheld with indifference by such patients, and the degree of ennui they feel is insupportable: this makes them have recourse to the stimulus which has exhausted their excitability, which in some degree removes this languor for a time; but it returns with redoubled strength, and redoubled horror, when the stimulant effect is over: and as this repetition exhausts the excitability more and more, the stimulus is repeated in greater quantity, and thus the disease increases to a most alarming degree.

There is no way of curing this state of nervous torpor, but by leaving off the stimuli which caused the exhaustion; and if the patient have resolution to do this for a few weeks, though, at first, he will, no doubt, find his spirits a little depressed, he will ultimately overcome the habit, and will be rewarded by alacrity of spirits, such as he never experiences under the most powerful action of artificial stimulants.

I must not, however, forget to notice, that there is a nervous state, or ennui, originating from a wrong direction of mental exertion, which exhausts the excitability to a great degree, and brings on a state of depression scarcely to be born.

When a person has by habit made his mind constantly dependent on dissipation, on gaming, and on frivolous, but not inactive pursuits, in order to produce pleasurable sensations, and at the same time neglected that culture of the understanding which will enable him to retire into himself with pleasure, and receive more enjoyment from the exercise of this cultivated understanding than he does in the most noisy, or fashionable circle of dissipation: I say, when there is this vacancy of mind, whenever it is not engaged in such pursuits as I have mentioned, a languor and weariness is experienced, which is intolerable, and which prompts the person so circumstanced, to fly continually to the only scenes which interest his mind. Hence, the passion for gaming, in which the anxiety attending it causes an interest in the mind, which takes off the dreadful languor experienced, when it is not thus employed.