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whose cutaneous surface has constantly been kept in a state of free and copious perspiration, is exposed to the chills of a colder climate, the balance of the internal and external circulation, which had been so long maintained, is disturbed, and the blood is repelled from the surface to the internal viscera, which, in time, suffer from the load, in proportion to the disposition to disorder which they may possess. The liver, bowels, and stomach itself, often suffer more or less in this way, and not unfrequently the lungs become the seat of disease from the same cause. Now the indication in those cases is sufficiently apparent. The low temperature of our native climate suppresses an abundant secretion and excretion, which had been maintained upon the surface of the body for many years in a hot country, and which cannot be permanently restored whilst exposed to a cold atmosphere. We should, therefore, most obviously look for some other natural outlet for the exhalations and excretions now diminished or entirely checked upon the cutaneous surface; and at the same time maintain the accustomed transpiration of the skin by every suitable means. Conformably, therefore, with this view, the healthy functions of the stomach should be promoted by light and digestible food taken in moderate quantity, and by temperance and regularity in the hours of diet and repose. The functions of the liver should be regularly attended to, and the actions of the bowels promoted by appropriate means. Amongst these, the blue-pill, or this with the aloes and myrrh pill, or the latter only, should be taken at bed-time, according to circumstances ; and a draught, consisting of infusions of gentian and senna, with some neutral salts, in the morning. These may be repeated, or continued, according to the effects produced and the peculiarities of the case. Warm clothing ought to be adopted and proportioned according to the temperature of the atmosphere, and the temperament and ailment of the individual. Flannel should be worn next the skin, and the feet be especially kept warm at all seasons.

The chief danger to which those returning to Europe with impaired digestive organs are liable, is the supervention of either hepatic or pulmonary diseases. Many cases have occurred of individuals who had never complained of disorder in the liver whilst they remained in India, and yet, upon residing for some time in England, and paying little or no attention to the state of their stomach and bowels, hepatic disease of the most serious aspect had supervened, and in some cases proved fatal. Upon arrival in Europe, the invalid should endeavour to take exercise, especially upon horseback; and even those who have returned with little or no ailment should take sufficient exercise to promote the cutaneous functions, without carrying it to the length of fatigue, and, equally with those who have impaired their digestive functions and their health generally, ought to attend most scrupulously to the early signs of disorder in the chest; and, upon the first appearance of cough, or oppression, or tightness, or pain in this cavity, resort to depletions, and to such remedies as are calculated to promote the actions of the great secreting viscera and surfaces, and to carry off any morbid secretions or excretions which may have accumulated in the first passages. But it is not a mere discharge of such accumulations which ought to be attempted, but a continued action of the secreting and excreting organs ought to be promoted; and the diet, at the same time, should be regulated in such a manner as to diminish vascular action when it exists, and to keep up the strength, so as to enable suitable purgation to be instituted when debility commences. Much advantage will occasionally be experienced from a dose of calomel given at bed-time, and followed by an active cathartic draught in the morning. The common black draught will answer the purpose sufficiently well; and will carry off those morbid secretions which will continue to accumulate from time to time in those who have resided in a warm climate, after they have returned to their own country. But the occasional exhibition of this more active medicine should not prevent the patient having recourse to gentle aperients, in order to keep up a regular action of the liver and bowels. For this purpose there is scarcely any thing better suited than the pills already noticed: and when chronic disorder exists about the liver, the artificial Cheltenham salts may be taken in addition, and the natural waters resorted to when the patient arrives in England.

BOOK 111.

ON THE DISEASES OF THE LIVER AND OF THE BILIARY APPARATUS.

Diseases of the liver may be considered as endemic in the eastern hemisphere. The annual average per-centage of hepatitis in the East Indies is at least treble what it is in the western hemisphere. In the different divisions of the Bengal army, the annual per-centage of inflammation of the liver varies from three per cent. to twenty-five, giving an average of thirteen per cent, in the effective strength. But this calculation is made with the nominal admissions. Calculating, however, from the imperfect data in our possession, the actual per-centage of admissions is much below what is now stated, and would appear to vary in this presidency from two to sixteen per cent., averaging between eight and nine per cent. in the effective strength. In the different divisions of the Madras army, the actual admissions are ascertained with more precision; and although, of course, much below the nominal admissions, they vary in these divisions from six to thirty-five per cent.,—the lowest per-centage being in these provinces which more nearly approach those under the Bengal presidency, and the highest in the more southerly and most parched districts. These facts render it probable that the difference in the per-centage of diseases of the biliary organs, particularly acute inflammation of the liver, is dependent, in a great degree, upon the nature of the soil and climate, and in the mean annual height of temperature; hepatitis being more frequent in the Coromandel coast and southern provinces of India, where the annual range of temperature is highest.

The influence which various morbid actions exert on the biliary secretions, the numerous changes which that secretion undergoes in disease, the particular local and constitutional affections which these changes induce, and the variety of disease and morbid structure observed in different countries in the substance of the liver, are objects worthy of more serious attention than has hitherto been bestowed by practitioners in the different regions of the earth.

The annual average of actual admissions of hepatitis in the effective strength of the Madras European army is somewhat more than twenty per cent.; and in the Isle of France and other parts of the same hemisphere, the annual per-centage ranges from eight to eighteen in the effective strength. But the number of cases given in the official returns as inflammation of the liver, forms only a part of the many instances in which the functions and structure of the biliary apparatus are diseased; for there are comparatively few cases of fever and dysentery, and even of diarrhoea and cholera, in which this part of the animal economy is altogether unaffected. Hepatitis, therefore, appears in the returns only when the liver has been the organ affected, or when it has betrayed disorder in a prominent manner. It is well known, however, that in a great many cases which have appeared, and been stated in official returns, as fever, as dysentery, and as chronic diarrhoea, dissection has disclosed most extensive disease in the liver. In some of these cases disorder of this viscus had never been suspected, and in others it had become manifest too late to be remedied. I am disposed to extend this remark to the fevers and dysenteries of the western hemisphere; and I believe that, although the annual average° per-centage of admissions of hepatitis in the effective strength is as low as two per cent. in some of the West Indian colonies, and never above ten per cent, as stated in the official returns, averaging altogether as low as four and a half per cent, annually,—disorders of the liver are actually more frequent than those returns make appear, and that those disorders are, in a great measure masked, as in the eastern hemisphere, by concomitant or consequent disease.

But besides those more palpable instances of hepatic disorder, which appear in the official returns as inflammation of the liver, being immediately recognised as such upon their admission into hospital,—and in addition to those cases of fever, dysentery, and diarrhoea, wherein the liver has been either in a state of co-existent or consequent disease,—there are other instances in which this organ is seriously affected; and yet they seldom come under treatment until more important disease has supervened, either in the liver itself or in some other viscus;—the primary disorder of this organ being productive of the consequent disease, which assumes the prominent features and attracts the whole attention of the practitioner, while, in fact, the primary disorder on which it depends is overlooked, and undiscovered unless when disclosed by dissection.

CHAPTER I.

ON FUNCTIONAL DISORDER OF THB BILIARY ORGANS.

Undeb the head of functional disorder may be embraced all ihose conditions of the liver and its appendages which depart from the heahhy state, and are productive of uneasiness to the patient, and lead to further disease. These conditions, although affecting the quantity and quality of the blood circulating in the liver, and of the fluid secreted by it, are not necessarily allied to morbid structure, although, when neglected or improperly treated, they often terminate in inflammatory states and in alterations of the organization of the organ. Indeed, these latter derangements generally proceed from this source, either immediately upon the first functional disorder, or after repeated or long-continued attacks of it. Amongst the disorders of the biliary organs embraced under this head, most frequently occurring in warm climates, are, increased secretion of bile, congestion of blood in the liver, congestion of bile in the biliary ducts and gall-bladder, and torpid function of the liver itself.

Sect. I.—On Increased Secretion of Bile.

One of the earliest effects of change from a cold or temperate climate to a very warm one, upon the European constitution, 'is an increased secretion of bile. This has been ascribed by Dr. Johnson to a sympathy existing between the hepatic functions and those of the skin, the former being increased when the latter is augmented. That an increase of these functions is generally coexistent, particularly soon after the European has arrived in an intertropical country, cannot be questioned; but, it cannot be readily conceded that the increase of the biliary secretion is so immediately the result of sympathy with the functions of the skin, as this author infers. The sympathy between the skin and the internal viscera generally, I admit; and in the treatment of disease, a knowledge of, and due attention to, the fact, are matters of the very first importance; but I am much more inclined to adopt

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