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put the practitioner upon his guard: for it is very frequently present during the premonitory stage of those diseases which are most prevalent in warm climates; and it, more certainly than any other sign connected with the pulse, indicates inordinate fulness of the vascular system, and that state of congestion about the great vessels and in the great secreting viscera most prone to become productive of fever or inflammation.

The pulse, if carelessly examined, may often mislead; and it requires great nicety of tact, and much experience, to discriminate between the various states of the system which the pulse indicates, and the progressive advance of disease. The irregularity of the pulse, already noticed as indicating the commencement of disorder, relates to both its strength and frequency. When the artery makes a few strong pulsations, as if by an effort, and then relaxes into a state of diminished and oppressed action, a congested state of the internal viscera is denoted, and the state of the liver should be inquired into. In this state there is reason to believe that disease is commencing in the liver, and that the constitution is, as it were, making efforts to remove the oppressed state of the organ, which will soon be productive of reaction, and even of inflammation of it, if means are not soon resorted to in order to prevent such consequences. Preternatural slowness, with fulness of the pulse, giving the impression of difficulty in the propulsion of the stream of blood, is always indicative of too great fulness of the vascular system; is generally the sign of incipient disease, particularly of fevers, of congestion of the vessels of the head and liver; and is a sure guide to the treatment which should be adopted.

Not the least important of all the symptoms which ought to be viewed as premonitory of intertropical diseases, are, the states of the surface of the body, and the appearance of the countenance. As respects the latter, it may be said generally, that whenever its colour, or its expression, in any way differs from its natural character, that disorder should be suspected; and that the severity and danger of the disorder may be learned, to a great extent, from the manner and degree in which the features and their expression are changed. When the countenance is collapsed, sallow, and languid, then the powers of the system may be viewed as being deficient. This state of countenance is often present during the premonitory period of febrile and inflammatory diseases, and in affections of the biliary organs; and is frequently accompanied with a muddy or dark state of the skin of the face, and deficient expression and liveliness of the eye. The opposite state of the features, viz. unusual

fulness, flushing of the face, and a prominent state of the eyes, with injection of the conjunctiva, indicate excitement of the vascular system, and the fully developed stage of fever, or of inflammatory action.

With respect to the state of the cutaneous surface, it may be said generally, that a dry, unperspirable, and harsh condition of it, usually ushers in the majority of diseases, and should always indicate the propriety of resorting to active measures, in order to prevent the impending consequences, and to re-establish the perspiratory function. With this state of the surface is often connected unusual coldness; and this is sometimes remarkable during the few days of partial ailment which elapse more immediately upon the first impression of those causes of disease which proceed from the soil and season. This lowness of the animal heat, taken in conjunction with the other concomitant phenomena, serves, most unequivocally, to point out the particular state of the constitution which these causes produce, and the means best suited for its removal. In many cases, and particularly when the period of the full development of the disease approaches, the skin, although dry, harsh, and unperspirable, is as hot, and even hotter, than natural. And even when the temperature is above its usual standard, the patient is often chilly and uncomfortable in his sensations. These feelings generally pass off as the febrile symptoms develope themselves; but when they are present, they indicate approaching disease, which may be arrested by active means, employed appropriately to the circumstances of individual cases, and with due promptness and perseverance on the part of the physician. When, in addition to a cold, harsh, and collapsed state, the surface of the body is covered by a damp, raw, and cold moisture, which is usually the case even at the commencement of the epidemic cholera, the threatened danger is then more urgent, and the means which are then requisite must be more energetic.

To ascertain the approach of disease, and to investigate its nature during its early periods, are objects which are most deserving the attention of the intertropical practitioner, as endowing him, to a great extent, with the power of arresting its progress, by the employment of suitable and energetic means; and, when that cannot be effected, of averting many of its worst or most dangerous consequences. Indeed, to arrest diseases at their first outset, and thus to prevent not only great consequent suffering, but also, in many cases, fatal results, must be viewed as the most valuable application of medical science.

The observations now made upon the propriety of attention to the premonitory stage of disease, and the suggestions offered in order to enable the inexperienced practitioner to detect it in its various forms, are the results of my own observations and experience. I do not bring them before the public as complete in all their bearings, and as amounting to what may altogether be desired upon the subject; but I venture to state them with confidence, being founded in truth and in nature; and offer them to the practitioner as a sketch which his own observation may fill up, and as materials which may awaken in his mind many important suggestions tending to the further elucidation of the subject.

L

BOOK II.

ON THOSE DISEASES OF THE STOMACH MOST PREVALENT IN INDIA AND WARM CLIMATES.

DISORDERS of the stomach are seldom met with in warm countries in a pure and uncomplicated form; and when existing as primary disorders, are often not much attended to on the part of the patient until they become connected with, or give rise to, more serious disease,-most frequently of the liver and intestines. Disorders of the stomach are not, however, rare; but they are so generally associated with very important and often dangerous diseases of the adjoining viscera, as to be in a great measure concealed by the urgency of the symptoms of those with which they are complicated; and when they obtain the attention of the medical practitioner, they are often viewed as merely symptomatic of those diseases. As, however, they sometimes stand forth the prominent disorders, and as they frequently lead, by neglect in their early stages, to those diseases which afterwards mask their existence, and which justly receive the chief attention of both patient and physician, as being the most urgent, I shall venture to make a few observations respecting them, the result of long experience in warm climates.

CHAPTER I.

ON THE FUNCTIONAL OR PRIMARY DISORDERS OF THE STOMACH, MOST FREQUENTLY OCCURRING IN WARM COUNTRIES.

THE functional and primary disorders of the stomach are frequently not much attended to by Europeans residing in intertropical countries, being generally viewed by them as the necessary consequences of the climate, and thus allowed to make progress until they produce effects which awaken the apprehension of the patient. This is the great evil to be dreaded from neglecting slight ailments; and such neglect is productive of much mischief in temperate as well as in hot countries. In the latter, however, it is the more deserving of attention and remedy, inasmuch as the consequences attendant upon negligence are here more rapid in their progress, and more injurious to the frame, than in the former.

SECT. I.-On the Causes, Symptoms, and Nature of some of the more frequent Forms of Indigestion within the Tropics.

The earliest symptoms which present themselves when the functions of the stomach are incompletely performed are, a feeling of oppression and distension, with flatulence and acid eructations after a full meal. These often continue to be present for months, or even years, in temperate climates, without being followed by any more serious disturbance of the system. In warm climates, however, this is less frequently the case, some more serious disorder generally soon supervening, as will presently be seen. At first, the above-mentioned uneasy sensations are generally got rid of by the patient taking less bulky meals, or more digestible food; for he soon learns to impute his uneasiness to the right cause. But if his appetite happen to be good, at the same time that the digestive powers are impaired,-a very frequent coincidence both within and without the tropics,-it very generally is observed, that he is thereby induced to eat a greater quantity than the stomach will digest, and hence disorder is likely to be produced, Indulgence

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