SECT. III.-On Disorders frequently depending upon the Accumulation of Morbid Matters in the Alimentary Canal, particularly in the Cæcum and Colon.

The frequent occurrence of serious disorder in the bowels themselves, and in organs sympathising with them, in consequence of accumulations of morbid secretions and fæcal matters in the large bowels has already been alluded to; and I now proceed to claim the attention of the reader more particularly to this subject. I shall, first, notice certain occasional effects of such accumulations upon the position of the colon, and which, when induced, generally perpetuates the disorder whence it proceeded, and superinduces others; and subsequently consider those affections which are sympathetically related to the morbid condition of the prima via, and which are of frequent occurrence in warm countries.

On Elongation and unnatural Positions of the Colon.-Accumulations formed in the lower part of the colon, and the restraint which is often, but very improperly, imposed upon the inclination to stool tending farther to increase such accumulations by frequent repetition, induce irregular flexures and displacements of portions of the colon, and even an elongated state of this viscus. I believe that the supervention of these consequences is favoured by a relaxed state of the mesocolon, the peritoneal covering of the bowel, and more particularly of the longitudinal bands which constitute a peculiar feature in the conformation of this viscus. We often find, in cases of old herniæ, considerable displacement and elongation of the colon, and a stretched appearance of the peritoneum and mesentery, particularly in certain places, and yet the parietes of the bowel will be free from morbid change. By the impaction of hard fæcal matters about the sigmoid flexure of the colon, from whatever cause resulting, an analagous condition is apt to supervene, and that part of the bowel, at the place where the obstruction exists, will be carried lower into the iliac region or into the pelvis by the increased action of the parts above; which action frequently repeated, or continued for an unusually long time, necessarily leads to partial displacements, elongation, and unnatural flexures of the bowel.

When unnatural flexures are thus formed, or the natural ones increased to the state nearly approaching to convolutions of the bowel, morbid accumulations are more readily and more frequently

produced; and, when once formed, very dangerous diseases of the colon itself and of the neighbouring viscera often supervene. Of these, inflammation of the bowel, accompanied with the usual symptoms of dysentery, is the most frequent; and next to it inflammation of the small intestines and of the liver.

In many cases, also, the obstruction thus placed in the way of the regular flow of the alimentary and secreted matters along the lower part of the digestive canal, even when it fails of inducing active inflammation, occasions a stagnation of the contents of the small intestines, with various severe dyspeptic symptoms and congestion and consecutive diseases of the liver, attended in several instances with hypochondriacal symptoms, which may terminate in melancholia and insanity in persons having a predisposition to those affections. That these latter consequences may result from accumulations in the large bowels, has been satisfactorily demonstrated by the histories of numerous cases of this description which have come under my observation and by the successful issue of the treatment adopted for their cure.

With respect to the particular treatment which may be adopted in cases where displacement or irregular position of the colon exists I have but little to advance. It must be admitted, that during the life of the patient there are no symptoms indicating the existence o this condition which may not equally proceed from other kinds of disorder. The treatment, however, which is applicable to this derangement is also appropriate to others seated in the same viscu, which are manifested by similar signs, and characteris by alvine obstruction: hence the observations made respecting the removal of accumulations of morbid matters in the large bowels, are perfectly applicable to the species of derangement now under consideration. When, however, there are great tension and fulness in the abdomen, occasioning general distress, restlessness, and oppression. in the chest, with uneasiness in the head, irregularity of the bowels and watery discharges by stool, without any of those symptoms that mark increased arterial action, we may fairly infer the existence of either displacement or constriction of the bowel. Either condition will produce these symptoms; and both equally require the fæcal contents to be kept in a fluid state, to enable them to pass along the canal. Here, however, if the nature of the disorder were cognisable during the life of the patient, the use of purgative or laxative enemata is particularly appropriate whilst an assiduous attention should also be paid to the preservation of a fluid state of

the evacuations and a regularly open state of the bowels, by means of laxatives taken by the mouth, and of emollient and gently aperient injections.

On Hypochondriasis, Melancholia, and Mental Alienation, in connexion with Accumulations of Morbid Matters in the Bowels.-Accumulations of excrementitial matters form in the large bowels generally in consequence of a low state of the vital energies of these viscera, and when they thus form, their presence tends most essentially to increase the morbid condition in which they originated, and to augment the debility of the frame generally. When deficient tone of the alimentary canal is followed by the generation and retention of morbid secretions and fæcal matters in the large bowels, the mental faculties not unfrequently become disordered in various grades, from the slighter shades of hypochondriasis, through the advanced stage of melancholia, until complete insanity is established. It seems very probable that the morbid secretions and excrementitious matters allowed to accumulate in the large bowels depress the powers of life, and lower the energies of the nervous system, at the same time that the irritation these substances produce upon the mucous surface of the bowels excite, in a sympathetic manner, the circulation in the membranes and substance of the brain.

M. Esquirol has stated that, in one hundred and sixty-eight cases of melancholia examined by him after death, he found displacement of the colon in thirty-three, the transverse arch of this bowel generally hanging down into the hypogastric region. Now whether this derangement proceeded from accumulation of fæcal matters in this viscus, or from great relaxation and want of tone of its coats and peritoneal covering, the necessary consequence of this condition must have been, in every case, to have favoured an unnatural retention and collection of fæcal and excrementitious matters in the bowel, and to have generated disease in the mucous surface on which they lodged, inducing sympathetic disorder in various parts of the system, more particularly in the brain itself.

This effect, although not necessarily or generally proceeding from morbid accumulations in the prima via, yet in those who are suffering from mental anxieties, who have experienced disappointments, who expose themselves to the direct rays of the sun, and who have an hereditary disposition to mental disorder, will very frequently supervene. And although the practitioner is not to consider morbid accumulation in the large bowels as the only, or even

on many occasions, as the chief physical derangement to which he ought to direct his remedial means, he should, nevertheless, pay sufficient attention to the pathological state now pointed out, more particularly as the indications of cure to which it leads are amongst the most important by which he can guide his practice, and, when decidedly acted upon, perhaps the most successful in its ultimate issue.

The ancients, although bad theorists, were nevertheless, attentive observers of nature. They have very stongly advocated the necessity of active and continued purgation in mental disorders, more especially in melancholia, and for this purpose employed the most active vegetable cathartics, particularly hellebore, conceiving that purging off black bile would remove the disease, which in their opinion, depended upon a depraved state of this fluid. But although they were mistaken in respect of the particular source whence this morbid and black secretion proceeded, yet they were by no means wrong as to its existence. In a very great proportion of cases of melancholic alienation of mind, and indeed in other forms of mental disorder, the stools procured by means of active purging are very dark, tenacious, and even of a pitchy blackness, resulting, as I conceive, from the accumulation and admixture of the various secretions, excrementitious matters, and imperfectly digested food, poured into the alimentary canal, and from the changes they have undergone during their retention in that situation.

With this view, I have always made it a point, to institute a most active and uninterrupted course of purgative remedies in conjunction with those other means which act directly in restraining the morbid action secondarily induced in the brain. Thus, while I have prescribed for months, without interruption, the use of purgative or laxative medicines daily, I have also directed general or local blood-letting, according to the circumstances of the case, when there appeared to be more blood circulating to the head than natural; and in cases characterised by deficient tone of the system and by exhaustion, I have exhibited tonic and cordial remedies, both with a view of supporting the energies of life, and preventing ex haustion during the full and requisite operation of the purgatives prescribed. In those cases where increased determination of blood to the head is remarked, the continued operation of purgatives acts beneficially in a twofold manner, they both remove morbid accumulations from the bowels, and they divert the current of circulation from the brain to the viscera on which they act.

Melancholia and mental alienation which so frequently occur in Europeans in warm climates, as far as my experience has extended, have always been benefited by the energetic employment of purgatives. In all these cases, the employment of purgatives brought away most abundant motions of a very dark, tenacious, and offensive description. In some of them, the purgative plan had been continued for many days and even for several weeks before it succeeded in detaching the morbid secretions adhering to the coats of the bowels; but, in every case, disorder began to yield as soon as these were carried off, and the motions to assume a healthy character.

In these cases, the practitioner should not intermit for a single day the exhibition of medicines which tend to evacuate the bowels, and promote the discharge of the morbid alvine accumulation until he succeed in procuring discharges similar to those above alluded to, and in improving the secretions. Nor should he consider, although the colour of the motions may not appear materially morbid, that they are not in other respects very remarkably deranged. They are often very offensive, of a peculiar disagreeable odour, and when minutely examined, they are observed to be tenacious, like bird-lime, of a putty-like consistence, and streaked with various shades of colour. The minute examination of the alvine evacuations is a point of the utmost importance in practice, more especially in the disorders under consideration.

On the presence of Worms in the Large Bowels.—Intestinal worms are very frequently met with in practice within the tropics; and are not only a frequent disease of themselves, but also a cause of other diseases, especially amongst the natives of Hindostan. When occurring amongst Europeans, they are generally the consequence of torpid function of the large bowels, and of accumulations of morbid secretions and fæcal matters in this part of the alimentary canal. Ascarides, lumbrici, and tæniæ, are the kinds of worms most frequently observed, more particularly the lumbrici. They sometimes occasion no marked symptoms; at other times, the usual signs indicating their existence in the prima via are well marked. In the natives of India they are often either productive of various functional and symptomatic disorders, or are complicated with them. Indeed, very vew cases of disease are met with amongst the Hindoo population, where intestinal worms are not found in the alvine evacuations procured during medical treatment.

Cases of asthenia, dyspepsia, colicky pains, diarrhoea, vomiting, pains of the head, of the upper and lower extremities, pains of the