remarks, showing the forms of ailment more generally met with in practice, proceeding either from an increased or disordered condition of bile; and, in the second place, make a few observations upon certain points connected with this department of pathology, and upon the measures which should be adopted in order to moderate the exuberance of this secretion, when in simple or morbid

excess.

seldom takes place without a During an exuberant flow of

First, increased secretion of bile change from its healthy characters. this fluid, a considerable portion of it is conveyed into the gallbladder, where it undergoes important changes, and acquires more acrid properties. With an increase of secretion also, an augmented flow of blood generally supervenes; for, conformably with the laws generally observed to obtain in the animal economy, there can be no increase of secretion without an augmented supply of the fluid or materials whence such secretion is derived. This augmentation in the flow of blood is frequently still greater when the secretion is possessed of acrid and stimulating properties: for acridity is productive of irritation; and wherever irritation exists, an increased afflux of the circulating fluid is the necessary consequence.

This increased afflux of blood may amount, to what is usually called active congestion, or increased determination, in the first instance; and this state, if not arrested by treatment, or not subsiding spontaneously, may run on to inflammatory action, differing in degree according to the peculiarities of individual habit and temperament, and the circumstances of the case. But the increased determination of blood to the liver is not always to be considered as a necessary consequence of an increase of the biliary secretion, although I believe that more generally active determination of blood either precedes or is consequent upon an augmented secretion of bile. From a close inspection of the appearance of the blood, when taken from a vein during the premonitory stage of intertropical diseases, and a comparison of it with the blood drawn afterwards, when a full secretion of bile had been for a considerable time going forward, I am satisfied that, in the first stage of disorder there existed certain materials or elements in the circulation which were incompatible with the healthy discharge of the functions, and upon the presence of which a great share of the disorder seemed to depend. My attention was first attracted to this subject, many years ago in Hyderabad, when bleeding a man suffering under acute rheumatism, attended with a torpid state of the liver. In this case the blood presented a very dark or pitchy tinge, with an oleaginous

appearance on the surface,-characters which disappeared after the actions of the liver had been for some time established. The result in this case raised a belief in my mind, which much experience has fully confirmed, that those materials or elements whence bile is formed existed in the blood greatly in excess upon the first occasion of depletion, and were productive of much constitutional disturbance; and the very copious discharge of green bile, which is generally observed to follow upon this dark and thick state of the blood, resulted from the abundant supply of the constituents of the bile which this condition of the blood furnished to the liver. When the functions of the lungs and of the liver become diminished at the same time, the one owing to a permanent cause-the high range of temperature, the other to temporary and accidental circumstances, whilst the blood continues to receive that exuberant and rich supply of carbonaceous and hydrogenous materials which animal food furnish, the supervention of much serious disease cannot be doubted, and in general it first makes its appearance in disorder of the hepatic functions.

During the first impression of the exciting causes of disease, and for some time afterwards, the nervous system has its energies greatly impaired; and this state is more remarkably observed during the premonitory period of disorder, which answers to the cold stage of fevers. In this state of disorder the functions of all the viscera are considerably diminished, and, consequently, those changes which are effected upon the blood by the secreting viscera are but imperfectly performed. Congestion of the blood in the large veins and internal viscera, frequently supervenes; and during this state, the venous character of the blood, and the predominance of its carbonaceous and hydrogeneous elements become still further increased; so that if the powers of life did not re-act under the load of congestion by which they are nearly overwhelmed, and thus enable the great secreting viscera to re-establish their functions, and remove a great share of the cause of disorder, life would soon become extinct. In many cases, when the efficient cause of disorder is very powerful, and the venous characters of the blood decidedly marked, and attended with extreme congestion of the internal viscera, the powers of life actually sink under the load, without any effort, or with very inefficient efforts to remove it. Such instances are met with in the cold fit of some agues, when the constitution of the patient has been much impaired, and in the early stage of the epidemic cholera. In the latter disease, the blood taken from a vein possesses the venous characters in the highest

degree; and even the blood flowing from an artery, at the time when internal congestion is at its height, presents well-marked venous characters. In such cases, the efficient causes of disease affect the energy of the nervous system, and co-operate with the influence of climate upon the circulation in impairing the activity of the eliminating and secreting functions of the internal viscera, and in diminishing the purity of the blood; and this impure state of the circulation, and the accumulation of hurtful materials existing in it, unfit it for the offices it is destined to perform, and further tend to perpetuate, and even to increase, that condition in which its own disorder depends, and to annihilate at last the powers and functions of life.

When sufficient energy remains in the system to enable the chief secreting viscera to act, to carry forward the blood circulating towards them, and to form those secretions which it is their office to elaborate from the blood,—and upon the due elaboration of which the pure and healthy state of this fluid depends, the healthy actions of the system are restored, and the animal machine assumes its usual tenour of action, if no part of its very complex organisation have received injury during the struggle.

Not only may the purity of the circulating mass be affected in the very general way now argued for, and of which familiar instances may be adduced from amongst fevers, cholera, and dysentery, but owing to causes acting in a partial manner, or to a limited extent, upon the economy, the circulation in particular organs, or in a particular series of vessels, or in the branches of a particular venous trunk, may assume appearances of impaired purity, and may possess the venous characters, as respects darkness of colour and diminished state of fluidity, in a much greater degree than the blood circulating in other parts of the system. From the appearances of the fluid when drawn by leeches and scarification, in different parts of the body, when suffering under symptoms of congestion, or of its opposite, increased arterial action, I am fully convinced that very dissimilar states of the circulation may exist in different parts of the body at the same time, as regards its sensible properties. Blood, for instance, drawn in the vicinity of, or from a part suffering under congestion of its veins, will be possessed of very distinct characters from that taken from another part even near to the same spot, in the same individual, where no such interruption or congestion is present. This is a point which must be familiar to every experienced practitioner, and is of more importance than has been commonly attached to it; for, in cases

where local congestion is considerable, the same dangerous consequences, which have been already stated as sometimes supervening upon a general state of venous congestion and vascular impurity, may supervene locally, and the functional capabilities, or even the vitality of the part, may suffer from the distension, and the condition of the blood with which it is loaded. In such cases, as indeed in the majority of those in which the vascular system is more generally affected, and the blood itself loaded with effete and noxious elements, the object is to promote circulation, at the same time that we attempt, by exciting the secreting viscera to increased action, to procure the discharge of the hurtful materials. Hence it is that general depletions, in a warm climate, are beneficial when the evil is extensive; and local evacuations, when a single organ or set of vessels suffer the chief load of disorder.

During the period of increased secretion of bile, the irritation occasioned by the flow of the stimulating fluid along the mucous surface of the alimentary canal will be productive, in many cases, of much constitutional disturbance,-will occasion great thirst, giddiness, and pain in the head,-an accelerated pulse, and a white tongue, thus giving rise to the phenomena which characterise a slight attack of fever, and even to those of bilious inflammatory fever.

SECT. II.-On the Treatment of Increased Secretion of Bile.

From what has been already advanced, it will be seen that the thick and rich blood of Europeans, loaded as it is with an excess of those materials or elements of which bile is composed, forms the immediate and principal cause of hepatic disorders amongst them; and that this state of the circulation prevails in consequence of a diminished change being effected upon the blood by respiration, compared with that which it undergoes in cold or temperate climates, and of the copious supply of these elements conveyed into it from the mode of living followed by Europeans residing in warm countries. It follows from this, that in order to procure exemption from those ailments, the European visiter or residenter in a warm climate should conform his diet and regimen so as to moderate or diminish the excessive supply of chyle, and should live principally upon those articles which, while they convey sufficient nourishment to the body, contain but little of those elements of which bile is constituted. The observations which have been already offered upon the subject of diet, and the mode of living there recommended, if at all closely followed, will prove as bene

ficial in this point of view as any thing that may be further advanced upon the subject.

When bile is secreted in an excessive manner it often possesses very acrid and stimulating qualities, particularly if retained for any time in the gall-bladder and biliary ducts; it is, therefore, essential to dilute it, and thus to render it less irritating during the time it is passing through the system; at the same time that attention should be directed to guard the mucous lining of the intestinal canal from the injury it may experience from the flow of a highly stimulating fluid, and particularly from its retention in any particular part of the canal. For this purpose, ipecacuanha emetics are useful when there is no determination of blood to the head, or any peculiar irritability of stomach to contraindicate their employment. Emetics ought to be followed by copious draughts of weak tea or of warm water; and afterwards, emollient draughts, with the sub-carbonate of soda, effervescent draughts, &c., may be given with advantage. Amylaceous and other emollient enemas, will prove most serviceable in obviating the effects of acrid bile on the intestinal canal ; and laxatives of a cooling nature, such as the supertartrate and tartrate of potass, will always be found useful. When, however, the disordered biliary secretion is impeded in its course downwards, purgatives will generally be required to bring it away with the requisite celerity; for if it be allowed to remain in any particular part of the tube, serious disorder may be induced by it in the mucous tunic of the part.

It very frequently happens, that during an increased flow of bile, the mucous surface of the intestinal canal, and even of the stomach, when the bile regurgitates into this viscus, suffers considerable irritation, even amounting to inflammatory action, from its irritating properties. In such case, the patient generally complains of pain, either in the situation of the duodenum, in the stomach, or in the intestines. When this is observed, cupping or the application of leeches should always be resorted to, in addition to the other means already noticed. The pain and uneasiness produced in the duodenum, in consequence of the inordinate flow of an irritating bile into this viscus, is, owing to the situation of the parts, often mistaken for pain and inflammation of the liver itself. This is, however, a matter of subordinate consequence in a curative point of view; for the treatment suitable in the one case is by no means inappropriate in the other. In a diagnostic point of view, it is otherwise; and yet, in a warm climate more particularly, it is almost impossible to distinguish between the one and the other. It is true, the expe