weeks ago to thank us for our successful treatment, and took no small pleasure in directing attention to his altered appearance and renovated health. This is a matter of no common interest; for cases of this description have been generally looked upon as beyond the reach of medical aid. You should, therefore, be very careful in your prognosis of such cases, and not give them up at once as incurable."-(Clinical Medicine, p. 568.)

SECT. IV.-Excessive and Defective Secretion of Bile-Unhealthy States of the Bile.

FROM the diseases just considered, we pass, naturally, to a very important class of disorders-namely, those functional disorders in which too much, or too little, bile is secreted, or the bile secreted is not healthy.

The secretion of bile may be disordered from organic disease of the liver, which renders it incapable of adequately performing its functions; or, without this, when the portal blood, from which the materials of the bile are drawn, is rendered unhealthy by medicines, by unwholesome food, by faulty digestion or assimilation, or by defective action of some other excreting organ. It may probably be disordered, too, by the direct influence of anxiety or strong mental emotion. In any case, the disordered secretion of bile is the effect of some other disease, or of some cause that deranges other organs as well as the liver.

But the bile has a long course before it passes out of the body, and serves an important office in the intestinal canal, and on these accounts, if it be in undue quantity, or unhealthy, however the change in its quantity or quality may have been brought about, it may cause various secondary disorders. In the first place, it may inflame or irritate the gall-ducts, or the parts of the intestine with which it is brought into contact. There is reason to believe that most of the diseases of the gall-bladder and gall-ducts are produced by irritating bile; and there can be no doubt that disorders of the bowels sometimes arise from the bile being in improper quantity, or unhealthy. But, besides these mere local effects, a faulty state of the bile may

render digestion imperfect, and in this way may impair nutrition; and the noxious products of imperfect digestion may be absorbed into the blood, and from this, again, many secondary evils may spring.

Unhealthy states of the bile are analogous to unhealthy states of the urine, and may result in the same way, either from fault of the secreting organ, or from an unhealthy state of the blood. Unhealthy states of the urine have excited more interest, because, from our being able to collect and analyze the urine, we can distinguish them, and trace them to the disease of the kidney, or to the faulty digestion and assimilation on which they depend. They are, some of them, as albuminous urine and saccharine urine, almost pathognomonic of certain fatal diseases which we might not otherwise detect. Unhealthy states of the bile have less importance in this sense, because we cannot distinguish them, and thus trace them to their source; but in another sense they are more important, from the bile serving an important office, and not being merely excrementitial, like the urine.

From our not being able to collect the bile during the life of the patient, and from the difficulty of analyzing what may be found in the gall-bladder after death, we have little knowledge of unhealthy states of this fluid. It is often easy to say, from the symptoms, that too much bile, or too little bile, is secreted, and something is known of the effects of this redundant or defective secretion, but we have little knowledge of changes in the composition of bile, except what is derived from mere inspection.

We may, therefore, first consider excessive secretion of bile; and defective secretion of bile.

Excessive Secretion of Bile.-The quantity of bile secreted, like the quantity of urine, no doubt varies very much, without disorder of health, according to climate, season, and habits of life. In certain circumstances, pointed out in a former part of this work, an unusually large secretion of bile is necessary for the maintenance of health. It can only be considered morbid when, from the abundance of the bile, and perhaps from its being at the same time altered in quality, secondary disorders arise. This frequently happens to persons on their first going to a hot climate. It is of very common occurrence among Europeans in India, and has been well described by Annesley, under the head, "Excessive Secretion of Bile."

In the slighter degrees of this bilious disorder, the patient has purging of bilious matter, which soon produces scalding of the rectum, with slight sickness, a bitter taste in the mouth, and a foul tongue, but without much fever, or the pulse being much quickened. These symptoms rapidly subside, when the redundant bile has been got rid of by an emetic, and by purgatives.

In a more severe form of the disease, together with purging of bilious matter, and vomiting, and foul tongue, there is a good deal of fever, with pain and tenderness in the region of the liver, and the complexion is bilious or dusky. The illness resembles a slight form of bilious fever, and is attended with much congestion of the liver, and, seemingly, with inflammation of the gall-ducts, caused by the bile, which, while it is increased in quantity, is doubtless also altered in quality, and irritating to the lining membrane of the ducts, as well as to that of the bowel.

In such cases, Annesley recommends bleeding from the arm, or cupping over the liver, calomel and saline purgatives, and copious draughts of hot water to dilute the irritating bile. Under this treatment, the patient, in most cases, soon regains his former health.

In this country, the same form of illness is often seen, especially among men of middle age, who have long been in the habit of living freely. Such persons go on for some time, without apparent indigestion or other inconvenience, but, at length, get what is called a bilious attack. This is marked by sickness and bilious diarrhoea, a certain degree of fever, with a feeling of general disorder, perhaps with headache, and by a foul tongue, and turbid urine. In some instances, there is likewise a sense of fulness or uneasiness in the region of the liver, and the complexion is bilious. These complaints are, in most cases, readily removed by brisk purging with calomel and salts, and the patient enjoys again, for some time, his former health. If he returns to his former habits, he, by and by, gets a similar attack, which perhaps is removed as before. In this way he may go on for years, his general good health being only interrupted by an occasional bilious attack of this kind, which, like a fit of gout, seems to clear the system for a time. As was remarked by Dr. Prout, the acid and unassimilated matters seem to accumulate in the system, and to be thrown off periodically.

The readiness with which these attacks are removed often makes people regard them lightly; but they are not unimportant, as evidence of disorders, which, aggravated by time and by continuance in the

habits under which they have arisen, may end in some organic disease, or in the total failure of those assimilating processes on which nutrition depends. During the attacks, signal relief is produced by a dose of calomel, or blue pill, followed by saline purgatives. If there should be pain or tenderness in the region of the liver, and the patient can well bear it, blood should be taken by leeches, or by cupping. These measures are generally sufficient for the time, but they do not strike at the root of the evil. Exemption from future attacks, and from the manifold and greater evils to which these disorders may lead as age advances, can only be procured by a change of habits. One of our objects, in directing this, should be to increase the amount of oxygen inspired, and thus to consume in respiration, or burn off, materials that would otherwise be left for the liver to excrete. The means most efficacious for this purpose are sea-voyages, riding, or other exercise in the open air, well-ventilated rooms, early rising, the cold or shower-bath, &e. Too much indulgence in sleep, which so much reduces the activity of both respiration and circulation, must be especially injurious, more particularly in rooms that are ill-ventilated, as most bedrooms are.

Another object, of equal or still greater importance, should be to limit in the food the supply of those materials-such as spirituous liquors, butter, cream, fat, sugar-which contribute directly to form bile, or which increase the quantity of bile indirectly, by serving as fuel for respiration. Some of those aliments-as cream and porter, for instance-seem to be not only pernicious in this way, but, also, by directly embarrassing the secreting function of the liver.

Plainly enough, it must be especially injurious for persons who suffer from the class of disorders we are considering, to indulge in sleep immediately after a full meal. To lessen by sleep the activity of respiration at the very time when the materials consumed in this process are being poured in large quantity into the blood, must lead in a twofold way to accumulation of bile in the system, and favor the occurrence of a bilious attack. In this way may be explained the ill effects of suppers in disorders of this class, and the well-known fact that a single indulgence of this kind may bring on a bilious attack in a person predisposed to it.

The medicines that are most efficacious are such as tend to promote digestion, and to keep up a regular action of the bowels. A few grains of rhubarb, alone, or in conjunction with a grain of ipecacuanha, taken habitually at dinner; or, if the patient be ple

thoric, occasional small doses of saline purgatives, taken in the morning, are often of service.

Fluids taken in large quantity, in the form of mineral waters, or pure water, have, also, often much efficacy in these disorders.

But our most effective resources are those hygienic regulations, before pointed out, which have relation to the great conditions of air, exercise, and temperature, on the one hand, and to the quantity and quality of the food, on the other. In the degree of confidence he places in these resources, and in the preponderance he gives them over mere drugging in the treatment of disorders of this class, the practitioner will give the best evidence of his real insight into their nature, and of practical skill founded upon it. It adds not a little to the value and importance of these means that they are so free from hazard, and that they act in a way in which no others can act, and therefore have no perfect substitute in any direct medication. By appropriate purgatives, we may temporarily drain the liver and intestines of redundant bile; but by the means here pointed out, we prevent its formation, and attack the evil in its source.

Diminished Secretion of Bile.-But disorder may likewise result from the bile being secreted in too small quantity.

The office of the liver is to purify the blood, by freeing it from the principles of bile, and, by means of the bile, to assist in digestion. The secretion of bile may, therefore, be defective in two respects. Too little bile may be secreted to purify the blood; or, without this, too little may be secreted to perform the necessary part in digestion.

The simplest form of disorder arising from defective secretion of bile is where, while the blood is sufficiently freed from the principles of bile, and the complexion remains clear, too little bile is secreted for the purposes of digestion. In such cases, digestion is performed slowly, and nutrition suffers; the bowels are irregular, and generally confined; the contents of the large intestine often become too acid, or otherwise irritating, and produce headache, or depression of spirits, or occasional diarrhoea.

Disorder of this kind is sometimes the effect of the spare diet to which weakly and nervous persons are often condemned by painful digestion, or uneasiness in the stomach after meals. Many of the evils of this state may be lessened by supplying the place of the bile, as a purgative, by aloes or colocynth; but the disorder will not be removed until the patient is enabled to live more freely.