Acholic diseases : comprising jaundice, diarrhœa, dysentery, and cholera with a preliminary dissertation on bile, the bilious function, and the action of cholagogues

Front matter

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Chapter I. On An Enteric Secretion Of Bile

I. Important distinction between Liver and all other Glands in its Blood-supply — Bile contrasted with Urine — Fallacy of any supposed Analogy between them — Portal System, its Relations considered— “Cholerized” Blood — Pathology of Hiematemesis and Melania — Hyper-Cholerization — Organs chiefly affected thereby. — II. Means of estimating the Biliary Secretion from aspect of Egesta but limited. — III. The Liver not Subsidiary to the Lungs. — IV. Results of Hyper-Cholerized Portal Blood — Constipation not a Result — True nature of Constipation, its Course, and natural Cure — Diarrhoea a Secondary Result. — V. On an Enteric Vicarious Secretion of Bile — Arguments in its favour — Serves to Explain various Anomalies in Pathology and Therapeutics — “ Acholia” — If other Tissues can Secrete Bile, much more the Intestines— How a Purgative, or Cholagogue, Cures a Diarrhoea — Interpretation of Dark-green or Olive-coloured Bile in the Motions.— VI. Source of Enteric Bile — Rudimentary Position of Liver — Intestinal Glands in effect Rudimentary traces of Liver — Opinion of Abercrombie respecting “Bilious” Diarrhoea — Does the Pancreas ever secrete Bile? — Instances of Vicarious Secretion in Disease. — VII. Illustrative Cases pp. 1 — 44

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Chapter II. On The Nature And Properties Of Bile

A Deficiency of Bile a Cause of Irritation and Disease, not an Excess of it — Antiquity of an opposite Opinion — Modern Opinion limited to Mechanical Obstruction as a Cause of Disease — Spasm of Ducts untenable — On the Excessive use of Purgatives — Abscess a consequence— Cases from Annesley — Distinction between an Excretion and a Secretion — Secretions cannot become per se injurious — No General Analogy between Urine and Bile — Elective Property of a Secretion proper — Suspension of an Excretion more fatal than of a Secretion — Consequences of a Suspension of Bile — Constipation— Diarrhoea — Dysentery — Cholera— Argument against Acrimony of Bile, from Pathology of Dysentery — Pathology of all Diarrhoea analogous to that of Dysentery — With these views our Treatment rendered “ rational” — Anomalous Effects of Calomel explained — Abercrombie’s Doubts quoted — Arguments from Nature of Jaundice — Icterus Cholicus and Icterus Choloides — A Condition of Jaundice not incompatible with Health . pp. 45 — 76

Chapter III. On Ciiolagogues And- Their Action

Importance of Liver— Apt to be overlooked — Excess of Bile within the Bowels comparatively harmless — The Secretive Process may, however, injure the Apparatus of Secretion — Injurious results of Over-stimulation — Cirrhosis — Explanation of Nutrition sustained after Function of Liver has expired — Phenomena of Salivation explained — Analogous Eclectic Action of other Medicines — Anomalous Action of Mercurials apparent only, not real — Sedative effect of Calomel in Disease — Liver not very sensible to Pain — Very sensitive to other impressions — Action of a sufficient Cliolagogue — Salivation impossible as long as the Liver is acting freely — Necessity of restraining this Action for that Object — Other sources of Restraint or Suspension — A Liver congenitally, or secondarily, inert — Resistance to Constitutional effect of Mercury a sign of a vigorous Liver — Beneficial action of Mercury in Infants — Absurdity of combining Opium except for a specific object PP- 77—90

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Chapter IV. Jaundice

Recapitulation of the Properties of true and false Bile — The presence in the Blood of the uncombined elements of Bile a source of irritation, as in Diarrhoea, Dysentery, and Cholera — Icterus Cholicus and Icterus Choloides — Intensity of Effect dependent on sudden application of Cause — Pathology of Snake-bites — Sign of favourable Crisis in Jaundice pp- 91 — 102

Chapter V. Acute Dysentery

Acute Dysentery a disease of Constipation — Premonitory or Incubative stage — How arrested — Predisposes to Cholera as well — Stage of invasion — Pathology of this stage — Transition into Chronic Dysentery — Scyhala, their origin — Htemorrhagic Dysentery — Two periods of Constipation ; in the Incubative, and in the Active stage — Pathology of the various forms of Dysentery in fact identical — Rationale of Treatment in Premonitory stage — Ditto in that of Invasion — Impropriety of using Opium — Indications of a favourable result — Importance of understanding these- — How these Sanitary processes are to be sustained — Choice of Remedies for this purpose — Other means of Treatment — Venesection — Leeches — Spongio-piline — Enemata . pp. 103 — 121

Chapter VI. Chronic Dysentery

Pathology — Indications of Treatment founded thereon — The reason that the Treatment is difficult and uncertain — Importance of change — Tendency to a deposit of Eat after severe Abdominal disease — An unfavourable sign — Sympathy between Liver and Stomach — Analogous to that between Uterus and Mammse —

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Treatment by direct Astringents rarely successful — Principle of Cure — To stimulate the Liver ; and, at the same time, astringe the Bowels — Mineral Astringents — Their successful use consonant with the true Pathology of the disease — Their Cholagogue, Astringent, and Tonic properties — Comparison of their efficacy — Use of Nitric Acid — Physiological use of Sugar — Nitric Acid Baths — Enemata of strong Nitric Acid — Regimen — Diet — Abscess in connexion with Dysentery — Not a consequence of Enteric Ulceration — Hepatic Abscess and Ulcerated Bowels both independent consequences of one common cause, namely, of Acholia pp. 122— 142

Chapter VII. On Cholera : Its Nature

Argument. — Cholera is an imponderable matter, or condition of matter ; tellurial in its origin ; existent in and with the atmosphere, but forming no component part of it, being of it as independent as are the rays of light ; attracted by some other matter, or condition of matter, existent in and peculiar to the human body. Where a great space, as a continent or arm of the sea, intervenes, the earth itself may become the conducting medium. But all matter, whether animal, vegetable, or mineral, serves as a conducting medium.

When present (that is, in the atmosphere, or supra-tellurial) it is attracted, and more or less neutralized, by every, even the healthiest, human body. In certain states, however, of the body, varying from health, the force of attraction is stronger, and the process of neutralization also more active and conspicuous. So long as the vital powers are sufficient to keep up this process of neutralization, and so preserve an equilibrium, the system is not overcome by the disease. But, under unfavourable conditions, the powers of life are not adequate to carry on, through the lungs, a continuous process of neutralization. The poison is then, of necessity, conveyed through tho lungs into the blood. Being there, a far more energetic process for its neutralization is required. A violent convulsion of nature ensues, and tho symptoms of “ Cholera” are present PP- 143 — 168

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CHAPTER VIII. ON cholera: its symptoms and treatment

The result of a sudden effect on the Respiratory function — Any other Poison similarly affecting that function might produce the “ Symptoms” of Cholera — Examination of its Pathology — Affinity to Snake-bite — Why there is no visible Jaundice in Cholera — Cholera a violent functional convulsion — Elimination of a Poison by Flux — Conjoint Elimination of Cholremic and Uraemic principles — Causes of the Irritable Condition of the Bowels — Signs of a successful issue — Importance of Alvine indications. — Treatment— Possibility of an Antidote. — None available after access of actual Invasion— Symptoms but manifestations of Nature’s efforts — Must not therefore be suppressed — Rational indications of Treatment — Use of Stimulants — Of Diluents — Of Ice — Of Cajeput Oil — Of Spongio-piline — Of Turpentine — Restoration of suspended Functions — Abuse of Opiates and Astringents — Use of Calomel — Signs of Recovery— Blisters and Sinapisms — Various Remedies of equal efficacy— Fatality of Cholera — Dangers of Premature Interment — Treatment of Premonitory Diarrhoea — Sequelae of Cholera — The results of Cholsemic and Uraemic Poisoning — Dysentery and Cholera distinct diseases 169 — 209

Chapter IX. On Sanitary Conditions

Our knowledge of Sanitary Conditions imperfect— The Human Body the greatest source of Impurity — Not “ Cubic Space,” but “ Area per Man,” must be allotted — Illustrations . . . pp. 210 — 222

Introduction

The beginning of the present century witnessed the apparition of a new and terrible disease. Whilst we watched in silent awe, but still in fancied security, its ravages in a distant quarter of the globe, and saw it decline, sated and exhausted — worn out apparently with its own devouring energy — already its unsuspected march in our own direction was commenced. Scarcely had Hindoo mythology numbered another among its most potent and dreaded deities, when Christian Europe turned aghast to science, in the hope to find some definite knowledge, some tangible conception, of this new and unseen power, this “ pestilence that walketh in darkness,” whose movements are so mysterious, whose advent in the midst of us is wont to be so sudden, and whose stroke is more deadly and swiftly fatal than that of any other malady that history has recorded — a form of approach more appalling than the king of terrors had ever before assumed.

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For the third time in less than half a centurygeneral attention in our own country has been directed, with a surpassing intensity of interest, to this now familiar, hut no less dreaded foe, whose movements, uncertain and capricious though they seem, advancing and receding alternately, like the swaying waves of a rising sea, former experience forbids to regard but with the utmost apprehension ; whilst with the majority of the profession this feeling amounts to a conviction that, in a shape more or less formidable, we shall shortly have to do battle with it here at home.

To them a strenuous appeal on the part of the public, through the medium of the press, has already been made ; and assuredly not in vain. Throughout the land the most earnest and thoughtful among us have been engaged in considering how the coming contest will best be waged. The fruits of former experience, the stores of modern science, and the past thinkings of able men, are all being brought once more to the light, anew to be reviewed, tested, and compared.

But in the midst of this general appeal from the public to the profession, there has arisen one voice,* solitary but strong, of reproach — reproach that our profession has not sustained that high place that our own arrogance had assumed, and that a generous public had conceded — reproach of an

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XV absence of method and logical accuracy in our inductions ; of inconsistency in our practice ; of disagreement amongst ourselves on the first principles, vital and fundamental, of our art. Abler pens have already responded to this undeserved attack ; and I only allude to it here to take the opportunity of pointing out, that a special occasion is probably now at hand, when we shall be enabled by our acts to refute what has been already, and eloquently, disclaimed in words — that part at least of the reproach that taunts us with a want of consistency.

Besides those more obvious sanitary and prophylactic precautions that are demanded for the conservation of a high standard of public health, and of that individual strength that will best enable each one of a community to resist and cope with a surrounding morbid agency, it seems to me much to be desired, that members of our profession generally should have recourse exclusively to such curative means as will accord with their own individual preconceived and settled views of the pathology of disease; so that theory and practice may be seen to go hand in hand. Let the essaying of far-fetched and preposterous remedies be left to empirics, who act under the sordid hope of luckily lighting on a specific that may in a twinkling elevate to fame and fortune — sic itur ad astra ! Even such subordinate and grovelling agencies may not be altogether without their use — melius aliud

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It has always seemed to me that the practitioner, who has an educated and intelligent patient, should be prepared to furnish to him, without technicality, a tolerably clear account both of his disease, and of the principles on which he is being treated. I would not, of course, be understood to imply that such an exposition is in all, or most cases, necessary ; but that the consciousness of an ability to do so will supply to the practitioner’s own mind satisfactory evidence that he is himself acting on common-sense — not to say rational — grounds. What then each individual member of the profession should be able to offer to his own patient we should, as a body, be able, if called upon, to answer to an intelligent public. We should be able to boast that, in our pathology, as well as in our treatment, we pursue those patient and laborious processes of investigation common to, and indispensable for, all scientific research ; guided ever by those acknowledged rules of inductive reasoning that have their foundation in immutable truth.

In an article published in the Lancet of the 7th October, 1865, I attempted to lay before the profession an epitome of my own experience and views regarding the pathology and treatment of Cholera.

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But in the endeavour thus to confine my remarks within the prescribed limits for publication, I felt throughout that I was labouring under a twofold disadvantage ; that, for want of sufficient amplification, I was incurring the risk of being misapprehended, or only imperfectly understood ; and, in default of sufficient illustration, of my views being deemed too crude and speculative for practical adoption.

Besides, in the endeavour to reduce to order and precision the ideas that my mind had in the course of many years — instinctively, as it were, and by an almost imperceptible process of reasoning — imbibed, I found, as many a one before, I suppose, has found (under like circumstances), that these ideas were by no means so definite and distinct as I had imagined ; that, though leading principles might show, clear and prominent enough, subordinate details had to be compared, tested, and worked up into relief. As also might have been expected, I found, in the course of my inquiry, that new channels presented themselves for investigation — suggestions that needed scrutiny, and objections that called for reply.

Amongst the principal of these fresh subjects of inquiry was a degree of affinity, or relationship, that I fancied might be not unprofitably traced between cholera and certain other diseases of the same organs, the investigation of which belief resulted in

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the addition of the chapters on Diarrhoea; and Dysentery, both Acute and Chronic.

Again, another addition has been found scarcely avoidable in the form of two chapters on Bile and the Biliary Function. In the course of my inquiry I found that in connexion with, and in support of, the views I desired to illustrate, a reference to the operations of those viscera more immediately and obviously involved in cholera, was of such frequent necessity as materially to interrupt and thereby confuse the even tenor of my theme. To remedy this, I was at first tempted to transfer all such inconvenient interpolations to the margin in the form of notes. But frequent, and still more lengthy, notes have always appeared to me hut clumsy expedients for associating what the art of the writer has failed harmoniously to incorporate. Nothing can he more trying to the patience of a confiding reader than to be carried along unwittingly through a note of some pages, and then to have, in sporting phrase, to “ hark back,” for the purpose of hunting out his forsaken text, and resuming, as best he may, the interrupted current of his thoughts. I therefore resolved on attempting to collect these cumbrous and unavoidable digressions, and to arrange them into one connected whole, such as would form a convenient and natural introduction to the main topic.

In reviewing, however, these annotations for that

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XIX purpose, I found that by far the largest proportion had reference to the liver, and to the part that great organ performs in health and disease, more especially in connexion with the pathology of cholera. But as it was no part of my plan to enter into a circumstantial account of the structure of the liver, with which I must suppose my readers sufficiently acquainted, hut only to make such general reference to this from time to time as occasion might demand, I found my ground of inquiry thus conveniently narrowed to an investigation of its function, and the product of that function, bile. Other and important viscera are, of course, implicated in cholera; indeed, it would he difficult to indicate any particular structure that is not. I need not now enter on this interesting question; nor will I anticipate my future subject by considering whether the liver he even the organ primarily affected. It may be deemed sufficient here to suggest, that though our acquaintance with the minute structure of the liver is now probably as complete as we possess in respect of any organ of the body, our knowledge of its function, for reasons I need not detail, is comparatively doubtful and imperfect, particularly when we consider its superior size and manifest importance in the economy. Preparatory, therefore, to the study of a disease in which the suspension of the hepatic secretion is one of the most prominent and constant features, it

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did seem very desirable that, if possible, some definite conception should be established respecting that function. In this was necessarily involved an examination of the nature of bile, its use in the economy, and the changes to which it is liable. And since, with this view, a very large proportion of the notes, as already stated, had had reference to the same subject, it seemed most natural and convenient to combine them, so as to form the two chapters alluded to on Bile and the Biliary Function. And in connexion with the same topic, a third short chapter has been introduced on the action of Cholagogues. Finally, and as a sequel to the subject of cholera, a few suggestions have been appended “ On Sanitary Conditions/'’ It is hoped that these various additions will not be regarded as superfluous ; but rather that some of the questions from time to time arising may serve to interest, even if the arguments adduced should not serve to convince, the reader.

Thus I have endeavoured to account for the origin and growth of the present treatise. And all imperfectly as I am sensible that my purpose has been earned into effect, I throw myself on the indulgent perusal of my brethren, trusting that my having attempted the task — pro tenuitate med — will, at least in part, be excused on the following grounds.

In the first place, I think it will, without much

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XXI hesitation, be conceded that, with regard to the nature, pathology, and treatment of cholera, a remarkable want of unanimity prevails. Of its specific nature, including its mode of progression, communication, increase, and exhaustion in a community, I think I may venture to assert that no consistent theory has ever been broached ; affirming this, on the broad ground, independent of reasons in detail, that no one of these theories has stood the test of accounting for all that has under those heads been observed ; whilst the same objection applies to the conflicting views respecting its pathology, these being singly insufficient to account for the whole of the objective symptoms, which in this, above all other diseases, are marked and constant ; differing only, as I hope to show, in intensity.

But when we come to the treatment, a still greater perplexity and confusion are conspicuous. It is not so much that every known remedial agent of any power has been tried in succession, and successively vaunted as possessing supreme claims, and a special virtue in control of the disease; this perhaps is incidental to the practice of an art so uncertain and so necessarily tentative as medicine, and not peculiar to the treatment of cholera. Besides (as before observed) that the results of even such indiscriminate and empirical practice are doubtless being carefully noted by the more

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sagacious and reasoning few, and by them utilized to a more perfect knowledge of the subject.

It is not, then, so much this variety of treatment that I refer to, as to a want of concord and logical relation between treatment and pathology — that these various remedies have often no necessary and obvious connexion with some special pathology entertained by those who use them, or with any pathology whatever ; but are resorted to tentatively by one, because in the hands of another a certain proportion of cases has, under such means, got well ; seemingly unmindful of the fact that an equal success, and under equally high authority, has elsewhere been recorded under a totally opposite treatment — nay, that possibly quite as many would have recovered without any treatment at all.

To the younger, therefore, of my professional brethren I would respectfully tender the counsel not to allow themselves to be fascinated by brilliant results recorded on paper, and to be especially mistrustful of figures and facts so called. These last are not nearly such stubborn things as is popularly supposed, but accommodate themselves with a marvellous pliancy to foregone conclusions. I would remind them that the noblest men of our profession in this country — those great and familiar names that stand out on the historic page with a lustre that renders needless enumeration — those lights of science have not much troubled the world with

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figures. For their proofs they have resorted to well-known and admitted facts, or to such within their own knowledge as allowed of personal experiment and verification on the part of their readers; and as for their convictions, the slow growth of multiplied experience conjoined with profound powers of observation, these have been always stated broadly and boldly, unbolstered by figures, and bearing on their face the unmistakable impress of united genius and truth.

I would, therefore, counsel them to be servile followers of no self-constituted authority — nullius addicti jurare in verba magistri — but to endeavour, in the treatment of this, as of all other disease, to form a clear and distinct conception of the object they have in view, of the means they propose to employ, and of the physiological grounds on which then’ expectations of success are based. Even if wrong, the notion of being right imparts to a man's actions a certain vigour and decision that is in itself a very important element of success. “ Let every man/' says St. Paul, “ be fully persuaded in his own mind" — advice no less sound in its application to secular, than it is to spiritual, matters.

To prevent, therefore, any misconception as to the purport and scope of the present work, I may as well, in limine, premise that I have no new remedy to propose, no new special treatment to recommend, which is to be persisted in under all

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conditions, and in every aspect, phase, or stage of the disease. My object — and I imagine it is my duty as well, for qui novit, neque id quod sentit, exprimit, perinde est ac si nesciret — is rather to lay before the profession the results of upwards of twenty years' experience and attentive observation of cholera and kindred diseases in India, with the conclusions I have arrived at respecting the rationale of treatment that it will he most prudent and safe to adopt ; leaving it open to myself as well as to others to have recourse to any remedies that may he used in consistency with those general indications, with an assumed pathology of the disease, and, above all, with the curative process of Nature herself.

Nor, perhaps, should I have considered myself sufficiently warranted, by the circumstance alone of having seen much of disease, to obtrude my observations thereupon, were I not at the same time impressed with a belief that some of my views, whether true or otherwise, have at least novelty to recommend them to the curiosity of the reader. From this character of novelty it also naturally follows that I have not often had occasion for, or possessed the advantage of, quoting the opinions of preceding medical writers, my conclusions being destined to stand or fall on their own merits ; whilst, on the other hand, I have not hesitated to select, wherever I could find them,

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XXV such authentic and commonly received facts as seemed concurrent with my own experience, or corroborative of the views I entertain — quod hausi concoquens .

I might, indeed, have quoted several facts and observations within my own personal experience that have, in the course of many years, contributed to the development and formation of the theoretical views that I now submit for the judgment of the profession ; but I think it will be found that I have consistently refrained, when engaged in such discussions, from adducing these or any other data, that rested solely on my own evidence, or on that of individuals. For I hold that, in the establishment of any general law in natural science, the propounder is bound to use such arguments only as can be referred to universal experience and testimony. It is also evident that rare and exceptional circumstances, even when of undoubted authenticity, are admissible in illustration only, not as demonstrative. I have accordingly confined myself, in such inquiries, to those familiar and generally admitted phenomena, that are within the scope and knowledge of every well-educated medical reader.

It would also have been easy, availing myself of precedent and custom, to have swelled this little work to double its present size, by a “judicious” selection, at the end of each chapter, of “ cases.”

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But my aim lias been rather to condense than to amplify ; and I imagine the reader will not be slow to excuse this omission.

Further I would remark, with respect to many of the theoretical views propounded in the following pages, that they are submitted with a perfect sense of them manifold defects, and palpable points of weakness. But at the same time I would venture to suggest to my more critical readers, that no “ theory,” properly so termed, can be expected to stand the test of absolute analysis, or can be founded wholly on facts. “ Theory,” indeed, has its perfect synonyme in “ speculation.” And a “ theory” based absolutely on facts would cease to be a theory — it would be a truth. But when, by means of a theory, there is furnished a consistent way of accounting for phenomena, whose real nature and origin is obscure, such a theory may be conveniently adopted, in the absence of more exact knowdedge. A theory may be even manifestly untrue, and yet of great practical value. No one supposes that the atomic theory is true, much less founded on ascertained facts ; but it is nevertheless adopted universally for its convenience and simplicity, and for its apparent consistence with known phenomena.

Theories arc indeed the inseparable accompaniments of an inexact science, such as medicine. By their judicious selection, however, and condi-

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XXV11 tional adoption, and by keeping them steadily in view, the physiologist is enabled to practise bis art, not blindly or empirically, but on principles that are at least intelligible, and that admit of definition. As already said, a theory must be regarded as a substitute only, and preliminary to more exact knowledge. With the growth of a science, theories once accepted as plausible are laid aside — a temporary scaffolding, to be taken down as the building itself acquires strength and permanence. A striking illustration may be found in the history of geology, and in its development as a science, within our own times.

I would express, therefore, a hope that, in the event of my failing, as is but too probable, to convey conviction, something of what I have thought and said may haply be found suggestive, and thus prove in other hands instrumental to the further advancement of truth. I would fain, also, think that other and more cogent arguments in support of my own views, and other and more striking illustrations, may not impossibly occur ; whilst it need scarcely be added, that any such aid will ever be gladly recognised, and gratefully acknowledged.

From the prospective tenor of the above “ Introduction/’ and from corresponding remarks in the chapters on Cholera, it will be seen that they

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were penned some time since, and whilst the advent of cholera was still a contingency only. But publication has been delayed by want of leisure, in consequence chiefly of domestic circumstances, that called for all the author’s attention. A condensed sketch, however, of his views on the Nature of Cholera having appeared as far back as October, 1865, in the pages of the Lancet, the article containing them is appended at the end of the work.

Chapter I. On An Enteric Secretion Of Bile

I. Important distinction between Livev and all other Glands m its Blood-supply— Bile contrasted with Urine— Fallacy of any supposed Analogy between them — Portal System , its Relations considered—“ Cholerized" Blood— Pathology of Hcematemesis and Melcena — Hyper-Cholerization — Organs chiefly affected thereby. — II. Means of estimating the Biliary Secretion from aspect of Egesta but limited. — III. The Liver not Subsidiary to the Lungs. — IV. Results of Hyper- Cholerized Portal Blood — Constipation not a Result — True nature of Constipation, its Course, and natural Cure — Diarrhoea a Secondary Result. — V. On an Enteric Vicarious Secretion of Bile — Arguments in its favour — Serves to Explain various Anomalies in Pathology and Therapeutics — “ A cholia" — If other Tissues can Secrete Bile, much more the Intestines — Hov) a Purgative, or Cholagogue, Cures a Diarrhoea — Interpretation of Dark-green or Olive-coloured Bile in the Motions. —