COURSE, DURATION, AND TERMINATION.—Those who are accustomed to experience attacks of biliousness suffer from them at certain intervals which may be tolerably regular—at intervals of a few days, two, three, or four weeks—when the cause is uniform; but they may happen very irregularly when the conditions producing them are variable. The duration of an attack is from two days to a week or more, according to the severity of the symptoms and to the character of the measures instituted for relief. The termination is in a return to the normal state. If the conditions which produced it continue, when one attack is ended the preparations for another begin at once, and at length sufficient derangement of the organs concerned arises to constitute the morbid complexus of biliousness.
TREATMENT.—Prophylaxis has great importance, since the causes of the malady are to a considerable extent, at least, preventable. Errors of diet in respect to the use of condiments, fats, meat, pastry, etc. must be corrected. When there is pronounced gastro-duodenal catarrh and acid fermentation in the duodenum, the saccharine, fatty, and starchy elements of the food must rather be excluded and lean meats allowed. Abundant exercise, bathing, and an open-air life in general should be directed. Whenever a malarial infection is causative a change of climate becomes imperative. Heredity cannot, of course, be excluded, but the tendency to hepatic derangement can be rendered inoperative by an abstemious life.
The remedial management includes the dietetic as well as the medicinal treatment. When the distress has reached sufficient proportions to justify such an extreme measure, the patient should be restricted to a diet exclusively of skimmed milk, of which he is directed to take a gill or more every three hours. This serves a double purpose, as aliment and as a depurative agent, for this considerable quantity of fluid promotes the urinary excretion and the elimination of waste products. If the case is not severe enough to allow of such an expedient, the diet should in any event be restricted to skimmed milk hot, milk and hot water, hot lemonade, a little chicken or mutton broth, a bit of dry toast, etc. As a rule, although not so palatable, hot drinks are more beneficial than cold, but if the preference is decidedly for cold, they may be allowed. After the more severe symptoms have subsided a little lean meat broiled may be added, and as the cure proceeds the succulent vegetables and acid fruits may be permitted. Abstinence from potatoes, hominy, cracked wheat, and oatmeal should be enjoined during the convalescence of those who suffer from habitual attacks.
Medicines may not be necessary to those who have the resolution to adhere to skimmed milk for several days or who can abstain from food altogether for a day. Many experienced sufferers, especially through the South and West and in England, procure rather prompt relief from a blue pill of ten to fifteen grains or from one to five grains of calomel at night, followed by a Seidlitz powder, Rochelle or Epsom salts, or phosphate of soda on the following morning. Such patients find that no other treatment is as serviceable. They get relief from other measures, it is true, but neither as promptly nor as satisfactorily. It is held by the advocates of this practice that the mercurial acts on the liver—that the surplus bile is carried off; and they point to the peculiar stools and to the relief experienced in evidence of the truth of this theory. Without entering on the argument, which would occupy too much space, it must suffice here to state that calomel and blue pill do not increase bile-production,3 but they do stimulate the intestinal glands and increase excretion from them. The peculiar greenish stools produced by these mercurials do not owe their characteristic appearance to the presence of bile, but rather to the chemical transformations of the mercury itself and to the waste products excreted by the intestinal glands. Since the researches of Rutherford have been published, euonymin has been much prescribed in cases of biliousness. From three to five grains are taken at the bed-hour, and a mild laxative in the morning. In the same group of cholagogues are ipecac, iridin, sanguinarin, and especially podophyllin; but the serious objection to their use is that they stimulate the liver when this organ is in an irritable state. As calomel and blue pill have a sedative rather than a stimulant action on the liver, they are more useful in biliousness than are the true cholagogues. It should be borne in mind that one-half of a grain of calomel will have a distinct purgative action on many persons, and that one grain will rarely need to be exceeded.
3 That calomel, the type of a mercurial purgative, does not increase the discharge of bile has been demonstrated on dogs by Röhrig and Rutherford, and confirmed by observation of the effects of 20 grains on Westphalen's case of biliary fistula in man—a case in which, for a time, all the bile escaped externally, and none apparently entered the intestine (Deutsch. Archiv f. klin. Med., 1873, Band xi. pp. 598 and 600).
In general, notwithstanding the unquestionable utility of the mercurial, it is better to relieve cases of biliousness by less objectionable measures. A saline which acts at the same time on the intestines and kidneys, as Rochelle salts, is usually effective in bringing relief. A bottle of solution of magnesia citrate, of Saratoga water (Congress, Hathorn, or High Rock), and of Blue Lick, the famous sulphurous laxative of Kentucky, may remove the disorder in mild cases if at the same time a suitable diet is enjoined. Phosphate of soda in laxative doses, with or without Vichy water, is also a good remedy, if somewhat slow. The warm purgatives, rhubarb, colocynth, aloes, etc., are useful when there is pronounced constipation.
Lithæmia.
DEFINITION.—By the term lithæmia is meant a condition of the system in which uric (lithic) acid is produced in excess, and in which certain derangements occur in consequence of the accumulation of this material in the blood. Uricæmia was the term first suggested by Flint, Sr.,4 to express this state, and subsequently lithæmia was employed by Murchison.5 The latter has been more generally accepted. In one of the most recent and valuable contributions to this subject by DaCosta6 lithæmia is the term used to designate the complex of symptoms produced by uric acid in excess.
4 The Principles and Practice of Medicine, Philada., 1882.
5 Clinical Lectures on Diseases of the Liver, 2d ed., p. 565.