of inspissated bile are deposited along the larger hepatic ducts, and
form in consequence of a deficiency in the amount of glycocholate and
taurocholate of soda, two methods of treatment are to be carried out:
free purgation by an active cholagogue to wash out the offending
substance, and the exhibition of a soda salt to promote the alkalinity
of the bile and the consequent solution of the bile-pigment. Harley's
method, which he strongly urges, consists in the administration of "one
or two drachms of sulphate of soda in a bitter infusion every morning
before breakfast, or from twenty to thirty grains of bicarbonate of
soda, along with a drachm of taraxacum-juice in a bitter infusion,
every night at bedtime at regulated intervals for a month or so,
according to the constitution of the patient and the severity of the
symptoms."
As persons who suffer from inspissation of the bile are naturally
bilious, it is of the first importance in the prophylactic treatment to
regulate the diet. Indulgence in malt liquors, in fatty and saccharine
articles of food, must be forbidden. Acid fermentation in the course of
duodenal digestion should be prevented by withholding the starches and
sugars. Peptonized foods, given with an alkali, are highly useful.
Milk, fresh meat, and the succulent vegetables are the proper
constituents of a diet for these subjects. Bread is one of the most
offending articles, and should be restricted in amount as much as
possible.
Next to a suitable diet, systematic exercise is a measure of the
highest utility in these cases. A daily morning sponge bath of a weak
alkaline water not only maintains the skin in a healthy state, but also
promotes the oxidation processes of the body. The alkaline mineral
waters of Wisconsin, Michigan, Virginia, and other States, especially
of the Bethesda Spring of Wisconsin, may be drunk with great advantage
to accomplish the same purpose.
{1080} We possess direct means for preventing inspissation of the
bile--remedies which act in the physiological way by increasing the
proportion of glycocholate and taurocholate of soda. Harley prefers the
sulphate and bicarbonate for this purpose, but my experience is in
favor of the cholate and phosphate of sodium, especially the latter;
for, whilst it plays the part of a soda salt, it exerts a decided
cholagogue action, thus effecting the results achieved by the combined
use of sulphate of soda and taraxacum. A cure may be confidently looked
for in this malady by the persistent use of sodium phosphate--drachm j
ter in die. It seems to act more efficiently when given dissolved in
hot water.
The paroxysms of hepatic colic due to the passage of inspissated bile
are to be treated in the same way as when this condition of things is
caused by the migration of formed calculi. The action of cholagogue
purgatives is more decidedly beneficial in the attacks due to the
passage of inspissated bile.
Biliary Calculi in Situ.--Notwithstanding their crystalline form and
firmness of texture, it is possible to effect the gradual solution of
biliary calculi. Outside of the body it is easy to dissolve a calculus
in chloroform, in Durande's remedy, etc., if time enough be given, but
the problem is a far more difficult one when the calculus is in
position in the gall-bladder or in a hepatic duct. As Trousseau[185]
has wisely observed, it is not safe to apply to conditions within the
body conclusions reached by experiments in the laboratory.
Nevertheless, facts are known which justify the belief that an
impression may be made on concretions in the gall-bladder. The motion
of respiration and the voluntary actions of the abdominal muscles cause
more or less attrition and breaking off of the angles and margins of
the crystals, thus permitting the solvent action of the bile. If,
however, the bile continues in the state in which it was at the time of
the crystallization of the cholesterin, it will make no impression on
this substance. We have now the means of restoring its power to
dissolve crystallized cholesterin. As a necessary preliminary, fracture
of the crystals must be effected. This may be accomplished, when the
natural forces have failed to effect it, by manipulation of the
gall-bladder through the walls of the abdomen, but especially by
faradization. Excellent results have been achieved by this
last-mentioned expedient, but no satisfactory explanation has been made
of its methodus medendi, unless we accept the mechanical effect of the
muscular movements. In applying the faradic current an electrode is
introduced into the rectum, and the other, a sponge well moistened, is
placed over the gall-bladder. An interrupted galvanic current is
indicated, the electrodes in the position just mentioned, when a
migrating calculus is stopped on its way. Such an application has
rendered important service in a few cases.
[Footnote 185: _Clinique médicale de l'Hôtel Dieu de Paris_.]
Except that calculi have been found in a state of decay, their angles
and edges broken, divided by cleavage, there is no evidence that they
have undergone solution when in situ, except the clinical evidence
which consists in a disappearance of the symptoms. The remedy of
Durande, which consists in a mixture of ether and turpentine--three
parts of the former and two of the latter--has been celebrated since
the close of the last century, and is yet much employed in France,
notably at Vichy. It {1081} is preferred by Cyr,[186] who advises its
administration in capsules taken immediately before meals. Chloroform
readily dissolves calculi out of the body, and hence it has been
proposed, and indeed much used, for the purpose of effecting their
solution in the gall-bladder; but, as Trousseau urges, there is no
warrant for the belief. Corlieu,[187] who first proposed its use, and
afterward Bouchut,[188] maintained that chloroform does exert this
solvent action, and reported cases in confirmation; but there are so
many sources of fallacy that such evidence must be viewed with
suspicion. It has usually been administered in small doses (five
minims) three times a day for a long period. That it is beneficial by
stimulating the flow of pancreatic secretion and by allaying spasms is
probably true, but that any quantity which can be administered in
safety will act as a solvent of cholesterin concretions cannot be
believed.
[Footnote 186: _Traité de l'Affection calculeuse du Foie_, p. 287.]
[Footnote 187: _Gazette des Hôpitaux_, 1856, June 19.]
[Footnote 188: _Bullétin gén. de Thérap._, vol. lxi. p. 49.]
If solution of hepatic calculi is possible under any circumstances, the
most rational mode of effecting it would seem to be to restore that
condition of the bile which in the normal state maintains cholesterin
in the state of solution. Cholesterin is precipitated and crystallizes
about a nucleus when the glycocholate and taurocholate of soda are
deficient in amount. The agents most effective in restoring the solvent
power of the bile are the salts of soda, of which the sulphate is
preferred by Harley. In 1873 the cholate of soda was brought forward by
Schiff, who prescribed it in doses of 50 centigrammes (8 grains nearly)
three times a day, to be gradually increased until digestive or
circulatory troubles arose. This remedy, which is eminently rational
from the point of view above indicated, has apparently been of decided
service in many published cases and in the writer's experience. It will
be found, however, that five grains three times a day is as large a
quantity as can be easily borne.
Another soda salt which in my own hands has proved in a high degree
effective is the phosphate. As has been explained when referring to its
use in cases of disorders due to inspissated bile, it has a distinct
cholagogue action, but the chief sources of its utility in this
affection are its chemical and resolvent powers. The usual quantity is
one drachm three times a day, dissolved in sufficient warm water.
Bile itself, in the form of inspissated ox-gall, was formerly much
used, a scruple to a drachm being given three times a day, and not
without good results. It was also prescribed with chloride of ammonium.
For the gastro-duodenal catarrh and the accompanying catarrh of the
bile-ducts this combination is sometimes useful.
I have recently proposed a new expedient for effecting the solution of
hepatic calculi. This method consists in puncture of the gall-bladder
with a fine exploring-trocar, and the injection through the canula,
after withdrawing the stylet, of a suitable solvent. Durande's remedy,
chloroform, and other solvents can be introduced in this way without
injury to the parts. I have punctured the gall-bladder, removed its
contents, and explored its interior without damaging the organ in any
way and without leaving after traces. The measure proposed offers no
special difficulties in its execution.
The Paroxysms of Hepatic Colic.--The pain of hepatic colic being {1082}
the most acute suffering known to man--in its severest form at
least--the most powerful anodynes are required. The measures employed
for relief of pain happen to be the most efficient for promoting the
expulsion of the calculus and for limiting, if not preventing, the
subsequent inflammation. As soon as the character of the seizure is
manifest a hypodermatic injection of morphine and atropine--1/8 to 1/2
grain of the former and 1/200 to 1/80 grain of the latter--should be
given; ether administered by inhalation if necessary; and by the
stomach chloroform, chlorodyne, or chloral. As the stomach is usually
exceedingly irritable, the subcutaneous injection of remedies is a
precious resource: this failing or contraindicated, relief may be given
by the rectal injection of laudanum or chlorodyne. As relief is often
afforded by the act of vomiting, the attempts to empty the stomach
should be encouraged, and to this end large draughts of warm water
should be given. Hot fomentations and mustard plaster should be applied
over the right hypochondrium, and an entire warm bath may be used if
available.
Great relief is usually afforded by the action of purgatives. The
irritability of the stomach forbids the employment of drastic
purgatives, yet podophyllin resin is warmly commended by Dobell. It
must be given in small doses, and preferably dissolved in spirit.
Calomel in one-grain doses, every four hours until it purges, allays
nausea and lessens the after-uneasiness in the right hypochondrium, but
mercurial treatment given with a view to a supposed cholagogue effect
only does evil by prolonged administration, especially if ptyalism is
induced. If evidences of portal congestion are present, such remedies
as euonymin, iridin, baptisin, and others of the cholagogue group give
good results. The most effective of the remedies of this kind is
ipecacuanha, given in purgative doses: the emesis induced by it favors
the extrusion of the stone, and the powerful cholagogue effect relieves
the portal congestion. Twenty grains at once, and repeated if need be
in three hours, is a suitable quantity.
The various complications which may occur, and the results which follow
the migration of the calculus, require treatment adapted to the
conditions existing, and will be mentioned in the sections devoted to
these topics.
Occlusion of the Biliary Passages; Stenosis of the Ductus Communis
Choledochus.
DEFINITION.--By occlusion of the biliary passages is meant an
obstruction, internal or external, of the hepatic, cystic, or common
duct. The causes of the obstruction are various, but the results are
quite uniform; hence the term includes a complexus of symptoms of a
very distinctive type. Occlusion may be congenital or acquired: it is
the latter with which we have especially to deal.
Stenosis signifies a narrowing which in its extremest form produces a
nearly complete obstruction; when the canal is entirely closed the term
occlusion is applied. Stenosis also may be congenital or acquired.
PATHOGENY.--The conditions producing narrowing of a hepatic duct or its
complete obstruction are numerous, and some of them complex in their
relations. As regards the ducts themselves, the interference may {1083}
be entirely within the canal, or it may affect the walls, or it may be
wholly extraneous; as, for example, when a cancer of the pancreas
encroaches on the common duct. It will be convenient to consider the
causes of stenosis and obstruction from these points of view: 1,
internal; 2, of the duct walls; 3, extraneous.
The most usual situations for the occurrence of those changes that lead
to occlusion by inflammatory adhesions are the beginning of the cystic
duct, obstruction of which is of little moment, and the end of the
common duct, which finally proves fatal.
The passage of a large polyangular calculus may cause such irritation,
abrasion of the epithelium, and subsequent inflammatory exudation as to
effect a direct union of the opposing sides of the canal. This takes
place at the beginning of the cystic duct especially, since, owing to
the spasm of the gall-bladder and the absence of muscular fibres in the
walls of the duct, the stone crushes into, without passing through, the
canal. The inflammatory exudation thus excited may close the duct. Not
unfrequently the gall-bladder, full of calculi, is thus shut off from
the liver permanently. In one instance the writer has seen a calculus
wedged into the orifice of the cystic duct, whilst just beyond the
lumen was permanently obstructed by an organized exudation. Permanent
closure of the cystic duct is of far less consequence than of the
common duct, and may, indeed, be a conservative condition, as in the
case above mentioned, where numerous polyangular calculi may have
migrated, except the closure of the passage.
The most usual point of obstruction in the course of the common duct is
the intestinal end, but various processes are employed to effect it.
The first in importance is catarrhal inflammation. This seems the more
credible when it is remembered that to a simple catarrh of the mucous
membrane is due the temporary stoppage of the duct, producing jaundice
in much the largest proportion of cases. When the epithelium is
detached and granulations spring up from the basement membrane,
adhesions of the surfaces will readily take place, and the union may be
so complete as that all traces of the duct will disappear. It is
probable that in many, if not in most, of these cases the initial
condition of the canal is that of simple catarrh, the more positive
changes in the mucous membrane arising from peculiarities in the
tissues of the individual affected, or from local injury caused by the
passage of a concretion or irritation of pathological secretions of the
duodenum.
Stenosis, and finally occlusion, of the common duct may arise from the
cicatrization of an ulcer. Such ulcers may occur in several modes. They
may result from catarrhal inflammation of a chronic type, much new
connective-tissue material forming, and in the process of
cicatrization, with the contraction belonging to it, the lumen of the
canal is so far filled up that the passage of bile is effectually
prevented. They may be produced in that state of the tissues which
accompanies certain cachectic and profoundly adynamic conditions, as in
severe typhoid fever. Such ulcers may also be due to the mechanical
injury effected by the migration of a gall-stone. In cicatrizing, a
tight stricture, impermeable to the passage of bile, may result, or the
lumen of the canal be entirely obliterated. In the latter case the duct
itself may disappear and leave no trace. An ulcer situated at the
duodenal end of the common duct and extending into the {1084} duodenum
may also in the process of healing so contract as to render the orifice
impermeable to bile. The same effect may follow the cicatrization of an
ulcer of the duodenum in the immediate vicinity of the orifice of the
common duct.
Without the intervention of an ulcer as a means of explaining closure
of the common duct, this accident may be caused by a catarrhal
inflammation which effects denudation of the basement membrane, and
thence union may be produced by the mere contact of the
freshly-granulating surfaces. Congenital occlusion of the bile-ducts or
obstruction occurring in a few days after birth, it is probable, is
effected in this way, but no direct evidence of the process has thus
far been offered. During intra-uterine life, as at any period in
after-life, it seems necessary to the production of such changes that a
peculiar constitutional state must exist; otherwise, such a result
might happen to every case of catarrhal inflammation of the bile-ducts.
The extent of the changes is further evidence in the same direction;
for not only are the walls of the duct in permanent apposition and
adhesion, but the duct degenerates into a mere fibrous cord, and in
some instances is nearly, even entirely, obliterated.[189]
[Footnote 189: _Ziemssen's Cyclopædia_, p. 589.]
The cystic or common duct--the latter to be chiefly considered--may be
occluded by the retention in its lumen of some foreign body. The
impaction of a biliary calculus has already been repeatedly referred
to, but there are some additional points demanding consideration. The
larger concretions may be stopped in the neck of the gall-bladder;
those small enough to enter the canal may be arrested at its bend
behind the neck, and the very entrance of the cystic duct may be
blocked, as in a case examined by the writer.
The hepatic duct is very rarely permanently occluded. As the calibre of
this canal continuously enlarges downward, there is no point at which a
stone is likely to be arrested; nevertheless, it occasionally happens
that such an obstruction does occur. An example has occurred under the
observation of the writer, but the cause was a gunshot wound of the
liver.
The most usual, and for very obvious reasons the most important, of the
sites where occlusion occurs is the common duct and at the termination
of the duct in the small intestine, the intestinal orifice. Just behind
and to the right of its orifice the duct is dilated into a fossa--the
diverticulum Vateri; and here concretions of a size to pass along the
common duct are stopped. It is not essential that the stone fit the
canal: it may do so and prevent any bile passing into the duodenum; it
may be a polyangular body, and, though wedged in, leave spaces through
which more or less can slowly trickle. The symptoms will be modified
accordingly. Again, the diverticulum may contain numerous concretions,
which distend the canal greatly, but through the interstices of which
some bile can flow.
Other foreign bodies very rarely close the intestinal end of the ductus
communis; thus, for example, a cherry-seed, a plum-seed, a mass of
raisin-seeds, may slip into the orifice after the passage of a
gall-stone has stretched it sufficiently. A much more common cause of
occlusion is an intestinal parasite, which crawls in and is fastened.
The common round-worm is the most frequent offender, and much less
often liver-flukes find a lodgment there.
{1085} The ductus communis choledochus may be closed by agencies acting
from without. They are various, but the most common are the
carcinomata. Primary cancer of the gall-bladder and gall-ducts,
although not of frequent occurrence, is by no means rare. It develops
in connection with the connective-tissue new formations produced by the
inflammation following the migration of large calculi. A very
instructive example has been examined by the writer. The patient, a
woman aged forty-eight, had had numerous paroxysms of hepatic colic,
and after death, which followed a protracted stage of jaundice by
obstruction, a large ovoid calculus, filling the gall-bladder, was
found, and an extensive organized exudation of inflammatory origin was
the seat of carcinomatous disease involving the cystic and common ducts
and closing the lumen of both. Cancer of the pylorus, of the duodenum,
of the pancreas, of the right kidney, and of the liver itself, not
unfrequently by exterior pressure permanently occlude the common duct.
To this category of obstructing causes must be added enlarged lymphatic
glands of the transverse fissure, large fecal accumulations, tumors of
the ovaries and uterus, aneurisms of the abdominal aorta, and
especially aneurism of the hepatic artery, several examples of which
have been reported, and one has occurred in a case seen by the writer.
The effects of obstruction are much less important when the cystic duct
is closed. The contents of the gall-bladder accumulate, constituting
the condition known as dropsy of the gall-bladder. A catarrhal state of
the mucous membrane is set up; the muco-pus formed mixes with the bile,
and the mixture undergoes fermentative changes which further alter its
character and impart to it irritating qualities, in consequence of
which the mucous membrane becomes more decidedly inflamed, and a still
more purulent fluid forms, so that ultimately the contents of the
gall-bladder are entirely purulent, and that organ may attain to
enormous size. Instead of a catarrhal inflammation leading to
suppuration, the mucous membrane may pour out serum abundantly, the
biliary contents and mucus disappear by absorption, and finally the
gall-bladder will be moderately distended by a serous-like fluid. No
further disturbance ensues, and the gall-bladder, thus shut off from
participation in the hepatic functions, ceases to give trouble.