[Frontispiece: Plate I. Occlusion of the Bile, and Pancreatic Ducts.]
JAUNDICE: ITS PATHOLOGY AND TREATMENT.
WITH THE APPLICATION OF PHYSIOLOGICAL CHEMISTRY TO THE DETECTION AND
TREATMENT OF DISEASES OF THE LIVER AND PANCREAS.
BY GEORGE HARLEY, M.D.,
Professor of Medical Jurisprudence in University College, London;
Assistant Physician to University College Hospital; Formerly President
of the Parisian Medical Society; Cor. Memb. of the Academy of Sciences
of Bavaria, and of the Royal Academy of Medicine of Madrid.
So rapid is the advance of science, that the theory regarded as true
to-day, may be recognised as false to-morrow. The facts, however, on
which the theory is based, if rightly observed, remain unaltered, and
unalterable.
LONDON:
WALTON AND MABERLY,
UPPER GOWER STREET, AND IVY LANE, PATERNOSTER ROW.
MDCCCLXIII.
LONDON:
WILLIAM STEVENS, PRINTER, 37, BELL YARD,
TEMPLE BAR.
TO
WILLIAM SHARPEY, M.D., LL.D., F.R.S.,
Professor of Anatomy and Physiology in University College, London,
AS A SMALL TOKEN OF A COLLEAGUE'S ESTEEM FOR A PROFOUND THINKER, A
SOUND REASONER, AND A TRUE FRIEND.
PREFACE.
"Time being money," quite as much to the professional as it is to the
mercantile man, the author has endeavoured in the accompanying
monograph not only to condense his material, but to exclude the
consideration of any question not directly bearing upon the pathology
or treatment of jaundice; indeed, as stated in the Introduction, one of
the chief objects of the author having been to point out how valuable
an adjunct modern physiological, and chemical knowledge is in the
diagnosis, and treatment of hepatic and pancreatic disease, he has
neither dwelt on the literature nor discussed the old theories of the
mechanism of jaundice, but limited himself almost entirely to a brief
exposition of his own views. For the sake of brevity, he has at page
132 put into a tabular form the pathology of jaundice, according to the
opinions expressed in the body of the volume.
As the object of all theory, and the aim of all science, is to insure
wise practice, the author desires to call special attention to that
portion of the work devoted to the chemistry of the excretions,
feeling, as he does, that we are entering upon the threshold of an
important department of medical inquiry, which, sooner or later, will
be followed by valuable practical results. He would also direct the
special attention of his readers to the chapter devoted to treatment,
being sanguine enough to imagine that the adoption of the principles he
has enunciated regarding the mode of action, and administration of the
remedies usually employed in hepatic affections, may conduce to a more
rational and successful method of treatment than has hitherto been
employed. He even goes far enough to hope that the result of the
treatment, as shown in the cases cited, will not only justify the
adoption of the principles on which it is founded, but also prove a
strong incentive to others to follow the line of diagnosis he has
striven to inculcate.
In some portions of the volume the statements of the author may,
perhaps, appear to be rather dogmatic; if so, he would remind his
readers that this has arisen from the circumstance of so many old
dogmas, and deeply-rooted prejudices having to be combated, for he is
quite alive to the fact, that what we regard as scientific truth is in
no case incontrovertible certitude, and that the deductions of to-day,
in an advancing science like that of medicine, may require material
alteration when viewed in the light of the morrow. But he is equally
convinced of the fact, that if men fold their arms, and refrain from
acting until every link in the chain of knowledge is forged, all
progress will be arrested, and the day of certainty still further
postponed.
Too long have we reversed the natural order of things, and commenced
the study of medicine where we ought rather to have left it off. Too
long have we striven, by studying pathology ere we were sufficiently
acquainted with physiology, to place the pyramid on its apex instead of
on its base; and thus it is we remained so long ignorant of the
fundamental doctrine, that the same laws which regulate health,
regulate disease. Nature does nothing on a small scale, and the more we
study her the more we admire the uniformity, and extensive
applicability of her laws. If we pry into the ultimate structure of our
bones, we find they receive their nutriment by a system of irrigation,
carried on through lakes, and rivers (lacunæ, and canaliculi); and if
we examine the periosteum surrounding them, the ligaments attaching
them, or the muscles covering them, we still find, that,
notwithstanding the diversity in structure, and use, the one system of
irrigation pervades them all. We may even go a step further, and say
that the same law which governs the animal governs also the vegetable
kingdom. Indeed, the further science advances, the more apparent does
it become, that not only the animal, and vegetable, but even the
organic, and inorganic, form but one world, regulated by the same laws.
A knowledge of organization, important though it be, is yet less
indispensable to the physician than a knowledge of healthy function,
for it is the latter which elucidates the dark problems of life, it is
the latter which proves the golden key to the comprehension of disease.
Although not even the most ardent admirers of medicine can say, that it
as yet merits the name of an exact science, this ought neither to
destroy our hopes nor trammel our labours. With the stethescope,
microscope, and other physical means of diagnosis a new era dawned upon
our art; and now the members of the new school which is rising up, and
carrying chemistry into the domains of medicine, are the pioneers of
the revolution which is soon to follow. If we look back to what the
exact sciences of to-day were in former times, we shall find they were
much less perfect then, than medicine is now. Astronomy and chemistry
were but astrology and alchemy. If, then, we draw a picture of the
future from the progress of the past, we need have no hesitation in
saying that chemistry rightly applied, and physiology justly
interpreted will, ere many generations pass away, reveal the deepest
secrets of diseased action, and although unable to banish death, will
yet enable the practitioner to follow with unerring certainty the
various morbid changes occurring in the frame.
77, HARLEY STREET, CAVENDISH SQUARE,
_March, 1863_.
CONTENTS.
PAGE
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Pathological conditions with which jaundice is associated--Those
of the liver itself--Those of the bile-ducts--General
affections of other organs of the body exerting an influence
on the biliary secretion--Zymotic diseases--The effects of
certain poisons . . . . . . . . . . . . . . . . . . . . . . . 3
Frerichs's theory of jaundice--Theory of jaundice hitherto most
favoured in England--Dr. Budd as its exponent . . . . . . . . 6
Nature of bile--Biliverdine--Bile acids; glycocholic, and
taurocholic acids--Cholesterine--Bile resin--Sugar--Inorganic
constituents--Specific gravity, reaction, and colour of normal
bile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Manner in which bile is secreted--Liver both a formative and
excretive organ--Animals without gall-bladders--Effects of
food on the colour and quantity of the bile . . . . . . . . . 11
Is bile essential to life?--Effect on the system of absence of
bile in the digestive process--Death from starvation as a
result--Benefit derived from an additional quantity of
food--Uses of bile in the animal economy--Necessary to the
absorption and assimilation of food--Bile as a digestive
agent--Its action on the chyme--Experiments on its influence
over the absorption of fatty matter--Its relation to the
pancreatic juice--Bile taken internally by Caffres . . . . . . 13
General view of the mechanism of jaundice--Two great
divisions--Jaundice from suppression, and jaundice from
re-absorption--1st subdivision: jaundice arising from
enervation, disordered hepatic circulation, and absence of
secreting substance--2nd subdivision: jaundice arising from
congenital deficiency of the bile-ducts, and from accidental
obstruction of the bile-ducts . . . . . . . . . . . . . . . . 19
General view of the pathology of jaundice from suppression,
showing how the coloration of the skin, and urine is produced
in such cases . . . . . . . . . . . . . . . . . . . . . . . . 20
Mechanism of jaundice as a result of enervation--Influence of
nervous system on secretion--Effect of mental emotion on
biliary secretion, as observed in dog with biliary
fistula--Action of fright in paralyzing nerve force . . . . . 22
Mechanism of jaundice from hepatic congestion--Active
congestion--General view of the effects of congestion on
glandular secretion--Reason why the biliary secretion is not
usually completely arrested--The absence of pipe-clay stools
explained--Example of jaundice from hepatic
congestion--Jaundice from zymotic disease, and other cases of
blood-poisoning, have a similar mechanism--Example of jaundice
following upon ague--Effect on the urine--Analysis of the
urine a clue to the nature of the case . . . . . . . . . . . . 24
Passive congestion of the liver as a cause of jaundice--Cases
associated with heart disease, pneumonia, &c.--Explanation of
the reason why jaundice is so frequently absent in such cases 29
Mechanism of jaundice arising from suppression consequent upon
absence of the secreting substance--Cancer, tubercle,
&c.--Effects of the position of the morbid deposit in
modifying the result . . . . . . . . . . . . . . . . . . . . . 31
Jaundice arising from acute, or yellow atrophy of the liver--State
of the urine in such cases--Presence of
bile-acids--Pettenkofer's test--Tyrosine and leucine in the
urine--An example of the affection occurring in a young
woman--Exciting cause--State of the liver tissue--Poisonous
effects of glycocholate of soda injected into the circulation 34
Mechanism of jaundice arising from the re-absorption of the
secreted but retained bile--Jaundice arising from a
congenital deficiency of the ducts--History of a case . . . . 39
Pathology of jaundice resulting from the accidental obstruction of
the bile-ducts--Mode of formation of gall-stones--Jaundice
only present when the stone is lodged in common duct--How
gall-stones may imperil life without inducing jaundice--Modes
of escape from the gall-bladder--Presence of foreign bodies,
such as cherry-stones in gall-duct--Jaundice arising from
hydatids impacted in the common duct . . . . . . . . . . . . . 42
Mechanism of permanent jaundice from obstruction--Resulting from
organic disease--Cancer of head of pancreas--Effect of the
dilatation of the bile-ducts in the liver--Effect on the
nutrition of the parenchyma of liver--Different stages in
size through which the liver passes--Difficulties of
diagnosis--Cause often obscure--Key to its detection . . . . . 46
Analysis of the intestinal secretion an aid to the diagnosis of
obscure cases of abdominal disease--Colour, nature, and
chemical composition of the stools--Changes produced in them
by different foods, and remedies . . . . . . . . . . . . . . . 51
Examination of the renal secretion--Diagnostic value of the colour
of the urine--Colour produced by urohæmatin to be
distinguished from that produced by biliverdine--Simple method
of separating the pigment from the urine--Advantage of at the
same time ascertaining the quantity of uric acid
present--Effect of the bile pigment becoming deposited in the
kidneys--Production of secondary disease . . . . . . . . . . . 55
Diagnostic value of the presence of the bile-acids in the
urine--Views of Frerichs, Städler, and Kühne--Hoppe's method
of detecting the bile-acids--Frerichs's theory of the
transformation of bile-acids into biliverdine shown to be
untenable . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Diagnostic value of the presence of tyrosine, and leucine in the
urine--Microscopic appearances of these substances--Mode of
separating them from urine--Chemical tests . . . . . . . . . . 63
Melanine in the urine in cases of cancer of the liver--The
characters by which it is to be distinguished from bile
pigment--Case related showing the value of the test . . . . . 68
Diagnostic value of ascertaining the quantity of urea, and uric
acid, as well as the presence of sugar in the urine in obscure
cases of jaundice--History of a case illustrating the value of
such knowledge--Significance of the presence of fatty acids in
the fæces in the diagnosis of pancreatic disease--Pancreatine
administered--Effect of bile-poisoning on the memory--Analysis
of the patient's urine--Diagnostic value of the quantity of
its constituents pointed out--Appearance of sugar as the
forerunner of a fatal termination alluded to--Disappearance of
bile-acids, and appearance of tyrosine and leucine in the
latter stages of the disease--Post-mortem appearances
described--Occlusion of bile, and pancreatic ducts--Analysis
of healthy and diseased bile--Change in the proportion of the
organic greater than in that of the inorganic
constituents--Microscopic appearances of liver--Presence of
crystals of cystine, as well as of tyrosine in the hepatic
parenchyma . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Jaundice from obstruction in its latter stage complicated with
jaundice from suppression . . . . . . . . . . . . . . . . . . 89
Epidemic jaundice--Among soldiers--Among pregnant women--Among the
entire civil population--Its mechanism--Its cause--Case of
jaundice supervening upon scarlatina . . . . . . . . . . . . . 90
Artificial jaundice--Mode of production--Experiments
related--Tyrosine, and leucine supposed to be the result
either of the arrested, or of the retrograde metamorphosis of
glycocholic, and taurocholic acids--Biliary acids detected in
the blood--Poisonous nature of the constituents of the
bile--Condition of the blood in bile-poisoning . . . . . . . . 95
Treatment of jaundice--Totally different in jaundice from
suppression and in jaundice from obstruction--Benefit of
mercury in cases of jaundice--General theory regarding the
action of mercurials--Benefit of acids, and of alkalies--Their
mode of action explained--Theory of their action in cases of
gall-stones--Lithia water--Treatment of jaundice by benzoic
acid--Cases illustrating its mode of action--Podophyllin a
bane, and an antidote in cases of jaundice--Its pernicious
effects in cases of obstruction pointed out--Author's theory
of its action in such cases--Method of detecting gall-stones
in the stools--Sulphuric ether, and chloroform in cases of
gall-stones--Taraxacum . . . . . . . . . . . . . . . . . . . . 101
Difficulties in the treatment of jaundice from obstruction pointed
out--Derangements arising from absence of bile in the
digestive process--Good effects of an additional quantity of
food--Establishment of an artificial biliary fistula shown to
be less hazardous than usually imagined--Mode of operation
explained--Treatment of permanent jaundice by prepared
bile--New mode of preparing bile pointed out--Theory of its
action--Time of administration shown to be of much
importance--Bile put into capsules--Benefits derived from bile
given in this form . . . . . . . . . . . . . . . . . . . . . . 122
Tabular view of the pathology of jaundice according to the
author's views . . . . . . . . . . . . . . . . . . . . . . . . 132
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
DESCRIPTION OF PLATES AND WOODCUTS.
PLATE I.
Represents the condition of the parts in a fatal case of permanent
jaundice, in which both the bile, and pancreatic ducts were completely
occluded.
_(a)_ Atrophied liver.
_(b)_ Transverse section of the left lobe, showing the mouths of the
enormously distended gall-ducts.
_(c)_ Enlarged gall-bladder.
_(d)_ Dilated cystic duct.
_(e)_ Distended hepatic, and common duct.
_(f)_ Ulceration in duodenum, in the situation of the opening of the
gall-duct into the intestines.
_(g)_ Pancreas with enlarged head _(h)_, and enormously distended duct.
PLATE II.
External surface of the left kidney, denuded of its capsule, in a case
of permanent jaundice.
_(a)_ Small specks of bile pigment deposited in the renal tissue, and
blocking up the urine tubes.
_(b)_ Small abscesses scattered throughout the tissue of the kidney.
WOODCUTS.
Fig. 1. Crystals of glycocholate of soda, mag. 90 diam.--Page 8.
" 2. Taurocholate of soda, as found in the form of globules of
various sizes.--Page 9.
" 3. Crystals of cholesterine.--Page 9.
" 4. Crystals of pure tyrosine.--Page 63.
" 5. Spiculated balls of tyrosine, from the urine of a case of acute
atrophy of the liver.--Page 64.
" 6. Globules of leucine.--Page 66.
" 7. Cholesterine crystals.--Page 82.
" 8. _(a)_ Crystals of cystine.
_(b)_ Hepatic cells, showing entire absence of fat globules.
_(c)_ Caudate or spindle-shaped cells, from epithelial lining
of hepatic ducts.--Page 86.
{1}
JAUNDICE: ITS PATHOLOGY AND TREATMENT.
INTRODUCTION.
Having entitled this monograph "Jaundice, its Pathology and Treatment,"
it may, perhaps, be necessary for me to state at the beginning that by
so doing it is not to be supposed that I regard jaundice as a disease
_per se_. On the contrary, I look upon it in the same light as I do
albuminuria, which is not of itself a disease, but only the most
prominent symptom of several widely-differing pathological conditions.
So also the peculiar state of body characterised by yellow skin,
saffron-coloured urine, and pipe-clay stools, is itself but a symptom
of morbid action. It may be asked, "Then why do you treat of jaundice
as if it were a disease?" To this I reply, "Because, although {2} the
condition called jaundice be merely a manifestation of morbid action,
and one, too, requiring neither skill nor experience to detect, the
proper comprehension of its true mechanism is of much practical
importance to the physician, for without this knowledge it is
impossible for him to treat it with any chance of success. Nay, even
the remedies for jaundice become dangerous weapons, if unskilfully
applied." In fact, it is almost unnecessary to apologise for treating
of jaundice as a disease _per se_; for, notwithstanding all that has
been written upon the subject, it is universally admitted that the
simplicity of its diagnosis is only equalled by the obscurity of its
pathology, and the uncertainty of its treatment; and no one at all
conversant with the literature of jaundice can be in the least degree
surprised at this statement. On the contrary, on glancing at the
immense variety of morbid states, and known pathological conditions
with which it is associated, he cannot fail to admit its truth.
Some of the pathological conditions are closely allied; others are
widely separated--so widely, indeed, that at first sight it is
impossible to discover from whence emanates the common symptom. We find
jaundice connected with diseases of the liver, of the neighbouring
organs, and of the general system. In some diseased conditions, {3}
jaundice presents itself when least expected. At other times it is
absent when, apparently, it ought to be present. On the other hand,
again, there are cases in which jaundice is evidently merely a symptom,
and others in which it seems to be in itself the disease. We have
temporary jaundice from transient derangements, and we have permanent
jaundice from stationary causes. There are cases in which the cause of
jaundice is visible after death to the naked eye. There are others
where the minutest research is baffled in ascertaining the cause. That
this is no exaggerated view of the case the following table will
show:--
JAUNDICE IS MET WITH,
Firstly, IN DISEASES AFFECTING THE LIVER--
_(a)_ Cancer.
_(b)_ Tubercle.
_(c)_ Cirrhosis.
_(d)_ Inflammation.
_(e)_ Atrophy.
_(f)_ Amyloid, and
_(g)_ Fatty degeneration.
Secondly, IN DISEASES OF THE BILE-DUCTS--
_(a)_ Congenital deficiency.
_(b)_ Accidental obstruction. The latter arising from gall-stones,
hydatids, foreign bodies {4} (such as cherry-stones and
entozoa) entering from the intestines.
_(c)_ Ulcer of the duodenum.
_(d)_ Tumours of the pancreas.
Thirdly, IN AFFECTIONS OF OTHER ORGANS OF THE BODY EXERTING AN
INFLUENCE ON THE BILIARY SECRETION--
_(a)_ Diseases of the nervous system.
_(b)_ Diseases of the lungs.
_(c)_ Diseases of the heart.
_(d)_ Imperfect establishment of the extra-uterine circulation
(infantile jaundice).
_(e)_ Dyspepsia.
_(f)_ Torpidity of the bowels, and consequent accumulation of fæces
in transverse colon.
_(g)_ Pregnancy.
Fourthly, IN A VARIETY OF ZYMOTIC DISEASES--
_(a)_ Typhus.
_(b)_ Yellow fever.
_(c)_ Ague.
_(d)_ Pyæmia.
_(e)_ Epidemic jaundice.
Fifthly, AS A RESULT OF THE INJURIOUS EFFECTS OF CERTAIN POISONS--
_(a)_ Snake bites. {5}
_(b)_ Alcohol.
_(c)_ Chloroform, etc.
Can it be wondered, then, that a state so easily diagnosed is
nevertheless so difficult to comprehend?
Notwithstanding the apparent incongruity of the diseases with which the
one common symptom of jaundice is associated, I trust to be able to
reconcile these discrepancies, and prove that the seeming discord is
but "harmony not understood."
All physicians, I think, admit that the peculiar state of the system to
which the name of jaundice has been applied, is essentially due to some
derangement of the biliary function, the exact nature of the
derangement being alone the point of contention. I need not, therefore,
waste the time of my readers, either by giving an account of the
literature or a detail of the symptoms of jaundice. Even in discussing
its pathology, I shall strictly limit myself to the consideration of
the opinions at present held by the more advanced of our pathologists;
the object of this monograph being, not to pourtray the views of
others, but to give a brief _exposé_ of my own, and to point out how
modern physiology, and chemistry have not only thrown a new light on
its pathology, but have also given us a clue to its successful
treatment.
{6} Frerichs, the most recent writer on this subject, in his elaborate
treatise on diseases of the liver, says that jaundice may result from
one of the three following conditions:--
Firstly,--Obstruction to the escape of bile.
Secondly,--Diminished circulation of blood in the liver, and consequent
abnormal diffusion; both of these conditions giving rise to an
increased imbibition of bile into the blood, and in both cases the
liver being more or less directly implicated.
Thirdly,--Obstructed metamorphosis, or a diminished consumption of bile
in the blood.[1]
[Footnote 1: Frerichs' "Clinical Treatises on Diseases of the Liver."
New Sydenham Society's Translation, vol. i. p. 93.]
From this it is seen, that the pathology of jaundice, according to
Frerichs, is very different from what we were formerly taught. For
while he has entirely laid aside the theory of jaundice as a result of
suppressed secretion, he has introduced two perfectly new
elements--namely, abnormal diffusion, and diminished consumption. The
latter theory, being, of course, founded on the supposition that bile,
after playing its part in the digestive process, is re-absorbed into
the circulation, again to perform another function in the animal
economy, before its final excretion from the organism as effete matter.
The theory of jaundice, hitherto most favoured in England, and which
found {7} such an able exponent in Dr. Budd, is, that the disease may
arise in two ways--firstly, by a mechanical obstruction to the passage
of bile into the intestines, and the consequent re-absorption of the
detained fluid into the blood; and secondly, by a suppression of the
biliary secretion arising from some morbid condition of the liver
itself, whereby the biliary ingredients accumulate in the circulation.
Now, although I am not prepared to admit the justice of the views held
regarding the origin and function of bile, on which these opinions are
based, I nevertheless believe that in the following pages I shall be
able, by the aid of modern medical science, to prove the correctness of
the conclusions themselves. In order to do this, however, it will be
necessary for me to begin by making a few remarks on the nature of
bile, and the physiology of its secretion.
ON THE NATURE OF BILE.
In a few words, bile may be said to be composed of the following
substances:--
Firstly,--Biliverdine, a green nitrogenized, non-crystallizable
colouring matter, analogous to the green colouring matter of plants,
and like it, leaving on incineration a distinctly ferruginous ash. This
colouring matter appears, like {8} urohæmatine, and all other animal
pigments, to be a direct derivative of the colouring matter of the
blood.[2]
[Footnote 2: _Vide_ papers by the author on the colouring matter of the
urine, Pharm. Journ., November, 1852. "Urohæmatine, and its combination
with animal resin." Verh. d. Phys.-Med. Gesellschaft zu Wurzburg, Bd.
V. 1854.]
[Illustration: FIG. 1. Crystals of Glycocholate of soda, a beautiful
polariscopic object. _(a)_ Fine needle-shaped crystals, separated from
a rosette-shaped group. _(b)_ Small rosette of crystals. _(c)_
Fan-shaped groups of crystals, which are merely portions of large
rosettes that have become broken up. _(d)_ A fragment of a bundle of
needle-shaped crystals. Mag. 90 diam.]
Secondly,--Two peculiar substances, named respectively, glycocholic,
and taurocholic acid--the former yielding, when in combination with
soda, a crystallizable, the latter a non-crystallizable salt.
Taurocholic differs still further from glycocholic acid, in containing
a large percentage of sulphur, {9} and being, under the influence of
hydrochloric acid, convertible into taurine, a beautiful white
crystalline substance.
[Illustration: FIG. 2. Taurocholate of soda is found in the form of
fatty-looking globules of various sizes. They differ from fat and oil
globules, however, in being soluble in water, and insoluble in alcohol
and ether.]
Thirdly,--Cholesterine, a crystalline, fatty matter, not, however,
peculiar to bile, but found in various tissues, and secretions of the
body.
[Illustration: FIG. 3. Cholesterine crystals appear in the form of fine
transparent four-sided plates of various sizes and shapes. The crystals
are freely soluble in hot alcohol, from which they are re-deposited on
cooling.]
{10} Fourthly,--A brown resinous substance resembling, in appearance
and consistence, shoemaker's wax.
Fifthly,--Among the constituents of the bile, I may mention sugar, for
both in the normal bile of man, and of the lower animals, the ox, and
the dog, I have detected that substance. On one occasion, I even found
torulæ in the bile twenty-four hours after its removal from the
gall-bladder of a healthy dog.
Sixthly, and lastly,--a quantity of inorganic matter, consisting
chiefly of soda, potash, and iron.
The specific gravity of bile fluctuates, of course, with the percentage
of solid matter it contains. From my own observations, I consider that
healthy human bile has an average specific gravity of 1020, and
contains about six per cent. of solid matter, five per cent. of which
is organic, and one per cent. inorganic substance. When fresh, bile is
almost neutral; but it rapidly undergoes decomposition, and becomes
alkaline.
In colour, human bile is usually of a brownish yellow hue; the colour,
however, varies with its degree of concentration, the kind of food
taken, and the state of the system. As regards the effect of food, if
we may be allowed to form an opinion from experiments on dogs, it may
be said that, as a {11} rule, animal food tends to give bile a yellow,
vegetable food a green, tint.
Next, as regards the manner in which bile is secreted. For a long time
it was thought, and, indeed, some people still think, that bile exists
pre-formed in the blood, and that the liver only excretes it, as the
kidneys excrete the urinary ingredients. Another class, running to the
opposite extreme, believe that the liver is not merely the excretive,
but also the formative organ of the bile. It appears to me, however,
that neither of these extreme views is correct, and that the truth lies
between the two.
It is, in fact, not at all difficult to prove that the liver
manufactures certain biliary constituents, while it merely excretes
others. Thus, for example, the two substances glycocholic and
taurocholic acids are never to be found either in the blood, tissues,
or fluids of the healthy organism, with the single exception of those
of the liver and gall-bladder; and after extirpation of the liver
neither acid is to be found in the body at all. On the other hand, such
substances as cholesterine and biliverdine, are not peculiar to the
liver or its secretion, but are the products of several organs, and are
always to be detected in the blood, independently of the presence or
absence of the liver. These facts, therefore, clearly show that the
liver {12} is both a formative and excretive organ to some, and an
excretive only to others, of the biliary constituents.
Lastly, the general opinion is that the secretion intermits, and, like
the gastric, and pancreatic juices, bile is only formed during
digestion. Were it so, however, where would be the necessity for a
gall-bladder? Is it not to store up the secretion formed in the
intervals of digestion, and to retain it until it is required? No doubt
there are several animals, such as the horse, and the deer, that
possess no gall-bladders; but there is undoubtedly in them some special
arrangement of the digestive apparatus, rendering the presence of a
gall-bladder unnecessary. In fact, it is easily shown that the biliary
secretion in ordinary cases is continuous; for if in an animal
possessing a gall-bladder a biliary fistula be established, and the
secretion of bile carefully watched, it will be found that at no period
of the day does it entirely intermit, although it is more active at one
time than at another, the minimum of its activity being during
sleep--the maximum during active digestion. The absolute quantity of
bile secreted in the twenty-four hours is tolerably uniform, although
the daily amount is slightly influenced by the kind of food.[3]
[Footnote 3: Arnold found that dogs secreted more bile on a bread, than
on an animal diet. "Zur Physiologie der Galle," Mannheim, 1854.]
{13} IS BILE ESSENTIAL TO LIFE?
Several physiologists have given it as their opinion that bile is not
essential to life, for animals have lived for many months after the
artificial establishment of a biliary fistula, through which the bile
was allowed to flow away, and be lost to the animal. Now, although this
is perfectly true, yet it is at the same time evident that the uses of
the bile cannot altogether be dispensed with, for all the animals with
a biliary fistula lose flesh, become emaciated, and weak; the hair has
a tendency to fall off, the bowels to become irregular; and a great and
an almost constant discharge of foul-smelling gases takes place from
the intestinal canal. At length, after a shorter or longer period, the
animal sinks, and dies. The fatal termination can, however, be retarded
by allowing him an additional quantity of nourishing food, for death
from want of bile, as is too often seen in the human subject, is
nothing else than death from slow starvation. The fact just related
regarding the beneficial effects of an additional quantity of food in
prolonging life, should never be lost sight of in the treatment of
cases of obstruction of the gall-ducts, for, by attending to this
circumstance, it is often in the power of the medical man to keep his
patient alive for a considerable length of time.
{14} It may perhaps not be out of place if I here briefly enumerate the
chief uses of bile in the animal economy. In order to live, not only
must the individual particles of our frames die, but they must be
continually replaced by new materials of a similar kind; and for the
accomplishment of this important end, nature has endowed animals with a
digestive apparatus in which their food undergoes the various physical,
and chemical changes necessary to its absorption, and assimilation. In
the animal laboratory or digestive apparatus there are five important
agents constantly at work--saliva, gastric juice, bile, pancreatic
fluid, and intestinal secretion, and each of these agents has a special
and definite office to perform in the elaboration of the food.[4] At
present, however, I must limit myself entirely to the consideration of
bile.
[Footnote 4: For an explanation of these offices, see the author's
article on "The Chemistry of Digestion," in the "British and Foreign
Quarterly Review," January, 1860.]
Bile is the first digestive agent with which the food comes in contact
on leaving the stomach and entering the intestines, and immediately on
the acid chyme mixing with the alkaline bile, a white flocculent
emulsion is formed, which emulsion has been described by many writers
as a precipitation of the albuminose (digested albumen). Later {15}
researches by myself and others have, however, shown that it is not the
bile which precipitates the albuminose, but the acid of the chyme,
which in reality sets free certain ingredients of the alkaline bile. In
the majority of cases there is not even a true precipitation, for on
throwing the milky-looking mixture upon a filter, I found that almost
nothing remained behind, and the filtrate was nearly as white as the
original liquid. Further, if the albuminose be separated from the
chyme, and the chyme then brought into contact with the bile, the same
flocculent-looking milkiness still appears. Nay, more, on adding equal
parts of sheep's bile (fresh) to gastric juice drawn from a dog's
stomach in full digestion, the apparent flocculent precipitate still
appeared, although the acidity of the gastric juice remained
unneutralized; and on throwing the whole into a filter, I found that
the liquid that drained through was as milky and flocculent-looking as
the original. The office of bile in the digestive process is neither to
act on the albuminous[5] nor amylaceous portions {16} of our food; its
chief action being to assist in the absorption of fats. When bile is
mixed with neutral fat, little change is observed, but when brought in
contact with the fatty acids, an immediate emulsion takes place. Lenz
and Marcet[6] pointed out how the neutral fats of our food are
transformed into fatty acids during their sojourn in the stomach; and
Bidder and Schmidt[7] illustrated by experiments on dogs the important
part played by the bile in their absorption. A dog, which in its normal
condition absorbed on an average 7 grains of fat for every 2 pounds of
its weight, absorbed only 3, or even as little as 1 grain, after the
bile was prevented entering the intestines, in consequence of a
ligature being applied to the gall-duct.
[Footnote 5: In speaking of the properties of the bile, I may mention
that, although bile has no digestive power (properly speaking) over
albuminous substances, yet, when injected into the subcutaneous
cellular tissue of a healthy animal, it eats its way out through the
skin, just as gastric juice or lactic acid does under similar
circumstances. Even the muscles with which it comes in contact appear
to be eaten away.]
[Footnote 6: _Vide_ a Discourse on the Chemistry of Digestion, by Dr.
Marcet. Journ. of the Chem. Soc., Oct. 1862.]
[Footnote 7: "Die Verdauungssaefte und der Stoffwechsel." Leipzig,
1852.]
Further, these last-named observers found that, while the chyle in the
thoracic duct of a healthy dog contains 32 parts of fat per thousand,
that in the thoracic duct of a dog with a ligatured gall-duct, contains
only 2 parts per thousand. These facts clearly prove that bile plays an
important part in the absorption of the fatty portion of our food. Next
comes the question, "In what manner does bile aid in the absorption of
fatty matter?" {17} As is well known, fats or oils have no tendency to
mix with water, and hence diosmose between an aqueous and an oily fluid
is next to impossible. Matteucci has, however, shown that if an animal
membrane be moistened on both sides with a weak solution of potash, it
allows oil to pass through it. It has also been observed, that when the
intestine is moistened with bile, it allows oil to pass through, which
would not otherwise be the case. To illustrate this property of bile, I
performed the following experiments:--
Firstly,--A clean piece of duodenum was filled with oil, ligatured at
both ends, and suspended in water, holding in solution a small quantity
of albumen. (The albumen was added to the water merely to imitate
slightly the albuminous blood.) On examination, twenty-four hours
later, no oil was found to have escaped through the intestinal walls.
Secondly,--A second portion of intestine had its internal surface
moistened with sheep's bile before the introduction of the oil. It was
then treated in the same manner as the preceding, and on being examined
after the lapse of twenty-four hours, a small quantity of the oil was
found to have penetrated through the intestine.
Thirdly,--Into a third portion of intestine was poured equal parts of
sheep's bile, and chyme obtained from a dog in full digestion, through
a {18} fistulous opening into its stomach. After being treated for the
same length of time, and in precisely the same manner as the others,
evident signs of the oily matters of the chyme having passed through
the walls of the intestine were obtained, for they were seen as a scum
floating on the surface of the albuminous water. Moreover, the fatty
matters were not in the form of pure oil, but of a soapy substance.
The bile is thus seen to possess one of the more remarkable properties
of the pancreatic juice. There is this important difference between the
action of these two secretions on fats, however, that while bile merely
emulsions and saponifies that portion of our food which enters the
duodenum in the form of fatty acids, pancreatic juice, on the other
hand, possesses the power, not only of emulsioning and saponifying the
fatty acids, but also the neutral fats; indeed, its power seems chiefly
to be exerted upon the latter. Hence it appears that both secretions
are in a measure necessary to the complete digestion and absorption of
the oleaginous constituents of our food.
On one occasion, while experimenting with bile at University College, I
was surprised to hear Minton, the servant who was assisting me, say,
that while he was travelling with Sir Andrew Smith in South Africa, he
had oftentimes seen the {19} Caffres drink bile direct from the
gall-bladders of the animals killed by the European party, and that,
while passing the gall-bladder round to each other, they would rub
their stomachs and say,--"Mooé-ka-kolla," signifying thereby, that it
was very good. It certainly seems very extraordinary that any human
being should not only drink, but drink with pleasure, a liquid so
bitter and nauseating as bile. Perhaps the poor Caffres, however, drank
the sickening tasted bile for the same reasons as the cattle in
Caffreland, at certain periods of the year, go thousands of miles to
drink at the salt-springs. There being scarcely any chloride of sodium
in the earth, there is insufficient for the animal requirements in the
herbage on which they feed, and they are forced to supply the
deficiency by artificial means. Bile contains a large percentage of
soda, and perhaps the Caffres drink it in order to obtain that
substance, just as the animals drink the brackish water of the salt
licks, feeling that it agrees with them, without knowing why.
THE MECHANISM OF JAUNDICE.
As said in the beginning of this paper, I believe, the pathology of
jaundice may be embodied under the two heads, jaundice from suppression
{20} of the biliary functions, and jaundice from re-absorption of the
secreted but retained bile. These are at best, however, but vague
terms, and in order to make the pathology of jaundice somewhat more
definite it will be necessary for me to subdivide these two great
classes in the following manner:--
(CLASS A.)--JAUNDICE FROM SUPPRESSION.
Arising from:--
(1) Enervation.
(2) Disordered hepatic circulation.
(3) Absence of secreting substance.
(CLASS B.)--JAUNDICE FROM RE-ABSORPTION.
Arising from:--
(1) Congenital deficiency of bile-ducts.
(2) Accidental obstruction of bile-ducts.
I shall now try to point out the pathology of these different states,
and see how far they are able to explain the occurrence of jaundice
under the various conditions already alluded to.
JAUNDICE FROM SUPPRESSION.
Although there can be no misunderstanding the meaning of the term
"jaundice from suppression," there may, nevertheless, be some
difficulty in comprehending how the skin becomes yellow, and the urine
high coloured, when the secretion {21} of bile is arrested. In order to
explain how this occurs, it will be necessary to recall to mind what
was said regarding the nature of the biliary secretion. It will be
remembered that I began by saying, that while some of the constituents
of the bile are generated in the liver itself, there are others that
exist, pre-formed in the blood.
If this view of the physiology of the biliary secretion be correct, it
is perfectly evident that when the secretion of bile is arrested, those
substances which the liver generates will be entirely wanting, while
those which it merely excretes from the blood will accumulate there as
soon as their excretion is prevented; just as urea accumulates in the
circulation when its elimination by the kidneys is stopped. Hence it is
that, as soon as the biliary secretion is in abeyance, biliverdine
accumulates in the blood (until the serum is as it were completely
saturated with the pigment), from which it exudes and stains the
tissues, and produces the colour we term jaundice. At the same time, or
even before the skin becomes yellow, the urine assumes a saffron tint
in consequence of the elimination of the colouring matter by the
kidneys.[8] From this it will be seen that I regard {22} the yellow
skin and high-coloured urine of jaundice as simply due to the deranged
secretion of biliverdine, quite independent of the presence or absence
of the other constituents of the bile, the effects produced by which
will be referred to elsewhere. Meanwhile we shall separately consider
the further pathology of the three subdivisions of jaundice arising
from suppression.
[Footnote 8: The true order of the occurrence of these changes is:--On
the second day the urine becomes high-coloured; in a day or two later
the skin assumes a yellow tint; and, in very severe cases, within the
first week or two, the sweat, the milk, the tears, the sputa, and the
serum in the thoracic and abdominal cavities, become of a more or less
decided yellow hue.]
JAUNDICE AS A RESULT OF ENERVATION.
It is now a well-established fact that all secretions are under the
direct influence of the nervous system. Stimulate a nerve supplying a
gland, and secretion is accelerated; stop the nervous action, and
secretion is as instantaneously arrested. Again, just in the same way
as volition can produce or suspend muscular movement, mental influence
can hasten or retard glandular secretion. As an illustration of this
fact, I need only call to mind the influence the mere sight of food has
in exciting the salivary secretion, and the effect of bad news in
arresting it. Exactly the same influence as is here alluded to, is
exerted by the mind over the biliary function. If, for example, {23} as
Bernard first observed, a dog with a biliary fistula be caressed, the
secretion of bile is actively continued; if, on the other hand, the
animal be suddenly ill-used, the secretion of bile is instantly
arrested. If he be again caressed, the secretion is re-established, and
the bile flows drop by drop from the end of the cannula. Here the
influence is entirely produced through the intervention of the nervous
system; and if such effects as are above described occur in the dog, we
can surely have little difficulty in understanding how the biliary
secretion can be influenced in the highly-developed organization of the
human being. Indeed, every one must have felt how quickly sad tidings
received during a meal not only destroy the appetite and retard
digestion, but occasionally alter the complexion. This effect, that all
of us must have experienced in a slight degree in our own persons,
several may have observed to a greater extent in the persons of others,
even to the production of well-marked jaundice. At this very time I
have under my care a young married lady, who during the last two years
has twice suffered from an attack of jaundice induced by witnessing her
child in convulsions, and this I regard as an example of jaundice from
enervation.
One of the reasons, no doubt, why jaundice does not more frequently
follow upon mental emotion is {24} simply on account of a certain
amount of pigment being required in order to produce a visible tinging
of the body, and it seldom happens that the emotional effect on the
biliary secretion is sufficiently permanent to permit of the requisite
amount of pigment accumulating in the blood. The reason, too, why
mental emotion is more apt to cause jaundice immediately after a meal
is, as will afterwards be better understood, on account of the
congested state of the liver at that time favouring the stoppage of the
secretion. A blow on the head, which is now and then observed to be
suddenly followed by jaundice, acts, I believe, in the same way as
fright, namely, by paralyzing the nerve force required for the
continuance of the biliary secretion.
I now pass on to the consideration of the pathology of the second kind
of jaundice from suppression, namely, jaundice resulting from hepatic
congestion.
JAUNDICE ARISING FROM HEPATIC CONGESTION.
This is one of the most common causes of the disease; but as there are
two kinds of hepatic congestion--active and passive--it will be
necessary for me to make a further subdivision, and consider each of
these separately.
{25} _Jaundice the Result of Active Congestion._
The mechanism of jaundice resulting from active congestion of the liver
is readily explained on physiological grounds.
The congested condition of any gland is unfavourable to secretion. We
all know, for example, that congestion of the kidney is accompanied by
a suppression of the urinary secretion, and that the secretion is
re-established as the congested condition of the organ diminishes. The
suppression of the renal secretion is no doubt due to the engorged
capillaries pressing upon the secreting structure, and ultimate
ramifications of the urine tubes, and thereby annulling their
functions. A similar explanation is equally applicable to the biliary
secretion; and just as it happens in the case of the kidney, that it is
exceedingly rare for a total suppression of its functions to take
place, so with the liver it seldom happens that the congestion is
sufficiently severe to induce complete arrest of the biliary secretion.
We find, therefore, that although there may be yellowness of the skin
and high-coloured urine in such cases, pipe-clay stools are frequently
absent, sufficient bile to tinge the fæces still finding its way into
the intestines.