disease, to remove, if possible, the exciting cause. When that is
accomplished, we can with safety turn our attention to the removal of
its effects. I need not here detail the different exciting causes which
it is our duty to remove. I have indicated them elsewhere, and the mere
mention of some of their names is sufficient to denote the line of
treatment which ought to be adopted. Thus, for example, if it be {102}
ascertained from there being symptoms of tenderness, &c., in the
hepatic region, that the jaundice arises from active congestion of the
liver, the first object would of course be to subdue the congestion of
that organ by means of leeches, hot fomentations, saline purgatives,
&c., according to the age, sex, and constitution of the patient. On the
other hand, if the jaundice be the result of passive congestion of the
liver, we know well that so long as the exciting cause exists
elsewhere, it will be worse than futile to attempt the removal of the
hepatic congestion by direct means. In such a case, therefore, if to
remedy the cause is beyond our power, our object will be to concentrate
our efforts on the mitigation of its effects. Thus I might go through
the whole list of causes of jaundice, and point out what appears to be
the most appropriate treatment of each; but I think the time of my
readers and my space, will be more profitably employed, if, instead of
doing so, I turn my remarks chiefly to the therapeutical action of
those remedies which we are constantly employing in the treatment of
jaundice. The first remedy that merits special notice is mercury.
The benefit of mercury in cases of liver disease cannot be denied; but
the injudicious employment of this drug in cases of jaundice, has
frequently been followed by the most disastrous results. {103} There
was a time when mercury was administered in all cases of jaundice,
irrespective of their cause; now, however, men are fortunately becoming
more careful in the employment of this drug. But there is still a
mistaken notion regarding the therapeutical action of mercurial
preparations. It was at one time thought that they stimulated the liver
to secrete bile, and now since physiology has shown that they possess
no such action, many have gone to the opposite extreme, and declared,
that if mercurials do not stimulate the liver to secrete bile, their
benefit in hepatic disease has been a delusion; and the dark stools
following upon their employment but the result of the sulphuret of
mercury formed in the intestines. I take a very different view of the
matter; for though believing that mercury does not directly stimulate
the liver to secrete bile, I nevertheless opine that it has an
important indirect effect in reinducing the biliary secretion, and
thereby curing certain cases of jaundice.
The action of mercurials seems to me, to be this--mercury is a powerful
antiphlogistic--it reduces the volume of the blood by its purgative
properties, and it impoverishes the blood by its direct action on the
red corpuscles. It has been poetically said by Dr. Watson, that mercury
can blanch the rosy cheek to the white of the lily; {104} and nothing
is more true, for in experiments on animals, I have found the prolonged
use of mercury reduce the red blood corpuscles to a minimum. From this
it is easy to understand how mercury acts in inflammatory affections;
and as in the majority of cases of jaundice from suppression, the
stoppage of the biliary secretion is due to active congestion of the
liver, mercury proves beneficial in such cases, not by stimulating the
biliary secretion, but simply by removing the obstacle to its
re-establishment, namely, the hepatic congestion.
As a good illustration of the correctness of this theory regarding the
action of mercurials in cases of jaundice arising from congestion, I
may be allowed to quote the following case, which appeared among the
Hospital Reports of the "Lancet" of the 7th December, 1861. The case is
headed, "Intense Congestion of the Liver, simulating an Abdominal
Tumour:"--
Alex. E----, aged forty-eight, was admitted into St. Bartholomew's
Hospital, under the care of Dr. Farre, on the 17th October, 1861. The
patient had, it appeared, been suffering from jaundice during six
weeks. He stated that the tumour in the epigastrium began about the
same time as the yellowness of the skin.
On examination, a prominent swelling was {105} noticed in the
epigastric region, possessing an indistinct feeling of fluctuation, but
it was found to be continuous with the liver. The motions were not
bilious, but were of a clay colour, and the urine looked like pure
bile. Three grains of blue pill and two of Barbadoes aloes were ordered
every night. By the 25th the hepatic tumour was less, and the icterus
was disappearing. On November 4th the urine was clearer and full of
lithates. The conjunctivæ were the only parts observed of a yellow
colour.
November 11th.--Although the pills had been continued up to this date,
the mouth was not sore. The urine and stools were natural, and the
patient was convalescent. A few days afterwards he left the hospital.
The result of the case clearly proved not only that the swelling was
from a highly congested liver, but also that the jaundice depended on
this state.
In this case it is evident that the primary beneficial action of the
mercury was to reduce the congested state of the hepatic organ, and no
one, I think, would venture to say that this was accomplished by the
power the mercury possessed of exciting the liver to secrete bile.
If, then, the above view of the therapeutical action of mercurials be
correct, it is easy to understand how, in cases of jaundice from
permanent {106} obstruction of the gall-duct, the administration of
mercury or any other lowering medicine, must prove detrimental by
hastening the fatal termination.
Although mercury has not, there are some substances which have, the
power of exciting the flow of bile, just as there are substances which
excite the flow of saliva. Among these the mineral acids, and soluble
alkalies, hold the first rank. It may seem strange that acids, and
alkalies, should be here placed in juxta-position; but the reason of
this arrangement will immediately appear.
According to a physiological law, acid substances have the power of
exciting alkaline secretions, and alkaline substances of stimulating
acid secretions.
Bile being an alkaline secretion, we can therefore have no difficulty
in understanding how the mineral acids act in cases of jaundice from
suppression, induced, for example, by enervation. They simply stimulate
the secretion of bile.
It is not so easy, however, to comprehend the action of alkalies in
similar cases. My explanation of their action is as follows:--When
taken after food, and when taken on an empty stomach, the action of an
alkali is entirely different. After food, and during digestion, the
stomach contains a {107} quantity of acid gastric juice, and an alkali
taken then, only neutralizes the acid. On the other hand, when an
alkaline substance is introduced into an empty stomach, it acts
according to the general law of exciting an acid secretion;
consequently, an immediate flow of gastric juice takes place. And I
believe it is the excess of this acid gastric juice, which, on reaching
the duodenum, stimulates the secretion, and excites the flow from the
gall-bladder of the alkaline bile, just as the mineral acids do under
similar circumstances. One remark further is, however, necessary. The
quantity of alkali employed for the purpose of stimulating the
secretion, or of exciting the flow of the already secreted bile must be
small, for if much be used, the greater part of the gastric juice will
be rendered useless, in consequence of its being neutralized as fast as
it is secreted. It may be laid down as a general rule, that when we
desire to increase the flow of bile by means of a mineral acid, the
acid must be given _after food_. When, on the other hand, an alkali is
selected for that purpose, the alkali must be administered _before
food_.
For obvious reasons, both alkalies and acids are counter-indicated in
cases of jaundice resulting from active congestion of the liver; and it
is equally evident that they can be of no direct {108} service in
jaundice arising from occlusion of the bile-duct, where our object
would be rather to diminish than to increase the secretion of bile.
Alkalies, or at least some alkalies, possess certain other properties
besides those to which allusion has just been made, which may be
usefully turned to account in the treatment of hepatic diseases. For
example, we have been long told that alkaline carbonates are valuable
remedies in cases of gall-stones, in consequence of their possessing
the power of dissolving biliary calculi. Now, although I am not
sufficiently enthusiastic to believe that alkalies can have much effect
in dissolving gall-stones when once formed, I nevertheless believe that
they are of the utmost advantage in preventing and arresting their
deposition. The alkali to which I give preference is the carbonate of
soda, and the reason why I prefer it to the carbonate of potash, is in
consequence of my believing that the advantages derived from
administering alkalies in cases of incipient gall-stones are entirely
due to our being able thereby to increase the amount of glycocholate,
and taurocholate of soda present in the bile; both of which substances,
separately or combined, retain cholesterine in a soluble form; and, as
is well known, by far the greater number of biliary calculi are
composed almost entirely of pure cholesterine.
{109} The carbonate of soda has yet another advantage. It was long ago
observed by Dr. Prout that gall-stones are very common in persons of a
gouty, and rheumatic tendency of body, a fact which I have myself been
able to confirm on several occasions, by making a quantitative analysis
of the uric acid in the twenty-four hours' urine, as recommended at
page 56. In such cases the carbonated alkali is of double service, for
while increasing the solvent in the bile, it at the same time
counteracts the uric acid diathesis. In a case of gall-stones, in a
woman aged 36, where there was an almost daily deposit of fine
crystalline uric acid in the urine, it was found necessary to continue
the administration of ten grains of soda, with five of rhubarb, three
times a-day during two months, before this tendency to lithic acid
deposit was entirely overcome.
Recently I have prescribed lithia water to persons of the uric acid
diathesis in whom I had reason to suspect the existence of a
predisposition to gall-stones; and when it was necessary to combine it
with stimulants, sherry has been the wine selected. For some further
remarks on the treatment of gall-stones, see pages 114, 119, and 123.
There is a remedy to which I wish to call special attention, namely,
benzoic acid. This substance was first recommended as a remedy in {110}
jaundice by a German physician, about six years ago. Since then, I have
tried it several times, and found it of benefit in jaundice arising
from suppression. In those cases of obstruction, on the other hand, in
which I tried it, it appeared to be anything but beneficial. I give it
in the form of pill, three times a day. Dr. Green, one of my former
pupils, who has just returned from India, tells me that he acted on my
suggestion, and tried it in a case of well-marked jaundice, following
an attack of delirium tremens; and that by the end of eight days it
would have required an experienced eye to detect the tinging of the
conjunctivæ.
The following may be cited as a tolerably good example of the value of
benzoic acid in cases of jaundice from enervation:--
William M----, aged eleven years, labouring under an acute attack of
severe jaundice, came under my care at University College Hospital on
the 2nd of February. The patient appeared to be a moderately developed,
and very intelligent boy. The jaundiced condition of the skin, his
mother said, was first noticed on the 30th of January, only two days
before he came to the hospital. It was further ascertained that,
although the boy had for some length of time been subject to monthly
attacks of severe headache, and bilious vomiting, he had never before
suffered from {111} jaundice. On the present occasion he complained of
headache, but it was unaccompanied either by sickness or vomiting. On
examination the liver was found normal in size, and not in the least
tender on pressure. The bowels were moderately open, and the stools not
clay-coloured. The urine was of a deep orange tint, and the skin of a
dark yellow hue. There was an abundance of bile pigment, but not a
trace of bile-acids in the urine.
As the jaundice appeared to be the result of enervation, brought on by
over mental exertion, the boy was ordered to be kept from school, and
not allowed to read any books (his mother said he was always reading).
At the same time three grains of benzoic acid were ordered to be taken
thrice a-day.
9th February.--The skin was now very much paler, the yellow colour
being nearly gone. The conjunctivæ were still yellow, although less so
than at last visit. The urine remained unchanged in colour. He was
ordered to continue the medicine.
16th February.--Skin perfectly normal in colour; if anything perhaps a
shade whiter than natural. Conjunctivæ no longer yellow. Dismissed
cured.
In this case no medicine whatever, except the benzoic acid, was given.
As far as my experience goes, benzoic acid {112} appears to be most
useful in jaundice arising from enervation or from active congestion,
as in the case related at page 27; but in cases of the latter kind it
seems to be of little service until the acute symptoms have
disappeared. I am still rather doubtful regarding the mode in which it
acts, although one point seems clear, namely, that it hastens the
re-absorption from the tissues, and elimination from the body, of the
bile-pigment. It thus appears to play the part of a whitewash; for, as
one of my lady patients once graphically said, the medicine had
bleached her. On one occasion I tried benzoic acid in a case of
jaundice following upon an attack of ague; but it proved of no service.
Indeed, quinine, combined with mercurials, seemed in that case to be
the only remedy.
There is another drug which proves of service in jaundice from
suppression, namely, podophyllin, or May-apple. This remedy, which was
first introduced from America, is supposed to possess both the
alterative and purgative properties of mercury. As an alterative, it is
given in doses varying from 1/8 to ¼ of a grain, three times a-day; as
a purgative, from ¼ to 1 grain, as a single dose. I have given this
remedy a tolerably fair trial, and although it seems to be very useful
as a purgative in hepatic disease, and to increase the flow of bile, I
have found it open to two objections: {113} firstly, its action is
slow, and not always certain; and, secondly, in delicate females it
gives rise to a good deal of griping. This latter objection can,
however, to a certain extent, be counteracted, by combining the remedy
with hyoscyamus. On the whole, I prefer mercurials to podophyllin, and
only administer the latter in slight cases of jaundice, or in those
where mercurials are counter-indicated.
For example, in cases of feeble liver, where there is an insufficient
secretion of bile from want of nervous power, podophyllin is decidedly
of service, for in such cases mercury is of course counter-indicated.
Moreover, podophyllin can be advantageously combined with vegetable
tonics, and, when given along with gentian or quinine, forms an
admirable hepatic stimulant in some of the cases usually denominated
"torpid liver."
I cannot refrain from making a few remarks on what I consider the
injudicious employment of podophyllin. Like every new remedy, it has to
run the risk of falling into disfavour, in consequence of its too
ardent admirers blindly prescribing it in all cases of hepatic disease;
in many of which it must of necessity prove unsuitable, if not even
detrimental. In cases of jaundice, for example, podophyllin is at one,
and the same time, the bane, and the antidote. The bane in _all_ cases
of {114} jaundice from obstruction, the antidote in a _few_ cases of
jaundice from suppression. Having already indicated the cases in which
it may be administered with advantage, I shall now call attention to
one of those where it cannot be employed without injury, and one in
which it is, nevertheless, frequently given. The case I allude to is
that of gall-stones. When once a gall-stone has formed, and is blocking
up the common bile-duct, thereby causing jaundice from obstruction, it
is easy enough to understand why a substance like podophyllin, which
increases the biliary secretion, is to be avoided. It is not, however,
so easy to understand why the remedy is equally counter-indicated,
either during the formation or sojourn of a gall-stone in the
gall-bladder. This, therefore, I must explain. In speaking of the mode
of formation of gall-stones in the gall-bladder (page 43), I have
stated that their formation is due to the deposition of the less
soluble parts of the bile, either as a consequence of these ingredients
being in excess, or in consequence of the solvent, whose duty it is to
retain them in solution, being in reduced quantity. It follows, then,
as a natural result, that the longer bile sojourns in the gall-bladder,
and the thicker it becomes, the more likely are its constituents to be
deposited, and increase the size of the already existing concretion,
{115} or give origin to a new formation. It may be further added, that
the greater the amount of bile secreted, the longer is it likely to
remain in the gall-bladder, and the more concentrated to become; for,
as is well known, there is a constant absorption of the aqueous
particles of the bile going on during the whole time it is stored up in
its reservoir. If, then, during the intervals of digestion, the liver
secretes merely sufficient bile to meet the requirements of the
succeeding meal, by the end of the digestive process the gall-bladder
will be entirely emptied of its contents, and ready to receive a fresh
supply. Whereas, if the liver secretes more bile during the intervals
of digestion than the wants of the system require; after the completion
of each succeeding meal the excess of bile will remain behind in the
gall-bladder, and, while becoming stored up with that subsequently
secreted, of necessity, favour the increase or excite the formation of
gall-stones in persons predisposed to them. There being nothing more
conducive to the deposition of biliary calculi than a well-filled
gall-bladder.
As a warning against the indiscriminate use of podophyllin, I may cite
the following case, which has come under my notice as these sheets are
passing through the press. A few weeks ago I received a telegram
requesting me to visit, as {116} early as possible, a lady dwelling in
the neighbourhood of St. John's Wood. On my arrival I found the lady
suffering from a well-marked jaundice, and considerably prostrated in
consequence of her having just arrived from Brighton, where she had
gone for the benefit of her health, but where, instead of getting
better, she got considerably worse. The history of the case was, that
the lady had been seized with pain in the back (middle of dorsal
region) about three weeks before I saw her. That there had been great
tenderness in the region of the gall-bladder--so much so, that she
could scarcely tolerate the pressure of her stays; and that she had
suffered from occasional attacks of sickness after eating.
On examining the patient I found the liver enlarged, and tender on
pressure. The gall-bladder much distended, and easily felt. The skin of
a yellow hue. The stools of a pale tint. The urine very dark-coloured,
and loaded with lithates. I had, consequently, no difficulty in
diagnosing the case as one of gall-stone impacted in the common
bile-duct; but on communicating my suspicions to the patient, I was
informed that such could not possibly be the case, for during a
considerable time past she had been carefully treated with podophyllin.
Indeed, I learned to my surprise that she had taken from a quarter to
{117} half a grain of that substance nearly every day during the six
previous months!
This incidental piece of information, instead of shaking my opinion, as
the patient had apparently expected, only tended to strengthen my
suspicions, for the reasons previously given, namely, that the
podophyllin must have tended to keep the gall-bladder constantly full
of bile. I accordingly prescribed for the case as one of impacted
gall-stone, and left instructions that the stools should be carefully
examined for its appearance.
On the following day the patient felt better; but the jaundiced tint
was deeper, the stools paler, and the urine still high-coloured. The
deposit of lithates had, however, slightly diminished. Still, feeling
certain that the case was one of impacted gall-stone, I ordered the
medicine to be repeated, and the stools to be again carefully
examined.[27] On my arrival at the patient's house the next day, the
maid met me with an expression of satisfaction which could not be
misinterpreted, and I had scarcely entered the sick chamber when, with
an {118} air of triumph, she showed me a gall-stone about the size of a
large garden-pea, or small field-bean. It had been passed that morning
about 11 o'clock, that is to say about fifteen hours after the second
dose of medicine. On analysis the stone was found to consist almost
entirely of cholesterine, and I have not the smallest doubt in my own
mind that to the constant use of the podophyllin may, in a great
measure, be attributed its formation. Unfortunately the stone had been
accidentally broken before I saw it, and I was consequently unable to
ascertain decidedly whether it was a solitary calculus, or one of many.
Had it been one of several, it would of course have possessed facets.
One facet would have indicated that the stone was one of two; two
facets that three stones existed; three facets, that the gall-bladder
had contained at least four calculi; while four or more facets would
denote that the stone was one of many; whereas, if it was a solitary
calculus, no such markings would be present.
[Footnote 27: We are sometimes told to add water to the stools, and
that if gall-stones are present they will be found floating on the
surface. I have never yet been able to detect a gall-stone in this way.
The plan I recommend is, therefore, to mix the stool freely with water,
and either decant the supernatant fluid, and then add fresh portions of
water till the whole of the soluble matter is removed, or to strain the
mixture through a hair-sieve. The gall-stone in either case remains
behind, and can be readily detected.]
I may merely add, in conclusion, that from the time the stone passed,
the stools resumed their normal colour--the first two or three were
much darker than natural, in consequence of the sudden escape of the
pent-up bile--the urine gradually became pale, and clear, and the skin
regained its wonted hue. The latter change was expedited by {119} the
administration of benzoic acid, and in a week from my first visit, a
stranger would have been quite unable to detect that the patient had
laboured under a recent attack of jaundice.
A few years ago a mixture of sulphuric ether, and turpentine was very
extensively used, especially in France, as a solvent for gall-stones.
This line of treatment was adopted on account of the well-known
solubility of cholesterine in sulphuric ether, and it was thought that
the remedy would act upon the cholesterine concretions in the
gall-bladder in the same manner as it did out of the body. After a
time, faith in the powers of the mixture became shaken, and it at
length gradually ceased to be employed.