theory with another form of remedy, namely, chloroform, which he
administers internally, with the view of dissolving any inspissated
bile or biliary calculi that may be lodging in the gall-bladder. Dr.
Bouchut states that he has treated one case of gall-stones in this
manner with success. Now, although I have not the slightest desire to
throw discredit on the statement of Dr. Bouchut, I must candidly admit
that I am very much inclined to doubt the accuracy of his observations.
In the first place, it is always {120} extremely difficult to ascertain
the existence of biliary concretions so long as they remain in the
gall-bladder, and it is equally difficult to know, after gall-stones
have been once passed by a patient, whether or not all have come away.
If, then, we administer chloroform to a patient, either before or after
a gall-stone has actually passed, we cannot, with anything approaching
to certainty, attribute the cessation of his symptoms to the
circumstance of the chloroform having dissolved a gall-stone. In fact,
on physiological grounds, I very much doubt the efficacy of either
sulphuric ether or chloroform as solvents of gall-stones in the living
body. Sulphuric ether, and chloroform would no doubt dissolve a
concretion of cholesterine in the gall-bladder were they admitted into
that viscus in sufficient quantity, and in a pure state. But we have no
proof that such is the case. On the contrary, we know, at least in as
far as chloroform is concerned, that exactly the opposite is the fact;
for no sooner does chloroform become absorbed, and mingled with the
constituents of the blood, than it becomes decomposed, the chlorine
combining with the blood, and the formic acid being set free.[29] And
even supposing that sulphuric ether and chloroform existed in the blood
in a free state, they could not possibly do so in a sufficiently {121}
concentrated form to be able to act as solvents of biliary calculi.
[Footnote 28: "Edin. Med. Journ." 1861, p. 398.]
[Footnote 29: Jackson, Comptes Rendus, February 25th, 1856.]
My own experiments on animals have shown me how rapidly fatal even
small quantities of chloroform are when injected into the circulation,
and a similar remark is equally applicable to sulphuric ether. A few
drops of these substances can very readily be injected into the
circulation with impunity;[30] but the quantity must not be increased
beyond a certain amount, far less than could possibly dissolve a single
grain of cholesterine, otherwise immediate death follows the operation,
by inducing a state of body closely resembling rigor mortis, from which
the animals never recover. I am, therefore, completely at a loss to
understand how these remedies can be of service in dissolving
gall-stones in the living body; and as I make it a rule as seldom as
possible to prescribe a remedy without a knowledge of its physiological
action, I have not yet ventured on an empirical trial of the effects of
sulphuric ether or chloroform administered internally in cases of
gall-stones. For some remarks on the passage of biliary calculi, see
page 123.
[Footnote 30: Vide the Author's paper on a new method of producing
diabetes artificially in animals, by the injection of
stimulants--alcohol, ether, chloroform, ammonia, &c.--into the portal
circulation. Comptes Rendus de la Societé de Biologie de Paris. 1853.]
{122} Taraxacum has been widely used in hepatic disease associated with
jaundice, and is believed to be particularly well adapted to cases
arising from congestion. As in such cases I generally trust to more
potent drugs, my experience with this remedy has been too limited to
admit of my offering an opinion of its value.
The majority of cases of jaundice from obstruction, are much less under
the power of remedial agents than those arising from suppression, for
we have here three distinct conditions to combat: Firstly,--The
derangements originating in the absence of bile from the digestive
canal. Secondly,--The morbid effects arising from its accumulation in
the ducts, and consequent interruption to the hepatic functions.
Thirdly,--The general poisonous action on the system, of the
re-absorbed bile.
As regards the first of these effects,--namely, the derangements
arising from an absence of bile from the digestive canal, it may be
said that if these were the only difficulties with which we had to
contend in cases of jaundice from obstruction, they could easily be
overcome. For, in the first place, the absence of bile is not attended
with any immediate danger, a circumstance which has led to the common
belief that the presence of bile is not absolutely essential to life.
Experiments on dogs {123} with biliary fistulæ, like those before
referred to, as well as cases in the human subject, have proved that
life may be sustained, under certain conditions, for a very long
period, without bile reaching the intestines. Indeed, the only
immediate bad effects which appear to result from its absence, are
costive bowels, great flatulence, and extremely offensive stools. The
indirect bad results,--namely, loss of flesh, &c., as has been proved
by experiments on animals, can be counteracted by giving an additional
amount of food; and even the direct results of constipation,
flatulence, and foetor, may be overcome by appropriate remedies.
The secondary morbid effects, namely, those arising from the
accumulation of bile in the ducts, are unfortunately not so easily
under control. Could we remove the cause of obstruction, these would,
of course, immediately cease. This, however, is seldom in our power,
except in the case of gall-stones, the expulsion of which we can aid in
various ways. In general, we can very successfully aid the passage of a
stone through the ducts by administering an anodyne containing a full
dose of the tincture of belladonna, which apparently assists in
dilating the duct. Placing the patient in a warm bath is also of
service; and when the paroxysms of pain are very severe, the occasional
inhalation of the vapor from a couple {124} of drachms of sulphuric
ether poured on a handkerchief, made into the form of a cup, is
generally attended with great relief. Each of these modes of treatment
may be followed either by a brisk emetic, or purgative, in the hope
that the efforts of vomiting or purging may hasten the expulsion of the
stone, either by the mouth or rectum.
It ought never to be forgotten, that the evil results of a gall-stone
do not always cease when it has reached the intestinal canal. Even
death itself has resulted from the impaction of a gall-stone in the
duodenum. When we have any suspicion that the stone is large, our
treatment must therefore be continued until its extrusion by the mouth
or rectum has been accomplished.
When the occlusion of the common bile-duct is caused by an organic
tumour, no treatment of ours can be expected to remove the obstacle,
and sooner or later the patient is carried to an untimely grave. Our
efforts of relief in such a case ought therefore to be directed to
another channel; and here, in order to give the sufferer at least some
chance of recovery, even although it be little better than a forlorn
hope, I cannot refrain from recommending, in cases of permanent
occlusion of the duct, in which there is great distension of the
gall-bladder, the establishment of an artificial biliary fistula. Were
this done, the patient would be placed, as {125} nearly as possible, in
the same condition as an animal in which the operation has been
performed for physiological purposes, and, we might almost hope, with
an equally favourable result, at least, in as far as the biliary
functions are concerned. In the first place, we would have removed all
the derangements resulting from the interruption to the flow of bile,
and consequent upon the distension of the ducts. In the second place,
we would have obviated the danger arising from the poisonous effects of
the re-absorbed bile, which the experiments previously cited (page 98)
show are of no trifling nature; and, lastly, we would only require to
combat the evils arising from the absence of the biliary secretion in
the digestive process, which, as was before said, can to a certain
extent be overcome by giving an additional quantity of food, and paying
attention to the bowels. In these remarks I have omitted taking into
consideration the effects that might arise from the tumour, or other
obstructing cause to the biliary secretion, for these would in no way
be directly influenced by the establishment of the biliary fistula.
The artificial establishment of a biliary fistula in the human subject,
is not such an Utopian idea as might at first be imagined. Distended
gall-bladders having been several times tapped with {126} success, both
in this and other countries, and the permanent establishment of a
fistula, if done in the manner I shall immediately point out, would, in
my opinion, be a much less hazardous operation than simple tapping.
Biliary fistula in dogs are generally made in a single operation, by
cutting through the abdominal parietes, seizing the gall-bladder,
stitching it to the lips of the wound, and inserting a cannula. Here
there is always some danger of the wound not healing by the first
intention, and of the passage of bile into the abdominal cavity. In the
case of the human subject, I should, therefore, recommend the inducing
of the adhesion of the gall-bladder to the abdominal parietes by means
of an escharotic, before making the opening; in which case, I can
scarcely imagine that the operation would prove one either of
difficulty or danger. But even supposing that it were not entirely free
from either, it would still surely be preferable to give the patient at
least a chance of prolonging his life, rather than to permit a fatal
affection to run its uninterrupted course, which we know can, at best,
be calculated by months only.
In those cases of jaundice from obstruction, where it might be
considered inadvisable to adopt the plan here suggested, we ought in
our treatment carefully to avoid the common error of {127}
administering mercury, or other substances supposed to have the power
of augmenting the biliary secretion. We must equally avoid the
administration of foods likely to produce a similar effect, for the
sufferings of the patient are not so much due to a deficient secretion,
as to a want of biliary excretion. Our whole energies should be
directed to sustaining the strength of the patient, and mitigating, if
possible, the physical effects of the accumulation of the bile in the
gall-bladder and biliary ducts, as well as the poisonous action of the
re-absorbed secretion. This, I believe, we can best do by administering
light and readily digested food, keeping the bowels open by gentle
purgatives, and favouring the elimination of the biliary constituents
from the blood by mild diuretics. Our object may be still further
advanced by artificially supplying the place of the absent bile in the
digestive process. _Not, however, in the way usually adopted, of giving
inspissated bile along with the food;_ a method of treatment which
originated ere modern physiology rent the veil of therapeutical
empiricism. In the first place, the bile prepared according to the
method indicated in the pharmacopoeias, has its most essential
properties destroyed during the process of preparation. And in the
second place, we have hitherto been instructed to administer it {128}
at the very time which modern research has proved to be the most
unsuitable that could possibly be devised. In administering bile
immediately after food, as is usually done, we most effectually produce
the contrary result to what is intended. When bile mingles with gastric
juice, it destroys the digestive power of the latter, so that by giving
the bile immediately or soon after a meal, we really diminish instead
of increase the digestive functions. My experiments, both chemical, and
physiological, have led me to propose not only a new method of
preparing bile for medicinal purposes, but also to suggest an entirely
new mode of administering it.
Firstly,--As regards the method of preparation. Nothing can be more
simple, and at the same time more effectual. Fresh bile, taken directly
from the gall-bladder of the newly killed pig, is filtered, through
very porous filter-paper, to free it from mucus; it is then as rapidly
as possible evaporated to dryness at a temperature not exceeding 160°
Fahr. The bile, as soon as dried, is ready for use. Simple as this
operation appears in theory, there are two practical difficulties
connected with it--1st, Bile filters very slowly, and consequently
little must be put into the filter at a time. 2nd, Bile is rather
hygroscopic, and consequently, in order to get it dried quickly, it is
necessary {129} to spread it over a large surface. If the bile has been
well prepared, that is to say, thoroughly freed by filtration from its
ferment mucus, and well dried, it will keep in stoppered bottles for
many months without losing any of its active properties.
Having stated that bile as at present employed more frequently does
harm than good, by retarding instead of hastening the digestive
process, I have now to point out the manner in which it may be given
with advantage.
If bile be administered, as I propose, at the _end_ of stomachal
digestion, it will, as in the healthy organism, act on the chyme at the
proper moment, and thereby render it fit for absorption. In order still
further to ensure the action of the bile being delayed until the food
is in a condition favourable to its action, that is to say, until it is
ready to pass from the stomach into the duodenum, I have had the bile,
as above prepared, put into capsules,[31] which are not readily acted
on by the gastric juice. While in the stomach, the capsules, however,
swell up from the size of a pea to that of a small gooseberry, and at
the same time become so soft that they will readily burst in passing
the pylorus into the duodenum, and thereby allow {130} the bile to
escape, and come in contact with the food at the precise moment its
action becomes requisite in the digestive process.[32] The capsules not
only preserve the active properties of the bile for an almost
indefinite period, but they have the advantage of most effectually
preventing the patient tasting the remedy.
[Footnote 31: The capsules were made by Savory and Moore, and I have
every reason to be satisfied with the manner in which they accomplished
the object in view.]
[Footnote 32: Prepared bile, made up into an ordinary pill, dissolves
in gastric juice in a quarter of an hour. When the pill is silvered it
is dissolved in half an hour, and when gilded, in forty minutes.
Whereas, in the same specimen of gastric juice, the capsules prepared
for me by Savory and Moore, although swollen to more than three times
their original size, were nevertheless intact at the end of an hour and
a half. They readily broke on being gently squeezed between the finger
and thumb, it is not therefore probable that they would pass the
pylorus in this condition without giving way, and allowing their
contents to escape.]
Each capsule contains five grains of the prepared bile; and five grains
is equal to one hundred grains of liquid bile fresh from the
gall-bladder. Two capsules therefore represent two hundred grains of
pure bile, a quantity (though less, perhaps, than the healthy organism
consumes during each digestion) which in most cases would be sufficient
for the wants of the system. If, however, a larger amount be considered
necessary, there is no reason why three or more capsules should not be
given. By the administration of prepared bile in the manner here
described, the physician is enabled to imitate nature, and {131} supply
an important element to the system; which, although incapable of curing
the disease, can nevertheless ward off for a time the fatal
termination.[33]
[Footnote 33: It is not alone in cases of jaundice that the prepared
bile may be of service, but also in the various forms of duodenal
dyspepsia, so common among the literary classes, consequent upon either
a deficient quantity, or an abnormal quality of bile.]
{132} TABULAR VIEW OF THE PATHOLOGY OF JAUNDICE, ACCORDING TO THE
AUTHOR'S VIEWS.
|From |Enervation. . . . . . |Fright.
|Suppression.| |Anxiety.
| | |Over-mental exertion.
| | |Concussion of Brain.
| |
| |Congestion |Active. . |Hepatitis.
| |of Liver. | |Direct Violence.
| | | |Dyspepsia.
| | | |Ague.
| | | |Typhus.
| | | |Typhoid.
| | | |Scarlatina.
| | | |Pyæmia.
| | | |Yellow Fever.
| | | |Poison.
Jaundice.| | |
| | |Passive. |Heart Disease.
| | |Pneumonia.
| | |Pleurisy.
| | |Imperfect Circulation
| | | in the Newborn.
| |
| |Absence of Secreting |Cancer.
| | Substance. |Cirrhosis.
| |Fatty Degeneration.
| |Amyloid Degeneration.
| |Atrophy. |Acute.
| | |Chronic.
|
|From |Congenital Deficiency |Small Ducts (?)
|Obstruction.| of Ducts. |Common Duct.
|
|Accidental Obstruction|Gall-stones.
| in course of Duct. |Hydatids.
| |Foreign Bodies
| | from Intestines.
|
|Closure of Outlet. . |Pressure of Pregnant
| Uterus.
|Impacted Fæces in
| Transverse Colon.
|Organic Disease of
| Pancreas, or of
| neighbouring Organs.
|Abscess in Head of
| Pancreas.
|Ulcer of Duodenum.
{133}
INDEX.
A.
Abscess in kidney, 58
in pancreas, 86
Acids, treatment by, 106
of bile, 8, 36, 58
Acute atrophy of liver, 34
Ague, jaundice in, 28
urine in, 28
Albumen in urine of ague, 28
Albuminose, 14
Alkalies, treatment by, 106
Artificial jaundice, 95
Atrophy of liver, 34
B.
Benzoic acid, treatment by, 109
Bidder's researches, 16
Bile, acids of, 8, 36, 58
tests for, 58, 61
action of, on albumen, 14
action on fats, 16
analysis of, 83
colour of, 10
diseased, 83
drunk by Caffres, 19
effects of food on, 11
inorganic constituents, of, 10
pigment in kidneys, 57, 86
mode of secretion, 11
nature of, 7, 83
in digestive process, 15
essential to life? 13
specific gravity of, 10
treatment of jaundice by, 127
resin, 10
Biliary fistula, 124
Biliverdine, 7, 56
Blood in jaundice, 100
Budd's (Dr.), views, 7, 30
C.
Cancer of liver, 32
of pancreas, 46
Carbonate of soda, treatment by, 108
Cherry-stones in bile-ducts, 45
Cholesterine, 8, 82, 108
Colour of bile, 10
Congestion, hepatic, 24, 104
Cystine, 86
D.
Diseases with which jaundice is associated, 3
Dyspepsia, 26
E.
Eiselt (Dr.), 68
Enervation, 22, 110
Epidemic jaundice, 90
F.
Farre (Dr.), case, 104
Fat in fæces, 54, 72
absorption of, 16
Flatulence, 13
Frerichs on mechanism of jaundice, 6, 33
Fright, effect of, 23
G.
Gall-bladder, absence of in animals, 12, 41
congenital deficiency of, 40
Gall-stones--
mode of escape from gall-bladder, 44
mode of formation, 43
in common duct, 44
in gall-bladder, 43
in intestines, 123
treatment of, 108, 114, 119, 123
carbonate of soda in, 108
chloroform in, 119
podophyllin in, 115
sulphuric ether in, 119
Glycocholic acid, 8, 97
Glycocholate of soda, 8
injected into blood, 39
H.
Heart disease, jaundice in, 30
Hepatic congestion, 24, 104
Hoppe's method, 58
Hydatids in bile-ducts, 45
I.
Impacted fæces, effect of, 46
Inflammation of liver, 24, 104
Inorganic constituents of bile, 10, 83
Intestinal excretion, analysis of, 51
Introduction, 1
J.
Jaundice, artificial, 95
from acute atrophy of the liver, 34
absence of bile-duct, 40
absence of gall-bladder, 41
absence of secreting substance, 31
ague, 27
blood-poisoning, 27, 93
blow on head, 24
cancer, 32
enervation, 22, 110
entozoa, 45
epidemic, 90
from fright, 23
gall-stones, 42, 116
hepatic congestion, 24, 104
mental emotion, 22, 110
active hepatic congestion, 25, 104
passive hepatic congestion, 29
disease of the pancreas, 46
pregnancy, 46
obstruction, 39, 71
scarlatina, 93
suppression, 20
typhus, 27
tubercle, 32
zymotic disease, 27, 90
mechanism of, 19
treatment of, 101
K.
Kidneys as eliminating organs, 11
Kühne's views, 58, 98
L.
Lenz's experiments, 16
Leucine, 63, 80, 95
Liver cells, 38, 85
Liver, extirpation of, 11
M.
Marcet (Dr.), 16
Martin (Dr.), 90
Matteucci (Prof.), 17
Melanine in urine, 68
Mercurials, treatment by, 102
Milk in jaundice, 22
O.
Obstruction, of bile-duct, 71
of pancreatic duct, 71
treatment in jaundice from, 122
P.
Pancreas, abscess in, 87
Pancreatine, 73
Pancreatic juice, 18
absence of, 73
Pathology of jaundice, tabular view of, 132
Pathological conditions with which jaundice is associated, 3, 132
Pettenkofer's test, 36
Pipe-clay stools, 52
Pneumonia, jaundice in, 30
Podophyllin, treatment by, 112
in cases of gall-stones, 114
Prance (Dr.), 71
Pregnancy, jaundice in, 91
Pregnant uterus, effect of, 46
Prepared bile, treatment by, 127
S.
Saint-Vel (Dr.), 91
Scarlatina associated with jaundice, 93
Schmidt's researches, 16
Specific gravity of bile, 10, 83
Sputa in jaundice, 22
Stools, fat in, 54, 72
colour of, 52
Sugar, a normal constituent of bile, 10
in urine, 70
Sulphuric ether, 119
Suppression, jaundice from, 20
Sweat in jaundice, 22
T.
Table of the pathology of jaundice, 132
Taurocholate of soda, 8
Taurocholic acid, 8, 97
Tears in jaundice, 22
Theories regarding mechanism of jaundice, 5
Treatment of jaundice, 101
by acids, 106
by alkalies, 106
by benzoic acid, 109
by biliary fistula, 124
by carbonate of soda, 108
of gall-stones, 108, 114, 119, 123
by Lithia water, 109
by mercurials, 102
of jaundice from obstruction, 122
by podophyllin, 112
by prepared bile, 127
by taraxacum, 122
Tubercle, 32
Tyrosine, 63, 80, 95
U.
Urea, 70
Uric acid, 56, 70
Urine, analysis of, 55
in acute atrophy, 36
in jaundice from ague, 28
in obstruction of bile-duct, 74, 78, 79
bile-acids in, 36, 58, 74, 97
colour of, 55
tyrosine and leucine in, 36, 80, 95
melanine in the, 68
uric acid, 56, 70
sugar in, 70
Urohæmatine, 7, 55
W.
Wilks's cases, 35, 40
Y.
Yellow atrophy of liver, 34
WILLIAM STEVENS, PRINTER, 37, BELL YARD, TEMPLE BAR.