Part 7
Into the cellular tissue of the back of a full-grown, and healthy-looking terrier dog, I injected the bile taken from the gall-bladders of three healthy dogs, two of which had just been killed, the other had been dead a few hours. The bile was in the first two cases neutral, in the third faintly alkaline. All the biles seemed perfectly normal. They contained no crystals of any kind. Eighteen hours after the operation the animal appeared quite well, and took his food heartily. Four hours later a remarkable change took place. The dog looked dull and drowsy, and could not sustain himself on his legs; when left to himself, he {99} lay on his side, and made not the slightest movement. He was not only paralyzed, but even the nerves of sensation had ceased to act, for when his tail, and feet were pinched, he was quite insensible to pain. The pupils were dilated, and the body felt cold. Death occurred twenty-three hours after the operation. Urine, and fæces were passed in small quantity immediately before death. The urine was strongly alkaline, and effervesced on the addition of sulphuric acid, thereby showing that it contained alkaline carbonates. Prismatic phosphatic crystals were present in the still fresh urine.
When tested for bile-acids, only the faintest trace was obtained, after the urine had been cleared with the acetate of lead and sulphuretted hydrogen.
The tissues of the abdomen and thorax were oedematous, but, within an hour after death, had not the disagreeable odour found in animals killed by injecting pure bile-acid. (_See_ foot-note at p. 39.)
This experiment was again repeated with alkaline bile. Two ounces of ox-bile of a specific gravity of 1025 were injected under the skin of a large pointer dog. In twenty-four hours the animal was dead; the sub-cutaneous tissue all round the seat of the injection, red, inflamed, and infiltrated with {100} blood. The urinary bladder was empty. The gall-bladder contained 1½ ounces of dark bile of a specific gravity of 1040. When examined with the microscope, the blood was found to contain a large excess of white corpuscles.[26]
[Footnote 26: It has just been said that the blood contained a large amount of white blood corpuscles. This reminds me of a fact that I have omitted to mention--namely, that in a case of severe jaundice from suppression, in consequence of cirrhosis of the liver, I found that the blood possessed a very treacle-like aspect. The serum was of a dingy yellow hue, and felt somewhat sticky to the fingers. Under the microscope the blood corpuscles were found to be large, and flabby, had a great tendency to adhere together by the edges, and become flattened on the sides whenever they came in contact. Moreover, the corpuscles looked as if they had no distinct cell-wall; some, and that too, in the freshly drawn blood, gave off buds, others split into two, each half when separate looking like a distinct blood corpuscle. In fact, the blood looked more as if it had been acted upon by some powerful chemical agent than anything else. I again examined it after the death of the patient, and found it presented all the above characters in a still more marked degree. To the naked eye it had a viscid, tarry appearance.]
These results rather militate against the theory of the bile being re-absorbed, in an unchanged state, into the circulation, after the completion of the digestive process.
{101} TREATMENT OF JAUNDICE.
After what has been said regarding the pathology of jaundice, I need scarcely remark that the treatment must vary according to the kind of disorder we have to deal with. A line of treatment found to be beneficial in one case of jaundice, might prove very hurtful in another. For, as has been shown in the foregoing pages, jaundice from suppression, and jaundice from obstruction, are, it might be said, two entirely different diseases, with only the symptoms of yellow skin, high-coloured urine, and pipe-clay stools in common. The success of our treatment will therefore depend on our powers of diagnosis.
The general principles upon which the treatment of jaundice must be founded are as follows:--
The first and great object is, of course, as in the case of every other 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.