Part 8
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.
Within the last year or two, Dr. Bouchut[28] has revived the same 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