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Ebook has 346 lines and 33832 words, and 7 pages

ated 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 faeces 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.

Represents the condition of the parts in a fatal case of permanent jaundice, in which both the bile, and pancreatic ducts were completely occluded.

External surface of the left kidney, denuded of its capsule, in a case of permanent jaundice.

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.

JAUNDICE: ITS PATHOLOGY AND TREATMENT.

INTRODUCTION.

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, 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:--

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."

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.

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 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 urohaematine, and all other animal pigments, to be a direct derivative of the colouring matter of the blood.

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, and being, under the influence of hydrochloric acid, convertible into taurine, a beautiful white crystalline substance.

Thirdly,--Cholesterine, a crystalline, fatty matter, not, however, peculiar to bile, but found in various tissues, and secretions of the body.

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 torulae 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 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 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.

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.

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. At present, however, I must limit myself entirely to the consideration of bile.

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 . Later 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 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 nor amylaceous portions 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 pointed out how the neutral fats of our food are transformed into fatty acids during their sojourn in the stomach; and Bidder and Schmidt 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.

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?" 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. 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 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.

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