"Time being money," quite as much to the professional as it is to the mercantile man, the author has endeavoured in the accompanying monograph not only to condense his material, but to exclude the consideration of any question not directly bearing upon the pathology or treatment of jaundice; indeed, as stated in the Introduction, one of the chief objects of the author having been to point out how valuable an adjunct modern physiological, and chemical knowledge is in the diagnosis, and treatment of hepatic and pancreatic disease, he has neither dwelt on the literature nor discussed the old theories of the mechanism of jaundice, but limited himself almost entirely to a brief exposition of his own views. For the sake of brevity, he has at page 132 put into a tabular form the pathology of jaundice, according to the opinions expressed in the body of the volume.
As the object of all theory, and the aim of all science, is to insure wise practice, the author desires to call special attention to that portion of the work devoted to the chemistry of the excretions, feeling, as he does, that we are entering upon the threshold of an important department of medical inquiry, which, sooner or later, will be followed by valuable practical results. He would also direct the special attention of his readers to the chapter devoted to treatment, being sanguine enough to imagine that the adoption of the principles he has enunciated regarding the mode of action, and administration of the remedies usually employed in hepatic affections, may conduce to a more rational and successful method of treatment than has hitherto been employed. He even goes far enough to hope that the result of the treatment, as shown in the cases cited, will not only justify the adoption of the principles on which it is founded, but also prove a strong incentive to others to follow the line of diagnosis he has striven to inculcate.
In some portions of the volume the statements of the author may, perhaps, appear to be rather dogmatic; if so, he would remind his readers that this has arisen from the circumstance of so many old dogmas, and deeply-rooted prejudices having to be combated, for he is quite alive to the fact, that what we regard as scientific truth is in no case incontrovertible certitude, and that the deductions of to-day, in an advancing science like that of medicine, may require material alteration when viewed in the light of the morrow. But he is equally convinced of the fact, that if men fold their arms, and refrain from acting until every link in the chain of knowledge is forged, all progress will be arrested, and the day of certainty still further postponed.
Too long have we reversed the natural order of things, and commenced the study of medicine where we ought rather to have left it off. Too long have we striven, by studying pathology ere we were sufficiently acquainted with physiology, to place the pyramid on its apex instead of on its base; and thus it is we remained so long ignorant of the fundamental doctrine, that the same laws which regulate health, regulate disease. Nature does nothing on a small scale, and the more we study her the more we admire the uniformity, and extensive applicability of her laws. If we pry into the ultimate structure of our bones, we find they receive their nutriment by a system of irrigation, carried on through lakes, and rivers (lacunæ, and canaliculi); and if we examine the periosteum surrounding them, the ligaments attaching them, or the muscles covering them, we still find, that, notwithstanding the diversity in structure, and use, the one system of irrigation pervades them all. We may even go a step further, and say that the same law which governs the animal governs also the vegetable kingdom. Indeed, the further science advances, the more apparent does it become, that not only the animal, and vegetable, but even the organic, and inorganic, form but one world, regulated by the same laws.
A knowledge of organization, important though it be, is yet less indispensable to the physician than a knowledge of healthy function, for it is the latter which elucidates the dark problems of life, it is the latter which proves the golden key to the comprehension of disease.
Although not even the most ardent admirers of medicine can say, that it as yet merits the name of an exact science, this ought neither to destroy our hopes nor trammel our labours. With the stethescope, microscope, and other physical means of diagnosis a new era dawned upon our art; and now the members of the new school which is rising up, and carrying chemistry into the domains of medicine, are the pioneers of the revolution which is soon to follow. If we look back to what the exact sciences of to-day were in former times, we shall find they were much less perfect then, than medicine is now. Astronomy and chemistry were but astrology and alchemy. If, then, we draw a picture of the future from the progress of the past, we need have no hesitation in saying that chemistry rightly applied, and physiology justly interpreted will, ere many generations pass away, reveal the deepest secrets of diseased action, and although unable to banish death, will yet enable the practitioner to follow with unerring certainty the various morbid changes occurring in the frame.
77, HARLEY STREET, CAVENDISH SQUARE,
March, 1863.
INTRODUCTION
Pathological conditions with which jaundice is associated—Those of the liver itself—Those of the bile-ducts—General affections of other organs of the body exerting an influence on the biliary secretion—Zymotic diseases—The effects of certain poisons
Frerichs's theory of jaundice—Theory of jaundice hitherto most favoured in England—Dr. Budd as its exponent
Nature of bile—Biliverdine—Bile acids; glycocholic, and taurocholic acids—Cholesterine—Bile resin—Sugar—Inorganic constituents—Specific gravity, reaction, and colour of normal bile
Manner in which bile is secreted—Liver both a formative and excretive organ—Animals without gall-bladders—Effects of food on the colour and quantity of the bile
Is bile essential to life?—Effect on the system of absence of bile in the digestive process—Death from starvation as a result—Benefit derived from an additional quantity of food—Uses of bile in the animal economy—Necessary to the absorption and assimilation of food—Bile as a digestive agent—Its action on the chyme—Experiments on its influence over the absorption of fatty matter—Its relation to the pancreatic juice—Bile taken internally by Caffres
General view of the mechanism of jaundice—Two great divisions—Jaundice from suppression, and jaundice from re-absorption—1st subdivision: jaundice arising from enervation, disordered hepatic circulation, and absence of secreting substance—2nd subdivision: jaundice arising from congenital deficiency of the bile-ducts, and from accidental obstruction of the bile-ducts
General view of the pathology of jaundice from suppression, showing how the coloration of the skin, and urine is produced in such cases
Mechanism of jaundice as a result of enervation—Influence of nervous system on secretion—Effect of mental emotion on biliary secretion, as observed in dog with biliary fistula—Action of fright in paralyzing nerve force
Mechanism of jaundice from hepatic congestion—Active congestion—General view of the effects of congestion on glandular secretion—Reason why the biliary secretion is not usually completely arrested—The absence of pipe-clay stools explained—Example of jaundice from hepatic congestion—Jaundice from zymotic disease, and other cases of blood-poisoning, have a similar mechanism—Example of jaundice following upon ague—Effect on the urine—Analysis of the urine a clue to the nature of the case
Passive congestion of the liver as a cause of jaundice—Cases associated with heart disease, pneumonia, &c.—Explanation of the reason why jaundice is so frequently absent in such cases
Mechanism of jaundice arising from suppression consequent upon absence of the secreting substance—Cancer, tubercle, &c.—Effects of the position of the morbid deposit in modifying the result
Jaundice arising from acute, or yellow atrophy of the liver—State of the urine in such cases—Presence of bile-acids—Pettenkofer's test—Tyrosine and leucine in the urine—An example of the affection occurring in a young woman—Exciting cause—State of the liver tissue—Poisonous effects of glycocholate of soda injected into the circulation
Mechanism of jaundice arising from the re-absorption of the secreted but retained bile—Jaundice arising from a congenital deficiency of the ducts—History of a case
Pathology of jaundice resulting from the accidental obstruction of the bile-ducts—Mode of formation of gall-stones—Jaundice only present when the stone is lodged in common duct—How gall-stones may imperil life without inducing jaundice—Modes of escape from the gall-bladder—Presence of foreign bodies, such as cherry-stones in gall-duct—Jaundice arising from hydatids impacted in the common duct
Mechanism of permanent jaundice from obstruction—Resulting from organic disease—Cancer of head of pancreas—Effect of the dilatation of the bile-ducts in the liver—Effect on the nutrition of the parenchyma of liver—Different stages in size through which the liver passes—Difficulties of diagnosis—Cause often obscure—Key to its detection
Analysis of the intestinal secretion an aid to the diagnosis of obscure cases of abdominal disease—Colour, nature, and chemical composition of the stools—Changes produced in them by different foods, and remedies
Examination of the renal secretion—Diagnostic value of the colour of the urine—Colour produced by urohæmatin to be distinguished from that produced by biliverdine—Simple method of separating the pigment from the urine—Advantage of at the same time ascertaining the quantity of uric acid present—Effect of the bile pigment becoming deposited in the kidneys—Production of secondary disease
Diagnostic value of the presence of the bile-acids in the urine—Views of Frerichs, Städler, and Kühne—Hoppe's method of detecting the bile-acids—Frerichs's theory of the transformation of bile-acids into biliverdine shown to be untenable
Diagnostic value of the presence of tyrosine, and leucine in the urine—Microscopic appearances of these substances—Mode of separating them from urine—Chemical tests
Melanine in the urine in cases of cancer of the liver—The characters by which it is to be distinguished from bile pigment—Case related showing the value of the test
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 fæces 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
Jaundice from obstruction in its latter stage complicated with jaundice from suppression
Epidemic jaundice—Among soldiers—Among pregnant women—Among the entire civil population—Its mechanism—Its cause—Case of jaundice supervening upon scarlatina
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
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
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
Tabular view of the pathology of jaundice according to the author's views
INDEX
Represents the condition of the parts in a fatal case of permanent jaundice, in which both the bile, and pancreatic ducts were completely occluded.
(a) Atrophied liver.
(b) Transverse section of the left lobe, showing the mouths of the enormously distended gall-ducts.
(c) Enlarged gall-bladder.
(d) Dilated cystic duct.
(e) Distended hepatic, and common duct.
(f) Ulceration in duodenum, in the situation of the opening of the gall-duct into the intestines.
(g) Pancreas with enlarged head (h), and enormously distended duct.
PLATE II.
External surface of the left kidney, denuded of its capsule, in a case of permanent jaundice.
(a) Small specks of bile pigment deposited in the renal tissue, and blocking up the urine tubes.
(b) Small abscesses scattered throughout the tissue of the kidney.
Fig. 1. Crystals of glycocholate of soda, mag. 90 diam.
Fig. 2. Taurocholate of soda, as found in the form of globules of various sizes.
Fig. 3. Crystals of cholesterine.
Fig. 4. Crystals of pure tyrosine.
Fig. 5. Spiculated balls of tyrosine, from the urine of a case of acute atrophy of the liver.
Fig. 6. Globules of leucine.
Fig. 7. Cholesterine crystals.
Fig. 8. (a) Crystals of cystine.
(b) Hepatic cells, showing entire absence of fat globules.
(c) Caudate or spindle-shaped cells, from epithelial lining of hepatic ducts.
Having entitled this monograph "Jaundice, its Pathology and Treatment," it may, perhaps, be necessary for me to state at the beginning that by so doing it is not to be supposed that I regard jaundice as a disease per se. On the contrary, I look upon it in the same light as I do albuminuria, which is not of itself a disease, but only the most prominent symptom of several widely-differing pathological conditions. So also the peculiar state of body characterised by yellow skin, saffron-coloured urine, and pipe-clay stools, is itself but a symptom of morbid action. It may be asked, "Then why do you treat of jaundice as if it were a disease?" To this I reply, "Because, although the condition called jaundice be merely a manifestation of morbid action, and one, too, requiring neither skill nor experience to detect, the proper comprehension of its true mechanism is of much practical importance to the physician, for without this knowledge it is impossible for him to treat it with any chance of success. Nay, even the remedies for jaundice become dangerous weapons, if unskilfully applied." In fact, it is almost unnecessary to apologise for treating of jaundice as a disease per se; for, notwithstanding all that has been written upon the subject, it is universally admitted that the simplicity of its diagnosis is only equalled by the obscurity of its pathology, and the uncertainty of its treatment; and no one at all conversant with the literature of jaundice can be in the least degree surprised at this statement. On the contrary, on glancing at the immense variety of morbid states, and known pathological conditions with which it is associated, he cannot fail to admit its truth.
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:—
Firstly, IN DISEASES AFFECTING THE LIVER—
(a) Cancer.
(b) Tubercle.
(c) Cirrhosis.
(d) Inflammation.
(e) Atrophy.
(f) Amyloid, and
(g) Fatty degeneration.
Secondly, IN DISEASES OF THE BILE-DUCTS—
(a)
(b)
(c)
(d)