Jaundice: Its Pathology and Treatment With the Application of Physiological Chemistry to the Detection and Treatment of Diseases of the Liver and Pancreas

"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.

CONTENTS.

PAGE INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

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 . . . . . . . . . . . . . . . . . . . . . . . 3

Frerichs's theory of jaundice--Theory of jaundice hitherto most favoured in England--Dr. Budd as its exponent . . . . . . . . 6

Nature of bile--Biliverdine--Bile acids; glycocholic, and taurocholic acids--Cholesterine--Bile resin--Sugar--Inorganic constituents--Specific gravity, reaction, and colour of normal bile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

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 . . . . . . . . . 11

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 . . . . . . 13

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 . . . . . . . . . . . . . . . . 19

General view of the pathology of jaundice from suppression, showing how the coloration of the skin, and urine is produced in such cases . . . . . . . . . . . . . . . . . . . . . . . . 20

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 . . . . . 22

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 . . . . . . . . . . . . 24

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 29

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 . . . . . . . . . . . . . . . . . . . . . 31

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 34

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 . . . . 39

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 . . . . . . . . . . . . . 42

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 . . . . . 46

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 . . . . . . . . . . . . . . . 51

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 . . . . . . . . . . . 55

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 . . . . . . . . . . . . . . . . . . . . . . . . . . 58

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 . . . . . . . . . . 63