Chapter I: Preface

"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

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 . . . . . 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 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 . . . . . . . . . . . . . . . . . . . . . . . . . . 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.

PLATE I.

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.

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.

" 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.--Page 86.

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JAUNDICE: ITS PATHOLOGY AND TREATMENT.