Chapter V: Introduction (4)

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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.

{133}

INDEX.

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

Benzoic acid, treatment by, 109

Bidder's researches, 16

Bile, acids of, 8, 36, 58
tests for, 58, 61
action of, on albumen, 14
action on fats, 16
analysis of, 83
colour of, 10
diseased, 83
drunk by Caffres, 19
effects of food on, 11
inorganic constituents, of, 10
pigment in kidneys, 57, 86
mode of secretion, 11
nature of, 7, 83
in digestive process, 15
essential to life? 13
specific gravity of, 10
treatment of jaundice by, 127
resin, 10

Biliary fistula, 124

Biliverdine, 7, 56

Blood in jaundice, 100

Budd's (Dr.), views, 7, 30

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Jaundice: Its Pathology and TreatmentChapter V: Introduction (4)

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