14 "Medical Times and Gazette," 29th March, 1862.
Through the kindness of Dr. Wilks, I had the opportunity of making a microscopical examination of the liver. The hepatic cells were very small in size, much broken up; very few possessed nuclei, and all were deeply tinged with brownish yellow colouring matter. Scattered throughout the hepatic tissue, I found numbers of well-formed cholesterine crystals, like those represented in [Fig. 3].
I must here mention, that jaundice does not necessarily follow upon absence of the gall-bladder; just as in the horse, the deer, the rat, and other animals that possess no gall-bladders, the biliary function is perfectly well carried on, so it may be in the human subject, labouring under a congenital or accidental deficiency of the gall-bladder. In such cases, the hepatic ducts are pervious, and consequently the secreted bile finds no difficulty in reaching the intestines. In the "Edinburgh Medical Journal" (May, 1861, p. 1045,) Dr. Alexander Simpson reports a case of this kind occurring in a child, which died when only a few weeks old. There was no trace of the existence of a gall-bladder; but on laying open the duodenum, the orifice of the bile-duct was at once seen in its ordinary situation, and a drop of pale bile was expressed from it. On tracing the duct to the liver, it was found to pass up undivided into the horizontal fissure, where it at once broke up and branched into the hepatic tissue of the right, and left lobes.
I shall delay entering into an explanation of the mechanism of jaundice from obstruction, until I come to the consideration of what may be termed Permanent Jaundice, as in that case one explanation will do for all.
JAUNDICE AS A RESULT OF THE ACCIDENTAL OBSTRUCTION OF THE BILE-DUCTS.
The second class of cases, namely, those in which the obstruction is in the course of the ducts, are of frequent occurrence, and in them the jaundiced state is usually merely transient, for no sooner has the obstruction been removed, than the jaundice begins to disappear. The most common cases of this kind are those arising from gall-stones. As every one is familiar with their history, I may merely mention, that we may have gall-stones, and even all the most painful symptoms of gall-stones, without the slightest trace of jaundice. This, I believe, arises in the following manner:—
Firstly,—The majority of gall-stones are formed in the gall-bladder; their formation being due to the accidental deposition of the less soluble parts of the bile, either as a consequence of these ingredients being present in excess, or in consequence of the solvent, whose duty it is to retain them in solution, being in reduced quantity. The deposition or formation of gall-stones follows exactly the same law as the deposition or formation of stone in the bladder.
Secondly,—In some cases the gall-stone, or stones—for there may be many, even hundreds, remain in the gall-bladder during the whole life of the individual, without giving rise to any disagreeable results, either as regards pain, or jaundice. In other cases, the gall-stones—and this usually happens when they are small—get into the cystic duct, and become lodged there; and in such a case, although the patient may suffer intense pain, there is still no jaundice. Moreover, it is not until the stone or stones have passed down into the common bile-duct, that jaundice is at all likely to be induced by them. For while a stone remains in the cystic duct, although it may completely block it up, and effectually prevent the bile either entering into or escaping from the gall-bladder, yet, as in this situation it cannot offer any obstacle to the direct flow of the biliary secretion from the hepatic tissue into the intestines, there is no retention, and consequent absorption of bile. In fact, the presence of the stone in this position, in as far as the biliary function is concerned, only reduces the patient to the state of a person in whom the gall-bladder is accidentally absent; or to that of a horse, or other animal, in which the absence of the gall-bladder is a normal condition.
Thirdly,—There are yet other ways in which gall-stones may give rise to great discomfort, and even imperil life, without inducing jaundice. For example, a calculus may remain in the gall-bladder until it attains a very large size, and then ulcerate its way into the stomach, intestines,15 peritoneal cavity, or even out of the body through an opening in the abdominal parietes.16
15 Vide a case of this kind published by the author in the Pathological Society's "Transactions" for 1857, p. 235.