The first and great object is, of course, as in the case of every other disease, to remove, if possible, the exciting cause. When that is accomplished, we can with safety turn our attention to the removal of its effects. I need not here detail the different exciting causes which it is our duty to remove. I have indicated them elsewhere, and the mere mention of some of their names is sufficient to denote the line of treatment which ought to be adopted. Thus, for example, if it be ascertained from there being symptoms of tenderness, &c., in the hepatic region, that the jaundice arises from active congestion of the liver, the first object would of course be to subdue the congestion of that organ by means of leeches, hot fomentations, saline purgatives, &c., according to the age, sex, and constitution of the patient. On the other hand, if the jaundice be the result of passive congestion of the liver, we know well that so long as the exciting cause exists elsewhere, it will be worse than futile to attempt the removal of the hepatic congestion by direct means. In such a case, therefore, if to remedy the cause is beyond our power, our object will be to concentrate our efforts on the mitigation of its effects. Thus I might go through the whole list of causes of jaundice, and point out what appears to be the most appropriate treatment of each; but I think the time of my readers and my space, will be more profitably employed, if, instead of doing so, I turn my remarks chiefly to the therapeutical action of those remedies which we are constantly employing in the treatment of jaundice. The first remedy that merits special notice is mercury.
The benefit of mercury in cases of liver disease cannot be denied; but the injudicious employment of this drug in cases of jaundice, has frequently been followed by the most disastrous results. There was a time when mercury was administered in all cases of jaundice, irrespective of their cause; now, however, men are fortunately becoming more careful in the employment of this drug. But there is still a mistaken notion regarding the therapeutical action of mercurial preparations. It was at one time thought that they stimulated the liver to secrete bile, and now since physiology has shown that they possess no such action, many have gone to the opposite extreme, and declared, that if mercurials do not stimulate the liver to secrete bile, their benefit in hepatic disease has been a delusion; and the dark stools following upon their employment but the result of the sulphuret of mercury formed in the intestines. I take a very different view of the matter; for though believing that mercury does not directly stimulate the liver to secrete bile, I nevertheless opine that it has an important indirect effect in reinducing the biliary secretion, and thereby curing certain cases of jaundice.
The action of mercurials seems to me, to be this—mercury is a powerful antiphlogistic—it reduces the volume of the blood by its purgative properties, and it impoverishes the blood by its direct action on the red corpuscles. It has been poetically said by Dr. Watson, that mercury can blanch the rosy cheek to the white of the lily; and nothing is more true, for in experiments on animals, I have found the prolonged use of mercury reduce the red blood corpuscles to a minimum. From this it is easy to understand how mercury acts in inflammatory affections; and as in the majority of cases of jaundice from suppression, the stoppage of the biliary secretion is due to active congestion of the liver, mercury proves beneficial in such cases, not by stimulating the biliary secretion, but simply by removing the obstacle to its re-establishment, namely, the hepatic congestion.
As a good illustration of the correctness of this theory regarding the action of mercurials in cases of jaundice arising from congestion, I may be allowed to quote the following case, which appeared among the Hospital Reports of the "Lancet" of the 7th December, 1861. The case is headed, "Intense Congestion of the Liver, simulating an Abdominal Tumour:"—
Alex. E——, aged forty-eight, was admitted into St. Bartholomew's Hospital, under the care of Dr. Farre, on the 17th October, 1861. The patient had, it appeared, been suffering from jaundice during six weeks. He stated that the tumour in the epigastrium began about the same time as the yellowness of the skin.
On examination, a prominent swelling was noticed in the epigastric region, possessing an indistinct feeling of fluctuation, but it was found to be continuous with the liver. The motions were not bilious, but were of a clay colour, and the urine looked like pure bile. Three grains of blue pill and two of Barbadoes aloes were ordered every night. By the 25th the hepatic tumour was less, and the icterus was disappearing. On November 4th the urine was clearer and full of lithates. The conjunctivæ were the only parts observed of a yellow colour.
November 11th.—Although the pills had been continued up to this date, the mouth was not sore. The urine and stools were natural, and the patient was convalescent. A few days afterwards he left the hospital.
The result of the case clearly proved not only that the swelling was from a highly congested liver, but also that the jaundice depended on this state.
In this case it is evident that the primary beneficial action of the mercury was to reduce the congested state of the hepatic organ, and no one, I think, would venture to say that this was accomplished by the power the mercury possessed of exciting the liver to secrete bile.
If, then, the above view of the therapeutical action of mercurials be correct, it is easy to understand how, in cases of jaundice from permanent obstruction of the gall-duct, the administration of mercury or any other lowering medicine, must prove detrimental by hastening the fatal termination.