On examining the patient I found the liver enlarged, and tender on pressure. The gall-bladder much distended, and easily felt. The skin of a yellow hue. The stools of a pale tint. The urine very dark-coloured, and loaded with lithates. I had, consequently, no difficulty in diagnosing the case as one of gall-stone impacted in the common bile-duct; but on communicating my suspicions to the patient, I was informed that such could not possibly be the case, for during a considerable time past she had been carefully treated with podophyllin. Indeed, I learned to my surprise that she had taken from a quarter to half a grain of that substance nearly every day during the six previous months!
This incidental piece of information, instead of shaking my opinion, as the patient had apparently expected, only tended to strengthen my suspicions, for the reasons previously given, namely, that the podophyllin must have tended to keep the gall-bladder constantly full of bile. I accordingly prescribed for the case as one of impacted gall-stone, and left instructions that the stools should be carefully examined for its appearance.
On the following day the patient felt better; but the jaundiced tint was deeper, the stools paler, and the urine still high-coloured. The deposit of lithates had, however, slightly diminished. Still, feeling certain that the case was one of impacted gall-stone, I ordered the medicine to be repeated, and the stools to be again carefully examined.27 On my arrival at the patient's house the next day, the maid met me with an expression of satisfaction which could not be misinterpreted, and I had scarcely entered the sick chamber when, with an air of triumph, she showed me a gall-stone about the size of a large garden-pea, or small field-bean. It had been passed that morning about 11 o'clock, that is to say about fifteen hours after the second dose of medicine. On analysis the stone was found to consist almost entirely of cholesterine, and I have not the smallest doubt in my own mind that to the constant use of the podophyllin may, in a great measure, be attributed its formation. Unfortunately the stone had been accidentally broken before I saw it, and I was consequently unable to ascertain decidedly whether it was a solitary calculus, or one of many. Had it been one of several, it would of course have possessed facets. One facet would have indicated that the stone was one of two; two facets that three stones existed; three facets, that the gall-bladder had contained at least four calculi; while four or more facets would denote that the stone was one of many; whereas, if it was a solitary calculus, no such markings would be present.
27 We are sometimes told to add water to the stools, and that if gall-stones are present they will be found floating on the surface. I have never yet been able to detect a gall-stone in this way. The plan I recommend is, therefore, to mix the stool freely with water, and either decant the supernatant fluid, and then add fresh portions of water till the whole of the soluble matter is removed, or to strain the mixture through a hair-sieve. The gall-stone in either case remains behind, and can be readily detected.
I may merely add, in conclusion, that from the time the stone passed, the stools resumed their normal colour—the first two or three were much darker than natural, in consequence of the sudden escape of the pent-up bile—the urine gradually became pale, and clear, and the skin regained its wonted hue. The latter change was expedited by the administration of benzoic acid, and in a week from my first visit, a stranger would have been quite unable to detect that the patient had laboured under a recent attack of jaundice.
A few years ago a mixture of sulphuric ether, and turpentine was very extensively used, especially in France, as a solvent for gall-stones. This line of treatment was adopted on account of the well-known solubility of cholesterine in sulphuric ether, and it was thought that the remedy would act upon the cholesterine concretions in the gall-bladder in the same manner as it did out of the body. After a time, faith in the powers of the mixture became shaken, and it at length gradually ceased to be employed.
Within the last year or two, Dr. Bouchut28 has revived the same theory with another form of remedy, namely, chloroform, which he administers internally, with the view of dissolving any inspissated bile or biliary calculi that may be lodging in the gall-bladder. Dr. Bouchut states that he has treated one case of gall-stones in this manner with success. Now, although I have not the slightest desire to throw discredit on the statement of Dr. Bouchut, I must candidly admit that I am very much inclined to doubt the accuracy of his observations. In the first place, it is always extremely difficult to ascertain the existence of biliary concretions so long as they remain in the gall-bladder, and it is equally difficult to know, after gall-stones have been once passed by a patient, whether or not all have come away. If, then, we administer chloroform to a patient, either before or after a gall-stone has actually passed, we cannot, with anything approaching to certainty, attribute the cessation of his symptoms to the circumstance of the chloroform having dissolved a gall-stone. In fact, on physiological grounds, I very much doubt the efficacy of either sulphuric ether or chloroform as solvents of gall-stones in the living body. Sulphuric ether, and chloroform would no doubt dissolve a concretion of cholesterine in the gall-bladder were they admitted into that viscus in sufficient quantity, and in a pure state. But we have no proof that such is the case. On the contrary, we know, at least in as far as chloroform is concerned, that exactly the opposite is the fact; for no sooner does chloroform become absorbed, and mingled with the constituents of the blood, than it becomes decomposed, the chlorine combining with the blood, and the formic acid being set free.29 And even supposing that sulphuric ether and chloroform existed in the blood in a free state, they could not possibly do so in a sufficiently concentrated form to be able to act as solvents of biliary calculi.
28 "Edin. Med. Journ." 1861, p. 398.
29 Jackson, Comptes Rendus, February 25th, 1856.
My own experiments on animals have shown me how rapidly fatal even small quantities of chloroform are when injected into the circulation, and a similar remark is equally applicable to sulphuric ether. A few drops of these substances can very readily be injected into the circulation with impunity;30 but the quantity must not be increased beyond a certain amount, far less than could possibly dissolve a single grain of cholesterine, otherwise immediate death follows the operation, by inducing a state of body closely resembling rigor mortis, from which the animals never recover. I am, therefore, completely at a loss to understand how these remedies can be of service in dissolving gall-stones in the living body; and as I make it a rule as seldom as possible to prescribe a remedy without a knowledge of its physiological action, I have not yet ventured on an empirical trial of the effects of sulphuric ether or chloroform administered internally in cases of gall-stones. For some remarks on the passage of biliary calculi, see [page 123].