30 Vide the Author's paper on a new method of producing diabetes artificially in animals, by the injection of stimulants—alcohol, ether, chloroform, ammonia, &c.—into the portal circulation. Comptes Rendus de la Societé de Biologie de Paris. 1853.
Taraxacum has been widely used in hepatic disease associated with jaundice, and is believed to be particularly well adapted to cases arising from congestion. As in such cases I generally trust to more potent drugs, my experience with this remedy has been too limited to admit of my offering an opinion of its value.
The majority of cases of jaundice from obstruction, are much less under the power of remedial agents than those arising from suppression, for we have here three distinct conditions to combat: Firstly,—The derangements originating in the absence of bile from the digestive canal. Secondly,—The morbid effects arising from its accumulation in the ducts, and consequent interruption to the hepatic functions. Thirdly,—The general poisonous action on the system, of the re-absorbed bile.
As regards the first of these effects,—namely, the derangements arising from an absence of bile from the digestive canal, it may be said that if these were the only difficulties with which we had to contend in cases of jaundice from obstruction, they could easily be overcome. For, in the first place, the absence of bile is not attended with any immediate danger, a circumstance which has led to the common belief that the presence of bile is not absolutely essential to life. Experiments on dogs with biliary fistulæ, like those before referred to, as well as cases in the human subject, have proved that life may be sustained, under certain conditions, for a very long period, without bile reaching the intestines. Indeed, the only immediate bad effects which appear to result from its absence, are costive bowels, great flatulence, and extremely offensive stools. The indirect bad results,—namely, loss of flesh, &c., as has been proved by experiments on animals, can be counteracted by giving an additional amount of food; and even the direct results of constipation, flatulence, and foetor, may be overcome by appropriate remedies.
The secondary morbid effects, namely, those arising from the accumulation of bile in the ducts, are unfortunately not so easily under control. Could we remove the cause of obstruction, these would, of course, immediately cease. This, however, is seldom in our power, except in the case of gall-stones, the expulsion of which we can aid in various ways. In general, we can very successfully aid the passage of a stone through the ducts by administering an anodyne containing a full dose of the tincture of belladonna, which apparently assists in dilating the duct. Placing the patient in a warm bath is also of service; and when the paroxysms of pain are very severe, the occasional inhalation of the vapor from a couple of drachms of sulphuric ether poured on a handkerchief, made into the form of a cup, is generally attended with great relief. Each of these modes of treatment may be followed either by a brisk emetic, or purgative, in the hope that the efforts of vomiting or purging may hasten the expulsion of the stone, either by the mouth or rectum.
It ought never to be forgotten, that the evil results of a gall-stone do not always cease when it has reached the intestinal canal. Even death itself has resulted from the impaction of a gall-stone in the duodenum. When we have any suspicion that the stone is large, our treatment must therefore be continued until its extrusion by the mouth or rectum has been accomplished.
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 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 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 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 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 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.