sometimes occurs without cause, and the first intimation of it is the
peculiar tint of the skin. It is certainly true that powerful emotions
are causative; thus, a violent anger has brought on an attack. In such
a case we must suppose a depression of the vaso-motor system, and such
a lowering of the blood-pressure as to favor the passage of bile into
the {977} veins rather than into the bile-ducts. Thus, it has been
abundantly shown that a slight difference in pressure will divert the
bile in either direction. Heidenhain[20] has demonstrated that the bile
passes in the direction of least resistance, and in the case of the
considerable vaso-motor depression caused by extreme emotion the least
resistance is in the direction of the vessels. More frequently than
moral emotion is catarrh of the bile-ducts. It is not necessary for the
catarrhal swelling of the mucous membrane to close the ducts to have
the bile pass into the veins; such a degree of swelling as to make the
passage of the bile somewhat difficult suffices. A simple hyperæmia of
the mucous membrane may cause sufficient obstruction of the bile-ducts
to give rise to jaundice. Gastro-intestinal catarrh plays an important
part in the production of simple jaundice. Frerichs[21] ascertained
that of 41 cases, gastro-duodenal catarrh existed in 34. Ponfick[22]
considers catarrh of the ducts the principal factor. In fact, at the
present time there is but one dissenting voice on this point.[23]
[Footnote 20: Quoted by Legg, _supra_, p. 253.]
[Footnote 21: _Diseases of the Liver_, Syd. Soc. ed., by Murchison.]
[Footnote 22: _Ziemssen's Cyclopædia_, vol. ix., _supra_.]
[Footnote 23: Harley, _Diseases of the Liver_, 1883, p. 440 _et seq._]
Gastro-duodenal catarrh extends by contiguity of tissue to the mucous
lining of the bile-ducts. The catarrhal state of the mucous membrane is
produced by errors of diet, acid indigestion, indulgence in condiments,
wines, and rich foods in general. Climatic changes, malarial infection,
exposure to cold and dampness, etc. are indirectly causative of
jaundice through the intermediation of gastro-duodenal catarrh.
Formerly, obstruction of the gall-ducts was supposed to be caused
sometimes by a spasmodic contraction of the organic muscular fibre
assumed to exist in the walls of the ducts. Although the presence of
these muscular elements has been denied, Heidenhain has lately,
apparently, demonstrated them. Audigé has made observations
confirmatory of those of Heidenhain, and Dujardin-Beaumetz[24] has
verified the statements of Audigé. It seems, therefore, in a high
degree probable that organic muscular elements exist in the walls of
the hepatic ducts, and that spasmodic icterus may therefore occur.
[Footnote 24: _Bull. gén. de Thérapeutique_, vol. lxxxv. p. 385, 1873.]
SYMPTOMS.--Simple icterus may exist without any other obvious symptoms
than the yellow discoloration of the skin. In most cases, however, the
yellowness is preceded for a week or more by the symptoms of a
gastro-intestinal catarrh, or these symptoms accompany the jaundice.
There is much mental depression and a general malaise is experienced.
Headache, mental hebetude, a total loss of appetite, a furred tongue,
and a bitter taste, nausea and sometimes vomiting, constipation or
diarrhoea, precede or accompany the jaundice. When these symptoms
precede for some time the appearance of yellowness, it is probable that
the biliary derangement is secondary to the gastro-duodenal catarrh,
but when they occur with the jaundice it is probable that they are due
to the absence of bile from the intestine.
The yellowness first appears in the conjunctiva for a day or two before
the skin is tinted, and within forty-eight hours after the flow of bile
into the intestine has ceased. The face next becomes yellow, then the
body, {978} and afterward the limbs, but in some cases the limbs remain
free from discoloration. The lips do not exhibit any change of color,
but the roof of the mouth, the palate, and the mucous membrane under
the tongue are yellow. The saliva does not, as a rule, contain
bile-pigment or exhibit any changes of color unless mercurial
salivation is caused, when it becomes greenish in color and has a
bitter taste.[25] A yellow tint of the sweat, especially under the
arm-pits, is common. The milk very often contains bile-pigment or is
changed in color in some way.
[Footnote 25: Legg, _On the Bile, etc._, _supra_.]
The feces are colorless or have a grayish or clay-colored tint, and are
semi-solid, although sometimes hard and dry. In simple jaundice
diarrhoea is very often present. There may be considerable flatulence,
and more or less pain in consequence about the umbilicus, and the gas
when discharged is very offensive. The stools also, in some cases, have
an odor of decomposition, and if carefully examined particles of food,
undigested and decomposing, will be found. The feces may have a
parti-colored appearance--part whitish or grayish or clay-colored, and
part of a normal color. This condition is not difficult of explanation.
The obstruction to the flow of bile may be in a part, and indeed in a
small part comparatively, of the liver, and hence there may be
sufficient bile flow down to color the feces to a greater or less
extent. But a small amount of bile-pigment in the blood suffices to
tint the whole surface of the body.
The urine may exhibit changes in appearance before the conjunctiva
becomes yellow. It is colored in all possible degrees, from a merely
high normal hue to a deep brownish almost black tint. It may be deep
red and clear like dark brandy or brown like porter, and thick with
urates. Usually, the urine of jaundice deposits abundantly of urates,
but this fact is more especially true of those patients retaining
appetite or having a voracious appetite and indulging in a full diet
without restraint. The reaction of the urine is acid, and the specific
gravity does not often descend below 1010, and may be 1030. The amount
passed in twenty-four hours varies, but does not differ materially from
the normal. Toward the termination of some fatal cases the quantity of
urine has greatly diminished, and in a few instances was suppressed,
but in such examples other factors than hepatic disease were concerned.
More or less albumen is nearly constantly present in the urine of
jaundice, but the detection of a trace is very difficult when the
urine, as is so often the case, is cloudy. The urine should be
carefully filtered before applying the test, and a specimen for
comparison should be placed alongside of that being examined. If on
boiling no haze appears, it may be developed by dropping in some nitric
acid. The nitric-acid test, so often employed by allowing some drops of
urine to trickle down the test-tube and observing the reaction at the
point of contact, is, in the writer's experience, very fallacious. The
source of the albumen in jaundiced urine is obviously the
blood-globules. As Von Dusch first demonstrated, and Kühne[26]
afterward clearly confirmed, the bile acids dissolve the red
corpuscles. As the quantity of albumen in the urine is small, it is
reasonable to conclude, as suggested by Legg, that the bile acids are
not present in the blood in any considerable amount.
[Footnote 26: _Archiv für path. Anat._, Band xiv. p. 333.]
When any large quantity of bile is contained in the urine, its
detection is not difficult. A strip of muslin dipped in the urine will
be stained, and the underclothing of the patient will have the
yellowish spots {979} caused by bile. Gmelin's test is the most
convenient. This is applied as follows: Some nitric acid containing
nitrous--which is the case of the ordinary commercial article--is put
into a test-tube, and some of the suspected urine is allowed to trickle
down the side of the tube to come in contact, but not mix, with the
acid. At the point of contact, when the urine contains bile-pigment,
first a zone of green, then blue, violet, and finally red color,
develops. As this play of colors takes place on the instant, the
attention must be sharply fixed to see the changes. Rosenbach[27]
suggests this test be applied by filtering some urine containing bile
through filtering-paper and touching the paper with a drop of nitric
acid. The result is, a green circle forms at the point of contact. The
usual mode of applying Gmelin's test is to place on the bottom of a
common white plate or on a porcelain dish a thin film of the urine, and
carefully bring in contact with it a thin film of nitric acid. The
color reaction mentioned above takes place at the margin of contact.
[Footnote 27: _Centralblatt für die medicin Wissenschaft_, 1876, p. 5.]
Besides the presence of bile and albumen, and some fatty epithelium
from the tubules, there is no material change in the composition of the
urine. At one time it was supposed that the amount of urea was greatly
lessened, but later and more accurate investigations have shown that
this excretion is in greater or less quantity according to the food
taken, and bears no relation to the jaundice. On the other hand,
Genevoix[28] maintains that the quantity of urea is increased in
spasmodic icterus, and in the same ratio the uric acid declines. As
regards the chlorides and other salts, there seems to be a tolerably
constant ratio in their variations with the changes of quantity of urea
and uric acid--are therefore nearly related to the amount of food
taken.
[Footnote 28: _Essai sur les Variations de l'Urée et de l'Acide urique
dans les Maladies du Foie_, Paris, 1876, p. 59 _et seq._]
As regards the condition of the liver, there is no apparent change. In
topography, in the area of hepatic dulness, and in the dimensions of
the right hypochondrium the local condition does not deviate from the
normal in simple jaundice. There may be more or less tenderness over
the epigastrium and along the inferior margin of the liver, but there
is rarely any actual pain.
The circulation of bile in the blood and the action of the bile acids
on the red corpuscles must have an influence on the functions of
various organs. In some cases of jaundice, but by no means in all, the
pulse is slow, in a few instances descending as low as 40 per minute,
and, according to Frerichs,[29] as low as 21 per minute. Usually, the
pulse-rate is not lower than 60. To observe the slowing of the heart
the patient must be recumbent, for the pulse rises to the normal or
above on assuming the erect posture and moving about. The occurrence of
fever also prevents the depression of the circulation. The slowing of
the heart is found to be due to the action of the bile acids on the
cardiac ganglia. The other elements of the bile were ascertained to
have no influence on the circulation. As the heart may be slowed by an
increase of inhibition through stimulation of the vagi or by a
paralyzing action on the cardiac muscle, it was necessary to eliminate
these effects to establish the influence of the bile acids on the
ganglia. By exclusion, and by ascertaining the effects {980} of the
bile acids on a properly prepared Stannius heart, Steiner and Legg have
succeeded in demonstrating this important point.[30]
[Footnote 29: _Diseases of the Liver_, Syd. Soc. ed., _supra_.]
[Footnote 30: _Archiv f. Anat. u. Physiol._, 1874, p. 474; Legg, _On
the Bile, etc._, _loc. cit._]
The temperature of jaundice is normal usually, sometimes below. When a
febrile affection occurs during the course of jaundice, the rise of
temperature belonging to it is prevented in considerable part,
sometimes entirely. The depression of temperature is referred by Legg
to the lessened activity of the hepatic functions; but it seems to the
writer more satisfactory to refer it to the action of the bile acids on
the red corpuscles, the conveyors of oxygen. Röhrig[31] has shown
experimentally that the injection of bile acids has this effect on the
temperature of animals.
[Footnote 31: _Archiv der Heilkunde_, 1863, p. 418.]
The nutrition of the body early suffers in jaundice; more or less loss
of flesh soon occurs, and debility and languor are experienced. There
are several factors concerned in this result. The diversion of the bile
from the intestine interferes in the digestion of certain materials;
when jaundice occurs, glycogen ceases to be formed--and this substance
has an important office in nutrition and force-evolution--and the
injury done to the red blood-globules interferes with oxidation
processes.
The functions of the nervous system are variously disturbed in
jaundice. Headache, frontal, occipital, or general, is present in most
cases to a greater or less extent. Hebetude of mind and despondency are
nearly if not quite invariable, although it is not unusual to see men
with jaundice engaged in their ordinary avocations. Drowsiness is a
common symptom. More or less wakefulness at night, or sleep with
disturbing dreams, not unfrequently coincide with drowsiness during the
waking moments. In severe cases of icterus dependent on structural
changes the cholæmia may produce stupor, delirium, convulsions, etc.,
but such formidable symptoms do not belong to the simple and merely
functional jaundice.
Vision is sometimes colored yellow, or, rather, white objects appear
yellow, but this must be a rare symptom, since Frerichs never met with
an example. Murchison[32] narrates a case, and the writer has seen one.
It is a fugitive symptom, rarely continuing longer than two or three
days. The term xanthopsy has been applied to it.
[Footnote 32: _Clinical Lectures on Diseases of the Liver_, New York,
1877, p. 321.]
A nervous symptom of common occurrence is pruritus of the skin. This
may be so severe as to prevent sleep, and in any case is a disagreeable
and persistent affection, always worse at night. It may appear before
the jaundice so long a period as ten days, as in a case mentioned by
Graves,[33] and two months in a case narrated by Flint.[34] It is most
severe at the beginning of the jaundice, and usually disappears before
the jaundice ceases, but it may continue to the end. It is not limited
to any particular part of the body. Pruritus is sometimes accompanied
by urticaria, and the irritation caused by the friction of the skin may
set up an eczema. Occasionally boils, and more rarely carbuncles,
appear during the course of jaundice. Another curious affection of the
skin which occurs during chronic jaundice is xanthelasma or
vitiligoidea. First mentioned by Rayer, this disease was afterward well
described by Addison and Gull[35] under the name vitiligoidea, and they
recognized two varieties, v. plana and v. tuberosa. The plane variety
is found on the {981} mucous membrane of the mouth, the eyelids, the
palms of the hands, and the flexures of the joints, and consists of a
yellowish-white soft eruption slightly raised above the surrounding
skin and varying in size from a pin's point to a dime in size. The
color is described as like that of a dead leaf or chamois-skin. The
tuberose variety consists of small tubercles from a millet-seed to a
pea in size. They have a yellowish color, are tense and shining, and
are placed on the ears, neck, knuckles, elbows, knees, and other parts.
Whilst the plane variety gives little if any uneasiness, the tuberose
is apt to become irritated and painful. From the pathological point of
view this eruption consists of proliferating connective-tissue
corpuscles, some of which have undergone fatty degeneration.[36] The
morbid process tends to occur symmetrically, as on the eyelids, to
which it may be confined, but it usually develops in patches, and may
indeed extend over the whole body, when it is called xanthelasma
multiplex.
[Footnote 33: _Clinical Lectures on the Practice of Medicine_, 2d ed.,
by Neligan, p. 637.]
[Footnote 34: _Philada. Med. Times_, 1878, p. 507.]
[Footnote 35: _Guy's Hospital Reports_, 1851, p. 265.]
[Footnote 36: Waldeyer, _Archiv für path. Anatomie, etc._, vol. lii. p.
318.]
The disorganization of the blood caused by jaundice sets up a
hemorrhagic diathesis. This result, however, is not usual in simple
jaundice, but belongs rather to acute yellow atrophy, sclerosis, and
other chronic affections of the liver. It will therefore be more
appropriately considered in connection with those maladies.
COURSE, DURATION, AND TERMINATION.--When jaundice is a symptom merely,
it pursues a course determined by the peculiarities of the disease. The
duration of simple jaundice varies from one to four weeks, the average
being about three weeks. If it continues longer than two months,
suspicions may well be entertained that the case is of a more
formidable character than simple jaundice. The termination of this form
of the disease is always in health. A favorable prognosis can be given
only in the case of an accurate diagnosis. Those cases may terminate
more speedily which, being of malarial origin, are treated by efficient
doses of quinine. If delirium and coma come on, the apparently mild
case means, probably, acute yellow atrophy, which cannot at the onset
be distinguished from simple jaundice. If any nervous symptoms occur or
if hemorrhage appears, the case will prove to be serious. A rise of
temperature usually indicates mischief. When the stools begin to
exhibit the normal appearance from the presence of bile, a satisfactory
termination of the case may be soon expected. The yellowness of the
skin disappears slowly after the natural route of the bile has been
restored, and the urine is the last to lose the pigment, as it was the
first to exhibit its presence.
DIAGNOSIS.--The diagnosis of jaundice as a symptom is usually easy. It
should be remembered that jaundice cannot be detected at night by any
ordinary light, and when it is disappearing the tint varies, now being
distinct, again absent. Mental emotion when the color is fading
develops it. Browning by the sun's rays causes an appearance which
might be mistaken by a superficial observer for jaundice, but it is
only necessary to look at the parts protected and at the urine to
discover the true state of the case. The detection of bile in the urine
and the ocular evidence of its absence from the stools will be
conclusive. In some cases of jaundice the stools are golden yellow, and
in many instances they are offensive.
{982} It is important to mark out the limits of the gall-bladder, if it
is of sufficient size to do so, for any accumulation of bile in this
sac signifies an obstruction of the ductus communis choledochus. If the
jaundice has come on after the symptoms of gastro-duodenal catarrh, is
recent, continues but two or three weeks, and then subsides without any
nervous symptoms or hemorrhage, it is a case of simple jaundice,
probably due to catarrh or spasm of the bile-ducts. If the jaundice be
preceded by attacks of severe pain, nausea, and vomiting, and
disappears after a week or two, the case is one of hepatic calculi. If
the jaundice persists months after such an attack of acute pain, and
does not disappear after a year or more, it is probably due to an
impacted calculus. The other diagnostic relations of jaundice are more
properly considered in connection with the malady of which jaundice is
a symptom.
TREATMENT.--For jaundice the symptom the treatment is included in that
of the disease. Here the treatment of simple jaundice, the functional
disorder, is to be discussed. If there is much nausea, the tongue is
heavily coated, and, especially if the seizure has followed dietetic
excesses, an emetic of ipecac may be highly serviceable. Recent
experiments have proved the accuracy of the clinical observations which
recognized the cholagogue property of ipecac, and hence the emetic
effect of this remedy is aided by its power to promote the discharge of
bile. Emetics are of course contraindicated when jaundice is due to an
impacted calculus, to malignant disease, to echinococci or other kinds
of tumor. If there is much irritability of the gastro-intestinal mucous
membrane, as shown in vomiting and diarrhoea, small doses of calomel
(1/12 to 1/4 grain) three or four times a day are highly useful. If
calomel possessed the property ascribed to it of stimulating the liver,
it would be injurious; it is beneficial here because it has a sedative
effect at first, followed, when a sufficient amount has accumulated, by
an eliminant action. Such hepatic stimulants as euonymin, sanguinarin,
podophyllin, jalap, colocynth, rhubarb, etc. have long been used in
cases of jaundice with the view that the liver is torpid and needs
stimulating. It may be inquired, however, If the bile already formed
has no outlet by the proper route, what utility can there be in making
the organ produce more? The true reason for the administration of such
remedies in any case of obstructive jaundice is to cause such downward
pressure as to force out of the duct an obstructing plug of mucus. The
writer has known this result to be accomplished by a dose of compound
jalap powder when a great variety of remedies had been employed in
vain. One of the most efficient remedies--in the writer's considerable
experience the most efficient--is phosphate of sodium, of which a
drachm or more is administered three times a day. This remedy liquefies
mucous plugs and promotes the flow of bile without harshly and rudely
forcing the biliary secretion, and it also has a marked curative effect
in gastro-duodenal catarrh. It may be given advantageously with
arseniate of soda--the latter in dose of 1/20 grain--and dissolved in a
tumblerful of Vichy water or Saratoga Vichy water, or preferably in a
wineglassful of hot water. Free use of alkaline and laxative mineral
waters is desirable, for a double purpose--to act on the liver and on
intestinal digestion, and to promote the excretion of biliary matters
by the kidneys. In this country we have a number to select from--the
Saratoga, Bethesda, Michigan, and others. Certain sulphurous waters,
{983} as the Blue Lick of Kentucky, are highly useful in the more
chronic cases. Sulphur baths may be conjoined to the internal
administration of the waters.
Nitric and nitro-muriatic acids have long been celebrated for their
good effects in jaundice. It is the presence of the acid chyme in the
duodenum which excites the normal flow of bile, and Bernard found that
applying acid to the orifice of the common duct in the intestine has
the same effect. There is then a rational reason for the administration
of this remedy. A nitro-muriatic bath, both local and general, was
formerly more used than now. Its utility is questionable, and the
difficulties in the way of applying it great.
Recently, Gerhardt[37] has proposed to faradize the gall-bladder, and
by compression with the fingers to empty it, forcing the bile into the
intestine, and thus clearing out obstructions. This seems to be very
questionable if not dangerous practice, but repeated successes will
justify it.
[Footnote 37: _Sammlung klinische Vorträge_, Volkmann, p. 112.]
Regulation of the diet is of the first importance. Fats, starches, and
sweets cannot be well digested when no bile enters the small intestine,
where they undergo conversion. These substances fermenting, much acid
results, and hence if a catarrh exist it is increased. An exclusive
diet of skimmed milk, kept up for two weeks or as long as possible, is
the best mode of alimentation for this part of the treatment.
Afterward, the diet should be composed of milk, meat-broth, lemonade,
and subsequently of the succulent vegetables, acid fruits, and fresh
meat. Indulgence in malt liquors, wines, and spirits should be strictly
prohibited.
A new method of treating jaundice has been lately proposed by
Krull,[38] which has the merit that no injury is done by it if no good
is accomplished. It consists in injecting into the rectum from two to
four pints of water at 60° F., which is retained as long as possible.
Each time the injection is repeated the temperature is raised a little.
Krull reports that he has uniformly succeeded, and has never found it
necessary to repeat the injection more than seven times. It may be
given twice or thrice a day.
[Footnote 38: _Berliner klinische Wochenschrift_, 1877, p. 159.]
II. STRUCTURAL DISEASES OF THE LIVER.
Hyperæmia of the Liver.
DEFINITION.--An abnormal quantity of blood in the liver, constantly
present, constitutes hyperæmia or congestion. During the period of
repose there is less, but during the period of activity more, blood
circulating in the liver, but the physiological hyperæmia is not, nor
does it contribute to, a diseased state unless abnormal conditions
continue it beyond the proper limits. The term hyperæmia, here used,
applies to a pathological state in which various structural alterations
grow out of the continual congestion of the blood-vessels of the organ.