influential causes. Exposure to cold and dampness, the body warm and
perspiring, will set up a catarrhal process in the bile-ducts and
intestine, especially in those having the special susceptibility which
belongs to certain bodily types. Malarial miasm is an especially active
cause in malarial regions. The writer has seen many examples in various
parts of the United States within the malaria-breeding zone. Other
miasmatic agencies are not without importance. The exhalations from the
{1052} freshly-upturned soil of some cities, the gases from cesspools
and sewers, and illuminating gas exert a causative influence. The bad
air thus made up has been happily called civic malaria.
The most influential causes of catarrh of the biliary passages are
local in origin and in action: they are the agencies which induce
catarrh of the duodenum. Disturbances of the portal circulation should
be first named. Whenever obstructive lesions of the cardiac orifices
exist, whenever the pulmonary circulation is impeded by disease of the
lungs, the portal vein is kept abnormally full, and as a necessary
result of the stasis a catarrh of the mucous membrane follows.
Congestion of the portal system may be a result of vaso-motor paresis.
The abdominal sympathetic may be the seat of various reflex
disturbances: those of a depressing kind induce stasis in the portal
system. Certain medicinal agents have this effect, and prolonged and
severe cutaneous irritation, it is probable, may act on the portal
circulation in the same way. The action of cold on the peripheral
nerves may be similarly explained.
Catarrh by contiguity of tissue is the most frequent factor. Catarrh of
the duodenal mucous membrane is the initial condition, and from thence
the process extends to the bile-ducts. Although the duodenum may be
alone affected, the usual state of things is a gastro-intestinal
catarrh, the stomach and the whole length of the small intestine being
simultaneously diseased. When the catarrhal process is thus diffused
the duodenal mucous membrane is most deranged, probably because the
acid and fermenting chyme is first received here, and what acridity
soever it may possess attacks this part in its greatest strength. It
must be remembered that the secretion of the duodenal glands and of the
pancreas and liver must also have an abnormal character; hence those
foods which in the healthy condition of things are digested in this
part of the canal undergo ordinary putrefactive decomposition and
furnish very irritating products. This observation is especially true
of the fats: the fat acids are in the highest degree irritating. The
digestive fluid of the duodenum has a more or less pathological
character, because the catarrhal process not only interferes with the
habitually easy flow of the gland secretions, but, extending to the
gland elements themselves, gradually alter their structure.
Gastro-intestinal catarrh results from the misuse of foods and the
abuse of certain condiments and of spirits. Excess in the quantity of
starchy, saccharine, and fatty foods which undergo conversion and
absorption in the intestine, habitually consumed, decomposition of such
portions as escape proper digestion ensues, and the products of this
decomposition exercise an irritant influence on the mucous membrane.
The daily consumption of sauces and condiments and of highly-seasoned
foods has a constant irritating action; but more influential than any
other causative agency is the abuse of malt liquors and spirit. Whilst
the latter acts more on the stomach and the liver proper, the former
affect more the duodenal mucous membrane and the bile-ducts.
To these causative agencies must be added a pathological state of the
bile itself. Under conditions not now known the bile seems to acquire
acrid properties and set up a catarrh in passing along the ducts.
PATHOLOGICAL ANATOMY.--The area affected by the catarrhal process
varies greatly. The termination of the common duct for a short space
may be the only part affected, but with this there is always more or
less, {1053} sometimes most extensive and severe, duodenal catarrh,
followed by jaundice. The extent to which the common duct is affected
may be exactly indicated by the staining with bile, which extends down
to the point of obstruction. The catarrhal process may invade the whole
extent of the common duct, the cystic duct, gall-bladder, and the
ramifications of the tube throughout the organ. The resulting
appearances will vary accordingly.
The first change observable is a more or less considerable hyperæmia of
the mucous membrane; but this is rarely seen, because the examination
cannot be made at the time when this condition is present. The
epithelial layer is swollen, sodden, the cells cloudy, undergoing rapid
multiplication and desquamating. The cast-off cylindrical epithelium,
mucous cells, and serum make up a turbid mixture, which, with bile,
fills the smaller ducts, and may in places, especially at the orifice
of the common duct, form an obstruction sufficient to prevent the
passage of the bile; which may, however, be readily pressed out with a
little force. Especially near the end of the common duct the mucus is
apt to accumulate, and a plug of it, often tenacious and somewhat
consistent, obstructs the orifice. It is probable that whilst catarrh
is the chief cause of jaundice, it may also, by a merely intermittent
activity, cause the condition of biliousness--now so far relieved as to
permit the bile to descend into the intestine, now so much obstruction
as to prevent the escape of any considerable part of that formed. When
the common duct is the seat of the catarrhal process, and the outflow
of bile thus prevented, it accumulates in the gall-bladder, which may
be so far distended as to present a recognizable tumor of pyriform
shape through the abdominal parietes.
When the catarrhal process invades the finer ducts the appearances are
somewhat different. There are no bile-stains along the course of the
common and cystic ducts, and the gall-bladder is empty, or at most
contains only some mucus, with altered bile. The tubes at or near their
ultimate ramifications contain a turbid mucus composed of cylindrical
epithelium and lymphoid cells, and tenacious enough to close them
firmly. More or less hyperæmia of the liver-structures proper, and
consequent increased dimensions of the organ, a more or less active
catarrhal condition of the duodenal mucous membrane, accompany the
changes in the finer ducts.
SYMPTOMS.--There are marked differences in the behavior of the more
acute cases of catarrh of the bile-ducts and the chronic examples of
the same disorder. The former is held to be the most frequent cause of
jaundice, whilst the latter is an important element in the so-called
bilious state, in lithæmia, and as a secondary condition in some
cardiac and pulmonary diseases. Also, the morbid complexus of catarrh
of the bile-ducts includes the symptoms of duodenal and gastro-duodenal
catarrh.
The acute form of this disease sets in with the symptoms of
gastro-duodenal catarrh. Usually, after indulgence in too highly
stimulating food or in some article having a specially irritating
character, an attack of acute indigestion supervenes. The tongue is
more or less heavily coated, the breath heavy, the taste bitter, pasty,
or sourish, the appetite poor or actual repugnance to food, especially
to the offending articles, is experienced, and nausea, not unfrequently
vomiting, ensues. The epigastrium and the hypochondriac regions have a
heavy, overloaded, distressed, {1054} and sore feeling; there is some
tenderness to pressure; sometimes the gall-bladder, abnormally full,
may be detected by careful palpation; and the area of hepatic dulness
will usually be increased. The abdomen is more or less distended by
gases, and eructations of offensive gases (hydrogen and sulphur
compounds, volatile fat acids, etc.) occur. Constipation exists when
the catarrhal process is limited to the duodenum, and the stools
consist of hard lumps having a light yellow, clay-colored, or whitish
appearance. When the whole extent of the small intestine is affected,
the stools will be soft, liquid, or watery, and will vary in color from
yellow to gray or white. In some cases the fecal matters will have an
offensive odor--the odor of decomposition--and considerable discharges
of very foul-smelling gas will attend the evacuations. This symptom
will occur when the intestinal digestion is suspended and the contents
of the bowel in consequence undergo putrefactive decomposition.
During the initial period of the disorder the urine will simply be
high-colored and loaded with urates and uric acid, but when jaundice
supervenes the pigment will convert the urine into a dark,
coffee-colored, and somewhat thick liquid.
With the onset of the malady symptoms referable to the nervous system
appear. Headache, dizziness, and hebetude of mind are present, and now
and then an attack of catarrh of the bile-ducts will have the objective
signs of an ordinary migraine or sick headache. Usually, however, as
the intestinal and hepatic troubles develop, headache and some mental
hebetude come on, but when jaundice supervenes the headache becomes
more severe, and very considerable mental depression, irritability of
temper, and moroseness are experienced. Chilly sensations, with flashes
of heat, are felt at the outset, but with the appearance of jaundice
the sensation of coldness predominates. In some cases, the intestinal
catarrh being extensive, there will be, after some preliminary
chilliness, a febrile movement, but this is never of a pronounced
character, and in the slighter cases of the disease or when the
catarrhal process is limited to the bile-ducts, there is no elevation
of temperature. With the first symptoms the pulse is somewhat
quickened, but as the bile acids accumulate in the blood they effect a
decided slowing of the heart's action, the pulse falling as low, it may
be, as 50 per minute. This lessened activity of the circulation is
accompanied by corresponding reduction of temperature, the body-heat
falling a degree or more.
The most distinctive symptom of catarrh of the bile-ducts is jaundice.
In the acute or quickly-developing form above described of catarrhal
icterus the symptoms of gastro-intestinal disturbance precede the first
indication of jaundice from five to eight days. Yellowness of the
conjunctiva and of those parts of the body exposed to the air is the
first manifestation; afterward the jaundice hue becomes general. The
tint varies in depth from a faint gamboge-yellow, only discernible in a
favorable light, to a deep greenish- or brownish-yellow.
In the more chronic cases of catarrh of the bile-ducts the symptoms are
simply those of a gastro-duodenal catarrh, to which some hepatic
disturbances are superadded. Some abdominal uneasiness felt in the
epigastrium and in the right hypochondrium, especially in two to three
hours after meals; flatulence, sometimes accompanied by colic; {1055}
constipation, persistent or alternating with diarrhoea--in the one case
in hard lumps with more or less mucus adherent, in the other soft or
liquid, and in both cases having a rather golden-yellow color, grayish
or black and tar-like appearance,--such are the symptoms referable to
the intestinal canal. The disturbances in the hepatic functions
produced by the catarrhal swelling of the mucous membrane of the ducts
are further exhibited in a somewhat sallow, earthy, or muddy
complexion, yellowish tint of the conjunctiva, high-colored, acid urine
loaded with urates and phosphates. Such subjects, although having, it
may be, a keen appetite, rather lose than gain in weight: they
experience lassitude, headache, much depression of spirits, and the
mental symptoms are most pronounced during the time intestinal
digestion is going on. In fact, the morbid complexus is rather that of
intestinal catarrh; nevertheless, the slight degree of obstruction to
the outflow of bile occurring in these cases has an influence both in
the intestinal digestion and in the nutritive functions. Any degree of
obstruction, as has already been pointed out, leads to serious
structural change of the liver, and this in turn produces well-defined
symptoms.
Disturbances of the hepatic functions, even jaundice, accompany the
paroxysms of malarial fever. Without the occurrence of fever, catarrhal
jaundice may come on during the course of chronic malarial poisoning.
Catarrh of the bile-ducts is the pathogenetic factor in these cases.
More especially in malarial regions, but also in temperate and warm
climates, paroxysmal attacks, with or without jaundice, are
comparatively frequent. These acute seizures occur in those having the
chronic form of the malady, and are excited by sudden climatic changes,
by excesses in eating, especially by the use of improper articles of
diet. Considerable nausea, flatulence, and constipation or diarrhoea,
weight, tension, and soreness in the right hypochondrium and sometimes
in the shoulder, chilliness, general malaise, headache, and an
increasing icterode tint of the skin, constitute the complexus of
symptoms belonging to these cases.
COURSE, DURATION, AND TERMINATION.--Acute catarrh of the bile-ducts
with jaundice has a well-defined course--in its mildest form, with
little gastric or gastro-intestinal disturbance--lasting ten days or
two weeks; in the ordinary form, with the accompanying gastro-duodenal
catarrh, running its course in a month to six weeks. In the chronic
form, with acute exacerbations due to indiscretions in diet or to
climatic influences, the course of the disease is chequered by
vicissitudes, the result of the causes just mentioned, and its duration
must therefore be indefinite and, as a rule, protracted. Catarrh of the
bile-ducts, or catarrhal jaundice, usually terminates in health after a
period of functional derangement of the intestines and liver. Without
exhibiting any features of a special character, some cases do not pass
through this benign course: the intestinal catarrh sets up an
ulcerative process at one or more points in the duodenum; but more
especially the obstruction to the free course of the bile caused by the
catarrhal swelling of the mucous lining of the ducts induces structural
changes in the liver--an hypertrophy of the connective-tissue elements,
a sclerosis.
DIAGNOSIS.--There are but two signs which indicate the nature of the
disorder, and only one that is really distinctive. Intestinal
indigestion with slight coincident biliary derangement is one, and
jaundice is the {1056} other. When, after the signs and symptoms of
gastro-duodenal catarrh have declared themselves, jaundice appears,
there can be no question as to the nature of the case. The diagnosis is
more difficult in the chronic cases with exacerbations due to the
exciting causes above mentioned, for the persistence of the jaundice
will suggest the occurrence of some permanent organic lesion. The
differentiation of the various kinds of jaundice has already been made.
TREATMENT.--Regulation of the diet is of the first importance. Those
foods requiring the intestinal juices for their solution and
absorption, and which cannot be properly digested when a duodenal
catarrh exists or when bile is absent, should of course be excluded
from the diet. These articles are the fats, starches, and sweets. The
mucus playing the part of a ferment, these substances are converted
into various secondary products of an irritating character. Flatulence
is caused by the evolution of carbonic acid gas and the hydrogen
compounds of sulphur and phosphorus; and acetic, butyric, and other
acids not only change the reaction of the intestinal juices, but are
directly irritating to the mucous membrane. In the acute cases a diet
of skimmed milk, taken hot and at three hours' interval, and after the
acute symptoms have subsided, in conjunction with some other aliment,
is the most appropriate mode of alimentation. Meats, fish, eggs, and
oysters are the chief articles of diet, besides the milk, during the
whole course of the more chronic cases; and to these may be added the
succulent vegetables, as lettuce, spinach, celery, raw cabbage, and
tomatoes. If, in consequence of irritability of the mucous membrane or
of idiosyncrasy, any article occasions distress, it should be omitted
from the diet.
The medicinal management includes the administration of remedies for
gastro-intestinal catarrh. The treatment of catarrhal jaundice has been
discussed. When constipation exists, saline laxatives, especially
phosphate of sodium and Rochelle salt, are useful. If there be
diarrhoea, the most appropriate remedies are bismuth, with or without
carbolic acid, Hope's mixture, oxides of zinc and silver, and other
mineral tonic astringents.
The propriety of the administration of special hepatic
stimulants--cholagogues--has been much disputed. When the disorder
consists merely in an obstruction to the outflow of bile, the utility
of stimulating the production of this secretion seems more than
doubtful. Much harm has been done by the indiscriminate use of mercury.
Its power to increase the production of bile having been assumed, and
the quantity of bile present in the feces being manifestly less in
cases of catarrhal jaundice, it followed that mercury should be
employed in this disorder. Modern experience has quite demonstrated its
inutility in the mode and for the purpose to which it was formerly
devoted. Nevertheless, good effects are had from calomel in small doses
as a sedative to the mucous membrane. When there are nausea, headache,
vertigo, and constipation present, excellent results may be had from
the 1/20 gr. to 1/10 gr. of calomel, exhibited at short intervals until
the bowels are moved. If calomel possessed the property formerly
ascribed to it, of stimulating the hepatic functions, it would be
contraindicated in catarrh of the bile-ducts. This contraindication
exists in respect to all hepatic stimulants.
If there be decided irritability of the stomach and constipation,
{1057} Seidlitz powders may be given at regular intervals. Phosphate of
sodium in drachm doses is highly useful for the double purpose of a
laxative effect and to prevent the tendency to inspissation of the
bile, which is one of the most important results of catarrh of the
bile-ducts and gall-bladder. In the more chronic cases the persistent
use of sodium phosphate is to be highly commended.
In this disease, especially as it occurs in gouty subjects, sulphate of
manganese is often decidedly serviceable. If anæmia and debility
coexist, this remedy can be combined with sulphate of iron and sulphate
of quinine--a combination which the writer has found peculiarly
effective under such circumstances. When oxidation is deficient and the
urates are present in the urine in excessive quantity, good effects are
had from the permanganate of potassium, a tablet containing two grains
being given four times a day. In the more chronic cases the salts of
silver, copper, and zinc are really very useful, especially the oxides
of silver and zinc; and of these the former is more efficient. Better
than any of those mentioned is arsenic, as arseniate of sodium or as
Fowler's solution, but the best results are had from small or medium
doses persistently used. If there be much intestinal catarrh and
consequent diarrhoea, bismuth and aromatic powder, oxide of silver,
Fowler's solution with a little opium, Hope's mixture, etc. are
appropriate remedies.
It is in catarrh of the bile-ducts that nitric and nitro-muriatic acids
have proved useful, rather than in cirrhosis and other diseases of the
liver-tissues. They prevent fermentation, promote oxidation, and
increase the activity of the assimilative functions. When there occurs
active fermentation of certain foods, and consequently considerable
flatulence, excellent results are obtained from the members of the
antiseptic group--from creasote or carbolic acid, salicylic acid,
biborate of sodium, the benzoates, etc. To these may be added quinine,
the dose of which will be determined by the purpose for which it is
prescribed. So often is catarrhal jaundice of malarial origin that
quinine becomes a remedy of high importance in the cases occurring in
the malarial-forming zone.
Certain special plans of treatment have been proposed for the cure of
catarrhal jaundice. One of the most effective of these is enemata of
cold water. By means of an irrigating apparatus the large intestine is
well distended with water once a day for several days. The first enema
has a temperature of 60° F., and subsequent injections are a little
warmer. The increased peristalsis of the bowels and the reflex
contractions of the gall-bladder dislodge the mucus lining and
obstructing the gall-ducts. When the bile flows into the intestine,
digestion is resumed and the catarrhal inflammation subsides. But with
the irrigation method may be employed other remedies, as above
indicated.
Faradization of the gall-bladder has been used successfully for the
expulsion of the stored-up bile and the removal of the mucus
obstructing the ducts. It is applied by means of one moistened sponge
electrode placed directly over the gall-bladder, and the other on the
opposite side of the body and posteriorly. A slowly-interrupted faradic
current is then passed. This expedient is not suitable when the case is
acute in character.
{1058} Biliary Concretions; Gall-Stones; Hepatic Calculi; Hepatic
Colic.
DEFINITION.--There are two classes of concretions which may occasion
symptoms: inspissated bile and regularly-formed gall-stones.
Slowly-developing symptoms of jaundice from obstruction may arise from
the deposit of particles of inspissated bile in the hepatic ducts, or
sudden attacks of hepatic colic be due to the passage of concretions.
When biliary calculi reach the intestines, certain kinds of disturbance
may be caused by their presence there. Under the term biliary
concretions must be considered, therefore, the mechanism of their
production, their composition, the symptoms caused by their passage
through the ducts (hepatic colic), and the intestinal disturbance due
to their retention in the bowel.
Formation: Inspissated Bile.--Those concretions consisting of
inspissated bile are irregularly-shaped masses of a brownish,
greenish-brown, or reddish-brown color, friable and crumbling into a
gritty dust with slight pressure of the fingers. When recent and before
drying, they are softer, almost pultaceous, and may take the form of
the canal through which pressed. But as seen after drying they present
the appearance of a dark vegetable extract, dried and partly
pulverized. When examined as found in the gall-bladder or lodged in the
larger hepatic ducts or distributed in irregular fragments (gall-sand)
in the various hepatic passages, they present the shape, color, and
general characteristics of a partly-dried vegetable extract roughly
broken up, but still soft enough to take any shape from pressure. The
writer has seen them thus in situ accompanying regularly-formed
gall-stones in a case of gunshot wound of the liver. These masses of
inspissated bile differ from gall-stones in composition; they consist
of bile, but with a preponderance of the coloring matter. According to
Harley,[153] who has given a more correct account of these bodies than
any other systematic writer, their composition is as follows:
Water 5.4
Solids 94.6
The contents of the solids are--
Bile-pigment 84.2
Cholesterin 0.6
Salts (iron, potash, soda) 15.2
[Footnote 153: _The Diseases of the Liver, with and without Jaundice,
etc._, by George Harley, M.D., F.R.S., Philada., 1883, p. 349.]
Some years ago, before I was aware of the nature of such concretions. I
detected a number in examining the stools of a patient who had in quick
succession many attacks of hepatic colic, but as the usual form of
concretion was looked for and not found, the relation of these bodies
to the symptoms in the case was not understood. I now recognize the
value of Harley's observations on these bodies.