The most typical example of jaundice as the result of active congestion, is to be found in those cases where it supervenes on an attack of hepatitis, such as is met with in hot climates, where indolent habits and high living favour portal congestion. It is occasionally met with in England, however, and is frequently associated with gastric derangement.
I had occasion to witness a good example of this form of disease in the person of a French gentleman, who was brought to me seven days after his arrival in England, on account of his skin having assumed a most intense yellow hue. It appeared that he had come to England on a visit to some of his friends, and rather enjoying the novelty of an English table, indulged too freely in a quantity and quality of food to which he had hitherto been a stranger. The consequence was, that within three days after his arrival he began to suffer from hepatic tenderness, and dyspeptic symptoms; the skin at the same time assumed a dusky hue, which soon merged into a decided yellowness. These symptoms were accompanied by pipe-clay stools and saffron-coloured urine; on the latter being tested it gave a distinct bile pigment, but no bile acid reaction—a point which I shall afterwards have occasion to show, is of a certain diagnostic value in obscure cases of jaundice. This gentleman, under the influence of benzoic acid, perfectly recovered his normal complexion in the short space of a week.
There is another form of jaundice from active congestion, viz., that due to the presence of zymotic disease, such as ague, typhus, and other fevers. As an illustration of this kind of affection, I shall cite one arising from the first of these causes, namely, ague. And the best example I can give is one that has recently fallen under my notice, and which occurred in the person of a member of our own profession. The gentleman was for several years surgeon to one of our large colonial hospitals, but in consequence of repeated attacks of intermittent fever, was forced to resign the appointment, as well as a lucrative practice, and return to England. He has now been at home for two years, and although his general health has much improved, still suffers from occasional attacks of his old enemy. On consulting me regarding his case several months ago, he mentioned, that while suffering from the above-named attacks, he occasionally suddenly passed five or six ounces of urine as dark as chocolate, and this would recur perhaps once in twenty-four hours, during two or three days, and then as suddenly disappear. This urinary symptom being an unusual one, I requested him to send me on the next occasion a specimen of the fluid. In the beginning of last November9 I received three samples of urine, one passed at eight A.M., which was clear, pale, of a specific gravity of 1025, of an acid reaction, deposited no lithates, and contained no albumen, being in fact normal in every respect; another quantity passed at two P.M., of a chocolate brown colour, opaque, turbid, having a specific gravity of 1032, of an acid reaction, depositing lithates, containing albumen,10 some sugar, and a large excess of urea (3·6 per cent.) and urohæmatine; a third sample passed at night, of a specific gravity of 1021, also with an acid reaction, depositing lithates in small quantity, but containing no albumen. The percentage of urea in this urine was exactly one-half (namely, 1·8) of what it was in the preceding specimen passed at two P.M.
9 This was written last year, and therefore refers to November, 1861.
10 When examined with the microscope, this specimen of urine was found to contain a large quantity of nucleated epithelium, and granular cells; free granules of a hæmatine colour, granular tube-casts, and a quantity of mucus; while the morning and evening urines were perfectly free of any such substances.
The varying conditions of these three urines clearly pointed to intense congestion of the chylopoietic viscera, of a transient and periodic character. Suiting the practice to the theory, mercurials were taken by this gentleman in order to remove the congestion of the chylopoietic viscera, and with the most favourable results, for, as I afterwards learned, the jaundice and other disagreeable symptoms soon disappeared.
Jaundice the Result of Passive Congestion of the Liver.
In this case the congestion, instead of arising from an increased flow of blood to the liver, as in the preceding, is the result of some cause impeding the outward flow of blood from the liver. Thus for example, passive hepatic congestion may arise from valvular disease of the heart, or from any pulmonary affection obstructing the circulation of blood through the lungs (pneumonia, &c.). Jaundice from the passive form of hepatic congestion, is not so common as jaundice from the active form, in consequence of the former being, as a rule, much slighter than the latter. Its pathology is, however, I believe, exactly the same, viz. the result of the engorged hepatic capillaries compressing the secreting cells and tubes, and thereby annulling their functions. Such being the case, it is unnecessary for me to do more than merely allude to this cause of jaundice.
It may, perhaps, be asked—"If the foregoing statements regarding the pathology of jaundice from congestion be correct, how does it happen that it is not present in every severe case of gastric derangement, fever, heart-disease, &c.?" This question is easily answered, for as Dr. Budd has clearly put it, while speaking of the action of medicines upon the liver—"In most persons, perhaps, a portion of the liver may waste or become less active without sensible derangement of health, they have more liver, as they have more lung, than is absolutely necessary. In others, on the contrary, the liver, from natural conformation, seems just capable of effecting its purpose under favourable circumstances." Persons inheriting this feebleness of liver, "or in whom, in consequence of disease, a portion of the liver has atrophied, or the secreting element of the liver has been damaged, may suffer little inconvenience as long as they are placed in favourable circumstances, and observe those rules which such a condition requires;" but as soon as the balance of their hepatic circulation is disturbed by causes like those above mentioned, jaundice makes its appearance; such patients being, as Dr. Budd says, "born with a tendency to bilious derangements."11
11 Diseases of the Liver, p. 55.