JAUNDICE AS A RESULT OF SUPPRESSION CONSEQUENT UPON ABSENCE OF THE SECRETING SUBSTANCE.
The pathology of this state is self-evident, for wherever secreting substance is wanting, secretion cannot take place. If then, the tissue which secretes bile be destroyed or transformed by disease, the biliary function must be suspended, and the ingredients which it is the office of such structure to separate from the blood, will accumulate in the circulation, and give rise to the usual chain of results following suppression of the biliary secretion.
In cancer, tubercle, fatty and amyloid degeneration of the liver, jaundice arises from the above-named cause. In these diseases it is not, however, a constant symptom, and this is simply on account of there being usually sufficient healthy tissue left to enable the biliary secretion to be carried on. If the cancer, or other morbid product, occupied the whole place of the secreting tissue, the biliary function could no more be carried on by such product, than by the same product occupying another organ of the body. In cases of jaundice arising from absence of the secreting substance, the amount of the jaundice depends on another cause besides the mere extent of the morbid deposit. This is its situation. A large amount of diseased tissue may exist in certain portions of the liver, and yet fail to produce jaundice, while a much smaller amount of the same diseased tissue, placed in another situation, may induce it. Should the morbid deposit, for example, be so placed as readily to interrupt the flow of the secreted bile, jaundice may rapidly occur, and be due as much to the re-absorption of the secreted bile, as to the suppression of the biliary secretion. This is, indeed, the true explanation of the fact, that diseases affecting the concave, are much more frequently accompanied with jaundice, than those attacking the convex surface of the liver. I might have chosen what at first sight appears a more typical example of absence of secreting structure, namely, a case of acute atrophy of the liver; for in such cases the hepatic tissues sometimes dwindle down in the course of a few days to less than a quarter of their original bulk, and give rise to intense jaundice. But in such cases there does not appear to be a total arrest of the secretion, until the very last stage of the disease, if it even occurs then; and besides, if I dare form an opinion from one case, I should say that, in consequence of the rapid disorganization of the parenchyma of the liver, the circulation in the organ becomes much disturbed, and gives rise to what Frerichs terms disordered diffusion. So that in cases of acute atrophy of the liver, the jaundice, although chiefly due to suppression, is complicated with re-absorption of the bile, as was proved in a case I examined, by finding in the urine, not only those products which are merely excreted from the blood, but also some of those which are generated in the liver itself. It will be necessary for me, therefore, to go more fully into this form of jaundice than I have done in any of the preceding forms of the disease.
JAUNDICE ARISING FROM ACUTE ATROPHY OF THE LIVER.
Acute, or yellow atrophy of the liver, is one of the most formidable of human diseases. It is sudden in its onset, rapid in its course, fatal in its termination. It is more common in women than in men; seldom attacks those above thirty years of age, and occurs most frequently in the earlier months of pregnancy. The immediate exciting cause of this strange disease appears to be, in the majority of cases, mental depression. The symptoms usually observed are jaundice, rapidly followed by sickness, and vomiting; by febrile excitement, and cerebral disturbance.
As the disease advances, the hepatic dulness diminishes; the urine becomes scanty, and high-coloured; the bowels confined. Extravasations of blood take place under the skin; and hæmorrhages from the nose, vagina, or bowels are frequently observed. Lastly, delirium, or coma, generally closes the scene, within a week after the commencement of the violent symptoms, and within a month after the appearance of simple jaundice. Frerichs, who has so well described these cases, even says, "that in the severest forms, the disease may run its course, and end fatally within twenty-four hours."12
12 "Clinical Treatises on Diseases of the Liver," vol. i. p. 197.
All cases of acute atrophy of the liver are, fortunately, not necessarily fatal. In some the violent symptoms gradually disappear, and recovery takes place after free evacuation of the bowels.
In every case of suspected acute atrophy of the liver, the urine ought to be carefully examined for tyrosine, and leucine, two abnormal products, which, according to Frerichs, are never absent. Some remarks on the diagnostic value of these substances will be found at [page 62].
Through the kindness of Dr. Wilks, I had the opportunity of examining the liver, and analysing the urine, in a typical case of acute atrophy, which he reported in the Pathological Society's "Transactions," vol. xiii. p. 107. The brief history of the case is as follows:—E. K., aged seventeen, a married woman, in the third month of pregnancy, was seized with a bilious attack, and jaundice, after having a violent quarrel with her husband, who accused her with infidelity. The patient was first under the care of Mr. Bisshopp, of South Lambeth, who found her suffering from jaundice, accompanied by some febrile symptoms, and vomiting. In two days she became delirious, had violent screaming, and convulsive fits, which were rapidly followed by unconsciousness. Next day the patient was seen by Dr. Wilks; she was then quite insensible, with slight stertorous breathing, and foam on the lips. The pupils were moderately dilated, and sensible to light. The pulse 120. The hepatic dulness reduced to a narrow band over the lower ribs. No urine had passed for twenty-four hours; a catheter was therefore introduced, and twelve ounces of clear bilious-looking fluid were drawn off. This urine I had the opportunity of analysing a few days afterwards. It was then of a yellow-ochre colour, and contained a considerable deposit.