Eighthly,—The head of the pancreas was considerably enlarged, and on cutting into it, a quantity of pus oozed out from an abscess in its interior. The abscess was found to communicate with a large ulcerated spot in the duodenum. ([Plate I.], f.) On microscopical examination, the tumour of the pancreas was found to consist of an hypertrophy of the normal gland tissue, being, in fact, a chronic inflammatory tumour of the gland substance.
In no portion of the body was a trace of cancer detected, nor any enlargement of the mesenteric or other glands, to justify even a suspicion of malignant disease. So the opinion arrived at regarding the pathology of this case is, that the disease originated in an inflammatory affection of the pancreas, during the progress of which, the openings of the bile, and pancreatic ducts became blocked up; the interruption to the excretion of the bile giving rise to the jaundice, and at the same time inducing engorgement, and enlargement of the liver. The inflammatory affection of the pancreas had probably ended in the formation of an abscess, which, pushing the enlarged liver forwards, admitted of the distended gall-bladder being seen, and felt through the abdominal parietes. At length the abscess burst, and suddenly emptied itself into the duodenum; the yellow fluid discharged from the intestines being not bile, as the patient had supposed, but pus. No sooner had the abscess emptied itself, than the liver returned to its natural position, and thus accounted for the distended gall-bladder so suddenly ceasing to be seen or felt. The ulcer in the duodenum appears to be the mouth of the abscess, which has probably been prevented closing, partly on account of the occasional draining away of pus, which, being in small quantity, and mixed with the stools, escaped detection; and partly to the constant irritation of the passage of the food, there being no bile or pancreatic fluid to neutralize the acidity of the chyme. This might even be sufficient of itself to delay the healing process. The ultimate gradual atrophy of the liver would arise from the continued pressure of the distended bile-ducts interrupting the hepatic circulation, as formerly pointed out at [page 48]. Lastly, there being no bile or pancreatic juice admitted into the intestines, the greater part of the food taken passed out of the body unabsorbed, and the patient, though possessing an excellent appetite, and taking plenty of food, actually died of slow starvation.
My object in giving such prominence to this interesting case, is to show how valuable an adjunct physiological chemistry is to the other methods of diagnosis in obscure diseases of the abdominal organs, and to encourage others to follow in the same path; for it must be remembered that the foregoing was no dead-house diagnosis, but that every fact here stated was discovered and recorded before death.
Having now explained the mechanism of the two forms of jaundice—that arising from suppression, and that induced by obstruction—it only remains for me to remind my readers, that there is frequently a combination of the two conditions. Jaundice from obstruction, for example, cannot long exist without becoming complicated with jaundice from suppression. The continued backward pressure exerted on the hepatic parenchyma by the over-distended bile-tubes, sooner or later impedes the circulation in the organ to an extent sufficient to induce an impairment, if not an almost total arrest of the biliary secretion. Hence it is, that in the last stage of jaundice from obstruction, the biliary acids gradually diminish, and at last finally disappear from the urine. We have it, nevertheless, in our power to distinguish between the two forms of disease—for whereas, in jaundice arising from simple suppression, there is only an absence of the bile-acids; in jaundice from obstruction, complicated with suppression, the absence of the bile-acids is usually associated with the presence of tyrosine, and leucine. For before complete suppression occurs as a result of obstruction, the hepatic tissue has already had its nutrition so impaired, as to admit of the formation of these foreign substances. Lastly, the history of the case will of itself be an important guide.
EPIDEMIC JAUNDICE.
It is seldom that jaundice attacks persons in an epidemic form; as it does so occasionally, however, and that too in almost all countries, it is necessary that I should say a few words on its pathology. In a quotation, in the "Medical Times and Gazette," from the "Recueil de Mémoires de Médecine Militaire," vol. iii. p. 374, it is stated that, "M. Martin gave an account of an epidemic of jaundice which he had the opportunity of observing among the artillery and engineers of the French army stationed at Pavia during the Italian war. It commenced during the great heats of August, and terminated by the end of October. There occurred 71 cases in an effective of 1022 men. The causes he considers to have been the unusual heat, which gave rise to great congestion of the liver, the fatigue of long marches (the mounted men suffering oftener in proportion than the unmounted), indulgence in alcoholic drinks, and marsh miasmata. Great increase in the size of the liver in most of the cases, and of the spleen in many, was observed, and all complained of pain in the epigastrium and in the hypochondria. In fact, this last was the first symptom of the approaching jaundice. None of the cases proved fatal. Professor San-Galli informed M. Martin that a similar epidemic prevailed in the town of Pavia at the same time."
That jaundice may also occur in an epidemic form among pregnant women, has been shown by Dr. Saint-Vel, who relates that, "In 1858 the island of Martinique was, without appreciable cause, visited by an epidemic of jaundice, remarkable for its severity in pregnant women. It broke out at St. Pierre towards the middle of April, attained its maximum height in June and July, and terminated towards the end of the year. All races were attacked; the patients were mostly adults; no liver-complication could be detected; nor could any resemblance be traced between the disease and yellow fever. It was fatal to females only, especially during pregnancy. Of thirty pregnant women who were attacked at St. Pierre, ten only arrived at the full period of pregnancy without presenting any other symptoms than those of ordinary jaundice. The other twenty all had abortion or premature labour a fortnight or three weeks after the commencement of the attack, and died in a state of coma, which appeared a few hours before or after the expulsion of the foetus. The females who died were from the fourth to the eighth month advanced in pregnancy. In some cases, slight delirium preceded the coma, which was never interrupted, but became more and more profound up to the time of death. Its longest duration, in two cases, was twenty-four and thirty-six hours. It was not preceded by any notable modification of the general sensibility, nor of the respiration or circulation. Hæmorrhage was absent, except in one case, where a female had it before delivery. When death was delayed till three or four days after delivery, the lochia were healthy. Almost all the children were still-born; some lived a few hours; one alone survived. None of the infants had the icteric colour; nor was there any sign of jaundice in the ten children born at the full term."
The foregoing translation from the "Gazette des Hôpitaux," 20th November 1862, appeared in the "British Medical Journal" of the 7th of February, 1863, p. 141.
We have it further stated in the "Lancet" of the 21st February 1863, under the head of the "Health of Rotherham," that, "scarcely had the late fatal epidemic of fever subsided ere another, less fatal, but as widely spread, took its place. In last November several persons were attacked with jaundice, and now not less than 150 persons are suffering from it. None of those who were attacked by the late fever are suffering from the present epidemic."