22 Ziemssen's Cyclopædia, vol. ix., supra.
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-Beaumetz24 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.
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, 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.
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 Kühne26 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.