CHAPTER I—ADDRESSES

The Significance of Jaundice as a Symptom in Disease of the Biliary Tracts

BY JOHN B. DEAVER, M. D., PHI ADE PHIA, PA.

Surgeon in Chief, German Hospital

It is my very great pleasure to acknowledge the compliment of being chosen to address the Ohio State Medical Association upon a surgical as well as a medical subject. As the topic of my address "The Significance of Jaundice as a Symptom in Disease of the Biliary Tracts"-appeals to the medical man as well as to the surgeon, and especially so as these cases, as a rule, first consult the family physician, I am sure my remarks will be apropos to the occasion.

The presence of bile in the circulating blood and its appearance in the skin, mucous membranes, exudates and excretions is a condition frequently observed, both in medical and surgical practice. To the surgeon, jaundice too often means more than the mere indication of some lesion of the biliary apparatus; it indicates a neglected condition or a disease which has advanced to the point when surgical interference is useless. To many medical men the appearance of the biliary coloring matter is sufficient evidence of a gall-stone in the common duct or of hypertrophic cirrhosis of the liver.

It is the purpose of the writer to call attention to the significance of jaundice as a symptom in diseases of the biliary tracts, and to the value placed by surgeons upon its presence when attempting to diagnose the pathology of affections of the liver and its ducts.

You are of course aware of the manner of the biliary secretion of the liver, its passage under low pressure to the duodenum, the function of the gall-bladder as a reservoir and

the orifice of the common bile-duct opening into a portion of the human body which is normally teeming with microorganisms.

The biliary ducts are comparatively small in diameter, with frequent curves and open by a minute orifice into the duodenum. This further aids any tendency to obstruction. The relations of the portal lymphatics and the head of the pancreas are so intimate to the common duct that their enlargement may easily obstruct the canal. Infection may reach the liver, not only directly through the common duct, but by means of the portal circulation; such infection may be carried from any part of the intestinal canal.

With such a multiple of ways which may cause obstruction, it is necessary that every factor in the history of the patient be examined and weighed, and that jaundice be regarded as a link only in the chain of evidence which may point to a certain disease.

The etiology of icterus may be considered under (a) disturbances of the liver-cells and (b) mechanic obstructions. The latter cause is by far the more frequent and is the one which calls for surgical intervention in nearly every instance.

I will dwell but briefly with the lesions due to disturbance of the hepatic cells. They are almost exclusively within the domain of the internist.

Bile is normally poured into the bile capillaries by the hepatic cells, and when the latter are diseased or disturbed the bile may be emptied into the blood along with the sugar and urea which is normally secreted by the liver-cells. Liebermeister and Pick have claimed that such a perversion of the bile pigment may occur from functional causes, even without demonstrable pathologic disturbances.

Pick, indeed, explains even the mechanic forms by nervous influences, or a paracholia, whereby a reflex is carried from the nervous supply of the gall-bladder to the secretory nerves of the liver.

Various poisons acting either upon the blood or upon

the liver-cells themselves may give rise, to jaundice. But such conditions do not interest the surgeon and it will suffice to mention Hunter's classification:

1. Jaundice produced by the action of poisons, such as phosphorus, arsenic and snake venom.

2. Jaundice met with in various specific fevers and conditions, such as yellow fever, malaria (remittent and intermittent), pyemia, relapsing fever, typhus, enteric fever and scarlatina.

3. Jaundice met with in various conditions of unknown, but a more or less obscure infectious nature and variously designated as "epidemic," "infectious," "febrile," "malignant jaundice," "icterus gravis," "Weil's disease" and "acute yellow atrophy of the liver."

In addition to this grouping it might be well to call your attention to the jaundice frequently associated with severe hemorrhage, starvation or lowered blood-pressure in the portal or hepatic vessels with increased tension in the smaller bile ducts. The latter condition is believed to follow certain forms of psychic irritation.

This brings us to the second group, or obstructive jaundice, frequently styled hepatogenous icterus and one having a special interest to the surgeon.

In order to approach the subject with some degree of order and clearness it seems advisable to discuss the significance and appearance of icterus from the etiologic standpoint. I will,. therefore, divide the lesions of the biliary tract causing obstructive jaundice into four groups.

1. Inflammatory and infectious.

2.

Cholelithiasis and its results.

3. Neoplasms of the gall-bladder and ducts.

4. Tumors or pathologic conditions of neighboring organs exerting pressure.

The so-called catarrhal jaundice which we so frequently see as a consequence of a gastrointestinal catarrh may vary in degree from a mild and transient yellowing of the skin to a deep and long persistent coloring. Such attacks rapidly

subside as a rule, with but little treatment, but the everpresent bacterial activity sometimes permits a suppurative cholangitis, pancreatitis, cholelithiasis, hydrops of the gallbladder, etc., to take place, and the original catarrhal condition is allowed to fog the perception of an otherwise easily apparent lesion.

The extension of the catarrhal process from the duodenum into the ducts causes a desquamation of their epithelium with a secretion of thick mucus. In the gall-bladder this may result in the formation of gall-stones, in the ducts and especially the hepatic ducts gall-stones may also be formed, or else the collection of the mucus into plugs may simulate impacted calculi, though I think the importance of such obstructions by mucus is much over-rated.

The history of these cases begins with the history of an over-loaded stomach, the drinking of iced drinks or the abuse of alcohol followed by nausea, vomiting, anorexia, and a feeling of sensitiveness over the stomach. The tongue becomes coated; headache, fever and constipation are observed. In about three days the skin begins to appear yellow, the urine becomes dark amber in color, and the brown appearance of the stool gives way to a lighter and lighter yellow. Pain is nearly always absent, and its presence should lead to a very careful observation of the course of the disease. In those cases with persistent jaundice for several weeks, the liver may become slightly enlarged and tender, or a feeling of oppression over the hepatic area may be complained of by the patient.

When treatment has been successful, the gastroduodenitis ceases, the urine becomes normal and finally the yellow discoloration of the skin and mucous membranes fades away. Attacks may recur, but except to those addicted to alcoholic excesses, such recurrences should be viewed with great suspicion and chronic gall-stone obstruction ruled out of the diagnosis for a certainty.

While it is probable that most of the cases of so-calied catarrhal jaundice are infectious in origin, this cannot

be positively proved. Suppurative cholangitis may follow the simple catarrhal form from the invasion of the duct by pyogenic microorganisms, especially by virulent types of the colon bacillus.

While cholecystitis and simple catarrh of the ducts is a very frequent incident in enteric fever, I have but rarely been called upon to operate for the severer suppurative variety.

In suppurative cholangitis icterus is variable in character and dependent upon the amount of obstruction.

In general it may be stated that the jaundice is pronounced, increasing in intensity nearly to the degree observed in malignant disease. The liver becomes much enlarged, smooth and tender to pressure. The purulent nature of the disease becomes manifest by the well-marked character of the fever, the sweating and the chills. Diarrhea, gastric disturbances,. anemia and loss of strength are frequently observed.

Cholelithiasis is frequently associated, and the calculi are usually forced out of the gall-bladder into the common duct. Such cases are very fatal in their termination as the obstruction to the bile-flow also causes retention of pus with diffusion of the purulent process and multiple abscesses of the liver as a result.

The following case is a good illustration of the jaundice occurring in the suppurative type of the disease due to infection with the streptococcus :

R. R., aged 49, married, is a laborer by occupation. One brother died of phthisis. The previous personal history is absolutely negative. For one week before admission, the patient remained at home on account of general indisposition, deranged digestion, loss of appetite, etc. Thirty hours before admission he was seized with a sharp pain along the rib margin on the right side, and in the epigastric region. Nausea and vomiting followed, the latter consisting of a bitter green material (bile). The bowels were constipated, there was anorexia, but there was no jaundice or pain in the shoulder blade. He was admitted to the German Hospital