bile liver obstruction yellow colour skin
JAUNDICE (Fr. Jaunisse, from jaune, yellow), or ICTERUS (from its resemblance to the colour of the golden oriole, of which Pliny relates that if a jaundiced person looks upon it he recovers but the bird dies), a term in medicine applied to a yellow coloration of the skin and other parts of the body, depending in most instances on some derangement affecting the liver. This yellow colour be regarded more as a symptom of sonic morbid condition previously existing than as a disease per se.
The manner in which jaundice is produced is still a matter of debate among physicians, but it is generally admitted that there are two classes of causes, either of which may bring about this condition. In the first place any obstruction to the passage of bile from the liver into the intestinal canal is sooner or later followed by the appearance of jaundice, which in such circumstances is due to the excessive absorption of bile into the blood. To this variety the term obstructive jaundice is applied. But secondly, a form of jaundice may be produced by causes not embracing obstruction, but including a variety of morbid conditions affecting either the secreting structure of the liver or the state of the blood, and to this the term non-obstructive jaundice is applied.
Obstructive jaundice may be due to the following causes: - (1) simple catarrh of the hepatic and common bile duct (see DIGEsnvE ORGANS), whereby the calibre of these channels is narrowed (this is frequently the result of cold or of temporary gastric disturbance, but it may become a chronic condition) ; (2) impaction of gall stones or plugs of hardened mucus in the ducts ; (3) general congestion of the liver, either alone or in connexion with pre-existing disease in the heart or lungs ; and (4) pressure of morbid growths either external to the liver or in its substance.
Obstruction from these causes may be partial or complete, and the degree of jaundice will vary accordingly, but it is to be noted that extensive organic disease of the liver may exist without the evidence of obstructive jaundice.
The effect upon the liver of impediments to the outflow of bile such as those above indicated is in the first place an increase in its size, the whole biliary passages and the liver cells being distended with retained bile. This enlargement, however, speedily subsides when the obstruction is removed, but should it persist the liver ultimately shrinks and undergoes atrophy in its whole texture. The bile thus retained is absorbed into the system, and shows itself by the yellow staining seen to a greater or less extent in all the tissues and many of the fluids of the body. The kidneys, which in such circumstances act in some measure vicariously to the liver and excrete a portion of the retained bile, are apt to become affected in their structure by the long continuance of jaundice.
The symptoms of obstructive jaundice necessarily vary according to the nature of the exciting cause, but there generally exists evidence of some_ morbid condition before the yellow coloration appears, Thus, if the obstruction be due to an impacted gall stone in the common or hepatic duct, there will probably be the symptoms of intense suffering characterizing " hepatic colic " (see CoLIc), after which the jaundice appears. In the cases most frequently seen - those, namely, arising from simple catarrh of the bile ducts due to gastro-duodenal irritation spreading on to the liver through the common duct - the first sign to attract attention is the yellow appearance of the white of the eye, which is speedily followed by a similar colour on the skin over the body generally. The yellow tinge is most distinct where the skin is thin, as on the forehead, breast, elbows, &c. It may be also well seen in the roof of the mouth, but in the lips and gums the colour is not observed till the blood is first pressed from them. The tint varies, being in the milder cases faint, in the more severe a deep saffron yellow, while in extreme degrees of obstruction it may be of dark brown or greenish hue. The colour can scarcely, if a' all, be observed in artificial light.
The urine exhibits well marked and characteristic changes in jaundice which exist even before any evidence can be detected on the skin or elsewhere. It is always of dark brown colour resembling porter, but after standing in the air it acquires a greenish tint. Its froth is greenish-yellow, and it stains with this colour any white substance. It contains not only the bile colouring matter but also the bile acids. The former is detected by the play of colours yielded on the addition of nitric acid, the latter by the purple colour produced by placing a piece of lump sugar in the urine tested, and adding thereto a few drops of strong sulphuric acid. This test for the bile acids is dwelt upon by Dr George Harley as an important point in serving to distinguish jaundice with obstruction from jaundice without obstruction, in the latter of which, although there is bile pigment in the urine, the bile acids are absent.
The contents of the bowels also undergo changes, being characterized chiefly by their pale clay colour, which is in proportion to the amount of hepatic obstruction, and to their consequent want of admixture with bile. For the same reason they contain a large amount of unabsorbed fatty matter, and have an extremely offensive odour.
Constitutional symptoms always attend jaundice with obstruction. The patient becomes languid, drowsy, and irritable, and has generally a slow pulse. The appetite is usually but not always diminished, a bitter taste in the mouth is complained of, while flatulent eructations arise from the stomach. Intolerable itching of the skin is a common accompaniment of jaundice, and cutaneous eruptions or boils are occasionally seen. Yellow vision appears to be present in some very rare cases. Should the jaundice depend on advancing organic disease of the liver, such as cancer, the tinge becomes gradually deeper, and the emaciation and debility more marked towards the fatal termination, which in such cases is seldom long postponed. Apart from this, however, jaundice from obstruction may exist for many years, as in those instances where the walls of the bile ducts are thickened from chronic catarrh, but where they are only partially occluded. In the common cases of acute catarrhal jaundice recovery usually takes place in two or three weeks.
The treatment of this form of jaundice bears reference to the cause giving rise to the obstruction. In the ordinary cases of simple catarrhal jaundice, or that following the passing of gall stones, a light nutritious diet (milk, soups, &c., avoiding saccharine and farinaceous substances and alcoholic stimulants), along with counter-irritation applied over the right side, and after a few days the use of laxatives which tend to promote the flow of bile, will be found to be advantageous. Rhubarb, taraxacum, podophyllum, mercury, are among the remedies which have long been employed for this purpose, but the recent researches of Professor Rutherford have brought to light certain other agents (euonymin, iridin, leptandrin, &c.), which exercise a powerful influence as cholagogues, and are now coming into use. Diaphoretics and diuretics to promote the action of the skin and kidneys are useful in jaundice. In the more chronic forms, besides the remedies above named, the waters of Carlsbad are of special efficacy. Where the jaundice depends on changes in the substance of the liver, altering its structure, such as cancerous deposit, all that can be accomplished is the palliation of symptoms, including the jaundice, which may be mitigated by the treatment already indicated. With the view of supplying bile to the alimentary canal, Dr Harley recommends the use of inspissated ox-gall in doses of 5 to 10 grains administered in capsules of gelatin.
occurrence. Many of such cases might probably, as Virchow observes, be found on careful investigation to depend on some obstruction in the biliary passages ; but there can be no doubt that many others admit of no such explanation, and as regards these it is generally held that they are probably connected with some alteration in the colouring matter of the blood, the source, it is believed, of the bile pigment. Others suppose this form of jaundice to be due to an excess in the normal reabsorption of bile into the blood. The pathology, however, is still unsettled. Jaundice of this kind is almost always slight, and neither the urine nor the discharges from the bowels exhibit changes in appearance to such a degree as in the obstructive variety. Grave constitutional symptoms are often present, but they are less to be ascribed to the jaundice than to the disease with which it is associated.
The name malignant jaundice is sometimes applied to that very fatal form of disease otherwise termed acute yellow atrophy of the liver. See ATROPHY. (T. 0. A.)