JAUNDICE. ("InTegos, icterus, morbus regius, aurigo, &c.) Jaundice is a disease of rather frequent occurrence, characterized by a yellow colour of the eyes, skin, and urine, and by the white appearance of the alvine evacuations. In addition to these general symptoms, the malady is frequently attended with extreme depression of spirits, languor, inactivity, and watchfulness; with a bitter taste in the mouth, thirst, loss of appetite, nausea, or vomiting; a sense of fulness or other uneasiness, if not also actual pain, at the epigastrium; occasional shiverings and profuse perspirations; a distressing degree of itching in the skin, and rapid emaciation. The urine soon becomes of a deep mahogany colour, yet gives a bright yellow tinge to substances immersed in it. The state of the bowels is variable, being in some cases relaxed, in other cases confined, but generally acted upon with facility by mild aperients.

The circumstances which predispose the system to an attack of jaundice are numerous. The melancholic or leucophlegmatic temperament, under mental excitement, whether of a pleasant or painful nature; an indolent mode of life, sedentary occupations, a full and stimulating diet, and habitual constipation, are among the most powerful. The occasional or exciting causes of the disease are chiefly such as either suddenly stimulate the liver to an increased secretion of bile, or obstruct the free egress of that fluid. Thus, a heated atmosphere, strong muscular exertions, sudden and powerful emotions of mind, spirituous or other fermented potations, a large and indigestible meal, fæces impacted in the transverse colon, pressure from a gravid uterus, may induce an attack of jaundice.

The proximate cause or essential nature of the disease evidently consists in an obstruction

VOL. III.

to the passage of bile in its course from the liver or gall-bladder to the duodenum, in consequence of which it either retrogrades into the bloodvessels of the liver, or is absorbed from the surfaces of the biliary ducts. There are many morbid conditions of the liver and its appendages, as well as of the adjacent organs, which may induce such an impediment. Not a few of these have been ascertained by the most conclusive evidence. Others, originally devised by the fertile imaginations of nosologists, and considered as adequate to the production of jaundice, have been successively handed down from author to author, not as merely probable causes, but as legitimate deductions from established facts. Instead, however, of specifying the greatest number of morbid conditions which may possibly give rise to jaundice, we shall endeavour to comprise, under a few leading divisions, those phenomena alone which pathology has clearly ascertained. Such, we think, may be conveniently arranged under four general heads.

1. Obstructions arising from biliary concretions or other altered conditions of the bile, as well as from worms, hydatids, or other foreign bodies.

2. Obstructions arising from diseased states of the liver, gall-bladder, or biliary ducts. 3. Obstructions arising from morbid conditions of the duodenum.

4. Obstructions produced by the pressure of enlarged contiguous viscera.

I. The first class of obstructions- those arising from biliary concretions or other altered conditions of the bile itself-have received an almost disproportionate share of attention from medical writers. The learned Heberden, for example, scarcely seemed to recognize any other causes of jaundice. There can be little doubt that a highly inspissated state of the bile

B

may alone produce temporary jaundice. In some instances, after great depression of mind and torpor of bowels, the stools become white, and the skin of a dusky-yellow colour. Under the operation of a brisk mercurial purgative, the patient voids a quantity of dark, pitchy, viscid matter, of sufficient tenacity to be drawn out in threads. He becomes immediately relieved, the, skin and the alvine dejections gradually resuming their natural colour. Such cases we may warrantably refer to a thickened and vitiated state of the bile, which, in other instances, has been found of the same pitchy tenacious character while contained in the gall-bladder itself.

Biliary calculi unquestionably form a very frequent cause of jaundice. Their mere presence in the gall-bladder does not usually seem to produce either general or local inconvenience. Out of nineteen instances of biliary calculi, which occurred to Morgagni, besides four to Valsalva, in post-mortem examinations, not one had experienced jaundice. Yet a general failure of health has been observed, where, after death, no morbid appearance could be discovered except that of calculi in the gall-bladder. Dr. Heberden remarks that," in nearly twenty persons, a supposed pain of the stomach, which had frequently afflicted them for months or years, was at length joined by a jaundice." In those cases, it is probable that the occasional pain arose from some change in the position of the calculi in the gall-bladder. That they do not always remain in the bile-receptacle with impunity is clearly proved by the testimony of morbid anatomists. Soemmering repeatedly found the mucous lining of the gall-bladder in a state of ulceration, occasioned by the irritation of the contained calculi; while other pathologists have observed a general thickening of its coats, and disorganization of its whole

texture.

The number of calculi sometimes contained in the gall-bladder is almost incredible. Morgagni took out of one body 3646; and in the Hunterian museum at Glasgow, 1000 are preserved which are stated to have been extracted from one gall-bladder. The form and size of these calculi are very various. In a few instances they have nearly taken the shape and attained the magnitude of the gall-bladder itself, but, generally, are from an eighth to a one-half of an inch in diameter, and of a polygonal form. The broken or divided portions of the larger calculi have sometimes corresponding convexities and concavities, proving that they were once united. And it is not improbable that the smaller calculi are often subdivisions of a larger mass, formed into distinct calculi before consolidation was completed. The sides of these calculi are often

Abercrombie on the Diseases of the Abdominal Viscera, p. 370.

+ Transactions of the College of Physicians, vol. vii. p. 171.

See Mr. Brayne's very interesting cases in the Medico-Chir. Trans., vol. xii.

flattened as if from close contact and pres

sure.

The chemical and physical characters of biliary calculi have been already described in this work under the general title of CALCULUS. In that condensed but highly-interesting article the distinguished author has given a very perspicuous account of the more frequent forms of biliary calculi; but may not have thought it necessary to allude to one or two kinds of uncommon occurrence, which yet, we conceive, may prove of some importance in a pathological point of view. We, therefore, make no apology for introducing them in this place.

The first of these, as we are informed by Professor Turner, was discovered by M. Bizio, of Venice, in a peculiar fluid, quite different from bile, which was found in the gall-bladder of a person who had died of jaundice. It is of a green colour, transparent, tasteless, and of the odour of putrid fish. It is unctuous to the touch, may be scratched or cut with facility, and has a specific gravity of 1.57. M. Bizio has given it the name of erythrogen.*

Another remarkable kind of biliary concretion is described by Dr. Marcet, in the following words.t "Within the last few days, I have seen and analysed a large biliary calculus entirely different in its chemical composition from the above description, and, as far as I know, presenting a new fact in the history of these bodies. This concretion contained no adipocire (cholesterine), and consisted wholly of carbonate of lime tinged by bile. It was of a bright yellow colour. It was heavier than water, and measured two inches five-eighths in length, and two inches and a quarter in its largest circumference." This extraordinary production was found in the gall-bladder of a dead body by Mr. Green, (now Professor Green,) demonstrator of anatomy in St. Thomas's Hospital.

The formation of biliary calculi is still involved in much obscurity. Many of the circumstances before enumerated as predisposing to jaundice generally, are found peculiarly to favour the formation of calculous concretion. Such are depressing emotions, deficient bodily exercise, a full diet and frequent constipation. Had biliary concretions been always found to consist merely of inspissated bile, there would have been no difficulty in conceiving how the want of exercise and similar causes, by favouring the retention of bile and the gradual absorption of its thinner parts, should ultimately lead to an actual concretion of the residual mass. And that this has sometimes occurred is sufficiently proved. Van Swieten, in his Commentaries, relates the case of a boy whose gall-bladder contained eight pounds of a thick sort of bile, consisting of a number of concentric strata, each stratum becoming firmer as it approached the circumference. There had, however, been no jaundice, although the stools were of a white colour. Biliary con

Dr. Turner's Elements of Chemistry, p. 656. Marcet on Calculous Diseases, p. 151, Note.