Case of a girl of 16 years, who became jaundiced when six years old, and re mained so six months. At thirteen there was another attack of jaundice lasting eight months, and at fifteen one of six months' duration. The fourth attack came on at sixteen, and when reported had lasted four months. According to the mother, an inflammation of the throat preceded every attack. In the previous attacks, especially the second, there was severe pain in the region of the stomach and liver, not colicky. Chills and fever have not been present. Re covery from the attacks begins suddenly. In the present attack there is no fever, the appetite is good, and bowels regular; the patient is emaciated and feels weak. The jaundice is intense; there is great itching. Ascites and enlarged spleen are absent. The liver is enlarged all over, dullness extending from the upper border of the fifth rib in the mammillary line to three fingers' breadths below the rib. The surface is hard, uneven, and sensi tive. The freces for months have been without bile-coloring matter. The case is probably one of gall-stone with second ary hypertrophic cirrhosis of the liver. Albu (Deutsche med. \\loch., No. 13, '98).
Slow pulse is very characteristic; it is usually from 40 to GO, but may be down to even 20 per minute. Such pulse changes are more frequent in catarrhal jaundice and are not usually of unfavor able significance. The respirations are usually normal, but may fall to 10 or less per minute.
In many protracted cases there is a marked tendency to hmorrhages, espe cially to purpura and to subcutaneous travasations. The blood requires in some of these cases eleven or twelve minutes to coagulate instead of three or four, as in normal states (Osler).
Surgical operations should only be un dertaken in case of chronic obstrnctive jaundice with clue regard to this change in the blood.
Ieterie blood is deficient in sodium chlo ride. This depends on a lack of .NaCI and a reduction in the volume of the serum. The latter is produced by an increase in the volume of the red corpuscles, which, in turn, is due to the presence of bile salts in the plasma. V. Lirnbeck (Ceti tralb. f. innere Med., No. 33, '96).
In chronic jaundice there is a marked tendency to lu-emorrhage and in oper ating upon such eases surgeons have to count this as a possible serious accident. Within the past few years, the writer has known of three fatal cases of tumor rhage following operations under these conditions. recent case suggests the possibility of the value of taking the blood-coagulation time. The case was one of jaundice with pains suggesting gall-stones, and Dr. Finney operated. The patient almost bled to death on the table. The wound was packed with
gauze, and the patient was taken back to the ward in a very exhausted condi tion. He bled very actively every time an attempt was made to remove the gauze, and it was at least three weeks before all of it was taken out of the wound. His blood-coagulation time, as taken with Wright's tubes, 1N-as between ten and eleven minutes, more than double the normal. It certainly would be ad vantageous to test this point in cases of chronic jaundice before operation, and it might be worth while also to follow out Piot, ssol right's suggestion, and to -9% c the chloride in full doses for st pet iod of ten s in order to increase, p. ssildc. the coagulability of the lood. :Man) Oster (Montreal Med.
tom., 1.111..
Pruritus is often a distressing symp tom in the chronic forms of obstructive jaundice. It occasionally precedes the onset of the jaundice. It is worse at and may be g,eneral or localized.
Scrateliiii‘: gives rise to various tions. Sweating is frequent. ITrticaria, lichen, and boils may be present, as may also xanthelasma.
Cutaneous pruritus, so common in jaundice from retention, may appear and persist for a long time before the icterus is evident. This precocious pruritus: is observed especially in eases in which the obstruction to the flow of the bile is caused by a neoplasm situated some where along the course of the biliary pas sages. Bouchard (Med. Rec., Apr. 14, '94).
The thyroid gland or extract exerts a favorable action on the pruritus which so often accompanies jaundice, this symptom becoming much less trou blesome, or ceasing. altogether while the thyroid \vas being taken. At the same time the bile-salts, tested for by Hay's sulphur reaction, gradually di.sappeared from the urine; this also occurred in cases free from pruritus. There was no alteration in the pigments of the urine, as shown by Gmelin's test. Gilbert and Herrscher (Comptes-Rendus d. Soc. de Biol.. Aug.. 1902).
Cerebral symptoms may be marked, in cluding irritability, great despondency, and even melancholia. There are often headache, vertigo, and dullness; there may be sleeplessness. Specially severe symptoms may develop in persistent jaundice and quickly prove fatal. Usually there is slight fever, rapid pulse, emaciation, and mild delirium. From this. typhoid state the patient may soon become comatose or develop convulsions. This condition was formerly denomi nated cholcmia, or sometimes ainia. Its cause is uncertain, but ably most cases are due to a "terminal infection." Etiology.—This class includes the eases that "result from obvious ical obstruction" and are "independent of changes in the blood or bile.' (Hun ter).