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icterus, bile, skin, consequence, according, vein, symptom, born and life

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JAUNDICE is common in early life. This symptom may be found in children as a consequence of the same causes which produce it in the adult. There is in addition a special form of jaundice seen in new-born babies which is called icterus neonatorum. It will be therefore convenient first to describe jaundice as it occurs in the new-born baby, and afterwards the symptom as it is met with in older children.

Icterus neonatorum, or infantile jaundice, must be distinguished from the yellowish discolouration of the skin which succeeds in many cases to the intense cutaneous congestion of the first few hours or days of life. This staining is not dependent upon the secretion of bile, and is not a jaundice at all. It does not colour the conjunctivae or the urine, but re sembles the staining of the skin which follows a cutaneous bruise. The face of the child who is born after a difficult or tedious labour, is often at first deep red, with a tinge of violet ; and the skin over the body is coloured with an erythematous redness. At the same time, or soon after, pressure upon the surface sufficiently firm to empty the blood-vessels shows a yellow tint of the skin. As the redness fades, the yellowness appears to increase, and soon remains the sole cliscolouration. Beginning, as a rule, on the second day, it usually persists for about a week, and is commonly over by about the tenth day, or a little earlier, although in exceptional cases it may last longer. By some writers, the term icterus neonatorum is confined to this false jaundice, and the same authors apply the name icterus in fantum to the true disease. This practice is calculated to give rise to unnecessary confusion. In the following pages the terms icterus neonatorum and icterus infant= will be applied indifferently to indicate a staining of the skin by the pigments of the bile.

Real icterus manifests itself in the child as it does in the adult, by a yellow tint of the skin and conjunctivae, light-coloured stools, and often by discolouration of the urine. It may be the result of some comparatively trifling derangement, and is then readily recovered from ; or may be the consequence of a serious malformation or grave organic lesion, and is then almost invariably fatal.

The milder form of jaundice—which may be called the benign variety —appears to be predisposed to by difficulty and delay in the process of parturition. A first-born child, exposed to serious and prolonged pressure before birth, and who, in consequence, is born in a state of semi asphyxia, is often found to become jaundiced. Again, according to Kebrer, premature birth, or other cause of weakness in the infant, is apt to be fol lowed by the same result. Exposure to cold and clamp, and, according to some writers, a vitiated atmosphere, can also produce it.

Many theories have been advanced to account for the frequency of this symptom in the newly born. Virchow attributed it to a duodenal catarrh, and plugging of the common duct with mucus ; and in children who have been exposed to cold this is no doubt a common cause of the derange ment. Frank thought it was the consequence of an accumulation of me conium. Cohnheim believed it to be due to a sudden increase in the bile secretion after birth—an increase too great for the bile-ducts to carry away ; but he has advanced no evidence in support of his theory. Many writers have referred the symptom to the disturbance in the hepatic circu lation consequent upon the change in the conditions of life incident to birth. The circulation is too full, according to Hewitt and Weber, so that the distended vessels compress the bile-ducts ; it is too empty, according to Frerichs, the circulation through the umbilical vein being suddenly cut off, and the tension of the hepatic capillaries diminished, so that the se creted bile makes its way into the blood-vessels.

There can be no doubt that the sudden transference of the chief sup ply of blood from the umbilical to the portal vein must at first produce considerable disturbance in the hepatic circulation. Weber has pointed out that if the functions of the umbilical vein are arrested before the es tablishment of respiration, as when a child is born partially asphyxiated, great congestion and cedema of the liver are the consequence. Birch Hirschfeld has shown that the vessels in the notch of the liver are sur rounded by a dense layer of connective tissue, and that this areolar sheath is continued into the organ along the branches of the portal vein. He has noted that in cases of difficult parturition, where the liver is the seat of great venous obstruction, this areolar sheath is (edematous. It becomes pulpy and gray in colour from infiltration of fluid, and a great accumula tion of round cells takes place into its meshes. This pulpy condition of the cellular layer is seen also around the umbilical vein, and may even extend into the gall-bladder. It is evident that the swollen tissue must compress the bile-ducts, and Birch-Hirschfeld has shown that this is actually the case. The bile-ducts are distended, and it is difficult to force bile out of the gall-bladder into the duodenum. In these cases he has de tected early- signs of jaundice where death has occurred during the first clay, and reports cases in which life had been further prolonged with a gradual increase in the icteric symptoms. In these mild cases, the pres ence of the bile-pigment cannot be always demonstrated in the urine ; but, according to this authority, the bile acids can be detected in fatal cases in the pericardial fluid.

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