CHAPTER XLVII
JAUNDICE AND THE LIVER AND SPLEEN IN TROPICAL DISEASES
JAUNDICE
Although the appearance of jaundice immediately suggests a disease of the liver yet as a matter of fact those diseases of the tropics in which the liver involvement is the sole or chief feature rarely show marked jaundice.
In _tropical hepatitis_ or congestion of the liver or, as it is often termed, tropical liver, there is rarely a distinct jaundice and if such occur it is only temporary. Such terms as earthy, muddy, sallow, sub-icteric or pale lemon tint are more often applied than jaundice.
_Liver abscess_ rarely gives rise to a definite jaundice unless the abscess be so situated as to cause pressure on the bile ducts.
In _clonorchiosis_, or the liver fluke disease of man, jaundice is not a feature of the disease except in the very late stages.
In those liver cirrhoses associated with _Katayama disease_, _malaria_ or _kala-azar_ there is no typical jaundice.
The tropical diseases in which jaundice is an important diagnostic feature are yellow fever, blackwater fever, bilious remittent fever and relapsing fever.
_Yellow Fever._—There are cases which succumb without having shown jaundice but immediately following death the yellowish discoloration has been noted. At autopsy the yellow fever cadaver is almost invariably deeply jaundiced.
Very important is the fact that the jaundice of yellow fever does not appear until late, about the third or fourth day. When jaundice appears earlier, as by the second day, the prognosis is almost surely a fatal one.
According to Dutroulau the designation red fever would be more appropriate for the deeply congested facies of a yellow fever case in its first days.
The icterus is more marked about the face, neck and upper parts of the trunk. The albuminuria precedes the jaundice.
_Blackwater Fever._—In a typical case of this disease we have within a few hours a marked jaundice which tends to deepen. It is usually more or less marked according as the haemoglobinuria may be. It does not show the tendency to persist as does the jaundice of yellow fever.
_Bilious Remittent Fever._—The jaundice appears rather earlier than that of yellow fever but is rarely seen on the first day of the paroxysm as with blackwater fever.
Of great diagnostic value is the early appearance of bile-colored urine as different from the haemoglobin-tinged urine of blackwater. The albuminous urine of yellow fever is not apt to show any bile coloring in the first three or four days of the disease.
_Relapsing Fever._—There is a clinical type of relapsing fever associated with jaundice and a high death rate which was first described by Griesinger from Egypt. This icteric type is not infrequent in Asia. This jaundice is late and the disease much resembles yellow fever. The enlarged painful spleen and the finding of spirochaetes in the peripheral circulation are essential to differentiation.
_Weil’s disease._—Much interest has been recently aroused in _Weil’s disease_, or epidemic jaundice, on account of the frequency of the disease in soldiers in the Balkan campaign. While a spirochaete has been shown by Inada and others to be the cause, yet many workers have isolated paratyphoid B organisms from the blood of such cases. Frugoni obtained cultures of this organism from the duodenal fluid of 11 cases from 48 cases investigated. The accepted cause of true Weil’s disease is _Leptospira icterohaemorrhagiae_. The jaundice begins about the third day of an irregular fever. Like yellow fever these cases showed injection of the conjunctivae and albuminuria. There were, however, usually a leucocytosis and enlarged spleen.
In severe cases of _spotted fever of the Rocky Mountains_ we may have a generalized jaundice. Rarely cases of _typhus fever_ may show jaundice.
ALTERATIONS IN SIZE OF THE LIVER
There is only a slight enlargement in the ordinary case of tropical liver but in some cases it may extend 3 or 4 fingers’ breadth below the costal cartilages or rarely to the umbilicus.
In _liver abscess_ the enlargement is a rather late feature, and the condition should be diagnosed before we have the assistance of protruding ribs and distention of the intercostal spaces. As the abscess is usually located in the upper portion of the right lobe the enlargement is usually upwards and is best made out with the X-ray, showing the cupola-like projection.
In _kala-azar_ the liver does not begin to enlarge until after about three months from the time of onset at which time the spleen will be quite large. Decided enlargement is generally noted by the sixth month.
The liver cirrhoses due to _schistosomiasis_ or _malaria_ may show slight enlargement or no particular change.
_Sprue_ is a disease which gives a decided atrophy of the liver. Some authorities have noted a decrease of the size of the liver in cholera. The liver of _yellow fever_ is of normal size and is not associated with splenic enlargement.
In the tropics one must always keep in mind the possibility of a liver enlargement being due to _syphilis_.
PAINS OF THE LIVER
In _tropical liver_ there is more a sensation of weight than one of pain. In _liver abscess_, however, there are painful dragging sensations and, at times, with abscess of the upper right lobe, pain referred to the right shoulder. There is a marked tendency to splint the liver as shown by the costal breathing and moderate rigidity of the right rectus. The patient tends to lie on his back as shifting to either side, especially the left, causes pain. The legs are drawn up to relieve tension. Any jolting of the liver in palpation is exquisitely painful.
When active suppuration is going on in the liver the pain may be of an acute throbbing character. With abscess of the left lobe the pains may suggest gastric disease while with an abscess of the concave surface of the liver there may be referred pain in the appendix region.
In _blackwater fever_ and _bilious remittent fever_ there may be tenderness of the liver as well as the more prominent pain in the spleen.
_Epidemic jaundice_ shows tenderness of the liver.
In _plague_ there is a marked congestion of the liver as of other viscera and there may be some tenderness.
The liver becomes tender as well as showing enlargement in infections with _Clonorchis_.
SPLENIC ENLARGEMENTS AND PAINS
Splenic puncture has been carried out for diagnosis chiefly in kala-azar, malaria and Malta fever. Some authorities have reported fatalities from spleen puncture in kala-azar approximating 1% so that many advise the safer liver puncture to that of the spleen.
Spleen puncture would only exceptionally be called for in malaria as there is usually no difficulty in making the diagnosis from a blood smear. Malta fever can usually best be diagnosed by blood culture taken at the height of fever and recent work by Wenyon and others would indicate that blood cultures on N. N. N. medium might take the place of spleen puncture in kala-azar.
_Kala-azar._—The splenic enlargement is the most conspicuous change in the disease, the spleen often reaching the umbilicus by the third month and later possibly filling up the entire left side of the abdomen. The coincident emaciation of the patient makes the splenic tumor more apparent. When first enlarging the spleen may be the source of considerable pain and tenderness.
Fluctuations in the size of the spleen have been noted in the course of the disease, diminution in size often attending severe diarrhoeal attacks. In spleen or liver puncture the needle must be dry so that the parasites shall not suffer distortion.
_Malaria._—Splenic enlargement and tenderness are important points in diagnosis of malaria.
In acute malignant tertian infections the spleen is often diffluent so that it is liable to rupture upon slight injury. One should even exercise care not to palpate the spleen too violently and the possibility of accident should be thought of in making a spleen puncture.
The typical malaria spleen is the _ague cake_ of malarial cachexia. Here we have a greatly enlarged spleen with a thickened capsule and firm consistence. This spleen may fill up one side of the abdomen.
_Malta Fever._—The splenic enlargement in this disease usually corresponds about to that of typhoid fever. At times, however, the size may be so great as even to suggest kala-azar.
_Relapsing Fever._—Splenic enlargement and tenderness are marked features in this disease, often being noted early in the course.
_Blackwater Fever._—The spleen is painful and enlarged. The splenic enlargement in this disease and relapsing fever is important in differential diagnosis from yellow fever, a disease in which the spleen is unaffected.
The spleen may be enlarged in _Japanese schistosomiasis_ as well as in rectal schistosomiasis.
Darling has recently noted that it may be difficult to differentiate the anaemia of malarial cachexia from that due to hookworm disease. As a matter of fact most authorities note a diminution in the size of the spleen in _ancylostomiasis_ rather than an increase and splenic enlargement would certainly favor a diagnosis of malarial anaemia.
One point of distinction between spotted fever of the Rocky Mountains and typhus fever is that the spleen of the former disease is enlarged three or four times the normal, while that of _typhus fever_ shows no increase in size. The palpable spleen of _Rocky Mountain fever_ is firm instead of soft as with typhus fever.
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