THE 
NERVOUS ORIGIN OF JAUNDICE. 
Read before the New York Neurological Society. 
BY 
A. D. ROCKWELL, M.D., 
New York. 
Reprinted from the International Medical Magazine for October, 189S. THE NERVOUS ORIGIN OF JAUNDICE. 
It is well known that disturbances of the brain, both organic and func- 
tional, may very seriously interfere with the functional activity of distant 
organs. Without questioning the well-attested fact that many of the cere- 
bral hystero-neuroses or hystero-psychoses are directly dependent upon 
uterine or ovarian disease, it is equally true that a cerebral disturbance may 
be the direct causative factor of very persistent derangements of the sexual 
apparatus. The bladder, intestines, stomach, and heart may also be disor- 
dered by diseases of the central nervous system, and so also may the kidney 
and the liver. Then, again, so closely and so strangely are the vascular and 
the general nervous system related to each other that their pathological con- 
ditions are often inseparably connected. The nervous system of vegetative 
life, as it is sometimes called (the pneumogastric, the great sympathetic, in- 
cluding the vaso-motor system of nerves), has an alliance so close with the 
functional activity of the secretory and excretory glands of the body that 
emotional disturbances, according to their character, act as depressants or 
excitants of the functional life of these organs. 
Some of the more common of these effects are every-day familiar facts, 
as when the flow of tears is excited through grief, or the secretion of the 
saliva and gastric juice through the smell of food. On the other hand, the 
salivary secretion may be at once arrested through sudden fear, and under 
the influence of supreme grief there is often a complete arrest of the func- 
tion of the lachrymal gland. I remember once to have witnessed a most 
interesting example of the profound effect of suppressed emotion in causing 
and perpetuating pain. 
This patient had lost her husband, to whom she was devotedly attached. 
She had for some months previously suffered from a mild form of facial 
neuralgia, but immediately after the death of her husband it assumed a 
most severe type, and for two weeks she suffered excruciating agony. 
During this time she shed no tears, and on one occasion, taking note of 
this fact, I said to her that this suppression of all outward emotion was 
the very worst thing that could possibly happen, and that if she would give 
way to her grief the neuralgia would in all probability be greatly allevi- 
ated. At this she burst into a copious flood of tears, and from that time 
she suffered no more. Now, just as these superficial and easily-excited 2 
A. D. KOCKWELL, M.D., ON 
glands—the lachrymal and submaxillary—are influenced by emotional 
causes through the nerves supplying them, so in all probability are the 
blood-making or ductless glands in great measure regulated and controlled 
by the organic nervous system. Diseases of the supra-renal capsules— 
diabetes, leucocythsemia, and other forms of malnutrition—are admittedly 
due to perversion of the functional activity of the several blood-making 
organs, which are so intimately linked, through the great sympathetic 
system, with sensory impressions referable to the cerebro-spinal system. 
Equally, and perhaps even to a greater extent, nervous influences are prone 
to atfect the function of the liver. 
Dr. Murchison, to wrhom the world is so indebted for enlightenment on 
this subject, fully appreciated the influence of the nervous system upon the 
secreting organs. He asserted that not only was the secretion of the bile 
interfered with by prolonged mental anxiety, worry, and incessant mental 
exertion, but that the process of sanguification and blood-change in which 
the liver takes part were frequefltly deranged from these same causes. 
Murchison says that “acute atrophy, in which the secreting cells are 
rapidly disintegrated and the functions of the organ arrested, appears in 
many instances to have a purely nervous origin, and very often the first 
symptoms of the disease have occurred immediately after a severe fright or 
an outburst of passion in a person previously healthy.” 
An impression made upon the brain appears to be reflected to the liver 
and deranges its nutrition. Even cancer of the liver appears sometimes to 
result from the functional derangement induced in the first instance by 
mental trouble. Dr. Budd, a keen observer, wrote that “Another con- 
dition that seems to me to have great influence on the production of gall- 
stones, or at least of biliary gravel, is mental anxiety or trouble.” 
Clinical experience, therefore, and our knowledge of the intimate re- 
lationship between nutritive centres and the various organs of the body, 
render it quite certain that any variation of its normal activity may pervert 
the functional activity of distant glands with which they are related. 
With jaundice due to some mechanical impediment to the flow of bile 
through the hepatic duct we have manifestly nothing to do in this presenta- 
tion, but with some of the causes, other than mechanical, of this not infre- 
quent affection our line of thought directly interests us. 
For one not in general practice I have had occasion to see and treat a 
considerable number of cases of jaundice dependent upon a great variety 
of causes, and have been impressed with the frequent occurrence of cases 
due to deranged innervation interfering with the normal metamorphosis of 
the bile. The old theory—the theory of Boerhaave and Morgagni—that 
jaundice was merely the result of a suspended secretion, that bile was 
formed in the blood, and that the function of the liver was to separate the 
bile from the blood, seems now to have little to commend it, and we must 
seek some explanation other than a suppression of the hepatic functions. 
According to Professor Frerichs, the bile-acids manufactured in the liver, THE NERVOUS ORIGIN OF JAUNDICE. 
3 
or the larger proportion, are absorbed either by the biliary passages or by 
the mucous membrane of the bowel, and thus enter the circulation. The 
bile, as well as the fluids from the gastric and intestinal glands, are thus 
absorbed, secreted, and again reabsorbed, becoming adapted through con- 
stant metamorphosis for the repair of tissue; while much of it, becoming 
finally oxidized, is eliminated by the various excretory organs of the body. 
The taurin found in healthy lung and the pigment in healthy urine are 
evidences of these normal metamorphoses. If, however, through the en- 
trance of poisons into the blood, through a deficient supply of oxygen, as 
in some cases of pneumonia, or where persons are habitually confined in 
small and ill-ventilated habitations, or where there is obstinate constipa- 
tion with excessive secretion of bile, and, finally, when the individual has 
been subjected to extreme nervous influences, such as fright or rage, and 
especially the depressing influences of great grief and anxiety, the proper 
oxidation of the bile-acids is interfered with, bile-pigment appears in the 
blood, and jaundice results. According to my own experience there is little 
to differentiate in the diagnosis between jaundice the result of purely ner- 
vous agencies and where it results from the various other non-mechanical 
causes, without it is the more sudden onset of the discoloration in the former 
class of cases. Jaundice from both obstructive and nervous causes are 
alike in the suddenness with which the symptoms frequently appear. A 
thorough history of the case will, however, generally enable us to deter- 
mine whether the exciting cause is of a nervous or non-nervous character. 
As between jaundice from mechanical and non-mechanical causes, it is the 
common observation that the discoloration of the skin is much more intense 
in the former than in the latter. If, however, the obstruction becomes per- 
manent, the complexion to a certain extent clears up, from the fact that the 
bile becomes diminished in quantity because of a progressive destruction of 
the secreting tissue of the liver. Another point of differential diagnosis 
between the two main divisions of jaundice is in the entire absence of bile 
in the fseces in obstruction of the biliary ducts, while in the non-mechanical 
cases bile is usually discharged with the passages. I have selected from 
some twenty-three cases of jaundice which have come under my personal 
observation and treatment three which mainly form the basis of the fore- 
going remarks, and which I propose to relate in no great detail. 
These three cases seemed to be of distinctly neurotic origin, and two of 
them indicated a very interesting hereditary tendency. 
Mr. B., aged fifty-three, a lawyer of excellent attainments and a hard 
worker, consulted me in March, 1888. That he was suffering from jaundice 
was evident on first sight and without a word of explanation. He was 
not constipated, nor were his stools greatly changed in color or unusually 
offensive. He suffered no pain, nor had he from the beginning; only a 
want of energy and a vague, indefinable sense of physical discomfort, asso- 
ciated with mental depression and a deplorable lack of mental vigor. This 
is his somewhat laconic but forceful description of himself: “I am a ner- 4 
A. D. ROCKWELL, M.D., OK 
vous man and always have been; my father before me and my mother too. 
When a child I had St. Vitus’s dance, and when I grew up I was afraid 
of everything.” 
It seems that at one time in his life morbid fears of various kinds had 
greatly distressed him, indicating a functional depression of the nervous 
system that rendered him for several years incompetent and inadequate for 
the duties of life. His success had indeed been greatly retarded by this 
excessive timidity. To a considerable extent, however, he gradually over- 
came these natural and inherited defects, and has been able to pursue the 
work of his profession satisfactorily. A short time before his visit to me 
he was feeling as well as at any time in his life, when an unfortunate occur- 
rence that entailed disgrace upon a member of his family produced an effect 
from which he found it difficult to rally. A few nights after the shock 
alluded to he retired with feelings of great depression. He was restless 
and somewhat flighty during the night, but towards morning he slept pro- 
foundly for several hours. While still asleep his wife noticed a strange 
discoloration of the skin, and when he awoke, about eight o’clock, the 
jaundiced condition of both the conjunctivse and skin was very marked. 
Taking into consideration the sudden onset of the jaundice, the absence 
of constipation, the natural appearance of the discharges, the excellent con- 
dition of the digestion, together with the neurotic history of the patient 
and the cause that so disturbed his mind, it seemed to me quite evident that 
the interruption of the normal metamorphosis of biliary secretion was 
directly due to nervous agencies. It is well understood that nervous ten- 
dencies are transmitted from generation to generation, and that in various 
branches of a family a certain vulnerability of the nervous system prevails, 
rendering its members liable, not necessarily to the same disease, but to 
some one of a group of diseases that has for its basis the neurotic habit. 
Hereditary or family tendencies along the line of visceral disturbances 
found an interesting exemplification in the two other cases, upon the obser- 
vation of which these remarks were suggested. 
G. F., aged nineteen, belonged to a family whose whole history indi- 
cated an extraordinary tendency. His grandfather had been an inmate of 
an insane asylum during the latter part of his life. His father had been 
for years a typical neurasthenic, and in 1875 had been under the care of 
the late Hr. Beard, and subsequently came under my observation. His 
mother was an exceedingly nervous woman, as I myself can testify from 
repeated interviews, and a few years before the present patient came under 
my care I had treated a younger sister for well-marked chorea. 
This patient (G. F.) came to me one morning, presenting a well-marked 
example of jaundice. The yellow stain extended all over the body, and 
was particularly deep under the hair of the head. The stools were natural 
in appearance, and there was no constipation and no unusually offensive 
odor. He complained of weakness, heaviness of head, and mental dulness, 
but suffered no pain. The attack was sudden. THE NERVOUS ORIGIN OF JAUNDICE. 
5 
The patient had been feeling in his usual physical health, but for some 
weeks had been more or less anxious and nervous on account of an ap- 
proaching scholastic examination. Once before he had failed, much to his 
mortification, but on this second occasion he felt well equipped and reason- 
ably confident of success. He was, notwithstanding, again rejected, and 
the revulsion of feeling that he experienced was extreme. It rendered him 
sleepless, with loss of appetite and profound mental depression. 
He received news of his failure to pass on Wednesday, and on the fol- 
lowing Friday he observed the discoloration of the skin. It was but a 
short time after this that the sister of this young man—the same whom I 
had treated for chorea in her childhood—came to me suffering from a 
headache that was quite persistent. Upon closer examination I easily 
detected a yellow tint to the conjunctivse, which gradually deepened during 
the next few days, until finally the skin became unmistakably discolored. 
I could trace back these symptoms to no special nervous cause, excepting 
the deep and very manifest sympathy with her brother and her very great 
disappointment at his failure, but that the remote causative factor was the 
distinct nervous diathesis that prevailed in this family admitted it seemed to 
me of no dispute. 
In regard to the functions of the liver, however, it has now come to be 
well understood that disorders of the secretion of bile are by no means the 
most important. 
Disorders of its metabolic function frequently result in absolutely in- 
curable disease, and in some respects the most serious to which the human 
system is liable. 
One of the most interesting things to the neurologist connected with 
faulty albuminoid disintegration is the striking similarity of the symptoms 
of neurasthenia with some of the manifestations of lithsemia. 
Now, while gout and the lithsemic condition generally is in the vast 
majority of cases dependent upon indolent habits and persistent over-eating 
and drinking, it is equally true that a small proportion of such cases un- 
mistakably originate or are aggravated through depressed nervous or emo- 
tional causes. There is in my experience no special dissimilarity of symp- 
toms between the ordinary gouty or lithsemic patient and the one where the 
lithsemia depends upon nervous influences; but between the latter con- 
dition and neurasthenia there do exist points of diagnosis which, while 
easily overlooked, are yet quite positively distinguishing. 
Upon this subject I claim the right to speak with some authority, since 
for many years I have had the advantage or disadvantage—depending upon 
the point of view—of studying the lithsemic state clinically in my own person. 
I believe in the term neurasthenia, and in the reality and frequency of 
the neurasthenic state, but I do sincerely deplore the frequency and persist- 
ency with which, by both patient and physician, disorders of the metabolic 
function of the liver are mistaken for functional nervous disorders, or for 
malaria, that other easy refuge for ignorance or carelessness. 6 
A. D. ROCKWELL, M.D., ON 
According to my own experience, one of the most common and distinc- 
tive points of differential diagnosis between lithsemia and neurasthenia is 
the difference in the character of the mental phenomena. 
Both the lithsemic and neurasthenic suffer from mental depression and 
a profound sense of misery, more marked, indeed, in the former than in 
the latter condition. 
While, however, the neurasthenic may suffer from the deepest melan- 
choly and imagine himself heir to a thousand ills, he becomes the victim, 
as a rule, of no such irritability and unreasonable outbursts of temper as 
the man whose brain is actually poisoned by the imperfectly transformed 
products of digestion. 
The neurasthenic may be at times extremely irritable, but this irrita- 
bility is more passive than active, and any ebullition of angry feeling is 
quite evanescent. His demeanor is as a rule quiet, and there is but little 
manifest tendency to make those dependent upon him miserable by his 
words and actions. 
The touchy mood of lithsemia, on the contrary, may last for days or 
weeks. 
It is due to actual toxaemia, is often, if not generally, accompanied by 
obstinate constipation, and may be temporarily relieved by a cholagogue 
cathartic. In neurasthenia, again, cold hands and feet are not by any 
means the rule; but in intestinal and liver derangements the nitrogenized 
wastes circulating in the blood cause by their irritation tonic spasm of the 
arterioles, resulting in the cold hands and feet so bitterly complained of by 
the sufferers from lithsemia. 
The condition of the tongue is an important diagnostic aid. 
In lithsemia it is coated far more frequently and to a greater extent 
than in neurasthenia, but in some cases of lithsemia the tongue is but slightly 
affected. It may at first sight appear perfectly normal, and it is only when 
looked at carefully from the side that an unnatural brownish color is 
observed. As regards the pulse, it may be said that in lithsemia it is slow 
rather than fast, and in neurasthenia fast rather than slow. 
In neurasthenia the oxalates are frequently found in abundance, while 
in lithsemia the lithates are often freely deposited. 
These observations, especially as they relate to lithsemia, have been 
suggested not because I believe that nervous agencies are the most impor- 
tant factors in the production of visceral disturbances. The preponderating 
influences in the causation of such conditions are undoubtedly vicious 
methods of living. How we live, how and what we eat and drink, and 
the hygienic influences of exercise in the open air will in great measure 
determine the functional activity of the great excretory and secretory 
organs, as well as the stability and strength of the nervous system itself. 
It is not always the simplest thing to diagnose correctly and at a first inter- 
view between a purely functional disease of the nervous system and dis- 
orders of the biliary and metabolic function of the liver. The lines of THE NERVOUS ORIGIN OF JAUNDICE. 
7 
treatment for the two conditions diverge about as abruptly as for any two 
pathological conditions in the whole category of disease, and it must have 
been within the experience of every member of this society to have seen 
cases of such mistaken diagnosis that involved mistaken treatment and 
misery unnecessarily prolonged. International 
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