Jaundice and night blindness

case of jaundiceEnglish is littered with words which were originally medical in their application but which have found broader or figurative usage. Melancholic, sanguine and phlegmatic are three good examples – all deriving from the terms for specific bodily fluids and the temperaments associated with them.

Another is jaundiced, often used to mean ‘hostile’ or ‘prejudiced’, but which entered the language (from the French jaune) as a term for a yellowing of the skin.  That original meaning is still with us, of course – jaundice is a common (and mostly harmless) finding in newborns, and is also encountered as a symptom of many infections and other acquired conditions. It’s caused by an excess of bilirubin, a waste product created by the breakdown of red blood cells, which produces the characteristic yellow tinge taken on by the skin and whites of the eyes.  There are many mechanisms which might cause such a build-up, but several of them involve the liver – jaundice often being a symptom of hepatitis or alcoholic liver disease.

So why the association between yellow skin and hostility?  Early medical writers, ignorant of the biochemical mechanisms at work, associated the condition with excesses of emotion.  As late as 1842 a professor of the Royal College of Surgeons of Ireland, Charles Benson, wrote:

It appears strange that mental emotions should give rise to jaundice, and yet nothing is more certain. Fright, passion, vexation, or agitation, may cause it…. I saw a gentleman myself who was completely jaundiced a few hours after a violent fit of passion.  

In 1694 the Philosophical Transactions of the Royal Society included an interesting case of ‘emotional’ jaundice seen in a young woman from Essex. The author was a Mr Samuel Dale from Braintree: 

About Christmas, Anno 1689, after much grief and trouble of mind in the foregoing autumn, Grace Dennis, of Braxsted in Essex, was seized with the jaundice; for which, after having for about 9 months used many medicines as advised by her friends and acquaintance, but without success, she in Sept. 1690, applied to me, when I administered some medicines, famous in the most celebrated authors for the cure of the jaundice, yet they were of no benefit; after which she had the advice of several learned physicians in the country and in London, but still without any effect; for her disease yet continues, and her body, which used to be plump and fleshy, is now become lean and emaciated, almost like a skeleton, and her appetite small and depraved. 

This additional symptom (emaciation) does not much help in narrowing down the possible causes of the jaundice: both might be associated with a large number of conditions.  But then a striking new symptom appeared:

In May 1691, after an extraordinary menstrual flux for about 3 months, she began, as soon as the sun was down, to be deprived of her sight by degrees till it was quite dark; when, although ever so large a fire or many candles were in the room, yet she could not discern any object, except a small glimmering of light: and thus she remained until the morning, as one stone-blind, when by little and little, as the light increased, her sight returned, till the sun arose, and then she recovered her perfect sight.

This is a beautiful description of night blindness: typically, those affected have no difficulty during the day, but severely impaired vision at night. This is highly suggestive…

And in this case she continued, till August 1692; when being returned from Epsom, where she had been drinking the waters for about a month, her sight returned to her again, so that she could see in the night perfectly. Thus she continued until January last, when an extraordinary menstrual flux again seizing her, her nocturnal sight likewise left her, and she became blind again as formerly. In July, 1693, she was seized with a fever, when her sight again returned, and continued for about a month, and then left her as formerly… 

Goodness. Her vision was switched on and off like a Belisha beacon.

…so that now, Oct. 1693, she has her nocturnal blindness, and her jaundice likewise continues. 

And that’s it. One unfortunate patient, several bewildered physicians.  So what was the problem?  Not being a doctor myself, I don’t know – but with the overconfidence of the woefully underqualified, I’m going to have a guess.

One possible clue appears in a paper published in the British Medical Journal in 1971, almost three centuries after Mr Dale’s case study.  It concerns a 67-year-old man who went to the doctor after developing jaundice. A specialist suspected a blocked bile duct, and during surgery an inoperable adenocarcinoma (a type of cancer) was found to be causing the blockage. Realising this was essentially incurable, the surgeon sent the patient home. And then:

In July 1970 he first complained of visual symptoms. In the half-light of the evening he found increasing difficulty in distinguishing objects in his room. If he rose from his bed at night he found he was completely blind, whereas light from the street would previously have been sufficient to allow him to move about the room. When the lighting was good his vision was satisfactory, with the exception that he was unable to read newsprint. He was deeply jaundiced at this stage and emaciated, with a dry scaly skin.

Another excellent description of night blindness – in fact, the overall symptoms seem identical with the case from 1691.  But the 20th-century doctors knew what to do about night blindness, since it’s the most obvious symptom of vitamin A deficiency:

After eight daily injections of vitamin A dark-adaptation was much improved, and within two weeks he was able clearly to distinguish objects in the dusk, and his ability to read print was completely normal.

Not quite a happy ending, since the patient was still suffering from an incurable and steadily-growing tumour; but as the authors point out, it offered a dying patient ‘some small solace’.

So what was going on?  Well, bile aids the absorption of dietary fat in the gut.  A blocked bile duct means fat is less efficiently absorbed.  And vitamin A is fat-soluble – so a patient with a blocked bile duct might not be receiving enough of it.  Hence the night blindness.

Of course we can’t know for certain what was wrong with the patient in 1690 – for all I know, her combination of symptoms might have been caused by some other condition. But the parallels between the two cases are striking.

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