Infectious Jaundice

INFECTIOUS JAUNDICE, a term denoting those diseases in which the dominant symptom is jaundice, and the etiological factor is infection. Both etiologically and clinically, infectious jaundice is undoubtedly not a nosological unit. On the contrary, under this name are combined numerous diseases, diverse both in relation to the causative agent and the clinical-anatomical picture. The infectious origin of certain jaundices was long suspected. Many facts spoke in favor of this: focal outbreaks of jaundice, often seasonal - in spring and autumn, household, family and military epidemics, individual cases of jaundice after eating spoiled meat, drinking contaminated water, etc. In the course of the disease itself, clinicians (Botkin, Chauffard and others) found a whole series of arguments in favor of the infectious nature of such jaundices: feverish condition, enlargement of the spleen, accompanying inflammation of the kidneys, a certain cyclical course, etc. Bacteriologists have proven the presence in the bile ducts of numerous and diverse pathogenic germs. Some infectious jaundices should be regarded as a manifestation of a general infection, with jaundice in such cases playing the role of a secondary symptom complicating the main disease - secondary jaundices (e.g., jaundice in sepsis, typhoid fever, relapsing fever, pneumonia, etc.). On the other hand, bacteriological and clinical study of certain forms of jaundice allows one to speak of primary infectious jaundices, since various microbes with different virulence primarily affect the liver. There is no doubt that the intensity and duration of the icterogenic infection influences the appearance of one or another clinical form; but the previous condition of the liver has a tremendous influence on the picture of the disease. This explains the greater severity and frequency of infectious jaundice in alcoholics, in pregnant women, and generally in subjects whose liver has been previously affected by infection or intoxication. Clinical forms of infectious jaundice, depending on the intensity of liver parenchymal damage and the degree of bile retention, are different. In epidemic foci, one can observe forms so mild that they manifest only by symptoms of mild dyspepsia: nausea, heaviness under the xiphoid process, loss of appetite, and constipation; the yellowish coloration of the skin is noticed only accidentally by those around, and usually after 2-3 days all symptoms disappear. In addition, the typical picture of simple, or catarrhal jaundice is observed with preceding symptoms of general infection (preicteric stage) and the appearance of all typical signs of jaundice: characteristic coloration of the skin [see separate table (Volume X, pp. 15-16), Fig. 2] and mucous membranes, change in urine color, discoloration of feces, slowing of the pulse, skin itching, etc. (see also Botkin-Weil disease, Jaundice). Various clinical forms of infectious jaundice, from unclear, barely outlined ones, to icterus gravis (with liver atrophy), should not be considered as separate nosological units - these are only clinical syndromes arising under the influence of very diverse pathogenic microbes. - As experimental studies and clinical observations show, various microbes can act on the liver either by the ascending route, penetrating through the common bile duct from the duodenum, or hematogenously in the process of excretion of the corresponding bacteria through the bile duct system, or the infection of the bile ducts can be autogenous, i.e., it is due to the manifestation of the life activity of those microbes that can normally be present in the bile ducts. However, autogenicity of infection is not confirmed by all authors, and, not denying the possibility of infection penetration from the intestine by the ascending route, it must be assumed that infectious jaundices most often result from penetration of infection from the blood itself. Some researchers have experimentally reproduced all variants of cholangitis and cholecystitis by injecting the most diverse microbes into the blood: typhoid and paratyphoid bacilli, staphylococci, streptococci, pneumococci, Friedlander's pneumobacillus. The liver is the organ through which microbes circulating in the blood are eliminated, and at present one can consider infectious jaundice as the hepatic localization of those infections that were initially general and in the first phase of which microbes can be found in the circulating blood. The circumstance that the liver can be affected by infection penetrating from the blood itself partly explains the comparative frequency of secondary infectious jaundices, e.g., in pneumonia, typhoid and paratyphoid processes, in syphilis and relapsing fever, in appendicitis, in postpartum septicemias and in large wounds during war. However, such secondary infectious jaundices may also not be connected with the presence of bacteria in the liver, but may belong either to hemolytic jaundices or to toxic paracholias. For another kind of cases, it is necessary to assume the possibility of only a brief stay of the pathogenic microbe in the blood and its rapid localization in the liver. Then jaundice is an early sign of the disease, and there are grounds to speak of primary infectious jaundices. The brevity of bacteremia and the comparative benignity of the infection complicate bacteriological research in these cases; however, in recent years, certain pathogenic microbes have been indicated for some primary infectious jaundices. In some epidemics of infectious jaundice, Ebert's bacillus, paratyphoid B, and Bacillus paracoli have been found in the blood. All these observations have been made in jaundices that are apparently clinically primary, i.e., in those where jaundice is an early and dominant symptom. Well-studied epidemics of paratyphoid jaundices during the last imperialist war are known (Clunet in the Dardanelles, Cantacuzene in Romania). Although in these diseases paratyphoid rods were isolated from the blood, however, the question arises whether they are not a microbial association with an unknown primary agent. It is possible that paratyphoid rods appear in the blood only as "microbes de sortie", all the more since Sanarelli often isolated paratyphoid bacillus (Bact. icteroides) from the blood in yellow fever, whereas it is now known that it is not the causative agent of yellow fever (da Rocha-Lima). Another form of primary infectious jaundice is quite definite - this is spirochetosis ictero-haemorrhagica, or Botkin-Weil disease (see). This form has been studied quite fully from the bacteriological side. Other forms of infectious jaundice are mostly benign and in them bacteriological research gives a negative result.

Prevention of infectious jaundice reduces to the same measures that are taken for such infections as typhoid, i.e., consists in individual hygiene (washing hands), caution in nutrition (spoiled meat, dirty water, etc.). The extermination of rats has serious importance in relation to spirochetosis. As the epidemics of infectious jaundice during the war showed, great influence is exerted by fatigue, overcrowding and insufficient nutrition. - The prognosis depends on the clinical form: with deep liver damage and with kidney insufficiency it becomes unfavorable. - Treatment: diet, bed rest, administration of glucose (5-10%) up to 500 cm³ in the form of rectal or intravenous (5%) infusion (in severe cases simultaneously with insulin) and prescription of cardiac and strengthening agents.