eign to the purpose of the discussion, the main object of which is to point out the necessity for restudying the subject. My conception may be erroneous but if it leads to the result desired it will have accomplished a useful purpose. DR. WALTER R. STEINER (Hartford): Dr. Blumer has presented to us some very timely remarks on infectious jaundice. We have been collecting facts upon this type of jaundice certainly since the time of Cleghorn, who reported an epidemic of this malady, upon the Island of Minorca, in 1740 and possibly, if we accept Cockayne's evidence, since the time of Hippocrates. But we need to correlate our knowledge and add more to it before we can come to any satisfactory state concerning this disease and no one is more cognizant of this fact than those who have worked on this field as Drs. Osler, Geoyn, Blumer and others have done. Of course literally we mean by infectious jaundice a morbid condition caused by the invasion and growth of pathogenic microbes within the body, and, as the word microbe implies, it may be either of an animal or vegetable nature. Some years ago I was called to see a patient who presented symptoms of Hepatic Intermittent Fever. She had had a chill, followed by fever, vomiting and sweating, which in turn was followed by an intense jaundice. Although I considered the case as one of Charcot's Hepatic Intermittent Fever yet I made a careful blood examination as a routine and discovered a number of malarial organisms of the tertian variety, so that under quinine she made a good recovery and has had no attacks since. This, then, is an example of infectious jaundice due to an animal parasite and Allport has reported some interesting instances of this variety while acting as Major in some of the British hospitals in Salonika. Generally, however, the term infectious jaundice is used to designate a condition of vegetable origin and this variety is frequently subdivided into the bacillary and spirochaetal types. Unfortunately, I have not seen cases of jaundice recently which could be placed in either of these types although twelve years ago I had a patient with jaundice whose husband had had a similar disease two weeks previously. The initial symptom in her case was a severe sore throat. In a study of the literature, however, I have come to an opposite impression from Dr. Blumer as the cases of Weil's Disease seem to me similar to those caused by the spirochaeta ictero-hemorrhagiae, Symmer's cases notwithstanding. To definitely prove it of course more knowledge is essential. The blood of all cases of infectious jaundice should be carefully examined by blood film, by dark field illumination and by intra peritoneal inoculation into the cavity of a guinea pig to discover the presence of these spirochaetes; (2) the urine should be microscopically examined for the spirochaetes, although such a diagnosis of this spirochaete requires the services of an expert as the urine contains spirochaetes in a variety of conditions, and the urinary sediment should be inoculated into the peritoneal cavity of a guinea pig, and finally, (3) tissues should be examined at necropsy by the Levaditi method for the detection of spirochaetes. Dr. Blumer's suggestion to consider all cases of catarrhal jaundice as infectious seems to me to be an admirable one. DR. CHARLES W. GARDNER (Bridgeport): Dr. Blumer has given us the essentials and a useful working classification of infectious jaundice. His comprehensive summary of the subject prohibits worth-while additions. I would, however, like to mention two or three points that seem to me of particular importance. The occurrence of acute catarrhal jaundice appears to be on the increase and this, with the knowledge that our own native rodents harbor spirochaetes, should be an incentive to keep the infectious types in mind, when confronted with cases of icterus. While the majority of cases of jaundice encountered in practice will continue to fall into the four common groups, simple catarrhal, gall stones, cirrhosis or malignant disease, the infectious types must be considered among the possibilities in differential diagnosis. Another fact, that seems to me of noteworthy significance, is the observation of variations in the virulence of the infection and the consequent variety of clinical pictures noted in different localities. Japanese observers record the combination of icterus and hemorrhages sufficiently often to designate the disease as ictero-hemorrhagica. Among the British troops, the infection was much less severe than that described in Japan, not over sixty per cent of the cases having jaundice. In France, the hemorrhagic form was less frequently seen than in Japan. Again in New York, Symmers observed an outbreak in which hemorrhage was the outspoken feature. His cases appear to be due to toxins not yet identified. The factors operative in these variations require further study. As Dr. Blumer said, we need additional information concerning the influence of seasons on the ordinary catarrhal and the relation of sporadic diseases to one another. Meteorological influences have appeared to play a part in the etiology of epidemics. Dr. Blumer's suggestion that the ordinary catarrhal jaundice may well be regarded as infectious is worthy of emphasis. This view best explains the occurrence of epidemics. In the light of our present knowledge, we have some justification in concluding that the reported epidemics from the War of 1812 down, excluding those cases obviously due to or associated with other diseases, have been caused by infectious organisms, possibly of the spirochaetal type. Further study is indicated from the pathological point. An extension of our knowledge does not appear probable, from the clinical side, since the clinical picture of the different types is similar, varying only in degree. From the paper, one gathers that the infectious types of jaundice are closely related pathologically. Future studies may permit the grouping of all types into one group. While jaundice is the conspicuous sign clinically and the liver changes, pathologically, the infection is general, the reaction produced depending upon many factors. These changes appear not infrequently, as Dr. Blumer has brought out, insufficient to cause death. This fact brings up the desirability of a further application of chemical pathology to clinical problems. Chemical changes from altered metabolism may be a factor responsible for death in these cases. Concluding, I would say that Dr. Blumer's paper awakens interest in the subject of infectious jaundice and he has opened up new lines of thought for future investigation. DR. BLUMER: The view that has been prevalent lately is that the ultimate mechanism in all varieties of jaundice is about the same. There are no sharp lines of demarcation to be drawn. The explanation of the absence of bile in the intestine in the absence of any complete mechanical obstruction is that in such cases the physical quality of the bile is changed. It becomes so viscid that it will no longer flow through the ducts. It is difficult to prove that this is the mechanism in jaundice in human beings because patients with catarrhal jaundice are practically never operated upon and in the few who come to autopsy the conditions are not the same as those present during life. Experimentally it is possible to show that obstruction is not necessary to prevent the outflow of bile, but that changes in the consistency of the bile itself may produce such a result. Since I wrote this paper I have been consulted by a physician with ordinary catarrhal jaundice, and I got a very interesting history. I give it for what it is worth. This physician was taken sick with jaundice two or three weeks after his newborn baby had died of infantile jaundice. The baby was healthy at birth and died of jaundice, and he was taken sick in two or three weeks. During the prodromal period of his sickness, he attended a patient in labor, and in a few weeks that patient was also taken sick and developed jaundice,—apparently an ordinary catarrhal jaundice. It seems probable that if we consider ordinary catarrhal jaundice as infectious and begin to question jaundiced patients more closely about their contacts we may find many more cases of this kind. In some of the fatal cases the lack of changes sufficient to account for death is very striking. In the case of the colored man who died in the hospital we had a clinical pathological conference on the case and the pathologists had to acknowledge that they did not know what killed the man. He had a few small areas of necrosis in the liver, but practically nothing else was found to account for the death. I think Dr. Gardner's suggestion that we should make more careful clinical studies is very important. I did not go into the details of the history but the fact that this third fatal case of the negro man showed some very pronounced changes in the chemistry of the blood, etc., the blood nitrogen and blood urea being enormously increased, indicated that there was some very profound metabolic disturbance going on in the man's system. |