No. 1

Y pyemia we understand a condition in which a primary focus containing usually staphylococci, occasionally streptococci or pneumococci has by means of the lymph or blood current, disseminated the exciting cause of the disease in the body. The pathogenic bacteria which are thus colonized cause metastatic suppurations. By the absorption of toxines a general intoxication is also present.

Septicemia differs principally from pyemia in that in this affection the bacteria spread from the primary focus over the

*The following papers were read before the Medical Society of the Missouri Valley at Council Bluffs, Ia., September 7 1913.

entire vascular system and grow. The action of the bacterial toxines in septicemia also is to be considered the most important factor of the affection. There is besides, the mechanical effect of the obstruction of numerous capillaries.

Now, a strict differentiation between. these two conditions is impossible clinically. Metastases sometimes result, but septicemia at other times according to the amount and virulence of the bacteria which find their way into the blood. Hence, except in extreme cases, the term septico-pyemia is applicable to the disease.

Generally speaking septic diseases have been grouped among the accidental wound

diseases and belong in the domain of surgery. However, in the year 1878 Leube, from a series of observations, called attention to a goup of septic cases in which proof of a traumatic infection was impossible. He proposed for such cases the designation Cryptogenetic Septico-pyemia. This qualifying term he derived from Kruptos hidden, and gennao to beget signifying of concealed origin. He discovered other such cases in the literature and in particular quotes Wunderlich as having, in 1847 accurately described cases of spontaneous pyemia." As a rule the disease is fatal. Exceptionally patients recover from such an attack. Luebe insists that this affection is much more common than is usually supposed, especially if those cases are included, in which a careful study leads to a diagnosis of septico-py emia, even though recovery takes place. Please observe that I shall draw freely upon the work of Leube in what I shall say.

First, as to the special mode of infection. The organism has been provided with a wonderful defence against the invasion of pathogenic bacteria. Under favorable conditions this defence is effective. However, adverse conditions may arise when this is not the case. Such are local traumata which damage the part in respect to its circulation or nutrition, or when great quantities of virulent bacteria disseminate through the blood. Thus the resistance is overcome and the organism succumbs. Other factors which lower the power of resistance to this invasion are exhaustion, hunger, anemia, diminished alkalinity and watery condition of the blood and also a flooding of the body with purid substances. Faulty elimination by intestines or kidneys is included in this catagory. In the group of cases under consideration we are not able to discover the source of the infection during the life of the patient, even with the minutest investigation. However, at autopsy it may appear in ulcerated bronchial or mesenteric glands, old abscesses in internal organs, residues of puerperal or appendiceal processes, and such like. And yet even at autopsy no such source of infection may be found. In such cases nothing remains but to assume that bacteria of extremely great virulence entered in large quantities by wounds so small that they cannot be demonstrated post-mortem or exceptionally by the uninjured surface of the skin or mucus membrane.

Edwards says that careful clinical and necropsy investigations reveal the atrium of infection in 94 per cent of cases. This being true there remain 6 per cent of cases

in which the point of infection is not found, and furthermore, there is a certain per cent in which fortunately necropsy investigation is impossible since the patients recover.

The story of the symptomatology and bacteriology must not detain you. It differs not at all from septico-pyemia, of which the organ is frank and open. Nor have I the time to discuss differential diagnosis, though obviously just here appears the paramount importance of familiarity with the matter now under discussion, so that one shall not be caught napping. The differential diagnosis is especially difficult when the localization of the toxin is a limited one, when one or the other organ is separately affected, thus simulating the presence of a local affection, or of another infectious disease, which especially attacks the organ in question. In this respect we must, according to the special manifestation of our case, have in mind acute articular rheumatism, intermittent fever, acute miliary tuberculosis and typhoid fever. Exceptionally other conditions may be suggested.

Unfortunately, the cultivation and demonstration of such bacteria, in the blood of the patient as are in genetic connection with the septic condition is comparatively rarely accomplished. This is due to the fact that death usually occurs before the specific bacteria have grown sufficiently to become disseminated in the blood stream.

My principal object in presenting this brief paper is to bring to mind the existence of the condition and the wisdom of keeping it before us, thus to avoid, perhaps, an error in diagnosis.

On Monday, February 27, 1911, the writer was called to see Miss F. The patient was an unmarried lady aged 40, an American, complexion fair, occupation housekeeper. The patient was of spare build but well nourished. The family history was negative. The patient had never been ill with the exception that a chronic pharyngitis, not of great severity, had given her some little trouble of late. For this she had had a few local treatments by Dr. James M. Patton. For several months she had felt weak and tired, but had continued about her ordinary household duties. Two days ago she went down town and called at the office of Dr. Patton for treatment. Yesterday, while the family were at church, she prepared the dinner, but was in bed the latter part of the day. This morning she arose as usual but complained of a general aching. Examination failed to show any local

evidence of disease. A provisional diagnosis of influenza was made and the patient given calomel with ipecac and soda in small doses to be followed by a saline, also salol, phenacetine and quinine. At this time she had slight rise of temperature. The following morning the temperature was 102. The patient reported a restless night and no movement of the bowels. She was given more salts. The next morning, March 1, the patient was feeling miserable with a temperature of 103. The bowels had moved a great number of times. Nothing new was discovered by examination. That after-noon she had had a chill which lasted one hour, but did not see her until the following morning. At that time she said she was feeling very much better in every way. Her temperature was 101. Nothing new was able to be discovered as indicating localized disease. Towad noon of this day she rather suddenly developed an attack of acute mania. She insisted on being dressed and was with great difficulty restrained from going down town. She talked incessantly and refused food. Her pulse was not very rapid and her temperature was not taken. She fell fainting once. The next morning her mental condition was the same. In spite of the medicine she had slept very little. She talked constantly, but said she felt well. In the afternoon she was seen by Dr. Joseph M. Aikin, who was able to suggest no other diagnosis than influenza with severe nervous symptoms. At this time the patient was part of the time rational. She had a temperature of 101 and pulse of 84.

The following day, Saturday, March 4, the condition seemed to be the same with one exception. The abdominal wall wast rigid to an extreme degree and very strongly retracted, a typical "scaphoid belly. There was, however, no tenderness to pressure at any point, or dulness on percussion. Prior to this time careful watching had failed to show any hint of trouble in the abdomen. The temperature was 102, pulse 80. Rigidity of the abdominal wall continued but within twelve hours the retraction had diminished and by the end of two days there was moderate bulging of the abdomen and a little dulness to percussion with marked tenderness over the whole of the abdomen to the right of the median line.

The signs were not localized at any point. This was the ninth day from the beginning of the sickness, the first sign of abdominal trouble having begun seven days from the commencement of the sickness. By the ninth day also the liver was much enlarged. This enlargement came on with

remarkable rapidity and to an enormous degree. By the end of another week liver dulness extended to the fifth rib in the axillary line and the lower margin was almost at the crest of the ilium. This enlargement appeared to be uniform throughout the liver. It was very sensitive to touch and caused constant pain which was greatly aggravated by any manipulation or movement of the patient. ment of the patient. It was impossible for the patient to lie upon the left side on account of the condition of the liver. It was difficult to determine the condition of the right lung at this time. The breathing over the lower region of the lung was broncho-vesicular and in certain places distinctly bronchial. Friction sounds were heard which may have been pleuritic. own opinion was that they were sub-diaphragmatic. There were no symptoms pointing to involvement of the lung or pleura, at this time or later. Six weeks elapsed before any improvement in the condition of the liver could be observed. At that time the pain and tenderness were diminishing and slight change could be noted in the way of lessened size. At no time was there even a trace of jaundice.

My

Four

On March 6, the eighth day of the disease, the right wrist was swollen, painful and tender to touch. The next day both wrists were in the same condition. or five days later the left wrist began a gradual return to normal. In the right wrist, however, redness appeared extending some distance upward on the forearm, on its palmar surface. This condition continued, sometimes worse and sometimes better, for thirty days from the first appearance of the pain. On April 4, an incision was made and two ounces of pus withdrawn. The abscess was under the deep fascia and did not involve the joint. It healed in four days. Through a misunderstanding the specimen of pus was lost, and unfortunately no bacteriological study of it was made.

On March 8th an area of redness, heat, pain and swelling appeared upon the dorsum of the right foot. This slowly inceased to such a condition that for two or three days it appeared that it must be opened. This operation being postponed it gradually subsided and disappeared. whole duration of this affair was about two weeks.

The

On March 12, the superficial veins over the lower part of the chest on the right side, covering an area of about six inches from above downward, and most marked in the axillary region, became enormously distended. This condition came on rapidly,