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= Incorporating =
An Judependent Monthly Magazine
Organized at Council Bluffs, Iowa. September 27, 1888. Objects: "The objects of this society shall be to foster, advance and disseminate medical knowledge : to uphold and maintain the dignity of the profession; and to encourage social and harmonious relations within its ranks."-Constitution
Ist Vice-President ....... Lyons, Neb.
B. T. QUIGLEY................. Mound City, Mo.
. St. Joseph
.Council Bluffs A. B. SOMERS....
........Omaha C. B. HARDIN..
........... Kansas City W. F. MILROY.....
.... St. Joseph
(EXCLUSIVELY FOR THE MEDICAL HERALD.1
W. F. Milroy, M. D., Omaha, Neb.
ị Y pyemia we understand a condition in entire vascular system and grow. The ac
which a primary focus containing us- tion of the bacterial toxines in septicemia ually staphylococci, occasionally strep- also is to be considered the most important
tococci or pneumococci has by means factor of the affection. There is besides, of the lymph or blood current, disseminated the mechanical effect of the obstruction of the exciting cause of the disease in the numerous capillaries. body. The pathogenic bacteria which are Now, a strict differentiation between thus colonized cause metastatic suppura these two conditions is impossible clinicaltions. By the absorption of toxines a gen ly. Metastases sometimes result, but seperal intoxication is also present.
ticemia at other times according to the Septicemia differs principally from py
amount and virulence of the bacteria which emia in that in this affection the bacteria
find their way into the blood. Hence, exspread from the primary focus over the
cept in extreme cases, the term septico-pyemia is applicable to the disease.
Generally speaking septic diseases have ciety of the Missouri Valley at Council Bluits, Ia., Septem
been grouped among the accidental wound
*Tbe following papers were read before the Medical So
ber 7 1913.
diseases and belong in the domain of sur- in which the point of infection is not found, gery. However, in the year 1878 Leube, and furthermore, there is a certain per cent from a series of observations, called atten- in which fortunately necropsy investigation to a goup of septic cases in which tion is impossible since the patients reproof of a traumatic infection was impossi- cover. ble. He proposed for such cases the desig- The story of the symptomatology and nation Cryptogenetic Septico-pyemia. bacteriology must not detain you. It difThis qualifying term he derived from fers not at all from septico-pyemia, of Kruptos hidden, and gennao to beget which the organ is frank and open. Nor signifying of concealed origin. He have I the time to discuss differential diag. discovered other such cases in the litera- nosis, though obviously just here appears ture and in particular quotes Wunderlich the paramount importance of familiarity as having, in 1847 accurately described with the matter now under discussion, so cases of "spontaneous pyemia.” As a rule that one shall not be caught napping. The the disease is fatal. Exceptionally patients differential diagnosis is especially difficult recover from such an attack. Luebe insists when the localization of the toxin is a limthat this affection is much more common ited one, when one or the other organ is than is usually supposed, especially if separately affected, thus simulating the those cases are included, in which a care presence of a local affection, or of another ful study leads to a diagnosis of septico-py. infectious disease, which especially attacks emia, even though recovery takes place. the organ in question. In this respect we Please observe that I shall draw freely upon must, according to the special manifestathe work of Leube in what I shall say. tion of our case, have in mind acute articu
First, as to the special mode of infection. lar rheumatism, intermittent fever, acute The organism has been provided with a miliary tuberculosis and typhoid fever. Exwonderful defence against the invasion of ceptionally other conditions may be sug. pathogenic bacteria. Under favorable con- gested. ditions this defence is effective. However, Unfortunately, the cultivation and deadverse conditions may arise when this is monstration of such bacteria, in the blood not the case. Such are local traumata of the patient as are in genetic connection which damage the part in respect to its circu- with the septic condition is comparatively lation or nutrition, or when great quantities rarely accomplished. This is due to the of virulent bacteria disseminate through fact that death usually occurs before the the blood. Thus the resistance is overcome specific bacteria have grown sufficiently to and the organism succumbs. Other factors become disseminated in the blood stream. which lower the power of resistance to this My principal object in presenting this invasion are exhaustion, hunger, anemia, brief paper is to bring to mind the existdiminished alkalinity and watery condition ence of the condition and the wisdom of of the blood and also a flooding of the body keeping it before us, thus to avoid, perwith purid substances. Faulty elimination haps, an error in diagnosis. by intestines or kidneys is included in this On Monday, February 27, 1911, the catagory. In the group of cases under con- writer was called to see Miss F. The pasideration we are not able to discover the tient was an unmarried lady aged 40, an source of the infection during the life of American, complexion fair, occupation the patient, even with the minutest investi- housekeeper. The patient was of spare gation. However, at autopsy it may ap- build but well nourished. The family pear in ulcerated bronchial or mesenteric history was negative. The patient had glands, old abscesses in internal organs, never been ill with the exception that a residues of puerperal or appendiceal pro- chronic pharyngitis, not of great severity, cesses, and such like. And yet even at au- had given her some little trouble of late. topsy no such source of infection may be for this she had had a few local treatfound. In such cases nothing remains but ments by Dr. James M. Patton. For sevto assume that bacteria of extremely great eral months she had felt weak and tired, virulence entered in large quantities by but had continued about her ordinary wounds so small that they cannot be dem- household duties. Two days ago she onstrated post-mortem or exceptionally by went down town and called at the office of the uninjured surface of the skin or mucus Dr. Patton for treatment. Yesterday, membrane.
while the family were at church, she preEdwards says that careful clinical and pared the dinner, but was in bed the latter necropsy investigations reveal the atrium part of the day. This morning she arose of infection in 94 per cent of cases. This as usual but complained of a general achbeing true there remain 6 per cent of cases ing. Examination failed to show any local evidence of disease. A provisional diag. remarkable rapidity and to an enormous nosis of influenza was made and the pa. degree. By the end of another week liver tient given calomel with ipecac and soda in dulness extended to the fifth rib in the axilsmall doses to be followed by a saline, also lary line and the lower margin was almost salol, phenacetine and quinine. At this at the crest of the ilium. This enlargetime she had slight rise of temperature. ment appeared to be uniform throughout
The following morning the temperature the liver. It was very sensitive to touch was 102. The patient reported a restless and caused constant pain which was greatly night and no movement of the bowels. She aggravated by any manipulation or movewas given more salts. The next morning, ment of the patient. It was impossible for March 1, the patient was feeling miserable the.patient to lie upon the left side on ac. with a temperature of 103. The bowels count of the condition of the liver. It was had moved a great number of times. Noth- difficult to determine the condition of the ing new was discovered by examination. right lung at this time. The breathing That after-noon she had had a chill which over the lower region of the lung was lasted one hour, but did not see her until broncho-vesicular and in certain places disthe following morning. At that time she tinctly bronchial. Friction sounds were said she was feeling very much better in heard which may have been pleuritic. My every way. Her temperature was 101. own opinion was that they were sub-diaNothing new was able to be discovered as phragmatic. There were no symptoms indicating localized disease. Towad noon pointing to involvement of the lung or of this day she rather suddenly developed pleura, at this time or later. Six weeks an attack of acute mania. She insisted on elapsed before any improvement in the conbeing dressed and was with great difficulty dition of the liver could be observed. At restrained from going down town. She that time the pain and tenderness were talked incessantly and refused food. Her diminishing and slight change could be pulse was not very rapid and her tempera- noted in the way of lessened size. At no ture was not taken. She fell fainting once. time was there even a trace of jaundice. The next morning her mental condition On March 6, the eighth day of the diswas the same. In spite of the medicine she ease, the right wrist was swollen, painful had slept very little. She talked constant- and tender to touch. The next day both ly, but said she felt well. In the afternoon wrists were in the same condition. Four she was seen by Dr. Joseph M. Aikin, who or five days later the left wrist began a was able to suggest no other diagnosis than gradual return to normal. In the right influenza with severe nervous symptoms. wrist, however, redness appeared extending At this time the patient was part of the some distance upward on the forearm, on time rational. She had a temperature of its palmar surface. This condition con. 101 and pulse of 84.
tinued, sometimes worse and sometimes betThe following day, Saturday, March 4, ter, for thirty days from the first appearthe condition seemed to be the same with ance of the pain. On April 4, an incision one exception. The abdominal wall was was made and two ounces of pus withrigid to an extreme degree and very strong. drawn. The abscess was under the deep lç retracted, a typical "scaphoid belly." fascia and did not involve the joint. It There was, however, no tenderness to pres- healed in four days. Through a misundersure at any point, or dulness on percus- standing the specimen of pus was lost, and sion. Prior to this time careful watching unfortunately no bacteriological study of had failed to show any hint of trouble in it was made. the abdomen. The temperature was 102, On March 8th an area of redness, heat, pulse 80. Rigidity of the abdominal wall pain and swelling appeared upon the dorcontinued but within twelve hours the re- sum of the right foot. This slowly intraction had diminished and by the end of ceased to such a condition that for two or two days there was moderate bulging of the three days it appeared that it must be abdomen and a little dulness to percussion opened. This operation being postponed it with marked tenderness over the whole of gradually subsided and disappeared. The the abdomen to the right of the median whole duration of this affair was about line. The signs were not localized at any two weeks. point. This was the ninth day from the On March 12, the superficial veins over beginning of the sickness, the first sign of the lower part of the chest on the right abdominal trouble having begun seven days side, covering an area of about six inches from the commencement of the sickness. from above downward, and most marked in By the ninth day also the liver was much the axillary region, became enormously enlarged. This enlargement came on with distended. This condition came on rapidly,