case of paratyphoid studied by Longcope* there were no lesions in the intestines and no splenic or lymphatic endothelial proliferations, showing that the lesions in that case differed from those of typical typhoid. Sion and Negelt also describe a fatal case of paratyphoid without typhoidal lesions. These authors also report a small series of paratyphoid fever and trace the source of infection to water. Just now the lesions of paratyphoid are matters of special interest to pathologists. In her valuable study of the fly as the carrier of typhoid bacilli in some of the Chicago tenement districts, in which typhoid fever last year prevailed to a greater extent than elsewhere in the city, owing principally no doubt to shockingly inadequate methods of disposing of dejecta and neglect in sanitary inspection, Alice Hamiltons shows that the fly may convey paratyphoid or paracolon as well as typical typhoid bacilli. This demonstration permits the inference that under favorable conditions paratyphoid may be spread by flies just as well as typhoid fever, and that these infections are amenable to the same hygienic and sanitary measures. No doubt the absence of agglutinins for typhoid bacilli in certain cases clinically like typhoid fever is explainable in some cases on the score of the disease being paratyphoid. The interagglutinability of typhoid and paratyphoid or paracolon bacilli presents an interesting field for exhaustive study. While the serum failed to agglutinate typhoid bacilli in Ruediger's cases of paratyphoid, others have found that some agglutination of typhoid bacilli may be caused by paratyphoid serum. It has been already pointed out that in some cases of true typhoid, agglutinins are recognizable only after the attack is well established. Under these circumstances it is clear that much weight cannot be placed upon the absence of agglutination in determining the nature of a given case or cases of doubtful character. In the Ithaca epidemic this point seems to have been overlooked. The bearing of this whole matter upon the epidemiology of the typhoidal infections is stated so clearly by the special commissioner of the Journal of the American Medical Association that I quote directly from his report.¶ *Am. Jour. Med. Sc., 1902, CXXIV, 209-218. See also articles by Buxton and Coleman, Johnston and Hewett in same number. † Centralbl. f. Bakt., 1902, XXXII, 483-488, 581-596, 679-692. An interesting report on this subject is given by Lucksch, from Chiari's Institute (Centralbl. f. Bact., 1903, XXXIV, 113-117). Jour. Americ. Medic. Assoc., 1903, XL, 576-583. See Castellani, Zeitschr. f. Hyg. u. Infektionskr., 1902, XL, 33-53. "Throughout the epidemic the situation has been singularly befogged by a tendency on the part of certain of the Ithaca physicians to deny the prevalence of 'genuine' typhoid fever, and to ascribe the prevailing illness to 'paracolon infection.' The evidence on which this view is based, appears to be that a negative result with the Widal reaction has been obtained in a considerable proportion of the cases that have been tested. There is no instance where any paracolon or paratyphoid organism has been isolated from any case of the disease. Even if it were conclusively proven that half, or even all, of the cases of fever' in Ithaca were true 'paracolon' infections, it is difficult to see why that fact should materially influence the general situation. It must still have been admitted that a disease of serious character which can not as yet be clinically differentiated from tvphoid fever, and which, so far as is known, does not demand essentially different treatment, prevailed excessively in the town. Whatever the nature of the organism, the probable mode of infection and the sources of the infection remained the same, as did the necessity for taking vigorous measures for preventing its spread. There was not a single particular in which the practical handling of the outbreak could have been affected, even if convincing evidence had been secured that all the cases in Ithaca were paracolon cases. The insistence on a distinction, which, under the circumstances, could possess only an academic value and did not facilitate immediate and aggressive action, was not a for•tunate policy." The superior diagnostic and practical value of bacteriologic examination of the blood is emphasized again by this reference to the question of the typically typhoidal or paratyphoidal nature of a given epidemic, and we may conclude this brief consideration with the statement that the method of blood cultures is destined to play a most important part in the settlement of the many practical and scientific problems constantly arising in connection with the typhoidal diseases, which, though so well-trodden a field, still invites continued exploration. CONCLUSIONS. 1. Bacteriologic examination of the blood by modern methods has proven of great scientific and practical value in the so-called septic diseases or septicemias, in pneumoia, and especially in typhoid and paratyphoid fevers. 2. In the typhoidal diseases blood cultures constitute the best means of diagnosis in the early stages, and that is the period when definite diagnosis is most difficult yet most desirable. 3. Etiologic diagnosis, that is, the recognition of the exact disease present, demands the application to practical medicine of laboratory methods, and henceforth the physician's work will require more and more the constant and intelligent use of the facilities of a wellequipped laboratory. Discussion. DR. JAMES B. HERRICK, Chicago-I wish in the first place to thank the Society for the courtesy of the invitation to discuss this paper of Dr. Hektoen's, and to meet the members of the Wisconsin Society. I wish to speak briefly of four or five points, some of which are merely repetitions, emphasizing the points made by Dr. Hektoen. to First, the bacteriologic examination of the blood is of great importance us as clinical physicians, because sooner or later, and we trust sooner, there will be specific therapy for the infectious diseases, and as physicians we must be ready to apply the specific medication that is presented to us. If to-morrow morning, for instance, we should wake up and read in some reputable medical journal that a specific medicine had been discovered for pneumococcus infections, or for streptococcus or staphylococcus infections, how many of us would be prepared intelligently to use this remedy? How many of us as we meet with our cases of so-called septicemia or "blood poisoning," would be able to tell by the clinical manifestations what was the infectious agent that was at fault? How many of us would be prepared to apply this bacteriologic method of diagnosis? So then, the first point that I would make-and I shall not elaborate these points, merely speaking of them in a suggestive manner-would be, that as practical physicians we must be ready to accept this specific therapy which we believe and trust will soon be offered to us. In the second place we must practice the bacteriologic examinations of the blood carefully and thoroughly in order that we may understand better the clinical course of these diseases. What I mean is this: We see cases and group them together very roughly as cases of blood-poisoning or septicemia. We cannot on clinical grounds, at present differentiate accurately between a case of pneumococcus septicemia, staphylococcus septicemia, or streptococcus septicemia. It is possible that if we study these cases carefully from the ordinary clinical standpoint, accurately regarding and recording symptoms, studying them in groups and controlling this work by careful bacteriologic examinations of the blood, we shall ultimately be able to have definite clinical pictures of these different forms of bacteriemia. In the early part of this century typhus and typhoid fever were confused. There was no clear clinical differentiation between those two different diseases, and yet the differentiation was made by a combination of the results of post-mortem examinations and clinical study. In a somewhat similar way we can, I believe, by careful study of our cases by bacteriologic examination of the blood, have definite clinical pictures, one representing a pneumococcus septicemia, another a streptococcus, another a staphylococcus septicemia, etc. Perhaps also it will be possible for us as clinicians to state in the future that one case is probably a paratyphoid infection, and another is probably a case of true typhoid infection. This will enable us also to make a more accurate prognosis, because we shall learn the definite clinical course of all these infections. We shall know what to expect in a given case. We shall know what complications we are likely to meet with in infection with one organism and what in infection with another. We shall therefore be the better able, even before the days of specific therapy, to apply our symp tomatic remedies. In the third place (and this I do not need to dwell upon because it has been brought out so well by Dr. Hektoen) we are enabled by bacteriologic examination of the blood, to make early accurate and definite etiologic diagnoses-really the only true diagnoses. This has been shown repeatedly in cases that have been under my observation, particularly in the cases of typhoid fever where diagnosis as early as the third or fourth day has been possible by this method, long before rose spots appeared or indications were obtainable from the spleen, or agglutination reaction was found. In the fourth place this method of bacteriologic examination of the blood is not only practical but it is practicable-it is feasible. I hope that Dr. Hektoen will give some of you the opportunity to see the little, simple technic employed. It is really just as simple, with the exception of the necessity of a little more scrupulous asepsis, as the giving of a hypodermic injection; it is attended by no more pain than a vaccination, in fact not so much. Now, this is feasible certainly in our hospitals where we have laboratory facilities close at hand. It certainly is feasible in our large cities, where with medical colleges and laboratories we can easily call in to our aid the laboratory expert. But the question comes up, how much of this can be done in the smaller towns, how far can the country practitioner adopt this method of diagnosis? That is a difficult question to answer, and we have to say as things are now, it can only be adopted in the larger towns; or it can be adopted in the smaller country towns where some exceptional man keeps up at his own expense, his own private laboratory. But this bacteriologic examination of the blood has come to stay; it will have to be adopted if the profession is to keep pace with the advance in science, and it seems to me that in the smaller country towns something like this might be adopted: Where there are ten or a dozen physicians in a group in one town, or in several neighboring towns, I can see no reason why one of them, perhaps one of the younger men starting out in practice fresh from the laboratory, should not institute a little laboratory of his own. The expense is not great, and if the laboratory could be started with the backing of the other physicians, with the understanding that other physicians could apply to this one for the bacteriologic examination of the blood in a given case, the one to be paid in any way that can be mutually arranged, I do not see why such a plan as that is not perfectly feasible, and certainly, if it were adopted, the profession in the smaller towns would have the feeling that they were keeping up with the procession. And in such a laboratory, of course, not only the bacteriologic examination of the blood would be made but as well the examination of urine, sputum, stomach contents, feces, tumors, exudates, etc. It is possible, too, that these laboratories in towns or counties might in some way be under the supervision of the county medical societies. There is another point that I would make in conclusion, and that is this: In spite of the fact that the general practitioner has to rely upon the laboratory in many instances for his diagnosis, we must remember that all laboratory work is, after all, to be controlled and to be interpreted by clinical observation. It is not enough for us to be told by the laboratory expert that there are typhoid germs in the blood, or pneumococci. It is not enough for us to be told by the laboratory expert that there are tubercle bacilli in the sputum. That means something to us-it clinches the diagnosis, if you please; but what, after all, do tubercle bacilli in the sputum mean, if that finding is not interpreted and controlled by the ordinary physical examination? In one case it means a little patch of infiltration at the apex of the lung, with practically no disturbance of the patient, with no fever and loss of weight; in another it means that the patient is in the terminal stage of pulmonary tuberculosis. We must control and interpret these findings of the laboratory by our clinical experience. The day of the feeling of the pulse, looking at the tongue, taking the temperature and listening to the sounds of the heart, has not passed, by any means. And if we jump to the conclusion that we must rely wholly and exclusively on the laboratory findings, we shall, I think, all of us make a serious blunder. How many of us have not at times had to make diagnoses in spite of the findings of the laboratory? You send a smear from the throat to the laboratory and get a report "No diphtheria germs," but your clinical experience tells you that that is diphtheria-you know it—and at times you have to make your interpretation in spite of the negative findings of the laboratory. I am sure the day of the general practitioner is not passing away because of the laboratories. The true way in which to look at this laboratory work is that it is an aid to practice. The laboratory man and the general prac titioner should go hand in hand. I regard this paper of Dr. Hektoen's as a very timely one, and I regard it as significant of good and great things that a laboratory man comes from his purely scientific work and presents to us a paper that shows us the practical side of scientific laboratory investigation. DR. O. THIENHAUS, Milwaukee-This is a very interesting paper and I would not like to let it go by without making a few remarks. When we have to deal with a severe septic infection on an arm or leg which does not yield to incision and drainage but even spreads in spite of large incisions; when at the same time the general condition of the patient is very grave, then the question arises, are we justified and are there indications to amputate the limb, and is this the only means of saving the patient's life? It is very difficult to give strict indications for amputation in such cases, and one has relied recently on blood examinations and has found, that when daily made blood cultures show that the amount of streptococci in the blood increases daily, this is a strong argument for amputation. Take another condition: When a puerperal uterus is infected and the general and local symptoms of sepsis are very severe, the question arises, is there here an indication for vaginal or abdominal hysterectomy to save the life of the patient? One has made blood examinations in these cases and has hoped to find arguments in this for or against operation, but the results up to this time are very far from being conclusive. Bacteriologic examinations of the blood may show the presence of streptococci in large numbers and yet the patient gets well without hysterectomy. In other cases you find hardly any streptococci in the blood, and nevertheless the patient dies promptly. Therefore we have hardly any help from the blood examinations up to this time, to form definite conclusions. At the last meeting of the American Medical Association a surgeon told me that he had done five vaginal hysterectomies because of puerperal septicemia, and all of his patients got well; but I told him that this was a sure sign that the operations should not have been performed, as the patients would probably have gotten well without hysterectomy. |