Dr. A.: A positive Widal of 1:320 to 1:100 is pretty unusual for the fourth or fifth day of typhoid fever.
Dr. G.: I do not think it is the fourth day; I think it is the tenth day.
Dr. A.: Even the tenth day is unusual.
Dr. H.: Dr. I., would a Widal become positive in an individual who has been previously vaccinated if he subsequently falls ill with an acute infection?.
Dr. I.: Yes, we have good evidence that it does. In typhus patients, if they come from surroundings where typhoid fever is prevalent, the Widal reaction often becomes positive in the first few days of the disease, before the development of the Weil-Felix reaction. In rabbits the antibodies which have disappeared from the serum sometimes are recalled by intravenous injections of non-related antigens. The early presence of agglutinins, as Dr. A. pointed out, speaks probably for the nonspecific nature of the agglutination.
Dr. A.: May I ask one question, Dr. I.? Which of these three positive blood cultures is the most significant?.
Dr. I.: I agree that the hemolytic streptococcus is the most significant. I cannot remember a single case in which we obtained hemolytic streptococci from the blood as a contaminant, while staphylococcus albus is a common contaminant of blood cultures. I believe that if he had typhoid fever the culture would be positive for the typhoid bacillus and not for hemolytic streptococcus.
DR. K.: I was asked to see this patients three or four days before he died and to transfer him because of typhoid fever. At that time he had, and I thought, definite tenderness in the lower quadrant with spasm, and although there were peristaltic sounds it seemed to me obvious that he had peritonitis. A great deal to comment occurred in regard to the presence of peristaltic sounds in this man, the commentators feeling that this ruled our peritonitis. In view of the fact that he had general peritonitis, and we felt that it was probably due to some inflammation of some viscus, I followed my fathers dictum, that he probably had Atypical appendicitis with peritonitis.
CLINICAL DIAGNOSES.
Typhoid fever?.
Atypical appendicitis with peritonitis?.
DR. A.S DIAGNOSES.
Acute hemolytic streptococcus peritonitis.
Septicemia, streptococcus hemolyticus.
ANATOMIC DIAGNOSES.
Acute generalized peritonitis, streptococcus hemolyticus.
Septicemia, streptococcus hemolyticus.
Acute peritonitis with effusion, streptococcus hemolyticus.
Septic spleen.
Duodenal ulcers.
Pulmonary atelectasis.
PATHOLOGICAL DISCUSSION.
Dr. H.: The autopsy on this man showed a diffuse acute infection of his abdominal cavity. There was a thick, yellowish fibrinous, exudate all over the peritoneum. No areas of localization or abscess formation were found. We hunted carefully for a source in the abdomen, but were unable to find one. He did have, however, two ulcers in the first portion of the duodenum, but although fairly acute they showed no evidence of perforation. His ileum was perfectly normal. There was slight injection of the jejunum, but no evidence of perforation anywhere. We felt that the diagnosis was idiopathic hemolytic streptococcus peritonitis, and were able to confirm it by culturing the organism from the peritoneum.
He had a small amount of fluid in the pericardium and in each pleural cavity from which we were also able to culture hemolytic streptococci. The blood culture at autopsy was also positive for hemolytic streptococcus. It is, as Dr. C. said, quite unusual to find this condition in an adult. I looked through our autopsy records and found only one or possibly two other cases in adults. One was in a man of 50 who had a septic sore throat and three or four days after the sore throat had abated the abdominal symptoms began. In children, however, it is not at all uncommon. We have had about five or six cases in which the infection started as a sore throat and the patients ultimately died of the peritonitis. In this case the record states only that the pharynx was red.
A Physician: Do you think his illness five months before had anything to do with it?.
Dr. H.: I do not see how it could. An interesting theory as to the pathogenesis of this disease was described a few years ago by Felsen and Osofsky.
They reported eight autopsied cases, three in adults and five in children, in all of which there was a history of a previous sore throat. The organisms cultured from the peritonitis were of the nonhemolytic type of streptococcus. In four of their cases they were able to reproduce the disease in rabbits by the intravenous injection of broth cultures of the organism. In most of the rabbits erosions and ulcerations were found in the ileum, and they felt that the peritonitis developed from a permeation through the intestinal wall (even if there was no necrosis of the wall) of the organisms which had originally reached the intestine through the blood stream. Their experiments were well controlled and the antigenic similarity of the organisms was checked by the complement fixation test.
DIFFERENTIAL THERAPEUTICS.
The clinical diagnosis here is at variance with Dr. A. and with the anatomic diagnosis.
The therapeutic symptoms are as follows: Frequent loose bowels; alternate hot and chilly feeling; vomitus–brown, yellow and green; epigastric tenderness; cyanotic skin; sordes of the teeth; purple, swollen throat; torpor, prostration; thin, copious, ichorous, bloody nasal discharge; livid eruption; burning, mouth to stomach; putrid discharge; ulcerative stomatitis with dirty gray membrane; necrotic areas of palate and fauces.
Repertory working here suggests three remedies: Ailanthus, Carbolic acid, Mercurius cyanatus; three outstanding remedies for septic conditions.
Ailanthus has many of the symptoms, the proving showing a cyanotic skin, the purple throat and great prostration, while Carbolic acid has more burning in the throat, the fauces being red.
There is no mention of putrid breath under Ailanthus, but this is a striking symptom found under Carbolic acid.
The face of Carbolic patient is a dusky red, white about nose and mouth, while Ailanthus is definitely cyanotic. Mercurius cyanatus has some cyanosis. However, its outstanding symptom is great exhaustion. It has gray membrane of the throat, and the necrotic areas of the soft palate; has the dark blood from the nose, which is also present under Ailanthus, but not under Carbolic acid.
Copious, ichorous discharge from nose is found under Ailanthus, but not under Carbolic nor Mercurius cyanatus.
Ailanthus has irregular patches in the throat, not necessarily necrotic. Mercurius cyanatus has distinct necrotic areas, while Carbolic acid has the dusky red throat.
Carbolic acid has an exudate of the throat but no mention of a distinct membrane is found as in the provings of Mercurius cyanatus.
The differential therapeutics here may be quite difficult. Both Carbolic acid and Mercurius cyanatus are deep acting remedies, but in consideration of the great exhaustion, the haemorrhagic tendency, the necrotic areas of the throat and the grayish membrane present, Mercurius cyanatus would seem to be the best remedy, although, as expressed by my great teacher, Dr. Walter M. James, of Philadelphia, we might be forced to “lop off” symptoms in the provings of the various remedies, following concurrently with Carbolic acid and Ailanthus before a cure could have been affected.
Thus, through such diagnostic and therapeutic gymnastics, as here demonstrated, we are able to present to the world the homoeopathic method of treatment and connect it intimately with accurate diagnostic methods.
SEATTLE, WASH.
Seattle.
Chairman, Bureau of Surgery