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Trains Young Men and Women for Business Life HE Business World is full of tempting THE opportunities for the earnest, energetic, The ignorant are crowded to the wall to make A CASE OF GENERAL INFECTION BY THE STAPHY- CLINICAL MANIFESTATIONS.* BY H. B. ANDERSON, M.D., L.R.C.P. (LOND.), M.R.C.S. (ENG.) Associate Professor of Clinical Medicine, University of Toronto. Elizabeth P., aged thirty-nine years; English; widow; occupation, cook; was first seen by me on Christmas Day, 1903. About five weeks previously she had been taken ill with severe pains in the back of the head and neck, chills, fever and profuse sweats. She soon developed pain in the lower part of the left chest, cough, and considerable expectoration of yellowish sputum. The patient looked very ill, was pale, emaciated, and had an expression of marked suffering. The attacks of chills and fever had been recurring daily, the patient feeling comparatively comfortable in the intervals. I had her sent into St. Michael's Hospital, and I am indebted to Dr. A. J. Fraleigh for having kept careful notes of her case during her subsequent illness. Family history shows no evidence of tuberculous taint; mother had *Read before the Toronto Clinical Society, October, 1904. suffered from rheumatism, and had an attack of pneumonia while the patient was in the hospital. Personal History.-Patient had suffered from the usual diseases of children, and six years ago had had a severe attack of typhoid fever. During the winter of 1902 she had been laid up for three weeks with some obscure complaint, during which time she says she had a hemorrhage from the bowels. About the same time she complained of pain in the left hypochondrium, and says she noticed a lump there. During the past summer (1903) she had been cook to a camping party in Southern Ohio, but had enjoyed good enough health. Patient had never been very robust. Her best weight was 120 lbs. She had always worked hard. Menstruated irregularly. She was in very fair health when she returned to Toronto in September, 1903. About the middle of November she was taken ill with chills, sweats, etc., as before stated. Condition on Admission (Dec. 27th, 1903). She is a small, delicate and emaciated woman, weighing 95 lbs.; she is pale and has a worried, anxious, pained expression. Skin is dry, harsh, with slight branny desquamation. It is of a slightly yellowish tint, with patches of dark-brownish pigmentation about the forehead, face and neck. Tongue is red and covered in patches with a white fur. Fauces and pharynx are congested. Bowels regular. Patient complains of shortness of breath. Chest is thin, clavicles prominent; expansion poor, but equal on two sides. Nothing definite detected on palpation or percussion. Some large bubbling rales were heard over the larger tubes and smaller bubbling rales at the right apex. Apex beat is in normal position. not appreciably increased. Area of cardiac dulness A distinct mitral systolic murmur is to be heard, traceable into the axilla. Pulse is not very rapid-96, but is rather weak and compressible. Superficial vessels are not appreciably thickened. Liver was readily palpable an inch below the costal margin. Spleen is much enlarged and easily palpable nearly as low as the umbilicus. There is extreme tenderness on pressure over the whole splenic region. Examination of the sputum showed no tubercle bacilli, but staphylococci, streptococci and pneumococci were present; also numerous pus cells, epithelial cells and some red blood cells. Urinalysis showed nothing of importance. Blood examination showed 3,770,000 reds, 6,900 whites and 80 per cent. hema globin. Stained, dried films showed no morphological alteration in the cells and nothing special in the differential count. Repeated examinations were made for the Plasmodium malariæ on account of the patient's residence during the previous summer, and the presence of an enlarged spleen, with recurring chills and sweats. The results were always negative. Repeated Widal examinations were also negative. The temperature at this time was ranging from 98 to 99 and 100 deg.; pulse about 90. Chills had ceased for the past few days. A diagnosis of septicemia of some sort, with endocarditis, bronchitis and acute splenic tumor with perisplenitis was made. The latter might have been due to infarction. The point of entrance of the infection it was not possible to discover. A few days after coming to the hospital-January 1st, 1904 -she had a chill, temperature rose to 102 2-5, and well marked physical signs of pneumonia and pleurisy appeared at the left base, though not involving a large area. January 4th, the temperature rose to 103 2-5, next day falling to normal with profuse sweating. January 8th, the temperature rose to 103 4-5, and examination showed intense engorgement of the vessels of the fauces, naso-pharynx and pharynx, with bleeding from some of the distended vessels. The throat felt very sore, and there was severe pain in the left ear and left side of the neck. January 9th there was severe pain in both ears, and the patient was quite deaf. The temperature, however, was lower, 101°. The pain and deafness continuing, Dr. Wishart saw her on January 12th, and incised both drum membranes. Some pus escaped, and the patient felt better. On January 13th, however, she had a chill lasting fifteen minutes, and temperature rose to 104 2-5, and the next day an intense and very typical erysipelatous rash appeared over the forehead and face, extending to the head and over the neck. The rash gradually subsided, the temperature falling to normal on January 18th. About February 1st, severe pain, tenderness and slight swelling appeared in the knee, ankle and wrist joints. The slightest movement was unbearable. At the same time all the tissues of the legs became extremely tender, the tenderness not being limited to any special structures, as muscle, nerves, or veins. The clinical condition was such as would ordinarily be called rheumatic, but was no doubt due to the infection acting on these structures. The pain and tenderness in these parts were most intractable, lasting, with alternating periods of improvement and exacerbation, for months. The swelling in the joints was also variable, at times disappearing in some of them and reap |