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M.D, ANl) KENNETH CAMERON, B.A., M.D. y JReprmted from Tni Journal jof^amiology anb Bacteriology. Edinburgh and Un>floki^p,\in^ S.'Bf^toQ;^, Jamiarij 1896. WiwWrli^^iW^: ?-'?7^>f''/!-^;yiv ■' ■ UPON GENERAL INFECTION BY THE BACIL- LUS PYOCYANEUS IN CHILDREN. UPON GENERAL INFECTION BY THE BACILLUS PYOCYANEUS IN CHILDREN. By E. P. Williams, M.D.,^ and Kenneth Cameron, B.A., M.D. From the Molson Patholoijical Laboratorij, M'Gill University, Montreal, The observations of Bouchard, Charriu (}), liuller, and others have shown that the Bacillus ^j^oc //««(; «s, obtained primarily as a contamination in tlie pus of wounds, is very definitely pathogenic for certain of the lower animals, notably rabbits. While occasionally met with in association with other microbes, it has been but rarely found as a primary cause of disease in man. The cases here related being, beyond doubt, of this nature are therefore of more than usual interest. Case 1. — C. E., an illegitimate male cliikl; born on 24th October 1893, in the Montreal Maternity Hospital, and admitted on November 17th to the Montreal Foundling and Infant Nursery with his mother, a Swedish woman in good health. He was entirely breast-fed, and gained steadily until the twenty-second week of age, when he became restless and ill, and began to lose weight. These indefinite symptoms, for which no cause could be assigned, continued for 5 weeks, when diarrhoja with green stools set in, accompanied by fever (99°-100°), abdominal pain and tenderness, but no tympanites. About the first week of May a group of half a dozen purple papules, 3-7 mm. in diameter, appeared on the abdomen on each side, midway between the umbilicus and the flank. The skin over the abdomen was relaxed, dry, and wrinkled. The child was then in a low, depressed state, lying listlessly in his mother's arms, frequently moaning, especially when disturbed. During the following fortnight numerous papules appeared, extending up and down from the original groups and across the hypogastrium, in the form of an irregular horseshoe ; still later many of these became confluent, and others appeared on the abdomen and chest. By the 1 8th the depression became extreme ; the green stools continued, although the abdominal pain and tenderness had ceased. The abdominal facies was very marked. The child could not, or would not, move his limbs. The legs were flexed upon the thighs and the thighs upon the abdomen, and any attempt to straighten them out caused the child to moan ; when released they at once returned to their former position. The papules now, for the first time, were seen on the thighs and shoulders. ' Since this paper was put into type Professor Adami lias written to say that Dr. Williams has succumbed to an attack of blood poisoning, contracted during the perform- ance of his pathological work. Dr. AVilliams was an earnest investigator, and there seems to be little doubt that overwork left him very susceptible to infection. — En. THE BACILLUS PYOCYAXEUS JN CHILDREN. 345 On tlio 22ikI there was ft very profuse cpistaxis, followed by a refusal to take food. On the 23rd the aui)erlicinl abdominal veins became distended. On the 25th subcutaneous lunemorrliages occurred from between the toes and from papules on the right thigh and ItacK. Nearly all the spots were now of a darker colour. The next day a slight purulent discharge from the left ear was observed. The child became comatose, and died on 27th May, two months from the onset of the illness. The case was looked upon as one of purpura hrpmorrhagica of septic origin. An autopsii was performed shortly after death. The body waa not markedly emaciated, there being a fair (juantity of subcutaneous fat. Sections through the blue spots showed deep pigmentation of the skin and infiltration of the subjacent fat and loose tissue Avith dark blood. The muscles and the thoracic and abdominal organs, except the spleen, were very pale. The heart was almost empty, save for a little Huid blood in the left auricle. The spleen was firm and of a deep crimson colour, the capsule firmly adherent, and the Malpighian bodies distinct. The kidneys were large, and on the inferior siu-faces there were two or three small purplish sfrots, over one of which the cajjsule was puckered and thickened. On section these resembled small, firm infarcts. There was no sign of any marked inflammatory lesion in the intestines, though the mucous membrane was thickened. Microscopic examination of the kidneys, liver, and spleen, showed that many of the capillaries Avere blocked with emboli, formed by minute bacilli ; in some instances the micro-organisms had passed through the walls of the vessels, infiltrating the surrounding tissue. There was a slight generalised parenchymatous nephritis, the tubides, especially in the convoluted portion, being swollen and cloudy and filled with granular debris. The liver cells were also irregular and cloudy. ^Minute portions of tissue were removed from the spleen pulp, and from one of the ha^morrhagic spots on the kidney, and put into culture tubes of gelatine (containing 1 percent, of Mercks' peptone and 0'5 per cent, of sodium chloride), and of agar-agar (1 ])er cent, peptone, 1 per cent, glycerine, and 0*5 per cent, sodium chloride). These tubes were kept at the ordinary temperature of the room, and on the sixth day miinite creamy white strife or films were seen upon the surface of the media. The tubes were then i)laced in an incubator, when by the following observations the growth was found to be that of the B. jJijoci/ancux. AVe shall enter at some length into the cultural characteristics of the organism isolated by us, inasmuch as the growths did not wholly correspond with those described by other writers on the B. pyocyaneus. To this point Ave shall refer later. On aiinr-aijnr the groAvth Avas moist, spread rapidly along the needle track and radiated over the surface of the medium, Avhich soon became a fluorescent light green, usually Avith a slight bluish tinge at the edge of the groAvth. Later, the agar became a deep grass-green, and finally a nut-brown. Eight Aveeks later some agar tubes prepared Avithout glycerine Avere inoculated from the first ones. The groAvth Avas at first the same, but after tAVO days the edges became moist, and soon the moisture ran to the bottom of the tube Avhere the groAvth rapidly continued. Upon the surface of the primary groAvth minute stellate spots, Avith a dry metallic lustre appeared, and rapidly coalesced and spread until the entire surface presented the lustre. On the gelatine a thin greyish film appeared on the surface, Avhile the upper portion of the medium rapidly liquefied. This film became thick and floated on the surface, Avhile colonies sank and continued the liquefaction. The liquefied portion Avas reddened Avith a greenish cloud in the upper part near the surface. When the tube Avas shaken the entire fluid became a bright opalescent bluish-green. This colour faded, but could be observed near the surface after standing. It could be at any time reproduced by shaking. Later 846 E. P. WILLIAMS AND kENNETH CAMERON. tho pelntino nil Ijecanic lij/o- cyancus 10 infant liodies have been examined (post-mortem), with the result that in two a general distribution f)f the B. pyocyancits has been found, and in one the bacillus was found present in the alimentary canal only. This fact, taken in connection with the observations of Neumann and Elders, shows clearly that the infant organism is suscep- tible to the invasion of the bacillus. The discovery of this micro-organism filone, associated with a train of symptoms closely resend)ling in so many respects the disease, pro- duced experimentally in rabl)its l)y liuft'er ("), — a-1io found present emaciation, diarrhoea, fever, muscular disorders, albun.inuria, and hitmor- rhages — the first and last being the most prominent in cases running a slow course, symi)toms which are by no means uncommon in infants, especially when they are gathered together in institutions, — indicates that the bacillus is distinctly pathogenic at that early age. AVe therefore conclude that in these two cases we have ol)tained a disease due to the growth of the B. jryocynncus, that, in fact, we have here two typical examples of this very rare coiulition of true pyocyanic disease, or, if the term be admissible, cyano-pyteniia. How this disease has originated, that is to say, by what channel the bacillus has gained admission into the organism in these two cases, must still, we think, be a matter of uncertainty. 350 E. P. WILLIAMS AND KENNETH CAMERON. It is possible that the entry was through some cutaneous lesion, and this would bring these cases into line with those in which the bacillus is found in association with other septic niicro-orgauisms in wounds. But it must be acknowledged that in none of our instances was there any antecedent cutaneous disturbance recognisable or noted. As regards this point, while Bouchard (**) has held that intraven- ous injection is necessary to produce a general infection by the bacillus, Euffer seems conclusively to prove that rabbits may be infected by subcutaneous injection. Another point of entry that might be considered is through sup- purative disease of the middle ear. That this is a possibility is shown by the observations of Dr. F. E. Blaxall ("), who found B. pyocyanms in the ear discharge occurring as a complication in scarlatina. In our second case the infant, when it entered the nursery, had a purulent discharge from both ears. This ceased before the pro- gressive emaciation characteristic of the pyocyanic disease began to show itself ; it is possible, however, that this was the starting-point of the malady. It must not be left out of account that the alimentary tract may have been the point of invasion. In favour of this view it is to be noticed that in two instances we have discovered the bacillus in the contents of the small intestine ; in one of these in association, in the other unassociated, with the general disease ; that Booker (}^) has discovered the B. 'pyocyancv.s in the intestinal tract of a number of children examined with reference to intestinal bacteria ; and that during the first few weeks of life the digestive functions of the infant, especially if artificially fed, aie but feebly established, and any impair- ment of these imperfect secretions renders the food taken a most favourable nidus for the production of abnormal fermentation and the growth of bacteria. In all the cases here reported signs of gastro-intestinal irritation were present for some time before the skin lesions appeared, but whether this was the result of the intoxication by the bacillus, or only favoured its growth, we have no means of determining, for bacteriological exam- inations of the stools were not made at the time. A careful bacteriological investigation of all cases of so-called " infantile marasmus," especially when complicated with skin erup- tions (whether petechial or pustular), diarrhoea, fever, and muscular disorders, may demonstrate that the distribution of this micro-organisni is much more widespread, and much more disastrous in early life than is generally believed. The close resemblance of the symptoms of Case 1 , to those generally described in text-books as purpura hivmorrhagica, suggests a causative relati(jn Ijetween the bacillus and that lesion. We are aware that several species of bacteria have been described in connection with purpura hivmorrhagica ; the most that we wish to suggest is, that in children the B. fyocymxcv.s may more frequently THE BACILLUS I'YOCYANEUS IN CHILDREN. 351 liu tlio uiiisal ugout ill the production of this lesion than has been heretofore lield. Ill conclusion, we wish to express our sincere thanks to Professor Adiuui for his assistance and advice throughout the study of tliese cases, Nok. — This paper was completed in August 1894. Unfortunately the copy first sent to the Journal was lost in transit. [Tlie first copy was announced hy letter, l)ut never arrived. — Ed.] 1. ClIAltlllN '1. EULEltS . . .'5. Neumann, W. 4. Gessahi) . . O. EUNST, 11. C. 0. KliNST, p. . 7. KuiTEii, ^1. A. (^. PoUClIAItl) . . y UlAXAIJ; . . 10. IJooKEli, "\V.M. 1). RKPKRKNCl-:8. " Lii MaluiUc pyiicyaiiiquL'," Paris, 18,S'J. lluxp.-Tiil., Kjohenh., Mai 1890. Ai'rh.f. Kiwlcrh., Stultg., 1890, hd. xxi. Ann. de I'Lut. Paateur, Puri.s, 1890, p. .SN, mul 1891, p. G5. Am. Jouni. Med. JSc, Pliiki., 1893, p. 570. yjsr/ii:/. Hi/;/., Leipzig, 1888, Ld. ii. s. 2. " Experimental luvcHtigation into the Nature of the Disease produced by the Inoculation of the BariUnx pijuinjaneiis" London, 1889. "Cours dc Pathologic Generale," 1888. Ih'il. Mi'it. JitiiriL, London, 1891, vol. ii. p. IIG. Trai/-: Iii/friinl. Mrd. Cuiif/rcx!', ninth session, vol. ill. IP. .")98. ma nakow ■■-/s