1079

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ROYAL FREE HOSPITAL.A CASE OF ULCERATIVE ENDOCARDITIS TREATED WITH

ANTI-STREPTOCOCCIC SERUM; RECOVERY.

(Under the care of Dr. SAINSBURY.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor-borum et dissectionum historias, tum aliorum tum proprias collectashabere, et inter se comparare.-MORGAGNI De Sed. et Caus. Korb.,lib. iv. Prooemium. -

THE serum-therapy of pyogenic affections has of late beenattracting attention in this country. Mr. Ballance and Mr.Abbott 1 recently recorded a case of hasmorrhagic septicæmiatreated by anti-streptococcic serum with recovery. On

Sept. 12th last Dr. P. Coleman and Mr. T. G. Wakeling recordedin the same periodical another successful case of septicæmiatreated similarly by injections of serum. In puerperal feverthere have also occurred successful cases of this treatment.

Malignant endocarditis is of the same class of disease,the organisms present in the vegetations being most com-monly streptococci and staphylococci, and the serum treat-ment has already been applied to the cure of this affection.The following case is a contribution to the literature ofthe subject, for the notes of which we are indebted toDr. Hugh Wingfield, house physician.A lad aged thirteen years was admitted to the Royal Free

Hospital on June 22nd, 1896, "for pain in the chest andheart." The patient first complained of pain in the chestabout June 6th. He was sleepless and could not lie down inbed. He became progressively worse, had a troublesomecough, became weak, feverish, and, later, delirious at

night. There was no history of rheumatism or chorea to beobtained. He had had measles and whooping-cough as ababy. On admission he seemed ill and was very dusky incolour. His skin was dry and harsh. The temperaturewas 103 2° F. He had a deal of cough. The cardiac dulnessbegan in the first left intercostal space and extended to theright sternal border. The heart’s apex beat was in the fifthspace four inches to the left of the mid-sternal line. Therewas a well-marked thrill and a double murmur at the apex.In the lungs there was some impairment of note at bothbases behind, with weak breath sounds and crepitations overthe whole of the right side of the back. The liver andthe spleen were not palpable below the costal margin. Theurine contained no albumin. Fifteen grains of salicylate ofsoda were administered every two hours in a mixture. OnJune 24th he was violently delirious at night, and the

temperature ranged from 100° to 101°. No streptococcihad been found in the blood. On June 25th there wasmarked dulness over the left lung behind and increase ofvocal resonance. The sputum was rusty. There had been no

rigor. On the 26th a symmetrical erythematous rash appearedon the buttocks spreading to the rest of the body; this lastedfive days. On July lst streptococci were found in the blood.On the 9th there was much general improvement in thepatient’s condition. Treatment with liquor hydrargyri per-chloridi was commenced. The temperature rose to 102° onthe 20th, where it remained until the 24th. The boy wasill and drowsy ; the rash had returned. The area of cardiacdulness was increasing. On the 28th the temperature was104’4°. There was no rigor, but there was vomiting andreturn of cough, with bloody sputum. On Aug. 5th heseemed worse ; the sputum contained streaks of blood and aclot; there was abdominal tenderness, and it was thoughtthat the spleen was felt. The boy was very languidand took food very badly. On the 17th 20 c.c. ofanti-streptococcic serum were injected. The temperaturewas 998°. This was followed by no local or generalreaction. On the 18th 10 c.c. of serum were in-jected, and on the 20th 10 c.c. more were injected.There was a marked improvement in the boy’s condi-tion and the skin which had peeled was rapidly clearing.On the 22nd a further 10 c.c. were injected, and on

1 Brit. Med. Jour., July 4th, 1896.

the 25th another 10 c.c. On the 26th there was a returnof the rash with much itching. The temperature range didnot remain at normal. On the 31st the patient was up andwalking in the ward and was very markedly better. Thearea of cardiac dulness was normal and the heart’s apex-beatwell internal to the nipple line. The blood was examined bythe British Institute of Preventive Medicine, and it was

reported that it contained no streptococci. On Sept. 1st,a further 10 c.c. of serum were injected. This was followed

by local and general slight reaction. The temperature roseto 102° and the patient seemed ill and complained of pain atthe puncture, this pain lasting for twenty-four hours. Onthe 10th the temperature had been normal since the lastinjection, and the improvement was maintained. On the14th the patient went out. He slept and ate well and wasgetting stronger daily.Remarks by Dr. SAINSBURY.—This case of malignant

endocarditis responded so promptly and satisfactorily to theserum treatment that no apology is needed for recording it.Before the injections were commenced the patient had lapsedinto a condition of marked cachexia ; within two or threedays the improvement in the aspect and bearing of the boywas unmistakeable-he was clearer-looking, brighter, and thepeeling skin cleaned rapidly. Neither local reaction at thesite of the puncture nor any general reaction was observedexcept on Sept. lst, the time of the last injection, when thesudden rise of temperature the general appearance of ill-ness and the pain at the site of the injection followedso speedily upon the injection that there seemed no

other explanation for the symptoms than the dose ofserum. The boy, however, soon rallied and then, curiously,took a fresh start ; his temperature for the first time becamenormal and his advance was then so rapid and uninterruptedthat there was no excuse for another injection. Thus all theinjections were markedly effective, but most so this lastinjection, which produced definite local and generalsymptoms. Was this reaction an unnecessary concomitant-the result of a by-product, or was it to be regarded as of thenature of a curative reaction ? In a recent case of ulcerativeendocarditis under my care at the Victoria Park Hospital forChest Diseases the anti-streptococcic serum failed to arrestthe disease and seemed to have no beneficial effects ; in thiscase, however, there was, in addition to the endocarditis,grave kidney disease with cortical destruction, which mayhave accounted for this; the disease was, moreover, in amore advanced stage and of more virulent type. Specialthanks are due to Dr. Hugh Wingfield, who, as house

physician, has had the immediate conduct of the case, alsoto Miss Knight, M.B. Lond., the pathologist.

DINORWIC QUARRIES HOSPITAL.A CASE OF CONGENITAL DEPRESSION OF THE LEFT

FRONTAL BONE WITH SYMPTOMS SIMULATING

CHOREA ; TREPHINING ; RECOVERY.

(Under the care of Mr. R. H. MILLS-ROBERTS)THIS interesting case should be included under the heading

of traumatic epilepsy arising, as it appears to have done,from a condition of the cranial vault which most probablyresulted from injury at birth. There are not many publishedcases which present a similar history, for many years elapsedbefore the abnormal growth of bone was sufficiently large top’oduce irritation. We take it that the symptoms were dueto the condition of the under-surface of the piece of boneremoved by the trephine and that the improvement whichfollowed operation was not due to any temporary readjust-ment of intra-cranial pressure. The causes to which trauomatic epilepsy have been assigned are as follows 1: ., (1) aneuralgic cicatrix in the scalp is the starting-point of reflexconvulsions ; (2) chronic osteitis of the part of the skullstruck, giving rise to thickening and induration in the

bone ; (3) from depression of bone, fracture of the innertable, and the formation of osseous stalactites pressing on thesurface of the brain in the motor area; (4) from chronicthickening of the dura mater ; (5) from cystic collectionsof fluid in the membranes ; (6) from scars or other lesions inthe area of the cortical motor centres." An interesting case 2has been recorded in which a groove more than three inches

long in the skull, the result of injury from forceps at birth, was

1 Erichsen : Science and Art of Surgery, vol. i., tenth edition.2 Dr. Lane: Annals of Surgery, St. Louis, November, 1891.

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removed by surgical means at the age of sixteen years, andepileptiform symptoms of two years’ duration relieved. Inanother case 3 an epileptic woman aged twenty-two years wastrephined and some depressed, eburnated bone removed, withrelief of symptoms ; the use of the forceps at birth hadcaused the traumatism in the first instance. In another case,4 a child aged six years, at the operation (successful) for reliefof epilepsy a spicule of bone was found projecting into thebrain; there was no history of injury to the part, but it is

probable that some was sustained at birth, for the symptomsbegan at six weeks of age.The patient, a boy aged fourteen years, first attended the

hospital in January, 1896, complaining of incontinence ofurine at night. From this he recovered. One day duringthe latter part of January, while having supper after return-ing from the quarry, his parents noticed that his manner andconduct were peculiar. He did not take his food as usual.He talked at random and did not appear to thoroughlyunderstand what was said to him. His conduct, however,was not violent. These symptoms only lasted a few minutes,and the boy went to his work as usual the next day, but wastaken home early owing to a repetition of similar symptoms.These attacks continued on and off for the next three or fourweeks, occurring sometimes two or three times a day, thoughnow and again a day or even two days would bemissed. During these times, between the attacks theboy was dull, morose, and melancholic, whereas hisnormal condition was bright and cheerful. Duringthe latter part of February the attacks occurred nearlyevery morning while the patient was dressing or getting outof bed. They now increased in frequency and severity ; thepatient often becoming delirious-shouting and talkingviolently-beating his head and hands together. At timeshe complained of severe frontal headache. He was veryexhausted and would often sleep after an attack. About thistime (the end of February) it was noticed that during theattacks parts of the body were being convulsed, at one timethe legs and at another time the arms or head. These con-vulsive attacks gradually increased in severity, but as theseverity increased the talking and delirium diminished andgradually disappeared altogether. The patient was admittedinto hospital on March 24th so that the case might bewatched, as hitherto Mr. Mills-Roberts had not seen anattack. On this day and the next there were four not verysevere chorea-like attacks, the convulsions attacking thewhole of the body, but lasting only a few seconds. The

patient was apparently well but dull during the intervals.Trephining was recommended, but the boy became frightenedand ran away on the 25th. Mr. Mills-Roberts was askedto see the patient again in a few days, being toldthat he was much worse. He did see him, and the boy wasre-admitted on April 10th, being persuaded to stay in thehospital by the companionship of other boys. It was correctthat the attacks were much worse. As a rule the patientwas warned of a coming attack by violent frontal headache,though at times the onset was so sudden that he would fallin the middle of the ward before help reached him. Theconvulsions affected in a greater or less degree the wholebody. Like chorea they were remarkable for their dis-orderly character, and were regular only in their irregularity.There might be violent spasms of any or all of the musclesof one or both arms, these being perhaps accompanied, pre-ceded, or followed by a similar condition of the legs, thehead and neck, and the back. The boy was conscious thewhole time. His pupils were dilated and his countenancewas pale. In a minute or so all would apparently be quiet.On being asked if he was better he would look up helplessand tired, being apparently quite exhausted. Sometimes hewould answer Yes or No, but oftener, before he had timeto answer, the convulsions would re-commence, so thatit was found better to leave him alone and to ask no

questions, but only endeavour to prevent him injuring him-self during the attacks. One attack might last as long asfive minutes, at the end of which the patient would fall backon his bed quite worn out, to suffer, perhaps, from moreor less violent frontal headache for as long as two hoursafterwards. In the hospital he generally had one or twoattacks like this in a day; one day he had three. Beforeadmission he was said to have had as many as twelve in oneday. The urine was normal, as was also the fundus oculi.The patellar reflex was slightly exaggerated. On April 19th

3 Medical and Surgical Reporter, Philadelphia, vol. ii., 1891.4 Dr. Kennedy: Medical Bulletin, Philadelphia, July, 1892.

the operation of trephining was performed. A semi-circular flap was raised from the bony depression, theposition of which corresponded with what should havebeen the frontal eminence. The pericranium havingbeen dissected up, a one-inch trephine was applied aboutthe middle of the depression. The inner plate of thecrown removed was very much thickened and its inner

aspect was tuberculated, the tubercle being rather largerthan a split-pea. The dura mater appearing normal thepericranium was replaced and the skin flap was sutured.

There was no drainage. The wound healed by first intention,and the patient left the hospital seventeen days after theoperation apparently well. The fits had left him and hisgeneral condition was bright and cheerful.Remarks by Mr. MiLLS-ROBBBTS.—The case is reported

somewhat in detail as it seemed worthy of record. It is nowsix months since the operation and there has been no returnof the fits ; the boy’s condition is in every way satisfactory,though about two months ago he had a slight temporarynocturnal incontinence of urine, and I thought the fits werepossibly about to begin again. However, as yet he is freefrom them and I hope will continue so. It will beinteresting to watch for a recurrence and, if there is, tosee if it is due to scar tissue or another bony tubercle.

Medical Societies.MEDICAL SOCIETY OF LONDON.

President’s Address.-Abdominal Section Performed a SecondTime on the same Sitbiect,

THE first meeting of this session of the Medical Societywas held on Oct. 12th, the President, Mr. REGINALD HAR-RISON, being in the chair.Mr. REGINALD HARRISON delivered the presidential

address on " The Treatment of some Forms of Albuminuriaby Reni-Puncture." He said that certain cases of albu-minuria had come under his notice in which he hadperformed an operation for the relief of some morbid con-dition which was supposed to exist but was not found whenthe kidney was exposed; the symptoms however were

relieved and the condition of the urine improved. Thishad led him to think that in certain cases of albuminuriagood might result from puncture of the kidney. He relatedthree cases in which he had so exposed the kidney :-1. Aboy aged eighteen years was suspected of having suppurationaround the kidney following scarlet fever. There was lumbarpain, and the urine was albuminous and contained casts.A small lumbar incision was made and the kidney found tobe tense and engorged. An incision was made throughthe capsule, and there was a full discharge of bloodand urine ; the wound healed on the tenth day. Theurine now became abundant, the albumin lessened, andthen disappeared altogether, the boy making a goodrecovery. 2. That of a man aged fifty years whoworked underground. He had presented symptoms ofof renal calculus for some time. Three months after beingfirst seen his urine was constantly albuminous, and he hadpain in the right lumbar region. The kidney was exposed,but no stone was found. The condition of the patient im-proved, the urine became normal, and the patient remainedin good health. 3. That of a woman aged forty-four yearswho had had haematuria for one year and pain on pressureover the left kidney, with albuminous urine at times.There was some history of her having passed a calculusat one time. A lumbar incision was made and the kidneywas found to be swollen and tense. This was incised andfree drainage of urine and blood ensued. The womanrecovered, the urine becoming normal. The first of thesecases he considered to be scarlatinal nephritis, the secondto be due to cold, and the third a subacute attack follow-ing influenza. He then referred to two cases of movablekidney (published by Dr. Newman of Glasgow in theMedical Week, Jan. 6th, 1896, p. 29) in which the albuminand casts which were present before the operation dis-appeared entirely after the kidney was fixed, and alsoto another case under the care of Dr. Hoeber of Ham-burg, in which relief had followed incision into the

right kidney. Having referred to the views of Sir ThomasGrainger Stewart and Sir Thomas Watson on the con-sequence of hyperæmia in the initial stage of nephritis, he