161 HOSPITAL MEDICINE AND SURGERY. OF HOSPITAL PRACTICE, BRITISH AND FOREIGN. WESTMINSTER HOSPITAL. (Under the care of Mr. W. G. SPENCER.) A CASE OF ACUTE PHARYNGITIS DUE TO STREPTOCOCCUS PYOGENES FOLLOWED BY SEPTICÆMIA, DEEP GLANDULAR INFLAMMATION, AND PERICARDITIS, AND RELIEVED BY THE ADMINISTRATION OF STREPTOCOCCAL ANTITOXIN. Nulla autem est alia pro certo noscendi via, nisi quamplurlmas et morborum et dissectionum historias, tum aliorum tum proprias cellectas habere, et inter se comparare.-MORGAGNI De Sed. et Gaur. Morb., lib. iv. Prooemium. - THE value of the anti-streptococcic serum has in few cases been more strikingly shown than in that recorded below. Only discredit can result from the employment of this very powerful remedy indiscriminately in all septic cases, for it .appears to be perfectly inert against other varieties of micro- organisms. We have published recently several cases in which this serum proved to be of service and others also in which but little benefit resulted. We need to be better acquainted with the capabilities and the limitations of the power of the anti-streptococcic serum and this is only possible by the publication of cases, such as the following, in which the treatment has been employed scientifically. A man, aged twenty-one years, was first taken ill on Oct. 16th, 1898, with a sore throat which was followed by swelling in the neck. The symptoms increased in severity and he was admitted to the Westminster Hospital where he was first seen by Mr. Spencer on Oct. 24th. The patient was partly onconscious, had great difficulty and pain in swallowing, and kept placing his hand over his heart where he felt pain. ’The face was very pale. The temperature was 101.4° F., having been 1030 during the night; the pulse was 120, small .and of low tension ; and the respirations were 30 and quiet. The mouth could only be partly opened; the tongue was ’somewhat swollen and covered with a dry brown fur. The tonsils were not enlarged ; the back wall of the pharynx was -covered with brown sticky mucus, but there was no sign of any membrane. The left side of the neck was much swollen, red, brawny, and cedematous. An incision had been made at the posterior border of the sterno-mastoid by Mr. Silas, the house surgeon, immediately after the patient’s admission ; swollen glands were reached from which a sanious fluid escaped, but no thick pus. On auscultation a loud pericardial friction rub <could be heard. Dr. Blaxall, bacteriologist to the hospital, - examined the mucus from the throat and the discharge from the wound in the neck. He found both in cover-glass specimens and upon cultivation mainly streptococcus pyogenes. In the cultivation from the throat a yeast, staphylococcus albus, and a few bacilli were also found. At 9.30 P.M. on the 24th-i.e., eight days after the first sign of the illness-10 c.c. of streptococcal antitoxin were injected, a second dose being given at 6 A.M. and a third at 4.20 P.M. on the 25th, and a fourth on the 26th. The effect was remarkable, the patient beginning to rally at once. On the 27th the temperature fell to 98° and did not rise above 100.8°; the pulse whilst still 120 had become much fuller and of greater tension. The patient had returned to consciousness and no longer complained of pain over the cardiac area. The pericardial friction was much less loud. The tongue was not so swollen, was moister, and showed signs of beginning to clean. Before the treatment by antitoxin there had been constipation, whilst for the next three days there were from five to eight aoose motions per diem. The incision in the neck was discharging pus from deep-seated glands. On the 31st no pericardial friction could be heard, but there was a well- marked pleural rub extending from the cardiac area upwards above the third left rib. On Nov. 5th no abnormal sounds, neither pericardial nor pleural, could be heard, but an impaired resonance existed above the third left rib, which Dr. de Havilland Hall concludpd to be due to pleural thickening and not to pericardial distension. This impaired resonance gradually cleared up. The patient was weak for some time, his pulse continuing to be rapid, and his tempera- ture showing some irregularity on his first getting up. Nothing further happened except a trivial attack of urti- caria caused by the antitoxin. The patient left the hospital on Dec. 14th to go to the convalescent home. The pulse and temperature were then normal and the wound in the neck had healed. Remark by Mr. SPENCER.-The above case is important as an instance of septic pharyngitis which would without doubt have ended fatally if the antitoxin corresponding to the organism causing the disease had not been administered. It would be useless, indeed harmful, to inject streptococcal antitoxin haphazard in any acute affection of the throat. To such treatment the identification of streptococci as the cause of the disease is an essential preliminary. In the present case beyond the organisms found there was nothing very marked in the pharynx. In other cases an acute œdematous inflammation attacks the glottis as well as the tongue and causes rapidly-increasing dyspnoea. Even if tracheotomy is performed death may occur from failure of the heart. GENERAL HOSPITAL, BIRMINGHAM. A CASE ILLUSTRATING A METHOD OF TREATING EXTRO- VERSION OF THE BLADDER IN THE FEMALE. (Under the care of Mr. CHAVASSE.) EXTROVERSION of the bladder has received an amount of notice quite out of proportion to the frequency of the occur- rence of this deformity and this is undoubtedly to be attributed to the difficulties which are experienced in its treatment. Very many procedures have been devised to remedy this malformation and probably the most elaborate was that described by Mr. Reginald Harrison at a meeting of the Medical Society of London in 1897.1 The method described by Mr. Chavasse is obviously only applicable to the rare cases in which the patient is a female child but it has given in this case at least good results. Tredelenburg’s method, which was at first em- ployed, is very ingenious, as are all the inventions of that eminent surgeon, but it is not always equally applicable ; it is probable that it would have proved of more value in this case if the treatment had not been interrupted. A girl, aged four years, was admitted into the General Hospital, Birmingham, in June, 1897, on account of extro- version of the bladder. The child had previously been the inmate of another hospital and from the cicatrises seen upon the abdominal wall it was evident that a plastic operation to remedy the defect had been unsuccessfully performed. The usual appearances associated with this congenital defect presented themselves. It was resolved to attempt to remedy the condition by separating the sacro-iliac sym- physes as advocated by Trendelenburg. On June llth both sacro-iliac synchondroses were separated and the innominate bones were pushed forward ; iodoform gauze was used to fill in the gaps left between the bones. To main- tain and to increase the approximation of the hip bones a weight-and-pulley apparatus acting crossways was applied to each buttock by means of strapping and fixed to the sides of the cot. The exposed portion of the bladder wall slipped back into the pelvis on the fifth day after the operation and at the end of a fortnight the deficiency in the abdominal wall was reduced to a slit-like aperture. The operation, however, seemed to cause a good deal of shock to the child who did not thrive well, took food badly, and developed bronchitis. The wounds consequently granulated slowly and healing was not complete till seven weeks after the operation. It was not then considered advisable to attempt any plastic operation and the child was sent to the Jaffray Suburban Hospital. Here it was deemed best by those in charge to leave off the weights and the pulleys attached to the buttocks so as to enable the child to reap the benefit of fresh air. As a result the defect in the abdominal wall speedily became more apparent and the bladder again protruded. The child’s health having much improved at the beginning of Decoibsr 1 THE LANCET, April 17th, 1897, p. 1091.
Transcript
161HOSPITAL MEDICINE AND SURGERY.
OF
HOSPITAL PRACTICE,BRITISH AND FOREIGN.
WESTMINSTER HOSPITAL.
(Under the care of Mr. W. G. SPENCER.)A CASE OF ACUTE PHARYNGITIS DUE TO STREPTOCOCCUSPYOGENES FOLLOWED BY SEPTICÆMIA, DEEP GLANDULARINFLAMMATION, AND PERICARDITIS, AND RELIEVED
BY THE ADMINISTRATION OF STREPTOCOCCAL
ANTITOXIN.
Nulla autem est alia pro certo noscendi via, nisi quamplurlmas etmorborum et dissectionum historias, tum aliorum tum propriascellectas habere, et inter se comparare.-MORGAGNI De Sed. et Gaur.Morb., lib. iv. Prooemium. -
THE value of the anti-streptococcic serum has in few casesbeen more strikingly shown than in that recorded below.
Only discredit can result from the employment of this verypowerful remedy indiscriminately in all septic cases, for it.appears to be perfectly inert against other varieties of micro-organisms. We have published recently several cases in whichthis serum proved to be of service and others also in whichbut little benefit resulted. We need to be better acquaintedwith the capabilities and the limitations of the power ofthe anti-streptococcic serum and this is only possible by thepublication of cases, such as the following, in which thetreatment has been employed scientifically.A man, aged twenty-one years, was first taken ill on
Oct. 16th, 1898, with a sore throat which was followed byswelling in the neck. The symptoms increased in severity andhe was admitted to the Westminster Hospital where he wasfirst seen by Mr. Spencer on Oct. 24th. The patient was partlyonconscious, had great difficulty and pain in swallowing, andkept placing his hand over his heart where he felt pain.’The face was very pale. The temperature was 101.4° F.,having been 1030 during the night; the pulse was 120, small.and of low tension ; and the respirations were 30 and quiet.The mouth could only be partly opened; the tongue was’somewhat swollen and covered with a dry brown fur. Thetonsils were not enlarged ; the back wall of the pharynx was-covered with brown sticky mucus, but there was no sign of anymembrane. The left side of the neck was much swollen, red,brawny, and cedematous. An incision had been made at theposterior border of the sterno-mastoid by Mr. Silas, the housesurgeon, immediately after the patient’s admission ; swollenglands were reached from which a sanious fluid escaped, butno thick pus. On auscultation a loud pericardial friction rub<could be heard. Dr. Blaxall, bacteriologist to the hospital,- examined the mucus from the throat and the discharge fromthe wound in the neck. He found both in cover-glassspecimens and upon cultivation mainly streptococcuspyogenes. In the cultivation from the throat a yeast,staphylococcus albus, and a few bacilli were also found.At 9.30 P.M. on the 24th-i.e., eight days after the first
sign of the illness-10 c.c. of streptococcal antitoxin wereinjected, a second dose being given at 6 A.M. and a third at4.20 P.M. on the 25th, and a fourth on the 26th. The effectwas remarkable, the patient beginning to rally at once. Onthe 27th the temperature fell to 98° and did not rise above100.8°; the pulse whilst still 120 had become much fullerand of greater tension. The patient had returnedto consciousness and no longer complained of painover the cardiac area. The pericardial friction was
much less loud. The tongue was not so swollen, wasmoister, and showed signs of beginning to clean. Beforethe treatment by antitoxin there had been constipation,whilst for the next three days there were from five to eightaoose motions per diem. The incision in the neck wasdischarging pus from deep-seated glands. On the 31st nopericardial friction could be heard, but there was a well-marked pleural rub extending from the cardiac area upwardsabove the third left rib. On Nov. 5th no abnormal sounds,neither pericardial nor pleural, could be heard, but an
impaired resonance existed above the third left rib, whichDr. de Havilland Hall concludpd to be due to pleural
thickening and not to pericardial distension. This impairedresonance gradually cleared up. The patient was weak forsome time, his pulse continuing to be rapid, and his tempera-ture showing some irregularity on his first getting up.Nothing further happened except a trivial attack of urti-caria caused by the antitoxin. The patient left the hospitalon Dec. 14th to go to the convalescent home. The pulseand temperature were then normal and the wound in theneck had healed.Remark by Mr. SPENCER.-The above case is important
as an instance of septic pharyngitis which would withoutdoubt have ended fatally if the antitoxin corresponding tothe organism causing the disease had not been administered.It would be useless, indeed harmful, to inject streptococcalantitoxin haphazard in any acute affection of the throat. Tosuch treatment the identification of streptococci as the causeof the disease is an essential preliminary. In the presentcase beyond the organisms found there was nothing verymarked in the pharynx. In other cases an acute œdematousinflammation attacks the glottis as well as the tongue andcauses rapidly-increasing dyspnoea. Even if tracheotomy isperformed death may occur from failure of the heart.
GENERAL HOSPITAL, BIRMINGHAM.A CASE ILLUSTRATING A METHOD OF TREATING EXTRO-
VERSION OF THE BLADDER IN THE FEMALE.
(Under the care of Mr. CHAVASSE.)EXTROVERSION of the bladder has received an amount of
notice quite out of proportion to the frequency of the occur-rence of this deformity and this is undoubtedly to beattributed to the difficulties which are experienced in itstreatment. Very many procedures have been devised to
remedy this malformation and probably the most elaboratewas that described by Mr. Reginald Harrison at a
meeting of the Medical Society of London in 1897.1The method described by Mr. Chavasse is obviouslyonly applicable to the rare cases in which the patient is afemale child but it has given in this case at least goodresults. Tredelenburg’s method, which was at first em-
ployed, is very ingenious, as are all the inventions of thateminent surgeon, but it is not always equally applicable ; itis probable that it would have proved of more value in thiscase if the treatment had not been interrupted.A girl, aged four years, was admitted into the General
Hospital, Birmingham, in June, 1897, on account of extro-version of the bladder. The child had previously been theinmate of another hospital and from the cicatrises seen uponthe abdominal wall it was evident that a plastic operation toremedy the defect had been unsuccessfully performed. Theusual appearances associated with this congenital defectpresented themselves. It was resolved to attempt to
remedy the condition by separating the sacro-iliac sym-physes as advocated by Trendelenburg. On June llthboth sacro-iliac synchondroses were separated and theinnominate bones were pushed forward ; iodoform gauze wasused to fill in the gaps left between the bones. To main-tain and to increase the approximation of the hip bones aweight-and-pulley apparatus acting crossways was appliedto each buttock by means of strapping and fixed to thesides of the cot. The exposed portion of the bladderwall slipped back into the pelvis on the fifth dayafter the operation and at the end of a fortnightthe deficiency in the abdominal wall was reduced toa slit-like aperture. The operation, however, seemed tocause a good deal of shock to the child who did notthrive well, took food badly, and developed bronchitis. Thewounds consequently granulated slowly and healing was notcomplete till seven weeks after the operation. It was notthen considered advisable to attempt any plastic operationand the child was sent to the Jaffray Suburban Hospital.Here it was deemed best by those in charge to leave off theweights and the pulleys attached to the buttocks so as toenable the child to reap the benefit of fresh air. As a resultthe defect in the abdominal wall speedily became moreapparent and the bladder again protruded. The child’shealth having much improved at the beginning of Decoibsr
1 THE LANCET, April 17th, 1897, p. 1091.
162 PATHOLOGICAL SOCIETY OF LONDON.
she was sent back to the General Hospital and on the 6th ofthat month the following operation was performed.Both ureters were catheterised and dissected clear of the
mucous membrane of the bladder. Two small obliqueopenings were then made in the upper part of the anteriorwalls of the vagina into which the ends of the ureters werepassed, each on its own side, and stitched to the edges of theincisions by horsehair sutures. The catheters were left inthe ureters and projected beyond the labia so as to carry theurine clear of the patient. All the exposed portion of theposterior wall of the bladder was then cut away and theresulting cavity was packed with iodoform gauze. This provedsuccessful; the right ureteral catheter came out spontane-ously on the third day after the operation, the left beingwithdrawn on the fourth day. All the urine from this timewas voided per vaginam. On Jan. 24th, 1898, Thiersch’splastic operation to close the cleft was performed, tinfoil
being employed for insertion under the bridge of skin dis-sected up on the right side. Three weeks later as the fiapwas granulating healthily it was divided at its upper partand swung round and found to cover in the whole of thedefect except a small portion at the left lower angle.The flap subsequently contracted somewhat, leaving an
exposed portion at this angle about as large as a shilling,but as it caused no inconvenience an ordinary indiarubberfemale urinal was applied and the child was sent home earlyin April. To close in what remained of the cleft she wasreadmitted into the hospital on July llth and a small flapwas made on Thiersch’s plan on the left side, tinfoil beingagain used. At the end of fourteen days the inner edges ofboth flaps were freshened and united. On Sept. 19th thepatient was examined under chloroform; firm union wasfound to exist between the flaps, the urine dribbled awayconstantly from the orifice of the vagina, but there was noexcoriation of the skin round the genital organs over thebuttocks or the thighs. No enlargement of either kidneycould be detected on palpation. The mother stated that thechild was readily kept dry by means of the urinal during theday and at night by the use of absorbent wool the wettingof the bed was prevented. The child’s health and generalcondition had manifestly improved, she took her food welland ran about most of the day as she liked.Remarks by Mr. CHnvACSE.-The patient was exhibited at
a meeting of the Midland Medical Society on Nov. 2nd, 1898.I then quoted some statistics of the late Mr. John Wood 1
showing that cases of ectopion vesicas in the female were as1 to 10 in the male and stated that this was the first time Ihad met with the condition in a female subject. Mr. LawsonTait in some remarks which he made on the case said thatwith all his experience of women’s diseases he had neverbefore seen this malformation in a female. On referring to theexperiences of others I find that the late Mr. Earle in a clinicallecture on the subject said : ’’ This is the only instance Ihave witnessed in a female, although I have seen severalmales. In looking for authorities on the subject I find only8 recorded instances of similar malformation in females,whilst no less than 60 cases of males are related by different authorities." St. Hilaire 3 calculates that one quarter of thecases thus affected are females. Martin and Taylor 4 statethat "exstrophy is usually observed in the male, very rarelyin the female," No figures are, however, given. Wood’sstatistics may therefore be accepted as approximately correctand the malformation be regarded as comparatively rare inthe female. In the present instance for more than a yearthe urine has been voided per vaginam apparently withoutdiscomfort to the patient, but whether as she approachespuberty the same immunity will continue remains to be seen.It is within the range of possibility that as time goes on theopenings of one or both ureters into the vagina may becomestenosed and that hydronephrosis or ascending pyelitis mayresult, but at present there is no evidence of any such com-
plication. If one may be allowed to draw any inferencefrom a single case my experience leads me to advocate thetransplantation of the ureters into the vagina as a methodof treatment to be considered in ectopion vesicæ occurring infemale subjects, as the operations are readily performed andthe results are so far satisfactory that they add materially tothe comfort of the patient and to those who have the chargeof her.
1 Heath’s Dictionary of Practical Surgery, vol. i.2 London Medical and Surgical Journal, vol. i., 1828.
3 Histoire Générale et Particulière des Anomalies de l’Organisationchez l’Homme et les Animaux, Paris.
4 American Text-book of Genito-Urinary Diseases, 1898.
Medical Societies.PATHOLOGICAL SOCIETY OF LONDON.
Cystic Accessory Thyroid Body.-Molluseum Fibrosum asso-ciated ?vith Neuroma.-Fracture cf the Cervical Spine.Cysts of the Suprarenal Body.-Tuberculous Cliolangitis. -M2cltiloceclar Cyst in the Hernial Sac.A MEETING of this society was held on Jan. 17th, the
President, Dr. PAYNE, being in the chair.Mr. A. E. BARKER presented specimens from a case of
Cystic Accessory Thyroid Body, already reported in 1896 tathe society, and which had since terminated in d2ath. Theywere removed at various times after 1896 as recurrences of
very slow development and of a very low order of malignancyin every other respect. The patient, a man apparentlyotherwise in the best of health, was operated on by MrBarker for the first time in October, 1889, when he was fiftyyears of age. The tumour was then enormous and had begunnine years before (1880) in a small nodule just above theinner end of the left clavicle. The operation and the clinicaldetails of the growth together with the microscopical struc-ture of the mass removed were reported in the BritishMedical Journal of June 21st, 1898. Although the patientremained in excellent health several recurrences took placeand were removed between 1889 and 1896 when the operatorreported the sequel to the society. Since then several otherrecurrences have taken place slowly and have been removed.Finally, in August, 1898, a large swelling, apparently aneffusion of blood, appeared at the root of the neck pressingupon the larynx and causing fatal dyspnoea. This effusion.was probably due to rupture of some of the delicate vessels.in the intracystic papillary growths already described. The
pathological interest of the case lies in the fact of the slowdevelopment of the tumour in the first instance lasting over-nine years and its recurrence in the glands of the neckduring the following nine years ; finally, in its destroy-ing life not by generalisation or cachexia but by an
accidental hæmorrhage pressing upon the air passages.--Mr. BERRY said that he thought the case was unique in its.long duration-eighteen years. Clinically these malignantadenomata might be -regarded as semi-malignant. Theywere entirely different from ordinary’sarcoma and carcinomaof the thyroid, cases of which usually ran their course withina year, and in one case which he had seen in three months.Such cases rarely came under the notice of the surgeon atan operable period. If the larynx, trachea, or pharynx wereinvolved he thought the formidable operations sometimesundertaken were hardly justifiable. The question of whethera thyroid tumour was adherent to the pharynx was often.very difficult to determine until the tumour was exposedduring the operation. He asked what was the relation ofthe sterno - mastoid and of the carotid vessels tothe tumour and whether there had been any implication ofthe recurrent laryngeal nerves,-Mr. SHATTOCK said thatthere were exceptions to the , rule that tumours of high;differentiation were of low malignancy and also to the rule ofthe duration of carcinomata stated by Mr. Berry. Hementioned a case which was operated on by Mr. Bryant. Atumour was removed, probably from an accessory thyroid,which proved to be a carcinoma of extremely simplestructure. Glands in the neck had been removed since ontwo occasions but although three years had passed there hadbe: no recurrence.-Mr. BARKER, in reply, said that thesterno-mastoid was adherent to the front and side of the-
growth. The vessels were directly under the tumour. The
patient was hoarse so that the recurrent laryngeal nerve wasprobably pressed on.
Mr. T. CARWARDINE (Clifton) showed ’Lantern Slides andSections from a case of Molluscum Fibrosum associated witha large Neuroma of the Outer Cord of the Brachial Plexus.and gland-like tumours, probably neuromata, in the axillæ,groins, and elsewhere. In addition to numerous molluscous.nodules there were many pigmented patches in various partsof the body. There was a large tumour in the posteriortriangle of the neck which inconvenienced the patient bysevere shooting pains referred to the arm. The tumour wasexcised and proved to be a soft fibroma growing from thesheath of the outer cord of the brachial plexus. The
