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TREATMENT OF ACTINOMYCOSIS
574 to the vertical, when the plane of the maxillary teeth will be found to be approximately horizontal. To prevent slipping, the " seat " may be tilted back slightly, most dental chairs permitting this while still keeping the back at the required angle. The anaesthetist should be well to the patient’s left side, from which position he can best observe the condition of the patient and the course of the operation, instead of playing blind-man’sbuff while balancing on one leg. Finally, it should be emphasised that a faucial pack is but one line of defence. The fingers of the left hand of the operator, ensheathing the blade of the forceps and moving to intercept all fragments which crumble or disintegrate, are the real guardians of the larynx. Plastic and Jaw Centre, B. W. PICKLING Hill End Hospital, N. L. ROWE. St. Albans, Herts.
TREATMENT OF ACTINOMYCOSIS SiB,—Dr. Shorvon is to be heartily congratulated on his account of a patient with actinomycosis of the liver steered by good management to complete recovery (March 20, p. 439). He was undoubtedly. wise to use all the known methods of treatment at the same time, as the condition is too serious to allow of any experiment. The multiplicity of remedies employed makes it, however, difficult to assess their relative values for future guidance. Probably different remedies would be effective in different are numerous patients, Colebrook having shown that there " strains, or species, of the " ray fungus pathogenic in man.
Many years ago I was faced with the problem of treating a middle-aged farmer who was in an advanced stage of lower abdominal actinomycosis and was almost moribund. Very little surgical interference was possible, and the patient was sensitive to iodine and its compounds, so .that none could be used. It was before the days of the antibiotic drugs. The patient was accordingly treated by Dr. Finzi with small doses of irradiation with radium plaques, and after the organism had been grown he was also given large doses of an autogenous vaccine. With this treatment the patient gained 1 Ib. a week in weight steadily over several months and finally went home quite well. The injection of vaccines produced no constitutional reaction whatever, and we were inclined to attribute the patient’s recovery almost entirely to the irradiation. The tissue reaction to actinomycosis forms
a
against all drugs, even those that are in the patient’s circulating fluids. Irradiation, to which the organism is usually sensitive, is therefore the logical answer, but the dosage must be kept small since the treatdense barrier
ment will have to be prolonged. Potassium iodide, the time-honoured remedy, is still commonly used, but there is little to be said in its favour, and it is probably useless. GEOFFREY KEYNES. London, W.1. POISONING BY FOOD PLANTS SiR,-During the summer of 1947 at Dresden a benign, syndrome suddenly appeared,. due apparently to the excessive consumption of two plants. Observations were made on three inpatients and three outpatients. For many weeks these patients had been eating, two to three times a day, two weeds, Chenopodium album and Atriplex patula, which are closely related to the garden spinaches and beets and make a fairly tasty vegetable dish. They grow abundantly on the ruins and rubble-heaps of Dresden and became a popular dish during the food shortage of the spring and summer. CASE 1.—A man, aged 71, was admitted on Aug. 2 with the history that since May he had eaten, three times a day, large quantities of both plants, but less of the atriplex, this being less abundant than the chenopodium. Gradual onset of fatigue and weakness. On Aug. 1 acute onset of oedema of face and hands, increasing rapidly in the next 24 hours. On adrmrissiorz yellow pigmentation of skin, especially of palms and soles ; pharyngeal wall also pigmented. Conspicuous oedema of face, particularly of eyelids, which could not be opened ; scalp and hands also cedematous. Generalcondition unimpaired; mentally bright and lively. Blood-pressure
125/85 ; erythrocyte-sedimentation rate (E.S.R.)5 and 13 mm. after 1 and 2 hours respectively ; Hb 77%(Sahli) ; red cells 3,820,000 per c.mm. ; colour-index 1-01 ; white cells 5800 per c.mm. (stab cells 2O{" segmented cells 65%, lymphocytes
33%); serum-protein by copper-sulphate method 6-5 g. per 100 ml. ; serum-bilirubin 0.51 mg. per 100 ml. TakataAra test negative. Fractional test-meal with caffeine: no free HCl, total acid 20. Urine normal. Progress.Patient made a rapid recovery on ordinary hospital diet, with addition of ’Betaxin ’ 1 ml. daily and a mixture of pepsin and HCl. He left in good condition after 4 weeks in hospital. CASE 2.-A woman, sister of case 1, and living with him, admitted about Aug. 4 with a similar history, except that she had eaten smaller amounts of the weeds. On admissio2: pigmentation and oedema as in case 1, but cedema less severe. General condition and mentality good. Blood-pressure 125/70; B.s.R.99 and 20 mm. afterand 2 hours respectively ; Hb 82% ; red cells 4,040,000 per c.mm. ; colour-index 1-02; white-cell and differential counts normal: serumprotein 6-9 g. per 100 ml. Progress.-Patient discharged herself on Aug. 14, feeling well; cedema had disappeared, but pigmentation was still present. CASE 3.-A male concrete worker, aged 19, was admitted on July 7 with several weeks’ history of increasing weakness. He had eaten both weeds daily since’April. 0 cMM&Ko; : findings as in cases 1 and 2. Blood-pressure IlOj75; fundi normal. E.s.R. 8 and 15 mm. after I and 2 hours respectively ; Hb 83% ; red cells 4,250,000 per c.mm.; colour-index 0-99 ; white cells 5200 per c.mm. ; differential count normal;’ serum-protein 7-2 g. per 100 ml. ; albumin 4-37 g. per 100 ml., globulin 2-83 g. per 100 ml. Fractional test-meal with caffeine : no free HCI, total acid 6. Blood-sugar 100 mg. per 100 ml. Progress.-Patient recovered on hospital diet and was discharged on Sept. 6 feeling well ; pigmentation of skin had nearly disappeared. CASE 4.-The mother of case 3 attended as an coutpatient with similar but less pronounced signs and symptoms. Both she and her husband, who had a similar condition but not severe enough to make him see a doctor, had eaten large quantities of the two weeds. CASES 5 and 6 reported with signs and symptoms identical with those of the other cases, but the oedema disappeared in a few days with no special treatment. was
,
A case of cardiac oedema is reported for comparison with the preceding cases : A woman was admitted with cardiac failure and cedema of legs. Palms and soles showed same pigmentation as in cases 1-6, but there was no oedema of face. Patient, who was a good witness, said that for 4 months she had eaten wild vegetables, nettles, dandelions, and yarrow. She recovered
rapidly with digitalis and was discharged in good condition, with pigmentation still persisting. There are two striking characteristics of this syndrome -the yellow pigmentation and the oedema. The pigmentation of peculiar distribution does not appear to have any special significance, since it is characteristic of an excessive intake of vegetable pigments and develops after overfeeding with other green vegetables and with The acute oedema of the carrots, citrous fruits, &c. face and hands associated with general weakness may, however, be taken as characteristic features of poisoning from
an
excessive intake of these two members of the
chenopodiaceae. The onset of oedema in July. when the plants come into flower, suggests that the flowers rather than the leaves contain the toxic agent, or that the plants develop the toxin at the flowering time. There is no clue to which of the plants is responsible for the syndrome; neither is known to contain any toxic agent, though saponins are known to occur in certain species-e.g., A. hortensis.
’
Kobert, citing Matignon, describes under the name of atriplicism " a syndrome occurring in China which is almost identical with the present syndrome and is attributed to the consumption of Atriplex littoralis. The symptoms are said to appear 10-20 hours after eating the whole plant, the young shoots being regarded as harmless. In our cases the whole plant had always been eaten. In the Chinese cases the cedema appeared on the exposed parts, and it is suggested that the toxin may be activated by sunlight. Protein undernutrition does not appear to be a factor in the causation of the syndrome, since the serumprotein levels of our cases were within normal limits. "
1. Kobert, E. R.
Lehrbuch der Intoxikationen.
Stuttgart, 1906.
TREATMENT OF ACTINOMYCOSIS SiB,—Dr. Shorvon is to be heartily congratulated on his account of a patient with actinomycosis of the liver steered by good management to complete recovery (March 20, p. 439). He was undoubtedly. wise to use all the known methods of treatment at the same time, as the condition is too serious to allow of any experiment. The multiplicity of remedies employed makes it, however, difficult to assess their relative values for future guidance. Probably different remedies would be effective in different are numerous patients, Colebrook having shown that there " strains, or species, of the " ray fungus pathogenic in man.
Many years ago I was faced with the problem of treating a middle-aged farmer who was in an advanced stage of lower abdominal actinomycosis and was almost moribund. Very little surgical interference was possible, and the patient was sensitive to iodine and its compounds, so .that none could be used. It was before the days of the antibiotic drugs. The patient was accordingly treated by Dr. Finzi with small doses of irradiation with radium plaques, and after the organism had been grown he was also given large doses of an autogenous vaccine. With this treatment the patient gained 1 Ib. a week in weight steadily over several months and finally went home quite well. The injection of vaccines produced no constitutional reaction whatever, and we were inclined to attribute the patient’s recovery almost entirely to the irradiation. The tissue reaction to actinomycosis forms
a
against all drugs, even those that are in the patient’s circulating fluids. Irradiation, to which the organism is usually sensitive, is therefore the logical answer, but the dosage must be kept small since the treatdense barrier
ment will have to be prolonged. Potassium iodide, the time-honoured remedy, is still commonly used, but there is little to be said in its favour, and it is probably useless. GEOFFREY KEYNES. London, W.1. POISONING BY FOOD PLANTS SiR,-During the summer of 1947 at Dresden a benign, syndrome suddenly appeared,. due apparently to the excessive consumption of two plants. Observations were made on three inpatients and three outpatients. For many weeks these patients had been eating, two to three times a day, two weeds, Chenopodium album and Atriplex patula, which are closely related to the garden spinaches and beets and make a fairly tasty vegetable dish. They grow abundantly on the ruins and rubble-heaps of Dresden and became a popular dish during the food shortage of the spring and summer. CASE 1.—A man, aged 71, was admitted on Aug. 2 with the history that since May he had eaten, three times a day, large quantities of both plants, but less of the atriplex, this being less abundant than the chenopodium. Gradual onset of fatigue and weakness. On Aug. 1 acute onset of oedema of face and hands, increasing rapidly in the next 24 hours. On adrmrissiorz yellow pigmentation of skin, especially of palms and soles ; pharyngeal wall also pigmented. Conspicuous oedema of face, particularly of eyelids, which could not be opened ; scalp and hands also cedematous. Generalcondition unimpaired; mentally bright and lively. Blood-pressure
125/85 ; erythrocyte-sedimentation rate (E.S.R.)5 and 13 mm. after 1 and 2 hours respectively ; Hb 77%(Sahli) ; red cells 3,820,000 per c.mm. ; colour-index 1-01 ; white cells 5800 per c.mm. (stab cells 2O{" segmented cells 65%, lymphocytes
33%); serum-protein by copper-sulphate method 6-5 g. per 100 ml. ; serum-bilirubin 0.51 mg. per 100 ml. TakataAra test negative. Fractional test-meal with caffeine: no free HCl, total acid 20. Urine normal. Progress.Patient made a rapid recovery on ordinary hospital diet, with addition of ’Betaxin ’ 1 ml. daily and a mixture of pepsin and HCl. He left in good condition after 4 weeks in hospital. CASE 2.-A woman, sister of case 1, and living with him, admitted about Aug. 4 with a similar history, except that she had eaten smaller amounts of the weeds. On admissio2: pigmentation and oedema as in case 1, but cedema less severe. General condition and mentality good. Blood-pressure 125/70; B.s.R.99 and 20 mm. afterand 2 hours respectively ; Hb 82% ; red cells 4,040,000 per c.mm. ; colour-index 1-02; white-cell and differential counts normal: serumprotein 6-9 g. per 100 ml. Progress.-Patient discharged herself on Aug. 14, feeling well; cedema had disappeared, but pigmentation was still present. CASE 3.-A male concrete worker, aged 19, was admitted on July 7 with several weeks’ history of increasing weakness. He had eaten both weeds daily since’April. 0 cMM&Ko; : findings as in cases 1 and 2. Blood-pressure IlOj75; fundi normal. E.s.R. 8 and 15 mm. after I and 2 hours respectively ; Hb 83% ; red cells 4,250,000 per c.mm.; colour-index 0-99 ; white cells 5200 per c.mm. ; differential count normal;’ serum-protein 7-2 g. per 100 ml. ; albumin 4-37 g. per 100 ml., globulin 2-83 g. per 100 ml. Fractional test-meal with caffeine : no free HCI, total acid 6. Blood-sugar 100 mg. per 100 ml. Progress.-Patient recovered on hospital diet and was discharged on Sept. 6 feeling well ; pigmentation of skin had nearly disappeared. CASE 4.-The mother of case 3 attended as an coutpatient with similar but less pronounced signs and symptoms. Both she and her husband, who had a similar condition but not severe enough to make him see a doctor, had eaten large quantities of the two weeds. CASES 5 and 6 reported with signs and symptoms identical with those of the other cases, but the oedema disappeared in a few days with no special treatment. was
,
A case of cardiac oedema is reported for comparison with the preceding cases : A woman was admitted with cardiac failure and cedema of legs. Palms and soles showed same pigmentation as in cases 1-6, but there was no oedema of face. Patient, who was a good witness, said that for 4 months she had eaten wild vegetables, nettles, dandelions, and yarrow. She recovered
rapidly with digitalis and was discharged in good condition, with pigmentation still persisting. There are two striking characteristics of this syndrome -the yellow pigmentation and the oedema. The pigmentation of peculiar distribution does not appear to have any special significance, since it is characteristic of an excessive intake of vegetable pigments and develops after overfeeding with other green vegetables and with The acute oedema of the carrots, citrous fruits, &c. face and hands associated with general weakness may, however, be taken as characteristic features of poisoning from
an
excessive intake of these two members of the
chenopodiaceae. The onset of oedema in July. when the plants come into flower, suggests that the flowers rather than the leaves contain the toxic agent, or that the plants develop the toxin at the flowering time. There is no clue to which of the plants is responsible for the syndrome; neither is known to contain any toxic agent, though saponins are known to occur in certain species-e.g., A. hortensis.
’
Kobert, citing Matignon, describes under the name of atriplicism " a syndrome occurring in China which is almost identical with the present syndrome and is attributed to the consumption of Atriplex littoralis. The symptoms are said to appear 10-20 hours after eating the whole plant, the young shoots being regarded as harmless. In our cases the whole plant had always been eaten. In the Chinese cases the cedema appeared on the exposed parts, and it is suggested that the toxin may be activated by sunlight. Protein undernutrition does not appear to be a factor in the causation of the syndrome, since the serumprotein levels of our cases were within normal limits. "
1. Kobert, E. R.
Lehrbuch der Intoxikationen.
Stuttgart, 1906.