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A CASE OF IODISM
820 morning of Nov. 29th he became unconscious and was brought to hospital. When first seen by one of us (G. B.) he was unconscious
and could not be roused. He was thin. pale, and had a coated tongue, his bowels not having moved since the onset of the His head was attack, and his temperature was 101 F. retracted and his neck muscles stiff. His pupils were ciilated and did not react to light. His knee-jerks were increased, but there was no ankle-clonus, and the plantar reflex was normal. Kernig’s sign was present and there was retention of urine. A lumbar puncture was performed and 20 c.cm. of cerebro-spinal fluid drawn off under considerable pressure. The fluid was stightly greenish in colour, very turbid, and contained an enormous number of polymorphs. A portion of the duid was sent for bacterial examination to one of us (E. S. It.). who reported that a direct smear showed a very few Gram-positive diplococci. Accordingly antipneumococcal serum was at once injected into the cisterna magna. Xext morning the clinical condition was unchanged, except for the temperature having dropped to 99° F. The bacterial report was received that a Gram-negative bacillus had grown front the fluid and was probably a contamination. A second cisternal puncture was performed, the fluid was drawn off for another examination and more serum was injected. On the following morning the patient’s condition was worse, his temperature being 104° F. and his pulse weak. A third intrathecal injection of serum was given : but the temperature continued to rise, and in the afternoon it reached 108° F. just before death supervened. Xo post-mortem examination of the body could be made.
Laboratory Findings. When the first specimen of lumbar fluid was received direct smears (Gram stain) were made in addition to culture A careful search of the on blood-agar and glucose brotli. smears in addition to the numerous pus cells revealed what appeared to be Gram-positive diplococci—very few in number—and a. provisional diagnosis of pneumococcus was made. However, both liquili and solid media gavepure cult ures of a Gram-negative bacillus. There were only a few colonies on the blood-agarplates. although the purulent ftuid had been spread thickly, and this perhaps accounts for the t’aiture to find the bacillus in direct smears. This was thought at first to he merely a contamination, but the second specimen of the gave exactly the same organisms. Examination for the tubercle bacillus was negative in both cases. The characteristics of the above organisms were as follows : A Gram-negative motile tiacillus morphologically resembling B. coli. The colonics on agar were large, white, and conftuent. and grew in a series of concentric waves. In broth there was a general turbidity with a putrid odour. There
A CASE BY MATTHEW THE
following
hæmolysis no
blood-agar.
Reaclinons.—Acid and
Fermentotion
lævulose;
m
and saccharose. Indol
reagent)on
gas
on
glucose
and
change with maltose. mannite. dulcite, lactose. a
Ehrlich’s broth after several not found when ordinary tryptic Gelatin was liquefied.
was
produced
in faint traces
special peptone (difco)
days’ growth, but was digest broth was used.
The classification of tlm proteus group based on either fermentation reactions or indel production is extremely unsatisfactory nt present, but the above organism corresponds fairly closely tu Proteus mirabilis in Bergey’s classification, or into group I. according to Besson. In our opinion the Gram-positive bodies seen in the smears were certainly artefacts, such as are often lt seems impossible to seen in films containing pus. believe that they could have been living pneumococci, as we have never failed to grow such (from cerebro-
spinal fluids) by inoculating it liberally into glucose It may be argued that. these were dead brotli. pneumococci, hnt in this case some signs of clinical improyement would have been expected, and it is hard to see how they could have disappeared completely fromthecerebro-spinal fluid in the 21 hours between the two punctures. On the other hand, it is difficult to state with certainty that the proteus organism was the cause of the fatal meningitis, but the fact must be significant that it was isolated in pure culture on two successive occasions. References.—1. Neal: Amer. Jour. Med. Sci., 1926, 172-7 40. Popa: Compt. rend. Soc. de Biol., 1925, 92-1082. 3. Bischoff and Brekenfeld: Ztschr. f. Kindcrh., 1925, 39-421. 4. Anderson: Jour. Path. and Bact., 1921, 24-478. Manual of Determinative Bacteriology, 1923. 5. Bergey: 6. Besson: Technique Microbiologique et Serothérapique, 1924. 2. Irimonoiu and
MASSER, M.B., CH.B LEEDS. has several interesting features.
case
ex-soldier, aged 31, who was receiving a pension for nephritis. came to me comptaining of persistent headache, general malaise and debility, gastro-intestinal discomfort, and poor alrpetite. Examination showed him to have albuniinuria and high blood pressure, to which hissymptoms An
war
attributed. a low protein and nuclein diet, and was given He was put on gr.5 potassium iodide three times daily. Four days later I was called to his house. The patient was iii bed and conlplaining of severe running from the nose, inflammation wc’re
right eye, and a sweiling on etther side of the neck. Examination showed conjunctivitis of the right eye and coryza, an acutely injected and œdematous throat. and a painless hilateral cervical adenitis. The tongue was thickty furred. The chest was norma) and temperature was normal. There was no rash visible, nor was there any history of chill. in the
scmnptoms were apparently due to iodism. they rapidly subsided on the cessation uf the iodides. The interesting features uf the case are the painless cervical glandular enlargement, which «-as the most prominent of the patient’s symptoms, and the possihility of the toxic symptoms being due to defective elimination of iodides by the damaged kidneys. The
as
A CASE OF
POST-MORTEM
CÆSAREAN
WITH DELIVERY
BY I. R. ROSIN, HOUSE
fluid
was no
OF IODISM
THE
unusual
following
SECTION,
OF A LIVE CHILD.
M.B., B.CH.DUB.,
SURGEON, THE INFIRMARY, BURY.
is
brief account ofit somewhat
a
case.
Mrs. T... K., aged 30 years, was admitted a- an emergency to Bury Infirmary on June 28th, 1926. in a state of unconsciousness. That morning at O o’clock her husband had gone off to work as usual. leaving her asleep in bed. At about 9.15 A.M. it appears that " she got out of bed and fell heavily to the floor in a queer condition." according to the littte daughter who immediately catted in a neighbour. The latter, knowing her to be pregnant and expecting shortly," called in the midwife, who immediately sent for a doctor. The medical man ordered her removal to hospital, where she was put tohe(L: but within a few minutes of her admission, while she was being examined, the faint trace of life still present case
"
fickered out.
Although realising that the patient was dead,T persevered for 15 minuter in an attempt to resuscitate her by iirtiilcial respiration and administration of oxygen. and hypodermic All these injections of strychnine. digitalin. and I)itititritt. were of no avail. Palpation of the abdomen during this time revealed tumultuous movements on the part of the fœtus and the foetal heart could be heard beating at the rate of 156 beat;; per rninttte. Under the circumstances. 1 decided to perform Caesarean section and delivered a full-time male child—in a state of asphyxia livida.—a quarter of an hour after the mother’s death. Twenty minutes of artificial respiration and alternate immersions in hot, and ci)l(l baths revived the child and he cried lustily. He weighed 7 lb., and has since made normal progress. At the post-mortem examination of the mother, the liver was found to be enlarged and studded with small hiemorrhages ; the spleen and kidneys were acutely inflamed, and the heart nauscle was soft and showed signs of fatty degeneration. The brain, on removal, appeared perfectly normal, but it was found that the entire left lateral ventricle was tilled with a large recent blood clot.. I am ruuch indebted to Dr. J. C. Turnbull, honorary obstetric surgeon to the Bnry Infirmary, under whose care the case was admitted, for permission to publish these details.
and could not be roused. He was thin. pale, and had a coated tongue, his bowels not having moved since the onset of the His head was attack, and his temperature was 101 F. retracted and his neck muscles stiff. His pupils were ciilated and did not react to light. His knee-jerks were increased, but there was no ankle-clonus, and the plantar reflex was normal. Kernig’s sign was present and there was retention of urine. A lumbar puncture was performed and 20 c.cm. of cerebro-spinal fluid drawn off under considerable pressure. The fluid was stightly greenish in colour, very turbid, and contained an enormous number of polymorphs. A portion of the duid was sent for bacterial examination to one of us (E. S. It.). who reported that a direct smear showed a very few Gram-positive diplococci. Accordingly antipneumococcal serum was at once injected into the cisterna magna. Xext morning the clinical condition was unchanged, except for the temperature having dropped to 99° F. The bacterial report was received that a Gram-negative bacillus had grown front the fluid and was probably a contamination. A second cisternal puncture was performed, the fluid was drawn off for another examination and more serum was injected. On the following morning the patient’s condition was worse, his temperature being 104° F. and his pulse weak. A third intrathecal injection of serum was given : but the temperature continued to rise, and in the afternoon it reached 108° F. just before death supervened. Xo post-mortem examination of the body could be made.
Laboratory Findings. When the first specimen of lumbar fluid was received direct smears (Gram stain) were made in addition to culture A careful search of the on blood-agar and glucose brotli. smears in addition to the numerous pus cells revealed what appeared to be Gram-positive diplococci—very few in number—and a. provisional diagnosis of pneumococcus was made. However, both liquili and solid media gavepure cult ures of a Gram-negative bacillus. There were only a few colonies on the blood-agarplates. although the purulent ftuid had been spread thickly, and this perhaps accounts for the t’aiture to find the bacillus in direct smears. This was thought at first to he merely a contamination, but the second specimen of the gave exactly the same organisms. Examination for the tubercle bacillus was negative in both cases. The characteristics of the above organisms were as follows : A Gram-negative motile tiacillus morphologically resembling B. coli. The colonics on agar were large, white, and conftuent. and grew in a series of concentric waves. In broth there was a general turbidity with a putrid odour. There
A CASE BY MATTHEW THE
following
hæmolysis no
blood-agar.
Reaclinons.—Acid and
Fermentotion
lævulose;
m
and saccharose. Indol
reagent)on
gas
on
glucose
and
change with maltose. mannite. dulcite, lactose. a
Ehrlich’s broth after several not found when ordinary tryptic Gelatin was liquefied.
was
produced
in faint traces
special peptone (difco)
days’ growth, but was digest broth was used.
The classification of tlm proteus group based on either fermentation reactions or indel production is extremely unsatisfactory nt present, but the above organism corresponds fairly closely tu Proteus mirabilis in Bergey’s classification, or into group I. according to Besson. In our opinion the Gram-positive bodies seen in the smears were certainly artefacts, such as are often lt seems impossible to seen in films containing pus. believe that they could have been living pneumococci, as we have never failed to grow such (from cerebro-
spinal fluids) by inoculating it liberally into glucose It may be argued that. these were dead brotli. pneumococci, hnt in this case some signs of clinical improyement would have been expected, and it is hard to see how they could have disappeared completely fromthecerebro-spinal fluid in the 21 hours between the two punctures. On the other hand, it is difficult to state with certainty that the proteus organism was the cause of the fatal meningitis, but the fact must be significant that it was isolated in pure culture on two successive occasions. References.—1. Neal: Amer. Jour. Med. Sci., 1926, 172-7 40. Popa: Compt. rend. Soc. de Biol., 1925, 92-1082. 3. Bischoff and Brekenfeld: Ztschr. f. Kindcrh., 1925, 39-421. 4. Anderson: Jour. Path. and Bact., 1921, 24-478. Manual of Determinative Bacteriology, 1923. 5. Bergey: 6. Besson: Technique Microbiologique et Serothérapique, 1924. 2. Irimonoiu and
MASSER, M.B., CH.B LEEDS. has several interesting features.
case
ex-soldier, aged 31, who was receiving a pension for nephritis. came to me comptaining of persistent headache, general malaise and debility, gastro-intestinal discomfort, and poor alrpetite. Examination showed him to have albuniinuria and high blood pressure, to which hissymptoms An
war
attributed. a low protein and nuclein diet, and was given He was put on gr.5 potassium iodide three times daily. Four days later I was called to his house. The patient was iii bed and conlplaining of severe running from the nose, inflammation wc’re
right eye, and a sweiling on etther side of the neck. Examination showed conjunctivitis of the right eye and coryza, an acutely injected and œdematous throat. and a painless hilateral cervical adenitis. The tongue was thickty furred. The chest was norma) and temperature was normal. There was no rash visible, nor was there any history of chill. in the
scmnptoms were apparently due to iodism. they rapidly subsided on the cessation uf the iodides. The interesting features uf the case are the painless cervical glandular enlargement, which «-as the most prominent of the patient’s symptoms, and the possihility of the toxic symptoms being due to defective elimination of iodides by the damaged kidneys. The
as
A CASE OF
POST-MORTEM
CÆSAREAN
WITH DELIVERY
BY I. R. ROSIN, HOUSE
fluid
was no
OF IODISM
THE
unusual
following
SECTION,
OF A LIVE CHILD.
M.B., B.CH.DUB.,
SURGEON, THE INFIRMARY, BURY.
is
brief account ofit somewhat
a
case.
Mrs. T... K., aged 30 years, was admitted a- an emergency to Bury Infirmary on June 28th, 1926. in a state of unconsciousness. That morning at O o’clock her husband had gone off to work as usual. leaving her asleep in bed. At about 9.15 A.M. it appears that " she got out of bed and fell heavily to the floor in a queer condition." according to the littte daughter who immediately catted in a neighbour. The latter, knowing her to be pregnant and expecting shortly," called in the midwife, who immediately sent for a doctor. The medical man ordered her removal to hospital, where she was put tohe(L: but within a few minutes of her admission, while she was being examined, the faint trace of life still present case
"
fickered out.
Although realising that the patient was dead,T persevered for 15 minuter in an attempt to resuscitate her by iirtiilcial respiration and administration of oxygen. and hypodermic All these injections of strychnine. digitalin. and I)itititritt. were of no avail. Palpation of the abdomen during this time revealed tumultuous movements on the part of the fœtus and the foetal heart could be heard beating at the rate of 156 beat;; per rninttte. Under the circumstances. 1 decided to perform Caesarean section and delivered a full-time male child—in a state of asphyxia livida.—a quarter of an hour after the mother’s death. Twenty minutes of artificial respiration and alternate immersions in hot, and ci)l(l baths revived the child and he cried lustily. He weighed 7 lb., and has since made normal progress. At the post-mortem examination of the mother, the liver was found to be enlarged and studded with small hiemorrhages ; the spleen and kidneys were acutely inflamed, and the heart nauscle was soft and showed signs of fatty degeneration. The brain, on removal, appeared perfectly normal, but it was found that the entire left lateral ventricle was tilled with a large recent blood clot.. I am ruuch indebted to Dr. J. C. Turnbull, honorary obstetric surgeon to the Bnry Infirmary, under whose care the case was admitted, for permission to publish these details.