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A CASE OF PURULENT PERITONITIS ASSOCIATED WITH EMPYEMA; RECOVERY.
1096
DR. H. ASHBY: PURULENT PERITONITIS ASSOCIATED WITH EMPYEMA. I
observations in a scientific spirit, and although the wordsextent of the inflammatory lesions. She was bright and "internal secretion" are not once mentioned in his cheerful when not in pain ; the vomiting had ceased, her original paper yet one cannot but feel they are writ features were not drawn, nor were there any signs of collapse. large across it. The records of our society show that The next 12 days produced no improvement and when I aw this spirit of observation has never been wanting in our her a second time (on the twenty-third day of her illness) it Fellows. It is only necessary to recall such names as was clear that the abdomen contained a large quantitv of William Blizzard, Clift-who though not belonging to our fluid ; the flanks were bulging and a well-marked fluid thrill society attended its meetings-the Babingtons, Richard could be obtained from side to side. The superficial veins Bright, John Hilton, and Jonathan Hutchinson to prove our were distended and a zone of redness was present around the intellectual affiliation with John Hunter. Let us in our turn umbilicus. The left pleura was full of fluid, being dull on see that we pass on the sacred fire to those who will come percussion, and the heart was pushed over to the right. The after us, ever mindful of the words of the greatest Hunterian patch of pneumonia present on the right side at the last orator that in the world of thoughthe that is mortal may examination had disappeared. produce that which is immortal.’"84, Operation was at once decided upon and Mr. G. A. Wright next day evacuated 40 ounces of pus from the abdomen by inserting a tube at the umbilicus, but before his arrival the pus had penetrated the skin at this spot and some had escaped. A CASE OF PURULENT PERITONITIS A rib was excised and the empyema was drained at the same time. Much pus drained away from the tube in the abdomen ASSOCIATED WITH during the next few days but it ceased to flow before the end RECOVERY.1 of the week and the tube was removed. The draining of the empyema was a more tedious affair but a good recovery BY HENRY ASHBY, M.D., F.R.C.P. LOND., eventually resulted. PHYSICIAN TO THE MANCHESTER CHILDREN’s HOSPITAL. Dr. W. J. S. Bythell was good enough to make a very examination of the pus and also cultures in Professor S. .: careful I Del6 pine’s laboratory. He reported as follows :-"Peritoneal membranes are no means serous of INFLAMMATIONS by was thick and viscid, not settling into layers ; pale 1 pus there be double one confined to locality ; may always grey colour, inodorous. Microscopically, richer in ‘ greenish pleurisy, pleuro-pericarditis, peritonitis, or ccells than in fibrin ; crowded with cocci which were arranged In these in associated with pleurisy or pleuro-pneumonia. i tetrads and capsulated, staining extremely good, but c not coloured by eosin. A careful examination of cases the double or treble lesion is due to infection by microcapsules ] slides failed to reveal any pneumococci. Phagocytosis organisms which have been carried from one organ to"’10 another by the blood-stream, or in some cases (as fromvery good. No tubercle bacilli. Vigorous cultures of microc coccus obtained on agar and gelatin, the latter the left pleura to the pericardium) infection has occurred by withouttetragenus liquefaction ; films well stained by Gram’s fluid. In "pneumococcal septiemmia," pleuro- No direct contact. 1 colonies of pneumococcus. Empyemic pus, on standing, < a greyish-green precipitate, supernatant layer clear pneumonia, peritonitis, and meningitis have been found inideposited the same subject, though in an early stage, as death has ! &amber egrave; colour. Microscopically, richer in fibrin than in cells; resulted from toxaemia, before the lesions were far advanced.a a small number of pneumococci, varying a good deal in size, In other cases the streptococcus or the tubercle bacillus has and è staining reactions ; no chains. A few capsulated cocci, been the organism which has given rise to the multiplearranged è mostly in pairs with a few tetrads. Phagocytosis inflammation. ]moderately well marked. No tubercle bacilli. Cultures < These associated serous inflammations have no doubt aL on agar, small isolated colonies of (a) typical pneumococci, certain analogy to multiple joint inflammationsand thisi(b) large and opaque colonies of micrococcus tetragenus. circumstance has probably suggested the names of "poly-IGelatin stab cultures were characteristic and without liqueserositisor "polyorromenitis."2 It must, however, be ; faction. obvious that cases of multiple serous infiammation5 differr This was in many ways a remarkable case and the comwidely from one another as regards the infection presentt plete recovery which took place with such inflammatory and the organs attacked, and nothing but confusion canx lesions was certainly surprising. When first seen the case result from their being included under a common name.. looked like one of ’’ pneumococcal septicmia"" associated The following case is, I think, of interest as illustrating one3 with general peritonitis and double pleuro-pneumonia and form of combined serous innammation—viz., a purulentt the prognosis seemed to be of the gloomiest. But at no time inflammation occurring simultaneously in the peritoneumi was there any very marked collapse such as would have been and left pleura, fortunately ending in recovery. expected and the vomiting after it ceased during the first The patient was a girl, aged eight and a half years, whoo week was not again troublesome. was delicate and had suffered a good deal from attacks of f What was the significance of the micrococcus tetragenus bronchitis. She had been fairly well up to Sept. 10th, 1901,, in this case ?1 It is apparently often found in suppurations when she was seized suddenly with vomiting, diarrhoea,, about the neck and respiratory tract. Dr. Bythell tells me r that he has found it four times in the pus of empyemata (out and pain in the abdomen. When seen next day by her ,s medical attendant (Mr. A. W. Senior) the temperature was of 40 examinations), but in association with the pneumod coccus in all four cases and once or twice with other cocci as 103° F., the vomiting was incessant, the stools were foul and liquid, and there were cough and some expectoration ofIf staphylococcus aureus. I am not aware that it has been The vomiting ceased in a few days but the diarrhoea a noted before in the lymph or pus of peritonitis. In this case mucus. continued for a week and the temperature remained at from n it was associated with an inflammation which ran its course e without producing the grave constitutional symptoms which 103° to 104°, while great pain was complained of in the abdomen and left chest. There was also jaundice for a few ? once would naturally expect, but whether this coccus produces a milder inflammation than most other cocci it is not possible days during the first week of her illness. iWhen I first saw the patient on Sept. 21st her great comto say. Le Which serous membrane was first affected ? The periplaint was the severe pain which she was suffering in the abdomen ; this came on in paroxysms and was evidently very ’y toneum or pleura’?’I As far as the evidence goes they comsevere. 3s There were marked tympanites and great tenderness menced simultaneously and there is no evidence to show all over the abdomen. In the left chest there were signs of f which was primary. consolidation in the lower two-thirds of the lung posteriorly, Was the peritonitis really pneumococcal in origin, the r, with bronchial breathing and consonant rales. There was 1S organism perishing before the pus found its way out, as the also a patch of pneumonia at the extreme base on the right lt peritonitis had been in progress for some 23 or 24 days before side. The respirations were rapid, the temperature was 101°, 0, any bacteriological examinations were made? Certainly the and the pulse was 140. 1 must confess that I thought very ry case closely resembles one type of pneumococcal peritonitis al as described by M. Broca.3 This author publishes three badly of the case, looking upon it as one of "pneumococcal d, cases very similar clinically to mine in which the pneumoperitonitis " with double pneumonia. On the other hand, her general condition was wonderfully good considering the ae coccus was present in the pus. In one of his patients the symptoms of peritonitis followed a day or two after the 84 Sir James Paget : Hunterian Oration, 1877, p. 36. 3 Péritonite à pneumocoques, par M. Broca, Gazette Hebdomadaire 1 A paper read at a meeting of the Society for the Study of Disease de Médecine et Chirurgie, Oct. 21st, 1900; abstracted in the Archives de in Children on March 21st, 1902. 2 See Dr. F. decine des Enfants, May, 1901. Brit. Mé Med. Jour., 1900, vol. ii., p. 1693. Taylor :
EMPYEMA;
-
,
meningitis ,
,
’
.
-
"
.
DR. J. S. BURY: TWO CASES OF PARALYSIS AGITANS IN THE SAME FAMILY.
1097
crisis of an apical pneumonia, in the other two the symptoms attitude, tremors, and other symptoms of paralysis agitans. of the peritonitis came on without being preceded or accom- In both cases the tremor affected the hands and forearms, panied by any pulmonary lesion, but one of these patients the feet, and to a slight degree the head ; in the man the died from a post-peritoneal broncho-pneumonia ; the other legs also shook as they lay extended on the bed. The tremor two patients recovered. The symptoms in all three came on affected the hands much more than other parts ; it could be suddenly with vomiting, diarrhoea, fever, and pain in the controlled by a voluntary effort; it was absent during sleep, abdomen ; in a few days there was obviously a collection of very slight on waking in the morning, and worse towards fluid in the abdomen, redness appeared at the umbilicus, and night or after any exertion. It was not symmetrical on the there was a discharge of pus at this spot. The author points two sides ; thus, the man’s left hand trembled more than his out that this rapid formation of pus and ’’ fistulisation rapide right hand. The movements of the limbs were weaker than de 1’ombilic " is characteristic of a pneumococcic peritonitis ’ natural. The weakness was irregularly distributed ; thus, and that such cases are liable to be confounded with acuteI the grasp of the man’s right hand was weaker than enteric fever, tuberculous peritonitis, or appendicitis. M. that of his left, while the muscular power of his SlowBroca also reports a case in which there was a local collection left leg was weaker than that of his right. of pus in the abdominal wall and a case of diffuse general ness of movement, however, was perhaps more conspicuous peritonitis which was rapidly fatal, both of which were than weakness. This was especially noticeable as pneumococcal. This last case appears to have resembled the regards the head movements. Thus, when either patient case of Dr. J. H. Bryant which was reported in vol. i. of the looked to one side the eyes turned quickly but rotation of Transactions of the Society for the Study of Disease in the head was slowly performed. The muscles of both arms Children. As and legs showed increased irritability to tapping. It is interesting to note that all seven of the cases referred muscular stiffness in the limbs this was slight or to above were in girls. This may be only a curious absent ; in the man no rigidity of limb could be detected, in coincidence ; or is it possible that the infection may take his sister the muscles of the forearms appeared to be a little The fingers did not occupy the place, like a gonococcal infection, from the vagina to the more rigid than normal. " peritoneum ? My above cases illustrate ’the well-known usual " interosseal position but were slightly bent at all the observation that prognosis is very difficult in peritonitis; joints. It is to be noticed that in both cases the little the most promising cases often go unexpectedly to the bad, fingers presented a congenital deformity, their first phalangeal while every now and again a seemingly inevitably fatal case joints being rigidly flexed owing probably to shortening of makes a good recovery. their tendons. Both patients presented the characteristic I must express my great indebtedness to Mr. Senior of stooping attitude. In walking the man showed a slight Levenshulme for his notes of the case and to Dr. Bythell tendency to hurry forwards, while in the woman there was a for his careful examination of the pus. marked tendency to retropulsion. A very slight push on the chest made her walk backwards ; the pace increased at each Manchester. step until she lost her balance and fell into the arms of the nurse walking behind her. In both patients the knee-jerks TWO CASES OF PARALYSIS AGITANS IN were exaggerated and in the man a true ankle clonus was obtained on several occasions ; sometimes it was absent. No THE SAME FAMILY, IN WHICH IMindications of ataxia or of sensory disturbance could be PROVEMENT FOLLOWED THE detected and the skin apart from flushing and sweating presented a normal appearance. ADMINISTRATION OF The patients were treated by massage and by the adminisHYOSCINE. tration of hyoscine. At first this drug was given hypodermically, the dose being gradually increased from 2toth to Tioth BY JUDSON S. BURY, M.D. LOND., F.R.C.P.,
regards
of a grain, which was injected once a day. As the larger dose produced nausea, dryness of the mouth, and giddiness the injections were discontinued. Subsequently hyoscine was IN the following cases the chief points of interest are given in chloroform water by the mouth, as recommended by (1) the presence of typical symptoms of paralysis agitans in Dr. R. T. Williamson. At first I-!- 5v th of a grain was given twice daily. This dose was gradually increased to .16th of a. a brother and a sister ; (2) the onset of the symptoms at a Both patients took this amount without any ill comparatively early age ; and (3) the improvement which grain. effects and while they were taking hyoscine in this way they administration of each of the followed the hyoscine during appeared to be much better. They stated that they felt more two periods when it was given. comfortable and were less troubled than formerly with flushThe patients first entered my wards in the Manchester ings and restlessness. The tremor became less marked, as Royal Infirmary on Sept. 17th, 1900, and remained under shown in tracings taken before the administration of hyoscine treatment for 11 weeks. They were readmitted on Dec. 31:tt, and again after the drug had been taken for some time. 1901, and left on Feb. 5th, 1902. The man, 41 years of Dr. A. Ramsbottom (my house physician) and others who age, was formerly a mill-spinner but he was obliged had watched the cases thought that the attitude and gait to leave off work at the age of 35 years owing to were also improved by the treatment. weakness in his legs and a tendency to fall on to Judging from an experience of several cases I am inclined his face. These were the earliest symptoms to attract to agree with my friend Dr. Williamson that hyoscine is his attention. A year later he noticed that his legs were probably the most useful drug that has hitherto been tried shaking ; after a few months his arms began to tremble in the treatment of paralysis agitans. As a rule, it and subsequently he noticed that his head shook at times. diminishes or arrests the tremor, checks the troublesome He attributed his condition to working in a very hot room restlessness and the desire to change position, and relieves and then going out into the cold. His sister stated that her the "hot flushes." and unpleasant sensations of heat. It is illness began when she was about 18 years old. The tremors important to remember that hyoscine is a very powerful came on so gradually that she could not be sure when they drug and hence must be administered with great care. actually commenced, but at the age of 19 years they were so It is safer to give it by the mouth than to inject it bad that she was obliged to give up her work in the mill under the skin. Merck’s hyoscine hydrobromate is probably at which she had been engaged for several years. She the best preparation ; this should be given well diluted in attributed her illness to her occupation, which involved the chloroform water. "A prescription which is useful is oneconstant contact of her hands with wet and cold yarns. eighth of a grain of hyoscine hydrobromate in six ounces of Neither in the case of the brother nor in that of the sister chloroform water. At first two teaspoonfuls of this may be could any history of fright, or injury, or previous illness be given, then three, four, or five teaspoonfuls. If necessary obtained. The father of these patients was asthmatical ; the dose may be increased to six teaspoonfuls (-llth of a they did not know the cause of their mother’s death. One grain), providing toxic symptoms are not produced. The brother died from consumption at 24 years of age and another hyoscine is best given in the morning, just after breakfasr, brother died from influenza. They stated that two sisters Otnd again in the evening (just before going to bed) if the had suffered from paralysis agitans but no confirmation of patient is troubled with restlessness and sleeplessness during the statement could be obtained ; one of these sisters died bhe night."1 PHYSICIAN TO THE MANCHESTER ROYAL INFIRMARY.
at the age of 16 years and the other at the age of 26
years. Both
patients presented
the characteristic mask-like
face,
Manchester. 1
R. T. Williamson :
Paralysis Agitans,
1 01.
DR. H. ASHBY: PURULENT PERITONITIS ASSOCIATED WITH EMPYEMA. I
observations in a scientific spirit, and although the wordsextent of the inflammatory lesions. She was bright and "internal secretion" are not once mentioned in his cheerful when not in pain ; the vomiting had ceased, her original paper yet one cannot but feel they are writ features were not drawn, nor were there any signs of collapse. large across it. The records of our society show that The next 12 days produced no improvement and when I aw this spirit of observation has never been wanting in our her a second time (on the twenty-third day of her illness) it Fellows. It is only necessary to recall such names as was clear that the abdomen contained a large quantitv of William Blizzard, Clift-who though not belonging to our fluid ; the flanks were bulging and a well-marked fluid thrill society attended its meetings-the Babingtons, Richard could be obtained from side to side. The superficial veins Bright, John Hilton, and Jonathan Hutchinson to prove our were distended and a zone of redness was present around the intellectual affiliation with John Hunter. Let us in our turn umbilicus. The left pleura was full of fluid, being dull on see that we pass on the sacred fire to those who will come percussion, and the heart was pushed over to the right. The after us, ever mindful of the words of the greatest Hunterian patch of pneumonia present on the right side at the last orator that in the world of thoughthe that is mortal may examination had disappeared. produce that which is immortal.’"84, Operation was at once decided upon and Mr. G. A. Wright next day evacuated 40 ounces of pus from the abdomen by inserting a tube at the umbilicus, but before his arrival the pus had penetrated the skin at this spot and some had escaped. A CASE OF PURULENT PERITONITIS A rib was excised and the empyema was drained at the same time. Much pus drained away from the tube in the abdomen ASSOCIATED WITH during the next few days but it ceased to flow before the end RECOVERY.1 of the week and the tube was removed. The draining of the empyema was a more tedious affair but a good recovery BY HENRY ASHBY, M.D., F.R.C.P. LOND., eventually resulted. PHYSICIAN TO THE MANCHESTER CHILDREN’s HOSPITAL. Dr. W. J. S. Bythell was good enough to make a very examination of the pus and also cultures in Professor S. .: careful I Del6 pine’s laboratory. He reported as follows :-"Peritoneal membranes are no means serous of INFLAMMATIONS by was thick and viscid, not settling into layers ; pale 1 pus there be double one confined to locality ; may always grey colour, inodorous. Microscopically, richer in ‘ greenish pleurisy, pleuro-pericarditis, peritonitis, or ccells than in fibrin ; crowded with cocci which were arranged In these in associated with pleurisy or pleuro-pneumonia. i tetrads and capsulated, staining extremely good, but c not coloured by eosin. A careful examination of cases the double or treble lesion is due to infection by microcapsules ] slides failed to reveal any pneumococci. Phagocytosis organisms which have been carried from one organ to"’10 another by the blood-stream, or in some cases (as fromvery good. No tubercle bacilli. Vigorous cultures of microc coccus obtained on agar and gelatin, the latter the left pleura to the pericardium) infection has occurred by withouttetragenus liquefaction ; films well stained by Gram’s fluid. In "pneumococcal septiemmia," pleuro- No direct contact. 1 colonies of pneumococcus. Empyemic pus, on standing, < a greyish-green precipitate, supernatant layer clear pneumonia, peritonitis, and meningitis have been found inideposited the same subject, though in an early stage, as death has ! &amber egrave; colour. Microscopically, richer in fibrin than in cells; resulted from toxaemia, before the lesions were far advanced.a a small number of pneumococci, varying a good deal in size, In other cases the streptococcus or the tubercle bacillus has and è staining reactions ; no chains. A few capsulated cocci, been the organism which has given rise to the multiplearranged è mostly in pairs with a few tetrads. Phagocytosis inflammation. ]moderately well marked. No tubercle bacilli. Cultures < These associated serous inflammations have no doubt aL on agar, small isolated colonies of (a) typical pneumococci, certain analogy to multiple joint inflammationsand thisi(b) large and opaque colonies of micrococcus tetragenus. circumstance has probably suggested the names of "poly-IGelatin stab cultures were characteristic and without liqueserositisor "polyorromenitis."2 It must, however, be ; faction. obvious that cases of multiple serous infiammation5 differr This was in many ways a remarkable case and the comwidely from one another as regards the infection presentt plete recovery which took place with such inflammatory and the organs attacked, and nothing but confusion canx lesions was certainly surprising. When first seen the case result from their being included under a common name.. looked like one of ’’ pneumococcal septicmia"" associated The following case is, I think, of interest as illustrating one3 with general peritonitis and double pleuro-pneumonia and form of combined serous innammation—viz., a purulentt the prognosis seemed to be of the gloomiest. But at no time inflammation occurring simultaneously in the peritoneumi was there any very marked collapse such as would have been and left pleura, fortunately ending in recovery. expected and the vomiting after it ceased during the first The patient was a girl, aged eight and a half years, whoo week was not again troublesome. was delicate and had suffered a good deal from attacks of f What was the significance of the micrococcus tetragenus bronchitis. She had been fairly well up to Sept. 10th, 1901,, in this case ?1 It is apparently often found in suppurations when she was seized suddenly with vomiting, diarrhoea,, about the neck and respiratory tract. Dr. Bythell tells me r that he has found it four times in the pus of empyemata (out and pain in the abdomen. When seen next day by her ,s medical attendant (Mr. A. W. Senior) the temperature was of 40 examinations), but in association with the pneumod coccus in all four cases and once or twice with other cocci as 103° F., the vomiting was incessant, the stools were foul and liquid, and there were cough and some expectoration ofIf staphylococcus aureus. I am not aware that it has been The vomiting ceased in a few days but the diarrhoea a noted before in the lymph or pus of peritonitis. In this case mucus. continued for a week and the temperature remained at from n it was associated with an inflammation which ran its course e without producing the grave constitutional symptoms which 103° to 104°, while great pain was complained of in the abdomen and left chest. There was also jaundice for a few ? once would naturally expect, but whether this coccus produces a milder inflammation than most other cocci it is not possible days during the first week of her illness. iWhen I first saw the patient on Sept. 21st her great comto say. Le Which serous membrane was first affected ? The periplaint was the severe pain which she was suffering in the abdomen ; this came on in paroxysms and was evidently very ’y toneum or pleura’?’I As far as the evidence goes they comsevere. 3s There were marked tympanites and great tenderness menced simultaneously and there is no evidence to show all over the abdomen. In the left chest there were signs of f which was primary. consolidation in the lower two-thirds of the lung posteriorly, Was the peritonitis really pneumococcal in origin, the r, with bronchial breathing and consonant rales. There was 1S organism perishing before the pus found its way out, as the also a patch of pneumonia at the extreme base on the right lt peritonitis had been in progress for some 23 or 24 days before side. The respirations were rapid, the temperature was 101°, 0, any bacteriological examinations were made? Certainly the and the pulse was 140. 1 must confess that I thought very ry case closely resembles one type of pneumococcal peritonitis al as described by M. Broca.3 This author publishes three badly of the case, looking upon it as one of "pneumococcal d, cases very similar clinically to mine in which the pneumoperitonitis " with double pneumonia. On the other hand, her general condition was wonderfully good considering the ae coccus was present in the pus. In one of his patients the symptoms of peritonitis followed a day or two after the 84 Sir James Paget : Hunterian Oration, 1877, p. 36. 3 Péritonite à pneumocoques, par M. Broca, Gazette Hebdomadaire 1 A paper read at a meeting of the Society for the Study of Disease de Médecine et Chirurgie, Oct. 21st, 1900; abstracted in the Archives de in Children on March 21st, 1902. 2 See Dr. F. decine des Enfants, May, 1901. Brit. Mé Med. Jour., 1900, vol. ii., p. 1693. Taylor :
EMPYEMA;
-
,
meningitis ,
,
’
.
-
"
.
DR. J. S. BURY: TWO CASES OF PARALYSIS AGITANS IN THE SAME FAMILY.
1097
crisis of an apical pneumonia, in the other two the symptoms attitude, tremors, and other symptoms of paralysis agitans. of the peritonitis came on without being preceded or accom- In both cases the tremor affected the hands and forearms, panied by any pulmonary lesion, but one of these patients the feet, and to a slight degree the head ; in the man the died from a post-peritoneal broncho-pneumonia ; the other legs also shook as they lay extended on the bed. The tremor two patients recovered. The symptoms in all three came on affected the hands much more than other parts ; it could be suddenly with vomiting, diarrhoea, fever, and pain in the controlled by a voluntary effort; it was absent during sleep, abdomen ; in a few days there was obviously a collection of very slight on waking in the morning, and worse towards fluid in the abdomen, redness appeared at the umbilicus, and night or after any exertion. It was not symmetrical on the there was a discharge of pus at this spot. The author points two sides ; thus, the man’s left hand trembled more than his out that this rapid formation of pus and ’’ fistulisation rapide right hand. The movements of the limbs were weaker than de 1’ombilic " is characteristic of a pneumococcic peritonitis ’ natural. The weakness was irregularly distributed ; thus, and that such cases are liable to be confounded with acuteI the grasp of the man’s right hand was weaker than enteric fever, tuberculous peritonitis, or appendicitis. M. that of his left, while the muscular power of his SlowBroca also reports a case in which there was a local collection left leg was weaker than that of his right. of pus in the abdominal wall and a case of diffuse general ness of movement, however, was perhaps more conspicuous peritonitis which was rapidly fatal, both of which were than weakness. This was especially noticeable as pneumococcal. This last case appears to have resembled the regards the head movements. Thus, when either patient case of Dr. J. H. Bryant which was reported in vol. i. of the looked to one side the eyes turned quickly but rotation of Transactions of the Society for the Study of Disease in the head was slowly performed. The muscles of both arms Children. As and legs showed increased irritability to tapping. It is interesting to note that all seven of the cases referred muscular stiffness in the limbs this was slight or to above were in girls. This may be only a curious absent ; in the man no rigidity of limb could be detected, in coincidence ; or is it possible that the infection may take his sister the muscles of the forearms appeared to be a little The fingers did not occupy the place, like a gonococcal infection, from the vagina to the more rigid than normal. " peritoneum ? My above cases illustrate ’the well-known usual " interosseal position but were slightly bent at all the observation that prognosis is very difficult in peritonitis; joints. It is to be noticed that in both cases the little the most promising cases often go unexpectedly to the bad, fingers presented a congenital deformity, their first phalangeal while every now and again a seemingly inevitably fatal case joints being rigidly flexed owing probably to shortening of makes a good recovery. their tendons. Both patients presented the characteristic I must express my great indebtedness to Mr. Senior of stooping attitude. In walking the man showed a slight Levenshulme for his notes of the case and to Dr. Bythell tendency to hurry forwards, while in the woman there was a for his careful examination of the pus. marked tendency to retropulsion. A very slight push on the chest made her walk backwards ; the pace increased at each Manchester. step until she lost her balance and fell into the arms of the nurse walking behind her. In both patients the knee-jerks TWO CASES OF PARALYSIS AGITANS IN were exaggerated and in the man a true ankle clonus was obtained on several occasions ; sometimes it was absent. No THE SAME FAMILY, IN WHICH IMindications of ataxia or of sensory disturbance could be PROVEMENT FOLLOWED THE detected and the skin apart from flushing and sweating presented a normal appearance. ADMINISTRATION OF The patients were treated by massage and by the adminisHYOSCINE. tration of hyoscine. At first this drug was given hypodermically, the dose being gradually increased from 2toth to Tioth BY JUDSON S. BURY, M.D. LOND., F.R.C.P.,
regards
of a grain, which was injected once a day. As the larger dose produced nausea, dryness of the mouth, and giddiness the injections were discontinued. Subsequently hyoscine was IN the following cases the chief points of interest are given in chloroform water by the mouth, as recommended by (1) the presence of typical symptoms of paralysis agitans in Dr. R. T. Williamson. At first I-!- 5v th of a grain was given twice daily. This dose was gradually increased to .16th of a. a brother and a sister ; (2) the onset of the symptoms at a Both patients took this amount without any ill comparatively early age ; and (3) the improvement which grain. effects and while they were taking hyoscine in this way they administration of each of the followed the hyoscine during appeared to be much better. They stated that they felt more two periods when it was given. comfortable and were less troubled than formerly with flushThe patients first entered my wards in the Manchester ings and restlessness. The tremor became less marked, as Royal Infirmary on Sept. 17th, 1900, and remained under shown in tracings taken before the administration of hyoscine treatment for 11 weeks. They were readmitted on Dec. 31:tt, and again after the drug had been taken for some time. 1901, and left on Feb. 5th, 1902. The man, 41 years of Dr. A. Ramsbottom (my house physician) and others who age, was formerly a mill-spinner but he was obliged had watched the cases thought that the attitude and gait to leave off work at the age of 35 years owing to were also improved by the treatment. weakness in his legs and a tendency to fall on to Judging from an experience of several cases I am inclined his face. These were the earliest symptoms to attract to agree with my friend Dr. Williamson that hyoscine is his attention. A year later he noticed that his legs were probably the most useful drug that has hitherto been tried shaking ; after a few months his arms began to tremble in the treatment of paralysis agitans. As a rule, it and subsequently he noticed that his head shook at times. diminishes or arrests the tremor, checks the troublesome He attributed his condition to working in a very hot room restlessness and the desire to change position, and relieves and then going out into the cold. His sister stated that her the "hot flushes." and unpleasant sensations of heat. It is illness began when she was about 18 years old. The tremors important to remember that hyoscine is a very powerful came on so gradually that she could not be sure when they drug and hence must be administered with great care. actually commenced, but at the age of 19 years they were so It is safer to give it by the mouth than to inject it bad that she was obliged to give up her work in the mill under the skin. Merck’s hyoscine hydrobromate is probably at which she had been engaged for several years. She the best preparation ; this should be given well diluted in attributed her illness to her occupation, which involved the chloroform water. "A prescription which is useful is oneconstant contact of her hands with wet and cold yarns. eighth of a grain of hyoscine hydrobromate in six ounces of Neither in the case of the brother nor in that of the sister chloroform water. At first two teaspoonfuls of this may be could any history of fright, or injury, or previous illness be given, then three, four, or five teaspoonfuls. If necessary obtained. The father of these patients was asthmatical ; the dose may be increased to six teaspoonfuls (-llth of a they did not know the cause of their mother’s death. One grain), providing toxic symptoms are not produced. The brother died from consumption at 24 years of age and another hyoscine is best given in the morning, just after breakfasr, brother died from influenza. They stated that two sisters Otnd again in the evening (just before going to bed) if the had suffered from paralysis agitans but no confirmation of patient is troubled with restlessness and sleeplessness during the statement could be obtained ; one of these sisters died bhe night."1 PHYSICIAN TO THE MANCHESTER ROYAL INFIRMARY.
at the age of 16 years and the other at the age of 26
years. Both
patients presented
the characteristic mask-like
face,
Manchester. 1
R. T. Williamson :
Paralysis Agitans,
1 01.