ROYAL UNITED HOSPITAL, BATH.

520 cardiac action. The administration of a purgative dose of the notes of this case we are indebted to Dr. W. H. Cooke,, sulphate of magnesium with the addition of a few drops of resident medical officer. A man, aged thirty-six years, was admitted to the Royal diluted sulphuric acid removed all remaining symptoms, though the vertigo lasted in several cases for from twelve to United Hospital. Bath, on Nov. 17th. He stated that he had not had rheumatism or syphilis; he had been an eighteen hours from the time of eating. There could be no mistake as to the root in question being abstemious man and always lived in England. His illness that of the scarlet runner bean, as it was planted by ourselves had commenced seventeen days previously with cold shivers from London seeds and grown in the garden amongst peas, and pains, which commenced in the back. These pains cabbages, and cauliflower, and I cannot conceive unless the disappeared from the back with the aid of strong root is per se poisonous, how it could have absorbed poisonoas turpentine embrocations, but reappeared in the limbs and material from any neighbouring plant. I may mention that head. He had had cold shivers daily and became very the bean itself was largely partaken of by ourselves and we feverish. There had been no vomiting or diarrhcea. His never observed any noxious effect. I forward you a specimen urine was examined three days before his admission-, of the root in question, also the plant and bean for analysis. it smelt strongly of violets. Cold nitric acid produced deleterious substance may be analogous to that a cloud, which appeared at the top of the urine first contained in the poisonous variety of cassava or deadly and cleared up on boiling. This was considered as due to manioc root which is referred to in Mr. Stanley’s book " In turpentine absorption. There was no albumin. On admisDarkest Africa." sion to hospital on Nov. 17th he was found to be well. Ravine Station, Uganda Protectorate. nourished. His complexion was pallid and muddy. Theconjunctivas were slightly jaundiced. The tongue was, slightly coated, white, and moist. The temperature was 1018° F. ; the left pulse 100, of good strength; and theCHILD IN UTERO CRYING DURING LABOUR. respiration 20. There was no distress of any kind, but he com" BY E. FITZGERALD FRAZER, L.R.C.S., L.R.C.P. IREL. plained of some pain in the right arm and right occipital region. There was no rheumatic odour, no cedema of’theI WAS in attendance on a case of twin labour here recently legs, and no effusion into any joint. The right radial artery was not pulsating and a clot could be felt in the middle third where I applied the forceps to the head of the first coming of the brachial artery. It was not tender. The anterior and child. Whilst using gentle traction, and the vertex being posterior tibial arteries of both legs were pulsating. The chest still upon the perineum, I was surprised, as was also the was well formed, resonance was good, and the breath-sound nurse, to hear the child cry. At first we thought we: normal. As to the heart, relative cardiac dulness commenced were deceived, but in a very short time after the: at the third left rib and was absolute at the fourth. The sound was repeated, and before any part of the head was apex was in the normal position. At the apex the first born the same phenomenon occurred several times. Nothing: sound was reduplicated and the second part of it ended unusual happened during the birth of the second child, whichiin a slight whiff; the second sound was pure and distinct. came away naturally. I cannot say whether the pressure ofEAt the base, over both the pulmonary and aortic valves, the forceps had anything to do or not with causing the crying. a faint soft systolic murmur was audible. With regard to the There were no marks of it on the head and the boy is doing spleen, dulness commenced at the upper border of the eighth well. This instance illustrates the possibility of uterine} rib and continued to the lowest border of the Jibs; it could breathing, as otherwise I cannot see how the vocal cordsnot be felt. The liver dulness was increased downwards. could have been called into play. I attribute the entry off The urine was of normal colour, 1020, acid, with no albumin. air into the lungs as having taken place during the time3 On the 18th the temperature at 8 P.M. rose to 1046°. He I was putting the forceps into place in doing which no3 did not shiver, but sweated profusely. There was no. difficulty presented itself. Thinking the particulars may rheumatic odour. On the 19th there was no change in thebe of interest to the readers of THE LANCET I havee cardiac signs. On the 20th he had had much pain in the calves during the preceding night. There was no blocking pleasure in submitting them. of the anterior or posterior tibial arteries. He was sweating Brighton. profusely. The bowels were rather constipated. He had been given an injection of 10 c.c. of anti-streptococcic There was no rash serum on the previous day at 1 P M. On the 21st or any other discomfort from the injection. had He the in the was sweating profusely. legs gone. pain OF He took nourishment well. The urine was 1020, acid, with a trace of albumin. The systolic murmur at the apex of the heart was becoming more distinct. On the 22nd he had BRITISH AND FOREIGN. had a better night, but felt rather faint in the morning. He had had some return of the pain in the calves. On Nnlls autem est alia pro certo noscendi via, nisi quamplurimas et mor- the 23rd he had two injections of 10 c.c. each, and similar as borum et dissectionum historias, tum aliorum tum proprias collectas injections were now made every day. The systolic murmar ’* habere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., at the aortic orifice was soft, whereas at the pulmonary lib. iv. Proœmium. orifice it was rough and loud (? two separate murmurs). ROYAL UNITED HOSPITAL, BATH. The pulmonary was louder than the aortic second sound. A CASE OF ULCERATIVE ENDOCARDITIS TREATED BY A loud, rough systolic murmur was heard in the midsternal region, probably exocardial. On the 24th he was ANTI-STREPTOCOCCIC SERUM. not so bright in the morning; he had had a bad night. (Under the care of Dr. A. E. W. FOX.) The murmur at the apex of the heart was becoming louder THis case illustrates one of the more severe types of and rougher each day. On the 25th he sweated profusely. There was no pulsation in either of the tibial arteries or the le malignant endocarditis. It is published to show the of the left leg. The leg was only slightly cooler of results of the injection anti-streptococcic serum, the use of popliteal the right. On the 26th there was no change. On from which was decided upon a perusal of the notes of a the 27th he felt a little better. The systolic murmur at or successful case which we brought forward in the Mirror the base of the heart was now loudest over the aortic of Hospital Practice. The duration of illness before orifice, the second sound being short and sharp. The treatment by the serum was about the same in both cases, British Institute of Preventive Medicine reported of blood It. taken from the left arm three days previously: "Streptobut the symptoms had been more severe in this patient. The value of the treatment will most probably be cocci not found either microscopically or by cultivafound to depend largely on the time the disease tion. No micro-organism has been isolated." On the The he 28th he felt and looked a trifle better. He had not has existed before the treatment is commenced. difficulty consists in making an early diagnosis; but when the had a good night. About the lumbar and lower scapular at- regions much boggy oedema had appeared from the numerous diagnosis has been successfully made the method of treatms ment by the serum has proved of great value in other forms injections in the scapular regions. The left leg and right of septicœmia. The publication of cases in which it has been ’en arm were of the same temperature as the corresponding tried, if they illustrate important points, is of much value, ae, limbs. On the 29th the injections were left off. On the For 30th the temperature, which fell to 100 4°, had risen again although the ultimate result may not be satisfactory. For

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521 to 1036°. The heart’s action was not quite regular. At the aortic orifice the systolic murmur was now very loud and rough, as also at the apex. He now had to be propped up in bed. On Dec. lst he was worse. He had been delirious during the night. He was drowsy throughout Nov. 30th and He now had was rather deaf in the morning of Dec. lst. diarrhœa. The injections were continued. On the 2nd he said he felt better, but was evidently worse. At 2 P.M. he The heart’s action was was much worse and was cyanosed. and the He had dyspnoea. At small. pulse very irregular 5 P.M. he died. The temperature varied from 98° on the morning of the 19th to 104.6° on the evening of the 18th, but was generally over 103° at night and above 100° in the morning. The influence of the serum was apparently nil as regards the temperature record. Necropsy.-The body was well nourished and muscular. Rigor mortis was present. There was no oedema. The pleuræ contained about a pint of ordinary serous fluid each side. There were a fey recent adhesions both sides. The right lung was normal. There was much recent lymph on the surface. With regard to the left lung the whole of the lower lobe was airless and in a state of hypostatic congestion. The pericardium contained from 3 to 4 oz. of clear flaid. There were a few patches of recent lymph. The heart weighed 14 oz ;it was enlarged ; there were three patches of recent lymph, the largest being on the right

it was much congested. Examination of the head was not allowed. The right brachial artery was dissected out, but unfortunately was lost. The staff of the British Institute of Preventive Medicine very kindly examined a section of the vegetation and found numerous streptococci. Remarks by Dr. Fox -The general aspect of grave illness presented by this patient, his rigors, sweats, type of pyrexia, enlarged spleen, cardiac murmurs, and embolic blocking of his right brachial artery pointed conclusively to the diagnosis of ulcerative endocarditis. We therefore determined, encouraged by Dr. Sainsbury’s successful case, to try the effects of the anti-streptococcic serum. This treatment was begun as soon as we obtained the serum-on Nov. 20thIn all he had twenty when 10 c.c. were injected. injections, the result being that he certainly looked brighter and said that he felt better. Though the sweats continued the temperature no longer showed such marked fluctuations. The report from the British Institute of Preventive Medicine upon the blood taken from his left arm on Nov. 24th stated : "Streptococci not found microscopically or by cultivation. No micro-organism has been isolated.’’ This was aftdr twelve injections of the serum. Though no streptococci were found in the blood, nevertheless after death streptococci were discovered under the microscope in the vegetations. These streptococci were so embedded in the vegetation that it is difficult to understand how they could have been acted upon by the serum. The fatal termination of the case was no doubt attributable to the almost complete blocking of the aortic orifice by the huge vegetation with its surrounding blood clot. In my own limited experience of ulcerative endocarditis, which began in 1878, when I published my first case in THE LANCET,l all treatment has been absolutely futile. I think, therefore, that more help is to be expected from the bacteriologist than from any other direction and I shall certainly give a further tiial to the treatment.

serum

Medical Societies. PATHOLOGICAL SOCIETY OF LONDON. Ringnorm Fungi.—Exhibition of Specimens. A MEETING of this society was held on Feb. 16th, the President, Mr. BUTLIN, being in the chair. On the motion of the PRESIDENT a resolution was passed expressing sympathy with the family of the late Mr. G. D. Pollock, a former president of the society. Dr. CoLCOTT Fox and Dr. BLAXALL gave a demonstration of the Plurality of Fungi associated with Ringworm. Microscopical specimens and over forty lantern slides were exhibited. They had examined over 400 cases, clinically and culturally, macro- and microscopically. Their results in the main confirmed the brilliant work of Sabouraud Left ventricle cut open to show the large mass of vegetations in Paris, but they differed from him in many details and in the aortic valves. (From a photograph.) on a few important points. They discussed four groups of Audouini, endothrix, ectothrix, and microsporon fungi-viz., ventricle. Both the right auricle and the right ventricle were some rare forms of fungi giving rise to ringworm-like’ lastly, dilated. The tricuspid orifice admitted four fingers ; there lesions, but yielding faviform cultures. The microsporon was no deposit or ulceration. The left ventricle was hyper- caused about 90 per cent. of scalp ringworm in London and trophied and dilated ; the mitral orifice admitted three was sometimes associated with some macules on the face, fingers; there was no deposit or ulceration. Almost entirely neck, &c., but only exceptionally formed circinations. It blocking up the aortic orifice was a vegetation which appeared was almost entirely confined to the human being. The to arise from the base of the left posterior aortic valve. This well-known uniform clinical macroscopical appearances vegetation was of the size of a walnut and measured about were then described. Microscopically they were cha.1 in. in depth andin. in breadth ; it was covered by recent racterised by a closely adherent external sheath of small blood clot. The base of the valve was replaced by vegetation. spores some distance beyond the mouth of extending There were two softened spots in the endocardium imme- the follicle and an infiltration of the hair shaft with by diately beneath the vegetation. This growth extended on mycelium mostly with scanty septa, and ending above to the surface of the anterior valve between which and the the bulb in a striking fringe. The macroscopical right posterior valve there was an irregular calcareous appearances of the cultures were demonstrated and deposit. There was slight atheroma of the aorta. The shown to be distinctive. The true fructification was then coronary arteries were not blocked. The spleen was very described as obtained by Dr. Fox and Dr. Blaxall from large, pulpy, and grumous ; it was taken out in pieces Klatsch specimens of the aerial portion of the cultures. and weighed about 20 oz. It was so much broken They found the fructification to be on the ame plan in down and disorganised that no infarct could be discovered. microsporon as in endothrix and ectothrix. Chlamydospores The liver was enlarged and weighed 71 oz. It was congested were commonly seen in microsporon cultures. The endothrix asd fatty. The light kidney was moveable and weighed fungi were so called from the fact that they were confined 920z ; the capsule peeled easily ; there was a white infarct. exclusively to the inside of the fully infected hair. The The kidney was much congested. The left weighed 6 oz. and 1 THE he capsule peeled easily ; there were several white infarcts ; LANCET, March 2nd, 1878.