1914 BMJ (Clinical Research Edition)  
although quoting several autlhorities wx ho lhave noted cases of this kind, point out that the condition has nLot been sufficiently sttudied. They give in detail particutlars of the case of a womani, aged 41, who was admllitted to hospital in a state of coma, wlich wvas soon succeeded by an epileptiform conivulsion affecting the face an(d limilbs. On examination, a soft diastolic mlurmur was heard, transmitted alongs the left border of the sternum, and a diagnosis of aortic insufficiency was
more » ... e. An examiniation of the urine showed the presence of albumin in large quantities. When the patient had suLfficiCntlyr recovered she stated that she had suffered froim continual lheadaches for some months, and that the eCpileptiform attack referred to was the third shie ha(d had. The patient soon after had another similar attack, and died in a state of coma. On autopsy the kidneys,swere found to be small, red, alnd congested, and there was evidence of a chronic nephritis with a superadded acute attack. 'Tile lhcart showed au acute vegetative enldocar(ditis, the vegetation being soft and easily destroyed by pressutre. The puieumocoecuis was found to be the invading organism. The uraei-mic initoxication alone -would not accouunt for the uldocarditis pr-esent. This was to be explained by the uperadded pneumococcic infection which developed the ml-ore easily on account of the lowered resistance of the tissues. The authors remark as a notable feature of the case that throughout there was no pyrexia and no m-yocardial synptomls. It is impossible to say whether this was duie to the feeble virulenice of the puneiumocoecuis presenit or to an inihibition of the thermic centres by the uraemic intoxication. 191. Syphilis simulating Tuberculosis. IN the course of one year H. KRAUS (JJ7ici. k1iln. Woch7., December 4tlh, 1913) has observed four cases of syphilis wlhich were admitted to the Wienerwald Sanatorium for tuberculosis. In one case the chance discovery of a gtumma led to the 1ight diagnosis, while in the other tllree cases there was no such sign of syphilis. The first patient was a miarried woman, aged 28, who had suffered in infancy from tuberculosis of the left knee. Shortly before admission to the sanatorium she became thin and weak, an(l developed intermittent fever and a slight couglh. There was no expectoration, and there were no definite plhysical sigus over the lungs. The temperature would be normal for a few days, and would then range from 99.51 to 101.40 in the eveniing for a few successive days. She also suffered from abdomiiinal pain and vomiting, which were independent of the febrile attacks. There were no signs of disease of the nervous system, but the liver and spleen were slightly enlarged. After several weeks' observation a small gumma -was founld breaking down in the left pharylnx. A positive Wassermanni reaction and a hiistory of an aborted anid macerated fetuis led to the prescription of mercury in the form of eniesol. After a few inijections the temperature fell to normal, where it remained. Thc patient was dis-chargedI perfectly well. The second patient was a married woman, aged 25, who during the past year had developed a periodic couglh and slight expectoration. No tubercle bacilli were denmonistrable, but she was repeatedly febrile, and her appetite was poor. A few dry rales were audible over both upper lobes of the lungs, but the Roentgen rays showed nothing abnormal with the exception of slight shadows over the hilus on both sides. After six months' treatment with febrifuge drugs, rest in bed, followed by slight exercise, the riles had disappeared, and the patient lhad gained 10 kilos and looked very well. But she was still occasionally febrile. The author's experience with tlme first case suiggested the employment of Wassermann's reaction, which was found to be positive. Injections of enesol were prescribed, and in a few days the temperature fell to normal, where it remained. The third patient was a painter, aged 39, who had suffered from intermittent fever dluring the past four months. While the fever lasted he felt miserable, but he could continue his work when the temperature was normal. A few rales were audible over the upper lobe of the right lung, but there was nio expectoration, and the Roentgen rays showed no disease. In the sanatorium febrifuge drugs, including pyramidon, lha(l no influeince on the temperature, wNhich would range from 99.50 to 101.60 in the evening. Sometimes the temperature would be normal for a whole day. There were occasioinal attacks of abdominal pain, nausea, vomiting, and anorexia. After this condition ha(d lasted for some time the patient confessed that he ha(d contracted sypllilis six years earlier, wlhen a raslh lhad appeare(l. He had received intermittent treatment for three years, since w%Nhen there had beeln no symptom. Wassermann's reaction was positive. A few inljectionls of enesol broughlt the temperature down to normtial, where it remained. The fourth patient was a busiless mai, aged 40, who had suffered from interimittent fever for a couple of mlonths. le was emaciated and su-ffered froim sligihlt jaundice, anoorexia, alnd occasional night swveats. There was nio couIglh or expectoration, but all the physicians lie consulted foutnd tlle condition of the luings suspicious. The examl-ination of the lungs at the sanatorium was negative. Here the patienit -was afebrile at first, but oln the evening of the sixth dlay the temnperature rose to 100.60, an(d duiring time followingadays it rose still higher. Syphilis Nas now suspected, a history of a chalncre sixteen years earlier was elicited, and Wassermain's reaction was fouind to be positive. After eight injections of enesol the teniperature fell to normal, where it remnained. With the exception of the gummla in the first case, the only sign of s-,pliilis;, apart fromn Wassermiann's reaction, was the intermittent fever. As this is not specific for syphlilis, its recognition in such obscure cases is depenident on Wassermainn's reaction, which should be employed when so-called cases of latent tuberculosis runi an atypical couirse. 192. The Cerebral Form of Subacute Hypo-adrenalism following Typhoid Fever. IT was shown by Sergent in the year 1902 that acute adrenial insufficielncy is a fairly comiimon sequel of iany acute infections, and that it does not always prove fatal, but may becoim-e subacute or chroniic. A case of the cerebral form occutrring after typhoid fever is recorded by DoNIus (Ar-ech. dc qidd. ct de i1harma. ail7itaires, 1913, lxi); according to him, the conmmonest forms of adrenal encephalopathy are the psychopathic anid the depressedl melancholic. His patient was a soldier, aged 22, who was in hospital for two months with severe typhoid. Two months after his discharge he returned in a profoundly wasted, pale, and asthenic condition; he answered questions reluctantly, aiid complained of lumbo-abdoininal pains. There was also severe persistent cephalalgia, with clouding of intellect, refusal of food, nocturnal delirium, inequalityof pupils, great tearfuLlness, hopelessness, mental slutggishness, and indifference; he complained of sciatic pains and iniability to warm liiniself in bed; his extrenmities were cold to the touch, and slightly bltuish, and he had obstinate vomitings and constipation. There was hypothermia, and a very feeble low-tension pulse, but Sergent's white-line phenomenon was absent. He was, treated by adrenalin, and improved steadily on it; at flrst he took 30 drops daily of 1 in 1,000 adrenalin solution; after a few days 40 drops was given; and this treatment was periodically stopped for a few days, and then resumed; he recovered in three months, and returned to military service. The slowness of development of the symptoms is attributed to adrenal sclerotic changes. 193. Estimation of the Renal Function. AT a meeting of the Hollcindische Gesellschaft ffir Chliurgie a new method of estimating the renal function Mwas published by VAN HOOGENHUIJZE (Zentralbl. fuir Chir., February 28th, 1914). It consists in the estimation of the creatinin content of separated urine. The advantages claimed for this method are-(1) that 5 of urine slufflce for the test; (2) that contamination of the uirine with blood does not interfere with the reaction; and (3) that the flgure obtained has an absolute as well as a relative value. The daily output of creatinin for any man on a protein-free diet is fairly constant, and, rotughly, proportional to the body weight. It depends upon the katabolism of body protein, the creatin so formed being converted into creatinin by the liver. On a mixed diet the creatinin excretion is raised, but the difference is so small that it may be neglected. Under ordinary circumstances, a healthy kidney separates about 8 mg. of kreatinin per 10 of urine. The actual estimation is simple. The 772 A
doi:10.1136/bmj.1.2779.e53 fatcat:3kk5jylogjbcxiiunblmwlbg2u