WESTMINSTER HOSPITAL. A CASE OF STREPTOCOCCAL CELLULITIS
A CASE OF STREPTOCOCCAL CELLULITIS. (Under the care of Dr. DE HAVILLAND HALL.) i Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, turn aliorum tum proprias collectas habere, et inter se comparare.-MORGAGNI De Sed. et Caus. Morb., lib. iv., Prooemium. -THE patient, a woman, aged 46 years, attended at Mr. P. R. W. de Santi's out-patient department at the Westminster Hospital on May 16th, 1904, suffering from acute lacunar tonsillitis on the
... sillitis on the left side with herpes of the lips. She was treated with salicylate of sodium and in ten days was apparently well. On the 30th she attended at the outpatient department, complaining of pain and of a great swelling in the mouth of 24 hours' duration. Finding that her temperature was 103.5° F. Mr. de Santi directed that she should be admitted into the hospital. On admission at 3.30 P.M. on the 30th her temperature was 104' 6° and her pulse was 140. The patient was unable to protrude the tongue, which was pushed upwards by a large œdematous swelling. There was also some brawny swelling beneath the chin. Nothing abnormal was to be detected in the respiratory or circulatory system. The urine was of specific gravity 1016 and contained a large quantity of albumin with blood and hyaline, granular, and cellular casts. The patient was ordered three pints of milk, two eggs, and three ounces of brandy in the 24 hours, and a mixture containing five grains of carbonate of ammonium, half a drachm of tincture of cinchona, and ten minims of tincture of nux vomica every four hours. The sublingual swelling was incised but only serum was evacuated. A mouth-wash of borax and boric acid was ordered to be used every hour. Three and a half hours after admission her temperature rose to 105 .4°. She was then injected with ten cubic centimetres of anti-streptococcic serum and this was repeated four hours later, when the temperature had fallen to 102°. By 11 A.M. of the 31st the temperature had fallen to normal. She was much better and the swelling in the mouth had much diminished. The pulse was 80. She had two more injections of serum on this day. From this date the patient's progress towards recovery was uninterrupted and the temperature only once rose to 100°. The urine, which for the first two days was very scanty and highly albuminous, rapidly increased in quantity ; on the sixth day after admission she passed 60 ounces containing only a trace of albumin. She left the hospital a few days later quite well. A swab was taken on June lst and Dr. R. G. Hebb gave the following report: "Fresh film shows streptococci, staphylococci, and bacilli (two kinds). Cultures show streptococci and a large thick bacillus (Gram staining) and a thin bacillus (non-Gram staining). No evidence of bacillus diphtheriar;" , Remarks by Dr. DE HAVILLAND HALL.-I happened to be in the ward when the patient was admitted and I was much impressed by her grave condition. She could hardly open the mouth, so that it was impossible to examine the pharynx and larynx. The conclusion I came to was that she was suffering from a condition closely resembling angina Ludovici and from the marked signs of septic intoxication I gave a very unfavourable prognosis. The immediate improvement which followed upon the injection of anti-streptococcic serum was so striking that there can be little doubt that it occurred as the result of the injection. I have seen similar cases in the pre-serum days run a rapidly fatal course. The result of the discussion at the Medical Society of London on Serum and other Inoculations in Pyogenic Infections on Jan. llth of this year was to emphasise the necessity of the early administration of the serum so as to neutralise the toxins before irrevocable lesions had been set up. As we are still in thew tentative stage of the employment of serums in pyogenic cases it is extremely important that a record should be kept of cases in which they are used, including the chief clinical feature of the case, a report on the bacteriological examination, and the result. If this were generally done we should soon be in a condition to appraise the serums at their true value. It was not possible to localise definitely the mode of infection but it was probably connected with the patient's teeth, as she had several decayed stumps on both sides. Oral sepsis is still too little regarded by the general public and it behoves the medical profession to draw attention to the necessity of keeping the mouth in a wholesome condition. The investigations of Dr. William Hunter on the causation of pernicious. anasmia indicate another danger of oral sepsis. The necessity of caution in drawing conclusions from the results of treatment was forcibly brought to my notice within the last few days. On July 19th I was called in consultation to see a young man, aged 20 years, with acute cedema of the larynx, following what appeared to have been a septic. sore throat. I found the patient with a temperature oi 10Z°' and a pulse of 104. He had great pain and extreme difficulty in swallowing. On laryngoscopic examination the epiglottis, right aryepiglottic fold, and the arytenoids were very cedematous, so that it was not possible to obtain a view of the interior of the larynx. The urine contained albumin. The conclusion I came to was that the patient had a streptococcal laryngitis and if I bad had the anti-streptococcic serum at hand I would have given an injection then and there. Shortly after the consultation the temperature rose to 103°. I had a telephone message in the evening to say that the patient was much better. During the night he had profuse sweating and when I saw him in the morning his temperature was normal and the oedema of the larynx had greatly diminished. Supposing that an injection of serum had been given overnight the rapid improvement would have been credited to it. The swab I took for examination showed the presence of streptococci and staphylococci. The patient made a rapid recovery. He was treated with a gargle and spray of borax and boric acid and the internal administration of the tincture of the perchloride of iron in full doses.