NOTES ON A CASE OF ADDISON'S DISEASE, RAPIDLY FATAL, WITH SYMPTOMS OF ACUTE TOXqMIA

H LECKY
1906 The Lancet  
letter to THE LANCET that bodies similar to the Leishman-Donovan holies of kala-azar might form a stage in the lifehistory of this organism, as also of the spirochseta pallida. We have made several attempts to cultivate these organisms but without success, though Professor Vincent in his paper in THE LANCET stated that the fusiform bacilli were readily cultivated in the ordinary media ; the media we have employed have been agar, blood serum, bouillon, milk, and peptone water, and attempts have
more » ... and attempts have been made, both aerobically and anaerobically, at temperatures of 37°C. and 42°C., resulting only in a profuse growth of the common cocci and bacilli of the mouth. Owing to the ease with which these organisms may be missed if swabs and cultures are taken, incubated, and examined in the manner customary with suspected cases of diphtheria, coupled also with the fact that many cases of ulcerative and even membranous stomatitis are not examined at all with a view to their bacteriology, we would suggest that cases of Vincent's angina are by no means so uncommon in this country as the rarity of cases hitherto reported might lead one to expect. The cases described by Dr. H. W. Bruce in THE LANCET 3 closely resemble those of this series in which the disease was confined to the tonsil. In addition, we have included seven cases of stomatitis in which the lesions exactly resembled those of the tonsillar cases. Considering the frequent association of carious teeth with this disease it would be of interest to know in what proportion of cases of carious teeth, unaccompanied by membranous ulceration, the organisms of Vincent can be demonstrated ; in a few cases examined by us only the ordinary bacteria of the mouth or the small curved vibrio of Miller have been seen. Since we have found that the organisms rapidly disappear from the mouth and the lesions readily improve under treatment, at any rate, in these comparatively mild cases, and since such cases are possibly infectious and if left untreated tend to progress, we have thought it worth while to place on record an account of the few cases observed at St. Thomas's Hospital during the past three months. HOUSE PHYSICIAN TO THE RADCLIFFE INFIRMARY, OXFORD. THE patient, a man, aged 38 years, was admitted to the Radcliffe Infirmary, Oxford, on Sept. 29th, 1905, under the care of Dr. W. Collier. He was sent to the hospital with a note from a medical man describing the case as one of rheumatic fever of one day's duration. The temperature was 101'2° F., rising in the first six hours to 103'8°. and the pulse was 120. The skin was not sweating. In colour it was rather dark all over the body. The face and hand. were like those of a man who had worked generally in the open air and in the sun. The areolas of the nipples were deeply and symmetrically pigmented. The scrotum and penis were unusually dark, as also were the axillas but to less degree. There were no other areas of pigmentation on the body, or on the buccal mucous membrane, or on the tongue or conjunctive. There was great pain in the ankles, the knees, the elbows, and the wrists and shoulders on movement. Severe pain was produced by pressure on the plantar fascia in both feet. The joints were not reddened and no excess of fluid was detected in any of them. The heart was not enlarged but the sounds were feeble. The pulse was markedly feeble on both sides. The abdomen appeared to be normal. There was no pain. The liver, the kidneys, and the spleen were not felt. The patient was a little deaf. The urine had a specific gravity of 1017 and contained a cloud of albumin but no sugar. Casts were not looked for. The patient was quite cheerful and did not seem depressed or low spirited. He gave his own history. He said that he had been at work on the preceding day and had had to stop on account of severe pains which came on in the 1 THE LANCET, knees, and within a short time invaded the ankles, the wrists, the elbows and the shoulders. He had never had rheumatism or any attacks similar to the present one. He had always been a healthy man and had taken about two or three pints of beer a day. No history pointing to tuberculosis in the family was obtained. The patient was treated with 60 grains of salicylate of sodium in the first six hours (in 20-grain doses) and subsequently with 20 grains every six hours. On the evening of Sept. 30th the temperature was 98' 4° and the pulse was 106. On Oct. lst and 2nd the temperature remained at 980, the pulse being 96, and the patient was losing all pain from the limbs. He was taking only milk and broth. The milk he objected to-it always disagreed with him. He was sick once on each of these days-each time after taking milk. There was nothing characteristic about the vomit. On the 3rd the patient seemed a little strange in his manner and was inclined to be restless, especially at night. He was, however, quite rational and answered questions correctly. On the 4th the temperature was 97' 4° in the morning. The salicylate of sodium was stopped. The amounts of urine for the first three days (Sept. 30th and Oct. lst and 2nd) were 25, 30, and 23 ounces respectively. The bowels were opened with cascara on Oct. lst and 2nd. The stools were normal. The patient appeared to be more ill. On the 5th the urine had altered to a brownish-red, smoky colour, and gave the blood reaction with guaiacum and ozonic ether. It contained a thick brown deposit. Under the microscope numerous red cells, a few granular casts, and much débris were seen. A number of crystals of leucine were also present. On the 6th and 7th there was profuse diarrhoea and at the same time great frequency of micturition, about from two to three ounces of urine being passed every few hours. The urine was smoky and contained a thick brown deposit of débris but no leucine. On the 6th two of the stools contained practically only bright red blood and mucus, intimately mixed. The other stools contained only a little faecal matter and darker blood. The last two or three stools on the 7th contained no blood. The patient's general condition had got much worse. He was rapidly sinking into a profound typhoid state. On the 7th the temperature rose to 100' 20 and the pulse to 116. The patient complained of slight pain in the abdomen on the 6th. It was worse on the 7th. He referred it to the centre of the abdomen. Pressure just above the umbilicus caused pain. The liver dulness was one inch in extent in the nipple line but it was normal in extent in the midaxillary line. The ears were examined and both were found to be normal. On the 8th the patient became much more lethargic and difficult to rouse. In the evening he was semi-comatose, but pressure in the abdomen between the umbilicus and the right costal margin caused a good deal of pain. On the 9th the temperature rose to 101° in the morning and to 104° in the evening, when death took place. The post-mortem examination showed typical fibiro-caseous tuberculosis of both suprarenals. No normal suprarenal tissue was seen, The right kidney was large and showed many nodular prominences ; it measured five inches by two inchts. On section the whole organ was converted into a series of cysts, filled with a putty-like material. The right ureter was blocked and was filled with cheesy matter and the walls were caseous. The left kidney showed marked compensatory hypertrophy and measured six inches by three inches. No tuberculous masses were present. There were two small caseous foci in the right globus major of the testis ; the vas was healthy to the naked eye. The bladder and vesiculse seminales showed no change. No other tuberculous foci were found either in the glands of the thorax or the abdomen, or in the lungs. The right internal ear was examined and was found to be healthy. Two days before the patient died the following history was obtained from the wife. The patient was a healthy, hard-working man. On Sept. lst he was taken ill (away from home) and had to go to bed. The chief symptoms were shivering and a change in the colour of the skin. One person, at least, said that the patient had the "yellow jaundice." The wife did not know if the whole body altered in colour. There was no sickness and the patient had a good appetite. The mind was clear. On the 6th he was able to go home but for the next week he had to keep in bed or sit over the fire as he suffered continuously with the " cold shivers." " There was a discharge of "matter and blood " from the right ear. No history Dointing to definite rigors was obtained. There W:,-8 no information as to the
doi:10.1016/s0140-6736(01)99438-3 fatcat:ii6oxwpts5dq7goif5m2jd2x5a