274 IRISH JOURNAL OF MEDICAL SCIENCE

and emphysema. IIe had inter alia, a moderate degree of Dupuy t ren ' s contracturo, involving the little and ring fingers of the r ight hand, wi th definite thickening of the palmar fascia. The fingers were flexed a t the carpo-phalangeal joints and also a t the first phalangeal joints. About the same t ime a note in the Roche Courier caught m y eye directing a t tent ion to Steinberg's article, and s ta t ing t h a t Vi tamin E in doses of 100 mg. , thrice daily, was recommended for the t r ea tmen t of early and moderate ly advanced cases of Dupuy~ren 's eontracture, and tha t no surgery was required except where calcification had occurred. Messrs, Roche kindly sent me a typed c o p y - - m i n u s the i l lus t ra t ions - -of Steinberg's paper. This man was younger and the condition less advanced than in the case referred to above, so it was decided to t ry the effect of a course of Vi tamin E. On J u l y 28th, he was given one 20 rag. tablet three t imes a day. On Augus t 9th the number was increased to four tablets , ie., 80 rag., three t imes a day, and on Augus t 14th, five tablets each of 20 mg. , three t imes a day. For over one hundred days he took 300 mg. daily of Vi tamin E. Their prolonged adminis t ra t ion produced no untoward physical s igns or symptoms . The pat ient though t he could move the r ing finger a l i t t le more freely, b u t objectively there was no definite change in the contracture or in the skin of the palm.

Both in the Practitioner (1947) and in the British Medical Journal (1947) reference has been made to Steinberg 's work, and it is felt that for an accurate appraisal of the value of the treatment advocated by: him and the stage of the disease in which good results may be expected, all cases favourable or otherwise should be recorded. It is only fair to point out that the description" moderately advanced " is open to various interpretations, and that as I have not seen the illustrations provided by Steinberg in his paper, I am not in a position to compare his cases with the one here recorded.

We, for the present, can only hope that this " advance in treatment " will not meet with the fate of some apparent advances reported by Lambert Rogers in the Practitioner for 1934, which he states in his most recent report (1947) have been found wanting and abandoned, and "are fast sinking into the grey twilight of forgotten things ".

References.

Brit. Med. Jo. (1947) Nov. 8. 757. Crouch, M. (1938). Canad. Med. Assn. Jo." 39. 325. Dupuyt ren , ]YI. (1831). Jo. Univ. et Hebdom de Mdd., Paris , 5352. Dupuy4ren, Baron (1834). Lancet, '2 ii, 222. Rogers, L. (1947). Practitioner, 159, 233. Rogers, L. (1938). Practitioner, 141, 372. Steinberg, C. L. (1946) Med. Assn., N . A . , 30, 221. Steinberg, C. L. (1941). Am. Jo. Med. Sci., 201, 347.

STAPHYLOCOCCAL PERICARDITIS" TREATMENT WITH PENICILLIN; RECOVERY.

By Jom~ COFF~'~.

I WISH to present this record of a case of purulent pericardial eff.usion, as I believe that the recovery of the patient was almost entirely due to the use of penicillin in adequate dosage. I am

further prompted to report it, as I am unable to find any record of a similar case in the British medical literature available to me.

Mrs. A. O., 39 years, a widow, was admi t t ed to the County Hospital , Tralee, under

STAPHYLOCOCCAL PERICARDITIS. 275

m y care on J u l y 7th, 1947. Her husband had died of pulmonary tuberculosis in 1945. She has four children. All these children had been under the care of the County Tuberculosis Officer, bu t none had active tuberculosis. Her previous medical history was good.

She had been ill for two days prior to admission. On admission, the temperature was 101°F., pulse 110, respirations 28 per rain. On examinat ion, I found a small area o~" congestion in the lower lobe of her left lung. Trea tment was s tar ted with sulphathiazolc tablets orally. On the th i rd day of t r ea tmen t her temperature fell to normal , and by the fifth day she was completely normal. She appeared to be an ordinary case of pneumonia. I n all, she got 25 grammes of sulphathiazole orally. No other t rea tment was given.

For the next nine days she remained completely well. On the t en th day, she had a very distressed and anxious appearance, and complained of pain in the prmcordium, radiat ing across the r ight side. She was obviously very distressed. Next day (August 2nd), she developed a temperature of 102°1 ~. On this and the following days, it was noted t h a t her heart rate had increased considerably, and tha t the sounds had become very muffled. The apex beat was not palpable. A tenta t ive diagnosis of pericardlal effusion was made, and t rea tment was s tar ted wi th penicillin, (50,000 uni ts every four hours). On A u g u s t 4th, X-ray examinat ion was made wi th a portable appara tus , and t h e diagnosis was confirmed, Dr. C. L. McDonagh report ing : " There is a very large peri- cardial effusion." As the temperature continued elevated, penicillin dosage was now increased to 100,000 un i t s every four hours. On Augus t 6th, some 200 c.e. of thick, green fluid were aspirated from the pericardial sac, and 500,000 uni t s of penicillin, in 10 c.c. sterile water, were administered intra-pericardially. The pathological report from Univers i ty College, Cork, on the aspirated fluid was :

Polymorphs. Gram-posit ive cocci present on direct examination. No tubercle bacilli found. Culture on blood agar : Staphylococcus aureus.

Dr. McDonagh reported on a later film (August 8th) : Lit t le change in pericardial effusion. Left pleural effusion has appeared.

Trea tment with penicillin sys temat ical ly was continued, and on August 12th, further aspirat ion of the pericardial sac yielded a few e.c. of pus. Report from U.C.C. on this specimen showed :

Polymorphs still present. Staphylococcal forms sti l l present in small numbers.

At th is stage, she appeared to be progressing favourably, and the penicillin dosage w a s reduced to 50,000 uni t s every four hours. On August. 17th, penicillin t rea tment w a s finally stopped. I n all, she had received 7,000,000 .uni ts intra-muscularly, and 500,000 uni t s intra-pericardially. Following the withdrawal of the penicillin, s h e developed a sl ight temperature of 99 ° F for a few days, bu t from Augus t 25th on, she made an uneventful recovery.

On Augus t 22nd, Dr. McDonagh reported : " Pericardial effusion considerably diminished, and also (though to a lesser

degree), the pleural effusion." Again, on November 18th : - -

" Litt le if any perieardial effusion. Most of the encysted pleural effusion on t h e left side has disappeared. A small amoun t of basal pleurisy remains."

Finally, on December 17th, Dr. McDonagh reported : - - " No evidence of fluid in pericardium or left pleural cavity, though a trace of

pleural thickening remains a t the left base." Eventua l ly the pat ient was permit ted to go home on December 23rd, 1947. She was

again examined on February 2nd, 1948. At this t ime, she was up for about six hours each day, bu t was doing practically no work. :Her general appearance was very good, she looked well and felt well. I found her heart sounds normal both in qual i ty and rate. On x . ray examin~tlon, I found tha t the r ight side of the heart was slightly enlarged.

My thanks are due to Dr. D. Buckley, my locum tenens, who looked after this patient in my absence; and to Dr. C. L. McDonagh, and Dr. Folan, of the Pathological Department, U.C.C., for their helpful reports.