Generalized Angioneurotic Edema Follow I ing Tonsillectomy BY E. C. ROBICHAUX, Excelsior Springs, Missouri 'N SEARCHING the literature, both foreign and domestic, we find that the generalized type of angioneurotic edema is a rare condition; and, when associated with tonsillar operations, we have been able to find but one case reported in the last ten years. Our patient had no previous history of these attacks, as in the case of Turnbull. His patient had a decided vasomotor instability manifested by repeated attacks of angioneurotic edema at short intervals of time during all of six years, before surgical interference was undertaken. The operations, one time on the sinuses, the other on the tonsils, were each followed by generalized angioneurotic edema. It is a question whether these particular attacks of edema might not have resulted from the evolution of its preëstablished cycle rather than from the surgical procedures per se; or again, since these operations were undertaken to cure and did cure the attacks of angioneurotic edema in this case, might there not be sufficient reason for suspecting that these vasomotor phenomena were due to the overwhelming absorption of elements 1 TURNBULL, F. M.: Jour. Amer. Med. Assoc., 1921, lxxvii, 858. of hypersensitivity from the operated areas? We wish to give briefly, in their chronological order, certain circumstances which apply to the study of this patient in order that he who reads might gauge his opinion from the same perspective: L. B. male, aged forty-seven. Diagnosis -sciatica, leukocytosis and hypotension. History unimportant and physical examination negative except for teeth and tonsils. No allergy except history of slight asthmatic wheezing when having a bronchitis. February 9. Food allergy tests. Intracutaneous method. No pseudopod reactions. February 18. Tonsillectomy by Dr. Keith, using aposthesin. Tonsils contained foul-smelling caseous material and pus. February 21. At night patient took a large dose of castor oil with good effect. February 22. At nine in the morning marked swelling of the left hand. February 23. In the morning, marked swelling of hands and face, feet and legs. February 24. At seven in the morning the crisis occurred. The face was much swollen, eyes closed, ears double in thickness, lips and nose markedly distorted, neck very large and the extremities, all of them huge. In addition there were giant hives scattered over the chest and back to add to the unusual torment of the patient. There were no systemic symptoms except for leukocytosis. This extreme condition February 25. Mild rise and fall in the condition prevailed throughout the day. February 26. Continued improvement. February 27. All symptoms had vanished by night and no other attacks, however mild, have occurred since. It is to be observed that food tests were done on him nine days before the tonsillectomy and thirteen days before the onset of angioneurotic edema. Only a few of the common articles of food were tested, among them eggs, milk, wheat and beef. In all only fifteen injections were made which in the aggregate would total an infinitestimal dose of foreign protein. We do not believe that this procedure was in any manner responsible for the angioneurotic edema, because: (1) the admittedly trivial dose of foreign protein; (2) the absence of any local reaction; (3) the delay in the appearance of symptoms (thirteen days after the tests were made); (4) the slow progression of symptoms to an overwhelming crisis on the third day suggesting a slowly maturing causative agent; (5) the gradual disappearance of symptoms by remission, suggesting a rise and fall in the causative agent. On the night of February 21, he took a large dose of castor oil with good effect. The very next morning the symptoms of angioneurotic edema began, as described. The diet had been restricted to eggs, milk and bread since the tonsillectomy and on the morning of the onset of symptoms he had eaten three raw eggs for his breakfast. Immediately upon notice, purgation was started with liberal doses of epsom salts frequently repeated; total abstinence from all foods for fortyeight hours and the use of alkaline waters. Also adrenalin was given at once, starting with 1 cc. of 1:1000 solution, every twenty minutes for five doses and thereafter every three hours during the day for four days. Atropine was also used. Despite it all the case went on to crisis on the third day. It is interesting to repeat that the patient was not sensitive by tests to any of the foods eaten immediately prior to the onset of symptoms, and also that after the crisis, these same foods were returned to the diet ad libitum without in the least affecting his convalescence. We therefore do not ascribe any significant part to the alimentary tract for the occurrence of this mysterious phenomenon. Many laryngologists admit their frequent encounter with urticaria after tonsillectomy. We think this syndrome is only a step under that of angioneurotic edema and that the etiological factors in connection with. tonsillectomy are the same in both. We believe that the condition was one intimately associated with the pathology in the tonsillar areas; that this patient was previously sensitized to the bacteria in the tonsils which when removed allowed for the production of anaphylatoxins in sufficient degree to upset his vagotonic balance. Barber2 maintains that in adults bacterial sensitization is a more frequent cause of urticaria, angioneurotic 2 BARBER, H. W.: Chronic urticaria and angioneurotic edema due to bacterial sensitization. Guy's Hosp. Rep., 1923, lxxiii. A Case of Auricular Fibrillation Occurring During the Administration of Thyroid Substance IT BY JOHN M. SWAN, Rochester, New York T SEEMS worth while to record the progress of a patient with myxedema who has been under observation for eleven years, apart from the fact that while he was under treatment with glandulae thyroideae siccae, U. S. P., he developed an attack of auricular fibrillation which stopped upon the withdrawal of the thyroid substance, reappeared on the renewal of treatment with thyroid substance, and disappeared again when the medication was discontinued. The recurrence of attacks of arthritis is of interest and appears to be a manifestation of the lower resistance to infection of a man with myxedema. The patient, who was a locomotive engineer, aged forty-two years, was first seen on April 14, 1913. He was complaining of pain in his feet and knees. His family history was unimportant. Aside from the usual minor diseases of childhood, an attack of influenza in 1902, and two attacks of gonorrhea, he had had no serious illness. There was nothing in his habits. that had any bearing on the condition. The illness began in February, 1909, with soreness and swelling of the right foot, and a diagnosis of inflammatory rheumatism was made. He was sick for three months. After having been back at work for three weeks, the symptoms returned and he was sick for three or four months longer. This process was frequently repeated in the following three years. In 1912, he began to complain of pain and soreness in the right knee. In July, 1912, he was awakened in the night with pain in one knee. In October, he was told that he had dropsy. However, he improved so that he went back to work on January 1, 1913, worked twenty-three days and then had to lay off again. and had not been able to work since. The physical examination gave little. positive evidence of disease. Aside from the obesity, a palpable liver. edge, and a slow pulse, nothing was noted except inability to palpate the thyroid body. The left knee was painful on pressure; but was not swollen, and there was no gross evidence of disease in the joints of the feet. There was no evidence of focal infection. A diagnosis of myxedema. was made and the patient was put on glandulae thyroideae siccae, U. S. P. gr. v. three times a day. In twelve days the dose was reduced to gr. ii three times a day. He was comfortable for ten months, when he had a temporary, discrete, papular eruption on the forehead, face, trunk and arms, relieved after calomel catharsis. Tracings made with the patient lying in bed. Resistance 900 ohms. Lead I. Average ventricular rate, 52 per minute. A rather marked sinus arrhythmia is present; the minimum rate being 43; the maximum 54. The complexes are normal in form. P-1 and T-1 are both positive. The P-R interval is slightly in excess of 0.2 second, although it is hard to measure this owing to the presence of a skeletal muscle tremor. R-1 measures 8 mm; S-12 mm. Lead II. The average ventricular rate is 55 per minute. The sinus arrhythmia noted in lead I is present in this lead; although not to so marked a degree. Maximum rate, 57; minimum rate, 50 per minute. The P wave is well defined and positive. There is a definite prolongation of the P-R interval, the conduction time varying from 0.24 to 0.22 second. T-2 is well defined and positive. The electrocardiographic complexes are all of the same tyre. Lead III. The average ventricular rate is 53 per minute. Slight sinus arrhythmia is present in this lead. The maximum rate is 58; the minimum 52 per minute. The P-R interval in this lead measures 0.22 second. P-3 and T-3 are both positive and of normal shape. R-3 measures 12 mm. S-3 is absent. Note: A special tracing was made to test the action of the vagus nerve. The rate before inspiration was 52 per minute, with a slight sinus arrhythmia. During inspiration this increased to 60 per minute and during the period of inhibition which came 3.4 seconds later the rate dropped to 34 per minute. This slow rate gradually increased until at the end of the test, a rate of 52 was found. Diagnosis: (1) delayed auriculo ventricular conduction (0.22 to 0.24 second). (2) Sinus arrhythmia. |