A man aged 33, of unestablished marital status and nominally working as barman, first attended St. James' Hospital, Birkenhead, in June, 1959. He denied sexual exposure since wife had been killed by horse 10 weeks previously in Eire, and complained of urethral discharge, dysuria, and swollen right knee for the past 9 weeks, all noted on clinical examination. Neisseria gonorrhoeae was cultured from the discharge. He was treated with intramuscular penicillin (P.A.M.) 450,000 units and admitted to St. Catherine's Hospital; 3 days later, the urine still being turbid though gonococci were not found, he was given 1 g. streptomycin intramuscularly and course of sulphadimidine. Within week, the urine was clear. After 12 days the right knee appeared normal and 4 days later prostatic smear showed no cells and he was discharged from hospital. He had been very troublesome in-patient, his departure being greeted thankfully. In September, 1959, now a life-long bachelor, he attended the Seaman's Dispensary, Liverpool, with another attack of gonorrhoea of 2 days' duration, following exposure to risk 14 days before. There was swelling of the right knee which subsided with the urethral infection, and which, with prostatitis and stricture eliminated, was considered cured 5 weeks later after the same treatment. In November, 1959, now happily married for the past 14 months with his wife pregnant, he attended at Birkenhead with mild (but not circinate) balanitis which rapidly responded to local measures. After 5 months, now single man, he attended in Liverpool with mild non-specific urethritis of4 days' duration which had started 3 weeks after exposure to risk. There was no knee involvement and treatment with streptomycin and sulphonamide was rapidly effective. In February, 1961, now divorced, he was once more an in-patient at St. Catherine's, Birkenhead, with an acute staphylococcal throat infection, which was suspected, for time, of being an acute chest, abdominal, or central nervous system emergency. Evidence was then obtained of previous treatment in the Birkenhead group of pleural effusion in 1947 and of gastric ulcer in 1953. On May 1, 1961, 14 days after exposure to risk, he reappeared with acute gonorrhoea of 5 days' duration and swollen right knee for 3 days. Three days after an intramuscular injection of 600,000 units P.A.M., there was no discharge and clear urine, but his right knee was much worse and the left knee also considerably swollen. He was re-admitted to St. Catherine's and, despite clear urine, both knees were much worse on May 8. In the hope of rapid cure and of keeping him within due bounds, it was decided to resurrect T.A.B. therapy and an initial intravenous dose of fifty million organisms was accordingly administered at 9.0 a.m. A satisfactory response ensued, the temperature rising to 104'F. and subsiding to normal by 8.0 p.m. The joint condition also improved. On May 10, doubled dose was given by my colleague, Dr. A. S. W. Egerton. This resulted in maximum temperature of 104°F. which by 11.30 p.m. was 99-8 F. (pulse 88) and at 12.30 a.m. 99-2 F. (pulse 84). During the evening, the nursing staff discovered some beer bottles and bottle substantially consumed, of whiskey, the last concealed between the bedclothes. The removal of these items was ill-received by the patient. (A further attempt at smuggling on the following day confirmed that delivery of the former consignment had occurred during the evening visit.) At 1.5 a.m. the patient was found cyanosed and struggling for breath and an injection of Nikethamide (Coramine) alone was administered before death. An autopsy by Dr. R. Rawcliffe, consultant pathologist to the Birkenhead Hospital Group, revealed acute oedema of the glottis, the lungs being macroscopically and on section apparently normal. In the opinion of Dr. Rawcliffe, death was undoubtedly due to oedema of the glottis, an anaphylactic reaction following the injection of T.A.B.
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Dec 1, 1990
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