389

have been already observed in the blood of patients sufferingfrom " pernicious anaemia." R. C- suffered, as I should imagine all patients will

when their blood undergoes important alterations, from asymptom which was most persistent, and one which wasmost difficult to treat-I refer to asthenia-a debility pro-found and unaccounted for by the condition of any of theorgans observed during lifz. As it seems to have been a

very prominent symptom in nearly all the cases which havebeen reported, we naturally consider it to be dependent uponthe changes which the coloured c ’rpuscles undergo; theyseem to lose their capillarity aod activity, and consequentlybecome ineSr-deat oxygen-carriers, and almost inert as

agents in the production of the changes concerned innutrition. It is just a question, too, as to how far thesealterations in the blood have not contributed to the want ofsuccess which has followed operations for the removal ofenlarged sp’een. Death has so frequently followed thissevere operation from what has been considered "shock,"the patients have never rallied, probably from the fact thatthere has not been the development of that nerve-forcewhich ensues on the interaction of healthy blood and nerve-tissue. Schiff’s experim-nts on dogs were successful.One of the points of interest in R. C-’s case is that there

was an increase in the number of the white corpuscles ofthe blood. This, with the condition of the blood-formingorgans found after death, naturally leads us to inquire as toits cause. It is true that the origin of blood-corpuscles inadults is still shrouded in mystery, but the spleen andlymphatic glands are supposed by all physiologists to beimportant factors in their production. The marrow ofbones, too, has received credit for a share. With thesefacts we are all more or less familiar as well as with this,that simple enlargement of an organ is usually associatedwith an increase of its functional activity. Clinical reportson some cases of gland enlargement are confirmatory "f this,notably one by my colleague. Dr. Philipson, in the BritishMedical Journal, May, 1875, wherein it is stated that"there was a considerable diminution of the red globulesand an increase of the white." This condition of matterswas found after dealh to have been associated with an en-largement of the spleen and lymphatic glands, an enlarge-ment, however, which was proved microscopically to besimply due to an increase in their normal elements.In the case I have reported the spleen, it is stated,was enlarged, but we have to remember that the en-largement was due to the presence therein of five or sixlarge nodules or new growths of a character quite differentfrom the spleen. The real splenic tissue was deficient, andconsequently the actual number of white corpuscles formedby the spleen, as spleen, must have been less than in health,unless we accept the view that the new growths themselvesacted the part of coutribu’ors. Instead of a decrease, we hadan increase-an increase associated no doubt with a generalenlargement of the lymphatic glands, but an enlargementwhich was not simple, for in them, as in the spleen, therewere new growths similar in structure to those which studdedthe trunk. Can the new growths then, as originating fromthe connective tissue, have taken on the heematoblasticfunction so ably advocated by Dr. Creighton in his paperon the Pathology of Sarc,)tua ?2 or are we to consider therelationship this, that owing to the destruction of splenictissue, the white corpuscles have not been transformed bythe spleen and lymphatic glands into coloured cnrpuscles?The state of the blood in "multiple sarcoma, then, is anincrease of the cotourless and a diminution and changedcondition of its coloured corpuscles. This was the con-

dition of the bluod in Dr. Philipson’s case of lymphaemia.and one I have been able to confirm by the use of Gowers’haemacytometer, in the pjrson of a woman who has justdi,-d from iy mphadenoma.To return to the starting. point of R. C-’s illness, iva

have the fact of an injury causing fracture of a metacarpalbone, and of the injury being followed by inflammation ofthe lymphatics and enlargement of the glands. There wasthe absorption of something from the wound which so actedupon the glands, pledisposed presumably, that, there was de-veloped a condition of matters which only finds its equal incancer, wh’.’re the glands nut only take on malignant action,but serve as foci for further constitutional infection. Long agoVirchow pointed out that simple irritation of gland-tissuewould give rise to a leucocytobis which is recoverable f, om

2 Journ. of Anat. and Physiol., April, 1880.

in most cases. We cannot help thinking, therefore, thatin the case which I have reported there must have super-vened in the gland changes other than those dependingupon septic irritation, for the lymphatic elements which hadjoined the current of blood seemed to have acted as units ofinfection, judged by the multiplicity of tumours.There is just one other point to which I would like to

draw attention, and it is this-the brain after death wasfound to contain many tumours, the presence of which wasulJattended by symptoms during life. There was no para-lysis, no impaired sensation, no ophthalmic changes. Therewas a slight tendency to stagger, but not more than isobserved in all debilitated subjects who have been confinedto bed. With the absence of symptoms on the one hand,we have on the other positive evidence of numerous foci ofcerebral lesion. Behind the right optic thalamus, and aboutone centimetre in front of the corpora quadrigemina, therelay a nodule of the size of a small walnut-a nodule largeenough surely to make its presence felt through action at adistance upon the neighbouring ganglia. In its situation itwas a little posterior to the lesion found in a case describedby Hughlings Jackson, quoted by Ferrier,3 and in whichthe symptoms were "feebleness of movement on the leftside, particularly in the left leg, great diminution of taciiiesensation on the left side, impairment of smell, or at least ofcommon sensibility, in the left nostril, doubtful diminu-tion of taste on the left side of the tongue, doubtfuldiminution of hearing in the left ear, and, which is one ofthe most interesting features of the case, left hemiopia ofboth eyes, owing to paralysis of the right side of bothretinae." In addition to the above and other smaller tumours,a nodule of a centimetre and a half in length, which hadundergone softening, occupied the left corpus striatum, andinvolved part of the lenticular nucleus. So long as thelenticular nuc’eus is undisturbed, I believe the corpusstriatum may be in great part destroyed without there beingany paralysis. Here, however, we have both, and no lossof muscular power. Now, the function of the corpora striata,according to Ferrier, is to reduce voluntary acts-acts atfirst begun under the influence of the will-to those of anautomatic nature. Anything like their destruction thereforecauses complete paralysis. I need not repeat that paralysiswas absent in my patient. This apparent want of harmonybetween lesion and disturbance of function is no proof thatall attempts to localise cerebral lesions are futile. On thecontrary, it only confirms the view that so long as the fibreswhich descend from the convolutions or the connexionsproper of the ganglionic cells with the peduncle remainintact, there may be destruction of part of the corpusstriatum and its lenticular nucleus without the productionof paralysis. Of this interruption we had no proof.

CASES IN COUNTRY PRACTICE.

BY WM. PRATT, M.D. F.R.C.S.,SURGEON TO THE MONTGOMERYSHIRE INFIRMARY.

(Concluded from p. 498, vol. ii., 1881.)

GLOSSITIS WITH ABSCESS AND HAEMORRHAGE.

T. J-, aged fifty-eight, a farmer, living about eight milesfrom Newtown, sent for me on Feb. 17th, 1881. There was, themessenger said, something the matter with his mouth. On

paying my vidt, I found the patient sitting by the fireside,unable to speak or even to open his mouth, and he couldswallow only with much difficulty. He pointed to his mouth,and intimated that there was nothing wrong anywhere else.With much pain and some force I got the teeth separated alittle, and found the tongue enormously swollen, especiallyon one side, indented all round with teeth-marks, very dirty,with a most offensive breath. The pulse was normal, andthe temperature but very little above normal. It was anevident glossitis, for which I could discover no particularcause. I now got the mouth sufficiently open to allow meto scarify the organ freely, and made the patient washit with abundance of warm water. The bleeding wasprofuse, but in a quarter of an hour the tongue was re-

duced in size, the patient could speak, and he professedhimself much better. I now ordered hot poultices under the

3 The Functions of the Brain, p. 244.

390

chin, warm washings to the mouth, liquid food, and a seemed a kind of fit; she was then helped up to a bedroom,purgative. Being of a thrifty disposition, the patient re- where she was very sick. All who saw her thought she wasquested that I should not call again unless he should send intoxicated. After remaining there about four hours shefor me. The next day his son called to say that his

was requested to seek her relatives. She then left thefather was certainly no worse, but rather better. How. hotel, with assistance, and was next seen sitting in a door-ever, on Sunday, Feb. 20th, a neighbour arrived on

way. About 9 P.M. she was able to appeal to a woman,horseback to fetch me in all haste, inasmuch as the who came near, to take her in, saying that she was

patient was " just" dead. A vein, he said, had burst in very ill, that she had been so for weeks, and that she hadthe patient’s mouth, and he was literally bleeding to death, been told by a Manchester medical man that she was suffer-When I reached the house I found the patient in bed, some- ing from diabetes. The woman believed her story, took herwhat blanched but able to speak, his pulse beating well, though in, and sent for a police officer, who managed to get at thesomewhat softer than before. I now learned that on the names of her relatives. These, being communicated with,Friday evening previous something had burst in the patient’s came to her at once and sent for me.mouth, and discharged much stinking matter, to his infinite I found E. R- in the condition described. She wasrelief. He now thought himself all right, but on Saturday not drunk, for there was no tremulousness of hands orevening blood began to flow from his mouth, and it flowed tongue, no nonsense talked when she was roused to con-more or less all Saturday night and Sunday morning. sciousness, and her countenance was not that of a drunkard.On opening the mouth, which was now effected without She was not apoplectic, for there was no paralysis. Theremuch difficulty, I found on the under surface of the tongue, was no history or appearance of injury. I thought itand exactly on the line of the ranine artery, a large hole uraemia. I ordered her to be taken at once to her aunt’s,full of black clots, and smelling most offensively. Evidently about half a mile off. I accompanied her thither in the con.a glossal abscess had formed and burst, and afterwards a veyance and saw her safe in bed. Even as I left the un-venous radicle of some size had given way into its cavity and conscious state was deepening.bled freely. I at once syringed the hole well with warm Next morning, about 9 A.M., I again saw E. R-. Shewater till I got it as clean as possible. On applying a had passed a restless night, and was now almost quite un-little pressure, some pus with a good deal of blood flowed conscious, only answering "Yes" or "No" when shoutedout. I inserted a small plug of lint, dipped in a very watery to. The pupils were dilated and the conjunctiva insensible ;solution of perchloride of iron, and directed it not to be dis- pulse 130, small ; respiration rapid and noisy. On ausculta.turbed until the morrow. The food to consist of good soup. tion the lungs were found to be without disease, and theNext day there had been no recurrence of the bleeding, and heart’s sounds very clear and normal. In the night timeall was progressing satisfactorily. I syringed the mouth well she had passed urine very freely, and had got out of bedout with diluted Condy’s fluid till all was quite sweet, and I herself to do so. The urine contained about one-eighth ofleft orders that that should be done several times daily. There albumen, and was loaded with sugar. At 3 P.M. she waswas no more bleeding. The tongue decreased in size daily, quite insensible ; pulse feeble ; extremities cold and dusky;the power of taking solid food returned, and in a fortnight’s respiration and pupils as before. She could still swallow,time T. J- called upon me, reported his health as perfect, though quite unconsciously. At 7 P.M. she was in a’i"ticuloand showed me his tongue, which, with the exception of a mortis, and died comatose at 8 P.M., twenty-two hours afterslight induration on its under surface, looked and felt I first saw her.quite normal. My treatment consisted in surrounding the patient with

ACCIDENT WITH A STRAW-CUTTING MACHINE. external warmth, in giving milk with a little brandy, and inACCIDENT WITH A STRAW-CUTTING MACHINE, trying to act briskly on the bowels. No post-mortem was

E. J-, labourer, aged sixty, on the 16th February, allowed, but an inquest was held, at which I gave the1881, was feeding a straw-cutting machine driven by steam, opinion that the patient had died of diabetes complicatedwhen his left hand was dragged below the knife, and four with Bright’s disease. I now think that I gave too muchof his fingers were dean cut off a little above the first pha- prominence in my thoughts to uraemia, being influenced bylangeal joint. There was a good deal of bleeding, which the seeming convulsion and severe vomiting in the hotel,was, however, stopped by cold water. The thumb was left together with the patient’s paleness. From no convulsionuntouched. When he was brought to me I considered that taking place whilst the girl was under mv care I doubt if anyit would be very unwise to take off the finger stumps which real convulsion ever did take place, end from the absence ofremained, and leave only the palm. If the stumps of the all anasarca I am inclined to think that acetonaemia, andfingers could be saved the hand would be of much use to him; not uraemia, was the actual cause of death. Mr. Cullingworth

- without them but little. Besides, is it true that there is no of Owens College, Manchester, the gentleman who saw theflexion of the first phalanges if they be left on ? That I ques- patient in Manchester, kindly wrote to me, saying that hetion. Why should not the lumbricales and the interossei saw the patient for the first and only time on May 9th, anddo a little flexion, even if the tendons of the large flexors that he diagnosed diabetes, and ordered her home withoutretire within their. sheaths and do no more work ? At all delay. He afterwards heard that she was somewhat con.events, I resolved to leave E. J- his stumps. I ac- fused at the Manchester station on May llth, when takingcordingly put the patient under chloroform, cut off the her ticket for Newtown. The coma was even then beginning.jagged ends of bones, and utilised every morsel of skin for Mr. Cullingworth further writes that he has met with aflaps, with the result that in a fortnight’s time two stumps somewhat similar case before, and directs attention to threewere quite healed up. From the other two portions of bone papers on what he calls "diabetic coma ’ in preference tocame away before a cure was effected, but in a little more" acetonaemia." These, for the sake of further inquiry, maythan a month the whole four stumps were healed. The be here mentioned. They are : Southey, THE LANCET,power of flexion is excellent, and the hand is very service- Feb. Sth, 1879 ; Elliott of Hull, THE LANCET, March 22nd,able. The patient is left-handed, much to his joy, he can 1879 ; "Acetonasmia," by B. Foster of Birmingham, Britishwrite and grasp nearly as well as ever. Medical Journal, Jan. 19th, 1878.

Diabetic coma, or acetonaemia, is a subject of the highestACETONSEMIA SIMULATING DRUNKENNESS. importance both to the physician and to the n edical jurist.

On Wednesday, May llth, 1881, about 10 P.M., I was re- There is blood-poisoning in diabetes, ending in coma andquested to visit E, R--, just arrived in Newtown. On death. What is the exact poison? Is there any antidote toreaching the house where the patient was staying I found a it ; or what is the proper treatment? There is a morbid stateyoung girl of about twenty-four years of age, pale and thin, which to the uneducated exceedingly resembles drunkenness;in a semi-conscious state, breathing rapidly and noisily, and the general practitioner when henceforth called to a casewith a small quick pulse. She was sitting in an arm-chair, of insensibility must bear in mind that it may be drunken-and could answer questions, but confusedly and with diffi. ness, or uraemia, or apoplexy, or injury, or epilepsy, or

culty. diabetic coma. The last state is scarcely alluded to in ourThe history given of her was a3 follows :-She had arrived text-books of medicine. Bristowe certainly says that "not

here by the 4 P.ii. train from Manchester. At the station liufrequently the patient dies comatose. It must be addedshe had a staggering gait and a confused manner, with that diabetic patients bear fatigue, mental or bodily, verysaliva here and there on her clothes, and was considered by badly ; and that at an advanced period of their disease theyall who saw her to be drunk. She took the omnibus to the are apt, after such fatigue, to fall into a state of almostprincipal hotel, where she asked for a little brandy-and- sudden collapse, from which they do not rally." That is all;water, which was supplied to her. In a short time she fell and it is certainly nut enough. In our text-books of forensicoff her chair in the commercial room of the hotel in what medicine it is not mentioned at all. In the last edition of

391

Guy and Ferrier, I cannot find a single paragraph upon thesubject. In mentioning the symptoms, I find that I haveomitted to allude to one-that is, the diabetic halitus, uponthe absence of which in acetonaemia Dr. Southey has some-what insisted. In E. R-’s case it was also quite absent.Newtown, Montgomeryshire.

POISONING BY LEAD DICHROMATE.

BY R. C. SMITH, M.D., B.SC. (PUBLIC HEALTH) EDIN.

ON February 12th, 1881, Mrs. B-, aged thirty, a weaverin a cotton-mill, came to me for advice and treatment. Shehad been unable to follow her work for the previous sixweeks, and was suffering from great weakness, wanderingpains in her limbs, and anaemia. Her gums showed well-marked signs of lead poisoning; there was no albumen inher urine. She attributed her illness to the inhalation of a

yellow dust that was given off from the yarn in the processof weaving an orange-coloured cloth. She had alwaysenjoyed good health before being engaged at this class ofwork. She gave as a reason that it was the coloured dust

(lead dichromate) which had made her ill; that her fellow-workers when engaged at the same kind of work sooner orlater sickened, and that there were many others at home illfrom the same cause.

_

Mary C-, also a weaver at the same mill, applied foradvice a few days after Mrs. B-, and had like her beenengaged as a weaver of orange yarn. The blue line was verydistinct. Her breath was offensive, and the skin and con-junctivae of a distinctly yellow colour. There was no albu-men or bile in the urine, nor had she any tenderness over theliver. She suffered from tormina and wandering pains overthe body, and was very costive. Under treatment theyellowness of skin passed away, but the blue line remainedlong after other symptoms of lead poisoning had disap-peared.Jane C-, sister of the above, was visited by me at her

own home on the same day. I found her also affected withlead poisoning. She appeared to be, at first sight, sufferingfrom an acute attack of jaundice. Her skin and conjuuctivaewere intensely yellow. There was obstinate sickness andpurging of dark sap-green motions, probably stained withchromic oxide. The urine contained albumen with a traceof chromium, but no bile or lead. This patient recoveredwith great difficulty; the staining of the tissues, sickness,and purging ceasing first, but the blue line is still present.The above are types of caces that were of constant occur-

rence nine months ago, in the practices of medical men inthe neighbourhood of the mill in question. I had eightcases at once under my treatment from the same mill forthis peculiar form of lead poisoning. Another medical manhas had twenty, and a third has had from thirty to fortysimilar cases in all under observation. One of the millhands, under the care of a fourth medical man, dying fromlead poisoning resulted in an inquest, when at the post-mortem ordered by the coroner the surgeon found distincttraces of lead in the liver. Public opinion having been thusdrawn to the dangerous nature of the work, pressure wasbrought to bear on the employers, who have since thencaused the yarn to be more carefully dyed and preparedbefore being woven. They have also insisted on the windersand weavers wearing a muslin respirator over the mouthand nose when at work, and the use of hooks instead ofsucking with the mouth the yarn through the eye of theshuttle. By these precautions having been rigorously car-ried out, the operatives, though still weaving chromes, nolonger suffer from lead poisoning. A microscopic exami-nation of the fibres of the cloth made from the yarn whichI obtained from the manufacturers, shows minute crystalsof the orange chrome adhering to the outside of the filaments,as well as others still more minute within the tubule and inthe interspaces of the cortex. The crystals on the surfaceare easily washed away by trituration with water and settltat the bottom of the washing, whence, if collected and fusedwith nitre and carbonate of soda, the characteristically yellowchromate of soda is produced. Ammonium sulphide blackensthe crystals at once.

’

In the cases which I have observed, the yellowness o:

the skin is the first symptom to disappear, and the blu(

gums the last; chromium exists in the urine, and mostprobably in the faeces. I therefore conclude that after ad-sorption the dichromate undergoes decomposition in theblood, the lead being fixed in the tissuq, whilst the chromicacid combines with soda, a compound which is intenselyyellow and stains the liquor sanguinis and skin for a time,ani finally leaves the body by the liver and kidneys.Ardwick.

_______________

CASE OF EXTERNAL BILIARY FISTULA.

BY J. MACKENZIE BOOTH, M.A., M.B. ABERD.

THE following case, which recently came under myobservation, is, by reason of its somewhat rare occurrence,worthy of being recorded.The patient, a laciy aged seventy-seven, had for ten years

suffered from well-marked attacks of hepatic colic ; and,until three years ago, these occurred at intervals of a fewweeks. Towards the end of September, 1878, I attendedher during an unusually severe attack, which lasted forseveral days. The attack was accompanied by retching andjaundice, but, though the stools were repeatedly searched,no gall-stones were found. Since then she has been entirelyfree from these seizures, only complaining from time to timeof slight pain or uneasiness in the right hypochondrium.In June, 1881, a painful swelling appeared on the right side,which remained some time before it became red and burst,giving exit to a scanty yellowish discharge. Save its per-sistence, she noticed nothing unusual, until, one nighttowards the end of December, while preparing to retire, shediscovered a hard black point protruding from the orifice ofthe wound. As it hurt her on being touched, she hadrecourse to a hair-pin, with which, after one or two vainattempts, she succeeded in dislodging a hird black bodyabout the size of a large pea. Next day two concretions ofa similar size were passed.On calling, I found the objects to be medium-sized gall-

stones, about a quarter of an inch in diameter. On exami-nation of the abdomen, a depression of the integument wasnoted round a small wound about a quarter of an inch inbreadth, situated on the right side, near!y midway betweenthe umbilicus and the crest of the ilium. A thick induratedband of about an inch in breadth could be felt deeplythrough the abdominal wall, passing up towards the gall-bladder until it was lost over the site of that organ at themargin of the costal cartilage. A scanty sero-purulent dis-charge slightly tinged with bile continued to ooze from theopening. Several more gall-stones have since been extruded,varying in size from that of a miilet-seed to that of a pea.Further than this there is nothing worthy of remark, savethat the formation of the fistula and the appearance of thecalculi explain the abrupt leave-taking (now three years since)of the patient’s periodic and painful visitant.Aberdeen.

NOTE ON THE

TREATMENT OF ACUTE TONSILLITIS BYSALICYLATE OF SODA.

BY JOSEPH W. HUNT, M.D., B.S. LOND.

WHILE the treatment of rheumatic fever by salicin andsalicylate of soda is under discussion in the page of THELANCET it may be well to notice the effect of the same drugsin an allied disease. The close connexion which has longbeen recognised between rheumatism and certain forms oftonsillitis induced me to try this remedy, and the resultshave been most favourable. In my hands it has actedalmost as a specific in acute tonsillitis. Provided that thereis no actual formation of pus, most decided relief is afforded inabout twenty-four hours-i. e., the swelling and angry-lookingcondition of the tonsils are reduced, pain diminished, and thepatient can swallow with comfort, while the temperaturebecomes normal and the pulse is reduced in frequency andimproved in quality. Since I have used this drug I havehad no single case go on to suppuration; nay, more, whereit has appeared, from the state of the tonsils and thebrawny and infiltrated condition of neighbouring parts,