A CASE OF CHRONIC PANCREATITIS.

454 There were no acromegalic or osteo-hypertrophic changes but there was marked adiposity. The necropsy showed the presence of a tumour of the pituitary body "of the size of a small nut,"vascular, cystic in character, and practically limited to the sella Turcica. It showed a small prolongation passing upwards into the third ventricle. It was a cystic adenoma and in its histological character presented features identical with those occurring in a case of gigantism to which reference has been made in THE LANCET.1 Attention is drawn by Dr. Cestan and Dr. Halberstadt to two points of interest in the present case-viz., first, the absence of skeletal changes and, secondly, the presence of mental changes, such as apathy, enfeeblement of Such memory and of intelligence, and somnolence. mental changes have been noted in cases of pituitary tumour by Woolcombe,2 Frohlich, and Schuster (1902). The last-mentioned writer states in a monograph on the subject of cerebral tumours aecompanied by psychical disturbance that out of a total of 775 such cases 61 were due to tumour of the pituitary body. Somnolence as a marked feature has been noted by Soca (1898), Schuster, and others. To reconcile the view that osteogenetic changes (acromegaly and gigantism) may occur in some cases of pituitary tumour while absent in others Dr. Cestan and Dr. Halberstadt suggest that when pituitary tumours or lesions appear in infancy they affect the nutrition of the osseous tissues and produced gigantism, that when they occur in early adult life the result is acromegaly, and, finally, that when the affection supervenes in middle or old age, after the osseous and other tissues of the body have attained the maximum of growth, the result is a preponderance of the mental symptoms of apathy and somnolence combined with obesity, as in the case to which reference is made above.

have passed a resolution that Dr. Buchanan should examine all lunatics, the power to call in a medical man rested with the justices and the resolution of the guardians was of no legal effect." It will clearly be advisable in future for workhouse medical officers on accepting appointments to have their position in regard to In some cases the fees for emoluments properly defined. certifying lunatics constitute quite a large proportion of the salary, so that the amount at stake may be considerable.

guardians

THE

ROYAL

COLLEGE OF

PHYSICIANS OF

LONDON. THE following lectures for the present year will be delivered at the Royal College of Physicians of London, Pall Mall East, on the dates named below at 5 P.M. The Milroy lectures will be delivered by Dr. W. Williams March lst and 3rd, the subon February 25th and ject being Deaths in Childbed, a Preventable Mortality. The Goulstonian lectures will be delivered by Dr. R. Hutchison on March 8th, 10th, and 15th, the subject being Some Disorders of the Blood and Blood-forming Organs in Early Life. The Lumleian lectures will be delivered by Dr. F. Taylor on March 17th, 22nd, and 24th, the subject being Some Disorders of the Spleen. A

CASE

OF CHRONIC

PANCREATITIS.

MOST recent writers on diseases of the pancreas have entered a plea for the more careful observation of the clinical phenomena of such cases and more regular and systematic examination of the pancreas at necropsies in order to furnish workable data for the filling up of the numerous gaps in our knowledge of the normal and pathological conditions of this important organ. Dr. Ferdinand Ehler of Brunn has carefully recorded a case of chronic indurative pancreatitis in the TIliener Kliniscke WochenPOOR-LAW MEDICAL OFFICERS AND SUPERANNUATION. schrift, No. 51, 1903, which presents several features of interest from the clinical and pathological standpoints. A MATTER affecting the interests of medical men concerned The patient was a woman, aged 56 years, who with in the administration of the lunacy law has just been dealt the exception of a few slight gastric attacks had enjoyed with by the Local Government Board and although we health until five months before going to hospital, regret the decision come to we note incidentally that it bears good when she suffered from severe lumbar pain which, howout entirely the opinion expressed recently in these columns ever, soon ceased so that she was able to return to her as to the position of workhouse medical officers in regard to I work. Four months later she had a recurrence of these fees for certifying pauper lunatics. On the superannua. more severe in character, and radiating to the tion of Mr. W. Buchanan, late medical officer to the Medway pains, followed by an intense jaundice. There abdomen, rapidly union workhouse, the guardians of that union resolved was no history of syphilis or alcoholism. On admission to to grant him an allowance based upon the fees which he had she was described as a cachectic, emaciated woman hospital received for the examination of lunatics during the past five of apathetic expression and olive-green complexion. The years. The district auditor disallowed the payments and was irregular, weak, and its rate was 60 per minute. surcharged the guardians who authorised them with the pulse The abdomen was slightly distended but not rigid or tender An appeal to the Local Government Board amount. and there was no ascites. A tumour of the size of a goose’s resulted in a confirmation of the auditor’s decision, the was felt beneath the right costal margin, presenting following reasons being given for the attitude adopted. egg the characters of a distended gall-bladder. The liver was "It forms no part of the duty of a medical officer of a its edge being felt below the costal workhouse to make the examinations to which the auditor moderately enlarged, The spleen was normal in size. The bowels were margin. refers and it is open to the justices, whatever their opened once or twice daily, the motions being of thin conpractice may be, to call in any medical practitioner sistence and free from bile pigment. The urine was dark, for the purpose. Consequently the medical officer of bile-stained, and free from albumin and sugar even after to seems be in the same position as a workhouse the administration of milk sugar. The temperature was subany other medical man and the fees paid to him under normal, ranging between 360 and 36.5° C. The alternative the Lunacy Act, 1890, by order of the justices are not diagnoses of gall-stones or of carcinoma involving the bilepaid to him in his capacity as medical officer of the work- ducts were made and laparotomy was performed, the house. Hence the Board are of opinion that the fees in distended gall-bladder being found and opened, but no question cannot be regarded as emoluments of Dr. gall-stones were discovered. On deep palpation towards Buchanan’s office and should not have been taken into the left side a hard tumour could be felt which was consideration in calculating the amount of his superannuaas carcinoma of the pancreas. The patient died tion allowance." In another part of the letter the same regarded four days later from pneumonia and cardiac failure. At the principle is enunciated in these words : "Although the necropsy no carcinoma was found but there was a condition of chronic indurative pancreatitis ; there was a retention cyst 1 THE LANCET, March 14th, 1903, p. 747. 2 Brit. Med. of the size of the fist in the tail of the organ filled with Jour., June 23rd, 1894, p. 1351.

455 turbid fluid of chocolate colour, the rest of the parenchyma being markedly indurated and permeated by fibrous bands. The common bile-duct was compressed and obstructed The liver below and dilated above the obstruction. w,is enlarged but showed no definite pathological change, The stomach was slightly dilated but its mucous membrane presented no macroscopic alterations. There were some fibrous myocarditis and a recent croupous pneumonia. Microscopically the pancreas showed marked overgrowth of fibrous tissue, apparently starting around the vessels and small ducts and thence invading the parenchyma of the organ. The interest in the case, considered pathologically, is that it was apparently primary and not the result of syphilis, alcoholism, or gall-stone obstruction, as these cases often are, and Dr. Ehler was inclined to regard this case as originating from a vascular change in the gland of the nature of arterio-sclerosis and referred in support of this to the fibrous condition of the myocardium (although no atheromatous changes were found in the aorta) and to the condition of the vessels of the pancreas, which were distinctly thickened. The interest from the clinical standpoint is that this case supports Courvoisier’s dictum that jaundice in association with distended gall-bladder is usually due to obstruction of the common duct from some other cause than gall-stones.

and the like. The exhibition should, we think, prove of great interest and as an example of what can be done with old-time material we suggest that "our Colleges of Westminster, Winchester, and Eton" be aked to send models of some of their older schoolrooms. Many of these are such as would cause a zealous School Board member to faint from horror and yet the institutions possessing them turn out boys who become men of great value to the State.

appliances

TUBERCULOSIS IN

DAIRY COWS.

WE have received a copy of a pamphlet with the above title written by Dr. J. Wright Mason, medical officer of health of Hull, and Mr. James McPhail, M.R.C.V.S., chief meat inspector. The writers point out that municipal and local authorities have obtained stringent powers to deal with tuberculosis amongst dairy cows. They have therefore published this pamphlet to give information couched in simple terms to persons in charge of dairy cows and to those who are directly interested in such legislation. They have succeeded well in this laudable object and have described in language devoid as far as possible of technical terms the symptoms which may be observed in cows suffering either from acute or chronic tuberculosis. The dangers that are attendant on drinking milk

when the udder is affected are The symptoms of this affection are THE RESUSCITATION OF DR. A. DARIER. indicated and although the dairyman cannot be expected to THERE was once an American editor who received a cal I a diagnosis of tuberculosis, yet when he finds the parts make from an indignant gentleman whose death he had chronicled in i the condition described it is undoubtedly his duty to draw in his paper. The indignant gentleman, producing himselftthe attention of his employer or the veterinary surgeon to the as proof of his words, demanded that a statement should be( animal. made in the paper that the editor was at fault. To this the editor replied that in his paper no mistakes were ever made,RUPTURE I OF THE TENDON OF THE EXTENSOR LONGUS POLLICIS. adding that, if they were, they were never acknowledged. After some argument, during which the editorially deceased IN the Boston Medical and Swrgical J01l’rnal of Dec. 10th, person was able to show that he had a real grievance, the 1903, Dr. C. L. Scudder and Dr. W. E. Paul have described a situation was met by the editor who, repeating the very rare injury-rupture of the tendon of the extensor longus impossibility of making a public declaration of error, added pollicis. A woman, aged 58 years, fell and struck the back that he would publish his visitor’s name in the next list of of her left hand on the edge of a stone step. There was births. It has been brought to our attention that in a tenderness near the proximal end of the first metacarpal summary of the ophthalmological work of the year 1903 bone and in dressing herself the patient felt pain at that we referred to Dr. A. Darier, joint-editor of La Clinique place. Three weeks later, when the hand felt practically Ophthalmologique, as deceased. This, we are very glad to well, on attempting to take hold of a chair she found say, was a mistake, and we admit it with none of the that the left thumb could not be used and remained reluctance to say peceavi that was shown by our American flexed in the palm. Examination on the next day colleague in the story. We resuscitate Dr. Darier in a showed that the proximal phalanx of the thumb could conspicuous part of THE LANCET and not in the birth not be extended, so that in grasping movements the column. We regret not to have made this amende to him thumb was closed Feeble upon by the flexed fingers. sooner, but no exact reference was given to the place in extension of the distal was readily performed. phalanx our columns where the slip had occurred, and until now All movements of the metacarpal bone were executed but we were unable to find that we had cut off the well known the range of extension and abduction was diminished. French ophthalmologist in his prime. We trust that he has The only indication of the site of the rupture was the not been seriously inconvenienced. assertion that there was some tenderness on from

-

a

tuberculous

strongly insisted

cow

on.

diseased

____

patient’s

THE

INTERNATIONAL CONGRESS HYGIENE.

FOR SCHOOL

THE first international congress for school hygiene will be held at Nuremberg from April 4th to 9th and in connexion with the congress there will be an exhibition of objects referring to school hygiene. Much interest has been taken in the announcement of this exhibition and the committee therefore intends to open it some days before the, commencement of the congress and to keep it open for somei days after the congress has closed. All objects referring. to school hygiene may be exhibited, such as plans andL models of school houses, treatises on the principles of schoolhouse building, treatises on the education of children botht at school and at home, school furniture, books, drawing; instruments, and apparatus for the medical examination ofE children and for their physical education, such as gymnastic} -

using

end of the dorsum of the the tendon of the extensor metacarpal brevis pollicis near its insertion was thought probable. Six weeks later an operation was performed. The tendon of the extensor longus pollicis was found to be ruptured the proximal end of the metacarpal bone. near The sheath was intact. Careful dissection along the wrist was necessary in order to find the retracted muscular which was six or centimetres from the seven belly, distal end of the torn tendon. Approximation of the ends of the ruptured tendon was impracticable. Tendon transplantation was therefore performed. ’The tendon of the extensor carpi radialis longior was partially cut on its radial aspect and split along its length for about three centimetres. The distal fragment of the tendon of the

the hand

extensor

surface.

the bone.

near

proximal Rupture of

was cut transversely to secure a smooth The tendons thus prepared were united by three

pollicis