A CASE OF NYSTAGMUS ARISING FROM AN UNUSUAL CAUSE.

1536 THE CAUSE OF GOITRE. To the Editors of THE LANCET. SIRS,—I have read with great interest, in TjtK LANCET -of Nov. 9th last, Dr. Gordon Holmes’s remarks on the pathogenesis of sporadic goitre. It is curious that, so tfar as I have read on this subject in the text-books and in the various articles in the medical papers, I can find no reference to the observations of Dr. J. Saint-Leger on the In his book-" h;tucles sur les Causes de - cause of goitre. .crétinisme et du Goitre Endémique," published in Paris in 1867-there are some very interesting and carefully worked .out observations on the origin of these diseases. He passes in review the various supposed causes and brings forward ’conclusive evidence against them. He traces the close connexion between goitre and cretinism, and maintains that the mumber of cretins free from goitre has been greatly exaggerated, pointing out that among cretins there is found .a form of goitre which shows very little externally, the swelling of the gland developing laterally and under the muscles ; he also adds that all cretins labour under embarrassed respiration as if from a mechanical obstruction. I may rmention that we found among some of the cases of goitre operated on during my period of residence at the Cumberland Infirmary that the disease showed very little externally, but had grown under the muscles, and in two cases the growth was found embracing the trachea, and the greater part was found posteriorly. As to the cause of goitre, Dr. Saint-Leger maintains that it is found in the drinking water, and after an exhaustive research into the geological formation of the goitrous districts he came to the following conclusions. 1. That endemic goitre coincides with metalliferous soils. 2. That the chief goitre-forming element is sulphide of iron - or iron pyrites. This is the most abundant and most frequent "element, and the only one which is never absent. 3. That mext in order of frequency comes copper pyrites (the double - sulphide of copper and iron), and then, but less frequently, the sulphides of lead, arsenic, and antimony. In support of this contention he brings forward most conTiucing arguments. It is the small dose of the sulphides frequently repeated that causes the disease. In three mice ,to which for three months he gave in their food small doses of sulphide and sulphate of iron, he produced very marked swelling of the thyroid, and in others to which were administered other supposed goitre-forming substances no such effect was produced. A very striking instance he quotes ,from Mr. Clelland’s observations :-"In the year 1831 two companies of the 30th Regiment of Native Infantry were placed in garrison at Lohooghal, while two other companies were stationed at Petoragur, a station to the north of Lohoogha having precisely the same altitude and mean temperature as the latter. At the end of three years there was not a single case of goitre at Lohooghal, while at Petoragur there were fifty. The water for the supply of the former station came from the metamorphic clay schist, while - that for the latter came from metalliferous limestone containing beds of schist with graphite and iron and copper

pyrites." Another

Leger was

daughter being affected with the disease.

pyrites as a cause of goitre. I

Fenrith,

out in this country. I am at present endeavouring to find out their truth as regards Cumberland and Westmorland, and hope to ,communicate the results of my research at some future -date. Goitre is endemic here, and it is well known that n the mountains of the Pennine range-and, indeed, in other hills in these counties-iron, copper, and lead are found in large quantities, and it would be interesting to find out if these metals are found in other goitrous districts in ’the country. With regard to Dr. Holmes’s remarks on predisposing causes of goitre, my experience here bears out the tfact that the disease is most prevalent in females and that it develops generally at puberty, though in some cases in


childhood.

more

I have

working

seen

several

cases

of mother and

am,

Sirs,

yours

truly,

E. STEVENSON, M.B.,

B.C. Cantab.

infection, as I considered, he returned to his home in Ireland. He

having

one

sister at home who

was

young and very

delicate, his parents resolved that he should go somewhere in

country before joining the family, for prudential reasons. Within three days of his leaving my care the sister fell ill with scarlet fever, although there had been no communication with the convalescent. Now, had the convalescent returned to his home I should doubtless have inferred that the sister’s illness was a "return" case of scarlet fever, whereas I have little doubt that she contracted her scarlet fever by travelling in a tramcar within four days of falling ill. It was known that there was scarlet fever in the town in which she resided. In my opinion some of these "return" cases of scarlet fever are doubtless freshly contracted cases arising from travelling in public conveyances-railway carriages, cabs, and tramcarswhich are the most infectious of all places-certainly they cause me great trouble. Within the last six months I have traced two cases to travelling in railway carriages, one while travelling to a football match, the other to a funeral. the

T

Rugby,

Dec.

a.m_

Sirs.

vnnr

obedient servant

CLEMENT DUKES.

6th, 1895.

"’TUBERCULOUS’ vel ’TUBERCULAR’?" To the Editors of THE LANCET. SIRS,—Among your annotations in THE LANCET of Dec. 7th one under the above heading. The difficulty and pertherein mentioned have long been recognised, and I plexity have publicly and privately suggested a very simple and, to my mind, perfectly satisfactory solution-viz., the use of the word "nodule " for the representation of an object otherwise capable of being called a small lump, and the correlative "nodular"or ° ‘ lumpy." As you say, custom has hallowed and made inviolate the noun tubercle," and I would suggest that the time has now arrived when tubercle, tuberculous, tubercular, &c., should be gracefully yielded up to the power of a specific bacillus, and only used to The old order connote its activity, past or present. changeth, giving place to the new, and I maintain that what was excusable in an anatomist in years gone by, to apply the term "tubercle" to any small lump, cancerous, sarcomatous, or of unknown origin, is now no longer so since an all-powerful bacillus has seized upon it for its own. If my suggestion be accepted confusion cannot arise, for if the bacillus be not actually searched for we can still say "a nodule was found (? tubercular)." About three-fourths of the literature of consumption would never have obscured our eyesight, physically and mentally, had the simple words nodule and nodular but been used in the place of tubercle and tubercular where doubt was in the mind of the writer as to the presence or absence of the bacillus.

there is

convincing proof brought forward by Dr. Saintfollows. Knowing the geological formation of

require

Nov.

LOUIS 12th, 1895.

family cannot always be interpreted as "return"cases. A boy at school here had scarlet fever, and when free from

as

and

interesting to

"’RETURN’ CASES OF SCARLET FEVER." To the Editors of THE LANCET. SIRS,-A record of the following history, which occurred in my practice some two years ago, may be of interest in showing that subsequent cases of scarlet fever occurring in a

’certain districts of France he marked on the map the localities in which there ought to be goitre and then visited them. He found no goitre in the districts where he did not expect to find it, but he did not find goitre in all ’the places he expected, but in these cases he found that the water-supply was either got from a different formation at a distance or from wells sunk in beds of transported alluvium ,covering the real geological formation. In all the other ,districts he found the disease. These observations are very

interesting

It is

mention, in conclusion, that Paracelsus and other physicians of the sixteenth and seventeenth centuries accused metallic waters of causing the neck to swell, and even mention iron

T remain

I

Christopher-street, E.C.

Sirs

yours

trnlv

FRED. J. SMITH.

A CASE OF NYSTAGMUS ARISING FROM AN

UNUSUAL CAUSE. To the Editors of THE LANCET. SIRS,—On reference to text-books I find the causes of nystagmus, or involuntary oscillation of the eyeballs,,to be divided into two classes according to the age at which the symptom manifests itself-namely, in early or in adult life. The causes in early life are congenital cataract, corneal ulcer and atrophy of the choroid ; whilst in adults, miner’s nystagmus and that occurring in locomotor ataxy are the

1537 In the case in question it was whilst them to the General Council of Medical Education for the" of the children that I first saw the father, appointment of additional examiners in surgery, in which i who is a gardener, and noticed that he had nystagmus. is stated " Irish opinion was much divided on the Council."’ I inquired whether he had ever been bothered with hisThe facts are as follows :-There are in all seven Irish repreeyes and obtained the following history. Up to the age sentatives. Two recorded their votes for the Hall. Oneof twenty-two his eyes were perfectly normal. One evening spoke most strongly in favour of the request, but was urgently he was stoking the greenhouse fires and some unignited obliged to leave before voting. Two other Irish members of’ gas must have accumulated, for on opening the stove doors the Council were absent, but wrote letters expressing theirthere was a burst of flame, which scorched his hair and opinions that the examiners ought to be granted. The two face, and from the effects of which he was laid up for a Irish votes given against the Hall were by two Fellows of thefortnight. On getting about again he found he could not see Royal College of Physicians, Ireland. I am Sirs faithfully yours as well as before on account of the movement of his eyeballs, ROBERT MONTGOMERY, M.R.C.S., Secretary. and his friends all noticed the change in them. He is nowfortythree years of age and tells me he can read perfectly both by Mary-street, Dublin, Dec. 9th. 1895. daylight and artificial light, and that his eyes do not bother *Our account and Mr. Robert Montgomery’s are il1tt him in the least except in bright sunlight, when he becomes accord.-ED. L. rather dazed." On examination I find he has horizontal nystagmus, that both eyes act together, and that their MIDWIFERY TRAINING FOR STUDENTS. movements are perfect in all directions. The oscillation still continues, but is reduced to about 120 a minute, when To the Editors of THE LANCET. the eyes are extremely turned either inwards or outwards. The corneæ are clear, and no abnormal signs can be seen SIRS,—My attention has been drawn to the fact that in about either eye. The pupils act well both to light and to your report of the proceedings of the General Medical accommodation. With the ophthalmoscope I find the lenses CouncilIam represented as saying that the Council have: transparent and without any signs of opacity. The discs recommended that every student should be required to attend are slightly injected, but otherwise normal. By retinoscopy three months’ practice in a lying-in hospital and conduct I twelve cases of delivery under the direct supervision of a. + 3 corrects the left eye and + 4’5 the right eye. have not attempted any treatment, not quite seeing what registered practitioner. The recommendation itself which course to follow, as the nystagmus is now of twenty-one quoted is to the effect that either attendance at a lying-in. years’ standing, and the subject is in perfect health and hospital or presence at twelve midwifery cases should be according to himself has " never had a day’s illness." With required, and it is only stipulated three of the twelve should regard to the pathology I am also at a loss, but suggest that have been conducted personally under the direct supervision changes have taken place in the nerves or nerve endings in of a registered practitioner. T am, am oil Sirs vmirs trnlvthe ocular muscles, due to peripheral neuritis caused by the i inflammation consequent on the burns received twenty-one D. J. LEECH. Mosley-street, Manchester, Dec. 9th, 1S95. years ago. The course of reasoning I have pursued is as follows. If a child be born blind and continue so, nystagmus generally "THE ADMISSION OF WOMEN TO THE supervenes because one of the first acquired coordinate actions is that of the harmonious and accurate movements of ROYAL COLLEGES OF PHYSICIANS the muscles of the eyes, whereby the child learns to look at OF LONDON AND SURGEONS an object, nystagmus being therefore a defect of coördinaOF ENGLAND" tion. Now the mechanism of coordination is : (1) sensory To the Editors of THE LANCET. paths for perception and conduction of impressions ; (2) receiving central ganglia; and (3) efferent nerves to SIRS,-Having to-day seen, for the first time, a letter carry impulses from centres to motor structures. Failure of signed " Albert Morton " in your issue of Nov. 16th, on the coordination may arise from defect in any one of these three " Admission of Women to the Royal Colleges of Physiciansb in for in we find the the locomotor structures, ataxy change of London and Surgeons of England," I beg you to allow me,, sensory structures, in cerebellar disease it is in the central somewhat late, to comment on one passage contained though whilst in the lesion is in the motor sclerosis ganglia, multiple in for an assertion that goes uncontradicted is sometimes. it, paths. Miner’s nystagmus, being due to excessive use and to be admitted. The paragraph is as follows:o supposed the is an of lesions in of ocular muscles, example straining " Dr. West the motor paths. Nystagmus occurring in locomotor ataxy justly says:What had women done for midwifery, which and a half was entirely in their hands ?’ I would go & is due to sensory changes. May not the nystagmus in the for a century deal further, and say that the modern medical women are doing. great case under consideration be due to changes in the nerve more to degrade and lower the standard of the profession than any body medical men have ever done, for they are at the present time seeking endings in the muscles, but whether sensory or motor, or of to attend midwifery for a fee of 5s., and for aught I know for even less. both, I cannot say ?-I am, Sirs, yours truly, than that. Does this show that there is any great and growing. A. DUNLEY OWEN, M.R.C.S., L.R.C.P. Lond. demand for the services of medical women even for members of their1895. Dec. 9th, Northampton, own sex ? Now is Mr. Morton sure of the accuracy of his facts? ? It *,* This case is one of exceptional interest. There are many other affections besides those mentioned by our corre- is always difficult to prove a negative, but I believe if anyone: the trouble to inquire he would find that no medical spondent with which nystagmus may be associated, as, for took woman in practice in England has ever taken less than a. with errors of refraction, especially high degrees example, Mras her minimum fee for a midwifery case. of hypermetropia, with retinitis pigmentosa in albinos, and guinea Morton’s mistake is probably founded on the fact that in. with disseminated sclerosis of the brain and spinal cord, certain maternities officered by medical women, to which a* with hysteria and with lead poisoning. The pathology of system of training for women students is attached, there the case may of course be that ingeniously suggested by exists a rule requiring the out-patients to pay 5s. to Mr. Dunley Owen, but we should be inclined to give another the fund8 of the hospital on registering their name for instead of receiving cards entitling them to, explanation to the effect that the shock of the explosion attendance, be attended free, as is the usage of those hospitals caused a small lesion of the choroid or retina at or near in connexion with which men students undertake similar the fovea centralis in one or both eyes, and that the work. The object of the rule was partly to avoid pauperising; amblyopia thus produced led to the oscillation of the globes. a new district, partly to limit the number of cases underMr. Dunley Owen does not give the distant vis:on of the taken, as the supply of women students is also limited. Thesum of 5s. was fixed upon in the belief that no one couldi patient.-ED. L. possibly mistake it for a doctor’s fee. It may or may not. have been judicious to adopt this change of method, but at. APOTHECARIES’ HALL, IRELAND. any rate the question involved is not " Do women doctors. To the Editors of THE LANCET. degrade the profession by taking lower fees than men" but, do they degrade it by insisting that even students’ wosk, SIRS,-The Court of the Apothecaries’ Hall, Ireland, would when supervised by fully qualified doctors, should be tocall your attention to an observation made in your valuable 1 THE LANCET, Dec. 7th, 1895, p. 1474. journal at page 1468 in reference to the petition presented by

usual forms

attending

given.

one

"