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ON TWO CASES OF SPLENIC LEUCOCYTHÆMIA IN WHICH ELECTRICITY WAS LOCALLY APPLIED TO THE ENLARGED SPLEEN.
1031 The treatment of these
cases requires that the general to the cure of rheumatism be put in Everyone knows how reeistant rheumatic affections are, because the local disease is only a manifestation of
principles applicable
force.
amount, and fish may be ordered instead of meat
Pastry should be interdicted. subject further. The rules for
at dinner. But I need not pursue this diet are to be found in Pavy’s
and other works devoted to dietetics.
evidence of
profound changes (To be concluded.) in the composition of the blood, which, being dependent on the mode of life and general surroundings of the patient, An intelligent surgeon are not easily modified or removed. ON TWO CASES OF therefore endeavours to effect an improvement in the general health of his patient, satisfied that if the digestion, which is SPLENIC LEUCOCYTHÆMIA IN WHICH often at fault, can be made more perfect, the circulation and ELECTRICITY WAS LOCALLY APPLIED respiration more active by vigorous exercise, and the secreTO THE ENLARGED SPLEEN. tions more free, the local disease may safely be left to itself and the reparative powers of the system, care only being BY G. VIVIAN POORE, M.D., F.R.C.P., taken to reduce inflammatory symptoms to moderate limits, i OF MEDICAL JURISPRUDENCE IN UNIVERSITY COLLEGE, AND and to avoid the occurrence of the special complications to PROFESSOR ASSISTANT PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL. which the eye, as compared with any other structure of the body, is liable. With these objects in view the patient My only reason for wishing to place the two following should be directed to avoid exposure to cold, and to remain in-doors. In the case of the poor, the admission to a hospital cases upon record is the fact that the blood-corpuscles were where they are at once placed under favourable conditions repeatedly counted. The enumerations were made on as regards temperature and freedom from draughts, to eighteen occasions immediately before animmediately after which they are so liable in their own dwellings, quickly the application of electricity to the spleen, and with this effects a change for the better. In the better classes the that on fourteen occasions the number of white result, room should not only be warm but well ventilated, and it is not expedient to keep the patient in the same room through- corpuscles was increased after the electricity, and on fifteen out the day and night; on the contrary, he should be made occasions the number of red corpuscles was diminished to rise and spend the day in another but still well-warmed after the electricity. The increase of white corpuscles is room. A good average temperature is 68° F. a result which may be explained as a consequence of the Many rheumatic patients suffer from constipation, and diminution in the size of the spleen, which was Abernethy’s practice of a blue pill and black draught is by slight noticed after the application of the electricity. frequently no means a bad introduction to other treatment. It clears the bowels, unloads the liver, and places the patient under It seems probable that the contraction of the spleen resulted favourable conditions for the employment of alteratives. in a forcing as it were of leucocytes into the general bloodIt is really astonishing in such cases what a quantity of current. The diminution of red corpuscles is less readily offensive material is shown to have accumulated and is dis- explained, but it seems to lend support to the theory that lodged, especially in those whose habits are sedentary and one of the functions of the spleen is the destruction of red very regular, even though, as we are assured, the bowels are corpuscles. It is not surprising that stimulation of the open every day. Having cleared the alimentary canal, we spleen should lead to increase of function, and if destruction may then adopt one of several plans. I have tried them all of the red corpuscles be really one of its functions the repeatedly with varying results, but upon the whole, as a diminution of these elements of the blood need cause no matter of routine treatment, I almost invariably commence The therapeutic effects of the application of with a combination of aconite, colchicum, and quinine, which electricity in these cases were, if anything, transient. For in a large number of cases proves extremely serviceable, re- a short time after the application the patient felt relieved, lieving the pain, procuring sleep, and tranquillising as well and the spleen was occasionally found to be smaller and as strengthening the patient. If this, in addition to the local softer, and the increased suppleness of the organ gave for a time greater freedom to the movements of the trunk. The measures which I will presently mention, does not procure relief in the course of three or four days, I exchange it for patients always expressed themselves as relieved by the potassium iodide and the decoction of cinchona, which acts application, and begged for its continuance, but it will be well when there is any suspicion of a specific taint. I have seen that, judging by objective signs, the electricity produced found from five to ten grains sufficient when given two or no permanent effect. Any merit which may attach to these three times a day, and have never ventured on the heroic cases belongs mainly to the gentlemen who undertook the doses now sometimes ordered, though it is quite possible they somewhat laborious task of the repeated enumeration of the might succeed where smaller doses fail. Where both of these corpuscles. To Mr. F. A. Dixey and Mr. F. G. Penrose methods fail and the case lingers on, the compound guaiacum I am indebted for the careful attention which they gave to mixture of the Pharmacopoeia is occasionally very useful, and the two patients whose cases are recorded, as well as for the I can recall several instances where it has apparently effected repeated enumerations of the blood-corpuscles, effected by a rapid cure. A disagreeable but powerful agent in rheumatic means of the hamacytometer, which in its present form we affections of the eye is to be found in turpentine. The great owe to Dr. Gowers. it are its flavour and the eructations to which it CASE 1. (The notes of this case have been compiled and objections to gives rise, as well as in rare instances the urinary troubles; the enumeration of the corpuscles made by Mr. F. A. Dixey, but the first objection may be met by giving it in capsules, who was one of the clinical clerks at the time.)-A. N and the latter by combining with it a little peppermint- aged fifty-eight, was admitted to University College Hospital water and tincture of opium ; in twenty-five minim doses on May 12th, 1880. Had first noticed a swelling with tenit has been in my hands very serviceable. Advantage derness on the left side of the abdomen two months preagain will be obtained in some cases from the alkaline treat- viously, in March, 1880. The family history was good ; no ment originally suggested or strongly recommended by personal history of syphilis or ague. Four years previously Dr. Fuller, in which the bicarbonate of soda and nitrate of had sharp bearing-down pains in her left. side and groin. potash are administered in some light vegetable tonic, such Has suffered for many years from chronic rheumatism and as calumba or gentian. Lastly, the salicylate of soda has constantly passes gravel in her urine. She is subject to Has been losing her sight been of great service at St. Bartholomew’s Hospital. severe nervous sick headaches. There is one other point of general treatment which should for two yeara. No marked enlargement of lymphatic glands ; act be neglected in any case of bad rheumatic ophthalmia those in both groins are hard, and readily felt. Spleen : A with ulcer—the regulation of the diet. A large number of large tumour can be felt in the left hypochondriac and lumbar the subjects of this disease take beer or wine or spirits in regions, reaching into the epigastric and umbilical regions, quantities far beyond the needs of the economy and it acts and extending half an inch to the right of the umbilicus. upon them, as our friends who wear the blue riband would The tumour moves with the respiration ; the anterior edge is say, as a poison. As a rule I am inclined to take this view, concave towards the right. Measurements: Thirteen inches and conatitutional disturbance,
an
surprise.
-
0
think that alcohol in all forms should be temporarily or at least the quantity considerably reduced. It may be advantageously replaced with milk and soda water, and this with two breakfast cups of coffee or tea in the morning and some tea at night, will supply the system with all it needs. The food should be limited in
given up,
the liquid
in circumference from before back; seven inches from above down, but the upper edge is under the margin of the thorax and cannot be defined. On May 28th twenty minims of the solution of perchloride of iron were ordered three times a day. June 2nd : Corpuscles 620 red per thousand, 100 white.July 2nd : 630 red per thousand, 14 white.—10th : Constant
1082 TABLE 1.
CORPUSCLES COUNTED
W[T!I
DR. GOWERS’ H7)’;MACYTOMETER.
(Ann N-, uged sixty. Case 1.)
*
After
t Galvanising.
gatyaniaing. TABLE II.
CORPUSCLES COUNTED
WITH
DR. GOWERS’ HEMACYTOMETER.
(George T-, aged twenty-three.
Case 2.)
1083 for five minutes, with diminution in THREE CASES OF the size of the spleen.-18th: Tumour extended an inch and Ordered solution of SUCCESSFUL REMOVAL OF TRACHEOTOMY a half to the right of the middle line. arsenic, five minims three times a day.-Aug. 3rd : Patient TUBES. discharged. Improvement in general health ; no alteration M BY HENRY in size of the spteen.—Readmitted on July 27th, 1882 : The SMITH, B. LOND., S. SCI, CERT. CAMB. tumour does not extend more to the right, but has descended and can be felt in the left iliac region, reaching within two AMONG the legacies bequeathed by house-surgeons to their inches of Poupart’s ligament. The treatment whilst in succeseors, it is no uncommon thing to find a child on whom hospital will be found in Table I. On twelve occasions, tracheotomy has been performed for temporary laryngeal when the patient was galvanised, the corpuscles were counted before and after galvanising. After galvanising, in nine times obstruction, and who beyond wearing a tube is otherwise the total number of corpuscles diminished ; in nine times well. It was my fortune to inherit three such cases on my the number of white corpuscles increased ; in ten times the appointment as house-surgeon to the Children’s Hospital, number of red corpuscles diminished. There were temporary Great Ormond-street, and for permission to publish them I diminutions in the size of the spleen after galvanising, but am indebted to the kindness of Mr. Thomas Smith and Mr. no permanent decrease. Howard Marsh, under whose supervision and with whose CASE 2. (The notes of this case have been compiled and the enumeration of the corpuscles made by Mr. F. G. Pen- approval the treatment adopted was carried out. CASE 1.—William P-, aged thirteen months, was adrose, clinical clerk to the case.)-G. T-, aged twentythree, was admitted to University College Hospital on Dec. mitted to the Children’s Hospital with diphtheria, and 20th, 1882. Family history on father’s side good, not tracheotomy performed on Sept. 27th, 1880. In June, 1882, obtainable on mother’s side. Is the eldest son of a family he was still wearing an indiarubber tube, and, though now of twelve. Some of these children suffered from rickets, able to do without it for hours together in the daytime, he never slept without it since the operation. He could patient did not. Most of the children are subject to severe had sick headaches. Past history : Bad sick headaches from ten run about the ward without dyspncea ; his general health to twenty years of age ; never had ague. When nineteen was fairly good, though he suffered from cough with copious years old he contracted syphilis ; during the same year, but expectoration of muco-pus through the tube. Voice good ; whether before or after contraction of syphilis he does not occasional sickness. On the evening of July 7th, 1882, the remember, he noticed a gradually enlarging swelling on his tube, having been out since the morning, was not replaced. left side, without pain. This enlargement quickly assumed -July 8th : Has passed a restless night, with noisy breathits present or even greater dimensions. During the last ing and well-marked recession of the lower ribs.-10th : The four years he has frequently suffered from shortness of tube, which had been out since the 7th inst., was replaced, the child looked pale and languid, owing to broken rest. breath, dyspepsia, nausea, flatulence, and jaundice. Has as The little fellow, who was a general favourite in the hospital, occasionally had attacks of epistaxis lasting nearly twenty- had not hitherto been restricted in his diet either as to quanfour hours ; after extraction of tooth bleeding for over thirty hours. State of spleen on admission to hospital: Abdomen tity or quality, and his occasional vomiting could generally accounted for by some indiscretion of this kind. He was markedly swollen on left side. This is felt to be due to a hard be now put upon a plain diet and all indigestible food withmass extending from beneath the costal margin to within one inch and a half of the pubes. It is freely movable by the held, with the result that when the tube was left out on the hand. The posterior edge can be felt to be rounded and 26th July no further occasion arose for its being used again. the opening into the trachea was covered with a nearly three inches distant from the vertebral spinous pro- At first cesses. In front it extends across the middle into the right piece of strapping, but as this could not easily be kept in half of the abdomen, so that at the level of the umbilicus the place, a small pad of cotton-wool covered with gauze was for it, and answered the purpose better. The edge can be felt two inches and a half to the right of that spot. substituted health the can be traced to the line of improved very much-he became livelier, lost middle the boy’s Above, edge cough, and his voice grew stronger, before he was transepigastrium. There is a well-marked broadened-out notch, his the most indented portion of which is an inch and a half ferred on Aug. 31st to the Convalescent Home at Highgate. above the umbilicus. On admission no lymphatic glands were When seen on February 22nd, 1883, he was very well, but found to be enlarged. During the patient’s stay in the hos- an opening large enough to just admit a small probe was left of ninety-five days he gained six pounds and a quarter in the trachea. pital CASE 2.-William M-, aged four years, came under in weight. There were slight variations in the size of the at the Children’s Hospital on June 6th, spleen and in the position of the notch from day to day, but Mr. Marsh’s care the spleen edge never extended more than three inches 1882, wearing a silver tracheotomy tube. The operation to the right of the middle line, and never approached that was performed for laryngeal spasm on March 30th, 1881, at line nearer than an inch and a half. On Jan. 9th phosphorus the Westminster Hospital, where several attempts had been rid of the tube. On admission to the Children’s pill (one-fiftieth of a grain) was ordered once a day. These made to get he was well nourished and in fair health, but was Hospital on From 28th the were discontinued Feb. Feb. 27th. pills cough and free expectoration of thick stringy patient was daily galvanised for twenty to thirty minutes troubled with At first the constant muco-pus. The tube was changed night and morning with over the region of splenic dulness. current was used, but afterwards the interrupted current, considerable difficulty ; for, objecting to be interfered with, and this was kept on as the patient preferred it. For he invariably worked himself into a passion, and struggled the first two times the area of splenic dulness did not so violently that he had to be held down while it was being diminish, but afterwards every day the edge approached the done. At these times he suffered from marked dyspnoea, middle line by about three-quarters of an inch at the level clearly brought on by his own ill temper. Mr. Marsh, of the umbilicus, generally from two inches and a half to pointing out the injury likely to result to the delicate mucous This alteration could be membrane of the trachea from the constant pressure of a one inch and three-quarters. noticed all along the anterior edge, there being a general silver tube, told me to substitute an indiarubber one as soon retraction along the edge of from half an inch to three- as possible; so on June 20th, when the child had been got more control, a Baker’s tube was used ; this he liked better quarters. At the same time the spleen instead of feeling under hard and tense was soft and limp. This improvement lasted than the silver one, and resisted its changing much less. for two hours, but the following morning the tumour had After removing it on the morning of June 27tb, and resumed its old dimensions and hardness. The counting noticing that he breathed quite comfortably, I deterof the blood-corpuscles, the blood being drawn from mined to leave it out; but this not meeting with the boy’s the finger, shows that after galvanising in five out of six approval, he threw himself into a rage, and tossed himself times the number of white corpuscles increased, the num- about until he had brought on such urgent dyspnoea that it ber of red corpuscles diminished, but the total number of required some firmness to resist the temptation to replace the tube, which he called for; however, he was made to corpuscles increased (vide Table II )) understand that it would not be put in, so after awhile he down. He next refused to eat his gave in and DR.WILLIAM COLLINGRIDGE, M.A., M.D., S. Sc. Cert. dinner, saying he should choke without the tube, but a good Camb., Medical Officer of Health of the Port of London, was appetite, with a little persuasion, furnished the best argua succcessful candidate in the recent examination for the ment against this. He was kept quiet in bed and strictly degree of Master of Laws of the University of Cambridge. watched. He went on with little difficulty of breathing
current ; eighteen cells
quieted
cases requires that the general to the cure of rheumatism be put in Everyone knows how reeistant rheumatic affections are, because the local disease is only a manifestation of
principles applicable
force.
amount, and fish may be ordered instead of meat
Pastry should be interdicted. subject further. The rules for
at dinner. But I need not pursue this diet are to be found in Pavy’s
and other works devoted to dietetics.
evidence of
profound changes (To be concluded.) in the composition of the blood, which, being dependent on the mode of life and general surroundings of the patient, An intelligent surgeon are not easily modified or removed. ON TWO CASES OF therefore endeavours to effect an improvement in the general health of his patient, satisfied that if the digestion, which is SPLENIC LEUCOCYTHÆMIA IN WHICH often at fault, can be made more perfect, the circulation and ELECTRICITY WAS LOCALLY APPLIED respiration more active by vigorous exercise, and the secreTO THE ENLARGED SPLEEN. tions more free, the local disease may safely be left to itself and the reparative powers of the system, care only being BY G. VIVIAN POORE, M.D., F.R.C.P., taken to reduce inflammatory symptoms to moderate limits, i OF MEDICAL JURISPRUDENCE IN UNIVERSITY COLLEGE, AND and to avoid the occurrence of the special complications to PROFESSOR ASSISTANT PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL. which the eye, as compared with any other structure of the body, is liable. With these objects in view the patient My only reason for wishing to place the two following should be directed to avoid exposure to cold, and to remain in-doors. In the case of the poor, the admission to a hospital cases upon record is the fact that the blood-corpuscles were where they are at once placed under favourable conditions repeatedly counted. The enumerations were made on as regards temperature and freedom from draughts, to eighteen occasions immediately before animmediately after which they are so liable in their own dwellings, quickly the application of electricity to the spleen, and with this effects a change for the better. In the better classes the that on fourteen occasions the number of white result, room should not only be warm but well ventilated, and it is not expedient to keep the patient in the same room through- corpuscles was increased after the electricity, and on fifteen out the day and night; on the contrary, he should be made occasions the number of red corpuscles was diminished to rise and spend the day in another but still well-warmed after the electricity. The increase of white corpuscles is room. A good average temperature is 68° F. a result which may be explained as a consequence of the Many rheumatic patients suffer from constipation, and diminution in the size of the spleen, which was Abernethy’s practice of a blue pill and black draught is by slight noticed after the application of the electricity. frequently no means a bad introduction to other treatment. It clears the bowels, unloads the liver, and places the patient under It seems probable that the contraction of the spleen resulted favourable conditions for the employment of alteratives. in a forcing as it were of leucocytes into the general bloodIt is really astonishing in such cases what a quantity of current. The diminution of red corpuscles is less readily offensive material is shown to have accumulated and is dis- explained, but it seems to lend support to the theory that lodged, especially in those whose habits are sedentary and one of the functions of the spleen is the destruction of red very regular, even though, as we are assured, the bowels are corpuscles. It is not surprising that stimulation of the open every day. Having cleared the alimentary canal, we spleen should lead to increase of function, and if destruction may then adopt one of several plans. I have tried them all of the red corpuscles be really one of its functions the repeatedly with varying results, but upon the whole, as a diminution of these elements of the blood need cause no matter of routine treatment, I almost invariably commence The therapeutic effects of the application of with a combination of aconite, colchicum, and quinine, which electricity in these cases were, if anything, transient. For in a large number of cases proves extremely serviceable, re- a short time after the application the patient felt relieved, lieving the pain, procuring sleep, and tranquillising as well and the spleen was occasionally found to be smaller and as strengthening the patient. If this, in addition to the local softer, and the increased suppleness of the organ gave for a time greater freedom to the movements of the trunk. The measures which I will presently mention, does not procure relief in the course of three or four days, I exchange it for patients always expressed themselves as relieved by the potassium iodide and the decoction of cinchona, which acts application, and begged for its continuance, but it will be well when there is any suspicion of a specific taint. I have seen that, judging by objective signs, the electricity produced found from five to ten grains sufficient when given two or no permanent effect. Any merit which may attach to these three times a day, and have never ventured on the heroic cases belongs mainly to the gentlemen who undertook the doses now sometimes ordered, though it is quite possible they somewhat laborious task of the repeated enumeration of the might succeed where smaller doses fail. Where both of these corpuscles. To Mr. F. A. Dixey and Mr. F. G. Penrose methods fail and the case lingers on, the compound guaiacum I am indebted for the careful attention which they gave to mixture of the Pharmacopoeia is occasionally very useful, and the two patients whose cases are recorded, as well as for the I can recall several instances where it has apparently effected repeated enumerations of the blood-corpuscles, effected by a rapid cure. A disagreeable but powerful agent in rheumatic means of the hamacytometer, which in its present form we affections of the eye is to be found in turpentine. The great owe to Dr. Gowers. it are its flavour and the eructations to which it CASE 1. (The notes of this case have been compiled and objections to gives rise, as well as in rare instances the urinary troubles; the enumeration of the corpuscles made by Mr. F. A. Dixey, but the first objection may be met by giving it in capsules, who was one of the clinical clerks at the time.)-A. N and the latter by combining with it a little peppermint- aged fifty-eight, was admitted to University College Hospital water and tincture of opium ; in twenty-five minim doses on May 12th, 1880. Had first noticed a swelling with tenit has been in my hands very serviceable. Advantage derness on the left side of the abdomen two months preagain will be obtained in some cases from the alkaline treat- viously, in March, 1880. The family history was good ; no ment originally suggested or strongly recommended by personal history of syphilis or ague. Four years previously Dr. Fuller, in which the bicarbonate of soda and nitrate of had sharp bearing-down pains in her left. side and groin. potash are administered in some light vegetable tonic, such Has suffered for many years from chronic rheumatism and as calumba or gentian. Lastly, the salicylate of soda has constantly passes gravel in her urine. She is subject to Has been losing her sight been of great service at St. Bartholomew’s Hospital. severe nervous sick headaches. There is one other point of general treatment which should for two yeara. No marked enlargement of lymphatic glands ; act be neglected in any case of bad rheumatic ophthalmia those in both groins are hard, and readily felt. Spleen : A with ulcer—the regulation of the diet. A large number of large tumour can be felt in the left hypochondriac and lumbar the subjects of this disease take beer or wine or spirits in regions, reaching into the epigastric and umbilical regions, quantities far beyond the needs of the economy and it acts and extending half an inch to the right of the umbilicus. upon them, as our friends who wear the blue riband would The tumour moves with the respiration ; the anterior edge is say, as a poison. As a rule I am inclined to take this view, concave towards the right. Measurements: Thirteen inches and conatitutional disturbance,
an
surprise.
-
0
think that alcohol in all forms should be temporarily or at least the quantity considerably reduced. It may be advantageously replaced with milk and soda water, and this with two breakfast cups of coffee or tea in the morning and some tea at night, will supply the system with all it needs. The food should be limited in
given up,
the liquid
in circumference from before back; seven inches from above down, but the upper edge is under the margin of the thorax and cannot be defined. On May 28th twenty minims of the solution of perchloride of iron were ordered three times a day. June 2nd : Corpuscles 620 red per thousand, 100 white.July 2nd : 630 red per thousand, 14 white.—10th : Constant
1082 TABLE 1.
CORPUSCLES COUNTED
W[T!I
DR. GOWERS’ H7)’;MACYTOMETER.
(Ann N-, uged sixty. Case 1.)
*
After
t Galvanising.
gatyaniaing. TABLE II.
CORPUSCLES COUNTED
WITH
DR. GOWERS’ HEMACYTOMETER.
(George T-, aged twenty-three.
Case 2.)
1083 for five minutes, with diminution in THREE CASES OF the size of the spleen.-18th: Tumour extended an inch and Ordered solution of SUCCESSFUL REMOVAL OF TRACHEOTOMY a half to the right of the middle line. arsenic, five minims three times a day.-Aug. 3rd : Patient TUBES. discharged. Improvement in general health ; no alteration M BY HENRY in size of the spteen.—Readmitted on July 27th, 1882 : The SMITH, B. LOND., S. SCI, CERT. CAMB. tumour does not extend more to the right, but has descended and can be felt in the left iliac region, reaching within two AMONG the legacies bequeathed by house-surgeons to their inches of Poupart’s ligament. The treatment whilst in succeseors, it is no uncommon thing to find a child on whom hospital will be found in Table I. On twelve occasions, tracheotomy has been performed for temporary laryngeal when the patient was galvanised, the corpuscles were counted before and after galvanising. After galvanising, in nine times obstruction, and who beyond wearing a tube is otherwise the total number of corpuscles diminished ; in nine times well. It was my fortune to inherit three such cases on my the number of white corpuscles increased ; in ten times the appointment as house-surgeon to the Children’s Hospital, number of red corpuscles diminished. There were temporary Great Ormond-street, and for permission to publish them I diminutions in the size of the spleen after galvanising, but am indebted to the kindness of Mr. Thomas Smith and Mr. no permanent decrease. Howard Marsh, under whose supervision and with whose CASE 2. (The notes of this case have been compiled and the enumeration of the corpuscles made by Mr. F. G. Pen- approval the treatment adopted was carried out. CASE 1.—William P-, aged thirteen months, was adrose, clinical clerk to the case.)-G. T-, aged twentythree, was admitted to University College Hospital on Dec. mitted to the Children’s Hospital with diphtheria, and 20th, 1882. Family history on father’s side good, not tracheotomy performed on Sept. 27th, 1880. In June, 1882, obtainable on mother’s side. Is the eldest son of a family he was still wearing an indiarubber tube, and, though now of twelve. Some of these children suffered from rickets, able to do without it for hours together in the daytime, he never slept without it since the operation. He could patient did not. Most of the children are subject to severe had sick headaches. Past history : Bad sick headaches from ten run about the ward without dyspncea ; his general health to twenty years of age ; never had ague. When nineteen was fairly good, though he suffered from cough with copious years old he contracted syphilis ; during the same year, but expectoration of muco-pus through the tube. Voice good ; whether before or after contraction of syphilis he does not occasional sickness. On the evening of July 7th, 1882, the remember, he noticed a gradually enlarging swelling on his tube, having been out since the morning, was not replaced. left side, without pain. This enlargement quickly assumed -July 8th : Has passed a restless night, with noisy breathits present or even greater dimensions. During the last ing and well-marked recession of the lower ribs.-10th : The four years he has frequently suffered from shortness of tube, which had been out since the 7th inst., was replaced, the child looked pale and languid, owing to broken rest. breath, dyspepsia, nausea, flatulence, and jaundice. Has as The little fellow, who was a general favourite in the hospital, occasionally had attacks of epistaxis lasting nearly twenty- had not hitherto been restricted in his diet either as to quanfour hours ; after extraction of tooth bleeding for over thirty hours. State of spleen on admission to hospital: Abdomen tity or quality, and his occasional vomiting could generally accounted for by some indiscretion of this kind. He was markedly swollen on left side. This is felt to be due to a hard be now put upon a plain diet and all indigestible food withmass extending from beneath the costal margin to within one inch and a half of the pubes. It is freely movable by the held, with the result that when the tube was left out on the hand. The posterior edge can be felt to be rounded and 26th July no further occasion arose for its being used again. the opening into the trachea was covered with a nearly three inches distant from the vertebral spinous pro- At first cesses. In front it extends across the middle into the right piece of strapping, but as this could not easily be kept in half of the abdomen, so that at the level of the umbilicus the place, a small pad of cotton-wool covered with gauze was for it, and answered the purpose better. The edge can be felt two inches and a half to the right of that spot. substituted health the can be traced to the line of improved very much-he became livelier, lost middle the boy’s Above, edge cough, and his voice grew stronger, before he was transepigastrium. There is a well-marked broadened-out notch, his the most indented portion of which is an inch and a half ferred on Aug. 31st to the Convalescent Home at Highgate. above the umbilicus. On admission no lymphatic glands were When seen on February 22nd, 1883, he was very well, but found to be enlarged. During the patient’s stay in the hos- an opening large enough to just admit a small probe was left of ninety-five days he gained six pounds and a quarter in the trachea. pital CASE 2.-William M-, aged four years, came under in weight. There were slight variations in the size of the at the Children’s Hospital on June 6th, spleen and in the position of the notch from day to day, but Mr. Marsh’s care the spleen edge never extended more than three inches 1882, wearing a silver tracheotomy tube. The operation to the right of the middle line, and never approached that was performed for laryngeal spasm on March 30th, 1881, at line nearer than an inch and a half. On Jan. 9th phosphorus the Westminster Hospital, where several attempts had been rid of the tube. On admission to the Children’s pill (one-fiftieth of a grain) was ordered once a day. These made to get he was well nourished and in fair health, but was Hospital on From 28th the were discontinued Feb. Feb. 27th. pills cough and free expectoration of thick stringy patient was daily galvanised for twenty to thirty minutes troubled with At first the constant muco-pus. The tube was changed night and morning with over the region of splenic dulness. current was used, but afterwards the interrupted current, considerable difficulty ; for, objecting to be interfered with, and this was kept on as the patient preferred it. For he invariably worked himself into a passion, and struggled the first two times the area of splenic dulness did not so violently that he had to be held down while it was being diminish, but afterwards every day the edge approached the done. At these times he suffered from marked dyspnoea, middle line by about three-quarters of an inch at the level clearly brought on by his own ill temper. Mr. Marsh, of the umbilicus, generally from two inches and a half to pointing out the injury likely to result to the delicate mucous This alteration could be membrane of the trachea from the constant pressure of a one inch and three-quarters. noticed all along the anterior edge, there being a general silver tube, told me to substitute an indiarubber one as soon retraction along the edge of from half an inch to three- as possible; so on June 20th, when the child had been got more control, a Baker’s tube was used ; this he liked better quarters. At the same time the spleen instead of feeling under hard and tense was soft and limp. This improvement lasted than the silver one, and resisted its changing much less. for two hours, but the following morning the tumour had After removing it on the morning of June 27tb, and resumed its old dimensions and hardness. The counting noticing that he breathed quite comfortably, I deterof the blood-corpuscles, the blood being drawn from mined to leave it out; but this not meeting with the boy’s the finger, shows that after galvanising in five out of six approval, he threw himself into a rage, and tossed himself times the number of white corpuscles increased, the num- about until he had brought on such urgent dyspnoea that it ber of red corpuscles diminished, but the total number of required some firmness to resist the temptation to replace the tube, which he called for; however, he was made to corpuscles increased (vide Table II )) understand that it would not be put in, so after awhile he down. He next refused to eat his gave in and DR.WILLIAM COLLINGRIDGE, M.A., M.D., S. Sc. Cert. dinner, saying he should choke without the tube, but a good Camb., Medical Officer of Health of the Port of London, was appetite, with a little persuasion, furnished the best argua succcessful candidate in the recent examination for the ment against this. He was kept quiet in bed and strictly degree of Master of Laws of the University of Cambridge. watched. He went on with little difficulty of breathing
current ; eighteen cells
quieted