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THE ELIMINATION OF ARSENIC.
815
THE ELIMINATION OF 11RSENIC.-iLKLIPEBIa.
THE ELIMINATION OF ARSENIC.
"
alkalotic "
reserve
alkali.
process-viz., the depletion of alkali by acapnia and compensatory excretion of A better
one
appears to
be
as
follows :
SiR,-The toxic effects following the administration " Acidosis may be defined as a depletion of alkali of arsenic have recently attracted the attention of the reserve due to the presence of excess of non-volatile medical profession, and the following facts which have acids, using non-volatile in the sense that they cannot recently come under observation seem worthy of ’ be excreted by the lungs like carbonic acid." This
notice, Six weeks
ago I
invited
by my colleague, Dr. D. Lees, of the venereal department, Royal Infirmary, Edinburgh, to see one of his patients, under treatment as an in-patient for syphilis. I was asked to see him on account of the development of very severe anaemia, and slight jaundice, accompanied by a palpable enlargement of the liver and spleen. The patient, a young man, had been under Dr. Lees’s was
observation from Nov. 8th, 1920, to the present time, first as an out-patient and for the previous two months as an in-patient. Between Nov. 8th, 1920, and Jan. 28th, 1921, the patient had ten injections of N.A.B., a total of 3-9 g. of 914 having been given in 81 days. Small doses of mercury and opium were administered in pill form for eight weeks, from March to May, 1921, and again from June to September ; no arsenic in any form had been administered for the previous 15 months. The examination of the blood showed a typical picture of a pronounced, so-called primary anaemia. The question aroseas to whether this condition was. (a) the direct result of the syphilis, (b) the result of the medicinal treatment, or (c) independent of either condition ; and he was transferred to my ward for further investigation. The first explanation was considered unlikely in view of the treatment that had been carried out. The third was, under the circumstances, also regarded as improbable. In view of the interest attaching to the second hypothesis, a careful chemical analysis of the stools and urine was made by Mr. Kumack, head of the chemical department of the Royal College of Physicians Laboratory. Both excretions gave a positive qualitative test for arsenic. Three weeks later the excretions were again examined, the result in the case of the faeces being again positive and the urine negative. The observations will be repeated later. Coincidently there has been a marked improvement in the general clinical condition of the patient and in the state of the blood. The striking delay in the elimination of arsenic is of interest ; so far as I know, it is not in agreement with the ordinarily accepted teaching on this subject. I am not aware of any literature on this subject, but would be grateful for any information from any of your readers which might throw some light on these interesting facts. I am, Sir, yours faithfully, CHALMERS WATSON, M.D. Edinburgh, April loth.
definition excludes the condition referred to. Dr. Symons defines alkalipenia as a term intended to convey partial depletion of alkali reserve--i.e., he includes two clinically different conditions arrived at by two entirely different processes-viz. : (1) Compensated acidosis or depletion of alkali reserve due to excess of non-volatile acid ; and (2) depletion of alkali reserve through over stimulation of the respiratory centre with CO 2, consequent washing out of the circulation of CO;;, and compensatory excretion of
alkali by the kidneysto preserve the normal pH of The term " compensatory acidosis " the blood. which Dr. Symons proposes to abolish served to distinguish these two conditions. Sellards’s bicarbonate tolerance test does not appear to be infallible and cannot give as reliable results as estimations of COZ content of alveolar air and blood. Palmer, Salveson, and Jackson, who investigated Sellards’s test in 1920, came to the conclusion that " it does not admit of estimating with sufficient degree of accuracy the degree of diminished alkali reserve to be of practical value." The cause probably lies in the varying degree of injury to the acid base regulating function of the kidney in disease, and in the fact that in the acapnial process diminution of alkali reserve may occur with alkaline urine as proved by Haldane, Kennas, and Kennaway. Dr. Symons suggests that the value of the test lies in the fact that it is both diagnostic and therapeutic. It appears to be unwise, however, to administer alkali indiscriminately. For instance, he uses alkali therapy in a case of acute rickets with tetany. It is well established now that tetany occurs in advanced alkalosis. Indeed, it can actually be produced experimentally by giving large doses of sodium bicarbonate or by breathing very low tensions of With regard to epilepsy, Dr. William oxygen. Alexander regards the cyanosis which accompanies the tonic stage as a beneficial act without which epilepsy would be fatal. Dr. Murray Bligh considers the determining factor in relaxing the spasm to be a CO2: acidosis brought about by the arrest of respiration. I am. Sir. vours faithfullv. LESLIE CUNNINGHAM, M.B. Biochemical Laboratory, University of Liverpool, April 8th, 1922.
TONSILS AND ADENOIDS.
the Editor of THE LANCET. THE LANCET of April 1st, p. 662, there ALKALIPENIA. appears a list of suggestions made by the Council of the Section of Laryngology of the Royal Society of To the Editor of THF. LANCET. regarding the treatment of children suffering SIR,--I have read with interest the paper by Dr. Medicine tonsils and adenoids. A large number of children from A. D. Symons on alkalipenia in THE LANCET of receive treatment for throat at this hospital, April 1st, more especially with regard to his views on and in the past they have affections been treated in the outthe relation of protein sensitisation to depletion of Thealkali reserve and ketosis. The relative frequency patients’ department as at other hospitals. of the occurrence of protein sensitisation and ketosis committee of management have given this matter and the comparatively grave prognosis of diabetes in special consideration during the last two years, and children together with the similarity of the nature of last autumn took the first step towards improvingconditions by providing an ambulance to convey ketogenic and asthmogenic agents, be they inhaled, the the children to their homes instead of allowing them ingested autogenous or the result of bacterial or other to travel in public vehicles shortly after their operation. are a fruitful field and activity very striking provide The committee have now decided to go much further. for investigation. The nomenclature of the various alterations occurring in the alkali reserve of the body On May lst a special ward of 10 beds is to be opened has undergone such frequent changes of late that it and will be reserved entirely for the admission of The children will be admitted the day seems rather a pity to add to the confusion by suggest- ’, throat cases. their operation and will stay in hospital three ing yet another one, especially as the nomenclatureI beforeand three nights, or longer if necessary. suggested by the Medical Research Council is the one days I am. Sir. vours faithfully. now almost universally adopted. THOS. CLAPHAM, Dr. Symons selects as the best definition of acidosis Secretary. that given by Sellards, which is unsatisfactory in that for Children, 1, Clapham-road, S.W. 9, Belgrave Hospital it includes a condition which is arrived at by an April 11th, 1922. ,
To
SiR,—In
THE ELIMINATION OF 11RSENIC.-iLKLIPEBIa.
THE ELIMINATION OF ARSENIC.
"
alkalotic "
reserve
alkali.
process-viz., the depletion of alkali by acapnia and compensatory excretion of A better
one
appears to
be
as
follows :
SiR,-The toxic effects following the administration " Acidosis may be defined as a depletion of alkali of arsenic have recently attracted the attention of the reserve due to the presence of excess of non-volatile medical profession, and the following facts which have acids, using non-volatile in the sense that they cannot recently come under observation seem worthy of ’ be excreted by the lungs like carbonic acid." This
notice, Six weeks
ago I
invited
by my colleague, Dr. D. Lees, of the venereal department, Royal Infirmary, Edinburgh, to see one of his patients, under treatment as an in-patient for syphilis. I was asked to see him on account of the development of very severe anaemia, and slight jaundice, accompanied by a palpable enlargement of the liver and spleen. The patient, a young man, had been under Dr. Lees’s was
observation from Nov. 8th, 1920, to the present time, first as an out-patient and for the previous two months as an in-patient. Between Nov. 8th, 1920, and Jan. 28th, 1921, the patient had ten injections of N.A.B., a total of 3-9 g. of 914 having been given in 81 days. Small doses of mercury and opium were administered in pill form for eight weeks, from March to May, 1921, and again from June to September ; no arsenic in any form had been administered for the previous 15 months. The examination of the blood showed a typical picture of a pronounced, so-called primary anaemia. The question aroseas to whether this condition was. (a) the direct result of the syphilis, (b) the result of the medicinal treatment, or (c) independent of either condition ; and he was transferred to my ward for further investigation. The first explanation was considered unlikely in view of the treatment that had been carried out. The third was, under the circumstances, also regarded as improbable. In view of the interest attaching to the second hypothesis, a careful chemical analysis of the stools and urine was made by Mr. Kumack, head of the chemical department of the Royal College of Physicians Laboratory. Both excretions gave a positive qualitative test for arsenic. Three weeks later the excretions were again examined, the result in the case of the faeces being again positive and the urine negative. The observations will be repeated later. Coincidently there has been a marked improvement in the general clinical condition of the patient and in the state of the blood. The striking delay in the elimination of arsenic is of interest ; so far as I know, it is not in agreement with the ordinarily accepted teaching on this subject. I am not aware of any literature on this subject, but would be grateful for any information from any of your readers which might throw some light on these interesting facts. I am, Sir, yours faithfully, CHALMERS WATSON, M.D. Edinburgh, April loth.
definition excludes the condition referred to. Dr. Symons defines alkalipenia as a term intended to convey partial depletion of alkali reserve--i.e., he includes two clinically different conditions arrived at by two entirely different processes-viz. : (1) Compensated acidosis or depletion of alkali reserve due to excess of non-volatile acid ; and (2) depletion of alkali reserve through over stimulation of the respiratory centre with CO 2, consequent washing out of the circulation of CO;;, and compensatory excretion of
alkali by the kidneysto preserve the normal pH of The term " compensatory acidosis " the blood. which Dr. Symons proposes to abolish served to distinguish these two conditions. Sellards’s bicarbonate tolerance test does not appear to be infallible and cannot give as reliable results as estimations of COZ content of alveolar air and blood. Palmer, Salveson, and Jackson, who investigated Sellards’s test in 1920, came to the conclusion that " it does not admit of estimating with sufficient degree of accuracy the degree of diminished alkali reserve to be of practical value." The cause probably lies in the varying degree of injury to the acid base regulating function of the kidney in disease, and in the fact that in the acapnial process diminution of alkali reserve may occur with alkaline urine as proved by Haldane, Kennas, and Kennaway. Dr. Symons suggests that the value of the test lies in the fact that it is both diagnostic and therapeutic. It appears to be unwise, however, to administer alkali indiscriminately. For instance, he uses alkali therapy in a case of acute rickets with tetany. It is well established now that tetany occurs in advanced alkalosis. Indeed, it can actually be produced experimentally by giving large doses of sodium bicarbonate or by breathing very low tensions of With regard to epilepsy, Dr. William oxygen. Alexander regards the cyanosis which accompanies the tonic stage as a beneficial act without which epilepsy would be fatal. Dr. Murray Bligh considers the determining factor in relaxing the spasm to be a CO2: acidosis brought about by the arrest of respiration. I am. Sir. vours faithfullv. LESLIE CUNNINGHAM, M.B. Biochemical Laboratory, University of Liverpool, April 8th, 1922.
TONSILS AND ADENOIDS.
the Editor of THE LANCET. THE LANCET of April 1st, p. 662, there ALKALIPENIA. appears a list of suggestions made by the Council of the Section of Laryngology of the Royal Society of To the Editor of THF. LANCET. regarding the treatment of children suffering SIR,--I have read with interest the paper by Dr. Medicine tonsils and adenoids. A large number of children from A. D. Symons on alkalipenia in THE LANCET of receive treatment for throat at this hospital, April 1st, more especially with regard to his views on and in the past they have affections been treated in the outthe relation of protein sensitisation to depletion of Thealkali reserve and ketosis. The relative frequency patients’ department as at other hospitals. of the occurrence of protein sensitisation and ketosis committee of management have given this matter and the comparatively grave prognosis of diabetes in special consideration during the last two years, and children together with the similarity of the nature of last autumn took the first step towards improvingconditions by providing an ambulance to convey ketogenic and asthmogenic agents, be they inhaled, the the children to their homes instead of allowing them ingested autogenous or the result of bacterial or other to travel in public vehicles shortly after their operation. are a fruitful field and activity very striking provide The committee have now decided to go much further. for investigation. The nomenclature of the various alterations occurring in the alkali reserve of the body On May lst a special ward of 10 beds is to be opened has undergone such frequent changes of late that it and will be reserved entirely for the admission of The children will be admitted the day seems rather a pity to add to the confusion by suggest- ’, throat cases. their operation and will stay in hospital three ing yet another one, especially as the nomenclatureI beforeand three nights, or longer if necessary. suggested by the Medical Research Council is the one days I am. Sir. vours faithfully. now almost universally adopted. THOS. CLAPHAM, Dr. Symons selects as the best definition of acidosis Secretary. that given by Sellards, which is unsatisfactory in that for Children, 1, Clapham-road, S.W. 9, Belgrave Hospital it includes a condition which is arrived at by an April 11th, 1922. ,
To
SiR,—In