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TUBERCULOUS RHEUMATISM.
477 was felt. The general health was excellent. Almost complete preputial atresia, stagnation of urine between the prepuce and glans, decomposition, and formation of calculi were diagnosed. An incision was made at the most dependent part of the tumour ; it passed through greatly hypertrophied and chronically inflamed tissue about 3 centimetres thick. Numerous small calculi of a yellowish-white colour were found filling the whole space between the prepuce and glans. They were removed, circumcision was performed, and the case ran the ordinary course. The calculi removed weighed 540 grammes. They were generally in the form of a calotte, convex on one side and concave on the other. The largest were of the size of a small haricot bean and weighed 40 centigrammes ; the smallest were of the size of a lentil and weighed about 20 centigrammes. They almost all contained a hard nucleus, around which was a more Chemical analysis showed that friable deposit. they were composed of calcium and ammonium-
calculus,
magnesium phosphates. ACCIDENTS FOLLOWING THE TRANSFUSION OF BLOOD. IT is generally supposed that transfusion of human blood is an operation without ill-effects, but a considerable number of cases in which hæmolysis or agglutination of the donor’s blood corpuscles occurred have been recorded, and some have been fatal. Delirium, jaundice, and, in severe cases, haemoglobinuria were the symptoms. In the Journal of the American Medical Association of Dec. 13th, 1913, Dr. R. Ottenberg and Dr. D. J. Kaliski have published an important paper, in which they show the value of preliminary blood examination in avoiding accidents. Haemolysis of one human blood by another is a pathological phenomenon which was thought to be especially characteristic of cancer and tuberculosis, but is now known to occur in a great variety of diseases. By means of a modified Wright’s capillary pipette Dr. Ottenberg and Dr. Kaliski examined the blood of 128 patients and found it to be haemolytic for The diseases several prospective donors in 17. in which this occurred were purpura haemorrhagica, carcinoma of the stomach, carcinoma of the rectum, lymphatic leuk2emia, pernicious anaemia, chronic osteomyelitis (due to staphylococcus aureus), and pelvic abscess. In all except two cases the patients’ serums were hæmolytic with only some of the prospective donors’ blood. In two cases, on account of the desperate condition of the patient, haemolytic transfusion had to be In one the disease was pernicious ventured. anaamia. The serum of the patient was agglutinative and weakly hasmolytic to the cells of the donor. The transfusion was followed by intense haematuria, which lasted 24 hours, during which the hæmoglobin fell from 34 to 31 per cent. instead of rising, as almost invariably occurred in other In spite of the loss of the transfused blood cases. the transfusion apparently had a favourable influence, as the patient improved slowly but steadily during the following month. He returned to hospital eight months later and a second transfusion was done from a donor whose blood was not agglutinated or haemolysed by the patient’s serum. This transfusion was successful; the patient was greatly improved and life was prolonged for a year and a half. In the other case (acute lymphatic leukaemia) the patient’s serum sharply agglutinated the donor’s cells, but only slightly laked
them after three and a half hours in the thermostat. No haemoglobinuria followed the transfusion, but blood smears showed phagocytosis of red cells by leucocytes in the circulating blood. The patient died 42 hours after the transfusionJaundice occurred in only one case and was slight and transient. The absence of haemoglobinuria in over 100 cases in which haemolytic donors were excluded shows the value of blood examination. Agglutination, unlike haemolysis, is not a pathological phenomenon, but occurs between normal human bloods. All human beings can be divided into four permanent hereditary groups sharply separated by agglutinative reactions. When the blood of two persons belonging to the same group is mixed no agglutination occurs. When the blood of two persons of different groups is mixed agglutination either of one by the other or Human of each by the other always occurs. are in small iso-agglutinins quantities present only and can be absorbed by a small number of susceptible cells. When the serum of the donor is agglutinative to the cells of the patient, it will be so diluted on transfusion that little, if any, agglutination will result. When the patient’s serum is agglutinative towards the donor’s cells the conditions are more favourable to agglutination, but even here it is probable that only exceptionally can massive clumps of agglutinated cells be formed, such as are seen in the test-tube. Only in these cases has phagocytosis of the cells in the circulating blood been observed. Dr. Ottenberg and Dr. Kaliski have seen three transfusions in which the serum of the patient was agglutinative to the cells of the donor, and in two of these the serum was slightly haemolytic. One was the case of lymphatic leukaemia referred to above. Another was a case of pernicious anaemia. Blood smears made after the transfusion showed phagocytosis of red corpuscles by polynuclear leucocytes. No urine was passed after the transfusion, and death occurred eight hours later. The necropsy revealed extensive phagocytosis of the red corpuscles in the spleen and lymph nodes. Agglutination need not be regarded as a contraindication to transfusion, but non-agglutinative donors should be chosen if possible. There is an important corollary not given by Dr. Ottenberg and Dr. Kaliski. As the principal danger of transfusion is haemolysis, and as this occurs only in disease, normal blood can be safely transfused in a case of
hæmorrhage.
____
TUBERCULOUS RHEUMATISM. THE relation between tuberculosis and rheumatism is a topic which has lately been discussed in many quarters. In THE LANCET for Jan. 3rd we published an interesting case of tuberculous rheumatism recorded by Dr. Nathan Raw, whose investigations, including inoculation experiments on guinea-pigs, clearly proved the tuberculous nature of the rheumatism. Some writers are apt to label polyarthritis as tuberculous when it occurs in the subjects of pulmonary and other forms of tuberculosis. Theirs is the view that various manifestations should, as far as possible, be "hung on one peg," instead of being attributed to Dr. Raw considers more than one primary factor. tuberculous rheumatism very rare. Professor Poncet and his school consider it very common. Several cases have lately been published in which injections of tuberculin provoked great pain and swelling in many joints already the seat of rheumatism, which has accordingly been regarded as tuberculous. At
478 recent meeting of the Medicinske Selskab of resort, removal to a hospital being impossible. A Christiania Professor Peter Holst discussed the boy, aged 7, was attacked by appendicitis on difficulties of correlating tuberculosis with poly- July 20th, 1913. Perforation occurred on July 22nd. arthritis. In 27 cases of chronic and subchronic Pulse 160, temperature 103° F. Two surgeons having arthritis he punctured the joints, and injected declined to interfere surgically, by July 23rd collapse the fluid thus obtained into guinea-pigs, or rapidly increased. The tongue was dry and coated he examined it microscopically. None of the black, and the boy was comatose. The temperature nine guinea-pigs thus treated developed tuber- sank from 103 to 96°, while the pulse rose to 180. culosis. Inoculation into guinea-pigs of glands At 8 P.M. surgical intervention was practised in excised from the neighbourhood of the swollen extrenzis. Laparotomy revealed generalised perijoints also gave a negative result. Diagnostic in- tonitis proceeding from a perforated and gangrenous jections of tuberculin provoked in almost all these appendix. The appendix was removed and the patients fever and general malaise, but with one abdomen drained. Two ounces of ether were exception there was no exacerbation of the arthritis. poured through the drain into the lower part of the The one patient whose arthritis was affected by abdomen. The pulse fell to 135, and a slight rise of 5 milligrammes of tuberculin was a girl, aged 17, temperature from 96° occurred. There was no whose chronic polyarticular rheumatism had begun vomiting, and the boy passed a good night. as an acute rheumatism. The tuberculin induced Next day saline transfusion was administered, one fever and the formation of a ganglion over one pint in the morning and half a pint in the evening, ankle. Fluid withdrawn from the ganglion con- The pulse was now 130, the temperature from tained lymphocytes and was injected into a guinea- 100’50 to 101°. On July 26th the temperature was pig, which did not develop tuberculosis. While the 980, the pulse 80, and the boy had his first normal Slow improvement took fuid withdrawn from the joints in this case con- movement of the bowels. tained no other cells than lymphocytes, the fiuid place during the next eight days; then serious withdrawn in all the other cases contained numerous symptoms again supervened, the temperature polynuclear neutrophil leucocytes and an occasional rising to 102° and the pulse to 130-140. Another macrophage. Speaking at the same meeting Dr. injection of two ounces of ether was given through Tillisch, of Grefsen Sanatorium, reported four cases a drainage-tube. After this recovery was rapid and of subacute polyarthritis with effusion which he definite, and in six weeks the boy was running had observed among his consumptive patients. The about again. It would seem that the rapid subsicondition resembled closely that of acute rheumatism, dence of serious symptoms on two occasions in this and in one case disappeared after a course of tuber- patient justifies a hopeful attitude in regard to culin. In two other cases swellings of the ankles this method of treatment, sufficient at least to disappeared spontaneously. In the fourth case the dis- justify its more widespread trial. appearance of the arthritis was followed by purpura hæmorrhagica and nephritis. Dr. Tillisch finds THE STUDY OF NEW GROWTHS. salicylates give relief in such cases, but on this point he stands practically alone. Menzer and WE have received the November-December many other writers consider salicylates and similar number of a bi-monthly’periodical entitled Tumori,1 drugs objectionable, as they may mask the condition under the superintendence of G. Fichera published which requires vigorous treatment with vaccines, at Rome. Among other interesting articles there tuberculin. Recent work on tuberculous including rheumatism leaves the impression that our know- are two which call for special notice. One is an account of a case of cancer of the stomach treated ledge in this field is exceedingly limited. by means of autolytic foetal products by Dr. A. Bazzocchi at the hospital at Ronciglione. The ETHER IN CASES OF PURULENT PERITONITIS. patient was a woman, aged 48, suffering from ON previous occasionsreference has been made abdominal pain after food and wasting. There was in our columns to the intra-abdominal use of a pyloric tumour and dilatation of the stomach with ether in France by Dr. Souligoux, Dr. Morestin, enlargement of the supraclavicular glands on thee and others. Dr. Morestin has systematically used left side. Extract of foetal organs, thyroid, thymus, ether in doses of two to four ounces in all and spleen, was injected on four successive .cases of purulent peritonitis. All accessible parts days, and improvement in the patient’s condition of the intestine are first washed with ether, was at once noticed. A year afterwards her weight and two to four ounces of pure ether are then had increased from 62 to 71½ kg., no trace of the tumour existed, and the patient was in poured into the abdominal cavity and left to pyloric The supraclavicular glands which florid health. Of course, all primary sources of evaporate. excised showed epithelial nests. The had been are infection, such as the appendix and so forth, treated, and if accessible removed. In 31 cases, second paper is a contribution to the study of hasmo-angioma of the mamma by Dr. G. some of which were apparently utterly hopeless, Marangoni, of the Hospital at Padua. This kind Dr. Morestin all the results exceeded expectation. of tumour is of extreme rarity, and the case of the of the simplicity speaks favourably is interesting on account of the clearness procedure and the rapid improvement of the reported with which the peripheral development of the the ether stimulates that He suggests patients. the intestinal circulation and acts antiseptic- neoplasm can be followed. ally. Dr. Souligoux and Dr. Temoin have each a
two apparently hopeless cases of perforative peritonitis -which terminated in recovery. To these Dr. Jeanneret, in a recent number of the Revue Alidicale de la Suisse Rozzzande, adds the following case treated by him in an Alpine health
reported
1 THE LANCET, March
Nov. 1st, p. 1253.
8th, 1913, p. 723; May 13th,
p.
1563; and
THE Milroy lectures at the Royal College of Physicians of London will be given this year by Dr. F. Shufflebotham, of Newcastle-under-Lyme. who will lecture upon the Hygienic Aspect of the 1 Tumori, Archivio bimestrale fondato da G. Fichera, Anno iii., Fasc. iii., December, 1913, Roma.
calculus,
magnesium phosphates. ACCIDENTS FOLLOWING THE TRANSFUSION OF BLOOD. IT is generally supposed that transfusion of human blood is an operation without ill-effects, but a considerable number of cases in which hæmolysis or agglutination of the donor’s blood corpuscles occurred have been recorded, and some have been fatal. Delirium, jaundice, and, in severe cases, haemoglobinuria were the symptoms. In the Journal of the American Medical Association of Dec. 13th, 1913, Dr. R. Ottenberg and Dr. D. J. Kaliski have published an important paper, in which they show the value of preliminary blood examination in avoiding accidents. Haemolysis of one human blood by another is a pathological phenomenon which was thought to be especially characteristic of cancer and tuberculosis, but is now known to occur in a great variety of diseases. By means of a modified Wright’s capillary pipette Dr. Ottenberg and Dr. Kaliski examined the blood of 128 patients and found it to be haemolytic for The diseases several prospective donors in 17. in which this occurred were purpura haemorrhagica, carcinoma of the stomach, carcinoma of the rectum, lymphatic leuk2emia, pernicious anaemia, chronic osteomyelitis (due to staphylococcus aureus), and pelvic abscess. In all except two cases the patients’ serums were hæmolytic with only some of the prospective donors’ blood. In two cases, on account of the desperate condition of the patient, haemolytic transfusion had to be In one the disease was pernicious ventured. anaamia. The serum of the patient was agglutinative and weakly hasmolytic to the cells of the donor. The transfusion was followed by intense haematuria, which lasted 24 hours, during which the hæmoglobin fell from 34 to 31 per cent. instead of rising, as almost invariably occurred in other In spite of the loss of the transfused blood cases. the transfusion apparently had a favourable influence, as the patient improved slowly but steadily during the following month. He returned to hospital eight months later and a second transfusion was done from a donor whose blood was not agglutinated or haemolysed by the patient’s serum. This transfusion was successful; the patient was greatly improved and life was prolonged for a year and a half. In the other case (acute lymphatic leukaemia) the patient’s serum sharply agglutinated the donor’s cells, but only slightly laked
them after three and a half hours in the thermostat. No haemoglobinuria followed the transfusion, but blood smears showed phagocytosis of red cells by leucocytes in the circulating blood. The patient died 42 hours after the transfusionJaundice occurred in only one case and was slight and transient. The absence of haemoglobinuria in over 100 cases in which haemolytic donors were excluded shows the value of blood examination. Agglutination, unlike haemolysis, is not a pathological phenomenon, but occurs between normal human bloods. All human beings can be divided into four permanent hereditary groups sharply separated by agglutinative reactions. When the blood of two persons belonging to the same group is mixed no agglutination occurs. When the blood of two persons of different groups is mixed agglutination either of one by the other or Human of each by the other always occurs. are in small iso-agglutinins quantities present only and can be absorbed by a small number of susceptible cells. When the serum of the donor is agglutinative to the cells of the patient, it will be so diluted on transfusion that little, if any, agglutination will result. When the patient’s serum is agglutinative towards the donor’s cells the conditions are more favourable to agglutination, but even here it is probable that only exceptionally can massive clumps of agglutinated cells be formed, such as are seen in the test-tube. Only in these cases has phagocytosis of the cells in the circulating blood been observed. Dr. Ottenberg and Dr. Kaliski have seen three transfusions in which the serum of the patient was agglutinative to the cells of the donor, and in two of these the serum was slightly haemolytic. One was the case of lymphatic leukaemia referred to above. Another was a case of pernicious anaemia. Blood smears made after the transfusion showed phagocytosis of red corpuscles by polynuclear leucocytes. No urine was passed after the transfusion, and death occurred eight hours later. The necropsy revealed extensive phagocytosis of the red corpuscles in the spleen and lymph nodes. Agglutination need not be regarded as a contraindication to transfusion, but non-agglutinative donors should be chosen if possible. There is an important corollary not given by Dr. Ottenberg and Dr. Kaliski. As the principal danger of transfusion is haemolysis, and as this occurs only in disease, normal blood can be safely transfused in a case of
hæmorrhage.
____
TUBERCULOUS RHEUMATISM. THE relation between tuberculosis and rheumatism is a topic which has lately been discussed in many quarters. In THE LANCET for Jan. 3rd we published an interesting case of tuberculous rheumatism recorded by Dr. Nathan Raw, whose investigations, including inoculation experiments on guinea-pigs, clearly proved the tuberculous nature of the rheumatism. Some writers are apt to label polyarthritis as tuberculous when it occurs in the subjects of pulmonary and other forms of tuberculosis. Theirs is the view that various manifestations should, as far as possible, be "hung on one peg," instead of being attributed to Dr. Raw considers more than one primary factor. tuberculous rheumatism very rare. Professor Poncet and his school consider it very common. Several cases have lately been published in which injections of tuberculin provoked great pain and swelling in many joints already the seat of rheumatism, which has accordingly been regarded as tuberculous. At
478 recent meeting of the Medicinske Selskab of resort, removal to a hospital being impossible. A Christiania Professor Peter Holst discussed the boy, aged 7, was attacked by appendicitis on difficulties of correlating tuberculosis with poly- July 20th, 1913. Perforation occurred on July 22nd. arthritis. In 27 cases of chronic and subchronic Pulse 160, temperature 103° F. Two surgeons having arthritis he punctured the joints, and injected declined to interfere surgically, by July 23rd collapse the fluid thus obtained into guinea-pigs, or rapidly increased. The tongue was dry and coated he examined it microscopically. None of the black, and the boy was comatose. The temperature nine guinea-pigs thus treated developed tuber- sank from 103 to 96°, while the pulse rose to 180. culosis. Inoculation into guinea-pigs of glands At 8 P.M. surgical intervention was practised in excised from the neighbourhood of the swollen extrenzis. Laparotomy revealed generalised perijoints also gave a negative result. Diagnostic in- tonitis proceeding from a perforated and gangrenous jections of tuberculin provoked in almost all these appendix. The appendix was removed and the patients fever and general malaise, but with one abdomen drained. Two ounces of ether were exception there was no exacerbation of the arthritis. poured through the drain into the lower part of the The one patient whose arthritis was affected by abdomen. The pulse fell to 135, and a slight rise of 5 milligrammes of tuberculin was a girl, aged 17, temperature from 96° occurred. There was no whose chronic polyarticular rheumatism had begun vomiting, and the boy passed a good night. as an acute rheumatism. The tuberculin induced Next day saline transfusion was administered, one fever and the formation of a ganglion over one pint in the morning and half a pint in the evening, ankle. Fluid withdrawn from the ganglion con- The pulse was now 130, the temperature from tained lymphocytes and was injected into a guinea- 100’50 to 101°. On July 26th the temperature was pig, which did not develop tuberculosis. While the 980, the pulse 80, and the boy had his first normal Slow improvement took fuid withdrawn from the joints in this case con- movement of the bowels. tained no other cells than lymphocytes, the fiuid place during the next eight days; then serious withdrawn in all the other cases contained numerous symptoms again supervened, the temperature polynuclear neutrophil leucocytes and an occasional rising to 102° and the pulse to 130-140. Another macrophage. Speaking at the same meeting Dr. injection of two ounces of ether was given through Tillisch, of Grefsen Sanatorium, reported four cases a drainage-tube. After this recovery was rapid and of subacute polyarthritis with effusion which he definite, and in six weeks the boy was running had observed among his consumptive patients. The about again. It would seem that the rapid subsicondition resembled closely that of acute rheumatism, dence of serious symptoms on two occasions in this and in one case disappeared after a course of tuber- patient justifies a hopeful attitude in regard to culin. In two other cases swellings of the ankles this method of treatment, sufficient at least to disappeared spontaneously. In the fourth case the dis- justify its more widespread trial. appearance of the arthritis was followed by purpura hæmorrhagica and nephritis. Dr. Tillisch finds THE STUDY OF NEW GROWTHS. salicylates give relief in such cases, but on this point he stands practically alone. Menzer and WE have received the November-December many other writers consider salicylates and similar number of a bi-monthly’periodical entitled Tumori,1 drugs objectionable, as they may mask the condition under the superintendence of G. Fichera published which requires vigorous treatment with vaccines, at Rome. Among other interesting articles there tuberculin. Recent work on tuberculous including rheumatism leaves the impression that our know- are two which call for special notice. One is an account of a case of cancer of the stomach treated ledge in this field is exceedingly limited. by means of autolytic foetal products by Dr. A. Bazzocchi at the hospital at Ronciglione. The ETHER IN CASES OF PURULENT PERITONITIS. patient was a woman, aged 48, suffering from ON previous occasionsreference has been made abdominal pain after food and wasting. There was in our columns to the intra-abdominal use of a pyloric tumour and dilatation of the stomach with ether in France by Dr. Souligoux, Dr. Morestin, enlargement of the supraclavicular glands on thee and others. Dr. Morestin has systematically used left side. Extract of foetal organs, thyroid, thymus, ether in doses of two to four ounces in all and spleen, was injected on four successive .cases of purulent peritonitis. All accessible parts days, and improvement in the patient’s condition of the intestine are first washed with ether, was at once noticed. A year afterwards her weight and two to four ounces of pure ether are then had increased from 62 to 71½ kg., no trace of the tumour existed, and the patient was in poured into the abdominal cavity and left to pyloric The supraclavicular glands which florid health. Of course, all primary sources of evaporate. excised showed epithelial nests. The had been are infection, such as the appendix and so forth, treated, and if accessible removed. In 31 cases, second paper is a contribution to the study of hasmo-angioma of the mamma by Dr. G. some of which were apparently utterly hopeless, Marangoni, of the Hospital at Padua. This kind Dr. Morestin all the results exceeded expectation. of tumour is of extreme rarity, and the case of the of the simplicity speaks favourably is interesting on account of the clearness procedure and the rapid improvement of the reported with which the peripheral development of the the ether stimulates that He suggests patients. the intestinal circulation and acts antiseptic- neoplasm can be followed. ally. Dr. Souligoux and Dr. Temoin have each a
two apparently hopeless cases of perforative peritonitis -which terminated in recovery. To these Dr. Jeanneret, in a recent number of the Revue Alidicale de la Suisse Rozzzande, adds the following case treated by him in an Alpine health
reported
1 THE LANCET, March
Nov. 1st, p. 1253.
8th, 1913, p. 723; May 13th,
p.
1563; and
THE Milroy lectures at the Royal College of Physicians of London will be given this year by Dr. F. Shufflebotham, of Newcastle-under-Lyme. who will lecture upon the Hygienic Aspect of the 1 Tumori, Archivio bimestrale fondato da G. Fichera, Anno iii., Fasc. iii., December, 1913, Roma.