TWO FATAL CASES OF POISONING BY STRYCHNINE.

1513 formed septa between them. The ureter was thickened for a considerable period, at a time, too, when aeration of its but pervious. The bladder showed no trace of disease. blood-supply was seriously interfered with. We believe the The left kidney was much hypertrophied, being about one heart under such adverse circumstances was unable longer to and a half times the usual size. It was globular in form and combat successfully the increased peripheral resistance movable. The tissue was normal and there was no trace offered by the diminished lung area and succumbed under the of tuberculosis. The uterus, tubes and ovaries were normal. difficulties we have indicated. An examination of the cranium or great veins of the neck Sa.n Remo, Italy. was not allowed. - BeMM’.—This case is a striking example of a primary tuberculous lesion remaining confined for four years to one TWO FATAL CASES OF POISONING BY kidney, without secondary deposits appearing either in the STRYCHNINE. lungs or other organs and without any direct extension along the genital or urinary tracts. The globular form of the left BY HENRY PILKINGTON, M.R.C.S. &c. kidney, presumably assumed during its compensatory hypertrophy, apparently favoured its becoming mobile, not only by CASE 1. -On July 13th, 1892, I was called at 6 A.M. to its increased bulk projecting into the abdominal cavity but also by its raising up the peritoneum and by its change of see a young woman aged seventeen, who was thought to contour. Clinically this condition of the kidney is of great be in a fit. On arriving at her abode (about seven or eight importance, for there was the great probability that pain and minutes’ walk) I found the girl fully dressed and lying on a enlargement of the left kidney, occurring consecutively to sofa, with traces of having recently vomited. She was quite similar events in the right with cystitis, were due to extension unconscious, the face was livid, the pupils were contracted, of tubercularisation to the other organ. But such an inferand thejaws were partially clenched ; the pulse was ence would entirely mislead the surgeon when weighing the about 90, rather weak ; and there were convulsive movements and cons of treatment. CatheterisR.tion of pros operative each ureter would be of great service, and also the fact of the extremities and slight spasmodic twitchings of the that the pain subsided after a few days’ confinement in bed. fingers like subsultus tendinum. Her parents stated that she The symptom of pain gave rise to some confusion, but the had risen about 5 A. M. apparently quite well, and to their knowtaken nothing, not even her usual cup of tea. They nephritic pain was of many months’ standing, whilst the recent ledge had shoulder pain probably marked the onset of the pleurisy. could not remember that she had that morning been apartfrom The intense pain which came on in presence of the large some one or more members of the family for even five minutes. effusion, and which subsided after aspiration, seems rather to Their statements were somewhat contradictory, but that might have been due to pressure on inflamed nerve endings than to have been due to their distress or anxiety. 1 left to get some any friction of opposed surfaces, as the lung was collapsed remedies, having given instructions to keep anything she and relief followed aspiration. The case illustrates some might vomit during my absence. When I returned I found interesting points as regards the percussion note commonly the girl was much worse. She had vomited about one ounce known as Skoda’s resonance. Its cause is obscure and the of greenish fluid and had been much convulsed, and her current theories of its causation somewhat at variance. face was darker and respiration was slow and laboured ; Whether this sign was present during the accumulation of the pulse was about the same ; and there were still convulsive The respiration slowed the fluid we do not know, but after complete withdrawal of twitchings as when I left her. She died about the fluid it made its appearance and remained unchanged until she only gave an occasional gasp. an hour I first saw or about an hour and a after for a in ten increase area for when the her, slight except days, necropsy demonstrated absence of fluid, either free orloculated. half from the beginning of the attack, the pulse beating The effusion therefore probably caused the changes in the regularly during and even after her last gasps. I reported lung which gave rise to the Skodaic resonance, but its actual the case to the coroner and police as a death not due to presence was not an essential factor for its maintenance, natural causes. I was informed that, after inquiring into though undoubtedly the two are generally found together. the circumstances, it was not deemed necessary to hold an Effusion acts merely as the exciting cause of other conditions, inquest and there was no necropsy. For my own satisfaction which appear to be diminution of the respiratory area of the I submitted the small quantity of vomit to an analyst and he lung in one part with airlessness varying in degree, and a sent me a certificate to the effect that he had found strychnine remaining crepitant part in contact with the parietes. in it. CASE 2 -On April 10th, 1893, I was called to see a man Though its commonest cause is fluid effusion, a similar four miles from my house. He was a chemist and observed above has been residing lung. hepatised phenomenon Dr. Wilson Fox has collected and summarised the recorded druggist, twenty-nine years of age, of very regular habits and At 11.30 A.M. the same day he fond of athletic exercises. cases of sudden death in pleurisy with the probable and verified causes of death. We quote those in which an interval was seen by a friend and made arrangements to meet him at in which the the cricket ground that afternoon. Twenty minutes afterelapsed between paracentesis and death result was not directly due to the operation.-Case 1Death wards the patient’s brother called at the shop, and seeing whilst washing out the pleural cavity one month after paracen- several customers waiting to be attended to, he entered the tesis. Haemorrhage into the septum of the heart was found kitchen behind and found his brother lying on the floor quite at the necropsy.—CM Fatal syncope on the seventeenth unconscious and observed that he had vomited recently. day. The heart was fatty and contained a thrombus which Local assistance was called in and I was telegraphed for. extended into the pulmonary artery.-Case 5Death on the I arrived at 2 30 P.M. (two hours and three-quarters after the thirteenth day ; no cause discovered.—Ch.s6 Death on the patient had last converged with his friend) and found twelfth day whilst walking upstairs, probably due to pul- him to be in the following condition : He was lyingmonary embolism.-Case 5 :Death forty-eight hours after on the floor quite unconscious ; the eyelids were very puffy operation (probable thrombosis of great veins of the neck) ; and red ; the pupils were very uneven, the right being con-t unverified -Cases 6 and 7 Death on the tenth and nine- tracted and the left dilated ; the pulse ranged from 84 to 90 : teenth days respectively from pulmonary haemorrhage. the temperature was 100 8° ; he had convulsions at quick and: Potain, Vallin and Lepine have also recorded cases in which irregular intervals, started by the slightest touch, even that paracentesis was not performed, in which death resulted from of feeling the pulse; there was inability to swallow, but cerebral embolism. Comparing this case with the latter no trismus ; and the fingers were clenched over the thumbs series it will be observed that there were no symptoms and the toes were incurvated. He had vomited, but un-. whatever of cerebral embolism. Of the former series it bears fortunately the vomit had been removed from the floor and most resemblance to Cases 2, 3 and 5, especially considering could not be collected. With the acquiescence of the practi-:. the presence of phlebitis of the external jugular and tioner present I gave an enema containing 30 grs. of chloral axillary veins. The analogy was not, however, borne out hydrate. Afterwards the convulsions decreased in number by the post-mortem examination, when neither thrombosis and severity, and the pupils became equal in size some little time before death. I was with the patient about three hours, nor embolism was found in the heart, lungs or thoracic vessels. We noted that though the displacement of the heart was con- during which time his pulse continued to be good, but about siderable it had not interfered with the normal calibre of the 5 P. M. respiration became very laboured and gradually slowed, great vessels. Cardiac failure rather than paralysis of the so that when I left at 5.20 P.M. he was only gasping at long to be intervals, although the pulse was regular and only a little respiratory centre appeared from the final the cause of death. The heart was organically weak ; it was weaker. He died seven or eight minutes after I left him. Post-mortem exam in ati.on, tiventy-t-ri hours after death.subjected to the additional tax of pressure and displacement

and

symptoms

1514 The weather was fine and cold. Rigor mortis was extreme all over the body, which was well nourished. There were no bruises or wounds to be seen. On removing the scalp the dura mater was nowhere adherent to the skull cap but was very congested, and the veins and sinuses about the brain and cerebellum were filled with dark liquid blood. The membranes were nowhere adherent to the brain. On slicing the brain horizontally, from above downwards, no local extravasations into the brain substance appeared. Both lateral ventricles were full of dark-coloured semi-fluid clots. Body : The muscles, including the diaphragm, were very congested, of a lake-red colour; the superficial veins of the stomach and intestines were greatly distended with dark liquid blood, and the pericardium was normal, its cavity containing about two The right lung was almost generally ounces of clear fluid. adherent to the chest walls laterally and posteriorly and to the diaphragm, no fluid being found in either pleural cavity ; the lungs were congested, the apices being healthy. The heart was normal in size, both ventricles and auricles heing empty and all valves competent. The liver was normal, ex.. cept slightly adherent to the diaphragm opposite to the adhesion of the right lung. The stomach contained only a very little fluid ; it was not opened but was tied, cut out and sent with the liver, spleen and kidneys in onejar, and with the brain in another, for chemical analysis. The intestines were slightly distended but empty. The right kidney was very large, a little congested, and the capsule was non-adherent ; the left kidney was very small (about one-fifth the size of the right), and the capsule was adherent. The bladder contained only a little urine. At the inquest, held on April llth, I gave evidence to the effect of the above notes, and in replies to direct questions I stated I thought that the death was due to poison and that the poison was strychnine. The inquest was adjourned till May 2nd to allow time for analysis. The reports from I the county and assistant county analysts were that strychnine had been found in the viscera sent. The verdict was, ’’ Death from poisoning by strychnine, but no evidence to show how administered. " In these cases I believe there are some symptoms not usually to be found in cases of poisoning by strychnine-namely, the vomiting and the almost immediate unconsciousness. I suppose that in each case a large dose of the poison was taken when the stomach was empty and the shock caused the haemorrhage into the ventricles. In both cases respiration slowed rapidly, whilst the pulse continued with slight alteration and stopped after cessation of breathing. Both the patients were healthy, strong and young, and were in comfortable circumstances. Such cases are rare in country practice, and judging from the strange circumstances and symptoms I think in all cases of sudden illness the possibility of poisoning should never be lost sight of and it is particularly to be desired that the vomit (if any) be preserved, for in some recorded cases of strychnine poisoning where the vomit has been lost the analysts have failed to find the alkaloid in the viscera.

one in a patient aged twenty-two and one in patient aged seventeen, both in an early stage ; two

elbows, a

diseased wrists, both

being old

cases

with

sinuses, in

patients aged twelve and fifteen ; and one interphalangeal joint of the thumb, in a boy aged fifteen. These cases were daily under observation for one month, and the treatment was carried out in strict accordance with the descripAt first a slight tion contained in Mr. Page’s article. be but this was noticed, fairly attributed may improvement to rest in bed and better surroundings. Everyone connected with a hospital knows that a few days in bed make a vast difference in the appearance of the tuberculous joint of an out-patient. At’the end of a month, in the cases referred to one of the elbows were excised and the ankle was amputated. The patient who was the subject of the other elbow case withdrew from the hospital and we could not trace him. The boy with the diseased inter-phalangeal joint of the thumb, whom we treated as an out-patient, certainly improved for a time, but we had every reason to suspect that he removed the ligature as soon as he left the hospital and replaced it just before he came up to be seen. The wrist cases remained in much the same condition as they were before the treatment was commenced. It will be interesting to know whether any more extended trial of the cedema treatment has been made, and, if so, whether any measure of success has attended its application. Whilst on theoretical grounds it appears reasonable to suppose that tuberculous affections of the skin might yield to the cedema plan, it hardly appears possible that the same result will follow when deeper parts are involved. The pain produced was not great. Of course it may be said that in all these cases the disease was too far advanced to permit of the passive cedema checking its course. I can only reply that the cases were in an early stage and appeared to answer the description of the class of cases mentioned by Mr. Page as being under treatment at Kiel.

above, both of the knees and

Queen-street,

Leeds.

ULCER

OF

THE

BY WM. ROBERTSON, SURGEON TO THE THROAT AND EAR

TONGUE.

M.D. GLAS., HOSPITAL, NEWCASTLE.

following

A SHORT account of the case, in which a novel mode of treatment was adopted with a successful issue, may not prove uninteresting. The patient, a man about forty years of age, when I saw him on March 20th last was suffering from an ulcer of the tongue. There was a history of a specific taint acquired about six years ago. The affection of the tongue had extended over a period of four years and he had been under treatment elsewhere. He had taken stimulants freely and had during the whole time smoked considerably. The organ was painful to touch and dunng mastication. On his protruding the tongue, which he Stanley-street, Ormskirk. could do freely, it was observed to be large, flabby and indented, and its surface was covered by a shaggy, grey thick fur. A large transverse track three quarters of an inch long, with an ulcerated floor, stretched across the mid-dorsal region, and at its right extremity there could be felt in the substance of the tongue a rounded, painful swelling. Rather more than a quarter of an inch in front of this fissure there OBSTETRICAL AND extended another one, which was neither so long nor so deep. but, like it, had an ulcerated floor. Two quadrilateral areas THERAPEUTICAL. of thickened and infiltrated mucosa were noticed in front, of and behind the anterior fissure, being hard to the touch THE TREATMENT OF TUBERCULOUS DISEASE OF and prominent To the right of these areas there extended longitudinally, for over one inch, a shallow ulcer less than a JOINTS BY THE INDUCTION OF LOCAL ŒDEMA. quarter of an inch broad, the edges being indurated. Two BY W. H. BROWN, F.R.C.S.I. symmetrically placed, round, indurated nodules were dis covered near the tip in the substance of the tongue and the were found to be enlarged and indurated. THERE appeared in THE LANCET of Nov. 19th, 1892, an submaxillary glands but painless. The treatment consisted in the surface of the account of the treatment of tuberculous disease of joints tongue being freely soaked for some time in a 20 per cent. by the application of elastic ligature above the affected solution of cocaine containing resorcin and then being dued parts. The results were noted as having been very satis- with cotton-wool. With a dermal curette the dense fur wa’ entirely removed, with the result that a much better view of factory. I have since had opportunities of trying this plan the lesions could be obtained. With a dermalgalvano-cauttn of treatment in nine cases taken from amongst my hospital at a red heat (after injecting a 20 per cent. soluriou of point patients, and my experience does not in any way enable me cocaine in a 2 per cent. carbolic lotion) the thickened areas fit to confirm the favourable report given by Mr. Page. The mucosa were freely punctured and the three ulcerated nact!-’ cases were as follows : Two diseased knee-joints, in an early The effect of th,were well scored over with the cautery. stage, without sinuses ; two diseased ankles, also in an early first application was the disappearance of pain from thfstage in children under seven years of age ; two diseased tongue, easier masticatinn &c. and a reduction in size of the

Clinical Notes:

MEDICAL, SURGICAL,