THE HISTOLOGICAL CHANGES IN SALVARSAN POISONING
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1234 THE HISTOLOGICAL CHANGES IN SALVARSAN POISONING. medical profession, and these are the objects towards which this association has already done so much, towards which it will be able to do far more in the future if its efforts are not curtailed by lack of funds. For fortunately it may as truly be said of the beneficent leaven of enlightenment as of the malignant leaven of rumour, that it acquires strength with its spread. - THE HISTOLOGICAL CHANGES IN SALVARSAN POISONING. THE nature of the untoward effects which sometimes follow the administration of salvarsan has been the subject of much controversy. Professor Gaucher has always insisted that they are due to arsenical poisoning. In the Cleveland Medical Journal for September Dr. H. 0. Ruh has recorded a case which bears out this view. It is of great importance, because a careful histological examination of the organs was made. A well-nourished and well-developed woman, aged 54 years, was admitted into the Lakeside Hos- pital. She had had nine children, of whom four were living and well, and five had died at the ages of 3 or 4 months. She had also had two miscarriages. At the age of 10 years a swelling began above the right knee and gradually enlarged until at the age of 18 it ulcerated. The ulceration persisted, and two years before admission a piece of the femur was resected ; four weeks later another piece was resected ; and five months later a more extensive resection was performed. Eighteen months before admission amputation was per- formed in the upper third of the thigh. The wound healed, but two sinuses persisted, from which there was a profuse discharge of pus. There was no family history of tuber- i culosis. On examination the stump showed three ulcerating 1 surfaces, each about 3 centimetres in diameter, from which 1 exuded foul pus. The edges were reddened, raised, and i granular. The heart and other organs were normal. The urine contained a few granular casts, but no albumin. The t Wassermann reaction was positive; 0.5 5 gramme of sal- 3 varsan was injected intravenously. After the injection she complained of severe abdominal pain, and in a few hours the temperature rose to 101’ 2° F., and the pulse to 120. No urine was passed until the fourth day after the injection, when 3 ounces were voided, but unfortunately this was not examined. No more urine was passed. On the fifth day a slight uriniferous odour was noticed in the breath. She became apathetic and gradually passed into coma, which terminated in death. At the necropsy the liver extended 4 centimetres below the costal margin. The heart was normal. The liver weighed 1565 grammes, and was soft and of doughy consistence and light-yellow colour. On section it was cloudy and the markings were rather indis- tinct. The kidneys weighed 175 (left) and 180 (right) grammes respectively, and were of a greyish-red colour. The capsule was thickened and stripped with slightly increased resistance, leaving a finely granular surface, on which were small irregular red areas. The cut surface was of a greyish-purple colour and very cloudy in appearance. The cortex was fairly well differentiated from the medulla, but considerably narrowed, and the glomeruli could be just seen. On microscopic examination the muscular fibres of the heart were slightly swollen and rather cloudy, but the striations were distinct. In some places there was marked fragmenta- tion. The hepatic cells in the centre of the lobules were irregular in size and shape, ragged and indistinct, and showed fat vacuoles. In some the nuclei could scarcely be seen, and the protoplasm was granular. Many contained bright yellow pigment. Several cells showed mitotic figures and signs of division. Towards the periphery of the lobules the cells approached the normal type. The interlobular connective tissue was slightly increased. The kidneys showed considerable increase in the connective tissue. There was enormous desquamation of epithelium, especially in the- convoluted tubes, which in all stages of degeneration fiYled’ the tubules. Throughout the kidney were irregular patches of ° polymorphonuclear leucocytic infiltration. The vessels were only slightly congested. Acute nephritis with an.uria has been observed in many of the fatalities due to salvarsan. It; has also been produced in experimental arsenical poisoning. Fatty changes in the liver cells as well as mitotic figures have also been produced in experimental arsenical poisoning.- Evidently salvarsan and arsenic produce similar effects on the liver and kidney. Why salvarsan may be given with- impunity so frequently and yet an ordinary dose prove fatal, as in this case, still remains a problem. The majority oil the fatalities have followed a second injection, and anaphylaxis has been suggested as an explanation. But, as in the present, case, this explanation cannot always be invoked. There was, evidently chronic interstitial nephritis, which may have: predisposed to the acute nephritis.. AN ANCIENT SURGICAL OPERATION. ONE of the most interesting studies in connexion with the evolution of the surgeon’s art is the extraordinary similarity . which ma,y be found between the procedures of modern active practitioners and those that were apparently practised, by their remote ancestors, for the native practitioner is a, . remarkably conservative type. The earliest form- of splint known, discovered in situ on the body of an Egyptian of the Fourth Dynasty, finds its exact counterpart in that which, is at present in everyday use among the barber surgeons of Upper Egypt. Many modern savage and semi-savage people perform surgical operations-and have done from time- immemorial-that wholly surprise those who, following a,. rather prevalent mode of thought, regard the major opera- tions of surgery as being of a very recent development. And: yet surprise at the boldness of these operations should always be tempered by the reflection that the more primitive the state’ of society the greater the familiarity with the details of severe wounding and subsequent repair of the human body. Even the mutilations practised by many races for purely aesthetic- reasons are operations of no mean magnitude, demanding some. degree of skill and boldness from the operator and a deal of’ fortitude from the patient. One operation, that of trephining,. has always proved a tempting theme to the student of the, history of surgical procedures. It is an operation practised’’ to-day among semi-barbarous peoples ; it is one that leaves its imprint on the skeleton and so may be detected in remains of great antiquity, and it is one that, in some places, is so firmly impressed on the popular mind that it seems to tell’ its history of a once more popular practice. Hudson, of Redruth, and John Fletcher Home have been the historians- of trephining in England; from America a mass of new- material has come ; and on the Continent Dr. Lucas- Championnière has studied the question in all its aspects.- His latest publication on the subjec;t 1 brings our know-- ledge of the history of trephining up to date, and adds a fund of interesting details culled by the- author from his vast experience. Among the Kabyles. Dr. Lucas-Championnière learned the lore from a re-- cognised practitioner in whose family trephining was- considered so much a matter of course that the man’s: father had submitted 12 times to the operation, and the son himself exhibited four palpable lesions in his own skull. Other peoples among whom the operation is-’, 1 Les Origines de la Trépanation Décompressive: Trépanation Néolithique, Trépanation pré-Colombienne, Trépanation des Kabyles Trépanation traditionnelle. Paris: G. Steinheil. 1912.
Transcript of THE HISTOLOGICAL CHANGES IN SALVARSAN POISONING
1234 THE HISTOLOGICAL CHANGES IN SALVARSAN POISONING.
medical profession, and these are the objects towards whichthis association has already done so much, towards which itwill be able to do far more in the future if its efforts are notcurtailed by lack of funds. For fortunately it may as trulybe said of the beneficent leaven of enlightenment as of themalignant leaven of rumour, that it acquires strength withits spread.
-
THE HISTOLOGICAL CHANGES IN SALVARSANPOISONING.
THE nature of the untoward effects which sometimes follow
the administration of salvarsan has been the subject of muchcontroversy. Professor Gaucher has always insisted that
they are due to arsenical poisoning. In the Cleveland
Medical Journal for September Dr. H. 0. Ruh has recordeda case which bears out this view. It is of great importance,because a careful histological examination of the organswas made. A well-nourished and well-developed woman,aged 54 years, was admitted into the Lakeside Hos-
pital. She had had nine children, of whom four were livingand well, and five had died at the ages of 3 or 4months. She had also had two miscarriages. At the
age of 10 years a swelling began above the rightknee and gradually enlarged until at the age of 18it ulcerated. The ulceration persisted, and two yearsbefore admission a piece of the femur was resected ;four weeks later another piece was resected ; and fivemonths later a more extensive resection was performed.Eighteen months before admission amputation was per-formed in the upper third of the thigh. The wound healed,but two sinuses persisted, from which there was a profusedischarge of pus. There was no family history of tuber- iculosis. On examination the stump showed three ulcerating 1surfaces, each about 3 centimetres in diameter, from which 1
exuded foul pus. The edges were reddened, raised, and i
granular. The heart and other organs were normal. The
urine contained a few granular casts, but no albumin. The t
Wassermann reaction was positive; 0.5 5 gramme of sal- 3
varsan was injected intravenously. After the injection she complained of severe abdominal pain, and in a few hours
the temperature rose to 101’ 2° F., and the pulse to 120.No urine was passed until the fourth day after the
injection, when 3 ounces were voided, but unfortunatelythis was not examined. No more urine was passed. On
the fifth day a slight uriniferous odour was noticed inthe breath. She became apathetic and gradually passedinto coma, which terminated in death. At the necropsy theliver extended 4 centimetres below the costal margin. Theheart was normal. The liver weighed 1565 grammes, and wassoft and of doughy consistence and light-yellow colour. Onsection it was cloudy and the markings were rather indis-tinct. The kidneys weighed 175 (left) and 180 (right)grammes respectively, and were of a greyish-red colour.
The capsule was thickened and stripped with slightlyincreased resistance, leaving a finely granular surface, onwhich were small irregular red areas. The cut surface was ofa greyish-purple colour and very cloudy in appearance. The
cortex was fairly well differentiated from the medulla, butconsiderably narrowed, and the glomeruli could be just seen.On microscopic examination the muscular fibres of the heartwere slightly swollen and rather cloudy, but the striationswere distinct. In some places there was marked fragmenta-tion. The hepatic cells in the centre of the lobules were
irregular in size and shape, ragged and indistinct, andshowed fat vacuoles. In some the nuclei could scarcely beseen, and the protoplasm was granular. Many containedbright yellow pigment. Several cells showed mitotic figuresand signs of division. Towards the periphery of the lobulesthe cells approached the normal type. The interlobular
connective tissue was slightly increased. The kidneysshowed considerable increase in the connective tissue. Therewas enormous desquamation of epithelium, especially in the-convoluted tubes, which in all stages of degeneration fiYled’the tubules. Throughout the kidney were irregular patches of °
polymorphonuclear leucocytic infiltration. The vessels were
only slightly congested. Acute nephritis with an.uria hasbeen observed in many of the fatalities due to salvarsan. It;
has also been produced in experimental arsenical poisoning.Fatty changes in the liver cells as well as mitotic figureshave also been produced in experimental arsenical poisoning.-Evidently salvarsan and arsenic produce similar effects onthe liver and kidney. Why salvarsan may be given with-impunity so frequently and yet an ordinary dose prove fatal,as in this case, still remains a problem. The majority oil thefatalities have followed a second injection, and anaphylaxishas been suggested as an explanation. But, as in the present,case, this explanation cannot always be invoked. There was,
evidently chronic interstitial nephritis, which may have:predisposed to the acute nephritis..
AN ANCIENT SURGICAL OPERATION.
ONE of the most interesting studies in connexion with theevolution of the surgeon’s art is the extraordinary similarity
. which ma,y be found between the procedures of modernactive practitioners and those that were apparently practised,by their remote ancestors, for the native practitioner is a,
. remarkably conservative type. The earliest form- of splintknown, discovered in situ on the body of an Egyptian ofthe Fourth Dynasty, finds its exact counterpart in that which,is at present in everyday use among the barber surgeons ofUpper Egypt. Many modern savage and semi-savage peopleperform surgical operations-and have done from time-
immemorial-that wholly surprise those who, following a,.
rather prevalent mode of thought, regard the major opera-tions of surgery as being of a very recent development. And:yet surprise at the boldness of these operations should alwaysbe tempered by the reflection that the more primitive the state’of society the greater the familiarity with the details of severewounding and subsequent repair of the human body. Even
the mutilations practised by many races for purely aesthetic-reasons are operations of no mean magnitude, demanding some.degree of skill and boldness from the operator and a deal of’fortitude from the patient. One operation, that of trephining,.has always proved a tempting theme to the student of the,history of surgical procedures. It is an operation practised’’to-day among semi-barbarous peoples ; it is one that leavesits imprint on the skeleton and so may be detected in remainsof great antiquity, and it is one that, in some places, is so
firmly impressed on the popular mind that it seems to tell’its history of a once more popular practice. Hudson, ofRedruth, and John Fletcher Home have been the historians-of trephining in England; from America a mass of new-material has come ; and on the Continent Dr. Lucas-
Championnière has studied the question in all its aspects.-His latest publication on the subjec;t 1 brings our know--
ledge of the history of trephining up to date, and
adds a fund of interesting details culled by the-
author from his vast experience. Among the Kabyles.Dr. Lucas-Championnière learned the lore from a re--
cognised practitioner in whose family trephining was-
considered so much a matter of course that the man’s:father had submitted 12 times to the operation, and
the son himself exhibited four palpable lesions in his
own skull. Other peoples among whom the operation is-’,
1 Les Origines de la Trépanation Décompressive: TrépanationNéolithique, Trépanation pré-Colombienne, Trépanation des KabylesTrépanation traditionnelle. Paris: G. Steinheil. 1912.
