The tongue was clean though dry, the gums were normal, there was no abdominal distension or tenderness, the liver was not palpable, but the spleen was slightly enlarged but not tender. The heart and lungs were normal, as was the urine. The penis showed marked priaprism, which condition was continuous and painful. A blood examination showed red corpuscles 1,620,000 per cubic millimetre and leucocytes 920,000 per cubic millimetre and it was found that the excess of leucocytes was due entirely to the large lymphocytes. On the twelfth day it was found that the spleen was still further increased in size and distinct enlargement of the glands in both axilla and in both groins was felt. The patient sank rapidly and died nineteen days from the commencement of the illness.

3.

The following points are, I think, worthy of note: I. The duration of the illness. The entire illness lasted less than three weeks. 2. The general symptoms. The mode of onset and the general symptoms (headache, malaise, pallor, and continued fever) suggested the probability of typhoid fever and the possibility of tuberculosis or of malignant endocarditis or some septicemic" condition. Typhoid fever, however, was excluded by the absence of any other symptoms or signs of the disease, including Widal's reaction, and, moreover, the course of the pyrexia and the presence of priapism militated against that disease. Tuberculosis and malignant endocarditis were excluded by the history and by a thorough examination. Splenic enlargement. This was not noticed until the thirteenth day of the illness. The spleen was only slightly enlarged and it was very firm and not tender. The splenic enlargement, associated with pallor and with purpuric spots on the flanks, suggested some diseased blood condition. It is to be remembered, however, that in cases of lymphatic leukemia the spleen is not always obviously enlarged. 4. Glandular enlargement. Enlargement of the lymphatic glands did not make its appearance until after the thirteenth day, by which time the diagnosis had been made by means of a blood examination. It may be noted that the glandular enlargement progressed rapidly in the last few days of life. 5. Blood examination. This showed conclusively that the case was one of acute lymphatic leukemia. An interesting point in this connection is the enormous number of lymphocytes present. 6. Priapism. During the whole of the time that this patient was under observation there was marked and continuous priapism and this condition gave rise to much distress. In conclusion, one may say that a case like this shows the very great clinical importance of a blood examination in

doubtful cases, and, indeed, in this instance it was thus possible to diagnose the presence of lymphatic leukemia before any glandular enlargement was observable.

Calomel as a Poison, with an Illustrative Case. T. L. Bunting, M.D. (EDIN.), Scotswood, Newcastle-on-Tyne, in The Lancet, Nov. 26th, 1904.

Guy

Calomel is very inconstant in its action as a poison. says that six grains have proved fatal, while an ounce has been taken with impunity. Rungberg records* a case in which three injections of one and a half grains each given within one month proved fatal, and he mentions other similar fatal cases after subcutaneous injections of small doses. The general assumption seems to be that calomel itself produces the symptoms of acute mercurial poisoning. But this is contraindicated by its insolubility, by the fact that it is not a mechanical irritant, by the fact that very large doses have been taken with impunity, and by the great variations in the fatal dose. This difficulty is met by the suggestion, which does not commend itself to Guy, that calomel acts as a poison only by its partial conversion into perchloride of mercury by the free hydrochloric acid of the stomach. On this supposition the very small fatal doses could be explained on the theory of an over acid stomach converting the calomel to perchloride more rapidly than usual, though it is more likely that an impurity (probably the perchloride) was originally present. It is certain that the action of calomel in medicinal doses is by no means always proportionate to the amount given, the purgation produced by one grain being often equal to that produced by five grains or more in the same individual. On the theory that it acts only by conversion into perchloride this is understood on remembering that, as soon as sufficient conversion has taken place, purgation will be brought on and the remainder of the calomel will be expelled unchanged. Calomel injected subcutaneously would in the same way be converted to perchloride by the chlorides of the blood. But in this case the action of a small quantity could not cause expulsion of the remainder. Hence, the fatal cases from small subcutaneous doses. If this be true, large doses of calomel should be borne with impunity by individuals with healthy gastro-intestinal tracts.

*Deutsche Medicinische Wochenschrift, No. 1, 1889.

That this is actually so is proved by a series of cases reported by Dr. Strong.* He treated lobar pneumonia by large doses of calomel. In most cases he gave 20 grains every three hours for twenty-four hours. In one case, that of a woman, he gave an initial dose of 60 grains, followed by 30 grains every three hours, making 360 grains altogether. In none of these cases was there more than moderate catharsis and there was no ptyalism. Dr. A. W. Messer informs me that he has given similar doses with the same result, and repeated doses of 20 grains have also been given with apparent advantage in cholera. A recent case of my own also illustrates the comparative harmlessness of calomel.

A boy, aged three and a half years, obtained possession of a bottle of 120 cachous, each of which contained one grain of calomel, and ate 110 of them. He came under treatment within about twenty minutes. This consisted first of a dose of eight grains of sulphate of zinc. This did not produce emesis, and was quickly followed by apomorphine, one-fortieth of a grain hypodermically, which produced free vomiting. The stomach was then washed out through an ordinary stomach-tube, bringing away more of the disintegrated pink cachous. A solution of bicarbonate of sodium was used in washing in order to neutralise the free hydrochloric acid and so prevent conversion into perchloride. After the washing five ounces of milk were poured down the tube and left in the stomach. The patient immediately fell asleep. Half an hour later he vomited again and then slept undisturbed for nine hours. There was no further vomiting. The first motion of the bowels did not take place until twelve hours after the calomel was taken; it was copious and soft but not liquid. A second motion, which consisted entirely of an almost gelatinous green mucus, occurred four hours later. After that the bowels were moved only normally. The patient never at any time showed any ill effects or any other symptoms than those recorded. Other cachous previously taken from the same bottle had produced their normal therapeutic effect, so there is no reason to doubt their reputed strength.

The absence of ill effects in this case may be largely due to the prompt energetic treatment, so that it alone proves nothing. But as at least half an hour elapsed between ingestion and the first emesis there had been plenty of time for absorption with so large a quantity present, and, further, as washing never absolutely clears the stomach some must have been left. It may

*New York Medical Record, March 16th, 1889.

1

therefore be said that this case, together with those mentioned above, tends to show that pure calomel possesses but slight toxic effects and that considerable overdoses may be given over a limited time without fear of either acute or chronic mercurial poisoning. A subsidiary point of interest is the early age at which a full-sized stomach-tube was used. There was no difficulty of passing it.

Tetany and Laryngismus Stridulus Accompanying Malnutrition in an Infant. C. C. BENEDICT, M.D., Menlo, Iowa., in the Journal of the American Medical Association.

Rarity of Cases.-The relative infrequency of tetany in infants has prompted me to report this case. That it is rare in this country is shown by the report of Griffith,* who was able in 1895 to collect but fifty cases, thirty-eight of which were in children. Sanger Brown was able to find but one hundred cases in this country up to 1898. He does not state the age at which it was found to occur most frequently.

A careful search of available literature fails to reveal a report of any cases of the disease occurring in infancy, which hardly corresponds with the observation of Holt. It is conceded that the disease is often accompanied by laryngismus stridulus, and usually accompanying rachitis or marasmus. In the following case there was a condition of marked malnutrition of a few weeks' duration only, and only a very few symptoms of rachitis were to be seen before the final termination.

Patient.-J. C. G., male, born May 6th, 1904, weight at birth 7 1-2 pounds.

Family History.-Both parents are apparently in good health. The patient was their fourth child. One child died of scarlet fever some few months ago. The other two children, a boy of about seven and a girl of about nine, are both bright and healthy.

Previous History.-When this child was born it was tonguetied, which was clipped about six weeks later. Mother states that she has always had plenty of milk in both breasts to nourish the other children well, but at the lactation just previous to this she thought the supply in the left side was not so good. The

*Holt's "Infancy and Childhood."

+Sanger Brown: Med. News, July 5th, 1904.

milk from left breast at present is poor in quality, showing low percentage of fat, and on standing, separates into opaque and transparent portions. From June 17th, when the frenum was clipped, until September 10th, the child did not come under my observation.

Clinical Course.-During my absence from home for a few days early in September, a fellow practitioner was called in on account of several superficial ulcerations presenting on the scalp and behind each ear which were slow in healing. There were also several small sores around the edges and end of the tongue, and on the corresponding buccal and labial surfaces. On September 10th I was hurriedly called on account of a spasm the child had just passed through. I found the child lying quietly in the mother's lap, uttering a low feeble whine, mouth wide open, eyes partly closed, skin bluish, features pinched and peaked, lying apparently oblivious to all surroundings and offering no resistance to manipulations. Temperature 101.4 (axilla); pulse about 125 and weak. The mother, in describing the spasm, said that the child's face became blue, the head was thrown back, the limbs became stiff and rigid. Respiration ceased entirely for a brief time, then began again, and the normal color gradually returned to the skin.

The mother stated that four or five weeks ago the child weighed twelve pounds; present weight nine pounds. He takes the nipple vigorously, but after three or four efforts drops it and begins to fret and cry; on changing to the other breast he nurses all right and seems to be satisfied. Suspecting poor quality and deficient quantity of milk to be largely the cause of the present trouble, an immediate change was made to a 5 per cent. preparation of cow's milk. The sores on the tongue and lips prevented the use of the rubber nipple, so we made use of an ordinary medicine dropper until he could grasp the nipple. The bowels were moving two or three times a day, but contained particles of undigested food. An examination of the lungs was negative.

September 11.-Temperature 101.4; pulse fair; slept quite well; takes bottle some; lungs negative; no distension of abdomen.

September 13.-Temperature 100.3; pulse strong; gave strychnine in 1-300 grains every four hours since first visit. Bowels moved three times. Child seems more lively, and takes more notice of things going on about him; cry is stronger, urine scant and of reddish color. Glottic spasms have been occurring each day at intervals of from forty minutes to three hours.