THE PRACTITIONER.

JUNE, 1874.

Original Communications.

TWO CASES OF LEAD-POISONING, WITH VERY LARGE QUANTITIES OF ALBUMEN IN THE URINE.

BY E. J. SHEARMAN, M.D., M.R.C.P., F.R.S.E., ETC.,

Physician to the Rotherham Hospital.

(Continued from p. 268.)

THE gentleman alluded to in the April number of the Practitioner, page 266, continued to improve so much in his general health that he was determined, in spite of my remonstrance, to walk a long way every day, until he felt cold and exhausted and could barely support himself in the erect position, and complained of dizziness and disturbed vision; but his appetite kept up, and he was enabled to attend to his professional duties, which he had not done before for many months. From 23rd January to 5th March the excretion of albumen in the urine rapidly increased, and there was not an atom of urea in it, its sp. gr. being only 1002. On the 7th March, after having been exceedingly excited, he was suddenly seized with apoplexy, and died on the 9th. I much regret being refused a post-mortem examination of the kidneys.

The lady has lost all her spasmodic attacks, and is very much improved in general health; but her face, feet, and legs have become œdematous, and she is often suddenly seized with slight

NO. LXXII.

D D

attacks of vertigo.

Since the 16th March the excretion of albumen in her urine has been gradually increasing, the sp. gr. being always under 1010, and often as low as 1002, with a very minute quantity of urea. There is no lead in the urine, and no blue line on her gums. I have exposed her to hot-air baths every other day, during which times I have collected from her perspiration as much urea as to be enabled to detect its crystalline flakes under the microscope most distinctly, and also proved it to be urea by converting it into nitrate and oxalate of urea. I have not yet detected any blood-discs in her urine. The head symptoms have been relieved by the hot-air baths; but the dropsical symptoms persist. She is going to leave her present residence shortly, and reside in a purer atmosphere.

Before these two patients began to drink lead water they were in perfect health. The condition of the kidneys in both seems to have been induced and kept up in consequence of the blood being contaminated by the poison of lead. I am anxious to ascertain if such cases have been noticed by any other practitioners, and, on that account, will continue the history of the present case in a future number of the Practitioner.

ON THE ACTION OF PURGATIVE MEDICINES.

BY T. LAUDER BRUNTON, M.D., SC.D.

Casualty Physician and Lecturer on Materia Medica at St. Bartholomew's Hospital.

(Continued from p. 350.)

HAVING now come to a conclusion regarding the manner in which purgatives act, let us consider some of their effects upon the body. It is evident that the increased peristaltic action of the bowels will hurry along the food and cause its expulsion before the nutritive matters it contains have been fully absorbed.

If a purgative be taken immediately before or shortly after a meal, the result will be much the same as if less food had been taken or the meal entirely omitted. Many persons who are accustomed systematically to eat more than they require will regularly take a "dinner pill" or a course of Seidlitz or Pullna waters, although they cannot be persuaded to deprive themselves of a single opportunity of enjoying the pleasures of the table or to put the least restraint upon their appetites.

Increased peristaltic action will also remove fæcal matters as well as food from the intestine, and it will be greatly assisted in this by the increased secretion from the intestinal wall which purgatives induce.

I have already mentioned that mechanical irritation, such as tickling with a feather or rubbing with a glass rod, will cause secretion from the cul de sac of intestine in Thiry's fistula, and hardened fæces seem to have a similar action. Thus diarrhœa is not unfrequently caused by the presence of scybalous masses or other irritating matters in the intestine, and nothing cures this

like a dose of castor-oil. At first sight it seems odd that the scybala are not washed away by the fluid which they cause to be secreted, but this secretion will probably be poured out only at or below the point where they lie, and thus it will have little effect on them, though it may wash out the lower part of the bowel thoroughly enough. A dose of castor-oil, on the contrary, will induce secretion in the bowel above the scybala, and the fluid in its downward rush will carry the fæcal masses along with it.

Irritating substances in the intestine, besides acting locally upon the bowel in the manner just indicated, may exercise an influence upon distant organs through the medium of the nervous system. Sir Charles Bell1 observed a case in which ulceration of the ileum was found in a man who had suffered severely from tic, but there was nothing wrong whatever with the fifth nerve, in which the pain was felt. He therefore felt convinced that although the pain was felt in the cheek, its true source was irritation in the ileum. Acting on this belief, he administered croton oil (of a drop in combination) in tic douloureux for the purpose of removing any morbid condition of the bowel, and obtained the happiest results from its employment; and Newbigging has found it equally efficacious in sciatica.

It is difficult to say whether the pain felt in the cheek is simply due to the irritation of the intestinal nerves being reflected, as it is termed, along the fifth nerve, or whether the irritation induces such a change through the vaso-motor nerves in the blood-vessels of the cheek as actually to set up a new irritation in the course of the fifth nerve itself. At any rate, the vessels of the face and head are very easily affected by any irritation of the stomach or intestines, as is easily seen from the extraordinary pallor which at once overspreads the face when a state of sickness and nausea has been induced. The effect of constipation in causing a feeling of fulness in the head is well known, and Ludwig and Dogiel3 found that when the intestines of an animal were moved by the finger the rapidity with which the blood flowed through its carotid arteries was greatly increased.

1 Bell, "Tractical Essays," p. 85.

2 Newbigging, Edin. Med. and Surg. Journ., Jan. 1, 1841.

* Ludwig's Arbeiten aus der physiologischen Anstalt zu Leipzig, 1867, p. 253.

The frontal headache which so frequently accompanies gastric or intestinal derangement may possibly be due to some of the intestinal contents which ought to be evacuated being absorbed and acting as poisons on the vessels of the head themselves. I am inclined to think, however, that although this may have much to do with it, yet the headache very often depends to a great extent on some alteration in the cerebral circulation caused reflexly by the condition of the abdominal organs; for I have myself had a headache, though not a frontal one, which alternated with nausea. The nausea would last for a few minutes, during which the headache would entirely disappear; then the nausea would leave me, and the headache instantly took its place. After evacuation of the stomach, both the headache and nausea disappeared, showing that in this instance at least they were due to irritation in the stomach. But in many instances, no doubt, not only headache but much more serious symptoms inay be due to the decomposition of food in the intestinal canal and the absorption of its products. Thus Senator1 relates a case where a simple gastric catarrh without fever was brought on by eating something which disagreed with the patient. This was followed on the second day by great belching of gas, smelling like sulphuretted hydrogen or rotten eggs. The urine also contained sulphuretted hydrogen. As soon as this occurred the patient collapsed suddenly, and became pale and giddy, with a small, frequent, and compressible pulse. The patient remained conscious, and in a minute and a half or two minutes the collapse passed away. A similar attack came on again during the same day, but after the bowels which had been constipated were opened, the patient rapidly recovered. Senator considers that the collapse was due to poisoning by the sulphuretted hydrogen absorbed from the intestine, and it certainly seems probable that this was one cause of the attack, even if it were not the only one.

Other poisons besides sulphuretted hydrogen may be formed in the alimentary canal and absorbed into the blood, where they exert their deleterious action. Among these may be mentioned. butyric acid, which has frequently been found in the stomach in

1 Senator, "Berliner Klinische Wochenschrift," 1868, No. 24, p. 254.