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THE NEW ENGLAND
A PHENOMENON OBSERVED IN THE BLOOD OF
BY S. C. FULLER, M.D. [Read before the Massachusetts Homæopathic Medical Society, Jan., 1800.] Some remarks on this phenomenon were made to this society at one of its meetings not long ago, and a preliminary note has already appeared in the annual report of the Westboro Insane Hospital for the year ending September 30, 1898. Nothing new has since been added to our know). edge of the subject. The present object is to give a more detailed account of our observations and the experiments made in connection with the study of this very interesting phenomenon; in short, to justify, if I can, the position that has been taken with reference to its origin.
A pathological picture must, like a photograph, take in every detail of the abnormality to be portrayed, and is only fully understood when every step in its development from its incipiency can be traced and studied. With the subjects with which the most of us have to deal this is not always possible. We have frequently to draw inferences based upon the data of our accumulated experiences; and when these inferences can at least be partially substantiated by experimental evidences, we may form an opinion, however qualified it may be.
be. All of the clinical symptoms of the cases about to be discussed were given due consideration ; but it is to a particular clinical observation that I wish to especially call your attention. Before doing so, however, it might be well
VOL. XXXIV.- No. 6.
to refer to what led to the accidental discovery of what so far has proven an interesting incident in the study of, and apparently peculiar to, cases of morphinism. It is the custom in the hospital here, with the other examinations made of patients on admission, to make one also of the blood. This is done because of the almost general association of a more or less marked degree of anæmia with all forms of mental disease. Leukæmia, if present, can be differentiated from Hodgkin's disease, and malaria may be detected. If a peculiar rise and fall of temperature suggests typhoid fever, this condition may be quite safely diagnosed or excluded by the count of the leucocytes. Further, certain peculiar neuroses have certain peculiar manifestations that are at times suggested by the differential count of the leucocytes. To make the examinations of value, uniform methods are followed throughout. So that if, for instance, the objection be made to the Fleischl hæmometer, that it is liable to error of from one to two degrees in its readings of hæmoglobin percentages when the results of several hundred separate examinations are studied, its compara. tive value is not impaired. For counting the red cells Gower's solution is invariably used as a diluting Auid, and for the leucocytes 13 per cent acetic acid in aqua dist. The coverslips are stained with Erlich's triple and Griffith's eosinmethyl blue stains.
It is certainly worthy of note that, in more than three hundred examinations where these uniform methods were used, five cases only, all of which were morphine users, showed on microscopical examination, where the blood had been diluted with Gower's solution, small crystals closely resembling the smaller crystals of morph. sulph. These crystals were colorless -- some needle-like in shape, others tapering to a point at one end, the other end having a broken-off or jagged appearance ; and with this variety there seemed a tendency to arrange themselves in stellate groups. This, of course, was never observed, as there was at no time a sufficient number to accomplish that purpose. Still another variety was of a long, narrow, parallelogram shape. The crystals ranged in size from about 30 4. (micro-millimetres) to 60 4. in length, and
about 3.14. to 64. in width. They were first observed in a specimen diluted 200 times with Gower's solution. Thinking that perhaps these crystals were due to fault in the technique, or perhaps to a deteriorated diluting fluid, a fresh solution was made up, another specimen of blood taken, and the examination conducted with great care, when they were again observed. Blood was then taken from three different sources of individuals who were not morphine users and examined with the two different fluids, and I could not demonstrate the crystals. Fortunately, there happened to be in the hospital at the same time another morphine patient who had been taking the same amount as the first patient — 25 grains per diem — and been admitted on the same day. An examination was made of the blood of patient No. 2; and I without any difficulty demonstrated crystals like those already described. The general condition of the blood in both these cases was markedly anæmic — great reduction of hæmoglobin percentages and red cells. Indeed, in all the cases of the opium habit that I have examined there has been marked anæmia. In one case the hæmoglobin, as estimated by the Fleischl apparatus, was below 20, and the red count less 2,000,000 per cubic metre. There have been nine cases in all, which were addicted to taking opium in some form, that have come under my observation.
Five of these may be considered habitués in the strictest sense; and it is singular that these five were morphine users, two of which were taking 25 grains per diem, one 6 grains per diem, one 8 grains per diem, and one 90 grains, with 30 grains cocaine additional. The two who were taking 25 grains per diem showed the greatest number of crystals. In fact, in one of these cases, where the drug was immediately cut off, they could be demonstrated, though fewer in number, two weeks after. In the other the drug was gradually diminished, but I could not demonstrate them when the patient was taking less than 3 grains per diem. In the one taking 90 grains I found only one crystal, quite a large one, but typical. This was observed on first examination, about twelve hours after admission. I should think from the greater numbers observed in the cases taking 25 grains
over those taking 6 grains and 8 grains per diem, that the cocaine was perhaps responsible for the small number appearing in the go grains case. Just in what way the cocaine influenced the number I am not prepared to say. The other cases, four in number, were not habitués in the strictest sense, at least not at the time of admission. One, according to statement, was accustomed, for a few months before admis. sion, to taking from 15 to 20 grains chloral alternate nights, paregoric quite frequently, and at intervals of a week or more morph. sulph. ; of this latter, however, never more than 14 grain at a time. According to the commitment paper, this patient had for several years taken drugs to produce sleep. The patient had evidently a neurotic temperament, and according to this statement the drugs taken were antikamnia, chloral, and morphine.
Another had been using opium in some form for three years. Began by smoking it, and kept it up for six months. Then started taking it in pill form, 16 grain morph. twice a day, and increased to i grain. Then began taking it in powder form, not measuring, but what was thought sufficient. From October, 1897, to June, 1898, took laudanum, 4 ounce twice a day, and gradually increased to 1 ounce per diem. The patient at this time — she claimed, to produce a sensation took 2 ounces of laudanum and went out for a walk, was picked up in an unconscious state and taken to the City Hospital, Boston. In two days was discharged, and on the evening of discharge took 72 ounce of laudanum and ten cocktails, and being
toxicated and under the influence of laudanum, was again sent to the City Hospital, remained three days, and was sent home, where she continued to take her customary dose, I ounce a day. She remained at home a week. Was then taken to the New England Hospital, where she remained a week and a half without receiving the drug. Was then sent to the hospital here, and the day after admission I made an examination, which was twelve days after the patient had been off the drug. No crystals were observed. The patient was anæmic, but not to so great an extent as the other cases.
Another patient was brought here from another hospital in
a very weakened mental and physical condition. She had previously been taking morphine, for how long and in what quantity she does not know, as she has no memory for recent events. There were no crystals found, but there was a very high grade of anæmia, as shown by the examination made a day after admission. The subsequent symptoms for the first week or more were those of demorphinization.
Still another case was one who had been taking the crude opium by mouth for more than fifteen years. No crystals were observed, but a very marked anæmia existed.
In these four cases I have not been able to demonstrate the crystals, and in most instances for obvious reasons.
Since — in the five cases where there was a straight history of morphinism, and patient taking the drug at the time when examination was made - all of these cases showed a peculiar crystalline formation, I have inferred that there must have been some chemical action between the blood of these morphinomaniacs and the Gower's solution; as when the blood was diluted with the 1/3 per cent acetic acid sol., distilled water, hydrant water, undiluted blood, and smears stained and unstained, I could not demonstrate them.
What would seem to make our present view tenable from a chemical point — that these crystals are due to the morphine taken into the system - is the report of a very interesting experiment of Prof. J. G. Wormley, of the University of Pennsylvania. (American Journal of Pharmacy, 1894, in an article on “ Some of the Tests for Quinine.") In a case in which “ 168 grams (about 26 grs.) of strychnine were admin. istered subcutaneously to a dog during a period of four hours, in divided doses, so as to keep the animal paralyzed, 56 mgs. of well-crystallized strychnine was recovered from the urine, 26 mgs. from the liver, and 14 mgs. from the blood." He gives as his opinion that " when morphine or strychnine is taken in excessive quantity, a portion seems to be distributed to the organs by simple exosmotic diffusion, and this may be readily recovered in the crystalline state.”
In the literature of blood examinations I have found no cases reported where these crystals were observed ; and in a