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MAY 18 1886

LIBRARTHS

N.

MEDICAL BULLETIN:

VOL. VIII.

A MONTHLY JOURNAL OF

MEDICINE AND SURGERY.

PHILADELPHIA, MAY, 1886.

A CLINICAL LECTURE.

GENERAL DROPSY,

No. 5.

to work hard in a brick-yard. She has not
used alcohol to excess, and there is no history
of syphilitic infection. She has had no severe
disease, with the exception of an attack of
rheumatism a year ago, which lasted several
months, affecting chiefly the joints of the left

PROBABLY
DUE TO HEPATIC DISEASE;
BRIGHT'S DISEASE
ASSOCIATED WITH EPITHELIOMA OF THE NOSE side, the arm being first involved.

AND PROBABLE EPITHELIOMA OF THE
STOMACH.

BY WILLIAM PEPPER, M.D., LL.D.,

The present attack appears to date back ten months, when she began to feel indisposed, complained of loss of weight and failure of

Provost of and Professor of Theory and Practice of Medicine and flesh and strength. There seems to have been

of Clinical Medicine in the University of Pennsylvania.

DELIVERED AT THE HOSPITAL OF THE UNIVER

G

SITY OF PENNSYLVANIA.

[Reported for THE BULLETIN by WM. H. MORRISON, M.D.] ENTLEMEN: To-day I ask your attention to a study of this somewhat complicated case. We have been able to obtain only an imperfect history of this patient. She is 53 years of age, has lately been engaged at housework. She apparently has a good family history, and her general health has been exceptionably good. She was married at the age of twenty-eight, and has had four children, all of whom are living. She has had no miscarriages. The menopause occurred four years ago, at the age of forty-nine. Two years before the menopause occurred, but when it probably was beginning, she commenced to have convulsions, which were sudden, and attended with general convulsive movements and complete unconsciousness, and followed by deep sleep, lasting for some hours. She was able to foretell the approach of these attacks by a feeling of general weakness, which came over her before the occurrence of the paroxysm. These attacks appear to have been epileptoid in character. Before she came to this country she was obliged

at this time no vomiting, no fever, no pain, and no acute symptoms of any kind. Two months later she noticed swelling of the feet. The oedema rapidly extended, until it became complete anasarca. The urine became somewhat scanty, was passed more frequently than usual, but no change in its appearance was noticed. At the end of two months the swelling began to pass away, but she states positively that she observed that the swelling of the feet would be most marked when she got up in the morning, and that it diminished towards evening. This is a very unusual statement, and quite the reverse of what we ordinarily hear.

Her condition has steadily grown worse, and for the past nine weeks she has been unable to assume the horizontal position, and this, although the general dropsy so far as concerns the face, arms, and even the legs and feet, has greatly subsided. Examining the legs, we find the skin hard, brawny, and infiltrated, presenting the appearances seen after long standing dropsy. On the feet this condition of scleroderma is present in a remarkable degree. It is clear that in addition to the oedema there has been irritation of the skin, with exudation of lymph which has infiltrated the skin and undergone partial organization, and

this has caused induration affecting not only the skin and subcutaneous tissue, but also the deeper tissues, and this has perhaps prevented the œdema from being as marked as it otherwise would have been. In this way the remarkable statement which she has made with reference to the oedema may be explained. At night, the warmth and long repose relaxes the tissues of the leg, permitting a more ready escape of serum from the vessels.

She thinks that she has lost fifty pounds in weight since she began to complain. She presents the worn expression of long suffering.

The abdomen is uniformly distended and its walls are oedematous, particularly at the dependent parts. There is a distinct wave of fluctuation developed on palpating the abdomen. There, however, does not appear to be sufficient ascites to explain the orthopnoea which is present. We find, on examining the chest, that there is effusion in both pleural cavities, on the right side reaching to the angle of the scapula, and on the left to a point two inches below the angle of the scapula. There is no evidence of effusion into the pericardial The cardiac sounds are normal. Owing to the ascites and the pleural effusion, it is impossible to determine the exact limits of the hepatic dulness, but the liver is certainly not enlarged.

sac.

During the past twenty-four hours she has passed twelve ounces of high-colored, cloudy urine, depositing a cloudy sediment on standing. It contains a trace of bile and a moderate amount of albumen. The microscope shows bladder and vaginal epithelium, some mucus, a few blood corpuscles, amorphous urates, but no tube-casts. The patient has, however, been under observation but two days, and we have, therefore, been able to examine the urine only a few times.

Here, then, we have a case of long standing dropsy, with dyspnoea, cardiac disturbance, and insufficient action of the kidneys. We are encouraged to hope that a large portion of the trouble may be attributed to the woman's life of hard work and exposure. Her family history has been good, and her personal freedom from excesses of all kinds is a favorable feature. The absence of cardiac disease is also to be noted as a good sign. The condition of the urine is interesting and important. If further examination shows that it really contains no tube-casts, but is merely scanty, high-colored,

and containing a trace of bile and a small quantity of albumen, indicating, therefore, that there is simply engorgement of the kidneys without organic disease, it would also be another favorable sign.

As to the cause of this general oedema, which has been more or less present during the past two years, and which is now complicated with ascites and hydrothorax, I feel somewhat in doubt. Learning, as we do, that the dropsy began in the subcutaneous tissues of the feet, and continued there for a considerable time before the development of ascites, we should naturally have expected to find cardiac or renal disease to account for it. It may be that the violent disturbance of this woman's nutrition connected with the establishment of the menopause, which, as we learn, was accompanied with violent convulsions, and probably with anæmia, will account for a considerable part of the œdema. On the other hand, you will not fail to note that the occurrence of these convulsions might point to a uræmic condition associated with organic renal disease, so that repeated examinations of the urine must be made before that question can be laid aside. The examinations thus far made are favorable, and indicate that the convulsions were dependent upon disturbances of the nervous system.

The condition of ascites and hydrothorax is somewhat difficult to explain. If we simply had ascites in a woman with a history of habitual alcoholic excesses, we should attribute the condition to cirrhosis of the liver. It is, however, a fact, that cirrhosis of the liver is not always the result of alcoholic excesses. It may result from idiopathic hepatitis, and arise in the most abstemious individuals, and, undoubtedly, the life of exposure and hardship which this woman has lived would undoubtedly predispose to the development of such lesions. The presence of hydrothrax interferes with the determination of the limits of hepatic dulness by percussion. We can say that the liver does not extend too low, but we are unable to map out its upper limit. There is no great enlargement of the subcutaneous veins of the abdominal wall. Again, the combination of ascites with double hydrothorax, when the ascites is not more marked than here, suggests some more general cause of the dropsy than mere cirrhosis of the liver. In that affection, the dropsy usually begins in the abdomen, continues until it becomes very great, and then in

volves the extremities and the serous cavities. Her history has not been such. I have no question that there is a lesion of the liver, but I am satisfied that there is something more than this. That additional element may be disease of the kidneys, which will be revealed by further examinations. It is, however, more probable that the oedema is to be attributed to a morbid condition of the tissues, resulting from protracted exposure, broken down nutrition, etc., in which a low grade of inflammation would be likely to be established. The condition of the legs and of the abdominal walls would indicate that they are the seat of a low grade of inflammatory action. This is not a clear typical case of renal, cardiac, or hepatic dropsy, but it is a complicated case, and one often met with, and one which taxes our ingenuity in assigning to each element its proper place in the production of the symptoms.

We notice on the side of the nose, an ugly spot which looks very much like epithelioma. The presence of this ulcer with the symptoms mentioned, the loss of flesh, strength, and color, the constipation and vomiting, gave rise to the question whether or not there was an epithelioma of the walls of the stomach? No tumor can be felt in the epigastrium, but while the presence of a tumor is a very valuable sign of malignant disease, yet its absence is not a posi tive proof against the existence of such a disease. There might be a carcinoma of the upper and posterior surfaces of the stomach, not very extensive, or an epitheliomatous ulcer which the most careful palpation would fail to detect.

When we came to treat the man, we found, in the first place, that the gastric symptoms yielded largely to treatment. The vomiting probably had been the result of coarse and improper food, and possibly of irritating remedies. It was much relieved, although he still vomits every three or four days, particu

Now, as to the treatment. Although the ascites is not excessive, yet, as it is associated with the conditions mentioned, I think it de-larly when severe spells of pain occur. Secsirable to get rid of it as quickly as possible. I shall use the aspirator to remove the fluid, and thus avoid the use of perturbing medicines. If this operation is carefully done, with a clean instrument, it is devoid of risk, and its simplicity justifies you in resorting to it at an early stage, instead of waiting until the distention is so extreme that life can no longer be prolonged if relief is not afforded.

Internally, I shall give full doses of tincture of nux vomica and tincture of digitalis, ten drops of each, three times a day, and Basham's mixture, each dose containing fifteen drops of the tincture of the chloride of iron, four times a day. If the pleural effusion does not diminish in the course of the coming week, I shall also remove that with the aspirator.

Chronic Interstitial Nephritis, with Epithelioma of the Nose, and Probable Epithelioma of the Stomach.-Our next patient is J. C., æt. 66 years, a native of Ireland and a farmer by occupation. He enjoyed good health until thirteen or fourteen months ago, when he began somewhat suddenly to have attacks of gastralgia. These attacks were somewhat relieved by pressure and the taking of hot drinks. For three months before admission to the hospital he vomited at least once a day. Since admission the attacks of pain have not been so frequent, and the vomiting occurs more rarely.

ondly, we not only found that the gastric symptoms improved, but also that he gained flesh, although not to an encouraging extent. He has gained in the past few weeks three or four pounds of flesh, which would be unusual if there were malignant disease of the coats of the stomach. At the same time, however, you may be thrown off your guard in such cases. A patient with organic, incurable disease, who has been improperly treated, comes under your care. Under appropriate diet and hygiene, he gains flesh and strength up to a certain point. This represents the result of

bad treatment. This may lead you to think that you have erred in diagnosis, but having reached this point, he begins to go down again, showing that the diagnosis was a correct one.

The

In addition to the gastric trouble, we find that the man has Bright's disease. Albumen is present in abundance in the urine. quantity of urine varies, and often it is excessive. Its specific gravity varies from 1.008 to 1.013. Hyaline and pale granular casts are seen in abundance in every field. The quantity of urine passed has varied from forty-eight to seventy-five ounces.

This is a case in all probability of chronic interstitial nephritis solely, or possibly mixed with chronic catarrhal nephritis, but with very unusual associated symptoms, which would be

likely to throw you off your guard if you did not examine the urine in every case. We have in the renal disease one explanation of the anæmia and emaciation which are present. He has never complained of symptoms referable to the kidneys, and it was only after the examination revealed the evidences of renal disease that we learned that micturition had been more frequent than normal.

ORIGINAL COMMUNICATIONS.

SOME OBSERVATIONS ON THE

RELATION OF DWELLING-
HOUSE WINDOWS

AND TEMPERATURES ΤΟ ACUTE INFLAMMA-
TORY DISEASES.

BY D. BENJAMIN, M.D., CAMDEN, N. J.

WHAT

7HAT is generally called a cold, is always produced by some change of temperature, with or without moisture, to which a part or the whole of the person has been exposed. In most all cases the change must be from a given temperature to a lower one, in order to

if a part and not the entire body be exposed to a low temperature. Dampness adds greatly to the power of a low temperature to produce a cold.

How far does this interstitial nephritis explain the serious gastric symptoms which are present? There is nothing incompatible between Bright's disease and carcinoma. There is no reason why a person with Bright's disease may not get an epithelioma of the nose or of the stomach. In post-mortem examination you will frequently find malignant disease co-exist-produce a cold. One is more apt to take cold ing with the lesions of nephritis. It is probable that in these cases there is no connection between the two conditions. Here, the existence of the renal trouble does not remove our anxiety with reference to the condition of the stomach. This case is an excellent illustration of the principle that we must not always explain the symptoms arising in the course of a chronic disease of some organ as symptoms of that disease. A person with chronic disease of the kidneys, liver, heart, or lungs may develop another disease, the symptoms of which are often referred to the original disease, while they are really dependent upon a second, wholly distinct affection.

Are these gastric symptoms such as are found associated with Bright's disease? They are

not.

With Bright's disease, we commonly find the symptoms of gastric catarrh. Added to these, we have in the present instance the remarkable development of pain of a paroxysmal character. As between the symptoms of gastric carcinoma and the symptoms of gastric catarrh with neuralgia, I must say, that if it were not for the epithelioma of the nose, I should have no hesitation in saying that the symptoms were more indicative of catarrh with neuralgia, than of epithelioma of the gastric mucous membrane. The one crucial sign of gastric carcinoma, the presence of a tumor, is wanting. If the case were not complicated by Bright's disease, the effect of treatment would demonstrate whether the gastric affection was organic or functional. The presence of this complication, however, renders this test inoperative. We have no way of positively deciding this point except by patient waiting.

A cold is a disturbance of the circulation of the blood, whereby a part of the body has too little blood in it, and, therefore, some other part has too much.

The part that has too much is said to be congested, and if the congestion is not promptly relieved by treatment inflammation is sure to follow. If in the throat, croup; lungs, pneumonia; bladder, cystitis, etc.

Heat expands everything known to man, and the absence of heat (cold) contracts everything. The human flesh is elastic and contractile, and, therefore, when cold is applied to a part it contracts, holding much less blood (fifty per cent.), consequently some other part must contain more than it should. Moreover, all vital action goes on more slowly in a cold than in a warm temperature, so that by cooling a part its nerve energy and vital force are greatly affected, causing delayed reaction, dangerous reaction, or actual destruction of a part, while the undue blood in some other part of the body lights up inflammation that would not have been called into existence without this stimulus.

Cold, applied to the skin, generally produces congestion of the mucous membranes, because of their similarity of construction, nerve supply, and continuity of structure.

The most healthy temperature for the human body to live in is about 70° Fahr.

In a slowly moving atmosphere at 70° Fahr. a person cannot take cold.

A change of 10° Fahr. is often sufficient to cause one to take cold.

The foregoing are undeniable truths, based | 70° or 80° Fahr., perhaps in a sweat, goes to a on physiology, chemistry, and physics. Their window and stands, without any change of clothimportance, and the practical application of ing or protection, for half an hour or more, in a them, especially in the prevention and treat- temperature anywhere from 30° to 55° Fahr. ment of diseases of the respiratory organs we How such a thing can occur without resulting will now consider. in croup or pneumonia, must be marvelous to any one who studies the subject even casually.

A few years ago, I began making some observations and experiments on the circulation and temperature of air in rooms, with results which appear to me to be of practical importance.

The conditions of temperature and circulation of air varies greatly in rooms, especially those that are in use.

Fig. 1 gives results of experiments in a room ten feet high, twelve feet wide, and twenty feet long, with a good stove and steady fire.

In many instances there is a small crack or opening either under the sash or at the side, and almost always at the junction of the upper and lower sash, where a stream of air is passing into the room almost as cold as the outside air, though it be below zero. Cold air, at a high speed, striking a child directly on bare throat or breast can seldom fail to produce some dreadful disease.

On a very cold day, in some of the frame houses inhabited by poor people with plenty of children and little time to look after them, children may often be found sitting on the

[graphic]
[graphic][subsumed][subsumed]

TEMP. OUTSIDE 24°

Three-story brick house, south front, twelve rooms, warm cellar. Out-door temperature 24° Fahr. By examination of Fig. 1, it will be seen that when the centre of a room is 78° Fahr., four feet from the window it may be 70° Fahr., one foot from window 54° Fahr., and at window 40° Fahr. (no doors or windows having been opened for thirty minutes), a difference in the room of 38° Fahr.

In Fig. 2, a vertical section of same room, it will be seen that while the head is in 75° Fahr., the feet may be in 50° Fahr. What must be the effect on a person who removes his warm boots and wears slippers, or the one that lies down to sleep on such a floor? Many do these very things, however.

floor in a temperature of 38° Fahr., or standing with nose against window pane at 20° Fahr., when the mother is washing or ironing in 65° Fahr. These people generally have but one fire, and that in a cook stove, that cannot heat the floor at all, with drafts from every room, and especially the stairway.*

In view of the principle already given, it seems to me that this is a striking state of affairs, and perhaps no principles of hygiene are so grossly violated as these. No wonder that the death list in Philadelphia alone in a single year reaches the dreadful sum of one thousand from pneumonia and about four hundred from croup (preventable diseases in most cases). It is also somewhat remarkable that the subject has not before been writ en up in the medical works. The thermometry of hygiene and the sick room is a valuable field for cultivation.

Fig. 3 shows an everyday occurrence among thousands, yes, millions of people. A child, three or four years old, from playing near a Stove, or on a nurse's lap, in a temperature of very injurious, and going out into the air at 10° or 20° Fahr.

In churches and theatres the galleries will be 85° to 90° when the floor is 70° Fahr., then the opening of a door or window is

also causes a dangerous strain on the system.

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