rice-mill in its present form and suggests boiling the Health and Marine-Hospital Service for permission to rice before milling to cause adhesion of the pericarp as report these, cases, and also the medical officer in com- a prophylaxis against beri-beri. He is of the opinion mand, U. S. Marino Hospital, Port of San Francisco, that the growth of beri-beri in this country will depend California, for copies of the case histories. on the methods of milling employed in the rice-growing states. So insistent, indeed, is Braddon on his rice theory that he is inclined to discredit any reported cases HYPERNEPHROMA OF THE KIDNEY, of beri-beri occurring in the absence of a rice factor in the diet. He out two ways by which the rice fac- WITH METASTASIS TO THE MANUBRIUM STERNI, SIMU- points AORTA. tor may have been unwittingly introduced : LATING ANEURISM OF THE 1. By the use of foodstuffs adulterated with rice-pow- AUGUSTUS A. ESHNER, M.D. der. Professor of Clinical Medicine in the Philadelphia Polyclinic and College for Graduates in Medicine; Physician to the Phila- 2. the use has stored in bins By of food which been delphia General Hospital; Assistant Physician to the once occupied by rice. Philadelphia Orthopedic Hospital and Infirmary He also describes a ship disease, a form of ptomain for Nervous Diseases. poisoning, with gastric symptoms, fatigue and , PHILADELPHIA. but no nerve implication. The term hypernephroma has been applied to a new To return to the crew of the Nederland. These men growth that, while exhibiting considerable variability in lived on ship's bread, salt meat, and beans. From an histologic arrangement, still presents the general struc- occidental ship owner's standpoint, rice was far too great ture of adrenal tissue. It may involve the adrenal gland a luxury for a merchant crew. The men all spoke of the itself, or be situated in some other organ or tissue. In beans as being "mouldy," and this may have introduced the first instance it is to be looked on as a hyperplasia a ptomain factor, though the disease rather followed the of normal tissue, while in the second it is believed to slow incubation period of beri-beri than the rapid course arise from misplaced so-called adrenal "rests." Acces- of ptomain poisoning. sory adrenals, or misplaced adrenal tissue, is said to With to the other of Braddon's ship be not uncommon, and has been found not only in the regard symptoms beneath the disease, fatigue and edema, these also occur in beri- immediate vicinity of the adrenal gland, beri. The nausea and vomiting present in several of capsule of the kidney, in the substance of the kidney in the renal in these cases might belong to ptomain poisoning, but the itself, but also and solar plexuses, the morbid anatomy of beri-beri shows a congested stomach, broad ligament and the ovary, in the testicle, between testicle and the and some symptoms would be As for the the epididymis, along spermatic vein, gastric expected. in tissue. rice-bins, these are not so common in European ships in the liver and the retroperitoneal connective as in those plying between the ports of the Orient, The exact histogenetic position of the hypernephroma which carry native crews and regard rice-bins and great is not yet definitely established. The macroscopic and cooking-pots as much a part of equipment as anchors. microscopic characters of the tumor have been fully At this late date I am unable to deal with the question described in the literature. Hypernephromata may be of the adulteration of the ship's bread with rice-flour. small and benign, remaining confined to the tissue in but adulteration is usually practiced to cheapen the pro- which they originate, or large and malignant, breaking down the which are sur- duction of an expensive article, such as arrowroot. characteristic capsule by they Would it be worth while to adulterate hardtack? Brad- rounded, and involving contiguous structures, or pene- a and to more or less don's disease shows no nerve implication. How many of trating vein, giving rise widespread In this bear an to Manson's symptoms and signs were present in these metastases. respect they analogy cases? adenomata, which, while ordinarily benign, may at any time assume There no Atrophy was not observed, as the oldest case was only malignant qualities. is, however, of four weeks' when received at the hospital. necessary relation between the .size of the neoplasm and standing of The men left before any atrophy appeared, and it was its degree malignancy. not possible to follow them after discharge. The kidney is the most common seat of primary hy- have been ob- In one case only were disturbances of special pernephroma, while secondary growths of sight and noted, while it is very hard to served in almost every tissue of the body, especially in of mental disturbances in north-country sailors. the bones. The latter may be the sole seat of metastasis, judge and the be the first indication of The cases were extremely sensi- secondary growth may showing the disease. other tive to touch or grasping of the muscles in the affected On the hand, the metastatic growth areas. may appear many years after surgical removal of the In one instance was ob- "We found in every case edema, dyspnea, tachycardia primary growth.1 pulsation served in a of the tibia.2 A or languor, fatigue on exertion; in every secondary hypernephroma palpitation, metastasis is a of case but one hyperesthesia and anesthesia, in one case single peculiarity hypernephromata. often occur in the such definite , in one case disturbed vision and Retrogressive changes neoplasm, as and in case but trouble in locomotion, necrosis and fatty metamorphosis, hemorrhage hearing; every two, result. from stiffness to inability to stand. In may varying slight The tumors in and the every case but two, we found involvement of the knee- vary considerably size, symp- toms to rise in with jerk, in three cases Romberg's sign was present, and iD which they give correspond general all cases but one there were in the affected muscles. Read before the Association of American Physicians, May 14, In the absence of a rice or other toxic grain element 1908. in the unless the bread was contaminated, 1. Paul Clairmont (Arch. f. klin. Chir., 1904, lxxiii, 620) diet, ship's reports a case in which, almost ten years after surgical removal a cause for the rice theory will not suggest what ap- of a tumor of the kidney, a hypernephroma developed at the bifur- to have been an outbreak of true beri-beri. cation of the trachea. pears 2. von Bergman[ill] Verhandl. d. Deutsch. Gesellsch. f. klin. I have to thank the Surgeon-General of the Public Chir., xvi, Congr., 1887, 30.

Downloaded From: http://jama.jamanetwork.com/ by a University of Victoria User on 06/04/2015 those caused other forms of Small for swelling of the knees thought to be rheumatic, and her by neoplasm. growths been may altogether escape clinical recognition and be dis- kidneys were at one time said to have diseased. She covered at had also complained of in the hips. Eighteen months only autopsy. before under observation the had noticed a Hematuria to be less common in connection coming patient appears swelling at the upper part of the sternum, which had gradu- with both and as an hypernephroma, generally early ally increased in size until it attained the proportions of a symptom, than with other forms of malignant disease "clenched fist." There was no pain, and the patient could not of the kidney. The amount of hemorrhage is extremely recall whether there had been pulsation or not. Under treat- variable, as are likewise the intervals between attacks. ment with an ointment the swelling diminished considerably The may take or be in- in size. Some six months later the patient had attacks of bleeding place spontaneously of the duced by various causes, such as physical exertion, vomiting independently ingestion of food, all readily relieved treatment. After the of a or more the manual examination or cold. A in favor of hyper- by lapse year point exhibited increase in size for a subse- as with other forms of swelling again time, nephroma compared malignant quently to become smaller. There had been no difficulty in disease of the is the of time over kidney long period swallowing, no unilateral sweating, no dyspnea, no palpita- which attacks of hematuria are sometimes repeated. tion. The appetite was poor, the bowels constipated. There In the absence of a palpable tumor the site of pain in had been gain in weight rather than loss, and the patient was connection with such attacks is an indication as to the quite well nourished and free from cachexia. She occupied organ affected. the dorsal decubitus principally, and slept much of the time. The amount of urine is likely to be diminished, and Examination.—The skin of the face was pallid and was microscopic amounts of blood, as well as albumin and marked by numerous dilated capillaries. The pupillary area of the was the a tube casts, may be present. Pain over the affected kid- right eye seat of dense opacity, while the left was in outline. Neither reacted to ney, apart from hematuria, is not uncommon. It may pupil irregular pupil light. The was small, alike on be an like it be pulse infrequent, arrhythmic, early symptom, and, hematuria, may both sides, and the vessels were thickened. The manubrium for a time before the actual disease be- present long sterni was the seat of a swelling of considerable size, yield- comes manifest. It is sometimes radiating in character ing evident pulsation synchronous with that of the heart and or referred to the testicle on the corresponding side. having an expansile character. The tumefaction yielded a A palpable tumor is present at some period of the of elasticity on manipulation and a dull note on percus- disease in most cases, though rarely as the initial symp- sion. No thrill was palpable, but a loud systolic murmur was on auscultation tom. Cachexia is more commonly absent than present. audible over the mass, together with the sec- ond sound of the heart. The was in the may be pres- apex beat visible fifth Digestive derangements superinduced by left interspace outside of the midclavicular line. The cardiac sure from the or as a result of reflex influences. growth impulse was of moderate but a distinct thrill was not in the intensity, Occasionally painless varicocele, disappearing palpable. The action of the heart was markedly arrhythmic. in a case recumbent posture, may develop rapidly of In the aortic area a short, squeaking systolic murmur was hypernephroma of the kidney. Fever has been noted in audible and transmitted into the carotids; it could be heard some instances. also at the ensiform cartilage. A systolic murmur was audi- Nephrectomy is the only permissible treatment when ble likewise at the apex of the heart. Except for a few moist the condition is recognized, except in the presence of rales at the bases, the lungs exhibited no abnormality. An multiple metastases and of complete immobility of the jr-ray examination made in the hospital laboratory failed to tumor. show the presence of an aneurism of the aorta, while the right, and perhaps also the left, ventricle to be While most common in adult appeared life, hypernephromata dilated and displaced to the left. A few small glands (calci- been at all even in new- have observed ages, and the fied) were visible at the apices of both lungs and in the Men born. appear to be the victims in greater number mediastinum. Numerous dilated superficial vessels were visi- than women. Neither kidney seems to be more predis- ble on the lower extremities. The urine contained albumin posed than the other.3 The affection may last from a and ganular casts. The number of leucocytes in the circulating few months to a number of years. While not common, blood was 13,000 to the cubic millimeter. The abdomen ex- it can be said to be rare. hibited no abnormality. scarcely under I have had the of a case of Subsequent History.—While observation the patient opportunity observing complained of occasional referred to the of the in which a secondary pain sternum, while hypernephroma kidney the tumor diminished in size. On April 25, 1907, retention in the manubrium sterni was mistaken for an growth of urine set in, with overflow dribbling, so tha-t catheterization aneurism of the its exact as well as the aorta, nature, became necessary. On April 28 there were occasional attacks and of presence of the primary growth other secondary of vomiting after food, and the general condition was growing growths, being discovered only at autopsy. gradually worse, with increasing weakness. On May 9 a state had with Patient.—A married white woman, aged 60, born in Ireland, typhoid developed, low, muttering delirium and incontinence of urine. was admitted to the Philadelphia General Hospital Feb. 5, Finally coma set in and death took 1907, complaining of pain and swelling in the upper extremi- place on May 16. ties. Autopsy.—On postmortem examination the body was found History.—Her father had died at 75; her mother at 50, from to be well developed, with rather an excess of subcutaneous asthma and dropsy. A brother had died at 40 from an un- fat, although the abdominal muscles were thin and pale. Over sterni a known cause, and one sister in infancy. A second sister had died the manubrium was small lemon-sized tumor of soft insane. The patient had never been pregnant. Menstruation had consistency, which on incision exhibited a grayish color. This was found to the begun at 15 and had been regluarand painless until the meno- involve entire manubrium and the cartilages of first second ribs at their pause at the age of 45. The woman had used tea and alcohol ex- the and junction with the sternum. cessively, but she denied venereal disease. She had had measles The right kidney contained at its lower pole close to the and chicken-pox in childhood, and pneumonia at 51. She had pelvis a new growth 4 by 5 cm. in dimensions, of firm con- and and Buffered from bronchitis and had had both cataractous crys- sistency gray color, containing areas of softening. talline lenses removed. She had been treated earlier in life The uterus at its fundus contained two small chestnut-sized growths, and the left lung a calcareous nodule at its apex and 3. Keen, Pfahler and Ellis (Trans. College of Physicians of a smaller nodule at its base. On histologic examination the Philadelphia, 1904, xxvi, p. 267) found the tumor on the right side growths in the kidney, lung and uterus and sternum exhib- in 18 of 26 collected cases; while Albrecht (Arch. f. klin. Chir., ited the structure of The heart was 1905. lxxvii. 1073) found the right kidney involved in 9 cases and hypernephroma. dilated the left in 19. and its musculature the seat of fatty metamorphosis. The

Downloaded From: http://jama.jamanetwork.com/ by a University of Victoria User on 06/04/2015 aorta was atheromatous and its valves sclerotic. The lungs ment, with weekly administration of tuberculin in the form were congested and edematous. The kidneys were the seat of baeillen emulsion (B. E.), starting with 0.0000001 gm. of passive congestion, with probable parenchymatous changes. Subsequent History.—On January 1 the patient had a feb- The age of the patient, the evidence of arteriosclero- rile attack, from which he apparently recovered completely. sis, the presence of a and tumor in An examination of the lungs showed at this time a consid- pulsatile expansile erable extension of the lesion that found at the first the course of the aorta, a murmur on auscultation, im- beyond . im- in the dorsal decubitus examination. Until January 9 the patient seemed to be provement together suggested proving and had gained another pound. On the morning of the existence of but this conclusion was not aneurism, that day his wife called me by telephone, saying that her the of confirmed by axray findings. The exact nature luiil and had shown a few streaks of blood in his sputum, and the disorder, however, remained undiscovered until dis- requesting that I come to see him. I arrived at the house at closed by postmortem examination. 10 a. m. and found the patient in bed, nervous and apprehen- 1019 Spruce Street. sive; temperature, 98; pulse, 84. After a few moments' con- versation he was reassured, and then announced his intention of getting up. He was advised, however, to remain quiet for a day or two before returning to business. His wife and I went into an adjoining room. In a few moments the patient, who had slipped on a dressing gown, joined us, remarking A CASE OF NON-TRAUMATIC HEMOTHORAX. that he felt perfectly well. The opportunity was taken to go over his lungs again. Findings were about the same as on F. T. BILLINGS, M.D. January 1. The examination completed, he resumed his seat PITTSBURG, PA. in a reclining chair. In 10 or 15 minutes he complained of a in the left This Non-traumatic hemothorax is a rare condition. It is sharp pain low down axillary region. soon became agonizing. He was immediately placed in bed and hot generally due to the erosion of a vessel due to some lesion. In tuberculosis of the the applications employed. His condition rapidly became grave; pathologic lung, pul- pulse, 130, weak and small; face and mucous membranes arteries or their are in- monary branches those generally anxious; restlessness, cold extremi- and pale; expression dyspnea, volved. The tuberculous process weakens the walls ties and a moderate amount of thirst. The symptoms all in many cases numerous aneurisms are formed. This pointed to shock and probable hemorrhage. There was no condition appears to be present more commonly about hemoptysis, excepting a few streaks of blood in sputum. In the middle of the lung and at the periphery (West). about two hours he had improved; pulse dropped to 120 and Search the literature that pain had ceased; color and breathing much better, and gen- through gives ample proof eral appearance encouraging. It was explained to his wife but few cases of non-traumatic hemothorax occur, or at that there had probably been bleeding from an artery into a are Sticker and both affirm- least, reported. Dieulafoy cavity of the lung, but presumably this was comparatively that hemorrhage (non-traumatic) from the lungs can small in amount and had ceased. I then left, promising to take place into the pleura. A case has been reported return in a few hours, leaving instructions that the patient of hemothorax due to tuberculous erosion of an inter- must not move under any circumstances, and that I be tele- costal artery, and W. H. Walsh1 reports two cases, phoned for immediately if any unfavorable symptoms devel- recorded by Andral, of hemorrhage into the pleura\p=m-\ oped. I returned to the house about 5 p. m. and found the had existed and in both instances the undertaker preparing the body. The patient had died an "pleurisy long hour before. His wife had been unable to reach me at once were tuberculous." Dr. Watson patients (1862) and had called another physician. Unfortunately an case in an enormous hemo- autopsy records a remarkable which under the circumstances was impossible. I felt assured, of the of the' however, thorax had caused enlargement left side that there had been a hemorrhage somewhere, and with this chest, effaced the intercostal spaces and pushed the theory in view made a careful examination of the body. Over heart over to the right of the sternum. The condition the left of the thorax on percussion dulness was found; a trocar was from the was caused "scrofulous ulceration," destroying two large borrowed undertaker and plunged by into the left in the of the ribs, and laying open one of the intercostal pleural cavity sixth interspace, axillary line; 40 ounces of blood were evacuated. arteries. Recently T. B. Richardson2 has reported a It seems from this case to case of hemothorax, probably due to secondary car- possible draw the follow- cinosis of the lungs. ing conclusions: 1. That on the The following case, I desire to record. morning of the day the patient died, there was no fluid in Patient.—H. T.. aped 35, married, occupation clerk, pre- absolutely the chest, which simply sented himself November 13, with the following history: showed the signs of a moderate tuberculous infection. History.—Previous diseases, none of importance. Family 2. Although purely surmise, we may believe that history, negative, except that one brother died at 27 of some a branch of the pulmonary artery, on the periphery "lung trouble." Past history, pain in left arm and shoulder of the diseased lung, had become involved in the tuber- and intervals two loss of 23 cough at during past years; cular infection, the walls weakened and an aneurism pounds in weight; sputum examination negative. Present formed; this and the blood the same as previously, with fatigue and dyspnea and ruptured following symptoms, course of least tore the weakened no hemoptysis or night sweats. resistance, through slight dyspepsia; tissue and Examination,—This showed impaired resonance in both lung pleura into the pleural cavity, thus supraclavicular regions and in left infraclavicular. Ausculta- giving the acute pain and symptoms of shock. tion was negative, except that a few sibilant rales were heard 3. The immediate causes of death were probably at the inferior angle of left scapula during inspiration. Heart shock, loss of blood, and sudden displacement of, and sounds were weak, but otherwise normal. Blood examina- interference with, the heart, by the large amount of tion showed hemoglobin 70 per cent., leucocytes 10,000, red fluid quickly filling the left pleural cavity. blood corpuscles 5,400,000. Urine was normal, except for a hyaline cast and a few red blood corpuscles. Calmette's ocular Invention of Matches Credited to a French Physician.—A reaction gave a negative result. Tuberculin hypodermieally French states that the small town of Saint-Lothian gave a result. exchange positive in .the Jura Mountains of eastern France has erected Treatment.—The patient was placed on the open-air treat- recently a modest monument to a local physician of nearly a century ago, C. M. who is credited with been the first 1. A Practical Treatise on Diseases of the Lungs, 1871. Sauria, having 2. Dominion Med. Monthly, 1903, xx, 193. to invent matches lighting by friction alone.

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