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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 edema, 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 senses pernephroma, while secondary growths of sight and hearing 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 hyperesthesia 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 formication, 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. pains 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 pain 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.

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