A CASE OF RUPTURE OF THE HEART.

A CASE OF RUPTURE OF THE HEART.

1347 Clinical and THE TEMPERATURE OF THE OVER LIPOMATA. BY HAROLD Medical Societies. Laboratory Notes. ROYAL SOCIETY OF MEDICINE. SKIN SPECIAL ...

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1347

Clinical and

THE TEMPERATURE OF THE OVER LIPOMATA. BY HAROLD

Medical Societies.

Laboratory Notes.

ROYAL SOCIETY OF MEDICINE.

SKIN

SPECIAL DISCUSSION ON CHRONIC ABDOMINAL PAIN IN NERVOUS WOMEN. A SPECIAL discussion on this subject was held on Dec. 17th, Sir William HALE-WHITE presiding. I7ztrod-zctory Remarks. Dr. R. I3ZTCHISON said that the cases under discussion did not exemplify any definite disease, but constituted rather what was generally known as a " clinical syndrome." He had described them as those of the chronic abdomen, and Dr. H. Cabotl had lately spoken of them as " those painful women." It had been difficult to decide on a title for the discussion ; the one eventually chosen implied that the patient was a woman who complained of constantly recurring abdominal aches and pains, otten referred to the right iliac fossa. She suffered also from dyspepsia, was profoundly constipated, and often passed mucus in the motions. Her menstrual functions were often deranged. In addition there were remote symptoms of various sorts-headache, " rheumatic " pains, tiredness, nervousness, and insomnia. The mental aspect of the case was often even more pronounced. The patient was depressed,

BURROWS, C.B.E., F.R.C.S. ENG.

IT is common knowledge that when a fatty tumour is palpated a sensation of fluctuation may be produced which is indistinguishable from that caused by a collection of fluid. A confused or mistaken diagnosis may arise from this cause if on account of its depth or for any other reason the lipoma cannot be readily recognised as such by inspection. For this reason any additional means which will help us to distinguish a fatty tumour from other swellings will be acceptable, and it is on this account that I wish to call attention to the fact that the temperature of the skin over a lipoma is constantly reduced when a comparison is made with due attention to symmetry and conditions of exposure. The relative coolness of the skin overlying a lipoma, as compared with that of a similar area on the opposite side of the body, is so considerable that it can be appreciated readily by palpation with the palm of the hand ; and as a diagnostic aid is reliable. As the test is by contrast only, care, of course, must be taken to make the comparison a proper one both introspective, self-centred, and peevish ; was always as regards the parts which are compared and the upon and magnifying her symptoms, and had time during which they have been exposed to the air dwelling an insatiable craving for sympathy. She was a prior to the examination, and it is especially to be connoisseur in doctors, specialists, and " treatments " ; remembered that appreciable differences of surface she had often acquired the operation habit, and temperature are noticeable in different parts of the although any new therapeutic plan usually relieved same limb. For example, the skin over the patella, her for a time the relief was always short-lived. The in health and in natural conditions, is cooler than was undernourished, often of a bad colour, and patient that over the quadriceps muscle ; while the back of exhibited a greater or less degree of visceroptosis. the calf is distinctly warmer to the touch than the The stomach was usually atonic, and the gastric skin where the tibia is subcutaneous. The reason secretion rather subacid. There was delay in the for these differences is obvious enough, but they must of the contents through the intestine, passage be borne in mind when inferences are to be drawn especially in the pelvic colon. Displacements of the from the results of palpation. uterus were common, but the other organs usually I suppose some apology ought to be made for no signs of disease. calling attention to such a simple diagnostic aid. presented The patient usually belonged to the upper classes ; Probably generations of surgeons have employed it. she was rarely met with in hospital practice. She was Nevertheless I have failed to find any reference to or if married, childless, and there the matter in print, and every help towards a correct generally unmarried, immediate environment some was often in her recognition of the nature of a tumour may be of value. relative who ministered to her constant demand for Portsmouth. ! She would have seen many. doctors, had probably had several operations, and would have A CASE OF RUPTURE OF THE HEART. undergone a great many more or less elaborate and BY J. KNOX THOMPSON, M.B., B.CH., B.A.O. R.U.I. expensive treatments without permanent relief to her _____

sympathy.

symptoms.

aged 71, an inmate of Behnont-road Institution, Liverpool, complained on Oct. 12th last .of gastric symptoms and debility. I sent him into hospital on that day, and he remained there until the 16th. When he got rp on the 17th he asked to be allowed to go back to the house as he was feeling better. About midday he was sitting on a chair in the tailor’s shop when he suddenly collapsed and died. At the post-mortem examination on the morning of the 18th I found the pericardial cavity filled with blood-clot, which was adherent to a small linear area A MALE,

.on the anterior surface of the left ventricle, and when the clot was removed the breach in the wall of the left ventricle was marked by a few threads of clot adhering The large blood-vessels and the valves were to it. found to be intact, and no aneurysm was present. The heart was about normal in size, but the wall of the left ventricle was perhaps a shade yellower than normal. ’The rupture was not a straight cut through the wall ; the channel was zig-zagged between muscular bundles on its way from the cavity of the ventricle to the surface of the heart, and the aperture was narrower on the inner side than the outei side. The liver was hob-nailed, and there was some sclerosis of the kidneys. ’The brain was normal. Liverpool.

I

Dr. Hutchison suggested that the discussion should be restricted to certain definite lines of inquiry, as follows: (1) To what extent were the abdominal as pains in these women due to an organic cause, such dragging upon nerves, kinks, and so forth ?’ The results of surgical treatment should help us here. If the pains could be definitely and p6?’meMM relieved by operation, it was presumptive evidence that its cause was organic. (2) If not always or not entirely of organic origin, what was the cause of the abdominal sensations ? Were they due to a low threshold for pain in these patients so that slight discomforts became magnified in consciousness, and, if so, how was this brought about ? Or were they " hysterical, a form of convenient arrangement " as Adler had called it, the result of a subconscious desire for sympathy ? The psychologists should be able to throw light on this aspect of the subject. (3) What was the relation of the physical to the mental state in these patients ? Was the mental side of the case the result of the physical or was it primary ? For example, was it the depressed emotional state in these patients that caused atony of the stomach and intestines, or did visceroptosis and atony lead to emotional depression ? If the latter, why did many 1

Medical Clinics of North America, March, 1923.