CLINICAL REMARKS ON A CASE OF ACUTE DROPSY WITHOUT ALBUMINURIA.

225 recovery.-Henry K-, aged thirty-four, came to me at Guy’s not attended with much pain, and she had sought advice more Hospital on April 21st, 1861, with an occluded right nostril, from the disfigurement occasioned by the disease than for the which had existed for two years. For several years before distress occasioned by the new growth. Having little doubt as to that, his nose had been sore, and had given rise to much pain. the nature of the disease, the cyst was tapped beneath the cheek, On examination, it was readily made out that the septum nasi and about two ounces of a blood-stained, limpid, albuminous and middle turbinated bone were in close contact, the mucous fluid drawn off. The cyst at once collapsed, and the features membrane covering these parts having become intimately con- recovered their normal shape. In a few weeks, however, the nected. From the history of the case it appeared probable that tumour became as large as ever, the fluid having re-collected. old ulceration of the mucous lining of the nose had originally The cyst was accordingly tapped again, and its cavity plugged existed, and that, in the process of healing, these two surfaces with lint. In four days the lint was removed, free suppurahad come into contact, and had granulated together. By means tion having taken place. Everything went on well for some of a blunt-pointed bistoury the union was divided, and by time, when a fresh collection of matter made its appearance keeping the surfaces separated by oiled lint,, aided by dilatation, towards the nostril. This was accordingly freely opened by a. recovery took

place, leaving the passage free. Remarks.-This case requires no comment. It explains itself, and is given here only as an interesting example of a rare condition. In the examples of disease of the nose which have been already quoted, malformations of the septum nasi, and an inflammatory affection of the mucous membrane lining the nasal cavity, have been the essential causes of the different conditions to which attention has been drawn. In the following cases the obstruction to the nasal passages was brought about by very different causes, new growths of different kinds existing in each. Each case will speak for itself. CASE 6. Obstruction to the left nostril from the presence of a warty growth

at its

aged sixteen,

was

bistoury into the nose, This patient when seen

when rapid convalescence followed. two months subsequently was quite

well. CASE 11. Obstruction to the right nostril for one year, due to the presence of sponge.-Thos. H-,aged four years and a half, was brought to me at Guy’s Hospital on October 26th, 1860, for some obstruction to the right nostril of twelve months’ standing, and fetid discharge from the passage. He had been under treatment, but without benefit. On making a careful examination of the part, the right nostril was evidently seen to be plugged with some foreign body, which turned out to be sponge. It was removed by means of forceps, and rapid recovery took place. CASE 12. Obstruction to the right nostril for three months from

orifice; excision; recovery.--Sarah’V6T a plum-stone.-Jane M--, aged four, was brought to Guy’s at Guy’s Hospital, in April, Hospital in February, 1858, with an obstruction to the right ,

brought to me,

to the left nostril of three years’, nostril of three months’ standing. A plum-stone was clearly It had been gradually becoming worse. On exa- seen blocking up the passage. Several attempts had been .standing. were seen filling themade to remove it without effect. mination, a quantity of By means of a bent probe nasal orifice, growing from the margin of the nose. They were introduced through the nostril the foreign body was hooked removed by excision, and a good recovery took place. down, some force being required for its extraction. CASE 7. Cartilaginous outgrowth from the septum nasii Finsbury-square, August, 1887. the nostril; excision; recovery.-Frederick M-, , obstructing aged nine, came to me, at Guy’s Hospital, on March 19th, 1863, for some obstruction to the right nostril, which had CLINICAL REMARKS existed for " as long as he could remember," but had gradually ON A CASE OF become worse. On examining the nose, an outgrowth was at once observed springing from the right side of the septum nasi, ACUTE DROPSY WITHOUT ALBUMINURIA. and projecting like half a filbert into the cavity. It was very 24th I and had a smooth On March outline. excised hard, BY W. R. BASHAM, M.D., the growth, which was evidently cartilage, and a good recovery SENIOR PHYSICIAN TO THE

1861, with an obstruction

’

warty growths

ensued.

WESTMINSTER HOSPITAL.

CASE 8. Cartilaginous outgrowth from the septum nasi; THE term "acute dropsy" is usually applied to a succesexcision ; recovery.-Edward W-,aged nine, was brought to me, on May 4th, 1863, with a small outgrowth, the size of sion of symptoms, originating most commonly from exposure a large pea, springing from the septal margin of the left nostril. to cold and wet, followed by rigors and febrile disturbance, It had been observed for six months, and was clearly closely connected with the septum. It was excised, and turned out more or less difficulty of breathing, scanty and all but suppressed urine, with or without traces of blood in it, and a to be well-formed cartilage. A good recovery followed. CASE 9. Fibro-plastic tumour growing from the nasal plate of diffuse, dropsical condition of the surface of the body, affectthe superior maxillary bone into the nose; excision; recovery. ing the entire areolar tissue, with albumen in the urine in Philip B-, a healthy butcher aged forty-two, came under greater or less abundance. These symptoms are usually observed to be so constant that my care in April, 1863, with some tumour expanding his left nostril and closing the passage. It had been observed only the term "acute dropsy"-a phrase of a past generation-has three months, having been discovered after a severe attack of been and "acute albuminuria" substituted; for this epistaxis, which had lasted for a whole week. The man’s form displaced, of is dropsy usually recognised as Dr. Bright’s first general health was good. On examination, the left nostril was morbus and acute firm with some fibrous but its exact variety, Brightii and acute albuminuria have tumour, evidently plugged

origin could not well be made out. April 21st the man was brought under of

become synonymous and convertible terms. the influence of The occurrence of a case of this familiar form of dropsy, in chloroform, and an incision made from the inner corner of the which not a trace of albumen could be detected in the urine left eye along the border of the nose, this incision allowing the throughout the entire course of the illness, possesses much left ala to be turned up and its cavity exposed. The tumour interest, as well to the practitioner as to the renal pathologist. was then seen to be closely connected and apparently growing Richard H-, aged twenty-six, employed in the gas works, from the nasal process of the superior maxillary bone. It was was admitted into King William ward on Jan. 22nd. He readily removed. The parts were brought into apposition stated that about a fortnight previously, having been exposed and the wound closed by means of a fine uninterrupted suture. to cold and wet, he suffered from cold chills and pains in his A good recovery ensued, with a scarcely perceptible cicatrix. limbs, followed by considerable febrile disturbance; and that a Microscopically, the tumour was made up of the elements of morning or two afterwards he suffered much distress in his the fibro-plastic growth. breathing, and there was a swollen and puffy state of the face, The patient at the present time (four years after the operaeyelids, and cheeks, as well as of the surface of the body tion) is quite well. generally. CASE 10. Cyst in the antrum, obstructing nostril; operaOn admission the aspect of the patient was strictly charaction; recovery.-Mary B-, aged thirty, a healthy marriedteristic of acute albuminuria. The face was puffy; the eyewoman, came under my care on the 2nd of August, 1863, withL lids were cedematous, as well as the backs of the hands and the arms as far as the elbows; the surface of the chest was a cyst which projected into the right nostril, causing its partial occlusion, and expanded the antrum so as to form a tumour inL slightly anasarcous, which was more pronounced from the the cheek. It had been growing for fourteen years, but hadL thighs downwards. The respirations were hurried, and the caused obstruction to the nose for only a few months. It was , breathing movement shortadeep inspiration could not be

point

On

226 taken.

The breath-sounds

throughout

the chest

were

tinot, and everywhere obscured by moist, wheezy

indis-

murmurs.

equal in the corresponding regions of the The sounds of the heart were indistinct, from the moist sounds in the chest. Pulse 90. He complained of a teazing cough, worse at night, and dyspncea, coming on in paroxysms. The expectoration was bronchial mucous. There was frequent micturition, but the urine was scanty in quantity, very high-coloured, of a bright sherry colour, and of sp. gr. 1022. Not a trace of albumen could be detected in it. Neither heat and nitric acid, nor nitric acid alone (Harley’s process) poured gently down the side of the tube so as to form a layer at the bottom, indicated the faintest trace; nor was any cloud produced by nearly pure alcohol. He was ordered the compound jalap powder, and an effervescing saline with chloric ether; to relieve the cough, the sweet spirits of nitre and comThe

resonance was

two sides.

tincture of camphor proved of service. pound The continued troublesome for next few

is sufficiently declared. I venture to say, further, that may still without impropriety retain in our nomenclature the words "acute dropsy," or, if it be more demonstrative, " acute febrile dropsy," since it is manifest from this case that a dropsical infiltration of the areolar tissue of the chief organs of the body may follow a febrile attack, without, as ordinarily happens, the transudation of albumen in the urine being coincident with it.

gnosis, we

______________

TRACHEOTOMY

IN

DIPHTHERIA.

FATAL RESULT.

BY FREDERICK

H. DALY, M.D.

IN THE LANCET of the 2nd February last are recorded, by the days, but Dr. Moon, of Brighton, the notes of a most interesting case of and the paroxysms of dyspnoea subin which tracheotomy was performed with a successful sided. The bowels acted freely with the powder, and by the croup, result. Believing that the record of fatal cases is often even fourth day there was a sensible reduction of the dropsy. Each more the urine was examined the several interesting than that of successful ones, I am induced to day carefully by processes named, and no trace of albumen was discovered. publish a brief account of a case of diphtheria in which I On the 31st, nine days after -admission, the dropsy of the tracheotomy, but which unfortunately tersurface had disappeared. There was no cedema of the face, recently performed minated fatally, not from anything connected with the operahands, trunk, or lower extremities. The cough had abated, and the chest-sounds were natural, save a slight bronchial tion, but from the continued progress of the original disease. In the latter part of January I was requested to visit a boy, murmur in the large tubes. An examination of the precordial region led to the detection of what at first was thought to be six years old, who had complained for some hours of soreness of the throat. His mother informed me that the previous evena slight systolic murmur, heard chiefly at the apex of the heart. It is due to the intelligence of Mr. Winckworth, one ing he complained of feeling cold, and would sit near the fire. of our most diligent students, to say that he first detected the Until then he was perfectly well. I found him with a hot dry murmur, and drew attention to the fact that it was less sys- skin, white-coated tongue, and rapid pulse. On examining his tolic than was at first supposed, for that a distinct to-and-fro throat I found that the velum palati and the right tonsil were covered with a layer of a whitish substance, resembling wetted murmur was heard if the ear was brought directly to the chest. There was no increased or irregular impulse-no tumultuous parchment; the remaining parts of the throat visible were of a action; the pulse was from 78 to 80, perfectly quiet and deep claret colour. I was able to remove with a forceps part natural; and the breathing unembarrassed. As the man had of the false-membrane covering the velum. I brushed the been under the care of Dr. Radcliffe for rheumatism some throat freely with a solution of nitrate of silver (twenty grains eight months previously, in all probability some pericardial to the ounce), and prescribed six drops of tincture of the mischief was then established. It was evident, from the state sesquichloride of steel, with three grains of chlorate of potash, of respiration, pulse, and heart-impulse, that no recent dis- three times a day, internally. I recommended milk, strong order of this organ could have occurred. The man left the beef-tea, and port-wine as the diet. For three or four days the hospital of his own accord, perfectly convalescent, on Feb. 9th, child continued in nearly the same state ; the velum then became free from the exudation, but the tonsil remained covered just eighteen days after admission. It is very clear from this case that all the usual conditions with a greyish layer of lymph. On the fifth day the boy apmay concur to establish a diffuse, or what was once called an peared better. The same treatment was continued. On the acute, dropsy, without the kidneys being in any way impli- seventh day he was decidedly worse. I was called to him early cated beyond such an amount of functional disturbance as may in the morning. His breathing was now for the first time embe indicated by scanty urine-simply deficient in the propor- barrassed, and the cervical and submaxillary glands were ention of water ordinarily present, and which usually accom- larged. Both the tonsils and the entire back part of the throat The were covered with a stratum of ashy-coloured slough. panies the mildest febrile disturbance. The heart was never sufficiently embarrassed to have had child vomited everything he took, and complained much of any share in the production of the dropsy. Moreover, the soreness when swallowing and of acute pain in the throat. I whole history of the case, as well as the condition of the patient continued the tincture of the sesquichloride of steel with the on admission, proclaimed that kind of febrile disturbance, with chlorate of potash internally, and also brushed the throat with bronchial congestion, the usual precursors of a diffuse dropsy, the former. I continued the nourishing diet, with port wine which hitherto has been all but universally associated with and brandy, and, in addition, ordered ice to be sucked. From this period he continued to get worse; the dyspnoea renal engorgement and albuminous urine; so much so, that on my first examination of the patient, and hearing the clinical and dysphagia increased, and on the tenth day the former was clerk read, out the category of symptoms and history, I un- so great that he could not lie down in bed or swallow anyhesitatingly exclaimed, "A case of acute albuminuria : now thing. The throat was almost completely blocked up with let me see the urine." The result has been stated. Such an sloughy exudation; there was a discharge from the nose; the instance has never occurred to me before. It is very clear face and lips were becoming livid; in short, he was rapidly that such cases must be very infrequent, as, with a tolerable dying of apnœa. Seeing now that medical treatment was of experience at this hospital and elsewhere, I have never met no avail, and death impending, I determined to open the with a similar exemption from albumen in the urine during trachea. Accordingly, at nine o’clock at night, assisted by the existence of a diffuse dropsy following rigors and febrile my partner, Mr. Mundie, I proceeded to perform tracheotomy, disturbance. The ordinary renal congestion, which, in acute without chloroform. Having first endeavoured to administer a little brandy, we ,dropsy, is usually as common as the pulmonary engorgement, was therefore entirely absent; and it is a singular example of placed the child on a table, beneath the gas-lights, and I made important organs escaping a complication which is so formid- an incision over the windpipe. It was extremely difficult to able in a great majority of cases that it may be truly said dissect down on the trachea, owing to the struggles of the that nineteen-twentieths of fatal cases of morbus Brightii date child from the pain, and also from the intense dyspncea, intheir origin from an inception analogous to this case, save in creased by his being held in the recumbent posture, with the the important feature of a non-albuminous urine. head thrown back. The hæmorrhage was pretty considerable. It is impossible to assign any cause for this exemption. The Before I could open the trachea, the pulse failed, and the child man’s antecedents would seem to justify an unfavourable in- ceased to breathe. I immediately freely opened the trachea, ference rather than otherwise. He had suffered acute rheu- and holding the edges of the opening well apart with a double matism rather severely; he was not very regular or steady in tenaculum on one side, and a pair of forceps on the other, Mr. his habits, and these were of the type which form so prominent Mundie kept up artificial respiration, and, in some fifteen a feature in most cases of morbus Brightii. From a clinical minutes, the child again began to breathe, the pulse returned, point of view, the necessity for an accurate examination of all and he swallowed a little brandy; but we did not stop the the organs, and of such excreta as are likely to assist in dia- artificial respiration for nearly an hour. At the end of that

cough the breathing improved,