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Schoenlein on hydrothorax (1832)
His torical
Miles tones
Schoenlein
on Hydrothorax
(1832)*
SAUL JARCHO, M.D. New York,
New York
EXCERPTS FROM SCHOENLEIN
THE difficulties that beset the historian in his effort to understand the development of ideas and processes, not the least is an inherent limitation in available evidence. Largely but not entirely restricted to written materials, he runs the risk of slighting those who have left no documents for posterity to examine. This is especially true of physicians. Some of the best are taciturn and inexpressive, others are merely busy. Such men may be undervalued by the historian in later eras. These considerations apply to the great German clinician Johann Lucas Schoenlein (1793 to 1864), who has been saved from oblivion by an eponym, the incoherent lecture notes of his students, the reminiscences of a few contemporaries and the essay of a sympathetic historian (ACKERKNECHT, E. Johann Lucas Schoenlein. J. Hist. Med., 19: 131, 1964). Schoenlein, the son of a rope-maker, was born in Bamberg and studied at Landshut and Wiirzburg, where he became a dozent in pathologic anatomy and later the director of an important medical clinic. Subsequently he obtained the professorship of special pathology and therapy. He was notably successful pedagogically and unfortunate politically, so that later years found him migrating to Zurich and then to Berlin. He talked much and wrote little, and his published lectures were issued by students, sometimes even against his will. Therefore, interpretations must be made with diffidence. The following excerpts have been translated from his Allgemeine und Spezielle Pathologie und Therapie. (NACH, J. L. Schoenlein’s Vorlesungen Niedergeschrieben und Herausgegeben von einem seiner Zuhorer, ed. 2, Vol. 3, Wiirzburg, 1832. pp. 246-250.) MONG
A
Hydrothorax. Generic Symptoms. The patients have difficulty in breathing, real dyspnea; the chest does not rise, and respiration is accomplished mainly with the abdominal muscles. Percussion yields, in a larger or smaller region, but always in one of the deeply situated places, an extremely dull note. This changes its location when the patient moves, since the water sinks or spreads out, and its level changes and becomes higher or lower. Where the deep tone is heard on percussion, absence of all respiratory sound is detected by auscultation. First type. Acute or febrile hydrothorax. The respiratory difficulty appears suddenly, often in a few hours. The dyspnea is severe, so that the patients sit erect in bed and breathe with the neck stretched lar out. Respiration is conducted predominantly by the abdominal muscles. Not rarely the intercostal spaces swell and protrude. Percussion and auscultation yield the phenomena mentioned, but in greater degree, so that the respiratory murmur is heard only at the apexes, especially over the posterior part of the lung. A complicating inflammation is often present; then the respiratory murmur at the places mentioned is crackling. In addition, there is strong cough, which is either entirely dry or brings forth scanty mucus resembling egg white; if complicating inflammation is present, the sputa are bloody. There are conspicuous venous phenomena, blue lips, blue cheeks, the face disfigured. In the lineaments great anguish is depicted, caused by lack of air. There are febrile phenomena : heavily coated tongue, intense thirst; in the beginning a burning hot skin and full, hard, tense pulse. Later the skin of the extremities becomes cold, the pulse small, weak,
* This study was assisted by Research Grant HE-10948 from the National Institutes Address for reprints: Saul Jarcho, M.D., 35 E. 85 St., New York, N. Y. 10028.
234
THE
AMERICAN
of Health.
JOURNAL
OF
CARDIOLOGY
Schoenlein
on Hydrothorax
compressed but showing lateral tension. All secretions are diminished ; thus, the secretion of the skin is only a cold sticky perspiration on the forehead. Urine is passed in scanty amounts; it is dark purplish red, sparkling. Etiology. The disease occurs only in puberty and in the years of effloresence, rarely in the later periods of life. It forms after suppression of acute exanthemata such as scarlet fever and measlrs, also after suppression of chronic cutaneous eruptions, for example in a person who has had solar erythema suppressed by cold affusions. Occasionally it also occurs after sudden chilling and antagonism of the skin through influences which suppress its normal or pathologic secretion. Course and Conclusion. Often very stormy, killing in 12 to 24 hours, but often protracted to the fourth or seventh day. The disease ends: 1. In cure. With copious sweating, urine containing abundant strong sediment and a quantity of purulent mucus as local crises. The fever disappears, and the respiration regulates itself. Even when the disease has this favorable ending it shows great inclination to recur, especially the form which is due to suppression of a chronic cutaneous eruption. 2. In partial cure, in which the topical crisis prolongs itself, and urethral discharge persists. 3. In death, through pressure of accumulated water on the lung, by which it is compressed and respiration becomes impossible. Since in this form the pressure does not ensue gradually, death in this way is unfortunately very violent. The accumulation of water often amounts to four or six pounds, so that the lungs are squeezed together in a mass that almost resembles spleen and only the apexes and the rear part are suitable for respiration. When complicating inflammation is present, these parts also are inaccessible to air [when the lung is] in the condition of hepatization . . . _ Therapeutics. That a very vigorous treatment is necessary against so stormy a condition needs no mention. The treatment must satisfy the following indications: To allay the fever, which has an inflammatory character. For this reason, a venesection is as little contraindicated as in inflammation of the pulmonary parenchyma, because of the phenomena which are commonly characterized as phenomena of weakness (distorted face, great lassitude and feebleness, small weak pulse, cold extremities). On the contrary, these phenomena require phlebotomy even more urgently. If the VOLUME
24,
AUGUST
1969
235
blood will not flow, since it has accumulated in the internal organs, the parts must be put into warm water or rubbed with flannel, or a counteropening must be made and this helps best. After the venesection the emetic antimony tartrate is given in large doses adequate to produce vomiting . . . . In very acute forms, however, when significant amounts of fluid often collect within three to four hours, paracentesis is indispensable, since through it alone the urgent danger to life is combated and the application of internal remedies becomes possible; without paracentesis these measures are fruitless, since the patient dies before they can take effect . . . . CHRONIC
HYDROTHORAX
Phenomena. The disease forms very deceptively and slowly and, indeed, in the form in which the patients feel oppression in the chest at the outset, this [feeling] is not constant but transitory and appears for the most part only when they make strong movements, such as climbing heights or stairs, or when they speak continuously, in which event the breathing becomes short, or distinct difficulty of breathing appears periodically toward evening. The patients awake in terror from the first sleep with a feeling of pressure on the chest, and of dyspnea. This can last for weeks or months. It may disappear after vomiting and vigorous sweating, especially in the warm season of the year, until finally the annoyance becomes constant. The dyspnea then increases steadily. The patients can no longer lie down horizontally but must sit up erect in bed. Finally, it becomes no longer possible to lie in bed, but the patients must sit in bed with their feet hanging down or even outside of the bed. Examination shows that the chest is enlarged on one side only, when the material is only in one pleura, or it shows that the ribs are pushed forward on both sides, when the material has exuded into both pleural sacs. On percussion a dull tone is heard, which changes its level with the position of the patient. On auscultation there is absence of the respiratory murmur at this place. Through the accumulation of water the diaphragm is pushed downward. For this reason the hypochrondria are felt to bulge on the side where the water has collected, especially in the erect position; and the liver or spleen, pressed downward, can be felt through the abdominal integuments ...
*
*
*
Jarcho
236 COMMENT ON SCHOENLEIN
A specific benefit of the newly expanded art of physical diagnosis is seen in Schoenlein’s readiness to advocate paracentesis in cases of hydrothorax. This maneuver had lost much of its terror since the development of percussion and auscultation now made it relatively easy for the physician to be certain that fluid was present-whereas previously he could only infer its presence by interpreting symptoms. In addition, he could now be relatively confident of the place where his trocar should be inserted.
Apart from his unquestioned excellence as a diagnostician and teacher, Schoenlein is chiefly significant as an early nineteenth century physician who transmitted to Germany the new physical diagnosis that had just been created in France. However, his descriptions of disease by no means derive from the French school alone; quite obviously they incorporate also the strong Hippocratic tradition of simple inspection, and this should not be overlooked.
DRUGS IN USE 258
32-02-W
U 8410/13
5/69 - 2363
Cardiac Depressants
Autonomic DrugAntiadrenergic
Oxprenolol HCl
TRASICOR CIBA
No. Patients Age:
pachycardia, spontaneous:
12-70 yrs.
Dowage & Duration:
e
A: 5 mu., single inj. 16 B: 10 mq. (2 inj. wlthin 15 min.) 6 C: 1 mg., then 5 ms., within 15 min. 7 D: 5 mg.. single inj. 16 Route:
A, B & C: Sinus rhythm Arrhythmia, absolute D: Prior to coronarography A, B & C: Various underlying diseases (details given)
2 after 2nd inj.
I
1
&g$ Heart rate/min.
c: Before After 1 mg. After further 5 mg.
120
93 a5
D: Signif. fall in heart rate. Improved coronary artery visualization during GraDhs aiven coron_awCommwt
i.v.
Dose-dependent decrease of heart is expected only in 1-5 mg. dose range.
n'agner,J.; Thelen, M.; Behrenbeck. D. & Hileer, H.H. (Med. U.-Klin. Bonn-Venusberg, Ger.) Tachykardiebeeinflussung durch den Beta-Rezeptoren-Blocker 1-Isopropylamino-F(o-allyl-oxyphenoxy)-2propanol-hydrochlorid (Trasicor) Deutsch. Med. ulschr.94:3Q6-3o9 (Feb. 14) 1969. L Jib,
Drugs in be
PrePared
Copyriehtb
1969 by Paul d. Ho.n, Inc.
AlI ripht. r..*r..d
Prinwd in U.S.A.
by Paul de Haen, Inc. for the drug index card system, “dcr Hncn Drugs in Use.” THE
AMERICAN
JOURNAL
OF CARDIOLOGY
Miles tones
Schoenlein
on Hydrothorax
(1832)*
SAUL JARCHO, M.D. New York,
New York
EXCERPTS FROM SCHOENLEIN
THE difficulties that beset the historian in his effort to understand the development of ideas and processes, not the least is an inherent limitation in available evidence. Largely but not entirely restricted to written materials, he runs the risk of slighting those who have left no documents for posterity to examine. This is especially true of physicians. Some of the best are taciturn and inexpressive, others are merely busy. Such men may be undervalued by the historian in later eras. These considerations apply to the great German clinician Johann Lucas Schoenlein (1793 to 1864), who has been saved from oblivion by an eponym, the incoherent lecture notes of his students, the reminiscences of a few contemporaries and the essay of a sympathetic historian (ACKERKNECHT, E. Johann Lucas Schoenlein. J. Hist. Med., 19: 131, 1964). Schoenlein, the son of a rope-maker, was born in Bamberg and studied at Landshut and Wiirzburg, where he became a dozent in pathologic anatomy and later the director of an important medical clinic. Subsequently he obtained the professorship of special pathology and therapy. He was notably successful pedagogically and unfortunate politically, so that later years found him migrating to Zurich and then to Berlin. He talked much and wrote little, and his published lectures were issued by students, sometimes even against his will. Therefore, interpretations must be made with diffidence. The following excerpts have been translated from his Allgemeine und Spezielle Pathologie und Therapie. (NACH, J. L. Schoenlein’s Vorlesungen Niedergeschrieben und Herausgegeben von einem seiner Zuhorer, ed. 2, Vol. 3, Wiirzburg, 1832. pp. 246-250.) MONG
A
Hydrothorax. Generic Symptoms. The patients have difficulty in breathing, real dyspnea; the chest does not rise, and respiration is accomplished mainly with the abdominal muscles. Percussion yields, in a larger or smaller region, but always in one of the deeply situated places, an extremely dull note. This changes its location when the patient moves, since the water sinks or spreads out, and its level changes and becomes higher or lower. Where the deep tone is heard on percussion, absence of all respiratory sound is detected by auscultation. First type. Acute or febrile hydrothorax. The respiratory difficulty appears suddenly, often in a few hours. The dyspnea is severe, so that the patients sit erect in bed and breathe with the neck stretched lar out. Respiration is conducted predominantly by the abdominal muscles. Not rarely the intercostal spaces swell and protrude. Percussion and auscultation yield the phenomena mentioned, but in greater degree, so that the respiratory murmur is heard only at the apexes, especially over the posterior part of the lung. A complicating inflammation is often present; then the respiratory murmur at the places mentioned is crackling. In addition, there is strong cough, which is either entirely dry or brings forth scanty mucus resembling egg white; if complicating inflammation is present, the sputa are bloody. There are conspicuous venous phenomena, blue lips, blue cheeks, the face disfigured. In the lineaments great anguish is depicted, caused by lack of air. There are febrile phenomena : heavily coated tongue, intense thirst; in the beginning a burning hot skin and full, hard, tense pulse. Later the skin of the extremities becomes cold, the pulse small, weak,
* This study was assisted by Research Grant HE-10948 from the National Institutes Address for reprints: Saul Jarcho, M.D., 35 E. 85 St., New York, N. Y. 10028.
234
THE
AMERICAN
of Health.
JOURNAL
OF
CARDIOLOGY
Schoenlein
on Hydrothorax
compressed but showing lateral tension. All secretions are diminished ; thus, the secretion of the skin is only a cold sticky perspiration on the forehead. Urine is passed in scanty amounts; it is dark purplish red, sparkling. Etiology. The disease occurs only in puberty and in the years of effloresence, rarely in the later periods of life. It forms after suppression of acute exanthemata such as scarlet fever and measlrs, also after suppression of chronic cutaneous eruptions, for example in a person who has had solar erythema suppressed by cold affusions. Occasionally it also occurs after sudden chilling and antagonism of the skin through influences which suppress its normal or pathologic secretion. Course and Conclusion. Often very stormy, killing in 12 to 24 hours, but often protracted to the fourth or seventh day. The disease ends: 1. In cure. With copious sweating, urine containing abundant strong sediment and a quantity of purulent mucus as local crises. The fever disappears, and the respiration regulates itself. Even when the disease has this favorable ending it shows great inclination to recur, especially the form which is due to suppression of a chronic cutaneous eruption. 2. In partial cure, in which the topical crisis prolongs itself, and urethral discharge persists. 3. In death, through pressure of accumulated water on the lung, by which it is compressed and respiration becomes impossible. Since in this form the pressure does not ensue gradually, death in this way is unfortunately very violent. The accumulation of water often amounts to four or six pounds, so that the lungs are squeezed together in a mass that almost resembles spleen and only the apexes and the rear part are suitable for respiration. When complicating inflammation is present, these parts also are inaccessible to air [when the lung is] in the condition of hepatization . . . _ Therapeutics. That a very vigorous treatment is necessary against so stormy a condition needs no mention. The treatment must satisfy the following indications: To allay the fever, which has an inflammatory character. For this reason, a venesection is as little contraindicated as in inflammation of the pulmonary parenchyma, because of the phenomena which are commonly characterized as phenomena of weakness (distorted face, great lassitude and feebleness, small weak pulse, cold extremities). On the contrary, these phenomena require phlebotomy even more urgently. If the VOLUME
24,
AUGUST
1969
235
blood will not flow, since it has accumulated in the internal organs, the parts must be put into warm water or rubbed with flannel, or a counteropening must be made and this helps best. After the venesection the emetic antimony tartrate is given in large doses adequate to produce vomiting . . . . In very acute forms, however, when significant amounts of fluid often collect within three to four hours, paracentesis is indispensable, since through it alone the urgent danger to life is combated and the application of internal remedies becomes possible; without paracentesis these measures are fruitless, since the patient dies before they can take effect . . . . CHRONIC
HYDROTHORAX
Phenomena. The disease forms very deceptively and slowly and, indeed, in the form in which the patients feel oppression in the chest at the outset, this [feeling] is not constant but transitory and appears for the most part only when they make strong movements, such as climbing heights or stairs, or when they speak continuously, in which event the breathing becomes short, or distinct difficulty of breathing appears periodically toward evening. The patients awake in terror from the first sleep with a feeling of pressure on the chest, and of dyspnea. This can last for weeks or months. It may disappear after vomiting and vigorous sweating, especially in the warm season of the year, until finally the annoyance becomes constant. The dyspnea then increases steadily. The patients can no longer lie down horizontally but must sit up erect in bed. Finally, it becomes no longer possible to lie in bed, but the patients must sit in bed with their feet hanging down or even outside of the bed. Examination shows that the chest is enlarged on one side only, when the material is only in one pleura, or it shows that the ribs are pushed forward on both sides, when the material has exuded into both pleural sacs. On percussion a dull tone is heard, which changes its level with the position of the patient. On auscultation there is absence of the respiratory murmur at this place. Through the accumulation of water the diaphragm is pushed downward. For this reason the hypochrondria are felt to bulge on the side where the water has collected, especially in the erect position; and the liver or spleen, pressed downward, can be felt through the abdominal integuments ...
*
*
*
Jarcho
236 COMMENT ON SCHOENLEIN
A specific benefit of the newly expanded art of physical diagnosis is seen in Schoenlein’s readiness to advocate paracentesis in cases of hydrothorax. This maneuver had lost much of its terror since the development of percussion and auscultation now made it relatively easy for the physician to be certain that fluid was present-whereas previously he could only infer its presence by interpreting symptoms. In addition, he could now be relatively confident of the place where his trocar should be inserted.
Apart from his unquestioned excellence as a diagnostician and teacher, Schoenlein is chiefly significant as an early nineteenth century physician who transmitted to Germany the new physical diagnosis that had just been created in France. However, his descriptions of disease by no means derive from the French school alone; quite obviously they incorporate also the strong Hippocratic tradition of simple inspection, and this should not be overlooked.
DRUGS IN USE 258
32-02-W
U 8410/13
5/69 - 2363
Cardiac Depressants
Autonomic DrugAntiadrenergic
Oxprenolol HCl
TRASICOR CIBA
No. Patients Age:
pachycardia, spontaneous:
12-70 yrs.
Dowage & Duration:
e
A: 5 mu., single inj. 16 B: 10 mq. (2 inj. wlthin 15 min.) 6 C: 1 mg., then 5 ms., within 15 min. 7 D: 5 mg.. single inj. 16 Route:
A, B & C: Sinus rhythm Arrhythmia, absolute D: Prior to coronarography A, B & C: Various underlying diseases (details given)
2 after 2nd inj.
I
1
&g$ Heart rate/min.
c: Before After 1 mg. After further 5 mg.
120
93 a5
D: Signif. fall in heart rate. Improved coronary artery visualization during GraDhs aiven coron_awCommwt
i.v.
Dose-dependent decrease of heart is expected only in 1-5 mg. dose range.
n'agner,J.; Thelen, M.; Behrenbeck. D. & Hileer, H.H. (Med. U.-Klin. Bonn-Venusberg, Ger.) Tachykardiebeeinflussung durch den Beta-Rezeptoren-Blocker 1-Isopropylamino-F(o-allyl-oxyphenoxy)-2propanol-hydrochlorid (Trasicor) Deutsch. Med. ulschr.94:3Q6-3o9 (Feb. 14) 1969. L Jib,
Drugs in be
PrePared
Copyriehtb
1969 by Paul d. Ho.n, Inc.
AlI ripht. r..*r..d
Prinwd in U.S.A.
by Paul de Haen, Inc. for the drug index card system, “dcr Hncn Drugs in Use.” THE
AMERICAN
JOURNAL
OF CARDIOLOGY