A CASE OF UREMIA IN AN ALCOHOLIC PATIENT WITH VISCERAL COMPLICATIONS Successfully Treated by Venesection, Diaphoresis and Nitro-Glycerine. Philadelphia Hospital. SERVICE OF S. SOLIS-COHEN, M.D., [Reported by W. E. Bruner, M.D., Resident Physician.] FROM THE MEDICAL NEWS, March 18. 1893. [Reprinted from The Medical News, March 18, 1893.] A CASE OF UREMIA IN AN ALCOHOLIC PATIENT WITH VISCERAL COMPLICATIONS SUCCESS- FULLY TREATED BY VENESECTION, DIAPHORESIS, AND NITRO- GLYCERIN. Philadelphia Hospital. Service of S. SOLIS-COHEN, M.D. [Reported by W. E. Bruner, M.D., Resident Physician.] J. S., an Austrian, thirty-six years old, was admitted to the Philadephia Hospital December 13, 1892. His family history was negative. He had had pneumonia when twenty years old. He confessed to gonorrhea, but not to syphilis. He had not had rheumatism, and had until recently considered himself in good health, although accustomed to have severe headache at times, and occa- sionally troubled with nausea. He has for years been drinking beer to excess, but not to drunkenness ; and is short, fat, and heavy, with the typical flushed cheeks and bloated facies of a beer-drinker, even after edema elsewhere has passed away. About eight months ago he was seized with severe pain in the lumbar region, which has gradually decreased until now it is only slight. For four or five months he has been obliged to pass urine several times at night. The urine is dark in color and small in quantity; mic- turition is attended with burning. For four months there Las been shortness of breath, and for two or three months slight impairment of vision—in fact, the man says he 2 was completely blind three weeks ago for a short time. Abdomen and feet began to swell about three weeks before admission. On admission the patient was quite dyspneic, but not cyanotic. He was completely “water-logged” ; the legs were markedly edematous, as were also the hands, arms, chest and abdominal walls, face, and conjunctivae. As- cites was present to a considerable degree, and rales of edema were heard posteriorly throughout both lungs. The heart’s action was feeble; percussion was not satis- factory, owing to the great amount of fat and the edema of the chest-wall. Auscultation of the heart was much inter- fered with by the loudness of the transmitted tracheal breathing. It revealed feeble sounds, as in dilatation, and with difficulty a mitral systolic murmur could be detected ; the second sound was not accentuated. The urine, of which but a few ounces were passed, had a specific gravity of 1021, and was laden with albumin, which made more than two-thirds by bulk when the urine was boiled and then allowed to stand for twenty- four hours. Granular and broad hyaline casts were abundant. Ophthalmoscopic examination revealed a marked degree of albuminuric retinitis. The man was placed at once upon cardiant diuretics; infusion of digitalis, with spirit of nitrous ether, supple- mented after two days by sparteine sulphate and caf- feine in small, frequently-repeated doses. Compound jalap powder was freely administered, and hot-air baths, aided at first by small doses of pilocarpine, were tried, but without inducing perspiration. The diet was re- stricted to milk. The mental condition was marked by stupor and irritability, and it was extremely difficult to get the man to take food or medicine. On the 16th he had a general convulsion. When seen a few minutes later, his face was slightly cyanosed, the breathing was stertorous, the pupils were widely dilated, and head and eyes were turned to the left. Conscious- 3 ness was completely lost. The vascular tension, as appreciable at the radials, was very high. Unfortunately the man was so restless that his temperature could not be taken. Three drops of croton oil were given at once, and twenty-four ounces of very black blood were with- drawn from the arm. Just as his arm was being ban- daged he had a second and terrific convulsion ; after the control of which, by inhalations of chloroform, the vein was at once reopened, and an additional half-pint of blood abstracted. The man then became wildly de- lirious. The lungs were filled with fluid, giving rise to moist rales; but, in spite of this fact, pilocarpine hydro- chlorate, gr. y%, with sparteine sulphate, gr. y, was given hypodermatically, and the steam-bath was started. The pilocarpine was repeated in an hour, with sparteine sulphate, gr. y, and the steam-bath was continued for three and one-half hours, with, however, but slight effect. Nitroglycerin (i per cent, solution), gtt. 2, sparteine sul- phate, gr. y%, and spirit of nitrous ether, fl gj, were given every hour during the afternoon and every two hours throughout the night. On the following morning the patient was perfectly rational and very comfortable. The heart was acting more steadily, more strongly and less rapidly; the murmur was more readily detected, and the second sound was clearer. Hot-air and, later, steam-baths were given daily, aided by pilocarpine, gr. y subcutaneously, or gr- by the mouth; but it was several days before any marked effect appeared, when very free sweating took place. On January 2d the patient was not so well. It had been decided to modify the treatment by giving alkaline diuretics with the sparteine and nitro-glycerin; but for several days he had been refusing to take his medicine, so that he got only what could be given hypodermati- cally, together with the baths. Urgent symptoms, how- ever, had been absent. He was very nervous on this 4 afternoon. His muscles were twitching and his hands jerking; his pupils were somewhat dilated, and he seemed on the verge of another convulsion. After a preliminary- inhalation of amyl nitrite, croton oil was again admin- istered, with pilocarpine and the hot-air bath ; after which nitro-glycerin (gtt. i of a I per cent, solution) was given at first every half-hour, and then every hour. On the following morning he was much better, and as he had considerable ascites it was decided to remove the fluid, and thus relieve the kidneys of that much extra work. Although some authorities advise against abdominal paracentesis under such circumstances, one hundred and ten (no) ounces of fluid were withdrawn, with no evil effect whatever, but with decidedly beneficial results. When the fluid had been removed, percussion in the right hypochondrium indicated smooth enlarge- ment of the liver to a moderate degree. Despite a severe attack of acute bronchitis, and later an attack of pleurisy, the patient has continued to im- prove. The edema has almost entirely disappeared, and the amount of urine in the twenty-four hours has increased to ninety ounces. Tested by heat, it con- tains about one-third its bulk of albumin. On sev- eral occasions the edema has rather rapidly increased ; but pilocarpine and the hot-air bath, with the free ad- ministration of nitro-glycerin, in addition to his regular treatment by diuretics and cathartics, relieved the urgent symptoms. An attack of tachycardia, with a pulse of 170 per minute, was relieved apparently by strychnine sulphate hypodermatically. An asthmatoid attack was relieved by wet cupping of the chest and hypodermatic injection of strychnine; on several occasions since there have been paroxysms of rapid breathing believed to be largely hysterical. Present treatment consists of regulated' diet, warmth, sparteine, caffeine, and nitro-glycerin, in alternation 5 with Basham's mixture of iron and ammonium acetate, and purgation as necessary. The noteworthy points in the case, as impressed upon the observer who saw it from hour to hour, and could compare its progress with that of other cases more or less similar in certain respects, are the prompt relief afforded by venesection in the first convulsion; the effect of frequently-repeated doses of nitro-glycerin in averting a second convulsion; the excellent result of abdominal tapping; the superiority of a combination of sparteine and caffeine in this instance to digitalis as a cardiant diuretic; the superior efficiency of diuretic mixtures containing nitrous ether over the same drugs unaided; the determination of the pilocarpine result to the skin and not to the lungs, notwithstanding the apparent counter-indication of pulmonary edema. Al- though caffeine was discontinued for a time during the period of cerebral manifestations, it is not believed that these can be ascribed to that drug. Its favorable influ- ence since would seem to negative such a supposition. Of any single measure, venesection was the most useful at the moment. The Medical News. Established in 1843. A IVEEKL YMEDICAL NE WSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMVTA TION RA TE, $7.40 PER ANNUM. LEA BROTHERS & CO. PHILADELPHIA.