kidney

Pain in Renal Disease.-Zimmerman, in the American Practitioner and News, points out the frequency with which pains located in the kidney region are misinterpreted. Grave lesions are often overlooked because the pain is supposed to be due to some affection of muscles, spinal column, or nerves; and, on the other hand, kidney disease is diagnosed when the lesion is really one of muscle, or bone, or of some organ whose location is remote from the kidney.

Pain is a prominent symptom of many surgical affections of the kidney and ureter. It may be local or referred. In character and severity it ranges from a heavy, dragging sensation in the lumbar region, scarcely to be dignified by the title of pain, to the most intense and excruciating agony of renal colic. Pain may be the result, either of irritation or of distention of the kidney or ureter. The origin of renal pain involves the question of the sensitivity of the viscera. This subject has received much attention at the hands of both physiologists and clinicians. It is a fact long since demonstrated that the viscera may be subjected to the action of intense chemical, thermal and mechanical stimuli without in the most evanescent or slightest degree affecting the attention of consciousness."'

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Auscultatory Positions of Cough.-Garvin, in the New York State Journal of Medicine, states that the positions of the cough in the respiratory cycle are four in number, with each one of the four positions in a sliding scale, depending upon the willingness and ability of the patient to cooperate. The first is at the beginning of inspiration, which also corresponds with the end of expiration, and is the most important one of the four. By moving the cough at the beginning of inspiration, or at the end of expiration as far as possible into the supplemental respiratory area, the cough yields relatively the largest wealth of signs. It is the one used in diagnosis.

The second position of the cough is its insertion at some place in the inspiratory phase of the respiratory cycle the insertion of the cough at any point short of complete inspiration necessarily cuts short that inspiratory phase and has to be followed by an expiratory phase of corresponding length. The cough by this second method is used extensively in moderately advanced cases

and yields abundant information; calls for minimum effort on the part of the examiner and patient, and where useful indicates extreme infiltration.

The third point at which the cough may be used is at the zenith of the respiratory effort which also corresponds to the beginning of expiration, and is to be mentioned only as not to be used. It is usually the first thing that the patient does when requested to cough. He promptly fills his lungs as full as possible and starts off with a thunderous cough at the zenith of inspiration or the beginning of expiration and obscures some fine signs, if they exist, and fails to develop others that appear more readily on the respiratory effort following cough, rather than the continued expiratory effort after cough. It is the method. that is promptly ruled out by changing the time of the cough.

The fourth method corresponds in some respects to the second method, and consists in placing the cough at some point in the expiratory phase where it finally is advanced and merges into method number 1, namely, at the beginning of inspiration or the very end of expiration. The nearer the cough is placed at the end of expiration, the more effective is the procedure.

To place the description of the cough at two arbitrary points, namely, at the highest inspiratory point, and the lowest expiratory point possible in the patient, is definite; to place it at any point in time in the inspiratory phase or in the expiratory phase, is relatively arbitrary and amounts to the same thing, as there is but one physiological way to cough, but these variables offer suggestions as to the possibilities that are numerous, in placing the cough in the respiratory cycle of any given patient that presents for diagnosis. As a matter of practice it is usually rapidly and satisfactorily accomplished.

Prostatic Obstruction.-Bransford Lewis, before the Mississippi Valley Medical Society, outlined the conditions which gave rise to obstruction at or near the vesical neck. He had been in the habit of considering the following features as essential in the diagnosis of such conditions, not only for the analytical study of the case, but as a working basis for treatment: 1. Hypertrophy or not. 2. If so, was it causing obstruction? 3. The amount of obstruction so produced. 4. The form and nature of the condition producing the obstruction. 5. The physical and functionating condition of the allied organs, particularly the kidneys and cardiac system. All of these points should be considered and determined accurately

before attempting to decide as to the treatment or operation, except for such measures as emergency treatment might call for and to relieve acute retention or sepsis, etc. There were two chief modes of studying a case for arriving at a diagnosis; analysis of the history and symptomatology and the physical examination. Of the two, the physical examination was by far the more important and enlightening. There had been no more brilliant or satisfying achievement in the whole field of medicine than had been wrought by surgery of prostatic obstruction in the past decade. It had brought order out of chaos, had turned misery into comfort for the aged prostatic, and it had been a well-rounded and precise diagnosis that had been largely instrumental in attaining these results.

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Summary of Wassermann Test.-Stein, in the Medical Record, thus summarizes the significance of the fixation test:

The non-syphilitic nature of a suspected primary lesion is not proved by a negative reaction. A negative reaction in an untreated suspected case, there being no primary lesion manifest, makes the diagnosis of syphilis improbable, but not positively negative, because it may be broadly stated that only about 95 per cent of cases of secondary and tertiary syphilis give a positive reaction.

cases.

Untreated secondary syphilis usually gives a positive reaction which is stronger than in treated Treated' secondary syphilis usually gives a positive reaction if the clinical symptoms are present. There are cases of secondary syphilis giving a negative reaction, which, on repeating the test (7 to 14 days later), becomes positive.

Untreated tertiary syphilis always gives a positive reaction, but in treated cases the reaction may be negative or weaker than in the treated ones. A gumma always gives a positive reaction (at times only moderately strong) by the method of Landsteiner, Müller, and Pötzl.

Latent syphilis often gives a weak reaction: 30 per cent incomplete, 20 per cent positive, and 50 per cent negative. Untreated cases of latent syphilis are more likely to give a positive reaction, whereas with well treated cases the positive reaction is less frequent and weaker. In nervous diseases, including tabes dorsalis, about 10 per cent are negative, 20 per cent incompletely positive, and the remainder positive. The fact that tabetic patients who have never been treated for syphilis always give a positive reaction tends. to support the theory that syphilis is the only cause of tabes. Cases of tabes where the syphilis

has been previously treated give a weak positive or entirely negative reaction.

X-Ray in Pycolography.-Braasch, before the Mississippi Valley Medical Society, emphasized the value of the radiograph and the necessity for further data to interpret correctly the X-ray plate. The value of shadows of abdominal viscera was not great. The data gained through the use of the cystoscope aided in interpretation. Through meatoscopy one might see evidence of stone, but secretion was often misleading. One might obtain evidence by means of the ureteral catheter. Obstruction by stone in the ureter was found in over two-thirds of the cases, and stones were passed in one-half of the cases. The stylet in the ureteral catheter when radiographed might be of value, but it might give an erroneous impression and often be insufficient. With pyelography one might be able to demonstrate changes in the outlines of the pelvis and ureter which accompanied most surgical conditions of the kidney and ureter. Hydronephrosis might be accurately determined by the pyelograph. It was particularly valuable with small distension and with marked constriction of the ureter. Inflammatory dilatation varied in extent. from slight changes of pyelitis to those of pyonephrosis. By using these data one was able to identify renal shadows by inflammatory changes seen in the pelvis and ureter. Stone in the ureter was recognized by the mechanical dilatation above it. Deformity caused by tumor of the kidney might be demonstrated in about twothirds of the cases. One should also use methods to differentiate tumors existing in other viscera.

Congenital anomalies, such as duplication of pelves or ureter, horseshoe kidney, etc., could be demonstrated clinically. There was not as yet a widespread adoption of the pyelograph, largely because of a lack of technical facilities. There was never permanent injury resulting from its use. The diagnosis in urinary tract conditions should be a part of the general abdominal diagnosis.

Nephrectomy in Renal Tuberculosis.-Barth, in Deutsche Med. Wochenschrift, has investigated the end results in 37 of 40 cases of renal tuberculosis treated by nephrectomy. Of these 12 were cured and 12 improved or still under treatment, while 13 died. The period of observation of cases termed cured ranged from one and onethird to nineteen years. A comparison of these results with those obtained in about the same number of cases not subjected to operation shows that the prognosis in the latter was far less favorable. From his studies Barth draws the following conclusions: So long as the disease is confined to one kidney and its ureter nephrectomy affords very favorable prospects of a permanent cure. If the bladder is already affected, a complete and lasting cure of the tuberculosis process can be expected only in a fraction of the cases, approximately one-fourth. About the same number succumb in the first year to tuberculosis, while in the others a more prolonged improvement can be anticipated. In five of the author's cases of renal and vesical tuberculosis treated by operation improvement persisted for 14, 12, 14, 2, and 9 years, while five others died after 2, 32, 5, and 912 years of the renal disease or other tuberculous involvement. Even after a complete cure has resulted in tuberculosis of the bladder, various disorders are apt to persist, such as frequent urination, especially at night, and for this reason every case of recognized renal tuberculosis should be nephrectomized, if possible, before the bladder has become involved.

Genital Tuberculosis in the Female.-Kraemer, in Deutsche Med. Wochenschrift, states that the treatment of genital tuberculosis in women, whenever possible, should be operative. In every operation for tuberculous peritonitis it is important that the genitals be thoroughly inspected, and, if necessary, the affected structures removed. If there is any prospect that this will eliminate the chief focus of the tuberculosis, intervention is not only permissible, but imperative. If the tubes are diseased it is advisable to simultaneously remove the uterus, as it is usually affected. On

the other hand, the ovaries are quite often found to be free from tuberculous infection and should then be preserved for their internal secretion. Even in apparently isolated tuberculosis of the endomentrium and cervix uteri the possibility of involvement of the myometrium is not to be excluded, and for this reason total extirpation per vaginam is the rational procedure. In view of the fact that peritoneal tuberculosis is particularly frequent in children from the first to the tenth year, while genital tuberculosis is most common after the occurrence of puberty, prophylaxis is of special importance at an early age.

While it has frequently been thought necessary to pass the catheter for injecting all the way to the kidney this is impossible to do with an obstructed or tortuous ureter. The injection of silver solutions obscures the position of a calculus in the pelvis or calices.

The advantages of inflating with air are: the catheter does not have to be inserted all the way to the kidney; air or gas surrounding a calculus accentuates its shadow; the air may be readily withdrawn after the radiograph has been made, and the sections between the calices are distinctly shown when the kidneys are inflated with air.

Where it is impossible or undesirable to insert the catheter all the way to the kidney the pelvis and calices may be inflated through the ureter by inserting the ureteral catheter only a few cm.

The air should be filtered through a wad of sterile cotton and may then be passed through a warmed alkaline solution. The catheter to be

used should have an end that may be expanded so as to fill the lumen of the ureter.

A radiograph should be made before the inflation is begun. After the inflation the radiograph should be made as usual save that compression should be avoided as much as possible. The danger from air embolism is negligible.

Anemias of Nurslings.-Finkelstein, in Berliner Klin. Wochenschrift, calls attention to the fact that even apparently healthy babies are often pale, with relatively low hemoglobin values. The latter range from 60 to 70 per cent, the red corpuscle count being high in proportion. Pseudoanemia is the term applied to pallid children with normal blood values. Children are often born with deficient iron in their blood; and if the iron at birth is normal or in execss, this slowly disappears from the organism unless food rich in iron is given. Some authorities claim that under normal circumstances the newly-born child is much richer in iron than is the adult because it is destined to subsist for months on milk, which is poor in iron. There is a so-called chlorotic type of anemia in the nursling which responds readily to iron medication. The hemoglobin in these cases may sink below 50 per cent. The author does not like the term chlorotic anemia and would substitute for it oligosideremia, meaning poverty in iron. This type is doubtless due to congenital insufficiency of the spleen and other blood-making organs. Another type of nursling anemia is the so-called anemia pseudoleucemica infantum, a condition described fully in textbooks. In addition to the types just enumerated, which are primary, we have secondary anemias, such as result from syphilis and other constitutional affections, diseases of the gastroenteric organs, etc.

Tuberculin by Mouth.-Möllers and Heinemann, in Deutsche Med. Wochenschrift reach the following conclusions after extensive investigations into this subject: It is practicable to administer tuberculin in capsules, provided the latter escape the destructive action of the gastric juice. In vitro pepsin and trypsin can so damage tuberculin that it no longer can produce its characteristic results in the animal organism. The patients who are most sensitive to the action of tuberculin do not in most cases show any reaction, febrile, general, or focal, when the drug is given by the mouth. Even when given per os in high doses there is no evidence of the formation of antibodies in the blood serum. It therefore follows that while some tuberculin may be absorbed

in the intestine the method of administration per os cannot be compared at all with the subcutaneous method; and that neither for diagnosis nor treatment does it hold out any material hope when given in the first-named manner.

惺惺惺

Chloretone in Tetany.-Croley reports his use of chloretone in tetanus in the Indian Medical Gazette for September, 1911. The following points he thinks are important.

1. The case was a very acute one, the spasms and trismus and opisthotonos being very marked.

2. Except for the chloral and bromide the first day and on the evenings of the seventh and thirteenth days no other drug was given but chloretone.

3. No antitetanic serum was injected.

4. The fact most worthy of attention was the relief of trismus, which enabled the patient to take ample nourishment and so maintain his strength.

5. The convulsions were a very marked feature of this case. In the note by Dr. Sheaf in the British Medical Journal article, he says that tetanus not only kills by the direct action of the toxin, but by the exhaustion produced by the convulsions, so the drug was given a most severe

test.

Croley is convinced that the man owes his life to chloretone, and he strongly recommends the drug be given a trial.

济济济

Incision for Colectomy.-Barker, in The Lancet, maintains that with the exception of the central third of the transverse colon, for which a median incision is suitable, all other segments may be best reached through an oblique flank incision on either side. The cut in the skin should begin near the end of the tenth or eleventh rib and run downward and forward nearly to the midline between the umbilicus and symphysis pubis. When the external oblique aponeurosis is exposed its fibers should be separated rather than cut, and the same may be said of the two deeper muscles. It is surprising what a wide opening can be obtained in this manner without actually dividing the fibers of the muscles in question. The nerves which supply the rectus, the oblique, and the transversalis muscles are also preserved intact with a little care, and very few vessels are cut. The innervation and blood supply of the abdominal wall are by these means preserved and its future strength is unimpaired. If the opening is not large enough, when it reaches the sheath of the rectus this may be opened and the belly of the muscle be drawn inward without difficulty,