what he has gained by an early operation, and what he and his patient have escaped by not waiting for late one.

CHRONIC NEPHRITIS IN THE AGED.*

J. PALMER MATTHEWS, M. D.

CARLINVILLE, ILL.

IN the examination of the old soldiers who come before the pension board I frequently find three marked symptoms of degeneration which when taken together are diagnostic of chronic interstitial nephritis.

The hardened arteries, hypertrophied heart, and insufficiency of the kidneys, are sequelae in a chain of symptoms which start from a faulty metabolism of animal proteids in the process of digestion, causing the formation of poisonous leucomaines, and the absorption into the blood of unoxidized nitrogenous byproducts.

The arterioles become spasmodically contracted, causing resistance in the circulation to the action of the heart which becomes bypertrophied to compensate for the added work.

These proteid substances have the same formula of N,H,CO urea, except that they are unoxidized. They are uric acid N, H N.H COg from nuclein cells and creatin NH, CO2+H2O from muscle. The formula of nuclein is C2H49N,O22P3.

8

In the process of digestion of meats the nuclein of the animal cells is oxidized into urea for excretion from the blood by the kidneys. The liver and small intestines are the places where this oxidation takes place. If they are inactive the poisonous by products are retained to the detriment of the whole conomy, and are not properly eliminated as urea, but circulate as forms of uric acid and creatin.

Acute dysentery or a lithemic attack may be the beginning of the absorption of products of putrefaction and progressive inflammation of the liver and kidneys, causing cirrhosis and interstitial nephritis.

The symptoms are persistent headache, dizziness, dull memory, nervous flushes and general uremic symptoms with a copious flow of pale, urine of low specific gravity and strong, slow pulse.

The histology of the kidney shows us malpighian tufts of blood vessels from which is secreted the solid constituents of the urine. A large supply of blood passes through arterioles, which are in contact with the uriniferous tubules. The water of the blood passes

Read before the Western District Medical Society at Alton, October 27. 1905.

by osmosis into these channels and into the pelvis of the kidney, where it is carried by the ureters to the bladder.

These arterioles have the muscular coat. discarded when they enter the kidneys, but their fibrous coat furnishes the connective tissue stroma of the kidney.

When the blood absorbs irritant proteid ferments from the alimentary canal and filters them through the kidneys there is produced a diapedesis of white blood cells through the irritated capillaries and a new formation of connective tissue in the fibrous coat. This process continues all over the body with hardening of the tissues of the liver, brain, kidneys and all organs well supplied with arterioles; altered blood supply produces amaurosis and congestions with loss of functions to these vital organs.

If

The heart hypertrophies to compensate for the resistance increasing in the narrowed brittle arterioles. The strong, full pulse of a sclerosed artery is a diagnostic sign. the condition is not remedied by glenoin, aconite or other arterial sedatives, apoplexy may suddenly end all, or the heart will weaken and cause blood stasis and general anasarca.

Diagnosis. Differential between interstitial and parenchymatous becomes clear when we see by the microscope that in the latter there is a proliferation of the epithelial cells of the uriniferous tubules, plugging them up with epithelial casts, causing scanty urine and large, white kidney from thickening of the uriniferous tubules in the parenchyma of the kidney. In the former, interstitial connective tissue from the outer coat of the blood vessels, does not stop the secretion of water, but shrinks up the malphigian blood tufts from which is secreted the solid constituents of the urine. So we have copious flow of urine with retention of solids in the blood; and a contracted kidney with adherent capsule from fibrous inflammation..

The presence of casts in the urine of parenchymatous nephritis is diagnostic of the chronic or acute stage. When the casts are epithelial they indicate an acute proliferation of cells in the uriniferous tubules. When the casts are hyaline they indicate a chronic degenerative process which follows the subsidence of the acute stage.

The presence of albumen in the urine of interstitial nephritis indicates a progressive inflammation with diapedesis of white blood corpuscles through the diseased capillary walls to form new connective tissue from the fibrous coats of the arteries.

When the albumen is diminished or absent the inflammatory process is in abeyance and the disease is chronic.

Interstitial nephritis is a degeneration frequently found in the aged, or those prematurely aged from disease.

The treatment of these symptoms of functional impairment of organs so vital is rest. The insufficiency of the liver and kidneys should be relieved by careful regulation of the diet and exclusion of the proteids of the animal kingdom. These are known to form -poisons when not sufficiently oxidized by the liver.

The eminent scientist, Mechkinott, of the Pasteur Institute, Paris, France, has found a cure for old age. He says man is as old as his arteries. He recognized that the absorption of products of proteid metabolism, decomposed in the alimentary canal was the cause of the degeneration of his arteries when circulating in the blood. He has found lactic acid to be an efficient destroyer of pathogenic germs By a process of yeast fermentation he prepares milk in the form of kumiss to predigest the proteid of casein sufficient for his bodily nourishment. The lactic acid. keeps the alimentary canal free from ptomain poisons.

Professor Neiswanger of the Chicago School of Electro-Therapeutics, has made the happy experiment of placing his nephritic patients on an insulated chair and giving them an electric bath from a static machine. Under this treatment the blood pressure subsides, and the albumen disappears from the urine.

When we recognize high blood-pressure with slow, full pulse and exaggerated second sound of an hypertrophied heart, with other evidences of uremic poisoning in our patients who are advanced in age we should warn them in time. Stop their meat and coffee, and call their attention to the proteid foods of the vegetable kingdom, which are so scientifi cally prepared, such as toasted wheat flakes of the Battle Creek Sanitarium.

AFTER removal of the appendix symptoms of appendicitis sometimes persist, leading the patient to believe that the organ had not been extirpated. These are generally due to a colitis, which must be treated by high irrigations, diet, etc.

Treatment of BUBO.-Orville Horwitz directs to shave and sterilize the overlying skin; puncture and evacuate pus with a bistoury; irrigate cavity with hydrogen peroxide till washings are clear, then with 1:5000 bichloride solution. Next fill cavity with ten per cent iodoform in vaseline, apply a piece of ice over the part till the vaseline is hardened, and dress with a firm compress of gauze.

In this prelude we refer to medical journalism, which in its varied phases, presents one at this time, which we believe is not to the best interests of the profession as a whole. We refer to the tendency in certain quarters to give to those medical journals, the property of State or National organizations, a recognition beyond that of the independent medical press.

Medical journalism should be democratio; should be governed only by the broad principles of democracy and not hampered or circumscribed by "expediency" or "the fear of consequences.

Every editor should be broad enough, and so full of the desire to approach the ideal of truth, that he can serve the interests of the profession as a whole, and consequently without prejudice or partiality.

There is a place for such an editor, whether he edit a small journal, or one of larger caliber, and in him should be vested the eternal rights of liberty and the pursuit of happiness, for the profession which he represents. No one editor knows all of the needs of the profession; he of the larger journal is cosmopolitan in all of his aims, and perhaps he of the small journal is more or less provincial, but both should aim only at truth-live up to it, fight for it, and convince his respective readers that it is only right living, right

practices, which hold our profession together and make medicine a noble calling.

When we lose sight of ideals we fall into the way of error, which leads to the undoing of professionalism, unmakes brotherhood and leaves a dark brown taste in the mouth.

The independent medical press is free to move, free to speak and free to serve, and should stand for its own and make for itself the place it deserves-the leader of medical thought and the believer in an optimism which should make the profession grander and better.

It is said that one of the prime characteristics of the men of culture is his freedom from provincialism, his complete deliverance from rigidity of temper, narrowness of interest, uncertainty of taste and general unripeness. We think this quotation applicable as evidence in forming judgment of an ideal independent medical press. The greater the culture shown in its policies, the greater its usefulness, because it creates authority, raises standards, broadens experience, and approaches near to the ideal in truth and

purpose.

Now one of the greater dangers of a state. journal, in its editorial work is in its tendency to be governed by isolated policies, which, alas! may not be for the benefit of the profession as a whole, for we know that a whole, for we know that medicine as a profession is full of provincialism and is always substituting a part for the whole, much to the detriment of a broad, wide experience so necessary to the development of progressive reforms. A long experience, as we all know, counts in the weight or estimation of the balance of usefulness and equipoise of a man, and why should we not apply the same measure to the organization as a whole, especially to medical societies.

If we

do this it is to be expected that the independent cultured press of years of experience will draw a fairly rational, conservative view of the needs of the profession, recognize the value of its creeds and help in develop ing wise and true policies for the good of the profession.

We do not want to decry State journals, not at all, we believe in them as a part of the State society, for the publication of transactions and as a mouth-piece of the organization, but they can never take the place of the independent journal in the broad scope and fullness of the ultimate end of journalism. Some of the State journals, unfortunately, in some regions, pose too much as Philistines-in their infallibility, their blind partisanship and rather dogmatic tendency.

The aim and end of all journalism is truth, and medical editors should always have this fact fixed foremost in their mind. F.P.N.

THIS disease presents many practical questions which are of especial importance to the

Cancer of the Breast.

physician. By the time they come to the surgeon they are already convinced in their own minds that an operation

will be required. The physician should devise some plan of education by which the woman with the "lump" in the breast will place herself under early observation. The dreadful results, of late, operations have driven the women to secrecy or to the quack. It is for the general practitioner to lead them back to rational understanding of the benefits of an early operation. No one knows fully what the benefit of early operations would be. There have been too few opportunities for such operations to give us as yet reliable statistics. We do know in general that the results are infinitely better than those operated late after metastases have taken place and the disease is beyond the reach of any kind of operation or treatment yet devised. More than 80% of all tumors appearing in the breast are cancerous. Of these all will have metastatic recurrence if allowed to develop. These extensions will be in the glands of the axilla and neck and remote parts; in the thorax; in the abdomen; in the brain; in the spine; in the bones. Every such lump" should be examined at once, and if there is the least possible doubt, it should be removed and a careful microscopical examination made. If this specimen is not not unquestionably benign, the breast and axillary and clavicular glands with their contiguous fascia and muscle, should be removed thoroughly and completely. In advising such a patient we must

in mind the terminal stages of these cases and often present them plainly and fully to the patient and family. No operation with any amount of loss of function of the arm or side can compare for a moment with the terrible ordeal through which many of these victims pass. of these victims pass. An early, radical operation, as now performed, will lessen enormously the number of these cases, and will completely cure a much larger proportion than is usually supposed. C. E. B.

BLISTERING FROM TINCTURE OF IODINE.— Claret (Journal de Medecine Interne; Revue Medico-Pharmaceutique) states that the application of starch, or even ordinary flour, with enough water to make a paste, will, when applied to the injured surface, form starch iodide, which is harmless to the skin.-N.Y. Med. Jour.

DR. J. D. MORGAN calls attention to the necessity for greater care in the examination of

Clinical Aspects of Rheumatic Endocarditis.

patients having acute articular rheumatism in order to detect immediate or remote endocardial disease at an early date (Med. Record, Jan. 13). Both patient and physician he says, often remain long unaware of any cardiac lesion. An investigation of the records of several hospitals and dispensaries showed that about 51 per cent of cases suffering from rheumatism were systematically examined. The proportion of heart lesions following rheumatic attacks is about 50 per cent. Another feature of interest shown was the greater preponderance of rheumatic patients in dispensary rather than in hospital work owing to tendency of rheumatics to keep up and about as long as While there were three times as possible. many women with rheumatism in the hospital wards as in dispensaries, there were double the number of men seeking dispensary treatment for the same disease as there were in the institutions.

PHENACETIN is said to be of value in the treatment of pertussis.

HYDROTHERAPY IN EPILEPSY.-Guy Hinsdale, Hot Springs, Va. (Jour. A. M. A., Jan. 20), reviews the literature regarding bydrotherapy in the treatment of epilepsy. In this country attention was first called to its value in this disease by Dr. Simon Baruch and the late Dr. G. W. Foster of the Government Asylum for the Insane. Systematic treatment by this method is being instituted in the New York State Asylum for Epileptics at Sonyea and the results are looked for with interest. Hinsdale believes that, as warm baths aid in the therapeutic administration of the iodides, they will also aid in the administration of the bromids. To some extent the treatment must of course be individ. ual, and more benefit might be expected in cases of so-called idiopathic epilepsy, alcoholic epilepsy and in cases arising from intestinal intoxication than in focal or traumatic epilepsy. The difficulties in private practice also would be greater than in institutions, as long-continued, systematic treatment and unbounded patience will be required. Its value will be as an auxiliary method, modifying the dosage and aiding the action of the bromids. It will also be an excellent hygienic measure, favoring the action of the skin and improving the general tone of the system.

CLINICAL TREATISES ON THE PATHOLOGY AND THERAPY OF DISORDERS OF METABOLISM AND NUTRITION. By Prof. Dr. von Noorden, Physician in Chief to the City Hospital, Frankfort, A. M. Authorized American edition, translated under the direction of Boardman Reed, M.D., Part IV. The Acid Intoxications. New York: E. B. Treat & Co., 1905. (Price 50 cents.)

The author's volume on acid intoxications is well in keeping with the preceding three monographs on disorders of metabolism and nutrition. This part represents an excellent and timely study on autointoxication with acid products of metabolism, the sources and formation of acetone bodies, pathologic nondiabetic acetonurias, diabetic acidosis, and a chapter on therapeutic considerations.

O.E.L.

LECTURES ON AUTOINTOXICATION IN DISEASE. OR SELF-POISONING OF THE INDIVIDUAL. By Ch. Bouchard, Professor of Pathology and Therapeutics; Member of the Academy of Medicine and Physician to the Hospitals, Paris. Translated with a Preface and new Chapters added by Thomas Oliver, A M., M.D., F.R.C P., Professor of Physiology, University of Durham, etc. Second Revised Edition. Crown Octavo, 342 pages. Philadelphia: F. A. Davis Co., 1906, (Extra Cloth, price, $:.00, net.)

This compact and up-to-date volume, so excellently written, deals with the subject of autointoxication in thirty-two lectures with an appendix of two chapters by the translator, embracing a comprehensive consideration of the natural defenses of the organism against disease and autointoxication of intestinal origin. Dr. Bouchard gives at length the views of other authors, but forcibly states his own convictions. The book, although dealing with a subject still somewhat in obscurity, contains much information of every day interest to the general practitioner. perusal of its contents will intimately acquaint the readers with an intelligent understanding of the process of metabolism and elimination, a subject of the utmost importance nowadays for the successful management of many diseases. This edition should increase the popularity its predecessor has enjoyed. O.E.L.

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PHYSICAL DIAGNOSIS, INCLUDING DISEASES OF THE THORACIC AND ABDOMINAL ORGANS. A Manual for Students and Physicians. By Egbert LeFevre, M.D., Professor of Clinical Medicine and Associate Professor of Therapeutics in the University and Bellevue Hospital Medical College, etc. Second Enlarged and Revised Edition. Illustrated with 101 Engravings and 16 Plates. Philadelphia and New York: Lea Brothers & Co., 1905. (Cloth, $2.25, net.)

Dr. LeFevre's splendid work is a representation of years of clinical experience and teaching. The second edition is constructed on the same plan as its predecessor. The five parts of its contents are as follows: Part I gives an accurate and concise description of the topographical and relational anatomy of the thoracic and abdominal viscera. Parts II, III and IV respectively take up inspection, palpation, percussion and auscultation.