ing of the second day, dropping to normal on the fourth day. Urine continued bloody for seven days, but at no time were clots of any size passed; nor was there ever any vesical tenesmus. The first dressing was changed on the morning of the second day, and it was found to be well saturated with blood. The drain in the wound of entrance was removed at this time, as there was very little seepage from it. The packing in the wound in the back was removed by degrees, the last being taken out at the end of the fourth day. No suppuration took place at the wound of entrance, but there was some little discharge of pus from the lumbar wound. On the tenth day it was discovered that urine was escaping through the wound in the back. This continued for three weeks. The patient remained in the hospital for five weeks, when he was discharged, with a slight granulating wound in the back, which healed a few days later.

Gun-shot wounds of the kidney may be simple or complicated, that is, the kidney alone may be involved, or the kidney wound may be associated with laceration of the large vessels, ureter, or some of the other abdominal viscera on the right side, with a wound of the liver, or ascending colon; and on the left side, with that of the spleen or descending colon. The complicated variety is by far the more frequent, and necessarily much more serious. Edler, as quoted by Greig Smith, says that of uncomplicated cases 85 %, and of complicated cases 16 %, and of all cases 56 % get well.”

According to this table, gun-shot wounds of kidney are not so dangerous as has been generally believed. The immediate causes of death are hemorrhage and shock, and the later peritonitis, diffused suppuration in the loin, with septicemia and pyemia. "The diagnosis of gun-shot wounds of the kidney is based on the location of the wound, hemorrhage into the bladder, escape of urine from the wound, if there be one in the lumbar region,

when there is no wound in the lumbar region, fluctuated swellings, composed either of blood, or blood and urine, will make their appearance in this locality." According to Belfield, cases have been reported where ecchymosis extended even to the scrotum. In addition to these symptoms, there will be marked pain in the lumbar region, and evidence of shock; the latter depending upon the amount of blood lost, and the complications with injury of other organs. Blood clots may plug the ureter, giving rise to all the symptoms of renal colic, and there may be violent vesical tenesmus, and pain from the distention of the bladder, itself, with clots. The only two symptoms, according to Bruce Clark, by which a positive diagnosis of wound of the kidney can be made are, blood in the urine, and the escape of urine from the lumbar wound.

Dennis and others claim that the absence of urine in the lumbar wound does not necessarily mean that the kidney has not been wounded; that urine will only make its appearance there when the wound penetrates the pelvis of the kidney or one of the calices; and then again, when the ureter alone is ruptured, urine will make its way into the lumbar wound, and if it is only partially torn across, considerable quantity of blood may make its way into the bladder. Sometimes particles of clothing are carried in by the bullet. Hennen reports the case of an officer, who, after being shot, had great pain in the back, and passed bloody urine. The ball was extracted from the back near the twelfth dorsal vertebra. Seven weeks afterwards an abscess formed in the lumbar region, which, on being opened, discharged a quantity of pus, with a strong urinous odor. A second abscess formed lower down, from which a similar discharge took place. He suffered later on from renal colic. Months afterwards the discharge of urine became more difficult, and finally could only be passed in drops. While making an agonizing effort to empty

the bladder, a burst of urine, accompanied with the discharge of a piece of cloth, covered with black grit, took place per urethram; after which the patient made a rapid recovery." Demme reports a similar case.

As to treatment, nephrectomy is indicated when the large vessels have been lacerated, the kidney badly mutilated, or the ureter cut through. Greig Smith says, "if only 15 % of cases of uncomplicated shot wounds of the kidney die, it is doubtful whether operation is ever indicated in this class, except on undoubted signs of hemorrhage, or perinephritic or peritoneal suppuration." It strikes me that it is best, in all cases, to provide immediately for drainage by a lumbar incision.

In cases of vesical tenesmus from a distension of the bladder with blood, an attempt should be made to cleanse this viscus by irrigation, through a very large catheter. Failing in this, a perineal or suprapubic cystotomy should be made, and the bladder cleansed and drained.

I did a suprapubic operation in a case of laceration of the kidney, resulting from a fall. The bladder was distended with such large clots that it was found impossible to empty it with the catheter. The patient made an uneventful recovery.

INTESTINAL AUTO-INTOXICA

TION.

BY F. C. SIMPSON, M.D.,

LOUISVILLE, KY.

In bringing before the Society tonight a subject that is very little known. and less written about, I recognize a very difficult undertaking.

The subject is one that I come in contact with so frequently, and one in which I get so little results, that I thought I would like to know the experiences of members of the Society. The point I wish to bring out is the condition of intoxication which results

*Read before the Louisville Medico-Chirurgical Society, Oct. 31, 1902. For discussion see page 259.

from decomposed food in a state of putrefaction; this forms poisons that are delivered through the intestinal epithelium to the blood.

Intestinal intoxication is frequently met with under what is considered very mysterious conditions. It usually begins with a gastric fullness, diminution of saliva, clammy state of the mouth, loss of the appetite-and this is very advantageous, as the stomach would be a fermentative vat if we continued adding food. It is certain the subjective symptoms felt by the patients cannot be accounted for by such a short period of let up in their feeding.

The putrid fermentations are explained by the bitterness in the mouth, headache, lassitude, followed by a great deal of depression. If you have no information as to the primary cause of such symptoms, you certainly have reasons for supposing that there is intestinal intoxication. There are circumstances in which we might suppose that stagnation of intestinal material causes fever. The surgeon frequently sees fever after a laparotomy which he cannot explain. He does not believe it is due to sepsis. What does he do? Cleans out the bowel, sees the fever disappear, and he knows that the trouble came from intestinal intoxication.

of auto

This explains an old surgical practice that they use to purge for three days before an operation and always with beneficial effect. Does the nervous system play a primary role in causation? We cannot give an absolute answer to this question. At times we can unquestionably trace the cause to the nervous system. The usual view intoxication is that the toxins are developed in the economy and are taken up by the cells and epithelium into the blood, and then follows the poison. You find that the chemist says there is too much indican in the urine, showing faulty proteid assimilation, yet its precise poisonous qualities are not known. A lowered tone of the nervous system renders the economy an easier prey to microbic infection, which, if the body

was in a state of health, would not take hold produceing diseases of different varieties. A circle is now formed, and on the one hand we have the gastrointestinal tract as a cause of intoxication of the nervous system, and on the other hand we find a depressed state of the nerves, which also tends to produce auto-intoxication especially as it frequently does if localized in the intestines. This condition makes the economy more receptive to morbid effects of microbic infection. What these products are precisely it is most difficult to state positively. We have too many instances of sudden and fatal poisonings at church festivals and wedding feasts which prove this (but we cannot say which are the real poisonous products); where no pathological lesions of definite value could be found, and where unknown "ptomaines" were the sole explanation afforded by the most careful inquiry and research on the part of our best skilled observers. The general nervous system must be toned up with iron, strychnine and arsenic. The treatment of this character of disease is by prophylaxis, dietetic, hydriatic and medicinal. Prophylaxis includes the avoidance of all foods capable of fermentation and putrefaction; especially foods already or partially in a putrefactive stage. Many vegetables produce auto-intoxication when not perfectly sound, such as cabbage, sauer kraut, cauliflower and others; certain kinds of cheese produce the same condition; eggs may give rise to the liberation of choline from lecithin. Many times we cannot say on physiological or pathological reasons why a food disagrees and produces auto-intoxication. We know it from experience.

Individual idiosyncrasies often make food sources of danger; some cannot digest strawberries; others can't digest crabs, lobsters and other shell fish. It is almost impossible chemically to disinfect the intestinal canal. One of the best disinfectants, and one that has given me the greatest satisfaction, is small doses of creosote,

next to creosote is salicylate of bismuth. Of course, the best disinfectant for the alimentary canal is normal peristalsis, and we restore that by purgation or lavage. Fortunately for our efforts at therapeutics, the greater part of the putrefaction takes place in the colon, and as we can wash it out thoroughly, lavage offers us one of the best treatments for intestinal intoxication. You get the fermentative changes in the small bowel and the putrefactive in the larger. The fermentative The fermentative stage is never as grave as the putrefactive. The poisons that gain access to the blood make their exit through the urine or the perspiration, therefore it is logical to stimulate both the skin and kidneys. Hemmeter has gotten good results from subcutaneous injections of normal salt solution with one gram of pure carbolic acid where the blood was over charged with the poisons. The same author reports three extreme cases of typhoid fever where he used the same injection and was gratified to find the temperature fall from 10 to 23.

In the light forms of intestinal intoxication, such as run their course in a few hours, diet does a great deal, followed by a blue mass pill purge and abundant drinking of pure warm water and exercise in the fresh air.

Most of the chemical intestinal antiseptics have a very limited range of usefulness. There is no doubt that a great many of the so-called intestinal antiseptics, like salol, beta napthol, nosophen, dermatol and other like remedies, accomplish very little in the way of disinfection.

If taken in a way to produce a decided disinfection, they would have to be taken in such quantities that the patient would become poisoned by the drug.

To sum up the matter, be careful in diet, give cresote or salicylate of bismuth, and last, but not least, use lavage, and keep on washing the colon until you change the tendency to these putrefaction conditions that cause so many vague and uncertain symptoms.

entirely healed, but on raising the arm (which you can now do to about a right angle to body) a small area, or rather line, of unhealed surface still remains. This tract is healing from the edges, and on account of the depth of original ulcer gives the "tucked in" appearance to the now almost healed surface. This brings the skin surfaces in contact and seems to make the healing process somewhat slow, although some rapid advance has been made in the last six weeks. You will note that the indurated mass above the scar on breast has great ly diminished since patient was last shown. There are a few small areas located in skin about half the size of a dime which are suspicious. One of these in axilla has recently broken down and is healing satisfactorily. After what has taken place in this woman's case, makes it fair to assume that these few remains of the original trouble will disappear.

ate.

this trouble she had ulceration of the same character involving upper lip, nose, and extending through hard palThe photographs taken in April will probably call to your mind her condition then. The trouble had lasted over a period of seven years, the patient having been treated in the clinics of various medical colleges. Through the courtesy of Drs. Evans and Koehler she came under the writer's care. She has been treated more or less steadily since April, the treatment being carried to the point of active dermatitis on several occasions. The lesion on face and nose is healed; the small tubercles on face and about nose have about disappeared; the ulceration in nose extending through hard palate is much improved; the septum, which at one time looked as though it would be destroyed, is now much improved. The patient has at no time had any internal treatment, and only a simple ointment, lanolin and zinc, locally when needed to relieve discomfort of dermatitis.

CASE II. Before treatment.

CASE II. This girl, age 16, was shown to this Society by Dr. Evans in April last in connection with his paper on Lupus of the Larynx. In addition to

The only doubt which can arise in this case is one of diagnosis; but her trouble has been diagnosed, as stated, by men of unquestioned ability. So far as I know, no microscopical examination has been made. The patient was sent to Dr. Evans' office for examination this morning, and he makes the following report: