The Medical Fortnightly

History. Patient, woman of 34 years; enjoyed good health up to present trouble. In summer of 1903 cough began, followed by dyspnea and expectoration. Sputum examination showed staphylococci, diplococci, streptococci, epithelium, etc. No tubercle bacilli, pneumococci or yellow elastic tissue. No fever present. Symptoms increased until November, when general examination was made. Dyspnea extreme and of inspiratory type. Pulse and respiration about normal. Coughing and dyspnea caused sleeplessness and exhaustion. Few rales heard over both lungs. Urine negative. Laryngoscopic examination showed paralysis of right cord, swelling of lower portion of trachea. Fluoroscopic and skiagraphic examinations gave negative results. Probable diagnosis was made of tumor, possibly aneurismal, pressing on trachea in region of innominate artery. Prognosis unfavorable. Patient died of suffocation and exhaustion after an attack of broncho-pneumonia. Autopsy showed no aneurism present. At about the lower third of the anterior wall of the trachea was a papillomatous tumor, which extends almost to the bifurcation of trachea, measuring 5 x 3

cm.

A few enlarged glands lay beneath this growth. Pathologic examination showed no ulceration. The tumor extended into the substance of the trachea and was accompanied by loss of tissue. The rings had disappeared and the tracheal wall reduced to a layer of connective tissue.

The situation of tumor, peculiarity of cells of which it was composed, the partial cornification of cells, suggest that the tumor had developed from an inclusion of esophageal epithelium in the wall of the trachea during embryonal life, and the author is lead to believe that this is the explanation of the origin of growth.

GENITO-URINARY.

T. A. HOPKINS, M. D.

Intravesical Separation of Urine for Diagnostic Purposes.-The subjects of urinary segregation and ureteral catheterization have been given a great deal of attention of late, and justly so. What has been accomplished makes possible a degree of accuracy in kidney work which is satisfying in the extreme. Moynahan (British Med. Jour., July 2, 1904) considers the procedures, going especially into the detail of segregation. He describes the instrument of Luys, of Paris, which he considers the first perfectly efficient instrument devised. This device is serviceable only in the normal bladder, it furnishes an artificial septum of the thinnest of India rubber, on either side is attached a catheter per

forated with several eyes, each catheter to drain its own side of the bladder after the septum has been created. He also describes the instrument devised by Cathelin, of Paris, which he considers good, but which appears somewhat less accurate, requiring as it does great care in placing to avoid twisting and a consquent mixed urine.

Moynahan's conclusions are that catheterization is probably the better method to employ with male patients and the Luy instrument with women. The American reader who is familiar with the employment of cateterization, and who appreciates its accuracy and ease of performance finds it difficult to believe that there is any class of patients in which segregation can be definitely declared its superior, though there may be and doubtless are many individual cases where inability to catheterize will necessitate the employment of segregation.

Two Cases of Chronic Nephritis Treated Surgically.-J. A. Nydegger (Med. Record, Nov. 4, 1904) gives the histories of two nephritics treated by having one kidney decapsulated. The first patient did well for about three weeks after the operation, and then gradually became worse and died three weeks later. The albumin did not diminish after the operation. The second patient was relieved of severe headaches, and the amount of albumin was decreased by the operation, so that he was discharged much improved. The author believes that two classes of patients must be recognized; one, those that are benefited, and finally cured by decapsulation; two, those that are not benefied. His two patients represent the two classes. With regard to the way in which decapsulation benefits, he says that the autopsy in Case I showed the kidney operated on to be covered with a rather dense smooth white scar tissue which seemed to offer a poor means of transmitting an increased blood supply to the cortical sub. stance. Perhaps we should look more to the theory that the decapsulation relieves internal cellular pressure and thereby allows the compressed cells to return to their normal relations and functions.

and only slightly painful, and which shall not confine the patient to his bed. For this he employs transposition of the testicle (Longuet) combined with eversion of the tunica vaginalis. The scrotum is held firmly by the assistant, who pushes the testicle upward 5 to 8 cm. according to the laxity of the scrotum, and the level of the other testicle. Under local, or exceptionally spinal or general anesthesia, a 4 to 5 cm. incision is made over the upper pole of the elevated testicle. A similar incision is made through the tunic, care being taken to carry it sufficiently high to avoid all folds or culs de sac. By means of pressure from behind, the assistant now luxates the testis from its serous sac, and then lifts it gently upward between two fingers, strictly avoiding traction upon the cord which will invariably cause pain and nausea. The different scrotal layers retract in the direction of the cord, the posterior surface of which comes directly into view. Laterally are the edges of the retracted tunica which are sutured around the cord, including the subjacent cellular tissue and approximating the edges of the serosa in such a manner as to make a snugly fitting, natural elastic bandage, as high as possible, around the cord. A continuous or interrupted catgut suture may be used. All folds in the tunica should be avoided. Both index fingers are now inserted into the loose connective tissue adjoining the raphe about 6 to 8 cm. higher than the original position of the testicle, and then rapidly separated a distance of 5 to 6 cm. This step is both painless and bloodless. The testicle is then carefully dropped into the resulting cavity.

The elevated position of the testicle can be made more secure by using the ends of the highest suture of the serosa in closing the upper part of the scrotal incision.

In its new position the testicle is slightly twisted on its axis, being in retro-lateral version instead of in normal anteversion. A similar twist occurs in the cord, and serves to augment the pressure upon its blood vessels. The scrotal wound is closed either in the tranvserse or vertical plane by means of Michel's staples, which contsitute an ideal suture for wounds of this region. A small gauze pad and a suspensory complete the dressing. It is unnecessary to keep the patient in bed after the first day. The staples are removed and the dressing changed on the fifth day. Both dressing and supsensory may be dispensed with after the first week.

Albumin and Casts in the Urine of Nephritics. Esbner (Medicine, December, 1904) considering the symptomatology and diagnosis of nephritis reaffirms that the most distinctive feature of any of the three forms,

the acute parenchymatous, chronic parenchymatous, and chronic interstitial nephritis, is the presence of albumin and tube casts in the urine. The amount of the one and the number of the other vary considerably in the different forms and in the same form in individual cases, and even in the same case at different times. In general the amount of albumin is large in cases of parenchymatous nephritis and small in cases of interstitial nephritis. In the latter it may even be

absent at times. It is more marked as a rule when the disease is acute or during eaxcerbations of the chronic form, and under such circumstances it may be associated with the presence of blood in the urine. The number of tube-casts also is susceptible of considerable variation, and it may be reduced to the vanishing point. Casts containing epithelial cells and blood-corpucsles usually attend acute nephritis or exacerbations of chronic nephritis, while hyaline and granular casts rather more commonly distinguish the chronic varieties of the disease. In addition to casts the urine may contain epithelial cells from the uriniferous tubules, red and colorless blood-corpuscles, and crystals of uric acid and calcium oxalate.

The albumin consists principally of serumalbumin and serum-globulin, although nucleo-albumin, albumose, and peptone are also present at times. The first two are normal constituents of the blood, from which they are permitted to escape by reason of the impaired functional acitvity of the diseased renal epithelium. The others are not normal constituents of the blood, the nucleo-albumin being supposed to be derived from disintegration of epithelial cells in the urinary tract, albumose occurring especially in connection with disease of the bones, and peptone resulting from destruction of leucocytes and other cells in connection with infectious processes in some part of the body or other, or by absorption from the digestive tract in the presence of disease of the intestine or the liver.

Tube-casts are believed to result from coagulation of the products of disintegration of the epithelial cells of the uriniferous tubules.

Albumin is present in infinitesimal amount. in normal urine, but its presence in larger amount, especially if repeated or continued, must be considered abnormal. Tube-casts, on the other hand, are probably never present in the urine under wholly normal conditions. Their character depends upon and will vary with the particular morbid process going on in the kidneys. The mere discovery of albumin and tube-casts in the urine does not necessarily establish the diagnosis of nephritis, although their continued presence must be so construed.

is said that the liver contains more iron dur

THE MEDICAL FORTNIGHTLY ing a fasting period than when the body is

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CLINICAL THERAPEUTICS

A forum of original experience, to which scientific contributions are invited. Responsibility for views promulgated limited to author.

SOME IRON THERAPY*

S. C. HAYS, M. D.

LOUISVILLE, KY.

Late Instructor of Pharmacology and Therapeutics in the Kentucky Senool of Medicine: Instructor in Bacteriology and Hygiene in the Kentucky School of Medicine.

THE Oxygenation of the human economy, as every one knows, is accomplished by the erythrocyte, which depends upon the hemoglobin for its oxygen carrying power. The higher the percentage of this hemoglobin, the greater the capacity for carrying oxygen to, and the greater the liberation of ozone into, the tissues and there increasing oxidation. Also, the greater the percentage of hemoglobin, the greater the amount of iron (organic) there is within the red blood corpuscle. There are several organs, such as the liver and spleen, as also the bone marrow, which are the storehouses for iron in the body. In these the liver leads It also, in fetal life, is the producer of the red cells. There is a limited portion of the small intestine only in which iron is absorbed. Since the body cannot utilize in its hemoglobin more than a certain amount of iron and greater amounts are absorbed, there must be and is stored up the excess for future use. It

*Read before the Butler County (Ky.) Medical Society, November 17, 1904.

Exhaustive texts have been writ

ten on the form of iron most easily absorbed, and its manner of absorption, and theory after theory has been advanced and about as often refuted (one even by its own author). Many interesting experiments have been conducted and may have shown, as might be said almost conclusively, that one form or another had the advantage, but it is generally believed now that the organic, or that take into the body in the food and called food iron, is the most easily absorbed.

The above, it is believed, is the general idea extant among the general practitioners. Many a successful prescriber of iron has so reasoned as to its disposal after ingestion. It was decided to investigate some cases at the Louisville City Hospital in order to note the character of results from the different salts of ferrum The ordinary drug-store wares had not proved of much value and as, at that time, we had a supply of pepto-mangan (Gude) we decided to administer the same to the cases that showed an impoverished blood state. The resident pathologist kindly assented when asked to make the blood counts and hemoglobin estimations, and to this end he employed the von Fleischl's hemoglobinometer and the Thoma-Zeiss hemocytometer. No hurry was exacted in the selection of the cases, but when admitted patients who were found to be anemic either primarily or secondary to some existing condition, were examined and placed on the pepto-mangan, and such synergists as would aid in the attainment of a better blood state, and also to correct the existing abnormal condition. the conclusion of our investigation, we had treated and examined nine cases of especial interest, the report of which can be seen here appended. In the iron administration alone, we would not have expected such results. For instance, in chronic rheumatism, the salicylates gave no relief by themselves, nor did the iron improve the anemia much, but with both agents administered at the same time the patient improved very satisfactorily from his anemic state and attained relief from the rheumatism.

The following is a report of the blood examinations of nine cases treated at the Louisville City Hospital:

Case I.-Aged 16; clerk. Chlorosis. Scanty and painful menstruation of greenish color. Anemic; put in bed, and fresh air and exercise when able. Red cells 3,600,000 per cmm. Hemoglobin 60 per cent. Under treatment of pepto-mangan, oz. ss, t.i.d., with rest and diet. Red cells increased to 4,300,000 per cmm. Hemoglobin 80 per cent.

Case II.-Amelia J.; age 19; seamstress; chlorosis. Had been taking tr. ferri chlor., but not much improvement. Red cells less than 3,000,000 per cmm. Hemoglobin 50 per cent. Treatment, rest, Fowler's sol. and pepto-mangan. When left, red cells increased to 3,500,000 per cmm. Hemoglobin 75 per

cent.

Case III.-Annie B.; age 47; housekeeper; chlorosis. Rheumatism for years. No results with salicylates. Anemia and heart murmur present. Blood examination: red cells 2,500,000 per cmm. Hemoglobin 50 per cent. Under combined treatment of pepto-mangan and salicylates, marked improvement noted. Anemia considerably lessened, as also pains at end of six weeks. Red cells 3,200,000 per cmm., and hemoglobin 65 per cent.

Case IV.-Pearl B; age 21; single; pregnant; delivered of healthy child, followed by post-partum hemorrhage. Patient was exsanguinated. Thirty-six hours after delivery administered pepto-mangan oz. ss every four hours (saline intravenous infusions immediately after hemorhrage). No blood examination, but in ten days' time the patient was able to sit up and in two weeks was out of bed. No results noted from size of dose.

Case IV.-Annie D.; age 30; married; housekeeper: lives in malarial district and shows malarial cachexia. Chills for several hours after admission. Blood examination: Plasmodium found. Red cells 3,750,000 per cmm. Hemoglobin 40 per cent. Quinine alone had no apparent effect, but with arsenic and pepto-mangan a marked improvement followed. At the end of two months hemoglobin had increased to 80 per cent, and the red cells to 4,250,000 per cmm. parently well.

Patient ap

Case VI.-Sarah B.; age 27; married; mother of three children. Skin and lips pale. Markedly anemic. Operated on; curetted: shock extreme. Blood thin and watery. Blood count: red cells 2,500,000 per cmm.; hemoglobin 35 per cent. Treatment: Pepto-mangan oz. ss t.i.d for two months. Patient felt better and was better. Menstruation restored. Blood count: 3,100,000 per cmm; henioglobin 73 per cent.

Case VII John S.; age 40; driver; hemorrhoids (bleeding). Suffers very verely. Considerable hemorrhage at each stool. Cold clammy skin and very pale. Refused operation. Bowels regulated. Peptomangan given and at end of two months showed considerable improvement. Hemorrhage still at times, but not in such quantity. Refused to be "punctured" for blood examination.

Case VIII.-Will K.; age 39; blacksmith; robust looking, but has chill every third day.

Blood at time of chill shows plasmodium. Red cells 3,900,000 per cmm.; hemoglobin 8 per cent. Treatment, pepto-mangan oz. ss t.i.d. and quinine. Complete recovery with hemoglobin 85 per cent, red cells 5,000,000 per cmm.

Case IX.-Ed. B.; age 29; rheumatism; anemic. Treatment, salicylates and peptomangan with rest and diet. No blood examination. After six weeks, during which time the iron preparation was given continously, patient left. No rheumatic pains. Good color, marked improvement, etc.

cysto

scopic and ureteral work that the possibilities of this field is as yet only partially appreciated by the profession. In spite of numerous demonstrations and authentic reports the journals of today abound in articles in which writers of wide experience and high repute express themselves as finding ureteral catheterization so frequently an impossibility that they are still using it in the exceptional cases and employing the cruder and less accurate method of segregation "until something better shall be devised." It would appear that a majority of workers need experience to give them skill or else that they are working with the wrong instrument. It should be a matter of considerable satisfaction to the St. Louis profession that one of our number has devised a ureter-cystoscope which is easy of successful manipulation, which makes possible the most thorough of bladder examination and direct treatment, and also double ureteral catheterization, making an absolute certainty of the

source of urine secured, and allowing for irrigation of the pelves. To our mind the chiefest virtue of the Lewis ureter-cystoscope, the instrument of which we speak, is the ease with which it can be manipulated, but it boasts several advantages over other makes: (1) it enables the operator to catheterize both ureters without withdrawing the cystosope, in which matter it is a pioneer and a success beyond all others; (2) it allows the operator to apply treatment direct to any portion of the bladder wall through the cystoscope; (3) the lamps are cold, absolutely eliminating the possibility of burning the bladder wall; (4) though primarily intended for air dilation accessories may be secured which will allow the use of water where that agent is preferred, though it is a fact that those who allow themselves to become familiar with the use of sterilized air could hardly be convinced that water could ever be as serviceable: (5) the instrument is readily sterilized and may be subjected to water, steam or hot air; (6) it is of smaller caliber than any other male cystoscope carrying two catheters These points make it plainly evident why the Jury of Awards at the St. Louis Exposition saw fit to award the prize to the manufacturers of this instrument and a personal Gold Medal to Dr. Lewis who devised it. The profession anticipated the action of the jury, they having voted it their approval some two years before the Fair opened.