very dangerous, the writer has given up its use, and follows out the procedure instead of injection of old tuberculin, which appears satisfactory and devoid of this danger.

A Critical Resume of the Newer Methods in the Diagnosis of the Functions of the Kidney.

Kingman B. Page (Archives of Diagnosis, Vol. I, No. 3, 1908) considers the various methods by which we try to determine the efficiency and functionating power of the kidneys. He states that while valuable information may be obtained from a chemical analysis of the mixed urine as it passes per urethram, still this kind of an examination must be supplemented by other tests and methods, if one wishes to get an exact idea of the character of the urine as it flows from each kidney. This, of necessity, can only be obtained by intra-vesical instrumentation, either with a segregator or a catheterizing cystoscope.

Nitze was the pathfinder in the cystoscope field, and since his origina! contribution the number of cystoscopes that have been devised is perfectly bewildering to one about to investigate this subject. They are all, however, merely minor variations of the same general principle, modified to suit individual taste. Practically there are but two general forms, that designed on the plans of Nitze (European type) and that of Tilden Brown. (American type). The essential parts of a cystocope consist of a lamp or source of illumination and the telescope or visual apparatus. The Nitze cystoscope consists of a lamp, with a telescope, fitted with various lenses by which one is enabled to look over the bladder field thoroughly. Channels are introduced into the tube, allowing the in-and-out flow of the bladder medium or the passage of small catheters for the catheterization of the ureters, or the passage of cauteries, snares, forceps, etc., for the performance of intra-vesical operations under control of the eye.

With this instrument urine from each kidney may be collected and studied separately. At the same time the condition of the entire interior of the bladder may be ascertained. Moreover, the possibility of supernumerary ureters and anatomical variations of the kidney may be definitely determined.

It would be of prime importance to be able, in given cases, to determine the efficiency of the kidney in relation to catabolism in general. Yet this can not be done. We can not determine the amount of nitrogen taken into the body as a general proposition, save in individual cases, and so the estimation of the amount of urea and other products of catabolism offers no information. Besides, as Heinrich Stern has made out, the constituents of the urine, especially those of nitrogenous character, do not represent the intake of the previous twenty-four hours, but from a much

longer period prior to that time. Nor is the nitrogen eliminated by the urine alone, but also by other excretions of the body.

It would be valuable information to know the functional efficiency of each kidney separately, but we can not determine this. We have ascertained that two kidneys work synchronously, so that the collection of urine from each kidney over, say one hour of time, ought to yield on analysis the same chemical results, but this is only a comparison of the efficiency of the kidneys towards each other, not in relation to the general bodily efficiency.

Again, we would be making a distinct advance in diagnosis were we able to determine the ability of one kidney to compensate for the insufficiency of the other, but this we can not do.

Cryoscopy was thought at first to be the long-looked-for means of determination of the efficiency of the kidneys, but an exhaustive analysis of this new adjunct to diagnosis shows that cryoscopy only affords us an accurate and simple means of determining relative efficiency as a comparative method in the examination of the separated urines.

Electrical conductivity, a method borrowed from the physical laboratory, being the reciprocal of the resistance which a certain quantity of fluid, between two platinum electrodes of given size and given instance apart, offers to the passage of an electric current of known strength, is purely in the experimental stage as a means of determination of the efficiency of kidneys.

The introduction of tests of the elimination or permeability to certain known substances into urological diagnosis has also been barren of definite results. Such substances are methylene blue, introduced by Achard and Castaigne; indigo carmine and salicylic acid. Tests of the chemical activity of the kidneys by introducing substances into the stomach and observation of the presence of new substances from these as they appear in the urine has also been devoid of practical results. Reference is here made to the use of benzoic acid and the observation of its conversion into hippuric acid in the urine; of the use of phloridzin and the presence or absence of glycosuria afterwards, etc.

From all these tests and observations it can be concluded that the various methods for determination of the functional diagnosis of the kidney have failed. They are of limited value, less so to the internist than to the surgeon. To the surgeon, by their use, particularly in the separated urines, information of more value may be gained, but even then the knowledge gained is only comparative, not absolute. They are steps in advance, however, and their judicious employment and continued study in this line of investigation will, no doubt, in time lead to the development of simpler and more accurate methods. The study of meta

bolism and the excretion of its "end products" is as yet in its infancy, and though today we are in the dark, the light may come with the morrow.

Hematuria, with Report of Cases.

Granville MacGowan (The American Journal of Urology, Vol. IV, No. 6, 1908), takes up the question of blood appearing in urine, and showed by the reports of a number of cases just how rules can be formulated fastening the bleeding upon one or another part of the genito-urinary tract, with exceptions which are strikingly significant as demonstrating the impossibility of following our rules on this point. By the agency of urethroscopes and cystoscopes of various patterns, the urethra, bladder, ureters and pelves of kidneys may now be viewed under electric light, and much of the guessing that was formerly in vogue concerning the diagnosis of bleeding points is easily done away with. The old rules concerning the diagnosis of bleeding from the color of the blood, the size and shape of the clot, the chemical analysis of the urine, whether the blood precedes, is mixed with or follows the urinary stream, etc., etc., have been so frequently shown to be false and misleading guides that they are no longer used by good diagnosticians.

When blood appears at the meatus in intervals of urination, the source of the hemorrhage is nearly always in front of the deep transverse perineal muscles, but there are frequent exceptions to this rule.

When the blood suddenly appears at or towards the end of urination. in a previously clear stream, it is reasonable to trace its origin, either in the bladder or close to the outlet, or within the prostatic urethra, or from the prostate. It is often of importance that this should be determined, and it can only be accurately determined by means of an instrument through which we can see; for sometimes, in a typical condition of this sort, the blood comes altogether from points anterior to the membranous urethra.

Often, in moderate hemorrhage from a kidney, at intervals the blood coagulates in the ureter, and lies there long enough to become partially fibrinated before it is dislodged, causing the appearance of long, thin fishworm-like clots in the urine. Yet the writer has seen similar clots occur in slow hemorrhage from a villous growth in the bladder near the ureteral orifices, where the jets of urine projected steadily against the bleeding point caused the clot to wave back and forth in the urine, like kelp in the rise and fall of the tide. He has also seen the same kind of clots produced in this manner: slow hemorrhage from an over-large, congested or ulcerated verumontanum, which blocked up the natural free passage from the prostatic urethra to the bladder, prevented the flow of the effused blood into that viscus, and hindered any forceful outflow of urine at the time of emptying the bladder.

The seat of the hemorrhage in any case may be the anterior urethra; the posterior urethra and prostate, seminal vesicles, bladder, ureters or kidneys. Hemorrhage from the anterior urethra may arise from mechanical injury, gonorrhea, stricture, warty growths, tuberculous ulcers. Hemorrhage from the posterior urethra may arise from enlarged or inflamed verumontanum, posterior urethritis, or inflammation of the prostate or seminal vesicles. The inflammation of the prostate may be gonorrheal, tuberculous, mixed infections or syphilitic (gumma). The seminal vesiculitis may be cancerous, due to mechanical violence or stone. Hemorrhage from the bladder may arise from cystitis, usually trigonal; edema of the bladder neck and interureteral fold, ulceration of projecting adenoma of the prostate; non-malignant, stone, tuberculous ulceration; simple ulcer, patchy gonorrheal cystitis, telangiectasis of the posterior slope between the vesical outlet and the ureteral openings; new growths, simple and malignant; bilharzia; mechanical violence, frequently from sounding.

Hemorrhage from the kidney may be from tuberculosis, essential or without appreciable cause; nephritis, violence, stone; sometimes in the form of uratic or oxalate showers, malignant growths, papilloma, angiomatous degeneration of a papilloma, disease of the adrenal, movable kidney.

Or hemorrhage may arise solely from diet, drugs, hemophilia, or degeneration of the blood due to disease, as in variola, typhoid and malaria. Hemorrhage from the ureters may come from the presence of stone, new growths or tuberculosis.

The writer then illustrated these different locations and causes of hemorrhages by well-selected cases. He is insistent upon the point that the treatment of practically every form of hematuria thus met with is surgical, but rest and the absolute prohibition of alcohol is essential in the treatment. Morphine and ergot, adrenal body extracts, etc., should also be used.

HOUSE FLIES AND TYPHOID FEVER.

Dr. Marshall Philip, says the Ceylon Observer, attributes the high mortality from enteric in Colombo during March to a considerable extent to the bad plague of house flies which existed in February last. "The guilt of the fly in disseminating disease germs is not merely a supposition; it has been proved by actual experiments, and Dr. H. H. Riddle, M. B., (Camb.), is responsible for the statement that a single member of the species can carry enough bacteria to devastate an army. Under the microscope, over 100,000 bacteria have been counted on the legs and mouth of a single fly! The human instinct of self-preservation should therefore lead householders to declare war upon the pest."—Indian Public Health, July, 1908.

EDITORIAL

THE BACTERIOLOGY OF THE PUERPERAL UTERUS.

The germ content of the uterus has been controversial ground for many years. Ever since Doederlein in 1887 made the statement that bacteria are not found in the lochial discharge in normal cases, many investigators have endeavored to show that he was in error, and that pathogenic bacteria are often present in the puerperal uterus without symptoms, and that Doederlein's observations were faulty. They have tried to back up these opposing statements by bacteriological investigations showing that various pathogenic bacteria are found in normal cases, often without producing any untoward symptoms. Doederlein's original conclusions on this point were as follows: (1) In normal cases the uterine lochia is sterile; (2) micro-organisms are almost always found in severe cases of puerperal infection; (3) infection is not always due to lack of care on the part of the physician. Von Ott and Czerniewski, in 1888, one year after Doederlein, arrived at the same conclusion, but the latter held that the streptococcus might be present in the lochia of normal cases in rare instances without symptoms. Since that time the ground has been fought over again and again, with victory now perched on the banners of the followers of the Doederlein theory, now perched upon the standards of the opponents of Doederlein.

But recently a most important contribution has been made upon this debated question. Nicholson and Evans, writing in the August issue of The American Journal of the Medical Sciences, show, through a carefully conducted series of observations upon the bacterial content of the puerperal uterus, what appears to be the exact facts of the case. They demonstrate in first order that many of the observations that have been made on this question have a most serious source of error, i. e., contamination of the cultures as the material is taken from the uterus. In order to obviate this disadvantage, they took their cultures through a specially curved cervical speculum, the distal end of which was fitted with a hinged cap, which could be opened after the instrument was in situ, and closed again after the culture material was taken into the receptacle in the speculum, thus protecting the material from subsequent contamination as it was drawn through the cervix and vagina. In addition to this, danger of outside contamination was done away with by washing off the tube containing the uterine material with a bichloride solution and then breaking the ends, pouring the contents directly into a sterile Petri dish. Cultures were made from this upon agar-agar stroke plates; glycerin agar