under the microscope, before the necrosed stage, there are certain evidences discoverable, such as localized, rough bronchial respiration and slight rise in temperature, accentuated after awhile, as the doctor has said, and other things that seem to centre around the local lesion and not distinguishable by the microscope that put us upon our guard, and after awhile, when we treat that case as a tubercular case, we find that it has been one all along. If we do not find the bacilli we do not wait for it, and we have anticipated what would have been a serious proposition. Therefore, I would urge the additional necessity of more care on those who are teachers in impressing upon students the great responsibility of exceeding care in the early stages of tuberculosis. It seems to me we have a great point there, so important that it becomes one of the fundamental things to impress upon all.

DR. GEORGE P. SPRAGUE, Lexington, Ky.: The question of careful diagnosis might be emphasized still more than has been done by the last speaker. I saw not long ago an advanced case. I had him stripped, as I always do, and he told me that I was the tenth or eleventh man who had examined him, but I was the first one who had stripped him. We all know that is very common. That is not an extraordinary case, and we also know that we cannot make a diagnosis of early tuberculosis unless we do strip the patients, and if it is a woman, or a young woman, and if we suspect or are concerned for tuberculosis and are too modest to strip them, we had better give up the case and send them to some one else.

We

DR. W. C. ABBOTT, Chicago, Ill. On the question of drug medication, as presented by the essayist, I agree. As to that being the basis on which all types of drug medication can be considered, and from which they should be wiped from the face of the earth, I cannot agree. give medicines, or are assumed to do so, for certain definite purposes-to do something. Now, unfortunately, much of the medication hitherto termed orthodox and put on trial for tuberculosis, as for many other kindred wasting conditions, has been given for its presumed dynamic action; and not knowing exactly what we give the medicine for, consequently are not able to look for definite results; and not getting definite results, we become nihilistic as to the action of medicines. Now, if I may be permitted to refer to the position taken by Dr. Porter, you will recollect that Dr. Porter said tuberculosis is an expression of degeneration in a person already, in common parlance, run down. I think you will agree with me on that hypothesis. Now, that patient that is run down has run down from a cause. That cause is usually malnutrition. Very many contributing causes may result in this malnutrition-overwork, excessive child bearing, lack of optimism or the presence of pessimism. And chief among these, or growing out of these, is an organic condition, an organo symptomatic condition of intoxication of the patient by himself through absorption from the alimentary canal and kidneys, and so on, whereby the patient is put in jeopardy, and put in a state of lowered vitality by this very action, all ready to receive the infection from the outside; for I do not take any stock at all in genealogical tuberculosis, excepting, if you please, predisposition. Then the

patient has tuberculosis. Now, we have started to do something. God bless you for fresh air! God bless you for better feeding! God bless you for everything done to uplift! But don't forget that a whole lot can be done by wise medication. In two or three minutes I want to ask these questions: Absolutely what occurs? What do you give medicines for? Who are the laborers of the body? What nourishes the body? What builds it up; tears it down? What carries out the débris but the circulatory system? Now, if you can nourish that by more and better food, give more and better food. Then, by what is it officered? The nervous system, of course. And through it you govern the blood supply. You carry more blood to a part or less to a part, just as you want to, and through your control of it you can accomplish something by means of the vaso-motors. That, gentlemen, is something worthy of your steel. There is something worthy of your best thought. I do not know, brethren, and I don't suppose you do, either, whether creosote ever helped a case of tuberculosis or not. Some get better. We don't know why it was used, excepting that we have noticed that some of it is exhaled from the breath, which led us to assume it was eliminated that way and produced disinfection. But no medicine known to man is known to act dynamically upon the physical system strong enough to modify the action of tuberculosis, without it is strenuous enough to do more harm than good. But we do accomplish something by controlling the circulatory and nervous systems through vaso-motor control, and with that thought properly applied we can do a great deal.

DR. EPLER: I felt a personal interest in this question, because in years gone by I fled from the northern climate on account of tubercular trouble and went to New Mexico, and went through the experience there which I detailed in part in the paper. In closing the discussion I will speak of the tendency of many physicians to send patients to higher altitudes when they are not in condition to go there and harm is done them. I have stood by the hour watching these patients, and have heard the remarks of the boarding house keeper or the livery stable keepers. They would say of a patient, "He will go back in a week," or "He will go back in ten days," or "He will be here for some time." They could figure on it pretty closely. It is a painful thing to say. And I have heard some of these patients tell of their mental anguish and homesickness. Some doctor had made a mistake. Only the earliest cases should go to the western countries, and only those who have the means to provide the comforts of life. It is all right to talk about sleeping on the floor of a ranch-house and get your own meals, as I have done. men there were warm-hearted and generous, but they did not have time to wait on me. And that is what we may come to.

The

As to the medical treatment spoken of by Dr. Abbott, much is to be done, and those medicines turned down from time to time by the profession are still good. I would say that excellent results may be obtained from some of them. Tuberculin we know is used by some few with wonderful advantages. It is discredited by others. But the great specific treatment, as pointed out here, is proper food and care and the hygienic treatment. DR. C. H. HUGHES, St. Louis, Mo.: I should

like to say in regard to patients sent out west, that I have travelled a dozen times to the coast and encountered the tuberculotic patients sent out there. The profession ought to take that subject into consideration. The nights there are so different from the day. They go out there with cotton underwear and the transition is too great, and people go there and cough and cough their lives away, whereas, if they went to a northern climate in the summer nearer home they would do better. I have seen patients there in adjoining rooms and would go and talk to

them and find that some doctor who had never been in that country had sent them to California. Now the sunshine there is illusory and deceptive. They have bright sunshine every day and a condition at night that requires two blankets and a comfort, without proper heating arrangements in the houses. The way I managed to keep warm those cold nights was to go to the bath-room and turn on the hot water. The hotels are a month behind with their heat. People do not know how to live in California, except those who are old settlers and people acclimated.

Definition.-A horse-shoe kidney consists of the fusion, coalescence of: (a) The proximal, or (b) the distal renal poles by means of a segment (of renal parenchyma or connective tissue), which extends across the vertebral column; (c) a third kind is that in which two lateral renal masses are united by a median segmenta crucial or circular form.

A horse-shoe kidney signifies coalescence or fusion of renal parenchyma from opposite sides of the body. Fetal lobulation indicates that the kidney is a composite organ and has coalesced bilaterally separate. The malformation in horseshoe kidney has no constant uniformity of manifestations. The fused renal masses are irregular in contour, form, dimensions, location and visceral relations.

THE FORM OF FUSED (HORSE SHOE)

KIDNEY.

The name horse shoe kidney is a general term for renal masses possessing crescentic, half moon, crucial, half-circular form. The form of fused kidney varies extremely in contour and surface dimensions.

The horse-shoe kidney arises in unnumbered forms, and no one exactly resembles the other. The frequent lobulation presenting in horse-shoe kidney indicates an arrest of development. The form of renal fusion depends on the proximity of the opposite segments of the kidney to each other. The form of the fused or horseshoe kidney is mainly symmetrical; however, non-symmetrical forms frequently exist with a tendency to present larger dimensions on the left side."

Three general forms of fused (horseshoe) kidney exist:

(a) Kidneys fused at the distal pole (Renes arcuati distal). The most frequent form of fused kidney is where the kidneys becomes united or coalesced at their distal poles. In fifty-five illustrations collected from literature, museum specimens and personal autopsies, the distal poles of the kidney were coalesced forty-nine times by a segment extending

FIG. 1.-Fused (horse-shoe) kidney. This illustration is drawn from a specimen which my pupil, Dr. J. B. Benker, presented me. Ventral view. It was secured by him while dissecting. Renal arteries (A. R) multiple, veins (V. R) single. V, vena cava. A, aorta. X, renal isthmus, located ventral to vena cava and aorta. 2, ureteral pelvis. 3, proximal ureteral isthmus.

across the ventral surface of the vertebral column-88 per cent. The concavity of the renal mass was directed proximalward. In kidneys fused at the distal pole the renal isthmus lies ventral to the vena cava and aorta in 90 per cent. and dorsal to the same in 10 per cent.

(b) Kidneys fused at the proximal poles (Renes arcuati proximal). Another renal form is produced by the fusion or coalescence of the proximal renal poles. The renal isthmus or segment which unites the proximal renal poles extends across the

illustrations (and a specimen which I observed) presented the renal mass ventral to the vena cava and aorta-100 per cent. DIMENSION OF FUSED (HORSE-SHOE)

KIDNEY.

The dimensions in fused (horse-shoe) kidney are variable in all diametershorizontal, dorso-ventral, and proximodistal. The dimension may not furnish a clue to its secreting capacity, as the renal parenchyma is interspersed with a varying quantity of connective tissue which is

ventral surface of the vertebral column. Among the fifty-five illustrations the proximal renal poles were united in four subjects-7 per cent. The concavity of the renal mass was directed distalward. In kidneys fused at the proximal end the renal isthmus lies ventral to the aorta and vena cava in 75 per cent. of subjects, and dorsal to the same in 25 per cent.

(c) Central medial renal coalescence (Renes composita central). A third form is coalescence of the bilateral renal parenchyma into a central mass, circular, irregular. (The Germans sometimes call it Klumpen nieren, or Kuchenniere). The medial renal coalescence may be continued or interrupted. Among the fifty-five illustrations, two subjects possessed renal masses of medial coalescence-3 per cent. In the central medial renal fusion the two

lodged in the depressions or grooves located between the renal lobes. The fused kidney of the fifty-five illustrations presented parenchymatous masses less in dimensions than one normal kidney or greater in dimensions than two combined kidneys. As subjects live perfectly healthy with a single normal kidney, these data furnish no clue of physiologic capacity to the clinician. In the fifty-five illustrations the horizontal diameter of the horse-shoe kidney varied the most, with the proximodistal diameter coming next, while the dorso-ventral diameter of the renal parenchyma varied the least.

THE RENAL ISTHMUS (ISTHMUS RENALIS)

IN FUSED KIDNEY.

The uniting tissue band between the renal masses I shall term the renal isthmus.

There are practically three methods of renal union or kinds of renal isthmuses. The nature of the renal isthmus is important in renal surgery from its relation to the calices and vessels. In the fifty-five illustrations three kinds of isthmuses or renal coalescence were evident.

(d) Isthmus of renal parenchyma. The most frequent kind of renal isthmus consists of a bridge composed of renal parenchyma. Perhaps this constitutes 80 per cent. of fused kidney. The dimension of the parenchymatous isthmus varies extensively, as well as its location, which chiefly occupies the distal, proximal or medial portion of the fused masses.

(e) An isthmus of connective tissue. The second most frequent kind of renal isthmus consists of a bridge of fibrous connective tissue. This constitutes the connective tissue renal isthmus, and is frequently the atrophied parenchymal renal isthmus due perhaps to extension, stretching from corporeal development. The connective tissue renal isthmus occupies mainly the region of the distal renal pole. This form of isthmus constitutes perhaps 15 per cent. of fused kidney. The fifty-five illustrations furnished two of a distinct type.

(f) Interlobular isthmus. A third kind of renal isthmus consists of interlobular constrictions, depressions between renal lobes or masses. The irregular renal mass may be divided into irregular lobes by transverse depressions. An indication of the borders of single renal organs does not exist and presents no definite relation to the renal hilus. The fused kidney may present the appearance of a condition of hypertrophy with hypoplasia. This form of renal isthmus constitues perhaps 5 per cent, of fused kidney. Its location is mainly in the central renal mass. The fifty five illustrations presented two of a distinct type.

LOCATION OF RENAL ISTHMUS.

The location of the renal isthmus possesses significant relations to the proximal and distal renal poles, medial renal mass, the blood-vessels (aorta and vena cava), and the vertebral column.

(g) Location of isthmus to distal renal pole. In fifty-five illustrations of fused. kidney the renal isthmus was located at the distal renal pole in 88 per cent.; 10 per cent. of renal isthmuses at the distal

FIG. 3.-Fused (horse shoe) kidney. This rare specimen was presented to me by Dr. White, Prosector in the College of Physicians and Surgeons of Chicago. It arose from the body of an adult negress. Ventral view. A, aorta. V, vena cava. X, isthmus renalis, located ventral to aorta and vena cava. I, ureteral calices. 2, ureteral pelvis. U, ureters, which have penetrated the renal parenchyma for two inches of the distal end. A. R., arteria renalis (single). From the ventral renal surface some renal parenchyma has been dissected in order to expose the vessels, calices (1) and ureteral pelvis (2). In fifty-five illustrations of horse-shoe kidney this was the only specimen in which the ureters penetrated the renal parenchyma.

aorta and vena cava, and 75 per cent. were located ventral to the aorta and vena

cava.

(i) Location of isthmus at the medial renal mass. In fifty-five illustrations of fused kidney the renal isthmus was located at the centre of the renal mass in 3 per cent. In this form of renal isthmus 100