processes in the lower extremities, or ruptured empyema due to thinness, so that, as Tuffier has remarked, the pleura touches the fatty capsule, allowing thus the thinness of paper between the two cavities. In this group of causes, burrowing of pus is the chief if not the only means by which the pus reaches and attacks the fatty capsule; and in an abscess of this type, certainly involving the fat around the kidney, it always behooves the surgeon to locate, if possible, the primary lesion, if there be one. Otherwise operative procedure may become not only unavailing but embarrassing.

Acute infectious diseases and localized lesions infested with pyogenic germs, in which in the first instance the bacteria are habitually present in the blood, or in the second are capable of invading the body as a whole through the blood or lymphatic circulation, produce this abscess. It is a well-established fact that the urine of a scarlet fever patient may carry the contagion. The same holds true of recurrent or relapsing fever, typhoid, and malaria. Within four hours after experimental injections containing bacteria, these organisms may be found in the urinary tract. Many varieties of germs have been thus experimented with, among which are coli communis, staphylococcus pyogenes, streptococcus, bacillus pyocyaneus, proteus, gonococcus, bacillus typhosus, bacillus tetrogenus, and the diplococcus of Friedlander.

It may thus be safely conceded that any germ capable of producing inflammation or pus, when once it has entered the blood, may be eliminated by the kidney. It is likewise a demonstrated fact that organisms eliminated by the kidney may or may not produce lesions either of the kidney substance or of the mucous lining of the pelvis, ureters, and bladder. Hence we cannot avoid admission that pathogenic organisms admitted to the general circulation are brought in greater or smaller numbers. into dangerous proximity to the perinephritic fat, into a region, in fact, directly connected by lymphatics, as I have shown above. with this fat. So also must we admit that these organisms, if they pass these lymph channels, may do so without involving the kidney structure, leaving behind no evidence of the route they

came.

As a matter of record, perinephritic abscess has been found after the following disorders: Smallpox, typhoid fever, scarlet fever, puerperal fever, diphtheria, actinomycosis probably metastatic infected wounds, and abscesses in various parts of the body. An illustration of the latter will be given at the end of this paper, in a case of perinephritic abscesses, synchronously bilateral, a condition that one can scarcely imagine an explanation for on other grounds, particularly in an individual in whom the most faithful search showed no history absolutely except several abscesses on a remote surface of his body.

Heavy strains, exposure to cold, traumatisms in the region of the kidneys, are also mentioned as factors in the etiology of these abscesses.

Perinephritic abscess is at liberty to spread rather widely over the dorsal wall of the abdomen, reaching often far below the crest of the ilium. Unless operated upon, these cases die either from septicemia, pyemia, or rupture. When rupture is the termination, it happens in many directions. Out of thirtyfour cases recorded by Kuster, eighteen were into the pleura and bronchi, eleven into the colon, two into the peritoneum, and three into the bladder or bladder and vagina. Morris says: "Compared with the frequency with which perinephritic abscesses perforate the colon, the pleura, or the lung, the other forms of spontaneous opening are rare. Probably it is not an exaggeration to say that of every twelve cases which pursue their own course. four or five open into the pleural cavity or the lung. Rarely do we find external rupture through the loin. Now and then, in a great while, these abscesses perforate the renal pelvis or the duodenum."

Symptoms of perinephritic abscess are those of sepsis primarily, and vary with the type of the infection. Usually a history can be elicited that some lesion capable of producing the abscess has been present. The patient complains of pain in the region of the kidney, and tenderness will be found there if searched for. This pain is dull, at times throbbing, agonizing, and paroxysmal. It is increased by motion. The pain may be referred to the knee. as is seen in hip disease and the observer is likely to be thrown off

by this symptom. As in cases elsewhere in which pus lies deep under the tissues, a certain boggy feel and the presence of edema over the surface covering the abscess, one of the surest signs of deep pus, is found where it is so deep that discoloration does not occur. The thigh is flexed to relax the psoas muscle; it is also rotated outward. To demonstrate that the psoas is suffering from inflammation, it is only necessary to attempt extension of the hip and inversion of the toes. Often there is difficult deflection, and general debility together with dyspnea. A mass may be found in the lumbar region not affected by respiration. Vomiting occurs as a frequent symptom. The urine is unchanged unless there is additional pathology of the kidney substance.

The symptoms of this condition are sometimes so insidious as to lead astray the most acute observers, and there is a chronic plastic form of fibroid paranephritis which has no distinctive symptoms. It occurs more frequently in males, and now and then fluctuation may be elicited, but the diagnosis should be made without waiting late enough for this sign.

Differential diagnosis of this as well as other abdominal conditions is often made exceedingly difficult. From nephritic abscess, urine examination is probably sufficient to make the differentiation. In perinephritic abscess the urine may be normal. It may contain pus, but contains no blood, no casts, while pyelonephritis gives both pus and blood. Hydronephrosis can be distinguished by the fact that septic symptoms are wanting and a different history is given. In hydronephrosis the tumor is more definite in shape and more easily outlined. If other signs are unavailing, the aspirating needle will settle the question. Appendicitis will very rarely be confused with this disease, and when it is, we must depend on the classical symptoms of the former and the history of the case. Even then obscure cases will arise.

Gibney has pointed out that perinephritic abscess may be mistaken for hip disease. Careful physical examination will reveal site of the inflammation, although this offers a wonderfully fine place for a guess to result disastrously to the patient.

The prognosis here is but a special application of the old

surgical maxim; viz., wherever pus is found in the body, it must be liberated. The treatment consists simply in opening, cleaning out, and draining the abscess cavity.

A. E. F., locomotive fireman, age 28, had no evidence of disease since childhood. In August, 1904, he got a superficial burn on his left olecranon, which became infected but healed kindly. After a few days an abscess developed near the burn. This was opened and healed. A few weeks later three or four other abscesses forming around the site of the original abscess, were opened or ruptured, and healed. In October he began having pains in his lumbar region, on the right side more especially, and awhile afterward gave up his work and took his bed. Pain in his right side described as a catch, and in his back a constant aching. He became distinctly septic. Liver dulness elevated one inch in the right nipple line. Right side one and one half inches larger than the left. Enlargement of the right loin very perceptible, and fluctuation present, pus on aspiration, urine normal.

Dec 15, 1904, I operated at St. Thomas Hospital, clearing out twenty-four ounces of pus. He became better, but had pain again from the beginning after this operation in his left side. It was aspirated, pus was found, and two weeks from the first operation a second was performed, removing eight ounces of pus from the left side, after which he made an uninterrupted recovery and has since gained forty pounds. The pus gave a pure culture of staphylococcus aureus.

tion between the two abscesses.

There was no connec

I learned from the patient at the second operation that Dr. Campbell, of Gordonville, had aspirated both sides, and found pus before I saw the patient.

SCIATICA. R. Cocain hydrochlorate, gr. j; morphin hydrochlorate, gr. 1-8; sodium chloride, gr. j; carbolic acid, mj; water, q. s. ad 3j.

M. Sig. Inject ten or fifteen drops deeply into tissue along course of nerve.- Medical Recorder.

FOOD ADULTERATION IN TENNESSEE. *

BY LUCIUS BROWN, A. B., A. M., CHEMIST, NASHVILLE.

Mr. President, and Gentlemen of the Tennessee Medical Society: The subject of adulteration in food materials is attracting such wide-spread attention, not only in technical journals, but in the daily press, and the practice itself is of such well-nigh universal distribution, that it may justly be called one of the most important matters now before the American public. Especially is this the case since the failure to pass the United States Senate of the so-called Hepburn and McComber bills regulating interstate traffic in food-stuffs. Such regulation is one of the duties imposed by modern conditions of life. In an earlier day, before concentration of population in cities and manufacturing towns, food-stuffs were largely grown by their consumers. The dietary was simple, and only the time-honored methods of preservation, such as salting, drying, and pickling, were used. At present it is manifestly impossible for more than a minority of the population of a civilized country to be producers of aliments; modern scientific discoveries of the preservative virtues of sterilization, canning, and refrigeration, together with the facilities afforded by modern methods of communication, have enabled the average man to live better than his forefathers, and have called into being needs and wants unknown to the latter. But with this increase in comforts has also come the disposition to abuse opportunities, the temptation to make chemicals take the place of recognized means of preservation, or to substitute inferior or harmful articles for those of known value. Public morality is outraged and public health seriously assailed by such fraudulent practices. The great importance of this matter is attested by the prevalent public concern, and a discussion of it is pre-eminently the province of such a gathering as this.

Adulterations of foods must, of course, have prevailed from the times when man replaced the chase by barter as a means of livelihood.

*Read at 72nd Annual Meeting of the Tennessee State Medical Association.