will probably be investigating the urine after it has dropped to the bottom and come back a considerable distance, but there is no evidence to show that there is at this time any important permanent damage to the kidney. That is the important fact for us to remember.

The natural history of these cases is sometimes very short and sometimes, we all know, very long. It has seemed to us that if our patient is bound to have a colon bacillus infection of the kidney, we should invite him to have a bad one, because then he will recover, whereas the cases that come on with few symptoms and are discovered only from few symptoms are the most unmanageable. I am inclined to think that the more severe the onset, the more likely it is to go on to complete recovery, probably because of the more satisfactory production of antibodies.

You all know the history of an acute attack quieting down to the stage of producing no symptoms and then continuing almost endlessly with a little trace of pus and albumin, coming and going, and with unnumerable colon bacilli in the urine which seem to persist as long as the patient persists.

The pathological condition at this stage is one of an infiltration of the renal pelvis with organisms living in the deeper layer and also, of course, close to the surface, but reproducing themselves at a tremendous rate and tending to produce a stiff condition of the renal pelvis. There is the beginning of the vicious circle which in time will destroy the kidneys. We have seen them at various stages from fifteen to fifty years after their onset, and they will slowly present the picture of an obstructed kidney which is obstructed by the loss of elasticity of the renal pelvis and of the upper portions of the urine and becomes a rigid sac which does not satisfactorily empty its con

tents.

The only true ascending infection which is concerned in this is the ascension of the infection between the pyramids. It has come down originally through the kidney to the pelvis; it now turns around and ascends through the kidney and destroys a portion of the kidney by choking scar tissue, a slow process which at the end of thirty or forty years may have decreased the kidney substance by perhaps one-half. Occasionally it goes on more rapidly, but as a rule it is a long slow process. The disease itself is a long, slow process which has not been reached adequately by therapeutics.

There are various interesting questions which come up in that connection. We know that the so-called pyogenes of little girls is an exceedingly

common disease. We know that the boys of the same age almost never have the disease and that infections of the kidney in little boys are quite as common with other organisms as with the colon bacillus. We know that these cases are often quite insidious in their onset and are discovered quite accidentally. It is proper for us to believe that a large number of them are never discovered at all, that children of inobservant parents may have pyogenes which is never discovered. We further know that pyogenes occurring in first pregnancy is unfortunately common, and I should be indeed glad if anybody could tell me whether or not these are cases of womb diseases or exacerbation of a long existing diabetes which has simply been flared into activity by the dilatation of the pelvis, of the kidney, which habitually occurs in pregnancy, having relation of course, more to the right kidney than to the left, but some degree of dilatation is practically habitually present during pregnancy.

Add to that the fact that the renal function during pregnancy is reduced one-half in practically all women and in a very large number more than one-half. These kidneys are working under a handicap, and the extraordinary thing is not, as I see it, that some of them are infected, but that a very much large number are not infected. They are overworked and they are handicapped as to their outlet.

There is another group of kidney infections which is much less known but which I think ought to be included here for the sake of completeness. I think it is commonly believed I was about to say that it is generally believed, which is perhaps not true-that the conditions which we call nephritis, whether acute or chronic, are either due to an infection of the glomerule or to changes of the blood, otherwise that they are primarily infectious or vascular. I think it is further generally believed that these infections are produced by a streptococcus and not by the streptococcus pygenos which I have already grouped together with the other pus producers. It is pretty clear that the streptococcus hits chiefly the glomerulus, and as you will know there are certain conditions in which you may predict that there will be found at autopsy acute glomerulonephritis, disregarding that the urine has remained absolutely normal throughout; commonly there is no change in the urine at any stage, and the diagnosis can be made only because you know it will be found by the pathologist and not by any sign given during life.

That constitutes the third group.. Whether or not there is any other organism than the streptococcus capable of attacking the glomerulus, I do

not know, but the association of acute glomerulonephritis involving the heart ought to be regarded as a separate classification, a separate group of kidney infection. Thus you have three groups of kidney infection, that which involves primarily the glomeronephritis streptococcus infection of the kidney, that which produces suppuration in the kidney produced by organisms which produce suppuration elsewhere, chiefly the pus producing cocci, with a few bacilli, and finally the group which produced no suppuration in the kidney itself, but passes lightly over the kidney substance, practically without damage, and comes to rest in the tissues of the renal pelvis. These, at the time of their acute infectiousness show somewhat different pictures. There is, so far as I know, no way of discovering the presence of acute glomerulonephritis. Some of them may show evidence of kidney lesion, but most of them do not.

The streptococci may be found in the urine during the height of disease, and in that way the presumption is rendered more certain, but the urine, in most of those cases, is substantially normal.

The pus producers in the kidney again produce a lesion of the kidney which produces symptoms, but no signs in the urine except in the rare case of an abscess situated close to the renal pelvis and rupturing into it. I have seen those cases. Finally, there is the group which produced comparatively slight symptoms in the kidney but overwhelming evidence in the urine. It shows at once in quantities of urine very large quantities of pus, it being the only one of the groups which does this.

From the point of view of treatment, a comprehension of these three groups is really important because in one group, if there is any treatment which should be applied at all, it is pure unmitigated surgery. In the other group, that is the rarest thing in the world, in fact, I believe surgery is never indicated in the early stages. It may be indicated a generation later.

The occus type of kidney must be treated as any other abscess. If an abscess has formed, whether it be in the kidney or in the subdiaphragmatic space, if it is to be treated at all, if we are to do anything but fast and pray for the patient, we must treat that surgically.

Undoubtedly, there are considerable groups of these cases which run their course undiscovered and uninterfered with by the surgeon and which go on to complete recovery.

In the last five years, we have been very much interested in a group of cases with cocci in the

urine, with limitation of the diaphragm on one side, with leukocytosis and with fever.

We have believed that there could be cases of peri-nephritis and probably very small perinephritic abscesses. We have refrained from operating because we believed it to be unnecessary, and they have gone on to complete recovery. Of course, in the majority of these cases there is a much larger abscess formation, and the limitation of the diaphragm becomes much more obvious.

In those cases in which the force of the infection is expended upon the kidney chiefly, you get the enlarged, tender kidney with considerable fever, with considerable constitutional symptoms and obviously some remedy is required. That remedy is surgery and nothing else. There is nothing in the power of medicine which will touch these cases in any way, shape or manner. The question in surgery is whether to do a nephrectomy or a nephrotomy, or the occasional partial nephrectomy. This can only be decided after the kidney has been or when the kidney is delivered. 1 defy anybody to come to a conclusion beforehand, except in the clearly acute cases in which the kidney must have been rapidly destroyed and in which removal of that toxic mass is indicated, but in the other cases one can only use one's judgment. It is my own experience that I have more commonly erred on the side of leaving these kidreys in, only to have to take them out with greater difficulty a week or two later, than to have removed kidneys which upon careful investigation I believe should have been allowed to remain.

There was, perhaps a tendency in the earlier years, when this disease was beginning to be recognized, to advise nephrectomy in all cases. The best advice I can give is when in doubt in regard to the indications for nephrectomy, do it. That is in contradistinction to the very sound general proposition: When you do not know what to do, don't do it.

The bacillus group of cases, as 1 nave already pointed out, is never in its early stages in the realm of surgery. It is within the realms of medicine. It is undoubtedly true that the group of bugs which split up in the urine with the release of formaldehyd has the power to make the colon bacillus somewhat dyspeptic. I think nobody believes that it really injures his feelings seriously, but after all, he is a stranger in a foreign land who has settled down at what appears to him to be a good locality. If you raise his taxes, he will get out. You don't have to kill him.

It is extraordinary that in this day and age there is altogether too little recognition of the

method by which these formaldehyd. solutions must be given. For instance it is not a month since I was asked to see a case in consultation by an internist of national reputation, and deserving of that reputation. He asked me to see a lady with acute pyelitis with a temperature of 104.5, and he was beginning to get worried, which meant that he was beginning to get bored because it might interfere with his going out of town over Sunday which would be a dreadful calamity. I asked him what he was doing, he said, "Oh, all the regular things; ten grains of hexamine every four hours and ten grains of citrate of potash at the same time." There was a poor woman paying for this expensive drug. We all know that from the decomposition formaldehyd can take place only in a strongly acid medium; it will not even take place in the normally acid urine. It known that the urine must be more than normally acid. Fortunately, the colon bacillus will attend to this himself if you will only leave him alone. He likes an acid urine, and that is why he doesn't like formaldehyd. The giving of hexamine is a dreadful waste, but it is shockingly common. In health the normal individual will behave very differently toward these formaldehyd containing drugs in sickness.

I remember when we first began to study the question of the excretion of formaldehyd, we took all the people working in the laboratory and we started them on ten grains every four hours and we pushed it until they began to have bladder irritation. Some of them had it at thirty grains and some of them did not have it at one hundred. Then it occurred to us that we might investigate the matter. We found that the people who didn't have it at a hundred were not putting it out. The urine was not acid; the drug was not decomposed. We were injecting hexamine and they were excreting hexametodid with no damage to themselves at all. If we had made those urines acid, (and two drugs would have done it most efficiently and most respectably-. boric acid and benzoate of soda) immediately those boys who were taking one hundred grains would have come around and asked us to stop. It has been satisfactorily shown that all that was necessary was to be sure that the urine was thoroughly acid, and by thoroughly acid I mean good, strong acid to litmus paper. Of course, that is an utterly inaccurate test to the chemist who wants to talk about all kinds of interesting questions of acidity, but in practice we worked it out by investigation, and if you get a strong test on litmus paper, you will break up these formaldehyd containing drugs except those carefully combined by

the manufacturing chemist with an alkali. There are a lot of those on the market and they are utterly worthless except to sell.

Again one finds the extraordinary contingency of very wise and competent internists giving this drug three times a day. Everybody knows the drug is excreted in five hours by the normal kidney. At the end of twenty-four hours there is no formaldehyd in the urine; the bug thinks you have quit and begins to grow. He will increase enormously in a period of rest of that kind. You can see the pus increase and diminish in the urine, and it is utterly worthless, assuming that you mean business, to give formaldehyd containing drugs less often than once in four hours.

With lots of patients it does not make much difference what you give them except that you get them well. The formaldehyd containing drug is not given often enough in most cases.

On the other hand, there is a clear group of these cases which are apparently unaffected by the drug and which will go on for several days. with a pretty high temperature and without change, and for them I know of no valuable remedy.

During pregnancy, I suspect that we shall be justified in dealing with the kidney through the medium of the catheter and pelvic divide, but that is a ground which is still new and ought not to be roughly trod upon. It has been my experience that within a few days all these people will come around. On the whole, those with the most severe symptoms will, in the long run, do the best. The crux of the matter comes in the attempt to abolish the organism which will persist in the urine, in the vast majority of cases. In that attempt, of course, vaccines have played a large part. The autogenous vaccine should here work well, but the fact of the matter is that it does not.

Several years ago, we followed fifty cases with autogenous vaccine for a year and then checked them up one year later, and the fact of the matter was that no single patient, having colon bacilli at the start, had failed to show colon bacilli at the finish. Fifty per cent of them were alleged to have been benefitted as to their symptoms.

I believe that, unless some new method of preparing vaccine is brought forward, it is, at the present time, safe to say that the autogenous vaccine is without benefit upon the colon bacillus infections of the kidney.

More recently, within the last three years, I think, or within a comparatively recent time, it has been shown that even in the comparatively early stages in these cases there is a moderate grade of renal retention, that emptying of the

renal pelvis and washing of the renal pelvis shows evidence of having an important effect upon the organisms.

I am not at all prepared to go further, because it seems to me perfectly clear that here is a procedure which may well become meddlesome. It is undoubtedly possible by instrumentation of any organ to do harm. Clearly, here is a condition. which only indirectly menaces life. We shall certainly not be justified in taking radical measures or in taking important chances of doing these patients harm. On the other hand, a very considerable number of them go on to ultimate destruction of the kidney, and where the disease is not rare, they may ultimately die of renal insufficiency. We are, therefore, undoubtedly entitled to carry out, with tentative observations on these cases, extreme caution: particularly is that true of pyelitis in pregnancy which commonly occurs about the sixth month and is at its worst during the sixth and seventh months. If, by local treatment of the pelvis and that kidney, we can tide them over that interval, we shall save ourselves, on the whole, a very great number of cases in which pregnancy has to be interfered with or interrupted in the interests of the mother. Every year, I see transferred to my service from the lying-in hospital a group of women who have had fever and pain in the kidneys for periods varying from two or three to five or six weeks. I find them emaciated, in bad general condition, with pulses running above 100, up to 110 and sometimes 120, and many of them have had to have pregnancy interrupted in order to save their lives. Recovery of the patient and important recovery of the kidney occurs in the great majority of cases, but the destruction of the fetus in those cases always seems a shocking admission of our inability to deal with the kidney in this condition over a comparatively short period of time.

If we can snuff out the infection and assist in the return of the tone of the renal pelvis, if we can really affect the organisms living in the region of the renal pelvis by chemical agents, surely we have made a great gain.

The important picture which I want to leave in

your minds is that this business of kidney infection is not a complicated business, that it is really simple, that it really forms into groups and that its apparent complications are generally due to lack of care in ascertaining precisely what organism you are dealing with. If you all ascertain from careful investigation early in the disease what the infection organism in that kidney is, you can predict with certainty what the condition in the kidney is and what course it will run.

One word more: a considerable group of cases with the spmptoms of so-called pyelitis are not pyelitis at all. I have recently been concerned with all the cases admitted to the Massachusetts General Hospital with a diagnosis of pyelitis. That was correct in exactly one case of four, so the diagnosis is commonly wrong.

Here is a theory which you will run into: if you deal with the catheter specimen containing pus, you will find it sterile. That is due to one of two conditions, either stone or tuberculosis. You can at once exclude the conditions of infection of which I have been talking, and you must then either demonstrate the tubercle bacillus in that urine or a stone in some portion of the upper urinary tract. You will see the late cases with a history going on for years of renal suppuration in which you will not be able to predict with great accuracy the condition of the kidney, but that is due to the lapse of time and to the fact that various factors have been here introduced, but it is, on the whole, very surprising how frequently, in the vast majority of cases, if you deal with the infecting organism as obtained directly from the bladder, you will be able to make a diagnosis of the conditions and a prognosis of that kidney.

If that is more widely done, there will not be the confused view of kidney infection because of which I see every week patients with renal tuberculosis getting hexametodids, persons with staphylococcus infections of the kidney being treated expectantly with colon bacillus and losing their kidneys.

RELATIONSHIP OF THE EYE TO FOCAL INFECTION*

SYDNER D. MAIDEN, M.D., Council Bluffs

During the past ten years there has been an abundance of literature on the subject of focal infections and their relationship to eye affections. realize the rapid strides that have been made in One has only to review a few of these articles to

this field and how it has broadened our knowl

edge and enables us to diagnose and treat a large group of pathological conditions of the eye with much more intelligence and with results more satisfactory to both the patients and ourselves.

If we stop to consider the anatomical structures of the eye, the relation between the orbit with its contents to the surrounding structures and their vascular supplies, we will better understand why

*Presented at the Sixty-Ninth Annual Session, Iowa State Medi cal Society, Section Ophthalmology, Otology and RhinoLaryngology, Des Moines, May 12, 13, 14, 1920.

The eye ball consists of three consecutive coats or tunics. The external is composed of condensed fibrous connective tissue which by its resistance to internal pressure gives shape to the eye. The posterior five-sixth is white and opaque and is known as the sclera. The anterior onesixth is clear and transparent and is called the

cornea.

The middle coat is essentially vascular and serves as a nutritive organ for the other coats as well as performing certain functions in vision. It is this middle coat that is of most interest to us on account of its histological structure. It is a soft, easily torn, extremely vascular meshwork containing pigment cells, nerve fibres, and muscular tissues. Its function is necessarily of a nutritive character lying between the other two coats, it serves to nourish both. Its vessel walls are very thin and allow nourishment to pass through as well as fluids which serves to keep up the intra-ocular tension thus forming a secretive organ of the very simplest form. Embryonically it is developed from the mesoderm and the ectoderm and therefore liable to participation in all of the systemic maladies which affect these tissues elsewhere in the organism. It receives its blood supply from the posterior and anterior ciliary arteries which arise from the ophthalmic. The inner coat is essentially nervous. The spaces within the globe are occupied by fluid or semi-fluid contents and are known as the chambers of the eye.

Considering the orbital boundaries in a general way, the outer wall of the ethmoidal labyrinth forms the inner wall of the orbit. The infraorbital surface of the superior maxilla forms the floor and the horizontal portion of the frontal bone forms its roof. Each of these bones forming the major portion of the bony wall of the orbit contain sinuses accessory to the nasal cavity which vary in sizes in individuals. Where they are markedly over developed the ethmoidal sinuses may extend horizontally over the roof of the orbit to a variable distance and even to the zygoma. Likewise the frontal sinuses may extend horizontally backward over the orbital roof, in such cases forming the supra-orbital ethmoidal or supra-orbital frontal sinuses as the case may be.

Thus it is possible to have the orbit surrounded above, below, and on the inner side by sinuses which harbor infection. The sphenoidal sinus. The sphenoidal sinus posteriorly is in close proximity with the nerves passing from the base of the brain to the orbit.

bone affords bony sockets for the upper teeth. These bones are all contiguous, their periosteum being connected and with their osseous canaliculi, afford direct communication between the teeth, sinuses, and the orbit.

The blood supply to these structures anastamose freely with one another thus playing an important role in considering the influence of focal infections. The ophthalmic artery arises from the internal carotid, passes into the orbit through the optic foramen where it supplies most of the orbital structures, giving off the following branches-lachrymal, muscular branches, posterior ciliary, anterior ciliary, central artery to the retina, supra orbital, posterior ethmoidal, anterior ethmoidal, frontal, and the dorsal artery to the nose.

The infra orbital artery, a branch of the internal maxillary, passes beneath and on the floor of the orbit supplying some of the structures in the orbit, and through the infra orbital canal and foramen. It gives off the anterior superior dental arteries which pass in the wall of the maxillary sinus supplying the upper canine and incisor teeth, as well as the walls of the maxillary sinus and other structures of the face in this area. Its end arteries anastamose freely with those of the ophthalmic. Other branches of the internal maxillary as the inferior dental, anterior tympanic, descending palatine, posterior superior dental, the ascending pharyngeal and palatine of the external carotid, all anastamose with each other in turn with the infra orbital and ophthalmic arteries.

The veins and lymphatics follow very closely the course of the arteries and form an extensive plexus in the pterygoid fossa surrounding the internal maxillary artery. So far as is known there are no lymphatics within the eye other than the fluids in the aqueous and vitreous chambers and the perichoroidal space which serve this function. This is of vital interest for here we have these chambers serving as large reservoirs for the lymph that drains from these various surrounding structures, which harbor infection in a large percentage of cases.

The fifth cranial nerve has a large distribution in this region and together with the intricate relationship of the ciliary nervous system also affords communication between these several structures.

Thus we have four routes that are possible for infections to pass to the eye by continuity, by way of blood vessels, by way of lymphatics, by way of the lymph sheaths of the nerves.

This