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increases in amount until the middle of the afternoon, when it begins to decline, that passed about bed-time being free or showing but a trace. There is passed not only serum albumin, but also alkali albumin.

Various theories have been advanced to explain the conaition. The congestive theory is that some influence, as a cold bath, by driving the blood from the surface, causes a hyperemia of the renal circulation which permits the leakage of albumin. The degenerative theory is that the epithelium of an occasional glomerulus or convoluted tubule has undergone degeneration, thus permitting a slight leakage with the minimum of provocation. Its adherents deny the possibility of albuminuria without structural changes. The hematogenous theory rests upon the hypothesis of a deficient amount of oxygen in the blood, this anoxemia releasing the albumin and permitting it to pass through normal epithelium. The dietetic theory asserts faulty metabolism of proteids, due to some obscure hepatic disorder. Some also advance the idea of a condition analogous to dietetic glycosuria. The neurotic theory is that there is lessened vaso-motor control of the renal circulation, and its advocates point to the fact that a large percentage of subjects are of an age when the nervous organization is unstable, and to the further fact that heredity appears to have some influence. The irritative theory is that by reason of mal-assimilation certain irritants are excreted by the kidneys, the albumin passing through by reason of their excretion. The advocates of this theory point to the frequency of calcium oxalate crystals and to the gouty family history. The postural theory is that the essential factor is the upright position. It is pointed out that so long as the subject is recumbent, no albumin can be found. He may have a hearty meal, he may swing about his arms and legs, he may be massaged, he may study intently, he may even have a cold bath, but so long as he remains recumbent no albumin appears, though within a comparatively short time after he assumes the upright position albumin is found. That the absence of albumin is not due to the warmth of the bed is shown by the fact that the subject may lie uncovered in a cold room and the urine remain free. Most of the cases of albuminuria in the apparently healthy belong to this class. There are, however, some cases in which the albuminuria is intermittent, but not cyclic, the apparent causes being cold bathing, eating of a heavy meal, violent exercise, severe mental effort or emotional disturbance. But for the most part the upright posture appears to be the essential factor. How this brings about the condition is purely conjectural. The sudden filling of the renal capillaries from lowered vaso-motor control is the most plausible explanation.

The diagnosis of the condition is important. Its very rarity increases the liability that it be overlooked. In order to reach a diagnosis the following things are necessary:

Ist. The demonstration of a persistent intermittent albuminuria unaccompanied by casts or other evidence of renal disease.

2nd. The elimination of diseases of other organs, especially of a left ventricular hypertrophy.

In order to reach this diagnosis the separate urine of each micturition for the entire twenty-four hours must be examined, and this examination must be repeated several times. Extreme care must also be taken, by means of centrifugation, to prevent overlooking casts, and there must be the most painstaking, systematic examination of the heart and other organs. If the urine is never entirely free from albumin there is structural disease.

The condition is probably harmless, though some assert that it always means ultimate organic change.

No medicines have any effect on the condition. In a few cases the limiting of proteids causes the temporary disappearance of albumin, but it reappears when the proteids are resumed. The condition may be present for years and disappear without obvious cause.

A well regulated life, free from all excesses, is the best treatment. The patient should be advised of the exact condition and of its harmless character in order that he may not be disturbed by its accidental discovery.

Diagnosis of Arthropathies with the X-Rays. - E. Broussilovsky and L. Buchstab (quoted in Medicine) have found that in gouty rheumatism a large clear space is noted between the extremities of the bones which is limited by the epiphyses forming the articulation. In chronic rheumatism this space is much darker and is sometimes completely absent; the epiphyses are much darker than normal, and their outlines are less distinct. In arthritis deformans the interarticular space is always dark, and phalangeal deformities are always present.



By WM. DOW, M.D.,

La Junta, Colorado.

In presenting this paper to the society, I will limit my remarks to the consideration of the following anæsthetics, viz.: Ethyl bromide, nitrous oxide, ether, chloroform and the subarachnoidean injection of fifteen minims of a 2 per cent. solution of cocain, the latter for operations below the diaphragm.

Before administering any anæsthetic in renal disease, in all cases except emergency ones, examination of the urine should be made beforehand for albumin, casts, urea and sugar, and not only the usual precautionary measures taken in the administration of an anæsthetic, but a preliminary preparatory treatment of the kidneys of an eliminative nature should be instituted. When albumin and casts are present, as in cases of Bright's disease and diminished excretion of urea, diurectics, moderate catharsis and daily warm baths should be given for a few days beforehand, in order that as little urea and other toxins irritant to the kidneys may be retained in the system as possible, and I use the infusion of digitalis with acetate or citrate of potassium as the diuretic because of the tonic effect of the digitalis on the heart, which is so often diseased and weakened in renal affections. This preliminary preparatory treatment of the patient I deem very important and may do much toward lessening the dangers, both at time of administration and after operation, from any anæsthetic in diseased kidneys.

The mode of administering the drug is also important, and if chloroform is used, from fifteen to twenty minutes of time should be consumed in putting the patient under by the drop method. Ether, when used, should not be crowded at first and some admixture of air allowed. As the evil effect of the anæsthetic upon the kidneys is in proportion to the amount used, it is essential to safety that no more of the anæsthetic be used than is imperatively demanded for the operation, and the method much practiced in England, and now used in the Johns Hopkins University and other hospitals, of giving nitrous oxide gas to rapidly induce unconsciousness and then continuing the anæsthesia with ether or chloroform, whichever may be selected, is, I believe, an excellent practice and minimizes the amount of the more powerful and much more dangerous drug used. The only exceptions to this rule of producing anæsthesia are in cases of diabetes mellitus and marked atheroma of the blood vessels, in which cases nitrous oxide is contraindicated, it having been shown that the gas inhaled sometimes produces a glycosuria, and its very rapid and great dilating effect on the blood vessels raises arterial tension to a point of danger from apoplexy when the coats of the vessels are markedly degenerated; in this latter condition of arteriosclerosis the same objection to the action of ether holds good, though to a much lesser degree. Nitrous oxide, except in the instances just named, has been shown to be almost innocuous. A Bennett inhaler is used for its administration at the Johns Hopkins, followed by ether. Of 12,941 anæsthesias by this method in St. Bartholomew's hospital in London, only one death occurred. By this method of producing unconsciousness and administering the ether or chloroform for more prolonged anästhesia, the amount needed of the more powerful drug is lessened. Ethyl bromide should be substituted for the nitrous oxide in diabetic patients.

* Read before the Colorado State Medical Society, Denver, Colo., June, 1901.

In considering the selection of the two most commonly used anæsthetics, viz., ether and chloroform, in advanced diseases of the kidneys, the consensus of medical authority is in favor of chloroform being the safer of the two, but only on account, as stated by Prof. Hare, of the lesser quantity required, its irritant properties, quantity for quantity, being at least equal if not greater than that of ether. If we only had to decide on the drug to use in renal disease per se we could much more easily cietermine upon which one to select, than what we find to be a clinical fact met with in practice, that in most cases of renal affections we have complicating heart lesions, weakened and degenerated cardiac muscle and secondary atheroma of the arteries. Ether is much safer than chloroform in weak hearts, but more likely to be followed by retention of urine and inflammation of the kidneys, and also more dangerous in atheroma of vessels because of rapid raising of arterial tension, rendering the risk of apoplexy greater. Bronchial irritation and oedema of the lungs are also more likely to follow its administration. So we find that in making selection of a drug for anæsthesia in renal disease, we have not only to consider the kidneys, but to take into consideration also the heart complications, which exist in a large percentage of cases, as well as atheroma of vessels, the secondary conditions sometime claiming more attention than the renal disease itself. Prof. H. C. Wood believes that in atheroma, with weak heart, ether is to be preferred; in atheroma, with diseased kidneys and a normal heart, chloroform is to be preferred.

The finest of judgment will often be required in making selection, and the fact that chloroform causes death in more than four times greater percentage of all cases than ether, should, I believe, place the balance in favor of the latter where the complications make it a matter of fine judgment, or what is preferred by some (among them H. C. Wood) in cases of weak heart with moderately hardened blood vessels, complicating diseased kidneys making doubtful cases, ether anæsthesia used at first until its stimulant effect on the heart is obtained and then continue the anæsthesia with chloroform; in this way the least possible strain is put on the heart and kidneys. This separate use of the two drugs in a single case I believe is to be preferred to the A. C. E. mixture of the English, in which the difference in volatility of the drugs makes it too uncertain the amount of each that is being taken up by the circulation.

Subarachnoidean injection of fifteen cain in a per cent. solution, into the lower

the lower part of the lumbar region of the spinal cord, as practiced lately, is still in the experimental stages. Professor Tuffier, who has operated many times with anæsthesia produced by this method, has included in those operations cases of nephropexy and nephrectomy without apparent evil after effects. Petesti, who operated one hundred and twenty-five times, cautions against its use in renal diseases, believing it unsafe in those cases, while Dr. John S. Miller states that the renal organs, with the heart and respiration, are not so seriously disturbed as by the inhalation method. Its comparative safety in renal diseases with that of drug anæsthesia by inhalation cannot at the present time be estimated.


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