CHRONICLE.

Medicine.

QUINCKE (VON H.). On the Pathology of the Urinary Organs. Deutsche Arch. f. klinische Med., 1904.

A GIRL aged 23 periodically passed a small amount of blood in the urine which, on standing, yielded clots of fibrin; the urine was copious, pale and almost always alkaline, and it contained a small amount of albumin. Under the microscope, in addition to red blood corpuscles and epithelium, large coarsely granular round cells were seen which, on the addition of acetic acid, became clear and showed nuclei. As the condition of the patient became worse, the left kidney (which was painful and could be felt to be irregularly enlarged) was extirpated. It consisted of a hydronephrotic cyst; the kidney-substance was only about half an inch in thickness and the pyramids were flattened out. After removal, the urine was completely suppressed and death occurred six and a half days after the operation. On section, the right kidney was found to have degenerated into a series of cysts which were filled with a clear liquid; the pelvis of the kidney and the opening into the urethra were wanting. v. Quincke considers that the large granular cells originated from the epithelium of the straight tubules; he believes that they are only found in hydronephrosis and attributes to them a certain diagnostic importance. The patient suffered from thirst which was occasioned by the polyuria. This is to be explained on the assumption that, under normal conditions, the cortex of the kidney secretes freely a watery liquid, which is diminished by absorption as it passes through the medullary substance; when, therefore, as in the case under discussion, the medullary substance is wanting, the copious excretion of the cortex undergoes no diminution and thus gives rise to polyuria.

It is well known that copious secretion of a clear urine of low specific gravity is a symptom of granular kidney; it is accounted for by the cardiac hypertrophy (occasioned by the changes in the kidney) developing such an excess of blood pressure in the glomeruli as to increase the transudation of water. This polyuria, however, is by no means of constant occurrence in contracting kidney; it may be absent during the whole course of the disease, notwithstanding pronounced hypertrophy of the left ventricle.

Hydronephrosis and cystic kidney are often accompanied by polyuria; especially in the cystic kidney which results from obstruction at the outlet of the bladder, as in prostatic hypertrophy. In pressureatrophy the papillæ are principally affected and, according to Ribbert, changes in the medullary substance are probably the cause of the polyuria.

v. Quincke has observed fibrinuria, similar to that which occurred in the case of hydronephrosis, in granular kidney. In such cases the urine was weakly alkaline and contained only a small amount of albumin. It is only in advanced cases of granular kidney that fibrinuria has been observed and then for not more than a day or two. The presence of fibrin and the alkaline reaction of the urine point to a direct transudation from the blood as the source of the fibrin.

DÉRÉMAUX and MINET.

Albuminuria after the Inhalation of Chloroform. L'Echo Médical, 1904.

THE authors examined the urines from fifty cases, at intervals from twelve hours to the second or third day (sometimes later), after the patients had been placed under the influence of chloroform for surgical. purposes. Previous to the operation the urines of all these patients had been proved to be free from albumin. In 31 out of the 50 an appreciable amount of albumin was found; in 7 only a trace; and in 12 no albumin was found. This represents 76 per cent., which is much higher than has been previously recorded. Most of the cases in which albuminuria occurred were women, and in them the amount of albumin was much greater than in men. The largest amount of albumin in the women reached 3 and even 4 grammes [per litre ?]; whilst in the case of the men it never exceeded half a gramme, and was usually much less. The occurrence of albumin in the urine and the amounts in which it occurs are largely determined by the quantity of chloroform that is absorbed and by the duration of the narcosis: the greater the absorption of chloroform and the greater the percentage of albumin.

BERTOYE (H.). Contribution to the Study of Bence Jones' Disease. Rev. de Méd., 1904.

AFTER giving more or less detailed accounts of all the published cases of Bence Jones' disease, and discussing the nature of the proteids which are present in the urine, together with the pathological anatomy, symptomatology and treatment, the author concludes an elaborate and exhaustive monograph by considering the etiology and pathogeny of the disease.

As

Bence Jones' disease most commonly attacks patients at, or past, middle life of 26 recorded cases in which the age is given, twenty occurred between 40 and 70 years of age; the youngest was 24. regards sex, 16 were males and 10 females. Among predisposing causes, rheumatism, gout, alcholism and malaria have been named. There are reasons for regarding the disease as a possible derivative of syphilis. Pernicious anæmia was an antecedent in three or four cases. In one case lymphadenoma, and in others multiple glandular enlargements occurred; in two cases the disease was preceded by myxedema.

A toxic origin, either of endogenous or exogenous derivation, has also been postulated, and the author asks what may be the rôle played by syphilis as a factor. Is syphilis the source of the toxic agent, or does it simply act by diminishing the resistance of the tissues to the effects of a toxine of other origin?

The paper, which concludes with a most comprehensive bibliography, is a valuable resumé of the subject.

REIGLER (C.). An Interesting Case of Cystinuria, with Cystin

Calculi. Med. Blätter, 1904.

CYSTIN is derived from proteid matter, but the mode in which it is produced has not been satisfactorily traced. The present case points in favour of the view that a relation exists between gastro-intestinal derangements and cystinuria. In this case diamines were found in the urine, thus strengthening the assumption that fermentation processes, due to specific bacteria, occurred in the intestinal canal. The author suggests that cystinuria may be an infection-malady, and that in cases of chronic gastro-intestinal derangements cystinuria is to be thought of. The treatment, in this case, consisted in the administration of intestinal antiseptics-calomel, salol, naphthol, chloroformwater and copious enemata of water. The diet consisted of milk, vegetables and a small quantity of meat. After two weeks' treatment, the symptoms disappeared.

J. DIXON MANN.

NICHOLSON (WM. R.). Neuritis as a Complication of some Portion of of the Child-bearing Process. American Medicine, May 28, 1904. Two cases are cited in which neuritis developed during the puerperal period. In one case the symptoms took the form of a paraplegia, chiefly affecting the extensors, with objective sensory disturbance; labour had been uncomplicated and in no way difficult, in the other case one lower limb only suffered. There had been some laceration of the cervix. A brief historical resumé of the subject is given, followed by a discussion of the views of various authorities. The writer is in favour of the following classification based upon the etiology:(1) Cases due to toxæmia; (2) cases due to septicæmia; (3) cases due to trauma. Very little explanation of the first class is forthcoming in the present state of our ignorance of the subject of auto-intoxication. Septicemia is obviously a more easily explicable cause. Trauma, the writer considers to be the commonest source of the neuritis following labour, and is practically never the result of instrumental interference in delivery unless the forceps be applied carelessly, but is due to the direct pressure of the foetal head on the pelvis. The paralysis, it is pointed out, is usually of a type that would follow an injury to the lumbo-sacral cord, especially to its posterior division, and anatomical

facts show that the lumbo-sacral cord is more exposed to the effects of intra-pelvic pressure than any other part of the lumbo-sacral plexus. Involvement of nerves in the scar tissue resulting from injury to the soft parts is also advanced as a cause of neuritis; the writer's second case is an illustration of this. If the neuritis be the result of trauma, the lower extremeities are, of course, alone affected, but in toxæmic or septicæmic cases both extremities may suffer. The neuritis may give rise to symptoms of any grade, from a moderate degree of pain and transient paræstheniæ, to a state of things clinically expressed by acute ascending paralysis. The possibility of neuritis spreading from the sacral roots on one side to the cord or the roots on the other side by the cauda equina is also mentioned.

Stress is laid on the importance of prophylactic measures which should include precautions against sepsis, a systematic pelvic examination before labour, in order to make sure that nothing exists which is likely to add to intra-pelvic pressure, and the use of chloroform during labour, if the pains be very strong and vigorous. Prognosis is usually good in mild cases.

W. L. ASCHERSON.

VOLLAND. On the Origin of Tuberculosis. Munch. med. Wochnschr., May 17, 1904.

THE author of this paper accepts von Behring's invitation to physicians generally, to give their ideås upon the subject of tuberculous infection. He believes with von Behring that for a generation the medical world has fought with an empty phantom in its conception of tuberculosis as primarily due to inhalations of the organism, and thinks that now that von Behring has spoken out the phantom will soon be laid, and a truer conception of the infectivity of the disease will arise. He does not, however, follow von Behring in the assumption that milk is the chief source of infection, but believes that "scrofula" plays the greatest part. What "scrofula" is precisely he does not explain, nor do we think his argument strong, even if we admit his premise. It appears to us that much stronger evidence than has yet been adduced must be forthcoming before the medical world relinquishes the conception of the spread of tuberculosis by inhalation; a path of infection which readily explains nearly all the lesions we meet with, and is inherently probable which is, moreover, established by many experiments in many skilled hands.

H. THURSFIeld.

ROTCH (T. M.). The Diarrhoeas of Infancy and Early Childhood. American Medicine, May 7, 1904.

DR. ROTCH has endeavoured in this interesting paper to revise our present system of classifying the diarrhoeas of infancy. Up to the present time we have been able as a rule to distinguish between disease of the large and of the small intestines, but though much work has been done in the bacteriology of the disease, no one has yet succeeded in

co-relating special clinical types with specific bacteria. Dr. Rotch quotes a series of cases examined bacteriologically, with special reference to the presence of Shiga's bacillus as the cause of the disease, and considers that of the 61 cases 16 were positively due to the presence of this organism. He does not, however, find any special clinical type associated with this organism, though it is most frequently found in connection with ileo-colitis. He concludes that we are still in the same position with regard to diagnosis, prognosis, and treatment as before the discovery of Shiga's bacillus, and that we must still trust to our imperfect and rough clinic classification. He concludes an interesting paper with some remarks on the serum-treatment of these diseases, which is still in its infancy, but appears to promise well for the future. H. THURSFIELD.

BAGINSKY (A.). Typhoid Fever in Children. Boston Med. and Surg. Journal, 1903. Vol. cxlix., p. 721.

DR. BAGINSKY states that the pathological anatomy of typhoid fever in children is distinguished from that in adults for the same disease by the greater prominence of degenerative and necrotic processes in the intestine of the former, and by the more evident hyperplastic process of the latter.

According to Wolberg for children between 3 and 5 years of age the average duration of an attack is 14 days, and with older children 17 days. From Montmollin's studies it seems that from the first to the tenth year of life typhoid fever shows a steadily increasing average duration. Long continuous fever occurs almost exclusively in older children. The tonsils are usually enlarged in the attack and the seat of follicular inflammation, and the writer states that the fact should never be lost sight of that an unusually protracted angina with very high fever may be the only symptom of typhoid.

Children, he says, are unquestionably more predisposed to relapses than adults, and according to Montmollin girls more so than boys.

In Vol. cl., 1904, p. 321, Dr. Sylvester gives a short resume of the subject of typhoid fever in infancy and reports the case of a child, 6 months old, whose mother died of typhoid fever shortly before the infant was attacked. In the infant meningeal symptoms formed a prominent feature, and were well marked. The Widal reaction was positive. The infant made a good recovery.

R. W. MARSDEN.

FREEMAN (ROWLAND G.). Etiology of Rachitis. Archives of Pediatrics, 1904. No. 4, p. 250.

SINCE rickets is essentially a disease of temperate and cold climates, and almost unknown in warm regions where people do not shut themselves up in close rooms, the writer suggests that deficiency of oxygen may be an important factor in its causation.