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the kidney or kidney pelvis, the reaction is invariably acid. This is especially true in renal phthisis. The acidity is not, as a rule, a normal and moderate mineral acidity, but is excessive, and there are present organic acids.
5. Upon the other hand, an alkalin pyuria, and especially a volatile alkalinity, points rather conclusively to cystitis. Here arises the question of combined renal and vesical infection, and it is sometimes difficult to solve where symptoms are puzzling. The following rules are of some value, however:
(a.) Where there are vesical symptoms and the urin is intensely acid, it is probable that the disease is primary in the kidney or renal pelvis and that the bladder mucosa is merely scalded, thus explaining the symptoms. This holds especially in renal tuberculosis and to some extent in colipyelitis. Cure of the renal condition will result in disappearance of bladder symptoms as a rule. I am inclined to regard the bladder as the "urinary stomach" in some of these diagnostic questions. The surgeon has learned in cases of stomach symptoms to look first to the appendix, gall bladder and duodenum. And in the same way in "acid cystitis" we had best look first to the kidney and renal pelvis before venturing a bladder diagnosis.
(b.) Casts, renal cells or kidney symptoms should lead us to suspect combined disease where the urin is alkalin (ascending infection), and here a cure of the kidney condition is not likely to relieve the bladder condition. In combined disease, the reaction of the urin is of great prognostic import
6. Do not rely on chemical tests for pus, but resort to microscopy in every case. The best chemical test is that of Donne. To the sediment, add a bit of caustic soda, and stir with a glass rod. If mucus, it will become thin and flaky, while pus will become gelatinous, thick and tough.
7. Polymorphonuclear cells argue for infection by the colon bacillus, pyococcus or semipathogenic bacteria. They may be present in late tuberculosis after secondary invaders have complicated.
8. Lymphocytes, endothelial leucocytes or other mononuclear cells, appearing in the majority, argue for pure tuberculous infection. Do not mistake renal cells for mononuclear pus cells. (See preceding article, in October WORLD, on urinary microscopy.)
9. The presence of many pavement cells along with the pus should lead the microscopist to suspect vaginal or urethral contamination, and inquiry should be made as to whether or not the specimen was taken by catheter. Nowadays some nurses know more than doctors, and in more than one case I have examined specimens where the physician supposed that the catheter had been passed, having ordered it done, but some other person decided that it was not necessary.
10. In males the first urin is usually contaminated with urethral cells and should always be rejected. The finding of the gonococcus raises a question, for gonococcus infection of the bladder is rare.
11. In case the nuclear figures are puzzling, do not forget to add a drop of acetic acid to the sediment, to bring out the sharp outlines.
12. Where there are but few or no pus cells and it is desired to stain for specific bacteria, it may be necessary to use a fixative to hold the sediment to the glass. The best fixative is 9 parts of steril and distilled water, 1 part of egg white, and chloroform to saturation. Use equal parts of fixative and sediment. Smear, fix by heat and stain.
13. The finding of large numbers of renal cells, ureteral cells, bladder cells or prostate cells in cases of pyuria have some weight in locating the lesion. Other factors are more important, however.
14. Urinary mucus is not pathologic; pus is. When the urin is ammoniacal, the pus may become ropy like mucus. Unfortunately the term, muco-pus has been applied to this sediment. The term "alkalin pus" is much better, for there is no actual increase in mucus.
I have referred to tuberculosis of the kidney in several of the above considerations, and will merely list briefly some of the main points. Since we have learned so much concerning colipyelitis and other urinary infections, we have come to realize that renal tuberculosis is, after all, not a very common condition, and has been diagnosed too frequently in the past.
1. A case which recovers without surgical operation is probably not a case of tuberculosis.
2. Renal tuberculosis is not a common disease.
3. Renal tuberculosis is rarely primary.
Lesions may usually be found elsewhereglands, lungs, spinal column, adrenal or Fallopian tubes.
4. In renal tuberculosis there is usually a loss of flesh. In colipyelitis there may be a loss of flesh, but usually the patient grows fat if given the rest treatment.
5. Early chills are suggestive of colipyelitis rather than tuberculosis.
6. It has been claimed that tuberculosis may complicate pyelitis. This may be true, but in a large number of cases I have not made this observation except perhaps in a single one, and this was doubtful.
7. If the patient is a female between the ages of zero and 45, think of colipyelitis before renal tuberculosis.
8. Colon bacilli are not always easily decolored by acids, and the morphology of the rods as well as the staining characteristics must be kept in mind. The smegma bacillus may mislead.
9. The pus is usually mononuclear, especially in the early cases.
10. The reaction of the urin is usually intensely acid, but intense acidity is noted in many cases of colipyelitis.
11. The urin when examined by the hanging drop method is apparently steril.
12. Now and then the typical beaded acidfast bacilli may be found in smears.
13. Some cases may be manifestly surgical, and interference may be necessary before the laboratory man can make a final diagnosis. Be careful here. Too many cases have been diagnosed and operated without laboratory data. Many a kidney doomed to a surgical grave has contained many stubby bacilli and not a single slender acid-proof rod.
14. The laboratory man's trump card is the cavy inoculation. This may be done especially in those cases where the urin is apparently steril. Do not expect the pig to live long enough to develop tuberculous peritonitis or adenitis if the sample is swarming with colon bacilli or pyococci.
1. Colipyelitis is probably the most common infectious disease of the kidney. It is routinely diagnosed clinically by some men as tuberculous kidney, and skilfully removed without laboratory examinations.
2. Some cases of colipyelitis are surgical; most cases may be cured by rest and urinary antiseptics.
3. Females are especially prone, but males do not escape.
4. The symptoms may be vesical, but the high acidity, if present, will suggest scalding.
5. History of cutaneous abscesses may precede the attack.
6. The urin rarely has a fecal odor. Do not expect it.
7. Chills are likely to occur at the onset. 8. A hanging drop may show thousands of stubby bacilli, some feebly motile. Pus may be absent at times.
9. The inoculations on special media furnish final proof.
Sometimes typhoid bacilli appear to cause a pyelitis, but usually the pyelitis following and complicating typhoid fever is caused by the colon bacillus. In some cases a gonorrheal infection may ascend from the urethra and involve the bladder. A gonorrheal cystitis is usually serious. I have never known of a fatal case, but the agony is intense. Speaking of urethral infections, I have seen several that were not due to gonococci but to other cocci. Primary staphylococcus infection of the kidney may occur, but it is rare. The staphylococcus may play the part of secondary invader in tuberculosis of the kidney. Remember what was said concerning the tendency of cocci to be found in almost every sample of urin, and that it is not always easy to accord to them a vicious rôle.
Semipathogenic Urinary Bacteria.
The most important of these is the proteus vulgaris, but there are many other micro-organisms which fall into this class. When for any reason there is urinary stasis. as in enlarged prostate, calculus, tumor or stricture, these saprogenic bacteria get a foothold and cause ammoniacal fermentation of the urin. Pus cells receive the word that the normal bactericidal properties of the mucosa have been broken down, and rush to reinforce. The condition is not a true infection, but urinary antiseptics are indicated. The main problem for the physician is that of removing the mechanical obstruction causing the stasis.
Other fermentations, but of an acid nature, must be held to account for renal calculus. In fact, the clinical oxalurias are doubtless due to unknown types of bacterial action rather than metabolic in origin.
Paris, Ill. B. G. R. WILLIAMS, M.D.
Comments on October WORLD.
The next article will treat of "Tissue habitually sacrifices himself to his duties. Examinations Worth While." But on one point I am emphatic-that the chief obstacle I have encountered in trying to cure these patients is the perfect ease with which they can secure supplies from druggists without prescriptions or any other authority. But this refers to pre-Harrison law times. Now it is different, and the druggists seem to have reformed. Moreover, some recent experiences have shown that with this danger removed the cure is easier and there is less suffering than ever before. My last case required during the day a combination of physostigmin with spartein; by night gelseminin, cicutin and cactus; with persistent mild catharsis, and careful feeding. Prolonged hot baths are very grateful and save many an hour of discomfort. But, above all, rest is essential. The man may feel fine and fit, ready to work and impatient to get at it; but let him take a light ax or a bucksaw, and in five minutes he is all in. Then come the aches in the
EDITOR MEDICAL WORLD:-The enjoyable thing to me about these chats with your big "family" is that one may sit down and talk, without going to the trouble of hunting out of the library all the recent work done on any topic, and giving a lot of textbookish material that anyone of us may get if he thinks enough of the matter to do the digging. We just give here our experiences and opinions, and anybody is at liberty to accept, deny, try, prove or disprove, at will and opportunity. There is a wealth of information among the medical men that would be invaluable if one could get it out; but we are so blamed particular, so afraid of committing some blunder, that we keep silent when we ought to talk and give the rest a chance at our ideas. Lots of times some WORLD reader has written to me, sometimes corroborating a statement and sometimes showing me wherein I was wrong. The net result is that I have learned a lot and given some in return. Wow!!! How quickly they picked me up once when I inadvertently spoke of using atropin in glaucoma!! Of course I knew better, and should not have been so careless; but I said it all the same.
THE WORLD reminds me of the anteroom of the lodge. We get out there, light up, remove our heavy regalia and coats, and the shirt-sleeve talk there determines what shall be done in the lodge.
My quarter-century of treating drug habitués does not permit me to give much testimony as to the responsibility for these habits. Of about 700 cases coming to me, by far the largest number were physicians. Of these, nearly all fell victims to the seductive drugs in the effort to fulfil the duties of the profession when physically unfitted by illness or fatigue. I have long since learned to look on a physician-habitué as a victim to professional devotion until another reason for the habit has been shown. Overwork, too much responsibility, and the knowledge that a "shot" will carry one thru and develop the best that is in him-there is the temptation placed before a man who
leg muscles to show him how fragile is his
"Wealthy Heights Estate."
Well, I have a few lots on Long Island, for which I paid a strictly nominal price— a few dollars. I was careful to write for a bill of the taxes next year, and the reply was that the property was not worth taxing. Considering the rule that non-residents are always in open season to the tax collectors and assessors, I concluded the lots must be mighty bad.
Taking Care of the Kidneys.
One sentence in Williams' article (page 379) arrests my attention-"Man numbers his life and health in hours by his normal renal cells." We all know how quickly death supervenes when the renal cells quit work; and we also know that when the solids of the urine fall far and continuously below the normal output, the patient is being poisoned as rapidly as the collateral elimination permits. But do we think of the hygiene of the renal cells, and the preservation of these most essential structures? I think there is no sanitary law most frequently and generally ignored than that which forbids the stimulation of organs that need no stimulation. In no tissue of the
body are the consequences more disastrous than with the renal parenchyma. Every drop of alcohol, every atom of volatile oil that we take, in relishes, pepper, mustard, horse-radish, and spices of all kinds, inflict on the excessively delicate renal cells an irritation that in time, multiplied several times daily, induce atrophy of the cells and hyperplasia of the connective frameworkorganic atrophy in fact.
Dr. Meek (page 387) can ask more questions in a minute than any one man can answer in a week. As to epilepsy in castrates, he should apply to the profession where eunuchs are more common than here. I do not now recall that I have even met one in America. (2.) Epileptic convulsions frequently persist after the original exciting cause has been removed. Push a rock down hill and it keeps moving after the foot pressure has ceased. (3.) Every asylum can tell that when the moonlight is bright there is far more noise and wakefulness at
night than in the dark weeks. (4.) Typhoid leaves the body loaded with toxins in addition to those normally produced; and it also leaves an impressible nervous system. (5.) Can't think of anything bright to reply. Dr. Meek is right as to the importance of this matter-but what do internes know, anyhow! Dr. Mann replies to one question, with an important case of recovery after removal of adenoids.
My criticism of the circumcision discussion is that one and all state their opinions, but do not cite facts and statistics on which we may make our own decision. Besides, if you wish to get at the truth of a matter, do not trust those who only seek to prove their own side. Who is there who does not care a doit which side wins, but has evidence to offer on either?
Inflammation, Pressure and
Sciatica induces an access of blood to the nerve and its sheath, and where this passes thru the sacrosciatic foramen or notch, the increase in the bulk of these structures causes pinching. This is relieved by anything that subdues the hyperemia, as Dr. Dreher (page 392) found when he applied his cups over the foramen. I used to apply very small blisters directly over this locality,
and get a magical relief. I think the same reasoning applies to Dr. Buck's method of blistering (page 392) for pleurisy and pneumonia-lessening the hyperemia relieves the painful pressure on the sensory nerves. But I suppose that nowadays they will tell us that an autoserum is this product that being reabsorbed antagonizes the disease-inducers. How is it? The benefits from reabsorption of the serum from blisters was noted when they were employed as cure for syphilis by a Norwegian savant, many years ago.
The method was condemned, as there was no distinction made between syphilis and chancroid, but the benefits from the blisters were recognized and occasioned some comment. Strong aqua ammonia causes a blister very quickly, and without the inflammatory reaction following cantharides. Fill a thimble loosely with absorbent cotton, wet it with ammonia, invert over the skin, and in a minute remove and the blister will be formed. Old Age.
I have suffered from advancing years lately-does any brother know of a remedy? WILLIAM F. WAUGH, M.D.
Germs and Their Relationship to Disease.— No. 1.
EDITOR MEDICAL WORLD:-All organic forms originate in cells, germs or spores. The human body is composed of a multitude of cells; the individual cell is the morphologic unit of the tissues and body of man. The earth, and water, are the habitations of myriads of germs and matured forms; somet of which are pathogenic to the human body.
In their life history germs are influenced by their environment and condition, and, hence, to mutations of form and physiologic activity. Tissues of the human body are likewise influenced by environment, conditions of life, and chemical and germ invasions. Of all the germs found in nature, the great majority are harmless. Those that affect the body injuriously are termed pathogenic.
The papers which follow have concern with only a few of the pathogenic germs in their connection with certain diseases.
As stated above, germs are subject to mutations of form and physiologic activity. This fact we wish to impress upon the minds of our professional brethren in order to neutralize the prevailing thought-that a spe
cific disease is the result of an invasion of a specific pathogenic organism.
We believe that disease is the departure in special tissues, or of the body as a whole, from the normal in special directions, thus preparing for the invasion and development of certain pathogenic germs.
These germs in their life history being subject to mutations of form and physiologic activity, may be rendered innocuous; thus health be restored to the victim of their invasion.
With regard to mutations of form in bacteria, Professor Ferdinand has the following in his work on "The Principles of Bacteriology," pages 12, 21, 22 respectively:
It must be remarked, furthermore, that even the typical forms (of bacteria) recur only under quite definite conditions, and that they vary according to the nutrient media in which the bacteria are growing. This holds true, indeed, to such an extent that the prevailing form of a given species may be assigned to one group or another according as it has been taken from one or another medium.
One of the greatest services Koch has rendered to bacteriology is his invention of pure culture, by means of which such isolated colonies, originating from a single germ, can be cultivated at will and obtained free from admixture with germs of other kinds. Such pure cultures, reared under perfectly similar conditions, always agree in form and physiologic activity. But this is not real constancy. The similarity does not depend upon the invariability of the bacteria, but upon the fact that the conditions of life suffer no alteration. If the conditions fluctuate, the bacteria will also vary in form and physiologic activity. * * *
The value, then, of the individual shapes fluctuates very greatly. At times it is the transitory form, at other times the common nature form that is deemed typical. On this account it is superfluous, at least in the beginning, to determine, with rule and compass, the regulation breadth or length of a species, while general morphologic questions remain unsettled. * * *
Bacteria depend for their provision of food and energy upon the conditions of nutrition. If these conditions remain constant one of three things comes to pass. Either the bacteria change in form and action, and adjust themselves to the new conditions, or they form spores, which preserve the species until better times for them to return, or they fail to adapt themselves at all and so perish.
Dr. Henry Plotz, a fellow-alumnus of the writer, in his biologic studies, has identified the bacilli found in Brill's disease and typhus fever as being two different strains of the same microorganism.
We quote additional evidence to support the preceding statement as to the mutability in form and physiologic activity under varying conditions of environment.
There is a growing suspicion that the typhoid bacillus is really nothing else than a highly educated strain ascending from the colon bacillus
(bacillus coli communis) of everybody's alimentary tract.
These two species resemble one another in form and habit, and midway between them are certain bacterial species which add to the more benign characteristics of the typhoid bacillus ; these latter being known as paratyphoid bacillus A and paratyphoid bacillus B. Paratyphoid is a milder disease than typhoid fever, and epidemics sometimes occur shortly after epidemics of true typhoid.
But still more confusing than the colon bacillus group is the group of apparently interchanging bacterial types which are concerned in the causation of throat and nose infections and so-called rheumatism or joint infections. The streptococfactor of tonsillitis and complicating or secondcus has been commonly recognized as a frequent ary acute rheumatic fever. Also in a large number of cases, bacteriologically studied, pneumococcus has been found in pure culture in and about the inflamed joints of articular rheumatism.
The very fact that some investigators found streptococci, while others found pneumococi in such cases, has only made practical physicians skeptical of bacteriologist's results.
Recent studies by Dr. Rosenow, and others, have demonstrated beyond question that an actual transmutation of pneumococci into streptococci can be brought about under artificial culture. The transmutation in all likelihood occurs in the human body under certain conditions.
Rosenow has taken pneumococci from the lung, from the sputum and from the blood of a pneumonia patient, grown them in culture tubes and gradually "educated" them till they became streptococci.
These transmuted germs, when injected into rabbits, produced joint, heart valve and heart muscular lesions seen in human beings with acute rheumatic fever.
Other laboratory workers have accomplished equally remarkable transmutation.
Mme. Victor Heuri, of the Pasteur Institute in Paris, began with the anthrax bacillus, a deadly microbe in animals and human beings, the most virulent she could find, submitted cultures to environmental changes, exposing them briefly to ultraviolet light, for instance, and ultimately produced a species of bacilli which failed to show the pathogenic effect when injected into guinea pigs.
Drs. Thiele and Emberton took bacillus miccides, a common, non-pathogenic microbe found in garden soil, grew cultures at low temperature (the germ will not survive at body temperature), gradually increased the temperature with successive generations and succeeded in educating the germ to grow at a body temperature in the incubator.
Animals were then injected with the educated bacilli, and it was found that the previously harmless bacilli had acquired the characteristics of the deadly anthrax germs.
The same experimenters have taken the smegma bacillus, a harmless microbe universally found on certain parts of the human body, educated it under artificial environment, and transmuted it into a virulent organism which produced tubercles and death in a week or two in animals, the postmortem findings being identical with those of tubercle bacillus, which resembles smegma bacil