vided their density differs from that of the tissue in which they are imbedded, and such

FIG. IV

FIG. V

is usually the case. Not all foreign bodies give their host troubles. This was not true,

however, in the case of Mr. B., who more than 26 years ago received a wound from a 38 caliber pistol on the inner side of the right knee joint. The ball lodged in the leg and he had a persisting sinus, for the relief of which he had undergone three or four operations. We found the ball in the tibia surrounded by an area of diseased bone. The ball was removed, proper treatment carried out, and he made a speedy recovery.

The instances here cited serve to show the importance of the subject, and are common every-day occurrences. There has been no attempt to cover the entire field of bone pathology. but I urge you to iet no bone lesion, especially, if it be about a joint, pass out of your hands without availing yourself of its aid.

DISCUSSION.

D. Y. Keith, Louisville: There is one point I would like to speak about in regard to ankle fractures which are diagnosed commonly as sprains, and while they are not of daily occurrence, we find them frequently in people who are X-rayed. The diagnosis is made of sprain in many instances of injuries about the ankle, when we f.nd they have a fracture, usually not of the tibia, but we find an oblique fracture of the fibula, with occasionally a little piece of the internal malleolus of the tibia broken. These cases are not infrequently diagnosed as sprains.

I had one such case in the office a few days ago, the accident happened in Cincinnati and the nan walked into the Marine Hospital in Louisville. He did not have any deformity; there was ro swelling and but very little pain. He had a Landage on which relieved the pain. We find a great many sprains of the ankles and injuries about the wrist joints in which the X-ray plates will show a fracture.

In the plate exhibited here by Dr. Mason, I believe there was a fracture of the posterior part of the tibia, with a backward dislocation of the ankle joint. Cotton, of Boston, on fractures states that it is one of the rarest fractures he has experienced around the ankle joint, having seen but cight or ten such cases in his own experience, and only about four of these coming under his own observation, the others having occured in the practice of other surgeons. They are the kardest cases to replace and keep replaced because of the posterior tibia being torn off the joint slips backward. In 4,000 or 5,000 X-ray plates I have seen but two instances of this type of fracture. When the posterior lip of the tibia is torn off you have a displacement of the ankle joint which is very hard to control.

In regard to infection you can in most cases differentiate between infection of the bone and tuberculosis even without the history. You find a staphylococcus infection practically always in

volves the diaphysis of the bone, while in tuberculosis it involves the epiphysis, while syphilis may involve any part of the bone. In syphilitic cases you find a destruction of bone, or you find ossification. You may have just a localized periostitis or an acute infection of the bone in which you cannot see the canal of the bone at all. In syphilis the periosteal covering of the bone is rough with thickened medullary canal or the canal may be entirely absent on account of the denseness of the bone.

tion goes.

I would like to emphasize what Dr. Mason has said regarding the practical value of having two plates in fracture work. We find a great many practitioners who make one exposure and give a negative diagnosis of fracture. You may make one exposure and the position looks all right. One picture, aside from making a diagnosis of fracture, is not worth very much so far as posiIn making shadows, I can hold my two fingers in this position (indicating), and make a shadow on a piece of paper, and outside of the increase in thickness of the shadow or density, where the over-lapping is, the bone will look all right, and if you have the least bit of overlapping it may look straight, but if you make another exposure at right angles to the first, you will rotice the displacement. Every fracture exposed in two positions at right angles to each other is better than stereoscopic plates.

There is one point about infections of bone that I desire to call attention to at this time, and that is, cases come into the laboratory quite often with history of a recent infection, an infection possibly of one week, ten days or two weeks, and the physician expects you to show a periostitis or some involvement of the bone, if you cannot do so he is very much disappointed. There have been made quite a number of experiments of infection of bones in guinea pigs, and it is believed in acute infections of bone that, aside from where you have a large abscess, showing a dark shadow, no bone involvement will show until about three weeks after infected. In a lesion of bone there seems to be some change in the bone, that we are not able to find in animals in less than three weeks time, and it is doubtful whether any acute infection, if it has not been longer than three weeks, can be found. If you have a plate made later you will find the changes. To have a change from the normal there must be either destruction of bone or new bone formation. The clinical picture in acute metastatic bone infection is perfect enough for diagnosis.

As to the location of foreign bodies, you will find very few metalic substances, that cannot be accurately localized by the method we have at our command. Many new methods for accurate localization of bullets, etc., are being used in the present war which, we are sure some definite practical technique will be put forward by some one of the many workers upon the firing line.

We have with us to-day

C. Z. Aud, Cecilian: Dr. J. B. Murphy, of Chicago, a man who needs no introduction to a Kentucky assembly of physicians. He needs no introduction to any part of the world. I move that Dr. Murphy be invited to take part in this discussion and be given a seat on the platform.

Motion seconded and carried.

President Kincaid: We are proud to have Dr. Murphy with us, and I would like to have him come forward, take a seat upon the rostrum, and participate in this an dother discussions if he desires to do so.

John B. Murphy, Chicago: Concerning the paper of Dr. Mason I have been very much interested in it. He brought out some very important features, particularly with regard to the use of the X-ray picture. First, its positive phase correctly, and second, its postive phase negatively. The X-ray picture can give you positive and correct information, and it can give you incorrect information. I put it in that way. X-ray pictures are often misleading, and the author placed great stress on a double picture, and often a triple picture is important in X-ray work in or der to draw positive conclusions. One picture in connection with fractures is of little or no value. There are certain places where the X-ray requires as careful analysis in reading in order to draw positive conclusions as does the physical examination of a patient. The most conspicuous one in which error occurs is in connection with shoulder joint injuries or luxation and fracture at the shoulder. Sometimes you may make three or four or even six X-ray pictures, and not one of them will show the true situation, while the physical examination will reveal the situation with exactness, so that it must be a combination of the physical examination, with the X-ray, or the physical examination confirmed by the X-ray that will enable you to draw a correct conclusion. In the second place, it is difficult to interpret correctly X-ray pictures in connection with lesions or injuries about the ankle joints, determining the type of luxation, the type of fracture and position, it is almost as difficult to read the X-ray correctly as it is to interpret the physical signs and manifestations immediately after an injury. The physical examination is rendered more difficult on account of the swelling that takes place in these injuries. This has been very well accentuated in one of the pictures you have seen, showing the difficulty of interpreting the X-ray picture in connection with ankle joint fractures. Where we get little or no definite information, where we get information that does not lead to good results, we should recognize that the absence of information through the X-ray is of no particular value in the acute tumors and in the acute infections. The sarcomata often attain considerable size, and metastatic carcinomata of

AND PREVENTION.*

By STINSON LAMBERT, Owensboro.

It is a sad misfortune that a disease so serious in its effects should receive so many definitions, misleading and confusing in its study. The terms exudative and non-exudative, parenchymatous and a host of like names.

occurring at its maximum at probably forty-eight hours, that is, forty-eight hours after infection is disclosed in the bone, we probably have the maximum of destruction of bone. If you are going to inhibit that destruction, you must therefore relieve the pus tension in the bone inside of fortyeight hours, and preferably inside of twenty-four hours. It is the same proposition with regard to the gangrenous appendix, if you would prevent perforation, you must have the abdomen opened and the appendix out on an average of thirty hours. If you would save necrosis of the shaft of the bone, you must have the abscess tended to inside of forty hours. Fortunately, again, we have in this class of cases such a typical classical uniform picture clinically, that when it is read right, a positive diagnosis can be made, and just as positive as any diagnosis can be made by means of the X-ray, and the proper method of treatment can be instituted. (Applause).

J. B. Mason, (Closing): I wish to thank Dr. Keith and Dr. Murphy for their discussions, both of whom emphasized great care in reading a plate after it is made. I very frequently make a plate from which I am unable to arrive at a diagnosis. I frequently submit plates to men of more experience and ask them for their opinion on them, and very frequently they have told me they were unable to make a diagnosis. Unfortunately, as Dr. Murphy has pointed out, the X-ray gives no information of these acute bone lesions. By the time you make a diagnosis with the X-ray of them there has been so much bone destruction, it is almost a question of minor importance. whether the diagnosis is ever made or not with the X-ray. If we interpret the X-ray picture exactly, we have one method of arriving at a diag nosis, but we should consider each individual case a separate entity, and the acute bone lesions should be diagnosed before we have any occasion to X-ray them.

It is no great wonder that it ran so long before its true history was given by Dr. Bright; since no two cases present the same features, clinically studied. This condition has more than any other cause led to mistakes in diagnosis, until the patient has fallen in the streets from being overcome by the slow poison and the apoplexy and paralysis tells us what has been going on in the vascular system. We may have relied on the test tube for our information but it is not to be relied upon solely. It is well to understand other means must be used before we are to

judge all cases. It is a very excellent assistance when taken with other instruments of decision, but to rely on its findings is to stop short of a true examination. It is of no use to say the findings of albumen or not finding of it gives a correct history of the disease; since you may be like the old woman who was called into court to give her opinion of good indigo said, "Wall you all can tell good in digo, jest put a small piece of it into a pan of water and it either sinks or swims," and she could not tell which.

So it is with the finding of albumen in the urine. It is or is not. You are still in the dark.

We find after death from chronic nephritis a great many varieties in the gross appearance of the kidneys. Some are large, some are small, some are red and others white. There is no regular correspondence between these gross appearances of them and the clinical symptoms, manifested before death. We find in these same kidneys changes in the renal epithelium, in the stroma, in the glomerulus and in the arteries. Sometimes one, somtimes the other of the elements of organ is most changed. There is no regular established order over another and the clinical symptoms, in any case.

In the year 1827 Dr. Bright promulgated his views of nephritis. He regarded the kidney as the sole cause of it. His pointing out that organ has been the cause of much study of all morbid pathology. We have learned much of it, but we do not now hold to the earlier notions. We have learned it is a general arterio-sclerosis or a parenchymatous dis

*Read before the Daviess County Medical Society.

ease and hence we are able to direct our treatment to cause and not effect. Many writers follow close on his discovery; each classifying and attempting to show that the varied clinical phenomena depended upon the stage of infiltration of this organ. And so they had this classical notions lined out:

1. The stage of hyperemia and of commencing exudation.

2. The stage of exudation, commencing transformation of exudate. Lastly: that of the failure of the functions and atrophy.

To this outlined classification many subdivisions have been named and though cling. ing to the older notions that the kidneys alone were at fault we owe it to that noble German Virchow's Cellular Pathology, published in the year 1858, a clear understanding about nephritis.

He developed the doctrine that in Bright's disease either the stroma, the tubes or the Malpighian tufts were at fault and hence the confusion in symptoms.

Now, having learned that albumen in the urine is similar to having a cough and that neither tell us the real cause we are better prepared to make our conclusions as to real causes. We may be deceived by our albumen test but if we check up with the instrument for taking the blood-pressure, sphygmomanometer, we have one of the best aids in correcting our understanding of the approaching danger of all else. This aid, high blood pres sure, is coming into its own as a clinical entity of far reaching significance, that it calls imperatively for attention. When found no time should be lost in correcting the faults causing this cardio-vascular change, since it brings the patient just that much nearer to the grave and serious condition that must soon follow, retinal and cerebral apoplexy and other alarming conditions following the pathological fulfilment of a deranged metabolism, the inevitable result of. wrong living. We should be on the alert to recognize the necessity of correcting high blood pressure, bring the patient's mode of life into something like compatibilty with the demands of physiological requirements. The quantity and quality of food are regulated, the excretory organs are looked after, exercise and general hygiene have their due share of attention, and yet one of the most important factors in the manage ment of these cases is frequently overlookedthe correction of the digestive derangement of the organs of internal secretion and digestion, involved in the pathological process. All other rectifying influences may amount to little if the importance be not recognized of restoring the glands of internal secretion and digestion to something like normal functional integrity.

It is safe to assume that a majority of interstitial nephritis are due to a toxemic origin. and a large number of them to an intestinal putrefaction, due to excessive ingestion of animal protein, in food. To the functional incapacity of the digestive glands to deal with the quantity and quality of food ingested.

It is not definitely known why the toxins arising from the the intestinal putrefaction causes this rise in blood pressure, but it is most likely due to the hyper-secretion of certain ductless glands. Take the pituitary, parathyroids or the adrenalins. What is the relationship between these glands and this general toxemia? We are unprepared to explain all these bad effects and what causes this abnormal change in the kidneys. We know it is an intoxication and it may be found to be syphilis as the greatest cause, malaria, al cohol, and last but not the least tobacco poi

son.

In fact sphygmomanographic readings plainly shows that it quickly affects the blood pressure and I am assured that this little innocent weed has a greater clientage than almost any other poison in the production of interstitial changes in all the delicate organs, and more especially that of the kidneys. Í cannot see why a thing so poisonous as tobacco taken into the system and producing such a great effect will not in the end do equal harm. Taking arterio-sclerosis and its kiddrea diseases we surely find it most common in the users of tobacco.

Viewing the anatomical arrangement of the kidney we may see that not all its parts are alike affected; that the process begins either primarily in the connective tissue between uniferous tubules or in the tissue present in the periphery of Bowman's capsule. This obstruction to the afferent and efferent vessels, causing cystic formations in the organ and this resulting in an over production of urine, formation of connective by reason of new tissue around the tubules and the filtering of water through the glomerulus.

In the beginning this passive congestion will cause an increase of urine with or without albumen, depending on whether the epithelium of the uriniferous tubules or glomeruleus have been damaged enough to cause the escape of white blood cells through the mem

brane or not.

It is here the doctor may be led astray, if he relies on his test tube solely for a diagnosis. It may be said there are but two forms of nephritis; The one where the epithelium is damaged, giving us the parenchymatous nephritis and the other where the chief trouble is at the interspaces between the tubules. or that of interstitial nephritis, where the interstitial stroma is first diseased.

Both are due to some auto-infection, or in

toxication of the circulating blood stream and there are a host of these causative agencies and if you will follow the action of the ductless glands I believe we will find in them many, if not all our gouts, diabetes, arthritis, the arterio-sclerosis, if not old age.

The intimate connection between the kidney and the sympathetic nerve system and the study of the effects of the action of the ductless glands may yet furnish the solution to the primary dilation of the arterial vessels of that organ, which become dilated and their walls thickened and unable to contract and consequently remain open after death.

This thickening of arteries and new growth in between the walls of the vessels, is due to the blood carrying toxic elements, causing the intima to be filled with connective, organized tissue up to and around the capsule, as I have stated, even entering into the glomeruli with this foreign growth. This enormous thick ening and loss of contractility easily explains to us why we have the abundant flow of urine. The pressure exerted upon the tufts of vessels within the Malpighian capsule, while the dilated extremity of the vessels in the uriniferous tubules is unable to control the flow of blood just outside of them. If for any reason this is constantly dilated, and its walls are thickened, it loses the normal contractility, and a greater volume of blood is poured into the tuft from vessels This with the unequal strain upon them, form the persisting blood pressure; hence a more copious urine is voided.

This is substantiated by both clinical and pathological data. It is here that the microscope, in the hands of an experienced and trained pathologist gives us the best help, coupled with our diastolic and systolic pressure taken with an approved sphygmomano

meter.

Continued high blood pressure is one of the first symptoms in interstitial nephritis, and the proper understanding of the treatment of the various conditions associated with which the arterial pressure is above normal calls for study of the underlying cause for the abnormality. Such cases, as a rule, may be divided into three groups: Mechanical, toxic, sympathetic and nervous. Mechanical when the arterial changes have gone and we have a general or local arterio-sclerosis. Toxic when we find the blood loaded with the elements, foreign to normal health requirements. Nervous when a reflex sympathy may load the kidneys with an undue amount of blood as in hysteria and like conditions.

These phenomena, no matter what they are, bring about changes in the composition of the blood and by this alteration of the pathologieal process, in which the transudation of blood

from the lumen of the capillaries into the tissue and perivascular spaces has been fully reached, the tissue of glands in which this abnormal phenomena has been developed, and which should be sustained in their normal process of growth and repair by the endosmosis and isomeric change, at once begin to undergo abnormal transformation. As a result of this action, there may be partial dissolution of the involved tissue or gland, or there may be destruction with replacement of the old and original structure by new and poorly formed white fimbriated connective tissue, in and around these delicate blood vessels in the Malpighian tufts.

By keeping constantly in mind a clear conception of the physiological laws which gov ern the nutritive supply and the excretory work to be performed by the renal glands, it is easy to explain and appreciate the methods pursued by Nature in producing these abnormal kidney lesions. With a clear understanding of the precise causation and methods of development, the treatment becomes rational and scientific and no longer pure empiricism.

The clinical evidence may be summed up with these facts: A high blood pressure with an occasional renal cast, accompanied with a small amount of albumen or none at all; and a diminution of urea, with morning headache is a strong evidence of interstitial nephritis.

This blood pressure may run from 160 to 260 and you may look for cerebral hemorrhage, uremic coma, optic neuritis, delirium and many unlooked for accidents to happen at any time. Many of the sudden deaths following trivial ailments, in which we are taken unaware are due to this hidden and mysterious kidney involvement. It behooves us to be on our guard and look well for it in all cases, where habits tell us histories.

By way of recapitulation, I wish to add what Dr. Charles F. Bolduan, the food expert of New York City Health Department, has to say, in an article in the Scientific American of July 17, 1915. "That 14 out of every 1000 die annually in the U. S. at the age of forty and over: that the diseases playing so prominent a part in the mortality of men over this were heart disease, arterio-sclerosis, including Bright's disease; and without citing the figures, says, "has revealed a marvelous increase in late years and also there has been a wonderful increase in certain diseases of the nervous system."

I may add that the figures taken from the Health Institute and Insurance Statistics show that 65 per cent. of all deaths show disease of the kidney and that the death from this is greater than consumption or cancer.

With the conception of the etiological fac