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DECORTICATION OF THE KIDNEYS
FOR THE CURE OF CHRONIC BRIGHT'S DISEASE.*
M. GOLTMAN, C.M., M.D.
THIS colored man gives his age as 36 years. He looks older; his arteries are somewhat thickened and he has had syphilis. He is a farmer, and this was his third attack of dropsy. His family history is unimportant. When he entered the hospital he was suffering from marked general dropsy, headache, marked tachycardia and irregular pulse. The urine showed 29 per cent. albumin, hyaline, granular, fatty, epithelial and uratic casts in abundance, many renal cells undergoing fatty transformation, many leucocytes and some red blood cells. The specific gravity was 1.009. The urea was very low, of 1% 1 per cent.
Dr. Shelton, who admitted him, considered him in a desperate condition. So did I when I saw him. Our diagnosis was chronic interstitial nephritis accompanied by rapid degenerative changes. We could elicit no causal influences other than those already mentioned, even after very rigid questioning. After testing the cardiac reserve force with digitalis and getting some response, I decorticated both kidneys on November 18, less than one month ago. Several gentlemen present at the operation, and at this meeting, questioned the wisdom of operating on a dropsical patient in such poor condition, with a pulse of 130 to the minute, markedly irregular, and of poor, very poor, volume. He not only stood the operation, but came off the table in better condition than when he went on it. I encouraged free bleeding of the kidneys in this case, as I do in all these cases, because it seems to improve the heart and general circulation.
The last rib on the left side being very short, and the pleura dipping down quite low, it was accidentally opened. Usually in such instances the kidney is easy to reach and to dislodge, but in this instance it was placed unusually high, necessitating a long incision. The accident did no harm and did not delay the operation a moment. The right kidney * A Clinic before the Memphis and Shelby County Med. Society, Dec. 15, 1903
bled profusely, so much so that I was compelled to reopen the wound and introduce some gauze packing, in spite of which you see I have obtained good union.
The kidneys were somewhat smaller than normal, markedly granular and hard, but still showing soft mottled patches sufficient to pronounce them in a state of chronic diffuse nephritis.
Since the operation the patient has done remarkably well. Eleven hours after being put to bed he passed twenty ounces of urine, which was much richer in cellular elements than the
last urine passed before being operated on. On November 23, unsolicited, he confessed feeling better than at any time since last July, free from headache and very hungry. Within ten days he was entirely relieved of his dropsy. He has now been up for a week, and eats everything and as much as he can get of it. His temperature is normal and his pulse is 74. Examine him, gentlemen; he is here for that purpose.
My interne, Dr. Weeks, who has taken deep interest in and exceptionally intelligent care of this patient, makes the following summary of the urinary findings: Average amount of urine for ten days preceding operation, 1950 c.c.; specific gravity, 1.004; urea, of 1 per cent. For first twenty-four hours following operation, 1020 c.c.; specific gravity, 1.024; urea, 3 per cent. There was practically the same finding for the next four days. For next ten days, 1500 c.c.; specific gravity, 1.018; urea, 2.9 per cent. For next ten days, 1800 c.c.; specific gravity, 1.017; urea, 2.7 per cent. So that considering the quantity of urine passed it can be said that the urea output is phenomenally large. Now, gentlemen, a man lying quietly in bed and carefully nursed and dieted does not elaborate so much urea, hence there can be only one deduction, viz., the kidneys are throwing off the accumulated urea and other poisons, and by so doing are rapidly relieving him of his uremic symptoms. Concomitant with the marked general improvement, the urine has kept pace, as shown by a lessening of the albumin, casts, renal and blood cells and increase of urea and total solids.
How long this remarkable improvement is going to last is still a question.
The operation is in its infancy and the experience up to date is not sufficient to warrant one in accepting too freely deductions which increasing experience may prove to be erroneous. This much can be said: The operation is certainly capable of prolonging life and bringing about a decided change for the better in desperate cases with a promptness, barring accidents, that is almost startling to the uninitiated.
This patient was in a dying condition before he was operated upon. Look at him now, less than one month after the operation. Observe that there is not a trace of swelling and
how strong and active he is. He took no medicine outside of an occasional cathartic and a few doses of bicarbonate of potash to lessen the acidity of the urine. Everything medicinal had been tried and found wanting before he was submitted to the operation. I am decidedly opposed to operating on these patients as soon as the diagnosis is made, in spite of the dictum of a fellow member of this society to this effect-a member who never saw a decortication until I showed it to him.
Kidney affections are better understood today than ever before, and I believe this operation has helped to bring this about. But after all, only time, patient observation and much additional experience can solve this most interesting problem.
In closing, I just want to utter a word of caution: Don't always accept an irregular and faint heart action as being of uremic origin in these cases. They are sometimes due to adherent pericardium and pericardial effusion. 502-504 Randolph Building.
N. F. RAINES, M.D.
I SHALL not speak of the different bacteria which occur in the gastro-enteric tract, and of the connection which they have with the different diseases. I wish to call your attention to a recent case in practice which I consider unique.
The only animal parasites which occur in the intestines of children important enough to speak of are the oxyuris vermicularis, the ascaris lumbricoides and the tenia solium. Their development takes place in the large intestine, and the mature worms deposit their eggs in the rectum. They enter the intestine through the mouth.
The most common symptom of the pin-worm (ascaris lumbricoides) is an intense itching about the anus. In girls there is frequently a vulvo-vaginitis. Whenever there are symptoms of reflex irritation in the neighborhood of the anus or the genital organs, the oxyuris should be suspected and sought * Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 19, 1903
for. There are no especial symptoms produced by the roundworm or the tape-worm, and we can diagnosticate the presence of either only by seeing it. The round-worm may produce a feeling of discomfort or colic in the region of the umbilicus. A distended abdomen, a ravenous appetite, picking at the nose, extreme restlessness and gritting of the teeth during sleep may be mentioned as symptoms. None of these symptoms, however, can be depended upon, and an anthelmintic is. required to determine whether the parasite is present.
The habitat of the round-worm is usually in the small intestine. It may pass through the rectum either with the feces or alone, and may migrate into the stomach, esophagus or nose. The diagnosis of the presence of these, as of other intestinal parasites, can be made only by finding the worm or its ova. When they are suspected, an enema of clear water should be given. If the parasites are present they will be dislodged, and careful inspection will disclose their presence. As to the ova, however, I admit that I am not an authority on worm eggs, and if I have ever seen one I did not recognize it.
Our knowledge of the diseases of the intestine is exceedingly limited, and is especially so where infants and young children are concerned. It is particularly important to diagnose affections in children early, from the fact that children succumb much more readily to the early stages of a disease than do adults, and may die before the later and more characteristic symptoms of the disease develop. In many cases we can arrive at only approximate conclusions as to the actual condition and the prognosis which should be given. Various reflex nervous disturbances in children are caused by animal parasites which infest the intestine. It is not, therefore, presuming too much to consider them the cause of many of those undefinable nervous manifestations which we cannot classify.
We should then look first to that region where the stress of the symptoms appears. This is usually in the lower ileum and colon, and frequently in the colon only. We cannot always depend on drugs to dislodge these various parasites. Drugs strong enough to kill the parasites will injure the mu