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blood; has a mucoid appearance, does not coagulate as readily as other blood, and wells up from the kidney like perspiration from the pores of the skin. This was well demonstrated in the operation this morning. It is undoubtedly this local bloodletting, which is free in proportion to the existing engorgement, together with the massage which the kidney receives in the manipulations to strip it of its capsules, which empties the uriniferous tubules and counteracts any ill effects that might otherwise arise from the anesthetic.
Men who have closely studied the urine of nephritic patients have frequently seen that in spite of the lessening of casts and other cellular elements, uremic symptoms increase. We see a similar condition in diabetics, that is, lessening or total arrest of sugar excretion, but rapid and fatal acetonemia. How is this explained? Simply by blocking up of the tubules of the kidney by the granular detritus-like casts, renal cells, blood and leucocytes, in the nephritic cases, and by sugar and the resulting swelling from irritation in the case of diabetes. Purely and simply it is a mechanical condition, explained on mechanical grounds.
Massage applied to the nephritic kidney without its exposure might prove dangerous, for the reason that it has been demonstrated that sixteen out of twenty-one floating kidney cases showed blood in the urine after more or less prolonged manipulation. (Quoted from Edebohls.) There was no blood present before the manipulation. Massage with the kidney exposed will empty the venous and lymphatic capillaries, absorption will.be hastened, and the tubules of the parenchyma -the partially or completely blocked drainage tubes, if you please-will be assisted to empty themselves into their true channels, the pelvis and ureter. I believe this to be the true explanation of the immediate benefits, for the reason that in my cases the first urine passed after the operation was richest in cellular elements and uric acid crystals. Halstead deliberately kneads the kidney, and I have practiced the same expedient in my cases. In parenchymatous cases this kneading must be done with care, the kidney being soft and mushy. A word as to the indications for this operation. So far it has only been the advanced or otherwise hopeless cases that
have been operated upon. In spite of this the results have been comparatively favorable. To say that the results will still further improve with more timely operative interference and improved technique, is not overstating the proposition.
You all know that it is not so long ago that appendectomy was, so to speak, a dernier ressort. Today it is a recognized fact that the sufferer's life is conserved by an early operation, and that a physician, morally speaking and sometimes legally too, is guilty of neglect of duty when he fails to consult or disregards the opinion of the qualified surgeon in such cases. May not the same thing be said some day of renal decortication? I never take up the mortuary statistics of this city without noting some deaths from uremia or Bright's disease. The same is true of other cities. Give these patients a chance. They have a right to it, they expect it. Only don't wait until too late and then lay all the blame on the surgeon.
The indication, then, is any form of chronic Bright's disease in which the patient has at least one month's lease of life before him. My own cases have been of the diffuse and parenchymatous varieties, but, according to Edebohls, the interstitial form does best after this operation. This is paradoxical, to say the least, since connective tissue overgrowth is nearly always a late sequence of parenchymatous nephritis. Nevertheless, it is experience, and that after all, is the best teacher.
To get the best results from the operation it should be done early, that is, before the heart and arterial system have so far deteriorated as to make after life a burden in spite of improved kidneys. It is well to remember that the blood poisoning, the uremia, is responsible for the cardio-vascular degeneration, and consequently should be checked early. It can be safely stated that the better the heart and arterial system the better the prognosis.
As to the operation itself. It is performed with the patient on his face over an Edebohls air cushion. Locate the margin of the erector spinæ muscle and cut from the last rib to the crest of the ilium alongside this muscle without opening its sheath until the quadratus lumborum is reached; then cut alongside this muscle and through the anterior layer of the
lumbar fascia, when the peri-renal fat, which is canary bird color, will appear. This should be freely incised and stripped from the capsule proper of the kidney. Adhesions are frequently encountered as a result of peri-nephritis, and often separated with difficulty. It is very easy to tear through this fat in certain places into the peritoneal cavity. After separating the fatty capsule an attempt should be made to bring the kidney to the surface, when the stripping and removal of the capsule is easily and quickly done. When this delivery is impossible, the capsule is incised in the depths of the wound, stripped, and as much as possible cut away; the rest will curl up toward the pelvis and give no trouble. When much dropsy is present, a few strands of silk wormgut are left in the depth of the wound for drainage, to be removed on the third day. The muscles and fascia may be brought together with through and through forty day catgut or in layers. In very muscular subjects I prefer the latter. I sutured in layers in the case operated upon this morning. The skin is united by catgut subcuticular sutures. I see no objection, however, to using adhesive strips. Every precaution against sepsis must be observed, for these cases have much lessened resistance. Rubber gloves should be worn by both operator and assistants. Ether has been the anesthetic in all the cases I have seen and done. In conclusion I want to thank the internes and nurses of the Memphis City Hospital - the former for their careful urinalysis reports, the latter for complete bedside notes and operating room facilities.
THE FINSEN LIGHT CURE.
H. JOHN STEWART, M.D.
HAVING read and heard so much about the Finsen light treatment in the cure of disease, I decided in April of this year to make a personal investigation to see and learn for myself if it was true that such diseases as lupus and rodent ulcer could be cured by light. I visited several institutions where the Finsen lamp was in operation. In Manchester,
England, in the Salford Skin Hospital, they had a Finsen light department under the supervision of Professor Brooke, who informed me that they were unable to treat half the sufferers who applied for treatment, and they had solicited by public subscription $125,000 for the erection of a new hospital for skin diseases, whereby they would be enabled to enlarge the "light department" so at least two hundred people could be treated daily, as there were people on their waiting list whom they would be unable to treat, with their present facilities, for an indefinite time. Professor Brooke was most enthusiastic over the wonderful results they were obtaining there.
I next visited the London General Hospital, of London, England, and found they were just completing an immense light department that had been established by the present Queen of England, then Princess of Wales, in 1900, who presented the first lamp at that time, and as it was found to be far too inadequate she had just given a second lamp, and Alfred Harmsworth had also given $50,000 for the perpetual endowment of another Finsen lamp in this department, and they were then building a platform on which to receive the King and Queen, whom they expected to come June 11th to dedicate this new department. Even with these increased facilities, I was informed by Professor Sequirey, there were patients on the waiting list who were unable to receive treat
I next visited the Light Institute at Copenhagen, and found that all the statements that had been made regarding it were not in the least exaggerated. I had the pleasure of meeting and studying under Professor Finsen, and was extended every courtesy by the Professor and his assistants at this institution. He seemed very much pleased to describe in the minutest detail the apparatus, treatment, etc., and gave me a detailed history of the lamp.
The Finsen light is a large specially constructed arc lamp of 20,000 candle power, or twenty times stronger than an ordinary street lamp, and uses from sixty to eighty amperes of current. This lamp burns a specially made carbon which can be procured only at Copenhagen. In the upper holder is a large carbon, while a smaller one is used in the bottom
holder; when properly adjusted for arcing a maximum number of violet and ultra violet rays are produced. The advantage of the Finsen lamp over others is in the greater number of violet rays produced. The Finsen lamp produces a much greater number of chemical rays than sunlight, as the atmosphere absorbs a large percentage of these rays. The light is so intense it is impossible to look at it with the naked eye, and it is necessary for all the attendants and patients to wear dense smoked glasses while the lamp is in operation; an aluminum hood about two feet wide surrounds the lamp, which hood is fringed on its lower border with a deep crimson-colored paper skirt to further aid in excluding the diffused light from the patients.
The concentrated rays are carried from the arc to the patient through four telescopic tubes, known as converging tubes, suspended at an angle of forty-five degrees, the tubes containing a series of rock crystal lenses so arranged that reservoirs for running water exist between them. By means of the water screen and rock crystal lenses all rays but the violet are eliminated, and these rays are converged and concentrated, thus vastly increasing the healing and bactericidal effects.
The heat from the original arc is so intense that to prevent cracking of the lenses and discomfort to the patient, a stream of cold water is kept constantly circulating through the reservoirs or water screens.
To further concentrate and cool the rays a compressor is provided which consists of two rock crystal lenses so arranged that a chamber for running water exists between them. This part of the apparatus is used to compress the affected area and make it bloodless during the treatment, thus facilitating deeper penetration.
The Finsen are light has been used with marked success in curing many skin diseases thought until this time incurable, especially lupus and rodent ulcer. During a period of six years the Finsen Medical Light Institute at Copenhagen has grown from a very small shed, where they were able to treat only one patient at a time, to a magnificent institution where they are now treating three hundred people daily, and light institutes have been established in Loudon, England; St. Pe