cent; kidney about one-half the size it was at the time of operation. He says he feels 'all right.' April 3, 1904: The patient has performed farm labor of all kinds for several months, and says he feels as well as ever. Urine normal; kidney cannot now be palpated." CASE 4.-In conversation with Dr. W. H. Bodenstab, of New Salem, N. Dak., the other day, he told me of a case of subparietal injury of the kidney that he had been called upon to treat, and kindly furnished the following history and account of the case: “Harry L——, aged 14 years, was kicked in the abdomen by a horse, on the 25th day of July, 1903, about 9 o'clock in the morning. I saw the patient about 12 o'clock; he was very anemic; pulse 120, very small in volume, and easily compressible. He had vomited several times before I saw him. Upon examination of the abdomen, there were found several small ecchymotic spots a little below and to the left of the umbilicus. The boy could not tell on which side he was struck, so he must have been unconscious for some time. The abdomen was distended and tender, especially on the right side, and the bladder could be felt above the pubic bone. He had not passed urine, so I catheterized him, and drew off about 20 oz. of apparently clear blood. Patient was taken to the hospital, and fearing an internal hemorrhage, an operation was decided upon. This was about 8 o'clock in the evening. An incision was made in the linea alba, and the peritoneum opened. There was no blood in the peritoneal cavity, but the small intestines presented a number of hemorrhagic areas. The bladder was apparently uninjured. Behind the peritoneum, on the right side, was found a dark, bulging, fluctuating mass. The median incision was at once closed, and another made in the right lumbar region. About a pint of blood, mostly clots, mixed with urine, was removed. The wound was not in a condition for examination of the kidney, and since the hemorrhage, apparently, had stopped, no further exploration was made. The wound was packed and drained. The discharge for a long time had the odor of urine, but that finally ceased. The abdominal wound healed without complications, and the intestines regained their vitality. On Sept. 15th the patient had regained his strength, was eating well, and felt perfectly well. There was left at that time a small sinus, which was discharging slightly. The last I heard of him he was getting along well. The boy left for the state of Washington on Sept 15th, and that was the last I saw of him. Upon inquiry, I was informed that he was doing well. Of particular interest is the fact that the external signs of injury were on the left side while the right kidney was the one injured." In case I particular interest centers in the late perirenal extravasation of urine, no doubt due to solution of continuity in the fibrous capsule, about the eleventh or twelfth day after injury, and to the lengthy persistence of the urinary fistula, with its final and permanent closure. In case 2 the great amount of hemorrhagic effusion indicated a serious laceration or rupture, and it is quite remarkable that there was no urinary extravasation. Especially noteworthy in this case, however, were the anesthesia, edema, gangrenous skin areas, and indolent ulcers of the right foot, coming on over a month after the injury to the kidney. Case 3 is interesting because of the intracapsular hemorrhage, great enlargement of the kidney, and the serious and prolonged hematuria. In case 4 (Dr. Bodenstab's) the noteworthy fact was the external signs of the application of the injuring force to the left side, while the right kidney was the one actually injured. From this series of four severe cases, all recovering without nephrectomy, it would seem that the inference to be drawn is that nephrectomy should only be performed early, when the renal vessels are known to be torn, or when there is such unmistakable disorganization of the kidney structure as to make it reasonably certain that resumption of function cannot be expected. NASAL SUPPURATION FROM A PRACTICAL STANDPOINT E. H. PARKER, M. D. Minneapolis According to the period in life, a purulent nasal discharge in the new-born infant usually means a syphilitic or blennorrhagic rhinitis. In childhood before the age of fifteen a chronic bilateral purulent discharge usuallymeans adenoid vegetations, while a unilateral discharge most commonly means a foreign body, especially from the age of two to five, when children are most inclined to push small objects into the nose. A child of five years of age was referred to me for an odorous, one-sided, purulent discharge of seven months' duration, the cause of which was found to be a shoe-button deeply imbedded between the inferior turbinate and the septum. The parents had no knowledge of the entrance of the foreign body, and supposed the child to be suffering from catarrh. Less frequently in childhood we may have an acute diffuse nasal suppuration from such infections as diphtheria, gonorrhea, etc. In adult life nasal suppuration is practically always due to localized disease, not to diffuse suppuration of the nasal mucous membrane. Many causes of nasal suppuration might be enumerated, such as syphilitic ulceration with necrosis of bone, degenerating malignant growths, and non-malignant growths or enlargements causing nasal obstruction may give rise to purulence by stagnation of normal secretions. Tubercular ulceration is rarely seen in the nose except in the last stages of pulmonary or general tuberculosis. By far the most common cause of nasal suppuration is disease of the accessory sinuses, and they constitute a large proportion of the nasal affections which come under the notice of the general practitioner. I think it is safe to say that most of these cases pass through the physician's hands with a diagnosis of catarrh, and the patient goes through life, perhaps, with pus and its attendant complications acting as a continual menace to health. Without going into details of anatomy, the accessory sinuses may be considered as a series of bony cavities surrounding the nasal passages into which they open, therefore liable to inflammation by extension from the nasal cavity. The sinuses are usually not present at birth, but are formed by absorption of cancellous tissue, reaching maturity at about the time of the eruption of the wisdom teeth. The antrum begins to develop soon after birth, the frontal sinus from one to two years, and the sphenoidal sinus from three to six years of age. On account of their small size it is not common to find disease of the accessory sinuses before the age of fifteen. Ball found, in twenty-nine consecutive cases of purulent rhinitis in children under fifteen years of age, twentythree affected with adenoids, four with foreign bodies, and two with empyema of the antrum. The average size of the mature sinuses is about as follows: Antrum, 11⁄2 by I by 14 inches. Ethmoidal-variable in size and number. All are large enough to harbor a dangerous amount of pus. The sinuses are best considered in two groups, according to the position of their natural openings of exit. The anterior group, consisting of the antrum, anterior ethmoidal cells, and frontal sinus, has its exits close together beneath the anterior end of the middle turbinate in the middle meatus. The posterior group, consisting of the posterior ethmoidal cells and the sphenoidal sinus, opens into the nose above the middle turbinate. The frontal sinus has its exit at its lowest level, thus favoring drainage and spontaneous cure. The antrum and the sphenoidal sinuses have their exits unfavorably located high up, rendering drainage very poor in case of suppuration. ETIOLOGY. The etiology of sinus empyema is no longer obscure. Through bacteriology we find most constant: influenza bacillus, diplococcus pneumoniæ, staphylococcus pyogenes albus and aureus, streptococcus, and even KlebsLoeffler bacillus has occasionally been found. We therefore find acute infectious diseases responsible for most cases, of which influenza is most often accompanied by suppuration of the accessory sinuses. Next in frequency we find measles, scarlet fever, typhoid fever, croupous pneumonia, variola, diphtheria, and erysipelas. By transmission from disease of neighboring organs, dental caries is responsible for many cases of antrum disease. Suppurating adenoids constantly provide a ready supply of infective material, and are responsible for more sinus disease than is generally supposed. The sinuses may become infected through traumatic causes, especially the frontal and antrum. Suppuration may be transmitted from one sinus to another. Chronic diseases more rarely produce sinus disease, such as tuberculosis, syphilis, malignant growths, etc. The pathology of acute sinus empyema is that usual to mucous membrane, namely, congestion, swelling, and infiltration with round cells. In the chronic form the mucous membrane is converted into a pyogenic membrane, thickened by connective tissue, destruction of glands, and much of the epithelium; often granulation tissue, polypi, polypoid degeneration, cysts, and necrosed bone. A closed empyema is formed when obstructive swelling closes the natural exit, when we get rapid distension, perforation, secondary abscess, fistula, etc. |