and unaided, bring about a cure, and states that operative measures are only of value when used in conjunction with proper hygienic and general treatment.

As a general rule, in tuberculosis surgery should be practiced only when the surgeon is driven to operate by necessity, because Nature makes a very determined effort to isolate and encapsulate the primary foci of this disease.

The theoretically ideal treatment would be a complete removal of the tuberculous area at the time lit is small and distinctly localized, but practically these cases are not diagnosed until after a complete removal of the focus is impractical or impossible.

The non-operative treatment will have for its purpose the assisting of Nature in her efforts to overcome the disease by isolation and starvation. The chief of these agencies is rest; others are fresh air, sunshine and food. In cases of "cold abscess" do not incise unless it must be done to prevent a spontaneous rupture.

Excision is followed by the best results in the knee joint, because it is much more easily exposed than are the other joints, and a complete extirpation of the infected tissue can be made more readily.

Tuberculous glands of the neck are rarely a primary condition. After internal and local treatment, with proper hygienic and dietetic management have proved ineffective, operative measures should be resorted to. If both sides of the neck are involved, the operation on the second side should be done after an interval. The glandular mass with the intervening tissue should be re

moved in one piece. Recurrence, i. e., enlargment of glands overlooked at the time of the operation, is not uncommon. Subsequent pulmonary involvement is rare.

In tubercular pleurisy the diagnosis is arrived at only by finding the bacilli in the fluid. When serous, aspiration is usually all that is necessary to bring about a cure. But when purulent, it must be treated as an ordinary empyema.

In tubercular peritonitis the diagnosis is frequently very difficult, cholecystitis and appendicitis being perhaps the most frequently mistaken conditions. Attention is particularly called to the temperature and the presence or absence of an afternoon rise.

Arguments and conclusions in favor of the medical and the surgical treatment of this condition are quoted at length to show the variance of opinion.

In conclusion, he says perhaps one will not be seriously mistaken if he gives these patients the benefits of hygienic and medical treatment, and advises operation in those who do not improve under it.

L. R. Williams (Medical News, March 18, 1905) recommends the open-air treatment of surgical tuberculosis along the same lines that are being carried out in pulmonary types of the disease. Fresh air, sunshine, rest, plenty of food and sea bathing, in conjunction with general treatment and special attention paid to the digestive tract, including the mouth and teeth, has been followed by very satisfactory and encouraging results in his hands at temporary hospitals on Coney Island.

The patients were poor children from New York, and all forms of surgical tuberculosis were encountered.

MOVABLE KIDNEY.

Sprigg (Am. Jour. Obst., Dec. '04) comments upon the principal causes of the failure of nephropexy, and these are herewith enumerated:

1. Delay in operating until the health of the patient is seriously impaired.

2. Failure to properly prepare the patient for the operation, and thus avoid vomiting, which may loosen the kidney

from its new attachment.

3. Chronic enteroptosis as a complication of nephroptosis. In such cases after the kidney has been anchored the general viscera must be supported by proper bandages in order to attain sucfcessful results.

4. Delay in operating until the kidney has become seriously crippled or an incurable inflammation of the organ developed.

5. Faulty insertion of the sustaining sutures, tearing out, or too rapid absorption.

6. Failure to completely detach the fatty capsule from the capsule proper, so as to separate the organ from the colon and duodenum on the right side, and the colon and small intestine on the left side.

7. Attachment of the kidney too low down where it will be subject to pressure by constricting waistbands, or when the suspension sutures are placed too near the lower pole, thus allowing the upper pole to fall forward or to form a flexure of the kidney.

8. Too early removal of the sustaining sutures or too early absorption of the fixation sutures.

The following deductions are therefore offered:

I. That the relief obtained from bandaging in any case of movable kidney will depend on the presence and degree of associated enteroptosis.

2. That fixation of the kidney in as nearly a normal condition as possible is the correct method of surgical procedure.

3. That in all cases where the relief of the symptoms can not be obtained, from either bandages or correct corsets, nephropexy is indicated.

O. M. S.

A CASE ILLUSTRATING SOME POINTS IN THE TREATMENT OF MOVABLE ! KIDNEY.

Grey (Edinburgh Med. Jour.) describes the case of a woman who had been operated on for movable kidney four years before being seen. For two years much relief ensued, but after this there was a gradual return of the symptoms. A month before being seen she had a fall, and from this time the complaint became greatly aggravated. Pain in the right side was severe, intensified on exertion and on standing. It was relieved by lying down. Severe retching came on in attacks, and on several occasions she had fainted. During the attacks there was frequency of micturition, and at times she was suddenly compelled to pass large quantities of urine, after which the pain was lessened. In very severe attacks blood had been noticed in the

urine. Her life was made wretched and she suffered from sleeplessness.

As she was a stout woman, palpation of the abdomen was difficult. There was great pain over the right side of the front of the abdomen and the region was tender on pressure, as also was the lumbar region on the same side below the scar of the incision. No satisfactory examination could be made, only when the patient inspired deeply was there a suspicion of a movable kidney being present; then the tenderness was increased while the hand was pressed back into the region of the kidney. Chloroform was administered, but examination under these conditions gave no further assistance. The urine was normal.

Operation was performed on Dec. 4. 1903. The right kidney was found to be firmly fixed (apparently) to the abdominal wall by strong fibrous adhesions. There were also two dense fibrous bands stretching across the front of the ureter about one inch below the kidney. Further examination proved that the upper three-quarters of the kidney were quite free from adhesions. While this portion was being palpated, the kidney suddenly swung downwards and forward so that its upper pole faced to the opposite iliac region. Clearly then, in the erect position, or on exertion, the organ might assume the transverse position described; the rotation of the kidney would thus tend to kinking of the ureter at probably two points. gall bladder and the appendix were both found to be normal. The under

The

surface of the liver was studded with hard nodules, the size of a split pea, and of grayish color. The nodules did not strike the author as being either tubercular or malignant. The peritoneum elsewhere was normal.

The kidney was freed from adhesions; in its lower portion the capsule had to be incised and shelled off. The fibrous bands over the ureter were divided. Strips of gauze were packed round the kidney, leaving its pelvis quite free. The ends of these strips. were brought out of the posterior part of the wound, the rest of which was sutured. The gauze was kept in posi

tion for seven days. tion for seven days. The strips were then removed under gas anæsthesia, and a thick drainage tube was inserted down to the kidney. The patient remained recumbent for one month. All symptoms, except sleeplessness, disappeared, and she was able to return to her duties.

The writer says that, by many, the operation of nephropexy is regarded as somewhat useless. He says that the operation is followed by an unneces sarily large number of failures. In some cases the kidney is as movable as before the operation; in others, the organ remains apparently fixed, yet the symptoms continue, or even become aggravated. This latter result was that which followed in the author's

case.

He believes that failure to fix the kidney is due to the fact that no effort is made to remove the layer of peritoneal fat which is found between the kidney and the abdominal wall. Should a fatty pad be left between the

kidney and the comparatively fixed abdominal wall, it is not easy to see how success can be attained. He does not use strips or special supports to the lower part of the kidney. These secure strong fixation of the lower part, but unless similar fixation can be secured for the upper portion of the organ, the symptoms due to rotation, as observed in this case, may, very probably, ensue.

During late years, the author has always examined the condition of the gall bladder, the bile ducts, pylorus, appendix and broad ligament, in all cases in which the diagnosis was doubtful. As he observes, it is often difficult to ascertain whether the case is one merely of movable kidney, or whether some affection of the parts just referred to is present as a complication. Palpation of these parts, which can easily be effected through the lumbar wound, will settle the matter. (Cher. Med. Jr.)

THE ETIOLOGY OF APPENDICITIS.

In the Annals of Surgery for March, 1905, C., Van Zwalenburg speaks of "The Relation of Mechanical Distension to the Etiology of Appendicitis." He states that the four conditions in the etiology of appendicitis are: concretion, constriction, pathogenic germs (which are always present), and distension. One other necessary condition is the hydrostatic pressure in the diseased appendix. Pressure upon the blood-vessels in the interior of the appendix lowers the resistance and the germs do their work. If continued, it

obliterates blood vessels, and produces necrosis and gangrene.

Many attempts have been made to explain the vascular changes by trauma, or pressure from concretions, foreign bodies, kinking, or torsion; but the fact that fluid can produce pressure upon blood vessels as well as solid bodies has been overlooked.

With the occlusion of the lumen of the appendix, there are three different fluids concerned in the process, each subject to different pressure and separated only by thin membranes. These are those of the veins, the lymphatics, and the fluid in the occluded cavity. The result is increased pressure, impeded circulation, lack of resistance of the cells, and infection. Following the infection there is complete strangulation, necrosis, and gangrene, if the pressure is not relieved.

The obstruction may be a kinking of the appendix, or even a plug of mucus of a fecal mass within the cæcum may close the opening of the appendix.

The degree of distension necessary 'to cause infection is still uncertain. 'Van Zwalenburg has made extensive experiments upon dogs, which are reported in detail in the Journal of the American Medical Association, March 26, 1904.

The germs involved in the process are normally present in the appendix in health.

The suddenness of the onset in many cases can hardly be explained except on the ground of a sudden mechanical change having taken place, and the sudden cessation leads to the same conclusion.

The author also asks the pertinent question, "Why is the necrosis or gangrene confined to the portion beyond the stricture unless that stricture is to blame for it?"

The practical bearing of this view rests upon a possible better understanding of the pathological changes that are taking place, and, therefore, a more rational interpretation of the signs and symptoms and their relation to each other, with a resulting increase of accuracy in the diagnosis, prognosis and treatment of appendicitis.

In the lay press considerable prominence has been given to an article by Joseph Kidd of London, in which the cause of appendicitis is attributed to "chills," when heated, especially after violent exercise, hurried eating and imperfect mastication, and, of most importance, the excessive use of aperient waters, salts and liver pills.

The London Lancet, Feb. 11, 1905, pays attention to the last etiological factor given above and concludes that there is little clinical or post-morten evidence in support of the proposition. The explanation that these laxatives remove the watery constituents of the feces and leave a residue at or near the opening of the appendix, is not substantiated by autopsies. The cæcum almost always contains liquid contents, and in autopsies upon those who die of appendicitis large accumulations in the colon are very rare.

The fourteenth annual meeting of the Erie Railroad Surgeons' Association was held last week in the Hotel Astor. Dr. F. A. Goodwin, of Susquehanna, Pa., presided, and about fifty physicians were present. Papers

Clinically, appendicitis occurs in young adults, and these drugs are not as a rule habitually taken at that time of life. Appendicitis is more common in men than women, still constipation is much more common in women than in men.

Therefore, the Lancet concludes that the use of these purgatives do not, in themselves, cause appendicitis. G. Hauser, in discussing "The Prevention of Disease of the Veriform Appendix,” in the N. Y. & Phila. Med. Jour., June 10, 1905, says: "The most prolific cause of appendicular trouble is probably over-retention of feces, due to the ever-prevalent constipation. A mass of undigested residue in the cæcum and colon undergoes decomposition and causes irritation and inflammation in the region of the appendix."

The prevention of this constipation should begin in childhood, and it must be remembered that the bowels may move naturally daily and still there may be retained within the intestine a large accumulation of feces.

A second cause of but slightly less importance is "indigestion" and the various hygienic and dietetic errors that lead to this condition.

The points in this article, which are practically the same as those of Kidd, will be found to be considered above by this writer in the Lancet.

F. G. C.

were read on many subjects, including the following: "The Eyes of Railroad Employees," "Reflex Pains," "Emergency Hospitals for Shops," and "Some Principles to be Considered in the Handling of Railroad Cases."