structure of the urethra, enlarged prostate stone in bladder or mere atony of the bladder. It is surprising how quickly the retained urine in an over-distended kidney pelvis can become infected and changed to pus, and a harmless hydronephrosis transformed to a dangerous pyonephrosis. This is due to the fact that the mere distention so changes the integrity of the lining epithelium of pelvis as to leave it a ready prey to any bacteria that may be floating in the urine. Until quite recently we have been inclined to regard floating or movable kidney rather lightly unless mechanically it interfered with some other organ or produced some reflex trouble. But a more careful study of the causes of suppurative nephritis has given us unmistakable evidence that a floating kidney is almost without exception doomed to become a diseased kidney in the course of time. This comes about through the buckling or kinking of the ureter, as the kidney descends into or towards the pelvis, and the urine is thus intercepted in its outflow. As the kinking is apt to come on suddenly, and to produce acute symptoms it has been called the Dietl crisis, after the man who first called attention to it. The crisis is characterized by sudden pain in the kidney region, nausea and vomiting, faintness, suppression of urine, to be followed later by polyurea. If now these crises occur frequently and the kidney pelvis becomes more and more distended after each crisis, it is only a matter of time ere the retained urine becomes infected and we have pyonephrosis. Following it still further, this retained pus in the kidney is not content to remain in the pelvis but insinuates itself into all the tubules, carrying destruction wherever it goes, and soon there is but a kidney shell left composed of thickened capsule enclosing shreds of cortical substances, blood clots and pus. I have had recently three well-marked cases illustrative of this type.

Stone in the pelvis of the kidney and stone in the ureter will act similarly to the kinking of the ureter, and produce the same. results, but with more serious and rapid consequences. We know full well that a kidney, no matter how badly riddled with pus abscess, will continue to do duty a surprising length of time, provided it has full drainage, drainage, of course, being through the medium of an open ureter into the bladder and on through the urethra. But once let that highway become blocked for any length of time and the kidney goes to pieces very quickly, or a general septic condition follows. I have but briefly gone over the pathology of suppurative nephritis. A minute consideration of the subject would easily consume a whole afternoon, but what we, as practical men and women, are more interested in is the treatment of the disease. Could we in every case recognize the red-flag symptoms that are waved so early in the case, such as bloody urine, great sensitiveness in the kidney region, the presence of abundant albumen and casts, we would at once seek to relieve the kidney of all work possible by keeping the bowels open and obliging the skin by means of baths to do the work. Then add no extra

work to the kidneys by keeping the patient on the lightest possible diet, such as milk. This with the indicated remedy would in the majority of cases if applied early enough result successfully.

After the suppurative process has been really established in the kidney there is still hope of cure without operative measures, but the secret is in drainage and elimination. Flushing of the kidney by means of the urethral catheter may in some cases effect a cure together with rest, diet, and posture. The patient should be kept in the sitting rather than the reclining posture most of the time. Massage of the kidney is an excellent method of aiding drainage if given scientifically. By this means, also, we can determine the quantity of pus in the kidney without catheterizing the

ureter.

When the disease process has gone so far that the palliative treatment is of no avail, or when there is evidence that the affected kidney is not functionating, as can be demonstrated by catheterizing the ureter, or when the size of the kidney is such as to make its presence a menace then radical surgical methods must be used. Nephrectomy is the only operation which will be of much avail in such cases.

It is both surprising and gratifying to find the absolute comfort and good health which a patient so generally obtains after the removal of one kidney. Nature seems only too willing to pass the burden of elimination to the other kidney and to effect the change with a minimum amount of disturbance. But, of course, the prime consideration in such an operation is always the assurance that the other kidney is equal to the task. I am well aware that I have not mentioned a great factor in the causation of suppurative nephritis, namely, tuberculosis of the kidney, as well as sarcoma and carcinoma. But these subjects should be considered apart by themselves.

The progress made in the past few years to a better understanding of the action of the kidneys under the stress of infection is due largely to our laboratory workers, and that knowledge is proving of immense practical benefit both to internist and surgeon. For its application means the arrest of many an acute form of nephritis and the surgical eradication of many a chronic suppurative nephritis.

TUBERCULIN IN SURGICAL TUBERCULOSIS.-Stern of Cleveland has written an extensive article in the Cleveland Medical Journal upon the above subject. Among other things he says:

"In the treatment of surgical tuberculosis, the use of tuberculin has been followed by favorable results in my hands. I can only repeat what I reported to this society one year ago. My results have been uniformly better, my patients have arrived at the point where they could be discharged from active treatment in shorter time (although they must continue to wear a protective brace and keep up their fresh air and forced feeding cure for at least two years thereafter), and my complications, although few before, are still less in number and severity."

THE IMPORTANCE OF CAREFUL MEASUREMENT OF

REFRACTIVE ERRORS.

BY ALBERT W. HORR, M.D., Boston, Mass.

There are four essentials to the fitting of accurate glasses: I. A thorough knowledge of the eye, its anatomy and physiology, and its relation to the other organs of the body. A thorough knowledge of physiologic optics.

2.

3. Patience and persistency in applying this knowledge to individual cases.

As large an experience in actual practice as it is possible

to obtain.

In these days, when an ever-increasing number of people. are advertising in the public prints and by circular, calling themselves Refractionists, Optometrists, Eyesight Specialists and the like, claiming superior qualifications for fitting glasses and the ability to relieve every symptom of eye strain, as well as many other symptoms due to causes entirely outside the eye, we cannot too strongly emphasize the importance of thorough preparation for such work and the great difficulties to be overcome in prescribing correct glasses. A few weeks of the study of optics with more or less practice with the trial case cannot teach one to fit glasses. A medical education is a prerequisite.

The majority of our patients come to us suffering from reflex symptoms. The eyes may or may not be the cause of the distress; and if the eyes, the trouble may be refractive or a result of muscle imbalance, or more probably a combination of both. A knowledge of the general physical condition of the patient is most important. Temperament, the condition of the nervous system, chronic constitutional diseases, all have their bearing on our success. These can be found out and given their due weight only by a trained medical mind, and then only by thorough study of each case. Routine will not suffice; we must individualize with the utmost discrimination. The fitting of glasses is much more than covering each eye alternately and finding the lens which will give the uncovered eye the clearest vision. Many things must be considered; first, we must learn the condition of the refractive media of the eye, and in trying to measure the error, employ many methods of test. Objective tests are as important, if rightly understood and intelligently applied, as subjective. We must know and use the ophthalmoscope, our most important instrument, the retinascope, the keratometer, the perimeter, in our objective examination; the trial case in the subjective. If the results of these varied tests. do not agree,—at least approximately, we must carefully go over them again and again, seeking to eliminate in every possible way any source of error. Even with the utmost care, with the most painstaking use of all the instrumental aids, there will be.

I believe, a large proportion of cases which will prove unsatisfactory unless a cycloplegic is used to paralyze the accommodative muscle. A reliable cycloplegic is essential. Because it has not been used, far too many have obtained only partial relief from the wearing of glasses, or after many fruitless attempts at wearing them have given up in despair. The ideal practice, I firmly believe, would be to use atropin in the eyes of every patient under forty years of age and in some instances in those of older persons. This method, though ideal, is, in many cases, impracticable. Those of our patients who are dependent on each day's wages cannot give up a week, ten days or two weeks in order to have their eyes thoroughly examined. Many others have a great fear of belladonna in the eyes, and it is difficult to persuade them that the atropin will leave no permanent effect. When, however, a cycloplegic can be employed, the superior results obtained fully compensate for any inconvenience it has caused. Especially is there need of paralyzing the accommodation in the case of children. I have come to believe that without such a proceeding the wearing of glasses by children is, in the majority of cases, worthless and too often does harm. The experience of many years in the Dispensary and Out-Patient Department clinics has taught me the impossibility of correct results, no matter how painstaking the examination may be, without the cycloplegic. If children's eyes cannot be examined during vacation it is much better to lose a week or two of school than to put on guess-work glasses. I think I am right in saying that in this, the observation and experience of most of my colleagues will bear me out. If we cannot obtain the increased knowledge afforded by the use of atropin, or, perhaps, one of the other quicker but less reliable cycloplegics, the utmost care must be used, together with a goodly degree of patience in the application of all the instrumental aids.

When we have measured the refractive error as accurately as possible, we may find in many cases that we have advanced only one step toward prescribing proper glasses. We must, as carefully, examine the condition of the extrinsic muscles, and if we find heterophoria (muscle imbalance) we must learn the effect of our lenses on this condition. Do the glasses- increase or decrease this tendency? Can we by increasing or decreasing the strength of the lenses modify the muscle strain? Will a slight decentering of the lenses relieve the symptoms or shall we incorporate prisms into our glasses, and if so, of what strength? What part of the theoretically correct prism will give the desired relief? What strength of prism is practical for everyday wear? These and many other questions arise before us and each and all must be given due weight.

If the symptoms of each case are painstakingly studied in their relation to possible disease of other organs, we may sometimes find the eye symptoms are due, not to refractive error or

primary disease of the eye, but to some more or less obscure lesion, or functional disorder of the nerves. Some such cases of neurasthenics will doubtless occur to many of those present. Yet, I believe it is true that in a good proportion of such cases, if refractive error or muscle imbalance be found. at least a measure of relief can be had by wearing glasses, if the prescription is made only after a careful and prolonged examination where knowledge of the eye and its refractive media is supplemented by thorough attention to every detail of the case.

A FEW REMARKS ON NOSE AND THROAT TROUBLES.

BY T. M. STRONG, M.D., Boston, Mass.

Conditions Causing Obstructed Breathing.

Or

Obstructed breathing arises from many conditions, adenoids, except in young children, playing a minor part. There may be the narrow choana, due to close approximation of the nasal and maxillary bones, so that very slight swelling of mucous tissue, the result of vaso-motor irritation, produces more or less contact. the turbinated bones and overlying tissues may be enlarged, either together or singly, vascular or hypertrophic. The vascular, intumescent, cavernous enlargement reduces more or less completely under cocaine; the hypertrophy, on the other hand, very slightly. If the main trouble seems to lie in the mucous tissue, then local and constitutional treatment will oftentimes give marked relief. The local treatment consisting of cauterizations, iodine, tannin and glycerine preparations; the constitutional, in regulating the diet, cold baths or sponging, with brisk rubbings, walking in open air as well as sleeping, the avoidance of tight collars or wraps. around the throat, except in severe weather. A number of remedies may cover the conditions, the leading ones being aconite, Baryta carb., calcarea carb., the mercuries, nux vomica and pulsatilla. If with the shrinking of the mucous tissues the underlying bone shows up out of all proportion to its surroundings, there is nothing to do for reasonably permanent comfort, except the resection of a part of the bone. When the bone simply dips into the inferior meatus and is thin, a section off this lower edge will be sufficient, but when the body of the bone is enlarged then a portion of this must be taken, the amount varying with each particular case. In either case the cut should be outward, upward and backward so as to thoroughly include the posterior end of the bone and tissues, for it is here, as a rule, that the greatest obstruction exists. On account of the free vascular supply in this region it easily swells and of entimes lo is the posterior choana, especially when lying down. This constant dilatation, hypostatic through the long hours of the night, associated with other catarrhal conditions, continued through season after season, finally produces the resisting irreducible hypertrophic tissue. This tissue appears in the postnasal mirror as a shining greyish mass. Removal is ac