Samuel West

The Lettsomian Lectures on some Clinical Aspects of Granular Kidney: Delivered before the Medical Society of London

localised, I felt that neither the Indian rhinoplastic or any of its modifications were indicated. Still less was the Taliacotian method. The following procedure I adopted: The columella having lhappily remained unaffected, I was saved the trouble of making one. I commenced by making an incision a little to the inside of the right ala, and carried it across the extremity of the nose to a corresponding point on the left side. The incision extended as high up as the point corresponding to the lower margins of the nasal bones. This incision was passed through all the tissues into the anterior nares. We

Case of Pyopneumothorax of Several Months' Duration Cured by Free Incision: With some Remarks on the Surgical Treatment of Pneumothorax.

outcome of the lifelong attention I have given to the subject upon which I have addrc Fsed you. The views I have set forth have sprung entirely from experimental physiological work on the one hand, and from practical experience in connection with diabetes on the other. With this foundation, they harmonise with the assemblage of facts to be dealt with belonging alike to physiology and pathology; and, at one and the same time, they bring the whole matter into a state of great simplicity, and supply a working basis upon which the treatment of diabetes may be rationally and reliably conducted. With the glycogenic doctrine the teachings of diabetes are absolutely irreconcilable, and it may, moreover, be said that modern research has removed the support upon which it was originally based. And yet the doctrine still lingers in the mind, influencing its conceptions and shaping its views, for persons seem unable to look at the points belonging to the subject otherwise than through the prepossessions that have been engendered thereby. The chapter, however, will have, sooner or later, not simply to be revised, but completely rewritten; and the sooner this is done the better, I feel I am justified in saying, will it be for the right comprehension of diabetes by the medical profession.

Bronchial Breathing and Râles: A Clinical Demonstration on some of the Difficulties of Auscultation given at St. Bartholomew's Hospital

AUSCULTATION is not really a difficult subject. It requires some little preliminary instruction, and after that its mastery is only a question of attention and practice; yet there is no doubt that it often appears confusing to students. The difficulties, however, are chiefly of our own making, and lie not in things but in words; for the facts of auscultation, their significance, and their relation to pathological lesions, are well known and understood, while the confusion lies in the technical terms used to express the phenomena observed. Among these technical terms the chief offenders are the two with which I propose to deal to-day, namely, bronchial breathing and rales. Technical terms are convenient, but to be really useful they must be strictly defined and accurately used; otherwise they introduce confusion instead of simplicity, and that is the case in auscultation. If we could only get rid of technical terms, and merely describe in simple language what we actually hear, there would be no confusion and little difficulty. Students feel this confusion of terms throughout their career, but most acutely at two periods of it: early, when they are first beginning to study auscultation; and later, when they are preparing for examination. Now, why if the facts are so plain and so easy to comprehend, is so much time and energy spent in discussing the meaning of terms? It is for the simple reason that the different terms are regarded as indicating different pathological lesions. These lesions are the important conditions to recognise, and the use of a wrong term would, therefore, -imply a wrong conclusion as to the pathological condition. Unfortunately, the same term has not always the same significance, that is to say, it does not always, in the mind of every teacher or examiner, correspond with the same pathological lesion, and it is because this difference of usage of terms is not recognised and taught that so much confusion is introduced into the subject of auscultation. I propose first of all to consider what the facts of auscultation are; what their meaning is; and why it is important to give certain of them special names. I shall then be able to show where the confusion comes in, and how it will be possible to avoid it. THE BREATHINGE SOUNDS. As the air passes in and out of the larynx and air tubes it makes sounds which are carried throughout the air tubes by the column of air contained in them. These sounds are very obvious if we listen over the larynx, and they have a certain loudness and certain character. If we listen over the trachea we hear the sounds as before, but with somewhat diminished loudness and different character. Again, over the bronchi-that is, beneath the manubrium sterni in front, or behind right and left of the second or third dorsal vertebrae, the breathing sounds are still heard, but are further diminished in loudness and altered in character. Finally, if we listen in the axilla or at the basebehind-that is, as far as possible away from the air tubes, the breathing sounds are entirely different from those heard in the other places specified. The breathing sounds heard in these various parts have since Laennecs time been called laryngeal, tracheal, bronchial, and vesicular respectively. Pathologically these terms become of significance when they are heard in places in the chest where they should not normally be heard at all. If in places where vesicular breathing ought normally to be heard vesicular breathing disappears, and in its stead some other kind of breathing is heard, the conclusion may be drawn, subject to a few reservations to be dealt with later, that that portion of the lung is in a condition of disease, and the more abnormal the breathing is the greater the pathological changes which have taken place. This is the real reason why so much importance is attached to these terms, for they are regarded as the measure of the pathological change. 6 Over the larynx inspiration is heard as well as expiration; both are loud, noisy as it were, and both have a peculiar character, such as might be produced in a large hollow space as we know the larynx to be. On account of this hollow character this kind of breathing when heard elsewhere is often called, not laryngeal, but amphoric or cavernous. Over the trachea inspiration and expiration are both heard. The sounds are still loud and noisy; though not quite so loud as over the larynx, they are somewhat raised in tone, and have lost some of their hollow character. Over the positions described where bronchial breathing may be heard both sounds are still audible, but with a still higher pitch and a much harsher character. When in disease instead of veEicular breathing other sounds are beard they are called laryngeal, tracheal, or bronchial, according as they approach most nearly to the characters of the breath sounds heard in these respective places. Now let us turn to vesicular breathing, and analyse what it is that we hear in those parts of the chest whieh are far removed from the large bronchial tubes. Here there is little noise: the sounds are muffled, blowing, soft, almost sighing in character, and what is more remarkable is that they are no longer double. We hear the blowing murmur with inspiration, but with expiration we either do not hear anything at all, or we hear the blowing murmur only for a short time during the early part of expiration. Thus vesicular breathing is characterised first by the absence of noise, secondly by its blowing character, and thirdly by the absence, or diminution in length, of the expiratory sound. All the forms of breathing may be represented diagrammatically by lines, the varying thickness of them indicatingthe amount of noise. Thus vesicular breathing may be indicated by a thin line for inspiration, with a very short thin,

A Clinical Lecture ON GRANULAR KIDNEY AND ITS SURPRISES: Being an Address delivered before the East Sussex Medico-Chirurgical Society.

THE signs of granular kidney are usually obvious enough, yet there is no disease that is more often overlooked, even at the present time. The diagnosis, is missed chiefly because the condition is not thought of. For this there are two special reasons: 1. That granalar kidney is for a long time compatible with apparent health-that is, is associated with no striking loss of energy or strengtb. 2. That the symptoms when present may be most misleading, and polnt almost anywhere else rather than to the kidney. Yet the pulse usually gives the indication if properly examined-not the pulse beats, for they may be unaltered; nor the pulse wave, for it may not be characteristic; nor the arterial tension, for this is not at all times high-but the artery itself, which is almost always markedly thickened. Arterial thickening in early middle life is almost always due to granular kidney, and in the elderly to atheroma or to both conditions combined. There is still another form of arterial thickening met with in young athletes. This is a physiological hyper. trophy accompanying the hypertrophy which takes place in the heart, but, with this exception, arterial thickening in persons below 50 should always raise the suspicion of granular kidney, and the suspicion once raised is confirmed on farther examination by the discovery of the characteristic chbanges in the urine, in the heart, and it may be in the eye. If granular kidney, then, be so often overlooked, the diagnosis of it frequently comes as a shock and surprise to patient and doctor alike. There are enormous reserves in the kidney as in every other important organ in the body. It has been shown that as much as two-thirds of each kidney may be removed in animals before life becomes impossible. So in granular kidney the wasting may go on to a very considerable degree before grave symptoms arise, but all this time, as the wasting of the kidney progresses, its reserves become less and less, until at last on some very slight extra demand, or even without any apparent cause at all, the limit may be reached, and the symptoms of renal inadequacy manifest themselves in more or less serious form. So it happens that no suspicion whatever may have been aroused until some grave condition arises which makes the diagnosis only too obvious. It is with these surprises or unexpected first symptoms that I purpose to deal in this paper. The morbid lesions of granular kidney are found in the kidney, blood vessels, heart and eye, and it is in connexion with these organs that the first group of surprises come. The second group is probably toxic, and is composed of conditions which are often described under the heading of acute or chronic uraemia, or, as it would be better styled, acute or chronic renal toxaemia-for example, general cachexia, skin erapticns, violent vomiting or diarrhoea, cramp, gout, headache, epilepsy, and uraemia. This is a long list, but there is something of interest as well as of importance to be said about each item of it. 1. Acuqte nephritis may be the first serious condition to arise in what has obviously been granular kidney of long standing, for accompanying the ordinary signs of acute nephritis there may be found present arterial thickening, hypertrophy of the heart, and even eye changes of a degree or kind impossible in aoute nephritis of short duration. Just as in a child acute nephritis would suggest some recent specific disease like scarlet fever or diphtheria, so in the adult it should suggest antecedent chronic kidney mischief, in all probability granular kidney, the evidence of which is obvious when looked for. This relation of acute nephritis to granular kidney is both of theoretical and practical importance. Acute parenchymatous nephritis, if it become chronic, may, of course, lead to interstitial changes, but even then not necessarily to granalar kidney. It is the common teaching of the day that granular kidneys are of two kinds-the white contracted kidney and the red; that the white is the end stage of chronic parenchymatous nephritis-that is, of the large whitebut that the red is due to other causes. The two forms of contracted kidney exist, it is true-namely, the small white and the small red-but the difference is simply one of colour. Anyway, the theory that the contracted or small white kidney is the terminal stage of the large white is a mere assertion, and is not supported by clinical evidence. With two such common diseases, if acute nephritis often ended in granular kidney there ought to be abundance of clinical proof of it; but this is not so. Per contra, it is well known that cases of granular kidney rarely give any definite history of antecedent acute nephritis. Lastly, acate nephritis is, as I have stated, often found associated with the lesions of antecedent granular kidney. It follows, therefore, that the true reaction between acute nephritis and granular kidney is the exact opposite of what is commonly stated, and that granular kidney is far more often the cause of acute nephritis than the result of it. This relation is also of practical importance, for in such cases of association of the two conditions there can be no question of the acute nephritis recovering to such an extent that the albuminuria will completely disappear. At the best the patient can only be restored to the con. dition he was in before the acute nephritis developed. In this way the persistence of albuminuria and the recurrence of haematuria must be referred, not to incomplete recovery from the acute attack, but to the antecedent granular kidney. It follows, therefore, that long. continued treatment of these symptoms by rest in bed, rigid dieting, and drugs is as unnecessary as it often is injurious. The relation between acute nephritis and granular kidney, is best set out in the accompanying diagram, the dotted line showing the weak link in the chain of evidence.

An Address ON DILATATION AND HYPERTROPHY OF THE HEART AND SOME OTHER POINTS IN CARDIAC PATHOLOGY: Delivered before the Eastbourne Medical Society.

It is probable that there are varieties in the quality and degrees of virulence in the provoking toxin of rheumatism. As I have just remarked, we are not justified in accepting the views of Singer to the effect that the disease merely represents an attenuated form of pyaemia due to various pyogenic organisms, staphylococcal and streptococcal. Perfect conviction on this question may perhaps only be reached after a continued and careful study by bacteriological methods of many fatal cases of chorea. Examination during life of the cerebro-spinal fluid by means of lumbar puncture, made early, may possibly reveal the specific micrococci, since they have already been found in that fiuid. In the meantime many of us must admit that the evidence in favour of the rheumatic nature of chorea is stronger, if possible, from the clinical than from the bacteriological side. Time will not fail, in my belief, to settle the question from both sources of inquiry in the direction just indicated.

Remarks on the Early Feeding of Typhoid Patients

On November 25th the condition was much the same. Ten c.cm. were injected at x.45 P.m. The pulse was xz6. On November 26th the pulse in the morning was II2, in the evening ioo. She seemed rather better. Five c.cm. serum were given at 3 P.M. Ehrlichs reaction was not present. On November 27th the motions were formed; the pulse I20; the breathing quieter. Five c.cm. serum was given at 3 P.M. On November 28th and 29tlv she was better. The convalescence was almost uninterrupted. There were two sudden rises of temperature, which lasted only a few hours. CAsE iii.-F. M., a male. aged ig. was admitted on December x6th, 2896. He had had diarrhcea, and had a few spots. The motions were loose and yellow. Ehrlichs reaction was present. The tongue was very furred. On December i7th he was much the same, and Io c.cm. serum were given. On December x8th there was no change in the temperature, but he seemed better. The tongue was clearing in patches. The spleen could be felt. Five c.cm. serum were inajected. On December Igth the tongue was clean, temperature rather higher. UJrticarial rash appeared on the right side. Five c.cm. serum were injected. On December 2oth he was about the same. The tongue was rather drier. Six c.cm. serum were injected. On December 2Ist there was a good deal of tenderness round the seat of injection, but no deep swelling or glandular enlargement. The rash had extended over the body and itched a good deal, otherwise he was about the same. On December 22nd the tongue was moist; he slept well, but was suffering from the rash. Ehrlichs reaction was present. On December 23rd he was better, with the exception of the rash. On December 26th he was about the same. but on December 29th he was better, and recovery after this date was uninterrupted.