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'BF=»A' THE PHTHALEIN TEST An Fxperim.nial and Clinical Study of Ph.nolsulphone- phthalein in Relation to Renal Function in Health and Disease I ,, i; (I W \ i i; i. i . Ml'. .1. ■{'. <; i: i; \<' n ' "i ^' "• m: i;,,,ri„lr,l fmm ihr Mchiies of Internal M<.Uri<,r M.inh. V.ni. Vol. •!. ;.)). -''^i •!•!"- ^ ClUCAOO \MI lir.AN Mll'l.Al. ASSIIII.VIIUS HK in Sl.IU;n AM' TlMIin-l-lVI PKARn.illN AVKXIE I'.llJ ...Oi\.^-.r: . . .04. J . o; cris.1 Voluiio TUK I'llTriAI.KIN" TKsr A\ i;xpi;i(iMi;.s"r\i. and iumcm, .--ri-DV (if i'iii:\oi.sn.i'iio\i:i'inii \- LiJi.N i\ i;i:i,\Tiii.v TO i;i:\A[, irxcTiox i\ liicAi.ra AM) i)isi:\si: * 1., (;. i;n\\Mi;ii:. md, an,, ,r i. (;i;i; ahii l^•. m d. l:\il IMcil.'L I'ii('iinl>iil],linm'i)lilli!ili'iii, uliiili Wiis lli-t ili^niliiil liy Kmi-on," is ;l Kri-M ivi\ c-rv?tallii:c imudci-. M.iiiru hat m,1uIiIi' in w.'it.r and a!r(ili(il and '■'■adily x.'nl.lr in tic |nv.,.ii(c ol' a]!.:alic^ 'I'ln- dm;', a^ dft-rinincd l.y Alu'l aihl i;.)\\ niri'..-' i- unii-ln.rir, iiiiii-irrilinil lui-dlv. and '- cMivtrd Ii!aftiia|!y ('i!iirr!\- |.\ tlic kidnr\~ :iihI \^illl i'\t rancd inai \- raiiidit\-. apprarinL' in tli^ mini' linniiaily \\it!;in :: fru- ininuti'- of injictinii. In alkaliiU' solution it ]nr-( iit> a hfilliant ifd co'or wliicli is idi-a'lv fidaptml I'oi' ([uantitativr coloriin' trie ''-timation. Tie I ink; In onv pailii-l uorl< onlv llu' linio of apiiiMraiKi'. tlie tinv- of nia\i- niiiin inlr-n-ity of rM'ivtion. ;uid llio tiinc o!' lto-s elimination wciv con- ^i niovoud in a drtinitc period of time. Twenty niinuto- to half an liour hefore administei ini: tlie test, tlio patient i- L'iven '.'OM t,, lod ,■.,.. ,,f unt.r in onhr to in^ive free urinarv ^eer^■tio?l. dtlierui-^e de'av.'d tine- of apjiraranee mav hi' due to lark of '■eeretion. I'ndei' a-eptie piecanlion- a rathoti-r i- inliodneed into I'le Madder and the hhid Iei- (.imphtelv (anptied. N'otitiL' tl"' time. 1 e.e. of a eai'e- fnll\- ]'repai'ed -ojutioir'' of the pheiiol-nlphoriephtlialein eoidainiiiL' mel 1111(1 Itcnvnlrr,.: .I,.ur. riiinii ;iiel i:\|..i 'riicinji., IIHVI. i. 2:11. :\. llii^ -ellltinii i-; (iM;inir(| ii » fell.nv-: di; ;.'ni, of pil(!y. iliti:lliirM-ii';ii-lv ni- iiitnivniMii^ly liv inc-iii- (i( all iKrii lately ;;rmliiatcil fyrin_s:o.* ■|'l"' ii'i"«' I- iil!'i»r,| 1,, ,!!aiii into a t.'st-tiiI,M in uliirli lia^ li.cii |ihuril a (Imp of •;:< \<-r .cut. soiliimi liyilnn.iii >oliili,,n and tlic time ol" tlic appraraiiii. nl' t|i,. i;.-t fainl jmiki-li liiiirc is iiotcl. In [latitnls «itiiout miliary (il.sfiiictioii tlie lalln tt r i- witlaliawn at till' tiiiir r( thi' :i|.pi'aiaiir.' ol' (h,. ,ln;^r j,, t],,, ,in,,r. and the patient i- in-tiurt>(l t" VI, id info a n(0]ilaeic at ll:r end ol' one lieiir :.ih1 ii^to a ?eiond mepta(!e at tlie end of the second liotir. A 1(ii:l;1i e-^tiniato of tlie time of appearanrc ean lie made l,v liaviiiL' llie patient void urine at fieipu-nt intervals without tlio use of tlii' eatlieter. In prostate ea-es it i~ wi^^.' to lia\e the ealle ter in place niiti! tlie end of the Ml,~ri\aiinn. The eatliet, v i. (.,,:h, d at the time of the ap|ieaiaiiee nf il:, diii.' in the urine ami the eori; i- removed iit the end "I' the fii-t hniii- and ai ihe en.l of the seeoiid hour, the Madd-r h-iiiL' thoroughly drained eaeh time. On many of the patients nf tliis Ivpe on whom our oh-i rvalion> liav,. h. en made, a retention eatlieter has heen in 'I-'' •■'" l':ii'l of the routine tieatnient on an-oiint of the r- -idual iiriiie. W li.ii a tat Inter i~ t^ he rniployed it is well ]irev!oi'-!y to have the patieii; under tl;e iiiiliiriHc nf he\n mctliv lennMi 1 n. Kaeli sampV (d' mine i-: mea>mvd and the spe-ifie ^ravitv taken. Siiilicient sodium hydiHvi.l {2', per cent.) i- added to make t!ie urine decidedly alkaline in ort'er to elicit the nuixiimim color. The lolor displayed in the acid urine is yellow or nranc-e. and thi- iiiiiieili:ite|y uive- plac,. ti, a Inilliant puiph-nd (c.'ni- \vheii ihe >(dution hicomes alkaline. Thi- M.!iit:,.n i- n..w plai.d in a liter ;iieasuriii,£r-fhi=k and di-lilled water added to make aeeiiintely 1 liter. The sidution i^ then thoroiiLdilv mixed and a sirall filtered portion tikcii in (nmpare with tht .standard, which is ii'!. ■fliii-;i|i,, I'lnn. 3 ■| hi- iii-liuiiiint is \U'1I :i(liihti(l for tin' |iiii pusi'. i- a|)|.r(i\iin;il..lv iici-iiiiilr. iiiiil i- iiiiu'li cluMi'tT iliiiii till' l)iili():-i(| ciiluriiiict. r. Fiiirlv lueiiriitc estiliiiitiniis. Iidwcvcr. can he olitailioil li'; me;ui- of jiiiiilllalril rvliiiilfis — t'(|lliil i|iuiinili('s ol' till' sl:ni(l:lld -njuticiii Mini I.ic ililiitcil iirino lii'inu' usrd in sopanitc cyliiiil.T- nml tlir d. iisim' sdlutidii lioing diluted iiiifil tlic cdlors l)i'coiiie idi'Titi.nl. Tlip niiioiint of dnii: in till' ?nlutiiiii liriiiLT known. Ilio ;iniount in llir iirini' rnn lir nniliiv Cillrld.-ltcd. \\\,i\\ the cirllcii.d iiiiiic liiis liirn nuidi' stion;:iv iiik.din. il i- ih ccs- siiv t" i-timntc llif plitkali'in wiiliin :i few li(ini> a- the red color fado? L'nt'liiidly nndci' tlieso conditions. When it is di>siral)l(.' or ncrc.'^sarv to defer the csfinialioii for Mime l)onr< or days, it is better to make the urine distinctly a<-id. iinih'i- whidi condilion the |iliiliali'iii ii'min- iini lian-cd. It -hoii'd of coiusc he made alk.'dino aL'ain when the e^liination is made. 'I'lie nielhnil heretofore utilized in connection with other test=. of di'lcniiinin;.' the time necessary for to'.-d c'iniin.ilion. is cironeous lor the folhiwim;- iva-dii: Whereas in ihc ca-e of |ihth.'il.'iii. a normal kidm \ CM-i-elcs till' ;.'i'eater pait of the d\e injiclcd within two houv< of the tii-^' of its admitiistration. and then only a Miiall tnuc I'.ir the n.\t luo hom-. the modei-alely disca-^ed kidiU'v sec lelc^ -a fair ; iinl w ithin the (ii-i \\\,, hours, ^ay .V) per cciil. (if that e.\creled hv the nnii,ial kidm-v. lint the i-oneeiitiation in tin' hlond >till hi'iii;: hi.irh it cnntinin- tn cNcicte a fair amount in the follouin;: two lioiirs. mi that at the i nd ,,:' fdin- •leurs little dilVerence may i\i.-| in the total wmk aeenmpli-iied. One h iir and at nil -t t'lVo-hoiir o]i-ervation< are therefore reconiniended. In ca-es in whieh onlv s'iuht ehanees in function e.\i.-t this can he most aiciiratelv deinoiHtrahd hv nne-hour eojlectinii folhiuioL' the ii-e of an intra- mu-eul.-ir ( liimh,-ir ) injertieii. iiii: ixri.i'i \ii: or tin; i;.'ii.i: m- M'sm;;'] mv ,iv -pm; uy'ri-: III" i:\ri;ri'io\ Il mii-l he adniitt.d liiai a factor otiiei- than ivria! excn-tion. vi/.. alisor|iti'in. enter- in i on>iderai imi in luniicction willi the ti-t when the phtliah'in i- adiiiini-lerd -ii! . iitatie,ai-!\- >ine diU'eienl nicthmU of adiiiini'^tiat ion ha- heen studied in some d' tail. IN ri; wii ,-( n m; wo ■-it,, it \\ iiic- \iisim;|'|iii\ ,ii- si'i I'liiix ri'M rii \T.i:i\- Mellzcr and .\uer" were the first to demon-trate that ahsorption from tlip intramuscular tissue is much more rapid than that frnni the -uhcuta- ti. Slcltzcr iind .Viicr: .lour. i;\|ier. Mni,. lnn.'i, \ii. .i!i riciiii- tissiirs. Tliiv uctlid Willi r|iiiic|.ln ill. luiniv, lliio'r-iin and inorjiiiiii. ;;nil (h niui:-l lalnl Ij, mhuI doulit tli.it tlll■^(' -nlL-laiici'-: loiind tlicir way iiitu ti;i' Liiuia! i irciihition iuik li iiioii' ia)iidlv win n tlic iliji'ilinii-; arc made inln tiii' inli-i hv-. I'alla' Ma> iiliaidr In d.In I aiiv ii,-r id' l)l(i(iil-jiii-s-mc lolli-uin^' tli.' int raiiiii-iidai- iiiirilidii nf i.>|.inr|ilirin and (oiirludiMl lliat tin' I't-idl- dlilainrd liy Mclt,:ci- and Aiht" wcw in i''alil\ diir In iiili'aMiMn- inj.Miinn-. Wallace.'' vwnkini' with i>|iini'plii'in, iildainiM] r.-u!t- iiK'iiliial with ll'i's^' of .Mi^it/rr and Ancr. livt al-n f(df lliat till' ri-iill- Wcl" dcp'ndilil iMi liaiilr^ nl' thr \,d;i. ami wriT in rrality iiilravrninis iiijccti mis. d(i-r|ili and Mrh/rr.*' in tlirir uoi'k in rdatinn lo pliy-ncti^r,,,;;] j„ |,i,j.;i,nj,,^r \,y maLrnr-ia -ait-, airain diMiuiii- .^-ti'alcd inl laniii.-cid.ai- ali-ni'jition (.i 1„. i'.h' >ii|i('ri'n- tn >ulicntanoo\is. Au(>r and Mi'Mzi-r.'" Iiy nictlmd- n-. il with -|ii'idllc inti-ntinii "T dctiH-tinir wlicthcr the r.aj'idity (d' inlraniiiMMdai- ah-'ii|iti(iii wa- ilfpci'drnt on the trarinLf id' vein- diiiinf ilir in jiTiini;-. n;- t'l tin' diit'ct in.-rr1ir,n of tiie lioedli' into n inu-i |r \rin. |iin\(d snti^lai tnii'y that >n:di .■iccldi'iitr: wore not n•>|)on^i!ll(■ fnr (hr lapidilv nf ali:-or]ition. hut th.at lapid ahsorption ocni'.- throULih ihr wall- of ih.. l.lond-vc-Md- of thr inu-tdc-. l-i the >anio coinniiiniralinii thr\ al.-n a^-crtt'd that ah-orptimi from tin" ininhar i- mtirli -iip( :hn- to tlial rmni the irhitciij niiisflc-;. i'hrtiol-ulphnniphlh.alcin. hv viitth' of thr pfnpi'ilit- 'Ahi'irhv it i- fapidl\- -md ipi.antitat i\(dv o\( |-fiod hv thr kidiii'V. fiiini-hrd an oxrrlleiit init'i"d nf -liiilyiii',' thi- pi'oh'rni. .\n inxi-t i'.'ation into tlic conipar.ativo (|uaniitativ(' cMivtimi nf phi'tiol-nlphoiirphthalrin follinvin:."- tla-c (wo inrthods (d' ndndin-lialioti wa- ( on-r(pirnt I v iindcftakon. 'I'hp lii'-t I'Npciiini'iit- \\(M(' caifiid on( mi hitrhr-. 'I'hi> timo of appraraiup of the clfULT in 'hi' iiriin' folhn\iii|_r snhi-iitnnron- adniini-tra- lion <>{ 1 cc. of jildlinlcin -uliiti .n (i! iws.) and tho (pianlita(i\.' output of plithalrin for prri.uh; nf varviiii:- hnLith- \yvr didcniiinrd. 'i'lie Innihnr nni-rli'- nf th'^-c ih"j-. wiTo t!nn i xpo-c.l h\- a -trail ii'i-inn. diicid intianiii-onhif inj'rlinii niadr. and tlm tiiiir nf appraraiiic nf tho diaii;- in the minn and ihc ipiaiitital i\(' milpiit fnr i-nriT-pond iinj pic: ind- a^'iiin dctcfiniiird. I''ina'i\'. intfaM'tmiw injortioti-: woio L:i\rii and similar oli-cr\atinn- wrw a::.-iin niadi'. 'i'hc tiino nf apprai.iiiir wa- drlrrmiiii'd a- follnw-: .\ catln'tcr was passed into tin' hl.aihh-r and thm 1 co. of -iilph.nneplithah'in wa- injcrtcd stihciitani'nii-l\-. iiitiamn-'iihirlv or ini ra\cnon.|y. 'I'lio hhnldcr w;is then inji'rlid at .■10--,Tnnd and nm -niiniilt' inh'fxaN with siral! ipiantitic- of warm sleriK' hoi ir Miliit ion a'-d llii- wa- inimrdiat' 1\" draimd into thi-h- 7. ralla : Aoli. il:il. .!.■ I i>'l . 1!iiri;, \|\i. Hi:!, ><. UalllK.': M.'l. Ilrr,. i:iii7. Ksi. STil. II. .I..,,.|,li .riiJ Mrli/,.r: .linir. rimini, ;ni.| 1-'^ |.('|-. I li.'i ;. p.. lIHHi. i, :iti!l, 111. ,\ii.r ami .M,'ll/cr: .Imir. JAprr. \Iiwl.. 1:111. \iii. lijs. ooiitiiiiiiii!.' a fi-W ilro|i> o| sniliinii li\ilri)\iil. 'I'lic ti -t iippuarance of jilitliiiloiii in the \vii.-liinjx.< \va= noted .iiid tli" iuiKHiiit of dniL' oxcrotcd for the vaning periods \va~ tl'.en dt i led. The results obtained from these . vutions appear in Table 1, from a f^tudy of whiili it will he seen that the time before appean.nce i? shortest for the intravenous and that the druj: appears nmeh more rapidiv (3.5 to T min.i followinji an intramuscular than fnllowinir a subciitancon= itijortion (•').."■) to 1*? minutes). The aiuount of excretion is depeiKleiit on liie amnuiir uf absorption, the ki.ln.v fuiution not plilvinL' a io!e inii-iinuli a- the -an^ (Iolt- were ti-. .1 th;'niii;liout for these I I, art I. — I urve i.i I'xii ^a.aai in a ilu^' lor one liour, e.stimationri licing made at len-niiniite interval^. TppiT '.lack line rcpres.MUs tlie excretion after intra- venous, the dotted line alter intraiiia^cular (lunibin ) and lon-r black line after the subciitaneiins administratiun. ♦ * experiments, tlio kidney fiincti(ui beiuj; therefore appr^-xiinately the same. It appears that the ahsoi-jjlion for one hour from the subcutaneous tissues averages from ."> to 10 ]icr cent, less than that from the intramM=fular. while at the same time considerable variation (3T to 02.8 per cent.) exists in the absorption for the same do,;; (Dog 5. Table 1). The absorption from the intram'iscular tissue for one liour appears to display less varia- tion (58.8-OS per cent.'), hut the absorption is not .ibsohitely complete, as tlip oxcix'tioti I'lir one liuiii- i^ siiiupwhat !e>s than that lolhuviiii: intfa- vpnnii> injections. 'The diffrreiic-o. howt'vor. in ti.e ahsoi'ption I'loin thf.-o two method? of administration is mncli more strikiuij when oif -lialf hour observations are taken i.mt i\\i(e as iniieli ahsni|ition foHciwiii^' intiaim;-' iiiai' injec- tions i)s (iiia|iaretihenIaiieous (Dogs A and ."., 'lahle li. 'I'his snjrgestcd to ns tiie idea ol' tlie necessity of comparini: the curve of excretion in order to obtain the real difTerence in the rate of absorption. Estimations were made at ten-niinute intervals followiiicr injections by all tlirec tnetbods of administration. A ("ni]iari-oii of tlie excretion in one doir (Xo. .->, Table 1) is indicated in Chart 1. A similar comparison for the ('.\(retion in man following: intravenous, lumbai-. n-hiieal and subciitaneoiis administration is shown in Chart 'v. T.ABI.K 1. I OMl>.Ml|S(l\ (IK K\CUrTIIIN 111 I'|C1'IIMII\ IN Doi,'- lii!lil\\|M m:\ois. In MIWii s( 1 I .\k i I.i miiaI! i . anh M i:i i ia ni ni -. Admin I- MIA uuv INII Doji I Do- Do- 1 imo iif .A|)|ieftrancp .\iiioiint l-l '._■ Ilunr Snii- Intra- Tntm- Siili Intr:!- Intr '•Ml. iiin», veil. cnl. inii r> 1 1 . Ill 11 :i':.. 1:; 'l I r>i.. Ooi; 4 I'l ( Pri>21l;Ult •' ' -• It a". ■f. ti 3'i 1),.- .". 5 Klj r. 7 r. s 4 - t (•) Not rond. ,) ' ._• lll'l III 111 •Jir 17.7 lt. :; ■J.' I 1.'. I 51. 46.S ."W :) .\Tiii)iiiit I Umir ntVM Sill. Intra Intra vrn. .•III. niiK. vcn. ■>4.!i r)7 4 t'i(i.7 -.4.1; d"). 5S..-) li-.'..i 'ill. .5-..(l .'iii,."i 4S. .Ml. (1.1. 17.7 1 1 . 1 ."i.').."! fill. 'ill '1 :!7.ii a-iw 114. 41.7 111.7 4.t..'i .17. !> 4.-..n ."i.'i.H (!4. ."ill. 114. !» .'17 5S.S ll-_' s (IS iii; 11 :i..i i:xnii:rio\ i\ nokmm, ivmviiirMs wn vM!i\Tinvs m-pt'vnrvT o\ Mi:Tiions or \nMivtsTri\Tin\ TliP pxcrption lins bpon studied in several Ininilnd rmrinnl mdividunls Tn our enrli'T work sulirntnnenu= adniitii-tv.atinn na- n-ed I'xclnsiveU . tlie lii-ii^ :i|i|K'aiin,i: m lln' uiiiH m fiuiii tivi- U> cli'veii ininute.-. 10 to fiO [n'l- n nt. (avi'niL:i> "iH pti- rent.) hiAuiX c.Nci'cti'il in the iir>t limiv afror it< apiRiiramo in thr luiin'. anil 00 to 85 per cent, for two hour~. In health the elimination i- fiiaiti. allv runipleteil in iwo hoiir>, only a I race beins: pre^enr iliiiitiL:' tiie tliiiii and fouilli li'iuis. On aecouiu of the iar.ue variation- in cm letion in normal imliv iduaU following siilieutatieou< ailniini-tralion. it \\a- tliouiilit a iai.'e paf .,' thi- \ai-Jatinii mi-hl Im dii.' to tavdiiie-- of ali^orption. The oxere ion following.'- intrniniiMiiiar (gluteal and lninl)ar) injeetinn wa-^ . oii-eqnently invest icatod. After .<;liileal injection (thirteen readiiiL'- in twelve indi- viclnals) variations fiorii 11.^ to (i'?.."i per rent, were eiieoiintered (Tal)le 1) for o:ie-hotir roadin'.'- (ten minnti- lieiiiL;- allowed tor tiino of app'ar- anee). an averncre of .ll per eent. heinir elirTiinat'-d, i lun; J. < ui\e (.1 i'\tii'I ion in ;i mi.mi iov on>' li'Mir. f-tiiiiatiotis l>tMni.' made at tin niinnli' iiitmal-. Ijijicr lilail. \\ur ir|ir.-iail^ i'\iTi-tion folliiwiiift intra viimn- i!i|i'.inin. iiijpi r dottod line, I'scntinii fiiliinvinz hiinliur injection; lower iilack line exeri'tion follouinj; jrliitenl iiiji'iiion. and tin' Imwit dnttcil lit:" ,epre- •.I'HI- e\cr('1ion follosunL' ^iilienlnnedii- inject ion. In tuint\ unr leadini:- on lonrlern iii'iinal individuals lla' variati\ iirr c cut. oil i-a. h m < a-ioii The ave-'nge .'< lilt' 4 S 7 :i-.5 -1> 5. C 7 '^2M JiJ.:! (i, M. :f-'..-i J 1. 7 7. V. . : M.:^ MM s. N. , li :i:i.:i ■-!i'-'< II. .1. -i -J'.i. J."). In, M. 7 -j:; I7,J 11. s. 12. O. in K. u. (I. .. . .\vmijzi" :ts.h •J4.4 I IImui .->1.(S Ii2.4 r.4..'i .58.' .-.4. ,^>4.3 .i2.0 ii;!.I .">4. tn.J (ill.'.t tin.i nil. -2 i;i.7 iii.i i;a.-.' .-.l.H t!2.."i 111).-..' .".7 1 1 .Mil i; I N iii.\vi;m>i ^ In.iiiiiii.x in .NiiiniM i \.--i ■ ( «Ke 1 iiiic '4 - I'.'i i.'Ill.lL"' I'A.'II |i.,i .^. \|>l)eari»nrt' M Half ■•m.I Half 1 Hnni 1. 1 Mitiiiti- HcMir ."id S lluiir ■j;t.:i HD.l IV U. 1 . ■t .■i:t.j lll.H ti4. 3. S. li. 1 lai.t; 1 .•t.4 SO. 4. I< 70. 5. .■<, 3Vi 4 1 1 112..'. (12.5 (13.3 70. 7 1. ."is.s 1 :).2 72 V 1 Ii4,l 1 ;{.s 7p ',1 s ■ 4li.7 11.1 57.8 1(1. .1. .15.5 ti2.5 10 J tl4.5 72.7 11 1' tf'/i tltl.U IJ M 4 112.5 115. s (15.5 l:i ^ 1 (12.5 1 1 ^ \m-iii(;i- 4 71.5 (iR.n i!7.f' *QiiO«ti)'t» as t(i Ix'iiii; noriiiiil. Itiiriivriious iiijcitioiis \\n\v lirpii >iii|iliniHl ('I"iitilp •'!) with three hhii- HI viiw, namelv. in order to (Iptermine, first, tlie total excretion for one hour; swnnd. what vnriation-' in kidney fiin to hU per tent., with one exception, Xu. 9, who excreted 57. 8 per mu, Tlii.- individual sravf a ?oniPwliat low o\it|nit following all methods of administration, alllmu^iii no otliM' cvidincc of renal disease rould he di-covereil. Table 4 -Ika^^^ tin varialioo- in iienenlage excretion for one-hour periods in the same individual- lollnw iivi -uhi iitaneou-;. glutca!, lumbar and intravenous administraficn. TAIU.K t --KX(RI;TinN !> NdllVIAl. IsmMhlWIS lolU.WlMi I'orli UlltKRK.ST Mr.riiiius OF .\t)MiM>i k\ nn\ IntraliiUM'ul.u ln( ravcnnii:! ^t= §„,, iy'"''^'--^ =t^ ^^ 1^ it? 8 l.i Ih !" ^"^ I- -"^ ^"J 1- 1 ~ I 5;[ .1 ,;"o .-, '. Ii4.1 l;i.S 77.!) .,' I,' •- _--^^ .^^ |,,,^ _._, 3'. s! '.'..'.'..... ;i5.7 47..1 ■••■ ■*6-7 II I S"« 4 S i>2X, .51! 7 ''--^ ti'.'.f) t!:i. 8. s. 1! lis^s -iiif. i:i.4 Hl» 6. u 4i,i; ..... :^>i> -i^-' 80 1 7 M "■-■ 4:t.i 4:!.i :!J.:! •ii.7 .""i. "■'•*' 58. ■< , , :):).:! Ji. .i^ :i ''"■•■' S. S ■J-2.7 17.1, •!-••"' n V tin.il 11.7 Jil:! 21'.. H o-.'.(i .. •If' 44.:! .... '"^-S 4.^1.5 ... Ill i; I'-'. ■')7.7 By stuihing the curve of excretion (riiart 1 ) for tivr- and ten-minute intervals it was found, however, that from '-W '" :!■" per (ent. is excreted in the fir-t tw minnt.- iifii'v .ippearan. e. this being half the total excretion fnr one liour. Il al on. e lieeonii- apparent, this being true. that obser\aiioM for one hour nei i, .K ;iie -ubjeit to the sani" oriticism that would appl.v to observalion o\er four or five hours foilowMi£; sub- rutancous injection or a study of total excretion. Wli.n intnivmous administration is employed, observation for more than fine-half hour should not be used, the amount of excretion for this time being almost equal to that for two hours following the subcutaneous injection. It has vet to bo determined if the same reliam e ,an be placed on the intravenous readings n- can tie plaei-d on the subeutaneou'^. or espciallv on the lumbar method of administration, as well as what decrease in excretion occuri> in dicraiie following the intra\enous admini-tnition.f tKurthrr InvcM ijjniion lius olinwn ili.it lie iTilT:iv,.ii,.ii.< iie-thod of Hdministrn fioii i« not H« nocurntr- in the intr.i'iiii-c-Mlnr. ...4i.eei,ill>- ^vll..|.• in.'t.T (■nlL.ti r-< ar.> employed. The nnrtiml viirintinnn in tlio fiinrtionite.' i"mfT fer -noli '•tiort periodn Of.'--,-. -.,.;!-.::fi^i :;:■ r.r.f \:::\f h:ilir STf tOO LT""* lu iifi'il !)»• '!iii!itii-: luivo The ^t^iklIlJr nijiidity of cliiiiiimtioii in iln' rn>i iru iiiimiti.'^ lii'ldwin^ intravcnoii? injection result.-, of ronr?i\ from tl'.p conrentriition of the 'Inisr in the ciiTukition. cacli ciibir centimotor of bloocl v hr siii.i'noNM:i'innAi.i:iN Because of tlie fact that many of the iiationis on wliom the functional test is made are rciial, caidiac. or cardiorcnal ca^e-:. and therefore tlie subjects of an imiuced diuresis, it becomes at once desirable to knew "hat influence these various diuretics exert on the ^ecretion of the drui in the urine: or. in other words, what cluinjres in renal function, a-- indicattnl bv the test, occur undcv the intlncncc of diuretics and to .vhat extent tlu'se changes occur. A studv of til.' inlliicMir ul uiuifUr-. is of value from another jjoint of view, inasmuch as the processi>s whereby diuresis is induced vary considcrablv with the ditfeient c'nsiies of diurctiis. consequently allnwin.!: inferences to be drawn reiiardinc the mechanism of excretion of sul- phonephthalcin from the infiuence these various cinsse? exert on its excretion. Two metlv'.'- "' •.-.•.••<;ii!e> •■ P.. n-IIlK nr been \\fei\. I. The '•llfcl of iheii adinit;i-liali(iM nt\ the out|nit of M.lpiioue- phthnh'in in cat* which received a constant inflow of «ultihononhthulpin. The method here adopted wa= as follows: fat- were lishtlv etherized and L'iven hv >toniach-tubn O.2.". ^m. thlorhutanel (known coniuierciallv a« chloretone) per kilo. fTlic c-hloihutanol wa>^ limdv .nnund i'l a mortar and then washed into the Momach with .".n to TOO c.e. of water.) The eats wcie allowed lo come out of the influence of the ether and were not used until one and onc-bi.lf or two hours had elapseurh condition^ iL was U,i\ud that an oMrliciiI uiiiKuv Kvittion ,uiild IK' ruii-tamly obtained tor loiij; iieriod-. Manv .u tfu_. animals iiaviiig btvii -ivi-ii anotluT siiiall do-f cil' clilovoton, i,.-Hl:rr w itii hot milt; by stomach-tube at tlie end nf a (hi.V.- expi rinicnt weie lound in -ueh good i-ondition the following nioinin- that (.h-ri-\ atiun- uvi,. .niitiiiiiod tlirougbout tlie second da\. From iho burette liu- Milutinu ..f -ulphoncpbthalein was allowed to run into tlio femoral \ein. (i wj. of the dru;: i)einj.' administ. red at tiie lirst injection. Tiie jihthalein was dissolved in either 0.8 per cent, salt or in IJinp-rV >oIntion. in -ome in.~lances D.O nig. to i.e.. in others 2 mg. 10 th.' <■.'■. 'i'lic timce!a|isiii'.'b-i'ore the aii|iearanii' of ihecjnig in the urine was noted, this WnuiS usually from one ami ono-half t.) four minute?. Collections were then made usually for lifteen-minute periods, oeea- sionallv for twenty, and in one or ,w(i instances for one-half hour periods. .Xt the end of each ])eriod the receptacle into which the urine drained was changed and >ulphonepl)ilialein wa> again allowed to run into the vein, a constant amount, u^ually l.S mg.. for each ].eriod. Where the period of collection was longer the aniouiit of plithak-in injected was of course greater, as for instance in Kxperiinent v'M. the amount of phthaleiu hiiected 'ar-h period being ^^ mg. in !.."> c-.c. Kin'ier's Milnth.u and the period of each cotlfclion one-lialf hour. Ccdlections were made for three or lour such )ieriods piiov to adinin- i^^ering any diuretic in order that an idea of the average excretion for each period could be bad f.u- comparison with the outiuit under the inflii.iiceof the diuiclic. It wa< found tluit in some instances the output .if ]ihtluilein remained approximately the sime over periods of one to one and one-linlf hours, although ihe .miput -d" urine varied considerably. 'Ihi- diuretic WHS now admiiMstcml Ihiougb the other femoral vein and its influence on Ihe amount of urine, the amount of sulphone- phtlmlcin as e*^tiniated by the nnl)osi(| colorimeter and on the reaction ..r (he urine noted (suliilionepbtlialein serving as tlie indicator^, observa- ijon in nniny instances covering a period of four to cidit hours. '!"he ai'companying charts rcpicsent the results obtained in some of the-e e\periments. I'ach period lasted (ifteen miniitcv nnl.-. otlicrwise stated. CdfciH.— Tliis fxort'* a stimulntintr inllueni " th.. -nrotury celN "f tlie i.iiiil f ilintos ami im-roa«.'s lli-ir «rcn'tinf: ihuvov . v,mi S.lirnp.lrr." .Viitoii." Arli" Mi.l Siilli-" Imv.' <|.iii(iiiMriil(Ml tl.U iimiiH-'tii.iiiil'l.v for 111.' finHV kiiln.'v i.n.l tti.' .,•111.' picsumnlily l.ol.l. for niainniiil-.. In.loul.t.-uly it i-^ Irup tlmt nthnr fiiotor-, •iirli ii« rtiniiiic of blorul pi.-iiiin- iiii.l inrrcHsp ;ii Kit. '' " •' '■ .\iiii. f. .•xp. l'..ili I'l.MlII! 11. V. Sfhropdcr xxiv. «.'>. 12. .Xnl.'ii: Ai'li inl.iTKif. 'I"' pliarinac.i.lvn . I'.mi. vio. t.i !. n. \,'h: Ai.li. f .xi..'! I'alli. ii. I'liarni.. lOOO. xliv. .■till M ( iilli<; .lour. l'li>-i..l , ItlOil. xxxiv f ll.iw tliinliull the ki'llli'S ISSC. x\ii, :W. mimI h-*: I.W. # * 12 (Aeli." ricli-licM. Uciiili i-nii anil l.oi'Ui' ,i arv ;hl(lii iiiw I mihI iiii|ioi t.ni; tacti.rs In 111.' |M.i.!iii'tii'ii ni' diiin-i-. 11 xcri'tinii .'I' tin' -mII.U niniiT tlir iiilhiriifi' of .Mill 111 i\nii S.-li:no(h-i. I.oi'wi' ) .1^ «i'!l lis till' uiitiT niitpiit i- aiiL'iiieiili'il. I'liiiTofl mill Slr.iulr'= -iiiiu tliiit there i- ii ti'iiiiioiary iiieriM-r in IIh' iiirlabci|i-iii lollnwril 1a a divira-i' iiiuli r tlir inlhiiMii'i' (if tlii~ ilrii^'. riii' ciri-ci of callViii nil 'lir rxcroticiii of siiliiliDni'plitlialiin i> iiulicatcil in r\|.i'i itiicnt 11. ( liait :i. I 111' aMTiii,'? outpm inior to tlii' adniinistratiun of lairoiii \v:i- 1.- iiiL'. for I'licli lifti'in niiniili's. ami after tlio aJniinistiation 1..') ni'_'. lor Mir -anil- Iriintli of tinir. Maiki'il iliiiii'si-i iiiidiM- the inllllcnei' of eafleiil 1- IliiTeforc as-iiiciateil witli an aiipn-cialilc iiicriiii-e in tl'i' plitlialiin oiilpiit. Siiiliinu Cliloritl. — A rational explanation of saline diuresis is that advanced l.\ I ii-lmv." Tli;^ [irei-cni'i' of liypiM tonic sodiiiin ehlorid in the hlood disttirli- tiii- ii-iiiot"ie rclatioTi^liip iiiiil i.-iilis in a ijieat irillnv of water into the blood from . lii.vliiiiiir.il procoss ,in.l can bo rcproihu'i'it jioiiit for |joiiit in tlie dead animal iSollmanni. Hypertonic sodiiini clilorid, oven wlien the diuresis i- ennrninns. eau^es no increase in output of sulplionephtliahin; indeed the avera;:e output for fifteen- minute ijeriods is sli^htlv .hrrea-ed from 1.2.-) mg. before to 1.15 m?. after the administration ((hart 4. KN|ierinicnt 12 1. We libutam)l ane-the-ia. KlTr, i of Midiiini rblorid and urea on urine output. ]dithaleiii excretion and reaction nf the iinnc. In addition to the lino already cvplaiiicd Ih.' .loublc line in Ihi- ;ind Inllouuif.' charts indicates distinct alkalinity ■>{ tie' mine iccM lliiin-iil to |iiiMlncc diuri-'i'' I by salt iicii<'n Ihe work of hows |li;it ill the frog's kidney. when only the tubules are allowe.l to participate in the fornK.li..n of urine, salines fail to produce diiircsi.'. whereas urea elicits an almndan! secretion. This cer- tninlv oidiciilc^ tliat the .ictbm of iinii r,v',i— I'lca li.'iii'j ,1 ,lillu-ib|.' -iib-tan.v ha-- 1 in till' -:une manner .w -oiliuin clilorid. that \- ( ullis. however, which wc are ,iblc to confirm. - itTer- inmcwhat from that nf -odium ^' 14 cliloriil. ill fiict, it indicates tliut tiioa i-xprt< ii stiiiiiil;itin!; ofToct on tlie cells of the renal tiilmli'^ just as cafTein iloe<. l-'iiitiieimore. Barcroft and Straub have shown tliiit diiiin'i in r.i diiirej-. m"vr than the iimiiial anioiinf of wor'; is per- «^ ('halt 111 ini' "!il| .'.. — lAii.iiniMil Is. I i.t. ( lilni liMUincl :uii'sthe-ij. l-:ili'ct "i iiren on 111, [ilillinlcin eM-ji-iinii and nMctioii of tlie urine. < Imrt 0. — Kxperinieiit -ii. Cut. ( lilorhiitanol. i;ir«rt ■ I de\iio-e "n urine out- p;ii. phthaicin txtnlion atrj ieaeli*»ii of iuin*- «l 15 furiiii'il h\ tlic I'.'ll- III i!ir liii.iili'~. till MU'li iticiiM-L' lirin;.' (li'inoii-tial)li' iluiinf.' tlic coiirM' lit :i -aliiir iliiiii-i-. rill' fact lliat uifa increases tlic excretion of sulphiiiioplitlialciii uhilc suiliiiin clilnriii does not iniliicnce it at all. or decreases it, al-o nupgcits llial a ililfprencc in tlic nietlioil of action i'xi-l<. Whereas in our experinient- i-mlimn rliloriil ifmrc-is was acco rapable „l -liinulatiii-' soeiftion l.v tlie tubules in Ik.-- ;.- «os -h.i\Mi l.y ( ullis." Hiart li ;-:x|»TiiiiPnl L'-J. in.li.iiti- ll.i>t it ills.) -li.^litly imiva-,- tli,' phtlialeiii cxciclion. (•(i/omc/--l almml is fla-iliid as au irritant .liurvtio raisin;,' the ^loincrular pressuie l.v .lilalin- H... reii.il arfri.il. -. It possibly »tininlatos ;,!-,. the vital 'ecretorv inn.tion ..f M.,- r.M.al .rll-. Thi. latter is su-M-t,,l l.y ih.. .W.uUni increa-e' uf j.hthalein excretii.n in < liart 7. Kxpeniuent >>. /'oaivMii". I <■«.(«(-;.— Altlu.u^'b this is Mippo-ed to exert only a salt ^i,t|..n. it will be seen tr-.in dinit S. lA|.erini.'nt, -Jll. that an increased plithaleni ..ntput was elicited. , , /)i,;i((i;|-,s- l)i"italis proiiuces dinrr.si- .■ntir.-ly through circulatory chan^'e^. i ,. jiaiv,-,. in heart action and increa>e.l blood-ni.ply re^.'ardless of the >li^'!it w.-ue.nistriction uhicli accompanies its use. The solids may not -hare at all in the diuresis Thev nniain the -airie or at most are but slightly increased. The ,,1, tint, ill ...itpiu 'in,- 11"' inrrca- im.hT He' inllii.'n.-,. „f dhjitali-. in -erne ease» ( liart !!.— Kxperinieiit S. i ai, ' hlui hiUai.nl iiiiiie output, phthaleiii eMTelinii ..ii ' n.oii.'ii 111. Ml.. .1 til.' r.ir.' 4 .linilllill- lUiiteicil durin" reinaiiiii.^' the -aiiie. In one in-taiii-.- a ih'.i.leil deerea.se \\a- the course of a niaikeil diuresis (Chart !•. Kxperimcnt (>i. P/,(or/ii:;.i.— According' to Loewi" this is not a .lireci .iiiii.ti.'. liie diuresis really reMiltiu^' from a loss of real. sorption power in the tubuh-. lullis," on the other iiand. shows that it has some direct .stiniidatinL' elVeet on tlic tubules ami ,d»o Hint l.v |..'rfii-ini.' it through tin Irog-s kic-ney a reducins body can be i.l.tain.'.i Ihi- work of Harcroft and Straub" aNo indicates that tin' socretion is an active process. As will be sc-n in I hart 10. Kxperimcnt -JS, a sli^dit increase from 1.7.-) to LiK! m^'. for one-half hour [.iriods was obtained followin2 its use. h'i>iii< r.t Sob, lion. —OnW a sli^iht diure-is was obtained with Uinjier's solu- tion (see t hart 11. Kxperimcnt -Jl). and at tli.' -.iiiie time practically no efleet on the phthnlein output, frea in this install..' di.l not increase the phthatein output, this hein^' the on.- instance in live ixperiments. Polnasium .ViVinfr.-rnder the conditions of the experimi-nt this s.,lt iirodiire.l .liuresis while sodium nitrate faile.l on several occisions. The potassium mn mn.t therefore plav some r.-.le in the production of .liiin'sis as well as the nitrate 19. Loewi; .\rcii. f '■vp" i'atb. .1. rhaiir,. irio.';. i. :i2ti. V 17 i,,„ 11,,. -,,l: ;i- M (IPiietic f.ill- iiit" Ihr -.mil' 'Jicni. ;i- tlir Mi.liimi rliloiUi. I'nu'tically no inlUionc- is exerted en the pl.tlmlein exerotion (ilKirt 12. I-aimti- iiient ^ni. the ;iviiiip' output liefore anil after liein? l.OS niL'. L'lKk'i- \\ V ciimlitinn- of our experiiiioiit- it wa? I'nuiul ihat tliOfe diim'tk< wliirh -Avv kiiMMi to exert some stimti!atine dituetios in connection with which pvidoiice i? at hand indicatini: a ^timiilatiiiL' action on the secreting: cells ( li;,,t 10. i:\iieii;iicnl j::. < .ii. I'.lVi'rt of phlorliiziii on urine ouipiil. [ihlhulein exeretiou and renetioii of lli,' urine. K^u'li i.eiioii one-lialf lioui. (rallrin. inea. ilextroso. ]ihIorliizin. calomel). sliL'htly increase the phtlialoin outiiiit. wliere.'iH tho>e diuretic;! which act entirely by changes in osmotic tension or 1a chaniios in blood-prcssure. etc. (hypertonic sodium chhuid solution, jiotassiuni nilttite and diiritalisK apparently have little or no effert on Us exi-retion. #! # 18 Tin: i:i'i-ij 1- ok oiruKTUS on i'Htiiai.kin kxchi-.tios- in- normal iNDivinrAi.s ■l'lii> iilitluil.Mii .\.ii'lion inlluwiii- iiitniiinHi'iihir (liinibar) injcclion \va> ftudicd in a mnnbi'i of iKUiiial iii(livi(liiMl> who wciv tin ;i given bv mouth variour- diuretics :n llie UMial dosigf I'oi- tuniD-lnur hniiiv pievinus to ivpcatMig tlie tc^t. 'I'lic crillritions were made lor one hour following the tune of apiicaian. .■ .d' the |ditiuilrin in llir urine. The drwj^r- emploved wne d;,L'ilaii>. ra'onud, diurctin. .aireiii. tlie ward -1 /' C" ■/ (.1 a '7 ID T t 1 <. 5 5 I I I hart 11.— Experinu'iil 21. I'al. ( Idoibiitatio! ain'>llic>-ia. KfTect nf Hir—r'^ -nlntion and ul urea tM--ii .Vc-etati- I r. ScilliP Spts. Etlieri* Nitro-i Aqllie <]. s. ill I Misc.— Si;r. 3ii '. i ■' .iiv r.iij .'liv * A.' The iv^ull- oi.laiiir.l nr^^ U. M.ii in TM.l. -V N- app.v, lablo effect ,„ phthalrin .N.nli ouki l-e .lelcvl.a in any in^laiuc with llu' onh- „a,y th.iaiHUlu .lo.-r. lielativrly m.uh Im-.i dn>.. u.iv a-,-,! ill the llllilllili l\|'tM uiieuts. ( l.Mit 12.-K.xpeiiin,-nt :i.l. .at. (l,l,.rl,uU.iiol ,um -1 Im. i:ir,vt nf |..,ias^i.in, liitratr ni, the urini' .Mitiml iiii.l plitliali in .•\iMv1ioii. IMMVUTM -. IM.IIUW,,-., iNUtAMlMllAll .LlMMMl- 1 SMKr, ION > Naiiip Niaiiial ... Kxori'tioTi I'lT CTllt. ol I'llTIIAMlN DiUKli K. M. M. S. s. w. ti:;..! i;ii.-2 C.S.J 48. F. 5rt.4 S. 4fl.7 V. • (iO.O 45.r. tili.ll •SlllirlllilMri.il- illjirliiill-. 1 .ilViiii 1:1. iii. t. i. il. Diiin-lin 'jr. w- '1- -• '"• '<" - ' '"■^■ i ,iloiii..l -1. 1 I'.i. M- '■- '"•• "1' 'f' '^ .loses. 'IVst 1 111-", afi'i- last ilo^e Diiiictin ^'1-. \v. <|. 4 lir. lor 24 lirs. Caircin 'jr. iii. 1- i- '1- f'"' --> '"■^• !lii-liiunV iiiivtiii" .'li. '|. 4 lir. f'lr •24 In-. Ditto Ward iliuu'iif "iii- <|. ■> l"- I'r. (lipitiili- 111. Nv. || •'' 111 for -^ ilosi'^. Iv'icrel ion .\ft>r Diuretic I'lT C-l'Ilt. ti2.r> liD.'.l 11(1.2 r, 1 ,7 1(4.1 .-,1.5 .)ti.2 4tS.') 111). 2 Tin; iNn.rKN.i: oi^ iiiri;i:M- "^ mi; in. a. ii"n of mi: i^iink In is:y, Fa!(k=' eallcd attention to 1h.> rn. t that the urine heiomes alkaline foHowiiiL' the mlirlnHtratioii of lai-e animint^ of ^a't solution 21. Fnl.'k: Vir ,.l„nv'- Vrili. t. patli. -\nat.. 1S72, Ki. 111." #1 m 20 l,v s^toiiiaili (11- imravi'noiisly. (.rubor-- iwiido.l similar observation in 1887. In h\< work on .ailVin, vnn SthrocdLM" encounlored the ^ame phcnoiiKiion invokrd by thi^ (iuuviu when ihe nerves to one kidnrv were destroyed. The urine from tlie side with .liun-i- wa- alkalinr. that Iroin the otiier side was still acid. itiidel.-- in 18!f^. mad.- a .aivlul study of tiiis subject working with numerous diuretics and found that alkalinil> very commonly resulted. KatMivanui'^* studied particularly the iidlu.-iuc of .atlein. nrea and diuretin in this respect. I'nder their influence the alkali, estimated as '•alkaline chlorids." is .m'eatly increased, sodium oxid is always increased, potassium oxid nuiy or may not be iiurea-ed. and these ehanges can occur under the influence of cairein even without marked diuresis. Urea increase- the chlorin and sodium oxid and alkaline chlorids only sliiihtl>. Diuretin iiureases markedly the alkalinity, as '-alkaline .lilorids." .blorin. potassium o.xid. sodium o.xids are all imreased. A change in reaction (alkaline urine) has been noted in manx of our diuretic experiments. \Ve have noted it after destroyinir the iu>rv. .•onnections of one kidney in two instan.es even when diuretic s were not adtnini-^ten^l In two other inslauces under similar conditions it failed to appear. Tnder the condilu-n^ of oui experiments, as .s't forth in the descrij)- tion of our work with diuretics on Ht«rtirif». 1HH7. .nmtHl from Rtlil<-1 "»:i Itllc in the cells actually engaged m e.xcreting it. By this method he demonstrated tliat indigo-carmin was excreted hv cells of the tubules. Thi^ method ca-.ot he utilized in connc.tion with phenol^ulphone- phthalein. as all ^f the ordinary fixatives fail to fix this dye in the cells. Omsciuentlv it was found necessarv to attempt to ascertain bv other methcd.^ which part of the excreting nun^hanism is concerned in the excre- tion of this body. EXCincTiON iiv Ti:i: fhoo'.s kidn'ky The work of Nussbaunr" indicating that the ivn.l tulmlc in the fro.Vs kidncvs are ...pplied by the renal portal >vste.,.. whu^h i. entirely separate and independent of the arterial supplv to the .lomeruM.al hough di credited bv Adam,.- was later -h..wn by Nus>baum = " and hv Beddani^ to be absolutely correct. The work .f CuHh al-o atTnr.U stnkin. corifii'ination. , , , . . 41 . ■Vdvanta-e was taken of tin- indepcn.lenee of cvulation to the tubules in th,e frog", kidney, in an attempt to di-eover the method ... excretion of sulphonephthalein. ■ T.ar.e ,„ale fm.. i:.u,„ u„,s}.n„n. weighing about nOO gm.. were i,|,,,l. t,,.. „,.,l,„nen opened bv Inn-, inci^on^ en each ^ide „f and parallel lo „„, nnterior abdominal vein. The left kidnev w:w exposed and ah the arter.a! eeimections sev, red bv mean« of the l>aque!,n eauterv. as «u.'m-ted bv Beddard. A .annuh, wa- then m^.led into the anterior abdominal vein and a .nail .las. catheter in.M d int. the b.ft ureter. A protocol will indicate the course nf tl xrenment and the result- obtained. „ , .1 1 11, « l!i„eer-s solutien wa^ perfn^, d r,e,n a Mar.et.e th,-k through the n-nal portal ss.t..m uiehr a prcMire of X, e,n. of water. Perfu^on from 2fl N,„.lmun,: nUlL-r'^ Ar.t. . I^T^. xv. 130. >in,l 1S.«. xvn, 890 27. .\.!iiii!i; .lour Phvcinl.. !«•<•!. vi. 3S2. "•» Nimlmimi: Anat. An7ci.."T. IS^fi- i- B7. :il |l,.,l,!„r,l .1e„r l'l,v- 1 l"l'-'. xxvi.i. ".» nf* tlie renal }.oiial vtin lor about liflfru ^ce■ona.■^ every three minutes was l.euun at l--.'::iO p. m. aiul eoiniiiued until 'i :■.'■"■ ]<■ ni,. no tlow of urine resulting. At 2:2', tlie same solutitin. but now containinj: l-J per eent. urea and also pllenol^ulpllonepllthaleln ( (10 v.\'i. to 100 e.c). was per- fused. Diuresis l)e.;anie ai,parent at 2:W p. ni. M :! •..-.O ].. ni. the urine readied the distal end of the catheter and was found to lonlain umsid- , rable phthalein. .\l 1 :1" i • ni. a >aturated aqueous solution of I'russian blue was injected, t!ie kidney inmieiiiately removed and placed in absolute alcohol. Serial sections were later made but not a trace of blue could be found in any d' the j:!omeruli. identical results were obtaineil on i.ddinj: eatlVin to Kinger's solution during the course of a purely venous perfusion. Si/i ' J_i_J::5Lj-.-i-.! L !z.>-.i...J..i _/Q1 13L. a -HI-; i liiip till' Mnidunl III' .illiMiiiiii in llii' uiiiH' in u'liiiii.- |ii'i liter. Thi? furni>hcs ilh.solute pn.of that j.h' nnhufphdiirplithnlnii , .ni hr rj-rrrlid hti nai/ of the cfiU of tlie hihnhK in the frog and pre^umaldy the same holds true for mamnmls. In another frog a purely nrterini perfusion, by (he method of Culli^. wa* made with hy|iertonic sodium chlorid solution. IIim' aUo the phthalein uns pxcn-trd. bnt under tliese rondition-: both tubule^ and glomeruli p.irtii ipate. nu iNFirK.sTK iiF .\\i:mi\ Hannd'l and Striiuh" Imve i>hown that nfter e\.'nding tb;' function of the renal tnhnlr.t by profuse blecdinir and the adinini-tration of lar^'c quantities of lliuL'fr's solution, an isotonic urine, a pure idomerular filtrate (an be oiitaimd 'I'hr excretion of phthalein under mh h inndi- tionP was investigated. .\ proteeol of an eyperiment m tbi- innneetion follows (Table i',V *y 23 tinn of lii^'. snlplioiu'l „f phtlKili'iri \v;i- ^;ivpn . il.lor.'l.iii.' :it 10 a. 111. \-2.-li-< iiijee- ^itliaiein i'ntravrn.m-h. At 1, :i.l "i .'^i^'l' I" "."1 1 -S -i,?. Cat. \\>ij!lit. -2.^ Ut-'. liiji-'ti.m. ".T liii IMlli: i;.— lACHMllIN "1 I'lllH Ml IN Al II I I |;|,s IIV r.l II 11IN<^ B lAll.l >I'iN '11- I'l'^' ""^ .1 Ri;.N.\L Time Qiianlity (if Liine in c.c. 0.6 0.6 0.7 0.6 n.fi II. s rUtlialein Excreted 1.02(1 D.'.l.')! l.(l-.ii( i}.T8'.i (i.ms 11.714 1J:):1 p. 111. I-':. IS l:l.i 1 ; ■-■■< I :4t 1 :ii^_l,|,.,l ■M.r, .'.e. an.l iiiji'.te.l 40 .ve. Uilitr-f- -olntim, - iMi ,„,.. pi.,lK,l.-i„ -Mia. _ ^^,^.. ■J:i:. p. 111. ;- ,.,.,s '-■'-^ i'3 1.1 Js ■J -4^1 ,■ ■ ■>'4-' ■'■47--l'liil 411 01". am! iiiieoliii .'lO iv. !!iii^ei ^. ',' -Z" ii.'.l II. Ill"- ■-■•';' ,4 (».li',i;i ■MIS In :i:12 M.d :ti> r,.. an.l inj.ete.l ;^n .• <■ llhi!:-.- T "-'l '"iT- phlliall'ill i\tl:l. ... :i;4:i . ,"•* ;i^:i "ivcii 1.') e.e. I!ini:er s solution. ir.-.s " '" .):IIS ..jix.M -.'O ,■.■. I!in'.;i't"- -olulioll. 4:11 ll.:i011 4 : J'.l 4::i7— i.ie.l :i:i I: 17 11.4 US I'.^lM ,.. ,,ii.i 'jn'U 20 CM'. i;ini;.T'- -olntmn. II !1 ('2711 ,,„„., ,,„|,.j,,,,,i .,,-,a4itr>rnp.l ^inil th-' :nnm;nt m' ,,l,tl,a!.in ]U I c llllil' <'»''lt illM'tl'I' 1 hi -tiiiiatnl. ^lin«i.iL' tiiiit tlio iiniouni of ,!■„- in tiu- W inrroasoil o.,int. ot tlr-t .xatmnatmn ontainin- O.imilS „,!.'. pT > ol.ir r..ntin..tiT. a.i.l in tbr la-l 'UM.,!. nvj. |i,T riiliic n iiliiiatrr. . . , , , ■ I n ,l,i- ,.x,wn.m4.t nft.,- lo-ofu-r h.M.iMlia.r .1. .n.tMn nt pli.lin hu dcH-rrasiil to npio'-iniatolv nn-fmirth nf „l:at ,t wa^ i...nni,llv. " " '■ at ,1,0 siHiio tMi... tl i.iMnnatinn ,.f tlio ilm.' in tlio lilooil w,t= .loublo.l . -o thnt with .ovo„. am una .ho oMiolin.' pinvor nf tho kiiloey wn= cl.KMTn^eil tn nnc-oiphtli of normal. rnU- tho hi r,no lio M'n ,.,niu..o. luivvrvor. l.ttlo olToot on tho „,,l„,loin oxoMtion uiM h,. imtoil. a. ran hr .cm from the ,.rorr,l,n!r protoool (Tahio ,S) ami from tho follnwim: rt-toml a^ uoll a^ fmm rlinioal oMilnu.' \vhioh nuI! ho pro-onto,! lator. (■„, WVi^lit. '2.H kg. fn.ler oMo.i.tone ane.tlioM,.. ,.,.,„„ ,„_.i OP. 4 pfr eent. Miiliiini olilorol -olntio.i ;-.: V :., „ rLoi-..,.ho,.,.<...n -.. :;-..:— '"T"::rr:r,7M"r:i:M;n::: •- -- ■■•• - -■-- • diiepd In il« plnrc. «• ♦«' 24 111. 1-1 r, 111— 111 rr oi -! vvv umiI. sniliuni cliU'ri.l. , . ;;;.4 : m-.i n^. of J,l„l,„„.,,l>thaloh, aa„ii,us,or,.,l. Dru, .H— " •" ,.o ninuiu: „„1 2: r.r -vnt. w... ..x.ivt.M in .ix,>-ix minutes. Thc=c n-ult^ show tluu inod.r.tr ,l.-nr> uf an.inia il<. imt inteilVr.^ ^vith the e.xcrefu.n of phU.alwn. l.ut that verv ^.vciv ,1..,mv.- of an.m.a. whuh Straub and Bavcroft have shown to result in the ei.tuv ven.ova, of the tubular function of the ki.lnev. nuiterially .bM'rea^e tl..' output of ,,l„halein Tin. ^voul,l imluate that the tnbuh- are enneerneil m the exerction of ,,hthal.-in but at th. -a.n.. tin,. -h„«- ihat .1).' .lon.-iul, al?o are capable of ex.retinir >onir of thi- dru--. „Tin;K rni:xoMrNv ni;MMv.; ox nii; MiMuoi. of i;xn!i:Tios of sri.iMio.M'.i'iriii \i.i:iN The fa. t that tl;. nutput ..f phthalein bears no relal.on to he excre- tion of water and ehlnrid- al-n -n-,M< that the i:lon,eruli plav onlv a minor role in its excretion. It is .,-, ricd \n- M.lxnidrr- that in ..xpe, inientally induced a^i.te tubular nephritis (produced liv n.rcirv bi.hlorid and bv potassium ,,,,„„„te-see Schlaver an^ " ,m.er^' ). there i^ a n,nrkcd dinm.ution i„ „,p .v.ntinn of phthalci- e in the vascular tvpe (p.oduced hv cuntharides or arsenic) little .. no lecreasc occurs at llr-t but a deerea-e docs occur later- Thi^ also su-ests that the ^lon.cndi plav a -ubsuliary role in the phthalein excntioii. The findings in our work with diuretics (discussed above) ,, e.. ,,>a those substances which probablv act bv stirnt.latin? into activuv the renal cdk increase the phthalein output, ul.le tbo.- diuretics wlmh act ou v ,„eehanieallv. as bv clu.n,e> in blood-pr-Mire or ,n o-„,otu tensuui do not influence the phtbabin output. ,ives additional condrniafcn to the theory of activity on the part of .1 IN of the tubule- iu the excrCon of phthalein. Tin; STfin or \i,i'in:ni^ Heretofore functional test= have not h,en ,onMde,ed o" ^".v P^«t value to the climrinn in relation to nephritis. In fact hvpcrpcvmeabd.ty to niethvlene-hlue. indi.oearnun and rosanilin has 1 n shown to ex.. in ncut,'- and in eluonie parenchvmatou. ..ephntn. xvhile. on the other ,,„„1 decrea-ed permeabilitv with slow appearan.e and prolonged excre- tion has been demonstrated in the chronic interstitial variety. a" McKnidcr: Ipfcniil luniiMnniciiticiii. 33 Schlaver an-l H«lin..r: n.nt.oh. Arob. f. Klin. .Me.l IfOT. xc. 1 an, xci. 34 Tl,e oxoretion of thl. .Ir,.. in ..x,...rin,on.«l n.plni.iile. i. now nn.l.r study. ..,.'.' For lifcrnlur. c-oncernhm "tl.-r functional WU «-. -ur original urt.ele. .Tmir. n.arm. and Kxp.-r. Thcrnp.. lOH'. 1. S''-'- 25 ACUTE NEPHRITIS Thu. far .c l.ave ha.l .pportunity to ^tu.ly onlv live ca.o. of a.ute and .Lowed evid.nco of ,r.ve <"-'"»■' \;^,;3ita An injecUnn of 6 mg. the toxemia wus due to the nepl.nt s or to t' « J>".' » J j^ of the phthalein «o. f.dlowod by ^'' V'/,i;T"' ? he d " wal excreted in the r'^::r^;^:r^:^ien^^;r:d^:nd^:h: :;,::;:>. .;;.,ete,. ...>. >. .« at the time of the lir>t t.-t. in- i .' „ , ,„,„vri-t^ Tlie tuojinosH ,„,oky from blood and contai.unf: .nuoh Mbumu, and nu.nN ca>t. . 1 e , . '"'t?' ^"'•,, „|,tl,.>le„> le.t wa. adnnni-t.red. the .Irug appearing in the urine Ihe uMial phtliakin u.i \ a i-xcreted in one hour, in twenty-two minute, and only /•^ '•^. '''';, ^ ,"-,,,„, „„,, ,he elinical Three weeks later, the nephrU.s '--l^^,," ^^^ ,/^;^X on ..f tl.< -ine. the oondUion '^-'^,^'-|>;^. ■;:?•;;:: „;;^'. ^^ 'he dmg m .even ,ninut.. and ,e-t -»V';i'7^";;:' ;,"^,„"'f, '!,ne hour. Six week> later the pafent was an exeret.on of .,S.l 1' y " . .,„ „,^ ,|„se in the first hour, entirely well an -"-;■':';';•„,,;.,. „f .„„,„„. ...nire assoe.ated w,,h r.\sE 3.-.\ boy of , .\ea.~ lad •> " " ; ^,, „,,,,p,„.ance of the purpura heinorrha.iea -'V';:; "^ , ' " " exeil d 1M.4 per lent, in the first r""""""; ::: r: :';";:; el:, 1';: neatl, ooeurrea .udden,y tive days severe gra.le. the prognosis being -"-de, .1 •'"' ' "^ ' ; ,^^./^,,^ ,,,„(,„, eon- en .imission «;v/, r*;::;!;/';! ::;e ;tp.n ;::dtu^-ed to .s.4 per oent^ -r^r^:'r■^--:'. ■-;:-;:;: ^:r^r';^ •-" • ,„e l'''«''"'-"p-'7";"7'-:;,' '':;., „nl a fe. ...U- before adn,.- . .VSK, 5-1 he patont. ■'/^ '^ ;, •',,^ ,, ,„, ,„a,ked edema. Marked M„n I May. i:ilt»i. when ''' ,'''^' ''''^ .,''.,■ i,,,-,,,. aneamt of albumin and ^' \ ; ;r'::;;";t;!:: ;;;::;. ;::::. i. niere we,. „-. l;,rp. „u,>dK.r of ..-ts "'!"•' subeutaneoii«lv. showed 211 p.T eent. -:„:";:;;";..;;:.■:''""'■--"'"-•«;' -• .— "■• '-"^: ;;:;:„r:l->-ii;M ":::-" :::«:' .:;'-•• « - ' nephritis. NVl.kMio ooiul.MoMs >an l,e ,l.iu,, tnim l;^lMases. i, is .......stivo that „, „„„„ ,.f „,„„ „,. n>e,o imroasoa pernu-abilitv. hut that .in thn oin- ,.,. the por,n..ah.l,.v was n.arke.llv .hn.n.sod .hon the con.lit,,.,, wa- :.,,,J,H„.anv,ravo. Ins,,,,,,. .,f „... .a-,, holow. .lassod as ,.,1,,. ..phr,,,-. a„ aottte «a.ori,ati,.,, .as ass,,.at,.l .ith th. cluon. n^p,,n,isa',hot,n.,.of.h..t,.-t. Hor,. aKo tho p-u.h ,tv w:. ,Weaso,l b„ w,n,th,-s„l,si,le,..,o.,fth,.a,„.,.p. ^-s „H. pon,.,.ih,h..v ,t,..roase,l. ,,,„„,., ,„. ,„„„„„!„.r,.,l. l„,wov,.r. that Nvhon an a.ut,- process ,s p,.e«.nt. va„at,„n~ n, UunU^u ,„:. ho v, ,v rnpul an,l that a .ood cl.,m- «• 2C natii>n un mir (iav iiuiv lie I'olloucil within a ilav ar two hy a niarki-il iU'c-ri>a-e in ruiicti'Hi ami rirr i-i'rsa. CiuiM'iiiirntly. in rasts of tin- tvjn' tlie ti'!-i yliiaiM lie rcpratcil l'ri'i|H('ritly. CltliONH I'AKINt IIVMAIOI .>^ M;1'1 1 11 lllS- In all. tweiitv-livr cases liehin.L'ini: to the -o-called type of paivnehy- iiiatuii- n.-iihritir. Ikim been >tii(lie(l. Tlie-c (ases represent ilifTerent a TABLE 7.— rARKNi'UVMATOUS NKriilUTlS flinir:il » "ntiiiiiiuii S. G. Albumin. 1— u. •J u rj ' C. n'.i )L> 111 ll'.l IL' 11 ll'.l r.' 1:; ll'.l r.' J4 111 !■-■ i;'.i HI n -I! 4 — \V 1. 1... iiL-.ci :;2. - 1 /HI 1 js, 10 .-. M . UCIil "1. . . ;i • .-) , ii> i— .1.' 11 1' ■•laid :'.4 . . . ilKc (i ".'.,. . . .1.. niz-''\ :'.ii. S . a 1:1 (1 Iir). .•1 1.- Ill L' 1 111 4 4 111 11/ T , III Some cdi'nia nnil nni'inia. KJinui anil lullil anomiu. lii'tlir . liiileallv H..|t.'i- c-llnl.-ally Svin|ifnni< uvi> innnllis ; mild. Fair .■unUltlun Vory mild s\ mpt'ini^i ; n Ii'iiia ; slialil aiii-niia. Had ; mild uriTiila pn vioiis to ndmisslon. Fair Fdi'nia. alit'lnia I-Idi-nia, aiu'iiiia Ill l.-l r .111 : oil i "■• .".1:: iM MA. aC'd 1 1 I\ '..'., IJ ,1 S , air.'d r 7,-..->.si r; K 14 r , n2Pd .'tn. . 1.-— S.. ngi-d i'H. 1' . 11:;. d : II r. Ill II 17— v.. nu.'d 48. 10— n,, n?.d 'J«. L'u- I-;. W . aL-(.l 11 14 111 11 i; 1 111 11 ;;ii 111 11 -ja HI 21 -r. nard 40. 7774.-1 22— E. D. nerd 10. 774L':i 2n— AB salvarsan 12 l.'i 10 Cllniia! .iiiidlliiin ixoiMllnaly grnvc No rhnni:«> Miiih bittir Much iH'ttcr No ►vmptnms; nl'pll^ltl^ iliti'rti'il nooidi'tit- alty. Iniiav. nous Inji'i'tion MM. I cavr I.jilior Ind 1 llvi' davs pn'vlims to list on nnomit or' thrrati'iifd I'llampsla ; fair nitnllllon. Illuli btood trnslon. aiiiTiila. siiuu- I'llt-nia. rri'inia : naii^. a and vomitini; Kdi'ina. dys|ini a : rllnlcally Kiavo .Ml ait Kann' rondliloii ;iii.- •_'(;:; No symptoms . . . I.umliar InJiTllon 4/18/11 I Kdomn : anuria for four days t)i fori' adml« I slon. niicknrlii' : no otIiiT symptoms .%2S/1I 5/ » ,'11 .'i/e/n Anitp nophrltls om' yonr ; no od.ina ; t»tood-pri'SKMri' 00 mm. Ilic Tub'Tiulou^ nrllirllls; no illiilial svnip- toms of pi-philtjs 1:14 17" L'L'l! 1111; 112 1 2r, 2:!ii 72.1 :'.74 I1111 l.-ii 70 73 0.1 200 400 1.012 l.O.-fO 1.(117 1.010 1.005 i.oi;t i!6(i7 1.011 .»o eases are seen in Table T. In five verv mikl case-; of short duration showing only slielit edema, with albumin and easts, but with a norma! urinary output, the time of appearance cf the drui: an' the amount e.xcreted was normal. In one of tlipsp (ii^cs (Xo. ■"), 'I'ablr . I the time of appearance was eidit minutes and tlie output ',2.r> prr c'-ut. for .me hour. Another patient ( N'o. 1"A ■lAi'.i.i: I'AIIllNrilVMATliIS NDI'IIKITIS I Mirro in.i.M-e uriii:Hy secretion l-.v furiili^' water. 2:1. S 4'.'L' 4(14 tt,*.i Tra(e. 411.4 IS.'t 2(1.4 ;!:t,n 47,(1 .•;:!.;! r.i (1 .'il.O L"i.0 '».'i 7 4^.1 ri.'i.ii Cl.tl Suhcut. 54.4 •47,0 .-,1.0 2.0 Illl.O l4:i I 24. :t No ilruK In 4 hrs (i.l) 1 .... .... I in.6 I Subeut ln.l. .-.1.(1 I .... 30.6 60.0 06.8 r.7.8 r.4.ft :t2..i Ii|e(1 of uremia two moiiili-i hiicr. CIven :i(l niK-. but output not estlmalid. Iile.t 11 IC. Ill, Autopsy: sev. re ainylolrl neplirltls. s.TpliilitIc : sen- erui iiniyloidosN, Re.v.v, re.l ; vporl- l.erself feclln-' well at pr. sent i'^oe|U for .denia l,\pril 1. I'.iU I, Left hospllal In fair eoiiiUlion. hut allinrjln 1 C. L'ni, per lllerl ami easts were still present. The exi-reilon for llr,-l lialf hour after luliaveioius ln.|eellon Is liehnv normal. Svniptoms for six years, onlv in winter. liliMl iw.i (lavs later lu uremia. Xo iiulop-y. Iieveloneil ervslpi-las and followlnu lids nn emiivema. whleli wa« drained. Died 41(1 11. Autops.v : Ijirne white kldiie.vs; subacute peritonitis. Albumin and casts dlscov, red ac. lUentally. Volrted freely after admission ; edetna disappeared lu a tew days. iJfl'^linspft'al In a few days: felt perfectly well: albumin and casta still tiresent. _, , Clinically Ibis case Is considered ti have a Kood prognosis. No symiitoms of ni phrlils ; olbumln and casts discovered on routlnn eiamlnatlon. • Ila!i-huur ti «t 28 ■n-a? a studont wlio considered liiiustlf piTl'citlv well Imt in \vlio?o urine albumin and caft.- were discovered liy clianee. On close inspection a slight edema about the eyes was detected. No other evidence or sn^';:cstion of the disease coidd be found. In this instance 03 per cent, for the first hour and ^.0 per cent, for the second liour was excreted followini: subcu- taneous injection. After intravenous injection -SO per (cnt. wa- excreted for the first half hour (sli.-rlitly decreased) and IT per cent, for the following hour and a half. In three other ca=e:^ a normal excretion was found but all three patients were free from symptoms, alhuniin and casts lieing the only indication of disease. In cases of longer standing or cases in which the disease is rf ordinary ^■veritv the tinu- of appearance has alwa\s been delayed slightlv ( t mm ten to twentv-five minutes) and the amount e.xcreted is definitely below normal. Tnlilo 7) who lias bepn under constant ot)-(>rv;ition (twenty minutes) ami tlii> aniiinnt In KV-v [latieiil i No for ni(ir.- tliaii a \.Mr I'nr time of appearance .- pxcreted for one I'lonr riO \ht cent.) lias r.Miiaine.l [iract ically tiiulian-ed. ( ically liis condition i-- liottcr than a \car a Anotii' r j'atii'iit i N .Vi V. ii."i. llilo. will admitted 11. lal.le 7 — If .il-o ( liart 1.3). age .'iO. IIS and a d.lliute parcncliymatous nephritis of at which \,,V ■',) IMIO WntI -li'MMiMM llU's .iii'i .1 ii'UMii^ |.„, . ..^ .,^. ...... ... , six months- .Inration s1h,h.,I an .mtpnt of .)7 p-r cent, for two hours at which time his urine contained oO -m. alliumin to tlic liter. December l(t In- phthahm nntpiit uas -,1 p.r eeiit. and the allmmin -'J fini. to the liter, while his j;er.eral condilioii showed hut little chaii-e. Ih'causc of the po-sihility of the nephritis l,ein.' svphilitie in ori-in 0,4.-. j.'"'- of salvarsan was f;iven intravennusly. Decem- tier id." his condition was ijelhiitely wiuse. urine decreased in annmnt ami tiie .1,...".:' :..-.,„... ,.,1 ,., e.s ..,„ tn the liter, the idithahiu output dropped to 31 aUiumin increased to I'.s i;ni. to the liter, tl per cent, .laniiaiy 3. hi- clinical condilinr. \va the liter and tin' plithalein excreti"ii was -22.7 per cent. was the -ame and Ihe idithalcin output iinclian^ed. (hi .lauuarv his clinical condition was imprevcd. alhumiii ilecreased in anmunt '' ' 7. tli(> eatient ua phthaleiu output droppe i vi'ry prave, albumin '.Mi f:iii. to damiary H. his condition 17. however. 1 the a ;.'a i n phtlialein output increased to 43 per (. ,- .- , in L'ood clinical cenditiim. the albumin only li (.'in. to the liter, while the output nt. l',-liniaiy 7. the ] ^ IT. cent. The blood pressure throughout range of phthalein increascl to .>-.. ii.'r eein. roe ..,..>.., |.,, ...... ^.. .■■ - from SO to nil ami no cvechang.s were present. .Mlhouu'li the phthnlein nutinit droiiped ftii ;e,,«« with the evaciTbation of the clinical manifestations, yet at no pcdnt dill it reach a level which wcmld indi.'ale an immediate danger, whereas, 1 .1 :.i I :....>i ; it.Kt clinical!} .\nedliei- illtercsliii h was (•<.nsidered imniineiil. (Xo. r?. Table T) is as follows: with tlie pxcepti"ii had disiippeared. In the most severe L'radcs of chnniic |iarcn( hvmatoiis nepliritis or wbirc the di^ia^e is of loot: slandinL' and a-^o, lateii with s,,ondarv 29 stlorutic cliangw, tlio outi.ut is reduce,! \ery iiiurkeclly, and in some instances no trace of the drug can liu found in the urine. Here also, as in the interstitial type, the absolute failure of excretion, or the excretion of a mere trace, has bc-en followed within a -hort time by death from renal failure. Some details rejiardin.LT a few of these cases may be of interest. F.'irale. n-'cl 'is, adniittr.l in Ai.-u-t. lIMd (Ca-e 18. Table 7). History of edema of faee for ov.t two v.^ars, SnIlViT.l some Iio.i. lieadache. For a few months t,.eviniig to admission had Urn u.iahle to work on account of t:emTal weakness. On admission had nausea and occasional vomitin-. Mentally clear. Marke.l anemia. Some e.lema of face. Vrine c.mtained larj-e amount ot alhnn.in and numerous casts. Outlet of urine small. I'hthalein test piven an.l no trace of dru" could be detected in the urine durinf: tlie next tlnve hours. She ^Mndu allv hocnme more uremic, the nausea and vomitin- becomin- rather cont.nu.,us althout;)! mentally clear. Death octiu red within f-mr (lays. Xo aulop-y was obtained. . . . . Another case (No. 10. Talde 7 1, one of .-.yidnlitic n. idiritis. was (,t latl.ei peculiar interest. -M. A., afied 23. admitted Oct. 24, ItlKI. exhihitm- severe Treneral anasarca and marked dyspnea. Symptoms bad existed for one month. Pulse small and of low f nsion. Some anemia. No sifius of uremia. Heart was normal. The urine had (i -m. of albumin to the liter but no casts were l.iiun . Tr'.ce ni sii„ar. Some davs after admission hyaline easts were discover^. November S.'the albumin liad increased to 30 f;m. t.> the liter, although the dvspnea was better and the peneral e.Uma somewhat decreased. Ihe phthalein output was at this time only (i per cent, for two hours. November 14, the f;en_ eral condition seeme.l about the same, but her phthalein output ba.l decrea.^ed to a mere trace, The following' day she became suddenly irrational and rapidly went into coma and , !ii;.'d 70. . . 1-. il-rd .-V. . . Ill- S . M.;..! 4n .'ill — r.. il:: :;i \V. 1! , ;li:. d .-II 77:.'iiii :'.!' — II.. aged 5(3.. . W.-V ;!4— T>r. (i. ii; ij ii;i i - ' 1 111 I Arf-riost'lrrusW. mild (\slitis; fair clirusis ; liiu-ii bliiod-pressun'. Tlo ' nun. Hu'. 11 !i,lii I'ri'niia ; lii.'li ;;radi' (hck'd disc; ani'iiila SCVtTl'. II 1,1 111 Arti'l-loscliTosI--. n^t o-arthrills ; bloiid- l-rr.sMire iiJti-li'J.i niiii. II:; II :.'i III Art.Tinsi-l.Tusis ; l.lunilpr.'-Min' I'lO -JUil mill. 11::. U Uli III : N;iiis.-u, lieadai !i.\ aiit'inia ; blnodpi-fssiiri' L'l.-. mm. H::. r_* ;! In : rniiditi'in wm <•' lL".'i lo 1 fenhrHl art.'ilii^i'li'i-nsls ; altai-ki .if iiiRon- sci..ilMi.ss : bl.i.irl-iin'ssiif.. l.SII-Vllll. rj i:i 10 I Kdema. dyspnea; bl.j.i.l-pf.ssnr.' Iilil-lMi.. 1 7 li j NauM'a and li.'rida.li.'. Iivpi.lliyi-i.i.lism ; l>l,,...l.pi'.>..a : men- 1 lallv cl.'ar ; bypiitr.ipby of piostat.'. 1 '7 10 I .....' 1 1" 111 Injection SO mg. philial.'ln .... 4 2Tt II I Na.isi'u. viimitlng; bl.i.idpresui.' lOn mm. 1 III.-. 4 11 II ' r.'i'.'brai ari.M'losrIorosls. mym-anlitls. cm- plivs.'ina : bliind-pri'ssure liin-l'l.-) mm. Ilg. .-,7 II I!a.| '.■llni.al .■.indltl.in 1 I'l II ' Iiv^t"i"a. nrtiTloscl.'i.isis : blo.i.lpr.ssin-i. I 'l7l!Ullll, 4 111 II Maik.d r.'r.'bval nrt.rlos.l.Ti.sis ; blood- I pri's.suie lino mm. Ilg. 4 L'l II I .\rt(M'lo«i-Ii'rosls and byi).'rt.'n«l.in : blood- I prcssim- 170; attacks of nncnscioiis. I ncss ; drowsy and oncoming nr.'mlii sus- I led. ;: .';o ll ' .\rti'rliis.'li.rosis. n-r.'brnl nrtorioscl'-rosls, .hr..nl.' n.'pbrlils; blood prcssufi' 1S5- 12411 mm. II'j. 4 '.ill 11 ! .Marked I'vc-.iiangcs. partially blind ; blood- ! pn'ssuiv liiii mm. Ilg; no cdi'ina ; good plivslcal coniiiii.m. .-'1,11 I .Vrtcrlosolorosls, bypcrtonslon ; good pliys- I leal condition. 5'1 It No svmpioms ..xc.pl bvpcrncldlty, gastric ; tr.nc r.r ::lb-.:m!n and few casts f'jr ten years. 1.-. i:!4 ir> i:i ij 4.-1 IJO 02 • • s .-.(Vl y.vi 470 i:ti; 4S loi; i:iii :;4 1114 4S 127 lln 70 1711 lOo L'lO lull l.-|0 :;4o 1.051' 1..117 i.iii'o i.ui;:t i,u-J4 1,023 1.000 1.O08 l.OUti 1,011 1.015 Alh, I-.-. G. to 1.. Trac... Trao.'. TraDsi.'Qt + I Trace ,if nlbumin I found a f.'W rimes. l,iii;i 1.008 1.014 i,oi;2 1.020 l.llll' 1 i.iiiin I i.iiiii i 1.0117 1,1108 + - Tr.lMV Trace. -f Trac. 1.015 1.00." i: i.iiiir. l.ou' 40 ... . 1.011' ! Tra. ! i I ?.n j ... ' Tra.- ; ii'O ' i,Oi;i) i Trac I . ! i::.-. I l.iVJd \ I :;i!o \ 1.01(1 I 52 I 1.020 I I I 24" 1,010 4.-> 1 1,02(1 + + TriU'o on oil'* oceasi.m. Tra.' IMLUsliriAL NKI'IIKITIS l"mdin;:s PfTcontagp of I OOP Hour. Two Ilom-i UfUiark^ llvaK and gran. ,asts. N,!ni*'rnus hynl. anil L;ran. casts. No casts. Casts. ('■ran. and byal. casts. i.'asts. 0.'cas. casts. Nil casts. Ni) casts. I'.'w casts. No casts. No casts. Ilya.. and gran. casts ; few If. B. C. Casts. -'(i.."i :!.ii Nu casts. Nrj casts. N-> casts. ( 'asts. casts. Casts. NiHucrous casts I'rw casts. lew casts. Casts. N,> casts. (1. -asi'iral casts 0.0 ■4S.;', 411.:: 4". .I ti.ll 0,0 ir,.o ■.\:\A n li .T.S ;i4.7 2(1. S no e.n 4.1) M.O 40 <> :;^ ." 11.11 (l.fl i 0(1 :xcM.-.l al.oul 1 i-r crrit fur on.. hn;ir : .li-l In iiivmic convulsions two w,',U^ lal. (■ ; no aulo|)sy. 0|t,(l IS..'-. I 0.0 1 ;'..!» I Tra.c. 2.0 Trace. Trace. 0.11 \:,-2:< r.'..' ;is.i I 4n.o 17.0 s.o soo 51.0 lii,.,l t«.. ni.indi- lal.'t: n.. aiilopsy ; syniiil..nis chcnic ur..mia. Died II 14 1". .\ut.ipsy: Small sranular kidneys with superimposed acuic h. ni.irrliasic neiitiriiis. ,.,,ci.. itmi.hv of Iii.ii n.l.-, Ill of liron.!i.ilin..(inionlM. Autopsy l.!4lill •>"'^,''",> "' rlL-tit kidn.'v'fruo ,kl r.nlil thro,„b..sls ; left, small, granular kidney. |.,,|„,rt 4 111: In liad condition ; unable to s.'t about ; vomiting', b.ad acli... el. ITlsehar-.d ill 7 11. fclln- b.it.r: li..ada. lies and nausea s.une better. ] Iii..d. ur.iuia. 4 17 11; no autopsy, l!.',-anie .in.wsy. :; -7 11 ; di.'d. ur.'mia. 4 1 11 : nephritis lo.t susp.'.ted lilc.Tof'l'i^b.Tculous i.neuue.nia; moderat.' trade of chronic n.^phritls. Tra... .,f albumin found before admission; about 4 n. he.idache and l,„, f albumin and few casts in urine; .i.ert in uremia. 4,10,11 Aulopsy : llxtr.llie -rad- clironlc inlerslllinl nephiitls Iii.,,1 in cma, 1 10 V<. Aut..|.sy : Kxlr.m.' u-ra.Ie int.Tstltial nepnrltis; liilTii^.' pyel..n.'pluiiis. Cr.'a I.' |i.r . 1 'aialas.. low. atala^e low ; .li.il in uienila. 4 Craniotomy: f.-ll.,wlni,. operation hecame "™Y.M\'ro„'."'lvl.e"rb'i1l.m ill...! uremi.- convulsions on.- wek later: probal.l> acut.. ..,\,i. i rD.iti.'n ■ if nepliritls followinL' elli.'r an.-lbesla. S..1U.- li.'Uiatiirla ; no iir.uiii.- syMipl.juis di'velop.'d. Had -ympl..insou a.l;iii"l..n ..f sli-lit .-er.'brai b.'in.irrhas cllui.iilly consld.led verv i;rn\i nepliritls. lllood-pressure not hUb : cmsider...! cllni.-allv t.i have onl.v a sllfht ixrade of nephritis. •A» i) ;?2 In mopt of the cases of this series t!ie time of appearance has been markedly deUiyed and the output of jihthalein markedly decreased; where the output is lowest, the delay in appearance is most pronounced. The time of appearance, hnwcer. is not so imjioitant as the amount of excre- tion. Details of some of these cases demonstrate the accuracy of the phthalein test. S. n. G. iXc). 25, Talilp St. ajroil i>.T, surgical No. ■2.'i.lT4. Adiiiittcil Pec 21. 1909. complaining' of difficMilt lUid freiinent urination. Ilic-'' nriiiarv ^yn.i.tnni- were ilcpencl.^nt on ))ro-latic' rnlar^rcnicnt. tlie residual nyiiic anio\intin;j ti> 410 c.c. Patient wa-i apparently in L'ood physical conilitmn, will nourislieice of elimination dnrini; two hour-. De-Jiile vi^'orous treatment, coma became ileeper and death suiHTvened five days later, ".\utopsy (3400) showec' an extreme fjrade of inter-titial neidiiitis with a sU]i(-rimposed acute hemorrhafjic nephriti-, Tn the folIowiuL^ case the diai:nn=is was cxcc^linLdy obscure until the evidence hrouL'ht forward by the test was added. Before the administra- tion of the t'-st. mphritis was only one of many possibilities entertained, Mrs. 0. (No. 22, Table S). aped 47, admitted March 23, 1911. In October. 1910, noted fati-ue am! dyspnea on slight exertion, toirether with sli.Tht edema of hnver extremities. In Tlecember nausea and vomitinji developed and have lieen pre-ent almost con-lantly since. On examination patient was poorly nourished and showc^l m.arked anemia. IWM blood-corpuscles 1 ,.500,(mil ; hemo^doldn 15 iier cent,; white lilond c.dls fi,000; -lijiht inerea-e in cardiac ihilness. apex slichlly i) 33 ao«„ an,, out, .ii.i.t >>.to.i. ■.,,,,■„,„. ■" H;;;'-':>,-;,;L:'^::r ::! ::!::t tie. Urine: Pa•^^■-•l'- •/I-''- i;:^^;\ 5 '''V^etri: negative. AUho,„h .epca,f,i ex,„mM„ho„. '''""'H- e-uro Uo. ^H . „„ln„„inont danger. „aus.a,o,i the ,.at„.„t «a. "'^ ' 'f ;„,;^' m s T«o davs later tlu- patient :::r':::;t;r^t::?:;;::::'-:;^^^^ -".-^ -- --•-- ^^ autopsy "as obtained. Chrotti. ttephvitis .an ..i.t ov.r a Ion, ,,en.nl without ro^^Rni^nn ..nd tnav ovon .xi-t in tl,o al.ene. of allu.ntm an.l .a.t. m tl- - n. Th followin,^ i< another .a-o ilht.tratinj: the pre.en.o of n^P'^'t'^J^" Z*^; Iwnco of po.itno -lini.al proof, and also the value of tho phthale.n toft in rcvealini: it> c\i.-tonce. V r ,\-„ n T.lde S^ a-.d 71. "Lo l,ad had .=^ix previous admissions (for I., f,. iNo. l.i. l,ii>i. -a,- artliriMs dc.fonnans) dunn- tlie „,alaria. fel.ricula. a-ute rheunmUe t.w l'"'^""';' , „f {^, „„,, ,egs, last nve years «.s ^;^-' - - l^^^^ ;J; '^ l^,, ..inalyses dur.n. these vertigo ani a'taeks of loss of .onstiousne . albunun at one ..missions .uied ,0 ''™-;:™-,i"::,::°::::;^o:^'r:;iSridid.pressure ...re sin-le exannnat.nn. -^n -"l;''"™" '" „.^,, emphvsematous, the heart recorded ..n prev.ous ^'- >"'-.n -• ' ;, , ^l ,J, , .», . ' Trine: pale, specific :r;' z"!z °: :;«: ::;*'" ;;."- vi «. .... *- -.... - •rranular kidney. The followin.' .a^e is an examplo of the difl'iculty eneountered at ti,,!' in d!l;:;;:;ui:Hn, .UnieaUv vanon. for.tts of toxemias frotn true nephritis with uremia. . ,- V ,- T.,l,h. s, .,...d 00, a.lmitted .Ian. :!. lull, in a drou>y toxic pressure 160 mg. The physK-al ^7'";"' ■\°;; "^pe ific gravity lt,3n, acid. -- ".y-arditis. T..e >u,ne ou.p ^ J;^f];^^ The^ysician in charge albumin 4 gm. to the hte.. 'J-''"^ ".^ ; .„ „,„„i,. „nd treatment for urem.a made a note saying "patient .s eertainU m . ^^^^ f,„. two hours which >"<'"■'"•; '" „,, ,,,rtnite physical signs of a pneumonia ,,ter the t-U-tur.. K-.e to^ UU ^ ' li^^umonU but exhibite<. myocardial ':::Z^:rZ^\^I-^^^^oZ: a,mo. identical case of pneumonia in which the phthalein cleaie,! U|. the d.agnosi-. -rho following ,a.> shows oven n.ore strikingly tite ahilitv of the „uinleM, tect to .-eveal the presence of nephnt.s m tne absence of anj Sle cl!:ieal evidence, heing a case in .hioh nephnt. wa^ not sus- pected hefore the nd.niniMration of the test. «• fy> Aiii.n » -ruTHAi.r.i.N oititt in 1 — Miss s.. seed 57. TSSSl 2— M, A.. BB.d 33. T.'.r.r.n 3— N. K . used 43. T34(il 4 — MI'is W . aired HI. 7."74-' .-.— M. .\I.. :iL'. 1 7/10 I 14 10 11' (i/(l!» 3 1 1 7 II 14 W .1 . nii"d 71. ir>- ir.- 17- 18 1 V, «• , ac-d «T S. ;:4!l.-.8 ■W . ni;r,l .).-, •J., agi'd 3a. . . — r>r, S.. BBPd 43 in/U 1 U/ll LVll/10 "."IS/HI 3 H 10 .1 IS 111 II 14 on II L>4 Of) 11' ir. 00 1 •Ji/io 4 in n .V J/ 10 4 II 11 4 I.". 11 Ac. eiacpibatldn of a ehr. oephrllls ; edema In uremia ; druwsy Syphilitic n.plirltis ; dyspnea rrenilc HloiM. prissiirc 21'(i ; hod had siippresVlfin and slight drowslnesN snme days previ- ciiis to ti'st ; no signs n( ureiiiia when I'-t Klyen. Xansea and vomiting; hlth.^iade choked disk : sever-' aneniia. Kdenia, nervousness, headache ; blood-prea- suri' L'l.'i. Nausia and vornlilnK; decreased urine output. Ilypnthjroldl-m : nausea and headache; liloml-pressure llii-I25. Condition tinelianu'ed HyilrarKyrlsin iicuti' Hitter : no nausea or hendaehe .[ C'-nernl anasar' ii : luvocardllls ; arterio- sclerosis : mitral Insulllclency ; blood- •■ ■sure IfWi-iJL'ii. To slilered to have Incipient uremia -Nausea, voiiiltlni:; chr. pareuchvuiatous nephritis. Nausea. sllKht he.idache : ihr. Interstitial nephritis: visual illsturliunce. Marked anasarca ; nausea ; hlood-iiressure 1311: no edema: chronic Interstitial nephritis. Sllfht headache; nausea in morninu' .Mentally clear; hypertrophy of prostate.. rui:Niv-FivK c.\si;s ok ikkmia ' r«'rrt>n(a>:t' nf Mtc-ns.'*tpli'al rindings. One Two Hour. Hours. Vuni'roiis costs. Ni mcrous casts. I 'W casts. 1'. w casts. I'-w casts. No casts : f- w casts. 1*. \v casts. Kfw casts. lew casts. K'-w casts. [■'■w casts. (I NiiuicrnuM casts. Vi:mcrons casts. \o casts. Jew K. B. C. I loudv from p\is. I'loudy from pus. tlniidv from pus. I lijiirty from pus. I tnudy f ri m pus. clnudv from pus. Cloudy from pus. Cloudy from pns. Cloudy from pus. Cloudy from pus. Cloudy from luis. N'unicrous casts. Numerous casts. Some ' Bsts. Casts. i Numi reus cisti. « I'us. ;i.i IS (I ■JO 4 II i; .■(.8 ".1.0 4.(1 8.(1 20.(J 20.4 0.1) .-..CI I Trace. Trace. Trace. I'racc. 1 1.0 0.0 Trace. .-,..-, (1.(1 triiie. Traci'. ISIt :'.,-5.2 1 14.S 40.0 72.4 .... ' S.fi 2:1.0 37.0 I R.o (to ISO 20.0 27.0 i 1 0.0 0.0 1.0 4.0 1N.5 ■.0 3.0 4:in 13.0 I'iiUciit recovered in lew 'luys after last lest. ;;.'l..)it> herself f(.ellii); well : . .lenia sdll present, lii.d l\l(i HI; coma develu|)e(i 11 15, l(i. .Viiiopsv : Seven' amyloid neplirltls. 111. U two wielis later; no autospy. i llii'il II H 10, Aul"i'-v: Si.iiiM j;raliiil:ir kidueys witli superimposed aeule nephrllis. Iteport 4 14 11, iu bad condition; uii:ilile lo cet iil.out ; nausea. Iieud- lolie, iMc. Disclnuxed 2 7 11 ; lieiul.-o 'le and niiuse.i heiter ; illeil iwo iniinilis iiii-r ieaviut; litspilal will) symptoms of uremia ; uepluitis was only reyarJc d as u possibility In this case until plillialelu test was performed. I'iiti'iit left liosplla! in I';ilr cnii.iition : ur. iiiia did not develop. No dnn: in four hours; died iwo ilays later In unuula. I'led In iir-iaia 4 17 II. r,ee:inie drowsy :; J7 '.ii; i!i- li In uremia 4 1, Ifi. Uled l.'I'.i 11 In uremic coma, .\utopsy: Kitreme grade chronic Inter- stitial nephritis and diffuse iiyelonephrltls Died lu uremic eonvnislons two months later; no autopsy. lioulile nephrot v done rapidly under ens 111 11 In hope of slvhm some rellif; dii'd In ui>mla ivltlilii t». my four hours; kidneys were Ihln-walled pus sacs. For three hours total excretion IIS per cent. Kor three hours total excretion 2."..1 per cent. I'erinenl pro.liitoioiov for remonil of obstruction :! '-1,10. Mini Uvlni; :! Ill I'erinenl prostato'omv 12, 22 nit ; nood recovery; sllll living. In irood condition. :< 111. Omdillon betame worse .iin! dli .! In coma one week later Cranial exploration 4 It II; fullowlmr oriernllon (eth"r nne«tli.-lai was droH sv and loid verv low orlniirv coilput ; died uremic .■onvulsloiis one Week Inter. pro|,iililv a. ute eiiicerliation of Ms ehroiile neplirltls l'r,istatec!i niv under lonit I'th.r anesthesia 4 111 11; suppres- on of urine at once; dl.-il 4/20/11 ; ni> mit..p-y. I'rea l.')! ; died In uremia two da.is later. Iiled In iiri'mic convulsions two we.ks later. Tniee of nlloitiiln found etoe prior to adnil'slon ; p..l.\urlii for two veais; ahoot t :; It heiolaelo's api.cared; 4 I/ll. trace of nlbolnln ; illed In ureiola 4 '.' tl Nutopsy Kiir.ine grade of chronic Inter mtlal nephritis; practically no renal cortes. Died about ten days after last test of uremia ; no oi»'ratlnn .Xutopsy ; Old chr..nlc pvone|.hro«ls of left kidney ; rluhl kidney hvpertronhlid. ■bowlD( cbr. dirr nephUtls iiri.l niiiiU.d diffuse acute pvelonephntls. «.v ..iioni r<.i ..Ki tr.rr,- l rir«l half hour 'J:> |ht ntnl ex.rctlon for one hotir. :!T per cent. to tlTC ir.tr.ntr-, cent. Normally (his nni. h c». 1. led in !.■ than (en tnttintes. *) 36 r.. C. iXo. 24. Talile 8). 115;.. 1 12. aciniittcl March 27. 1!U1, a^ an intercstins ease uf .lial>oti'.s in.sipiiliis. '1 h,. pa-t history contained notliin^ "f importance except that hirj;c quantities of urine had lioen voided fur some time and he expeiienccil marked thirst. !i. was well nourished, n.t anemic and apparently a normallookin^r boy. His blood-pressure ranged around IW) mm, ]!;.'. Some thickening of the radial arteries was noted; no definite eyecliai! -. 'I'he urine <, showed an output of only 7 per cent, for two hours. 'Ihree >d. April H. I!)ll. Aufo]i-y; A nio-t inlensi' grade of chronic intersliti.il nephritis was present, uith almo-t (omplete di-appearance of the corte.\. A sliglit grade of acute iii'[i|ii ill- wa- -nperim|io-ed. n;i:MiA In twtiitv-fivf rases! iiikIoi- study iircinia lias \wn present (see Table 9). In .-i.\tcon of these the uremia was ■^\d\o. tho patients exhihitins: nausra. voniitintr, drowsiness or coma ,ind 111 several iii-tanres convuisions. hi the reinaininrf nine, mild symptom- milv wore present ami liail persisted over loni' periods. Kloven >•( the sixtoiii patient-: with L'lave iremia died dui-inLT the attai k. /;; ti^l nf tins,' nisi .■< Hit' plilluih in 1 'Imnuitinti irns zero III- 11 faint iraic onlij for two hours. Of the five fiatients recoverini; fioin their uremia, in two insfarifes the output was 'iO pei- cent., ti'o uremia licim: the res^dt .if an aeute e.xaeerhation of a chronii' nephritis. In two tlie per cent, died within two ninnths. one e.vcretinj; .1 per cent, in one month, and the others are still livinfr. one after four nionth=. one after two months, ami tbo other after three weeks, hut all an- nt [iresent cxhiiiitin? evidence of chronic uremia. In two patients (Xo«. 1.S and 10. Tab!" <)) not exiiihitin.' uremia but with a markedly decrcnsed pbtbalein outjni. (i|ieralinn with Ions.' ether anesthesia in each instance waa f.dlowcd li\ uremia arnl death. CAliDIAr AND I'AIiDlOliKN'AI. ( A.Si;> An alloiiipt liU5 lieen inaile to tliirorentiau- b\ iiican> ol this test l)elwfen lliose Lardiac cajtr- with hnikeu (oiiipensation and passive con- gestion of th.' kidiiev, associated with tlic presence of albumin and casts in tiie urine- and tliose cases in whicli cardiac insufficiency is associated with varying grades of true nephritis. Jn tiiis lonncition thirty-th.ree cases have been studied. Tiiere were eighteen cases in wiiicli the purely rUnical diagnosis was that of uncomplicated cardiac disease, and (ifteen cases of cardiac disease associated with ne|iliriti.-, I'lnm a study o( these cases there appears to be no doubt but that decrea?e in function accom- panies marked passive congestion of the kidneys in the abseuce of any true nephritis. As the cardiac condition improves, liowever, the passive congestion i)ecoming less marked and edema subsiding, the output of phthalein increases, and in one case rose from 1(> per cent, to normal in the course of one week, the patient in the mcaniime lo-inv^ .-evcntv pdiinds in weight with the disappearance of a general anasarca. The opportunity of comparing the result of the plithalein test witli the findings at autopsy was afforded in tlir fnllowiiig ( ase: II. H. (No. 7(iT10i. !i^.-,l -JH. luhnitti'il -hui. 'iO. lllll, i-oiniiliiiniiin of -cvoii' clysj'iioa ;i!i(l >-««'lliii^r "l" f>' week* only. I'livsit'ul .xaminntion revcalo.l iiKirkcilly imioase.l oardiar (liilnc<>. mitral ami aortic insuffic-ipiuy, dilatation of the l.cart. wmc ascites. lironi-lio|MiiHimonia. bloodpri's- ~iMc mo. moderati' iirade of swondiiry anemia. Irini-: liigli ooloreil. specific -ravily lO-tti. acid, aliiuinin + + +. larj;e numlier of hyaline ami f.'raniiliu- casts, riitlialcin test showed an olil|iut of 21! |).-r cent, for t^^^ honis, Pali. tit died un the I'.iv followinj; admission. ,\ulo|i-y: ( hronie mitral and aortic endocarditis, chronic mycpcarditis, markesed arntr mpliiilis Dctli in ihis in-taiic.' was in L'reat pari dne to cariliac failnre In those -ases witli l.r.'keii , ,iiii|ieir-,il inn \vlii( li presented a high phthalein e\ tioii. m nearly every instance albumin inid <;i-ts entirely ilisappeared with the improvement in Mie cardiac ronditimi. \n .'vample of this cliiss is the following case: I he pal nut r. \V.. presented n severe itrude of ({•'neral nnnsarea with nlhuinin and ca-ts in tl.e nrinc' at the lime of the te«l. lie excreted (W.S per c.nt, nf phlhahdn in two hours. .\i> (he anasarca dwreaseil. alhtimin and casts entirely disappeared, the Kidncv- showing' n.. prrnian.-nt injury fmni the hreal> in com- pensat ioir The presenie of a L'eni'ral jna-iirci. particiilarlv when rdi'iiiii exist!" at the point of inj(>in excretion will indicate with lonsiderablr . .itainty the jjic'^ence of [v. iiiiaiient organic changes in tlie kidney. ;eel. however, tliat a inucli larger serie'^ should be >tiulied clinirii nl iit avitopsy l)cforc very (hfinite <-onrlusi()ns can be drawn. Tahik 10 — Illi; lUlMUiN Hi I'ilTMAI.KIN OlTl IT 111 Ml ' 1 'ill .■■^rni:. TO IM.WI.IS IN TIIK KyK fiROl \n.S .\M) Ml nil. liiiMin I'KT 10: l';.li..lit \'\ .' ( II nuilll^ -■v-l. i:.M nil. I'litliali'iii liiiMid Ol!- I'.'T (lilt put I'li'—mi' . .'lit. I'lM I'Pllt. .\lr>. V. .\t pn-^iMit nonn;il 220 :iSll 32 lliinv li. IKO a.joo.ooo 00 2(1 Tr. » . Noiiiiiil . i-.'ii 5,5.5 1 111. I.B. Ntiiniiil IOiMlVi 4.0.tO.OllO 7."» :!(i <;. w. NcMIIKll s.-. 1 1 :. -t.oiiiroHo 7.'i (15.8 1.. K. S. Ni'rni:il I.SIIO.OOII 70 48 K. X. s \..rn::ll 210 :i.;ioo.ooo '.n 40 S. 1!. ISO Jill 3;!.:! (i. !• i."i.l 170 ."..III 11 1.000 00 22.7 1'.. -m 1.000,000 7.*» 15 1.. W . 1 !!.'. 1-J."> 54.3 S. \V. \..rin.il 1 10 |!M1 t.200.000 70 30 i;.. 1 Imk.Ml ill-:. ico-.'ls i.."i00.000 H.'i 52 1!. S l.l.'i 170 4.000.000 OS 35.7 C. It so i;io .'i. 100.000 OS 44.4 .1. .1. Hir 110 4.H00.00O so 71.5 !■•. K. . Ila/y ilii-U-. wliili' -plulf :iiul torliiDiis veswl- . . . ir, i:io IHO 4.700,OIM) .'llf 27.5.13.3 11. <;. 80 120 XO-UO 4.2m).o(iii .■..000.000 70 105 ti.lit) K.. . KiloiiiH nf dUk'^ 47.22 47.52 .1. s. . Hlli-.'IO 2.700.000 42 20 .1. s. . . . ISO 220 i:io i.->oo.(H)ir 15 34.7 Ml-, o NiKativi- .\. T Niiriiia! KM) ISO 4.r)Oo.ooo 7s 20.H U. K. 170 21.-> 1.700.000 Its 5 !.. W 2..100.000 3(1 (lO.O II. 1.. . \<').Mtivi' 110. no 4.200.000 (12 3.S M. \, . N«*vtitiv(» .... . .. 100120 :i 400.000 55 1 (!. II Dim Diitliiic. old liemorrlmgie HH)'-.>-Jlr 33 rt'l initio 1'. S. Netwt ivi- OP ill .">.2O0,000 !14 iiO.4 ('. X... !I0 170 j.tioo.ooo SO 2li.3 .1. T. Ni'pillv' 120 150 1I2.O 1!. 1) . .\l')!Htlvr .'l.llOO.OOO (•5 «5 Ml-. U . ( liok.'ll .ll , 2:to- so l.OIIO.IHIO 2'* .\. 1 . . Norntal IliO 210 4..~)00.000 fr 20 (;, i>. . Xoriiuil 100 IHII .■..ooir.ooo 74 25 !••. (i. . . Niirmal 22tl23,-i 4.500.(MIO HO 15.5 S. K. . . Noriiiiil liiO 50 r. K. . . . Niirniiil s.-i loir :i, 200.000 50 M. M. J 1 .'> .'■1.21M1.000 75 11. 3 n 220 40 .M i.>^(i;i.i..\.v i;oi"8 I ASKS .\ lame niiMilMT of mippolloncoiio inodiesl disease!; have been al.so studied from (lie standpoint of phthalcin evrrotion. anione the numb(>r beinR ten rnse.s of lobar pnetiinoniii. 'I'"" "I" (htudii'il. has marked rediuli.'U of the |)hthalcin e.xerction been etuountiMcd. Till-: i(i:i.ATi().N OK iMiiii.\Li;iN outi'li lo nui()U-i'iii;.ssi-iii:. to (•ir\Mii;s i.s Tin: i:ye-grounds. wn to TtlE BI.OOD-TUTDHK In the majoritv of eases of ehronie neple',i> in whieli the l)lood- pressure has been liijjli. the plithalein elimination has been markedly decreased, but no e.\act pnrallclisni exist.s inasmuch as not a few instances have bein encountered in wliieli the s\stolie i)rcssure lia' been over •200 mm. Eg and the plithalein output one-half of nnrnial. while, on the othci' hand, there have been instances in which the blood-pressure ha? been normal while the jilithnl.in output h.is been zero or nearly so. the patient? sliortly afterward dving in uremia. While a high blood-pressure when present is considered of dia-nostic and prognostic vahip taken in .onjunction with other clinical data, yet many patients died of renal insuftlciencv and exhibited a blood-[iressnre which was normal or prac- tically so. Xor is the blood-pressure, even when high, increased in inverse proportion to the decrease in renal function. Wliilc in some instances marked changes in the ey(>-grounds. choKed disk, tortuous vessels, hemorrhage-, etc.. have been present loincidcnt witli a very low plithalein output, in many case:?, even of the most advanced and even fata! nephritis, no changes whatever in the eye- grounds could bo detected. il'<' ■■ntl.-nt at the -aine tin,.- failinu tci eliminate tV.e plithalein. Moderate or rather severe grades »! .-r<(mdaiy anemia in ti.c absence of (license .if the kidneys can be pre-ent without any diminution in the phthalein elimination; for instance, two patients, one with 2..')00.000 red cells and hemoglobin :!0 per cent., the other with lunioglobin ;?0 per .ent., eliminated •)! and 'u per cent., respectively, for two hours. .\ dog, with a red count of ;,390.()0(> and a plithalein output of ■*!.' por cent, for one hour, was bled 120 c.c. resulting' in re coi lu't tion. >inic the development of urenua or renal failure ha? been responsible foi- a ^reat i-arl ..f tlir ninrtalitv l'ollo\vin<: surgical interl'croncc. As a result of obstruction in the lower nrinarv tra(t. palholo.izieal changes mav occur in the ureters an of this test in relation to obstnulioii in the lower urinarv tract, see O'lr previous publications on the pbthalein test.'" In the majority of cases the test indicates more or Ich-^ of renal inipair- menl. aud taken in (onjunction with the clinical conditi.n it is of more value than the ^tudv of urine output, total solid-, total nitrorreii ;nid inva estimation combined. A marked deerea-^c in the amount evcret*Ml invariahlv means severe derangement of renal function, xvhi.li nuiy be of either a temporary or permanent character. Knder -uch conditions one should proceed with extreme caution and no surgical intervention shotild be attempted wilhou! further study together •. ith preliminarv treatment. This prcliminarv treatment, ns introduced some years ago into this clinic bv Dr. Young. ,-onsists of drainage by meiins of a retention catheter or frequent catheter- ization, together with the administration of large quantities of water. T'nder tliis regimen repeated functional tests will denmnstratc even- tuallv the nature of the derangement, for in true interstitin! nephritis the output will continue low, whereas, if the derangement is purely func- tional or secondary to pvelonepbritis usuallv improvement will follow as a result of the treatment and will be indicated bv a decrease in the time 3rt See Rpferoncf i. nnil ulso \iui. li tnnt. il. Oil' \tnrch. 1(111. nn.l Tr. .^m. .'V-n. r.on.rrin. Siirif.. I'Mii I i.'ii I T in I'l'ln nary and t^ 41 of niipcaraiu-e o!' the (Jni.i;- ;iiicl ^ilInllti^n(■oll^ly an inimi>c in the amount I'liniinated. Thf- functional (h'iani;ciiiL'nt tluu to inftvtinn in theso cases is a nuicli more daniicious condition than is tlio presence of even a fair! ailvancwl ■•ondition of inlerstitiai no]ihriti.-. The u-e of the test enables one to select a favoiahle time for operation. In cases exhibiting a continued suspiciously low o\itpiit. the nse of nitrons oxid gas or spinal anesthesia is sn^'gested as preferable to ether in (U'der to protect the kidneys. Wlien onlv a trace of the dnig continues to he excreted, operation should not he attempted at all except in an emergency, evi^n though th.e patient presents no evidence c'.' tireiuia. In our original paper- we stated that a dropping jjlithalein ri!rcriON .\s recard- the amount of excretion, hclow which one should not operate, we do not attempt to draw a definite line. Tiie test simply indi- late? the renal function and it de|iend« on the operator what risks lie is willing to assume, the probabiliticr of fatality increasing as the phthalein output decreases. We do. liowever. recognize when we have low function which otherwise' mav he unrecognized and have found that preliminarv treatment in most instances, wliether it be by suprapubic, perineal or ratheter drainage, allow* a regeneration of function which will be indi- rated li\ the tei i 11 1 IN t\vi;ntvsix Niiliilw^r of rin'' ! an; 111 Is-Mi. Z ij i:; i-j 4 HI l!'l III ir. Ill 7 HI 4n--r '- III 111 so i: M lu' H; Hi 51 — K I'j IV. Ill 82— n 11.' 1 -•: 1" i:; 1 1 s;i i>r. n . . 11' .111 Hi I II 11 1 1 r. Ill 1 1 I L'll 11 1 jr. 1 1 Total ftinvtion .' 'rubi'rnilo.is ol bi>th kidneys Tiilal fiinctliin. N.phrocromy 12/15, H).. Kxrri'tlon ol roniiilnint: kidney l-:.\ereiiun of renialniiiif kidney UlMbi uephralsia : pelvic cap. -'> e,e Iji-rt nepbroptosis ; pelvic dilafati'.n I** c.c. (ak'iill left kidni'y; one ealeiiluu- iinl.ro pelvic .iiinetnre. I ahiiloiis p)elijnepl.rili-. lel'l 'riibercniiisls left kidney After nephioctniny function of remalnlDK kidnev. Sliuht Infection 1' fl kidney: |>revloiis neplirolitholuliiy. Sli:;bt pelvic dilalation ti'^tit Nid'- Multiple absrevsps left kidney; [■onoriii' al 'rnbercubnis pyonephros! K. I.. It. I,. It. I.. It. I... 10 It. •; I., i:; It. s U 40 n. H) '. 1 :; i; 15 I.. It. I., none. It. 15 I.. Ill i: 1.". I. 7 i: ■- I. .".II II Uil I,. It. I.. It. U 5.5 II. ... I. 5 It. II U 4..S It. U.ft 150.0 1.10.0 5:i.o .-iH.O 17.5 L»4.5 (11.0 Sti.O .50.0 .5',).0 oa.o lon.n 700 (J3..> 125.1. •JIO.O :;40.o 2(M1.0 85. IHi.O l.'.O + + + + + + + + + + + + + + + + + + 115.0 125.0 IHIO.O liO.O t no.o I L'4I) II 11 II 11 II 40.0 108.0 10 5 14 II 2111.0 350.0 85.0 13.0 ».8 (15 mlD.) ;i.8 (15 min.) • I'ortv two cases not shown In Ihl- table will be found In pre t Aild reaction Indbnted by plus; alkaline, hy inlnus lASES OF SURGICAI^ DISEASES OP THE KIDNEY* I nnd Mliros.opliiil h'indinys. Ii'iir War us and tiiberck' liHcilU. Cl'Mr I loudy : p«s cells and cncfi j I'lcar j riMir I'loiidy. pale: pus colls Tew j tubiTcio bacilli. I sliihtl.v cloudy : pus cells ; I tubercle bacilli. Sliihlly cloudy: pus cells ; | tubercle lincP.li. I I I'tir -nr : negative . .If : negative I! corpuscles : no pus . 'lis or bacteria. ■ .-ir: no pus cells or bac- iria. iiuily : pus ; bacilli. ■ iiidy : ptis : bacilli. !I:t/v : cocci : no pus cells tiace ulltuDitn. 'I' :ir : no nlbumin iliir Niiidy : pus . . . .Mliumin i I'tire : pus iiinctlon remaining lildney : ■ ollectlon 1 lir.. Hi niln. I lenr Uloody lifd itlood-corpuseles : I'ew leukocytes. I'lear > lear; few leultocytes I'li'ar TntHi IllrtioU witUoUt Catll- eteri/atinn. t'l'iir. no pus or bacteria. t'tt-ar. no pus or bacteria. • 1' itr : few pus cells " i'-nr ; few pus cells Illeed (old) e-';ii I';i' leils and cocci I'lis cells and cocci ''letidy ; no pus. red Itlood' '■iH'puscies or bacteria. I'ie<, lincilil and cocci "'leuilv ; pus cells ' I'ur. pale eiir |<'|..iir I clear I I ■li'.i r I CI., -If Ci.;ir Icle.Tr h 21.0 17.0 ;;.o :i4.o 15.0 :ji).o sti.i) ivc I'l.O 20.0 tii.o .TS.ll •M.r, no.o is.o in.2 15.2 lit.'j 28.0 :to.() ■13.0 20.0 :!i;.(i 2(1.0 2r>.o 12.3 40.0 10.0 0.0 44.0 Trace. iri.o 27.0 1.0 21.0 ."i" () l.'i.O IS.O 14.0 1-2 0.0 3:j.n ri.2 0.1 1 27.0 21.0 1.0 27.0 Trace. IR.O 15.8 12.8 60.0 no 23.0 22.0 11.0 10.7 r.0.0 21.-1 10.0 32.0 ri7.o (iX.d O.s.d 44.0 no.n 5.1.0 45.0 22..-. til.O 84.8 31..-. C8.0 30.0 8(i.(l 20.0 70.8 42.0 OS 1 100.0 04.8 2.8 21.0 OOO 32 (• 20.0 108.0 13.0 20.0 100.0 100.3 8.0 13.0 Left collected tr((rsveslc:(l : ll..phl'iti)liiy ; IjMtl'y diseased kldncv ; recovery, Ne]>li:ipluTuy : lower nlie-tbifd kidney lilleil with calculi. (jplier twu-tliirds nortnai : ri'covei-y. Xi'lihrectomv 12 5- Id: recovery: 12 7 I". :;2 iier cent, ei- eret.il one kidney one hour: 12 i:i Id. l'.s per cnt. excreted one kidney DUe hour: 12/20, In. .'d pec . ..nt, excreted one khiney one lio((r, Ijcaka^e of 27 c.o. with per cnf. urea and :'. per cent. plttlialel'i. [.robiibly fioin l.ft. as sniall catheter used on this si.ie : [[ephceeiuKiy. [i;;lit side: re. overy ; kidney badly diseased. Suspension : cute. Suspension : cure. Neplirolithotoniy : c([re. Nepllle, Iniiiy ; ree.ivery. Xephr. ciotuy : recovery: I. .ft collection trtiiisv. -.ileal. No opefallon. Suspension, Xephrertoniy : C'cnvei y Nephre. toTuy : re. ncry ; left . .lU.'.'leil traif-vesical. Neplitc. t.tKiy : .l.'iith. fimrlh diiy. fi.un li.'Umrrhair'' : slL-lit traces .if I iL'ht ki.in.-y .inly, altti.i^t cridr.lv te'.iplnst i.-. Nepbfolith.'t.'tii.c : cufi'. ltein..V)(I of .al.'iiliis; rpcov.r\. No ..p.iati.ui, Nephrecttimy. liKht si.l.' : . .inyenlial atrophy kldne\' witli dif- fuse cortliai Infection : death sixth day. fnun pn.'uiuouia, Xephrectoniy ; hir:.-.-, thln-walie.l sac ren(OV.'(l. Ijeak((ce 21it .■ .', I ,- per cent, urea ami Id, 'J per cat, phi hah In l.nkaL'.- from left sidi' iiroljahly. N'ephre. t.'niy : re. ..very ; kt.iney sh.iw. d s.v< fe <>!.! (tyeio- neplii ills Total funilioii ne,.jt .lay Kith.iut .,ith.li'i>, I.". i>.'r ..nl. 4.-. per cent, for one lialf hour Kidneys are appnnnlly ii..rnial. 41 I ration lui.< iiceii omphmd. wlicifliy tliu tinio iicic>sitaleil for ubservation lias been reduced to half an hour, collections bein- iiukIc at titleen-minute interval?. Where it is desirable to determine whether iho suppusedlv healthy kidney can as>unie suilicient function to prniit of tlie removal of the other kidney, only a half-hour period of observation i- necessary. For the particular> ( oncernin.;: the technic of application of the test in association with ureteral catheierization. see our orip:inal publication.^ ni:sri.Ts obtainkd with riii: imitii m.f.in tkst in nxn,\Ti:n\i. wn nil. MKKAI. IMSICASI. or Till-: KIDM-.Y In normal ia>es the tinu- of the a|ipeaiami' of the drug Invn the two sides has been almost always the same and in the iiuijority of cases this has been live to ten minutes foUowinj: subcutaneov.s and three to five minutes following intravenous injection. The time of aiipearance, of course, will vary somewhat with the I'ate of urinary secretion. Xormallv the amount excreted by each kidney will be practically the same. The series of cases studied inchide tuberculous or pyogenic infection, unilateral or bilateral, (aliuli. !ivdrone|)lir ■ '-. hyperneuhiouiata. .'t.-.f When one kidney only is diseased, the .u-.o of the appearance of the dru-r i^ delayed on th.e diseased side and the amount excreted is not only r.-latively iiut ubsoliitely decreased. 'I'lie amount of delay in the time of appearance is comparatively of little value. Reliance i< to be placed only on the (piantity excreted during a period of on.'quarter. onc-hnlF or one hour, depending on the method of administration. .Vlthough in the majority of these ca-^e^ of unilateral disea-" the com- bined output is equal to that of two normal kidneys, the greater part of the excretion i< shown to be performed by the healthy kidney. In propor- tion to the ilcerea-e in function on the diseased side, a]iproximMtely there i-; a proportionate increase in the function on the healthy side. In such i-a.'^es following' m plireetomy the remaining kidney eliminate^, after the lapse of two or tlii'-e week-, an amount of drug which is normally excreted l.v two healthy kiduev.^. In all cases studied, the output from the remain- in" kidn.\v has been greater than tin' cnnihincd output from the two kidne\s prior to operatic:\ While the total urea from the ■•onibined urine i- no true iiiilev of tlir functional activity of the kidneys, the ( ompaiative urea output from each kidney is of decided value. The same amount of urea is pre=ented to each kidnev for elimination, and therefore it is possible to e-iimate to some extent the proyiortionate amount of work which each kidney is performing I'.arringer has pointed out that when the output from one kidnfV is four times as great a^ that from the other it i-^ safe (o leiiiove ■i TliP (let.Til- (■"innniniontions. Or;r. '^''-fi. isri". (■oni'Pininir iVnty nv" ' Uic^f i-i-'- ■<"■ . ,iii-i.i.'i.'.l in in.'vi.ius Tr. Am. .\^-^ii n-'. lilll. iin.l .\nn. d. Mat. <1. -„i,- 1 M.....1, ini 1 4u the disca.-ed kidney, provided tliut tlie urine from tlie 0|ipo.-ite -ide give? no indieation of disease. It is of most value when there is a marked disproportion from the two sides. 'I'liis test, liftwever. lias its failings, as this proportion docs not ahvaj's e.\ist. Again, the uiea determination indicates only the relative amount of \voi-k that each kidney i.s perfnrniincr. and as the e.\acl amount of urea jiresent in the blood is not known, the te.st shows only the relative artivity of each kidnov and 'uit tlieir absolute functional activity. Again, it affords no indiiatioi, as lo whetlier the kidney i> woi'king at its ordinary capacity, or as to whether the reserve force is called on and the kidney is working at it- maxiTTiui, . and therefore nnnlile tn with- stand any additional strain. The inef!iciency of these metliods ha- neeessitatfKl the introduction of tlie more recent methods of estimating the functional ability. A striking parallelism exists between the relative amounts of plithalein excreted and tlie relative urea output for any period, but the plithalein has an additional advantage inasmuch as it indicates not only the relative e.xcreting capacity of the t\\(i kidneys, but fnrnislii>- an approximate idea of the absolute ca]iacity of each kidney. In all seventy-five cases of unilateral oi' liilater;il renal disease have been studied in coiijuni tinn with urctcr.il catheterization, the series com- prising cases of renal calculi, renal tuhen ulosis, non-tuberculous infection, hypernephroniata, liydroneplirosis and nephroptosis, ureteral calculi, ure- tei'al strictiii'i'^. luMualnria. m-e-; of polvcy^tic !'|.ai;itfil iniiu'" yielded r.eft ins e.c. t luiidy I 'us cell- Inliercle liacilli Alliiiiniu + Ilea (" existed on both sides ami Iroin the liiaraeler of llie urine it was inipossildc to determine wliicli side was more badly .li-eased, the idithalem indicate, that the left kidney. althoUf-h diseased, had the function ..f a normal Uidnev. The rijzht kiUnev in this ea.se was evhlcntly the prinnuy seat of disease. Nephrectomy of rij;lit kidney was successfully undertaken, hein- followed hy a marked improvement in the patient's fieneral condition. The function of the left kidney s'a'li'aH.v increased iinlil the output at the end of three weeks was 30 per cent., opial to that -. Ij-.e kidney removed was liadly diseased. It si'oin- ].n)liabk' that in tlii.s iiist.' tlio infection was liniited to a localized area and tluit the jircater part of the kidney was hfaltliv and gub>eqiientiv was able to underfro ponipensatory hypertropliv. In a case of bilateral pvonephrosiii due to calctdu;=. .striking coi'.liiina- tion of the accuracy of the Ihulings of th;' tc-t «ns atr-ivdod by th.e follow ine case : 1'. K.. a'.'cd ST. admi'ied -Kni. 1. l!Ul. uiih vomiting' ami pain in epi-astriuni. Oiajinosis: douhle renal calculi and iiyonephrosis. uremia. In HI03 patient had ri'jht renal colic for first lime. f(dlowint<.ms reappeared and the plithalein output was a^ain ?ero. .\ doulile neph- rotoniv under fias was rapidly done in the hope that some relief might be thus secured. Hotli kidnevs were found to he merely thin-walled sacs filled \yith calculi and |.i:s. Patient died in uremi.- , ..nvul-ioii- in less than twenty-four hour-. 'I'll.- e\i-tciui' of an iiil'niitile kidney may lie readily overbioked ina?- iniieh as under rinnnal lonilitiuns ilie urine from sueii a kidney may b.- nbsoltitcly normal so far as color, specific gravity and urea percentage are concerned. The literature abounds witli ntuneron? report= of death f__„, -pri-'.l fiidure fidlowin" nenhre: tome ,1no tn the innliilitv fo recorrnize the prejciitf nl an infantile kiilne}. Iffn-ntly, Kuniiin'l'' and M. Anliiir^"' have eaeli reported deatli? followiiic; neplirectoiny wliere an inranli'i' kid- ney had hien left to assume the work. In our series, two such kidneys, the seat of disease, have been removed, am! in a tliird rase with hladiler tuberculosis and suspected renal tuljeic ulosis without Inralizini: -yniptoni-i on either side, an exploration of the left kidney levealed a healthy hut infantile kidney. Mxploiation was n'?eessary inasiuueh as t!ic bladdei- was markedly contraeted and it was found impossible to eathoterize the ureters. ,\ similar condition was encountered in a eat utilized in onv experimental work (described below). The details of one of these cases is presented: t .. ailtnittiil .\liirrli I!'. IttlO. ■I'liljoiTiilosis in an infantile kidney. Tlii' left ureter wii- oatlieteri/od Imt on aiTount of ulceration of the ri^'lil iiretoriil orifiei' it wan found impossible to eatlierize this ureter, the urine from this side tlieicfon beins; colleeted trnnsvesieally. 'J he «eparatiil urine-; were as follmvs: f,..ft 40 e.c. (tear Normal .\ei cl.:.-r ipically ciiitaiiicl a few leukueUt-. ii.i iirgaiii-iii>. ( y.,to.,CO|)y The left ureter was readily catlicterize.l but an but niiiTO-eopi revealed a nornuil libuMer revealed ;i ii.Jiiiiai inaii-nri. i "^ l\^y^ ...w.. ....- .■ - obstruction at the lower end of the rigbt ureter obstructed the catlieter ..u this side, necessitating- transvesical collection. The separated urines were Ki-hl as f.illow- Left 45 CO. Aci.l I lear Specific firavity H.Jt I'rea 05 ej;. I'lithalein appear.'.! in :!:' per cent exciit.'.l 7(1 e.c. I I.Mr linii I'.'w liiii.iieyt.'S \ I. (irnaiii-nis A. -1.1 iiin. Spocillc j.Mavit\ I'rea 111 c^. rhthalein appcar.'.l in -'< "I'li. ."i per I'. 'II'. .'xcr.'li.ni On account of tiie I.jvv function and tlie presence of the ur.l.'ial stri.'lurc. a probable diafjuosi- of tuberculosis of tbe rijiht kidney was nade an.l a nephrec tomy p.'rforined. tin examination tliis Ui.lney was found to be ba.ily diseased. :illh'.'U'.:li til.- urine contain. 'd ni. p;itli.il.i^i. al features. Ofcaoioiiallv it is impossible t.i . ntlit-tcnze (itlicM' uictcr. |iartirul;irlv in marked v.-sical ttiherctilusis. Here bv tlie aid of iiuli.iocarniin. iintiii? the time of the a[ipearan(e of tiio diniir on eaeli side and from tlu- evidence obtaiiici! from < y.stoscopv ami from localizing clinical symptoms, it will SCEcrallv be po.ssible to arrive at a probable dia?nosi= as to which ki.lnev is involved. The total function as determined hv m.aiis of phthalein will determine whether the di.«ease is unilateral or bilateral. Wlien one kidney is siisjiected and vet a crnnd total iviial fi'.mtion has lieon indicated, this side can be explon.l an.l if f..inul to pu -out cvi.lcn.i' .if ]>iaiki'd disease can be removed with safety without exploration on the oppo-jte side. Obviously exi-retion of a larfie amount of phthalein must have been performed by the opposite kidney. Such a case is here recorded : The patient bad marked vesical -ytn|.loni- aiul pvnvi;. uilli tubercle bacilli in the \irine. On cvstoseopie cxaminntioii the wbol.- tri(;..iie vva- bailly inllanied an.l p.|emntou-. Tlie risilit ureteral oritiee wa« badly uberated an.l could not be catlieteri/e.l. An attempt to catheteriye the !eft side also failed on account ..f lhi> eept. 1!>. IttlO. had ureter" entbeteri?ed anil the separated uritien yielded the follow ing data Left lliKl't n..') o.c I" <■'<•• Aeid •l™'" MIoodv Arid fren IH c' 21 rf. ur.'a Phthalein 11 min. AppeHreil 11 mm II per cent, exoreteil II r-'f '"''" exereted l'.» f 'I iiu following' il.i.v tiiliil tiiTiclioii without oatiicteri/.itioii wus sludii'il. iiuiput he'tni: 2\l per cent. 'Ilie cqtuU and decreased function us indieatnl bv tlu> plithalein allowed a bilateral renal di«en«e due to clironic ncphriti*. A tew ca-^ts were I'i'iiiid in tile luinf. Till' value of tlip plitlialoiii output over thnt of urea is ptrikin<;ly lit nioiistrntcil in tl'.c ciisi' Just cited, eliniination lifinsr practically equal for t!ic tun -ill, -. Iiiit iin imliialinn was afTonlril of the redueeil total renal funi'lioii, Tn two out of thiee rases witli In'peini'jilivoiiia a deiica-e in fiiiirtion was inilirateil. In tlie tliinl fa-e tio dilTerenie in function for the two sides was inlii ated. Tlie phthalein. the urea, specitie prax ity and quantity of urine colleitcd from each side were identical and nonual. On account of pain dm lo a slight livdronephrosis. the kidnev w.is explored ; ;id the lunioi- di-iovercii. The hvpetnephroiiia had not invaded the kidni'V hut wa= ^!ruply altr.rhed to its upper polo, in all lik'elibnod not 'nterferinsr at all \\ith renal function. The test ha- lui ti u-ed li\- \i< i Oir) I'nlvii.ia fe-l ■ Left ■»4 re. U'O cc. ir,'-. ce tritii Heeled in L'O niintit.- nenoiU. Riplit •22 c c. ■22 e.r. 41 c c 5t. 'I'liis inhil.'.tion of function liiiiu urctii- (aJictci- has al-n been noted by Keyes. Jr.. and A. K. fetevens.'" The MKi>t serious disturbance in our e\perienei' occurs slinrtly after the intro(iuction of the catheters ami it is wise to wait until the eatlieters are workiujr frwiy and snmothlv before jrivinp: the ]ilitlialein injection. If tliis tec-hnie is followed, inhi- bition will probably not play an important rfdc in the crei";' mnjority of cases. ni;\"AL KUM riON lilFOlIi; and AITKU NKI'IIDF.CTOMV 'I bis problens bus been investijjated from the experimental and from ti.o clinical side. The cats employed in the diureti( work (referred to above) were utilized also for the •itudy of this problem. Hurinsr the course of active secretion one kidrnv wa- suddenly tied off, the .|iianti- tative secretion of urine and phthalein bein? subse(]uently studied and foniiiared with the excretion prior to this nephrectomy, the condition- of the experiment of course beind the urinary flow and at the satne time reduced the (>titlial in "ufjiut to one-tifth of its former level. Thi-- fiudinjr was unique. In this (ase, however, it was feund that the remaininii kidnev was concenitallv atrophic or infaiiti'e ;u rliara(ler and wei'jhe*! onlv fi ) ■_'iit,. while tile kidtici wliiih had I.e. n icine\rd «' iehed '.'I'l. I 'jin. ThiJ is 11 strikuiL' exaiup'' nf ih,. value ef the |e. i iti dcteeiJMi: the ti-tie func- tional cjipacity of a kidpev .IB. Kap'ttmnii-r : Sr.' "iieeiiit |i:ii"'r lli'f, 'i. 40 Ki'\"-i- IVfioniil reiMiiniiic.ilien ^j 51 The fiinctioii of the two kmur}< mi tlic (hi\ ol' the operation hu.- heell estimated and toiii;>aivi] with tiie ruiutioii of the leinaining kidiiev us it is on the day i'ollowing operation. Cliart J 4 shows the curve of excretion prior to and the da\ fuilnwiiiL; iiephieitoiny in a dog. the estimations being made at livp-niinute intervals after tlu- appearance of the dru? in the urine follnwing an intia\rnoiis injection of mg. of phthalein. Alllioiigii the rate of ..m i. noii i- hiwi'r, no great deciease in function IS indii-.-ii d at ihi . mi ,,i a half-hoiii'"> (ih-eivation. ' li-iii ) I. ■ I 111' iii>prr Mil.' ri'iir.'siMit^ tli.' plifliiil.Mii cMTotinii f.ir .-u- li.ilf Imiir liilliiwiiiC iiilrini'iiriii* injivtidii I h.' i -tirnnl inn- ]„■;,,._, ,ii,ii|.' mi (he iciiiirir. int-i vnN. Ihc Ic.u.'i line r.'|in-cMt- th ,...(i,.ri ni i!„ ..,„,.■ ,1,,- Im, ...n- li-lii'v within HviTity fnin lidtir* iifii'i ri|iliiiriniin in tho-e,a-f> m \v|,i, |, il,,. fi.n, ilnii o| ||,r irniainiiig iicalliiy kidney wa> e^tinlated af'. r an int. rv:il i.f thve we.k> lo one month follnwine nephiectomv. the fiim Ikhi w:i- iiuariah'\ r..iin(l ikiI merely lo e(|iial thi- ■ nmhined fun, tion of the iIi^m-, d ami heatlhv l,idnev prior to r.prrat inn. iiilt to h.' lU'linit'MV .jr. all 1, In a 'rw ,:\-~ m whlih th.' fur. |i..n ua- oHtitnati.d af an interval of a few ,\:i\< I., a week following neplire.-tonn . ttir lumtioii coi re-pond- wyy cJo-Lly to lii..t whieh existed in il'at kidiiev previdii- lo np,iati..ii. I.ni at the rnd of a period of tliree week- ,r a mnnth the fun'tion wa* a!wa\s ecpial to that of (wo normal kiilne\-. In one case of doiilile n^nal tnhen uiosi- in wlii.li the fmidion of the kidney h^fl hehin.i wa-^ ■,'(; per . .'mI. for one liour prior lo op.Tation. if increased until at the cinl of one month a phthalein exerethm of '0 per i-ent. for one hoer was attained, whiih wn- ronsiderahlv ereater than tlie lotiiliined funi ti.m of 111,, h,,, kidnev- prior (.) operation hi thi- in-tancp ■lAiii.i: ii.>.--At riirsv 1—1!.. UL'.-.I •■:'.•. . . 774U1 1'--Ij.. apf'cl 4B.. . . 77,->4:t :!— G.. acod 71 . . . 7.')74 1 4 — T., aeed :'..". . . 772«S 5 — McC. ;itiotit GO 7 Mr«. \V.. need L'l. 7:i74L' S—T. r. . ni;.d .".7. !l I... ns^ll "li. . . SurK. So. -Ti.'.lO 111 -<;.. naiod .'..'. . . Suri;. X". ■-•.-.174 II II T . nu.'d 20, 7iiiini IJ— O., need 12. 774.W i:' 11 !T.. 70710 m— O . nsid n.'!. 10- T . iiir.il r.n 17 !• , hlvmI 77, Siiris. No. 28Sn8 10— I,. »KPd .-M . 20— r. I., nsfd no. 202:111 21— R.. aifid m . Burg, Nn, 2.".ii:'.7 Dal>' riiiiicnl IM;i;.'liii.«ls :■. 2s n .-1 2S ■ 1 1 11 11 M :; .■•,1 '111 11 r, M II 14 in 11 n/10 1 .".,'11 1 7 11 1 '!) 11 1 1 1 1 1 1 22 '10 1 20 10 2 4 1 1I 12 22/00 I • 7 10 AliHc" crdoearditl--. luitnil ln-. -r -r : casts. .\lli, 4- : no casts. .\P», - ; cloudy from p'i~ Alb. -:- : cloudy from pn- Alb. - ; cloudy from pu-- Alb. -•- and casts ; c! r:i Aih, -f and casts: cloudy Trine pale; cioudv freai pus. Tiioe aih,. sllirhtly clou. I Horn pus. Trine more 1 huidy Cloudy. Nciintivc. \o nih or casts. All. . . : f.'w casi. Alb. :ind -h..K. Ill I asls, 21"! c 1' from rli:ht. ' 7 /lO I Hypertrophy of prostate ; niToriirdttt* 017/111 I calhi ter clrnlnnL'c 10 1 'in ' Catle h r dialnaee HI' 7 '10 I Carclniucii .if pr.istale ; iivurin 10/17/10 I . 10/21/10 I 7 10.10 ! H\ p.Tfrnitiv of prostate; acute retention; I uood coliillllon. ;! 2<'in HyiHutrophy of prostate; retr.iveslral ah- sc'ess ; septic tenipiTatiire ; fractur.- hip; bad shape. t^loiidy : ftiis ; .-mail amount ulb I'us and aili .Mb. -*- ; pus. Alb. -f ; pus .\lb -t- ; pus Alb, + :i '.ll 10 4 12 10 4/2.1'10 V»ry *lrk : suprapubic drilniii)'. I'yurla ryurl«. • l. :in..j ir.r, u< I .■i:t.(i (IS, II •jn (V'J (Ml Trn,-,.. (III no iii.i Trnro. 5.5 Faint trn ■I'l.ii ;ii.o 41;. 8 s.s X'.H 1 Traie Traco. Trarc. ."m.ii li .111 nil L'dO r:; I 8,0 I 1.-. Kin I 25." I . I 18.0 ■-'.% ITriKP.l I" I T.fl I I-. ! I.M i 1 t'S.S "II I 15.0 1:1 I Irtfl I I 4.15 i;i.o .■11.2 :iN.ii an 5 7 I 12 5 1 2.(1 20.3 .■1.1.8 580 4011 45.2 IMrcl 4 111 II. .\ul..psy: ,\rl.rf>w,l,.|-„sK. my.i,-.iirli( U, Mr, it., .irill.il Mn,i I ri.ii ,|,i,l 11 l".'anlllls, .Mrlll.. „n.l ll,..,l..| ;, Ir ,Ih..1H,' ,lin-|vr ll..|,lllili.s; ,„ I.,!,!, 1 it l^ „f "Illy II |,.». (I..HS ilnriillon ' i',!,M *■,."•, "i;.'''i'l"al '•iiib..liw. ,\,iin|wv .•l.-,.-ir. : riroialhv ani'tl,- .■mln.anliiN. . I" \.);i'iaiiyn ,ii,l„, aniitis l,.ri .nirirh. ; .ardl.ic (illalalliMi ami In p.fti ..pliy. ■ linailc II11.-MVC' .iiiiHi sill, n iif vi.., .1:1 ■' ' • .\ut..p»y : .\lii,l,.|-ali. Kfailc of chn.i.ii .lilliiv,. i,,.|,1,iIik M. ■! ciipi, ,11111. inia Ivii ilavB laliT ; n.i (.piiati..n \iit..i...\ \V. p"h.v~li,- ki.lll.y.s. ' • ■ "'■'I -I "• III. Ill i<. ma. .\iil..p-.y: .Si'ViT.. aliiyli.i.l 11. plii ii U, il. V.' ,1 d..iil.l. ''■■''' " 'I 'II .\iil"P-v: Siii.iU i;iiii,iil,ir ki.lii.ys. ..iip..riMip..-..,|;i..r,. ii,.pliriiis. 1 1111 .l.,iil,l,. ni'phn.tnmy : ,ll,..l i„ iw.niy (-..lu- l„.,ii-; lJ,li„.vs liii. ,1 uiMi ■ a!.. III. hi'lii;; 111, .10 ililiMvallid pii,^ ^al^. .f li. ai I fiiihir l'l-ii.; iliMi,!.. M-iii,.r,,il anas ,,f a. in.. |..u.|..n..plii in- W. ,,t Int. I . ,.iiia 1 IS 111 :,ii,i ,ii, ,1 I t;i 1,1 .\,it..p-y : S..ti,.. ,lil:il;i,|„„ ,.f ,„.|v.s, wlli.li vv.i-.. 1,11. ,1 with p.i- : n,.i,k.-.l .•i.i.l.'- ..f "•■'-'■'•Kli- lliniH, kl.ltlrys b..lli« ■„ „,,,„ii,| ^ur; ...„i..'.|i,T„M, pvl'.n.pl .\iit..i.-y .'ill..'.!: |.-atly ,l,.t-i'ii..faii,,„ ,,f vi-y. I'n. im|,i,|ii,_ |,i.ii,.», IM..1 in iir. tiii.i 4 11 II. ■^"Jmr,'!,',,,!'"',""" r""''' ;'^'. '"■"■'.''■ inti i-Utlal n.-phiiii. ; ..„i...s alii,.,.| ,|, .,,,.>..! : ^iip.'i imp.. .^.,,1 ..Kilt,, ri.plirlti.* iVi ■ «hnu-",',",-i'"H"' ,"""""""■ ' -" ;> .Mi'iil-v: My,..a,-,|it l<. p.,ri.ai i. ; l.iiln.v. :'z,!:";^;z::rZur{u: """ "" '"""'"^ ""^ ■""'"•'"^ """ ■> ■^■" "",'.'' ' ",' " ,1 ■^'",;'l'"> ;•*'■"■ 'liri.nl.' an.l a,- •.■ iiiili.il ,i,i,! ;i,.it|,. niv,.,anlit i- "I '' lai.lla. illlalalli.n. :i. ,il,. unil ni,-.|. rat. ,lir..iii, liitT.i.., n.pliriti- .V. j.lii... I..111V iiiiil rluhi kl.In.y f,,i:n,l aln...^l .ntlnlv .l.,«.i.,vr,t ,|i. ,| f,,,„ ,Pn< '"^uHiri.r;:;;!-:,;;;:";:,,^;:;., -^^iZ'^J^lir'"" ■" -"- "-■'"" --'■' M. ,1 I. 1, ilayv aft.T lii-t I. -t. In iir. iiil.i .Mil^ipsv .-li.vs (11,1 ,lii„iil,' |.y..ri.-|.l,r,isls „f l..fi kl.ln. v : ri;;l,i ki.ln.'V l,vp..rti.,|.lii..,l l,n vlnmint' rl,r..nl.. ,1 fT„.,. n.plirltl.^ nn,l a tnark.,1 ,li(r,i... a.-iit..' pv,.l.m,,pli', His '.,t'.,l"',',.'.',nyi.'"'i"''T ' i '"';. «i';k- aft.r „p..ralh,n n,y.., ai ,|il Is l.,.,an,.. .y^^vH <.it.-,l. iininia di'vihip, il. ,,i,.i|nL' In il.ath, i-r, "i,',7 •.'.''„! ■ '"(■"""•• '■1'^'" '■I''":-''- ■■ III' l- "li'i^i'il • liiiini.' ,I1IT ,i,.i.hillN .11 I , "'"'."'■ '■'r "'l-*'!""^!" ; "llil will fill- 111 v~: 1... am, -ll,,;,l...l urfnil.i (l,.v,.l.ipi.,| iind (ll,.|| »„ni,. ,|,iv» |,ii,.r '''I'a'ili' •'■■♦'■'"• -^"''i' iiK'li'rlllK and |.y,-lllls; . hr..iii,- .iliTii.,, n, pluMis ..f .. v.i. "'Kl.lm.vJ'l'i',' i'";' '"""«lni» I"-"",'-""i-"iniv. friim ,•, rclirnl lii.ni.,rrliaKe .\((lo|w>- : III 1 - .irt.Tl,iK,-|..r„i:,. r.,riii .,f n. I'liritls ' '' hr, .■t";,',ii',', )'" '""'"■, '''"■""''■ iii.vnrardltls. arl.Tlas.-lorosls : ,-lir„ii v«llll.. riMi. iir.ipln „r p,..sini,.. r. ir..v,..|, al ai.„-,.ss ; kl,ln,.v» kIi.iwwI K„nii. rlimnlr ...niih^ir:!;.''.:,';,':.,,:.!''' """'"■'' •'"""■"■" ■"•" ■ "»■ """•' '«■'■"••■ ■•' <■"'"»••« ^A 54 till' Ulhi'lt-lllnii.-- I'lirM- Wii- |i|.'i);ii)l\ Mii:i!l illld ('( ill lillril. -d tli;it ,lie ii'lll.-; ill - iiiLT lu'iiltliy ]ii'itiiiii |iinl.:ili!y iiml 1 Avriil i()iii|Hns;iliir\ li\ |i('rlri;i'!'v. ci)Mi'.\i;i-ON 1)1' I'll III \i.i:iN i;\( iiLiiov with ai.-toi'sy iimiiniis An o)i|i(iituiiit\ \\;i> ;iil'i)riliil ill t«fnty-iiii(> r;i.-o- (.-i'(> Talilc ]'i) ..f (•i.in|i;iriiii: till' jililliaifiii fxcrolidii witli the ]i;itli(il(ii.'ir;il cnnilitioii nt ilic kidiicvs lit luit'ii'-y. Ill tlic cii-i'- in v.liirl; tlh |>lit liii k'ili I'Mivli.in \v,i- liiiiilcnih'lv .liirciwnl the kidiH'vs showcil modiMiitc iinthol(i;_:i< al < hiiintri'-. In thu-c casi- in whirh nil ]ihtliahMn ua,- dM-n.'ttd. ni- mdv a -iiial! aiiiniiiit. cxte- ,-ive and sovi'i-r renal di-triut;i>ii wa» iiivarialdy tniiiid. li; niii- la^ait ca-r i \,i. I I, 'I'aM.- 1 '.' l -hnw m-- an cxtietioii nf 1. ■',..-) y^-y (Ciit. fur twii liiMir~. «hirli is a il-linili' lii;l nindci-ati' rcdiictidii. onl\' a jias>;ive L'i)ns'('>tioii \ia- tound. 'I'liat thi.- iimditinn an ii!(i'i-|'on> with fiinctinii nthi'r rliniral i a-i< -c m tn Kinliriii. Ill one ca.-c ilmiMi' polycystic kidneys ucic ciinninlcrctl. a'll!oiii:h liic Iilitlialcin cxcictioii wa- nciinal. The ]iaticiit cxhiliitcd im syiiiptdiii- fi'iiii this (I'lidition dininir life d'-alli hciiiLr due In |iiieiiiiionia. 'I'lic fai't that polycyslie kidiii'\- iiiav he pre-eiit i'oi a ^rcat many vcirs wii'eiiit syiiijitniiis ainl al-n thai tiny are ii~ua!ly iiiic'\]ioc(c(lly di-ici\ered at aiitnpsy ill patients duni.' ruiin n\\,:-i- lendition? is ijooil proid' of their funcliiinal enieioncy. 1 o\i i.rsioNs 1. 'The ah-orptiiai >■( plieiiiil-nlph.diieplilhah in I'oihiw ill:; injection iiit" thi' liinihar inii, on ac iiiint of its cnrlv appenratice in the nriii'' and the rapiilih- and completcne-s of its (dimi- nati'n hv the kidnev and the reliance to he plaeed on it-; (Indinjis. > 65 '''■ 'I'll'' 111, liind (if i|iiaiilil;ili\(' i-l iiiiiil ion nf iliii ■imniinl nf driiLr C.Xvlvtcd is .-|||||ilc illlll ('\(r. (lin-ly ,■!. l lll-;ll|.. II. It i- nr iiriipoiisr value fi.in: .-i .!i:i,;,'iio~tii' and piu-nostio stand- I'liint III iiciilirilis ii;a it revmi ilir ,h.:m> of functional doran.irr- iiiont in ni'ii],!ili,^ ulicllur of ili,. aeiitr or ihroiiii- \arictv. l'», |]i tliu (ardiniriial cases ?o far -studied the tc-t has proved of valuo in dclcrniiniiij; to wliat dr!;tvo rrnal insnilicicncv wa-; ivs|),,nsih!o for |ho clinical pictiir.' jirc-i^nlcd. II. 'i'hp test liii" proveil of vahic not unlv in diaLMiosiiii: nrcmia from i-onditions siinnlaliiMr il. hnt has also sue, cs-i'iiHv indicat.d thai nreniin uas inipciidinL' wh.m u,, diniral c\id. ncc n{ i|. e\i-|,.ncc a( tli" time was pri'sctit. r.'. 'I he test ha- pi-nvcd nf LMvat valin' in M'vcalinL' the tiaie renal comlilinii in ca-i-^ ul' ininarv oh-trncl i..n. It is here of more value tlinn the nrinarv (,utput. total -ciids in.a or total iiitro-, n, and ciiahle^ the Miri:eon to M'lect a time for opciatinn wjan the kidnevs arc in tlieir most favorahlc fnrictiona! condition. The inipiovMcent in the lenal ...iidition m rasos of nrinarv ohstnidion fol'owinLT the in-tii ut ion of prelmnnarv treatment is strikinLrlv indicitcd hv this tr^st. 1". In nnilatcial and hilaleral kidney di.soases the absolute amount of w.uk done hv each kidi:ev as well as the relative proportion can he ilcterinini'd when the mines aie ohtained s,.parately. Il \< «itli (lie -iral.'M picaMOc lliat we tliaiik lti. !l II. ^,,n,|^- f,„ |,i, ,..|rly •""' ■"iilii I iiiicic^t ill tlii- nnvU aid fnr tlie L'-iicoia- -iipplv cf clnnral ,i! ,;,.. ri.il ivf,a,.,l (,, „. l,v liini: Dr. Ilaikcr. Dr. TIk..^,-, .,,i.1 (he ..tli'or incniUa < .if (lu- stair (,f III,, me.lical clinic fur tic o|.i.(ntiiiii(v ..f Mii.hiiiL' llic car.liac aii.l nciiji. ritic rasps: Dr. G. }.. Iliinncr and Or. K. K. Ciillcn fnr (lie privilc-o ,,f stn.lvin" many siirfiioal nITccdons nf tlio kidney-. Dr. V. W. lleMnn.oi f.,r liis ^;,l^■al.le a--i-laiice in carryin;.' on ( Ic- work; an. I Hi Diinniicr cf il,e tlnii el" ll>ii-eii ami Weseull fnr (he