299

in in four hours is only partly excreted by the kidneys,and the amount of water retained is larger whencommon salt is given in physiological concentration inthe water. These observers concluded that there isan extra-renal delay in the transport of the salts andwater. Wengraf’s observations dealt with the outputof all the water including the insensible perspiration,which latter was determined by repeated hourlyweighings. The insensible perspiration correspondedto that of the kidneys. Breast-fed infants in generalexcrete in excess, whilst healthy bottle-fed infantsexcrete only the water (120 to 160 cm.) taken in fourhours. Diuresis in breast-fed babies begins in thefirst hour and reaches its maximum in the second hour,while during the last two hours there is only a moderateaddition to the amount excreted. In bottle-fedinfants there is a steep diuretic rise usually in thesecond hour which reaches its maximum in threehours. The diuresis seems to be determined by thecourse of the hydraemia and not by the wants of thetissues. The water-excretory apparatus of a slightlydyspeptic suckling has not such control over theingested water; the excretion curve follows the normaltype, but the amount excreted is less, 30 per cent.being retained. In severe dyspeptic cases the excre-tion is irregular and the retention greater. Inalimentary toxaemia only the insensible perspirationresponds to the diuretic stimulus. The kidneys excreteno water and the retention amounts to 50 per cent.,due to some renal cause. In experiments, combiningcommon salt with the water ingested in naturally-fedchildren, it was found that in one-half of the cases thewater taken in was excreted in four hours, in the otherhalf 40 per cent. of the intake was retained. Theurine in the former cases contained very little commonsalt-only 0*2 to 0’4 per cent.-a concentrationgreater than obtains in experiments with water alone.It is evident that the kidneys can alter the concentra-tion. These two groups show marked variations, theone excretes the water in four hours, but retains thegreater part of the sodium chloride, while the otherretains both salt and water. In this latter group thereis perhaps a retention of water due to extra-renalcauses.

The author discusses the functional compass of thekidneys in early infancy. To determine this, experi-ments were made by adding common salt or urea tothe food. The condition of the urine as well as theNaCI of the blood were determined. It was foundthat by increasing the common salt by giving one largedose of salt the percentage of salt in the blood isconsiderably increased, without the NaCl in theurine being in greater concentration than that in theblood. Even when large doses of urea were given, insome cases there was no corresponding urea-diuresis,and even after 24 hours the excretion of urea was notcomplete. Dr. Wengraf concludes that the kidneys inearly infancy are capable of secreting a urine of

variable concentration, but their functional compassis somewhat limited in the sense of an iso- or hypo-sthenuria. In the condition of hyposthenuria, inaddition to an extra-renal component, there is alsoa renal factor. This limited functional capacity ofthe kidney, when the available water is diminished,as in acute dyspeptic disturbances, may play a notunimportant part in the pathology of infantiledisorders of nutrition.

____

SHELL-FISH AND ENTERIC FEVER.

Dr. J. T. C. Nash, Medical Officer of Health for theCounty of Norfolk, has stated in his annual report for1919-20 his belief that one of the main factors inthe marked and continued reduction in the incidenceof enteric fever in England during the present centuryhas been the persistent warfare on " boiled " cocklesfrom polluted layings which he initiated in theopening years of the century when medical officer ofhealth for Southend.l At that time, although rawshell-fish were already under suspicion, it was thought

1 THE LANCET, 1903, ii., 1533, and 1906, ii., 836.

that the boiling of cockles rendered them harmless ;but he demonstrated that " boiled " cockles frompolluted layings gave rise to many cases of typhoidfever, and that the so-called boiling was not realboiling, the heat employed only being sufficient tokill the cockles and open the shells. He found oncutting into " boiled " cockles riddled through a sievethat the interior contents were uncooked and barelywarm, the internal temperature being below thethermal death-point of typhoid bacteria. It was aremarkable fact that from the time the " cocklers "

could be prevailed upon to cease from laying thecockles in grossly polluted creeks, and, further, tosterilise them by prolonged steaming, the incidenceof typhoid fever fell extremely rapidly, not only inSouthend, but also in London and other large townsto which the so-called " boiled " cockles were sent inlarge numbers. A certain number of cases of entericfever have also been traced to the contamination ofsmall flat fish, such as dabs, which are often caughtnear sewers, and being too small to be gutted, areeaten entire after cooking insufficient to sterilise thegut contents. Dr. Nash also formulated a theory thatinfection might be conveyed from shell-fish gatheredin polluted waters to other fish on the same stall bythe hands of the fishmonger. He noted severalinstances of infection amongst cooks under circum-stances where no other member of the householdcontracted typhoid ; in each case the cook had handledand gutted the’ raw fish, which other persons ateafter it had been boiled or fried in oil or grease.Although emphasising the rarity of such means ofinfection, he believed that this was undoubtedly oneway by which not only typhoid but cholera and otherallied diseases were spread. 3 Their diminishedincidence affords satisfactory evidence of the safe-guarding of a popular foodstuff.

ARTERIAL HYPERTENSION AND CHRONICNEPHRITIS.

ARTERIAL hypertension is a manifestation ofchronic nephritis, and at the same time persistenthypertension may occur without the presence or

subsequent development of chronic nephritis. Thisfact has been recognised clinically by the adoptionof the term hyperpiesia, a term introduced by SirClifford Allbutt for those cases of maintained highblood pressure in which there is no evidence of kidneydisease. Clinical evidence of kidney disease is notalways easy to obtain in the earlier stages of chronicnephritis, and it is sometimes absent during irregularintervals in the later course of this disease. In recentyears clinical evidence has been supplemented bycertain functional tests of renal efficiency, and alsoby the micro-chemical examination of the blood. Ithas been shown by a number of workers, particularlyin France, America, and in this country, that a reten-tion of sugar and non-protein nitrogen occurs in manycases of severe nephritis, and in some forms of kidneydisease an increase of non-protein nitrogen in theblood may be apparent at a relatively early stage.It would appear that uric acid retention makes itsappearance before urea retention, while creatinineretention does not occur until the later stages of thedisease. It might be expected that the applicationof these methods of blood examination to cases ofarterial hypertension would throw a sure light on thequestion of coincident nephritis, but unfortunatelyother conditions than kidney disease lead to uricacid and urea retention in the blood. Heart failurewith passive congestion in the kidneys is the most

important cause of urea retention that is not due tonephritis, while gout is a cause of uric acid retentionthough it is uncertain as yet how far the commonlyassociated nephritis is here responsible for the increaseof uric acid in this disease. J. Lisle BVilliams4 hasrecently reported his results from the examination

2 Ibid., 1905, ii., 369.3 Ibid., 1910. ii., 1306.

4 Archives of Internal Medicine, June 15th, 1921

300

_ of the total non-protein nitrogen constituents of theblood in 55 patients with arterial hypertension inwhom there was no clinical evidence of nephritis.He comes to the conclusion that there is a disease,arterial hypertension, which when uncomplicated bynephritis or cardiac decompensation gives no func-tional evidence of kidney insufficiency, and that theheight of the blood pressure bears no relation to theamount of non-protein nitrogen substances in theblood. In short, the application of micro-chemicalmethods of blood examination to certain cases ofarterial hypertension fails to convict these cases ofchronic nephritis, and in the meantime they may beproperly classed under the rubric of hyperpiesia. Inany serious attempt to investigate the non-proteinnitrogen content of the blood in hyperpiesia, suchconditions as chronic nephritis, heart failure, gout,diabetes, and malignant disease must be excluded,since these diseases are known to influence the non-protein nitrogen in the blood. Yet the 55 patientsexamined by Dr. Williams had only one clinicalfeature in common-namely, hypertension-and inother respects form a motley group. Though it isstated at the outset that his patients had no clinicalevidence of nephritis, in a later paragraph he speaksof evidence in kome of the cases of renal impairment,and a significant proportion were clinically diagnosedas chronic nephritis ; there are also included cardio-renal cases, patients with heart failure, arterio-sclerosis, tertiary syphilis, diabetes, cirrhosis of theliver, gout, and chronic arthritis. The subject is oneof considerable difficulty. Arterial hypertension isnot a disease, though it may be a sign of disease,and for the elucidation of the problems it presentsuncomplicated cases should be selected for investiga-tion. Further, it is not statistics of 50 or 100 casesthat are required so much as detailed clinical recordsof single cases combined with adequate records ofrenal function tests and blood analyses, followed, ifpossible, over a period of years, and finally completedby post-mortem examination with the application ofmodern histological methods.

X RAY TREATMENT OF ENLARGED TONSILS.CHRONIC hypertrophy of the tonsils is a condition

which has excited little interest in medical circles

except among the few, and has been the subject ofactive interference rather than pathological study.Probably this is because the disease is so commonand the material available for investigation so abun-dant, for it is always the minor malady which isregarded as inevitable and as offering but a limitedfield for research. We should hesitate to hazard aguess as to the proportion of tonsils removed byoperation which are submitted to microscopic exami-nation, but it must be surprisingly small, amongquite the minor decimals. Nevertheless, the condi-tion seems to merit more careful consideration. Inthe Archi,ves of Internal .1J.ledicine for June, Dr. CarlVernon Weller records the results of the routinehistological examination of tonsils removed by opera-tion from patients of either sex and varying age.Nearly 9000 consecutive cases were examined, and ofthese 2-35 per cent. were found to be tuberculous.The incidence of tuberculosis in the tonsil is aboutequal in the two sexes, but it is particularly high ininstitutions for the care of children, and amongnurses, students, and interns in hospitals. In childrenthe organism is usually of the bovine type, and thisprobably explains the type of tissue reaction found,for this is essentially chronic, and caseation is rare.In adults the infection is more commonly of thehuman variety, as anyone would suppose who hasexamined his nasal secretion after a morning spentin the routine clinical investigation of phthisicalpatients.

Another aspect of the subject is dealt with by Dr.James Murphy and his collaborators in the Journalof Experiniental edici-ne for the same month. Itis established that X ravs have a selective destructiveaction on lymphoid tissue, and the authors have

utilised this knowledge in the treatment of enlargedi tonsils. With carefully graduated doses of rays they, have brought about shrinkage of the tonsils and, eversion of the crypts, with emptying of their septicr contents. The cure thus brought about is apparently

permanent, and the treatment may safely be appliedto the ordinary chronic septic tonsil, since the infec-tion is limited to the crypts which, on account of theshrinkage of the lymphadenoid tissue, appear to be

I mechanically everted and drained. Whether thistreatment is equally suitable for tuberculosis of thetonsil is another matter. It is true that, accordingto Dr. Weller, some 60 per cent. of tuberculousinfections of the tonsil are crypt infections, with noinvolvement of the lymph follicles themselves, butinasmuch as the lymphocyte appears to be particu-larly concerned in the tissue reaction to the tuberclebacillus, the wisdom of destroying it may be open toquestion. This point will, no doubt, be settled byfurther work, and in the meantime it is satisfactoryto learn of a method of treatment which appears tohave considerable advantage over the usual surgicalprocedures. ____

THE MODE OF ACTION OF KAOLIN.THE successful use of kaolin in the treatment of cases

of Asiatic cholera, described by Dr. R. R. Walker in ourpresent issue, is of great interest, although, as SirLeonard Rogers pointed out at the meeting when thepaper was read, the results cannot be regarded asquite conclusive in view of the comparatively smallnumber of cases treated. Dr. Walker explained at thetime that when administered by mouth kaolin wasinert and insoluble and did not pass into the circula-tion. He attributes great importance to the action ofkaolin in removing toxins, and the possible value ofthe drug in bacillary dysentery is not escapingattention. It is necessary to consider the fundamentalchemical details concerned in Dr. Walker’s experimentsto arrive at a tentative explanation of the action ofkaolin. Proteins, which consist of a " mixture " of18 to 20 amino acids, are acted upon by bacteria invarious ways ; in the case of putrefaction, aminesmay be produced by the loss of carbon dioxide fromthe amino acid. Except histamine from histidine,tyramine from tyrosine, and indol-ethylamine fromtryptophane these amines are not very toxic. Thetoxicity of histamine and the rest is not comparablewith the toxicity of the real bacterial toxins, and it isprobable that these are more complex protein deriva-tives of the nature of a polypeptide or simple peptone,containing in its molecule one of the toxic amines,in cholera perhaps indol-ethylamine. Cholera vibriosare identified amongst other tests by the " indol

"

reaction- i.e., by the production of indol itself orsome simple indol derivative from tryptophane.Indol and its simple derivatives, such as indol-acetic acid, which have a slight toxic action, are notabst-)i:bf-.0. by kaolin, but the complex toxin is absorbed.The absorption probably occurs by the mutual pre-cipitation of oppositely charged colloids, the kaolinand polypeptide. The actual effect of the kaolin inthe intestine is thus most likely to be one of adsorp-tion. For a mechanical action it would be necessaryto conceive the whole of the absorbing mucousmembrane of the intestine being covered by the kaolinso as to prevent the passage of the poison.

Sir Ernest Eodder-Williams, C.V.O., has beenappointed a Knight of Grace of the Order of St. Johnof Jerusalem in England, and Dr. James WoodwardRiley has been appointed an Eqiire of the Order.

INDEX TO "THE LANCET," VOL. I., 1921.THE Index and Title-page to Vol. I., 1921, which

was completed with the issue of June 25th, is now

ready. A copy will be sent gratis to subscribers onreceipt of a post-card addressed to the Manager ofTHE LANCET, 1 and 2, Bedford-street, Strand, W.C.2.