RANDALL AND HUGHES--ACUTE ABDOMINAL PAIN FROM UPPER URINARY TRACT LESIONS
as an initial ulcer experience, a formes frustes type of
perforation. A typical ulcer symptom picture developed.
The perforation occurred while he was on a vacation in
Bermuda, and, as stated, during the succeeding weeks
and months a typical epigastric ulcer type of pain de-
veloped. He also had very severe pain precisely in the
left lumbar region which we found extremely difficult to
interpret. This would keep him awake during all the
hours of the night, and for a brief period he suffered
greatly. Pyelograms and X - r a y films of the kidney were
negative. Because of a demonstrable duodenal obstruction
due to the ulcer he was operated upon and the surgeon
reported t h a t the duodenum was shortened and bound
down to the pancreas with a mass on the posterior duo-
denal wall. The surgical report states: "The pancreas
was as wide as my three fingers, at the head, and con-
siderably thickened." I t is obvious t h a t we could account
for the left lumbar pain on the basis of a diffuse, sub-
acute pancreatitis. The surgical diagnosis was: "Acute
duodenal ulcer with acute pancreatitis."
I wish to strongly emphasize the point that an essential
requisite in diagnosis in the group of ulcer cases with
back pain is accurate history-taking.
DR. S A R A M. J O R D A N (Boston, Mass.) : I think the
society is to be congratulated on this idea of Dr. Jones's
Acute Abdominal Pain from Upper Urinary Tract lesions
By
A L E X A N D E R R A N D A L L , M.D.
and
BOLAND H U G H E S , M.D.
PI-IILADELPHIA, PENNSYLVANIA
A CofU TuEp paebrd oumr iinnaarl y p at irna c tis disease.
o f t e n t h e first s y m p t o m
Frequently the
a b d o m i n a l p a i n and a s s o c i a t e d g a s t r o - i n t e s t i n a l syrup-
toms, t h o u g h e n t i r e l y r e n a l o r u r e t e r a l in o r i g i n , a r e
so t y p i c a l of t h e acute s u r g i c a l a b d o m e n t h a t l a p a r o -
t o m y is p e r f o r m e d . T h i s is m o r e l i k e l y to occur i f
u p p e r u r i n a r y t r a c t s y m p t o m s a r e m i n i m a l or, as is
o f t e n t h e case, c o m p l e t e l y a b s e n t .
I n s t u d y i n g t h e v i s c e r o - v i s c e r a l reflex t h a t p e r m i t s
t h i s ' t r a n s f e r s y m p t o m o t o l o g y ' we a r e p r i m a r i l y con-
cerned with two factors:
1. Conditions u n d e r w h i c h p a i n f u l s t i m u l i a r i s e
in t h e u p p e r u r i n a r y t r a c t .
2. M e c h a n i s m b y which t h i s p a i n is r e f e r r e d to
a b d o m i n a l cavity.
P a i n f u l s t i m u l i f r o m t h e u p p e r u r i n a r y t r a c t have
either an intrinsic or extrinsic origin. Intrinsic stimuli
a r i s e f r o m i r r i t a t i o n of t h e v e g e t a t i v e n e r v e e n d i n g s
w i t h i n t h e u r i n a r y t r a c t ; e x t r i n s i c f r o m i r r i t a t i o n of
t h e c e r e b r o s p i n a l s e n s o r y n e r v e e n d i n g s in t h e p e r i -
u r i n a r y p a r i e t a l p e r i t o n e u m . B o t h i n t r i n s i c and ex-
t r i n s i c p a i n m a y m a s q u e r a d e as s y m p t o m s of a c u t e
i n t r a - a b d o m i n a l disease, each, however, b y a d i f f e r e n t
anatomical-physiological mechanism.
INTRINSIC PAIN STIMULI
I n t r i n s i c p a i n can a r i s e f r o m t h e r e n a l pelvis, r e n a l
capsule o r u r e t e r . T h e v e g e t a t i v e n e r v e fibres w h i c h
@Read at the Annual Meeting of the American Gastro-Enterological
Association, Atlantic City, ffune 7-8, 1987.
From the D e p a r t m e n t of Urology Hospital of the University of Pen-
nsylvania.
739
that we should have at this meeting a correlation of in-
ternal medicine and gastro-enterology. Dr. Mixter has
j u s t given us a paper which demonstrates the importance
of back pain in gastro-enterology. In our experience a t
the clinic, we feel when we have a patient who has back-
ache, t h a t if the orthopedic, the neurological and the
gynecological services are convinced t h a t the cause of the
backache is not to be found in their fields, we should in-
vestigate the gastro-intestinal tract.
We often find t h a t backache is due to some condition in
the colon, frequently just a functional condition, spasm or
dilatation. I think Dr. Mixter also mentioned spasm of
the colon as causing backache. We find it frequently re-
lieved completely by the relief of the functional condition
in the colon.
Low dorsal backache we have come to r e g a r d with a
good deal of importance from the gastro-enterological
standpoint inasmuch as we find that an ulcer either of
the duodenum or of the stomach, which has involved the
posterior wall and penetrated into the pancreas, is often
the cause of backache and may indicate t h a t an ulcer
cannot be healed with medical measures because it in-
volves the adjacent pancreas.
a c c o m p a n y t h e r e n a l blood vessels i n t o t h e p a r e n c h y m a
apparently transmit one' vaso-motor and not pain
impulses. W e k n o w s u r g i c a l l y t h a t , w h e n o p e r a t i n g
u n d e r local a n a e s t h e s i a , w e can incise t h e k i d n e y
p a r e n c h y m a w i t h o u t c a u s i n g pain. W e also k n o w t h a t
ordinary s t i m u l a t i o n of t h e capsule, pelvis or u r e t e r
does n o t cause a n y s e n s a t i o n . This, o f course, i s t r u e
of all t i s s u e s w h i c h a r e i n n e r v a t e d b y t h e a u t o n o m i c
n e r v o u s s y s t e m in c o n t r a d i s t i n c t i o n t o t h o s e t i s s u e s
innervated by the cerebro-spinal system. Painful
stimuli, however, do a r i s e : (1) ~if t h e r e n a l pelvis or
u r e t e r a r e s u d d e n l y d i s t e n d e d due to u r i n a r y o b s t r u c -
tion, (2) i f t h e r e n a l capsule is s u d d e n l y d i s t e n d e d
due to p a r e n c h y m a l swelling, (3) i f t h e r e n a l c a p s u l e
is involved in a n a c u t e o r sclerotic i n f l a m m a t o r y
process. I f d i s t e n s i o n of t h e r e n a l pelvis, u r e t e r o r
capsule be g r a d u a l p a i n u s u a l l y does not occur.
These intrinsic painful stimuli are mediated through
t h e v i s c e r a l a f f e r e n t 'fibres w h i c h t r a v e r s e t h e r e n a l
plexus. I n m a n t h e r e n a l plexus is composed p r i n c i -
p a l l y of b r a n c h e s f r o m t h e coeliac g a n g l i o n w h i c h
in t u r n receives connections f r o m t h e v a g u s a n d
s p l a n c h n i c a n d ' also f r o m t h e s u p e r i o r m e s e n t e r i c
g a n g l i o n a n d a o r t i c plexus. J o s t w a s a b l e t o demon-
s t r a t e in t h e r a b b i t a definite connection b e t w e e n t h e
a b d o m i n a l s y m p a t h e t i c s and t h e r e n a l plexus a n d t h i s
connection w a s c l e a r l y shown in m a n b y t h e c a r e f u l
a n a t o m i c a l d i s s e c t i o n s of H i r t . In addition, the
s p l a n c h n i c m i n o r a l w a y s sends a d i r e c t b r a n c h t o t h e
k i d n e y - - t h e p o s t - r e n a l n e r v e ( H e l l e ) . W e see, t h e r e -
740 AMERICAN JOURNAL OF DIGESTIS/E DISEASES AND NUTRITION
fore, that, through the sympathetic system, the upper
urinary tract enjoys direct nervous contiguity with
the gastro-intestinal tract. KSlliker and later Langley
have proven histologically that the sympathetic system
contains afferent senory fibres. The actual viscero-
visceral reflex of intrinsic pain t r a n s f e r f r o m the
upper urinary t r a c t to the gastro-intestinal t r a c t
occurs in the spinal cord but, differing f r o m viscero-
sensory and viscero-motor reflexes, the irradiation is
not confined to o n e s e g m e n t but is transmitted through
the entire cord and brain stem. This multi-segmental
cord irradiation explains the variegated systemic
manifestations of upper u r i n a r y tract pain.
We must consider the entire question of upper uri-
n a r y tract symptomotology not f r o m a standpoint of
individual disease entities but f r o m t h a t of system-
physiology. Any pathological process m a y produce
intrinsic pain stimuli if any of the t h r e e pre-requisites
already outlined are satisfied; any pathological process
m a y remain ss,znptom-free if they are not satisfied.
Thus we may have slow-growing stones completely
filling both renal pelves and causing g r e a t i m p a i r m e n t
of kidney function without ever producing intrinsic
pain. We also see the severest renal colic resulting
f r o m t e m p o r a r y blockage by a minute stone f r a g m e n t
dislodged f r o m the renal papilla.
We m u s t also consider the question of pain t r a n s f e r
to the gastro-intestinal t r a c t in the same manner.
There are anatomical, physiological reasons and
clinical data to support the statement t h a t any lesion
of the upper u r i n a r y t r a c t which produces intrinsic
pain stimuli m a y be referred by means of a viscero-
visceral cord reflex t h r o u g h the sympathetic system
to the abdominal cavity as indefinite non-localizable
pain. Considering the fact t h a t in this pain t r a n s f e r
to the abdominal cavity, true upper urinary t r a c t
symptoms may, be minimal or absent, we should accept
as a diagnostic necessity the urographic examination
in all cases of abdominal pain which is not explained
by definite intra-abdominal pathology.
This diagnostic axiom, however, is even more ap-
plicable to those cases of upper urinary t r a c t disease
causing e x t r i n s i c pain stimuli. Let us consider this
more in detail.
EXTRINSIC PAIN STIMULI
As already mentioned, painful stimuli f r o m the
upper u r i n a r y t r a c t can also arise f r o m irritation of
the sensory nerve endings in the parietal peritoneum
by pert-renal, pert-pelvic or peri-ureteral inflamma-
tion. Whereas the visceral layer and serous surface
of the parietal layer of the peritoneum are insensi-
tive, the outer surface of the parietal layer is abun-
dantly supplied by sensory cerebro-spinal nerve fibres.
Chronic infectious processes of the pert-pelvic or
peri-ureteral structures do not, as a rule, sufficiently
irritate the sensory nerve endings in the parietal peri-
toneum to cause pain. An exception to this, however,
occurs in chronic perinephritis, particularly; in the
sclerotic type associated with the contracted pyelone-
phritic kidney.
Often, however, a chronic pert-pelvic or pert-
ureteral inflammation is the deciding factor as to
whether sufficient acute distension will result f r o m a
renal ptosis to cause painful stimuli to arise f r o m the
intrinsic vegetative nerve endings. In this case the
pain would be entirely of the intrinsic variety.
Typical extrinsic pain practically always occurs if
the pert-renal, pert-pelvic or peri-ureteral inflamma-
tion is acute or sub-acute in character. We have
known clinicall:~ t h a t acute perinephritis or peripyeli-
tis produces pain which does not radiate and which
the patient can always definitely localize to the renal
region. T h i s s a m e localization o f the p~in occurs in
acute or sub-acute p e r i - u r e t e r i t i s .
I t is this peri-ureteral syndrome t h a t simulates,
more t h a n any other lesion of the upper u r i n a r y tract,
acute inflammatory or obstructive gastro-intestinal
disease. Capps has shown t h a t stimulation of the
parietal peritoneum gives rise to direct pain which is
accurately localized by the patient a t the site of irrita-
tion. I t is this accurate localization which distin-
guishes extrinsic f r o m intrinsic upper u r i n a r y t r a c t
pain. I t is the location of the peri-ureteral inflamma-
tion which determines whether the pain resembles
that arising f r o m acute disease of the r i g h t or left
upper abdomen or r i g h t or left lower abdomen.
To illustrate this, we have selected the following
cases of peri-ureteral inflammation for presentation
because in each case the outstanding, and f o r a time
the only s y m p t o m was abdominal pain simulating t h a t
of the acute abdomen.
It is impossible, however, by u r o g r a m alone, to
diagnose an acute or sub-acute peri-ureteritis. Roent-
genologically there are the same findings as in a
chronic peri-ureteritis plus the clinical evidence of
fever and acute pain localized to the area of parietal
peritoneum directly affected by the inflammatory
process. On urogram, however, the following findings
are significant: (1) fixation of the ureter (on more
than one plate), (2) dilatation of the ureter or pelvis
above the affected area, (3) impaired or absent kidney
function in those cases in which a chronic peri-
ureteritis slowl~ occluding the ureter has existed
previously. When kidney function is impaired or
absent, we can only obtain the roentgenological evi-
dence of peri-ureteral pathology by retrograde pyelo-
gram.
Case 1. Survey film of abdomen and intravenous
urogram of male patient fifty-eight years of age, admitted
to the hospital with diagnosis of beginning intestinal ob-
struction. Acute constant pain in extreme lower ab-
domen. Temperature 100 ° F. Survey film shows disten-
sion of large intestinal loops. Urogram shows poorly
functioning right kidney, no visualization of right ureter,
distension of left ureter to point of narrowing in extreme
lower portion. History of suprapubic prostatectomy three
years previously. Minimal urinary symptoms, though
residual urine found to be 350 c.c. Patient treated with
indwelling catheter with subsidence of acute abdominal
pain within twenty-four hours. Subsequent cystoscopy re-
vealed a definite ureteral constriction on the right side 5
cm. above ureteral orifice. Constriction also on left side
at point indicated on urogram. Vesical orifice shows
fibrotic contraction. Endovesical resection performed later.
Acute abdominal pain relieved, however, by catheter
drainage. Etiology of abdominal pain--acute exacerbation
of bilateral chronic peri-ureteritis resulting from infec-
tion of adnexa.
Case 2. Intravenous urogram of female patient, age
sixty-two, who was admitted into the hospital with acute
pain in lower left abdomen. No urinary symptoms or
signs. Slight elevation of temperature. Abdominal pain
so severe that exploratory laparotomy was performed,
 RANDALL AND HUGHES--ACUTE ABDOMINAL PAIN FROM UPPER URINARY TRACT LESIONS
suspecting an acute diverticulitis. Urogram done post-
operatively reveals a non-functioning left kidney. At
cystoscopy it was impossible to insert catheter beyond
the ureteraI meatus though the meatus itself was per-
fectly normal. Diagnosis--acute exaceration of chronic
occluding peri-nreteritis. Complete absence of kidney func-
tion. After prolonged febrile course, patient discharged
symptom-free.
Case 3. Air-pyelogram revealing a ureteral constriction
on the right side opposite the lower border of the fourth
lumbar vertebra. Constriction due to peri-ureteritis ap-
parently originating from within the ureter itself due to
ureteral stone which, at time of cystoscopy, was pushed
by the catheter to the renal pelvis. At time of admission
main symptom, acute constant pain in right mid-abdomen.
No history of definite lumbar pain, though patient had
complained for past two years of occasional vague back-
ache. Survey film taken because of microscopic hematuria.
Acute abdominal pain due to acute peri-ureteritis at point
of ureteral constriction.
Case 4. Survey film and intravenous urogram of patient
admitted to hospital with diagnosis of acute appendicitis.
Acute constant pain in right mid-abdomen for twenty-
four hours previous t o admission. History of dull, inter-
mittent pain in same location for three months previously.
No lumbar symptoms. Temperature 100-3/5 ° F. Urine
showed moderate amount of pus cells and red blood cells.
Survey film and urogram show renal stone with blockage
at pelvo-ureteric junction due to peri-ureteritis, which
was found at time of pyelolithotomy.
CONCLUSIONS
1. E x t r i n s i c upper u r i n a r y t r a c t p a i n due to p e r i -
u r i n a r y i n f l a m m a t i o n m a y resemble the p a i n of the
acute a b d o m e n due to its localization a t the p o i n t of
i r r i t a t i o n of t h e s e n s o r y c e r e b r o - s p i n a l n e r v e e n d i n g s
in the p a r i e t a l p e r i t o n e u m .
2. I n t r i n s i c u p p e r u r i n a r y t r a c t p a i n due to i r r i t a -
t i o n of the v e g e t a t i v e n e r v e e n d i n g s i n the r e n a l
pelvis, r e n a l capsule, or u r e t e r m a y resemble the p a i n
of the acute a b d o m e n due to its r a d i a t i o n t h r o u g h the
s y m p a t h e t i c n e r v o u s s y s t e m to the g a s t r o - i n t e s t i n a l
tract.
3. C o n s i d e r i n g the fact t h a t in t h i s p a i n t r a n s f e r
to t h e a b d o m i n a l cavity, t r u e u p p e r u r i n a r y t r a c t
s y m p t o m s m a y be m i n i m a l or absent, u r o g r a p h i c ex-
a m i n a t i o n should be a d i a g n o s t i c necessity in all cases
of a b d o m i n a l p a i n which are not explained by definite
i n t r a - a b d o m i n a l pathology.
DISCUSSION
DR. LEON BLOCH (Chicago, Ill.): About six years
ago I presented a paper on this subject before the Chicago
Urological Society, calling attention to the fact that
gastro-intestinal manifestations of urologic origin might
be divided into four groups, with gastro-duodenal, biliary,
colonic or appendiceal symptoms.
I shall restrict the discussion simply to that type of
patient in whom the symptoms are of renal origin. One
of the things we have to pay particular attention to is
the finding of occasional white or red blood cells in the
urine, in patients who come for gastric disturbances, be-
cause the existence of these abnormal cells in the urine
should arouse our suspicions that the trouble comes, not
from the gastro-intestinal, but from the genito-urinary
tract.
Occasionally one encounters patients who have gastro-
intestinal symptoms, in whom the urine does not show
anything. An example, is the case of one of our internes
who had typical symptoms of duodenal ulcer i n whom,
on X-ray examination, a suspicious defect was found in
the duodenum, but who did not respond to treatment. The
741
symptoms became acute and on X-ray examination of the
abdomen a large kidney was found. The intravenous
urography revealed a large congenital hydronephrotic
kidney. Following a retrograde pylography, a tempera-
ture and chill developed.
After a nephrectomy all his gastro-intestinal symptoms
disappeared. I n another patient whose symptoms began
acutely with very severe abdominal pain, nausea and
vomiting, presumably after a meal of shellfish the night
before, the diagnosis of ptomaine poisoning was made.
No urine examination had been made. On the first ex-
amination in our office a few red cells were found. The
patient complained of neither b u r n i n g nor pain on urina-
tion.
An impacted stone in the lower end of the ureter was
found on X-ray examination and when the stone was
ultimately passed, he became free of all his symptoms.
Not infrequently a small stone may not be found on
X-ray examination and still the patient will complain of
regularly recurring distress which is sometimes very
severe. An example in point is my own case. I had several
attacks of renal colic and have had X-ray examinations
made in several laboratories in Chicago, but no stone was
ever demonstrated. It was not until after I had passed
three small calculi that I became completely relieved of
all my gastro-intestinal symptoms.
The important thing to remember is that in those
patients in whom there are symptoms of gastro-intestinal
disturbance, in whom no pathology is found in the gastro-
intestinal tract on fluoroscopic and film examination, and
in whom an occasional red cell or a few white blood
corpuscles are found in the urine, attention should be
directed to the genito-urinary tract rather than to the
gastro-intestinal tract.
DR. B. B. V I N C E N T LYON (Philadelphia, P a . ) : I
should like to discuss this paper of my old classmate, Dr.
Randall, from a little different view in regard to silent
renal pathology.
There was a gentleman whom we reported about fifteen
years ago, who was then fifty, who went through a series
of passings of renal calculi without much pain, merely
hematuria, and the recovery in his u r i n a r y secretion of
multiple small calculi. We persuaded him finally to be
studied, although he was not suffering pain and we found
he had a hydronephrotic kidney with numerous stones left
behind.
The interesting thing in connection with that case was
that he was a polycythemic. He had a blood count of about
11.4 million, Hb. 115% and a white count of about 12,000.
This was at a period when we could find nothing in the
literature as to whether polyc'ythemia was a contra-indi-
cation for major surgery. I remember we called up most
of the authoritative men in Philadelphia in medicine and
surgery to find out whether we could legitimately advise
him to undergo operation because of polycythemia. There
was no information available. The situation was ex-
plained to the patient and he was operated upon.
Now, it is interesting that he claims himself to be a
Spanish Basque, and he attributed the fact that he felt
no pain in the passage of renal calculi to the supposed
fact that in the Spanish Basque area they are stoics, like
our American Indians. He was operated on by Dr. Leon
Herman, and it was a very t r y i n g operation. The right
kidney was bound down in adhesions. The man should have
suffered an enormous amount of pain. I was called to the
hospital that evening because the nurses could not control
h i m five or six hours after operation, and he was sitting
up in bed smoking innumerable black Havana cigarettes,
and he said, "Dr. Lyon, something happened. You didn't
take out my kidney."
"Yes, your kidney is in the laboratory."
He said, "I don't feel any pain."
His wound healed very rapidly. He insisted on being
742 A M E R I C A N J O U R N A L OF DIGESTIVE D I S E A S E S AND N U T R I T I O N
out of bed on the eighth day and requested his discharge
from hospital. I t was not granted.
That part was interesting but the effect on the poly-
cythemia was even more interesting. Daily blood counts
were carried through and immediately after operation
his red blood cells began to reduce toward a normal five
million, but his white blood cells went up to 260,000. W e
could not interpret this. Three weeks after operation the
blood count showed Fib. 88%, R.B.C. 4.4 million, W.B.C.
22,800.
I have followed this gentleman now for fifteen years
and there is no longer any evidence of any remaining
polycythemia. His blood counts in recent years have been
within normal limits.
DR. P A U L W. A S C H N E R ( N e w York, N. Y.): Mr.
President, Ladies and Gentlemen: It is with great pleasure
that I greet m y colleagues, Dr. Randall and Dr. Hughes,
of the American Urological Association, here, and who
have seen fit to bring to our attention a phase of the
subject of differential diagnosis in which I have been
interested for a long time.
For m a n y years the urologists have been attempting to
educate the surgeons in the importance of excluding
urinary tract pathology in all cases of unclear abdominal
catastrophes. It n o w seems no more than fitting and
proper that the gastro-enterologists should be so educated,
who are very likely to see the patient before the surgeon
is called in.
As Dr. Randall has properly said, we have two types
of cases to deal with, the cases of acute abdominal symp-
toms, and the cases with subacute or chronic abdominal
symptoms. As to the acute cases, they are most likely to
occur in such a manner as to simulate perforated ulcer,
acute cholecystitis, acute pancreatitis, and acute appendi-
citis, and, lastly, intestinal obstruction.
As Dr. Randall has shown, m a n y renal lesions come
about by virtue of radiation through the nerve pathways
stimulating these conditions.
In the acute case it is not feasible nor practicable, to
m y mind, to resort to excretory urograms for the dif-
ferential diagnosis. In the first place, one hesitates to
give catharsis to a patient in an abdominal condition and,
to get good urograms you must have good catharsis and
no gas in the intestinal tract.
In the second place, one cannot dehydrate these patients,
which is also esential for good urograms; so it has been
m y practice, where I have an acute abdominal condition
Intubation Studies of the Human Small Intestine: VII. Factors Concerned
in Absorption oF Glucose From the Jejunum and Ileum
By
W. OSLER ABBOTT, M.D.,t W A L T E R G. KARR, Ph.D.
and
T. G R I E R MILLER, M.D.
PHILADELPHIA, PENNSYLVANIA
H E a b s o r p t i o n of food is r e g a r d e d as o c c u r r i n g
T chiefly i n t h e small i n t e s t i n e . Selecting glucose as
one of t h e s i m p l e s t food s u b s t a n c e s a n d one which has
From the Gastro-Intestinal Section of the Medical Clinic, University of
Pennsylvania Hospital.
*Aided by g r a n t s from the Committee on Scientific Research of the
American Medical Association and from Smith, Kline and French
Laboratories.
t F . M. Kirby Fellow in Surgical Physiology.
Read a t the Annual Meeting of the American Gastro-Enterologlcal
Association. Atlantic City, June 7-8, 1987.
in which I wish to exclude u r i n a r y tract pathology, and
I think it is the safest practice, to use the cystoscope and
observe whether there is good influx from the two ureters
and any evidence of retention in the pelvis of the kidney
or in the ureters.
I n subacute cases it is true one can use the excretory
urographic methods.
There are a few types of kidney lesions one is likely to
forget about, which produce violent conditions, and in
which the urine is absolutely negative, and in which even
the cystoscopic and urographic evidence may be mislead-
ing. One of these conditions is the condition of a septic
infarction of the kidney which occurs with mitral stenosis
and can produce all these symptoms of acute upper ab-
domen.
Another type is cortical infection of the kidney with
staphylococcus of a metastatic variety. Intestinal obstruc-
tion occurs in two forms in this group of cases. In one
way you have a stone iri the left lower ureter, producing
a marked sigmoid spasm with intestinal distention, and
distention of the cecum. These are frequently operated
on for intestinal ob.~truction. Then you have the other
type of cases in which there is silent renal pathology, and
the patient has uremia and retrograde fecal vomiting,
and these cases are not infrequently operated upon under
the misapprehension of acute intestinal obstruction.
DR. BOLAND H U G H E S (Philadelphia, Pa.) (closing
the discussion) : Perhaps a word in defense of the acute
surgical abdomen would at present be appropriate and
this is mentioned in connection with the etiology of acute
periureteritis. We know clinically that acute periureteritis
arises either, (1) extrinsically from extension of chronic
infection in the adnexia, or, (2) intrinsically from ulcera-
tion of the ureteral mucosa due to the presence of a stone.
On the right side of the abdomen, however, one of the
principal reasons for acute periureteritis is extension of
an infection from an inflamed appendix. This extension
of infection from the appendix gives us all the roentgen-
ological signs of an acute periureteritis with the clinical
picture of the acute abdomen. We should amend therefore
the diagnostic axiom that Dr. Randall mentioned, to say
that in all cases of gastro-intestinal pain, be the case
acute or chronic in character, a urogram is necessary, but
in right-sided periureteritis in which the pathology and
etiology is questionable, even though you have u r i n a r y
signs and symptoms, removal of the appendix is the
proper therapy to be employed.
been extensively s t u d i e d in lower a n i m a l s , we have at-
t e m p t e d a q u a n t i t a t i v e s t u d y of its a b s o r p t i o n i n t h e
j e j u n u m a n d i l e u m of n o r m a l h u m a n subjects. T h i s
has n e c e s s i t a t e d a n i n v e s t i g a t i o n of v a r i o u s aspects
of t h e b e h a v i o r of glucose i n those p a r t s of t h e small
bowel: (a) its n o r m a l r a n g e of c o n c e n t r a t i o n i n the
small g u t a f t e r a glucose meal, (b) t h e v a r i a t i o n s i n
t h e osmotic p r e s s u r e of t h e i n t e s t i n a l c o n t e n t s result-