Talk:Paper - Congenital renal anomalies: with special reference to horseshoe kidney (1939)

CONGENITAL RENAL ANOMALIES*

WITH SPECIAL REFERENCE TO HORSESHOE KIDNEY

By Cart F. Ruscue, M.D. AND SAMUEL K. Bacon, M.D. Hollywood Discussion by Robert V. Day, M.D., Los Angeles;

Benjamin H. Hager, M.D., Los Angeles; William E. Stevens, M.D., San Francisco.

DOUBLE kidneys, reduplication of pelves and ureters are the most frequent anomalies of the upper urinary tract. Next in frequency is horseshoe kidney. In general, this interesting renal mass may be defined as a symmetrical, semicircular fusion of the two kidneys across the vertebral column by a bridge or isthmus which, even without concomitant disease or gross pathology, produces a clinical syndrome called horseshoe kidney disease ; an entity due to pressure, which is characterized by indefinite epigastric or umbilical pain, intestinal and urinary stagnation.

CLASSIFICATION

In order to institute better clinical and surgical management of horseshoe kidney, Gerard, and later Gutierrez, have classified the subject into symmetric and asymmetric groups. The symmetric division refers to fusion by a bridge of renal or fibrous tissue of the two organs at the lower poles with concavity upward, or fusion of the upper poles with concavity downward. This organ rests astride the vertebral column, The asymmetric type refers

• Read before the Urology Section of the California

Medical Association at the sixty-seventh annual session, Pasadena, May 9-12, 1938.

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to irregularities in shape, location, and position. This entity is less common and the individual types accordingly are termed unilateral fused kidney, L-shaped renal fusion, fusion en glatte or disc form, sigmoid fusion, fusion en masse, and fusion without form.

INCIDENCE

With the advent of urography, the incidence of this anomaly has markedly increased. Various averages from the statistics of several necropsy surgeons before the introduction of pyelography, fix the rate to about 1: 1000; however, with this method of urologic diagnosis the frequency has been increased to about 1:400, and even more recently the ratio is reported to be 1: 200 pyelograms. In 68,989 necropsies reported by Carlier and Gerard, there were eighty horseshoe kidneys, or 1:862; Kuster, 1:1100; Davidsohn, 1:1000; Judd, Braasch and Scholl, 17: 2424 operations on the kidney; Bettez, 1:715; Guizzetti and Pariset, 1: 1142; Marynski, 1: 683; Naumann, 1 : 600; Jeck, 1:643; Thompson, 19: 12,888 (1: 671) ; Motzfield, 92: 73,489 (1: 710) ; Lipshutz and Hoffman, 105: 70,502 (1:671) ; Legueu and Papin, 1: 600.

EARLY LITERATURE

In the annals of medical history, from the ancient down to modern times, one can find a fascinating story of this subject. First, the ancient anatomist and post-mortem surgeon reported this “monstrosity” ; then, with the commencement of kidney surgery late in the nineteenth century, the anomaly was discovered during abdominal exploration for tumor ; and, finally, this history continues on to an era of clinical diagnosis by physical examination, and more recently, to conclusive diagnosis by retrograde or intravenous urography.

Early in embryonic life it is an established fact the pronephros, mesonephros, and metanephros arise from both entoderm and mesoderm. The pronephros degenerates early and is considered rudimentary in character; the mesonephros is important during embryonic life, and its remnants enter into formation of the genital tract ; and, lastly, the metanephros establishes itself as the permanent kidney. The renal buds appear behind and at the lower end of the mesonephros or Wolffian duct during the fourth week and progressively change their shape and position; hence, the opportunity for anomalous development between the fifth and seventh week, These anlagen arise on a level with the second sacral vertebra below the umbilical arteries and aortic bifurcation, and migrate upward. This vascular mechanical obstruction, according to several writers, may impede the ascent and rotation and permit fusion to take place.

SYMMETRICAL FORM

The most common or symmetrical form of horseshoe kidney is a semicircular mass of renal substance whose concavity is upward, and united at the lower poles (90 to 95 per cent) by a bridge or isthmus of renal or fibrous tissue which crosses the spinal column. The renal parenchyma usually retains some marks of fetal lobulation, and the right and left halves are seldom exact in position May, 1939

or shape. The asymmetrical organ presents a remarkable tendency to dystopia.

The isthmus connecting the lower poles is in close apposition to the surrounding structures, namely, (a) posteriorly, the inferior vena cava, abdominal aorta, solar plexus and vasovisceral branches, the great lymphatic reservoir, and the spine; (b) anteriorly, the parietal peritoneum and intra-abdominal viscera. Usually the bridge is low at the umbilical level, the aortic bifurcation, or level of the fourth to fifth lumbar vertebrae.

The pelves, usually two in number, are generally anterior to the blood supply, incompletely rotated, and extend on to multiform calices in the reverse position. The latter frequently cross a portion of the spine. The ureters cross the isthmus and connect each pelvis to the bladder. If fusion of the upper poles (5 to 10 per cent) is present, the ureters usually arise from the upper portion of the kidney mass and do not cross the isthmus.

In collected studies from the literature, from four to six renal arteries supply and support the median and two lateral sections ; however, anomalies predominate. The solar plexus, splanchnic nerve, sympathetic and parasympathetic nerves, phrenic nerves, and other regional interanastomoses enervate the kidney. The lymphatics are multiple and run parallel to the retroperitoneal vessels. In close proximity is the cisternal chyli.

DIAGNOSIS

In clinical practice the diagnosis of horseshoe kidney is made usually after the urine has become infected. Pressure of the isthmus on the adjacent structures produces extensive nervous and circulatory phenomena. Then stasis in the renal pelves, due to ureteropelvic juncture obstruction, high ureteral implantation, and structural dependency, initiates the sequelae of infection.

Horseshoe kidneys undergo the same pathologic lesions as normal kidneys ; however, because of the predominating factor of stasis, hydronephrosis, pyelonephritis, pyonephrosis, and calculous disease are common sequelae. Cases of tuberculosis, neoplasm (parenchymal or pelvic), polycystic disease, and chronic diffuse nephritis, have been reported.

The clinical history and physical examination are seldom sufficiently significant to suggest the possibility of a tentative diagnosis of horseshoe kidney. Gutierrez’s horseshoe kidney syndrome, consisting of umbilical or epigastric pain, chronic constipation, and urinary findings, is worthy of emphasis by repetition. In the thin patient an abdominal mass and isthmus may be palpated. Israel and others have stated that “the surgeon must bear in mind the possibility of such a congenital kidney malformation.” Symptoms, signs, and findings such as, or of, renal colic, nephritis, pyelonephritis, uremia, and chronic cystitis, are to be considered.

The conclusive diagnosis of horseshoe kidney has been reduced to simple mechanical technique since the era of cystoscopy and urography. Routine urologic study, consisting of medical history, physical examination, urinalysis, blood chemistry, phenolsulphonephthalein test, roentgenography, cystoscopy, ureteral catheterization, differential renal function tests with phenolsulphonephthalein, and

CONGENITAL RENAL ANOMALIES—RUSCHE-—BACON 345

retrograde bilateral pyelography or intravenous urography without cystoscopy, adequately provides a complete diagnostic armamentarium. The horseshoe kidney pyelographic triangle of Gutierrez is fascinating and seems to be pathognomonic; at least practical in its application.

Certain roentgenological and pyelographic findings, such as delineation of renal poles of both kidneys, close proximity to vertebral column, obliteration of psoas outline, renal calculi in transverse position near midline, “flower vase” figure of ureteral catheters, inversion and rotation of pelves, inversion of lower calices and directed medialward, bizarre pelves near spine, “bottle neck’’ ureteropelvic appearance, “minimum lower angle of horseshoe kidney triangle,” if critically employed should establish conclusively the diagnosis of this anomaly.

TREATMENT

The treatment of horseshoe kidney varies with each individual case, and is particularly dependent upon the existing pathologic lesions. Indwelling ureteral catheter drainage is necessary in the presence of acute manifestations. Intermittent drainage may be sufficient as a temporary procedure in chronic urinary stasis. In infected hydronephrosis, pyonephrosis, tuberculosis, or neoplasm, involving half of the renal mass and in the presence of a normal half, resection (heminephrectomy) is a rational procedure. The surgical technique is comparable to that carried out in similar pathologic processes in a normally formed kidney. Transperitoneal anterior as well as retroperitoneal lateral and anterolateral approaches have been recommended and practiced. The transperitoneal anterior incision simplifies the operation. During surgery in infected cases, care should be exercised to avoid peritoneal contamination, and with tight peritoneal closure a retroperitoneal stab wound and drain are recommended. Conservation of renal substance is even more axiomatic in dealing with this congenital anatomopathologic entity. Pelviolithotomy should be stressed more seriously than resection, because of the potential danger of subsequent disease of the opposite parenchyma or pelvis. The literature attests to the rational of symphysiotomy and nephropexy in “chronic cases of horseshoe kidney disease with clinical symptoms.”

To demonstrate several of the above ideas, which are in no way original with us, we give below the clinical history of one recent case of horseshoe kidney which we personally observed, and our surgical technique will be shown in motion pictures in color.

REPORT OF CASE ‘History—A white female, aged 56 years, was admitted to the hospital on May 10, 1937. She complained of blood in the urine, dull pain and a sensation of heaviness in the upper and right side of the abdomen, extending through to the back, especially for the past four months. The patient stated that passage of the uniformly bloody specimen of

urine was without bladder discomfort. The familial and early personal history were not relevant.

Examination—The examination revealed a very well _nourished female, who was alert, codperative, and in no

acute distress. Temperature was 98.6 degrees; pulse 78. The abdomen was characterized by a hard, slightly moveable mass about the size of a large grapefruit, located in the epigastrium, but more prominent just to the right of the 346 CALIFORNIA AND WESTERN MEDICINE

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Fig. 1

Fig. 2

Fig. 3

Fig. 1.—Antero-posterior roentgenogram of the kidney, ureter, and bladder area, showing a large calculus near the

spine and indistinct delineation of the kidney poles.

Fig. 2.— Bilateral pyelograms showing calculus in right kidney pelvis; left pelvic dilatation although incompletely filled; pelves near spine, and improperly rotated; ‘flower vase” figure of ureteral catheters; 22 degree “minimum

lower angle of horseshoe kidney triangle.”

Fig. 3.—Postoperative (11 months) bilateral pyelograms showing satisfactory anomalous kidney pelvis and enor mously dilated left kidney pelvis.

midline. A very hard, protruding irregularity (calculi), particularly noticeable upon inspection and palpation, was localized to the right of and somewhat above the umbilicus.

The urine was suggestively bloody grossly and contained many red blood cells, pus cells, and Gram-positive cocci in clumps. Blood non-protein nitrogen, 25 milligrams per 100 cubic centimeters. One cubic centimeter of phenolsulphonephthalein given intravenously appeared in three and three-quarter minutes; 45 per cent and 10 per cent recovered in the first and second thirty-minute periods,

Fig. 4.—Surgical specimen, staghorn faceted calculus reassembled.

respectively. Blood Wassermann and Kahn tests were reported negative. Hemoglobin, 85 per cent; red blood cells, 5,250,000; white blood cells, 9,600; 69 per cent polymorphonuclear leukocytes.

Kidney, ureter, and bladder roentgenogram (Figure 1) presented a large staghorn calculus near the spine, on the right side at the level of the third and fourth lumbar vertebrae. Several small opacities were reported in the corresponding area on the opposite side. The renal silhouettes were indistinct ; however, the lateral borders of a mass of tissue seemed to be closer than normal to the midline.

Cystoscopic examination presented evidence of a mild cystitis, The ureters were readily catheterized and specimens of urine obtained from the renal pelves showed the following: Right—many pus cells and Gram-positive cocci in clumps; left—few pus cells and Gram-positive cocci. Differential renal function test, using one cubic centimeter of phenolsulphonephthalein intravenously showed: Right— appearance time eight minutes, 5 per cent excreted in twenty minutes ; left—appearance time five minutes, 15 per cent excreted in twenty minutes.

Other roentgenograms, including bilateral pyelograms (Figure 2), disclosed the following findings: (a) Large right staghorn renal calculus near the vertebral column; (b) small densities (?) in the corresponding area of the opposite side; (c) “flower vase” figure of the ureteral catheters; (d) inversion and rotation of bizarre renal pelves; (e) inversion of lower calices directed medialward; (f) bilateral pelvic dilatation, especially the left; (g) “bottle neck” ureteral position; and (h) 22 degree lower angle of horseshoe kidney triangle. The diagnosis of horseshoe kidney with calculous disease was definitely established. Surgical removal of the calculi in the right renal pelvis was recommended and accepted.

Operation.—(May 25, 1937, recorded in motion pictures in color.) Under inhalation anesthesia, an incision was made parallel to and one and one-half inches to the right of the abdominal midline, commencing high in the right epigastric area and extending a few inches below the umbilicus. After opening the peritoneum the intra-abdominal contents were readily displaced to expose the horseshoe kidney. Incidentally, a 2.5 centimeter calculus was discovered in, but not removed from, the gall-bladder. The posterior peritoneum was incised longitudinally and the anomalous kidney, particularly its right half and isthmus, was exposed. Fusion of the upper poles was readily dis _cernible. A moderately dilated, highly implanted right

ureter and thickened, distended anterior pelvis were found. After opening the renal pelvis several large faceted calculi, forming a complete silhouette of the pelvis, were removed May, 1939

(Figure 4). Due to the thickness of the pelvic wall, it was possible to make a substantial repair. A Penrose drain was directed retroperitoneally to the costo-iliac space and retrieved externally through a small stab wound. Each peritoneal incision was closed tightly without drainage, and the remainder of the abdominal wall was repaired with chromic catgut and skin dermal sutures.

Postoperative Course.—At no time did the temperature exceed 100.4 degrees, or the pulse 100 per minute. These were normal on the fifth day. The abdominal wound healed by primary union and only a slight amount of serous drainage came from the stab wound. The abdomen remained undistended and peristalsis was active. The patient was discharged from the hospital on the twenty-second, postoperative day, ambulatory and apparently in good health.

Unfortunately, this patient did not keep her clinic appointment and was not examined until January 1, 1938 (seven months later). At that time she complained of severe aching in the left abdomen and costo-iliac space. Examination disclosed the following: Well-healed surgical scars; tenderness in left abdomen and costo-iliac space. Temperature 98.6; pulse 80; respiration 20. Bladder urine: many pus cells and Gram-negative bacilli. Phenosulphonephthalein test: Appearance time four minutes, 50 per cent first half-hour, 15 per cent second half-hour. Blood nonprotein nitrogen, 23 milligrams; kidney, ureter, and bladder roentgenograms negative for calculi. Cystoscopic study, ureteral catheterization, and bilateral pyelography presented mild cystitis, large irregular, left hydronephrosis, and sharply defined minor calices of the right pelvis. Urine from the right pelvis was negative for pus and bacteria; however, the left one contained many pus cells and myriads of Gram-negative bacilli. Phenolsulphonephthalein, one cubic centimeter intravenously, appeared in 5 minutes and 11 minutes from the right and left pelves, respectively, and the right excreted 22 per cent in 20 minutes; the left 214 per cent. This study substantiated a diagnosis of left infected hydronephrosis. The patient responded with left ureteral dilatation and lavage of the kidney pelvis.

Again the patient was discharged from the hospital; however, one of us (S. K. B.) recently (April 14, 1938), subjected her to another complete kidney study. The essential points of interest are: No demonstrable urinary calculi; only a trace of function from the left pelvis; right pelvic urine without pus or bacteria; left, “loaded” with pus and Gram-negative bacilli and, according to the pyelogram, consistent with a far-advanced hydronephrosis (Figure 3). At this writing no further treatment has been instituted, since the patient has established residence in a distant rural community.

CONCLUSIONS

1. A case of horseshoe kidney (fusion of the upper poles) with calculous disease is reported ; its clinical history given and the surgical treatment (transperitoneal pelviolithotomy ) recorded through motion picture in color.

2. Urinary stasis, due to anomalous pelves and ureteropelvic juncture obstruction, is the main causative factor of associated pathology.

3. Roentgenographic procedures, especially bilateral pyelography, offer a conclusive diagnosis.

4. Surgical technique is comparable to that carried out in similar pathologic processes in a normally formed kidney. We, in this instance, chose the transperitoneal approach.

5. Conservation of kidney substance is even more axiomatic in dealing surgically with this congenital entity because of the potential danger of subsequent disease of the corresponding parenchyma and pelvis.

1680 North Vine Street.

DISCUSSION

Rosert V. Day, M.D. (1911 Wilshire Boulevard, Los Angeles) —With the advent of excretion urography, fewer cases of horseshoe kidney are overlooked—as stated by the authors. But even greater emphasis should be placed on

CONGENITAL RENAL ANOMALIES—RUSCHE-—BACON 347

the careful study and correct interpretation of urograms obtained both by the intravenous and retrograde methods. The clinical syndrome in itself is highly suggestive, and calls for adequate urologic investigation. In their modesty, and apparent attempt not to appear dogmatic, I fear the authors have not sufficiently stressed these points, although the case history shows how painstakingly all these were carried out. Excretion urography is of more diagnostic import in horseshoe than in other forms of upper urinarytract anomalies, for the reason that in so many of the other anomalies of the kidney and ureter one segment is apt to be entirely functionless and no radio-opaque agent is excreted in this segment.

At this point it might not be amiss to state that when one is too eager to discover rare anomalies he is apt never to find them. But if we strive with wide-open minds to make correct and total urologic diagnosis in each and every case as they are presented—simply assaying the patient for whatever pathologic condition, lesion or disease that he may have—the rare anomalies will seldom be overlooked. This does not mean, however, that we should carry out routine major urologic diagnostic procedures which the clinical history, subjective symptoms and simple subjective findings do not warrant. Individualizing of cases, and their careful study, supply the clues which indicate the kind and extent of urologic investigation that should be carried out.

The authors’ case is an interesting one from several standpoints. First of all, the fusion was at the upper pole— quite rare.

From the clinical standpoint, one is bound to note the wise conservativeness of the authors in the management of this case. Moreover, the practical results attest this. Each case is apt to present a specific problem, and perhaps their next case of horseshoe kidney would call for a quite different surgical procedure, such as, for example, division of the isthmus and unilateral nephropexy.

I wish to commend the authors on their clear, succinct presentation of a rare and interesting case history, and their sound judgment in its management.

&

BenyaMIn H. Hacer, M.D. (1136 West Sixth Street, Los Angeles).—Doctors Rusche and Bacon have presented a most unusual case of congenital anomaly in which a huge stone could be readily palpated through the abdominal wall. This unquestionably was the factor which decided the transperitoneal approach, a very courageous one in the presence of kidney infection. It has been established that horseshoe kidneys, in the absence of pathology, often give rise to a characteristic syndrome. This anomaly likewise is prorie to develop symptoms arising from interference with urinary drainage—hydronephrosis, stone and infection being rather common complications. More lasting benefits are apt to follow surgery if attention to stasis is instituted. I have been very much impressed with the teachings and results of Doctor Foley of St. Paul, who makes it a practice, when feasible, to sever the communicating isthmus and perform a nephropexy at one sitting. This is followed, at a later date, by nephropexy of the remaining half. His records show an enviable result from the standpoint of complete relief of symptoms. x

Wuttam E. Stevens, M.D. (490 Post Street, San Francisco).—In reviewing the literature some years ago I found that, in the combined reports of 148,329 autopsies, horseshoe kidneys were present in 198 or once in 749 cases. As Doctors Rusche and Bacon have stated, they are found more often clinically since the advent of pyelography.

In the horseshoe kidneys that have come under my observation the most frequent symptom has been pain or discomfort in the abdomen, usually increased by exercise and relieved by rest in bed. A smooth, apparently oval mass was occasionally detected on palpation. The isthmus, unless composed of fibrous tissue, will often be more clearly outlined following excretory rather than by retrograde pyelography. Concomitant abnormalities of the genital organs are common, and horseshoe kidneys are not infrequently confused with lesions of the pelvic organs in the female. Pyelography is always indicated in the presence of an abdominal or pelvic mass of uncertain origin.

I wish to present brief histories and lantern slides of three cases: 348

Case 1. A young married woman complained of pain in the right groin (worse during menstruation), frequent urination and a sensation as if ‘ ‘something was pressing on the bladder.” The characteristic pain was reproduced during vaginal palpation. The urine was negative. Pyeloureterography revealed a horseshoe kidney, and it was thought her symptoms were partly due to this anomaly. These disappeared, however, following the removal of infected tubes and a cystic right ovary. Many horseshoe kidneys exist without symptoms. The urine was negative in two of these cases I am reporting.

Case 2. A married woman, sixty-eight years of age, complained of a burning pain in the entire abdomen and frequent urination. Her urine contained numerous pus cells. Both pelvic and urinary-tract pathology were suspected. Pyelography revealed a horseshoe kidney. The isthmus is unusually well outlined in this case. The patient refused further investigation.

Case 3. Although previously reported, I am again presenting the following unique case, as it is interesting in ‘connection with Doctors Rusche and Bacon’s paper. The patient, a young woman, twenty-three years of age, complained of lower lumbar backache, worse during menstruation, and relieved by rest in bed. She also suffered from obstinate chronic constipation and malaise. The urine was negative. Pelvic and gastro-intestinal examinations were likewise negative. A firm oval smooth abdominal mass, the size of a large hen’s egg, could be palpated a little to the right of the midline above the umbilicus in this case. Forceful aortic pulsation could be detected over the inner half of this mass. Cystoscope was negative and the ureters were easily catheterized. Kidney function was slightly increased on the right side. A pyelogram of the right kidney showed marked overlapping of the calices. Unfortunately, the patient, a very nervous individual, refused further cystoscopic or pyelographic investigation. Exploratory laparotomy revealed a somewhat kidney-shaped mass with a pelvis lying transversely across the fifth lumbar vertebra. A third ureter ascended about 1.5 centimeters from the center of this mass, turning to the right and descending about one centimeter, where it joined the right ureter. The mass was fused at both extremities with the right and left kidneys, respectively. Another unusual feature in this case is the normal position of the left kidney. Both kidneys are almost always lower in fusion of the horseshoe type. The patient’s symptoms improved and eventually disappeared, following the removal of an appendix which showed evidence of previous inflammation and a cystic right ovary. Should this be classified as a fused third kidney or a horseshoe kidney with three ureters?

Doctors Rusche and Bacon’s paper has been most interesting. They are to be congratulated on both their surgical conservatism and their excellent motion picture. According to statistics, operative mortality is increased following operation on horseshoe kidneys.

SOBISMINOL: ITS ORAL ADMINISTRATION *

CLINICAL RESPONSES AND ADVANTAGES IN FIVE LUETIC PATIENTS IN PRIVATE PRACTICE

By Wivarp E. Kay, M.D. AND Joun W. Fricke, M.D. San Francisco

SOBISMINOL is a soft mass in capsules, each capsule containing equivalents of 0.2 gram sodium bismuthate, 0.4 gram tri-isopropanolamin, and 0.1 gram propylene glycol. The bismuth content is about 70 per cent, equivalent to about 0.14 gram of bismuth metal in each capsule. The re* Through the courtesy and kindness of Dr. P. J. Hanzlik, of the Stanford University School of Medicine, San Francisco, and the Cutter Laboratories, Berkeley, we have had the privilege of treating five cases of syphilis orally with sobisminol in our private practice. The clinical responses in

all five cases has been so satisfactory that it seems warranted to publish them.

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action product has not yet been identified chemically, but appears to be a complex organic bismuth compound with unique properties. The description of the product and its actions, absorption, excretion, toxicity, etc., have been reported in several papers from Doctor Hanzlik’s department,’ and the following brief summary of the product will suffice here: High stability in body fluids, tissues, weak acids and alkalies ; readily and adequately absorbed from the alimentary canal; bismuth distributed to all tissues ; excreted in urine; low toxicity, but has a fatal dose in animals; tolerance good; potent antisyphilitic actions in experimental and clinical syphilis in all stages. A solution can also be used intramuscularly. The gastro-intestinal absorption, urinary excretion, tolerance, and high antisyphilitic potency of oral sobisminol in patients have been confirmed by Cole, Sollmann, and Henderson of Cleveland,? who feel that sobisminol is the most potent bismuth compound of all bismuth compounds by any method of administration. Sobisminol is the only compound of several proposed for oral administration that is really adequately absorbed and effective in antisyphilitic treatment. The favorable reports on sobisminol justified the clinical trial we have given it. Brief protocols of our cases follow. REPORT OF CASES

Case 1—Mr. A. W., age 83, a capitalist, first seen at his home on July 2, 1935, complained of agonizing pains in the lumbar and lower dorsal regions (which had come en three months prior, following a prostatic resection), an incontinence and nocturia as often as twelve times per night. The pains were especially prone to occur at night while the patient was in bed and particularly when changing position, and were described as lightning and knife-like, radiating from the lower dorsal spine region to the midabdominal region.

Physical findings were: an old chronic antrum infection, a chronic bronchitis with bronchiectasis and emphysema, an enlarged heart (chiefly left ventricular hypertrophy), a widened and thickened aorta with especially supravalvular widening, an accentuated aortic second with a loud systolic blow, moderately thickened peripheral blood vessels, pulse rate 68, blood pressure 200/80 in both arms, a palpable liver but not tender, marked tenderness over the descending colon (x-ray later revealed chronic diverticulosis), moderately atrophic gonads, slightly hypertrophied and firm prostate, and some lordosis, and scoliosis and tenderness of the lumbar and lower dorsal spine. Tendon reflexes of lower extremities could not be obtained. No Babinski or Oppenheim. Romberg was negative, no past pointing. Motor force was good. No sensory disturbances. The pupils were regular in outline, myotic, but reacted sluggishly to light. The blood Wassermann, Kline, and Kahn were three plus. No spinal puncture was done because of the patient’s age. Inquiry from his genito-urinary specialists disclosed the fact that he had, in years past, been extensively treated with neoarsphenamin, which always gave him a severe reaction, with temperature reaching as high as 102 and 104 degrees, and mercury, intramuscularly, topically, and orally.

Iodobismitol with saligenins was exhibited intramuscularly every five to seven days, which brought about prompt but not complete relief from the pain. After twenty-four injections the Wassermann, Kahn, and Kline, however, did not improve. At this time, April, 1936, the patient decided to take a trip through the Panama Canal to New York, and it was then that sobisminol was administered by mouth. Two capsules of sobisminol were taken each day for approximately fourteen days, at the end of which time he would usually manifest symptoms of intolerance, characterized by weakness, depression, sleeplessness, slight diarrhea, and frequent urination. Upon the earliest signs of saturation the patient would discontinue the capsules for two or three days, and then again feel quite well. After