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 OK 'in 
 
 A!Mn 
 
 iUill 
 
 i\T- Nil' 
 
 
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mmmm 
 
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 IvOf^M 
 
DISEASES 
 
 OF TIIK 
 
 KIDNEYS Ai\J) liLADDER: 
 
 A TEXTBOOK 
 
 KOK 
 
 STUDENTS OF :\IEDlCmE. 
 
 HV 
 
 'IcXlJTT, M.I). M.Jj.c.s. Ka. L.R.c.p. Rd., 
 
 'K.CUTVi .:X.ACTINU .S8,»r*VT nH,...,N t. .. 
 KAVV, tTC. 
 
 r » I I, A I) E L !• H I A : 
 
 J. B. LIPPINX'OTT COMPANY. / 
 
 1893. Uil'^^^ 
 
 ( OCT 15 1892 t<- 
 
 \%^-.\ 
 
 f- 
 
 -> «l»BM lu n,jj ..iM-nw:mm,ja,m» . 'K m 
 
 W?ff^1WJ"!WBi^ 
 
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 ^0 
 
 
 Col'VllIGllT. \^'J2, 
 
 nv 
 
 J. H. liirrlNCdTT CoMI'ANV. 
 
 Printed bv J. B. Lipfincott Cokpan*, Phiuoiiphi*. 
 
IVUKFACK. 
 
 T.'iis hook is liasi'tl ii|i(iii iiutfs of li'cturt'H dclivcrtd to 
 tln' iiu'diciil htiidcnts of tlic I'liivcisitv of Ciilifoniiii. 
 
 Some of till' li'ctiin's Imvc hccn rcviscil ;iiii| clalioriiti'd, 
 iiTid dividi'd into cliaiitiTs. 
 
 'I'll*' iioiiifiicljifiiri' of kidiicv diseases, |iai-ticidarlv of 
 tlie iiiMaiiiiiiatorv varieties, lias heeii sinipiitied as niucli 
 as iiossihle, ill tlie hope that it may tlius lie tiie more 
 readily understood hy the student. 
 
 The illustrations are oritrinal. and tor sonn- of the 
 |iatho|otricaI s|K'cimens I am indehted to my i-nnfrtri'H 
 I'rofessors ]{. A. Mi-Lean and 1). \\^ Montiroinery, and to 
 Professors J. II. Stallard and Louis Mazet of the I'ost- 
 (Jraduate Department. 
 
 I Inive uIho to express my thanks and olilii-ation to Dr. 
 Frances M. (ireeiie for the int*'rest, zeal, and intelliirenee 
 she exhihitccl in reporting these lectures, and for assist- 
 ance in their revision. 
 
 104 Si'TTKit .Stkekt, San Frantisco, 
 September, ISrrJ. 
 
 lit. 
 
• ' 
 
 >j 
 
• » 
 
 CONTKNTS. 
 
 SKCTION I. 
 
 I. Ariiiloiiiy ntid I'hv«i(i|o;;v of the Kidn.'vs . 
 II.— Afiutimli. .«.,(• l'(,Mti..n, Foiin, iin.l Niinihor 
 
 PAdK 
 
 7 
 
 SUCTION II. 
 
 PIsKASKs OK TiiK KlliNKVS. 
 
 I. — NpphnilijiH 
 
 II.— Uvpcni'iniu— CdimcstiDii nf tli.' Kidiii'VH 
 
 III.— Hiifiiiitiiriii ' 
 
 IV.— Kdil.'tiiic HnuMiitiiiiu 
 
 V.-H,,.m,.tinun,. -.S,.un,..i.- or Fnls,. IIirmatum-H,,.,.!.,- 
 
 i;loliiniiriii 
 
 VI. — Anii'iiiiii 
 
 VII 
 V!!l 
 
 IX 
 X 
 
 XI 
 XII 
 
 XIII. 
 
 XIV. 
 
 XV. 
 
 XVI.. 
 
 WII.. 
 
 XVIII.- 
 
 XIX.- 
 XX.- 
 
 ;io 
 
 41 
 
 41 
 
 — DiMii-c- of llic Koiiul lilood-Vfsscls 
 -rriiH' 
 
 --C'ii.Ht.H of ihi! UiiiiifiToiH Tiilmlcs 
 
 — .Mhunnn 
 
 -Ni'|>liriti-i -llri!,'|it'a Disoiwc 
 
 -Ti.lMilar N.'i.liritH-Tu».nliti.s-Ti.lml VridirilH-ln...^.,!,,,- 
 
 iiiatlvo- r„ta.Thal -Croup,, us ^ Aout.' - Huliacutc - 
 
 CliMnic 
 
 -IntortulMilar Nophritis-Infrstitial Nopbritis-Granular 
 Kidncy-(;ou»y Kidn."y-ContraH,d Kidn,.v-Cirr!.,.(ic 
 Kidney . , 
 
 -N'.j.hritis-Difrusp No,)hritis— Nephritis Vt.ra-I'ar..n<liv- 
 nuitous Ncnhrltis 
 
 -Suppurntivi' Kidney— Abscess— Surgical Kidney . . j,); 
 
 -TuLereular Ki.lney-Nepl,ro.plithi-i.s-Tul)er(uloH8. . kw 
 — Uneniia 
 
 -Degenerations- Amyloid Dp,i;<.nerution — Lurdacoous .,r 
 Wnxv Kidnev . ... 
 
 -1,") 
 
 4i\ 
 4S 
 04 
 (1« 
 73 
 
 ID- 
 IOM 
 
 11. t 
 
 IL'O 
 
 -Atrophy and nypertro)i)iy ,.,,, 
 
 -Tuinur- and New Growth.-s jitr 
 
 J6e«fflSaS55«ESWlft5J«>sBS=!.5ar»r 
 
(•(>.\n:xTs. 
 
 '1 • 
 
 SKCTIUN I 1 I 
 
 msRAKKS iiK TIIK I'KIA IH. 
 
 rllAKr>H '*"" 
 
 I. -Ki-iml Ciiloulu*, St.iii.., Stotiy (•..niMinim— Ki'iiul Cnhv— 
 
 N.Hlin.-l,itlii«»i*— Pyi'liti" I'lil' iil.iMi— ("iili'iili K<imliu . . 13S 
 
 |I._l'j..liliH '■♦7 
 
 III.— rv<).Nt.|.lir.>(.ii<(Nc|)liP'>-l'y'>«ii<— Pyl'i-Ni'l'lT"*!") '•*" 
 
 1\'. ||\.|r..-Ni>|.hr...i» (llytlroim Ui'iitiliH— Uy(lni-N('|)lirciiil . . . 150 
 
 V -I'liiiP jiliiilU '''- 
 
 VI.— rp't.Ti ''["i) 
 
 VII.— Suit.'iriil Ti"iitiii(>iit 111' till' KiiliM-VH l'"'^ 
 
 SKCTION ! V. 
 
 MSK.XHK.S itV TIIK III.AI'I'K.U. 
 
 1. — Atiiitniny of till- lilucMrr '|]|* 
 
 II. -('\-tiilKiii ']]" 
 
 III — IlyixnisthiMii (Iiritiiblc Hlmlil'T) ^'J 
 
 IV.— AniPHllH-Kiii (Aloiiy) '""^ 
 
 v. — Cystospn^iims (Vc>icHl S|msiii -Spii>m i.f the Itliuld'T - 
 (■\.t(.-|,MMii— SpiiMiius VtHira'— li-chiiriii S|p|i«liii)ili<'ii— 
 
 ('y-to-|m.-titiis— IIypi'r<'iri<'>i>) . . 1*^' 
 
 VI._C'\>t(>i.icLriii (riirHlv>iH ..(• till' Ulii(lil.T-Acin(«iii— VfMoil 
 
 ■I'iv) . . . .■ '^■■' 
 
 VIT.—V.'sifiii riil'iili (Cy-to-Litliiii-i^l 1**^' 
 
 Vlll.— t'y<l<.rilmf;iii (Vi-i-ui llniniitnria— Ilcmorrhmjn t'nuii ihc 
 
 "lil.ul.l.r) '**" 
 
 IX.— Cvstitis— Acuti', Sulxuutc, aiitlChmiiii' !>*« 
 
 X. — Pcrioy>titis 
 
 XI.— Ilyi.iTtmi.liy (.f lht> nindiliT '''J' 
 
 XII.--NVW <ir.iwtiisHii(l F.T(i._'ii Hoilic's in till' niaiKlcr 20|1 
 
 XIlI.~Knim>is NtKturna (Nocturiiiil IncontinenciM '-'l>i 
 
 t 
 
 SECTION V. 
 
 T. — Diulioto.s .' ' ' ' " 
 
 II.— Diiiln'lc- Mollitus (MoUituria— (llyoosurin— (JlucosuriiO . . 211 
 
 111.- Diiilii'ti'* InMi.iiiii*' I Pi'lynna— Uso/.cniii— Ilyosuritt) . . . . 224 
 
 IV.— Anazoturiii— ()lii,'iiria— Aisoturia 230 
 
 I 
 
PAiiR 
 
 .hr- 
 
 — 
 
 lii . 
 
 . 1.1.1 
 
 
 147 
 
 
 . 14!» 
 
 
 , 150 
 
 
 . IW 
 
 
 . \r,.\ 
 
 
 . v,-> 
 
 
 \w 
 
 1 « • • 
 
 17'J 
 
 . . . . 
 
 174 
 
 . . ■ • 
 
 17H 
 
 ulll'T — 
 
 
 iidifii — 
 
 
 
 181 
 
 ■Vi'sii'iil 
 
 
 » . . ■ 
 
 18H 
 
 . . ■ ■ 
 
 18f. 
 
 nlU tln' 
 
 
 » . • ' 
 
 1H7 
 
 
 18M 
 
 • • • • 
 
 108 
 
 . . . . 
 
 190 
 
 . . . . 
 
 20; 1 
 
 • t • • 
 
 ao7 
 
 210 
 211 
 224 
 230 
 
 MST OK ILLUSTRATIONS. 
 
 I. 
 
 H. 
 '.I 
 
 U\ 
 
 II. 
 
 12. 
 
 M. 
 14. 
 
 l.l. 
 
 Ifi. 
 17. 
 
 18. 
 
 V 1 1.. 1 ''A'"! 
 
 .N'lniiMi Kiijni'v ., 
 
 rni'il'.rdii- '^ihiilis iiriil .Mul|)ii;liiiiM Tiil'ii* n 
 
 iliiiM'fihoi. Kiilmy .,(. 
 
 riic A<'i,l <'rv>tiili ... ' ' % 
 
 0( 
 
 I nitl' ri| S'mIIiiIII ("rV'tlll.i ru 
 
 • Kaliiti' of I.iiiK- ('rytiiU 50 
 
 .\iiiiiiiiiiiiiiii l'li(i-|ilmlis ,l(, 
 
 'I'll 111! t'nst.< ^,, 
 
 I'M'iiih s Allmiiiiri M.ti'P -,, 
 
 I'us Cori.iisclr.s t'ri.>li, I'lH ('..r|)iiscl,.s i.ltiT tli.) nctidii of Atvtic 
 
 Aiiil -.^, 
 
 .Micrnsc(.pir Scitic.n, Tulmliir Nt'iilirili.s nO 
 
 IiitiiMitiiil Ni|)liriti>, — Oriiiniliir Ki<liii'y {)(•, 
 
 Miiriiscdjiic .-crtioii, Cliroiiic IntiTtuliiiliir Nephritis <)7 
 
 Ml(rn.((i|iic ■.(.(•ti.iii, Nt.|,liritis (ilitCuM') 104 
 
 'riilx'tfular ivi<Iiii'y j]() 
 
 (\\-tic I)i'i;i.in.iiiti(in of Kidiiuy ];(i 
 
 Ni'plii-ii-litliiii.-is |.jr 
 
 l{flml C'nl(.'UlU8 will 
 
 1» 
 
 ■'wCT»Dg!paaM^SSg!a?Fg. w ;wK:::.? >8 Pfwm« »i ' iM!i ' .i '' ■ »>«' •' 
 
-^J 
 
 ii 
 
 11 
 
 !!• 
 
 11 
 
 i 
 
 ^ f-i— 
 
 itaM 
 
-^J 
 
 DISEx\SES 
 
 Of THE 
 
 KIDNEYS AND BLADDER. 
 
 SECTION I. 
 
 CTIAPTEIi I. 
 
 ANATOMY AND I'll YSIKI.OCY UK TIIK KlUNKVS. 
 
 TilKRK iiiiiy 1h' ortrans in tlu- ImkIv tlu' fticiloiry iuid 
 patlioldiry of" wliosi' (lisi-asi-s \vc may iimK;rst!tinl antl 
 ju'rhaps treat iuti'llij^t'iitly witlio.it a knowlodifo of their 
 anatomy and |tliysiolo,i;y ; but the kidneys cannot he ehissed 
 anionu: them. A thorou<rh knowledtre of tlie normal anat- 
 omy, pliysioloiry, and liist(doiry of the ki(hiey is indis- 
 pensahh' to tile |»roper nnderstandinij of the etiology and 
 sym])toms of its patlioloijieal conditions. 
 
 The tirst tliiiiLr to realize is that the kidneys are <;landn- 
 lar orLTans, sitnatcil one on each side of the vertel)ral 
 column, behind the peritonoim and iK'twH'cn tlie ujnier 
 border of tlie twelfth dorsal and tliird lumbar vertebnw. 
 The rii^lit kidney, by reason of its vicinity to the liver, is 
 s]it,'htly lower than the left, its upper border beiti<; on u 
 
 ••■««-«iaerasisf'«i aii»a9g^»teai!!MKSBga.Mtt«i»ni»»«M "« i « -i<y iii i »»»i 
 
fi i)isi:.i.si:s or riii: i<ii>.\i:ys. 
 
 lovcl with the lower iiinruin <>t' llif rlrvrnlli rili, wliilc tliat 
 ot'tlir left siilc Itcuiiis ;it t iu' iipitiT iiiaru'iii of tlu' siiiiu' ril>. 
 
 Tlir kidiH'Ns iifc aliiMit I'niir iiichrs ill Iciii^tli, tVuiii t\V(» 
 to iwip ami a liali' iiiclu.- in Ipnailtli, ami rather more than 
 ail imh in thi.kmss. 'rhe\vei;:hl ofthe kidiieviii tiie iiiah- 
 is from four and a half to six oiniees; in the female it is 
 somewhat less. 
 
 It is well to p'liiemlier that on the i-iirht side the kidm y 
 is in relation ahove with the riiiht lolie of the li\er, and 
 Itelow willi the deseeiidinir portion of the ihioileiium and 
 the ii|)|u'r part ofthe ase»'iidiii,u- t'oloii : on the left side, with 
 the under siirtluv of the stoinaelu the extremity of tho 
 liam-reas, and the deseendiiii;- colon. 
 
 In exaiiiininn- the kidney for eiilaru'eineiits, ttimors, etc., 
 alwavs place the |iatieiit in the dorsal posilion and use tlu' 
 himanmil method.— one hand i.eini;' under the patient on 
 the Imiihar re^'ioii lietwecn the lowi'f rih and the cnst 
 of the ilium, tlu' other on the alidoinen directly over the 
 
 kidney. 
 
 A few spasmodic efiorls of the haiul on the alidoiueii 
 will fail of rcsiilt>. I5iit with the patient's knees drawn 
 up and pressure made steadily witli the upi>er hand durin.i;- 
 expiration, kecpinu- it liriii and inactive diiriny- inspira- 
 tion and continiiiuii- the p.-i'ssurc duriiiir the next few 
 exjuratioiis, you will tind that in a few minutes the kidney 
 will l>e lictwi'cn your liands, ami you can ted its si/.e and 
 shape. This, of course, cannot he easily accomplished in 
 corpulent persons, .lerky movements will cause failure in 
 U)iv case. On percussion you will tind diiliiess hi'twei'U 
 the twelfth Hit and the crest of the ilium, and you must 
 judiii' ofthe size ofthe or<raii hy the area of the dulness : 
 ite careful, however, not to confound it with liver-duluess, 
 as iHTcussion doi's not always yield a very e.xact kuowl- 
 odire of the size of the kidneys. Do not forget thut they 
 
 • • j m'i T 'r Bnn ' Dm t r ' 
 
.I.V.I /'".u J' .iM> riiyxioi.Dtiv. 
 
 9 
 
 lie l.t'liiiid till' pt riti.iu'iiiii, iiiiil tliut the ri^lit k'ulncv 
 iimvi's witli rfs|iir;itit>n. 
 
 Si» t'iir as till- 'lisciiscs of the kidney iirc idiicfnu'd, it is 
 lu'ci'ssafv I'ltr tlic |>ii_v.-ifi:m to iH'iiu'iiilKr that tlir kidney 
 
 Kki. 1. 
 
 Capsule 
 
 Pyramid 
 Calyx 
 
 .Cortical Portion. 
 
 consists of throe distinct tissues, — viz.. nrinifiTons tnhnh'S, 
 l)l(.od-vcsst'ls with their Mal|»i,i!:hian tnfts, and the iiiter- 
 tuhular sti-nctnre, i^eiierally called tihrous interstitial tissue. 
 Wo divi'lc the kidney into two i»rinci|»ul portions, the cor- 
 tical and the niedullarv. The inediilhiry portion is sulxli- 
 
 ■"'ftl».JW l-l 
 
.r^r 
 
 111 
 
 jusKAshs nr rtir. KinsEvs 
 
 vidi'd into i.,vraiMi<ls. ( i.iii|M)siil tui- the iiio>t imrt nl'.-t'';ntrlit 
 
 rullctillU'-tulK'S. wllosr hilMS VvM oil fll<' corlif;!! l.ii!'li(>U 
 
 ami uliusi' !i[iii'' "oiivfi'irf lov^aid tlic cciitrr, wlicif lIu'V 
 f.irii' llii- papillii wliirli itrojt'ft into tin' caliri's or i'X|iaii- 
 ■<i.iiis oftlu' iirfliT. TIh' cortical iiortioii i-* iiiofc vascular 
 than the iiuilullary, and contains the greater nunil.cr of 
 Malpiirhiin hodics, sn)all roundi-il masses a\cra;-in,!:' al'out 
 on* onc-hiin»lrc(l-aii(l-t\vciiticlh ot" an inch in diameter. 
 
 Kach of these little hodii's i> eonilposed (d' two pari-, a 
 central i:'loinernliis of vessels, calle.l a Maliii-'hian tull. and 
 a niendii-anous eapsule, or cai.sule of Hownian. which is 
 the eoninicnccHient of a iiriniferous tnlmle. Tiiese Nhil- 
 piirhiaii tufts are made up of a net-work of capillars hlood- 
 vessi'ls held toiri'lher hy scanty i-onnective tissue and 
 dt'rived from a small arterial twiir, the afferent vessel, 
 which, with the roultini; vein, tlie efferent vessel, pierces 
 the capsule at a jioiut opposite that at which it is eoniK'cti'd 
 with the tuhe. Tlu' capsule which siirrounds the ;loii,cr- 
 iilus is composed of hyaline memlirane (•(•ntainiii:; i >nuill 
 amount of fim- connective- tissue' which is continuoii with 
 that of the tul>e and is also reflected over the caj.illar.s net- 
 work and covereil l)y st|Uamous epitiielium. Thus a cavity 
 is formed hi'twet'U the capsule and the ,i;l"inerulus, which 
 variivA in sizi- accordiu-r to the state of secretion and the 
 amount (.f fluid present in it. The urinifen.us tul.ules 
 commence at flu- constriction or neck of the capsuU', and 
 heeome convoluted while iMirsuinu: a considerahle course 
 in the cortical portion, where they are ti'rmed the i>rn.f- 
 Imal roin-uhifnl tiih'ihs. The convolutions then disappear, 
 and the tuhules, now ti^rmed the /'//'"/<>• ';/' Srh,irln„ni, 
 approach the nieilullary portion of the kidm-y in a more 
 or less spiral maniu'r. As they I'uter the medullary por 
 tion, the tuhules suthleidy heeome much smaller, straiirht 
 in direction, and, dippinu; «lown for variahlo depths in 
 
ASATOM)- A.\l> l-nVSHtWdV. 
 
 11 
 
 iil'sfiMirlit 
 
 ;ll ]Mi!'ti('il 
 liclf lIli'V 
 
 or fX|iim- 
 (■ viisculiir 
 iiiiiilpif lit' 
 riiiu; iil'iiut 
 
 illluttT. 
 
 ^■(t |i;irts, a 
 11 tiil't. and 
 I. which is 
 'lu's.. M'll- 
 larv hhiixl- 
 li-siif aii<l 
 rlU vessel, 
 <cl, |iirrees 
 
 collllcrti'd 
 he :liilhiT- 
 II- I >iiiall 
 luoi. \y\t\\ 
 |(ilhir_\ iit't- 
 iiis a cavity 
 ihis. which 
 >ii ami the 
 Ills Iiiliiilfs 
 [ilisulc, and 
 I hie cdiirse 
 1 tiu' in-nx- 
 
 (lisaippcar, 
 
 Si'hdrliiiiru, 
 
 \,- in a nioi'o 
 lullarv ]iiir 
 IT, straiirht 
 (h'jiths in 
 
 the ityraniids, eoiistitiiti- the deseeiidin.i; linih of a curve 
 known as llenU-'s loop; eiilar.t-in.ir as they reasci-id to tlie 
 corti.al poftion, they hecoine apiin spiral in din'etion, 
 t'oniiiiiLf the asiviidiiii; liniii of Ileiile's loop. After eiiter- 
 
 1, ViilplKliiftii tiilt; 2, cpltliclium liiiiiiK' linwinan's cnpsiile; 
 n, I'liilhclial (MivcriiiK-. 1. •■imvolutod luhes of Cdrticul pmtiini; 
 5, Ui'iile'sloDp; i>, <'()lk'ctlii« tubes. 
 
 iuff the cortical portion narrower and irre.iriilar in outline, 
 they once more dilate, heeoine convoluted, foiininir the 
 distal, '<n}r„hih<l tiih,\ and with a final heiid enter the strai,<;ht 
 collectin.ij tiil.es, which continue downward throu.t?h the 
 medullary nubstatice to open at the apices of the pyramids, 
 
12 
 
 hisK.isKs OF Tiir: KH>.\j:is. 
 
 1 ( 
 
 iicfiiiu; siiiinly us ducts lliroiiyli wliidi tin- nriin' funis its 
 wiiv into tlic pi'lvis uf tlu' kidiicv iiiid iirctt'i'. 
 
 Tlu'si' colU'ctiiii; tidmlcs, coiiiiiu'iiciiii^ l»_v iiiiiiiiti' o|icii- 
 iiiirs ;if tlic n|iiccs of tlif iiii|iillii' jiiid cxti'iidiiii;' iiitii the 
 kidiicv, dividiui,^ diclKitoiiioiisly, lonii tlio _ijroiitiT pait <it" 
 llu' |>_vriiiuids (tf tlic iiicdulliiry sultstaiicc. In the cdi'ticid 
 |((M'ticiii tlicv arc arraiiijcd in conical ,ii'r(tii|is. called iiii'did- 
 laiT ravs, of [ivraniids dl' Fcrrcin, and rcci'i\ c on cadi side 
 the curved extri'initics of the convolutt'd tuhules. 
 
 J'J/iif/u/iiiiii. — The e|)ithclial lininii' of the tuhnli urinifcri 
 ditlcps in its character in the various parts of the tuhes. 
 Till' ca|isiiU' and neck are lined with Hat cells contain'ini^ 
 an oval nucleus. In the proximal convoluted tuhes, tho 
 spiral tulii's of Schachowa, and the distal convoluted tuhes, 
 tlu- epithelium is |iol\-|u'dral in shape. These cells are 
 made lip of more or less rod-like tihres, one of whose ex- 
 tremities rests upon the basomont memhrane, the other 
 pn tiiii,' into the lumen of tlio tube, ^ivinu; the cells a 
 flistinctlv striated appearance. In the desccndin<i' limb 
 of Jlciile the ei>itlielii.m resembles that which lines the 
 eajisule an<l luck, while in the asceiidinir limb it a.u'ain 
 beeomi'S polyhedral in shape. The cells liniiii; the 
 irreg'ular tubes are very angular, with more prominent 
 striations and rod-like markinii's than any otlu-r jiortion 
 of the tubules. The t'pithelium of the strai_u;ht tubes be- 
 eonu's more or less columnar, this tendency inereasinjjf 
 toward the jiapillary portion, where it is distinctly colum- 
 nar and transparent. This arraiii^enu-nt must havi" some 
 design. Charcot says he believes that the epithelial cells 
 are the real seeretiui; portion of the organ, all tlu; urine 
 that is not iiltered through in tlie capsule being secreted 
 here. The constrictions in parts of tlie tubules would 
 sei'in to be for the purpose of arresting the too rapid 
 onward flow of the urine until the eiiithelial cells have 
 
.ty.lTiiM) .I.V/) I'liysln/.ntii: 
 
 18 
 
 \v finds its 
 
 illlltf oprll- 
 
 wjj; iiitii llio 
 III r parf of 
 tlic ('(H'tical 
 It'll iiii'diil- 
 11 I'iicli sido 
 
 ili iirinifrri 
 
 tlu' tlllll'S. 
 
 coiitirniiiiuf 
 
 tulti's, tho 
 
 utc'd tiilics, 
 
 (' (U'lls arc 
 
 whoso I'x- 
 
 , the other 
 
 tlic colls a 
 
 idiiiii' liiiib 
 
 1 linos the 
 
 1) it a<jain 
 
 lininif tho 
 
 proiniiiont 
 
 UT portion 
 
 t tllllOS l»o- 
 
 iiu'ri'asin<ij 
 •tly ooluni- 
 liavo some 
 liilial oolls 
 I tin; urine 
 i<^ secreted 
 des would 
 too rapid 
 cells have 
 
 pcrroriiii'd tlu'ir otlico ami addod t.i tlio walfi'v portion 
 of the urine its solid iiii^roilionts. 
 
 It is vorv ii.'cossarv tor voii to roiiH'inlior tlic principal 
 toatiiros of the oirciilation. Tlu' first thin,::: loalliari voiir 
 attention is the fact tlii't tho roiial artorv is tho larirost, in 
 ])rop(irtion to tho si/o of tlu' ortraii siippliod, nfanv artery 
 ill the liudy. It may sooni stramj:^- that it is tho larn'ost, not 
 only ill that rospoct, hut also in proportion to the ronul 
 vein. When wo ooiisidor, liow»'vor, that in olhor orn-ans 
 uhoiit the same amount of hlood is rotnriiod iiy liio veins 
 us enters the origans throiiirh tlu' artorios, while in the 
 kidney a (piart or two of tliiid is filtered throiiiih tho cor- 
 jtuselos each day, wo shall see tho necessity for its veins 
 hoiiiir of smalh-r oalihro than its arteries. The renal aiterv 
 on oiiteriiiir the jwlvis of the kidney divides into sowral 
 hraiichos, hoarini; the naiiio of artoriu' propriie renales, 
 which, aftiT travorsini; tho oolinnns of iJortitii, supplyini; 
 in part the pyramids of the nu'dnlla and atioreiit vt'ssols to 
 tho Malpii^hian hodies in that ri'irioii. divide at the liaso 
 of the pyramids into two sots of hranchis for the further 
 supi>ly of tho or^^m, — viz., tlie interlohular artoriis and 
 the Jirteriohe roctie. The interlobular arteries pass 
 directly outward hetwoen tho pyramids of Foiiein and 
 ti'rminate in the capillary not-work of the oa]isiile. From 
 these arteries are derived the afferent vessels of the 
 Ijlomeruli of the cortical portion. The artoriohe rocta> 
 supply the medullary pyramids, whose substance they 
 traverse, terminating at their apices. 
 
 The veins, as we see, are derived from the three arterial 
 divisions. Those i)enoath the capsule are stellate in 
 arranijomont, pass downward, rocoivint; branches from the 
 plexuses about tho tnladi contorti, and at the bases of the 
 Malpiirhian pyramids join the vena' recta', which are 
 derived from the plexuses at the apices of the pyramids 
 
 2 
 
 'iai M U ai 'nJi -mi e t »n f< 'm ..f ^ai 
 

 14 
 
 iHsiiAsKs <*/•• rill-: A7/>.\7;)-v. 
 
 iiiid t'iKiii till' [.rnpiT ri'iiiil vtiiis. 'I'lif viiiM' |M«t|iri!i' 
 rciiiilis iiiiM>iii|)iiiiv tin- artcriii- |iri>|i'Mii' ri'iiiilts Itctwtcii 
 tlif iivnmiitlH, ri'ccivinjx iti their coiirsf tlic tflt icnt vrsstls 
 iVinii till' trluiiu'i'iili, im«l ill tlif sinus of tin- kidiny juiii 
 witli till' veins lioin ntlier |>_\ ratniils to t'orin llie reiiiil vein, 
 whose nitiniiite (hstiiiiitioii is the inferior vena eiiva. 
 
 All the iirteiies iiinl veins interhiee ami eoMi|ihtely sm- 
 roiilitl ll'e tiliiMJes. 
 
 It is well to iu'ar tlie foreiroinir iiiets in iiiind. as we 
 rtliall see wlieii Wi- eonie to tlie suiijeel of li y|>era'iiiia lliat 
 tho rosistaiiee elleonntereil liy tile hlooil wiiieli passes 
 thronifli tlie irlonientli is fiir jjri'ati'r than that met li\ the 
 vessels that tiow direetly into the eapillaries, ;nnl heiK'e, 
 when the ltloo(l-i>ri'ssni'e is raisetl to any tleirree from the 
 lieurt's aetion, tlu' hypenemia will he eoiiiimMJ to those 
 portions of the kidney wliere the hlood mei'ts the trreatest 
 rosistanee. which are, of eoiirse, tin- i^loineriili and the 
 eortex. This explains the inereased seeretion of urine 
 tVoni heart-pressure. We shall see, on the other hand, 
 that when the hypenvMiiia is tlii' result of venous ohstrue- 
 tioii, the ensfor^ifeinent is eontiiied to the vi'iiis and 
 capillaries and cannot extend throiiuh the narrow etVereiit 
 vessels into tlii' j^lomeruli. Vou will then understand the 
 natural ri'sults of such conditions. 
 
 Thotihrous intertnhular or interstitial tissue is not very 
 ahundant. In the cortical jiortioii the tuhi's are not sui'- 
 ronnded hy much Hhrous tissue; hut I desire to impress 
 upon your mind the fact that the I'apsules are completely 
 enveloped in this lihrous tissue, and that the capillaries of 
 the irU)ineruli are covered with a tine, delicate connective 
 tissue, whicli also lines the capsules. This will he recalled 
 to you when we take up the patliolo^ry of «;outy kidney. 
 
 The kidney is plentifully supplied with nerves from the 
 solar plexus, the semilunar ganglion, and the splanchnic 
 
 =!;viniSl:-J«,.sw.;y-= >»a»Wi.^y!«w»ili»*lM«»»«»v.f».i,aW«aWH54S«BC>^^ 
 
.i.v.ivou) .i.v/) i'insii)/,t,i,y. 
 
 16 
 
 lur |tl(i|inil' 
 
 U'A llctWt'Cll 
 
 •r»'iit vi'sst'U 
 kidiH'v jiiiii 
 
 • I'tlKll Vtill, 
 
 I cava, 
 »|»lctt'l,v Hiir- 
 
 iiiiiiil. as we 
 ci'a'Uiia llial 
 liicli passes 
 iiift liy tin- 
 , ami lifiK'f, 
 vvr t'roiii till' 
 n'd to those 
 the iTl'rati'st 
 'iili and the 
 on of urine 
 otliiT lianti, 
 
 KtUS ()l>stlMU'- 
 
 viins and 
 TOW ctK'rcnt 
 dcrstand the 
 
 f is not very 
 art.' not s\n'- 
 e to iniprosH 
 e conijiU'toly 
 •ai»illaries of 
 contu'i'tivc 
 
 II 1)0 recalled 
 ity kidney, 
 ■ves from the 
 e sphinchnic 
 
 nerves. Thest- coni|iletely siirronnd the tnladcs and 
 Mood-vessels, — a dis|io>ition '.vhich explains how it is that 
 sniull iid'arcfioiis or tri'i'vel may iri\c rise to the exi|iiisitt' 
 |iain which they occasion. They also coniniiirdcate with 
 the s|ierniatie plexns, whence the sympathy existin.}; Iie- 
 tween the kidneys and the testicles. 
 
 A \\i>rd aliont the nrine itself. We know that it is 
 made lip lari;ily of water holdinu' in snspension orifiinit! 
 and inoriranic salts, the most important ot' the toiiiu-r 
 heinu-two sidisfaiices rich in nitroijcn, — vi/,., una ami nric 
 mid. In other words, it holds in suspension the salts 
 which are the result of tissuc-nietaniorphosis. Tlie skin, 
 liver, and howels do their part in elimination, as must 
 also the kidney. The (piestion now is. What part of the 
 kidney secretes the nrine ? There is no lomjer any douht 
 hal the Malpii^hiaii tuft is the part where nn»st of the 
 watery portion of the urine is separated from the hlood ; 
 and it is prohahly almost a mere filtration. Lndwiii' and 
 others ti'll us that the uriiu' is entirely the result of fdtra- 
 tion, and hence is an excretion. This is an error: if the 
 tuft excretes the watery portion and the s.ilts also, for what 
 purpose were the intricate and delicate tuhules with their 
 ei)ithelial linini; a<lded ? The short straii^ht tuhes woidd 
 have heen sufHcient. 
 
 As it is, the watery portion must follow tlie course of 
 the tul)\des, hein^' retained in the constricted portions and 
 in close contact with tlu' epithelial linimrand its secretiiii; 
 cells. It is hero that most of the salts are received and 
 secreted hy the e]tithelium. The filtration is a purely 
 physical procoas, while the secretion of salts in the tubules 
 is a vital one. 
 
 .Some authors contend that even the watery portioji is 
 not a filtration, hecanse of the fact that the epithelium 
 lining the cuiisules is reHeeted on the tuft. It is a thin 
 
 ■I 
 
'^!i 
 
 ■') 
 
 i^n 
 
 1 
 
 U 
 
 nisH.tsHs t,r Tin: hii>.\h:ys. 
 
 ">"'••'"" '"^ ""■••"■ lfifs..rv.. , th.r |.,r,.u,., i, ,.„,. 
 
 Iiiip- iv^iilat... tl... liltiiiliuM. iiMTniHiiiir or IrsHrniiiL^ f|„. 
 
 <l"''"tltV. MS ,1... ,,,M.. ,„„v 1.... It hi.s >,.lM..tl.i„.,. fo ,|„ 
 
 Willi tlir liltriiiiun, mi.l luiiv li;.vr iini.l, i,. ,1., uid, (|„. 
 I'Xfrrcii.in ot'iilliiMiii'ii. 
 
 S-'in.. uril,,. s.lt. i;.iiii.l in tl.r iiii,,,. i,,v Iniiinl in .n.i.ll 
 
 ';''"l""""""' "'" ' • '»'tl,......„.vnMn.l,„i.. „..i,|a,v 
 
 '■"■ """"' ""l""-'">it. Ili,,|,„rir :,..i,| n.Ml .•.vntin .-uv n... 
 loiiriil Ml tlic Ii|(i,m|. 
 
 WlM.tl,..ri,||ll... lUTMrnul .iri.'M..i,lissin.|.lv.li,ni.,Mt..,| 
 '■'"" ""• '•' ' '"^ '^"'•t'- <••■ "li.lh.r |,Mrt ..f it is s,.,.n.j...| 
 
 I'.V til.' .IMflHlilMl. linin- tllC tlllMlIrS, is iu. llM.hTi.1,.,1 
 
 '|"''stM.n; l.iit 111.. |.i'..l.i,|,ilifi..sMr.. lliiif tlM-|„l.,.|..s |,|av 
 
 i;" Mi.|.Mrrnnt part in thrii- sc.ivti Immmiis.. nilnr salts 
 
 '""""•' '" ''"' "••'"'• '"••' i'«'t ImiiikI in ll... I.Iu.mI as sn.^li, 
 an. I i.iiist l.c Kcrivti-.l I'.vtli.. r|,itli..|iiMn ..r til., till. 111. s. 
 
 rilAI'TKl{ f r. 
 
 ANOMAMKS OI- I'.isiTDN, K..lt.\|, \m, :.. mhku. 
 
 TllK ki.IiH'Vs, liki" ..til..,- ..rirans. aiv si,l,j,.,.t f,, crrtinn 
 (Ic'viutinns Irotn tlfir natural |..,siti..n, f;,nn, an.l „„nil.,.r. 
 Most ot thcs.. ari' (•..n,ir..nital ; ..tju-rs an- M..,|iii|....| lati-r 
 I'l IK.-. tlm.u.iTl, a.vi.L.nt ..r .lis.-asc. S..in.. ..f (1,,.^ arc 
 ai.|.r,...ial.|,. .Inrinir lit'.', an.l may sinmlat.. \vi.K.|v (lifi;.r..nt 
 |.atlh.l..iri..al ...n.liti.Mis, .•l,all..n.ri„. tl... .an ri.l' atl..nti,.n 
 ot both |.l..vsi,.ian an.l siirirn.n, a corn'..! .liaimosis i„ tho 
 »nai..nty ..f instances Loin-r very dilH.ult an.l in s-nu- oihos 
 iiupossiM. , 
 
 Mon. froquontly, hcwevi-r, thcsf an..,nali..s ,,ro.ln,-o 
 littl.- .,r no inc.nvcnionw, the ronal nin.-ti..ns iKJn.r satin- 
 tuc'torily perlortiied. " 
 
 !! f 
 
 ■-*iiw < j ^ j i j-iiBji-^ jwyi M i v i R'Vtfi*. 
 
A.MtM.t/JKS ■>/• I'ltsirms. 
 
 17 
 
 |iMi|M.,,., it pcr- 
 ' li^-^tiiiriif till- 
 
 lM(t|ii|,._r (,, ,1,, 
 " 'In U itil llic 
 
 t'uiiiiil ill siiiiill 
 <l mil' ill-id life 
 I'l'i'iitiii iii'i' iiui 
 
 I'lv tliiniii:,t(.(| 
 I' it is s.rictcd 
 
 ill) lll|i|i'ri(|)'(| 
 
 «• fiiliiilcs play 
 
 l.-^f otlltT KilltS 
 
 •IoikI as Milch, 
 ln' IiiImiIcs. 
 
 'MIIKR, 
 
 'ct f(i certain 
 and miiiilicr. 
 <'||iiii'cd lafcr 
 of lliciii arc 
 • li'ly diifcrcnt 
 'I'ld attciitiiin 
 lirnosis ill tlic 
 in sdiiii' cases 
 
 lies ))r(KlMce 
 s bfiny i^atin- 
 
 A ' oiiiliiiiatioii III' several nl' tlieiii iii>v occasiniiallv lie 
 |ire,eiii ill flic same siiliject witliuiif ;ri\iiiir pi^,. f,, any 
 diHfiirlmucc whicli mii-lit ..ad I., tlcir detection diiriti'ir 
 
 liCc. 
 
 I ANOMAMKS OK IMSI'lloN 
 
 Mis|,la.'eiiiciits .»»■ flic kidney arc iisiially ilividcd into 
 llircc varieties, Hxed, inovaldc. and tloafin;;', acc(irdiii<r as 
 the iiiis|ilaced ofiraii reinaiiH perniaiiciit in its al>niiniial 
 I'n>iti.>n. moves in the refr(..|Mrituncal space with more or 
 li'ss rreedoiii, or lloats in the ahdoininal cavity. 
 
 Fixed niiil|iositioiis of the kidney are mostly coiiifcnital, 
 the ortrani^ also lieimr lre(|iieiitly aliiiornial in size and 
 Hliape, whih', as a rnle, they arc normal in stnictiire. 
 
 When ac(|iiircd, the imd|iositinn is often the result of 
 tumors flrair.u'ini; or |»iisliiiiir the kidney out of its normal 
 position, \vhcii it hccomcs lixcd hy iiiHammafory acii(.n. 
 
 Thu arranircmcnt of the renal vessels and ureters often 
 deviates more or less from the normal; and malposition 
 of some |>ortion of the lari;c intestim- and pcritoncMiii is 
 not an nmisnal complication. 
 
 The siipra-rciial capsiih- rarely acc(.mpanies the mis- 
 phiced kidney, hut occupies its usual position. Some 
 writi'is assirt that this is invariahly the case; hut in three 
 cases out of eiirht ol.served hy |)r. David Xewmaii the 
 lapsiilc was found misplaced with the kidney; and in up- 
 ward displacements it is found, accordinif t(» Cruvcilhier, 
 on the inner side of the kidney. 
 
 The ahnormal positions in which the kidney is liahlc to 
 !'<• tixed are numerous. It may he fixed in front of the 
 vtrteitrii', on the hrim of the pelvis, or within that cavity, 
 where it may he tcit either throuirh the ahdomimil wall 
 of throuirh the vagina and he mistaken for a tumor. 
 When so situated, it is liahle seriously to emharru.ss and 
 eomplieato iiarturition. 
 
 b 8* 
 
I« 
 
 ;»/.s7,M.v/;.s' "/• 77//; A7/» v/;j-.v. 
 
 Til" iiKi^f rr((|ii(rif itiiiir,.|iiiji| iiiiil|ii)>.iiiiiii is tliiit in 
 wliirli til.' kiiliicy Im t'oiiiiij Iviii;; nlili(|iii'lv on tlir fiiicni- 
 iliiic svii(lniiii|r(.«iM. It litis iiIsM licfii t'niiiiil >iliiiittt| In-. 
 hi<l'' fill' iifcni-*, Iviii.if tiitiis\risflv iMiwtcii tlu' n'ctiiin uinl 
 tli( lil;ii|ilir. or inrosH tin' |iri>iiiimiii'<' nf tlif Hiicrtiin, 
 
 'I'lic ii'ii.il iiiiiiv ill tlifsc casi's iiMiially arisrs fium uiif 
 of tlu' ilims, iir I'ikm llic ufiita iniiicdiatrlv iiliuvf jtH 
 liiriiriiitinii. Ill a rase ri|i'iit( (I Itv Mr. hiirliani.' in 
 vvliidi tlic left Ixiiliicy was ruiiiKJ over flic sai in-iliac svii- 
 (•liiiiidrnHiH, tlitrc were llircf arfcrifs, tlic princiiial one 
 lifini; a liramli of the aorta arisinir Just above itH liili.rra- 
 tion, aiiotlicr arisiii</ t'loiii tin- riiiiiiiion iliac n{' tlic o|i|'0- 
 nilc ^i(lc, and a I'.ird Iroiii the inter. lal iliac ..1' tlic miiiii' 
 Hide, eacli wii|i|i|yinir diHerent parts of the origan. 
 
 Occasionally the lolmlatcd a|i|icaraiice of the f.ctal kid- 
 ney is preserved, sii<f<;estinc; an arrcs^ of development in 
 ••ally fdtal lite. In a case recorded l»y Mr. Canton, Mlie 
 left kiiliu'y, loliiilatcd an<l of a rudely o\al shape, was 
 situated helow the liifiiication of the aorta and hctween 
 the eoiiiiiioii iliac arteries. Its pelvis was directed foi \var<l 
 and dilated, owiii'.r to the iinpactioii in the upper pari of 
 the ureter of an oxalate of lini*' calcnliis wciifhiii!; two and 
 a half draehins. The patient died of hroiichitis at the n<r*> 
 of twciity-seveii. There had hccii no renal syniptonm 
 diirini; life. 
 
 <'oiic'cnital lixeij misplaceiiients affect hy prcfert'iicc the 
 left kiiliiey. In twenty-one eases eolli-etcd hy Uoherts, 
 tifteeii occurred in the left kidney and six i- tlicrii^ht; 
 in every instance the ahimrrnality was connned to one 
 kidney. Of forty-four cases co!lccte<l hy Weishach, thirtv- 
 five occiine<l in the left, ei;,dit in the ri;;^lit, and one iti 
 
 » Ouy'g H.)sp. Rep., IWiO. 
 
 • Putholojrifal TningiictionH, vol. xiii. 
 
A.\OM.tt,IHS OF I'usirin.W 
 
 i:i 
 
 Mil ]■* lliat ill 
 
 nil llir HlltTU- 
 I Hillliltill lie- 
 
 li«' rt'cliiiii mill 
 
 ;' HIHTlllll. 
 r'lHfS I'iflMl ulU' 
 
 fly iilmvc itH 
 hiirliiiiii.' ill 
 n tn-ilinc syii- 
 |iriiici|)al one- 
 vo itH bill rcii- 
 ■ (tf till- ()|i|(i. 
 
 • (if till' Mlllll' 
 
 •^niii. 
 
 till- t'uiiil l<;.|- 
 ■vt'lu|iiii('iit ill 
 . {'iiiitdii/ till' 
 il sliiijic, was 
 ami iutuitii 
 (•(•ted forward 
 ii|i|Mr part of 
 fliiii:; two and 
 ilis at till' aiyo 
 lal s_viii|itoinrt 
 
 ifiH rt-iicc tin? 
 I liv liolfcrts, 
 i- the rii^'lit ; 
 
 II. lied to oiiu 
 
 isiiacli. tliirty- 
 , and ono ia 
 
 Im.iIi kidncvi*. Ah niranlH hcx, nii'ii ncfiii niorc prrdi*. 
 |>H»rd tliaii woin.ii : of I wrnty-niiit' caHcs, twenty wtif in 
 linn and nine in wonnn.' 
 
 .\<i|iiiird tixi'd nial|io.«ition of tli.' kitlin'v ociimm ih ilif 
 n-iilt of roiitinin-d |irt'sr*iirc iijion the otiran citlicr l»y a 
 fiiinor t'rowini; in the vicinity or liy an inlaiircd liver, 
 'lilttii. itancrcus. or sii|ira-rinal liody. jr \i\i< .■ aUo lii> the 
 roiilt of liirlit laciiiir; or the kidiny may lie <ii lo.add l»v 
 a siidtlrii jar or lilow . and iM.nnd down in it- m\v situation 
 liy snlH(i|ii(iit adli('>ioii>. 
 
 'I'lic niovaltif kidney is usually an aeijinied atfeetioii. 
 Tile relation of the ori;an to siirroiimliiiLr parts is perffttlv 
 normal, I'Xeept for the increased laxity (d" its attacliiin-iits, 
 w liirli is due to a diininiilioii in the ainoiint of 'at snr- 
 roiiniliiit,' it or to defaelinient of the |icritoiie.iiiii ti,,iii tht> 
 nnisele, 
 
 SoiMftiin»'»« the adipose eapsnie is larire and loo>e. and 
 ]»rmits of the inov« nieiit of the kidney within il ; in other 
 instances it closely surrounds the kidney and moves with 
 it : whilst in still .itlnrs the kidney moves within its adiposi- 
 ciipsnl.', and the capsule also movi-s about with the kidney 
 behind the peritcnieiini. 
 
 The movable ki<Incy is .dten healthy, and when found 
 disi'ascd there is no positive evidem-e that its moliijitv is 
 responsibli' for its patholoirical condition. The disease 
 may have preceded and caused itn nnddlitv. 
 
 'I'his condition is almost never accpiireil dnriiiir child- 
 hood or after the tiftieth year. Ft occurs in w(.iinn at 
 least five times as often as in men, and three or four limes 
 more Ireipu'iitly on the riirhf side than on the Idi. The 
 <lci;ree of iindiility varies considerably, thoiiirh. of course, 
 it is always limited i)y the It'iiifth of the renal vissels. 
 
 / 
 
 * Zieipsseu's Cycloprodia. 
 
 -'*fr^Wi* ^-"v: r' . ■*-> -• 
 
20 
 
 i>isi:asi:s or riii: A7/>.v/;r.v. 
 
 Tlic iiiTitoiifUiii may lie siillicii'Uflv loosi' to nllow tlu' 
 kiiliit y Mioviiit; Mi'hiiKl it to loavi- its iiatiirul position and 
 I'iiU l..l<»\v till- lirini of the pelvis, or us tar forwan! as tin- 
 anttiior alxloniinal parictes, or across to tlu' ojipositr si<k' 
 of tlic spinal colunni. 
 
 In tin- nport of tin- <'oiniuitti'o of (Ik- l'atlu)l(»,iri('al 
 Sociciv of liomloii,' nuT.tion is inadr of a case in whii'li 
 tin- kidni'V niovi'fl nndcr tlu- pcntonciini tlirou-rli a space 
 di'scrilu'd as a circle witii a diameter of eigiit or nii'.e 
 
 inclie 
 
 1 Anionu,- the causes for movalile kidney rapid cliild-liear- 
 inir comes lirst, it is not dilUcult to perceive lio\'. in the 
 foiviiilc contraction of the diaphn; ;in durinj; vomitin,!; 
 and parturition, and the c<»nse(iuent downward prt'ssure 
 more especially exercised on tlie liver and riyht kidney, we 
 have a comltination of conditions fav(»ral»le to the di'velo]*- 
 nient of movalile ki<lney: espt'cially if the woman too 
 early resumes the erect jiosture, thus y^'w'xui^ the displaced 
 orsiau no time to hecome tixe(i. 
 
 \\m will find in all your hooks on this suhjoct that the 
 sudden l»»srt of intra-alxlominal pressuri' after delivi-ry is 
 looked up(Ui as a powerful etiolou:ical factor in displace- 
 ments of the kidney, and to this loss of pressure is lariTely 
 attrihuted the frequency of that condition in child-heariui; 
 wonuii. This is, however, a fallacy. If the kidney has 
 not Iteeii disjilaeed hy the voniitintr of ]>re,!rnancy and the 
 forcihle ('(Uitraction of the diajihrairm upoi\ the livi-r and 
 kidney iluriu>r the lahor, you n'l.y rest assured that the 
 relaxed ahdominal wall after delivery will not drau: the 
 oriran out of its place. The notion that the kidney can 
 be thus displaced is as ahsurd as the one you will lind 
 repeated in so many of your books on the treatment of 
 
 ' Piitli. Soi\ Trans., vol. xxvii. 
 
A.\tiM.U.li:\ (}]■• I'OSITKkX. 
 
 21 
 
 lll(t\V tllC 
 
 ition and 
 n! as tin- 
 Ksiti' si<k' 
 
 lu)lc»ii:it'al 
 in wliiili 
 li a s|iate 
 : or iiiro 
 
 liil(l-1»car- 
 »\', ill tlif 
 vo'nitiiijj; 
 lircssurt- 
 idiK'V, wi- 
 
 '. (U'Vt'll*]!- 
 
 )iiiaii too 
 (lisplac'ftl 
 
 t fliat tlif 
 iflivi'rv is 
 1 (lisiilac'c- 
 
 is larirt'ly 
 l»l-l)*'ariii<; 
 idiicy has 
 y anil tlu' 
 
 liviT and 
 1 that till" 
 , dra^ thr 
 cidiU'V can 
 I will lind 
 atincnt of 
 
 ronal colif, — viz., '• ( Jivi' hot hatlis nnd opiatr. to n-Iax 
 till' uri'tiT, ill order to lit tlu' stoiir jiass tlifouurli." Tin* 
 stono is Coi-cfd tliroiiifli tlu- iiri'tiT Ity tlu' aiTUiiiiilatioii ot' 
 iiriiiu hi-hind it. 
 
 Till' iiitliiriiir ot" voinitiiii; and rcti'hini; in dis|ilariiii; 
 till' kidiit'y is iiiiiiii'diati'ly a|ipariiit. \ t'vw days -inco I 
 i'xaniiiud a man (a |tliysiiiaii) wliosi' r'li: kidiify is vcrv 
 inovaltli'. ill' disroviTe'd its nioiiility at tin- tiTinination 
 ot' a loiiij si'a-voyai^e which had involved ciifhtccii days o'" 
 Hca-sickiU'ss, with constant voinitinij: and rctcjiiim-, and the 
 cinariatioii was considcralilc. 'i'lic cinariation no doiiiit 
 assisted the voinitiiiu; and retchiiiLC in dis|)!aein_Lf tin- 
 kiiliu'v. 
 
 It is stated that niovahle kidney is very coimnon aniont; 
 cliild-heaiiiiLr Women of the poorer classi's in Austria, 
 l'oland,and llolstein. liapid «;<'Mi'ral emaciation and al>- 
 sorption of tiu' pt-ri-nephritic tiit naturally favor iiioliility 
 of the kidney. Increased weit^ht, either from a tumor 
 developed in the kidney or from ntones impacted in its 
 litivis or ureter, may tend to loosen and drair it down. 
 The congestion of the kidney which, accordint,' to necipiet,' 
 takes place at every menstrual period, n»ay also he an 
 I'tioloi^ical factor. This opinion is shared hy Koherts, who 
 states that in a case under his ohservation a disphu'ed and 
 movai>le kidney set'ined to hecome lariji-r and more seiisi- 
 tivi" to the touch two days hefore the catameiiia appeared. 
 It may havt' heen the woman and not the kidney that 
 liecame more sensitivi-. In a ease ohserved l»y Dr. 
 Ritchie and cited hy Roberts, who was afforded an op- 
 portunity of watchiiii; the condition of the kidney duriiii; 
 two menstrual i>eriods, its size wu.s seen to he increased 
 hy ipiite one-half, and it was much more sensitive to the 
 
 ' Modical Tillies iind Gazette, 1C87. 
 
 ■'i 
 
insi:.\si:s iiF Tin: Kinsiivs 
 
 tj'l /*/>/■, .1. >/•..> "I' I III. HII'.W.I- 
 
 mm 
 
 ti.ii.'li. Kiilarirfiiicnts of tli.' liv.T force t'l.- ri.ii-lit kidm-y 
 • lowii.tliiis .li>srctiii,<r il]. till' iiiTolar tissue whi.li fasteiuMl 
 tlic |.eril()iicuia to tlii' ImiilKir iiiusdis. lli-avy liflin.sr, 
 ,.s|.c.'i:illy ill |KT>oiis With loose alMloihinal walls, is lial>lc 
 to start llir kiiiiKV iVoiii its Ihm! : fails aiv ol'tcii tin- ratisv, 
 and iMThai-s in soiiu- .-asrs a iHTiiicpliritis. In oih- rase 
 which caiiK' under my care I thouniit it jiossihle that th»^ 
 eoiistant u>e of a s.'\viim--n.acliine had caused the trouhie, 
 llu- nioiiou of the muscles si'i.aratin.ir the kidney from tlie 
 luTitoneiim and allowin.ir it to move in the retro-iieritoneal 
 
 ried. She had never worke.l on the se\vin,u:-»iiii«'miie, aim 
 was at present doin.L!,- very li,i-ht work, which, however, ne- 
 cessitated her heinjiou her feet iiH.st (.f theday. Uoth ki.l- 
 neys were movahle,— the ri.u'ht very much more so than the 
 Irt't. The al.dominal walls wer*' very thin and rela.-. d, lH)th 
 kidnevs heini:- readilv felt. Tlie ri-ht ki.lney would move 
 down" t.. the iliac fossa and wIumi pn'ssed upon w..ul.l 
 uuicklv rituru t.. its normal position. Its lateral Juotion 
 was also considerahle. While the left kidney was quite 
 
,).\o.V.IA//> "/•• I'OSirioS. 
 
 •1^ 
 
 t ki<lm y 
 
 tiisti'iu'tl 
 
 y lifliii.ir, 
 
 , is liiiMc 
 
 111.' I'lUlSl', 
 (iMC fUSl' 
 
 ■ thiit tin- 
 
 ■ troultlc, 
 tVuiii lln' 
 
 nTltdlU'lll 
 
 Id coTisnlt 
 IS sli^litly 
 n'l'ii mar- 
 •liinc, iiiid 
 kvrvv r, iH'- 
 r.otli ki<l- 
 (> tliaii tlu' 
 ii;-, (1, Itoth 
 mild HiDVi". 
 
 lOll WdUlll 
 
 rill )m)tii)i» 
 was i[inti! 
 Mu" jiatu-nt 
 *• \v('iii"lu'(l 
 wi'iirht is 
 an attack 
 •\}vv voiiiit- 
 iuii, with a 
 H' mobility 
 1 told this 
 and a IV \v 
 
 ■ of the k't't 
 
 Vloatinir kiilnt'y, tho thinl variety, di']ifndrt on a con- 
 <j:fnital ii'nuiilarity ol'tlic disposition oftht; |ifritoiu'iiiii, a 
 t'l.ld ol' tlii:' Mii'iiiliraiu' roiniiictt'ly fnvtlo|iinir the kidni'y 
 so as to tiirni a iiicsonc|>iiron, thns allowini; the oriran to 
 float ahont in tlu- ahdoniinal cavity in auy direction. 
 
 This anomaly, to wliicli tlu- distinctive term " II oat in l!,-" 
 kidney has lu-i'ii apiiPu'd, is necessarily associated witli an 
 elolllfation of till' renal vessels. .\li intelliiediate t'ollii, 
 also coiiiTcnital, has Iteeii found, in which there is no nieso- 
 ne|)liron, nor is evi'ii the anterior surface of the kidney 
 covt'red hy |»eritoiieiun, hut, owint; to some ahnormal ar- 
 raiiircinent associated with maliiositioii of the colon, the 
 kidiu'v is left misiiii|>orted and tree to move hetueeii di- 
 veririiii; processes of the pei'ifoiieiim. The report of a ca.se 
 of this kind, hy Mr. Durham, will he found in (Jny's 
 llo-jntal Kejiorts of iSiJO. These varieties are of rare 
 
 OCClU'l'llCl'. 
 
 l)i'n/iii)sis. — Any movahle tumor ahont the size and 
 shape of a kidney may he mistaken for a tloatinjf or 
 movahle kidney. It is necessary to hi-ar in mind that 
 a movaitle kidney may l>e misshapen, and larjrer or 
 siiialliT than normal. A kidney, however, that weiiths 
 over I'iii'ht or ten oiinees is not likely to he very movahle. 
 
 Omental or mesenteric tumors may simulate movahle 
 kidnev, while small ovarian tumors are less likely to 
 
 no so. 
 
 Upon physical examination oiu' miirht mistake scirrhus 
 of the pylorus for movalile kidney. The history of the 
 ease, however, ouirht to _i;uide to a correct diairnosis. 
 
 r onet' found a uterine fihroid with a huitr jii'iliele that 
 Oil first examination I took for a Hoatiiii; kitlney. On 
 another occasion \ had a patient with a very movahle 
 tumor about tlu' size and shape of the kidney. It was 
 imiiossible to nuike a positive diagnosis, but iho tumor 
 
•24 
 
 /)/.v/;.i.v/;.v o/- THE iiii>si:ys. 
 
 was tlioiitrlit to lie a iloatiiiij: kiiliu v Imtli l»_v luysolt' and 
 liy ullici's who cxainiin'il it. Tlir woman liati honic cliil- 
 (liTii. Slir liail tliiii, lax aliiloiniiial walls, and \\\v tumor 
 conld lu' |.lainl_v tilt. She finally ditd of Mriirlit's disease 
 and ilironic diai'rlm'a. .\t tlu' autojisy the tumor was 
 found tt» lie composi'd of normal lu'iiatic tissue susprndcd 
 from the livir \*\ a lu'dirlc. It liud never i^iven the 
 patient niueh pain, exeept oceasionully from the pressure 
 of her tiarmeiits, 1 hav<' never seen nor heard of any other 
 ease of this kind. 
 
 l>isteuded trall-liladder nniy he mistaken for inovaMe 
 kidni'y, as also may a tumor of the panrreas. 
 
 Afti'r all, when we find a niovahle tumor in the upper 
 part of the aliilonieii, ahout the size and shape of a kidney, 
 wi- must rely lai'srely for a diairnosis upon the extent of 
 its mohility. and upon our ahiliiy to pres> it haek into 
 the normal position of the kidney, where it is likely to 
 remain so lonir as the patient eontinnes ])erfeetly (juii't. 
 'I'his eatniot hi' done with a lloatiiiiT kidm^y, or with an 
 onu'ntal, niv-senti'rie. uterine, or i»varian tumor. A ilis- 
 tended ir.iH.l, ladder is not very inovahle downward, atid, 
 hesidi's. us\ndlv tjives one the feelinir of a evst, whieh 
 ouiriit always to he aspirated with a tine needle. 
 
 Trt'iidiKnt, — In the majority of eases of movalde kidney 
 no treatnu-nt is called for. If physical exercise jiroiluces 
 unpleasant symptoms, perfect (|uietmlo must be enforced. 
 Functional disorders of the bowels slionld be corrected, 
 and unu-mia or loss of muscular tone sliould be dealt with 
 bv appropriate renie(lies. A fat-niakinu' diet should lie 
 pri'scrihe<l, with the vii-w of increasinir the natural packinj; 
 oltlie kidney. Some sort of truss-like support, sui-h as an 
 accurately-tittint; bilt or a pad, espei'ially one of inflated 
 rubber, nniy bo worn with benetit. The temjiorary 
 BUpiiort given by si gravid uterud has been known to 
 
AMOMALIKS OF /'O/^.U. 
 
 26 
 
 diininisli tlio riioltility oftlu' kidiu v. In a sniiill pruportion 
 of cnscs tlic siitli'riii«;; is so t;n'iit, liowt'Vcp, fluit soiiic iiiort- 
 railical luraiis lliaii tlir use ol'a licit or pad is callid lor. ( )t' 
 tlif two opi'i'atioiis wliicli Iiavi' Iu-cm I'liiploycd in such 
 cast's, — viz.. ncpliroi'i'liapliv, or fixation ot' the kidiicv liv 
 sntnrcs, and nephrectomy, or removal ot' the kidney, — the 
 t'ornier shouhl he ehosrii when praeticahle. (See chapter 
 un SuriCery ot'tlie Kidni'V.) 
 
 sr.MMAItY OF ANttMALlKS OF POSITION. 
 
 ri.\i;i». 
 
 Cuii'ifiiifiiJ. — .M(iri' fnM|iii'iit in nun tlitm in wmncn; atl'oct-i liy jti'diTcnco 
 the lilt kidiury; a-isucliitCMl with ulinnrniiil iiiTiiniri^nicnt > if renal vc^si'Im, 
 unlcT, mill liiri^i' int<'<tini'; kidiwy I'ri'qui'ntly niis-lmiM'n, as well hh urn- 
 j)liu'c(l ; .«u|irii-rrnal cMpulc usinilly in it> natural pu-itinn, tlnaiiiii ncoasion- 
 ally airiiinpanyiiiic lln' kidney. 
 
 Ar</iiiriil. — Itcsults t'mni pnv-isnrc by atiininr nr an cnlartjcd iu'ii,'liliiirint; 
 orc»n ; I'nini tiirht lai'lnj;; fnmi a sinldeii blnw or jar, with .suhscijuuiit 
 iiillaniniatory adhesions. 
 
 MOVAlMd-:. 
 
 Arijiiiird. — More Cn'mient in women than in ini'n ; aflects l>y preference tho 
 rii:ht kidney; results from emaeiation, rapid cliild-benriiig and too early 
 ri-uniption (d' ordinary duti<'s, tiijht laeintc, vomiting, etc. 
 
 FLOATINO. 
 
 CiingcnUdl. — Hare. 
 
 II.— A.NOMALIES OP FORM. 
 
 ^fal formations of tlie kidni'y are mostly oon<;enital. 
 Occasionally, however, we meet with aeipiired eases, the 
 kidney haviiii; heeome chanired in ontline and dimension.s 
 in conse(|nenee of disetisi' of the ort^an itself, as hvdro- 
 nephrosis, jiyo-nephrosis, (•y^itic enlari^einents, cirrhosis, 
 and morhid irrowths, or as a residt of pressure of tumors or 
 inorliid I'lilarsrements of neiirhhorini; viscera. Mi.sshapen 
 kidneys are irenerally also misplaced. The more or lesti 
 lohidated kidney, already mentioned (pao-e 18), is not uii- 
 
 B 3 
 
 i 
 
 m 
 ■•??- 
 
 
2(\ 
 
 j>isj:.\si:s nr riii: uii>\i:)s. 
 
 rniiiiiioii, or tln' (ii'iraii (li\i(lc(l iiilo two or tlirt'c 
 
 imlistiiicl ii'i'i'u:iiliir |»orii i_v sluillow (l('|ti'i'ssioiis on its 
 
 SlirtilfC. Solllctillics ollr kidlliV is t'oiiinl to \n- two nr 
 
 tlircc times liiru.-t'r tliaii its iMlow, liotii liciiiLT otlirrwisf |>i'r- 
 f'l'ctlv litjiltliv ; tliiscoiitlirioii ih'oIimIiIv iiriscs tVom dclicii'iit 
 (K'\ I'loiniii'iit ot'oiif ot'tlif fi'iiiil iiftci'it's. 
 
 Till' viii'icty of inalt'oriiiiitioii most l'rc(|iH'iit|y met witii 
 is till' so-calli'<l lii)r»osh(H' kidiu-y {Vvj;. -h, tin- two oruans 
 
 Kill. .'!. 
 
 )}■ 
 
 Mi 
 
 Ilursfshuc kidmy, frmn iiiitl i)r's I'dllictioii in rnivor>itj- Miisoum (niiturftl size). 
 
 l)i'inir t'usi'd into otu' liv nirans oj' an intcrmi'diatc tfaiis- 
 vi'i'si' ])ortioii, usually consistiiiir of triK' ri'iial srcri'tini; 
 strui'tiuv, tliouii'li somi'tinu's nu'ri'ly of oondi'iisi'*! filn-oiis 
 tissue, wliii-h I'oinu'i'ts tlii'ir lower ends across the front 
 of the vertebral eolumn so as to form a eresceiit or horse- 
 slioe-shap'jd body, with the coiioavity dirootod upward. 
 
 'IL 
 
.1 vou.i/,//;.s or SI Miii:ii. 
 
 27 
 
 rw ISC |K r- 
 1 (l»'li<'iciit 
 
 met witli 
 ,() (>ru:!iiis 
 
 III r:iii' iiistiiiiifs till- tniicavitv is dinifcil duwiiwiinl, tlic 
 ii|i|M r cutis iM'iiiir miifcil, or the (•(UiinTtiiiL;' l«ii(li;r inav 
 I'Xti'iid rrtiiii tin- liiliiiii nfuiu' kiiliifv lu that ot' tlic oiIht. 
 Tlif two lialvi's (il'ji horsc'slidc kidiitv arc iisiiallv coniiilcfc 
 ill tliiiiisflvcs, liaviii"; cacli a distinct pelvis and ureter. 
 Mi-st l'rci|iiciitly the ureters descend in iVniit ot' the Iraiis- 
 \cisc |M.rtion. when lliis unites the lower ends of'the kid- 
 iievs; more raielv tliev |iass hehind it. In a few exeeed- 
 iimlv rare eases the sii|>eriiiinierarv renal |tareneh\nia is 
 not united to the tw(» kidiievs, so that the middle |.ie,'e 
 constitutes an inde|ien(lcnf kidney, ri'ceivint; Itjood iVom 
 liolh the lateral parts, hut posscssiiii; also imh-pciidciit 
 vessels. 
 
 There arc a few cases on record wlicrt' one or hoth 
 kidneys have hail two distinct pelves, jn must instances 
 tliesi' have lie*"ii louml to unite so as to t'orni one sini{h' 
 ureter. Ill a case reported hy |)r. Kvarts, however, hoth 
 kidiuys were furnished with two distinct pelves and 
 ureters which ended separately in the hladder, all four 
 ureters heiiii; pervious. 
 
 52^^^ 
 
 atiiral size). 
 
 late trans- 
 secri'tini; 
 
 I'd tihroiis 
 the front 
 or horse- 
 
 I u[)Wiird. 
 
 Ill — ANoMALFKS OF M'.MBKR. 
 
 Siipernumerury kidneys with separate hlood-vessels and 
 oxcrt'tory ducts are occasionally met wi.h, while in a niiiii- 
 liir of instances only a siuirle kidney has heeii found. As 
 loiiir :is this remains healthy there is no derangement 
 of the urinary function; hut should it hecome diseased or 
 itri excretory (hict ohstructed, tiital iiruMuia will rapidly 
 su].ervene. The term "solitary kidney" is sometimes 
 iipplied to all eases in which there is only one renal oriran. 
 Ordinarily, however, it is limited to fusion of the two 
 kidneys into one mass, entire ahseiue of one kidney heint; 
 desiirnated as " iinsymnietrical kidney." The f(U-mer is 
 always eon_.,^'nital, the latter usually so, except where one 
 
 
28 
 
 JHsHAs/-:s or Tin: kihskys. 
 
 ! ill 
 
 kiiliifv liiif* lu'cii rciiiovid l>v in|(lir('<'tuniy or (U-Htrowd 
 liy disciist'. ('(iiiiiciiitMl iiti'o|iliy or rmliiiU'iitaiT kidin-y 
 iM'loiiLrs |inicticiillv to the saim- class. 
 
 Ainoiiir tlif I'ccoriird casts of solitary kidney \vc find 
 every coiiccivalilc variety of form and dcirri'c of fusion, 
 from tlic ordinary liorsi'shot' kidney (/•(// //////"//Vo/z/f/.v), 
 whicll represents the lowest irrade of fusion, to tlie coin- 
 jih'tely uiiiti'd variety, in whieli the two (nuans form a 
 siiiijle disk-like mass provideil with a donlile or single 
 |ielvis. hr. I>roe>ike, of Merlin, riports' a case of 
 S-sha|ied fusion of both kidiu-ys [nn sii/mniili itiii),r()un\>^t'\i\if 
 in union l»y wunl tissue Itetweeii the lower end of the left 
 kidney, which occu|>ie<l its nornnd position, and the upper 
 end of the riirht. which lay wholly to the left of the ver- 
 tehral column, with its hilum dii'ected to the left and its 
 convex liordir to the riirht. On the anteri(tr surlace of 
 this douhle kidney, which i-Ntcuded from lietwcen the 
 eleventh and twelfth dorsal vertehne t(» the middle df tin- 
 last lumhar, tlu' line of uidon luMwcen the two organs was 
 indicated hy an ohlitpie furrow runninir downward ami 
 outward (to the left), ami lodiriii.tr in the left iireti'r. the 
 posterior surface heini; perfectly smooth throui^liout. A 
 much-divided renal artery, eiiterimr at tlu' hilum, supipTu'd 
 the ni>per, or left, kidni'y, while the lower, or riuiit, re- 
 ceived two distinct arterial trunks, one arisinir from the 
 norta just above its Itit'urcation and eiiterimr the convex 
 hordi-r of the kidney; the other, a branch of the hit com- 
 mon iliac, ti-rminatim; near the lower hortler of the hilum. 
 
 in iinsyminetrical kidney, or comrenital alist'nce of one 
 orsjfan, the renal vessels as wi-ll as the nn-ter are likewise 
 wantiniT. Where these exist, the case may lie jiresnmed 
 to be one of atrophy, coiiifenital or acquired. When the 
 
 ' Viirhow's Arfhiv, Nov. 1884. 
 
 i*t^«aM«»M 
 
- 1. vow. I A //.'s o/' M MltHh: 
 
 •Jll 
 
 ttiily ('\i.-tiiiir kidiii'V lias tWd urctfi's iiinl a doiililc sit <•!' 
 
 Ill l-vosfls, it iiiiiv lu- Pi'irardtd as solilarv. 
 
 A siiiirlc kidney, of w liiclicvcr variety, is in liic majurify 
 dl" iiistaiii'cs, liiit nut always. liy|K'rtr(»|thiiM|, and may 
 attain an enonnoiis si/.i', weiirliinu; sivcial pounds. It is 
 iVi'ipifntly inisplaied and more of less almorinal in form. 
 It slioidd lif renivmln'ivd tiiat anomalii's of the kidney afe 
 often asso(iat».'d with sutu*' def»'et of the irenerafive ori^'ans, 
 ami. uliere tlie latter exists, tlie Utmost caution slmuld 
 lie eXereised wlier*' nt'plireetomy is eonteni|ilate(l. lest an 
 
 oidy kithu'y lie removed and the patient he left without 
 any renal or<ran. 
 
 Alisenee ot' lioth kidiu'ys, as well as of the iii'eters and 
 liladder. has oth'U heeii found in still-horn ehildreii. espi'- 
 eially in acephalous iiuuisters. M. Moulon, of Trieste," has 
 
 I't riled the easeot'a irirl who dieil at the at,^• of fourteen 
 
 of ehionie pistro-enteritis, in whom neither kidiu'ys iior 
 ureters were found. The hhnhhr was also wantinsj:; anti 
 the undiilicus, from which there had, since hirth, heen ii 
 continual discharir*' <»f u uriiu'-Iike liquid, was situated 
 wlu're the luons \'eneris usually is, the sym|ihysis puliis 
 heinir replai-e(l hy a wide irup covered only hy the skin. 
 The extenud ire itals were very defective, and the anus, 
 which was itiordinately lurire, opened where the vai^inal 
 oiitice shouhl have heen; hut the uterus, ovaries, and 
 Fallopian tuhcs were perfect. M. Moulon concluded that 
 the hlood in this casi' pive uji to the liver those constitu- 
 ents whi<'h Lfo to form the urine, and that they were con- 
 veyed hy the umhili<"il vein to the undiilicus, and there 
 excreted. The liver was <fanirri'nous, as were alstt the 
 intestines in spots throuirhout their extent. The pancreas 
 was converted into a sac of pus, and the ^roat omentum 
 was in part destroyed. 
 
 ' Ari'hivrs GeinJralcs do Mnducinc, t'>me xvii. p. 424. 
 3» 
 
f 
 
 SKCTION II. 
 
 DISEASES OP THE KIDNEYS. 
 
 I 
 
 1! 
 
 "^ 
 
 ( II A I'TK li I. 
 
 m:i'|||i \i,<;ia. 
 
 N'KI>lllt.\l..;|A. nr ll.iin.l^rii, ,,|' ,i„. |.i,|,„.v i, ., „.,„,,. 
 i'l'l''"'! ill it jrciici-iil wnv f,, ,,j,ii, in t|„. kidm-v. 
 
 lvnnl.,MiV.— |5y (•;„• ll,.' IM..st f.v.|ll..l,| ciMlMS uf Ii..|,l,ri.l- 
 
 ,iria i.ivivni.l .i.I.uli.^.iilu.r lar-c ,:,I,Mili in tli.. jM-lvis or 
 t^iiialKr oiHs ill 111,, iiiiiiifl. rolls tnlmlcs. 
 
 _ Til,. ll,.x( ninsl lV..|MrIlt .illlX'S ofpiiin aiV 11, .u Ulowllis 
 
 111 III,. ki.liii..\ .— .aiir.r, ,.ysti.. .Iis,.asi.s, ,.(<■. W,. lii„| il,.,t 
 .iroiity ki.liH._v is sul.j.vl lo riv.|iu.iil iH.|,l,raI-i;,s, „s ar also 
 tlir ki.lii,._vs oC tlios.. a(l(li..(,..| to al.o|„,lisi,i: i|,:,f of ili,. 
 «'..niur may 1... <|,i.. lo tl„. .•..ntra.t,..! .•oii.lition of ih,. 
 ki<liitv ..r to iriitatioi, ,aiis,.(l l.y .Icposits ,.f .rvstais of 
 mat,' ofs.Mlimii, wjii,.), ii,,. t;„i,„l in „.,.,,.,! „„.m1.,"is in fl.c 
 intcrtulmlar spa.Ts. I,, tli.. latter .asc ll„. ;, in niav W' 
 •I'lf lithrr to III,, irritatintr <|"itlity of tin. uriiic or t(." tli,. 
 liyi.iia'i.ii.. roii.litioM of th,. ki(lii,.y. \\\. l,;,v,. aliva.lv 
 <»l'su-v,..l, ill st.i.lyiMir ,l„, iiiiatoiiiyof tlu' ki.liu'V. that, 
 fn.iii flio nrraiiir.iiu.Mt of its iu.rvr-sii|,|,lv, a (lisf,.|„I,.,i 
 n.ii.lition of tlu- lilood-vi.ssi.ls, fithcr active- .".r iKissivi-, miist 
 iit'ctssarily iiroduc,. pain. 
 
 A inoval.l,. or floatii.^ ki.liu'y often ijivcs r's,. to pain. 
 
 Sv.Mi'TnMs.— Pain is th." pathoiriionioiiic symptoni of 
 nq.hral.iria ; that is, pain of a sharp, soVfrc,'lan.iiiatii 
 
 80 
 
 'fe' 
 
SF.rilKM.UlA. 
 
 SI 
 
 luitiiri'. I'liiii (if II (lull, li.iivy. iicliini,' ( liunicttT i- not 
 culled iicii|iriili;iii. 'I'll.' |>iiiM (illcii I'dlhiws llic line df tin- 
 iiitU'r to llic iri'diii. ill times iinxliieiuir |,i,;ii 'm (|,,. testicle 
 or ill ilie liciid of tlie Ileitis, or exteiMliiii; |iiirtiull_v iiroiiiid 
 llic lioily. 'I'liis is pjiiticiiliiilv the c:ise with tlie inteiii- 
 |>crati', who, diiiiiii,' or lollowini; the attiick, ( .\|ici'ieiice 
 fVei|ii(.|it iind |iiiiiil'iil iiiirtiii'itioii, the urine lieinir hiwh- 
 colored iiiid fiirliid. In the iiit.iii|ieriite the ne|i|ii-idu'iii is 
 occasionally acconi|ianie(| l.y heinorrhasri'. c\en u hcic 
 there is neither stone, iroiil, cancer, ikm* tiilierciilo.-is. In 
 this class of cases, however. We arc apt to tiiid alhiinicn. 
 I may add that ih phial^'ia is often acco!n|ianied hy Hovoro 
 voiiiitini;' or rt'tcliini;. 
 
 IM VdNiisis. — In niakinir a diaLfnosis it is necessary to 
 rciiieiniicr that pain in the riirht kidney miirlif be iniM- 
 taken for heptaliria, or passai^i' of irall-stoiic, for the severe 
 pain of olistfiiction of the ascendinir colon, or even for 
 jiaiii in the appendix. Xephraliria on the left side is not 
 HO a|it to he mistaken. 
 
 For the diairiK'sis of the ditfcrent conditions tliaf irive 
 rise to iiepliral-fia, we shall find a detailed account of tlu' 
 fyinptoin.s under their icspcctive luadini^s. ns stone, 
 tuherculosis, etc. 
 
 Titi:\r.\ii:.\T. — The indicjition for treatment is to relieve 
 fti*' pi'iii Heat is sometimes etHcacioiis. Morjihine 
 Hhould Ih' administered liypoderniically. that heinir tli»' 
 hest way to administer this analiresic in ncphraliria, as we 
 have seen that the pain is apt to cause excessive vomitini;; 
 or, where a syrinire is not at hand, morphine or opium 
 may lu' <;iven l.y tin- rectum in the form of injection or 
 suppository. The desired relief may hi- ol.taiiied hy the 
 inhalation of chloroform (M\ ether. Further indications 
 for treatment will he found under the headinirs of the 
 diseases of wliich nephralgia form.s u imjminent symptom. 
 
 ■.•71'nin ff 1-. Ill, 
 
f 
 
 i 
 
 
 iV2 /)/.va;.iskn oa Tin: hn>.\i:)s 
 
 (11 A i"i" K i: I I. 
 
 II YI'KIl. K.MIA — foNilKSTIoN til' nil; KIUNKVS. 
 HkXAI. lis |n'r»'lllill IIIIIV lir ili'tivi' <'!■ |iilSHivt', 
 
 Ivriiii.nia — .I'/'Vi. — III inkiiiir up tlic siiltjcit nl' liv|Mr- 
 
 ICIIliil. lit nil' aifllill illl|it'(>r4 llpnll Vnll the illl|Hi|'tilll> r of a 
 
 tlii>i'<>iii:'li iiiiili't'siiiiiiliti!.'' lit' tilt' rii'i'iilatiiiii in tlif kiiliirv. 
 (Sif iliaiilir (til Aiialmiiv.) Ni» ilmiltl llif larirf »i/,i' ol' 
 tln' ifiial iirtt'iT Hicilltati'M li_\ lufa'iiiia w luir tin re i^ ttvcr- 
 arlioii III' till' Inarl ri'niii li_\ |M'i'tri>|i|i,v ol' tlii' tii'iran m riHin 
 ii\t r-.-liiniilati(iii Iivsuili ilniLr'^aHiliirii'.lis ; I nit inativtli UiTf*, 
 siicli as liii'|it'ntiiii>, laiitliar'nlt's, i 'iiD.ilia, t iilitlis, ami rar- 
 liiilif aciil, may taiist' liyiiti'Miiiia. artinir. Iinwfvi r. l.y 
 (lir«'it irritatittii tir stiimilatitui nf ilif kiihiry itM'If. 
 
 !t may lie jiriMliiciil liy iiijiirit's, rtiial i ali iili, or cnii- 
 
 I'lrtliiiis in tile tnliiiji's. ami imt intVri|in'ntly it a mi- 
 
 jianii s till' aciitt' int't'ctioiis ilisrascs. ( >t'tlii' amtf intt'i'tiniis 
 iliscasi's.starlatiiia.i'lioK'ra, ami (li|tlitln'ria imwt lVi't|iU'iitly 
 |ii'imIuii' liy|ii'ni'iiiiu. Kxposiiii' ot' tin' liody to smldfii 
 «'liain.''t'-* of tt'iii|ii ratiM't' is aiiotin r caiisf ol' niial liypt'i-- 
 ii'iiiia ; ami I iiniy rtiniinl you that this conilition always 
 _'ft cttlt's acnti' intlaininatioiis of the kiiliny. 
 
 I'lTssiirc u|ioii till' alMlominal aorta liclow tin- renal axis 
 must, of roiirsi', iirodufc imi't'ast'il lilooil-jii'i'ssiifi' in thf 
 kitltnys. ami coiisciiui'iit liyiicru'inia. 
 
 J'li.^.sii-i'. — I'assivc hyiKiainia is causftl Ity 'iirh tumors 
 ill thf alxltimiiial cavity as may imss ii|ion or inti-rftTi' 
 with the iiifi'Pior vt'iia cava ahovc the ciitramc ot' the 
 ri'iial Veins, — aneurism, cancer, etc 
 
 Diseases of the renal veins may oh.struct the circulation 
 ami |iro(luee passive liy|terieiiiia ; ami (liseast'>, of the liLjht 
 nitle of till' heart, sucii as fatty (U'^oiienition and dilutution 
 
 I iili Wiiili I n • I" 
 
 w^VtfwM-^m^vaMVCii 
 
in I'Kii.r.Mi [—cttsuF.xrins or riii: Kin.srys jj.j 
 
 KYf*. 
 
 ■I III' liv|n'r- 
 irtiiiifi' i>\' a 
 till- kiiliicv. 
 I'lTf >i/.c ul' 
 WW i.i ovci"- 
 iraii III' tViiiii 
 iiaiivtIriiLrs, 
 lis, ami lar- 
 
 oWcVcl', li_V 
 
 M.jf. 
 
 iili, or cdii- 
 V it ai'CKiii- 
 If iiili'i'tiuiis 
 1 tVi'i|iu'iitl_v 
 
 to slKJilcli 
 
 fiial liyiH'i- 
 ilidii alwavs 
 
 (• ri'iial axirt 
 
 ■IHUIT ill till' 
 llill tllllinrs 
 
 or iiitiTltTo 
 
 nice III' till' 
 
 ' firciilatidii 
 of tiu' rii,'lit 
 (I dilututioii 
 
 • ir iiiilnil iciriiiu'itatiMii, wliiili iirmliKf iilwfnirtiiin i.t' flic 
 |iiilriMiiiarv rinnlatioii, will liriiii; alMiiit tlif saiiif r."«iilf. 
 
 >>ii aUo limy any nr^'aiiif disiaxc (»f thr Iiiiii;s >\|ii<|| 
 III. -fill. trt flic r\^Ut iH'arf, as filiroiis iilithi^is, rxn-^sivi- 
 |i|tiirific uillu-MioiM, tiii|i|iysciiia, <lir<.ni.' l.nuiclilf'H, »'fc. 
 
 SvMiTiiMs — Aifin. — 'I'lic |iafii'iit will i'oiii|iIaiii ofiicliimr 
 paitis aliniit flic IniiiH, Hniiifliuu's fxtcinliiiir almux Hie 
 tMiirst' ..f thf iirrtrrM, ur radiatiiiir to iJi.- hips. 'I'liirc 
 is usually ffiuK'nicss uii pn's^iir*-, ami iiof iiilVt'.ni,.|if|y 
 nausea, an. I lurliaps voiiiifiiii;, ai('oiii|iaiii(>il or imt l.y 
 liiailai'lii'. 
 
 No iloiiiil flu- iiicrcasid t|iiaiitity otiirim' that is iisiiallv 
 |ir«'s.i>f in iroiify kidiiry is owint; fo the Iiiir|, pnssmv 
 from III.- |pyi.,.rtro|.|ii,..| heart. ( hi the oih.r liami, we not 
 iiifrf.|iifiit|y tiiid 1,1, „„! ill flu- iirim- wlicri' flii-iv is active 
 hy|itrii'iiiia, iiartindarly in that of acute iie|ihritis, in the 
 hy|icru'inia of flu- iiitemiierafe, ami in that following 
 injury. 
 
 /',/v,v,V,._li, this condition, aside from the syiii|.t(»nH 
 of the lesion which causes the hyptnciiiia, there will ho 
 a diminished excretion of urine, which will he porter- 
 'olorcd, owinir to the presence of disiiitcirrati'd hlood, and 
 will contain sonic uIImiiikmi und ('asts. 
 
 Care must he taken not to mistake this for the urine of 
 acute |{ri_i;ht's disease. An examination of the heart imiv 
 reveal the cause of the passive coiiLjotion or renal ol.stnic- 
 fi<in. The heart will he, perhaps, in a state (.f fatty do- 
 t'eneration ; or there may he dilatation ..f the ri-rlit iicart 
 
 *"''«» f.iranic disease of flu- liiiitrs, ,,y a severe mitral re- 
 
 guiiritation may he produein,«r the pulmonary ohstnicfion. 
 In these conditions of the lieart, not only the kidneys, 
 I'Ut also th,. liver and the jiortal <Mrculati,iii suffer from' 
 the passive con<restion ; and it is this fact that enaliles us 
 to differentiate hetween passive and active eoiiirestioii, as 
 
 «iW6<»«Sn *ff«wn 
 
 J 
 

 ^fi 
 
 3^ DISIIASF.S i)F THE KIDSKYS. 
 
 Nwll asto.listinun.i^li tlu' iiihiinu'iM.f i-assive o.iii:v>tiuii 
 tVuiii thiit oi'afuti" I'>ri,i,^lit's disciisi'. _ 
 
 l'\Tllul.u,iV — .l-Z/'T. — In Urtivr 1. VlKTirillii. tlu" IDorl.ld 
 
 ,.r,,rc.>s lirs iiuiinlv ill llu' renal xxyWvw^ and tlu' artrrirs of 
 iIh. Mali.i'-l.ian tnfts. Tl.e ki.liH'.v. aiv tai-v, nmist. and 
 „,• , .lark iTd .■ulnr. Tin- cai-^uU- stril^s .asily. On s.t- 
 ,i,,n tlir Malpl.trliiiin Lndirs an- ivr..-iii/A'«l as dark-iv.l 
 iM.ints that dot tliv surfafc 
 
 />„,,,v,v,._In passivi- livi.eni'niia, which has its scat iii 
 ,1k- veins, tho kidm-vs in the c.rly sta-os may he enlarged, 
 hut later will U' ..f normal or diminished si/e. 1 he 
 whoU' oiran is tinn, with an elastic or tou-h feeliiiir, and 
 is of a shitv-hlue color. The capsule is easily removed. 
 On section! the Mali>i,u-hiaii ho.lies are seen to he i.roim- 
 neut, hut the most marked changes are in the medulla, 
 the bases of the (.vrami-ls sh-.wino- marked coii-estioij, 
 an.: the deei.lv-eon-ested vessels shinin,i; cut very i.roiin- 
 nently between the bundU's of urinifen.us tubules, -ivm- 
 the tissue a striated appearance. 
 
 In (d.l-standimr c-ases, irivijular pale patches makc^ their 
 .,,,,,„nnice, and the or-aii may feel almost fibroid. 
 
 ,.,,„...,osis.— In active hyperiemia, the pro-nosis depends 
 
 on the excitin- cause; when this is tunetional the hyper- 
 romia is simplv transitory. 
 
 In passive livpenemia we must .jud.ire of the pro-nosis 
 by a consideration of the disease which pro.lnces ae 
 
 obstnietion. . . , 
 
 'p,ij,v,.MKVT— Jr//r,.— In treatin.tr active hypera-nna the 
 indication is to remove the cause, if possible. Where it 
 dev-ends upon hvpertrophy <.f the heart, for instance, we 
 nn.st modifv the heart's action. When it acconipa.ues the 
 acute infectious diseases there is no special mdieatmn tor 
 treatment. Where injury is the cause, absolute (puet and 
 rest will be necessary, with cold, eupping, or perhaps 
 
 ^;i 
 
 :rrr!?ir?.araffSK3"ws«v-;-v ■ -j^ 
 
y;,7'/.;A'.7:.U/.l— ro.V(./>77".V of Tlli: A7/'.V/;).s 
 
 :{.') 
 
 till- iiiorliiil 
 
 • , moist, iiiitl 
 
 ly. On si'C- 
 
 iis (Uirk-ii'tl 
 
 IS its srilt ill 
 
 lie t'liliirirc'd, 
 1 size, 'rill' 
 I tViTinir. iiixl 
 ;ily rcMiiDVi'il. 
 to 111' jiroiui- 
 tlif uiciliiUii, 
 il conicstiou, 
 1 very |iroiiii- 
 ihulrs. <:iviii!:: 
 
 08 rnnkv tlioir 
 filiroid. 
 
 miosis (U'|n.'ii<ls 
 iiul the liyi'tT 
 
 tilt' ]>roirnosi9 
 prodtici's I'ho 
 
 lypi'Tivniiii the 
 )io. NVlicri' it 
 )r instancL', wo 
 .'Oonipiuui.'stlio 
 indication for 
 i)luto (luiot and 
 ig, or \(orliaps 
 
 1,„,1ks. ai-l.ru'd to iIk- hark. -ivr sonHtlnu- t.. allay 
 ,,,„ ,„i,i. avoid stiniulauts, and o-ntin. tlu- patiHit stnrtly 
 ,„;„„„.nitro.vuou> dirt. Ian. in tla. l.al-it ..f koopm- 
 tiiv iKiticnts on tliin ri<c <:-i'nrl. _ _ 
 
 ■/»„..„,.— In rasc-s whi.'li d.'i.rnd on dilatation ot tlio 
 ,i„-l,t .ido of tiif hrart or on fatty d.-.-nrration. \hv patient 
 n^'iudlv .v.inifrs l.oth alroholir and h.art stiniulant.: tl,at 
 i, it is tlu- hrart that n.ir.irrs trcatiniMit, rather tiian tlio 
 k;,hHVs;attlu. sanu- linu., tlu. portal .innlat.on, hasn.^ 
 
 MNorMHM'io.H.Mlthrl'ii^^'^-^'''''''.^'*''^^'''"' '*'''"''•'' '''■'•''''''' 
 l,v a sdiiu- cathartir. Whriv thr passivo ron-.-tion is 
 ;,„,„,,„1 l.v tn.uors, anrurisn., vU:, it is .nttrrly a n.att.r 
 .,,■ ..Ualin- with tlK. oanso, whh-h wr may or may not 1m- 
 
 iihlo to ri-movi'. .. 1- • 
 
 \m..n.- hrart stimnlants we havo tlu- .-hoi.v <.t digi- 
 talis ron\.illaria, stn.phanthus, ratU'i.u., nitt'o-o'lyrvriiiotc. 
 
 \h.nv patients wlim onr. rolievcMl hy stimnlants will l.o 
 
 o-.va'tlv lu-notitod hva systematir .•onrse ot heart t..nirs, 
 
 Thr hrst ..f wliirh ill m.v iiai.ds has h.vn ^try^hn^H^ -'ven 
 
 with i.hosphorio arid t<. older patients ami with in-ii to the 
 
 vonn-er. I usnallv he-in a eonrse of stryhnine with 
 
 ;ins.s'~of from ..ne-tiftieth to one-sixtieth of a -ram, in-Mvas- 
 
 i„... to one-thirtieth or <.ne-tweiity-tifth of a -ram. Oeea- 
 
 sim.allv, h..w..ver, it produees headaehe : in this ease 4UI- 
 
 „i„e will he found to he a -oo.l snhstltute. I ha'-- also 
 
 ,„n,id patients who took nnx vomi.-a and phosphorie aei.l 
 
 with heiietit, in whom stryehnine prodnee.l liea.hiche. 
 
 As the amount of urine socrotod depends ehietly upon 
 tl,, de-ree of pressure within the vessels ..f the -lomerulo, 
 it< .oeretion neeessarilv heeomes nioiv prof-ise in that lonn 
 of renal hvperromia whh-h involves the anerial s^st.m ot 
 tlu. kidnev, ineludin- the vessels of the Malp.-h.an tiilt. 
 1„ sneh eases tho pressure in the -lomerule is hardly ever 
 suiheieiit to oeeasioi. transudation of alhiniieii, ur to rup- 
 
 SC!05»P8K3«tira»^-;it>' ^■. T 
 
 p. tf.i;>.i»SK2i«s«rr ■*iA5*a:.'^*^--^J*^J» 
 
T' 
 
 :{•; 
 
 i>isn:.\sr.s or riii: kidsevs 
 
 tiirc flic Vfssi'1-i iiiid cuii.-f fxtnivasiitiiiii of lilooil into the 
 Miil|iii:'lii;iii coriiiisclcs. 
 
 A vci'v (litlri'fiit ti'jiiii of s_viii|>ttiiiis follows u I ion a iiiod- 
 iTutf (jcurrcr of nltsfriirtiri nii/oi'ifiiiKiif. In almost I'Wi'y 
 case of olotniftioii of tlic Veins of tin." kidiu'V, flic (K'lriH'i- 
 of tfiisioii uitliin its arteries is verv small, ;;;nl tlicre is a 
 tliiiiinutioii iiisttad of an incn'asc in the secretion of mine. 
 ( )n tlie other hand, tlio ntrain npon the caiiillaries ln'conies 
 exeeedinii'lv severe, since tiicv cannot diseharire their con- 
 tents into the alreadv overloaded vi'ins until tin- jin'>sure 
 within them exceeds that in the veins, lltnce, not oidy 
 doi's the I'lasnia of tlu' hlood escape from them into the 
 tultnles, so that the scanty, concentrated, tlark-colored 
 nrine contains alhumen casts, hut the (U'licati' walls of the 
 capillai-ies u'ive way het'ore the strain, so tliat the urine is 
 also fidl ot" Itkuid-eoriiusck's.' 
 
 CIIAPTEH 1 I I. 
 
 ll.K.MATl UIA. 
 
 TT.KMATIHI.A is tlie term emjiloyed to denote the iiresenco 
 in the nriiu' of Mood derived from any j)art of the urinary 
 tract. — whether from the kidneys {ii(iiliri>rrli'i(/''H), the 
 ureters (iinfnrrliiK/id), the Madder {ri/sf(irr/<(ii/!ii), (ir tlie 
 uretlira {>intlifiirrhn;/i<i). 
 
 Ivriui.ixiv. — We not intro(|Uently find hiiMuaturia in liy- 
 peru'iuia, either active or passive, as well as in cases of con- 
 tusions, wounds, and other injuries of tlie kidneys. Heavy 
 liftimr or ovir-cxertion sonietiiuos jiroduces liemorrhairc. 
 Keual calculus is one of the most coinnioii sources of 
 
 ' Nieincyur. 
 
 1.eirrj-«.,Jk»r.?Wi«wa^»-jWO9W*0to4W!»t''tairi«KM?«»lt^ 
 
(Ill into tlio 
 
 |i(iii a iiiod- 
 iiitist evcrv 
 tlif di'iriTi' 
 il tliiT'' is ii 
 on of iiriiii'. 
 ii'S ln'coiiu's 
 t' tlicir coii- 
 lii' invssuiv 
 ce, not only 
 •ni info the 
 liirk-coloroil 
 Willis of tilt' 
 tlio uriiK' is 
 
 he prcsoiu'o 
 
 the urinarv 
 
 rl'tif/ia), the 
 
 f/ifi), <ir the 
 
 turiii in hy- 
 .'iises of c'on- 
 ■ys. Heavy 
 lemorrhaire. 
 sources of 
 
 ILKMATl'IilA. 
 
 ;{7 
 
 lueinatiifia. In ironty j)atieiits with dist-ased arterii-s, this 
 contlitiou occasionally arises. It is not fr»MiMint in ihc 
 course of tnlHilar nephiitis, except in initial active hyper- 
 !eniia,orin patit'nts addictt'd to the exct'ssive use of alcohol. 
 'I'uhcrculosis, tuniois, an<l cancer of the kidney causi' 
 di'struetion of tissui- and luinorrhai^e. 
 
 ( )f thi' hlood _i,'lan<lular dist'ases and diseasis of nutrition, 
 imrpiira laeniorrhatricii and scurvy are the most apt to In; 
 ai'<'onipanied hy Inennituria. I have had sevi'ral cases ot 
 ha-niaturia durini; the conircstive staict' <»f nnilarial fever, 
 and have set-n maliiruant attacks of an acute infectious dis- 
 ease ]iroduce it. Nor must we overlook the facts that 
 hieniaturia may hi' vicarious, and that syphiliti*- jiatieuts 
 may he the suhjects of licnKU-rhairi' from the urinary tract, 
 as well as from any otlu-r mucous memhrane. 
 
 I'atiiolouy. — The patholo«;ical condition of the kidney 
 whii'h is tlu' suhject of ha-maturia varii's with the etiolou-y. 
 That resulting; from renal calculus may i»e either from 
 hypenvmia of tlu' kidney produced hy the presenci- of the 
 stone, or from suhse(|Ucnt ulciTatioii of the mucous mem- 
 hrane of tin' pelvis. Ila'maturia from injury is the result 
 either of ruptured hlood-vessels or of hypera-mia. Tlu' 
 lu'nu)rrlia.iii' from t^out is usually dept'udent on a diseasi'd 
 condition of the hlood-vessels and hyiiera-mia, while that 
 from jturpura lia'morrhajj:ica, si-orhutus, and the hlood 
 li'lamlular diseases is ijeiu'rally due to the patlioloi;ical 
 comlition of the hlood, althouu;h it nniy depend upon an 
 alinormal state of the hlood-vessels as well. The Inema- 
 turia of renal tuberculosis is due to ulceration. whiK- that 
 from cancer or other tumors is likely to hi' from hyper- 
 aunia in the lU'iirhhorhood of the neoplasn\s. ' The so- 
 called endemic luenuituria is the result of the hyperaunia 
 produced in the mucous monihrane hy the iiri'sence of 
 [)arasites. 
 
 i 
 
 f 
 
 iM^lK»4in«ea!9KfK.'jUK' 
 
 ■Ws«9WiW«rrtW!W»«WWW*i:.V*^^ 
 
i>isi:.\sj:s or riir. kii>.\i:)s. 
 
 II 
 
 h 
 
 m 
 
 Sy.mi'Tii.ms. — Tlic I' 'iii^'tMiiioiiii' >yiiii't((iii is. of (•(nirsc. 
 Moiiil in the iiriiif, wliidi iiiiiy It nf ii (lai'i<. -iiioUv imImt, 
 tlir 111.. 1.(1 litiiiiT disiiitctri'iitnl. At (itluT tilin- tlir lili'ixl 
 iiii|i;irl~ \i> llif iiriiK' a tVrsli rcil colui', oi' it iiiav lie Vdiili-il 
 ill clui,-. \\\ circt'iil tilpsci'vaticii jiikI »'Xiiiiiiiiati(Hi of tlu- 
 uiinr \v.' Icaiii wlicin'i' tln' lu'iiiiirrliai.^c coiiics. It tiif 
 iii'iiir i- alkaliiir, tiif ln'iiun'rliaur is prdltalilv tVoiii liic 
 Maddi'i', ami tlic ii!(in(l-c(.r|nisclrs will soon lir<'()iiif disin- 
 toirratnl ; if il is aiid, thf .•..rpiisclcs iTiiiaiii tlistiiirt and 
 tlu' JK'inorrliaiiT is jn'oliaMv t'nun the kidiuy. If thr 
 lijodd r(inu'< from tiu' kidiicv, it will lie (•(UnpU'tily 
 mixed with tlu' iii'iiu'. uidi'>s tlic luimn'rliaLi'r is (.Ncosivf, 
 wlii.'h is si'ld.ini tl ••use cxcciit wlnTf it is tfauinatic 
 If tlir iii'inr contains ciots opsti'i'aks of' Mood, tin- ItladdtT 
 is tho scat of tlu- troidiit". If the blood is almost |(iiiv and 
 is jiasscd jii^t in advance of tiic iifiiic. wc must look to tlic 
 urctlii'a ; if it tollows the urine, the hase of the hladdci' is 
 it- luo-t I'Toliahli- soufce. 
 
 Dai'k. smoky. iiortef-lookiiiLr ufiiie. of a hii:'h siiecitic 
 trravitv. eoiitaiiiiuir disinteici'iiteil Mood-cofpuscles and 
 all>umeii. is the characteristic urine in heinorrhatre from 
 juissive coiiLi'estioii of the kidni'V. In such eases invi'sti- 
 irate the ki.lney itself. It may 1)0 eidarireil. There may 
 he tiiherctilar troishle or cancer. Ts the patient ,t;'outy '.' 
 (lotity patii'iits may have liyiiertrophy of the heart, and 
 frei|Uently de<reneration of arteries, with conse<|nent 
 hemorrha-re. the result of hiifh hlood-jiressurc* ami arterial 
 rupture. In cases wheri' there is any douht. the miero- 
 seope will determine the presence of hlood-i-orpuseles in 
 tlie urine. 
 
 When The hlood comes from the kidney, besides heinir 
 well mixed with tlu' urine, the jiatient iroiierally complains 
 of nnea>ines<. heat, and dull pain about the back, while 
 occasionally the blood, by distending tlie iielvis or ureter, 
 
 ;'^l^^.JJJ^^"■g3^^i^^^:.la^<At;^.-^■■f^'W^j»^^^fJa^lafeaJe:■i«^ 
 
. dt' loursi', 
 inky colcir. 
 
 - t lu' llll M >i I 
 I lie \ I iiilf<l 
 
 tidii of tin- 
 •>. If tlu- 
 \- tVolll tlu' 
 •dllH' (lisiii- 
 istiiiit iiiiil 
 y. If tlu' 
 
 cnlnjili'trly 
 S i'XiH'>sivi', 
 
 tramiiiilic 
 till- l.huMrr 
 st purr aiitl 
 
 look to tlu- 
 r liliuMiM' is 
 
 iii'li siifcili'' 
 lUscU's iiinl 
 •rliuiTr from 
 isos iuvi'sti- 
 TliiTc may 
 iciit polity? 
 ' heart, and 
 
 (•onse(|m'iit 
 ami artt'i-ial 
 
 tlu- mirro- 
 iriuisc'k's in 
 
 'sides liein<r 
 y complains 
 back, wliik' 
 is or ureter, 
 
 ii.VM \-n niA. 
 
 .".!• 
 
 irives rise to severe j.ain (nepliralv:ia) simnlatin-r an atla.k 
 of n-ravil If Willi the well-mixed .leposit of I.I.mmI we 
 111,.? .aMs tlieri' ean he littK' douht that llie hemorrhaiiv 
 
 IS renal 
 
 |.,,,, , ,,,si<._Tiie i.ro,i.nio.-is must deiiiiid mlirely upon 
 liu. rliolo.;-y of the heiuorrlia-v. In eases of injury iIh' 
 pr.ii:r,o>i> is ui^iu'rally fairly .>j;o..d, unless the kidney is 
 di>or-'anized'.u- <.!iier injiirii's have luvn ri^eived of a 
 seri.m^ nature. In <'aneerous kidney the only liope of 
 ,veov*.rv lies in the early removal ..f tiie or-an, while 
 tulKMviilar kidney is LCeiierally eomplieated with tuher- 
 euh.^is of other ori;-ans, the hla.hler. testicles, or lun--s. 
 In Inematiiria from iroiity kidney tlu're is sehh.m dan-'er 
 from mere loss of l.lood. The pro.trnosis in these cases 
 must .h'peiid on the e(.nditi..n of oth.'r oru'ans, the hlood- 
 vesseis particularly, as many of these patients .lie from 
 apoplexy. ireiiK.rrhai^^e i'auscd hy a calculus is not likely 
 to he seri.Mis, and the jn-o.-rnosis, as far as the hemorrhaiiv 
 is concerned, is good. Serious residts, howev*'r, may i»e 
 produced upon the kidney. 
 
 Tkkatmknt.— In the treatment of hicmaturia we mils'- 
 he s^overned in a measure hy the etiolo.-^y. Ahsolute rest. 
 however, and the strictest attention to diet, apply e.|ually 
 to every ease. You will lind that nniny insist up<.ii milk 
 diet. I have, however, found that thin rice trnu'l— that 
 is, rice-water made from irroiind rici — answers the hest 
 purpose, and \ would stron,-,dy advise you to try it. It is 
 prepared hy l.oilin.ir for half an hour a teaspoonfu! of rice 
 tlour in a lialf-pint of water, with a little salt added. h\ 
 eases where liemorrha.s;e is the nsult of injury, it may 
 often he well to apply leeches, or eui)S, wet or^dry,over 
 th.e hack, while ice applied over the ivi,non of the kidn»'y 
 mav he found efiicaeions in any case. 
 
 Mkuicines.— A irroat variety of astrinsreiits and hemo- 
 
 J£ 
 
 3S?^jWB^Ma»wtt>«'«gy«)i':w-awip«'j«^ 
 
40 
 
 nisn.tsEs nr the kidsevs. 
 
 \: 
 
 .^tiitits arc iistil. Sdiiu'tiiiiis tlir lu'iii(»rrliat;t' is iiicdiii- 
 |iaiii('il liv |iaiii, ami will rciiiiiit- opiates in (oiiiltiiiatiiin 
 with astriiiL^'iits. I'ikIci- tlicsc circiiiustauci's yon will 
 tiiid that uiir li'raiii ot'aci'tati- ot'h-ad ami tVoiii two to live 
 LTiains ot' hovi'i's powiU'i- ivt-ry two lioiifs will aiiswir 
 adiiiiralily. 
 
 Of tlu' astriiii^i'iits, wlKTt,' tio opiati' is n'i|uir('<i. ifallic 
 acid ill tni-trraiii ihiscs vwvy two hours will usually iiu'i't 
 the iiulicatioii. In tin.- adiiiiiiistiatioii ot" u-allic acid it is 
 lii'ci'ssary to irivi' it at short intervals, at least every two 
 lioiirs, in order to k»'e|i up its etVeet, as it is readily 
 ahsorhed and (|ui(l<ly eliniinatt'd. A \ery nice prep- 
 arati(»n is the eoinpoiind syrup of _<j:aUie aeid, an old 
 Hdiiihurii'li dispensary fonniila, whii-h can he eonihined 
 with a little laudanuin wlii'U there is pain. Tincture of 
 eaniiahis indiea, from five to ten iiiiiiiins, repeate<l every 
 two or three lioiifs, I soinetinies use suee<'sstully. 
 
 'riirpeiitine, <;iven in eiiiulsion with powdered aeacia 
 and einnanion-wati'r, in ten-drop doses evi'ry two hours, 
 often does well in uoiity eases. 
 
 Of the ferrui::iiious preparations, [ have found the 
 aiumonio-sulphate of iron — the alum iron of the driiii'irists 
 — the Very hi'st preparation, t;iveii in ahout teii-irraiii 
 doses, well diluted in water, ivery two hours. 
 
 Fluid extract of ert;ot, alone or eomhiiied with tannic 
 ai'iti, or ertfotine *;iven hypoilermically, soTiietimes stops 
 the lieinorrhaLTc where all other reiiu'ilies fail. 
 
 T would liavi' you remeiiiher that for the treatment 
 of hiematuria dei»eiidiiiir ujion jiassive conirestion of thu 
 kidneys, especially that form which you are most likely 
 to meet, namely, iliat rt'sultinu; from disease of the heart, 
 astrimrents are not indicated. In these eases the liviT 
 and other ahdominal oriTiins are eijually in a stat<' of 
 jiassive congestion. The iiitlications, therefore, for treat- 
 
 ■a- n>I H'i W ofcV''.-rj-:>^V>W^«i.»«»««A<wiJ>*«i«>ai.-j*^^»^-j^-tj«.n.-.«)>ICw*»l> ■■»li«CT!W«?Tafgl«1r»<a«>M»»iiiiV'tfil»riill>IIIIWIii<'llii|?- 
 
IS JlCCdlll- 
 
 iiliiiiiitiiiii 
 
 von will 
 
 iVd to live 
 
 II ansut'i- 
 
 •t'd. iTiiliu! 
 iiillv meet 
 :iei(l it is 
 I'Vei'y two 
 s reiidily 
 ici' |il'e|i- 
 1, nil old 
 eoiidiilieil 
 IietUl'e ot' 
 ted t'Very 
 
 eil ileileia 
 
 vo lioiirs, 
 
 iMiiid the 
 di'iiii'ifists 
 teii-iri'iiiii 
 
 til taiiiiie 
 iiu's stops 
 
 trt-atnu'iit 
 on of thu 
 ost likely 
 till' heart, 
 the liver 
 stati' of 
 for treat- 
 
 Esnh'.Mir ii.KMA'rriiiA 
 
 41 
 
 asinii«»«»e»i«« » 
 
 nieiit are an a-liv.- saline eathartie to iiidoad tlie portal 
 .•iividalloii and deplete tlie eoii.iri-sted alMloiidnal orpiijs. 
 Mild the freeadiiiiiiistratioiiof.-ariliaestiiimlaiits, di.tritalis, 
 .tryhniiie, and aleolnd. I'mh^r this treatment (he 
 li..l,ioiTha,ir«' will eeasi-, as will also tlu' alhiinieii. 
 
 StroiiLivlns -ri.ir:'^ >■■< '' parasite which is seldom fonnd in 
 the kidn.'ys and urinary passa.u'fs ofman,l>nt which ol't.-n 
 occurs in* lower animals. It is l.arely possil.le that it 
 niitrlit produce Inematiiria. 
 
 ("HAI'TEK IV. 
 
 KNl>i:.MI<' II.KMATl lUA. 
 
 Kndkmk' or l*arasitic Ui'inaturia occurs endemically in 
 many hot countries, and is caused hy a jiarasite eiiihedded 
 in tlie ^-lnall veins of the mucous memhrane of the jielvis, 
 till' kidney, the ureter, and the hhulder. 
 
 lIisi'oKY.— The endemic nature of this form of ha-ijia- 
 turia was first estahlishe.l in \HV2. l.y (Miapotin, in the Isle 
 of France. Dr. Bilharz, while studyini,' the diseases of 
 Kirypt, iirst discovered the cnto/.oon that ].roduccd the 
 ndschief. Suhsecpu'iitly Dr. dohii llealey, while stmlyin^' 
 the diseases of the (^ij.e of (lood Hope, estal.lished heyolid 
 a douht that the eiideinic hiomaturia of hot climates is 
 caused l.y a j-arasite. Uesi.les Ksrypt and the Cape of 
 (iood Htipe, this hemorrhaijce is indi,u;en(ms to Brazil and 
 the Mauritius. Dilharz named the parasite Dlsfowu 
 iriiiiiitnhiiini : Dresinir nanu'cl it (T//nirn,/,liur'is Ihton- 
 tnhiiis; C'ohhold, however, named it for the discoverer,— 
 viz., Bilhirzto ILcmahhlnni. The last is the name gener- 
 
 ally used. 
 
 it is a white, elongated, soft-skinned, hisexual entozoon, 
 
 4* 
 
 i 
 
 •i 
 
 T^*srA*a*r» s ttnt i w w ptf« ^wig- ■afe^w 
 
 l#i.i**««*«WJ3IT»WWM«»9«»«MU»W^e'>'^''!'^^>*W«'*' 
 
I: 
 
 insi:.isj:s or riii: hii>\i:)s. 
 
 r 
 
 tlll'cf or t'lilll' lilies ill Icim'tll, and lulnliirs to tllr tri'liiiildilc 
 
 (Hilcr (if wiiniis. 'I'lic IkmIv i>|' ilir niiilr is ((PiniMratiMlv 
 thick iiiid >li(ii't, iiiid is luipvidrd on its vciitfal a>|p(it uitli 
 a riiiTnucd canal (niiiu/i.^ i/i/mi cuii/inni.^) fur tlic rci ciitiiin 
 of tlic loiiii'cr, delicate, lilit'orni female diiriiii;' conurcss. 
 The ovisac dehis<'i>s loimfiti'idinally ; the ci^.^.'s ai'i- ahoiif 
 one oiiediniidi\'il-aiid-sevcnt_v-si.\tli of an iinli loii;.'-. and 
 arc oval, with an anterior teiniiiial s|iiny proji-ction. 
 'I'lu' iie\vly-csca|ied »'iiilirvo is lla>l<-slia|ied and eoverid 
 with cilia, liy the aid of which it moves ra|iidly alioiit. 
 
 Iv|•l^|,(l(i^ . — It is now heyoinl ijiie.-tioii that ihelueiiia- 
 tnria is caused \t\ the |irt'scnce oj'ihc IHIInirzi'i Jlii ni'i/n/iiniii 
 ill the small veins of tlu' niiicoiis inenihrant . It is not, 
 
 liowevi'r, clearly uiiderst 1 how it liiids it? lodcement 
 
 there. It I'lolialily enters the liody in vai'i<Mis ways. — 
 heiiii; laki'ii into the stomach with the water, vcLict aides, 
 or niollusca. It has hei'ii siiii-ifi'sted that the ova may 
 attach tlu'iiif-elves to the skin of jicrsons hathiiiir, Miid 
 theiiee iiiid tlieir Way into the tissiu's. Most of the cases 
 ot'ciir hetweeii the aiji'es ot' five and t weiity-fivi' yeai's, more 
 males heiiiir attacked than females. 
 
 I'ATllol.miv. — 'Pile |iafasite is not always confined to the 
 mucous iiiemliraiie ot'rhe urinai-y tract. It has lieeii found 
 in the portal veins, in the liver, ami in the veins of the 
 alinieiitai'y canal, where it causes heiiiorrhaiii', diarrlui'a, 
 or dysi'iitery. When endu'dded in the mucous vt'iiis of 
 till- alimentary canal ii doi's not, as u rule, pfoduce so 
 much distui-haneo and disor<;ani/,ation as it does when 
 present in the mucous inemhrane of the bladder, where it 
 is found mole fri'(|Uently tli- .n the pidvis of tlu' kidney 
 or the ureter. When the p..i-asites are deposited in <;rt'at 
 numliers, they thicken the mueoiis iin'mhrane. and in this 
 way somotinus eaiisi- ohstruetion in the ufeters. 
 
 .I'-U'tisitie <>v:i ha.ve lieeii f^niMil fo f',)r!!l tll'J !1U'."1','US uf 
 
 
 i 
 
 ^»iB(*ip*s*^i>r. . .\i^-,atfi», •j*;.Tx»%;s*^.v?f.'-^v-i''i«'Jw%i«:''-«i»'«- ae-a»i^^ 
 
 ^Mi 
 
■ lli'llliltndc 
 
 ii|Mr;iti\ily 
 ii-|ic.t with 
 
 • rti ( |itiiiii 
 
 X CdllLll'l'SS. 
 
 lire nliMiit 
 lull;,''. :iii(| 
 
 |in>jccti(iii. 
 
 ml coviivtl 
 
 • illiollt. 
 
 lilt' Ilil'llKl- 
 
 1(1 lll'll'iliiillli 
 
 It is IKit, 
 
 llMlLiClllCllt 
 
 us wavs. — 
 vcLi'italilcs, 
 i' o\ a iiiav 
 tliinir, iiiid 
 I' till' cast's 
 icat's, iiiiirt' 
 
 iiu'd tit the 
 hvc'ii loiiiid 
 ciiis of the 
 , tliarrlid'a, 
 IS vi'iiis ot" 
 !ir(»dut'i' st,i 
 docs whi'ii 
 r, where it 
 till- kidney 
 cd ill ijiH'at 
 ami in this 
 
 imi'li'iK of 
 
 1 ; 
 
 n.KM \Tl\r- l.i. 
 
 48 
 
 ,, >t,„i.. iM.tli ill the iMlvi- t.f the Ui.l.iey aii.l in llf 
 
 "livMi'it.Ms.— The i.atlw.irnotnonie synipffin is l.ltM.d in 
 ,,,„ „,ii... intimately mixed wlien it .•-.mes iVtmi the 
 Uidnev. an.l in eh.ts t.r tnllt.uin- the mine when it eoim- 
 ,.,,„„ •,,„. i,i,,d.ler. Kxeivise ilielvaM-s the .,nantity t.t 
 
 1,1 1. tht.u-h the aiiit.nnt -f mine is n..t liUely to he 
 
 .,„;,.,,„| There is little ..r no pain, exeept as the ivsillt 
 of violent exeivi.e. If lot.- eoiitiiuied, aniemiu inn-t 
 
 ' I'limiNoSlS. — VefV feW tleaths tail he traced ili recti V tc 
 ,1,,' etU'ets.-f the hemt.rrha-e, Utld ehildrell seem to out- 
 frow the hcniorrhairi'' temleiiey. 
 
 " Tiii:at.mi.:.nt.— l>r. Ilealey I'stahlishe.l the fact that it is 
 useless to trive the t.r.linary astrin.iivnts »iiii.loyed in other 
 tonus of I'ueniatmi.i, hut that the parasites or ova in the 
 pelvis of the kidney can he .le>tr..yed hy turpentine and 
 
 oil of male fern. . 
 
 For their reim)val from the hlad-ler he fomu. iiothin.: 
 ,,, .„,nal injections of a solution of iodide t.f pt.ta>simii 
 coMlainiiiir ahout live -i-fains to the ounce of wafer. 
 
 C 11 A I' T K \i V. 
 
 „,,,,,.,,^,.,UA-SinKims OR FAI,S1-; ll.V.MATnUA — h.kmo- 
 
 (ii.oinMiaA. 
 
 11 KMATiNiiUA is a luiroxysiiial disease or con.lition char- 
 acteri/.e.l hvthe passa.ire of hloody-lookiiiir urine, almost 
 l.lack or p.".rter-colored, and containing alhumeii, hut no 
 casts or Mood-corpuscles. _ 
 
 ETiOLO.n-.— Wc know little of the etiolosry of this dis- 
 ease. It occurs iilmobt exclusively in imiles, ami usn.ally 
 
 
 tm6V¥t>^!61tle*»S^Vi* 
 
 .;:S™« «!»»'*«****«'* ■ 
 
 ,»-.«l*»*vvl-MW^ttO* «i;4'ta*«H»#WU:*.c^*'*.* 
 

 44 
 
 /'/.vAM.vA'.v ((/• /•///; hii).\t-:y.s. 
 
 I'ttw.M II thf HIT'-' n|' Iwciity iiml I'ortv. \\v\ lew ca.'^i's 
 "'(•riir iit liny iiir<' iMllin- twenty or iitUT forty. Some aii- 
 tliors tell IIS llml it i> in'oiliictd \,\ cuM, as tin- |paiN>.\y>iiis 
 !ir.' ii>iiiilly |. need, (I l.y ri>|i| ami rcnirfciit diilU. 'I'lic 
 • ■old ami cliills, lio\vi'\»r, are proliaMy tlic r.>iilt ol" tin- 
 fomlitioii o|' tilt- lijooii, ami not its caiiM'. 
 
 Ila-iiiatiiiiiria is soiiiftinn's caiisid liy a s^'ptic comlitioii 
 iiKliici'ii Ity tin- iiilialatioii of ciTtaiii iruscs, fs|i('cially 
 arsniiiin'ttcd liydid.fcn, r.iid is likely to he pioeiit in 
 Mood ulamlidar diseases. 
 
 I' A riioi.iKiv. — 'j'lie dixolorafioii ot' tlie mine is caiiseil 
 I>y tlie disintegration ot" the li|oo(l-eoi'|inseles settinir I'ri'o 
 the liieiiion!,,l,iii ,,1. eoloriiiir-niatter of the hlood. I'nder 
 ordinary eireiinistanees the ha-niatin of the hlood heeonies 
 the iiiirnuiit of tin- nrine, hut in liaMnatiiun'ia the di-in- 
 te>;rytion taki's place too rapidly and the Ineinatin i-> in 
 e.xei'ss. It is hari'ly possihle that the eoloriiiir-niatter of 
 the eorpiiseles may escape without corpuscular di-inteirra- 
 tiou. So little is known (»f the patholouy of the diseasu 
 that it is dillicnlt to (h'cide whether it is purely a dis'-asu 
 of tin- hlood, a disease of nutrition, or a hlood iilandiilar 
 disease. The oidy case that I n'collect iiavinir had under 
 my cluirir*' was the suhject of chronic malaria with en- 
 larijeiiu'iit of the liver and spleen. 
 
 Sy.mi'TOMs. — Attacks are usually paroxysTual, wi'cks or 
 even months clapsimj hetween them. The passairi- of the 
 hlack urine is precided hy a chill, de]u-ession ot' tin- ner- 
 vous system, and pain ahout the loins. The urine always 
 contains alhuinen. hut iK'ither casts nor hlood-corpusdes. 
 That voidi'd diirinir the niirht is Lfenerally free from the 
 ahiiormal color; that jiassed duriuir the day, for perliaps 
 several days, will he of the color peculiar to tlu- diseasi'd 
 condition. Patients are sreiierally cachectic, and often 
 sutt'er from chronic malaria. 
 
 ..>«;%;/. :««:^ju...)ae»l.%JC'il«i«>■(33C'^w*u;«<e»«H»{•f«M^ 
 
Suiiii' au- 
 la n».\_vsi I M 
 ills. "tIic 
 lilt III' tilt- 
 
 ('i>ii(litii>ii 
 <-|M'(Iall_v 
 iiTxiit ill 
 
 i~ raii-cil 
 •I tint; I'vvv 
 1. I'll. I. T 
 
 1 llCl'lHllL'S 
 
 till' (ri>iij- 
 
 atiii is in 
 
 lll.lttt'l' ot' 
 
 lisiiitfirra- 
 u' (liscasi! 
 
 a (lis'-asy 
 n'lamliilar 
 lad iiiKJcr 
 
 with fii- 
 
 Avi'i'ks (ir 
 i.iro <it' tlu" 
 
 ' till- lUT- 
 
 IK' always 
 iriMisfU's, 
 tVdiii tilt' 
 I" inTiiaps 
 • (iist'asfd 
 
 iiul ntU'll 
 
 A\.KMIA. 
 
 Ah 
 
 l«,,,„;vn. IS.— Tlu' pi-Miriinsis is srctn'rully p»<»«l s.. I'ar as 
 ,1... ,,an.xvsii, is ruii.vn.r.l. ami utlH-nvis.. is p»vrni..l 
 ,.„ti,vl.v by »li'' '"ii.litinii (.f til.' patii'iit,— that is, wh.th.r 
 hf is .-iiiri riiiir iVnni urirai'if discasf or imt. 
 
 'ruKAiMlAT.— As y.t \v»' have fi.iiinl ii.. s|M..itir fi.r this 
 .lis.as.'. aii.l i.n.l.al.iv w shall liiid imiir mitil wr Uiimw 
 ,„uiv of its ..ti..lo,iry aii.l |.atli..h.i:y. Tlu- nmst su.'.vsslnl 
 ttvaliii.Mt ...nsists ill l.hi.iiiir thf liati.iit iiii.hT the lu-st 
 hyuii'iiir and dhtary .•.■ii.rui..ii.^ : ivst, .iiii*t, and tonic 
 tivatnicnt. .■oiisistiiiii- of in.ii. stryrhniin', ars.'iii.', vU:, 
 tmitiuLr any or-iaiii*- distas.' as iiwlirati'd, if juvsi'Mt. 
 
 fMina^timimJ-:iB 
 
 (' II A I'T KIJ V r. 
 
 AN.KMl \. 
 
 Tin: kitln.'vs, like all tho othii- oaMiis of the body, may 
 W til.' siil.ie.'t of aiiii'inia, an<l must shaiT in any «r.'n.'ral 
 anu'iiii.' .•..nditioii, sii.-li as chlorosis, i.crni.'ious anicmia, 
 etc. Wc may have jirimary anii'inia of the ki.liicys from 
 ..l.striiction of the roiial wssds, the r.'siilt of .liscasc ..f tlic 
 arteries, or of timmrs, caticer, etc., which may press iiim.u 
 those vessels. I'lnh-r any ..f tlii'se circumstances the 
 ki.liu'y must suiter in fuiiition and in nutrition. 
 
 It will he apparent from the etioh.Lry that aniemia from 
 ol.struction may he c..niined to one kidm-y, while in ,t;en- 
 .ral amemia hoth ki.lneys will he .(iiially atU^.te.!. 
 
 I'atiioi..h;v.— Wlu-re the conditi..n is that of .sreneral 
 anu'iiiia, we should iiml a pale, ana'mi<-l.K.kiii,-r or-raii; 
 hut where the umemia is the result of ohstriictioii for a 
 loiiir period, we sliouhl expect to tind the or^'an atroplii.-.l 
 as wi'll as anivmie. 
 
 Symptoms.— There are no special sympt.»ms to indicate 
 
 I 
 
 _,-_.-i' 
 
 ■H 
 
ref- 
 
 ill 
 
 insi:.isns i,r Tin: a7/».va').v. 
 
 tlli-. r..||i|iti(i|l : lillt it' lIllIT lir il Illlllnl' ill till' lllMlnliirtl 
 
 aihl il iiiiiik.il l.-sfiiiMLT "t" tln' «|iiiiiitify ut' uriiH- willmnt 
 iilliiiiniiiiiii!! mill iinirji sutnitiiiir. wi- niiiv .iiiil,Lr>' Hial llir 
 kiiliiiv is siiU'iiiin; iimii Im-k nf niitritiuii. Wlnrc uiil\ 
 Mill' killing is iiiM.Kiil. tin- pi'iihiiliilitiis inc tliat tli.iT w ill 
 III' no iiiijii-iitiiiii ul'tlir ruiiilitiiiii. 
 
 I'|Iim;\MS|S. 'I'llC |irilLriH)'is l|t'|ii'l|lU II|mi|| tin' flMlSf. ]{' 
 
 till' atiifiiiia \<r tlir ri'Hiilt ut' a laiii-rnms «a(lit\ia, tlir 
 prnirndsis will \>r Imd; ifnl' ililun.sis, it will l.r tiiVMialilc. 
 'ri!i:\r.Mi:Nr. — Tln' tiiatnuiit iiiii>t tli'|iriiil ii|iiiii tin- 
 itinlu^fv. III a iri'iicral aiiiiMiiii' ••iiiulitiiiii uc imisl rely 
 i>ii lifiirral ticatiiiiiil. In >|ii"ial anaemia- ..f tln' kiilmy, 
 — that is, wliiiT lliiTc is (ilislnntioii — ih.' indiciiiii.n i», nl' 
 rtiUisi', to niiio\c tin- cailsi'. 
 
 (11 A i'TKK V 11. 
 
 ii!si;asi;s nr tiii; iiknat. iii.nuit.vi:s,sKi,s, 
 
 Till-: I'l l-vt'ssfls ot' till' kidiu'vs ari' siiliji'it to tlic >aiiK> 
 
 ilisiasi's as llioso ofotlii'i- parts oftlic ImmIv. In tlic kiilm-y, 
 liowcviT, llu'v arc of more intciTst to tlic |iatlio|i.^-i>t iIimii 
 to the clinician, as it is cNtiviiicIv dillicult, ami so|||c^inlcs 
 cviii iinpussililc, to diatrnosc their exact condition. It is 
 iievirtjicless iiii)M)rtaiit to know that ohsciiic syni|itoins, 
 and |iain in oi- Iicniorrhairc tV' Mic kidiicv. may dc|icml 
 uitoii a itatiinloi,'ical conditio • renal hlood-vessels. 
 
 l)E(iK.\KI! OF AUTEIIIKS 
 
 The causes that proM.. atheroma or i-alcan'ous dcifeii- 
 eralioii ot" tlie rt'iial arteries are the same as those that 
 |»rodiice tri'iieral atheroma of the otiu'r hlood-vesselrf. 
 W'hetlur the leiial arteries are as suhject to atheromatous 
 
 ~::rnrx^vrs-rTin^,-iSK^-rf^r^^i^^»,msKMmmJ2^^ 
 
lilllSf. W 
 
 lu'xi:i. llic 
 tiivoialilc. 
 ii|M)ii the 
 III list ii'ly 
 
 ir kiillKV, 
 llinll i», iif 
 
 1 tile >iiliit' 
 K' kidiifv. 
 i>Lri>t iliMii 
 ■iiiiHfiiiifs 
 
 nil. It is 
 
 yiii|>tuiiis, 
 
 l_V <l»'l.clli| 
 1-vc'ssds. 
 
 US (it'irt'ii- 
 
 liiisr that 
 
 xl-Vi'SSels. 
 
 M'oiiiatouf* 
 
 Disr.Asf.s or Tin: /;/.vt/, iii.noii.VHssrJ.s. 
 
 II 
 
 .ia^r;i<iw«.'M »• ■' 
 
 .h'lr.lUTiltiMli a. th.' nlli.r iirtrlirs is V.TV .itl.;-ti..|iill.U'. 
 
 Wliilf it is II. .t imiH.ssilih' \nv liir niml iiit. ri.s \n !..■ ih.- 
 siiLj.. t »\' atli.r.'iii;! iii.h|.fii(hiitl.v ..f ii ^'I'lu'fal hiiiiihir 
 (•oti.litioii, it Im pioliahly v.tv s. Iih.m th.' cast-. 
 
 Wi- tiiiil tin- niial artciifs tlic .-iil'jcrls nf alh>r.>iiia in 
 •TdUtv ami ihniiiiatif [latii-iitM. 
 
 'I'll.' hn'iiialmiii in jT'iiity palii'iitH i« im .h.ulil ..ftrii dwinir 
 
 t.. this caiiHi. At th.' Ham.' tiiii.-. th.T.- is ii.i |H.:.sil.h' way 
 
 olairiviiiLT nt .'.Ttaiiity as to tli.- »'ti.ih>,i.'y of a hn'iiiatiiiia. 
 
 W.' >hall s.'t' tlial this coll. liliMii of th.- art.'ri.'s phiys an 
 
 iiii|.ortaiit part in aln.i.hy ..t'th.' ki.hi.'y. In "l,! |M.rs..ns, 
 
 at |.n-,t-iii..rt.iii III.' ki.liu-y is ..rt.'n t'onntl small from alro- 
 
 |.li\,tlu' ri'siill of iiiilnliv.'ili>tiirhan.'.' .'aiis.'.l l.y a h'ssoi- 
 
 iii'.!' of thi! caril.r.' of th.' art.'iii'S fr.mi ath.roina ..r .al- 
 
 .•ari'..us (h'i..)>its. T'>" vt'ss.'ls aiv also v.tv fiv.|i!.'ntly 
 
 athi'i-omatoiis in th.' small tri'unular khliu'V, hnl in this 
 
 install. •<■ Ih.ir .•on.liti.>ii is not th.' .-ins.' .>f th.' small siz.' 
 
 of th.' origan. 
 
 ANKUUISM. 
 
 'rh.i'f is no reason why we may imt liav.' an.'iiri>ni of 
 th.' renal arf.'i'y. A'^ » matt.T of fact, w.- .lo, .•.•.•a>ioiially. 
 at ii.ist-mortcms timl an.'urism ol" this vessel. It is, as a 
 nil.', .lis.'overed .mly after .h'ath ; since, mil. 'ss .|uite larir.'. 
 it woiihl he ini|M.ssihl.' to .liairn.'^^' it ihiriiiir Iif.'. I'ain in 
 th.' ki.liu'y a.'c.tini'ani.'.l with laematnria an. I a pulsatiiiLr 
 tum..r woiiM c.Ttainly justify -i .liairnosis ..f anenri>iii .>f 
 the I'.iial art.'i'y. 
 
 EMBOLISM .AND TIII'.OMHOSIS. 
 
 It is imiDssihIe to ascertain the fre.inency of emltolism 
 
 in the renal art.-ries as comi>are.l with emhoHsni in the 
 
 (i-ain. for instance; sin.'e it is sel.l.mi, if ever, possihle t(» 
 
 .lia<rn.)se such a coii.lition of the renal arteries. Frein the 
 
 large si/.e .)f the artery uri compared with the organ itself. 
 
 1 
 J 
 
»f ' 
 
 48 
 
 7)/.s7;.i.s7;.v or riii: a7/).v/;jx 
 
 111 
 
 w 
 
 <t i- iiufural to sMpiiost' tliiit it is ot'tcti tlii' sulijcct nt" cm- 
 Itdlisiii. There is IK) (l(iMl)t tliiit iil»scess of the kiiliiey 
 often results tVoiii this eoiiilitioii. Wliere :i hirtrt' ''r;iiieh 
 of tlie iirterv is olistntrted ii iriMieral iiejihritis miylit result, 
 ■ or iiifaretioiis take |ilaee. The etioloiry of eiiibolisiu of 
 the I'eiial arterii's is, ot'eoiu'se, till' same as that of I'laho- 
 lisiii oceiirriiiir in other origans ; aeiite eiidoearditis, athei'o- 
 liiatous <K'<;eiieratioii of tln' eiuloeanliuiii or of the valves, 
 or vet^t'tative detaelmieiits, iniLrh' 'n- the cause. 
 
 Thronihosis is <;enerall\- the result of injury, atheroma, 
 or invasioi, of the arti'ries liv intlaminatory conditions of 
 other oruMin. Throinhosis of the renal veins is likely to 
 occur from injuries, such iis hlows, falls, iH'iictratinir 
 Vvounds. from the coiiiiiression of alxloniinal tumors, or 
 from ir .laminiition extcndinu' from otiier ortjans. One 
 result, _io\vcver, that is likely to follow tliromhosis of the 
 veins is jiassive «"on<restion of the kidneys. If tlie other 
 causes that ]>roduee passive conirestion of tin.' kidneys can 
 l)c eliminated, it will he iiiir to suspect thrombosis. 
 
 *|l 
 
 k 
 
 ciiArTKK virr. 
 
 IRIXE. 
 
 UiuNE, the secretion of tlie kidney, consists normally of 
 a solution of substances, ortranic and inor<ranic, the result 
 of tissue-metamorphosis. It is a transparent tluid, of a 
 pale Uinon-ydhnv color, of acid rcacti<in, huvinsi u specific 
 c.avitv rauiiintr from 101.') to 10-2"), and is jiassed in (|nan- 
 tities averairiniT frotn forty to fifty ounces a day. Kaeh of 
 these characteristics is, however, subject to variation botli 
 in health and durintr the proiirress of diaertse. The jirin- 
 cipal organic constituents are urea, uric acid, xanthiii, 
 
 •T^rn^Ts'Js^f^^tnssr' 
 
i_H'ct (it cm- 
 tlic ki<lm'_v 
 irtrt' liniiicli 
 liii'lit rt'sult, 
 
 lllbolislll nt' 
 
 lit of »'m!)i)- 
 litis, atlu'i'd- 
 
 ' till' VillVi'S. 
 •, atlHTdlUil, 
 
 mditioiis ot' 
 is likely t(t 
 |ic'iictratin<r 
 tiiiiKH's, or 
 ;ims. Olio 
 hdsis of tlu' 
 If tlu" otlior 
 kidiK'V.s am 
 Jtisis. 
 
 iioniially of 
 c, tin." ivstilt 
 t lluid, of a 
 iii( u spt'citic 
 iv(\ ill (|nan- 
 V. Kacli of 
 nation hotli 
 The prill- 
 id, xiuitliin, 
 
 nusK. 
 
 49 
 
 kivatin, kn.atini.u., oxali." arid, oxalnri.- a.id, l,iH>..n. 
 .,.,•,,1 vtr TIk- iM..n:aHir coiistitucllts collllM-lse sulpliunr, 
 i.vdro.hlorir, a.i.l idio^plioriy acids, sodimii, i.-.tas^uiiu, 
 ;,iiminniiiiii, iiia,<riH'siniii, ealriuiii, I'tc. 
 
 y',„7,;,/;/,/._Tlit' nriiu- may Uecom.' turl.i.l wlim tlir 
 „„„„„t si-rn-trd is small in -["""tity and from tl.r fivs- 
 ^,,„,, „,• ,„,it.s. tlu' i'artJiy liliosidiafs of .alrmm and 
 ,„;,.,,H.i,im,or the mixed urates of sodium, i..,tassium, 
 ..al'ium.ai.dmaumesium. In the female it is ottm eloudy 
 i,,,„„ admixture with va-i..al s<..'retions. None o the 
 al.ove eMiiditions are of necessity al.n..rnial, althuu-li tli<. 
 ,,..,..istent presence of phosphates may indicate an excessive 
 .'ikalini.v which mayre.,nire treatment. Iheturudity 
 inuv In. cause.l hv admixture with the urine ol hlood, pus, 
 ,n„cu>. or tat, ..; may he the result . if a decomposition ..t 
 ,1,.. urine i. the Idaddcr. Sarcime are occasionally touud 
 i„ ,1,,. mine, reiiderinir it turhi.l when voided, and set- 
 tli„. as a whitish riocculent .lepo.it. The urine may coii- 
 taiiMuither pus nor mucus, the turhidity heiii- due entire y 
 
 to the sarcime. Tliey prohahly tind their way int.. the 
 nrinarv tract hv means ..f unclean catheters. 
 
 r„/„V— The e.dor of the imrmal uniu' varies trom tlie 
 ,u,,rlv coh.rless urine that tolh.ws the iii-esti..n ,.f a -ivat 
 nuaniitv ..f li.iuid ('"•'•/'" /'"'">■), t.. th.' .lark wme-yellow o 
 tlH" eoiu-eiitrated urine passe.l in the m..rim.-, ..r hy sueli 
 as have an excessive acti..n of the skin or in wh..m the re- 
 spiratory exhalations are .irreater, thus reheviii- the hh.o. 
 of much .)f th.' watery ex.-retion whi.-h is usually passe.l 
 l.v wav ..f the kidney. The normal ..olorin-matter ot 
 the hlo...l is ur.dulin, whi.-h is f..rme.l imlire.-tly m the 
 liver from haMilT.-h.hin. The nrine umlei-oes .•han-e m 
 e..l.>r f..ll.>winir the use ..f .-ertain .Iru-s: ,.;/., rhul.arh a 
 d.'cp vellow •, santonin, -ohlen yelh.w; senna, br..wnish; 
 earhoii.- acid, tar, or creasoto, hn.wn or bhuk. Blood will 
 c d 8 
 
 ?s;?i; 
 
 'r-«';,-5'iUff.i'-'.'ff •SI-''* 
 
 n ^ . •fl?'*-*^*'^'' 
 
tW " 
 
 50 
 
 I)Isi:asks or r/ir: i\ii).\/:ys. 
 
 
 ll ' 
 
 cnliii' til*' uriiii' ri'il, or, wIhti' it is <lisiiitt',i;ratt.'<l, ti-ivi- it n 
 lir()\viii>li or I'oi'tcr-foloird iiiiiiraraiict'. In jamidici' tlio 
 l»iliarv inattri's u'ivi' risi' t(» various tints, from dark vrllow 
 to Itrowu or i;rccii. Tiis or fat will iiii|>art to it a (•rcaiiiy 
 color. |)ial)c'tic' iiriiu' lias a rliarartoristii' ii^'lit tiivonisii 
 color. 
 
 /iciirtioi). — Tlif n-actioii of normal uriiii' is acid, caused 
 \>\ tlic jiiTsciicc of the aciil pliosphatc of sodium. Somh- 
 time after iH'iuir voided the contained mucus and or<;'anie 
 coiistitui'iits decompose, and, actinir upon the urea a-^ a 
 ferment, cause the proiluction ot' carlxmate of ammonium, 
 which i::ives to tlie urine an alkaline reaction and an ani- 
 moniacal odor. It is important to di.-criminati' lu'tween 
 uriiu' I'ciidci'ed alkaline hy decompositioii after heiiii'' 
 voided and that which decomposes in the lila<lder. 
 
 Tile ve^vtaMc ami mineral acids will make the urine 
 more acid. The urine voided several hours aftei' meals is 
 often found to he alkaline, for which circumstance several 
 theories have been advanced, tlio most proi»al)U' of w hich 
 is that ot' Kol)erts, who believes that it is due to an 
 admixture with the Mood of the alkaline elements k[' fond, 
 which ai'i' lai'irdy in excess of other elements. 
 
 S/>ti-ilii- (ii-iirHi/. — Till' specitic trravity varies in health 
 tnuu inl,") to lO:i.'). It may in Krin'i /mtus he as low as 
 1(1(1."). or less, in healthy persons, while in warm weather 
 and when tlu're is a fri'c action of the skin it may lie as 
 hiuh as l():iS. or even 1(»:}0, in wiiicli case the urine will he 
 small in amount. It will depend i^reatly upon the amount 
 of fluid imrested, heart-pressure, mental emotion, condition 
 of the stomach, or activity of the howels. The specific 
 ii-i-avity ot" the uriiu' is of irreat importance, hotli for the 
 (iTaii'iiosis ami for the pron'nosis in disease of the kidney. 
 We mav look for a patholoirieal <'ondition when the spe- 
 cilic u'ravitv is low and the urine small in amount, as in 
 
 ^1 
 
 J 
 
 1:1 
 
 vr;^;i!5Sg^v«v#s.\if!i&^s^7i&i«vAjS,ai!(*}to't^^ 
 
fA'/.v/;. 
 
 f)! 
 
 , li'ivc It i\ 
 iidict' tlu- 
 I'U vclliiw 
 a iTciiiiiv 
 ii'i'i'i'iiisli 
 
 (1, caust'il 
 
 II. Sollli' 
 
 il (ii'ii'anic 
 iria a-^ a 
 iiiioiiiuiii, 
 <l an aiii- 
 
 lll'tWCl'll 
 
 ■r. 
 
 lln' uriiif 
 I' iiu'als is 
 (•(■ st'vcnil 
 
 (if w lllrll 
 
 liu' t>i an 
 
 tS dt t()M(|, 
 
 in licaltli 
 as low as 
 n weather 
 uav lie as 
 ne will lie 
 le amount 
 eonditioa 
 le s|(eeitie 
 th for the 
 le kidney. 
 II till' spe- 
 nnt, as in 
 
 „.U,,i,is, Of when It is hi,h and the amount voided is 
 
 lar.T. ;is in diahetes m*'llitus. 
 
 f nn.ke the s,K.eiti.- ,n.vitv of value ,,yiK..noM.^^^ 
 
 ,,iU,,e,u.eessarytotaketha,..t'as,,ee,men.ron,aeoll.- 
 tion of nmu. for the whole twenty-tour hours. 
 
 ,^,„,;.,_The avera^. un.ount ot urn.e , ^.d 
 „vu.tv-iour hours is ahout tiny outuvs hut varte.u.tU 
 ',;,.,,-,,. of the skin and howcls atnl the amount o 
 
 , i,„e',ed. rathoh.,h-ally, the an>ou..t o. urn.e > 
 :;;„,,,U. i,.ereased in diahote-, ,n hyster.eal or oh 
 
 --^=''''^^-r^:;:t.;;;:x^ 
 
 ;;rrr:;:;: .;:;■ :n.:;:;..-iti. th.. i. di.ni.d.in..i ... 
 
 : eXm;\uHl when the dituinution in amont.t .. a...o. - 
 ;:;-edwhhah>wspecitie,ravity,itn.eansad.,n.,u.hod 
 
 ^•^O:;!:' ^n-^'ollor, whu-h has hoett deserihed as swoott.^^ 
 or unmumcs vat'ies i.. in.e,,sity with th. atnonnt o e.,n. 
 
 .entvation of the nritK. Wlu-n d.-otuposed h > 
 atntnotnacal odor. Cortain dru>rs mq-art oh, turn 
 ,,,,,,teristie odors, as do also ee.1a,n vep.tal .. 1 
 
 ,.,„ti,u- -ives it the odor of vh.lets; euhehs. eolK"'" • '^"'^ 
 !:;;dal.v^od on i,n,.art to it the odor ,eeuhar to thctn- 
 selves, as does also asparaiTUs. 
 
 CHEMICAL COMPOSITION. 
 
 Tho n.Uowin..^ table, eopied frotn Hotf>nat> and rit/.- 
 ,,,nn, .ives the iu-inei,.al solid eonstituents ot nortnal unnc 
 
 and the average (luantity exereted : 
 
 mf^s^^^^a^^^ 
 
 >i<«Jti.<i'"jf*C*»"»^' 
 
f 
 
 ill 
 
 52 i>isi:.\si:s of tiii: a7/>.y/;j.v. 
 
 iiriiiiniii- I'rr i cut. 
 
 Sdiil" "10 Til 4.:! -4.0 
 
 frfii :in 4(i I'..". --:!.'.' 
 
 III.- mill 4-- .s .{)■', .ti.-. 
 
 ciiiMiid.- 1(1 -I;; .7 .s 
 
 Kniitiiiiiii^ .") • 1.0 .li:ii'i .W2 
 
 llipl'iiiir iiciil ii— 1. .ti'J .(m; 
 
 K:irt)iy |iliM>]iiiiitcs U- \:.\ .117 .(i,s 
 
 rii..>|.ii.Ti,' iici.i 1.'..". :;..'> .w .'j-j 
 
 Sul|iliiii ir iu'iil l..'i 2,.') .Ir, ,17 
 
 Ki'oiii till' iilidVi' talili' \vi' SCI' that llic imi-t iin|iiirtaiit 
 (if till' solid: — that is. thosi' ('Xci'i'trd in ii'i-catot i|Uaiitit v — 
 ale iifra ami chlofidcs. the otliffs licin^- sn small in <|iiaii- 
 titv that thfii' |ii'c>riicc or aliscucc has init little ctrctt ii|piiii 
 the s[H('itir u'favitv tit'thc urine. 
 
 nlMiA.MC ((iNSTniliNTs. 
 
 f'l-i'i is the iihi-t iiiiii'U'latit, iieitii:- jiassed in lai'ii'est 
 
 aiimunf of any of the solids, and its aiiseiiee indieatinu" 
 
 iii'a\i' distufhaiii-e of the u'eiiei'al economy. The amount 
 
 of urea passed in tweuly-four houis varies. aeeoi'diiiLT to 
 
 e.\el'ei-e. t'ooil. oeellliatioll, etc.. iVom t\\i> llUlldl'i'il ami 
 
 fifty to five hundfed and tit'ty iiTains. l)e|ieudinir as it 
 doi's upon the activity of llu' liver and thu amount of 
 tissue-waste, it will vary with the amount of nitrogenous 
 
 food iuLl'ested. 
 It is iiicri'asi'd — 
 
 1, When much nitfo<renous food is taken. 
 
 2. Fn conditions of the livi'f in which thefi' is incivased 
 activity. 
 
 '.]. In the I'arly sta.ii'es of disi'ases in which there is 
 increased activity of cells. 
 
 4. Wliere liai'd muscular work is performed. 
 
 '). FeviM'.-'. (It is a (|Uestion wlietlier in ceases ot' fevers it 
 is due to increased metamor]ihosis. or to chanii'i's in the 
 food from failure to assimilate at so hitrk a teiuiieriituro). 
 
 'M,U I 
 
 T!:^;ei5-?*Ji?K3SS??35m7^s:JF?3!SE^,^ 
 
iitish:. 
 
 :>:$ 
 
 lit. 
 i i; 
 
 .O'l 
 
 > 
 
 .(Mi 
 .(IH 
 
 .17 
 
 illl|iii|-t;illt 
 UillltitV — 
 I in •|iiaii- 
 
 tl'l'tt lllMlll 
 
 II lai'ii'ist 
 mlicatiiiL;" 
 I' aiiiiiiint 
 Di'diiiii' ti) 
 (li'L'd ami 
 liiiir as it 
 iiKUint of 
 troi^oiious 
 
 im-ivasud 
 1 tluTc is 
 
 •t'fcvrrs it 
 :rs ill tiu' 
 penituro). 
 
 ,; |„.ilalK.t>.snu.llin.sa.Hl.lial..t.si..si,.i.lus 
 
 tr in Unnirinir al»iut laii- 
 
 „,,. ,,, yvn^huy tl.r iiMiMnal !un..nn 
 is(liniini>li<'<l t'orniatioii in ' 
 
 tlii'li\HT,«»r tlu'ivis ilimini-livd 
 
 ^.xnvlinn in tlu- ki.liu'.v. 
 
 1 Wli.n-tiu. i'='tiH.tisat,v.t,nnnnlk.l,..t. .1 Ut,n 
 
 .; W1H..V tlH..v isa^ln-i^l. .■undition ..,• a tun.t.onal 
 
 :1 Wlu.>vtlK.,visdis..as.oftlu.Uidn.v,n,..rU.nn.u,,l. 
 
 ^■'ui^!^' fs di>.as>M.ould not h.Mlia^nosM fro.n tin. a,n.^^^ 
 .,.,,,; ......,.dJu.tJ<.u.win,tl...dis...s..tol..,.,v^^^^^ 
 
 .H„u,us!u.d .Nr,vtion of uiva wonld .•on-.^...n.t.. tl. d,a;:> 
 
 , Lis, and tlu. :unou,. .x..M.d would ,nv son,.. ,d.o^^ 
 
 he oxtont of kidm.v involved. If vou know that th. In. 
 
 ^"^.^ .. . . , ui... ..,,,1 fn.d the normal amount 
 
 and other tissues a,v lu-ahhv and tind tin. u 
 
 ,t-n,-oa present, you tnay he ......tain that the d.sea.. ot tlu 
 
 kidnev is not very ext(.nsiv(.. . 
 
 4 In ehronu. diseases where tissue-eha.,^e ,s ,,n,,a,re.l. 
 
 5 T„ehl..rosisaml other ansvinnis. _ 
 
 Of late the suhjeet of tlu. ahsolute and relatnv a,u.m,.t 
 
 ,,.,„.^.^, ,,,l .laorhles ,..-ese,.t in tlu. urtne UMatu... .4 ^^ 
 ston,a.hhasreeeive.leonsiderahh. attent.on. Ihe e ha 
 
 not '-oen a sutHeient numher ..f ...xam.uatu.ns as y to 
 "t^^hlish a rule tor dia,n..sis ; hut it w.>uld seem a..eonhn, 
 
 I ,,,„,,,, that the ttrea is i.u-reased and the <hlort.les 
 are diininishe.l in caneer of the stomaeh 
 
 Considering^ the n<.rmal ,.n»iK>rt,on oi ut-ea ..the .hh>- 
 
 Pides to he a; "2 t.. 1, Ih.uveret of Ly..ns tou.ul in eatu-er 
 
 ;^Jst.unaeh the relative ,-ath. to he ^H..l: tin. ts>o 
 
 parts of ut-ea t., ±4 ,arts.,feldo.-ides; hut lunmelor^^^ 
 
 of Brussels, who has .triven the suhjeet eot.stderahle attui- 
 
 tt a-utnes the tu.rtnal an.out.t of urea to h. twenty-hve 
 
 nu nines, and li.uls that when it is redueed to ten .ratntues 
 
 V^gt«»«;»iAs*o*JW;=K*'** 
 
r" 
 
 ^- 
 
 54 
 
 DisKASEs or Tin: i<n>.\/:is. 
 
 &: 
 d 
 
 I- ' 
 
 jur ilii'iii ill ii ciiM' (ifirastnc disciisf it iii;iv lie sat'fly cou- 
 
 siililcil railrrn.lls. It will prolialilv l>c I'iMIIkI to <ir|ic!l(l 
 
 iilinii the aiiioiiiit lit' voiiiitiiii:-. W'licii tjiis is t'xci'.s^ivf 
 thr ell!. .rides will iiatiii'allv lif (iiiiiiiiisliiMl. 'I'lic siil.jcct 
 (Ic^crvcs cai'diil stmlv. 
 
 I i-ir .\,nl ami /'I'ltts. — Aiiv increase in the aiiKiiint 
 present (it' these ediistitllellts is iisiiallv (lile III the same 
 itiiiditiMii that causes a diiiiiniiticii of urea. 'Phev are 
 siiii|)l_v urea iiiiiierteetlv o\_vi:-eiii/i>d. I'ricaeid is raroly 
 I'Xercted tree, lieiiiiT ,ir<'nerally in conilmiation with po- 
 tassiiiiii. soiliiiin, and aiiiiiioniiiiii, and also with inau:iie- 
 siuiii and calciuni, loriiiiii!:.- wiiat are known as the mixed 
 urates. We iiml an incri'ase in uric a<id or iirati'S from 
 increased in<festion o1' nitrcureiioiis food, where too much 
 Work is thrown on the diijestive system, the food hcintr 
 poorly digested in the stomach and the liwr heiii<r unahle 
 to pi'rform its work. In other words, it nu'ans an imper- 
 fi'i-t oxidation of nitroi^eitous tood. We find this in i^outy 
 patients, in chronic hroiicliitis, where tliore is ohstruc- 
 tioii to the Venous system and passive congestion of the 
 liver, in heart-disease, and where outani'ous rospiratiun is 
 diminished, also in the insane. 
 
 IJesides the ahove eoiistitiieiits the urine contains small 
 <|Uantities of liippurie acid, wliieli is formed in tlii' hody 
 from proteids; kri'atinine, derived from musele-kreatin, 
 increast'd in fevers, pneumonia, etc., and diminislied in 
 ana'inia and wastintr diseases; and xanthin : all of which 
 are simjily less conniletely oxidized products of tissue- 
 ehauijes than un-a. 
 
 IMiKiiAXIC COXSTITrEXT.S. 
 
 Of the iiiorifaiue constituents the most important are — 
 1. Thf C/doridiS. — The cldorides in human urine con- 
 sist almost exclusively of chloride of .sodium with a very 
 
 .v.wajK:sm'Cj/-U;^'^v^-<i^'i^v«?:.fcji;cife:&;s- 
 
 iiiM 
 
riiisr. 
 
 i)<) 
 
 <iifi.'ly I'oM- 
 
 tl> <1('|IC||(1 
 
 t'\rf»ivf 
 lie sllliji'ct 
 
 <' aiiKiiiHt 
 
 llic saiiii' 
 
 Tlii'V are 
 
 I is rarely 
 
 I with ]io- 
 
 ll lllilLTIH'- 
 
 iiic iiiixfd 
 rati'S iVoin 
 too imitli 
 r)o(l lifiiitr 
 n<r uiiahK' 
 an impiir- 
 s in ijouty 
 r* ol)striU'- 
 oM of the 
 
 •iration is 
 
 ains small 
 tho liody 
 
 le-kreatiii, 
 
 iiiislu'd in 
 of which 
 
 of tissuL'- 
 
 tant are — 
 irine con- 
 ith a Very 
 
 .,nall .n.ount of chloria " ,.otas.ium ^"'''"'•'•!', "'|,^;; 
 
 ,;;;;;;! ,;.,,sal.outon.-t;.urtl. of .lu total soh.lsotlu.aUh> 
 
 , . ,1 u f.i^tf to till' st't rctioH. 
 
 "U ; ,;,vas.l in Hri,hfs .liscas., in .ln> Wt.s, .n. 
 ,,, . l..,;.vo..aa.rpuroxysn.sof.;™ K -l""'"-' j 
 „ ,,., ,.„,,. •„ ,t r.st, an.l in pncnnonn, and a . 
 ;;,i:,-K. ,lis.as.;, .s,..'ially those ao-on.i.anu.a 1, ..,on> 
 c.NU.lati-ns or watery passa.ires. _ 
 
 .. '/•/„ rhos,,h>hs are, of two varieties, the ea.tl.N an.l 
 th:alkaline ,hos,.ha,es. The earthy ,.h..s,hates are ho.e 
 
 re leiuia an.l nUne^iun.. >'' --^''-''^ \' '^lin nt 
 ,,,,,,,. I in sohuion, hut iheyare.hr-'teaa. >e.hin.nt 
 
 ^■'•'-:;::;:;;;;;;:\;th;: earth. ,.os,.ates is oi.^^^^^^^^^^^^^ 
 
 ,,,• i.o.u., ..ste.miala.'ia an.l neket., m n 
 
 ,,,,l,,i,i., i„ .liseases of the nerve-.-ntres an.l atte, ,ir. ■ t 
 m'ltal Strain. Koo.l an.l .Irink, the latter es,ee,alU, 
 iiK Ti-a-e the nhosnhates. . • n i ,. 
 
 , 1 flw.v Mi-e for the nn.st part .h'rive.l, a Muall 
 
 ;::;;^: ::;:;hi;.: ."ive.uv.nn ;h.;^aisinte,^^^^^^^ 
 
 ' -. u. .u.l museular tissnos, so that inrta.nn.ation t..e... 
 ;::::: i~l activity of the vital processes w..iihnav.,r 
 
 the eii.nination of a -reater ani.mnt. 
 
 The ..ther inoi-anie constituents are ot s.> 1 tth.' 1. ual 
 ■ . th.,t we ^hall eonsu.ne no further tune m their 
 
 importance that ne>iuui ton , »• u.>..lc Tv<on 
 
 con.i.lerati.,n, referriiitr you to the works ..t Ikak, In. on, 
 Koherts, an.l .^hers up..n the suhjeet. 
 
 !'i'K/ci'^^->'"'T."-^;^ 
 
if" 
 
 :.»i 
 
 [usi:.\si:s i,r r/ri: hin.Mns. 
 
 ntlNAKV lii:i'(»<ITS (i|; SIIKIMKN'I'S. 
 I riii:iiv ilr|i.)sits ai'i' (ruiilcd inid fun riasso, tin- //(- 
 "/•//"/('.■ iiiK I \\\i' iin/iiiii,; T\\t' ni'iiyitn'r deposits ai'.' tliosc 
 • •lfiiifiil> uliicli li.nii |.art of tlic iK.nnal iiiinarv .unstit- 
 lU'iits. I. lit uliirli l.v rt.a>..ii .,f some cliaiiHT in tlic iii'iiii', 
 or i>{ an cMo^ivc iiincax' in tlirii- (|iiaiititv. Iktmihc in- 
 solnidc an. I art' |ircri|.italr(|. 'I'lic nn/mn'r tU-^H»\\> ..m.-ist 
 ofurti'aiiic snl.stan.fs wiiicli umltT nonnal ciMKlitiuns ilo 
 nut exist in tin- urine, am! uliieli wlien jn'oent tliei'e are 
 inefely lielil in sMs|»ensiun. 
 
 The tMlI.iwinu' taMe. .|U(.te.l t'rnni 'IVsoii, einhraces \u,\U 
 varieties : 
 
 flinrt/ilini' I )i jKisHs, 
 
 1. Trie iiiiil (<n>iiilliiir). 
 
 j '/. Acid ^oiliiuri iinili' (iiMi()r|i|iims, ncca-ioimllv crvs- 
 
 II. I rir nc\i\ \ 
 
 .■■■iiiIi-iukI-. j ''• -^'i'' l"''''"i"'i' iin"'' (iiiM.>i|,li,,us). 
 
 c. Acid I'lilciiiMi iiriiti' (iiiiii)r|>linu>). 
 
 I ''. Acid miiiiinniiiiM iiiiili' (en >tiillinc). 
 
 III. Wxiilutc 'f lilllc (ilV-tllllillc). 
 
 I\'. K.irlliy I II Aiiiiii"iii(i.iimLcncsiiiiii |)iiiis|ilintc (cry.^tiiliiiic). 
 
 li|i-pli:ili> ( /- Culciiiiii pli<i-|ilmlf ^ulii(ii-iiii(iiis and cry^tiilliiic). 
 \'. ('illriiilM C!ll-tin|iiltc (cryst«llinc). 
 VI. ('iilriiiiii »iil|>hiitc (cry-t.illiiic). 
 Nil. Li iiciii Mild tyriisiii (cry.-tnlliin'j. 
 \' 1 1 1. Cv.-tiii {(■ryslallinc). 
 
 Oi'ijiiliic I)i piisits. 
 
 I. Mucus iiii'l iiu>. V. S|>(Tnmti7,()ids. 
 
 II. Ki.itliciimii. VI. Fuii'xi imd iiifii.-oriii. 
 
 III. HI 1. VII. Klcmciit.'^ nfiiidilrid ;;•.•. wth. 
 
 IV. Ciists. VIII. Knt..z..:i. 
 
 INiiHii.wic DIM'osiTS. 
 
 Urii- Ar'iil wluMi (le|iosite(l a> a sediment taki's the t'ofin 
 of uranii'e-red erystals. I'ldt-ss deposited within a <V'\v 
 hour.'^ after the voidintr <'f the urine, it is of little elinieal 
 
 ^.i'r*j;iaa!«:*' 
 
 *y*i;.»i«;tteiiiiaMiite*^sHe«Siii(^iS«^ 
 
//.".v/;. 
 
 r.7 
 
 'aci's ImpiIi 
 
 I'imllv (Tvs- 
 
 iillitii'). 
 ■^tiilliii.''). 
 
 111. 
 
 d !,'r iwfh. 
 
 the t'ol'iii 
 ill a t'l'W 
 t' (Tiiiical 
 
 si.r„iti.'ai..v,as l.ralthv luinr will .Irpusit im.' a.^i.KP .iT. 4) 
 if allowr.l to iva.h tl.r sta.uv -.f a.i.l f.TinrMtati.M.. 1 1.'- 
 .li.,.as,- ill wl.irl. it,< |..vs..,..-.. in lai-v .,H;M.titi.s is rliarar- 
 trri^tir i> u^n.it: an.l of its ivlatioi. to thr si.l.rH now 
 „„.l..r . oMsi.hTation I uould say timt !!..• .-iii^'f .la..-.r to 
 !„■ aitnlHiul.'.l iVoiM its i-iTsnuv in liH-^' .luantm.'s is 
 
 Fid ». 
 
 I'ric iii'M rrysliiN. 
 
 not so nm.'h in tin- aiiu.unt rx.-rrtr.l as in tl..' .•tlcct oi the 
 .vtai.R.l rrvstals on tin- Uidiu'V-tissiu-, .•lo.ir.irii.i; 'i). the 
 tuhulrs an.l i>ro.lii.'in;r irritation in the intertnhular ti>sue, 
 thus lavinir the fonn.lation lor a ehronie interstitial iie- 
 ,,1, litis" Therefore if we ohservi' a very raphl dei-osit of 
 nvu- aei.l we apprehen.! the same to he o.eurrin- in the 
 ki.lnev-tissueorBome part of the urinary traet, either pro- 
 .Inein""- irritation or forniiii,i; a ni<lus tor urinary .'alenlns. 
 I'rie aeid ervstals are always of dark eolor, ami have an 
 infinite varietv of form, the typh'al shapes l.ein- tliose <.t 
 a tour-sicle.l rhomh and a six-sided plat... They also ap- 
 pear in a>'i,n-e!rations as roseires, in spear-, fan-, and eomh- 
 shapes ete. The .Ininh-hells (.f nrie acid nniy he distm- 
 '.niVhed from those .jf oxalate of limo by their dark eolor, 
 
 Kft'ellrifS: 
 
r'' 
 
 M'^ 
 
 M 
 
 /)/.v/;.iv/;,v or Tin: ian\i:ys. 
 
 liiriffP sizi', iiinl itiiilv sdliiliility in iilkiilit ■^*. Wr iiftcti 
 liml ill till' iliii|M'rs ut' lu'W-Iiurn inliints red, Lrrittv t|i|Mi>its 
 iif iiijc iirid ami iii'mIc^. flic iia^-^ii'/i' "I' wliirli uivi^ lliriii 
 lintcli pain. 
 
 /'/■'■ .|r/</ ( 'nioiiiilllii/^. — 'I'llf llliltrs nl'tlli' ill kllli'- iU'C 
 
 iTi'in Tiillv (ii'iKisitcil ill llif urine as an anioi'iilioiis |i(i\v(liT, 
 varviiiL;' in color fnini llic hrick-iliist or " latciitimis" iK- 
 jiosit to an alnio>t ulii.c sciliiiicni, tju' color (li|a'nirMi,i.' 
 
 Fill. r,. 
 
 I'mli' 111 MMJiuiu. 
 
 u|ioii tlic density and (olor of the urine iVom wliidi it is 
 deposited. This sediment may he t'ouiid in tiu- urine of 
 lu-atthy persons, where it is of ii liiLfli ih'iisity, acid reac- 
 tion, and low temperature, as after profuse sweatiii«r or in 
 viry cold weather. I'atholoirii'al'.y we tiiid the di'posit 
 occurriii!.r most Ireipieiilly in fehrile conditions. 
 
 Heat will dissijiate any cloudiness or deposit of urates. 
 
 ■ :?;'.:j. ^ij-V?ii.-;.jt«i'!^.?t . "S f i '-i' -54 tf't •(■.'tfiSii^' 'ii'ii 
 
W'r lift. 11 
 ivf< tlirlii 
 
 kiiliis iin- 
 
 « |Mi\V(liT, 
 
 fiiiiH" ill', 
 liluiidiiiir 
 
 iliicli it is 
 • urine of 
 acid I'ciic- 
 itiiiLT of ill 
 ic (U'jiosit 
 
 of urati's. 
 
 "■^^;,;::;,;r:;;::';;:l:hi. •,■> - '-h— >"■ 
 
 <"'- - " >^"'':.:;"';:t;:u";:ii i- •> >"■ 
 
 •1" "■"■" ■",' ■" ' ' .,,„i,,.v.taU..rtri|.l.-pl'"" 
 
 ''' . ; . .".rv^fiHiMr. .n.l UM.Ur tl>r .uu-rosn.l.c- 
 
 :r:;:i::;n;;'H::^M'...-- "■■ ■"•'"■"'•- 
 
 Fid. 0. 
 
 /c 
 
 '^ 
 
 
 '^a ^^'l^ 
 
 oi- 
 
 
 ' *% 
 
 (»xi\liiUM)rUnu<ry-taH. 
 
 .,„. .■,.,.,„a,i —,.... .Hi ■;.;:;'•':,•;"• 1,:',: 
 
 ■■'■"- " ■■''■';''':,r;;:;.' u7mi;■,.,n.r,l,.■ 
 
 ::5S?^;7i5?^^ 
 
r 
 
 m 
 
 /•/s7,|v/.s »>/• /•///; hil>.\His. 
 
 \ , 
 
 nxiilntf tA' lime in>t;il-<. Ollur iiiitli«»rs cuiitciiil tliat 
 • (.Miliiir «if lime is (liTivnl irniii a (k<t»iii|M».'4iti(iii of uric 
 iii'iil iiikI iiiMlcs. 
 
 n\iilalf of Unit' ti\-.ti(l. !i|i|ii'at- in a<ii| mine unlv. 
 'I'luir Hlia|ii' i^ wvy ilmnKicii^ti • '\\\n t'urms arc nid. — 
 llic Mctalicilia ami tlic iliimli-licll cr_v>tals. 'I'lic octaliciira 
 arc tiaf, retract the liirlif, ami sunictinics a|i|icar as nicrc 
 I">int-, wliilc at ntlicr tinns tlicv assnnic tlir cnvdnpr 
 hliapc. 'I'lic clinical sii^niticancc of tlic oxalate of linic 
 crystals is almost iticntical witli tliat of the apiMarance of 
 urate's in the urine; hut ulnii the (hiinh-h.ll form- aie 
 met \vi' shouhl Itcar in mind the tint that thev are in- 
 clined to aecumidate in the tuhuli urinifcri and form 
 calculi, 
 
 E<irth>i rhnsjihiil, -:. — 'I'lic amor|>|ious ciirthy |ihos|i|iateH 
 are fr»M|Uentl_v found in urine that is alkaline, ^^Y that has 
 umK'rirone ammoniacal dectuiiiM)sitiou, as a _t;ravi>h-u hite 
 
 Fill. 7, 
 
 AMiiniiiiiiiiii |.|ic>s|i|ial('<i. 
 
 Sediment. Any cause which occasions alkalinity t>f the 
 urine may jiroduce this sediiuent. The crystallized idios- 
 
 '"'■'Xik.'i^iy'i'-'.'','--^'''-- 
 
 ■ r^-^i'-^fm 
 
I i!i.\r. 
 
 t'.l 
 
 • nil iliitt 
 HI nt uric 
 
 irif Kiilv. 
 re iiu't. — 
 M'talii'ilia 
 r as inert' 
 
 lll\ clnlK' 
 1' of lillM- 
 llillicr III' 
 iillllS illi' 
 
 y arc iii- 
 iihI roriii 
 
 ii>s|t|iatcn 
 
 tliat lias 
 
 isli-wlilto 
 
 y of the 
 
 L'll jlllOlS- 
 
 ,„„...,,..,M„„.i.,.,n.ai.. ,.al,., tan.tlv.a...l unn... an.l 
 
 r.l,iL('J' '■ i.ara.v.l.l.u.ii.Ml..m.a.M.n.uJmt 
 
 i. IUM1..1 al.MU.IaMtl.N intl.at ..nl... h..rsi-. 
 
 r././ .sw,/""- ■'-''- "••"•■""••"""■> ^'■"""■' * 
 
 „,i„„ u|,i,.l, U l.„ I will, l,ili„n ,..I...M.v'.iMa.l,..-. "-I 
 
 ;;,,;,„ii,;,Mv ■.,.„v,.,ii...a«,.;ni..>iv..- ,.-.,.,. .v..ii..w 
 
 iiti'.ii.liv ami iihuM.lioni^ iM)is..iiiii,Lr. 
 
 "";•,,,..,! ..rl , ...li n., wl.i.L .l.v.l..i.-|" 
 
 ,„„„',„■ s„l,l,m..>„..n..v,ln.,,-. ... -11 - ,.1 um,u,m,a u, 
 
 (IccMiniHisetl iiriiif. 
 
 oni;\Nii' i'i:i'n-irs. 
 
 J/.,... //•...--Nln.us.xi-Ninv..rvHnallMnanri.Yn 
 
 h.al.l.v MHU... 1. f..nn. a lain, tlo,...nl..n, .Ion,) win- , 
 
 l.;,,.wanl.lH. louM- ,,ar,nr,l,..l!uu al.HM^^^^^^ .- 
 
 ,.,.,. ha. 1 n allnuva .o Manil ..m. .MM. ana .s ..o,n- 
 
 ,: I ..,• epithelial ..■11.. n.un.l .raunlar l.u.l.es ..alle.l 
 
 ,.n,.us.e..r,a,seles, a.al a llnia ,--ti.n. the /-r-'' """'• 
 \\Mmmm.h ens is luvsent in lar.e an.Mun. >t .hn. e> s.,,,H 
 
 Lnrl.un.o in tin. urinary traet. ana wlu.M the ae,.n.e ..t 
 ;;;.;;;;.,.anee increases thoeharaeteruf, he .le,,.s,t ehan,es, 
 
 »•';' l?'^^^•''' '": 'n;'':,, , ,,.,,,i,l,.n.sta^e to .listin^uish 
 t s iiiiiio>sil)U' m the tian>nii'n u ,_ , 
 
 1 , .nul 1,11^-colMinsc iS, hut 111 tlK' 
 
 Uctween iiiueus-eoq.useh.s an.l i.u> .' |m, i 
 
 ,,ter Sta...-S the ,.U>-eor,.US..les will ho ohsenea to 1k 
 
 , . ,,„.,.,,an,lyVu,,.lu..l -ith nudei than the mueus 
 l,,n<..les. Solon^J.owevei-.asunne....nta,nn,^nn u. 
 i, ^ vithout alhun.en. so h.M- inay i.us Ik- sahl to 1.. al.sent, as 
 
 ,„„.,„. i,...f eontains no alhnnien, while pus a ways .loe>. 
 r;'in!,.ontainin. pus is turhi.l an.l inilky when voi.le.l. 
 
 „,l ,,ur stan.lintr awhile .lep-sits a aei.se yelh.w.^h- 
 
 ,-.'i)t,u»<ii ;„ ' jay«S* 
 
DisKAsKs or Tin-: KiDyKis. 
 
 wliito si'diinc'iit. Wlini tlu- uriiu- is alUaliiu' tlu' pus 
 cnlicrcs into 11 viscid, li'iimiitiis mass wliicli ciiii 1k' drawn 
 (Hit into Idiiu:, t(»u<;li striiitjs. lU-alu iin'iitioiis tlic tact 
 that Jills is tVc(|iu'iitly met with in thi' iifiiic ot' iicrsons 
 past till- mi(hlK' jicriod of li!c whose n-ciicral licalth is 
 iCood. It slioiild not lie I'orii'otteii that in I'einali's pus is 
 apt to appear in the urine Iron i leueorrhiea or othir puru- 
 lent discharp' from the vaii'ina. 
 
 When- the alhuiiien contained in purulent uriiu' is 
 larsii' in amount, it will ho well to luuk closely for renal 
 easts. 
 
 Jilniji/. — Trine containini; Mood from any jmrt of the 
 urinary tract will always contain alhuiiu'ii. The urine is 
 usually smoky wlu'ii the hlood is derived from tlu' kidney, 
 unless thwre is a tree liemorrhiii;e ; when the liloml is 
 derived from the hhulder the urine is often of a lirii:-ht 
 red color, or the hlood comes in clots. AVhcii the 
 lu'mori'hay'e is from the urethra, it either jirecedes or 
 follows the How of urine. 
 
 IJlood is usually doiiosited from the urine as a ri'ddish- 
 Iirowii sediment. The color of the ijlohules differs accord- 
 iiiiT to the reaction of the urine, heinu* of a lirii^hter red 
 when the urine is neutral or alkaline, and dark or lirown- 
 ish where it is acid. Examination hy the microscope is 
 the surest method el' diiiirnosis; althouj;h in urine of low 
 specitie tjravity and in ammoniacal urine the corpusiles 
 disappear very rapidly, Tt will be sei-n that the cor- 
 jiuscU's do not run into rouleaux, as they do when drawn 
 directly from the blood-vessels, but ajipear distii;r't and 
 separate. Where the urine is dilute, the corpuscles ex- 
 pand from imbibition and a}iiiear as delicate cirifles 
 without visible contents; where it is more concentrated, 
 they are small and preserve more of their biconcave 
 contour, and at times are shrunken and nn>Jsliapen. 
 
Liiiyi:. 
 
 t;:5 
 
 ' tlu' pus 
 \k' (Iriiwu 
 ■; the tact 
 ^t' luTsoii-i 
 lu'iiltli is 
 Ics pus is 
 lliii- puru- 
 
 uriiu' is 
 tor rc'iial 
 
 irt (if tlu' 
 \v urini' is 
 10 kiiluoy, 
 l)lo(nl is 
 :' a lii'iti-lit 
 Vhvu tlio 
 o<'(.'<li's or 
 
 a rrddisli- 
 'I's arconl- 
 iu;litt.'i' I't'd 
 or l)ro\vn- 
 I'osc'opo is 
 iuc of low 
 .•orpnsclt's 
 the cor- 
 K'U drawn 
 itir.'^'t and 
 usc'les ox- 
 to (.'ircles 
 ceiitratod, 
 liii-oiK-avo 
 
 (VW..-T1U. sul.)..t of ntsts is fully discussed in the 
 
 followiiiii ehai'tcr. r , , .c fi... 
 
 N/..../..--./.^ iVe,uently o....ur UJ the sedmu. . o 
 
 ,t- healthy men. When ahnndant tl-N '. a 
 i.ht tloe.ulent elou.l in the urine, hut .generally then . 
 
 .o^hin^intheappearan nluMjri.K. whu.h wou d .^^^^^ 
 
 a suspicion of their presence, and they nu.st he .hauuo.ul 
 l>v the microscope. 
 
 ,„„„r'i„ ,u.c.,n„.osn.« «n.. uln.h w... t".--- . ... U 1 
 
 : : .hlo h, .l,..ir .«,„■■,., «n.l »>■.. „su„n,v u,,.,. ;. ; .- 
 ,V;,,K.nt .>!.......' tlu.n, »,v l....tc..-,a. ,.om..,lUm, ,.-1. .."... 
 
 ,,,,,.,.,. f„„,n,s. S»r.ni... ..l-. im-t with ocn..m,..ll.> . 
 
 „,. ,, ,K.. C.lls .„■ .■,■»,'>.,.„.» ..f a gn.^.l. ma, l.. !....„., 
 
 , , ,„„st 1... r«u.,ul,wv.l that aln,..st every .-l.al.u ..I 
 
 a ari.. .V...n .1,. cells of, ho l.la.Wcr .lurmg uMla.a. 
 
 ,,.,„• ,„, ;,,,i„„u,„. Frag,m.n,» of canccn.as p « 1, 
 
 „, „,„, „,„,, w„yin.o ,l,c urine a- f'-™".^ "' 
 
 vill.ms variety, an.l .t.ay k1,„w tl,e ea,„llary ve-.el» that 
 
 '"t:t"».a«re.eW.,,nti,,,,,.ii,,,i.e„,-i..ei...l.^ 
 ,,-,t..e. TItere have l-ve„ several i..sta„ees ■„ wl„..h 
 eelmmeoeeus evsts aiul h....klets U'ere ohserve.l. 
 
 .I..l,„ Harley f,.u„.l in the urin,. ol several xtttents 
 sntle.'in.' with the en.le.ni.- ha-matana »i .< '^^ (.''l"' "/ 
 G,!;,ni;.,.e thee,.,san,l eiliate.l e,nhry.,s of the litlhar.ta 
 
 ''The'ih:,'ia ««..«ni,,is l.ontinis, the ..arasite whhh h,. 
 ,J„ shown to have so intin.ate an ,tsso«a„..n w„h 
 ehvhiria, is sometimes fo.in.l in the tmi.e. 
 ^' bilto,;,a ha„na,.,l.in,n has heen '""n, .n he hla.l.le, 
 ureters, an.l velvis ..f the ki.lney, espeetalK ... I.»l"- 
 
 ■■ 
 
64 
 
 DisHAsKs (>/•• Tin: hiDMjys. 
 
 (MI A I'TKIi IX. 
 
 CASTS Ol- Till-: ntlMlKIUHS TllilLES. 
 
 TliK ipri'si'iico of rusts in tin- \iriiu' was first olisiTvcd liy 
 Vuula ill ls:57-3.S; Simon of lU'i-liii also tU'scnluMl casts 
 in iiis "Medical Clu'iaistry"' in 1S4:2; Kayor mentions 
 tlu'm as early as 1«:iS; iiut none of these oliservers made 
 any attemjit to exiilaiii their tuigin, stnu-ture, or signirt- 
 eaiiee. 
 
 Jleller apjiears to have been the first to offer an exjila- 
 nation of their origin, Imt he also t'aih'd to apiu'eciate their 
 import, a careful study of vhiidi is a matter of recent 
 date. 
 
 r.eale, Johnson, Dickinson, (iuU, (Jrain.ii'er Stewart, 
 and many French and (Jerman writers havi- y-iven tho 
 ori^'iii iind dia^'nostic value of urinary tul)e-casts careful 
 attention, as also have Millard and other American 
 writers. 
 
 Meyer says, "The casts are iirodnets of an alhu- 
 miiious exudation from the hlood-vessels plus the swollen 
 and destroyed eiiithelium." 
 
 C'hareot is of opinion that some casts are composed of 
 broken-down epithelial cells, and others of albuminous 
 substance, while epithelial casts consist of epithelial cells 
 more or Ic^ss altered. 
 
 Cornil believes that casts are the result of a jpatholo.ii'i- 
 cal secretion from the cells of the convoluted tubes, wh'ch 
 olttain the nniterinl for exudation from the neiirhborini? 
 capillaries, and that the epithelium is descpiamated in the 
 straiirht tnbes only. 
 
 Millard's theory, that casts are invariably an albu- 
 minous exudate into the tubules from the surrounding 
 
 ^m 
 
r.i.sT.s' OF THE nii.\'ii-i:ii<>is tiuilex- 
 
 (■),'» 
 
 ihod (lists 
 
 luciitioiis 
 
 vers uiiulo 
 
 of siiTiiiti- 
 
 an cxjila- 
 
 ciiitv tlu'ir 
 
 of ri'ft'iit 
 
 • Stewart, 
 iiivcn till' 
 
 sts can' fill 
 AiiiiTU'aii 
 
 ail all)U- 
 
 1r' SWdlll'll 
 
 111 posed oi 
 ll)Uiniiious 
 lu'lial colls 
 
 patholou'i- 
 Itys, wliA'h 
 L'iirliliorinu; 
 [ited ill the 
 
 • an all>u- 
 irrouiuling 
 
 cavillarioH wliieh saturatiM, diste.i.ls, and leads to partial 
 or entire destruetion «.f the epithelium, appears to n.e to 
 he the one most worthy ofaeeeptanee. 
 
 (\ists may originate in any part of the nrinitenms 
 tuhiiles, and" may even ho found in the Malpi-hian hodies 
 S.mie writers state that most .'asts are f..rmed m the 
 Htrai.M.t tuhes; hut, as the east is an exmlatioii Ironi the 
 hlood-v.ssels, and as the eortieal portion <.f the ki.lney is 
 nuieh more ahundaiitly supplied with vessels than the 
 nvrami.lal portion, it seems reasonahle to suppose that tlie 
 exii.lation is more likely t.. take plaee into the eonvo uted 
 tuhules of the eortex than into the strai-ht tuhos ot the 
 
 ^'^rlllis^range from .^^ to rh^ of an inch in dlanieter. 
 Their shape is determined hy the si/.e and form ot the 
 tuhe from whieh tliey are derive«h 
 
 Thev are the result of inflammatory exuchition, witli 
 the exeeption of the hlood-east oeeasionally found m 
 hvpera>mia, either aetive or passive. It is usual to rhissity 
 casts according to their structure; that is, epitiuoa., 
 hvaline, granu'lar, tatty, waxy, and hlood casts. 
 ' F.pitI '. 1 and hlood casts occur in acute nephritis, and 
 •ire the result of a fihrinous exudation containing a few 
 hlood-corpusclos, into the uriniferous tuhules, destpia- 
 mating and entangling their lining epithelium. ( asts ot 
 coaiTuiat' I hlood sometimes occur in hypenemia, either 
 pas>i\e ar active, and in hannaturia. 
 
 Hvaline casts are the result of an alhuminous exudate 
 into'a tulnile already devoid of epithelium. 
 
 The .--ranular, hyaline, and waxy casts are more com- 
 monly t?nin(l in intertuhular and chronic tuhular nephritis 
 A .n-anular east contains degenerated epithelium and 
 l.lood-corpusdes. Fatty casts are simply the result of a 
 further and fatty degeneration of the exudation and eon- 
 
 c* 
 
 ^■teo 
 
66 
 
 nisKAsF.s OF rut: KiuyF.vs. 
 
 tiiiiu'd fi.itlu'liuiii,:iii(l i!.:iy occur in cither iicutc (ir chronic 
 nephritis; whih' the waxy cast is a waxy or hmhiceous 
 (k'^ciicration of the name i-k'nients. 
 
 Itohin is responsiltle tor tlie statement that tube-c iHts 
 are sometimes fonnd in urine, tlie excretion of a jicrfectly 
 
 Fid. H. 
 
 TVDE Casts.—:, criinular casts; 2, hyaline casts; 3, waxy casts; 4, t'liUhclial casts; 
 5, blond casts ; 6, fatty citsts. 
 
 normal kithiey. Tliis view, however, is as doubtful as la 
 the existence of physit)logical albuminuria. 
 
 ClIAPTEK X. 
 
 ALBIMKN'. 
 
 As the presence of albumen in the urine is the charac- 
 teristic feature of inflammatory diseases of the kidney, it 
 will be well to refer brietly to it before proceedin.u; to the 
 
 tnsideration of those diseases. The views of the medical 
 world as to the part that albumen plays as a symptom of 
 
 M 
 I i 
 
 iiMi 
 
. ,.' .*.'».►.• 
 
 .i/,/.T.u/;.v. 
 
 67 
 
 ir chronic 
 mlaccous 
 
 hibc-c ists 
 ])crt('ctly 
 
 UhfUa! casts; 
 
 btlul as is 
 
 he c'luirac- 
 kidiK'V, it 
 linu; to the 
 le nu'dical 
 mptoiu of 
 
 a ■-.imrii i» iiiMih .u«.i>» I'l' >' .,.,,1 „i„l,.r 
 
 i-iiK. •tiiciit ot" the kiiliicvs. 
 
 " ^^ " wc now hcu; ...uch on the subiect ot l-hy-o- 
 JLa aihunnnnria, hut alhunuM. in the nnnc .s no eon 
 li.Terea physioh,,ieal where it is in excess ol one-thutath 
 or one-fortieth of one per cent. 
 
 For n.v.clf. I <h. not believe that albumen ever exists ,n 
 ti J llle with a periectly nornK.1 eondition of the knlneys 
 
 '^'lu!;;;! n.y, it is true, aH>oar m^^^^^^^^^^ 
 hcartv meal consistin.u' of albununous lood,-e->, tc, 
 He- after prolon^n-d an<l excessive n.ental or phssu d 
 ^^nlin in asesofoveractionoftheheart;dnm.,he 
 
 : 2..;i severe ehills of nndarial tever ; oc..s.onally 
 Inrin.^ the course of tlie acute ndc'tums d sea^o . and tt 
 is u t'n.u.sual in the course of an attack ot vneunnuna 
 
 I .V of these eircumstances, however, it ,s no phys- 
 ,,WU^ dbunnuuria. The kidneys are probably ma 
 
 vp^r^nuc condition, or the tiltrati<.n ot f^-^^'Z^^ 
 due to a slii^^ht degenerath.n of the epUheha ot the idt or 
 
 a pathoi;.ieal eondition of the blo..d ; ,.r perchance, 
 n Lml cas^, albumen is secreted by the epUhebum ot 
 
 u nles.- Xow and then we nu-et with a patient who 
 
 enbnin. apparently perfect health, but whose urme toi 
 
 ; hL^ielir been long free from a tra.. ot . bumeu 
 
 1 have two such patients at the present tune. It i^m 
 po U le to Bay exactly upon what cause the presence ot 
 
t;s 
 
 i>isj-:asi:s or the kidsevs. 
 
 alliuiin'ii ill tlicsc Clip's (lc|ifii(ls, liiit it (lots iHit rc'iuirc ii 
 vt TV li\fly iiiiiiiriii;itiiin to siipiiosc that tiifiH' is an aluiiir- 
 iiial (11' |iatliolo<;ical condition ot' the cjiitlu'lial liniiiif of 
 tlif tulmk's or tut'ts, or an almorriial coiiditioii of the Mood 
 or lilood-Vfssfls. I liavt' known in'oiilc to he in fairl.v 
 li'ood licaltli for tiftv years, with a luitlioloiiical condition 
 of the lirojichial niucons inondtruiu' or a <'atari'hal cystitis. 
 Manv |>crsons enjoy i;ood health for years with atlu'mnia- 
 tous arteries. 
 
 Xnnierous theories liave hi'cn advanced to exphiin the 
 preseiici' of alltnineii in the urine. Some helieve that it is 
 due entirely to a patliolotrieal eon<lition of the Mood; 
 others attriimte its presence to an alti-red condition of the 
 vi'sscl -walls or epithelinnj : while the theory of chanires in 
 the vascnlar tension as a cause has its adherents. 
 
 r iK'lieve, with Sti'wart, tliat normally the hlood-pressnrc 
 in till' caiiillary loo|is and walls of the vessels, with their 
 thin eiiitlu'lial coverini;, is so halaneed as to permit the 
 transudation of thiid and yet prevent the [>assa_i;e of alhu- 
 men. 
 
 Of the theories holdini; tliat alhnminuria de]ten(ls upon 
 hlood-chanjres, the most plausihle is that wliicli rei^ards 
 the excess of salts as the causi'. Kxperiments have shown 
 that when the salts in an alhuminous solution are increased 
 the alhunien transudes more readily throusjli animal 
 mend)rane, and it is possil)le that this prineii>lo holds good 
 as regards the hlood also. 
 
 When the halanee of pressure in the glomeruli is dis- 
 turhed hy increased heart-action, or when the vessel- 
 walls or epithi'lium are diseased from inflannuation or a 
 pathological condition of the blood, as in scarlet fever, 
 jioisoning, venous stasis, hlood glandular diseases, etc., 
 wc naturally expect the transudation of albumen to re- 
 sult. 
 
jar. 
 
 TESTS Fon M.nrMHS. 
 
 69 
 
 1„ .U-om-ration of th. opitluruMU th. i.n;sr„.v ot all.u- 
 nK-nin7lu-unuoistlu..vs,.lt..ftuo....u.it.ons. 
 
 Fir.tJu.n^asinotl..^,:H•.s.,^.lu.l.o.ly,wlH.un.;u. 
 ,,,,;.,„ i. ,n.sc.nt tlK-n. will b<. an Ml.unuMo.s..^^^^^^^ 
 
 soc-otullv, as tlu. rcs.Mt of .U-s,na.nat,on ot tlu^ .p'tl" ' 
 ,„.l ..onso.,.u-nt.hau,..-s in tl.. hasc-nent nu.,nl.ra.u., tin .. 
 will iH. a fnv transu.latio,. of ulb.n.u-.. Iron, tlu. v.sm.1. 
 
 into thu t»il)iiU''<. 
 
 TESTS KOU ALIilJMKN. 
 I„ all instances wlKT. tluMU-ino to ho U.Hto.nsn.>nH.r. 
 
 ,V,,tlv rU.a. , it shouM »H. Hlt.rcMl hofo.-o aiM-lyn^M h. t.sts. 
 T;-!;nn.yi:eaon.inan.wnnnnt.s.,ymo..s..; n.^^^^^ 
 ,,,„,, or ahsorlK-nt cotton and a tnnn.l. 1 W mo>t 
 !Xi,le tests tWr aUnnncn are the heat tost and the n.tr.e 
 
 A te<t-tuho Is tilled to one-fourth or one-third of its 
 depth with ,.erfeetly elear aeid nrine, a.ul heat a,>,.he.l 
 S. , oiling oeenrs! If turhidity results^ U . dt.o ho 
 .resenee of albntnen or of phosphates. It eans..! hy he 
 atte- the tnrhidity will disappear on the add.tton ot a 
 IjlX-onutrie'or aeetie aeid; if hy allMunen, the tur- 
 
 hiditv will ho i>ennanent. 
 
 '"X^ .xeelU-n^dan is to apply heat to the upper i....to,. 
 
 of the nrine, whe,>, by contrast with the elear ur.ne helo. , 
 the slightest cloudiness will heeonie apparent. 
 KItrir AH'I, or H:'ll<'-s llsl. 
 Upon a quantitv of pure, colorless nitric acid in a stnall 
 tost, ubo, allow to- trickle down the sides ot tlu- tube tnn 
 V pi pett , an enual amount of clear urn.e, wh.ch shoulu 
 ;.4H;etheacid!n,>tnnxwithit. Ifalbutnenbe,.^^^^^ 
 •It the poi.it of contact between the nrine and the n t.u 
 'leid tlLro will appear a sharply-dotine.l wlnte ban<l or 
 
70 
 
 /)/>/, MSA'S "/•• 77//; /»■//' v/;j'.v, 
 
 Fill. 't. 
 
 zoiif, wlii.h will viirv in lliirkiirss iir.-..r.liii,u- t.. tlif (|U:iii- 
 filv of iill.miini piv^riit. I'ratrs ..r tlir ivsiiis ini,L:lit 1m- 
 mistiiUi'ii fiT ihr wliilc /(111.' (.f :ill.iiiiicii. 'riif loniHT is 
 less distill. t. with pourly-ili-liiicd iii;irunii>,n><iiil.liii,';><>iiu'- 
 whiif 11 .loud of siiiokf, and on .'XiiniiniitioM will !•»■ seen 
 to diU'iis*- ils.ir into tlu' nrinr iiliovc. Ilfiit will dissiputc 
 the .loud, whiK- it will intensity tli.' x.oim- t'ornud l.y al- 
 liuiiii'n. It' 111. oil.)! ln' inl.K'il. tin- /oiii' t'oi'nu'd 
 l.y till' r.sins will di-.ii|i|M'ar. while that of the 
 alliunifu will lu'i'onu' uioih' niai'U.'d. 
 
 ( Hill r tots in list' ai'c tlir \>'u'v\r acid, sodium 
 tuntrstatf, |iota-sio-nifr.Mirii' iodide ft.-., lor 
 lurtluT iiifonnation con.'fiMiinu' which I rcl. r 
 volt to Tyson's. Ucalc's. Uol.crts's. and otlu r 
 I'Xci'Ucnt w.»rks on the pnn'tical cxaminaiion 
 of uriiit". 
 
 For the ([uantitativc analysis of alhunicn 
 the most eonvt'uieiit method, and a sullici.'Utly 
 iu-eui-ato one. is that of Ivl.ach. A tul.e t-Tad- 
 nated lik»' that in Ki.ir. !• is t.. he em|.loyed. 
 Dr. Hshach's test solution is preitaird hy dis- 
 solvintr ten u-ramines of jiicri.- acid and twi'iity 
 -rfanimes of eitri.' acid in nine hun<lred cuhic 
 eentimetiTs of hoilMi-r distilled water, addinir, 
 when cold, siitHcie .r watiT to make one litre. 
 The liltered aeid ui-ine is j.oufeil into the 
 irlass tuhe up t.i the mark f\ and the fi'airent 
 is added till the U-vel of the li.iuhl stands at 
 }i. Mix the li(|nids th<u'ouirhly, without shak- 
 imr, hy iH'vei'sini; tlu- tuhe a (h)/.en times; 
 close witli a cork, and allow it to stand twenty- 
 four houi-s. The heit;ht at which the eoairu- 
 him then stands, read off on the scale, will indieato the 
 nuiuher of pai-ts per tliousmul or grauimes of albumen in 
 
 11 
 
 II 
 
 SI 
 
 K'.lliull'!. lllbU- 
 
 mm iLutrr. 
 
 
inritiA—i'inrriiiA 
 
 71 
 
 o„. litre. T1,H .livi.lr.l l.v t.n will pv. th. ,u..v..,»tn^r.. 
 p.Mitr./.t numot 1.. a.vurat..lv ...thnuMl l.v tin. nu.tlwHl. 
 
 \\V M... tlu. t.nn i.vum t.. iMMi.at. tl.M''--'^--'-' '''^^ ^ 
 ;„„,,,„,;,„, ,.,..nlK.ss of tlH.,-.'t uf t W unn.ry tn..t 
 ,,.,,,,;.,, Ui.M.nv.l: just us w.usMl..wonll..-m:. 
 
 have S....M in stu.lvin- tl.. .litK.vnt <l.s.as.s ..t th. U. l- 
 ; that ,Ms a,,:ars in tlu. miH.Mnul.r a ,n.at van.ty 
 
 /..n.litil.ns. 111 hav nsi.U.n.l tl. ..u.lu.y an- 
 
 .,,„„,„.,. of tlH.s. ..on.litions. N.v..rtln.U.ss, on a-you t 
 :,-theh;M.ortan..oftlH.,n...n..of,usn.tlu.u^^^^^^^ 
 
 , „„.U.r of .lia.irnosis an.l ,.ro,.M.os,s, ,t n.ay l.e «.l t. . u. 
 now, nn.UT tin- Load of l-ynria, to c.,>Uon.u. tl.o .tK. ..^^ - 
 ,,, ,i,vu.nstan.-c.s an.l patholopcal <M,n.ht.uns an.!..- u In. I. 
 
 '' XC-I" tl- l<i.ln..y itsc-lt; i.y..litis <.r ul-vrat^ion, 
 nl,....ss.'.s ...• tul>.Mvula.- ki.ln.'v, an.l ,.er.m.i.hnt.s wIkt.. 
 tlH. abs..oss oiK-ns into the i-olvis ..f the knlm^V, w.U -ins.' 
 .vuria lTrot..ritis, .-ystitis, ahs.-.'ss.'s m th.. snl.nuu-<.n. 
 ti..ne .'^f th.> hla.hU-r, r.'ri.-ystitis ..r lu.lvi.- ahs.-ess..s o,..-n- 
 i,;,: into the l.la.l.ler, an.l urethritis, always ^nv pns m 
 
 '^'^•;;;;:i;,--There will l.e no .litH.-ulty i,. .lia^n-.sinj, 
 pus i,; the urine if th.- urine is alkaline fr.>m anunonnu-a 
 U,.,.„n,><-tion. Vn.ler su.-h .-on.htn.ns the ,>us 
 ,,, J into a visei.l, tena.-i.ms n.ass whu-h ..an 1. .Irawn 
 
 out in lonsr strinu^s. If the ur.ne he a.M.l the l-us- 
 ,.„,,„seU.s will he .listin.-t, an.l .'henueal an.l nu.-n.se..- 
 .i.,!,l .xan.inations will he ne.-essary t.. .let..rnnne he 
 lia-nosis. Urine that .'..ntains pus is always n.ore ..r less 
 turhi.l, the .le^^ree of turhi.litv .lei.en.ling ui...n the am..unt. 
 
/>/.s'a;.i.va;.v of rm: KinsHvs. 
 
 uf \\\\< iPiisciit. Al>r.(iliif< Iv clfiir mine ilms not ((Hitiiiri 
 |»Urt. All liiriiid iiritic, linwcvfi', diu's not ii*'r«'H.saiilv (i>ii- 
 tjiiii |.iis. Tile tmliiilitv iiiiiy il(|ifii(l ii|m)|i catiiiilinl 
 iiiiirii> iViiiii tilt' liliulilci' ur tidrii till' |ii'l\ is (if tlic ki(|iii\ ; 
 III' it iMiiv lie <liu' to tlir |iri'si'ii(f III' |ilHis|i|iiiti's (ir urates. 
 'I'lie tiirliiilily laiised liy |iliu,-,|i|iates will «lisa|i|iear (Hi liie 
 aililitiuii (it' an acid to tlie heated mine; that (if urates will 
 (lisa|iiiear(in tlie a|i|ili(ali(in of lieat aIon«'. Tlie turKidity 
 (if acid urine (diitainini; pus must increase on tlie apidi- 
 eation of lieat aloiie, liecaiise of tlie c(ia,i;ulaliility ot' tli«_' 
 allimneii contained in the rKpior (luris. 
 
 Km. I(». 
 
 I. I'us-torpusclf!', frcsli ; 2, pus-corpuaclus ttlltT tin; uulkjii of acilic ni'lJ. 
 
 Upon iiiicroseopical examination we di'toot tlie iinniis- 
 takahle presence of piis-corpiiscles ; lint we must not for- 
 •rct. in examiniiiir urine for pus. that the pus-eorpus*'le is 
 not always to In' distinguished from the white lilood- 
 corpusde or from the miicus-ettriiuscle. In catarrh of the 
 liladiler, however, no matter how iiuiik rous the mucus- 
 
y,,i.„,i,ns~.iiui<iiirs nisHAsn 
 
 78 
 
 ,.n ,i,.....i.-..i .-min-,,.,..,, ;''■'",■'';''•;',',,,,,;,, ,1,,;, 
 
 .l"'"ln ntaM,.n,.|..,s. I " " .n,,;.,. ,,,„„ 
 
 s,,,|,. „m.v . I.." ll. 1^",' ., „,, HMv ,„ 1... mn.l, 
 
 ;S::;: "";:"" '"^-: ,„„..>„,„..,. 
 
 sUj^l.t iVvor. alHco^scK that huvo ..i-mumI 
 
 '"',' , , ■ ,1,1 tl,.. .■hlawimnt «„.n.-."l>Ti»-' "" 
 
 several coiirtecutivi- <lay=^. 
 
 ClIAPTEU XI. 
 I 
 
 NEPIIUIT1.<— IllUtilir's DlrfKA^K. 
 
 „ .,„.l-,tiiro „fiulliuiHiu.t..iv ,hs,.'asw ,.l tl..' M.lii>y«- 
 ;: ' ,;„;lw.„l „o„..n,.la,„.o „,• .... n.,la„nua„.r, ,hs. 
 
 The 
 
 V 
 
 wm 
 
I 
 
 />/va;. ISA'S or Tin: hiD.M-ns. 
 
 caHcs lit' till' kiilinvs i> im il.mlit liiru'flv iTs|i(iiisili|c lni' tlic 
 liopflt'Mslv imli linitr iilr:i ol' tlic |>:illiu|n<ri<'iil riiinliiinii 
 wliitli ilic trim iSiiirlii's <lis»'iisc tMinvevpi. 
 
 < Ml fKiiiiiiciiciiii.' tlic stmly n\' (lism^ts ut' tlu' k'nliH'V-< tlit> 
 ^liuliiil u^iiiillv limU liiiiisclt' I'lilniiirlcil in llic iiii^Ihs nt' 
 I'liiifiisiiiir ftTiiH, — siicli lis <l(>i(iiiiiiiiitivc iir|iliriti-i, |iiinii. 
 t'liviiiiiti.o-' iH'|ilii'it'H, tiil)iiliir ii('|)|irit'H, tiilmlitis, tiilml 
 iir|i|iriti-. irli'-iKTiilit-iu'iilirili-*, iiitci'-tifial iii'|»liiiti-i, intrr- 
 tiilmliir iu'|ilii'ili-, iroiity kiiliU'V, firrlinsis, alisccss ol^tlu' 
 k'uliii'V, iiiiivlitid (Icir»'iii'ratinii. waxy kiiliii-v, liinltu'cdiH 
 kidiifv, alliiiiiiiiiiiria. Miiirlit's disnisc. liiiul dixiisc, iinitf 
 niiirlit's ilis( asr, cliniiiic IJriylii's discii-c, iiilaiiliiil iii'|iliri. 
 tis. iT(iii|M»iis iifplirilis, iiiurliiis llriirlitii, aciitc diU'iisc 
 ni'|iliritis, irraiiiilar kidiu-y, liTaiiiilar coiitiiutiiiir kidney, 
 diU'iisc interstitial iu'|iliritis, rtU|tiiurativc nciiluiti^, ii(|iliri- 
 lis Vela, red i;raiiidar atiii|iliy, cniisciiiiivf Mrii,dit's dis- 
 I'ilsf, etc. 
 
 It Would lu' just as rcasdiialdr, and no nii>rt' |n'riii(iiiiis 
 or ('(inlusiiii;-. t(i use tlic iini|iialiticd tcini liinu' Icvcr i'ur 
 all dist-ascs of the Iniitrs, liaviiiij no definite terms t'or 
 Itroiieliitis, capillary limncliitis, Iininclio-pneiinioniii, pneii- 
 nmnitis. or lihroiis plitliisis, as it would lie to iipply most 
 ol'tliese terms iiidiserimiiiatelv t(» aiiv and all inllammatoiv 
 diseases o|' tlic kidneys. 
 
 We liavi' a nephritis, as we have a piuMimoiiitis, which 
 involscs in intlamination the entire oriran, and ;ii either 
 ease terminates in recovery, ahscess, or chronic disease. 
 
 It is only iieee.vsary to hear in mind that i'or all practi- 
 tical purposes till' kidneys are made up essi'iitially of three 
 tissues, — \iz., hlood-vi'ssels, tuliules, and interstitial or 
 iiilertuliiilar tihrous tissue. In one case the lesion is 
 primarily and i-sscntially an iii/cr.'^lHiiil t>f/>lirifl.i, whose 
 patholotrieal con<lition is the result of the hypi'r|ilasia of 
 tlu' lilirotis interstitial tissue and itssuhse<pK'";t eontraetictii. 
 
>' 
 
 ,v/.;/'//w/r/><-/"'"'"'"^ '""''"■ 
 
 <•> 
 
 T .■•■.; ;''■>: ';:;:i;j.i:;r;r;^;*": 
 
 orjrauswl.i.hn ^''''^ '":'';';:,,... ot' .h. u.in.., 
 
 '-'-'•f It:: ;:r :i" >-^-- 
 
 ,vl,;m..iv.. .x.nmKitlon. ,.„,., ui.i„..y., :>s in 
 
 '" ''"' Mo.m.u.latmvuMhsu.. ,.;,„., ,1.. 
 
 ,1... of .li..a.- ..f any <>»»..,• -^' ; ' 1^, , ,„, ,.,i- 
 
 ;r.rr'';^::':;;::ir;:i;;i'.-^;;;:rr,,:;;'';;; 
 -;■•- ': ;;"?r ;,::;;::;:• :ir;::;;,;:;;l::' ., .,. 
 
 i:;:i;t:::;:^-,. ,,...,..-;.,; - 
 
 (• iiui 'i^"- '"^ • , . I .,,,, <i I ft' we snail "I' 
 
 „,;'::.::' 'i. "..I.-.- '•'■■■.";" ""■^'"'^■"^ 
 
 I^BMft 
 
7*i niSKASI-JS OF THE KIDSEYS. 
 
 W 
 
 CHAPTER XII. 
 
 TUnULAU NKPHIUTIS — Tflifl.TTIS — TriiAL NEl'IlIlITrs — KKS- 
 ylAMATIVK — CATAUKIIAL — CKOUI'OUS — ACITK — .<115- 
 ACUTK — ClIKONIC. 
 
 Aetitc. tubahir ncphrilis may be (lofincd as an acuto iii- 
 HaDitiiation of tho tuliiilcs and Malpiufliian oorpusclL's of 
 the kidney. 
 
 Etiology. — Injuries, sneli a.s l)lo\V!^ falls, or wounds, are 
 not infretiuently the cause of acute tubular nephritis, as 
 are also the acute infectious diseases, more particularly 
 scarlet fever, diphtheria, cholera, and erysipelas. In 
 addition to these, there is that mysterious eliolouii-al 
 factor which operates we know not how, — viz., catching 
 cold. 
 
 Suppression of the action of the skin is a fre(iaent 
 cause, as, for instance, lying on the cold ground after 
 excessive physical exertion, or exposure to draughts while 
 [lerspiring, as is the case with bakers, firemen, and 
 moulders, and particularly in those addicted to the use of 
 alcoholic liquors. 
 
 I'yicmia is responsible for some cases ; and a constant 
 source of acute tubular nephritis is pregnancy. 
 
 Intlamnuition may invade the kidney from other organs ; 
 for instance, the right kidney f'-om hepatitis. Perine- 
 phritis may be the primaiy trouble, or a cystitis may 
 involve the ureter and extend to the kidneys. 
 
 At times, when very hard pushed, we may be com- 
 pelled to fall back on our old friend "idiopathic." 
 
 Age is a factor in "^he etiology. The great majority 
 of cases occur betweoi the ages of fifteen and forty. It is, 
 rare in children exce[it us -ui a(!Companiment or seouela 
 
 g r r .TO ' .T. '.taorr j y t-g B T ;n a v ' TO ' *^HK«j:cW a'^'^igU ff i i ' ' g' t "f i« "c:r»^rTi"''^^^ ^ 
 
 f#^fe«W!JK?>*tii'W>»»«S'«a»a*«r* 
 
TriilLMt XKI'Ifh'ITIS. 
 
 77 
 
 
 TIS — DKS- 
 TK — .<115- 
 
 iU'Uto 111- 
 iUsc'Il'S ol' 
 
 uiids, are 
 ihritis, nti 
 rticularly 
 'las. Ill 
 tioldii'U'al 
 catc'liiiig 
 
 frequent 
 iiul at'tor 
 ht8 while 
 icn, and 
 
 he use of 
 
 eonstant 
 
 r organs; 
 Periiie- 
 
 itis may 
 
 1)0 eoiii- 
 
 majority 
 ty. It is, 
 [• sor'uela 
 
 „f tl.e aente infeetious diseases, and is not tivim-nt after 
 l,v, oxeept in the intem,erate or in se^tie conditions and 
 oX.las; Males are more sul.jeet to It than toinalc. 
 ,,,;.i, . ,,.,th to their hal.its and to their oeenpations. In 
 n oahMneiit of the fui.etion of the liver the elnninatK.n ot 
 ;;:;,iary salts, a.d elements the result .. ine..n^^ 
 tissue-metamori.hosis not iiifre<iuently pn»vokes a tidn 
 Nephritis. This may oec-ur also where the ki.lney is ealled 
 UDon to eliminate sugar. 
 
 ' Aeute tuhular nephritis is met with in all el.niates but 
 ,nore tVeHi.eiitlv in the eold, .lamp months <n the year tl mil 
 the wirm summer months. Syphilid is responsible h>r 
 some <-ases. Tvson has been nuoted as saying that nienta 
 anxiety resulting from grief or from business or finaneial 
 embarrassments may cause IJright's disease. 
 
 That anv man broken down by cares and anxiety might 
 d..velop Brioht's disease is not surprising, nor is it un- 
 u I stJange that mental anxiety should bo the remote 
 cause of disease of any organ. The same cause will p.o- 
 duee dittorent diseases in ditferent individuals according 
 to their respective diatheses. ^ , -, ^ 
 
 Only a few years ago Dr. Sommola, of Naples, advanced 
 the lL>ry that nephritis is a blood-disease , and tln^ tlie 
 i,nary cause of every case of albuminuria is ui the blood 
 Tl at it i. the pathological chemical condition of the bhM I 
 w leh irritate; and intlames the tubules is true ; but it this 
 morbid condition is produced by the suppression of the 
 f^netions of the skin or the liver, I do not see how h 
 blood condition can be called the priinary cause. I bo h vc 
 it was I)r C. Letzorich who, several years ago, first dc- 
 Libed bacteriological nephritis. He had one season a 
 hirge number of cases of nephritis in <^^^^^-;;^:^ ^^ 
 whom had had an ac-ute infectious disease. They al ex- 
 hibited similar symptoms, and ia every case h. ound .... 
 
 ^hwtnsMs^ 
 
 «»it.'it*»w.6aK.-. 
 
7S 
 
 nisi:.is/:s or the kidseys. 
 
 siimo liiU'ti'ria in tlii' uriiu'. Dr. Lctzn-ich, if T ri']iu'inl»or 
 rii^litly, looked iiiion tlie disciisi' in thcso cast's as an cu- 
 (k'liiic condition, tlii' particular bacteria Imvinj; ,uaincd 
 access to the blood tbrotiiili the niediuni of drinkinir-water. 
 It lias lonj; bei'ii noticed that a sliu;lit amount of albumen 
 cften occurs in the urine durinu; an attack of erysipelas; 
 while in many instances it is accompanied l)y a more or 
 less severe attack of acute tubular nei)hrit".s. 
 
 Moulin in his recent AWU'k on snrsiery instances 
 Bri_u:ht's disease as an etiological factor in erysipelas. To 
 be sure, gouty people with cirrhosis of the 1 idney often 
 contract erysipelas, but in the many coml>incd cases of 
 ervsipelas and acute tubular nephritis that have come 
 under uiy notice I have alwiys considered the former the 
 cause of the latter, either as the direct result of the ]»res- 
 ence of the Stirptococcits eri/sipdatosus in the blood-vessels 
 of the kidney, or indirectly from the chemical condition 
 of the blood due to ptomaines. The bacteriological 
 etiology of tubulitis, however, will, I an' fully convinced, 
 be found to api)ly eiiually well to the nephritic iniiamnui- 
 tion that accompanies or follows any of the other acute 
 infectious diseases. Aside from the micro-organisms of 
 the acute infections diseases, whether special nephritic 
 bacteria will ever be discovered is a matter for the future 
 to decide. 
 
 The etiology of the tubular nephritis accompanying 
 presinancy is oljscure. Some writers consider the pressure 
 of the gravid uterus upon the kidney responsil)le for the 
 trouble. I have seen nephritis and dropsy as early as the 
 third or fourth month, certainly before the uterus had 
 attained a size sufficient to exert any pressure upon the 
 kidney, tlius leaving us to look for other causes to account 
 for the intfammation. 
 
 Other writers have suggested the possibility of the in- 
 
 -'VKSiJaii^£S:?)Xaeau^. 
 
«iiAJJi!^-«*---^-*--'-*^' ■ 
 
 TUBVLAR NHI'lllUTIS. 
 
 79 
 
 iis. To 
 
 fl.nnuatu,u boinj, th. rosult of vuss.vo -»^-^- 
 ,.,,,s.u.v oftlK- .,n-avi.l utorns on tl.. n-nal vcu.s, !>„> ,.H- 
 . .ntin.- tho .vturn <.f I.I00.I. A,.un, tl.e theory has h..n 
 ^dvu.:;^ that iTossuro upon the ureters may he an c.,o- 
 htieal ta.tor. Exactly how ohstruetu.u ot the u ete . 
 .;uhl disarrange the kidney without l'-*--^;;;^' j;;^ 
 and .,n-eat pain from pelvie diste.mon it ,s d.theult to coin 
 
 ''t::L plausible theory is the one whieh su,,ests that 
 V,re.suro upon the iliac arteries or the ah. ounnal ao.ta 
 "p,'oduc n, an intense hypenenna of the knlney, cause 
 he' Ihununm-ia. We nu.st not tor^et that n, s..n.e cases 
 \„„„,,„,,i, durin, pregnancy there .s a l--'>;l'ty; * 
 nenhritis havin.^ been present before the women became 
 ;^^^ and^his suggestion is, I believe strengthenc^ 
 ^y Ihe l^tthology, as we occasionally hnd m cases ^ 
 won.en who have died in puerperal convuls.o.is he ^nall 
 TvhUe kidney or the atrophied v hite kidney ot chronic 
 
 "i:tr^:U>le that the kidney c.mld.nle^ 
 chan.res in so short a time ; and hence it is almos crtain 
 ma hi these fcw cases, at least, the w.>men had .dbuminu- 
 ^a bet<,re they became pregnant K the women were 
 .ninipara. they had probably had albunieiyv .tl hur 
 previous pregnancies, and the kidneys had tailed to 
 recover themselves during the interim. ,,.,,' 
 
 ThoiKdi there is no absolute proof of the hypothesis, the 
 .t..on.. probabilities are that puerperal nephritis is gener- 
 
 d V ff not always, the result of the profound bl<,od-change 
 that^ occur duHng pregnancy, especudly the nicrea. o^ 
 
 extractive matters with the general increased hcart- 
 
 '^S:S;?:?1^: ""^"^- ^«..-The etiohjgy of 
 subacute tubular nephntis ditlers in no way from that ot 
 
so 
 
 DISEASES OF THE KIDSKVS. 
 
 the acute t'oriii. Tt is only in tlu- cliiiiciil history tliat we 
 tiiid ii difi'crt'iict", it l)oiii<r iiioiv insidious in it» invasion. 
 
 A larifc nninlitT of casi's aro associated with cirrhosis 
 of till' liver or with aiiy form of chronic hepatic disease 
 which distnrhs the fnnction of the liver. 
 
 Etlnloifi/ iif Chronic Tahnhir Nephritis. — (/hronic tnbnlitis 
 is simply the result of acute or subacute tulnditis. 
 
 ]'.\Tii()Lu(iV. — In acute tubular nephritis we find a lartje, 
 smooth kidney, in most cases red in color, the eidar<;e- 
 ment confined chiefly to the cortex. The caiisule is easily 
 detached. The microscope reveals tlie fact that the puth- 
 oloirical change, except the hypera'mia and the serous 
 exudation, is confined entirely to the c]»ithelium lining 
 the tubules and Mali»ii>liian corpuscles, with more or less 
 involvement of tlie eiulothelium. 
 
 Fig. 11. 
 
 
 The epithelium will be cloudy and swollen, from the 
 al)sorpti()n of the exuded albuminous fluid, and may be 
 granular, from the infiltration of oil-globules and detritus 
 partly exuded from the blood-vessels and partly the result 
 of destruction of the epithelial protoplasn jlf. 
 
 In a more advanced stage the epithelium has a coarser. 
 
 !t> ««ii»MBwna:t«><aicaff' W 8 » ii- miwaB i «cs*h -■ 
 
Ti'iiUi'Hi sErimiTis. 
 
 «l 
 
 :::L:"not involve.l,und the bU><.,l-ve..cl. ronuun un- 
 
 ^'^Xd;..-ln .nbacuto tubular ncphnti. wo om. W 
 .V U.ht-folorod or the .,M-alU..l white kidney. I he cap- 
 ^ullr^Irip. easily. The epithelhun is swollen and granular, 
 
 -VZl^:ZZ!:'o^ ehronie tubular nephritis . 
 von- h ^0 whence it is usually called the large white 
 ^hie^ Th^ capsule is easily detached, the cortex is 
 t ".enlarged, the endothelial cells are swollen, an<l most 
 r h "q tlieli^m is de.piamated. The cast, found in 
 t. tubeiand urine are of the hyaline variety-. An exc.,.- 
 tn n W.e is apt to occur in the chronic tubu ar nephriti 
 o th in" mperL. The kidney is ot^en small in size am 
 r d iu color, the reduced size of the organ being he 
 lu of an'atrophy, not of a e-trac^ion. W ere the 
 disease is of long dur xtion there is a slight thickening of 
 the interstitial tissue and of Bowman's capsule. 
 
 SYMPTOMS.-Acute tubular nephritis is generally ush- 
 ered n by a chill or recurrent chills, which may no^^ be 
 ^:; ver'e, followed by fever, the temperature not ike 
 o "be over 102° or 103° F., and accompamed by heaxN 
 .Chi M-ins in the back, which extend around the groin 
 ::^^ it-t n down the ureters. There is frequent inictu - 
 In with the passage of a small quantity ot urine. The 
 H^i high- olored, of high specific gravity, and con- 
 ^n^lbun^n, a lessened quantity of urea, aiid ..netm.^ 
 blood-corpuscles. The patient is usually troubled with 
 
 iii 
 
82 
 
 /)/.s7;.i.s7;.v or the kidsevi^. 
 
 i 
 
 iiauscii and v<)mitill,i.^ and is soMom witlumt sowit lioad- 
 aclic. This (•(.lulitioii may last for two or tliivc days, 
 wJHMi tlu- uriiu' iiKTcasos in (unmtity, Ix-ronu's of iowiT 
 spoc-itic frravity, tlu' Idood disapiK-ars, tlic pains ocasf, the 
 temprnitniV fidls to 100°, vonntini,' diniinisla-s or c'l'ascs, 
 and tlu' iR'adarhe subsides. 
 
 Voinitinji; is a tivtiue-nt symi.tf.ni in allmniinnria, and 
 its si'Vi'ritv often sucnis to bo in dircH-t relation to tlio 
 olifiuria. ' This well-known tendency to voniitin.i; in 
 nephritis is often attrihnted by writers to retlex action. 
 Tt is most probably dne to one of two canses, or in >:(.nie 
 cases perhaps to both: first, to the fact that the .ixastric 
 secretions are deficient especially in free hydroc-hloric 
 acid, in consequence of which the food fails to be diirc.sted, 
 and produces irritation, pain, and vomitini;; secf)ndly. to 
 the elimination by the mucous membrane of the stomach 
 and bowels of waste material whii-h should be eliminated 
 by the kidneva, just iw in gout patients so freciuently stitter 
 from severe ^ittacks of vomiting, diarrha-a, bronchitis, 
 a-sthma, or cvstorrhrea. 
 
 In the latter of these cases it is no doubt owing to the 
 elimination of urate of sodium by the respective mucous 
 
 membranes. . • e *- 
 
 AnaMuia, we have seen, is one of the characteristic ti'at- 
 ures of acute tubular nephritis. Whether it dei.ends upon 
 deficiency of digestion and assimilation, or whether the 
 diminished gastric secretion is owing to the ansvmia, is a 
 cpiestion of importance. The auicmia of acute tubular 
 nephritis is probably a primary condition of the blood, 
 and the <liniinished gastric secretion the result. 
 
 For some not very readily explained reason, we often 
 have, accoinpanviuii these symptoms, <vdema about the 
 face, particularly under the eyes, and after a few days the 
 anlema may also appear about the ankles. 
 
 »'rRlS»»M»»*»il»>eSW!a 
 
 i;.«,»ftW«Mfcn>K»«SS«iS«-»y?''S»»«»'»'»*'»*'™^^ 
 
TUnVLAR SKPIUdTIS. 
 
 h:\ 
 
 In ..tl,or oaso., wLiU- tl.o lusuhu-h. in a HH-.sun- suh- 
 
 , isai.lK'U.-s, l.ut tlK« all.ui.uM> lurmis.s. 11. l-ati-ut 
 r^r l-mUu.. Thoc.on.mion,nay,.o,aa,ntln.U>r. 
 levoral wod<s ..r inonths, an.l .lisaH-oar cnturly, <.r the 
 h , V may .teadilv incroas., the a.uonnt .>t all..u.u.n oon- 
 H • . bout the ;auu., while earetnl cxanunatu.n hy he 
 L..:.o,e will reveal tul>e-.ast. n ahmu^^^^^^^^ 
 C.ithelial, irranular, and fatty varieties I he -. tu ntj t 
 omu^s j^nvdually more aiuemie, or rather the l,loo,l may 
 he said to he in a hydraMiiie i-oiidition. 
 
 With droi.v of the lower extremities there may he 
 ,,,„,, „t- the'whole eellnlar tissue, or general anasarca, 
 with effusion or aeeumulation of tiuhl in tlie serous eaM- 
 
 cvhlent, a t^al termination may oeenr from u.lema 
 !^ .U , ..dema of the lungs, or ett^.sion intc> tlu- pleural 
 c ^ V <>• the ,eriear,lium; and when so-ea led uneini 
 ^ !nun., eoin-ulsions, or eoma oecur in this hu-ni c. 
 Brh^ht's disease, it may he due to oedema ot the h.am or 
 effusion into the ventrielcs or subarachnoid _ 
 
 There ib seldom disturbance of vision, albuminoid i ti- 
 „iU: or epistaxis in this t^.rm of Bright's disease. In the 
 "wases where dimness of vision occurs it iB due to ii. 
 terference with the optic centres, and not to any lesion of 
 the (.ptic nerves or the retina. 
 
 On the other hand, the patients are very subject to 
 pericarditis or eiidoearditis, an.l pneumonia. 
 ^ S,.>nto.>,s ofSaharnte yV/../;//..-The symptoms in what 
 I ;ro >ose to describe as subacute tubulitis differ from th<,se 
 of the acute form principally in the first stages; for in- 
 
 o-4*e^rt*.«E*«B&si*' 
 
 itfWW 
 
84 
 
 nisi:.isi:s or the Kinsins. 
 
 f .'^ 
 
 wtaiict", it is not iislHTfd in liv diills. tluTi' is no t't'VT, 
 tlicn- \vYv no iiciiin.tr I'ains altont tlu- loins, iind tlicir may 
 1(0 ncithrr nausea nor voniitini; lor wt'cks. I lau'L' liad 
 Buvcral such iiuticnts, JK-ru'viiiir tlu'insdvcs iiortW-tly well, 
 who have |>nsente(l themselves for examiiuition for life- 
 itisurance. rpou examinini; the urine, a lariTc (juantitv 
 of alhumen is found to he jtreseiit. On careful iiH|uiry 
 ono may elicit the fact, wliich the individual had not 
 !iotic<'d, that micturition has heen a little more fre(|Uent 
 than formerly. Tf the microscope in such cases shows 
 tuhe-iasts, ejiithelial and ,<;ramilar, or if tho quantity of 
 alhumen is too threat to he accounted for hy the so-called 
 physiolojrical alhuminuria, these patients will, within from 
 six to twelve months, hecome anaunic and dropsical. In 
 fact, the later syitiptoms of acute tuhular neiihritis will 
 hecome evident here. 
 
 Many of these patients consult the physician I'or head- 
 ache, and perhaps for nausea or indiirestion. They may 
 tell him that they have consulted several physicians, whose 
 prescriptions have failed to u'ive them relief. If these 
 symptoms are of several months' standinir, tlio jtatient may 
 also complain of some dyspnrua or weakness, and there 
 will he more or less anorexia, hut no complaint peculiar 
 to the urinary or<;ans. 
 
 Careful examination and inquiry may, in these cases, 
 a.irain elicit the fact whidi the ^latients had failed to no- 
 tice, that micturition has heen of late somewhat more 
 frequent than usual, they prohahly jrettinjj: up once during 
 the night to emi»ty the bhulder. Such patients seldom, 
 however, fail to exhibit a jieculiar cachexia, which I have 
 heen in the hahit of calling the "kidney expression." 
 It is not the smoky, dusky look of pneumonia, nor the 
 cyanotic appearance caused hy valvular insufficiency, hut 
 a putty, doughy appearance peculiar to these cases. The 
 
 t' 3«j«!B»<sa!«!«!aBa»)W»*ft«f«««Sfe«WK*» - 
 
 .•,.wt■S!■^^^^i>i^»ig^»^^g<g 
 
TViiirMi MirimiTix. 
 
 85 
 
 uTf iiiiiy 
 
 iiu'L' hat I 
 
 •tly well, 
 
 tor lit'i"- 
 
 (|iiimtit_v 
 
 1 iii(|uiry 
 
 liiul not 
 
 t'rc'((uc'iit 
 
 LS shows 
 
 aiitity of 
 
 so-called 
 
 thin iVoni 
 
 <'u'al. In 
 
 rhis will 
 
 lor liead- 
 riii'V may 
 us, whose 
 
 If these 
 tient may 
 xnd there 
 
 peculiar 
 
 ese cases, 
 led to no- 
 hat more 
 ce during 
 ts seldom, 
 ich I have 
 pression." 
 ix, nor the 
 iency, hut 
 ises. The 
 
 ,,,,,,,,, .Kaminati.>nJnvarial.ly sh..v.tluMMvs.u.e.d^^ 
 , p.;an.ount wt^dl.nnn.n, with tlu- n.nal .as > . - 
 
 • , 1 „l,l tJ... ."He i.ro>rress untavonihly, theie \\ HI 
 „,,,ths. should the.... . ,„,,..,.. o.dema of the 
 
 he droi.sv. anasarca, a-eite., an<i ptiu-i 
 
 ,,.J...\.,lnsion into the pleural eavuy as. e 
 
 riHdy seen, ditlering in no way fron. the la.e. >ta,. > ot 
 the acute t^n-n.. ^,v,/.-;//..-Then. i. no 
 
 anasarca, I usually designate as cases ot elnon.e tubulai 
 
 "tlnv^^f these cases live t;.r one or two years, and oc.. 
 
 .h.nlv a case of evide.xt tuhular nephrit.s may live es en 
 
 °''i;:;t::n,.„p.v U so c„,.s..nt . eon,Utu,„ i,> ...e acute 
 
 •"^:r:n:::"^;op,. .f ...« .«.. ^x..™m., ™i 
 
 n cltos from iwrtal oLstmcfmn, a» in i'.n-li..s.s .. .amir 
 ^nt W the ar„,«y i» clue ... oolla.eral l,l,,.,l-i.,y».m-e 
 rthe V iu,whne tl» ,U.,.,,v of Bright-. ....-• - ■ll- 
 JIt her to a™tho..enic eon.lition of the hloo,l or hh.o.l- 
 ;l:rbrou;*t aSout by. he elu„i„a.io„ of all,u„.e,> or 
 thp roteutior of uric acid, etc. 
 
 The e-ai>e of .er„,u iron, the hloo,l-ve.HeU m.o the 
 
 8 
 
 .iwUM I IwMl i 'i 
 
 ^ t^fSi^^i^^SS' 
 
m 
 
 DISK.ISF.S OF Tin: KinSFAS. 
 
 oilliilur tissm- irt a tniiisddation. ii iin-iv i-liysical or ii»"- 
 cliaiiical i.n.fc-ss, whicli lakrs placr I'n.iii tlu' rapillarii'.-A 
 into thf iiitiTsticfs of till' .•(.'llular tissiu" tastiT t!iaii it 
 ,.i,ii l.c talon n|. I.y tlir vfiiis and Iviiiphatics ; diiri-rin^^ 
 fiitiri'ly tVoiii tlu- i-xiidatioii of iiitlaiinuation, which in 
 a vitai'i.i'oi't'^s, the oscain-d lluid hoin.ir capahlf of organi- 
 zation. . 
 
 Whatever the |.atholo,<rifal condition .(f the IiUumI, it is 
 clcarlv not a mere ana-mia or hvdra'iiiia. 
 
 Dropsy is often a syinptoni of diseases of nntritit.n and 
 the l.looil .ijlandnlar origans, hnt it is never iireseiit in the 
 exti-i'ine (U'lrpee in which we find it in these cases. 
 
 A peenliarity of the dropsy of Hri-lifs .lisease is its 
 tun.lency to shift ahoiit, a ciivntnstance that is dithcult to 
 understand. With the exception of the pefit<.neal cavity, 
 all the sei'ons cavities are more likely to till in Bri-hfs 
 than in any other disease. 
 
 Freqnen'tlv, in Uriirht's, we find the dropsy .lepend- 
 injr api.aivn'tly upon the secretion of urine. When the 
 urTne is scanty the dropsy develops more rapidly, disap- 
 pearinir in a measure when the kidneys act freely. 1 h .w- 
 over, a"t other times there may he extreme dropsy with a 
 free seeretion i)f urine. 
 
 The condition of th(^ arteries in acute Brii^ht's has not 
 received from mic-roscopists and histologists the attention 
 the subject deserves. 
 
 Xoainhitious student of medicine need feel discouratred. 
 There are pleiitv of discoveries yet to he made in every 
 departnu-nt of iuedieine, especially in the etiology and 
 
 patholo'i'V of disease, 
 
 rROONOSls.— Time was when the proirnosis ot albu- 
 minuria iTcnerallv was held to be much more lun'oless 
 than at present. The name Bright's disease has a great 
 terror for the laity. I am surprised, in the light of my 
 
 .-.^»a.v ,r^rfia»*«S*itfefciia)«tWHr*^^ 
 
 i«ii(Ul6»l»ei«««*^'^*^ 
 
Tfitri.An sKi'iih'iris. 
 
 87 
 
 ,1 (ir lu"- 
 ijiilliirit'H 
 t!iini it 
 ililli rintr 
 ,vliifli in 
 f ufii'imi- 
 
 m1, it is 
 
 CM 
 
 itidii aiitl 
 lit ill tho 
 
 isL' is its 
 
 ilHrnlt to 
 
 ill cavity, 
 
 Brinht's 
 
 ■ (li'])fii(l- 
 Vlu-n till- 
 ly, (lisai.- 
 y. lldW- 
 isy with u 
 
 's has not 
 attention 
 
 oonrntco(h 
 
 in vwvy 
 L)lt»i>'y and 
 
 1 of alhu- 
 i hopeless 
 las a _i!;reat 
 jht of my 
 
 , 1 : . .lie ,io ... r...... .......|.ii.-';-.. •■'";'.•'""■;;;; 
 
 ;;;';;t,:r;;:^:;:'::;;^r:i,,;i::r;:^:;:;i 
 '1.::: ::;:::';--., .::«'' n.... ,„.........-; -- 
 
 n we h'lve no spe-ilie in nie.lieine that will aeeon.,.1. h 
 
 r W-^u , however, in a nieasnre, relief, the patu.it s 
 
 luLs^^uia .:inH.al to the .cin and howels to assist m 
 
 (loin- the suspended work ot the kuhieNS 
 
 Absolute i-Lt is to he eiMoined, with the siniphstd 
 
 .on.isti...' <.f milk and water ov ruHMvater. l)i>-cnp 
 n^ ^applied ..ver the rejxion of the knlneys, a.so hot 
 ""oM applications, whichever is more a,reeahle to the 
 
 ^^Thf howels should he kept freely open hy a saline ea- 
 thn-tie and diaphoresis should he insured. 
 ' ir^,r estorU the tixneti<ms of the kidneys, some .i^ 
 vise d uretics, while others advocate the seenn.n^ as nea.l.> 
 :r;^ mo complete physiological rest ibr the knlnoys. 
 
 " ^Mftft^^H'tCU ll*ii^/#0'^&*!^ 
 
±^ 
 
 HH 
 
 niSH.iSHS nr Tin: KIDXHtS. 
 
 I licliiVi' till' Inif fdllisc lies l>(l\\c»'i| tllfsc t\\(i i\- 
 
 trtiiiis; tliiit is, lii'twt'cii stiiimliiliiii; tlif kisliu-v-* liy 
 
 fliliri'tifS nil tlic nlic lllltul, IIImI fllt'nicillir l'Olll|il(tc |p||\>i(i. 
 
 loi^ical rvM oil tlii> otlicr. I att('iii|)t to ki'fp up Hoiiif 
 li|on(I-|irt'ssiiiH' oil tlic kidiifvs with ih little irritation to 
 tlu' oi\ij;aiis as [lossililc, so tliat wliiK- I eii_joiii n-t, rnrorri' 
 tlu' Htrifti'st r>'j;iim'ii as to diot, aitpciil t<» the liowils and 
 skill, and take advantat;*' ol' fxti-nial application^ to re 
 licVt' colinrslion, I endeavor to keep up the hlood-pvessiire 
 in tlu- kidneys l>y ullowiiiir the patient lari;e (|iiantities of 
 eold water or rice-water. 
 
 As the lessfiied (|iiantit_v of urine must depend in a 
 iiu-asiire on the oi»struction of tin' tiilniles \>y easts and 
 cNudatioii, it would seem reasonahh' to suppose that 
 iilood-pressure kept up in thi' ijlonieruli, without irrita- 
 tion, would assist in cleariiiij the tuhules. ff iiiort- ai^reo- 
 nhle, tlu- patient may take carltoiiizcd or mild mineral 
 water, sueh as Xapa soda, Coronado, TJartlett, t'te. 
 
 Here let iiie sav, /»//• jxifi iitliisi\ that if praetisini; on 
 this coast, when you do use minerul water you should hy 
 all lucans ^ive the preference to the spriutfs of California, 
 as their varii'ty is Icirion. 
 
 In the majority of cases a few days will hrinir relief to 
 till' patient. The lii'adache or vomitinir, if iircseiit, hen'ins 
 to yield, and the t|uantity of urine soon increases. It no 
 Ioniser coiitaiu.s l»l(»od, hut ii large amount of alhumi-n is 
 still present, with lessened urea and ahundant epithelial 
 tuhe-casts. The diet may he i^radiially increased. The 
 indications for appealing to the skin and bowels are 
 less urgent, and we shall soon find our jiatieut becoming 
 ainvmic, tor we liave already seen that where there is 
 much albumen there is disintegration of red blood-cor- 
 jiusdes and a consetiuent bydriemie condition of the blood. 
 
 lu tliis stage of the di-sease, tluit is, when the acute 
 
 .;.»»»(-;■.- OT*»i«£!Si.!iS5»W!i.Hf.-"=.*swe»fl»a!o- ^m^m .mm»»e*mmsiiie:-. 
 
^%. 
 
 
 IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 
 / 
 
 ^/ 
 
 /. 
 
 O 
 
 
 
 s^ ^^ 
 
 
 
 7^ 
 
 1.0 
 
 I.I 
 
 l^|2£ 12.5 
 1^ 1^ ill 2.2 
 
 t u& 1110 
 
 1.8 
 
 11.25 illU IIIIII.6 
 
 V 
 
 <^ 
 
 /} 
 
 o^. 
 
 ^^ J^^ V 
 
 
 Photographic 
 
 Sciences 
 Corporation 
 
 23 WEST MAIN STREET 
 
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 (716) 872-4503 
 
 .«*] 
 
 ^Mi 
 
L<? 
 
 &. 
 
 CIHM/ICMH 
 
 Microfiche 
 
 Series. 
 
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 Collection de 
 microfiches. 
 
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 Historical Microreproductlons / Institut Canadian de microreproductions historiques 
 
 f.mm!»<^iS^^!i^^sm^f^%^^^i^i^^^^^^'^i^^''^^- i 
 
Ti'iiirM! .\i:riniiTis. 
 
 89 
 
 tVbrik- svniptnms liiuv .lisair'^»T.l, ..r in sul.u.M.tr cases, 
 MiiM (liilivtu's, with or xvithout iM-q.anitini.s ut in.ii, srcii. 
 t.) U'ssi'ii tlu' .iiiaiitity of iill>miic-ii. 
 
 I luivi- sfcii p.arkvMl in.i.n.vci.U'Mt, in Ifssmui- tl.c 
 ,,,uu.titv ofall.nuuM., rostorin- tl.c apiK'tit.", ami anvstiiig 
 tlK'anii'mia, from tlie admiiiistnition ..f oiu- or otlior ot 
 tlu' following formula': 
 
 B Li(i. !ii>i'iiiri clili'viili, ."^i; 
 Tiiiit. firi-i clilMii.li, 
 Spl. itli'Ti- iiiiio-i, iii'i giv ; 
 (ilvctM-iiii lul ^iv.— M. 
 Si.,r._.V tcispoonful in wiitn- adw viwh mcml, iitxl ,it iH'dtiin.'. 
 
 In some cases 1 in-oscrilK- only one-half drachm of tho 
 li,.„„r arscnici chlori.li, giving a teaspoonfnl in water 
 everv two hours during the day, occasionally either add- 
 iu.' to this or substituting foi the arsenic one-hali gram 
 of^hydrartrvri bichloridum, and sometimes I give the 
 hydrargyr'rhiehlori.lum alone in doses of ..ne one-hun- 
 dredthOf a grain every hour or two. 
 
 In addition ro its containing the iron which is so neces- 
 <.,rv a "-reat advantaire .>f the tincture of chloride of iron 
 is that it supplies the .loticieucy of free hydrochloric acid 
 in the gastric secretions. The a.Mition of the arsenic and 
 bichloride of mercury prevents the decomposition ot the 
 food in the alimentary .-anal, and the otfensive ..dor ot the 
 evacuations, so often present in IJright's, is comi-letcly 
 
 Aiiother favorite prescription of mine, an<l one that will 
 perhaps bo more ot>en of benefit than any other that I 
 have tried, is the following: 
 B Sulphur, pr.ecipitiitum, 
 FiTi'i c'nrbi)natis, 
 Glyc'Tini, Afi giv ; 
 
 A<Juii> ciiitmin.mii, vd iiqusD copnibii', .^iv.— M. 
 Si- -A tcHspoonful every two hours, or after meuU and at bedtime. 
 = , 8* 
 
•M) 
 
 DISHASKS Oh- THE KU).\i:ys. 
 
 Tlic in>i< i-^ iiurwiit.'d by the aiuiMiiiii, l.ut the hfiu'ticial 
 ivsults iin' nut i-ntiivly .lu- t.. the iron, as tlu-so imtionts 
 ,1.) iK-ttiT wli.'n it is fon.l.inf.l witi. the snlplnir. It is 
 jiossiliU- that it arts luMU'tirially on tin- nincons nicnil.rano 
 <,f thr l.(.\vi-ls l.y tlu" elimination of inorhitir niatrrial. 
 
 Thr following!: is anotluT mixturr wliidi iti subacuto or 
 rhionir tnl.ular lu'iiliritis is often i?ivon with hunotit : 
 
 li Aciili urscniiwi, nr. \; 
 Forri iiirimimtis, ^\ ; 
 IJiils .(ipiiitiaj (in-p), 3>— ^'^ 
 Div. ill ciiiisiilii- 11!' XXX. 
 Si.^r._()nc ut'liT <ii' li "ii'i'l. i">'l »' '"■•lliinp. 
 
 Thoiv arc, of coursi-. many other comhinations and 
 iMH.i.arations'of iron. When''r have any sus,.ieion of a 
 HVi.liilitie history, I always prefer the tbllowinir, whieh has 
 served an admirable jinrpose: 
 
 li Hydnii-','. liiiiitulidi, i;r. ss ; 
 Piit!i->ii iodidi, ^>^ ; 
 S\ r. iV'iri iiMlidi, ;5i:i ; 
 Aiiuii' dolilliitiu lid ^iv. — M. 
 Sig.— A u■ll^ll."'ll^ul every two hniirs. in wiitiT. 
 
 Tn many eases, however, there are symptoms and eom- 
 pli,-ations\vhi<-h we must treat as oeeasion r»«(iuires. The 
 dropsv often becomes so ur^'ent that it demands immediate 
 relief." The general anasarca is extn-me, while some one 
 „f the serous cavities may also contain ai larirc amount of 
 flnid. The more acute the case, the less likely are we to 
 obtain diuresis, even if stimulation of the organs is jnsti- 
 tied. We have then to di'i)en<l on elimination by the 
 alimentarv canal and the skin. 
 
 .\< for ".liuretics. onlv the mildest should ever be used 
 in acute tubular nephritis. When the very acute symp- 
 toms have passed, I often prescribe the following pill : 
 
 I 
 
 ^iM 
 
r 
 
 I' lii'Motifiiil 
 ■sc piitionta 
 •liiir. Tt is 
 nu'iultranc 
 iiiUt'i'ial. 
 sul»ii(Mik' or 
 K'lK'tit : 
 
 nations and 
 sjtii'ion of a 
 ir, wliicli lias 
 
 lltlT. 
 
 ins and I'oni- 
 (|jiiri.'s. Thi' 
 Is ituniodiati' 
 die some one 
 ri' atnonnt of 
 ely are we to 
 trans is jnsti- 
 ation l>y the 
 
 ever be nsed 
 • aeute symi)- 
 wing pill : 
 
 rrnrLAi: .v /•;/'// A'/r/.v ^1 
 
 IJ Mii--;f liyilniri,'., 
 I'lilv. (lii;it»li-, 
 Kxt. oiil'cyiiilii'li-'i 
 I'ulv scillii'. Mil irr. i. — M 
 Si.._Ai..ll.'V.:-y tw.,tlMv,.,orl..Mrl.,mr.. 
 
 Should this tail ... iu-.vas.. th. s...vti..n of urine, 
 u.. .n.all doses of the iodide or aeetate o pota^.uun 
 :;:;,/:;. without digitalis, o.- haUun eo,.ad>a and u-on 
 
 ^•'t;:;::^tlK.newdiuMiesfn.n.w.ldelMnuehisex,eet.^ 
 
 i. diuvetin. Those who have experuuented with U thu 
 ;•: and seenWo adnnt its diuretie quality are n<,t a,^^^^^^^^ 
 
 ns to its nnxle of aetion. • i :., 
 
 Le<>hserversn.aintain,hatitisahourttonn.and - 
 
 .,:..es the Huantity of urine hy nu-ans ot mereased hlood- 
 
 '^'it- ih^^e measures tail .o ,r<,duee a tree diuresis, .unl the 
 .V M.toms heccne urgent., we n>ay appeal to the slon 
 Th vodernde inieetion of ,.ih,earpin or the not-ajr .^^^^ 
 
 l^U.; ame thue eausing the howels to aet very tree . Uh^ 
 
 1 n. driehm doses of eonipound .lalap powder exe.v 
 
 i:::^';^!' tl^s or resorting't,. (MutterhueU's ehderuun 
 
 Td .^ofone-tweltVhto<,ne-tithvnthofagranua..^ 
 
 ,.„.U,ined with a little blue .nass, every wo to io 
 ;;:„;:r The adnunistration should he eont.nued untd 
 ooi. ions watery diseharges are seeured. 
 
 t has heeu mv eust.uu, eaeh year, to mt,-oduee to the 
 ..•al tin.^elass:while at the .puz in n, othee nu t..t 
 ^^.^r;;-aeut tuhnhn- nephritis whieh entn-ely reeoy- 
 el^lTgentlennu. is now and has been lor years, n 
 
 , ■ .t health WlH.n he c.nsulted n.e he had snttered 
 '^^^^^.^ri.nr.non.U^. The atta.dcl.gan with 
 :;;;;;dlilK,.nen.ver, pains in t..bae.,.^^^ 
 
 vomiting. 
 
 soini ie>ei, i>iiii>.' ■ - , . . 
 
 'The dn.psy was extreme. The phys.eian 
 
 BH 
 
')-2 
 
 i>isi:.isi:s III' Till-: a//.'.v/;j-.s. 
 
 wli'iiii lie hail pri'vidiisly (•(disiiltcil luiil iiiailc incisions in 
 his t\'v\ and h-ir^, tii prfvciit, as lie said, liic skin from 
 
 hiirstiniT- 
 
 He was vcryaiii'-inic, liad a vt'rv weak imlsr, with ^ivat 
 dysiUHi'a, and was, in fact, coiniilctidy watcr-loir.ii'cd. 
 
 The urine when hoiK'(l in the tnlii' showed two-tiiirds 
 of its liulk solid. 
 
 I coniiueiiced the treatment hy ahdoTninal aspiration, 
 taking; away fourteen <iuarts of Unid, contininj; him to a 
 milk dii't, and i^ivint; him a comhination of ai'senic, iron, 
 and halsam co|iail»a., with an occasional dose of compound 
 jalap jiowder to secure wati'ry discharsres. 
 
 After aspiration the anasarca (U'creased to a coiisiderahlo 
 extent, hut at the end of tw(» weeks it was almost us had 
 as it had hei-n hefore, while the ahdominal cavity tilled to 
 such a de!.n'ee that on my second aspiration I removed 
 eiu'lit (piarts of Huid. 
 
 After this tappins; [ continued tlio ahove mixture, as 
 also the jalap once in two or thri'c days, irivini; Idni every 
 alternate day a hot-air hath, which relieved him each time 
 of a irreat ((uantity of water. 
 
 Hice was added to his milk diet, with good mutton- 
 hroth once a day. 
 
 There was no more ascites. T!ie anasarca soon dis- 
 appeared, and in two or three months no trace of alhumen 
 was found in the urine. As I have said, this was my first 
 had case of acute tubulitis which recovered. 
 
 Pneumonia is a c<tmplication which we are frecpiently 
 called upon to treat. 
 
 The i.neumonia of Uright's is of a peculiar character. 
 It is seldom that we find a characteristic lohar pneumonia 
 ushered in hy a severe chill or hitfli fever and involving a 
 whole U)he of the lung. 
 
 The patient is likely to have slight chills or rigors, fol- 
 
TCiui.Mi .\i:riii{iTis. 
 
 9^ 
 
 u'lsKtns 111 
 skill tVoiii 
 
 ^vitli ifiviit 
 
 t\v()-tliir(ls 
 
 is|iii'ati(>ii, 
 
 liiiii to a 
 
 I'liic, iron, 
 
 i'Olll|ioUll(l 
 
 urtiderablo 
 lost as bad 
 ty filli'd to 
 [ rciMoved 
 
 iiixtun', as 
 liim fvcry 
 oacli time 
 
 id mutton- 
 
 1 soon dis- 
 )fall»nnion 
 as my first 
 
 frequently 
 
 character, 
 |>neumonia 
 nvolving a 
 
 rigors, tbl- 
 
 lovvcl l.v a tcmpcratuiv ..f hy^ or 10:',° F., with more ol 
 a l.n.ii. iio-iMicumoiiia tlian a lobar pncumoina. 
 
 The lun-^ he.M.mes involved from .liU'erent centres. 
 lU.voiul the inflamed ,.ortions we tind u .lein;., with its 
 s„herci.itati..ns. The dys,.nu.a ..fteii hecomes nruvnt, as 
 not <.i.lv does the fortion ..f the lung not inilamed heeome 
 ced.ma'tons, hut the other lung as well. In examnnng 
 thesr h.n.^s |.ost mortem we tind that the intlammatio.i is 
 developed from difVerent centres, as in lol.iilar l.nen.nonia. 
 
 The Inn.' is not s.didlv hepati/cl, as the exudation is not 
 vorv lihrinons. In cutting into it the whole Mir»a.'e_ is 
 hatiied in hlood, and we Hnd the air-cells tilK'd with 
 hlood, serum, mucus, and leu.'o.ytes; never the dry, hrm, 
 fibrinous exudation of a pneumonitis. 
 
 Only a few weeks ago my last patient who died of pneu- 
 mmiia while suffering from tubulitis had a succession of 
 chilly sensations from da.N to day as the pneumoma kept 
 invailint; the lung. It commenced at the left base, and 
 proirressod upward until almost the entire lung became in- 
 volved. Ab..ut the fourth day of the pneum..nia (cdeina 
 betran in the ritjht lung, with some hypenemia. Although 
 I iH.pealed to the skin and bowels and tlu' urine was not 
 verv scanty, I failed to arrest the (edema of the lungs. 
 The dyspiioni became extreme, and death occurred m 
 
 eonsecpience. 
 
 As soon as the patient leav(«s the bed, in acute as well 
 as in chronic eases, great care should be taken with the 
 ch.thintr. lleavv, warm underwear should be worn coii- 
 tinuouslv, and a"n over<-oat should always be at hand to 
 insure the patient against the effects of sudden changes 
 in temperature. It n.ay be safely said that no <lisease is 
 more benefited l)y a warm, eipiable climate than tubular 
 
 neithritis. 
 
 (?/om(77//o-.V<7>/*/v7;...-Klebs was the first to call atten- 
 
 ttman 
 
!>4 
 
 i>isi:.isj:s OF THE KinsKYs 
 
 tioii to this tonii of in'pliritis, (iccurriiiic I'sin'cially in ^H'llr- 
 h't tV'Vcr. It isoi" iiKii'c iiitiTcst to tlic jtiitholoti'ist tliaii to 
 tli(; ('liiiician, us it \voiiI<l la- iiiipossihlL' to (li'tiiiiiiiic in 
 iiiiv ciisi^ ot' iu'|iliritis wlu'tlicr the disuiiso was roiitiiifd to 
 the ,i;-l(*iiu'nili. Wo liavi,' jdri'ady otH'rfd tho sUiLr,ir«'sti()ii 
 tiiat ill so-calli'd jih_vsioloi;i( al allduninuriu the distuiliiiiicc 
 is coiitiiit'd to the ":loiiu'ruli. 
 
 ci[APTi:i{ xrrr 
 
 ■ I 
 
 i! 
 
 INTRRTrni'I-AR NKl'llHITlS — INTKKSTITIAIi NMOlMIUITIS — 
 (illANl'l-AR KIDNKV — (ioiTV KIDN'KY — CONTKACTKI) KIIJ- 
 NEY — CIKUIIOTK! KIDNIOY. 
 
 Wk sliall uso tile term iutertiilmlar nephritis to desi;;- 
 tiate tlmt form of nepliritis in which tlie priiiiarv iiitiam- 
 mation eoinmeiiees in the iutt'rtiihnlar or tihroiis tissue, 
 
 K'rioliOtiY. — The eticdotry of iiitertuljidar nephritis is 
 limited. Its eaiiacs are less numerous than those of tubu- 
 lar nephritis. 
 
 (■/iiiKitc. — Like tuhular nephritis, this eondition is more 
 common in the temperate than in the torrid or frii^id 
 zones. While elimate can hardly he said to be an etio- 
 lo,u:ieal faetor in this form of Hrityht's disease as it is in 
 tubular nephritis, cold, damp seasons are eertainly re- 
 Kponsible for exat-erbations of the aft'ection. 
 
 A(/r. — As a rule, intertuhular or interstitial nephritis 
 may be said to be almost exclusively confined to those 
 who Inive passed middle life. We have already seen that 
 tubulitis is more fre(pient in childhood and early life. 
 Where occasionally we find intertuhular nephritis in 
 childhood or early adult life it is ^'cnerally in a case of 
 hereiUtary gout or strong gouty diathesis. Of course 
 
 u_ 
 
isTEiiTi r.fi.Mi si:rnniri><. 
 
 05 
 
 ]_v ill rH'iir- 
 
 ist tlllUl tn 
 
 I'l'iiiiiic ill 
 oiitiiii'd to 
 iiiiru't'f^tioii 
 iMturliiiiicc 
 
 iMIltlTIS — 
 ■Ti;i) KID- 
 
 s to (k'siu- 
 irv iiiriaiii- 
 irt tissue, 
 .'idiritis irt 
 SI' of tiilm- 
 
 iiii is iiiort' 
 I or friijid 
 bo an t'tio- 
 as it is in 
 rtuinlv ro- 
 
 iu'i)liritis 
 il to tliose 
 y soon tliat 
 early life, 
 pliritis in 
 1 a ease of 
 Of oonrso 
 
 l,a.l-i.oisonin-ora..,tono,.linti^ '"iKl't l.nn- al.out tl.is 
 ron.litio.iinllu'ooiiii.anitivoly vounir. 
 
 .sv, -\lalos aiv niurh nio.v suLjo.-t to tl.is .lisoasr than 
 fomalos: -out iH.i.m- nuiol, nioro fro.,urnt in n.alos than 
 i, foniak-s, an.l mon, hy ivason of ti.oir hahi.s an.l u- 
 
 ,.atioi.s, boin^ n.oiv oxposo.l to untayorabh. •">l'"-;';-; 
 
 ItisvorvsoMom tlio ivsult of in.p.ry or amtr tubu . i 
 ,H.,,britis, ami it is baroly possible that it is o.v, .mally 
 
 the result of liyi>eneiiiia. _ 
 
 Aloohol is sui.l.oso.1 to l.ro,luee this eon.lit.on : wlion 
 it does, it l.robablv follows aleoh..lie hyi-eneiiiia. Nune 
 of the eases are attributed t.. obrouie malaria; a l.w are 
 
 erodited to sypliilis. 
 
 It is a .luestion whether the exoossivo use ot vor.N stn...,^ 
 tea may not be a faetor in produeing a hyperi-lasia ot 
 iibrous tissue in the kidney. i • i i 
 
 It is imt an infre.iuent oeeurrenee tor workers in lea<l- 
 nnnes, painters, .u. tli..se who are eonstantyinhan,. or 
 
 abserbin,^ lead, to sutfer with this tonn ot l.r.^d.t . d.>. 
 
 ease (saturnine poisoninji)- . , , • • i 
 
 But the oxperionee of all observers is that the pnu.ipa 
 cause of intertubular nephritis, -ranular kidney, is r". 
 We mav even tind this eonditb.n in people ot ^-outy 
 .Uathesi.; wlm have never exhibited any of the ordinary 
 
 svmptoms of srout. 
 
 ■ PVTIIOLOU v.- Unless the patient dies tron. some inter- 
 current disease, we do not have an opportunity ot oxam- 
 iniuii the kklneys in the earlier sta.u^'s ot intortubular 
 nooi.ritis. When sueh an opp<.rtunity <loes otler, we tiiul 
 the.n oulanred from the proliferation and inerease ot 
 iibrous tissue, just as the liver is in the early sta^e ot eir- 
 rhosis of that oi-an. W." .iTenerally see the kidnoN . n hen 
 thev are small in size, irregularly eonti.a-te.l ami nodular 
 by "reason of the eontraetion of the new tibrous tissue 
 
 «Maa 
 
w 
 
 i)ish:.\si:s or riii: hiiKShns 
 
 !i 
 
 (st'c K'lL'. !-)■ A' timi's tlirv ii'> IniiLTtT |ir.'s«r\ f till' >li;ii'f 
 ..fa kitliH.v.ntt.ii .•xliil.itiiiir a liirir.' iiiiiiiImt of .vsts tVoin 
 llir size uV a lull |M tliat of a walnut. 'IMir rai.^ulc i> 
 
 ..losrlva.lhrrrnt.aii.l in ouri.iVorts t<. n-inovoit the .irranu- 
 lar tissue" (.ftlic ki.liu-y is uth'ii torn. Tliis tot-nis a n)in- 
 pU'to contrast to tlu- sniootli sliinin.ir surface aii.l casil.y- 
 strii-i-i..! rapsulr of tul.ular lu^phritis. A section of this 
 ki.lnev un.ler tlie microscope shows ,irreat increase of 
 fihrou"s tis>ue. with con)i.ressi(.u and atrophy or (U'struc- 
 tion of many of the Mal^i.-rhian corpuscles as well as 
 tuhules. (Set' FiLr. l;5.) i^iiiall cysts are often found scat- 
 tered throu./li the cortical i.ortion of the kidney, and are 
 the result of dilatation of the Malpi.irhian tufts in eonso- 
 ,,u..uce of ol.structiou of its tuhules hy new lihrous tissue. 
 
• ill.' -]\H\>r 
 
 cysts tVoiii 
 lUiisiiU' is 
 
 ri'iiiiivfil friim a 
 r ixIriMiiily cull, 
 ivcll till' >.'iiiimliir 
 null mill iirciiily 
 iiiry iiiilliipUit!i('iil 
 f result 111' ariiti' 
 I'l'jvi'ii yt'iir- I'M. 
 Icr lu'iiltli iliirliii! 
 • urine. Imt viiry- 
 il tiniilly ilieil III 
 } iii'curred in the 
 
 it tlio irraim- 
 
 oriiis u c'oiii- 
 
 1111(1 i'iisily- 
 
 .•tioii nt' tliis 
 
 ilUTl'ilSl' dt' 
 
 ,• or (Icstruf- 
 s as Wfll as 
 I) touiiil srat- 
 \n'\, and art' 
 fts in I'oiiso- 
 l)rous tissue. 
 
 lyTHirn mi. mi .\i:i'IIIiitis 
 
 '.•7 
 
 noui„;.irs rni.Mil.. aiul the ualls -f tlir 1.1u.h1.v..ss..1s a.v 
 tl.i.k.nr.l. aii.l many of tin' ti.l.uK-s aiv .l.i.inl.'.l nl tlinr 
 i'|iillu liiini. 
 
 Km. VI 
 
 Stiruun. ,.h..t,,|..nM..ie,, .,y .1. r. Speiieer )--., ., vertleal .n„ ,„„K.t....u,al senl.m 
 
 Moiiiiteil l>y J. n. 
 Iiiial seclloii 
 rimvU's mill 
 
 Stulliiril mill ,.li..tui;m|.lie.l i.y .i. v ■ .-l-e , ■ . -■-■■•." . ,.„r,,„.,.u.. 
 
 .,,aii i.rtery ^llo^^,„« vi.mi reniil elimiKOs; ,■, el, inters of ^'"'" « l';"'"' "■ 
 ,,n.llfer,aeil liitirtuM.lur lil.nms llNS,ic.-<'omi,lete abs^'nee of tulmlts 
 
 Symi>t..ms.— As svv have ulroady socn from tlio etiolo.iry, 
 tlu. iiutient is pn.l.al.ly a male, past mi<l.llr lilV, ami ni 
 n.unv cases the subject of -out. Fii tin' early stajres ot 
 tlu' disease the symptoms, as a rule, are m.t sutheieiitly 
 marked to attract the atti'iition of either patinit ..r phys- 
 ieian. The disease is very slow and inddi-us. In some 
 eases, however, there is sufHeieiit hypenemia to produeo 
 
 9 
 
 i 
 
08 
 
 i>isi:.\si:s itr riii: kidmis. 
 
 iifliiiii; pain iil"Mit ili.- liack ami l«iiiM. with f'n'i|iiciit mic- 
 tiirilinii. wliilf iM< ;i»i..iiiill.v u>- iin'.t wifli In iiinrrluiirf in 
 tlu' «'aflit'>l slairi'-' <'t' ,ir<'ii«v kiilm y. 
 
 Art tlif ilirtt-a:'!' ailvantTi, flic f_viii|itniiis litrmnr -iitli- 
 ficiitlv (Iffiiit.l to iiltrii.t tlir altciitinii ,>\' ilu' patiiiil. 
 \Vr r-hall us lally »iii<l rii inm-iisfil i|ii:uirn,v nt' iiriiir. of 
 liirlit >|«f<ilit ,iria\il\ ami rolor. nuituiiiiiiii' a sniiill t|iiaii- 
 r,;v ■•!' !il!;;imtii (\v«' art' luTt' ri'liTrinur |iiirti«'iilaily to 
 iruiilv kiiliicv). Willi v.'ry U\\ lulM-.ii>ts. wliicli iiillri' iirc 
 n| til. Iiviilinc varii'tv. Analysis will sIk.w ii .l.tiritn.y 
 in ilic iiiiiuiiiil III' iirt;i cxcn'tftl. 
 
 'I'l'i.- fniiilitiiiii (.1' tliiiiii's may ir" "n fi.r mmitlis or years, 
 till' (list'iisf lifiniT very cliroirK'. ami rlir palinil may ••on- 
 siili lli>' |iliv>i.''iiii tor coiiiiirKMiioiis or iiitfrniiTii't ilis- 
 vast's lis tlu'V arise. X'oiiiitiiiir may Utoiiic ti'oiil>K'-omc, 
 or scvf.'i' lii-adaclics may (lfVflo|i ; not iiitrf.|m'ntl\ llii- 
 iiMliciil (■oii>ults till' pliysiriiin on account of lo>s of >iL'lit, 
 (Hill Irani- for tin' fii>l time that he has chronic I'.riv'ht'rt 
 ilisi'usi'. 'rill' ilisi'.isf o|' the i-yc most common is retinitis; 
 anil \\< characteristics are .>o marhcil that oculists iVe- 
 ijuently make a <lia,trm>is of chronic i'.right's tlisease tVoi.M 
 the aiU'caranee <>f the retina. 
 
 Another coni|.lieation whicli these i>atieiits rarely eseaiu; 
 i> hviicrtrojihy of tie/ left heart. Various theories have 
 hceii ailvanced to eN|.laiii this eomlitioii. Mritrht. hiiiisclt', 
 atlriliute.l the cardiac hy|iertro|.liy to chemical ehanu'es in 
 
 the 1.1 1, or. a< he e\|iresses it. an impure state of the 
 
 hloo.l which stimulaii'il the heart to excessive actMty. or 
 hv reason of its altered (juality re.|uired more hn'ce to 
 jiroiiel it throuirh the ea|iillaries. 
 
 Trauiu' was of oiiinioii that the increased ai-tioii of the 
 lieart was due entirely to an ohlitcration or contraction 
 of a lari^e niimher of renal arterioles. This theory, how- 
 ever, has heen shown to he untonahlo. 
 
 t - 
 
 mm 
 
iSTKirri III i.M! SEi'iiiiins. 
 
 00 
 
 lent tlllc- 
 
 I'l'liiiiri' ill 
 
 lllr -lltH- 
 
 ' |i:iti('iit. 
 iirliii', of 
 mil ijiiaii- 
 iil:irl_\ ti' 
 lallt'i' ill')' 
 ictiriiiify 
 
 iiiav coii- 
 rni't ilis- 
 iMi'-iiiiif, 
 ciillv lllf 
 ^ ..r >ii:-lit, 
 ■ Till -I It's 
 rrtiiiitis; 
 ulists tVf- 
 «'iisi' iVoi.'i 
 
 vly cscaiK! 
 irics lijivi- 
 I, iiiiiiscll', 
 •liaiiircs in 
 
 ate ct' till' 
 
 (t'vity, or 
 I' t'on-i' to 
 
 iuii of till' 
 oiitractioii 
 I'orv. liow- 
 
 (!,.or,u'*- .lnliii>oii al lir>l a.lvaii.r.i llir i<l.a thai tlf 
 |,y|.rrlro|.l.v wa^ owiiiiT »" >i lii.^'l' l'l"o.|-|.n"iiiv -aiisr.l 
 |,"v u tl.irk.'nii.i; of ll... imi.Miilar walls of tl.r ivnal art-- 
 
 riolrs. l.iil s.il.MM,ii.ntly f. 1 ilial lli»' lliirk»'iiiii.if was not 
 
 • •onliiii'il to tlif arltriolrs ..f tlir kidney. 
 
 Sir William (lull iin.l Siitlon .•oiifirm.Ml l! i-inioii of 
 
 .IuIhhom in ivu'iinl to tl..' tlli-'kruill- of ihr walls of tlu- 
 m-t.Tiol.'s. .lolin>..n niainlaii.r.l that tl.r mus.nlar .•,..! 
 uf tli.' Nvss.-ls was tlii.kolKMl. wl.ilc (lull au.l Sutton sl.uwr.l 
 
 that tin- niMs.nlar <'oat in ivally atrophi.d, it h.inir tin- 
 •„,„..,• an.l *xt»rnal roats whhh aiv thi.-kcin.l. an<l that 
 tl„. nal patholouMnil ••on.lilion is a irmnal ait.rio-.apil- 
 laiv fii.rosis. with a U'ss.'nin,ir of tin- Ininina of the Vfssi-is, 
 thu^ foiviniT a ,M.nii...nsalory i'MTtion npon thr heart. 
 
 A lar-T'- niiiiil"'f "f patimts siilhTiii- iVoni int.Ttnhnlar 
 ,„,,,l,ntis soon.r or latrr .h^vlop an athrron.atons .•on.li- 
 tioM of thr art. Ti.-. an.l this. .■..n.hin.Ml with th.' .'Xtra 
 ,;„,.,. fn.n. th.- hyiMTtn-phi.-l heart, offn results in heni- 
 urrha-'.-s from various art.-ri.'s. ami parti. Milarly m eere- 
 l.ral ap"'l'l''^v, many .lyin- in this way. N.. <' "iht th.' 
 l,,,,„„rrhairi-s fr..m th.- ki.lii.'y in th.' later sta.tres ar.' also 
 il,,. r.-ult of this .l..nhl.- .•anse,— viz.Jiyperlrophie.l heart 
 ami alher.imatons arteri.'s. 
 
 Anoth.'r fre.pu'iil synipt..iu, th.' r.'snit ..f th.' ah..ye 
 eauses, ami rarelv .x'.'urrin.i; in tuhular n.-phritis. is epis- 
 taxis. I have lia.l s.'vral pati.'iits with int.'i'tnl.ular 
 nephritis who have heeii th.' sul-j.-.ts ..f atta.'ks ..f ha-ma- 
 tem.'sis imlepemlent ,.f .'irrlM.sis of the liver or uh'erati.m 
 
 of the st.iiuaeh. 
 
 It is in this f..riu ..f Hriirht's disease that w most 
 fiv.pu.ntlv tin. I ura'mie p..is..nin,tr, manif.'.-t.'.l .ith.'r l.y 
 eonvulsi.uis .)r hv .'..ma : while, .*.i the ..ther haml. we s.'l- 
 ,hmi meet with what is nea.:,- always present in tuhnlar 
 nephritis,-nainelv, dropsy. Thus, a .u will ..hs.'rve. the 
 
 i 
 
 J 
 
100 
 
 nisF.Asi:s or riir. i<insi:yt<. 
 
 i ! 
 
 ..liniral histnrv i^ n.arki-.ll.v .litKiTnt in llu'so t\v.. foriiH 
 „f nrplirilis, as aiv als.. tlir i-tiol.»Lrv and i.atl.nh.-r.v. (M 
 rours.- in tlu- ton- casi-s ..f intcrtMl.iilar nrpiintis rrsnlt- 
 in.^'p.iM tnl.nlar nc].l.nlis tlic syniftoins aiv lliosc ..t a 
 rhn.nir ..r i.n.l.m-r.l .•..n-lition of tiiLiilar luflintis, ratlu-r 
 than tliosi" pivsi-ntcd durinLT \\xv insidious pn.irivss of an 
 iiitiTtuliidar tupliritis. 
 
 Int.Ttul.Mlar nephritis tho .vsult of ha-I-poisonni-^ is 
 „ut so rhronir nor so lil<rly to In- a.ron.i-anir.l l.y .•ard.a.- 
 hyiKTln.i.liy or ivtinitis : hut synii.toms of .•hronic Icad- 
 noisonin;;- will 1k' pn'scnt. _ _ 
 
 IntiTtnlmlar nrphritis tl.c result of ••lironi.- malaria is 
 usuallv iuvoinpanird l.y n.oiv or loss fnlar-nnrnt ot tlu. 
 snkH'n' and livrr and .K'ran.i^^-nu'nt of the latter viscus. 
 
 ]»,i„,iN..sis.— The proiriK'sis of inti'rtul.ular luplintis 
 dcurnds laru^'lv uvon tlu' sta.iro of the disease in wl.ieh w.- 
 ti„d the patient, fn the earlier sta-es the pro-nosis is 
 favoral.le so far as anv iinniediate danu'er is eoneerned : 
 hut the kidiu-v never re-ains its i.hysi-.lo.irieal condition, 
 a„d the disease steadily pro-resses. Later, we must he 
 verv iruarded in our pro.irnosis, as an athenunatous artery 
 mav "ive wav at anv time, produ.injr eerehral apoplexy, 
 or"hrm..rrhairelV..m the lun-s or the st.unaeh: or the 
 patient's life mav he out oH" summarily hy ura-nue eon- 
 vulsions or eoma, hv a severe attack of .ir-ut, or hy pneu- 
 „,„„•,,, or capillarv hroiu-hitis, to whi.-h sul.je.'ts ot this 
 disease are very liahle. Pericarditis or endocarditis may 
 
 terminaU' the case. 
 
 TuKM-MKNT. — NVe have no specific lor mtertuLuiar 
 „,,,,hntis: no wav of rest.u-ini; the kidney to its normal 
 condition. We can .K> much, however, hoth to prohmi; 
 the patient's life and to make it more comfortable hy strict 
 attention to diet and hy,i;ienic surroundinjxs. 
 
 The diet shouhl he nourishing, hut not excessive or 
 
 M 
 
 J 
 
 ^mm 
 
isTF.iiTi lULMi yF.i'imrris. 
 
 101 
 
 (t ioriiH 
 xy. < >r 
 
 * rt'sult- 
 ost' of a 
 s, ratluT 
 SH (if an 
 
 iiniii!^ if< 
 ,■ canliac 
 lie Icad- 
 
 lalaria is 
 i\t of tlio 
 iscus. 
 iu'|>liritis 
 ,vliicli \vf 
 i!;ii()sis IS 
 nconu'il : 
 oiiditioii, 
 
 must l>i' 
 »ns artcrv 
 [ijioiilrxy, 
 1 ; or tlu' 
 ■mic c'oii- 
 
 by piR'U- 
 ts of t]liH 
 
 '(litis may 
 
 tortui Hilar 
 ts normal 
 to proloniT 
 k' by strict 
 
 :cessive or 
 
 stinuilatinL', and shonld Ik- lar.ijcly non-nitro,-r«'noiis, con- 
 sisting of' rice, milk, vcirctablcs, tish, and fowl, with a 
 limits amount of otlicr meat. Clothin.i; slionld receive 
 special attention. Tiie patient should he completely 
 clothed in \vo,.l. As to climate, there are few diseases, 
 n()t even exceptimr those of the Inni^^s, which arc more 
 lu-nefited hv a mild, cMiwdde climate than is intertnhnlur 
 nci-hritis. "in other words, tiie function of the skm must 
 Ik. carcfullv watched, the Hannel clothintr assisted by the 
 warm climate encoura-riiK-r aii e(iuable and active c..ndi- 
 tiou of the skin. As for medication, it is larijely a matter 
 of treatiiiir sympt-.tiis; and the symptoms which anso 
 during an" intertubular nephritis are in many cases the 
 results of deran.irement of oru'iiiis other than the kidney.s 
 themselves. The patient, perhaps, has vomiting, which 
 must l)e c(mtrolled hy appropriate treatment; or he may 
 iomplain of headache, or there may l>e epistaxis, which 
 demands our attention. 
 
 Frecpi-ntly we are called upon to treat an attack of ir<>ut 
 or uruMiic symptoms; while few of these patients j,'et on 
 without more or less chronic bronchitis. Tiie treatment 
 of any of these complications, even to that of ajioplexy, 
 must "he Conducted lar-jely on .ireneral medical principles. 
 The kidneys themselves, however, often exhil)it symp- 
 t(.ms that re(piire attention. They may become byi.er- 
 iiMiiic or the subject of hemorrhajje, while occasionally 
 thev suffer from "attacks of tubulitis; that is, durini: the 
 course of this disease we often find tlie urine .!,n-owin«,r 
 less in (pmntity, of hijrher specific gravity, and containing 
 a larger amount of albumen, (I'denia of the extremities 
 lieing simultaneously present. We immediately enforce 
 absolute rest, and resort to the remedies that have already 
 been referred to in describing the treatment of subacute 
 
 or chronic tubular nephritis. 
 
 9« 
 
r 
 
 lOli 
 
 nisi:AsKs or riii: i<ii>M:is. 
 
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 X 
 
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 ^ 
 
 ^■ft-'.i- 
 
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 X 
 
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SF.l'IIUITlS 
 
 103 
 
 (MlAl'TKU ^"V. 
 
 NKl'lUUTlS-l.lKKrSK N KIMIUITIS— NKIMIIUTIS VEUA-PAHICN- 
 OIIVMATorS NKl'llHITlrt. 
 
 Ik tho un.inaliti.Ml Wvm lU'i.l.ritis is un.U'isto<..l an 
 juMiU' intlan.iuation of tlu- ki.ln.v wl.i.'l. iMv..lvi.s all tl.o 
 ti.<iu's, and .•orn'siM.ii.ls t.. that om.liti..n ot the lnnj,'s 
 whu-h wt. .losiirnati- as imrnnionitis or lu^pati/.t-l Inn,-. 
 
 E'rioLo.iY.— TluTc" is n.. rausc that pn..lu.rs a tiihuliti. 
 Nvhic-h niavn..t vro.lmv a .•..n.pK'to nophntis. For in- 
 stanns a nq.hritis iuvonipanvin- scarlet fever or .lii.h- 
 theria mav he tuhular, ueute, or snhaeute, or a nophnt.s 
 nnmer involvin- the entire strueture of the ki.lnev. the 
 (lilfereuee in the intlarnnation in tlu-se .-asi'S he.n.ir one ot 
 dco-ree; so it nuiv also l»e when resulting from nevere 
 eo'hl su.hlen suppression of the perspiration, pre,<rnaney, 
 sovere injurv, or anv of the hloo,l-poison« that produce 
 tuhular nephritis. We shall find that the .litferenee is 
 patholoirieal and elinieal rather than etioloj-u-al. _ 
 
 I'MHOLO.iY.-It nuivnot he possihle to distinguish hy 
 thi> naked eve the lar^^e red kidney of tuhular nephnt.s 
 from the lar-e re.l kidney of a recent case ..t dithise 
 nei.hritis, as in the earlv sta-c of the latter the kidney m 
 its -ross appearance will he practically the same as in a 
 
 tuhulitis. 
 
 Outtincr into these larfje kidneys, we shall hnd th*'m 
 hvpenemie in hoth eases, with an oozin.ff of hh.o.l on the 
 ciit surfaces, and the Malpi-hian hodies distendc.l. l.ater 
 in the disease the crtex is pale, and often .edematous, 
 eontrastin- stroni^ly with, the <lark congested pyramids. 
 
 k:^ 
 
1 
 
 104 
 
 nisi:Asi:s or tiik h-inxins. 
 
 5 
 
 A iui.r..M..i.i<-al .^cfticn ..1' thr ki-liirv of lu'i-liritis will 
 
 sliow a iiii>ri' f()!ui>lfli' filiri- 
 Fid. 14. iioiis fNiiiliitioii into till' iiitiT- 
 
 gMir^'-^i Vv^'j -^ , tiiliiilar sjiaffs than ocriirs in 
 
 ^^^-'d' KfyiL':0/ -jI tiii.iiiitis. 
 
 Till' I'liitlu'l"':;! (clls air in a 
 
 conilition of iri-aiinlar d* u'*'!!- 
 
 'f^'KSf^i^^M:^'''^^^^- .ration, and tin- intiTtuWiilar 
 
 JA'<^:VJ^'^f'l'''X<-'.'i.'^iy'^ li^siii' is swtilli'ii, (r(U'iiialt)US, 
 
 anil iiitiltniti'il witli ih'W rrlls. 
 Till' I'fUs I'DVi'iinir till' tnt't 
 
 
 
 Wi^rafl^M^i^'^r anil liiiin- U.-wniairs rapsnlo 
 
 "Ji'-.v 
 
 coTi;]!!'- --stlK'.tjlonu'niliis. lii- 
 i'ai.tiitns are niurt' likely to 
 Ih- unil in diirusr than in 
 tiiliui,,! lU'pliritis. ''atholo.iii- 
 cally it coriH'Siionils to tliu 
 lu'l.atizi'il Uiiiir of iHU'iinio- 
 iiitis, whili' in tlu- tnlmlar va- 
 
 I'i^. II shows ni'iitt' iu'liliriUs |<llf- 
 fuse. viTii]. .«iiim' cif till' lilla's are 
 nUfil Willi oxmliUicin iiml slmw tlu' 
 
 i.plllirliiiin sWdlU'ii. iiM.l nil iricL-uliir . . i i 
 
 ooniimsMi.ii fniin tin- swelling of "ii'i viotV of IH'llhritis till' I'XUUa- 
 ex«.lHll.min.o,lu.inU.r,„.,ular,i.Ma.. ^,^^-^ ,-„„„l,,tOS n.oR' I'loSC'ly 
 
 that of a hroni'ho-imi'iinionia. In otluT words, in tnlmlar 
 ,H.,,hritis the inti'rtnl.nlar spacos aro not ,<o tl.oroiiirlily dis- 
 ti'iiiU'd with exudation from the hlood-vrssi'ls nor is the 
 fihrons tissiu' so swolU'ii, as tlu'y are in nephritis proper. 
 The epithelinni of the tubules suffers alike in hoth eases. 
 It is i'videiit from this patholoirieal condition that the 
 suppression of urine would be much more eomplete m 
 nephritis i.roper than in tubular nephritis, beeause ot the 
 ,,„npression of the blood-vessels by the exudation; and 
 for the same reason this form of nephritis may, like pneu- 
 monitis, end in abscess. 
 
 .-^-.WBJW»■-»'-««•''^^ -..^-i*^WM«pW»»«(6i««n'»«»»M<P«^'» 
 
 jM J tlW ' ^ W g^ M'aW"^ ■ 
 
litis will 
 ■\v tiliri- 
 
 lic illtlT- 
 
 xTiirs in 
 
 iii'r in !l 
 r (Icii't'n- 
 •rtultnlar 
 I'Mialous, 
 
 U'W Cl'lls. 
 
 till' tult 
 s capsulo 
 inffcasi'tl 
 )nii'linn.'rt 
 iilus. In- 
 likrly to 
 
 than in 
 'atlioloiri- 
 s to till' 
 
 imi'iinio- 
 ilinlar va- 
 11' I'xuda- 
 •0 I'losi'ly 
 m tnhnlar 
 nii'lily dis- 
 nor is the 
 is |)roiii'i'. 
 >otli casi's, 
 I that the 
 iiniili'tt' in 
 usi' of ihi' 
 ition ; and 
 like pni'U- 
 
 .v/;/'///.7/7.s'. 
 
 lo:. 
 
 Symptoms. — I iiis i 
 ui'iiti' intlaniniation of th.' kidn.'vs. 
 
 II SI 
 
 i.ltuu-.'lhrf the Si'ViTl'st fonn of 
 It is nslu'itd ill hy 
 
 , ,,vi.riT .•hill and hi-ii.T t;.v..r than is thr .arlv >ta-.' 
 ,,.,,,,,,,,,, H.,,hntis. and is ar..m.i..ni.'d hy si.vvivlM.ad- 
 
 ,,,!„.. nrarlv always hy voinilin,!.-, Mipi-iTssion ol nnnr,- 
 i„ n,,,,:uinna,-with n.o.v or Irss ,.ain and .Iwtn'ss n. 
 thr hark Tlu'iv is vrrv f.v.,nrnt aiul |.aint.d inirtuntioii, 
 ,,•„,, „H. rassauv of only a f.w dro,.s of Idoody nnm-, ot 
 l,i.,.l, .n....iti.. -ravitv an.l i-ontainin- hlo.Hl-..or,M,srU-s aijd 
 tnhr-.asts. On hoilin-, tlu- uriiu' luTon.rs almost soli, m 
 tlK-tnhi'. Th.' o..lrn,a ahont tlu- I'y.'s is viTy ....tni.al.l.', 
 and is soon f -llowf.l liy dro|isy. 
 
 This is th.' form ..f a.Mitr intlaniniation ol tlu- knln.'y 
 that is most lik.'ly r.. t.-nninati' nipi-Uy m .h'atli, ..ll.'U 
 
 ni'ovini: fatal in a f.'W days. _ 
 
 If howrviT, tin- .-asc -.'.'son, an.l tin- i.nm- is not voidi'd 
 in .Mvatcr .,nantitv, still .Mmtainin- hlo-Ml-capsnlcs an.l no 
 h.ss allmnu'ii, th.' .lis.'asi' nia.v tiTiniiiati' in ahsross; or, 
 if all till' symptoms inii.rovi',lii'a.larlii' an.l naiisi'a lu'.-oiii- 
 i„.r h.<s, th.' nriiu' in.ri'asin.i; in .luantity, an.l ti'ViT std.- 
 ,i;H„.._tlu' ki.liu'V may so..n hi'.-.>nii' ..f tlu' hir-.- wliiti- 
 varii'tv and tin' .asi' tiTininati' in m-ovrry, in .hroHK- 
 tuhuhu tu'i-hritis, or possihly in inti-rtnhnlar iii'i.hntis,.|iist 
 as i.iH'nm..nia may omisLmally end in i-ut1k.sis .d tiie 
 
 ""vhout thm' voars asfo T was cnll.'d to soo a patii'iit, a 
 stevo.l.,ri', who/whili' workin- vory hanl in tlii' hold ot a 
 shii., and w.'arin- hut little i-hithin- ami iKTspinn- Iri'.'ly, 
 had .•OHIO ..). on .l.'.'k mi.l sto.ul tWr a few minut.s m a 
 cold, .lamp win.l. He was alnn.st ininu'.hately sei/ed 
 with a severe ehill, ae.'onipanie.l hy voniitmir. His h'l- 
 l„w-worknieii sent him lionu- in a .'arna.ir,., ami I saw hini 
 a few honrs later. His temperatni-.' was l(l4 1< . H.' 
 eomi.laine.l of severe heudaehe, eoiistant v..mit,i.g, great 
 
 — '" ■' 
 
106 
 
 i>isi:.isi:x '>r Tin: a/d.vkjn. 
 
 |.!lill illiollt tlir 1.11. U 1111.1 .l..\VM the U-V.-ill. 1111.1 11 most 
 
 iH'cnliiii- .Ivspii.i'ii. II.' .viis .•..iist:iiitly .•ii.l.'iiv..riii,ii- t.. 
 urituit.'. iiiiil lit ciU'li ctlnrt piisscl al..)ut ii liiilt'-t.'iisi.<H.nfiil 
 ,,f l.l.MMiv uriii.'. Til.' lu'Nt 'lay li.' still .•..nii.liiiiu'.l of 
 lit'iiiltu'li.' 1111. 1 nausea, his t.Mni.cratiiiv .•..iitiii.U'.l lii-li. an. I 
 tlifff w a> v.TV little ill. Tease in llie aiiiouiit of mine, w lii.'li 
 still e.intaiiieil M.i.nl. 
 
 N..t\\itlistan.lin.ir tlie I'a.M that I apiK'nle.! t.. th.' skin 
 aii.l l...\vels to assist the ki.liH'Vs. .Mipi.e.! him ..ver the 
 h.ins, an.l inii.h' I'Very etlort t.. ivlieve his he i.laelu' iiinl 
 nausea, the >ynii.t..nis wei'e very litlh' mititi-at. <l. Dr.'i.sy 
 iipiieare.!. an.l lu' d'wd on llu' tiflh .lay. 
 
 On |M.st-niortem.the ki.lneys were t'ound vei-y lar^'e an.l 
 re.l. the eai.siile sti'ii>i>in^; easily, ami a tVe.' ...-/iiiu' .>f 
 1,1. mmI .m the .'lit siirfaees. Thi- tihiviis tissue was swolh'n, 
 im.l th.' Mali-i.u'hian ho.lies .•oiild Ik- seen with th.' luike.l 
 eve. 'riieri' was a eoini.lete exii.liitioii into the tnhiiles 
 anil iiitertiihuliir siuiees. In other wonls, tlu' ease was 
 one of a thoroiiirhly lu-putizi'd kidney. 
 
 I'lUMiNosis.— We" havi- already seen that .-ases may ter- 
 minate in (U-iith, ahseess, or ehronic tnhular nephritis: 
 nevertheless I have attended cast-s in whi.-h, fr..in the 
 syinpt..ms exhihited, I ha.l every reas..n to helieve the 
 ati"e.-ti..n to hv nephritis rather than tuhnlitis, yet whh'h 
 ond.-.l in |.erfeet reeovi'ry in from four t.) twelve or six- 
 
 tei'll weeks. 
 
 'rni:AT.MKNT.- -Th*- treatment of this f..rm of kidiu'y- 
 inrtammati..n is th.^ saiiu' as that whi.-li has heeii dii'i'.-te.l 
 for a.'ute tuhnlar nephritis. In fa.'t, we ean .1.. nothm,-; 
 more than has heeii ahva.ly advise.l in tuhnlitis,— namely, 
 enfor.-ement of ivst, attention t.. .Hot, euppin.ir. an.l ap- 
 iiealins; to the howels and tlu- skin. 
 
 ii 
 k 
 
r 
 
 si I'l't i{ATi\i-: KiPM.y. 
 
 101 
 
 (' 11 A I'TKU W. 
 
 siiMTUATivi; K,,.M.;v-\i.s.'i:ss-srinii.'\i, kilnky. 
 
 \< 1 have iiliviulv sai.l, nut cViTV ras.. of n.-pl'nti^ (<>''- 
 f„M'nrnl,ntis).MHlsinal.srt.ss; l.ut auv .as.. Muv.lns..; 
 „„, „,, ,11 al.s.css.s tlu- nsMlt ..f .liiVus.. ,H.|.l.nt.s. M.ny 
 j„, tlu- ivsult ..fa ri.v.n..s.Til.nl i„tlimn.iat.o„ svlnrl, M 
 ,l,u. to variniH .•a,isrs,-iM,)ury or wo.m.ls, infa.vtioi.s, tlu' 
 ro.uU ..f .lisrasr.l ai-tcTU-s or iiy|K.nv.ui.' intlaimiialions, 
 .-ravrl, a.MH.sits in thr tul.nlvs, cMnLolisnis, pvaMnia, sup- 
 ;.n.ativr pwlitis or ryslitis will, or withont stn-tnr.- -t 
 tlK- urvtl.ra, tuhm-ulosis. an.l s..n,fnlous ki.lnrv. One- ..r 
 l.oth ki(lni-vs may l>i' inv(.lvc.l. 
 
 TUv al.^.Vssi.s n.av 1... very small an.l nnn.rr....s, .m.m- 
 tin...l nu.r.. ,.arti.-..larly to tlu' ...rtL-al portmn ..r th.y 
 „.ay coaU'soo, .oavertin- n.arly tin- whole- Uwhu-y mtu 
 
 on.' lairulinit mass. 
 
 The tul.rr.-ular ki<liu.\ . while- ri.l.llcl with al.s.-..ssv>, 
 .litl-ors in its .■ti..l..iry, l.ath.,l.W. symi.t..n.s, an.l pr..- 
 „osi. Whrn the al.s.vsses are snmll ami s.'attero.l, t he 
 other iM.rtions ..f the ki.lney are likely t.. j-ieseut the 
 charaeteristies of tuhulitis ..r intertuhnlar nephritis 
 
 j),„j^.osis.— It is ii..t iM.ssil.le t.) .lia.unDse small seat- 
 toiv.l ahseesses in the ki.lney while ther.- is no pus 
 .soipin- with the nrine: an.l when there is pus u. the 
 urine it is sometinu-s .litlienlt t.. say whether it .l..es ..r 
 iloi-s not e.)nu- tVoin a pyelitis or a .-ystitis. 
 
 \. a rule, Imwc-ver, a eorreet .lia-n..sis ean he ma.le 
 from the historv of the ease, the .-omlition of the patient, 
 ,, ,areful examination of the hla.l.ler, himannal exaunna- 
 ti..n of the ki.lney, and analysis of the urine. 
 
 (■ ^: 
 
 I 
 
 ma^ 
 
lOH 
 
 DisHAsKs or Till-: kipsevs. 
 
 Symptoms. — Tlifn- will lie recurrent diiils witli ft vit, 
 \\\v iiiovniiciits 1)1" tlif ImhIv cimsiii^' piiiii whicli t'Xtfiuls 
 iiloiiir tin- liiif of ttu' WYvWv t(i till- -fniiii nr tin- tfstifU-. 
 \'(iiiiitiiii; and lii'inliiclu- iiiiiy In- prt'si'iit. 'IMu' uriiu' 
 will 111' irri',u;iiliir in (|Miiiitit_v, (•(iiitiiiiiiii.!;' |>ii.-< and hlootl- 
 I'orpuscKs. Till' kidncvs arc til'trn I'nlarSp'ctl and always 
 ti-ndt-T, wliilc the jXiMU'i-al mnditidii is liki-ly tt> U- mndi 
 worst' than in a iivclitis. It is nc<»ssary to rtiiHinin'r 
 that wlu'ii only one kiilncy is involvfil pus may a|>iK'ar in 
 till' urini' paioxysnially. 
 
 pRoiixosis. — A small ahsci'ss may hv converted into a 
 eali'are'ons mass, or nniy opi-n into tin- jH'lvis anil lical. 
 
 I have t'oiind post-mortem fvidi'iico ofalisci'ssi's lavinir 
 healed in this way, U-avinu; the kidney healthy. 
 
 Ahseesses may open into the ahdomimd cavity and 
 ciiuse death, or into the cellular tissue and result in ex- 
 tensive perinephritis; or the whole kidney nmy he de- 
 stroyed, the patient dyin^^ from exhaustion or pyiumic 
 poisoniiifj;. 
 
 Treatment. — For the manatrt-ment of abscess of the 
 kidney, see the cha^tter on Suri;ical Kidney. 
 
 cnAPTKu yvr. 
 
 TUBERCULAR KIDNEY— NEIMIROI'IITUISIS— TUBERCULOSIS. 
 
 Inasmuch as the urine in this form of kidney contains 
 pus, the product of the cheesy tubercular intiltrati.)n()f 
 the organ, it is proper to consider it here in connection 
 with supiMiratini; kidney. 
 
 It is seldom that we meet with a primary tubereuh)sis 
 of the kidney; nor is it very often that the kidney suffers 
 from a tubercular deposit in a general acute miliary tu- 
 
 i - r a i yi ji .vf R4 ' ;.cpy ¥jqyT-^:'urff 
 
 »smKncKsr?5 jwsK*''w«*' 
 
tlu- 
 
 rriti:ii' I i.Mt Kii^si'.y 
 
 lo'.t 
 
 , ;, Thi- mvatrri.nn.lM.r..ftl..-as,.saivs......,Ml- 
 
 ;::,.:;:;;l-: ,.:;'•> -• i... .■.i-->vi^- - 
 
 1 . f,. iiivdU't' tho urinarv tract. 
 
 ''''',.;::.:■.,■..- i ■■•'■"■■if ■■•t'^ ■':,:;■:: 
 
 -n.i, ,„l„.,v„lur ki.ln.y shown ,.. !■..'. 1- ' ;' ^ • ^ ! ^'^. 
 
 «„.., „.i,h a.,.v, ""■;■■■:,•;";;;;■;';;,„ ;:„.,-„. 
 
 tlnvo times the nonnal si/r. and a> iiu ., i 
 lar-lockiiiij as the ki.lnev itsrlt. tiwt-u-le^ 
 
 (,„, or lu.th ki.l.u.ys ,nayl.e .nv..lve.l. I e t..tuk. 
 Jt. l.la.l.ler may In- attaeke.l Hrst, am tWe a s. >e 
 :;j:;i npwar.1, or the ki.lm-y may l.e atta..k..liu.t, and 
 
 ^^^v'^T:'"r::^^T; -.... tui.en.nio.is ot- the 
 
 Sv\ii> roM;*. — I" a ^«'^^ "■ i , ,. • ^.i . 
 
 !«;,;;;; ,,11 «? the ^m»«ni..,. tvo„> .1.... ..t- ,„«..,„„.»«„, 
 
 caneer, or other new growth. 
 
tl'l 
 
 /i/v/;is/> "/■ Tin: az/'V/.) v 
 
 
 h'l.i \r>. 
 
 
 
 ■-VI^ Ik.**', 
 
 TiihtTouliir ki 
 hIm 
 
 X :;::!:; :h... .Mi...... T),oo.h..rWMo..ywa^-,or '_'-"";-;-'"'" 
 
 i. n..t ..tlarwis.. in.i.li.'atr.l. wr sl.all .H-rtaiiily he- justifuMl 
 in susiKH'tin- liilK.r.'ulusis ..f the ki.ln.-y if tl.e ..i-an is 
 
n r.i:i;rn. \i: kiI'M:). 
 
 II 
 
 i;;;;.:„.na a. tl... fi.M -un, Un. un.,) n 1 ^ 
 
 III 
 
 III 
 
 ,.,in.. w....;i.in... l.-'.r.ai.M.r,l,...lu.i..M.... ul...,..nb 
 
 .•.. 1,; with. Lis ....n.li.i..n,.li..l.l:nl-."l ..n.:^ 
 
 i..i;....,.,l... ...i.l.-sl inlil.ia...Ul..n.w,ll.. 
 
 M-..^iinloM...rl..aiiv.l..ul..al.,.u, .h,..l,a,..i.M. Ii 
 
 ;^!. ,..w..v..r.ui.l.wi.i.liu.. .■.v.,i..n. > ='^ 
 
 .: •:. ,ul....vMla, ..li.i.moni... ..M,..l..M...ria, 
 
 ....nl...>.-i.in:.l-si.l.swi.Usul im.M. ,ul.,.,v,il..M. 
 
 of tlu' kitlix'V. 
 
 "'t ;; litS rniii..^ ,Ml,anlKl.....n.aU..n. 
 
 ,„..„,„, ,i.... .x.,„ ..an...-. ^V.. .ia.ul.l -...,. _-t 
 ,:..,..U.aHintla,..n.a,i..Mwi,i...ut,i.l...r..ul..>M .; ..'I^^^ 
 
 ,1 v,l, tW lu-in.. n.av 1.. ,...H-tly <.I-.^ - w^^ 
 :;:,l.;nins,..al<in,or.i.,,u..a,in.l<,an..v,..,.us^^ 
 ,,.,^,.i„,lH.nnn..,.M-l.a,.s.a.v..v.|.v.u..o 1 . ...^^ 
 ' Tl.isismon. liU..lyt.. .M...|.rintulKT..ulark.ln.. tlun 
 in •n,,,.u•a.in.^ n.M.4..1iHvu!a,- ki.ln.. sn,.... .1... lun...n 
 
 „ ' „,„.,, is n..t .. lik..ly ,.. 1... K.ss..n... a._ in .. 
 
 , ...h.,- van..tv. wlu... i. s.M..n. ..s..a,..s liav.n^ .W 
 
 ... ,ul...,....na,-..l.anu.n.ras,l,.. ki.lii..van.lus,...lv,s. 
 
 (it 
 ti 
 
 iilatf in <|iiantily sntH- 
 
 ,,u. until tl... m.iii..aii.ll.i.sa,-.Mnn. wm, „,, ,„. 
 
 .•„.,„ t..lo|.....tlH. l.usthn.u-l.t.. til- l.la.Mof. \ 1.... til 
 
 ^1 lula.->...n....nvisla,...ly.l..--.-';l,-..-al.^^^^^^^^^ 
 
 ;, ,v...k tnay flaps. l...t.Mv any ufuu. tn.m th.. .l.Ma>..l 
 
 ki.liuv foaclu's tho lihuMi-r. 
 
 ; .S..S..S.-W. hav. ahva.ly s.cn un.l.r wl.at ....•..un.- 
 ,JJ:;,;, ,.,,,. i„.,..ssil.,..t.M.ik.aaUU..nn^^ 
 
 uosis in tlu- rarliiT statri's 
 
 Manv cases of brokfii-.l.'wn. 
 
 :,r.;M,-„...l ki.ln,,vi„ ..■r,.f..l....« ,.a,U.n.s ,,:,.. t.r ,.,« 
 „f;„Wr..nl,..R Wlu.„,l,...lis..„s,.i..-..nh 1 .„ .1... k„l. 
 
i 
 
 ^,.j /)/>/ is7;s or Tin: i<ii>M:ys 
 
 „..v „.,t .v.n i.UH/.nL' .l"VM' u,iii.|.li.i>tini.'tl.-"r.-t.T. it 
 i.'nnt lik.-lvtu 1... t.,lM.,vulu>i.. In ll..-stn.u.o„..a..-H 
 ,1... .li.nr-.'imi/MtiuM i.nHM.r.U tVuM, a i-vl.ti. .r a I'vn- 
 „,,,1„..M-. svl.il.' III.' tMlH.r.Mlar.l.r-^""'*'"'' I""""-' > """ 
 
 ,1 rli.'ul iM.i'tinM ..f tl..' Ui.ln.'V ..!• > ...Ian K. tulM..'.'..- 
 
 l.„. .l..,,M~its .'ImwIi. T.-. r, 1 , I 
 
 ,„ ,1,., I;,,..,- >ta-.'^ t.ilM.iv.ilar Ui.ln.'.v i- imt liU.'l.v I.. 1'.' 
 
 n,i.|;.l.-.. I'..r imvtl.in- Imt s..|.im''^"'"-' •^'"''"■> ;"" '•;'.";'■''• 
 K,„. ,1,.. ,li,.irn..-*iH..rHUi.i.iiratiiiLM.Mi.-tulM.iTiihn' ki'ln.N 
 vvr -iH.ul.l l.;.N.' to .l.'p.'n.l Mu tl..- I.-Ht..rv ..f tiK' .'u-'. an.l 
 
 l,u.ur..lv..n tl mliti !• tl..' pati-'Mt. if w.- l...n..l no 
 
 ,,vi.|.'U.-..ftMl..r.l.'ina..y..tli.'ri.art -I tl..' IhhI.v 
 
 -n... „uM-.'xiM.'i..'.-..fir.'i>"fal t..lM.i'.ul..M<WMMl.l al-. I..- 
 ,^,, ^.,,.,„,,,„ •„, ,1,., .Ih.iriH.sis ..r .an.'.T, whil.' .'n.a.tatwm 
 .,„.l ,;,„.•.. n.,M .•a.'h.'xiaw.Hil.l assist in .'..Mlinmn./ it. 
 
 1, i. I,ar.'lv iH.ssil.l,. in s.m..- .'a<.'s f- .li..'..v.'.' iuI.-t- 
 ..K.-l.a.'illi in" tl.. ...in.'. This fa.'. .aMM.-t !.■ .l.'l..'...M 
 „,...„ as ..fn,...'lMli'a.un...sti.'valM'. 1. has 1...... .u-.sU'. 
 
 „;^„ ,„-„„,l, n.iLTht 1..' iM...'ulat...l wUh th.' s.,-., .'.1 
 
 „,i,u-. whi.h, if ha.illi UV.V i.r.'M'nt. w.ml.l .U'V.'L.l. 
 
 tilh.'i'rilhisis. ,. . . 1' I 
 
 l.„„..^.,.m —n.l.'ss th.- tuh.T.'.llai' .'n|..|ltl..n IS .'..Mhll.-I 
 
 t.,..n.' Ui.ln.'V. tl,.-l.r..irn..sis will, of .•..u.'s.'J.rl.a.l In 
 
 ...... v,.u a.v iWrtunat.. .'^.o-v^h to n.ak.' th.- .l.airnns.s whik' 
 
 ,1„ ."liM.as.. is i-riniarv an.l whil.' ..nl.v ..n.' knUu-v is ui- 
 v.lv.-.l. tlu" .v.noval ..f tl..- ki.'M..y u..ul.l ..f .'.Mifsr n.ak.' 
 thi' i.rotrn.isis in.>r.' favorahlc 
 
 'P;^,,^.,.„,.^•,..— Wh. c." th.- .lisi-asv is .-..nhn.'.l t..on.' ki.l- 
 H..V nn,..val is th.- ..nl.v n-un-lv. Th.- .'..n.lit.uns t..r 
 sui'h r.'n.oval w shall la-rouu- a.Miuainti'.l with n. th.- 
 l,.,tm'.' .'n siiriri.'al ki.ln.'.v. 
 
 Wl,..,-.. oih.-r or-ans an- involv.-l t.. sn.'h an .-xt.-nt as 
 to n.ako an o,K-ration n..,ins.iiial.l.', w. n,nsl_runt.-nt ...u- 
 si.lv.'s with tmitinir th.- syn.pt..ins as tlu-y arise. 
 
 .,_ ^t^i .'-t*«U.^>»*»* 
 
 f. Bi#42#.iia*.:i^.aafeH-9«- 
 
I n.K.MIA. 
 
 \\'.\ 
 
 Amu iimtt.r..|iiit. iv,t \n\hr |.iitliM|oi;ir.t nitluT tliati t.. 
 til.' .•liiii'i;!!!. I iMMV iviniirk tli;il in miiiiy nx^^^ «'!' |'m1- 
 iiiMiuiiv |.litliir*is til.' ki.lii.v- mv f'.'im.l Hlii;lifly .iiliiru'.-l. 
 tlu'.'ii|Hiilrs thi.U.ii.'.l an.i I. ><..»•. mwl tlir .pitli. limn in u 
 rttat.' of fatty .l.^'inTatioii. Tli.- ««nly ^yniptuui of .li^- 
 rasf that tln'-f <•a^••■» iiianifr^t .lufiii.if lilt- i-* a sli.ulit Ira.r 
 of iill»iini.n in til.' m ii.'.witli |MTlia|.ssuiiir t.iMl.'nicsH,.!! 
 
 (' II A I'TKU \ \ 1 I. 
 
 ni.KMlA. 
 
 Uli.KMlA i-i a t.iiii ai-pli.-l to a .Miulitioii. siipi-osi'il to 
 Im- .iiiH.'il l.y .liM"iM-4 of the ki.lm'ys. in wlii.li tlio-*.- ..r- 
 irans fail to |..Tfonn tluir iioriMai » ftioii of fliiniiiatii.n, 
 an. I all..\v material to !..■ .•liininat.-.l wlii.'li slmuM !..• iv- 
 tain.'.l in tli.- I.Io.mI. It is cliara.t.'ri/.'.l l»y .ly-on.ra, 
 iu'a.la.li.'. tli/zini'ss, voniitiiv-r, .liarrlin'a. .•onvnl.-i.Hi<, ami 
 foina, th.' syni|.toiU(* varyint; in indivi.lnal .as.s. 
 
 l.;,.,,,i,u,iv.— 'rii.M'ti.)lo,-ry •>f iiraMni.'|>oisonin,iri'<'>l"*f>i''*'i 
 hut .•.Ttainly in soin.- .-asi's, at l.•a^t, tlic synipfoms art' 
 tin.' to til.' non-.'liinination <•! fX.Ti'tni'iititioiis mat. rials 
 l.v til.' ki.lii.-ys. Symptoms atv l.nt tin- .•xi.n'ssn)ns of 
 patliol.virital .•omlitions, and many poisons tak.'ii into tliu 
 1.1. .n.l or jr..norat('.l tlu-ri- manif.st tli.'ir morl.i.l .^'tlW'tH 
 tlironirli thf Itrain an.l the spinal .onl. 
 
 .Nranv thi'orics liav.' Iiffii advan.'.'il as to tlic j.rimary 
 raus.' .".f this .-omlition. It was ass.Ttf.l that an cx-.'ss ..f 
 urea in th.' I.Io.mI pr.xhu'i'tl nra-mia; hut nr.'a inj.'.t.'d 
 int.. th.' I.Io.mI was touml to act ..nly as a diinvtic. It was 
 als.. maintained that urea wa^ dc'cmposed in th.- 1.1. mmI, 
 sc'ttiniT free carbonate of ammonium, which acted as the 
 ^h 10* 
 
 t-'^tam^'-vam''- 'J». v-'SfT'.'!^^' S'' 
 
u 
 
 lHsi\iSi:s OF Tin: KIDSF.VS. 
 
 tdxif iitrt'iit. Tlii> iilso liiis l-r.'ii .lisiin.vvd. Tlu- tlifory 
 \v.\< Ihiii ailviin.ril ilial tin- ('(.iKlitioii is autoirfiK.us,— that 
 is. tlait tiir i«>i-(«ii is alisoi-hfd iVoiii tlu' aliiiu'iitan canal. 
 Tlif iii.Thani.al tiH<.rv. that ui'ii'iiiia is tin- ri-siilt of (viU'iiia 
 (.f tlic l>i'aiii, has slill many ailiu'fi'iits. llowtviT. tiir 
 (liMiciilty may iif in tlic iart that in thv diseases u-ivinir 
 rise t(» this (•(.iidition the di'si|namati(.ii of the enitlielinm 
 in tlie ttihiiK'S jn-events tlie inannfaetnfe of iifea fiom the 
 various waste jUMxhiets. ami that the tifa'mia arix'S lu't so 
 iiiu.^li from the retention of Ufea as from laek of its i.fo- 
 .Inetioii. Mo>t i-foinineiit amon,<r these retaine(l |iroduets 
 are creatin and ei-eatinin. 
 
 Tiie stronu- i.rol)aliility is that the nru'inie condition or 
 (■onvnl>ion is sometimes the ri'sult (.fa chemical condition 
 of the l.lood, ami at other times dei.eiids upon (edema of 
 the l.rain or etfiision ; the etfusioii may he ventricular or 
 
 arachnoid. 
 
 \V,' have all seen how the .edema will shift ahout : one 
 morninu-. in a case of I'.ri.ijhfs, we tind (I'deiua perhaps 
 of tlie arm. while the next day it may he in the dottis or 
 he contined entirely to the lunii-s. 1 have m.t the sli-rhtest 
 (h.uht that some of the cases of so-called iinvinic convnl- 
 Kimis are tlu- result of (edema or etVusion. 
 
 This theory has heen supplemented hy lluirhlin.irs Jack- 
 son ami Uosenstein, who have suLT-Ti'^ted that the initial 
 ehantiv is spasm of the cerehral hlood-vessels, leading,' to 
 convulsions hy cuttin,-r oil* the hlood-supply, and followed 
 l»v effusion it'.o the lymph-spaces of the hrain. 
 
 While it is possihle that some cases of so-called uriemic 
 nmvulsions are due to .edema of the hrain or suhara.di- 
 noid etfusion, it must n..t he fortrottet» that nephriti(' dis- 
 eases otteii produce nutritive disturhances either of tho 
 br;'in or the memhranes or of hotlu and that the convid- 
 sions mav he due to these i\utritive lesions. In fact, I 
 
 !W?S«S^. ja»*»!)»KUe6*V^SSi^^ ■ 
 
 mm 
 
1 li.lMIA 
 
 115 
 
 lu'lit'Vc it iiiiiv lie liri)ii(lly stutcil that, willi the .■xcfption 
 of till' kidiicv itscll'. Ill) (iriraii is iiion- liUi'ly tliaii tin- lirniii 
 to siiIUt nutritive lrsioii> diiriiiij; tlic coiirsi' of iici>liriti«' 
 (lisi'iiscs; and it is t'oily to attrilmtc I'vcrv case of coiiviil- 
 sioiis tliat oiciirs in tlii-se disi-ast-s to a |iatliolo<i-iial tln'ini- 
 cal conditio' of tlir Mood. 
 
 Not lonu .int'i' I was caliiil in consultation to sec a 
 voiiii,!; man, a medical student, who was in violent con- 
 vulsions. His attendinu- p'.iysician said that he had had a 
 severe chill two days liefoi'e. which ushered in a pneu- 
 inonia. On iii(|uiry as to the condition of the kiilneys, I 
 was told that tlu're was \\i> allnuiieii nor any imlication of 
 nephritis. I soon leanu'd from the yoiin.u: nian"s mother 
 that he had siitl'ered with an attack of meiiin,Lfitis a year 
 and a half hefore, from which his father, who was a 
 phvsician, tliou.trht he had never entirely recovered. 
 
 ills convulsions were (•ontn)lled only for the time hy 
 chloroform, and he soon dii'd. I ohtaiiu'(l a post-inorti'in, 
 at which the meniniri's were found to 1h' connvsted and 
 infiltrated with serum and pus, with adhesions :dtout tlio 
 middle of the longitudinal fissure, the hrain showini; ii 
 trranular roujrheiu'd comlition eorrespondintr to tliat pro- 
 duced hy calcareous deposits at the hase of the falx eeri'hri. 
 
 Had this case heeii one of nei>hritis instead of pneu- 
 monia, the convulsions would undouhti'dly havi' heeii 
 eallctl unvmic, a post-mortem wouhl have heon considered 
 unnecessary, and the hrain-lesion would never have heeii 
 discovered. 
 
 It has occurred t.) nu' that it is possihle for at least some 
 of the cases of so-called iiriemia ti) he the result of poison- 
 ous animal alkaloi<ls, — viz., ptomaines or h'liconiaines. 
 These poisonous chemical suhstances have heen shown to 
 consist of decomposed alhuminoid matter. 
 
 The study of these poi^ous is only in its infancy, and is, 
 
r 
 
 11 fi 
 
 /</.vAMv/> or THE i<msi:yx. 
 
 ! t 
 
 Bi t 
 
 » 
 
 no (liMilit, (lotiin'fl to r\|.l;rm itiiiiiv not y>'t wi'll-iiiultT- 
 
 Stoixl septic (•(•llditinlis. It is proliilMf tllllt solllr of tilt! 
 |itoiiiiiiiit> iiiT tlic imlirrct n'suit of miiToln's, tin- :ill»u- 
 iniiioii' (IccoiiiiM.siiioii Ufiiiir set ii|> liy tlu'ir i»ffsi'iict' : 
 wliilf tlif Iciii-oiiiaiiifs arc tlu- n'siilt <»f tin- all>iiiiuii(>itl 
 (K-.(.iiii.o.-.ili(.ii sft up Ity tlu' pivsi-iKv in llic liloml of 
 rln'iniriil materials dut- to tin- iiii'taiiiorpliosis ot" tissue. 
 This pliysiolouical jn-occss of tissui'-\vast»- is, of course, 
 iiices.-ant. and kei'ps up tlic ireiieratioii of products tliat 
 should he eliiuinatetl, — products whose retention has hceii 
 hIiowu to set up iilhuniinoid di'coniposition, producini; 
 material ot' a hi<!;hly pois(tnous nature. 
 
 It can t'a.sily he seen how even functional dcrauircment 
 of an important I'liminative ortran may pioduce the most 
 serious restdts, and that organic disease of the ort;an must 
 eventually prove tiital. 
 
 [n suddon suppression of th function of elimination hy 
 the skin or hy that <;reat eliminative oriran. the liver, wo 
 have examitles every day <)f poisonous accumulations in 
 the hlood, no douht the result of alhuminoid decomposi- 
 tion due to the presence of retainecl metamorphic ma- 
 terial. 
 
 Patients with tuhular nciihritis hecoi e aiiiemic very 
 rapidly, and the disintejrration of the red hlood-corpuscles 
 may in some cases manifest its deleterious effects on the 
 nervous system hy uru'inic symptoms. 
 
 Symptoms. — You will find in some of your text-hooks 
 a irreat variety of sym[>toms attrihnted to unemic poison- 
 inir. Many of these symptoms, howi'ver, are the result 
 of the ansemia and other diseased conditions rather than 
 of the unemia. while some are no douht the direct result 
 of the urienuc poisonin<r. 
 
 The so-called unemic convulsions are epileptoid in their 
 character, and in fact in some cases it wyuld he impossi- 
 
 ■ i»IHJl'r ! IJJ'l-'! ! , ' '.ll ' ^ ' ,! 
 
 1 
 
nt.KMIA. 
 
 117 
 
 Itli' to <listiii,t;uis]i tlu'in trmii ciiilcptic attacks. As a nili", 
 till' patients ill iiia'iiiic coiivulsioiis ar*- not so iirofoiuiillv 
 unconscious as tiiosc in cpili'|isv. Tlicy will often injuri' 
 tiicir tont^ucs, and simulate \vy\ closclv an cpili'iitic at- 
 tack. If a liistory of tlie case could l>i' olitaincil, it would 
 Ite of <;reat assistance in diai(nosis, < lier cases of iira'inic 
 convulsions very cl(»sely n'setnl>. .ttacks of apnplexy, 
 even to the proilucin<r of a ]tartial paralysis of oni' side. 
 In ajioplcxy tlie patient will almost always turn the head 
 with convulsive twitchinijs to the side of the hcinorrliau;*', 
 and 1!! njany cases the teiniteraturi' will rise to 104°- 
 1().'»° F., hoth of which syniittoius are not present in 
 uneniic convulsions. I have never st'cn a patient live 
 more than a few hours when the tejujterature rose to 
 10.")° itnniediatcly aftt-r the apoplexy. 
 
 We (tfti'ii ohservo a dropsical condition of the patient, 
 which would indicate ura'mic poisonini,' rather than apo- 
 plexv; and on drawinu: the urine in doubtful casi's the 
 indicaticui would bo stren_i;theni'd if we found albumen. 
 In some oases of uni'mio jioi-soninsj: which resemble cases 
 <»f epilepsy or apoplexy the patient may have no o'dema, 
 and albumen nniy be absent, or i)o present in only a 
 very small (piantity, the easoH being th(»so of interstitial 
 or j;onty nephritis. 
 
 Hysteria is an(»ther condition from wliich urirmic con- 
 vulsions must bo ditierentiate<l. In hysteria the pupils, 
 pulse, and temperature remain normal, and tin' patient is 
 always conscious, while the irreiriilar, jerky movementH, 
 the spasmodic respiration, and the chokini; sensation so 
 often pn'sent in hysteria are absent in unemic convul- 
 sions. 
 
 Airain, the urivmic poisoninj^ nniy assume a comatose 
 form, and closely resemble opium-poisonini;. If nothini!: 
 is known of the historv of the case, we may judijre par- 
 
 L 
 
r 
 
 118 
 
 I)Isi:as/:s di' tiii: i\ii>M:is. 
 
 tiiillv Iroin tlif ((niditiuii of tin' |Mi|iils, wliidi ar»' tinuly 
 (•imlfactiMl ill n|.iiiiii-|>ni>imiiiir (I Imvi'. liowi-vt-r, smi 
 tlu'iii (liMs ciiiilriictcil ill iiiii'iiiia), \>y llif slow rcs|iiratii>M, 
 ami I'.v tlrawiiijr llic uriin' troin tin- lilail4tr and cxamiii- 
 iiiir il toi' alliuiiirii and casts. 
 
 Of till' tillitT svmiitoias oftfii allriliiitcfl to iiriciiiir 
 |»(iis(>niiiir, siirii as severe attaelss of tliarrlKCM, vniuitiiiir, 
 astliiiiii, aiiiiilvopia, intense lii'adai'lie, and extreme re>t- 
 lessiiess and nervuiisiiess, it is verv liard to say exactly 
 liow niiicli is due to aiisoliite ura-mic iioisoniim', and liow 
 iiiiieli to tlie circulation of other retaincil or alisorlied 
 matters in tlie idood. The headache may he due to 
 nniiMnia, or to oriranie lesions, and the vomiliiii:-, as well 
 as the diairhd'a, to j^astfaluia |iroduced hy indiirestioii or 
 other causes. 
 
 TuKATMDNT. — The indications for treatment when the 
 Kvni|itoms are not very iirirent are to remove the cause. 
 Ill very nrireiit cases, attended hy convulsions and coma, 
 the relief of the syiniitoins demands our lirst attention. 
 
 For the relief of thi" spasm, ciiloroforin or «'tlu'r iriveii 
 Ity inhalation is usually more )iroin|)t and in some eases 
 safer than the hy|iodermic injection ()f morithiiu'. There 
 is a ireiieral im|iression in the jtrotessioii, the ri-sult ot 
 oxperieiiee, that patients lahorinii' under alhuininuria are 
 extremely sensitivi' to oiiiiiin ami its alkaloids. 
 
 llaviiii; allayed the spasm hy means of chloroform, 
 otlii'r. or the hypodermic injecti<tn of mori»hine, the 
 jiroinpt evaiMiation of the howels is the siiri'st iiu'thod of 
 securinir more than temporary reru-f. In fact, the ndief 
 fre(|iieiitly ohtained from the evacuation of tlie howt'ls, 
 vvi'U where no iTi'i'iit drojisy I'xists, would seem to indicate 
 that the poison was heiiiif absorhi'd from the alimentary 
 tract, or was n-adily eliminated througii that channel. 
 In our effort to iiuhiee the kidneys, in this disease, to 
 
I II. KM I. i 
 
 — I 
 
 flimiiiiitc tlic |>iiisiiii, we iirt' too dt'tcii (lisji|i|i(iiiitttl in tlic 
 iirtii)ii of diiiiTtus ; 1)111 \vc sliiiiild iifvcr Ihil, in inldilion 
 t(i till' use (»r cathartic ini'dicinc, to ii|i|icid t(» tin' sUin. 
 cillicr hy tin' liyiMxIcrniic use ot" |iil()Ciir|(iin' or \>\ otln-r 
 activt- diaphoretics. Hot air is iisnally i|nitc sate, ami is 
 always a sure means of prodiicini; active dia|ilniri'sis. 
 The jtaticnt can he |ilaced in a canc-lKtttoiiietl chair, siir- 
 ronndetl l>y hlaidxcts, ami liy im-ans ot'an alccdnd laiiMi or 
 hv the crmler method ot" Imrnini; alcohol in a sancer, 
 called in coinimm parlanee " nun sweat," the desire<l 
 I'tlect can he |in)duci'(l. The ordinary hot-air a|t|iaratu.s 
 is the most convenient and etKcit nt it' we have it at hand. 
 Of the cathartics, tin- saliiu's serve the hest imrpose, 
 eX(H'|it where coma is present, in which case, the patient 
 lieiiiiT unahle to swallow, we resort to a tew di^ps of cro- 
 ton oil plaeetl on the toiiLTne, or to urain doses of calomel 
 administered every half-honr in the same manner. 
 
 It may, in addition, he necessary to resort to stimulants, 
 which slntnld he alcoholic rather than pri'parations of 
 ammonia. While I am hy no means sure that ammonia 
 is di'trimental, still, as we have no definite knowledi^e 
 that it is not om' of the iiii^n-dieuts of the toxic aLTeiit, it 
 is Well to avoitl its administration. 
 
 Ilavintj relioved the patient hy tln'se means, the very 
 Htrictest diet is necessary, milk, rice, etc., and the elimi- 
 natiniT origans — viz., the howels, the skin, and the kidneys 
 — nnist he kejit in the hest possihie condition, relyiiii? 
 principally upon the howels and the skin when dinn'tics 
 are contra-indicated or when they fail to stimulate the 
 kidnevs to activitv. 
 
r 
 
 120 
 
 Disr.Asr.s or the kidsevs. 
 
 ('H.\I»TKI{ X'VIir. 
 
 i^l 
 
 DKdEXEKATIONS — A.MVlJiIH DKilKNKUATlttN — I.AllU.VCKOl'S OK 
 
 WA.^Y KIUNKY. 
 
 Ii' \vc wislicd to i-liissilV iis iiitliiiiiiiiatorv all tin- discjisis 
 Mt'tlic kidiicv wli'uli yr\\\. cuii-.tiiiit allmiiiiiiuriii, uc sIhuiM 
 lie (iM'mcd ttt iiicliidf aiii.vloid dfi^ciicratioii : and tlicrt' 
 arc writers wild cuiisidfr aiiivluid dcu'i'iuTatioii an iiitlaiii- 
 iiiatiiiii. 
 
 Difkiiisoii ('(tiisidirs uiidir the lirad of allniiirumria all 
 till' (lisi'iisi's wliicli u:ivo constant all)unu'n. However, in 
 tills <'oinieetion wi' shall <'online the intlanirnatorv diseases 
 to one section, and consider anivloid and tiitty kitliiev us 
 de<;enerations. 
 
 Erioi,ii(iv. — The etiuloiry ot" amyloid deueneration is, in 
 a nieasnrc, limited, — most cases lieiiiLj the result of chronic 
 supiMiralion, — from tiihercnlosis of the lunirs, from dis- 
 eased lioiK's or cartilat;i's, tVom old sinuses, tVom loni;- 
 discliaririiiu: empyi'mas, or from chronic ulcerations of 
 whatever nature. Syphilis is also an etioloijieal factor, 
 and |ierha|is some of the Mood tjlandular disiasi's are 
 causes of it. 
 
 The excessive use of mercury may also <;ive rise to it; 
 whil" occasionally in chronic tul»ular nephritis we find 
 sliirht amyloid exudation. 
 
 l*ATiloi,oiiV. — .\myloid de<;eneration always ln'iriiis in 
 the hlood-vt'ssels, ajid is first notici-ahle in the vessels of 
 the Malpiii'hian tufts. The chemical nature of this exu- 
 dation is not (U'tiniti'ly known, hut it receives its name 
 from its peculiar reaction with iodine and sulplniric acid, 
 whieli is identical with that of starch. It is called " waxv " 
 
 itott 
 
1 
 
 DEGEXEHATIitSS. 
 
 121 
 
 lu'canso of itrt ]H'<'iiliiU' iippcaranii' wlioii cut. Aiiiyli>iil 
 (K'UTiu'nitioii i-< not otU'ii, pfrliaiis is lu'vcr, strifllv >'<'m. 
 tiinil to till' kidney, Imt involves otlu-r orLrans, i's|n'cially 
 tlie liver, the lynipliatie jrlands, and the hhx.d-vessels of 
 thi' niueous iiu'Uihrane of the stoniaeii and howels. 
 
 We find tile kidneys niiieli enlart;ed, ami, when eiit 
 into, preseiitinLC a waxy or lar<i.iee(iMs appearance, ratiier 
 dry, with very little hlood on the surface. 
 
 I'pon the application of iodine and sulphuric acid to 
 the cut surface the characteristic reaction appears; with 
 the former, the di'posit assumes a reddish maroon color, 
 and with both, a violet appearance. 
 
 The epithelium linin,ir the tuhules suffers less than in 
 any of the inilanimatory conditions of the kidney. 
 
 "SvMi'ToMS. — As amyloid de,irciierati(»n is not contiiietl 
 to the kidneys and is secondary to other chronic diseases, 
 the ,srcnenil exhausted condition of the patient cannot he 
 attrihuted t(» this disease of the kidneys. The special 
 synijitom oxhihited hy the ki<lneys is their enlari,'emcnt 
 with some tenderness; hut the characteristic feature is an 
 excessive quantity of urine containini; alhumcn in lari^e 
 (luantities. AVhen we find a patient who is the subject 
 of chronic suppuration or has a history of syphilis with 
 enlarircment of the liver and kidney and who is makin<r 
 a lariTc (piantity of allmminous urine, we may l>e sure that 
 we are dealini; with a casi' of aniyloi<l dejreneiation. 
 
 DiAtiXOSls.— The dia,<rnosis of this form of alhuminuria 
 depends upon the imjtiication of other orsrans and the his- 
 •torv of the ease to <listinjiM'ish it from other forms of 
 enlargement of the kidney or polyuria. 
 
 Prooxosis. — The projrnosis deitends u;reatly ui)on the 
 stasre of the disease. \Vhen thi' ainyloid deposits in the 
 kidneys, lunjrs, and other orj^ans are no lonjrer recent, 
 and the patient is much weakened by the chronic disease, 
 
122 
 
 I)Isi:asi:s or nii: kidseys. 
 
 tln' |'i'<>u'iii>>is is V"'rv iiiit'iiVDriilili' ; iifViTtlu'lfs,-, in soiiu' 
 (jiiili' ailvaiiccil ciiscs of s_v|iliilitir oriu'iii tlif |>iitii'iit may 
 
 Olltil'flv I't'CnVlT lllllilT S|K'citi(' tl'iMtlllcllt. I*'v('ll ill old 
 
 cast's caiiscii liv siiiiimratioii, wlicrc tlic discaM'il Ipihic dt 
 (ttlit'i" siiii|iiirativi' cause can 1k' rt'innvcd, tiic aiiiyloid dc- 
 jMi-iits may lie alisorlicil and the |iatient ivcdver. 
 
 'I' in: AT mi: NT. — 'Piie indications for trcatineiit arc tor tlie 
 removal of tile cause ot' tlie disi-ase, — vi/,., sjieciHc treat- 
 ment ill syphilitic cases, and the removal of lu'croscd lioiie 
 or cai'lilaii'e where |iossihle. 'I'he |>atielit should he |ilaced 
 under the hest hyu:ieiiic conditions, with iri'nei'al tonic 
 treatnu'iit, — iron, (|ninine, stimulants, etc. In chronic 
 Hii|>|>iiralion of the limits or other irreiiiediahle disi'ase 
 the treatment must he lari;ely symiitomatic, in the liopu 
 of itruloiiging the life of the patient. 
 
 FATTY DKCKNKItATlON. 
 
 Tile kidneys are suhji-ct to fatty dc_<reneration when 
 their uutrilioii is interfered with hy disease of the hlood- 
 vessi'ls. or hy pressure upon the vessels liy new trrowths or 
 exudations; in shoi't, anythiii<; wlTu-h produces a iiernui- 
 iieiit amemia of the origan will he liki'ly to cause a fatty 
 metamorphosis. (V'rtain poisons taken into the hlood, 
 and certain patholoifical conditions of the lihjod, are calla- 
 ble of brint;iii,<; ahout fatty kidney. 
 
 AmoiiiT the poisons t^iviiii; rise to fatty kidney are phos- 
 phorus, arsenic, antimony, and alcohol; amoiiii: the dis- 
 eases causinu; it are i>hthisis pulmonalis, scr.ilet fever, 
 small-pox, and puerperal tever. 
 
 Especially when the epithelium is in an advanced sta<re 
 of deireiieration will we find alliumen, — not, however, in 
 such (juantities as in amyloid dcireneration or tuiiulitis. 
 It is very probable that in many cases of sliii'ht ''.Ibumi- 
 nuria in preijnancy or in tbe acute infectious diseases, or 
 
 >'JLi 
 
 dMl 
 
ATitoi'iiy .\M> iiyi'rirrnorm: 
 
 1J:{ 
 
 ri-siiltinirt'n.in thr a.lministratiui. ..f |.Mi-nn ul.-iv ili.iv 
 is n.. .Iropsv, it is .In*' to .l..,irfn»Taii..i.,— tl.at is, a luitritiv.. 
 .list-as.. of ill.' r|.itl..-liMiii. Wl.ri, tlic .alls.. ..f tin- imtn- 
 tivi' .listiirl.aiuv is iviii..v..l, tiu' .K.,irviuTati..ii, as a nil.-, 
 
 irt s.iKii r.'|iaii'*''l 
 
 cii A i*T i:u X I X. 
 
 ATUOIMIY .\M» IIYI'KUTHOI'IIV. 
 
 Atu.iIMIV .)f tJK' l<i.iii.-y may U- .•oiii^mital or a.'.iuiml. 
 Wlu-M .•..Mir.'i.ital it is liUrly t.. 1... miilat.Tal. uitli .■n- 
 lariri-tii.'iit or liyia-rtropliy of tlu- .)thiT ki.lu.-y. A.-iuirra 
 atrophv is tlu- "ivsult of a imtiitiv.- .listiirl.aii.f. 
 
 lAniJuMiY.— Anything' wlii.-li .listiirl.s tiu- imlrition of 
 tho ki.liiov may pPMlu.'.' atn.i.i.y. Sii.-li w..ul.l 1... tiio 
 case where tumors of the al..h.m<ii press u|...n or inv<.lvij 
 the renal artery; oJiiholism, tliroml.osis. ..r (UIj.'V disease 
 of the vessi-U sutH.-i.'iit t.. .h-prive the ki.iiiey of its |.r.)i.er 
 nourishment may .'ause its atn-phy; while in .•lin.nie 
 tuhular nepliritis we often tin.l nutritive disturhan.-e an.l 
 oonse.iuent shrinkaire of the or<;au. 
 
 These tw.) kidneys whi.h I n..w show you (h» not wei-ch 
 more than tw.. an.l" a half ..un.cs ea.-h, the patii-nt havin.ir 
 (lio.l ..f ehroni.' tuhular n.-fhritis, the result of ex.-.'ssive 
 use of aleoliol f.)r tw.. or tliree years. I .lesire to .all 
 your attention to the faet that hoth ki.ln.'ys are c'.,ual1y 
 atrophie.l, an.l that tlu- atn-phy is at the expense of the 
 
 cortical i.orth.n. 
 
 When the atr.iphv is the result of pr-ssure of ah.lominal 
 
 tumors it is generally unilateral. 
 
 We occasionally tin.l ohl age a.-ting as an eti.. logical 
 
 «k 
 
124 
 
 Disr.tsh..; fir TiiK i\ii>.\i:ys 
 
 fiiftMr, tilt' k'uliifvs III' iild |i('ii|i|c Id'iu^' "I'ti'ii tjiiiti' siiuill 
 ami |iiiitjikiiiir in n imasiirc (if the u'cmriil atrnpliy dt" 
 otliir ()ri;iiiis. 
 
 I'ATiini.ipiiv. — In virv ulil |>(n|ili' w f tVfi |ii(iil 1 V HikI tlu' 
 kidiicvs siiuill or atr(i|iliii'(l witliniit tluir litiiit; dlsca-^t'tl 
 ntlHTwisc tliaii ill lia\ iiiir siitliicil wiiiu' fattv tli-p-iicnitinii. 
 Ill (•(iiii.''iMital cases I have si'cii inif isiiiall ami oiii' lariat' 
 kiilii<_\. iniltur litiiiLT tliscascd. 
 
 Wf liavf alrtaily runsiiliTcil tin- paflioldiry (if tliu 
 atropliv of cliruiiir tiilnihir in'|iliritis iiiidfr its iiropcr 
 lit iidiiiLT. I>iit it inii^lit \>v wfll to rt'iiiark lnii' that tin- 
 .filial! irraniilar kiiliit y t)|' iiiftrstitial !it|iliritis is imt, prop- 
 crly Hpiakiiitr, mi atrti|iliii'd kidm-v, iiiasimifli as its rc- 
 (lutlii)ii ill si/.f dfptiids licit upon a pMural atrophy of 
 thf Di'^iii, Itiit upon foiitiiiftioii of tilt' luw tilinms tissiu'. 
 
 Symptoms. — 'I'lnrt' an- no siilijfftivt' syniptoins which 
 would assist us in diaLrnosiiii; this condition diiiiiiir Iil<'; 
 hut i)y careful hinianual cxainination in vt rv wparc persons 
 with relaxed ahiloininal walls it is sometitiies possihle. 
 
 I'ltodMisis. — If diairiiosed, th' protrntisis iniist depentl 
 lariTely on the cause of the atrophy. In chronic tulnilar 
 nephritis, or where the renal artery is implicated in a 
 catieeroiis jxrowth, it is iiad ; where only t)iie kidney is 
 atrophied, unless the din-ase which causes the atrojihy 
 interferes with the patient's health, the proLrimsis is favor- 
 ahle, as persons can live very well with tire kidney. 
 Till' atrophy of oltl people is not likely to interfere with 
 their lon<;evitv. 
 
 FIVrKKTItOPHY. 
 
 Ve usually reco<;ni/e a etintreiiital and an acquired 
 hypertrophy «)f the kid ley. As u rule, eoni;enital hyjier- 
 trophy is unilateral, ami the other kidney is atr<)i»hied or 
 ahsent. 
 
1 
 
 Ti Wilis .i.v/) vKii iiiifiwrns 
 
 125 
 
 Tt i^ tt w.'ll-kiiuwn ni.t tliat wli.r.' oiu' ki.lii»y 'h iv- 
 
 ,„o\V.l or l.iTnimH ulrul.l.ir.l llio olIuT l.\ l..Tfln|.l.irMll..l 
 
 in many (Won am l.i' iv.o.cni/..a I.v Imuanual ixanii- 
 natinii. 
 
 (MlArTKU XX. 
 
 TiMoii, 11!* i\Y\A\vi\ to til." ki.liiivs, "h (.ftrn a ratli.T iii- 
 (li linitf ('Xi)n-<sioii. 
 
 All till- ,-nlaru'''i>i.'nts of tlic ki.ln.'V an- usually I'la.'.d ii> 
 tliU .-laViH.-ation. TikI.t tliis li.a.lii.u' w." shall roMsi.l.T 
 n.ali.ifnant and non-niali-uant j^rowths, as vwU as cysts 
 anil jiarasiti'S. 
 
 MALKINANT (nioWTlIS. 
 ('„,.,.;„„„>„.— 'X\wVK' may l.c sai.l to .'xist tl.n-f lu'cnliari- 
 tit's al.oiit can. •IT of tlic kidneys,— vi/. : 
 
 1. The kidney is .nini.arativfly i'Xfmpt from camcr. 
 '1. Wln-n it is tin- sulijcct (.f .an.cr it is fn-cnu'iitly met 
 wi'li in vounu' cl.iMrcil, and less friMHuntly at tli.- usual 
 cancer aye. Wlien cancer is present in y<.un,tr cliildr.-n, 
 the kidnev is mon- ofti'ii atta.kcl than any other orpin. 
 It is, however, i-rohahle that nniny of the so-.-alled cancers 
 of the kidnev in children are sarconuit< us. 
 
 3. The meilullary variety is of mos', fre-iucnt (u-curn-nce. 
 Kt,„,,o(1Y.— We "know no niori- of th*' causi- of carci- 
 n.mui of the kidnev than we do of the cause of .•arcinoina 
 of other orirans, nor have we any satisfactory explanation 
 of its frequent ooonrreiice in younu' <hildren. It is tan- 
 to suppose that heredity i.lays ahont the same part in can- 
 cer of this (U-iran that it does in others. It may he pri- 
 marv or «ec'omlary. When primary, it u usually confined 
 
 11* 
 
 MHBrt 
 
120 
 
 /)/v/.M\A.'v nf rut: i<n»\h:\s 
 
 ti» niif kidiu'V. W'Ihii !.i'iiiiii|iirv, liotli itrjfaii-* aif likily 
 
 fii Ire ill\iil\ii|, t'Xrf|if ulliTf till' lI'lHcaKl' Irt tln' n'KllIt ot' 
 
 ilirtM't I'Xti'iHiiiii tVuiii iiiiidlii r iiii:iiii. 
 
 Ill ixliilt lite iiimIcs ar*' iiiikIi nt'tt'iicr attarkiil tliaii 
 triiialf-. Ill rliildnii Hex |tlav>« tin |iart. 
 
 I'\ nini.iHiv. — It i>* |ii'itliali|i' tliat caiirt r nf ihr ki<liitv 
 «l<K'rt lint alwavs uritr'niati' in llif i-aiin' .-tnnruic. In M>im' 
 nisfrt tli«' niin'i'i'-i't'lls (iiitiinalf in llif tjiilliijiiini uf the 
 
 tiiiiiilcs, wliilc sdiiif |iatliii|i»i,'i>|-* maintain tliat ll aii- 
 
 (•fidiis trruuili lMLj:in-« in tin- tfjlnlar li-^iif ainiinil tlic 
 Mal|iiirliiaii liotliis, Srlnofdi r tliinkr* tliat raini r nl'tcii 
 (trii;iiiat<-' in lln' tn.l'iilicjinin nf tlii' IiIoimI-soscIs. 
 
 SvMi'ii'Ms. — h, i.iMiiilarv <anr(ii)iis i'r|iu>it in the kid- 
 ticy tlif svni|il.iiiis arc •^cldnni u<|| marked ; in lai-t. \»\^\- 
 tiiurteiii I'xaminatiiin nl'tiii nvcaN finirrruiis dt'|M»its 
 wlu'i't' tlu'V \v»rc nut ivcn f<iis|i(itfd dnriiiir lit'f. At 
 otliiM' tiniTH till' |iatit'nt may i'tini|ilain <it° pain, and mi ix- 
 nmiiisition tnlarirtnii'iit ut' oiu' nr ixitli kidneys lie I'iiuikI. 
 Wlicrt' liotli kidmys are invdhcd. a diai;ni.-is is a matter 
 of less jiraetieal ini|H(rtanee. as lliere may lie depiisits in 
 (itlier organs, and iititliiiiLC is tc lie lioped I'.ip rinm treat- 
 ment. 
 
 In jirimary eaneer oltlie kidney we L'eiurally have tour 
 |iroiiii)ient syiii|»toms, one tir more nt' wliieli arc always to 
 lie I'lMiiiil. — viz., Iienii»rrliai;«', |iaiii, tiimnr or enlariremeiit, 
 and eaiK-iToiis eaeliexia. Ileinorrliatre is present in al'oiit 
 olie-lialt" tlie eases, heiliij si nietinii'S tile Hl'st sym|itom 
 wliicli altraets the attention ot' the patient or physician. 
 In utlu-r cases ha'tnatnria may occur at wry irretrnlar in- 
 tervals (luriiiiT the coiirsi' of the disease. When heiiior- 
 rha<re iic<'iirs as a very early syniptoni, lu't'ore the api>eiir- 
 ance ot' any tumor or cancer. uis cachexia, it is not possihle 
 to make a diatrnosis, as the hemorrhage iiiitjht he from 
 liypencmiu or stone. 
 
Tl Mons AM> VKM UHUWTUS \'i1 
 
 Pain in ih.i iiKvav- pr.'^.iit, in.r (.tt«'ii h.v.it. iiikI ii.ViT 
 pr.Hlur.'K tlif Hfvnv iitta.-kMof niial .ulif tlial ary a-... 
 riiil.Ml Willi III- pas-a-r.- of rnial .'alruli. ( ».va-i..Mallv 
 ^..vnv |.ain mav iv»iill iVnin tl.r pivsm.^ (>n.ln.H|..l..is in 
 ll.r iiivt.r-. Wli.'ii sii.li i' III'' 'iiM., Imiic ^triiijTH ..r .Intr* 
 ,,|- 1,1, „)il will It IuiiimI ill iIk' iiiiiK'. Tli.- pain Lmih a 
 nilr. .lull aii.l a.liiii'.' in .liaia.t.r. siliialr.i al.niit tli.- Lark 
 an. I loins, uftrn pas^iii.tr .lown lln- l»';;s nr inio tin- Ma.l.l. r, 
 l.nt it is s.l.loin s.'vnv in tlu- fi-stid.-, iik irt tiv<|nfnllv tlio 
 i-asc in irravi'l. 
 
 A .•iin I'lil l.iinaniial .•xainination will alwavs .l.ti'.t any 
 r.nwi.i.Tal.l.' tumor Ih-Iw.tii tli.' L.w.r ril> ami llir iliar 
 K-YK'sX. Till' tumor, mil.ss wvy larLff. p-m-rally itlaiiiH 
 K.mn-wliat tin- sliap.' of tli.' ki.ln.'V. It is nsnallv lixy.I, 
 an.i .Im.s not move with llif ad of i-i'spifatioii. 'I'll.' 
 jrrowtli may involve 111.' inf. rior v.'iia <'ava ami i-kmIii.-.' 
 ,.n,irorir''m''i>t of tlic ulHl.nniiial v.-ins, willi <lr.>|.sy of tin' 
 ft.t aii.l l.'L's. 
 
 Oil tilt' ri.irlit side tli.' Ii.'patif .liK't may lu' inv.ilvcl ami 
 jaiiii.li.'.' I'.siill, ..!• til.- portal .•ir.'nlati..n i....y l>o int.'r- 
 f.i'..l with, wli.'ii, lu-si.l.'s .p.l.-nia .if tin,' fc-ct iUul K'^'s, 
 as.'itfs will Mipt'rv.'in'. 
 
 The caflu'xia in .an.'.r of ih.- ki.lii.'y is i|nit.' .-liarac- 
 tcrisli.'. 111.' pati.'iit assiiminir a hroiiz.'.l ratli.r than lli.- 
 l.lan.'li.'.l aiia'ini.' Inn'. My last pati.'iit who di.'.l ..f ivnal 
 caii.'cr ha.l iKinorrhat;.' as an »'aily synipt.mi. ami siihsc- 
 • pu-ntlv had a tixcl kidm-y-shapcl tnnior, pain, s.'v.-ro 
 lu'a.la.'ht', an.nvxia, ami vomitin.ir. For months l...foro 
 d.'ath t'M'rc was st.'ady .'iiiaiiatiim, as also »>xtr.'iiif irrita- 
 l.ilitv of tin- hla.hU'r, with oliirmia. 
 
 Primary cam-i'r .>f tli.' ki.liuy in yomi'r rhildr.'ii arrows 
 v.'ry rai-i.lly. often pro.liu'inir i-normous dist.'iition of tlu> 
 nlaiomcn. It in not uHsociati-d with mmh wastin,;; or 
 attended hv scvero liain. There may he Inematuria, hut 
 
12S 
 
 DISKASES OF THE ICIDXEys 
 
 this (uriirs mori" t'm|ii.'iitl_v wlu-ii tlu' siiliji'ct is an old 
 iiorsoii. As tin- I'lisr in'OLrn-sscs. scfoiidiiry iiodulfs may 
 l.c tomid in tlu' otluT ki-liifv or in tlic Inn-rs, i'lnariation 
 will ainirar, and tin- )iatifnt will i>n'scnt tin- nsiial caclicxia. 
 
 'I'm: AT Mi: NT. — Tlu' trfatniciit consists in attcnii.tinir to 
 proloiiLr lit*' l»y noiirisliini'nt and tonics, and in ,uivin,tr re- 
 lid' tVoin i>ain l)y the use of opiates on the one hand and 
 nnioval of the kitlney on the other. 
 
 Wliin the disease is primary and nnilateral and an i-arly 
 diau-nosis can he made, removal of the kidney— nephrec- 
 tomy— is indicated. (See chapter on Surgery of the 
 Kidne_\.) 
 
 non-mali(;nant oh UENIUN (IHOWTHS. 
 
 Non-)nali!;mint jrrowths of tlio kidney a-e extremely 
 rare. We do, however, oeciwionally find a lihroina, 
 lipoma, anjrionia, or adenonni. 
 
 These irrowths have no well-marked clinical character- 
 istics that woidd enalde \is to dia,u;nose them. 
 
 Althouirh extremely interesting: to the patholojjist, they 
 hardly demand much attention fron» the clinician. 
 
 When a tihronut does occur, it develops in small nod- 
 ules, and jrenerally in the pyramidal jiortitMi of the kid- 
 m-y. The noduU's do not often ^^row to a large size. 
 Fihronni, like any other now growth in the kidney, may 
 trive rise to Inematuria. 
 
 Liponiata, or fatty growths, have heen thought to c(mi- 
 menco in the fatty cellular tissue outside the kidney, 
 whence they invade the kidney, destroying tae renal tis- 
 sue, protlucing atrophy, and converting the organ into a 
 mass of fat. There is no possihle means l)y which this 
 condition can he diagnosed during life. 
 
 Adenoid deposits have heen found in the kidney ac- 
 companying leucocytluvmia and lymphadenoma. 
 
(USTS <»r THE A7;>.VA)'. 
 
 1-29 
 
 Cases of uTioiiiii have lu't'ii n'i..)rtc(l t'lom tinu' to tiiiic 
 as small tumors .Uvelopfd in flic cortex (.f the kidiu'V. 
 
 CYSTS OF TIIK KIDNKY. 
 Cysts of tilt' kidney are divided into simple, eoii,ir«'iiital, 
 ovstic dcj^eiKTution, and hydatid cyHts. 
 " Ivrioi.o.iY.— SimpU' cysts may he dilatations of tnlmlefl 
 or Malpighian capsules, and he the result »-ither ..f oh- 
 ^truction in the luminaof the tuhules or of their ohliteni- 
 tioii hv compressioii. 
 
 (\)n"irenital eysts prohahly orii^inate in the same way. 
 Virchow ascrihes the conixenital cysts to ohstruction of 
 the uriniferous tuhules hy inflammation duriiiii' f'l'tal life. 
 The oriran is found at hirth to he in a state of cystic de- 
 generation ; in other words, hein.u a mass of cysts in \vhi«-h 
 the proper secreting structure is lost, and attaininsr such 
 a size, at times, as to he an imi.ediment to the hirth of the 
 
 child. 
 
 Some pathologists doubt the existeni-e ot cystic do- 
 generation,— that is, that cysts originate from enlarge- 
 ment of the secreting cells of tlie kidney. 
 
 The kidney is not the subject of hydatid disease as often 
 as the liver and tin- lungs. 'Exactly how the parasite finds 
 its way from the digestive organs to the kidney has always 
 been a matter of speculation. 
 
 Patiiolo(}Y.— In the condition of simple cyst, the kidney 
 may he normal in appearance or irregular, with the out- 
 lines of cysts from a minute size up to that of a walnut 
 plaiidv visible under the capsule. 
 
 In "cutting open a kidney of tubular nei>hritis a great 
 number of small cVsts may "be found. It is in this patho- 
 logical condition that we find the cysts, as dilated tubules 
 f r^Malpiirhian capsules, the result ..." obstruction of the 
 tubules by blood, pus, concretion, or fibrinous exudation. 
 
 i 
 
l:]0 
 
 DisKASEx <ti' Tin: KHK\i:ys. 
 
 Ou tlu' c.mtnirv. th.' cysts f.Min.l in intvrstUial lu'i-hritis 
 luv tlu- n-sult ..f ..l.litrratioi. <>f tlu' tulmlcs hy tlu- cuu- 
 tractioii of till' new tilirnus tissue. 
 
 Cv.ti.- <lr.<.-n.Tati..n shows an .■..lar-muMit of sc.-ivtint; 
 ,.,.li: „n.l .•o..s...,U(Mt .on.pivssion of tlu- stnu-tuiv ot tlu- 
 ki.lm-v, .aiisin.tr .U.,i:.',uTati..n of its tissiu-s, ivsi inMm.ir m 
 a ni.asuiv the ovarian .yst. (See V\i£. If.. I 
 
 Hydatid eysts are formed hy the eiieapsuhition and I'V- 
 liferation ofthe parasite ta>nia e.liino.'orens. 
 
 Symptoms.— Thi' ki.hiev may eontain a htr^o nniiilKT 
 <,f <n.all evsts seattered throu-hont its eortieal iH.rtion 
 1,„,1, i„ ..l,n,„ie tnladar an<l in interstitial nej.hntis, and 
 .nve no indieution of their existence. Shouhl the eysts 
 he verv hirire and directly nncU-r the .avsule, they nn-ht 
 lu. reco.niized hv [.liysical examinati.m. I have seen 
 ,„,,.,„Hna uluTc" Mwh cysts were fonnd, hut wo as otten 
 have ha.n.atnria in chronic tuhnhir ov interstitial nq.hntis 
 where no cysts are j.rcscnt. 
 
 Hvdatid cvsts, usuallv unilateral, are likely to soon ac- 
 quire so hir-e a si/e as t.. he easily reco<rni/cd hy mspec- 
 tion or l.hvsical examination; in fact, they may hll the 
 whole side'of the ahdomen, and may he mistaken on the 
 left si.le for .-ystic disease <.f the si-leen or ovary, and on 
 the ri'Mit side for hvdatids of the liver. 
 
 i:ai?an.t..n.ii"s have heen ma.le tor the removal ot ovarian 
 t„,nurs where the operaK.rs found they had to deal with 
 hvdatids of the kidnev. When they arc Mualler they mi.-ht 
 he mistaken f..r a hy.lrone,.hr..sis. In any case as,.ini- 
 ti„n on-ht to cstahlish the dirt'erential dia.uMiosis hetw-een 
 ovaria,rrtuid. urine. an<l hydathl Huid containing portion, 
 of the hvaline walls of the dau-hter cysts of the cohino- 
 ..oecus. ■ Hvdatid cvsts may rupture into the pelvis ot the 
 kidney and" the fluid es.-api- with the urine m which it 
 ,au h'e recoirni/.cd. The passage of this Huid through 
 
 ItaMMIt 
 
J^ . m ■ ^ ^ ..M- 
 
 cysrs or riu: /»'//).v/:i', 
 
 i.n 
 
 lu'i'liritirf 
 xUv roH- 
 
 scrl-rtillir 
 W (»t' llu' 
 
 nlilin.ir in 
 
 aiitl in'ti- 
 
 > nuiiiluT 
 il |ii»rtiiin 
 iritis, iiiid 
 tlic cysts 
 loy miirlit 
 layt' sei-n 
 f as ot'ti'U 
 1 nojihritis 
 
 o soon ac- 
 hy inspoc- 
 ay till the 
 ken on the 
 ry, au<l on 
 
 of ovarian 
 t (h'al with 
 they niijrht 
 asi' aspira- 
 ■;is bi'tweon 
 iij; portions 
 the echino- 
 ic-lvis of the 
 ill wliieh it 
 id through 
 
 Fid. If.. 
 
 Cyslic det{eneriili<ai of kiJiiey. 
 
 I 
 
 1 
 
 m 
 
;,- -• 1*— r ■ 
 
 "1 
 
 III 
 itiiiii 
 
 J32 • /)/s7; ts7> or riii: lansrvs. 
 
 ,. nrrt.r and uivtl.ra is s..uu-tinu-s a<ro,niKinu"(l by much 
 
 'p,;„,,..„s._TlK' siinpU. cysts ofcMth.-r tul.ular or in- 
 torsti.ial nephritis ,.rohahly i..t.ri;.n- litth;. if at all, wUh 
 the t.r-nvss of th.- .liscas... I.a,-. cyst..- .h-yn.rat.on 
 lv\.o,;i.U.t.lv destroy thon.nal tissue. In hy.latuls the 
 ;ni^.n..si; is certainly unlavorahle. The eyst n.ay o,-. 
 Lt.rthe uhaon.inal eavity or the eellular t.ssue surn.un.l- 
 hiK the ki.lney. hut in favorahle .-uses the kuhu-y n.ay he 
 removed an.l the i.atieiit reeover. 
 
 r,.,,,,,,,,,,.Nr.-There is no nii.lieal treatment api-lieahlo 
 to the evsts of interstitial or tuhnlar nephritis. 
 
 When, unilateral and eou-enital, the indi.-ation is to 
 remove the ki.lney. (See chapter on Sui-ery.) 
 
 O.-easionally hydatid cysts have luvn iuspirated, lodme 
 injected, and the c£we reported as cured. 
 
 itaM 
 
.;*as^^ 
 
 'd by inuih 
 
 mliir or iii- 
 at all, with 
 I'tjciuTation 
 iy(lati«ls tlie 
 t may ojn'M 
 i- siirroUMtl- 
 lu-y iiiiiy l»e 
 
 it ap|>rK':il>le 
 
 ication i^ to 
 
 •■) 
 
 i-uted, iotline 
 
 HK.XAL lAurLis, sTost:, sTosy coycjarnoss. 133 
 
 SKCTKJN III 
 DISEASES OF THE PELVIS. 
 
 (Ml A I'TKK T. 
 
 RENAL CAU-nAVS STONE, STONY CONCRETIONS-HENAI. COl.ir 
 _ NEl'llHC-l.ITIIIASIS— I'YEMTIS CAIX'ILOSA — CAU ILI 
 KEN A LI A. 
 
 [v .•(msi.UTin- tlu' (lisiMisos of tlic folvis of tho ki.l.u.y, 
 Wi' sl.all tako ni. stoiu- as one. of tlio most imi.ortant. 
 
 Tlu- term renal .•al.ulus is .^ronorally uniU'rst.M.d to 
 nu-an stone in the pelvis .,f the kidney, hnt there n.ay he 
 deposits also, either eon-enital or ae(,uired, m the tuhnlos 
 „r in the kidney proper. These tubular .lei-osits are olten 
 desiiiiiated " coneretions " or " ^'ravel." , , . ,, 
 
 Whether e.meretions in the tubules or eah'ulus in the 
 pelvis, these deposits, as a rule, partake of the nature ot 
 the salts of the urine,-uric ac -ul, the pliosphates, lime, etc. 
 
 IvriOLOUY.-The cause of stone, (■omretions, or grave , 
 whether in the kidney proi.er, in its pelvis, or in the blad- 
 
 der, is obseure. . ,. ^. 
 
 To savthat they are the result of defective digestion 
 and assiinilati...! -ives us no exact knowled.irc on the ..nb- 
 ject as the nature of the tault in the di-estion or assimi- 
 iati<.n which produces the stone has never been satistac- 
 torilv explaim-d. 
 
 Amonir the manv theories on the subject may be meu- 
 ti.me.l one which ascribes the deposit to the inability ot 
 the urine to hold its salts in suspension. 
 
 1 
 
-" . .i g gimif v r. 
 
 l:U 
 
 i)isi:.{si:s OF the kid. sins. 
 
 Tl.is, limvcvcr, is iiuilty. as it a^iirns ii.. .-xiict <lM'tni.Ml 
 rrasni. \nr llu- lUilmv of i1h> ii.im' to I1..I-I its suits in solu- 
 tion. . . . 
 
 Miclvi'l maintains tliat tlu' foriMation of pivniMfatos is 
 not iv(iuisiti' for tl.f i.rudnction of a niinarv ralmlns, 
 l.iit tliat it .l.-iMuds ni>«.i\ a spociHc fatanii (.f tli»' urinary 
 passa-jri's. falK'il I'V iiim >• stonc-formin.u ratarrli." 
 
 In tliis .•on.litio'n tlic mucous nu'ml:nuu' is fV.ii.|K>KtMl to 
 sr.nt.' a tou-h adiicsivi- mucus wliich lias a tctidcu-y to 
 .i,.i,l frrmcntation, .iurin.ir wl.irli tin- ..xalati- of linu'. ap- 
 ocars. lie liolds tliat almost all stones consist prnnarily 
 „f oxalate of rune, to which m.u-c is added from the do- 
 c.omi.os..d urine. If the urine l.ec..mcs alkaline, he main- 
 tains, the oxalate of lime in the stone is displaced at hrst 
 hy uric aci.l and urate of ammonium and afterward hy 
 the phosphates, thm ecmverting an oxalic into a phos- 
 phatic calculus. ^ 
 
 Whatever \\\v chenrnal causes arc, there is no doul)t 
 that heredity plays an important part. There is in cer- 
 tain families a stnm.i; hereditary tendency to' the forma- 
 tion of urinary calculi ; in other words, s(un<' persons 
 posst'ss a stone diatlii-sis. 
 
 In this connection I may mention that there seems to 
 be an intimate relation between the gouty diathesis and 
 the urinarv calculus diathesis. We not infrequently see 
 in the same family some members who are the subjects 
 of urinarv calculi, while others are victims of gout: and 
 it often hapi.ens that persons who Inive luul attacks ot 
 renal colic ov stone in the bladder in early life develop 
 
 '" CMiinate v-an hardly be said to be an etiological factor 
 in this disease, whih- locality has a very decided mtlu- 
 enee. It is found to bo particularly prevalent in hme 
 districts, where the drinking-water contains lime in ex- 
 
 iiiM 
 
( clicmiciil 
 Its ill solii- 
 
 •ijiitatcs i^^ 
 
 k- Cilll'lllllS, 
 
 ln' uriiiiiry 
 
 ;i|i|)(>M'tl to 
 
 ciMlfiu-y to 
 it' liiiH' mt- 
 t |irimiirily 
 oiu tho (ln- 
 ic, he inain- 
 ci'd at tirst 
 fti'i-warcl I'V 
 ;it() a phos- 
 
 s no (l()ul>t 
 IV is in vi'i'- 
 •tlK' t\>riiia- 
 iiu' juTsons 
 
 n'd socnis to 
 iatlK'sis and 
 L'quontly see 
 tho snhjofts 
 f i^oiit ; and 
 I attacks of 
 lite devehtp 
 
 otj;ical factor 
 
 L'ciihMl intlii- 
 
 U'lit in lime 
 
 lime ill ex- 
 
 A'/;.v,i/, (wr.rrr.r^. wo.vk, srn.sy rn\rt;i:Tii>\s. 1:{.'> 
 
 ,M-ss; for instance, in the eastern section of Kndand 
 urinary calcnli are nindi more piwalenf than in th.' west- 
 ern. Xorway and Sweden are notahiy i'xempt. not, la.w- 
 pver, on a<-coiint of tlieir cold climate, for stone is of 
 fre.,nent occnrrem'c in {••eland. On the other hand. 
 India, with a hot .liniate, ontrihwtes a -"""H.v 'l""'»'' "' 
 
 eases. . 
 
 .h/c— That renal stone is more tre(,u,'nt m youni; adult.^ 
 than in the ai^'ed seems to he the prevailin- idea of m..st 
 writers. My own experience, liowever, i-oints m the 
 
 Fio. 17. 
 
 ''""I' In n 
 
 , i\»^ 
 
 \V^ 
 
 ..i.V^^'' 
 
 .,v\ 
 
 SlOIlf III tM'lvlK. 
 
 Stone in iiroliT. 
 
 NVphro-lithlasls. 
 
 opposite direction. T have collected a lar-e nnmher o1 
 rcMial eahaili, all of which are from eases oceiirnn- in my 
 own practice, ami not one of them is from a i-erson under 
 
 the age of twenty. 
 
 
 'rA 
 
c «r 
 
 186 
 
 i)ish:Af<i-:s nf Tin: i\in.\i:is. 
 
 Tln' iiiiii ri'tioiis simkcii of as <»c( iirriiii; "m tlif tiiliiilcn, 
 liowfvor, jiiH- iu» <l«tiil»t (ifti'iuT tiiiuul ill iliililrcii tliiiii in 
 ((itlcr i.trsiiiis. Miilfs iirc iiiiicli iiKirc lrc(|uciitly siil»i<'(t 
 to tliis foiiilitimi tliiiii t'l'iiuilts. 
 
 Fiir. J" irivi's a Itianlilnl iiliistratioii ol" tin- iiuidi- of 
 foniiatioii of ri'iial caiciili in tlif pelvis ami tlii' sulistaiice 
 of til.' i<i(lm'y. Tilt' lartri'st stone eoiiiiiletely tills the 
 pelvis, while tliefe are three other stoiu's in the hodv of 
 the kiilni'V. The stone in the ni'i-ter must have heroine 
 (letai'hed from till' pelvic stoiu- an<l foiiml its way into the 
 ureter, wiiere it ln'came imjiaeted, or il may have made 
 its way into the ureter from the pelvis hofore the forma- 
 tion ol' the liirire pelvic stone. 
 
 The stones in the hody wer*-, of course, primarily de- 
 posits in the tuhules. 
 
 The patient, a native of France, thirty-nine years of 
 a.<re, consulted Dr. L. Hazet, of this city, in Xovemlu'r, 
 iS'.tl, complainiiiir of severe couirh, great «"jiiaciation, and 
 irritahle hla Ider. lie ha<l contracted a urethritis in his 
 tweiity-st'cond year, and had since had several attacks. 
 
 His family history was good. In 1888 he was treated 
 in I'aris hy I'rof. (Juyon lor cystitis. 
 
 He came to (\ilifornia in 18S!», in fair health. When 
 admitted to the Polyclinic Ward of the City and County 
 Hospital in Deiemhcr, 1891, he was much emaciated, 
 ve;y ieehle, had a severe cough, and complained of pain 
 over the jiuhes radiating to the right luml.ar region, with 
 freipient micturition of mnco-puruleiit urine. There was 
 a cavitv in the apex of the right lung, and hepatization 
 in the c base. Hectic fever was present; tuhercle- 
 ha<-illi ahounded in the sputa. 
 
 To relieve the irrital.ility of the bladder Dr. Uazet 
 performed cystotomy. The iiatient died fourteen days 
 afterward, of pulmonary complications. He had never 
 
tiilmli'n, 
 tliiiM ill 
 
 V Sllltjt'l't 
 
 lllixli' ol" 
 
 ultstaiicc 
 
 tills the 
 
 hotlv ul' 
 
 Ikh-uiiu' 
 
 • into tho 
 
 VC lllil<U( 
 
 10 foniiii- 
 larily ile- 
 yi'iirs of 
 
 DVflnlllT, 
 
 tidii, and 
 tis in liis 
 
 ttiicks. 
 IS tri'iitt'd 
 
 . WUi'u 
 (I County 
 iniK'iiitt'd, 
 1 of |>ain 
 jion, with 
 'luTo was 
 latization 
 tiil)iTcle- 
 
 )i-. r>azot 
 tern days 
 lad iK'Vi'i' 
 
 A'.' ,.\i. r.i/.rrr.rs, smxh:. sruM' fo\fHh:ri>).\s. l:l7 
 
 ('oiiii>laiiiid of pain in tlif rcirioii of tiic kidin-y. N'ot- 
 witlistaiidinjr tlif liirj^*- stone inipactt-d in the iiritcr, llnrt- 
 was no liistorv of renal eolie. 
 
 The irrilallilify of the liladder and the iiiuco-|.iiriileiit 
 urine wi-re attiiituted to tiilienular cystitis, which the 
 post mortem *'xaiiiinatioii showccl to lie ahseiit. 
 
 I'A'riiOLOdicAi. Anatomy. — Three varietii-s only of cal- 
 culus are common, — nanudy, uric acid ai d its coiiipoiiiids, 
 oxalate of lime, and tin' mixed phosphates. 
 
 Calculi of large nize are seldtim of the same coiiii)()siti<in 
 throuiihoiit, lii'int; usually arran,<red in conei-ntrie layers 
 altout a nucleus, which may he of uric aciil. oxalate of 
 lime, hlood-clots, or forei^Mi liodies, hut is very rarely one 
 of till- phosphates. 
 
 T/vV arl'l calculi are the most eommon. They an of 
 reddish color, and <,'enerally smooth, hut may lie tuhcnii- 
 
 lated. 
 
 OxnJiile nf limr calculi an- of a dark-hrown or .trray 
 
 color, and usually tuherculated, whence the nam. lul- 
 
 herry calculi " often applied to them. ()c"asioiially they 
 are "small and smooth, constitutint; the so-called " hemp- 
 seed calculi." 
 
 ('alcidi of the )ii!jril phrtsphntes are ('(imposed of jihos- 
 phate of lime and triple phosiihate of ammonium and 
 mairnesium. The phosphates often make up the external 
 lavers of calculi of various composition, hut seldom con- 
 stitute the nucleus of a calculus. 
 
 Calculi have sometimes heeti found comjiosed of car- 
 honate of lime, xanthin, cystin, and urostealith. 
 
 Sv.Mi'To.Ms.— We shall take up the symptoms under two 
 ]ieads, — namely, renal calculus and renal colic. 
 
 The first includes the symptoms that result from the 
 presence of stone in tho pelvis of the kidney or from 
 tuhular concretions; tho latter, the symptoms attending 
 
 J2» 
 
V\H 
 
 ni.sHASKs nr TiiK KinsF.ys. 
 
 tllf l.iHriiliTf nl' tin- siMll.' t'n.Ill tlir |Hlvi^< ul' ill.' lo.lll.'V 
 tliiuiit;li llif iirctiT to III" l.lii'ltl.T. 
 
 Ciii.Mili s..iiicliiiM's piiMlii.T M.I paiti. Iiul. ii< ii nil.', .■illuT 
 tiiliiliir ...IK TfliniM ..r llif pri'Sfii.*- of sloii.' in tli.- imIvih 
 will lie ali.ii.l.'.l l>v III..!.' ••!• l.'ss |.iiiii, of imIiiII, iKliin,!,' 
 (•liaia.'ttT. .'iilit r .•.•ii^tniil <.r iiit.'riiiitltiil, itir.irniviitfil l.v 
 111. .vfiii. 'Ills ..f 111.' ImhIv, and s..iii. liiii.' t'..ll..'.viii.Lr lli<' 
 .•..uiM' ..t' th.' ur.'i.r !<• tlif .trroin ..r iIk' t.'sli.l.'. Il may 
 ....mimi,' lur ni..nllis an. I l.c a.'.'..iti|.ani.'.l l.y t.ndi'rn.'ss 
 on pii's^ur.'. In piTliap- I. all' lli.' .as.'s lli.r.' i^ lia-nia- 
 turia. wlii.'li is siil.if.'l l.» n" nil.' a-^ !.> lli.' t'r.'.iu.n.'.y of 
 its o.'.'un.'ii.'.'. S..m.'lini.'s tli.T.- will 1..' Imt a .T^'lit 
 
 1„. nhiiLr.': at ..iIkt times lli.' alia. 'ks will ln' i|uit.' piT- 
 
 sisl.nt, an.l pi'iliaps a.'.'..mi>ani.'.l l«v i-Vflitis; wliiK' in 
 still otluT .'as.-s 111.' st.iiH' may 1..- iv'taiiu.l ai-panntly lor 
 11 ./r.'at Icn.irtli ofiim.' in ih.' ju'lvis witli..nt i.roauciiijf in- 
 tlamiiiati.)!). 
 
 In infants, .l.'|).isifs of urates or |>lios].liat.'s are often 
 ,;,„„.l i„ ,h,. .liaiMTs. Tlii'se prohaMy have tl.eir ..ri.irin 
 i„ 111,, nil.iiles an.l lli.'ir passajre tlir.Mi,i;li tli.' nr.'ters 
 causes e.tnsiili'ialile pain. 
 
 The lirst in.li.ati..n ..f r.'iial .'oli.- is ireiierally a sudden 
 oiislau,i;lil ."f I'ain as the stone eiit.rs ih.' ureter.^ Tin.* 
 seM..ni ... •ems while th.' |u-rson is walUinir or sittiiiu: np- 
 r^dii, l.nt lakes plae.' when he is stoopin-r, heiidin,-r over, 
 or lyin.u' down, as th.' lM..|y is the-i in a more favoruhle 
 positi.>n for the stoii.' t.) eiit.r the ur.'ter. 
 
 The sntferiiiLr is sonu'tiines so severe as to cause faint- 
 in.;:, the patient fallinir into a e<.llapsed .'on.lili.ni, soon, 
 however, rallyiniT to riali/.e the intensity of his pain. 
 
 At lirst the pain is so <rreat as t.> make it dirti.ult .>f 
 exaet loeation, the patient in his a«r.>ny referrin.ir it to the 
 
 
nr.SM. rttl.ir 
 
 ITJ 
 
 If k'wliH'^ 
 
 lllc, citlliT 
 
 till' I'tlvin 
 ill, iK'liiii,!; 
 •avatt'il liy 
 iwiii.!,' fll"' 
 It iiiav 
 
 ilMtil'riH'KK 
 
 is liiiMim- 
 
 (lUillfV <>t 
 
 t a I'.'lit 
 (|uitf pfi'- 
 ; whili' ill 
 iirtiitly tor 
 uliiciiii; in- 
 
 I art' ot'tt'U 
 luir orii^iii 
 \\v urt'ttTs 
 
 V a suddt'ii 
 i.trr. Till* 
 
 sittiiiu: ii|)- 
 idiiii; oviT, 
 
 V tiivombU' 
 
 cause faiiit- 
 itimi, soon, 
 s |iain. 
 ilitHrult of 
 iiiT it to the 
 
 ,.|itiiv al.ildinni: ami it is ,.iil.\ l.v tlir do^rst .|iirstioiiiiii: 
 niiil alt.iitiuii oil til.' part --I' iIm' pliysiriaii that it will !..• 
 JMcati'ii ill oiii- or thf otlit r ki'lmy. 
 
 As thf stone passfs down tin- ureter the pain heemnes 
 l.-ss ^r.-neral, euiitiniiiLr itH»'lf prill, ipally to the eoiirse of the 
 ureter, lieiii,!,' aniioyiiij; in the leLrioii of the Madder, and 
 lev.'ivin the jrroiii and often ill iIk- tesliele; and when the 
 eidenlns arrives at the hase of the hladch'r it fiviiueiitly 
 products iiitenso pain in the head of tin- [.cnis, with 
 tcncsniUM. 
 
 The extreiiie atToiiy which the patient sntfers <d'len 
 makes it impo^sihle for him to r.inain more than a few 
 iiK.nients in any tixed position, lie rolls over th.' Led, 
 and even on the floor, and will oct-asionally lind i. Ihf l.y 
 ^I'ttiiiir on his knees and pn'ssintr one or liotli hands into 
 the alMloniell over the atfected ureter. 
 
 The pains are almost always accompanied hy severe 
 vomitin-r and retchinjr, which add ir''«'iitly to the distress 
 ot' the patient. Some complain also of intense hoiuhiclu'. 
 There is usually ,<ricat mental depression, tt.ircther with 
 pallor. c(dd feet and hands, and profuse cold sweatii^tr. 
 
 These attacks may l>e of a few Ijours" duration, or may 
 continue for (hiys. In one of mv earlii-st cases the attack 
 lasted nearly ten days, the patient hardy survivimr the 
 passajfo of the stoiu'. 
 
 The stone may hecoine impacted, convertintr the eas'e 
 into one of h\dronephrosis, or it may uh-erate lhrou<,'h 
 the ureter, death ensuin<r in this event from the entrance 
 of the retained urine into the ahdominal <avity. Durinir 
 attacks of renal colic I have sometimes known the pain 
 to intermit, irivinir the patient immunity for a few min- 
 utes or oven half an liour: in sueli eases the cessation of 
 pain is prohahly the result of the escape of the urine past 
 the stone. 
 
140 
 
 /)/s7;.isK> or Tin: A//'A>;r\ 
 
 
 DlKKKIlKNTIM. 1)| \'1N'>SI,-. — Ijrillll iiilic tMlirllf IH>ttii1t<' 
 
 iiii'tiik.M t'ur.iitiTiilv'iii.«'\'-i|"i.l"iliiil'-*.ii> >•"■ "'iiiiiifM'i- 
 III. lit ul" 111.' iittu.k vvli.ii ill Im.iIi fii^t-H iIm' piiiii H.i'iiM to 
 lie ilistriliiit.il t'|iiiillv <»v.r ili.' iilMluin.ii. 
 
 (Ml ill.' ru'lit t*'u\i' it niiiilit I"- |MM^il»l." t.i iiii'^lnk.' tin- 
 liiiiii ..t' rt'iiiil ••'•li.' I"..r tliiit .if i.mI1-^I<'Ii«'. '"" "'" " '''^^ '"""'^ 
 til.' |inin of till' loriii.T pas-..-; .l..uii tli.' iir.l.T, wliil.- llint 
 ol"iriilI->toin- ir« loiitiiH'd t.> tlif .■|.i'.M'iiium ami ili.' r.'L'ioii 
 ,,|' ilic iiv.T. Uoih iiiiiy lu' iu'f(»m|iiiui<'<l liv i-Xfcs^iv*- 
 voinitiuir, rclrliiiiu'. .-wcalini:. pallor, niiil cxIiaiHtioii. 
 hat.T, in irall-^>'>".'. Jaiimlir.' .siiiuTVi'iu's. 'I'll.- |iassa.!;f 
 tlii'.Miu'li til.' uri'ttT of .lol^ of lilooil, liydatiils, or niii.'o- 
 ■piiruli'iit mall, r iiia.v pr.xliio' s.'v.r.' pain. Iml in notl.in.u 
 like what is I'xpirii'iKH'd in any oiilinary alla'k of niial 
 c.lii'. I oiK't' liail a patient in wli.piii a lar-;.' .•on.r.'tiou 
 wiH inipa.l.'.l in tin- npp.T part of tli.- (l.'s.fn»rmiCc<.lon, 
 ^'iviiiir risi' to irrcat pain, and siiiinlatiiii; closely K-ft renal 
 roli.'. Soon, however, thi- howelrt iH-ennii' p-eatly dis- 
 leiid.'.l, and the preseii.e of ..lislrn.tioii was evi.l.'nt. 
 
 I'lioiiNDsis. — As a rnle, tlu' pro;inosis is favoraMe. The 
 piilient, in u few days after the piissaj;e of the stone, will 
 liave entirely reeov.red. 
 
 Oeea-ionallv a sl.me heeotnes ini|taete<l. and death may 
 result from nleeratioii or rnptnre of the pelvis <»f ihe ki<l- 
 nev; hydronephrosis or pyi'lilis may f.dlow, and result in 
 destruetioii of the kiilney. 
 
 Tkeatv The treatment of renal eoiK-retions and 
 
 stone ie ,is of the kiiliiey will of necessity he moro 
 
 or I . .niatic, and usually .'onsists in allayiiii; pain, 
 
 if .ruhle, with attempts to dissolve the coneri'tions 
 
 or si.Mic hy solvents. The success of solvent medicinert 
 will depend larijely on tlu' character of tin- stone. The 
 most saULruine therapeutist would hardly expect to dis- 
 solve un oxalate of lime calculus. Many, however, have 
 
NKS.il' ifu.n'. 
 
 Ill 
 
 „-...rt...l tl.rir uLiliiv t.. .li^M.lvc, l.-.tl, ii. ll..' 1" Isi- "f '1'" 
 ki.lM.v i.n.l ill tl..' l.la.l.lrr, K».m.-- loniir.l ..I i.nilr. mi..I 
 
 ,„• ivn.r.li.M mU'UiM lor . |..i.iiiiir tl..- ml..- ot fl..ir 
 
 ....iwivtiMM. ;n..l 1 iMv.lis.nlvin- .al.nli, \{nUrrt.. ^^Un 
 
 |„M .MV.M M...IV i.ll.nti..ii I.. tl.iH s.il.'rt timii i»TlnM.s .m.v 
 oth.T ■mtl...iitv. think, umst liiiililv mI" tlic ritn.t.. .....I 
 
 „,.,al.- of l...tu^HUiM. Tli.'sr ..ilts sl.u.iM 1h" triv.n m trnni 
 
 o„..-l,all' 1. .• <1>».-I.i>i 'l-'S ^v..ll .liliil.'.l will, wal..-, 
 
 .,v..iy tl.iv.' or Wuu- Lours. Tli.ir iulMiiirMtn.ti..ii may Ik- 
 ,,,„„i„„,.l t;,r vv.vks, au.l .wi. in s..n..- .us.-s lor n.ontlis, 
 without tl.'tnin.-nt |,. tl..' .li,u"'>*liv«' ori^aiH. 
 
 WIn-ii it l»-.-..ni.s i-vi.hiit that th.-iv i-* a st.m.- in tin' 
 iH-lvis oflh.- ki.ln.-v, ami it.-« |.n-s»-n.v is nnl..-aial.h- .-itlii-r 
 from pain ..r in .•onsn,n.-ii.v of tin- i.ro.ln.-t..m ..1 disc-asi-, 
 „n,l solvi-nt rc-im-.lit-s huv.- fiuU-.l, tlu- ki.liioy must Ik- ro- 
 ,nov.-.l l.y siir-i.al i.n.cv.Uuv. (S.-.- rhapt.r on Suru^'ry 
 
 of thf Kitlm-y.) 
 
 [l,„,,l ('M:—\n .-a.s.-s cf (-olhips.>, wlu-n- tin- pnlsi- is 
 
 oxtivim-lv woak, tin- .•.mnti'iiau.-*- i'ul.-, uiul tia- t.-»t and 
 
 l.aials rohl, tin- in(li.ati..ns aiv to apply hi-at, ami ,|:iv.. 
 
 stimulants with opiat.-s until na.ti..n is .stahhsla-.l. 
 
 Whm- tlu-rc is no .ollaps.- lla- in.li.ation \^ to adimnist.-r 
 
 „,,iatos in sulK.i.-nt .,uantity t.. luakr tl..- pam ,.n.!ural.lo 
 
 durinu' tht' I'i'^-"'".-'' "• •''^' '^*""'"- , , 
 
 V„n will tiu<l that many writ.-rs n-omnn-nd hot Laths 
 in a.lditi.m io ..piat.-s. with tin- vi»-w of n-laxin- tin- ur.-t.-r ; 
 hut hot haths ov the appliration of h.-at sulH.-n-nt to k.-.p 
 up a constant and oxcoHsivo Hwc-atin,!/, whilo tlu-y may 
 jrivc some n-licf, will rc-turd rathor than fa<-ilitatr tla- pass- 
 
 airo of tin- stone. 
 ' 'flu- .-ahulus m-vcr passes thron-h the uivter hy reason 
 of its relaxati...., hut is foree.l throu-h l.y the pressure ..t 
 the urine l.ehind it. So long us there is oxcesHive a.-tion 
 
1 12 disi:asks of tui: hin.\/:y.s. 
 
 lit" till' skill tlic iirtioii lit' tilt' kiiliicys will lit- iiisiilHcit'iit 
 to loHH'. with iiMV (Iciircc ot' riipiditv, the jiiissiin'i' ot' tlio 
 stoiii'. 'I'liis is fsjii'ciiillv till- cast' as tin- i-xtrt'iiit' VDinitiiiif 
 nt'tfii iiiakfs it iiii|iossililt' to rt'taiii tliiiils in tlif stipinacli. 
 
 M_v iiwii iiit'tliiMl t)t' trtatiiiij: niial colif is to ix'wv o|iiat('s, 
 iTfiicrallv iiioi'iiliiiic iiv|ii>(K'riiiifally, iiiiK'ss tiifi-c is unifli 
 follajist', ill w' icli fast' 1 use tin- tiiiftiira ojiii. 1 in>ist 
 ii|Miii the |>a. ..t's (Iriiikiiii^ t'lvt'lv of water, farhoni/tii or 
 iiiiiii'ial, weak tea, t>r whatever Maud li(|iii(l he |prt'l'ers. in 
 the htijie that some will lu' retaiiieti. 
 
 Wht'ii |iossiltlt', I ki'eji the patient on his tei-t, walking' 
 ahtnit the room, to irive him the heiietit of the actitm t>t' 
 ijravitv, whit'll is eoiisiderahle where the stone is near the 
 hiadder and tiu' ureti'r is iilletl with urine. 
 
 Where the voniitiiii; is so I'Xeessi'.e that it seems iui- 
 jiossihle tor tluitls to lie retainetl Itinir enoiiixh to he ah- 
 Horhi'd, I have thought that it niiirht he well to use larue 
 I'liemata of 'varni water, thus su[ijil\iii<; urine to t'oree 
 aloni- the stt>iu'. I have not yet tri"d this ]ilaii. litiw- 
 over. 
 
 IV'cause of the vtimitiiitr, it is usually iieeessarv to ad- 
 minister opiates either h\|ioderniieally or pi^r reetiim. I 
 seldt)ni use less than one-half uraiii of morithine for the 
 first injiftion, followed every hour or two hy oue-eiijhth 
 or oue-i|iiarter of a i^raiii. as the easi' may re(|uiri'. 
 
 Laudanum may Ik- injeeted intt> the reetiim in tlraehni 
 doses every lumr or two until the jiain is hearahle. An 
 exeelleiit su|)|tositorv, when that methotl of nietlicatioii is 
 resorted to. is tuie eonsistiiiij t)f morjihine one-half ijraiii, 
 hyoseyainiis five ti'rains, ami a sufHcii'ut ([Uinitity of oil of 
 theohroma. 
 
 When there is an itliosynerasy airainst mor|iliine or 
 o|tium. the next hest remetly is ehloroform or ether atl- 
 ministered liy inhalation. 
 
 dMi 
 
irv to ad- 
 ■ctiiiu. I 
 U' tof tlu' 
 lU'-t'i'i'litli 
 
 II (li'acliiii 
 il.U'. An 
 licatidii is 
 alt' <rra'm, 
 of oil of 
 
 r]iliiin' or 
 otluT ad- 
 
 riioi'ini.A.Mx or /.•k.v.iA cM.cri.i. 
 
 148 
 
 Should thr atlark .oMtini.r for srvcTal davs, as s..i.u'- 
 tl„H.s hapiions. th.. patimfs stivii^th ..n.st 1.. n.a.ntauu.d 
 l,v ivrtal iioiinshninit. In .hh- of ni.v tirst casrs, al.va.l.v 
 ,u..|itiono.l as lasliii^ t.n davs. tin- patiml l.an■l^ siirviy..! 
 ,1,.. nassa-n- of tin- stoiir, altlmn-li hr n-nvrd iionnsh- 
 ,„.,„, l.vtliol.ouvlsn-nlarly: and it n.av l.. uvtl to say 
 l...n. tllat thr .Inratimi of thr attack was ,.rol.aMy ..wn.t; 
 to tho tivutnuMit nitlHT than to tin- si/, of tin- stony. I.o 
 c.onsultinLC l-hysi.ians in llu' .aso wo.v .urn ..t al..l.ty 
 ,„,1 ,.x,K-ri-nc*.. I was a younjrstor then, and .-arru'd < nt 
 ,1h. instnu-tions of my .I.Kts. whi.-h w.iv to ,ir.vo o,,.at.s 
 rathor spariuirlv, and .onstant haths as h..t as th*' iiatn-nt 
 ,„„ld otnlnr. ilu'tn. His voinitin- was v.ry d-.st.vssin-, 
 and, tiuT.' iK'iL.i,^ l»it littU. fluid s..,Totod hv t'.K- kidiu'ys, 
 tho i.assaixo of tho stono was dolayod. 
 
 I'ltOPllYLArTIC TUKATMKNT (>F UENAL CALcrLI. 
 A pationt who has oxporionoi-d a sovoiv attaok ..f ivnal 
 ,..,r,o is anxious to osoapo a roourron.'o of the torrihlo pan., 
 and ho naturally asks, '> What oan I do to provont suoh 
 sutlorintr in tho futuirr' 
 
 WliiU' niuoh oan oftou bo don*, to ward ott subsc(iuont 
 attaoks, phvsioians wl... l.avo had any oonsidoral.lo oxpo- 
 rionoo with" theso oasos ar.' ohli.iro.l to aoknow1od-o thoir 
 frequent failure to provont such attaoks. 
 
 In nianv oasos tlu'ro sooms to ho a stron.ir stono-inakni.s; 
 ,li,thosis,"and when wo have done all that lies in ..nr powor, 
 scoonded hv the oonseientious ofi'orts ..f tho patient, the 
 formation .if renal oalouli still oontim.es. Su<-h taduros, 
 however, must not dis,-<.ura,iro us and provont us Iron, 
 hohlin- out In.pos t.. the pationt that ho nniy stdl get 
 
 roliof from his malady. ^ , 1 1 
 
 We have overv roas<.n to holie e that tlie primary trouble 
 is with the digo^tivo orga.is. The diet should reeeivo our 
 
 mmM 
 
144 
 
 DISHASHS OF Till-: hIDSKiS. 
 
 I 
 
 lirst iittt'iitioii. Wt' imist iiiii>ri'ss upon our imticiit tla' 
 iiii|inrli(iici' (>(■ cxtTcMsiiiu: irrciit ciirt' in ri'Hiinl Id liis food. 
 
 Till' <|uaiitit_v of footl slioiild Iff iiiodorati- and ri'ixulatod 
 willi iifdciuo to till' lialdls ot" tlif individual, wlu'tluT 
 active of sftK'iitary. 
 
 If tlif ]iatirnt is liviiij^ a vtTv activi- lifi', or from sonio 
 individual |H'i-uliarit\- i\'(|nii'i's more than an ordinary 
 amount of food, let iiini eat four or live time's a day, 
 rather than ovtM'load his stomacii hy takinjr two or tiiree 
 too hearty meals. 
 
 The unality of the food is as important as the (piantity, 
 if not I'Vt'ii more so. Xourishinir ami eusily-diirested fo;>d 
 is what w*' siionld advise; anil in doing so we must re- 
 memlier that doctors often nnike mistakes in being too 
 arltitrary with other peoiile's stomadis. Most digestive 
 organs liave tiieir pecidiaritit's. As a rnle, meat should 
 not he too freely indnlged in, hnt shonhl bo jtartaken of 
 sparingly twieo a (hiy at most. The meat sh<»idd he varitMl, 
 the patient being warned against too irecpieiit indiilgiMieo 
 in beef. 
 
 Fisli is nsmtlly allowed, but I have doubts as to its pro- 
 priety where the stones are phospliatie. 
 
 The manner of eating food, no K-ss tlnm tlie quantity 
 and the (piality, is of great importance. When the stonuieli 
 digi'sts food Well, the patient shotdd eat slowly; when it 
 does not, he sliould eat very slowly. 
 
 Let the non-nitrogenous foods prevail in the stone- 
 making and gouty diatheses, limiting the vegetaldes which 
 are richest in phosphates when the ealcidi passed are phos- 
 pliatie, and avoiding those whieli abound in oxalates when 
 oxalate of lime prt'dominates in the ealeuli. 
 
 Kice is an exiidlent article of diet in most of these eases, 
 und a taste for it should he cultivated. 
 
 i'ork, veal, hashes, highly-sesusoned gravies and dress- 
 
 rtMi 
 
i-RnrHVLASix or uksm. cm-ci i.i. 
 
 14.") 
 
 iit'u'iit the 
 I liis t'otid. 
 regulated 
 , wlietlier 
 
 Voiii some 
 
 (ii'diiiary 
 
 les n (lav, 
 
 (» of three 
 
 ' (Hiaiititv, 
 ■ested t'o.xl 
 ' must re- 
 bel II t^ too 
 : dii^estive 
 •at shouhl 
 irtakeii of 
 he varied, 
 n(hil,u;enco 
 
 to its pro- 
 
 e quantity 
 lestotuaeli 
 \- ; when it 
 
 the stone- 
 ])]i.':i wliieh 
 il are i>hos- 
 ihites wlieii 
 
 hese cases, 
 
 and dress- 
 
 iiiiXS, witli rieli (U'sserts, must he ahsohltelv es.hewed. 
 The preparation of tlie foo.l is uu important factor. Meats 
 shouhl he broiled or n.aste.l, rather than stewed, fried, or 
 baked. The very In'st food can l)e rendered indi,i;estil)le 
 in its preparation. 
 
 Ne.xt in importance to re.v'ulation of the too.l m tlie 
 prevention .)f stone are the .pnintity and variety of Ihpiids. 
 Individual physicians ditU'r alu.ut the variety, m re-ard 
 to ..timulants, tor instance. T.ut there can he no .luestion 
 that a pcrs.)n with a .stone-makin.ir diathesis sliould take 
 m(ue than the ordinary amount of tiuid. 
 
 In individual cases mineral waters are no <h.uht hene- 
 iicial. Sprin-s containin.i,^ different salts ar.- hi.irhly recom- 
 mended hv various authorities and apparently in the same 
 elass ..f .-ases. Patients, too, are often h.ud in their praises 
 of certain sprins^s to which they happen to have been rec- 
 (mimendod. I str.>mrly suspect, however, that the beneht 
 derived from a sojourn at Carlsbad, f<.r instance, is often 
 due more to what the patient d\d not take while there 
 than to the therapeutic etfeet of the mineral waters. 
 
 I have great eoiitidenee in distille<l water or carbonized 
 distille.1 water taken freely: nevertheless patients will 
 often take mineral water with more relish and in greater 
 cn.antitv than they will distilled water. I <uice had pre- 
 pared ti.r a patient of mine, in whom everything e se had 
 tailed to prevent tlie producth.n of st..ne, distilled water 
 eliarged with oxvi;en gas, without benefit, however. In 
 Bom^ cases wher; what is really ncede.l is rest, with less 
 food and less whiskev, we may often prevail on the patients 
 to trv the springs when every other means to secure rest 
 and the most stringent restriction in diet have proved of 
 
 ""Besi'des the srreat number of the springs of Oalifornia 
 with every variety of water at every temperature, we have 
 ok 18 
 
14«i 
 
 DISEASES or THE KIDXEiS. 
 
 tlu' ii(l\ lint aire nviT tlii' iiiiiuTal spniitjs of all other conn- 
 trii's. ill tTuiiatr: we liavi' springs at tin- i(h)1 soa-sidc. in 
 tlu' hot valkys, ami at all altitudes. W'l' are thus oHereil 
 as irreat a variety in teni|>eratiire and eliinute iis in the 
 eoniposition of the iniiuTal waters. 
 
 1 do not In-lieve that there is one per eent. of these cases 
 that the use of toltaeco will not injure; and the same may 
 be said of the use of ale<)iM)lie liiiuors. 
 
 A healthy aetitui of the skin should be insured by reg. 
 ular bathinir. txenise, and the wearing of wurm tlaimcl 
 underclothing summer and winter. 
 
 As to tlu' administration of medicines, let me say that 
 there is no specific that will prevent the formation of renal 
 calculi. We are fori'ibly reminded by this Htone diathesis 
 that the scii'iice of medicine is not an e.xact scien«-e. I'ntil 
 we posst'ss a more exact knowledgi' of the etiology of renal 
 calculi we must grope iibout in the dark for u remedy to 
 prevent their formation. 
 
 Medicines are of use in keeping the bowels soluble and 
 in maintaining the secretions and digestion in as good con- 
 dition as possible: Henry's magin'sia and rhubarb answer 
 well for this purpose. I am in the habit of prescribing a. 
 mineral acid in combination with a vegetable toni<- wher 
 the tendency is to oxalate-of-lime deposit, and the iodide, 
 citrate, or acetate of potassium with calutnba or quassia 
 when the phosi)hates or urates prevail, adding wine of 
 colchicum in gouty cases; citrate of litliia often Keem.« to 
 be ctHi-acious. It is very ditHcult to di'tcrmine the bene- 
 ficial results of any special com-se of tri-atrnt'nt, for the 
 reason that in some cases of renal cahulus without trt'at- 
 nu'iit there is no recurrence of the trouble, while in other 
 csises there is a constiuit repetition despite any method of 
 treatment employed. 
 
 There is a possibility that the new remedy piperazin, 
 
I'YEI.ITIS. 
 
 147 
 
 )ther conn- 
 si'ii-sidc, ill 
 lius iifli'ii'd 
 ! lus in tlie 
 
 tlu'Sl' CilSOS 
 
 ' saiiH' may 
 
 red I)y roj^- 
 inii tlatiiiol 
 
 no say that 
 i<tn of renal 
 »e diathesis 
 iieo. Tntil 
 \iry of renal 
 I remedy to 
 
 solnlile and 
 
 s yood ((in- 
 
 )arl) answer 
 
 ^eseribinj; n 
 
 tonic wher 
 
 the iodide, 
 
 or qnassia 
 
 n\r wine of 
 
 L'n seein.' to 
 
 e the heiie- 
 
 .'iit, for the 
 
 itliont tri'ut- 
 
 lile in other 
 
 method of 
 
 )• piperazin, 
 
 whi.li is now hein.s tried for tlie .ondilion .ailed hv Mr 
 William Uoherts nrastosis, will prove elHia.ious m pre- 
 veiitiiii; the formation of st(.ne composed of urates. 
 
 ClIATTEU II. 
 
 PYELITIS. 
 
 I'YF.MTls is an inflammation of the mneous meml.rane 
 lininij the pelvis of the kitlney. 
 
 KTM)Lo«iV.— This is rarely a prinuiry disease, that is, a 
 disease urisin- from takin- cold, from injury, or from some 
 HO-ealled idiopathic cause. 
 
 Secondarily, however, it fre.iuently *.ccurs lus an accom- 
 paniment or 'a se.iuel of some one of the acute inlectioUK 
 lli^eases,— particularly scarlet feyer, diphtheria, .-holera, 
 and typhoid fever. I have had si'veral cases of pv<-litiB 
 aocompanvim; or followin- la -rippe. Occasionally the 
 pelvis is si.id to be the seat of a true diphtheritic exn<.a- 
 
 tion. . „ 
 
 Renal calculi are the most constant causes of intlamma- 
 tion in the pelvis, while pyelitis is found in every case- ot 
 tuhen'ular kidney, as W(>11 as in most cases ot renal 
 
 abscess. , . ^, 
 
 A. rain, we constantly meet with -condary inflammation 
 of the pelvis extending' from lon-standin- sti'icture <.. 
 the nn'thra with .-vstitis, and from inflammations ot other 
 abdominal orjrans. Thus we see that a-e, se.x, and chmate 
 have little to do, directly, with thi' etiolo.try ot pyelitis. 
 
 pATiioLoav.— I have spok.-n in previous chapters of 
 pyelitis produced by urinary calculus, as well ius ot the 
 Tivelitis of tuberculosis. 
 ' When the pyelitis follows or accompanies one ot ttie 
 
 ._J 
 
148 
 
 Disr.isEs or Till-: KinsEvs. 
 
 1 i 
 
 ju-iit*' inli't'tious disfiiscs, or is tlic nsult of cxtciisioii t'n»in 
 tilt' lihuldcr. \v«' i-xjurt tlic iiitliiiiiiiiation wliiU- it is coii- 
 tiiH'd to till- iiiiuous iiiiMiltraiif to i!;'^*' ^ 'i"'"' «'iitarrli!il 
 coiKlitioii tlic patlioloiry «»f whirh ditH-rs in no way troin 
 tliat of iiitlaiimiation of tin- imicoiis Mn.'iiil»raiH' in any 
 otluT or^an. 
 
 SYMnoMs.— \V»' liavi' discuss.d tlif synii»tonis of stoni' 
 in the pflvis; tlit- pain, <f.'., hrini-- tiu' n-snlt of the stcmu 
 rather than of inHaniniation. Catarrhal intlannnations 
 si'comhiry to tho lu-ute inf«'ctio<is dismasts or to cystitis art; 
 not likely to bo ushered i;i by a distinct chill, thouirh the 
 jtatient may experience chilly st'iisations, Tluri- will not 
 he nnich fever while the intlannuation is confined to tho 
 luucons miMnhrane. 
 
 We nsually find teriderness oviT the rocion of the 
 kidney, soreness and lameness njion movements of the 
 hody,'and perhaps dnll achinjr pain following' tlie eonrse 
 of tile ureter and occasionally felt in the testicle or bladder. 
 Micturition is frecpient, but not urtrent, and the urine is 
 very turbid from the i)resence of mucus. The microscope 
 may show pus-cells, an occasional blood-corpuscle, and 
 possibly the e|>ithelium charai-teristic of the jielvis of the 
 kidney. When there is pus there will, of course, be u 
 slijfht trace of albumen. 
 
 Prooxosts.— The proijnosis must be di'termined entirely 
 bv the cause of the pyelitis and the condition of the 
 patient. Tt is seldom that jtyelitis adds much to the 
 gravity of the ease, whether it be strii'ture of tlu' urethra 
 and cystitis, or one of the acute infectious diseases. The 
 pyelitis, however, may involve the kidney, in which event 
 the projinosis will be serious. 
 
 TuKATMKNT.— The indication for treatment, as a rule, 
 is rather to remove the cause than to treat the disease. 
 This is particularly the ease in stricture, cystitis,^ and 
 
 IMmMU ' 
 
 ditt 
 
ryn.\F.riir{<t^i'< 
 
 149 
 
 tension from 
 L' it is con- 
 ■iK' I'atiirrliiil 
 no way tVoin 
 )ranr in any 
 
 onis ot" stoni' 
 of the stom; 
 itlaniniations 
 (» cystitis art! 
 1, tliouirli iIh' 
 'luiH- will not 
 intint'd to tiie 
 
 ['Ci<^ii of the 
 nu'nts of the* 
 1^ the course 
 tie or hhulder. 
 the urine is 
 le microseope 
 or|iusele, and 
 ' pelvis of the 
 
 nined entirely 
 dition of the 
 much to the 
 if tlu' urethra 
 liseases. The 
 u which event 
 
 , , ...,,,,,,1; \or does the catarrhal intlannnation f.d- 
 ;:: 1:1 ;euU.in.VHious diseases call t;...ive,pd- 
 
 I • •„. .... t ouiet li-'ht nourishing diet, perhaps 
 
 :;;:;;,.::; mIx; ';'':« n..L. ^..M-i„. ,w 
 
 ,:;L-, ■■■I.lori,;,. or iron an,, .plri. • ..J.n- ■- •; 
 
 -;i;S I'l:; l:;-:r;' ,;x;'',,:ri^w,:i 
 
 antemie is the follow iiiir: 
 
 U Sulpliur. jirH'cip., 
 Fciri <iirl>., 
 (Jlycorini. fu'i 5^8; 
 Alp'"' '"1 .^iv-— ^1- 
 8i^r._A te.i<i.-onful ev.-ry two to four hours. 
 
 Cod-liver oil i^' very henefioial, espeeially in weak 
 aelicate ehildret* convalescing fro.n acute udect.ous d.s- 
 cases. 
 
 CIIAPTETl TIT. 
 
 PV0-NEPnR0SIs(NEPHKO-PYOSIS-I'YELO-NEI.nKOSIS). 
 
 Tub tern> pyo-nephrosis designates dilatath.n of the 
 
 nelvis of the kidney with pus. . 
 
 •^ T , » v.-Th,;.on,r,tio.. is lial.lc to aris. ,luru,^ any 
 of « '"n,,.nra,ivo i„flan>n„v.u.n» of the kLlnoy or ot the 
 mucous membrane of the i)elvis. 
 
 The pathology must ditter according to the cause. The 
 
 ' 13» 
 
 ^■Ai 
 
160 
 
 DisK.isr:s OF riih: KiDsr.ys 
 
 IK-Ivis will 1... .Iis(..„.|..,| will, |M,s uh,.,u.vc.r i(s i-sriipc. is 
 pri'Viiilcd l»v (tltstnicti.iii in ilic nii-ttT. 
 
 SvMiTuMs.—Tlu. sviii|.t..riis w,. haw alica.lv .IctaiU.l 
 uiidrr the li.a.ls ..r the viiiioiis .imscs ,,f til,, .lisi.asv. 
 
 The .■l.iira.t..nsii,- ,lia-Mu>tic Icaturv in this .•oiwlilioi, 
 
 IS Ihi. p.vmia, |.r..vi.|...l th,. urctor Ik- |.cTvi.,iM. Whrn 
 
 iH'th l<i.|ii..vs aiv ii.v..|vnl, tl... pus ii, the mi.u. is .•,.„- 
 
 Hti.i.t. Whri, ..Illy u),.. k-i.liu.v is <lisi.as(..l, tho urin,- may 
 
 1)«' V..I.I..I li„i„ the healthy kidury an.! W pcrCMtly th'.. 
 
 th.m |.Ms t;.r .lays, (lu. pus that aciiiimlatrs in th".- .li.s. 
 
 I'lis.'.l ki.hu-y os.apiiiu intiTiiiittciitly int.. tin- l.la.l.l.r. 
 
 _ Tho iiriii,. s...-ivfnl issoiiL'timcs vcfvsinall in aiiminit, 
 
 jiist oii...i,-h to .liiw tlu' pus thn..ii;h ihr dis.aso.l nivt.T 
 
 on.'.. ..!• twi.v a wook. Sh..Ml.l tl... rnvt..,- Ih..(..,u. ,..mi- 
 
 pK'U'Iy .»l.stni.t...l th." py.)-m.plM-..sis i„iirhf i;,rin a ....ii- 
 
 Hi.l.'i-al.l.. liiiiKM-, it) uhi.h case its .lia^'uosis \v..ul.l ho 
 
 l)ost mad., hy aspication. 
 
 As a nik., ill pyuria then, is no irmit ditH.-nltv in 
 makinir tli.' (litll'iviitial diairnosis iK.twfi.n pus fn.m" the 
 ki.lm.y an.l pus n-..iii th.' hla.I.l..|-. Th.. pain aii.l l..n.l..r. 
 tii'ss ,.v..r th.. iviiidii ..f tlu' l.la.l.l..!-, with tVe.im.nt an.l 
 pamliil mi .tuntion, ..n fh.- ..nc han.l, an.l th.. pain an.l 
 t'nlari;,.m..nt of th.' ki.ln.'y ..n the ..tlu-r hand, will ir,.„. 
 orally he siifH.ienf t.. ..iiahle us to make a .liairiiosis. '^ 
 TliKATMKNT.— The treatment is essentially sur<,n.'al. 
 
 OirAPTEH IV. 
 
 lIYDnO-XEPIinosiS (HYDUOI-.S RENALIS— HVDUO-NEI'IIKON). 
 
 IIvniD-NEPiiKosis, or an ueeumulation of urine in the 
 polvis of the kidney, is the result of obstruction of tho 
 ureter, and is generally unilateral. 
 
 iJjM 
 
 ■■JrttiititaiiiiyMliMi 
 
 riM 
 
^ 
 
 iiyniio.\h:i'iinosis. 
 
 i:.l 
 
 I'ly <KtaiU<l 
 lisoaso. 
 Is •'oiiditioM 
 •lift. When 
 riiif is cdii- 
 .' iiriiif II lay 
 'l-rcitly free 
 ill the tlis- 
 lila*l(l( r. 
 
 ill Mlllnllllt, 
 
 asud nrt'tvp 
 '••oiiii' cdm- 
 •rill a con- 
 
 i Wolllil IiU 
 
 lifKciilty ill 
 IS from tlio 
 111(1 tciidor- 
 'qiu'iit am] 
 ' pain and 
 I, will iTc-ii- 
 iiosis. 
 finical. 
 
 JEPIIHOX). 
 
 ine ill tlio 
 ion of tho 
 
 Ktini.odY. — Olistnictioii of tlif iii'ctcr fi-om lui.v .iuisr 
 wliilf iIh' kidiii'V \r* ill a comlition to scri'ilc iiriiif will 
 produce dilatation of tlie pelvis, or li_vdro-ne|ii osis. Im- 
 pii.ted stom- and strietiire of the ureter the result of in- 
 llaiiimation are fretiueiil eauses. Strietiire of the iirethrii, 
 or irrowtlis in t\u' Madder olistrnetinj; the ureteral open- 
 imr-'. will t,'ivo rise to a hilatorai hydro-m'|tlirosis. Inllam- 
 matioiis in the jielvis prodiieimc eontraetioii ami olditera- 
 lion of tlu' ureter, or eiineer in tiie altdoniinal cavity, may 
 involve tin" ureter; ami sometimes lariro alMlomiiial tumors 
 press upon and olistruet if. In other words, the olistnic- 
 tion may 1k' in tin- <aiial of the ureter, may ho caused l»y 
 disease of its walls, or may hf the result of pressure 
 oxerteil extt'rnaily to it, of trrowths at tho hase of tho 
 liladdor, of hypertrophy of the prostate, or even of 
 phimosis. 
 
 l*A'ril(ii,o(iv. — Whatever tho causi' of tho olistruction. the 
 aoeumulation of urine in the pi'lvis distends it to a ucreater 
 or U'ss extent, and |U'esses upon the papilla*, eausinu; their 
 llattenins; and iii<lnration, and atrophy of the kidney 
 tissue. Tho ealieos are o!»literati'il. ami notliiiiLr may Ite let't 
 of the kidney hut a cortical shell. This internal pressure 
 «oon stops the seoretion of urine, and honeo prevont.s any 
 inoroasc in tho size of the tumor. Sonn- patholoj^ists are 
 of the opinion that after llio Hoerotion of urine eoasis 
 tlio tumor iiicroasi's slowly in si.-'.e from soerotion l>y tho 
 mucous inemhrano. 
 
 Sy.mi'To.ms. — The general history of the aymptoms is 
 that of disease of the hladder, alMlominal tumors, or im- 
 paotion of a renal caliulus, which <-auses tho ohstriic- 
 tion, and the tlnetnatiii<; tumor of liy(lro-noi»hrosis is the 
 j)atlio_ifnonionie symptom. 
 
 I)lA(iXosi.-.— Tlie diti'erential diagnosis is determined hy 
 aspiration. 
 
 ■ I ■ ^■ l. ' JW "*' -" * ? ' ■ '■' 
 
U2 
 
 nisH.isHs or Tin: KinxKis. 
 
 li 
 
 I'uoiiNosrs. — TIk' |iri)jrii(isis i-t trt'iiirallv Hrrioiis, Ix.tli 
 fViMu the lint fil' the ilisiiitcirmf ioii lit' ilic kiiliHV, and mu 
 
 ai'i'Uimt of" till' (•||l|<c IM'oiIlhiliir tile <(»lnlil'nui. 
 
 'riti:\iMi;Nr. — Uniiiivc tin; (aiisf wluro iio^^^ililc (St'u 
 C'lia]it('i' oil Siirgt'iT.) 
 
 err APT KR v. 
 
 I'KKINi:niKITIS. 
 
 I'lnuNKiMiurris is an iiillaiiiiiiatinu of tlu' rdliilar tissue 
 and adiposi' capsiiK' suiToinidiMi; the kidney. 
 
 Iviiui.otiV. — It may he caused liy iiijurii's, sueh as falls, 
 hlows. Wounds, ete., Iiiit is usually llie i-esult of su|i|iura- 
 tive iiitlaiuniatioii of tlie kiiliuy or its [ulvis, or ut' pelvic 
 Htones wliiili have caused uleeiation or ]ii'rfoialion. 
 
 Tuhereular kidney is ofteu aee(un|ianied hy |)erine|thri- 
 tis, and intlatuniation may s|ireail from other ortrans to 
 the adipose capsule (»f the kiiliiey, as sometimes happi'iis 
 in perityphlitis or lunihar aliscess. 
 
 Symptoms. — This conditiou is usually ushen'd iu hy a 
 chill or recurrent chills, followed hy rise of •■■mpt'ratui'e, 
 with pain, swellinii', and tt'iidcriiess over the n iiioii of the 
 kiilney. Any motion of the hody aLri^ravates the pain. 
 
 There is likely to he fre(|uent micturition; hut the con- 
 dition of the urine (K'pends upon the state of' the kidiiev 
 rather than ujion the perinephritis. 
 
 Sujipuration will soon take place, and often an ahsccss 
 can lie distinctly felt and easily diatrnosed. 
 
 At times, howi'vcr, tin- pus escapes a](»ni; the jtsoas 
 muscle and prcsi-nts itself undi'r I'oupart's lipiment. It 
 may find its way into the pelvis of the kiihiey and escape 
 
 itaai 
 
rinrmis 
 
 i:i;J 
 
 crioiH, liMtli 
 
 liicv, uikI Mil 
 
 lliiliir tissiu' 
 
 iK'li as lalls. 
 tit' sii|i|iiira- 
 <•!• of pflvic 
 atiiiii. 
 pi'tiiii'iiliri- 
 
 I' nriTiillS to 
 
 US lia|i|ii'iis 
 
 rill in hy a 
 "iiilitTatiiri', 
 li'iitii (if ilio 
 tlic |iain. 
 Mit the ('()ii> 
 till- kidney 
 
 t an a1)soi'Srt 
 
 r the psoas 
 
 ^anient, ft 
 
 and escape 
 
 with tlif mint', and it lias onasinnally Imtii known to pif- 
 t'oiatf tlif diaphiaLrin and fscapi- tliroiiudi tlic Innu's or 
 opiii into the liowt'ls or the alxjoininal easily. 
 
 I'ltiniMtsis. — The prot^nosis is serious nnle>s the di-ea-M' 
 is the result of injury. The very tiiet that it is so often 
 secondary to suppuration ot' the kidney niak«s the proi;- 
 no>is unfavoraldc. 
 
 Titi; mmi;n T. — The indications for treatnient depend en- 
 tirely upon the cause. In cases of injury, cuppinu- or 
 leechinL;, followed l>y hot or cohl appli<ations, may he 
 t'oiind iiecessarv. The pain may necessitate «»piafes, and 
 the li'Vi'r antipyretics. As soon as suppuration is appar- 
 «'nt, nephrotomy is indi<'ated ; aii<l when the perinephritis 
 is prcifded hy suppurative nephritis, nephrcctoiiiy hecoincH 
 not only justifialdi' hut even imperative. (See chapter on 
 Sur!;ical Kidm^y.) Tlu' striitest diet must he eiiioincd, 
 especially in injuries involvin<; the kidiu'y. 
 
 ('II A pTKit vr. 
 
 t iii:ti:iis. 
 
 UuKTKniTis is prohahly never primary, hut tlu' result <d" 
 iniIammati(Ui spreadiiiiC from the hladihr, frmii tlu' pelvis 
 of the kidney, or fnuii the ahd(uninal origans, or of the 
 passajje of renal calculi. There are no symptoms, suhjec- 
 tivi' or objective, hy which \\v can dia<rnose a special in- 
 Hammation of the un-ters. 
 
 They are prohahly always more or less involved in the 
 ahove-named conditions. 
 
 OhsU-iirlinn of the Ureters, — One of the most common 
 causes of obstruction of the ureters is the impaction of a 
 
 
1 
 
 IM 
 
 msH.isF.s Of Tin: i\Ut.\h:ys. 
 
 1 1 
 
 Htttiif ill its iiiis-iii^c Iriiiii tlic inUi-* III ilic l<iiliii\ ; or tlu' 
 nlt;.rnittitiii iiiiiv I"' raii:*fil • \ u -tii<tiiif of tlic iii« tif the 
 
 ri'Klllt ol' illthllllllliltioM |i|oi|l|r.i| liV tlic |.;lssil>:r of il cal- 
 
 iMiliiH. Ill tiilifrtiilosis of tlif kiiliiiv of of tlif liliuliltr 
 til*' wall- of tlif iirt't»Tr< an- tliitktinil am' irnufiilar. -ohh- 
 tiiiirs (•aii>iiiLr ttiii|ionirv olistrmtion. Nfw i;ro\vtlis in llir 
 lilaiMi r iiiMV oli>lru<t the oiific.' of tlic iirct'Ts, ami tumors 
 ill llif alMloiiu'ii or pi'lvis caiisi- oli^trmtioii from iin>?*m'i', 
 while caiKcr may iiivailf the iin-tfr ami closr it. 'I'lu- 
 uri'ti TH ait' o(ia->ioiiail_v acfiilciitally ciicloscil in liiratiin-rt 
 iliiriii<; livstfrciloiiiy ami o|M'ratioiis for ovarian or ollur 
 pi'lvi.' tiiiiiors. Till' s_viii|ttoiiirt rt'siiltiiii; from oli^trmtioii 
 of till- |iassa)X<' of iiriiif would he pain from distiiitioii of 
 till' tiilii', ami liytlro-mplirosis, or. in sonic casis, rii|itiiri' 
 of tlu' luvtor ami I'scapi' of uriiu' inl«i tln' alMloiuinal 
 
 cavity. 
 
 I)il,if<i/i'on can rt'sult only from olistrmtioii. 'Plif un-tcrs 
 uri' soiiiftiiiu's (•iiormoU'ly dilatt il ami tortuous. 
 
 l\ri'in-iitli)ii. — Pfrfoiatioii is most likely to lie the result 
 of eaiieeroiis in\ olveiiieiit or ot' nleeratioii from im|iaeteil 
 stone. Oeeasiolially the ureter is aeeitlelitally opemMl 
 (liirini: operations. In anycuse the urine eseajies into the 
 alxlomiiial cavity or the eellular tissiu', jirtMliieiiig serioiw 
 ri'sults, if not death. 
 
 Jl'/l-ir/m/iliif ,niil Ali'»i>li;/. — In tuluTenlar disease of the 
 kidney we find the ureter j^reatly eiilarijed and thickened, 
 which condition, of course, is not a true hypertrophy. It 
 is doulitful whether we ever meet with a true hypertrophy 
 <if the ureters; thouirh it is hari'ly possilile that the <-on- 
 (litioii niiirht occur in diahetes or partial olistruction. 
 
 The ureters ai'i' often atrophii'd, and sometimes com- 
 pletely ohiiterateil, throULth disea-c. 
 
 Milfitnmitiiins. — Occasionally in tin- dissectinjf-room or 
 ut post-niortfUis malfornuitions of the ureters arc r.x.'t with. 
 
Imv : tir tlic 
 ic nitt( r till- 
 >llf«' nt' u mi- 
 tilt' liliiiMtr 
 i;iiliir. -Hiiir- 
 
 (iWtllS ill ihr 
 
 , :iiiil liiiinirr* 
 III! |iri'>suri', 
 i»-c it. Till' 
 ill liiTiitiiri's 
 riaii or otliiT 
 I (ilistnictiuii 
 listiiitioii ut" 
 ;isi's, rii|)tiiri' 
 I' iiliiliiiiiiiiiil 
 
 'I'lif urcttTx 
 us. 
 
 1m' till- nsiilt 
 mil iiii|iii('t*'il 
 tiillv oikiumI 
 ai't-'H into the 
 luiiig f^iTimirt 
 
 lisciisi' ot' till' 
 1(1 tliickfiii'd, 
 iTtropliy. It 
 liy|K'rtr()|tliy 
 that till- I'oii- 
 nictioii. 
 U'tiliU'S rolii- 
 
 tiiij;-rt>(ini or 
 arc iiM't with. 
 
 sruuir .. Tin:rnth:sr <>r rm: lansrys \■^:^ 
 
 'I'll. V hasv hr.u lomi.l. our or Loth. imiKTvi-nis at hiith. 
 (),.,. ki.lii.-v i...i.v haw two urrt.-fs, or th.r.. ma.v h. two 
 ,V„M, o.H. ki.ln.'V whi.h miit.. iM.fori. ....t.r....; i m' Ma-hhr. 
 Th.-.v an- ..f no |.rarti.al im|H.rlanrc', i-xivpl wh.n uupi'f- 
 vioii-, ami in alMloininal »*iirj.'i'i\v. 
 
 in 
 
 CJIAPTKU VII. 
 
 81 IKM.'M. TUKATMKNT ol' illK KILNKYS. 
 
 T.iK operations for tin- sin-i.i.l tr.alnnnt of lli.' Unhu-vs 
 .,yl.f .l.si-natr.l as follows: aspiration, nrpliiorrhapliv, 
 nephrotomy, nrphio-lithotu,„y, ami n.phiv.tomy. 
 
 ASIMItATloN 
 
 Aspiration is tvsort.-l to in .asis of si.iipl.' or hy.lathl 
 cyst,, or of hy.lro-nc.phrosis. ("uros hayo hoen .fh-tiil, 
 i,\ tlu'se .US.USI.S, l.y a.-i.irati..n alon., or in .oiipnution 
 ^vithio.^.n..inil•.■tions. WIhiv animation fails,nii.hrotoniy 
 i. iiMially ivs.'.rti'.l t... Sliouhl this proy*. in.thTtnal tin- 
 ,i„^,, „„n,al M.rans still ivinains to ,H,-nani.ly, ni-phiv.- 
 \. a ni.'aiis of .liairnosis or to prociin- ti'iiiporary 
 
 toniy. 
 
 n.ih.t; wi. u^. aspiration .n .'Usls of al.s.vss, pyo-n..,.hro.,s, 
 „r tulu.,vular khlm-y. It is .-ortainly of ^Mvat n,iportan.-o 
 as a nu.tho.1 of .lia^'nosis, ...lahlinir us to .l.thtvnt.atc. 
 '>.twi-i-,i hy.lro-ni.pl.--osis, pyo-imphrosts, ami sinipli. or 
 hy,l. till .'vsts. Till- small i-ysts of .•hron.r tnl-ular or 
 int.rtul.ular m.pl'n'''^ ">-*' ""'^ ^" '"' '"M-initiU. Inta.t, as 
 ,v.. hayi" s..i.n, it is impossil.lr to aia.rnos. tlm.r ex.ston.e. 
 Mnnni. OK Asi'iK.vnoN.-lt is almost supiTtlmms to 
 nav that tho skin wluiv tin- pnnrf.iv is to la- nia.K-, ami 
 tho nt-L-illc to he use.1, must ho ahsolutely usi-ptic. 
 
 ■I 
 
ff 1 
 
 1 
 
 h 
 
 i.-.t; 
 
 i>isi:.ts/:s or riii: kidskvs 
 
 :i 
 
 1 |iri'li r ;i irocur lu'cillc iiiid the liottli' or Allen iis|iir;it<)r 
 ('X«'('iit tor (liiitrnostic or fX|(l<iriitorv |iiir|ioscs. In iiitro- 
 
 • lllrini; tlic llccdlc oili' must he ciircl'lll to kft'|i outside of 
 the pctitotifUIu ; otluTwise tlic iliti'stilies luiiv he iujuri'd, 
 or when tlie iieeclle is witlidrMWii the eyst nuiy dniiii into 
 the ahdoiuinid ciivitv. We must reniendur th;it the left 
 kidney is a little liii;her than the riti'ht, and that tho 
 neeille should he introduced lower on the riifht sidi- to 
 avoid the liver. \o very iiw-M harm, however, would ho 
 likely to ri'sult from jiiereinir the lower marijin (d' the 
 liver. I fre([uently aspirate the liver for hypenemia, with 
 very siitistiU'tory results. In numy eases of cysts, pyo- 
 ni'phrosis, or ahseess there is a jirominent soft tluetuatint^ 
 point which readily indicates where it is hest to introduce 
 tho noodU". M(U'ris advist's enti-rini; the needle just 
 anterior to the last intercostal space for the left kidney, 
 hut lower and farther hack for the ri<;ht kidney. 
 
 '* If there he no indication for operatini^ olsewln're, the 
 l)est s]iot to select wlu-n the tumor is of the ri<;ht kidney 
 is one half-way hetween the last rib and the crest of the 
 ilium, hetwei'U two inches and two inches and a lialf 
 behind the anterior superior spine of the ilium. This 
 spot is on a level with the front of the bodies of the 
 bnnbar vertebne, and a needle here ])asse(l horizontally 
 inwards will be alto<;t'ther in front of the normal kidney, 
 and will either transfix or pass in front of the ascendintj 
 ecdon when in its usual place. It may, however, with 
 safety be conjectured that in any ease of hydro-ne|»hrosis 
 of tho right side requiring to be tapped, if tho troi-ar lie 
 insi'rted at the ])lace I jtropose, and directed somewhat 
 forwards, the ])eritonenni and' colon will be sufficiently in 
 front to eseaj)o injury, the liver will be safely out of reach 
 above, and tlu' kidney behind, while tho dilated pelvis of 
 the kidney will be tap[ted at its anterior and lower part." 
 
 lU*. 
 
NEl'lIKfUUllWIIV- 
 
 157 
 
 II as|)ii':it()r 
 III iiifro- 
 
 (lUtsillc of 
 
 Ik- iiijiiri'd, 
 (Iniiii into 
 ilt the left 
 I that tlic 
 i;lit sidi- to 
 , would lie 
 ixiii of t!io 
 I'lnia, witli 
 I'vsts, ]iyo- 
 lliictiiatiui"^ 
 I introdiicu 
 (■i'<ll(' just 
 ft kidney, 
 
 wliiTc, the 
 flit kidiU'V 
 rest of the 
 nd a lialf 
 um. This 
 ies of the 
 jrizoiitally 
 lal kidney, 
 ascciuiiiiif 
 ■ever, with 
 i-uejilirosis 
 ' troear be 
 pomewliat 
 [leiently in 
 it of reach 
 1 pelvis of 
 vver part." 
 
 liaviiiu^ seUvted the spot at which to introdnee the 
 needle, it" is lu'St to use tirst a hypoderniie injection of 
 eoeaiue and in.'ise the skin with a bistoury, aft.'r which 
 the nee.Ue can he pushed easily throu.u-h the soft tissues 
 without dantrerof plun,-;in,-r it farther than is necessary. 
 It is often necessary to make repeated aspirations in eases 
 nf hvdro-nephrosis l.i'f<.re a cure is effected or hi'tore 
 rcsurtini,' to nephrotomy and draina,-re or nephrictoiuy. 
 
 NKPHIloUUHArilY. 
 The surtrical operation for tlu- fixation of a movable 
 kidiU'V is .-'ailed m'phrorrhaphy. The etiolo.uy. symptoms, 
 and diairnosis of movable kidney, as well as the morpho- 
 loiiical difference between it and tloatint; kidney, have 
 already been studied in the chapter on Anomalies of the 
 
 Kidliev. 
 
 There can be no <b.ubt about the propriety of resortniif 
 to nei.hrorrhaphy when the imin and discomfort of the 
 movable kidney become very .irreat, when the mental 
 anxietv is tellinjr seriously on the ^ijeneral condition of the 
 patient, when life is in dansri-r, or when relief is not 
 afforded by the use of banda,!res and i.ads as already 
 
 advised. 
 
 The operation, however, is not unattended by danjrer, 
 which makes an intelli,i;ent trial of all other appliances 
 for relief of jrreater iniportanee. The oi>eration is a 
 comparatively new one. Ilalin of Berlin, in IHSl, was 
 probably the first to perform uephrorrhaphy. ^fany 
 surtroons, l>oth in Europe and in America, have since 
 performed this operation. 
 
 Professor Keen, of Philadelphia, rev.orts four eases 
 operated on by himself, and ;;,nves a synopsis of one hun- 
 dred and thirty other eases operated upon in this country 
 
 and in Europe. 
 
 14 
 
 mamM 
 
h I 
 
 ir)8 
 
 I)Isi:asi:s of the Kinsins. 
 
 Tait ri'ports tliivf cast's dt' tu'iilimrrliaiiliy in tlu' British 
 Muli,;il Jtiiirmil \'ov ISSit. One patit-iit died, aii«l tiii' ntliiT 
 two WHTo not l)i'n('titod, Tait lias oxjirfsst-d hiiusolt' as 
 tlioroniflily distrusted with the operation. 
 
 Mktiiod. — Since Hahn's first operation, indivichial oper- 
 ators have nioditied liis method in aeeonhuiee witli thi'ir 
 i>wn views. 
 
 Till' operation of nephrorrhaphy is neither very ditK- 
 eiilt nor attended with nimli damper. AVitli ordinary 
 eare the only accident likely to happen is that of openini; 
 into the peritoiu'al cavity, which in itself would not he a 
 vi'i'v serious niatti'r. It will scarc»'ly hi' possihle to mis- 
 take the liver for the kidney, as the liirhter color of the 
 latter will he reco<;ni/,ed. When there is any doulit it 
 will only he necessary to follow with the Hn<;er the out- 
 line of the origan in ipiestiou. 
 
 The patient should lie on his sound side, i>ver a pillow 
 or support, in order to make the distance hetwceu the 
 crest of the ilium and the last rih as jrreat as possihle. 
 IFo shoidd also he in such a position that a i^ood liirht 
 will fall into the opeiiiiiir. 
 
 A competent assistant should stand on the side oppo- 
 site the operator and confine himself entirely to pressing 
 the movalile kidney toward the incision. 
 
 The following is (juoted from Prof. Keen's excellent 
 monograph on the suhject : 
 
 " An ol)li(pu' incision is made hetween the last rib and 
 crest of the ilium, heginning ov>'r the outer hordev of the 
 (juadratus lumhorum. Rarely, i*^' ever, will a rih have to 
 he resected to gain room. The ettge of the muscle heing 
 recognized, the perinephric fat i^ fo'in.l 'vrimediately 
 at its outer horder. This fat having 1'>en .ut or torn 
 through, the kidney may he seen at oi.ce. 
 
 " If it is a movable kidney, but not displaced too far 
 
 ^iM 
 
NKrUROlilUIAPlIY. 
 
 169 
 
 tlu' British 
 
 1(1 till' ntluT 
 
 hiiiisolt' as 
 
 kidtial oiH'i'- 
 ,' with tlK'ir 
 
 • vi TV ilitH- 
 )i (inliiiary 
 ot' o|iuiiiiiu; 
 lid not 111' a 
 ililc to iiiis- 
 rolor of the 
 iiv th)iil>t it 
 jer the out- 
 
 viT a pillow 
 
 ii'twi'i'U the 
 
 as possible. 
 
 1 jfood lii^ht 
 
 ' side ofipo- 
 ■ to pressini; 
 
 I's fxeelleut 
 
 last rii) and 
 lordi'v of the 
 I ril> have to 
 iiusvle heing 
 immediately 
 
 L-iit or torn 
 
 need too far 
 
 from its normal position, the movemontw.il be se.n to 
 W svnehronous with the respiration, and may b. very 
 wide in extent. Uut if tli. ki.l.iey he far away tion, ,ts 
 ..ortnal position, it will not bo seen wlu-n the pi'muphne 
 fat is torn throu,,d,, but nmst b. sou.irht tor, not o.dy b> 
 the tinu^T in the wound, but also either by the hand ot 
 ^,,^. . ;,,,tor or the assistaut. on the anterior abdomma 
 wall, i.i order to push the kidney baek toward ,ts normal 
 
 ^'''wheu the kidnev is not easily reaehed and eannot be 
 pro^^e.! up into tlu' ineision by the assistant, it may be 
 ,„„l<,d bv a tenaeulum or draw.i up by a volsellmu. 
 llavin- drawn the kidney into the ineis.on, it is h.ve.l by 
 
 sutures, eat.irnt or silk. , , v . ,„i.. 
 
 The sutures mav be passed throu-h the adipose eaps le 
 alone, as llahn di.l in his tirst operation throu-h the 
 fibrous eapsule or the eortieal portion of the kidney, wink- 
 some operators have ineised the eapsule, stripi-ed it ott, 
 ami passed the sutures th-tr-i.^k the eortex. ^ 
 
 The kidnev slmuld be fixed as nearly as possib e in it. 
 normal position. Both the lower and the upper eud should 
 be secured, whieh will make it less likely to i.iove with 
 the respirations or the other movements ot the l.od>. 
 From three to six sutures are usually employed. In passni.t; 
 the sutures throu-h the ed-es of the ineision they should 
 include a firm hold on the muscular tissue. 
 
 Some operators have passed the sutures around the 
 lower rib, a plan that is certainly not advisable. In the 
 matter of sutures, silk will probably give the most satis- 
 
 faction. , , ^ i u „ , 
 
 " The question has arisen whether the sutures shall re- 
 main temporarily in place, or whether they shal be lett 
 permanentlv. I have little doul.t as t<. the .lesirahilitN ot 
 leaving them permanently, but in doing so we must re- 
 
ItlO 
 
 Dl.SEASKS OF Tin-: h'lD.XKyS. 
 
 TiifiiilKT tlio lari;i' niiiii^or of silk Iiir:ituns tluit liavt- ^ivon 
 risf to siiltsi'(|iii'nt tniulflf, ('s|icciall_v in iil>il(iiiiiiial siii-sj:*'rv. 
 It is iiii|>()ftaiit. I tiiiiik, that the silk slioiiM lie as tiiio as 
 j»()ssil)h', lint tliick I'lioiiirli to In- stroll;;."' (Kcfii.) 
 
 Siiiiif opcratofs leave tulies tor drainage in tiu- wouih', 
 wiiile otliers close tile wound with sutiiri's, hut the most 
 satiKliietorv method is to leave the wound oiieii and dress 
 it with ixaiize. 
 
 The after-treatment does not difier in aiiv way from the 
 tisual methods ohserved in all woiintls of like eharaeter. 
 The patiiiit should he ki'pt (|uiet for from four to six 
 wi'eks ; and it is usual to applv an aeeurati'ly-tittiiiir haiid- 
 aire, to he worn lor several months atter the patient is on 
 his feet. 
 
 NKPHIIOTO.MY. 
 
 Nephrotomv, or ineisiiiLT tlu' kidney for the purpose of 
 evaeuatini; pus in suppuration of the ortraii or of t)iK'nin!j 
 cysts, is resortecl to undi-r the following: eonditions : pyo- 
 nephrosis, nephro-pyosis or ahseess, oiistruetion of the 
 ureter hy a calculus, tuhereular kidney, and such cases of 
 simple cysts, hydatid cysts, or hydro-nephrosis as have not 
 boon cured by asjiiration. ('uttiii<r down upon the kidney, 
 but not into it, is necessary in ]>eriiu'phritis. 
 
 Where an operation is re(|uired, eithv'r for suppiurative 
 disease or for cystic conditions, we may tind the tluid so 
 near the surface that the indications for incision are aj)iiar- 
 ent. AVhere no such indications exist, we should place 
 tile patient in the same i>osition atitl make our incision in 
 the same manner as directed for nephrorrhaphy. Always 
 bear in mind when makiuir the iticision that drainaire will 
 ]>(' necessary, the tubes to be placed in the most dependent 
 portion. 
 
 When the i-yst-wall is not firmly adherent to tbe renal 
 tissues it may be necessary to bring the cut surfaces of the 
 
 ^Mi 
 
SEI'linoroMY—NKnina-I.ITIIOTOMV. 
 
 161 
 
 liavf ^ivt'ii 
 
 lal siiririi'V. 
 
 )i' as tine as 
 
 ■i-ii.) 
 
 till' wouikI, 
 
 it till' most 
 
 II and ih'L'ss 
 
 \\\ t'l'diii lliu 
 .' iliarartor. 
 four to six 
 ittinir hand- 
 tatioiit is on 
 
 imrjiose of 
 of oponina: 
 itions : pyo- 
 tion of the 
 U'li casos of 
 as liavc not 
 the kiilnoy, 
 
 snpimrative 
 the tlnid so 
 n are ai)|)ar- 
 hould phioe 
 r incision in 
 y. Always 
 rainai;e will 
 t dependent 
 
 to the renal 
 faces of the 
 
 walls to the inaririii of the opening;, to whith they whould 
 he attached, if more than one ahseess is found, the smaller 
 one-; may lie punctured with a nee<lU', the openin.i^s dilatid, 
 and a drainai^e-tnln' plact'd in each. The jjjri'at ohjcct is 
 to Sicnrc a free evacuation of the pus and at the sann' 
 time atlord the tncaus of antiseptic irrigation. 
 
 Alter i\'acliin<^ the ahsci'sscs there will not prohahly he 
 mn<li lieniorrlia<i:e, e.xeept in cases of tubi'rcular kidney, 
 when the remnant of renal cortex is very vascular and had 
 hettir be torn with the tintjer than cut with the knife. 
 
 Small I'ircumscrihed ahscessea are generally reached l»y 
 exposing tlie capsidi' and j>uncturing with a line as{)iratinsf 
 needle until pus is found: the punctured n|iening may 
 then he dilati'd and the cavity waslied out and drained. 
 
 NEPHUO-LITIIOTONJY. 
 
 Xephro-lithotomy is the term ajiplied to the operation 
 for the removal of a calculus from the kidney, its pelvis, 
 or its calices. 
 
 This is probably the oldest o|)eration made upon the. 
 kidney. It was recommended by Hippocrates; but it is 
 doubtful whether in his time the operation was undertaken 
 for the removal of stone except where pus was present. 
 
 Xeiihrodithotomy is indicated in cases of troublesome 
 h;e!naturia or great pain and distress in the region of the 
 kidney which can be relieved only temporarily by medical 
 treatment and which are believed to be caused by the 
 presence of a stone in the pelvis of the kidney. 
 
 At best the diagnosis cannot be positive. The hamia- 
 turia and pain may depend, as we have already seen, \\\)o\\ 
 other coiKlitions. When these symptoms are present and 
 the patient lias had previous attacks of renal colic and 
 passed gravel, or where small particles of gravel are con- 
 stantly passing from the bladder, as we sometimes see 
 
 mm 
 
lt;2 
 
 DisK.isr.s or Tin: kidm'.vx- 
 
 wla-n tlHTc is a riiKulus in tl.c hhuldcr ..r in the pelvis of 
 tlu' ki.liH'.v, the .liutriiosis is iit least siiilirii'iitly .•.Tlaiii to 
 warrant tin- operation. _ , , 
 
 MKTHuu.-Thf Ui.lney is i'XiK)se(l by tho lumbur incision 
 
 Kfiial I'ulculu.s. 
 
 and carofitlly oxaminod with the fino^er for eirenmserihed 
 indurated spots, either in tlie oortex or in the pelvis, that 
 niisrht indicate the presence of a stone. 
 
 ikM 
 
M-:i'iii{r.< Tn.My 
 
 lt;:{ 
 
 1 the pelvis (if 
 lilly tHTliilu to 
 
 imliiir incision 
 
 3) 
 
 '7 
 
 »r eircumscrilnd 
 . tho [ic'lvls, tluit 
 
 'riic IvMiicy i':m It prt^sfil u|i to the tuiirfr «>l' \\n- 
 opmitor l«y an iis>istinit, as In nciilir<irrlia|.liy. it' .xanil- 
 nation l),v tlif tiii>rtr atlunis no inili<'atlou of tlic stonr, tli.- 
 kiiliH'V niav !(«■ ininctnrfil \>y a lini' nfftllf ; or if llif tiiii:*'!- 
 discovers an induratnl spot, tlu- ncfcllc may ln' nsc.l aUo. 
 In many <'asi's, liowrvcr, tlic stimc will prmlncf suppu- 
 ration and Ik- finlu'ddfd in an al>s<'css, wliidi can I'l' easily 
 d.t.'.'Icd with till' linu-iT. I'nlcsrt several punctures are 
 niaile, stones will t>ftcn iscape detection. 
 
 Wlieii the stone is found it must lie cut down upon, ami 
 rmioved, either with a scoop ov with the fni,u-cr, ihrouirh 
 the ineision. or it may he seized hy a pair of foi'eeps. 
 
 Where the stone is very larLre it nniy he hroken and 
 removed in jiieces. The wound sho\dd he dealt with art 
 in nephrectomy and nephrotomy. The urine \isually 
 escapes for a tin\e throu^di the wound, hut should cease 
 tu do s<» in a few weeks. The specimen represented in 
 Fitr. IS weit^lu'd when removed foiirteen ounces,— the 
 larircst stone I have ever seen. It was removed hy my 
 confrere, Prof. R. A. McLean. Tlu" nuin was surt'eriiiir a 
 irreat deal of pain in the rejfion of his kidm-y, and had 
 pus in the urine. The kidney was enlarifed. On account 
 of the .un-eat size of the stone, it was hroken durinj; its 
 removal. The man was eomi-letely exhausted hy the 
 disease, and consequently failed to react after the opera- 
 tion. 
 
 NKrHIlECTOMV. 
 
 Nephrectomy is tin- term which desiirnates tho o]iera- 
 tion f(.r the removal of tho kidney froni the livin-r hody. 
 
 This operation is also comparatively new. Simon of 
 lleidolhori? first iiitentionally removed the kidney for 
 disease, in 18(in. Tho kidney had heforo hoen several 
 times unintentionally removed, tlie operators not sup- 
 
 marnm 
 
Mil 
 
 i)isi:.\st:s o/- Tin: KinxKi's 
 
 pusiii-r ill til*' liiiif tliiil iIk'V wvw rciiiovinu: it. Thcso 
 <.|i.i!iti.>ii> wtTc iiiiidf l>y iilMloiiiiniil st'ctioii. Simon si-cms 
 to liiivf l.tiii llir lirst t.t iii:ikf tin- liiiiil>iir n|M'iiiti..ii. 
 
 The ciiMs ill uliitli tlic o|irriiti(>ii is iiiiliiiiti-il aw tlu' 
 tuUuwiiiir: 1, iiiovaliK- ixitliu'.v in wliidi lu-plintrriiiipliy 
 has I'aiii'il !.• itiaiii tiic IxidiifV in tlir iiicisioii ; -J, wlu'iv 
 lu'iiliionliiipliy is iiiiiirafti<'!il>l»' iKHiiusc ()f tin- «lis(asc»l 
 (■..n.rnioii (.1' till' kithifv; :!, iiiuvalilc kiiliuy wlifri- w- 
 plirorrhapliy is iiia.lini>sil»U', as tli.' kidney raniiut lu- 
 pri'sstil up to or near its normal position and is I'itlicr 
 disi'aM'd or trivis rise to so mucli pain as to n-ndcr its 
 ronioval impcrativi- : 4, lloatiiiir kidney that iv(|uiri's an 
 operation I'itlu-r for disease or tor pain; ."..simple cysts, 
 hydatid evsts, ahseesses, or hydro-nephrosis which aspira- 
 tion and nephrotomy liiivo laiU'd ti> cure; »!, tuliercular 
 kidney when tin' conditions of other orpins will alh.w 
 of an (.peration,— that is, when tuherculosis is not pres- 
 ent or is not too far advanci-d in other ortrans, such as 
 tin- hladder, the testicles, or the liintfs, or when hoth 
 kidneys are not involved; 7. primary canciT, sarcoma, or 
 non-mali-rnant tumors; S, nephro-lithiasis when nephro- 
 lithotomy has faih'<l to afford relief on account of the 
 disori,nini/.ed condition of the kiilney; i>, very severe 
 wo-nds or injuries of the kidney, when to leave the 
 ki(:.iU'y would he danjrcr(»us to lite ; 10, pyi-litis or ureteral 
 urinary tistuhe. 
 
 Nephrectomy should never he performed unless the 
 operator is reas(»nal>ly certain that the patient han another 
 kidiu'y and that it is not diseased. It is not always an 
 oasv matter to diairnose positively which kidney is dis- 
 eased or that only om- is diseased. 
 
 I assisted at a nephrectomy not loniT as;o ; the operation 
 was done most skilfully, and the removed kidney was 
 verv nuieh disoriranized. The patient died three days 
 
SEriiiiKtniM) 
 
 HI') 
 
 iii; it. IlioflO 
 
 SiiiiuM mn'iiis 
 i|K'i'iiti<)n. 
 iiatcil an- tlu' 
 it'|iliri>nlia|ihy 
 *ioii ; 'J, wluri' 
 f till' «lis(iisi'»l 
 lU'V wluTo nc- 
 if.v caimot Ik' 
 
 aixl is litliiT 
 s to ri'iitlcr its 
 at rc(|uiri's an 
 1, siiii|tK' cvsts, 
 ■< wliicli iiMpiva- 
 
 <!, tulKTctilur 
 ans will allow 
 ■^is is not |»iH'.s- 
 (I'ijaiis, siiih iw 
 or whtii both 
 tT, sarroiiia, or 
 
 wliLMi m'i>liro- 
 in'coiuit of the 
 i>, vorv severe 
 1 to leave the 
 litis or ureteral 
 
 led unless the 
 
 Mit has another 
 
 not always an 
 
 kidney is «lis- 
 
 I ; the operation 
 •ed kidney was 
 lied three days 
 
 after the operation, when a posi-niortiin n-Vi'aled the tint 
 that tlie retnaiiiini,' kidiny was in a nnnli worse londition 
 tlian the one that had heeii removed. This, nnfortii- 
 nately, is not the only instanee of the kiml. 'I'lie east-s 
 in which the ditfeniitial diairnosis is found to he the most 
 ditlieult ari" those of pyuria where the pus is evidently 
 iVom the kidney and where neither kidney is eiilarired nor 
 one inm-h mor*' tender than the other. Several methods 
 have heeii suji'iTi'sted for diseovei'iuLr from which ureter 
 the pus is eseapini; into the iiladder. 
 
 Catheteri/inir the ureters has heeu resorted to. — a jiro- 
 eetlure that may occasionally lu' adopted, hut whi< h will 
 never he of much pra<-tical value, from the dilHculty of 
 its accomplishment. It has also Keen proposed to open 
 the hladder hy tin- supra-puliic operation and e'.ilur 
 eatlu'teri/.e the ureters or ol)serve the outtlow <<f pus. 
 A'Min, the eiidoscoiu' has heen hrouirht into re(piisition 
 and has sometimes yiehled valualtle infornnition. I>ut, 
 like catheterization, it will prohahly nt'ver come into 
 j;eneral use tor this purpose. 
 
 The kidney ean he cut down upon, exposed, and tx- 
 amine<|, hut as a <liairnostic measure this may l»e said to 
 be heroic; and should the kidiu'y be found to be diseased 
 there is a possibility of the other one beini: in a worse 
 eoudition. There must always be a small perci'UtaLre of 
 eases in which it is impossible to be absolutely positive 
 whieh kidney to remove. 
 
 It is somewhat surprising to find Morris makiui; the 
 statement that nephrectomy for cancer will probably be 
 abandoned. For secondary canci-r, of course, if shoidd 
 not he attempted; but for primary cancer, except in 
 younj)^ ehihlren, the operation will probably become more 
 ap]»reciated and will be oftener resorted to in the near 
 future. 
 
 ma^ 
 
ii'.t; 
 
 nisi:.\si:s "/• rin: k//'.vk)-.v 
 
 >a1 
 
 M . , Tl... ki.lii.v 'h us.mlly ivmovr.l l.y ..i... 
 ''"'■' :';ri^^i.-l..rn.rl.nVtou,v ana alHl.Hun.al 
 
 '^^V:" : ;;. i>.u.-v mIhI....! is tl -uaUy 
 
 |)i.rit.iii«uiii ii'Ti 
 
 t;l,L.. h,,.. .1..- M..l...uinM ...vuv W, l-ll. 
 
 ■ '<«-'••■'-'""!'■ ^■;';;;;,' ■;.,. ,---.- 
 
 • 1' 
 
 ("(iHlUli'lH-f till' 
 
 „.|„.m.v,T •.. will ..ll.-.- ll- ,-"■"'<-' ■ " \ I ,,. „„„. 
 
 •n- i^"i-.v 1; '^ ;;::;,■;::'';,,.,, iiHi.-..r no 
 
 ,,,,n„.rlM"-- II" «„,-,.,■. will, liul.- "'■ "" 
 
 ,.ust.mKirvto|.:\ss tlu' lii 
 
 ..ust.muiry to|.ass uu i>^- T'..- .UtHcultv of 
 
 this ,.1-o.H.auiv usuallN .1 1" MM _ M l»assinu' a 
 
 tviiiiX Olio faeli \miv l^ n'l- ^ui^-iv 
 
■-) 
 
 SI'.l'llltlU T'lMV 
 
 If.T 
 
 ril l>y I'll*' <>r 
 mil alHloiiiinal 
 „. ,iiic u^uiilly 
 i. lattir: K ''"' 
 iiii-rt- from tliii 
 riality is U'ss; 
 1^ oUviatfd ; '», 
 I viiiilfd. li"lli 
 
 lit tor iiriiliror- 
 atois, liowi'Vfr, 
 rst InntiitiMlinal 
 
 As sati>t'ai'tory 
 . till- iial'unt in 
 
 ("(iiiiiiu'i\fc tho 
 ACT ril>, niiiniu.i? 
 „,si' tlu' kiiliuy : 
 iK', if iK'ci'ssary, 
 
 t(. tlu- oju'i-ator. 
 
 JH ri atlily ''iiii- 
 H'vw littlr or no 
 ,•1, ..iivmiistaiu'i'rt 
 ^vitli littK- or no 
 wlu'tv tluTi' has 
 •V I'Utiivly airu'ln- 
 md llu'ir sfjiara- 
 
 rrliaiX*'- 
 
 tin- lijxatnri', it i^^ 
 lie nrt'tiM- and tin* 
 
 T'le- dilHculty of 
 > amount of adlie- 
 siu's. Tassinir ii 
 ■isnial Ui'odK" and 
 easiest nietliod. 
 
 Wlinv no adlu-sions exist, tli.> kidn.y is witlioiit dilli- 
 ndtv drawn n|> snllirimtly t.. all..\v tl..' liiialmv to lu- 
 ^,Y,'lM'i\ well down nj.on llie p.diele. so that on renioviiijj 
 iIh. ki.lnev enou.!;h «.f the pediel- will ivinain t,. pnvmt 
 thr iijratniv iVoii'i .lippin,-; otV. A seeoi.d lipitnre .an !..• 
 thrown over I ..■ mtire prdirh'. whi.h will add to it. 
 MTiirity. The iM.li.le >honhl then \n- divid.d and the 
 kidn.v nmov.d. The wo.md must he drawn uril opni. 
 iiiHl. with Ih.' ai.l of a ,-ood li.irhl thrown into ih.' '....tton. 
 ..I'llir iii.'isioii,«-very hieedin-r artery imist he liiial.'.l with 
 line silk or .atirnt. ' The iid'.iior renal artery is likely to 
 lie the most tronhh'some. 
 
 The liiriitures are «ut riose, the wonii.l is washed out 
 with an antiseptic s..hitioii. drained hy m.'ans of tuhes, 
 ,,n,l the in.-isi..n j.a.'ked with antisei^lir v^nnw or its »'<l,ires 
 l,rmiu;ht toirether hy sntnres. The patient sl.onld he kept 
 pcrfntly ipiiet, and ii hamla-j*' "•!• pad ai.plied when he 
 ,,,iiHm'm'es to walk ahont, as recommend. •.! in cases ..f 
 iiephrorrhaphy and nephr.)tomy. 
 
 Where ther".' is ,trreat dilH.Mdty in applyin.ir the li,i:aHires, 
 u stroniT Inenmstatic forceps with a well-curved handle 
 iiMirht (iiiviate the mri'ssity for a li.irature, just as we uso 
 the lontr-jawed forceps in hysterect..my without resortint,' 
 
 to a liii'ature. 
 
 Ahdominal nephrectomy is not often performed at 
 present, and is to he preferred in very few cas.s, .)ne of 
 which is for the removal of tloatint; ki.lney. It presents 
 (M.e a.lvanta.ire in the tact that the otla^r ki.lney .aii l.e 
 examin.'.l before the removal ..f the one (h'sired. The 
 usual incision in the m.-.lian line can he ad.^pted, or, 
 what is njore common, th.' incisiun alonir tlie .mter horder 
 ,,f the rectus muscle on the side from which the kidney 
 is t.. he removed. The operation in this case is to he 
 conducted (»n the same principles as any other laparotomy. 
 
SECTION IV. 
 
 DISEASES OF THE BLADDER. 
 
 (•II A I'TKU I. 
 
 AN.\H>MN <ir Tin; lll.AlUiKlt. 
 
 HilFoui'; fdiiiniciiciiiir llu' stmlv ol' tin' iialiiolnijiciil cnii- 
 tlilidiis of this ofLran it will ln' well to nvitw its iniiiripiil 
 aiiiiliiiniciil Itatiirts. 
 
 Tlic hladtU'r is a imisciilo-i'H'iiiliraiious sai-, siliiatnl in 
 til.' prlvis iK'twrcii tlic |.iil»is and ri'ctmii in tii*' iiial.' ami 
 iu'twci-n tlic |tnlii's anil vairina ami ntfiiis in the rmiaif, 
 its sliapi', position, ami ri-latioiis luinn' iiitlni'ncnl hy ai;f, 
 Si'X, and dti;rir of disti'iition of llif origan. In inliim'V 
 and rliildliooil it is conical in hIuiju', the vortical diameter 
 bciut; tlic lonirer. In the female it lias a i^rcatir lateral 
 than vertical iliameter. In old aire the vertical diameter 
 airain hecomes tlu' Ioniser, while in adnit life when t|niti' 
 empty and contracted it is triaiiirular in shaiie, place<l 
 deeply in the pelvis, tlatteiied from Itefore hackward, and 
 reaching; as hii^li as tl.c npper horder of the symphysis 
 pilhis. 
 
 When slii^htlv distended it is rounded in form and still 
 remains in the pelvic cavity, Imt when <;reatly distt'ndi'd 
 it hecomes ovoid and rises into the ahilominal cavity, 
 often as hiirh as the nmhilicns. 
 
 When moderat-'y distended it measure's about five 
 inches in leiiirth :Mid three inches across, and ordinarily 
 it contains ahoui a pint. 
 
 108 
 
 ^Ml 
 
>|u!;it'!il coii- 
 its iirlii<'i|iitl 
 
 ', siliiiiti'tl ill 
 lie male iiinl 
 I tile I'rillilli', 
 licril hy iin'f, 
 III ililiility 
 (111 (liiiiiutcr 
 ».jit»i' latniil 
 I'ul tliaiiu'trr 
 ■ wIm'Ii (|iiiti' 
 liaiii', plao'il 
 ckwanl, aiitl 
 I' syiiiphysis 
 
 )rin and still 
 tly (list»inlf<l 
 iiiiial cavity, 
 
 ^ alioiit livt." 
 1(1 otiliiiarily 
 
 .ivi7v»vi nr Tin: iii.u>ni:i{. 
 
 169 
 
 'n„. l.l.i.l.l.r |(.r ...iivniinicf <.f .li'srn|.ti.m nuiv l»i' 
 diviil.d iiitd Hiiimiit, iM.dy. l-a-c, ami ii>«l--. 
 
 Tlu- .Mininiit, or a|K-x. i^ n.mi.l.d and diiv( I. .1 tuiwurd 
 ,,nd upward. Ii i- .■..iiiu'.t.'d with tl.r iniil.ili.M> l.y 
 ,|„ iinudius and lli<' ..l.litciat.d |M.rti..iir. ..f the livj...- 
 ■ rastri.- artfiW. Tl.M i...rti..n ..f tin- .iiininil wln-li Ins 
 Uliind tlic iiia.liM: i- .-..vrivd l.y i.rnl..nriiiii, Nslmli is 
 wanlin-; »u tlir p..rtiuii anIiTiof to it wliith ivsts a-rainst 
 
 tlic alHloiiiiiial wall. 
 
 Tlic l...(|v (.f llic l.la.l.hT is that pcrticii whnh Ins h.- 
 tu.cn the ap.-x and the wsical ..p.nintrs nf the uivtiTS, 
 li i^ n-.l (c\«'rcd in tV..nl l.y prrilciniini, and is in ivlii- 
 tioM hnv with the trianirnlar li,u'aiinnt. the pnstt'i'ior 
 Hiirfa.v ..r the sviiiphv>i> pnl.is, tho intiTiial ..l.tnialur 
 iiiusrii-s, and, win-n disfndrd. with the al.d-.n.inal wall. 
 Tin- p.ist.-ri.»r surface is .(.iiiph-trly (•..v.icd l.y p.ri- 
 t..in-uni.andisin n-lati-.n with tin- ivHuin in tin- niaU- 
 and with tin- utt-rus in tin- f* inaU-, s..iin- r(.nv(.lntn.ns ot 
 Hiiiall iiitt-stiiR- l.cinj; int»-rp(.sfd. 
 
 Tin- has.-, ..r lundus, is directed d..wnwar.l and hack- 
 ward, and is that part which lies helow the plain- whi.-h 
 marks the level ..f the h..dy. In tin- male it rests up..n 
 the second p(.rti(.n ..ftln- rectum, and is partially o.vercl 
 hv pei-itoneimi. which is rcllectcd ui-on tin- rectum, t..rm- 
 i,;,. the rect..-visical lul.l. in tin- female it is in relatn-n 
 with the h.wer i.ait of the cervix nteri, and in a.lhercnt 
 to the anti-rior wall of the va.irina, a foM ..f pent(.ncum 
 iutervenint; hetwciii it ami tin- upper part ..I the anierior 
 surface ..f the c.-rvix. Tin- most important port ions ..t 
 the hodv are that portion which Ihs l.etweeii the vesn-al 
 opeiiin-s <.f Ihe uret(-rs heliind and the vesical ..rdice ot 
 tl.c urethra in fn.nt, which is km.wn art the v.-sical tn- 
 aiiirk-, or tri^irone, and that portion of tin- has.- which lies 
 lust liehind'the urct.-ri.- ..p.-nin.t-s, called the has-foiul. 
 
 «ww«>«;w«i»!f »»"'>'E»''»'***^'"'"" 
 
170 DISKASES OF rilE BLADDER. 
 
 Tlio (HTviN, or •H'.'k, is tluit .(.ustncto.l portion of 
 th, ap.x of ti.o tri-one wliirh is ooi.tinuous w.tli the 
 urothra. In the- niak' it is surromuUd l.y tlit- prostate 
 
 '"''Ai-.'or.lin- to souk- autliors, the l^hi.hler is eomposed of 
 thr... eoats; Ciray, however, nanies tour -s.rous (whu-h 
 i. hut in.rtial), nmseular, suhnuu-ous, and n.neous. 1 he 
 sc.rous „r peritoneal eoat eovers tlie posterior surtaee trom 
 opposite tlie opening' of the nreters to the sunnnit, an. ib 
 r'.tieeted 0,1 the pelvie and ahdominal walls, tor.nn.- the 
 false ligaments. 
 
 Tlu' nmseular eoat eonsists of several h-yers -an ex- 
 ternal laver, in whieh the iihres are arranged lon^ijUu<li- 
 nallv, a "nnddle layer, in whieh they are arran^'ed m a 
 ,i,,;Uar manner, and an internal layer, m whieh they 
 a-ain have a geueral longitudinal arrangement lie 
 iihres 01 these layers interlaee so elosely that praetioally 
 thev niav be eonsidered as one layer. Toward the lower 
 paA of ihe bladder the cireular fibre, are closely aggre- 
 gated, forming the sphineter vesieivs whieh in the mal' is 
 eontinuous with the prostate gland. 
 
 Two bands of obliqne fibres, known as the museles ot 
 the ureters, take their origin just behind the ureters, and 
 converge to the baek part of the prostate gland where 
 thev ai-e inserted. They weie formerly supposed to pre- 
 vent the reflux of urine into the ureters, but j.robably 
 thev have little if any special action. 
 
 The submucous coat consists of a layer ot areolar 
 tissue connecting the muscular and mucous coats, and 
 
 vcrv adherent to the latter. • , .1 , p 
 
 The mucous coat is thin and continuous with that ot 
 the ureters and the urethra. It consists of a basement- 
 membrane supporting several layers of epithelium, in some 
 parts squamous and in others cylindncal. It is ..)Osely 
 
0(1 portion of 
 nous with the 
 )y tliC! jirosttite 
 
 is composefl of 
 —serous (wliich 
 
 mucous. The 
 ior surtiu'c tVoni 
 
 surinnit, uud is 
 Us, tbriiiiug the 
 
 I'-yers,— an cx- 
 tUgod h)ngitu<li- 
 i arranged in a 
 
 in which they 
 ngenient. The 
 
 tliat practically 
 Dward the lower 
 i-e closely aggre- 
 .'h in the mal > is 
 
 19 the muscles of 
 . the ureters, and 
 ite gland, where 
 supposed to pre- 
 srs, hut iirobahly 
 
 layer of areolar 
 ucous coats, and 
 
 lous with that of 
 ts of a hasement- 
 )itheliuni,insonie 
 eal. It is l')Osely 
 
 AXATOMy (>!■ TllK BLADDER. 
 
 171 
 
 attached to the muscular coat, except at the trigone, at 
 the neck, and al>out the oritices of the ureters. 
 
 It is provided with mucous glands and tolhcles, not 
 vcrv numerous excepf 'i>«>'»t ^he vesical neck. On account 
 ol' Ihe looseness of the attachment of the mucous coat, 
 wlien the hla.hler is not disten<led it is thrown mto tolds 
 except .<t the points of close attachment. Projecting 
 from the lower anterior part of the hla.hler into the orihce 
 of iie urethra is a slight elevation of mucous memhrane, 
 called the uvul'i vesioe, whicli is hut little developed m 
 the female. The arteries supplying the bladder arc 1:ho 
 sui-erior, middle, and inferior vesical in the male, with 
 additional branches from the uterine and vaginal m the 
 female. These are all derived from the anterior trunk 
 of the internal iliac. The anastomosis is very free, the 
 .,bturat,.r ami sciatic arteriesalso supplying small branches. 
 The veins, after forming a complicated plexus about the 
 neck, sides, and base of the bladder, terminate in the 
 internal iliac vein. 
 
 The nerves of the bladder are derived from two sources, 
 the sympathetic and the si»inal. 
 
 The sympathetic are hraiu'hes from the hypogastric 
 plexus, which also supplies the vagina, uterus, and rec- 
 tum ; while the spinal are derived from the ibiirth sacral, 
 occasionallv the third, and rarely the second. ^ 
 
 The nerve-supplv is particularly rich to the small tri- 
 angular space known as the trigone, which is the most 
 seu.-'tive part of the bladder. 
 
 1.. bladder is retained in place by ligaments, which 
 are divided into true and false, there being five of each. 
 Of the true ligaments the tv ? anterior extend from the 
 back of the pubes, one on each side of the symphysis, to 
 the front of the neck of tb > bladder; the lateral are at- 
 tached to the sides . f the base of the bladder and the 
 
172 
 
 DISEASES or Till-: liLADDF.It. 
 
 lateral partK of tlic prostata; and the urachus, a tiltro- 
 imiscular cord, oxtciids between the hu niuit and the 
 nmhilicns. 
 
 The t'alrte li«!;anients, composed ot" reflections of the peri- 
 toneum, are the two j)osterior, which i)ass forward from 
 the sides of the rectum in the mali; and of the uterus in 
 the female to the posterior and hiteral aspect of the hiadder, 
 and contain the obliterated hypogastric arteries and ureters, 
 togother with vessels and nerves; the two hiteral, from the 
 iliac fossa to the sides of tlie bladder; and the superior 
 fold of peritoneum, extending from the summit to the 
 umbilicus and covering the urachus and the obliterated 
 hypogastric arteries. 
 
 t 
 
 CHAPTER II. 
 
 CYSTALGIA. 
 
 The bladder, like the other hollow viscera of the body, 
 is subject to diseases and to disturbances of both its motor 
 and its sensory nerves. We will first take up the subject 
 of its nerve-disturbances, beginning with cystalgia, or 
 neuralgia of the bladder. 
 
 Etiolo(jy. — In many cases neuralgia of the bladder is 
 produced by stone, concretion, or other foreign bod v. 
 Sometimes it is the result of the chemical condition of 
 the urine, that secretion being alkaline or perhaps exces- 
 sively acid. We often find patients having severe neu- 
 ralgia of the bladder ,vhich is purely reflex, the disease 
 being of the rectum, — fissure especially, — or of the urethra. 
 Stricture in the male and caruncles in the female are the 
 most frequent urethral causes. I have seen people of 
 
CVSTMOIA. 
 
 173 
 
 I'liUH, 11 tiliro- 
 iTuit and the 
 
 IS of the |K'ri- 
 forwanl from 
 the uterus iu 
 f theldiuhh'r, 
 •sand ureters, 
 eral, from the 
 the superior 
 immit to the 
 le obliterated 
 
 of the body, 
 oth its motor 
 ip the sul)jeet 
 
 ejstalgia, or 
 
 le bladder is 
 breigii body, 
 condition of 
 erhaps exees- 
 ^ severe neu- 
 :, the disease 
 if the urethra. 
 3male are the 
 jn people of 
 
 .routv diathesis suffer from violent attacks ot eystalo;,a. 
 Surli attacks are presunuibly the result of an excessive 
 a.iditv of the urine, or they may arise from the same cause 
 that creates disturbances in the other hollow vis.-era ot 
 
 such sulyects. ,.<.,- ,-,„f 
 
 It is not infre.pient for one who is the subject ot .tcout 
 to have violent attacks of asthma, -astralgia, or enteralsia, 
 with diarrlm-a or oystalgia. Perhaps in all these cases the 
 ivspcctive mucous membrane involved eliminates urate ot 
 
 sodium. . , .,, , 
 
 Occasionallv a person sufferini? from sciatica will have 
 a VK.lent attack of eystalgia accompanying or alternating 
 with the sciatica, owing, no doubt, to the tact that a vis- 
 ceral branch is given off from the third sacral nerve to 
 
 the bladder. . ,. , 
 
 Cvstal-ia may be the result of ulceration ot the mucous 
 nuMubrane of the bladder, just as gustralgia is caused by 
 a chro, • irritable ulcer of the stomach. [ know ot no 
 reason whv the bladder should not oc(.asionally sutter from 
 malarial neuralgia, as does every other organ ot the b..dy. 
 I feel (luite sure that whenever a case of severe eystalgia 
 presents itself, if the practitioner will keep well m mmd 
 its etiology and carefully examine for one of these causes, 
 lie will verv seldom he obliged to call it idiopathic. 
 
 PATiiOLO^Y.-It is quite apparent that the path<)logical 
 condition of tlu bladder must depend upon the etiology; 
 that is, the pathology may be in the urine itself, or it may 
 be in the urethra or in the rectum, or stone may be 
 
 ^"SYMPTOMB.-Puin is the pathognomonic symptom of 
 neuralgia, whatever organ or nerve be involved. In eys- 
 talgia the pain may be constant or paroxysmal and accom- 
 panied by violent spasms, in whi(-h case it is usually desig- 
 nated by the term cystospasmus rather than eystalgia. 
 
 16* 
 
 ^^vr^' 
 
w 
 
 1!" 
 
 174 
 
 DISEASES or THE lU.ADDi.lt- 
 
 AVitli i!k' cystal-ia tluTo is liUfl.v t.. Uo u (■.)nstant dosire 
 to inu-turaU" or aii iiiahililv to ivtuin the uriiK-. 
 
 TiiKATMKNT.— Tlu' iiidicutioMs tor ti-'jiitmont arc to allay 
 tho'i.ain a.i.l ivmovc- tlu- causo : ivmovin,!,' stoms or iWr- 
 c-,.n. l.o.rus as the ease may he; treatiu- the -out (.r 
 malaria, also the reetum or urethra where the aiieetiou 
 is retlex, or the uleeratiou of the hladder when that .•on- 
 (liti.mh i"-^'^^'"t; examiniu- earefully the ehemual e.m- 
 (litiou of the uriue aud eorreetiu.t; it, if ahuormal, hy 
 arids or alkalies as indieated. For the relief of lunn [ 
 have found opium and hyoseyamus the two most reliable 
 druus, and their administration in the form ot reetal 
 suppositories the most satisfaetory method. For the im- 
 mediate relief of severe eystal-ia, T am in the hahit ot 
 orderintj suppositories eontainiuK one-half i,n-ain ot mor- 
 phine and ttve grains of extract of hyoseyamus, with heat 
 applied over the bladder. 
 
 CHAPTER HI. 
 
 IIYPER.ESTIIESIA (IRRITABLE BLADDER). 
 
 This is another aftection of the sensory nerves of the 
 
 bladder. , ^ i 1 1 1 1 
 
 Etiolo.jy.— The etioU.gv of hypcra^sthesia of the bladder 
 is sometimes verv apparent, at other times it is obscure. 
 
 It may be either the result of irritation of the peripheral 
 extremities of the sensory nerves of the bladder, or en- 
 tirely reflex. 
 
 The iinm"^= te irritation is often caused by concretions, 
 foreign bou.es, or growths in the bladder, which simply 
 produce irritation without inflammation. 
 
 ll-lWfMlM-'' ■fUtU-'l.'^'-- 
 
iiyri:ii.KSTiii:xiA. 
 
 175 
 
 I'oiistunt (U'sire 
 
 •iiH'. 
 
 L'lit are to iiUiiy 
 
 stones or t'or- 
 ;j; tlio j;out or 
 i.' tho iitit'ction 
 wlu'ii that coii- 
 
 I'lK'iuiral eoii- 
 ' abiionnal, l>y 
 rt'lu't'of l»ain, I 
 o most reliable 
 fori 11 of rectal 
 1. For the im- 
 111 the habit of 
 f ijraiii of mor- 
 uuus, with heat 
 
 dder). 
 
 'y nerves of the 
 
 lia of the bladder 
 s it is obscure. 
 ;)f the i)eripheral 
 bhuhler, or eu- 
 
 \ by coiicretioiirt, 
 er, which simply 
 
 \t other timert the hvpenestliesia sivms to depend upon 
 an abnormal con.riti..ii of the urine, which may be cou- 
 ,,,,„, .,,,,,1 and hi-hly acid or else excecdm-ly alkaliiu'. 
 
 The urine of <liabctic patients is sometimes .-xtrcmcly 
 i,,itatin-, as is also that which c.ntains oxalatc-ot-linie 
 ervstals." Patients of -outy diathesis are liable t(, this 
 nmdition, wliich is probably caused by the hi-hly acid 
 
 '" Patients with hypertrophied prostatic glands are con- 
 stant sufferers. „ . . ^. • u 
 We not infrciueiitly tind the source of irritation in the 
 
 spine or the brain. 
 
 Pre-uancv, especially during the first few months, and 
 mcrine disease, arc frequent sources of irritation without 
 
 iiitlammation. , , ,. x 
 
 Of the reflex irritations, hemorrhoidal disease seems to 
 ,, lav the most prominent part, while many patients who 
 aie subjects of stricture, caruncles, or iuflammatum ot 
 tl.e urethra suiier great annoyance from a puri'ly irritable 
 bladder. In bovs, phimosis is a frecpient cause. 
 
 In portal obstruction, in malarial liver, or m passive or 
 active congestion or organic disease of this organ, the 
 vessels of the bladder become turgid, impinge upon the 
 nerves, and produce much irritation. 
 
 Symptoms.— The i.athognomonic symptom ot hyperfes- 
 thcsia is of course the intolerance of the bladder for 
 mine when there is neither inflammation nor ulceration 
 present. The patient has no fever and little or no pain, 
 but suflers the great inconvenience of constant desire to 
 micturate. Unless prostatic enlargement or stricture is 
 1 •resent, there is no straining and little tenesmus. 
 
 Treatmknt.— The indication for treatment, after being 
 satisfied that no inflammation is present, is to render the 
 bladder t(derant of its contents. This we can do only 
 
w 
 
 176 
 
 I)Isi:asi:s or the uladdf.r. 
 
 l 
 
 urtir .iint'iil iiH|niry into tlic i'tiolo.iry. It' the coiiditioii 
 is caiisiMl l>y clK-iiiinil .lian.ircs in the urine, thcci- must be 
 
 obviated. 
 
 In ease of coneentrate.l lii,i,^lily aiid urine, iiiilil diuretic 
 alkalies W()\ll(l be likely to meet Hie indieatioii, wliieh is 
 to increase tlie (iiumtity of urine and elian^'e its (luality. 
 This form of irritable bladder is more often than any 
 other successfully treated by the administration of alka- 
 line luiueral waters. In Kurope such patients are sent to 
 Carlsbad, Vichy, or some other noted \vaterin,«;-iilace, but 
 here in California we have the best of waters at our own 
 door, — Napa Soda, Hartlett, yKtna, Coronad(», Viehy, 
 Shasta, and many others. As a substitute tor mineral 
 water, the followinj,' mixture will often act like a charm : 
 
 B I'dtassii iicctiilis, Jvi-viii; 
 Spt. ii'theris nitiosi, giv; 
 Tinct. hydscyiimi, .^i; 
 Syr. ci.dfi, ^'\ ; 
 
 Aquic chlorofornii lul _^i.— M, 
 gi<r._gi every two lioiiiv, wi'll diluted. 
 
 Bicarbonate of potassium or bicarbonate of sodium 
 may be substituted for the acetate, and infusion of bella- 
 donna or fluid extract of triticum repens for the hyos- 
 cyamus. 
 
 " For the irritation accompanying projLCnaucy I have been 
 in the habit of prescribing: the following : 
 
 B Spt. irtheris nitrosi, 
 
 Tinct. liyf'soyami, 
 
 Glyccrini, aa .^i. — M. 
 Sisr. — 3 i every two hours. 
 
 This last prescription, with a few directions as to diet, 
 will in most cases allay the irritation of pregnancy. In 
 other • cases it may be necessary to give a suppository of 
 
 Eawts»»sw«i*r*»«K'»*'«<«»e'*'^' ' 
 
n. 
 
 It' the condition 
 e, thfci! must be 
 
 10, milil diuretic 
 ciition, wliicii irt 
 in_u;<.' itr^ (luality. 
 often than any 
 stration of ali<a- 
 [ionts arc sent to 
 iti'ring-placi', hut 
 ivtera at our own 
 oronado, Vichy, 
 tutc for niinLM'al 
 ict liko II charm : 
 
 iiij i:ii.EsTiij:siA. 
 
 177 
 
 uted. 
 
 Miato of sodium 
 infusion of bclla- 
 •ns for the hyos- 
 
 laney I have been 
 
 ections as to diet, 
 )f pregnancy. In 
 e a suppository of 
 
 hyoscyamus and morphine at bedtime, or tlie prescrip- 
 tion ("ontainintr acetate (»f potassium already nu'ntioned, 
 wliile some .h-rive great benefit from hot vaginal douches 
 ,,1-hot rectal encnuita. Cream of tartar tea— that is, a 
 saturated solution of cream of tartar in hot water, allowed 
 t,. cool and nuido pleasant to the taste with a littU- sugar 
 _is a lavorite prescription of mine for the irritai>le 
 hladdi'r of prciruancy. > 
 
 Triticum repens tea will often answer the p>iri)ose 
 admirably; l>ut a remedy which must never be forgotten 
 in irritiib'le bladder, no matter what the cause of the irri- 
 tati..n, consists in snudl doses i.f chloral hydrate, two or 
 three u;rains every two to four hours. This seems to 
 auicsthetize the irritated extremities of the nerves. 
 
 In irritable bladder from cerebral or spinal disease, 
 bromidi' »)f potassium, with or without chloral hydrate, 
 is an excellent remedy. Here, however, it is the prinuiry 
 lesion in the brain or spinal cord with which we liave to 
 contend. When there are diseiuses of the urethra or of 
 the rectum they must be removed when possil)le. For 
 the immediate relief of irritation resulting from rectal 
 diseases the most prompt and efficient remedy is a sup- 
 pository containing from one-quarter to one-ludf grain 
 each of morphine and cocaine and from three to live 
 grains of hyoscyamus. 
 
 In the irritable bladder of gouty patients I have often 
 found the most permanent relief from a combination of 
 carbonate of magnesium, powdered rhubarb, and col- 
 chicum, as follows : 
 
 B MuijiU'.-ii curb. (Heiiry'sl, 
 Puiv. rhi'i (Turk.). '"' 3'''> 
 Vini cok'liici, giii; 
 Syr. luiraiitii corticis, Ji; 
 Aqu:e menthio pipuritaj iid % iv.— M. 
 Sjg._2 ii every two or three liours. 
 m 
 
fflT 
 
 178 
 
 DISKASHS OF THE UnADDNJi. 
 
 This is to III- «M)iitiinu'(l until it oiu-ratt's freely on the 
 bowt'lH, when the irritiitioii usuiiUy suhsith's, jmrtly iVoni 
 the eliemieal chimi^e in the urine prodiieeM !'y the iilkiili, 
 but prohiihly in still ^'reatiT dej^ree from the relief atfoided 
 till' portal eireulation. 1 must not omit to mention that wo 
 often "-et exeellent ri'sults in this irritable eomlition of the 
 bhuhler from very small doses of bulsam of copaiba. 
 
 When it is evident that the bypera'sthesia of the blad- 
 der depi'iids upon some eoiii^i'sted condition of the Wvvv, 
 the exhibition of any of the above-named sedatives must 
 be preceded or accompanied by such cathartics us will 
 thoroughly unloatl the portal eireulation. »Saline eatbar- 
 ties may be used for this purpose, or the magnesia mix- 
 ture already mentioned. 
 
 In the dietetic management of diseases of the bladder 
 we t-ainiot exercise too nuich care. 
 
 The avoidance of nitrogenous foods in ii-ritable bladder 
 and cystitis must be strictly enforced. 
 
 Tlie articles of diet best adapted to these conditions are 
 milk, bread, and rice. Those to 1)C avoided particularly 
 are nitrogenous foods, and very acid fruits, unless the 
 iirine be alkaline, when the latter are often beneticial. 
 
 The same may be said of the mineral acids. 
 
 CHAPTER IV. 
 
 ANAESTHESIA (ATONY). 
 
 Anesthesia is an affection of the sensory nerves of 
 the bladder, consisting in an entire loss of nervous sensa- 
 tion. 
 
 Etiolooy.— This condition is due in most cases to dis- 
 
It. 
 
 I's IVc'cly <»ii tlio 
 (k'H, \\MX\y tVoiii 
 ■d !iy till' alkiili, 
 u' ri'licfatl'ni'dcd 
 iiit'iitiDii that wu 
 condition of tlio 
 of copaiba. 
 I'sia of tlu' Itlad- 
 ion of the livi'i", 
 1 sedatives must 
 itliartii's us will 
 Maline catliar- 
 ! magnesia niix- 
 
 >8 of tho bladder 
 
 irritablo bladder 
 
 se conditions are 
 ided particularly 
 I'uits, unless the 
 en boneticial. 
 ncids. 
 
 AX.KSTIIHSIA. 
 
 17!> 
 
 insory nerves of 
 of nervous senaa- 
 
 most cases to dis- 
 
 ease of the spine or (.f tlu- brain, eausintr, as il were, a 
 paresis of the sensory nerves of the bladder. Aside from 
 ciises in which it is due to diseases of the spine nv of the 
 l,iain, we shall probaiily si^hluiii meet with anu'sthesia of 
 the bladder except from pressure on the orijan durintr par- 
 turition or occasionally followiiii; ovi'r-distention. 
 
 Ten or fifteen years a,t>o, when 1 conducted a laru'e ob- 
 stetric practice, I'for a time adnuiiisti'rcd chl(»ral hydnite 
 ill the first sta«,'c of labor, to (piiet primary pain and lacili- 
 tate dilatation of the os; and in a lars>v number of these 
 cases I was oblip'd to use a catheter on ac<'ount of ames- 
 thesia of the bladder. I availed myself of this action of 
 chloral in treating; hypenesthesia of the bladder. 
 
 Symi'Toms.— Fn this condition the presence of urine in 
 the bladder fails to produce the usual sensation of fulness 
 of the oi\u:an. The bladder will bei-ome distended and yet 
 the patie'i^it have no desire to empty it of its contents, and 
 it is not until the distention becomes very great that he 
 has any sensation of its fulness. The bladder will often 
 overflow of itself when, in the absence of pain, even the 
 phvsiciaii may think there is no possibility of the ori-an's 
 bciii<,' full of urine. I have one patient who, though he 
 has no well-marked disease of the spine, has, tievertheless, 
 ana'sthesia of the bladder, lie is a very methodical man, 
 who never trusts to his memory, but consults his memo- 
 randum-book for all engagements. To insure the proper 
 evacuation of his Idadder, I have had him enter in his 
 memorandum-book against certain liours, " fJrii'ritc" 
 This entirely precludes the possibility of over-disteiition. 
 Treatment. — The proper treatment of these cases of 
 ana'sthesia is a matter of very great importance, as paralysis 
 of the bladder, as well as inflammation, is often the result 
 of failure to properly evacuate the organ in this condition. 
 Inflammation does not so fretpiently result from paralysis 
 
f 
 
 ISO 
 
 i)isi:.ts/:s o/' Tin: iir,.\i>i>i:n. 
 
 and aiiu'silicsiii as li.riiici Iv, nii ar.uiint of tho gmit iiii- 
 pnivciiiciit ill catlii'lt rs. 
 
 Tlic intlicaliuii for tivatiiH'iit so far an the ItlacMt-r is 
 t'ltiicfnuti ill aiia'sllicsia wiuif tin if is also paralysis is to 
 I'vacuatc tlic liladtlcr at ri-uiilar aii<l tint too ion-;' iiitnvalrt 
 witli a suit and alisdliitfly «l<iiii catiict.T. 
 
 Whrii you iiistriut liu" |iati(iit or luirsc in tlic use of 
 tln' soft f;itlH'ti-r, iriw tlio most carcfiil dirfctioiis to secure 
 its cliaiiliiii'ss, it is not sutlicicnt iiuicly to wasli tlio 
 catluli'r ill watt'r; you luiisl sec t(. it that it is placed in 
 ail uiitisi']>tic solution until used auaiii. or at least for a 
 KutUcii'iit time to insure disinfection. Very often, in an- 
 a-sthesia, wlieii the hladder is emptied it contracts (luickly 
 and normally, sliowinu; no implication whatever <»f tlio 
 motor nerves. This is esi)ecially true of many of the cases 
 of so-calii.l paralysis of the bladder after parturition. I 
 am Hatistied that in the majority of these cases w»> have to 
 deal simply with an aiacstlu'sia; hut the hladder is evacu- 
 ated prohJihly only twice every twenty-four hours hy the 
 physician, and lu'iice hecoiiies j^reatly distended, which 
 jtroduces partial paralysis. This may continue (or weeks; 
 while if the cathett'r had Ix'eii used from four to six times 
 in the twenty-four hours the-hhulder would liave recoveri'd 
 its normal sensation in a few days and shown no disposi- 
 tion whatever I :) paralysis. 
 
 ,;, 
 
i:i{. 
 
 cySTOSfASMIS. 
 
 181 
 
 I i»f tlif giH'iit ini- 
 
 aH tlic lilii(l<lrr is 
 Uso iiiiriilvsis is to 
 too long ininviilrt 
 
 • 
 
 iirsc ill tin' use of 
 ircctioiis to scciuv 
 ■icly to wasli till' 
 liiit it is i>lii<'»'(l ill 
 , or at least lor a 
 Very oiK'ii, in an- 
 I'oiitracts ([nickly 
 whatever of tlio 
 'many of tlio casos 
 rr i»arfurition. I 
 casts \v»' have! to 
 ' Madder is evaeii- 
 foiir hours hy the 
 distended, whieh 
 )ntinue lor weeks; 
 
 II four to six times 
 iild have recoveri'd 
 
 tjliowu no dispoai- 
 
 (11 APTKK V. 
 
 rY^TOSl'ASMlS (Vf.SIC.M. SIV\S.M-Sf ASM ol- TlIK lU.AI.I.CIl- 
 ,.VST.)S1'ASM— SPASMIS VKSIC.K— IsamUIA SI- NSMulurA — 
 CYSTOSPASTICI'S— IIVI'KIICINKSIS). 
 
 In evsto.niismus there is a <listurhan.e of l.otli tlw sen- 
 s..rvand the motor ne.v.s of the hla.hler ; that irt, there 
 is spasmodie eontraetion of the hladder, with pain. 
 
 l.Vr,o,,()(iv.— Cvstosi-asmiis is oeeasioiially dein'iideiit on 
 disease (.f th*" hVaiii or ..f the spinal eord, hut is usually 
 ,..msed hy loreign h.xlies in the hladder or hy inllammatioii 
 of the oVtran, or is rellex from some reetal disturhan.r. 
 The most fre.iueiit eaiise is st..ne. Amte cystitis, ulieii 
 the muscular stru.'ture of tJie wall is involved, is usually 
 ,,,„,npanied hy severe spasms and tenesmus. Strn-turc 
 ■of the urethra, or urethritis, will pr.xlii.'e it only when the 
 neck of till- hladder is involved. In highly nervous patients 
 the introduction of a catheter will provoke a spasm i.t the 
 sphincter vesi.'.e, and in hysterical patients this condition 
 may ho the result solely of the general nervous condition, 
 frritatiou of the uterus, fissures and a hemorrh<.idal con- 
 dition of the rectum, are sometimes responsihle tor these 
 attacks. ()ne of the worst cases I ever atteiidi'd was caused 
 bv a pericvstitis, whii-h, however, in this instaiiee was the 
 result of a goiiorrh.eal cystitis, the eystosi.asnius or cyst..- 
 spastic condition not manifesting itself until the inilamma- 
 tion had spread hevoiid the walls of the hhuhler. 
 
 ^„„.TOMS.— There is gi-nerally great intolerance ot the 
 ],ladder to the urine, with severe spasms atten.lmg the 
 etlbrts at micturition, and teiu'smus that is as painl.il as 
 the tenesmus of dysentery. The hlad.k'r contracts u.to a 
 hard hall. When the spasm is the result of urethritis or 
 
 10 
 
■T'* 
 
 i 
 
 182 
 
 jusr\tsi:s of tiik nt.Annr.K. 
 
 ..I 
 
 ••yHtitis, till re will III' livcr. When <ini!<iil l»y ntotu-, it i-t 
 iKif likely to lie very Ht'Vi-n' imloHHcyHtitis is |ircH»'iit Tin re 
 lilt' lew tliseiises tliiit life niitfe (listreftslli^ tliuii ueiiti' eyn- 
 titis ae('niii|(imie(| hy eystiM|iasiMiM. 
 
 Tin: M MKM'. — The imlieiiliini is t<» allay the \esieiil ini- 
 tatioii li\ reiiiiiviiiji; tlie eaiisi-, if |i(Wrtil»U'. Tliis eaii usu- 
 ally l>e tluiie when stoiic (»r I'orci^^n liodies are |iri'se?ii ill 
 the lihiililer, or wlwii there is a diseased eoiiditioii of the 
 reetiiiii, such as lissiirc, heiiiorrlioids, ete. When it ae- 
 et)iiil»atiies ueute ey(*titis it may take some time to (iiiiet the 
 irritation. 
 
 It will he advisahle iirst to dilute the iiriiH" well, hy the 
 administration of eonsiderahle (|uantities of mineral water 
 or riee-water, milk, or lluid I'Xtraet of tritieiim repeiis. 
 
 Hot sitz-lmths or hot a|>|ilieatioiis across the lower part 
 of tln'iihdomeii, with rectal suiipositoriesof morphine, will 
 fru(|ucntly (piiet tlie hladder for a lew hours. 
 
 Tincture of hyoscyamus with morphine and irotrmaiin's 
 uiiodyne or spirit of nitrous ether, l»y the mouth, are some- 
 times successful in allayini; the irritation. Occasionally, 
 ill spite of lu'at, sitz-haths, sedatives, or suppositories, we 
 ureohlisieil to resort to tilliiii; tlu- hladder with warm water. 
 Hot rectal enemata arc useful in many cases. (Jreat heiie- 
 tit ofton results from chloral hydrati' in doses of from ti-n 
 to fifteen tfrains t'very two to four hours. In the spasms 
 occurrin<^ from cerciiral or spinal initatioii, relief is 
 jfeiierally obtained fi(jm the udministratiun of bromide 
 and chloral combined. 
 
IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 
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 u;^V^?i'-?a^?^*i-^-'^as^K«S!^'»^:esii^A^!S^ 
 

 CIHM/ICMH 
 
 Microfiche 
 
 Series. 
 
 CIHM/ICMH 
 Collection de 
 microfiches. 
 
 Canadian Institute for Historical IVIicroreproductions / Institut Canadian de microreproductions historiques 
 
 vV 
 
 ■mwmiSZiSmm^^msm^m^m^/^sm^;.. 
 
CiSTOl'LECIi- 
 
 ls:i 
 
 (-llArTKK VI. 
 rvsToru^nA (.■auai.vsis ok tm. m,A..nKU-Ar.NKsis-vKsi- 
 
 CAI, 1'ALSY). 
 
 T.n. is a imivlv motor n.nrosis, :nwK US a rnl- .1.1-n.ls 
 
 t' ,,U;. (>v...-.r.st.ntionoftlu.Ma.M..r,n,.l.,->..'ntl 
 ,.:...us..of.vt.ntion,willU.av.tl .-.an ,,avab-.M. 
 
 L.nt or a.-ut. intlan.uation of ,!>. ,rostar. j^Uvna. L t 
 ' ,K.at it is not tlu- .-a-.s. of th. n...ut,..n that ,>ro, n.H"> tlu 
 ; ;tlj.ntth.M.v....ist..i<.n. l'n.ssu...M^ 
 
 ,v tlK- .'hiLrs lu'a.l anrin- partunt.on xv.ll soim'tiuu". U.ut 
 hJ aLMna,avaly.c.a<-onaition:la.n.l.ow,.^^^ 
 
 ,., ,,..,. ,„ a,Kvstlu.sia or u ..t.ntion ..t nnn. n. a 
 .w.Uin^- of tlu- urethra, .ans.d hv tlu- ,a-.ssuro ot tlu- lu ad, 
 ntlRT than a true paralysis of tlu- l.la.UUr. 
 
 F tv a...-u.ration a.ul atropl.y <.f tho inu^nlar walls 
 of tiliaaaaor .onstitnto a .auso of paralyse of th. organ 
 •nl.onu.n. In fever, of a s.v.ro typ. tlu. power ot 
 ,u.rv.-.on<l.u-tion is often either lost or unpjurea. 
 '"s,„,,.,MS.-\Ve often tina a lar.n- roun.l t.nnor in the 
 U,; ,. p rt of the ahaomen, risinjr up hehina the p,a>es, n«n- 
 !;;;; :.!ntral ana paintnl, when the aistentu.n ,s the result 
 of ineehanieal ret»'ntion. 
 
 It is <.ften nnae..onM.aniea hy pain when the resnlt c f a 
 
 central nerve lesio.i, ..n.l, thou-h the viscus may he ^.-reatl^ 
 
 an. lea, the patient ana son.etimes even the physunm 
 
 ;^- he d^ceivc^l a. to the natnre of the tn,n.>r, ow.n, o 
 
 L laet that in many of these ease, there ts a constant a. ,1 - 
 
 in. of urine, while in son.e of them, in eonse<iuenee ot 
 
 'iss4cs«=i-i®^ssm-'ss«*' 
 
isl 
 
 nisK.isrs III' Tin: i'.i..\nni:ii. 
 
 tlir ;iliii(p-t ((iiiiiilcli' |i;i:'alysis nC the s|iliiiiit(i' iiiuscli's, the 
 Itliulilci' i- iini ovci-ilistfinlcil. the (li>i(iitii>ii luiiiL;' r* Ticvi-d 
 liy the ovirtldw. Asiilc t'nnii tlic s\ miitoins (•(iiiliiUMl to 
 tlic liliiildcr, tlnTc iifr Mt'icii otlicr f(Hiiiilic;iti(His nsiiltiiiLr 
 fViiiii (Ir. I'llorts 1)11 till |i;irt of till' patient to (.■ iqity a jiafa- 
 ly/.rd or |iaitially-|iaialy/.i'(l lilailijff. 
 
 llfiiiorrlioiils and |ii'ola[tsiis of tlic I'frtiiiu aic tin' most 
 coiiiiiioii ot' till- distris>iii!X roiiditioib. that ai'isi'; l.iit 1 liavf 
 seen tlic constant stfaininu" |proi|ii(c liroiicliial and cinpliv- 
 scinatous conditions, and acute cystitis ai'isi' iVom the <lc- 
 (•oni|M)sition ol' the fetaiiied mine. 
 
 Th i:\T.M i:nt. — in the treatment ot' pai-alysis de|ien(h-iit 
 on sjiinal of cei-el>t'al disease the most tliat can he done i;^ 
 to use the soft catheter at re;,nihir intervals. Strychniiu', 
 electricity, 'riction. eantliarides, are ail likely to in-ovo 
 useless nidess tin' central lesion he imiiroved hv the retne- 
 «lii's em|»loyed. In paralysis cansed hy over-distention of 
 tlu' oiyan resnltimr tVom sonu' mechanical ohstriiction, 
 the Madder is likely soon to recovei- it' the ohstrnctioii is 
 removed and the urine is proju'i'ly evacnated at reti'ular 
 intervals. In the paralysis followinij,- parturition the 
 rapidity of the recovery will depend larirely n|>on whether 
 or not the nriiie is drawn t'roni the hiailder sntlicientlv 
 often. It is the haiiit of many medical men. in these 
 circiiinstances, to use the catlu'tcr oidy twice a day, thus 
 allowiiiLj tin- hladder to he constantly distended, -o that 
 perhaps Weeks may elapse hefore it retiiinstoits normal 
 condition; while, if the nrine wcri' drawn more fre- 
 (pie.itly, <»ver-<listention Ih'Iiil;: provided apiiiist, the con- 
 dition would disappear in a few days. 
 
 This precaution of tV<'(iuently emptyinij' the hladder i.s 
 rei|uisit»' in any other ease of paralysis eausi'd hy over- 
 distention. 
 
 .Mo>t ot' these eases recover without the aid of niediea- 
 
VESICA I. CM. en. I. 
 
 IS;-) 
 
 ■r iiniscli's, the 
 lirilli;- rrlic\ I'd 
 lis (■uiiliiii'il to 
 ioiis rtsiiltiiiiT 
 t'lilitv a |piira- 
 
 1 ai'c till' llinst 
 si' ; liiit 1 liavr 
 ill and ciiijiliy- 
 i' liDiii tlic de- 
 sis di|irlldi'llt 
 •an l>r di)ni' "h 
 Stryrlniiiie, 
 <rly to |H("V(.' 
 
 I l»y till' rcnu'- 
 -distrutinii of 
 1 olistnictidii, 
 obstnu'tioii is 
 U'd at rrii'ular 
 I'luritiiiii the 
 ii]inn wliether 
 •r ^utlil•il•lltl_v 
 nen. in these 
 re a day, thus 
 nded. -I) that 
 to its normal 
 k'li more tVe- 
 liiist, the t'oii- 
 
 lie liladder is 
 ised liy over- 
 id of inedica- 
 
 lioii. When it heeomes necessary, eleitriiily. niassaL-'e. 
 and stryelinine aie the lie>t remedies. 
 
 i tVeiinentlv u'ive a eomliinatioii of tincture of nnx 
 Vomica and spirit ot' nitmns eti r, and lind it answers an 
 admirahle iinriio>e. Here let me aiTiiin '"iH attention to 
 tlie imiH.i'iaiice of keepin;.'' catheters ah^olntely clean, 
 n>ini:' f"r that |niriiose salt, carholized, or iiichloride 
 solution. 
 
 ClIAPTKU VII. 
 
 VKSIC.M. ( M.ril.I (cYSTn-MTIIIASIs). 
 
 l/,-,,,i,n(;v. — Wiiat has Iieen already said of the etiolotry 
 of renal calculi api'lies eiiually to vesical calculi While 
 air*', sex, and location as etiolouical factors play ahout tlio 
 sanu' part hen', catarrhal iidlammations are responsilde 
 for more vesical than renal calculi. A calculus in the 
 ]K'lvis of ihe kidney will undoulitedly produce pyelitis, 
 and a calculus in the liladder almost invariaidy proiluces 
 cystitis; hut in a laruH' numlier of cases of stone the 
 catarrh of the Madder precedes the stone and is resi.oii- 
 sihle i\n- it. There may he special stotie-makinir catarrhs, 
 its A'ickle suu-iri'sts. As to tile nature of the vesical 
 calculi, they corres[iond with what we have already seen 
 in renal calculi. 
 
 Sv.Mi'Tii.Ms. — Stone in the bladder ,!.cenerally indicates 
 its existence hy one or niori' of the followiiiir symptoms: 
 irritation of the Madder, cystitis, cystorrluiiria, and pain 
 ill the hladder, followins; tlu' course of the urethra and 
 often referred to the head of the penis. (Vstospasmus is 
 occasionally present. The patient will sometimes find 
 that in the act of urinatin.iX the sti-cani is suddenly cut 
 
 10* 
 
 -.*is^^88i«»#»«s^«««rf»«aB^^ 
 
]Si\ 
 
 Disr.AsHs iti Ti'i-: iii..\i>i>i:ii. 
 
 (tir lict'urc the liliiddt r is ciiiiilicil, |in.li;ilil,v ciiuscd \<\ llic 
 stuiii- iiilliiiL,'' iiijii'""^' 'Ik' outlet tit' till' IthidtltT. 'I'lif Kiily 
 tlmi'iMiiilily !•( Tiiililf iiicaiis of (li:iL''nii>is, liowcvi'i'. i> thr 
 (Icliliilistl'iltinll of stiilU' in tlu' l>l;i(I(|c|- li_V lucjms III' tlu' 
 stniud. wliirli slioiild iilwiiys In- used in siisjiirii ms ciiscs. 
 Win II tlif stone is siifc'ilatcd. it is dillinilt to discover 
 its |iresence I'Veii witli llie soiniil. When tiie Miidder is 
 initiilde and iiaiiil'iil. an<l a satisl'aetopv exainiiiation ean- 
 iiot lie niaile liy means ol' the local use ot' coi'aine, it is 
 hettei- to ana'stheti/.e the [latieiit and detenniiie ahsoliitely 
 whether or not stone is |iresent . nor must we I'ori^-ct that, 
 inasmuch as cystitis is iVeijiientlv the cause ol' stoiie. it is 
 neeessarv where a cystitis is oi' loiii!,' duration to t-xaniiue 
 tile hladder carefully from time to time, say at least ever_\ 
 thi'ee months. I have known a patient >iitrerinu' troni 
 cystitis to have lieen caret'iiily examineil t'or stone with 
 iu'<rati\e results, and yet al'ter some months, he havinir 
 lias>ed in the mean time into the hands of aiiotlu'r phy- 
 sician or surireon. an »'.\amiuation revealed the |>risenee 
 of a >tono, when hoth surii'eon and pjitiiMit si-emi'd per- 
 t'ectly salistieil that tlu' t'oriiier examiner was incoiiiiietent. 
 It never oecurri'd to them that tlu' stone had formed since 
 tile previous examinafitui. 
 
 Ti!i;\t.mi:nt. — The removal of vesical calculi lu'louii's to 
 the domain ot' surirery, unless the physician for some cases 
 sees tit to try what is usually known as Koherts's solvent 
 treatment, w hich consists in both the administration ot", 
 ami hx'al treatment !iy, nieilicines calculated to ilissolve 
 the stiuie. We have st'eii in the chapter on reinil calculi 
 tliat the oxalate-of-limo or mullH'rry stone resists all 
 sohiiits. 
 
VYSTitltnilMilA. 
 
 1S7 
 
 <1I!1S('(1 |i_\ lilt' 
 
 IT. 'I'lif Miily 
 
 (i\\f\rr. i> till' 
 
 llU'illls nl' till' 
 
 s|iiciiins cascr*. 
 lit to discover 
 the Madilff is 
 iiiiiiiiition i-:iii- 
 t' cociiiiii', it is 
 line iilisolutcly 
 ,v(' l'oi-i:-(t that, 
 ' ol' stoiic, it is 
 ioii to I'xaiiiino 
 / at least cvcrv 
 >iill('i'iiiu' iVoiii 
 tor stoiif with 
 tlis, \\v haviiii!; 
 r aiiotlu'r I'hy- 
 1 tlu' pri'sciicL' 
 
 it Sl'l'llUil \ivY' 
 
 IS iiir<>iiili*.'t(.'iit. 
 
 i(! t'ol'llK'd siiici! 
 
 culi holoiiii's to 
 
 I lor soiiit' casoH 
 •In'rts's solvi'iit 
 iiinistratioii ot", 
 tt.'(l t() dissolve 
 
 II rriial rak-nli 
 oiiL' resists all 
 
 ClIAl'TKK V 1 II. 
 
 ,'VSTOUlMl\.ilA (VKSWM. „ ,,M AT. IM \-lIKM<>UUn A.IK FlU-M 
 
 Tin; iti,.\iM>i:ii)- 
 
 ETi..i.n,.v.— Th.'iv aiv various .auses which -ivc rise to 
 hciiioi-rhaLC'' t'l'oiii the hlaildcr. 
 
 l„im-U's,oitlu'r th.iii l.lowsor iVoiii pcnctratiii- w.miids, 
 are ,vs,.onsihU' for s..nu' rases. ( )ceasioMally such diseases 
 us ..urimra |iaMnoi-rha-i."> and s...rhntiis produce it. 
 
 StoH.. ill the hla.lder is a fre.iue.it .'ause, as is ais.. 
 ul.^erati.MK siiuple, syiihiliti.-, ..r tuhereular. 
 
 (irowths ill the hla.hler, inali-uaiit c.r heiii-n, seld.un 
 fiil to -nve fise to int*'reurrent heiuorrha.iTi', eaiicer and 
 ,he luucus i.olyp heiii- i.u.st fre.iueiitly atteiuh'.l hy this 
 
 sVlllWtolU. ,. , ^ ,. 
 
 ■ Acute evslitis n..w an.l then -ives a sh.ixht aiu..unt ..t 
 fresh iv.l "hl<>"<l i" tlu. urine, while a passive eouirestioii 
 <,r the vesi.-al veins from cancer, or cirrhosis of the liver 
 ,,, otlu'r ohstruetion to the p.-rtal eiirulati.ui, must he re- 
 niemhere.! as a i...ssil.le source. We have alrea.l^- state.l 
 in the etiolo-v of luematuria that parasites tuay l.xl-c in 
 tlu' mueous meml)rane of the hlad.ler an.l produee hem- 
 
 ' Sv.MPTO.MS.— For the differential dia-rnosis from hemor- 
 rhatre derived from other p.)rtioiis of the urinary tract, 
 see the chapter on hiematuria. 
 
 Tui:\TMKNT.— The ruh's as reirards rest an.l diet, wliieh 
 we have already i?iven in the chapter on luvmaturia apply 
 e.iually whethJr the hemorrha.ire comes from the hhuhU'r 
 or from the kidney, ami the same may be said ot the 
 udministrath.n of medicines. In ad.lition, however, we 
 have the advantage of local ui.plicatiuu of remedies. 
 
 ,-JS»aS^3^ 
 
 ««^aE03KSSpP!3We^J'iSW*«A*««*''*-iia^ 
 
 ■msa- 
 
 \ 
 
 wm 
 
ls,s 
 
 /)/.sA'.(.v/.;\ 1,1 Tin: /.7,.i />/)/./,•. 
 
 Wlicll llic lHIil(.M-|i;iL;-..is(.l.stilliltr, wllctlicrrn.lll llIciTM- 
 •'"" '"■ ''""I "l'' |'I'*'>>'M'<- <'ril.'<.|.li|Sllls, W,. |i,;i_V Wiisli ..lit 
 tl.c l.|;i,|.|,.r with aMiill-rnI IcfiullS lll„I tlllls's..||M'tillU.S 
 
 will sii,T..,.,| in iirnstiiiu- tlir liciii..iTli;ii;-,. wlicii svstL'ini(! 
 ninr.lics liiivc I'iiil...!. of lli,. iistriiii.'-.Mit Wiisli.s. tlios.- of 
 ,ir;illic ji.i.i iiiiil tiiiiiii.' iiri.l :ir,. d,,. siiH.st and iiK.st .•Hi. •lent. 
 (Uliri- iistrin.ircnls wli.n |.r.)|.,.Hv dilnti'd cjui l.c used 
 wilhuiii .l.tiiniciii t.. til.. I.lad.l..!-. Wl,,.,! thr li.ni..n'li!itr(! 
 •I'T'i"!-^ >i|.<iM ii n.w irn.wtli, <.r ii|„.ii .-al.'iiliis, ilic trcat- 
 iiH'iil iimst \)v siiruical. 
 
 <'I1AI'TKH rx. 
 
 CYSTITIS— ACtTi;, sriiACITK, AM) rilRONIC. 
 
 AVk dfsii.ni:!!.' f li." iiiflamiiiatioiis of f h.. Maddn- as acute, 
 Htiliaciii.', .(f .'lir.ini.' cystitis. 
 
 Ivn(»l,u.;v cK ACITIO AM) SlIiAcrTr, CvsTITtS. — .|//r.— 
 
 (>titis oc.Mirs at all a,i;cs. Fii cjiildivii, however, tlio 
 disease is usually of a mild, suhaciite character, except 
 wh.'iv produced l.y vesi.'al calculi or followin.t; the acute 
 intectious diseases. 
 
 ,SV.,-._rn childhood l.otji sexes are e(iual]y subject to 
 cystitis. In early adult life youn.i; men sutfer oftener 
 thau youui; women, l.ecause of their more tVe(iuent 
 attacks of ironorrliu'a au.l lial)ili(y to stricture. 
 
 Women durin<r the ch;id-I)earinir period are verv sub- 
 .ject^ to catarrh of the bladder, .)win<r to the vesical hyper- 
 .•emia caused by iireijnancy and to the injuries incurred 
 by tlie blad.ler and neii(hb.)rini( tissues du'rin«,' deliverv. 
 
 Tn old a-re, say after sixty, men are far more subject, to 
 <-ystitis than women, from their tendency to prostatic 
 disease. 
 
1 
 
 cysTiris. 
 
 isi» 
 
 I'l' iVdlii IlIciTll- 
 liliiv Uiisli out 
 
 HIS soiiH'tiiiu'K 
 vlu'ii systemic 
 
 IsllCS, tlldSC ot" 
 
 iiKtst I'tlicitnt. 
 
 cim l)c usod 
 
 I' lif'iiori'luiii'c 
 
 iliis, tlic tl-fllt- 
 
 RONIC. 
 
 • Idcr iis iK'tito, 
 
 riTis. — Af/r. — 
 llOWt'VlT, tlio 
 
 ^actor, oxci'pt 
 iii.tr the iic'uto 
 
 lly siihjc'ct to 
 
 ■iifU'r ofti'iRT 
 
 ore tViM^iK'Ut 
 
 re. 
 
 aro vi'rv sub- 
 
 ■fsicivl llVplT- 
 
 rios incurred 
 liC delivery, 
 re subject to 
 to prostatic 
 
 Tiijuries. direct blows. Tails, ..r peMetratiii- wouixls iiiv 
 eticluuical taet(.rs, as well as vesical calculi ..r oilier 
 foreiii'll b.Mlies ill tbe bladder. (Vslilis is ofK'U caused 
 Hccondarily by invasions of the bhidder from a urethritis, 
 specitic (u" otlierwise, diseases of tbe kidneys or ureters, 
 peritonitis, pelvic cidlulitis, and inilauimat ions of tbe pi'lvie 
 
 orirans or tbe prostate .irland. It not infre([Uently bappeiis 
 tbat i'-om some obstruction iuterferinn' N^-'b tbe complete 
 emptying- (.f tbe bladder, as in i'nlar<i'c<l prostate, pbiniosis, 
 paralysis, etc., decomitosition of tlu' urine takes place and 
 pnxluces intlamniation. 
 
 Another source of cystitis, which fortunately is not so 
 tVeipient as formerly, is the use of unclean catheters; and 
 cystitis occiisionally residts from the mere passinji; of a 
 sound or •. catheter. Any of the acute infi'ctious dis- 
 eases, as also pya-mia, nniy be accompanied or f.dlowed 
 by cvstitis, with or without intlamniation of the kidneys. 
 Oeeasionally we encounter a diphtheritic cystitis, which 
 is usually secondary, with or without ityelitis. 
 
 In deidiuti; with intlamniation of the blacbUr we must 
 never forii-i't that ill-defined etiolo,u;ical factor, catchini? 
 ^.(,ld,— especially tretting the feet wet; and if pi-ri'bance 
 wt" iind a case that we can truce to no known cause, we 
 must satisty onr i)atient"s c\iriosity, if not our own intelli- 
 ireiice, by designating it as of idiopathic origin. \ bayo 
 more than once been assured by pliysicians that a certain 
 disease was idiopathic, tbe dictum beinijc uttered with such 
 an air of wisdom and dit^nity tbat I could not but believe 
 that the word conveyed to them some idea of definite 
 etioloirical information. The word may be eonvenieiit 
 for lazy physicians, l»ut it is the cause of inealculable 
 mischief. 
 
 Men with gouty diathesis have a greater tendency than 
 others to cystitis; and the mucous nieiiibraiie of the 
 
 .;539:«'3'3i!»*.-=S»!'^^'^-'^:?*^^^'6*!E=^53OT'^^ 
 
1!»0 
 
 Disn.tsKs or Tin: ni.MthiiH. 
 
 I>liiili|i'i', liki' iiiiv otiii r iiMit'oiH iiii'iiiltniiii', muv iiithiiiic 
 iMul iilccrali' iliiiiiii; tin- course of s_\ |.|iilis. I Imsc -rcii 
 a •ystitis \\\v oiilv ii|i|iiirciit ciiiisc ul' u liirh wms |phitii<i»is. 
 N'i'W jji'iiuths ill ilic liliiildcr trfiu-nillv |p|(m1iicc initiiiiMii 
 aixl <'at;it'rli. The iiniiiiiiMiis or too lon^- runtiii'ieil use 
 of eertaili liiedi.iins will soilietiliies set ii|i ail iiithiliiliJii- 
 tioll ot' llie Maihler, tliis iteilii; es|ieeially till- ea>e with 
 tur|ieiitiiie, eii|.ailia, ami eaiitharideK. 
 
 Ivrioi,o»iv or CiiitoMc ("vstitis. — Va\'\'\ ease of rlnonie 
 e_\>-titis is the roiilt of an aeiite cir u siihaeiite altark ; liie 
 Kultaeiit.' attack, liowevef iiiiM, may liiially ri'siilt in a 
 aovi'fe chronic inlhiiiiniatioii. 
 
 I'atiioi.ikiv. — The |iathoh>Lry of acute cystitis (|c|ieiiiis 
 npoii tile severity of the case and n|Min tlu' tissues in\ ul\ cd. 
 
 WhiK' it is siiiiiijy catarrhal, that is, while the niiicoMs 
 ineiiihfaiu' alone is involvt-d, there is hy|ieiiciiiia ; the 
 iiieiiilirane is red, relaxed, and (i'(leiiiatoiis, and it> suit'acc 
 beeonies denuded of its e|iitheliuiii and is eo\cred with 
 
 IIIUCMS. Thel'e is a lit'olilcratioii ot' yollHi; eell-li'rowths. 
 
 the urine hein,:; turhid and loailed with mucus- and |ius- 
 (•orpuscles. Cystitis, liki' all othei' int!animation> ot' 
 mucous niemhraiics, may t«'i'minate in resolution, ulcefa- 
 tioii, or chi'onic int!aniniati(Ui. 
 
 In an attack of acute <'ystitis whieli involves the siiii- 
 intu'ons and miis<'ukir coats, the whole wall ot" the hladdcr 
 hecoiues thickiMied, owiiiij to an e.\iHlati(>n and |>rolit'cra- 
 tioii of cells that take [ilaee in the sultmucous and mus- 
 cular structures. 
 
 In clii(riiie cystitis the mucous m- nihrane is no Ioniser 
 red and relaxed, hut is of ii i^rayislt color, irrcirularly 
 thickened, and covired with a |iurnlcnt-lookiiiir secretion 
 of muciis and |ius. The sidtmiicoiis and muscular struc- 
 tures heeonie nuieli thickened and hy|iertroiihied, jiai'tly 
 from exudation and partly from contraction. Tlu' urine 
 
If, IllilV llltlilllli- 
 is. I llllSc xi'll 
 
 I ujis |p|)iiiii>His. 
 iilii<'c initiiiinii 
 
 • oiiliii'ii'il lis*' 
 i|> all iiitlaiiiiiiii- 
 
 tlu- »iisi' willi 
 
 (•use III' ilndiiic 
 iitf jiltack ; till' 
 illv ri'siilt ill a 
 
 •ystilis tl('|K'ii(ls 
 issiii's iii\(ilv»'(l. 
 lie the iiiilciiiis 
 v|K'i'a'iiiia ; tlit" 
 , aiitl it> siirt'aci' 
 
 is (■(iNTI'l'd uitl) 
 
 lu; ft'il-ii'rnwtlis. 
 iiiii'iis- ami |iiis- 
 laiiiniatiiiiis of 
 iitliitidii. iilcrra- 
 
 VOIVCS till' Sllll- 
 
 I of tln' l)la<l(irr 
 I aii<l |ii'(>litira- 
 U'tiiis ami iiiiis- 
 
 iiic is iKt iDiiifcr 
 lof, in'ci^iilarly 
 i)kiii<x S('ci't'tii>ii 
 iiiisciihir stnic- 
 miiliii'il, iiai'tly 
 )ii. Tlu' uriiK! 
 
 rysTiTis. 
 
 I'M 
 
 in tui'l.i.l. nihil alUaliiir. ami sniii.tii.i. s ,„iiiii..ma.al. I la' 
 ,„.„,. ,l„,,„i,,li.'.r.s>.a>.'.llH'lrsslik.'ly is it tot..|n..i,;.t.' 
 ivrnwrv.all.l th.' IV IiU.lv tn IVMllt ill iilr.Tat i.m, 
 
 HI I 
 
 ,„.,,;„,„;,„■,. or sill... lU.M.us al.s.vss. ami t- |.in.li..'.' ni..r.' 
 .,!• 1..^^ l,vii.'iti-..i.liv ami .'uiitra.'tiuii of lli.' I.la.l-l.r. 
 
 SvMnnMs.-Thr sVlliptollls of a.iitr .'yMilis .l.iM.ml 
 , ,,„ ,1,., ..x,..,it of involvriiirnl of til.' Ma.l.l.T-wall. 
 Whrn uiilv 111.' ninroiis .iminlmiiu- is ii,v..Kv.l. un iiiatt.T 
 how a.'.it.'' tlu' attarU. tlu- f.-wr is vvi'V im'o.i^.U'faMr. tl.o 
 t.n.iH'raf,.v m.t uft.u ri-in.tr ahov. l.m'^ or KT. I li.'.v 
 i. not lilo'lvto 1... aiiy.li>ti.i.I,..r nitlirr il.tnm.l, rliill, 
 altl.oii.^h tlu'ro arc- ..ftni iviu'ivi.t .Inll.v srnsiti..ns. Iii- 
 tolrran.'.' n\' tlu' l.la.l.l.T to tlir uiMm- will 1'" pn'sHit, 
 c.s,K'.'iallv wlu'ii walkiiiir, an.l tlirn- will W soiim t,'ii.l.'r- 
 nrss o\vr tlK' l.la.M.T i.l.nv.' tlu' pulu's. Mirtiintimi h 
 tV-'MiU'i.t an.l |,aintiil, 111.' pain l..in,ir most si'V.iv at tlm 
 .•losi- of til.' .'llWrr an.l l.-'ato-l in tlic iK't'iiauiii. 1 lio 
 „,.•„,.. i. turl.i.K ami whni si'ttU'.l shows a lai-v aim.mit 
 „,• ..loU.lv liiurus at tlu' lM.tt..lil nf tlu- .Lchiss. Wli.'li tlu- 
 wlioK' l.ia.Mw-wall is involvnl in tlu' intlaimnati.Mi the 
 svnn.to,nsaivv..rvs.'Vr.v. This form of cystitis, wlmtlmr 
 .;,.i.,.i,iatii.',' in tlu' iK.rit.m.'al .'ovnin- ..f tlir l.la.l.l.T an.l 
 tlu'.mc invlviiiLT tlu" wh..U' Ma.l.l.T-wall, ..r .•..n.ni.'mniu' 
 in the nni.MMis nmiiihram' an.l iiiv..lviii,- tlu' nms.'iilar an.l 
 .KTit.'iH'al n.ats, is lik.'ly t.. ho nslu'iv.l in hy a .h-tiii.'t 
 ami often severe el.ill, f..ll.A\H'.l hy hi.U'h f.'Ver, .i^reat pan. 
 in the hvi...irastri.' ivirion, extreme nitoh'ran.e ol th.- 
 l.la.hlrr to the nrin.', an.l aln...st .'..nstant iuirturiti..ii, 
 th,' |.air. (lurimr mieturiti..n h.'in- almost hey.m.l liMiiian 
 Mi.lnran..' an.l a.T.Miii.anie.l hy a-.-ni/in- tenesmus ami 
 evstospusnms, often m..." unemlurahle evn than the 
 spasms ami teiu'smus ..f tin- severest reet.t.s. 1 une 
 several times se.'U, in eases ..f s.'Ver.' a.'.lte -ron.u-rha'al 
 cystitis, retenti.m of urine, ..win.ir, prol>ahly, partially to 
 
 1 
 
 -la^seaam^KfoifS' 
 
 r"«airTMii«;>rt*«f-ii- .".!niiBer-:w«* ■■MSHBti, u:.- 
 
ina 
 
 /»/>/; iv/.s o/' Tin: i,i..\hi<i:it. 
 
 till' t Iciiiif niiitriirtitiii (if tin- >|i|iiiirtri' vc-ii'ii' mill |i:u'tiiilly 
 
 til til Il'llllltull'^ ilinl >Uii||rll rnllililiiill nl' |||i' l|l'<'tliril. 
 
 Ill tll(-»' cil-ii'S till' U-c III' till' ( illlnli'l' in'(i)llir> ;l in rr-«it y. 
 
 I iii'ViT >;i\v ii Iniiiiiiii liiiii'^' >iiiri'i' i.q'1'iilt'r ii'^mis lliaii 
 tl'nl a yoiiiiir iiiiiii uf >triiiii(iii> iliiitlirois ulm ilinl in i ul- 
 
 lil|i-'t' nil till- fi'Vclltll llilV n[' nil Ihllli' ('\>lltis ilinl illiiMlt llic 
 
 twrll'tli thiy (if II iT'iiiitnlin'ii, 
 
 Till' mini' in ii lew liour^ lici'iiiiii'- mrliiil uitli niii<Miis 
 Hi'diinciil. iiiiiy i mitaiii muih' Mi mi I, and -miui (l(|pii-iis pns- 
 
 «'((|'|in-' Ir^. 
 
 'I'lifir \-* aiiuiJHi- variety ot" ariitc ly-tiii-i uliiili is i;iiiic 
 ('liaia<l«'ri-li''. It orriirs in luinilysis of tlic lilnildcr ur in 
 old null w itii t'lilai'i^i'd |ir()stiitcs. 'Plir idaddcr is iiol ijior- 
 oiiLrldy riii|ilii'i|. an! 1 1 ir retained urine ( |ierlia| is oil aeeoiiiit 
 of naeilli earried inin the hladdei' liy iinelean eallieters) de- 
 «'oiii|ioses, iiiid aiiiinoiiiaeiil, initatiiiL:', alkaline iiriiu- is tlio 
 fesuli. uliieji oi'ieii f.1 Is ii|i a ,-ii|i|iiirative cystitis lli: t may 
 ill a fi'W days iiid fatally, llie paliiiit dyiiii; in collaiise. A 
 lariri' |iereelltairt' <>f the mine in these eases settles as a 
 stiinuy. tenaeioiis niiieo-|iiiriileiit sediineiit. 
 
 Sithiiriil, (';isi:iis, — Suhaeiite cystitis is always catarrhal, 
 
 the liilieiilis liicniliralie alolie lieinu; in\dl\ed. 'I'lie slllijec- 
 
 tivi' syiii|tioiii:- are ct'icii iici;ati\i' ; there is no t'ever, little 
 or no jiain. and the hiadder >ho\vs scarcely any intoleraiic*.' 
 of its contents, exci'|it when t'xccf^sivcly distended, when 
 pai'i develops and it hccoiiies ini|'os>il(le to retain the urine. 
 The characteristic features or ohjectivi' syin|)tonis of 
 these suhaeiite catarrhs are that the urine is voided some- 
 what more fre(|iicntly than normal, is tiirhid, and when 
 allowed to settle a Lfrcat (|iiaiitity ot' cloudy niiiciis is seen 
 at the hottoiii of tin.' iflass, — not decomposed, ropy, strinsxy 
 mucus, iiur tlocciileiit mucus, 'I'he uriiu' is nearly always 
 Very plio>phatic. Some of these cases linally tcriuinate in 
 u chronic inlhuiiiuutioii. 
 
nsrrns. 
 
 103 
 
 •If iiiii] iiiirtiiilly 
 • if tilt' iii'i'tliia, 
 iiio ii iii'ctwsity. 
 iiiT iiL:i'ii\ tliiiii 
 III) ilii'il ill (III. 
 is mill itiiiiiit tlic 
 
 ill u illi iinii'Miis 
 HI ili|iii'its |iiin- 
 
 s uliiili 'h >;uiti> 
 II' lil:iili|i'i' ur ill 
 iltltT is mil ihur- 
 
 li;l|iS(i|| ill riHIIlt 
 
 111 liillii'tirs) i\v- 
 iliiif nriiu' is the 
 _v>titis tlii t iiiiiy 
 : ill «'(illa|isi'. A 
 
 isi's scttKs lis 11 
 
 I. 
 
 Iways ciitanlial, 
 (1. Till' sulijcc- 
 s 111) t'cviT, littlo 
 any intuit raiice 
 listcniKMl, wlu'ii 
 retain the urine, 
 e syni|it(inis ut' 
 is voided Sdliie- 
 rliid, and when 
 y niiuns is seen 
 ■d, ropy, st rill iry 
 is lu'ai'ly always 
 dlv terniinalt' in 
 
 ('hl'iiillr ^'-/«^'//v._'PI|i re is no Well-detilled line nl' lie- 
 
 niarnition Ixl ween a >nltaeiite ey>tiii> f liat liei min's elirnnic 
 and ail iieiife ei'se that |ia'~es into a iliiunie eunditioii. 
 Wlieli an aellte ease nl' eyslilis lias riMlliniled liir Weeks, 
 |ierlia|is tnoiitlis, and tlie aeiite syniptoiiis — that is, tlu' 
 lever and ir.nst ut' the |iaiii — have in a nieasiin' snhsided, 
 liiit the tri'i|U('nt niietiiritioii eonliiiiies and there is a 
 niiii'i>-|iuriilent sedinn-nt in the urine, the ear>e may he 
 
 ( iill-ideled to have lieeoine ehroiiie. As the ehrollie in- 
 
 llaiiiinatioi) eoiitiniies, the Madder euntrai't« riuiii the too 
 I'reijnent evaeiiatioli, and the ea^e heeonies one of eoneen- 
 trie hyiiertrophy, with |ierlia|is nieeiatioii. 
 
 When l>lood-eor|ilisiles are present in the sediment Wi' 
 may Ih' Hurr that there is nleeration. Sonu'times tiiere is 
 very free heinorrha'je. or the iileer may perl'orate the wall, 
 prodiieiui; pelieystitis, ahseess, etc. I'atieiits who me the 
 snhji'i'ts of ehrollie cystitis ari' pi'eiry >iire sooner or later 
 to lose their appetite, mid heeoiiie anii'inie, weak, and 
 emaeiated. Sleep is distiirhed and lirokeii from tliolieees. 
 sity for constant iiiictiirition ; the >kin has a dry, harsh 
 feel; the patient ii«_^es last, mid looks hiiiTirai .. < ►ccasioii- 
 ally the intlanimation spreads np the ureters, and pyelitid 
 and tnlinlitis nsnlt. 
 
 PuiMiNosis, — Most cascH of'rtubacntc cystitis, with proper 
 dii't and treatment, irct well, a.s do also a lartrc iiumlier of 
 the most acute easi-s. It is not often that an acute lasc 
 terminates fatally, Imt it frciiuently ends in chronic in- 
 tlminnatiofi, which when it heeonies of lonj^j standinir is 
 seldom ciirctl. 
 
 Tiu:.\tmi:nt. — WhiK' the methods of treatment of acute, 
 sniiacuto, and chronic cystitis diller entirely, the rules in 
 rcirard to diet apply c(pially to them all, and the same may 
 he said in rei^ard to clothint; and rest. 
 
 As to diet, the indication is to '"iider the urine as non- 
 1 :i 17 
 
 ^«»«V«'»l»<5r-v. 
 
 ■ r.:^^.~vM'.-f: i^^r- ~ v.»»,:.;vTr'.iTr«rj«sfC- 
 
VM 
 
 Disr.ASKs or THE i\i.mu>er. 
 
 irritatinir to tlu- imic.us m.'i.il.ran.' of \\xv MixMi-r as j.-.s- 
 sil.K' ; an.l in ..nl.T to accoiiii.li>h tliis it is of course iic.vs- 
 sarv to avoi.l lii-lily si-asom-d ai\<l siMc.d foods, as wi-U as 
 liiulilv iiLroLTfiioiis foods. 
 
 Milk, tier. iMvad, and potatoi's an' suitahU' in every caso, 
 while the amount of m.^at allouvl the patient must depend 
 „p„„ the sevefitV of the dis.'ase. Aleohol an.l t..haero 
 are to l.e ahs.dut.'lv forhiddeii. We ean always allow a 
 ivasonahle amount i.f meat in snhaeute eystitis unaeeom- 
 pauied l.v murh hvpera'sthesia, provide<l that li.|Ui(ls tn 
 sufUeient" .piantitv an.l ..f ....n-irritatin- .luality are also 
 taken,— sueh as milk, .'o.'oa, w.^ak ti'a, .-..tree ..f m.xlerate 
 e^remrth. h"t milk. an.l. as a rule, pleitty of mineral water. 
 As w.' have already sai.l, it is n..t oidy unneeessary to uso 
 the imp.u-te.l mineral waters, hut ahsolntely imp..ssihle_t.) 
 <ret wat.'rs of any country snp.'ri.>r t.) th.tso of California. 
 ^ As t.. the .•l..thin,<r in eystitis, it is i-ssential to he warndy 
 (dad. I have foin.i j.nvat henetit in suhaeute and <'hr..nie 
 cystitis fr.im tlu' use of eham..is shirts, whi.-h keep the 
 a'h.lomeu an.l pelvis well pr..te.'te.l fr..m the .■..1.1. Rest 
 is e.pially l.enetieial in all eases of disease of the hla.l.ler. 
 There are s.ime torms of ex.r.ise t.) he av.)ided, j.artieii- 
 larly horsi'haek-ridin.-r, li.lin.i; in oarriajres over ront?h 
 stre'ets, an.l, for women, the use of the sewin.ir-niaehiiu'. 
 Too mueh walkin.ir. of e.mrse, is injurious. With strict 
 atteiiti.)U to .liet an.l c1othin.<;, and or.linary care as to 
 exercise, a lar;;.' numh.'r of .'ascs of std.a.'Ut.- cystitis will 
 jrct well without medicine. Oth.'rs, atrain, re.iuire s.muc 
 medical assistan.'O ; an.l amon.ir the most ctHcient remedies 
 I have foun.l are eubehs and eopaiha. I often pivscriho 
 tw.. tirains ..f the extract or powden;d euhehs with thri'O 
 or four trrains of the inspissate.l balsam of eopaiha in ea].- 
 sule forin ivery two or tliree h.)urs. S..inetimes uva ursi 
 answers an exe'ellent [.urposo, as does also huehu. Whero 
 
OSTITIS. 
 
 lO.') 
 
 liliiddtT as jtos- 
 
 »t' ('((lirsi' lU'Cl'rl- 
 
 )(mIs, as Well as 
 
 K'iii I'vcrv caso, 
 lit imist (U'lK'ixl 
 (tl and toliacto 
 ahvavs allow a 
 stitis nnacrom- 
 tliat li(|ui(ls ill 
 luality an- also 
 fv'.' ol' iiKtiltTate 
 ' niiiirral wator. 
 lUH'fssary to use 
 ly iinpossihlt' to 
 ;o of Calit'ornia. 
 al to !»•-' warmly 
 uto and chronic 
 uhich kcop the 
 tho cold. Rest 
 of the hladdcr. 
 I voided, jiarticu- 
 iXi's over rontJjh 
 *c\vin<r-niacliinc. 
 us. With strict 
 inary can- as to 
 cute cystitis will 
 n, rc(|uiri' some 
 ■tHciciit rciiu'dit's, 
 [ often ])rescrilte 
 iihehs with three 
 f copaiha in ca])- 
 netinu's uva nrsi 
 ) huehu. Where 
 
 then- is some hvpera-thcHa nr irritahility 1 have lound 
 e,,ual i-arts of tin.ture of hyoscyaimis. spirit uf inlr...is 
 ,.ther. trlvcerin. and syrup ..f codeine, a drachm every two 
 hoiirs,'to an^w. r an i.dmirahlc purpose. T.. tiiis 1 some- 
 tiiurs add a.'etate of potassium four to six drachms to the 
 four-oiuicc mixture. 
 
 Se.latives, however, are not oft.'U m'cessary in >ul.acn!e 
 cystitis. ! have made a syrup of turpentine from an old 
 Kivnch formula that has ^nvcn mc mu.di satisfaction, and 
 iu eases when, ana-mia is pr^^scnt I have f..nn<l say tour 
 .Ini.-hms each of precipitat.-d sulphur, carhonate of iron, 
 water, and irlvcerin, with chloroform or peppermini-watcr 
 sullicicnt t.i make a four-oum-e mixture, answer e-iually 
 well in suliacute and chronic <-ystitis. 
 
 In the treatment of all vari»'ties it is well to keep tho 
 skill active hv warm or steam haths, while in cases tiiat 
 seem disinclined to yiidd to treatment the patients slionUl 
 sp.'ud a few Wi'cks at one of our sprinirs, where, if they 
 he careful of their <liet, take hot mineral haths, and drink 
 from four to six pints of mineral water daily, tlu'y will 
 ottt'ii net well in a short time. 
 
 Aoutc 0/.n7/7;.v.— The treatment of acute cystitis depends 
 entirely on the amount of hladder-involvement. When 
 tlie inilamination is coiittne<l to the mucous memhrano 
 there is little fever to he comhated, and the pain is not 
 usually severe. With attention to the rules already laid 
 down as to diet and rest, hot applications over th.^ rcirion 
 „f the hhnlder, plenty of warm demulcent drinks, warm 
 rice- or harley-water, flaxseed tea, or dec-oction of tritieuin 
 repens, and the twentieth of a irrain each of sulphate of 
 morphine ami tartrate of antimony every hour or two, (.r 
 iive irrains <.f Dover's powder every two hour>, or tincture 
 of h'yoscvamus, spirit (.f nitrous ether, and syrup of mor- 
 phia', of each a drachm, in water every hour or two, will 
 
 AiirtSsSMBewKtiaw'KstB* ^■ffl''-- «■"' 
 
iO« 
 
 nisi:Asr.s or rni: i:f..\ni>j:/r 
 
 oft. Ml be ill! tlif iiK'.liciitioii tliiit i< iirrrssarv. S(.nu'tinK's 
 iriTiit relict' is (.l.tiiiii.'il tVom a mixtiin' of ten to litU'cn 
 irraiiis (.f l.roini(U' oi (.otussimii and five .un-aiiis of rliloral 
 hydrate I'Vt rv two or tlirct- honiv. 
 
 ' W'liri-c th.' muscular structure ami perliaiis the perito- 
 neal iiiciiil.rauc as well are involved, as has already been 
 stated, the pain is very s.-vere, fever often hi.irh, eysto- 
 si)asnni> pn'Si'Ut, and the tenesmus of the hladder extreme. 
 Ilypodermie injeetioiis of morphine are othn lu'cessarym 
 these cases. Lar<re rectal eiiemata of hot water sometimes 
 assist in i^ivinir relief, and it is usually necessary to resort 
 to supposititries. 1 often .ijive in that form morphine .mo- 
 lialf irrain with extract of hyoscyanms live irrains every 
 three or four JK.urs, at the same time applyintr heat to the 
 sacrum and over the hladder. ( »c.'asionally there is re- 
 tention of the urine, when it will he neeuasary to use the 
 oatheti-r. In all these severe eases opivnn is the medicine 
 that irives relief most spiedily. I have found, however, 
 that chloral hydrate in ten- or titleen-,irrain (h)ses, with 
 one-eiirhth of a .irrain of morphine, will ofton act admir- 
 ahlv. In some of the very worst cases a few days of 
 this treatment will hrinjr relief, when tho h()t appli- 
 cations may he suspended and the amount of opiates 
 lessened. When any of these cases hecome chronic the 
 treatnunt must he chan-red. The fevi-r will have .lisap- 
 peared and the pain lar-rely subsided. The bladder, how- 
 ever, still remains irritable, may be (piite contracted, and 
 pus and mucus still be observed in the urine. 
 
 The balsams here an- otU-n of iH'notit,— balsam of co- 
 paiba, balsam of IVrn, and turpentine. I have found 
 their eflica.y assisted by condunation with ereasotc. 
 
 Creasote alone often acts well in chronic cystitis, ospe- 
 eiallv where there is a tendeney to fermentation and de- 
 composition of the urine. 
 
 ^.--j*-i*aWR - ■^»:— W* »» »W « 3g*ft»CVtt 
 
rysTiTis. 
 
 11>7 
 
 AnotluT ivnu'.lv fomxl l.riull.ial in .•l.n.iii.- .•vstitis in 
 
 l»i'ii/()i(' iui<l. 
 
 Sulol I liiivf lat.lv trir.l with iK'Hrtit. 1 liavf als<. iia.l 
 assistati.v from salirvlati^ of so.limn, an.l l.avi- fomi.l sa.- 
 rlianii,asivromi.u-n<lr.l l.v Dr. LittK-. of DuLlii.. to yvosy 
 iK-ni'H.'ial. In a lar-r miiiilHT ..f .'a., of cl.ronir cvstitis 
 inoiv iHMM'fit has Ihvm .Iriivnl from loral applhatioiis ami 
 washiiiir .)ut tin- hla.l.h'r than from ihr int.-nial a.lm.ms- 
 tnitioii'of mfdirim.s. i^>rati' of so.lium makrs a .ltoo.I 
 l.ri'paratioii for washiii.tr out tlu- l.la.hh'r, as .lors also a 
 wiak sohition of horacic aci«l. 
 
 Woak solutions of chloral hy.lrat.- answer a .r<">'l l"»r- 
 j.osc, an.l few thing's aiv h.tter than a s..lution of .•ommoii 
 salt, a (Ira.'hm to tho quart .(f water. 
 
 Nitrate of silv.'r an.l nilri-' aei.l have also been n'.-c.m- 
 m.Mi.le.l, hut it will he h.-st tirst to try almost any of the 
 other r.'ine.lies. 
 
 lu obstinate eas.'s in w.)men it is sometimes noeossary 
 to estahlish a vesi.'o-va.ijinal Hstula, hy whieh means the 
 hla.hler is kept constantly draiiie.l ami the intlanunati.m 
 
 remove. 1. 
 
 When ther*' is e..ntraeti.»n or .'om-entric hypertr.tphy, 
 ,lilatati..nof the hla.hler is ne.vssary, the .lir.'.ti.ms ton 
 a.vomplishin.LT whieh are ,i;iven under the treatm.'ut of 
 that .'on.lition. 
 
 It is har.llv necessary to say that while pursuing this 
 course of treatment, either by the a<lministrati.)n .)f ine.li- 
 .iues or hv local applications, the dietary rules canix.t he 
 too strictly enforced, uii<l the i.atient must abstain from 
 ali'oh.dic beveraircs of all kinds an.l fn.m tobac.M>. In 
 i^pite of all onr etibrts we are sometimes .lisappointed with 
 the results, there heiui? few diseases less amenable t.» treat- 
 ment than chr.tnic intlammation of the bladder. As has 
 been sai.l in the proirnosis, viM-y few patients ever i;et eu- 
 
 17* 
 
 l-.M2»^"S»«Sl'*P5rj*'.»* "W I"-- ,«aSt.'~nS!W 
 
 r aja ^,r- ft ;r:iif:?'^.--«^»»^'^'aBni»w«a^ 
 
108 
 
 nisK.isKs (>/■• Tin: iii..\niu:i{. 
 
 tinly w.U. It is woiid. rful, Iiow.mt. 1im\v h.iih' of tlic 
 v.TV w.rst .•as.'s of .hnmir .-y^titis. wl.i.l, Law ivsistr.l 
 all our .■H;.rts t(.. ■lire, will 1... iiui.n.vr.l l.y a trw w.vUs' 
 ,„• n.imths- suinurn at thr llinlMU. Uaftlrtt, Z*'i.irl'T, Paniiso, 
 lli.irl.hiii.l, Nai'U So.lu, ..!• any otluT ..f our Califuniia 
 liiiiifral spriiiirs. 
 
 (11 A I'TKli X. 
 
 I'KKlfYSTITIS. 
 
 l.v,.„„,,„iV._ri(Ti-s soiiu'tiiiiis iKTt'onitc tlu- l)1a(l(U'r-wall 
 Hiid icivc rise to luTicyslitis, and ocvasioiially an aciito 
 cystitis without ulci'i-ation I'Xtfiids thn.u.irli tlu- l.lad.U-r- 
 wall and involves tin- suri-onndin-' cclhdar tissue. 
 
 in chronic cvstitis there is often sonu- i.ericystitis. 
 Al.out f..ur vear's asro I had a :ale patient in whotn .iTon- 
 „n-h.ea ,xti-nded to the hla.hi. tlu' cystitis hein,<r very 
 acute and cniniinatin.ir in a severe attack of pericystitis. 
 It may also occur from intlammation of <.ther or,irans, 
 such as the rectum or the uterus, or of the peritoneum. 
 A year a-xo, I had a female patient wilh i-elvic j^eritonitis 
 accompanied hv a pericystitis. 
 
 Pericystitis may follow any of the acute infections dis- 
 eases. 1 have had in my practice a case of pericystitis 
 foUowin- typhoid fever. Septiciemia is an etiolop^al 
 factor that must he home in mind. 
 
 Symi-T()M.s. — The symptoms of pericystitis occurrinsr 
 duiiiiu' a t'ystitis are .irreat increase of pain over the 
 hladder. usually retention of urine, recurrent chills, in- 
 crease of fever," and iri'iu'rally tlu' formation of ahscesses, 
 wliich can be felt throu.i;h the va.irina or rectum or ahove 
 the puhes. The abscesses may open into the bladder, the 
 
 
V ot" tilt' 
 
 resisted 
 
 ■ \V('l'i\S 
 
 l';n'iiis(), 
 iilit'i)niiit 
 
 iiYVKitriidi'in "/•' '/'/"•■' tii..\nDi:ii 199 
 
 r.-ti.i,., or tl.e luritniu:.' ravitv, or tl.rou,L'»> ll..' lu-ri- 
 
 iii'iim. 
 
 Ill flu- i.cri.-vstitis nccomi-iiKyinu' clironie rystitis tlio 
 irroiin.liii,-; ci-ilular tissue is otU ii inaurated mid adlu nut 
 to tiie ;id)aeent parts. 
 
 Tkimmknt.— Tiu- medi.-ation must 1h> directed to tlu- 
 ullcviation ..f the iiiereased severity of tlu- symi-toiiis. 
 Opiates iire .U'inaiide.l, tin- eatlieter is likely to Ik- luros- 
 wirv, and abscesses iiiiist Ik- t-vaeiiated. 
 
 1 
 
 Ider-wall 
 111 acute 
 hlatlder- 
 
 i-ic-ystitis. 
 olii iToii- 
 ■iiit; very 
 rieystitis. 
 • origans, 
 itoiu'Uiii. 
 eritouitis 
 
 tiourt dis- 
 c-ricystitis 
 tioloLjical 
 
 neeurrillir 
 ovt-r the 
 chills, in- 
 ahseesses, 
 1 or ahove 
 iddor, the 
 
 (MIArTKU XT. 
 
 llYPKKTllorllY OK TUK IM-ADDKU. 
 
 TllK term hvpcrtrophv of tlu- bladder is used to desi,!;- 
 nate thiekei.in- of the blad.ler-wall. The hypertrophies 
 of the bladder are divided into two varu-tu-s,— nann- y, 
 ..oncentric and excentric. Tn concentrh- hypertn.phy 
 there is a thickened wall, with a diminution ot the cavity; 
 i„ excentric hvpertrophy there is a thickened wall, with 
 enlar.'ement of the bhuhler-cavity. These two varietur 
 ditf.r in their etiolo.ijy, uivatomical ai)pearauce, symptoms, 
 
 proo-nosis, and treatment. 
 
 F-nouxiY.— r'<-//r<v(//vV-i/v/>.77r<v)%.— Coiu'entnc liyper- 
 
 troi.hy i^ i-aused by or accompanied with inflammation 
 or livpt-rsvsthesia of tho bladder. 
 
 DuriniT a cvstitis or a hypenesthetic condition ot flu- 
 bladder '^he oWm i^ very intolerant of its contents, and 
 micturition is excessively Vre.pient. The bladder is, ot 
 course, never .listende.l with urine, and hence becomes 
 contracted. This condition occurs irrespective ot tlu- 
 cause of either the cystitis or the hypera'sthesia, there 
 
 ffl»s»«W*iKSiW!rs...s^«C,:s'a»»««ts«,e»r»--w 
 
 -i!«ot.s;.»*.,r<w-^a*»s*-»as:i'>s?--^»~*^' 
 
 Bsjis<«aB!»»fr"-sra!;»='""^*"-»*^^^ 
 
I 
 
 200 
 
 DisK.isr.s OF Tin: iii.MU)i:n. 
 
 l.fiii-r t»'vv «!i'"'^ uf.lin.nir cvstilis that .1.. not i'li.l in .■..n- 
 fi'iilri.' hviuTtrnpliv. It is .niit.- .■..iim...n t.. tiii.l .uiH.n- 
 trio liyiK'Vtfoj.liv wiicn^ tluMv is a vrsiral raKiilus. wli.ll.t r 
 til." stum- has caiisrd much iiitlaimiialioii or>imi.lv l.vp.T- 
 
 pcrtn.i.hv is oiitiivly .liHoiviit. It .oiu.s iVum an ..I.- 
 HtiMi.tinnt.. thr cvacnaliou •:'tli>' .'..iitciits of the hla(hKT, 
 will If tluTc is no hyju'iii'stln'sia. 
 
 In these cases tlie lirilie accuiimhiles and disteinU the 
 Ma.i.hT-cavitv, and it re(,niirs extra niuscnhir i'.xeftion to 
 emptv the hh"i.lder of its contents. The musenhir coat of 
 the hladder-wall hi'conies hyiK-rtn.phied uikUt these cir- 
 ennistanees upon the same princii-U' as tlie heart liyper- 
 trophies to overcomi' I'M raordinary resistance, as in arterio- 
 
 'sch'rosis for instance; that is, tlie hypertropliy in hoth 
 instances is compensatory. Tlu' ohstnietion is irc-uerally 
 an cidar-re.l prostate. It n.ay, however, he stri.tnr*' ; hut, 
 as a rnU", the ohstnietion of stricture is likely to he a.-eoin- 
 panied hv more (U- K'ss hyju'ra'sthesia of the hhuhh'r, 
 which in a measure prevents this distention, and intact this 
 f.irm ol i.hstnietion mi,u;ht also produce concentric hyper- 
 trophv. I helieve that a phimosis ini,-;ht he responsihle 
 for hvpertrophv. either i'..ncentric or excentric. thou,i;h I 
 have "never nu t"with a .ase ..f this kind. Diahetic patients 
 are fre(iuently the suhje<-ts of hyportrophii'd hladder of 
 either variety. Those diahi-tic iiatieiits who have con- 
 centric hvpertn.phy are ju-rsi-ns in whose clinical history 
 there is 'not the symptom of ,irreat thirst. They take 
 very little tluid, and complain irenerally of irreat mus- 
 cular exhaustion. The urine, not l.ein^i; increased in 
 .(uantitv, is of hiirh speciiic .ijravity, and contains a larifo 
 amount of suirar, which is very irritatin.ir to the hUuUler. 
 It is the constant micturition that prevents distention 
 
 ^t 
 
 ,,,..ft*.^f»Vli.—-e'ft'.r' 
 
 ■-_-^ .••■.^)(;i,««AA-*i*.lt*-^-. '^■- 
 
 .. ^it.~tvrmtciu:i*,^t:., , 
 
iiYVKimtoriiy or riii: in. \i>i>i:i{. 
 
 m 
 
 .,„, ,„H.. .■.M.s.Mumt ..o,H.....nr l.viKTtrupl.v In .lia- 
 
 ■ J vuM.t..n., an.l wl... n..l.UK. ...on - M-; ^ 
 
 r vatH^....l H.m.t. a uMvat a...o,.,.t of ....... ..!..• I'l-M-^ 
 
 :,:;;' othy,u..-a.t,.ti.. I -->•-;•'-'-"";:: ^^^ 
 
 ,., ,,,,.1 so ,.,v;.t a H''a..titv t'.v.i'U..tly .a..s. a t.,.. *x 
 
 ,,:',,iu.On.... .l..-..ni.-.-y.tUistl..s..,-ta.vot ,1.. nn,.;ous 
 
 n.l ,lu. i.loo.l.vc.ss.ls a.v .lilatM ai.. U.Uu^. 
 T , , is .U.SMn:....a,lo,, of tW .puMiu..., a...l VH'V .m..^ 
 
 , ,,„,,tion. Tlu. l.laa.K..-waU is so.„.ti.....s v...oi;...o..sb 
 
 k 1" I l.av. s..,. it al.oMt o.u. i..-l. u. .h..k..-s. 
 
 S^i;;t;;is.on....t.-i. variety the tl.i.U...i,... snot. ^ 
 
 ^.„n,vlv to ...•,.s..„la.- l.y,K..-tro,,hy, as ts .,s,.a 1> .tat 
 T, .v'h a,. i....vase i.. ,uM-..svth of tl.e tilM-o..s .ssue ....- 
 . li ..; tl.e .....s...lar lascintli, a...! i.. u.na,m..atory 
 : tW,v is also a ,.vat i.K.rouse i.. the ,n.wtl. .. u- 
 ,;,,.,,^,, ,,Hih.ous tiss,.e ..f the ....u-o,.s ,.,e...l.ra..e a> Y 
 
 \.,- the s..h,n..eo..s eoat. ^he st.l>se,,,.eut eon ..^^^^^^ 
 ,Ohis t.ewly-to.-...e.l tissu.. a.hls very .....eh to e h k 
 
 ,,i„, of tl.e wall, so tl.at eo,..e,.t,.e l.y,K.-t... .h , - t^ 
 ,,U:iJsha.-aiyat...ehy,K..-t.-o,hy;.....eho the h k^ 
 
 ,ni,..' is ..o ao..ht .hie t.. the ..o,.t.-aet.o.. ..t th. ^^.'l^ 
 r;h^..ke..i.., ..f the st.„..a..l.-.all -->lts -....-. tn 
 ti.,„ whe.v there exists, for n.sta...-e, a str.(t...e . t .1. 
 !;:s.;,ha,n... This thieket.i.,. ..f the st..n.ueh .s elea.l> 
 
 not an iiyi'iTtrophy. w ....v thirk- 
 
 1,1 exeenfi.- hypertrophy there .s ve.;y Uttle ,f ans th, k 
 enin. ..f the n.ueous n.e...hra..c, nor is Uh suriaee .rreK..la. 
 
 •^;t:l;ti.larKeu.nlthewallisthu.k,h..titist^ 
 nuLlar .-oat aUme that is thieke..ea; m other ...hK 
 
 *i6e;OT^:?**'2StVC£J »/irWaSW'"»- 
 
 ,rKMV-Jj-AA;,»<-*-'-.4Ai^*»^*"*'*^'* 
 
 ■■Mi, .^'.<i .Miin-MteK,'4m^<»^ - 
 
 mm 
 
202 
 
 insi:.\si:s or riii: nr..\ni>j:/i. 
 
 i. I: 
 
 I r 
 
 lliiTf is a tnic li_v|«i rtro|iliv, !>r<>iij.''lil iilioiit, as we have 
 alifailv sciii, liv llir tlToits ut' ilic imiscular wall of tin- 
 liladilt r to I'Xpfl tlif (■(iiiltiits ol' llif (ti'uaii. 
 
 SvM|.|nMs. — III ((tiici'iitric li_v|K'rtr(i|iliv tin- usual syTiip- 
 tuiiis art' llmst' ol" cliroiiif ivstitis. rpoii idivsical ixaiiii- 
 tiatioii. Ity the liiiiiaiiiial iikIImkI, wc liiid the tliirUnicil 
 I'diitraftnl i.lail«l(i\ t'nliii.ir lil<t' h huvA l»all, ln'liiii'l tlu' 
 itiilns. WIh'Ii tin- ((mfriitiic li_\ itcrtropliy is diu' to liyiicr- 
 ii'stliisia, till' syiiiittoiiis t<\' clironif cystitis aiv lacUinir. 
 
 Ill (Xiciitric liyiurtrivpliy, i'Xi'i'|it in diain'tt's, \vi' liavo 
 tilt' flinital history of tin- oitstniftioii wliidi faiisi'd tin.' 
 dilatation, ami liinl oil I'Xaiiiiiiatioii a lai'iri' liard tiiiiit>r in 
 tlu' liy|io<i:asti-if n'<.'ioii. Soiiu'tiiius ilu' liyin'rtrt>|iiru'tl 
 lilaildtT fNti'iitIs u|» to till' imiliiruMis. Tlit'i'i" u'.'iH'i'idly is, 
 al">, liyiurtro|iliy of tlit- iimscK's of tlii' aluldiniiial wall, 
 from till' ftlui-ts of tlii'st' iiiiisflt's tt> assist tlit- MadtltT in 
 I'xiit'lliiiu: its fonti'iits. Till' strainiiii; to fxpi'l tln' iiriiu' 
 oftfii t-aiist's jirolapsi' of tlu- rcftuiii, ami soimtinus fiii- 
 jiliysfina ami Inniifliitis. 
 
 I'lcdiiMisis. — 'riif iin>,irMt>sis dcpt'iids upt)ii tin.' etiology 
 and pathology in the individual ease. 
 
 in dialietes, when the patient is eiired of the primary 
 disease the hypertrophy tlisappears. The exeeiitrie hyper- 
 trophy tlue to eiilargeil prostata' will often tlisappear under 
 the prt>per use of the eatheter. The progntisis in the eon- 
 eeiitrie liyi>ertrophy whieh aeeoinpanies ehroiiie eystitis is 
 bati, as it is also wlien the kidney is iiivtdvetl. 
 
 TitKATAiKNT. — III exfi'iitrie hypertrophy due to prostatic 
 t'lilargeiiieiit the constant use of ti st)ft jierfeetly clean 
 eatheter entirely relieves the patient of everything but the 
 eiilartretl gland. A few years ago I was called to see a 
 geiitleiiiaii whtise condition was wretched indeed. lie was 
 unable to leave his bed, the pn)state was very large, the 
 hypertrophied bladder (cxeentrie) formed a large hard 
 
 
 
 '^ " ' W. iUfr-'ie ■■ 
 
 rv:3gf w ^J. . ^ lJ J^^^H■^.«l«tiP^■''l^a^gIrig1^iWWg«w?':^-^^v.**^?'^?g*«^^**'^■^^ 
 
.vKii- /./.•OH77/.S /.v 77//: ni.Anni:n. 
 
 20fi 
 
 ,,,,,,,,, ,,,,t,,n,n.l..M to ,h.mnbiU.MH,:m.ltl..alMl..m 
 U.S w..,v nuul. tl.i..U.u..l. Anv..fl..r.to,.as.wat. 
 Ll,rola,.-<.rtlu.m-tun,,an.l,ina.l.lmon 1.;..^^ 
 
 :taI.tns..o.Ml..H.n<.a.!u..n-atn.,ularn.U.na.s.m^^^^ 
 
 tlti.. .Mlar,.-nu-Mt an.l tlu- ..ui.l.vso.na, a.M 1>. .vsmu.-l 
 lii-* \\<\\a\ occiiiiatioii. . , , , , 4. 
 
 l„. ,lila„..l «i,l, «„.,.,■, a. 1,... a, ,;a„ !„■ l......... - ,1, T 
 
 :;:.!ivt;atnu.ntn,rthe.ontnu.tlonis.lila.anon .^ 
 
 l,u,suc.;i this .ourso t^>r ci^htc..,. y.ars, -'»'/-';; ^^ 
 I,,,, of surcss than aay otlu-r trcann-nt utU. nl. ^^ l.n 
 
 .^Ll ai well us aistond.l, 1 use. a son donUU. rubber 
 
 cutUeti-'r. 
 
 C II A r T K U X 1 1. 
 
 N.W ..ROWTIIS ANU KOREiON BODIES IN THE ni.AU..KK. 
 
 While the treatment of new jrrovvth. and forei^-n bodie. 
 
 is essentially sur^ieal, it is, -^^T'^''''''' "7:::Zlt 
 ,,,tter of <liaj.nosis or ditn.ent.al f •''^-^-j^ ^^^'^'^ 
 Bieiat. should understand their etioh.-y and symptoms. 
 Z:.Z are divhled into two great elasses,-ben,gn 
 
 " N:^h!^'al^'so common in the bladder as elsewhere in 
 
 a,a«»«ri!««B»«e«=^ 
 
 s«as»irw«iwpi^"«i>**'>""™'':' 
 
' I 
 
 204 lusEAsF.s or Tin: i',i..\niu:n. 
 
 iMiuniiH jiifiiiliniiH-', wliicli is ilitiilitlfs-i owiiiir to tlif I'ii'f 
 tliiit ill liu' lihnlilrr, •x.cpt, it iiiav ln', in tiif vicinity •'!' 
 till' iiifk, tlic niiifoii; un'Mil»fun»' is jkhh- in sccn'tinif 
 ;rliiinls, Hunn- iiutlmfs ii^sfrtintr lli<ii iniil>ililv to linil iiii.v. 
 Mijt, liowi'ViT h'ss tVfinn'iitly tlusf ^'louili,- o.riii- in this 
 incniliraiii', we tiiMl tlif siiini' varii'tv. 
 
 'I'lic bciiit^M tri'ou llis ioiii|irisc nivxoniii, liliroinii, mvoiiia, 
 invo-tiltfoiiia, ami tiiln rclc 
 
 Till' \aiiriirs nf tlif iiialiirnaiit arc, as iii oiluT orLraiif*, 
 ♦•|iitlnlioiiia, iii.'c|.lialoii|. sriirlnis, etc 
 
 \Vf know as little of tin' rtiolo!.'y ot' these new -.qowtlis 
 1 the hhuliler as we <lo of the iiew >;rowths in other 
 
 nieolis Iiielllhraiies. 
 
 Ill the l)la«l<ler as we «lo ol tne new ^n-owins III oilier 
 linieolis ineHlhraiies. 
 
 The syniptoins ict'erahle to the I'la.Mer iliU'er hut little 
 whether the uTowth is heiiiirii or nialiirnant, the pain and 
 initatio:i heiiiir "liie to the loeatioii and si/.i' ol' tin- ixi'owtli 
 rather than to its ehaiaeter. Constitutional syiniitoins, 
 howiver, are imieh more marked in th«' mariirnant than 
 in tlK heiiiiTii variety, ("aneer of the hladtler produces 
 the usual characteristic ca<'hi\ia. while the profound aii- 
 
 ^•C. 
 
 ^.•■■wt^.rr-Wt'-l-.t-i.***' fc'.^ry^^';**'^-'' 
 
 .- .j-*«tU^:-S-«J»^<rf>'C*JiC^*«®**Wt''**^*'''^^*M*'i'*J^ 
 
,,i^.th..>umM.ill..■^in.l.•MK.l..o^iM.I.•lH.u>^•;^vl.il^ 
 ^•„,....,nl ,.... 'nu..u...Hv..rtl..v.. .1. .an ... n.auv 
 
 Tl,..,vis.H. .M.l.a^to.l.. s..vm.V..t .1... ..NMu,.V...l 
 .„„.,.„,.,,,„„•„,, ur .!..■ .M.r.ir.KU.. tn. -. I "•u- 
 
 As " l.av. :.l...a.ly ..i.l, the t.vatn....t of th..v ,'n.wth« 
 IK fSKoi.tially Hi..\i,'i«'al. 
 
 FOUKKiN noDIKH IN TIIK MLADDKU. 
 AV. ...av .ns..ov..- i.. tlH. l.la.1.1..,- ^.vi^.. '""1--^ ''';';' 
 
 ;;;.;.„.;a.l...i.-wavi...otW.avi,ytln-o.,,h,tsw^ 
 
 ■.,utl..u,vt..-s,o..l.yway..rtlu....vth.-.. .. 
 
 ,,H.,vi.atr.vatva.Vty: .l.nno.l t.....o.s <..• t-rtal 1 m. . 
 
 , xt.-:ut..-i... ,.v,..a....y, ;..n-sto,...s o.- ......tH.t. ot 
 
 ' ..n.sti..os, all of ul.i.l. .nay a.ll...v »<> a.ul uU...,-ato 
 
 tlin.iiirli the walls. -if i„„,..c 
 
 (i.u.shot wo,....ls ,..ay nuM-y l.ulh.t.,^'W''nl.v' ot h...H>, 
 
 or l.it^ of c-l..thi..>r into thf l.la.hUT. 
 
 (;lvvl-..o„or.tio..s tVo... th. ki.hH.y., o..t..Mn^ the 
 ,.,.,,.,. l.v wav ..f the n,H.t..-s, ...ay Ikh-o,.,. the ..u.h . 
 olCe BUme., o,- hy.lati.ls ,..ay ...tor it 1.-0... the k..l- 
 
 .ItV. 
 
 .■atl-iH' 
 n.aiiv other eurious 
 
 s articles have been fonml. 
 18 
 
 «i^««iv4a9VAu>i'' 
 
 ,-,-.^.-i:«*^.;^raw»' 
 
 .H--na<?»i-*«JWt^'^ ' 
 
 ,«fl#r,-,-.:^.«ft,'-»V"-»^ 
 
•'(Ml 
 
 insi:.isi:s nf Tin: hi.\i>i>t:ii 
 
 > r, 
 
 Tin- lilt mis of iliiiirii.mir* me tlif l»iimiimiil ('Xiiiuiiiutiori, 
 tin' Hiiiiinl. iiml tlir tiiilH.((i|M'. 
 
 TIh' irialiiuni i'*, «•!' .oiirsf, Hiir^'i<al. 
 
 TI'IIKIH I'l.OSIS OK TIIK llF.AUKKIt 
 TlllllTfUlnMS of tlu' ItlailllfP i"" prol.ilMv VflT r.tl<l.>||| a 
 
 i.tiiiiarv disease. In tlu' male it is ii>iialiv assnciatiil with 
 tiil.(f.iil'>:.is of tlif trstiilc. tin- kiiliuv, ami orcaslonallv 
 III.' iuMirs; wliilf ill tlir frinal.' it is c.iirrally acroiiipaiii.d 
 l»v tiilKiciilosis of llif kitliH'V or tlif liiiiifs. 
 
 TInTf is mails always laciiiatiiria at sotiic i.tijoil in 
 till' roiirsf of llu' tlisrasf, lilliii' from tlif Ma.l.l.r or ihc 
 kitliii'V or from liotli. wliiU- tlio ulceration ami tliickiiiiiij; 
 art' likfly to involve tin- wlioU- K'iij;tli of tin' iinti rs. 
 
 W'c have alrcatly irivcii a <litail.(l acroiinl of tla- 
 patlioloirv ami syniptonis in tiilnrriilosis of the kidiu'V. 
 An »'\ainination witli tin' cystoscoiK" will sliosv cxtciisivo 
 111. •.•ration, ami tli.' nrinc will W found loaded with piini- 
 
 l.nl matter and oeeasioiially to eonlain Id 1. Himaniial 
 
 exaiiiinatioii l«y flie riTtum or vaL'ina shows a thifk.ned, 
 irreunlar. ami lender comlition of the l>ladder. 
 
 r\Tiini.oiJV. — 'Piiliereiilosis of the Madder eonimenees 
 in the siihiiimoiis tissue, iriviirir the mucous luciiihrano 
 an irr»',irular aiij.earam'e. The deposit is at first irelatiiioiis, 
 hut soon hecoiiies ojiaiiue and cheesy. As the clu'i-sy 
 deposit softens it involve? 'In- uiucous nieinhraiie. jiro- 
 diminix characferistie tnher. iilar nlei'iation. the urine e.ni- 
 tainini' juis, hloo 1, and disinteirral»'d tissue. 
 
 'rreatnieiit is jialliative. washimr out of the hladder, etc., 
 Iti'inn i;.iverned I'V the coiiiplicalious. 
 
 » ^'n^n.-^^.^tfWitvO*^^ 
 
initiation, 
 
 ^ 
 
 1 
 
 KMiir.sis sntrrus.t. 
 
 •207 
 
 •'t'liliiiii ii 
 atcil uitli 
 •asioiiiillv 
 Diiipanit'd 
 
 |ii'iiui| in 
 Ici- or till' 
 liicki'iiin^ 
 
 I'tfl'S. 
 
 It i>r tiic 
 
 I' kitliii'V. 
 t'Xtciisivo 
 
 k'itll |>U!'II- 
 
 irniiiiiiiial 
 liiiUciicil, 
 
 nimiriiccs 
 iiciiiliraiu' 
 fi'lntiiKiiis, 
 lie fliri'sy 
 
 rant', pro- 
 nriiif roii- 
 
 lldtT, L'tC, 
 
 (• 11 A r'i'i:i{ Mil. 
 
 |:MIU>1S Nh.I 1 NA (NnrnUNAI. INCONTINKNtK). 
 TllK rtinl.M'V Ull.l pullinlntrV nf tills .•.•lulilioll alV llS Vft 
 
 v.TV uUmuiv. n.if is it |.ns.il.lr to ..xplaih vvl.v it in ain...Ht 
 
 c.ntitvlv .M.ntinr.l t.. rl.il.livn. Wli.n It uis in adnltrt 
 
 i( i. piMTallv till" ivsiilt of n.r.li.iins or i.aivoti.-s; in 
 t;,.t. it i^' nut a Vi'fv unusual tl.ini; lor nun wli<. >,'.. tu l.r.l 
 .Inu.k to l.avi- tlii- .•..nt.tits of llnir l.la.l.lcfs rH.apo tn- 
 voluntarilv. TIn-ro aiv inanv tlioofii-H advan.v.l as to tlio 
 .,..,nal <aus,. of tlli^' n.ndilioii. iait noin- of tlimi aiv satis- 
 ,„..,orv If tin- .•ontcnts of tla. i.l-l.U-r .'s.aiM. Lcausi, 
 „f pui'alvsis ..f til*' spl.in.t.rs. wl.y is tlniv no paralvHis 
 .Imiu" "tlu- ilav? (»n tl.r ..tluT l.an.l, if it is i.ur.y a 
 sonsoiy neurosis, why .lo.s tlir .listiirban.v or.iir only at 
 
 '"~It'liasl..'.'nsuu'LCi.st.'.l that with .-hihlrni thus afU'cti'd 
 sh'.]. is unu.uaUv |.rofoun.l : hut 1 do not >..• thai this 
 MlVords a satisfactorv i'Xi.lanati.ni of th.' inrotitiiifn.'c. 
 Thnc is, in nivoi.inioi., adisturh.d rathrr than a |.fo. 
 f.uind slrt'i., n.i' tlu' reason that ivtlex dislurhan.'.s oltcii 
 ,,h,v an important j-art in this condition, su.h as piii- 
 woiiiis in th.' roctuin, iindipstc.l foo.l in th.' howi'ls, 
 rlon.Mtr.l, adh.n'iit, nv irritati'.l pivpiuf, ston.' in thc^ 
 ,,,^„,',l,,, „, ,„h1iu' ix.it.n.rnt .lurin.tr th.' .lay wliuli w..ul. 
 ,..uis.. th.' .•hil.l to .hvani an.l h.' r.'sth'ss. Tin- HU.-.'csstul 
 tivatnunt hv sc.lativcs scciiis ids., t.. iM.int t.. its h.inir a 
 rcstU'ss ratll.'r than a j.rofoun.l sU'cp. My own holu't is 
 that it .l.)t's not dc'ia'ii.l upon an aiavsthi'sia ; .>n the oun- 
 
 ■•'■i^^^MMfVfHStilMP. 
 
 ».'*.. *»*iW***ftf»«-==^' .>»ii*^'' 
 
208 
 
 visi:.\si:s OF Tin: i'J,.\nni'f!- 
 
 
 I. ;, 
 
 ■ iH 
 
 ■■"lit 
 
 trarv, T liol.l that tl..-y \\-r\ tlu- -U'si.v t.. uriiiat.., aii.l .i.ipt.v 
 tlH.'l.la.l.l.T uikI.t til.- sanu. nu'.ital .M.n.l.tu.M ,n whu'l. 
 ,l,,v ini-ht Nvalk .,,• talk ii. llu'ir sl.^r--"''" " ''^ ''' 
 non.ial voluntary art, th- .vsult of an un.'u„M.,ous .v.v- 
 
 braliim. , , , 
 
 Y,i,^rMi:NT.-Mai.v of tlu-so .•l.il.lrri, ran hv .Min.l l.y 
 Htri.-t attention to In-ioms that is, nuv as to tlu-ir .lu>t. 
 avohlin- too nuuh .Irink in tlu- lattn- i^ut ot tlu- .lay, 
 ,„„1 ..•uar.linir a-ainst ov.T-i.x.'it.'.nont .)r ox.TtH.ij at any 
 tiuH." 'I'lH-v shouM not hi' alh.w.Ml to -.. t.. thv .•uv.'s .>r 
 Wihl West shows in tlh' .'ViM.in-. Wh.-n tluT.- is an 
 ,„llu.n.nt. .■!. i-at.'.l, ov irritahlo pr.'im.v, .■imnn.'isi..n is 
 not onlv justitiahl.', hut vwn nooossary. 
 
 Thi- "ivotuiu shoul.l hv oxaiuiiu'.l tor ,.in-w<.nns; in 
 short, in this .>on.lition, as in all ..thor .liscasos, raiytul 
 in,,uirv shoul.l hr n.a.U' int.. tlu- oti,.l..-y hcf..ro lu-tscrihing. 
 
 Manv'of thi-sc- .-hihlri-n rniuiiv ,i,^om-ral tonu- tr.-atnu-nt, 
 ;,,„; „i,n,u-, .-(..l-liNvr ..il,.t.-.,with n,...U-rate ..ut-.hmr 
 ,.x.-r.is. an.l .-han-.- ..f c-li.nat.. Tlu- sju-.-ial ivnie.ly 
 that ^.-.■ms to 1h- ..f nu)st use in my han.ls is h.-11a(U)nna, 
 •ihout tivL- .lr..i.s of the tincture jrivon at three or h.ur 
 in tlu- afternoon an.l repeated at l.e.ltime. When this 
 iUils, 1 have oeeash.nally sueeee.le.l hy .•onihinm.ir the hel- 
 la.h.nna with tlui.l extraet of erir-.t, n^xv-xx, an.l I have 
 pometiiues found er.tcot alone to answer an excellent pur- 
 
 nose. 
 
 Tin.ture of hv. sevainns, with or without spirit ..f nitrous 
 ether, has heen'found eiHeient with s.une chihlreii ; while 
 \n v.-rv nerv.>us children hromi.le .-..inhiiu-.l with chh.ral 
 hv.lran- has sueeee.le.l, showin.i; that in those eases, at least, 
 theiH- was present a hypera-sthesia rather than an anscs- 
 thesia. Another .-xi-el'lent remedy is eodi-ine. 
 
 If thes.- ehil.lren are watched, it will he found that most 
 of them sleep in the dorsal p.)sitiou ; and it is while lying 
 
 m^ 
 
 i:r4:T.JS-!iSS«*fc«<J<Hl«i'«» •*«<""" 
 
 ^.-,«M(»i*«(<Ma«».^t&.''««**«w«"«'<»-'^«'*«*^^ -' 
 
1 
 
 iTi- IS ail 
 urision is 
 
 orins ; in 
 's, carot'ul 
 ■escribing. 
 :reatmont, 
 ' out-door 
 il n'UK'dy 
 i'lla<loniia, 
 M or tour 
 allien tliis 
 :i!j: tho bol- 
 111(1 I have 
 olloiit pur- 
 
 EMiiHsis yorrrnxA. -09 
 
 on the l.a.'k that tli • evacuation takt's placo. A means 
 i.iiii.l..\v(l l.v many mothers, wl.i.li often provi's cmra.'ious, 
 is to tie a"to\vel'alM.ut the i-liil.l witli tlie knot l)elnn(l, 
 wliieh wlien lie turns on his haek either awakens him or 
 causes him to ehani^a' his position. 
 
 18» 
 
 tot' nitrons 
 fell ; while 
 ith chloral 
 ics, at least, 
 n an aujcs- 
 
 il that most 
 while lying 
 
 .■.!«*«a9?«sr"''««-fWB!!!«-»^' 
 
210 
 
 DiAiiirn.s 
 
 'M 
 
 SBCTION V. 
 
 CIIATTKli T. 
 
 i 
 
 
 DIAllETKS. 
 
 IIHTOUY.— The first cU'i.r .Irs.-npti-.n of a case ..f .lia- 
 lH.t<.s'nu.t with in i.u..li.al lit.rat.uv is in tl.o wr.tn.-s o 
 (Vl<u^ Uv calls attention tc pationts who .■..niplain ot 
 irn.at weakness, excessive thirst, cxtn n.e emaciation, an,l 
 tlu' uassaiTc of lari;e (,uantitios of urnu'. 
 
 ArotirMis is crclitcl wi^h havin- iirst use.l the tern. <h<- 
 /.7.., referrintr to the<lis..,se as follows: '> Diabetes .s a 
 won.l Tfnl atieetion, not verv fre.inent ainon- men, hem- 
 n n.eltinir down of the flesh an.l lin.hs int.. nnne : . . . 
 the patients never stop makin.i,^ water, hut the flow ,s ni- 
 eessant as if from the opening of a.iueclnets. Calen also 
 makes mention of the disease. 
 
 Little or no advance was made in .lu- knowledge ot the 
 disease until the time of Willis, in \m. He aserd.ed 
 the sweet taste and smell of the urine to the presence ot 
 Ku.ar. Soon after this suggestion hy Will-, sugar was 
 separated from diabetic urine by chemical analysis, and 
 all doubt was thus removed. 
 
 It is about one hundred years since KoUo observed that 
 vegetable foo.l increase.l the .pumtity of sugar m the urine 
 .,ud in conseuuence advocate.l a purely animal diet >o 
 until 1823 was it discovere<l by TuMlemann and (.melin 
 that starchv food was converted into sugar during the 
 process uf digestion. Soon after this sugar was demon- 
 
 mi 
 
 — :ii»ofiR;3nr!?^""-*p****ttww 
 
 3'»it->i.-««'"S 
 
 AMi 
 
DIMiKTKS MF.iJ.nrs. 
 
 •211 
 
 \\ ritiiiirs of 
 '()mi»lain of 
 L'iutioii, luul 
 
 Ik' torni '/'"- 
 I'liilu'toH is il 
 mi'ii, boiiig 
 uriin' : . . . 
 o tlow is in- 
 GaK'ii also 
 
 Ic'dijo of the 
 He userilH'd 
 > presenee ot 
 s, suu;ar was 
 iiiialysis, and 
 
 observed that 
 r in the urine 
 nil diet. Xi»t 
 and (Imelin 
 ir dnriiiu the 
 r was denion- 
 
 stratol t.. he i.ivsc.nt in the hloo.l. Claude IVrnanl was 
 tlu- first to .h-in.Mistrate tliat sn.irar is ••onstantly i>resent n. 
 ,1,., l.lo.Ml of th.. ri-l.t shle of the heart, while it is almost 
 ...itirrlv absent on the h'ft si.le, an.l that it ent.rs the 
 inn.ri.M- eava by the hepatie win. He also foun.l but a 
 trare of sn.srur in the portal vein, thi .wn.- that the 
 
 livrr is thf irreat snirar-iinxlininir orti, 
 
 IJrrnar.l Vnrtln'r tau-ht that the liver ha.l two su-ar 
 nui.ti..ns,— nanuOv,tlmt.)fe..nvertinKsujiarint.)!:lye.^iXei., 
 
 or its jrly.M.ironetie function, and that of convertin.i,' .srly- 
 coiTon Tnt.. suu-ar, or its .-lyeojrcnie funetion. liernard's 
 tliwries have never l)een unanimously ueeepted by physio- 
 loiXieal rhemists. 
 
 We usually niaki- a division of diabetes into two classes, 
 — iliahetes niellitus and diabetes insipidus. 
 
 ClIAPTEK IT. 
 
 DIABETES MELUTUS (MELMTUKIA — ULYCOSURIA — 
 
 olucosimua). 
 
 DiAWETES MEi.LiTUS is a disease whose I'tiolojry and pa- 
 thology arc obscure, hut whose pathognomonic symptom 
 is the presence of sujrar in the urine. 
 
 Etiolo(JY.— While it is impossible to state the exact 
 cause of diabetes mellitns, we have learned from observa- 
 tion numy of the conditions which seem to act as etiolo<?ical 
 
 factors. 
 
 (7/,,,„/,.,_This has probably little or nothmg to do witli 
 the production of diabetes, althouj^di it is often stated that 
 iiussia, IJrazil, and the Antilles possess a peculiar exemp- 
 tion from this disease. 1 imagine, however, that in coun- 
 
 — J 
 
IVl 
 
 i)i.\iii:ri:s 
 
 ,,i.. -i.arsrlv sHtl.-l wn.l with t;.w ,<u..H.ul mumk tl.. intW'- 
 
 :::n:.l...i.;n,.o..t..i ;-'-;-•';-•;;:; ;;;^ 
 
 .!,.,,:,rul .x.nm..tio,. of th.. un.H.. ^^ '■/'', ^""^^1 
 
 ,,,i.ns,.t-urLas,luM'l>vsi.iaMswl.odooho. ,'.•u.' 
 , ,,,.. eitics, nor anM...nntry-i-.,.U-, as a ruK.. s.. ,..;. Ml;t 
 :r.onsul,in, a ,,h>>i.ian as an- .l.oso wl.o .vswl. w. 
 
 Cltll'S. 
 
 rUn.ato, thoroior., is n..t an .nolo.i..al ta.tor of any 
 jd'oniinciu'i'. 
 
 Tlu' sanu' niav Ik- said of seasons. , , • i 
 
 1/ ._M.un\vnn.rson.lialK.t.ssta...thattho.I..v,sh 
 
 ,,,„, .s ,,ar,i.ularly liaUK- to tl.is d.s.as. an.l tl^at^thc 
 African nuv is i.o.'uliarly i'xoini.t 
 
 Xi-itlior of tlu'so 
 
 ; .ts is n..;..t. In llu. c-aso of tlu. HoW- ins 
 
 V to .lialK.t.s is no .lonbt tlu- r.snlt ot Ins »>a..Us, 
 
 ;.,ion,H..ratlu.r,lKn.ofl.isnu.;.nl....a^^ 
 
 tlH. \fri.an,tlu..va,vn.Mlatat<.Nvan-anttho assert on ot 
 
 II;: ;.l,.,ion, an.n.is haUits a.v n..t sn..h as wonl.l tonn 
 
 ii uri'tHsiiosinir cansi'. ,. , ^ ,i ,., 
 
 '.V, ,._lln adults nn.U.s aro n>o.v sul.joot to Oabot.s than 
 IV.nalrs. In .hiM.rn sox is not an i'tiolo-u..! a.t..r 
 
 ' -N-'^- - ^'>^^''''l'*- The a,.-s that inrn.sh th. 
 Ur^;L pcnvnta^. of .as^s aro, in n.al.s, tnun th.rty to 
 .ixu voars, and in f.nnd.s tn.n, Wn to tlnrty years 
 ■ ■//;/,;/. -Ihd.its of lifo an<l oc.ui.ation, no douht, pla^ 
 ^, ,,„t part in the ,.rodiu-tion of tins d.s.aso 1 
 ^ .\vill-o.tahlish.d ta..t that se.l.ntary hah.ts and lu^h 
 WU ,m.dis,os. to diahetes; and M.I.V. that th^^^ 
 
 Uvo nu tors a.'-ount for th. nnusual proportion ot llchr... 
 i„ „„, i„... ..iti.s who snflVr from this .on.ht.on 
 
 ;;;;../;/;-I)iah.t.s is not a w.ll-n.arkcd hcnnhtary <hs^ 
 ,,.,.. althou-h w. d.. nu-vt with casos ,n whuh th. tanul> 
 history pohits stron.udy to lH.rc..litary pr.disi.osUion. 
 
 '^i^ 
 
 ^; _. . ,^^(gj^eg!.i!!SrsT-:--^'^l»#-*»=*^'»*®'^^ 
 
 ^^j„-;^?«»Mh**.«-*arti««»*.«a^^ 
 
DIMiKTES Miii.i.rns 
 
 m 
 
 . tlif iiitVc- 
 tfd to link 
 kiiiiw tliat 
 icir I'Xiiiiii- 
 II' iinutifi' 
 , so jtroiiil't 
 o R'siik' in 
 
 •tor of any 
 
 tlu' .Iiwisli 
 1(1 lliat till- 
 LT ol' tlu'so 
 tlolm-w, \\\^ 
 f liis liiil'its, 
 \v in that of 
 ansertion of 
 wonM form 
 
 liiilu'ti's llum 
 I fa<-tor. 
 
 fnrnisli tho 
 oTii thirty to 
 
 years. 
 
 ) (lonlit, i>lay 
 \ (lisiiisi-. It 
 lits antl lii.irli 
 /t' that tlu'so 
 n of Ilohrews 
 ition. 
 
 uToditary <lis- 
 it-h the family 
 )osition. 
 
 Pn<i)iitiivfi. — It is not luiroiniiioii t(» \\\u\ suirar in tlu' 
 nrinr .hirin.ic prt'iriiancy, nor is ii iiiuisiial to liiul lli<- 
 sMirar tlisappfar after hiltor. wiilioiit trcatnunt. 
 
 Snirar oft»'n api^i-ars trnqiorarily in tlir nrinc after an 
 exeessivi! (|nantity ot" siii^ar has lieen taken into tlie sys- 
 tem, after l)lo\vs or slioeks, after i.eriods of exeessive stiuly 
 or <if stroiiix mental emotion, and after epileptic tits. 
 
 Dialietes attacks two very ditferent types,— namely, the 
 stont, oheso, mns.'iilar person of ijonty hahit and tin- thin, 
 nervous, iienralt^ie suhjei-f. 
 
 There are many snhstanees which when taken into the 
 sv-tem in excess prodnei- diahetes, at least tcmpoi'arily : 
 for instaiH'e, hy«lrocyanic acid, earhoiiie acid u'as, nior- 
 plilne, mercury, etc. 
 
 I'.\Tiloi.<MiY.— We have already ohserved that tiie pa- 
 tholo--y of diahetes is ohscure. While it is a fact that in 
 no ca-^i" .)f death from diahetes is every or,i,'an in the hody 
 found to he normal, it is e(pnilly true that there is no one 
 or-'an that is always found in a patholoj!;ieal condition. 
 
 When a i)ost-mortom does reveal a patholo,t,'i<-al condi- 
 tion of an oi\tran if is impossihle to say whether tlie dis- 
 eased organ Caused the suirar to appear in the urine or 
 whether the su,«rar in the hlood produced tlu' oru-aiiic 
 ehantri'. In other words, there is no patholo<;ical anatomy 
 characteristic of diahetes, 
 
 f/n-ir.—\\ is not infreipient to find the liver (piite 
 nonnal in api.earance. Ofteiier, however, it is eidaru'c'l 
 and hvpenvmic, the capillaries heinir niuch distended and 
 the hepatic cells swollen. (Occasionally there is an in- 
 <ipient cirrhosis or a fatty de.irem-ration ; hut there is no 
 evidence that the cirrhosis is the result of tlu- suirar. 
 
 P,mrvi'ii!i.—\X is douhtful whetluT any one ortan is 
 more often tound diseased in diahetes than the ].anerea8. 
 In one ease it nniy he hypertroi.hied, in another it may 
 
 ««!M«a>it»4w 
 
 mmmm^ 
 

 V 
 
 
 ^U 
 
 214 nunKTHs. 
 
 ,,^.^,,,, ,,■„,., ......vstir. (•on.Tc.tions..l.stnu-Hn^r,lu..ln.t 
 
 ,,,vM.'..MonM.K ;u.l tattv a.u-.HTation .s not a ran. .■..,.. 
 
 '*''i;":,,_Tlu.s. organs an. otWn t;MUwl ais^^^^^^^ 
 ,,,t.s;tlK. patl.ol..^i.-.l .•oM.liti..Ms lH.i..,r .;.n.,n. l.ron- 
 ,.,.iti, til.n:nsi.l>tlMsis,o,-tnlK.n.ul..s,s. ^M" ^ ' ^ ; 
 
 ' X lu. ain..t result onho su^a.- in tlu. 1 00.1 .MS 
 ;l;;s;i;.le that m ,h.se ease, tho sugar l>as ,ro.lu.....l the 
 
 '^'^;^",_TlH. spU-cn has lu.-n to.uul hy,K.rtro,.hh.a in 
 
 M.nu- rases an<l atroi'lii''^ \n <»tlu'rs. 
 
 ■ ';;';,/,,,WlMu.kianovsar.vc.ryot-ton,hutnotn.vam.l , 
 
 ,..,a,...;i. Th..nhn-gc.nu.nt,wh.n,.vsom,.snuMv ,k.y 
 ,„ ,,;,lu. to hyiK.n.nna than t.> organic .hseas.. Lh.l h 
 Urts tlu.t th' cr'tl-l-H'-n <.t- Il.nk.'s lo..,. )s ahva . a.- 
 
 ;,.„.,nu.a in aialK.,.s,ana that it Uaglv.>gc.n.. .^^^^^^^ 
 • .. . . .,,... ;. .1,.. ..roiouhisni ol tho .i'lls al\va\s con- 
 
 oration; that is, the i.rotoi.lasni 
 
 „•„, .,vc<....n. It is l.rohahU> that there is n.> spec k 
 ..U,..,,.nieae.eneratn>nJ>ut that the hypcraMma ..t the 
 kianev l.roauces a celluhu- nntritive necrosis or .K-ene.a- 
 r,..n a'na that the cells ahsorh glycogen from the ur.ne 
 
 When tnh.Uar or intertnhnlar nephritis is present, it is 
 i,n,...ssihle to aetennine its relation to .liahetes. 
 
 V/</.r.-The Ma.l.ler is ..ften greatly hypertrophiea, 
 
 the result of functh.nal activity. The hypertn.phy may 
 
 .ither concentric or excentric, the former oecurnng 
 
 :,:, ,,, .,,ar proauces hypera-sthesia am trcMuent 
 
 l.ncturition; the latter, xvhen the ..uantity ot unne ,. 
 
 verv irrcat aiul hypera-sthesia is not present. 
 
 .;,;,,,./.-The appearance of the sto,na<-h ana intes- 
 tines on post-mortem furnishes no explanation ot the 
 . .nous appetite ana insatiable thirst so otten <-..m- 
 laot^hyona, perhaps, sonie enlargement or hyper- 
 
 «,*«:./J»».^«i«-*»>«l«5a*^'-i*^T»«»»-«^^ 
 
 EIBSfi.ii 
 
/./.i/!/;r/-:.v mki.iatvs. 
 
 •215 
 
 the tlilft 
 rare iini- 
 
 •d ill tliil- 
 iiic Itroii- 
 
 . tlllTl' H 
 
 I'litf tluit 
 IikmI, it is 
 
 IucvmI till' 
 
 dl.liird ill 
 
 iivariiiltly, 
 unT likoly 
 . Klirlich 
 always tUv 
 iiir (k'treii- 
 Iways cou- 
 nt) sporitic 
 iiiiii of tlio 
 • (K'jiviK'ra- 
 10 uriiK'. 
 ri'siMit, it is 
 s. 
 
 iiTti'()phii'<l, 
 trophy may 
 r ocfurrinir 
 1(1 iVotiiii'iit 
 of uriiR' is 
 
 ai\(l iiit.'s- 
 
 tiou of the 
 
 ofti'ii coui- 
 
 nt or hyiicr- 
 
 trophy of tin. stoM.a.h whhh is th. .vsult of thr mvossary 
 
 fuiiftioiial activity. 
 
 /</,„./ -The hloo.l n..nnally contains a small amount 
 of suuar, an.l it Is only wh.-n this .,nantity has l.ccn cu- 
 .i.lcral.lv incrcas,..! that wc .Icsi.^inatc the con.l.tu... as 
 ..Ivka.mia an.l the conso.pUM.t presence ot sn-ar in tl.e 
 
 urine as glycosuria. 
 
 Symptoms.— There are no suhjcctive symptoms patl.oif- 
 nomonic of .liahetes, ami there is hut one ohjcct.ve symp- 
 
 to,„,_namelv, ex<-ess of siit^ar in the hi I as evn leme.l 
 
 ,,v its appeanu.ce in the urine. There are teW pa , cuts, 
 ,;.„vever, who ,h. not complain of excessive wc-akness, 
 muscular dehility hein.-r sehh.m alwut. 
 
 rw.r-As su-ar in the urine is the patl.o.miomomc 
 .vmptom of .liahetes, it will he well first to consnler the 
 nVniptoms exhihite.l hy the urinary orj^ans. a lenh. 
 .;.iaom complain of pain over the ix-ion ot the knlne^s 
 ,,„, ,.nen experience a dull, heavy, dra^^m^ sensa o 
 ahout the loins. Xor (h. they often complain ot pain n 
 the hladder. Occasionally they exhih.t .n-at •••ntahil 
 ^,,.^,,^, l,ladder,the hypenesthesia heu.LM.o douht p.o- 
 
 .lueed hvthe irritatin- .p"^l't.V -'" <''^' "'"'^■- /'^^ *'"'.'' 
 there will he a catarrhal cystitis, with some pain on m.c- 
 »„,ition. rn other cases there will he well-marked hyper- 
 troithv of the hladder. . . , , i 
 
 ;),.;asionallv we tind phimosis, with an irn ah e ami 
 .x.oriated condition of the prepuce, while m the tcmialt 
 ,;,„,Uus vulva, is often an extremely unnoyu.iT symptom 
 Diahetic patients usually void an <;'^^^-';r 'l'^^ '^-y; 
 ,.,i,H., some micturatii,,^ tVe.piently, heii.i, .listurhed otten 
 at ni.'ht, ami makin.ir in the twenty-fonr hours a -alh.n or 
 more of liirht-trreenish cr straw-colored urine. 
 
 The amount, of course, varies with the amount o huuul 
 ingested, although some experimenters maintain that the 
 
216 
 
 i>i.\iii:ti:x. 
 
 >\ 
 
 ij 
 
 ' I 
 
 (it 
 til. 
 
 „,in.- voi.l..4 is on.n in .x-.-s of tl,.- .,nantity ..f tl.u.l 
 tiiloii int.. til.' stoiiia.li. 
 
 .,.,,., ,,, .i.l ,l.or,..iu,. of tlu. ll.M.l Iro.M .1... MlM.u.Mt.n 
 ,„„, i.v ,1... l,loo.l-v.ss,.l. tak.s l.la.v in a.v..nl...... wUl. 
 
 U.ki.nui. J.l.vsi.al law of ohuhwih. , 
 
 •n.., .uin. l.a. a swvvl, sirk-nintr o.Jor ';>"; '^ f^^'^;''^^ ' 
 H.,.. Its s,..-if.. .M^avity ran..> f.o.u lu->.. to K.-.O. 
 ,;.:;„:. ^...H-raUv al.out lu:;o. Th. an.ou.^t ot su^ar 
 vuric^fron. two to ..i,.. ,kt o.^.. or fn.,u two or timv 
 enm,^ to lw..„tv-fnv Lrrains to th. o.,mo. \\ I.«U- th| 
 ;.n.mnt of una to llu. onu.v of nri.u. is Msaallv a.m.as,.. 1, 
 
 ,,,,.,,,,, i.v ..m.t..l in twvntsMour In.urs mua.ns a -on 
 th,sanM-as"inl..altl.. I, is onl.v in .as.s wIh.v no tl.u^t 
 is ,x,K..irnr...l that thr M":"'tity ..f urin. l.ass.<l is lens 
 
 "'/;;'!^I-!!;!_TI... n.ajority of .lialKtir i-ati.nts l>ay. rav.n- 
 .,..ap,..ti..s,a..on.,.ani..ai.yinsatial.l.- thirst. lh.y|o,n- 
 ,,lain of a ,.an-h..a ana .Iry ,n..nth ana t In-oat, ana a,. 
 Lontinnally' ...avin, n.on. a..ink. ;nH' '..;»!., -P-aly- 
 vou,..' iKTsons. .hvay rapiaiy, own.-r I-fohahly to an .uul 
 V,n„:,.tatiouof thoso.Mvtionsof th.. ni..uth. 
 
 ,„ ,.uM,v ras.s, notwithstanain.u^ tin- .ij.vat uniount ot 
 tinia ana f.u.a takH. into the stonuuau the. ,.atu.nts n.m- 
 
 ,.l,i„ v.TV litth- of inai.^stion; whih- otlu-rs, wh.. take 
 ,ut littl.'tooa, olh.n vo,nit, at.l aro ..n.stantly .h.t,vssc.a 
 
 ,, ,,,s in the stonuuh ana how.ls, tats .s,K.y,al v h.u^ 
 .linhuh for tlu.n. to ai.u.st. Thisn.nait.oti nn,.a.t w.l ho 
 anti.il.at.a fron. th. ta.t that aiahoti. i-atunts aro so ott.n 
 „.,. suhj.vts of a ,.atholo,./ual ...naition ol the- l.an.-rca. 
 
 ""V^Lr, 0,v/....-IVyona tho w.ak p.a^. tVo.n a 
 ,.,.,u.rat.a ana atro,hi.a -...aiti..,. o. tho h.JJ. nn. 
 .lih.tation of th. .H.rohral v.ss.ls, thotv ar. no .t„k,ng or 
 von^tant svtnpton.s .on.u.-toa with the c-urulatu.n. 
 
 ■ '^'^Nwmf-^a .^.v«t^>*«««*'^««*««^^ 
 
DIAHr/rHS MI'JJJTI'S. 
 
 •217 
 
 <.r tiui<i 
 
 iiiu'iiliiry 
 iu«' with 
 
 s\vt'«'tisli 
 to in.-)!). 
 
 i)t' siiLi'ar 
 
 ol' llll'i'i' 
 \'W\W tlH' 
 
 ii.'( ivasctl, 
 liurt alioiit 
 . Ill) tliii^t 
 111 is K'ss 
 
 \w ravi'ii- 
 riu'vcom- 
 , and an- 
 l»f<ially in 
 to an tici'l 
 
 miount of 
 
 ii'iits I'oiii- 
 
 wlii) tai<»' 
 
 distri'ssod 
 
 ially I toil lie 
 
 irlit WH'U \ni 
 
 iro so ot'ti'U 
 (.' ^lain'roas 
 
 Isi' fVoiii u 
 Ill-art and 
 striking or 
 
 tioti. 
 
 ^^,„„/,,__Nh,nv .lial.ti- i-atiH.ts .li*' ..!' l-l.tJiisis .illuT 
 tulKT.nlar or til'.rous, wl.il. a la.-, nun.lur a,v ll.. sub- 
 iertH of .-hroni.- l.nMi.l.itis. Thuv is ....tlung rliarartor- 
 isti.- in the pulniouarv syMiptoins of .lial..ti.- patu-nts 
 
 \ar.n>s S>islrm.-\\'U\\v Ik-u.Iu.-Ik. is n..t a c-o.istant 
 .vnn.ton., it' is l.v no nu-at.s infmi.wnt, sonu- i-atu-nts 
 i;,i„„ th. sulMc-Hs of intcnsi- l..-n,i.fania. Nm.al-ia ot 
 „,lu.r n.TV.s is oft.n a .aus. of .list.vs>, an.l .li//..nrss an.l 
 vcrti-o aiv orcasiunallv tr..ul.Usoni.. Many i-atu-nts l.v- 
 c-o,n ".Nt.H-.n.lv irritul.io, whik- ..tlnTs an- given to in.lan- 
 ,.h„r.a. Tin' .li/-//nu'ss, VL-rtig.., inital.ility, or nulanHiolia 
 eouM be at.tiripatr.l fro.n the fa.'t that pathologteal eon- 
 .litiuns ..f the eoiehi-al eir.'nlation an- otien presc-nt 
 
 ,s7,;,,._Thi' skin is often vei-y dry, harsh, an.l sealy, an.l 
 seldom is there mueh perspiration. 
 
 In ol.ler persons, carhutxles sh. .nld always he .ons.de.e.l 
 ^,„ i,„,i..ation for an examination of the .nine tor sngar, 
 as in a lar-e n.unh.r of eases the two are assoen.ted. 
 
 The nn.st fre.pient skin .Hseasc- in female pat.en s how- 
 ,v.r is the ee/.enia that results Iron, the ,.r.,ntns lah..l.s. 
 The exeoriations ahont the vtdva aiid thighs are cxeessively 
 ,,nn..ving and exeeedingly intraetahle. ,.,...,, 
 
 K;ze...as appear on other po.-t,....s ot the l.od.N, otte, 
 disappeariniT as the .ugar din.inishes u.nler treatn.ent, a..d 
 ,,,,.urrinir with the reai.pearanee of the sugar. 
 
 ( )....asionally in elderly gouty patients there is gangrene, 
 ros.mhliuir senile gangrene in its eourse. . ^ ,. , , 
 
 Zona...r herpes zoster, is often assoenited wUl. dial.etes, 
 ospeeiallv in the gouty. Whether or n<.t there ,s any re- 
 laiion between the tw<. it is ditHeult to say, as we otten 
 havi- herpes in the g.mty witlu.nt st.gar. 
 
 .sv,//,/._('ataraet and amblyopia are fre.iuently associa e. 
 with a diabetie e.mdition. hon.e at.thors nuuntain that 
 there is an impairment of the eihary musele. 
 
 ■idAliS^iv 
 
 .WW«W|ff«»W-'"' 
 
•««■■ 
 
 21 H 
 
 i)iMii:ri:s. 
 
 I 
 
 i ••! 
 
 •''^ I 
 
 Thf MMlniia wlii.l. is riv.in.Mlly ).ivs».|it is pmlMLlv tlu- 
 result of il.-l.iiilv, iis in ..tli.r loniis ..f ainvniiii. 
 
 KiiM.i,iti..M is sum.tiiii.s .Mivm.-, im.l ...•.urs ir.M.. niil.v 
 i„ tl.n... patiiiits vvliu a.v n.i.n.l-i.' or i-l.ll.isi.-al an.l ..t' 
 snaiv l.al.it, an.l in wl-.u. tl..^ ai-pi-tit.^ is raNvnuus an.l 
 • h.. tl.iist v.TV u'lvut. In oili.T ras,s. in.t a.v..Mii.aiMf.l l.y 
 ,.,„.„.•,.„•„,„. ,1,;,,.,. nuiy !»■ initluT incmiM'.l api-'Ht^' "">• 
 
 I'Xt't'ssivc lliii'>t. 
 
 Tlirti'niiKTatmv is usually siil.n..rnial, lli.' paiiiiit ..tim 
 
 iM.nii.lainiML' «'|' iot-lini; diilly. 
 
 .l,,/„/ur„/;'/.— iVmrs first ..1.s,tv.m1 .lialK-tic touia. At- 
 t,.nti..n was .lin'itnl t.. lli.' a.H..m-liki' sincll of tli»- unuo 
 in IS.M. an.l it was sui-pos,.,! to I..- .In.- I.. tl.»' pivs.!...' ot 
 ar.ton.. in tl... LL-.l. Tlu- syn.pt.mis usually .Ks.f.l.... I 
 as in.li.atin.ir a.'.l.'ua'inia liv.nniitly inanif.st tlinnsolvert 
 oitli.T tlir.>uirli.>iil .•!• lat.' in tli.' rours.' of tli.' .lisfas*-. 
 
 Til.' syinptonis vary. Kut an- <.t't*-n nniiiili'st.'.l in three 
 Uistinrt'statr^'s.— nan'.rly, a sta-.' ..f ..x.itiinu.t, ..n.' of 
 iTivat r.stlissiuss, uiK'asiniss, an.l .lyspnoa, an.l .ui.' ..t 
 Tonia. Durin,-- tlics.' sta.uvs tlio su.irar is loiin.l in nnwli 
 small, r amount in tli.' uriuf, or may I'ViMi Ik- ahsmt. It 
 was f.ir this n-asoii that actom' was sui.im.sim1 t.. a..uinu- 
 jatf ill th.' l.l.M.'l. wK.iu.' till- iiaino a.-ctoiiuMnia. It has 
 Ills., h.vn i-n.jM.sf.l io .U-si-natc tlu- r..ii.lith.n as hypc-r- 
 .rlyka'inia. 'I'll*' .onsiMisiis ..f ..i.ini..u of i-\p.'niiicntcrs 
 si'niis at i-ivs.-nt t.. !..• that a.vt..m' is thi> |.ro,lu.t ..f the 
 UTiiu'iitation .>f trrapi- suirar. 
 
 'I'h.' svmi.t<.ms in many cases are similar to tln.se ot 
 s..-calK'.l" ura'ini.- i.oisoniii.iT : the sta,iie of ex.-iteiiient in 
 the latter is ni..n- lik. ly t.. h.- a.'...mi.anie.l hy .•onvulsive 
 eontraetioiis ..f th • mns.les, while in the toiiner (aeeton- 
 ieiiiia) it manifests itself hy .irreat .lis.|uietu.le, with in- 
 e<.lieienee an.l iii.listin.tnes. ..f speeeh, fre-iueiitly iu- 
 tersperse.l with atta.ks ..f .lyspn.ea, remiu.ling one ut 
 
 -!sr:r:r^:sj?>3srrasr 
 
 ^g~~gjnK^^JJ|S£*"^^*'fl.*5«-J 
 
DiMthriT.x MHi.t.irrs. 
 
 2H» 
 
 Ml 
 
 IV till' 
 
 ItflHl'llllV 
 ill illlil <>l 
 ||iill> il)l*l 
 
 jiiii'iol l>y 
 
 "U'llt ofU'll 
 
 Illlil. At- 
 tlic uriiu- 
 
 •CSl'llCt' 1)1 
 (ItMl'illt'tl 
 
 luiiisi'lvert 
 isi'iisf. 
 (I ill tlirci- 
 it, out' ot" 
 
 111 dlU' ot" 
 
 il ill iiiiK'li 
 
 lllSCIlt. It 
 
 II iiiciumi- 
 iii. It lias 
 I iis liypor- 
 ciiiiiciiters 
 luct of till' 
 
 to tliosi- of 
 
 •iti'iiu'iit in 
 
 foiivulsivi' 
 
 llT (ilCl'totl- 
 
 t', with iii- 
 mu'iitly in- 
 iii; uiK' of 
 
 .,,,,i,.. i.,h,i... Ki,n.llvtl..',.ati.ut.inkHintoa.oniato.. 
 
 ..on.litioii, ott.M .Ivini: in a ti'u I'.'".-. 
 
 To-uiii .1... th.n. tlirn. mv Ivvn .li>l»i.t . l..> . - ot 
 , i 1 O, h.s.will.on...l..l..'l'l'V>"':'"-l""'; 
 
 , „M.i«i..M':-- 'I-' I"- ■"" "" I"".-;:'- ."""-,• •■",.' 
 
 ,,il ;:,:..,„'•,.„. >!.. .,ma. l...,-,,,-.. ,..v«.ril.u,, 1...- 1- 
 
 '■";;,:,„.„,|v ■„ will 1... r.mn.l 1" l".v,. „ .1 Hi,. :.n,vl,v ,.f 
 
 I -1 .^l^^■.v^ I'MIIII lU' t U' UlUlf \\ll«M 
 
 ,i„„» nm.v 1... ,.r.«-"t, ...■ .nay ''.'^ "I ■'•,',„, ,,,,,„„,, 
 K,m..ii..i".. i» utUn thf i.r,mn..L'.it I...IUK, 
 
 oxtrt'iut'. 
 
220 
 
 /)/ I///-77V 
 
 f 
 
 I 
 
 •: i! 
 
 l.„„„N..m.-.— Tl.r |.n.iriiM.'H .U-|.rn.lK irn-utly upon tli.- 
 
 „,r,. of ll.r iMli.i.i un.l III.' fnT.l.m. fV... mpli. i.ti.-,,.. 
 
 "Wr iMii'l alwav- Im- LrM.ir.l.d in oiir pL.-m.-is it- 
 ,.|.,|,i,i,. l.iun.l.ili.. pii.i.inoi.i;.. .arl.ui.rl.'s lmi.-ivu.'. 
 „..,,l„iti.. nr .Tivl.n.l in.,. I.I.' n.i.v -i.iMiv.i.r. ..,• il,r .•>...■ 
 
 ,11.1 ill infinity. . ,, , .i 
 
 Tl.r vuuu-.r tl..' palirnt. tli.- iimiv r:i|.i.llv .lu.s tlir 
 .|i-..„..."iiii. it. .•..i.iM-..l.il.l.vM aii.l Vullll-ll.ll.lt- Mitrl. 
 .ivi.i- in a f.-vv iiiniitlis, wl.ilo in .•l.l.rlv pru,.|.. i. Iiv,,ii.iitly 
 j" n,.s .limiiir. M.-ar l..i>''-' .••.n^lantlv f..mi.l in tlir 
 
 'ritl-MMKM'.-iJi'lolV .■ulllllinirini; tl..' t IVi.t lll.'llt n\ il 
 ,,i,,,,,,i, ,,„•„,„,. it nilll..'U.lllnrnst..r;,!ltu,i,.ll.l that 
 w.. kn..w littl.' ..r notliin- -f tlu' ..tiolu-v ul ll..' -Iisras.-, 
 „„.l ,!,;„ vv.. Iiiiv.' Imtii iinal.l.' t.. .lis. ..v.t its i.atl...I..,-rv: 
 ,1,;,, i. u.. I.av.' l....... uni.l.!.' to .>ti.l.lisl. tl..' la 't tl.iit any 
 
 „. .-'an is inva.ial.ly lo.ui.l in a i.;.tl.nl.../i.al .o.i.l.th.n. 
 
 \l til.' >aiii.' tin..- \v»- must .•.'iiii'iiil..'- that it is s.'l.l..ni 
 ,|,i„ ..„„.' .....' ..r i«i"'>' '"•.^■'"•^ "'■•■ ""' '" " 1""1'"'".-'"'"1 
 ,„,„,•„•„,„. Tl.is l..'in,ir tl.v -as.', an.l tl..'iv !.'•'..,- in. 
 si....'iti.' to.' .r.alut.'s. w.' ni.ist m'.in.'iK' ..ursclvi's I.. ti'i'Ut- 
 
 iU"" s\ llllitolll" olilv. 
 
 A> a niatt.'i' ..t' .'onv.ni.'nr... tli.' ti'.'atnii-nt may 1k' 
 .livi.U'.l int.. l.Vtfii'ni-, .lii't.'ti.'. an.l ni.'.li.inal. Of tli.'M', 
 it is .ri'in-i-allv stat.'.l l.y a..tl....'s that tl..' .li.'t.t..' is l.y lar 
 
 tin- n...st ini'iM.i'tant. Tl is. l...u -vvi', is tl..- fa.t ....ly in 
 
 n.-a.-.l to tl..- ti'.'atn.i'nl ..f tin' i.atlio,i:i..'in..ni.' syinpt...... 
 
 — iianulv, til.' irly<'.>snria. 
 
 //,^,//,;,;,,_As .lialK-ti.' pati.'i.ts have nsnally a s.il.- 
 ....v.i.al t.'n.i..'nit.u'.-, .'l.ill i-asily. ami .'...ni.lain ..f .'oM, it 
 is i.upo,tant to l....k well to tl.i-ir .L.tliin-. as w.ll as t.. 
 tli.'if atmos|.l..-ri(' surr...imlin,-rs. 
 
 Sri,<l th.-n. t.. a wai-n. .'limat.'. wl..'.'.- i.os>.l.i.-. an.l 
 alvvavs .liH-ss tl..'.ii in lla...ul. V.-n will liml that many 
 
 ■^> 
 
 -Mi 
 
 r y - ;.,. . j^. z ..0^i-",^-^M 
 
 f;x'rfc.i)SKt;'^%i»'''' 
 
 
r^iMirrrs w//.//rrv 
 
 mm I 
 
 |mUI t1l(> 
 It'll. III*. 
 
 lO-ir*, UH 
 
 iiiiiri'<'i>«'. 
 
 llir I'llM- 
 
 lilies till* 
 Its oftt'll 
 ■ii|iU'lltl_V 
 .1 ill till' 
 
 rs. 
 
 flit of il 
 
 iiinil th:it 
 • ilisi'iisf, 
 itliuloLi'y ; 
 tliiit any 
 •iiiiilit'iDii. 
 is si'lili'iii 
 
 llldloLliral 
 
 iK'iiiix iii> 
 s to tri'iit- 
 
 t may In- 
 
 Of tlllM', 
 
 (• is iiy far 
 ct only ill 
 syiiii>ti>iii. 
 
 ly a >iil>- 
 
 of ciilil. it 
 
 well as t(» 
 
 siliU'. ami 
 that iiiuiiv 
 
 ,,,■ tl..s. luitiuit. a,v w.amiu' l.v »avi.. v.,T houvy llam.ils. 
 1 .. Juvavs 1 M ill till. I.al.i. i.f .lin.ti.i,' a l.u.n- 
 
 1 ;;tl:.iK. siik-ami.w....ii..n ..i... hi. ."•-«- 
 
 ,li.. l.Mlv well l.ri.t..Ma,..lu aiMi. ami. sl..ss,U. 
 
 ,M.imli... than a sin.l.. I.nivy woolU.n vest wi. . ^ 
 Wlmn .111- ,...-.. l-V'.-. •! u..f V..S alisiulis ,11. 
 
 ,vH-v.lial..ru.,.ati..,.tslioMl.ll...,.oviil...lw.,lial,..av 
 
 -,.,,.,,,.„ .l.ouliM.. l..-oti..t...l hum .lam,...- IN u. an. u 
 'lUsl samltl.iu -tt..,ii...ilks.H.ksu,..l.T> IK-n 
 
 "'"\: u.. l.av.. al.-.-a.ly so..,, tlu-s. ,.a.i....^ ^.'v HU-lv to 
 ,,,;.: iliv. liai-sli. sialy ski.is, s., that ,V..i,...»t w>..-m 
 l:;;;;.i..,witl asmnalst..ami.rh..t-ai.-l.atl.s.sl.k..ly... 
 
 pii.vr hiirlily I'.ii. li.ial. .. • , .. ...u- i^ 
 
 ' N,x, ,.. l... .rmt.'tii- tn.att.mt.t ... hi.mtm.al .vslUs ,h 
 
 .,;.nWi.. .1 r--^ ami ..f alltWni. .. .-.-.•, 
 
 ;,".; wl.iil. ..-.•n.s to 1 f tl- .....St l-..t.t '"'''-tu- 
 
 i.ati.'iits is walkimr. 
 
 ^ N..niatti.rhosvu.aktlmya.vo,howmml. ' "> ""■ 
 
 ,.lai„ of iK.l.ility ...• iUti,,Mm o.. .'X.-.tio-i. v". ^^^^^'^^ ^^f'^^ 
 M..1.- that till, sl.all walk .a.;l..h.y ......... -tl..,^ 
 
 ,,U,.out .xtro.m- fati,..m. If .t .s t-'/''""'^ ' ' ,; 
 
 t,,.,v will soon iK. ahl. to ...ak.. thro. ...• i...u-. !-< jL' -' 
 
 .... th. .Hsta...... ....til tlu.y .a., walk l.o.ii >,x .o 
 
 Xli. ...il.-- -y '1"V- Thoy .....St ..... l.'.us. .h....s.lv..s 
 
 f.ir a littl, ."liii or colil. 
 
 , , .,„../.-K..r ,1... uv.„„.„. "I- .1- i«ti".|-:".- ;: 
 
 ; u,.. Ti;.... (i.a. i.av,. v-.v.-i i"-';™;' '" '"7 
 
 ;„„1 .vawnia, l.n.nnJc of uis.'.nc l.rc.«.ib>..l ;u tlt.uuw 
 
222 
 
 DIMiETFS. 
 
 solution, or arsenic in tin- form of Fowler's solution. 
 Villi riiin, (|uiniiit'. nitnite of silver, and mineral watiT. 
 
 Kenieilies that have lu'eii hiirhly extolled \\\ some writers 
 liiive fiiiied entirely in the hands of others, owiiiu' no 
 doul)t to tlie faet that many of the eases have heeii .'ases 
 (if transient <rlyeosnriu. 
 
 Amonti- the medicines thus recommended are hromide 
 of |i(.tassi\im, snudl doses of calomel, iihosj.horus, stry«h- 
 nine, iodoform, iodol, sulfonal, sulphnr. salicylate ot 
 sotlium or salicylate of hismnth, and the Hlkalies, es- 
 ]>e<'ially tiie carhonate of lithia and many others. I'nder 
 this head would come, 'of course, treatment hy alkaline 
 mineral waten;. In Europe, (\irlshail and Vichy are the 
 most favored. In (^difornia we have many excellent 
 alkaline waters, our Viciiy heinu; very similar to that of 
 France. 
 
 In itrescribini^ eodeia it is well to commence with a halt- 
 grain three or four times a day, either alone or in eom- 
 l)ination with valerian and (luinine. A favorite prescrip- 
 tion with me is — 
 
 R Codciio, t:r. »s ; 
 Ext. vuloriiiiiii'. 
 Quill, siilpli., im i:r. ii. — M. 
 Big.— Threu to five times in twciity-l'"ur h'\u-. 
 
 Some of these patients are very t(derant of opium, and 
 will take two- to three-jrrain doses three or four times 
 daily with the etfeet of lesseninjr the sujrar, polyuri >, and 
 polydypsia. 
 
 It is usual to prescribe the bromide of arseni" as 
 CU'mens' solution, commencin^tr with throe drops after 
 each meal and increasin<r the dose to six or ei^rlit drops. 
 This remedy in my hands has proved second only to 
 opium and its alkaloids. 
 
 t^ulphur, alone or in combination with iron, answers 
 
 '^!< :^ 
 
 "**^i. 
 
 ^ ., :j R?-^ ...,~k^M.Ji,,^'iih^y'>:,^ 'mi^.^:'^-^^^ 
 
 es'^SBisar. 
 
/)/.i/iK77:v yiKi.t.irrs 
 
 •l-l-^ 
 
 well i.. .•as.s that .lo n..t sM n..<lilv to ui.imu or .rs.ni.. 
 ' .ntlH.;uu..ousnu.M.l.nnu>ot-tlu.alun.n.an-n..K,l > 
 II skin, tlu- swout-lan.ls 1.1..,^ .U-fuu.nt .n aln.ost all 
 
 *'' For' mti.,.t. wl.o Uv. in malarial .-limatos or ar. tlu- 
 „.L ., uf .-hroni. malaria, tlu- follow.n,. vn.s.r,pt,on 
 wili' olt..n ,n.ve H.rvi.-.al.U. in loss.nin., the i.ronunonl 
 svnuitonis: 
 
 li Aiiili iirx'iiiiisi, !;r. i ; 
 
 Ext. vftliTittini', 
 
 (iiiin. >ulpli.. Aft 51; 
 
 Si,,_„no pill fr-n. tl.ivc t.. six limos .hiily, with an occus,„nul ni.r.unul 
 laxativi'. 
 
 Other n.^licino. will ofWn have to bo a.lininistoro.l vn 
 thi. .IKcas. tor .u.-h conq.li.ations as may .0 tou.ul m the 
 tt;'uar<as. This .an easily Uo a,>ti.u.al.l rom the 
 •arioty of patholo-ieal conditions tonn.l m .l.abetes. 
 ""i.-Tl.o ol,i:.-t to bo attainoa by .hot - to roauoo 
 .lvka>mia an.l thus roduoo the .ly<-osuruu WIpIc Ave 
 flo ot know h<,w numy of the ,atlK>lo,u.al eon.htum 
 tllul post uu>vtont are ,n>.luee.l by the ----;i-;^ ^ 
 of su ju- \n the bloo.l, cxporienoe teaehes us that it nc 
 lessen the nnantity of su.u^ar the pat-ent munoamtel 
 t:^us to re^un hi/ strength. We aeeou>phsl. tins ol^oot, 
 ;,;;; Iv th'; reauetion of sugar, by eUmmatmg from 
 ^ 2 all saocharine matter, as well as such tooas as 
 eontain stareh. The auuexed list will serve as a guule 
 to the proper aiot of suoh patients. 
 
 The ahlbetio patient may eat : almoml rusks almol 
 bisouits. gluten bread, gluten biseuit, Btale breaa (toaste.l), 
 In- u-aA bacon, butter, cheese, eggs, boet^ea ana tlnn 
 soupsfbeU mutton, gante una poult.v : hsh, oysters; 
 
•2l'4 
 
 DIMtKTES. 
 
 ciililiMi:!', Uttiicc, striii.ir-l'fiiiis, trrcfii pl'a^^, toiiiatcns, 
 spiiiiicli, <:i'.'»'iis. olives, artifliokcs. iisjiarairus ; <Mistanls 
 without siiLiiir. jfllii's >nis\vi'i'ti'iH'<l ; lea, coHct', cocoa 
 without siinar, water, mineral waters, claii't, milk. hutttT- 
 iiiilk; aciij tVuits. lemons, cherries, currants, strawherrii's, 
 
 nuts. 
 
 The t'ollowin.ij articles must he iorltiihleii : |>eas. heaiis, 
 lentils, potatoes, sweet potatoes, carrots, heets, rice, maize, 
 wheat liour, oatmeal, macaroni, liver, made dishes, arrow- 
 root, luickwlu'at, sairo, tapioca, puddiniis and pastry u'en- 
 orally: apples, bananas, and sweet fruits u-eiierally, iii- 
 (.'liKlinLT raisins; sujxar, ehoctdate, aU's, swi'et wines. 
 
 My own expi'rieiice is that jiatients do hetter on the 
 nii.xed diet indicated hy the above list tlian on a too 
 exclusive diet as has bei'U ot'tc^n recommended. Stuiie 
 writers, for instance, recommeml the restrictitui of the 
 ))atient to a meat (Hot exclusively. l>r. Donkin a few 
 vears a<ro advised a diet eonsistin.t:; only of skimmed 
 milk. i'>oth of these T have tried upon more than one 
 occasion, with sitjfnal failure. 
 
 The diet of diabetics must be strictly sujiervised, as 
 many of them liave ravenous appetites, are always thirsty, 
 and eat and drink to excess. 
 
 ClIArTER TIL 
 
 DIABETES INSIPimS (iMJIATHIA — ISOZEMA — HYOSIRIA). 
 
 r)lAnETES INSIPH>1'S is a e()nditi<»n eliaraeterized by a 
 persistent increase in tlie (piaiitity of urine, vliich con- 
 tains neither albumen nor sugar, and usually aceoni])unied 
 by polydypsia. 
 
/)/.! IIF.THS ISSIl'ini \. 
 
 225 
 
 , toinatoc'S, 
 is; ciistiinls 
 ofi't'i', ('(icoa 
 iiilk. ItiittiT- 
 ^ti'awln'nics, 
 
 |lCilS, lu'lltlS, 
 
 , rirc, iiiaizc, 
 
 isln'S, lllTOW- 
 
 I jiiislrv LTi'ii- 
 I'lifi'ally, iu- 
 wiiu's. 
 
 I'ttor oil tlie 
 111 on a too 
 ili'd. Soiiio 
 ctioii ot" tlic 
 oiikiii a IV'W 
 of skiuiuu'd 
 )vv tliaii one 
 
 i|i(,'rvis('(l, a8 
 ways thirsty, 
 
 -IIYOSrUIA). 
 
 'tori/.otl l)y a 
 I, wliivli <^on- 
 aceonipanied 
 
 In (lalen's tinic tlic tiTiii dialu'ti's iiiclniU'd all cases of 
 jtolvuriu. It was not nntil clu'iiiical analysis of the uriiu' 
 • li'iiionstratod siiu-ar in sonu' cases that the ditfcrcntial 
 diairnosis was t'stalilishcd. 
 
 lvrii)i,iMiY. — \Vi' arc absolutely ignorant of the etiolo<;y 
 of this (■onditioii, and, as is the ease with all diseases 
 wliose causes are unknown, many tlieories as to its oriirin 
 have been evolvech 
 
 Thouirh in many cases tlie kidiu-ys havt- heen found 
 diseast'd, it is very iircthalde that this disease is not of 
 renal oritrin- ^'*'t it is possible that in some cases, at 
 least, it has its oriirin in a nutritive derani^ement or 
 (U'<i'eneratioii of the tuft-wall or its ct'llular lining;. Tiie 
 Maljiiuhian vessels themselves may sutier det^eiieration. 
 The dcireiieration and perhaps des(|uamation of the mi- 
 eh'ated lininu; may not only allow the more rapid Hltra- 
 tion of urine, hut also weaken the tuft-wall and allow 
 the dilatation of the vessels of the tiitt, or the vessels 
 may dilate in coiise(|Uence of degenerati<»ii of their walls. 
 It seems to tue possiliVe to have dilatation of the tuft- 
 vessels independently of vaso-motor paralysis. .'!ie de- 
 "•enerative chamres could well he owiiii:; to chemical 
 ehantres in the hlood. Inosite, for instance, has heen 
 found in the urine in some eases of this disease, and it is 
 l(ossil)le that an abnormal material may yet he found in 
 the urine which shall be as pathoirnomonic of diabetes 
 insipidus as snijar is of diabetes mellitiis. 
 
 The consensus of opinion, however, appears to be that 
 this disease is a neurosis and has its orij;in in the dilata- 
 tion of tin' renal arteries from paralysis or irritation of 
 their vaso-motor nerves. It seems to me that for |»olyuria 
 to be produced it is not absolutely necessary that there he 
 either dilatation of the renal arteries or extra blood-press- 
 ure. It is very probable that there are special secretory 
 
 ^. ( 
 
 h. 
 
 
 m 
 
 -.3!W!ru£KS?^^';K?:^tew-'^iti^- -.■;?:"r?rai'r--«pn>«w * 
 
 - B L ' W- ' ^ ' Wr ' JU JM. ' J. ' . 
 
2'2(\ 
 
 DiMir.rrs: 
 
 ;;,;.,,,,„..„ ,.x..lu>iv,.lv,o,l,..,ul...U.s. Tl...l.lK.n..H...s,n 
 ,1,. ..nil.n. of tlH. tulM.K.s i.MlH'ir .unvulul.W :.M.I turn.uus 
 
 .,„„-.....,. unlvlK. lor tlu. ,,un.o».or,vt;mhn,tl:. too 
 ,,,,„, .....p.. ..l" .!-.• tilt.ml urin... N..W. iH us >n,,,..- 
 ,li,,lH..,Lial>....v,in,n..n...iil.vs:.v,.ralv^ 
 
 lH.,H... .1... .nl IUts linl.. or nu vual —':'-• 
 
 ....a,,., of urin., tl... rosult will br ,-lv>.na u uliout .11..- 
 t.,ionof,lH.l.l..o.l-v.ssJsor.xtral.lood-,.vssn.v. Uns 
 
 .,,...... as n.tional an .x,lanaru.n on.varn.K. . 
 
 ,1 , whi.l. a.tril.ut.s i, ,o ailat.tn.n ot llu. .vnal ... - 
 
 V..SS..1S. lntluMat,..r..as. tlu-n.s,s,.n....o, tWljUU 
 V.SS..1S wonl.l s.ill Imv. t.. !..• ov.Mv.mH.. an.l .•.■rta ml iK 
 
 ,,,..,.,,.,.n.ssn.v tV..n. nuMv dilatntiou ..r tin- v.ss.ls ot th. 
 tult vou\i\ not In- viT.v ,-i-m.tly in.iv:.s...l 
 
 ,,,, . ,.^^, „,,t in.jnri.s t.. tlu- ..■rvnul synq^.tlKt,.. ... 
 s,inal....nl..rhM.ita,i..n..niu.ll....rortlu.touHl.v..n.-U. 
 
 ..n.v...Mtu.n.nn..i.-..n,in<..Ml.isl.nn...,...y^^^^^^^ 
 I^.ili..-anl...l.n..nstn.to..ltlwUtlK. rc.nal nn.to . 
 
 ,.,,^i.lv.l ..vor l.v si..'.ial s...Mvt..ry nvrvc-fl-n.. .t u .U 
 
 of .lialH'tc's insipidus. 
 
 .SV,-._Tluso,u.liti..ns...n>st.>lu"nuu-. nuMv ...ju nt 
 in nu.n tlun, in w..nu.n. tlK. ,n.,.ovt,..n l...n,. l...n tla 
 ,anu. as that in .lial...t..s nu.Uitus.-al...ut tluv.. t.. ..m. 
 
 ;Lno a..> is .x.n,,t tn.n. .lial...t.s n.s.pj.l,;.. 
 
 TiL all ttu:..as..su, t.. sixty y.a... .fa,... t^K-t. u.ty 
 
 n./;n.n. tw..n,yt.. tit-ty,.n..ln.val...ut tw...lnnls.,l 
 
 ;;,;. ..as..s, tlu. t..u y..ars tV..n. tuvnty t<. tlnvty Wu.^ tlu- 
 .U-ra.K' in wl.i.'h Hi..st .-ases ...■.■ur. 
 
 //...%.-lKM...lity is .vi.U-ntly u..t a v.ry a.tnv .tu- 
 
re (list I'll '- 
 
 iTllliTS III 
 
 I torliu'iif* 
 o- till' too 
 s siipposc 
 Ivzfil ;iinl 
 lice to tlic 
 lioilt dilii- 
 ll-r. Tills 
 vdruriii as 
 Mill l>loo(l- 
 thc lilood- 
 rtiiinlv tin' 
 ssi'ls of the 
 
 |iiitliftic or 
 ill vfiitr'nU' 
 
 II is .-troiiir 
 )t' jiolyiiria. 
 fiuH'tion is 
 iiH's. it will 
 vous oriiriii 
 
 »n> tVcfim'nt 
 
 _r lioUt tlio 
 (■ to olH". 
 
 ^ iiisiiiidus. 
 c. tlu' tliii'ty 
 vo-thirds oi" 
 tv bc'inji" tlir 
 
 ■ iirtivc ctio- 
 
 systciii, siifh 
 
 /)/.i/iK77> i.\sirii>rs -s^i 
 
 as falls, jars. coiuMissions. or Idows on lli>' head, or oii the 
 si.iiir, iiiidoiil.ti'dly play an a.'tive |.arl. 'I'luiioi-.. apo- 
 pK'NV. and lu'iiiorrlia,L^is and intlaniiiiations of llu' Inaiii 
 i„v anion-- \\n- .'aiisfs ; so al.>o mv r\c>'s>i\c nnnlal niio- 
 
 tioiis. 
 
 Till' alnisi' of alcohol, of iliurrtics. or of icc-Wiitrr has 
 sonictinirs Ikmmi followrd hy this .•onditioii : and ...•.a- 
 sioiiiilly it o.'ciirs as onr of the s(M,iuda' <.f the acute 
 ilUeetioiis diseases. 
 
 |'.\Tiloi,(i(;v.— Diahetes iii>i|iidtis, liko diahetes niellitiis, 
 has no liNi'd i.atliol,.iry. Thoiiirh as yet theiv ha- hirn 
 no one ofu-an invarial.ly found diseased, lliei*' are tew 
 east's in which some one or more origans art' not found in 
 a iiatlndoLrical condition. 
 
 To he sun', tin,' kidiu'ys have heen ofteiier found (lis- 
 eased than in diahetes iiiellitiis, sometinu's in a c(.iiditi(»n 
 of de..:-cneratioii ; a-xain, a .iTivat iiumher of ahscesses Inive 
 heeii found. .\t other times a hyperaMiiia or dilatation 
 <,f the hlood-vessels will he jiresent ; while in some caseH 
 the kidneys have heeii in an a|>i.arently normal state. In 
 many instanc»'s the hrain has heeii found in ahout the 
 same diseased condition as in diahetes nu'llitus; that is, 
 tumors, tuhercular masses, and deireiurative chan.i^es ia 
 the Idood-vessels in the floor of the fourth ventricle or in 
 the mi'diiUa ol>lon<>-ata have heen ohservi'd. 
 
 Symptoms.— The constant hyiH'rseereti(.n of urin.' is tlu- 
 ehara.ti'ristii; symi.tom of diahetes insiifnlus. Most of 
 the other symjitoms, as thirst, emaciation, ami dryness 
 of the skin] are j.rohahly dm- to the enormous amount 
 ,,f wati'r vohle.l. Patients not infre<iuently |.ass from 
 two to four irallons daily. As a rule, these i.atients make 
 a greater <iuantity of water than do those with diahetes 
 mellitus. The urine is li.icht in color ami wei.u'lit, the 
 ^leeilie gravity varying from 100:5 to 1010. it is usually 
 
 saswi^tsiw'ra"'*'^^^*'****'^''*'**''^ 
 
 l»Ta3aSSi»KPK^WS«««!«!Sa8PS«W-™™"'''-^^ 
 
 .Jj 
 
•2-2f< 
 
 DIMIKTI-.S. 
 
 v,.iv sli-htlv a.i.l iin.l (lr..oi„,M.s.s qui.kl.v. 1 1n- H..h.ls 
 „.a"v 1... inriva^..!. .s,...riallv una au.l tin- i.lu.si.l.atrs. 
 lH/,.itr is o-va^iomillv .Irtivt*..!, as is alx. hip,.«n'i.' ari.l 
 
 T1...S.. uati.'Mt> aiv imt >o likely tu MitUT tVo.u .arl.muK.s 
 a,„l l...ils as the sul.jeets ..f diaLetes MU.Uitns: er/e.na 
 ,„„1 ,,,„nlus are iH.t so apt to appvar, imr .> the api-et.te 
 so often inemised, as ill that disease. 
 
 Manv more svmpton.s of this .lisease an. enuM.enile.l 
 hv wri'ters, l.ut"thev are onlv expressive ..f the (hllerent 
 ;„,,„,.„.,i.,,l .,,n.litions that we have alrea.lv seen t.. exist. 
 (),u. pi.tient. in a.hlitiou to hv.lruria an.l thirst, may 
 Inve a tumor of the l.rain: another, .h-eneratn.n ot the 
 medulla, or tuheivulosis, or syphilis. The symptoms 
 varv aeeordin-lv: for mstanee, in one there will l.e a 
 .Usn.rhanee of "sensihility. in another a disturhanee ot 
 ,aoti..n, whileathinl may sutler from headaehe or eon- 
 vulsions. While the thirst is often .piite as -reat as in 
 (liahetes mellitus, the houlimia is rarely present. 
 
 j),,„^„sis.— The term diaheles insipidus is used tor 
 n^^t as we use the term neural-Ma tor pa'.n. 
 
 iiolvuria 
 
 When pain is the result of or-anic- lesion, sueh as eaneer 
 or intl.immation, tumors or uleers, we are not ,n the 
 ,,,l,i, of desi-uatin- it as neural-ia. ^\ Ium. <.ne is su 
 i;.,i„... ,,ain for whieh we eaniiot liixl a eause, we si 
 
 ut- 
 'V 
 
 the patient has an attaek of neural-ia. W hen a patient 
 ha. hvdruria. i>assin-, say, over a hundred ounees ot 
 urine per .liem, an<l we find no ..r-aiii.' lesion to aeeount 
 
 i;,, it, we .lesiixnate the ease as one of .Uahctes insipn us 
 Iwa< ealled in eonsultati<.n not Ion- sim-e to see what 
 was sippose.l to he a ease of .liahetes insipidus. I he 
 .„ti,,„t was a y<.u.>u^ man of twenty-tive, who pa^^^d one 
 ,„„„lred and tiftv ..unees of urine daily. 1 tound a typieal 
 .ase of amyloid .le-eneration. This, then, was not a ease 
 of diahetos insipidus. 
 
 i 
 
DiMir.Ti'S lysii'inrs. 
 
 229 
 
 'he solids 
 lospliatis. 
 ■\v iifi'l. 
 iirliiuiiK'^ 
 
 ; ; I'czcllia 
 
 I' mn'i'titf 
 
 uiimiiilid 
 • ditViTrnt 
 n to exist, 
 lirst, may 
 ioii of tlu- 
 
 ^VIlHltoIllS 
 
 will 1k' a 
 irhance' of 
 111' or t'oii- 
 irrt.'at as in 
 t. 
 
 s iisttl for 
 I lor jKiin. 
 \\ as cam'*.'!' 
 not ill llie 
 
 oni' is suf- 
 isi.', \vt' say 
 .'11 a i>atioiit 
 
 OlUU'C'S of 
 
 1 to accoiuit 
 s insipidus, 
 to si'i- what 
 [,i(his. The 
 I passed one 
 ind a typii-al 
 IS not a ease 
 
 A few months airo 1 was eonsiilti'd l.y a nudieal praeti- 
 ti.m.r. aire.l sixty-tive, for dialutrs insipidus, lie made 
 ahout oiu' humlred oiinees of urine .laily. lie presented, 
 with the exeeption of alhumeii and easts, a well-delmed 
 ease..f intertul.ular nephritis,— irouty diathesis, ath.'roma 
 of valves and arteries, and hypertrophy of th*' leit heart, 
 —and had had an attiiek of Inematuria two years h.'tore. 
 He eonsi.lere.l his ease oue of .liahetes insipidus heeause 
 he had found no alhumen nor easts. 
 
 l»K.mN..sis.— .\s we know nothin.tr of the etioloi;y, and 
 us the patholotrieul .'oiidition found after <leath varies fn.m 
 ahseesses of tlie khluey to tumors of the hrain, the pro.t;- 
 nosis must of euurs,' vary aee<.rdin.ir to the individual ease. 
 A.'e is not so important a faetor as it is in diahetes niellitus. 
 Some eases run a rapid course, lastiuf? hut a few months, 
 in spite of all treatment, while others are very ehronie, 
 the patient liviuiT f.»r years in comparatively .trood health 
 and without treatment. It is a very curious fa.'t, otteii 
 settiiiir at delianee the most skilful pro.irnosis, that in 
 some of the most acute cases, where the emaciation and 
 del.ilitv have heen extreme and the polyuria ixcessive, 
 no iKitlKdou'ical i'ondition can he f.uind after death to 
 a.-eouut for the svmptoms. As a rnh', eases following 
 iu.jurv, as well as thosi- that eommence suddenly, are 
 likely to he acute, while many of the ehronie eases die ot 
 
 intercurrent disease. • • • i 
 
 TiUv\TMKNT.— We have no specific for diahetes insipidus, 
 
 and it is necessary to rememher that it is the patient and 
 
 not the disease that is to he treated. 
 
 We mav follow the same ,i:eneral plan of treatment as 
 
 in diahetes mellitus,— that is, hygienic, dietetic, and me- 
 
 dicinal. The dietetic treatment in this disease is much 
 
 less successful in alleviating the characteristic symptoms 
 
 than it is in diahetes mellitus. 
 
 'JO 
 
 I I 
 
 II 
 
 ■ :.-^'^;y. .«lW-*1E.!aKfM«'R!S»3-l 
 
 B,a3j^/fj»««^sx=£;;*.«Ba:o^8*«----'ira»'^^ 
 
 tm 
 
'IW 
 
 /»/. I/!/; /•/>■. 
 
 ,,,•„„..,•,;,.,,,, .,n..tii..irlli.-tlui.lHan.lfu...l has nut 
 jrivM .■Mrnura-iu^ nM.lt>, s..rvi.,;r only to m.-ivas. tli. 
 fiiiafiiitinii aiiil iltliilitv. 
 
 ,.liM.a^...,ttln~natiuva.v„.Mv>sanlvas inn.n^tant a.ul 
 ,lisa,M-i..tiM^ a> tlu. ,...l.olM;rv ot' tlM. .lisras.. i. UT.-u^^^ 
 N..vl'tl..l-> w.. fuM .■.TtaiM Mu-ai.in.s .xtulUa Wv wntors 
 
 (»t' r<'|inlali<>n. 
 
 -,,,;^,, ^^ ,,..,li,.,,,. ,,av 1... tnn.i.l t.. .vlirv.. a synipt..... M. 
 
 a .vrtaii. nu.nlK.r ..!■ ,as..s of tln> .li>.as.. \s to lu. .n,..H.m1 : 
 
 ,„„ „,, „.vu,.„ ,„.,.li..i,u. .l.ouhl 1.. >;-.uMu.n.M as u 
 
 ,„,,. ,;,, .iial..t..s u,>i,.i.lus S...-M.S tl.. h.-,.^l.t ot al.sunhtv. 
 
 VaUria... .an.i.liur. ..i-iun.. or .U.-tncUv u.a.v .vhrvc 
 
 ,1,, .vMiplo,,,- iiMu.uro,iM-«i''"t'*'^^-l''l^" »»''• i'':^!''''''''''' 
 .,,■ •,,;„,. .t,v..hnin.. or .(..iiiiiu- ..ft... l..-..vc> ns.l.i ... .'asos 
 ,,,• ,„„,H,ia"a...l a.l.ir.tv. Ast.-u.,!.o'...s. s...-l. ..s M and 
 „„„•.... so„>.ti....s U-ss.... tl.r .,..u..tity of .,.•,...•• NU'.vH.y 
 .n.l io.li.l.. of potass-,,.... sl.o„M !..■ a.l,M,...sU..va w .;'.. 
 „,., „i.,,., i„s or is s„s,K..t.a of havm.t.- syplnhs. D...- 
 n.fu's l>av.. l.a.l th.i.' a.lvo.atcs. I..,t, of .-...•sy. oo.ikl bo 
 l,e„.f..ial o,>lv •„, cortai., oases with kidney lesions. 
 
 (MI A I'TKK TV. 
 
 AXAZUTIUIA— ul.l.il KIA— A/nrrKIA. 
 
 An- .^UI^ is a e..n.r,tion <ha,aete,-i/.ea l.y the see.v- 
 ,i.„;o. a .,onnal a,n..unt of n.-ine whi.l." is dehe,e.,t ... 
 „;.;.;, -n.. s,eeiii<- ..-avity .......es f.-..n. 1002 to DOS, and 
 
 neithe.'alln.iiien „o,- easts a.-e pivsent _ 
 
 Si,- \„.hew Chn-k ti,-st dese.'ihe.l these eases in IMS.}, 
 as renal inade^uaey. and. having had an opportunity to 
 
 m^M 
 
\y.i/.nrrHl.\—<>l.l(irill.l—.\/.nTllll.\ 
 
 231 
 
 ,„nko i> iM.st-iu..rtrii,, \\>nuA im. AUvam- of tl.c \iuhu-y. 
 Tl.c Ui.lm-vs rttriii iiir;ii»al.l.' o\' fxrivtin-r ii -niit.r .|iian- 
 tilv, iiniwi"llistiiii(lin-r tti>' I'iif'u'iit iiiiiv iKirti.Ur of a laiy..' 
 .„;„„„„ „,• ,i„i,i. Thr -.'Mrral cl.ara.'t.T of ll.r .lisni>^i', 
 is v»TV similar tu that of ,lialK-trs mrliilus. Tl.r |Mtici.trt 
 iM.mi.iaiii ..I'wcakiirss, i'ina.'iati..u, liradadu'. uaii.M'a. and 
 .■hilly s.nsatiuns. 'rii.'V Lrar suriri.al oprrations l.a.lly, 
 and ot't.'ii dif of inlfrciirri'Ut disi'as.-. 
 
 'PivatuK'Ut soeins to fail to ivstoiv tiir linutioii of the 
 kidiifys, 
 
 OLUintlA AND AZOTUIUA. 
 It is a fact that many \n-o\Av maki' nincli h'ss^ than the 
 avrni'--.' fortv to sixtv oun.-cs of urine \h'V dn'in. with 
 in.MVii"sc ..f sluH-ifn- .irravity and of tlu- ann.unt ..f niva i-.T 
 ouii.T. and vet are fre.' from disease of tlir kidn*ys. A 
 f,i,nd of mine, a m.Mli.-al man of ahility, iid'orms me that 
 jil.ont ten vears airo lii^ attenti(m was eaUed t<. the small 
 nuaiititv .d- urine that he was passin-. Ur made an ex- 
 amination of tlie urine, and also had it examnie.l by 
 several medi.'al frii^nds. He states tluit. re-anlless o\ 
 the qnantitv of ^*olid or li-iuid nourishineiit lie has taken, 
 or „f nu'dieatioii, hi' has not dnrin- th»' past ten years 
 nnide thirty onnees of urine in any twenty-h.ur eonseeu- 
 tive hours. 
 
 )J * 
 
 j--,4<«»«wu.<iws»»a*«5»'<«»»»=»^'**«'««'*^ ••***'*'"*"■ 
 
 r.M»wJ<».H«t'f««t*«»« -UM ii t* m m K stiimf»iisxi - 
 
 tm 
 
1 N DKX. 
 
 At-(«s.< of kiiliii'V, 107. 
 Ac >iiiiiii'iiiiii, -I**- 
 
 Aci'l, liipimiir, 4'.». 
 
 ciXlllK', 4'.' 
 
 (iXHluric, 4!>. 
 uric, 4H, W, r.7. 
 Aiiiti' <y-tit'H, 188. 
 
 lii'I'hrilis, T'l. 
 Ailiuiiit'ii, "It!. 
 
 sijjnitti'uiice of, 07. 
 ttsts for, 0',), 70. 
 thi'iiriis of, <18. 
 A'livldiil Ji-neiieriitiiiii of kiilnoy, 
 
 l-JO 
 Aiiii'i liii of kidney, 4'i. 
 utioloKV of, 45. 
 jiatholoi^y of, 45. 
 pro)ino8i!* of, 4(1. 
 »yiiipt'iins of. 4-5. 
 trt'iitiiiint of, li), 
 
 AllilSlhcsill nf MikMcI'. 17H. 
 
 ihioiul liydrati' for, 179. 
 etiolotty of, 17H. 
 cymiitoiiis of, 170. 
 tfi'iitnu'iit of, 170, 180. 
 Anatomy of bladder, 1(18, 171. 
 of kidney, 7. 
 
 Bowman's cnpside, 10. 
 cortienl portinn, '.' 
 Midpiijhmn tiil't, 10. 
 inedulliiry portion, ft. 
 pynmud", 10. 
 
 ao» 
 
 Aniil.'iiiy of kidn>'y, uriniferoux 
 
 tuliuies 10. 
 Anu/oturiii, -HO. 
 
 <ltliiition of, 'JllO. 
 Aneliri^in III' p'llid M -I Iv 47. 
 Arterie!* of kiilney, IM. 
 
 iiiH'urif'iiis of, 17 
 
 dei;i'iii'riili"n of, 4"'>. 
 
 di-ince of, 4ti. 
 
 uinlioli^ni of, 47. 
 
 throiiilioKis of, 47. 
 Aspiriition of kidney, 15.'i. 
 
 iiii'tie'd nf, \r,:y. l.Vl. 
 Aton.v of liimldiT, 17H. 
 Atropliy of kidney, 'JH, I'J:!. 
 
 ptiology of, l-'i. 
 
 piitlioli'ny of, I'.M. 
 
 pro^no^is of, llil. 
 
 ^ymptoInH of, 1U4. 
 of unters, l.')4. 
 Azoturiu, 1!30, 2M. 
 
 Hertini's columns, 1!1. 
 Bladder, anii'»tlie>ii» of, 178. 
 
 imatoiny of, 1"',H. 
 
 arteries of, 171. 
 
 atony of, 178. 
 
 beninn Rrowtli^ in. '-'04 
 
 bit-i of eloth in, '20o. 
 
 (•oaf of. 170. 
 
 de-rription ..f, 100. 17(i. 
 
 fort'it;n bodies in. '2(».'i, 'JO.j. 
 
 treatment of, -JO."), 206. 
 
 i!33 
 
 «rTWM1l««^"-' 
 
 tnartR-x J"-'~J-» -> •* •kHf.^--'^''-'^ ■" "' 
 
 Ai 
 
2:51 
 
 i.\i>i:.\ 
 
 |»lii.l.|.r,u»l»-»i"n'"l" •-'"■' ; 
 
 jjriiMl ill. '-'»>■> 
 
 lllMllnnllliU'' "'• '^^' 
 
 |i\|iiiii»ilii'piii III'. I"'*' 
 Ji>|M iiiii|'l'.* ••' ''•'■' 
 iiiliiiMiiiii''.i"ii "•'. l****' 
 irriMlil''. I'^' 
 linuiiii lilt III'. 171, 1 1"' 
 timlluimiil LTiiwilis III'. ailU 
 niui'iiiiii i''i"i 'i'' '""• 
 ihiiM'iiliir iimt III'. I'l'"- 
 iii.fvi« iif, 1 Tl . 
 i.i'uniluiu III'. n'J. 
 ni'W Kriiwtli* in, «"•' 
 
 uiiil fiiniu" liii'Ji''^ '"t 
 •Jd.l 
 jiunilyi'ii' "I'. '**•' 
 ixmitiiin III'. I'W- 
 »hii|i<' ot'i I'i^' 
 
 III infiiinv, 10H. 
 ^/.^••(, It'iH. 
 njMiHiii 111', '**!• 
 
 ►t in. IHH, 'jn.-i. 
 
 tiiliirnilii-iit III', '-^*'''- 
 vurii'ty iif uMwlliti in, 
 vt'inn I if, 1"1' 
 HIhkI in iirinf. <M- 
 HoWtimiiV niliMili'. 10. 
 Hrii^lit .* (li-iii-f, '•i- 
 
 '203. 
 
 (,'iiliiili III' ' 
 Ciiiiulus 
 
 ;yiil ]iliii«|>liiiU'^, 137- 
 , i:!:?. 
 
 y iif. 133. 
 ilucnci' III' »i:<' "I'll li'^' 
 i.f c'linmti' iin. 135. 
 Mii'kcl'.* thi-iry nl', 134. 
 Cimii-r nt' Uiilniy, l'J5. 
 Cast' n|>li.unini'i' nf, (i'l. 
 (Irtliiiti'iii "I', •'il- 
 fiirniatiun i>li ^^ 
 
 Cii.tK, liUliiry I'f, *H. 
 
 viiri''ii'- 'il'i ••''• "•' 
 ruliinlml iniihn'i'. ""■ 
 Ciiiln liri/.iiii: nil l<i-i l*l'>- 
 CliLiriilin ill Hiint', 64. 
 ('iirmiii' ry"tiii». '**** 
 Ciriliiiiii' kiilin'y. '.'•• 
 «..lmiiii-iir Hirtliii, 13. 
 t'niM nil It'll l^lllnl■y, '.'4. 
 Criu.otii in ••limnii' lytili-, •'•"• 
 Criiiiiviii- iii|ilifiii-, '•'•• 
 
 Cy-iiilu'i'i 1'^'- 
 
 il.'tliiiiiiin III'. I'^'-' 
 
 fliiil"«y III". ''■- 
 
 lljnsrMilllll- I'T. 1T4 
 
 ' |iiilliiiliiiiy nil ''•'■ 
 
 iiiliil mipiiiiMtiiii'i' l''"'i '"••• 
 Hyiiiiiliiiiii* III', IT3. 
 tri'iiiniiiii III', l'i^4. 
 (•yiit,. il.nininilii'ii »( tl>" k'J'"')'. 
 'I'Jii, 131. 
 
 Cynlili-. I***- 
 lU'Ulf, IHH. 
 
 (hliinil hyilniti' in, 196. 
 
 clnlhinu' i"' l''^' 
 UillniliiiM III', IHH. 
 .lii't 111. I'.M 
 etinliiuy III', IHH. 
 ijouty tliHtlii'i'i* in- ^^^ 
 liyivi.liTiiiic injfcti'i"'* tori 
 
 ItM'i. 
 
 injnrii'" in, 1H9. 
 
 jmtliiili'Cy III", l'''^)- 
 
 j.i'(liitivt'« in, l'.»5. 
 
 Rcx in, IHH. 
 
 sviniitnnii 111', li'l- 
 
 tnutnnnt nf. 1''3, 106. 
 chrnnii'. IHH. 
 
 linniti' iif i>ii*li"n> fi'i'i ^^''• 
 Ciilifiii-ni" ininiTiil wiiti'i-* 
 
 fur, I'.tH. 
 etiiiliigy of, 190. 
 
ISDF.X. 
 
 i:\r> 
 
 ., MMl. 
 
 III' kiJiK'y, 
 
 in, \'M). 
 I. 
 
 <». 
 
 
 
 in. 
 
 ISO 
 
 
 jf<'t 
 
 nns 
 
 lor, 
 
 ). 
 
 !)0. 
 
 
 
 15. 
 
 
 
 V.tl. 
 
 105 
 
 
 mi 
 
 lor, 
 
 197. 
 
 lunil « 
 
 iitfi 
 
 )0. 
 
 ('y-tit,», rliiMiiic, iiiinili' "I' -ilviT 
 
 iMf, l'.»7. 
 
 |iiilli"l"U\ if, I'.iO. 
 .iiImI III, lt(T, 
 
 K\ (llllllllll- 111', I'.liJ. 
 
 trriiUiHiit 'if. Hilt. 
 WH'ln'» lor, 1U7. 
 »u)iu<'Uli', !>•>•■ 
 
 ii(iii|.iU_\ 111, Ihrt. 
 |iriii»iiiimK lit', 111!!. 
 
 J>\ lll|ltl>lllK 111', U'-'. 
 
 In iiiiinjit of, lua. 
 
 (.'v-tii-liiliiii-i-, !>*''. 
 fNil"plfi;i». l"". 
 
 (•IUlM'« 111", lH!t. 
 
 <!• tIniliiiM «(. 1«:i 
 
 ill liiiiiiinli'ilil'. \M. 
 
 in iilil wonii'ii. I^H. 
 
 iiMii|iiiiinH iif. 1h;). 
 
 tPiiUiii'iit III', IHl. 
 ('yt"riliiii;iii. :tt!, 1H7. 
 
 itiiiliii.'y 111", 18", 
 
 ni'W yriiwtli" u» niii'M'. IH7. 
 
 nyiii|)tiiiii' lit', 1h7. 
 
 triiitini'iit 1)1", IH7. 
 
 uU'iTiitii'n in. 1*^7. 
 ('y-t"-pii'*iiiii-. l^'- 
 
 ilitliiiliiiii 111', IHl. 
 
 .•tii.liiL'V 111', IHI. 
 
 >\ lii|itiiiii'' iif. IHl. 
 
 tinctiHi' "t' liyii-c.Miiiius t'nr, 182. 
 
 tlfiillnrut nl', 1H"J. 
 ("v-t"-|iii>ti<'il'<, IHI. 
 
 Cy>t-. hvilutiils, 11)0. 
 nf kidii.-y, 120. 
 
 cnniri'nitiil, I'JO. 
 
 I'linlllU'V 111'. I-'O 
 
 lii|mfiitiiiiiy t'nr, 130. 
 luitlioliiuy i>f, 120. 
 priiiliiiisiii of, 13'J. 
 Kyiniitniii" of, I.'IO. 
 ticutiiifiit of, 1.'!!!. 
 
 l)iH.ii niti"ii', I'-il*. 
 uii.yloi.l. I'Jti. 
 cy-tli, I'JO 
 iliiinnii-i» of. I'-'l, 
 Hiiilouy of. Ii.'<». 
 I'iat\, l*-'"J. 
 
 Iiirilii iiiK, I'JO. 
 
 ,inil...|oi:y of, I'JO 
 iiroijiiiKiii of I'JI. 
 »yiii|it"in» of, I'JI. 
 
 tl-i'lllllll'llt of, I'J'J. 
 
 wiix.v, I'JO. 
 Di-iliimimiiM' iii'i'liiiti', 71. 
 
 Diiii.ii.-v ::n>. 
 
 hiMon of. 'JiO. 
 
 li\|iirtroI>li.v of lilidili !■ ill. 'J0-, 
 
 IIIKIIlillll'-, '-'Jt. 
 
 .l.-ili.itioii of, :"J4. 
 aiiiuno.iH i.f. 'J'JH, 'JliO. 
 Hioloity III". 'J"-">. 
 cxcitinu iiiu-i'« of, JJil. 
 |iiiiUil> ill, "JJii. 
 putliolony of, 'J'J7. 
 ((yiii|>toiiin of, •J'J7, 'J'JH. 
 
 t'lVHiiMi lit of, -j-jo, 'j;;o, 
 
 IllfllittIS, I'll. 
 
 iit;c in, 'J I 'J. 
 
 H|l|ll'liti' ill. 'Jl'l. 
 
 I'litiinli ill. -!'• 
 
 chiiriH'lir of iiriin' in, 'Jl'l. 
 
 «;oiiiil in, 'JIH, 
 
 coiiilitioii ot'MiiiliiiT in, 'JH. 
 
 of IiIoihI ill, 'Jl t. 
 
 of tiiiliii'V in, 'Jl*. 
 of liMT in, 'JI3. 
 of hmi; in, "JH. 
 of luinciiii^ in, 'Jl'5. 
 of >iil«i'ii in, "Jl I 
 ot rtoiiiiu'li in, 'J14. 
 dfHiiitioii of, 'Jll. 
 
 iJ 
 
 -O-JA***^ ' 
 
'2:M\ 
 
 JSDKX. 
 
 
 l)i;ilirlrs iiiillilus, dii't in, '2'^^^. 
 
 ciimciiitiin in, -iH. \ 
 
 ciidlii^y lit', iJll. 
 
 lmliit~ in, '2\'2. | 
 
 hiniiit\ in, 'il'J. 
 
 inllin n<(Mit't'lii"ttti'in,'211. 
 
 ncrviiiis systi'in in, 'J17- 
 
 j)iilii.iliiu'y "f. -1!'- 
 
 plilliiM> ■' , -l"^- 
 
 jiiMUni I, -'-^• 
 
 nu'c in, -I'-J. 
 
 srx ill, 2V2. 
 
 sliiu ill, (MimliU"!' "f, -'7- 
 
 suniir in, '2\'>. 
 
 gviiiptoms I't', '215. 
 
 tiv.itmHit.'f, 2-J0,--i21,2-^2, 
 
 •>'Z;\, 224. 
 ui'iiiH in, '215. 
 DiUitiitiiiii I't" nn tt'i-s, 154. 
 Disloinii h;i'iimt(iliimn, M. 
 
 Enilioli>in of ifniil iirtory, 47. 
 Emliniic lui'nmturiii, 41. 
 ctiiilogy of, 42. 
 history of, 41. 
 pnllioloj^'y of, 42. 
 proi;no.>is of, 43. 
 symptoms of, 43. 
 trriitiiii'iit of, 43. 
 Entozou in uriiu', 113. 
 Kniiri'sis iiocturna. '207. 
 ftiol.u:y of, 207. 
 ]mili.aoi.'y of. '207. 
 ti-t'iUmiMit of, '208. 
 Epitholium of tubules, 12. 
 Erysipt'lrt.'- ft-> ''HUSO of nephritis, 78. 
 
 F. 
 
 Forn'inV ^n-runids, 12. 
 Eilariii biingiiinis liominis, G3. 
 
 Koni'^n liodios in MiuMer, 205. 
 
 llilli,'no>ir< of, '201). 
 
 Floating kidney, u:',. 
 
 coii|;eiiiUil, 25. 
 
 diiifjniwia of, '23, 
 Fuiini in urine, 113. 
 
 Giill-bliidder, distended, '24. 
 
 Glioiim, 1'2;). 
 (Jloiuerulo-nepliritis, 03. 
 
 Ulueo-uiiii. 211. 
 (Jlycoi-iiriu, 211. 
 (Jly'Kieiiiiii, 223. 
 Gouty iddney, 04. 
 Gruiiuliir kidney, 94. 
 (iruvid, 1'13. 
 
 H. 
 
 HiiMiiiitinuriii, 43. 
 detlnition of, 43. 
 etiidojiV of, 43. 
 piitholntry of, 44. 
 prou;nosi< of, 45. 
 symptoms of, 44. 
 trt'iitment of, 46. 
 llicmiituriii, 30. 
 
 detlnition of, 30. 
 endemic, 41. 
 etioloiry of, 30. 
 
 false, 43. 
 
 in irnuty pntients, 47. 
 
 in tubeirulosis of bladder, 200 
 
 piiriisitie, 41. 
 
 piitb'doiiy of, 37. 
 
 prou;nosis of. 39. 
 
 spurious, 43. 
 
 stronirylus };ii;iis tus causo, 41. 
 
 pyniptoms of, 38. 
 
 treatment of, 39. 
 Hipnioclobinuria. 43. 
 Hen.orrbage of bladder, 187. 
 
lyniLX. 
 
 'j;]7 
 
 Ilclll'^ \>«']<. 11. 
 
 UoiNi'shoc kidney, *-5. 
 llvdati.l cy-ts of kidney, VM. 
 rii|iliiit' of, VW. 
 llydniK' of clilond in iiculc cystitis, 
 
 lite. 
 Hydro.iii'|iliron, \i>0. 
 Hydro ii('|iliio>is, I ">0. 
 di'liniiion of, loO. 
 diuirnosis of, 161. 
 etiology of, 151. 
 imlholouy of, 151. 
 jifoi;no>is of, 152. 
 -ynijitonis of, 151. 
 triutinint of, 1.52. 
 HydrojH ii'nalis, 1130. 
 Hyo^uriii, 224. 
 Uyperii'miii of kidney, 32. 
 
 etiology of active. ,32. 
 
 of pas'sivc, 32. 
 pathology of, 34. 
 jii'ognn>is of, 34. 
 symjitoms of, 33. 
 treiitment of, 34. 
 Ilyperw-thisia of bliulder, 174. 
 diabetes as cause, 175. 
 etiology of, 174. 
 gouty diathesis in, 175. 
 in cerebral or spinal disease, 
 
 177. 
 pvognaney a.s cause, 175. 
 symptoms of, 175. 
 treatment of, 17ti, 177, 178. 
 trilieum rcpens for, 177. 
 Ilypeninesis, 181. 
 lIyi)ertrophy of bladder, 109. 
 
 anatomical appearances of, 
 
 201. 
 concentrie, 100. 
 definition of, 109. 
 eccentric, 190, 200. 
 etiology of, 109. 
 
 Hypertrophy of bladder in diabetes, 
 202. 
 progno>is of, 202. 
 MMiptoms of, 202. 
 treatment of, 202. 
 varieties of, 109. 
 of kidney, 124. 
 of ureteni, 154. 
 
 K 
 
 Kidney, atrophy of, 28, 123. 
 cirrhotic, 04. 
 conliaeted, 04. 
 flouting, 21, 23, 25. 
 gouty, 04. 
 horseshoe, 2t'). 
 hypenemia of, 30. 
 hypertrophy of, 3(1, 124. 
 movable, 10, 20, 25 
 
 etiology of, 20, 21. 
 single, 20. 
 
 weight of, 29. 
 solitary, 20. 
 Kidneys, ubsenee of both, 29. 
 amyloid, 120. 
 
 amemia of, 45. 
 
 anatomy of, 7. 
 
 aneurism of, 47. 
 
 anomalie> of, Ki, 17. 
 
 arteries of, 13. 
 
 as))irntion of. 155. 
 
 blood-vessels of, 13. 
 
 cancer of, 125. 
 
 circulation of, 13. 
 
 collecting tubes of, 10. 
 
 conge.stion of, 32. 
 
 cortical portion of, 10. 
 
 cysts of, 129. 
 
 disease of arteries of, 46. 
 
 embolism of, 47. 
 
 exi. lination of, 8. 
 
 fatty, 122. 
 
 i,.k!rj**.»*«.^*>*'»»*^*' 
 
 ',■;«*•«; tu—v**. 
 
2:jh 
 
 isnr.x 
 
 l',.iiii I't', ■-•'»• 
 i^niimliir. 'M 
 liaiimliniiriu "f, 43. 
 )i;iiii»lunii <'t', !it>. 
 liy.liilHl cysts (if, l!'.0. 
 iiHiMsiitiiil tissui' of. 1-1. 
 iiitfrtul)iilMr tis-uc of, It. 
 Kli'li«si;l..iiiiTulo-iiiiOiriti>, ".»:'>• 
 
 nmlt"riiiiitH'n "''• -•'' 
 Malpi-liiii" lioilics lit', 10. 
 
 tufi-. 1<» 
 inraulliin |»'rli"ii "!'■ 9- 
 
 ini-ii''"'''""'"''' "'' '"' 
 licnialiiiii "'i ''0- 
 IK'fVCS i>t, 14. 
 iii'W npnwllis. 1'-''>. 
 i„.ii-iii»lii.'Muiit f;n.\vUis of, 
 
 I'JH. 
 uuniliir lit", -•■ 
 (iliy.-i"l'"4y "I'l "■ 
 jici-itii'ii III'. ". '"' 25. 
 pynmiids of, 10. 
 ri'liitimis of, 8. 
 S-hiliicil, i!8. 
 si/.i' of. ^• 
 Mip|ninitivi', 107. 
 surtticiil tiPiitniint " 
 tlironilmsis of, 47. 
 tis^ui's (if, 0. 
 tulicri'dltir, 1(^8. 
 tumors of, rJ-'>. 
 urinifi'i-ous tiil)ul<'s of. 9, 11. 
 veins of. 14 
 weight of, 8. 
 
 L. 
 
 Lisiiiimnts of bladder, 171, 172. 
 
 M. 
 
 Mnlf irniiitionp of kidney, 25. 
 of ureter, 154. 
 
 165. 
 
 Muli-imnl -rowtbs of kidmy 125 
 
 etiolojiy of. 12'- 
 
 jintlioloiiy ol, 12i'i. 
 
 Hyiiii.loiiis of, I2i'i. 
 
 tniilnnnt of, 128. 
 Midl>iijhiiin Uifl-. 10. 
 Minitiiriii.211. 
 Mimiul water f..r elimnio <y>Utis, 
 
 I'lH. 
 Morliid irrowtlis in uiiin', •!•!■ 
 Movable kidney, 20. 
 
 aeniiired, 1'.'. 
 
 rhild-lieiirini: a- caii-e, 21. 
 
 tMiiaciation a- eauM', 2-. 
 
 etioloiiy of, 20, 21. 
 
 larjje liver as cause, 22. 
 
 8ea-si<'l<nes;i aseause, 21. 25. 
 
 treatnieiil of, 24. 
 Mucus in unne, ill. 
 
 N. 
 
 Npplirali:i»i S'*' 
 
 di»i;nosis of, 31. 
 
 ctioloi-'y of. 30. 
 syniptosns of, 30. 
 treatment of. 31. 
 Nephrectomy, l''i3. 
 alidoTninal, I'm. 
 delinition of, lii3. 
 ditl'erential di»i;nosis in, 105. 
 liis'ory of, l'i3. 
 indii'ations for, H'>4. 
 metliod> of, lt;8. 
 Nephritis, 73. 
 ditfuse, 103. 
 ijinity, 94. 
 interstitial. 04. 
 intertuliutar, 94. 
 
 ditl'erential diatcnosis of, 
 
 102. 
 etiolosry ot', 94. 
 pathology of, 95. 
 
 ^Ka 
 
i.\i>i:.\: 
 
 2;i9 
 
 Nc|iliritis, iiitiTtut>iil!ir. pmgnosis 
 (.f, luo. 
 !-yiiiiitiiiiis lit", ',)". 
 
 tlllltlllillt nl', 1()0. 
 J)nrcIlrliyMlUliiU^, 1(K!. 
 
 fti<>l>f,'y of, lo;!. 
 micrcisciiiiy <>(, HH. 
 piiiliiilnny 111', 103. 
 jiP'i;ii">i- I't", lOil. 
 >yiii|)ti>iu-* iif, lOo. 
 tri'i'''.iicnt Hi' 106. 
 tubu'mr, "il. 
 
 lU'lltO, '*')■ 
 
 ciitiiirliiil, "ti. 
 
 chn'Mie, T'l. 
 
 cldthini; iti the troiitiiicnt 
 
 of, li:;. 
 croupous, T'i. 
 dt'sinuimutivc, T'i. 
 dirt'iTfiitiiil diii«no>i,< of, 
 
 10-'. 
 diiinlics in the Ireatiiifnt 
 
 of, 00. 
 dropsy in, 85. 
 etioloi,'y of, 76, 79, 80. 
 miiicnil \vati'r> in tln' tn'iit- 
 
 mi'nt of, 88. 
 piitholojjty of, 80, 81. 
 pnL'umoniii in, 92. 
 pro;;iio-i-i (if, 86. 
 suluicnti', 76. 
 synij)toins of, 81, 8S, 85. 
 trciiliiient of, 87. 
 vera, 102. 
 Ncphro-lithiusis, 1"..^, 135. 
 Nephro-litliotomy, 161. 
 definition of, 161. 
 indiciitions for, 161. 
 McLean's, Dr., case of, 163. 
 nieth-dof, 162. 
 Ni'phro-plitliisis, 108- 
 Nephro-pyo.si.<, 149. 
 
 Ni'phrorrliiii;ia. ■?6. 
 Neplimnliapiiv , 157. 
 
 (litillitioll of, 1,'(7. 
 
 llalin'.s nirilind of. l.W. 
 
 Kei'n s, l)r., iiioiiiiM;rapli on. 
 
 157, l.-)H, l.V.t. 
 Tiiit'8 case of, 158. 
 Nephrotomy, I'lO. 
 
 di'tinition of. lno. 
 Nerves of l)l;idiii.tr, 171. 
 Nervous system in diahot'S inellclus, 
 
 217. 
 Neurali;i!i of lilaiMer, 172. 
 Noetiirnai ine iiitiiicnc', 207. 
 Nomenclature ot' discuse.s of the 
 
 kiilni'V, 7;{. 
 Noii-inaliu'iiant mrowths of thu 
 l.i.iilder, 12M. 
 vurietiea of, 128. 
 
 Olistructioii of ureters, 153. 
 
 Oligiiri". 2;W, 2:il. 
 
 Oxalate of lime calculi, 1.17. 
 
 j Paralysis of the bladder, 183. 
 j Parasitic hieinaturia, 41. 
 Pelvis of kidney, diseases of, 133. 
 
 stone in, 13.1. 
 Perfi>rati(in of ureters, 154. 
 Pericystitis. 198. 
 
 acute and infectious diseases as 
 
 cause, 198. 
 etioloiiy of, 198. 
 gonorrhren a.s c»u»e, 198. 
 symjitonis of, 198. 
 tP-atinent of, 199. 
 Perinephritis, 152. 
 definition of, 152. 
 etiology of, 152. 
 prognosis of, 153. 
 
 !l 
 
 ^mmSmm »* "^ rtftw* **« 
 
 Mi 
 
240 
 
 JSDF.X. 
 
 I'lriii'pliiiti^. ^vtiiptiiin* of, l.VJ. 
 
 Iri'iitiiiciil of, liJ'!' 
 l>li,).lihiiU'- ill urine, til. 
 I'll j>ii ill >','y c'f kidiH'V, 7. 
 I'ipraziii in proi-liyl-olic tr«'iilinont 
 
 of rciml oiiliMilus, 14ii. 
 l»,,lycl>p-iM, 224. 
 l',.lMiriu, 22 I. 
 Pyilili-, 11". 
 
 (■nliiili"-!!, 1:5!^. 
 (■li.il.ij;y "f, 147. 
 J.athnl.'l,'y of, 147. 
 pniunn.sis of, 14^<. 
 rcniil <'iilcu\i a.s cau.«', 147. 
 syiiiptoiiis of, 14H. 
 tnwitmi'Ml of, 148, 149. 
 Pyelo-neplirosis, 149. 
 I'yo-iii^i'hrnsis 14'.»- 
 ilitiiiition of, 149. 
 ,.tinloi:y..f, 149. 
 piillioloijy of, 149. 
 gyiniitoms of, ioO. 
 tmitiin'iit of, 150. 
 I'ynuiiiils of Ferrcin, 12. 
 Pyuria, 71. 
 
 diiitcnosis of, 71. 
 
 i'tioloi;y of, 71. 
 
 microscopic appeurances of, 72 
 
 Itcnal colic, hypodermic iiijwtions 
 ,.f linclurc of opium in, 
 142. 
 progiio.<i> in, 140. 
 trfiitmciit of, 140. 
 inudwiuacy, 230. 
 
 S. 
 
 Schuclio\vii'.s tubule-. 10. 
 SiL;lit in iliiil.ctcs mcllitu>, 217. 
 8kin in iliubctcs mcllitu>, 217. 
 Spiism of bladder, IHl. 
 Speriniilozoid-i in urine, C3. 
 Stone in Madder, 1H5. 
 
 in kidney, 133. 
 Stronijylus gifjas, 41. 
 Subacute cyftitis, 1H8. 
 Su^ar in urine, 215. 
 Sui'purativi' kidney, 107. 
 Surgical kidney, 107. 
 
 diairnosis of, 107. 
 
 etioloiry of, 107. 
 
 prognosis of, 108. 
 
 symptoms of, 108. 
 
 treatment of, 108. 
 
 treatment of kidney, 156. 
 
 Renal calculus in infants, 138. 
 
 patliological anatomy of, 
 
 137. 
 prophylactic treatment of, 
 
 143-147. 
 
 symptoms of, 137. 
 colic," 133, 138. 
 
 collapse in, 141. 
 difl'erential dias^nosis of, 
 
 140. 
 enemnta in, 142. 
 excessive vomiting in, 142. 
 
 Thrombosis of renal vessels, 47. 
 Tubercular kidney, 108. 
 diai^nosis of, 111. 
 
 etiology of. 109. 
 
 pathology of, 109. 
 
 proirnosis of, 112. 
 
 treatment of, 112. 
 Tuberculosi.s of bladder, 206. 
 
 examination of, 206. 
 
 females in, 206. 
 
 hiematuria in. 206. 
 
 patliology of, 206. 
 
 primary, 206. 
 
 treatment of, 206. 
 
 I 
 
03. 
 
 L\Di:x. 
 
 w 
 
 'ruliular ni)ihriti», "fi. 
 Tuliules, in||(..e'tiiii:, 12. 
 
 ilihiti'd Willi .ysl-, 129. 
 
 I'pithiliiiia of, 12. 
 
 of SchiiL'li')W(i, 10. 
 
 urinit'i Tdiis, 10, 
 Tubuliti-, "It. 
 
 U. 
 
 I'm mill. 1 1'i. 
 
 lil.'tiMili'Ml of, 113. 
 eliolo;;}' of, 113. 
 syiiiiitoma of, lUi. 
 tliooiii'S of, 114. 
 ti'i'iitmont of, 118. 
 Uru>ti>-i-, 147. 
 Urato of utiimniiium, 69 
 of ciilciutn, 69. 
 of j)otH»iuiii, 59. 
 of sodium, 58, 69. 
 Urates 54. 
 Uri'ii, 4s, 50. 
 
 iminiuit of, 62. 
 diiiiiimtion of, 53. 
 in euiK'iT of stnnmcli, 63. 
 ill chlornsiH, 53. 
 in cbr.iMie lUstnises, 53. 
 inctva>i' of, 62. 
 Ureteritis, 153. 
 Urot.TS 3(5, 153. 
 atrophy of, 164. 
 cntlioteri/.ini;. 1<)5. 
 diliitiition of, 154. 
 hyppi'tropliy of, 154. 
 niiilforniation of. 154. 
 obstruction of, 153. 
 {)erforation i>f. 154. 
 Uivthrorrbiiuiii, 30. 
 Uretorrliiiiriii, 3i>. 
 Uric acid, 48 54, 50, 57. 
 calculi. 137. 
 compounds, 58. 
 
 L q 
 
 I'lic acid ciy-tai.s, 57. 
 Urine, 48. 
 
 albiiini'n ill, OC). 
 
 aiiiiiH'iiiuiii plici-plmtcs in, 00. 
 
 unite ill, 69. 
 blood in, 02. 
 
 calcium carbiinatu in, 01. 
 i-ulpliati' in, 01. 
 urate ill, 59. 
 (■ii>t> in, t>3, 04. 
 ehriiiinil cniiip..>itinii (if, 48, 49, 
 
 51. 52. 
 chlorides in, 54. 
 color of, 4H, 49. 
 composition of, 15. 
 cystin in, 01. 
 dctiiiition of, 48. 
 deposit* in, 60. 
 curtliy pbosphates in, 00. 
 t'lcmints of iiiorbid growtli-s in, 
 
 03. 
 f'lito/.oa in, 03. 
 
 fllaria .sani^uinis hominis in, 03. 
 fuiiLji and infusoria in, 63. 
 inorganic constituent^ of, 54. 
 
 dcjKisits of, 60. 
 leuciii and tyrosin in, 01. 
 niucu.s and pus in, 01. 
 (xlor of, 51. 
 organic constituents of, 52. 
 
 deposits of, 50. 
 oxalate of lime in, 59. 
 pli.'Spb - of, 55. 
 j)iitassiuin urate in, 69. 
 jms in, 71, 72. 
 
 diiiLCnosis of, 72. 
 etioioiry of, 72. 
 microscopic apjiearanco (jf, 72. 
 (piantity of, 51. 
 reaction of, 48, 50. 
 salts of, 16. 
 secretion of, 12. 
 
 21 
 
 « ■ "Kf '••• n f^rr'-OK *'i-^ 
 
■242 
 
 iM>i:.\. 
 
 {■run; s(Tivti,.n of, rr<"" '"■'"'■ 
 j)ri-.smf, H. 
 ■.(•(Imntit.-' "I", M. 
 Midimii nriiti' in, '>'■>■ 
 ti|i.(illi' irmvily "\\ tH, "»(). 
 
 of. in (liiilH'tos, '210. 
 sjuriimli'/.Kiil'^ i"i •''•'• 
 hiit;iir ill, -I'J- 
 tiiiliiility <>{, •••• 
 wliirc .^ii'cnticl, 15. 
 
 r 
 
 4i>/,i'iiiii, "4. 
 
 V. 
 
 
 V 
 V 
 
 fins iif Miul'li 
 
 I'^icul I'liliiili. 
 
 .■ti..l..- 
 
 H\ nipt 
 
 r, IT 
 IH.V 
 
 V (.f 
 
 I. 
 
 isr>. 
 
 .f, 185 
 
 
 trt'iitinftil 1 
 
 i; iH'i. 
 
 
 li:rinilllirill 
 
 , 1H7 
 
 . 
 
 
 iml-v, W>- 
 
 
 
 i 
 
 •f , 
 
 THE KNU. 
 
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