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THE NEW SYDENHAM

SOCIETY.

 

INSTITUTED MDCCCLVIII

 

VOLUME CX.
SELECTED MONOGRAPHS

COMPRISING

ALBUMINURIA IN HEALTH AND DISEASE.

. BY

Dr. H. SENATOR.

SOME CONSIDERATIONS ON THE NATURE AND
PATHOLOGY OF

TYPHUS AND TYPHOID FEVER.

BY THE LATE

ALEXANDER P. STEWART, M.D.

MOVEABLE KIDNEY IN WOMEN.

BY

Dr. LEOPOLD LANDAU.

LONDON:
THE NEW SYDENHAM SOCIETY.

1884,
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PRINTED BY J. E. ADLARD, BARTHOLOMEW CLOSE.
ALBUMINURIA

IN

HEALTH AND DISEASE

WITH TWO APPENDICES

(1) A CONTRIBUTION TO THE THEORY OF URINARY
SECRETION.

(2) THE HYGIENIC TREATMENT OF ALBUMINURIA.

BY

Dre. H. SENATOR,

PROFESSOR EXTRAORDINARY OF MEDICINE; PHYSICIAN TO THE ROYAL CHARITE
HOSPITAL, AND TO THE AUGUSTA HOSPITAL OF BERLIN.

WITH ONE LITHOGRAPHED ILLUSTRATION.

TRANSLATED BY

Dr. T. P. SMITH.
Daditater

TO

HERR RUDOLF VIRCHOW,

IN

COMMEMORATION OF HIS SIXTIETH BIRTHDAY

AND OF HIS

TWENTY-FIVE YEARS’ WORK

AS A

TEACHER IN THE FREDERICK WILLIAM UNIVERSITY.

Uniting, as I do, with that large concourse of your
admirers who now approach you with expressions of gratitude
and every good wish, I should like, so far as lies in my
power, to bear witness to the fact that practitioners also look
up to you as their pioneer and master, and that therapeutics,
in the strict sense of the term, is not behindhand in
gratitude and in the recognition of the enormous obligations,
which it, no less than theoretical medicine, owes to you. It
does not require my pen to recall these services to the
memory of our contemporaries, nor to protect them from
future oblivion, for so long as there is a history of medicine,
the mighty epoch-forming impulse, which all branches of
this science have received through you, will be duly recorded
in its pages. I will dwell only upon one point, which, in
the abundance of the meritorious services now so vividly
vill DEDICATION.

remembered, might be, if not forgotten, at all events too
little appreciated. When about three decades ago a new
development of medical science took its rise, due in no small
degree to the powerful influence of your labours, when new
branches shot up vigorously on the old but ever regenerating
tree of medicine, and one branch alone, the oldest indeed
—which seldom puts forth true blossoms, but when it does
so, brings to maturity precious fruit, blessed by all mankind
—remained sterile and, to all appearance, a hard, hopeless
twig, when it was a mistake to believe in therapeutics—at
that crisis you, most honoured Sir, were not afraid to come
forward and avow your participation in this supposed error.’
You had faith in therapeutics; you considered it to be not
a dead branch, all but given up though it was by those who
were especially called upon to make use of it. Your fore-
sight has not deceived you; with the growth of the tree,
so much of which it owes to you, that branch also has
received a fresh stimulus, and the indirect effect of your
labours and the direct effect of your words, spoken in due
season, have been to introduce it to the workmen and the
care of which it stood so much in need. Therapeutics has
once more become prominent, having received from you both
aim and direction.

In this treatise, which I have the privilege of presenting
to you, a place could not be found for therapeutics, for the
reason that albuminuria, which is its subject, is upon the
whole but little amenable to treatment. But as you have
not shown any scepticism on therapeutics in general, when
that science seemed all but extinct, so we are not without
hope that in this particular case the power of medicine will
some day be proved. These pages appear to me to be not
unworthy of being dedicated to you, because their contents 4
fall within the lines of “ pathological anatomy and physio- i

1 «Handb. d. spec. Pathol. u. Therap.,’ i, 1854, Vorwort, 8. xi.
DEDICATION, ix

logy and of clinical medicine,” departments to which you
have given such abundant space in your Archives, the
‘imperishable monument of united work in scientific medicine
and a motto for all your successors.

H. SENATOR.

BERLIN ;
October, 1881.
CONTENTS.

PAGE ©
INTRODUCTION . ‘ z x 3 = 3 - I

I. Taz Various Forms in wHicH ALBUMEN 1s ExcrETEeD ‘ 3

The possible sources of albumen in the urine. True and false
albuminuria. Albuminuria in the strict sense of the word,
or the excretion of albuminous constituents of the blood
(serum-albumin and globulin) coagulable by heat. Pepton-
uria. Propeptonuria (the excretion of hemi-albumose).
Mixed albuminuria. Methods of demonstrating coagulable
and non-coagulable albuminous substances.

II. AtsumEn as a Constitvrnt or Normat URINE se, Ee

Statements with regard to the occurrence of a ferment-like sub-
stance (nephrozymasis) and of albuminous substances proper
in normal urine. Physiological albuminuria, its frequency
and the difficulties attending its demonstration. The sources
of albumen in normal urine are the Malpighian bodies which
yield a filtrate, but no secretion. Laws of filtration and
transudation. The urine composed of the fluid of filtration
and specific glandular secretion.

Ill. Tue DerEnpENcE oF ALBUMINURIA UPON ALTERATIONS IN
THE BLOOD-PRESSURE . ‘ . a a - 39

Difficulties in estimating the influence of alterations of pres-
sure. Attempts to increase the arterial pressure by irri-
tating the spinal cord, by producing dyspneea, &c., by ligature
of the aorta, by dividing the renal nerves, by increasing the
bodily temperature, by muscular activity, by the work of
digestion, by poisons. Venous congestion due to ligature
of the vein, artery, and ureters respectively. Differences
between long-continued and temporary ligature. Explana-
tion of the processes in the various forms of renal congestion.
Comparison of the venous congestion experimentally produced
with the clinical forms of the same condition.
xl CONTENTS.

IV. ALBUMINURIA AS DEPENDENT Uron DEGENERATION OF THE
Rewnat Errrarniom ‘ . . ‘ . :

The renal epithelium is considered as a protective against the
escape of albumen. Albuminuria in fatty degeneration of
the epithelium (phosphorus-poisoning, pernicious anemia),
in parenchymatous degeneration and - coagulation-necrosis.
Origin of albumen from metamorphosed epithelium.

VY. THz Conpition oF THE BLOOD 4s INFLUENCING THE Pro-
DUCTION or ALBUMINURIA

Quantitative changes in the composition of the blood, especially
with regard to the quantity of dissolved albumen, salts, and
urea, and their influence upon the filtration of albumen under
physiological conditions (albuminuria of digestion). Influence
of the same under pathological conditions. Qualitative
changes. The appearance of egg-albumen and other soluble
albuminous substances in the blood, the occurrence of peptone,
propeptone, and dissolved hemoglobin, under physiological
and pathological conditions. Influence of increase in the
temperature of the blood upon filtration. Condition of the
specific secretion.

VI. Cerrain PEcutiaR Forms or Morsip ALBUMINURIA .

The impossibility of explaining all forms of morbid albumin-
uria. Albuminuria in congestion, convulsions, poisoning.
Febrile albuminuria, Albuminuria in cholera and diarrhea.
Albuminuria in the various forms of nephritis, acute and
chronic nephritis, and cirrhosis of the kidney. Various
differences. Amyloid degeneration of the kidneys.

PAGE

77

94

108
ALBUMINURIA

IN

HEALTH AND DISEASE.

Inrropvuction.

“ History teaches us that the views of modern times constantly revert to
those points which were regarded by earlier observers as settled, and thus,
particularly nowadays, when so few have leisure for the historical study of
science, there is perhaps ample justification for bringing old notions within
the intellectual view of a succeeding generation.” —R. Virchow’s Preface to
his ‘ Gesammelte Abhandlungen zur wissenschaftlichen Medicin,’ 1856.

I can think of no better introduction to the following
treatise than Virchow’s words which I have placed at its
commencement. For, as holds good with regard to so many
other scientific questions in medicine, so likewise and in an
especial manner with reference to the doctrines on albumin-
uria, they possess in my opinion complete validity and at
present perhaps more than at any previous time. The older
views, nowadays if not entirely abandoned, at all events but
little regarded, assigned as is well known, various causes for
albuminuria, viz. alterations in the circulation in the kidneys,
alterations in the membranes placed between the blood and
the urine, and changes in the condition of the blood. To
one or other of these three factors was a greater or less
share attributed in the origination of albuminuria, and ac-
cording to the existing state of science, attempts were made
to determine the influence of each of them. The most ener-
getic and successful opponent of these doctrines was J. B.
Stokvis, who, supported by extended experimental and clini-

1
2 ALBUMINURIA IN

cal investigations, declared that every alteration of the cir-
culation which checks the afflux of arterial or the escape of
venous blood, causes albumen to pass into the urine, but
that all other conditions to which the phenomenon had been
formerly attributed are to be rejected as ineffectual (1). Ac-
cording to this view, the only recognised cause of albumin-
uria is a retardation of the flow of blood in the kidneys,
for such is the necessary result of every alteration in the
circulation, in the sense applied to the term by Stokvis.
Only a slight advance was now required in order to deter-
mine which of the two functionally different portions of the
vascular system of the kidneys was the site of the circulatory
disturbance which caused the albuminuria, and the results of
the most recent investigations made with the view of deter-
mining this question agree in showing that the Malpighian
tufts are the portions implicated in the disturbance. Accord-
ing to Runeberg, (2) and Posner, (3) with whom Ribbert,
(4) and Litten, (5) agree, these vessels are the sole or the
only necessary seat of the excretion of albumen; the cause of
the escape of albumen from them is said by Runeberg to be
the diminution of the pressure of the blood, while importance
is attached to the retardation of the current by Posner and
Litten, the latter being supported by Runeberg’s views with
regard to the effect of the lowering of pressure upon the ex-
cretion of albumen.’ Retardation of the current, when pro-
longed, changes, as Cohnheim (7) has shown, the condition of
the walls of the vessels, inasmuch as it renders them ab-
normally permeable by the constituents of the blood and
especially by the albumen. Cohnheim himself likewise (8)
considers the disturbance of the circulation in the Malpighian
tufts to be the cause of the albuminuria, but the ill effects of
this disturbance are of less serious import upon the walls of
the vessels than upon the epithelium which covers the glome-
rular yessels, for he agrees with Heidenhain (g) in attributing

1 It is true that elsewhere Litten has expressed a different opinion, viz.
that the epithelium of the convoluted tubes is concerned in the excretion of
albumen, inasmuch as under pathological conditions it does not remove the
albumen from the transuded secretion pressed through the loops of the
vessels of the glomeruli, and which in the normal condition contains
albumen (6).
HEALTH AND DISEASE. 3

to this epithelium the retention of the albumen under normal
conditions.

Such then is the shape which in recent years the theories
with regard to albuminuria have assumed, mainly in Ger-
many, but also in other countries, as may be inferred from
the latest writings of Charcot, (10) Lépine, (11) and others.
It is obvious that this theory has the advantage of great
simplicity as compared with the older views, for all other
factors, to which formerly so much thought and investigation
were directed, are now held to be inoperative; they are even
scarcely mentioned. Posner, indeed, does not think it worth
while to discuss them, for he asserts that they are devoid of
any real basis. He goes, however, much too far in his
assertions ; for some time past facts have accumulated clearly
indicating the dependence of many forms of albuminuria
upon alterations in membranes other than those of the Mal-
pighian tufts, and yet concerned in the secretion of urine,
or upon changes in the condition of the blood.. The facts
referred to could not therefore be excluded from a treatise
on this subject, and they will be examined in the following
sections after the influence of circulatory changes has been
discussed, for to these latter they are undoubtedly subordinate
in importance.

I. Taz Various Forms 1n wHich ALBUMEN 18 EXCRETED.

In calling attention to the older views with regard to albu-
minuria, I do not mean that they should be simply received
in the somewhat vague and indefinite form in which they
have been handed down, but I wish to show that, as com-
pared with the most recent, simple, but one-sided doctrines,
they make better allowance for facts, inasmuch as they pro-
ceed from:a higher stand-point and embrace a larger field of
view. It is. true that even they do not so comprehend all
points of view that none are left out; the circle of possibili-
ties may extend itself beyond past and present ideas. How
much of them is worthy of consideration, and for what cases
the one or the other possibility is deserving of notice will be
discussed in the following pages.
4 THE VARIOUS FORMS IN WHICH

There is one general meeting-point for all received theories
of albuminuria, old as well as new, inasmuch as without ex-
ception they all place the source of the urinary albumen in
the blood, and almost exclusively in the blood of the Mal-
pighian tufts. There is a universal absence of doubt on this
point, so that the question as to the possibility of anv other
source of the albumen has never once obtruded itself and has
certainly never been discussed.1 But a thorough and un-
biassed consideration forces us to acknowledge that the al-
bumen may have places of origin other than the blood of the
Malpighian tufts ; and as none of the received theories, which
make no reference to such a possibility, suffice to explain in
a satisfactory manner all the various forms of albuminuria,
as further description will show, a discussion of the other
ways in which albuminuria may originate does not appear to
be superfluous, however little it may harmonise with our or-
dinary notions. It is certainly not necessary in discussing
the origin of albumen in the urine, to claim as possible
sources everything in the kidney that contains or is com-
posed of albumen, and this remark is especially true with
regard to the constituents of the tissue, such as the inter-
stitial connective tissue, the substance of the walls of the
blood-vessels and lymphatics, or the basement’ membrane of
the urinary tubes, for only if these tissues were completely
destroyed could their albuminous elements pass into the
urine. There remains, however, the blood of the interstitial
vessels, the lymph and the various epithelial cells of the
kidney, all of which might yield albumen to the urine, and
there is no reason of any kind for totally excluding these
from discussion. On the contrary, there is abundant cause
for examining into any possible participation of these tissues
in the production of albuminuria, because conjointly or separ-
ately they are more or less affected in the processes which
lead to albuminuria—in congestion, and in the various forms
of inflammation and degeneration of the kidney.

In the first place it is necessary to form a clear conception

1Ona former occasion (Virchow’s ‘ Archiv,’ Bd. lx, 8, 478, u. 497) I have
drawn attention to other possible sources of albumen in the. urine, and

Bartels has partially assented to my views (in v. Ziemssen’s ‘ Handb. der
Pathol.,’ ix,"1, s. 36, u. 38).
ALBUMEN IS EXCRETED. 5

of the term “albuminuria,” for the present limitation of its
meaning has become insufficient, owing to the increase of
our knowledge with regard to the albuminous substances
which are found in the urine. The custom has been to
distinguish only “ genuine or true albuminuria” from “ false
albuminuria,” and to signify by. the latter term those condi-
tions in which non-albuminous urine from the parenchyma
of the kidney subsequently receives an admixture of an
albuminous fluid, such as the semen or prostatic fluid, or
blood, pus, lymph, or the fluid of disintegrated tissue. This
false albumiiuria requires no further explanation. In true
albuminuria, in which albumen together with other con-
stituents of the urime is yielded by the parenchyma of the
kidneys, our thoughts are usually directed only to the
excretion of albumen coagulable by heat. The property of
coagulation possessed by the urine led to the discovery of
albuminuria by Cotugno. ‘It occurs in nearly all cases, and
harmonises, in a general way, with the idea which regards
the blood alone as the source of the albumen. We can
therefore readily understand how that at the present day the
term ‘ albuminnria”’ is used in the same sense as it has
been for a century past, and that it leads to confusion when
albuminous substances, tion-coagulable by heat, are found in
the urine, even if in other respects they entirely resemble
urinary albumen, and that such cases are not regarded as
belonging to albuminuria. Coagulation, however, on being
heated, is no more a property of all albuminous substances
than it is peculiar only to one of them, so as to render
it possible for the term ‘ albuminuria” to be limited to
the excretion of this one coagulable form of albumen.
On the contrary, if we accept the current idea of the
origination of the urinary albumen from the blood, it would
necessarily follow that more than one coagulable albuminous
substance should pass into the urine, for the blood normally
contains at least two such substances in solution, viz., the
serum-albumin (serine) and the globulin. There is not the
slightest ground for the assumption that always, and without
exception, only one of these two substances, possibly the
serum-albumin, as generally supposed, escapes from the
blood; there is more @ priori reason for expecting that, if
6 THE VARIOUS FORMS IN WHICH

not always, at least in a greater or less number of cases,
both substances escape, though possibly not in equal propor-
tions. And the fact accords with our expectation, for in
most cases in which coagulable albumen is found on heating
the urine, we are able to demonstrate the presence of both
serum-albumin and globulin. It therefore certainly appears
not impossible that, under certain circumstances only one of
these substances should pass into the urine, at least in an
appreciable amount, for different as may be the views with
regard to the process of excretion of albumen in the kidneys
(and these views are by no means clear, as we shall presently
see), they all agree in allowing that the capacity for diffusion
and filtration possessed by the various albuminous substances
plays a considerable part in their excretion.

-In this respect, however, there is an important difference
between the two albuminous substances which normally
occur in the blood, for globulin is much more diffusible
(possibly also more capable of passing through a filter) than
serum-albumin, and therefore much more likely to be found
in the urine, supposing that fluid to contain only one
albuminous substance in appreciable quantity. If the recent
statement of Estelle (12) be verified, which is to the effect
that sometimes only the albuminous substance which is preci-
pitated by magnesium. sulphate (viz. globulin) is to be found
in the urine, this theoretical assumption would be thereby
remarkably confirmed, and it would be necessary to make
use of the term “globulinuria.” At present, however,
sufficient attention has not been paid to this subject, and the
methods in use for demonstrating the presence of globulin
are, as Hammarsten (13) has shown, unsuitable for the
purpose, inasmuch as they are inexact, and altogether fail
for the detection of small quantities. It is therefore to be
anticipated that the new method described by Hammarsten,
and used also by Estelle, will enable us to detect globulin in
the urine, in larger quantities, and more often than at
present. That serum-albumin alone should pass into the
urine, that is, that a pure “ serinuria,” as it might be called,
should occur, is less probable from the reasons given above.
It is true that up to the present time the fact that globulin
has not, in all cases, been found associated with the serum-
ALBUMEN IS EXORETED. 7

albumin has rendered probable the existence of a pure
serinuria, but the failure to detect the globulin has been
doubtless due to imperfect methods of examination.

The foregoing statements have conclusively shown that
even when the term “albuminuria” is used in its present
limited signification, it does not describe the excretion of one
and the same albuminous substance. And in addition to
this, albuminous substances have been recently discovered in
the urine which are deficient in the capacity for coagulation
hitherto deemed a distinguishing characteristic. Peptone is
the most remarkable example of this kind. Whereas for-
merly nothing was known of its occurrence in the urine, and
subsequently it was regarded as a doubtful constituent or as
a curiosity, quite recently Hofmeister and his pupils have
shown that under certain, by no means rare, circumstances,
it occurs in the urine in considerable quantities and that this
excretion, this ‘‘ peptonuria” is of scientific and practical
importance (14). At the same time it must be remembered
that only slight traces of peptone are discoverable in the
blood, and that often these are absent. Compared with the
current theory of the origin of all urinary albumen from the
blood, this might seem very puzzling, did we not possess
other experiences which help to solve the mystery. We
know that the kidneys by virtue of a peculiar attractive
power excrete certain materials in large quantities, and with-
-draw them from the blood which contains scarcely more than
mere traces (as, for example, urea, uric acid, kreatin, &c.),
and in like manner Hofmeister explains peptonuria as the
result of a specific peculiarity of the excretory elements of
the kidneys, inasmuch as he found that after the injection
.of peptone into the blood, or under the skin, the urine is sur-
charged with it, while scarcely an appreciable trace is dis-
coverable in the blood. This explanation appears to be very
plausible, and is doubtless accurate for certain cases which
are analogous to this experimental administration of peptone,
as for example, when exudations containing peptone are
absorbed, as occurs in pleuritis, pneumonia, and rheumatic
arthritis. It is another question as to whether this is the
only way in which peptonuria can originate, or whether it
may not have other sources. This question appears quite
8 THE VARIOUS FORMS IN WHICH

justifiable, as we are taught by recent observations, to the
effect that no such sharp distinction exists between albuminous
substances proper and peptones, as we were formerly disposed
to believe. Not merely as a result of digestion, but likewise
in consequence of various influences of a different kind and
especially of incipient putrefaction, albumen undergoes
modifications which more or less resemble that which we call
“peptone.” It is quite conceivable that in certain morbid
conditions, the ordinary albuminous substances in the blood
and the fluids of the body or in the kidneys, become so
changed as to lose their coagulability on boiling and their
capacity for precipitation. on the addition of certain acids
and metals. There is indeed no lack of indications of the
occurrence in the living body of such processes as can effect
alterations in the albuminous substances, similar to those
produced by digestion and many fermentative and putre-
factive processes. Thus, in these days, the idea has become
very familiar to us that in fever certain fermentative pro-
cesses take place in the body, and it is in febrile diseases
that the occurrence of peptone-like bodies in the urine has
surprised observers more often than was the case in former
times. And the processes of tissue-metamorphosis in various
conditions of poisoning, especially in phosphorus poisoning,
present numerous analogies with the processes of fermentation
and putrefaction, and Selmi (15) has quite recently drawn
attention to their similarity, and these again are exactly the
circumstances (phosphorus-poisoning being the most remark-
able of them all) in which these bodies are to be found in
the urine. These examples are sufficient to show that by
no means invariably only that form of peptone which is con-
tained in the blood and lymph is excreted with the urine,
but that possibly, or probably, changes of combination
occurring in the blood, the lymph, and even in the elements
of the tissues, may convert the ordinary albuminous sub-
stances into peptone-like modifications. We are likewise
justified in supposing that certain intermediate products,
which are formed during the transition of the albuminous
substances proper into peptone, may occur in the economy,
and are also excreted by the urine, and that there is just as
little reason for maintaining a strict distinction between
ALBUMEN IS EXCRETED. 9

“peptonuria ” and albuminuria as between peptone and
albuminous substances proper.

Recent investigations have likewise shown that the con-
version of albuminous substances into peptone takes place
gradually and in stages, certain intermediate or transitional
products being formed, and at least one such product is.
clearly recognised, analogous in some respects with albumen,
and in others with peptone, viz. hemi-albumose or pro-peptone-
(16). The most important peculiarity of this substance is.
that it is not precipitated from its watery solution by boiling,
but is precipitated in the cold state by acetic acid and
ferrocyanide of potassium, nitric acid, acetic acid and con-
centrated solution of chloride of sodium.' This substance,
or one very similar to it, has been discovered by Virchow
in the medulla of bones in cases of osteomalacia, and re-
cently by Fleischer in the normal bony meduila. An
exactly similar substance, or perhaps a mixture thereof
with another form of albumen, had been previously dis-
covered by Bence Jones in the urine of a patient suffering
from osteomalacia. Langendorff and Mommsen made a
similar discovery in a case of this nature, although they
were not able to demonstrate the presence of any similar
albuminous body in the bones after death, and lastly Kiihne
found hemi-albumose in the urine of a patient the subject of
osteomalacia. There are, in addition, a few isolated reports
with regard to the presence in the urine of an albuminous
substance, non-coagulable by heat, or dissolved by boiling, if
precipitated in any other way (17). However, from the gene-
rally very meagre character of the statements it is impossible
to decide as to how far they always refer to the substance in
question. Prout, Gerhardt, Beneke, Fiirbringer, and Gowers.
make, however, sufficiently definite statements on this subject,
and from these we may infer the occurrence of hemi-albumose-
in various morbid conditions (18). In addition, Stokvis (19)
has found it in the urine of a dog after injecting it into the.
rectum ; and finally, Lassar (20) asserts that having rubbed
petroleum into the skin of rabbits, he found, after a certain
interval, hemi-albumose with all its characteristic peculiari-
ties in the urine. On the whole it would appear from these

1 Por additional reactions I refer to Kithne and Salkowski’s statements.
10 THE VARIOUS FORMS IN WHICH

scanty and not altogether positive statements, that hemi-al-
bumose or pro-peptone (pro-peptonuria,! as I shall henceforth
call it,) was an extremely rare occurrence in the urine, and
unworthy of consideration. My own observations, however,
directly contradict such a notion, for they show that though
pro-peptonuria is not very common, it is vastly more frequent
than current ideas and the literature of the subject would lead
us to believe. During the past three or four years I have met
with seven cases, one being a man aged forty-four, who had
several times been the subject of syphilis, and in the course
of years had undergone various courses of anti-syphilitic
treatment. When first admitted into the Augusta Hospital,
he was fairly well nourished, slightly jaundiced, his liver
and spleen were considerably enlarged, and there was pro-
fuse diuresis, to an extent of 6000 cctm. daily, corresponding
with the somewhat intense thirst. The urine had a sp. gr.
of 1004—1006, and was free from sugar. It exhibited a
decided cloudiness on the addition of acetic acid and ferro-
cyanide of potassium, and a similar reaction with the same
acid and a concentrated solution of sulphate of magnesia.
It remained clear on boiling, and the subsequent addition of
nitric acid made no difference. When warmed with solution
of caustic soda and a very small quantity of sulphate of
copper, a red colour was produced. For more minute
examination a certain quantity of urine was mixed with
about three times its bulk of absolute alcohol, and the preci-
pitate, after settling, was mixed with distilled water and
filtered. The clear solution became cloudy on the addition
of nitric acid, and also when acetic acid was used 3 excess
of the latter, however, caused the clearness to return ; boiled
with nitric acid it became clear and a faint yellow in colour,
with soda and sulphate of copper the solution assumed a
beautiful violet, and not a red colour. The urine gave the
same reactions on further examination a few days later, but
not afterwards, the quantity and specific gravity having at
the same time become normal. The patient was discharged

1 The name hemi-albumose, which has been applied by Kiihne to the
product of digestion referred to, is older than the term pro-peptone suggested
by Schmidt-Miihlheim, but I have preferred the latter as being more
euphonious.
ALBUMEN IS EXCRETED. 11

much improved after a five months’ stay in hospital, and on
his subsequent return on two occasions for short periods and
for slight ailments, nothing abnormal was discovered in his
urine.

The other cases were as follows :—A man, aged 61, with
right hemiplegia ; a woman, aged 58, with pneumonia on
both sides; a child, with diphtheritic laryngitis, on whom
tracheotomy had been performed in the surgical ward; a
man, aged 55, with cancerous stricture of the cesophagus; a
man, aged 26, with pneumonia on the left side; and lastly
a theological student, aged 21, who, as stated by his
physician, had suffered four years previously from diphthe-
ritic inflammation of the throat, with dysentery and hemor-
rhagic nephritis as sequele, and lastly from neuritis of the
left brachial plexus, followed by paresis and atrophy of all
the muscles of the arm. This latter affection had entirely
subsided after lasting about a year, so that when I examined
him in July, 1880, the action of the left arm was almost normal,
and the limb appeared to be only a little weaker than the
right. (Its circumference, as measured at various points,
was still .5—2 ctm. less than that of the right.) For some
time albuminuria had remained as a sequela of the nephritis,
and the patient had learnt how to test for albumen by
boiling his urine. After about a year and a half had
elapsed, during which time the quantity of albumen had
gradually diminished, nothing abnormal could be discovered
by means of this test; subsequently, on boiling the urine,
albumen was occasionally discovered. When I examined
him, only the urine passed after the midday meal became
permanently cloudy on long boiling and the addition of acid
(see II and V, Albuminuria of Digestion), the urine passed
at other times contained no albumen coagulable on boiling,
but certainly pro-peptone. It should be remarked that the
patient had never suffered from cedema, and in spite of the
four years’ continuance of the albuminuria there was no
trace of any cardiac hypertrophy. He felt also perfectly
well, and applied to me only for an explanation with regard
to the state of his urine.

Tn all cases the test for pro-peptone was that the urine
remained clear on boiling, but became cloudy or yielded a
12 THE VARIOUS FORMS IN WHICH

precipitate with acetic acid and ferrocyanide of potassium.
For a further examination, we adopt the method described
in the first case, that is, by precipitating by alcohol. It was
not always possible to test all the reactions for hemi-albumose,
mentioned by Kiihne and Salkowski, partly because they
were not known at that time, and partly because the pro-
peptonuria had disappeared before the minute and systematic
examination could be made. But this much was determined,
in addition to the reaction with acetic acid and ferrocyanide
of potassium, that boiling alone left the urine clear, that
nitric or acetic acid produced cloudiness in the cold urine,
and that clearness was restored by heat. Small differences
in the behaviour of the urine, and deviations in the reactions
of the hemi-albumose obtained during digestion repeatedly
occurred, thus in the biuret test violet often took the place
of red, or acetic acid and concentrated solution of sulphate
of magnesia, or of chloride of sodium, caused no cloudiness,
or only a very slight degree of it in cold urine, and still less
on boiling. In my opinion much importance need not be
attributed to these deviations, for the quantity of saline
constituents of the urine and other admixtures may well
account for them.

It appears more important to call attention to the fact
that it is highly probable that cases occur in which hemi-
albumose and albumen coagulable by heat (serum-albumin
and globulin) occur together in the urine,—cases which can
be designated by the term “‘ mixed albuminuria.’? I have
repeatedly met with cases, and my experience is certainly
not solitary, in which the urine yielded a slight precipitate
on boiling, while the addition of nitric acid without previous
heat, or of acetic acid and ferrocyanide of potassium,
produced a copious precipitate, and further that the precipi-
tate caused by the nitric acid was diminished, and not
increased. on boiling the mixture. I had hitherto always
thought that an explanation must be found for this in the
variety of the saline constituents of the urine, or perhaps in
the fact that in the cold urine uric acid was likewise pre-
cipitated, until I closely investigated a case of sub-acute
nephritis, in which these reactions were very striking. The
urine which was very acid was boiled, while a drop of acetic
ALBUMEN 18 BXORETED. 13

acid was added, a flocculent precipitate was the result; the
hot fluid was thrown on a filter and the clear filtrate, mixed
with thrice its bulk of absolute alcohol, allowed to stand for
twenty-four hours. The white precipitate was readily soluble
in distilled water, forming a clear solution, the slightly acid
solution remained clear on boiling, but became decidedly
cloudy on the addition of nitric or acetic acid, and cleared up
completely on boiling, the solution containing the nitric acid
becoming yellow, and the cloudiness not returning on cooling.
The precipitate caused by acetic acid was soluble in excess,
but not so that caused by nitric acid. In the solution, again
made clear by excess of acetic acid, ferrocyanide of potassium
caused a considerable precipitate. The addition of soda and
sulphate of copper produced a beautiful violet colour. The
behaviour of this precipitate certainly differs in some respects
from that of hemi-albumose and especially in this that the
precipitate caused by nitric acid and dissolved by heat does
not reappear on cooling, but, on the other hand it differs so
essentially from the ordinary albumen of the urine that we
can only assume that we are dealing with different albumi-
nous substances, or that some modification has taken place
as a result of the treatment (boiling and alcohol) to which
the urine has been subjected. But inasmuch as ordinary albu-
minous urine treated in a similar manner does not become
thus modified, the conclusion is perfectly natural that the
case is really one of “ mixed albuminuria.” Additional
instances of its occurrence are to be collected.

The peculiarity of hemi-albumose (pro-peptone), of not being
coagulated by heat, certainly accounts for the fact that so
little is known up to the present time of pro-peptonuria.
For, in the method commonly used for discovering albumen
in urine, viz., boiling, and then adding nitric or acetic acid,
its discovery is impossible, unless the mixture is set aside and
examined when perfectly cold, but this detail is, as a rule,
neglected, and if attended to there would be this source of
doubt viz., that uric acid and the products of the urinary
colouring matters gradually separate from urine thus treated.
It has also been repeatedly pointed out that this test is
inadequate in other respects, inasmuch as it is not sufficient
for the detection of very small quantities of ordinary albumen
14 THE VARIOUS FORMS IN WHICH

inthe urine. As, however, notwithstanding these drawbacks,
the test in question is the only one in common use, it will
not be superfluous to give a brief account of far more reliable
tests which should be used in doubtful cases, or I would
rather say in all cases in future. These are as follows: (1)
to acidify the urine with acetic acid, and then add carefully
a (concentrated) solution of ferrocyanide of potassium,
according to Hofmeister the most delicate of all the tests for
albumen, and which precipitates all the albuminous bodies,
but not peptone.’ 2. The careful addition of nitric acid to
the (non-warmed) urine, followed by boiling if any cloudiness
results. 3. The addition of a concentrated solution of
chloride of sodium, or sulphate of magnesia to urine acidu-
lated by acetic or nitric acid. All three tests, or at least
the first and one of the others, should invariably be tried.
If after applying the second or third, a precipitate which is
formed on heating, entirely or partially disappears, the pre-
sence of pro-peptone is indicated. Hindenlang (21) has
lately recommended metaphosphoric acid as a delicate test
for albumen and it also precipitates peptone. As far as my
present experience goes, and as regards delicacy and con-
venience of testing, I can support his recommendation,
but for cases where great exactness is required, I would
recommend that recourse should also be had to the other
tests, both for the purpose of checking results, and also
because when the quantity of albumen is small, the saline
constituents of the urine, the presence of other organic sub-
stances and other unknown influences are apt to cause slight
differences in its behaviour towards one or other of the
reagents. For the discovery of pro-peptone, however, it is
necessary to have recourse to one test which is applicable’ to
cold urine and to another which requires the addition of
warmth. =
If, as we may assume from Hindenlang’s statement,
metaphosphoric acid is adopted for the discovery of very
small quantities of peptone in the urine, we shall have
obtained a very convenient method for the detection of
1 Salkowski states that this test fails only when a large amount of

chloride of sodium is present, but the urine never contains this constituent
in such quantities as to prevent the precipitation of albumen.
ALBUMEN IS: BXORETED. 15

peptonuria. A precipitate caused by the acid, but not by
acetic acid and ferrocyanide of potassium, in the original
urine will indicate peptone to the exclusion of other sub-
stances. But if the urine gives a precipitate with the two
last-named reagents, it is necessary first to boil and then
filter it so as to remove the coagulable albumen (serum-
albumin and globulin) ; the filtrate, which must remain clear
on the addition of acetic acid and ferrocyanide of potassium,
may then be tested with metaphosphoric acid for peptone
(and pro-peptone ?). At any rate the filtrate could be con-
centrated by evaporation and the precipitate caused by excess
of strong alcohol could be mixed with water and tested. As
a matter of course the positive results yielded by the tests
must be confirmed by other reactions. ~

The occurrence of such various albuminous substances in
the urine, especially of such as are not found in the blood
under normal conditions, suggests the idea that changes in
the composition of the blood may be concerned in the pro-
duction of these peculiar forms of albuminuria. We have
in consequence learnt to recognise an additional factor for
the causation of albuminuria and shall therefore have to
consider the kidneys, and also changes in the conditions of
the circulation and of the epithelium and likewise alterations
in the condition of the blood.

II. Anpumen as A Constirvent or Normat Urinz.

The question as to whether the urine in its normal condi-
tion does or does not contain albumen must always form the
starting-point for all investigations with regard to albuminuria.
That this question should be raised at all may seem heretical

1 The following méthod is recommended by Hofmeister for the demon-
stration of peptone for clinical purposes. About one tenth of its volume of
concentrated hydrochloric acid is mixed with the urine, an acid solution of
the phosphortungstate of sodium is added, and the mixture is filtered without
allowing any precipitate to subside. The precipitate is washed with dilute
(g3—§ proc.) of sulphuric acid, placed in a mortar and rubbed up very
thoroughly with baryta in substance, then mixed with a little water and
warmed for a short time. The fluid filtered from the insoluble baryta com-
pound is then used for trying the biuret reaction.
16 ALBUMEN AS A CONSTITUENT

to many persons, inasmuch as it is regarded as long since
disposed of, and answered in a decidedly negative manner.
However, in spite of the fact that the doctrine that normal
urine does not contain albumen, and that albuminuria is
invariably a sign of disease, has not yet been exploded, it is
nevertheless true that occasional doubts as to its validity
make themselves heard with increasing force, and even its
most determined supporters, in consideration of the most
recent observations, which I shall presently mention, now
admit that exceptions exist to a dogma which only a short time
ago was held not to admit of them. This change of opinion wag
caused by the demonstration that, without any renal disease,
small quantities of albumen, formerly overlooked, appeared
in the urine, but without assuming significance, in the course
of many varying morbid conditions, and in the second place
by the discovery of albuminous substances, already referred
to, distinguished from the albumen coagulable by heat,
ordinarily occurring in the urine, by being imperfectly
coagulable, but more soluble and diffusible, and whose
escape therefore from the blood must, according to current
ideas, seem very obvious. Improved methods of investiga-
tion, and the discovery of delicate reactions have further
resulted in the discovery of albumen, in very many instances,
but in very minute quantities, in the urine of perfectly
healthy men, and this albumen, so far as it was possible to
judge from these small quantities, differed in no respect from
the albumen of the ordinary forms of albuminuria. I make
this assertion, because some years ago statements were made
to the effect that a substance with properties resembling
albumen or peptone could be found in all specimens of
normal urine ; but little reliance was placed on these state-
ments, by reason of the defective methods of demonstration,
or certain irregular reactions exhibited by the substance
demonstrated. Thus, to pass over the statements of earlier
observers, Harley, but especially Béchamp and after him
Foster, Vintschgau and Cobelli have obtained from the
aleoholie precipitate of urine a substance called ““nephrozy-
masis,’’ which, however, on account of its diastatic properties
was regarded as a ferment, and not as a form of albumen (22).

It is not, however, possible to make a complete distinction
OF NORMAL URINE. 17

between albuminous substances and ferments, even supposing
that the latter could be obtained in a pure state, inasmuch
as Seegen and Kratschmer’s (23) investigations show that
substances unequivocally albuminous may exhibit diastatic
properties. Moreover, Leube, who in examining the urine of
twenty-one healthy men, found albumen in the alcoholic
precipitate in fourteen instances, distinguishes the latter
from the diastatic ferment, since in four of those fourteen
cases albumen occurred alone, and in seven out of the
twenty-one only the ferment was demonstrated. In its
reactions the albumen resembled paralbumen (24).

Be this as it may, there are now additional observations
with regard to the occurrence of albuminuria in healthy
men. ‘That in these cases the substance referred to is
albumen in the ordinary sense, there is no room whatever for
those doubts which were constantly evinced towards the
statements of the older observers, such as Becquerel, Simon,
C. Schmidt, and Canstatt. In recent times such observations
have constantly accumulated in proportion as urinary investi-
gations have been more numerous, and conducted with greater
care and more improved methods than formerly. I have
already referred to these methods (see p. 14), and we may
with certainty expect that as they become more frequently
employed, the discovery of albuminuria will become much
more common than hitherto. There is, however, at the pre-
sent time a considerable number of abservations of a
trustworthy character and to a great extent demonstrative,
although the most delicate methods have not always been
employed, of the excretion of albumen going on in healthy
men for a greater or less length of time, no sign of disturbed
health showing itself while this was going on, and during
an interval of some years. Cases of this kind have been
noticed by Frerichs, J. Vogel, Ultzmann, Guéneau de Mussy,
Leube, Gull, Moxon, Rooke, Dukes, Saundby, Edlefsen,
Marcacci, Munn, Bull, Firbringer and Kleudgen (25).

This large number of recent observers, a portion of whose
discoveries were made quite accidentally, forbids us to
suppose that this albuminuria forms a very rare exception or
curiosity unworthy of consideration. Still more cogent in
this respect is the proportionate frequency discovered by

2
18 ALBUMEN AS A CONSTITUENT

certain observers who have specially investigated this sub-
ject. According to Leube albumen was found in the urine
of 19 out of 119 healthy soldiers, or in 16 per cent. ;
according to Munn in 24 (12 per cent.) out of 200 apparently
healthy persons who presented themselves for examination
for life-assurance. Fiirbringer found albumen in 7 out of
61 healthy children (11°5 per cent.), Kleudgen in 14 out.
of 32 healthy nurses, (44 per cent.), and likewise in the
others when the urine was concentrated and its specific
gravity exceeded 1014. Kleudgen, therefore, thinks that
(apart from imperfect methods of testing) the dilution of the
urine is the sole cause why, as a general rule, no albumen is.
discoverable in it. Certainly the dilution of the urine is an
element of very considerable importance in the demonstration
of its albuminous constituents, a point to which I shall draw
particular attention ; but it must not be supposed that by
merely concentrating the urine until its specific gravity
becomes very high, albumen previously undiscoverable will
be invariably and at oncefound. This is by no means the case,
aS we can convince ourselves by evaporating every specimen
of urine which the ordinary tests show to be free from albu-
men. The saline constituents, which are thereby increased in
proportion, constitute an additional element in reference to
the demonstration of albumen, and as these are liable to
considerable variations in natural urine and under physiolog-
ical conditions, there is at least one obstacle, of a physiolog-
ical character, to the discovery of albumen in normal urine,
and even though it be of a high specific gravity. On the
other hand, in concentrated urine, after a portion of its saline
constituents has been precipitated by alcohol, it is certainly
easier to discover albumen than it was before. It would
appear, however, that other physiological factors are at work
in producing the result that albumen is sometimes found in
the urine and is absent at others. My own observations are
definite on this point. Some years ago I had, in common
with other observers, occasionally found albumen in the urine
of perfectly healthy persons, but especially in convalescents
or in patients suffering from ailments of a slight nature and
totally unconnected with renal affections. The discovery
naturally gave rise to the suspicion that the persons were the
OF NORMAL URINE. 19

subjects of chronic interstitial nephritis (true atrophy of the
kidney, renal sclerosis), but this was not confirmed by further
observation. My attention having been aroused by this
varying symptom, occurring in myself and my three young
colleagues (assistants in the Augusta Hospital), all of us
enjoying excellent health, I examined the urine at different
hours of the day for a long period, and at one time or other
discovered albumen in the urine of each of us, certainly only
in faint traces, which might well have been overlooked had
less delicate tests been employed.’ No definite rule governing
its appearance could, however, be discovered, for the urine
might be examined for several days without once finding
albumen, which would then appear for a day and again vanish
as before. In my own case I found it most frequently
during the morning (11—1 o’clock), and only exceptionally
in the late afternoon after the principal meal. In one of my
colleagues it was several times found after dinner, in another
likewise during the period of digestion, but only when much
meat had been taken ; in the third the urine was examined
only a few times, but sufficiently often to show the occasional
presence of albumen.

Many observers have asserted that it is easy to discover
albumen in the urine during digestion, others have indicated
muscular activity as a factor giving rise to this result. The
physiological conditions are, however, by no means exhausted
by these statements, as my own observations incline me to
suppose, indeed they supply good reason why I should con-
sider it not improbable that if we were to examine the urine
for long periods at different hours of the day and with great
care, we should, sooner or later, find it to contain albumen in
the case of every healthy man. If, however, the usual
custom be followed, and the total quantity or a large propor-
tion of the urine passed in a single day be submitted to exam-
ination, the small amount of albumen contained in one portion
is still further diluted by mixture with the remainder, and
the obvious result is that even after prolonged examination
the urine is never, or only exceptionally, found to be albu-

1 To avoid any error which might be caused by admixture of semen or
prostatic secretion, the porticns of urine first passed were not used for exami-
nation,
20 ALBUMEN AS A CONSTITUENT

minous. It is much to be desired that the urine passed at
different times of the day, by a still greater number of healthy
men, should be subjected to methodical and continuous
examination.”

There is, however, something more to be said with regard
to the observations that have been made. ‘To take only the
smallest of the numerical proportions referred to, if it be true
that among eight or nine healthy men, there is one who
excretes albumen once or more often in his urine, it is
impossible simply to regard albuminuria as a symptom mor-
bid in its character under all circumstances; but the admis-
sion must be made that if the occurrence in question does
not form the rule, it comes-at any rate within the bounds of
a physiological condition. It must be admitted either that
albumen is present in all urine, but in varying quantities, so
that sometimes it eludes observation by the means at our
command and sometimes, under certain physiological con-
ditions, it can be discovered, or that it is altogether absent at
certain periods and appears in the urine only when certain
conditions are in existence. The former of these two assump-
tions, viz. that the urine always contains albumen but only
occasionally in appreciable quantities, appears to me to be
the more reasonable and eligible, for the two following
reasons. In the first place it cannot be denied that our
power of demonstrating albumen in urine has a certain limit,
even in cases where there is no doubt as to its presence.
The truth of this assertion is supplied by specimens of urine
in which no albumen is discoverable by the ordinary methods.
For it is well known that all normal urine, after remaining at
rest for some time, exhibits a slightly opaque cloudiness
(nubecula), which is caused by the epithelium of the urinary
passages, and contains albumen, as can be proved by collect-
ing it in considerable quantities (16a). The objection might
be raised that this albumen is mixed with the urine but not
dissolved in it, but even when its solution is effected by
adding liquor sod, no reaction due to albumen is shown by
the urine, as was likewise the case before the addition of the

1 The urine of the animals commonly used for experiment (rabbits, dogs,

and cats) very often contains traces, and not seldom considerable quantities,
of albumen under conditions of apparently perfect health. ,
OF NORMAL URINE. 21

soda. We are therefore perfectly justified in stating that our
present methodsare not sufficient for the detection of extremely
minute quantities of albumen in the urine, and that therefore
urine in which no albumen can be found may yet contain traces
of that substance. In the second place, it is more in accord-
ance with our other experiences and ideas to assume quan-
titative oscillations of a function within physiological limits
rather than qualitative changes. For example, still to confine
ourselves to urine, we daily see that any one of its normal
constituents may be excreted in quantities greater or less
than the average, but it is a far rarer occurrence, if after all
under physiological conditions, for an entirely new substance
and one hitherto absent to appear in the urine, unless it or
something from which it could be immediately derived, had
been introduced into the blood. Indeed, when something of
this kind takes place, z.e. when a substance previously
unknown in normal urine is discovered therein, we are, @
priori and with justice, disposed to assume that it is a normal
constituent of the urine, but one which has hitherto escaped
recognition, by reason of the minuteness of its quantity or
because our methods of investigation were inadequate for its
detection.

Of late years numerous experiences of this character
have been afforded by various constituents of the urine. I
refer especially to two of them, viz. grape sugar’ and oxalic
acid, because they play in pathology a part similar to that of
albumen. How much controversy has taken place as to
whether these substances belong to the normal constituents
of urine, or whether their occurrence is under all circumstances
a morbid phenomenon! Nowadays we know that they do
occur normally in urine, but in such insignificant quantities
that a large volume of urine and very delicate methods are
required for their demonstration ; and we also know that

1 According to the most recent investigations the reactions supposed to be
due to the presence of sugar in the urine may depend upon glycuron acid.
For our purposes, however, this question is of no consequence, for sugar is
referred to here only for the sake of comparison, and besides it’and oxalic
acid there are several other substances with regard to which the above
statements equally hold good. These are hippuric acid, glycerin-phosphoric
acid, inosite, xanthin, indoxyl-sulphate of potash (indican), phenol, pyro-
catechin, &c.
22 ALBUMEN AS A CONSTITUENT

sometimes, and even under physiological circumstances, they
appear in larger quantities easily recognisable, and that
therefore we must admit the existence of a physiological
glycosuria and oxaluria. Considering that there are admitted
limits to the physiological increase in the normal excretion
of sugar or oxalic acid, why should not those cases of the
excretion of albumen in healthy men be regarded as exhibiting
simply the physiological increase of a normal process?
Nothing prevents us from assuming the occurrence of a
physiological albuminuria which takes place just as physio-
logical glycosuria, oxaluria, or other physiological increase
of those normal urinary constituents, the discovery of which is
attended with difficulty,—that is to say, that certain conditions
may cause them to make their appearance in larger and there-
fore more demonstrable quantities. The conditions with
regard to the appearance of albumen are by no means more
unfavorable than for that of other substances.

As regards the origin of the urinary albumen in all these
cases, there is no lack of a source extremely rich in this sub-
stance. This, as a matter of course, is the blood flowing in the

Malpighian tufts, for the blood of the interstitial vascular

system, or the lymph, or any other source, under normal
conditions, needs not be considered, and this statement
requires no further explanation. The albumen therefore
must have its origin in the blood of the Malpighian tufts.
This statement corresponds, to some extent, with the theory
of the excretion of urine, which for some time past has been
advanced by Kiiss (26), von Wittich (27), and Henle (28),
but which has met with few supporters and many opponents,
in the first place, because it makes it difficult to explain the
absence of albumen in ordinary normal urine, and likewise
because it is not altogether in accordance with the fact
recently discovered of the slight diffusibility of albumen as
a colloidal substance. After what has been stated with
regard to physiological albuminuria no importance can be
attributed to the first objection, the fact being that normal
urine is often found to be albuminous, if properly examined,
and all causes may be assumed to account for albumen being
a normal constituent of the urine, though its presence cannot
always be demonstrated. As regards the other objection,
OF NORMAL URINE.

the slight diffusibility and capacity for filtration of albumen,
this must, at least to some extent be waived, inasmuch as
membranes, permeable by albumen, are to be found throughout
the body. On the other hand, quite recently the belief has
arisen that the escape of albumen from the Malpighian tuft
is prevented by the epithelial investment of the vessels ; and
this theory is now acquiesced in by all those who endeavour
to explain the absence of albumen in the fluid which leaves
the tuft, this view being adopted especially by Runeberg,
Heidenhain, and Cohnheim, as already mentioned.' Nothing
-could appear more simple and intelligible than this explana-
tion, and it might be adopted forthwith if it could relieve
us of any one difficulty, and did not too obviously contradict
patent facts. In the first place, it contradicts the well-
known fact, insisted upon always, except only upon this
occasion, that egg-albumen passes without difficulty into the
urine, and, as has been shown by Nussbaum on frogs, and
Ribbert on rabbits, through the vesselsof the Malpighian tufts.
The explanation for this is sought for in the greater ease
with which egg-albumen passes through a filter, an explana-
tion to which as yet no one has raised any objection, and the
same will apply to peptone. This marked capacity for filtra-
tion has been incidentally shown on dead animal membranes.
It is obvious that, when with regard to these cells, it is only
-a question of a greater or less capacity for filtration, it is
impossible to understand how they can be completely im-
permeable for the normal albuminous constituents of the
blood. For there is no doubt whatever that these albuminous
substances are capable of filtration, especially from saline

1 A different view is adopted by Ribbert in his recent work on ‘ Nephritis
and Albuminuria’ (29). He attributes no importance in this respect to the
-epithelial covering of the Malpighian tufts, but thinks that these capil-
laries, which, according to him, are almost entirely without nuclei, possess
more cohesion than other capillaries, and therefore prevent the escape of
albumen. It is hardly possible to take this view even if we choose to
admit as correct Ribbert’s isolated assertion with regard to the paucity of
nuclei of those capillaries. There are, moreover, no capillaries which are
impermeable by albumen, and experiments made with this view on kidneys
both before and after death have demonstrated that there is no difference be-
tween these and other organs in this respect; and, lastly, the investigations

-of Frommann and of Riemer on argyria have shown that solutions of silver
pass as readily through the Malpighian tufts as through any other vessel (30/.
24 ALBUMEN AS A CONSTITUENT

solutions, such as the serum of the blood. We are therefore.
forced to assume that they also filter through the Malpighian
tufts, but in an extremely minute quantity, corresponding
with their small capacity for filtration.

Let us then consider the epithelium somewhat more closely,,
as to it is assigned the task of retaining the albumen. This
consists, after birth, of extremely flat, thin cells, which
most closely resemble the endothelium of serous membranes.
“This epithelial investment,” says Cohnheim, “is something
quite peculiar to the glomerulus, having at the most a distant
analogy with the endothelial membrane covering the choroid
plexus, the seat of the secretion of the cerebro-spinal fluid,
which is almost free from albumen.”? If the analogy
referred-to be real though distant, there is clearly one con-
clusion to be drawn therefrom, and this is that the capillaries
of the Bowman-Miiller’s tufts permit the escape of a fluid
“almost,” but not quite, free from albumen. And we are
the more justified in arriving at this conclusion, from the
fact that it is in complete harmony with what we know
regarding other normal transudations (and it may be added
abnormal ones also) which pass through capillaries and epi-
thelial membranes, and which all without exception contain
large and varying quantities of albumen. Not merely does
the cerebro-spinal fluid contain albumen, but the transuda-
tions of all serous membranes which have an epithelial
investment are albuminous, and normally so, as is evidenced
especially by the pericardial fluid; in the majority of the
other sacs too little fluid is present for purposes of demonstra-
tion. The aqueous humour which transudes in the anterior
chamber of the eye, which has a complete epithelial covering,
contains albumen, the perilymph and endolymph of the
auditory labyrinth, which are certainly separated by epithe-
lium from the secreting capillaries, contain albumen.
Certainly all normal transudations (to say nothing of
abnormal ones) contain albumen; in whatever part of the
body fluid escapes from the blood without the interposition of
specific glandular epithelium, it contains albumen, even when
it has to pass through an epithelial covering, as well as a
capillary wall. It would therefore be marvellous if the

} This fluid contains albumen in the proportion of *3—3 per I000..
OF NORMAL URINE, 25-

fiuid which escapes from the glomerular vessels of the kidney
did not contain albumen.

It is true that we assume that this fluid is in reality only
a transudation, that is, pressed out by filtration, but not a
product of secretion, and in this we are in complete harmony
with the general opinion.’ Quite lately Heidenhain alone has
expressed a different opinion to the effect that the process
which goes on in the kidney is a real secretion, just as that.
of other glands, since the excretion of water in the kidneys.
depends upon the functional activity of those cells of the
glomerular vessels, the quantity of blood contained in them
in a unit of time determining the rate at which the process
is carried on. The function of these cells is, therefore, the:
separation of water (and of the salts by which it is always
accompanied) and the prevention of the passage of albumen
from the blood. When this function is interfered with, as may
occur when the flow of blood through the arteries is checked
for a short time, water is separated in smaller quantity
and the secretion contains albumen. Heidenhain himself does.
not attempt to conceal the difficulties connected with this
assertion, and, indeed, it is very difficult to attribute the.
possession of secretory glandular activity to epithelial cells,
such as those which cover the glomerular vessels, and are:
altogether different in their nature from that of all known
glandular cells. A greater objection, however, to this.
assumption is formed by the condition of the secretory func-
tion of the kidney, when the blood-pressure is increased
without diminution of the flow through the arteries, a state
of things which may result from impeded discharge from the
veins, the heart’s action remaining undisturbed, or from
active congestion under conditions of increased afflux without
any impediment to the escape of blood. In the first case,
the rapidity of the flow is checked, in the second, it is.
increased. According to Heidenhain the retardation of the

1 Runeberg, who very justly refers to the fact that all normal and
pathological transudations contain albumen, nevertheless asserts, in contra~
diction to this statement, that epithelial membranes do not permit albumen
to pass through them, and for proof of this he relies upon the tears and the
perspiration. Both of these, however, are not transudations, but secretions..
It may also be remarked in passing that albumen has been found in both.
26 ALBUMEN AS A CONSTITUENT

current must produce a disturbance of the nutrition and
function of those epithelial cells, and as a consequence,
diminution of the quantity of urine and escape of albumen.
In the second case, increased secretion of urine free from
albumen is the necessary consequence. But this is not what
really takes place. The first condition, increased pressure
with retardation of the current, can be very easily produced
by entirely or partially closing the renal vein or the inferior
vena cava, but it is difficult to form any definite conclusion
with regard to the alterations in the quantity of urine under
these circumstances, the only positive fact being that the
urine is thereby rendered albuminous. In the human
subject, in which it is easier to observe quantitative changes
in the urine, occlusions of the renal vein or inferior vena
cava very rarely occur, and almost always under conditions
in which the arterial blood-pressure is reduced, as takes place
in marantic thrombosis, or in occlusion due to cancer, &c.
Only in very rare exceptions has arrest of the escape of blood
from the kidney been observed in conjunction with well-
maintained cardiac activity and normal arterial pressure.
For a case of this kind we are indebted to Bartels (31). It
was one in which there was impeded escape of the blood of the
renal vein, in consequence of thrombosis of the inferior vena
cava, occurring in a very robust man, forty-four years of
age ; it was, therefore, not a case of ordinary congestion as a
result of defective action of the heart, in which there is also
diminution of arterial pressure. Now this patient, as Bartels
states, passed “enormous quantities” of urine (on an average
1640 ccm. daily in spite of most marked cedema), generally
containing a considerable quantity of blood, and with a
specific gravity varying from 1-o1r to 1°013, and always con-
taining much albumen and a sediment of red blood-cor-
puscles and epithelial and other casts. This case furnishes
evidence of a more decided character than any experiment
against Heidenhain’s view of the function of these epithelial
cells. For in spite of the retardation of the current, which
obviously existed, there was no diminution, but a consider-
able increase in the quantity of the urine. According to our
view, which moreover is admitted as an explanation by
Bartels, both phenomena, viz. the increased quantity of urine
OF NORMAL URINE. 27

and the escape of albumen and blood, find their inter-
pretation in the increased pressure in the glomerular vessels.
Heidenhain’s supposition is also contradicted by other clinical
experiences, not perhaps in such a striking manner as by the
above-mentioned case, because the conditions are less simple.
They are fully deserving, however, of being mentioned.
Thus it is a well-known fact that in certain stages of chronic
nephritis and nephro-sclerosis, a very watery and more or
less albuminous urine is secreted, whereas the glomerular
vessels are in a great degree or almost entirely destroyed,
and their epithelial investment has completely perished.
Under these circumstances no secretion of water can occur
from these parts.

The second case, increase of blood-pressure with accelera-
tion of the current, has often been a matter of experimental
and clinical observation, and will be thoroughly discussed in
subsequent pages. It may here be remarked that under
these circumstances, in which there is no kind of question of
any disturbance of nutrition and function, albuminuria may
occur, a fact utterly irreconcileable with Heidenhain’s view,
but perfectly intelligible if we adopt the filtration theory.
How it comes to pass that albuminuria is not to be discovered
in every case of increased blood-pressure of a like kind, will
be discussed later on, when we come to deal with this
subject (S. IIT).

A consideration of these details will cause us to accept
without scruple the generally received view which forms the
starting-point of the above description, namely, that the
fluid which escapes from the glomerular vessels is a transu-
dation, formed in accordance with the laws of filtration, and
not a glandular secretion. In this respect I adopt Ludwig’s
theory of the secretion of urine, but I differ from him in
regarding the filtrate as not wholly free from albumen. On
the other hand, in another respect, I completely assent to
Heidenhain’s thgory, in so far as he considers that the

epithelium of the tubuli uriniferi are actively employed in
the secretion of certain specific constituents of the urine. It
appears to me that this combination of the two theories
satisfactorily gets rid of all the difficulties particularly
connected with the simple filtration-theory, and which have
28 ALBUMEN AS A CONSTITUENT

led Heidenhain to assume that the epithelial covering of the
glomerulus is an agent in the secretion of water, as I shall
show further on. To facilitate the comprehension of what
follows, I will now only observe, that according to my view,
the assumption universally received and which forms the basis
of every theory, @.e. that the water of the urine is normally
furnished only by the glomerular vessels, is thoroughly
untenable, and that we ought rather to assume that the
vessels in question supply only a portion, though certainly
the larger portion, and that the remainder is yielded by the
true secretory elements of the kidney, the epithelium of the
uriniferous tubules. This last supposition is based upon the
fact that we cannot imagine a glandular secretion without
water, unless we picture to ourselves that the whole process
consists in nothing else but fatty degeneration of the
epithelium, as takes place for example in the formation of
the sebaceous secretion of the skin. Nothing of this kind,
however, can be thought of in connection with the kidney.
Moreover, direct proof that these epithelial cells, 7.e. those
which invest the tubuli uriniferi, are actively engaged in the
secretion of water, has been furnished by Nussbaum (32).
The urinary water has therefore two sources, and is partly
a transudation and partly a secretion. A firm grasp of this
fact is an important aid in explaining the different changes
which take place in the urine under various conditions.

If therefore the fluid which escapes from the glomeruli be
a transudation, is there any reason why it should form an
exception to all other transudations, as regards the albuminous
constituent which is a feature common toall? Certainly the
glomerular vessels are exceptional in this particular, that in
them the lateral pressure is greater than in any other
capillary system of the whole body.

We know, however, that ceteris paribus, the quantity of
albumen which filters through an animal membrane from an
albuminous solution, increases with the increase of pressure,
but not in a degree proportional thereto. And in fact this
increase is an absolute one, and not relative in proportion to
the total amount of the filtrate passing through in a certain
unit of time, inasmuch as, with the augmented pressure, the
degree of increase of the quantity of water which passes is
OF NORMAL URINE. 29

greater than that of the albumen. In other words, the
greater the pressure under which filtration takes place, the
greater the quantity of the filtrate in general, and the
smaller its percentage of albumen ; but for all this, for equal
periods the total amount of the filtered albumen is greater
when the pressure is high than when it is low. It follows,
therefore, as regards the glomerular vessels, that they must
yield a transudation richer in water, but poorer in albumen
than any other set of capillaries in the whole body.

The investigations which have been carried on in Ludwig’s
laboratory with reference to the phenomena of the formation
and flow of the lymph, which are not influenced merely by
changes of pressure, have caused us to regard as inadmissible
the application of the laws of filtration, as they are found to
apply in the case of animal membranes outside the body, to
‘the processes of transudation which take place within the
body. But although the connection between the formation
of lymph and transudation from the capillaries is a very
close one, yet the lymph which escapes from an opening in
a lymphatic trunk cannot be regarded as a simple transudation,
and just as little reason would there be in supposing that the
conditions of the current in such a vessel were the same with
those of transudations from the capillaries, so that our ideas
with regard to the one could be simply transferred to the
other. The fluid which escapes from a lymphatic vessel differs
essentially and in many respects from transudations due to
congestion of capillaries. Morphologically, the distinguishing
characteristic of “lymph” is the abundance of colourless
cells which it contains; chemically, “lymph” and transuda-
tions are very dissimilar indeed. It is a well-known fact
that “lymph ” coagulates on exposure to air, whereas the
real transudations never exhibit this phenomenon, unless
they are mixed with blood, or “lymph,” or products of
inflammation. The transudations, without exception, contain
either no potash whatever, or at most only very slight
traces, as little, indeed, as the serum of the blood, when this
is obtained perfectly free from corpuscles; the lymph, on
the other hand, invariably contains potash in considerable
amount, for the analyses of Hensen and Dahnhardt show a
proportion of more than three per cent, after incineration (33).
30 ALBUMEN AS A CONSTITUENT

It might be considered, therefore, that these differences
would suffice to indicate the diversity between the two fluids,
and tosuggest an origin, partly perhaps, but not altogether iden-
tical. Moreover, that observations made upon the discharge of
fluid which takes place from an opening in a lymphatic vessel
do not justify the conclusion that the process is identical with
a transudation, is demonstrated by the fact that the current
from such a vessel entirely ceases after a certain time,
whereas there is no ground for supposing that transudation
has ceased, and besides this, the stagnant current of lymph
can be made to resume its movement, by active and passive
movements, such as gentle rubbing, these manipulations pro-
ducing no effect on transudation. There is, lastly, this fact,
that even the total occclusion of all the lymphatics of a
portion of the body is never followed by local cedema (34).
If the current in a lymphatic trunk were in complete analogy
with transudation from capillaries we should be justified in
expecting that occlusion of the former would cause the
transudation to accumulate and that cedema would result.
But all these facts prove that the lymph-current is altogether
unessential for transudation, and observations upon it cannot
therefore enable us to draw any positive conclusions with
regard to the conditions under which the latter process takes
place.

The function of the lymphatics is that of auxiliaries to the
veins. Fulness of the lymphatics indicates inadequacy on
the part of the veins for the removal of transudation, but
diminution in the current of lymph, so long as the flow
through the veins is free, by no means indicates diminished
transudation, for the power of absorption and of removing
transuded fluids, possessed by the veins, can be increased far
beyond the normal amount, as is evidenced by the non-
appearance of cedema when the lymphatic current is arrested :
the veins can, without aid from the lymphatics, fulfil their
task, the removal of the transuded fluids, but the latter cannot
thus dispense with the assistance of the former. It follows
that the non-appearance of cedema under conditions of
increased arterial pressure, the current through the veins
being unimpeded, is no proof that the transudation is not
increased. ‘here is an increase in this respect, and also in
OF NORMAL URINE. 31

the rapidity of the current and the removal of the transudation
by the veins, and only in rare cases, when these means do not
suffice, does the current of lymph become more copious (35).
These are facts the truth of which has been firmly
established by experiment, and they are in harmony with all
pathological experiences. In addition to this, everyday
practice at the bedside clearly teaches us that the formation
of transudations, cedema, depends directly upon the pressure
in the capillary system, and particularly that the quantity of
the transuded fluid rises and falls with the pressure.
Runeberg’s views, put forward some years ago, differ from
the above account, and contradict the universal assumption
with regard to the cause of the passage of albumen through
animal membranes by referring the phenomenon to a diminu-
tion of pressure below the normal height. But this theory, as.
Heidenhain has shown, has its origin in the fact that Rune-
berg has misinterpreted his own experiments. Properly
estimated, and due care being taken to keep separate the
absolute and relative amounts of albumen, they are in com-
plete harmony with the law just described, and are as con-
firmatory thereof as the recent investigations of D. Newman
(36), Gottwalt (37), von Bamberger (38), and numerous.
clinical experiences, to say nothing of the researches of an
older date. If all the clinical facts are not sufficiently clear:
and simple to be regarded as demonstrative, they are never-
theless in complete harmony with our statement; on the
other hand, it is difficult to reconcile them with Runeberg’s.
views, and we can do so only by adopting forced premises,
not altogether in harmony with one another. That this is so
is best evinced by his attempts to explain by his theory
all forms of albuminuria, as will be shown in subsequent
pages of this treatise. I may here just refer to the simple
and well-known example of ascites, the cause of which is
increased pressure in the vena porte, whereas according to
Runeberg, it must necessarily occur when the pressure in the
vena porte sinks below the normal. This point is passed
over by Runeberg, he mentions only the fact that when an
effusion has once taken place into the abdominal cavity, the
albumen of this transudation increases with the quantity of
fluid, the certain result being that the difference between the
32 ALBUMEN AS A CONSTITUENT

pressure inside and outside the blood-vessels,and consequently
the filtration-pressure, become diminished. This pheno-
menon, which he regards as supporting his view, has been
simply explained by F. Hoppe (Seyler) as exemplifying the
-generally received view concerning the influence of pressure,
that is to say, that with increasing pressure more water is
absorbed, the fluid becomes concentrated, and as a matter of
course the quantity of albumen is thereby increased (39).

Notwithstanding the above objections, there is a sense in
which we can accept Runeberg’s assertion that albuminuria
is caused by diminution of the blood-pressure in the kidney,
but we do not agree with him in supposing that the altered
circumstances permit albumen to escape in places where
hitherto no such passage had occurred, the true explanation
being that relatively less water escapes, the quantity of
albumen is therefore increased, and the albuminous transu-
dation ig rendered more distinct—it becomes, that is, an
appreciable phenomenon. The diminution of pressure
therefore facilitates the discovery of the escape of albumen.
In addition to this, the diminished pressure favours the
appearance of albumen by reason of the influence it exerts
upon the second factor concerned in the formation of urine,
viz. the secretion of the epithelium of the uriniferous tubules,
a factor altogether neglected by Runeberg, and all others
who have endeavoured to explain the phenomena of albu-
minuria. We shall explain at length in a subsequent page
‘how albuminuria occurs through the collective effects on
both factors, of a reduction in blood-pressure when this is
present (8. ITI).

Our principal task now is to show how it is that under
normal conditions albuminuria, i.e. the manifest presence
of albumen in the urine, is not an ordinary occurrence, and
with regard to this, the second factor, the secretion of the
true glandular epithelium, is of considerable importance.

This secretion, containing the so-called specific consti-
tuents of the urine, dissolved in water, and free from albu-
men—a fact requiring no demonstration with such views
as are now prevalent—passes into the tubuli uriniferi and
mixes with that transudation from the glomerular vessels,
which, as we have seen, is extremely poor in albumen. It
OF NORMAL URINE. 83

is pretty certain that no direct increase of albumen takes place
in the further passage through the urinary tubules, and there is
no ground for the supposition that, owing to the absorption
of water with or without salts, the contents of the tubes
become relatively richer in albumen. It is well known that
no decision has yet been arrived at on the question as to
whether any absorption really takes place from the uriniferous
tubules, as is assumed in Ludwig’s theory of the secretion of
urine, but in opposition to the general and well-grounded
opinion on this point. It is, nevertheless, conceivable that
absorption might occur, if not in all parts of the urinary
tubules, at all events, perhaps, in that portion contained in
the renal medulla, which is so copiously supplied with veins
and lymphatic vessels, that is therefore in the straight tubes,
and in the ascending and descending limbs. But if this be
so, we could not expect that albumen actually in a state of
solution should be excluded from absorption. For if this
latter process involves all portions of the fluid contents of
the urinary tubules, it would affect the albumen as one of
them; but if, as Ludwig’s theory requires us to assume,
materials are selected for absorption, the specific constituents
of the urine being excluded, the albumen must certainly be
absorbed. For least of all can the albumen be considered
as a specific constituent, and when it is present in a state of
solution, and not merely floating about in a fluid, it is
constantly taken up wherever absorption is going on.

The urine, which therefore represents a mixture of the
transudation from the glomerular vessels and of the secretion
of the uriniferous tubules, is probably on the whole more
concentrated, that is, richer in other fixed constituents, but
poorer in albumen, than the transudation peculiar in that
respect, and whose proportion of albumen must be less than
the lowest percentage of any transudation. If we represent
the percentage of albumen in the transudation from the
glomeruli as a, and the amount of the secretion from the
glands which is added thereto as n, then, if no absorption
takes place, the amount of albumen in the urine as a whole

a
will amount only to a It is, therefore, not hard to
100

a
oO
34 ALBUMEN AS A CONSTITUENT

imagine that the demonstration of albumen in normal urine
is beset with difficulties. It is likewise to be supposed that
differences may occur even in the normal condition, and that
the discovery of albumen sometimes succeeds and at other
times fails. Not only does the pressure in the glomerular
vessels vary under physiological conditions, a factwhich admits
of no doubt, the result being that the fluid which transudes
from them contains sometimes more and sometimes less
albumen, but in addition, that portion of the urinary
secretion which depends upon true glandular action, being
under the influence of physiological conditions, is sometimes
abundant and sometimes scanty. This latter fact is equally
certain, and corresponds with our knowledge of all other
glands. The more productive the activity of the glandular
epithelium, the poorer will the urine be in albumen, other
conditions being equal, and the more difficult the demon-
stration, and the reverse. And thus if comes to pass that in
consequence of the varying action of the two sources of the
urine under physiological conditions, different combinations
can be imagined, as a result of which the discovery of
albumen may be easy, or difficult, or impossible, that is to say,
that albuminuria may or may not be demonstrated, according
as both sources either co-operate or act in opposition with refer-
ence to the quantity of albumen in the urine. Increase of the
pressure under which filtration takes place in the glomerular
vessels, and of the secretion in the epithelium, will cause
albuminuria to be absent (7.e. obvious excretion of albumen),
diminution of both those factors will produce its appearance,
increase of the one and diminution of the other will produce
a result dependent upon the influence which preponderates,
as will be shown in special cases in subsequent pages (p. 39 é
seq.)» If to all these considerations we add the individual
differences with regard to filtration and secretion, which are
properly allowed to play so common a part in the dissimilar
reaction of different individuals under physiological and patho-
logical conditions, we shall have scarcely any difficulty in
understanding the fluctuations to which physiological
albuminuria is subject.

All this discussion, all the matters of fact and the con-
clusions deduced therefrom, are therefore incorporated in
OF NORMAL URINE. 35

the assumption that under normal conditions a fluid
extremely poor in albumen transudes into Bowman-Miiller’s
capsules, and that physiological albuminuria is dependent
upon the albuminous contents of this fluid. An assumption
certainly is not equivalent to a direct proof, but, in the
absence of any such, is perfectly justifiable so long as it
cannot be shown that there is any error in the facts upon
which it is based, or that experiences and analogies are
unjustly brought forward in support, or lastly, until we have
direct proof to the contrary. Not long ago it was regarded
as impossible, by direct observation or examination, to prove
whether the fluid contained in the Bowman-Miiller’s capsules
is albuminous or not. To Posner is due the credit of having
indicated a method of directly observing that transudation by
an improved method of boiling—and to him we are indebted
for the positive proof that in many cases of pathological
albuminuria the source of the albuminous secretion is to be
found in the glomerular vessels—a fact which until recently
could only be guessed at with more or less probability. But
Posner has gone further than this, for he believes that he has
positive proof for his assertion “that the kidneys under
normal conditions are not albuminuric, that is, that no
albuminous substances transude from the blood-vessels of the
glomeruli.” He holds this opinion, because in normal
kidneys he has not been able to detect any excretion of
albumen in the capsules, but he manifestly over-estimates the
efficiency, as a test, of the method of boiling and of the micro-
scope. For there is no doubt that albumen may be and is
present without becoming visible after boiling.’ I will not
discuss the fact that in normal kidneys, even after boiling, no
trace of coagulated albumen can be discovered in the lym-
phatics, which, according to Ludwig and Zawarykin (40),
surround the vessels and the urinary tubules, and, according
to Ryndowsky, (41) probably enter the capsules and wind
round the glomerular vessels. Can there be any doubt of the
presence of lymph and albumen, simply because they are
invisible? But more than this ; albuminuria can be induced
in various ways, and the most minute examination may fail to

1 What is true of boiling holds good also with regard to hardening and
soagulation by alcohol.
36 ALBUMEN AS A CONSTITUENT

detect any excretion of albumen in any part, and especially in
the capsules of the boiled kidney or after hardening by alcohol.

This may be very easily and securely effected in rabbits,
by rapidly heating them (see page 48), or by injecting a
very small quantity of phosphorised oil ($—}3 cctm. of a
solution of one part phosphorus to eighty olive oil) under the
skin (see 8S. IV). Often immediately after a single injection,
but always after a repetition on the second or third day there
is evident albuminuria, the urine contains finely granular
casts and occasionally renal epithelium easily recognisable..
After boiling the kidneys and hardening them in alcohol, they
exhibit changes corresponding with the degree in which they
have suffered. These are sometimes of a transient character and
take the form of patches of hyperzemia, minute hemorrhages,
swelling of the epithelium, and perhaps coagulated albumen
in the capsules alone or in the urinary tubules as well, or
there may be nothing remarkable, no albuminous coagula or
none at least in the capsules. The same description holds
good of albuminuria occurring after rapid heating, and also.
of the same symptom resulting from the injection of egg-
albumen into the blood. Miss Bridges Adams (42), in a
series of experiments under Cohnheim and Weigert’s direction,
noticed albuminuria as a constant phenomenon in six cases
in which the injection was made, and in all of them without
exception the boiling method failed to detect any albuminous
secretion in the capsules. And yet albumen has certainly
been present in the capsules, for, as Ribbert has shown, it
really escapes from the glomerular vessels and from them
alone under those circumstances, and may be seen in the
capsules after coagulation. But that it must necessarily be
visible under all circumstances is untrue, as the above-men-
tioned experiments strikingly show, and as might & prior
have been expected. For in the normal condition the glome-
tular tuft completely fills the capsule, and is in such close
contact with it that even “ with a magnifying power of 800
diameters applied to very fine sections of a pig’s kidney re-
moved during life, and placed in a freezing mixture, we areable
to distinguish only a scarcely measurable cup-shaped fissure
between the capsular and the glomerular epithelium.”? This

1S. W. Krause, ‘Allg. u. mikyosk, Anat.,’ 1876, &. 246,
OF NORMAL URINE. 37

fissure represents the space occupied by the minimal amount
of transudation present at that moment, and a consideration
of these facts will make it appear quite natural that the infini-
tesimally minute trace of albumen contained in this minimal
transudation, should remain invisible even after coagulation.
To obtain some approximate idea as to how far the minute
traces of albumen with which we are dealing are within the
limits of vision, supposing that they can be thus included, it
is sufficient to take a simple estimate based on the well-
known dimensions of a Malpighian corpuscle, and the
thoroughly admissible supposition that the corpuscle is per-
fectly globular in form. The diameter of such a corpuscle,
and therefore of the Bowman-Miiller capsule, is on an average
"25 mm., its capacity is therefore ($r*r) ‘00818 cbmm.
If we assume that this space is not, as is really the case,
quite completely occupied by the glomerular vessels, but only
to three-fourths of its extent, so that a complete fourth of the
contents is taken up by the transudation, our supposition will
have exceeded the most exaggerated demands. There is then
at a given moment ‘00204 cbmm. of transudation in a capsule,
or, expressed in weight—for it is somewhat heavier than
water—-o00206 milligrammes. This transudation,as we have
explained in a previous page, must be poorer in albumen than
the poorest normal transudation, than, for example, the
cerebro-spinal fluid. But if we here also advance the most
exaggerated assumption, and estimate that the quantity of
albumen contained in the fluid of the capsule is equal to that
in the cerebro-spinal fluid at its highest amount (see p. 24},
that is, 3 per 1000, we should have ‘00000618 milligrm. of
albumen in ‘00206 milligrm. of transudation. That is the
result of a calculation based upon figures exaggerated beyond
all belief in order to obtain as large an amount of albumen
as possible; and the most extravagant fancy would find a
difficulty in supposing that this quantity, even when com-
pressed into a spot, would be visible under the microscope,
to say nothing of its being more or less diffused in the capsule,
and therefore necessarily only partially exhibited on a trans-
werse section.

As a matter of course the circumstances are different
ander abnormal conditions, when more albumen ‘transudes,
38 ALBUMEN AS A CONSTITUENT

when the transudation is stemmed in consequence of impedi-
ments to its escape and its albumen is increased owing to.
the absorption of water, and when, lastly, this stemmed-up,
copiously albuminous, fluid compresses the glomerular vessels,
and forces them away from the capsule. The albumen thus
becomes visible, but by no means always in every capsule, even
where they are all involved, though in varying degrees of
intensity, in a diffuse process, but it very frequently happens
that only more or less of them present traces of albumen, the
remainder being apparently free from it, because the accu-
mulation has not been sufficient to make itself visible.
Very instructive in this respect is the condition which is
produced after prolonged stagnation of urine, the result of
applying a ligature to the ureters. Here at a certain period
(see S. III) we find the urinary tubules and the capsules
distended, and in several of the latter the glomerular vessels
forced back by coagulated albumen, in others by a more or
less broad and clear ring of fluid without any visible trace.
of coagulated albumen. This fluid must, however, be albu-
minous, and it does contain albumen (as appears on examina-
tion of the urine obtained immediately after the ligature has
been removed from the ureters), and much more than there
can possibly be in the normal transudation under the most
favorable hypothesis. And as, notwithstanding this, it
appears clear and transparent, we cannot expect, as a general
rule, to see coagulated albumen, or anything more than a.
small clear ring, between the glomerulus and the capsule.'
It follows, therefore, that there is at present no reason for
supposing that microscopical examination can furnish any
proof of the presence or absence of albumen under normal.

* The application of a ligature to the ureters of rabbits can be so easily
and neatly effected, that any one may convince himself without any great.
difficulty of the correctness of the above statement. The best proof, how-
ever, is furnished by a repetition of Posner’s own description of the appear-
ances which the kidneys present after ligature of the ureters for two or four
hours, after which we know, and Posner himself asserts, they are in a state
of acute congestion, and red blood-corpuscles (?) are mixed with the secre-.
tion. ‘On microscopical examination in this initial stage, besides the
excessive capillary hyperemia and partial hemorrhages, all that is seen is-
dilatation of the urinary tubules, but there is no coagulable exudation and.
no unequivocal casts.”
OF NORMAL URINE. 39

conditions in the fluid yielded by the capsules. We must
continue to maintain the assumption, which is supported by
other considerations, that the transudation which exudes
from the glomerular vessels is feebly albuminous in its
normal state, and this supposition furnishes us with a means
whereby we may explain the presence of the minute proportion
of albumen in normal urine, and the occurrence of physio-
logical albuminuria, in a manner at once complete and satis-
factory (see p. 22, et seq.).

III. Tae DerenpEence or ALBUMINURIA UPON ALTERATIONS IN
THE BLoop-PREssurRE.

Proceeding from the supposition, which we have shown to
be perfectly tenable, that the normal fluid in the Bowman-
Miiller’s capsules is a transudation yielded by filtration, and
as regards its constitution dependent upon the pressure of
the blood, many experimenters have endeavoured to produce
albuminuria by altering the general blood-pressure of the
body, or the pressure in the vessels of the kidney. It is
necessary that we should minutely discuss these attempts, on
the one hand, because endeavours have been made to obtain
conclusions therefrom as to the origin and secretion of the
urine and the importance of the blood-pressure in the pro-
cess, and secondly, because these experiments have been
made to serve as a basis for the explanation of pathological
processes. Unfortunately we find many difficulties in form-
ing conclusions as to their value for the above purposes, and
these we shall presently endeavour to point out. The con-
ditions are not sufficiently simple to justify the expectation
that the discovery of albumen in the urine would enable us
to decide as to how far its production had been influenced
by any possible change of pressure in the renal circulation.
For, although we are correct in supposing that the transuda-
tion in the Bowman-Miiller’s capsules is subject to the laws
governing filtration-pressure, we are by no means to conclude
that the urine as a whole is placed under the same rules.
The urine is, as I have already explained, to be compared to
a stream fed by two sources, which differ from each other as
AO ALBUMINURIA DEPENDENT UPON

regards the quantity of water they yield and other condi- |
tions, and are governed by laws not altogether similar in
character. The one source, the transudation from the glome-
rular vessels, certainly yields more water and contains a
little albumen in addition to the ordinary constituents of
all transudations ; the other, the secretion of the glandular
epithelium in the urinary tubules, is, perhaps, less abundant

as regards quantity, is free from albumen, but loaded with

the specific constituents of the secretion. The former is, as

I have before said, subject to the laws of filtration, whereas

the glandular secretion is, as we all know, governed by other

influences. In the second place, the fact has been over-

looked that, although with increased pressure the quantity of

the filtrate becomes augmented, its composition becomes

changed, and particularly that the proportion of albumen

undergoes a relative diminution, and therefore that increased

pressure renders its demonstration more difficult owing to

the greater dilution of the urine. Thirdly, as has been fully.
recognised since Virchow’s investigations (43), the vascular

distribution in the kidney is so peculiar in its arrangements,

and so different from that of other organs, that alterations

of the general blood-pressure, or of the pressure in the

principal vessels going to or leaving the kidney, can and

must affect unequally the two sources concerned in the secre-

tion of urine. Fourthly, as a result of certain changes in

the biood-pressure, the nutrition of the walls of the vessels

or other membranous structures, and also the epithelium, may

become affected, and these may in consequence become abnor-

mally permeable for aloumen. Fifthly and lastly, the condition

of the flow of lymph in the kidneys is also dependent upon the

state of the blood-pressure, and is not without influence upon

the composition of the urine. The fact must also be men-

tioned that, at all events, increase of pressure in the venous

system is accompanied by alterations in the purely mechanical

conditions of escape, as was shown by Ludwig some years

ago (44).

These facts and considerations teach us how complicated
the conditions are, and how difficult it is to estimate the
results of experiments upon the changes in the blood-pressure
in the kidneys. If we also consider that in certain series of
ALTERATIONS IN THE BLOOD-PRESSURE. Al

experiments, undesigned and yet potent conditions have been

introduced,—conditions frequently overlooked, or their action.
erroneously interpreted,—we shall not be surprised that some

of the experiments with regard to the influence of alterations

in the blood-pressure have led to results mutually contra-

dictory, while others, even where the results were congruent,

as, for example, in venous congestion, have had very discordant

explanations attached to them.

The conditions with regard to the increase of blood-
pressure in the arteries are the simplest and plainest of all,
yet the influence of this change upon the production of
albuminuria has been made the subject of very different
statements by the various investigators. It is true that many
of the experiments have either been incorrectly performed,
or they lead to a conclusion just the opposite to that which
their performer deduced from them. If, taking our stand
upon pure theory, we ponder over the views developed in
the foregoing pages, and reflect upon the necessary conse-
quences of the increase of arterial pressure within the kidneys,
we find that the result must be a combination of the influence
of the increase of pressure upon the transudation from the
glomerular vessels, and of the influence upon the secretory.
elements of the uriniferous tubules. The condition of the
transudation may be predicted with perfect certainty, it will, as
has been already explained (see p. 28 et seq.), be more copious
than under normal conditions, and its percentage of albumen
will be diminished. The condition of the proper secreting
elements of the kidney cannot be predicted with a like
certainty, for they cannot be subjected to a separate
experimental test, as is the case with the elements of other
glands. Following, however, the analogy of other glands,
especially the liver, we may assume that with the increase of
arterial pressure (and of the rapidity of the current) the
secretion will, at all events, be increased up to a certain
point, and no albumen will appear therein. The result, as
regards the urine, will be an increase in its quantity ; on the
other hand, it will contain a still smaller percentage of
albumen than is assumed to be normally present. If we
take, as before, the percentage of albumen in the transudation
as a, it will, under the assumed conditions, be a—#, and the
42 ALBUMINURIA DEPENDENT UPON

quantity of the secretion yielded by the epithelium, instead
of n, will be rather n+, so that now the urine as passed will
a—w
contain only ra mty of albumen, always supposing that no
100
absorption takes place from the urinary tubules.

It follows, therefore, that if the experiments be really
successful, and free from all objection, we may expect to
find less albumen than normal in the urine; but simul-
taneously with the increase of pressure, other conditions must
prevail, which, without causing any other alteration, diminish
the quantity of urine, and therefore raise its percentage of
albumen, enabling us to demonstrate its presence.

Let us consider once more the experiments that have
hitherto been made, and their results in particular. There
are various methods which may be used, and for the most
part have been used, for the purpose of increasing the
pressure in the arteries in general, or in those of the kidneys
only. The greatest increase of pressure in the aorta can be
produced with ease and precision by electrical irritation of
the cervical spinal cord, by producing dyspnoea, by poisonous
doses of strychnia, digitalis, &c. All these means have been
employed to produce albuminuria, and it may be asked, with
what result? All observers agree in stating that invariably
during the rise of the aortic pressure, and at its height,
the flow of urine altogether ceases ; subsequently, when with
the falling pressure secretion is restored and is more copious
than before, a (gradually diminishing) excretion of albumen
takes place. In the first period there is a general spasm of
the small arteries, which causes the pressure to rise in the
great trunks. The small renal arteries, as Griitzner (45) has
shown, participate in this spasm, and the natural result is
the exhaustion of the flow of urine; with the subsidence of
the vascular spasm, as a matter of course, there is increase of
pressure in the arteries and capillaries of the kidneys (as in
other organs), and exceeding the original height in a degree
corresponding to the previously abnormal increase in the
aorta, until the dilatation of the vascular channels causes the
normal conditions to be restored. In this period, in which
the pressure and the rapidity are both increased, with active
ALTERATIONS IN THE BLOOD-PRESSURE. 43

vascular dilatation as a result, the increase in the secretion
of urine is accompanied by appreciable albuminuria.’ Can
we now draw any conclusions therefrom with regard to the
influence of the increased blood-pressure upon the albumi-
nuria? At the first glance, the position of cause and effect
seems so clear that this conclusion might be accepted without
any hesitation. But there is one important fact of a contrary
character, namely, the defective supply of arterial blood
while the vessels are constricted. It makes no difference if,
as is generally stated with regard to these experiments, the
flow of urine altogether ceases during the period of vascular
spasm, and the albuminuria consequently afterwards appears
with the returning secretion of urine, for undoubtedly
this phenomenon is to be referred to the previous period,
unless hemorrhage sets in. We shall see later on that, when
the supply of arterial blood is considerably reduced, but not
altogether cut off, the secretion of urine continues, and is
accompanied by manifest albuminuria, the causes of which
will then be described. The only question at present is to
establish the fact that even the diminution of the supply of
blood, which occurs in the first period, explains per se the
albuminuria, and that, consequently, these experiments are
of no force at all as arguments in favour of the influence of
increase of the arterial pressure.

These experiments would have far greater demonstrative
force, for or against the existence of this influence, were it
possible so to perform them that this effect of pressure,
and nothing else, came out as the resultant. The idea
formerly was that the pressure in the aorta and other

1 Litten (46), who has performed the above-mentioned experiments with
the same result, especially with regard to the albuminuria, and was disposed
to consider this latter as caused by the increase of the arterial pressure,
explains this now as the consequence of the dilatation of the vessels and of
the resulting retardation of the current of blood, and he finds in this a
positive confirmation of Runeberg’s views, which he had regarded as correct
(see pp. 2 and 31). But inasmuch as the condition in question is that of an
active dilatation, as a matter of course there can be no retardation of the
current of blood, a fact which is also incidentally revealed by the increase in
the quantity of urine. It is evident that other conditions prevail when the
pressure is raised in consequence of impeded escape from the veins and
passive vascular dilatation.
Ab ALBUMINURIA DEPENDENT UPON

arteries could be easily raised by placing a ligature on
peripheral arteries. Observations with the kymograph have,
however, taught us that that idea is erroneous, and have
shown that the organism sets in action compensatory arrange-
ments whereby, even when large vascular districts are cut
off from the circulation, the general blood-pressure is kept
at the normal height. The pressure in the aorta can be
greatly increased only by ligature of the carotids or, indeed,
of one carotid, but, as Nawalichin (47) has shown, this is
merely in consequence of the irritation thereby induced in
the vaso-motor centre and of the general vascular spasm
which ensues, just as takes place in the first series of
experiments which we have already discussed. Without
tying the carotids the pressure in the aorta can be certainly
and considerably increased only by applying a ligature to
the vessel itself below the diaphragm, but above the kidneys.
But the obvious consequence of this is that the supply of
blood to the kidneys is almost, although not altogether, cut
off, and the experiment is therefore useless for our purposes.
Ligature of the aorta alone, below the kidneys, causes no
increase of pressure ; Litten, indeed, found a slight increase
on tying the cceliac and superior mesenteric arteries in addi-
tion to the aorta, but this gradually subsided. These facts will
‘cause us to regard the changes which the urine may present
after ligature of the aorta below the renal arteries, not as
the consequences of the increased arterial pressure, but as
due rather to the incidental injuries, unavoidable in so
serious an operation, to the pressure to which the kidneys
or their vessels have been subjected, and to laceration and
injury of the splanchnic nerves, &c. Considerations of a
‘similar character may be raised against those experiments,
by which the blood-pressure can be really raised by placing
a ligature on the aorta and other arteries. And a review of
the results obtained by various investigators will confirm
our scruples. G. H. Meyer, who was the first to tie the
aorta in order to decide this question, found albumen in the
urine passed afterwards, Robinson, on the contrary, found
no albumen, Frerichs found traces of it in a few cases, but
invariably considerable quantities when he removed a kidney
mm addition to tying the aorta. The same result was obtained
ALTERATIONS IN THE BLOOD-PRESSURE, 45.

by Ph. Munk. Correnti found albumen after simply tying
the aorta; H. Cohn also, but only exceptionally, after
removal of one kidney; Litten, after tying the aorta alone,
found no albumen, and he noticed the same result when:
both the cceliac and the superior mesenteric arteries were
tied, slight increase of pressure being consequently induced.
I myself have twice tied the aorta in rabbits, and subse-
quently found the urine to be albuminous, but I also con-
vinced myself of the very serious character of the operation.
To avoid injury Stokvis has applied compression, externally
through the abdominal wall, to the aorta in rabbits below
the kidneys, by means of a belt fitted with a screw ; in two-
out of three cases the addition of nitric acid to the urine
produced a slight cloudiness, which he did not consider to
be albumen, but which could not, I think, have been any--
thing else. No importance, however, is to be attached to
these experiments, for if in reality only the aorta were:
compressed below the kidneys, we could not, as above stated,
expect with any degree of certainty that the blood-pressure
in that vessel would be raised. Asa matter of fact, how-
ever, in these experiments, the pressure in the abdomen
generally, and consequently the pressure to which the
kidneys are subjected, must necessarily be increased, and
must produce considerable congestion of those organs as a
result, and we know that this condition is sufficient to cause:
albuminuria (48).

What, then, are the conclusions to be drawn from all
these experiments? Without raising the pressure in the:
aorta (ligature of the aorta alone) one observer always finds
albumen, another never finds it, a third discovers it occa-
sionally, and traces of it only; by raising the pressure
(ligature of the aorta and ligature of, or checking the flow
through, other arteries), albumen is constantly found by
one experimenter and not by another. My own opinion is,.
that that series of experiments, as a result of which no
increase of pressure can be expected, really proves nothing ;.
and that the albuminuria observed in connection therewith
is to be ascribed to the above-mentioned injuries which are
incidental to the operation. In those experiments which
are attended with real increase of the arterial pressure, one:
46 ALBUMINURIA DEPENDENT UPON

assertion contradicts the other, and the question still waits
decision. At the same time, Litten’s experiments, in which
no albumen was found, must be allowed to possess the
greatest force as demonstrations ; for, though it is easy to
understand how in such serious operations the urine becomes
albuminous owing to incidental causes, we cannot readily
imagine, if the increase of pressure per se caused albuminuria,
how this could be accidentally masked, always supposing
that proper methods were used for discovering the albumen,
of which in this case there can be no doubt. If, therefore,
Litten’s experiments be regarded as demonstrative, the result
thereof corresponds exactly with our hypothesis (see p. 42).
If albumen is, as a general rule, not to be found in urine,
increase of the arterial pressure, unless the quantity of urine
be simultaneously diminished, will assuredly not cause any
albumen to appear.

The experiments in which the renal nerves are divided
have yielded results more in harmony with each other, mainly
because in performing them it is difficult to avoid pressure
or injury to the renal vessels. The latter causes can per se
produce albuminuria, and this fact may explain why some
observers, as in recent times von Wittich and Vulpian, have
noticed it after dividing the nerves, while others, as M.
Herrmann and Knoll, have observed this symptom only after
injuries incidental to the operation (49). Considerable import-
ance must be attached to these negative results, for the same
reasons as in the experiments in which the aorta was tied. The
same thing then occurs as after the division of the nerves, as
a result of which the blood-pressure and the rapidity of the
current in the kidney are increased, that is to say, we are not
able to discover albumen, because in all these experiments
the quantity of the urine is very considerably increased.

Greater results than those of all these experiments are, as
already said, to be expected from a method which increases
the arterial pressure, and that alone, and at the same time
diminishes the water of the urine so that the discovery of
the albumen is facilitated. Such a method we possess in
the elevation of the bodily temperature. That this should
raise the general blood-pressure can be & priort inferred from
the well-known changes which take place in the blood-vessels
ALTERATIONS IN THE BLOOD-PRESSURE. 47

and in the circulation when the temperature of the body is
raised.

The increased pulsations of the heart, the enlarged calibre
of all the arteries, and their greater fulness, the pulsation of
small vessels in which no pulse was previously felt, the red
and injected appearance of all visible parts, in a word, all
those well-known phenomena of “ fluxion” as they occur
locally or generally after the operation of warmth, are the un-
questionable consequences and proofs of the increase of blood-
pressure in the arteries (and of the rapidity of the current).
At the same time, in the numerous and multiform experi-
ments of a bygone and recent date, and performed with a
view of measuring the pressure, but little heed has been paid
to this condition, and thus it comes to pass that with regard
to the direct estimation of the arterial pressure, when the
general temperature is raised, we have one solitary incidental
communication made by Paschutin (50) when he was investi-
gating the lymphatic system in dogs. He found, as a mat-
ter of fact, that the pressure was considerably increased.
In addition, J. Zadek (51), who performed experiments on
men by Basch’s method of indirectly measuring pressure,
likewise found that the pressure in the arteries becomes ab-
normally high when the bodily temperature is increased.
These statements are, however, inadequate, and I have there-
fore performed a great number of experiments on rabbits, in
which the pressure in a carotid artery was measured while the
surface of the body was somewhat rapidly warmed. The
detailed account and a description of further experiments
made at the same time do not belong to this part of the sub-
ject and will follow hereafter. I may here just say that,
asa matter of fact, when the temperature of the body is
raised within certain limits, the pressure in the carotids is
increased, and possibly to an extraordinary degree. If, how-
ever, the temperature rises above a certain limit, the intense
heat produces its well-known effect upon the heart, and the
result is that the pressure falls rapidly and far below the
normal degree, and death may ensue.

It is therefore an established fact that, by applying heat
to the body, the blood-pressure, and indeed the general arte-
rial pressure in the whole body, can be increased. There is
48 ALBUMINURIA DEPENDENT UPON

no cause for the suspicion that, as occurs in the methods
previously discussed, the pressure in the aorta alone, or the
pressure in certain portions, is increased at the expense of the
pressure in other parts, or that this increase is preceded by
a lowering of pressure with diminished supply of blood, but
in this method from the very commencement, immediately
the warming begins, the superficial and deep arteries and
those of the viscera become dilated,—a fact in harmony with
our expectations, and of which we may fully convince our-
selves by examining any organ we choose and especially the
kidneys.’ The first condition for our experiment is there-
fore present in a manner which leaves nothing to be desired.
There is no difficulty with regard to the fulfilment of the
second condition, which is, that the quantity of the urine
should be diminished. The condition is perfectly fulfilled
provided that neither a bath nor a room saturated with mois-
ture has been the means adopted for raising the temperature,
for the increase of water given off by the skin and lungs
causes the urine to become diminished in quantity. This fact
is too well known to require me to allude to it any further.

All that we have to do, therefore, is simply to examine the
urine for albumen, before and after heating the animal. I
have performed these experiments upon a great number of
rabbits.

As a heating apparatus we use a kind of oven or a drying-
closet, made of copper-plate, and such as we find in chemical
laboratories, with double walls all round for holding water,
except at the side, where thereis a door. The water is poured
in through an orifice in the upper part. Another opening goes
through both walls and reaches into the interior of the oven;
this is designed to admit the thermometer which measures the
temperature of the oven. This latter is of sufficient size to
allow a large rabbit (and only such should be chosen for the
experiment) to sit quite at ease in it. It stands upon a broad
tripod, beneath which the heat is applied. Before placing the
animal in the oven, its bladder should be emptied by com-

1 It need hardly be said that the heating must be a gradual process, in
order that the phenomena may appear in the way above described, and that
on the other hand sudden exposure to intense heat acts upon the body as @
violent irritant, and could only disturb the results of our experiments.
ALTERATIONS IN THE BLOOD-PRESSURE. 49

pressing it, and the temperature is to be taken in the rectum.
As a general rule, in order to save time the oven was first
slightly warmed, and after the introduction of the animal the
temperature was more or less rapidly increased. In order to
give sufficient air, the door was not quite closed, but left
somewhat ajar. When the heat had been applied for a suffi-
cient length of time, the temperature in the rectum was
taken while the animal remained in the oven, but with the
door open, or immediately after removal ; then the bladder
was emptied by pressure, and if no urine could be obtained,
the animal was placed in a cage from which the urine could
escape. Experiments made at the same time with a view of
examining the urine as regards its correspondence with the
measurements of pressure and its variations, are attended
with some difficulty, which, however, may perhaps be over-
come by using large animals, such as dogs. For various
reasons, however, and for the most part extrinsic ones, I
avoid experiments upon large dogs. I have made a few
experiments with the view of measuring the pressure in
small dogs, but which were not altogether satisfactory on
account of the numerous unavoidable difficulties connectod
with the production of anesthesia in dogs. And in connec-
tion with those few experiments in which it was sought to
obtain urine from rabbits while estimating the pressure, there
was this drawback that the excitement caused by handling
the animal was a thing to be avoided; moreover, in the short
interval, urine could not be obtained from the bladder for
examination if the organ had been previously compressed.
The secretion obtained from the ureters on one occasion was
not free from an admixture of blood, which was attributable
to the unavoidable irritation and injury of the mucous
membrane.

The result in all cases was, the production of albuminuria
when the bodily temperature had been increased by 1°5—3'0C.
with sufficient rapidity, or the heat continued for a sufficient
length of time, and where this symptom was normally present,
it became more marked.’

1J have already stated (p. 20) that even in animals the urine in the
‘normal condition very often contains albumen. I found it in more than
half the number of these I submitted to experiment, and even in those

4,
50 ALBUMINURIA DEPENDENT UPON

If the temperature were very rapidly raised to an extreme
degree, blood appeared in the urine, and in quantities which
did not require the microscope for its detection. In addition
to this, and even when no blood-corpuscles were visible, the
urine often contained pale hyaline casts, and sometimes
finely granular ones, in greater or less abundance.

That the excretion of albumen, or its excretion in an
increased degree, is a direct result of the elevation of tempe-
rature, and not a secondary phenomenon manifesting itself
while the temperature is falling, is demonstrated by two
cases in which the animals passed water while in the hot
oven, and a portion was caught for examination. This
proved to be albuminous, while the urine shortly before had
been found free from albumen.

We could & priori assume with a degree of probability
almost amounting to certainty, that the capsules are the seat
of this excretion of albumen. In order to prevent any doubt
on this point, I examined the kidneys in many cases with
this particular object, killing the animals by cutting their
throats immediately after heating them, and then at once
removing the kidneys and hardening them by boiling. In
proportion to the intensity of the action, there were, in these
cases as in those of poisoning by phosphorus (see p. 36),
variously strongly marked changes in the kidneys; in those
least affected there was only a very slight deposit of albumen,
not visible in all the capsules, whereas in the more violent
cases there was not only a marked deposit of albumen, but like-
wise hemorrhages in many capsules and uriniferous tubules,
whilst in others there was no abnormality, with the exception
of more or less marked hyperamia.

With regard to the strictly ultimate cause of this albumi-
nuria, we could at once recognise therein a confirmation of
the view already unfolded, that with the increased pressure
more albumen escaped, and could be more easily found by
reason of the simultaneously diminished excretion of water,
if we were quite sure that the purely physical agent, the
increased temperature, might not per se, modify the filtration
of albumen in this direction. That this is so cannot be

recently brought to me and kept in the open air during the summer. It is
true that the albumen was often discoverable only after careful examination.
ALTERATIONS IN THE BLOOD-PRESSURE. 51

asserted with our present knowledge. We know from the
experiments of W. Schmidt (52) and Eckhard (53) that the
filtration of saline and albuminous solutions through animal
membranes goes on with increased rapidity as the tempera-
ture is raised, just as Poiseuille has found to be the case in
filtration through glass capillary tubes, but unfortunately, we
can draw no certain inference from Schmidt’s experiments,
which specially related to albuminous solutions, as to what pro-
portion the albumen in the filtrate bore to that of the original
fluid. If the percentage of albumen increased in the filtrate,
this, as a matter of course, would alone suffice to explain the
occurrence of albuminuria without any changes of pressure,
whereas the latter alone entered into our considerations. I
‘see, therefore, in these heating experiments, no irrefragable
proof of the dependence of albuminuria upon an increase of
blood-pressure, but certainly a support to this view, and one
which taken in connection with other experiments pointing
in the same direction give to it a weight by no means in-
considerable. In any case, these experiments support the
theory, according to which filtration takes place in the
capsules.

There are, however, sundry other conditions which more
or less decidedly increase the blood-pressure in the aortic
system, and serve as a test for our view—the most important
of these is muscular action. Its influence in this respect
has been so constantly observed since the introduction of
the kymograph by Ludwig that there can be no doubt
whatever in regard to it. Its influence upon the production
of albuminuria has not, however, so far as I know, been
experimentally investigated, but Litten in describing his
above-mentioned experiments states that albumen often
appeared in the urine as a consequence of the muscular
action of the dogs while they were fastened, whereas the
urine previously obtained through a catheter was free from
albumen. On the other hand, in healthy men frequently
after intense muscular exertion, in parturient women as a
consequence of difficult labour (without any previous dis-
order) albumen has been found in the urine (see p. 19), and
also in pathological conditions, in convulsions of all kinds,
but particularly in epilepsy, albuminous urine has been very
52 ALBUMINURIA DEPENDENT UPON

frequently observed, and its appearance has been often con--
nected with the extraordinary muscular exertion and the
accompanying increased arterial pressure.' That the pressure
in the human subject is increased by muscular exertion may
be confidently assumed from the analogous effects observed
in experiments on animals, and from the condition of the:
organs of circulation, resembling as it does that which is
produced by raising the temperature (see p. 48), and, besides
this, positive proof is furnished by the experiments of Zadek,
which have been already referred to. He found that active
muscular exertion (running, for example) was accompanied
by an increase of the arterial pressure by about one-fourth
of the normal degree. But in addition to this, in all mus-
cular exertion of any degree of intensity, as daily experience:
teaches us, and as countless experiments have proved beyond
doubt, the escape of water through the skin and lungs in
the form of perspiration and vapour is enormously increased,.
and as a result the urine contains less water; we have,.
therefore, a perfect combination of the two conditions which
we have laid down at the commencement as essential for
distinguishing that form of albuminuria dependent upon
blood-pressure, that is to say, increase of the arterial
pressure and simultaneous diminution of the water of the:
secretion, and these conditions are fulfilled under the cir-
cumstances before us as decidedly as, or even more so than,
when the temperature is raised by experiment. For if the:
latter could be supposed to be open to any slight objection
as to its validity as a demonstration, nothing of this kind
can arise with respect to muscular exertion, and I cannot
conceive of any well-founded hesitation in accepting the
explanation which I have given. But for all this, the
attempt has been made to explain the process in another
way, and this has been done from the standpoint of Rune-
berg’s theory by Edlefsen, who has been followed by Rune-.
berg himself. Confiding in the correctness of this theory,
which assumes that the escape of albumen is due to a
diminution and not to an increase of the normal pressure in

To meet any possible objection it may here be remarked that in the
muscular exertion of the healthy subjects, and also in the majority of the
pathological cases, there was no symptom of dyspnoea, or risk of suffocation
ALTERATIONS IN THE BLOOD-PRESSURE. 53

"the vessels, Edlefsen attempts to prove that during muscular
exertion the arterial pressure in the kidneys falls below the
normal, and he founds his view upon J. Ranke’s (54) obser-
vations on the subject of the interchange of activity among
the organs of the body. According to these observations,
during tetanus, the muscles contain more blood, the other
organs, and especially the glands, less blood than when the
muscles are at rest. But such a conclusion is most assuredly
not justified by Ranke’s observations, for the conditions under
which these were made were fundamentally different front
those associated with the muscular exertion of healthy subjects,
and those which obtain in the majority of convulsive attacks.
‘Ranke caused tetanus of all the muscles by administering
poisonous doses of strychnia or irritating the spinal cord ; or
tetanus of single groups of muscles by electrically irritating
the nerve trunk of one extremity. In the first form, causing
tetanus by acting on the spinal cord, a violent contraction
of all the small arteries takes place—a fact to which we have
incidentally alluded (see p. 42), and this is least marked in
the muscles, the arteries of which, according to Hafiz (55),
are. far behind those of the skin and the abdominal organs
as regards both the degree and also the duration of the con-
traction.' It was therefore that Ranke noticed that little or
no blood escaped from the incised vessels of the skin in
tetanus, whereas the muscles were full of blood, and bled
freely on incision. This fact alone would suffice to demon-
strate the difference between the conditions in Ranke’s
experiments and those which obtain in ordinary muscular
exertion, even of the most severe character. But in the
ease before us, are the vessels of the skin abnormally empty?
On the contrary, there is visible and marked congestion,
that is, an increased supply of blood to the skin, and not to
the skin alone, but doubtless to other organs, such as the
lungs, brain, &c. The cause of this fluxion, at least an
important if not the only cause, is the increase of the bodily
temperature which is associated with all muscular exertion,
and therefore the conditions, so far as we are concerned with

1 The albuminuria which is sometimes observed in connection with

tetanic convulsions probably depends upon this intense constriction of the
renal vessels, as explained above (see p. 42).
54 ALBUMINURIA DEPENDENT UPON

them, are in all respects similar to those which obtain when
the temperature is raised by simple exposure to heat. Can
there be any doubt that the kidneys participate in the-
general increase of temperature caused by muscular exertion,
and can we possibly conceive that, notwithstanding the
fluxion to these organs and the rise in temperature, the renal
vessels should be diminished in calibre and receive a smaller
supply of blood? We must reject all previous experience
before we can entertain such a suggestion. As far as
regards, however, the tetanic irritation of nerve-trunks by
means of electricity, we must allow that Heidenhain is
correct in the objection he raises, to the conclusions drawn
from these experiments, with regard to the activity of
glands in muscular exertion, his belief being that the abdo-
minal vessels probably become contracted in a reflex manner,
just as occurs when the sensory nerves are violently irritated
(56).

The diminution in the quantity of urine and its concentrated
condition, which follow muscular exertion, are brought
forward by Runeberg (57) a8 proofs that the pressure is
diminished in the renal vessels. We are exempted from
any controversy with regard to this view, inasmuch as we
have given an obvious and very simple reason why the urine
becomes less watery after muscular exertion.

We may in the last place specify the process of digestion,
and certain poisons, as factors by which the arterial blood-
pressure can be more or less positively raised, or is perhaps
regularly increased. With regard to the former of these,
certainly I do not know of any experiments in which the
pressure has been directly measured, but Zadek in his re-
searches, has indirectly observed that the pressure is increased.
Besides this, however, the existence of such increase might,
with some probability, be inferred from the fact long since
observed by Vierordt and Aberle that the size of the arteries
is increased after taking food (58) ; and also, that during diges-
tion certain changes take place in the circulation which, at least
faintly resemble the condition which follows muscular exer-
tion and exposure to heat, and have therefore been designated
as “digestion-fever.” It is true that this increase of pressure
does not appear to be very considerable as a general rule ;
ALTERATIONS IN THE BLOOD-PRESSURE. 55

according to Zadek it amounts to from one-twelfth to one-
sixth of the normaldegree. Itis therefore doubtful whether
this increase can exercise any appreciable influence upon the
transudation of albumen. Moreover, the albuminuria often
observed during digestion cannot be attributed to increased
pressure, for, as we know, the urine is increased in quantity
while the process is going on. This albuminuria of digestion
can be satisfactorily explained in another way, as will appear
later on. (See V.)

No methodical experiments have yet been made with the
various poisons which raise the pressure in the aorta, such as,
in addition to those previously mentioned (see p. 42) nicotine,
picrotoxin, &c. ; only incidentally has albumen been observed
in the urine during the employment of one or other of these
remedies. For our purpose we can scarcely expect to obtain
any definite explanations from such experiments as these,
for when poisons of this kind are administed very different
conditions co-operate, which make it difficult to connect
causes and effects together. With regard in particular to
the increase of pressure and its connection with albuminuria,
we must take into consideration the fact that the increase
depends upon a narrowing of the vessels when most of these
substances are administered, and therefore proves just as
little as other experiments based on the same process (see
p- 42 et seq.) ; and likewise that these drugs often cause
spasm of various groups of muscles, and exercise a disturbing
influence upon the nutrition of the tissues, &c.

A review of the total results of all these numerous expe-
riments, having for their object the production of albumi-
nuria by increasing the pressure in the aorta, produces the
impression that the majority of the experiments have failed,
and that the labour devoted to them has been, for the most
part, expended in vain. The few trustworthy experiments
performed with unequivocal results, and facts of a like im-
port, and in harmony with the experiments observed, in the
human subject, appear to justify the following conclusion,
viz. that the increased arterial pressure in the kidneys per se
produces, or may produce, albuminuria, if by the removal of
water through other channels, the urine is simultaneously
decreased in quantity below the normal amount.
56 ALBUMINURIA DEPENDENT UPON

In venous congestion of the kidneys the processes are
vastly more complicated and difficult to fathom. It is true
that the experimental investigations on this subject have
shown, with a mutual conformity otherwise rare, that apart
from other changes, the urine under these circumstances
always becomes albuminous, and with this result the expe-
riences of renal congestion in the human subject seem to
accord, so that there has been no hesitation in interpreting
in the same sense all the experiments having for their object
the arrest of the venous blood; and in regarding al] of
them, like the clinical examples, as of equal value. Ii,
however, we look more closely into the matter, we find that
there are very important differences among the experiments,
and to a greater extent between them and the clinical exam-
ples, in spite of the fact that a certain similarity exists.
With regard to the clinical examples, we do not require
much experience to know that, in the first place, with the
exception of those extremely rare cases which have scarcely
any clinical significance, the phenomena of congestion in the
human subject are induced by conditions which lower. the
pressure in the aorta, and that in the proportion in which
this takes place the congestion becomes increased ; and in
the second place, that the conditions generally become deve-
loped very slowly, that is to say, in the course of many
weeks, or at least days, and hardly ever in the course of a
few hours or minutes. In the experimental investigations
performed for the purpose of explaining the conditions in
the human subject, there is much that contravenes the
above experiences. In order to produce congestion, the pre-
ference has been given to experiments in which the renal
vein is tied, and these have been used for purposes of com-
parison, although inasmuch as the arterial supply to the kid-
neys continues unchanged, the circumstances are the oppo-
site of those of the pathological conditions of the human
subject. Moreover, in the majority of cases, and especially in
recent times, when these questions have assumed considerable
prominence, the effects of the various operations regarded as
necessary have neither been gradually induced nor allowed
to continue for a brief period, but suddenness and extreme
results have been aimed at, and thus, for example, the move-
ALTERATIONS IN THE BLOOD-PRESSURE. 57

ment of the blood has been completely arrested during many
hours, and indeed, for days. As a matter of fact, the final
result of all such experiments in which, however much the
conditions are changed, one at last is always attained—the
arrest of the circulation and of the renewal of the blood; I
say, the final result of all such experiments is, as could be
easily foreseen, always the same, namely, the escape of
albumen and blood throughout the kidneys, and these pass
into the urine when the secretion is again restored. But
that under the various conditions which induce congestion,
the phenomena should develop themselves in an unequal
degree might certainly @ priort be regarded as more pro-
bable than the contrary ; it is also certain that these differ-
ences could not be recognised if the changes were investigated
only after they had become very far advanced, and the mis-
chief had thoroughly and universally affected all the various
elements of the kidneys ; and in the last place it is no less
certain that the course taken by the phenomena may be very
different according as the disturbance is a sudden one or of
a slow and gradual character. We know that all the organs,
and the kidneys are no exception, are very sensitive to dis-
turbances of the circulation, but notwithstanding this fact,
when the disturbance is of a gradual character, they accomo-
date themselves very well to the altered conditions, and
within certain limits can discharge their functions in a
manner approximatively normal. A consideration of all these
facts will prevent us from expecting, on the one hand, any
uniform course of the phenomena in the experiments on con-
gestion, and, on the other, any collective and individual
coincidences between the clinical appearances of renal con-
gestion and those experimentally induced.

. If the escape of venous blood be completely prevented by
tying the renal vein, or by any other plan which does not at
the same time arrest the action of the heart, inasmuch as
blood will be supplied as freely as before, there must neces-
sarily result the fullest imaginable engorgement of the organ
with extravasations of blood due to lacerations of the smallest
vessels, and the only limit to this engorgement will be the
distensibility of the renal capsule. In rabbits, for example,
this limit appears to be reached when the escape of blood
58 ALBUMINURIA DEPENDENT UPON,

has been prevented for from half-an-hour to an hour. The
kidney is then enormously swollen—to double its normal size
or more—and in addition to extravasations varying in size
and number, its entire substance, cortical and medullary, is
turgid with blood. After the organs have been hardened by
boiling, according to Posner’s method, and then coloured,
microscopical examination shows that coagulated albumen
and numerous red blood-corpuscles are deposited in the cap-
sules and in the uriniferous tubules. The same appearances
are found, according to Posner, when the inferior vena cava
and not the renal vein is tied, and the same holds good, par-
ticularly with regard to the excretion of albumen (to antici-
pate further statements on this head), in every form of con-
gestion due to other causes, provided only that the condition
be of sufficient intensity and duration, stopping short, how-
ever, of causing the engorgement and extravasation of blood
to attain the same degree. During the existence of such
intense congestion, the function of the kidney is almost, if
not altogether,in abeyance. In experimenting upon rabbits
I could not succeed in obtaining any trace of secretion from
the ureter of that side, if, before applying the ligature, the
tube had been emptied of its contents. Cohnheim (59) states
that immediately after the vein is tied a bloody liquid, highly
albuminous, may at first distill from the ureter ; this gradu-
ally but decidedly diminishes, until at last the secretion
entirely ceases. When the ligature is removed, supposing
that it has not been retained for too long a time, the secre-
tion is restored, and the fluid, as a matter of course, contains
blood and a considerable quantity of albumen. How far this
fluid, containing as it does so much albumen and blood,
deserves to be called urine, is a question which may be left
undecided.

An experiment of this kind can, as I have already said,
teach us nothing with regard to the order of sequence of
the process of the development of the albuminuria, especially
upon what it depends. The production of such an intense
congestion injures more or less all the elements concerned,
the glomerular vessels, the interstitial vessels, the various
epithelia, and possibly other constituents of the tissue. With
regard especially to the tubular epithelium, it is true that
ALTERATIONS IN THE BLOOD-PRESSURE. 59

no marked changes can be possitively detected under the
microscope, but this is clearly no proof that the cells have
escaped all injury, for the glomerular vessels appear un-
changed, notwithstanding the fact that blood and albumen
have escaped from them in appreciable quantities.

The appearances are of a different and more simple
character when the flow through the vein is checked for a
very short period only, the obstruction being removed before
the symptoms have reached their acme. We are indebted
to Ludwig, whose studies on the secretion of urine led him
to try the effect of these very brief interruptions to the
venous outflow, for a knowledge of the very important fact
that the closure of the renal vein (the arterial supply con-
tinuing unchanged) causes the uriniferous tubules of the
pyramids and medullary substance to be compressed by the
much dilated veins surrounding them, even to the extent of
producing complete closure, so that the flow of urine may
be interrupted, to be immediately renewed when the blood
is allowed to flow. In such a kidney, removed from the
body immediately after ligature of the vein, all that can be
recognised, both with and without the microscope, is great
dilatation of the numerous vessels of the renal medulla, but
no excretion of albumen, none at all events in the Bowman-
Miiller’s capsules. If the vein is allowed to remain occluded
for a somewhat longer period, for eight to twelve or at most
fifteen minutes, the changes will be found to have advanced.
a step further—there is now distinct excretion of albumen
in the kidney, but this has taken place exclusively, or very
nearly so, in the uriniferous tubules, particularly of the medul-
lary substance, in the collecting tubes, but not in the capsules.

The appearances are very beautiful and distinct on sections,
doubly coloured with picro-carmine, of the renal tissue
hardened by boiling with or without subsequent treatment
in alcohol. Everywhere within the tubuli we see the tiny
coagula of albumen with shrivelled blood-corpuscles, whereas
in the capsules we look in vain for albuminous deposits ;
perhaps here and there an isolated specimen may be found,
if the experiment has been somewhat more prolonged.’ If
the ligature be retained for more than the brief interval

1 See fig. 1.
60 ALBUMINURIA DEPENDENT UPON

mentioned above, the conditions more and more closely
approximate to those already described, and the excretion
of albumen within the capsules generally is a manifest
phenomenon. At the same time, it is important to notice
that the epithelial cells of the tubules blocked-up by the
masses of albumen are, like the epithelium in general so far
as can be recognised, in a perfect state of preservation.
When the interruption to the circulation is of such a brief
character, no detachment of cells from the basement mem-
brane can be made out, but if the congestion lasts a little
longer, the epithelium is seen to be removed from its bed
by a layer of coagulated albumen.

No other conclusion can be drawn from these experiments
than that the medullary substance of the kidney is that por-
tion which is primarily and most seriously affected when the
renal vein is occluded, and the flow of blood through the
artery allowed to continue; and that the abnormal excretion
of albumen first occurs in the uriniferous tubules of this
portion, the visible escape of albumen into the capsules being
a subsequent phenomenon. I do not know of any other way
of interpreting the appearances before us, for no one can be
expected to assume that the albumen is excreted into the
capsules, and drains away into the tubules in the course of a
few minutes, and to such an extent that nothing beyond a
mere trace, if even so much as this, remains behind in the
capsules. There is nothing extraordinary in the fact that
this conclusion has hitherto not been recognised, or that it
should have been repudiated as illegitimate by experimenters,
for as I have already said, the experiments hitnerto made
have not been properly performed, at least with regard to our
present purpose.’

This explanation of the origin of the excretion of albumen
when the renal vein is completely occluded for a brief period,
during which some amount of circulation is probably kept up
by other veins, can also be applied to explain the same

I have shown in a former treatise (1. c.) that the process of the excretion
of albumen, when the flow through the vein is interrupted, goes on as above
described, but I then made no distinction between occlusion of the vein
without any change in the arterial pressure, and the same condition
accompanied by a reduction of that pressure.
ALTERATIONS IN THE BLOOD-PRESSURE. 61

phenomenon occurring when the renal vein is only partially
occluded or the inferior vena cava is tied,—in either case the
escape of venous blood not being interrupted for too long a
period. From some statements of Weissgerber and Perls
(60), in whose experiments the flow through the vein was
thus checked, but for too long an interval for our purpose, we
may gather that the excretion of albumen took place primarily
and in the most marked degree in the pyramidal portion and
medulla of the kidney. For they found the albuminous.
coagula, which they described as “ hyaline cylinders,” chiefly
and primarily in the pyramids and looped tubules, but more
rarely and only sparsely in the convoluted portions.

A second method of producing congestion consists in
cutting off, or reducing, the supply of arterial blood. After
a ligature has been applied to the artery for several hours,
the macroscopic and microscopic appearances presented by the
kidney are, as already mentioned, but little different from
those observed when the vein has been similarly treated for:
an equal period; the kidney, however, is less swollen, and
the engorgement of the medulla as contrasted with that of
the cortical portion is more conspicuous ; there is no appreci-
able difference with regard to the excretion of albumen. It
is no wonder that those who performed experiments of this.
kind, discovered no sort of difference between the processes
of congestion induced in either manner. But the state of
the case is different, if the interruption, this time of the:
arterial supply, is removed after a short interval, say eight
to ten or twelve minutes. Then we see a considerable
excretion of albumen, but in the capsules alone, and only
after a longer interval in the urinary tubules as well, and
then only in a very inferior degree, altogether different there-
fore from what takes place when a ligature is kept on the
vein for a short time. A similar result will in all probability
be induced, if the artery is not quite closed, but its calibre:
very much narrowed for a somewhat longer period, as has been
done by M. Herrmann and von Overbeck, (61) and resulting
in the production, according to their observations, of albu-
minous urine, while the afflux of blood continued, though in
a reduced quantity, the urine itself undergoing a very
considerable diminution before the albumen appeared. I
62 ALBUMINURIA DEPENDENT UPON

have not made any experiments with regard to the first
appearance of albumen and its distribution under these
circumstances.

With regard to the condition of the urine, the fact is not
without significance that, contrary to what happens after the
vein is completely occluded, viz., the almost invariable ap-
pearance of blood in the secretion, this, in the case before
us, is only an exceptional phenomenon. Stokvis discovered
albumen, but no trace of blood, in the first specimens of
urine passed after the circulation in the renal artery had been
completely interrupted for a prolonged period. The albumen
under these circumstances cannot have been yielded by the
remaining healthy kidney, for, as Frerichs, Rosenstein and
others have shewn (62) the complete removal of one kidney
is not followed by albuminuria. We must, in preference,
assume that, when the. principal artery of the kidney is tied,
the circulation is partially maintained by means of certain
small arteries, and that a secretion of urine, certainly abnormal
in its characters, goes on. To this category must be referred
those instances in which, in consequence of a morbid con-
striction of the small arteries, the supply of blood is checked
and albuminuria results—conditions which have been observed
in the experiments previously alluded to (see p. 42) in
which the irritation of the spinal cord, the poisonous effects
of strychnia, dyspneea, &c., were produced—and likewise the
albuminuria observed by Cl. Bernard (63), when he irritated
the peripheral portions of the divided renal nerves. We may
fairly assume that, in all these instances, there was an abnormal
escape of albumen into the capsule while the spasm of the
vessels continued, and that it was washed onwards by the
subsequently restored current of blood. Blood may appear
in the urine passed under these latter circumstances, just as
it may in that which is secreted when the circulation is
restored in the artery after complete interruption, for at this
period the blood passes under’ abnormally high pressure
through vessels more or less damaged as regards their
nutrition, in consequence of the previously defective supply
of blood,—conditions under which hemorrhages are prone
to occur.

In connection with the above details we must, in conclu-
ALTERATIONS IN THE BLOOD-PRESSURE. 63

sion, allude to those experiments of tying the ureter, which
have likewise been adduced in order to explain the alterations
of pressure in the kidney. They may be legitimately used
for this purpose, provided that the ligature be not retained
for too long a period, for in that case the results will tend
to produce further obscurity instead of contributing towards
an explanation. If the ligature be retained for a very long
period, several hours or more, Posner states that the same
changes will be produced as are observed after a prolonged
occlusion of the vein or artery, viz., marked accumulation of
blood, with rupture of vessels here and there, and later on
(according to Posner, after the ligature has been retained
for three days) albumen in the capsules and tubuli. There is
therefore either no difference at all, or only a very slight one,
between this form of albuminuria and others produced in
other ways, so that Posner in the case before us can discover
nothing more than the consequences of acute congestion.
The circumstances however, are not exactly similar. In the
first place after ligature of the ureter, the blood continues to
circulate for at least a considerable time, perhaps not in an
altogether normal manner, but without indications of much
disturbance, a fact which can be demonstrated by opening
the vein. It has been supposed that the retention of the
secretion in the urinary tubules would check the flow through
the vein, just as obstruction of the latter checks the flow of
urine, but this, as Runeberg justly remarks, is a purely
arbitrary assumption (64). Certainly no comparison can be
drawn between the enormous increase of pressure, the result
of occlusion of the vein, and the pressure caused by the con-
fined urine, and the uriniferous tubules are very much less
distensible than the veins. Granted therefore that the con-
fined urine may possibly directly obstruct the escape of blood,
the obstacle is certainly not a considerable one and its action
is very far indeed behind that of the congestion due to occlu-
sion of the vein.

If the ureter be kept closed only for a shorter period, ten
to fifteen minutes, the principal change, and, indeed, the only
one when the period is very brief, is marked distension of
the uriniferous tubules, to such an extent that even the con-
voluted portions present a wide clear lumen, filled with fluid,
64 ALBUMINURIA DEPENDENT UPON

and secondly, an enormous dilatation of the lymph-spaces
(edema) especially in the medullary portion. The intervals,
generally hardly recognisable, between the urinary tubules
and in the neighbourhood of the vessels, appear as wide clefts ;
the adventitia of the small arteries is enlarged to thrice or
more times its normal breadth, and its nuclei in consequence
are separated from each other by considerable intervals. On
sections, prepared as already described, the appearances are
very remarkable indeed, and we also noticed that the interior
of these lymph-spaces is often filled up with a very finely-
granular mass (coagulated albumen). Besides this there is
congestion, though not of a very marked character, of the
medullary veins. When the ligature is retained for a some-
what longer period, we find a decided excretion of albumen
in the capsules as in the uriniferous tubules. Whether this
occurs first in the former or in the latter structures I have
not been able to decide, but on the whole the albuminous
excretion appears to me to preponderate in the capsules, even
when the flow of urine is obstructed for the briefest intervals,
so that its appearance is probably earlier and its quantity
greater in these portions of the kidney than in the uriniferous
tubules.?

The urine secreted after removal of the ligature contains
more or less albumen, according to the length of the interval
during which the flow of urine has been obstructed. It
also contains blood, but always in very small quantity, even
when the congestion has been maintained for several days
(65). In my experiments, when the ligature had been
retained for brief intervals, there was scarcely any trace of
blood-corpuscles visible under the microscope.

These results of all these experiments may therefore be
summed up by saying that the various forms of congestion
correspond with each other in so far that they all produce

1 See fig. 2.

2 Posner states that only after three days was he able to discover marked
albuminous engorgement of the capsules and tubules. Perhaps the cause of
this later appearance, as compared with my experiments, is to be found in
the fact that he tied the ureter close to the bladder, whereas I tied it near
the kidney. The ureter is very distensible, and, therefore, more time will

he required for it to become distended throughout to such a degree as to
cause the obstruction to be felt in the kidney,
ALTERATIONS IN THE BLOOD-PRESSURE. 65

albuminuria, but that differences exist not only as regards
the degree, but also as regards the place in which the
excretion of albumen occurs. Only after a distinct interval,
varying according to the method of experimenting, do these
differences become effaced, especially so far as the deposition
of albumen is concerned, uniform or nearly uniform condi-
tions are then developed in the kidney, all the tissues
becoming gradually involved. The albumen escapes most
rapidly and abundantly when the vein is occluded, and the
escape of blood in considerable quantity is also a regular
phenomenon ; cutting off the arterial supply would seem to
come next as regards these effects, while confining the urine
by tying the ureter occupies the last place.

What are the causes of the differences in the development
of the albuminuria and other changes in the kidney, in these
various forms of congestion? In estimating the processes,
we may be guided by the changes of pressure in the blood-
vessels and lymphatics, and the disturbances of nutrition
which are invariably associated with certain degrees of these
changes, since in all cases of congestion, however produced,
there is a retardation of the current of blood, with disturb-
ance of nutrition as a constant accompaniment as time goes
on. These two factors, the retardation of the current and
the disturbance of nutrition, must therefore not be separated
from each other. It must also be remembered that in the
production of urine two factors co-operate, viz. the glome-
rular vessels which are governed by the laws of filtration,
so long as their nutrition is unaffected, and the glandular
epithelium proper, which is subject to influences of a different
character, and only partially understood.

The process takes the simplest form when the arterial
supply is interrupted, that is, when the congestion is the
result of ischemia. The natural consequence of this inter-
ruption is that the blood-pressure in both capillary systems
of the kidney falls below the normal. How the filtration in
the capsules will be thereby affected can be stated with
certainty ; there will be a diminution in the quantity of the
filtrate, but an increase relatively in the amount of albumen
it contains (compare p. 28) ; and this will be decidedly the
first direct effect of the diminution of the pressure, and one

5
66 ALBUMINURIA DEPENDENT UPON

which must occur immediately, before any possible distur.
bance of nutrition can take place, provided that any pressure
exists and any filtration goes on. The consequences as
affecting the glandular epithelium of the kidney can be esti-
mated only according to the analogy of other glands in
which secretion and not merely filtration takes place. Ibis,
however, certain that every secretion becomes more scanty
as the blood-pressure diminishes. Whether, in cases of
simple diminution of blood-pressure, albumen, previously
absent, passes into the secretion, has, so far as I know, not as
yet been experimentally determined with regard to the liver,
the only gland with a non-albuminous secretion suitable for
an experiment of this kind. I should, however, think it not
improbable, considering the results obtained by occluding an
artery for brief intervals and which have been described in
a previous page (see p. 59). The result would be different
if the congestion were of long duration. Examination of
the kidney in this case furnishes no positive explanation, for
deposits of albumen are found both in the capsules and in
the uriniferous tubules, but this appearance is no irrefragable
proof that the albumen is derived from the interstitial capil-
laries, for it may have escaped from the capsules into the
tubules. On the other hand, from the condition of the biliary
secretion in the human subject, after prolonged congestion,
it may be allowable to draw conclusions as to the secretion
of the renal epithelium in similar circumstances. In connec-
tion with this, much importance is attached to Frerich’s
statement (66) that albumen has been found in the bile in
several cases of passive hyperemia of the liver. It proves
that even in this form of congestion, besides the glomerular
system of vessels, the secretory apparatus of the kidney may
also yield albumen.

But however this may be, the combined results at any rate
of the diminution of pressure upon the two sources which
participate in the production of urine, must be a considerable
diminution in the quantity of that fluid and an increase in the
percentage of the albumen it contains. The percentage of albu-
men in the fluid yielded by the capsule will now therefore be
a+ instead of a; the quantity of the epithelial secretion will
be represented by n»—y and therefore the percentage in the
ALTERATIONS IN THE BLOOD-PRESSURE. 67

a+ %
urine when the arterial supply is diminished will be pe ery A
100

comparison with the formule previously given (see pp. 33
and 42), for the normal and for the increase of arterial pres-
sure, makes the difference sufficiently obvious. Ifin this case
albumen really appears in the true glandular secretion, we
might naturally expect an increased quantity in the urine.

When the ureter is closed, the action which the confined
contents of the uriniferous tubules exercise upon the glome-
rular vessels and the secreting epithelium is the factor which
determines the result. Runeberg has set forth in a proper
light the consequences as they affect the former portions; he
states that the stagnation of the urine causes an increase of
the pressure upon the external wall of the glomerular vessels,
that the filtration-pressure—that is, the difference between the
external and internal pressure—is decreased, always supposing
that the current of blood remains unchanged, or at least that
there is no increase within the glomerular vessels. That this
supposition is perfectly right may be positively assumed only
with reference to the first beginnings of the process. As we
have already explained (see p. 63), when the ligature is
retained on the ureter for a short time only, the circulation
is certainly not completely interrupted, and the obstruction
which the distended uriniferous tubules cause to the blood-
vessels can at first be only very slight, so long as there is no
great accumulation of fluid confined within the excretory tubes
of the renal medulla.’ A diminution of the filtration-pressure
may therefore be admitted to exist in the earliest stage, and
the evident deposition of albumen in the Bowman-Miiller’s
capsules is capable of explanation in accordance with the
descriptions already given. It is difficult, however, to make
any further statement with regard to the conditions and cir-
cumstances of the pressure as the process goes on. It is
possible that the blood-pressure within the glomerular vessels
may be increased to an extent exceeding that of the external

1 Hyven when there. is prolonged and complete occlusion of the ureter,
circulation of blood to a sufficient extent may continue, as clinical observa-
tion shows. A case of this kind, interesting also in other respects, has been
recently reported by Schwengers and Leichtenstern (67).
68 ALBUMIN URIA DEPENDENT UPON

pressure to which they are subjected ; in that case the filtra-
tion would become almost normal; or if the preponderance of
pressure within the vessels increased, the resulting filtrate
would contain more water and would be poorer in albumen.
There is also the possibility that, the secretion by the gland-
ular epithelium being continuous and actively carried on, the
predominance of pressure might become so decided in the
uriniferous tubules that the fluid of the capsules might take
a backward course, and that absorption might go on until the
internal and external pressures became equalised.

There is no doubt that the secretory epithelium of the
uriniferous tubules continues to possess and exhibit its secre-
tory activity after the ureter is occluded. That this is so is
positively shown by the increasing fullness of the uriniferous
tubules, the great dilatation of the lymphatic channels
depending upon the pouring into them of secretion not
removed in the ordinary way, and by the behaviour of other
glands under similar circumstances. It is, however, another
question whether the secretion is altogether normal in char-
acter, and in particular whether it is free from albumen as is
normally the case. The liver is the only organ which could
be used to assist in deciding this question, but, so far as I
know, no investigations have been made upon its secretion
after tying its excretory ducts. But the albuminous deposit
which I found in the uriniferous tubules after a ligature had
been kept on the ureter for a brief interval (see p. 63), it
being impossible that the albumen can have got there by
escaping from the capsules, is evidence in favour of the
supposition that the real secretion of the epithelium contains
albumen, as might be expected with regard to every cedema-
tous gland. It is, therefore, highly probable that both the
glomerular vessels and the interstitial vascular and lymphatic
systems participate in the production of the albuminuria that
ensues after the impediment is removed.

When the escape. of venous blood is prevented without
interfering with the arterial supply, the circumstances, first
and foremost, with regard to the blood-pressure, are ve
different from those which obtain in the oth eg

: er two kinds of
congestior, and especially in that caused by tying the artery.
When the supply is cut off, the pressure in the capillaries
ALTERATIONS IN THE BLOOD-PRESSURE. 69

falls, as we have said, below the normal ; if, when the occlu-
sion is complete, compensation takes place by a retrograde
movement of the blood from the spot where the renal
vein opens into the inferior vena cava, the pressure in the
radicles of the renal vein will become equal to that in
the vena cava, and therefore as a matter of course always
lower than the normal degree. The case is, of course,
different when the vein is occluded, for then the pressure
must reach an abnormal height, the degree varying with the
degree of completeness of the closure. In consequence,
however, of the peculiarity involved in the fact that the
majority of the branches of the renal artery break up into
the glomerular capillaries before passing into the interstitial
capillary system, the increase of pressure in the various por-
tions of the vascular system must differ in amount (68). It
will be most marked and its occurrence earliest in the inter-
stitial capillary system; it will appear later and in a less
degree in the glomerular vessels. The production of cedema,
here as everywhere else, necessarily follows as the second
direct effect of occlusion of the vein with unimpeded arterial
supply. And thus it is that this form differs from the
ischemic congestion, which per se does not immediately pro-
duce cedema, but which, only after a much longer period, and
when in consequence of the deficient supply of blood the
nutrition of the tissues has become affected, may be the
indirect cause of a dropsical swelling. Thirdly, and lastly,
as I have already more than once mentioned, the excretory
portions of the uriniferous tubules, especially in the medullary
substance, are compressed by the congested veins and stag-
nation of urine is the result.

These three sets of consequences blend with each other
and their mutual influence is to some extent contrary, so
that it is difficult to separate their effects, and to determine
separately the share which each has in the disturbances they
jointly produce. The stagnation of urine in particular
counteracts to a certain extent the increase of pressure, as
already explained. If we therefore leave this complication
out of the question, we shall have less difficulty in estimating
the effects of tying the vein upon the two factors concerned
in the production of urine, always of course supposing that
70 ALBUMINURIA DEPENDENT UPON

the discharge through the vein is not entirely checked, for
if it be, the function of the kidney is rapidly extinguished
(see p. 60). Cohnheim’s researches upon venous congestion
(under conditions, as in the case before us, of unimpeded
arterial supply), justifythe conclusion that in the parts in which
transudation occurs, the. glomerular vascular system, there
will be an escape of fluid, in quantity exceeding the normal
and containing blood. Both of these, the quantity of fluid
and the blood, are in direct proportion to the degree in
which the pressure of congestion exceeds the normal amount ;
and the blood especially is the characteristic which distin-
guishes the transudation of congestion from that which is
normal,and likewise from that yielded by the kidney when only
the arterial pressure is increased ; and whether the blood-cor-
puscles escape by diapedesis, or in consequence of rupture
of vessels, is for our present purpose a question of no import-
ance.

The condition of the secretory apparatus may also be
determined with some degree of certainty, although in this
cage a comparison with the liver is again wanting. For, so
far as I am aware, no observations have been made with
regard to any changes which may occur in the bile after
ligature of the hepatic vem. But we may regard it as certain
that an cedematous gland—and with such we are certainly
dealing at present—not only secretes more copiously, but also
allows albumen (and probably also blood) to pass abnormally
into its secretion, as a matter of course from the interstitial
vessels. This is also proved by the discovery of albumen
between the epithelium and the membrana propria, an
appearance which, in this form of congestion, is speedily
produced at a much earlier period than in the other forms in
which it may occur after a longer interval. If, however, this
hypothesis be rejected, and the albumen in congestion be
supposed to escape from a source other than the glomerular
vessels, it would then be necessary to interpret these appear-
ances by supposing that the epithelium first became detached;
and then that albumen drained from the capsules between the
epithelium and the membrana propria. It is, however, easy
to foresee the relation that would then exist between the
basement membrane which had lost its epithelium and the
ALTERATIONS IN THE BLOOD-PRESSURE. 71

lymph-current in which itis bathed. This thoroughly forced
explanation is therefore discarded.

An abnormally copious secretion yielded by the interstitial
vascular apparatus, containing albumen, and possibly blood
as well, will therefore be added to the already abnormally
copious and blood-containing transudation of the glomerular
vessels, and the collective results of the venous occlusion will
consequently be the production of urine abnormally copious
in quantity and containing albumen and blood. This effect
will, however, in part, be weakened by the confinement of
the urine within the tubules, which is associated with the
occlusion of the vein, and which counteracts the pressure in
the glomerular vessels. We have already seen that in these
vessels the increase of pressure per se is less than in the
interstitial capillaries, and is also later in appearing, and it
follows that. the effect of occlusion of the vein upon the
glomerular vascular system will be much less and occur later
than the same effect upon the interstitial vascular system and
the uriniferous tubules.

So far as any knowledge can be obtained from experiment
and clinical observation, they confirm in the most striking
manner the correctness of these explanations. It is certainly
true that experiments in which the occlusion of the vein is
complete and continued for several hoursfurnish no explanation
at all, or none of any use for our purpose. Under such
circumstances the function of the kidney scarcely exists,
and extravasations of blood and albumen are the general
‘appearances on anatomical investigation. On the other
hand, our experiments, in which the vein has been tied only
for brief intervals, have really shown that the first effect is
produced in the sphere of the interstitial capillaries and the
uriniferous tubules (see p. 60).

As regards the condition of the urine, it is not easy to
come to any decision in experiments of such brief duration,
for the secretion soon becomes abolished when the closure is
complete. In the experiments already referred to of Weiss-
gerber and Perls, in which the vein was completely occluded;.
but for a longer interval, the special feature was the appear-
ance of albumen in the collecting tubes and loops, and only
in a portion of the cases in the convoluted tubes as well:
72 ALBUMINURIA DEPENDENT UPON

In five cases it is twice mentioned that the urine contained
blood, so that these may be regarded as confirmatory of our
explanations. These latter are also supported in a very
marked manner by Bartels’ case, already referred to (see
p- 26), and in many respects so very interesting, of throm-
bosis of the inferior vena cava occurring in a robust man,
a case presenting precisely the same conditions with those in
Weissgerber’s and Perls’ experiments, viz. obstructed venous
outflow with unimpeded arterial supply, and this, moreover,
is the only known case of the kind in which any reference is
made to the quantity of the urinary secretion. “In this
case the result has been,” to quote Bartels’ own words, “‘not
only a profuse secretion of urine, but also the escape of
albumen, and even of considerable quantities of blood into
the urine, probably in consequence of rupture of several
vascular tufts of the glomeruli.’ If an obstacle to the venous
outflow, limited to one renal vein or to the inferior vena cava,
is formed in the human subject, the conditions under which
this generally occurs do not permit of any comparison with
venous occlusion produced by experiment, since the arterial
pressure is simultaneously diminished. This is what occurs,
for example, in the most common clinical thrombosis of the
‘renal vein of new-born children, for this is always of marantic
origin. But even in the very rare cases as well, in which
the vein is occluded by tumours, generally of a malignant
character, other complications being likewise present, the
arterial pressure is usually in a similar condition. Corre-
sponding with this, there is in these cases a difference as,
regards the quantity of the renal secretion. According to
the rapidity of the development and growth of the obstacle
the urine invariably becomes more or less scanty, and at the
same time contains much albumen and blood.

The admixture of. blood distinguishes this urine from
that which usually and frequently occurs in congestion
in the human subject, this condition of the kidney being
the result of diminished cardiac activity. The conditions
are different from those of artificial venous occlusion,
and so likewise are the consequences as regards the renal
secretion. The statement so frequently made to the effect
that the ordinary urine of congestion in the human subject
ALTERATIONS IN THE BLOOD+PRESSURE. 73

contains blood and abundance of albumen, is not at all in
accordance with facts, and there is, by no means, the most
perfect harmony between clinical observations and the
experimental venous occlusion, as is generally pretended.
For these reasons it will not be superfluous to describe
somewhat minutely the urine of congestion, as it daily
comes before us in disease of the circulatory or respi-
ratory organs, and such a description will be useful for
another reason, viz. because certain changes in the urine,
especially with reference to the proportionate amount of its
several constituents, and which may be of importance in the
explanation of the processes going on in the kidney, can be
determined in a satisfactory manner only in the human
subject. The first and most constant phenomenon is the
diminution of the water, and therefore of the quantity of
urine, this being determined by the amount of water present.
There is little known with regard to the proportionate amounts
of the solid constituents, but the total quantity of these is
not diminished in the same proportion as the water. On this
account the specific gravity of the urine is increased, its colour
becomes deeper, and there is a tendency to the formation of
sediments, these being due to the fact that the urates, which
are not very soluble in cold water, and uric acid itself, are
readily precipitated during cooling from urine which contains
less than the normal amount of water. It is, however, more
than probable that the solid constituents, or at all events
a portion of them, are excreted in diminished quantities,
although their diminution does not proceed pari passw with
that of the water, and they may therefore be relatively in-
creased with reference to that fluid. The urea at least,
according to my observations, is always absolutely diminished
in quantity, notwithstanding the relative increase, which may
amount to three or more per cent.’ The condition of the
uric acid is more difficult to estimate, inasmuch as the respi-
ratory troubles almost always present in this form of renal
congestion, give rise to complications which apparently exert

1 The absolute diminution of the urea can partly be explained by the fact
that less nourishment is taken and absorbed, and partly also by the
consideration that the urea finds its way into any dropsical effusions that
may be present, and into the discharges from the bowels.
74 ALBUMINURIA DEPENDENT UPON

some influence on the formation of uric acid in the system (69).
At the same time that the water becomes diminished, or
shortly afterwards, albumen is often’ to be found in the urine,
but always in small quantity, provided that the condition is
that of congestion and nothing more. It would seem that
this statement cannot be too often repeated. It is true that
when the congestion is of long duration and of great intensity,
the quantity of. albumen is much increased at a later period,
but the consecutive phenomena of the stagnation of blood and
lymph (inflammatory processes and conditions of induration,
nephritis from passive congestion), have by that time invariably
made their appearance. Blood is—and this is a fact which
must be repeatedly insisted upon—scarcely ever present in
macroscopic quantities, and even with the microscope it is only
in a minority of cases that we are able to detect isolated red
blood-corpuscles, and generally a few colourless cells. It
appears to be doubtful whether, in such cases, this slight
admixture of blood has its origin always in the renal paren-
chyma, rather than from the mucous membrane of the bladder,
ureter, or pelvis of the kidney; for, as a general rule, the
mucous membrane of these parts is the seat of more or less
marked hyperemia which, as in other mucous membranes,
may give rise to more or less considerable hemorrhage. Pale
(hyaline) casts are often found associated with the albumen.

We have thus given the details of the ordinary kind of
renal congestion with which every physician is familiar.
Another circumstance, equally well known, may be added,
viz. that so soon as the heart recovers its power, the urine
very rapidly returns to its normal condition. I need only
refer to the action of digitalis in cases of mitral deficiency.
In its origin and the way in which it becomes developed,
this form of renal congestion obviously most resembles that
which is induced when the arterial supply is cut off for a
brief interval or in an incomplete manner, for in both: cases
diminution of the arterial pressure within the kidney is the
first thing that happens. In the experiment. certainly,
in order to produce the most striking phenomenon in the
brief period of observation, the arterial pressure is very
considerably reduced, or perhaps altogether abolished, a
condition not belonging to the pathological examples, The
ALTERATIONS IN THE BLOOD-PRESSURE. 75

case before us, however, differs from the experiment in
which the artery is tied, in the fact that an obstacle is
introduced in the direction of the current of venous blood,
the pulmonary vessels and the right side of the heart being
engorged with blood. The effect, therefore, with regard to
the difference of tension between arteries and veins, which
is the main point in the question, may be exactly similar: in
the experiment, in consequence of the marked diminution of
the arterial pressure, the flow through the vein being unim-
peded: in the pathological conditions, in consequence of a
smaller diminution of the arterial pressure, but with a co-
existing impediment to the escape of blood through the vein.
It comes to pass, therefore, that there is an anatomical
resemblance in the main feature between the kidney in the
ordinary state of congestion and in that due to cutting off
the arterial supply, any difference being due only to the fact
that in the human subject death does not result as soon as the
congestion begins, and that this latter condition is of longer
duration, time being thus afforded for the development of
those consequences of stagnation which have been already
mentioned. There is seldom an opportunity, except in cases
of sudden suffocation, to examine kidneys in a marked state of
venous congestion of recent origin, and in which, when death
took place, the congestion had rapidly advanced so far as to
produce albuminuria. In the few cases which have come
under my notice, and which to some extent coincided with the
requirements, a very moderate increase in the size of the
kidney was the only thing to be observed; but this did not
even approximately resemble that enormous increase which
took place in a rabbit’s kidney after tying the vein, and
never even once reached the degree attained in cases of
recent inflammatory swelling of the kidney. The congestion
presented the usual appearances, being most marked in the
pyramidal portion in which veins are numerous, but less
prominent in the’ Bowman-Miiller’s capsules. Under the
microscope a deposit of albumen was not always to be found,
at least not in every section ; where, however, it was present,
it was contained almost invariably in the capsules alone.

The results, therefore,’ of clinical observation coincide, in
a manner practically complete, with what follows when the
76 ALBUMINURIA DEPENDENT UPON

arterial supply is artificially cut off, and are most satisfac-
torily explained by those processes which are induced by this
experiment, as above described (see p. 63). These are, the
great diminution of the water as the aggregate result of de-
crease in pressure upon the filtering and secreting apparatus,
the diminution of the specific constituents of urine as repre-
sented by urea, the small proportion of albumen present, the
total absence of blood, or its presence in very minute quan-
tities. Considering the experimental and clinical facts, it is
not necessary to discuss the influence of an alteration in the
nutrition of the epithelium and vascular walls upon the com-
mencement of the process, even when the arterial supply is
completely cut off, and it is still less necessary to do so
when the supply is reduced but not entirely abolished. M. ~
Herrmann as well as v. Overbeck noticed the appearance of
albumen in the urine a few seconds after they had tied the
renal artery, and they also observed that it disappeared after
a very short interval, even within half-an-hour. It has been
already mentioned that the circumstances are often very
similar in the human subject, and that the urine changes,
so to speak, at once when the circulation becomes regu-
lated, being more abundant in quantity, and exhibiting no
trace of albumen. It would be necessary to magnify con-
siderably our notion of disturbed nutrition and to regard
every disorder of the circulation as coming within this cate-
gory, if in cases like these we attempted to attribute the
rapidly appearing and transient albuminuria to deranged
nutrition of the elements of the tissues. It is, moreover,
difficult to reconcile the scanty excretion of albumen and
the very slight admixture, if any, of blood in the urine, with
the assumption that there is any disorder of nutrition in the
glomerular vessels or their epithelial investment.

It would, however, be improper to deny that, as time goes
on, disturbances of nutrition become a prominent feature in
the congestion we are now discussing. It is certainly
difficult or even impossible to specify the degree to which
the arterial supply must be reduced in order to cause
nutritional disturbances, and therefore in forming an estimate
of this influence considerable latitude must be allowed to
individual discretion. According to the stand-point which an
ALTERATIONS IN THE BLOOD-PRESSURE. 77

observer takes up with regard to the effect of mere changes
of pressure, will he be inclined to claim the right of laying
stress upon the influence of derangement of nutrition, at an
early or late period, for the purpose of explaining the disturb-
ance of function. It is only in estimates of extreme con-
ditions that certainty can be attained, and we shall not go
wrong in laying down the two following propositions :
First, that no considerable disturbance of the nutrition of
the tissues can take place if the supply of blood be inter-
rupted for a very brief period only, say for a few seconds,
and during no portion whatever of the time in a complete
manner; or if a retardation of the circulation be moderate in
extent and slow and gradual in its development, so that, as
already mentioned (page 58), the tissues accommodate them-
selves to the diminished blood-supply. Secondly, that if the
circulation be completely interrupted for several hours or
days, severe disturbance of the nutrition of the tissue must
necessarily ensue.

The third form of renal congestion, viz. that which is due
to impeded escape of urine, occurs in the human subject,
though less frequently than the’ other forms. A comparison,
however, cannot be so freely instituted between the sym-
ptoms at the bedside in these cases and those produced by
experiment, because for the most part only one kidney is
affected, so that the urine, secreted by the healthy kidney
alone, either presents nothing abnormal, or, if, the discharge
from the affected kidney be not completely suspended, the
result is a mixture of normal with abnormal urine. Another
fact which affects the comparison is that the obstacles to
escape of urine are usually of such a character that abnor-
mal admixtures, e.g. albumen or blood, become superadded
to the fluid after it has left the kidney. Instances of this
kind are, among others, the obstacles due to concretions
which irritate the mucous membrane, tumours in the urinary
passages, &c. We have also no knowledge of the anatom-
ical appearances of the human kidney from the very first
stages of the process involving complete stagnation of urine,
which can be compared with the result of tying the ureter ;
we likewise know nothing as to the part in which albumen
is deposited in these kidneys.
78 ALBUMINURIA DEPENDENT UPON

TV.—ALBumiInvria AS DepenDENT Upon DEGENERATION OF THE
Renat ErrrHepivm.

Of the tissue-elements, other than those of the vascular
system, which compose the renal parenchyma, the epithelium
alone remains for consideration in our study of albuminuria.
The most important are the epithelial cells of the uriniferous
tubules, next come those of vascular tufts, and in the third
place, though these are not so directly concerned, the epi-
thelial cells which line the internal surface of the Bowman.
‘Miiller’s capsules. In former times the epithelial cells were
credited with the possession of a considerable amount of
influence in the causation of albuminuria, but this was
attributed only to those of the first class, the existence of the
others not being recognised. Two principal ideas prevailed
on this subject. It was supposed that in morbid states of
the epithelium, the albumen which normally transuded
through the glomerular vessels, to be taken up and assimi-
lated by the epithelium, no longer underwent this process,
but escaped by the urinary tubules ; or, secondly, that the
albumen passed into these channels from the blood-vessels
by which they are surrounded, because the epithelial cells
having undergone nutritive derangement, were unable to
discharge their normal function of preventing such escape
from taking place. Modern theories pay little attention to
this question, but they usually cut the matter short by
asserting that in fatty or other degeneration of the epithe-
lium, as in phosphorus-poisoning, in severe anemia, and
severe febrile infectious diseases, no albumen is found in the
urine, and therefore the epithelium can have no share in the
production of albuminuria. And yet these very theories are
based upon the doctrine that the epithelium prevents the
escape of albumen from the blood, and that normal urine is
therefore free from this constituent. The contradiction
stares us in the face! At all events those who assume that
the albumen is retained in the blood. by the agency of the
epithelial investment of the glomerular vessels, must allow
the possibility of albuminuria being caused by derangement of
DEGENERATION OF THE RENAL EPITHELIUM. 79

the nutrition or destruction of this epithelium in particular.
The other epithelial cells, especially those of the uriniferous
tubules, of the proper glandular elements, are either not
mentioned at all, or else they are expressly alluded to as
altogether unconcerned in the production of albuminuria. .

It is well known that some of the secretions proper, that
is, the sole products of really secreting glandular epithe-
lium, are albuminous, while others are free from that con-
stituent. The products of the former, which are the more
namerous class, owe their albumen to the constant metamor-
phosis and separation of the cells which mix with the secre-
tion; the other glands yield a product which is non-albumi-
nous, because according to the general and almost sacred
theory, their epithelium does not decay under normal con-
ditions, and their products consist only of definite matters
which they take up from the vessels or prepare within them-
selves, but not of albumen. Whether these epithelial cells
really continue without any change during the whole period
of life, or whether they undergo an imperceptible metamor-
phosis, similar to that which is constantly taking place in
the organism as a whole, are questions with which we are not
concerned at present. It is enough for our purpose that the
normal function of its epithelial cells is assigned as the
reason for the absence of albumen in the secretion of the
liver, the most prominent of the second class of glands, and
likewise in the secretions of the perspiratory and lachrymal
glands, supposing it to be the case that these latter secre-
tions in their pure state are really non-albuminous. If the
urine be regarded simply as a true non-albuminous glandular
secretion, the epithelium must be credited with the function
of preventing the escape of albumen from the blood ; but if
my view be adopted, and the urine be regarded as a mixture
of a transudation with a glandular secretion (see p. 33), the
latter at least being the produce of the epithelium of the
uriniferous tubules must for the samé reason be considered
to be non-albuminous, whatever view may be entertained as
to the presence or absence of albumen in the transudation
from the glomerular vessels. The conclusion is forced upon
us that, when their nutrition and functions are disturbed, or
when the epithelial cells of the uriniferous tubules are in a
80 ALBUMINURIA DEPENDENT UPON

state of complete decay, albumen will escape from the blood
and lymph and show itself in the urine hitherto apparently
non-albuminous, that is, that albuminuria will become deve-
loped. Observations which are alleged to prove the contrary
must be based upon error or defective investigation, for if
not, all our doctrines with regard to specific glandular secre-
tion must be thrown to the winds.

Fortunately, there is no such discord between observation
and theory in the case before us. It is well known that
fatty degeneration of the epithelium, of the most intense
character, is induced in acute poisoning by phosphorus and
with arsenic acid, and a few other toxic agents, and phos-
phorus-poisoning, the type of this class, is adduced as
evidence against the theory of the participation of the
epithelium in albuminuria, because little or no albumen
appeared in the urine in cases of this kind. So far as I
see, this entirely erroneous view owes its existence to the
statements of Stokvis and Kohts (70), who, as a result of
their experiments with this poison, felt bound to adopt the
conclusion that no connection existed between albuminuria
and fatty degeneration, whereas up to that time the observa-
tions of Ph. Munk and Leyden (71) had been taken as
evidence that albuminuria is an almost constant symptom of
poisoning by phosphorus. But in reality the experiments
of Stokvis and Kohts do not contradict the hypothesis of a
connection between albuminuria and phosphorus-poisoning.
As far as Stokvis’s experiments are concerned, in the first
place he employed as tests nitric acid or acetic acid and
boiling, all of which were at that time considered to be
sufficient for demonstrating the presence of albumen, though
now we know that such is by no means the case (see p- 13
and 14). Inthe second place, even with these not very
delicate tests, he discovered the presence of albuminous
substances, viz. serum-albumen and hemi-albumose (propep-
tone), in three out of his four experiments, and in the fourth
experiment the attempt at poisoning appears to have been
altogether unsuccessful.’ With regard to the hemi-atbumose,

1 In the notes of his experiments, published by Stokvis, we find as follows:

—Exp. 1, A rabbit poisoned by phosphorus. Death on the second day.
The urine during this time without any trace of albumen, The bladder
DEGENERATION OF THE RENAL EPITHELIUM. 81

these experiments permit us to infer its presence, or at least
they do not prove that it was absent, inasmuch as the addi-
tion of acids caused a precipitate or cloudiness which disap-
peared on heating, and which Stokvis, without further
testing, referred to the presence of fat or of fatty acids.
But since we now know that peptone-like substances fre-
quently occur in the urine in cases of phosphorus-poisoning,
there is quite as much probability in the former assumption,
viz. that they were present in these experiments, as that the
reactions manifested were due to the presence of fat.

Kohts has performed eight experiments with poisonous
doses of phosphorus—six on dogs, two on rabbits. With
the exception of the case of one dog, which died suddenly on
the second day, and one rabbit, the reports of all the other
experiments state that, after the poisoning took place, albu-
men invariably appeared once or several times in small
quantity, and that in one rabbit the quantity was consider-
able. No mention is made of the methods used for its
detection, but we may suppose that the ordinary means were
employed, viz. boiling and nitric acid. It follows that the
sentence with which Kohts concludes his report, that “no
albuminuria appeared in any of the animals experimented
on, with the exception of one rabbit,’’ directly contradicts his
own observations.

Investigations on this subject have been very carefully

contains clear, acid urine, which is rendered slightly turbid on the addition of
nitric acid, excess of which causes the turbidity to disappear. The same degree
of cloudiness is obtained when the urine is heated with a little acetic acid.
This can be only serum-albumen, which Stokvis’s own experiments show
to be soluble in excess of nitric acid, in cold urine. Exp. 2. A dog poisoned
with phosphorus. Death on the fifth day. The urine on the last day con-
taining biliary colouring matter, and rendered turbid by nitric and acetic
acids, but not by heating; urine found in the bladder exhibiting the same
reactions. Exp. 3. A dog poisoned with arsenious acid. Death on the
fourth day. Urine of the last two days turbid on addition of nitric and
acetic acids; the turbidity disappears on heating, and does not return on the
addition of sulphate of soda; urine in the bladder gives similar reactions.
Exp. 4. Dog poisoned with arsenious acid; killed on the eleventh day,
though then appearing pretty well (!) The report on the urine simply states
that there was no trace of albumen, but only a few epithelial cells in a state
of fatty degeneration. Nothing found post mortem, but very slight (!) fatty

degeneration of the organs.
6
82 ALBUMINURIA DEPENDENT UPON

made by Schultzen and Riess (72). In six dogs poisoned
with phosphorus, they found more or less albumen in the
urine in every case.

The statements, however, of Stokvis and Kohts, cast some
doubt upon the subject, especially with regard to the appear-
ance of albuminuria in rabbits, and I therefore performed four
experiments with phosphorus upon as many animals of this
kind, all previously healthy and vigorous. A solution of phos-
phorus in oil was injected under the skin. Albuminuria was
the result in all four cases, or where there were previous evi-
dences of albumen (see page 20, noée) its quantity was found to
be increased. I append brief details of these experiments.

I. March 20, 1880.—A large vigorous rabbit, fed on oats.
Urine passed on compressing the bladder, acid, clear on filtra-
tion. The addition of acetic acid and of ferrocyanide of
potassium causes a slight cloudiness ; the same appearance
results on adding acetic acid and concentrated solution of
sulphate of soda to the cold urine, the cloudiness remains on
boiling. Nitric acid produces a slight cloudiness. On subse-
quent boiling, the colour becomes so deep that it cannot be
ascertained whether the cloudiness has disappeared or not.
Three-quarters of a cubic centimeter of a solution of phos-
phorus in olive oil (1 to 80) are injected beneath the skin.

March 21.—The rabbit is pretty lively. Its urine is
acid, clear on filtration, and gives a decided precipitate with
acetic acid and ferrocyanide of potassium; with acetic acid
and sulphate of soda, marked cloudiness, increased by heat ;
‘with nitric acid; marked cloudiness, and on subsequent
' boiling the urine becomes very dark and a_ precipitate
gradually falls. Another injection as before.

March 23.—The rabbit died early this morning. The
urine previously voided gives same reactions as yesterday.
Under the microscope, sediment is found to contain very’
finely granular casts, and a few renal epithelial cells in a fair
state of preservation.

II. March 23, 1880.—A large rabbit, fed on oats.
Urine acid, clear on filtration; yields a doubtful trace of
albumen with the three tests above-mentioned. Injection of
half a cubic centimeter of the phosphorised oil.

March 24.—The rabbit’s bladder contains a large quantity
DEGENERATION OF THE RENAL EPITHELIUM. 83

of urine, when as recently passed has an acid reaction and is
found to be pretty strongly albuminous with all the three
tests. Only a few finely granular casts in the sediment. A
portion boiled with acetic acid and sulphate of soda, and a
precipitate formed. The filtrate gives no peptone- (or biuret-)
reaction. Rather more than half a cubic centimeter of the
phosphorised oil injected.

March 25.—Urine copious, paler than yesterday, acid,
‘contains more albumen than before as shown by the three
tests. No peptone-reaction in the precipitated urine. The
sediment contains a good many coarsely granular casts and
a few renal epithelial cells in a state of fatty degeneration.
No injection.

March 26.—Death early this morning. The urine pre-
viously voided is very pale, acid, and very highly albuminous,
as shown by all three tests. The sediment contains coarsely
granular short casts and isolated epithelial cells in a state of
disintegration.

III. March 28.—A very large rabbit, fed upon oats and
turnips. Urine abundant and acid, clear on filtration; no
cloudiness with all the three tests for albumen. Injection
of half a cubic centimeter of phosphorised oil.

March 29.—Urine acid. Acetic acid and ferro-cyanide of
potassium added to the clear filtrate produce slight cloudi-
ness; the same result on boiling with acetic acid and
sulphate of soda. Nitric acid alone causes no decided tur-
bidity ; boiling causes the urine to become so dark that
nothing can be recognised. Injection of half a cubic centi-
meter of phosphorised oil.

March 30.—Urine acid, yields a clear filtrate which is
shown to be decidedly albuminous by the two first-mentioned
tests; nitric acid causes slight cloudiness, which seems to
become more marked on boiling, so far as can be made out
in the dark discolouration which appears in the urine.

March 31.—Rabbit found dead. Urine by mistake not

) examined.

\ IV. April 2—A medium-sized rabbit, kept in a cage

i since the day before yesterday, and fed upon oats and
turnips. The urine obtained by compressing the bladder is

acid, somewhat gelatinous, semi-fluid, but yields a clear
84 ALBUMINURIA DEPENDENT UPON

filtrate in which a slight cloudiness after long standing is
produced by acetic acid and ferrocyanide of poles alone ;
the other two reagents cause no alteration.

April 3.—Urine clear, acid; the clear filtrate feo from
albumen with all three tests. Three or four drops of
phosphorised oil injected.

April 4.—Urine acid; acetic acid and ferrocyanide of
potassium added to the clear filtrate cause slight cloudiness ;
no effect with other two tests. Half a cubic centimeter of
phosphorised oil injected.

April 5.—Urine acid; the filtrate slightly albuminous
with all three tests. _

' April 6.—Urine acid ; the filtrate highly albuminous with
all three tests. The rabbit died this evening.

The condition of the kidneys, which in the first two cases
exhibited macroscopic fatty degeneration of their parenchyma
at various points, has been already briefly alluded to in the
discussion of the question as to how far albuminous excretions
in the kidneys can be detected under the microscope (see page
36). The kidneys were first examined just as taken from
the body, and subsequently one half was hardened by
boiling and the other in strong alcohol. In the two first
cases, in addition to hemorrhage in several capsules and
uriniferous tubules, we could distinguish deposits of coagu-
lated albumen, some finely granular, others rather hyaline,
in the tubules and capsules; in the third and fourth cases,
on the other hand, besides slight fatty degeneration of the
epithelium, there was only very moderate hyperamia of the.
cortical substance, but no sign of albuminous excretion in
the capsules or the uriniferous tubules could be recognised.” :

The perfectly harmonious results of these four experi-
ments rendered it unnecessary to pursue the subject any
further in this way, for I regard the conclusion to be
deduced as absolutely positive, viz. that albuminuria is
produced in rabbits as well as in dogs by very small doses
of phosphorus, which disturb the general health only to an
almost imperceptible degree, and, with the exception of fatty.
degeneration of the elements of the tissues, cause no remark-
able changes in the kidneys ; certainly no visible evidences
DEGENERATION OF THE RENAL EPITHELIUM, 85

of inflammation. That the albuminous excretion in the first
two cases was Visible in the capsules, and not merely in the
uriniferous tubules, is a proof that phosphorus, as we might
& priort expect, acts injuriously, not merely upon the epithe-
lium of the uriniferous tubules, but upon that of the glome-
rular tufts as well, and possibly upon these vessels them-
selves. The last supposition is borne out by the fact that
effusions of blood appeared in the capsules. No fatty
degeneration within these parts could be detected under the
microscope, because the poisonous doses of phosphorus were
very small, but in one case of poisoning by this agent in a
girl, I noticed that the glomerular vessels were in a state of
profound fatty degeneration.

The clinical observations of cases of phosphorus-poisoning
are in complete accordance with the experimental results,
and it therefore appears extraordinary that the absence of
albuminuria should be described as a normal occurrence in
poisoning of this kind. The truth is that albuminuria is
the rule, and its absence the exception in such cases. In
1864, at a time, therefore, when phosphorus-poisoning first
began to attract general attention, Meischner found albumi-
nuria seven times in a collection of ten cases, and in a
recent treatise Hessler tells us that he found this symptom
twelve times in fifteen cases (73). We are justified in sup-
posing that in the cases in which it was absent, its non-
detection was possibly due to the fact that only the usual test,
viz. boiling, was tried, and the more so, since in phosphorus-
poisoning, as I have already mentioned, peptone-like bodies
‘appear in the urine (see pp. 8 and 81). It almost appears as if
the albuminuria in these cases had been disregarded for the
sake of certain theories, or, possibly, the cause of the disre-
gard may be found in the fact that the quantity of albumen
“was so insignificant. But to my mind this is a proof that
the fatty degeneration of the epithelium, and especially that
of the uriniferous tubules, as the anatomical examination
shows, is the real cause of the albuminuria; and that this is
‘not due to other complications, such as acute inflammatory
processes, for as a result of these latter, the urine always
‘contains a very considerable quantity of albumen. On the
other hand, in mere fatty degeneration of the epithelium, it
86 ALBUMINURIA DEPENDENT UPON

may easily be supposed that but little albumen is allowed
to escape abnormally into the secretion, for there is always
the basement membrane to be traversed, and more than this,
the epithelial cells do not all at once completely lose their
functions. The secretion of the liver would furnish the
desired analogy, but, unfortunately, we have no definite inves-
tigations with regard to its condition. Many years ago two.
statements were made, from which, if they were sufficiently
minute, we could conclude that albumen is really found in
the secretion when the glandular epithelium is in a state of
fatty degeneration. Thus Thénard states that he found
albumen in the bile in five out of six cases of “ fatty liver,”
and Lehmann makes the same statement with regard to two.
cases of “ fatty granular liver” (74). But even without these
statements, what we have previously adduced definitely
proves that albuminuria occurs in fatty degeneration of the
renal epithelium following phosphorus-poisoning, and this
latter should certainly no longer be adduced as evidence
against the dependence of albuminuria upon fatty degenera-
tion of the epithelium, for it is evidence of an opposite
character. It is not denied that other factors may co-
operate in the production of albuminuria in cases of phos-
phorus-poisoning.

Almost equally indefensible is the statement that the.
absence of albuminuria in various conditions of anzomia is evi-
dence against the connection of the former symptom with
fatty degeneration of the epithelium. It is certainly true that.
no albumen can be found in the urine in many cases of anemia,
but it is also indisputable that fatty degeneration of the
renal epithelium does not accompany every form of anzmia,
even when of a very severe type—I need only refer to chlo-
rosis. There are in particular certain pernicious forms of
anemia which lead to fatty degeneration, but the insignifi-
cant amount of albumen excreted in these cases has caused
its appearance to be disregarded. But albuminuria though
trifling is a real symptom, and as deserving of notice as the
albuminuria of congestion, which is likewise trifling as a
general rule. The amount of significance to be attached to
the ‘absence of albuminuria” in pernicious anemia is
shown by the single circumstance that, while from the stand-
DEGENERATION OF THE RENAL EPITHELIUM. 87:

point of one observer peculiar emphasis is laid upon the fact,.
another regards the occurrence of albuminuria in “ progressive
pernicious anzemia”’ as evidence in support of his own different
view (75). Asa matter of fact albuminuria occurs sufficiently
often in severe forms of anzmia, in which fatty degeneration
of the epithelium may fairly be supposed to exist or is found
after death; and if some regard it as a rare’ phenomenon, a
more uncommon one than my experience compels me to con-
sider it, this difference is probably due to the fact that in
such cases the quantity of albumen contained in the urine
is certainly inconsiderable, provided that other morbid con-
ditions are absent, and is often enough overlooked when the
customary but not very reliable test by boiling is applied.
And if the albuminuria is not an invariable occurrence, and.
even fails to appear in the majority of cases, we are not jus-
tified in concluding that the condition of the epithelium is of
no importance; for the extent to which its function is dis-
turbed, and whether this impairment has reached such a stage
as to become manifest and capable of demonstration, are doubt-
less dependent upon the intensity of the degeneration. We
must abstain from drawing general conclusions as to the im-
portance, or unimportance, of disturbances which perhaps
occur with a certain amount of regularity, but differ as regards
their intensity and therefore, perhaps, as regards their impor-
tance. It is a well-known fact, for example, that fatty
degeneration of the epithelium of the gastric glands is a
regular occurrence in phosphorus-poisoning, and this is ob-
seryed even when the drug is not administered by the
stomach; and yet the evidences of disorder in this organ
are often altogether inconsiderable, or at least in no way
marked, especially when the poison is introduced into
the system in some other way. Are we then justified
in characterising the condition of the peptic glands and, of
their epithelium as of no consequence so far as the function
of the stomach is concerned ; but must we not rather assume
that in such cases the degeneration is not sufficiently intense
for the production of manifest disorder? We are compelled
to adopt this assumption, because we know from other
sources how important are the peptic glands for the discharge
of the functions of the stomach. The case is a parallel
88 ALBUMINURIA DEPENDENT UPON

one with regard to the epithelium of the uriniferous tubules.
We ascribe to these cells, and to these alone, the power and
the task of preventing the albumen of the blood in the inter-
stitial vessels, and of the lymph, from escaping into the uri-
niferous tubules, and we must therefore infer that when their
degeneration, fatty or otherwise, has reached a certain degree,
the fulfilment of their task will become impossible. Cer-
tainly, it is said, when they are in a state of fatty degenera-
tion, but not in that of fatty infiltration! It would scarcely be
necessary to advert to the difference between these two con-
ditions, were it not for the fact that the physiological occur-
rence of epithelial cells, containing fat, im the kidneys of
several animals, e.g. dogs and cats, has been referred to as
evidence of the insignificance of fatty changes (76). But in
these instances the condition is that of fatty infiltration, and
no demonstration is requisite to show that the absorption of
fat by otherwise healthy cells is one thing and the conversion
of the substance of the cell into fat is quite another thing,
and that the fatty changes in the two cases are of entirely
different import as regards the function of the cell. It may
be remarked that a “physiological albuminuria” often
enough occurs in dogs and cats; this, however, has nothing
whatever to do with any fatty contents of the renal epithe-
lium, but is dependent upon other causes (see note, p. 20).
Fatty degeneration of the renal epithelium occurs in animals
after long-continued exposure to excessive heat. The urine,
however, becomes albuminous very soon after the heat is
applied, long before any fatty degeneration can be demon-
strated, and, as before shown, this result is due to other
causes (see p. 47). When, however, in the further course
of such exposure, albumen occurs in the urine—a fact of
which there can scarcely be any doubt, though I have no
knowledge of this subject—a share at least in its causation
must be attributed to the degeneration of the epithelium,
and the more so since that cause to which the appearance
of albuminuria at the commencement of the exposure tO
heat must be ascribed, viz. the increased blood-pressure,
ceases to operate with the continuance of the abnormally

high temperature and of its deleterious effects upon the
muscular tissue of the heart.
DEGENERATION OF THE RENAL EPITHELIUM. 89

Another kind of degeneration of the epithelium, the
parenchymatous degeneration, is a well-known phenomenon
in febrile infectious diseases. It is also well known that these
diseases are characterised by the presence of albuminuria, to
which the epithet “ febrile? has been attached, and there is
a point of resemblance between it and the albuminuria which
occurs in phosphorus-poisoning and pernicious anemia, namely
this, that though as a general rule it is more marked than in
these latter conditions, it is usually not a prominent symptom,
especially when compared with the albuminuria of nephritis
or of amyloid degeneration of the kidneys. On this account
it was unknown or disregarded in former times, and only
recently has it been considered worthy of consideration, but
the instances of its occurrence become more and more
numerous the greater the care bestowed upon its discovery.
Whereas a few years ago the term “ febrile albuminuria”
was scarcely heard of, the condition is now universally
regarded as an ordinary symptom. It is, however, difficult
to estimate the share taken by the parenchymatous degener-
ation of the epithelium in the causation of this albuminuria,
because a series of other conditions invariably co-operate
therein, and to which, even more than to the degeneration
of the epithelium, a certain influence must be ascribed, as
will be shown in a subsequent page (see Section VI).

It remains now to allude to a peculiar form of degenera-
tion of the epithelium, viz. the coagulative necrosis, types
of which can be artificially produced by the administration of
certain poisons, especially chromic acid, and likewise by
petroleum, croton oil,and cantharidin. Albuminuria speedily
follows the administration of these poisons, as Gergen has
found in experiments with chromic acid. Lassar has discov-
ered a marked peculiarity with regard to petroleum poisoning,
viz. that a stage of propeptonuria precedes the excretion of
the albumen which is coagulable by heat (serum-albumin,
and globulin), that is, albuminuria proper (see page 10).
Weigert (Kabierske) states that in animals poisoned with
chromic acid salts, after some hours interval, only the epithe-
lium of the convoluted uriniferous tubules is involved in the
degeneration, whereas the glomerular vessels, the interstitial
tissue, and the epithelium of the straight tubes remain intact.
90 ALBUMINURIA DEPENDENT UPON

A similar description is given by Lassar of the condition of
the kidneys in poisoning by petroleum. This author and
Kabierske have experimented with injections of indigo-sul-
phate of soda, which, when suitable methods are adopted, as
Heidenhain has shown, is well known to be excreted only by
the epithelium of the uriniferous tubules ; and they were able
to convince themselves of the destruction of these cells as a
result of the administration of chromic acid and petroleum,
and that all the other elements of the tissue remained appa-
rently unaffected. Nevertheless, it must be assumed that the
mischief is not confined exclusively to those epithelial cells
and to the proper secretory apparatus, for, according to Pos-
ner, Voorhoeve, and Kabierske, the microscopical examination
of kidneys after the administration of chromic acid shows that
albumen is deposited not merely in the uriniferous tubules,
where it has separated the epithelial detritus from the base-
ment membrane, but in the Bowman-Miiller’s capsules as
well. And a similar description is given by Browicz and
Vodrhoeve in cases of poisoning with cantharidin, but with
this addition, that inflammatory changes were also indicated.
In this instance, therefore, as in phosphorus-poisoning, it
would appear that the albumen is derived partly from the
interstitial vascular system and partly from the glomerular
vessels, which, together with their epithelial investment, have
likewise become affected (though to an extent not perceptible
under the microscope), since in these cases there are manifest
extravasations of blood in the capsules and uriniferous
tubules (77).

The conclusion to be drawn from the above statements is
that albuminuria occurs with a certain amount of regularity
in all forms of degeneration of the epithelium, and especially
of that of the convoluted tubules, and likewise that, under the
same circumstances, the appearance of peptonuria and of pro-
peptonuria takes place, a symptom which, as Lassar has shown,
(and as other experiences prove to be not improbable, see page
12), may pass into albuminuria proper, though the presence of
these substances is liable to be overlooked when the ordinary
methods of investigation are employed. Whether it will hence-
forth be regarded as proved that the degeneration of the epithe-
lium alone, in the sense in which we have explained it, is or is
DEGENERATION OF ''HE RENAL EPITHELIUM. 91

not the cause of the escape of albumen, will depend entirely
upon the degree of credit which is attached to the evidence
yielded by the microscope. He who steadfastly refuses to
recognise any lesion unless it can be demonstrated under the
microscope, will be forced to regard the connection between
albuminuria and epithelial degeneration as proved beyond.
doubt, for the appearance in question is all that the most
expert microscopists have been able to discover. I for my
part do not adopt this stand-point, which is based upon an
over-estimate of the capacity of the microscope, as is also.
evidenced in the attempt to procure microscopical demonstra-.
tion of the albumen contained in the normal transudation of
the capsules (see page 35, et seq.). I am, therefore, very far
from wishing to discover in all the cases which have been
adduced, a rigid proof of the dependence of albuminuria upon
degeneration of the epithelium, but I see in them evidence of
a very strong character against the assertion that the condi-
tion of the epithelium of the uriniferous tubules is a matter
of no importance with reference to albuminuria. There is
still less evidence in favour of this assertion. On the other
hand, so low an estimate will hardly be formed of the value of
microscopical investigation as to cause it to be rejected as
altogether worthless. In the albuminuria in question, the
microscope shows us intense degeneration of the uriniferous
tubules as a constant appearance, but no other striking alter-
ation. Neither more nor less can be detected. It is there-
fore extremely probable, as a result of this investigation, that a
connection exists between the two conditions, and that at least
a considerable share in the causation of the albuminuria is to
be attributed to the destruction of the epithelium. This con-
clusion is converted into a certainty by the fact that these obser-
vations only confirm the proposition which the theory of glan-
dular secretion, and of the function of glandular epithelium,
has laid down by anticipation as a necessary postulate, namely,
that when these epithelial cells are destroyed, the obstacle to
the escape of albumen from the interstitial vessels is broken
through.

A peculiarity exhibited by the albuminuria which is con-
nected with the various forms of epithelial degeneration be-
comes intelligible from this point of view. In fatty degene-
92 ALRUMINURIA DEPENDENT UPON

ration, as in phosphorus-poisoning, or in pernicious anemia,
the excretion of coagulable albumen is, as I have already
stated, as a general rule only slight; on the other hand, in
the coagulative necrosis due to chromic acid salts or petro-
leum, the urine contains large quantities of albumen. In
the former instances the degeneration is the result of the
conversion into fat of the protoplasm of the cells, which,
however, usually remain connected with each other and
occupy the same position when death occurs; in the latter
case, as Weigert expresses it, destruction goes on rapidly
and the cells become detached to a considerable extent. It is
evident that in this last-named lesion, the rapid destruction of
the entire epithelial investment must be followed by total, or
almost total, abolition of function, and the disturbance at any
rate must be far more serious than in that slighter form of
degeneration in which, so to speak, the obstacle to the escape
of albumen is certainly damaged, but is not entirely
removed. This at least is the rule, for it is perfectly clear
that even fatty degeneration may finally lead to complete
disintegration and detachment of cells, and consequently in
exceptional cases to a more intense degree of albuminuria,
Just as in such cases the detachment of these cells in a state
of fatty degeneration and their passage into the urine, simul-
taneously with the albumen, will induce a form of chyluria—
a chyluria the result of phosphorus-poisoning, which has really
come under observation (78).

We are thus led to consider the possible occurrence of
a form of albuminuria, as a simple result of the passage
into the urine of detached epithelial cells belonging to any
portion of the renal parenchyma. For some years past, I
have drawn attention to this possibility, and it must, I think,
@ priort, be admitted, without any scruple, that when epithe-
lium becomes detached, it is not merely the fixed and
therefore undissolved albumen contained in the substance of
the cells which finds its way into the urine; for this is a
matter of course, unless all the cells separately and
collectively were converted into fat; but a portion of the
protoplasm, in a state of disintegration and passing into a
fluid state, may become dissolved in the neighbouring
current (79). There can be no dispute on this point, and
DEGENERATION OF THE RENAL EPITHELIUM. 93

no dispute has arisen, but a process of this kind has been
thought unworthy of consideration, as appears from the
notion expressed by Bartels (80) to the effect that these
admixtures of albumen can amount only to very minute
quantities, a notion which, as in phosphorus-poisoning and
other forms of albuminuria, has led to the error of totally
disregarding this symptom. But even so slight an albumi-
nuria as this may be, is a real albuminuria; and it is the
more remarkable that it has attracted no sort of attention,
when it seems as though sufficient consideration could not be
attached to the excretion of albumen in cases of renal venous
congestion, amounting as it does (and as Bartels himself so
justly remarks) “rarely to more than o*1 per cent.” of the
urine. If an excretion of albumen, amounting within
twenty-four hours at most to half-a-gramme or a gramme,
as is common in renal venous congestion, be not so minute as
to be unworthy of consideration, it follows that albuminuria,
as a possible result of disintegration of the epithelium, has
certainly some claim upon our notice. But why must this.
latter form be so insignificant a symptom? Is it the case
that all the epithelial cells which may decay and become
detached,—the epithelium of the capsules, of the glomeruli,
and of all the other portions of the uriniferous tubules,—are
not in sufficient quantity to yield a daily supply of half a.
gramme to a gramme of albumen, even if all these epithelial
cells do not simultaneously perish? In my opinion a positive
presumption is abundantly justified by estimating how much
of the weight of the renal parenchyma is made up by the
aggregate of these epithelial cells.

If, therefore, no objection can be raised against this view—
and I can think of none that is really tenable—it must be
admitted that the disintegration and detachment of cells may
give rise to the appearance in the urine of albuminous sub-
stances, differing from the albumen of ordinary albuminuria.
As a general rule the cell-protoplasm appears to contain albu-
minous substances (vitellin and myosin) resembling globulin,
and which as such, or in some other stage of transformation,
may find their way into the urine; indeed, according to Gott-
walt’s observations, the kidneys free from blood contain from
seven to eight times as much globulin as serum-albumin (81).
94 ALBUMINURIA DEPENDENT UPON

We know that globulin along with serum-albumin is
found in the urine in very variable quantities, so that’ we
might perhaps suppose that, according as the albumen of the
renal parenchyma is mixed with the urine, this latter secre-
tion will contain more or less globulin in proportion to the
serum-albumin. Our defective insight into the chemical pro-
cesses of living and decaying cells does not allow us to
do more than indulge in guesswork on this point. But
it appears justifiable to mention it, for it is in these
forms of albuminuria which are connected with rapid and
severe epithelial decay, that the albumen exhibits several
reactions differing from those ordinarily met with. This
is, however, not the only possible means of explaining the
occurrence of unusual forms of albumen in the urine, for
there is another and a more probable explanation, viz. that
the substances in question may be conveyed to the kidneys
with the blood, in consequence of some change in the com-
position of that fluid. We shall now discuss this subject,
‘so far as the change alluded to has any influence in the pro-
duction of albuminuria.

V. Tae Conpition or tHE Broop as INFLUENCING THE
Propuction of ALBUMINURIA.

That albuminuria is caused by an abnormal condition of the
blood, is the oldest view, and the same which Cotugno, the
discoverer of albumen in the urine, suggested, and which his
contemporaries and immediate successors adopted and dis-
seminated ; and this theory necessarily remained unshaken so
long as observers were ignorant of the connection between
albuminuria and dropsy and renal disorders. But the views of
physicians were dominated by this theory even for some time
after the connection between these conditions was discovered
by Dr. R. Bright ; subsequently, however, it lost its promi-

nence, as the progress of investigation led to the discovery

of various disorders of the kidney in states of disease
accompanied by albuminuria, while little or no further
knowledge was gained with regard to the supposed alterations
THE CONDITION OF THE BLOOD. 95

in the blood. These changes in the blood were supposed
to be due to a morbid condition of the albumen, which, in
consequence, differing from the normal albumen of the blood,
passed into the urine; and the cause of this morbid condition
was sought for in some abnormal process of digestion or of
tissue-change, or in the retention of excrementitious matters,
&c. But all that could be brought forward in support of
these theories resolved itself into more or less obscure suppo-
sitions or arbitrary assumptions, and consequently it was only
to be expected that the theories which attributed the causa-
tion of albuminuria to the condition of the blood—the theories
of a hematogenous albuminuria—would be set aside in favour
of a nephrogenous albuminuria, so that at the present day the
former views have very few adherents (82). Moreover,
it has been shown by the very ingenious experiments of
Stokvis, that at least in ordinary cases of albuminuria and
dropsy, or of so-called ‘ Bright’s disease ” and amyloid dege-
neration of the kidney, the albumen does not, certainly as a
general rule, possess the power of inducing albuminuria in
healthy kidneys. Albuminous urine, or the blood-serum of
patients suffering from albuminuria, was injected into the
blood or under the skin of healthy animals, and in twenty-
one out of twenty-three experiments of this kind no albumen
was found in the urine. In the two cases in which albumin-
uria occurred, it was very remarkable that the urine used for
injection had been taken from a patient suffermg from
albuminuria without demonstrable renal disease. The very
cautious conclusion drawn by Stokvis is, that in the majority
of cases a modification of the albumen of the blood is not the
existing cause of the albuminuria, but that it must be left
for further experiments to decide whether such may be the
case under exceptional circumstances, as it is not improbable
from & priort considerations (83). My opinion is, that this
conclusion must be adopted in its entirety ; it corresponds
even now, after nearly a decade and a half, with the actual
state of our knowledge of the subject. That view especially
must be rejected which attributes the occurrence of albumin-
uria in renal diseases to changes in the blood, particularly in
the conditions, including amyloid degeneration and conges-
tion, formerly, and to some extent also nowadays, classified
96 ALBUMINURIA DEPENDENT UPON

under the name “ Bright’s disease.”” There is no doubt that
a cause for the symptom in question is to be found in a renal
lesion. This latter certainly may (and this view is highly prob-
able) often originate in a morbid condition of the blood,
which may therefore be fairly described as the indirect cause
of the albuminuria in these cases.

It may be difficult to explain the occurrence of albuminuria
in those much rarer cases in which no lesion of the kidney
exists. For it is beyond doubt that there are such cases, and
that albuminuria is not always symptomatic of a nephritis or

-of some other demonstrable kidney-lesion. I need only
refer to the detailed description already given (see page 15,
et seq.) of albuminuria as occurring in perfectly healthy men,
or to the albuminuria in patients who show no other indica-
tion of kidney-disease, and in whom when death occurs from
some other cause, the most careful examination fails to detect
any abnormality in the kidney, any trace of degeneration of
the epithelium, any swelling and cloudiness of the parenchyma,
appearances which are yet regarded by many indeed as devoid
of significance with regard to albuminuria. We have become
acquainted with the existence of circumstances which, in
certain conditions of the circulation, may give to albuminuria
in the absence of any disorder of tissue in the renal paren-
chyma ; but not in all cases of this nature can the circulatory
changes be positively demonstrated or even assumed as prob-
able, without straining the interpretation of the symptoms.
It appears to me that for such cases, probability must be
admitted for the theory that the albuminuria is due to changes
in the composition of the blood. I say designedly “ changes
in the composition of the blood,” and not “changes in the
albuminous substances in the blood ” as is usually expressed
by those who make use of the term “ hematogenous albumin-
uria.” Not that I consider an abnormal condition of the albu-
minous substances as impossible ; on the contrary, I regard
it as not only possible but even not improbable, so far as
many cases are concerned, and I will soon give my reason for
so doing; but I think it is at least as probable that
other changes in the composition of the blood, having no
connection with any abnormal condition of the albumen, may
induce albuminuria, and I am alluding not to hypothetical
an A " ef S . oa
THE CONDITION OF THE BLOOD. 97

changes of composition but to such as can be demonstrated
‘beyond possibility of doubt.

The urinary secretion in great measure depends, as has been
already sufficiently explained, upon filtration from the plasma
of the blood, that is, from a saline albuminous solution ; and
in accordance with the numerous experiments which have
been performed with regard to the filtration of such fluids, ib
can be regarded as quite certain that the quantity of
albumen contained in the filtrate is, ceteris paribus, dependent
upon the quantity of albumen and salts contained in the
original fluid. The more albumen the latter contains, the’
more of this constituent, ceterts paribus, will be found in the
filtrate, though this latter quantity does not rise and fall in a
degree exactly proportionate to the amount contained in the
original fluid. As regards the influence of the saline con-
stituents, the results of the investigations of Hoppe-Seyler,
v. Wittich, and Nasse, notwithstanding a few differences in
details, practically agree in showing that the quantity of
albumen which passes through the filter increases with the
increase of the saline constituents of the fluid. This is espe-
cially the case in regard to chloride of sodium, with which
the majority of the investigations were made, but it is also
true in the case of other salts (nitre, chloride of calcium) ;
and it is important to observe that it holds good with respect.
to urea, the influence of which in facilitating the passage of
albumen through a filter has been observed by Hoppe-Seyler,
and recently by Newman (84).

In face of the above facts there is no reason to refuse to
accept the theory of a hematogenous albuminuria, as is now
almost universally the custom, for there cannot be a moment’s
doubt that, under multiform normal and pathological condi-
tions, both the dissolved albumen and the salts of the blood
may become increased, and further, that such increase really
takes place. After every meal, which does not contain too
great a proportion of water or an unusually small quantity of
albumen and salts, the composition of the blood may become
altered in the manner described, and may be a cause of albu-
minuria, in so far as more than the normal amount of
albumen transudes through the glomerular vessels. As a
matter of fact, with healthy kidneys, the occurrence of

7
98 ALBUMINURIA DEPENDENT UPON

albuminuria during digestion has been noticed by numerous
observers (see page 19), and to it, therefore, a peculiar name,
“ digestion-albuminuria ” (albuminuria alimentaria), has been
attached. That likewise, in the ordinary forms of morbid
albuminuria, an increase in the excretion of albumen is a
frequent result of digestion, altogether independently of
other conditions, is a fact already noticed by Parkes and
Gubler (85), and one that has been minutely investigated by.
Brunton and Power (86), and confirmatory evidence of which
abounds on all sidés. Moreover, in addition to the increase
of albumen and salts, the above-mentioned investigations of.
Hoppe-Seyler and Newman show that regard must be had
to the increase of the quantity of urea in the blood, which
occurs some time after the digestion of albuminous food, and
manifests itself in the increased excretion of urea. It is
well known,.on the other hand, that the urine becomes
increased in quantity while digestion is going on, and such
increase is in a measure independent of the process of.
filtration, and is in excess of the activity of the latter, inas-

much as the glandular secretion proper is at the same time
augmented, owing to the influence of the urea, the salts, &c.
These facts, as we have already explained (see pages 28, 40),
constitute a reason why in most cases the discovery of the
quantity of albumen of the urine is rendered difficult. For.
if a fluid containing much albumen transudes through the
glomerular vessels, and receives in addition, a greater
quantity of non-albuminous fluid, consisting of the secre-
tion of the glandular epithelium, the quantity of albumen in
the urine as a whole may be very small, and may pro-
gressively diminish until it reaches the proportion observed
when no digestion is going on, or even falls below it.

The concurrence of particularly favorable circumstances is,
therefore, required for this “ digestion-albuminuria ” to make
its appearance, and it may be soonest expected after a meal
containing much albumen but very little water. Food con-
taining much saline matters will be less favorable in this
respect, for the ordinary salts may act in two directions,
since on the one hand they facilitate the filtration of albumen
in the glomeruli, but on the other, the secretion of water by.
the glandular epithelium. This purely theoretical deduction
THE CONDITION OF THE BLOOD. 99

is confirmed by experience, for the diet after which
“ digestion-albuminuria ” is noticed is usually one in which
animal food largely preponderates. Christison has noticed
temporary albuminuria in persons who had eaten much
cheese (87). I have already (page 19) alluded to the same
symptom occurring in an otherwise perfectly healthy physi-
cian, after almost every meal consisting largely of meat,
and many similar cases are recorded in the literature of this
subject. I am now referring not merely to the instances in
which albuminuria occurred after eating eggs, for these are
only partly traceable to the same cause, and in the main a
different explanation is to be found for them (see page 100).

It is extremely probable that under pathological conditions
similar changes take place with regard to the quantity of
albumen and salts contained in the blood, and especially in
the direction of an increase, whether of an absolute or of a
relative character. But this assumption is based only upon
theoretical considerations, for we have at present no obser-
vations which would prove its truth. Only in the case of
cholera, and other conditions associated with profuse watery
evacuations, we know from C. Schmidt’s classic investiga-
tions that the albumen of the blood becomes relatively
increased and that the saline constituents are similarly
affected for a very brief interval (88). We know somewhat
more with regard to the increase of urea in disease. Gscheid-
len (89) has shown that the quantity of urea contained in
the blood becomes increased in the febrile state, and the
same thing will take place in all those conditions in which
increased disintegration of albumen is accompanied by dimi-
nution of the urinary secretion, as in phosphorus-poisoning,
according to Storch, Bauer, and Cazeneuve, and, according to
A. Frankel, as a result of insufficient supply of oxygen (90).
In all these cases there will be an abnormally large forma-
tion of urea which will be excreted with the urine, but the
amount excreted may easily be less than the excessive for-
mation, since, for reasons which we need not here discuss,
there is a considerable and simultaneous depression of the
renal activity. The result, therefore, in such cases may be
an accumulation of urea in the blood, whereas in other cases
in which the increased formation of urea is met by a corres-
100 ALBUMINURIA DEPENDENT UPON

ponding increase in the secretion of urine and urea, as, for
example, in diabetes, no accumulation can be supposed to
occur. An accumulation of urea in the blood has been
clearly demonstrated in disease of the kidney itself, simply
as a result of impeded excretion, and always associated with
diminution of the quantity of urine.

There is, therefore, in all these cases in which the albumen
or the urea, and possibly also the salts, are increased in quan-
tity, a certain factor present, endued with the power of
causing a much increased transudation of albumen, and con-
sequently albuminuria. But it is by no means a single
factor, for a number of more or less active influences, capable
of producing the same effect, come into play in the above-
mentioned instances. Thus in phosphorus-poisoning, there
is the degeneration of the epithelium, and the diminution in
the quantity of urine consequent upon diminished arterial
pressure; this latter is also present in cases of profuse
watery evacuations, in cholera, violent diarrhceas, &c., while
in fever, of which we shall presently speak particularly,
many other factors co-operate, by which the albuminuria may
be explained.

While, therefore, there is a positive basis of facts for the
assumption that quantitative changes in the composition of
the blood may, under certain circumstances, cause albuminuria
to appear, or increase this symptom if already existing, the
other assumption, hitherto maintained only by the supporters
of a hematogenous albuminuria, to the effect that the sym-
ptom in question has its origin in qualitative changes in the
albumen of the blood, can claim no equally definite and
positive facts as a foundation but only sundry reasons which
invest it with a certain amount of probability. This, how-
ever, holds good only with regard to the pathological
albuminuria, for there is a certain kind of physiological
albuminuria which is doubtless a result of qualitative
changes in the albumen of the blood. This is the albumi-
nuria which occurs after the introduction of egg-albumen
into the blood—and not merely after the immediate introduc-
tion or its injection under the skin, as often done in experi-
ments, but likewise after its introduction into the stomach.
Many observers, namely Tégart, Brown-Séquard, Becquerel,
THE CONDITION OF THE BLOOD. 101

and Barreswil, Hammond, Cl. Bernard, J. Chr. Lehmann,
and Stokvis, have observed albuminuria after eating many
eggs, or a long-continued diet of this character, the experi-
ments being performed on themselves, or on other persons,
or on rabbits and dogs (91). As a general rule, this albumi-
nuria is explained as due to the readiness with which egg-albu-
men passes through a filter ; it is consequently supposed to
traverse the glomerular vessels more readily than is the case
with the normal albuminous substances of the blood ; and I
have already drawn attention to the fact (see p- 23) that
this generally received explanation involves a recognition of
the theory according to which the albuminous substances
really do pass through those vessels, though in quantities
varying according to the capacity for filtration possessed by
each. The investigations of Lehmann, Stokvis, and Creite
(92), show beyond doubt that egg-albumen is really excreted
as such, and that in the majority of cases the albuminuria
disappears with its excretion. It must, therefore, be assumed
that in those cases in which a large number of eggs are in-
troduced into the stomach, a portion at least escapes the
action of the gastric juice and passes unchanged into the
blood; and this theory is supported by the fact that Stokvis
failed to produce albuminuria in rabbits when he introduced:
coagulated albumen into the stomach. The portion really
digested may, however, by increasing the quantity of normal
albumen in the blood, have contributed to the production of
albuminuria in the way just described (see page 97, et seq.).

It appears, however, as if the admixture of dissolved egg-=
albumen might lead to the production of albuminuria in
yet another way, for both Lehmann and Stokvis several times
observed that a long-continued albuminuria was the result
of injecting the albumen in. question into the blood, and that
more albumen (in one of Stokvis’s experiments, four times
as much) was excreted than was injected. In these cases,
therefore, the presence of an extraneous albuminous substance
in the blood must have set up, probably in the kidney, some
kind of process which led to the production of albuminuria
in the strict sense of the word—that is to say, to the excretion
of coagulable albumen of the system itself. Here we are re-
minded of the fact that Creite often witnessed the occurrence
102 ALBUMINURIA DEPENDENT UPON

of albuminuria without admixture of blood, in rabbits, as a
result of the injection of the blood-serum of animals belong-
ing to different species. To explain this we must assume,
either that the albuminous substances of these kinds of
serum more readily filter through the kidneys of rabbits than
through those of the animals to which they belonged; or that
extraneous serum of this kind induces serious derangements,
with albuminuria as an accompaniment. Taking into con-
sideration the effect, presently to be discussed, of the serum
upon the blood-corpuscles of other animals, it must be
admitted that the latter assumption is the more probable of
the two.

Nothing certain is yet known as to the effect produced by
the injection into the blood of other soluble albuminous sub-
stances, peptone chiefly excepted. J. Chr. Lehmann observed
no albuminuria after injections of Lieberkiihn’s albuminate
of soda, of solutions of syntonin, myosin, and fibrin, whereas
Runeberg witnessed the occurrence of albuminuria after the
injection of an albuminous substance, which he obtained by
dissolving in soda casein precipitated from milk by means
of acetic acid, but not when he injected pure milk or milk
mixed with soda (93). The former fluid possessed great
capacity for filtration, and the question arose whether the
albuminous substances made use of by Lehmann were less
adapted for that process, for solubility alone is no measure
of the capacity for filtration.

The other albuminous substances, distinguished by their
capacity for diffusion and filtration, with which we are
acquainted, are peptone (probably also propeptone) and
hemoglobin. No experiments in this direction have as yet
been made with propeptone, but it may with certainty be
assumed that its behaviour is the same with that of the
other two substances, which, introduced in a state of solu-
tion into the blood, are, in accordance with theory, readily
excreted in consequence of the marked capacity for filtration
which they possess. With regard to peptone we know that
it may find its way into the blood by injection, or by the
absorption of exudations in which it. is contained (as in
pleurisy, pneumonia, and rheumatic arthritis), and that
peptonuria then makes its appearance. The same origin
THE CONDITION OF THE BLOOD. 103

may be assumed in the case of propeptonuria. It is well
known that the colouring matter of the blood is dissolved,
not merely as a consequence of the injection, but likewise
under various circumstances, as a result of the destruction of
‘the red corpuscles in the blood. In this way its excretion
takes place, and thus we find hemoglobinuria (methemoglo-
binuria, hematinuria) as a result of various poisons, and in
certain states of disease (periodic hemoglobinuria, severe in-
fectious conditions), and, as Creite, Landois, and Ponfick have
observed, after the introduction into the circulation of blood,
or only blood-serum, of an animal belonging to a different
Species (94). The excretion of the hemoglobin, however,
appears to take place not only by filtration through the
glomerular vessels, but besides this, as is the case with
other colourmg materials, in a specific manner through the
epithelium of the uriniferous tubules (95).

This, then, is almost all that is known with certainty with
regard to the dependence of albuminuria upon qualitative
changes of the blood, and particularly upon alterations of the
albuminous substances. All the results of experiments in
reference to this question amount apparently to this, viz. that
albuminous substances, normally not dissolved in the blood,
appear in solution in that fluid, and that they are excreted by
the kidneys in proportion to their capacity for filtration, just
as was to be anticipated from the views we have developed
with reference to the filtration in the glomerular vessels. In
consequence of the greater capacity for filtration possessed
by these substances a larger amount passes through the
glomerular vessels than in the case of the normal albuminous
substances of the blood ; it therefore follows that the former
will be more easily discoverable in the urine than the latter,
and the albuminuria is mainly accounted for by this fact. It
would, moreover, appear that abnormal excretion of the
ordinary albumen may be induced as a result of extraneous
admixtures of this description.

It might be thought that these facts amounted to suffi-
ciently presumptive evidence in favour of the view that
many forms of albuminuria are dependent upon qualitative
changes of the blood, and particularly of its albuminous
constituents. It is true that this view has met with but
104 ALBUMINURIA DEPENDENT UPON

little acceptance of late years, but for a reason which, if
carefully scrutinised, will be found to be strictly of an
‘extrinsic and formal character. The invariable custom is to
include in the term albuminuria nothing but the excretion of
coagulable albumen from the blood, and, as before noticed,
to consider that the excretion of other alouminous substances
is not comprehended under the same term, In this sense
the only recognised albuminuria, which assuredly depends
upon a qualitative change in the blood, is that which is
‘caused by the introduction of egg-albumen; but this ig
‘usually considered as devoid of significance in a clinical
respect. And it is quite true that up to the present time
our knowledge of this albuminuria has been derived from
experiment and not from clinical observation. It is indeed
possible that that which is brought about in a healthy man
or animal by the ingestion of an excess of egg-albumen, may
become developed in a diseased organism, especially in one
which possesses abnormal capacity of digestion, by a
moderate or even small amount of such food, and in that case
this excretion of egg-albumen would certainly possess a
Clinical significance as well—the same significance as may
perhaps be assigned to the ingestion of amylaceous food by a
‘patient suffering from mild diabetes, who, when he avoids
such food altogether or limits its quantity, excretes no sugar,
and in a general way shows no symptom of disease. It is
well known that even healthy persons may be made to
excrete sugar (glycosuria alimentaria) by feeding them upon
large quantities of sugar and starch, and since this fact
does not induce us to remove the so-called mild form of
_diabetes from the category of pathology, there is no greater
amount of objection to regarding this excretion of egg-
albumen as devoid of significance in a pathological respect.
The question would be to determine the boundary between
moderation and excess of supply—obviously a difficult task,

With regard to the other albuminous substances which
occur in the urine, not merely in the course of experiments,
but likewise under purely clinical conditions in various forms
of disease, we are quite justified in separating heemoglobi-
nuria from albuminuria proper, inasmuch as the hemoglobin,
as well as the colouring matters derived therefrom, does not.
THE CONDITION OF THE BLOOD. ‘105

‘belong to the albuminous substances properly so-called. On
the other hand, no strict line of separation can now be drawn
between “ peptonuria,” “ propeptonuria,” and albuminuria,
for the two former occur alternately with albuminuria in the
strict sense of the word, and also combined with it (see p.
g, et seq.). If, however, they must be considered as be-
longing to albuminuria in the wider sense of the term, this.
view involves the admission that forms of albuminuria exist
which are dependent upon qualitative changes in the albu-
men of the blood, for I scarcely know what other form of
albuminuria could be expected to arise from such qualitative
changes, and otherwise we should find ourselves in an end-
less circle of terms. If coagulable albuminous substances:
are excreted, and albuminuria in the ordinary strict sense
therefore exists, the substances in question must necessarily
be invariably regarded merely as serum-albumin or as globu-
lin (we can disregard egg-albumen, as that appears only
after introduction from without), and it will therefore be
needless to assume the existence of any qualitative change,
or of any modification of the albumen of the blood. If,
however, one of the substances, in other respects resembling
albumen, but wanting in coagulability, is found in the
urine, if, therefore, some modification be present, this is
set aside as “ peptonuria or propeptonuria,” and is re-
garded as something. peculiar. But in this way it will
scarcely ever be possible to’ prove or disprove the exist-
ence of. albuminuria due to changes in the condition
of the blood. For the distinctions once considered impor-
tant aids towards demonstrating modifications of albumen in
the urine, and consequently in the blood, are of quite subor-
dinate significance if we take into consideration the facility
with which the several albuminous substances undergo con-
version; and all the experiments, especially those performed
some years ago, with the view of demonstrating the presence
of morbid modifications of albumen by the variations in the
diffusion of albuminous urines, are of little value, because
such variations are caused by alterations in the quantity of
the saline constituents, the urea, &e.

Much more value would be attached to a physiological
experiment which would demonstrate a property of the
106 . ALBUMINURIA DEPENDENT UPON

albumen contained in the urine or the blood in cases of
albuminuria, that is, if it could be shown that this albumen
injected into the blood or subcutaneously, was, like egg-albu-
men, capable of producing albuminuria. It is true that, con-
nected with this subject, we have a single isolated statement
by Stokvis, which has been already incidentally referred to
(see p. 95). As an exception to, and differing from, the
great majority of his other experiments in this direction, he
found that the albuminous urine of a patient, free from any
manifest disease of the kidney, produced albuminuria in one
dog and one rabbit, the symptom disappearing in a few days.
We cannot suppose that this extraordinary result was due
to any oversight or confusion; had any such existed, Stokvis
must have discovered them, for these two experiments
are inconsistent with the conclusions warranted by all the
others, and must therefore remain as unexplained exceptions.
For the present, however, it will be well not to invest them
with any great amount of significance, but to regard them
only as an index for further researches in this direction,
Until the time comes that they are confirmed, the question
as to the existence in diseases of a modification of the albu-
minous substances, capable of producing an albuminuria not to
be designated peptonuria or propeptonuria, must be regarded
as unsettled.

In like manner the question as to the means whereby any
modification of albuminous substances of the blood takes
place, must be considered as still awaiting solution. There
are many possibilities, but at present there is no theory which
can be proved and certainly none which can be disproved.
It is therefore possible that, in accordance with the theory
especially favoured by Prout among English observers, ab-
normal processes of digestion are responsible for the passage
into the blood of an albumen differing from the normal sub-
stance; or that under the influence of some kind of morbid
condition in the blood and fluids of the body, such altera-
tions take place; as the old doctrines of crasis were always
ready to assume. Inasmuch, however, as we are not as yet
able to recognise with certainty any single morbid modifi-
cation of albumen in the blood and fluids, we ought in this
matter to assume an attitude of reserve, if not of incredulity.
THE CONDITION OF THE BLOOD. 107

Among the alterations in the condition of the blood, we have
finally to notice one which contrasts with the above-described
devtations which concern only the chemical composition.
The alteration in question is of a physical character, having
perhaps the power of increasing to an abnormal extent the
transudation of albumen until albuminuria is produced. I
refer to an incteased temperature. We have already alluded
to the fact that filtration of albuminous solutions is facili-
tated by increase of temperature, but we do not kuow what
proportion the albumen contained in the filtrate bears
to that of the original solution (conf. page 51). We must,
therefore, be satisfied with having drawn attention to this
point which may, among other things, be of unmistakable
importance in reference to the albuminuria of febrile dis-
orders. There is also another point, possibly connected with
this one just mentioned, but to which in the present state of
our knowledge we can make only a passing allusion, viz. that
with the elevation of temperature the molecular composition
of the albuminous substances becomes so changed, that they
pass more readily through a filter than is the case in their
normal condition. On this subject conjectures have been
hazarded from many quarters, but nothing certain is known,
and, in accordance with the explanation already given, the
occurrence of such a change under the influence of increased
temperature, may be capable of recognition only because the
coagulable albuminous substances are converted into peptone
and propeptone.

As far as we have gone at present in our description of
the influence of modified conditions of the blood upon the
production of albuminuria, we have referred only to the pro-
cesses of filtration going on in the kidneys, but we have said
nothing about the process of secretion proper, because, to all
appearances, this latter, in the majority of cases, is only
indirectly concerned. I know of only one instance which
supports the view that true glands may allow the abnormal
escape of albumen, when extraneous albuminous substances
are present in the blood, one of these substances being allowed
to escape. This observation, likewise made by Stokvis,
refers to the case of a strong dog, in which egg-albumen
was subcutaneously injected, with the result that the secre-
108 -CERTAIN PECULIAR FORMS OF °

tion from the parotids, previously filtered and found perfectly
non-albuminous, now contained a marked proportion of egg-
albumen. If it be desired to draw any conclusion from this
observation, it may be assumed as probable, that not only the
glomerular vessels, whose action in this respect has been
proved, but likewise the interstitial vascular system parti-
cipates with the epithelium of the uriniferous tubules in the
excretion of egg-albumen in the kidney. Besides, the latter
portions of the kidney may, as already stated, in consequence
of morbid changes in the condition of the blood, indirectly
contribute towards the production of albuminuria, inasmuch
as the latter gives rise to derangement of nutrition and
degeneration of the epithelium, conditions which, in the way
already described, lead to the excretion of albumen.

VI. Curran Pecutiar Forms or Morsip ALBUMINURIA,

In the foregoing sections we have become acquainted
with so many varying conditions which may assist in the
production of albuminuria, that we cannot agree with the
attempts which have been made to attribute to a single
cause all those forms of albuminuria which do not originate
in the coarser disorders of the kidney. How the conditions
which are submitted to our consideration, viz. the state of
the circulation and of the blood-pressure, the condition of
the membranes concerned in the secretion, and the state
of the blood, act in various diseases, is in a general way too
little known for us to be able to estimate the influence each
exerts in every case. But this much we know, that in the
majority of diseased states the separate conditions mutually:
influence each other, so that it is very difficult to discover in
every instance the really active condition, and altogether:
impossible always to point out the only one that is so. The
conditions are proportionately simple in a few cases only,
and these have been described in their proper places im
foregoing pages ; we refer especially to the albuminuria in’
venous congestion (page 71, et seq.), in convulsive conditions.
(page 51, et seq.), and at any rate in many forms of poison-
ing (pages 55 and 80). In all other cases the conditions are’
MORBID ALBUMINUBIA. 109

less simple and intelligible, so that although it may be posi-
tively affirmed that the albuminuria has originated in some
one or other or in several of the ways above described, its exact
cause, and wherein consist the conditions for one or other mode
of origin cannot be so definitely stated. The best illustration
of the manner in which various conditions co-operate to pro-
duce albuminuria, and how these may alternate in one and the
same morbid process, is to be found in what Gerhardt was
the first to designate as “febrile albuminuria” (96). And
in this instance we are in the position of being able to recog-
nise, with distinctness, at least a few individual conditions.
Even with regard to the conditions now occupying us, there
is still much that is wanting for the completion of our know-
ledge of the processes in fever, but the more recent investi-
gations with reference to the circulation, tissue-changes, and
nutrition, enable us to indicate the conditions, some with
certainty and others with more or less probability, which
will give rise to albuminuria in various febrile disorders
unaccompanied by any special lesion of the kidneys, _ In the
first place, as regards the circulation, and the blood-pressure,
in particular, which, as previously explained in detail, has the
greatest influence in. the production of albuminuria, it. is
obvious that it does not remain the same, or invariably
undergo changes of the same character, in all febrile
diseases, or in any single disease throughout its whole course.
That it should remain unchanged is not to be expected, inas-
much as the heart’s functional capacity, upon which the
blood-pressure mainly depends, varies according to the
nature and duration of the disease. As a general rule, in
those febrile conditions in which the cardiac activity has not
been previously impaired by the severity of the infection, the
action of poison and the like, the blood-pressure at the com-
mencement.must of necessity be increased in consequence of
the numerical increase in the heart’s pulsations which accom-
panies the rise of temperature, the force of the contraction
in each separate systole remaining the same, or possibly
augmented by the increase of temperature. This result has
been obtained in the few experiments recently performed. by
Zadek and Basch with the object of measuring the pressure if
febrile conditions (97). In'this respect, therefore, the condi-
110 CERTAIN PECULIAR FORMS OF

tion of a patient suffering from fever exactly resembles that
of an animal artificially heated, so long as the increase in the
bodily temperature does not exceed certain limits and does not
exercise a paralysing effect upon the nervous apparatus (see
page 47). The diminution also in the quantity of urine is ag
common in fevers, and for reasons that are well known, as in
cases where the temperature is artificially raised, so that those
instances of febrile albuminuria which present themselves,
accompanied by a properly maintained action of the heart,
a strong pulse, &c., may, without any hesitation, be classed
together with that form which is induced by the artificial ap-
plication of heat. The elevation of the bodily temperature is
the essential, if not the only condition for the production
of the albuminuria, the immediate origin of which has been
explained in previous pages. The conditions may be entirely
different in the subsequent course of a fever, or in cases of
severe infection or poisoning, or even at the commencement
of a fever in a person already debilitated. In these cases,
no doubt, the blood-pressure will fall below the normal
degree. And therein, as we have seen when discussing the
influence of diminished pressure, may be discovered a condi-
tion for the production of albuminuria, but one which will
probably be insufficient per se for such a purpose, inasmuch
as the pressure is not usually reduced to a considerable
extent. But there are other factors of various kinds which
act in the same direction, and whose influence is greater in
severe febrile conditions accompanied by decreasing cardiac
activity than in others; among these a prominent place may
be assigned to derangements of the nutrition of the renal
epithelium and possibly also of the walls of the vessels. We
know that such derangements occur, and that their intensity
varies with the disease which originates them, and we have
already discussed their possible influence in the causation of
albuminuria. As a further step we have to consider the
altered condition of the blood in fevers. We do not know
much about this, but we know enough to enable us to assert
that this factor also can play a certain part in the production
of febrile albuminuria. I here refer to what has been stated
in a previous page with regard to the influence which the
increased amount of urea contained in the blood exercises
MORBID ALBUMINURIA. 111

upon the filtration of albumen (see page 97, et seq.) The
above-mentioned factors are assuredly sufficient for the
explanation of every febrile albuminuria ‘in the ordinary
sense of the words, involving as they do only the excretion
of coagulable albumen. But the possibility is by no means
excluded that the febrile varieties of the metamorphosis of
tissue, the changes in the condition of the blood, unknown
it may be to us, but doubtless present, may serve as a
screen for a number of other factors favorable to the deve-
lopment of albuminuria. This supposition must almost
necessarily be accepted with regard to the instances
designated by Gerhardt as “latent albuminuria,” in which
albuminous substances, non-coagulable by heat, were excreted ;
and consequently for cases of peptonuria or propeptonuria, as
these occur not merely in non-febrile but also in febrile
diseases, and, as it would appear, often under the influence of
the fever alone, and not of the particular disease which the
latter accompanies. The few statements that can be made
on this subject have already found a place in the fore-
going sections (see pp. 8 and 107). Unfortunately, under
the circumstances, the domain of facts has its narrow limits.
while there is a wide field for hypothesis.

This wide field would have to be thoroughly traversed if
the attempt were to be made to explain every instance of
albuminuria occurring in the course of disordered states, but
without the kidneys being deeply involved. I do not assert
that the morbid processes are everywhere enveloped in
so much obscurity, that the causes which have led to the
albuminuria are always beyond our comprehension. This .is
by no means the case, for in this or that disorder the par-
ticular circumstance to which the albuminuria is due can
often be definitely specified ; we know, for example, that the
albuminuria in cholera is due to the great inspissation of the
blood, whereby it is made to contain more albumen and, for
a short time, more saline constituents (see pp. 97—99) ;
secondly, to the intense venous congestion of the kidneys; and
lastly, to that degeneration of the epithelium and walls of the
vessels which necessarily results when the tissues are tra-
versed by abnormally constituted blood flowing in an abnor-
mally retarded current. Hach of these factors may per se, as
112 CERTAIN PECULIAR FORMS OF

already explained, give rise to albuminuria ; two or three of
them combined will, as a matter of course, be the more
certain to produce it. With regard to the temporary albumi-
nuria, not seldom to be observed in diarrhceas of other kinds,
and which has recently attracted attention (98), we are to
some extent justified in attributing it to the diminution of the
water of the blood and the diminished blood-pressure which
usually co-exists ; but these exhaust the category of morbid
conditions, apart from kidney disorders proper, in which there
are ab least a few facts as a basis of support for the ex-
planation of any existent albuminuria.

There are, as a matter of course, on the whole but few
difficulties in explaining the excretion of albumen in renal
disorders proper, i.e. nephritis in its various forms and
amyloid degeneration ; that is to say, in those processes in
which albuminuria is so constant and so marked a. pheno-
menon that they were in former times simply identified with
it. And the acute inflammatory processes are the simplest
of all as regards the facility with which the albuminuria can
be explained. For the fact is that each vascular portion ina
state of inflammation is abnormally permeable, and permits
the escape of a fluid containing in particular a large amount
of albumen and of cells in addition. Albuminuria is con-
sequently a necessary symptom of all active inflammations in
the kidneys, that is, both of those forms which are acute from
their commencement, and throughout their course, and of the
acute inflammatory exacerbations which occur in the chronic
forms. If it be not invariably observed in inflammations of
a purely circumscribed character, the reason for this may be
partly because the connection of the inflamed portions with the
discharge-tubes is interrupted, and partly also because the
amount of albumen yielded by the area in question is too
small to be detected, especially if such circumscribed inflam-
mations do not affect the glomerular vessels. For there can
be no possible doubt but that the glomeruli are invariably
the principal and most prolific source of the albumen, and
hence it is that the urine containing the highest proportion
of albumen is always yielded in cases of acute (diffuse)
nephritis. In every acute inflammation of the kidney the
glomeruli are especially affected, or we may rather say tha

t
MORBID ALBUMINURIA. 1138

-they are the starting-point for the inflammation, as has been
-shown by the investigations of Klebs, Salvioli, Cohnheim,
Friedlander, and Ribbert (99) on the subject of glomerulo-
nephritis. In all cases the deposit of exudation in the
Bowman-Miiller’s capsules can be easily demonstrated. The
possible participation of the interstitial vascular system in
‘the excretion of albumen must, however, be assumed,
because the interstitial tissue and the epithelium of the
-uriniferous tubules almost always become involved, and an
escape of albumen into the interior of the tubules may
‘doubtless take place in consequence. But from the
-anatomical appearances it is easy to form a conception of
the condition of the urine in some other respects in every case
-of acute nephritis, and it would appear especially that the
diminution in the quantity must necessarily be referred to
the co-operation of several conditions. In the first place the
. glomerular vessels are compressed, on the one hand, by the
escape of the exudation into the capsules, and by the cell-
proliferation proceeding from the walls of the latter ; on the
-other hand, their walls become infiltrated with fluid and
.Swollen, and their calibre greatly diminished. A second
factor is the retardation in the current, which, according to
-Cohnheim, takes place in inflamed tissues; and, lastly, the
uriniferous tubules situated in the inflamed interstitial areas
.must become occluded by the pressure from without, and
by the infiltrated and detached epithelial cells.

It is, I think, a less easy and a less simple task, to arrive
-at an explanation of the processes which take place in those
renal affections which are embraced under the term “‘ chronic
nephritis ” or ‘chronic form of Bright’s disease.” This is
not the place to enter minutely into the question, so warmly
- discussed of late, as to whether all those affections included
under that designation, are naturally connected and invari-
-ably depend on one and the same process, or whether and to
what extent they are to be distinguished from each other.
It is the less necessary to discuss this question inasmuch as
no great difference of opinion prevails on those points in
which we are now interested, that is, with regard to the con-
-dition of the urine, and to the anatomical appearances in the

-kidney—the differences in question mainly relating to the
8
114 CERTAIN PECULIAR FORMS OF

development and succession of the processes, and to the
relation which the hypertrophy of the heart, and the vascular
changes in general, bear to the renal affection. It is thus
almost universally admitted that, from a clinical point of view,
there are two well-marked types of chronic kidney disease.
The first of these exhibits from the commencement the follow-
ing characteristics : more or less extensive anasarca, marked
anemia, highly albuminous urine abounding in morphotic
constituents (casts, red and white blood-corpuscles, epithelial
cells), scanty in quantity when the disease is at its height,
or scarcely reaching the normal amount, and, lastly, no mani-
fest hypertrophy of the heart. The second variety commences
without anasarca, and generally without any remarkable dis-
turbance of the general health; the urine is limpid, clear, poor
in albumen, but excessive in quantity, and these symptoms
are usually associated with hypertrophy of the left side of the
heart. Every physician who has had only a moderate
amount of experience is acquainted with cases of disease
which correspond to the one or other of these types—cases,
the symptoms of which, without any other disease or any
precursory stage, make their appearance exclusively in one
or other of these modes, and which run their course for many
years, it may be, with variations in intensity until death
ensues.’ In like manner, considered anatomically, two typi-
cal forms stand out sharply from the great variety of all

1 Tn discussing the question of the development of cardiac hypertrophy in
renal diseases, several authorities attach considerable importance to the
influence of the prolonged duration of the latter, and the chronic character
of their course, and I therefore make the express remark that I have
repeatedly seen cases belonging to the former of the above-mentioned types
going on for many years without cardiac hypertrophy, but with good general
nutrition, if death occurred before the above-described first type became
changed ; that is, before it passed into that named by myself and other,
secondary atrophy, a process the development of which may require many
years. It is true that in these cases the whole series of symptoms was not un-
interruptedly present ; the dropsy altogether disappeared at intervals, wheress
the albuminuria, and, therefore, the renal lesion as well, were continuous. At
the present time there is in my division of the hospital a strong carpenter,
admitted for the third time, whoa year and nine months ago first fell ill with
symptoms of the first type of nephritis, but apparently regained his
strength and went on with his work. After being under treatment fot
several months the dropsical symptoms have now again abated, and the
MORBID ALBUMINURIA. 115

chronic renal affections ; the one described as the large white
or mottled kidney (chronic parenchymatous, diffuse nephritis,
Weigert’s sub-chronic nephritis, &c.), and the other known
under the name of the “ red granular or contracted kidney ”
(genuine renal cirrhosis) ; the former is the more inflammatory
form, the chief microscopical characters of which are swelling
and fatty degeneration of the epithelium of the uriniferous
tubules and accumulation of round cells in the interstices
(and likewise in the Malpighian capsules) ; the latter is more
of an indurated character, in consequence of the development
of a firm connective tissue with but few cells and tending
towards atrophy, and of wasting of the glomerular vessels: I
repeat that there are these two forms, standing out clearly by
reason of their marked character, but I also lay stress upon the
fact that all chronically diseased kidneys by no means corres-
pond exactly to one or the other type, but that numerous cases
occupy an intermediate position between them, or approach
partly to the one and partly to the other type ; and that conse-
quently these two types may be regarded as the terminal
extremities of a series in which there are gradual transitions
from the one extremity to the other. And this further
remark must be made that the first form may even clinically
pass by degrees into the second, and inasmuch as we are
accustomed to regard the anatomical changes in both cases
as of an inflammatory nature, those of the first type being
of more recent origin, those of the second of an earlier date
and as resulting from the former, we may well suppose that the
second type represents, in its anatomy at least, a later stage
of the first type, or, at all events, a slower form of develop-
ment. But the question may well be asked, do all these
considerations constitute a sufficient reason for adopting a
modern view, which regards all forms as mutually connected
in every respect, and promulgates the doctrine of the “unity
of chronic nephritis ” or of “ Bright’s disease of the kidney ?””
If this view be a reasonable one, then no distinction, clinical
patient appears to be in good health. Notwithstanding the long duration of
the disease there is not a single symptom of hypertrophy of the heart, and
there is no ground whatever for the suggestion of amyloid disease, in which
the hypertrophy is. absent. On the other hand, it is well known that in the

second type the earliest symptom of renal disorder is usually accompanied by
cardiac hypertrophy, which can for the most part be clinically demonstrated,
116 CERTAIN PECULIAR FORMS OF

or anatomical, could be drawn between “chronic interstitial
pneumonia or cirrhosis of the lung” and other forms of
“ chronic pneumonia,” for these conditions are precisely anala-
gous to those of the chronic affections of the kidney. Among
the vast number of forms of chronic pneumonia, there is one
which clinically stands out so sharply from all the others,
that every experienced physician immediately recognises in
it the typical cirrhosis of the lung which, since Corrigan’s
classical description, has been and still is, unhesitatingly
regarded as a peculiar form. And need I say that there are
other forms of ‘chronic pneumonia,” whose symptoms differ
from this latter type, as widely as day does from night, so that
the two cannot be confounded together? or need I say that
between these typical forms, placed as they are at each
extremity of the large series of chronic pneumonias, there
exist sn innumerable number of cases representing very
gradual stages of transition from the one to the other, in
such a manner as to prevent any definition of an exact limit
to the series ? And is the case different in an anatomical point
of view? No anatomist will have any hesitation in recog-
nising a typical “ cirrhosis of the lung,” set up perhaps as
a result of pleuritis or of some disease due to inhalation of
irritating dust, and in distinguishing it from other chronic
forms of inflammation of the lung, notwithstanding the
numerous imperceptible transitions from the latter to the
former and vice versd., and in spite of the fact that a really
pure interstitial pneumonia as little exists as a pure, ex-
clusively interstitial nephritis, Neither in cirrhosis of
the lungs, of the kidneys, or of any other organ is the
morbid process confined exclusively to the interstitial tissue,
nor in the other chronic inflammations is the so-called paren-
chyma alone involved and the connective-tissue framework
unaffected. It would be difficult to imagine that any such
exemptions exist in the living body, in which no system of
the elementary tissues is separated from its neighbour by 1
impenetrable wall. We are scarcely able in all cases of chronic.
pneumonia even to determine which system forms the starting-
point of the disease, and there is just the same difficulty in
many cases of chronic nephritis. The important point is
determine the predominant factor in the morbid process, what
MORBID ALBUMINURIA. 117

it is that impresses special features upon the disease and
stamps the anatomical marks upon the affected organ. This,
in typical cases of cirrhosis, is represented by a development
of fibrillary connective tissue, which forces everything else
into the background in consequence of its vast predominance
and its results; on the other hand, in the cases which are
the farthest removed from this type, the new formation of
connective tissue recedes into the background when contrasted
with the cellular infiltration and the parenchymatous degene-
ration of the epithelium. It is not the longer duration and the
more tedious progress of the disease which are the primary and
principal factors in the production of the cirrhotic type, for,
as I have already mentioned, years may pass by without this
type becoming developed, while in other cases it makes its
appearance after a brief interval. A better opportunity is
afforded us in the lungs than in any other organs, of watch-
ing the development within a few months of a perfect state
of cirrhosis, such as in other cases of chronic pneumonia is
not attained after an interval of several years. It is, there-
fore, not the peculiarity of every chronic inflammation to
induce cirrhosis; for there are, for example, suppurations
running a very chronic course, but the production of cirrhosis
necessitates the antecedent occurrence of something or other
that is peculiar, or its supervention in the course of the
disease. The nature of this peculiarity does not fall within
the scope of our present investigation.

It would, moreover, appear that the diversity in the course
of the two types is not dependent upon the renal affection
alone. In addition to the fact that dropsy is as constant in
the one type as it is rare in the other, the way in which this
symptom makes its appearance is so peculiar that the idea
suggests itself that some disease of the skin is concerned in its
production. Itis perfectly evident that the dropsical effusion
cannot be referred to suppression or diminution of the urinary
secretion, an explanation advanced by some observers. Hven
the complete interruption of the discharge of urine, which
may originate from obstruction in the urinary passages, does
not, per se, produce dropsy as a consequence. Cohnheim
(100) very particularly refers to the fact that neither hydramia
nor hydremic plethora can be the cause of the dropsy in
T18 CERTAIN PECULIAR FORMS OF

those diseases of the kidney. Its proportionately rapid
supervention, the great extent of the anasarca, and above
all its localisation, would rather seem to indicate the exist-
ence of special local abnormalities, which Cohnheim is inclined
to look for in some inflammatory change of the skin or its
vessels. Itis in fact difficult, without some such assumption,
to explain how it comes to pass that, in the first form of
chronic nephritis (and also in acute nephritis), the eyelids or
the scrotum are the usual seats of the oedema, and often
those which are first affected; for, as regards these parts, the
influence of gravity cannot be a sufficient cause for the
appearance of the symptom.’ How different are the
features presented by the genuine renal cirrhosis! Even
in this affection a period of dropsy may set in, especially if
the heart’s action becomes defective and the typical features
of the disorder become obliterated. The condition of such
patients obviously then resembles that of cases of heart-
disease in the stage of defective compensation, and especially
with regard to the dropsy, which in these latter depends
mainly upon venous congestion. Hence in these cases the
localities in which cedema first appears are the lower extremi-
ties, and the dependent parts in general; and this cedema is
accompanied by more or less intense cyanosis, of which no
trace is exhibited by the dropsical patients included in the
first category, unless, perhaps, some special causes supervens
in addition.

All these diversities serve to explain the dissimilar cor-
ditions of the urine in the two typical forms. In the one,
the large white (mottled) kidney, the condition which infi-
ences the result is the abnormal permeability of all the
elements of the tissue, due to the swelling and fatty deger-
eration of the epithelium, and to the infiltration of the organ
by round cells ; a condition from which the glomeruli ani
their capsules are not exempt. Under these circumstances,
the transudatory and secretory apparatus must necessarily
yield a highly albuminous fluid, in the production of whid

1 In two cases of scarlatinal dropsy without albuminuria I noticed adem
of the face alone in one instance; in the other only cedema of the face a
‘scrotum, persisting for several weeks, in the latter case without the previow
appearance of any other trace of dropsy.
MORBID ALBUMINURIA. 119

the swelling and degeneration of the epithelium, namely,
of the capsules, glomeruli, and uriniferous tubules, though
not unconcerned in the escape of the albumen (see page 78),
have not even been taken into account. It is evident
that there will be no lack of blood and pus-corpuscles,
epithelial cells and casts, whether these last are formed out
of coagulated albumen or epithelium. In like manner it is
obvious that the urine must be reduced in quantity in conse-
quence of the pressure which the infiltrated cells exercise
upon the capsules and glomeruli, and likewise upon the
uriniferous tubules, and in consequence of the more or less
decided occlusion which will take place in the last-named
structures as a result of the swelling, degeneration, and
detachment of the epithelial cells. In this respect the con-
ditions resemble those of acute nephritis, but in the latter
the progress of the symptoms is of a more violent character,
and corresponding with the acuteness of the inflammation, is
marked by intense hyperemia and considerable hemorrhage.
But even in the chronic form, to which we are now alluding,
such acute exacerbations are by no means rare; on the other
hand, an improvement may set in, the morbid process coming
to an end in certain spots, though complete restoration does
not take place. That such changes occur is shown by the
varying condition of the urine, and especially by the diminu-
tion from time to time of the formed constituents.

We have already stated that it is more than probable. that
simultaneously with this nephritis some peculiar disorder of
the skin sets in, causing it to become cedematous. When
this is the case, it is obvious that an improvement may occur,
accompanied by absorption of the watery effusion, which is
more freely removed by the kidneys, if at the same time the
morbid process of which they are the seat undergoes an
improvement or its progress becomes arrested. But even in
the absence of any such improvement in the state of
the kidneys, the absorption of copious effusion would
cause a strong current of ‘fluid to set in towards these
organs, and any inflammatory products that might be
present would be thereby steadily removed. As a matter
of fact, we often notice that as cedema disappears, the
urine becomes more abundant, but without losing any of its
120 CERTAIN PECULIAR FORMS OF

other characteristics; that is to say, it remains cloudy, con--
tains more or less blood and much albumen, and deposits a
copious precipitate of formed elements. Possibly this is to be-
explained by the fact that the inflammatory processes in the
kidney still continue, whereas the condition of the skin becomes.
improved. The increase in the quantity of urine, which occurs
at a certain stage in this form of chronic nephritis, might con-
sequently be regarded as due to the absorption of the dropsical
effusion ; but the converse could not be assumed, viz. that the-
disappearance of the latter is due to increased diuresis..
This latter process takes place when the form of disease has.
its starting point in (“ secondary ”’) atrophy, which is induced
when the development of the fibrillary connective tissue pre-
ponderates. The conditions in that case more and more
approximate to those of the primary or genuine cirrhosis of
the kidney. :

In this last-named condition it is not the abnormal permea-
bility of the tissue and of the vessels in particular which is.
the determining factor, but the increased arterial pressure.
We may not assume that the vessels embedded in the close:
meshes of a fibrous connective tissue, and themselves for the
most part thickened and indurated, are to an abnormal extent
permeable by albumen; and such a view is also decidedly
contravened by the state of cicatricial connective tissue in
other parts, e.g. the skin, when dropsical effusion exists.
The small and the varying amount of albumen found in the
urine in cases of renal cirrhosis must, therefore, in my
opinion, be referred to the coexistence of small inflamma-
tory areas, the predominance of which is a feature of the
former type, but which are not altogether wanting in the
disease in question. In cases in which these are absent, or
no longer active, the albuminuria, that is, the manifest
excretion of albumen, will disappear, and the more so because
the quantity of urine will be simultaneously increased and its
percentage of albumen consequently still further reduced.
It is universally admitted that the increase in the quantity
of urine is the result of the enormous increase of pressure,
which must occur in the vessels which are still pervious, in
consequence of the wide-spread destruction of these parts
and the co-existent cardiac hypertrophy. TI regard it also as
MORBID ALBUMINURIA. 12t

certain, that in this cirrhosis, in which the large majority of
the glomeruli are not seldom destroyed, the increase in the
quantity of the urine is in great measure due to the increased
activity of the secretory epithelium, a large portion of which
is usually in a normal condition. This view is further sup-
ported by the fact that the quantity of the specific urinary
constituents (at least of the urea), secreted by such kidneys,
corresponds absolutely with the conditions connected with
the nutrition, though the percentage is reduced. The epi-
thelium in this case acts similarly to all other glandular epithe-
lium when under increased arterial pressure (conf., p. 40).

Disorder of the skin with tendency to cedema, as occurs
in the first type, or in acute nephritis, is absent in the-
typical cirrhosis, although the cutaneous arteries are not
seldom thickened just as those in the kidneys (101). This
vascular disorder, however, is not such as to cause cedema.
It is only when the heart’s action becomes feeble that
cedema and other effusions set in, and are accompanied by
decreased secretion of urine.

I must repeat that the above descriptions correspond only
to the marked types of chronic nephritis, to those which
stand at the ends of the scale, and that there are numberless
cases in which the typical characters are more or less.
obliterated. To arrive at a proper estimate of these con-
ditions it will always be useful to remember the analogy
they present with chronic inflammations of the lung, the
mutual relationships of which, however, are more distinct.

Finally, with reference to amyloid degeneration I can be
very brief in my remarks, for I have little that is positive.
to state with regard to the influence of this condition upon
the secretion of urine. I agree with others in supposing
that the vessels in a state of amyloid degeneration are
abnormally permeable, and therefore offer less than the
normal obstacle to the escape of the albuminous substances
dissolved in the blood. No strict proof can be adduced.
for that hypothesis, which, however, is perhaps supported
by the fact that obstinate diarrhoea is such a common
symptom in cases of extensive amyloid degeneration
of the intestines. This may, however, be due rather to
defective absorption and increased peristaltic action. It
122 LITERATURE REFERRED TO.

appears to me to be probable that.not only the glomerular
vessels when in a state of amyloid degeneration, but that
the epithelium and the interstitial vascular system as well,
when similarly affected, are involved in the excretion of
albumen. When examining kidneys in a state of amyloid
degeneration I have repeatedly noticed a marked deposit of
albumen in the tubuli uriniferi, especially of the cortex,
with but very little excretion in the capsules. Posner also
incidentally alludes to the same appearances (102). It is,
moreover, a well-ascertained fact that pure amyloid degene-
ration rarely occurs alone, but is far more often associated
with interstitial nephritis; the urinary secretion, in such
cases, exhibiting corresponding alterations.

LITERATURE REFERRED TO IN THE TEXT.

(1) J. B. Stokvis, Recherches expérimentales sur les conditions patho-
géniques de l’albuminurie. Bruxelles, 1867.
(2) Runeberg, Deutsches Archiv f. klin. Med., xxiii, 1879, S. 41.
(3) C. Posner, Virchow’s Archiv, lxxix, S. 335.
(4) Ribbert, Centralblatt f. d. med. Wiss., 1879, S. 836; Nephritis und
Albuminurie. Bonn, 1881.
(5) Litten, Centralblatt f. d. med.’ Wiss., 1880, S. 161.
(6) Litten, Frerichs’ und Leyden’s Zeitschrift f. klin. Med., i, S. 177-178.
(7) Cohnheim, Virchow’s Archiv, 1868, xli, S. 220.
(8) Cohnheim, Allgem. Pathol. Berlin, ii, 1880, 8. 315.
(9) R. Heidenhain, in Hermann’s Handb. d. Physiologie. Leipzig, v, 1880,
8. 336 u. 375.
(10) Charcot, Progrés médical, 1881.
(11) Lépine, Revue mensuelle de méd. et de chirurgie, Paris, 1880, Mars,
Avril.
(12) Estelle, Revue des sciences méd., 1880, No. 9.
(13) Hammarsten, Pfliiger’s Arch., xvii, 1878, S. 413.
(14) Hofmeister, Hoppe-Seyler’s Zeitschr. f. phys. Chemie, 1880 u. 1881;
Maixner, Vierteljahrsschr. f. pract. Heilk., 1879, 3; R. Jaksch, Prager
med. Wochenschr., 1881, Nos. 7—9.
(15) Selmi, Mem. dell’ Acad. di Bologna nach Virchow-Hirsch’s Jahresb.,
1881, 8. 140.
(16) W. Kiihne, Verhandlungen des Heidelberger naturhist. Vereins, N. F.,
1876, i, S. 194; Schmidt-Miihlheim, du Bois-Reymond’s Arch. £
1880, 8. 33; E. Salkowski, Virchow’s Archiv, lxxxi, 1880, 8. 552.
(164) Kiihne, Phys. Chemie, S. 466.
(17) Virchow, dessen Arch., iv, 1852, S. 309; Fleischer das. lxxx, S. 482;
Bence Jones, Philos. Transactions, 1848, i, Pp. 55; Langendorff und
Momnsen, Virchow’s Arch., lxix, 9. 452; Kiihne, 1. c., ii, S. 6.
LITERATURE REFERRED TO. 123

(18) Prout,s. bei Beneke, Grundlinien der Pathol. des Stoff{wechsels. Berlin,
1874, S. 232; Fiirbringer, Berliner klin. Woch., 1878, No. 15;
Gowers, Lancet, 1878, ii, No. 1.

(19) Stokvis, Maandblaad der Sectie voor Naturwetensch, 1872, No. 6.

(20) Lassar, Virchow’s Arch., lxxvii, 8. 157.

(21) Hindenlang, Berliner klin. Wochenschr., 1881, No. 15.

(22) Harley, Med. Times and Gaz., 1865, Novbr.; Béchamp, Comptes rend.,
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Kleudgen, Arch. f. Psychiatrie und Nervenkrkh., xi, 2.

(26) Kiss bei J. Picard, Thése de la présence de l’unée dans le sang. Strass-
bourg, 1856 und: Legons de physiologie.

(27) v. Wittich, Virchow’s Arch., 1856, x, 8. 325.

(28) Henle, Nachrichten von d. G. A. Universitit zu Géttingen, 1863,
8. 257.

(29) Ribbert, Nephritis u. Albuminurie, S. 5, 6, und 66.

(30) Frommann, Virchow’s Arch., xvii, 8.141; Reimer, Arch. d. Heilk., xvi,
1875, S. 296 ff.

(31) Bartels, Nierenkrkh. in v. Ziemssen’s Hdb. d. Pathol., ix, 1,8. 39 u.
177.

(32) Nussbaum, Pfluger’s Arch., xvi u. xvii.

(33) Hensen u. Dahnhardt, Arb. aus d. Kieler physiolog. Inst., 1868. Kiel,
8. 27.

(34) Cohnhein, 1. c., i, 8. 409.

(38) Emminghaus, Berichte der siichs. Ges. d. Wissensch. (aus dem Leipziger
physiol. Inst.), 1873, 8. 414, 475.

(36) D. Newman, Proceed. of the R. Soc. of Edinb., 1878, p. 648.

(37) Gottwalt, Hoppe-Seyler’s Ztschr. £. physiol. Chemie, iv, 8. 423.

(38) v. Bamberger, Wiener med. Wochenschr., 1881.

(39) F. Hoppe, Virchow’s Arch., 1856, ix, S. 245. s

(40) Ludwig und Zawarykin, Wiener ak. Stzsbg., xlviii, 1863, S. 16.

(41) Rindowsky, Centralbl. f. d. med. Wiss., 1869, 8S. 145.

(42) Bridges Adams, Hamoglobinausscheidung in d. Niere. Dissertat. Leip-
zig, 1880.
124 LITERATURE REFERRED To.

(43) Virchow, sein Arch., xii, 8. 310.

(44) Ludwig, Wiener ak. Stzgsb., 1863, xlviii, Novbr.

(48) Griitzner, Pfliiger’s Archiv, xi, 1875, 8. 370.

(46) Litten, Verhandlungen d. Berl. med. Gesellsch., 1878, Mai 29 und
Centralblatt f. d. med. Wiss., 1880, S. 161 ff.

(47) Nawalichin, Centralbl. f. d. med. Wiss., 1870, 8. 483.

(48) G. H. Meyer, Zeitschr. f. physiol. Heilk., 1844, 8. 149; Robinson,
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(49) v. Wittich, Kénigsberger med. Jahrb., 1861, iii, S. 52; Vulpian, Gaz.
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Stzgsb., 1861, xlv, S. 317; Knoll, Eckard’s Beitr. zur Anat. u. Phys.,
1870, vi, 8. 39.

(50) Paschutin, Ber. der sachs. Ges. d. Wiss. (aus dem Leipziger phys,
Tnst.), 1873, S. 229.

(51) Zadek, Zeitschrift f. klin. Med. v. Frerichs u. Leyden, ii, S. 509.

(52) W. Schmidt, Poggendorff’s Ann. der Physik, &c., 1856, xcix.

(53) Eckhard, Das, 1866, cxxviii, S. 61.

(54) J. Ranke, Die Blutvertheilung und der Thatigkeitswechsel der Organe,
Leipzig, 1871.

(85) Hafiz, Ber. d. siichs. Ges. d. Wiss. (aus dem Leipziger physiol. Inst.),
1870, Aug. 1.

(56) Heidenhain, 1. c., S. 262, 263.

(57) Runeberg, Deutsch. Arch. f£. klin. Med., 1880, xxvi, S. 211.

(58) Vierordt u. Aberle, Die Messung des Arterienumfanges. Tiibingen,
1856.

(59) Cohnheim, 1. c., ii, 8. 310.

(60) Weissgerber u. Perls, Arch. f. exp. Pathol. u. Pharmacol., vi, 8. 130 ff.

(61) M. Herrmann, Zeitschr. f. rat. Med., 1863, xvii, S. 1; v. Overbeck,
Wiener ak. Stzgsb., xlii, 2, S. 189.

(62) Frerichs, l.c.; Rosenstein, Virchow’s Arch., liii, 8. A. 8. 14, 15.

(63) Cl. oe Lecons sur les propriétés physiol., &c., Paris, 1859, ii,
p. 136.

(64) Runeberg, D. Arch. f. klin. Med., xxiii, 8. 59.

(65) Stokvis, 1. c., 8. 84; M. Herrmann, 1. c.

(66) Frerichs, Klinik der Leberkrkh, i, 8. 373.

(67) Schwengers u. Leichtenstern, Berliner klin. Woch., 1881, Nos. 34 u. 35.

(68) Ludwig, Wiener ak. Stzgsb., 1863, xlviii, Novbr.; Senator, Virchow’s
Arch., lx, 8. 496; Heidenhain, l.c., S. 316.

(69) Bartels, Deutsch. Arch. f. klin. Med.,i,S. 13 ; Senator, Virchow’s Arch.,
xlii, S. 1.

(70) Stokvis, 1. c., S. 106; Kohts, Deutsch. Arch. f. klin. Med., v, S. 198.

(71) Ph. Munk u. Leyden, Die acute Phosphorvergiftung, Berlin, 1865.

(72) Schultzen u. Riess, Ann. d. Charité-Krankh., xv, 1869, 8S. 102 ff.

(73) Meischner, Die acute Phosphorose, Diss, Leipzig, 1864; Hessler,
Eulenberg’s Vjhrschr., 1881, xxv, 8. 256.
LITERATURE REFERRED To. 125

(74) Thénard bei Frerichs, Leberkrkh, i, 8. 316 ; Lehmann, Physiol. Chemie,
i, S. 57.

(75) Runeberg, l.c., xxiii, S. 259.

(76) Cohnheim, Lc., ii, S. 78 und dagegen i, S. 543.

(77) Gergens, Arch. £. exp. Pathol., &c., 1876, vi, 8. 149 ; Weigert, Virchow’s
Arch., lxxii, 8.254; Kabierske, Dissert. Breslau, 1880 ; Lassar, Virch.
Arch., lxxvii, 8. 157; Posner, 1. ¢., 8. 333 u. S. 348; Browicz, Cen-
tralblatt £. d. med. Wiss., 1879, 8. 148 ; Voorhoeve, Virchow’s Archiv,
lxxx, 8. 247.

(78) Ermann, Eulenberg’s Vjschr. f. ger. Med., xxiii, 1880, S. 61.

(79) Senator, l.c., lx, S. 477.

(80) Bartels, 1. c., S. 36.

(81) F. Hoppe-Seyler, Physiol. Chemie, S. 75; Gottwalt, Ztschr. f. phys.
Chemie, 1880, iv, S. 437.

(82) Jaccoud, Des conditions pathogéniques de l’alb. Paris, 1861 ; Semmola,
Arch. gén. de méd., &c., 1867, ii, p. 616 f£; Revue mensuelle de méd.,
&c., 1880, No. 3.

(83) Stokvis, l.c., S. 63 ff.

(84) F. Hoppe-Seyler, Virchow’s Arch., ix, 1856, S. 248, u. Physiol. Chemie,
8. 1524£; v. Wittich, Miller’s Arch., 1856, S. 286 ; H. Nasse, Mar-
burger naturwiss. Sitzgsber, 1866, Nos. 5 u. 7; Newman, l.c.

(85) Parkes, Med. Times and Gaz., 1852 and 1854; Gubler, Union méd,,
1857, No. 155.

(86) Brunton u. Power, St. Barthol. Hosp. Rep., xiii, p. 283.

(87) Christison, On Granular Degeneration of the Kidneys. Edinb., 1839,

p. 36. :

(88) C. Schmidt, Zur Characteristik d. epid. Cholera, Mitau u. Leipzig, 1850.

(89) R. Gscheidlen, Studien tiber den Ursprung des Harnstoffs, Leipzig,
1871.

(90) A. Frankel, Virchow’s Arch., Ixvii, S. 273.

(gt) Tégart, Thése. Paris, 1845; Brown-Séquard bei Tessier, Thése sur
Vurémie. Paris, 1856; Becquerel u. Barreswil, Union méd., 1857,
No. 144; Hammond, Journ. de physiol., &c., 1858, p: 416; Cl. Ber-
nard, l. c., ii, S. 136 ££; J. C. Lehmann, Virchow’s Arch., xxx, 1864,
8. 593; Stokvis, l.c., 8. 40 ff.

(92) Creite, Ztschr. f£. rat. Med., xxxvi, 1869, 8. go.

(93) Lehmann, 1. c., Runeberg, Arch. d.'Heilk., xviii, 8. 44.

(94) Creite, 1. c., Landois, Centralbl. f. d. med. Wiss., 1873, S. 883 ; Ponfick,
Virchow’s Arch., xlii, 1874, S. 273.

(98) Ponfick bei Heidenhain, l.c., 8. 351.

(96) Gerhardt, 1. c.

(97) Zadek, 1. c.; v. Basch, Ztschr. f. klin, Med. von Frerichs u. Leyden,
lii, S. 502.

(98) J. Fischl, Prager Vjhrsschr, 1878, cxxxix, 8. 27; B. Stiller, Wiener
med. Wochenschr., 1880, Nos. 18, 19.

(99) Klebs, Path. Anat., ii, S. 644; Salvioli, Archivio per le sc. med., 1879,
iii; Cohnheim, l.c., ii, 8. 3204; Friedlinder, Verhdlg. der physio).
Ges. zu‘Berlin, 1880, Novbr. 19; Ribbert, Nephritis u. Albuminurie.
126 LITERATURE REFERRED TO.

(100) Cohnheim, 1. c., ii, S. 434 ff.

(101) Gull u. Sutton, Med.-Chir. Transact., lv, 1872, May 28; Senator, Ver-
handl. der Berliner med. Ges., 1880, Mai 12.

(102) Posner, l.¢., S. 323, Anm.

EXPLANATION OF THE ENGRAVING.

Section of rabbit’s kidney hardened by boiling and alcohol, coloured by a
solution of picro-carmine. The red colouration is not shown inj the
drawing. :

Fig. 1. After a ligature had been kept on the vein for ten minutes.
a. Deposit of albumen in the uriniferous tubules of the
medulla.

Fig. 2. Ligature on one ureter, retained for thirteen minutes. a. Ex-
tensive lymph-spaces filled with albumen, between the much-
dilated tubuli uriniferi. 6, Zdematous adventitia of an artery.
ip

PS as
 /OL
i a

 

ot cf fs S
De Boachobf Ol Mb. Schirige’ Sith. Sank. sw Berbir
A CONTRIBUTION

TO THE

THEORY OF URINARY SECRETION.’

Ir is well known that there are, at the present time, two
opposite theories on the subject of the secretion of urine;
one of these may be described as the filtration theory, the
other the secretion theory. The former, originated, as we:
all know, by Ludwig, transfers the entire process of secre-
tion to the Malpighian corpuscles, and assumes that the.
filtered fluid is subsequently converted into urine in accord-
ance with purely physical laws. I may take it for granted
that this view is well known.

In like manner I need not enter upon a minute discussion
of the objections to this theory, and which, especially of
late, have assumed some prominence. Although these do
not all possess an equal amount of demonstrative force, and,
from the standpoint of Ludwig’s theory, one or other of
them may be invalidated (as I shall by-and-bye have some
opportunity of showing), it must be admitted that certain
facts are irreconcilable with the theory in question. These
objections have been recently summed up by Heidenhain,*
and, so far as they refer to the secretion of the so-called
specific constituents of the urine, he has, I think, given a
very proper estimate of them. The result is that more
weight must again be attached to Bowman’s view with regard

1 A translation of a lecture delivered by Dr. Senator before the Physio-
logical Society of Berlin, December gth, 1881, and appended to the fore-
going essay at the author’s request. ‘ Archiv fiir Anatomie und Physiologie,’

1882.
? Hermann’s ‘ Handbuch der Physiologie,’ v. i.
128 THE THEORY OF THE

to the secretory function of the epithelium of the uriniferous
tubules, and since Heidenhain and his pupils have experi-
mentally demonstrated the correctness of this view, there
can scarcely be any doubt as to this function, even apart
from the consideration, adduced also by Bowman, that the
nature of these cells places them in the category of the
glandular epithelia. I consider it, therefore, to be an
established fact that the epithelial cells of the convoluted
uriniferous tubules, and possibly also to some extent those
of Henle’s loops, do secrete in a specific manner certain
constituents of the urine.

But Heidenhain has lately gone a step beyond this, inas-
much as he regards the excretion of the water (and of the
salts, its invariable accompaniment) from the vascular tufts, as
an instance, not merely of filtration, but of a real secretion
from the epithelium covering the glomeruli. And indeed
he believes that the activity of these epithelial cells depends
upon their supply of blood—its diminution when the current
is retarded being an especial feature—and that their normal
activity is also shown in preventing the escape of the serum-
albumen. The last remnants of Ludwig’s theory would thus
be demolished. It seems to me, however, that, on the one
hand, this portion of Heidenhain’s theory is destitute of a
sufficient basis, and is open to numerous objections ; and, on
the other, that there is no necessity for abandoning the
assumption that filtration takes place from the glomerular
vessels, whilst the epithelial cells of the tubuli uriniferi are
the seat of secretion.

In the first place it appears to me that to regard those
epithelial cells as actively secreting agents, that is, as
glandular epithelium, involves a very bold assumption, since
they differ in their histological characters from all the really
glandular epithelium with which we are acquainted. For,
after birth these cells are quite flat, and resemble the endo-
thelium of serous membranes or possibly the connective-
tissue cells ; and we should scarcely be disposed to attribute to
these such secretory activity as belongs only to cells very ditf-
ferently constituted, even if it were merely a question of the
secretion of water. We are the less inclined to do so,
inasmuch as we are acquainted with glands exercising such
SECRETION OF URINE. 129

a function, but as a matter of fact, exhibiting very dif-
ferently constituted epithelial cells. The glands in question,
which secrete only water and the salts which are its invari-
able accompaniment, are the lacrymal glands and the sweat-
glands. Their glandular epithelium is, however, not to be
compared with the epithelium of the vascular tufts. And
also in other respects, the condition of these glands is very
different from that of the glomeruli. The former are to
a certain extent independent of the blood-supply; on the
other hand, they are to a large extent influenced by specific
irritants and the condition of their innervation, as has
recently been demonstrated particularly with regard to the
secretion of the sweat-glands.! It is a point of special
importance that the secretion of sweat continues even
when the flow of blood is diminished. With regard to the
influence of the blood-supply upon the lacrymal secretion,
there are no experimental observations possessing an equal
amount of demonstrative force, but all experience supports
the view that similar conditions obtain. We know at least
that lacrymation is not checked in spite of the greatest
reduction in the arterial pressure and notwithstanding the
most profound anemia; the flow, indeed, is rather more
copious in these conditions under the influence of the ordinary
stimuli. And it may here be mentioned that Cl. Bernard in
his experiments upon horses, fully under the toxic influence
of curara, noticed that the lacrymal secretion was increased
before death—when the blood-supply was assuredly dimi-
nished.

The circumstances of the case with regard to the glomeruli
are of an entirely different character. Their excretion is
dependent exclusively upon the supply of blood, and no
stimulus can re-establish it when it has been arrested by
reducing the supply. In this respect this excretion differs
essentially from that which takes. places in the uriniferous
tubules. For our knowledge on this point we are indebted
to Heidenhain’s investigations, and also to those of Nuss-
baum, Griitzner, and others. In animals in which the
spinal cord has been divided, and the blood-pressure is conse-
quently so much reduced that no urine is secreted, the secretion

1 §. Luchsinger in Hermann’s ‘ Handbuch der Physiologie,’ v. i.
130 THE THEORY OF THE

may be re-established, and even without increasing the blood-
pressure, by the employment of various forms of stimuli, but
especially by injecting the so-called “ specific potential con-
stituents of urine”’ (harnfahige Stofe). This excretion, how-
ever, is solely the result of specific glandular secretion in the
uriniferous tubules, as is shown by the fact that it continues
after the vascular tufts have been excluded, either by (as in
frogs) applying a ligature to thei vessels, or by cauterisation.'
The epithelial cells of the tubuli uriniferi behave like other
glands, the activity of which is called forth or increased by
adequate stimuli; the vascular tufts, on the other hand,
notwithstanding their epithelial covering, do not exhibit a
similar capacity. Heidenhain is therefore compelled to assume
further that the quantity of water in the blood is the factor
which alone determines the activity of these epithelial cells,
and is at the same time their adequate stimulus; although he
does not overlook the necessity which consequently arises of
assigning an exceptional position among all glandular cells
to these epithelial structures.”

If, then, the assumption of a specific secretion of water
by those epithelial cells appears to be open to serious
objections, there are also many pathological facts which
flatly contradict it, and are evidences against the existence
of those peculiar properties which Heidenhain is compelled
to ascribe to the cells in question. We know that in renal
atrophy a large proportion of the vascular tufts, with their
epithelial investment and their capsules, are completely de-
stroyed, and yet the quantity of urine is not diminished, but,
on the contrary, very considerably increased. If the filtration
theory be accepted, the explanation of all this is very simple,
viz. that the pressure is very considerably increased in the
vessels which have escaped destruction and in those of the
interstitial vascular system ; in the first place because a large
number of small vessels of the kidney have been destroyed,
and in the second, because of the cardiac hypertrophy which
is not simply the mechanical consequence of the destruction
of the vessels. In this case the attempt might be made to
explain the increased secretion, if Heidenhain’s view be

1 See Heidenhain, ibid., pp. 338—340, p. 350, ef seq.
? Tbid., pp. 337-338.
SECRETION OF URINE. 131

adopted, by supposing that the epithelial cells of the non-
affected glomeruli secrete more freely than usual, in con-
sequence of the increased arterial pressure and the increased
blood-supply associated therewith. But anyone who has
ever seen a kidney of this kind, in which only a few
remnants of parenchyma are discoverable, will assuredly
come round to the opinion that it is scarcely possible
to attribute such an increase of secretion to the few
unaffected glomeruli. Nevertheless I admit that this is
no cogent objection against Heidenhain’s view, and that
the explanation referred to, although a highly improbable
one, might be admitted in its favour. There is, however,
more difficulty in the case of amyloid degeneration of the
kidney. In this affection the degenerative process usually
involves first and foremost the Malpighian tufts; it is
frequently confined to these and to their epithelium, of which
nothing is eventually recognisable. At the same time the
quantity of urine is not only not diminished, but as a general
rule, is increased beyond the normal amount. This fact can
scarcely be reconciled with Heidenhain’s assumption, but
it is a necessary result if we adopt the theory that the
Malpighian tufts are the seat of filtration. For in amyloid
degeneration, hydremia, that isto say, an abnormally slight
concentration of blood, is always present; and it is well
known that ceteris paribus, a diluted solution passes more
readily through a filter than a concentrated one. In order
to explain only the increased quantity of urine excreted, it is
not necessary to assume that the vessels in a state of amyloid
degeneration are abnormally pervious, an assumption that
may do well for the explanation of the albuminuria, and
which, moreover, has no connection with Heidenhain’s view.
In addition to this, amyloid degeneration of the kidneys some-
times occurs without albuminuria. Lastly, we are indebted to
Bartels! for a clinical observation which completely contradicts
that view of Heidenhain’s. In the case of a man suffering from
thrombosis of the inferior vena cava, but with normal action
of the heart, the urine passed was copious in quantity and
contained much blood and albumen. In consequence of the
thrombosis, there existed a marked congestion in all the
1 See v. Ziemssen’s ‘Handbuch der Pathologie,’ ix, 1, pp. 39, 177.
132 THE THEORY OF THE

rootlets of the inferior vena cava (as evidenced by the
intense cedema of the lower half of the body), and conse-.
quently a retardation of the blood-current in the kidneys,
which, according to Heidenhain, would necessarily impair-
the function of the epithelium in question, and cause a
decrease in the quantity of urine. In this manner indeed, he
explains the albuminuria, associated with a diminution in
the quantity of urine, which occurs in other kinds of venous.
congestion in the kidneys.! Now, in this case of Bartels’, either
the nutrition and function of the epithelium were impaired in.
consequence of the retardation of the blood-current, in which
case the excretion of urine must have decreased and not
increased ; or else they were not injured in spite of the
‘ retardation of blood, a supposition, however, which is not,
compatible with Heidenhain’s view. And moreover, they
would, if intact, allow no albumen or blood to pass. And if
it be supposed that in this case the albumen and blood
could be derived not from the vascular tufts, but from the
interstitial vascular system, an assumption which Heidenhain.
himself decidedly opposes, we do not get out of the difficulty ;
whereas if the filtration theory be accepted, the condition as.
a consequence of the highly increased pressure, admits of a
very simple explanation.

There are, besides, experimental facts which controvert
the assumption that the epithelium is capable of secretory
activity in the manner suggested ; or at least negative the
idea that the cells permit albumen to transude only when
the blood-supply is diminished or the blood-current is
retarded, but not when the supply of blood is increased.
As these matters belong to that division of albuminuria
which is to some extent pathological, and have already been
discussed very briefly in another place,? I shall not enter
into them here, and will only express the opinion that they
ean easily be explained if we accept the theory of filtration,
and not that of secretion in the tufts.

All alleged objections, some of which have a greater and
others a lesser weight, appear to me sufficient as a whole
to upset the assumption of a secretory action of the epithe-

1 Thid., p. 371.
* See pp. 39—77 of the foregoing translation.
SECRETION OF URINE. 133

lial cells which cover the tufts. Nevertheless there is some
justification for the reasons which have caused Heidenhain
to give up so completely the filtration theory. So far as
they relate to the excretion of the so-called specific con-
stituents of urine, and these latter are regarded as a product
of secretion by the epithelium of the uriniferous tubules, and
not the result of filtration, there can, as I said before, be
no question as to their correctness. It is, in some measure,
these same reasons which have induced Heidenhain to allow
that the process which takes place in the kidneys in general
is one of secretion, and not of filtration, and have, therefore,
caused him to place these organs on the same footing with
all other glands in which indubitably no mere process of
filtration takes place. For, as he very justly says, “as
regards all other glands, without exception, we know defi-
nitely that the passage of water out of the blood into the
secretion-spaces does not depend upon simple filtration.” }
But, according to my judgment, this very comparison with
all other glands would necessarily prevent us from expecting
that the processes in the kidneys would take the same
course. For the kidneys differ in their construction very
essentially from all other glands; it is not only by leaving
out of consideration the whole system of the Malpighian
bodies, with their afferent and efferent vessels, that any
general comparison can be instituted between the kidneys
and other glands. But as they most assuredly possess that
system, we are the more justified in expecting differences in
the processes of excretion rather than a conformity with
those of other glands. From this point of view, therefore,
we have certainly no grounds for refusing to admit that
filtration takes place in the vascular tufts. Heidenhain thinks
that his view is further supported by the fact that the quantity
of urine by no means invariably coincides, that is to say, rises
and falls, with the increase and diminution of pressure, as
would necessarily be the case if the excretion depended upon
filtration. This objection can easily be refuted by the state-
ment that, in point of fact, the kidney is no mere filtration
apparatus, but is in some degree a true gland, and that
therefore we must not expect that its action will be entirely
1 Thid., p. 331.
134 THE THEORY OF THE

dependent upon pressure. The reason, however, why
Heidenhain maintains this plea is that he considers the water
of the urine to be derived as a rule only from the Mal-
pighian tufts, and not from the capillaries surrounding the
uriniferous tubules, in accordance with the opinion hitherto
held with regard to the former structures. However, this
assumption also seems to be contrary to all analogy and
probability, for no true gland yields a secretion free from
water! And that the uriniferous tubules, after removal of
the glomerular system, can supply a true fluid urine has been
proved by Nussbaum in his experiments on frogs. The
potential constituents of urine, which are constantly present in
the blood, form, as I have already mentioned, the stimulus to
the secretory activity. When the force of the circulation
has been diminished after experimental division of the spinal
cord, a proportionately greater quantity of only one of
these potential urinary constituents is required in order to
excite to secretion the epithelium whose function the retarded
supply has impaired. The case must obviously be different
under normal conditions of circulation. In the first place,
the epithelium of the uriniferous tubules, when in a state of
normal nutrition, will react to slighter stimuli; for the blood
which circulates around these tubules is, as Ludwig urged
some years ago, concentrated by the escape of water, and
therefore conveys proportionately more urinary materials to
the epithelium. There is also this other fact to be con-
sidered, viz. that in the present case several urinary con-
stituents (urea, uric-acid-salts, chloride of sodium, &c.) co-
operate, and may, under normal conditions, produce an
effect identical with that which under abnormal conditions
(after division of the spinal cord, &c.) is evoked by a larger:
quantity of a single constituent. It must, therefore, be con-
sidered as proved that a portion of the water of the urine,
and doubtless the smaller portion, is supplied by the epithe-.
lium of the uriniferous tubules, and is a product of true
glandular activity. If, therefore, the watery constituent of
the urine is not always excreted in such quantity as Lud-
wig’s theory of filtration would lead us to anticipate, the

1 In the sebaceous glands there is no real secretion, but only proliferation
and fatty metamorphosis of the epithelium.
SECRETION OF URINE. 185

explanation is to be found in the fact that the kidney is a
filtrating apparatus only to a partial extent, and that the
anomalies are due not to the filtered, but to the secreted
elements of the urine.

But even if we admit, just for a moment, that all the
water in the urine is derived only from the tufts, yet the
facts adduced by Heidenhain with reference to the secretion
of water are by no means inconsistent with the filtration
theory. These facts are:—1. That after constriction or
closure of the renal veins the urine is immediately dimi-
nished in quantity (and at the same time becomes albu-
minous), whereas the pressure in the glomeruli is increased.
The usual explanation of this, according to Ludwig, is that
when a ligature is applied to a renal vein, the efferent
uriniferous tubules are compressed by the turgid veins in
the pyrainidal portions, and thus the escape of urine is pre-
vented in a purely mechanical manner. MHeidenhain does
not agree with this explanation, because such a dilatation of
the veins requires a certain time for its development,
whereas immediately after ligature of the veins the flow of
urine almost entirely ceases and is very soon completely
arrested, indications which point to the conclusion that the
process of excretion is rapidly suspended.!_ Much import-
ance cannot certainly be attached to this objection, for it
appears to me very probable that when the escape of blood
is prevented, the mechanical obstacle is ¢mmediately produced,
and in the direction from the pyramidal portions backwards
towards the glomeruli, and that a few seconds only are
required for this to take place. But even if, in this case,
the flow of urine ceases with such remarkable rapidity, the
fact appears to me to be inconsistent rather than otherwise
with the assumption that the excretion has come to a stand-
still. For in true glands, as, e.g. the liver and the salivary
glands, the excretion does not cease at the very instant that
the blood-current is interrupted, but only in a gradual
manner *—a, fact which is perfectly intelligible.

2. The other point relates to the condition of the urine as
regards its quantity when a liquid is conveyed into the blood.
On the one hand, for instance, according to Ponfick, a con-

1 Thid., p. 325. 2 Heidenhain, loc. cit., pp. 264, 46.
136 THE THEORY OF THE

siderable quantity of serum or dog’s blood can be injected
without any perceptible increase in the excretion of urine;
on the other hand, according to Pawlow, the absorption of
large quantities of fluids from the stomach produces an aug-
mentation of the urinary excretion without any rise in the
blood-pressure.’ I cannot conceive that these facts consti-
tute any obstacles to the theory of filtration. For, as
Heidenhain! himself insists, if, in the first case, when
fluid is injected into the blood, the pressure does not rise in
the manner previously supposed, it follows that there is,
ceteris paribus, no reason why increased filtration should
take place : but as regards the diuretic effect of the introduc-
tion of fluids into the stomach, in this case the question of
the dilution of the blood has to be taken into consideration,
for, as we all know, the filtration is very considerably pro-
moted by the dilution (see above). As a matter of course
the dilution produces the same effect, even when it is not the
result of absorption from the stomach. Thus, if instead of
serum or blood a dilute solution of chloride of sodium be
injected into the blood, a considerable increase in the quan-
tity of the urinary excretion would be noticed just as before,
and this increase would be unattended by any increase of
pressure.

If all these considerations do not directly establish the
truth of the filtration theory, at all events they do not con-
tradict it.

But finally, and this is a fundamental point of great im-
portance, Heidenhain thinks that, generally speaking, the
capillaries are not endowed with any universal capacity for
allowing larger quantities of fluid to pass through their coats
when the arterial blood-supply is increased, and that the
capillaries of the renal glomeruli, on account of their epi-
thelial covering, must offer more than usual resistance to
the filtration pressure. The latter point, i.e. the greater
resistance of a wall covered with epithelium need not be
contested, but surely the statement that transudation from
the capillaries is independent of pressure and especially of
arterial pressure, is contrary to the laws of filtration. In
proof of his assumption, Heidenhain appeals to experiments

1 Thid., p. 333.
SECRETION OF URINE. 137

made in Ludwig’s laboratory, with regard to the condition
of the lymphatic current under increased arterial pressure.
I do not consider this comparison. between the flow from an
opened lymphatic and transudation from the capillaries
to be admissible, for reasons given in the monograph
already alluded to, and which, to avoid prolixity, I will
not again discuss. It is quite sufficient for me to point
out that morphologically as well as chemically, the contents
of the lymphatic trunks differ from transudations; that
those contents cease to flow under circumstances which
undoubtedly have no similar effect upon transudations ; and
that all the lymph-channels in one portion of the body may
be cut off without inducing edema. The invariable and only
cause of cedema is the insufficiency of the veins, or of the
veins and lymphatics together, to carry away the transuded
fluid. Therefore what is true of the contents of the lymphatic
trunks does not apply as a matter of course to transuda-
tion from the capillaries. In order to discover how transu-
dations are affected, they themselves must be studied, and so
far as this has been done, the result has always proved that
augmented pressure is invariably followed by increased
transudation from the capillaries. Chabbas, acting under
Griinhagen’s direction, has found this to be correct with
regard to the aqueous humour” which most certainly is to be
considered as a transudation, and our manifold clinical ex-
perience confirms the statement that real transudations (not
exudations) rise and fall with corresponding variations of
pressure. This statement, however, as a matter of course,
does not exclude the possibility that other conditions may
co-operate.

And now to recapitulate my observations, I consider myself
justified in concluding that there are no reasons whatever
for relinquishing the theory that a transudation alone escapes
from the glomerular vessels of the kidneys, in accordance
with the laws of filtration. Secondly, that a secretion of
the specific constituents of urine in a watery (concentrated)
solution takes place in the convoluted uriniferous tubules,

1 *Die Albuminurie,’ &c., pp. 283—30, and the foregoing translation, 29—31.

? Dogiel and Jesner’s later investigations on this subject refer to the
alterations in the quantity of albumen.
1388 THE THEORY OF THE

and it therefore follows that perfect urine represents a mix-
ture of a transuded with a secreted solution.

 

Now if the fluid which escapes from the Malpighian tufts
be a transudation, it must necessarily contain the constituents
common to all transudations—that is to say, besides water
there are the materials held in solution in the blood-plasma,
in proportion of course to their capacity for filtration, and,
therefore, not merely salts, traces of urea, &c., but also
albuminous substances (serum-albumin ahd globulin). For
there is no transudation without albumen, and if a fluid con-
taining albuminous matters in solution filters at all through
an animal membrane, the albuminous substances will like-
wise pass through in a quantity corresponding to their
capacity for filtration, such capacity being usually slight, the
quantity also being subject to variations under different
conditions. These conditions are: the quality of the mem-
brane, especially its thickness, the concentration of the solu-
tion, the salts it contains, its temperature and the pressure
under which filtration goes on. As these conditions
undoubtedly vary in different parts of the body, there need
be no surprise at the differences as regards quantity of
albumen in the transudations. Those normal transudations
in particular which are separated from the capillaries by
epithelium, such as the aqueous humour, the cerebro-spinal
fluid and the endo-lymph, contain so little albumen that
they are often set down as “almost non-albuminous.” For
the same reason the transudation from the glomeruli must
likewise be considered as only very slightly albuminous, but
certainly not as absolutely free from albumen.

It is well known that the older theories of Kiss, v. Wittig
and Henle assumed that the glomerular transudation contains
albumen. In order to explain the non-appearance of this
substance in normal urine, the idea was suggested that the
epithelium of the uriniferous tubules withdraws the albumen
from the passing fluid. The correctness of this last view
has never been thoroughly demonstrated, but just as little
has it been effectually controverted. It used to be asserted
that degeneration of the epithelium is not followed by albu-
SECRETION OF URINE. 139

minuria, but this statement is not correct.! All that can be
maintained against the view in question is, that it scarcely
coincides with our ideas as to the function of glandular
epithelium to assume that these structures absorb anything
from the secretions whose escape is unimpeded, and it is still
more extraordinary that albumen alone should be absorbed.
In contrast with this theory, Ludwig, as we know, imagines
that the filtrate which escapes from the tufts is free from
albumen, but he does not explain why this should be the case,
and regards the question of the absence of albumen as un-
solved, and one which requires elucidation.” It would appear,
however, that the sole object of his assumption is to explain
the absence of albumen in normal urine. In the mean-
time, however, the state of the question has become changed.
Many recent investigations have shown that small quantities
of albumen are to be found in the urine of healthy persons,
and that this is not a rare occurrence, but one whose fre-
quency is remarkable, considering the views hitherto received.*
Physiologists have taken no cognisance of this fact, or have
devoted no space to it in their discussions; but treating it
with neglect they go on searching for an explanation of the
absence of albumen from normal urine, and especially
from the fluid which escapes from the Malpighian tufts.
The majority of physiologists adduce as an explanation that
the normal albuminous substances of the blood-plasma are
unable to escape from the vascular tufts, being prevented by
the epithelial investment, or the peculiar structure of the
walls of the vessels. This assumption is destitute of all
analogy ; and if it be true that all other capillaries, whether
with or without an epithelial covering, are permeable for
albumen, it is clearly the less admissible, inasmuch as certain
albuminous substances which pass readily through a filter
(egg-albumen, peptone, &c.) do undoubtedly pass through
the glomeruli. We may, therefore, reply that the assumption
is only made ad hoc, that is to say, only for a desired pur-
pose—in order to explain the absence of albumen in urine.

1 See Senator, ‘Die Albuminurie,’ &., p. 73 (p. 78 of foregoing trans-
lation).

2 «Lehrbuch der Physiologie,’ ii Aufl., ii, 1861, pp. 428, 429.

3 See Senator, l. c., p. 15.
140 THE THEORY OF THE

‘But this purpose is defeated, for as a matter of fact, albumen
can be found even in normal urine. How is this fact to be
explained by the aid of that assumption ??

The opinions hitherto maintained with regard to the con-
‘stituent parts of the glomerular transudation are therefore
unfounded. It must be admitted that this transudation does
contain albumen, but, as I have already mentioned, the
epithelial investment prevents the quantity of albumen from
eing otherwise than extremely minute. And there is
another important circumstance which must cause the
‘quantity of albumen in this transudation to be still less than,
for instance, in the so-called “nearly non-albuminous”
transudations (the aqueous humour, the cerebro-spinal fluid,
‘the endolymph) ; the fact in question being that this filtrate
‘escapes under much higher pressure. We know that the
highest capillary pressure in the body (not excluding that in
the intestinal capillaries) prevails in the glomerular vessels.
If the filtration pressure rises, then more fluid will pass out
from an albuminous solution, but this fluid will be relatively
‘poorer in albumen though the absolute quantity may be
increased. Consequently, the transudation from the glome-
ruli will be still poorer in albumen than those above alluded
to as containing the smallest proportion of that constituent.
But, finally, and in the third place, it must be mentioned that
when this transudation reaches the uriniferous tubules, the
specific secretion of the latter, which is undoubtedly free from
albumen, is added to it; so that in proportion as this addition
is made, perfect urine will finally contain a less percentage of
albumen than is to be found in the glomerular transudation.

So far as I can see, this explanation rests upon no
‘arbitrary assumption, but upon recognised physical laws, and
‘it offers us a means of explaining the occasional appearance
of albumen in normal urine. For, doubtless, even in the
normal condition of things, the pressure in the glomeruli, as
well as the quantity of the secretion escaping from the urini-
‘ferous tubules, is liable to variations; and in proportion as the
influence of these two factors is increased or lessened, will
the urine contain either more or less albumen, the pre-

? For additional details see Senator, “ Albuminurie,” pp. 22—24 (the same
pages in the translation).
SECRETION OF URINE. 141

sence of which will be more or less easily detected. The-
circumstances, therefore, with regard to albumen are com-
pletely analogous to those of many other normal constituents
of urine (sugar, oxalic acid, pyrocatechin, &c.), which are
found, under physiological conditions, sometimes in infini-
tesimally small quantities, and sometimes in larger proportion
and therefore more easily detected. I refrain from entering
into further particulars, inasmuch as in the monograph
already alluded to I have discussed at some length other
circumstances which, even in the normal state, may conduce
to the appearance of large and easily detectible quantities
of albumen in the urine, that is to say, may set up a physio-
logical albuminuria. I have also in that treatise explained
the influence of changes in the renal circulation and of other:
pathological conditions. |

ap
THE

HYGIENIC TREATMENT OF ALBUMINURIA?

 

In the treatment of various disorders of the kidneys, and
especially of those usually classed together as acute or
chronic forms of Bright’s disease, albuminuria is the sym-
ptom which deserves the closest attention ; but not, as is still
generally asserted, because a long-continued excretion of
albumen impairs the nutrition of the system. This, in my
opinion, is a mistaken notion, founded as it is on a highly
exaggerated estimate of the loss of albumen such as
occurs in most cases even of very serious affections of the
kidneys. In a very marked case of albuminuria, the
albumen rarely amounts to more than a few tenths per cent.,
and we know that the percentage generally increases with
the diminution in the quantity of urine and diminishes when
the latter is increased. If, therefore, the proportion of
albumen in the urine be very considerable, say °5 or ‘8,
this being an extraordinarily high percentage, the daily
amount passed will weigh only a few grammes, perhaps six
or eight, or possibly ten as a maximum. A loss of
albumen exceeding this amount is altogether exceptional,
and, when it occurs, is of very short duration and never lasts
for many days or weeks. Losses of albumen to this extent
do not appreciably injure an adult, unless his system has
been extremely reduced in other ways. Six to eight
grammes of albumen represent the quantity contained in
forty grammes of beef; and it is evident that if that is all,
half-a-pound of meat would almost suffice to cover the

1 A lecture delivered before the Berlin Medical Society, October 11th,
1882.
HYGIENIO TREATMENT OF ALBUMINURIA. 143

weekly loss of albumen, even when very considerable in
amount.

The importance of albuminuria, as a symptom, is due
rather to the fact that it furnishes us, so to say, with a means
whereby the existence and gravity of renal disorders may be
determined and estimated. If this symptom were absent, it
would not be easy to diagnosticate with certainty a renal
affection, and it would be still more difficult to decide that
the case was one of Bright’s disease (though in this latter
albumen may sometimes be absent from the urine) ; moreover
in estimating the gravity, the progress, or the retrogression
of the disease, we depend, as a general rule, upon the
quantity of albumen contained in the urine. Another
reason for the importance of albuminuria as a symptom may
also be adduced, viz. the possibility that in some cases the
excretion of albumen may act as a stimulus to the kidney.
We do not, indeed, know that this effect can be produced by
those forms of albumen which are found in the urine in cases
of ordinary albuminuria, but we do know that egg-albumen
acts in this way. When this substance finds its way into
the blood, it is excreted by the kidneys, but frequently this
is not all that happens, for, as J. C. Lehmann and Stokvis
have observed, more albumen is excreted than is introduced ;
as a matter of course not more egg-albumen, but a form
which possesses the properties of the ordinary albuminous
substances of the serum (serum-albumin and globulin). It
is not improbable that peptone likewise, and perhaps also
hemi-albumose (propeptone) may act in a similar way, i.e.
excite albuminuria. Moreover, the idea has been repeatedly
entertained, both in ancient and modern times, that the
albumen in ordinary albuminuria, in the various forms of
Bright’s disease, is not altogether the same with the normal
albumen of the serum, and if this view be correct, though
its truth hag never been demonstrated, it may well be
supposed that this albumen also has an irritative action on
the kidney, like that of a foreign body or possibly of a
poison.

As regards the therapeutics of albuminuria, every un-
prejudiced physician will confess that up to the present
time we have not on the whole been very successful
144 HYGIENIC TREATMENT OF ALBUMINURIA.

with our purely medicinal treatment. This is the reason
why new remedies are continually being recommended.
They are, however, as little efficacious as the old ones.
Neither the astringents, tannin in particular, nor fuchsin,
nor pilocarpin, nor the acids, produce the effects with which
they have been credited, and the same remark applies to
nitric acid, lately recommended in accordance with Hansen’s
prescription forty years ago, but which Frerichs’ has already
found to be useless. There is, at most, one drug, viz. iodide
of potassium, which must be allowed to possess a certain
amount of efficacy in some forms of chronic nephritis. It
must be understood that I am referring now to the albumi-
nuria, and not to other symptoms such as the dropsy and
the asthmatic attacks, for which we possess really efficacious
remedies.

It is easy to be deceived with regard to the usefulness of
a remedy employed in cases of acute renal affection, for these
very often terminate favorably without any medicinal treat-
ment, and the albuminuria in particular, which not unfre-
quently continues for some time as the last remaining sym-
ptom, eventually disappears, unless the circumstances are
altogether unfavorable. And in dealing with chronic renat
affections it is easy to over-estimate the value of a remedy
if we forget that their course is usually fluctuating, and that
whether medicines are given or not the quantity of albumen
in the urine may go on diminishing for days and weeks.
Such fluctuations are due to the fact that the inflammatory
process in the kidney is not uniform but irregular in its
course, and to the occurrence of complications which increase
the albumen ; while against these may be set the avoidance
of injurious influences and the adoption of suitable hygienic
arrangements. tbe

Since we can do s0 little with medicines in the treatment **,
of albuminuria, the greatest importance must be attached to
hygienic measures, and experience teaches us that the
results to be anticipated, if not remarkably brilliant, are
far better than those attained by any medicinal treatment:
whatever in the absence of such measures. That such is
the case is proved by the fact that in chronic renal affections

? * Die Bright’sche Nierenkrankheit,’ 1851, s. 237.

 
HYGIENIC TREATMENT OF ALBUMINURIA. 145

better results are often obtained in hospitals than outside
these institutions. For ordinary hospital patients are under
much more favorable hygienic: conditions than are found
outside, and I have not unfrequently seen patients improve
in hospital either without medicine, or under the same treat-
ment to which they had for a long time been subjected, and
without benefit, as out-patients,

The most important question is that which refers to the
diet. Some amount of attention has been given to this
subject, but it appears to me that the indications have not
been sufficiently considered, nor the full purport of the
question properly appreciated. In discussing questions as
to the dieting of patients suffering from nephritis, there are
two points to be considered :—(1) The influence which the
process of digestion per se has upon the albuminuria, and (2)
the influence which the hind of food has upon the symptom
in question. With regard to the first, recent observations
have shown that during digestion the excretion of albumen
is augmented in patients suffering from albuminuria, or that
the symptom recurs when temporarily in abeyance ; and a
transient condition of albuminuria has indeed been noticed
in healthy persons during the digestion of a full meal.
Hence the rule that in albuminuria the demands of the system
for food are to be satisfied by small quantities frequently
repeated, and not by abundant supplies.

The choice of the food, however, is a still more important
consideration. Physicians long ago noticed that the albumen
was increased after the ingestion of certain articles of food
and drink ; but it is only recently that these observations
have been tolerably well understood and added to by others.
The fact has been demonstrated by the experiments, already
alluded to, of J. C. Lehmann and Stokvis, and it must be
further observed that the injurious effect of egg-albumen
was witnessed not only when this was injected into the blood,
but when introduced in large quantities into the stomach—a
fact noticed by other observers besides those above men-
tioned.

It would therefore appear that egg-albumen acts injuriously
not only when it is introduced as such into the blood, but

also after it has undergone alterations in the stomach and
10
146 HYGIENIC TREATMENT OF ALBUMINURIA.

bowels. At any rate 7 is advisable strictly to forbid the use
of eggs whenever albuminuria exists.

With regard also to other albuminous articles of food, and
especially meat, if we wish to get rid of the albuminuria, we
must limit the supply within much narrower bounds than
physicians now prescribe, guided as they are by what I have
already alluded to as an exaggerated estimate of the loss of
albumen. I have repeatedly noticed the occurrence of albu-
minuria in apparently healthy men after eating heartily of
meat, and still more frequently observed increased amount
of albumen in cases of albuminuria. Similar observations
with regard to cheese have been recorded by Christison.

It is unnecessary now for me to enter into an explanation
with regard to the injurious effects of highly albuminous food,
for a year ago I had the honour to address you on the sub-
ject of the pathogenesis of albuminuria, and I then discussed
this question.’ I will just add that Lichtheim? has recently
pointed out another danger attendant upon a full albuminous
diet, viz. the possibility of an accumulation of urea in the
blood and its accompanying results (uremia), as a conse-
quence of the abundant formation of urea with co-existent
disease of the kidneys ; and this warning holds good not only
of urea but of other final products of the disintegration of
albumen, especially of phosphoric acid, the excretion of which,
according to Fleischer’s investigations, is likewise impeded in
renal affections.

We must therefore adopt the rule of limiting the amount
of meat, and if it cannot be altogether withheld, we must
recommend those kinds which contain less albumen, such as
veal and young fowls, 7.e. the so-called “ white meat.” For
the same reason fish, which also contains less albumen than
beef, for example, may be more safely recommended for such
patients.

After what has been already said, I need not further
expla why the use of vegetable food may be freely per-
mitted. Green vegetables, salads, cabbages, and the like,

} Vide ‘Verbandlungen der Berliner med. Ges.,’ xiii, 1881-82, and
Senator’s foregoing treatise ‘Albuminuria in Health and Disease,’ Berlin,
2382, pp-19; 54; 94, et seq.

Corresp.-Bl. der Schweitzer Aerzte,’ 1882, No. 7.
HYGIBNIC TREATMENT OF ALBUMINURIA. 147

which are poor in albumen, are preferable to those which
contain more of this constituent, and especially to the legu-
minous kinds.

As a matter of course, the choice of the several articles
of diet will depend upon the state of the digestion and other
individual conditions. And especially with reference to the
question as to whether fat in large quantities is to be allowed
or not—a very important point as regards nutrition when
the supply of albumen is limited—the answer to this will
depend simply upon the condition of the organs of digestion.

With regard to liquids, alcoholic drinks have been
hitherto forbidden for purely empirical reasons, based, how-
ever, upon clinical experience to the effect that renal
diseases are caused by the misuse of alcohol, and especially
by the immoderate consumption of brandy. Quite recently
it has been proved by Pentzoldt’s! experiments that-inflam-
matory renal affections canbe produced in dogs by adminis-
tering ethyl- and amyl-alcohol. The patients must there-
fore be confined to water, effervescing drinks, and the
various alkaline acidulous waters; but it will be difficult
altogether to forbid alcohol, especially to patients accus-
tomed to its use. Spirits, Cognac, &c., must be forbidden
under all conditions unless their employment be necessitated
by special indications, e.g. collapse, &c. The prohibition
need not be so strict with regard to wine. I have hitherto
adopted the rule of allowing claret, more from habit than
for any special reasons. Some importance has been
attached to the amount of tannin contained in claret, but
the quantity is too small to be of any consequence, and, as
before observed, I am unable to attribute any great efficacy
to tannin as a remedy. Beer is generally considered to be
more injurious than wine, although the strongest kinds of
beer contain less alcohol than the majority of wines. But
beer appears to me to act more injuriously than wine in
cases of albuminuria. Only in one case of so-called albu-
minuria with healthy kidneys, occurring in a colleague, the
patient stated that wine invariably caused a reappearance or
increase of albumen, whereas no such effect was observed
after drinking beer.

1 ‘Sitzgsb. d. phys. med. Soc, zu Erlangen,’ 1882, Juni 19.
148 HYGIENIC TREATMENT OF ALBUMINURIA.

In the last place experience teaches that hot spices and
highly cured meats are hurtful; errors of diet of every kind
always do mischief. I have had repeated opportunities of
observing cases in which the albuminuria was undoubtedly
increased after grave errors in diet.

It is a fact of the greatest interest that the dietetic treat-
ment of albuminuria, the so-called ‘“ milk-cure” which was
long ago adopted and still maintains its deserved reputation,
is in perfect harmony with the principles laid down in the
foregoing remarks. It is true that a dzet consisting
exclusively of milk, though very often talked about, can but
rarely be persevered with for a lengthened period, and the
expression, therefore, is not to be taken quite literally. If,
for example, a patient takes two litres of milk per diem, a very
considerable quantity, he does not obtain even the minimum
amount of albumen which an adult requires to support life.
Voit! states that an adult prisoner, doing nothing and
receiving only the so-called “‘ sustentation-diet,” requires a
daily supply of 85 grammes of albumen, 30 grammes of fat
and 300 grammes of hydrocarbons, and that even for old
women, the objects of charity and living under very miser-
able conditions, the amount of albumen must not be reduced
below 76—80 grammes. If, however, we take the average
percentage in milk as 3°41, two litres will contain only 68 to
70 grammes, or considerably less than the quantity required
to support life. The fat contained will amount to 74
grammes or more than twice the necessary quantity; the
hydrocarbons again, not quite 100 grammes, will be much
below the standard. This latter deficiency will, however, be
partly made good by the excess of fat which can supply the
place of the hydrocarbons. A further supply of the latter is
required to cover the deficiency. I have already said that
according to my experience, milk alone is scarcely ever taken
or tolerated, at least for more than a few days, but patients .
can and will take it if hydrocarbons, especially in the form —
of a few hundred grammes of white bread, be added, and if,
instead of pure milk, we give them milk-gruel made with
flour, oatmeal, &. <A “milk diet” of this kind can easily
be continued for many weeks with very good results, as

1 “ Physiol. des Stoffwechsels,” &c., in Hermann’s ‘ Hab.,’ vi, 1, 1881.
HYGIENIC TREATMENT OF ALBUMINURIA. 149

it appears to me, corresponding as it does to the recommenda-
tions I have made with regard to the. diet for cases of
albuminuria.

I append a few remarks with regard to the employment
of mineral waters, though these belong as much to the
medicinal as to hygienic treatment. Some good results are
often obtained from the external and internal use of these
waters, but we are not always able to explain the manner
in which the effects are produced. Experience teaches us
that for drinking purposes, the saline, or the alkaline-saline
waters produce the most favorable results, and for certain
special peculiarities connected with each case, which I cannot
now discuss, either a cold or a warm spring may be selected.
In accordance with ordinary notions, we should expect that
these waters would act injuriously rather than otherwise,
inasmuch as saline substances are considered to be renal
irritants, and the general rule is sedulously to avoid all
irritants when dealing with inflamed crgans. It therefore
appears to me that the effect must be explained in another
manner. It may be that these waters have a beneficial
effect upon the digestion, and subsequently upon the blood,
either by producing quantitative changes in the composi-
tion of the latter, or by altering its quality, especially in
regard to its albuminous constituents. On these latter
points we have, however, no certain knowledge. In
England the opinion has for a long time prevailed that a
faulty assimilation and condition of the albumen are the cause
of albuminuria, and that the latter is to be treated by
improving the digestion and assimilation. But as this idea
is based rather upon speculation than upon positive
proofs, it has, generally speaking, gained no acceptance
among us. We must not, however, in my opinion thus
absolutely refuse to entertain the idea of a faulty condition
of the blood as a cause of albuminuria, and from this point
of view the internal use of certain waters is the more intel-
ligible. With regard to treatment by a course of baths,
the effect of these in promoting tissue-changes is unquestion-
able, and they may possibly so far have a good effect upon
the albuminuria, but their purely local action upon the skin
is a matter of still greater importance.
150 HYGIENIC TREATMENT OF ALBUMINURIA.

And this brings me to the second portion of the hygienic
treatment, viz. to the attention to the functions of the skin.
In the treatment of renal affections this point has always
been regarded as more important even than the diet, doubtless
from a consideration of the fact that these disorders may result
from taking cold and from other injurious influences acting
upon the skin; e.g. burns and certain irritating applications
which produce inflammation. Moreover, the fact that, in
some respects, the skin and kidneys act vicariously for each
other, has led to the practice of exciting the activity of the
cutaneous functions in treating renal disorders, with the
object, as we say, of relieving the kidneys. We can only
suppose that with increased activity of the skin, the kidneys
have to excrete less water and a smaller quantity of solid
constituents, since their blood-supply is reduced. I will not
attempt to decide whether these causes alone are sufficient
to produce such results. The fact is that, when a consider-
able quantity of water passes off through the skin, and the
urine in consequence is very much diminished in quantity,
the albumen is absolutely reduced, but perhaps relatively
increased. It may be that a portion of the albumen passes
off through the skin, for this substance is found in the cuta-
neous perspiration (Leube) though in very minute quantity ;
or perhaps some proportion of the albumen, which otherwise
would have escaped with the urine, remains in the system.

It is, therefore, advisable that the skin should be con-
stantly kept in a more or less active state of perspiration,
and thus we find a reason for the good effects of a course of
bathing, not that any good results while the bath is being
taken, for much less water is then being excreted by the skin,
but because repeated warm baths, even when the water is
pure, increase the turgescence of the cutaneous vessels. But
a prolonged use of saline baths causes this turgescence to be
still more protracted, because the tissue of the skin becomes
impregnated with the saline constituents, and these, which
are only gradually removed and remain for some time after
the course of bathing is ended, have an irritating action
upon the skin and keep up a certain amount of congestion,

It follows from what has been said, that the patients ought
to take the greatest care to avoid chile and that they should
HYGIENIC TREATMENT OF ALBUMINURIA. 151

wear woollen under-clothing. Our object is best attained by
keeping the patients in bed for as long a period as is possible,
for weeks, and if necessary for months ; the adoption of this
plan keeps the skin under the most favourable conditions for
promoting its function. It involves also another point, which
is an important one as regards treatment, viz. it prevents as
far as possible muscular movement.

Observations have repeatedly proved,as I stated in my essay
of last year, that active muscular exertion increases the albu-
minuria. The obvious cause of this increase I then explained,
and I need not now recur toit. The patients must, therefore,
be prevented from taking excessive exercise, and even when
we wish to give them the benefit of fresh air, which is highly
desirable owing to the anzmia characteristic of renal affec-
tions, all active exercise must as far as possible be avoided,
and the patients must not walk or run or ascend heights,
&c., but confine themselves to driving about, under proper
precautions against chills. But otherwise it will be best to
confine the patients to their beds, where so many favorable
conditions exist in combination.

In addition to the three above-mentioned points with
regard to the diet, the cutaneous function and muscular repose,
there are a few other conditions which influence the course
of albuminuria, and which are, therefore, deserving of consid-
eration ; among these are psychical influences. Itis probable
that some of you have noticed that sudden affections of the
mind, such as anger, fear, &c., increase the albumen in the
urine. Several very striking instances of this kind have
come under my own observation. The rule must, therefore,
be adopted of guarding the patients as much as possible from
such influences, and the best way to do this is to enforce a
prolonged withdrawal from business and other avocations.

In the last place I have observed that the albumen is
regularly increased in female patients during menstruation.
I need scarcely say that this observation refers to perfectly
pure urine, and not to such as contains any admixture of
menstrual blood. It may be that the pelvic congestion which
occurs in menstruation, causes an increase in any inflamma-
tory processes which exist in the kidneys, and thus augments
the albumen; or perhaps the various systemic processes,
152 HYGIENIC TREATMENT OF ALBUMINURIA.

the changes in the metamorphoses of the tissues, which cer-
tainly take place in menstruation, affect the symptom in
question. It is a well-established rule that the patients, at
these periods, must be even more carefully and_ strictly
watched than at other times, and kept absolutely to their
beds, in cases in which some relaxation of this rule has been
allowed for a greater or less portion of the day.

In taking as far as possible a full and complete survey of
all the points which seem to be of importance in the treatment
of albuminuria, you will easily have gathered from what I
have said that a suitable climate is preeminently indicated.
For this includes a combination of all possible and desirable
conditions for producing a favorable effect. The improvement
or cure which may result from baths and changes of climate is
due, not to any single factor, not merely to the water and the
air, but to a variety of other conditions which have been
already indicated.

Southern and dry localities, such as Gries and Meran, are
to be recommended for our purpose, and better than theso
are various spots on the Riviera, especially Bordighera,
Cannes, &c., but the best of allis Cairo and Egypt generally,
which, however, owing to political circumstances, is not very
inviting just at present. A lengthened sojourn in such
places is decidedly advantageous in consequence of the effects
produced upon the cutaneous functions and the removal of
the patient from all unfavorable mental impressions. Active
exercise also becomes unnecessary, and, lastly, the diet, which
in southern latitudes contains more vegetables and less animal
and albuminous substances, fulfils the indications above
detailed.

In the case of poor patients, admission into a hospital,
though not to be compared with a suitable climate, has in
some respects a similar effect, as I mentioned in my introduc-
tion, and it is for these patients a kind of substitute for
change of climate. In the wards of a hospital they are at
any rate quieter and more sheltered than they could other-

wise be, and the greater part of the day or even the whole
day can be spent in bed.

T cannot conclude this address without uttering an impres- 4.

sive warning against too sanguine expectations with regard ~
HYGIENIC TREATMENT OF ALBUMINURIA. 153

to the results of the above methods in dealing with chronic
albuminuria. Astonishing and brilliant cures are just as.
little to be obtained by these as by any other plans. With
a certain amount of perseverance we can sometimes succeed
in considerably reducing the amount of albumen, and even
in causing the symptom to disappear for a longer or shorter
interval—a change which some may proclaim as a cure. We
must for the present be content with these modest results in
a domain which presents so many difficulties to therapeutics.

Nors.—The proof-sheets of this translation of Dr. Senator’s.
essays have been revised by the author, whose kindness and
courtesy the translator desires gratefully to acknowledge.

*
INDEX.

 

PAGE
Albumen, forms in which excreted 3

— in normal urine 15, 138
— intransudations . 24, 140
— in urine after digestion . 19, 44

— — of animals : ‘ . 20
— losses of, in albuminuria - 141
— modifications of,in urine . 8
— morbid conditions of, as a

canse of albuminuria . 95

— urinary, source of . 3 - 4

— — tests for . . . 14
Albuminuria, after division of the

renal nerves. 46

— after ingestion of ege-albumen 100
— after ligature of the renal

artery . - » 61
— — of the renal vein . 57
— — ofthe ureter . . - 63
— alcoholic beverages and - 147
— as a result of increased tem-

perature . 5 . 47
— asaresult of muscular exer-

cise . 5 . 51, 151
— asa result of the condition of

the blood . 94
— as depending on altered blood-

pressure . . - 39

— diet most suitable for ‘ . 145

— drugs used in treatment of . 144
— factors of . 1
-—~ from degeneration of the
renal epithelium . - 78
— hygienic treatment of . - 141
— in amyloid degeneration of
the kidneys. 121
— in animals as an effect of
heat . 5 * - 386, 48
— in fevers i é 89, 109
— in petroleum poisoning . . 89
— in phosphorus poisoning 36, 80
— in progressive anazmia . - 86
— in renal diseases proper . 112

— in venous congestion of the

kidneys. ‘ . 56
— meaning of the term 5 - 6

 

PAGE

Albuminuria, meat as diet for, its
drawbacks F . 146
— milk diet for j ‘ . 148
— mixed . és é x . 12
— normal. 3 ‘ é . 15
— true and false 5 - 6

— without lesion of kidneys - 96
Alcoholic a and albumin-

uria - 147
Alterations in the blood pressure

as a cause of albuminuria 39
Amyloid degeneration of the kid-

neys, albuminuria in . » 121
Anemia, progressive ees

albuminuria in . 86

Aorta, effects of ligature of . 44
Arteries, increase of blood-pres-
sure in, and albuminuria . - Al

Baths, in the treatment of albu-

minuria . . 149
Blood, condition of, as m cause of
albominprin ‘ 94

Blood-pressure, alterations of, in
kidneys and albuminuria . 39
— diminished, results of . . 65
— methods of increasing . « 42

Cardiac hypertrophy in reual dis-

ease . 114
Changes, qualitative, i in : bod asa

cause of albuminuria % - 100
Chloride of sodium as a test for

albumen . - . 14
Cholera, albuminuria i in - 100,111

Climates, suitable, for cases of
albuminuria - 152

Coagulative necrosis of the renal
epithelium and albuminuria . 89

Congestion of kidneys, various

forms of . : . . 65
Convulsions, albuminuria i in . 51
Cutaneous cedema in certain renal

diseases, cause of . . 117
156

PAGE

Digestion, albuminuria of 19, 44, 98
Diminished blood-pressure and

albuminuria . . 5 . 31

Hep beaet results of ingestion

of . 5 + 100, 142, 145
Epithelium, renal, degeneration
of, asa cause of albumin-

uria . . 78

— — degeneration of, in ‘phos.
phorus poisoning : ‘0
— of glomeruli, function of 78, 1380

Febrile albuminuria. - 89,109

Ferrocyanide of potassium and
acetic acid as tests for albumen 14

Filtration in the kidneys . 25, 51

Glandular secretion in the kidneys 32
Globulin in the urine . . » 6
Grape sugar in normal urine - 2

Hematogenous albuminuria . 97
Hemi-albumose (propeptone) - 10

Increase of temperature as causing
albuminuria. , « 36, 46

Lymph, formation and flow of, as
compared with urine - 29,137

Malpighian tufts, epithelium of
the, in relation to albuminuria. 24
Meat diet, drawbacks of, in albu-
minuria . - 146
Menstruation as influencing “albu-
minuria . . 151
Metaphosphoric acid as a test for
albumen and peptone . 14
Milk diet in cases of albuminuria 148
Mineral waters in the treatment of
albuminuria. ‘ 3 . 149
Muscular action as producing
albuminuria . ‘ » 61,151

Nephritis, chronic, types of . - 114
Nitric acid, as a test for albumen 14

Oxalic acid in normal urine . 221

Peptone and peptonurin . 8,102
Petroleum- ene and albumin-
uria . - . - 89

 

INDEX.

PAGE
Phosphorus-poisoning and albn-

minuria . . . - 80
Pro-peptone, tests for . - 12,18
Pro-peptonuria - 9, 102

— cases of - “ » 10,11
Psychical affections, as influencing
albuminuria. é . - 151

Rabbits, experiments on, with
phosphorus . - 82

Renal artery, effects of compres-
sing and tying . ‘i « 61

— cirrhosis . . - 115
— diseases proper, albuminuria
in - 112

— nerves, effects of division of. 46
— vein, effects of tying . - 57
Rest, bodily and mental, in the
treatment of albuminuria . - 151
Retardation of the blood-current,
as a cause of albuminuria . - 26

Serum-albumin in the urine - 6

Skin, attention to functions of
the, in the treatment of albu-
minuria . . 150

Sweat and tears, gedration of, com-

pared with that of urine... 129
a daa increased, effects
of . - 86,46

Theories of 1 urinary secretion 27, 127

Urea, increase of, in blood, in
fevers, phosphorus - poisoning,
&e.

Ureter, effects of tying 5 63, 67

Urinary secretion, theories of 27, 127

Urine, a product of filtration and

of secretion ‘ - 83, 128
— condition of, in venous con-
gestion of the kidney . 71

‘Venous congestion of the kidneys

and albuminuria - 56,68
— effect of, on glomeruli and
secretory apparatus . . 70
— resulting from ligature of
vein (57), of nee (6), of
ureter : - 63

Waters, mineral, and baths for
albuminuria. j z . 149
SOME CONSIDERATIONS ON THE NATURE AND
PATHOLOGY

OF

TYPHUS AND TYPHOID FEVER,

APPLIED TO

THE SOLUTION OF THE QUESTION OF THE IDENTITY OR
NON-IDENTITY OF THE TWO DISEASES.

BY
THE LATE

ALEXANDER P. STEWART, M.D.

(Read before the Parisian Medical Society on the 16th and 23rd
April, 1840.)

EDITED BY

W. CAYLEY, M.D.,

PHYSICIAN AND LECTURER ON MEDICINE TO THE MIDDLESEX MOSPITAL;
PHYSICIAN TO THE LONDON FEVER HOSPITAL.
ON THE NATURE AND PATHOLOGY

OF

TYPHUS AND TYPHOID FEVER.

Ir is my object, in the following pages, to attempt, by a
reference to facts, the elucidation of a question, which is
confessedly surrounded with difficulties, and has called into
the field of controversy some of the most gifted men of the
present day,—some of them espousing one opinion, some
another, while others still suspend their judgment, till the
production of new facts and reasonings shall have dissipated,
in part at least, the darkness in which the subject is
involved. It is, indeed, not a little remarkable that, in a
country like Great Britain, where typhus sacrifices yearly its
thousands of victims,—where it is all but universally ad-
mitted that the local lesion of the intestinal follicles is not a
characteristic sign of the disease,—and where, on that very
ground, the doctrines of Broussais have never been able to
establish themselves, there should still be wanting any
standard work upon the nature, symptoms, and necroscopic
appearances of typhus, such as those of Chomel, Louis, and
others, who, on this side the Channel, have achieved the
triumph of pathological science in aclass of diseases of which
the anatomical lesions were so long unknown. Hence the un-
certainty that prevails in France in regard to the question I

1 This paper is reprinted from a copy in the library of the Royal Medical
and Chirurgical Society, which contains many marginal corrections in the
handwriting of the author.
160 ON THE NATURE AND PATHOLOGY OF

have chosen for consideration—a question which, beyond a
doubt, has been for a dozen years, and is still, exciting an
interest here, to which British medical men are compara-
tively strangers. Hence the tours of inspection undertaken
from time to time by distinguished continental physicians, with
a view either to weaken the conclusions that may be drawn
from facts already published, or to dispel a scepticism which
these facts, so limited in number, have not been able to
overcome. Hence also the objections naturally enough
raised to the information collected by them, on the ground
of defective opportunities, hurried observation, and imper-
fect knowledge. Hence, in short, such reflections on the
doubtful character of the information received from English
authors, as are made by Chomel in his ‘ Lectures on Typhoid
Fever,’ those of MM. Gauthier de Claubry and Montault, in
their prize essays on the ‘ Analogies and Differences between
‘Typhus and Typhoid Fevers,’ and the following words of
Valleix,’ in apology for citing American instead of English
authors, in reference to fevers prevalent in Great Britain.
“We admit that it would have been better to have presented
a series of observations on typhus made in England itself;
but where can we find them ?”

These observations will derive great additional weight
from a brief consideration of the work of Dr. Tweedie,
entitled ‘ Clinical Illustrations of Fever,’ which is referred to
by most of the French writers on the subject, and whence a
great part of their ideas on English typhus is drawn. I
confess I have been puzzled, in perusing the above-named
treatise, to find out what definite meaning the distinguished
author attaches to the word “ fever; whether he under-
stands by it a symptom produced by a local affection, or a
distinct disease arising from a specific cause. His valuable
remarks upon contagion, and his strictures upon the doc-
trines of Broussais, would lead to the latter, while the cases
detailed give countenance to the former supposition. I
cannot better or more shortly give an idea of the cause of
my difficulty, than by giving an analysis of the cases
referred to.

Of 73 patients who died, 54 were inspected. Of the latter

1 © Arch, de Médecine,’ 3rd series, vol. iv, p. 216.

/!
TYPHUS AND TYPHOID FEVER. 161

number, 10 seem referable to typhus, and 17 to typhoid
fever. Of the remaining 27, I find that 4 died of well-
marked and extensive meningitis, 1 of phrenitis, 2 of erysi-
pelas of the head and neck, 5 of phthisis, 4 of pleuro-pneu-
monia, 3 of pneumonia, 2 of pleuro-pericarditis, 1 of pleuritis,
1 of pulmonary apoplexy, 1 of abscess of lung, 4 of
peritonitis. Two of the above cases were sequele of scarla-
tina and smallpox. Of those cases which were not
inspected, there are, as faras can be gathered from the brief
account of symptoms, 5 of typhus, 3 of typhoid fever, 3 of
meningitis, 2 of pneumonia, and 1 of phthisis. Of several,
it is stated that they were evidently cases of purely head,
chest, or abdominal affections, and in one, which was proved
by dissection to depend on intussusception and gangrene of
a considerable portipn of gut, it is remarked, that “ the
symptoms were referable to some obstruction in the intes-
tines, rather than to any form of fever.’? In the above
summary, I have been careful to exclude those that were
evidently, or appeared to be sequelx of continued fevers,
and to include those only in which the feverish symptoms
clearly depended, throughout their course, on local affec-
tions. Deducting, however, those I have alluded to, and
which form rather more than the half of the cases detailed,
there still remain 35, more or less clearly marked out as
belonging to two kinds of specific fevers, the one differing
from the other in the extraordinary gravity of its sym-
ptoms, the rapidity of its course, and the absence of local
lesions.
This leads ‘me to remark, in concluding these preliminary
observations, that when I.began, in 1836, the practical study
of fever, I was much struck with the simultaneous occur-
rence, in the wards of the Glasgow Fever Hospital, of two
sets of cases, in which the symptoms (however little most of
them might seem to differ, when viewed individually) pre-
sented, when taken collectively, characters so marked as to
defy misconception, and to enable the observer to form, with
the utmost precision, the diagnosis of the nature of the
disease, and the lesions to be revealed by dissection. More
particularly, it was remarkable to observe that while, in the
one disease, the affection, in those who presented no erup-

11
162 ON THE NATURE AND PATHOLOGY OF

tion, was so slight and of so short duration, as to make it
very questionable whether it deserved the name of typhus,
and while the fatal cases presented an abundant and gene-
rally a profuse eruption; those labouring under the other,
which equally, and even in a much higher proportion, went
on to a fatal termination, rarely presented any, and then
only a very scanty eruption. It was further remarkable,
that while in the one several successive patients had either
been restored to health, or fallen victims to the severity of
the affection, the disease, under which those laboured, who
lay side by side with them, though characterised by much
less urgent symptoms, pursued its gradual course through
weeks and months consecutively, and in the majority of
cases to a fatal issue. And finally, it was more remarkable
still, that, to complete the contrast already so striking, dis-
section proved the existence, in the one disease, of most
extensive local lesions, in the other, the absence of all pro-
minent local lesion. whatsoever.

Another circumstance, I must not forget to mention, viz.
that though, during the summer and autumn of 1836, the
cases of typhoid fever were numerous; from the month of
November in that year (at which time both the type and
the amount of typhus became much more formidable), till
June, 1838, the period that my connection with the hospital
ceased, not more than a dozen cases—if there were even so
many, and these at long intervals, were admitted for treat-
ment. In speaking of the two varieties of fever as totally
different diseases, before going into the proof of the asser-
tion which is the point in dispute, I have merely employed
a phraseology in common use, of which even those who
maintain the complete identity of the affections have not
been able to rid themselves, and whereon, if I were disposed
to insist upon words, I might found a strong argument in
support of my position; and have expressed a conviction
forced upon me by the consideration of facts and reasonings,
which I now proceed to unfold.

It is far from my intention, in this paper, to take up in
all its bearings the vast subject of the “analogies and
differences between typhus and typhoid fever.” That task
I hope to be able, along with my friend and fellow:worker,
TYPHUS AND TYPHOID FEVER. 163

Dr. Anderson, to undertake hereafter. My present object
is to develop, as shortly and as clearly as I can, some of
their leading features of difference, in support of the position
I have taken up. I propose, then, to consider ;—1. The
probable origin of the two affections. 2. Their proximate
causes. 3. Their course. 4. Somie of their symptoms. 5.
Some of their anatomical lesions. 6. Their treatment.

I. Without entering upon the abstruse question of infec-
tious germs, or discussing theoretically the probability of
the opinion that ascribes the origin of continued fever to
animal, as intermittents are known to proceed from vegetable
miasmata, I proceed at once to examine the question in a
practical point of view. Dr. Copland, in his able article
upon infection, places exanthematic typhus under the third
class, viz. that of “specific infections,” characterised as
“immediately or mediately disseminating and perpetuating
their kinds,” &c., and directly refers that form of typhus to
“‘ emanations from the secretions, excretions, and surfaces of
persons already affected.” Under the second class, viz. of
“conditionally perpetuating or contaminating infections,” he
places “animal effluvia,’’ or more particularly, ‘“ emanations
from living bodies in close and unventilated situations.”
Among the “ diseases resulting therefrom,” stand “ adynamic,
putro-adynamic, and malignant fevers.” Now, in this
classification, it is plain that while we are informed of the
origin of the latter, we are only told the mode of propaga-
tion of the former. Hxanthematic typhus is said to be the
result of ‘‘emanations from persons already affected ;”’ but
whence the original disease? In reference to this question,
I observe, that Dr. Roupell’ had given the weight of his
name to the opinion that exanthematic typhus does not
originate from vitiated air, extreme filth, closeness, &c. I
cannot but express my surprise at this opinion, as the amount
of evidence against it seems quite ovérwhelming.

On no two points (and so far I must anticipate my
remarks on the eruption in typhus) are the distinguished
authors who describe the frightful epidemics of army typhus
during the last six centuries more completely agreed, than

1 * Roupell’s Treatise, &c.,’ p. 64, quoted at p. 107, vol. xxxi of ‘ Med.-
Chirurg. Review.’ ‘
164 ON THE NATURE AND PATHOLOGY OF

on the influence of impure air in the production of the
disease, and the very frequent presence of the rubeoloid
exanthema in those affected with it. Dr. Tweedie, in his
interesting observations on the ‘ Influence of Impure Air on
the Generation of Typhus,’ refers to the opinion of Sir John
Pringle, who states, “that he has observed the hospitals of
an army, not only when crowded with sick, but at any time
when the air is confined, and especially in hot weather, pro-
duce fever of a peculiar kind, which is often mortal ; and he
remarked, that the same thing arose in full and crowded
barracks, and in transport ships, when filled beyond a due
number, and detained long by contrary winds, or when the
men had been long kept at sea under close hatches in stormy
weather.”’? He also refers to the experience of Mr. Pearson,
who, he says, ‘‘ told me, that when he was surgeon of the
Lock Hospital, he uniformly observed, when more than a
certain number of patients were placed in any of the wards,
fever became prevalent in the establishment ; and that, from
repeated observation of this fact, he was induced to restrict
the number of beds in each ward, and never afterwards wit-
nessed the recurrence of fever in the house.” It appears to
me that the instance cited by Dr. Roupell (at p. 54 of his
work) of fever coming on, in the Refuge, open in 1830-3],
on the north side of the Thames, at a time when the wards
were crowded to excess, might alone suffice to cast strong
doubts on the correctness of his opinion.

If we consult the details given from p. 7 to p. 42 of Gau-
thier de Claubry’s elaborate treatise, of various epidemics of
typhus, described by such men as Pringle, Roux, Hufeland,
Ducastaing, Reveillé Parise, Tresat, Tort, Gilles de la Tourette,
Laurent, Ardy, Magnin, &c., and his summary from p. 100
to p. 114, we find the unanimous voice referring the gene-
ration of the disease to vitiated air, arising from the crowded
state of the hospitals, the carnage among troops and inhabi-
tants, and the want of burial; the scarcity of provisions,
depressing passions, exposure to cold and fatigue are like-
wise more or less frequently mentioned ; but we are entitled
to regard these as merely accessary ; for we have already
seen the development of typhus where these conditions were
wanting. Montault, from an extensive induction of facts,
TYPHUS AND TYPHOID FEVER, 165

likewise comes to the same conclusions; Copland,! ex-
pressly points out the influence of the circumstance in
question, in producing “ highly infectious and typhoid forms
of fever.”

How, indeed, is it possible, except on this supposition, to
explain the appearance of typhus in a country, and in the
midst of armies, perfectly healthy, till the development of the
conditions in question, but which, under their influence,
were desolated by a pestilence, whose ravages, more fright-
ful than those of war, consigned many, whom the sword had
spared, to ‘an ever-yawning and never-satisfied grave ?”
We cannot, in order to account for this, admit the idea, that,
by some strange and inexplicable principle of election,
infectious miasmata direct their course from distant shores
to the seat of war, especially when we see in their invariable
antecedence and sequence, the relation of cause and effect so
clearly made out between the conditions referred to, and the
appearance of the disease. What reasonable cause can be
assigned for the murderous epidemic that arose, in the spring
of 1810, on board the Plymouth prison-ships, and cannot be
referred to contagion or infection, as the disease first
declared itself among the prisoners confined in what have
been well termed “these floating tombs,” if not the very
natural one of the long-continued confinement of hundreds of
persons, in a situation uniting all the conditions most adverse
to health? These considerations are borne out by the un-
disputed fact, that the type of fever becomes much more
malignant in hospitals crowded to excess, and by Gauthier
de Claubry’s curious statements at p. 148 of his work, where,
speaking of the treatment of typhus, he mentions that,
during “the wars of the empire,” patients previously
despaired of, notwithstanding the assiduous use of thera-
peutic agents, were quickly restored to health, on the eva-,
cuation of the hospitals, with fresh air, barley-water, and
lemonade. How completely does this agree with the
experience of Pringle, as quoted above. Let me further
refer to a paper by Dr. Peebles, in the forty-fourth volume
(No. 125) of the ‘ Edin. Med. and Surg. Journal,’ as detail-
ing the results of his own experience in Italy, and giving a

1 Art. “Infection,” p. 352.
166 ON THE NATURE AND PATHOLOGY OF

remarkably clear, succinct, and comprehensive digest of the
mass of evidence bearing on this interesting subject. Dr,
Alison’s statements in his recent pamphlet on the Scottish
Poor Laws fully confirm the general opinion. I have only
to add, in again partly anticipating details, to which I shall
presently advert, that 22 of 30 patients who positively

eclared to me that they had not in any way been exposed
: infection, replied as follows to my inquiries respecting the
number who lived together. In three cases there were 4;
in seven 5; in two 6; in three 7; in two 8; in oneg; in
-one 10; in one 12; in one 13. Many of those, who traced
their affection clearly to contagion, stated the number of
those who lived together as 12 and 13, and in one or two
instances, as “16 at least.”” This, be it recollected, in one,
or at most two small rooms, in the most miserable, darkest,
and worst aired purlieus of a large manufacturing city.
After the facts I have adduced, I think we may safely con-
clude, that “animal effluvia,’-to use the term of Dr.
Copland, or “emanations from living bodies in close and
unventilated situations,” possess the property of generating
the specific poison, whatever be its nature, that gives rise to
exanthematic typhus.

With regard to the producing cause of typhoid fever, all
is vague and uncertain. Chomel, after his analysis of the
causes assigned by patients, remarks (p. 306), “ Thus,
scarcely, out of a number of patients so considerable (115),
is there one in four who attributes his state to some slightly
energetic cause.”? But what chiefly concerns us to know is,
whether the conditions we have seen to be so powerful in
the production of typhus are the same, or anything like the
same, in regard to typhoid fever. Exactly on this point,
Louis remarks,’ “No more can the dwelling in places, low,
and inhabited during night by too great a number of indi-
viduals, figure among the causes in question, one eighteenth
only of the patients being in that condition ;” and he con-
cludes, from a comparison of all the commonly assigned
causes with the facts ascertained by himself, in these remark-
able words: “ The deepest darkness then prevails regarding
the causes of the affection under consideration,” Chomel

1 Vol. ii, p. 457.
TYPHUS AND TYPHOID FEVER. 167

likewise (p. 300) uses almost the same words in beginning
his third article, ‘The causes of typhoid fever are wrapt in
the greatest obscurity.” It were difficult to find a more
striking instance of the little effect of the circumstances we
have .mentioned, in producing typhoid fever, than the
epidemic at Bischofsheim, in the department of the Lower
Rhine, in August, September, and October, 1832, described
by Ruef in the ‘ Gazette Medicale’ for 1834, and referred to
by Gauthier de Claubry, who maintains the identity of that
disease and typhus. (P. 133, e¢ seq. of his essay.) The
disease first showed itself, without suspicion of being trans-
mitted, in the upper, best aired, and, as is expressly said,
“the most healthy part of the village,’? which is situated
partly on and partly at the foot of a rising ground, and
spread successively to the middle and lower quarters.
Again, the result of Lombard’s researches, conducted at
Geneva throughout several successive years, is, that the
cases of typhoid fever are numerous during the autumn, and
comparatively few during the winter months; whereas the.
ravages of typhus, as everyone knows, are most formidable
during winter.

II. I come now to consider the proximate causes of the
two diseases. To avoid all ambiguity in the use of the terms,
infection and contagion, which have caused, perhaps, a
greater war of words than any two terms in any science, I
shall merely state that, with Dr. Copland, I take infection
in ‘its classical sense, and understand by it the imparting of
any taint, pollution, or contamination whatsoever, to a
person previously in health. By contagion, I understand a
mode of infection, viz. infection by contact. As applied to
the subject of fevers, it will at once be seen that infection
has not merely a reference to disease, but to miasmata, or
specific poisons, independent of disease, to the contaminating
agent, as well as the individual contaminated, and communi-
cating disease. In this point of view, the question is set at
rest by the remarks offered under the first head. Hence, we
consider typhus as a truly and eminently infectious disease.
The same, we have seen, cannot be said of typhoid fever.
The question, then, we have now to consider, narrows itself
into one of transmission or propagation from a diseased to a
168 ON THE NATURE AND PATHOLOGY OF

healthy person. The difference, in this point of view,
‘between infection and contagion is one of degree, and not of
kind ; and there are cases of morbid impression, which it
would be very difficult, if not impossible, to refer either to
the one or to the other, so imperceptibly do they glide into
each other. It is natural, however, to conclude that, as the
genus includes the species, so a disease that is first produced
by the action of a specific infectious agent on the animal
economy, must be directly transmissible from a person
diseased to a person in health. ‘To argue at any length in
favour of the transmission of typhus, whether through the
medium of the atmosphere, or by the direct inhalation of the
morbific matter from a persom labouring under its effects,
would be a waste of time. It is admitted all but univer-
sally. The fearful rapidity with which it extends its
ravages; the great number of cases in which patients refer
their complaint to living with, or attending others affected
with it; the all but universal occurrence of the disease in
nurses and resident medical attendants, put beyond a doubt
the communication of the disease. Lassis, shortly after pub-
lishing his ingenious work, ‘ Recherches sur les Veritables
Causes de Typhus, ou de la Non-contagion des Maladies
Typhoides,’ fell a victim to the contagion, the existence of
which he denied. Need I further refer for the proof of this
position to the names of Sydenham, Morton, Pringle, Hux-
ham, Hildenbrand, Chomel, Tweedie, Roupell, Gauthier de
Glaubry, Montault, Lombard, indeed to almost all the.
writers on the subject? The facts stated by Tweedie, from
p. 85 to p. 99 of his treatise, by Gauthier de Claubry (p.
100 to 114), and by Dr. West in his able paper on ‘ Exan-
thematic Typhus,” in the fiftieth volume of the ‘ Hdinburgh
Medical and Surgical Journal,’ are conclusive as to the com-
munication of typhus to medical attendants, nurses, and
patients labouring under other complaints, and they are com-
pletely borne out by my own experience. It is well known,
that, for many years past, every resident clerk in the Glas-
géw Infirmary, with very rare exceptions, many students
who frequented the fever wards, several of the acting physi-
cians, and almost all the nurses, have, at one time or other,
heen attacked with typhus, and that not a few have fallen
“TYPHUS AND TYPHOID FEVER. 169

victims ; and Dr. Cowan, under whom I had for a long
period the honour of serving, in his pamphlet, entitled
‘Statistics of Fever and Smallpox in Glasgow,’ says (p.
10) of the district surgeons, “Few of those gentlemen
escape an attack of fever.” Dr. West’s statements as to the
spread of the disease among patients admitted for other com-
plaints to St. Bartholomew’s, but placed in the same wards
with others affected with typhus, and the necessity of at
length closing the ward, show the groundlessness of the
objection that contagion arises merely from concentration.
During the winter of 1837-38, an isolated case of typhus in
one of the medical wards of Glasgow Infirmary, communi-
cated the disease to most of those in the same ward, and
several died. The following are the results I obtained from
the statements of 139 patients, whose cases I investigated with
particular care in the years 1837-38. Much more extensive
researches subsequently made by Dr. Anderson and myself,
the details of which, unfortunately, I have not with me, will,
I doubt not, bear out this statement.

Doubtful or From in- Typhus in in same Conta-
cause unknown, fection. 1 family. house. gion.
Males . 21 . 39 ~~ Of | 27). 8 . 4
Females . 18 - 61 whom ‘ 42 ‘ 12 ‘ 4
39! 100 L 69 20 11

I have already spoken of the conditions in which 22 of
the patients were placed who denied the influence of infec-
tion in the production of their complaint. Gauthier de
Claubry remarks (p. 113) that it requires “some degree of
medical courage”? to uphold the propagation and perpe-
tuation of typhus by specific infectious germs, according to
Hildenbrand. On the supposition of its identity with typhoid
fever, this may be so; the difficulty vanishes on supposing
them different.

What is the state of the case in typhoid fever? It is well
known, and stated both by Chomel and Gauthier de Claubry,
that the all but universal opinion in France is against its
being infectious. Louis does not even mention it; Andral

1 Of these 39, there were 30 who positively denied contagion, 6 are not
marked, and 3 were doubtful.
170 ON THE NATURE AND PATHOLOGY OF

(p. 728, English edition) gives his verdict against it;
Montault (pp. 12 and 186) recapitulates the arguments
against it. On the other hand, MM. Bretonneau, Gendron,
Chomel, Lombard, and Gauthier de Claubry maintain, more
or less decidedly, the contagious nature of the disease. It is
rather amusing that the last-named author, while arguing
for the contagion of typhoid fever, in order to prove its
identity with typhus, adduces the contagion of the latter in
the English hospitals, in support of his position, while
Montault, holding the difference of the two affections, feels
constrained, in order to get over an imaginary difficulty, to
express a doubt (p. 12) as to the cleanness and salubrity of
the British, as compared with the French hospitals, and to
assert that “the English physicians are not perfectly
acquainted with the anatomical alteration of typhoid fever ;”
while Gauthier de Claubry, in order to get over the. real
difficulty arising from the absence of anatomical lesions in
the Glasgow and Edinburgh typhus, speaks of the “ serious
circumstances of misery and exhaustion of strength, which
have so deplorably modified the constitution of the inhabi-
tants of these wretched countries, Scotland and Ireland.”
Those who know the admirable cleanness and ventilation of
our fever hospitals, and the acquaintance of our medical men
with the lesions referred to, will readily dispense with any
serious refutation of such gratuitous suppositions; and the
too sweeping assertion of Gauthier de Claubry, as we shall
afterwards see (though partially borne out by the recent
statements of Dr. Alison, regarding the condition of the lower
classes in the large cities of Scotland), even were it
admitted in its fullest extent, proves nothing in his favour.
Chomel’s third conclusion (p. 339) is, that, if the identity
of the anatomical lesions in the two diseases were proved,
the question of contagion would be set at rest. We shall
see hereafter what is the testimony of facts in regard to the
lesions in typhus. Meantime, let us consider the facts in
reference to contagion.

Louis, I have mentioned, does not allude to the subject.
From this we might conclude, that he had found no facts in
support of the theory of contagion, for we can scarcely sup-
pose that an observer so scrupulously accurate would neglect
TYPHUS AND TYPHOID FEVER. 171

so important a branch of his subject; but we prefer an
appeal to positive facts. Chomel, we have already seen,
states how very few patients ascribed their illness to any
energetic cause. Five only out of 115 were placed “in cir-
cumstances favorable to contagion,” 79 could “assign no
appreciable cause ”’ (p. 306). In accordance with this I may
state that, in no case, though questioned with the greatest.
care, either in Scotland or in the hospitals of Paris, have I
ever found the disease referred to contagion. On the other
hand, it appears from the statements regarding the epi-
demics of Nancy by Leuret, of Chateau de Loire by Gendron,
of Andlau and Stolzheim by Mistler, of Bischofsheim by
Reuf, and those contained in Bretonneau’s memoirs (com-
mented on by Gauthier de Claubry, from p. 118 to 135), and
from the clear statements, borne out by dissections, of
Lombard (in his valuable paper upon the Geneva epidemic
of 1835, inserted in the ‘ Gazette Médicale’), seem to prove
the possible transmission of typhoid fever, when epidemic.
Without hazarding any decided conclusion on a point still so-
keenly debated, I would simply direct attention to the differ-
ences as regards the probable origin and propagation of the
two diseases, which the foregoing facts appear to establish ;
and also to the interesting question, whether, if typhoid fever
really depends on, and is propagated by a specific poison,
that poison is, or is not generated in the same circumstances
as the infection of typhus ?

III. There are circumstances connected with the course of
the two diseases well worthy of attention. The fact, as un-
doubted ag it is remarkable, that the mean duration of
typhus is about one half that of typhoid fever, is one
that perplexes considerably the advocates of their identity.
Chomel argues (p. 337) that it only shows a difference of
intensity. Gauthier de Claubry, who very judiciously does
not venture to face the statistical details on the subject, and
treats of it only under the head of the relative intensity of
the two diseases, meets the objections on the same ground
ag Chomel. I have already remarked the extraordinary
difference of the duration in the Glasgow epidemic of 1836.
Hildenbrand states the mean duration of typhus at about
twenty-two days, and that of the Glasgow typhus, from the
172 ON THE NATURE AND PATHOLOGY OF

results of many thousand cases, during successive years,
approaches very nearly to this result, beimg about twenty-
one days. An analysis of my own cases gives me a mean
duration of 20°82 days, or, deducting three cases, one of
which terminated fatally from phthisis on the 42nd,
another not convalescent from consecutive paralysis on the
6oth, and a third restored to health about the rooth day,
after severe attacks of glossitis, pleuro-pneumonia, and a
variety of other complaints, 19°6 days. Valleix, in his third
memoir on ‘Typhus and Typhoid’ Fever,’ states the mean
duration of six cases of the former, and seven of the latter
{observed in London by Dr. Shattuck, of Boston), as
respectively 244 and 22! days. ‘To account for this discre-
pancy with the unanimous voice of other authors, it is enough
to refer to the small number of cases, and to state that the
cases of typhus were of great severity (five out of six having
died), while those of typhoid fever were very mild, and only
one in seven terminated fatally. It appears, on the other
hand, from Chomel (p. 44), that three fourths of the cases
cured began to show signs of amendment, only between the
15th and 3oth, and eighteen of the whole number only
between the 31st and goth days. Louis again (vol. i, p. 9,
13) mentions the duration in cases of death to be from
eight to beyond forty days; in serious cases which were
cured, from fifteen to beyond fifty; or on an average thirty-
two days ; while that of the light cases was twenty-eight or
twenty-nine days. Montault (p. 22) states, that of sixty-
three cases observed by him, the mean duration was thirty-
six days. The mean duration of nine cases of all different
shades of intensity, very carefully watched by myself, chiefly
in the wards of M. Chomel in the Hétel Dieu, is 38°7 days.
One of these, admitted on the 13th of last December, has
not yet terminated. I take the duration of the fever from
his first. convalescence (on the 75th day), after which he had
a relapse without any marked local affection, and his
recovery is very doubtful. M. Chomel in his summary on
the 22nd of last March, of all the fever cases (twenty- five in
number) that had occurred duri ing the previous six months,
stated

1 * Arch. ds Médecine,’ 3me série, t. vi, p. 135-138.
TYPHUS AND TYPHOID FEVER. 173

The mean duration of the very serious casesas - 31 days.
those of moderate intensity, as 18
the lightest cases, as - - 10

giving an average for the whole number of 19°6 days. He,
however, called particular attention to the fact, that the cases
were much. less numerous, and the affection greatly milder,
and much less fatal than usual, the mortality, commonly 1
in 3 or 4, being only 1 in 12°6.

Being firmly persuaded that the remarkable length of
typhoid fever often depends upon conditions not commonly
adverted to, I beg the reader’s indulgence while I go into
some details on the subject. What I wish to establish is,
that typhus, when uncomplicated with any secondary affec-
tion, terminates in convalescence or death in the course of a
single attack; in other words, that a second attack of
typhus does not occur in the course of one and the same ill-
ness. On the other hand, it shall be my object to prove
that such is not the case with typhoid fever.

With respect to typhus, I allege generally, notwithstanding
the high authority of Dr. Copland, who maintains directly
the contrary,’ that (apart ‘from secondary complications,
which often completely change the course and termination of
the disease) however long may be the period of excitement,
—however long the adynamic stage,—however tedious the
period of convalescence, I have never, among thousands of
cases, seen a single case of relapse, in the proper sense of
the term, after the symptoms had begun to decline. Is this
objected to as vague? I appeal to the following facts. Of
139 cases, examined during” the course of the disease with
great minuteness, I find that 119 presented no secondary
complications. Of these 20 died at the height of the fever,
the symptoms having presented a constantly increasing inten-
sity till the fatal fermination. The remaining 99 offered,
without a single exception, a steady aggravation of all the
symptoms till a certain period (more or less distant,
according to circumstances, from the beginning of the
disease), after which they exhibited as steady a decline.
The remaining 19 were complicated in varying proportions

1 * Dictionary,’ p. 1012, art. “ Typhus Fever.”
174 ON THE NATURE AND PATHOLOGY OF *

with phthisis, pneumonia, chronic bronchitis, hemiplegia,
erysipelas, bedsores, diarrhcea, &c., to one or other of which
diseases four fell victims, the secondary affection generally
declaring itself after a temporary amendment.

Let us now inquire into the state of the case in typhoid
fever. I find Montault (p. 18), when treating of con-
valescence, remarking, that “relapses are easy” in that
period. Louis,’ speaking of the same period, uses these
words: ‘ Yet several of them (the healthy functions) were
re-established very slowly in several individuals, and con-
valescence was thereby retarded. The heat was more or less
great ; the pulse continued more or less quick ; the diarrhoea
persisted, though it could not always be referred to impru-
dences in diet.” This is all I have been able to find in the
various authors I have consulted. I shall now cite several
cases in point.

On the 26th of February, 1838, a young man, seventeen
years of age, was admitted to the wards of the Glasgow Fever
Hospital. He had been ten days ill with most of the symptoms
of follicular enteritis. On admission he had a few rosy
spots on the belly, very red and papillated tongue and
fauces, circumscribed flushing of cheeks, disturbed sleep,
tickling cough, extensive bronchitis, dull pain, tumefaction,
and gurgling in the belly, with moderate diarrhoea. He had
expistaxis on the rath, 18th, 19th, and 23rd days of the
disease, and on one occasion to the extent of one or two
pounds. The eruption became pretty copious, then declined,
and on the 3oth day disappeared. At that time the pulse,
which had ranged between 104 and go, fell to 80 and 76;
the bronchitis all but disappeared ; the tongue, which ‘had
been excessively red, chapped, and aphthous, became smooth
and less florid; the gurgling less; and the appetite good.
On the 20th March (the 32nd day), he had rigors, continued
on the 21st with rise of pulse to 104, and followed on
the 23rd by pretty copious eruption on breast and back, by
return of thirst, clamminess of tongue, loss of appetite, sibi-
lant wheeze in chest, renewed tenderness of belly, frequent
bilious vomiting, continued for five days, and epistaxis for

1 Vol. il, p. 11.
TYPHUS AND TYPHOID FEVER. 175

six days running. The symptoms followed their regular
course, and the eruption had nearly disappeared, when, on
the 4th of April (47th day), a fresh, elevated, lenticular
eruption appeared on the chest and epigastrium. The only
altered indication after the appearance of this eruption was a
temporary rise of pulse from g2 to 104. On the 11th of
April (54th day) he was dismissed by his own desire; and
I heard some time aiterwards that he had rapidly convalesced
after his removal.

The phenomena observed in this case scarcely require any
comment; and I therefore proceed to detail others that have
fallen under my notice.

On the gth of last December, a young woman, xt. 22,
entered M. Chomel’s female ward, the Salle St. Augustin,
with symptoms of typhoid fever of ten days’ standing. The
affection was mild, the eruption abundant, the intelligence
good. Amendment soon took place. The countenance,
previously very languid, became more lively, the pulse sunk
to 92, and she seemed rapidly convalescing, when, on the
24th of December (25th day)—as I learn from the reports
furnished me by my friend M. Gueneau de Mussy, to whose
experience and kindness I am much indebted—the pulse rose
to 108. There were marked and sudden prostration, pain,
and crepitant rale in the right subscapular region ; deafness,
which had been considerable, became complete ; stupor and
involuntary discharges came on after some days, and death
followed on the 28th of December. Inspection disclosed the
followed appearances. Incomplete splenisation of lower
part of right lung; diseased aggregate glands at the lower
part of the ileum, some ulcerated, some going on towards
cicatrization, others not ulcerated, and in the state in which
they are described about the sixth day of the disease. Who
can ascribe the supervention of such serious symptoms as
those I have sketched to the inflammation of a small portion
of the lower lobe of the right lung? Is it’not much ‘more
rational to refer them, and to ascribe the morbid appear-
ances, as M. Chomel did in his lecture on this case, to a
fresh intestinal eruption of a few days’ standing ?

Again, on the 27th of last February, a young man, at.
21, entered the Salle St. Louis in the Hétel Dieu, on the

‘
176 ON THE NATURE AND PATHOLOGY OF

8th day of typhoid fever. The eruption appeared next day,
became pretty copious, and on the 13th of March (the
23rd day of the fever) it is reported as all but gone. All
the symptoms had diminished greatly in intensity. The
pulse had fallen to 76. Convalescence took place. He was
eating and relished the half-diet of the hospital, when, on the
afternoon of the 31st, the pulse, in the morning 90, rose to
136. Violent diarrhoea came on. The pain of belly,
formerly slight, became considerable, and a pretty copious
eruption of well-marked “typhoid spots”? appeared. The
chest, minutely examined, presented nothing unusual. On
low diet the symptoms declined ; and I find him marked in
my notes convalescent on the 4th of April. He is about to
leave the Hétel Dicu.

I refer further to a case detailed at p. 30 of the first
volume of Louis’s work. The patient had been three weeks
ill. During the first fortnight the ordinary symptoms, it
seems, were observed ; more particularly headache, relieved
by expistaxis, during the first week; then gradually
increasing diarrhoea and pain of belly. In the third wéek
renewal of rigors and heat of skin. Appearance of the
eruption and recurrence of epistaxis on the 23rd day.
These phenomena were followed by violent delirium, termi-
nating in partial stupor, and death on the 26th day. On
dissection solitary glands, not ulcerated, in the upper ; both
solitary and aggregate glands ulcerated in the lower part of
the small intestine; ‘(a great number of small tumours
flattened, not ulcerated,” in the large intestines. Do not the
symptoms fully bear out the opinion, that the formation of
the tumours described by Louis was coincident with the
aggravation of symptoms in the third week, and that the
extensive ulceration at the foot of the ileum was the result
of disease of much longer standing? The invaluable
researches made of late years into the pathological anatomy
of this affection by Brétonneau, Petit, and Serres, Andral,
Louis, and Chomel, would necessarily lead to this conclusion.
And, in point of fact, Louis says (p.. 37) that they were
“most probably developed at the same time as those in the
first half of the small intestines, being, like them, not ulce-
rated.” Now, according to the generally received theory, the
TYPHUS AND TYPHOID FEVER. 177

glands in the upper half of the small intestine are developed
at an advanced period of the disease.

I conclude my remarks on this head with a reference to
Chomel’s work. At p. 361 is the case of a patient, admitted
on the eighth day of the disease. Prostration, nausea, some
epigastric pain, slight diarrhcea, “a few rosy spots,’ were
the leading symptoms. They quickly yielded ; the diarrhoa
had almost ceased, and a great amelioration had taken
place, when, on the 23rd day, all the symptoms returned,
in a much graver form, accompanied by stupor, violent
diarrhoea, “inclination to vomit (it is expressly said), like
that at the beginning of the disease ;”,—“ slightly marked”
improvement on the 27th and 28th days; recurrence of
same symptoms, with delirium and erysipelas, on the
30th day ; extension of erysipelas to whole right side of face,
and neck, and also to scalp. Almost every trace of it had
disappeared on the 34th day, when epistaxis and stupor,
approaching to coma, were observed. Death ensued on the
35th day. Dissection disclosed a lobule of grey hepatisation
in one of the lungs. In the upper part of the ileum,
“patches partially ulcerated; in the last fifteen inches,
numerous ulcerations of very small extent, and which appear
to depend on the alteration of the isolated follicles ; besides,
that a great number of the last-named glands present an ab-
normal volume, without ulceration ’’ (p. 364).

The symptoms mentioned as recurring on the 23rd day,
after the almost complete cessation of the diarrhoea and other
unfavorable signs, cannot certainly be accounted for by the
“lobule of grey hepatization,” found after death, nor by the
erysipelas, which did not come on for seven days afterwards,
and was then ushered in by a new exacerbation, after a
second decline of all the symptoms. In fact, we have
there all the phenomena of a fresh attack on the 23rd
day, followed on the 3oth by erysipelas as a sequela.
Am I not warranted, then, in concluding, that the exacer-
bation observed at the former. date was accompanied by a
fresh eruption. of isolated follicles? This is strongly sup-
ported by another post-mortem appearance observed, viz. the
uniform rosy tint of the whole of that portion of the small
gut that lay in the lower pelvis.

12
178 ON THE NATURE AND PATHOLOGY OF

After the facts that have been. adduced, I feel almost
entitled to expect assent to the likelihood of the opinion,
which, I am convinced, future observation will confirm, that
in ¢yphus, when uncomplicated with any secondary affection,
a second attack does not take place, while in typhoid fever
the contrary is the case.

I have a few more remarks to offer upon the duration of
typhus. There are cases which are said to run their course
in a few days. I do not speak of the typhus siderans of
Saragossa, Torgau, and Mayence—a disease that was often
mortal in a few hours. It is not to these cases of frightful
intensity that I allude, though I may remark with Montault,
that the earliest death recorded in typhoid fever is, I believe,
that of a patient of M. Bretonneau, on the 5th day. The
cases I refer to are those in which a cure is said to take
place on the 7th or 8th day, or even earlier. Many
authors of distinguished eminence detail cases wherein certain
modes of treatment, early applied, have cut short, as the
phrase is, attacks of continued fever. In short, it has been
often laid down, that an early bleeding, an emetic, a strong
purgative, can crush the hydra in the birth, and restore the
patient to health. Dr. Henderson in his part of the Report
on the Epidemic Fever of Edinburgh,’ states expressly,
“Tf the presence of macula, red spots, or typhoid eruption,
be considered as conclusive of the nature of the disease,
though not necessarily a symptom in all cases of continued
fever, then I can have no hesitation in deciding that this
fever may run its course in a few days; for instances of
convalescence have occurred to me on the 7th and 8th
days, in which the eruption had existed, without which the
diagnosis would have been perplexed, as in other cases.”

Without denying the possibility of the above, I remark,
that it would have been desirable to know, whether, in the
cases spoken of, very minute inquiries were instituted re-
specting the exact days on which the patients were first
attacked ; for every one knows that the premonitory period
of languor and uneasiness, extending often over a week, or
even more, is seldom taken into account by patients in
describing their complaints. But I object to the general’

1 «Edinburgh Medical and Surgical Journal,’ No. 141.
TYPHUS AND TYPHOID FEVER. 179

position on other grounds. It is matter of notoriety that
very many cases of catarrh at all seasons, of influenza when
it is epidemic, and of bilious affections during the heat of
summer, are sent to the fever hospitals, because they simulate,
in a most remarkable degree, the symptoms of commencing
typhus. So it was in Glasgow Fever Hospital. These cases
yielded in a few days to the exhibition of one or other of the
above-mentioned remedies, while the same means were used,
apparently without any effect, either as regarded their dura-
tion or intensity, in very many cases of genuine typhus.
So firm is the belief in Glasgow that those which terminate
in a few days are not cases of continued fever, that they are
not permitted to go into the convalescent wards, where sad
experience has shown the much greater contagiousness of
the disease. In fact (and this militates strongly against
Hildenbrand’s opinion, that typhus is most contagious during
the “nervous stage,” beginning to be so when the eruption
appears), scarcely one of the hundreds dismissed from the
acute wards ever returned labouring under typhus, though
they had remained for a week or ten days in wards some-
times crowded to excess; while, of the few who, by mistake,
went into the convalescent wards, scarcely one escaped the
disease, and several died. No patient who presented the
eruption was ever known to contract the disease anew, even
among the convalescent patients.

I cannot omit to notice another circumstance connected
with the course of the two diseases, which appears to me
one of considerable interest; I mean the occurrence of
crises. I do not refer, by this expression, to the dark and
debated question of critical evacuations, nor will I institute
any inquiry as to whether certain discharges, on certain
days, are or are not attended with an improvement in the
general symptoms. All that I insist upon is the frequent,
I may say, the common occurrence of a perceptible crisis,
or what is vulgarly termed a turn in typhus. I think I may
appeal to the experience of every physician, and more espe-
cially of every resident clerk in a fever hospital (for they
have more constant opportunities of observation), whether
they have not often been struck at seeing, during their
morning visit, the glassy eye, the haggard features, the low
180 ON THE NATURE AND PATHOLOGY OF

muttering delirium, the stupor approaching to coma, the
tremor, the subsultus, the carphology, the rapid, thready,
tremulous, and intermittent pulse, of the previous evening,
the formidable array of symptoms, in short, which seemed
to indicate a speedy and fatal termination, exchanged for
the clear eye, the intelligent countenance, the steady hand,
the comparatively slow and firm pulse, and the returning
appetite of approaching convalescence. To such cases as
these we might almost apply the Scripture phrase, “At such
an hour, the fever left him;” and if the crisis is not very
frequently so marked, we can, in the great majority of cases,
point with precision at least, to the day on which amendment
began to take place. In reply to the question whether this
is the case in typhoid fever, I can only adduce my own
experience, when I state, that neither in the numerous cases
I saw in Scotland, nor in those I have watched in Paris
(about a dozen of them very carefully), have I ever seen
anything approaching, in the remotest degree, to what I have
noticed so frequently in typhus.

IV. I proceed to a fourth and very important branch
of my subject, viz. the consideration of symptoms. I shall
not be tempted, by the highly ingenious and visionary con-
clusions drawn by Valleix, from his six cases of typhus,! to
make any lengthened digression. That author actually
considers the absence of headache and affections of the
organs of sense as important diagnostic marks of typhus.
Instead of wearying the reader with the laboured refutation
I had prepared of this strange fancy, I shall merely state,
regarding my own cases, that, excluding those in whom the
headache ceased before the 5th day, it was present after
that period in 98. In between one sixth and one seventh
of this number it ceased before the roth day; in the remain-
ing five-sixths it continued throughout the advanced stages
of the disease, being present in many till the 2oth and 25th
days ; and in 11 throughout the whole course of the affection.
Hearing, again, was either more acute, or perverted, or
impaired in 69 patients. And finally, while I refer to the
almost unanimous testimony of the multitude of distinguished
authors cited by Gauthier de Claubry in pp. 5 and 39 of his

1+ Arch. de Méd.,’ 3me série, t. vi.
TYPHUS AND TYPHOID FEVER. 181

work, I find recorded in my notes, as among the most
constant symptoms, excessive intolerance of light (of which
I can add my own experience) ; suffusion of the eyes to an
extent rarely if ever witnessed in typhoid fever; and minute
injection of the conjunctival vessels. In not a few cases
chemosis, corneitis producing ulceration and onyx, iritis, and
in two or three cases Hgyptian ophthalmia, occurred in the
course of the disease. What, again, are more common in
typhus than the glassy eye (considered by Rochoux peculiar
to it, from its very rare occurrence in typhoid fever), the
immensely dilated and extremely contracted pupil, and even
total blindness? If reminded that, in adducing those facts,
I am proving the identity of the two diseases, I reply, that,
if to prove the existence of analogies is to prove identity,
there is an end to all conclusive reasoning and accurate
knowledge. In order to establish from analogy the identity
of any two diseases, the resemblances must be so numerous,
so striking, and, above all, so important, and the differences
so few, so trifling, and so easily accounted for, as to warrant
the overlooking of the latter conditions, which have certainly
not as yet been answered in the case before us.

1. I have now to consider symptoms that have a material
bearing on the decision of this important question. The
state of the abdomen and bowels during life is naturally
regarded as worthy of particular attention. The common
use of purgatives in Great Britain throughout the course of
typhus, and their well-known beneficial effects, while they
render the declaration of Montault (p. 93), that- Hamilton’s
method “ still counts some partisans in England,” not a
little amusing, and ‘passing strange,’”’ the sweeping con-
demnation pronounced against their repeated administration
by Gauthier de Claubry (p. 156-172), prove at the same
time the existence of certain symptoms to be combated.
Though not called upon here to undertake a defence of the
English mode of practice as applicable in all cases of typhus,
I refer to it as furnishing some very remarkable facts bearing
on the question at issue. Dr. West, in his able paper on
Exanthematic Typhus (in the fiftieth volume of the ‘ Hdin.
Med.and Surg. Journal’), makes the following observations :—
“The action of the bowels was not disturbed in the great
182 ON THE NATURE AND PATHOLOGY OF

majority of cases; in fact, the administration of mild laxatives
was necessary, in most instances, in order to obtain an
evacuation, once in forty-eight hours; and in some of the
most severe cases the bowels were very constipated. Diar-
rhoea occurred only in 10 of these 60 cases; in three of
which the patients died, and it was only four times that it
lasted for longer than forty-eight or sixty hours. . . .
In 13 cases the bowels were constipated.”” The following is
an abstract of the statements of Dr. Henderson in regard
to the state of the bowels in 154 cases of typhus.

Males. Females, Total.
Bowels easy in. ji 26 ‘ 13 : 99
loose in. 7 — . 5 . 5
costive in é 19 - 31 F 50
45 Tog 154

In reference to the following results obtained by myself,
I have only to remark, that in many of those cases in which
diarrhoea is described as spontaneous, the requisite informa-
tion was unfortunately not got as to the previous adminis-
tration of purgatives.

Males. Females. Total.
( Spontaneous in 3 : 13 . 10 5 23
Diarrhea co medicinein . . 26 . 27 . 53
Donbtfulin . 3 , I : —_ ‘ I
40 37 77

Costiveness notwithstanding the exhi-
bition of purgatives . . ‘ 20 ‘ 42 j 62
60 79 139

Thus, according to Dr. West’s observations, the bowels
were constipated in nearly one fourth; in Dr. Henderson’s
in about one third; in my own in between one half and one
third of the cases. Again, spontaneous diarrhoea occurred
in one sixth of Dr. West’s; in only one thirtieth of Dr.
Henderson’s, or, adding three, in which it came on very
late in the disease, and might be referred to secondary
affections, in one nineteenth ; and in nearly one sixth of my
own. cases.

How different is the state of matters in regard to typhoid
fever? Chomel (pp. 6, 10) mentions diarrhoea as a symptom |
TYPHUS AND TYPHOID FEVER. 1838

scarcely ever wanting, and states it as occurring (p. 230) in
40 out of the 42 fatal cases recorded by him. In the still
more precise observations of Louis, we find it wanting in
only 3 of 128 cases, and in 58 of these it was contempo-
raneous with the commencement of the affection. Spon-
taneous diarrhoea was present in every one of the 9g cases
observed by myself; in 3, it was one of the first symptoms,
having declared itself on the first day, along with the general
premonitory symptoms. In one, it began on the 4th; in
another, on the 6th; in two more, on the roth; in an eighth,
on the 11th; in the ninth, it was observed after a few days’
illness, the precise day not being specified. This symptom
was present, in one case, from the rst till the 22nd day,
recurred on the 36th, and continued, during a second attack,
till the 46th day. Its shortest and longest durations were
respectively ten and forty-three days ; and. its mean duration
above twenty-two days.

As to its characters, in two it was very violent, and opium
had little effect in checking it. In two, it occurred in severe
attacks, which assumed a periodic character ; and in the rest
ib was moderate but always or nearly always present. With-
out insisting further on the comparative duration of the
diarrhoea in the two diseases, though it would, if minutely
investigated, bring out still more clearly the extraordinary
contrast already presented,—I proceed to the consideration
of the state of the abdomen in the two complaints. This
I propose to do under two heads, relating, first, to the
feelings of the patient, and second, to the sensations of the
medical attendant.

2. In 30 out of the 60 cases observed by Dr. West
there was pain in the abdomen, but in only 9 was it severe.
Dr. Henderson remarked it in 46 out of 198, and never in
the right iliac fossa. The following are the results of my
own observation :

Abdomen painful in 109 out of 139 patients.

Males. Females. Total.
Pain intense, or at least severe, in . ; q , 24 A 44
slight . 5 3 ‘ js é 24 , 41 : 65

a _ —

41 68 109
184 ON THE NATURE AND PATHOLOGY OF

The duration of the abdominal pain was as follows :

Males. Females. Total.

Throughout the disease, in . ‘ : 18 : 24 ‘ 45
a considerable part of it, in . 6 . 9 x 15.

From two to six days, in . i . 12 . 24 : 36
One day only 5 5 ‘ 2 ‘i 5 ‘ 8 3 13
41 68 109

Deducting the 13, in whom this symptom was present
only one day, and in whom it may fairly be attributed to
some accidental cause, we have 96 cases out of 139, in whom
abdominal pain was somewhat permanent, and in 60 only
did it continue throughout the greater part of the illness.
In the great majority, the pain was general,—in 32, it was
chiefly or entirely confined to the region of the liver, a cir-
cumstance noted by Dr. West ;—3 of those in whom this
was observed had long laboured under chronic hepatitis.
In 17 of the 32 alluded to (between one half and one third
of those in whom the pain was severe) the liver was exceed-
ingly tender to pressure; and it was the seat of pain, more
or less acute, in 20 out of the 60 patients in whom the
abdomen was tender during the greater part of the disease.
Dr. West mentions the usual duration of the abdominal pain
as “about four days, though once it continued for fifteen
days, and in three other instances from six to cight days.”
In 11 only of my own cases was pain observed in the right
iliac region, 8 of these presenting it during one day, 2 during
two days, and only one for three days consecutively. Valleix
notices the presence of diffuse pain on pressure, for three or’
four days, in two of six typhus patients; and of pain on
pressure and constant uneasiness in four, and of colic ina
fifth of the six labouring under typhoid fever.

According to Louis, abdominal pain was present in 112
cases only of 128, was rarely general, occupied in the vast
majority either the iliac fossee or the hypogastric region,
continued generally throughout the greater part of the disease,
its duration being commonly from ten to twenty-five days..
In six cases it lasted a whole month. The results of my
own observation are, that abdominal pain was present in
every case examined by me; and that in six, in whom pain
TYPHUS AND TYPHOID FEVER. 185

was observed during their residence in the hospital, it was
either confined to the ileo-cacal fossa, or more severe there
_ than elsewhere, having been diffused over the belly in three
of them during a part of their disease. It began in four
on the ist, in one on the 6th, in one on the roth, in one on
the 14th day of the fever. In the remaining two, it was
present, in a decided degree, on their admission to the
hospital, on the 11th and 13th days, and had most likely
been present for some time before, though not felt by the
patient.

This leads me to observe that the leading diagnostic
symptoms in the Glasgow epidemic of 1836 were the red,
chapped, and papillar tongue, the dull, circumscribed abdo-
minal pain existing for weeks together, along with constant
diarrhoea, harsh skin, and obstinate bronchitis. But what
chiefly merits attention is, that while in typhoid fever the
pain accompanies diarrhcea, in typhus the pain is often most
severe when the bowels are costive, and is relieved on the
exhibition of a purgative, proving its frequent connection
with and dependence on a loaded state of the intestinal
canal. In typhoid fever, on the other hand, it exists in-
dependently of any such condition; a circumstance which,
along with its fixed seat, demonstrates its dependence upon
local lesion. This is particularly pointed out both by Dr.
West and Dr. Henderson, and it is fully confirmed by my
own experience.

To sum up what I have stated on this head; abdominal
pain occurred in 186 of 403 cases of typhus, or, deducting
those in whom it was altogether transitory, in 173, t.e. between
one half and one third of the whole; while in the 128 cases
of Louis, it occurred 112 times (about five sixths), or, adding
those detailed by Valleix and myself, in 126 out of 143 cases,
i.e. in about ten elevenths of the whole.

3. The next subject that demands attention is the feel
of the abdomen. Dr. West mentions 11 cases out of 60,
as presenting “some fulness and tympanitic distension ; ””
Dr. Henderson, only 8 out of 198. In those observed by
myself, I find that the abdomen was
186 ON THE NATURE AND PATHOLOGY OF

Males. Females. Total.

Highly tumid and aes in. ‘ ‘ 12 3 15
Slightly so. ; ‘ ‘ ‘ 12 24 39
24 3° 54

Of natural feel i ‘ ‘ ‘ . 35 5° 85
59 80 139

This symptom lasted throughout the disease in 9 3 12
During a considerable part of it, in A 3 2 5
From two to six days 7 16 23
One day . 5 9 14
24 30 54

Deducting, again, as I am fairly entitled to do, those
cases in which the symptom was very transitory, there
remain only 40 in whom it was at all permanent, and in 17
only out of 139 did it continue during the greater part of
the affection.

In typhoid fever, on the other hand, Chomel (p. 12)
remarks its almost constant occurrence, and Louis discovered
it in 89 of 134 cases, in the great majority of which it lasted
during the greater part of the disease. In one only did
it disappear in twenty-four hours. Valleix' remarks its
transient existence in one out of six or seven cases of typhus
observed in London by Dr. Shattuck, whereas it was present
at an earlier stage, in a much higher degree, and for a much
longer period (its mean duration being about nine days) in
five out of six patients labouring under typhoid fever. It
was remarked in eight of the nine cases examined by myself,
and was present from four to thirty-four days, or on an
average a little more than nineteen days. In the remaining
case it was so very slight as to render it doubtful.

Adding together all the cases of typhus above referred to,
we find the symptom in question occurring in 74 out of 403
cases, or between one fifth and one sixth of the whole.
Deducting those in which it was transitory, it occurred in
59 only, or in less than one seventh of the whole number;
whereas it was observed in 102 out of 149, or in rather more
than two thirds of all the cases of typhoid fever—no small
difference assuredly.

1 © Arch, de Médecine,’ 3me série, t. vi, p. 142.
TYPHUS AND TYPHOID FEVER. 187

4. Yet the statements I have made are very far from
exhausting the evidence on the subject. I, therefore, proceed
to inquire into the relation subsisting between the symptoms
spoken of ; and first, in regard to the coexistence of pain
of belly and looseness of bowels in typhus. Of 50 patients
in whom pain and diarrhoea existed at one period or other
of the fever :

Males. Females. Total.
Dineviven, ane { spontaneous in 2 : : 8 9 17
consecutive in . ; ‘i » 15 18 33
23 27 50
Pain and constipation were observed in . - 16 41 57

The numbers in which diarrhcea and constipation were
observed were respectively 77 and 62. Therefore, had
abdominal pain occurred in the same proportion in those
who had diarrhoea, as it did in those who had constipation,
instead of having 50 only, we should have met with it in 70°8.
In other terms, the occurrence in the same cases of pain and
diarrhoea is as 1 : 1°54, while that of pain and constipation
is as 1: 1°08.

Remarkable as this difference is, it is in reality much
greater. I find from a further and very careful analysis
of the cases before me that abdominal pain and diarrhea
were

Males. Females. Total.
Coincident in . 3 ; é - F - I4b 16 30
Not coincident in. ‘ 5 . . : 3 4 7
Pain was relieved by supervention of diarrheain 4 8 12
21 28 49

Again, abdominal pain and constipation were

Males. Females. Total.
Coincident in. 3 16 35 Br
Not coincident in j ° 6 6
16 41 57

Thus, in only 30 out of 77 cases in which diarrhoea, either
spontaneous or consecutive, was noticed, did abdominal pain
and diarrhoea exist simultaneously; whereas, out of 62 cases
in which the bowels were confined, pain in the belly and
188 ON THE NATURE AND PATHOLOGY OF

constipation coexisted in no less than 51. Had the latter
proportion been kept up, we should have had 63°3 instead
of 30, so that, according to our present data, the coincidence
of abdominal pain with constipation in typhus is to its occur-
rence along with diarrhoea as three is to one. I might still
further heighten the contrast, by deducting one who died
of phthisis, in whom the abdominal pain did not supervene
till after the fever had run its course, and in whom it was
found on dissection to depend on very extensive tubercular
suppuration and ulceration of the intestines; another in whom
it supervened about the 20th day, along with a profuse dis-
charge from a very large bedsore; and a third, in whom the
evacuations, though frequent, were mixed throughout with
scybala; but the difference is striking enough without any
such refinement.

I have marked a considerable number of the above as
relieved by diarrhoea, a circumstance which naturally pro-
vokes inquiry into the previous state of the bowels. I find,
then, that of the 30 in whom pain and diarrhoea were con-
temporaneous, 10 may be called cases of spontaneous diar-
rhoea, t.e. the purging was not, so far as I know, brought
on by medicine; while in the remainder it may be ascribed
to that cause. In 28 of those in whom diarrhoea, whether
spontaneous or consecutive, was observed, the bowels were
more or less obstinately constipated during the first stage
of the fever; and in that number are included almost all
those in whom diarrhcea gave relief to pain. And finally,
of the 51 in whom constipation lasting throughout the disease
was accompanied by pain (in many cases exceedingly acute)
the operation of purgative medicine,—of castor-oil, turpentine,
Jalap, calomel, or the neutral salts, given according to the
strength of the patients, and the indications presented in the
course of the disease, was followed by decided and immediate
relief in 20 cases. Dr. West mentions, that of 30 who had
pain, 8 only had diarrhea, while 15 were constipated; a
result that fully bears out my statements.

Abdominal pain and spontaneous diarrhoea were coincident
in all of the nine patients labouring under typhoid fever to
whom I have alluded. The shortest period of coexistence
was four, the longest thirty-two, and the average is a little
TYPHUS AND TYPHOID FEVER. 189

more than fifteen days. So constant did Louis find the co-
existence of these two symptoms, that (vol. ii, p. 34, 38) he
considers abdominal pain, both in typhoid fever and other
diseases, as pathognomonic of an inflamed state of the
mucous membrane. In opposition to this I may quote Dr.
Henderson, who remarks in his report, “‘In eight, a degree
of general tenderness of the abdomen coexisted with tumidity
and tension, in only one of which was there diarrhoea.”

These statements form the best possible apology for the
judicious administration of purgatives in typhus, while the
spontaneous supervention of diarrhoea in many whose bowels
were confined demonstrates its propriety beyond the shadow
of a doubt, and fully warrants, as it appears to me, a most
important conclusion, in proof of which I have adduced the
above rather dry and tiresome details, namely, that whereas
in typhoid fever there is an early and almost uniform ten-
dency towards looseness of the bowels, there is as constant
a tendency in typhus to constipation; that while in the former
diarrhoea is a symptom, and a natural, I might almost say a
necessary, result of a constant local lesion, it arises in the
latter from the presence of an irritating substance, which
it is the object of the vis medicatrix to eliminate from the
system.

5. I shall offer only a few remarks on the connection
between the state of the bowels and the feel of the belly.
Of 54 patients in whom, as has been seen, more or less
swelling and tympanites (meteorismus) were observed, 25 had
diarrhoea, and 29 were constipated. The following tables
will show much more concisely and clearly than I could
express it in words the duration and extent of the tympanites
in these two groups of cases :

Bowels loose. Bowels bound.
Males. Females. Total. Males. Females. Total.
Tympanites continued through-

out the diseasein . : 6 I 7 3 2 5

Throughout the greater oe af
it in I ° I I 2 3
From two to six dave in . 5 4 9 2 12 14
During one day in . 4 4 8 2 5 7
16 9 25 8 21 29
190 ON THE NATURE AND PATHOLOGY OF

On this table I have only to remark, that 7 of the 25 had
spontaneous diarrhea, but of these 7 only 2 had tension of
the belly for more than one day. But, by a careful analysis
of the cases, we arrive at still more remarkable conclusions.
The following are the results of my investigations :

Males. Females. Total.

Tympanites and diarrhoea coexisted in a : 12 5 17
Did not coexistin : s . 3 2 5
Tympanites was relieved by diarrhea in I 2 3
16 9 25

Tympanites and constipation coexisted in 8 18 26
Did not coexist in ° 3 3
8 21 29

Of the 20, the distension was relieved in 3 by the exhibition
of purgatives. The 5 in whom diarrhcea and tympanites
did not coexist were constipated at the time the tumefaction
was noticed, so that in point of fact distension of the belly
was coexistent with diarrhoea in 17, whereas it existed along
with constipation in 31. Finally, of the 7 mentioned above
as having meteorismus and spontaneous diarrhea, the two.
symptoms existed simultaneously only in 4. Dr. West,
I observe, states,’ that of 11 cases in which “there was
some fulness and tympanitic distension of the abdomen,”
diarrhoea was coexistent with it in 7, ‘‘ while in 3 the bowels
were constipated.” As to the extent of the tympanites,
I find that

Bowels loose. Bowels bound.
Males. Females. Total. Males. Females. Total.

The abdomen was highly tympanitic in 8 ° 8 4 3 7
Moderately or slightly so in , . 8 9 17 4 18 22
16 9 25 %S 2 29

6. In 46 (17 males and 29 females) out of 54, in whom
meteorismus was observed, abdominal pain was also present
at one period or other of the complaint, but the two ‘sym-
ptoms were coexistent only in 37 patients, in several of whom
the pain was so very transient and so slight, in comparison
to the duration and extent of the distension, as scarcely to

1 «Edinburgh Medical and Surgical Journal,’ vol. i, p. 134.
TYPHUS AND TYPHOID FEVER. 191

merit notice. To show still further that there is no pro-
portion between the extent of abdominal tension and the
pain experienced, I would merely state that, of 15 patients
in whom the belly was highly tumid, 6 only felt severe pain;
in 5 there was slight tenderness; in 4 none whatever. Of 44,
on the other hand, in whom the belly was acutely painful,
we have seen that only six presented any remarkable tension;
in 18 it was slight; in 20 there was none at all. Dr. West’s
statements are widely different. He states (loc. cit.) that
pain was present in all, except one, of those in whom the
belly was tympanitic.

I shall conclude my remarks on this head with a few
statements regarding the simultaneous occurrence of the
above symptoms in my own cases of typhoid fever. Tume-
faction of the belly and diarrhoea coexisted in eight patients,
from 4 to 30, giving an average of fifteen days and three-
quarters. Tumefaction was unaccompanied by pain in one
patient, and lasted from the 12th to the 33rd day. In another,
abdominal pain was present on admission, but disappeared
next day, though the distension persisted throughout. Ina
third, the abdomen was swollen, but not painful, from the gth
to the 24th, both swollen and painful from the 25th to the
31st day. In the remaining 5, the symptoms coexisted from
four to thirty-four days, or on an average about twenty days
and a half.

I go on to speak of the eruptions observed in the two
diseases. This subject has lately begun to excite much
interest, more, perhaps, in Great Britain than in France.
The proposal which has been made to overturn long-received
opinions, and to blot out a long and elaborate section from
the nosological dictionary, by placing typhus among the
exanthemata, could not fail to awaken a most interesting
controversy, and to bring under review the whole history,
and much of the symptomatology of typhus. Hildenbrand
was the first to propose this innovation. But it was started
in England and Scotland by two physicians, who had neither
had any communication with that distinguished author nor
with each other, viz. by Dr. Roupell, who, it appears from
his work, brought the subject under the notice of the London
College of Physicians in 1831; and by my friend Dr. Peebles,
192 ON THE NATURE AND PATHOLOGY OF

who, on his return to Scotland in 1832, after a long residence
in Italy (where he had been struck with the constant occur-
rence of an eruption in the epidemics of contagious fever),
‘ drew the attention of the profession in Edinburgh to its
presence, previously unnoticed, in the typhus of that capital ;
and after two years of attentive inquiry, published the result
of his researches, accompanied with a comprehensive sketch
of the history of eruptions in contagious fever, in the forty-
fourth volume of the ‘Edinburgh Medical and Surgical
Journal ’—being the first, as I believe, to submit his senti-
ments to the medical world. I observe that Dr. West, in an
able and learned paper in the last number of the same
periodical, maintains the opposite opinion. For several
reasons I shall not enter upon this controversy. Besides
that the proof of the positions I mean to take up does not
require it, it appears to me that we are not yet in possession
of data sufficient to demonstrate the truth of the doctrine.
That must be the work of many years of patient and very
extensive inquiry. I may remark, however, that there is
everywhere a growing conviction in its favour, and that,
if the claim of typhus to rank among the exanthemata has
not yet been fairly made out, its remarkable analogies with
that class of diseases are attested, alike by the uniform
experience of the past, and the observation of present times.
Nor can I consent, without reserve, to conclusions drawn
from the alleged absence of eruption; for the fact I have
already referred to (viz. that the eruption in the Edinburgh
typhus was unheeded before 1832), shows how appearances
may escape the eye of the most distinguished and practised
physicians when their attention is not particularly drawn to
them. It is also well known to many that, previous to a
visit which Dr. Peebles made to the Glasgow Fever Hospital
in the spring of 1835, the exanthema of typhus, then found
to be of general occurrence, had neither been looked for nor
registered in that institution, and was actually hailed as a
new discovery. And finally, I must express my conviction,
founded on observation, that a very large proportion of those
cases mentioned in fever reports, as having no eruption,
consists of patients (such as I have already referred to) in
whom the disease is only of a few days’ duration, and does
TYPHUS AND TYPHOID FEVER. 198

not, for the reasons stated above, seem to merit the name
of typhus fever. These considerations, it appears to me,
have an important bearing on the decision of this debated
question.

While, however, I decline making any further remarks on
this branch of inquiry, I must refer shortly, for the practical
elucidation of my subject, to the history of the typhous
eruption. Much confusion prevails on this point. The
meaning of the term petechiw has, in the course of time,
undergone a great change. That it was used by the old
authors (loosely enough, doubtless) to denote what would
have been much better called an eruption, is evident from
their writings, and has been very clearly shown by Dr.
Peebles, five years ago, and by Dr. West in the April number
of the ‘ Edinburgh Journal.’ Dr. Peebles accordingly pro-
posed to retain the old term in its altered but now generally
received acceptation, and to consider the rosy eruption as an
exanthema. Yet many, from the use of the term petechial
by the older writers, persist in denying their acquaintance
with the eruption; some, on the other hand (Rasori, Pinel,
Tweedie), having used’ the same word in reference to the
eruption, are blamed for want of “‘ precision and exactness
in the use of terms;” Chomel (p. 336) considers “ the true
petechiz or purple spots”? to be very much more frequent
in typhus than in typhoid fever; Valleix' maintains the
eruption to be always dark and persistent, and takes it as
synonymous with vibices; while Copland® and Montault
(p. 154) describe “ ecchymoses and petechiz as common to
typhus and other diseases,” and the measly eruption as
peculiar to it. Again, Roupell quotes Louis and Chomel in
support of his views as to the true exanthematous character
of typhus. One of his reviewers,® reasoning on the generally
admitted difference of the French and British continued
fever, retorts Dr. Roupell’s arguments as proof positive
against the truth of his theory, while, with praiseworthy
consistency (p. 103), he cites Chomel’s statements regarding
the eruption in support of his own opinions.

1 © Arch. de Méd.,’ 3me série, t. vi, pp. 133-4-6, 148-9.
2 * Dictionary,’ p. 1010, art. “‘ Typhus.”
3 «Med.-Chirurg. Review,’ vol. xxxi, p. 99.

13
194, ON THE NATURE AND PATHOLOGY OF

I shall now endeavour, in proof of the two following pro-
positions, to present, in small compass, the very numerous
statements of authors, to reconcile their apparent contra-
dictions, and to give the results of my own observation
regarding the exanthema of typhus. The points I wish to
establish are:

First, That the rash in typhus is permanent ; that in all
cases it presents the two periods, longer or shorter, according
to circumstances, of increase and decline; that, in the more
severe cases, it may exhibit, during the period of increase,
four different states, being florid, dark, livid, and petechial ;
and finally, that it is quite different from vibices and purpura,
which are of rare occurrence.

Second, which partly flows from the foregoing, that the
abundance, and particularly the darkness of the eruption,
may be said to be proportional to the severity of the disease.

1. When I say that the rash is permanent, I mean that it
does not consist of successive eruptions of spots, each of which
disappears in the course of three or four days, but that the
same eruption continues throughout the disease. As the
accuracy of this position will be clearly brought out in
treating of the changes the eruption undergoes, I shall only
state that it was ascertained by surrounding a certain number
of spots with ink, and observing them carefully several times
daily.

Dr. Copland and Dr. Peebles, to whom he refers, lay
down the proposition that the “eruption usually appears
from the 3rd to the 7th day of the fever, but may be delayed
till the 12th or 14th day.” Dr. West, in his last paper,
mentions that in the Vienna fever of 1757, when the disease
ran its regular course, it appeared “on the 4th, or, at latest,
on the 7th day.”’ Montault (p. 154) refers to Drogait,
Biett, Rochoux, and Pringle, as having observed it generally
on the 4th, 5th, or 7th, and sometimes (according to Pringle)
on the 14th day. Gauthier de Claubry (p. 75) remarks,
“That of seventeen observers who make express mention
of it, four noticed it on the 4th, two on the 5th, eight in the
course of the 6th and 7th, and generally, all point out its
manifestation between the 7th and roth days.” Dr. Roupell

1 «Edinburgh Journal,’ No. 143, p. 298.
TYPHUS AND TYPHOID FEVER. 195

maintains its almost uniform appearance on the 3rd or 4th
day. Dr. Cowan, in his ‘ Statistics of Fever and Smallpox
in Glasgow,’ p. 24, says that it ‘‘ generally makes its appear-
ance from the 4th to the oth day of the disease, occasionally
at a later period.’”’ Dr. Henderson states that in 8 out of 12,
in whom the day on which it appeared could be ascertained,
it appeared from the 3rd to the 6th, in “the remaining 4
severally on the 7th, gth, and 11th day.’’ I have been able
to ascertain the exact date of the appearance of the eruption
in a much larger number than Dr. Henderson, to whose
statements, in addition to the following tables, I refer for
the proof of what I have advanced respecting its increase
and decline. The first table refers to the time of its appear-
ance, the second to the period at which it began to decline,
the third to the date of its final disappearance.

Males. Females. Total.

It appeared on the 2nd day in I I 2
3rd_,, 2 I 3

4th 5 3 2 5

sth sy, 4 12 16

6th =, 4 9 13

7th IT 4 5

8th ,, 2 I 3

oth I 3 4

13th i, ° I I

18 34 52

From this statement it results that in more than half of
the entire number it appeared on the 5th and 6th days, and
that, in exactly three fourths, it appeared from the 4th to the
jth day. Taking an average of the whole, it appears most
commonly on or about the 6th day. I must, however, direct
attention to the fact that in not a few cases ib was so verv
copious, and in several so dark, on the 6th day, as to warrant
the belief that it had appeared some days before.

Dr. Henderson states that the eruption began to fade
“in 11 before the 1oth day; in 20 between the roth and
12th, inclusive; in one, as late as the 17th.”’ The following
table gives the results of my own observation. It refers only

2 *« Report,’ &e., p. 13.
196 ON THE NATURE AND PATHOLOGY OF

to 48 of the 52 cases above referred to, 4 having died before
the eruption began to recede.

Males. Females. Total.

It began to decline on the 8th day in . I ° I
oth : 3 3 6
toth ,, ° 5 5
mith =, 2 3 5
12th ,, I 4 5
3th ,, 5 3 8
14th, 3 3 6
sth I 3 4
16th ,, ° 2 2
17th a, ° 2 z
ith =, I 2 3
1oth ° I I
17 31 48

It is evident from the above table that we cannot fix
any particular day, from the gth to the 15th, inclusive, on
which, much more frequently than any other, the eruption
begins to fade. It did so, however, on one or other of these
days, in 39, or five sixths of the entire number, the average
of which, (12°8), assigns the 13th as the day that the change
most commonly takes place.

The length of this paper, already too great, renders it
impossible, as its object happily renders it unnecessary, to:
analyse the circumstances whereon the variations I have
noted depend, such as the age, the constitution, the strength,.
the habits of the patient, and the greater or less intensity
of the disease, all of which have a material influence in
modifying its duration.

I shall now, in a third table, show the various dates of the
disappearance of the eruption, in 45 cases, 3 more having
died, very shortly after it began to recede.

Males. Females. Total,

It disappeared on the 13th day in 3 2 0 3 3
14th ° 4 4
15th 2 I 3
16th 2 2 4
17th ° 2 2
18th 2 5
19th ° 5 5
TYPHUS AND TYPHOID FEVER. 197

Males. Females. Total.

It disappeared on the 2oth day in i zo 2 3
21st : 1 I 2
22nd 3 2 5

11th, rath, Saud, oath,
25th, 26th, and
days in ‘ 4

| eo
wr

15 39° 45

The differences in this are still more striking than those
jn the preceding table. It would be easy, were such a part
of my present purpose, to demonstrate that the long con-
tinuance of the eruption depends, in almost every case, on
its having been dark, livid, or petechial during the disease ;
but, as the proof of it would not aid me in my present inquiry
I go on at once to deduce some more practical inferences
from the data I have furnished. Where so many disturbing
forces are at work as those I have alluded to, it would be
vain to look for anything like an exact proportion between
the periods of increase and decline in the typhous exanthema.
Accordingly, I find, from a laborious analysis of the above
eases, that though in 8 the two periods agree exactly,
and in 8 others, very nearly, in length, they vary, in the
remainder in all different proportions. As it would be quite
useless here to enter into details, I shall simply subjoin the
results of my calculations :

Days.
Shortest period of increase 3 2 3
Longest 33 as : . - 13
Average ‘s 55 . . - 708
Shortest 3 decrease . i .- 2
Longest a 5 : 2 - 13
Average 35 53 : ‘ - 445
Shortest duration of eruption i . 6
Longest * 5 3 . 24
Average 3 ; ; . II'59

These conclusions form a considerable contrast to Dr.
Copland’s tater; «The duration of this eruption is from
three to five days.’ Dr. Henderson infers ‘ that the whole
duration of the eruption occupied commonly nine or ten
days,”—a result which approaches much more nearly to that
I have arrived at. Though I could have adduced a much
198 ON THE NATURE AND PATHOLOGY OF

greater number of facts regarding the decline and disappear-
ance of the eruption, I have preferred confining my attention
to those patients alone in whom the date of its commence-

ment also was ascertained, for, having been selected for
examination solely because they presented themselves in the
early stage of the disease, they form a perfect group, whence
general conclusions may with safety be drawn.

Before entering on the consideration of the various states.
of the eruption, let me refer to some of the opinions put
forth respecting it. Valleix, I have already stated, holds
the eruption to be always dark, and persistent under pressure,
both during life and after death. “It is,” says Copland,
“of a florid, reddish, or reddish-pink colour ; disappearing
on pressure, but soon returning when pressure is removed.
This circumstance is sufficient to distinguish it from petechia.”
Again, “If petechiee occur in this fever, they seldom are
observed before the 8th or t1oth day, and then this
eruption has usually disappeared. When the petechiz are
earlier, or the eruption continues longer, so that both exist.
together, they are quite distinct and different in their appear-
ances ; for the latter is never so dark or livid as the former
generally is.’ Further on, he remarks, ‘In the more
malignant cases, or when petechia appear early in the
disease, the colour of the eruption may, however, become
deeper.’ Still further, ‘‘ The petechial affection
may occur in the advanced stage of any fever
and is not in any sense of the word an eruption, as it fee
been very improperly denominated by some writers. ‘i
The petechiz or cutaneous ecchymoses vary in dimensions
from minute stigmata to large patches and vibices, and in
the deepness or shade of colour. . . . But the exanthe-
matous eruption attending true typhus . . . has been
confounded with petechiew, with which it is often associated
in the advanced stages of the fever.” These opinions agree
entirely with those expressed in his paper by Dr. Peebles.
Dr. Henderson (p. 16) has the following remarks: “ Purple
petechiee, the result of ecchymosis, were frequently present
in the second week of the disease. In some cases they were
very abundant, but in very few exceeded the number ol
typhoid maculw, which commonly existed along with them
TYPHUS AND TYPHOID FEVER. 199

One vibex only was remarked in the whole number of cases
The petechie continued often distinct, though the eruption
was declining.” To disprove, as far as my observation
enables me, what appears to be incorrect in these opinions,
even though upheld by such high authority, is the task I now
propose to myself,

The statements of authors on this subject are very
numerous. Dr. West, in tracing the history of the eruption
downwards from the fifteenth century, cites Fracastorius and
Ambrose Paré, who both speak of the eruption assuming a
dark colour. Conradinus is more explicit. In the article
referred to,’ I find these words: ‘In addition to these sym-
ptoms, however, spots like flea-bites appeared on the skin of
all the patients. In some cases, these spots were of larger
size than others; occasionally they occupied the whole body,
but usually were confined to the chest, the spinal and inter-
scapular regions, and the arms; and they were observed to
assume a livid or blackish colour in dying persons.” Willis
(same paper, p. 289) mentions as one of the symptoms of the
epidemic among the troops near Oxford in 1643, an eruption
of spots, some of them small, and of a bright-red colour,
while others were larger and of a more livid hue. The
reviewer of Dr. Roupell, formerly alluded to, says,’ “The
rash is not accurately described by any of the authors cited,
so that it is impossible to say whether it was the same in all.
One author (Pringle) does not even mention its existence.”
Now, as it so happens that Pringle has given, both in his
work on ‘ Diseases of Armies,’ and in his letter to Mead, a
description of the eruption so clear as to make it be referred
to by most writers on cruptions in continued fevers, it may
be as well to quote his own words, which have an especial
bearing on this and other portions of my subject. ‘‘ There
are,” says he;* “certain spots, which are the frequent, but
not inseparable, attendant of the fever in its worst state.
These are less usual on the first breaking out in the hospitals ;
but when the air becomes more corrupted the spots are
common. They are of the petechial kind, of an obscure red
colour, paler than the measles, not raised above the skin,

1 ¢Hdin. Journ.,’ No, 143, p. 282.
* «Med.-Chirurg. Review,’ vol. xxxi, p. 103.
200 ON THE NATURE AND PATHOLOGY OF

of no regular shape, but confluent. The nearer these spots
approach to a purple colour the more ominous they are,
though not absolutely mortal.” The most of the authors
quoted by Gauthier de Claubry mention the existence both
of the “rosy and petechial eruptions,” the latter coming on
at a later period of the affection, and in adynamic patients.

Dr. Roupell, in speaking of the opinion of some authors,
that the “conversion of petechiz into the rash is a common
occurrence,” has evidently, as his reviewer remarks, said the
reverse of what he meant to convey to his readers. My friend,
Dr. Staberoh, of Berlin, from observations of which I can
attest the accuracy, made in Glasgow Fever Hospital, where
I then resided, drew attention to the frequent conversion
of the rosy eruption into petechie, in a paper published in
the ‘ Medical Gazette,’ for March, 1838, and in reference to it
Dr. West has the following remarks: ‘ My attention having
been called to the point by a paper of Dr. Staberoh, I have
endeavoured to ascertain, whether, as he asserts, the spots
often change into ordinary petechiz, but have not yet been
able to satisfy myself upon the point, though, from one or
two cases which I have seen, in which the spots greatly
resembled petechiw, I should think that his statement is
very probably correct.” Dr. Staberoh, in his thesis on the
Exanthematic Typhus at Halle, in 1834, maintains the same
opinion. Having thus, by quotations, shown that my opinion;
so far from being original, has been partly recognised for
centuries, and has been fully developed, of late years, by
other writers, it only remains for me to offer the fruits of my
own observation.

Having observed with care, several times daily, the cases
referred to by Dr. Staberoh, in which a considerable number
of spots were circumscribed with ink, I have seen the changes
referred to going on in the most gradual manner; indeed,
the fact was so clear that I find, in my daily reports of
numerous cases, taken months before his arrival, and when
my attention was not particularly directed to the point, the
phrases, ‘pale, florid, darkening, dark, livid, petechial,”
applied successively to the eruption at various stages of the
disease. In the details I am about to give the general .

principle is all I wish or need to establish; the periods at
TYPHUS AND TYPHOID FEVER. 20]

which the changes take place I do not now seek to deter-
mine. Having specified the four states of florid, dark, livid,
and petechial I would have it borne in mind that, when
florid, the eruption disappears readily under pressure ; when
dark, it still disappears, but more slowly ; when livid, semi-
petechial, or pseudo-petechial (as it has been called), it is
only partially effaced; when petechial it is not in the least
affected by pressure. In many cases, it remains florid
throughout ; in others, it presents one or more, and in not a
few, all these alterations ; and after it has reached its height
the process is inverted, and it passes through the various
phases of lividity, darkness, redness, and paleness, before its
evanescence. When death took place at the time the eruption
was petechial, the ecchymoses (for they are true ecchymoses)
remained after death—a circumstance noted by Dr. West,
and particularly insisted on by Valleix in the paper already
referred to. Dr. Henderson says (p. 12), ‘‘In a few, the
tint was somewhat purple ; and this colour could be assumed
by an eruption that had formerly been scarlet.”” By including
in the following tables the deaths in the various groups of
cases, they will serve for reference, when I come to speak,
as I shall do presently, of the relation that subsists betwecn
the states of the eruption and the gravity of the cases.
The colour of the eruption was:

Cases. Deaths. Rate of mortality.

 

Pale throughout in . 34 3 1 in 113
Florid : ‘ 25 2 I in 123
Darkish in 5 ; 16 2 Tin 8
Dark ; . 32 8 Tin 4
Livid or semipetechial in . 15 7 rin 24
Petechial . ; 17 4 Iin 4}
139 26 Tin 5%

Hence it appears that the eruption was pale in about one
fourth; florid in between one sixth and one seventh; darkish
in between one eighth and one ninth; livid in rather less
than one ninth; petechial in about one eighth of the whole
cases. Dividing them, then, into two groups, we have the
following result:
202 ON THE NATURE AND PATHOLOGY OF

Cases Deaths. Rate of mortality.

 

Eruption light coloured in . 59 5 rin 11%
dark coloured . 80 21 1in 3%
139 26 lin 53

I have been thus minute in my subdivisions, in order to
show more clearly the almost insensible gradations by which
the rash is transformed from its florid or exanthematous
into its petechial state ; and in order to demonstrate at once
its difference from purpura and vibices, and the truth of my
concluding position. I met with purpura spots in three,
and vibices in only two cases. In one of the former, a
plentiful crop of purple spots appeared suddenly on the 14th
day, on the chest and belly, amid a “pale, scanty, and very
small”? eruption. The pulse, which had before gradually
increased in frequency, was 128 on the 12th day; on the
13th, it fell to 116. It continued to fall steadily, by about
six beats each day, becoming gradually fuller and firmer ;
the intensity of all the other symptoms diminished as steadily,
and convalescence was completely established on the 21st
day. In another case, a large crop of very minute spots,
differing completely in colour from the eruption, which had
been petechial for days before, appeared on the 12th day,
on the right arm, and faded away long before the eruption.
The pulse, 120 on the roth day, fell on the 11th to 104, and
on the 13th to 96, and during the four following days to 54;
on the same day epistaxis occurred, and the violence of all
the symptoms diminished, but the severity of the attack left
the patient exceedingly weak, and convalescence was not
fairly established till the 31st day. In the third case, very
numerous spots, similar to those already described, appeared
around the left elbow on the 1oth day, amidst a ‘‘ darkish”
eruption. On the same day the patient died. The coun-
tenance, which the day before was wild, flushed, and much

- oppressed, is reported “languid, much better ;”? and the
pulse had fallen from 136 to 128, and was of better strength,
but an intense bronchitis and the supervention of pneumonia,
with great pectoral oppression, proved fatal. The difference
in the appearance of the spots is well described by Dr.
Staberoh. The spots of petechial eruption are ill-defined
and shaded off at their margins, and have a dusky, reddish-
TYPHUS AND TYPHOID FEVER. 2038

brown colour, while the spots of purpura, besides having
abrupt and very clearly defined margins, present a decided
shade of blue, which, as Dr. Staberoh, remarks, renders the
name applied to them very appropriate. Vibices appeared
upon the chest in, one case on the toth day, amid a pale
eruption, that became afterwards more marked, while the
ecchymoses grew paler. The pulse, on the gth day 124, had
fallen to 112; the state of the patient improved rapidly, and
convalescence took place ou the 18th day. In another, the
vibices were pretty numerous, large, and very irregular in
form, and appeared on the 12th day, amid livid and petechial
eruption ; the pulse fell from 132, the number of pulsations.
on the day before, to 122, and convalescence was complete
on the 2oth day. From these details it appears clearly
that purpura and vibices are of rare occurrence in typhus,
are quite distinct from the typhous eruption, and that, instead
of being attended with peculiar danger, they would actually
appear to be critical. We may also conclude that if, as Dr.
Copland insists, ‘the petechial affection is not in any sense
of the word an eruption’’—“ the exanthematous eruption is”’
not only “often associated with” petechie, but is often itself
petechial.

I now proceed to my second proposition. Dr. West (loc.
cit., p. 141) says, that in the cases he observed “ the abun-
dance or scarcity of the eruption was not at all in proportion
to the severity or mildness of the different cases.” He
considers petechixw not to be particularly ill omened”’ (an
opinion somewhat borne out by the facts stated above), ‘‘and
certainly by no means so much to be dreaded as the dark
and livid hue of the eruption, and of the skin generally, which
is sometimes observed.’ To the first assertion, so vague
and so general, I oppose his own words (at p. 290 of the
‘Edinburgh Journal’ for this year), where, speaking of
Willis’s account of the epidemic that broke out in the spring
of 1643 among the troops near Oxford, and was for some
time unaccompanied by eruption, he says, ‘‘ About midsummer
the disease increased in fatality,’ and then goes on to give
the description of the eruption already referred to. I oppose
to it also the general fact that the eruption is seen in its
greatest perfection in extensive epidemics, during which the
204 ON THE NATURE AND PATHOLOGY OF

disease is much more violent and fatal ; and the fact, that in
Glasgow, when the cases were few, the disease very mild,
and the deaths 1 in 10, or 1 in 12, the eruption, if present,

was never observed; whereas, when the cases became more ---

numerous, the disease more malignant, and the deaths
amounted to 1 in 8 and 1 in 64, the eruption became steadily
more and more abundant. Dr. Peebles accounts for the
scantiness of the eruption in Hdinburgh, at the time he made
his observations, by typhus not being epidemic. Dr. Hender-
son states the deaths among those with abundant eruption
as 1 in 5; among those with scanty eruption as 1 in 8°3.
Two of the three fatal cases in the latter class presented
“ extensive visceral disease of long standing;”’ while not one
of the thirteen in the former class had any such disease.
The duration of the cases was, on an average, between two
and three days longer in the one than the other. My own
observations, likewise, show the relation between the abun-
dance of the eruption and the severity of the disease. The

eruption was :
Cases. Deaths. Rate of mortality,

. Universally in 6 I 1in
C { y 9 9 m5
ae Partially in . 32 5 I in 64
Scanty : 2 IL 1! Tin I

The dark tint of the eruption is noted as ominous by all
authors. The quotations I have given above prove the
general opinion; and I may likewise refer to most of the
authors cited by Dr. West, and Gauthier de Claubry, to
Dr. Tweedie (p. 73), and Dr. Henderson (p. 12). The
existence of a mortality in those with dark, three times
greater than in those with light-coloured eruption, in the

tables I have presented above, shows in the clearest manner ©""'

the truth of these opinions, and renders needless any further
comment. This fact ascertained, we cease to wonder at
Valleix’s sweeping conclusions, drawn from six cases, five
of which were fatal.

Typhoid fever has also its eruption,—a circumstance much
insisted on by Gauthier de Claubry, in proof of its identity
with typhus. It is generally agreed (Chomel, Louis, Gauthier

1 In this one case the eruption was petechial, and, on inspection, I found
disease of old standing, and aneurismal dilatation of the aorta.
TYPHUS AND TYPHOID FEVER. 205-

de Claubry, Montault), and my own experience leads me to
assert it, that it appears later than the exanthema of typhus,
but that is a point of very minor importance; the main
question is, are its characters the same? According to all
the best authors on the subject (Chomel, Rayer, Biett,
Rochoux, &c.) it is distinguished from the morbilliform
eruption of typhus by being distinct, rounded, slightly elevated
above the skin, and of nearly uniform size. In only one case
(which I saw in the Hétel Dieu last winter) have I noticed
anything like an approach to the irregular, and very often
confluent, rash of typhus, which is generally level with the
skin, or if raised, is very slightly so, and that only during
the stage of excitement. In all the other cases of typhoid
fever in which I have seen the eruption I should say that it
appeared in small spots, rounded, and almost papular in form,
being considerably elevated in the centre. Dr. Perry, of
Glasgow, was the first whom I heard maintain the complete.
difference of the two eruptions, and I am now fully satisfied
of the accuracy of that opinion, for the following reasons :

1. The typhoid eruption is not permanent. That the
typhous exanthema is so, has, I think, been shown by
abundant evidence; but it is generally agreed that the rash
in typhoid fever is “composed of several successive erup-
tions,”! that its duration varies from three to seventeen days,”
the mean duration being seven and a half, and that ‘‘each
rosy spot is not commonly visible for more than three or four
days, and sometimes less.” I have often been able to verify
this remark.

2, Ihave never seen a single case in which the typhoid
eruption became petechial or even dark, and no author I have
consulted pretends that it does. On the contrary, it always
retains the same characters, the last crops (and I have seen
them appear the day before death, in cases where there was
the most complete prostration) being as florid as the first.
Reflections on the necessary relation between the state of the
blood and the appearance of the eruption, which I cannot
now develop, but which are strongly confirmed by the frequent
occurrence of a buffy coat, and a pretty firm coagulum, in

1 Chomel, ‘ Legons,’ &c., p. 19; also Louis, vol. ii, p. 232, 241.
? Chomel and Louis.
206 ON THE NATURE AND PATHOLOGY OF

typhoid fever, will naturally suggest themselves to every
mind.

3. It is beyond a doubt that there is no relation between
the eruption and the severity of the cases. I confess that
I long felt inclined to believe that the more plentiful the
eruption the less serious the case. I was particularly led
to think so by the total absence or extreme scantiness of the
eruption (though carefully sought for) in the Glasgow epidemic
of 1836, which was very deadly, and by afterwards finding
it more or less copious in sporadic cases presenting a much
less intense form of the affection. After further inquiry,
I find, that though in its fullest sense the opinion is incorrect,
it is to a certain extent true. From a careful perusal of the
valuable work of Chomel, I find that a large proportion of
the worst cases, and of those who died, had either a scanty
eruption or none at all; and it appears from the lucid state-
ments of Louis,' that it was wanting in 9 out of 35 fatal
cases, and that it was scanty (en petit nombre) in 18, or three
fourths of the remaining 26, some of them presenting only
five or six spots; a number reckoned by Chomel (p. 18) of
no value, fifteen or twenty being necessary, according to
him, to “characterise the typhoid affection.” Fifty-four of
fifty-seven patients who had severe attacks, but recovered,
had the eruption, and of the remaining three, two came to
the hospital on the 14th and 4oth days of the disease. ‘In
some cases,’ he adds, “there was only a small number of
spots.” In twelve “the eruption was very abundant.”
It was present “in all the cases where the affection was
slight,”” whence he infers, that “its cause is special,” or
specific, and that it is not like other secondary phenomena,
proportioned to the gravity of the disease and the febrile
movement.” Hence we may at least conclude, that in severe
attacks of typhoid fever, the eruption is less frequent, and
generally less plentiful than in those that are less serious.
Does any one object that these reasonings prove not the
difference of the eruptions, but merely a different determi-
nation of one and the same eruption, in the one case to the
skin, in the other to the mucous surface, which has been
called “the inverted skin?”—I reply that, according to this

1 Louis, vol. ii, 231, et seq.
TYPHUS AND TYPHOID FEVER. 207

hypothesis (for it is a pure hypothesis), there should be in
typhus with scanty eruption a decided abdominal determi-
nation; but the fact, as undeniable as it is conclusive, is
exactly the reverse; for numberless cases of typhus with
scanty eruption are remarkable only for their mildness and
the absence of any visceral complication. This is particularly
the case in children, in whom the eruption is seldom seen.

We may also conclude generally that the facts detailed
go against the opinion of Chomel (p. 336), that “the cutaneous
exanthema offers the same characters in the two affections ;
the only differences being in the number of the spots, and
the time of their appearance,” and that, on the contrary,
the typhous differs from the typhoid eruption in its form,
its duration, the changes it undergoes, and the relation it
bears, as to colour and quantity, to the severity of the
disease.

V. In the plan I laid down, I proposed to consider some
of the anatomical lesions. To enter on a comparison of the
whole pathological anatomy of the two diseases were a task
as tiresome as it would be barren of any definite results.
Instead, therefore, of inquiring into the state of all the
organs in all the different cavities, I shall at once meet the
question, Is the lesion of Peyer’s glands so constantly met
with in typhoid fever, frequently, or is it ever, found in
typhus ? @

Chomel (p. 339) appears to me to put the question in its
true light. His third general conclusion is as follows:
“Tf further observations demonstrate in typhus anatomical
lesions similar to those met with in the typhoid affection,
the identity of the two affections would be put beyond a
doubt.” To the philosophic caution of the inference of the
French professor the following remark offers a strong contrast.
A reviewer of various works on typhus and typhoid fever, in
the ‘British and Foreign Medical Review’ for last year, after
asserting (p. 432), that the symptoms during life are the same,
and quoting a passage from Gauthier de Claubry (referring
to the experience of four out of twenty-two observers who
described the epidemics of army typhus during the wars of
the Empire as decisive of the question), thus proceeds, ‘ We
do not know that any additional facts from the morbid
208 ON THE NATURE AND PATHOLOGY OF

anatomy of the intestinal canal are required. In our own
country we do not require any argument to persuade us of
the identity of these supposed distinct diseases ; the evidence
is constantly before our eyes!”? Montault, notwithstanding
the assertion of his reviewer that his remarks are valueless,
points out clearly the absence of the intestinal affection in
typhus, and cites numerous authors to that effect. Roupell
considers the absence of this lesion, which he fully admits,
as accidental. Tweedie combats strenuously the opinions of
Broussais (p. 57), and adduces the frequent absence of
intestinal lesion as proof of their incorrectness. I remarked
at the outset that, in the cases detailed by Dr. Tweedie,
there were evidently two kinds of fever, the one distinguished
from the other during life, by difference of intensity and
duration, and after death by the lesions observed. In point
of fact, I find thirteen cases in wnich ulceration of Peyer’s
glands had taken place, and nine in which there was no
intestinal lesion whatever, but general congestion. Dalmas,
in his account of what he heard and learned (not saw) at
Dublin, cannot deny that the lesion is frequently absent;
but only says, ‘it is perfectly well known” there. So it
was in Glasgow, but even to me, a perfectly inexperienced
observer, the distinctive symptoms were well known also.
Gauthier de Claubry, evidently feeling the force of Chomel’s
remark, has laboured hard, throughout a very large portion
of his work, to get rid of this very strong objection to his
opinion. Reveillé Parise, on whose testimony he lays much
weight, observed in those who died at Saragossa, “some
gangrenous points in the interior of the intestines, and on
the exterior, violet patches”? (p. 18). Ducastaing (p. 16)
found in many of those who fell victims at Gaéta in 1802,
“the mucous membrane ulcerated in several points.” Tresat,
at Walcheren, in 1809, found “gangrene of some parts of
the intestinal canal” (p. 19). Tort, at Dantzick, in 1813,
found “the small intestine sprinkled with gangrenous eschars”
(p. 23). Gilles de la Tourette, at Torgau, in 1813, found
“serous and bloody effusions, inflammations, ecchymoses, gan-
grenous spots of the mucous and serous membranes”? (p. 24).
MM. Laurent and Ardy, Magnin, and Fauverge, mention
inflammation, ulceration, gangrene in some points, violet
TYPHUS AND TYPHOID FEVER. 209

patches, scirrhous indurations of the mucous membrane of
the small gut, as occurring in the Mayence epidemic of 1813,
‘(p. 26-7). Thouvenel, in the department de la Meurthe, the
-same year, found “generally some gangrenous spots in several
parts of the membranes of the intestines,” (p. 35). In the
epidemic of the Salpetriére in 1814, Pellerin, “in adynamic
fever with diarrhoea, which,” says Gauthier de Claubry, “he
-apparently believes a distinct disease in this circumstance,”
describes ulcerations that seem to correspond very closely
with those found in typhoid fever, as “ often,” not always,
met with.

After the foregoing investigations, are we not warranted
in considering it, with Pellerin who witnessed it, “a distinct
-disease ?’””? Chomel, also, with his customary caution, when
speaking (p. 337-8) of the same epidemic, remarks that he
“* cannot place entire confidence in his recollections.”’ If such
disease as is daily found in the intestines of persons dying
-of typhoid fever, had been present, it could not, I should
think, have been easily forgotten. Is it, then, really on such
statements as these, on the existence of “ violet stains’ and
*‘gangrenous spots”? (which might, for aught we know to
the contrary, have been the effect of decomposition, in a
‘disease that often terminated with frightful rapidity), that
Gauthier de Claubry and his reviewer would rest the decision
-of the question at issue? It was but yesterday that I saw,
-at M. Barth’s rooms, large elliptical patches of ulceration in
the jejunum of a female who had died of puerperal fever,
with rupture of the uterus and peritonitis,—ulcers which,
had they been found in a patient who had presented the
‘ordinary symptoms of typhoid fever, would certainly have
deen looked upon as characteristic of the disease. Is, then,
‘puerperal fever identical with the typhoid affection? I also
saw a few days since, at M. Barth’s, in a portion of gut taken
from a patient who had, I believe, died of phthisis, large
patches, of no determinate shape, extending around the whole
-calibre of the tube, the mucous membrane being in these
parts immensely swollen, raised a couple of lines above the
surrounding surface, traversed by deep rug, and having a
greenish-black colour, with the characteristic gangrenous
feetor. Is it beyond the range of possibility that such may

14
210 ON THE NATURE AND PATHOLOGY OF

have been the state of the intestines in the army epidemics
referred to? Is it not rather highly probable that, where
everything indicated a deeply altered and corrupted state of
the blood, and local gangrene was of frequent occurrence,
the gut as alleged by all the observers cited, may have been
actually sphacelated? All that I have in view in these
remarks is to demonstrate that, even were the existence of
such lesions proved beyond a doubt, the alteration of the
glands of Peyer, and the isolated follicles, now called charac-
teristic, is very far from being proved thereby.

But are there no facts that bear against the reasonings of
the French essayist? On the contrary, there are many.
Lombard has graphically described his surprise on finding
no lesions whatever in several cases he saw inspected while
in Scotland and Ireland. We have seen the supposition
Gauthier de Claubry has recourse to in order to explain away
his testimony ; and, even granting that “the circumstances
of misery and exhaustion,” in which, according to him, the
people of Scotland are placed, do, as he supposes, produce a
strong resemblance in the prevailing fever to army typhus
(p. 143), does he advance one step towards a removal of the
difficulty by gaining such an admission? Nay, rather, if
M. Gauthier de Claubry has made out his position, that the
intestinal lesion is present in typhus as well’as in typhoid
fever, whence this allusion to army typhus to explain the
want of intestinal lesion—an allusion by which he demolishes
the structure his work was intended to raise, and unwittingly
discloses his own distrust in his own opinions? Again,
M. Delbose (cited at p. 38), in his account of the epidemic
at Alby in 1823, mentions only “a rosy colour of the peritoneal
tunic,” and M. Keraudren and the Toulon physicians, “though
their attention was specially directed to that point by the
questions addressed to them by the Academy of Medicine,’
never observed any intestinal lesion in the typhous epidemic
at Toulon in 1829-30. I have already referred to Dr.
Tweedie’s data, and have cited M. Dalmas’s silence as im-
partial evidence, though in the United Kingdom very few
require evidence to convince them, that in Dublin, as else-
where, a form of fever exists, of highly malignant character,

1 Chomel, p. 338.
TYPHUS AND TYPHUID FEVER. 211

and most extensively fatal, in which no intestinal lesion is
found even on the most careful inspection. Dr. Alison, of
Edinburgh (from whom I cannot quote accurately, not having
access to his work), corroborates the experience of other
‘ observers.!

I now proceed to give some more circumstantial details
upon this interesting subject. Dr. West? gives the results
of ten inspections. In five (I merely speak of the state of
the bowel) “there was no morbid appearance whatever ;”
in the other five “there was increased vascularity of the
intestinal canal, extreme in one instance.” “Once the glands
of Peyer appeared enlarged, and twice there was very con-
siderable enlargement of the solitary glands; but I never,”
‘says he, “found them ulcerated. Once the mucous mem-
brane of the cecum was very much softened and congested,
and there was slight abrasion of the surface of some of the
congested patches.” Dr. Reid® states, that of 1o1z cases
examined in the Edinburgh Infirmary, by his predecessor,
the late Dr. Home, “ the elliptical patches were well defined
in 29; they were more or less ulcerated in 7 of that
number and in 2 out of the 7, perforation had taken
place.” He next gives* a summary of the morbid appear-
ances in 41 cases inspected by himself. In 24, “ Peyer’s
glands were apparent and distinctly defined;”’ in 6, ‘scarcely
visible ;”? in 11, invisible to “the naked eye.” ’ In 4 only
were they “ distinctly elevated ;”? and in 2 of the 4, “ this
elevation was to no great extent, and limited to a few patches.”
In 2 only was there “ any appearance of ulceration.”’ In 4,
the solitary glands were “distinctly visible.’ Regarding
the connection of the symptoms during life with the post-
mortem lesions, he says,” “‘In g cases only out of the 24, in
which the elliptical patches were distinctly visible, were there
any abdominal symptoms during life, and in some of those

1 Dr. Alison -has published no separate work, but Observations, &c., in
the twenty-eighth volume of the ‘Edinburgh Medical and Surgical Journal,’
p. 233.—Ep.

2 «Hidin. Journal,’ vol. 1, p. 132-3.

3 Report, &c., p. 33-

4 Thid., pp. 30, 31.

5 Tbid., p. 34.
212 ON TIE NATURE AND PATHOLOGY OF

cases these certainly could not be referred to any affection
of the elliptical patches of Peyer.” ‘In one case in which
they were not visible, the bowels are stated to have been
rather loose, the stools watery and dark coloured. In other
two cases there was considerable abdominal tenderness,
without diarrhoea.”

I shall preface with a few remarks the two following and
concluding tables, which give the results of my own observa-
tion. They refer to twenty-two inspections,—but a small
number, it is true, yet made with as great care and attention
to accuracy as I could bestow on them. The solution of the
interesting question, Is there any connection between the
abdominal symptoms during life, and the state of the intes-
tinal follicles in typhus? may be attempted in different ways.
We may compare the symptoms, whether positive or negative,
with the mucous follicles, as regards (1) their number, and (2)
their degree of development. And after having, as far as
our data enable us, determined these points, we must not be
unmindful of the objections that may be urged, as, for instance,
that our terms are vague ; that our cases are too few to draw
conclusions from; that absorption of morbid matter may have
taken place before death, or, it may be, that death has arrived
before its deposition was possible. I shall meet some of these
objections beforehand. The cases, I acknowledge, are few,
but I maintain that they are a fair sample of hundreds that
occur yearly, and at the same time direct attention to the
numerous facts I have already cited. To take away all
vagueness from the terms I employ, I make the following
statements respecting the state of the intestinal follicles.
It was very rare, in the cases of typhus which I either in-
spected or saw inspected, during a two years’ residence in
Glasgow Infirmary, to see these glands elevated a quarter
of a line above the surrounding mucous membrane, and in
the vast majority it was very difficult to determine whether
they were really elevated or not, the slight roughening or
irregularity of their surface often causing a visual deception.
When, therefore, we speak of the elevation of the aggregate
glands in typhus we are no longer occupied, as in typhoid
fever, in the measurement of palpable magnitudes, but for
the most part with elevations, which French pathologists,
TYPHUS AND TYPHOID FEVER. 213

as I have frequently witnessed, scarcely reckon any deviation
from the healthy state. To avoid overlooking, not one, but
many, of these (enlarged?) glands often requires very minute
attention. The other objections I shall leave to be answered
by the facts about to be adduced, only remarking that the
removal by absorption of the morbid matter from the follicles
_is a very rare termination, even in typhoid fever. Chomel
mentions two cases in which that process had probably taken
place,’ and I cannot see why it should be more common and
more speedy in typhus. The first of the following tables
refers to the number of follicles met with in the small gut ;
the second to their state of development.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diarrhoea, Tympanites. Abdominal pain. “State of follicles. f
No. of 3 s |s ry > |) |) sd
enlarged g £ 3 3 . (3 s 3
follicles. e132 5 . 3B |23} 5] B4
a} 8128/3} 2/3]s/a)/se] 3s] E]S*)} 3s] 8
#2} 8 | a /2| =] se] s]/e]/ ea) 8 | & |e | es] ss
S|) S |) a) 5} 4) a] 4] 4] & le Ala
None J 1] 1]/—|J—-) 1}/—}—}] r]/—}]—}/—!—}]—-|—-
1to 5] 4/ 2 I I I 2 I 2 Ij]—-t|—~—|—] 4
5 to lo] 44 — | 3- I I 21 4/—!]—/—|] 2/—] 2
10 to 15] 4| 1 Tr) 2) a] 2) Trl) 3] rpm] 2) 2)— J
15 to 20) 3) — | 2) 1 —]} 2) tr} —}] 3]—/—] 8i-l|—
20 to gol 44 —]| 1] 3} —|]—] 4] 2/—] 2] tr] ry] 2t—
goto go) 11} — |] rt l—-f r}—}—} ry—Jy—]} ry—j|—]—
4oto 50) 1} — | tl-} tr}—}—}m—] ty myomyocy ite
22} 4/10] 8 6] 6]10] 9| 9| 4] 2] 8] 5] 6
'
Diarrhea, Tympanites. Abdominal pain.
a ; | a 3
: Cases.| 3 =| 3 a
Intestinal follicles. 3 3 3 g
i a 3 a is s a 4 tal
2/2/2/2/3)¢e)4/8] ¢
2/8) 2) 2/812] 2/8.| 8
: ws 5 5 a 5 a a < a
Distinctly elevated in || 2; —| ©] TT] r}—| ry 2;—]—
Very slightly elevated |. 8] 1/ 4] 3] 1] 3] 4] 3] 4] 1
Not elevated a) oy oe) oa | EB) ale | gl
Scarcely seen 6; 2} 3/ 1] ti rl 4] 4] rf
21} 3|10} 8] 5/ 5]1r} 9] 8] 4

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Observ. 14 and 15, pp. 169, 173.
214 ON THE NATURE AND PATHOLOGY OF

Thus we see that 4 only of the 23 in whom diarrhoea was
spontaneous rank in the above list. In one of the 4, the
diarrhoea depended on an attack of simple enteritis, which
came on after partial convalescence, and carried off the
patient on the 34th day. No trace of follicular disease was
found on inspection, but “ universal softening of the mucous
membrane from the duodenum to the rectum.” ‘T'wo of the
remaining 3 may almost be said to have presented no trace
of follicular disease, for the three or four follicles observed
in each were barely perceptible to the naked eye. In the
fourth, fourteen Peyer’s glands, scarcely at all elevated, were
detected. But what chiefly concerns us to notice is the striking
fact, that, as the number of enlarged follicles increases, the
cases of spontaneous diarrhcea diminish, and those in whom
consecutive diarrhoea and costiveness were observed become
more numerous. In fact, not one of those in whom the
greatest number of enlarged follicles was observed, but was
either constipated, or had diarrhoea brought on by medicine,
during life. This confirms our former deductions, agrees
entirely with those of Valleix, and shows that the appearances
observed in typhus depend upon local irritation and not on
specific disease.

It will also be observed that in 10 of the 22 (including
5 of those in whom from 15 to 30 enlarged glands were
observed) the feel of the abdomen was natural throughout
the disease. Of the 6 in whom the belly was slightly tym-
panitic, that symptom was observed only one day in four
patients (the one in whom the greatest number of enlarged
follicles was found being among them); in one with forty
enlarged glands, it was present during two days; the sixth
was the patient who died of enteritis. Of the six, on the
other hand, who presented a high degree of tympanites, in
not one were there so many as twenty, and in one whose
abdomen was excessively distended scarcely a trace of fol-
licular disease was detected.

There seems, at first sight, to be more connection between
the presence of abdominal pain and the number of altered
glands, but this is only apparent, for a reference to the
figures given above shows that, in 8 of the 9g in whom
the pain was acute, not more than twenty were found in the
TYPHUS AND TYPHOID FEVER. ‘215

whole course of the gut; that, of the 9 who complained
of slight pain they were either not at all, or very slightly
affected in 6; and that, if 2 of. those in whom they were
noticed in large numbers (twenty to thirty), had slight pain,
2 more of the same group had no pain at all, at any period
of the disease. The concluding part of the table proves that
quite as little analogy exists between the number of follicles
and their degree of development. As a fitting commentary
on what I have now advanced, I find that in the only case
in which considerable elevation of Peyer’s glands (about
half a line), and a few ulcers (not follicular) in the cecum,
were observed, the bowels were obstinately constipated, the
feel of the belly was natural throughout, and the abdominal
pain was either exceedingly slight or absent, till within a
few hours of death, having come on after the administration
of a clyster, composed of equal parts of turpentine and castor-
oil.

These remarks are still further confirmed by a reference
to the second table, in which the symptoms are considered
with respect to the degree of development of the follicles.
The same dependence of the intestinal lesion on local irritation,
the same entire disproportion between the extent of the lesion
and the intensity of the symptoms, are brought out so clearly
by it as to render any further reflections needless. The
utter futility of the objection founded on the possible absorp-
tion or non-deposition of morbid matter, will appear from the
following facts. Comparing the number of follicles with the
days of death, I find that, of those belonging to the first
group, one died on the 12th, another on the 13th, a third on
the 14th, and a fourth on the 16th day. Of the second
group, two died on the 12th, another on the 17th, and a
fourth on the 36th day. Of the third, one died on the 1oth,
one on the 14th, the other two on the 21st and 24th days.
The three belonging to the fourth group died severally on
_ the 13th, 15th, and 19th; those in the fifth, on the roth,
11th, and 13th, the two in the 6th and 7th, respectively on
the 11th and 22nd days of the fever. Thus, then, of two
who die on the same day of the affection, one presents scarcely
a trace of disease, another as many as thirty enlarged glands.
In one who dies on the 11th day, no less than forty Peyer’s
216 ON THE NATURE AND PATHOLOGY OF

glands are observed, while in others who die on the 12th,

13th, 14th, and 16th, scarcely any morbid appearance is
detected ; in another, who dies on the 22nd, no less than

forty-five, while in a seventh, who dies on the 24th, only

ten or eleven Peyer’s glands are obscurely visible.
Again, if we consider the development of the glands, in-

reference to the day of death, we find that, of the first group, | °°

one died on the roth, another on the 11th day; of the second,
one on the roth, another on the 11th, a third on the 13th,
a fourth on the 15th, and the remaining four, respectively,
on the 17th, 19th, 24th, and 36th days; of the third, one on
the 11th, another on the 13th, a third on the 14th the
remaining two on the 21st and 22nd days; of the fourth,
three died on the 12th, and the remaining three severally
on the 13th, r4th, and 16th days. Thus two die on the otk
and 11th days with Peyer’s glands distinctly elevated (in
one of them to the extent of about half a line); they are
scarcely discernible in four who die on the 12th and 13th
days ; while they are in a state of slight elevation in eight,
who die on all different days between the 1oth and the 36th.
Does this, I ask, look like the steady course of a constant
lesion, depending upon a constant and specific cause?

The solitary glands were visible, in small number, in three
cases ; in one, in the small, in two, in the large intestines.
I have, however, seen them very numerous, both in the one
and the other, though they were never larger, and seldom
so large as a pin’s head. They were white, sometimes

surrounded with a vivid red areola, and each had a small -

black point in its centre. The aggregate glands, situated
on the free border of the gut, were of all sizes from two or
three lines to two or three inches in length, and varied from
a couple of lines to nearly an inch in breadth. They were
sometimes white, sometimes greyish, sometimes slate-coloured,.
frequently dotted over with small black points, often reticu-
lated, while sometimes neither the one nor the other appear-
ance was noticed. It is a remarkable fact that, in several
cases, the glands were much more numerous in the jejunum
than the ileum, and that in two there were none near the
ileo-ceecal valve. Not unfrequently, the mucous membrane
around them was pale, at other times they were situated amid

{1
TYPHUS AND TYPHOID FEVER. 217

patches of very dark congestion, in which case they partook
more or less of the dark colour of the surrounding membrane.
Sometimes, but very seldom, the mucous membrane itself
was reddened, and injected with minute. vessels; the con-
gestion of the veins of the submucous cellular tissue was,
on the contrary, very common.

No one denies the very frequent affection of the mesenteric
glands in typhoid fever. The experience of every one who
has seen the inspections of patients cut off by that disease
must confirm the facts stated by Chomel, Louis, and Petit
and Serres. Though very rare in typhus, it is nevertheless
sometimes found. I find it noted by Dr. Tweedie in two
cases (1 and 44). In the former, “ the lungs and abdominal
viscera were healthy, excepting the mesenteric glands, which
were enlarged and partially affected with suppurations of a
scrofulous character’’ (p. 108). In the latter, “there was
no ulceration of the intestines, but the glands of the mesentery
were enlarged.” Of my own cases, the mesenteric glands
were enlarged in four; in one very slightly, in two in a
greater degree, in a fourth to a large extent, but not sup-
purated. In the first, death took place on the 11th day,
and twenty or thirty Peyer’s glands, not at all elevated,
were found in the small gut; one of the next two presented
eight very slightly developed, the other none at all; and in
the fourth, there were nineteen very slightly elevated. In
all of those, then, in whom the enlarged follicles were very
numerous, including the only patient in whom they were
considerably elevated, the mesenteric glands were unaffected.

I have been enabled, by the kindness of Dr. Reid, to
present the reader with a much larger mass of information.
From the publication of the Report till the end of June,
thirty-tliree cases of fever were inspected in the Edinburgh
Infirmary. Of that number only two presented the charac-
teristic lesion of the intestinal follicles met with in typhoid
fever. In both of them’ ‘the lardaceous deposit (plaque
gaufrée) was most distinctly seen, and both the aggregate
and solitary. glands were affected in great numbers, the latter
forming the whitish “ flattened tumours” so well described
by Louis. Neither of the patients belonged to Edinburgh ;
both were workers on the Edinburgh and Glasgow Railway,
218 ON THE NATURE AND PATHOLOGY OF

and were sent from Linlithgow. If, then, dothinenteritis is
the same disease, and depends on the same causes, as typhus,
how does it happen that the former is produced at Linlithgow
and at Anstruther, and not in Edinburgh, where the latter
is constantly occurring, and where so many circumstances
favorable, not only to its production, but (by the hypothesis)
likewise to that of dothinenteritis, are always at work. The
duration of these cases is also remarkable. The one, it
appears, had been four, the other five, weeks ill. One of
them had convalesced, but had a relapse, of which he died;
and, on dissection, the intestinal follicles and mesenteric
glands were the only parts diseased, so that the relapse
cannot be referred to any lesion of any other organ. It is
further remarkable that the aggregate glands were in a
state of advanced ulceration, while most of the solitary glands
around them were quite entire. In the remaining 31 cases—

Peyer’s glands were distinctly elevated, but not ulcerated, in 4
oa sa visible, but not elevated, in 9

3 a scarcely visible in 4

55 by not visible in 3 : It
3I

The solitary glands were slightly developed in two of the
above cases. The mesenteric glands were healthy in 25,
slightly enlarged in 4, considerably enlarged and softened
in 1, and in a 6th increased in size, and partially converted
into chalky matter. Dr. Reid also informed me that, in a
man who died lately of the effects of compound fracture,
Peyer’s glands were more distinctly diseased than in any
case of typhus he had met with.

Having thus entered pretty minutely into the pathological
anatomy of typhus, I put it to every one who has ever seen
the two diseases, or read the descriptions given by the best
authors, of the lesions so constantly observed in typhoid
fever, whether those found in the former disease can with
any truth be called “ perfectly identical’? with those of the
latter. That the existence of trifling intestinal disease in
typhus attests its general family resemblance to typhoid
fever, as the presence of organs ina rudimentary state shows
the analogy subsisting between individuals of different species
TYPHUS AND TYPHOID FEVER. 219

in the animal kingdom, might be more readily admitted ;
but that they are one and the same species, numerous well-
established facts seem most clearly to disprove. If asked
to describe shortly the pathology of typhus I might sum it
up in these words—general congestion, no prominent local
disease—a congestion so general and so excessive as is rarely,
if ever, met with in typhoid fever or any other disease—
a congestion singled out by most authors as one of its leading
characteristics—a congestion that is evident, during life, by
the livid skin and petechial eruption, and is found, after
death, to have affected more or less every organ in the
animal economy—a congestion so constant as to be often
passed over as almost valueless, but which future researches
may prove to be the grand peculiarity of typhus ; and which,
in common with many other considerations, directs attention
to the blood as the essential seat of the disease. If required,
on the other hand, to give a bricf account of the pathology
of typhoid fever, I should be inclined to sum it up in these
words—prominent local lesion, comparatively little general
congestion.

VI. From the treatment of the two diseases we can infer
but little. The interesting discussions held at various times
on the subject in the Académie de Médecine,’ strikingly
show the discordance of sentiment that prevails in France
on the treatment of dothinenteritis. One upholds the pur-
gative system as the best and the only proper one, another
condemns it as fraught with the greatest danger ; one insists
that the rational method, which consists in combating sym-
ptoms as they arise, is the only rational one, but another
condemns it as most irrational, because it kills one in three ;
one strongly recommends the frequent use, of the lancet,
according to his formula, even in advanced stages of the
disease ; while another, condemning not only the lancet, but
all treatment whatever, advocates a method in the purest
sense expectant, and unlimited faith in the workings of
nature, any attempt to interfere with them being attended
with evil results. And every one has facts on his ‘side.

1 See more particularly those on Delarroque’s Memoirs in the ‘ Bulletins
de l’Académie’ for March 14th, 21st, and 28th, and April 4th and rth,
1837. Also Bouillaud’s statements at vol. i, p. 250.
220 ON THE NATURE AND PATHOLOGY OF

The most remarkable statements, perhaps, of any, are those
of Professor Bouilland, who, employing his “ bleeding
formula” (viz. small bleedings repeated two or three times
daily, sometimes even during the adynamic stage, when the
patients presented “fuliginous teeth and tongue, and the
last degree of prostration”), and including only those cases
that were somewhat Rerigas, found a mortality among his
patients of one in 65.1 Again, at one of the meetings in
March, 1837," he declared, that, ‘counting all the cases,
he had lost only one in 24, and excluding all the slight cases,
one in 16 or 17.” Who that is acquainted with typhus, and
‘ has seen the sudden and alarming asthenia that often follows
the abstraction of a few ounces of blood during a state of
great excitement and oppression, but must feel convinced
that, treated after M. Bouillaud’s method, 99 out of every
100 would die? Gauthier de Claubry, while he concludes,
from his own experience of typhus, and the statements of
numerous distinguished authors whom he cites that ‘ blood-
letting (p. 153) may be useful, if not absolutely indispensable
in certain cases, indifferent in a great number, hurtful in
many others” (an opinion he shares with Pringle, Hilden-
brand, and the immense majority of British physicians), con-
fesses (p. 167) that the general opinion is in favour of its
use in typhoid fever; and besides referring to the constant
employment of it in the beginning of typhoid fever by Louis
and Chomel, states, that “twenty years of an extensive
practice, and of observations made in the hospitals of a large
city, as also a comparison of the results of the private practice
of a great number of physicians,” have led him to adopt a
similar treatment. As to the use of purgatives, I may state
that while in Glasgow they were generally used in typhus,
the marked difference in the state of the bowels in typhoid
fever led to the general use of opium, either alone, or com-
bined with mercury and chalk. All, in short, that we can
infer from the practice at present in use is, that the treatment
generally proscribed in the one is generally adopted in the
other disease.

On a review, then, of all that has been advanced, it would

* *Séance de l’Académie,’ October 16th, 1835.
* See ‘Bulletins de ’ Académie,’ vol. i, p. 520.
TYPHUS AND TYPHOID FEVER. 221

appear that typhus and typhoid fever present important
differences, as regards their probable origin, their proximate
causes, their course, many of their symptoms, their diseased
appearances, and the treatment applied in each. Are they
then identical, or are they not? I feel that it would be pre-
sumptuous in me to hazard a direct reply ; nor do I demand
an answer in the affirmative merely on the faith of what
I have stated. All I can ask or wish for is careful, extensive,
and minute inquiry, without prepossession or love of system,
and a satisfactory solution must soon be arrived at.

** Notwithstanding all the works,” says Chomel (p. 338),
‘which the last few years have produced on the typhoid
affection, its identity with typhus, though probable, is not
yet certain; and yet there are few questions of which the
solution would be so highly important.” I have accordingly
attempted in the preceding pages to concentrate attention,
as far as lay in my power, on the leading peculiarities of the
two affections; I have endeavoured, by frequent reference
to the works of approved authors, by collecting together
valuable facts hitherto widely scattered, and by adding the
results of my own observation, to bring as large a mass of
information as possible to bear on the question in debate ;
T have attempted—with what success others must judge—to
establish certain important distinctions between the two
diseases ; I have particularly sought to found my conclusions
on practical knowledge rather than theoretical reasonings ;
and if I have contributed towards the elucidation of this
obscure subject, or shall be successful in drawing the attention
of abler and more experienced observers to its investigation,
my trouble is more than repaid.
MEMOIR OF DR. A. P. STEWART.

Dr. AexanperR Patrick Stewart was born at Bolton,
East Lothian, on August 28th, 1813. ' He was the son of the
Rev. Andrew Stewart, M.D., the minister, of the parish,
who before entering the ministry had acquired considerable
reputation as a physician, especially by his treatment of
consumption. His mother, Margaret, was the daughter of
the tenth Lord Blantyre. He received his general education
in the Faculty of Arts of the University of Glasgow, where he
studied in the class of Sir Daniel Sandford, and was dis-
tinguished as a good Greek scholar. From 1828 to 1830 he
travelled with his family on the Continent, and acquired a
thorough knowledge of the French language. Onhis return
he entered ‘ag a student of the Medical Faculty of the
University of Glasgow, and graduated as Doctor of Medicine
in 1838. He held the appointment of House-Surgeon at the
Glasgow Infirmary, where Dr. Perry was one of the physicians.
And it was here that he made those observations which
convinced him of the specific distinction of typhus and
typhoid fever. After leaving Glasgow he pursued his studies
for about eighteen months at Paris and Berlin. He then, in
1839, settled in London where he continued to practise till
his death. In April, 1840, he communicated the results of
his researches on fever to the Medical Society of Paris, and
his paper, the present memoir, was published the same year
in the fifty-fourth volume of the ‘ Edinburgh Medical and
Surgical Journal.’
MEMOIR. 223.

In 1850 Dr. Stewart was appointed Assistant Physician,
and in 1855 Physician, to the Middlesex Hospital, where he
also held in succession the Lectureships of Materia Medica
and Medicine. In 1866 heretired from the Middlesex Hos-
pital and was subsequently elected Consulting Physician.
At the Middlesex Hospital Dr. Stewart was remarkable for
the minuteness and accuracy of his observations and his great
kindness to the patients.

He was elected a Fellow of the Royal College of Physicians.
of London in 1855 and an Honorary Fellow of the King’s.
and Queen’s College of Physicians of Ireland in 1867.

In 1850 he became a member of the British Medical Asso-
ciation, and continued during the rest of his life to take an
influential part in its proceedings. He was Secretary of the
Metropolitan Counties Branch from 1858 to 1874, and was for
twenty-nine years a member of its Council. He was also a
Vice-President and member of the General Council. On his
retirement from the office of Secretary the members presented
him with a testimonial, which with characteristic generosity
he applied to the formation of a fund for the recognition
and encouragement of researches into the origin and spread.
of epidemic disease.

In connexion with the aséciation Dr. Stewart took an
active part in promoting medical reform, and gave much time.
and attention to sanitary questions. He published several
papers on medical and sanitary subjects, among which may
be mentioned one on Cholera in the Middlesex Hospital,
which appeared in the ‘ Medical Times and Gazette,’ in 1854.
And one on the Workings of Some Provisions of the Laws
relating ‘to Public Health, which was read before the Metro-
politan Counties Branch of the Medical Association in 1867,
and afterwards published in a separate form. But by far
his most important work, and the one on which his reputation
mainly depends, is the present treatise. :

Dr. Stewart was a man of much, though intermittent,
224 MEMOIR.

energy, of acute observation, of clear ideas with great facility
in their expression. His high integrity, his warm heart, and
his genial disposition, caused him to be universally beloved
and respected. His religious convictions were strong, and
he was an earnest member of the Presbyterian Church in
which he held the office of an Elder, and in connexion with
which he devoted much time to religious and charitable
works. His life may be said to have been thoroughly con-
sistent with the principles he professed.

Though in consequence, perhaps, of a certain innate
deficiency in habits of business-like punctuality, he never
attained to that leading position in practice which his high
qualities merited, he has left behind him an unblemished
reputation, and his name will always be associated with one
of the great: discoveries of medicine.

Dr. Stewart, who was never married, died at his house in
Grosvenor Street July 17th, 1883, having nearly completed
his seventieth year.

Much controversy has taken place as to whom the
discovery of the distinction between typhus and typhoid
fever is to be attributed, and as to the share Dr. Stewart
had in determining this question; but, as so often happens
in disputes as to priority, it will be found on impartial inves-
tigation that the discovery was arrived at gradually, successive
observers adding fresh links to the chain of argument till at
last the conclusion was securely established.

Although it cannot be claimed for Dr. Stewart that he was
the first to make out the distinctions between typhus and
typhoid, nevertheless at a time when the great majority of
observers regarded them either as the same disease or at
most only well-marked varieties, his own observations,
made at Glasgow from 1836—38, and at Paris in 1839, con-
vinced him of their essential distinction. And in the present
memoir he demonstrated this more fully and conclusively
than had been done before, at least in this country ; for in
MEMOIR. 225

America Messrs. Gerhard and Pennock, in a paper published
by Dr. Gerhard in the ‘ American Journal of Medical Science ’
in 1837, had fully described all the more important points
of difference, and perhaps they have the strongest’ claims to
be considered the first to have clearly proved the complete
distinction between the two diseases. Nevertheless, all the
leading facts and conclusions had been established before by
gradual steps.

The distinction between the slow nervous fever and the
putrid jail fever had been observed in England since early
in the eighteenth century. In the middle of the century
De Haen described accurately the rose rash of typhoid.
And Pringle, in his controversy with him, pointed: out its
difference from the petechial rash of the jail fevers, and also
the different class of persons liable to be affected by the two
forms. In 1810 Hildenbrand, who regarded the two diseases
as entirely distinct, showed how they differed in contagious
properties. The essential lesions of typhoid fever were
gradually established by French pathologists, especially
Bretonneau, who invented the term .dothienenteritis, though
he regarded the disease as a specific fever, and not as Brous-
sais had done, a mere inflammatory affection. In 1829 Louis
gave the name of typhoid to the dothienenteritis of Breton-
neau, but in France it was generally regarded as identical
with the typhus of England, and in England dothienen-
teritis as an occasional complication of typhus.

In 1835 Dr. Peebles, who was familiar with the contagious
typhus of Italy, pointed out its characteristic rash to Dr.
Perry, of Glasgow, Dr. Stewart being present, and from this
time Dr. Perry taught the difference between contagious
typhus and dothienenteritis, and he appears to have been the
first in this country to have done so; though in his paper,
published in 1836, he does not seem to have regarded dothien-
enteritis as a specific fever accompanied by a rash of its own,

but as an affection which might complicate other diseases as
15
226 MEMOIR.

typhus and smallpox, or occur independently. Subsequently
he appears to have recognised and taught the distinction
between the two rashes.

In 1836 Dr. Lombard, of Geneva, who had studied fever
both on the Continent and in this country, published a paper
in the ‘ Dublin Medical Journal,’ in which was maintained for
the first time that two separate and distinct fevers occurred
in Great Britain, one contagious typhus and one identical
with the dothienenteritis or typhoid fever of the French. But
he did not discriminate between the eruptions and symptoms
of the two.

The progress of these doctrines, notwithstanding the con-
clusive arguments of Lombard, Gerhard, Shattuck, H. C.
Barlow, Stewart and others, was very slow, and in this
country it was not till the publication of Sir William Jenner’s
papers in 1849, 1850, and 1853, that they obtained any-
thing like general acceptance.

On the whole, from this very brief résumé of the question,
I think it will be evident that to no one observer can any
exclusive merit be ascribed. To Dr. Stewart belongs the
eredit of being one of the first to see clearly the truth and
to have supported it by arguments which appear now to be
absolutely convincing.
MOVEABLE KIDNEY IN WOMEN.

BY

Dr. LEOPOLD LANDAU,

PRIVAT-DOCENT IN THE UNIVERSITY OF BERLIN.

WITH NINE WOODCUTS.

TRANSLATED AND EDITED WITH NOTES BY

FRANCIS HENRY CHAMPNEYS, M.A.,
M.B. Oxon., F.R.C.P.,

ASSISTANT LECTURER ON OBSTETRICS, AND ASSISTANT OBSTETRIC PIIYSICIAN TO ST, GEORGE’S
HOSPITAL ; EXAMINER IN MIDWIFERY IN THE UNIVERSITY OF OXFORD ;
LATE RADCLIFFE FELLOW IN TILE UNIVERSITY OF OXFORD,
TRANSLATOR’S PREFACE.

THE scope and interest of the ensuing work are by no
means expressed by the limited description on the first page.
Dealing professedly with a single abnormal condition, it
includes a great portion of the anatomy and physiology of
the abdominal cavity, and some of the pathology of the
pelvis. Interesting as such a work must be to every
medical man, it is doubly so to the physician, the focus of
whose work lies in the pelvis and lower abdomen, and it is
a welcome addition to his knowledge at a time when the
subject of uterine displacement seems to be approaching a
more rational estimation.

The scientific value of the treatise is great; its literary
value would have been greater had some of the references
and all the quotations been revised. The latter having been
found almost invariably inaccurate, are given in this trans-
lation direct from the original sources.

The Translator, who has found the usual difficulties in
the way of producing a version at once idiomatic and precise,
begs to assure his readers that any faults which may appear
are due to anything rather than want of care.

Lonpon, 1884.
PREFACE.

Tue significance of moveable kidneys in their pathological
and therapeutical relations has not yet been rendered suffi-
ciently clear in spite of many valuable works.

It has been in part wrongly interpreted, in part over-
looked. By most persons it is regarded without serious
clinical interest as an anatomical curiosity, the diagnosis of
which leads to nothing further than the relief of the patient
from the fear of a presumably serious malady. A view directly
opposed to this has been lately promulgated, namely, that
moveable kidney is a disease dangerous to life, which must
be removed as quickly as possible by extirpation.

In the presence of this difference of opinion it is worth
every doctor’s while to obtain clear views on this disease, so
often seen and so often mistaken. For the gynacologist
especially, the knowledge of this malady is all the more
important since it attacks women by preference and stands
in a far more intimate relation to affections of the female
sexual organs than is commonly supposed.

The observation of numerous cases of moveable kidney
has led me to conclusions differing in many respects from the
views hitherto entertained, and I have thought it advisable
to embody them in a systematic treatise on this disease.

LANDAU.

BERLIN ;
July 16, 1881.
CONTENTS.

PAGE

I. Hisrory anp Lirerature » 233
II. Derinirion anp Nomencnature - 236
III. Torocrararcan Anatomy - 236

Position of the kidneys, as7s relations of the bidneys ie
adjacent organs, 238; mode of fixation of the kidneys, 241.

IV. Sratisrics ‘ : + 244
V. Parwotoaican Anatomy + 247
VI. Air1oLoay anp ParHoGgENEsis - 263

Anatomical causes: influence of Gamuars of the liver and
spleen, 264; of caries of the lumbar vertebral column, 265 ;
of absorption of fat from the capsula adiposa, 265 ; of the
abdominal wallsand pendulous belly, 266 ; of menstruation,
268; of sexual disorders, 268; of hydronephrosis, 269; relation
of sexual disorders to hydronephrosis, 269 ; physical causes,
273; acute injury, 273; repeated injury, 274; influence of
stays, 275; reasons for the frequent occurrence of moveable
kidney on the right side, 276.

VII. Symproms . ‘
Arising from the nervous avatars, 283; fied the arent vessels,
285; from the digestive tract, 285; from incarceration of
the kidney, 290; from secretion and excretion of the urine,
300; hydronephrosis of a moveable kidney, 307 ; intermit-
tent hydronephrosis, 312; relations to pregnancy « and
labour, 316.

VIII. Onsective Siens
Inspection, 318; percussion, 318; palpation, 320; > auBeulta
tion, 322.

IX. Dracyosis
Differential diagnosis fea domes of ihe: liver, iad ; tumours
of the gall- bladder, 325; carcinomata of the colon, of the
pylorus and pancreas, 326; faecal tumour, 327; moveable
spleen, tumours of the spleen, of the ovary and uterus, 327-8 ;
phantom tumour, 329; diagnosis of adhesions ; of symptoms

of strangulation, 330; of hydronephrosis, 330.

281

+ 318

a 822
232 CONTENTS.

PAGE
X. Prognosis . : ; ‘ ; + 332
XI. Treatment . : 333

Of uncomplitated moveable kidney, 334; extirpation thereof,
338; treatment of complicated moveable kidney, 340; of
strangulated moveable kidney, 340; of hydronephrotic
kidney, 342.
XII. OrrernaL OBsERVATIONS é : : + 344
Table, 356.

XIII. RererEnces . . ‘ . ‘ - 358
MOVEABLE KIDNEY IN WOMEN.

I. Hisrory anp Lirerarurs.

AurnoucH the congenital alterations in the position and
form of the kidney had at an early date excited the attention
of medical men, especially the anatomists, acquired moveable
kidney remained long unknown. Frangois Pedemontanus (1)
is the first who speaks of a dislocation of the kidney arising
from internal and external causes (percussio), without, how-
ever, attaching special importance to this anomaly.

Riolan (2) was the first to set forth the clinical import-
ance of the disease to which he gave the name of disloca-
tion of the kidney. His description of this disease is far
too characteristic for me to neglect to repeat it in this place :
“Quamvis renes adipis glutine videantur tenaciter affixi
lumbis, interdum tamen luxantur et antrorsum procumbunt;
interdum in hypogastrium delabuntur, non sine vitw detri-
mento; hoc ita verum est, ut nullo modo sit dubitandum.
Id potissimum accidit, non tantum liquata pinguetudine, qua
sunt obvoluti, sed etiam ex pondere, ubi tam grandes sunt, ex
tumore vel calculo in cavitate concluso, ut suis retinaculis in
sua sede contineri nequeant, tumque ibi aliquamdiu sub-
sistunt, sed tandem putrescunt et abscessum patiuntur.

(Renes) comprimunt psoam et nervos ad crura descendentes.

. . ‘Si vena reseretur, aut rumpatur, urine cruentz
funduntur: et quoniam renes communicant per nervos stoma-
chicos cum ventriculo, ecorum affectibus condolescit aut com-
patitur nauseabundus aut vomituriens.”

1 This sentence is incorrectly quoted by Landau.
234 MOVEABLE KIDNEY IN WOMEN.

Notwithstanding this suggestive description, certainly
founded on excellent observation, the disease, ‘‘ moveable
kidney,” remained entirely unknown till the beginning of the
present century or was regarded only as an anatomical
curiosity, even by Haller (3), for instance, who, in the case
of a woman who had died from dropsy and had suffered
during life from a tumour above the navel, found the kidney
filled with water in the lower part of the abdominal cavity.

Baillie (4) mentions a tumour which he had observed four
or five times, loose, in the region of the kidney of one or
other side, which could be moved upwards and downwards
by slight pressure with the hand, and which was pretty firm,
and generally had the shape and size of a kidney. The
patients concerned were very little inconvenienced and their
general health little if at all disturbed. In women, as
Baillie mentions, the tumour was often mistaken for an
enlarged ovary; but it had not its shape and could not,
moreover, be felt in the situation in which such a body can
be usually felt. The author in question had no opportunity
of making an autopsy, and was doubtful as to the nature
of the tumour, but was inclined to regard it as a moveable
kidney.

The contributions on this affection by Otto (5), Meckel (6),
and Portal (7), which were certainly very imperfect, remained
entirely unnoticed.

The first accurate post-mortem records associated with
clinical descriptions were furnished in four cases by Aberle
(8). He was followed by Girard (9) and King (10), who
each observed one case of moveable kidney. King himself
made an attempt even at that early date to remove the
moveable tumour, but failed to find it after opening the
abdominal cavity. The woman concerned felt herself, strange
to say, better after this abortive attempt to extirpate her
kidney than before.’

But a somewhat more general acquaintance with this
malady dates from the publication of the excellent work on
kidney diseases by Rayer (11), who himself observed several
cases of moveable kidney. Then followed the publication of

1 A similar relief from symptoms is not unknown after other unsuccessful
essays in abdominal surgery.—TRANSLATOR.
MOVEABLE KIDNEY IN WOMEN. 235

single cases by Braun (12), Brochin (13), Urag (14),
Petters (15), Oppolzer (16), Hare (17), and Henoch (18), so
that Fritz (19) in 1859 was already able to collect 35 cases
from the literature of the subject.

The knowledge of the clinical symptoms of moveable
kidney was next substantially enriched, by Dietl (20), who
pointed out the frequency of moveable kidney and particularly
of a chain of symptoms caused by it, which had been till
then but little regarded. It is true that Dietl only con-
sidered this complaint as one which occurred with particular
frequency in the Polish race.

Stress was laid by Becquet (21) on the intimate relation
between the sexual life of the female and the production of
moveable kidney, while Chroback (22) referred to the
connection between hysteria and mobility of the kidneys.

Weare indebted to Rollet (23) for the first monograph on.
the pathology and therapeutics of this affection. In 5500
patients of Oppolzer’s clinique this author found 22 cases,
and described 10 of them. He himself mentions that this
number does not nearly represent the total of those actually
present, since some of these patients only present themselves
in the out-patient department (Ambulatorium) withont, being
admitted to the wards; some to whom this affection causes
no special discomfort, never come under medical examina-
tion ; and, finally, the frequency with which cases occur in
the wards is influenced by deliberate choice of the cases
admitted.

Among more recent works must again be particularly
mentioned the important publications of Durham (24),
Lancereaux (25), Trousseau (26), Guéneau de Mussy (27),
Fourrier (28), Henderson (29), Howitz (30), Oerum (31), and
Keppler (32).

Isolated cases have been. published by Gueterbock (33),
V. Dusch (34), Keckeis (35), Wilks (36), Edwin Day (37),
Gilewski (38), Ehrle (39), Mosler (40), Drysdale (41),
Schultze (42), Steiger (43), Pieper (44), Wiltshire (45),
Schiff (46), Heslop (47), Flemming (48), Gontier (49),
Thun (50), Ferber (51), Mac Evens (52), Herr (53),
Tzschaschel (54), Jago (55), Kliipfel (56), Peebles (57),
Defontaines (58), Grout (59), Cabarellas (60), Kovatsch (61),
236 MOVEABLE KIDNEY IN WOMEN.

Hertzka (62), Le Ray (63), Stiller (64), Pitois (65), Schenker
(66), and Hunter (67).

Lastly, attention must be called to the appropriate sections
in the handbooks on kidney diseases by Rayer, Vogel, Rosen-
stein and Ebstein.

II. Dertnition AnD NOMENCLATURE.

By the name wandering kidney is understood that patho-
logical change in the position of the kidney under which
it is permanently or temporarily removed from its normal
situation and manifests a greater or lesser amount of
mobility. This anomaly has been also called ‘ Moveable
kidney,”’ “ Descent,” “ Displacement,” “ Prolapse,” ‘“ Heto-
pia” of the kidney. The older authors speak of “ Dislo-
cation of the kidney,” and, from the analogy of dislocations of
the limbs, of “‘ Spontaneous ”’ and “‘ Traumatic’’ dislocations.
The French sometimes use the phrase “ rein flottant,” the
English “ floating ” or “ moveable kidney.”

A moveable kidney may become fixed in an abnormal
situation and is then called “ fixedly dislocated”? (fix dis-
locirt). Kidneys which are dislocated and fixed are mostly
congenital anomalies (for instance the so-called “ horse-shoe
kidney,” and the “ kidney lying deep down in the pelvis”),
and are combined with other malformations, such as abnormal
positions of the intestines and low insertion of the vessels.
These congenitally dislocated kidneys, which are only in rare
cases found moveable, and may now and again indeed give
rise to disorders of labour, are generally unimportant clini-
cally, and, having already been often sufficiently described,
will not in this place be further considered.

III. Torograruicat ANATOMY.

With a view to the better comprehension of the pathology
of acquired moveable kidney, it seems advisable, as in the
case of descent and prolapse of the female genital organs, to
direct our special attention to the normal position of the
MOVEABLE KIDNEY IN WOMEN. 237

kidney and the forces which maintain it in this position.
The accounts of the old anatomists, which have mostly found
their way into the modern text-books, give only imperfect
explanations on both these points. At one time pathological
conditions have been taken for normal, at another too little
regard has been paid in the treatment of many kidney
diseases (which was till lately considered hopeless) to certain
intimate anatomical relations between them and the neigh-
bouring organs.

Thus, Haller (68) says that the kidneys may lie on both
sides of the vertebral column alongside of some four vertebre
between the eleventh (thoracic) and fifth lumbar, while Vogel
(69) says that the kidney in its normal situation may project
as far as the iliac crest or even farther into the false
pelvis.

Among recent productions may be named the valuable
works of Rayer (70), the excellent representation of the
topography of the abdominal cavity by Sappey (71), Luschka
(72), and Riidinger (73) ; and the works of Pansch (74), and
His (75). These works, as well as investigations on the dead
subject, have been followed in the ensuing description.

Position of the Kidneys.

The kidneys lie against the posterior wall of the upper
part of the abdomen, and are partly within the bony cavity of
the thorax close to the transverse processes of the vertebral
column, their inner border having an average distance of
seven and a half centimetres from the middle line. They
extend on either side from the lower border of the eleventh
thoracic vertebra to the lower border of the second lumbar
vertebra. Pansch is correct when he speaks of an “ average ”’
position of the kidney, for its boundaries are not absolutely
fixed, the variations from the average boundaries are, how-
ever small, and differences of even the height of a vertebra
are to be considered pathological.

The majority of authors say that the right kidney lies
lower down than the left. Thus Bauhin’ (76) says:
“‘ Horum dexter proxime Hepati subiacet propter eius molem

1 Incorrectly quoted by Landau.—TgansLatTor.
238 MOVEABLE KIDNEY IN WOMEN.

in homine altero est inferior, ipsi tanquam nobiliori cedens,
et ad tertiam lumborum vertebram suv fine descendit.”
Spigel’ (77) says: ‘“Incumbunt renes sima sui parte mus-
culorum, quos oa¢ Hippocrates vocavit, . . . capitibus.

Inaequalis etiam utriusque positio est, cum laevus
dextro elatior sit, non tamen dimidia sui parte.”

These authors are followed by those of later date in as-
cribing the cause of the lower position of the right kidney
to the liver. Few only, as Legendre, Luschka, Riidinger,
Sappey and His, assert that both kidneys are nearly on the
same level. Pansch (78), indeed, found the left kidney slightly
lower than the right in every third subject. Certain it is
that the difference of level between the right and left kidney,
if any difference exists at all, is but trifling, as observations
made on the cadaver make certain. The less regard need be
paid to the influence of the liver on the position of the kidney,
since, as recent investigations by Braun (79) and His (80)
show, the liver is normally so extremely soft (like fat or
cellular tissue) that it yields to the movements and displace-
ments of neighbouring organs. The flexibility and softness
of “ fresh liver-tissue ”’ is so great that it is much nearer the
truth to say that the shape of the liver depends on the
volume of adjacent organs, as is shown by their impressions
on it (faciecula renalis, &c.), than to say that the liver is
capable of regulating their shape. I lately had an opportu-
nity of satisfying myself of the softness of the liver in the
living body, in the course of two operations for hydatids of
that organ, and it felt under these circumstances more like a
flaccid cyst than a solid gland.

Relations of the Kidneys to adjacent organs.

The anterior surface, in the foetus lobed, in the adult
smooth, convex, directed a little forwards and outwards, is
covered by the peritoneum in its whole extent. On the right
side two-thirds or three-fourths, or sometimes even the whole
of the kidney lies beneath the liver and therefore to a greater
or less extent: beneath the ascending colon or hepatic flexure
of the colon (flexura coli dextra), and more or less close to

1 Tacorrectly quoted by Landau.—TRansLaror.
MOVEABLE KIDNEY IN WOMEN.

239

the vertical portion of the duodenum and the vena cava in-

ferior.

On the left side the anterior surface of the kidney

is covered in its upper third by the spleen, and in its lower
two-thirds by the descending colon or splenic flexure of the

colon (flexura coli sinistra).

Its inner border abuts on the
extremity of the cardiac end of the stomach.

Part of it

lies beneath the pancreas, which is indented by it and the

renal vessels.

Fia. 1 (after Sappey).

20 12 79
24 22

       

a 728

a6

1. Superior horizontal limb of the
duodenum turned to the right
side with the pyloric end of the
stomach,

2. Vertical limb of the duodenum.

3. Inferior horizontal limb of the
duodenum, bounded on the left
by the superior mesenteric artery
and vein.

4, 4. Head of the pancreas.

5. Body of the pancreas.

6. Tail of the pancreas.

47, 4. Its main duct.

8. Accessory duct.

g. Left lobe of the liver.

10, 11. Right lobe of the liver.
12. Lobus Spigelii.

13. Obliterated umbilical vein.
14. Gall-bladder. :

18. Hepatic duct.

   

3277,

 

Soha le 6 25

16. Cystic duct.

17. Common bile-duct, opening, to-
gether with the pancreatic duct,
into the Ampulla Vateri (common
gall and pancreatic duct) and the
duodenum.

18. Portal vein, covered on the right
by the common bile-duct, and on
the left by the hepatic artery.

19. Ceeliac axis.

20. Hepatic artery.

21. Coronary artery of the stomach.

22. Cardiac end of the stomach.

23. Splenic artery.

24. Spleen.

25. Left kidney.

26. Right kidney.

27. Inferior mesenteric artery and
vein. ;

28. Vena cava inferior.
240 MOVEABLE KIDNEY IN WOMEN.

The posterior surface, which is nearly flat, inclined a little
inwards and broader than the anterior, lies against. the crura
of the diaphragm which separate it from the last rib, the
last intercostal space, and the lowest part of the pleural
cavity. Itis separated from the quadratus lumborum muscle,
against which it also lies, by the anterior layer of the
aponeurosis of the transversus abdominis muscle, and by the
two branches of the lumbar plexus (? the ilio-hypogastric
and ilio-inguinal nerves, Translator). The wpper third and
sometimes the upper half of cach kidney lies therefore above
the lower limit of the pleural cavity.

The external surface, which is convex and directed a little
posteriorly, corresponds to the angle of separation formed by
the two layers of the fascia propria of the peritoneum. This
border also is separated above by the diaphragm from the
twelfth rib and last intercostal space, and lies below against
the aponeurosis of the transversus abdominis muscle and the
outer border of the quadratus lumborum.

The internal border (Hilum) which is concave, directed a
little forwards, roundéd above and below, and concave in the
middle, abuts on the psoas major. According to Sappey it
is coveted below by coils of the small intestine. I have,
however, frequently found nothing but large intestine
covering it.

The internal border (? of the right kidney.—TRanszaror)
is bounded above and to the right by the vena cava inferior
and vertical portion of the duodenum.

The upper end of the kidney is rather greater in circum-
ference, more curved and nearer to the vertebral column,
than the lower. It corresponds to the intervertebral disc
between the eleventh and twelfth thoracic vertebra.

The lower end is bounded by the intervertebral disc
between the second and third lumbar vertebra.

The average length of the kidneys, according to Sappey,
amounts in women to 12:2 centimetres, their breadth to 6°9
centimetres, their thickness to 2°8 centimetres ; according to
Pansch they are 10°-3—11 centimetres long.

The weight of the kidneys varies considerably, averaging,
according to Sappey, 170 grammes; of forty kidneys the
lightest weighed 107 grammes, the heaviest 284 grammes.
MOVEABLE KIDNEY IN WOMEN, 241

Their specific gravity, as I have found by several determina-
tions, is greater than that of any of the solid abdominal
glands.

Mode of Fixation of the Kidney.

The kidney, firmly surrounded by a tunica propria, lies
comparatively loose in the envelope, called by Riolan (81)
membrana adiposa, by Haller (82) capsula adiposa, the name
now in common use. This capsule, however, in the foetus
and young subject contains no fat, but consists entirely of
connective tissue. It arises from the lamina fibrosa of the
fascia propria peritonei which on reaching the kidney divides
into two layers, one of which runs with the peritoneum
transversely over the anterior surface of the kidney, while
the other passes on the posterior surface beneath the pelvis
and vessels of the kidney, in which situation it joins the
anterior layer again.. Englisch (83) describes this membrane
lying behind the renal vessels as a layer consisting of closely
compressed compact connective tissue running inwards, and
passing partly into the adventitia of the aorta, partly into the
fascia lying over the pars lumbalis diaphragmatis. According
to’Englisch this layer contributes in a special manner to-the
fixation of the kidney and acts as a proper hgamentum
suspensorium renis.. At the upper end of the kidney these
two layers join again and separate the kidney from the
supra-renal body; from the lower end of the kidney they
pass as far as the brim of the pelvis, becoming thinner and
thinner in their course. The anterior layer is intimately.
connected with the peritoneum by a fine connective tissue
destitute of fat ; the posterior, on the other hand, is some-
what loosely united to the posterior abdominal wall and all
surrounding parts. The capsule of the kidney is connected
to its tunica propria by loose connective tissue with large un-
dulations. It is not until the eighth to the tenth year that
the wide meshes of the connective-tissue capsule begin to be
filled with fat, the abundance of which frequently stands in no
sort of proportion to the panniculus adiposus elsewhere. It:
provides the kidney with a soft cushion, protects it against the
pressure of adjacent viscera, and by virtue of its softness and
mobility permits a moderate amount of change of position.

16
242 MOVEABLE KIDNEY IN WOMEN.

The capsula adiposa, connected as it is with the peritoneum
in front and secured as it is to the abdominal walls behind
and at the sides, represents the kidney’s immediate means
of fixation, and justly deserves the title of ligamentum renis
conferred on it by Bartholin.

In addition to the above, the kidneys are maintained in
position indirectly by the mesocolon which is short and tense,
attached to the posterior abdominal wall, and is sometimes
only indicated ; this to a certain extent opposes its descent
inwards and downwards after the manner of a barrier. Any
movement of the kidney outwards and downwards, or out-
wards and upwards, is prevented by the renal vessels which
are tensely, and the aorta and vena cava which are almost
immoveably fixed.

The kidney is still further protected by lying close to that
very part of the vertebral column which is not affected to
any considerable extent by flexion, extension, or lateral
movements of the body, this region. being according to Meyer
(84) the section from the ninth thoracic to the second lumbar
vertebra which must be regarded as a nearly immoveable
mass. Lastly, the enclosure of the greater part of the
kidneys within the bony cavity of the thorax protects them
from lateral and anterior pressure. Haller happily compares
the spot where the kidneys lie to a nest in the following
words :' “ Renes ponuntur ad utrumque latus spine dorsi .

‘ quasi in cavato sibi nido.”

Apart from these anatomical factors there are also physical
conditions which oppose the descent of the kidneys, especially
the adspiratory force of the diaphragm and the intra-abdominal
pressure produced by the normal act of straining. If one of
these factors is eliminated in experiments on the dead subject
as may be done by opening the abdominal cavity or removing
the diaphragm, the kidney is seen almost invariably to sink
slightly by virtue of its weight. In spite of this, the anato-
mical fastenings are so strong, that Sappey found as a result
of 24 experiments in which the cadaver was raised upright,
that the kidneys remained immoveable in 21, and in3 only sank
2centimetres. Though the descent of the kidneys is ascribed
by Sappey in these experiments solely to their weight, it

1 Incorrectly quoted by Landau.
MOVEABLE KIDNEY IN WOMEN.

243

must not be forgotten that their weight cannot come into
operation until the abdominal pressure is eliminated by
opening the abdominal cavity and removing the abdominal

viscera,

Fia. 2 (after Sappey).

 

1,1. The two kidneys.

2, 2. Capsula fibrosa, by which they
are fixed to the posterior wall of
the abdomen.

3. Pelvis of the kidney.

4. Ureter.

5. Renal artery.

6. Renal vein.

4. Suprarenal body.

8, 8. The liver, raised, in order to
show the relations of its lower
surface to the right kidney.

g. Gall-bladder.

10. Terminal portion of the portal
vein. :

11. Origin of the common bile-duct.

12. The spleen, turned outwards, in

 

order to show the relations of
its inner surface to the left
kidney.

13. Semicircular pouch on which the
lower end of the spleen rests.

14. Abdominal aorta,

15. Vena cava inferior.

16. Left spermatic artery and vein.

17. Right spermatic vein opening into
the vena cava inferior.

18. Subperitoneal fibrous layer or
fascia propria, dividing at the
convex border of the kidneys
into two folds, to form their
sheath.

19. Lower end of the quadratus lum-
borum muscle.
244 MOVEABLE KIDNEY IN WOMEN.

Thus during life the kidneys remain almost immoveably
fixed. Even deep inspiration does not depress them,
although they lie against the crura of the diaphragm, to a
great extent above the lowest limit of the pleural cavity.
Under these circumstances, as is shown by experiments on
animals as well as by palpation in suitable cases in human
beings, the most that occurs is a slight rotation of their
upper part forwards round their transverse axis. I have
searched in vain in the physiological handbooks for any note
on this point, in Pansch alone I found a short remark to the
same effect as that just made.

IV. Sraristics.

Notwithstanding theynumerous publications mentioned
above, moveable kidney is a complaint still often overlooked
or wrongly interpreted, and of far more frequent occurrence
than is generally imagined. Since, moreover, as I shall
show, many maladies which are really secondary results of
moveable kidney are imayined and described as diseases sut
generis, statistics never so carefully prepared cannot fail to
be affected by many sources of error. Although, however,
they do not for this reason permit us to draw final conclu-
sions as to the frequency of moveable kidney, other infer-
ences deduced from them as to its mode of production are
nevertheless valuable, and I therefore append a short
collection of cases in point, of which I have personally
observed 42.

The complaint has been most frequently observed in
patients between 30 and 4o years of age, as is shown by the
following data :
MOVEABLE KIDNEY IN WOMEN. 245

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author. Bp of ; 5 Age. i ‘
cases. | |_10 10—20 20—30 30—40 40—50|50—60 60—70
Aberle 4 == ates = 2 = 25 2
Rayer q -— _ I 2 4 = =
Dietl 9 as ae 2 3 4 = pao
Rollet 22 _— 2 6 11 I I I
Keppler . -| IL I _— 2 5 2 I =
Steiner . : 3 3 = a 5 many os a
Hirschsprung ‘ 2 2 gs as 2: — —_ rN
Landau . -| 42 — — 4 20 10 7 I
100 6 | 2 1g | 43 | 2t 9 4
It affects women by preference.
I
Author. No. of cases.| Womer. Men.

Aberle 4 3 I

Rayer . 7 q °

Dietl . 9 8 I

Rollet . 22 18 4

Henoch 6 4 2

Lancereaux . 8 8 °

Jago . . 5 5 °

Kowatsch 5 5 °

Schultze : 3 3 °

Guéneau de Mussy 12 11 I

Thun . : i 4 3 I

Klipfel 3 3 °

Fourrier 6 6 °

Steller 3 3 °

97 87 10

 

 

 

 

 

 

Hbstein’s collection consisted of 96 cases, 82 in women
and 14 in men; I'ritz’s, of 35 cases, 30 in women, 5 in men ;
Lancereaux’s, of 64 cases, 55 in women, 9 in men; Hare’s,
of 23 cases, 20 in women, 3 in men. The above numbers
added together give 314 cases, 273 in women, and 41 in men,
a proportion which may be taken as nearly representing the
truth, although in this total certain cases are counted more
‘than once. This proportion would turn out still more in
favour of the women if we were to include in the above
collection the data of authors whose practice lies exclusively
246 MOVEABLE KIDNEY IN WOMEN.

among women. Thus Howitz observed 34 cases, Chroback
19, and I myself 42. Dietl stated the proportion of women
to men as 100 to 1, but this is certainly an exaggeration.

The right kidney is the one most commonly found
moveable.

 

 

 

 

 

Kidneys moveable.
Author. De :

eAege Right. Left. Both.
Aberle . : 4 4 4 — _
Rayer . 7 5 I I
Dietl 9 8 _ 1
Rollet 22 18 3 I
Henoch . é . 6 5 _ it
Guéneau de Mussy . 12 i I _—
Jago. 5 5 as a
Schultze. 3 3 = —
Kowatsch 5 5 —_— —_
Thun. 4 3 I —_
Kliipfer - 3 3 _— —
Fourrier . 5 F 6 5 — I
Keppler . 3 i é II 10 1 _
Oerum-Howitz e 34 28 4 2
}Landau . 5 . . 42 39 I 2

173 152 12 9

 

 

 

 

 

 

 

If we add to these 5 other cases of double moveable kidney
(Philippson, Wiltshire, Heslop, Schiff, Schenker, and Hunter,
having observed one case apiece) we get 178 cases of move-
able kidney, 151 right-sided, 13 left-sided, and 14 bilateral.

 

Kidneys moveable.

 

 

 

 

 

Author. ene 4
collected. | Bisht, Left. Both.
Hare . . . . 23 18 5 _
Lancereaux . 5 ; 43 gl 5 4
Ebstein . : 5 ‘ 91 65 14 12
| 157 | 114 | 24. 19

 

An opposite proportion is observed in congenital malposi-
tion of the kidney, which, as we learn from the statistics
of Willis and Gruber, is far more frequently found on the
left side.
MOVEABLE KIDNEY IN WOMEN. 247

Most of the women with moveable kidney had had several
children, as is shown by the subsequent table of my observa-
tions, Out of 42 cases observed by me, only 2 concerned
women who had never borne children.

With regard to the station in life and occupation of
patients with moveable kidney, it must be remarked that
most of them belong to the labouring class, as would be
naturally expected to be the case with hospital in-patients
and out-patients, who furnish our material for observation.
This complaint is, however, by no means confined to the
poorer class, as is shown by the six cases published by
Henoch, which one and all concern persons of fairly good
position.

V. Parnotogica, ANATOMY.

Little attention has hitherto been paid at post-mortem
examinations to the changes produced by moveable kidney.
It is true that the old classical anatomists, Hustachius,
Bauhin, Morgagni, Ruysch, and Haller, quote cases of kid-
neys lying low down, horse-shoe kidneys, abnormalities in
the renal vessels, &c., but they do not give much more infor-
mation about the conditions in acquired moveable kidney as
regards pathological anatomy, than the recent textbooks and
handbooks on renal diseases and special pathology. Cruveil-
hier contents himself with the statement that the kidneys
not only leave their situation but also rotate on their axis.
Rokitansky is even less explicit in specially mentioning the
congenital abnormalities of position.

Moreover, in the monographs of Rollet, Le Ray, and Defon-
taines, we look in vain for an explicit account of the condi-
tions as regards pathological anatomy, so that we are driven
to study isolated post-mortem records as the only means of
arriving at a better understanding of the subject. How
scanty these are, however, is best recognised by the fact that
Durham only found two cases of displacement of the kidney
in 1600 autopsies, and that of these one was congenital. In
the same way Schultze found only five cases of moveable
kidney in 3658 autopsies in the Charité Hospital of Berlin
248 MOVEABLE KIDNEY IN WOMEN.

between 1859 and 1866, and of these he unfortunately gives
no description. By the kindness of Geheimrath Professor
Dr. Virchow I was permitted to look through the post-
mortem records of the Charité between the years 1870 and
1879 containing about 6000 autopsies, and among them I
found moveable kidney only four times noted, and even then
without any special statement about it.

This slender result, however, can surprise no one who re-
members that moveable kidney as such never produces a fatal
result, and rarely gives any indication either to the clinical
physician or to the pathological anatomist to specially inves-
tigate on the dead subject the amount of the mobility of the
kidneys. Since, in addition to this, a moveable kidney,
even in well-marked cases, is frequently in the habit of re-
turning to its normal position during life under the condi-
tions of dorsal decubitus, and still more so immediately after
death (see below), even well-marked cases are very apt to
escape our observation during an autopsy conducted in the
usual manner, particularly as it usual to remove the kidneys
from the abdominal cavity before removing the intestines and
other abdominal viscera.

In the last place, however, moveable kidney sometimes
gives rise to complications of such a nature that its presence
can no longer be seen but only inferred in the cadaver ; this
is the case in many -peri- and para-nephritic abscesses, hydro-
and pyo-nephroses, thromboses of the vessels, &c., which are
regarded as diseases sui generis, whereas their proper place
belongs to the pathology of moveable kidney.

Considering, therefore, the rarity of post-mortem records
it would seem not superfluous to enumerate them in this
place, scattered as they are, and collected with much labour.
In the performance of this task it is evident that the most

accurate and serviceable accounts date from the period ante-' °°

cedent to the microscope, whereas in the autopsies dating
from more recent times, the coarser naked eye changes which
concern us in this place are generally neglected.
‘MOVEABLE KIDNEY IN: WOMEN. 249

(1) Moveable Kidney on the right side, violent gastric pain.
Death in consequence of apopleay. (Aberle, 1820).

A man, thirty-two years of age, who had suffered for
‘many years from severe abdominal and digestive disturbances,
had been much distressed for the last three years by a tumour
in the abdomen, situated in the right hypochondriac and
umbilical regions, which drove him to the use of various, and
sometimes injurious remedies. This supposed tumour could
be squeezed upwards at the patient’s pleasure, when he lay in
a particular position in bed, especially in the morning.
Under these circumstances, a firm, smooth, not tender body,
of the shape and size of a hen’s egg, could be felt more or
less to the right, somewhat above and near to the navel,
which however, when not fixed from above by the pressure
of the hand, slipped away again from the examining finger,
often quite suddenly, and retired to the right side, backwards
and upwards beneath the liver. By degrees the tumour
grew and could be pushed in front of the bodies of the lum-
bar vertebra. As the diagnosis remained doubtful, the
physicians refrained from active measures ; the patient how-
ever fell a victim to a consumptive disease and died with
symptoms of apoplexy.

At the autopsy, with the exception of the softening of the
right corpus striatum, &c., the several organs were found
healthy; “the tumour however was formed by the right
kidney which was found very moveable in its normal position
in the right loin, from whence it could be very easily dis-
placed in front of the bodies of the lumbar vertebrae beneath
the duodenum downwards: and forwards, that is to say, in the
very same direction in which the supposed tumour appeared
and disappeared again during life. Its vessels were com-
paratively long; the cellular capsule of this kidney (fascia
renalis) was completely destitute of fat, the hepatic flexure
of the colon was unusually distant from the liver, and de-
pressed somewhat towards the middle of the abdominal
cavity.”

The kidney seemed to Aberle congenitally predisposed to
mobility, and this tendency appeared to him to have been
encouraged by the repeated attempts to render the tumour
250 MOVEABLE KIDNEY 1N WOMEN.

apparent. The length of the vessels seemed to him to prove
the congenital predisposition.

(2) Moveable Kidney on the right side. Remarkable dis-
placement of the large and small intestine. (Aberle,

1841.)

At the autopsy of a woman sixty-six years of age who had
died after several apoplectic attacks, the opening of the ab-
dominal cavity at once disclosed a body on the right side of
the umbilical region glistening through the peritoneum
which lay over it, destitute of fat and quite loose. This
body was kidney-shaped and on closer examination proved
to be in fact the right kidney lying somewhat obliquely in
front of the psoas in such a position ds to turn its concave
border somewhat upwards. Besides this, the ascending
colon and right part of the transverse colon were so much
depressed from the right hypochondrium towards the hypo-
gastric region, that no ascending colon could be found in
this region, but the caecum passed at once into the transverse
colon, which ran down towards the pelvis and then up
towards the spleen in the shape of a V to pass through the
splenic flexure into the descending colon. Again, on turning
the liver up, the duodenum itself, somewhat depressed, was
very distinctly seen through the anterior layer of the obliquely
placed transverse mesocolon, between the liver and meso-
colon. The stomach descended more obliquely than usual
towards the duodenum from left to right. The small intes-
tines and part of the great omentum were for the most part
depressed in the abdominal cavity. The left kidney was in
its normal position.

Ihave found a similar observation with regard to the
situation of the colon in Sandifort (85) in the section; De
preternaturali diversarum partium statu, in cadavere mulieris
viso.' “ Colon ex caeco enatum, juxta renem dextrum adscen-
dens, et ad hepar pertingens, mox reflectebatur, juxta caecum,
ad pelvis marginem usque descendens, inde ad ventriculum
et lienem adscendebat, denique, iterum descendens, pelvim
intrabat. . . . Ren dexter sanus, sinister morbosus.”

1 Incorrectly quoted by Landau.
MOVEABLE KIDNEY IN WOMEN. 251

The colon therefore lay in the same position as in the
former case except that the same displacement had been here
produced by a hydronephrosis on the left side.

(3) Moveable Kidney on the right side ; compression of the
vena cava; thrombosis of the vena cava; cedema of the
right lower extremity ; death in consequence of tubercular
pleurisy (Girard, 1837).

A woman, forty-seven years of age, had suffered for twenty
years from febrile symptoms and chest troubles which showed
themselves by violent attacks of coughing, shortness of
breath, and palpitation. She lost flesh rapidly, and six
months previously, after a particularly violent attack of
coughing, became conscious of severe abdominal pain. For
the last month the right leg had been greatly swollen. The
patient died with the symptoms of consumption.

At the post-mortem, besides pleurisy on the right side,
cavities, &c., the right lower extremity was swollen to twice
‘the size of the other, the abdominal viscera healthy, the left
‘kidney in its normal position. The right kidney showed a
remarkable abnormality. The peritoneum, instead of merely
covering its front surface, enveloped the whole kidney except
the hilum and thus formed a sort of true mesentery about
two inches long. The kidney also floated in the abdomen
at the level of the third lumbar vertebra and at the inner
side of the ascending colon, which, distended with gas,
pressed the kidney forcibly against the vena cava inferior.
The vein showed at this spot a considerable constriction with
a dilatation below to nearly double its size. From the heart
to this constriction it was healthy in its course ; but below
this point it showed true areolar or cavernous tissue like that
of the penis, which filled the whole calibre of the vessel, and
reached to within two or three inches of the groin. The
femoral and saphenous veins were of the normal diameter.
The right kidney itself presented no special point of interest.
252 MOVEABLE KIDNEY IN WOMEN.

(4) Moveable Kidney on the right side; neuralgia of the
leg; death from entero-colitis and peritonitis (Rayer,
1841).

A woman, fifty-one years of age, who had been employed
at hard work in a tobacco factory for thirteen years, and had
lost flesh rapidly, stated that ever since a fall she had
suffered from severe pains in the right leg and in the right loin,
radiating as far as the labium majus.. Nothing but rest on
her back relieved the pains, and as soon as the patient tried
to turn in bed they returned violently in the region of the
right kidney.

Bimanual examination easily detected the kidney, which
quickly slipped out of the fingers, the patient at the same
time experiencing a pain radiating to the right knee. Con-
-Stipation is present; the urine contains no albumen.

Ten days after she came into the hospital symptoms of
‘peritonitis appeared, and she died of marasmus two months
later.

At the post-mortem the voluminous and very congested
liver was seen to extend low down, and a narrow and thin
band of it, which lay against the right lateral wall of the
abdomen, reached as far as the iliac crest. Its growth had
displaced the right kidney, which lay superficially at the
sides but more anteriorly in front of the vertebral colamn—
pressed from above downwards but still more from behind
forwards—in the obtuse angle formed by the iliac vein and
vena cava, both of which were closely apposed to it. Exter-
nally it was bounded by the prolongation of the liver, but
only at its outermost border ; its anterior surface was exposed
only in the lower half, the upper half being covered by the
liver ; posteriorly it lay on the projecting angle formed by.
the muscles occupying the lower part of the abdomen and
the upper part. of the pelvis, and rising partly below and
_partly above the iliac crest. Its inferior extremity reached
as far asthe middle of the fibro-cartilage between the fourth
and. fifth lumbar vertebra.

It follows from the above relations that the lower end of
the right kidney lay in the immediate neighbourhood of the
anterior abdominal wall, and on a plane obliquely inclined
MOVEABLE KIDNEY IN WOMEN. 253.

from before backwards; this explains the ease with which it:
could be felt with the hand and pressed backwards. Its
mobility was increased by extreme looseness of its connec-
tions.and peritoneal investment ; the condition of the vessels
was similar, except that the transition to them was more
direct and shorter.

The left kidney occupied its normal position (?). It was
packed away much deeper at the side and behind the verte-
bral column, and projected downwards as far as the fibro--
cartilage between the third and fourth lumbar vertebre, thus
lying not much higher than the right which seemed to be
displaced more markedly forwards than downwards.

The right kidney weighed 80 grammes, the left 150, the
right was 0'4 centimetres shorter than the left. The shape
of the right was slightly altered, its upper end was pressed
against the liver, and actually flattened by contact with it ;
besides this it showed an anterior convexity and a posterior
_ concavity, corresponding to its position on an oblique plane,
double-inclined and convex anteriorly.

The left kidney showed marked increase of its tubular
substance.

The right supra-renal body was found in its normal
position.

(5) Double moveable Kidney (William Roberts, 1852) (86).

In a phthisical, very thin woman, both kidneys were very:
plainly felt through the abdominal walls, the right much lower:
than the left.

At the autopsy the right kidney was found lying loose.
one and a half inches below the liver, and attached only by
its vessels and ureter ; it was entirely destitute of fat. The
left kidney had a normal position, but lay an inch lower (than.
usual). The artery and vein of the right kidney were half
an inch longer than those of the left.

(6) Moveable Kidney on the right side ; schirrhus of the uterus ;.
hydronephrosis (Braun, 1853).

In a woman, fifty years of age, suffering from cancer of
254 MOVEABLE KIDNEY IN WOMEN.

the womb and ascites, a solid moveable tumour was made
out during life in the umbilical region. Death occurred with
symptoms of coma.

At the autopsy a large steatoma was seen on the right
side near the umbilicus, enveloped in a yellowish white mass,
On opening this, the right kidney could be seen lying in it,
enlarged, pale, soft, in a state of fatty degeneration, the
cortical substance being hardly brownish-red and bloodless.
The renal vessels tore when it was disturbed, and the renal
artery alone showed any remaining firmness of texture; the
ureter was distended to the size of a finger, and filled with
fluid down to the bladder.

Braun’s opinion was that the mobility of the kidney was
due to the pressure and maceration of the abdominal glands—
that this was the cause of the ascites—and that the tenesmus
and relaxed state of the abdominal contents had largely con-
tributed to the displacement of the kidney.

(7) Moveable Kidney on the right side; adhesions between it
and the liver, gall-bladder, and transverse colon ; hydro-
nephrosis ; uterine infarct ; multilocular ovarian cyst

on the right side (Urag, 1857).

In a very thin woman, sixty-five years of age, a tumour
could be felt under the anterior edge of the right lobe of the
liver. It ran obliquely above and inwards, downwards and
outwards ; its shape was oval, the upper border convex, the
side flatter; it seemed elastic, well defined, moveable,
sinking and rising with respiration, and in shape resembled
the kidney. It would not rotate on its axis, but could be
pushed as far as the middle line, into the right renal region,
and also somewhat downwards, though these manipulations
were painful to the patient. Compared with the left lumbar
region the right was sunken and tympanitic on percussion ;
if the tumour was pushed into the right loin it became full
in appearance and dull to percussion. The quantity of urine
secreted in twenty-four hours amounted to 1190 cubic centi-
metres, its reaction was acid, it was slightly turbid, deeply
yellow without deposit, its specific gravity was 1015.

The woman died in consequence of bronchiectasis, At
MOVEABLE KIDNEY IN WOMEN. 255

the post-mortem the right kidney was found lying in imme-
diate contact with the anterior border of the right lobe of the
liver and adherent to it as well as to the gall-bladder and
transverse colon by dense connective tissue, the adhesions.
permitting the kidney to be pushed back into its normal
situation and also as far as the middle line or into the umbi-
lical region (mesogastrium), though not without dragging on
the liver. The outer border of the kidney looked upwards,
the upper extremity inwards, the lower extremity outwards,
the hilum downwards; the kidney was twelve centimetres
long, seven broad, four thick ; the peritoneum investing it,
as well as its capsule, thickened. The capsule was distended
irregularly and in the shape of vesicles (blasig), it felt elastic
and fluctuating. The substance of the gland had entirely
disappeared, and in its place was found a colourless clear
thin fluid, enclosed by the empty septa (Fachern), of the
capsule which was shining and smooth internally. The renal
vessels were elongated and contracted, the pelvis thickened
and four and a half centimetres broad, the ureter as far as
the bladder was two centimetres in diameter, its mucous
membrane reddish-grey, thickened and granular. The left
kidney was firmly seated in its normal position, it was in an
early stage of hydronephrosis.

The size of the uterus corresponded with the third month of
pregnancy. The posterior wall, which was four centimetres
thick was chiefly answerable for its increased bulk. Its
tissue was yellowish-red, soft, infiltrated with pus. The
cavity was small, and occupied by glairy mucus. The pos-
terior wall of the bladder was closely adherent to the uterus,
and on pressing the uterus pus escaped into the bladder from
several points ; the opening of the right ureter was closed,
the opening of the left narrowed. In the right ovary were
five serous cysts, the smallest as large as a chestnut, the
largest as big as a lemon; a cyst the size of a hazel-nut
lay at the brim of the pelvis.

Urag attributes the hydronephrosis to the pressure of the
uterus on the ureter.
256 MOVEABLE KIDNEY IN WOMEN.

{8) Moveable Kidney on the left side; neuralgia of the leg
hydronephrosis mistaken for an ovarian tumour. (‘ Bul-
letins de la Société Anat.,’ 1854, s. le Ray, p. 382.)

In a woman forty years of age, much reduced in health,
who complained of violent boring pains in the lumbar region
_ and left leg, a large hard tumour was found to the left of the
linea alba and reaching nearly to the false ribs. Bimanual
examination detected the same tumour in the left fornix
vagine. The uterus was descended and moveable; on pres-
sing it upwards very restricted movements were produced in
the tumour which was large and hardly moveable by itself.
The tumour was taken to be a malignant tumour of the left
ovary.

At the autopsy it was found to. be the kidney elongated
and enlarged to three times its size, lying with its lower ex-
tremity on the fundus uteri and the left broad ligament. It
lay in the iliac region a little obliquely from above down-
wards and from without inwards. It was nineteen centi-
metres long by seven broad. It was decolorised, lobed ex-
ternally, soft, and giving marked fluctuation at the level of
the hilum, or rather over the whole inner border. Section
disclosed large, inter-communicating spaces, which were in
fact the dilated infundibula and pelvis. These dilatations
contained a turbid serous fluid without any gritty or calca-
reous deposit. The mucous membrane of the excretory
ducts was very thick and covered in its whole extent as far
as the bladder with false membranes, giving it the appear-.
ance of shagreen or of the back of a calf’s tongue.

The ureter was also hypertrophied, its calibre uniform and
nowhere occluded except at the hilum, where it was closed
by false membranes. The renal substance was also changed,
the cortical part being amyloid and uniformly greyish-white.
The pyramids of Malpighi were distinguishable only in the
upper and middle parts of the kidney, by their triangular
outline and pale red colour, but their striated appearance .
was almost completely lost. i

It is unfortunate that no observation is made, in this as
in most of the accounts in point, as to the origin and condi-
tion of the renal vessels, nor as to the position of the colon
=. SS Se

MOVEABLE KIDNEY IN WOMEN. 257

and its relation to the kidney, so that it is impossible to set
at rest the doubt whether this might not have been a case
of congenital displacement.

(9) Moveable Kidney on the left side, with eatreme mobility ;
displacement of the colon (Durham, 1860).

At the autopsy of a woman thirty-four years of age the
left kidney was seen to project remarkably. The descending
colon lay much nearer the middle line than usual and instead
of forming the sigmoid flexure on the left side, it ran across
the lumbar vertebra into the pelvis to the right of the sacrum.
Slight pressure caused the kidney to slip into its usual posi-
tion, and closer examination proved it to be moveable not
only with extreme ease but also to a great extent.

When the patient moved in various suitable ways and
under gentle manipulation the kidney glided away with
equal case across the vertebral column and under the ribs,
or even somewhat to the right side into the iliac fossa. On
closing the abdominal cavity and palpating the lumbar region
the kidney was felt as a smooth, oval, half-elastic tumour,
which slipped away when pressed by the fingers.

The peritoneum was abnormal. Instead of passing over
the anterior surface of the kidney it only just touched the
lower part of its inner edge, and then after forming the des-
cending mesocolon, again came into contact with the outer
border of the kidney. Moreover, the lesser cavity of the
peritoneum (sac of the omentum) reached so far towards
the left side as to cover the posterior surface of the spleen,
and so far downwards as to be in contact with the upper
border of the kidney. The kidney had no distinct mesen-
tery (mesonephron). In the loin hardly any fat was found
but only loose cellular tissue. The absence of fat partly ex-
plains the mobility of the kidney. The renal vessels had
their normal origin, but were perhaps longer than usual.
The left supra-renal body moved with the kidney only to a
dimited extent.

17
258 MOVEABLE KIDNEY IN WOMEN.

(10) Moveable Kidney on the right side. Adhesions to the
liver ; parametritis of the left side (Lancereaux).

In a woman aged forty-one who was a drunkard, had suf-
fered from frequent vomiting and cough, and was very thin,
a moveable kidney could be very easily made out on the
right side of the abdomen.

After the patient’s death from erysipelas of the face the
right kidney was found not against the quadratus lumborum
muscle but tightly pressed against the right side of the ver-
tebral column. It was much smaller than the left kidney
and slightly lobed. Its right border was adherent to the
liver which was rather large.

The posterior wall of the uterus was adherent to Douglas’s
pouch by old false membranes, which were confined to the
right half of the posterior surface of the right broad liga-
ment. The inflammation had extended along the ureter as
far as its upper extremity. The right ovary which was in-
volved in this focus of inflammation, was two or three times
as large as the left, the tube was sinuous, its end was closed
and adherent to the peritoneum opposite the posterior fundus
vagine, and enlarged to the size of a nut.

(11, 12) Moveable Kidneys on the right side (Lancereaux).

In a consumptive woman, aged sixty years, the right
kidney was found astride (i cheval) of the second and third
lumbar vertebrze, covered with peritoneum. The vessels and
ureter appeared normal, somewhat elongated ; the liver was
congested and seemed to have pressed the kidney downwards,
though it could be presumed that the kidney had changed
its position previously. The right ovary was unchanged, but
the uterus was studded with fibrous tumours.

A woman who died with stenosis of the mitral valve
showed a condition precisely similar.

(13) Moveable Kidney on the right side (Mosler, 1866).

A woman, aged thirty-six, died of double pneumonia after
amputation of the thigh. Grohe, who made the autopsy,
fonnd the following conditions :
MOVEABLE KIDNEY IN WOMEN. 259

Liver enlarged. On turning it up, the right kidney,
which was, however, very deeply situated, at once came into
view. The kidney was rotated half round so as to bring its
outer convex border almost entirely horizontal and looking
downwards and on a level with the crest of the ilium, the
hilum looking upwards and inwards. The right renal vein
ran obliquely upwards and opsiied into the vena cava inferior
at a somewhat acute angle. The ureter which was entirely
covered at its origin by the kidney, first describing a slight
curve, ran upwards over the trunks of the great vessels, and
then passed towards the pelvic cavity as usual. The diameter
of the vein, artery, and ureter was normal, no special altera-
tions attributable to the abnormal position of the kidney
could be made out. The only difference between the kidneys
was that the right was somewhat smaller than the left. The
right kidney was 43 in. long, 23 in. broad, 1§ in. deep; the
left was 52 in. long, 23 in. broad, 13 in. deep.

(14) Moveable Kidney on the right side (Jago).

In a woman who had lost much flesh from obstinate
vomiting, a moveable kidney was discovered on the right
side. Pressure against its lower end made it slip away from
the hand upwards, and the upper end could be pressed to
right or left. Pressure on the upper end drove the tumour
plainly, but only a little, downwards. If seized with the
whole hand it could be pushed upwards, but the hilum could
not bereached. If pressed downwards, it was so smooth that
it slipped away.

At the autopsy tke kidney could be displaced from the loin
to the extent of two inches above and three inches below,
this mobility not being restrained by the vessels. The peri-
toneum was adherent to the whole anterior surface of the
kidney, and to part of its lateral and posterior surfaces, but
did not enclose the emerging vessels so as to form a mesen-
tery (mesonephron). The peritoneum passed somewhat
loosely from the kidney to the adjacent organs in the loin.
260 . MOVEABLE KIDNEY IN WOMEN.

(15) Moveable Kidney on the right side; caries of the
thoracic spine ; formation of a mesentery (mesonephron)
(Henderson).

A woman, aged fifty, had long observed a moveable
tumour in the lower abdomen, which could be felt in the
right side of the hypogastric region, disappeared beneath the
liver on slight pressure, and reappeared on bending forwards.
There was caries of part of the vertebral column of some
years’ standing.

The patient died of pneumonia. At the autopsy the bodies
of the fifth and sixth thoracic vertebrae were found to be so
far destroyed that two fingers could be introduced into the
vertebral canal. The right kidney was suspended and quite
moveable in a prolongation of the peritoneum like a mesen-
tery ; it was quite normal in size and structure. ‘The left
kidney was loosely attached, but not moveable. The
liver appeared normal, except that it was rather small.

(16) Moveable Kidney on the right side; caries of the fourth
lumbar vertebra (Ebstein).

In the body of a woman fifty years of age and much
emaciated, the right kidney was found lying across the verte-
bral column on the usual level with the hilum looking back-
wards and upwards, the convex border looking downwards
and forwards, the capsule of fat entirely absent ; the kidney
which was of normal shape could be displaced as far as the
brim of the pelvis.

(17) Moveable Kidney on the left side ; caries of the first to
the third lumbar vertebre (Cullingworth) (87).

In the body of a ballet-dancer, thirty-two years of age,
who had had nine children, the psoas muscle was found
almost completely destroyed ; the left transverse process and
the left half of the body of the second lumbar vertebra had
disappeared, the tips of the transverse processes of the first
and third lumbar vertebra were also carious, the kidneys
MOVEABLE KIDNEY IN WOMEN. 2614

and their calices dilated; on the inner and posterior side,
where they were connected to the lumbar vertebra, an open-
ing was found forming a communication between the diseased
vertebra and the renal tumour.

The ureter had been occluded by a perforated piece of
carious bone ; and this perforation could only have happened
subsequently to the dislocation downwards of the kidney.

Other post-mortem records were useless on account of
excessive brevity. or of inaccuracy. Those which have just
been quoted establish the fact that moveable kidney both in
life and after death is found by preference on the right side
and inwomen. Again, moveable kidney presents no constant
condition either during life or after death, but varies in
respect of its position and degree of mobility. The first
observation of Aberle, in which the kidney felt during life to
the right of the umbilicus was found after death in its normal
position, is very instructive. In this case, unless special
attention had been given during the autopsy to the question
of its mobility, the moveable kidney would certainly have been
overlooked, as perhaps often happens.

The kidney is usually covered by small intestine and lies
near the vertebral column in the region of the second to the
fifth lumbar vertebra, and, besides being displaced from its
normal position, is rotated on one or two of its axes. In
some cases its outer border is turned upwards, its upper end
inwards, its lower end outwards, so that the hilum looks
inwards instead of downwards (Urag) ; in others it lies in an
exactly opposite position, transverse in the abdomen with the
hilum upwards (Mosler). It is rare for the lower end to be
directed forwards (Rayer) ; most frequently it lies obliquely
from above and externally downwards and inwards.

In correspondence with this, the position and relation of
the renal vessels and ureter to each other and the neighbour-
ing organs is changed. The lower down the kidney lies the
acuter the angle between the renal vessels and the vena
cava and aorta must be, and the more curved must be the
ureter; the more the kidney is rotated round one of its axes,
the more must the calibre of the vessels and ureter be
narrowed by torsion. Little attention unfortunately has
262 MOVEABLE KIDNEY IN WOMEN.

hitherto been paid to these changes in the cadaver, the vessels
being only now and then described as elongated and
narrowed.

The kidney which is moveable is in many cases remarkably
small and light, in which case the other is hypertrophied by
way of compensation. In Rayer’s case the moveable kidney
weighed 80 grammes, the other 150 grammes. It is usual
for the kidney which is not moveable to be more deeply situ-
ated than normal. In some cases the kidney substance is
itself degenerated, sometimes by fatty change, sometimes by
the contraction of connective tissue within it, and it is some-
times in a state of hydronephrosis. Quite recently numerous
cases of sarcomatous moveable kidneys have also been
reported, as for instance by Wolcott (88), Kocher (89),
Jessop (go), Czerny (91), Lossen (92), and Barker (93).
Under such pathological circumstances as these, indeed,
the mobility of the kidney is so far the lesser evil that it is
not considered.

Hydronephrosis of moveable kidneys has been mentioned
it is true, but not brought into any closer connection with
the mobility of the kidney. Simon indeed stated expressly
so late as 1876, that up to that time no case of hydronephrosis
in a moveable kidney had been described.

The capsula adiposa shows a pretty constant condition,
being destitute of fat in many cases where there is no great
degree of general emaciation. The capsule of the kidney is
then like an empty bag, which is bulged forwards by the
kidney as far as its size and the looseness of the cellular
tissue permit. By this means a kind of mesentery of the
kidney, a mesonephron, is found, which is sometimes very
long (Girard, Ocrum-Howitz, §c.). This mesentery has been
erroneously regarded by many authors (Portal, Rollet,
Hbstein, §c.) as a congenital cause of moveable kidney.

Again, the hepatic and splenic flexures of the colon are
found almost constantly displaced, being either bodily
depressed downwards and inwards together with their mesen-
teries, or having the two layers of the mesocolon separated
by the kidney which has in a sense migrated between them.
A similar effect is produced by hydronephrosis, or, in the
case of the broad ligament, by the growth of tumours of the
MOVEABLE KIDNEY IN WOMEN. 263

ovary or uterus within its substance. In this respect, therefore,
hydronephrosis and moveable kidney behave alike, as the
foregoing post-mortem records show, except that in the case
of hydronephrosis the two layers of the meso-colon are kept
apart by its constant growth, whereas in the case of move-
able kidney it is the movements of the kidney which separate
them (conf. the observations of Aberle and Sandifort). The
displacement of the colon has also been erroneously regarded
as a congenital cause of moveable kidney.

Moveable kidney produces no effect on the solid organs
near it, thuseven the supra-renal bodies are constantly found
in their normal position.

Among other pathological changes observed in the dead
subject are adhesions, contracted by the kidney with neigh-
bouring parts. A favourite spot for these adhesions is
the lower border of the liver, the gall-bladder and transverse
colon.

It is rare for a moveable kidney to produce thrombosis
of the vena cava inferior by compression (Girard).

VI. AitioLogy anp PatHoGENEsis.

Ifan attempt were made to explain the causes and mode
of production of moveable kidney from post-mortem appear-
‘ances only, the scarcity and incompleteness of post-mortem
records would yield but imperfect results. Besides this, it
would be impossible thus to decide the question whether the
changes discovered after death were causes or consequences
of moveable kidney. In this way indeed the length of the
renal vessels, the presence of a mesentery of the kidney
(mesonephron), and the displacement of the colon have been
considered actual causes of moveable kidney, while accurate
observation shows that they are just as much results of move-
able kidney, or that both pathological conditions are possibly
consequences of a third common cause. Finally, there may
be present during life certain anatomical disturbances which
have an important bearing on the pathology of moveable
kidney, and yet cannot be recognised either by post-mortem
examination or by examination of the fully formed patho-
264 MOVEABLE KIDNEY IN WOMEN.

logical specimen, such for instance as compression, torsion of
vessels, and pressure on nerves.

We have already seen that the kidney, lying as it does
in the capsula adiposa, against the quadratus lumborum
muscle, and for the most part within the bony enclosure of
the thorax, is maintained in its position directly by physical
pressure, as for instance by the intra-abdominal pressure, as
well as by its anatomical attachments. ‘As soon, therefore,
as one of these factors fails, the kidney may become
moveable.

a

Anatomical Causes.

Many authors (Rayer, Rollet) have mentioned the pressure
exercised by neighbouring organs when enlarged (especially
tumours of the liver and spleen) as important causes of
moveable kidney; but this is erroneous. It is true that’
moveable kidneys have been found in patients with ague or
splenic leukezemia or hypertrophy or tumours of the liver, but
the well-established fact that they are not constantly found
in these diseases proves that the mobility of the kidney can-
not be laid to their charge. Since, moreover, tumours of
the liver and spleen grow downwards over the anterior
surface of the kidney and not in the direction of the long
axis of the kidney, such tumours would tend to maintain the
kidneys in their position rather than to depress them. The
only tumours which could displace the kidneys by virtue of

1 [The logic of this sentence as it stands seems doubtful; the author
probably means that all the factors are necessary and no more than are neces-
sary to maintain the position of the kidney. But this again is not proved.
It seems more probable, from the analogy of other organs, that, one or
more factors are essential and generally sufficient, the others coming into
play only in case of failure of the first. Thus in a railway train the screw-
couplings are generally sufficient, but the chain-couplings are added in case
of their failure. Or take the case of the uterus, whose descent is not pre-
vented by the perineum unless its ordinary means of attachment fail; the
perineum generally does not deserve to be described as one of the means of
preventing descent of the uterus. This may be seen any day in women
whose perineums are completely gone, the uterus nevertheless remaining
high up in the pelvis. The question belongs to a large and important.
department.—TRansLaTor. |
MOVEABLE KIDNEY IN WOMEN. 265.

their position are tumours of the suprarenal bodies and
pancreas, examples of which are furnished by Rayer and
Bonnet.

A similar effect is produced on the mobility of the kidney
by tumours of its own substance, such as sarcomas, carci-
nomas, and hydronephroses. In this case the mobility is
produced by the great stretching and relaxation which the
capsule—the most important attachment of the kidney—
sometimes suffers through the increase in weight and size
produced by these tumours.

This is seen typically in cases of caries of the last thoracic
and first lumbar vertebra, and in psoas abscesses (Hender-
son, Ebstein, Culligworth), in which the kidney is deprived.
of its firm base of support.

One of the most important and frequent causes of mobility
is absorption of fat from the capsula adiposa and relaxation
of the peritoneum. The absence of the fat round the kidney
can of course only produce mobility in cases in which it was.
previously present in considerable quantity and then became
rapidly absorbed. If, however, the fat is only slowly re-
moved, an accommodation takes place, and the kidney main-
tains its position just as it does in very young subjects who
have never had any fat in the capsules of their kidneys. In
the other case, however, after a rapid absorption of the fat,
the capsule looks like a relaxed wide-meshed envelope, easily
capable of being bodily dragged down from the posterior
wall of the abdomen, and within which it is easy for the kid-
ney to descend. We see here just the same conditions as
we do in the skin, which can be lifted up from the muscles
‘in folds whose size is greater the more rapidly and thoroughly
the panniculus adiposus has been absorbed.

It generally happens, however, that at the same time as
the fat round the kidney is being absorbed, that in the peri-
toneal structures and the abdominal walls is also becoming
absorbed, so that the means by which the kidney is indirectly
secured are also deprived of their strength, and under these
circumstances! slight bearing down efforts, such as those

1 [Here for the first time in this treatise we meet with the very important

but very obscure question of the “Intra-abdominal. pressure.” That there
is such a force, that it varies, that it has laws of its own, that its effects are
266 MOVEABLE KIDNEY IN WOMEN.

which occur during defecation, are sufficient to dislocate the
kidney downwards.

We ought not therefore to be surprised at finding among
those suffering from moveable kidney a large number who
have recovered from acute febrile diseases, such as enteric
fever and ague, or who are still suffering from chronic and
rapidly emaciating affections such as phthisis, &c. Thus out
of nine of Dietl’s cases, severe ague and enteric fever had
preceded the moveable kidneys in four.

A conspicuous part in the production of moveable kidney
is also played, especially in women, by affections of the
abdominal walls, which are exposed normally in pregnancy
and pathologically in the numerous cases of tumours of the
genital organs, to serious alterations in compactness, firmness

important, and that it is not always positive, has been definitely proved by
Matthews Duncan and Schatz; but beyond this very little is practically known.
And at the outset difficulties meet us. In the first place it seems certain
that hernia, descent of the uterus, and descent of the abdominal organs
are conditions due to closely allied if not identical causes (this will be dis-
cussed again later on, p. 357). In this class of cases the intra-abdominal
pressure would seem to be increased. Butincreased intra-abdominal pressure
is equivalent to diminished specific gravity or increased buoyancy of the
intra-abdominal organs, which (in the case of the kidneys for instance) would
mean diminished tendency to descend.

With regard to the effort of straining as being an exciting cause of descent
of the kidneys this explanation seems more than doubtful ; for if the kidney
is squeezed downwards by the diaphragm with a certain force, it is squeezed
upwards by the abdominal muscles with an equally great force, besides the
increased buoyancy produced by increase of the intra-abdominal pressure
which would tend rather to lift than to depress it.

The effect of jerks and falls and perhaps vomiting is a question of impetus
and belongs to a different category; their effect in dislocating the kidney,
especially when the abdominal muscles are not braced, is easily explained.

The only possible mode of reconciling facts with regard to the conditions
of the intra-abdominal pressure in our present state of ignorance would be
to regard the kidney (and other abdominal viscera) as generally having
tendency to descend, even when their buoyancy was at its greatest, and to
regard the apparent increase in the intra-abdominal pressure in hernia,
descent of the uterus, &c., rather as the result of diminished resistance to
a generally positive pressure, with which the weight of the viscera would
co-operate. Against this view would have to be put the occasional high
position of floating pelvic tumours and of the pregnant uterus. It is not,
however, proved that the intra-abdominal pressure is the same in all parts of
the abdominal cavity even at the same time.—TBansLaTor. |
MOVEABLE KIDNEY IN WOMEN. 267.

and elasticity. True it is that it is normal for the abdominal
walls which have been physiologically stretched during
pregnancy, to make as good a recovery as the womb; but
in cases where the lying-in has gone wrong, where labours
and abortions have succeeded each other rapidly, they become
flabby, shrivelled, and thin, and pendulous belly, which is
here so injurious, is apt to follow, with or without divari-
cation of the recti muscles. If now the intra-thoracie pres-
sure is increased (i.e. if the diaphragm is forced down), as
in lifting, in difficult defecation, or severe efforts of any sort,
the efficient means of fixing the abdominal contents furnished
by well-braced abdominal muscles fails, and the descent of
the kidney is opposed by diminished resistance. But the
subjects of pendulous belly are just the persons who are also
predisposed to severe bearing down efforts, inasmuch as they
are usually much constipated. Finally, however, where
pendulous belly is present, the action of the intra-abdominal
pressure, which normally presses with equal force on all the
viscera, is reversed, inasmuch as the bowels which occupy
the loose sac formed by the abdominal walls exercise trac-
tion on the superjacent parts, including the kidneys, when
the patient stands upright. The’ fatter and heavier the ab-
dominal walls, the gredter the pendulous belly and the
greater therefore this traction. This is the obvious explana-
tion of the occasional great difficulty of breathing in persons
with pendulous belly, the traction of the viscera impeding
the normal expiratory movement of the diaphragm. But by
the frequently recurring distension of the abdomen, whether
physiological or pathological, the peritoneum also is relaxed,
and in pendulous belly the anterior peritoneal layer of the
capsule of the kidney, and with it the kidney, is subjected
to direct traction.

The injurious effect of the above-named causes is confirmed
by clinical observation. The vast majority of women affec-
ted with moveable kidney have borne many children, and, as
shown by the appended table of my own observations, it is
striking how frequently their deliveries had followed each
other closely. Among the forty-two cases observed by me

1 [It is, however, a fact that hernia and allied conditions are commoner in
thin, flabby individuals than in fat ones.—TransLaror. ]
268 MOVEABLE KIDNEY IN WOMEN.

only two are nulliparw, and of these one had carried a large
ovarian tumour for eighteen years, and had acquired pendu-
lous belly after I had removed it. Similar observations
of cases in which the abdomen had long been distended
by tumours or ascites are contributed by Oerum-Howitz
and Rollet. Ruptures are frequently found in women along
with moveable kidney, as observations by Rayer, &c., show.

Menstruation, again, has been named by Bequet, Lancereauz,
Fourrier, and others among the influences contributing to the
production of moveable kidney. According to these authors
every menstruation produces congestion of the kidney and its
capsule, and therefore increase of its volume, through a con-
nection between the ovarian and renal plexuses, which connec-
tion, however, has yet to be proved. The relaxation of the
capsule, its distentionat nextmenstruation,'and so on, gradually
enlarge it to such a degree that the kidney becomes moveable
within it. Although clinical symptoms show that a connec-
tion between moveable kidney and menstruation exists, and
that the renal and uterine vessels are closely connected (as
the investigations of Virchow (94) prove), a direct relation of
cause and effect between menstruation and moveable kidney
must be rejected, for, on the above theory no woman who
menstruates should fail to have a moveable kidney.

There are, however, a series of other influences, hitherto
too little regarded, which demonstrate the dependence of
moveable kidney on the sexual department of a woman’s
organism, besides such causes as repeated pregnancy, tumours
of the lower abdomen, &c., which have already been men-
tioned :—these are the numerous displacements of the generative
organs, the descents, prolapses, and inversions of the vagina
and uterus. In the first place these affections have important
causes in common with moveable kidney, such as impeded
involution of the generative organs post partum, relaxation
of the peritoneum, and rapidly repeated deliveries ; this is
proved by their pathology. In the second place, however,
descent of the genital organs favours the descent of the
kidney by direct traction. Since the female generative
organs are directly connected with the kidneys by the peri-.
toneum as well as by the ureter, which runs close to the body
of the uterus and in the substance of the upper third of the
MOVEABLE KIDNEY IN WOMEN. 269

vagina, this traction is increased by the bladder which is
usually prolapsed in these affections. It either happens that
the kidney yields to this traction, or that the ureter becomes
closed by it..

Finally, a whole series of diseases of the female sexual
organs contributes directly to the production of moveable
kidney by inducing hydronephrosis which relaxes the capsule
of the kidney. In consequence of the intimate mutual rela-
tions existing, as we shall see, between moveable kidney and
hydronephrosis on the one hand, and between affections of
the female generative organs and moveable kidney, as we
have already shown, on the other hand, it seems imperative
to consider very briefly the relation between certain affec-
tions of the female generative organs and the production of
hydronephrosis.

Relations of Sexual Disorders to the production of
Hydronephrosis.

Even Walter (95) explained the frequency of hydrone-
phrosis in women by the circumstance that they possess more
organs capable of pressing on the ureters and thus giving
rise to accumulation of urine, than men.

Morgagni (96) had already called attention to the mutual
relations between the pregnant uterus and the kidney,
remarking on a case in point: “ Inter caetera autem detri-
menta quae mulieribus afferunt cruciatus nephritici, non
dubito, quin abortus, aut non infrequens et foetus, et matris
interitus sit referendus. Cum enim uterus crescens ureteres
premendo, minus per hos facilem reddat urinae defluxum, et,
quod consequitur, nonnihil in renibus eam moretur.

? &e.

Cases, again, are not rare in which an autopsy has shown
compression of the ureter by tumours of the uterus and ovary.

A far more frequent cause of hydronephrosis is cancer of
the uterus, in which hydronephrosis is almost one of the
regular phenomena, as. Virchow, Sdxinger, and others have
shown.
270 MOVEABLE KIDNEY IN WOMEN.

Freund’ (97) and Hildebrandt? (98) have convincingly

1 [Freund, Deutsche Naturforscher-Versammlung, Karlsbad, 1862;
‘ Verhandlungen der gynakologischen Section,’ S. 119.

The whole reference to this paper (which I succeeded in finding in the
library of the Royal Society, after a fruitless search in those of the Royal
Medical and Chirurgical and Obstetrical Societies, the College of Surgeons,
and the British Museum) is as follows :

“ Amtlicher Bericht iiber die sieben und dreissigtste Versammlung Deuts-
cher Naturforscher und Aerzte in Karlsbad im September, 1862,” Karlsbad,
1863, S. 295.

“According to Dr. Freund hydronephrosis is often found in cases of
retroflexion of the uterus: its causes are :

“1, Actual narrowing of one or both ureters, e.g. from chronic changes in
the pelvic cellular tissue.

“9. Dislocation of the uterus may cause kinking (Knickung) of the
ureters. The ureter is often fastened to the side of the uterus after peri-
metritis; this would explain the symptoms of hydronephrosis during life,
namely, violent pains in the loins passing downwards along the ureters,
pains in the lower extremities, headaches, frequent desire to pass water,
dyspeptic troubles—which have been hitherto, according to Dr. Freund,
wrongly attributed to hysteria. The symptoms of hydronephrosis are inter-
mittent, the quality of the urine resembles that in catarrh of the bladder.
Dr. Freund believes that pyelitis is a frequent sequela; he mentioned a case
which ended in cure. After kinking of the ureters hydronephrosis only
occurs on the right side; after narrowing of the ureters, on both sides.

“ As the 3rd cause, Dr. Freund cites atrophy and hypertrophy of the pelvic
contents; the former often extending to the bones, the general suffering
small. The origin of both is problematic.”

This seems nothing more than a collection of general statements; the
‘ Official Report’ contains not a single fact in favour of the theory laid down
in the text. ]

* (Hildebrandt, ‘Volkmann’s Sammlung Klinischer Vortrage,’ Band i,
Abth. 3, Gyn. No. 5, “ Ueber retroflexion des Uterus.”

“Frau H., who had suffered from annoying urinary troubles besides the
usual syraptoms of retroflexion, was sent to me by her family doctor to be
examined for a somewhat voluminous soft tumour above the left Poupart’s
ligament. I found retroflexion, and gave as my opinion that the tumour
was to be regarded as a dilatation of the ureter in consequence of the retro-
flexion. My diagnosis was verified easily and promptly. I first replaced
the uterus with the sound, then introduced the cathether and drew off the
water, pressing on the abdominal walls at the same time. The tumour
diminished as I did so from the size of a child’s head to that of an apple.”

This case seems far from proven. To have proved Hildebrandt’s point it
would surely have been as well to pass the catheter before replacing the
uterus; by his method he has destroyed the proof that the retroflexion had
any connection with the urinary symptoms.

Ihave quoted both passages at length to enable readers to judge fur
MOVEABLE KIDNEY IN WOMEN. 271

proved that the common retroflexions of the uterus produce
hydronephrosis by kinking (Knickung) and downward drag-
ging of the ureters.

A rarer cause of hydronephrosis in connection with the
female generative organs is mentioned by Stadtfeldt (gg), viz.
the compression of the ureter by parametric cicatrices. I
find a similar observation in Sandifort (100). Significant
cases in point have been quite recently communicated by
Frankel and Maass (101) and by Schottelius (102). The latter
found in a woman forty-three years of age the pelvis of the
left kidney dilated into a sac holding six litres of fluid,
the ureter somewhat dilated and tortuous, but admitting the
passage of a probe as far as the bladder. The bydronephro-
sis was due to a displacement of the uterus, and fixation of
the left ureter by dense connective tissue, the result of
former parametritis, to the cervix, above the opening of the
ureter into the bladder.

Parametritis may ‘therefore produce obstruction of the
ureter in two ways, either through direct compression of the
corresponding ureter by the deposit, or by contraction of the.
cicatricial tissue drawing the uterus to its own side and thus
dragging on the opposite ureter and occluding its calibre.

A hematometra may also produce hydronephrosis by com-
pression of the ureter in the same way as a parametritis, as
Tringel (103) has shown.

One of the most important causes of hydronephrosis how-
ever, though hitherto little regarded, is descent of the female
generative organs first indicated by Virchow (104). It seems all
the more necessary to consider this cause in the present
place, inasmuch as we have already recognised descent of
the female generative organs as a cause of moveable kidney
itself; so that the relations of descent of the female genera-
tive organs to moveable kidney are twofold, contributing as
it does directly through traction on the one hand, and indi-
rectly through the production of hydronephrosis on the other
hand, to the mobility of the kidney.

We owe the first observation in which descent of the

themselves how far they consider that retroflesion of the uterus has been
“convincingly proved” to be a cause of hydronephrosis. Descent of the:
uterus, with or without retrollexion, is another matter.—TRinsLaror. }
272 MOVEABLE KIDNEY IN WOMEN.

female generative organs was recognised as a cause of hydro-
nephrosis and confirmed by an autopsy, to Virchow himself,
who found in a woman, forty-three years of age, the subject
of an irreducible procidentia, the ureters much constricted as
far up as the sacro-iliac synchondrosis, and the pelyis of the
kidney dilated. This condition was explained by Virchow
from the circumstance that the base of the trigone, that is
the spot where the ureters open, was drawn forwards beneath
‘the symphysis pubis, necessitating compression and there-
‘fore obstruction to the passage of urine. Virchow remarks,
“The possibility of such obstruction, and the production of
hydronephrosis in cases of prolapsus uteri of this kind, is well
worthy of attention in practice, though not hitherto men-
tioned. It stands on the same footing as the hydronephrosis,
which so very often accompanies cancer of the womb, and
which is also usually disregarded.” This hint by Virchow
has, however, attracted little notice, for apart from his own
‘observation I have been able to find only one solitary notice
of the same kind by Philipps (105), who found in a 4 para
‘thirty-five years of age (who had suffered since her first
confinement from procidentia of the uterus and died coma-
tose), the capsule of the kidney adherent, the glandular
substance much contracted, the pelvis dilated, the pyra-
maids flattened and changed into cavities, hardly a quarter of
the glandular substance left, the mucous membrane of the
urinary passages thickened, the ureters dilated to the thick-
ness of a finger. The ureters and bladder contained milky
purulent urine, the muscular tissue of the bladder was hyper-
trophied, the uterus lay in front of the vulva as large as an
:apple. The procident mass consisted of the neck and part
of the posterior wall of the bladder in front, and of the pos-
terior vaginal wall and greatly thickened peritoneal covering
-of Douglas’s pouch behind. The orifices of the ureters were
‘found. beneath the pubic arch and had thus been exposed to
‘a considerable pressure.

Although in this case the mechanical cause of the pro-
‘duction of the hydronephrosis doubtless consisted in com-
pression of the ureters against the pubic arch, as is proved
by the dilatation of the ureters down to their vesical
orifices, in other cases it seems to consist in occlusion of the
MOVEABLE KIDNEY IN WOMEN. 278

ureters by traction (such as may be produced by stretching
an india-rubber tube) higher up than the point of application
of the traction, as can be seen in Virchow’s case.

Physical causes.

We have so far studied the primary changes in the
direct or indirect means of fixation of the kidney as produ-
cing its mobility, but in all cases pressure from above or
traction from below must contribute to its development.
These physical influences are competent, by themselves and
without any previous anatomical changes of importance, to
produce moveable kidney.

Thus acute injury is frequently cited as a cause. In this
case, of course, just as in cancer of the breast, the bare state-
ment of the patient that a tumour developed in the abdomen
after a fall or a blow, &c., should not be implicitly believed.
In the case of moveable kidney as well as in cancer of the
breast, it is an external occurrence which first directs a
patient’s attention to the existence of the malady. The oc-
currence of this luxatio traumatica renis is established by
trustworthy observations. Thus observations are quoted by
Rayer, Henoch, Ferber and Le Ray, in which this complaint
was acutely produced by a fall from a carriage or from
horseback, or by a blow on the side. If it is remembered
that isolated ruptures of the liver, spleen or kidney have
been found after severe injuries, the possibility of the occa-

1 Attention should be called in this place to a remarkable class of cases
in which marked dilatation of the ureters and hydronephrosis occur. These
may be described as cases of urinary obstruction from irritation. The first
division of the class concerns the subjects of incontinence of urine. Three
cases are recorded by Dr. Alexander James, ‘ Edinburgh Medical Journal,’
1878, p. 135, in which death occurred, and in the two of these in which
a post-mortem examination was obtained dilatation of the ureters and double
hydronephrosis was found. The second division concerns the subjects of
extroversion of the bladder, in which affection a similar condition is gene-
rally found (Champneys, ‘St. Bartholomew’s Hospital Reports,’ vol. xvi,
1880, p. 111) in spite of the absence of any structural obstruction to the
ureters. In both of these cases the obstruction is spasmodic, and the com-
parison of the two classes shows that its seat; must be the orifices of the
ureters. The bearings of this on the previous remarks in the text are
obvious. —TRANSLATOR. |

18
274 MOVEABLE KIDNEY IN WOMEN.

sional occurrence of isolated ruptures of the capsule of the
kidney by a blow or its ‘“contrecoup” will not be doubted.
I myself have seen two patients in whom caroful investigation
proved the sudden appearance of an abdominal tumour, in
one case after carrying a heavy weight with the trunk bent
sideways, and in the other case after a fall, in both cases
without any predisposing anatomical cause.

In a similar fashion other authors have seen moveable
kidneys actually develop in the course of labour after severe
bearing down ; but in these cases it is questionable whether
a moveable kidney already produced had not been pushed
up during pregnancy by the growth of the uterus, and
merely reappeared after delivery.

This complaint, however, is more frequently induced by
repeated injury, especially by the shock of cough in bronchitis,
pleurisy, whooping-cough, and particularly when favoured
by other factors, such as the rapid emaciation of phthisis.
Even Riolan and Portal drew attention to the importance of
this influence, and they have been confirmed by the obser-
vations of Le Ray, Defontaine, Olivier, Keppler, and Rayer.
I myself cannot doubt, when I consider that the kidney lies
above the lowest part of the pleura, that every pleurisy with
effusion must necessarily depress the kidney, so that under
these circumstances, violent concussion of the diaphragm
may very easily produce mobility of the kidney.

But repeated exertions, such as prolonged and severe
labour, lifting great weights, carrying heavy children, violent
straining at stool, may act in the same way as fits of cough-
ing in loosening the attachments of the kidney and thus
contributing to its mobility. Literature contains many
vouchers for their occurrence. Thus a patient under my
care, in whom no predisposing anatomical cause of moveable
kidney could be ascertained, had been used to carry heavy
burdens on the hips, with the trunk bent sideways.”

1 [The steady squeeze, presumably equal in all directions, produced by any
of the above methods is surely a very different thing from shocks, such as
that of coughing, blows, or falls. This has been remarked in a previous
note—TRANSLATOR. |

? (This unsymmetrical position may have been a very important factor in
the case.—TRanstator. |
MOVEABLE KIDNEY IN WOMEN. 275

Finally, the stays have been quoted from the most various
quarters as an important factor in the production of move-
able kidney. Cruveilhier especially remarks; “ J’ai ren-
contré plusieurs fois chez les femmes qui usent de corsets
fortement serrés, le rein droit dans la fosse iliaque du méme
cdté. Ce déplacement arrive, lorsque par la pression exercée
par le corset sur le foie, le rein est forcé de l’espéce de loge
qu’il occupe a la face inférieure de cet organe, 4 peu prés
comme un noyau entre les doigts qui le pressent.”’

If we consider, however, that many women who have
moveable kidney have never worn stays and that only a few
of those who wear stays get moveable kidney, it follows that
this article of clothing, as such, is guiltless of the production
of moveable kidney. Neither can the laced bodices (Schniir-
leibchen') on which blame is laid by Muiller-Warneck be
allowed to rank as causes. This author, as well as Bartels,
assumes that lacing of the bodice will directly compress the
kidneys; but this assumption is incorrect, for the bony
thorax, within which the kidneys lie, and round the lowest
part of which the laces are braced, is far too rigid to pass
on the pressure to the subjacent organs. The damage
which the articles of apparel mentioned above do neverthe-
less inflict consists far more in this, viz. that too tight
lacing round the thorax prevents its expansion on inspira-
tion and obliges the diaphragm to descend deeper by way of
compensation and thus to depress the subjacent organs, the
liver, spleen and kidneys. Again, the bodices (Schniirmieder’)
may produce an injurious effect directly on the kidney in
cases in which the kidney has already become moveable and
lies against the anterior abdominal wall. It is especially
important to remember that, when once a kidney has become
moveable, a number of other factors contributing to the
further development of its mobility come into play, which, so
long as the kidney remains in position, have absolutely no
effect in producing its displacement. This is true, for

1 [Schniirleib, Schniirmieder, are articles of clothing unknown in Eng-
land. They are laced bodices of simple construction, and worn still very
generally. The lower orders wear them often outside their other garments.
Similar bodices are worn outside by the Italian peasantry, and form part of
the proper dress of Margaret in ‘ Faust,’—TRansLator. ]
276 MOVEABLE KIDNEY IN WOMEN.

instance, of the movements of the spinal column, which, as
we have already seen, is to be regarded as immoveable only
in the region occupied by the kidney in its normal position.
Besides, a well-fitting pair of stays, which is only used for
supporting the breasts and strings of the garments, is, as we
shall see, much more calculated to prevent than to produce
mobility in a normally placed kidney.

It now remains to state plainly the causes which especially
contribute to the mobility of the right kidney. This position
is all the more forcible inasmuch as, with the exception of
sudden violence affecting one side, the causes of mobility
hitherto considered act equally on both sides of the body.

(a) The assumption that the right kidney is the larger and
heavier is disproved by numerous determinations by Rayer
and Sappey.

(b) Guéneau de Mussy assigns the usual tendency of the
uterus to rise in pregnancy towards the right side as a cause,
without further explaining the connection.

(c) Lancereaux thinks that there is possibly a special con-
nection between the right ovarian and renal plexus, produ-
cing at every menstrual period congestion and consequent
expansion of the capsule of the right kidney.

(2) Cruveilhier in this connection also makes stays answer-
able for depressing the right kidney, on the ground that their
pressure squeezes the kidney beneath the liver, just as a
slippery cherry-stone is flipped between two fingers, whereas
the left, hypochondrium, occupied as it is by the spleen and
cardiac end of the stomach, bears the pressure of the bodice
with impunity.

(e) According to Miiller-Warneck also the liver, and
therefore the “ right kidney which normally lies distinctly the
lower down,” are specially affected by laced bodies. This
supposition is, however, not to the purpose, for normally the
right kidney lies very slightly if at all lower down than the
left, so that the left kidney being deprived of the protection
of the bulky liver must be much more exposed to pressure
than the right.

(f) Other authors make the liver alone answerable for the
frequency of moveable kidney on the right side, but finally
acknowledge with Rollet that: “The reason why the right
MOVEABLE KIDNEY IN WOMEN. 277

kidney becomes moveable far oftener than the left is not as
yet sufficiently explained.”

(9) It seems, however, to me that the explanation of this
peculiar relation ought not to be sought, as has hitherto been
the case, in causes which would seem to imply that the right

Fia. 3 (after Sappey).

 

a1. Lower surface of the liver. 13. Upper end of jejunum.
2, Gall-bladder. : 14. Lower end of small intestine passing
3. Section through the diaphragm. into colon.
4. Posterior surface of the stomach | 15. Mesentery.
turned up. 16. Caecum.
5. Lobus Spigelii. 17. Vermiform appendix.
6. Coeliac axis and hepatic artery. 18, Ascending colon.
4. Coronary artery of the stomach. 19, 19. Transverse colon.
8. Splenic artery. 20. Descending colon.
g- Spleen. ‘ 21. Sigmoid flexure.
10. Pancreas. 22. Rectum.
11. Superior mesenteric vessels. 23. Urinary bladder.

12. Duodenum.
278 MOVEABLE KIDNEY IN WOMEN.

kidney is exposed to greater pressure than the left. Other
things being equal, the left kidney would be much more
easily displaced laterally in the left hypochondrium which is
not occupied by firm abdominal glands, than the right, for
the right kidney could only be displaced by more intense
pressure or traction from under the liver, which occupies the
whole of the right hypochondrium. But the different
behaviour of the right and the left kidney seems to me
to be best explained by the differences in their mode of
attachment.

1. The upper end of the descending colon lies higher and
is attached to the ribs further to the left and further down
(seitlicher und tiefer) than the ascending colon. Whereas.
the ascending colon lies against the middle of the right.
kidney, the descending colon lies against the external convex
border of the kidney. Hence it follows that the left kidney,
although placed on the same horizontal level as the right,
is fastened to the posterior abdominal wall both higher up
and more firmly (héher hinauf und stirker) than the right.’

2. The descending colon and the splenic flewure are tauter
(straffer) and shorter in their attachment to the posterior
abdominal wall than the ascending colon and hepatic flexure ;
in other words, the mesocolon of the splenic flexure is shorter
and tauter than that of the hepatic flexure. This indirect.
means of attachment is therefore stronger on the left than
on the right.

3. The ascending colon does not form a right angle with
the transverse colon as the descending colon does, but an obtuse
angle, or even forms a dependent loop before passing into the
transverse colon.

The reason for this peculiar behaviour of the ascending
colon, which I have seen a few times in children, and many
times in adults, and which Sappey has described as normal,
appears to me to be the upward movement of the feces in

1 [This sentence, which is somewhat obscure, seems to mean that the colon
(which by means of its attachments to the posterior abdominal wall on the
one side and to the kidney on the other, is one of the defences of the kidney
against downward displacement) is itself attached to the posterior abdominal
wall higher and more extensively on the left side than on the right.—
TRANSLATOR. |
MOVEABLE KIDNEY IN WOMEN. 279

the ascending colon contrary to the action of gravity, and
only effected by the peristaltic movements of the bowel. By
this means the spot where the ascending becomes the trans-
verse colon is gradually dragged downwards so much as to
form in extreme cases a fairly long loop, though it usually
passes obliquely or with a curve into the transverse colon.

But during the passage of the feeces from the transverse
into the descending colon, the weight of the column of feces
and peristaltic action work in the same direction, no stagna-
tion takes place in the splenic flexure, which maintains its
original form. This difference between the hepatic and
splenic flexures explains also in its turn how the right kidney
has more room to descend than the left.’

4. The descent of the left kidney is opposed by the position
of its vessels above the inferior or horizontal part of the duode-
num. Moreover, the position of the aorta on the left side
of the spinal column makes the left renal artery shorter than
the right ; this shorter attachment by means of the renal
artery (which is naturally considered in this capacity before

1 [This explanation seems highly questionable. In the first place it
belongs to the category of “ fecal theories” which are pressed into service
on very small provocation, and have, generally speaking, no positive evidence
in their favour. Among the unsymmetrical conditions which they have been
called in to explain may be mentioned varicocele (left), uterine obliquity and
torsion (to the right), and torsion of ovarian tumours, which this is no place
to discuss ; but with regard to the question now before us the following
objections may be urged :

a. It is probable that the question of ascent or descent of the fecal
column has very little to do with it. Take a familiar instance—a monkey
climbing up a rope and then down it, the rope being connected with a spring
weighing machine; how much difference in tension will there be? The
only point of difference, addition or deduction, in the case of the colon will
be the rate of movement of the fecal column. How fast is that P

b. If this explanation were correct we ought constantly to find the
ascending loops of intestine full, and the descending empty, or at least one
fuller than the other. Where is this evidence P

c. This explanation assumes a permanently perpendicular position. This
ceases for about one third of each day at least. Again, here we ought to
have evidence of a difference between the position of faeces in bed-ridden and
other people. Where is this evidence? Is it not, on the contrary rather,
these very bed-ridden people who are predisposed to moveable kidney P

In the absence of direct proof, and in the face of the above considerations,
we think this explanation ought not to be entertained.—Transzaror. |
280 MOVEABLE KIDNEY IN WOMEN.

the thin-walled vein) renders the mobility of the left kidney
the more restricted. Less stress must be laid on the circum-
stance pointed out by Ocrum-Howitz, that the lef suprarenal
vein opens into the renal vein, while the right suprarenal
vein opens directly into the vena cava, the left kidney (as
opposed to the right) having thus an additional indirect
connection with its suprarenal body (see Figs. 1 and 2).

5. The left renal vessels are closely connected by cellular
tissue with the head and neck of the pancreas, which thus
furnishes an additional attachment to the left kidney, of which
the right is destitute ; for the right renal vessels lie bare,
except for their peritoneal covering (see Figs. 1 and 2).’

These reasons seem to me to explain sufficiently why
descent of the left kidney, though not impossible, is consid-
erably rarer, other things being equal, than that of the right.

The direction in which the kidney is permitted to move is
prescribed by the normal attachments and normal position
of the kidney, and is nearly constant. Since the insertion of
its vessels (t.e. the aorta and vena cava at the level of the
first lumbar vertebra) is a fixed point, it follows (presuming
the most favourable conditions for mobility, namely the
complete separation of the renal vessels from the posterior
abdominal wall) that the right kidney is capable of moving

1 Conf. H. Zuckerkandl, “Beitriige zur Anatomie des menschlichen
Korpers.” ‘Wiener. med. Jahrb.,’ 1883, 8. 58; ‘ Centralblatt med. Wiss.,”
25 Aug., 1883, S. 611.

If, after removal of the capsula adiposa, the right kidney is raised from
the posterior abdominal wall, a membrane composed of connective tissue and
varying in thickness is seen, which passes into the parietal peritoneum at
the borders of the kidney and suprarenal body. This fascia is entirely
unconnected with the aponeurosis which covers the anterior surface of the
quadratus lumborum. Thus, the right kidney is enclosed in a capsule
(besides the capsula adiposa and fibrosa), the anterior wall of which is formed
by the peritoneum, and the posterior wall by this post-renal fascia. In the
case of the left kidney the colon runs along its side and not in front of it,
as it does on the right side. Thus, the front of the capsula adiposa of the
left kidney is covered not only by the parietal peritoneum, but also by the
descending mesocolon, and these are joined together. This, however, applies
only to the portion of the left kidney which lies beneath the transverse
mesocolon, while above this the pancreas lies. The left kidney thus appears
decidedly more firmly fixed than the right, and this is perhaps the reason
why the right kidney is oftener moveable than the left.—[TRansiaror. |
MOVEABLE KIDNEY IN WOMEN. 281

within the segment of a sphere of which the centre will be
the entrance of the right renal vein into the vena cava infe-
rior, and the left within the segment of a sphere of which
the centre will be the origin of the left renal artery from
the aorta. Hence, it follows that the presumption of some
authors, among whom is Sappey, that a moveable kidney
moves vertically downwards towards the corresponding iliac
fossa, is not correct. It is much nearer the fact that it can
only move downwards, forwards, and inwards; its move-
ment upwards and outwards being impossible on account of
the presence of the spleen, liver and diaphragm, not to
mention other reasons.

The degree of its mobility depends not only on that of the
relaxation of its capsule and vessels from the posterior ab-
dominal wall, but also from the resistance of the organs
lying below it, the amount of the pressure of the abdominal
walls, and the weight of the kidneys.

Again, the kidney, as it descends, never maintains its orig-
inal relation to external dimensions (wird sich . . niemals
sich selbst parallel nach unten bewegen), but is compelled
to rotate, as it descends, on one or more of its awzes, by virtue
of the obliquity of the planes over which it glides, as well
as by changes in the attitude of the body. The more it
descends, the more transversely will rotation round its
centre cause its long axis to lie; the farther forward it ad-
vances, the more will its outer border and its upper end look
forwards.

The deepest possible position. of the kidney is determined
by the length of its vessels, which, together with the ureter,
suffer manifold torsions and kinks during the displacement
of the kidney, varying according to its depression and rota-
tion round its axes, as indeed might have been assumed
a priori. :

VII. Symproms.
The opinions of authors as to the clinical consequences of

moveable kidney are very various. Rosenstein observes :
“More important than congenitally displaced kidney is
282 MOVEABLE KIDNEY IN WOMEN.

moveable kidney, although it properly possesses rather a
negative than a positive interest, so that a knowledge of the
facts in point is more important as a means of avoiding
errors in diagnosis than on its own account, since the affection
itself causes no great inconvenience, and treatment is power-
less to relieve it.”

This view is adopted by most of the handbooks and text-
books, while Keppler, on the contrary, regards even uncom-
plicated moveable kidney as a deadly disease, which should
be extirpated whenever it gives rise to symptoms.

It is therefore most important, considering such opposite
opinions, to obtain clear views of the symptoms and conse-
quences of moveable kidney.

It is evident from the study of its pathogenesis that ac-
quired moveable kidney is but very rarely to be described as
the primary lesion. We often find with it maladies, which
have either arisen from similar causes to those which pro-
duced the moveable kidney itself, or have themselves produced
the moveable kidney. Moreover, the degree of mobility
and the anatomical consequences of moveable kidney, as well
as individual susceptibility, are different in different persons,
so that moveable kidney calls up no idea of a typical disease
but rather the idea of a disease of many various forms. It
is, therefore, more necessary to individualise with regard to
this than with regard to almost any other complaint.

It is rare for a moveable kidney to leave the patient quite
unaware of its presence. This is most likely to happen in
the case of persons who are otherwise very healthy, and who,
as we know, sometimes feel no inconvenience from other
displacements, such as those of the womb, or from ruptures ;
or it may happen in those who are very ill, as for instance in
consumptive patients, in whom the symptoms of moveable
kidney are'obliterated by the principal complaint.

Generally, however, moveable kidney exercises an injurious
moral and physical effect on the patient in its capacity as a
foreign body, by dragging and compression of nerve-trunks,
vessels and viscera, and by functional disturbances.
MOVEABLE KIDNEY IN WOMEN. 283

Symptoms arising from the Nervous System.

Patients who are the subjects of moveable kidney are
usually affected with hypochondriasis, especially if they dis-
cover a tumour in their abdomen by accident, and this frame
of mind increases if the malady is diagnosed as a malignant
growth by the doctor, or if, in spite of a contrary opinion on
his part, the patient takes it for one. This unfortunate
humour finds tangible pabulum if the patient feels pains in
the abdomen, whether due to the tumour or other causes,.
and often grows so much on her that she readily decides of
her own accord to have the moveable kidney removed. This:
condition, which is seldom found even in the case of malig-
nant tumours, can easily be explained when one considers
that these patients are reminded by a moveable kidney
more than by any other tumour—at every step, on dressing
and undressing, even on turning in bed—of the presence of
an apparently serious malady ; and in this view they are often
confirmed by doctors. :

Some patients complain of a feeling of pressure and weight,
of dragging and drawing in the lower abdomen, they feel
* as if something had been unhooked in their belly.”? Others
feel beating, or a more circumscribed gnawing griping pain
in the region of the navel. These unpleasant sensations are
compared by women who have had children to foetal move-
ments, and they sometimes think themselves pregnant, espe-
cially if they wish to be so. Among other characteristic
expressions may be mentioned the feeling asif one of their sides:
was dropping off, or as if something was turning round in their:
belly. Often, but wrongly, these complaints are regarded as
hysterical. No doubt among the women who have moveable
kidney some are hysterical, but we should not agree with
Chroback (who in nineteen cases saw hysteria eight times) or
with Lancereawe (who saw it in cases of moveable kidney
four times), in considering the moveable kidney as the cause
of the hysteria. It is intelligible that the imagination of an
hysterical patient will be unusually excited by the presence
of a moveable tumour in the abdomen, but the painful and
unpleasant sensations caused by moveable kidney ought not
284 MOVEABLE KIDNEY IN WOMEN.

to be regarded as hysterical, inasmuch as we find them of
the same kind and intensity in women who are not hysterical,
and in men. One sign that these painful sensations are not
hysterical is that they are increased by sudden movements or
great bodily exertions, but in the recumbent position and
during rest they disappear.

Besides these vague, insufficiently localised sensations of
pain, one not uncommonly observes circumscribed neuralgias
in remote spots, arising reflexly through dragging on the
nervous plexuses and ganglia which plentifully surround the
kidney. Now the capsule of the kidney normally lies upon
the two last branches of the lumbar plexus, and is surrounded
by a rich network of sympathetic ganglia. Thus we often
find pains down the front of the leg as far as the knee, between
the ribs, in the loin, and in the abdomen. Sometimes these
radiate as they do in liver affections to the scapula, some-
times along the ureter as far as the labia majora. These
neuralgias are usually confined to the affected side, more
rarely they are transferred to the opposite side. Gueneau
de Mussy observed intercostal neuralgia of the left side in a
moveable kidney of the right side; and among my observa-
tions are two in which there was lumbar and intercostal
neuralgia on the left side, the right kidney being moveable.
On pressing firmly against the kidney, which is easily mani-
pulated, both patients alike complain of circumscribed pain in
the region of the opposite kidney.'

Menstruation produces increase of pain and impairment of
the general comfort. We then observe the same phenomena
as those described by Matthews Duncan under the name of
aching kidney, these complaints consisting essentially of dull
pain in the region of the kidney radiating thence into the
bladder and sacrum. As a matter of fact this pain can
almost constantly be found in women with moveable kidney
at the menstrual period, even when they are free from it
betweenwhiles. Whether it is induced more by menstrua-
tion or by the moveable kidney cannot now be decided. The
fact, however, that it sometimes quite ceases after menstrua-
tion and after the menopause, proves the existence of

} [The same transference is sometimes observed in the case of the ovaty.—
TRANSLATOR. |
MOVEABLE KIDNEY IN WOMEN. 285

vasomotor connection between the generative organs and the
kidney, that is between the ovarian and renal plexuses, as was
supposed by Lancereaue and Fourrier.

It is rare for the pain in the renal region to cease during
menstruation, as it did in some observations by Grout and
Le Ray.

The recumbent position alleviates the diffuse pains as well
as the circumscribed neuralgias, as set forth by Miller (106)
with regard to the lumbar neuralgia which frequently occurs.
with moveable kidney. ,

Symptoms arising from the Great Vessels.

Although the above symptoms arise principally from pres-
sure and traction of the great nerve-trunks and small nerve-
fibres, we sometimes meet with symptoms of pressure by the
kidney on the great vessels, especially the easily compressible
vena cava, with subsequent thrombosis from pressure and
cedema of the corresponding lower limb. A very instructive
case is communicated by Girard (see above, Case 3), only it
is doubtful whether in this case the intestines distended with
gas, or perhaps some adhesions had not pressed the kidney
against the vein. JI have observed one case of moveable
kidney on the right side with subsequent cedema of the right
lower leg, for which no reason could be found except the
pressure of the kidney on the vein. The cedema began to-
disappear as a pregnancy, which had supervened, advanced.

Symptoms arising from the Digestive Tract.

Very many persons affected with moveable kidney suffer
from gastric disturbances, varying from slight epigastric
pains and nausea, to phenomena which sometimes amount to
the well-marked signs of chronic gastric and intestinal
catarrh, jaundice, or even attacks of peritonitis.

These gastric disturbances depend on complaints which
happen to coincide, or they are consequences of causes similar
to those which produce moveable kidney. When, therefore,
diseases accompanied by rapid emaciation, such as enteric or
severe intermittent fever, or rapidly succeeding labours,
286 MOVEABLE KIDNEY IN WOMEN.

prolonged suckling, or generative affections of all sorts have
preceded or still persist, we are hardly justified in calling
moveable kidney the cause of the gastric disturbances. A
primary chronic gastro-intestinal catarrh or a gastric ulcer
may, however, so impair nutrition that these affections may
be justly regarded as furnishing a cause for the mobility of
the kidney, rather than as being themselves caused thereby.
When, therefore, Keppler attributes the disturbances of
nutrition, emaciation, even death to a moveable kidney, it is
necessary for us to be emphatically warned against these
practically injurious exaggerations, as has been done by
Oerum-Howitz with reference to the cases described by
Keppler. The real ill-consequences of moveable kidney,
even in its bearings on the digestive tract, are only obscured
by such performances.

Asa matter of fact moveable kidney may contribute to
gastric disturbances, as might be assumed beforehand from
the nervous and vascular connections between the renal and
other abdominal organs. This connection is completely con-
firmed by clinical observation, imasmuch as persons with
moveable kidney experience epigastric pains and digestive
‘disturbances which are otherwise inexplicable. It is often
possible by pressing on the prolapsed kidney to produce
epigastric pain, nausea, and retching, in these patients, to
reproduce in short exactly the same condition which they
will tell you unasked is that from which they are suffering.

A very plausible theory has lately been suggested by
Bartels, of Kiel, to explain the frequent coincidence of dila-
tation of the stomach and subsequent gastric and intestinal
catarrh with moveable kidney on the right side. According
to this, the right kidney displaced forwards and inwards by
the pressure of tight lacing (as described by Miiller- Warneck
(107) ) compresses the fixed descending portion of the duo-
denum which lies between the hilum of the right kidney and
the vertebral column, and thus produces a mechanical
obstacle to the escape of the chyme from the pylorus, and
dilatation of the stomach with its well known consequences.

Oser (108) has rightly opposed this hypothesis, and espe-
cially on clinical grounds. He thinks it is self-evident that
a moveable tumour which has a tendency to sink either
MOVEABLE KIDNEY IN WOMEN. 287

downwards or backwards as the patient stands or lies, can
hardly exercise such a pressure on the bowel as’ to produce
obstruction while the abdominal walls are lax. In spite of
_the opportunity of observing very many cases of moveable
kidney, he never once found hypertrophied stomach, which
is usually found in cases of stenosis of the pylorus. Finally,
he proved the complete competence of the pylorus by directly
distending the stomach with air, in cases of moveable kidney
in which another method had seemed to prove its incom-
petence, and, therefore, the truth of Bartels’ hypothesis.

On the whole Oser considers the causal connection between
displacement of the kidney and distention of the stomach as
not proven, and only allows the possibility of this connec-
tion in cases in which the displaced kidney is so firmly fixed
in its new position that it is able to compress the duodenum.

The principal objection, however, to Bartels’ assumption is
its inadmissibility on anatomical grounds. The right kidney
even when in tis normal position lies with only its upper half
parallel to the descending portion of the duodenum, as Fig. 1
shows, and, when moveable, lies with its upper end below
the inferior horizontal part of the duodenum, so that the two
organs are actually not in contact. Besides, the specific
gravity of the kidney, which alone can be considered as con-
tributing to real compression (the intra-abdominal pressure
being probably somewhat the same as that of water), is far
too low to exercise such compression, so that a force is still
needed to press the kidney against the gut, and this force is
wanting.

Moreover, since chronic catarrh of the stomach is found
even when the moveable kidney is on the left side, in women
who do not lace, and in men who have moveable kidney, it
is evident that another explanation of general application
must be sought for the connection between gastric disturb-
ances and moveable kidney. Such an explanation seems to
me to be easily found in the fact that the posterior parietal
layer of the peritoneum covers at once the anterior layer of
the capsule and vessels of the kidney and passes over the
duodenum, so that if the kidney becomes displaced forwards,
inwards and downwards, a tendency to dragging and kinking
of the limbs of the duodenum both on the right and left side
288 MOVEABLE KIDNEY IN WOMEN.

must be produced, especially as these limbs, but particularly
the flexure between the duodenum and jejunum, are fixed by
somewhat firm connective tissue to the vertebral column, and
are comparatively unyielding (see Fig. 1). Of course this
kinking should not be represented as permanent, as the
kidney changes its place with various movements of the
body, and in the recumbent position generally returns to its
normal position, thus instantly relieving the dragging pro-
duced through the peritoneum. When, however, this drag-
ging and the consequent obstruction to the calibre of the gut
are frequently repeated as the erect position is assumed, and
when other influences, such as pendulous belly, which acts in
a similar manner, supervene, distention of the stomach and
chronic catarrh of the stomach will not fail to appear.

With respect again to the jaundice which occurs in move-
able kidney, direct compression of the common bile duct by
the right kidney has been cited as the cause of the jaundice
by Litten (109), who observed in Frerichs’ clinique (in the
case of a woman, thirty-seven years of age, suffering from
frequent attacks of pain in the right hypochondrium induced
by a moveable kidney on the right side) a jaundice recurring
twice within two weeks and only lasting a few days. Lvtten,
who was unable to find a similar observation on record, put
aside the idea of gastro-duodenal catarrh and of gall-stones
as a cause for the jaundice, and assumes a temporary com-
pression of the common bile duct.

Stiller (110) had already alluded to the possibility of this
connection, when he replied to the assumption by Bariels of
compression of the duodenum by the moveable kidney, that,
if the descending portion of the duodenum were really com-
pressed by the kidney, this same pressure must produce
jaundice by pressing on the diverticulum Vateri (the common
gall and pancreatic duct) in this situation. This objection,
however, according to Stiller is enfeebled by the anatomical
consideration that the right kidney in becoming moveable
must sink down along the right or outer surface of the duo-
denum, and the compression can hardly be so complete as to
close the orifice of the common bile duct which lies on the
opposite or left surface. Besides (says Stiller) the subject
is at present too novel for us necessarily to accept the
MOVEABLE KIDNEY IN WOMEN. 289

assumption that as cases in point are collected we shall have
to recognise this as an additional cause of jaundice.

Although I have scen jaundice supervene on three occa-
sions in women affected with moveable kidney (in one of
them four times within a short space, lasting on each occasion
a few days), I cannot regard these cases as a clinical proof
of temporary compression of the common bile duct, as this is
impossible for the same reasons as the direct compression of
the duodenum. How, moreover, can we explain an isolated
compression of the common bile duct which opens on the left
side of the duodenum by a moveable and not fixed kidney
on the right side! JI am much more inclined to refer the
frequent appearance and disappearance of the jaundice,
which I also saw in my case, to a temporary occlusion of the
duct by mucus or a gall stone, particularly as this peculiar
appearance and disappearance of jaundice is not a very rare
occurrence even among women who are not the subjects of
moveable kidney, as I have often had occasion to observe.

It is, however, certain that women who have moveable
kidney are more prone than others to jaundice, but only
because they more frequently suffer from gastro-duodenal
catarrh, forthe reasons above enumerated, and because a move-
able kidney not infrequently, contracts adhesions to the gall-
bladder. Thus, in a case observed by me (see below), in
which there was jaundice which persisted several weeks, the
cause for the jaundice appeared to be connected with a firm
adhesion between the moveable kidney and the lower
surface of the liver and gall-bladder (mit dem unteren Leber-
lappen und der Gallenblase).

Still more serious disturbances are said to be produced by
moveable kidney through compression and consequent
obstruction of the colon. ollet relates a case in Oppolzer’s
clinique of a woman, twenty-six years of age, and apparently
consumptive, who had a moveable kidney, and who had
suffered many years previously from small-pox, later from
enteric fever, and in early years had been in the habit of
masturbating. Inasmuch as she in the meantime, up to six
months previously, had suffered (especially after bodily exer-
tion such as dancing) from violent colic, and since her
admission into the hospital had frequently suffered from

19
290 MOVEABLE KIDNEY IN WOMEN.

obstinate constipation often lasting six or seven days, from
frequent colic, swelling of the abdomen, retching, desire to
vomit, and sensitiveness of the abdomen, the following diag-
nosis was made: Intestinal obstruction, caused by pressure
exercised by the kidney on the ascending colon. This case,
however, is so far from proving obstruction of the colon by
the kidney that it ought not to be let loose on literature
without a query, until it is proved by an appropriate autopsy
that the improbable assumption is true, viz. that the colon
can be permanently compressed by a moveable kidney. The
origin of such a compression in adhesions formed by the
moveable kidney is not unlikely. Certain it is, however,
that a moveable kidney is competent to produce (by mechan-
ical injury and dragging on the bowels) colics and dull boring
pains in the abdomen, which are not otherwise easily explic-
able, and which we not infrequently find in patients with
moveable kidney, without any other discoverable cause.

The Symptoms of Renal Incarceration so-called.

Patients with moveable kidney are subject, generally after
violent exertion or rapid movement, to a sudden piercing
pain in the abdomen, which forces them to lie down. Soon
the whole abdomen becomes sensitive and distended, and the
side (especially in the region of the prolapsed. kidney)
becomes painful on palpation. A profound feeling of general
discomfort follows. The patient is weak, giddy, palpation
of the renal region easily makes her faint, a cold sweat
covers the brow, the pulse is small, the respiration superficial.
Sometimes there is a desire to vomit, actual vomiting often
supervenes. The urine is dark and scanty, often coloured
red from the admixture of blood. The attack is not always
ushered in by a rigor, in fact the pyrexia is slight throughout.
The observer detects (as far as the tension, resistance, and
tenderness of the abdominal walls allow him) in the region
of the prolapsed kidney a large tumour, confined to the
corresponding side, over which percussion is impaired, and
which is hardly moveable.

In the course of one or two weeks, however, this tumour
MOVEABLE KIDNEY IN WOMEN. 291

entirely disappears, as aJl observations agree in stating, the
threatening symptoms having reached their acme on the
fourth to the sixth day. One of the first signs of recovery
is the copious excretion of clear urine of low specific gravity.
Dietl, who first directed attention to this hitherto unknown
train of symptoms and gave it the name of renal incarceration,
considers its essence to consist (as in the case of ruptures) in
incarceration of the kidney in the surrounding connective
tissue and peritoneum, with subsequent circumscribed peri-
tonitis with effusion. He is followed by nearly every writer.
Thus Rollet gives the following explanation: ‘In order to
understand the symptoms of renal incarceration we need only
consider the physical processes which must take place when
the kidney (under bodily exertion, violent straining, shock,
or congestive swelling at the menstrual period, &c.) changes
its place and is displaced from its normal position with more
or less force. Apparently it must first make its way within
the connective tissue surrounding it, and in which no vacant
space exists. It is inevitable during this that parts of the
surrounding connective tissue, and even the peritoneum
passing over it, should be dragged and pressed, and the
vascular arrangements disturbed in some manner. In con-
sequence of the irritation and vascular disturbance in the
surrounding connective tissue, produced by changes in the
position of the kidney, the connective tissue becomes the seat
of inflammatory swelling. The kidney is all the more likely
to stick in the narrow meshes of the sub-peritoneal cellular
tissne and to become really incarcerated there, as its retreat
into the normal situation is in a moment cut off. The sym-
ptoms caused by the incarceration of a moveable kidney tally
with this representation of facts. Ifthe incarceration of the
kidney is not reduced early enough, either spontaneously
(by the recumbent posture, observation of strict dict, and
softening fomentations), or artificially by gentle or, if the
diagnosis is quite certain, even powerful pressure on the
kidney in the contrary direction, not only does the cellular
tissue surrounding the kidney become inflamed, but the
inflammation easily spreads to the peritoneum and a more or
less violent circumscribed peritonitis supervenes, with inflam-
mation of the capsule and parenchyma of the kidney.”
292 MOVEABLE KIDNEY IN WOMEN.

Ebstein accepts this view, and considers the clinical sym-
ptoms as produced by the production of a more or less con-
siderable peritoneal effusion.

According to Gilewski the incarceration of the kidney is
produced by the wedging of the kidney between the last rib
and vertebral column, and by its being held there by the
morbid contractions of the abdominal muscles. In a case
observed by him this mode of incarceration is said to have
been favoured by a curvature of the spine. The kidney thus
incarcerated pressed the ureter against the vertebral column,
produced pyelitis, acute hydronephrosis, and the symptoms
above described.

Ocrum-Howitz accept.this explanation only in part.

To me, neither the character of the acute attacks described
(pointing to the incarceration of the kidney), nor the clinical
symptoms themselves (referred to the supervention of cir-
cumscribed peritonitis, or, according to Gilewski, to acute
hydronephrosis) appear to be correctly explained.

It is a priori unlikely that the kidney should become incar-
cerated in the cellular tissue which is everywhere so yielding,
and especially in the neighbourhood of parts so soft as the
intestines. But granting that it could become wedged for
a moment between the vertebral column and ribs ; the force
to hold it fast in this position would fail, for one cannot
possibly assume with Gilewski a contraction of the abdominal
muscles lasting for days. A wedging of the kidney between
the vertebral column and the anterior surface of the arch of
the rib in the healthy skeleton is, however, impossible,
because its longest diameter is less than the distance between
the parts mentioned. On the supposition of an incarceration
it would be most remarkable that the train of symptoms
under discussion should, so far as at present observed, in-
variably end in recovery without any active treatment, and it
is not apparent how an incarcerated kidney could free itself
from its incarceration without external interference. Finally,
the incarceratidn of a kidney would certainly be a far more
frequent occurrence than it actually is, considering that drag-
ging of the cellular tissue and peritoneum takes place in
every case of moveable kidney.
MOVEABLE KIDNEY IN WOMEN. 293

Taking the analogy of a strangulated' hernia the symptoms
consequent on incarceration of the kidney have been explained
in this bearing also by the supposition of a circumscribed
peritonitis. This idea has been strengthened by the resem-
blance of the clinical symptoms to those of circumscribed
peritonitis due to other causes, such as perimetritis and peri-
typhilitis, by the supervention of great distention, which was
taken for effusion, and finally by the fact now and then
observed that during and after an attack the mobility of the
kidney is restricted.

The invariably favourable course, however, of this supposed
peritonitis with effusion, as well as the circumstance that the
effusion, which is sometimes “ enormous,” disappears in from
six to eight days, cannot fail to throw doubt on the correct-
ness of this explanation. Besides, the peculiar outline of
impaired resonance which is found diffused around the move-
able kidney, does not admit of easy explanation on the assump-
tion of circumscribed peritonitis.

The opinion of Gilewski that acute hydronephrosis produced
by incarceration of the kidney constitutes the essence of the
process under discussion, appears again unlikely, inasmuch
as the weight of a normal kidney is far too small to be able
to overcome by its pressure the pressure under which the
urine is secreted into the ureter ; besides an acute hydrone-
phrosis is not competent to distend the pelvis of. the kidney
to the size found in those cases, and, moreover, it does not,
as we know from numerous experiments, produce the sym-
ptoms we have named. A dog whose ureter has been tied,
secretes, as Cohnhetm (111) says (when the operation is not
followed by inflammation, the general health remains unim-
paired and the same food is taken), the same quantity of
urine and that of the same specific gravity as before. And
this not only in the first days and weeks after the operation,
but also later, when the occluded kidney is attacked by

1 [Great difficulty has been felt in deciding between “strangulation ”
and “incarceration ” as the equivalent of ‘ Hinklemmung ;” but the latter
word has been chosen, as tallying best with the facts, as a word used synony-
mously with Einklemmung frequently in the text, especially in connection
with the name of Dietl, the author of the term. But, in the present passage,
the reference is obviously to the general class of Strangulated Hernia.—

TRANSLATOR. |
.
294, MOVEABLE KIDNEY IN WOMEN.

hydronephrotic atrophy, becomes anzemic and ceases to secrete.
But in the case of moveable kidney we see from the com-
mencement disturbances in the secretion of the urine,
amounting even to hematuria. In a woman, the subject of
an uretero-vaginal fistula (112), moreover, I produced an
unilateral hydronephrosis by the use of the probe, but this
was not followed by the symptoms enumerated above. In
unilateral hydronephrosis again produced unintentionally by
sewing up the ureter in the course of the operation for vesico-
vaginal fistula, I have seen symptoms develope which were
essentially different from those under discussion.

We must, therefore, look out for another explanation of
the production and of the clinical symptoms accompanying
so-called renal incarceration, and this I find in an intense
local disturbance of circulation in the moveable kidney, caused
by twisting or kinking or acute angular insertion of the renal
vessels, especially the vein, in consequence of the change of
position and rotation of the kidney.

Although the authority of Cohnheim (113) (who thinks that
renal obstructions due to local obstacles to the return of blood
in the renal veins play hardly any part in pathology) is
opposed to this supposition, its correctness seems to me to be
supported by a series of important reasons.

We have already discussed the relation of the renal vessels
and ureter during descent and rotation of the kidney, a rela-
tion which is of great importance for the train of symptoms
before us. We have also already found the acute angular
course and torsion of the renal vessels established by some
autopsies. In order, however, to bring these relations more
prominently into view I have got some preparations of
kidneys made artificially moveable in the dead subject drawn,
these preparations showing some kinds of twisting and kink-
ing of the vessels (see Figs. 4 and 53).

But my hypothesis is supported by experiment and by
observation of the clinical changes even more strongly than
by these drawings.

1 T have to thank Dr. Guttmann, Director of the State Hospital at Moabit
for furnishing me with a subject, and Dr. Smidé for help in preparing the
dissections. Figures 4 to 8 are drawn after nature by Herr Grohmann.—
AUTHOR.
MOVEABLE KIDNEY IN WOMEN. 295

 

a. Left kidney. 5. Ureter.
2. Right kidney. 6. Abdominal aorta.
3. Left renal vein kinked and twisted. 7. Vena cava inferior.

4. Right renal vein compressed.

There are, perhaps, few pathological processes which have
been so accurately investigated as the coarser disturbances
of circulation in the renal vein. Max Hermann and Ludwig
(114) found that after tying the renal vein the tubuli uriniferi
became completely closed in consequence of the obstruction
to the return of the blood, so that the secretion of urine
ceased. If the renal vein became pervious again, the secre-
tion of urine became quickly reestablished. Litten and
Buchwald (115) who completely tied the renal vein, saw the
kidney very quickly swell up, as the following example shows.
Even within four hours of the ligature of the vein, the weight
296 MOVEABLE KIDNEY IN WOMEN.

E1G...5-

   
 

beereriaeeas( Oy
I

1. Left kidney. 7. Right renal vein twisted and
2. Right kidney. kinked.

3. Left renal vein. 8. The ureter bent round and
4. Left renal artery. wrongly inserted.

5. Left ureter. g. Abdominal aorta.

6. Right renal artery. to. Vena cava inferior.

and measurements of the two kidneys bore the following pro-
portions to each other:

Rabbit's Kidney.

Side not ligatured. Side ligatured.
Weight . . 4°7 grammes. 6°7 grammes.
Length . . 2°g centimetres. 3°2 centimetres.
Breadth . 3) TY 5 15 -
Thickness . 15 4 1°6 35

Breadth of cortex 0°25 5 03 ”
MOVEABLE KIDNEY IN WOMEN. 297

No inflammatory processes were remarked. The ligatured
kidney usually became rapidly smaller after the sixth day,
and very soon returned to its former size. In some cases
the ligatured kidney became atrophied after some weeks.

Cohnheim (116) observes that when the renal vein is tied,
the kidney swéils up so rapidly from obstruction to the
return of blood and from the supervention of cedema, that
in-less than an hour it may be twice as heavy and big as the
other.

Just as in the experiment, we find clinically in human
beings a sudden onset of the symptoms of incarceration so-
called ; in them also there developes in a very short time a
tumour sometimes twice as large as the kidney itself, undis-
tinguishable by the most accurate palpation from the kidney,
and generally disappearing without leaving a trace in six or
eight days.

Again, the symptoms furnished by the secretion of urine
tally with those in the experiment; in men as well as in
animals under experiment at the beginning of the attack a
dark urine, sometimes containing blood, and scanty for the
first few days, is secreted, which does not become replaced
by a profuse clear watery urine till recovery has set in.
Inasmuch as the function of the affected kidney is naturally
impaired when the renal vein is obstructed, or even as soon
as its calibre is narrowed (as Robinson (117), Perls and
Weissgerber (118) found), the quantity of urine of course
diminishes at once. The subjective symptoms are likewise
very easily explained by this hypothesis, since, when one
kidney suddenly ceases to act the other does not at once
supply its function, so that for a short time slight symptoms
of ureemia are produced.

The favourable issue lastly tells in favour of my ‘hypothesis ;
for in animals, even after complete ligature of the renal vein,
we see the kidney recover its function completely by means’
of the establishment of a collateral circulation, to which the -
vasa aberrantia which are often present, and the veins of
the capsule of the kidney and of the supra-renal bodies con-
tribute.

It is difficult in an individual case to decide from the
gravity of the symptoms, whether we have to deal with
298 MOVEABLE KIDNEY IN WOMEN.

complete obstruction of the vein with subsequent thrombosis,
or kinking, or only considerable narrowing by twisting.
If the patient immediately assumes a quiet horizontal posture,
we have at once the most favourable conditions for the
organisation of a thrombus, or the untwisting of a twist, or
the straightening of a kink in the vein.

Finally, my hypothesis explains certain processes, the
causes of which have been hitherto obscure. Among these
I count the atrophy of the moveable kidney comparatively
often found post-mortem, which has been observed by Litien
and Buchwald after ligature of the renal vein in animals,
especially when a delay or imperfection in the reestablishment
of the collateral circulation has suspended the function of the
whole or of certain parts of the kidney. Similarly it is probable
that the colloid degeneration of the epithelium, observed by
these authors, and due to the same causes, stands in intimate
relation to the discovery of colloid material in the cyst of a
hydronephrosis, in which, also through pressure, the function
of the kidney has been considerably impaired.

But it is certain that the perinephritic and paranephritic
abscesses of moveable kidneys mentioned by Jtiolan himself,
and finally the so-called putrefaction or formation of abscesses
in the kidney itself, are best explained by thrombosis of the
renal vein. A thrombus in a larger or smaller branch of
the renal vein remains of course harmless provided it is not
infectious and the kidney is healthy. But if these conditions
necessary for the harmlessness of a thrombus are absent,
especially if there is pyelitis, or if the collateral circulation
leading to recovery does not become properly established,
abscesses in or near the kidney, or even peritonitis and
pyemia easily supervene. |

We cannot be surprised that obstruction of the renal vein,
producing cedema of the kidney, &c., will cause dragging on
the peritoneal investment of the capsule, and secondarily pro-
duce pain like that of peritonitis, as in twisted ovarian pedicle.
In the next place slight adhesions between the kidney and
neighbouring organs may form ; but the essential part of the
process is produced neither by incarceration of the kidney
nor by circumscribed peritonitis. Moreover, these adhesions
are often produced by the samo chronic process as affects
MOVEABLE KIDNEY IN WOMEN. 299

tumours of the ovaries and uterus, and without symptoms
of inflammation; the process consisting in friction of the
peritoneal surfaces, abrasion of the epithelium, and subsequent
adhesion of the abraded surfaces, so that the presence of the
adhesions does not always indicate ‘previous inflammatory
changes.

It would perhaps seem strange, on the above hypothesis
explaining the origin of the symptoms of incarceration, that
these symptoms are not more frequently observed. This would
certainly happen often, if there were not other causes to
prevent the danger of frequently occurring complete or long
persistent occlusion or narrowing of the renal vein. These
causes receive additional support from the fortunate circum-
stance, that the renal artery and vein are not equally long,
owing to the difference between the course of the aorta and
vena cava inferior, so that spiral twisting of both vessels in
their whole extent (like that for instance in the umbilical
cord) is here rendered impossible.

We must further remember that the part of the right renal
artery between the aorta and the right border of the vena
cava inferior, and the part of the left renal vein between the
vena cava and the left border of the aorta (see Fig. 2) are
very firmly fixed by connective tissue to the main trunks,
4.e. to the vertebral column, and are therefore protected
against kinks in part of their course, though a comparatively
small part. But it is just here that a series of small veins
from the capsule of the kidney, and on the left side from
the suprarenal body open, and these effect a collateral cir-
culation easily and quickly, if the circulation in the renal
veins becomes obstructed. This end is favoured by the
double renal vein found especially on the right side, the
frequency of which was pointed out even by Riolan and Haller
(1 19). It must also be remembered that if the renal vein
is kinked or twisted, the renal artery, although provided
with very thick walls and a large calibre, will be narrowed
at the same time, so that the diminished supply of blood will
slightly alleviate the excessive engorgement of the renal
vein.

Finally, however, quiet horizontal decubitus, and a return
of the kidney to its normal position will very often relieve
300 MOVEABLE KIDNEY IN WOMEN.

the disturbance of the renal circulation under discussion,
before the supervention of thrombosis or long persistent
kinking of the renal vein.

All these causes explain the reason why, in spite of the
probability that kinks and twists often occur in the vessels
of a moveable kidney, it is rare for disturbances of the cir-
culation to persist long and produce the symptoms of incar-
ceration so-called, and it is also rare for narrowing or occlu-
‘sion of the renal vein to arise. Decisive post-mortem proofs
are hardly to be expected, since even the ligature of a renal
vein never of itself causes death, and on the other hand if
fatal complications occur, the vascular changes will be
obliterated.

Symptoms arising from the Secretion and Excretion of the
Urine.

It is denied by almost all writers that moveable kidney
produces any effect on the secretion and excretion of the
urine. Rosenstein (120) especially insists on the absence of
all symptoms of diuresis. Henoch (121) lays stress on the
healthy nature of the urinary secretion established by
Oppolzer himself, only one of whose patients complained of
frequent desire to pass water when in the erect position,
which Henoch thought might have depended on other causes.
Trousseau (122) observes: “ Quant a la sécrétion urinaire, elle
n’est en aucune facon influencée, il en est ainsi de la miction.”
On the other hand I have frequently observed disturb-
ances in the secretion and excretion of the urine in patients
with moveable kidney, and believe that they play an essen-
tial part in the pathology of this disease. These disturb-
ances are shown not so much in colicky pains radiating from
the renal region along to the bladder, as in alterations in the
quality and quantity of the urine, which is sometimes scanty,
high coloured and depositing a copious sediment, at other
times becoming more copious and profuse than normal.
Heematuria is also seen in cases of moveable kidney, a
phenomenon which in the absence of every other cause must
be considered to depend on the moveable kidney. A par-
ticularly striking case of this kind has been recorded by
MOVEABLE KIDNEY IN WOMEN. 308

Ehrle (123) in Niemeyer’s clinique, who, without any cogent
reason, assumed a stone in the kidney as thé cause of the
hematuria. In the same way Rollet (124) mentions a case-
of left-sided displacement of the kidney in Oppolzer’s clinique,
in which the urine was passed with pain and contained blood.
I myself have frequently been able to prove the presence of
blood in the urine, especially when the patients complained.
of considerable pain in the region of the kidney. But we-
have already become acquainted with the most intense form
of disturbance in the secretion of urine, in the form of sup-
pression caused by venous engorgement, when considering
the symptoms of renal incarceration so-called.

If we recall the kinks and twists of the renal vessels,
especially the vein, which inevitably follow displacement and
rotation of the moveable kidney, we shall be compelled to:
regard the symptoms described as also dependent on local
disturbances of circulation, and to a certain extent as the
first, and certainly often very transitory, stage of renal in-
carceration so-called. It will depend on the duration and
degree of interruption to the circulation in the renal vein,
whether in any individual case we have to deal with a sup-
pression of urine of short duration, or a more or less copious.
discharge of red-blood corpuscles, or finally with regular
hematuria or epithelial denudation, and subsequent pyelitis.
The instructive experiments of Perls and Weissgerber and of
Robinson! already mentioned, who found exactly the same
changes as those above-named in the secretion and excretion
of urine in the animals under experiment, point in the same
direction, namely, that here an obstruction to the circulation
in the renal vein takes place. In the same way frequent
impediment as well as total obstruction to the circulation in
the renal vein is capable of producing atrophy of the kidney.
Whether such local disturbances in the circulation may also
lead to parenchymatous nephritis, as Frerichs (125) and Leudet
(126) imagine, must remain an open question.

By far the most important disturbances however take
place with reference to the excretion of the urine. We have
already seen that this is disordered even by local disturbance
of circulation in the vessels, and this is confirmed by

1 [ Robertson” in the text. But see p. 297,—TRansLator. ]
302 MOVEABLE KIDNEY IN WOMEN.

Fia. 6.

 

a. Right kidney, twisted on its hori- 4. Right ureter, kinked and twisted.
zontal axis, and with its outer 5. Abdominal aorta.

border looking downwards. 6. Vena cava inferior.
2. Right renal artery. ;. Left kidney in its normal situa-
3. Right renal vein. tion.

numerous experiments involving the ligature and artificial
narrowing of the renal vein. In this relation however the
disturbance of the circulation, even when it occurs more or
less contemporaneously with the disturbance of the circulation,
is secondary, and caused by the alteration in the secretion.
But I must affirm, contrary to the general opinion, that the
secretion of the urine especially, may be primarily suppressed.
by narrowing or occlusion of the ureter.

As soon as the kidney descends, the origin of the ureter,
which is normally placed at the lowest point of the renal
pelvis, and therefore at the point most favourable for the
MOVEABLE KIDNEY IN WOMEN. 303

 

The last dissection (Fig. 6) seen in profile. References the same as to Fig. 6.

escape of the urine, moves to a higher position, and, if the
kidney is very low down, to the very highest point of the
pelvis. But as the kidney rotates (as it usually does) the
ureter will also become twisted on its axis. In the former
case kinking of the ureter results, in the latter torsion, in
either case obstruction to the flow of urine must result.

Here, as in the case of the renal vessels, I have endeavoured
to render the torsion, kinking and bending of the ureter
intelligible by the help of drawings. Figs. 6 and 7, in which
the ureter is bent and twisted, represent the same dissection
from two different views; Fig. 6 from the front, Fig. 7 in
profile. The very perceptible upward bend of the ureter,
which we have already seen in Fig. 5, is repeated in Fig. 8
below. If this is compared with Mosler’s post-mortem account,
(see above p. 258) the resemblance between the course of the
ureter as there described and as here drawn, cannot fail to
be seen.

It is in fact probable that the colicky pains often observed in
patients with moveable kidney depend on temporary obstruc-
tions and occlusions of the ureter, and the simultaneous local
disturbances in the circulation. The suppression of urine is
however usually soon relieved, inasmuch as the loosening of
the capsule of the kidney from the posterior abdominal wall,
304 MOVEABLE KIDNEY IN WOMEN.

which we find in cases of moveable kidney, allows the pelvis
of the kidney and upper part of the ureter to gradually
separate itself from the posterior abdominal wall also, and
follow the kidney in its movements. In this way an obstacle
to the escape of the urine arising from the abnormal course
of the ureter is more easily overcome by the pressure of the
retained urine than when the ureter remains kinked and not
moveable. To this must also be added that the pain caused
by the retention soon obliges a patient to lie flat down, and
that in this position the kidney returns to its normal position
and the-kinked or twisted ureter at once rights and untwists
itself.

If however, under the influence of severe or prolonged
bodily labour, especially in the erect posture, or in con-
sequence of extreme descent and rotation of the kidney, the
obstruction to the escape of urine becomes more frequently
repeated, and increases in intensity, the continual change
between tense repletion and complete evacuation of the
pelvis of the kidney must result by degrees in its diminished
elasticity and increased distension, and finally in the condition
described by Cohnheim as the consequence of so-called kink-
ing and improper insertion (and, I would add, torsion) of the
ureter—that is, in hydronephrosis. According to his clear
description, when, for instance, the ureter is inserted into
the kidney opposite the upper part of the pelvis, in the erect
posture the urine cannot overflow into (? out of) the pelvis of
the kidney until the pelvis of the kidney is full to that point.
“The pelvis of the kidney is enclosed by a yielding and
expansible wall, which gradually dilates under the pressure
of the urine collecting within it, until the sac reaches such a
size as to be capable, on its part, when full, of completely
compressing the ureter, which lies immediately in contact
with it. But only in the erect position! For as soon as
the owner of this kidney lies down, as for instance during
sleep, the urine flows away continuously, and without any
obstacle, out of the sac into the bladder. In the case of
kinks, on the other hand, the change is produced by the
segment of the ureter situated above the kink, rising some-
what as the distension becomes greater, in such a way that
the point of bending comes rather to resemble the point
MOVEABLE KIDNEY IN WOMEN. 305

Fra. 8.

 

: . Right kidney.

. Right renal artery kinked.

. Right renal vein.

. Right ureter bent, and inserted into the highest
point of the pelvis of the kidney.

5. Abdominal aorta.

6. Vena cava inferior.

7. Left kidney in its normal situation.

PWN

where a funnel passes into its neck. But as soon as the
greater part of the urine has escaped, the ureter becomes
kinked again at the old spot. But even in the case of
simple narrowing, however little the obstacle itself changes,
there is by no means always the same impediment to the
secretion of urine. Suppose a case in which a considerable
obstacle arises suddenly during a period of plentiful secretion,
a moment will be reached (not, indeed, so rapidly as in
complete obstruction, but in a relatively short time) in which

the disorder of relation between secretion and escape will
20
306 MOVEABLE KIDNEY IN WOMEN.

result in so great a repletion and distension of the pelvis
of the kidney and proximal segment of the ureter, that
absolutely no urine will be able to issue from the kidney
into the pelvis. But the pelvis of the kidney soon relieves
itself of its excessive contents, which escape through the
narrowed spot, partly by simple gravitation, partly by the
powerful aid of the peristaltic movements of the ureter,
which are abnormally excited by the obstacle, and then the
process may begin again.”

The reason why the largest specimens of hydronephrosis
are produced by an obstruction in the ureter, which is not
permanent but alternates with periods of patency, is to be
found, according to Cohnheim (127), in the state of the urine
after removal of the unusual resistance. ‘* No sooner is the
obstacle which prevents the escape of the urine secreted
removed, no sooner are the glomeruli relieved of the pressure
upon them, than a copious secretion of limpid urine of low
specific gravity begins. It is just for this reason that, in the
case of men with abnormal insertion of the ureter, as long
as they are recumbent, so great a quantity of urine is secreted
into the bladder, and is then excreted therefrom; when
however the passage to the bladder is not completely patent.
(as happens in the same persons when they stand or walk,
and as happens in narrowing of the ureter) the profuse
secretion fills and over-distends the pelvis of the kidney and
the ureter with greater and greater quantities of urine. And
because the secretion of urine never ceases as long as any
escape from the distended renal pelvis is possible, years and
tens of years may pass in the same process, though of course
not without a very considerable expansion of the parts
affected”? *

1 The same kind of “hysterical” urine is secreted under a variety of cir-
cumstances, including any retention in the bladder sufficient to raise the
pressure in the ureters. A familiar instance is furnished by the frequently-
observed phenomena of Retroversion of the Gravid Womb, the prominent.
symptom of which is retention of urine. The urinary symptoms do not.
cease with the evacuation of the bladder, nor with the simultaneous reduction
of the incarcerated uterus, but a “ copious secretion of limpid urine of low
specific gravity ” continues for some time, and often for some days, the-
quantity being enormous. The same set of facts is discussed in a paper
alluded to in a previous note (Champneys, ‘St. Bartholomew’s Hospital.
MOVEABLE KIDNEY IN WOMEN. 807

Although however, no further demonstration is needed
to prove the impossibility of so marked an alternation between
tense repletion and complete evacuation of the pelvis of the
kidney as Cohnheim has assumed in the above exposition ;
the origin of hydronephrosis by means of mobility of the
kidney as assumed by me contradicts this assertion.

So little attention has hitherto been paid to the production
of hydronephrosis by moveable kidney, that Lancereaua,
Trousseaw and others describe it only by the way as an
occasional cause of moveable kidney, and Gilewski only
mentions acute hydronephrosis, and that in an erroneous
connection with the symptoms of incarceration so-called.
The reason of this is that the formation of the hydrone-
phrosis entirely obliterates the primary causes, not only in
their clinical relation, but also in their anatomical appearances
on dissection.

In order therefore to establish my hypothesis, (that
moveable kidney furnishes one of the chief causes of hydro-
nephrosis, and that very many cases whose causes are con-
sidered obscure are nothing else than hydronephroses in
moveable kidneys) not merely upon the above somewhat
theoretical arguments, I shall here give additional proofs
from the pathogenesis of hydronephrosis founded on patho-
logical conditions, experiment, and clinical symptoms.

(1) Proofs derived from the Pathogenesis of Hydronephrosis.

That form of hydronephrosis, in which no cause of com-
pression or obstruction of the ureter is found after death,

was known even to ancient writers.
Schénlein (128) disagrees with the assertion of P. Frank

Reports,’ vol. xvi), treating of the dilatation of the ureters in Extroversion
of the Bladder, the author’s theory being that of obstruction to the flow ‘of
urine by spasm of the vesical orifices of the ureters caused by irritation of
the extroverted bladder. Similar urine is often secreted by children suffer-
ing from incontinence, and is probably due to the same cause. In all these
cases dilatation of the ureters and renal pelves is produced by the same
cause, viz. a considerable but not absolute obstacle to the escape of urine.—

TRANSLATOR.
308 MOVEABLE KIDNEY IN WOMEN.

(that the dropsical kidney arises from mechanical causes,
ene of the ureters being compressed and preventing the
escape of the urine, which is retained in the kidney and
gradually distends it), and expressly remarks that cases are
met with, and indeed are the majority, in which the ureters
are quite patent. ‘ But the conditions of the malady are
still unknown.”

Cruveilhier propounded the following explanation for these
cases, which has also been accepted by Englisch (129): “If
an organic ¢ac or tube has once been expanded and its
tissues overdistended so as to lose some of their elasticity, the
distention of the walls! remains, and the collection becomes
permanent.” In the foetus an obstruction of this kind
may be produced by the adhesion of the contiguous epithelial
layers.

According to Rosenstein the cause of hydronephrosis in the
absence of any discoverable impediment, is in many cases
obscure.

Virchow (130) observes that those cases are the strangest
of all in which extreme hydronephrosis is present, in spite
of patency of the ureter. Virchow has frequently examined
such cases, and has each time found a valvular obstruction
caused by a folding of the wall due to an oblique origin of
the ureter out of the pelvis of the kidney.

Simon (131) has also observed this sort of hydronephrosis,
which according to him most frequently gives occasion to
operative proceedings, and to which, although practically
the most important, but little attention has hitherto been
paid. In two cases examined by him the completely pervious
ureter arose not only at an acute angle from the pelvis of the
kidney, but its upper part even lay in the wall of the pelvis
for a length of seven to ten centimetres, yet not in the proper
wall of the renal pelvis, but between this and its peritoneal
investment. The valvular closure at the renal orifice of the
ureter (ostium pelvicum) was so complete, in spite of the
perviousness of the ureter, that, even when the sac was filled
with water at a considerable pressure, not a drop escaped
from the ureter.

Cohnheim (132) alludes to the abnormal insertion of the

} Wunde, a misprint for Wainde.—TRANsLATOR.
MOVEABLE KIDNEY IN WOMEN. 309

ureter as an important cause of hydronephrosis, when he
says he considers it to be a congenital malformation. The
ureter, instead of rising, as usual, from the lowest point of
the pelvis, rises higher up, so that in the erect position the
urine cannot escape until the pelvis is full up to the level
mentioned. The idea that these were cases in which the
ureters had originally been double, and that one of them had
subsequently become degenerated and disappeared, is excluded
by the fact that where there are two ureters there are also
two pelves, and that these are very rarely amalgamated.
“The reason for the occasional abnormal condition of the
transitional spot between the pelvis and ureter is in fact un-
known, and moreover in a dissection nothing can usually be
ascertained with accuracy, as the distension of the pelvis,
which is never absent under these conditions, and is often
quite enormous, has already completely changed the original
conditions. Moreover, we sometimes meet with quite sharp
kinks in the course of one of the ureters, which must pro-
perly be considered congenital, in the complete absence of
bands of connective tissue caused by adhesions and cicatrices.”’

Although however all writers regard the angular insertion
and valvular closure of the ureter as the cause of the hydro-
nephrosis, which view appears to me to be confirmed by the
examination of the new-born infant, Simon considers hydro-
nephrosis to be the cause of the morbid changes in the course
of the ureter. Owing to some impediment or other, as even
Cruveilhier assumed for the case of the foetus, a hydrone-
phrosis forms, and the ureter, which was not enlarged above
the impediment, becomes displaced at an acute angle at its
pelvic orifice (ostium pelvicum) as the tumour grows larger.
This causes a valvular closure, by which the lower half of
the distended renal pelvis compresses the upper part of the
ureter. Here, therefore, the same mechanism is in operation
as that by which, in the case of diverticula of the alimentary
canal, the part immediately below the diverticulum is kinked
and occluded with a valvular closure. As the distension of
the pelvis of the kidney increases (which can only proceed
horizontally forwards and outwards, the vertebral column
offering an obstacle on the inner side), the substance of the
kidney becomes pressed outwards and backwards together
3ro MOVEABLE KIDNEY IN WOMEN.

with its calices. Through these changes in position, the
upper portion of the ureter, which normally lies on the inner
side, comes to point more forwards and outwards, and comes
to be placed between the anterior internal wall of the dis-
tended renal sac and the peritoneum which invests it.

Englisch similarly gives his opinion against the assumption
of a primary abnormal course of the ureter as a cause of
hydronephrosis.

When, however, Simon, starting from this explanation, goes
on to assert that the ureter, occluded by a stone, or com-
pressed by a parametric cicatrix, or hindered in its evacuation
ef urine by the distension of the bladder, collapses above the
impediment, this hypothesis is actually impossible, for the
result of urinary obstruction is to produce distension above
the point of compression. Thus, the conclusions drawn from
this explanation appear unjustifiable. The origin of hydro-
nephroses of this kind is therefore inexplicable, either from
the artificial explanations of Cruveilhier and Simon, or from
the general hypothesis of the congenital character of the
morbid insertion and valvular occlusion of the ureter.

Moveable kidney, however, appears from the above con-
siderations calculated to produce urinary obstruction and
consequently hydronephrosis, by frequently repeated dis-
placement and twisting and kinking of the ureter. This
view is confirmed by the fact that the majority of hydrone-
phroses of obscure origin are seen in women of considerable
age, and on the right side.

_(2) Proofs derived from Anatomical conditions.

When dealing with the post-mortem appearance in move-
able kidney (see above), we mentioned some cases in which
an abnormal position of the hilum (which sometimes pointed
upwards and sometimes forwards), and of the ureter (which
sometimes ran upwards in a curve above the pelvis of the
kidney) were actually shown. Although hydronephrosis was
not simultaneously present in all these cases, we cannot con-
clude from this circumstance, as Mosler has done, that it
eannot be caused by these abnormalities, but only that it
MOVEABLE KIDNEY IN WOMEN. 311

does not always necessarily result therefrom. In addition
to those given above I have found the following pathologico-
anatomical reports which confirm my hypothesis.

Sandifort (133) reports a case of hydronephrosis in which
the ureter, which was pervious, was twisted on its axis:
“Ren dexter sanus; sinister morbosus. Hic quippe, ex-
pansus insigniter, ultra quinque pollices longus, tres cum
dimidio latus, et pressioni cedens, singularem et pelvis et
totius corporis monstrabat expansionem, vere hydropicam .

Ureter . . superiori in loco quidem parum prominulus,
sed dein contractus et quasi contortus erat, ad vesicam sanam
descendens, et toto hoc in tractu minime expansus, verum
potius contractus, non tamen tantopere, quam superiori in
loco, ubi haec constrictio tanta erat, ut, compresso maxime
rene, non nisi pauce liquoris flavi urinosi prodirent guttule.
Fisso uretere contractus maxime ureter et ferme occlusus
apparuit, ubi ex pelvi originem trahit.”” The ureter was
therefore pervious.'

Haller (134) reports: ‘In a woman who had died of
dropsy, a tumour had grown some years since below the
navel, and was regarded by the surgeon asa rupture. After
death it was found that this lay beneath the peritoneum and
omentum, it was membranous, white, and filled with water,
an ureter arose from it, and traces of renal papillee were found
in it. A remarkable instance of alteration in the position and
structure of the kidney. The other kidney was quite healthy
and lay on the right side.”

The two following cases are still more striking :

Hare (135) found double hydronephrosis in the body of
a woman, 38 years of age, in whom a large tumour
in the left as well as in the right side had occasionally
appeared and disappeared. That on the right side was still
full, the left nearly empty. The only impediment to be
found was that both ureters were twisted on their own axis.
As soon as the ureter was separated from the surrounding
tissues and untwisted, the urine collected on the right side
flowed freely away. Hare regarded the cause of the twisting

as congenital.
P. Wilse (136) saw in a woman agéd 39 (who had had

1 Incorrectly quoted by the author.—TRANsLATOR.
312 MOVEABLE KIDNEY IN WOMEN.

eleven children and had suffered at times from violent
gastric disturbances), a tumour in the left side of the abdo-
men which sometimes disappeared. After death, hydro-
nephrosis of the left kidney was found. The left ureter was
neither obliterated nor occluded by a stone ; on the other
hand it was curved upwards at the point where it sprang
from the pelvis, and thus formed a valve which closed the
orifice of the ureter as soon as a certain collection of urine
took place, but if the accumulation became greater, was
unable to maintain the occlusion. A temporary hydro-
nephrosis was thus produced, which explained the attacks.

The analogy between this and the condition of the ureter
in cases of moveable kidney strikes one at once (see Figs. 5
and 8), but in neither case was it thought of. Besides these,
we find in pictures of hydronephroses the ureter twisted on
its own axis.

(3) Proofs derived from clinical observations. Intermittent
Hydronephrosis.

Cases of Hydronephrosis associated with and caused by
moveable kidney certainly occur oftener than has been
hitherto imagined. Even Simon (137) in 1875 was acquainted
with not a single example of hydronephrotic moveable kidneys,
although his own explanation of the origin of hydronephrosis
from temporary disturbances frequently repeated ought cer-
tainly to have led him to regard moveabie kidney as the
cause in doubtful cases. Since then hydronephroses in
wandering kidneys have been observed with certainty
(namely by operation), by Pernice (138), Ahlfeld (139),
Czerny (140) (two cases), Wagner (141), and Landaw (142).
All these observations concerned women and the right kidney.

The connection between moveable kidney and hydro-
nephrosis is recognised most unmistakeably by a symptom
which must be regarded as quite pathognomonic in the pro-
duction of hydronephrosis by moveable kidney, namely, the
periodical filling and,emptying of the sac of the hydro-
nephrosis. This phenomenon, which attracts our notice
MOVEABLE KIDNEY IN WOMEN. 313

by the frequent appearance and disappearance of a tumour,
and which can be called (as Cole (143) and Morris (144) have
done), intermitting, or temporary, or relapsing hydro-
nephrosis, has been described in moveable kidney by no one
but Hger (145), so far asI can see. I myself have also seen
a case in point (146). The refilling and disappearance of
the hydronephrotic sac could be repeatedly proved. In the
woman especially on whom I operated, the torsion or valvular
closure of the ureter was relieved by changes in posture and
by diminution of the pressure of the hydronephrotic fluid
following moderate aspiration, the escape of the urine be-
coming re-established. Both observations are appended
below.

The reason why intermittent hydronephrosis is so seldom
observed may be that, as long as the alternation between
repletion and evacuation goes on, the hydronephrotic sac has
still a small volume and therefore easily escapes recognition.
But as soon as it becomes larger and more easily palpable,
the valvular closure or the abnormal insertion of the ureter
is generally so firmly established that the hydronephrosis
remains permanent. Thus it happens that intermittent
hydronephrosis in moveable kidney is often overlooked or
otherwise interpreted.

Tulpius (147) is the first to report on this peculiar form
of “ischuria,’”’ which he observed in a patient each time at
full moon. It lasted in his case five days on each occasion,
and only yielded to a venesection. He was unable to explain
this peculiar condition during the life of the patient :' “ Sola
anatome, post obitum instituta, eruit illic feliciter veritatem
in profundum demersam ; et ostendit distincte, qui angusta,
renis sinistri, pelvis, excrevisset in eam amplitudinem, ut
suppleret commode vicem, vesicae urinariae.’ Quae propterea
tam fuit vacua, quam ren repletus.”

Sauvages (148) described this form of retention of urine,
connecting it also with the moon, i.e. with the “ Ischuria
lunatica ‘Tulpii.”

Johnson (149) observed in a woman pregnant for the
eighth time a remarkably changeable condition of the urine,

1 The case is reported under the heading “Ischuria lunatica’” and the
original contains ** uniariae’’—a misprint for “ urinariae.” —TRANSLATOR.
314 MOVEABLE KIDNEY IN WOMEN.

which was either scanty and dark or plentiful and milk-
white; in the first case its excretion was accompanied by
great pain, in the last case it was easily passed. After
delivery a large tumour was noticed on the left side, pro-
jecting four inches above the surface of the abdomen, and
measuring seven or eight inches in diameter. 'The tumour was
tense and smooth over its whole surface ; on gentle palpation
there was distinct fluctuation; pressure on it caused pain.
The diagnosis of an ovarian tumour was made. Soon after
the patient died; the autopsy showed bilateral hydro-
nephrosis.

Schénlein (150) distinguishes two varieties of renal dropsy
(Hydrops renalis). In the first, in which the ureters are per-
vious, the patients pass an enormous quantity of pale greenish
urine, four to six quarts’ or more in the twenty-four hours.
In the second variety, in which the ureter is closed, the urine
passed is scanty, dark, and reddish; the tumour in the
renal region and the sympathetic symptoms are much more
plainly marked in the second than in the first. ‘The dia-
gnosis is very difficult. The disease has not hitherto been
recognised till after death, in several cases it has been taken
for ovarian dropsy.”

Rosenstein (151) quotes a case of supposed hydronephrosis
which, in consequence of the sudden disappearance of the
tumour, he erroneously considers to have been an ovarian
tumour, as he remarks: ‘ In cases where the development of
the tumour is not observed, there will always be sources of error
in diagnosis. The statement of the patient also, of occasional
spontaneous evacuation through the bladder, is well worthy
of consideration, as this is more likely to happen when
an ovarian tumour is adherent to the ureter than in hydro-
nephrosis, where the mechanical occlusion occasioned by the
hydronephrosis is hard to overcome.”

Hillier (152) relates the case of a woman who showed a
tumour in the right side, which occasionally disappeared and
then reappeared. As long as the tumour remained she had
violent pain and the urine was scanty, as soon as it dis-

1 A “ Maass” is a German measure for beer, different in different States.
It seems to be about a pint on an average, but in this place must mean a
larger quantity —TRaNnsLaToR.
MOVEABLE KIDNEY IN WOMEN. 815

appeared the pain went away and the urine became profuse
and turbid.

The similar observations of Hare and Wilse have been
already mentioned above. In the discussion which followed
the relation of a case of intermittent hydronephrosis caused
by cancer of the bladder, by Morris (1 53), altogether three
or four cases of intermittent hydronephrosis were mentioned
by Hare and Smyth, of which I believe, as I also do of
those mentioned before, that they were caused by the same
mechanism as the hydronephroses observed by Eger and me.

(4) Confirmation by experiment.

If the moveable kidney, pelvis, and ureter are represented
by an india-rubber elastic ball loosely fastened on a firm board,
with a thin afferent and efferent tube (154), intermittent
hydronephrosis is easily reproduced under exactly the same
conditions as in the living subject.

(1) If the bag filled with water is lifted up vertically
and bent so that the efferent tube occupies the highest point,
evacuation will not take place until the pressure of the water
overcomes the elasticity of the india-rubber bag. Analogue:
Moveable kidney with the ureter inserted into the highest
point of the pelvis.

(2) If the bag is laid horizontally, evacuation will spon-
taneously take place if the efferent tube is intact.

(3) If the bag is filled in a horizontal position and placed
so that the efferent tube forms an angle with the bag, and
the tube is then twisted ; as the pressure of water increases
in this position, the bag will become more and more elevated
and distended, and no evacuation will take place until the
board on which it lies is considerably tilted to the side,
which will cause the bag to turn on its side and thus untwist
the efferent duct.

(4) If on the contrary the board is made vertical, the
bag if moderately filled in this position will bend towards

‘the efferent duct and form a kink init. It will depend on
the size of the angle and the downward resistance occasioned

s
316 MOVEABLE KIDNEY IN WOMEN.

by the further influx of water into the expanding bag?
whether the bag can rise so as to diminish the angle between
it and the efferent tube. Analogue: Intermittent hydro-
nephrosis caused by the descent of the kidney and axial
rotation of the ureter.

(5) The effect of increased and diminished pressure can
also be easily imitated with this apparatus. As in the
patient, when the bag is filled, evacuation will at one time be
rendered possible by increase, at another by diminution of
pressure, according to the position of the bag.

(6) The causation of hydronephrosis by prolapsus uteri
is illustrated by hanging a weight on the efferent duct. As
the weight is increased the walls of the efferent duct toa
greater or less height above the weight are seen to become
firmly pressed together and to close the duct.

Phenomena of Moveable Kidney during Pregnancy and
Labour.

According to the scanty observations hitherto available,
the troubles caused by moveable kidney appear to be rather
diminished than increased.

(a) The growing womb pushes the intestines gradually
up, and with them indirectly the kidney, as I have observed
in two cases ; and by this means the evil effects of dragging
and kinking of the vessels and ureter are usually alleviated,
just as is the case when pregnancy supervenes in a case of
descent of the generative organs.

(6) To this is to be added the circumstance, that during
pregnancy there is usually a copious deposit of fat in the
panniculus adiposus and in the subperitoneal cellular tissue,
which gives additional firmness to the attachments of the
kidney.

(c) Moreover the circumstance that menstruation (which
exercises an untoward influence on the capsule of the kidney
both anatomically and also symptomatically in its effect on

1 i.e, On the action of gravity as against the tendency of the elastic bag
to erect itself as it becomes tense P—TRANSLATOR.
MOVEABLE KIDNEY IN WOMEN. 317

the general health) ceases during pregnancy, contributes
essentially to the relief of the disturbances caused by moveable

kidney. Some observers, as Hare and Oppolzer, have indeed _

observed cures of moveable kidney during pregnancy, which
cannot be doubted when the same experiences are remem-
bered in the case of prolapse of the vagina and uterus.
Whether moveable kidney exercises an injurious influence on
the other hand on the pregnant uterus, is as yet unknown.
It is however not unlikely that where it has descended very
low, or in case of complications such as interruption of the
circulation in the renal vein (in the former case mechanically,
in the latter by the great disorder of the circulation), it is
capable of inducing abortion, as indeed happened in the case
related by Hger. That this is not inevitable in cases of
intermittent hydronephrosis is proved by the observations of
Johnson and Eger, in whose cases also the growing uterus
appeared to undo the kinking and twisting of the ureter, and
to make it pervious for the urine.

Dearth of observations prevents us from stating a priori
‘the exact mutual relations between labour and acquired
moveable kidney. The cases of Chambon de Montaua (155)
(in which a kidney was found incarcerated behind the grow-
ing uterus), Boinet (156) (who observed a deviation of the
uterus, caused by a kidney lying behind the bladder), and
Hohl (157) (in which a displaced kidney is said to have
formed an obstruction to labour), one and all concern cases
of congenital malformation and probably of displacement with
subsequent fixation. Moreover the case of Hohl is so inac-
curately and unscientifically described that it cannot be
utilised to prove anything.

It is however obvious, as well as established by many
cases, that the pressure which occurs in labour is capable of
acting injuriously on the kidney. Women therefore who
have a moveable kidney must be cautioned against bearing
down too strongly during labour.
318 MOVEABLE KIDNEY IN WOMEN.

VIII. Ossecrive Sians or Moveaste KiIpnery.

Moveable kidney is capable of attracting attention both
by its absence from its normal position and by its appearance
in an abnormal situation. It will therefore be necessary to
examine the question what physical signs, both in the anterior
and posterior lumbar region are due to it.

Inspection.—In thin subjects with a moderate amount of
pendulous belly, the moveable kidney may occasionally be
found against the anterior abdominal wall in the erect posture.
Its outline can in some cases be also made out when the
patient lies flat on the back or on the side opposite to that of
the moveable kidney. Sometimes the kidney can be seen to
map itself out by a sulcus parallel to itself which moves down-
wards on deep inspiration along the anterior abdominal wall.

The condition of flattening or depression of the corre-
sponding lumbar region, especially plain in the knee-elbow
position, described by the majority of writers (158) as constant,
is an untrustworthy and exceptional sign. Its small value is
best seen by the fact that in a patient whose right kidney
had been removed, and whose great emaciation also furnished
the most favourable conditions for its production, I was
unable to see this flattening. Keppler also failed to find
this depression. - The fact that in certain positions, especially
when the legs are adducted, the so-called lateral lumbar
sulcus corresponding to the lateral border of the sacrospinalis
muscle normally comes out pretty plainly in thin subjects,
has in my opinion given rise to many mistakes of this kind.

Percussion.—The resonance over a moveable kidney in the
abdomen is generally dully tympanitic. It is only when the
kidney has a long mesentery, and relaxation of the subperi-
toneal cellular tissue allows the ureter to detach itself far
from the posterior wall of the abdomen, that the resonance is
absolutely dull (and then of course only on superficial
percussion), because in this case no intestines separate the
kidney from the abdominal wall. On the left side the
resonance is also but seldom quite dull, because the
voluminous stomach and intestine filled with air always lie in
MOVEABLE KIDNEY IN WOMEN. 319

front of the kidney, unless this is very low down; and
although purgatives may evacuate the air which masks the
true percussion sound from the intestine, they cannot do so
from the stomach. A special value has been laid on the
percussion signs in kidney diseases, caused by the relations
of the kidney to the colon. Whereas in the case of tumours
of the kidney the colon almost invariably lies on their inner
side, and the percussion sound on their outer side is dull (as
would naturally be supposed in the case of extraperitoneal
tumours), moveable kidney has had the percussion signs of
an intraperitoneal tumour assigned to it (Simon, Ahlfeld), and
it has been believed always to lie on the inner side of the
colon, and always to be bounded on the outer side by
tympanitic resonance. This relation however is only found
where the kidney has a long mesentery, and where in addition
the flexure of the colon is very long or the kidney has.
migrated between the folds of the mesocolon. But when the
mesocolon is taut and short, even if the kidney is moveable
the colon is usually pressed inwards, and the percussion note
on the outer side of the kidney remains dull, as in the case
of a subperitoneal tumour. A moveable kidney therefore
behaves with regard to percussion, at one time as an intra-
peritoneal and at another as an extraperitoneal tumour.

Here also it is generally believed that the absence of the
kidney from its usual position in the lumbar and posterior
abdominal region furnishes important percussion signs.
According to Rollet, Trousseau and others, the note over the
side corresponding to the displaced kidney is clearer and
fuller than on the other side.

The majority of the textbooks and handbooks on
percussion say the same. Piorry (159), the founder of renal
percussion, claims to have percussed out even the slightest
changes of size in the kidney.

According to Guttmann (160) the diagnosis of a moveable
kidney (whenever at least a proof is needed), rests on the
circumstance that percussion shows the absence of the kidney
from the normal place, by the diminished dulness. “If a
kidney is displaced the lumbar region of that side is more
resonant than the other side.” :

Numerous investigations however have convinced me of
320- MOVEABLE KIDNEY IN WOMEN.

the untrustworthiness of this sign. Even strong percussion
hardly detects any difference between the two sides in move-
able kidney. When one considers that one percusses a thick
layer composed of the muscles of the back, the ribs, and the
quadratus lumborum muscle, it is not to be expected that
the dulness will be changed into resonance by the absence
of the kidney. If the kidney is displaced on the right side,
which is generally the side in point, its place is at once taken
by the posterior’ surface of the liver, which of course in no
way changes the original dulness. Thus neither Weil (161),
who examined a patient whose kidney had been removed by
Czerny, nor I under similar circumstances found any differ-
ence in resonance. Moreover Keppler (162) justly denies, on
the ground of careful examination, the so-called physiological
kidney dulness.

Pansch (163) again has pointed out, from minute topo-
graphico-anatomical investigations, the errors of the clinical
observers like Gerhardt, according to whose account of the
kidney dulness the kidney normally reached as far as the
crest of the iliam, whereas it does not reach so far by three
to five centimetres. Pansch moreover correctly observes
that even an area of dulness reaching to the crest of the
ilium is not necessarily identical with the proper kidney dul-
ness, since the capsula adiposa lying below the kidney
is often as thick as the kidney itself which causes the
dulness.

After all we shall therefore be obliged to agree with
Skoda’s (164) statement already mentioned: ‘The size of
the kidney has very little to do with the state of the reso-
nance in the lumbar region. This may be quite dull when the
kidneys are very small, and tympanitic although the kidneys
are very large. We must therefore when possible press the
plessimeter down until we get complete dulness and the
resistance of a solid organ. By repeating this process at
several spots we can judge where the kidney shows a striking.
enlargement.”

As a matter of fact even in the case of moveable kidney
the most unmistakeable signs are furnished by palpation.

Palpation.—A moveable kidney is generally to be per-
ceived beneath the free edge of the ribs, rather towards the
MOVEABLE KIDNEY IN WOMEN. o21

middle line and the navel, as a smooth, oval, solid sensitive
body. Now and then we succeed in feeling the shape of the
kidney, but rarely (as happened in Frerichs’ clinique) in
feeling the pulsation of the renal artery. The right kidney
is easier to feel than the left, because the left is surrounded
by softer and more yielding parts than the right, and can
therefore more easily slip away. The extreme mobility of
the kidney is remarkable, for a slight touch or the contrac-
tion of the abdominal walls is sometimes alone sufficient to
make it change its position, and in the horizontal posture it
easily slips back into its normal place. The mobility of the
kidney is often so great that one has actually to surprise it
in order to catch it for palpation. Once back in its normal
position it is sometimes hard to render it apparent again.
Some patients can press it into the flanks and bring it
forward again by peculiar sidelong movements of the trunk.
This however does not always succeed, and so, after making
a diagnosis one is often subsequently at aloss. This habit
that the kidney has of retreating into its normal position and
staying there is so characteristic that in two cases in which
a moveable kidney was certainly present and a long incision
had been made in the linea alba with the view of removing it,
it could not be brought forward into the wound in the abdo-
men without shaking and changing the position of the
whole body (see Keppler (165) and Lawensteim (166)). On
a third occasion even the shaking was in vain, and King
(167) (whose case it was) was obliged to abandon the
operation.

Palpation must be practised with the patient in different
postures and always bimanually (168). The knee-elbow
position which was formerly recommended is least suitable for
this purpose, because in this position the kidney tends to
fall towards the diaphragm, that is, into its normal position ;
the most convenient is the horizontal posture with the upper
part of the body moderately raised and the legs moderately
bent, a position which is usual in gynecological examinations
on account of the diminution in the intra-abdominal pressure
which it causes. It appears useful to place the patient on
the left side to feel the right kidney, to press the right hand
firmly against the lumbar region and to press ee kidney

2
322 MOVEABLE KIDNEY IN WOMEN.

with the right hand against the left hand resting on the
abdomen. In the case of the left kidney vice versé..

By these manipulations it is surprisingly easy in favourable
cases to feel the lower end even of the normally placed
kidney, and when it is moveable to move it to and fro
between the hands. At the same time an impression is
gained by practice whether one or other lumbar region is
more easily indented than usual or than the other. This
condition, constantly to be observed in moveable kidney and
important for diagnosis, depends upon the fact that when
the kidney is absent from its normal position, the soft parts
situated in the flank, the muscles and intestines, are more
easily pressed under the arch of the ribs; but is not, as has
been erroneously supposed, explained by imagining that the
kidney which is normally situated beneath the arch of the
ribs betrays its absence directly by this diminished resist-
ance.

Palpation itself is generally painful. Sometimes violent
pressure makes a patient vomit. Trousseau (169) made use
of the tenderness caused by pressure on the kidney for dia-
gnosis, comparing it with the tenderness produced by pressure
ever the other kidney.

Auscultation has not hitherto been utilised for diagnosis
in the case of moveable kidney. It is not however to be
doubted in this case also a whistling murmur will be
audible when twists and narrowing of the vessels occur.)

IX. Draenosis.

The recognition of a moveable kidney depends on the
physical signs, especially those derived from palpation, and

* The auscultation of abdominal tumours is in so unsatisfactory a state
that little can be said about it. A murmur is said to be occasionally heard
in ovarian tumours, but what these tumours are, or what are the circum-
stances under which murmurs occur in them is not stated. It would be a
picturesque circumstance for a murmur to develop in an ovarian tumour
during twisting of the pedicle ; but where is such a case recorded ? The uterine
murmur in some fibrous tumours is well known. The wisest course in the
present chaotic state of knowledge is to follow the advice of the American
ambassador, and ‘“‘ Never prophesy unless you know.”—TRANSLATOR,
MOVEABLE KIDNEY IN WOMEN. 323

the knowledge of the numerous symptoms caused by it. The
fact that they are so very often overlooked or wrongly
interpreted depends not only on want of acquaintance with
their subjective and objective symptoms, and on the usual
supposition that the patients are hysterical or hypochondriacal,
but also on real difficulties standing in the way of their
recognition.

When indeed one succeeds in seizing a solid body situated
in the abdominal cavity in such a way that one can move it
more or less backwards and forwards between the lumbar and
umbilical regions, in finding the pulsation of the renal artery
and the hilum, there is no difficulty in making a diagnosis.
But if a kidney possesses only moderate mobility or is
situated within a patient with strong and fat abdominal walls,
the physical symptoms afford but an uncertain conclusion, and
the subjective symptoms are generally of such a nature as to
be capable of other equally justifiable interpretations.
Finally, if one even succeeds in feeling a solid round body in
‘the abdomen without recognising the shape of the kidney,
there are a large number of other pathological conditions
(tumours and so forth) which can easily be mistaken for it on
account of the similarity of their subjective and objective
symptoms. On examining the statistics of moveable kidney,
we find in fact that the same may be said of them as Simon
(170) asserted for hydronephrosis: “‘ That. they consist of a
long series of errors of diagnosis followed by an equal
number of inappropriate interferences.”” Now since moveable

‘kidney has no pathognomonic symptoms, it is quite necessary
to ascertain the differential signs between it and many
pathological conditions which give similar manifestations.
Even then it will often be impossible to make a correct
diagnosis except by exclusion. An enumeration of all
possible sources of mistake would amount to a treatise on the
diagnosis of abdominal tumours. Only the most important
and frequent will therefore be given here.

Partial contractions of the Recti, Transversi and Obliqui
Abdominis muscles frequently give the impression of a smooth
oval tumour, which after a certain time disappears on pressure
by the palpating hand, just like a moveable kidney. Ifthese
patients are put under chloroform, it is true that the influence
B24 MOVEABLE KIDNEY IN WOMEN.

of tension of the abdominal walls is eliminated, but the
differential diagnosis cannot always be made, because a
moveable kidney also usually retreats into its place during
narcosis. A conclusion is however arrived at by frequent
examination, and especially by carefully conducted strong
percussion over the supposed tumour.

It may be very hard to decide whether the tumour is a
tumour of the liver, a liver deformed by tight lacing,
hypertrophy of the liver, ,a liver developed in lappets
(Zipfelbildung’) ; or a moveable kidney without complications,
or adherent to the lower. border of the liver ; because the same
signs on percussion and palpation hold good under both
conditions, and the symptoms in both cases may consist of
gastric disturbances, jaundice, and vague pains in the lower
abdomen. It has alrdhdy been mentioned that the physical
signs deduced from the absence of the kidney from its normal
situation are not decisive.

I have observed a patient (see below) who frequently
suffers from jaundice, and in whom a diagnosis of moveable
kidney adherént to the lower border of the liver would be
impossible but for the fact that the moveable kidney could
be felt before the formation of adhesions.

Lastly, aconclusion may frequently be arrived at by the
presence of some etiological element, or by the course and
consequences of treatment. In this way it took me several
months of observation in the case of three patients to diagnose
a moveable kidney and exclude an affection of the liver; in
two cases a tumour finally declared itself as a hypertrophic
cirrhosis of the liver of obscure origin.

Trousseaw (171) relates a case of moveable kidney in which
ten physicians had made the diagnosis of a tumour of the
liver, an instance to which I could add many others. When
le Ray (172), referring to the differential diagnosis between
affections of the liver and moveable kidney, remarks that a
sulcus must intervene between the moveable kidney and the
liver, it must be remembered that palpation just at the border
of the arch of the mbsis much hampered, and that a similar

1} There is no English word equivalent to Zipfelbildung. The lappets are
generally more or less isolated and moveable over the right lobe. Many of
* them represent conditions found in the lower animals.—TRansLaTorR.
MOVEABLE KIDNEY IN WOMEN. 325

sulcus may be easily felt on palpating lappets of the liver
(Leberzipfeln) and livers deformed by tight lacing.

The most decisive sign is that furnished by the observation
of the further course of the affection, and a conclusion is of
course quickly arrived at when malignant tumours are
present.

A mistake between moveable kidney and cystic tumour of
the lier (Echinococcus) or of the gall-bladder (Hydrops
vesicee fellesx) or solid twmours of the gall-bladder, is very
likely. The former is ascertained by tapping, the latter only
by the course of the disease. How little the statements of
textbooks can be trusted (173) when they say that tumours
of the gall-bladder are firmly fixed, are situated on the outer
border of the rectus muscle, are pear-shaped and give rise to
colic, can be seen from the following observation.

On the 24th of February, 1880, I saw Frau E. R—, thirty-
six years of age, a patient of Herr Geh. San.-Rath Dr. J.
Meyer, complaining of a swelling in the abdomen and
violent epigastric pain. She was fairly well nourished, of
healthy appearance, she had had five children quickly and
had been till lately free from all discomfort.

Her present ailment is said to have been caused by hard
work.

Present condition :—Thoracie organs, &c., healthy ; well
marked pendulous belly. Beneath the right lobe of the liver
is a firm tumour of the shape and size of a kidney, remark-
able for its extraordinary mobility, and which can be easily
pushed downwards, outwards and inwards away from the liver
without causing the patient much pain, but (as in Urag’s case
described above) when the pressure is relaxed, returns to its
original position nearly in the parasternal line. The tumour
itself was painless on pressure, but pressure caused a circum-
scribed pain in the epigastrium. The functions were normal
except that lately the patient had lost her appetite.

The most obvious supposition founded on the above con-
dition was that of a moveable kidney adherent to the liver,
which, in spite of its great mobility, was pulled back to the
liver by its adhesions as in Urag’s case. On the other hand
it had been pronounced to be a tumour of the omentum,

Meanwhile, after some time an increase in the tumour and
326 MOVEABLE KIDNEY IN WOMEN.

deterioration of the general health were observed, so that
thoughts were naturally entertained of a malignant growth.
But even then it was impossible to interpret the signs except
on the hypothesis that a moveable kidney had become can-
cerous, especially as the mobility of the tumour remained
very considerable. The appearances did not change till June,
when pain persisted even during the horizontal position,
jaundice appeared, and emaciation advanced so rapidly that
it became possible on deep bimanual palpation to feel plainly
the lower end of the right kidney in its normal situation.
Although the tumour was neither fixed, nor situated at the
outer border of the Rectus, nor pear-shaped, nothing but
cancer of the gall-bladder could now be diagnosed.

The autopsy, held in the Elizabeth Hospital, Berlin
(where the patient attended at last), confirmed this dia-
gnosis.

The instances in which, vice versé, a moveable kidney is
taken for an affection of the liver (as has already been men-
tioned), are still more frequent. It should also be remem-
bered that both affections may occur together. In the case
of Aberle mentioned above, gall-stones coexisted with move-
able kidney ; moreover I have seen a similar case myself (see
below). If well-marked gall-stone colic, yielding to large
doses of morphia, and the passage of gall-stones had not
been ascertained, the jaundice which occurred in this case
would very likely have been referred to the moveable kidney.

The presence of pain occurring even during quiet decubitus
ought to prevent us from mistaking cancers of the stomach or
pancreas for moveable kidney, even apart from the relative
immobility of these tumours.

Such a mistake however is more likely to be made in
cancers of the ascending and descending colon, which frequently
cause nothing for a long time but digestive disturbances
(Stenosis), and present to the examining hand a moveable
tumour lying beneath the abdominal walls in the region of
one or other flexure (I examined such a tumour in the Jewish
Hospital of Berlin, which had been wrongly considered to be
a moveable kidney). Then again the differential diagnosis is
decided by the circumstance that the percussion note over a
small cancerous growth in the colon lying immediately
MOVEABLE KIDNEY IN WOMEN. 327

beneath the abdominal walls is always tympanitic; in the
case of such tumours when larger and more diffuse, there are
so many signs of local and general disturbance that a move-
able kidney would hardly be thought of.

In like manner fecal masses long retained in a loop of colon
with a long mesentery may simulate a moveable kidney, for
the hepatic flexure is a favourite place for feecal accumulation.
A long-continued constipation indeed suggests this complaint,
which is at once ascertained with certainty as soon as we
succeed in pushing the supposed tumour down into another
portion of gut. This however is only rarely possible, and
besides, defeecation can proceed almost normally past a fecal
tumour lying in a diverticulum. This condition, viz. that
the ingesta lying in proximal portions of the alimentary canal
take precedence of those lying in distal portions must be
remembered, in order to avoid the mistake of excluding the
idea of a fecal tumour on account of regular! defecation.
This can. sometimes be easily recognised by the shape of
the tumour and its retreat after passive movements into a
situation in which moveable tumours are not met with.

A moveable kidney on the left side may be mistaken for
a moveable spleen. The spleen however during spontaneous
and passive movements always lies immediately beneath the
abdominal walls, while a moveable kidney when moved
upwards retreats from the abdominal wall and slips under the
intestines. The note over the spleen is therefore always dull,
over the kidney at one time dully tympanitic, at another
tympanitic. This sign appears much more trustworthy than
the assertion that the spleen must be recognised by its more
elongated shape.

It is otherwise in the case of tumours of the spleen (Ague,
Leukzmia, Amyloid Spleen), the size of which indeed forbids
their being mistaken for anything but moveable tumours of
the kidney, but which also, when of a certain size lie close
beneath the abdominal walls. In this case however the pre-
sence of splenic dulness in the normal situation is decisive,
but still more the circumstance that in leukemia, &c., there

1 Lonce saw a woman who had swallowed a small coin, and who, in spite
of purgatives and consequent copious daily motions, did not pass it for ten

‘day s.— AUTHOR.
328 MOVEABLE KIDNEY IN WOMEN.

are other distinct signs arising with certainty from disease
of the spleen.

In the case of the frequently occurring doubt whether we
have before us a tumour of the womb or ovary or a moveable
kidney, the direction of the mobility should be tested before
all things. Ifa tumour can be moved towards the lumbar
region without causing much pain, a tumour of the generative
organs seems excluded. On the other hand a moveable
kidney cannot be excluded on the score of slight mobility of
the tumour towards the pelvis, for such a tumour can
sometimes be moved in that direction. Moreover even tym-
panitic resonance over the true pelvis does not absolutely
disprove’ the presence of tumours of the generative organs,
as the following case observed by me in the gynecological
clinique of Breslau shows.

In a woman who had been confined some months previously,
a tumour of the shape and size of the kidney was observed
at the level of the splenic flexure of the colon. Examination
of the generative organs threw no light on itsnature. There
was tympanitic resonance above the pubes. The autopsy
showed the tumour to be an ovarian tumour with a thin
pedicle about 20 centimetres long. The tumour owed its
unusually high situation to the recently pregnant uterus,
and had during the course of pregnancy contracted adhesions
with the mesentery and posterior abdominal wall, which held
it fast in its abnormal situation in spite of the diminution
and descent of the uterus into the true pelvis. As the
pedicle which was very likely originally long and thin had
been much drawn out, coils of small intestine had naturally
taken up their position between the generative organs and
ovarian tumour, and thus the tumour, though really intra-
peritoneal, had given the physical signs of a sub-peritoneal
(retro-peritonealen) body.

On the other hand moveable kidneys have frequently been
taken for ovarian tumours, as Spiegelberg (174) and others
point out. I saw how hard their differential diagnosis from
fibrous tumours with long pedicles can be, from two cases, in
which it was only in the course of the operation that I was
able to make out the connection of the kidney-shaped fibrous
tumour with the uterus. In both cases the mobility of the
MOVEABLE KIDNEY IN WOMEN. 329

tumour was extreme, and a certain diagnosis could only be
made from the circumstance that in spite of the superficial
situation of the tumour and the possibility of grasping it
eat the pulsations of the renal artery could not be
elt.

The stock signs given for the diagnosis of tumours of the
kidney (175) are useless under the circumstances under dis-
cussion.

In making a diagyosis therefore it is recommended to
proceed by first disregarding entirely the doubtful tumour
itself, and looking to see if the other organs claiming attention
are to be found and are of normal shape. With a view to
this, bimanual palpation of the kidneys should be attempted,
the result of which is however seldom trustworthy. But
before all things the diagnosis of the presence of the normal
uterus and both normal ovaries should be attempted by the
usual bimanual examination or Simon’s rectal exploration
with the entire hand, which is only of value in this case (176) ;
and these facts can nearly always be ascertained. In making
a differential diagnosis between tumours of the kidney and
generative organs therefore, the presence of the normal ovaries
and of the normal uterus will confirm the diagnosis of a
moveable kidney ; the presence of only a single normal ovary,
that of a tumour of the other ovary.

Lastly, there is still a condition under which the wrong
diagnosis of a moveable kidney is likely to be made, namely,
that of so-called phantom tumour, whose symptoms consist
of a permanent and extreme distention of the abdomen with
unusually tense abdominal walls, and the ztiology of which
is still obscure. Women affected by this complaint generally
feel themselves pregnant, say they feel the movements of
the child, and soon. The thickness and firmness of the
abdominal walls and their contraction on the slightest touch
renders palpation useless without anesthesia, then indeed it
is usually possible to recognise the nature of the apparent
tumour and to exclude moveable kidney. It is still more
frequent for moveable kidney to simulate so-called spurious
pregnancy, which will however hardly be mistaken after a
careful examination of the generative organs. Other possibili-
ties of error, such as isolated collections of fat in the omentum
330 MOVEABLE KIDNEY IN WOMEN.

and tumours in the abdominal walls need only be borne in
mind to avoid mistakes.

The Diagnosis of the Complications of Moveable Kidney.

A moveable kidney may be supposed to be adherent when
the kidney lies more or less immoveable in an abnormal
situation, but still within an area not much farther remdved
from the first lumbar vertebra than the length of the renal
vessels. It is however extremely rare for a displaced kidney
to become fixed in an abnormal position ; the statements of
some writers that the kidney contracts adhesions now and
again with the neighbouring parts and becomes surrounded
with deposit, like an ovary embedded in a parametric’ deposit,
are entirely unproven. The adhesions are usually very
delicate and loose, permit movements of the kidney to
continue, and by no means prevent it from being replaced in
its normal position. It is true that the kidney returns to the
place to which it adheres, which is generally the lower surface
- of the liver (untere Leberlappen), gall-bladder or transverse
colon, so that its return is a test for the diagnosis of the
adhesions. No further symptoms are caused by the adhesions,
as would be expected from their usual non-inflammatory origin.

The recognition of the symptoms of incarceration so-called
is only specially difficult when the existence of a moveable
kidney is unknown or overlooked. Under these circum-
stances the extreme sensitiveness of the abdomen and the
fixation of the kidney in a high state of cedematous swelling
and infiltration forbids careful palpation, so that this condition
is frequently mistaken for perityphlitis or perimetritis, on
account of the resemblance between the symptoms of these
diseases. The sudden appearance of violent symptoms, the
conditions of the secretion and excretion of the urine, the
suddenly commencing and rapidly proceeding disappearance
of the apparently large deposit, however, establish the dia-
gnosis even in these cases.

The hydronephrosis of moveable kidneys affords only a
single sign which distinguishes it from hydronephroses due

1 P Perimetric—TransLatTor.
MOVEABLE KIDNEY IN WOMEN. 331

to other causes, namely, its frequently intermitting appearance
attracting even clinical attention.. These intermissions are
of course observed under other circumstances, as for instance,
in cancer of the bladder in the region of the trigone, or in
the case of the repeated passage of stones from the kidney,
but other symptoms characteristic of these disorders render
it almost impossible to mistake them for hydronephrosis in
a moveable kidney. It should not be expected that, after the
disappearance of the tumour, remains of kidney tissue in the
hydronephrotic sac will be palpable through the abdominal
walls ; the sac is far too thin for accurate palpation and when
empty sinks back against the vertebral column. Even after.
complete evacuation of unilocular ovarian tumours, the most.
searching bimanual palpation sometimes fails to make out
their walls, as I have repeatedly ascertained.

Besides this, hydronephroses of moveable kidney have
nothing at all special about them; indeed, as their origin
implies, when they become larger they completely resemble
the hydronephroses of fixed kidneys. Both grow in the
direction of least resistance, the fixed variety downwards,
the moveable upwards, so that it is only when they are of
a certain moderate size, i.e. repletion, that their relations to
neighbouring organs, especially the colon, are different. The
assertions of Simon (177) that in the case of the hydrone-
phrotic sacs of moveable kidneys, the ascending or descending
colon remains in its normal situation; and of Ahlfeld (178)—
that hydronephrosis in a moveable kidney developes in front
of the intestines like an ovarian tumour, cannot therefore be
regarded as correct. Again, the hydronephroses of moveable
kidneys gradually grow into the lumbar region, so that when
of a certain size they cannot be distinguished from the
hydronephroses of fixed kidneys. I will not here dwell
further upon the remaining diagnostic points, especially upon
the value of exploratory tapping and the differential diagnosis
between hydronephroses and other tumours.
332 MOVEABLE KIDNEY IN WOMEN.

X. Proenosis.

The prognosis of uncomplicated moveable kidney is
favourable as far as life is concerned. No case has been
hitherto recorded in the literature of the subject in which
death could be even probably attributed to it. The fatal
case quoted by Keppler (179) can hardly be regarded as a
proof that an uncomplicated moveable kidney can cause
death. Still more must the assertion of Keppler (180)—that
‘© Moveable kidney, even without any complications at all,
gives rise to slow but continually developing disturbances of
nutrition, which, as time goes on, infallibly undermine the
health and even life ’’—be rejected as quite unproven; and
we can only agree with Trousseau (181) who—referring to the
treatment of moveable kidney by leeches, venesection, and
still more questionable measures—expressed his opinion as
follows : ‘ Le pronostic du rein déplacé n’a vraiment pas de
gravité ; il ne devient grave que par les erreurs aux quelles il
peut donner naissance, et le traitement erroné qui en découle
est ordinairement d’autant plus actif que le médecin est moins
convaincu.’’ ,

The prognosis of uncomplicated moveable kidney has
however grown decidedly worse since men have begun to
remove healthy moveable kidneys, basing their practice on
the view set forth by Keppler. Of course some of the patients
(who otherwise would not have been killed by the moveable
kidney which gave occasion to the operation) now pay for
this with their lives.

Spontaneous cures of moveable kidneys are commoner,
especially in cases of acute traumatic dislocation, and they
have been observed in cases in which emaciation following
acute febrile affections occasioned the mobility of the
kidney.

Rollet (182) gave a correct explanation of this when he
said that when the kidney is put back into its normal position
and kept there by suitable means such as quiet decubitus,
the stretched subperitoneal cellular tissue around the kidney
and against the posterior wall of the abdomen, as well as the’
peritoneum itself, gains time to contract more firmly by
MOVEABLE KIDNEY IN WOMEN. 833

virtue of its elasticity, and thus to afford a powerful obstacle
to the displacement of the kidney. Oppolzer, Rayer, and
Hare have proved the ocurrence of cures after the superven-
tion of pregnancy. In like manner many observers have seen
considerable relief to all the troubles (amounting to cure)
follow the menopause and the proper treatment of symptoms
by drugs, diet, and mechanical appliances. A cure is some-
times effected by nothing more than a correct diagnosis, and
an explanation to the patient of the benign character of her
complaint; after which her hypochondriacal frame of mind
and numerous imaginary maladies disappear suddenly.

Even with regard to the complications of moveable kidney
a good prognosis as far as concerns life is on the whole to be
given. Thus, even the menacing symptoms of incarceration
have never yet been described as the cause of a fatal termi-
nation.

The prognosis after the establishment of hydronephrosis
and perinephritic and paranephritic abscesses is less favour-
able, but even then only in case of improper treatment.

XI. TREATMENT.

Moveable kidney does not require treatment corresponding
to the Indicatio morbi, unless it is the ruling cause of the
morbid symptoms. To direct one’s treatment against a
moveable kidney in a case of general disease due to consump-
tion or cancer, would be just as much beside the mark as to
treat a moveable sarcomatous kidney on account of its
mobility. Attention must before all things be paid to the
causes of the moveable kidney. If they are of such a
nature as to act continually on the mobility of the kidney
(such as pendulous belly, or ‘prolapse of the generative
organs), it will be useless to treat the moveable kidney alone.
Fortunately the Indicatio morbi often coincides with the
Indicatio causalis ; but in debating different methods it is
important to be clear from the first about the object to be
aimed at in each individual case, and about the end which it
is possible as welt as desirable to attain by one method or
334 MOVEABLE KIDNEY IN WOMEN.

another; the more so as moveable kidney gives rise to
different symptoms in individual cases, even under the same
etiological and anatomical conditions.

As in displacements of the uterus and herniz, it must
here be our task to restore the kidney to its normal situation
and keep it there."

Reposition is very easily affected in the horizontal decubitus
by moderate pressure after removing all tight articles of
clothing. In recent cases, especially such as have arisen
after acute injuries, horizontal decubitus persisted in for some
time, during which the kidney remains in its normal situation,
may be sufficient to produce a cure.

The maintenance of a moveable kidney in its normal posi-
tion is however extremely difficult. To effect this object a
number of the most complicated orthopzedic appliances,
bandages, renal trusses, &c., have been proposed and tried.
The most inconvenient are those which depend for their
support on the soft abdominal walls alone, for they are
constantly shifting, and, to start with, do not admit of a
mode of fixation similar to the ordinary trusses for keeping
up the bowels. Better than these are the bandages to fasten
on the thorax and provided with a pad, which exert leverage
for the most part on the spot occupied by the kidney in the
erect position. Guéneau de Mussy has described an angular
pad for this purpose, the lower and horizontal arm of which
is intended to support the displaced kidney, and the perpen-
dicular arm to prevent its moving in an inward direction.
All these pains however to maintain the replaced kidney in
its position must remain fruitless, for the kidney is covered
by the bowels, and is exposed to no pressure from the pad
when the pressure is moderately strong, while an increase of
pressure will drive it away from the pad. These appliances
therefore, being useless and much more apt to cause pain
and discomfort than their relief, are soon discarded by the
patients of their own accord.

On account of the incompetence of mechanical appliances
tq fix a moveable kidney in its position, it has been quite
recently proposed to fasten the kidney by operation, namely

1 This association between moveable kidney, hernia, and descent of the
uterus will be mentioned further on, see p. 357.—TRANSLATOR.
MOVEABLE KIDNEY IN WOMEN. 335

by sewing it to the abdominal walls (183). Favourable
results however from this proceeding, based as it is on
incorrect anatomical and pathological ideas, is not to be
expected. If an attempt were made (as by Hahn) to make
an incision in the lumbar region and get the kidney to heal
in it, this proceeding would displace the kidney, whose normal
situation is higher and more lateral than the lumbar incision.
But if an attempt is made to sew the kidney into its normal
situation, it would be necessary to resect one or two ribs, or
insert sutures at random into the last intercostal space
through the muscles and the kidney. In either case one
would expect to open the pleural cavity and to puncture
important vessels and nerves. But even after the sewing
has been safely accomplished, a cure of the moveable kidney
is not to be expected, for we have not two serous surfaces,
capable of mutual adhesion, to deal with, and the causes of
the mobility of the kidney are of course not removed by
sewing.

All these experiments, unpromising and dangerous as they
would seem a priori, can however be abandoned, as it is not
necessary, in order to remove the discomforts caused by
moveable kidney, to fix it in its normal situation ; but just
as in the case of retroflexion of the uterus it is generally
sufficient to keep it as immoveable as possible. With this
view we must act indirectly on the kidney by fixation of the
abdominal walls and viscera, since it is impossible to act
directly upon it. This is best accomplished by a comfortable
and firm binder encircling the whole abdomen. If the
kidneys are only prevented from constant movements down-
wards and inwards, and from rotation on their axes, the
discomforts caused by dragging of the nerves and vessels as
well as by pressure, cease. It is of course difficult to produce
‘general immobility of the abdominal contents and walls by a
binder, because the size and shape of the abdomen vary not
only in different individuals, but even in the same person,
during breathing, and with different postures, movements, &c.,
Even binders accurately made to the measures of the abdomen
Jo not therefore fulfil the desired end, for they ride up as
the patient walks, and leave the lower half of the abdomen
free for the descent of the abdominal contents, or they exert
336 MOVEABLE KIDNEY IN WOMEN.

an unbearable pressure over the region of the stomach by
their upper circuit.

The material and shape of the binder must therefore be
varied in the most manifold ways according to the condition
and occupation of the individual. Elastic binders of india-
rubber are least of all to be commended, as they produce the
greatest pressure and also retain the perspiration. Ticking
is better in summer, flannel in winter, with lengths of some
elastic material let in. Further, it may be convenient to
prevent the abdominal binder from riding up by means of a
T bandage or perineal bands (Schenkelbander), and io fix it
by braces to the shoulders. I have never seen any special
good from padding the binder over the situation of the dis-
placed kidney. It is preferable to let in a thin concave tin
shield over this spot, as I have often tried with success.

All these binders are however uncomfortable for many
reasons, and I have therefore tried to find a material which is
more or less capable of forming an artificial abdominal wall
by itself. My experiments with poroplastic felt, thin tin and
whalebones let into the front surface of the binder have not
however been very successful, but I have been led by these
experiments to an appliance, which, modified to suit our
purpose, is capable of almost completely fixing the abdominal
walls and with them the moveable kidney—namely, the
much abused stays, the use of which is at once shown by the
support it gives to the breasts and the defence it affords to
the abdomen from the pressure of the strings of the garments.
I have obviated the disadvantage of the usual short stays
reaching about to the navel, which compress the upper part of
the abdomen and allow the lower part to bulge, by having
the longer stays lately come into fashion Jengthened as far
as the pubes and both Poupart’s ligaments. Shaped thus,
they cover the whole abdomen, they exercise an equable’
pressure on the abdominal contents, without being tightly
laced, and (unlike all forms of abdominal binders) taking
‘their support from the bony thorax, they are not displace-
able.

There are few women, mostly those whose bellies are very
pendulous, or who suffer from violent epigastric pains, who
cannot bear these stays. Women again who have sedentary
MOVEABLE KIDNEY IN WOMEN. 337

occupations cannot wear them unless the lower end of the
middle piece, the so-called busk (Blanchette) is well padded,
or, as I have tried, arranged to fold up. But in most cases
these long stays act extremely well. The favourable effect
of this artificial abdominal wall consists not only in
rendering the abdominal contents immoveable, but at the
same time in the temporary removal of one of the fundamental
causes of moveable kidney, pendulous belly, for the radical
treatment of which we possess no method.

The abdominal muscles, which are generally loose in cases
of moveable kidney and pendulous belly, must however be
also directly strengthened. To this end the use of cold in
the form of cold compresses and douches, or sensible
hydropathic treatment or sea bathing, or lastly electrical
treatment of the abdominal muscles by the induced current,
are to be recommended.

Methodical shampooing of the abdomen again appears benefi-
cial in many ways in the treatment of moveable kidney ; in the
first place it strengthens the abdominal muscles, in the second
place it is capable of removing constipation with its peculiarly
evil consequences, by exciting the peristaltic movements of
the intestines, and in certain cases by direct mechanical de-
pression of the feces (184).

By the combined use of the above methods remarkably’
good results are often obtained. A stay of several weeks at

1 The above considerations on the very important subject of stays lead us
back to the question of the intra-abdominal pressure. Moveable kidney
seems to be a member of the Hernial Group (including Hernia, Pendulous
Belly, and Descent of the Pelvic Organs, including, probably backward dis-
placements of the womb even where descent is not well-marked, Prolapsus
Ani, &c.), one of the characteristics of which is the relative increase of the
intra-abdominal pressure (relative that is to the resistance afforded by the
supports). We need not again discuss the question of increased. buoyancy
of the kidney by increase of the intra-abdominal pressure, which seems not
to be the main question. But increase of pressure by stays will increase
the intra-abdominal pressure, and will almost certainly tend to increase the
descent of a hernia, of the pelvic organs, or of the rectum, all of which
must be considered together. It is quite likely that the stays will tend to
fix the viscera, but they are at best only palliative appliances, and it must
not be forgotten that by increasing the intra-abdominal pressure they come
under the class of palliatives which increase the original morbid state.—

TRANSLATOR.
22
338 MOVEABLE KIDNEY IN WOMEN.

sea-bathing places or hydropathic establishments, in which
shampooing and electricity can be applied by skilled hands
is therefore advisable for patients afflicted with moveable
kidney and pendulous belly.

It is obvious that associated maladies, such as chlorosis,
anemia, chronic catarrh of the stomach and intestines, as
well as descent and flexions of the uterus require special
treatment, and that in the case of serious general diseases
treatment which gives exclusive attention to the moveable
kidney is inadmissible.

An entirely different method has been lately recommended
for the treatment of moveable kidney ; this will be discussed
in the following section.

On the removal of Uncomplicated Moveable Kidney.

After Keppler’s (185) assertion, that “‘ Moveable kidney as
such, even without any complications at all, should be removed
by excision through the abdomen, as soon as it causes any
disturbances in the system,” and in accordance with this advice,
—up to the end of 1880 six healthy moveable kidneys have
been removed, four of them by Martin (186), with two deaths,
once by Smyth (187), and once by Merkel; in whose case the
result was fatal. Thus of six persons three died.

The excision of a healthy moveable kidney, however, is in
every sense unjustifiable. We possess milder mechanical
and therapeutical means of alleviating the discomforts of a
patient with moveable kidney, nay even of removing them
entirely, as is shown by numerous observations of the most
trustworthy writers. Reasons again for the extirpation of
an organ so important for the human economy as the healthy
kidney have neither been produced, nor indeed do they exist.
There neither exists an accepted case in which death has
been caused by moveable kidney, nor are the cases brought
forward by Keppler as proof of its injurious influence un-
equivocal or conclusive. The fact that patients whose
healthy moveable kidneys have been removed felt well im-
mediately after the operation, and suffered no inconvenience
from the moveable kidney, can only astonish and enlist on
MOVEABLE KIDNEY IN WOMEN. 339

‘the side of the operation a man who would think it remark-
able that a woman, whose healthy ovaries and healthy uterus
thave been removed, ceases to suffer from uterine hemor-
rhages.

It requires no demonstration that an operation, however
“brilliant, does not seem to be indicated for its own sake, but
‘only when it restores the patient to health. From this point
‘of view the amputation of a normal cervix uteri or the removal
of normal ovaries, which perhaps give rise to dysmenorrhea
or other slight ailments, is not to be endorsed; how much
more blameworthy does the extirpation of an organ, so im-
“portant to life as the kidney seem to be!

What should we say of the recommendation to amputate
a leg for sciatica or varicose ulcers, a recommendation which
‘stands on the same footing as that here given—to remove
‘the kidney ?

Besides it is certain that if the operation is undertaken
‘én the above indications, some of the patients will die from
the operation itself (septicaemia, hemorrhage, &c.). More-
over, putting these accidents aside, a fatal issue is certain
‘if (as in Merker’s case), after the moveable kidney has been
‘removed, the other, in a state of fatty degeneration, is no
longer capable of vicariously supplying the function of the one
removed ; or if (as in a case of Lange’s) the other kidney is
‘hydronephrotic and so the occurrence of uremia is inevitable.
It ought also not to be forgotten, in considering the recom-
‘mendation to remove healthy moveable. kidneys, that cases
in which there is only one kidney are by no means rare.
Even Willis (188) collected thirty-six such cases out of the
literature of the subject, Bewmer (189) forty-eight. There
is however no means of diagnosing the absence of one
kidney without opening the abdomen. Thus in many cases
the operation in question will be the direct cause of death.

But the life even of those patients who survive the
operation will be shortened if the other kidney, although
present, is attacked by certain diseases, such as stone, hydro-
‘nephrosis, Bright’s disease,—complaints which, in the presence
of a second kidney to supply vicariously the function of the
‘first, are by no means fatal. It is no accident that calculous

-affections are especially frequent in cases in which only one
340 MOVEABLE KIDNEY 1N WOMEN.

kidney is functionally active. Lastly, it is not a matter of
indifference—even in the case of other diseases which (apart
from the weakness of old age) finally befall every human
being—whether one or two kidneys provide for the secretion
and excretion of the urine. Although under physiological
conditions one kidney takes up the function of the other,
hypertrophies, and so on, it appears very doubtful whether
in case of affections of the heart, lungs and liver, one kidney
is enough to discharge the renal functions in the presence
of the disorders of elimination present under these conditions
and to replace the other. Certainly the chances of the main-
tenance of life are less in persons with one kidney than with
two; how much more when the second kidney also is or
becomes moveable.

All these dangers must be faced by the physician who
advises so serious an operation, even although the chances, as
far as the operation is concerned, are of the most favourable
kind im the present state of surgery. The rage for operation
is far more dangerous in its consequences when it concerns
the kidneys than when it concerns the cervix uteri and
ovaries which are not necessary for the maintenance of life.
The hypochondriacal frame of mind and the wish of the
patients to get thoroughly rid of a malady which they
regard as malignant, ought not to decide the physician to
undertake, for the sake of an exploit which imposes on the
laity, an operation which endangers and shortens life. Un-
fortunately, nephrectomy which frequently saves life in cases
of abscess, stone in the kidney, &c., is only discredited by
such proceedings.

Treatment of the Complications.

Special consideration is required with regard to the
treatment of the symptoms of incarceration so-called.
The importance of a correct estimation of the pathogenesis
of this train of symptoms is here very plain. If these
symptoms were due to the actual incarceration of the
kidney, it would be our duty to try and replace the
MOVEABLE KIDNEY IN WOMEN. 841

kidney by every possible means, at any stage of the com-
plaint. As in the case of strangulated hernia, the in-
flammatory and other concomitant symptoms would dis-
appear after reduction. But experience shows us that
forcible attempts at reduction are useless, and that the
complaint usually ends favourably without them. We should
therefore lay well to heart the advice of Rollet (190), which
is contrary to the ordinary views of the nature of this affection.
ollet says we should put off the reduction of the kidney
“until the inflammatory symptoms have yielded to anti-
phlogistic measures, which, as experience shows us, generally
happens ina few days.” Indeed reduction is usually contra-
indicated by the condition of the kidney itself, which swells
in a very short time, and in some cases in a few hours, to
double its size, and therefore is too big for its old situation.
But when, some days later, the inflammatory symptoms have
subsided, all attempts to'replace the kidney become at once
superfluous. For the cure of the kink, twist and subsequent
thrombosis of the renal vein proceeds spontaneously, either
by the establishment of a collateral circulation, or by organi-
sation of the clot, or by the undoing of the kink or twist in
the vein, without any interference, if the patient is kept on
her back.

If it is however decided to attempt reduction, the attempt
should be made in the first few hours of the attack, with the
greatest precautions, if possible, in a warm bath and under
chloroform, especially as we can never know whether the
renal vein is already thrombosed, and, if so, how far. Finally,
a purely expectative treatment and the avoidance of further
injurious influences are advisable. It is proper to assuage
pain by opium and warm baths according to the symptoms ;
if inflammatory symptoms become prominent, it is sufficient
to apply an ice-bag over the prolapsed kidney. It is also
advisable—not so much with a view to mitigating the inflam-
matory symptoms as to relieving the engorged kidney—
if the swelling becomes intense, to apply several (six to ten)
leeches to the renal region.

This expectative treatment must however be at once
abandoned, as soon as symptoms of a perinephritic or para-
nephritic abscess manifest themselves ; but this will be seldom.
342 MOVEABLE KIDNEY IN WOMEN.

Free incisions in the region of the abscess, and even the:
removal of the kidney are in this case, and this case alone.
indicated. This event is happily so rare, that I have not.
succeeded in finding a single case in point in recent litera
ture.

Treatment of Hydronephrosis im a Moveable Kidney.

Although Hydronephrosis in a moveable kidney shows its.
characteristic intermissions from a clinical point of view, we
can wait quietly till it has become stationary. But even then
nothing but the general treatment of hydronephrosis is
appropriate ; and indeed only two methods deserve considera-.
tion, namely, total extirpation of the sac, and establishment of-
an abdominal fistula from the pelvis of the kidney.

Kroner’s (191) list shows that the whole sac has been.
extirpated eight times up to the present date; of these.
operations four were performed unintentionally by mistake.
for an ovarian tumour; four were fatal. I will not discuss
the performance of the operation, nor the special question
whether the entire sac should be removed through: an
abdominal or lumbar incision, especially as the last interesting
question has been exhaustively discussed by Barker (192)
and Ozerny (193). We.should be particularly careful in
dealing with the pedicle, on account of the frequent abnor-
malities of the renal vessels, especially the vein, and on
account of an eventual thrombosis of the renal vein. As
in the case of tying the navel-string in new-born children a
clot may be pressed through the ductus venosus (Arantii).
(194), so here the same cause may force a clot in the renal.
vein also into the vena cava. Thus, in a case of Barker's,
embolism of the pulmonary artery was found after the
unfortunate removal of a sarcomatous moveable kidney.
The renal vein was found cut across close by the vena cava; it
was not observed either on dissection or during the operation ;,
there had been hematuria during life, so that it does not
seem to me impossible that death was caused in this case by
a clot in the renal vein, as described above.

The prognosis of the second method of cure now under
MOVEABLE ‘KIDNEY IN WOMEN. 343

consideration, namely, the establishment of an abdominal fistula
from the pelvis of the kidney, as recommended by Simon,
is far more favourable. All the cases hitherto treated in
this way, by Ahlfeld, Pernice, and Landaw ended favourably.
The evacuation of the urine. through the fistula in no way
interfered with the occupations of the patients; and the site
of the fistula, as my case (see Fig. 9) shows, was situated
most favourably for the escape of the urine.

With regard to the mode of operating, it is advisable to
operate at one sitting, as has already been often done after a
wrong diagnosis has been made, and as I have done inten-
tionally. In this case, as in that of abdominal hydatids (195)
and of extra-uterine pregnancy (196), I consider that my
plan of stitching the’ sac of the hydronephrosis (to the
abdominal wall) before opening it (as against Kroner’s plan)
offers decided advantages ; for the contents of the sac, which
may be mixed with pus, the products of decomposition, and
colloid masses, are not harmless to the peritoneal cavity. It
‘appears however highly disadvantageous to operate at two
or more sittings; of such methods, Simon’s method by
puncture is certainly the best.

The question whether, after an abdominal fistula has been
successfully established in connection with the pelvis of the
kidney, Simon’s proposal of passing a probe along the ureter
from the bladder or from the wound, in order to make it
pervious again, and then closing the abdominal wound
should be adopted, has still to be discussed. But attempts
to effect this offer little prospect of success, as dissections of
hydronephroses show ; and even if they were to succeed, the
reappearance of the old hydronephrotic condition might be
anticipated, so that it seems better to put this operation
entirely aside.

An attempt might also be made to destroy the remains of
the kidney which still secreted urine, by caustics, the actual
cautery, &c; but this is painful, and (as Simon’s attempts,
in such a case which lasted for months, show) it is hardly
possible. In this case we should still have to perform
extirpation of the remains of the kidney by a subsequent
operation, which could have been done in the course of the
first operation. But this also seems to me unjustifiable, for
344 MOVEABLE KIDNEY IN WOMEN.

extirpation is a dangerous operation, and the presence of
kidney tissue which is still healthy, able to discharge its
functions, and cannot be replaced, is here of the greater
value, since the risk of the affection of the other kidney (as
autopsies on cases of moveable kidney show) is increased.

In debating the question whether one should decide once
for all to extirpate the whole sac, or to establish a fistula,
apart from the above considerations, individual circumstances
must be considered, such as the age and occupation of the
patient, the presence of still active kidney tissue, and the
state of the other kidney. Other things being equal, I
would not myself decide on extirpation, even if it were no
more dangerous than the establishment of afistula. Hxperi-
ence shows that after the establishment of a fistula, the
flattened renal papille, now freed from pressure, recover
themselves and secrete urine nearly normal in quantity and
quality, so that by this operation the patient regains at once
the use of a kidney which had been rendered useless.

XIT. Oricginat OBSERVATIONS.

(1) Moveable Kidney on the right side, Pendulous Belly,
urinary troubles.

Cl. St—, 44 years of age, has had 11 children in 12 years,
the last seven years previously. She complains of violent pain
and a swelling in the right side, the removal of which had
been advised on the ground of its malignant nature. She
suffers from frequent calls to pass water, pains in the loi,
&c. After using a long pair of stays the patient feels quite
well, for the tumour is nothing but a moveable kidney.

(2) Moveable Kidney on the right side, Pendulous Belly.
D. Kr—, 32 years of age, has had 7 children and 2 mis-

carriages. She is to undergo an operation for an abdominal
tumour. She is a strong buxom woman with very little dis-
MOVEABLE KIDNEY IN WOMEN. 345

comfort, and nothing amiss except a moveable kidney on the
right side and a large pendulous belly. She gets on very
well with an abdominal belt and without an operation.

(3) Moveable Kidney on the right side, Pendulous Belly after
ovariotomy.

N. S—, 47 years of age, no children, observed an abdominal
tumour when only 19 years old ; this has constantly increased
for the following 24 years. When taken in to my clinique
the circumference of the abdomen was 108 centimetres.
After the removal of a multilocular ovarian tumour the
patient at first felt very well, but a ventral hernia formed,
and, together with lax shrivelled abdominal walls, contributed
to form a pendulous belly. Since then she has complained
of feeling as if she had something alive in her abdomen.
Examination shows a moveable kidney on the right side.

(4) Moveable Kidney on the right side. Sensation of a foreign
body in the abdomen, increased inconvenience during men-
struation.

Frau A. H—, 34 years of age, has had several children in a
short time. Since her last confinement (two years ago) she
says she has worked very hard and in doing so has strained
herself. She has never worn stays. Whenever she stands
she suffers violent dragging pain in the abdomen. Her
feelings, according to her own account, are ‘as if something
had been unhooked in her abdomen, or as if all her inside were
falling out. Now and then as if a heavy body turned round in
her belly.” If she lifts her right arm up she has a peculiarly
unpleasant sensation, “as if all her side was falling away.”
All her troubles are worse during her menstruation (which is
regular) and during work. Also she has frequent calls to pass
water, and has not been able to lie on the side for two years.

I found an unusually moveable kidney on the right side.
On moving this to and fro the same unpleasant sensations
846 MOVEABLE KIDNEY IN WOMEN.

were produced as those which the woman complained of.
The generative organs were normal except that the uterus
was low down.

The account of this woman, who was considered hysterical,
is all the more valuable from the fact that neither she her-
self nor the doctors who had treated her had detected an
abdominal tumour.

(5) Moveable Kidney on the right side, symptoms of tncar-
ceration, adhesions to the liver, jaundice.

J. W—, 55 years of age, has had 4 children, last menstrua-
tion nine yearsago. After the last confinement, sixteen years
ago, the patient observed a lump in the right hypochondrium,
which was at first very moveable. For some years she has
suffered from a peculiar boring and pinching pain deep down
in the abdomen. Two days ago she was suddenly seized
with retching and a darting pain in the abdomen especially
on the right side, and became much collapsed. The abdomen
is much distended and painful even on the slightest touch.
Percussion is dull from just below the liver to the level of the
iliac crest. Palpation is impossible on account of abdominal
tenderness. Improvement soon followed the use of opiates
and ice poultices. It was some weeks before the kidney
could be felt, easily displaceable into the lumbar region.
On pressing this kidney the patient complains of a circum-
scribed pain in the! left side of the epigastrium and the left
lo. The dulness below the liver has quite disappeared.
A year later, examination showed the right kidney no longer
so moveable as before ; on pressure it can be replaced into
the lumbar region, but on relaxing the pressure it soon
reappears, even in the horizontal posture, below the right
lobe of the liver.

Two years after the first acute attack Frau W— had a fresh
attack of violent pain in the abdomen, which again became
yery tender and distended, the tumour below the liver

1 The fact of pain on the opposite side to the kidney affected (see Cases 5
and 7) must be remarked. A similar transference of sensation is not very
rare in the case of the ovaries.—TRANSLATOR.
MOVEABLE KIDNEY IN WOMEN. 84:7

considerably increased, but little moveable, the kidney shape
recognisable. After some days distinct jaundice appeared,
and lasted some three weeks, accompanied by symptoms of
high fever which showed a distinctly intermittent type; the
spleen was very large. The fever only yielded to large
doses of quinine, so that I do not hesitate to consider this.
an intercurrent attack of ague. How far the adhesion of the
kidney to the right lobe of the liver, which had meanwhile
taken place, contributed to the jaundice, I will not decide.
At the present time the patient is quite well.

(6) Moveable Kidney on both sides, especially the left.

Cl. V. S—, 30 years of age, has had no children, she has.
menstruated regularly, and has lately lost much flesh, which
circumstance alone induces her to seek medical aid. On
examination on April 23, 1881, I discovered both kidneys
very moveable, especially the left, the uterus retroflexed ;
nothing else. There was no discoverable cause for the
moveable kidney except the extreme and apparently rapid
emaciation.

(7) Moveable Kidney on both sides, right more than left.

M. St—, 25 years of age, had a child five years ago..
Complains of violent pain, especially in the left side of the
abdomen, in the last left intercostal space, and in both loins.
The urine is now and again scanty and dark, during which
time the patient feels worse. She also complains of am
increase in all her symptoms at every monthly period. Both
kidneys moveable, the right more than the left. Pressure
on the right kidney causes pain in the left side. Moderate-
pendulous belly, moderate amount of subcutaneous fat. No
other cause than the habit of carrying a heavy coal-box om
the hips, as the patient has done for years, can be found.
348 MOVEABLE KIDNEY IN WOMEN.

(8) Intermittent Hydronephrosis in a Moveable Kidney on the
right side. Perinephritic abscess, establishment of an
abdominal fistula from the pelvis of the kidney at one
sitting. Cure.

C. M—, 60 years of age, has had 2 children, born respec-
tively forty and thirty-six years ago. After the last confine-
ment the generative organs became prolapsed. For about
the last ten years she has suffered from pain in the sacrum,
constant abdominal discomfort, epigastric pain, gastric troubles,
dragging and pain in the loins and pressure in the region of
the bladder. Hight years ago she observed for the first time a
moveable tumour in her abdomen, which however disappeared
from time to time, and was variously regarded by the different
physicians under whose care she was, as a hydatid of the
omentum, an ovarian tumour, and as a tumour of the liver.
On September 14, 1879, the patient came to my out-patient
room.

Present condition.—A pale emaciated woman with prolapse
of the anterior vaginal wall and uterus. In the right hypo-
chondriac and epigastric regions is a tensely elastic globular
tumour, passing almost imperceptibly into the liver above,
and reaching internally almost to the linea alba, externally
almost to the axillary line, and inferiorly some three centi-
metres below the level of the navel. The tumour is freely
moveable, especially inwards and downwards. On depressing
the tumour downwards, a sulcus is remarked between it and
the liver. The percussion note over it is dully tympanitic,
and quite dull only on the summit of the convexity; in the
axillary line it is impaired.

Aspiration with Dieulafoy’s finest needle (which withdrew
about three cubic centimetres) proved the contents of the
tumour to be a limpid fluid, white even to transmitted light,
clear, destitute of formed elements, non-albuminous, and
containing abundance of chlorides.!

It could therefore be only a hydatid of the liver or kidney,
or a hydronephrosis in a moveable kidney. After repeated
examination in different postures on September 20th, 1879,

1 Specific gravity P—TRANSLATOR.
MOVEABLE KIDNEY IN WOMEN. 349

and after withdrawing about three cubic centimetres of fluid
by a second aspiration, the operation was fixed for the fol-
lowing day. On the next day however the tumour had
disappeared, and percussion showed the presence of intestine
in its place. Deep palpation failed to detect any firm body,
even on pressing deeply beneath the right arch of the ribs.
On inquiry, the patient—who felt comparatively well—declared
that after the examination of the previous day she had passed
an unusually large quantity of limpid and clear urine, an
occurrence by no means unusual with her, for the quantity
of urine was constantly varying. The urine itself was
normal.

It was still doubtful whether the fluid from the cyst had
escaped by the fine puncture of the sac into the peritoneum
or had been passed per vias naturales. In the former case,
the diagnosis would remain doubtful, in the latter it would
certainly be hydronephrosis. It was possible that the kinked
or twisted ureter might have untwisted itself by rotation of
the sac in consequence of examinations in the very various
postures which had been adopted; or it was possible that
the diminution of pressure in the sac in consequence of
puncture might have removed a valvular impediment.

For the first few weeks however the diagnosis remained
doubtful, for the urticaria characteristic of hydatid did not
appear, and the tumour did not return. It was not until
February, 1880, that the patieat came back complaining of
unbearable pressure in the abdomen, and presented much
the same appearances as on the first examination. The
diagnosis of hydronephrosis was now sure, and was moreover
confirmed by a careful chemical examination of the fluid which
was now withdrawn in somewhat greater quantity. The
report on the result of this examination kindly made by
Priv.-Doc. Dr. Lewin is as follows :—“ The fluid was slightly
turbid and its reaction, as far as could be determined by
gaslight, faintly alkaline. The turbidity disappeared on the
addition of nitric acid, This circumstance shows the turbidity
to be due to the presence of phosphates. No uric acid
crystals can be found, and the proof of the presence of uric
acid by the murexide test remains doubtful on account of its
being conducted by (artificial) light. Urea, on the other
350 MOVEABLE KIDNEY IN WOMEN.

hand, is proved to be present; for after eliminating the
phosphates, the addition of nitrate of mercury to the fluid
gave a white precipitate of hydrargyrate of urea. The proof
of the presence of urea by converting it into nitrate of urea
succeeds even better; for on leaving the fluid treated with
nitric acid to spontaneous evaporation, characteristic rhombic
crystals of nitrate of urea lying over one another like tiles on
a roof, separated out.”

I was able to observe the refilling and emptying of the
cyst four times more, each time with the above described
symptoms connected with excretion of the urine. At last
however the sac did not disappear, the general health visibly
declined, a course of Carlsbad failed to improve the gastric
‘symptoms, continued pyrexia ensued, the aspirated fluid, which
was formerly clear and destitute of formed elements, contained
many pus corpuscles, so that I could no longer delay the
operation. Meanwhile the tumour had increased, and had
become very tense, and very tender to the slightest touch.

On June 20th, 1880, I operated, making my incision from
the angle of the right costal arch, more or less parallel to the
fibres of the internal’ oblique muscle, towards the navel, and
about twelve centimetres long; a fleshy-looking cyst-wall
appeared. As the excessive tension of the tumour prevented
its being grasped, it was punctured with a fine needle and
some 300 cubic centimetres of very purulent fluid drawn off,
the incision was then prolonged for some three centimetres
towards the axillary line, after which it became possible to
get round the tumour in all directions. It was found to be
bounded above by the liver, internally and in part anteriorly
by the intestines, externally by a second tumour reaching to
the vertebral column, which proved on puncture to be a
perinephritic abscess with thicker, more tenacious and more
purulent contents than those of the hydronephrotic sac. The
idea of the entire removal of the sac was therefore given up
on account of this perinephritic abscess, and the cyst-wall
was stitched to the abdominal wall on both sides of the

1 In the above sentence the word “internal” appears to be a mistake for
“external.” The fibres of the external oblique run downwards and inwards
those of the internal oblique in this region downwards and outwards.—
“TRANSLATOR.
MOVEABLE KIDNEY IN WOMEN. 351

wound, beginning from the inner angle of the wound, the
sutures thus running at right angles to the direction of the
incision. The peritoneal cavity was thus protected from the
escape into it of purulent fluid, a circumstance which proved
very useful in the sequel, for in an endeavour to lift the
tumour a little forward by grasping the posterior surface,
the wall of the perinephritic abscess tore, and ‘a copious dis-
charge of pus took place. The sac therefore, stitched to
the abdominal wall in its entire length, was cut through in
the direction of the first incision, and united with the peri-
nephritic abscess by incision of the partition between them
formed of atrophic kidney tissue, in order to establish a
single wound cavity. The part of the hydronephrotic sac
lying in apposition with the anterior abdominal wall does
not consist, as usual, of the wall of the pelvis of the kidney,
but of genuine kidney substance, flattened by pressure and
atrophied. This bled freely on incision and was tied en masse.
The fluid evacuated was highly purulent, its hydronephrotic
receptacle larger than a child’s head, everywhere studded
with flattened and atrophied portions of kidney. The open-
ing of the ureter could neither be seen nor found by a probe.

The sac was now further secured by several (12) sutures
and the cavity drained. The subsequent course of the case
presented nothing remarkable. On July roth the whole wound
was Closed with the exception of an opening at its inner angle,
as big as a finger. In this an india-rubber tube was left,
passing easily some fourteen centimetres into the cavity, and
allowing an easy escape to the urine which was at first scanty,
but gradually became more and ‘more copious, and also
permitting the cavity to be washed out. The fluid, which
was at first purulent, became more and more clear and
urinous, the sac contracted towards its ‘centre, the renal
papilles which were flat and atrophic became more and more
compact and hypertrophied. The ligatures on the renal
substance did not come away for three and a half months.
A renal papilla was seen to be slightly everted through the
inner angle of the wound. os

A portable urinal was not well borne, and was moreover
superfluous, for the patient was by no means impeded from
leading her ordinary life and pursuing her ordinary occupa-
852 MOVEABLE KIDNEY IN WOMEN.

tions with a simple linen bandage, and a simple drainage-
tube in the inner angle of the wound. The appended
drawing, taken after the expiration of a year, shows the scar

 

to have contracted, but otherwise to have undergone but
little change in relation to the wound. The fistulous
opening which remains, situated at the inner angle of the
wound, is only about one centimetre in diameter.

(9) Peculiar connection between Moveable Kidney and Hydro-
nephrosis (Eger).

Frau M—, 29 years of age, had been delivered of a son
ten years previously. Nine months later she began to feela
slight gnawing pain in the left lumbar region, which dis-
appeared after a short period of recumbency, and during the
next few years returned but seldom and-then always after
mental disturbance. Four years back she became pregnant
for the second time; during the first two months the gnawing
pain returned, and remained till sixteen weeks after her.con-
finement. At this time she weaned her child on account of

1 I had the opportunity at Breslau of examining this case, which was
under Eger’s treatment, and was described in the ‘ Berl. klin. Wochenschr.,’
1876, No. 28.—AvTHor.
MOVEABLE KIDNEY IN WOMEN. 353

anzmia. Shortly afterwards the pain in the left lumbar
region increased and violent attacks developed, which did
not leave the patient for years, defied all treatment, and
persisted until Hger saw her for the first time on January
13, 1874.

She is a slender but muscular woman, with normal circula-
tory and respiratory organs, normal spleen and liver dulness.
‘The only striking thing about her is the absence of subcu-
taneous fat, anemia and the remarkable laxity of the
abdominal walls. The attacks alluded to were much alike ;
their mode of occurrence was that, independently of phy-
sical exertion, imprudent conduct, the monthly period, or
psychical disturbance, the patient is attacked while at work
by a pain in the left lumbar region, radiating to the inguinal
and umbilical regions, which is so violent as at once to
render her incapable of work. A rigor then occurs, followed.
by violent vomiting of bile-stained mucus, with coldness and
pallor of the extremities, fainting fits, and deep depression
of spirits. The pulse is small, infrequent, no rise of tem-
perature. Immediately after the, commencement of the pain,
a smooth, bean-shaped tumour, with its convexity directed
outwards and downwards quickly makes its appearance
beneath the left arch of the ribs in the umbilical and hypogas-
tric region, which at once feels like the kidney. “Usually it is
closely apposed to the abdominal wall, but is nevertheless
overlaid by coils of intestine; it is always separated from
the hepatic and splenic dulness by wide areas containing
intestines. The tumour maintains the same size throughout
the attack, and is immoveable. Any attempt to displace it
is extremely painful and always unsuccessful. On one
solitary occasion the attempt to displace the tumour upwards
succeeded, though with enormous suffering, but the attack
-ceased. some hours earlier than usual.

Simultaneously with the appearance of the tumour, fre-
quent and very annoying desire to pass water set in, during
which only a few drops of clear and always non-albuminous
urine were voided.

A whole day usually, and often a day and night or longer,
elapsed before the attack ended. The troubles were as
severe during the whole night as by day, every morsel of
354 MOVEABLE KIDNEY IN WOMEN.

food and every drop of water swallowed were vomited. Then
the pain ceased, usually all at once, and the tumour disap-
peared as rapidly as it came, with eructations, vomiting, and
the passage of an increased though not considerable quantity
of urine, which was bright yellow, clear, and always non-
albuminous, and the health became perfect with the exception
of an easily intelligible weakness.

Inthis mannerthe attacksreturned at intervals of fourteen to
twenty days, once they ceased for six weeks. Anattempt to
prevent the descent of the kidney (which was the only imag-
inable condition) with a padded binder was unsuccessful.
Morphia alone afforded the patient constant, though only
slight relief.

Then, in July, 1874, the patient became pregnant again,
for the first time for three years. Instead of the relief hoped
for from the chance of the mechanical prevention of the
prolapse of the kidney, a considerable aggravation of the
symptoms ensued during the next few months. The attacks
became more violent and the intervals were often hardly as
long as a week. When at last the attacks seriously threatened
the general condition of the patient, they suddenly ceased
between the fourth and fifth months of pregnancy. The
patient became free from pain for the first time for three years, |
an occasional gnawing in the left inguinal region (which did
not amount to real pain) was the only reminiscence of the
terrors of the past. Pregnancy, and labour, which ensued
on March 12, 1875, ran their course without disturbance.
The uterus was however hardly quit of the child and after-
birth, before a tumour of the size of a small child’s head
pushed itself forward without any pain, in the left side of the
hypogastrium, beneath the left arch of the ribs. It was
tense, elastic, irregularly nodular, not tender on pressure,
and absolutely immoveable from its place. Entirely unlike a
kidney, it remained hardly half a centimetre from the linea
alba and usually had coils of intestine in front of it. The
percussion note over it was dull, or more or less tympanitic,
according to the position of the coils of intestine over it. It
was separated from the hepatic and splenic dulness by broad
bands of intestinal resonance. The uterus and its appendages
proved, on subsequent examination, to‘be entirely unconnected
MOVEABLE KIDNEY IN WOMEN. 355

with it, and normal. The tumour, which gave the abdomen
a peculiar, irregular appearance, underwent during the time
of its persistence not the least diminution in size or consis-
tence. There was always an evacuation of anormal quantity
of non-albuminous and clear urine.

With the exception of an uncomfortable feeling of reple-
tion, the tumour gave the patient no trouble. On the 15th
of May—eight weeks after her confinement—while the patient
was going to bed, she felt the size of the tumour diminish,
without any disturbance of her general comfort. Next
morning it had disappeared. The abdomen now remained
quite free from the tumour till May 28, on which day the
monthly period reappeared for the first time, with some slight
indisposition, and a feeling of weight in the lower abdomen,

‘but sleep was not especially disturbed by it. Next morning
a small tumour appeared in the old place, and within a few
hours reached the size of that which had been there. before
the confinement. It behaved in all respects like the former
tumour, and remained till June 20, without any disturbance
of the secretion and excretion of theurine. On that day the
patient washed the room and staircase with bare feet. The
next night she experienced frequent desire to pass water, and
passed an enormous quantity of limpid urine. Next morn-
ing the tumour had vanished, and has remained invisible till
now (August). The patient, who resumed her work in the
manufactory soon after her confinement, has never felt so
well as now, her appearance is incomparably more healthy.
Her urine, which has been frequently examined, is normal
in quantity, always bright yellow, clear, free from albumen
and morphological constituents.

In the annexed table I have given a short resumé of the
cases which I have observed up to April, 1881, and most of
which I have demonstrated in my courses for doctors in
practice and in my Lectures.
356

MOVEABLE KIDNEY IN WOMEN.

I. Moveable Kidney on the right side.

 

 

 

 

 

 

No Age. Aunibar af Solin Other ailments.
1. W.| 36 9 Retroflexion of the uterus.
2. R. | 32 7 Pendulous belly.
3. F. | 35 : Pendulous belly.
4. R. —.
5. B. ra 7 in 14 years| Prolapse of the anterior vaginal wall.
6. H. | 47 12 Cancer of the womb.
4. R. | 48 | 5 in 6 years | Retroflexion of the uterus.
8. D. | 32 Pendulous belly.
9. E. | 44 |7 ing years | Right inguinal hernia.
10. H. | 34 4 Extremely pendulous belly.
ir. M. | 28 4 Pendulous belly; prolapsus of the uterus.
12. T. | 32 |6in 73 years| Pendulous belly; descent of the uterus.
13. St. | 44 |11 in 12 years} Pendulous belly.
14. ©. | 24 ° Acute injury.
15.8. | 47 ° Ovariotomy.
16. R. | 30 | 8 in 7 years } Retroflexion of the uterus ; jaundice.
17. J. | 35 |6in 12 years| Pregnancy; wdema of right leg.
18. W.| 32 | 2in 1 year | Pendulous belly; symptoms of incareera-
tion.
1g. St. | 34 | 4 im 5 years | Pendulous belly; jaundice; gall-stones.
20. 8. | 30 7 Retroflexion of the uterus.
21. L. | 58 |8in 14 years) Commencing cancer.
22. H. | 34 8 Morphia habit.
23. H. | 39 10
24. Z. | 41 5 Right femoral hernia.
25. G. | 38 3 —
26. G. | 34 9
24. F. | 41 2
28. C. | 38 P
2g. L. | 51 P _| Retroflexion of the uterus.
30. L. | 49 P —
31. L. | 52 ? —
32. B. | 60 P Cancer of the womb.
33: BP. | 44 P a
34. G. | 40 P —
35. R. | 29 2
36. N. | 68 P
37. R. | 38 3 Descent of the uterus.
38. N. | 34 2 —.
39. W.| 55 4 Adhesions to the lower border of the liver;
symptoms of incarceration; jaundice.
40. M. | 59 2 Prolapsus of the uterus; hydronephrosis.

 
MOVEABLE KIDNEY IN WOMEN. 857

II. Moveable Kidney on the left side.

 

 

 

No. Age. Aan Eees ite Other ailments.
41. 8. | 40 I Pendulous belly.
42. W.| 36 P —.
III. Moveable Kidney on both sides.
43. St. | 25 I Repeated injury.
44. Sch.| 36 ° Consumption.
45. M. | 60 P Cancer of both kidneys.

 

 

 

Note.—In the above tables, under the head “other ailments,” the
author sometimes uses a dash (—), and sometimes a blank. It has been
concluded that their meaning is different, and that the dash (—) is
equivalent to “ ditto.”—TRansLaToR. .

Note.—These figures are capable of various summaries; but one is too
important to omit. It will be seen that the following conditions occurred as
below.

Pendulous belly ‘ . occurred in 11, or about 25 per cent.
“Retroflection””’ of the uterus __,, hs 15 os
Descent of uterus or vagina a 6 ” 13 ”
Hernia : ‘ ‘ ‘ 55 3 » 7 9

Now, “retroflexion” is the only term here used for backward displace-
ments, and no note is taken whether it was accompanied or not by some
descent. It becomes increasingly probable that backward displacements are
indications of descent, which is therefore the main condition. If it were
true that these 7 cases of “retroflexion” were of this nature, we should
have the remarkable result that descent of the uterus or vagina, with or
without backward displacement, occurred thirteen times in 45 cases. or in
nearly 30 per cent.

Family history does not find place in this memoir, but in
any subsequent investigation inquiry should be made for
rupture, prolapsus ani, descent of the uterus, §¢., varicose
veins, and other “hernial” conditions. Though not always
found, family histories are sometimes unexpectedly compre-
hensive, as the following family history of a woman who came
to me at St. George’s Hospital a few days ago will show :

Emma R—, xt. 52, lawndress, complains of womb coming
358 MOVEABLE KIDNEY IN WOMEN.

down outside for twenty-five years.’ (It is im fact procident.)
Father had a rupture, mother a procidentia. Patient’s eldest
daughter (zt. 30) has a procidentia ever since xt. 21. All
patient’s sons (three) had prolapsus ant as children.

Similar histories could no doubt be multiplied by observers
with such material as lies at the disposal, for instance, of the
Truss Soctety.—TRANSLATOR.

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(137) lie, S. 211.

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(142) s. below, cap. xii.
REFERENCES. 363

(143) Cole, British Medical Journal, 1874, 26 Sept.; Med.-Chir. Tyans.,
vol. xli, p. 221, 1846.

(144) Morris, On a Case of Intermitting Hydronephrosis, Med.-Chir. Trans-
actions, vol. lix, p. 224,

(145) Eger, Ueber eine eigenthiimliche Verbindung von Wanderniere mit
Hydronephrose, Berl. klin. Wochenschr., 1876, No. 23. ;

(146) s. Centralbl. f. Chir., 1881; Verhandl. des deutschen Chirurgen-
Congresses.

(147) Tulpii, Novae observationes medicinae, editio nov. Amsteloduni
Elzevir, 1672, p. 173.

(148) Boissiers de Sawvages, Nosologia methodica, Amstelod., 1773, t. iti,
8. 367.

(149) Johnson, Monthly Medico-Chirurgical Journal, July, 1816 ; see Kénig,
Praktische Abhandlungen iiber die Krankheiten dev Nieren,
Leipzig, 1820, 8. 189 ff.

(150) le, S. 274.

(151) lc, SS., 360, 361.

(152) Hillier, Transactions of the Royal Medical and Chirurgical Boctety:
vol. xlviii, 1856.

(153) 1. ¢., and British Medical Journal, 1876, April 29.

(154) see Krakauer, Ueber Hydronephrose, Inaug.-Diss., Berlin, 1880.

(155) Montaux, Observat. clinic., Paris, 1789.

(156) Botnet, Archives générales de médecine, 1835, p. 348.

(157) Meckel’s Archiv fiir Anatomie u. Physiologie, 1828, p. 355.

(188) Rolled, 1. c., 8. 24.

(159) Piorry stad Maillot, Untersuchungen der Niere mit dem Plessimeter.

_ Examinateure médicale, 1843, Avril, s. Canstatt, 1843, Bd. iii,
8. 464.

(160) Guttmann, Klinische Untersuchungsmethoden der Brust- und Unter-
liebs-Krankheiten, 8. 351, 3 Aufl., 1880.

(161) Weil, Handbuch und Atlas der topographischen Percussion, Leipzig,
1880. P

(162) lic, S. 556 ££.

(163) l.c., S. 338 £.

(164) Skoda, Abhandlungen tiber Percussion und Auscultation, iii Aufl,
1850, 'S. 222.

 

1 Ancient authors include the condition which we now call Hydronephrosis '
(Rayer) under the name Ischuria. Even Galen must have known this con-
dition, as appears from a passage in lib. 3, de symptom. caus., p. 246: “Cum
urina omnino in vesicam non venit, vocat etiam vulgus medicorum ischuriam,
quamquam ischuria non sit, et permittendi sunt profecto ita nominare, cum
propriam appellationem non habeant.” i

[The original is as follows: (Ed. Chart., vii [98]. Ed, Bas., iii raga
keg’ 4 [98].) “ «eadovor d8 oddéy arrov of wodXoi Tay iarpdy ioxoupiay Kaxetvo
78 cbprrupa, Kairorye ob« iy ioxoupia, tedyy pndddus cig ry Kborw agucveirat
76 odpov, daohAupivyg riv veppay Tijc évepysiac. Kai cvyxwpytiov ye adbroic
évopdZew obrws amopovot mpoonyopiag éucciag.” —TRANSLATOR. |
364 REFERENCES.

(165) 1. ¢., 8. 550.
(166) Lauenstein, Archiv fiir Chirurgie, Bd. xxvi.

(167) 1. c., No. 18.

(168) s. Jenner, British Medical Journal, Jan. 2,18; Feb. 6, 13; March[6,
1869; and Freund, Hufeisen-Niere, Beitrage zur Geburtshiilfe
u. Gynikologie, iv, 2.

(169) 1. ¢., 8. 759,

(170) l.c., 8. 176.

(171) Ivec., S. 757.

(172) l.c., 8. 50.

(173) s. le Ray, 8. 45.

(174) Spiegelberg, Die Diagnose der Eierstockstumoren, besonders der Cysten,
in Volkmann’s Sammlung Klin. Vortr., Bd. ii, 8. 445.

(178) Spencer Wells, Lancet, 1865, und Eierstocksgeschwiilste (P “ Diseases
of the Ovaries”).

(176) Landau, Ueber den Werth der Rectaluntersuchung mit der vollen
Hand., Arch. fiir. Gyn., Bd. vii, 8. 541, 1875.

(177) l.c., S. 217.

(178) lic, 8. 120.

(179) l.c., 8. 527.

(180) l.¢., S. 527.

(181) lc, 8. 763.

(182) Le, 8. 28.

(183) s. Deutsche medicinische Wochenschr., 1881, 4 Juni; Anm. Referat
iiber den Chirurgen Congress, 1881.—In the meantime Hahn has
described (in the Centralblatt fiir Chirurgie, Juli, 1881) two cases
treated by him by the operation of sewing. The above considera-
tions, however, are not in the least weakened by Hahn’s statement
that one case was cured, since the period during which they were
observed is far too short. Moreover (with a view to estimate such
isolated cases of alleged cure properly) it should be remembered
that King saw improvement follow an abortive attempt to remove
a moveable kidney.

[The name “ Nephrorrhaphy ” has been lately given to this operation.
For an account of its first performance in England by Dr. David
Newman, see Lancet, April 28, 1883, p. 749. Relief is said to have
resulted.— TRANSLATOR. |

(184) Buch, Ueber die Behandlung des Tleus mit Massage, Berl. klin.
Woch., 1880, No. 41, 8. 584.

(185) 1. c., 8.522.

(186) Ibid. and Barker, Med.-Chir. Transact., Ixiii, 1880, p. 588.

(187) Schmidt's Jahrb., 1881, i Heft.

(188) Willis, Die Krankheiten des Harnsystems und ihre Behandlung.
Uebersetzt von Heusinger, Hisenach, 1841, 8. 462 £f.

(189) Virchow’s Archiv, Bd. xxii, 1878; Falk, ibid., 1881, Bd. Ixxx.

(190) le, 8. 31.

(191) Kroner, Rechtsseitige Hydronephrose, &c., Archiv fiir Gynikol.,
Bd. xvii, 8S. 102, 1881.
REFERENCES. 3865

(192) Barker, Nephrectomy by Abdominal Section, Med.-Chir. Transact.,
vol. lxiii, 8. 182 ff.

(193) Czerny, Archiv fiir klin. Chir., Bd. xxv, Heft 4, und xxvi, Heft 4.

(194) Landau, Ueber Melaena Neugeborener, nebst Bemerkungen itiber die
Obliteration der fotalen Wege, Breslau, 1874.

(195) Landau, Zur operation der Echinococcen in der Bauchhéhle, Berl.
klin. Woch., 1885, Nos. 7 and 8.

(196) Landau, Zur Lehre der Hierstocks-schwangerschaft, Archiv fiir Gynak.,
1880, Bd. xvi, 8S. 436.

[See also D, Newman, Glasgow Med. Jour., Aug., 1883.—TRANsLATOR. |
INDEX.

PAGE PAGE

Abdominal bandages in the treat- Albuminuria in animals as an
ment of moveable kidney . 335 effect of heat 36, 48
— organs, relation of kidneys to 238 — in fevers , 89, 109
— pain in typhus and typhoid . 183 — in petroleum poisoning . - 89
Abscesses in connection with —in phosphorus poisoning 36, 80
moveable kidney . - 298 — in progressive anemia . - 86

Absorption of surrounding fat as

a cause of moveable kidney . 265
Affections of the abdominal walls

as a cause of moveable kidney . 267
Albumen, forms in which excreted 3

— innormal urine . 15, 138
— intransudations . a 24, 140
— in urine after digestion. 19, 44 |
— — of animals . - 20
— losses of, in albuminuria . 141
— modifications of,inurine . 8
— morbid conditions of, as a
cause of albuminuria . 95
— urinary, source of . : .
— — tests for . - 14
Albuminuria, after division of the
renal nerves . 46

— after ingestion of egg-albumen 100
— after ligature of the renal

artery . . - 61
— — of the renal vein | . 57
— — ofthe ureter . ° - 63
— alcoholic beverages and . 147
— as a result of increased tem-

perature . i 47
— asaresult of muscular exer-

cise . 51, 151
— asa result of the condition of

the blood . é 94
— as depending on altered blood-

pressure . . - 39

— diet most suitable for . - 145
— drugs used in treatment of . 144
— factorsof . 1
— from degeneration of the
renal epithelium . wo
— hygienic treatment of . - 141
— in amyloid degeneration of
the kidneys. . . 121

 

in renal diseases proper . 112
in venous congestion of the
kidneys. 3 . - 56
meaning of the term . » 5
meat as diet for, its draw-
backs ‘ * 5 . 146

hi

— wilk diet for . 148.
— mixed . i : 2 . 12
— normal. ‘ a ‘ . 15
— true and false eo o5

— without lesion of kidneys - 96
Alcoholic pereraays and albumin-
uria . 147
Alterations in the blood pressure
as a cause of albuminuria . 39
Amyloid degeneration of the kid-
neys, albuminuria in . . 121
Anatomical lesions in typhas and
typhoid . ; - 207
Anatomy, pathological, of move.
able kidney. . 247
— topographical, of the kidneys 236
Anemia, progressive ee
albuminuria in - 86
Aorta, effects of ligature of. 44
Arteries, increase of blood-pres-
sure in, and albuminuria . » AL
Artificial supports for abdomen in
moveable kidney . 3 « 336

Baths, in the treatment of albu-

minuria . . 149
Bleeding, results of | in typhus

and typhoid. - 220
Blood, condition of, as a cause of

albuminuria =. 94

Blood-pressure, altérationa of, in
kidneys and albuminuria . 39
— diminished, results of . . 65
368 INDEX.
PAGE PAGE
Blood- -pressure, methods of in- Epithelium, renal, degeneration
creasing . - 42 of, in phosphorus poisoning 80
Bowels, state of in typhus and — of glomeruli, function of 78,1380
typhoid. . 7 . 181 | Eruption, duration of, in typhus
194, 196
‘Cardiac hypertrophy in renal dis- — in typhoid, its characters . 204
ease - 114 | — in typhus and typhoid . 191
Cases of moveable kidney, left side 256 — in typhus, darkness of, pro-
— — right side « 249, 344 portional to severity of dis-
Causes of moveable kidney - 264 ease . . . 203

— of typhus and typhoid 163, 167
Changes, qualitative, in blood as a

cause of albuminuria . . 100
‘Chloride of sodium as a test for
albumen . i , 14

Cholera, albuminuria in 3 100, 111
‘Circulation, disturbances of, in
moveable kidney . - 294
Climates, suitable, for cases of
albuminuria. 152
‘Coagulative necrosis of the renal
epithelium andalbuminuria . 89
Colon, obstruction of, due to
moveable kidney”. - . 289
‘Colour of eruption in typhus . 200
Complications of moveable kidney 330
— — treatment of - 340
‘Conditions likely to be mistaken
for moveable kidney é - 323
Congestion of kidneys, various

forms of . . : . 65
‘Convulsions, albuminuria i in » 51
Copland, Dr., on exanthematic

typhus: . 7 . 163

Crises in typhus and typhoid - 179
Cutaneous oedema in gertain renal
diseases, cause of . . - 117

Diagnosis of moveable kidney . 322
Diarrhoea in connection with state

of Peyer’s glands. . 214

— in typhus and typhoid . - 182

Digestion, albuminuria of 19, 44, 98
Digestive organs, symptoms con-

nected with, in moveable kidney 285
Diminished pines Sens and

albuminuria. 31
Displacements of the " generative
organs as w cause of moveable

kidney. - 268
Duration of typhus and typhoid,
differences in the. . - 171

Egg-albumen, results of ingestion
of . + 100, 142, 145
Epidemic Fever of Edinburgh,

report on . : - 178
Epithelium, renal, degeneration
of, asa cause of albumin-

uria . i : ‘ . 48

 

— varying statements regarding 198
Excretion of urine, disturbances

of, in moveable kidney . 801
Experiments illustrating inter-
mittent hydronephrosis - 315

Fat, absorption of, as a cause of
moveable kidney . ‘ « 265
Features of difference between
typhus and typhoid é - 163
Febrile albuminuria 89, 109
Ferrocyanide of potassium and
acetic acid as tests for albumen 14
Filtration in the kidneys . 25, 51
Fixation of kidney, mode of . 241

Gastric disturbances in cases of
moveable kidney . ‘ . 285

Glands, intestinal, state of, in
typhoid . « 212
Glandular ecrefion in the kidneys 32

Glasgow,epidemic of fever in 1836,
symptomsin . - 185
— Fever Hospital, cases in 1 1836 162
Globulin in the urine . si » 6
Grape sugar in normal urine - 2i

Hematogenous albuminuria - 97
Hematuria in moveable kidney . 300
Hemi-albumose (propeptone) - 10
Hydronephrosis and moveable kid-

ney, caseof - 352
— as produced by moveable kid-
ney . . 306

— due to angular insertion and
valvular closure of the

ureter - 309
— in moveable kidney, ‘treat-
ment of . ; . . 342

— intermittent 5 a . 312
— its relations to sexual dis-
orders : 5 3 - 269

Impure air, influence of, in the
generation of typhus ‘ - 164

Increase of temperature as causing
albuminuria =. + 86, 46

Injury as a cause of moveable
kidney. : ie » 273°
INDEX.

PAGE
Intra-abdominal pressure as: a
cause of moveable kidney - 265

Jaundice in cases of moveable
kidney . . 288

Kidney, moveable, in women - 233
— — etiology and pathogenesis
£

0 : . - i - 263
—-—as affecting pregnancy

and labour 5 5 . 316
— — casesof . e - 249, 344,
— — complications of - 830

—- — definition and nomencla-
ture . e . 3 . 236
— — diagnosis of . : - 322
— — history and literature of . 233
— — objective signs of . . 318
— — original observations re-
garding . 7 . - 344
— — pathological anatomy of . 247
— physical causes of . . 273
— prognosis in . 332
— references to authors on . 358

—-—vemovalof . . 338
— — statistics regarding . . 244
— — symptoms of . . - 281
— — topographical anatomy of 236
—-— treatmentof . ..:  . 333

if i ! i
Landau, Dr., on moveable kidney
in women , " ‘ 3
Lymph, formation and flow of, as
compared with urine 29, 187

233

Malpighian tufts, epithelium of
the, in relation to albuminuria. 24
Meat diet, drawbacks of, in albu-
minuria . = : . - 146
Memoir of Dr. A. P. Stewart « 222
Menstruation and moveable kid-
ney, connection between
— as influencing albuminuria . 151
Mesenteric glands, state of, in
typhoid. . 5 » «217
Metaphosphoric acid as a test for
albumen and peptone .
Milk diet in cases of albuminuria 148
Mineral waters in the treatment of —
albuminuria. 3 . 149
Mobility of kidney, conditions in-
fluencing . : . . 280
Moveable kidney in women . - 233
— — (see also Kidney, move-

able). .
Muscular action as producing
albuminuria . 5 51, 151

Nephritis, chronic, types of . . 114

- 268 ©

 

369

PAGE

Nervous symptoms in moveable
kidney z : : .
Neuralgias caused by moveable
kidney . . : . . 284
Nitric acid, as a test for albumen 14

283

Objective signs of moveable kidney 318
Obstruction of colon from move-

able kidney 2 5 - 289
Operations suggested in cases of
moveable kidney . 334
Oxalic acid in normal urine.  . 21
Pain, abdominal, in typhus and
typhoid . a 2 as . 183
Palpation in moveable kidney  . 320
Pathological anatomy of moveable
kidney . . . 247
Peptone and peptonuria 8, 102
erinephritic abscess in'a case of
moveable kidney 348

Percussion as a means of diagnosis
in moveable kidney . : - 318
Petechiz and ecchymoses in ty-
phus and typhoid’ - |. “ , 193
Petroleum-poisoning and albumin-
‘uria. |. a é . - 89
Peyer’s glands, state of, in typhoid 211
Phosphorus-poisoning and albu-
_ Ininuria . , Ke - 80
Pregnancy'and labour, phenomena
of moveable kidney during 316
=— as a cause of moveable kidney 266

Prognosis in moveable kidney . 332
Pro-peptone, tests for . 12,13
Pro-peptonuria 9, 102

— cases of “ 10, 11

Psychical affections, as influencing
albuminuria... ’ , 151

Rabbits, experiments on, with

phosphorus. ‘ . 82
References to authors on move-

able kidney ; . - 358
Relaxation of the peritoneum as a

cause of movéable kidney - 265
Removal of moveable kidney - 338

Renal artery, effects of compres-
sing and tying . 3 - 61
— cirrhosis is - 115
— diseases proper, albuminuria
in. ‘ . 7 - 112

— incarceration in patients with
moveable kidney - 290
— nerves, effects of division of . 46
— vein, effects of tying . . 57

— vessels, occlusion of, in move-
able kidney . . - 294
Reposition of moveable kidney . 334,

24
370 INDEX.
PAGE PAGE
Rest, bodily and mental, in the Typhus and typhoid, crises in ‘ . 179
treatment of albuminuria . . 151 — — differences in anatomical
Retardation of the blood-current, lesions in . : . 207
as a cause of albuminuria . - 26 — — Dr. Stewart on nature

Right kidney more often displaced
than left, reasons why. . 276

Secretion of urine in cases of move-

able kidney. - 800
Serum-albumin in the urine - 6
Sexual disorders, their relation to

hydronephrosis . - 269
Shampooing in cases of moveable

kidney. . 837

Skin, attention ‘to fanetions at
the, in the treatment of albu-
minuria . . 150

Statistics of moveable kidney - 244

Stewart, Dr. A. P., on typhus and

typhoid fever . . - 159
— memoirof . . . 222

Sweat and tears, secr etion of, com-
pared with that of urine . - 129

Symptoms connected with the

digestive organs in move-

able kidney - - 285
— — vessels in moveable kidney 285
— of moveable kidney’ . - 281
— of typhus and typhoid . . 180

Tables of cases of moveable kidney 356
ee increased, effects
of - 86, 46
Theories of urinary secretion 27,127
Tight-lacing a cause of moveable

kidney . - 275
Torsion of the ureter 1 as a cause
of hydronephrosis. - 811

Treatment of moveable kidney - 333
— of typhus and typhoid . . 219

Tweedie, Dr., illustrations of fever 160

Typhoid and. typhus, difference in

the duration of . é . 171
— cruptions in. - 204
— non-infectious character of . 169
—relapsesin . . 174
— state of mesenteric 2 glands i in 217
— — Peyer’s glandsin . . 211

Typhus and typhoid, cases of, in
Glasgow Fever Hospital . 161

 

and pathology of . - 159
— — features of difference be-
tween : f - 163
— — pain and diarrhea in 187
— — probable origin of . - 163
— — state of bowelsin . - 181
—-— summary of differences
between . ‘ : - 219
— — symptomsof . 5 - 180
— — tympanites in . - 185, 189
— — views as to treatment of . 220
Typhus, eruptionsin . : - 191
— petechiz and ecchymoses in . 193
— transmission of, through the
atmosphere . - . 168

Urea, increase of, in blood, in
fevers, phosphorus - poisoning,
&e. . 99

Ureter, effects of tying ‘ 63, 67
— torsion of, in cases of move-

able kidney * ‘ - 803
Urinary secretion, theories of 27, 127
Urine, a product of filtration and

of secretion 33, 128

— condition of, in venous con-

gestion of the kidney . 71

— secretion and excretion of,

in moveable kidney . - 300

Venous congestion of the kidneys
and albuminuria 56, 68

— effect of, on glomeruli and
secretory apparatus . . 70

_— resulting from ligature of

vein (57), of artery (61), of

ureter x

Vessels, symptoms connected with

the, in moveable kidney . . 285

Wandering kidney, description of 236

Waters, mineral, and baths for
albuminuria. . . 149

Women, moveable kidney i in . 233
REPORT

PRESENTED TO THE

TWENTY-FIFTH ANNUAL MEETING

OF THE

NEW SYDENHAM SOCIETY

HELD AT LIVERPOOL,

Aveust 87x, 1883.

WITH

Classiieds ist of Published Works

AND OTHER INFORMATION.

LONDON:

THE NEW SYDENHAM SOCIETY.

1883.
OFFICERS FOR 1883-84.

President.
*Sm WILLIAM BOWMAN, F.R.S., LL.D., Bart.

Wire- Presidents,

“HENRY W. ACLAND, M.D., F.RS.,
LL.D. (Oxford).

G. W. BALFOUR, M.D. (Edinburgh).

ROBERT BARNES, M.D.

*E. R. BICKERSTETH, Esq. (Liverpool).

W. H. BROADBENT, M.D.

JOHN CLELAND, M.D. (Glasgow).

Sm W. W. GULL, M.D., F.R.S., Bart.

Sm JOSEPH LISTER, F.R.S., Bart.

Sm WILLIAM McCORMAC,

Counc

. JAMES ANDREW, M.D.
J. H. AVELING, M.D.
THOMAS BARLOW, M.D.
*RICHARD BARWELL, Esq.
R. L. BOWLES, M.D. (Folkestone).
*J. CRICHTON BROWNE, M.D.
LAUDER BRUNTON, M.D., F.R.S.
THOMAS BUZZARD, M.D.
*W. B. CHEADLE, M.D.
W. CHOLMELRY, M.D.
W. CLEMENT DANIEL, M.D.
(Epsom).
J. LANGDON H. DOWN, M.D.
J. MATTHEWS DUNCAN, M.D.
JOHN EASTON, M.D.
BALTHAZAR FOSTER, M.D.

 

ROBERT McDONNELL, A.B., M.D.
(Dublin).
Sm JAMES PAGET, F.R.S., LL.D.,
Bart.
*Sirn G. H. PORTER, M.D. (Dublin).
*JAS. RUSSELL, M.D. (Birmingham).
WILLIAM RUTHERFORD, M.D.,
F.R.S. (Edinburgh).
HERMANN WEBER, M.D.
T. SPENCER WELLS, Esq.
il.
*T. F. GRIMSDALE, Esq. (Liverpool).
Cc. J. HARE, M.D.
G. E. HERMAN, M.D.
T. R. JESSOP, Esq. (Leeds).
THOS. KEITH, M.D. (Edinburgh)
*G. H. KIDD, M.D. (Dublin).
STEPHEN MACKENZIE, M.D.
*S. W. NORTH, Esq. (York).
W. B. PAGE, Esq. (Carlisle).
WILLIAM ROBERTS, M.D.
(Manchester).
G. H. SAVAGE, M.D.
J. W. F. SMITH-SHAND, M.D.
(Aberdeen).
SEPTIMUS W. SIBLEY, Esq.
*E. R. TOWNSEND, M.D. (Cork).

(Birmingham). *C. WHIPPLE, Esq. (Plymouth).
Trensurer.
W. SEDGWICK SAUNDERS, M.D., F.S8.A., 18, Queen Street, Cheapside, E.C.
Auditors.

E. CLAPTON, M.D.

S. FENWICK, M.D.

F. M. CORNER, Esq.

Bow. Secretary.
JONATHAN HUTCHINSON, Esq., F.B.S., 15, Cavendish Square, W.

 

Those marked with an Asterisk were not in Office last year.
REPORT

PRESENTED TO THE TWENTY-FIFTH ANNUAL MEETING oF
THE New SyprenHam Soctery.

 

In presenting their Report for the past year the Council
has little to state beyond the record of the works published
and the announcement of those in preparation. The
production of the Lexicon of Medical Terms has been
continued with as much speed as circumstances have per-
mitted, and two numbers have as usual been issued during
the year.

The issue for the current year will probably consist of—

A Fasciculus of the Atlas of Pathology.

Selections from the Works of Duchenne (of Boulogne),
edited by Dr. Vivian Poore.

Two or more Parts of the Lexicon of Medical Terms.

The first Volume of Hirsch’s work on Historico-
Geographical Pathology.

A Volume of Selected Monographs, of which Senator
on Albuminuria and Landau on Movable Kidney will
form part.

The works which have been issued during the past year
are the following :—

Dr. Stokes on Diseases of the Chest, with a Portrait of
the Author, and a Memoir by Dr. Acland.

The Collected Writings of the late Dr. Warburton
Begbie, edited by Dr. Dyce Duckworth, with a
Memoir and Portrait.
4 REPORT.

 

A Translation, by Dr. Hadden, of Charcot’s Treatise
on the Localisation of Cerebral and Spinal Disease.

The Sixteenth Fasciculus of the Society's Atlas of Skin
Diseases.

The Seventh and Highth Parts of the Society’s Lexicon
of Medical Terms.

Amongst those which are in preparation are the fol-
lowing :—

A Fasciculus of the Atlas of Portraits of Skin Diseases.

The Collected Works of Dr. Peacock, with Memoir and
Portrait.

One or more Volumes of Selected Clinical Lectures,
from German sources.

The Society’s accounts for the year have been audited
as usual, and a balance sheet prepared.
‘MHNUOO "WA
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‘NOLAVIO GUVMCH

 

 

 

 

 

 

 

 

 

 
 
 

 

 

 

 

 

 

 

 

 

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a

88

T ¥of LAGHS WONVIVE
CLASSIFIED LIST

OF THE

SOCIETY’S PUBLICATIONS.

 

PMevicine.

ON THE TEMPERATURE IN DISEASE: A MANUAL
OF MEDICAL THERMOMETRY. By Dr. C. A. Woxprr-
uicH. (Leipzig). Translated by Dr. Batnursr Woopman.
With forty Woodcuts and seven Lithographs.

“Tt is well to recollect that this contains not only observations on the
temperature in disease, but also in health, and is a complete epitome as.to the.
history of the subject up to date. It is a work of reference absolutely necessary
for all who would keep themselves abreast of the day in relation to so im-
portant a matter as corporeal temperature.” Edin. Med. Ffourn., May, 1872.

“In short, without pledging ourselves to Wunderlich as infallible, we may
say, emphatically, that his is a masterwork, in which every part of his subject
is considered with that thoroughness which comes of ripe knowledge. and.
reflection. Let us add that Dr. Bathurst Woodman, following one or two
laudable examples that have been set by other translators for the Sydenham
Society, has enriched the work with notes of his own observations and those of
other English writers, which are of no small value, and unquestionably do much
to make the volume complete and full.” — Lancet, April 20, 1872.

“ The translator has rendered into readable English, and enriched with
practical notes, a book which, even in its original form, has started into active
work many physicians in England, France, and America, and which now, in its
popular form, must render the diagnosis of disease infinitely more accurate.” —
Medical Times and Gazette, June 3, 1871.

‘‘ The publication of this volume marks an epoch in the history of medical
thermometry. The very possibility of such a book—full not only of exact
knowledge, but of important generalisations—is an indication that the great
problems relating to the alterations in the human temperature—the problems of
fever and collapse—are now being studied in a manner calculated to throw light
on the hidden processes of disease... .. The value of this great work of
Professor Wunderlich is that it lays open his vast clinical experience of the
thermometer, and that it sketches in general terms the course of the temperature
in various forms of disease.”—Glasgow Medical Fournal, August, 1871.

“This treatise displays so much perseverance and thoroughness, such’
admirable caution and insight, and such wide and minute learning, that it may
be said not only to establish this branch of investigation for the first time upon
a deep and lasting basis, but also to build up a very great part of the edifice,
and to point out with clearness the directions in which future labour must be
applied.”—Dr. Alibutt in Brit. and For. Med. Chir. Rev., April, 1870.

LECTURES ON CLINICAL MEDICINE, delivered at the
Hotel Dieu, Paris. By Professor Trovsszav. Five Volumes.
Vol. 1, translated, with notes and appendices, by the late
4 THE NEW SYDENHAM SOCIETY.

 

Dr. Bazrre. Vols. 2 to 5, translated from the third edition,
revised and enlarged, by Sir Jonw Ross Cormack.

“We are indebted to the New Sydenham Society for this rich contribution
to our medical literature. . . . . . Trousseau is an author to be read rather than
reviewed. He can only be criticised worthily at the bedside. .... . We com-
mend this great physician’s work to the study of every reader.”—Lancet,
October 15, 1870.

“The above-mentioned works constitute the nineteenth annual issue to its
subscribers of the New Sydenham Society ; and, though relating to different
subjects, we have classed them together, because it seems of more importance
to the profession that they should know the very valuable practical information
they can secure for one guinea, than at this time of day they should be
treated to an elaborate critique on Trousseau’s Clinical Medicine, or on
Wunderlich’s Treatise on Thermometry ; the worth of these volumes being well
known to all but the merest tyro in medicine.”—Edinburgh Medical Fournal,
May, 1872.

“ We should think any medical library absurdly incomplete now which did
not have, alongside of Watson and Graves and Tanner, the clinical medicine of
Trousseau. The work is full of the results of the richest natural observation,
and is the production of one who was enlightened enough to combine with new
methods of investigation the vigorous and independent ideas of the old
physicians, whom he so eloquently magnifies. The volume is an extremely
rich and valuable addition to the library of physicians and practitioners gene-
rally,”—Lancet, December 4, 1869.

LATHAM’S COLLECTED WORKS. 2 vols. Edited by
Dr. Roszrt Marti. With Memoir of Larsam by Sir Tuomas
Warson.

“It indicates discrimination and taste on the part of those who conduct the
New Sydenham Society, that they have selected for publication a work so
different in many respects from the ephemeral books which issue in such
numbers from the teeming press of the present day...... This is one of the
few books which deserve to live, because it is full of real and conscientious
work,—of observations, carefully, reverently, and modestly made during a long
series of years,—of thoughts pondered and repondered with candour and self-
distrust and willingness to be taught, while the literary execution is unmistakably
that of a man of education, culture, and taste.””-—Edinb. Med. ¥our., March, 1877.

“The different subjects are dealt with in a way which will always render
them fresh to the reader from tbe peculiarly original bent of the writer’s mind,
and the acuteness of his reasoning. We quite agree with the editor that
‘where all are so admirable, it were perhaps well to avoid the singling out of
any one as though pre-eminently good.’ If we made any exception to this, it
would be to specially direct attention to the articles on ‘Treatment’ and
‘Cure.’ We commend their perusal to all practical physicians.’—Dublin
Fournal of Medical Science, August, 1879.

 

CLINICAL LECTURES ON MEDICINE AND SUR-
GERY. Translated from the German, and selected from Pro-
fessor Volkmann’s Series. Two Volumes..

 

MEMOIRS ON DIPHTHERIA; containing Memoirs by
Bretonneau, Trousseau, Daviot, Guersant, Bouchet, Empis, &c.
Selected and Translated by Dr. R. H. Sumere. :
CLASSIFIED LIST OF PUBLICATIONS. 3

 

“ Bretonneau’s memoir must be considered the fullest and most searching

that has et appeared in any country on this extraordinary dise e.”— British
t y seas

“Like honour is due to M. Bretonneau for his admirable investigations.
- ++. + His treatise on Diphtheria constitutes the greater part of the volume
recently published by the New Sydenham Society. Of the remaining memoirs
each contains much valuable material... ... There is no part of the volume
which will better repay study than the researches of M,. Empis.”—Medical-
Chirurgical Review.

RADICKE’S PAPERS ON THE APPLICATION OF
eee TO MEDICAL INQUIRIES. Translated by
1. Bonn. ‘

“We can hardly conceive an object to which the New Sydenham Society
could better devote a portion of its rapidly-increasing resources than to the
introduction of papers such as these to the profession. It is by such work as
this that the Society is calculated to confer inestimable benefits on the profession
of this country.”——Medical Times and Gazette, January 25, 1862.

 

LECTURES ON PHTHISIS. By Professor Nremnver. Trans-
lated by Professor Baumurr.

“‘ Niemeyer’s work is eminently suggestive, not only as regards pathology,
but alsé as regards treatment and prevention. There is no work on treatment
of Phthisis in the English language so advanced in its pathology; it leaves the
crude theories of Laennec and his followers far in the rear, and by showing the
essential dependence of tubercle on preceding inflammatory processes, it shows
also how we may ward off this intractable disease from our patients, and how
we may most usefully employ the remedies at hand for its prevention.”—
Edinburgh Medical Fournal, December, 1870.

“The members of the New Sydenham Society must be well content with
the works supplied to them for their subscription. Those issued of late are of
peculiarly solid and lasting value. We have now three before us, which,
besides the recommendation of intrinsic scientific value, have that of high
practical utility. We refer to Trousseau’s ‘ Clinical Medicine,’ Niemeyer’s
‘Lectures on Pulmonary Consumption,’ and Stricker’s ‘ Histology.’ "—Brit. and
For. Med. Chir. Rev., April, 1871. '

THE COLLECTED WORKS OF DR. ADDISON. Edited,
with Introductory Prefaces to several of the Papers, by Dr.
Wiixs and Dr. Datpy. With Portrait, and numerous Litho-

graphic Plates.

‘We must cordially commend the decision o1 the Council of the New
Sydenham Society, which led to the publication of this historically interesting
and practically valuable book. Few names have, of late years, been better
known to the profession than that of the eminent physician whose contributions
to its literature, too few in number, have nevertheless been, one and all, highly
and justly esteemed. A brief but kindly and discriminating biography of Dr.
Addison precedes the collection of his papers. .... .”—Edinburgh Medical
Fournal, December, 1868.

“No one who has studied the valuable papers, published by Dr. Addison
in the Guy’s Hospital Reports, can fail to be pleased that they are now rendered
more widely available by this separate publication, His great and extensive
6 THE NEW SYDENHAM SOCIETY.

 

knowledge of skin diseases renders the articles on that subject of much interest.
If, however, we were asked to select the one most likely to be useful to the
practitioner, we should unhesitatingly point to that on the Physical Examination
of the Chest.”—Medical Times and Gazette, July 4, 1868.

A GUIDE TO THE QUALITATIVE AND QUANTITA-
TIVE ANALYSIS OF THE URINE. By Dr. C. Neupaver
and Dr. J. Vocrn. Fourth edition, considerably enlarged.
Translated by Witiam O. Marxuam, F.R.O.P.L. With four
Lithographs, and numerous Woodcuts.

“ The New Sydenham Society have conferred a benefit, not only on their
own subscribers, but on the whole profession in this country, by publishing the
work of Drs. Neubauer and Vogel.”"—Medical Times and Gazette.

‘“ It is one of those works in which there is not an unnecessary line nor eyen
a word. It is quite a text-book upon urinology for the scientific physician, and
may be handled likewise by the youngest student.” —Lancet.

MEMOIRS ON ABDOMINAL TUMOURS AND INTU-
MESCENCE. By Dr. Bricur. Reprinted from the ‘ Guy’s
Hospital Reports,” with a Preface by Dr. Bartow. Numerous
Woodcuts.

“Dr. Bright’s object was to bring his vast clinical experience and great
diagnostic tact to bear on the elucidation of confessedly a most obscure depart-
ment of medical disease—the discrimination and diagnosis of abdominal
tumonrs; and this he has done by briefly stating their principal characteristics,
as they are produced, either by the presence of tumours dependent on a cepha-
locyst hydatid, by ovarian tumours, or diseases of the spleen, liver, or kidney.
Under each of these heads we have valuable features recorded, by which in life
they may be recognised, whilst after death their pathological characters are de-
scribed in a manner that leaves but one impression on our minds, that here
indeed the author has held up the mirror to nature; and under each section
we have a perfect embarras de richesse, in the shape of illustrative cases. The
whole work is profusely filled with woodcuts and outlines descriptive of the
several diseases described, by which means the author’s verbal descriptions are
more vividly presented to the ‘reader’s understanding.”—Dublin Quarterly
Fournal of Medical Science, May, 1861. :

_ The memoirs possess a permanent value, as models of clinical reports, as
exhibiting the method by which the investigation of this difficult class of
organic diseases may be pursued with greatest certainty of success, and as
furnishing the great general outlines of the inquiry. Itis by the study of such
models that the difficult art of medical observation may best be understood, and
may to some extent be acquired. Certainly no papers in our periodical literature
were more worthy than these of being republished and circulated in a eollected
and accessible form.”— Edinburgh Medical ¥ournal, January, 1861.

A CLINICAL ACCOUNT OF DISEASES OF THE
LIVER. By Prof. Frericus, 2 vols. Translated by Dr.
Morcuison. With coloured Lithographs, and numerous
Woodcuts.

‘ Frerichs’ book is one of those treatises that will frequently be taken down

Ben ae book-shelves to be consulted, both by physiologists and physicians.”
—Lancet.
CLASSIFIED LIST OF PUBLICATIONS. 7

 

“We shall look forward with interest to the completion of this very
hr ee addition to the Clinical History of Liver Diseases.’—Medical Times
ar azette.

CZERMAK ON THE PRACTICAL USES OF THE
[eee Translated by Dr. G. D. Grss. Numerous
oodceuts. :

“ What has been given will, we trust, convince any one who may hitherto
have doubted the value of laryngoscopy, that it is a real acquisition, To those
who are desirous of becoming more fully acquainted with the subject, we
strongly recommend the study of the work [Professor Czermak’s] from which
we have chiefly culled our extracts.” —Medico-Chirurgical Review, Oct., 1862.

A HAND-BOOK OF PHYSICAL DIAGNOSIS COM-
PRISING THE THROAT, THORAX, AND ABDOMEN.
By Dr. Paut Gurrmann, of Berlin. Translated by Dr. Narimr,
of Glasgow.

‘““ We are persuaded that if the practitioner will carefully study this work,
and conscientiously carry out its suggestions, he will find an incalculable
advance in the realistic appreciation of diseases by means of their physical
phenomena. The work is not properly a ‘ students’’ book. It presumes a
certain familiarity with the diseases of the organs with which it deals, and the
endeavour is made to connect the physical phenomena with the pathological
conditions present in these diseases...... It was a wise decision of the New
Sydenham Society to place a translation of it in the hands of their subscribers.”
—Glasgow Medical ¥ournal, March, 1880.

“The New Sydenham Society has done well to put within the reach of their
subscribers a work which not only has attained to a third edition in its own
language, but has also been translated into Italian, Russian, Spanish, French,
and Polish... ... . As a systematic and scientific treatise it well repays
perusal. The book concludes with a good account of laryngoscopy, and of the
physical signs of the principal diseases of the larynx: The acoustics of
percussion and auscultation are elaborated with great care, and the precise
explanation of the causes of many familiar physical signs will be very acceptable
to teachers of clinical medicine, who have hitherto felt the want of an adequate
scientific exposition of the principles of physical diagnosis.”—Dublin Fournal
of Medical Science, November, 1880.

AN ATLAS OF ILLUSTRATIONS OF PATHOLOGY,
COMPILED (CHIEFLY FROM ORIGINAL SOURCES)
FOR THE SOCIETY.

The Committee in charge of this work consists of Dr. Grz,
Dr. Greex, Dr. Moxon, Dr. Surroy, Mr. Hozmes, and Mr,
Hourtcainson.

FIVE FASCICULI have been published, and it is proposed
to issue one every year.

The following subjects have been illustrated ;——
8 THE NEW SYDENHAM SOCIETY.

 

FIRST FASCICULUS.
Scrofula; Syphilis; and Lymph-Adenoma.—Plate I.

Fig. 1. Scrofulous Disease of the
Kidney and Ureter. Fig. 2. Scrofu-
lous Disease of the Kidney. Fig. 3.
Scrofulous Disease of the Kidney.

Fig. 4. A Mass of Syphilitic Deposit’
in the Cortical Substance of the Kid-
ney. Fig. 5. Lymph-Adenoma of
Kidney.

Nephritis after Diphtheria; Scarlet Fever; and Burns.—Plate II.

Fig. 1. Nephritis after Diphtheria.
—Section of Kidney. Fig. 2. Subacute
Nephritis after Scarlet Fever.—Outer
surface of kidney. Fig. 3. Subacute
Nephritis after Scarlet Fever. Fig. 4.
Acute Nephritis after Scarlet Fever.
Fig. 5. Subacute Nephritis after

Scarlet Fever. Fig. 6. Acute Nephritis
after a Burn.—Outer surface of the
kidney of a child who died after a very
extensive burn. Fig. 7. Acute Ne-
phritis after a Burn.—Section ot the
same kidney.

The Granular Kidney in different stages.—Plate III. .

Fig. 1. Extremely Granular Kidney.
Fig. 2. Extremely Granular Kidney.—
Section of the same kidney. Fig. 3.
Less Granular (contracted) Kidney.—
Outer surface of the right kidney taken
from the same subject as the left
kidney shown in Figs.rand2. Fig. 4.

 

Granular Kidney of Bright. Fig. 5.
Contracted Granular Kidney, in sec-

tion, Fig. 6. Contracted Granular
Kidney; exterior. Fig. 7. Large
Granular Kidney. Fig. 8. Large

Granular Kidney with cysts.

Embolism ; Infarction Processes from Pyewmia; Jaundice and
Purpura; Scrofula.—Plate IV.

Fig. 1. Embolic Changes in Pyzmia.
Fig. 2. Embolic Changes in Pyzmia.
Fig. 3. Pyzmic Deposits in Kidney.
Fig.4. Pyzemic Deposits in the Kidney.
Fig. 5. Results of Jaundice and Pur-

pura. Fig. 6. A variety of the Scrof-
ulous Kidney.—The substance of the
kidney is wholly destroyed and re-
placed by cavities containing a white
mortar-like substance.

SECOND FASCICULUS.
Diseases of the Kidney.—Plate V.

Fig. «. Amyloid Disease of Kidney
in advanced stage. Fig. z. A section
of the same Kidney. Fig. 3. The pale

flabby Kidney. Fig. 4. The same
organ seen in section. Fig. 5. Me-
dullary Cancer of the Kidney.

Various Diseased Conditions of the Spleen.—Plate VI.

Fig. 1. Hodgkin’s Disease of Spleen
(Lympho-sarcoma). Fig. 2. Acute
Splenic enlargement in Diphtheria.
Fig. 3. Suppurating infarction of

Spleen from a case of Ulcerative En-

docarditis. Fig. 4. Embolic changes
in Pyemia. Fig. 5. Rupture of the
Spleen.

Diseases of the Supra Renal Capsules and Spleen.—Plate VIL.

Fig. 1. Cancer of the Supra Renal
Capsule. Figs. 2, 3, 4. Adenoma of
the Supra Renal Capsule. Fig. 6.
Addison’s Disease of the Supra Renal
Capsule (in section). Fig.5. Addison’s
Disease of the Supra Renal Capsule.—

‘“‘Fibro-calcareous or strumous dis-
ease.” Fig. 7. Tubercle of the Spleen
(external surface). Fig. 8. Tubercle
of the Spleen (in section). Fig. a.
Lardaceous Spleen,
CLASSIFIED LIST OF PUBLICATIONS. 9

 

Microscopic Pathology of Kidneys.—Plate VIII.

Fig. 1. Lardaceous Degeneration of
the Kidney.—Section of cortex. Fig. 2.
Lardaceous Degeneration.—g. A glo-
merulus from the same kidney, as in
Fig. 1, which has undergone lardaceous
degeneration and is becoming fatty.
Fig. 3. Part of the same seen with a
higher power, showing contents of one
of the tubules. Fig. 4. Lardaceous
Degeneration in earlier stage com-
bined with interstitial fibrous change.
Figs. 5 & 6. Lardaceous Degeneration
(after Cornil). Fig. 5. Section show-
ing the hyaline membranous wall of
the tubules a a much swollen, stained
violet-red, showing waxy degeneration.
Fig. 6. Transverse section of one of
the pyramids, near summit of cone.
Fig. 7. Granular Contracted Kidney.
Fig. 8. From the same.—A thickened
arteriole surrounded by fibroid growth.
Fig. 9. Partial Fibrous Degeneration
of Malpighian body in slight chronic
intertubular nephritis. Fig. 10. From

the same kidney; showing early
changes around Malpighian body.
Fig. 11. Multiplication of Nuclei on
glomerulus with adhesion of capillary
tuft to wall of capsule. Fig. 12. Sub-
acute Interstitial Nephritis with large
white kidney. Fig. 13. Scarlatinal
Nephritis.—Intertubular exudation in
a case fatal on 7th day of fever. Fig.
14. Subacute Interstitial Nephritis.
Fig. 15. Acute Catarrhal Nephritis,
showing swelling and granular de-
generation of epithelium. (100 diam.)
Fig. 16. Part of the same seen with a
higher power. Fig. 17. Section of
cortex from a case of parenchymatous
catarrhal) nephritls at a later stage
so-called “fatty”? kidney). Fig. 18.
From nearly transverse section near
base of pyramid in similar case. Fig.
1g. Casts in tubes in interstitial ne-
phiitis (post scarlatinal). Fig. 20.
Col'oid cast, b, in tubule; a, unaltered
epithelium,

Microscopic Pathology of the Kidney.—Plate IX.

Fig. 1. Scarlatinal Nephritis. Fig.
2. Shows two of the glomeruli from
same section as Fig. 1. Fig. 3. Sec-
tion from the same.—Part of the wall
of a Malpighian body from which the
capillary tuft has fallen out. Fig. 4.
Scarlatinal Nephritis.—(From a case
fatal about 12 weeks from attack of
fever). Fig. 5. Scarlatinal Nephritis.
—(From a case fatal 15 months after
attack of scarlet fever). Fig. 6. From
same kidney as Fig. 5, but in a deeper
part of cortex, close to medulla. Si-
milar growth of interstitial connective
tissue. Fig. 7. Subacute Interstitial
Nephritis, probably Scarlatinal, under
low power; showing diffuse infiltration
and cluster of dilated tubules. Fig. 8.
Chronic Parenchymatous Nephritis
(large white kidney) with little or no
interstitial change.—Section of cortex,
showing changes in epithelium of
convoluted tubules. Fig. 9. Kidney in
leucocythemia—to show localisation
of changes around glomeruli and ves-
sels. Fig. 10. Swelling of inner coat
of small artery in granular contracted
kidney. Fig. 11. Tuberculous Pyelo-
nephritis. Fig. 12. Fatty Degenera-
tion from Alcoholic Poisoning (after

 

Lancereaux). Fig. 13. Fatty Degene-
ration in Cancer. Fig. 14. Individual
epithelial cells from the preceding
section; in various stages of fatty
degeneration. Fig. 15. Cystic Dege-
neration of Kidney (after Lancereaux.)
Fig. 16. From a cyst in kidney near
base of pyramid. Fig. 17. Colloid
Degeneration of Kidney. Figs. 18,
Ig, 20, and 21, illustrate the hyaline
changes found in the splenic arteries
in certain febrile conditions. Fig. 18.
From a section through the spleen of
a case of early scarlatina, showing
hyaline degeneration of the coat of an
artery, transversely cut. Fig. 19.
Artery in longitudinal section. Fig.
20. Malpighian corpuscle from the
spleen of a case of early scarlatina.
Fig. 21. Part of the central and inter-
mediate zone of the same Malpighian
corpuscle as in Fig. 20, only more
highly magnified (180 diam.) Fig. 22.
Hodgkin’s Disease. — Section of a
spleen to show the overgrowth of the
lymphatic sheath in Hodgkin’s disease.
(x inch.) Fig. 23. Adenoma of the
Supra Renal Capsule, showing the
columns stuffed with fatty granules.
10 THE NEW SYDENHAM SOCIETY.

 

Microscopic Pathology of Spleen and SupraR enals.—Plate X.

Fig. 1. Capsulitis of the Spleen.—
Vertical section of fibrous nodule in
the capsule of the spleen, showing
that the thickening of the capsule
takes place by cellular growth in its
deeper layers. Fig. 2. Fibrosis of the
Spleen.—From the enlarged spleen of
aricketty child. Fig. 3. Fibrosis of
the Spleen.—Showing a more advanced
‘or fibrous condition spreading round
some dilated veins. Fig. 4. Muscular
Hypertrophy.—Over-growth of mus-
cular trabecule in the spleen. Fig. 5.
Muscular Hypertrophy. — Extreme
stage of fibro-muscular growth in the
spleen. Fig. 6. The Leucocythemic
Spleen.—Section of the edge of a
Malpighian corpuscle, showing the
compressed fibrous tissue between it
and the splenic pulp. Fig. 7. The
Leucocythemic Spleen.— The pulp
and stroma are normal. Fig. 8.

lymphoid nodule in the spleen of
Hodgkin’s disease. Fig.9. Tubercular
Spleen. (37 diam.) Fig. ro. Tuber-
cular Spleen. Fig. 11. Induration and
Atrophy.— A section of the spleen
from a case of heart disease. Fig. 12.
Lardaceous Spleen.—The sago spleen,
showing the Malpighian corpuscles
and small arteries mapped out by
structureless hyaline lardaceous mat-
ter. Fig. 13. Lardaceous Spleen.—
Transverse section of a Malpighian
corpuscle, or small artery, with its
surrounding lymphoid sheath. Fig,
14. Addison’s Disease.—Vertical sec-
tion of a supra renal capsule from the
exterior inwards, to show the early
changes in Morbus Addisonii. (250
diam.) Fig. 15. Addison’s Disease.—
Section of a supra renal capsule, to
show the late, or fibro-calcareous,
stage of Morbus Addisonii.

 

Hodgkin’s Disease.—The texture of a

With Essay on the Pathology of the Kidney, by Dr. Greenfield.
Essay on the Pathology of the Spleen and Supra Renals, by
Dr. Goodhart.

“We look on this Pathological Atlas, in all its three fasciculi, as one of the
best things that the Society has as yet done. The illustrations are nearly life
size; the colouring is beautiful and true to nature; and we have not seen in
this or any other country any work of this kind that satisfied us so much.
Taken alone, it would be well worth the annual guinea; and will, when
finished, constitute a treatise which every practising physician should possess.””
—Medical Press and Circular, June 2and, 1881. 2

THIRD FASCICULUS.
Diseases of the Liver.—Plate XI.

Lymphadenoma of Liver.

’ Diseases of the Liver.—Plate XII.

. Dilatation of the Bile Ducts in the Liver from pressure of a gall stone
in cystic duct.

Cancer of the Liver, with dilatation of the ducts and staining of the
hepatic tissue. .

Diseases of the Liver.—Plate XIII.
Syphilitic Cirrhosis of the Liver.

Diseases of the Liver.—Plate XIV.

. Red Atrophy, with acute Yellow Atrophy of the Liver.

Fig. z. Microscopical appearances of the yellow swollen parts of the Liver
(Acute Yellow Atrophy).

. Microscopical appearances of Red Atrophy of the Liver,

Fig. Ze
CLASSIFIED LIST OF PUBLICATIONS. 11

 

 

Diseases of the Liver.—Plate XV.

Fig. 1. Lardaceous Liver.

Fig. 2. Lardaceous Liver, showing the iodine reaction.

Diseases of the Liver.—Plate XVI.

Fig. x. Cancer of the Liver.

Fig. 2. Nutmeg Liver, Chronic Congestion, and Atrophy of the Liver from

mitral disease.

FOURTH FASCICULUS.

Diseases of the Liver, including one Figure of Spleen.—Plates
XVII. to XXII.

Diseases of the Liver and Spleen.—Plate XVII.

Fig. 1. Cirrhosis of the Liver resembling the Nutmeg Liver.
Fig. 2. Brown Atrophy of the Liver.

Fig. 3. Cirrhosis of the Liver.

Fig. 4. Lymphadenoma of the Spleen (Hodgkin’s Disease).

Diseases of the Liver.—Plate XVIII.

Fig. 1. Fatty Liver from Poisoning by Phosphorus.
Fig. 2. Cirrhosis of the Liver.

Fig. 3. Tubercular Liver.

Fig. 4. Cirrhosis of the Liver.

Diseases of the Liver.—Plate XIX.

Cystic Disease of the Liver.

Diseases of the Liver.—Plate XX.

Fig. 1. Lardaceous Disease of the
Liver. Fig. 2. Fatty Liver. Fig. 3.
Early Cirrhosis. Figs. 4&5. Cirrhosis
of the Liver (after Hamilton). Fig. 6.
Cirrhosis of the Liver. Fig. 7. A Ve-
getation from the surface of the Liver.
Fig. 8. Spindle-cell Sarcoma of the
Liver. Fig.9. Disseminated Growths

of Fibrous Nature in the Liver. Fig.
Io. Lardaceous Disease of the Liver.
Fig. 11. Cavernous Tumour in the
Liver. Fig. 12. Acute Yellow Atrophy
of the Liver. Fig. 13. Cavernous Tu-
mour in the Liver. Fig. 14. Early
Cirrhosis. Fig. 15. Columnar Epi-
thelioma of the Liver.

Diseases of the Liver.—Plate XXI.

Fig. 1. Cirrhosis of the Liver. Fig.
2. Cirrhosis of the Liver. Fig. 3.
Monolobular Cirrhosis. Fig. 4. The
Nutmeg Liver (Romose Atrophy of
Moxon). Fig. 5. Tubercular Liver.
Fig, 6. The Nutmeg Liver. Fig. 7.
Miliary Gummata. Fig. 8. Idiopathic

 

Anemia. Figs. 9 & 10. Cancer of the
Bile Ducts. Fig. 11. Cancer spreading
from the Biliary Ducts. Fig. 12. Early
Gummatous Infiltration of the Liver.
Fig. 13. ““Common” Cirrhosis. Fig.
14. Tubercular Liver. Fig. 15. Idio-
pathic Anemia.
12

THE NEW SYDENHAM SOCIETY.

Diseases of the Liver.—Plate XXII.

Fig. 1. ‘Pericellular’? Cirrhosis.
Fig. 2. Cirrhosis of the Liver. Fig. 3.
Nutmeg Liver. Fig. 4. Cystic Liver.
Fig. 5. Cystic Liver. Fig. 6. Early
Cancer of the Liver. Fig.7. Extreme
Tubercular Disease of the Liver. Fig.
8. Brown Atrophy of the Liver. Fig. 9.
Extreme Tubercular Disease. Fig. 10.

Myxcedematous Liver. Figs. 11, 12 &
13. “ Contracting Scirrhus of the Liver
simulating Cirrhosis.” Figs. 14,15 & 16.
Varieties of Cell Vacuolation and Pro-
liferation. Fig.17. Primary Adenoma

of the Liver. Fig. 18. Leukemic
Liver. Fig. 19. Primary Adenoma of
the Liver. :

FIFTH FASCICULUS.

Diseases of the Liver (chiefly of the Gall-Bladder and Larger
Bile Ducts).—Plate XXIII.

Syphilitic and Lardaceous Disease of the Liver.

Diseases of the Liver.—Plate XXIV.

Fig. 1. Abscesses in the Liver.
Fig. 2. Papilloma of the Gall-Bladder.

Diseases of the Liver.—Plate XXY.

Cancer of Gall-Bladder and Liver.
Gall-stones, with Obstruction and Dilatation of the Cystic Duct.

Diseases of the Liver.—Plate XXVI.

Cancer of the Stomach extending to the Cystic Duct.
‘“« We have nothing but praise to bestow on these plates, which are wonder-

fully good, and well worth the whole guinea subscription.”—Medical Press,
August 29, 1883.

ON THE DISEASES OF OLD AGE. By Prof. Caarcor.
Translated by Mr. Winuzam Tuxe.

‘The New Sydenham Society has been well advised in presenting to its
readers one of the most important neurological works which has appeared of
late years......
—British Medical Fournal, June 23, 1883.

THE DIAGNOSIS AND TREATMENT OF DISEASES
OF THE CHEST. By Dr. Sroxes. A Reprint Edited by
Dr. Hupson, of Dublin.

‘His fame as one of the foremost physicians of his age may, we think, rest
securely upon his two main works—on ‘ Diseases of the Chest,’ and on ‘ Diseases
of the Heart and Aorta.’ Each of these treatises is to be reckoned a ‘historical
landmark in medicine,’ and it was from this point of view, as it would seem,
that Dr. Hudson undertook the editing of the volume under notice.......
Prefixed to this edition is a graceful and sympathetic memoir of Dr. Stokes, by
his attached friend, Dr. Ackland.” —Dublin Fourn. of Med. Science. Oct., 1883.

THE COLLECTED WORKS OF DR. WARBURTON
BEGBIE. Edited by Dr. Dyck Duckworta. With a Memoir
and Portrait.

“The Council of the Sydenham Society, and Dr. Duckworth, in particular,

have done a good work in collecting these writings together into a volume, and
the profession in Scotland and in many places beyond will feel grateful to them

Charcot’s volume is a book to read and re-read forall of us.”
CLASSIFIED LIST OF PUBLICATIONS. 18

 

for this memorial of one who lives in the affectionate rememb

eae ad professional brethren and associates, and whe, indend peg
earned in the public esteem the title of the ‘beloved physician.’ °—-Edinb:
Medical ¥ournal, June, 1883. cacti Bdinbareh

“The New Sydenham Society has acted well within its best i
publishing this selection from the works of the late Dr. J. Warburton Begbie.”
—Lancet, July 21, 1883. ;

SELECTIONS FROM THE CLINICAL WORKS OF
DR. DUCHENNE (of Boulogne). Translated and Edited by
Dr. Vivian Poors.

“ The work of condensation and selection appears to have been admirably
performed; nearly all the material is drawn from Duchenne’s great work,

which bears the somewhat misleading title of ‘ L’Electrisation Lotalisée.’ "—
British Medical Journal, Jan. 12, 1884. ite

Surgery.

ESMARCH ON THE USES OF COLD IN SURGICAL
PRACTICE. Translated by Dr. Montgomery. Woodcuts.

‘“‘Esmarch’s treatise is of high practical interest.”’—British Medical Fournal,
December, 1863.

BILLROTH’S LECTURES ON SURGICAL PATH-
OLOGY AND THERAPEUTICS. A Hand-book for Students
and Practitioners. 2 vols.

“While being rendered in most fluent and unconstrained English, it is
singularly free from obscurities and ambiguities with which translations. gene-
rally abound.”—London Medical Record, April, 1878.

“Whether looked at as a text-book for students or as a work of reference
for the hard-worked and busy practitioner, it deserves to be spoken of in high
terms of commendation.”—Brit. and For. Med. Chir. Rev., July, 1873.

INVESTIGATION INTO THE ETIOLOGY OF THE
TRAUMATIC INFECTIVE DISEASES. By R. Kocu. Trans-
lated, with Lithographic Plates, by Mr. Watson Carynz.

ON THE PROCESS OF REPAIR AFTER RESECTION
AND EXTIRPATION OF BONES. By Dr. A. Wacner, of
Berlin. Translated by Mr. T. Hotmus.

CLINICAL LECTURES. Selected from Professor Volkmann’s
Series. 2 vols. (See ‘Medicine.”’)

THE WORKS OF ABRAHAM COLLES. Chiefly his
Treatise on the Venereal Disease and on the Use of Mercury.
Edited, with Portrait, by Dr. McDonnext, of Dublin. ;
14 THE NEW SYDENHAM SOCIETY.

 

 

Gynaecology.

ON THE MORE IMPORTANT DISEASES OF WOMEN
AND CHILDREN, with other Papers, by Dr. Goocu. Re-
printed; with a Prefatory Essay by Dr. Roperr Fercuson.
With woodeuts.

“ The work of Dr. Gooch is so well known and highly appreciated by every
lover of medical literature that we need say nothing in its praise. It has been
before the world for thirty years, and only one opinion has been expressed upon
its merits. We cannot but consider, therefore, that the Council of the New
Sydenham Society has done well to republish it, more especially as the Council
has had the good fortune to persuade Dr. Robert Ferguson to furnish an intro-
ductory essay on the author’s life and writings.”’—Lancet.

 

CLINICAL MEMOIRS ON DISEASES OF WOMEN.
By Drs. Bernurz and Govurit. 2 vols. Translated and abridged,
Dr. Mzapows.

“The careful study of these valuable memoirs is imperative on all who are
interested in gynecology.” —Lancet, October, 1866.

SMELLIE’S MIDWIFERY. 8 vols. Edited and Annotated
by Dr. McCutntocx, of Dublin. With Portrait of Sueuuin.

“ This book begins with a fine engraving of the author, and had the N.S.S.
done for Smellie’s memory no more than the publication of this valuable print,
it would have a strong claim on the gratitude of the profession. McClintock’s
life of Smellie is a very interesting contribution to medical literature. His
works show that he was a very great man and midwife, but his biography was
needed to show his peculiarities. ..... Let the reader carefully peruse Dr.
McClintock’s annotations, and he will see how Smellie’s Editor recognises
Smellie’s keenness of eye in discerning how to make progress.”—Edin. Med.
Fournal, March, 1877.

“ The New Syd. Soc. has doné nothing more commendable than to produce
the work we are now about to notice... ... Smellie was the Sydenham of
Midwifery. Although it was a chief part of his glory to have studied deeply
and soundly the mechanism of labour as a natural process, and in that study to
have laid the ample foundations of the highly finished art of midwifery as we
see it practised by the best obstetricians of the present day, we also see evidence
in every one of his ‘cases’ of shrewd and sagacious medical views, showing
that his great manipulative faculties were governed and controlled by good
judgment, physiological considerations, and that great respect for nature which
is a characteristic of all great physicians. ..... In short, he was a model
practitioner in midwifery whose influence grows rather than diminishes, and
whose works will be found to contain the germ of most of our practice and
doctrine. . . . . . Dr. McClintock has fairly placed alongside of Smellie’s prin-
cipal views those of modern authorities, including his own, derived from an
experience altogether exceptional, and has produced a joint work without which
no obstetric library will be complete.”—Lancet, August 4, 1877, is

 

 
A
CLASSIFIED LIST OF PUBLICATIONS. 15

Discases of the Eve and Lay.

ON THE ANOMALIES OF ACCOMMODATION AND
REFRACTION OF THE EYE, with a PRELIMINARY
ESSAY ON. PHYSIOLOGICAL DIOPTRICS. By F. C.
Donvers, M.D., Professor of Physiology and Ophthalmology in
the University of Utrecht. Written expressly for the Society. .
Translated from the Author’s Manuscript by W. D. Moors, M.D.
_ This splendid monograph, from the hand of the accomplished professor

. of physiology and ophthalmology, of Utrecht, will be hailed as a boon by all
lovers of ophthalmic science.” —Lancet.

THREE MEMOIRS ON GLAUCOMA AND ON
TRIDECTOMY AS A MEANS OF TREATMENT. By
Professor Von Grae. Translated by Mr. T. Wrvyvsor, of
Manchester.

“ This is the fifth volume of the first year, and contains translations of three
important and well known essays from the German.”—Lancet.

“ The value—the great practical value—of these memoirs will be admitted
by every one who peruses them.”’—Medical Times and Gazette.

ON THE MECHANISM OF THE BONES OF THE
EAR AND THE MEMBRANA TYMPANI. (Pamphilet.)
By Professor Hztmnortz. Translated by Mr. Hinton.

“ This little work is the translation of a very valuable essay published’ by
the great physicist of Berlin, and which is thus rendered accessible to a wide
circle of English readers.” —Lancet, July 5, 1873.

THE AURAL SURGERY OF THE PRESENT DAY.
By W. Kramer, M.D., of Berlin. Translated by Henry Power,
_Esq., F.R.C.8., M.B. With two Tables and nine Woodcuts.

VON TROELTSCH’S TREATISE ON DISEASES OF
THE EAR. Translated, with Notes, by Mr. Hinton.

 

 

Forensic Medicine,

A HANDBOOK OF THE PRACTICE OF FORENSIC
MEDICINE, BASED UPON PERSONAL EXPERIENCE.
By J. L. Caspzr, M.D., late Professor of Medical Jurisprudence
in the University of Berlin. Translated by G. W. Batrour,
M.D. 4 vols.

“ Casper’s great work, based as it is upon a minute and laborious. observa-
tion of facts, must prove the most trustworthy guide in the interpretation of the
ofttimes difficult questions which the medical jurist is called upon to solve.””—
Lancet.
16 THE NEW SYDENHAM SOCIETY.

 

“This work must be regarded as a valuable and judicious addition to the
publications of the Society from which it emanates. The advantages to be
derived by the reader from its perusal cannot be over-estimated or too eagerly
sought for.”—Madras Quarterly Fournal of Medical Science.

Diseases of the Perbous Systenr.

SCHRGEDER VAN DER KOLK ON A CASE OF
ATROPHY OF THE LEFT HEMISPHERE OF -THE
BRAIN. Translated by Dr. W. Moors, of Dublin. Four
Lithographs.

ON THROMBOSIS OF THE CEREBRAL SINUSES,
By Professor Von Duscu. Translated by Dr. Warriey.

LECTURES ON DISEASES OF THE NERVOUS
SYSTEM. By Professor Cuarcor. (First Series.) Translated
by Dr. Siczrson, of Dublin. With woodcuts.

“ These lectures of M. Charcot are too well known in the original to call
for any special criticism here. They have, indeed, obtained an European
reputation, and it has long been felt that it would be a great gain to our literature
to have them rendered into English... ... We strongly advise all those of
our readers who may not yet have made themselves acquainted with these
lectures to lose no time in doing so...... The translator, Dr. Sigerson, a
former pupil of the author, has succeeded admirably in his rendering of the
elegant literary style of M. Charcot...... It is, without doubt, one of the
most valuable books that has been issued by this Society since their translation
of Trousseau.”—Lancet, August, 1877.

“This volume will be highly prized by the members of the N.S.S. M.
Charcot’s name ranks among the very foremost of those who have advanced the
knowledge of nerve-pathology. The work he has done is marked by great
accuracy and close observation, and by great acumen in interpreting facts and
drawing inferences.” —Brit. and For. Med. Chir. Rev., July, 1877.

A SECOND VOLUME OF LECTURES ON DISEASES
OF THE NERVOUS SYSTEM. By Professor Cxarcor.

Translated by Dr. Stezrson. With this volume all the Plates
to the two volumes will be given.

A MANUAL OF MENTAL PATHOLOGY AND THERA-
PEUTICS. By Professor Grimstncrr. Translated by Dr.
Locxuart Rogerrson and Dr. James Ruruerrorp.

‘The thanks of the profession are due to the Council of the N.S. S. for
the selection of this work... ... We need scarcely say that each section is

full of instruction, and carries upon its face the evidence of great experience
and close and deep thought.”—Medical Times and Gazette, September, 1867.

ON EPILEPSY. By Professor Scureper VAN DER Koux.
CLASSIFIED LIST OF PUBLICATIONS. 17

 

CHARCOT’S TREATISE ON THE LOCALISATION

OF CEREBRAL AND SPINAL DISEASE. Translated
by Dr. Happen. :

“It will give to its reader a clear understanding of what is known of the
subject it professes to treat of.” —Edinburgh Medical Fournal, Dec., 1883.

“ Dr. Hadden is to be congratulated upon having produced a translation
of these valuable Lectures, which, whilst faithful to the text, is not marred by
being too literal.” —Medical Times and Gazette, October 27, 1883.

Anatomy, Phvstology, and General Pathology.

A MANUAL OF HUMAN AND COMPARATIVE HIS-
TOLOGY. By S. Srricxzr. 83 vols. Translated by Mr. Powzr.

“ This work, edited by Stricker, and having as its contributors nearly all of
the best names in Germany, is one well deserving of attention, and constitutes,
we think, a very valuable addition to the stores ot the New Sydenham Society.”
—Medical Times and Gazette, December 10, 1870. ,

‘There has hitherto been no work which contained a full and complete
account of the various elements of animal structure, still less of the way in
which minute examination of these elements should be conducted. The book
before us supplies this want in a very remarkable degree. ..... The work is
illustrated by over a hundred woodcuts. Modern medical literature of the
higher class so teems with histological references, that a treatise in which they
are explained has become almost a necessity.”—Lancet, December 3, 1870.

“We must congratulate the New Sydenham Society on their enterprise,
and thank them for making so important a work accessible to the English
reader.” —Quarterly Fournal of the Microscopic Society, April, 1873.

* Ably translated and edited by Mr. Henry Power. ..... The members
of the Society may be congratulated on the addition of such valuable treatises
to their libraries.” —Brit. and For. Med. Chir. Rev., July, 1873.

EXPERIMENTAL RESEARCHES ON THE EFFECTS
OF LOSS OF BLOOD IN PRODUCING CONVULSIONS,

By Drs. Kussmavz and Tenner. Translated by Dr. Browner,
of Bradford.

A MANUAL OF PATHOLOGICAL HISTOLOGY,
intended to serve as an introduction to the study of Morbid
‘Anatomy. By Professor Rinpriziscx. (Bonn.) 2vols. Trans-
lated by Dr. Baxrer.

Vor. 1.—‘ Rindfleisch’s work forms a mine which no recent pathological
writer could afford to neglect who desired to interpret aright pathological
structural changes. ... .. The special part treats of the anomaliés of the
blood, the circulatory apparatus, of the serous and mucous membranes, skin,
lung, liver, kidneys, and so on. As a specimen of the scientific spirit with
which Rindfleisch has entered upon his very laborious work, the reader cannot
do better than to peruse the part devoted to normal as a type of the pathological
growths, and that which immediately follows on interstitial inflammation and
specific inflammation. ....-.- Altogether the book is the result of honest, hard
labour,” —Lancet, April 6, 1872.

 
18 THE NEW SYDENHAM SOCIETY.

 

Vou. 2.— ‘The members of the Society may be congratulated on the
addition of such valuable treatises to their libraries... ... The Society ought
to flourish whilst it caters so well for its members. Thzy have every reason to
be content both with the quantity and quality of the matter supplied.”—Brit,
and For. Chir. Rev., July, 1873.

AN ATLAS OF ILLUSTRATIONS OF PATHOLOGY.
(See ‘« Medicine,” page 10.)

ON THE MINUTE STRUCTURE AND FUNCTIONS
OF THE SPINAL CORD. By Professor ScuRapER VAN DER
Kotx. Translated by Dr. W. D. Moorz. Numerous Litho-
graphs.

ON THE MINUTE STRUCTURE AND FUNCTIONS
OF THE MEDULLA OBLONGATA, AND ON EPILEPSY.
By Professor Scuraprr van pER Korx. Translated by Dr. W.
D. Moorz. Numerous Lithographs.

Retrospects, and Wilorks of General Reference.

A YEAR-BOOK OF MEDICINE AND SURGERY, AND
THEIR ALLIED SCIENCES, for 1859. Edited by Dr.
Harzey, Dr. Hanprimip Jones, Mr. Hurxe, Dr. Grainy Hewrrt,
and Dr. Opuine.

“Our space will not admit of a further statement of the excellent character
of the Year-Book and the other works issued by the New Sydenham Society,
but we should strongly urge every member of the profession, who has the
advancement of medical knowledge at heart, to lose no time in forwarding his
name, should he not already have done so.” —London Medical F¥ournal.

YEAR-BOOK for 1860. Edited by Dr. Harury, Dr. Hanpriztp
Jones, Mr. Hurxe, Dr. Gray Hewitt, and Dr. Sanprrson.

 

“ This is, as it professes to be, an improvement on its predecessor. On the
whole the editors have done their laborious work well.”—British Medical
Fournal, December 31, 1861.

YEAR-BOOK for 1861. Edited by Dr. Hartey, Dr. Hanprieip
Jones, Mr. Hurxe, Dr. Gramy Hewirr, and Dr. Sanperson.

YEAR BOOK for 1862. Edited by Dr. Monrcommry, Dr.
Hanprietp Jones, Mr. Winpsor, Dr. Grammy Hewirr, and
Dr. SanpErson.

YEAR-BOOK for 1863. By the same Editors.
CLASSIFIED LIST OF PUBLICATIONS. 19

 

YEAR-BOOK for 1864. Edited by Mr. Hinton, Dr. Hanprre.p
Jones, Mr. Winpsor, Dr. M. Brieut, and Dr. Hizton Facer.
‘Of the usefulness of these reports all who have consulted them will bear

the fullest testimony. They supply a very valuable bibliography; they enable

the reader to judge what papers or works he may study with advantage to his

peculiar pursuits; and they present a eondensed summary of the most im-

portant advances and improvements in medical science.”’—Edinburgh Medical

Fournal, a

A BIENNIAL RETROSPECT OF MEDICINE, SUR-
GERY, AND THEIR ALLIED SCIENCES, for the Years
1865 and 1866. Edited by Mr. Power, Dr. Anstm, Mr.
Horuus, Dr. Barnes, Mr. Winpsor, and Dr. Hinton Facer.

A BIENNIAL RETROSPECT OF MEDICINE, SUR-
GERY, AND THEIR ALLIED SCIENCES, for the Years
1867 and 1868. Edited by Mr. H. Powsr, Dr. Anstm, Mr.
Hotuss, Mr. R. B. Carter, Dr. Barnes, and Dr. THomas
STEVENSON. :

A BIENNIAL RETROSPECT for 1869 and 1870.

“ As to the Biennial Retrospect, it is as good as any of its class; while ot
little value to town practitioners, possessing easy access to large, well-selected,
and well-catalogued libraries, it is no doubt of great value to country practitioners
whose resources in that respect are more limited.’”” — Edinburgh Medical
Fournal, May, 1872.

A BIENNIAL RETROSPECT ior 1871 and 1872.

A BIENNIAL RETROSPECT for 1873 and 1874.

“ Full justice is done to English observers, and the whole volumeis creditable
to its compilers and to the Society under whose auspices it is published.”—
Lancet, January, 1876.

THE MEDICAL DIGEST. Being a means of ready reference
to the principal contributions to Medical Science during the last
Thirty years. By Dr. Ricuarp Neate.

“The Council has certainly acted wisely in publishing the work before us
It is a section of what has long been a desideratum—a general index to medical
literature, and as a section its great value cannot but suggest how inestimably
valuable a complete work of this kind would be. ....- Compiled by a
practitioner for his own use, it is calculated especially for the use of the
practitioner.”’—Lancet, January 5, 1878.

“ The idea of this volume is a good one. Something of the kind had been
all along contemplated by the Society, but never carried out till now, when Dr.
Neale offered his manuscript, exactly as it is printed. ..... We have been at
‘ the pains of testing the index in a good many instances, and have come to the
conclusion that it may be relied on for discovering easily the contents of the
volume.” — Edinburgh Medical Fournal, April, 1878.
20 THE NEW SYDENHAM SOCIETY.

 

BIBLIOTHECA THERAPEUTICA; OR BIBLIO-
GRAPHY OF THERAPEUTICS. By E. J. Ware, M.D.
2 vols.

“The preparation of such a catalogue as the present one must have
entailed enormous labour, such as few men are capable of, and such as rarely
brings them the thanks they deserve. We are quite sure, however, that all
those who are engaged in the study of Materia Medica, who are not satisfied
with merely looking at a few recent papers, but are desirous of learning all
that has been done regarding the particular drug which may be the object of
-their attention, will be exceedingly grateful to Dr. Waring for sparing them so
much labour.” —Practitioner, December 18th, 1879.

‘We feel sure that, although not exactly what we would like in a
work of the kind, Waring’s ‘ Bibliotheca Therapeutica,’ with its copious and
valuable indices, will be frequently referred to with advantage, and with
considerable confidence as regards its accuracy.”—Glasgow Medical Fournal,
Sept., 1879.

“With the Index of Diseases before him, the student has a bird’s-eye view
of the priticipal remedies recommended from time to time in the treatment of
individual diseases, and the dates of their respective employments; whilst
further reference to the body of the work, in the manner pointed out in the
index, will disclose the name of the authority, and other particulars of special
interest to the pathologist and therapeutist.”—From Preface to Vol. 2.

A LEXICON OF MEDICAL TERMS. Edited by Mr.
Power and Dr. Sepewicx. Parts 1 to 8. This Lexicon is
based upon the well-known work of Dr. Mayyz, the copyright
of which was purchased by the Society. It is, however,
entirely rewritten by the present Editors, and very much
enlarged. ”

“The work is carefully and elaborately done, and comprehends every

reference which the medical or scientific inquirer could possibly require.”—
Medical Press and Circular, June 22nd, 1881.

 

Diseases of the Skin and Syphilis.

ON SYPHILIS IN INFANTS. By Pavt Day. Translated
by Dr. Wurrizy.

_‘ The work of M. Diday is of great merit ; it contains dll that has been

written on infantile syphilis, and he puts the whole subject in a well-airanged

form for further investigation as well as present use.”—Brvit. and For. Med.
Chir. Rev.

ON DISEASES OF THE SKIN, INCLUDING THE
EXANTHEMATA. By Professor Hzsra. 6 vols. Translated
and Edited by Dr. Hizron Facer, Dr. Pyn-Smrn, and Mr.
‘Waren Tay.

_,‘‘Had we space we should have been glad to enter into a lengthened
critique of the second volume of Hebra’s work. We are relieved from any
misgiving, however, by the fact that the work will be very largely circulated
amongst our readers by the Sydenham Society, and that they, with others who

 
(

CLASSIFIED LIST OF PUBLICATIONS. 21

 

aspire to any real knowledge of skin diseases, would not, under any circum-
stances, be satisfied without studying the work for themselves...... This
second volume contains information relative to the most important diseases of
the skin; and_/it will, we are confident, do good service in helping on the cause
of cutaneous medicine in England.”’—Lancet, November 7, 1868:

‘Of all the works produced by the New Sydenham Society this is one of
the most valuable and most welcome. ..... It is: to be remarked that this
book is not a mere translation of the German work; it is.a new and revised
edition, undertaken by the author for his English brethren.’”—Medical Times
and Gazette, April 27, 1867.

“ The New Sydenham Society has done. good service to the medical pro-
fession by undertaking the translation and publication of Professor Hebra’s
excellent work. In several respects the English edition is greatly superior to
the original. In closing its pages we have but one regret, namely, that the
New Sydenham Society does not embody the whole medical confraternity,
so that every member of our noble profession might have on his bookshelves
a copy of this most valuable book.”—¥ournal of Cutaneous Medicine, April,
1877. ,

VoL. 3.—‘* Mr. Tay has performed a difficult task with great ability and
success, and the work is far pleasanter to read in its English dress than in the
original. Mr. Tay has enriched the work with valuable notes of his own,
embodying the views of English authorities and sometimes his own experience
on the question discussed in the body of the work.’—Medical Times and
Gazette, June 20, 1874.

VoL. 4 —‘ The entire work is admirable for its lucidity of arrangement, its
simplification of confused and intricate subjects, and not least for the avoidance
of those pedantic and repelling terms which a celebrated dermatologist has
grandiloquently styled the ‘terminological innovations of modern nomen-
clators.’”"—Dublin $ournal of Medical Science, May, 1875.

LANCEREAUX’S TREATISE ON SYPHILIS. 2 vols.
Translated by Dr. Wuittey.

“The work is the most exhaustive book which has been published on the
subject, and has been quoted by all the recent writers in this country, America,
and the Continent. It is a perfect mine of information. The translation is
well done, and the New Syd. Soc. may be congratulated on having added such
an important treatise to its list of works.”—Lancet, March, 1869.

 

The Society’s Atlas of Diseases of the Skin.

In sixteen Fasciculi comprising the following subjects. Unless
otherwise indicated, the Plates are original.

PLATE
Fayus, From Hebra. a‘ : . : ‘ « Ls
Tinea Tonsurans. From Hebra. : ‘ ; feds
Lupus Exulcerans. From Hebra. . ‘ ‘ . TI.
Psoriasis Diffusa. From Hebra. ; ‘ ‘ « LV. -
Ichthyosis. From Hebra. . . ~V.

Lupus Serpiginosus; Alopecia Areata. From Hebra. VI.
Lupus Vulgaris et Serpiginosus (Cicatrising). From
Hebra. ; ‘ : : : . . . VI.
22, THE NEW SYDENHAM SOCIETY.

 

PLATE

Herpes Zoster Frontalis (affecting the Frontal and —

Trochlear Branches of ‘the Fifth Nerve). VIII.
Molluscum Contagiosum, a, on a Child’s Face ; 3, on

the Breast of “the Child’s Mother ; c, ddatorical

Characters of the Tumours; p, Microscopie Cha-

racters. . : ‘ . .
Morbus Addisonii. X.
Leucoderma. XT.
Pemphigus. é XI.
Pityriasis Versicolor. XII.
Psoriasis Inveterata. . XIV.
Eczema Impetiginodes on Face of Adult. XV.
Eezema on the Face, &c., of Infant; Eezema Rubram

on Leg of Adult. XVI.
Psoriasis of Hands and Finger- nails; Syphilitic

Psoriasis of Finger-nails ; Congenito- Syphilitic

Psoriasis of Finger- and Toe-nails; a

Maligna; Chronic General Onychitis.. XVII.
Molluscum Fibrosum seu Simplex. XVOI.
Psoriasis-Lupus (Lupus non Exedens, in numerous

Symmetrical Patches). XIX.
Porrigo Contagiosa (e pediculis). XX.
Erythema Nodosum.. XXI.
Morbus Pedicularis. . : XXII.
Herpes Zoster (with scars of a ‘former attack). XXUT,.
Erythema Circinatum. XXIV.
Eezema (from Sugar). . XXYV.
Acne Vulgaris. . . : ; a . .XXVI.
Scabies (on Hand of Child). Scabies (with Gidema, *

&e.) Scabies Norvegica. ; ; . XXVII.
Porrigo Contagiosum after Vaccination. Circinate

Eruptions in Congenital Syphilis. : . XXVIII.
True Leprosy (Tubercular pe True Leo

(Anesthetic Form). . . XXIX.
Pityriasis Rubra. —. XXX.
Papular Syphilitic Eruption, with Indurated Chanere

on the Skin of the Abdomen. XXXI.
Pruriginous Impetigo after Varicella. . XXXII.
Lichen of Infants. XXXII.
Kerion of Scalp after Ringworm. XXXIV,
Eruption produced by Iodide of Potassium. XXXYV.
Tinea Circinata. XXXVI.
Rupia-Psoriasis (from inherited Syphilis). XXXVI.
Prurigo Adolescentium., . XXXVIII.
Purpura Thrombotica. i . XXXIX.
Syphilitic Rupia, with Keloid of Scars. XL.
Frambeesia (Hndemic Verrugas). XLI.
Lupus Erythematosus. XLII.
CLASSIFIED LIST OF PUBLICATIONS. 23

 

PLATE
Uleerating Eruption from Bromide of Potassium. . XLII
Morphea, or Addison’s Keloid. . j : : . SLIV.
Purpura Hemorrhagica. . ‘ ; ; : . XLV.

Molluscum Contagiosum, . ; ; : . . XLVI.

‘This Fasciculus supplies life size portraits of pityriasis rubra, papular
syphilis, with indurated chancres, and pruriginous impetigo following varicella,
which are extremely beautiful, and look life-like.”"—Edin. Medical Fournal,
May, 1872.

“ They are better, to our mind, than any other plates in use amongst us;
and there cannot be a question as to the Society’s issue being as popular as it
is useful.”—Lancet.

“ We have received the thirteenth fasciculus of this splendid collection of
drawings, of which no further praise is needed than to say that they are
executed with the same artistic skill and fidelity to nature which have charac-
terised the whole series.”"—Dublin Fournal of Medical Science, May, 1874.

A CATALOGUE OF THE PORTRAITS COMPRISED
IN THE SOCIETY'S ATLAS OF SKIN DISEASES.
Prepared, at the request of the Council, by Mr. Hurcurnson.
Parts 1 and 2.

‘‘ The descriptions, cases, and plates are well given... ... There is one
good feature in some of the cases described. Take that of Addison’s Keloid,
p. 160. In it we have notes, &c., of a rare skin disease, which has been
accurately described by the observers under whose care the patient had been at
various stages of the case. This is, therefore, a valuable contribution to medi-
cine.” —Edinburgh Medical Fournal, February, 1877.

 

 
Vou.

. Day on Infantile Syphilis.

. Goocs on Diseases of Women.

. Meworrs on Diphtheria.

. Van DER Koxx on the Spinal Cord, &c.

- Monoerarus (Kussmaul and Tenner, Graefe, Wagner, &c.)

oo COD eH

co Om OD

LIST OF PUBLISHED WORKS

Arranged according to the Year of Issue.

1859. (First Year.)

1860. (Second Year.)

 

. Dr. Briegnt on Abdominal Tumours.

. Frericus on Diseases of the Liver. Vol. I.

. A Yearsoox for 1859.

. Aruas of Portraits of Skin Diseases. (1st Fasciculus.)

1861. (Third Year.)

. A Yearsoox for 1860.

. Monocrapus (Czermak, Dusch, Radicke, &c.)

. CaspEer’s Forensic Medicine. Vol. I.

. Atuas of Portraits of Skin Diseases. (2nd Fasciculus.)

1862. (Fourth Year.)

. Frericus on Diseases of the Liver. Vol. II.

. A Yearsoox for 1861.

. Casprr’s Forensic Medicine. Vol. IT.

. Arzas of Portraits of Skin Diseases (8rd Fasciculus.)

1868. (Fifth Year.)

. Kramer on Diseases of the Ear.
. A YEarpoox for 1862.
. NEUBAUER and VocEt on the Urine.
LIST OF PUBLISHED WORKS. 25

 

Vou. 1864. (Sixth Year.)

al.
22.

23.
24,

32.
33.
84.
35.

36.
37.
38.
39.
40.

Casprer’s Forensic Medicine. Vol. III.

ee on the Accommodation and Refraction of the
ye.

A Yearsoox for 1863.

Artuas of Portraits of Skin Diseases. (4th Fasciculus).

1865. (Seventh Year.)

 

. A Yearsoox for 1864.
. Casper’s Forensic Medicine. Vol. IV.
. Artas of Portraits of Skin Diseases. (5th Fasciculus).

 

1866. (Highth Year.)

. Beanutz and Gouri on the Diseases of Women. Vol. I.
. Arzas of Portraits of Skin Diseases. (6th Fasciculus.)

. Hepra on Diseases of the Skin. Vol. I.

. Bernutz and Gouri on Diseases of Women. Vol. II.

1867. (Ninth Year.)
Brenn1au Retrospect of Medicine and Surgery.
GriesinceR on Mental Pathology and Therapeutics.
Artas of Portraits of Skin Diseases. (7th Fasciculus).
TroussEau’s Clinical Medicine. Vol. I.

1868. (Tenth Year.)
Tur Collected Works of Dr. Addison.
Hepra on Skin Diseases. Vol. II.
Lancerravx’s Treatise on Syphilis. Vol. I.
Arnas of Portraits of Skin Diseases. (8th Fasciculus).
Catatocur of Atlas of Skin Diseases. (First Part.)

1869. (Eleventh Year.)

. Lancerzaux’s Treatise on Syphilis. Vol. II.

. TroussEav’s Clinical Medicine. Vol. II.

. Brenntat Retrospect of Medicine and Surgery.

. Aruas of Portraits of Skin Diseases. (9th Fasciculus.)

1870. (Twelfth Year.)

. Trousseau’s Lectures on Clinical Medicine. Vol. III.

. Nremever’s Lectures on Pulmonary Consumption.

. Srricker’s Manual of Histology. Vol. I.

. Aras of Portraits of Skin Diseases. (10th Fasciculus).
26

THE NEW SYDENHAM SOCIETY.

 

Vou. 1871. (Thirteenth Year.)

49,
50.
51.
52.

57.
58.
59.
60.

61.
62.

63.
64.

65.
. Caratocus of Atlas of Skin Diseases. (Second Part.)
67.
68.
69.

70.
. Cuintcau Lectures by various German Professors. Vol. II.
72.

73.

74.
. Tux Medical Digest, by Dr. Neale.
76.
77.

WuwNDERLICH’s Medical Thermometry.

Brenniau Retrospect of Medicine and Surgery.
TroussEavu’s Clinical Medicine. Vol. IV.

Arttas of Portraits of Skin Diseases. (11th Fasciculus.)

1872. (Fourteenth Year.)

. Stricker’s Manual of Histology.. Vol. IT.

. Rinprietscn’s Pathological Histology. Vol. I.

. TroussEau’s Clinical Medicine. Vol. V.

. Arzas of Portraits of Skin Diseases. (12th Fasciculus.)

1873. (Fifteenth Year.)

Srricker’s Manual of Histology. Vol. III.
Rinprieiscn’s Pathological Histology. Vol. II.
Brenniau Retrospect of Medicine and Surgery.

Atuas of Portraits of Skin Diseases. (18th Fasciculus.)

1874. (Sixteenth Year.)

Hepra on Skin Diseases. Vol. IIT.

Von TrorutscH on Diseases of the Ear. /
Hetmuoutz on Membrana Tympani, &c. (In one Vol.)
Artas of Portraits of Skin Diseases. (14th Fasciculus.)
Hesra on Skin Diseases. Vol. IV.

1875. (Seventeenth Year.)
Brenntat Retrospect of Medicine and Surgery.

Aras of Portraits of Skin Diseases. (15th Fasciculus.)
Curnicau Lectures by various German Professors. Vol. I.
Larnam’s Works. Vol. I.

1876. (Highteenth Year.)
Smeuuie’s Midwifery, by McClintock. Vol. I.

Cuarcot’s Clinical Lectures on Diseases of the Nervous
System. Vol. I.
Brtrotx’s Lectures on Surgical Pathology. Vol. I.

1877. (Nineteenth Year.)
Smewue’s Midwifery, by McClintock. Vol. II.

BittRotw’s Lectures on Surgical Pathology. Vol. II.
Attas of Illustrations of Pathology. (Fasciculus I.)
LIST OF PUBLISHED WORKS. 27

 

Vou.

78.
79.
80.
81.

82.
83.

84.
85.

86.
87.
88.
89.
90.

91.

98.

100.
101.
102.
103.

104.
105

106.

1878. (Twentieth Year.)
BrstiorHEca Therapeutica, by Dr. Waring. Vol. I.
Suetuie’s Midwifery, by McClintock. Vol. III.
Latnam’s Works. Vol. II.
Lexicon of Medical Terms. (First Part.) Issued with
Part IT. only, as Vol. 88.

1879. (Twenty-first Year.)
BristiotHeca Therapeutica, by Dr. Waring. Vol. II.
Lexicon of Medical Terms. (Second Part.) Including
re-issue of First Part.

Manvat of Physical Diagnosis, by Dr. Guttmann.
Artas of Illustrations of Pathology. (Fasciculus II.)

 

1880. (Twenty-second Year.)
Hepra on Diseases of the Skin. Vol. V.
Lexicon of Medical Terms. (Third Part.)
Kocn’s Researches on Wound Infection.
Luxicon of Medical Terms. (Fourth Part.)
Cuarcot’s Clinical Lectures on Diseases of the Nervous
System. Vol. IT.
Atuas of Illustrations of Pathology. (Fasciculus III.)

1881. (Twenty-third Year.)

 

. Sexections from the Works of Abraham Colles.

. Lexicon of Medical Terms. (Fifth Part.)

. BrutRotH’s Clinical Surgery.

. Cuarcot on Diseases of Old Age.

. Lexicon of Medical Terms. (Sixth Part.)

. Arnas of Illustrations of Pathology. (Fasciculus IV.)

1882. (Twenty-fourth Year.)
Stoxes on Diseases of the Chest.

. Arzas of Portraits of Skin Diseases. (16th Fasciculus.)

Tue Collected Works of Dr. Warburton Begbie.

Lexicon of Medical Terms. (Seventh Part.)

Cuancot on Localisation of Cerebral and Spinal Disease.
Lexicon of Medical Terms. (Seventh Part.)

1883. (Twenty-fifth Year.)

Arzas of Illustrations of Pathology. (Fasciculus V.)
Sriections from the Works of Dr. Duchenne.
Hirscu on Geographical and Historical Pathology. Vol. I.
LIST OF SURPLUS VOLUMES,
With Prices.

N.B.—The prices affixed can be continued only for a limited period until
surplus stock is disposed of.

ATLAS OF SKIN DISEASES.  Fasciculi 2, 3, 4, 6, 7,
II,14,and 15. Separately, ros. 6d. each. Most of the stones have been
destroyed, and only a limited number of impressions remain in-stock, and a
few are out of print.

ON SYPHILIS IN INFANTS. By Paut Dipay. Trans-
lated by Dr. WHITLEY. 2s. 6d.

GOOCH ON THE MORE IMPORTANT DISEASES
OF WOMEN AND CHILDREN. Prefatory Essay by Dr. ROBERT
Fercuson. Woodcuts. 2s. 6d.

MEMOIRS ON DIPHTHERIA. By BRETONNEAU,

TRovussEau, DavioT, GuERSANT, BoucnuT, Empis, &c. Selected and
Translated by Dr. R. H. SEMPLE. 33s. 6d.

ON THE MINUTE STRUCTURE AND FUNCTIONS
OF THE SPINAL CORD. By Professor SCHROEDER VAN DER KOLK.

-ON THE MINUTE STRUCTURE AND FUNCTIONS
OF THE MEDULLA OBLONGATA, AND ON EPILEPSY. By
Professor SCHROEDER VAN DER Kok. Translated by Dr. W. D. Moore,
of Dublin, In one volume, with numerous Lithographs. 5s. ;

EXPERIMENTAL RESEARCHES ON THE EFFECTS
OF THE LOSS OF BLOOD IN INDUCING CONVULSIONS.

By Drs. KussMAuL and TENNER. Translated by Dr. Bronner, of
Bradford.

ON THE PROCESS OF REPAIR AFTER RE-
SECTION AND EXTIRPATION OF BONES. By Dr. A. Wacner, of
Berlin. Translated by Mr. T. Hotmes. Numerous Woodcuts.

PROFESSOR VON GRAEFE’S THREE MEMOIRS

ON GLAUCOMA, AND ON IRIDECTOMY AS A MEANS OF
TREATMENT. Translated by Mr. T. Winpsor, of Manchester,

Three Monographs in one Volume. 2s. 6d.
LIST OF SURPLUS VOLUMES. 29

 

 

 

MEMOIRS ON ABDOMINAL TUMOURS AND IN-
TUMESCENCE. By Dr. Bricut. Reprinted from the ‘ Guy’s Hospital
Reports,’ with a Preface by Dr. BarLow. Numerous Woodcuts. 7s. 6d.

A CLINICAL ACCOUNT OF DISEASES OF THE

LIVER. By Professor Frericus. ‘Translated by Dr. MurcHIsoN.
Numerous Woodcuts and coloured Lithographs. 2 vols; 12s. 6d. Vol I.
separately, 3s. 6d.

CZERMAK ON THE PRACTICAL USES OF THE
oe Translated by Dr. G. D. Giss, Numerous
oodcuts.

DUSCH ON THROMBOSIS OF THE CEREBRAL
SINUSES. Translated by Dr. WHITLEY.

SCHROEDER VAN DER KOLK ON ATROPHY OF
i Bee Translated by Dr. W. D. Moore, of Dublin. Four
ithographs,

RADICKE’S PAPERS ON THE APPLICATION OF.
STATISTICS TO MEDICAL ENQUIRIES. ‘Translated by Dr. Bonn.

ESMARCH ON THE USES OF COLD IN SURGICAL
PRACTICE. Translated by Dr. MonrcomMeEry.

Five Monographs in one Volume. 5s.

A HAND-BOOK OF THE PRACTICE OF FOR-
ENSIC MEDICINE, BASED UPON PERSONAL EXPERIENCE
By J. L. Casper, M.D., Professor of Forensic Medicine in the University
of Berlin. Translated by Dr. G. W. Batrour. Vols. II.. III., IV.
7s. 6d. each. 4 vols., complete. £2 2s.

THE AURAL SURGERY OF THE PRESENT DAY.
By W. Kramer, M.D., of Berlin. Translated by Henry Power, F.R.C.S.,
M.B. With two Tables and nine Woodcuts. 2s. 6d.

A GUIDE TO THE QUALITATIVE AND QUAN-
TITATIVE ANALYSIS OF THE URINE. By Dr. C. NeuBavErR and
Dr. J. Vocet. Fourth edition, considerably enlarged. Translated by
by W. O. Marxuam, F.R.C.P.L. With Four Lithographs and numerous

Woodcuts. 55.

ON THE ANOMALIES OF ACCOMMODATION AND
REFRACTION OF THE EYE, WITH A PRELIMINARY ESSAY
ON PHYSIOLOGICAL DIOPTRICS. By F.C. Donpers, M.D., Pro-
fessor of Physiology and Ophthalmology in the University of Utrecht.
Translated from the Authors’s Manuscript by W. D. Moors, M.D. 7s. 6d.

TROUSSAEU,S CLINICAL MEDICINE. Vols. IV.

and V., separately 58. each.
¢
30 THE NEW SYDENHAM SOCIETY.

 

YEAR-BOOKS OF MEDICINE AND SURGERY.
1859—64. Six Vols. 2s. 6d. each vol.

BIENNIAL RETROSPECT OF MEDICINE AND
SURGERY, 1865—74. 5 vols. 2s. 6d. each.

STRICKER’S MANUAL OF HISTOLOGY. 3 vols.
31s. 6d. Vols. I. and III. separately, 5s. each.

RINDFLEISCH’S PATHOLOGICAL HISTOLOGY.
Vol. II., 5s. .

HEBRA’S TREATISE ON DISEASES OF THE
SKIN. Vols. 1 to 4, 21s.

LANCEREAUX’S TREATISE ON SYPHILIS. Two

vols. 5s.

NIEMEYER’S LECTURES ON PULMONARY CON-
SUMPTION. 2s. 6d.

LATHAM’S WORKS. 2 vols. 7s. 6d. Vol. I., as. 6d.

CLINICAL LECTURES BY VARIOUS GERMAN
PROFESSORS. First series, 5s.

LEXICON OF MEDICAL TERMS. Parts I. to V.,

forming Vol. I. (in Parts), 25s.

GUTTMANN’S HANDBOOK OF PHYSICAL DIAG-
NOSIS. 5s.

Several of these works are well suited for presents to
Students or for Class Prizes. Amongst them may be espe-
cially mentioned StrickEr’s Histology; Frericu’s On Dis-
eases of the Liver; Larnam’s Works; Donpzrs On Anomalies
of Refraction; and Gurrmann’s Physical Diagnosis, &c.
LAWS OF THE NEW SYDENHAM SOCIETY.

 

I,—The Society is instituted for the purpose
of supplying certain acknowledged deficiences
in the existing means of diffusing medical
literature, and shall be called “THe New
SypENHaM Society.”

I1.—The Society shall carry out its objects
by a succession of publications, of which the
following shall be the chief:—1. Translations
of Foreign Works, Papers, and Essays of merit,
to be reproduced as early as practicable after
their original issue. 2. British Works, Papers,
Lectures, &c., which, whilst of great value,
have become from any cause difficult to be
obtained, excluding those of living authors.
8. Annual Volumes consisting of Reports in
Abstract of the progress of the different
branches of Medical and Surgical Science
during the year. 4. Dictionaries of Medical
Bibliography and Biography. Those included
under Nos. 1 and 2 shall be held to have the
first claim on the attention of the Society;
and the carrying out of those under Nos. 8 and
4 shall be considered dependent upon the
amount of funds which may be placed at its
disposal.

I1I.—The Subscription constituting a Mem-
ber shall be One Guinea, to be paid ix advance
on the 1st of January annually, and it shall
entitle the subscriber to a copy of every work
published for that year. No books shall be
issued to any Member until his subscription
for the year has been paid.

IV.—The Officers of the Society shall be
elected from the Members, and shall consist
ot a President, sixteen Vice-Presidents, a
Treasurer, a Secretary, and a Council of
thirty-two, in whom the power of framing
Bye-laws and of directing the affairs of the
Society shall be vested. Twelve of the Council
shall be provincial residents.

V.—Five Members of the Council shall form
@ quorum.

ViI.—The Officers of the Society shall be
elected by ballot at tie General Anniversary
Meeting of the Society. Balloting lists of
Officers proposed by the Council, with blank
places for such alterations as any Member
may; wish to make, shall be laid on the
Saciety’s table for the use of Members.

VII.—The President, Vice-Presidents, and
Council, shall be eligible for re-election, except
that of the Vice-Presidents four, and of the
Council eight, shall retire every year.

VILI.—The Council shall appoint local Hono-
rary Secretaries wherever they shall see fit.

IX.—The business of the President shall be
to preside at the Annual and Extraordinary
Meetings of the Society; in his absence one of
the Vice-Presidents, or the ‘lreasurer, or any
Member of the Council chosen by the Members
present, shall take the Chair.

X.—The Treasurer, or some person ap-

\ ‘pointed by him, shall receive all moneys due

5

to the Society.

 

XI.—The money in the hands of the Trea-
surer, which shall not be immediately required
for the uses of the Society, shall be vested in
such speedily available securities as shall be
approved by the Council.

XII.—The Council shall select the Works to
be published by the Society, and shall make
all arrangements, pecuniary or otherwise, in
regard to their publication. In the event of
any Member of the Council being appointed to
edit any Work for the Society, for which he is
to receive pecuniary remuneration, he shall
immediately. cease to be a» Member of the
Council, and shall not be eligible for re-
election till after the publication of the Work.

XIII.—The Council shall lay before the
Members at each Anniversary Meeting a Report
of their proceedings during the past year, and
also an account of the Receipts and Expendi-
ture of the Society; and shall further cause to
be printed and circulated among the Members
an abstract of such Report and Accounts im-
mediately after such Anniversary Meeting.

XIV,—The annual Accounts of the Receipts
and Expenditure of the Society shall be
audited by a Committee of three Members,
selected at the preceding Anniversary Meeting
from among the Members at large.

XV.—The Secretary shall have the manage-
ment of the general Correspondence of the
Society, and of such other business as may
arise in carrying out its objects.

XVI.—The local Secretaries shall further
the objects of the Society in their respective
districts, and shall be in communication with
the metropolitan Secretary.

XVII.—The Anniversary Meeting shall be
held in the same town as, and at the time of,
the Annual Meeting of the British Medical
Association, notice of it having been given
to all Members at least a week before the day
fixed on.

XVIII.—The Members generally shall be
invited and encouraged to propose Works, &c.,
and to make any suggestions to the Council
they may think likely to be useful.

XIX.—The Works of the Society shall be
printed for the Members only.

XX.—No alteration in the Laws of the
Society shall be made, except at a General
Meeting. Notice of the alteration to be pro-
posed must also have been laid before the
Council at least a month previously.

XXI.—The Council shall have power to call
a General Meeting of the Members at any time,
and shall also be required to do so within three
weeks, upon receiving a requisition in writing
to that effect from not less than twenty Mem-
pers of the Society.

XXII.—Al Special General Meetings of the
Society shall be held at such place as the
Council may appoint.

XXIUI.—The Council shall meet at least
once in two months, unless by special resolu-
tion to the contrary.

e2
GENERAL INFORMATION.

A Tuirp Eprrion of the Votumss for 1859 was printed,
and a second of that for 1860. For subsequent years the
First Edition was much larger; and it is not likely that any
of the Volumes will be reprinted.

Most of the stones for plates, &c., both those for the Atlas
of Skin Diseases and those for printed Volumes, have been
destroyed, and will not be reproduced.

The Society is now in its Twenty-fifth year. Arrangements
have been made by which new Members can obtain single
Volumes, or sets of Volumes, from the Society’s stock in hand.
Some of the Volumes, of which a larger surplus exists than of
others, can be purchased at fixed prices (for which see list).
The Society’s Agent is empowered to make special arrange-
ments with new Members who may wish to obtain any of the
past Volumes.

Carriace, &c.—The Society's Works are supplied free
of cost to any address in London, Edinburgh, or Dublin;
but the expenses of Carriage to all other places must be borne
by the members to whom they are sent. Members wishing
to receive their Volumes by Book-post can do so by pre-
paying the postage. Members are requested to give detailed
instructions respecting the mode by which they wish their
Volumes to be forwarded, and also to remember that the
Society’s responsibility ceases when the Book has been
delivered according to the instructions given. Members
wishing to receive their Works by Book-post can do so by
prepaying the sum of 2s. 6d. for the year.

The Subscription is One Guinea annually, to be paid iv
ADvANCE. ‘The best mode of sending money is by Post-office
Order, payable to Mr. Henry Kine Lewis, at the London
Office; or by Cheque to the order of. the Treasurer, Dr.
Sepewick Saunpers. It is requested that in future all
communications in reference to the payment of Subscriptions,
or the issue of Books, may be made to Mr. Lewis, the Society's
Agent, and not to the Secretary.

JONATHAN HUTCHINSON,

Hon. Secretary.
15, CavenpisH Square, W.
GENERAL INFORMATION. 33

 

** Any Member wishing for additional Copies of this
Report, &c., can obtain them by applying to Mr. Hurcuinson;
or to the Society’s Agent, Mr. Lewis, 186, Gower Street, W.C.
The Council will be much obliged by its distribution amongst
those thought likely to join the Society.

PS.—The Society's Agent is prepared to supply, at fixed
prices, CasEs for binding the Lexicon, and Porrrorios for
the reception of the Plates of Skin Diseases, and for the
Pathological Atlas.

IMPORTANT NOTICE TO NEW SUBSCRIBERS AND LOCAL
SECRETARIES.

New Members who subscribe for not fewer than three past
years at once (with the current one) will be allowed to select
volumes from the surplus stock to the value of one guinea
without additional payment. The like privilege will be
‘secured each year by any Local Secretary who has the sub-
scriptions of all the members on his list (the number being
not less than ten) paid before the end of March for the current
year.
LIST OF HON. LOCAL SECRETARIES,

Anp or Towns WHERE IT IS DESIRED THAT AN APPOINIMENT
SHOULD BE MADE.

 

The Council will be much obliged to any ‘gentlemen willing to act
as Local Secretaries in Towns where the appointment is vacant, if
they will communicate with Mr. Hurcuinson. Any suggestions of
suitable names will also confer a favour. The duties of Local
Secretaries consist in arranging for the distribution of books, the
collection of Subscriptions, and canvassing for new members.

 

England and Wales.

Aberdare

Abergavenny ste a awe
Aberystwith sie dies ... Morris Jones, Esq.
Abingdon ... i ai ... Paulin Martin, Esq.
Accrington .. ‘i sais neh

Acton (see Ealing)...

Alfreton :

Alnwick oe se ste

Andover... ai ae .. W.J.H. Lush, M.D. (Fyfield).
Ashbourne ... ‘ ae i

Ashford

Ashton-under- -Lyne ie

Aylesbury «.. oes ve ... ©, Hooper, Esq.
Bacup . eh be St

Banbury

Bangor i

Barnet, Herts.

Barnsley iv ais as

Barnstaple ... aed a .. BR. Budd, M.D.
Barrow-in-Furness...- ... ou

Basingstoke sian sa .. 6. Andrews, Esq.
Bath se .. A. W. Fox, M.B.
Beaminster and Bridport .. .. d.8. Webb, Esq.
Beaumaris, sa aaa

Beccles... i wie . WM, Crowfoot, Esq.
Beckingham

Bedford ... 7 ... RB. H. Coombes, M.D.
Bethesda, Carnarvo onsluire. A
Beverley
LIST OF HON. LOCAL SECRETARIES. 35

 

Bewdley

Bideford

Bilston oe
‘Birkenhead...
Birmingham i
Bishop Auckland ...
Blackburn ... ae
Blackheath ...
Blackpool

Bolton sf
Boroughbridge
Boston, Lincolnshire
Bournemouth sais
Bradford, Yorkshir
Brecon be oes
Brentwood ...
Bridgend

Bridgwater ...
Bridgnorth ...
Bridlington ...
Brighton

Bristol ;
Bromley, Kent
Burnley, Lancashire
Burton-on-Trent
Bury, Lancashire ...
Bury St. Edmunds
Buxton, Derbyshire
Cambridge ...
Canterbury ...
Cardiff

Carlisle

Carmarthen
Carnarvon ...
Castleford ...
Chatham ... we
Cheadle, Cheshire ...
Chelmsford ... ates
Cheltenham
Chertsey

Chester 2
Chesterfield
Chichester ... eu
Chippenham, Wilts.
Chorley, Lancashire
Christchurch
Cirencester ...
Colchester ..-

* Qongleton ..-

J. Gabb, Esq.
W. H. Ackland, M.D.

George Walker, M.D.
W. Wright Wilson, Esq.,

; [F.B.C.5S. Ed.
Matthew J. Rae, M.D.
Gay Shute, Esq. (Greenwich)
W. B. Richardson, Esq.

A. Mercer Adam, M.D.
J. G. White, M.D.

T. C. Denby, Esq.
Talfourd Jones, M.D.

W. L. Winterbotham, M.B.
Alfred Mathias, Esq.

C. F. Hutchinson, M.D.
Ed. Mackey, M.D.

F. R. Cross, Esq., F.R.C.S.

H. Briggs, M.D.
G. Lowe, M.D.

F. Crompton, Esq.
F. E. Image, Esq.

T. Hyde Hills, Esq.
James Reid, Esq.

W. B. Page, Esq.
J. Hughes, Esq., F.R.C.S.

KE. W. Kemp, Esq.
J. Langston, Esq., F.B.C.S.
E. T. Wilson, M.D.
T. §. Parry, M.B., M.R.C.S.

John Carnegie, M.D.
N. Tyacke, M.D.

BE. Waylen, Esq.
36 THE NEW SYDENHAM SOCIETY.

 

Coventry ...
Cowes, Isle of Wight
Crewe as
Croydon anh
Dalton-in-Furness ..
Darlington ..
Dartford 5
Dartmouth ...
Deal, Kent ...
Denbigh
Deptford
Derby

Devizes
Devonport .
Dewsbury ...
Diss ..

Doncaster ate
Dorchester ...
Dorking...
Douglas, Isle of Man
Dover
Droitwich
Dudley
Durham
Ealing
Eastbourne...
East Grinstead
East Retford
Edmonton ...
Ely ...
Enfield

Epsom
Evesham
Exeter
Exmouth ...
Falmouth ...
Faversham ...
Folkestone ...
Forest Hill ...
Frome "
Gainsborough
Gloucester ...
Godalming ..
Gosport
Grantham ...
Gravesend .
Great Grimsby

Greenwich ae Blackheath

Guernsey

J. Brown, M.D.

J. Atkinson, Esq.
A. Carpenter, M.D.

J. Lawrence, M.D.
J. C. Weddell, M.D.

T. L. Gentles, L.F.P.8.
G. Waylen, Esq,

T. BE. Amyot, Esq.
J. Sykes, M.D.
Alfred Emson, Esq.

Charles Parsons, M.D.
8. 8. Roden, M.D.

B. Roberts, M.D.
W. B. Pritchard, Esq.

W. Clement Daniel, M.D.

H. Davy, M.D.
G. W. Turnbull, M.D.

R. L. Bowles, M.D.
J. Bright, M.D.
Edmund Cockey, Esq.
D. Mackinder, M.D.
F. Needham, M. D.

G. W. Shipman, Esq.
R. Innes Nisbett, Esq.

Gay Shute, Esq.
B. Collenette, M.D.
LIST OF HON. LOCAL SECRETARIES.

37

 

Guildford

Halifax

Hanley

Hanwell

Harlow

Harrogate ...
Harrow-on-the- Hill
Hartlepool ..
Haslingden ... as
Hastings
Haverfordwest
Heckmondwike ;
Hemel-Hempstead...
Hereford ae
Hertford

Hexham ....

High Wycombe wie
Hinckley, Leicestershire ...
Hitchin ae
Horsham, Sussex ...
Hounslow ...
Holywell...
Huddersfield

Hull... :
Huntingdon ay
Hyde and Marple ...
Ilfracombe ... of
Ipswich

Jarrow

Jersey

Keighley

Kendal

Kettering ..
Kidderminster
Kingsbridge sins
Kingston-upon-Thames & ‘Surbiton
Lancaster ... ‘
Langport
Launceston...
Leamimgton
Ledbury

Leeds

Leek

Leicester

Leigh, Lancashire.
Leominster ..
‘Leytonstone

Lewes

Lichfield

R.N. Day, Esq.
G. Oliver, M.D.

J. Underwood, M.D.

F. B. Lee, Esq.
Russell Steele, Hsq., L.R.C.P.

Thomas Turner, Esq.
C. BE. Shelley, M.D.

John Irving, M.B.
Kelburne King, M.D.

L. Newton, Esq.

J. Johnson Bailey, M.D.

C. W. Hammond, M.D.

W. W. Kershaw, M.D.
R. Clark, Esq.

T. W. Thursfield, M.D.
R. N. Hartley, M.B.
Joseph Kenny, Esq.

T. Blunt, M.D.

F. W. Cooper, Esq.

H. P, Welchman, Esq.
38 THE NEW SYDENHAM SOCIETY.

 

Lincoln

Liskeard

Liverpool

Llandovery ...
Llandudno ... n
Llanelly ©... 5
Longton, Staffordshire
Loughborough

Louth

Lowestoft

Ludlow

Luton

Lymington ...

Lynn wate
Macclesfield
Maidenhead
Maidstone ...

Malton

Malvern
Manchester...
Mansfield

Margate i

Market Drayton ...
Marlborough, Wilts.
Martock ... aa
Merthyr Tydvil
Middlesboro’-on-Tees
Mold sé sei
Monmouth ...
Morpeth ... ane
Moseley... re
Newark-upon-Trent
Newbury, Berks.
Newcastle-under-Lyne
Newcastle-upon-Tyne
New Malton, Yorkshire
Newmarket, Cambridgeshire
Newport, Hants. iy
Newport, Mon.
Newton Abbot
Newton-le- Willows...
Northallerton
Northampton

North Shields
Norwich

Nottingham

Odiham

Oldham

Oswestry

T. Sympson, M.D.

J. Muir Howie, M.B.
D. Thomas, Esq.

F.. Fawsett, M.D.
W. H. Clubbe, Esq.

H. C. Allinson, Esq.

E. Ground, Esq.
W. T. Colby, M.D.

F. M. Pierce, M.D.

C. Biddle, L.R.C.P. Lond.

F. H. Appleby, Esq.

J. B. Bunny, L.R.C.P.,
[M.R.C.8.

F. C. Coley, M.D.

W. W. Morgan, M.D.

Charles Jewel Evans, Esq.
Robert Peart, M.D.
Haynes S. Robinson, Esq.
W. H. Ransom, M,D.

J. M‘Intyre, M.D.

T. Platt, Esq.
LIST OF HON. LOCAL SECRETARIES. 89

 

Otley

Oxford

Penge

Penrith

Penzance
Peterborough
Petersfield ...
Plymouth
Pontefract ...
Pontypool ...
Poole

Portsmouth (see Southsea)...
Preston
Prestwich
Ramsgate
Reading

‘Redruth

Reigate eG
Richmond, Surrey...
Richmond, Yorkshire
Ripon

‘Pochaula

Rochester (& | Chatham & Strood)...

Rochford

Romford, Essex
Ross... . .
Rotherham ..

Rugby

Rugeley...

Ryde, I. of Wight ..
Saffron Walden

St. Albans ...

St. Austell ...

St. Helen’s Lancashire
St. Ives, ae
Salford 8
Salisbury
Scarborough

Settle

Sevenoaks .
Shaftesbury
Sheerness ...
Sheffield ...
Shepton Mallet
Sherborne ...

Shipley

Shrewsbury...
Sidmouth ies
Smethwick ... vet

A. Winkfield, Esq., F.R.C.S.
J. B. Montgomery, M.D.
Leonard Cane, M.D.

Connell Whipple, Esq.

8. B. Mason, Esq.

R. Allen, Esq.

T. L. Walford, Esq.

J. Walters, M.D.
KE. Fenn, M.D.

J. Langston, Eisq., F.R.C.S.
T. King, M.D.

H. D. Foote, M.D.

Stear, Esq.
R. Lloyd, Hid M.R.C.S.

Twyford, M.D.

H.
R.
E.
W. R. Grove, M.D.
W.
R.

P;

R.

D. Wilkes, Esq.
B. Cooke, Esq.

E. Swales, M.D.
M. Martin de Bartolomé, M.D.

E. Andrew, M.D.
40 - THE NEW SYDENHAM SOCIETY.

 

Southampton

South Molton
Southport ...
Southsea...

South Shields
Spalding

Stafford

Staines a
Stalybridge...
Stamford

Stockport ee
Stockton-on-Tees ...

Stoko-on-Trent (Potteries)
Stourbridge... dete mens

Stowmarket

Stratford, Essex
Stratford-on-Avon ...
Stroud, Gloucestershire
Sunderland...
Surbiton...

Sutton, Surrey
Swansea

Swindon

Sydenham (see Forest est Hill)

Taunton
Tavistock
Teignmouth
Tenby a
Tewkesbuty...
Thetford
Tiverton
Todmorden...
Torquay
Totnes on
Tottenham ...
Towcester ...
Truro
Tunbridge Wells
Twickenham
Ulverston : —
Upton-on-Severn ...
Uxbridge
Ventnor...
Wakefield ...
Wallingford
Walsall ais
Walthamstow
Warminster
Warrington...

T. W. Trend, M.D.
T. Sanders, Esq.

W. iH. Axford, M.D.

J. Frain, M.D.
E. Morris, M.D.

W. Newman, M.D.

J. A. Ball, Esq.

R. W. Foss, M.D.
Samuel Johnson, M.D.
A. Freer, Esq.

J.J. Nason, M.B.

M. Douglas, Esq.
W. W. Kershaw, M.D.

T. D. Griffiths, M.B.
G. M. Swinhoe, Esq.

W. Liddon, M.B.

P. Minns, M.D.

K. H. May, M.D.

E. Sharp, Esq.
F. Manser, Esq.

&

. Braddon, Esq.

. H. Wood, Esq.
. A. Barrett, Esq.

Qr

‘J. H. Gornall, Esq.
‘LIST OF HON. LOCAL SECRETARIES. Al

 

Warwick
Watford
Wednesbury
Wellington” Salop ..
Wellington, Somerset
Wells, Somerset
Wem :
West Bromwich
‘Weston-super-Mare
Weybridge ...
Weymouth ...
Whitby ane
Whitehaven
Wigau se
Wimbledon...
Wimborne ...
Winchester ...
Windsor
‘Wisbeach
Witney ae
Wolverhampton
Woodbridge
Woolwich
Worcester ...

Workington, Cumberland on

Worksop
Worthing
Wrexham ...
Yarmouth .
Yeovil

York

Aberdeen
Airdrie

Ayr ...

Banff
Brechin
Campbeltown
Crieff per
Cupar, Fife ...
Dumfries
Dunbar
Dundee
Dunfermline
Edinburgh ...
Elgin
Falkirk
Forfar

Scotland.

W. Fairbanks, M.D.

J. Manley, M.D.
BR. Alford, Esq.

J. F. ’ Anson, M.D.
G. G. Tatham, M.D.

J. Ellison, M.D.

A. Batt, M.D.
Vincent Jackson, Esq.

W. J. Harris, Esq.
C. Palmer, Esq.

iM B.C.
W.H. Jalland,Esq., L RO,

8.
P.,
John Wight, M.D.

G. McKerrow, M.D.

W. Whitelaw, M.D.

A. D. L. Napier, M.D.
R. Sinclair, M.D.

W. Husband, M.D.
G. Duff, M.D.

W. F. Murray, M.D.
42 THE NEW SYDENHAM SOCIETY.

 

Glasgow
Greenock
Haddington...
Hamilton .
Helensburg...
Inverness
Kelso
Kilmarnock...
Leith

Lerwick (Shetland) ir

Linlithgow ...
Lochgilphead
Montrose
Paisley

Perth
Renfrew
Rothesay

St. Andrews, Fife ...

Stirling
Thurso
Wishawton ...

Ardee
Armagh
Athlone
Ballinasloc ...
Ballymena ...
Belfast
Carlow
Carrick-on-Suir
Cashel Sas
Cavan
Clonmel
Cork...
Corofin ‘ie
Downpatrick
Dublin
Dundalk
Ennis a
Enniskillen...
Galway
Killarney
Kilkenny
Kingstown ...
Letterkenny
Limerick
Lisburn, Antrim
Londonderry

J. W. Anderson, M.D.
James Wallace, M.D.

A. W. Macfarlane, M.D.
James Struthers, M.D.

G. Hunter, M.D.
James C, Howden, M.D.

D. Taylor, M.D.
D. H. Stirling, M.D.

Charles Gibson, M.D.

Ireland.

Thomas J. Moore, M.D.
H. Fraser, M.D.

J. W. Byers, M.D., M.A.
J. Martin, .D.

Denis Donovan, M.D.
G. N. McNamara, Esq.

J. W. Moore, M.D.

T. Kane, M.D.
W. Bernard, M.D.
LIST OF HON. LOCAL SECRETARIES’ 43

 

Mallow
Monaghan ...
Mullingar
Nenagh
New Ross
Newry
Omagh ;
Parsonstown
Queenstown
Rathmines ...
Roscommon J. Harrison, M.D.
Rosstrevor ... T, A. Vesey, M.B.
Sligo
Tipperary <
Tralee
Tullamore ...
Waterford ...
Wexford H. H. Boxwell, M.D.
Youghal
Paris.
India.
Calcutta
Madras E. I’. Brockman, M.D.
Bombay K. BR. Kirtikar, L.R.C.P.
Lahore
Moulton
&. Australia.
Adelaide
Victoria.
Melbourne ... Edward Barker, M.D.
New South Wales.
Sydney
New Zealand.
Christchurch J. Irving, M.D.
Nelson Sad on ine cats ;
Napier, Hawkes’ Day ae .. F.L. De Lisle, M.D.
: Queensland.
Toowomba, Brisbane
Canada.

Montreal
44

THE NEW SYDENHAM SOCIETY.

 

Abingdon, Ill.
Baltimore ...

United States.
Madison’ Reece, M.D.

Boston R. H. Salter, M.D.
Cincinnati ...
New York ... Messrs. J. H. Vail & Co.
Philadelphia Richard J. Dunglison, M.D.
(Mr. Presley Blakiston).
Barbadoes.
Robert R. Walcot, M.D.
Japan.
Yokohama and Yeddo ile ... §. Eldridge, M.D.

General Secretary (Hon.)

JONATHAN HUTCHINSON, Esq., F.R.S., 15, Cavendish

Square, London, W.

Agency and Depot for Books.

Mr. H. K. LEWIS, 186, Gower Street, London.

LONDON: WEST, NEWMAN AND CO., PRINTERS, 54, HATTON GARDEN, E.C.