THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 A TREATISE 
 
 BRIGHT'S DISEASE AND DIABETES,
 
 BY THE SAME AUTHOR. 
 
 A GUIDE TO THE PRACTICAL EXAMINATION OF URINE, 
 
 for the use of Physicians and Students. Third Revised Edition. 
 Cloth. Price, 81.50. 
 
 THE CELL DOCTRINE : Its History and Present State, together with 
 a Copious Bibliography of the Subject. With a Colored Plate and 
 other Illustrations. Second Revised Edition. Cloth. Price, $2.00. 
 
 AN INTRODUCTION TO THE STUDY OF PRACTICAL HIS- 
 TOLOGY. For Beginners in Microscopy. Cloth. Price, $1.00.
 
 X.R.Xiinrrede Piiixit . T Hunter.Lith .Phila . 
 
 INTRAOCULA?. LIPAEMIA.
 
 A TREATISE 
 
 OK 
 
 Bright's Disease and Diabetes. 
 
 "WITH ESPECIAL EEFERENCE TO 
 
 PATHOLOGY AND THERAPEUTICS. 
 
 By JAMES TYSON, A.M., M.D., 
 
 PROFESSOR OF GENER.A.L PATHOLOGY AND MORBID ANATOMY IN THE UNIVERSITY OF 
 
 PENNSYLVANIA; ONE OF THE PHYSICIANS TO THE PHILADELPHI.4. HOSPITAL; 
 
 ONE OF THE VICE-PRESIDENTS OF THE PATHOLOGICAL SOCIETY OF 
 
 PHILADELPHIA ; MEMBER OF THE COLLEGE OF 
 
 PHYSICIANS OF PHILADELPHIA, ETC. 
 
 WITH ILLUSTKATIONS. 
 
 INCLUDING A SECTION 
 
 ON RETINITIS IN BRIGHT'S DISEASE. 
 
 By WILLIAM F. NORRIS, A.M., M.D., 
 
 CLINICAL PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF PENNSYLVANIA. 
 
 PHILADELPHIA: 
 
 LINDSAY & BLAKISTON. 
 
 188 1.
 
 COPYKIGHTED, 
 
 By JAMES TYSON, M.D., 
 1881.
 
 Btumedical 
 Library 
 
 353 
 
 Tn7t 
 
 TO 
 
 MY FRIEND AXD COLLEAGUE 
 
 WILLIAM PEPPER, A.M., M.D., 
 
 PROVOST AND PROFESSOR OF CLINICAL MEDICINE 
 
 UNIVERSITY OF PENNSYLVANIA. 
 
 624071
 
 PREFACE. 
 
 It is quite usual for authors, in their prefaces, to give some 
 reason for having written the book which they thus introduce, 
 — in a word, to apologize for its appearance. In the present 
 instance the existence of excellent treatises on both subjects 
 covered by the title, make it more than usually difficult to 
 justify the appearance of another. The writer can only say 
 that, for more than fifteen years, his thoughts, his studies, 
 and his practical work have all been in the direction suggested 
 by these subjects, and that during that time material has passed 
 under his observation which ought at least, if properly used, 
 to have resulted in an experience which should be useful to 
 others. Whether this has been the case or not, must be left 
 to the decision of those who may first read or examine the 
 work. 
 
 In carrying out his object, the author has necessarily, in 
 order to insure completeness, availed himself of the w^ork of 
 others, as well as his own, endeavoring, however, in all in- 
 stances, to give credit where credit is due, and if he has omitted 
 any proper acknowledgment it has been entirely unintentional. 
 In the section on the " Histology of the Kidney," while he has 
 used the illustrations of other writers, he has also added a 
 number of original drawings, from the careful pencil of Dr. 
 George C. Piersol. It is thought they will add to the accu- 
 rate knowledge of the subject.
 
 Xn PREFACE. 
 
 The very wide difference in the nature and pathology of 
 the two sets of diseases, has not been overlooked in including 
 them under the same cover ; but Avhen it is remembered that 
 although diabetes is not a urinary disease, it is nevertheless a 
 disease to a knowledge of which a study of the urine is indis- 
 pensable, and that one Avho devotes himself to the latter must 
 inevitably be brought into frequent and intimate contact with 
 diabetes, it is but natural that the consideration of the two 
 conditions should be united. 
 
 1506, Spruce Street, April Ist, 1881.
 
 TABLE OF CONTENTS. 
 
 BEIGHT'S DISEASE. 
 
 SECTION PAGE 
 
 I. Structuke of the Kidney, 17 
 
 II. Testing for Albumen — Albttminuria, its Sources 
 
 AND Mechanism of its Production, .... 50 
 
 III. Casts of the Uriniferous Tubules — Their Nature 
 
 AND Clinical Significance, 62 
 
 IV. Classification of Bright's Disease, . . . .79 
 V. Acute Parenchymatous Nephritis, .... 85 
 
 VI. Chronic Parenchymatous Nephritis, . . . .124 
 
 VII. Lardaceous Disease of the Kidney, .... 148 
 
 VIII. Interstitial Nephritis, 165 
 
 IX. Retinitis in Bright's Disease, 192 
 
 X. Suppurative Interstitial Nephritis, .... 200 
 
 XI. Cyanotic Induration, 219 
 
 DIABETES. 
 
 I. Diabetes Mellitus, 227 
 
 II. Diabetes Insipidus, 298
 
 LIST OF ILLUSTRATIONS. 
 
 COLOKED PLATES. 
 
 Eye-ground in a case of diabetes, frontispiece 
 
 Waxy casts, some of them treated witii iodine, . . opposite page 68 
 
 WOODCUTS. 
 
 FIG 
 
 PAGE 
 
 1. Longitudinal section through the kidney, pelvis of the kidney, 
 
 and a number of renal calyces, .18 
 
 2. Partially diagrammatic sketch of the structure of the kidney in 
 
 longitudinal section, ......... 19 
 
 3. Polygonal appearance of the lobuli when cut transversely, . . 19 
 
 4. Diagrammatic representation of the course of two urinary tubules, 21 
 
 5. Diagrammatic exposition of the method in which the uriniferous 
 
 tubules unite to form the primitive cones, . . . . .23 
 
 6. Section through the cortex of a fresh kidney, showing cloudy epi- 
 
 thelium, 25 
 
 7. Transverse section through a convoluted tubule of a fresh dog's 
 
 kidney, without the addition of any fluid, 26 
 
 8. Section of a convoluted tubule of a dog's kidney, ammonium chro- 
 
 mate preparation, 26 
 
 9. Surface view of a convoluted tubule, ...... 26 
 
 10. Isolated cells and rodlets from the rat's kidney, . . . .27 
 
 11. An isolated fragment of a descending' limb, showing the clear, 
 
 delicate epithelium, with alternate- projections caused by the 
 nucleus, 27 
 
 12. Ascending limb of loop, showing imbricated arrangement of co- 
 
 lumnar cells, according to Ludwig, ...... 27 
 
 13. a, a portion of a convoluted tubule; b, of an ascending limb of 
 
 Henle's loop, according to Heideuhain, . . . . .27 
 
 14. Irregular tubule from the cortex of the kidney of the dog, . . 28 
 
 15. Section through cortical substance of a human foetal kidney, show- 
 
 ing epithelium covering glomerule and lining capsule, . . 31 
 
 16. Distribuiion of the larger bloodvessels of the kidney, . . .32
 
 XVI LIST OF ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 17. Diagrammatic representation of the bloodvessels in the cortex of 
 
 the kidney, 33 
 
 18. Diagram of the circulation in tlie kidney, 34 
 
 19. A part of a convoluted tubule from the newt's kidney, showing 
 
 capillary vessels and nerve-fibres, ... ... 42 
 
 20. Longitudinal section through the cortex of the kidney, . . 43 
 
 21. Tangential section through the cortex of the kidney, ... 44 
 
 22. Transverse section through a papillary portion of a medullary 
 
 cone, 45 
 
 23. Testing for albumen by nitric acid, 53 
 
 24. Blood-casts, 63 
 
 25. Epithetial casts, 63 
 
 26. Granular casts, 65 
 
 27. Oil-casts and fatty epithelium, 66 
 
 28. Pale granular and hyaline casts, 66 
 
 29. Hyaline casts, . 67 
 
 30. Proliferation and thickening of the capsular epithelium with com- 
 
 pression of the glomerule, 95 
 
 31. Desquamative glomerulo-nephritis, .96 
 
 32. Capillary loops, with proliferation of the nuclei, ... 98 
 
 33. Suppurative nephritis — cystic kidneys — impacted calculi, . . 211 
 
 34. Course of glycosuria influence, 236 
 
 35. Course of glycosuria influence, 236 
 
 36. Fat emboli in bloodvessels of lung, 265
 
 BRIGHT'S DISEASE. 
 
 SECTION I. 
 
 STRUCTURE OF THE KIDNEY. 
 
 The few facts in the coarser anatomy of the kidney which it 
 is necessary to recall with a view to a correct understanding 
 of its diseases, are, before section of the organ, its size, weight, 
 color, consistency, and the relation of its capsule to its sub- 
 stance; after section, the appearance of the cortex or convo- 
 luted portion, as contrasted with the pyramids of straight tubes 
 in the medulla, and the relative area of each. 
 
 As to size and weight, the adult kidney is usually about 11 
 centimeters (4.4 inches) in length, 5 centimeters (2 inches) 
 wide, and .75 centimeter (.3 inch) in thickness. It weighs 
 in the male 113.5 to 170 grams (4 to 6 ounces); female, a little 
 less, 113.5 to 156 grams (4 to 5 J ounces). Its color in health 
 is dark red, .sit^/ace smooth, and in consistence it is usually firm 
 and slightly elastic. The capsule is easily stripped oif from 
 the substance of the organ, dragging none of the proper glandu- 
 lar structure with it. 
 
 On section of the kidney the cortex is found to be granular in 
 appearance, and uniformly light-red in color. It varies some- 
 what in width, but is usually 5 to 6 millimeters {\ to J inch) 
 wide, and in longitudinal section is seen to dip down between 
 the pyramids of the medulla. These pyramids, ten to fifteen 
 in number, are striated or fibrous in appearance, uniformly 
 dark-red, and terminate in as many papillae in the pelvis of 
 the organ. 
 
 2
 
 ]; 
 
 bright's disease. 
 
 More important to a correct understanding of the pathology 
 of kidney diseases is a knowledge of the minute structure of the 
 organ. Even the naked eye can discover further differences on 
 the surface of a longitudinal section of the kidney, such as is 
 
 Fig. 1. 
 
 Longitudinal section through the kidney, the pelvis of the kidney, and a number of 
 renal calyces. A, branch of the renal artery; U, ureter; C, renal calyx; 1, cortex; 
 1', medullary rays; 1", labyrinth, or cortex proper; 2, medulla; 2', papillary portion of 
 medulla, or medulla proper; 2", border layer of the medulla ; 3, 3, transverse section 
 through the axes of the tubules of the border layer ; 4, fat of the renal sinus ; 5, 
 5, arterial branches ; * transversely coursing medullary rays. — After Hexle:. 
 
 presented in Fig. 1 ; and these differences are rendered still more 
 striking if the bloodvessels are injected with a coloring matter. 
 From each papilla as a centre radiate the excreting tubules, 
 which appear as dark-red striae in the natural organ. For a
 
 STRUCTURE OF THE KIDNEY. 
 
 19 
 
 short distance they remain in contact, forming a continuous 
 surface, known as tlie papillary jjortion of the medulla (Lud- 
 wig), or the medulla proper (Heule). This is represented at 
 
 Fig. 3. 
 
 ■-■'] 
 
 Fig. 2— Partially diagrammatic sketch of the structure of the kidney in longitudinal 
 section, and, Fig. 3, Tangential section through the cortex; bloodvessels injected. 
 After Rindtieisch and Ludwig, modified, k, papillary layer; i, border layer ; h, cortex. 
 The lighter striae, PF, are bundles of uriniferous tubules, a part of which are seen pro- 
 longed into the cortex as medullary rays or pyramids of Ferrein. Between each two 
 of these in the cortex is the renal labyrinth, or secreting portion proper of the kidney. 
 o, a, a, embrace the bases of the renal lobules, which, in transverse section at Fig. 3, ap- 
 pear as polygonal figures. MA, a larger branch of the renal artery, which separates the 
 medulla from the cortex ; HV, lumen of a renal vein which takes up the interfascicu- 
 lar vessels ; the latter appear in transverse sections on the surface as stellate figures ; VR, 
 straight vessels (vasa recta) ; PA, surface of a renal papilla. 
 
 Fig. 3. — Polygonal appearance of the lobuli when cut transversely. F, transverse 
 sections of the tubules forming the pyramids of Ferrein. 
 
 2', Fig. 1, and at h, Fig. 2. As they proceed towards the periph- 
 ery, the strife become separated into bands of nearly equal 
 width, between which are collections of other strise. These in
 
 20 bright's disease. 
 
 an injected kidney exhibit the color of the injecting fluid, but 
 in an uninjected organ, though lighter or less opaque, are 
 scarcely distinguishable from the bundles of straight tubes with 
 which they alternate, unless they happen to be filled with 
 blood. These striae are, therefore, bloodvessels, and the por- 
 tion of the medulla which is thus made up of alternate bands 
 of bloodvessels and straight tubules is called the boundary 
 layer, or marginal layer of the medulla {2", Fig. 1, and i, 
 Fig. 2). Clpse examination, especially with a low magnifying 
 power, enables us to trace into the cortex almost to its border 
 the bundles of striae or straight tubes which come from the 
 papillae (1', Fig. 1, and PF, Fig. 2). In this situation they 
 are called medullary rays, or pyramids of Ferrein. Alternat- 
 ing with these medullary rays in the cortex is a granular por- 
 tion, yellowish-red in the uninjected organ, which is the 7'enal 
 labyrinth, or cortex proper. 
 
 The further study of the minute structure is best facilitated 
 by a separate consideration of the tubules, bloodvessels, and con- 
 nective tissue elements, and the lymphatic and nervous elements 
 which accompany them. 
 
 I. The Uriniferous Tubides. 
 
 These, with the bloodvessels, make up the great bulk of the 
 organ. They may be studied from their beginnings in the 
 cortex, or backwards as it were, from their terminations in the 
 discharging-tubes on the papillae. Selecting the former, the 
 little granules visible to the naked eye in the labyrinth are 
 the beginnings of the uriniferous tubules. These are spherical 
 dilatations, .15 to .2 mm. (y e o ^^ 125 inch) in diameter, formed 
 of basement membrane lined by a mosaic of pavement epithe- 
 lium. They are the so-called Malpighian capsules (1), Fig. 4, 
 and are continuous, by a necklike construction (2), with the 
 proximal convoluted tubule (3), which winds towards the 
 adjacent medullary ray ; reaching which, it passes vertically 
 downward as the spiral tube (4) of Schachowa. These por- 
 tions are all in the cortex, A. At the junction of the cortex 
 and the border layer, the spiral tubule becomes suddenly nar-
 
 STRUCTURE OF THE KIDNEY. 
 
 21 
 
 rower, and (lij)s down tlirough this layer, B, as the descending 
 limh (5) of Henle's loop, the loop itself (6) being formed in the 
 
 Fig. 4 
 
 Diagrammatic representation of the course of two urinary tubules.— After Klkin and 
 
 Noble Smith. 
 
 papillary layer, C. Ee-entering the boundary layer, the tube 
 becomes suddenly enlarged and slightly wavy in its course, 
 forming "the first thick portion" (7) of the ascending limb of
 
 22 bright's disease. 
 
 Henle's loop. At the middle of the boundary layer it again 
 becomes narrower and spiral in its course, forming the " spiral 
 part" (8) of the ascending limb. The ascending limb now 
 re-enters the cortex in the medullary ray, again becoming nar- 
 rower, though not of uniform diameter, and straighter, but 
 still slightly wavy in its course (9). Sooner or later, after re- 
 entering the cortex, the tubule dips away from the medullary 
 ray and passes into the labyrinth as a tube irregular in outline, 
 breadth, and course, whence it is called the irregular tubule (10). 
 Fairly in the labyrinth, it again becomes wider and convoluted, 
 forming the intermediary segment (Schaltstiick) of Schweig- 
 ger-Seidel, or distal convoluted tubule (H). Finally, by an 
 archlike turn, whose convexity is towards the circumference of 
 the kidney, it passes back tow^ards the medullary ray as a nar- 
 rower "curved part" (12) of the collecting-tube, which, uniting 
 with other similar tubules, forms the "straight part" (13) of 
 the collecting-tube in the cortex. The collecting-tube passes 
 down, still as a straight tube (14), though growing gradually 
 wider, through the boundary layer. In the papillary layer it 
 becomes the large collecting-tube, or tube of Bellini, which, 
 uniting with others, forms the "ducts" or " discharging- 
 tubes " which open on the papilla. 
 
 In its course from its commencement in the Malpighian cap- 
 sule to its termination in the collecting-tube the uriniferous 
 tubule changes its diameter many times. First, there is the 
 constriction at the neck of the capsule, which is less than one- 
 half the diameter of the convoluted portion immediately suc- 
 ceeding it, and of which the average width, in the adult, is 
 about .06 mm. {-x^-q inch), and in the newborn child, about 
 .016 mm. (yg'^o inch). The third change is found in the nar- 
 rowing as the tubule becomes the descending limb of the loop 
 of Henle. The fourth is the slight dilatation just before or 
 after the loop is formed. Fifth, a slight temporary narrowing 
 at the " spiral part " of the ascending limb. Sixth, a further 
 narrowing as the ascending limb re-enters the cortex. Seventh, 
 the numerous changes in the irregular tubule (10). Eighth, 
 the widening of the intermediary portion, of which the diame-
 
 STRUCTURE OF TUE KIDNEY. 
 
 23 
 
 ter about equals that of the convoluted tubule. And, ninth, a 
 constriction as the latter terminates in the collecting-tube. 
 
 After the collecting-tube is formed it receives, just below its 
 summit, a few additional canals, and then passes singly down 
 to the papillary part of the medulla. Its diameter in the med- 
 ullary ray is between .04 mm. (g.^g inch) and .08 mm. (gfo 
 inch) in the adult, and in the child .008 (3 j'.j = inch) and .05 mm. 
 
 Diagrammatic exposition of the method in which the uriniferous tubes unite to form 
 primitive cones. — After Ludwig. 
 
 (5 oT inch), the narrowest canals being in the centre of the ray. 
 Having reached the papillary portion, the collecting-tubes unite 
 by twos ; first those of a single medullary ray, forming the 
 principal or excreting tubes ; then these unite with other excret- 
 ing-tubes to form the papillary ducts, of which fifteen to twenty 
 open on the surface of each papilla into the pelvis of the kidney. 
 Dr. George H. Rose, in an able graduation thesis On the 
 An'angement of the Ui'iniferous Tubules, presented to the 
 Medical Faculty of the University of Pennsylvania, in March, 
 1879, concluded, first, that not all of the tubuli uriniferi go to 
 form loops of Henle ; second, that the medullary rays are
 
 24 bright's disease. 
 
 made up of the convoluted tubes which do not form loops, as 
 well as the collecting-tubes and ascending and descending 
 limbs of Henle.* 
 
 Strucfure of the Uriniferous Tubules. — The Malpighian cap- 
 sule is composed only of the basement membrane and mo- 
 saic of epithelial squams to which allusion has already been 
 made. The cells, as seen in nitrate of silver preparations, 
 are relatively large, although not uniform in size, and are pro- 
 vided with round and oval nuclei. The nuclei are arran<i;ed in 
 groups of from two to ten. The group nuclei are round, about 
 .01 mm. i^-so-f) inch) in diameter, and, though flat, project 
 slightly into the cavity of the capsule {d, Fig. 15). Each is 
 surrounded by an amount of protoplasm, which is smaller the 
 greater the number of nuclei in a group, whence the varying 
 size of the cells. In the young kidney these cells are less 
 flattened, and the nuclei project still further into the cavity of 
 the capsule, as is seen in Fig. 15. 
 
 The capsules thus formed surround the capillary ball or 
 glomerulus presently to be described, forming with it the Mal- 
 pighian corpuscle. The latter are encircled by a few concentric 
 layers of connective tissue, which are most numerous about 
 those nearest the medulla. (See Fig. 15.) 
 
 This single layer of cells lining the capsule, which is com- 
 parable to an endothelium rather than an epithelium, extends 
 into the neck of the capsule, whence onward to the papillary 
 portion of the medulla the uriniferous tubule is composed of 
 a basement membrane lined with an epithelium. The base- 
 ment membrane contains an occasional nucleus, and in nitrate 
 of silver preparations the convoluted tubules may be imper- 
 fectly mapped off into endothelial plates like the walls of blood 
 and lymph vessels similarly treated ; but the membrane is 
 otherwise quite glasslike, affording, when the epithelium is 
 washed out, one of the most satisfactory and typical examples 
 0^ a homogeneous membrane. 
 
 * Dr. Hose's studies were made with extreme care upon macerated 
 preparations of tlie kidney. Tliey were many times rejaeated, and his 
 thesis received the award of a prize.
 
 STRUCTURE OF THE KIDNEY. 25 
 
 The epithelium below the neck varies greatly, although it is 
 everywhere single-layered and nucleated. The nucleus, alone, 
 of the various cells is quite uniform, being round, sharply 
 defined, and slightly granular. On the other hand, in the 
 convoluted part of the tubule, the protoplasm of the adjacent 
 cells is not diiFerentiated, but each cell fuses, as it were, into 
 its neighbor, so that the lining of the tubes, especially when 
 acted upon by acetic acid, presents the appearance of a 
 nucleated protoj)lasm rather than of a number of separate 
 nucleated cells. At intervals may be observed, however, 
 more especially if the tubules have been injected, certain 
 
 Fig. 6. 
 
 Section through the cortex of a fresh kidney, showing cloudy epithelium. The sphe- 
 roidal nuclei are concealed. In the wider tuhules irregular, in the narrower, regular 
 fissures divide the epithelial mass. After Ludwig. 
 
 clefts or fissures where the cell bodies are not thus completely 
 fused. These are well shown in Fig. 6, from Ludwig. Ac- 
 cording to Klein, the clefts are occupied by minute septules, 
 containing here and there an oblong or angular nucleus, which 
 pass in from the basement membrane. Of importance in con- 
 nection with the study of diseases of the tubules is the fact 
 that, in this portion, the epithelium is but loosely attached to 
 the basement membrane, and may even be pressed out in the 
 shape of a solid epithelial cylinder, or left as such by retrac- 
 tion of the basement membrane. The protoplasm of the cells
 
 26 
 
 BRIGHT S DISEASE. 
 
 in this situation is more or less " cloudy " in health, from the 
 presence of a number of dark granules of albuminous compo- 
 sition, and even of some minute fat-globnles. These serve to 
 render the nucleus more or less obscure, while the addition of 
 acetic acid, dissolving the albuminous granules, renders it again 
 distinct. 
 
 R. Heidenhain* adds to the structures as above described an 
 
 Fig. 7. 
 
 Fig. 8. 
 
 Fig. 9. 
 
 ^,<^r^^r:y. 
 
 
 ■:^^^^S 
 
 '"^tiijiiB^ 
 
 VC^^ 
 
 Fig. 7. — Transverse section through a convoluted tubule of a fresh dog's kidney, 
 without the addition of any fluid. Hartnack inim. ix, tube in, drawing prism. Mag- 
 nified 500 diameters. — After Heidenhais. 
 
 Fig. 8. — Section of a convoluted tubule of a dog's kidney, ammonium chromate 
 preparation. Hartnack Obj vii. Drawing prism, tube out. Magnified 440 diameters. — 
 After Heidenhaix. 
 
 Fig. 9. — Surface view of a convoluted tubule. Same treatment and amplification. — 
 After Heidenhain. 
 
 additional element, the effect of which is, as he says, to make 
 the epithelial cell of the convoluted tubules a very complicated 
 organized structure. According to him the protoplasm is fur- 
 ther differentiated into a large number of delicate cylindrical 
 structures, which he calls " rodlets " (Stiibchen). These, rest- 
 
 * R. Heidenhain, Mikroskopische Beitriige zur Anatomie und Physiol- 
 ogie der Nieren, in Max Schultze's Archiv fiir Mikroskopische Anato- 
 mie. Bd. X, 1874, s. 1.
 
 STRUCTURE OF THE KIDNEY. 
 
 27 
 
 iiig their peripheral ends on the basement membrane, perforate 
 the epithelial layer in a radiated manner, imbedded in a very 
 small quantity of formless matrix. The rodlets envelop, "like 
 a mantel," the nuclei, which are placed at regular intervals, 
 surrounded by a considerable remnant of undifferentiated pro- 
 toplasm. According to Heidenhain the minute granules, for- 
 
 FiG. 10. 
 
 Fig. 11. 
 
 Fig. 12. 
 
 Fig. 13. 
 
 Fig. 10.— Isdlated cells and rodlets from the rat's kidney. Same treatment and am- 
 plification. — After Heidenhain. 
 
 Fig. 11. — An isolated fragment of a descending limb, sliowing the clear, delicate 
 epithelium, with alternate projections caused by the nucleus. — After Ludwig. 
 
 Fig. 12. — Ascending limb of loop, showing imbricated arrangement of columnar 
 cells, according to Ludwig. 
 
 Fig. 13 — a, a portion of a convoluted tubule ; 6, of an ascending limb of Henle's loop, 
 according to Heidenhain. The ascending limb has tlie greater lumen. Klein confirms 
 Heidenhain in all essential particulars, but says, also, that, in the narrow part of the 
 ascending limb, about the middle of tlie boundary layer, "many cells appear possessed 
 of short processes and are more or less imbricated, a fact already known to Steudener." 
 
 merly described as present in the matrix of the cells, are nothing 
 but the transverse sections of the rodlets. 
 
 Figs. 7, 8, and 9, from Heidenhain's paper, exhibit the ap- 
 pearances described. 
 
 Dr. Klein, of London, substantially confirms the observa- 
 tions of Heidenhain, but says these rods or fibrils, when looked 
 at from the surface, are clearly connected into a network, so 
 that they are more probably "septa of a honeycombed network
 
 28 BRIunx's DISEASE. 
 
 seen in profile/' In the Atlas of Histology, part xi, Fig. 1, 
 recently issued by Dr. Klein, in connection with Mr. E. Noble 
 Smith, this peculiarity in the structure of the epithelium is 
 exquisitely brought out. 
 
 In the narrow descending limb of Henle's loop is found a 
 single layer of epithelium, the cells of which are characterized 
 by a transparent protoplasm and oval nucleus, whicli projects 
 into the lumen of the tubule at alternate points, as shown in 
 Fig. 11. The resemblance of these tubules to capillary blood- 
 vessels is very marked, especially in transverse section ; but, as 
 Klein points out, the nuclei are more numerous than in a 
 capillary, and the tubule has, further, a membrana iwopria 
 outside the layer of cell-plates. 
 
 In the ascending limb of the loop, where the diameter again 
 becomes greater, Ludwig describes the epithelial cells as colum- 
 nar, arranged in an imbricated manner, and distinctly differ- 
 
 FlG. 14. 
 
 Irregular tubule froiu the cortex of the kidney of a dog. — After Klein. 
 
 entiated by a cleft about half way between two nuclei, as in 
 Fig. 12. But according to Heidenhain's investigations, the 
 epithelium of this broader ascending limb agrees essentially 
 with that of the convoluted portion of the tube, the rodlets be- 
 ing similarly developed, as shown in Fig. 13. It is, however, 
 tolerably easily distinguished from the convoluted tubule by 
 the fact that the lumen of the latter is much narrower in 
 consequence of the greater thickness of its cells, which, there- 
 fore, encroach more upon its lumen. 
 
 The irregular tubule, as figured by Klein, Fig. 14, is a strik- 
 ing object. He describes it as follows : 
 
 " It is situated among the convoluted tubes of all parts of 
 the labyrinth ; it has a very irregular and angular outline ; in 
 some places three and four times as thick as in others, and then
 
 STRUCTURE OF THE KIDNEY. 29 
 
 of almost the same breadth as a convoluted tubule. But this 
 greater thickness is due merely to a greater thickness of the 
 lining epithelial cells, the lumen remaining everywhere a nar- 
 row canal. The cells show, in the profile view, exceedingly 
 thick rods of a bright, homogeneous aspect, more distinct than 
 in any other section of the urinary tubule. The cells are very 
 angular and, in many places, imbricated ; but in this, as in the 
 former cases, this imbrication is due to the irregular outline of 
 the tube and the great variation in height of the adjacent cells. 
 Each cell possesses an oval or angular nucleus next the lumen." 
 
 In the intermediary portions the epithelium reassumes the 
 appearance of that of the convoluted segment of the tubule ; and 
 here, again, Heidenhain and Klein reintroduce the rodlets, or, 
 rather, their ends, as the cause of the faintly granular appearance. 
 
 In the collecting-tubes the epithelium is described as colum- 
 nar, but the cells are more nearly cubical ; they are sharply 
 defined, rather broader at the base, which is seated on the wall 
 of the tubule, while their truncated apices are directed towards 
 its lumen. In the smaller canals, which unite in the medullary 
 rays to form larger tubes, the round nuclei are surrounded with 
 but a small amount of protoplasm. In the larger tubes the pro- 
 toplasm is more abundant and the nuclei about the same size 
 as in the smaller. Isolated cells from both regions exhibit pro- 
 jections and prolongations of protoplasm, so that it is really 
 only in transverse sections of the collecting- tubes that the 
 columnar or cubical appearance of the cells is maintained. In 
 the papillary ducts a basement membrane can no longer be 
 differentiated from the connective tissue around it, and the 
 cells, which are here more elongated and typically columnar, 
 rest upon the connective tissue alone. 
 
 Heidenhain says that, in the primary branches of the col- 
 lecting-tubes, he has, here .and there, observed that the so-called 
 cylindrical cells are placed in an oblique manner, so as to give 
 an imbricated appearance, and suggests that this may have 
 given rise to the view of Ludwig, already described in these 
 pages, that the ascending broad limb of Henle's loop is thus 
 lined.
 
 30 bright's disease. 
 
 Anatomical Peculiarities of the Glomerulus or Malpigliian 
 Tuft; its Epithelial Covering, etc. — It is now generally con- 
 ceded that, in addition to the mosaic of epithelium which lines 
 the Malpighian capsule, the glomerulus itself is covered with 
 a layer of epithelial cells, but all observers are not agreed as 
 to its exact arrangement. According to some it simply covers 
 the surface, bridging the space between the capillaries and the 
 lobules which compose the glomerulus. Others consider that 
 it also dips down between the capillary loops. The studies of 
 Heidenhain"^ and of Langhans,t which are among the most 
 recent, lead them to accept the latter view, while Schweigger- 
 Seidel| and Von Seng§ adopt the former. The cells are for the 
 most part well defined, but differ somewhat according as they 
 cover the surface of the glomerulus or dip down between the 
 capillary loops. In the former instance they are thin vaulted 
 plates, whose concave surface rests upon the convexity of the 
 capillary loop and is moulded to it. The shape of the cells 
 also varies somewhat, according as they cover one or more 
 capillary loops. In the latter instance the under surface of the 
 cell is divided by projecting edges into several concave areas 
 for the reception of the individual capillary loops. The edges 
 unite at the centre, at which is the nucleus, which itself is 
 conical in shape. At this situation — the seat of the nucleus — 
 the external or upper surface is frequently depressed, so that 
 the lateral extensions of the cell assume a pterygoid appear- 
 ance. Other cells are concave on both surfaces, an effect prob- 
 ably due to their being insinuated between two capillary loops. 
 
 The nuclei measured by Langhaus are oval, .01-.014 mm. 
 (a-s'oTj-iAg i"-) long and .006-.01 mm. (^^igg-^J^ in.) wide, 
 and somewhat flattened. The cells themselves reach .025 mm. 
 
 * Heidenhain, Arcliiv fiir Mikrosk. Anatomie, B. x, 1874, p. 3. 
 
 f Langhans, Ueber die Veriinderungen der Glomeruli bei der Nephritis 
 nebst einigen Beraerkungen iiber die Entsteluing der Fibrincylinder. Vir- 
 cliow's Archiv, 76 Bd., erstes Pleft, April, 1879, p. 85. 
 
 X Schweigger-Seidel, Die Nieren, Halle, 1865, p. 76. 
 
 § Victor von Seng, Ein Beitrag zur Lehre von den Malpighischen Kor- 
 perchen der Menschlichen Nieren. Wiener Sitzungsberichte, Ixiv, 13 
 April, 1871.
 
 STRUCTURE OF THE KIDNEY. 
 
 31 
 
 (ttsW '"•) ^^ diameter at a maximum. In some instances the 
 line of junction between neighboring cells is not demonstrable, 
 so that the covering of the glomerulus appears as a homogeneous 
 nucleated plate. The cells and nuclei are much more easily 
 demonstrable in the foetal kidney, in which they are more cubi- 
 cal, as seen in Fig, 15, from Klein's Atlas ; undergoing a 
 change after birth which is compared by Schweigger-Seidel to 
 the post-foetal transformation of the alveolar epithelium of 
 the lung. The epithelial covering of the glomerule is con- 
 
 FiG. 15. 
 
 Section through cortical substance of a human foetal kidney, a, glomerulus ; c, epi- 
 thelium covering the glomerulus; (/.flattened epithelinm lining Bowman's capsule;/, 
 urinary tubules in section. — After Klein and Noblk Smith. 
 
 tinuous with the epithelial lining of the capsule, as is well 
 shown in Fig. 15. 
 
 According to Axel Key the capillary bloodvessels of the 
 lobules of the glomerules are held together by a homogeneous 
 connective tissue containing flattened stellate and nucleated 
 connective tissue corpuscles. But Langhans was unable to 
 convince himself of the presence of connective tissue, except 
 the adventitia of the vas aiferens, which extends only until 
 the vessel begins to break up into capillaries. 
 
 The capillaries of the glomerule or Malpighian tuft, like all 
 capillaries, are provided with nuclei, which in common with
 
 32 
 
 BRIGHT S DISEASE. 
 
 all tlie cellular elements named are subject to pathological 
 change. 
 
 There are no Malpighian corpuscles in that part of the cortex 
 immediately bordering the capsule, nor in that bordering the 
 boundary layers, that is, in the most external and most internal 
 portions. See a and a, Fig. 4. 
 
 II. The Bloodvessels of the Kidney. 
 The renal artery, before it enters the substance of the organ, 
 
 Distribution of the larger bloodvessels of the kidney. Engrared from a photograph 
 of an injected and macerated preparation by Hyrll iu the Museum of the College of 
 Physici.ms, Philadelphia. A, the artery. B, B, B, B correspond to the di.stinct lobar 
 divisions of the kidney, to each one of which the branches of an artery are distributed, 
 which again unite to form the area of the coriex. The open spaces correspond to the 
 areas of the straight tubules or pyramids, which containing comparatively inw blood- 
 vessels were washed away iu the maceration. The vertical interlobular arteries alluded 
 to in the text are not seen, because the kidney is shown entire and not in hemi-section. 
 
 breaks up into two or three branches, which penetrate the cap- 
 sule at the border of the pelvis of the kidney, and, after fur- 
 ther rapid subdivision, radiate directly to the upper part of the 
 marginal layer of the medulla. From branches arching more 
 or less irregularly along this border ascend vertical branches.
 
 STRUCTURE OF THE KIDNEY. 
 
 33 
 
 These pass into the labyrinth midway between two medullary 
 rays, and are called interlobular or interfascicular arteries. 
 From them pass off, laterally, numerous smaller branches called 
 afferent, — vasa afferentia, — each one of which promptly perfo- 
 rates the nearest Malpighian capsule at a point opposite to the 
 constricted neck of the latter. The vas afferens, according to the 
 measurements of Thoma,* is .014 to .02 mm. (y^gg to ^^'^j 
 inch) in diameter. Having perforated the capsule, it immedi- 
 ately splits up, forming a capillary ball — the Malpighkin tuft or 
 gloriienile. The capillary vessels of this ball reunite within the 
 
 Diagrammatic representation of the bloodvessels in the cortex of the kidney, m, region 
 of the medullary ray ; 6, region of the tortuous portion of the tubules ; AI, interlobular 
 artery ; VI, interlobular vein ; VA, vas afferens glomeruli ; VE, vas elTerens ; GL, Malpig- 
 flian capsule containing in its interior the capillary ball known as the glomerule, or Mal- 
 pighian tuft ; VZ, venous twig of the interlobular vein. — After Ludwig. 
 
 capsule to form a vessel, — the vas efferens, — which perforates 
 the capsule outwards at the same point at which the vas 
 afferens enters, and slightly exceeds the latter in diameter. The 
 efferent vessel proceeds towards the nearest medullary ray, and 
 becomes a second time capillary. The resulting network em- 
 braces partly the straight tubules of the medullary ray, and 
 partly the tortuous tubules, and, in the extreme periphery of the 
 cortex, to which the medullary rays do not extend, the tortuous 
 
 * Thonia, Zur Kenntniss der Cifculationstorung in den Nieren bei chron- 
 ischer interstitieller Nephritis. Vircliow's Archiv, Bd. 71, 1877. s. 65. 
 
 3
 
 34 
 
 BRIGHT S DISEASE. 
 
 tubules only. To these capillaries are added others, derived 
 from a few minute branches given oif by the afferent vessels 
 
 vb-J 
 
 vp-- 
 Diagram of the circulation in the kidney.— After Lcdwig. 
 
 before they reach the Malpighian ca])8ule. A few onlv of the 
 vasa cfferentia lying adjacent to the medulla do not thus di-
 
 STRUCTURE OF THE KIDNEY. 35 
 
 vide, but distribute their branches in a manner presently to 
 be described. With these exceptions, the eajiillaries from all 
 the neighboring eiferent vessels communicate with each other, 
 and the whole cortex becomes interpenetrated, as is well shown 
 in Figs. 16 and 18. The meshes of the resulting network sur- 
 rounding the convoluted tubules are small and nearly round, 
 while those embracing the medullary rays are larger and wider. 
 According to Ludwig, the vessels are not closely applied to the 
 tubules, but lacuniform spaces, frequently filled with fluid, in- 
 tervene between the two. The terminal branches of the 
 interlobular arteries reach the capsule of the kidney. 
 
 That part of the network which surrounds the medullary rays 
 is continuous with the capillary system of the medulla, but the 
 blood from the cortical plexus is, for the most part, collected by 
 a system of veins (r/. Fig. 18) corresponding to the interlobular 
 arteries. Some of these, at least, begin on the surface of the 
 kidney by the union of a number of minute veins from the 
 external layers of the cortex, which unite in a radial manner, 
 so that the resulting vessels are called stellate veins (see Fig. 
 18, vs). Thence they descend, each vein in company with an 
 interlobular artery, towards the marginal layer of the medulla, 
 receiving numerous branches from the capillaries of the cortical 
 plexus above described. The interlobular veins which do not 
 begin in the stellate veins of the periphery begin in the labyrinth. 
 
 The interlobular arteries, with their afferent branches, and 
 the glomeruli may be compared to a bunch of ripe currants, the 
 interlobular vessel corresponding to the vertical stem of the 
 raceme, the afferent vessels to the lateral branches, while the 
 currant itself is the red glomerulus or capillary ball. 
 
 The Vasa Recta and the Bloodvessels of the Meelidla. — It was 
 stated on p. 33 that not all the vasa effereutia split up into the 
 capillary system described, but that a certain number lying 
 adjacent to the medulla distribute their branches differently. 
 These branches are sent down directly into the medulla, in the 
 shape of straight vessels, comparable in their distribution to 
 the drooping branches of the willow-tree, and are called vasa 
 reda. But although straight vessels, they are not arteries, though 
 sometimes called arteriolce, since they are without circular nuis-
 
 36 brigiit's disease. 
 
 cular fibre-cells in their walls. They are simply elongated 
 efferent vessels (See Fig. 18, «r'). These contribute, however, 
 but a small proportion to the vasa recta. The majority, Avliieh 
 are true arteries, are derived from the same arching branches 
 which give off the interlobular vessels at the upper edge of the 
 marginal layer of the medulla, but pass in the opposite direction. 
 The straight vessels from these two sources, passing down- 
 wards, enter first the spaces between the bundles of tubules in 
 the marginal layer of the medulla, dividing and subdividing 
 in a brushlike manner (Fig. 18, ar and ah) until they finally 
 become capillary, and embrace the tubules in wide meshes. 
 The number of trunks of the straight vessels progressively 
 diminishes as the tubules become closer and the papillse are 
 approached, until the latter are reached, when but one or two 
 remain to form a plexus of capillaries on the papillee them- 
 selves. The capillaries reunite to form veinlets, corresponding 
 to the straight arterioles, and these veins accompany the arte- 
 rioles in the fissures between the bundles of tubules, reuniting 
 to form larger trunks, which finally empty into vessels at the 
 border of the cortex, corresponding with those which give off 
 the straight arterioles (see Fig. 18, vb and vr). 
 
 The system of the vasa recta is one of great importance in 
 the circulation of the organ. It has been remarked that the 
 capillary system at the border of the cortex is in communica- 
 tion with that of the medulla ; but it is evident also that the 
 vasa recta, derived from the same branches as the interlobular 
 arteries, admit of the transit of a large amount of the blood 
 of the kidney through a coarse-meshed capillary plexus without 
 its passing through the complex system of the labyrinth. This 
 is an important provision, which doubtless tends to preserve 
 the integrity of tlie kidney in congestions, or when a large 
 amount of blood is driven through it. Under these circum- 
 stances a short cut is, as it were, provided for the blood out of 
 the organ, and the more delicate vessels of the labyrinth are 
 protected from rupture. 
 
 We are indebted to Virchow and INlcDonnel for the discov- 
 ery of the vasa recta, and to Virchow, Ludwig, and Beale for 
 our present accurate knowledge of their arrangement.
 
 STRUCTURE OF THE KILNEY. 37 
 
 III. Tlie Connective Tissue of the Kidney. 
 
 From a pathological standpoint the connective tissue of the 
 kidney becomes one of the most important of its elementary 
 structures. All anatomists and renal pathologists, however, 
 are not agreed upon its proportion and importance. 
 
 While none deny its presence in the medullary portion of 
 the kidney there is still a difference of ojjinion as to its exist- 
 ence in the cortex. Goodsir, in 1842, described the connec- 
 tive tissue framework or matrix of the kidney in the cortex, 
 as well as the medulla, as though it were as distinct from the 
 vascular and tubular structures of the organ as the l^eams and 
 rafters of a house are distinct from the materials between them. 
 Von Wittich,* in Germany, first contested this view, claiming 
 that the intervals between the tubules are occupied only by 
 capillary vessels, and that there is no connective tissue in the 
 cortex. In this he was for a time sustained by German histolo- 
 gists generally. Arnold Beer,t in 1859, reasserted the impor- 
 tance, from an anatomical point of view, of the connective 
 tissue as a stroma or framework for the support of the tubules 
 and vessels. Henle,| in 1864, asserted that demonstrable 
 quantities of connective tissue are only found in the apices of 
 the pyramids, where they occupy the intervals between the 
 tubules. Accordiup; to Ilenle it is a substance which in the 
 fresh condition is clear and transparent, and it is only after the 
 long-continued action of chromic acid and chroraate of potash 
 solutions that delicate fibres appear, containing round and el- 
 liptic nuclei. Further inwards, towards the cortex (boundary 
 layer of the medulla), the nuclei become less numerous, and 
 finally disappear altogether, leaving between the tubules only 
 delicate layers of a finely fibrillated tissue, which cannot be con- 
 sidered an artificial product, because the fibrillse are often ar- 
 
 * Von Wittich, Beitrage zur Anatomie der gesunden und Kranken Niere. 
 Virchow's Archivfiir Patholog. Anatomie, Bd. 3, 1849, s. 142. 
 
 t Arnold Beer, Die Bindesubstanz der menschlichen x^iere im gesunden 
 und krankliaften Ziistiinde. Berlin, 1859. 
 
 X Henle, J., Handbuch der Systematischen Anatomie des Menschen. 
 Zweiter Band, zweite Lieferung. Harn und Geschlechtsaparat. Braun- 
 schweig, 1864.
 
 38 brigiit's disease. 
 
 ranged circularly arouixl the tubules. lu tlie cortex the 
 tubules and vessels are so closely intercalated that we can, as 
 a rule, only speak of a cementing (verbindenden) substance 
 rather than an intertubular and intervascular substance 
 (zwischen-substanz). " True connective tissue/' says Henle, 
 " is found in the cortex and medulla only in the immediate 
 neighborhood of the bloodvessels." 
 
 At the present day Drs. Johnson and Beale, of England, 
 also assert that the connective tissue is of minimum impor- 
 tance, that it has no share in the anatomy of the organ, and 
 therefore, none in the pathology. Dr. Beale says :* " 1. In the 
 cortical portion of the kidney there is no evidence of the ex- 
 istence of a fibro-cellular matrix distinct from the walls of the 
 tubules and capillaries. 2. The fibrous appearance observed 
 in those sections of the kidney which have been immersed in 
 water is fallacious, and is due to a crumpled, creased, and col- 
 lapsed state of the membranous walls of the secreting-tubes 
 and capillary vessels. 3. A small quantity of transparent 
 material is to be demonstrated between the walls of the tubes 
 and the capillaries in health, and not even this can be de- 
 tected at an early period of development." 
 
 Dr. Johnson says :t " The so-called matrix has no ex- 
 istence apart from the basement membrane and capillaries. 
 The convolutions of the tubes and the network of capillaries 
 mutually support each other. No connective or supporting 
 tissue is required ; and, as Dr. Beale well remarks, the inter- 
 vention of any such tissue would tend to increase the distance 
 between the secreting cells and the blood, and so render the 
 gland less fitted for the discharge of its function." .... 
 " If there be any connecting medium it is a homogeneous and 
 structureless element." 
 
 Modern histology has solved the problem consistently with 
 all observations. It is true that there is no distinct frame- 
 work or "supporting" structure of connective tissue for the 
 
 * Beale, Kidney Diseases and Urinary Deposits. Philadelphia, 18(59, 
 p. 23. 
 
 f George Johnson, Lectures on Bright's Disea-se. New York, 1874, p. 7.
 
 STRUCTURE OF THE KIDNEY. 39 
 
 tubules and vessels of the cortex, for they requh-e none. At 
 the same time, we know that no bloodvessel of any size pene- 
 trates a gland without carrying with it its adventitia, and 
 althouo-h this diminishes with the growino; fineness of the 
 subdivisions of the artery, it is scarcely possible to draw the 
 line where the cells of the connective tissue sheath entirely 
 disappear. The interlobular arteries described are doubtless 
 accompanied by such cells. Further, the researches of Ludwig, 
 Kulliker, and Schweigger-Seidel have shown that the con- 
 nective tissue of the cortex and of the marginal layer of the 
 medulla is not of the fibrillar kind, but of the reticular or 
 ])urely cellular variety; very delicate, soft, and scanty, as this 
 kind of connective tissue usually is, winding its spindle and 
 reticular cells in sparse numbers between the tubules and 
 bloodvessels, yet sufficiently numerous to permit an isolated 
 cell to be seen in almost any slide prepared from the fresh 
 organ. These small isolated fusiform cells are described both 
 by Ludwig and Schweigger-Seidel as being placed with their 
 longer axes transverse to the direction of the convoluted 
 tubules. 
 
 These two sources, therefore, the reticular connective tissue 
 of the cortex and the adventitia of the bloodvessels, while they 
 do not afford a matrix or framework, still furnish connective 
 tissue cells in sufficient numbers to become the focus of an 
 overgrowth. Further, in the case of the Malpighian bodies, 
 no one who is in the habit of examining kidney sections under 
 the microscope can have failed to see that they are surrounded 
 by a capsule of fibrUlar connective tissue, especially in the 
 region of the medulla. This is a fact of great importance, 
 because, in the case of diseased organs, it becomes necessary to 
 distinguish such capsule from a pathological overgrowth of 
 the same tissue. 
 
 As we recede from the boundary layer of the medulla 
 towards the apices of the cones — the papillae, the proportion of 
 fibrous connective tissue increases until it becomes quite abun- 
 dant in the latter region, surrounding the tubuli in a concen- 
 tric manner.
 
 40 bright's disease. 
 
 It is even claimed by Axel Key that a reticular connective 
 tissue formed of stellate cells is found uniting the capillaries 
 and capillary lobules of which the glomerule is composed. 
 
 The Capsule of the Kidney. — The kidney is surrounded 
 by a firm capsule, composed mostly of fibrillar connective 
 tissue imperfectly laminated. In health it is very loosely ad- 
 herent by a looser and more delicate layer, to the cortex of the 
 organ, whence it is therefore stripped with facility, the only 
 attachments being a few filaments of connective tissue, and 
 some small bloodvessels which pass from one to the other. 
 In certain diseased states, especially where the connective tissue 
 is involved, this adhesion is more intimate, so that it is impos- 
 sible to strip off the capsule without dragging more or less of 
 the secreting structure of the kidney with it ; and in descrip- 
 tions of post-mortem conditions, we constantly read that the 
 capsule stripped off easily or was closely adherent, etc. Eberth 
 describes a plexus of unstriped muscular fibre-cells under the 
 capsule of the kidney in man. 
 
 The blood-supply of the capsule is derived partly from those 
 branches of the interlobular arteries which do not proceed as 
 afferent vessels to the ]\Ialpighian bodies, and partly from 
 branches of the phrenic, lumbar, and supra-renal arteries. 
 These form a large-meshed capillary system, whence the blood 
 is collected by corresponding veins, including the stellate veins 
 of the cortex. 
 
 IV. The Lymphatic Vessels of the Kidney. 
 
 The extended information recently acquired with regard to 
 the lymphatic system in general, only partially includes that of 
 the kidneys, although the researches of Ludwig and Zawarykin* 
 have furnished some facts of importance. From them we 
 learn : 1st, that the capsule of the kidney is provided with well- 
 defined lymphatics possessing even valves; 2d, that similar 
 larger trunks issue from the hilus of the organ along with the 
 artery and vein ; and, 3d, that the spaces between the tubules 
 
 * C. Ludwig mit Zawarykin, Wiener Akadeniische Sitzungberichte, 
 Bd. xlviii.
 
 STRUCTURE OF THE KIDNEY. 41 
 
 and vessels of the cortex are of tlie nature of lymphatic spaces. 
 These spaces are less numerous in the medullary rays, and 
 still less in the medulla. These observers have also shown 
 that communication exists between the lymphatics of the cap- 
 sule and those of the cortex, and between the latter and the 
 lymphatics of the hilus, but the exact paths of such communi- 
 cation are not determined. 
 
 \. Tlie Nerves of the Kidney. 
 
 While the nerves of the kidney doubtless play a most im- 
 portant role in its physiology, they are less demonstrably 
 influenced by its pathological states than any other of the ele- 
 mentary tissues composing it. They are derived chiefly from 
 the sympathetic system, and it is probably for this reason that, 
 except in the case of acute Bright's disease and of impacted 
 calculus, pain is a rare symptom in renal diseases, although 
 this is contrary to popular opinion, which ascribes almost 
 all pain in the back to kidney disease. We are indebted for 
 many new facts, indeed for almost all we know about the mi- 
 nute distribution of the nerves in the kidney, to Professor 
 Lionel S. Beale, M.B., of London. According to Dr. Beale, 
 nerves, pale and dark-bordered (medullated), are distributed to 
 the secrcting-tubes and capillaries as well as the arteries ; con- 
 nected with the nerve-bundles are numerous ganglia and gan- 
 glion-cells similar to those found in connection with the 
 ramifications of the sympathetic generally in mammalia.* I 
 have myself,t following Dr. Beale's methods, demonstrated 
 these cells in connection with nerve fibres in the pig's kidney. 
 Dr. Beale says further, that these " nuclei," so numerous on 
 the nerves of the kidney, as well as on all the peripheral nerve- 
 fibres of various tissues of mammalia, have been hitherto 
 included among the connective tissue corpuscles of the matrix. 
 He considers that the nerve-fibre distributed to the walls of 
 the uriniferous tubules constitute an afferent system capable of 
 influencing through the nerve-centres the efferent fibres distrib- 
 
 * Beale, Kidney Diseases and Urinary Deposits, 1869, p. 15. 
 f American Journal of the Medical Sciences, October, 1839.
 
 42 
 
 BRIGHTS DISEASE. 
 
 uted to the arteries, the calibre of which they govern, and thus 
 regulate the amount of blood flowing through the capillaries. 
 The ganglia within the kidney are connected by nerve-fibres 
 with those external to the organ, and with the spinal nerve- 
 
 Fie. 19. 
 
 A part of a convoluted portion of a uriniferous tube from the newt's kidnev, show- 
 ing capillary vessels and nerve fibres, and the thickened basement membrane contin- 
 uous in structure with the connective tissue. X 21o. (After Beale.) The finer dark 
 lines, N, represent the nerve fibrils with nuclear thickenings. C, capillary bloodvessels. 
 
 fibres, and through these with the great nervous centres. And 
 thus he would explain the well-known influence of the emo- 
 tional centres over the secretion of urine. 
 
 VI. Suggestions as to the 3Iethod of Studying the Histology of 
 the Kidney. 
 
 For a proper study of the minute changes in a kidney, 
 whether healthy or diseased, it is necessary that sections should 
 be made in two directions : 1st, longitudinally, or in the direction 
 from the cortex towards the papillse ; 2d, transversely to this 
 direction, or tangentially. In this manner the relation between 
 the elementary tissues which make up the organ is preserved.
 
 STRUCTURE OF THE KIDNEY. 43 
 
 and tlie changes in them may be studied understandingly. From 
 cuts in the first direction one picture only is obtained, which 
 may extend from the cortex to the papillae. Cuts in the latter 
 present a different picture, according as they are made through 
 the cortex, or at different situations in a medullary cone — near 
 the cortex, between it and the papilla, or at the papilla itself. 
 It will be found that in the various forms of Bright's disease 
 the cortex alone is generally involved, so that for the study of 
 these conditions it is necessarv only to make sections throuo-h 
 
 Longitiuliual ^section through the cortex. Tubules tunning medullary my in centri% 
 showiug fauitly outlines of epithelial cells. Malpighian bodies among sections of con- 
 voluted tul)ules ; in several places these have been laid open, exposing the lumen of the 
 tubule. The nuclei are seen imbedded in the dark granular protoplasm lining the 
 tubules. Thestiiated appearance of the cells is also well shown. Certain tubules are 
 also transversely cut. X 160. 
 
 this portion. It is especially desirable that the normal picture 
 should be familiar, in order that the abnormal may be under- 
 stood. 
 
 Fig. 2 will give an idea of the appearance, under a low 
 power, of a longitudinal section of an injected kidney. Fig,
 
 44 bright's disease. 
 
 6, however, presents the ])ictiire of a portion of the cortex 
 under a higher power, wliich is necessary for the correct appre- 
 ciation of pathological changes. 
 
 In Fig. 3 is seen the appearance which will be afforded under 
 a low power by a transverse section through the cortex, a short 
 distance below the capsule, of the same kidney from which 
 Fig. 2 represents a longitudinal cut. It also affords a correct 
 notion of the lobular structure which the kidney really pos- 
 sesses, but which would not be suspected without the iniero- 
 
 FiG. 21. 
 
 Tangential shcii ' Ifcting tubes in centre cut transversely. 
 
 Two Malpighiau bodies. Numerous sections of tuliules, some iii transverse section show- 
 ing dark binien of tubuli. Sections of several vessels, V, are seeu near the central collecting 
 tubes. X 150. 
 
 scope. The renal lobules are seen to be j)olygonal figures, of 
 which the sides are formed by the branches of the interlob- 
 ular vessels already de.scribed. The centre is occupied by the 
 straight tubes of the pyramids of Ferrein (medullary rays), 
 and between these and the border is the labyrinth, which is 
 the seat of the most important lesions of interstitial and pareu-
 
 STRUCTURE OF THE KIDNEY. 45 
 
 chymatous nephritis. A section immediately at the surface, 
 just under the capsule, would not give precisely the same pic- 
 ture, for it will be remembered that the medullary rays do not 
 extend quite to the surface of the kidney. A section at this 
 most superficial position would show only convoluted tubules 
 and their intermediary portions. Not even Malpighian bodies 
 would be here seen. In the longitudinal section, shown at 
 Fig. 2, the brackets indicate the boundaries of the lobules. 
 Figs. 20 and 21, show, under suitable enlargement, the ap- 
 pearance of transverse and longitudinal sections in the cortex. 
 Fig. 22 a transverse section through the papillary portion of 
 the medulla, showing the relatively large proportion of con- 
 nective tissue between the collecting tubes in this situation. 
 
 To Prepare Sections of the Kidney for 3Iimite Studi/. — As 
 to the method of making sections for study, no means can 
 
 \r^': 
 
 
 
 'Sald 
 
 Transverse section through papillary portion of a medullary cone. a. Collecting tubes 
 ill transverse srction separated by connective-tissue fibres and cells, b. Portions of 
 loops, c. Bloodvessels. X 150. 
 
 produce cuts in Avhich natural appearances are so well re- 
 tained as the freezing niicrotom, which should always be used,
 
 46 lriqiit's disease. 
 
 if possible. But at i)resent it is expensive and not always 
 obtainable, and in its absence, portions of kidney may be liard- 
 ened in alcohol, which should be gradually increased in 
 strength from day to day; or Miiller's fluid, which should 
 always be changed after twenty-four hours and afterwards at 
 longer intervals, until the tissue is thoroughly hardened. 
 Sometimes, where haste is necessary, portions which have been 
 for some days in Miiller's fluid have to be transferred to alcohol 
 before the hardening is sufficiently accomplished by the former; 
 and of the two methods that by alcohol is always the more 
 speedy. But this general truth may be laid down, that the more 
 speedy the process of hardening employed, the more likely are 
 natural appearances to be altered. The pieces of kidney thus 
 hardened may be imbedded in a mixture of wax and oil or 
 paraffin and benzin, or may be even compressed between suit- 
 able segments of carrot or tuiuiip and cut with a razor of 
 which one side is ground flat; or a section knife made expressly 
 for the purpose may be used. The wax and oil mixture recom- 
 mends itself over the paraffin, because from it there is no evap- 
 oration, and the specimen may lay imbedded a long time if it 
 is not convenient to cut it immediately ; whereas in the paraffin 
 mixture it becomes dry and worthless after twenty-four hours. 
 Paraffin and tallow make an excellent imbedding mixture, 
 which has the advantage of always keeping close to the tissue 
 imbedded in it, while it also slips readily off* the knife after 
 cutting. 
 
 The sections thus made, which are of desirable thinness when 
 the edge of the knife can be clearly seen through them while 
 cutting, should then be stained by a solution of carmine or of 
 lisematoxylon ; if by the former, they should be immersed in 
 a saturated solution of oxalic acid until the excess of carmine 
 is removed ; if by the latter they should be v/ashed in distilled 
 water. They are then returned to common alcohol. If it is 
 simply desired to study them without preserving them perma- 
 nently, they may then be clarified in oil of cloves, placed on 
 a slide in a drop of the clove oil, covered with a thin glass cover 
 and studied ; or they may be transferred from the alcohol into
 
 FUNCTIONS OF THE KIDNEY. 47 
 
 glycerin instead of oil of cloves, and similarly mounted in a 
 drop of the former. The glycerin also clarifies the section. 
 Even thns mounted they may be kept for many days. 
 
 If the sections are to be permanently mounted, they are 
 transferred from the oil of cloves into a drop of Canada bal- 
 sam or dammar solution ; the excess of oil of cloves being first 
 removed by bringing the edge of the section in contact with a 
 piece of bibulous paper. The balsam is best prepared by 
 evaporating the ordinary Canada balsam to dryness and redis- 
 solving in chloroform, benzole or strong alcohol. 
 
 Sections may be also advantageously doubly stained by ap- 
 propriate solutions of carmine and indigo-sulphate of sodium. 
 The sections are first fully stained in the carmine, placed in 
 acid solution, washed in water, and then transferred to a weak 
 solution of the blue indigo-sulphate, where they remain until 
 the satisfactory tint is obtained ; again soaked in acid solution, 
 and finally thoroughly washed in water, after which the usual 
 process of preparation is followed. The double staining may 
 be effected by a single immersion in a mixture of the two 
 staining fluids, but the separate use of these is preferable, owing 
 to the greater certainty of success and the facility with which 
 the relative intensity of the tints is controlled. 
 
 VII. Nature of the Act of Secretion of Urine. 
 
 It is commonly known that two widely different views exist 
 as to the nature of the act of secretion of urine. According 
 to the much older view of Bowman, it is partly j)hysical 
 and partly vital. According to the later theory of Ludwig 
 and his school it is a purely physical act. Ludwig claims that 
 all the constituents of the urine are separated in very dilute 
 solution by a pure act of filtration from the capillaries of the 
 glomerulus into its capsule ; and that in the convoluted tubules 
 there occurs merely an aqueous reabsorption resulting in a 
 concentration of the fluid. Professor Kiiss* goes so far as to 
 
 * Kiiss, A Course of Lectures on Physiology (second edition). Trans- 
 lated by Dr. Amory, Boston, 1875, pp. 465-4G7.
 
 48 brigiit's disease. 
 
 claim tliat the filtered product is really the serum of the blood, 
 whence in health the albumen, as well as some of the water, 
 is reabsorbed in the convoluted tubules; and Kiiss explicitly 
 asserts that " the epithelium of the uriniferous tubes simply 
 absorbs, but does not secrete." 
 
 According to Bowman, on the other hand, the filtrate sepa- 
 rated in the Malpighian capsule is almost a pure water. In it 
 may be dissolved some of the inorganic salts of the urine ; but 
 the most important ingredients, the organic nitrogenous, — in- 
 cluding urea, uric acid, creatin, creatinin, — and extractives are 
 added in the convoluted tubes. 
 
 It is now generally conceded that these organic constituents, 
 as well as the inorganic, exist preformed in the blood ; and al- 
 though the experiments of Oppler,* Perls,t and Zalesky;]: led 
 to opposite conclusions, they lack confirmation, and now few, 
 if any, claim that the urea and extractives are manufactured, 
 so to speak, in the kidney. They are believed to exist pre- 
 formed in the blood, and are selected therefrom by the cells of 
 the convoluted tubules. 
 
 A priori there are two important reasons why we should 
 expect that the proper gland-cells of the kidney should have 
 some more highly specialized function than that of aqueous 
 reabsorption : 1st. The fact that they possess the anatomical 
 peculiarities of glandular epithelium whose function every- 
 where else in the economy is an elaborating one. 2d. The 
 important reason, drawn from pathology, that when, as the re- 
 sult of disease, this epithelium is practically stripped from the 
 tubules we have the retention of urea and often the phenomena 
 of ursemia. But notwithstanding these important facts, the 
 tendency of modern physiology has been to accept the purely 
 physical view of Ludwig until the researches of R. Heiden- 
 hain were published. The indigo sulphate of sodium (indigo- 
 
 * Oppler, Beitriige zur Lehre d. Uriiaiie, Virchow's Archiv, vol. xxi, 
 p. 260. 
 
 t Perls, Beitriige zur Lehre d. Uriiruie, Konigsberg Med. Jahrb., vol. 
 iv, p. 56. 
 
 X Zalesky, Untersucli. iiber d. Uriimisclien Process, Tubingen, 1S65.
 
 FUNCTIONS OF THE KIDNEY. 49 
 
 carmine) is a substance which, when injected into the blood of 
 animals, is promptly separated by the kidneys and appears in 
 the urine. Heidenhain injected this substance, and after ap- 
 propriate intervals, removed the kidneys and examined them 
 microscopically. In no instance did he find any of the indigo- 
 carmine in the Malpighian capsules; but the cells of the con- 
 voluted tubules and the ascending loop of Henle were filled 
 with it, as was also the lumen of the tubes if the animal was 
 killed sufficiently long after the injection. 
 
 Similar experiments with urate of sodium showed that this 
 substance is secreted in precisely the same situation.* With 
 these facts before us it no longer seems reasonable to deny a 
 direct selective action on the part of the cells of the convoluted 
 tubules, and I accept, therefore, as the correct view of the 
 nature of the urinary secretion, that the water of the urine is 
 filtered out in the Malpighian capsule, the condition favorable 
 to such filtration being supplied by the increased blood-j^ressure 
 M'hich exists in the glomerulus. In this water may be dis- 
 solved some of the inorganic constituents of the urine, but the 
 most important nitrogenous principles, the true effete and 
 poisonous matters which it is the office of the kidney to remove, 
 are separated by the agency of the cloudy cells lining the con- 
 voluted tubules, the ascending limb of Henle's loop, and the 
 intermediary segment of Schweigger-Seidel. From these cells 
 they are pushed out into the lumen of the tube by the vis a 
 tergo of additional secretion, and dissolved by the water which 
 comes down from the Malpighian capsule, thus producing the 
 urine, which is gathered up by the collecting and excreting 
 tubes, by which it is emptied into the pelvis of the kidney at 
 the papillfe. 
 
 * The details of these experiments are very interesting, but tlie reader 
 must lie referred tc the jjaper of J. Heidenhain in Max Schultze's Archiv, 
 vol. X, 1874, p. 1 ; also to liis paper, Aersnche liber den Vorgang der Harn- 
 absonderung, in Pfliiger's Arohiv, vol. ix, p. 1, 1874. Good abstracts are 
 also found in Foster's Physiology, p. 277 (first edition), 1877, and in Char- 
 cot's Treatise on Bright's Disease, translated by Millard, 1878. 
 
 4
 
 50 bright's disease. 
 
 SECTION II. 
 
 TESTING FOR ALBUMEN. ALBUMINURIA, ITS SOURCES AND 
 
 MECHANISM OF ITS PRODUCTION. 
 
 Testing for albumen lies at the bottom of all cliagnosis in 
 Bright's disease, and there is no form of kidney affection in the 
 investigation of which we dare omit to determine the presence 
 or absence of albumen. Further, I am confident that even at 
 the present day small amounts of albumen are not unfrequently 
 overlooked in hasty examinations. Hence it cannot be out of 
 place to discuss briefly this matter. 
 
 When large quantities of albumen are present in urine, its 
 detection is most easy. The addition of from 5 to 30 drops of 
 acid — nitric is commonly used — to half an ounce of urine in 
 a test-tube, will promptly precipitate the albumen, if much is 
 present. Or, if the urine is acid in its reaction, the albumen 
 is as promptly thrown down by boiling ; and if, after boiling, 
 a few drops of acid are added, the solution of any phosphates 
 precipitated by the heat is secured; while any albumen which 
 may have remained in solution because the original urine was 
 alkaline when boiled, will be thrown down. It should not be 
 overlooked that, unless a considerable amount is present, albu- 
 men is not precipitated by heat from an alkaline urine. 
 
 But it is the small amounts of albumen which escape atten- 
 tion, and it is to these that I would especially direct attention. 
 Under ordinary circumstances, by far the most distinctive test 
 for small quantities of albumen is that form of the nitric acid 
 test known as Heller's, to be presently described. But, in the 
 course of an experience involving almost daily examinations of 
 urine, I have met a number of instances in which it failed to 
 give evidence of the ])resence of albumen, when the ordinary 
 heat and acid test a2)plicd in the manner to be described, proved 
 it conclusively. 
 
 Many Avho have often tested urine for albumen by the or-
 
 TESTING FOR ALBUMEN. 51 
 
 dinarv heat and acid test, will have observed that after boiling 
 the clear urine, and adding a few drops of nitric acid, the re- 
 sulting fluid will be apparently clear ; but upon setting aside 
 the urine thus treated, say for twelve hours, or until the next 
 morning, there will sometimes be found a small deposit. Sup- 
 posing the urine before testing to have been caref ally filtered, 
 this deposit is either : 1st, acid urates ; 2d, uric acid; 3d, ni- 
 trate of urea ; or, 4th, albumen. The first result from a par- 
 tial decomposition of the neutral urates by the nitric acid 
 added ; the second by a further action of the acid upon the 
 acid urates, and a resulting complete separation of the uric 
 acid from the sodium, potassium, etc., with which it was com- 
 bined; the third is found only when the urine happens to be 
 highly concentrated and contains an unusual proportion of 
 urea. The second and third have well-known forms of crys- 
 tallization, by which they can be easily recognized under the 
 microscope, but the acid urates and albumen are both amor- 
 phous and cannot therefore be thus distinguished. All, liow- 
 ever, except albumen, disappear on the reapplication of heat. 
 In all doubtful instances, urine which has been tried by heat 
 and nitric acid should be boiled again after cooling and stand- 
 ing from six to twelve hours, and if the sediment is not dis- 
 solved by such ebullition it is albumen. 
 
 My own method, therefore, of examining a specimen of 
 urine for albumen is invariably as follows: 
 
 I. Unless perfecily clear it is first filtered. A portion of 
 the filtered urine is then boiled, and carefully watched in a 
 suitable light for detection of the least diminution in transpar- 
 ency.* I say asuitable light, because it is not always a bright 
 
 * In these directions 1 have omitted the one of previous acidiihvtion con- 
 tained in the similar directions in my little book on the Practical Exami- 
 nation of Urine, third edition, 1880, p. 33. I do this because, in the first 
 place, in a large number of instances, the urine is acid to begin with, and in 
 the second, the addition of the drop or two of acid after boiling accomplishes 
 the same purpose, while it also dissolves any phosphates which may have 
 been precipitated by the heat. On the other hand, the previous acidulation 
 does not obviate the necessity of the addition of the drop of acid after boil- 
 ing, and in the method given in the text, one manipulation, and, therefore, 
 time, is saved.
 
 0"J BRIGHT S DISEASE. 
 
 light that is desired. A diminished transparency might easily 
 be overlooked in it, and it is generally desirable to shade the 
 liglit a little with the hand or a book before the diminished 
 transparency can be noticed, if the latter is slight. On the 
 other hand, an insufficient light, such as is shed on a dark day, 
 is altogether unsatisfactory. A drop or two of nitric acid is 
 then added, and if any turbidity which has resulted from the 
 action of the heat, disappears, such turbidity is due to phos- 
 phates and not to albumen. It is sometimes desirable to com- 
 pare the tube and contained urine with another filled to the 
 same depth with urine which has not been heated. If any 
 degree of turbidity remains, it is caused by albumen, and the test 
 may end here, although it is well to put the test-tube aside, in 
 order that, after subsidence, the albumen may be approximately 
 estimated. If, however, there is the least doubt about the 
 presence of albumen, the tube must beset away, carefully pro- 
 tected from dust, for from six to twelve hours, in order that 
 any appreciable sediment may subside, and be subsequently 
 again tried with heat. 
 
 II. Another small test-tube is then filled to the depth of 
 half an inch with colorless nitric acid. About as much urine 
 is then allowed to fall gently upon it from a pipette, in the 
 manner represented in the figure, while the point of junction 
 of the two fluids is carefully watched for the white line of al- 
 bumen. This is best seen by shading the tube by the hand or 
 a pamphlet placed behind and slightly below the line of junc- 
 tion, so that the light may fill obliquely upon it. The gradual 
 delivery of the urine from the tube is greatly facilitated by ro- 
 tating the latter imder the index finger, especially if the upper 
 end of the tube is a little roughened. This secures such a 
 gradual entrance of the air as permits the urine to descend 
 very slowly without mixing with the acid below. 
 
 Precautions. — In urines of high specific gravity, from con- 
 centration of the ordinary constituents, a white band makes 
 its appearance at the l»order between the two fluids, which 
 is not albumen, but acid urates, resulting from the partial 
 decomposition of the neutral urates and the preci])itation of 
 
 I
 
 TESTING FOR ALBUMEN. 
 
 53 
 
 the more insoluble acid salt. But the behavior of the band 
 thus produced is quite d liferent from that of the albumen. 
 
 F;g. 23. 
 
 Testing for albumen by nitric acid. 
 
 Although sharply defined at first, the lower border stands at 
 a slightly higher level than that of the albumen, while the 
 upper edge soon ceases to be circumscribed and rises upward 
 into the urine like a cloud, soon pervading the entire super- 
 natant urine ; whereas the albumen remains sharply defined 
 at the line between the two fluids, until, in the course of 
 several hours, if its quantity be small, it may be completely 
 dissolved by the excess of acid present. Further, the cloud 
 of acid urates is promptly dissolved by the application of a 
 moderate heat. If, as sometimes happens in acute fevers, the 
 urine is both concentrated and contains albumen, there may 
 be two layers, an upper cloudy one of urates, and a lower 
 sharply defined of albumen. But in chronic Bright's disease, 
 at least, urine is generally of low specific gravity, and the 
 complication is not likely to occur.
 
 54 bhight's disease. 
 
 When tliese precautions are observed in connection with 
 the above donble test, it is almost impossible to err as to the 
 presence of albumen. 
 
 It sometimes happens, however, that, in consequence of age 
 and putrescence, the urine has become alkaline, precipitated 
 phosphates pervade the fluid, and it swarms with bacteria. 
 As a consequence, it is so opaque that small quantities of 
 albumen cannot be detected. Filtering does not mend this. 
 The bacteria and finely divided phosphates pass through the 
 minute openings of the filter with the filtrate. Under these 
 circumstances it becomes necessary to clarify the urine. For 
 this purpose I use a method suggested by Hoffmann and Ultz- 
 mann. Boil a portion of the urine with an equal bulk of 
 officinal liquor potassse, and filter. If still not quite clear, 
 add a few drops of the " magnesian fluid, """^ warm again, and 
 filter. To the clear fluid thus obtained Heller's acid test may 
 be applied, or, after careful acidulation, the heat test. In this 
 manner very small quantities of albumen may be recognized 
 in urine which would not otherwise permit its detection. 
 
 To Indicate the Proportion of Albumen in a given Specimen 
 of Urine. — In practice it is scarcely possible to apply the 
 only exact quantitative method of estimating albumen, by 
 coagulation, filtration, drying, and weighing, because of the 
 time it necessarily occupies. Even the method suggested by 
 Dr. William Iloberts,t of INIanchester, is for the same reason 
 unavailable to the busy practitioner. Nor can it be said that 
 these more accurate methods are necessary. For practical 
 purposes it is sufficient to compare from day to day the bulk 
 of precipitated albumen with that of the urine tested. For 
 this purpose it is convenient to have a test-tube graduated 
 to one-half its depth, so that after coagulation by heat and 
 
 * The magnesian fluid is made by dissolving magnesium sulphate and 
 pure ammonium chloride, each one part, in eight parts of distilled water, 
 and adding one part of liquor ammonise. 
 
 t American Journal of the Medical Sciences, January, 1878, p. 209, from 
 the Medico-Chirurg. Transactions, vol. xli, 1876. Also, the 2d ed. (1878), 
 p. 39, of the writer's work on The Practical Examination of Urine. For 
 the reason mentioned in the text it was omitted from the 3d ed.
 
 ALBUMINURIA. 55 
 
 acid, and allowing sufficient time for subsidence, the esti- 
 mation can be made. In writing or speaking, this should 
 be referred to as one-half, one-fourth, or one-tenth the bulk 
 of urine tested, as it may happen to be. A very careless 
 habit which exists of speaking of these proportions as 'per- 
 centnr/es should be avoided. Thus, when the albumen in a 
 given specimen of urine equals one-fourth its bulk, it is often 
 carelessly said that there is 25 per cent, of albumen. Xow when 
 we remember that the serum of the blood does not contain more 
 than 5 per cent, of albumen, and the most highly charged 
 albuminous urines rarely contain more than 2 per cent., the 
 absurdity of this mode of expression is evident. Only when 
 the albumen is coagulated, dried, and weighed, and the weight 
 compared with that of the urine whence it is taken, should we 
 speak of percentage ; otherwise the proportion of bulk is re- 
 ferred to, and it should be clearly indicated. 
 
 Seat of Transudation of Albumen in the Albuminuria of Renal 
 Disease. — It is commonly believed that when urine is albu- 
 minous, the albumen transudes along with the water into 
 the Malpighian capsule, although there has never been any 
 absolute demonstration that this is the case. Experiments 
 of Heidenhain, with a view to settling the question, led to 
 negative results, and until some positive demonstration is 
 afforded to the contrary we may accept on theoretical grounds 
 the view usually held. These lie in the fact that in the first 
 place there is a physiological constriction at the orifice of the 
 efferent vessel by which the blood leaves the glomerulus. This 
 is of course increased under jiathological conditions when there 
 is hypersemia of the second capillary network, producing swell- 
 ing and overgrowth of the cells of the convoluted tubules, 
 which compress the bloodvessels of the rete, and further resist 
 the egress of the blood from the glomerulus. Under these 
 circumstances we have the increased pressure under which 
 albumen will transude, although its osmotic equivalent is very 
 low, and under normal conditions it will not pass out. This 
 well-known property of albumen is a sufficient reason against 
 the view of Kiiss, already alluded to, page 47, that under
 
 56 bright's disease. 
 
 normal conditions the transudate into the Malpigliian ca])sule 
 is the serum of the blood, from which the albumen is reab- 
 sorbed by the cells of the convoluted tubules. It is hardly 
 necessary to say that this view, if correct, would explain an 
 albuminuria which might be present either when the tubules 
 are stripped of their cells or the latter are functionally inert 
 from degeneration or malnutrition ; and indeed Kiiss makes 
 use of this fact as an argument in its favor. 
 
 Albuminuria from other Sources than the Parenchyma of the 
 Kidney. — It is well known that albumen may enter the urine 
 from other sources than the secreting substance of the kidney. 
 The pelvis of the organ, the ureters, the bladder, and the ure- 
 thra, and in the female, the vagina and uterus in addition, are 
 these sources. In all of them except the uterus it is almost 
 invariably the serum of pus formed during inflammation of 
 their mucous surfaces which furnishes the albumen. The 
 presence of pus-corpuscles, therefore, in sufficient number in 
 the urine is usually sufficient to explain the source of such 
 albumen, which is moreover usually small in quantity. It 
 must not be overlooked, however, that the two sources, that 
 of the kidney itself and the mucous surfaces, referred to, may 
 be combined, in which event careful microscopic examina- 
 tion would sooner or later discover tube-casts, while the quan- 
 tity of albumen would be larger than could be accounted for 
 by the presence of pus alone. 
 
 I have, however, in several instances of disease of the blad- 
 der where there had been suppuration and albuminuria from 
 such disease, found that with an insignificant residue of pus 
 there remained an albuminuria, not large, but altogether dis- 
 proportionate to the amount of pus remaining, and where the 
 most careful examination failed to discover renal disease. 
 These cases I cannot satisfactorily explain, and allude to them 
 here hoping the attention of others may be called to the matter. 
 Bartels* mentions copious albuminuria, with an inconsider- 
 able sediment of pus, after the free use of cantharides internally 
 
 * Bartels, Carl, article on Diseases of the Kidney, in Zienissen's Cyclopae- 
 dia of Medicine, vol. xv, p. 31, New York, 1877.
 
 ALBUMINURIA. 57 
 
 and externally, as a form of albuminuria to be distinguished 
 from that which so constantly accompanies Bright's disease ; 
 but it seems to me the condition thus resulting ought to be 
 regarded as the first stage of acute Bright's disease or paren- 
 chymatous nephritis. 
 
 Menstrual or lochial blood need only be referred to as 
 sources of albumen in the urine, hardly likely to be overlooked 
 by any physician ; while hemorrhage from any one of the 
 mucous surfaces referred to, as well as the kidney itself, would 
 be a source of albuminuria. 
 
 It is usually comparatively easy to determine whether a 
 luemorrhage has its source in the kidney on the one hand or 
 tlie mucous membranes above mentioned on the other. In the 
 former, coagula are never present, but the blood entering the 
 pelvis of the kidney, slowly and intimately mixed with the 
 urine, imparts to it when acid in reaction a smoky hue which 
 is very characteristic. The coloring matter of the corpuscles 
 is mostly dissolved out by the urine which it thus tinges, and 
 on standing the stroma of the corpuscles sinks to the bottom in 
 the shape of a brownish sediment. The microscope reveals 
 these corpuscles shrunken, almost colorless, and often crenated. 
 I have said that the smoky hue is present only in acid urine. 
 When the latter is alkalized, either by spontaneous or arti- 
 ficial change in reaction, it assumes a brighter red hue, the 
 degree of which depends upon the quantity of blood. The 
 same cause, acidity, produces the smoky hue of blood which is 
 vomited, and therefore mixed with gastric juice. When blood 
 comes from the pelvis of the kidney or the ureter in any quan- 
 tity, coagula, which are moulds of the ureter, are sometimes 
 found, the descent of which is often attended with severe pain. 
 
 Another source of albuminous urine, though not likely to 
 cause error, should be mentioned, and that is the so-called 
 chylous urine, or chyluria, in which, in consequence of some as 
 yet imperfectly understood communication between the lym- 
 phatic system and the urinary tracts, chyle enters the urine 
 and imparts its physical and chemical characters more or less 
 thereto. These are a milk-white appearance, due to the pres-
 
 58 BRIGHTS DISEASE. 
 
 ence of fat in a molecular state of division, and a large amount 
 of albumen. The disease is one of tropical countries usually, 
 but I have met two cases in this latitude. 
 
 The Immediate Cause of the Transudation of Rencd Albu- 
 men. — It has already been intimated that obstruction to the 
 onward movement of the blood is the immediate agency which 
 forces albumen, an otherwise non-osmotic substance, through 
 the walls of the capillary bloodvessels. It was at one time 
 claimed that a peculiar state of the albumen of the blood in 
 disease facilitated its transit, but the exhaustive experiments of 
 Stockvis* have refuted this view, which has no longer any 
 supporters. The required obstruction is produced by any 
 cause which sufficiently resists the movement of the blood 
 through the kidneys, whether that cause resides in the organ 
 itself or the venous system beyond it, whence the albuminuria 
 which so often attends extreme valvular disease of the heart. 
 
 It is equally certain, however, that the transudation is 
 facilitated by changes in the capillary walls. In the first 
 place it is conceivable that some change in the texture of 
 the memljranes takes place analogous to such as occurs in 
 a filtering membrane through which a fluid is forced by pres- 
 sure, an increase in the size of the apertures or pores of 
 the membrane if we so choose to term it. But it must be 
 remembered that this is a direct result of the intravascular 
 pressure and would not exist without it. On the other 
 hand, the experiments of Cohnheim upon inflammationf have 
 shown that among the phenomena of inflammation a free 
 transudation of albumen accompanies the wandering out of 
 the colorless corpuscles of the blood. This element of in- 
 creased albumen exudation would be found only in the more 
 acute inflammatory conditions of the kidney, and accounts for 
 the increased quantities of albumen in these as compared with 
 the more chronic processes where pressure is the sole agent. 
 
 * Stockvis, RecherchesExperimentales sur les Conditions Pathog^niques 
 de I'Albuminurie, in Journal de M^decine de Bruxelle. Vols. 44, 45, 
 1867. 
 
 f Cohnheim, Ueber Entziindung, Yirchow's Archiv, Bd. 40, S. 77.
 
 ALBUMINURIA. 59 
 
 The effusion of albumen takes place, not only from the glom- 
 erulus into the uriniferous tubules of the kidney, but also in 
 the interstices of the organ outside of the tubules, wherever 
 the colorless corpuscles wander, furnishing there a pabulum 
 for the overgrowth of the intertubular and intervascular 
 connective tissue, which always takes place if the jirocess be 
 sufficiently long continued. 
 
 It is possible, also, that small quantities of albumen pass 
 into the uriniferous tubules of the kidney, which would not 
 otherwise do so, in consequence of alterations in the epithelial 
 lining of the tubules, the result of disease. But the quantity 
 from this source must be very small, and the fact remains that 
 intravascular pressure, aided by alterations in the capillary 
 walls in inflammation, is the chief immediate cause of albu- 
 minuria, at least in acute renal disease. 
 
 In chronic albuminuria another important influence operates 
 in facilitating the ti'ansudation of albumen. This is the hy- 
 drjemic state of the blood, which is itself a consequence of 
 albuminuria. 
 
 One other source of renal albumen requires to be alluded 
 to, although not really a symptom of kidney disease as ordi- 
 narily understood, that is, it is not due to structural alteration 
 of the organ. It is the albumen which appears in the urine 
 in grave cases of infectious disease, as typhoid fever, small- 
 pox, etc., and even in local inflammations other than renal, 
 attended with much fever, as pneumonitis. That albuminuria 
 of diphtheritis and scarlatina, which is due to an intercurrent 
 parenchymatous nephritis, is of course not referred to. The 
 albuminuria alluded to is not usually large, and disappears with 
 the decline of the disease. Gerhardt* first suggested that this 
 albumen represented the disintegration of numerous red blood- 
 disks, and the observations of Obermullerf tend to the same 
 results. But Bartels thinks it unnecessary to adduce such an 
 
 * Gerliardt, Ueber die Eiweisstoff'e des Harns, in Deutsches Archiv fiir 
 Klin. Med., Bd. 5, S. 213. 
 
 f Obermiiller, Beitriige zur Cheraie des Eiweissharns. Inaug. Dissertat. 
 Wiirzbtirg, 1S73.
 
 60 bright's disease. 
 
 explanation, on the ground that globulin, the albumen of the 
 blood-corpuycles, possesses different properties from serum 
 albumen, which is the albumen of urine. He agrees with 
 Gerhardt that in subjects of acute fever, whose temperature 
 stands persistently above 40° Cent. (104° F.), albumen passes 
 into the urine, because the process of filtration by which the 
 urinary secretion is effected in the INIalpighian bodies, is, by 
 reason of the abnormally elevated temperature, conducted 
 under entirely abnormal conditions; that the elevated temper- 
 ature relaxes the walls of the bloodvessels, or makes them yield 
 more than they otherwise would, to the hydrostatic pressure 
 of the blood streaming through them. But it is the nature 
 of the filter, by which the urine is secreted, that is disarranged; 
 for, inasmuch as the surface of the filter is enlarged, its pores 
 must of necessity become more roomy.* Finally, he con- 
 cludes that febrile albuminuria is akin to the overflow of 
 albumen into the urine which follows section of the vasomotor 
 nerves of the kidney, the excessive heat of the body acting the 
 same way as such section. 
 
 This seems a circuitous method of accounting for what 
 may be explained in a much simpler manner, although of 
 course theoretically also. It is to be remembered that it is 
 only in the cases of most intense fever, where the temperature 
 is persistently above 40° C (104° F.J, that albuminuria, in- 
 dependent of renal disease, presents itself; also that in these 
 there is the most rapid destruction or combustion of tissue of 
 all kinds, including the corpuscles of the blood; that in the 
 course of such combustion there must inevitably be incomplete 
 oxidation of its products, and that such products would natu- 
 rally find their way into the urine in the shape of albumen, 
 just as among the ashes of a rapid and imperfect combustion 
 in a furnace, portions of partly burnt fuel are found. The 
 exudation of such albumen would be facilitated by the ten- 
 dency to stasis which exists in the kidney in common with all 
 organs, but is greater in it in consequence of the peculiarities 
 
 * Bartels, op. cit., p. 53.
 
 ALBUMINURIA. 61 
 
 of its capillary circulation. Such albumen might be supposed 
 to have greater diffusive power than belongs to typical serum 
 albumen, since, if time and favorable circumstances permitted, 
 it would have been entirely converted into urea, and, as such, 
 removed through the kidneys. It would be comparable rather 
 to the extractives, which are also partially oxidized products, 
 which pass from the blood into the urine.
 
 02 brigiit's disease. 
 
 SECTIOX III. 
 
 CASTS OF THE URIXIFEROUS TUBULES — THEIR NATURE 
 AND CLINICAL SIGNIFICANCE. 
 
 A SO-CALLED " urinary cast" or "tube-cast " is a mould of a 
 uriniferous tubule. To this all are agreed. But beyond this, 
 opinions differ not a little as to its exact mode of origin, com- 
 position, and significance. I retain the term " cast," in com- 
 mon with most English physicians, in preference to that of 
 " cylinder," because it conveys the idea of what is meant with 
 sufficient preciseness, while it implies nothing more. The 
 adjective "fibrinous" I also discard as conveying an erroneous 
 impression as to the composition of many tube-casts, although 
 it is true that some are fibrinous. 
 
 Casts may be studied as a sediment in the urine or in situ 
 in the uriniferous tubules where they are formed. They are 
 characterized by differences in appearance and structure, as 
 the result of which they are variously named. Thus there 
 are hyaline casts, epithelial casts, blood-casts, oil-casts, waxy 
 casts, and granular casts. Of the latter there are two sub- 
 divisions, — the jiale, or moderately granular, and the dark 
 granular casts. As to the material of which they are com- 
 posed different views are held. I will first present my own, 
 because it will enable me at the same time and in the briefest 
 manner to describe the several varieties. 
 
 In the first place, all casts are not of the same composition. 
 Thus, what are known as blood-casts are made up of coagu- 
 lated fibrin and blood-corpuscles, the latter being entangled in 
 the coagulura precisely as they are in a clot formed out of the 
 body. The blood, by transudation or because of rupture of 
 the capillaries of the Malpighian tuft, trickles down into the 
 tubule, where it coagulates, forming a mould of the tube, and, 
 after contraction, slips out into the pelvis of the kidney.
 
 TUBE-CASTS. 
 
 63 
 
 whence it passes by the usual channel into the bladder. Blood- 
 casts are represented in Fig. 24. 
 
 Fig. 24. 
 
 Blood-casts. — After Wuitakee. 
 
 Second, the terra epithelial cast (Fig. 25) is applied to any cast 
 to which epithelial cells are attached, be they few or many. In 
 the latter case, the entire mould is often made up of closely- 
 
 FiG. 25. 
 
 Epithelial casts. X 200. 
 
 packed desquamated cells, which may be cemented by their 
 own adhesive properties or by a small quantity of fibrin, from
 
 64 briqht's disease. 
 
 simultaneously effused blood; for blood-casts and epithelial 
 casts constantly accompany each other. When the epithelial 
 cells and their fragments — often their nuclei only — are few, 
 they are separated by intervals, at times quite regular, of a 
 hyaline material, to which they may be attached, or in which 
 they may be imbedded. And it is the nature of this hyaline 
 material which is the subject of dispute. It seems most reason- 
 able to consider it an exudation from the blood of a fibrinous 
 or an albuminoid substance, which coagulates after entrance 
 into the tubules, entangling there, as does fibrin, whatever 
 substances may be in the tubule, and occluding it for the 
 time being. That it is true fibrin coagulated is not incon- 
 sistent with the modern doctrine of fibrin formation. For 
 this, fibrinogen and fibrinoplastin are essential. The former 
 is furnished by the blood-plasma, the latter by the blood-cor- 
 puscles, and as the latter are constantly present, although it 
 may be not always in large numbers, the conditions of coagu- 
 lation are furnished. Where there is hscmorrhase into the 
 tubules, both conditions of coagulation are abundantly present 
 and blood-casts are also formed. It is true, the chemical prop- 
 erties of casts have been investigated, by Axel Key, and also 
 by Rovida, who assert them to be altogether different from 
 those of fibrin. But, that the hyaline material is in many in- 
 stances some sort of exudate rather than a result of a metamor- 
 phosis of cells, is sustained by the fact that the hyaline is the 
 only shape of cast formed in the slightest derangements of the 
 kidney, as when there is a mere transitory congestion of the 
 organ, and where there is no alteration of the epithelium 
 whatever. The same objection holds to their being a secretion 
 of the cells lining the tul)ules. 
 
 Third, the two forms of f/ranular ca.^t have probably differ- 
 ent modes of origin. In the case of the dark granular cad 
 the cells have undergone com])lete disintegration, and the prod- 
 ucts of this form a closely packed, dark, granular mass. If 
 many red blood-disks happen to be in the tubule and share 
 the breaking up, a yellowish tinge is communicated to this form 
 of cast. In other instances the granular matter is less abun-
 
 TUBE-CASTS. 
 
 65 
 
 dant, and a pah granular cast is the result. The granules here 
 are less easily accounted for. They may result froni a similar 
 disintegration of cells fewer in number, or they may be due to 
 
 Fk;. 26. 
 
 f V 
 
 M^'. 
 
 '\:\ 
 
 
 Granular casts. X 225- 
 
 a precipitation of granules from the albuminous substance of 
 the hyaline cast, similar to that which occurs in the so-called 
 cloudy swelling of cells. They would then be the result of the 
 further metamorphosis of a hyaline cast. 
 
 Fourth, the oil-cast is a like product. Here the cells have 
 undergone a fatty degeneration, some having completely broken 
 up into fatty globules, while other cells retain their continuity
 
 66 
 
 BKIGHT S DISEASE. 
 
 and shape, forming compound granule-cells and other forms of 
 fatty cells. The oil-drops and fatty cells are seldom so abun- 
 
 FlG. 27. 
 
 Oil casts aud fatty epithelium. 
 
 dant that they form a closely packed mass constituting the cast, 
 but they are more or less separated by the hyaline basis re- 
 ferred to. Fatty casts in urine are apt to be accompanied by 
 free oil-drops and free fatty cells, as seen in Fig. 27. 
 
 Fig. 28. 
 
 Pale granular and hyaline casts, one of the latter of small diameter, protruding froin 
 a tubule iu which the epithelium remains intact. A cast of the same tubule bereft of 
 its epithelium would evidently be of larger diameter. — After Rindfleisch. 
 
 Fifth, hyaline casts are the simplest form of cast. They are 
 delicate, structureless, or almost so, and composed of the trans- 
 parent substance already referred to. They are of diiferent
 
 TUBE-CASTS. 67 
 
 width, even when produced in the same tube, according as the 
 cast is formed when the tubule is bereft of its epithelium or 
 
 Fig. 29. 
 
 Hyaline casts. X 225. 
 
 the latter remains adherent. This will be understood by ex- 
 amining Fig. 28. In the former case a hyaline cast of " large" 
 diameter is produced, in the latter one of "small" diameter. 
 The range of width thus produced is from .025 mm. to .05 
 mm. (, o'ljo^ to 5^Q of an inch). Hyaline casts are sometimes 
 so delicate and transparent as to be scarcely visible, and require 
 care in illuminating the field of view of the microscope to bring 
 them out distinctly. They are also often characterized by 
 peculiar indentations or partial fractures, as shown in Fig. 29. 
 Hyaline casts occur in all forms of renal disease. 
 
 Sixth, waxy casts are also hyaline, but more solid and glis- 
 tening in appearance, more highly refracting, and apt to pre- 
 sent a yellowish tinge. From their supposed resemblance to 
 molten wax, they have been called "waxy," but they bear no
 
 68 bright's disease. 
 
 essential relation to the so-called "waxy" or lardaceous or 
 amyloid kidney, by all of which terras it is known. The 
 material of which they are composed has, at least, different 
 refracting properties from that of the ordinary hyaline cast, 
 and probably originates differently. It will be seen, presently, 
 that it is this form of cast with regard to which there is most 
 unanimity in ascribing it to a fusion and hyaline transforma- 
 tion of desquamated epithelium, or of other cells within the 
 tubules. The same objections which lie in the way of admit- 
 ting such an origin of the simple hyaline casts do not exist 
 here, and it is not unlikely that they thus arise. It should be 
 clearly understood, however, that the transformation is not the 
 so-called waxy or amyloid transformation, the presence of 
 which in the bloodvessels, tubules, and cells of the kidney 
 constitutes the form of kidney disease known under that name. 
 For these waxy casts do not, as a rule, strike the iodine reac- 
 tion of the amyloid change. That they do occasionally, is 
 attested by the dark mahogany- red tint of the two casts 
 pictured in the colored plate opposite, a result I obtained, 
 however, only after many times carefully and systematically 
 treating these casts with iodine. The more usual coloration 
 by iodine is that of the yellow casts shown in the same 
 plate. Bartels* has obtained the same reaction in two in- 
 stances, and suggests that the age of the material forming 
 the cast may have something to do with the transforma- 
 tion into true amyloid material. And Rindfleischt also says 
 that he is convinced that casts which are long retained in 
 the urinary tubules, especially in the bends of the looped 
 tubes, undergo a glassy swelling, and assume the micro- 
 chemical characters of amyloid substance, striking the iodine 
 reaction, even in kidneys which are not otherwise amyloid. 
 That they are not always the altered epithelium of the tubes 
 is evident, for the reason assigned by Rindfleisch ; in the first 
 place the epithelium is seen well preserved between the casts 
 
 * Bartels, in Ziemssen's Cyclopaedia of Medicine, vol. xv, p. 90. 
 t Rindfleiscli. Patholog. Histol., New Svd. Soc. Transl., vol. ii, 1872, p. 
 14-4. Fifth German edition, 1878, p. 4-43.
 
 m 
 
 
 
 \ 
 
 
 ^ 
 
 *^
 
 TUBE-CASTS. 69 
 
 and the basement membrane, and in the second, it is only in 
 the highest degrees of the amyloid degeneration of the kidney 
 that the cells are involved. 
 
 Again, waxy casts are found in all forms of chronic renal 
 disease, it is asserted by some, in chronic interstitial nephritis 
 more frequently than in the amyloid form. But I have seen 
 them very numerous, also, in situ in the large white kidney. 
 
 Views as to the Nature and Formation of Tube-casts. 
 
 Dr. A. Burkhart, in a successful prize essay* presented to 
 the medical faculty of Tiibingen, in 1871, furnishes an inter- 
 esting historical sketch of the study of casts, from the time of 
 their discovery to the date of his essay. Although Simon is 
 the reputed discoverer of casts, several observers had pre- 
 viously published descriptions of objects found in urine, which 
 were evidently casts. The first of these was Vigla, who, in a 
 paper on the microscopic constituents of urine, published in a 
 journal called V Experience, in ]837, spoke of " finely granular 
 longish albuminous plates." He gave no further description, 
 and did not state in what kind of urine they were found. In 
 1838 Donne, in the same journal, denied the occurrence of 
 these albuminous plates. To this A^igla replied that he had 
 observed them in the urine of Bright's disease. In the same 
 year, 1838, Rayer, in his treatise on diseases of the kidneys, 
 described certain membranous, irregularly shaped, finely gran- 
 ular, white or yellow lamellse, as occurring in albuminous 
 urine, but said nothing of their composition. The first un- 
 mistakable description of these bodies was given by Nasse, of 
 Marburg, in a notice published in Schmidt's Jahrbuch, in 
 1838, of Donne's plates of urinary sediments, and more clearly 
 in a paper by him on the microscopical constituents of the 
 urine in Bright's disease, published in 1843.t Simon first 
 
 * Burkhart, A., Die Harncylinder niit besonderer Beriicksichtigung ihrer 
 diagnostischen Bedeutiing. Gekronte Preisscbrift. Mit Einer Tafel. 
 Berlin, 1874. 
 
 f Xasse, Mediziniscben Correspondenzblatt rheniscber iind westpbal- 
 iscber Aerzte, No. 8, s. 121, 1843.
 
 70 bright's disease. 
 
 described casts as constituents of urine in Bright's disease in 
 his work on practical chemistry, in 1842. 
 
 Henle was the first to study casts in situ after he had pre- 
 viously examined them in the urine of a case of Bright's dis- 
 ease. This he did in 1844,* and then asserted their fibrinous 
 composition, whence the term " fibrinous " cast still in use. 
 From this time forward numerous communications appeared, 
 and by 1845 the presence of casts in the urine of Bright's dis- 
 ease was an acknowledged fact.f In this year Scherer pub- 
 lished Heller's theory, according to which casts were the 
 result of congestion and exudation of liquor sanguinis. 
 
 To pass to more modern observers, Traube also held that 
 casts are composed of fibrin, which is caused to exude by a high 
 degree of intravascular pressure. 
 
 At the present day Dr. George Johnson J says : " The basis of 
 all renal tube-casts is the fibrin within the uriniferous tubules; 
 but these casts assume various appearances, according to the 
 nature of the products which they contain and the condition 
 of the tubes in which they have been moulded." 
 
 Dr. Beale§ says : " The transparent material probably consists 
 of a peculiar modification of an albuminous matter possessing 
 somewhat the same characters as the walls of some epithelial 
 cells, the elastic laminoe of the cornea, etc., but not condensed 
 like these structures." This, according to him, is the basis 
 substance, which, becoming solid, entangles epithelial cells, 
 nuclei, granular matter, blood-corpuscles, or whatever may be 
 in the tube at the time the effusion occurs ; or which solidifies 
 in the shape of a hyaline cast, if the tube be empty, or the 
 epithelium so firmly adherent that the cast slips out without 
 detaching it. 
 
 Dr. Dickinson|| believes that, as a rule, fibrin forms the basis 
 
 * Henle, in Henle und Pfeufer's Arcliiv, Band i, Heft i, s. 6U, 1844. 
 Henle, in Zeitschrift fiir rationelle Medizin, Bd. i, s. 68. 
 
 t See the work of Burkhart alluded to for a full historical sketch, more 
 particularly of German authors. 
 
 X Johnson, Lectures on Bright's Disease, New York, 1874. 
 
 ^ Beale, Kidney Diseases and Urinary Deposits, Philadelphia, 1 869, p. 339. 
 
 II Dickinson, W. Howship, On the Patiiology and Treatment of Alliu- 
 minuria, 2d edition, London, 1877, p. 19.
 
 TUBE-CASTS. 71 
 
 of all casts, but says " it sometimes happens that cylinders are 
 formed in the urine, which appear to consist entirely of com- 
 pacted epithelial cells, or of epithelial cells held together by 
 fibrin so small in amount as to be barely perceptible." 
 
 Dr. Grainger Ste\yart* says tube-casts are composed of co- 
 agulated fibrin with altered epithelium and not unfrequently 
 blood-corpuscles. \Yeissgerber and Perlsf are among the 
 most recent who adhere to the view that casts are formed of 
 exuded fibrin, while Robin, as early as 1855, protested against 
 the use of the term " fibrinous " cast, as being erroneous. 
 
 Axel Key,| having shown that the chemical characters of 
 casts were incompatible with a fibrinous composition, earlv 
 claimed that at least the so-called "hyaline gelatinous" and 
 "hyaline waxy " casts are composed of desquamated epithelium 
 which has fused and degenerated into a hyaline mass, and that 
 dark granular casts are also formed by an agglomeration of 
 degenerated epithelial cells. O. Bayer§ asserted that all va- 
 rieties of casts originate in this melting together and trans- 
 formation of cells. Schachowa,|| in some experiments upon 
 the artificial production of nephritis in dogs, by means of can- 
 tharides, obtained results which sustained the same conclu- 
 sions. On the other hand, Qildmansson^ claimed that all casts 
 originate as a secretion from the epithelial cells lining the 
 tubules, and Qi^rtels** defends the same view. 
 
 Langhans, in a recent article,tt says that while many casts 
 
 * Stewart, Grainger, Bright's Disease, 2d edition, New York, 1871, p. 80. 
 
 t Weissgerber vind Perls, Archiv fiir Experiment. Patliologie, Ed. vi, 
 1876. 
 
 X Axel Key, Om. des k. Tabularafgjutningarnas olika former och bild- 
 ning vid sjuckdomari Njurarne; Med. Archiv, Stockholm, 1863,1, 233- 
 277, 2 pi. 
 
 § O. Bayer, Ueber den Ursprung der sogenannt. Fibrin-cylinder dea 
 Urins, Archiv fur Heilkunde, 1868, s. 136. 
 
 II Schachowa, Untersuchungen iiber die Xiere. Dissert., Bern, 1876. 
 
 ^ OEdmansson, quoted by Bartels, op. citat., p. 84. 
 ** Q^rtels, Experimentelle Untersuchungen iiber Diphtherie, Deutsches 
 Archiv fiir Klin. Med., Bd. viii, .s. 292. 
 
 tf Langhans, Theodore, Ueber die Yeriindernngen der Glomeruli bei der 
 Nephritis nebst einigen Bemerkungen iiber die Entstehung der Fibrincyl- 
 inder, Yirchow's Archiv, Bd. 76, erstes Heft, 1879, 85.
 
 72 bright's disease. 
 
 arise from a metamorphosis of cells contained in the urinifer- 
 ous tubules, he is far from claimino; that all easts originate in 
 this manner. It is especially the waxy casts that are thus 
 formed, while the pale homogeneous cylinders are a kind of 
 secretion from the epithelium. According to Langhans, the 
 cells which undergo conversion into waxy casts may be either 
 the desquamated epithelium of the tubules, lymph-corpuscles, 
 or red blood-disks. In either event, first meltino- into each 
 other, they break up into a finely granular mass, which sub- 
 sequently undergoes a glasslike transformation. This begins 
 at the periphery, and extends thence towards the centre. A 
 yellowish tinge and more highly refracting character result 
 when the cells thus converted are red blood-disks. 
 
 Rovida,* whose observations on the nature of casts have 
 been alluded to, makes but three varieties of casts, — the 
 colorless, the yellow hyaline, and epithelial, of which he con- 
 siders the colorless and yellow hyaline a secretion from epithe- 
 lial cells. 
 
 Bartelsf admits three modes of origin for casts. First, that 
 dark granular casts originate directly by an agglomeration of 
 degenerated epithelial cells, by which agglomeration I infer also 
 he forms epithelial casts, although he makes no direct state- 
 ment to that effect. He insists, however, that in every case in 
 which he has examined microscopically thin sections of diseased 
 kidneys whose tubules were blocked by the dark granular casts, 
 the tubules invariably exhibited an epithelial lining. He 
 reconciles this fact with his view by admitting that the theory 
 of Key and Bayer, that the epithelium thus shed is rapidly 
 reproduced, may be correct. Secondly, he believes that the 
 yellow (waxy) casts arise as a species of secretion from the 
 epithelium. Third, Bartels holds that certain "homogeneous, 
 transparent, lightly streaked, or faintly shaded varieties, or 
 the forms which are so delicately stippled with the finest 
 granules or minute oil-drops, — in a word, the casts which are 
 
 * Rovida, Ueber das Wesen der Harncylinder, Moleschott's Untersuch- 
 ungen zur Xaturlelire des menschen uud der Thiere, Bd. xi, s. 1. 
 t Bartels, op. citat , 84, 85, 86.
 
 TUBE-CASTS. 73 
 
 most rightly called hyaline, are formed by a coagulation of 
 tlie albumen and its derivatives secreted with the urine." 
 Their occurrence he considers entirely dependent upon the 
 albumen mixed with the urine. 
 
 Rindfleisch* thinks the matter is not yet ripe for decision. 
 He says that he has long favored the view that the epithelial 
 cells of the straight tubes furnish a solidifiable colloid ma- 
 terial in their protoplasm, which they pour out into the lumen 
 of the tubules, and he gives a drawing in his work on Patlio- 
 logicalHistology which he believes lends support to this view. 
 
 At the same time he says he is forced to admit, with Klebs, that 
 this may be a post-mortem product, or the result of a method 
 of preparation ; also, that casts may be the result of a liquefac- 
 tion and fusion of red blood-corpuscles; and finally, that for 
 the present the matter must rest with the statement that a fluid 
 albuminous substance is poured out into the lumen of the 
 tubule, which coagulates, and that thereby the fibrin-cylinder 
 is formed. In the next paragraph, however, under " amyloid 
 infiltration," he says that in advanced stages of this condition, 
 when aloue the epithelium becomes involved, casts may be 
 formed by the fusion of the infiltrated cells. 
 
 Charcotf is not at all explicit, but denies that they are 
 fibrinous, and considers that some (certain granular casts) are 
 made Up of broken-down epithelial cells, others (hyaline and 
 some granular) of an albuminous substance, while epithelial 
 casts are agglomerations of epithelial cells more or less altered. 
 
 The Part of the Uriniferous Tubule iii which Casts are Formed. 
 
 Casts may be formed in all parts of the tubules of the 
 kidney, but it is commonly asserted that most of those found 
 in the urine come from the looped tubes of Henle and the 
 collecting-tubes, because from these escape is easier than from 
 
 * Kindfleisch, Pathological Histology, New Syd. Soc. Transl., vol, ii, 
 1873, pp. 144. Fifth German edition, 1878, 442, 443. 
 
 t Charcot, On Bright's Disease, translated by Millard, New York, 1878, 
 p. 29 et seq.
 
 74 briqht's disease. 
 
 the convoluted tubules; not, however, easier thafi from the 
 intermediary or intercalary portion, in which each ascend- 
 ing limb terminates before it empties into a collecting-tube. 
 This part of the tubule is identical in structure with the con- 
 voluted portion, Rindfleisch says that casts are formed only 
 exceptionally in the convoluted tubules, and that when found 
 in situ in the cortex of the kidney, it is in this intermediary 
 piece of Schweigger-Seidel, and not in the convoluted portion, 
 that they usually lie. While there are difficulties in the de- 
 scent of a cast from the cortex of the kidney, and while such 
 descent is doubtless more rare, I do not consider it impossible. 
 The cast is smooth, flexible, and may contract its dimensions 
 decidedly. Under these circumstances the vis a terr/o of the 
 newly secreted urine, which must be considerable, may be suf- 
 ficient to force it downwards along the loop of Henle and 
 through the intermediary piece into the collecting-tube. It is 
 scarcely necessary to say that a blocking up of the convoluted 
 tubules by casts is a very much more serious matter than of 
 other portions, and that if it were of frequent occurrence a 
 larger proportion of cases of Bright's disease would be imme- 
 diately fatal. 
 
 It is not unlikely that those cases of chronic parenchymatous 
 nephritis, with large albuminuria and very few casts, such as 
 that of the young girl which will be further alluded to on page 
 76, are cases in which the convoluted tubules are exception- 
 ally involved ; for in that instance the cortex was crowded 
 with casts, while the urine contained but few, and the fatal 
 uraemia which terminated the case may have succeeded this 
 involvement. 
 
 The Significance of Casts found in Urine. 
 
 It is said that hyaline casts are found in urine from healthy 
 kidneys,* and that epithelial casts are found as a result of the 
 administration of diuretics;! but while I have found, in a very 
 
 * See Charcot on Bright's Disease, New York, 1878. Charcot says this 
 was first pointed out by M. Robin in 1855, and confirmed by Axel Key, 
 Rosenstein, and many others. f Ibid.
 
 TUBE-CASTS. 75 
 
 few instances, casts in urine in which there was at the same 
 time no albumen, I have never found true casts in urine from 
 what I considered normal kidneys. In cases of irritation of 
 the bladder, ureters, and pelvis of the kidney, there occur 
 what, following Dr. Beale, I call mucous casts, very long, 
 delicate, hyaline, faintly striated, often branching casts. They 
 are evidently formed in the largest collecting and excretory 
 tubes, and are probably mucus. They are due to irritation, 
 propagated from irritated mucous surfaces. Sometimes their 
 resemblance to casts is even closer in consequence of precipi- 
 tation upon them of granular urates or amorphous phosphate 
 of lime. But this granular deposit, when present, incrusts 
 everything which may be in the urine, epithelial cells, foreign 
 matter, etc., besides forming a copious precipitate of its own. 
 
 It is not very unusual to find cases in whicli there have 
 been albuminuria and casts, where, as improvement progresses, 
 the albuminuria disappears, and casts are found in the urine 
 for some time longer. I have observed this in several cases, 
 and I suppose, if watched for, more frequent instances would 
 be found. My friend, Dr. Milner, of Chester, Pennsylvania, 
 having had his attention called to the subject by a publica- 
 •tion of my own, in which it was stated that during recovery 
 from acute Bright's disease casts might be found in the urine 
 some time after albumen had disappeared, examined carefully 
 the urine of a child recovering from scarlatinal nephritis, 
 and found casts for two weeks after albumen had disappeared. 
 Such cases require no further comment. Bartels correctly 
 says : " The formation and the excretion of a cast need be by 
 no means contemporaneous events." 
 
 An adult woman, on admission to the Pennsylvania Hos- 
 pital, exhibited a slight puffiness and pallor of countenance, 
 which suggested an examination of her urine. No albumen 
 was found by the physicians at tlie hospital, but a considerable 
 number of slightly granular and hyaline casts. Dr. James H. 
 Hutchinson sent me a specimen of the urine, and by no test 
 could I discover the presence of albumen, but found delicate 
 granular and hyaline casts. One week later a searching ex-
 
 76 bright's disease. 
 
 araination of the urine of the same patient revealed neither 
 cads nor albumen. This hist observation settled the question. 
 The case had been one of Bright's disease which was conva- 
 lescent. Finally, A. Henderson reports for Osier, in the 
 Canada Medical and Surgical Journal, Montreal, 1879, vol. 
 vii, a case of persistence of casts and blood-corpuscles in urine 
 after albumen had disappeared. Now if we add cases of oon- 
 tracted kidney, in which occasionally for a time either casts or 
 albumen may be wanting, this category is complete. 
 
 On the other hand, occasional instances of true renal albu- 
 minuria, and large albuminuria without heart disease, are some- 
 times met in which casts are absent. But even here, if the 
 opportunity for repeated examinations is present, there comes a 
 time when a few casts will be found, while later again an exami- 
 nation may fail to discover them. Such a case of supposed amy- 
 loid disease of the kidney I have now under observation, fully 
 noted. I have notes of another case of copious albuminuria, 
 in which three careful examinations failed to discover casts, 
 and the patient subsequently died ; but no post-mortem exam- 
 ination M'as made. ]\Iy own relation to the case was confined 
 to the urine examination. It may have been one of heart 
 disease, but I believe it was one of parenchymatous nephritis. 
 Recently I was asked to see a young girl of 14, the daughter 
 of a physician, who had copious albuminuria for nearly a year 
 before I saw her. During this time her urine was examined 
 for casts several times, but none were found. At my exami- 
 nation, although there was large albuminuria, only a very few 
 casts were found. She died in a few days in uroemic convul- 
 sions, and the autopsy revealed two typical large white kid- 
 neys, weighing each about eight ounces. Upon microscopic 
 examination of sections, the tubules of the cortex were found 
 to contain numerous waxy casts. Finally, I am confident that 
 there are many instances of albuminuria where the absence of 
 casts is reported in which the examination is at fault, being 
 carelessly performed. 
 
 From these remarks it may be inferred that I attach no 
 small significance to the presence of casts in the urine. Although
 
 TUBE-CASTS. 77 
 
 I have never seen casts in the urine from healthy kidneys, I 
 will not deny the possibility of its occasional occurrence. But 
 when we remember that urine is seldom investigated with tiie 
 microscope, unless we are searching for the cause of an evident 
 or suspected ill health, we may lay it down as a rule, to which 
 exceptions are so rare that they may be ignored, that when 
 casts of the uriniferous tubes are found in a specimen of urine 
 the kidneys whence they come are not in a normal state. That 
 state may be temporary, but if so the casts pass away with it, 
 while, if it is permanent, the casts continue during its exist- 
 ence. The doubtful cases are, of course, those unaccompa- 
 nied by albuminuria. I presume no one will claim that the 
 kidneys Avhich shed both casts and albuminuric urine are 
 healthy. Cases of the former category require, of course, to 
 be studied, and the issue will always clear itself. I cannot 
 comprehend the position taken by Charcot in his recent work, 
 where, in addition to saying that " in a general way, the clin- 
 ical importance of urinary casts has been very much exagger- 
 ated," he also says of epithelial casts, " it may be said that, 
 from a clinical point of view, they do not possess much im- 
 portance ;" and of hyaline casts, " even when renal disease ex- 
 ists, the hyaline casts are of no interest, except from their long 
 persistence." 
 
 When we come to ask the question, whether by the kind of 
 casts present we can diagnose the nature of the renal malady, a 
 less positive reply can be given ; but, nevertheless, some of the 
 varieties give us considerable assistance in making a diagnosis. 
 The following general statements may be made : 
 
 1. Hyaline casts are found in all forms of Bright's disease, 
 as well as in temporary congestions of the kidney, active or 
 passive. 
 
 2. Epithelial casts are found in acute, subacute, and chronic 
 parenchymatous nephritis. In the latter two forms the cells 
 are generally degenerated and fragmentary. 
 
 3. Blood-casts are found in acute parenchymatous nephritis, 
 and where haemorrhages have occurred in the kidneys. 
 
 4. Pale granular casts are found in interstitial nephritis
 
 78 bright's disease. 
 
 (contracted kidney) and chronic parenchymatous nephritis 
 (large white kidney). 
 
 5. Dark granular casts are found in parenchymatous ne- 
 j)hritis, acute and chronic, and rarely in interstitial ne])hritis. 
 
 6. Waxy casts are found only in chronic Bright's disease, 
 and attend either of the three principal forms. 
 
 7. Oil-casts are found in subacute and chronic forms of 
 Bright's disease, and may attend any of the three principal 
 forms, but are most numerous in chronic parenchymatous ne- 
 phritis. 
 
 8. Free fatty cells and free oil-drops are found in chronic 
 parenchymatous nephritis. 
 
 9. The form of fatty cell known as the compound granular 
 cell is found in acute and chronic parenchymatous nephritis. 
 
 i
 
 CLASSIFICATION OF BRIGIIT's DISEASE. 79 
 
 SECTION lY. 
 
 CLASSIFICATION OF BRIGHt's DISEASE. 
 
 Whatever may be the objections to retaining the term 
 Bright's disease or Bright's diseases in medical nomenclature, 
 there is every reason to believe it will remain in use for many 
 years, if not as long as medical science exists. This being the case, 
 I see no reason for excluding from the category any one or more 
 of those affections of the kidney attended by albuminuria, 
 dropsy, and tube-casts, either simultaneously or in close rela- 
 tion to each other. For, accurately described and delineated 
 by Bright as were some of these forms of disease which he 
 studied, it is evident that he had no correct notion of the inti- 
 mate nature of the processes which constitute them ; while it 
 is almost certain that among those cases of dropsy and albumi- 
 nuria which came under his notice were examples of forms of 
 disease which certain authors would eliminate from the cate- 
 gory of Bright's disease. Thus it is scarcely likely he could 
 have failed to have had under his observation in a large hos- 
 pital experience cases of the so-called lardaceous or amyloid 
 disease of the kidney, though he failed to recognize it as a sepa- 
 rate form, and probably included it under one or another of 
 the three described by him. 
 
 Again, great pains have been taken to draw a sharp distinc- 
 tion between Bright's disease and the structural changes which 
 take place in the kidney as the result of passive congestion, 
 such as obtains in valvular disease of the heart, although, as 
 will be shown later, the histological results are the same as 
 those which in a much more advanced stage constitute the 
 granular contracted kidney of Bright. I would, however, 
 retain even this condition under the category of Bright's dis- 
 ease, notwithstanding the fact that the alterations seldom reach
 
 80 briqut's disease. 
 
 even the sliiihter degrrecs of contraction essential to the morbid 
 anatomy of the contracted organ. Traube and Kelsch are, so 
 far as I know, alone in desiring to discard the term Bright's 
 disease altogether. 
 
 Bright's* first paper appeared in 1827, and of the earlier 
 writers after him, Rayer was the first to assign an inflammatory 
 character to the changes in the kidney described by the great 
 English physician. Rayer also said of the six forms which he 
 himself described that they are "probably successive." Roki- 
 tansky (1842) was the first to include lardaceous disease in the 
 category of Bright's disease. 
 
 Reinhardt (1850) and Frerichs (1851) after careful histo- 
 logical investigations also concluded that the conditions de- 
 scribed by Bright were the result of inflammation, and sought 
 to establish the proposition of the "unity" of Bright's disease, 
 that is, that the different forms represent three successive stages 
 of this process: 1st, hyper^emia; 2d, exudation with fatty 
 degeneration of epithelium : and, 3d, new growth of connective 
 tissue with resulting atrophy of the kidney. 
 
 These observers laid especial stress upon the casts found 
 in the urine during life and in the uriniferous tubules after 
 death. Supposing their fibrinous nature established, they con- 
 sidered the inflammation a "croupous" one, and applied the 
 term "diffuse croupous nephritis" to the entire process on 
 account of its uniform distribution over the organ. Finally 
 they included under Bright's disease all affections of the kid- 
 ney attended by casts; among them, therefore, the results of 
 passive congestion, or, as they are now called, cyanotic indu- 
 ration and lardaceous disease. Traube (1856) first insisted 
 that the former was a distinct process and should not, there- 
 fore, be included under Bright's disease. He also showed how 
 lardaceous disease could be distinguished from other renal 
 diseases; and although Bamberger earnestly strove to replace 
 the former in the category, the views of Traube have since 
 generally prevailed in Germany. 
 
 * Bright, Kichard, Report on Medical Cases, London, 1827.
 
 CLASSIFICATION OF BRIGHT's DISEASE. 81 
 
 Virchow (1852), in his famous paper on parenchymatous 
 inflammation,* makes, first, a milder degree of inflammation, 
 which he terms cafarrhal nephritis, in which there is first, a 
 liyperplasia of epithelial cells, and later an alteration and 
 shedding of the same; second, a croupous inflammation, 
 wherein a fibrinous exudation is added to the catarrh; and, 
 third, a jjarcnchymatous inflammation, in which, too, the 
 cells are altered, swollen, cloudy, granular, and subsequently 
 break up. To what he considers the very rare combination 
 of these three condition, — catarrhal, croupous, and parenchym- 
 atous nephritis, — he suggests that the term Bright's disease, 
 if used at all, be restricted. In his Cellular Pathology (1858), 
 however, Virchow includes under the term Bright's disease 
 three conditions, one of which originates in the tubules (paren- 
 chymatous nephritis), a second in the intertubular tissue (in- 
 terstitial nephritis), and a third in the vessels (amyloid degen- 
 eration). Thus Virchow was the first to call attention to the 
 intertubular connective tissue as the special seat of a change. 
 To this he had, in a more general way, alluded in his earlier 
 paper. Arnold Beerf and Traube,| on the other hand, located 
 the entire primary process in this tissue, making the changes 
 in the epithelium altogether secondary, and do not acknowledge 
 such a process as parenchymatous nephritis. 
 
 Klebs (1870), in his Handbook of Pathological Anatomy, 
 excludes cyanotic induration and lardaceous disease from mor- 
 bus Brightu. 
 
 Ilosenstein,§ in his work on Diseases of the Kidneys, treats 
 of congestive hypei-semia, catarrhal nephritis, diffuse nephritis, 
 and amyloid degeneration, and says these are what have com- 
 monly been included under the tel'm Bright's disease. But 
 he himself uses the term as a synonym for his "diffuse 
 
 * Ueber Parenchymato:<e Entzunclung, Berlin, ]8o2. 
 
 t Beer, Die Bindesubstanz der Menschlichen Niere, Berlin, 1859. 
 
 X Zur Patliologie der Niorenkranklieiten, Gesainmelte Beitriige zur 
 Pathologie und Physiologie, 2 Ed., 2 Abtbeiliing, Berlin, 1860. 
 
 I Die Pathologie und Therapie der Nierenkrankkeiten. Zweite verbes- 
 serte Auflage, Berlin, 1870, ss. 51, 100. 
 
 6
 
 82 brigiit's disease. 
 
 nephritis." He adopts the older view of the "unity" of the 
 disease, and by his diffuse nephritis he means wliat most writers 
 of the present day call a parenchymatous nephritis, that is, a 
 nei)hritis in which the tubules and their epithelium are the 
 chief centre of change. Of this, however, he makes three 
 stages, after the scheme of Reinhardt and Frerichs, a stage of 
 hvperpemia, one of exudation, and one of atrophy, the result 
 of which is the granular contracted kidney. Thus atrophy 
 may result from the parenchymatous process alone, by a fatty 
 degeneration and breaking down of the cells ; but is, for the 
 most part, acconipanied by changes in the interstitial tissue, 
 which consists sometimes in a fibrillar and sometimes in a 
 cellular hyperplasia, -whose contraction co-operates to produce 
 the atrophy of the organ. Rosenstein's catarrhal nephritis 
 corresponds with Yirchow's, that is, it is a slight degree of 
 parenchymatous inflammation. Of interstitial nephritis as a 
 special form he makes no mention. 
 
 The English authors, and notably among them Dr. George 
 Johnson, were most instrumental in breaking up the notion of 
 the "unity " of Bright's disease for a long time so stubbornly 
 held by the German and French pathologists, and still main- 
 tained by Rosenstein and some others. Among those who 
 have emancipated themselves most thoroughly from this doc- 
 trine are Bartels and Charcot. The former, in his recent article 
 in Ziemssen's Cyclopcedia of Medicine (1877), says that among 
 the diseases originally grouped under the title Bright's disease, 
 his clinical experience and pathologico-anatomical investiga- 
 tions have led him to include hypersemia, acute and chronic, 
 ischsemia, parenchymatous inflammation, acute and chronic, 
 interstitial inflammation ©r connective tissue induration, and 
 amyloid degeneration. He also announces his firm allegiance 
 to the English view of the nature of the disease. Charcot 
 says :* " In my opinion, therefore, which is only, so to sjieak, 
 the reflex of the English theory, Bright's disciise is a class 
 comprising several distinct species, not only from an anatomico- 
 
 * Charcot on Bright's Disease, translated by Millard, New York, 1S78, 
 p. 36.
 
 I 
 
 CLASSIFICATION OF BRIGIIT's DISEASE. 83 
 
 ]iatliological point of view, but as regards etiology anJ symp- 
 tomatology." These distinct species are parencliymatous ne- 
 jihritis, interstitial nephritis, and the amyloid kidney. Of 
 modern French writers, Cornil and Ranvier, Lancereaux, Le- 
 corche, Labadie-Ijagrave and others, hold the same views. 
 
 Of the English writers above referred to. Dr. Johnson first 
 ]>romulgated his views in his larger work on Diseases of the 
 Kidney, published in 1852, but his most recent views are 
 found in his smaller treatise, entitled Lectures on BrigMs Dis- 
 ease, published in 1873. He describes an acute and chronic 
 form. The former is represented by acute nephritis, the latter 
 by the red granular kidney, the large white kidney, and the 
 lardaceous or waxy kidney. Roberts, Dickinson, and Grainger 
 Stewart, while diifering somewhat as to the exact pathology 
 of the different forms, adopt practically the same arrangement. 
 Beale agrees entirely with Johnson. Grainger Stewart and 
 Dickinson are the most systematic, and attempt a sharper dif- 
 ferentiation of the diflPereut forms of parenchymatous nephritis. 
 The former writer makes : 
 
 1. The inflaimiiatory form, of which tliere are three stages, 
 that of inflammation, that of fatty ti'ansformation, and that of 
 atroj)hy. 
 
 2. The iraxy or amyloid form, of which there are also three 
 stages, that of degeneration of vessels, that of secondary changes 
 in the tubes, and that of atrophy. 
 
 3. The cirrhotic, contracting, or gouty form. 
 Dickinson makes : 
 
 1, Acute tubal and diffuse nephritis, involving primarily 
 the tubules, but extending, sooner or later, to the interstitial 
 tissue, terminating in fatty degeneration and subsequently 
 contraction, if early death or recovery does not take place. 
 
 2, Granular degeneration. 
 
 3, Lardaceous disease. 
 
 In the following pages I shall retain the term BrigMs Dis- 
 ease, which I subdivide into acute and chronic. 
 
 I. Acute Bright's disease is represented by a single form, 
 acute parenchymatous nephritis.
 
 8-i brigiit's disease. 
 
 II. Chronic Bright's disease includes the following: 
 
 1. Chronic parenchymatous nephritis. 
 
 2. Lardaceous disease, a chronic process. 
 
 3. Interstitial nephritis which is only chronic. 
 
 As acute hyjjeixemia is represented by the first stage of par- 
 enchymatous nephritis, and is not characterized by a clinical 
 history essentially different, I will not devote to it a separate 
 consideration. 
 
 In like manner cyanotic induration, the pathological product 
 of passive congestion, is the result of a process similar to that 
 of interstitial nephritis, with the first stage of which it might, 
 with some propriety, be considered to correspond. But in con- 
 sequence of its relation to valvular disease of the heart, which 
 is its immediate and almost exclusive cause, Mhile there are 
 also some symptoms peculiar to it, I will devote a separate 
 section to its consideration. 
 
 Finally, to secure completeness, I shall devote a section to 
 suppurative interstitial nephritis, or pyelonephritis, Avithout de- 
 siring to be considered as including it under Bright's disease.
 
 ACUTE PARENCHYiMATOUS NEPHRITIS, 85 
 
 SECTION V. 
 
 ACUTE PAREXCIIYMATOUS NEPHRITIS. 
 
 Si/nonyms. — Acute nepbritis, acute desquamative nephritis, acute tul)al nephritis, acute 
 Bri^ht's disease, acute catarrhal nephritis, croupous nephritis, albuminous uejthritis, 
 haemorrhagic nepliritis (Traube), acute albuminuria, acute renal dropsy. 
 
 ACUTE PAREXCHYMATOUS NEPHRITIS IS AN ACUTE IN- 
 FLAMMATION OF THE KIDNEY, IN WHICH THE EPITHELIUM 
 OF THE TUBULES IS THE PRIMARY AND PRINCIPAL SEAT 
 OF INFLAMMATION. 
 
 Etiology. 
 
 INIost cases of acute parenchymatous nepliritis are caused by 
 scarlet fever, and occur, therefore, in children. A certain 
 number originate in exposure to cold, especially cold and mois- 
 ture, while the body is warm and perspiring. The latter cause 
 is particularly efficient if the person be fatigued or exhausted. 
 
 As to the method in which scarlatina causes the nephritis, 
 while it cannot be said to be undisputed, it is most likely that 
 the specific poison of the disease operates through the blood 
 upon the epithelium of the kidney, which probably seeks to 
 remove it. In evidence to support this view is the fact that 
 it is by no means the cases in which the eruption is most 
 profuse, and in which the skin is therefore most sensitive, that 
 the renal complication occurs; also that there are specific 
 agents which, when introduced into the blood, produce iden- 
 tical results. Such agents are cantharides, turpentine, and oil 
 of mustard. The independence of cold, of certain cases of 
 nephritis following scarlatina, is further attested by those in- 
 stances, familiar to every practitioner of experience, in which 
 the disease has succeeded upon scarlet fever during a convales- 
 cence in which the patient has been kept in bed, while the 
 barefoot pauper may have run the streets with the eruption upon 
 liim, and throughout convalescence, with utter impunity. But
 
 86 briqht's disease. 
 
 while it cannot be claimed that cold, by causing the retrocession 
 of blood from the skin to internal organs, can alone produce the 
 nephritis of scarlatina, it cannot be denied that it may co-operate 
 with the peculiar poison in producing the same result. And 
 in those cases of acute nephritis which result from exposure to 
 cold, the immediate cause is probably a congestion due to the 
 introcession of the blood from the surface of the body; but 
 here again, it is not unlikely that the supplemental function 
 assumed by the kidney in consequence of the suppression of 
 excretion by the skin, contributes secondarily. The same may 
 be said of the acute nephritis which succeeds upon extensive 
 burns of the surface of the body. 
 
 In like manner, other grave infectious diseases, as diphtheria 
 and small-pox, cause acute parenchymatous nephritis, the 
 former frequently. In both it presents itself, if at all, at the 
 acme of the disease. Acute endocarditis and acute articular 
 rheumatism are also occasional causes ; while measles, erysipe- 
 las, jyycemia, jaundice, and diah.ctes have been known to cause 
 it. In a case of chronic Bright's disease under my care a 
 sharp acute attack was evidently induced by an attack of ery- 
 sipelas ; and a pair of kidneys, removed post-mortem from a 
 case of diabetes and sent to me for examination, presented all 
 the signs of an acutely congested kidney. The alterations 
 which take place in the kidney after cholera are generally 
 acknowledged to be those of inflammation. Skin diseases, as 
 well as extensive burns of the skin, are acknowledged causes; 
 the former rarely, but the latter almost always if the burns be 
 sufficiently extensive. 
 
 Pregnancy is the cause of a good many cases of acute par- 
 enchymatous nephritis, indeed so important a cause of it that 
 some writers, as Bartels, devote a separate section to the acute 
 parenchymatous nephritis of pregnancy. 
 
 ]Most cases of acute nephritis due to other causes than scar- 
 latina, cold, and pregnancy, are mild in degree ; and even in. 
 cases due to pregnancy, if the patient is once through with her 
 confinement, recovery is usually rapid. 
 
 In looking for the evidence of nei)hritis in acute infectious
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 87 
 
 diseases it must not be forgotten that intense febrile move- 
 ment may cause albuminuria, independently of any structural 
 change in the kidney due to the zymotic agent. When thus 
 caused the albuminuria is always small. 
 
 When acute nephritis supervenes upon scarlet fever it does 
 not usually make its appearance until the end of the second 
 week. Indeed it is often during supposed convalescence that 
 it most unexpectedly occurs. Bartels, in a single case, detected 
 it on the tenth day, and never later than the thirty-first. He 
 found the twentieth day to be the mean limit, while the great- 
 est number of cases also presented themselves on this day. 
 
 Dr. Tripe* concludes from his observations that dropsy 
 may come on at any period of scarlatina, even the earliest, but 
 that it most frequently appears on the fourteenth day. Dr. 
 West says it is most frequently in the second week that it 
 occurs, and that if delayed later the symptoms are generally 
 milder. Dr. Dickinsonf found the majority of cases occurring 
 in the third week, but says: "Speaking generally, it may be 
 said that after the end of the first month the danger is small, 
 but until after the lapse of the second the patient cannot be 
 looked upon as safe." These are safe limits. I cannot but 
 think that the earliest cases of Dr. Tripe — those which oc- 
 curred say within the first week — may have been cases of albu- 
 minuria resulting from the intensity of the febrile movement, 
 which of itself may cause albuminuria though not nephritis. 
 
 Certain specific poisons of vegetable and mineral origin are 
 capable of producing acute nephritis. Alcohol is one of these. 
 Although by no means so frequent a cause of Bright's disease 
 as formerly su})posed, undoubtedly a few cases are directly 
 traceable to it, in one instance, quoted by Dr. Dickinson from 
 Dr. Goodfellow,! apparently to the inhalation of its vapor. 
 Among the best known of these substances are cantharides, 
 turpentine, oil of mustard, and phosphorus; in a less degree 
 the mineral acids, arsenic, nitrate of silver, lead, and me7xury. 
 
 * Tripe on Scarlatinal Dropsy, Med.-Chir. Rev., 1854-55. 
 
 t Dickinson, op. citat , p. 90. 
 
 X Dr. Goodfellow on Diseases of tlie Kidney, p. 177.
 
 88 bright's disease. 
 
 I think loormseed oil may be placed in the same category, for 
 in a ca.se which came under my observation, an adult male died 
 twenty-four hours after taking an ounce of this oil, death 
 being preceded by coma and convulsions, Avhile the urine was 
 found to contain lialf its bulk of albumen. 
 
 Age and Sex. — As may be inferred from the etiology, acute 
 nephritis is a disease of early age, although when caused by cold 
 or any one of the causes named except scarlatina, it is as more 
 likely to aifect adults as these latter are more frequently sub- 
 jected to such causes. 
 
 In one instance only have I known acute nephritis to 
 originate in a person over thirty years of age. The patient 
 was a woman, and the cause exposure. The possibility of 
 its later occurrence cannot be denied. Dr. Dickinson says it 
 is rare after forty, almost unknown after fifty. The oldest 
 child I ever knew to have scarlatinal nephritis was a girl of 
 fourteen, Avho died. 
 
 More males are attacked than females in adult life, evidently 
 because they are more frequently exposed to the causes. But 
 even in childhood there is a slight preponderance of cases in 
 boys affected, which can hardly be thus accounted for. 
 
 Morbid Anatomy. 
 
 This varies somewhat with the stage of the disease as well 
 as its severity. In the first place, as ordinarily caused, it is 
 symmetrical, both organs being alike involved. The altera- 
 tions may be so trifling as not to be recognizable by the naked 
 eye. But the kidneys are generally sooner or later enlarged, 
 in the latter stages always, sometimes to more than twice their 
 normal volume, and they may weigh from eight to twelve 
 ounces, those of children reaching the former, and those of 
 adults the latter. 
 
 The capsxde is distended by the enlargement, and, therefore, 
 gapes when incised.* It may be otherwise unaltered or slightly 
 
 * Dickinson reports a case in which the capsule of both kidneys burst 
 from the extent and suddenness of the tumefaction. Dickin.sou, Albuminu- 
 ria, 2d edition, London, 1877, p. 97.
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 89 
 
 injected, and strips off easily, without dragging any of theparen- 
 chynia with it. Bereft of its capsule, the kidney itself is softer 
 than in health, inelastic, doughy. Its surfoce is smooth and ex- 
 hibits a peculiar mottled appearance, which is due to the fact 
 that the little circlets of veins which form the boundary of the 
 lobules are distinctly injected, while the area included by each 
 circlet is paler than in health, and in the more advanced stages 
 even yellowish-white in color. This " irregular mixture of 
 congestion and anemia," as Dr. Johnson calls it, is further con- 
 tributed by the injection of other veins, indistinct in health. 
 The stellate veins, which are also more or less injected, are not 
 so conspicuous as in chronic parenchymatous nephritis. Spots 
 of hemorrhagic extravasation are also found scattered over the 
 surface. 
 
 0*1 section it is evident that the enlargement is due to 
 change in the cortex and the interpyramidal convoluted portion. 
 The cut surface is smeared over with a dark-red or chocolate- 
 hued blood, but on scraping or washing it away, the vessels are 
 found similarly injected to those of the surface, and between 
 them the same paleness or yellowish-white hue. The Mal- 
 pighian bodies appear as distinct dark-red dots, and any lin- 
 ear vessels are distinctly filled, while punctiform haemorrhages 
 may again be present as on the surface of the organ. 
 
 The pyramids are usually not essentially altered in appear- 
 ance. They may be congested, and this may increase the vivid 
 contrast already existing between their dark-red color and the 
 pale cortex. In cases of extreme swelling, the pyramids may be 
 compressed in their central portions by the interpyramidal con- 
 voluted structure, which shares the enlargement of the cortex 
 of which it is an extension, producing the very characteristic 
 appearance first compared by Rayer to a wheat-sheaf. 
 
 Minute Changes. — These are confined almost solely to the 
 cortex. They begin at least in the epithelium, and vary a 
 good deal with the stage of the disease. The earliest con- 
 dition of the cells is undoubtedly that of cloudy swelling, 
 the result of increased nutritive activity. In this state the 
 cells are swollen, slightly more cloudy than usual, in couse-
 
 90 bright's disease. 
 
 quence of a deposition of albiiininous granules in their interior, 
 which may accumulate to such extent as even to obscure the 
 nucleus. Although kidneys removed after death from cases 
 of acute parenchymatous nephritis have as a rule advanced far 
 beyond this stage, yet it is often possible to find points less 
 advanced at which cloudy swelling exists alongside of more 
 advanced stages, while alongside of these again may be tubes 
 in which the epithelium is healthy. As a result of the cloudy 
 swelling, the cells are larger, and the tubes are therefore 
 broader than they are in health, but a stage later the widen- 
 ing is more marked and the tubes are filled with more highly 
 as well as moderately granular cells, to which are added free 
 granular matter and often red blood-corpuscles. Under a 
 low power the tubules appear as black, more or less opaque lines. 
 The granules result from the breaking down of the cells, and 
 the blood-disks are, of course, derived from the capillary vessels. 
 
 A closer examination of the cells ffX this stage, as obtained 
 by scraping or examined in situ, shows them to be granular 
 in various degrees. In some the nucleus is still visible, in 
 others demonstrable by the aid of staining fluids, but otherwise 
 invisible, and in others still, entirely obscured. Occasionally 
 a few fat-drops may be present. In otiier situations the 
 cells are so closely packed in the tubules that they cannot be 
 differentiated, are apparently fused in one continuous, dark 
 granular mass. This is the result of a hyperplasia of cells, 
 and it is to these tubules thus distended with granular cells 
 and their debris, dark by transmitted light, but white by re- 
 flected, that the pale or white color seen between the injected 
 bloodvessels owes its origin. 
 
 Minute extravasations of blood visible to the naked eye have 
 been referred to. These are found to occupy the tubules, and 
 come either by diapedesis or rupture, from the capillaries of 
 the Malpighian glomeruli, which, in the fresh condition, are 
 also distended with blood-corpuscles. In a still more ad- 
 vanced stage, however, the Malpighian bodies may be paler, in 
 consequence of the compression exerted by the still more 
 swollen tubules, or by the proliferated cells peculiar to the 
 capsule and its glomerule (glomcrulo-nephritis).
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 91 
 
 Casts of the uriniferous tubules are also often found in situ. 
 These are either blood-casts or small hyaline casts. These 
 hyaline casts are fibrin, and when after contraction they are 
 expelled from the tubule they may carry the epithelium of the 
 tubule with them, thus producing a so-called epithelial cast. 
 
 Oertel claims that in renal diseases following diphtheria 
 he has found "great numbers of micrococci and exuberant 
 proliferations of the same," both in the renal tubes and Mal- 
 pighian bodies. Heller* alleges he has repeatedly found the 
 bloodvessels and their branches in acutely inflamed and swollen 
 kidneys from cases of pyaemia, greatly dilated and plugged 
 with masses, which under low powers presented a peculiar 
 grayish-yellow appearance, and with higher powers were 
 found to consist of extremely minute, highly refracting gran- 
 ular particles, placed at equal distances from one another. 
 These particles he considered spherical bacteria, and the re- 
 sulting masses bacterla-emboli. 
 
 The epithelium lining the tubules of the straight tubes is 
 inichanged, but the tubes themselves often contain the same 
 cellular and granular material contained in the convoluted 
 tubes, Avhich has descended from the latter. 
 
 The Interstitial {intertubular) Tissue of the Iviclneij in Acute 
 Parenchymatous Nephritis. — The changes above described, it is 
 seen, belong to the tubules and bloodvessels. In most cases of 
 acute parenchymatous nephritis, there is no interstitial change, 
 no formation or deposit of new material between the tubes. 
 This assertion may be reaffirmed, but requires some further 
 comment. It is certainly not present in the earliest stages; but 
 sooner or later such changes do present themselves, and it is a 
 matter of duration of the disease as to whether they appear or not. 
 If the disease continues without permanent amendment for three 
 months or longer, they will certainly have made their appearance. 
 But here the border between acute and chronic parenchymatous 
 nephritis has been passed. It is impossible to say, however, 
 
 * See Bartels, in Ziemssen's C'yclopa?dia of Medicine, vol. xv, 1877, p 272.
 
 92 bright's disease. 
 
 precisely when they make their appearance, and for some time 
 before such changes are recognizable by the naked eye they 
 are discernible by the microscope. They consist in a hyper- 
 nucleated overgrowth resulting from . the proliferation of the 
 connective tissue corpuscles always present, or from the fixa- 
 tion of wandered-out colorless blood-cells, and are doubtless 
 due to the long-continued hyperemia. It is possible, too, that 
 there may be cases of such extreme severity that a diffuse 
 nephritis, involving both the tubes and intertubular ele- 
 ments, may exist from the very beginning. Dickinson 
 figures a section of a kidney showing such involvement, from 
 a case of diffuse nephritis of ten weeks' standing in a boy 
 of seven.* 
 
 Changes in the Pelvis of the Kidney. The mucous mem- 
 brane of the kidney may be injected, but is otherwise unchanged. 
 
 Alterations in the Glomende and its Capsule. 
 
 I have decided to describe here the pathological alterations 
 of the ]\Ialpighiau body, known as glomerulo-nephritis, because 
 the changes are most frequently found associated with acute 
 nephritis, although not exclusively. 
 
 The earlier writers on Bright's disease very generally 
 described changes in the elements of the Malpighian body in 
 both the acute and chronic forms. Thus Foersterf speaks of 
 proliferation of the capillary nuclei, thickening of their walls, 
 and desquamation of the enlarged epithelial cells lining the 
 capsule. Virchow;{; described a cloudiness and increased num- 
 ber of nuclei in the capillaries of the Malpighian tuft in chronic 
 nephritis, together with a thickening of their walls and greater 
 width of the capillary coils. After these observers no allu- 
 sion seems to have been made to such changes until Klebs 
 published in his JJandbook of Pathological Anatomy, in 1870, 
 an account of some further changes in this body in acute ne- 
 
 * Dickinson, op. cit., p. 28. 
 
 t Foerster, Pathol. Anat., Bd. ii, s. 512. 
 
 X Virchow, Gcsammelte Abhandl., s. 485.
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 93 
 
 phritis after scarlet fever. These he incladed under tlie title 
 glomerulo-nephritis, and ascribes them to a proliferation of the 
 nuclei in the interstitial tissue of the glomerule, the existence 
 of which Axel Key had previously asserted. In this condition, 
 according to Klebs, the Malpighian bodies appear to the naked 
 eye as little white bloodless points. The urinary tubules are 
 often not at all altered, though sometimes the convoluted 
 tubules are slightly cloudy. The microscope discovers neither 
 proliferation of epithelial cells (the so-called renal catarrh) nor 
 interstitial alterations — nothing but the phenomena of conges- 
 tion, if the INIalpighian bodies are ignored. But the cavity 
 of the Malpighian capsule is tilled with small angular nuclei 
 imbedded in a fine granular mass which almost completely 
 covers the vessels. This, Klebs says, is not the endothelial 
 lining of the capsule, because, on careful dissection by needles, 
 this endothelium is found very slightly altered; Ordinarily 
 clearer and more firmly adherent than in health, occasionally 
 fattily degenerated. He believes it is the compression of the 
 vessels of the Malpighian body by this hyperplasia which 
 sometimes causes the sudden, almost total suppression of urine 
 and acute dropsy in cases of scarlet fever, followed by uraemia 
 and death in from 12 to 24 hours. 
 
 Johnson* remarks that the nuclei in the walls of the capil- 
 laries of the Malpighian body are abnormally conspicuous. 
 Birch-Hirschfeldf describes a proliferation of nuclei between 
 the vascular loops and the epithelium ; Cornil and Ranvier]; a 
 swelling and granular condition of the capsular epithelium and 
 nuclear proliferation and fatty degeneration of the capillary 
 wall. Bartels§ gives a drawing by Colberg of a glomerule from 
 a case of chronic parenchymatous nephritis, in which the capil- 
 lary nuclei are in a state of proliferation. And Litten|| has 
 
 * Johnson, Lectures on Briglit's Disease, New York, 1874, p. 30. 
 t Birch-IIirschleld, Patliol. Anat., Leipzig, 1877, p. 1021. 
 X Cornil and Ranvier, Pieds d'Histologie Pathol., Paris, 187G, p. 1026. 
 American Ed., 1880, p. G16. 
 
 § Cartels, in vol. xv, Zienissen's Cyclopiedia, New York, 1874, p. 373. 
 II Litten, Charite Annalen, t. iv, p. 30.
 
 94 bright's disease. 
 
 described marked proliferation and desquamation of the epi- 
 thelium of the glomerulus itself, as well as of the capsular 
 epithelium in a case of scarlatina. 
 
 But Langhans* has quite recently furnished the most com- 
 plete and thorough account of the changes in the ISlalpighian 
 body yet published. I have already made use of Langhans's 
 paper in my account of the histology of the Malpighian body. 
 It will be remembered that there are, according to him, three 
 sets of cells contained in it, viz., the cells forming the lining 
 of the capsule, the epithelial cells covering the glomerule or 
 capillary coil, and the nuclei of the capillary vessels. Langhans 
 was unable to convince himself of the existence of the stellate 
 elements which Axel Key described as connective tissue cells, 
 nor of the presence of any connective tissue within the capsule, 
 except the adventitia of the vas afferens, which extended only 
 as far as .the branching of this vessel. But of the three sets of 
 cells described by him all share in the pathological processes 
 of the kidney. 
 
 First, as to the epithelium of the capsule, it exhibits in its 
 slightest degrees of alteration, such as occurs in a congestion of 
 the kidney, a simple overgrowth of the cells, so that instead 
 of being flat they are more comparable to the epithelial lining 
 of the tubules in their convoluted portion. The nucleus is 
 larger, oval, and fills the cell almost completely. This degree 
 of alteration occurs in any of the forms of Bright's disease. 
 Increase in the number of cells, resulting in stratified layers, 
 is a much more rare occurrence, but Langhans has seen it in 
 acute nephritis where there were haemorrhages within the cap- 
 sule. Here the Malpighian body is elongated in a direction 
 parallel with the axis of the medullary rays. This is due to 
 the presence between the capsule and the glomerule of a cres- 
 centic mass of cells, of which the thickest portion is opposite, 
 or nearly opposite, the point of entrance of the vas alferens. 
 In the spaces between the layers of these cells, which are more 
 
 * Langhans, Theodore, Ueher die Veriinderungen der Glomeruli bei 
 Nephritis nel>st einigen Bemerkungen iiher die Entstehung der Fibrin- 
 cylinder, Virciiow's Archiv, Bd. 76, 1879, s. 85.
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 95 
 
 or less epitheloid in shape, are found smaller and larger 
 lymphoid cells. More frequent than this extreme degree is 
 partial thickening of the capsular epithelium. 
 
 Proliferation and thickening of the capsular epitlieliiim with compression of the 
 glonierule. X 120.— Alter Langhans. 
 
 With regard to the effect of this proliferation upon the func- 
 tion of the kidney it is not unlikely that by exerting a pressure 
 upon the capillaries of the glomeride it diminishes the quan- 
 tity of urine secreted, especially as in Langhans's cases such a 
 diminution occurred, and especially also as proliferation of the 
 interstitial tissue in conti'acted kidney is attended by an opposite 
 result; and alterations of the epithelium of the tubules are 
 not necessarily attended by such results. The haemorrhages 
 which sometimes occur in the Malpighian body where these 
 alterations exist, Langhans would locate, not in the capillaries 
 of the glomerule itself, but in those of its capsule, since the 
 blood is not found on the surface of the glomerule, but be- 
 tween the layers of the thickened capsular epithelium. 
 
 Next, as to alterations in the glomerule-epiilielium, it is 
 found that in inflamed kidneys the epithelium is not so readily 
 removed in shreds, but rather in isolated cell elements; in
 
 96 BRlGin's DISEASE. 
 
 Other words, the cement substance uniting the cells seems to 
 be dissolved, and the cells are probably also less closely ad- 
 herent to the capillary loops. The cells themselves are very 
 little altered, in some instances swollen; and when this is the 
 case, the thicker nucleated })ortion of the cell is exclusively 
 involved, and forms prominent button or clublike processes, 
 which are attached to the convexity of the capillary loop, 
 sometimes by a broad base, and sometinaes by a delicate 
 
 Fig. 31. 
 
 I 
 I 
 
 De.squaniative gloiuerulo-iiephritis. X 300. The .surface of the capillaries, the 
 details of which are omiited iu thediawing, is covered with numeioiia ctUs. — After 
 
 L.\NGHANS. 
 
 pedicle. This may separate completely, leaving the free nu- 
 cleated portion as an independent cell between the capsule and 
 the glomerule. Although the number of these is usually 
 small, they may be so numerous as to enlarge and change the 
 shape of the -Malpighian body to an oval whose longer axis is 
 parallel with the medullary rays and nearly .3 mm. (g'^ inch) 
 in leng^th. These cells are even sometimes found between 
 the lobules of capillary vessels which make up the glomerule 
 so as quite distinctly to separate them. 
 
 This condition, so far as the swollen state of the cells is con- 
 cerned, is not infrequent. Langhans has never failed to see 
 them in connection Avith the large white kidney. lie also 
 found it in a single case of acute nephritis along with marked
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 97 
 
 hsemorrliages from the glomerule and conspicuous thickening 
 of the capsular epithelium ; also in a slight degree in granular 
 atrophy of the kidney. On the other hand, in five cases of 
 scarlatinal nephritis he failed to find any considerable swelling 
 of the glomerule-epithelium. A single case of large white 
 kidney, with hypertrojihy of the left ventricle, attended during 
 life by a very copious (4000-5000 cc, 133-166 f.5) highly 
 albuminous urine and numerous casts. Langhans thinks a 
 good deal of light has been shed upon it by this condition of 
 the glomeruli, in which alone the case differed histologically 
 from other large white kidneys. To this he thinks may be 
 referred the extraordinary increase in the c|uantity of urine, 
 while the condition itself may be compared to a desquama- 
 tive catarrh of the mucous membrane, which is in like manner 
 attended by the exudation of a highly albuminous exudation. 
 He does not, however, venture a decided opinion, since he lost 
 the most favorable opportunity for investigating the condition 
 of the capillaries. I cannot myself comprehend why such a 
 proliferation should increase the quantity of urine, but would 
 rather expect that it would operate similarly to the overgrowth 
 of the capsular epithelium to compress the glomerule, and thus 
 diminish the quantity of urine secreted. 
 
 Finally, as to changes in the capillary nuclei, according to 
 Langhans these are by no means so rare as the silence of 
 modern literature on the subject would lead one to suppose, 
 although for their recognition more careful investigation is 
 necessary than for the recognition of either of the two already 
 considered. To this end complete isolation of the capillaries 
 from each other and from the epithelium is essential, and is 
 accomplished by means of dissection with and without artifi- 
 cial injection of the vessels. Even by low amplification a dif- 
 ference is observed between these Malpighian bodies in which 
 the capillary nuclei are altered and those in which there is a 
 proliferation of the epithelium. The glomerule is enlarged 
 (.2 to .35 mm., y.Jg to i^\ inch), and fills closely the entire 
 cavity of the capsule, appearing, especially in the fresh 
 condition, as a compact intensely clouded mass. But in hard- 
 
 7
 
 98 
 
 BRIGHT S DISEASE. 
 
 ened preparations its peculiar subdivisions are easily recogniza- 
 ble. The epithelium of the glomerule as a rule exhibits 
 simply swelling, especially the nuclear portion, as well as a 
 marked extension of the single cells whose convexity has a 
 radius considerably longer than normal, corresponding to the 
 increased lumen of the capillary. The capillaries themselves 
 are increased in diameter to .03 mm. (g^ inch). After re- 
 moval of the epithelium of the glomerule, the lumen of the 
 capillaries is found more or less occupied by a cloudy, finely 
 granular substance, which sometimes contains a few and some- 
 times a large number of minute fat-drops, takes up carmine, 
 clears up and swells somewhat on the addition of acetic acid. 
 In it are found numerous small round nuclei, .006 to 
 .008 mm. (^j^gg to syV^^ inch) in diameter, exactly similar 
 to the normal capillary nuclei, and quite different from the 
 large oval epithelial nuclei. They are separated from each 
 other by a distance equal to half their own diameter. That 
 
 
 % 
 
 <X^ 
 
 Capillary loops with proliferation of the nuclei, the epithelium being retained only at a. 
 X 300.— Alter Lanohans. 
 
 these nuclei truly lie in the finely granular mass and are 
 not adherent to the capillary wall, is seen at points of 
 rupture, or still better on pressure, when nuclei and fine 
 granular matter well-up without breaking up into single cells. 
 These capillaries are still pervious to blood, but a higher 
 pressure than usual is required to fill them, even then with but
 
 ACUTE PARENCHYMATOUS NEPHRITIS. S9 
 
 partial success. The extreme resistance results in a dilatation 
 of the vas afferens outside of the Malpighian capsule and of 
 the aiferent arteries. Langhans found the diameter of the 
 former vessel from a boy twelve years old who died of acute 
 nephritis, .06 mm. (^ig- inch) in diameter, the normal in an 
 adult being .014 to .02 mm. (ttW to xyVo inch). From 
 this resistance also result extravasations of blood into the 
 capsule through the walls of the first branches of the vas 
 afferens. Later, this finely granular mass appears to fuse 
 more intimately with the membrana propria of the capillary 
 M^all and acquires the same optical properties as it. This 
 j)roccss, although apparently independent of the nuclei of the 
 capillary walls, Langhans calls " proliferation of the capillary 
 nuclei." He also remarks that evidence is wanting as to 
 whether the colorless corpuscles share in the process. 
 
 As to the circumstances under which these alterations occur, 
 Langhans has never found them absent in the large white kid- 
 ney, all the glomeruli being affected. He has also found them 
 in acute nephritis, in one case along with proliferation of the 
 capsular epithelium. Upon scarlatinal nephritis he had, how- 
 ever, made no observations. In granular atrophy the altera- 
 tion is absent as a rule ; it may be present, however, as a stage 
 preliminary to contraction. 
 
 The influence of this nuclear proliferation of the capillaries 
 upon the secretion of urine is difficult to determine in conse- 
 quence of important alterations in the other elements of the 
 kidney. It is very probable that it may cause a diminution 
 in the quantity of urine secreted, and in this Bartels agrees 
 with Langhans. 
 
 After carefully examining this subject I cannot but think 
 that the proliferation of capillary nuclei is the same condition 
 as that described by Klebs as a proliferation of the nuclei of 
 the interstitial connective tissue of the glomerule, but which 
 Langhans has been unable to discover. Klebs's drawing in his 
 Pathological Anatomy, p. 646, is very coarse and difficult of 
 interpretation. Both authors describe a nuclear proliferation 
 imbedded in a granular matrix, but while Klebs puts it out-
 
 100 briuiit's disease. 
 
 side of the bloodvessels, Langhans puts it within. The 
 question is by no means an easy one to settle, and I would 
 not pretend to decide which is correct. I have carefully 
 studied preparations in which this nuclear proliferation in the 
 glomerule was marked, but by the optical means at my disposal 
 could not decide upon their exact seat. Reasoning from the 
 fact that they were accompanied by a general nuclear prolif- 
 eration in the situation of the connective tissue elsewhere in 
 the kidney, it would appear likely that they should occupy 
 it here in the glomerule. But Langhans's work seems to have 
 been carefully done, and the difficulty of artificial injection as 
 well as the dilatation of the afferent vessels point to the cor- 
 rectness of his views. Further researches are necessary to 
 settle the question. In either situation the proliferation would 
 necessarily have the effect of diminishing or suppressing the 
 secretion of urine. 
 
 Symptoms and Course of Acute Pare7ichymatous Nephritis. 
 
 The mode of onset of acute nephritis is not uniform, but 
 among the symptoms earliest noticed is slight swelling or 
 puffiness in the face, below the eyes. This oedema rapidly 
 extends to the upper extremities and trunk, and thence, if the 
 disease does not abate, into the lower extremities and ab- 
 dominal walls. In the male, the scrotum and prepuce are 
 favorite seats of swellinof. I have known the latter in a little 
 child to be so great as to obstruct the passage of urine and re- 
 quire catheterization, and that of the scrotum to result in 
 sloughing. The great serous sacs are the last to fill with fluid 
 in acute nephritis, although in bad cases ascites not unfre- 
 quently occurs, while there may also be transudation into the 
 pleural and pericardial cavities. The degree assumed by the 
 general anasarca is sometimes enormous, resulting in the ex- 
 tremest distortions. The eyes may be actually closed by the 
 swelling, and movement of the lower limbs rendered almost 
 impossible. Dropsy does not always follow the order here 
 named. Much depends upon the position of the patient.
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 101 
 
 Thus if he be upon his feet, the latter may be the first to swell, 
 or if he be lying in the recumbent position, the back may be 
 the seat of the first swelling. 
 
 Simultaneously with, and sometimes earlier than the drop- 
 sical symptoms, is a diminution in the quantity and alteration 
 in the qualify of the urine. The former may amount to actual 
 suppression. The latter is manifested by alteration in color, 
 specific gravity, sediment, and chemical composition. 
 
 First, as to color, instead of the normal amber or lemon-yel- 
 low hue, the urine presents, if acid in reaction, as it always is 
 in this disease when freshly passed, a peculiar smoke-hue, due to 
 the presence of a small amount of blood. This peculiar hue is 
 difficult of further description, although once recognized is 
 always remembered. As stated, it requires an acid reaction 
 for its production, and the same urine alkalized presents a 
 brighter red color. The smoke-hue also becomes red if the 
 quantity of blood is large, which is not often the case ; but here 
 again the peculiar tint returns if the blood is allowed to sub- 
 side. If the urine is very small in quantity, and there is much 
 sediment, the former is turbid, and may have a brownish tinge. 
 The bloody urine of acute Bright's disease disappears sooner 
 or later before the other acute symptoms subside, and may 
 reappear. 
 
 The specifie gravity of the urine at first is high, 1025 to 
 1030, partly due to the diminished quantity and partly to the 
 admixture of blood. Later, if the symptoms abate, the specific 
 gravity diminishes with the increase in the quantity. Or if 
 the disease lasts for any length of time, or passes over into the 
 chronic form, a similar reduction in weight occurs ; this may 
 result in a specific gravity of as low as 1010. 
 
 As to chemical composition, the chief alterations is in the 
 presence of albumen. This is generally large, the urine often 
 solidifying on the application of heat and acid, while it con- 
 stantly contains more than half its bulk. This albumen is 
 derived in part from the extra vasated blood, and in part is a 
 result of the inflammatory action. 
 
 I have already referred to the carelessness of expression often
 
 102 bright's disease. 
 
 used in indicating the quantity of albumen. Thus it is said 
 that albumen is 50 or 75 per cent, when this proportion of the 
 bulk tested is intended. In point of fact it is rare that more 
 than a haff of one per cent, of albumen is found in acute ne- 
 phritis when accurately determined by gravimetric measures. 
 These are rarely used on account of the time required for their 
 use. Pains should, therefore, be taken to indicate exactly what is 
 intended. The actual amounts of albumen found in acute ne- 
 phritis, though relatively large, may be as low as .2 of one per 
 cent. Bartels reports a case in which the albumen reached 
 1.525 per cent., or 12.962 grams (200 grains) in twenty-four 
 hours. 
 
 Xext in importance is the reduction in the amount of urech 
 which is invariable until convalescence sets in. The degree of 
 diminution is, on the other hand, quite variable. There is a 
 good deal of range, within the limits of health, in the quantity 
 of urea eliminated in twenty-four hours — from 20 to 40 grams 
 may be admitted in the adult. In a case reported by Dickin- 
 son the amount declined to .72 grams (11.1 grains) in twenty- 
 four hours; in another, by Rosenstein, to 1.4 grams (21.5 
 grains) ; in another, by Bartels, to .8 of one per cent, (normal 
 .015 to .03). More frequently the amount is reduced to one- 
 fourth or one-half the normal. Such diminution, if large, is 
 of the gravest importance, as some of the most serious symp- 
 toms depend upon it. 
 
 In general it may be said of the other normal constituents 
 of the urine, uric acid, phosphoric and sulphuric acid, chlorine, 
 etc., that they are all diminished, but no clinical significance 
 attaches to such diminution. 
 
 As to sediment, the urine of all cases of acute parenchyma- 
 tous nephritis deposits a sediment which in the early stages, 
 at least, is copious and brownish or reddish-brown in hue; 
 later it may diminish in amount and assume a lighter color. 
 Ilieroscopieal examination reveals this deposit to be made up 
 mainly of casts of the uriniferous tubules, free cells from these 
 same tubules, blood-corpuscles, red and colorless, and very 
 constantly crystals of uric acid, together with granular urates.
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 103 
 
 Tlie casts include the varieties known as epithelial casts, blood 
 casts, hyaline casts, and dark granular casts. The hyaline 
 casts are probably pure, fibrin. The epithelial consist of the 
 same material, to which epithelial cells of the tubules and blood- 
 corpuscles have become attached. The epithelium thus at- 
 tached, as well as that which is found free in the urine, is 
 variously altered. Some of the cells are merely the scat of 
 cloudy swelling, others are decidedly granular, while others 
 again are converted into compound granule-cells, or exudation 
 cells, by complete fatty degeneration. The latter indicate 
 such extreme derangement of nutrition from pressure, re- 
 moteness of the cell from its blood supply, or other cause of 
 loss of balance between the nutriens and nutrlendum, that fatty 
 metamorphosis occurs. Casts containing a few oil-drops may 
 also be present ; but much oil is not found until the case has 
 continued for some time, in fact become chronic. 
 
 Acute parenchymatous inflammation of the kidneys is rarely, 
 if ever, so intense that suppuration results ; so that pus is almost 
 never found in the urine from this cause. There may be an 
 increased number of leucocytes which have passed through the 
 capillary walls into the tubules during the inflammatory process, 
 and thence down the tubules with such urine as may be secreted, 
 but the number is rarely so great as to constitute pus. I, at 
 least, have never known it to occur. The blood found in the 
 urine doubtless comes from the ruptured bloodv'cssels of the 
 Malpighian glomerule. 
 
 Along with the diminished quantity of urine is often met a 
 disposition to frequent micturition, the efforts at which are 
 only partially successful, resulting in the emission of from 
 a few drops to a tablespoonful. This frequent desire to pass 
 water is a purely reflex symptom, the bladder being free from 
 disease. It sometimes precedes, in point of time, all other 
 symptoms. 
 
 The train of nervous symptoms usually known as urccmic, 
 and ascribed to the accumulation of excrementitious substances 
 in the blood, does not invariably present itself. When present, 
 however, it adds a phase of gravity which dare not be over-
 
 104 bright's disease. 
 
 looked. We should, therefore, be always on the alert to recog- 
 nize them. 
 
 The first of these usually observed is drowsiness, which may 
 be sudden or gradual in its onset, and may be slight or pro- 
 found. From the latter degree the transition is easy to the 
 next symptom, that of coma, which is indeed notliing but a 
 profound sleep from which the jiatient may or may not be 
 temporarily aroused. Alternating with the latter may be epi- 
 leptoid convulsions, wdiich are the most alarming and dangerous 
 symptom of Bright's disease. This is not always the succes- 
 sion of these symptoms. Convulsions most frequently succeed 
 drowsiness, but as often precede coma, and they may occur 
 without being preceded by drowsiness while the child is play- 
 ing and to the unsuspecting parents convalescing. Indeed 
 there may be no suspicion of Bright's disease whatever until 
 convulsions suddenly seize the child and possibly continue 
 with alternating coma, and no return to consciousness until 
 death closes the scene. Drowsiness, in like manner, may be 
 the first symptom of the renal disease to attract attention, 
 others being overlooked or possibly even absent. The convul- 
 sions exhibit every grade of movement, from the slightest 
 twitching to the most violent epileptiform spasm. 
 
 Impairment of vision or actual blindness suddenly occurring 
 is another symptom of acute uraemia, which sometimes super- 
 venes upon other symptoms of urseraia, or it may itself usher 
 in the unfortunate complication. This blindness, it must be 
 remembered, is something altogether different from that which 
 is the result of organic retinal changes, which are rare in acute 
 nephritis, but common in some of the chronic forms. The 
 exact cause of this blindness, in acute uraemia, is as yet unde- 
 termined. 
 
 Headache and irritability of temper are occasionally due to 
 uraemia, wdiile nausea and vomiting are not infrequent. They 
 show themselves at different stages and in different degrees. 
 When vomiting accompanies scanty or suppressed urine, the 
 vomited matters sometimes exhibit a urinous odor, the elements
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 105 
 
 of urine, more particularly urea and its derivative, ammonium 
 carbonate, being thus supplementally eliminated. 
 
 Itching of the skin is another symptom sometimes present 
 in unemia. It is probably due to the irritant action of the 
 urea upon the nerves of the skin as it is being supplementally 
 eliminated by that organ. That such increased elimination 
 takes place is attested by that rare, but still unquestioned oc- 
 currence in which the entire integument is covered with a frost- 
 like coating which has been found upon analysis to be crystals 
 of pure urea. 
 
 Another rare symptom of uraemia, which belongs rather to 
 the uriemia of chronic renal disease, is asthma, uncmic asthma 
 as it is called. This is a true asthma, a spasmodic contraction 
 of the bronchial tubules, accompanied by the usual labored 
 breathing, which occurs in paroxysms, most frequently at 
 night, and which break up with the appearance of copious 
 frothy secretion just as in the ordinary spasmodic asthma. 
 The view that these attacks are ureemic in origin is sustained by 
 Bartels,* Dickinson, f and Allbutt,J but denied by Rosenstein. 
 They are to be distinguished from paroxysms of dyspnoea due to 
 (jedema of the lung, which u not infrequent in acute nephritis, 
 by the absence of the fine, moist rales which attend the latter; 
 and from other conditions involving the lungs and pleura, by 
 the absence of the physical signs present in these conditions. 
 Of course it is not impossible for nephritis to happen to an 
 asthmatic whose attacks would then occur as before, indepen- 
 dent of the ursemic cause, or might be increased in frequency or 
 rendered more unmanageable by the latter. 
 
 The symptoms of acute parenchymatous nephritis which 
 have been detailed are those which may be considered most 
 essential to its recognition. There are, however, others which 
 are less peculiar to it, or occur also in other diseases. These 
 should be referred to in order to give completeness to our pic- 
 ture. 
 
 * Bartels, op. citat., p. 111. 
 
 t Dickinson, op. citat., p. 177. 
 
 X Allbutt, British Med. Journ., September, 1877.
 
 lOo bright's disease. 
 
 One of these \s fever. It would be expected that in inflam- 
 mation of the kidney, as in inflammation of any organ, there 
 would be fever. Such is the case. But two circnnistances 
 combine to make this symptom of little diagnostic value. In 
 the first place, it is of itself not very marked, and in the second 
 there is very constantly fever in scarlatina to which it is so often 
 superadded, and the increment thus resulting is not sufficient 
 to demark it from such variations in temperature as the orig- 
 inal disease itself is subject to. Of course, the fever of an acute 
 idiopathic nephritis, resulting from exposure to cold, would be 
 more promptly noticed, but here, again, there is nothing dis- 
 tinctive about it. 
 
 Pain over the region of the kidney is another of these symp- 
 toms. It is more frequently absent than present, and when 
 present it is not great. More frequently it may be elicited by 
 strong pressure. When present it may radiate from its central 
 seat to the groin and surface of the thigh. 
 
 Again, acute nephritis, after scarlatina, may be ushered in 
 by vomiting, which is probably the result of a reflex irritation 
 of the stomach, and is quite independent of that which has 
 been referred to as the result of ursemia. Obstinate derange- 
 ment of digestion may result from the same cause, which is 
 particularly manifested when an attempt is made to use solid 
 food. 
 
 On the other hand, some of the best-known and most con- 
 stant symptoms are sometimes wanting. This is the case with 
 dropsy, which is occasionally absent, especially in cases fol- 
 lowing diphtheria. But still more remarkable are those very 
 rare cases in which albuminuria and casts, one or both, are 
 wanting. This unquestionably happens in grave cases, for 
 short periods of time, but has never been known to exist 
 throughout a case where examinations have been repeated and 
 continued. Bartels, during an epidemic which prevailed in 
 1853-54, met a feio cases in which dropsy set in after scarlet 
 fever, although the urine passed by the patients contained no al- 
 bumen. In all these cases very little urine was secreted, in 
 one, only two tablespoonfuls in the twenty-four hours ; very
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 107 
 
 soon affcncards a more abundant excretion of bloody urine set 
 in, while the dropsy increased and the cases passed through the 
 course of scarlatinal nephritis. Henoch reports a case, which 
 is quoted by Bartels, wherein a boy of twelve, three weeks 
 after having had scarlatina, was admitted to the Charite, in 
 Berlin, with oedema of the face and scrotum. His urine was 
 scanty, acid, deposited a sediment, but was free from aJbximen. 
 The microscoj)e " revealed no elements which would indicate 
 the existence of a nephritis," the sediment consisting entirely 
 of amorj)hous urates which disappeared on the application of 
 heat. During the next two days the oedema increased, but 
 the urine remained unchanged. At the end of this time, at 
 night, he had a violent convulsion followed by unconscious- 
 ness. The next day the urine, drawn off by catheter, contained 
 a large amount of albumen and hyaline casts beset with fat- 
 granules. He died two days later and the autopsy revealed 
 well-marked parenchymatous nephritis in both kidneys. In 
 another case of anasarca after scarlet fever, described by He- 
 noch, the urine for two weeks sometimes contained albumen 
 and sometimes not. The only explanation of these cases 
 is that suggested by Bartels, that in the spread of the ne- 
 phritis over the organ, portions become involved to the extent 
 of actual suppression of urine while others remaining healthy 
 secrete the onlv urine w^hich enters the bladder. Of course 
 such a thing would be impossible if the entire area of both 
 kidneys is involved, which ordinarily happens sooner or later. 
 Here we must have either entire suppression or albuminous 
 urine. It is possible also that in acute nephritis we may have, 
 temporarily, albuminuria without casts, and casts without al- 
 buminuria, but such conditions must be very temporary and 
 exceptional ; and the statement of M. Phillippe, referred to by 
 Dickinson as quoted by Jaccoud, that of sixty patients affected 
 with scarlatinal dropsy, there was not one in whom there 
 was albuminuria is simply absurd. I have already shown 
 (p. 59) how in convalescence the albumen may disappear 
 before the casts contained by the tubules had all escaped. 
 On the other hand, the proportion of casts varies greatly;
 
 108 bright's disease. 
 
 generally quite numerous, they are sometimes scanty. Albu- 
 men, although also varying in amount, may generally be said 
 to be abundant, notwithstanding the small gravimetric per- 
 centage alluded to. 
 
 There are no symptoms by which the alterations in the Mal- 
 pighian corpuscles which have been described under the term 
 glomerulo-nepliritis are recognizable. We only know that 
 they are most frequently found in those dying of acute ne- 
 phritis, and that in such cases suppression of urine is a con- 
 stant symptom, while the occurrence of this symptom is well 
 explained by the histological changes which the Malpighian 
 body has suffered. 
 
 Tlie duration of acute nephritis is very variable — from a 
 few days to many months and even years. The former class 
 of cases are usually fatal, for very few which recover do so in 
 a few days. The most rapid usually require a month. As to 
 the cases of longer duration, the possibility of recovery at any 
 time cannot be denied, but nothing is better determined than 
 that the longer the duration the more difficult the cure. Of 
 course such cases cannot be spoken of as acute. An interest- 
 ing question presents itself: Where shall we draw the line of 
 demarcation between acute and chronic parenchymatous ne- 
 phritis ? A good histological landmark would seem to be the 
 superaddition to parenchymatous changes those of the inter- 
 stitial tissue, that is, the presence of intertubular nucleation. 
 But this, too, may occur at a very variable period. It has been 
 observed as early as at ten weeks, but I should not call a case 
 chronic that had lasted for this length of time. Perhaps six 
 months might be considered a suitable period, as by this time 
 intertubular changes are probably established in all cases. 
 
 Complications. 
 
 These are not numerous in acute as compared with chronic 
 Bright's disease, and some which are described as complications 
 are not really such, but local symptoms. Thus, oedema of the 
 
 I 
 I 
 
 I
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 109 
 
 lungs occurs as a part of the general tendency to dropsy, and may 
 be a grave symptom resulting in death by suiFocation. It is not 
 the result of an intercurrent bronchitis. Pneumonia, on the 
 other hand, is an occasional legitimate complication. Inflam- 
 mation of the serous membranes is more truly a complication, but 
 not every case in which there is effusion into a serous cavity is 
 of such a nature. Such are, again, local dropsies. . But inflam- 
 mation of serous membranes is rather more prone to occur, 
 while the exudate is apt to assume a purulent character, thus, 
 also, increasing the gravity of the case — indeed causing its fatal 
 termination. Pleurisy is the most frequent form of this in- 
 flammation, pericarditis next, and peritonitis next. 
 
 Hypertrophy of the heart is not a frequent complication of 
 acute nephritis. It is a well-recognized one of chronic Bright's 
 disease, and is ascribed by some to the impurity of the blood 
 and consequent resistance of the arterioles to its admission into 
 them, and by others to the resistance to the movement of the 
 blood through the diseased kidney. In either event time is an 
 essential condition to its production. It is not, therefore, until 
 the kidney disease has existed for some time that it can ordi- 
 narily occur. Hence in true acute nephritis it would not be 
 present. If, however, the disease be much prolonged, so as to 
 become subacute or chronic, it may present itself. It occa- 
 sionally happens, however, that the hypertrophy occurs earlier. 
 Thus Dickinson reports a case recognized at eight weeks, and 
 confirmed by post-mortem examination at ten weeks, in a 
 child of seven years. In children the heart hjqiertrophies 
 more rapidly than in adults. 
 
 Allusion has been made to the gastric symptoms which very 
 commonly attend acute nephritis, especially after scarlet fever. 
 Dr. Fen wick* and Dr. Wilson Foxf have shown that these 
 are associated with orranic chano-es in the structure of the 
 stomach. Dr. FeiiAvick characterizes these as gastritis, as 
 evidenced by increased vascularity of the mucous membrane, 
 
 * Fenwick, Samuel, The Morbid States of the Stomach and Duodenum, 
 1868, p. 177. 
 
 t Fox, Wilson, Medico-Chirurg. Transac, vol. xli, p. 361,
 
 110 bright's disease. 
 
 distension of the tubes Ijy a confused mass of cells and gran- 
 ular matter, and occasional thickening of the basement mem- 
 brane. To these Dr. Fox has added thickening of the inter- 
 tubular tissue. 
 
 Notwithstanding the frequency of convulsions in acute ne- 
 phritis, structural alterations in the brain are almost unknown. 
 Apoplectic effusions do not occur in most cases, probably 
 because of the comparative structural integrity of the blood- 
 vessels of the brain in the young, in whom the disease mainly 
 occurs. 
 
 In like manner the blindness which not infrequently occurs 
 as a symptom of urremia, is unattended by retinal changes, nor 
 does that condition known as albuminuric retinitis occur in 
 acute parenchymatous nephritis except with the extremest 
 rarity. 
 
 Diagnosis. 
 
 The diagnosis of acute parenchymatous nephritis is ordi- 
 narily quite easy. The previous history, the usually easily 
 recognizable cause, the suddenness of the attack, the scanty 
 and bloody urine with its high specific gravity, the copious 
 albuminuria, the blood and epithelial and dark granular casts, 
 the blood-corpuscles, free epithelium and compound granule- 
 cells in the urine, — these are a combination of symptoms 
 which admit of only one interpretation. At a later stage, the 
 absence of one or more of these symptoms may somewhat 
 increase the difficulty, but it is scarcely possible to err if those 
 which remain are duly considered. It must be remembered 
 also that an acute condition, such as this described, may 
 supervene upon any one of the chronic forms of Bright's 
 disease to be described. 
 
 It is very desirable for the sake of treatment that the renal 
 complication caused by scarlet fever should be recognized at 
 the earliest possible moment. To this end the test of Dr. ]Ma- 
 homed for minute traces of haemoglobin Mhich are present in 
 the pre-albuminuric stage of scarlatina will be found invalu- 
 able, provided his views are sustained. According to him, the
 
 ACUTE PARENCHYMATOUS NEPHRITIS. Ill 
 
 first result of the high vascular tension which forms part of 
 the nephritic process, is the transudation of a minute trace of 
 hsemoglobin, before the albumen makes its appearance. In- 
 deed the test is inoperative when albumen is present in the 
 urine. Dr. Stevenson's modification of the test,* acknowl- 
 edged by Mahomed to be the more brilliant in its results, is 
 performed as follows : To a drop or two of urine in a small 
 test-tube, add one drop of the tincture of guaiacum and a few 
 drops of ozonized ether ; agitate, and allow the ether to collect 
 at the top. If haemoglobin be present, the ether carries with. 
 it the blue color that is produced, leaving the urine colorless 
 below. The discovery thus made, according to Dr. Mahomed, 
 often enables the practitioner to avert the inflammation by a 
 brisk purge or copious sweat. The test will also respond just 
 after the albumen has disappeared, as well as just before it 
 shows itself. Saliva, nasal mucus, iodine in minute quanti- 
 ties, all strike a blue color with tincture of guaiacum, some 
 without and some with ozonic ether. Their presence should 
 therefore be guarded against. 
 
 Prognosis. 
 
 ' Grave as is justly considered this disease, recoveries from it 
 are numerous, and the prognosis is generally favorable. Even 
 without treatment cases are known to have recovered, and 
 much may be accomplished by a judicious treatment. The 
 prognosis should, however, always be guarded, as insidious 
 causes may produce death when it is least expected. Among 
 the most important of these is uraemia, and I can best illustrate 
 my meaning by narrating a case: 
 
 A child about five years old had an imperfectly developed 
 attack of scarlatina, which was considered simple sore throat, 
 and he was allowed to go out of the house in winter weather. 
 Dropsy supervened, and the mother carried him to a homoeo- 
 
 * Dr. Mahomed's original test may be found in the author's Manual on 
 the Practical Examination of Urine, 3d ed., 1880, p. 73.
 
 112 briqht's disease. 
 
 path, "vvlio failed to appreciate the condition or its cause. He 
 prescribed, hoNA'ever, directing the child to return. He did 
 so several times, growing constantly more cedematous. I 
 was finally asked to visit him, when I found enormous 
 ftidema throughout the body. A little examination satisfied 
 me as to its cause. The smoky urine was highly albuminous, 
 almost solidified on use of heat and nitric acid, and contained 
 blood- and epithelial casts, with numerous blood-corpuscles. 
 He was placed on appropriate treatment, when the dropsy and 
 albumen diminished. He was a wilful boy, and his indulgent 
 parents again allowed him to be exposed to cold. The dropsy 
 increased, and the albumen as well. So great was tlie oedema 
 of the prepuce that his urine had to be drawn, and so difficult 
 the introduction of the catheter that it was finally allowed to 
 remain. The scrotum was also enormously swollen, and 
 sloughing ensued. Under appropriate treatment, however, all 
 these symptoms subsided ; the catheter was no longer required, 
 the albumen rapidly diminished, and the quantity of urine was 
 sufficiently abundant. I saw him at 2 p.m. of a Saturday, and 
 believed him to be convalescent. Between five and six of the 
 same evening, after slight vomiting, he became suddenly un- 
 conscious. I did not reach him for several hours ; but all 
 effiarts were unavailing, and he died at one o'clock following. 
 Very careful questioning of the mother elicited that he 
 seemed a little drousy on the previous day, but was jiarticu- 
 larly bright on the afternoon in which coma supervened. 
 
 Bartels says that death from uraemia has never occurred in 
 his experience, except when the disease has resulted from scar- 
 latina or diphtheria ; but Dickinson narrates a fatal case re- 
 sulting from exposure, in which death was preceded by coma 
 and other symptoms of evident uraemic origin.* 
 
 Pulmonary oedema is another of these causes of sudden 
 death, the patient drowning as it were in his own secretions. 
 Its onset is characterized by shortness of breath, frothy expec- 
 
 * Op. citat., p. 75-78.
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 113 
 
 toratlon, and abundant small rales. Purulent exudation into 
 the serous cavities may also precipitate death. 
 
 The symptoms of gravest import are therefore those of 
 ursemia, manifested in any one or all the various ways, the 
 presence of any of the complications alluded to, and especially 
 supjjression of urine. Cases should not, h(jwever, be despaired 
 of even when there is complete suppression of urine. My 
 friend Dr. Wharton Sinkler reports a case of recovery in which 
 there was suppression of urine for five days, following scar- 
 latina.* Always, however, suppression of urine is the gravest 
 of symptoms, and death generally ensues within a couple of 
 days after it sets in. The possibility of sudden death should 
 always be borne in mind, and mentioned to the relatives 
 of the patient, although the number of cases in which this 
 occurs is not very great. Of course the longer the duration 
 of the case, the less the likelihood of recovery. 
 
 Treatment. 
 
 There is no doubt that many cases of acute nephritis re- 
 cover while the conditions of rest, quietude and warmth are 
 maintained. And it is further certain that, whatever other 
 means of treatment are used, these three conditions are abso- 
 lutely necessary to recovery. A patient with acute Bright's 
 disease, therefore, whatever its mode of origin, should be put 
 to bed, kept quiet, and warmly covered. 
 
 I should seldom, however, be satisfied with this mode of 
 treatment alone. The selection of other remedies will depend 
 somewhat upon the severity of the case. If the urine be sup- 
 pressed, dry cups, or in severe cases, cut cups to the loins, will 
 so divert the blood as to permit a relief to the stagnation which 
 always exists in the acutely inflamed kidney. These cups 
 should be followed by a warm, moist poultice to the same 
 region, which, indeed, should be used under any circum- 
 stances, whether the cupping is necessary or not. Poultices 
 
 * American Supplement to the Obstetrical Journal of Great Britain and 
 Ireland, Dec, 1878.
 
 IIJ: brigut's disease. 
 
 should, therefore, always be resorted to, and if the symptoms 
 are at all severe, — that is, where there is complete or almost 
 totiil suppression of urine, nausea, headache, or delirium, — 
 should be preceded by cupi)in<^. Although at first thought 
 it would seem that the kidneys are quite remote from the 
 seat whence the blood is immediately removed, it must be 
 remembered that we are relieving the blood pressure in the 
 lumbar arteries which come off from the aorta near the renal 
 arteries, and thus divert the blood from the latter. Under 
 all ordinary circumstances, dry-cupping is sufficient ; cut- 
 cupping should be reserved for the most extreme symptoms, 
 where the strength of the patient has not been previously 
 reduced. Some care must, however, be exercised in the use 
 of dry-cupping, lest we defeat its end. The object of dry- 
 cupping, as justly observed by Dr. G. .Johnson, is to facilitate 
 the movement of the blood through the capillaries into the 
 veins, — to draw the blood rapidly through the part, and thus 
 relieve the pressure of the blood in the renal vessels. To do 
 this, the cups must be removed as soon as there is a decided 
 redness, and placed on another part in the vicinity. By allow- 
 ing them to remain too long, the blood is stagnated in the 
 capillaries, its onward movement prevented, and there is, there- 
 fore, no derivation of blood from the involved organ. 
 
 The above means have for their object the direct relief of the 
 congestion of the kidney. But this is not the only indication 
 while the kidney is congested. The congestion, in some in- 
 stances, is altogether due to an excess of work thrown uj)on it 
 in consequence of suppressed or deficient action of the skin, 
 and in all cases the carrying out of the natural function of the 
 organ tends to increase any existing congestion. Can the kid- 
 ney be in any way relieved of this functional irritation ? Are 
 there any organs, in other words, which can supplement the 
 kidney ? The bowels and skin are such organs. A second 
 indication, therefore, is to increase the action of these. 
 
 First the bowels. Purgatives are useful in aiding the relief 
 of congestion as well as to secure a complemental act of secre- 
 tion, and for these purposes they should always l)e employed.
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 115 
 
 But the reason for which I early employ a purgative is not 
 more for either of these objects than to promote the action of 
 other remedies, a purpose which applies not only to the treat- 
 ment of Bright's disease, but also to that of all diseases. It is 
 a well-known fact in the absorption of fluids, borne out by the 
 phenomena of osmosis, that this does not take place rapidly 
 when the bloodvessels are congested and there is a slowly- 
 moving current. The well-known experiment of Magendie 
 beautifully illustrates this. This consisted in injecting into 
 the peritoneal cavity a colored fluid, which at first was not ap- 
 preciably absorbed, but which, on opening a bloodvessel, dis- 
 appeared rapidly before his eyes. The treatment of any case 
 of acute Bright's disease is therefore well commenced by the 
 use of a cathartic, and after its effect the prompt action of other 
 remedies may be looked for. Indeed, it is almost useless to 
 administer any remedies before some action is obtained from 
 the bowels, as they will be many hours in producing their 
 effects ; whereas after such influence they will be as many 
 minutes. For these purposes an aperient should be given 
 early in ordinary cases of acute Bright's disease. The purgative 
 most suitable for this is a saline. A simple dose of bitartrate or 
 sulphate of potassium, of magnesia for children, or citrate of 
 magnesium, or epsom salts for adults will be sufficient. The 
 indication is to get a watery stool as soon as possible. In view 
 of the fact that the stomach is often sensitive, it is desirable 
 to use an aperient which is not nauseous or irritating, and 
 to this end, some one of the delicate effervescing preparations 
 so common in modern pharmacy may be used. 
 
 Next, or simultaneously, we have to promote the action of 
 the skin. This is favored by the maintenance of warmth and 
 avoidance of cold, already insisted upon. But we are not con- 
 fined to these protecting measures. The skin may be made to 
 do the work of the kidney itself, and thus one of the most 
 alarming dangers of Bright's disease, ureemic intoxication, 
 averted, while at the same time the congestion of the kidney 
 is also relieved. 
 
 The class of remedies Avhich produce this action are diapho-
 
 116 bright's disease. 
 
 retics ; and, of the simple remedies, none is better than the ordi- 
 nary sweet spirit of nitre, especially if it be eomV)ined with neu- 
 tral mixture and small doses of ipecacuanha. If more active 
 measures are required, some one of the preparations of jaborandi 
 may be used; the dose varying with the effect it is desired 
 to obtain. If moderate diaphoresis only is desired, doses of 
 from ten to fifteen drops of the fluid extract may be given to 
 adults every two hours, and increased, if necessary, until the 
 effect is brought about. To children, five to ten drops may be 
 given in the same manner. The further use of this important 
 remedy, and its active principle, pilocarpin, will be again re- 
 ferred to in treating the effects of uramia. 
 
 Another method of accomplishing the same end is by icarm 
 baths, or, better still, by the so-called warm or cold pack, 
 in which the patient is wrapped in a wet sheet and then en- 
 velo}>ed in a sufficient number of blankets. Perspiration is 
 thus copiously induced, and when thus caused, is agreeable, 
 and never attended by the faintness which sometimes follows 
 the use of the hot-air bath, — another means of accomplishing 
 the same end, which will be further considered under the 
 treatment of chronic Bright's disease. In an ordinary severe 
 case of acute Bright's disease, a single pack of this kind will 
 remove all symptoms which may cause anxiety, and happily 
 inaugurate the convalescence, while it may be repeated daily, 
 if necessary. 
 
 Nothing has been yet said of the use of diuretics, which are, 
 perhaps, the first means thought of by most practitioners in 
 the treatment of Bright's disease, acute or chronic, and, no 
 doubt, in many cases they deserve an early consideration. 
 Yet the propriety of their use has been much disputed, and at 
 first thought there would seem to be legitimate objection to 
 them in the treatment of acute nephritis ; for with the idea of 
 increased secretion of urine is generally associated that of an 
 increased flow of blood to the kidney. And the question 
 naturally arises, shall a kidney already congested and inflamed 
 be further jeopardized by crowding more blood into it ? 
 
 On the other hand, it is well known that convalescence in a
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 117 
 
 case of acute Bright's disease which has been left to recover 
 without treatment is always ushered in by a most copious 
 diuresis. This is usually explained by the fact that urea 
 itself is a decided diuretic, as may be shown by injecting it 
 into the bloodvessels of any animal, — an operation which is 
 followed b}^ coj)ious diuresis. In the early stages of Bright's 
 disease the urea and other organic constituents are retained 
 in the blood, and when the circulation through the kidney 
 becomes free, they exert their diuretic action. It will be 
 observed, however, that this takes place only after the circula- 
 tion becomes free, and it must be looked upon, therefore, not 
 so much as a cause, as a result of an improvement in the 
 condition of the organ. Nevertheless, to facilitate such a 
 condition of affairs as copious secretion of urine, and with it 
 the elimination of those eifete matters the accumulation of 
 which constitutes the chief danger of Bright's disease, — urae- 
 mia, — can only be considered desirable if it can be done with- 
 out exciting congestion of the kidney. 
 
 The secret in the proper use of diuretics lies in the selection 
 of such as effect their object without producing a stagnation ; 
 and such there are. To understand this properly, it must be 
 recalled that the secretion of urine is largely a process of filtra- 
 tion, a process of squeezing out the water and dissolved ele- 
 ments by pressure from behind, and that this is accomplished 
 in the Malpighian bodies by the agency of the arterial pressure 
 and the force of contraction of the heart. It must be remem- 
 bered that there are two sides to the renal capillary circulation, 
 an arterial side and a venous side. The first consists in the 
 afferent arteriole, and the capillary ball contained in the di- 
 lated end of the convoluted tubule, and forming with the latter 
 the Malpighian body ; the second, of the capillary network 
 formed by the splitting up of the efferent vessel after it leaves 
 the Malpighian capsule, and closely embraces the convoluted 
 tubules. The area of this is great, and the movement of the 
 blood slow. As a consequence, a condition favorable to in- 
 creasing the blood-pressure in the Malpighian body exists. 
 Such pressure is obtained by increasing the force of the heart's
 
 118 bright's disease. 
 
 contraction, or increasing the arterial pressure by the introduc- 
 tion of fluids within the bloodvessels. The effect of this is to 
 produce a more rapid filtration ; that is, more water is squeezed 
 out from the bloodvessels into the Malpighian capsules, 
 whence it is carried downward in the tubules. Now, whatever 
 remedies increase the force of the heart's action, or the arterial 
 pressure by absorption of fluids, will increase the amount of 
 water thus filtered out. Such remedies are digitalis, the .sa- 
 lines, and diluent drinks generally, — digitalis by increasing 
 the force of the heart's action, the salines and diluents by in- 
 creasing blood-pressure through their absorption. 
 
 Digitalis is certainly the diuretic most to be relied upon, and 
 Avhen combined with the salines, freely diluted, affords a power- 
 ful lever for good. It is necessary, however, to have a reliable 
 preparation, and unless one is sure of the quality of the tincture, 
 it is best to use a freshly prepared infusion. At the same time 
 it is also true that much smaller doses of the tincture are 
 usually given than of the infusion. Thus, of the lat-ter, f oSS. 
 is often administered, equivalent to three and three-quarter 
 grains, while eight minims or sixteen drops of the tincture, 
 equivalent to one grain of the powder, are considered a full 
 dose, a discrepancy which must account for at least a portion 
 of the diminished effect of the tincture. Digitalis should 
 therefore be given in sufficient quantity, — foss. to f 5i of the 
 infusion to children, and f5ij to f.^ss. to adults, — repeated 
 every three hours until an appreciable effect is produced on 
 the rate of the pulse, when it should be diminished. Not until 
 then can we look for a diuretic action. Digitalis, when thus 
 administered, should, of course, be watched, and the patient 
 should be seen twice a day until an effect is produced. I prefer 
 to give it at first alone. Of the salines with which it may be 
 combined, acetate, citrate, and bitartrate of potassium are to be 
 preferred. Their diuretic action doubtless depends upon the 
 impetus they give to the osmosis of fluids which hold them in 
 solution, thus increasing the arterial tension and contributing 
 to the flushing of the kidney. To adults half a drachm of 
 these may be given every two or three hours freely diluted,
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 119 
 
 because water itself is an excellent diuretic; ten grains to chil- 
 dren as often. There can be no doubt that an increased filtra- 
 tion of water into the Malpighian capsules aids the separation of 
 the organic constituents in the second capillary network referred 
 to, both by facilitating osmosis, and by washing out from the 
 secreting cells of the convoluted tubules the organic matter 
 already excreted by them. 
 
 Another admirable diuretic combination, including all of 
 these elements, is Trousseau's diuretic wine, wdiich consists of: 
 
 Junip. contus, ........ ^x 
 
 Pulv. digitalis, ^ij 
 
 Piilv. scilise, 5J 
 
 Vin. xerici, ........ Oj. 
 
 Macerate for four days and add 
 Potas. acetatis, . 5iij. 
 
 Express and filter. 
 S. Tablespoonful three times a day for an adult. 
 
 By such means as these, after the unloading of the blood- 
 vessels by the action of a purge, we may greatly serve our 
 patient by diuretics. 
 
 On the other hand, turpentine, cantharides, copaiba, and 
 the class of diuretics which produce a congestion and stagna- 
 tion of blood in the second or venous capillary network, are 
 mischievous, and should not be employed. 
 
 Infusion of digitalis may also be used in the shape of fomen- 
 tations. Cloths wrung out in hot infusion of digitalis and 
 laid over the abdomen of the patient, have been known to 
 produce diuresis when all other measures have failed. But 
 this is not likely to be called for in mild cases. 
 
 The diet of patients with acute Bright's disease, while it 
 should be nutritious, should be of the simplest and most easily 
 digestible character. The irritability of the stomach in this 
 disease has been alluded to, and it is important that it should 
 not be excited. Milk may be considered the typical food, not 
 merely because of its easy assimilation and nutritious character, 
 but because there is abundant testimony to prove that albu- 
 minuria diminishes under its use, while the proportion of urea 
 contributed to the blood is less than by animal flesh. While
 
 120 bright's disease. 
 
 solid animal food is not to be recommended, there is no reason 
 why animal broths and beef teas should be precluded, pro- 
 vided it is desirable to break up the monotony of a milk diet. 
 Rice and farinaceous preparations generally, are suitable ad- 
 juvants to the milk diet. The combination of lime-water, and 
 still better of carbonated water with milk, should not be over- 
 looked in the treatment of the sensitive stomach. 
 
 Treatment of Acute Urcemia. — The alarming and dangerous 
 character of the symptoms of this condition lead me to a sep- 
 arate consideration of the measures required in their treatment. 
 The treatment which has just been described is such as would 
 be called for by an ordinary case of acute nephritis of a decided 
 character. The tendency of it will be to prevent the retention 
 of those effete matters, whatever their precise nature, which 
 constitute the essence of uraemia, while it is not intended to 
 reduce the patient by secreting and purging. But notwith- 
 standing all of our efforts in this direction they sometimes fail, 
 and we are called upon to contend against convulsion or coma, 
 or more frequently both in alternation. How shall they be 
 met? The indication has already been explained. It is the 
 retention of effete urea and its allies which causes the uraemia. 
 These must therefore be gotten rid of. The kidneys are not 
 acting and the secretion of urine is suppressed. There remain 
 therefore but the bowels and skin to operate upon. But the 
 patient is unconscious and cannot swallow voluntarily. Such 
 remedies must therefore be used as do not require his co-opera- 
 tion. These are croton oil and elaterium. Of the former two 
 drops, slightly diluted with plain oil or glycerin, or in case 
 of extreme necessity undiluted, may be introduced into the 
 mouth, whence it is quickly absorbed. Its operation may be 
 facilitated by a rectal injection. Of elaterium a quarter of a 
 grain in powder may be introduced into the mouth. 
 
 In like manner the skin may be made to substitute the ac- 
 tion of the kidney. At the present day jaborandi is the most 
 efficient agent by which to accomplish this. The most con- 
 venient method is by subcutaneous injection of its active prin- 
 ciple pilocarpin. For an adult one-third of a grain of the
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 121 
 
 dissolved muriate thus administered, is generally sufficient to 
 excite the most profuse diuresis and salivation within half an 
 hour. Should it not, the dose may be repeated. In the 
 absence of pilocarpin the freshly prepared infusion of jabo- 
 randi may be injected into the rectum, with almost equally 
 prompt results. Care must be taken to keep the bulk within 
 limits lest it be rejected. Four ounces of hot water may be 
 poured upon a drachm of jaborandi leaves, and when suffix 
 ciently cool strained and injected. The doses here referred 
 to are intended for adults. My friend Dr. Horace Williams 
 has used the fluid extract in suppository, with excellent results. 
 A fluid drachm may be inspissated and put into a single sup- 
 pository. They should be reduced in size, for children, suit- 
 ably to the age. 
 
 I have never seen any of the extreme prostration which is 
 said sometimes to result from the use of jaborandi. There is 
 undoubtedly a feeling of weakness and relaxation after a copious 
 sweat from this as from other causes, which may be combated 
 by stimulating and supporting measures where they can be 
 applied, but under the urgent circumstances here supposed this 
 needs not be considered. Dysuria is said to occur occasionally, 
 resulting from jaborandi. 
 
 Should these measures produce their physiological results of 
 purgation and sweating, without relief to the urgemic symptoms, 
 they may be repeated in four to six hours. 
 
 The hot-air bath, warm-water bath, and warm pack which 
 were our sole resources for these purposes before jaborandi 
 and its preparations came into use, may still be used if the 
 latter fail or are not at hand. The hot-air batli is easily 
 used. A tin pipe two or three inches in diameter with an 
 expanded extremity under which a spirit-lamp is placed, while 
 the other end is placed under the bed clothing, will answer 
 the purpose very well. An ordinary rain-spout may be used. 
 The warm pack or bath is not so available in acute urisemia 
 because of the unconsciousness of the patient and his inability 
 to help himself. Sometimes even the hot-air bath fails to 
 make them perspire, and all efforts seem unavailing.
 
 322 brigut's disease. 
 
 Under tliese circumstances I should not licsitate to take a 
 small quantity of blood from the arm for the relief of urajmic 
 convulsions and coma, provided the patient is not too feeble. 
 No one doubts the efficiency of bleeding in puerperal convul- 
 sions, and if puerperal convulsions are urfemic as I believe they 
 mainly are, then bleeding should be of service in the urseraic 
 convulsions of acute Bright's disease. My friend. Dr. Hiram 
 Corson, of Conshohocken, Pa., is the only physician I have 
 known to bleed in the convulsions of acute nephritis after scar- 
 latina, but he informs me that he has done so with great ad- 
 vantage. I wish to be clearly understood, I do not advocate 
 bleeding for the cure of the nephritis. It is simply suggested 
 as a rational measure for the relief of the convulsions when 
 other measures fail. 
 
 The hydrate of chloral should not be forgotten ; indeed it is 
 one of the most valuable remedies for convulsion, and should 
 be one of the first measures tried. In the case of an adult, 
 a drachm may be injected into the rectum in solution; fifteen 
 to thirty grains for a child. Its use is sometimes followed by 
 the promptest favorable results. 
 
 The use of ojnum requires to be alluded to. The caution 
 which has always' been suggested in its use I believe to be, in 
 the main, a wholesome one, and I should prefer to produce 
 hypnotic, sedative, and antispasmodic effects by chloral and 
 the bromides whenever it is possible. I am sure I have seen 
 death accelerated in one case of {previously unsuspected chronic 
 Bright's disease, in which large doses of opium were exhibited 
 for another purpose, — overdoses, in fact, but quite insufficient 
 of themselves to })roduce the fatal result, which was preceded 
 by ura^mic stupor. After death the urine was drawn by a 
 catheter and found to be albuminous, and a post-mortem ex- 
 amination revealed a contracted kidney. It is well known that 
 Professor Loomis, of New York, treats with apparent success 
 cases of ursemic convulsions with hypodermic injections of large 
 doses of morphia (one-half grain or more), doses which I would 
 fear to use under ordinary circumstances in the absence of 
 renal disease.
 
 ACUTE PARENCHYMATOUS NEPHRITIS. 123 
 
 Treatment of Complications. — Conij^lications should be treated 
 by remedies called for by such conditions indef»endent of the 
 renal cause. Effusions into the pleural cavities and abdomen 
 are often best relieved by paracentesis, or aspiration; pneu- 
 monia and bronchitis by counter-irritation. 
 
 These same measures which have been detailed, excepting 
 the general bloodletting and chloral, may also be employed in 
 the treatment of suppression of urine or of obstinate dropsy 
 without urjemic symptoms, M'ith such modifications as circum- 
 stances may suggest, due regard being paid to the strength of 
 the patient. They will be further referred to when discussing 
 the treatment of the chronic forms of Bright's disease. 
 
 Sooner or later also, in the treatment of acute parenchyma- 
 tous nephritis, supporting treatment is rendered necessary to 
 repair the losses which the blood suffers by the albuminuria, 
 and to some extent also by the depleting measures of treat- 
 ment. These effects should indeed be anticipated by proper 
 diet, tonics, quinine, especially iron, wine, malt liquors, 
 whiskey, or brandy as indicated. These measures will also be 
 more particularly alluded to in the treatment of chronic Bright's 
 disease.
 
 124 brigeit's disease. 
 
 SECTION YI. 
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 
 
 Synonyms. — Chronic tubal nephritis; chronic catarrhal neiihritis; chronic difl'use 
 nephritis; large white kidneys. 
 
 CHRONIC PARENCHYMATOUS NEPHRITIS IS A CHRONIC 
 HYPERPLASTIC PROCESS IN THE KIDNEY, WHICH HAS ITS 
 ESSENTIAL AND PRIMARY SEAT IN THE EPITHELIUM OF THE 
 TUBULES, BUT IN WHICH INTERSTITIAL CHANGES OF THE 
 NATURE OF NUCLEAR PROLIFERATION ARE ALSO MORE OR 
 LESS CONSTANTLY PRESENT. 
 
 Etiology. 
 
 The etiology of chronic parenchymatous nephritis cannot 
 always be traced. While it is frequently a simple continuation 
 of a process which begins as acute parenchymatous nephritis, 
 more frequently it originates de novo. To the former category, 
 scarlatina and pregnancy contribute the greater number. Of a 
 certain number of the second category, the causes are undis- 
 coverable. Habitual exposure to cold and moisture doubtless 
 produces some cases. Residence in damp houses may thus 
 cause it. Chronic suppuration, such as occurs in bone dis- 
 ease, phthisis, tertiary syphilis, psoas abscess, etc., are among 
 the causes of this, as well as of the lardaceous form of chronic 
 Bright's disease. 
 
 Long-continued exposure to malaria is now a recognized 
 cause of chronic parenchymatous nephritis. Indeed, Bartels 
 says that next to chronic suppuration it is the most frequent cause, 
 but I have never myself been able to trace a case to this cause. 
 Dr. S. C. Busey, of Washington, D. C, presented a paper at 
 the session of the American Medical Association, in 1880, on 
 " Malaria as a cause of Bright's Disease in Children." T. 
 Koike published a case of nephritis from malaria, in the Tokei 
 MedicalJournal, March 27th, 1880. 
 
 Although alcohol is not a common cause of chronic paren- 
 chymatous nephritis, yet I cannot but think that the chronic
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 125 
 
 nephritis which we find in confirmed drunkards, those who 
 are always saturated with whiskey when they can get it, owes 
 its presence to the latter agent. To be sure it cannot be denied 
 that the exposure to which these outcasts are subjected, may 
 be the cause. 
 
 That mercury is a common cause of chronic nephritis, as was 
 believed by the older physicians, is denied by Bartels, who bases 
 his denial upon the most extended experience in the use of mer- 
 cury for syphilis in the hospital at Kiel. 
 
 In all the modes of origin of chronic nephritis the rationale 
 would seem tot)e that some noxious agent in the blood, whether 
 introduced from without or retained there from deficient action 
 of the skin, produces the alteration in the kidney by a slow 
 but constant irritation of the epithelium which attempts to 
 remove it. 
 
 3Iorbid Anatomy. 
 
 There are two distinct stages in the morbid anatomy of 
 chronic parenchymatous nephritis, if the disease is of sufficient 
 duration, viz., the stage of enlargement, or the large ichite kidney, 
 and that of contraction, or the fatty and contracting kidney. 
 
 I. Stage of Enlargement. — There are few more striking ob- 
 jects in morbid anatomy than a typical example of the large- 
 white kidney, as the product of this stage of chronic parenchy- 
 matous nephritis is called. The kidney is large, smooth, white, 
 or slightly tinged with yellow ; weighs generally from seven to 
 ten ounces, but is often much heavier. It is usually doughy, 
 sometimes elastic in consistence. 
 
 TTie capsule, which may be thinner than in health, strips oif 
 easily, but occasionally drags a little of the parenchyma with 
 it. When the smooth white surface thus uncovered is examined, 
 the little capillary circlets bounding the lobules in the normal 
 organ are in some places indistinct, in others conspicuous ; the 
 same is true of the stellate veins of Verheyn. Numerous 
 yellow specks are seen scattered ov^er the surface. Hsemor- 
 rhagic extravasations are also occasionally present, but very 
 much more rarely than in the acute form. Alongside of these 
 the greater translucency of more nearly normal areas results 
 also in a mottled hue.
 
 126 briqht's disease. 
 
 On section it is at once evident that the enlargement resides 
 altogether in the cortex, which is at the same time markedly 
 ana}raic, its intense white contrasting strongly with the pink hue 
 of the cones, which, though paler than in health, are much less 
 so than the cortex. Closer examination of the cortex reveals 
 the same yellow specks found on the external surface. They 
 contribute, with similar alterations less decided, to form a 
 series of dull white striie which alternate with somewhat 
 broader translucent strife radiating towards the surface ; the 
 former correspond to the area of the convoluted tubules and 
 Malpighian bodies, — the labyrinth, — the latter to that of the 
 medullary rays. In consequence of extreme swelling of the 
 masses of convoluted tubes which dip down between the cones, 
 as seen in longitudinal section, there may be produced the 
 same sheaf-like distortion of the latter which was referred to 
 as sometimes occurring in acute parenchymatous nephritis. 
 
 The pelvis of the kidneys in chronic parenchymatous nephritis 
 is the seat of catarrhal swelling and a slight degree of hyperaeraia. 
 
 Minute Change. — Microscopic examination of thin sections 
 shows the involvement of both tubes and intertubular substance. 
 Turning our attention first to the former, many are found 
 choked with o;;ranular cells and the g-ranular debris of cells, cans- 
 ing them to appear, under the microscope, as black opaque lines 
 by transmitted light, very similar, indeed, to the tubes in acute 
 nephritis. In other situations the tubules are filled with fat- 
 globules and cells in a state of fatty degeneration. Again, the 
 two elements are combined. In places the lumen of the tubes 
 is preserved, in others not. In other situations the cells 
 are nearly normal. Tlie parts presenting a yellow tinge are 
 those in which the fatty elements have replaced the normal, 
 and this is the composition of the yellow specks already alluded 
 to as visible to the naked eye. They reoresent a coil of tu- 
 bules filled with oil-drops or fatty cells.* 
 
 Here, again, certain tubules contain casts, usually of the waxy 
 
 * Very great differences are noted in different kidneys in the amount of 
 oil present in the cells, which liave never been satisftictorily explained. Dick- 
 inson says the cells have a greater tendency to be fatty when cold is the cause.
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 127 
 
 kind. Sometimes, indeed, they are very numerous. Rarely 
 hsemorrhagic extravasations are al"o found in the tubules. 
 
 The capillaries of the cortex are completely or nearly empty 
 of blood, which has been expressed from them by the dis- 
 tended tul)ules. To this, it need hardly be said, is due the 
 extreme whiteness of these kidneys, whence the name by 
 Avhich they are known. The Malpighian capillaries are 
 subject to the changes already described, of proliferation of 
 capillary nuclei ; so, too, the alterations of the epithelium of 
 the glomeruli there described may also be present as well as 
 those of the capsular epithelium. From the first would re- 
 sult thickening and more or less opacity of the capillary walls. 
 The muscular walls of the afferent arterioles are sometimes 
 hypertrophied, and the \ essels dilated in consequence of the 
 resistance to the entrance of blood into the glomerule, but 
 general arterial hypertrophy is not constant in this st^ge of 
 the disease. The intertubular capillaries and veins present 
 no changes except those already referred to as the result of 
 the compression by the distended tubes. 
 
 The mcdidlary cones in chronic parenchymatous nephritis 
 are more altered than in the acute form, but the changes in 
 them are quite secondary in importance, and their microscopic 
 appearance is scarcely altered. They are sometimes a little 
 paler, owing partially to a granular and fatty alteration in the 
 cells lining the straight tubules, and partly to the presence of 
 similar cells pushed down from the convoluted tubules above 
 them. On the other hand, they may even be slightly deeper 
 in hue from congestion. The straight tubes of the cones as 
 well as the looped tubes of Henle often contain waxy casts. 
 
 In chronic jxirenchymatons nephritis the interstitial tissue 
 is always altered, and, it may be said, proportionately to 
 the duration of the disease. It has already been said that 
 any case of parenchymatous nephritis, sufficiently prolonged, 
 is attended by a hyperplasia of connective tissue cells, al- 
 though it is difficult to say when this overgrowth begins. 
 Langhans reports* a case in which death, occurring five 
 weeks after the appearance of the first symptoms directly 
 
 * Loc. citat., p. 105.
 
 128 bright's disease. 
 
 traceable to a thorough wetting, the stroma was markedly 
 thicJcened. And in a case of Dickinson's already alluded 
 to, intertubnlar cellular formation, "though approximating 
 as much to pus as to fibre," was found within six weeks of 
 the outset. Again, cases of much longer duration may be en- 
 tirely without it. Interstitial fibrosis may, however, be con- 
 sidered as a superaddition of chronicity, and wherever a 
 case is distinctly chronic it may be inferred, with t( Jerable 
 certainty, that it is present. 
 
 The interstitial change is generally conceded to be the result 
 of the long-continued hyperemia. But it will have been 
 observed that it does not usually make its appearance until 
 the primary hypersemia begins to decline, and although the 
 latter may contribute, in a degree, yet I am inclined to think 
 it is rather the result of a secondary hypersemia, induced by 
 the irritation of the cellular accumulations in the tubules. 
 These act as foreign bodies and induce interstitial hyperplasia, 
 just as the cheesy collections excite interstitial hyperplasia in 
 the lungs, where catarrhal products in the bronchial tubules 
 are always, sooner or later, attended by interstitial change. 
 
 In this overgrowth the thickness of the trabecule of tissue 
 between the tubules varies extremely, being sometimes so slight 
 as to be discoverable only on microscopic examination of thin 
 sections ; at others it is appreciable to the naked eye. 
 
 Minute examination reveals the thickened trabecule to con- 
 sist of numerous round and oval nuclei, between which may 
 be a homogeneous or more or less distinctly fibrillated intercel- 
 lular substance. 
 
 II. The Stage of Atrophy — The Fatty and Contracting 
 Kidney, or the Large Contracting Kidney. — The interstitial new 
 formation above referred to possesses all the characteristics of 
 new connective tissue formed elsewhere. It invariably ex- 
 hibits a tendency to contract, and in doing so, it gradually 
 distorts the shape of the previously enlarged organ, while it 
 obliterates also a variable quantity of its tubular structure. 
 The degree of this distortion varies greatly, increasing with 
 the duration of the process. The kidney continues as large and
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 129 
 
 even larger tlian the normal organ. It is, however, smaller 
 than the large white kidney, uneven, lobulated, but never 
 presents the hobnailed or granular appearance of the kidney of 
 interstitial nephritis. Its capsule does not strip oflP easily as 
 from the large smooth organ, but drags with it considerable of 
 the tubular structure. The capsule removed, however, the sur- 
 face of the kidney exhibits, between the constrictions, the same 
 pallid speckled appearance, distinct stellate veins, etc., already 
 described ; and on section the same enlarged antemic cortex. 
 
 Mkrosropically, sections exhibit the same alternation of 
 groups of normal and choked tubules already described, along- 
 side of other places in which the tubules together with the Mal- 
 pighian bodies at their extremities are obliterated. Between 
 them is found a large amount of interstitial tissue, and the 
 Malpighian bodies are surrounded by concentric layers of the 
 same. Even minute cysts, the result of obstruction of tubules 
 by the constricting tissue, are found. These will be more fully 
 described when we come to consider the contracted kidney 
 of interstitial nephritis, with which also this stage of atrophy 
 in chronic parenchymatous nephritis will be more carefully 
 contrasted. 
 
 It not infrequently hapjiens that along with the changes 
 constituting chronic parenchymatous nephritis, are found, to 
 a certain extent also, those of lardaceous disease. Thus in a ' 
 large white kidney, the Malpighian bodies will often strike the 
 mahogany red reaction with iodine, characteristic of this con- 
 dition, although the alteration may not be recognizable by the 
 naked eye. Occasionally the alteration may even affect the 
 afferent and efferent vessels. This secondary amyloid change 
 is ascribed, by Dr. George Johnson, to the exhaustive drain 
 which is constituted by the long-continued albuminuria, such 
 drains, as will be more fully considered under lardaceous dis- 
 ease, being the common cause of this disease of the kidney.
 
 130 bright's disease. 
 
 Symptoms of Chronic Parencliymxxtous Nephritvi. 
 
 There are few distinctive symptoms of chronic })arenchyma- 
 tous nephritis, but by a thorough investigation of the case in 
 all its bearings a diagnosis may generally be made. 
 
 Dropsy is, however, almost always present, and it is very apt 
 to be general, at least involving the subcutaneous connective 
 tissue generally — the face, hands, feet, legs, thighs, and trunk. 
 The serous sacs also frequently contain fluid, almost always in 
 severe cases. But dropsy is not always thus general. It may 
 be confined to the extremities or to the face, and in a case now 
 under my observation, where the diagnosis is peculiarly sus- 
 tained by the characteristics of the urine, the dropsy is confined 
 to the scrotum, which is enormously swollen, while there is no 
 oedema elsewhere. It is not impossible that dropsy may be 
 entirely wanting, but as a rule no symptom is moi'e constant, 
 and none gives the patient so much inconvenience, as this one 
 of dropsical swelling. His legs and thighs are twice their nor- 
 mal dimensions. They are so heavy he cannot lift them, while 
 they are often excoriated, and moist with exuding serum, and 
 smarting with irritation. Very frequently, as the result of 
 spontaneous rupture of the skin, the discharge of serum is pro- 
 fuse, saturating the bedclothing, and even dropping upon the 
 floor ; occasionally, also, with relief to the patient. 
 
 Another very constant symptom is ancemia, producing a 
 peculiar translucent waxy appearance, which is really very 
 characteristic when present in marked degree, and Ls often alone 
 sufficient to suggest the disease. But there may be very slight 
 degrees of it which are not at all peculiar. 
 
 Again, the debility of those suffering with this condition is 
 very striking. If able to walk at all, they soon get out of 
 breath, are immediately exhausted. Locomotion is often im- 
 possible in consequence of the extreme swelling, even if the 
 strength otherwise permit it. 
 
 Now if such a patient be questioned, and it be found that he 
 took cold three or four months previous, following which im- 
 mediately was noted this dropsy, which did not disappear, or 
 which disappeared and returned; or if it be found that he had 
 scarlet fever some months or even years previous, following
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 131 
 
 which there had been swelling which had been more or less 
 continuous, — if these points are made out the diagnosis is easy. 
 For it has been a case of acute parenchymatous nephritis which 
 has become chronic. If, however, there be no such history, 
 but an insidious beginning, traceal^le to any one of the causes 
 named, or to no cause, the case is not so clear. But the urine 
 affords additional symptoms. 
 
 Condition of the Urine in Chronic Parenchymatous Nephritis. 
 — The urine is diminished, Ijut somewhat variable in quantity, 
 pale in color, of low specific gravity, highly albuminous, and 
 deposits often, but not always, a copious white sediment. 
 
 First, as to quantity. This, as stated, is diminished, but 
 quite variable, ranging from 300 to 1200 cc. (10 to 40 oz). 
 It is, however, seldom suppressed, as it sometimes is in acute 
 nephritis. The quantity of urine also increases as the patient 
 improves, or as the stage of contraction is entered upon, so that 
 it may even exceed the normal. 
 
 The specific gravity, notwithstanding the small quantity of 
 urine, is less than the average of health. It varies somewhat, 
 inversely with the quantity of urine, but the most usual range 
 is from 1008 to 1015. 
 
 The albumen, while also large, varies as to its percentage 
 amount with the quantity of urine passed — from 1 to 5 per cent., 
 or from one-half to seven-eighths the bulk of the urine tested. 
 The variation in the 24 hours' quantity of urine should always 
 be remembered. This is particularly important in testing the 
 value of various therapeutic measures, some of which, by in- 
 creasing the quantity of water passed, diminish the percentage 
 of albumen without diminishing the 24 hours' quantity. This 
 is often overlooked. The amount of albumen lost in the urine 
 is sometimes enormous. It has even occurred that the per- 
 centage proportion of albumen in the urine has exceeded that 
 in the serum of the blood from the same patient. Bartels 
 accurately determined the 24 hours' quantity in several cases 
 under his observation, and found in one instance an average 
 of 17.36 grams (267.85 grains) daily, for the last month 
 of the patient's life; in another an average of 15.28 grams 
 (235.76 grains) daily, for two months; and in a third 10.04
 
 132 brigiit's disease. 
 
 grams (155 grains), for six months. The last lost 6804 grams, 
 or about 18 pounds troy, in a period of 27 months. From 
 this may be appreciated the cnoi'mous drain upon the system by 
 this " haemorrhage " of albumen. The quantity of albumen has 
 very little effect upon the specific gravity. Indeed, the lighter 
 urines are generally those which have the larger amount of albu- 
 men, because highly albuminous urines contain little urea. 
 
 The copious white sediment is made up of variously granular 
 casts, among which the dark granular are conspicuous by their 
 numbers and size, and especially their width. There are also 
 found oil-casts, and casts containing entire and fragmentary 
 epithelial cells, which are also granular and oily. Finally, yel- 
 low waxv casts are also found. These, which are also ""ener- 
 ally of larger diameter, are of especial value in indicating 
 the chronic nature of the disease. Casts generally increase 
 in numbers with the progress of the disease, being at first less 
 numerous. They are not, however, always thus numerous, 
 being indeed sometimes wanting. Much granular debris, 
 similar to that making up the black granular casts, and prob- 
 ably therefore derived from the disintegration of epithelium, 
 is also found free in the urine. 
 
 Leucocytes are also often very numerous in the sediment of 
 chronic parenchymatous nephritis, while red corpuscles, al- 
 though occasionally present, are much less common. 
 
 The sediment, when mixed with the urine, gives the latter a 
 turbid, dirty appearance, which is sometimes permanent, but 
 when the sediment has subsided the supernatant fluid is tolera- 
 bly clear. 
 
 The normal constituents of the urine are generally dimin- 
 ished in quantity. The most important of these is urea. To 
 the reduced amount of solids, and particularly of urea, the re- 
 duced specific gravity is due. And although the quantity of 
 albumen is large, and must therefore increase somewhat the 
 specific gravity, such increase is not ordinarily sufficient to 
 compensate for the decline. 
 
 The above statements with regard to the urine are borne out 
 by my own experience; but Bartels, who has added so much to 
 our knowledge of chronic nephritis, adds some others appar- 
 
 J
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 133 
 
 ently at. variance with them. I desire, therefore, to make 
 separate mention of them. He states that at the height of the 
 disease, when the smallest quantity of urine is secreted, the 
 specific gravity is regularly above the normal.^ He has fre- 
 quently found the specific gravity of such urine above 1040, 
 higher, consequently, than the specific gravity of the blood 
 serum before it was secreted. Tliis was determined by actual 
 trial of the serum of the blood drawn from the arm at the 
 time. He also says the proportion of albumen to the specific 
 gravity is a pretty constant one, rising as the specific gravity 
 rises, and diminishing as the specific gravity falls. f 1 have 
 already said that it is the uriues of low specific gravity which 
 contain more albumen, the low specific gravity being due to 
 the small quantity of urea which these urines contain. He 
 adds, however, that the specific gravity of an albuminous urine 
 does not by any means correspond with a certain fixed per- 
 centage of albumen, while we are only justified in assuming 
 that the percentage of albumen has increased or diminished, 
 because the specific gravity has risen and fallen, when the 
 change in the latter takes place within a very short period. 
 Further observations may remove the apparent discrepancy. 
 
 Notwithstanding the small proportion of urea which is ex- 
 creted in this affection, uramiia is rare, especially so before 
 the stage of contraction is reached. And if it be asked why 
 this should be, I know no better reason than that assigned by 
 Bartels, that all the physiological sources of urea production 
 are less active. The appetite and digestion are bad, less food 
 is taken, and thus the principal source of urea in the economy 
 is cut down. Further, the nitrogenous tissues are wasted and 
 tissue change is less active, so that the urea from these sources 
 is less produced. Furthermore, some of it may be stored in 
 the abundant serum which occupies the interstices of the tis- 
 sues and the serous cavities which share in the dropsy. 
 
 Are there any symptoms by which we can recognize the 
 stage of contraction, which takes place sooner or later, provided 
 the patient lives? The most valuable evidence that this has 
 
 * Op. citat., p. 357. f Op. citat., p. 360.
 
 134 bright's disease. 
 
 occurred is the presence of hypertrophy of the left yentrlcle. 
 Altlioiigli tlie possibility of an earlier hypertrophy in children 
 cannot be denied, it is very seldom that it occurs in parenchym- 
 atous nephritis prior to the stage of contraction. From this 
 I would not have it inferred that I believe the hypertrophy is 
 caused by the contraction and the consequent difficulty encoun- 
 tered by the blood in its movement through the kidney. This 
 was Traube's view of the production of hypertrophy of the 
 left ventricle in the contracted kidney of interstitial nephritis, 
 and is held by Bartels and others. I am inclined to be- 
 lieve that the hypertrophy is due rather to the resistance to 
 the movement of the poisoned blood through the arterioles of 
 the entire system, and not the kidneys alone. This was the 
 original view of Bright. Dr. George Johnson has further 
 shown that this resistance results in a thickening of the mus- 
 cular coat of the bloodvessels, which still further augments 
 their power to resist the heart. This contracts still more 
 powerfully to overcome the increased resistance, and becomes 
 further hypertrophied. As already stated, time is required to 
 reach this stage, and by the time hypertrophy is developed con- 
 traction of the kidney is likely to have occurred. Long dura- 
 tion of the disease also aiFords presumptive evidence that 
 contraction has taken place. This cannot always be ascer- 
 tained. But if a case come under observation as a case of 
 undoubted parenchymatous nephritis, and continues under ob- 
 servation for a year or more, the process of contraction is likely 
 to have commenced. 
 
 The dropsy diminishes and may disappear as the stage 
 of contraction is entered upon. So also the urine changes in 
 its properties. The quantity, previously small, is increased, 
 while the specific gravity remains low ; the quantity of albu- 
 men is also much less than during the stage of inflamma- 
 tion. In these respects — absence of dropsy, large amount of 
 urine, and small amount of albumen — it resembles the true con- 
 tracted kidney of interstitial nephritis, with which indeed it 
 may be confounded in the absence of a previous history. But 
 the casts continue numerous, and exhibit much the same char- 
 acter that they do in the stage of enlargement, although they
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 135 
 
 too may become scanty ; and if we have not a knowledge of 
 previous history the diagnosis between contraction secondary 
 to previous enlargement, and primary contraction the result of 
 interstitial nephritis, may be impossible. 
 
 Urcemia is rather more common in the stage of contraction 
 than that of enlargement, but still comparatively infrequent. 
 When present it exhibits the symptoms already detailed under 
 acute pare nchymatous nephritis. 
 
 The duration of chronic parenchymatous nephritis is very 
 variable. Many cases terminate unfavorably within a year 
 after they have been established ; but I have one now under 
 observation in the stage of contraction which I have known to 
 exist for seven years. Another patient has just died who was 
 under my care four years. Both of these cases apparently 
 originated from cold. 
 
 Complications. 
 
 The complications of chronic parenchymatous nephritis are 
 the Same as those of acute. QEdema of the lungs, bronchitis, 
 pneumonia, inflammation of serous membranes are all liable 
 to occur. Hypertrophy of the left ventricle is more common 
 than in acute nephritis, for the reasons already referred to, 
 but still very much less so than in interstitial nephritis. 
 Derangements of digestion are very constant, probably due to 
 a more advanced stage of the structural changes described 
 under acute nephritis. The acute blindness unattended by 
 retinal changes, described as occurring in the uraemia of acute 
 nephritis, rarely occurs here, while retinal changes are rather 
 more frequent, but still uncommon compared with interstitial 
 nephritis, under which they will be described. 
 
 Diagnosis. 
 The diagnosis of the inflammatory stage or stage of en- 
 largement is ordinarily easy. The extreme pallor of the pa- 
 tient, the diminished urine of low specific gravity, the very 
 large amounts of albumen, the numerous dark granular, oil- 
 and waxy casts of large diameter, free fatty cells and compound 
 granule cells, especially if we are able to trace a history of
 
 136 brigut's disease. 
 
 long duration, all point to the disease. And if there is an an- 
 tecedent history of scarlatina or exposure to cold, pregnancy 
 or long exposure, there can be no mistake. 
 
 The symptoms of amyloid or lardaceous kidney very closely 
 resemble those of the large white kidney, and it has been men- 
 tioned that the same causes are capable of developing both. 
 Occasionally it is absolutely impossible to say which form of 
 disease is present. It has usually been considered that if there 
 is enlargement of the liver and spleen, or persistent diarrhosa, 
 and the cause is one which may produce lardaceous disease, it 
 is certain that the latter condition exists ; but recent observa- 
 tion has shown that the first two at least may be present, to- 
 gether with all the causes and other symptoms which are 
 regarded as favoring lardaceous disease, and yet the disease be 
 parenchymatous nephritis.* As a rule there is not so much 
 dropsy in lardaceous disease, casts are more scanty, and gener- 
 ally hyaline, though sometimes oil-casts are found. Some- 
 times, too, the two forms of disease coexist, either as the result 
 of the same cause, or the amyloid disease may be the result of 
 long-continued parenchymatous nephritis. 
 
 The sta2;e of contraction is more difficult of reco":nition un- 
 less we have had the case for some time under observation, 
 and are able to trace its continuation with the stage of inflam- 
 mation. The resemblance to the contracted kidney of inter- 
 stitial nephritis may otherwise be very close. But here again 
 the albuminuria is apt to be larger and the casts more numer- 
 ous, and to include the numerous varieties mentioned instead 
 of the scanty, small pale granular casts which attend intersti- 
 tial nephritis. In the latter the quantity of urine exceeds the 
 normal, while in the former, although the quantity is larger 
 than in the stage of enlargement, it is still within the normal. 
 
 Prognosis. 
 
 The prognosis of chronic parenchymatous nephritis is un- 
 favorable so far as recovery is concerned. Most cases terminate 
 
 * See an article by Dr. Paul Fiirbringer, Zur Diagnose der amyloiden 
 Entartung der Nieren. Virchow's Archiv, Bd. 71, 1877, s. 400.
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 137 
 
 unfavorably within two years after they are thoroughly 
 recognized, and sometimes within a few months. Many cases, 
 however, may be very much prolonged by treatment, and if 
 prolonged to the stage of contraction the patient may be toler- 
 ably comfortable for some time, seems indeed to have another 
 lease upon life. But sooner or later the dropsy returns, and 
 the patient dies of exhaustion. Or some one of the complica- 
 tions, or possibly uraemia, intervenes to carry him off. Of the 
 former, oedema of the lungs or of the glottis, und pneumonia, 
 are particularly dangerous. In the stage of enlargement, 
 uraemia, while it is of rarer occurrence, is also less apt to end 
 fatally than in the stage of contraction. 
 
 Treatment. 
 
 While it occasionally happens that spontaneous recoveries 
 from acute nephritis occur, this is far from the case with the 
 chronic form. Here the expectant plan of treatment does 
 not suffice. The patient with chronic parenchymatous ne- 
 phritis, if left alone, grows steadily worse, and although 
 measures of treatment may not frequently result in recovery, 
 they very often, if judicious, cause marked improvement, and 
 long avert the fatal end. 
 
 There is always an intermediate stage between that of 
 acute nephritis and the condition of the large white kidney, 
 from which recovery often takes place, which calls for a modi- 
 fication of, or an addition to, the treatment described for the 
 acute, and which is indicated by an impaired quality of the 
 blood, due partly to the gradual accumulation of effete matter, 
 and partly to the drain upon the system of the large albumi- 
 nuria. But, as it is a condition growing out of the prolonged 
 presence of the disease, it is practically covered in the treat- 
 ment of the chronic form, and requires, therefore, not to be 
 separated from it. 
 
 The chief indications in the treatment of chronic parenchym- 
 atous ne]ihritis are two : first to improve the (][uality of the 
 blood, which has become aniemic and loaded with urea and 
 allied organic compounds; and, second, to combat the symp-
 
 138 bright's disease. 
 
 toms and complications which form a source of great inconve- 
 nience and danger to the ])atient. 
 
 The first of these indications is chiefly fulfilled by the use of 
 iron, salts of quinia and strychnia, nourishing food and 
 proper hygienic influences ; and also by depurating tlie blood 
 of its retained urea. It may be laid down as a rule, to which 
 there are few exceptions, that the continuous use of some one of 
 the preparations of iron is indicated. The well-known Ba- 
 sham's mixture, really a solution of acetate of iron, and made 
 by adding to tincture of the chloride of iron, acetic acid and 
 solution of the acetate of ammonia, has the advantage of at 
 least tending to eliminate, Avhile it also strengthens.* But the 
 tincture of the chloride of iron, alone, is a powerful agent, 
 which is always accessible, and when combined with the sweet 
 spirit of nitre, is perhaps as efficient as the Bashara's mixture. 
 To either, the quinia and strychnia salts may be added, if de- 
 sired ; while to the latter the infusion or tincture of quassia 
 makes a compatible addition. 
 
 With regard to food, while it is true that an abundance, 
 and of good quality is desired, a question has properly arisen 
 as to the propriety of using the highly uitrogenized substances, 
 as animal flesh. It is now well determined that the urea 
 formed in the blood and eliminated in the kidneys is derived 
 chiefly from the azotized elements of the food, and that the 
 more nitrogenous food we consume the more urea accumulates 
 in the blood, which the kidneys in their disabled condition are 
 unable to remove. The results of reasoning have been sus- 
 tained by experience, and it has been observed that where the 
 appetite is good and large quantities of meat are eaten, ur?emic 
 convulsions have been more frequent, whereas, when the aj)pe- 
 tite has been bad, and little food taken, urremic convulsions in 
 chronic nephritis are very rare. While, therefore, it is not de- 
 sirable to omit all such food, it is desirable to limit it to mod- 
 
 * The formula for Basham's mixture, wliicli I commonly write, is as fol- 
 fows: K. Tinct. ferr. chlorid., f^ij ; Ac. acet. destillat., f^ij ; Liq. ammon. 
 acetatis, f5iij; Curncoie or synipi simpl., Aqure, aa q. s. ad f5vi: M. et 
 S. Tablespoon fill three times a day, in half a tumbler of water.
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 139 
 
 eratioii, and, while drawing elements of mixed food from the 
 vegetable kingdom, to make up the deficiency in meats by the 
 free use of milk. The good results of the milk treatment in 
 cases of chronic nephritis are now among the best acknowl- 
 edged in the treatment of the malady, as evidenced in the dim- 
 inution of albuminuria, decline in dropsy, increase in the quan- 
 tity of urine passed, and general amelioration of symptoms. 
 And of the different methods of employing milk, the* pure milk 
 diet has been most satisfactory. I find that from three to 
 three and a half quarts a day meet the requirements of an 
 adult male, this quantity having been used for months by one 
 of my patients, without any practical change in weight. The 
 milk should not be skimmed, for it is by retaining the cream, 
 that the nitrogenous principle, the casein, is maintained dis- 
 proportionately small. The better way is to drink a fixed 
 quantity at stated intervals, say, six to eight ounces every two 
 hours. As to the rationale of its operation, there is reason 
 to believe that it operates by affording an easily assimilable 
 food freely diluted, which can be taken in sufficient quantity to 
 provide the forces of the economy without surcharging the 
 blood with nitrogen. When the idiosyncrasy of the patient is 
 such that a pure milk diet cannot be borne, it should constitute 
 as large a proportion as possible. 
 
 An invariable effect of the milk diet in my experience is an 
 increase in the quantity of urine passed, which would of course 
 result in a diminished percentage of albumen, while the abso- 
 lute quantity in twenty-four hours might be unchanged. But 
 in my observations I have avoided this source of error, and 
 succeeded in demonstrating an absolute diminution in the 
 quantity of albumen passed. 
 
 Next to milk, rest is the most useful measure to ameliorate 
 the symptoms of chronic nephritis. I have frequently, by 
 means of the milk treatment, reduced the albuminuria to a 
 point beyond which, however, it seemed impossible to influence 
 it further in walking cases of chronic nephritis. The same 
 case has then been put to bed, the milk diet continued, and a 
 still further reduction of albuminuria has immediately ensued.
 
 140 brioht's disease. 
 
 A reversal of the method has been as promptly followed by 
 the opposite condition. The patient was allowed to get up, 
 the milk diet being still continued, and immediately the albu- 
 men increased. He was then allowed to use a mixed diet, 
 and as promptly a further increase in the albumen appeared. 
 The beneficial effect of rest upon oedema from any cause is too 
 well recognized to require other than an allusion. 
 
 The advantages of rest in bed are sometimes more than 
 counterbalanced by the disadvantage to the patient of confine- 
 ment and want of fresh air and outdoor life. These of course 
 must be weighed, and that one adopted Avhich serves the pa- 
 tient best. 
 
 Under hygienic measures is included suitable clothing. 
 That next the body should be of wool ; for it must be re- 
 membered that, on the one hand, the skin is a powerful ad- 
 juvant to the kidney in its eliminating operations, and, on the 
 other hand, that any interference with or suppression of the 
 action of the skin must throw more work on the kidney. Cold 
 is the agent which produces such suppression, and warmth the 
 means by which the action of the skin is encouraged ; and no 
 texture prevents the former or secures the latter more effectu- 
 ally than wool. 
 
 For the same reason, while the maximum amount of fresh 
 air is desirable, cold and dampness should be avoided or suf- 
 ficiently guarded against. 
 
 The second indication is to depurate the blood of accumu- 
 lated imparities, as well as to combat the symptoms and com- 
 plications Avhich cause inconvenience or jeopardize life. These 
 symptoms are those of dropsy, effusions into the serous cavi- 
 ties, and congestions. The patients suffering from them are 
 usually confined to the house, or go out of it at such great in- 
 convenience as to make it intolerable to do so. Of dropsy 
 there is abundant evidence to the naked eye ; but of the neces- 
 sity of depuration there is, unfortunately, no direct means of 
 estimation except by a volumetric analysis of urine, which 
 involves so much trouble and care as scarcely to be possible to 
 the general practitioner. Fortunately, however, the means
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 141 
 
 which are best calculated to relieve the one are most likely to 
 relieve the other. These measures are, in addition to diuretics, 
 such as promote a more decided action of the skin than any 
 yet alluded to, and certain purgatives. 
 
 With regard to diuretics, nothing need be added to what has 
 been already said, bearing in mind that digitalis is our most 
 powerful lever. But with regard to measures which promote 
 a decided action of the skin, I desire to add a little more. 
 These are the loarm bath, warm-pack bath, and the hot-air 
 bath already alluded to. The latter, in consequence of its 
 more ready application, is to be preferred whenever it can be 
 borne. Previous to the introduction of jaborandi, I used a 
 great deal in my wards at the Philadelphia Hospital, the hot- 
 air bath, and made some observations to determine its value. 
 The results of these satisfied me that we have a much more 
 useful agent than many of us have suspected. A patient with 
 large white kidney was under my observation for more than a 
 year. During a portion of this time his urine was carefully 
 measured, and a portion of the twenty-four hours' urine ana- 
 lyzed for urea by Liebig's volumetric process, which was re- 
 peated to insure accuracy. He was a very large man, passing 
 copiously of urine, and the quantity thus arrived at was 35 grams 
 (540 grains) ; the total quantity of urine being 2000 cubic cen- 
 timeters (66| f S). He was then ordered a hot-air bath daily, 
 during which he perspired most freely. The twenty-four hours' 
 urine was of course diminished ; but on estimating the urea in 
 the twenty-four hours after the sweating had been continued 
 three days, it was found to be 46.3 grams (714 grains) in 1700 
 cubic centimeters (56| f 5) urine, — actually an increase over the 
 amount secreted when not using the baths. This can be ac- 
 counted for by the increased celerity of the circulation ^vhich 
 would naturally result. If we add to this the amount of urea 
 contained in the increased perspiration, which was of course not 
 determined on account of the difiiculties of collection, we will 
 perceive how powerful a means of depurating the blood of its 
 urea is thus at our disposal ; and I am cpiite certain that if the 
 use of the hot-air bath were more common, our power over
 
 142 bright's disease. 
 
 Bright's disease would be greater. There is a common im- 
 pression that it is troublesome and difficult of application. 
 But this is not the case with the simple appliance descriljed 
 M'hen discussing the treatment of acute nephritis. Still simpler 
 is it to j)lace the patient upon a chair having a perforated seat, 
 placing a spirit-lamp under the latter, and covering the patient 
 and chair by an india-rubber waterproof. Sometimes, how- 
 ever, these hot-air baths are not well borne by patients ; they 
 do not perspire, the head and face become flushed, and the 
 former throbs and aches. The latter symptoms may often 
 be relieved by tying a wet handkerchief about the head, as is 
 done in the Turkish bath. In the event of failure, however, 
 the "warm" or "cold-pack " may be used, or the warm bath. 
 In the former the patient is wrapped up in a wet sheet, either 
 warm or cold, and further enveloped in a sufficient number 
 of blankets. A very comfortable sweat generally ensues. In 
 the use of the warm bath the patient is immersed in it at a 
 temperature of about 40° C. (104° F.), and kept there from 
 half an hour to an hour. He is then removed and wrapped 
 in blankets. 
 
 These measures may be resorted to on alternate days, or for 
 a short time daily. It may be objected that they are exhaust- 
 ing to the strength of the patient; but- 1 think they will be 
 found less so than is commonly supposed. Due regard should, 
 of course, be paid to this tendency, and the strength of the 
 patient may at the same time be maintained by alcohol, milk, 
 iron, and tonics. 
 
 It has been said under the treatment of acute parenchyma- 
 tous nephritis that these effects are more conveniently and as 
 efficiently brought about by the use of jaborandi and its de- 
 rivative |>t7ocarpm. The directions for their use, given in con- 
 nection with acute nephritis (p. 116), need not be repeated here. 
 They may be used about as often as the baths, usually on alter- 
 nate days, occasionally daily, with advantage. 
 
 The use o^ purgatives for depurative purposes and to reduce 
 the dropsy has long been common in the treatment of chronic 
 nephritis, and to this end it has been common to select a pecu-
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 143 
 
 liar class of purgatives, viz., those which produce profuse 
 watery evacuations, as elaterium, scammony, gamboge, and 
 jalap. In addition to the indications to relieve general venous 
 congestion with a view to promoting absorption, the advantage 
 to be derived from the use of a brisk, prompt cathartic has 
 already been alluded to in speaking of the treatment of acute 
 Bright's disease. But it must be remembered that in the cir- 
 cumstances now under consideration it is not a temporary cause 
 the effects of which we desire to obviate, but a constantly act- 
 ing one, so that to be of service the purgative must be con- 
 tinued day after day, or every other day at least. Now, such 
 use of the hydragogue cathartics above mentioned cannot be 
 continued for any length of time without materially reducing 
 the strength of the patient, much more decidedly than by the 
 daily sweat. I do not deny their effect in diminishing the 
 dropsy. On the other hand, I have many times observed this 
 effect, and in some I have observed the dropsy totally disap- 
 pear, — but with it the strength of the patient to such an extent 
 that as the dropsy subsided the life of the patient went out with 
 it. I am not, therefore, very partial to the continued use of 
 cathartics in chronic Bright's disease. But it is to the prolonged 
 use that I refer. To relieve a sudden emergency, as the occur- 
 rence of urpemic symptoms, — in a word, under the same cir- 
 cumstances under which I would use them in acute Bright's 
 disease if they could be administered, — would I give them. 
 So, too, it may be sometimes of advantage to alternate their 
 use with the sweat treatment referred to. 
 
 Of the remedies mentioned, undoubtedly the one which most 
 strikingly produces the desired eifect is elaterium. The profuse 
 painless discharges which it effects in doses of one-tenth to one- 
 fifth of a grain are well known, while the small quantity re- 
 quired makes it peculiarly easy of administration. 
 
 But in most cases of chronic nephritis, a stage is finally 
 reached at which all treatment of the kind described fails to 
 relieve the dropsy, which becomes eventually the sorest burden 
 of the malady. The body becomes greatly increased in weight, 
 the integument of the extremities is stretched almost to burst-
 
 144 brioht's disease. 
 
 ing, and sometimes it does rupture, when it is attended by a 
 leakage, which, although in one way inconvenient, is in many 
 senses a great relief to the patient, by diminishing the tension 
 referred to. Acting upon this, physicians have long been in 
 the habit of puncturing the swollen parts to produce the re- 
 quired leakage. In my early experience I once had such 
 horrible results in the sloughing away of the entire scrotum of 
 a little child with scarlatinal nephritis, after I had punctured 
 it, that I declared I would never repeat it. But as other 
 cases came under my observation my prejudices thus excited 
 gradually disappeared, and I now resort to puncture when it 
 seems likely to give relief. It only remains to determine the 
 best method of performing the operation. It is a common 
 practice to make a number of minute punctures with a needle 
 or sharp-pointed bistoury. Dr. George Johnson, of London, 
 recommends making a free incision half an inch long, just 
 above the outer or inner ankle of each leg, and deep enough to 
 enter the areolar tissue beneath the skin. This may be done 
 with a bistoury; but Dr. Johnson used an instrument mounted 
 like a spring-lancet, which he recommends as more efficient 
 and le-s painful than the repeated fine punctures. He relates 
 an instance which is so remarkable and so admirably illus- 
 trates the possibility of recovery when the symptoms have 
 reached an advanced stage, that it is quite worthy of re- 
 narration. In July, 1861, he saw a clerk, aged 22, who had 
 suffered from general dropsy since the end of March, after 
 exposure to cold. The urine became nearly solid on addition of 
 acid and heat, while it contained numerous oily casts. Purga- 
 tives and diuretics failed to lessen the dropsy, and at the begin- 
 ning of September the swelling was so great that the skin 
 cracked and Avater oozed through the fissures. The legs were 
 now incised; a copious discharge of water occurred, and the 
 urine became more copious. From that time he steadily im- 
 proved ; the dropsy passed away, and gradually the urine 
 ceased to be albuminous; but it was not until the end of 
 April, 1862, more than a year from his illness, that all traces 
 of albumen had disappeared. The chief medicinal treatment
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 145 
 
 after the incision of tlie legs was tlie use of tincture of per- 
 chloride of iron three times a day, and a dose of broom tea in 
 the morning. Such recoveries as this are rare, while tiieir 
 possibility shows the value of hopeful perseverance in treat- 
 ment. I have never seen the instrument referred to, but 
 have made the large incisions with satisfactory results, al- 
 though I can point to none so satisfactory as Dr. Johnson's. 
 Dr. Dickinson,* on the other hand, relates a case in which, for 
 the relief of dropsy, one leg was punctured by a needle, and 
 on tlie other a lancet was used. He does not say how deep 
 were the incisions by the lancet, or whether they were mere 
 punctures ; but the openings made by the needle healed with- 
 out any bad result, while those made by the lancet gave rise 
 to deep suppurations, pus being discharged through five of 
 the punctures. 
 
 The ireafment of the complications is in no way different 
 from that of the same conditions under other circumstances. 
 The point to be impressed is the importance of being constantly 
 on the lookout for them. Oedema of the glottis requires sepa- 
 ate allusion as a complication most alarming and threatening 
 to life. Inhalations of steam may be tried, but prompt punc- 
 tures or incisions are the only certain means of relieving the 
 patient and saving his life. 
 
 Special Methods of Treatment. — The above described prin- 
 ciples of treatment are those which, modified by the peculiar 
 requirements of each case, are usually found most satisfactory.. 
 With regard to special curative measures directed to producing 
 structural change of the kidney and a return to its normal 
 histology, or directly diminishing albuminuria, I have not had 
 very satisfactory results, and most of the measures which have 
 been from time to time suggested are completely useless. 
 
 Calomel has been used for long periods to the production of 
 its specific effects. For what object, except to hasten the blood 
 dyscrasia which is the ultimate cause of death in this form of 
 nephritis, I do not know. It requires to be mentioned only to 
 be deprecated. 
 
 * Op. cit., p. 67. 
 10
 
 146 brigut's disease. 
 
 Tannic acid and gallic acid I have tried systematically with- 
 out any result in diminishing the albuminuria. 
 
 Ergot in some one of its forms I have thought had some effect 
 in diminishing albuminuria, but in no degree comparable to 
 tiie effect it produces in haemorrhage from the kidney, where 
 it is undoubtedly useful. The most convenient form of ad- 
 ministration is a pill of ergotin containing three grains, of 
 which two or three may be given at a dose. The fluid ex- 
 tract of ergot may be given instead, in the dose of half a drachm 
 to a drachm three times a day, but is not so well borne by the 
 stomach.* 
 
 The fluid extract of eucalyptus globulus I tried in a single 
 case, in doses of ten drops three times a day, without any re- 
 sults. This remedy is strongly recommended by Drs. J. B. 
 Leary and William Anderson, f of Brooklyn, New York, and 
 deserves a further trial. I>r. Anderson uses it in connection 
 with the milk diet, to which some of the effect must be at- 
 tril)uted. 
 
 Several years ago it occurred to me that sandal-wood oil, so 
 efficient in catarrhal conditions of the bladder, ought also to 
 be of service in catarrhal nephritis, and I began to administer 
 it in the form of capsules to patients with albuminuria, giving 
 at first three a day, and increasing to six a day, two after each 
 meal. Its use was followed by a fall in the amount of albu- 
 men in some cases, but those intractable cases which refused to 
 yield to other remedies, failed to respond also to the sandal- 
 wood oil. But there is reason whv sandal-wood oil should 
 do good, and I hope others will give it a trial in cases of ob- 
 stinate albuminuria. Dr. Edw. T. Bruen, informs me that he 
 has seen albumen diminish under its use. 
 
 The most recent remedies suggested for albuminuria are 
 
 * Xlie preparations of ergotin made by different manufacturers are prob- 
 ably not of tlie same strength. Tliat of McKesson and Robbins, of New 
 York, purports to be such that 1 grain equals 10 grains ergot, a 3-grain 
 pill being etpial to half a teaspoonful of the fluid extract. 
 
 t Proceedings of the Medical Society of the County of Kings, N. Y., vol. 
 iv, No. 6, August, 1879.
 
 CHRONIC PARENCHYMATOUS NEPHRITIS. 147 
 
 fuchsin and rosanilin. Feltz and Boiichet* were apparently 
 the first to use them in pills and mixture in doses of three 
 grains a day. They say that under their use, albumen soon 
 disappeared from the urine, and that both these coloring agents 
 are relatively harmless and well borne by the organism. Most 
 recently,! Professor E. di Renzi, of Genoa, has published the 
 results of treatment by fuchsin. He reports a decided fall in 
 the quantity of albumen under its use, as well as of mucus, 
 which he says is often present in the urine of Bright's disease. 
 He ordered it in solution or in pills, preferably in the latter 
 shape, 2J centigrams (3.8 grs.) to a pill, beginning with 5 
 centigrams (7.7 grs.) and increasing it to 25 (38.5 grs.) in the 
 twenty-four hours. The remedy produced a marked coloration 
 of the urine. If it does not pass over into the urine it is use- 
 less in diminishing the albuminuria. I have not as yet had 
 an opportunity of testing this new remedy. 
 
 My friend Dr. Albert H. Smith has used with apparently 
 decided advantage, in two cases, the benzoate of lime, in doses 
 of 10 grains every three hours. I failed to obtain the same 
 results in a single case, but am anxious to repeat the trial. 
 
 Professor di Renzi also made use of apoDiorphiu in dosps of 
 5 to 6 centigrams (7.7 to 9.2 grs.) a day without any effect 
 whatever upon the albuminuria. 
 
 He found rest in bed a very useful measure, and when united 
 with the milk diet found it more effectual than any other meas- 
 ure in reducing the albuminur'a. 
 
 I have already expressed my preference for these latter 
 measures with a view to diminishing the albuminuria.. Should 
 they fail, others of course should be tried. For the reduction 
 of the dropsy the systematic diaphoretic treatment, preferably 
 by jaborandi, but also by the hot air and warm bath, are most 
 useful, having due regard to the strength of the patient, which 
 must be kept up by iron, tonics, and, if necessary, alcohol in 
 the shape of the malt liquors, v\ ine, or even the strongest alco- 
 holic preparations. 
 
 * Deutsch. Med. Wochensohr., 1879. 
 
 f Vircliovv's Arcliiv, vol. 80, p. 510, June, 1880.
 
 148 bright's disease. 
 
 SECTION yii. 
 
 LAEDACEOUS DISEASE OF THE KIDXEY. 
 
 Synonyms. — Amyloid disease, albuminoid disease, waxy kidney, depurative disease. 
 
 LARDACEOUS DISEASE IS THAT FORM OF CHRONIC BRIGHt's 
 DISEASE IX WHICH THE TISSUE ELEMENTS OF THE KIDNEY 
 ARE MORE OR LESS INFILTRATED WITH A PECULIAR AL- 
 BU:HINOID SUBSTANCE, RESEMBLING MOLTEN WAX OR 
 BOILED STARCH, BUT WHICH IS BEST RECOGNIZED BY ITS 
 STRIKING A DEEP MAHOGANY-RED INSTEAD OF THE ORDI- 
 NARY YELLOW COLOR, WITH A SOLUTION OF IODINE.* 
 
 Etiology. 
 
 The most frequent cause of lardaceous disease is acknowl- 
 edged to be profuse and long-continued suppurative discharge, 
 such as occurs in chronic bone disease, whether syphilitic or 
 traumatic in origin ; or such discharge as constitutes the ex- 
 pectoration in cases of chronic phthisis and chronic bronchitis 
 with bronchiectasia. Syphilis itself, independently of the ter- 
 tiary conditions which it produces, is a frequent cause of lar- 
 
 * I do not consider it necessary to discuss the nature of the lardaceous or 
 waxy material. Its albuminous composition is now everywhere acknowl- 
 edged, C 53.58, H7, N 15.04,0 24.38 being its formula (Kekule and Fried- 
 reich), while that of albumen is C 52.7 to 54.5, H 6.9 to 7.3, N 15.4 to 6.5, 
 O 20.9 to 23.5, S .8 to 2 (Gorup-Besanez). The question as to whether the 
 deposit is a metamorphosis or an infiltration is not so definitely settled, but 
 it seems to me to deport itself altogether like the infiltrations, and unlike 
 the metamorphoses ; I shall tlierefore include it among the former until 
 some good reason is found for altering this position. I retain the terra 
 lardaceous disease because it defines the piiysical characters of the deposit 
 better than any other, although not the chemical ; further, because it is the 
 terra adopted in the revised noraenclature of the Eoyal College of Physicians 
 of London.
 
 LARDACEOUS DISEASE OF THE KIDNEY. 149 
 
 daoeous disease. Chronic dysentery, ulceration of the bowels, 
 chronic albuminuria itself, may all become the causes of this 
 condition. 
 
 Age and Sex. — Either sex is equally subject to lardaceous 
 disease, but as men are more frequently exposed to its causes, 
 it is in them rather more common. Very young children are 
 rarely affected, for evident reasons. Dr. Dickinson has known 
 a case to be fiital at five years of age, and refers to a case of 
 Dr. Gee, in which the lardaceous change was found in the 
 spleen but not in the kidneys of a boy two and a half years 
 of age who had had a profusely discharging abscess of the 
 thigh. The following table from Dickinson shows the dis- 
 tribution as to age of sixty-one cases : 
 
 Age. No. of cases. 
 
 to 10, 3 
 
 11 to 20, 11 
 
 21 to 30, 21 
 
 31 to 40, 10 
 
 41 to 50, 10 
 
 51 to 60, 3 
 
 61 to 70, .3 
 
 Over 70. None. 
 
 Morbid Anatomy. 
 
 The incipient stages seldom present alterations recognizable 
 by the naked eye unaided by reagents. But if, after section 
 of the kidney, the cortex be treated by a solution of iodine and 
 iodide of potassium,* numerous mahogany-red points make 
 
 * The Test Solutions. — The best test solution for macroscopic purposes is 
 one made by dissolving .162 grams iodine by the aid of .324 grams of iodide 
 of potassium in 30 cc. of water (2j grains iodine, 5 grains iodide of potas- 
 sium to a f§ of water). The solution contains about one-half per cent, 
 of iodine. For microscopic preparations a solution weaker than the 
 above, or a one-fourth per cent, of iodine dissolved by twice the quantity of 
 iodide of potassium, is more suitable, and sometimes a solution containing 
 as much iodine as water alone will take up answers best. There is a de- 
 cided difference of opinion as to the effect of the subsequent addition of
 
 150 bright's disease. 
 
 their appearance; or if by a solution of violet-anilin, as many 
 red or pink points. These are the Malpighian bodies, whose 
 capillary tufts are the first to be affected by the change. The 
 kidney in this early stage is normal in size, or very slightly 
 
 sulphuric acid to preparations treated with iodine. Virchow' originally an- 
 nounced that a blue or violet color was assumed by the amyloid tissues 
 thus treated. In this he is sustained by all sulisequent German patholo- 
 gists, including the most recent. Most English writers, on the otlier hand, 
 either deny this reaction altogether, or speak of it as uncertain and unre- 
 liable. Thus Dickinson^ says: "This appears to be an error of observa- 
 tion, partly arising from the fact that when sulphuric acid acts upon iodide 
 of potassium — a salt generally present in the test solutions used — a precipi- 
 tation of iodine takes place, which usually blackens the tissue." So, also, 
 a Russian writei-, Morochowetz,^ says the reagent is useless because sul- 
 phuric acid produces with iodine solutions alone, a violet or blue coloration 
 by a precipitation of iodine crystals. The disci-epancy is undoubtedly due to 
 methods of manipulation. Boettcher* and Kyber,* whose papers are among 
 the most careful and practical recently issued, both declare that a delicacy 
 is obtained by the use of the sulphuric acid which far exceeds that of any 
 other test. Both ascribe the want of success to the use of too concentrated 
 sulphuric acid. Kyber uses an iodine and iodide of potassium solution of 
 the above strength for macroscopic work, and watery solutions of iodine for 
 the most part for microscopic preparations ; and sulphuric acid diluted fif- 
 teen to twenty times witli water. Bcettcher uses the solution of iodine and 
 iodide of potassium, above given, for botli macroscopic and microscopic 
 work, and 7 to 8 cc. of sulphuric acid to 100 cc. of water. Kyber also says 
 that in the treatment of sections by the iodine solution, the normal tissues 
 should not be allowed to assume a deeper tint than a pure yellow. If they 
 are browned the section is worthless for further treatment, and should be 
 thrown away. 
 
 The Anilin-violet Solution. — Jiirgens* and HeschFin Germany and CorniP 
 in France were the first to call attention to anilin-violet as a test for the 
 lardaceous substance, although the late Dr. Bennett, of Edinburgh, had pre- 
 viously called attention to tlie fact that carmine and magenta [produce 
 distinct coloration. The anilin-violet, of which a 1 per cent, solution is 
 
 ' Virchow's Archiv, Bd. vi. 
 
 " Op. cilat., p. 231. 
 
 ' St. Petersburg Med. Weekly, vol. iii, 1878, p. 75. 
 
 * Bcettcher, Arthur, Beobachtungen uber die amyloide Degeneration der Leber, 
 Virchow's Archiv, Bd. 72, 1878, s. 506. 
 
 ' Kyber, Eduard, Weitere Untersuchungen ii'ber die amyloide Degeneration, Virchow's 
 Archiv, Bd. 81, 1880, s. 1. 
 
 • Eine Neue Reaction auf Amyloidkiirper, Virchow's Archiv, Bd. 65, 1875, s. 189. 
 1 Sitzb. d. Wiener Akad., iii. Abth., Oct., 187G. 
 
 » Archiv de Physiol. Norm, et Path., t. vii, p. 673, Paris, 1875.
 
 LARDACEOUS DISEASE OF THE KIDNEY. 151 
 
 enlarged. Its capsule strips off readily, leaving an organ 
 which exhibits no peculiarities, or a paleness or translucency 
 which readily escapes notice, but may be more easily recog- 
 nized at the edges of a thin section. Very often too, they are 
 completely overshadowed by other alterations, which are es- 
 pecially apt to be associated with these slight degrees of lar- 
 daceous disease. Thus the large white kidney of chronic 
 parenchymatous nephritis may exhibit this degree of lardaceous 
 change, and the latter altogether escape notice without the use 
 of iodine. Hence the iodine reaction should be tried upon all 
 kidneys whose morbid anatomy we may be investigating. 
 Under the microscope, however, thin sections exhibit a trans- 
 parency of the structures involved which does not require 
 iodine to secure its recognition, but beautifully distinct demon- 
 stration results from its addition to such preparations. 
 
 In a more advanced stage of uncomplicated lardaceous 
 change the kidneys are both enlarged, usually symmetrically, 
 but the extreme degrees of enlargement are usually associated 
 with fatty degeneration of the epithelium. Such organs were 
 a pair weighing 23 ounces, which came under Dr. Dickinson's* 
 notice. Dr. Johnsonf refers to a case in which the two kidneys 
 weighed 28 ounces. Rindfleischl has seen a single instance of 
 
 suitable, strikes a red or pink color with the amyloid material, which con- 
 trasts with tlie violet staining of the normal tissues, and beautiful prepara- 
 tions for the microscope maj' be thus obtained. Eberth^ and Fiirbringei^ 
 are recent German writers who prefer this test solution, which the former 
 says is decidedly to be preferred to the iodo-sulphuric acid test to demon- 
 strate the first beginnings of the amyloid change, and Fiirbringer also says 
 it is a more delicate test. Kyber says it is this very stage which is best 
 shown by the iodo-sulphuric test. Eberth also says that the anilin-stained 
 microscopic preparations also keep the longest, which is probably true. The 
 blue tint received by the normal tissues, however, rapidly fades, so that the 
 contrast is not maintained. 
 
 In my own experience I have found the simple iodine reaction without 
 the use of sulphuric acid sufficiently distinctive for practical purposes. 
 
 * Dickinson, op. citat., p. 249. t Johnson, op. citat., p. 104. 
 
 X Rindfleisch, Path. Histology, New Syd. Soc. Trans., 1873, vol. ii, p. 167 
 
 1 Eberth, C. J., Die aniyloide Eutartung, Virchow's Arcliiv, Bd. 80, 1880, s. 138. An 
 excellent paper. 
 
 - Fiirbringer, Paul, Ziir Diagnose der ainyloidea Entartung der Nieren, Vircliow's 
 Archiv, Bd. 71, 1877, s. 400.
 
 152 brigiit's disease. 
 
 that very rare condition, complete lardaceous infiltration, that 
 is, in which the basement membrane of tlie nriniferous tubes, 
 as Avell as the capilhiries, were infiltrated, where the kidney 
 was enlarged to nearly twice its normal size. 
 
 In the uncomplicated forms of lardaceous disease the cap- 
 sule is not adherent, but if interstitial changes exist to any 
 extent it is adherent. When removed, the surface of the kid- 
 ney is pale and anaemic ; occasionally the stellate veins are 
 conspicuous. The characteristic translucency may even be 
 recognized in the organ in bulk, but in sections is more striking. 
 When the change is present in high degree the edges of a thin 
 section are almost as translucent as a similar section of bacon. 
 
 On bisection the cortex is seen to be enlarged ; it is pale, 
 anaemic, waxy, firm, and resisting. The pyramids are normal 
 in hue and area. The iodine solution added to such a kidney 
 produces its peculiar coloration, not merely in the Malpighian 
 capillaries, but also in the afferent and efferent vessels and the 
 vasa recta of the pyramids. 
 
 In a still later stage, that of atrophy, the kidney becomes 
 contracted, diminished in size, rough, and even distorted in 
 shape. The capsule is adherent, and on section the cortex is 
 found narrowed, sometimes as much so as in the contracted 
 kidney of interstitial nephritis. 
 
 The most diverse views as to the cause of this contracted 
 lardaceous kidney are held by authors. Thus Dr. Grainger 
 Stewart and Dr. Johnson ascribe it to a wasting and destruc- 
 tion of the epithelium and tubules ; Virchow, Klebs, and 
 Bartels to a simultaneous or previously existing contracting 
 disease. Dr. Dickinson believes that it is due to the contrac- 
 tion of a new-formed intertubular tissue, which is the result of 
 an irritant property of the lardaceous material, similar to Avhat 
 occurs in the second stage of parenchymatous nephritis. This, 
 once formed, contracts in accordance Avith its invariable ten- 
 dency, and produces the rough granular appearance and di- 
 minished size of the organ. Rindfleisch also supposes the 
 amyloid change of the vessels to be primary ; that the mechan- 
 ical obstruction thus resulting induces a collateral hypersemia
 
 LARDACEOUS DISEASE OF THE KIDNEY, 153 
 
 of the cortex ; this produces the conditions favorable to a 
 cellular hyperplasia, which succeeds immediately or upon the 
 addition of some further irritant. I do not doubt the correct- 
 ness of the latter view in the majority of instances, and that 
 the further irritant is the lardaceous material itself, as Dick- 
 inson suggests. It is of course not impossible for a case of 
 lardaceous disease to be ingrafted on one of interstitial nephritis. 
 
 As to the microscopy of this disease, in the first stage, in 
 which the naked eye often fails to detect anything abnormal 
 without the aid of iodine, a microscopic examination of thin 
 sections reveals a lustrous or waxy appearance of the Malpig- 
 hian bodies, due to an infiltration of their capillary tufts by 
 the peculiar lardaceous material. They are also enlarged, in 
 consequence of a thickening of the capillary walls. At this 
 stage there is no visible alteration in the tubules or their epi- 
 thelium. 
 
 In the second stage we have the involvement of larger ves- 
 sels, the vasa aiferentia and efferentia, in the cortex, and also 
 the vasa recta of the cones. The other capillaries of the cortex 
 are also involved, and an exudation occurs into the tubules, of 
 a glistening material which forms casts. I have already dis- 
 cussed these casts on p. 68. Dickinson* believes the mate- 
 rial to be, occasionally at least, identical with the lardaceous 
 substance, although he admits that it very rarely exhibits the 
 peculiar reaction with iodine. According to Grainger Stewart, 
 this material presents neither the ])eculiar translucency nor 
 the coloration with iodine which are characteristic of the waxy 
 degeneration, but exactly resembles the material of hyaline 
 tube-casts. t Cornil has never found them to strike the red 
 reaction with the anilin-violet solution, while Jiirgsen obtained 
 the reaction with this solution in several instances. The re- 
 sult of my own eiforts in treating these casts with iodine after 
 their extrusion from the tubes into the urine, after many pre- 
 viously ineffectual trials, is shown in the plate opposite p. 68. 
 It is to be remembered, too, that similar casts are found in the 
 tubules in other forms of chronic renal disease. 
 
 * Op. citat., p. 253. f Op. citat., p. 126.
 
 154 bright's disease. 
 
 Tlie arteriole n-alh are thickened by an involvement of both 
 interna and media. This thickening is attended by an extra- 
 ordinary distinctness of the muscular fibre ceils of the circular 
 coat. The middle or muscular coat, since the original an- 
 nouncement by Yirchow,* has always been considered the first 
 involved. But Cornilf has recently asserted that in every case 
 the lesion is localized in tlie internal coat of the renal vessels. 
 It is true the interna is sometimes disproportionately changed 
 in the small arteries, but this does not necessarily alter the seat 
 of primary deposit. A very distinct demonstration of the 
 thickening of the muscular walls is obtained by injecting the 
 kidney wtth a transparent injecting mass, and then examining 
 sections by the microscope, although the injection of such kid- 
 neys is very difficult. 
 
 As to the involvement of the tubules themselves and their 
 epithelium there is some difference of opinion. Dr. Johnson| 
 insists that, in the large majority of instances, the changes in 
 the secreting structures are primary, and says further that he 
 has not met with a single case in which thickening of the 
 bloodvessels in any form was unassociated with extensive 
 changes in the secreting structure of the kidney. 
 
 Klcbs and Rindfleisch admit that the lardaceous change only 
 rarely attacks the basement membrane and epithelium. The 
 latter says that amyloid infiltration of the tubes is found 
 chiefly in the papillae, where it is accompanied also by similar 
 changes in the vessels, especially the vasa recta; thence it ra- 
 diates into the pyramids of Ferrein. He has never seen it in 
 the convoluted tubes, although he does not doubt the possi- 
 bility of its occurrence there, where it is hard to distinguish 
 the diseased tubes from the vessels which are similarly affected. § 
 Grainger Stewart has seen the cells present the swollen, dimly 
 translucent appearance, but never the peculiar coloration. He 
 
 * Cellular Pathology, Chance's Transhition, Philadelphia, 1860, p. 417. 
 
 t Arcliives de Physiol. Normal, et Pathol., t. vii, 1879. 
 
 t Op. citat., pp. 104-106. 
 
 ^ Kindfleisch, op. citat., p. 145.
 
 LARDACEOUS DISEASE OF THE KIDNEY. 155 
 
 has often found the basement membrane thickened and waxy- 
 looking, without any coloration taking place on the applica- 
 tion of iodine, but on a few occasions he has seen that colora- 
 tion.* Bartelsf says, "a similar change may subsequently 
 aifect the tunica propria and epithelium of the tubuli urinif- 
 eri." Dickinson describes alterations in the tubules and their 
 lining cells, due to their infiltration with lardaceous material, 
 as the result of which " their normal structure is displayed with 
 abnormal distinctness." " Fibrinous casts are abun- 
 dantly formed and displaced, and yet the epithelial lining of 
 the tube undergoes no disturbance."^ Axel Key also admits 
 the involvement of the cells, and holds that the Avaxy casts in 
 the amyloid kidney are the direct result of the fusion of the 
 epithelial cells which have succumbed to the amyloid infiltra- 
 tion. Boettcher§ describes the change in the renal cells as 
 "decided," and Cornil|| says they sometimes become the seat 
 of amyloid infiltration, when they are transformed into little 
 glassy blocks which exhibit the characteristic coloration with 
 iodine and sulphuric acid. 
 
 The facts appear to be these : The bloodvessels are first in- 
 volved, for the excellent reason that, whatever is the ex- 
 act morbid condition, the source of the infiltrating material is 
 the blood. Naturally, therefore, the walls of the vessel-walls 
 become first involved. Beyond are the epithelium and base- 
 ment membrane, which are also capable of tlie alteration. 
 That the cells of the liver become thus the subject of waxy 
 change all except E. Wagnerf admit, and reasonably also may 
 those of the kidney, Avith the basement membrane on which they 
 are seated. We would expect them, however, to be more recently 
 involved, and the change may be delayed indefinitely. When 
 cells become the subject of the lardaceous change, they acquire 
 
 * Grainger Stewart, op. citat., p. 127. 
 
 t Bartels, op. citat., p. 519. J Dickinson, op. citat., p. 2o4. 
 
 § :^oettcher, Virchow's Archiv, Bd. 72, 1878, s. 534. 
 II Manuel d'Histologie Pathologique, Paris, 1876, p. 1017 ; American 
 Translation, 1880, p. 46. 
 
 ^ Archiv der Heilkunde, Bd. ii, s. 486.
 
 156 lrioht's disease. 
 
 a peculiar translucent glassy hue, are enlarged, and lose all 
 distinctness of outline, neighboring cells appearing to be fused 
 together. The basement membrane also becomes thickened 
 and translucent. 
 
 It is also very common for the epithelium of the cells to be in 
 a state of fatty degeneration, and the capillary walls to contain 
 aggregations of fat-globules, while the urine in the latter stages 
 contains oil-casts and fatty cells. 
 
 From the above considerations it is evident why the kidney 
 in this stage is enlarged. The arterioles and capillaries are 
 thickened and occupy more bulk, while the cells are swollen, 
 the basement membrane of the tubules thickened, and the 
 tubes themselves more or less distended with the material of 
 the casts. 
 
 In the third or contracting stage of lardaceous kidney, minute 
 examination reveals, in addition to the appearances described, 
 the hypernucleated intertubal overgrowth, already referred to 
 as causing by its contraction that of the kidney itself. Cysts 
 are occasionally present for the same reason that they are found 
 in the granular contracted kidney of interstitial nephritis, and 
 an approximate rough granulation is also sometimes assumed, 
 although never the typical granular appearance of interstitial 
 nephritis. 
 
 It is not very rare to find at least the ]\Ialpighian cap- 
 sules in the large white kidney the seat of the lardaceous change, 
 but the iodine test is, in my experience, generally necessary to 
 demonstrate it. Dr. Johnson first suo;o;estsd that it is tlie direct 
 result of the drain upon the system incident to tlie large al- 
 buminuria which attends parenchymatous nephritis. But Dr. 
 Dickinson* says that, while among his earlier observations he 
 thought he found reason to admit this cause occasionally, later 
 experience has served to show that where the lardaceous con- 
 dition is associated with one of the other forms of renal dis- 
 turbance, the former, lardaceous, is usually the primary change. 
 Bartels also calls attention to the very frequent coincidence of 
 
 * Op. citat., p. 245.
 
 LARDACEOUS DISEASE OP THE KIDNEY. 157 
 
 amyloid disease of the kidney with other renal affections, and 
 especially with chronic parenchymatous nephritis in both kid- 
 neys, of which, he says, both processes are apparently " co- 
 effects of one and the same cause." 
 
 Dr. Dickinson's present views are certainly not sustained 
 by those cases occasionally met, in which are found, first, in a 
 marked degree, the causes which all acknowledge to be most 
 efficient in the production of lardaceous disease ; second, copi- 
 ous albuminuria and casts, with extreme dropsy, and, finally, 
 death, with the post-mortem examination revealing the most 
 typical form of large white kidney, in which, however, the 
 iodine solution also reveals amyloid infiltration of the Mal- 
 pighian tufts only. On the other hand, the fact, which can 
 hardly be controverted, that the same set of causes is capable 
 of producing either disease, makes it much more reasonable 
 to consider, that when both conditions are present, they are 
 "coeffects of one and the same cause," as claimed by Bartels. 
 
 Symptoms and Clinical History of Lardaceous Disease. 
 
 An individual who has had syphilis, or who has phthisis^ 
 c hronic bronchiti s, b one diseas e, or other affection in which 
 there is an exhaustive drain, observes that he feels always in- 
 tensely weary, has no disposition to exertion whatever, or even 
 to rise from his bed. Increased frequency of micturition may be 
 observed at the same time, such that he may have to rise once 
 or twice during the night to micturate. But this symptom 
 may be totally absent. Accidentally, periiaps, a somewhat 
 copiou s albuminuria is discovered. At first no casts are met, 
 or they are exceedingly scanty, a single one being found in 
 several successive slides, or one or two may be found on a 
 single slide. Those which are noted are hyaline or faintly 
 granular. Later, a slight oedema of the feet may make its ap- 
 pearance while the patient is up and about, but disappears 
 during; the night while he is in bed. The albuminuria is now 
 copious but still varies, and casts may be more numerous, or may 
 still be scanty and continue hyaline or faintly granular. The
 
 158 briqht's disease. 
 
 i irinc is now decidedly increased i n quantity, 1600 to 2500 cc. 
 (53 to 80 oz.), its specific gravity low, 1005 to 1015. The 
 patient exhibits a worn and cachectic appearance, which may 
 be present earlier, and is sometimes the first symptom which 
 strikes the attention of the observer. There is sometimes a 
 p eculia r fetor of the breatj i. Still later, all thase symptoms in- 
 crease; the dropsy is persistent, the u rine loaded with albumen, 
 and, in addition to the ordinary delicate hyaline casts, may contain 
 the gl istening waxy casts. Fatty casts and free fatty epithelium 
 from the tubules of the kidney may be superadded, as well as 
 free oil-drops. Epithelial casts are unfrequent. Dropsy now 
 becomes general, involving the arms, trunk, and face, as well 
 as the lower extremities, and even the serous cavities, the peri- 
 toneum, pleura, and occasionally also the pericardium. Qildema 
 of the lungs may also occur as a serious complication. In gen- 
 eral, however, it may be stated that dropsy is seldom as ex- 
 treme as in parenchymatous nephritis. 
 /^ Towards the close of the disease, the urine, which had been 
 7 increased, becomes diminished in quantity, but is seldom sup- 
 { pressed, indeed seldom falls below (600 cc.) 20 ounces. 
 ^^ Of the solid chemical constituents, it may be said of all, that 
 they are, as a rule, slightly diminished, but not sufficiently to 
 influence the course of the disease. It is in consequence of 
 this that uraemia is almost unknown in lardaceous disease, the 
 urea and extractives being eliminated in sufficient amount to 
 avert this evil. 
 
 Convulsions or ursemic symptoms of any kind seldom occur, 
 probably for the reasons just named, the free elimination be- 
 ing secured by the copious secretion of urine. Bartels reports 
 a single case in which ursemic convulsions were present. In 
 forty-eight cases reported by Dickinson in which there were 
 autopsies, there were three instances of ursemic convulsions, 
 two of coma, and one of unnatural drowsiness. 
 
 But lardaceous disease of the kidney never occurs alone. 
 It is always accompanied by similar changes in t he^ liver,. 
 spleen, and often of the intestinal canal. Hence, evidences of
 
 LARDACEOUS DISEASE OF THE KIDNEY. 159 
 
 alterations in these organs are more or less marked. Thus 
 the percussion areas of the liver an d spleen are almost alwa ys 
 enlarged, and the bloodvesse ls of the stomach and intestines are 
 ofteii involved . In the former event obstinate vomithig., and 
 in the latter equally obstinate diarrhoea results. The latter is 
 for more frequent than the former. 
 
 As to duration, the disease generally runs a very chronic 
 course, which is limited only by the disease of which it is a 
 complication. As such it is always of shorter duration than 
 interstitial nephritis, and may be shorter than chronic paren- 
 chymatous nephritis, although the latter affection and lar- 
 daceous disease more closely resemble each other in respect to 
 duration. It is only reasonable, that when superadded to pre- 
 viously existing exhausting disease, the two would hurry an 
 issue more rapidly than either alone. Yet the renal affection 
 is subject to the same improvement to which the general or 
 local one may be subject. I have now under my observation 
 a case of chronic phthisis in which lardaceous disease has been 
 recognized as present for over two years, while the phthisical 
 one has existed much longer, and the patient's condition is in 
 all respects better than it was two years ago. When obstinate 
 diarrhoea and vomiting supervene the end usually is not re- 
 mote. 
 
 Comjili cations. 
 
 So much has already been said of what may be properly 
 called the causal complicatioms of lardaceous disease that they 
 require no further mention than enumeration in this connec- 
 tion. They are phthisis, syphilis, caries, necrosis, long-continued 
 suppuration from any cause, and long-continued exhaustive 
 drains upon the system, including albuminuria. 
 
 As common results of the same causes, rather than as compli- 
 cations, are to be mentioned amyloid disease, with enlargement 
 of the liver and spleen, and amyloid disease of the bloodvessels 
 of the gastro-intestinal tract, with the vomiting and diarrhoea 
 resulting from these. After these, lardaceous disease is subject 
 to the complications of the other forms of renal disease, but
 
 100 bright's disease. 
 
 they are less numerous. Bronchitis occurs most frequently. 
 Pleural, pericardial, and peritoneal effusions are very rare, as 
 are also hypertrophy of the heart and retinal changes. En- 
 docarditis, erysipelas, and epistaxis have occurred. 
 
 Diagnosis. 
 
 There are some instances in which lardaceous disease is 
 easily recognized. If a patient has had syphilis with secondary 
 and tertiary symptoms, or has long been a victim to phthisis, 
 and he is discovered to be oedematous, and to have a lartre albu- 
 minuria, with waxy hyaline and fatty casts, and an enlarged 
 liver and spleen, and obstinate diarrhoea, there can be little 
 doubt but that lardaceous disease is present. But M'here neither 
 of these two general diseases are present, or the phthisis has 
 not existed a very long while, or there is not decided evi- 
 dence of enlarged liver and spleen, we cannot be certain. 
 While it is never safe to diagnose lardaceous disease without 
 the presence of enlarged liver and spleen, the presence of these 
 enlarged organs along with large albuminuria, and the other 
 symptoms which attend it, do not necessarily imply lardaceous 
 disease. The symptoms and course of the disease, particularly 
 in its latter stages, are so like those of chronic parenchymatous 
 nephritis that it is sometimes impossible to distinguish the two. 
 Further, there is every reason to believe that chronic nephritis 
 is sometimes caused by the same dyscrasic conditions as pro- 
 duce the lardaceous disease. In such cases, therefore, a diag- 
 nosis is impossible. Dr. Paul Fiirbringer* has recently, in an 
 article already alluded to, reported four cases which so admir- 
 ably illustrate these difficulties that I feel justified in occu- 
 pying the space necessary to mention them. In all four cases 
 there was chronic phthisis with ulceration of the bowels. In 
 all four he was fortunate enough to be able to watch the ap- 
 pearance of that series of symptoms which are accepted as 
 pointing to the diagnosis of amyloid disease of the kidney. In 
 
 * Zur Diagnose der amyloideii Entartung der Nieren, Virchow's Arcliiv, 
 Bd. 71, 1877, p. 400.
 
 LARDACEOUS DISEASE OF THE KIDNEY. 161 
 
 all four was there splenic and hepatic enlargement, and in all 
 four, autopsies were made. In case one, neither the kidney, 
 liver, nor spleen responded to the iodine test, but the kidney 
 and spleen responded to the anilin-blue test. There was, there- 
 fore, amyloid disease, which was uncomplicated by chronic 
 nephritis. In cases two, three, and four, there was no reaction 
 on the pai't of kidney, liver, or spleen to either test. In case 
 two, there was neither amyloid disease nor chronic parenchym- 
 atous nephritis,* and cases three and four were well-marked 
 cases of parenchymatous nephritis. 
 
 Finally, the two conditions may exist jointly, where a 
 parenchymatous nephritis may be ingrafted on a lardaceons 
 kidney ; or the two may result from the same cause, or 
 possibly the lardaceons disease may be the result of the ex- 
 haustive albuminuria of a previous chronic nephritis, as origi- 
 nally suggested by Dr. George Johnson, So that in a certain 
 number of cases, also, the separation of the two is impossible. 
 
 When these combinations do not exist the urine in larda- 
 ceous disease is more abundant and lighter in color, casts are 
 fewer and hyaline, with a few oil-casts, while in parenchymatous 
 nephritis they are more numerous and include every variety. 
 Blood-corpuscles are rarely found in the urine of lardaceons 
 disease, while they are occasionally present in that of chronic 
 nephritis. If the original disease, the possible cause of a 
 lardaceons disease, has entirely disappeared before the renal 
 malady was detected, the chances of the latter being lardaceons 
 disease are decidedly fewer. 
 
 The only other form of renal disease which it is at all 
 possible to confound with lardaceons disease is interstitial 
 nephritis. But in this we have the almost total absence of 
 dropsy, small albuminuria, and scanty sediment, in which gran- 
 ular and hyaline casts are found. While the quantity of urine 
 is increased in both these forms of chronic Bright's disease, the 
 quantity is larger in interstitial nephritis. Hypertrophy of 
 the left ventricle, an almost invariable symptom in contracted 
 
 * Fiirbringer does not say what form of kidney disease existed here, but 
 leaves us to suppose that the kidneys were normal. 
 
 11
 
 1G2 BRIGHT S DISEASE. 
 
 kidney, is very rare in larclaccous disease, while enlargement 
 of the spleen and liver are common, and do not occur in inter- 
 stitial nephritis. 
 
 Contracted kidney may also be associated with lardaceous 
 disease. With regard to this relation, Bartels says he would 
 prefer to consider the gradual cachexia produced by the genuine 
 contracting kidney to be the primary mischief and the cause 
 of the secondary amyloid degeneration of the vessels of the 
 kidney. Why he should admit this, and yet not admit that 
 the same result may be brought about by the cachexia of pa- 
 renchymatous nephritis, which is so much more marked, I 
 cannot understand. I should prefer to consider these two either 
 an accidental complication, or the interstitial disease secondary 
 to the lardaceous disease, the amyloid material acting as an 
 irritant and producing the interstitial hypernucleation and 
 fibrosis in the manner already alluded to. 
 
 Profjnosls. 
 
 In the matter of prognosis much depends upon the presence 
 or absence of the original disease causing the lardaceous change 
 in the kidneys. If the former cannot be cured the effect of 
 the latter can only be to hurry on the unfavorable termination 
 of the former, although it is subject to tlie abatements as well 
 as exacerbations of that affection. If the original disease is 
 curable, and the patient young, there are no limits to the pos- 
 sible improvement, although it is scarcely likely that the dis- 
 eased structures are ever restored to their normal state. But 
 as it is unlikely that all the renal vessels are involved in the 
 change, and the organ itself, especially before its complete de- 
 velo})ment is attained, is one capable of assuming an extraor- 
 dinary degree of supplemental function, it is not impossible 
 that there may be a complete restoration. 
 
 If the patient is past middle life, even if it should happen 
 that the original disease has disappeared, the probabilities of 
 recovery are a minimum, while a decided degree of improve- 
 ment is not impossible. If the stage of alteration of the blood- 
 vessels of the stomach and intestines, as attested by obstinate
 
 LARDACEOUS DISEASE OF THE KIDNEY. 1G3 
 
 vomiting and diarrhoea, is reached, the disease is necessarily 
 rapidly fatal. 
 
 Treatment. 
 
 Of lardaceoiis disease it may be said with greater emphasis 
 than any other form of renal disease, "an ounce of prevention 
 is worth a pound of cure." A due appreciation by surgeons 
 and syphilographers of the causes of lardaceous disease would 
 prevent the occurrence of many cases; the timely amputation 
 of a limb, long the seat of suppuration, and the thorough treat- 
 ment of syphilis being all that is necessary to accomplish this. 
 To this end also freq^uent examinations of urine should be 
 mide by the surgeon in charge of cases of the kind so often 
 roferred to, and the slightest indication of albuminuria should 
 ITe the signal for prompt interference, if such be possible, while 
 the possibility of the occurrence of this renal complication 
 (should always be before the surgeon's mind. 
 
 In syphilis the faithful and persistent use of remedies for a 
 ifiBcient time after all symptoms of the primary and secondary 
 anbctions have disappeared is essential. From a somewhat 
 careful examination of the subject, rather than from personal 
 experience, I am satisfied that the " continuous/' rather than 
 the " intermittent," treatment of syphilis, by small doses of 
 mercurials long continued, is the plan most likely to secure 
 the eradication of the disease, and subscribe heartily to the dic- 
 tum of Dr. E. L. Keyes, announced in his paper read before 
 the International Medical Congress* in Philadelphia, 1<S76 : 
 
 " I think that a case treated from the first symptom should 
 receive mercury continuously in small doses for a period not 
 less than two and a half years, or, in any event, until at 
 least six months have passed after the entire disappearance of 
 the clearly syphilitic symptoms." By small doses are meant 
 doses of g'gth to g^jjth of a grain. This is practically the treat- 
 ment of liicord, although he M^ould also use iodide of potas- 
 sium six months after he had discontinued the use of mercury. 
 The iodide being a remedy rather for the symptoms than a 
 cure for the disease, should be administered in sufficient doses 
 
 * E. L. Keyes, Treatment of Syphilis, Transactions of the Intei-na- 
 tional Medical Congress, Philadelphia, 1877.
 
 164 bright's disease. 
 
 as required, in fact interruptedly, while the mercurial treat- 
 ment should be continued for the period named. 
 
 With regard to phthisis, a greater stimulus to our efforts 
 both to prevent and cure than already exists, is scarcely pos- 
 sible, while the futility of those efforts in the very large num- 
 ber of cases is very well known. 
 
 If the causing disease continues to exist, the treatment of the 
 lardaceous disease is the treatment of the former, — if it is syphi- 
 lis, iodide of potassium and mercurials; if phthisis, cod-liver 
 oil, iron, quinia, an abundance of nourishing food, in which milk 
 and cream should be conspicuous, alcohol and restorative meas- 
 ures generally, together with fresh air and suitable exercise. 
 
 Supposing the original disease to have disappeared, the meas- 
 ures of treatment indicated are precisely those of parenchyma- 
 tous nephritis, for the details of which the reader is referred to 
 the chapter on that disease. 
 
 As to special modes of treatment directed to the disease, I 
 have little confidence in them. Bartels recommends the use 
 of iodide of potassium as curative of the disease, believing he 
 is indebted for the favorable issue of the cases which have 
 recovered under his care to that remedy, although he does not 
 know how it acts upon the diseased walls of the vessels. lie 
 supports, at the same time, the general nntrition by prepara- 
 tions of iron, vigorous diet (meat and milk), and good wine, 
 and maintains sufficient action of the skin by baths. Dickin- 
 son also recommends iodide of potassium when the disease is of 
 syphilitic origin, directing the remedy to the affection causing 
 the lardaceous condition rather than to the latter. He also en- 
 deavors to compensate the loss which the system suffers in ex- 
 haustive suppuration, not by general diet alone, but by salines, 
 chiefly potash salts, and has reason to be well satisfied with the 
 results obtained. Liebig's extract of beef should be especially 
 useful under these circumstances, as it supplies the saline con- 
 stituents of beef in a concentrated form. 
 
 The treatment of complications is in no way peculiar, and has 
 been so fully covered in previous sections that no further allu- 
 sion is here required.
 
 INTERSTITIAL NEPHRITIS. 165 
 
 SECTION YIIL 
 
 INTERSTITIAL NEPHEITIS. 
 
 Synonyms, — Contracted kidney, ehronicaJly contracted kidney, renal cirrhosis, cir- 
 rhotic kidney, granular degeneration, granular kidney, red granular kidney, gouty 
 kidney, renal sclerosis. 
 
 INTERSTITIAL NEPHRITIS IS A SLOW INFLAMMATORY PRO- 
 CESS SEATED IN THE INTERSTITIAL TISSUE, WHICH, BECOM- 
 ING ABNORMALLY INCREASED, SUBSEQUENTLY CONTRACTS 
 AND DESTROYS THE TUBULAR ELEMENTS OF THE KIDNEY ; 
 REDUCING ITS SIZE AND PRODUCING OTHER CONDITIONS 
 MORE OR LESS COVERED BY THE SYNONYMS, OR MORE 
 CLOSELY DESCRIBED IN THE SECTION ON THE MORBID 
 ANATOMY OF THE DISEASE. 
 
 Eliologi). 
 
 Of all the reco2:nized forms of Brio;lit's disease, interstitial 
 nephritis presents the largest number of instances in which the 
 cause is undiscoverable. There are, however, some well-de- 
 termined causes. 
 
 Among the most tangible of these is gout. Gout is associ- 
 ated with so many cases of contracted kidney, that the term 
 gouty kidney has come to be a well-recognized synonym for 
 the product of interstitial nephritis. There are probably no 
 cases of gout, which have continued for any length of time, 
 which are not accompanied by this condition of the kidney. 
 It would seem to be the accumulation in the blood of the 
 poison of gout, — the excess of uric acid and its compounds, — 
 which causes the interstitial inflammation. 
 
 Another well-recognized cause is lead poisoning. The lead 
 in the blood, like the essential poison of gout, being the irri- 
 tant which excites the proliferating activity of the connective 
 tissue elements. Hence painters, glaziers, workers in lead in 
 any shape, are frequent victims. Dr. Dickinson considers it
 
 166 brkhit's disease. 
 
 safe to assert that, of painters, at least one-half eventually die 
 of granular degeneration of the kidneys. 
 
 Long-continued cystitis, especially following gonorrhoea, is 
 undoubtedly a cause in a few instances, the inflammation trav- 
 elling up the ureter to the pelvis of the kidney and thence to 
 tlie intertubular tissue. 
 
 Among the causes, the operation of which cannot be so di- 
 rectly proven, is mental anxiety, whether the result of grief or 
 of business and financial cares. Dr. Clifford, quoted by Dr. 
 Robert T. Edes,* goes so far as to attribute " twenty-four out 
 of thirty-two cases, in private practice, to some long-continued 
 anxiety or great grief." Certain it is that this disease very 
 often exists for a long time undiscovered in business men who 
 have lived under a state of constant mental tension. 
 
 Hereditary influenee is occasionally *a cause of the contracted 
 kidney. A remarkable instance of this hereditary tendency 
 has recently come to my notice. I was recently consulted by 
 a gentleman, aged 30, who has granular kidneys. His father 
 and mother both died of Bright's disease, aged 56 and 63 years 
 respectively. The mother had convulsions. A brother died 
 of Bright's disease, without convulsions, at the age of 37. Two 
 children of this brother had Bright's disease when 4 and 7 
 years of age. A second brother died at the age' of 29 with 
 convulsions. A third and fourth brother, aged 23 and 32 
 years respectively, have had Bright's disease for six years. A 
 sister, aged 36, has had Bright's disease for five years. A 
 brother, aged 26, and a sister, aged 34, have as yet no signs of 
 Bright's disease. A maternal cousin died of undoubted Bright's 
 disease, and other members of the family, belonging to pre- 
 vious generations, died with symptoms which suggest Bright's 
 disease. The patient himself has undoubted granular kidney, 
 discovered in August, 1880. An examination of his urine in 
 1876 revealed no evidences of the disease. There is no gout 
 in the family. Dr. Dickinson also relates the history of a 
 
 * Edes, Robert T., Some of the Symptoms of Bright's Disease. Boston 
 Med. and Surg. Jour., vol. ciii, Xo. 2, July Sth, 1880.
 
 INTERSTITIAL NEPHRITIS. 167 
 
 family in which a hereditary albuminuria existed, apparently 
 independent of gout. 
 
 Alcohol, formerly thought to be a potent cause of the cir- 
 rhotic kidney, is now acknowledged to be an infrequent one. 
 The analogy of this condition to the cirrhotic liver suggested 
 a similar irritant action of the alcohol in the blood upon the 
 interstitial tissue of the kidney. But although the portal blood 
 contains a large amount of alcohol after its liberal ingestion 
 into the stomach, by the time the blood passes through the 
 heart and lungs and gets into the kidney, very little if any re- 
 mains unoxidized. It is barely possible, however, that when 
 enormous quantities are used, enough may remain in the blood 
 passing through the kidney to irritate its connective tissue, and 
 also the cells lining the tubules. The latter, from their efforts 
 to remove it, are probably more frequently irritated than the 
 former; whence also the possibility, though rare also, of 
 chronic parenchymatous nephritis being caused by it, as re- 
 ferred to in discussing the latter disease. 
 
 Valvular disease of the heart is another cause of interstitial 
 nephritis, which is the immediate result of the venous conges- 
 tion shared by the kidney in conjunction with all abdominal 
 organs, when there is insufficiency of the heart's valves. But 
 while the kidney is always altered in every case of valvular 
 disease which has existed for any length of time, yet it is sel- 
 dom granular. The kidney most frequently found at autop- 
 sies of cases of valvular disease is hard, dark-red or bluish, 
 congested and somewhat larger than the normal organ, but 
 smooth, not granular. This is called the cyanotic kidney, 
 the kidney of cyanotic induration, or of passive congestion. 
 On section, the same vascular appearance is seen, the pyramids 
 being more deeply colored than the cortex. Minute exami- 
 nation reveals the capillaries and veins distended with blood, 
 as far back as the Malpighian bodies. The epithelium of 
 the tubules is unchanged or perhaps slightly more granular 
 than in health. The interstitial tissue is but slightly increased, 
 but tougher and more distinct than in health. Now this is the 
 condition of the kidneys found in most cases of valvular heart
 
 168 bright's disease. 
 
 disease which have continued, say a year or more. But if the 
 disease be still more prolonged we have the essential patho- 
 logical condition of the granular kidney. There is a positive 
 overgrowth of the interstitial tissue, which is especially evi- 
 dent about the Malpighian bodies. Contraction takes place, 
 interfering with the nutrition of the epithelium of the con- 
 voluted tubules, which become granular, fatty, disintegrated, 
 and portions of the tubes themselves and their Malpighian 
 bodies are destroyed, producing cicatricial depressions, and 
 an uneven granular surface. It is true that the granula- 
 tions are never so large or distinct as in the typical granular 
 kidney, nor is the organ ever so much reduced in size, per- 
 haps never below the normal size. But the mechanism of 
 the production of the condition is precisely that of the ordi- 
 nary granular kidney. It is simply a difference in degree. 
 Therefore I do not hesitate to place valvular disease of the 
 heart in the category of causes of interstitial nephritis. In 
 this view I am sustained by Dickinson and Lecorche. The 
 former,* in 153 post-mortem examinations of persons dying 
 with valvular disease of the heart, found the kidneys in 67 
 having granular surfaces, and more or less contracted cortices. 
 In 29 the kidneys were hard, congested, and increased in bulk, 
 but still smooth. Dr. Barclay,! in an analysis of 79 cases of 
 valvular disease, found 28 having granular kidneys. Bartels, 
 on the other hand, prefers to consider it a separate process, 
 chiefly, if I understand him aright, on the ground of its slow- 
 ness or chronicity. He compares it with brown induration of 
 the lung as it occurs in connection with valvular heart disease, 
 or the thickening of the peritoneum which follows upon portal 
 congestion. I do not think simple duration sufficient to sepa- 
 rate one process from another with which it is otherwise iden- 
 tical. Of course this condition of the kidney as the result of 
 heart disease is to be disting-uished irom that in which the renal 
 disease is primary, as occasionally happens. 
 
 * Dickinson, op. citat., p. 155. 
 
 f Med.-Chirurg. Transac, vol. xxxi, p. 9(5.
 
 INTERSTITIAL NEPHRITIS. 169 
 
 Pregnancy is rarely, if ever, a cause of interstitial nephritis. 
 I have already named it among the fertile causes of acute 
 and chronic parenchymatous nephritis, being here in accord 
 with Bartels and against Dickinson. Indeed I am unable 
 to understand how the latter writer draws the conclusions 
 which he does from the cases he reports. For the morbid 
 appearances he describes seem to me more those of acute and 
 chronic parenchymatous nephritis than of interstitial nephritis, 
 some of those which most resembled the granular kidney 
 being in the stage of contraction.* 
 
 Age and Sex of those Affected. — Interstitial nephritis is com- 
 monly considered a disease of middle age. And so it is in the 
 sense that the majority of persons in whom it is discovered are 
 past forty. And I confess to some surprise when, on investigat- 
 ing the matter, I found that there were so many cases, although 
 still a small number under thirty. The youngest patient whom 
 I have had was twenty-six. But it will be seen from the ap- 
 pended tables by two of the largest observers, Dickinson and 
 Bartels,t that the number of cases occurring under forty years 
 of age is not inconsiderable. The figures indicate the age at 
 which death occurred, and there was an autopsy in each case. 
 
 Bartels. Dickinson. 
 
 1 was 18 years. 1 was between 11 and 20 years. 
 
 1 was 19 years. 24 were between 21 and 30 years. 
 
 r were 20 years. 50 were between 31 and 40 years. 
 
 4 were between 20 and 30 years. 93 were between 41 and 50 years. 
 
 9 were between 30 and 40 years. 76 were between 51 and 60 years. 
 
 4 were between 40 and 50 years. 47 were between 61 and 70 years. 
 7 were between 50 and 60 years. 17 were over 70 years. 
 
 5 were between 60 and 73 years. 
 
 33 308 
 
 * The reader who is sufficiently interested in the subject is referred to a 
 paper by the writer on " The Causal Lesions of Puerperal Convulsions," read 
 before the Pathological Society of Philadelpliia, April 28th, 1878, and 
 published in the Transactions for 1878-1879. The entire subject of Puer- 
 peral Convulsions in its relation to albuminuria and Bright's disease is here 
 discussed. 
 
 t Bartels, op. citat,, p. 411. Dickinson, op. citat., p. 145.
 
 170 bright's disease. 
 
 It must be remembered that there is a tendency to over- 
 growth in the interstitial tissue of the kidney as of other 
 organs in old age. Hence the term senile atrophy of the 
 kidney. It is not safe, therefore, to call every instance of 
 atro])hied kidney met in the post-mortem room a case of inter- 
 stitial nephritis. The clinical history, or some one of the 
 well-marked symptoms of the disease, as albuminuria or uroe- 
 mic symptoms should have preceded to sustain the diagnosis. 
 This was the defect in the method followed by Gull and Sut- 
 ton,* who, in the post-mortem examination of a large number 
 of cases, independent of previous disease, noted that out of 
 thirteen cases examined between the age of sixty and seventy, 
 twelve had contracted kidney. At the same time, this atrophy 
 of old age may proceed to such degree as to attain positive 
 pathological degrees, manifested not only by the morbid anat- 
 omy of the kidney, but by the symptoms of interstitial ne- 
 phritis. 
 
 As to sex, nearly twice as many males are subjects of the 
 disease, because of the more frequent exposure of the former 
 to the causes of the affection. 
 
 Ilorhid Anatomy. 
 
 In interstitial nephritis, both kidneys are involved, but there 
 is often a marked difference in the amount of disease in each. 
 
 IlacroscojjicaUy the organs are evidently smaller than in 
 health, often less than half as large. I have occasionally seen 
 them less than five centimeters (two inches) in length. Xext 
 to this reduction in size, the most striking feature of the con- 
 tracted kidney is its uneven or granular surface, which is, how- 
 ever, not always recognizable until after the capsule is removed. 
 Very characteristic also is the presence of cysts with more or 
 less clear watery or gelatinous contents, often visible through 
 the capsule. These are not invariably, but quite constantly 
 present. The capsule, itself thickened, strips off with difficulty, 
 
 * On the Pathology of the morbid state commonly called Bright's disease 
 with contracted kidney ( Arterio-cajiillary fibrosis). Med.-C'hirurg. Transac, 
 2d series, vol. xxsvii. 1872.
 
 INTERSTITIAL NEPHRITIS. 171 
 
 dragging portions of tlie secreting structure with it. Owing 
 to the resistance which the blood meets in its passage through 
 the kidney, as the result of pathological alterations to be pres- 
 ently described, a larger portion of it passes out of the organ 
 by way of the capsule. Hence the bloodvessels of the latter 
 are dilated, as are also the lymph spaces. 
 
 Bereft of its capsule, the kidney is granular, hard, tough, 
 and usually darkened in color; whence one of its names, the 
 "red granular kidney." This color is in strong contrast to the 
 white or slightly yellow tinge of the fatti/ and contradmg kid- 
 ney, and although not always marked, but sometimes even 
 substituted by a paleness, it is still easily distinguished from 
 that of the contracting kidney of parenchymatous nephritis. 
 
 The granules on the surface of the contracted kidney are 
 distinct round and oval elevations of the surface, ranging in 
 size from that of a pin's head to a pea, or from one to five 
 millimeters (^'g to \ of an inch). Those of smaller size are 
 most numerous, and at first correspond w'ith the lobules, the 
 bases of which are visible on the surface of the normal organ. 
 The larger ones result from the coalescence of two or more 
 smaller. The granules themselves are of a lighter color than 
 the depressed circlets between them, which are tinted with vas- 
 cularity, and have a purplish or fiiint red hue. 
 
 The cysis already referred to are now more distinct (after 
 removal of the capsule), and vary also greatly in size. While 
 equalling in minuteness the smallest of the granules, some of 
 them are as large as a walnut. The larger are apt to be 
 ruptured on stripping off the capsule. 
 
 On section it is at once evident that the reduction in size of 
 the kidney is almost wholly due to a narrowing of the cortex, 
 although the medulla is also contracted. The former may not 
 be more than three or four millimeters {\ to ^ inch) in width, 
 and exhibit every degree between this and the normal. The 
 Malpighian bodies are smaller, less numerous, and can scarcely 
 be detected by the naked eye, wdiile the small arteries are 
 more prominent from thickening of their walls. The in- 
 creased density and firmness of the organ are apparent. If
 
 172 bright's disease. 
 
 the conditions occur in a gouty subject, linear chalk-marks of 
 urate of soda may be present, more particularly in the pyramids 
 of straight tubules, and are contained within as well as be- 
 tween the tubules. The little cysts in varying numbers are 
 scattered throughout the section from cortex to papillae, but 
 they are more numerous in the former. Rindfleisch says 
 the cysts in the medulla, in the neighborhood of the papillae, are 
 formed in the flexures of the looped tubes, where they originate 
 in the colloid metamorphosis of cylinders of fibrin. The cysts 
 may be altogether wanting. 
 
 The pelvis of the kidney may be unaltered. It is sometimes 
 enlarged from retraction of the pyramids. The calyces may 
 be elongated. On the other hand if the kidney is very much 
 reduced in size, the capsule may be pursed up, and propor- 
 tionately smaller. 
 
 Da Costa and Longstreth, in a recent article,* call atten- 
 tion to the constant presence of an increased amount of fat 
 surrounding the contracted kidney, even in emaciated subjects. 
 
 Minute Structure. — Minute examination of thin sections 
 through the cortex, clearly reveals the change to be an over- 
 growth of connective tissue, with destruction of the tubules and 
 blood v^essels. The process is best studied if the sections in- 
 clude the capsular edge, as it progresses from wathout iu- 
 w^ards. In these may be seen extensive tracts of connective 
 tissue of different ages, separating the tubules, which, in sections 
 of healthy kidneys, are seen to be closely in contact without 
 appreciable intertubular substance. The younger connective 
 tissue exhibits a simple hyperplasia of cells, with a scanty 
 transparent intercellular substance, while that which is older 
 contains fewer corpuscles and a more or less distinctly fibrillated 
 intercellular substance. 
 
 The tubules themselves, appear, in places, quite normal ; in 
 others they are represented by fragmentary portions in which 
 the cells are still unchanged ; in others again the cells ex- 
 hibit a granular degeneration ; some are evidently dilated ; 
 
 * Researclies on the State of the Ganglionic Centres in Bright's DiseasCi 
 Am. Jour. Med. Sci., N. S., vol. 80, 1880, p. 25.
 
 INTERSTITIAL NEPHRITIS. 173 
 
 others still are completely shrivelled, while it is evident from 
 the larger areas of connective tissue that many have com- 
 pletely disappeared. In a few tubules, waxy casts are present. 
 The Malpighian bodies are surrounded by concentric layers of 
 nucleated connective tissue. Many of them are shrivelled and 
 atrophied, and an attempt to inject them with colored injecting 
 fluids fails either partially or completely. Some thus altered 
 lie detached from the tubules with which they should be con- 
 tinuous. 
 
 The cysts originate partly in dilatations of obstructed seg- 
 ments of the uriniferous tubules, and are partly the result of a 
 dilatation of the Malpighian capsules. Proof of the latter 
 mode of origin is found in the fact that compressed capillary 
 tufts are sometimes found lying up against one side of the wall 
 of the cyst. 
 
 The same overgrowth of connective tissue takes place in the 
 medulla, but it appears here later, extends more slowly, and 
 never reaches the degree found in the cortex. For this reason 
 the contraction is not nearly so great, but the medullary area is 
 still somewhat diminished by retraction of the pyramids. The 
 excreting tubes in the medulla are in some places dilated, and 
 in others twisted. 
 
 Minute examination of the granules on the surface of the 
 kidneys shows them to be made up of tubules in a tolerably 
 perfect state, the mass having been caused to project by the 
 constriction of the connective tissue encircling its base. 
 
 The vascular system of the contracted kidney is the seat of 
 important changes. In the first place it shares with the tubules 
 the compressing effect of the contracting new formation. As 
 the result of this, a part of the capillary system is destroyed, 
 and in the part thus destroyed are many capillary coils in the 
 Malpighian bodies. Hence, as many afferent arterioles send 
 their blood directly into the second capillary network, which 
 is also cut down by the pressure. The vessels which remain 
 are often dilated and twisted, and in consequence of the destruc- 
 tion of numerous Malpighian bodies, send much of their blood 
 out through the capsule.
 
 174 bright's disease. 
 
 A further very striking vascular alteration is a hypertrophy, 
 with subsequent degeneration of the muscmlar coat of the 
 arteries and arterioles, and thickening of the external fibrous 
 coat. This alteration has given rise to a good deal of discus- 
 sion. Dr. Bright noted changes in the renal artery in kidney 
 disease, but Dr. George Johnson, in 1867, described the change 
 more thoroughly, and showed it was common to the Avhole 
 body. He considered it a pure muscular hypertrophy, — a reflex 
 reactive overgrowth, whose object is to resist the entrance of 
 the contaminated blood into the tissues. Drs. Gull and Sutton, 
 in 1872, showed that along with the muscular hypertrophy 
 there was also a thickening of the external fibrous coat. They, 
 however, made the condition of the renal arteries a part of a 
 general one, atfecting the entire arterial system, which, while it 
 commonly begins in the kidney, may begin primarily in other 
 organs. Indeed, according to them, the kidneys may be but 
 little if at all affected, whilst the morbid change is far advanced 
 in other organs. They characterize the condition as a " h^'aline 
 fibroid " formation in the arterioles and capillaries, and suggest 
 for it the name "arterio-capillary fibrosis." They say further, 
 that the morbid state is allied to the conditions of old age, 
 and that we cannot refer the vascular changes to an antecedent 
 chano-e in the blood due to defective renal excretion, but that 
 they are due to distinct causes not yet ascertained. The ele- 
 ment of tliickening of the external coat, in addition to the 
 hypertrophy of the muscular, these observers have established ; 
 but their view as to its being but a part of a general condi- 
 tion, and in no way the result of kidney disease, is not ac- 
 cepted, so far as I know, by any. Nor have their views as to 
 its causation been any more favorably received. 
 
 This condition is invariably associated with hypertrophy of 
 the left ventricle of the heart. The two increase pari passu, 
 and it is therefore impossible to disassociate their considera- 
 tion. That they are both the result of the renal condition it 
 seems to me requires no further proof than that furnished by 
 Johnson and Dickinson, in their respective treatises and papers. 
 
 As to the immediate cause of this hypertrophy and over-
 
 INTERSTITIAL NEPHRITIS. 175 
 
 growth, Dr. Johnson's view best explains the facts, while it is 
 consistent with the modern physiology of the arteries. It has 
 already been said that he ascribes the thickening of the middle 
 coat to a reactive overgrowth. This is stimulated to occur in 
 two ways. The arterioles contract forcibly to resist the admis- 
 sion of tlie blood poisoned with the accumulation of excreta 
 usually eliminated by the kidneys. This is the first stimulus. 
 The heart then contracts with additional power to overcome 
 this resistance, and thus it hypertrophies. But the arterial 
 vessels contract still more forcibly to resist this impulse, whence 
 the second stimulus to overgrowth of the muscular coat. As 
 Johnson considers the change purely a muscular one, he is 
 not called upon to explain the thickening of the adveutitia. 
 But the same causes which excite the hypertrophy are capable 
 of exciting an inflammatory overgrowth of the connective tissue 
 which forms the outer sheath, whether it be increased blood 
 pressure or the irritant character of the blood. Both probably 
 co-operate to produce it. So far as the arteries in the kidney 
 itself are concerned, it is very likely that the thickening of the 
 external coat is partly due to the inflammatory clianges which, 
 in this form of disease, select the connective tissue of which 
 it forms a part. 
 
 In the last edition of his admirable treatise on the Pathology 
 and Treatment of Albuminuria,* Dr. Dickinson, in advocating 
 the older view of Bright, that both the cardiac hypertrophy and 
 thickening of the muscular coat of the arteries are the result of 
 a capillary resistance, points out what he believes to be a serious 
 objection to the view of Johnson. The office of the muscular 
 coat, says Dickinson, is not to resist, but to aid the heart in the 
 propulsion of blood; the force of propulsion, which begins 
 with the cardiac systole, being continued as a wave of contrac- 
 tion, which passes in a peristaltic manner from the orifice of 
 the aorta throughout the arterial system. It is true, this may 
 be one of the offices of the muscular coat of arteries, but it is 
 secondary to a much more important and better determined 
 one of regulating the calibre of the bloodvessel, in accordance 
 
 * Page 328.
 
 17G bright's disease. 
 
 witli the temporary demands of an organ or tissue for blood. 
 This is a reflex operation, controlled by the vasomotor nerves, 
 and although it resists the heart in one sense, this resistance is 
 never sufficient to induce hypertrophy of the left ventricle, be- 
 cause, -while the blood may be partially cut off from an organ 
 or set of organs, by the stopcock action of the muscular coat, 
 all the remaining arteries of the system are relaxed and ready 
 to receive the extra blood thus shut off. But in the case of the 
 poisoned blood, from insufficiency of secretion by the kidneys, 
 all the arterioles are resisting its admission. There is no free 
 outlet. The heart, in its efforts to overcome this resistance, 
 hypertrophies in its left ventricle, against which the arteries 
 again react, and thus the antagonism keeps up, and an increased 
 hypertrophy results. 
 
 Finally, all physiological studies go to prove that the capil- 
 laries do not possess an active power of changing their calibre 
 and, therefore, of resisting the admission of blood. And 
 although the destructive compression of capillaries, and prob- 
 ably even arterioles which occurs in the kidney itself, in cir- 
 rhosis of that organ, obstructs the movement of blood through 
 it, such local resistance is not sufficient in the presence of 
 the unobstructed state of the remainder of the arterial system 
 to produce a universal hypertrophy of the muscular coat in- 
 cluding that of the heart. 
 
 The degeneration alluded to, as succeeding the thickening 
 of the bloodvessel wall, are of the kind which usually succeed 
 hyperplasias, viz., fatty. In the muscular coat the nuclei of 
 the fibre-cells waste, and finally disappear, leaving the coat 
 recognizable only by its transverse striation, although this ap- 
 pearance may also be obscured by the presence of fat-drops, 
 and even crystalline matter. The subsequent changes in the 
 external sheath consist in the conversion of the thickened fibroid 
 adventitia into a more hyaline material. 
 
 The final effect of these alterations is to produce a brittleness 
 in the arteriole walls, which disposes them to rupture on very 
 slight increase of intravascular pressure. Hence, the frequent 
 fatal termination of cases of interstitial nephritis by apoplexy.
 
 INTERSTITIAL NEPHRITIS. 177 
 
 Drs. Da Costa and Longstreth, in a recent paper,* have cle- 
 seribed as more or less constant in Bright's disease, and espe- 
 cially in the contracting kidney, certain changes in the nervous 
 renal ganglia, which consist essentially in a hyperplasia of the 
 connective tissue and a fatty degeneration of the nerve-cells. 
 
 They say that while this lesion might be looked upon as 
 forming a part of the general process of degeneration in connec- 
 tion with the kidney disease, they think it is the cause of the 
 renal malady and precedes the degenerative changes. 
 
 Also that the diseased condition of the ganglia furnishes the 
 clue to the alterations of the vessels of the kidneys. 
 
 And finally, that similar changes producing similar results 
 may exist in other ganglia ; for instance, in the cardiac plexus, 
 explaining the hypertrophy of the heart. 
 
 Da Costa and Longstreth in the paper alluded to, say they 
 do not think the heart hypertrophies because of the opposition 
 the passage of the blood meets in the renal circulation, but that 
 it is to be traced to a central origin ; in one case to the cardiac 
 ganglia, and in the other to the renal. " The same statement 
 applies to the changes in the vessels and tissues in other organs 
 of the body, and when they in their turn are affected the gan- 
 glia which preside over them as centres most probably have 
 been acted upon in a similar manner as the ganglia already 
 mentioned." 
 
 For a description of the retinal changes which occur most 
 frequently in this form of Bright's disease, see the following 
 Section IX, by Dr. William F. Norris. 
 
 Symptoms and Course of Interstitial Nephritis. 
 
 The degree of uncertainty as to the origin of a large majority 
 of cases of contracted kidney is only equalled by that of the 
 insidiousness of their approach. The beginning of the disease 
 is certainly not marked by any distinctive symptoms ; and its 
 progress is often unmarked by any, until those of ursemia, as 
 manifested by the unexpected convulsion, drowsiness, or stu- 
 
 * Amer. Jour, of the Med. Sciences, N. S., vol. 79, July, 1880, p. 17. 
 
 12
 
 178 bright's disease. 
 
 por, mark the beginning of the end. The attention of the 
 physician being thus directed to the urine, albuminuria and 
 casts are discovered and confirm the condition. To the observ- 
 ing i)hysician, perhaps an unaccountable weakness or slow 
 convalescence from acute disease, or other unexplained con- 
 dition, may suggest an examination of the urine ; or the pe- 
 culiar tense and bounding pulse of hypertrophy of the left ven- 
 tricle, or the more tangible symptom of a slight swelling of the 
 feet or ankles, recognizable only at night or through the unex- 
 pected tightness of a boot, may lead to the same examination. 
 
 Attention being called to the urine, it will be found to pre- 
 sent characters which are more or less distinctive, and com- 
 monly in connection with the absence of other symptoms, al- 
 luded to as so characteristic, lead easily to a diagnosis. It is, 
 when freshly passed, acid in reaction, copious, often exceeding 
 the normal amount, never scanty except in the last stages of the 
 disease. The quantity may reach 2700 cc. (90 oz.), but this is 
 very rarely. The patient very commonly has to rise at night, 
 probably not more than once or twice, to pass his water. Con- 
 sequently, the urine is light in color and of low specific gravity, 
 — 1010—1015, — and contains a trifling or moderate flocculent 
 sediment. It is generally albuminous, but the albumen is 
 small in amount, and may be temporarily absent, or it may be 
 absent before a meal, and present after it. Later, however, it 
 becomes constant. It seldom exceeds one-fourth the bulk of 
 fluid tested, and is very constantly a good deal less, showing 
 a delicate line of white by Heller's nitric acid test. 
 
 Tube-casts are present, but not usually numerous. They are 
 almost solely hyaline, and pale granular. Some of the hyaline 
 casts are delicately so, requiring nice illumination for their de- 
 tection ; others are distinct and sharply cut; others, still, con- 
 tain two or three glistening oil-drops. Casts may at times be 
 absent and again reappear, as is the case with albumen. Towards 
 the termination of cases of interstitial nephritis the urine di- 
 minishes in quantity, the specific gravity increases, and the casts 
 become much more numerous, and include among them highly 
 granular or dark granular, and occasionally even blood-casts,
 
 INTERSTITIAL NEPHRITIS. 179 
 
 in addition to those alluded to. In a case which recently ter- 
 minated under my observ^ation, the specific gravity rose to 
 1030, and the urine diminished to about 25 cc. (8 oz.). The 
 low specific gravity of the urine in the early stages is largely the 
 result of the increased quantity, which often equals 1800 to 2100 
 cc. (60 to 70 oz.), and even rarely 2700 cc. (90 oz.). 
 
 The iwea is also diminished sooner or later, and in this 
 manner the lower specific gravity is contributed to. This dim- 
 inution becomes marked towards the close, accounting for the 
 urseiuic symptoms which often first announce the disease. It 
 may be as low as 1 gram (15 grs.), and may be anything be- 
 tween this and the normal 24 hours' quantity, which may be 
 put down at from 20 to 40 grams in an adult. 
 
 All the remaining normal constituents may be said in gen- 
 eral terms to be diminished. 
 
 As to the other symptoms which were alluded to as suggest- 
 ing an examination of the urine, a feeling of unaccountable 
 weakness or of being tired was mentioned. This is very often 
 present, but it is a symptom which is present in many con- 
 ditions, and should only be considered as suggestive. 
 
 SVu/lit oedema about the feet and ankles is often present, 
 being so slight as to escape detection, or is discovered acciden- 
 tally. When present it is significant, but it is often entirely 
 wanting. We have the explanation of this slight oedema or 
 its entire absence, in the free secretion of water, which is such 
 a decided symptom of the early stages of this disease. 
 
 Hypertrophy of the left ventricle of the heart is so constant 
 that it may be properly considered as a symptom rather than 
 a complication, which it strictly is. No case of interstitial 
 ne])hrltls has existed for any length of time without the pres- 
 ence of this condition, and as few cases are discovered until 
 they have existed a good while, few are found without hyper- 
 trophy, although it is not always marked. In about one-half the 
 cases, however, there is evident hypertrophy. Corresponding to 
 this, the pulse has a peculiar tense and bounding character. 
 These two symptoms have, therefore, a diagnostic value. I have 
 already alluded to the cause of this hypertrophy, — the in-
 
 180 BRIGnx's DISEASE. 
 
 creased effort of tlie heart to propel the blood through capil- 
 laries which resist its presence. Ordinarily there are no 
 symptoms of this enlargement except the increased percussion 
 area and the peculiarity of the pulse. Occasionally, however, 
 there are symptoms of cardiac distress, dyspnoea, and palpita- 
 tion. Also accentuation of both sounds and reduplication of 
 the first. The latter is probably due to a want of synchronism 
 in the systole of the two ventricles,* There is usually no 
 murmur because there is no valvular disease. The latter may 
 be present, however, in one of two ways. The patient may 
 have had valvular disease prior to the renal malady, or the 
 latter itself, by its long continuance, have produced endocar- 
 ditis and atheroma which are among its results, particularly in 
 those who have passed middle life, thus increasing the natural 
 tendency of age to this condition. 
 
 Increased arterial blood-pressure is another symptom, which 
 is the direct result of the hypertrophy of the left ventricle. 
 This continues as long as the power of the heart lasts. When 
 the latter begins to fail, the blood-pressure diminishes, and 
 with it begin a train of symptoms, among which diminished 
 secretion of urine and dropsy are the most conspicuous. It oc- 
 casionally happens that, although this hypertrophy is a com- 
 pensating measure, it is the cause of inconvenience, manifested 
 by the cardiac distress, dyspnoea, palpitation, and dizziness, 
 alluded to as sometimes present. 
 
 The atheroma and the increased arterial blood-pressure are 
 the causes of another symptom which frequently determines 
 the mode of death, — rupture of a bloodvessel in the brain ; in 
 a word, apoplexy. As stated, this accident occurs generally 
 late in life, but Dickinson reports a case in which cerebral 
 haemorrhage occurred in a girl of twelve. The proportion of 
 cases of recognized interstitial nephritis in which this occurs is 
 not large, but many cases of apoplexy are directly traceable 
 by autoj^sy to unsuspected renal cirrhosis. Dickinson believes 
 that of fatal cases of apoplexy one-half are preceded by this 
 form of disease. 
 
 * Sibsoii, British Medical J(nini:il, April 1st, 1871, p. 238.
 
 INTERSTITIAL NEPHRITIS. 181 
 
 Hicmorrhages in other situations are referable to this same 
 altered state of the bloodvessels, as into the retina, from the 
 nose, and even into the stomach. Hence sudden blindness, as 
 well as dimness of vision due to retinitis albuminurica, is a 
 symptom which occasionally presents itself. 
 
 The latter symptom, dimness of vision due to i-etinitis albu- 
 minurica, is a grave one. The pathological alteration in the 
 retina which causes it presents itself usually only at an ad- 
 vanced stage of the renal disease, and is but little remediable. 
 The condition itself I deem of such importance as to demand 
 separate consideration by an ophthalmologist. Accordingly, 
 my friend Dr. William F. Norris has kindly furnished an 
 article on the Retinitis of BrigMs Disease, which will follow 
 this section. 
 
 The termination by urcemia occurs more frequently in this 
 than any other form of Bright's disease. Bartels says that 
 nearly all the patients he has seen die in the extreme stage of 
 atrophied kidneys, sank under the symptom of chronic urtemia. 
 I can say the same of my own experience as to ursemia, but 
 acute ursemia has been as frequent as chronic. As already 
 stated, it is frequently the first intimation of the existence of 
 any derangement, and manifests itself in any one or more of 
 the forms already described under acute nephritis. Headache, 
 drowsiness, convulsions, stupor, delirium, maniacal excitement, 
 renal asthma, restlessness, nausea, vomiting, any one of these 
 symptoms may usher in the dreadful train which is so apt to 
 be fatal. But coma or a partial coma is here more frequent 
 than convulsions. Drowsiness and severe headache are also 
 frequent beginnings. Dr. E. C. Seguin has recently called 
 attention to occipital headache as a symptom of ursemia.* In 
 a case which terminated recently under my observation, in 
 which delirium, coma, and maniacal symptoms were present, 
 but interrupted by active treatment, the tenijyerature was very 
 hish, rano-ino; from 102° to 105°, and rose to 107° immedi- 
 ately before death. During the stupor the patient was quiet, 
 and there was no stertor. 
 
 * Archives of Medicine, vol. iv, No. 1. New York, August, 1880.
 
 182 bright's disease. 
 
 Dyspeptic symptoms with obstinate vomiting, particularly 
 in the morning before eating, are apt to usher in a chronic 
 ur?emia. Diarrhoea is less common, but also sometimes occurs 
 towards the close, when it may be very difficult to control. 
 
 The duration of this form of renal disease is indefinite. 
 Always a chronic process, it may last for years undiscovered, 
 and when discovered before it is too far advanced, the knowl- 
 edge of its presence will suggest measures of precaution and 
 treatment, which may so prolong life that it need only be de- 
 termined by its natural limit or some other disease. Yet com- 
 plete recovery from well-established interstitial nephritis dis- 
 ease is probably unknown. 
 
 Complications. 
 
 These are, in addition to what have already been considered 
 as symptoms, but of Avhich some might with propriety be 
 classed among complications, bronchitis, pericarditis, pleurisy, 
 pneumonia; and, more rarely, endocarditis, peritonitis, inter- 
 tubular gastritis, and even inflammation and ulceration of the 
 bowels. But all inflammatory complications except bronchitis, 
 pleurisy and pericarditis are less common than in acute ne- 
 phritis. Bronchitis is said to be the most frequent complica- 
 tion, while pericarditis is the most dangerous, being almost 
 invariably fital. The former occurs in about 33 per ceut. of 
 the cases, and the latter in 25 per cent. Pleurisy and pneu- 
 monia are also of tolerably frequent occurrence, Grainger 
 Stewart finding the former in 15 per cent, of his cases and 
 pneumonia in 7 per cent. The latter author found pericar- 
 ditis also in only 7 per cent., while Dickinson found recent 
 pericarditis in nearly 25 per cent. ; a proportion which would 
 be much increased if old false membranes and adhesions are 
 included. Acute endocarditis and peritonitis occur but very 
 seldom. It is possible that the obstinate vomiting in some 
 cases may be due to intertubular gastritis, the occasional pres- 
 ence of which is asserted by Drs. Fenwick and Wilson Fox, as 
 distinguished from the follicular inflammation found in acute 
 nephritis. Three cases of ulceration of the ileum are mentioned
 
 INTERSTITIAL NEPHRITIS. 183 
 
 by Dr. Dickinson, and one by Dr. Bartels. The occasional 
 obstinate diarrhoea may be due to this cause. 
 
 The cause of this tendency to inflammation attending con- 
 tracted kidneys is probably the irritant state of the blood, poi- 
 soned with the retained excretions which the damaged kidney 
 is unable to remove. 
 
 Diagnosis. 
 
 The diagnosis of an interstitial nephritis is usually easy, 
 if by any means an examination of the urine is suggested. 
 The increased, or at least undiminished quantity, the low spe- 
 cific gravity, small albuminuria, delicate hyaline, and pale 
 granular casts, in the absence of other symptoms, are sufficiently 
 distinctive. The conditions which should suo-o-est such an ex- 
 amination are a feelinoj of constant weariness, slig'ht swellino; 
 of the feet, drowsiness, intense headache, confused intellect, 
 dyspeptic symptoms, obstinate nausea, delirium, coma, and 
 convulsions. 
 
 Prognosis. 
 
 The prognosis is unfavorable as to complete recovery, but 
 favorable as to prolongation of life if the diagnosis be made 
 sufficiently early. If it is not made previous to the setting 
 in of unemic symptoms, little may be expected. But even at 
 this stage energetic treatment may still avail to avert the im- 
 mediate danger and prolong the patient's life. The possible 
 sudden occurrence of convulsions and coma, and of death 
 therefrom, should always be remembered and impressed upon 
 the relatives of the patient. 
 
 Treatment. 
 
 From what has been said under prognosis, it is evident that 
 the most hopeful result to be expected from treatment is the 
 protection of the patient from the consequences of his malady, 
 rather than the restoration of the kidney to its normal condi- 
 tion. Our power in the former respect depends largely upon
 
 184 bright's disease. 
 
 the stage at which the disease is discovered. But let us first 
 suppose tliat it is detected, as it often is, at a period in which 
 the urine is tolerably abundant, the albuminuria small, the 
 casts are few, and there is no oedema. Here, again, the indi- 
 cations are, first, to maintain the integrity of the blood, chiefly 
 by preventing the accumulation of urea and its allial com- 
 pounds, and by compensating the loss by albuminuria, which 
 is at first not great ; and, second, to treat as they arise, the acci- 
 dents and complications which are often so dangerous to the 
 patient. 
 
 The first of these is best accomplished by dietetic and 
 hygienic measures, aided by the use of a few remedies. 
 
 First, as to food, all that was said under chronic paren- 
 chymatous nephritis is more than applicable to interstitial 
 nephritis, because the appetite is still good and a suitable se- 
 lection can be exercised. 
 
 As there stated, it is now generally recognized that the urea 
 found in the blood and eliminated by the kidneys in health, 
 has its chief source in the azotized elements of food, and that 
 the more nitrogenous food we consume, the larger is the accu- 
 mulation of urea in the blood, and the greater the work thrown 
 upon the kidneys. Xow while it is not possible nor desirable 
 to exclude all nitrogenous food, it must be of advantage in this 
 disease to reduce it to a moderate amount. This is accomplished 
 by the substitution of all, or perhaps preferably, of a part of 
 animal flesh by milk and cream, while drawing the elements 
 of a mixed food from the vegetable kingdom. The so-called 
 vegetarians have proved conclusively that it is possible to live 
 and maintain good health upon milk and an otherwise exclu- 
 sively vegetable diet. And while this diet may not be com- 
 patible with the highest mental and physical development of 
 which man is capable,* which is not at all proven, the resulting 
 life is perfect enough for all its objects, and will doubtless be 
 acce])table to those who prefer to live. On such a system I 
 have known the patient with contracted kidney to maintain 
 apparently perfect health for many years. 
 
 * See Carpenter's Physiology, 7tli English ed., 1869, p. 77.
 
 INTERSTITIAL NEPHRITIS. 185 
 
 With regard to beverages, there is no doubt that the use of 
 strong alcoholic drinks should be avoided, and brandy, whis- 
 key, and strong sherries and ports should be prohibited. The 
 ligiit wines, and especially the red wines, and lighter alcoholic 
 drinks, as lager beer, porter, etc., may be used. 
 
 What was said of clothing, fresh air, and exercise, in con- 
 nection with chronic parenchymatous nephritis, is even more 
 applicable to interstitial nephritis. Warmth of the body, main- 
 tained by woollen garments next the skin to encourage its action, 
 and the avoidance of damp and cold which check it, are 
 peremptory. The wetting of the body by rain, or of the feet 
 alone, has frequently been the exciting cause of a ursemic at- 
 tack which was fatal. Rubber overshoes should be worn in 
 all damp weather. 
 
 In this connection sea-bathing requires to be alluded to. It 
 is well known that sea-bathing sometimes induces albuminuria 
 in individuals perfectly healthy, or at least in individuals at 
 other times free from albuminuria. This must of course be 
 due to a temporary congestion of the kidney, the result of an 
 introversion of the blood from the skin, which is kept up by 
 the length of the bath. Still more mischievous, therefore, 
 must be the effect of prolonged sea-bathing upon one whose 
 kidneys are already damaged and incompetent to perform their 
 office. I am confident that one case of latent contracted kid- 
 ney that recently came under my observation, was hastened to 
 its fatal termination by this cause, the patient in this instance 
 remaining in the water two or three hours at a time. Sea- 
 bathing, therefore, or indeed any form of cold bathing should 
 be interdicted to the patient with contracted kidney. Sea- 
 bathing is especially mentioned because it is considered so 
 healthful, and involves remaining in the water so much longer 
 at a time. On the other hand the warm bath, and especially 
 an occasional Turkish bath is advantageous. 
 
 For the same reason there is no doubt that residence in a 
 warm equable climate is often of signal service in interstitial 
 nephritis; and cases are reported where the albumen has dis- 
 appeared and apparent recovery taken place during such resi-
 
 186 bright's disease. 
 
 dence, where the previous duration was such as to make re- 
 covery at least improbable. 
 
 I recall the instance of a lady past middle life who had 
 granular kidneys, and who had already begun to suffer the 
 numerous inconveniences of advanced renal disease. She went 
 abroad, and, during a residence in Southern Germany, was en- 
 tirely relieved of all unpleasant symptoms. She described 
 herself as feeling during that period like a young girl. She 
 had no sooner reached Liverpool, on her return, than all of these 
 symptoms returned, and she died in a few months after reach- 
 ing home. I have no precise knowledge of the frequency of 
 Bright's disease in the southern j)art of the United States, but 
 I seldom hear of cases originating there. 
 
 Prolonged bodily or mental fatigue should also be avoided 
 by these cases, as they have been known to be the exciting 
 cause of uraemia and death. The patient should live a life as 
 easy and as free from any of these causes which have been 
 considered, as his circumstances will permit. 
 
 As to drugs, they are of limited utility. The tonics, iron, 
 quinine, and strychnia, are useful and necessary to combat the 
 tendency to anaemia and weakness, which sooner or later the 
 albuminuria will induce. Iron is perhaps the most important 
 and indispensable, and may be given in the shape of the acetate 
 or the well-known Basham's mixture, of which the formula is 
 given on p. 1 38. But it is a question whether the sense of weari- 
 ness so characteristic, is not due, in a measure, to the accumula- 
 tion in the muscles of effete matter, which should be eliminated 
 by the kidneys, as the tired feeling so characteristic of diabetes is 
 probably due to a retention of sugar in the muscles, the oxi- 
 dation of which relieves the sense of fatigue. In that event 
 this weary feeling in interstitial nephritis would be more 
 likely to be removed by encouraging elimination by measures 
 which promote the action of the skin. I would, however, 
 resort to no very active treatment of this kind, but would 
 recommend an occasional warm bath, or especially a Turkish 
 bath, with thorough friction and precaution from cold ; the com- 
 bination of a gentle diaphoretic, as the sweet spirit of nitre or
 
 INTERSTITIAL NEPHRITIS. 187 
 
 the solution of acetate cf ammonium, with tonics and chalybe- 
 ates, or brisk exercise in the open air, with proper precautions 
 against subsequent exposure while perspiring. These, united 
 with sufficient rest, all tend to supplement the action of the 
 kidneys and avert the consequences of their defective action. 
 
 Diuretics are not indicated in this stage, because the secre- 
 tion of urine is already free and not likely to be much increased 
 by further diuresis. The bowels should be kept regular by 
 the use of the natural aperient waters, the Hunyadi, Friedrichs- 
 halle, and Rakoczy, or an occasional blue pill, but there is 
 no need of decided purgation. The aperient may be combined 
 with iron, and for this purpose sulphate of magnesium or 
 potassium are useful. An ounce of the former, ten grains of 
 sulphate of iron, and a drachm of aromatic sulphuric acid may 
 be added to a pint of water, and of this a wineglassful taken 
 before breakfast. Of course, later in the disease, when the 
 urine is again scanty and we want to bring to bear all avail- 
 able means of increased elimination, both diuretics and purga- 
 tives may be desirable to avert the calamity of uraemia. The 
 same principles are to govern us in using them as have already 
 been laid down under acute nephritis. I will mention, how- 
 ever, digitalis as being a diuretic which is at once usually 
 efficient as such, while it will also serve to sustain a failing 
 heart. 
 
 The second indication mentioned, the treatment of the com- 
 2)lications and accidents incident to the condition, resolves itself 
 into the treatment of the bronchitis, the pericarditis, the pleu- 
 risy, pneumonia, endocarditis, gastric and intestinal disorders 
 which have been named as occurring, and especially of the 
 most serious calamity of all, uraemia. The treatment of the 
 complications is that of the same conditions under other cir- 
 cumstances. Prompt restorative and even stimulating meas- 
 ures are, however, here earlier called for than in these same 
 conditions uncomplicated, and when to these are added counter- 
 irritation, the chief indications for the thoracic troubles are 
 fulfilled. Paracentesis is a measure which is often of signal 
 service in effusions into the chest, and occasionally of the 
 pericardium.
 
 188 bright's disease. 
 
 Opium should be cautiously employed, not only in the 
 gastro-intestinal troubles, but under all circumstances, as it 
 undoubtedly increases the dangers of uraemia. This has been 
 abundantly proven. It need not be discarded altogether, for 
 there is indeed no substitute for it in most bowel affections 
 and conditions of severe pain, but it should be given in 
 smaller doses than usual, and its effects watched. In like 
 manner hypnotic, sedative, and antispasmodic effects, when 
 desired, should be produced by chloral and bromides if 
 possible. 
 
 Dyspeptic symptoms are best treated with pepsin and acids. 
 I have found full doses of the wine of pepsin, f .5ij to fSss., 
 with 5 to 10 drops of dilute nitromuriatic acid, and ^^ to ^^ 
 of a grain of sulphate of strychniura, here, as elsewhere, among 
 the most efficient remedies for dyspepsia. Or the powdered 
 pepsin in 8 to 10 grain doses may be dissolved in an aqueous 
 acid solution. 
 
 Finally, as to the treatment of urcemia, when it occurs, the 
 immediate indication is, of course, increased elimination of a 
 decided character. This is accomplished by sudorifics, purga- 
 tives, and diuretics. The degree to which these should be 
 pushed will of course depend upon the urgency of the symp- 
 toms. If there be simple drowsiness, headache, or gastric de- 
 rangement, a brisk purge by ^ of a grain of elaterium, or IJ 
 drops of croton oil, or a saline, followed by full doses of infu- 
 sion of digitalis, with acetate or citrate of potash, may suffice 
 to avert the evil. Or, a drachm of jaborandi-leaves may be 
 infused in six ounces of hot water, and a tablespoonful admin- 
 istered to an adult, and repeated if necessary until a sufficient 
 diaphoresis results. If it be de'^ired to counteract any depress- 
 ing effect, which can hardly exist with so moderate a dose, a 
 drachm of solution of acetate of ammonium, which is also 
 diuretic, may be added to the mixture. The fluid extract of 
 jaborandi, which I have not found so reliable as the freshly 
 prepared infusion, may be given for the same purpose in 20- 
 drop doses. If there is headache, full doses of bromide of 
 potassium are indicated.
 
 INTERSTITIAL NEPHRITIS. 189 
 
 Usually, however, when the symptoms of uraemia appear in 
 this disease, they are urgent, and require more active treatment. 
 Coma is very frequently present, and the administration of 
 remedies by the mouth is difficult or impossible. Then ^ or J a 
 grain of muriate of pilocarpin may be given hypodermically, in 
 solution. I have given | of a grain at a single dose, but the 
 occasion was very urgent. A J grain is perhaps the most 
 reliable, as I have known ^ grain to be insufficient to pro- 
 duce the sweating, although it generally suffices. If the 
 remedy acts, profuse sweating, with or without salivation and 
 diuresis, will take place within half an hour, and this is often 
 attended with a prompt return to consciousness. If pilocarpin 
 is not at hand, half of the above-directed infusion may be 
 thrown into the rectum, and the remainder in half an hour, if 
 sweating does not result. But while waiting for this effect, 
 the patient may be dry-cupped over the loins and at the 
 back of the neck, and, if necessary, a couple of the cujis at the 
 neck may be cut. At the same time a couple of drops of 
 croton oil, diluted with plain oil or glycerin, may be dropped 
 into the mouth, or 5 of a grain of elaterium dissolved in a little 
 water and introduced into the fauces. These latter remedies 
 under the most favorable circumstances are apt to require 
 several hours before they operate, but they are useful in keep- 
 ing up the effect. Hot-air- or vapor- or hot- baths may be 
 used when neither pilocarpin nor jaborandi are available or 
 efficient. Diuretics may also be given with return to con- 
 sciousness. I again give the preference to digitalis, but other 
 remedies may be substituted or alternated with it. The infusion 
 of scoparius (broom tea) is a favorite remedy. Trousseau's 
 diuretic wine, containing juniper, squill, digitalis, and acetate 
 of potash, is an efficient diuretic. Squill alone I have never 
 found to have diuretic properties. Compound tincture of ju- 
 niper or gin may be used, especially where stimulants are indi- 
 cated, and to meet the popular demand for them. 
 
 If convulsions are present, alternating with or to the exclu- 
 sion of coma, chloral should be given. A drachm of chloral 
 hydrate may be given to an adult by enema, often with the
 
 190 bright's disease. 
 
 most promptly satisfactory results. General bloodletting 
 should not be forgotten. The same indications which make it 
 the best remedy in puerperal convulsions call for it here; and 
 while it is less efficient than in puerperal eclampsia, it still may 
 be used, with due regard to the strength of the patient. 
 
 The asthmatic attacks, which are a part of the uremic con- 
 dition, will be relieved by the same class of remedies, but the 
 antispasmodics, chloral, the bromides, Hoffman's anodyne, 
 and inhalations of ether may be used as adjuvants. 
 
 Apoplexy, which is not an infrequent termination of the 
 disease, in consequence of the defective character of the blood- 
 vessel walls, is recognized by the paralysis, general or partial, — 
 most frequently hemiplegia, — which accompanies the uncon- 
 sciousness. Remedies are here generally futile, but such may 
 be used as are indicated for apoplexy elsewhere. Bleeding, 
 counter-irritation, and, if the patient survives the immediate 
 accident, iodide of potassium, with a view to promoting ab- 
 sorption of the extra vasated clot, may be used. 
 
 Hcemorrhages in other situations, as from the nose or alimen- 
 tary canal, are treated by the same measures as when they occur 
 under other circumstances. 
 
 As to specific treatment, or treatment directed to the removal 
 of the interstitial overgrowth in the kidney, there is only one 
 remedy which theoretically could be expected to be of service, 
 and that is iodide of potassium. Unfortunately the peculiar 
 requirements of its administration, viz., the length of time 
 during which the patient must take the remedy before any re- 
 sults may be expected, and the consequent difficulty in accu- 
 mulating a sufficient number of cases, are such that it is almost 
 impossible to determine whether it can be of any service or not. 
 
 Owing to these difficulties I cannot say that I have had 
 suital)le opportunities for testing this remedy. Bartels says 
 of his experience : " The patients whom I treated upon this 
 principle before the occurrence of any threatening symptoms — 
 before their exhibiting any trace of dropsy or uraemia, with- 
 drew themselves from my observation too early, so that I can- 
 not, as yet, venture to form an estimate of the ultimate results
 
 INTERSTITIAL NEPHRITIS. 191 
 
 of this method of treatment." He states, moreover, that he 
 gives the iodide in sokition to the extent of 1.5 to 2 grams (20 
 to 30 grains daily) for an indefinite period, and has seen no 
 prejudicial effects from its nse uninterruptedly for many- 
 months. I have long been convinced that the iodide of potas- 
 sium in ordinary closes is harmless for an indefinite period. 
 With these facts before us, it certainly merits a trial, but it is 
 to be remembered that nothing is to be expected unless its use 
 is begun in the earliest stages, before dropsy, uraemia, or defects 
 of vision have made their appearance. It is best given fasting 
 in the morning.* Smaller doses thus suffice, and there is less 
 interference with the administration of food and other reme- 
 dies required. From 10 to 20 grains a day thus administered 
 may be continued indefinitely. 
 
 * The value of this nietliod of adniinistration, also reconiniended by 
 Bartels, is well illustrated in an excellent paper published in the Philadel- 
 phia Medical Times, vol. x, 1880, p. 445, by Dr. John Guiteras, on the 
 therapeutic advantages of administering iodide of potassium during fast- 
 ing, with some remarks upon interstitial hepatitis with enlargement of the 
 liver.
 
 192 brigiit's disease 
 
 SECTION IX. 
 
 RETINITIS IN BRIGHT's DISEASE. 
 
 By Win. F. Norris, A.M., M.D., Clinical Professor of Ophthahnolo(jy in the 
 University of Pennsylvania. 
 
 The occasional occurrence of amblyopia in the course of 
 Bright's disease has been observed ever since this malady has 
 been diagnosticated and studied ; and although Bright himself, 
 in his first paper on the subject (1827*) gave no eye symptoms 
 beyond oedema of the eyelids, he in ISSGf recorded eleven cases, 
 " illustrating some of the more insidious attacks which attend 
 a fatal termination," in four of which failure of vision, coming 
 on at a period varying from six weeks to six days before the 
 fatal termination, was one of the prominent symptoms. In 
 1840| the same author published twenty-four cases, with de- 
 fective vision in three of them, and in 1843§ Bright and Barlow 
 reported thirty-seven cases of the disease accompanied by 
 ursemic poisoning, with five cases of defective vision among 
 them. It was not, however, till Turcky in 1850 demonstrated 
 the occurrence of splotches of fatty degeneration in the retina, 
 that the anatomical changes accompanying it were known ; 
 and six years later we find a more exhaustive study of the 
 same subject by Virchow.*^ The first ophthalmoscopic de- 
 scription of these changes was published by Heymann** in 1856 
 — just five years after the discovery of the ophthalmoscope by 
 Helmholtz, and in 1859 Liebreichff added still further to our 
 
 * Reports of Medical Cases, by Richard Bright, M.D., F.R.S., vol. i> 
 London, 1827. 
 
 t Guy's Hospital Reports, 1836, pp. 338-380. 
 
 % Guy's Hospital Reports, 1840. I Guy's Hospital Reports, 1843. 
 
 II Zeitschrift der Gesellschaft der Wiener Aertze, 1850. 
 11 Virchow's Archiv, vol. x, pp. 17U-193. 
 ** Archiv f. Oplithalmologie, Bd. ii, part 2, pp. 137-150. 
 ft Ibid,, Bd. V, part 2, pp. 265-2(38.
 
 RETINITIS IN BRIQHT'S DISEASE. 193 
 
 t 
 
 knowledge of the subject, illustrating his descrii^tion with a 
 colored lithographic plate. Since that period the literature of 
 the subject has grown to such proportions that the mere enu- 
 meration of the various articles and works on the sul)ject would 
 require of itself many pages, and the reader will find at the 
 end of the chapter a reference to several works where an ex- 
 tended bibliography is given. 
 
 Symptoms and Description. 
 The retinitis of Bright's disease presents very various aspects, 
 not only in different cases but also in different stages of its 
 development in the same case, and distinguishes itself mainly 
 from other forms of inflammation of this nervous sheet by its 
 marked tendency to fatty degeneration. As seen by a spe- 
 cialist or at an eye hospital the disease usually presents a type 
 quite different to that predominating in the wards of a general 
 hospital. In the former the blood-poisoning seems to fall with 
 peculiar intensity on the nervous system, and the patients come 
 complaining of headache, dizziness, and dim vision, these being 
 the only marked symptoms of the malady, while the anremia 
 dropsy, and other symptoms are either absent or present in so 
 slight a degree that the patients have not supposed themselves 
 suffering from any constitutional malady or needing advice 
 from their medical attendant. The retinal changes in such 
 cases are usually very extensive, and those in the cerebrum 
 would possibly be found equally developed if we had only as 
 accurate a method of investigating them. In the wards of a 
 general hospital, however, we have a much better opportunity 
 to study the development of the retinitis, and it is there most 
 frequently encountered among those suffering from marked 
 dropsy and cardiac disease, with transparent w^axy skins, whose 
 appearance indicates at a glance how seriously their nutrition 
 has been impaired by the ravages of the disease. In these we 
 often see only a few white splotches in the retina, either with or 
 without haemorrhages, and occasionally only a slight atrophy 
 of the optic disk due to a previous retinitis. When the indi- 
 vidual lives and is not markedly relieved by the rest and 
 
 13
 
 194 bright's disease. 
 
 treatniGiit adopted, we frequently liavean opportunity of seeing 
 the development to a greater or less degree of the typical form 
 of the affection. 
 
 Typical Cases. 
 In typical cases the retinal changes commence with slight 
 oedema of the disk and surrounding retina, with a few irregu- 
 lar white splotches and striated hreraorrhages in the fibre-layer. 
 We see the white patches multiply and extend, mostly within 
 an area of two or three disk diameters from the optic entrance, 
 until in high grades of the aifection they coalesce and form a 
 broad zone around the disk, which is itself swollen and promi- 
 nent, its outlines being hidden by the opaque nerve-fibres 
 which diverge from it. Fresh hnemorrhages occur from time 
 to time, and are striated when in the fibre-layer, and of irregu- 
 larly rounded outline when invading the deeper portions of the 
 retina. They are usually either entirely absorbed or leave 
 behind them a fatty clot, which adds an additional white 
 splotch to those already existing in the retina. At times they 
 leave spots of black granular pigment as the marks of their 
 previous presence. At the same time irregularly linear or 
 c^uadrate white splotches are developed, which radiate from 
 the fovea centralis throug-hout the macular region. These were 
 formerl}^ supposed when present to be absolutely characteristic 
 of the disease, but it is now asserted by several good observers 
 that similar appearances have been seen in the neuro-retinitis 
 caused by brain tumor or by basilar meningitis, where there 
 was no accompanying disease of the kidney. (Grafe, A. f. 
 O., xii, 2 ; Schmidt and Wegner, A . f. O., xv, 3 ; Magnus, Ophth. 
 Atlas, Taf. vi, fig. 2 ; Leber in Grafe and Saemisch, Bd. v, p. 
 581; Carter, Diseases of Eye, p. 382, Am. edit.; H. Eales, 
 Birmingham Med. Review, January, 1880, p. 47.) 
 
 Changes in the Color of the Fundus and of the Iietinal Blood 
 
 Columns. 
 In manv cases occurrino; in the last stages of the disease a 
 remarkably yellowish tint of the fundus is observed, together
 
 RETINITIS IN BRIGHT's DISEASE. 195 
 
 with deckled alteration in the color of the blood columns in 
 the retinal bloodvessels ; the blood in the arteries being too 
 yellow, and that in the veins presenting too little of its usually 
 pronounced red-purple tint; in short, a state of affairs approx- 
 imating in some degree to that which we find in cases of per- 
 nicious anjfimia. 
 
 Cur ability. 
 Where a patient with albuminuric retinitis is admitted to 
 hospital, and under the treatment adopted, the generivl health for 
 the time improves, we not infrequently see the vision improve 
 with it, and the retinal changes become regressive and partially 
 disappear. I have several times seen patients with a vision of 
 only 20-CC on admission, in a month improve so that they had 
 a vision of 20-L, and could once more read ordinary print and 
 perform for a time their usual duties. I have, however, 
 never witnessed a complete disappearance of all retinal changes 
 except in acute cases, and can well recall a case of albuminuric 
 retinitis occurring during pregnancy, where, three years later, 
 there was no trace of the disease beyond a slight atrophy of the 
 optic disk. 
 
 Forms of Kidney Disease in which it may be Developed. 
 
 This form of retinitis may be developed (as has been abun- 
 dantly proved by careful autopsies) during any form of 
 Bright's disease, either with the enlarged mottled kidney of 
 acute parenchymatous nephritis, or with the large white 
 kidney, the amyloid kidney, or the cirrhotic kidney of chronic 
 disease. In the vast majority of cases, however, it is devel- 
 oped in the later stages of the last-named form of disease, and 
 seems to be in some w^ay related to the blood-poisoning caused 
 by it. 
 
 Exceptional Forms of Albuminuric Retinitis. 
 
 While the foregoing description gives a fair picture of the 
 development of the disease as ordinarily met with, neverthe- 
 less we may encounter other varieties. Thus I have seen 
 cases which, at the start, could not be diagnosticated by the
 
 196 bright's disease. 
 
 oplithalnioscopc from cases of retinal hremorrliage from other 
 causes (and Magnus has published similar cases), and there 
 are recorded other cases where the only changes seen in the 
 fundus oculi were a pronounced choking of the disk similar to 
 that with which we are familiar in cases of brain tumor. (Mag- 
 nus, Samelsohn, Gowers.) 
 
 Morbid Anatomy. 
 
 We find serous swelling of the disk and surrounding retina, 
 especially of the neuroglia ; and in the fibre-layer nests of what 
 are usually described as varicose or sclerotic hypertro])hy of 
 the nerve-fil)res. These swollen fibres are, when slightly de- 
 veloped, spindle-shaped, at other times so dilated that, with 
 their large nuclei, they much resemble ganglion-cells, and they 
 were described by Virchow as sclerosed ganglion-cells. Owing 
 to their position, which is frequently just below the membrana 
 limitaus interna, and to the fact that their processes can readily 
 be demonstrated to be continuous with the nerve-fibres of the 
 fibre-layer, they arc now classed by most authors as varicose 
 hypertrophies of the nerve-fibres. This affection is, however, 
 by no means peculiar to this disease, but is not infrequently 
 developed in other forms of neuro-retinitis. 
 
 We find also fatty splotches, consisting of large numbers of 
 compound granule-corpuscles, usually either in the nerve-fibre 
 layer or in one of the nuclear layers. The radial connective 
 tissue fibres (fibres of Mliller) also present numerous minute 
 fat-drops, which, when massed at their upper end, cause the 
 well-known radiating white stripes on the macular region. 
 
 The bloodvessels of the retina exhibit dilatation of the veins 
 and capillaries, with fatty degeneration of their walls, often 
 only of their adventitia, and also so-called sclerosis, a trans- 
 parent thickening of their walls, which resembles amyloid 
 degeneration, but does not respond to the action of iodine. 
 Haemorrhages are almost invariably present, cither striated, and 
 more or less linear in shape between the retinal fibres, or in less 
 regular masses in the outer retinal layers, or in the vitreous 
 humor. The choroid often exhibits changes in its bloodvessels
 
 RETINITIS IN BRIQHT'S DISEASE. 197 
 
 similar to those described in the retina, especially sclerosis of its 
 capillaries, with fatty degeneration of their endothelium. As has 
 been already mentioned, these changes in the retina are apt to 
 be developed in the later stages of chronic disease of the kid- 
 neys, and therefore correspond to the period at which we 
 find marked cardiac hypertrophy, and it has been supposed 
 that this was essential to their development. Thus Traube 
 claimed that the hsemorrhages arose solely from this cause, 
 Avhile he inclined to the belief that the other changes were due 
 to the retention of urea. It is evident that the greater the 
 force of the blood-current the more readily would it rupture 
 the degenerated bloodvessels, and we must therefore assign to 
 hypertroj)hy of the heart an important role in the production 
 of retinal hasraorrhages ; but the fact that they are found in 
 acute cases where no cardiac hypertrophy has had time to de- 
 velop, and that many autopsies are on record where there was 
 no cardiac hypertrophy, proves that it is not an essential factor 
 of their production. The fact also of the abundance of reti- 
 nal haemorrhages in cases of pernicious ansemia where there 
 is no increase of the blood-pressure, points to the same conclu- 
 sion. 
 
 Statistics. 
 
 The proportion of cases of Bright's disease in which albu- 
 minuric retinitis is developed has been variously stated by dif- 
 ferent authors. Bright himself has not reported his cases with 
 a view to determining this point, but the clinical record of 
 them is so complete that we can readily do so. Thus we find 
 in the four papers previously referred to records of 95 cases, 
 in 12 of which failure of vision is recorded (12.62 per cent.). 
 In these as in all other preophthalmoscopic data we are fairly 
 entitled to consider the real ratio as far higher than that re- 
 ported, because marked retinal changes frequently exist with- 
 out decided impairment of vision, which is only necessarily 
 interfered with w^hen the region of the yellow spot is attacked. 
 Frerichs* gives 10 cases of retinitis in a total of 78 cases, a per- 
 
 * Frerichs, quoted by Leber, in Grjife and Saemiscli, vol. v, p. 585.
 
 198 briqht's disease. 
 
 centage of 12.82. Galezowski* gives 47 out of 154 cases (30.15 
 per cent.), and quotes Lecorche as giving G2 cases out of 286, 
 or 21.71 per cent. AVagnerf gives 12 out of 157 cases, or 7.64 
 per cent. Tie rejects, however, six cases of retinal changes, 
 which, in his judgment, were not sufficiently characteristic, and 
 which would, if accepted, raise the percentage to 11.46. Mr. 
 H. Eales,! the most recent writer who has examined any con- 
 siderable number of cases with a view to determining the fre- 
 quency of retinal disease in them, gives 100 cases, in which 28 
 had retinal changes, and 3 alterations of the optic disks. I 
 regret that my own researches throw so little light on this sub- 
 ject; but although I have carefully examined a considerable 
 number of cases of albuminuric retinitis, I at first devoted my 
 attention exclusively to the mode of development of the affec- 
 tion, its various forms, and the kind of kidney disease accom- 
 panying them, and failed properly to note the negative cases 
 in which there were no retinal changes. For an opportimity 
 for studying these cases, I am much indebted to m}^ friend Dr. 
 J. H. Hutchinson, who has for years placed his wards at my 
 disposal, and also for similar courtesies to Drs. W. Pepper, J. 
 Tyson, and J. M. Da Costa. In the last 41 cases which 
 I have examined, taken as they occurred in the wards of 
 general hospitals, I found 11 cases of decided retinal change, 
 such as oedema with white splotches and haemorrhages, and 
 have not counted several cases of slight degrees of atrophy 
 of the disk possibly due to foregoing changes. This would 
 give 26.82 per cent; but the number is too small to allow 
 proper conclusions to be drawn from it, and can only be of value 
 as a contribution to the total statistics of the subject. 
 
 Treatment. 
 Kest in bed with moderate purgatives and diaphoretics ; in 
 short, the remedies usually prescribed for the constitutional 
 
 * Galezowski, L'Union Mfedicale, 1873, pp. 924-928. 
 
 ■]■ Wagner, Vircliow's Archir, Bd. xii, pp. 219-271. 
 
 J Eales, Biriuinghaoi Medical Review, January, 1880, pp. 35-52.
 
 RETINITIS IN BRIGHt's DISEASE. 199 
 
 treatment of the disease are the most effective means of clear- 
 ing np such cloudy retinre, and I know of no drug or local 
 application to the eye which acts in any degree as a specific. 
 
 Urcemic Amaurosis. 
 Urseraic amaurosis is much more rarely encountered than 
 is albuminuric retinitis in the course of Bright's disease. It is 
 rapid in its development and in its subsidence, is without reti- 
 nal changes, and the blindness is evidently due to some transient 
 affection of the cerebral centres. It is, however, occasionally 
 developed in cases in which albuminuric retinitis already exists. 
 
 Bibliography. 
 
 Bv consulting the followino;-named books the reader can 
 find a full discussion of the subject and an extended bibliog- 
 raphy, while the atlases mentioned will afford good pictorial 
 representations of the various forms of the disease : 
 
 Allbutt, Use of the Ophthalmoscope in Diseases of the Ner- 
 vous System and of the Kidneys. London, 1871. 
 
 Leber, in Grafe and Saemisch's Handbuch der Augenheil- 
 kunde, vol. v. Leipzig, 1877. 
 
 Forster, in Grafe and Saemisch's Handbuch der Augenheil- 
 kunde, vol. vii. Leipzig, 1877. 
 
 Gowers, A Manual and Atlas of Medical Ophthalmoscopy. 
 London, 1879. 
 
 Liebreich, Atlas d'Ophthalmoscopie. Paris, 1863. 
 
 Jaeger, Ophthalraoscopischer Hand Atlas. Wien, 1869. 
 
 Magnus, Die Albuminuric in ihreu Ophthalmoscopischen 
 Erscheinungen. Leipzig, 1873.
 
 200 bright's disease. 
 
 SECTION X. 
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS. 
 Synonyms. — Pyelo-nephritis ; interstitial suppurative nephritis; surgical kidney. 
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS IS THAT FORM 
 OF NEPHRITIS WHICH RESULTS IN THE FORMATION OF AB- 
 SCESSES RANGING IN SIZE FROM THAT OF A MERE POINT 
 TO THAT IN WHICH THE ENTIRE KIDNEY IS CONVERTED 
 INTO A SINGLE PURULENT SAC. 
 
 The term interstitial is used for this condition because the 
 inflammation which results in these abscesses always begins in 
 the interstitial tissue of the kidney. In contradistinction to 
 the form of disease under consideration, the contracted or cir- 
 rhotic kidney is the result of a 7Jon-suppurative interstitial 
 nephritis. Most frecjuently this form of nephritis starts in the 
 pelvis of the kidney, as a pyelitis, and thence extends along 
 the interstitial tissue of the organ into its parenchyma. Hence 
 the term pyelo-nephritis is often appropriately applied to the 
 same condition. It also happens that the nephritis does not 
 start from the pelvis, but in the interstitial tissue of the sub- 
 stance of the organ, as when the result of an infectious embo- 
 lus or traumatic cause, or obstruction of the tubules by con- 
 cretions. But I do not consider it necessary on this account 
 to make two divisions of the subject, as some authors do, con- 
 sidering one as pyelo-nephritis, and the other as suppurative 
 nephritis, including in the latter those cases which begin in the 
 substance of the organ. The processes are essentially the same. 
 
 Etiology. 
 
 Probably the most frequent cause of suppurative ne])hritis 
 is retention of decomposed urine. Such retention and decom-
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS. 201 
 
 position are the result of long-continued obstruction to the 
 descent of the urine from any cause, as stone in the bladder, 
 inflammation of the bladder as the result of stone or other 
 cause, impaction of stone in the ureter or pelvis of the kid- 
 ney, or stricture of the urethra. 
 
 Calculous concretions in the substance of the kidney are 
 another frequent cause, producing most of the cases not the 
 result of the backing of retained urine on the pelvis of the 
 kidney. It is easily understood how these may act as irri- 
 tants to the interstitial tissue, and excite therein suppuration. 
 
 Infectious emboli cause a small number of cases of suppu- 
 rative nephritis. These emboli are usually derived from the 
 valves of the heart in cases of ulcerative endocarditis, but they 
 may also arise in putrid wounds, stumps, or other seats of 
 putrid inflammation. The abscesses found in the kidney in 
 common with other organs in pyaemia are thus produced. 
 
 Traumatic injuries, as blows, kicks, or penetrating wounds 
 in the neighborhood of the kidney, or falls from a distance 
 and striking upon the sharp edge of a fence or similar object, 
 may also cause supjuirative nephritis. These causes, however, 
 rarely produce the condition, because if extremely severe, rup- 
 ture of the organ and peritonitis generally cause death before 
 suppuration sets in, and if less serious they are apt to be fol- 
 lowed by hjematuria, which lasts for a few days, when the pa- 
 tient recovers. 
 
 Infectious vegetable organisms — bacteria — are claimed to be 
 a cause of suppurative nephritis. Indeed according to some, 
 notably Klebs,* they are an indispensable prerequisite in all 
 cases. Xeither position can be admitted as proven, but suffi- 
 cient evidence has been adduced, both from pathological anatomy 
 and clinical observation, to demand the precaution of using only 
 scrupulously clean instruments, catheters, sounds, etc. It is 
 very likely, at least, that decomposition in urine previously 
 pure may be induced by these organisms, and thus an efficient 
 cause of the pyelitis and nephritis produced. 
 
 * Klebs, Dr. E., Handbuch der Pathologischen Anatomie, dritte Liefe- 
 rung, Berlin, 1870, s. 655.
 
 202 bright's disease. 
 
 Suppurative nephritis may occur at any age subject to the 
 operation of the cause. The youngest patient I liave met is 
 the boy, whose case is related on pp. 208-212. Suppurative 
 nephritis was undoubtedly here present when the boy was two 
 years old. 
 
 Morbid Anatom;/. 
 
 The appearances vary necessarily with the stage of the dis- 
 ease, and also somewhat with the cause. 
 
 In the earlier stage, as most frequently caused, by the reten- 
 tion of decomposing ammoniacal urine, which produces a dif- 
 fuse inflammation of the connective tissue, starting from the 
 pelvis of the kidney, the organ is enlarged and vascular. The 
 capsule strips off easily, but in places drags shreds of the renal 
 substance with it, while its under surface is otherwise slightly 
 rougher than in health. The shreds are found to correspond 
 with the seats of little punctate abscesses about a millimeter in 
 diameter, on the surface of the kidney, which are thus rup- 
 tured. Others are noticed scattered over the reddened surface 
 of the organ. They may be isolated or arranged in groups 
 of from three to six. At this stage, too, they will be found 
 scattered over one or more areas, each corresponding to the base 
 of a single Malpighian pyramid, while other pyramids may be 
 entirely free. Each abscess is surrounded by an intensely red 
 border. On principal section of the kidney, these little abscesses 
 appear as yellow strife running in the direction of the tubulesj 
 between which they are found on minute examination to be 
 placed. The striae converge a variable distance into the me- 
 dulla, becoming, as they do so, more closely aggregated, and 
 extending occasionally as far as the papillae. In the medulla 
 they accompany the connective tissue about the vasa recta, and 
 in the cortex the interfascicular veins, the beginning of which 
 on the surface of the kidney corresponds with the ])unctate ab- 
 scess, which latter is, as it were, the outer end of the streak. 
 According to Klebs they contain, in addition to pus-corpuscles, 
 minute shining granules, which are not altered by the action 
 of alkalies or acids, are dissolved neither by alcohol nor ether, 
 and which he considers, therefore, bacteria.
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS. 203 
 
 At a later stage, these little collections of pus unite to 
 form larger ones, these again to form others still larger, de- 
 stroying the tubular structure of the kidney as they encroach 
 upon it; and it is at this stage that cases of pyelo-nephritis 
 not unfrequently terminate unfavorably, and the specimens 
 come under observation. At first each of the abscesses thus 
 formed is confined to the region of a single pyramid, and it 
 not unfrequently happens that a kidney is partitioned oif in 
 the manner shown in Fig. 33, drawn from a specimen in the 
 possession of the author. Before this o(;curs, however, the 
 abscess bursts through the papilla and calyx into the pelvis 
 of the kidney. The pelvic end of the papilla is then bounded 
 by an uneven ulcer, which gradually enlarges and deepens 
 until the entire pyramid is destroyed, with more or less of the 
 cortex corresponding to it. If the case lasts long enough even 
 the partitions referred to may be eroded, and thus it occasion- 
 ally happens that the entire kidney is converted into a huge 
 purulent sac. This of course can occur with one kidney 
 only, while the other is, in a measure, able to continue its 
 function of secretion, although the two kidneys are sometimes 
 so fiir altered that it seems incredible that death from uraemia 
 should not have occurred much earlier in the course of the 
 disease. 
 
 INIore rarely, it happens that the abscess ruptures through 
 the capsule and leads to the formation of subperitoneal ab- 
 scesses, which may open posteriorly or gravitate towards the 
 pelvis and open under Poupart's ligament. 
 
 The ])elvis of the kidney is always dilated, and the seat of 
 a purulent catarrh, the product of which passes down the 
 ureter with the urine into the bladder. As often, the ureter is 
 similarly dilated, being sometimes converted into an intestine- 
 like tube. This is more particularly the case when it is im- 
 pacted with the calculi, as in the drawing presented, or there 
 is some decided obstruction to the passage of the urine from 
 the ureter into the bladder. The pelvis of the kidney itself is 
 even more frequently impacted with calculi than the ureter, 
 when the latter, unless it at the same time contains stones or
 
 204 bright's disease. 
 
 is also obstructed at its outlet, is less dilated. According to the 
 degree of obstruction, the pelvis and ureter also contain more 
 or less decomposing and stinking urine, mixed with pus and 
 crowded with bacteria. 
 
 Almost invariably fatal as these cases are, a complete arrest 
 of the process is said to be not impossible, followed by inspissa- 
 tion, caseation, calcareous metamorphosis, encapsulation, and 
 recovery. 
 
 Klebs* describes a still earlier stage of pyelo-nephritis than 
 that of the punctate abscesses described. In this, the kidney 
 is enlarged and vascular and the capsule non-adherent. He says 
 that at this stage there are no m^ertubular changes whatever; 
 that the tubules themselves are broad, their epithelium cloudy, 
 sometimes fatty ; their lumen is widened and filled with bacteria. 
 
 Ebstein, in his recent article in Ziemssen's Cyclopcedia of 
 Medicine, vol. xv,t confirms the description of Klebs, and 
 sustains his view as to its parasitic origin, while he also claims 
 that it has now the most adherents. These adherents contend 
 that the bacteria themselves excite the inflammation, causing, 
 in the first place, a purulent pyelitis, and subsequently circum- 
 scribed renal inflammation. 
 
 They adopt the suggestion of Traube, that the bacteria gain 
 admission from without, generally by the introduction of dirty 
 catheters. I regret that I have nothing to offer from expe- 
 rience of my own in the examination of kidneys in this early 
 stage of suppurative nephritis, but supposing the observations 
 of Klebs and Ebstein to be correct, the question of the parasitic 
 origin of pyelo-ne|)hritis becomes only a part of that of the para- 
 sitic origin of disease generally, which, to say the most, must be 
 considered not proven. On the other hand, we have to remem- 
 ber, first, that numerous cases of pyelo-nephritis have occurred 
 in which a catheter has never been introduced ; and, second, 
 that very few occur in which there does not exist a cause in 
 the shape of a mechanical irritant which is amply sufficient to 
 account for the irritation. 
 
 * Klebs, o\i. citat. f William "Wood & Co., New York, 1877.
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS. 205 
 
 Where the abscess is embolic in origin its seat is at first occu- 
 pied by an area of intense hypersemia, resulting in hsemor- 
 rhagic extravasation, which takes pUice also into the tubules, 
 causing bloody urine. To this succeeds suppuration. The size 
 and number of the abscesses depend upon that of the plug 
 obstructing the bloodvessel, which is usually one of the inter- 
 lobular arteries or a vas aiferens. The embolic abscesses may 
 also be multiple in consequence of the breaking of the embo- 
 lus into a number of minute fragments. 
 
 Where the cause is traumatic the process is not so easily de- 
 fined. Circumscribed abscesses may occur, or the kidney may 
 be converted into a soft pulpy mass, a mixture of pus, blood, 
 and broken-down renal substance. 
 
 Symptoms and Course of Suppurative Nephritis. 
 
 The symptoms of this condition are not numerous, and, 
 apart from the characters of the urine, are not very distinctive. 
 Pain and tenderness are the most constant, but it has occurred 
 that considerable inroads have been made upon the structure 
 of the kidney without pain resulting. On the other hand, the 
 pain is often of a very severe character, while the tenderness 
 over the region of the kidney affected is also evident. Most 
 frequently, but not always, the severest pain is in the region 
 of the kidney itself, whence it radiates towards the front of the 
 abdomen and the groin, and is accompanied often by re- 
 traction of the testicles. Where the condition is the result of 
 impacted calculus, the seat of the impaction is the seat of pain. 
 Thus, in the little patient whose case affords a typical illustra- 
 tion of one due to impacted calculi, and which is therefore 
 narrated at the end of this section, the region between the 
 umbilicus and the pubis was the seat of numerous and severe 
 paroxysms of pain, and the post-mortem examination revealed 
 that both ureters, in that part of their tract corresponding to 
 this region, — on the lumbar vertebne, — were thoroughly im- 
 pacted with calculi. The pain is always intermittent as to 
 degree, sometimes totally so, but generally there is more or 
 less constant pain of a less degree, which is paroxysmally in-
 
 206 bright's disease. 
 
 creased. Various positions are assumed by the patient with a 
 view to easing the pain, among which that on the face is not 
 infrequent. 
 
 A distinct tumor can sometimes be discovered in the region 
 of the kidney by palpation and percussion. This imjdies an 
 enlargement of the organ, which is either due to its complete 
 conversion into a purulent sac, or an augmentation of its size, 
 due to the distension of its pelvis with pus or calculi or both. 
 In the case to be narrated at the end of this section a distinct 
 tumor could be felt below the umbilicus, which was found, at 
 the post-mortem examination, to be due to a mass of calculi 
 impacted in both ureters, in this locality. 
 
 Fever is also an intermittent synaptom. Possibly in a very 
 few latent cases it may be altogether absent, but except in these 
 there is always slight frequency of pulse and slight elevation 
 of temperature. These latter at times become decided, and in 
 advanced stao;es the fever is sometimes hectic, bcino; followed 
 by profuse sweats. 
 
 In acute cases the beginning of suppuration is often marked 
 by a chill or succession of chills, but in most instances it is quite 
 impossible to recognize the beginning of the suppurative stage. 
 
 The characters of the urine, as intimated, are more distinc- 
 tive. This, except in acute infectious cases (pyaemia), almost 
 invariably, sooner or later, contains pus, and unless it does 
 contain pus no certain diagnosis can be made. Blood is also 
 a very constant constituent of the urine from cases of suppu- 
 rative nephritis, but w' hile such urine is scarcely ever examined 
 by the microscope without discovering a few blood-disks, yet 
 the quantity is not often large enough to be recognizable to 
 the naked eye. The quantity of pus is also very variable. 
 While it may be so copious as to produee a heavy white opaque 
 deposit, equalling one-sixth to one-fifth the bulk of urine, it 
 may be represented by little more than the normal proportion 
 of leucocytes. This variation will also occur at different times 
 in the same case. Pus from the kidney and its pelvis is dis- 
 tinguished from that formed in the bladder by the absence of 
 that glairy property which is so characteristic of the latter, due
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS. 207 
 
 to the admixture with mucus and the alteration which the pus 
 itself assumes by the action of the carbonate of ammonium 
 formed out of urea during decomposition. Pus from the pel- 
 vis of the kidney is also occasionally fetid, containing bacteria, 
 and prone to decomposition, but very rarely as compared with 
 pus from the bladder. 
 
 Tube casts, on the other hand, in ray experience, are very 
 rare in this form of kidney disease. 
 
 The urine is also diminished in quantity, the degree of dimi- 
 nution depending upon the proportion of kidney structure de- 
 stroyed in the suppurative process. Comjjlete suppression is 
 not uncommon towards the close of cases presenting extreme 
 degrees of destruction. Notwithstanding such diminution, the 
 color is pale and the specific gravity low, owing to the small 
 proportion of urea present. I have known the range of spe- 
 cific gravity in a single case to be from 1003 to 1016. In 
 reaction the urine is faintly acid, neutral, or alkaline, and, as 
 already stated, is often prone to rapid decomposition, and 
 therefore to assume the alkaline reaction. 
 
 It is ahcays albuminous, but the quantity of albumen is 
 never excessive, and varies generally pari passu with the quan- 
 tity of pus and blood. Yet I have been much impressed with 
 some disproportion in this respect, to which I am not aware 
 that attention has heretofore been called. Thus I have noticed 
 in some cases a disproportionately large amount of albumen 
 associated with a small amount of pus, and, on the other hand, 
 a quite large bulk of pus is sometimes associated with but a 
 trace of all)u men. lam as yet unable to explain these dis- 
 crepancies, but think I have found the degree of structural 
 disintegration greater in those cases where there was a dispro- 
 portionately large amount of albumen, as compared with the 
 quantity of pus. Such cases are, therefore, more serious. It 
 sometimes happens that there is a sudden increase in the quan- 
 tity of pus in the urine, followed by a gradual diminution, or 
 the urine previously clear may suddenly become loaded with 
 pus. Such occurrences indicate the probable period of rupture 
 of an abscess through a papilla, and a pouring out of its con-
 
 208 bright's disease. 
 
 tents into the pelvis of the kidney. Accumulations and sud- 
 den evacuations of this kind may also be due to temporary 
 obstructions to the descent of the pus. It rarely happens that 
 a small portion of the substance of the kidney is thus dis- 
 charged with the urine, when it may be recognized by micro- 
 scopic examination, which will discover the tubules and Mal- 
 pighian bodies of the kidney. Two instances of this are re- 
 lated by Ebstein.* 
 
 Occasionally, also, the abscess, instead of rupturing into the 
 pelvis of the kidney, perforates into the perinephritic tissue, 
 burrowing in different directions and producing fistulous 
 openings. Perforations may thus take place posteriorly in 
 the lumbar region, or anteriorly at the groin, especially into 
 the colon, and more rarely into the lungs and liver, and even 
 peritoneal sac. 
 
 The course and duration of suppurative nephritis are very 
 various. Traumatic cases are comparatively rapid, either to 
 recovery or death. Pytemic cases may run their course in 
 forty-eight hours, and are invariably fatal. f But cases due 
 to impacted calculus, to stone in the bladder, cystitis, or 
 other cause of obstruction to the descent of urine from the 
 kidney, may be prolonged indefinitely, while some terminate 
 without being discovered. Sooner or later the patient gen- 
 erally succumbs to exhaustion, but even in youth, life may 
 be sustained for years with jiaroxysms of the severest suf- 
 fering and a surprising degree of destruction of the kidneys. 
 The greatest danger to those thus affected, is intercurrent ill- 
 ness, which is always more seriously influenced and much more 
 apt to terminate unfavorably. It is well known that the oper- 
 ation for stone is much more apt to be followed by a fatal re- 
 sult when the subject happens to have a surgical kidney, a very 
 prominent instance of which is that of the ill-fated Napoleon 
 
 * Zierassen's Cyclopaedia of Medicine, New York, 1877, vol. xv, p. 557. 
 
 t In an able experimental thesis, presented to the Medical Faculty of the 
 University of Pennsylvania, March, 1881, Dr. Louis Brose has shown that 
 interstitial changes may make their appearance in 22 hours, and aliscess of 
 the kidney at the end of six days after injecting tincture of cantharides.
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS. 209 
 
 III, late Emperor of the French. The operation is, however, 
 not necessarily fatal, even when tliere is suppurative nephritis 
 of both kidneys, as is shown by the appended highly interest- 
 ing and illustrative case : 
 
 On April 21st, 1877, when 3 years and 10 months old, W. H. was cut for 
 stone by Professor D. Hayes Agnew, who removed an oval, smooth phos- 
 phatic calculus, 3.5 cm. long by 2.2 cm. in its longest conjugate diameter; 
 on section, also white, loose in the texture of its central portion, and witliout 
 a nucleus. It was of the same composition throughout. The cut made by 
 the operation was very slow in healing, the latter not being completed until 
 October 1st. At least two years before the operation — that is, when less than 
 two years old — he began to complain of bladder symptoms ; previous to this 
 he had been delicate. He came under my care about May 1st, 1878, one 
 j'ear after the operation for stone. He was then suffering with the symp- 
 toms of cystitis, such as are present with a calculus in the bladder, but usu- 
 ally subside soon after the removal of the stone. There was frequent mic- 
 turition, a small amount of pus, and a very small degree of albuminuria, 
 while the urine was either alkaline when passed, or became so very soon 
 afterwards. He was subject, however, in addition, to paroxysms of extreme 
 pain, which was confined almost exclusively to the region of the navel. The 
 attacks occurred about once a week, and succeeded upon days on wliich he 
 felt unusually well, played a good deal, and tired himself thereby ; they 
 lasted until paregoric sufficient to relieve them had been given. Pie was 
 very pale, aufemic, and appeared a very delicate child. 
 
 I put him on benzoic acid, which was to be given until the urine was dis- 
 tinctly acid, and at the end of two weeks he was greatly better. The par- 
 oxysms were less frequent ; there was less pus in the urine. To the ben- 
 zoic acid treatment was added sandalwood oil, and the two were continued, 
 more or less constantly, either together or alternately, as the condition of the 
 urine and other symptoms suggested, throughout the entire sunmier. This 
 was spent at the seaside. Iron and quinine were also given as tonics when 
 required. It was considered that during this time there was a gradual 
 abatement of his severer symptoms. 
 
 About September 10th he had a decided retui-n of his symptoms, this 
 time accompanied with great pain over the bladder and frequent micturi- 
 tion, during which he seized his penis in his hands; he passed water from 
 three to six times in a night. His general health, I thought, at this time 
 greatly improved- The urine was very pale, almost colorless, acid, specific 
 gravity 1003, and contained a few leucocytes and a small quantity of albu- 
 men. By the middle of October he was again relieved of the painful symp- 
 toms, the specific gravity of the urine increased to 1007, but the albumen 
 had increased decidedly to half the bulk of urine tested. No tube-casts 
 could be found, nor were any ever found in the entire course of the sickness, 
 at least while he was under my observation. 
 
 14
 
 210 briqht's disease. 
 
 By the middle of January, 1879, the alhuraen liad again become very 
 small in quantity, there was a scanty sediment of leucocytes, and the urine 
 had attained a specific gravity of 1016, — the highest it ever was while he 
 was under my care. The special treatment during this time was sandal- 
 Avood oil directed to the cystitis, and benzoic acid, to influence the reaction 
 of the urine, as required. 
 
 On February 3d, 1879, he had a haemorrhage from the bladder, accom- 
 panied by great pain. It was, however, at a single act of micturition, and 
 what I examined by the microscope, eight hours after this, contained no 
 blood-corpuscles, but one-half its bulk of albumen. The haemorrhage did 
 not recur. 
 
 February 12th, Professor Agnew sounded for stone successfully. On 
 March 11th he operated, and, after some difSculty, removed the second 
 stone. This was much smaller than the first, being also oval, 2 cm. long 
 by .6 cm. wide. More than half the external surface was white, the 
 remainder brown, and projecting from the former were a number of spic- 
 ules, by which it was supposed it was imbedded in corresponding depres- 
 sions in the bladder, whence the difficulty in extracting it. On section, 
 the external concentric laminpe were white, but in the centre was a brown, 
 oval nucleus, 1 cm. long and .5 cm. wide. Portions of this nucleus almost 
 totally disappeared on incineration, but the residue responded to the mur- 
 exide test. It, thei'efore, contained some uric acid. 
 
 He was kept in bed six weeks, until April 3Utli, when he was allowed 
 to get up, although the wound was not ouite healed. Until April loth there 
 was a good deal of pus and some blood in the urine, but upon that date we 
 returned to the treatment by sandalwood oil, after which they rapidly di- 
 minished. He had some pain on passing water, which continued until 
 April 15th, wlien this too disappeared. Immediately after getting up the 
 urine dribbled through the opening in considerable amount, but this grad- 
 ually diminished until it was scarcely sufficient to soil a napkin during the 
 entire day. On May 10th the urine contained a mere trace of albumen, a 
 small sediment composed of pus and earthy phosphates, was faintly acid 
 when passed, but became alkaline soon thereafter, and presented a specific 
 gravity of 1005. Soon after this he went to the seashore. 
 
 On Atigust 14th the little patient's mother called upon me to report his 
 condition. She said that for as much as two weeks at a time there was no 
 dribbling of urine from the wound ; then an attack of pain was succeeded 
 by dribbling for a time. He was very well in every other respect, although 
 thin. He ate heartily and played all day long. He continued taking the 
 sandalwood oil, and for a time the benzoic acid. 
 
 Early in September the boy returned from the seaside. He was very 
 thin, but his wound had entirely healed. His mother reported that soon 
 after his return he took cold two or three times in rapid succession, his 
 stomach becanje deranged, his appetite disappeared, and he became weak 
 and emaciated. I saw him September 20th, the first time since his return, 
 and was much struck by his emaciated and cachectic appearance. The urine
 
 SUPPURATIVE INTERSTITIAL NEPURITIS. 
 
 211 
 
 presented about tlie same characters as when last examined. He was im- 
 mediately put to bed, placed on restorative treatment, and for a time seemed 
 to grow stronger ; but, as though in consequence of the absence of treatment 
 especially directed to the urine, the latter contained much more mucus and 
 became alkaline, and these characters continued until the benzoic acid was 
 re-ordered, when they partially disappeared. 
 
 The improvement in his general condition was, however, only tempor- 
 ary, and early in November it was evident he was again declining. He ema- 
 ciated, grew weaker day by day, and died on the afternoon of November 
 15th, 1879, although he was out in his coach two days before. On tiie day 
 
 Fig. 33. 
 
 before his death he had to be catheterized, but there was considerable urine 
 in his bladder, and there was no reason to suppose there was suppression of 
 the secretion. He also suffered a great deal of abdominal pain for two or 
 three days before he died. Very interesting in connection with the results
 
 212 brigiit's disease. 
 
 of the post-mortein examination is tlie fact that liis father, wliile feeling- his 
 abdomen on the afternoon before he died, discovered a hard, iriegular mass 
 in the neighborhood of the umbilicus. 
 
 The post-mortem examination was made fifty hours after death. The body 
 was extremely emaciated, but all the organs were found normal except the 
 kidneys, ureters, and bladder. Both kidneys were cystic, each being con- 
 verted into a multilocular cyst, of which the loculi were distended with a 
 mixture of pus and urine, the former apparently predominating, as there 
 was very little urinous odor. The left kidney was the larger, measuring 
 10.5 cm. by 5.5 cm. Its surface contained numerous white tubercles (see A, 
 A in the figure), ranging in size from that of a pin's head to a pea. The 
 pelvis of this left kidney was distended with the same fluid which filled the 
 loculi, and the left ureter — dilated throughout its extent — was almost com- 
 pletely occluded by a single calculus of most peculiar shape. It was spi- 
 rally twisted and somewhat spindle-shaped, much constricted near its 
 middle, and 5.5 cm. long by 1.5 cm. in its thickest part. 
 
 The right kidney was smaller, measuring 8.5 cm. by 4 cm., but in all 
 other respects similar. The pelvis and ureter were dilated, and the latter 
 packed with three fragments of what was originally a single stone, con- 
 stricted at two points, where it had probably been fractured in removal, 
 making three pieces. The original stone was arcuate in shape, 10.5 cm. 
 long and 1 cm. wide at its middle. The same tubercles were scattered 
 throughout the cortex of this kidney. 
 
 The bladder contained a small stone, which had evidently descended since 
 the last operation, and was apparently a fragment of one of the stones re- 
 maining in the ureter, the fracture having taken place at a point of con- 
 striction. This stone was about 2.5 cm. long, and varied in diameter from 
 .5 to .75 cm. The bladder was thickened, the mucous membrane thickened, 
 and no traces of the cut made at the time of the operation were discov- 
 erable. 
 
 The pediculation observed on the stone removed at the last operation, 
 ■which was believed to have occurred during its presence in the bladder, 
 most probably did not occur there, as the stones found in the ureter exhib- 
 ited the same peculiarities, although these pedicles were probably the means 
 of its" attachment to the bladder. 
 
 This case was a rarely interesting one, not only in its unique morbid 
 anatomy, and as showing the rapidity and extent of sedimentary processes 
 in the urine, but also in snggestini; a possible explanation of certain recur- 
 rences of stone in the bladder; while from the therapeutic aspect it is not 
 ■without its uses. 
 
 It is evident that the hard mass felt through the abdominal walls just 
 before death was made up by the calculi, which, although contained in 
 separate ureters, united to form a single confused mass in the median line 
 just above the sacrum. How long before death this could have been felt I 
 do not know, for I had not examined the abdomen for some time. Tliere 
 is every reason to believe, however, that it might have been recognized
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS, 213 
 
 at any time subsequent to the emaciation, which began during liis absence 
 from the city, in the summer, and which so impressed me wlien I first saw 
 him, some time after his return. The practical hint to Ije deduced from it 
 is that frequent examinations of the abdomen should be made in cases of 
 suspected impacted calculus. 
 
 There are no complications peculiar to suppurative inter- 
 stitial nephritis other than those mentioned as causing it or 
 as resulting from unusual accidents of rupture, of abscess, and 
 perforation of neighboring organs. 
 
 Diagnosis. 
 
 Tlie diagnosis of suppurative nephritis may be easy or dif- 
 ficult. It is easy when there is the history of a traumatic 
 cause followed by hsematuria, and later, purulent urine, with 
 tenderness and pain over the region of the kidney. On the 
 other hand, while the long continuance of inflammation of the 
 bladder, stone in the bladder, nephrolithiasis, or other causes 
 of decomposition of urine and of obstruction to its descent, 
 are always just causes of suspicion that suppurative nephritis 
 exists, it is not easy to find data on which to base a positive 
 assertion of its presence. If, however, the urine contains pus 
 which by its characters is known to come from a source above 
 the bladder, either permanently or at intervals, along with the 
 symptoms of any one of the conditions named as causing sup- 
 purative nephritis, its existence may be averred with tolerable 
 certainty. And if, moreover, there is tenderness over the 
 region of the kidney, and especially if a tumor may be mapped 
 out, there is less doubt. Beyond doubt this category of cases 
 — those due to obstruction — is by far the most important to 
 the practical physician, including, as it does, those which he 
 most frequently meets. 
 
 A most important practical question, one which if correctly 
 answered would be of infinite service in diagnosis, is the fol- 
 lowing : How long can obstructed conditions of the ureter and 
 pelvis of the kidney exist before producing suppurative ne- 
 phritis? Unfortunately I have no precise data on which to 
 base an answer to this question. In the case of the boy Willie,
 
 2H bright's disease. 
 
 whose case is related on pages 208-21 2, 1 have no doubt tlie con- 
 dition was present when lie came under my care one year after 
 the first operation for stone. The stone was in the bladder two 
 years before it was removed, so that the suppurative process 
 was present within three years after the process of impaction 
 set in, and probably sooner. I think, however, it may be 
 safely stated that vjhcre obstructive conditions of the ureter or 
 pelvis have existed for three years, the corresponding kidney 
 or kidneys are probably the seat of suppurative nephritis, and 
 partially cystic. 
 
 Pyajmic abscesses of the kidney can only be suspected to be 
 present as a part of the pyemic process, which is recognized in 
 surgical cases presenting conditions favorable for its causation, 
 by the occurrence of chill and other symptoms peculiar to it. 
 
 Prof/nosis. 
 
 The prognosis so far as recovery is concerned is unfavorable. 
 Traumatic cases may recover if the injury is not too extensive, 
 while very grave injuries are usually rapidly fatal. Cases due 
 to obstruction of the ureters cannot get well as long as the 
 obstruction and irritation continue, and as their removal is 
 often impossible such cases gradually grow worse. On the 
 other hand, their fatal termination may be indefinitely delayed. 
 It is often a matter of surprise and wonder, on viewing the 
 post-mortem appearances of cystic purulent kidneys, that the 
 patient has lived as long with the extreme structural changes . 
 which are found to exist, the barest remnant of secreting 
 structure being sometimes found to be present. It is impos- 
 sible to say how extensive a lesion of the kidney thus pro- 
 duced might be repaired, provided the removal of the cause 
 could be secured. Conditions of this kind might occur where 
 a stone in the bladder has been removed after having been 
 long enough present either in the bladder itself or in the 
 ureter to cause suppurative nephritis. While it is not likely 
 that the essential structure of the kidney could in any degree 
 be reproduced, there is scarcely any limit to which such as 
 remains could be made to supplement the lost function of parts
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS. 215 
 
 completely destroyed. The fact remains that there is no posi- 
 tive evidence to prove that any one has recovered either par- 
 tially or completely from a suppurating cystic kidney, while 
 numerous instances are constantly occurring in which the vic- 
 tims of this disease hav^e lived for many years, sometimes even 
 unconscious of ill-health. It is scarcely necessary to say that 
 such persons are in imminent danger from the operation of 
 any cause, such as cold or acute disease, \v'hich tends to sup- 
 press the action of kidneys already crippled in their function. 
 The following case illustrates ray meaning : 
 
 The patient was a gentleman, forty-tliree years of age, whose business 
 was farming and the purchase and sale of cattle, on account of which he 
 made frequent f\xtiguing journeys to the West. He first consulted me in 
 May, 1878, and stated that his first illness was in 1864. It was evidently 
 nephritic colic. Severe lumbar and abdominal pain continued to recur, 
 more particularly after exposure to cold, until 1865. when he passed a small 
 calculus. He was relieved for three years, having then another attack, 
 during which he passed a sediment which he described as "steel-colored," 
 and, finally, another small calculus, also " steel-colored." There was again 
 an interval of relief until 1873, when there occurred a long series of attacks, 
 in the last of which, in 1874, he passed quite a large stone, three-quarters 
 of an inch long and one-third wide, which he described as having a white 
 coating (phosphatic?). From this time up to the date of his visit, there 
 had been more or less dull pain. His urine, which for some time previous 
 had been dark-hued, had lately assumed a lighter hue, and while brick- 
 dust sediment formerly was observed it had lately disappeared. Pus was 
 first observed in his urine in 1875, by Professor Reamy, of Cincinnati. He 
 had had no acute attack during the year 1878, up to the date of his visit to 
 me. He had been sounded for stone in the bladder four times — twice in 
 1864, once in 1865, and once in 1875 — without any result. 
 
 At the time of his visit to me he was rising at night to pass water from 
 four to eight times, and during the day could not retain it longer than one 
 hour and a half. His urine was pale amber in hue, had a specific gravity 
 of 1012, and deposited a considerable amount of pus (^^ its bulk). There 
 was also a small amount of albumen, not more than a line bj'^ Heller's acid 
 test. The bladder symptoms were very much relieved by sandalwood oil, 
 but he continued to have attacks of lumbar pain, always after exposure to 
 reduced temperature, especially if he happened to be overheated at the 
 time. 
 
 On the evening of January 15th, one week after his return from a trip 
 to the West, during an extremely cold season, he was seized with one of his 
 attacks, the pain being chiefly on the left side. The attack was one of un- 
 usual severity, but he was relieved by a hypodermic injection of half a grain
 
 216 bright's disease. 
 
 of sulphate of morphia by his physician, Dr. W. H. Barr, of Micldletown, 
 Del. The relief was complete, but he remarked to Dr. Barr, on the morn- 
 ing of the 17th (about thirty-six hours after the attack), that he had not 
 passed water since two o'clock of the loth, and had no desire to pass any. 
 I saw him on the 18th, reaching Middletown at two o'clock, just seventy-two 
 hours after he had passed water. The bladder was empty, as shown by the 
 use of the catheter. He was entirely free from pain, but was sufi(?ring a 
 good deal from nausea, which had made its appearance the day previous. 
 He was slightly drowsy, but he was so far conscious that he could pass the 
 catheter on himself, as was occasionally his custom. The drowsiness, how- 
 ever, increased during the four hours I spent with him. He was cupped 
 over the loins, and the cupping followed by hot cataplasms, and, in the 
 course of the next nine hours, was freely purged by elaterium, and sweated 
 by jaborandi. The treatment availed nothing, however, in relieving the 
 suppression. The drowsiness increased, and he died at noon of the 20th, 
 one hundred and eighteen hours (within two hours of exactly /i'e days) after 
 he last passed water. 
 
 The autopsy was made by Dr. Barr, fifty-six hours after death. The 
 bladder appeared not to have been examined, but all the other organs in the 
 abdomen except the kidneys were noi-mal. The latter I presented to 
 the Patliological Society of Philadelphia, but the left one had lost almost 
 entirely the appearance which made them, in conjunction, among the most 
 striking specimens of morbid anatomy I have ever seen. The right was 
 sacculated, the cjsts ranging from half an inch to one and a half inch in 
 diameter, and were round and oval ; in one of them was imbedded a cal- 
 culus as lai-ge as a pea. The others were filled with a yellowish and odorless 
 fluid containing albumen. They were not lined with an epithelium. The kid- 
 ney was also larger than the normal organ, weighing six and a half ounces. 
 The capsule was strongly adherent. Microscopic, examinations of thin sec- 
 tions exhibited the appearances of interstitial nephritis, and the condition 
 was evidently one of long standing, the result of the constant hyperemia 
 caused by the calculi which have from time to time formed, and all of 
 which seem to have escaped except the one still shown in position. In the 
 parenchyma numerous infarctions of blood were seen, and the epithelium 
 was fatty in places. The left kidney exhibited a great and most interesting 
 contrast to the right. It was throughout of a beautiful bright-scarlet color, 
 weighed seven ounces, and was hard in consistence. The capsule was only 
 slightly adherent; surface smooth. On section, it presented a homogeneous, 
 very bright-red color. There were no cysts. The pelvis was somewhat 
 dilated. Microscopic examination showed large, swollen tufts, the epithe- 
 lium of the tubules largely swollen and desquamated, the bloodvessels 
 normal but overdistended by blood, with other features of a parenchymatous 
 nephritis. 
 
 Treatment. 
 
 There is no curative treatment for suppurative nephritis 
 without a removal of its cause, and as tiie latter is almost in-
 
 SUPPURATIVE INTERSTITIAL NEPHRITIS. 217 
 
 variably impossible, it follows that our measures are mainly 
 palliatives. One of the most frequent indications is the relief 
 of pain, which is usually so severe as to call for powerful 
 anodyne measures, — opium and its alkaloids being absolutely 
 essential. Hypodermic injections of the salts of moqjhia, in 
 doses of ^ to J of a grain, repeated, if necessary, are favorite 
 and effectual methods of relieving the intense pain, which is 
 often due, not so much to the inflammatory process as the 
 cause of obstruction. Suppositories of J to 2 grains of the ex- 
 tract of opium may be substituted. Hot fomentations are 
 also valuable adjuvants. 
 
 The catarrhal process which is constant in the kidney itself, 
 in its pelvis, and the ureter, and also in the bladder, requires 
 treatment, and, although in consequence of the pei'sistent oper- 
 ation of the cause is incurable, is nevertheless capable of de- 
 cided improvement. The only remedies I have found efficient 
 are the balsams and benzoic acid. Of the former I prefer 
 sandalwood oil, both on account of its efficiency and because it 
 is better borne by the stomach. Given in gelatin capsules, 
 each containing 10 drops, of which one or two may be taken 
 three times a day, it will be found to have a decided effect 
 upon the catarrhal inflammation, seen in a diminution of the 
 amount of pus in the urine. 
 
 Benzoic acid fulfils another indication, that of securing an 
 acid reaction of the urine, which is very often either alkaline 
 or so faintly acid that it rapidly becomes alkaline, and thus 
 ])redisposes to decomposition. The benzoic acid is best given 
 in the form of compressed pills. For an adult three or four 
 5-grain compressed pills daily are usually sufficient to keep 
 the urine acid. Larger closes than these may be given. It 
 may be given either alone or in conjunction with the sandal- 
 wood oil, the former being given before and the latter after a 
 meal. To children smaller doses may be given. I usually 
 begin with one grain three times a day and increase it. To 
 the boy Willie, whose case is related on p. 208, I gave five 
 grains three times a day. I have never found the careful 
 administration of these remedies to produce deraao;ement-of
 
 218 briqht's disease. 
 
 the storaarli, and by their use have greatly ameliorated the 
 symptoms. Benzoic acid is sometimes advantageously com- 
 bined with opiates. 
 
 The various vegetable diuretics, as buchu, pareira brava, etc., 
 I have never found of any use in these affections, suppurative 
 nephritis and pyelitis. 
 
 The constant and inevitable tendency in these cases to run 
 down in general health, in consequence of the drain and wear 
 and tear to which they are subjected, renders due attention to 
 restorative measures essential, and the use of quinine, iron, 
 milk, and other nutritious articles of diet is constantly indi- 
 cated ; while the dangers to which the patient is subjected from 
 exposure require constant precautions to be observed against 
 cold and dampness, which, by inducing acute nephritis, may 
 lead to a rapidly fatal issue, as illustrated by the case just 
 related. 
 
 « 
 
 I
 
 CYANOTIC INDURATION OF THE KIDNEY. 219 
 
 SECTION XI. 
 
 CYANOTIC INDURATION OF THE KIDNEY. 
 
 Syyionym.— Passive congestion of the kidney. 
 
 CYANOTIC INDURATION IS A PECULIAR INDURATED STATE 
 OF THE KIDNEY DUE TO A SIMPLE HYPERPLASIA OF ITS 
 INTERSTITIAL TISSUE, WHICH RESULTS FROM LONG-CON- 
 TINUED PASSIVE CONGESTION. 
 
 Etiology and Pathogeny. 
 
 While any agency which obstructs the movement of the 
 blood through the kidney may become a cause of cyanotic in- 
 duration, the only ones encountered in actual practice are 
 valvular disease of the heart and chronic pulmonary diseases 
 involving considerable areas of the lung, such as emphysema, 
 phthisis, etc., or pleurisy, with extensive effusion, or marked 
 adhesions, etc. 
 
 In either event the mechanism of its production is the same. 
 The blood is crowded into the venous side of the vascular sys- 
 tem. In mitral insuflficieney the blood is regurgitated from the 
 left ventricle into the corresponding auricle, and thence into the 
 lungs ; the latter organs become engorged, and again resist the 
 entrance of blood from the right side of the heart, whence 
 it is backed into the valveless vena cava. The smaller veins 
 of the extremities at first resist it by means of the valves with 
 which they are provided. But the veins of the abdominal 
 organs, including the liver and the kidneys, are without valves, 
 and are the first, therefore, to receive the brunt of the stag- 
 nation. They become gorged with blood, and it is as though 
 a string were tied around the renal vein, preventing the exit 
 of the blood. What is the consequence? The connective 
 tissue so abundantly present in the liver — and although sparsely 
 present in the kidney, still there in sufficient quantity to be- 
 come the starting-point of new formations — becomes infiltrated
 
 220 brigut's disease. 
 
 with Uquor sanguinis, the natural pabuhim of the tissues. 
 Thus suj)plied with food, the connective tissue corpuscles pro- 
 liferate. Others are formed by the proliferation and fixation 
 of the amcjeboid white corpuscles, which, under the favorable 
 circumstances afforded by a stagnated circulation, wander out 
 in great numbers from the capillaries and small veins. These 
 new cells are differentiated into connective tissue fibres. The 
 condition is really that of an interstitial nephritis, but for the 
 reasons stated on p. 84, I shall consider it here briefly. 
 
 In pulmonary or pleural disease the obstruction begins in 
 the lungs instead of the heart, but the mechanism is the same. 
 
 Ilorbid Anatomy. 
 
 The kidney of cyanotic induration or passive congestion is 
 hard, firm, and bluish-red as to its external surface. In the 
 earlier stages it is enlarged simply from the presence of the 
 large amount of blood detained in its parenchyma. The stel- 
 late veins are unusually distinct. The capsule strips off easily, 
 and on section the enlargement is found to involve the cortex 
 but the veins of both cortex and medulla are engorged, that of 
 the straight veins causing the medulla to appear darker in hue 
 than the cortex. The Malpighian bodies, on the other hand, 
 are not always engorged. The cut surface of the kidney is 
 moist and succulent, but the microscope reveals no further 
 changes, cither in the cortex or the medulla, the epithelium 
 being unchanged. 
 
 But the kidney is rarely seen in this stage. When found at 
 autopsies of cases of heart disease, the enlargement referred to 
 has nearly or quite disappeared, and the kidney is slightly if 
 at all larger than the normal organ, though rarely if at all 
 smaller. The other superficial characters of hardness, smooth- 
 ness, and bluish-red color, however, remain. Sometimes there 
 appears a slight tendency to lobulation, or even a slight 
 disposition to unevenness, by reason of certain shallow super- 
 ficial depressions, but very seldom anything like a granular 
 appearance of the surface of the organ stripped of its cap- 
 sule. In this event the capsule does not strip off quite as
 
 CYANOTIC INDURATION OP THE KIDNEY. 221 
 
 easily as usual, but may drag small portions of the parenchyma 
 with it. 
 
 On section the relations of the cortex and medulla are not 
 much altered, but the succulency of the parenchyma which 
 characterized the early stage has been replaced by a uniform 
 hardness throughout the entire organ. The capillaries are less 
 turgid, and contribute less of their hue to the cortex, Avhich is 
 therefore paler, although the Malpighian bodies may be rela- 
 tively more distinct by the retention of the blood in their in- 
 terior. The microscope explains the cause of the induration 
 in a simple rather than a corpuscular overgrowth of the con- 
 nective tissue between the tubules and vessels, that is, there is 
 no relative increase in the proportion of cells, but a uniform 
 increase of both the cells and fibrillar-intercellular substance. 
 This tends slightly to contract, to compress, the capillaries, and 
 thus interfere with the proper nutrition of the cells, which may 
 become more granular or even fatty, and may waste, resulting 
 in destruction of portions of the convoluted tubules ; hence the 
 superficial depressions of the surface alluded to. 
 
 Occasionally there may be a corpuscular increase in the 
 interstitial tissue, that is, there may be an increase of the lym- 
 phoid cells between the tubules; but this is rare, the process 
 being in the main one of simple hypernutrition resulting from 
 a copious access of pabulum rather than a process of an active 
 inflammatory character. 
 
 The condition is also to be distinguished from a pre-existing 
 granular kidney, upon which cardiac disease may have been 
 ingrafted secondarily. 
 
 Symptoms of Cyanotic Induration. 
 
 The symptoms of this condition are primarily those of the 
 disease of which it is the consequence, which I will not repeat. 
 
 To these are superadded generally a dropsy, scanty urine, of 
 high specific gravity, containing usually a small amount of al- 
 bumen and a few small hyaline casts. 
 
 The dropsy is usually of the lower extremities, in the area 
 drained by the inferior vena cava, while it will be remembered
 
 222 briqht's disease. 
 
 that tliat of renal disease more frequently involves the upper 
 extremities. There also occur, however, effusions into the 
 pleural sac and peritoneum, and the hands and arms may be 
 involved. 
 
 The vrinc, as stated, is scanty, and of high specific gravity, 
 often 1030, and even higher. It is turbid with urates, de- 
 positing a copious sediment of them and of ui'ic acid. 
 
 The «/6ume7i, as stated, is usually small in quantity, but may 
 become larger if the obstruction to the movement of the blood 
 is great. 
 
 The casts are small, transparent, or faintly granular, and 
 not numerous, indeed often absent. Fatty casts are also occa- 
 sionally present. 
 
 Further, a kidney thus constantly engorged is much more 
 liable to attacks of acute inflammation than one which is in 
 the normal state. This fact explains the frequency with which, 
 in cases of this nature, the urine becomes suddenly bloody, 
 highly albuminous, and filled with epithelial and blood casts, 
 even after slight exposure, such as would be without effect 
 upon a healthy individual. In the intervals between such 
 attacks the blood-casts disappear entirely, and the epithelial 
 and granular casts also become much less numerous, and often 
 disappear, the granular continuing longest, while even fatty 
 casts which were present may disappear. 
 
 Diagnosis. 
 The supervention of renal disease upon cardiac disease may 
 be suspected when all the symptoms of the latter become ag- 
 gravated, the dropsy becomes })eculiarly persistent, and the 
 urine is scanty. The high specific gravity of the urine, and the 
 presence of albumen and casts, confirm the suspicion. 
 
 Prognosis. 
 With the supervention of the renal involvement, the incon- 
 veniences and annoyances of the cardiac disease become many 
 times greater, while the dif^cnlties in th« way of improve- 
 ment are nearly proportionately increased. Yet the results
 
 CYANOTIC INDURATION OF THE KIDNEY. 223 
 
 wliich sometimes follow appropriate and energetic treatment, 
 and the substitution of favorable for unfavorable hygienic 
 surroundings, such as succeed the admission of a neglected 
 outcast to the wards of a hospital, are often astonishing. Under 
 these circumstances it is not unusual for the dropsy to decline, 
 the albumen and casts to disappear, and the patient to be re- 
 stored to comparative comfort, without, however, any change 
 in the original lesion, which upon the slightest provocation 
 will re-excite all the symptoms. 
 
 Treatment. 
 
 As intimated under prognosis, the substitution of favorable 
 for unfavorable hygienic surroundings is the primary requisite. 
 Shelter, warmth, rest, good food are indispensable. After this 
 digitalis is our most powerful lever, and for evident reasons. 
 We have here to deal Avith a dilated, weak, failing heart, un- 
 able to drive the blood forward. Its power must be increased, 
 and we have a remedy capable of doing this in digitalis. But 
 sufficient doses must be given, whether of the tincture, powder, 
 or infusion. The infusion, freshly prepared, is the most reli- 
 able preparation, although much of its efficiency is due to the 
 fact that it is given in larger doses than the other preparations. 
 Thus it is not uncommon to give f^ss. of the infusion, which 
 is equivalent to nearly four (3|) grains of the powder, and 
 thirty minims, or sixty drops, of the tincture. Yet rarely are 
 such doses of the latter given. Less than fifteen drops of the 
 tincture — equivalent to about one grain of the powder — is too 
 small a dose for an adult. Fifteen drops may be given every 
 three hours if the patient is seen daily, or oftener if the case is 
 seen twice a day. Under such doses, if the cardiac disease is 
 not too advanced, the urine may increase, become clear, its 
 albumen and casts decline, and with these also the dropsy, 
 dyspnoea, and restless, sleepless nights. 
 
 Due attention must also be paid to the bowels, for the sake 
 of securing prompt action of the diuretics as well as the elimi- 
 nation which their free action secures. Even the hydragogue
 
 224 bright's disease. 
 
 cathartics, such as elateriuin and the salines, may be used with 
 advantage. 
 
 The appended case illustrates so fully the cause, symptoms, 
 eifects of treatment, and morbid anatomy of this condition that 
 I cannot but think it will form an ajipropriate and useful con- 
 clusion to this section: 
 
 Mary K., 39 years of age, married, was admitted to my wards in the 
 Philadelphia Hospital on November 15th, 1873. Both of her parents suf- 
 fered from rlieumatism and subsequent cardiac disease, and her mother 
 died with dropsy, which came on after confinement. The patient herself 
 had several attacks of rheumatism, but in other respects enjoyed fair health 
 until aljout five months before admission, when she began to notice short- 
 ness of breath on exertion, together with oedema of the legs and ascites. At 
 that time she was five months advanced in pregnancy. These symptoms 
 grew slowly worse up to the time of her confinement, after which they con- 
 tinued to increase even more rapidly. Her labor was quite normal, and 
 took place five weeks before her admission to the hospital. At admission 
 her abdomen was enormously distended, the lower three-fourths wei'e abso- 
 lutely fiat on percussion, and a marked sense of fluctuation was communi- 
 cated to the fingers on palpation ; tlie lower portion of the abdomen rested 
 upon the thiglis, and the friction of the opposed surfaces had caused exten- 
 sive excoriation. The legs, from the feet upwards, were cedematous, and 
 there was also some oedema of the hands and arms. The dyspnoea was so 
 great as to render it almost impossible for her to lie down in bed ; the res- 
 pirations, wlien she was sitting up, numbered sixty per minute. 
 
 There was no evidence of any disease of the lungs or jileura. The area 
 of cardiac dulness was increased, and a double mitral murmur, with an 
 aortic systolic murmur, could be distinctly heard. The pulse was feeble 
 and frequent, beating one hundred and fifteen times a minute. Tlie urine 
 was found to be diminished in quantity, high-colored and acid in reaction, 
 and to contain a large quantity of albumen, the precipitate by acid and heat 
 being equal to at least three-fourths of the bulk of the fluid tested. The 
 microscope revealed numerous /i?/oZme and /a/^y casts. Her general health 
 was much reduced, desire for food was almost absent, and her bowels were 
 constipated. 
 
 She was ordered half an oimce of Basham's mixture three times daily, 
 twenty drops of tincture of digitalis, repeated according to its action on the 
 pulse, small doses of elaterium to relieve the constipation, and a nutritions 
 diet, with a small quantity of whiskey (f3ij in twenty-four hours). Under 
 this treatment the abdomen became somewhat less tense, a larger quantity 
 of urine was passed, and the number of respiratory movements fell to thirty 
 per minute, but the pulse remained frequent, and seemed to be unaft'ected 
 by the digitalis, althougli its administration was pushed to tlie limit of 
 safety.
 
 CYANOTIC INDURATION OF THE KIDNEY. 225 
 
 This improvement was but temporary, and on November 20th it was de- 
 cided to perform paracentesis. Six pints of a liigiily albuminous fluid were 
 allowed to flow from the abdomen, when the canula was withdrawn and the 
 aperture allowed to remain open. Two hours after the operation, the pulse, 
 which had been beating one hundred and twenty per minute, fell to fifty, 
 then to forty-six, and became dicrotic. The dicrotism was evidently car- 
 diac in its origin, being produced by a second effort at systole on the part 
 of the left ventricle. The patient was, however, in every respect better ; 
 indeed, felt quite comfortable. The effect on the heart and general condi- 
 tion was attributed to the digitalis, which was now, however, suspended. 
 
 November 24th, the pulse was seventy-two, somewhat irregular, though 
 entirely free from dicrotism ; the respiratory movements were reduced to 
 twenty-six, and were much more free, while the oedema was greatly dimin- 
 ished. She passed, on an average, three pints of urine each day. At this 
 date the latter was found to contain an unusual number of mucous cor- 
 puscles, some spherical epithelium from the bladder, and a few hyaline casts; 
 the amount of albumen was reduced to one-sixth of the bulk of the urine 
 tested. Since the operation a large quantity of fluid, estimated at six pints, 
 had trickled from the orifice in the abdomen. Quinine was added to the 
 treatment. 
 
 Notwithstanding the continued use of diuretics (bitartrate of potash and 
 infusion of juniper, infusion of seoparius, and free doses of digitalis), the 
 ascites slowly increased, and on December 12th she was again tapped by 
 Dr. Bruen, the resident physician, and one hundred and thirty ounces of 
 fluid were removed. This was again followed by amendment, the oedema 
 continuing to diminish. By December 22d the opening of paracentesis 
 was closed, the icrine was free from albumen, and no casts were found after 
 prolonged and careful examination. 
 
 On December 24th, after exposure to cold, she became much worse, and 
 by December 25th the legs were again swollen almost to bursting, and had 
 assumed an erysipelatous hue. The respirations were hurried, the skin 
 was hot and dry, and the urine was so charged with albumen that it became 
 almost solid on the application of heat and nitric acid. Paracentesis was 
 performed for the third time, fifty ounces of fluid being removed. No relief 
 was experienced from this operation ; in fact, the dyspncea steadily in- 
 creased, and the pulse became so feeble that it could scarcely be counted at 
 the wrist. 
 
 At 3 P.M. on December 27th the pulse at the wrist was extinct and no 
 cardiac impulse could be felt, but on auscultation the heart was found to be 
 beating one hundred and thirty-nine times a minute. Upon extending the 
 examination to the other parts of the chest, the physical signs of pleuritic 
 eff'usion were detected on the right side. At 6 p.m., as a last resort, this 
 side of the chest was tapped, and twenty-eight ounces of liquid removed ; 
 immediately afterwards the patient felt easier, but soon began to sink, and 
 died at 9.30 p.m. 
 
 The general plan of treatment remainect the same as tliat already men- 
 
 15
 
 226 bright's disease. 
 
 tioned* throughout the course of tlie illness, although, as the indications 
 varied from time to time, the quantity of digitalis used, as well as the form 
 of its administration, was changed ; as stated, other diuretic preparations, 
 such as acetate of potash, juniper, sweet spirit of nitre, etc., were also tried. 
 
 At the autopsy, which was made twenty-four hours after death, a quan- 
 tity of fluid, eighteen ounces In' me:isurement, was found in the right pleu- 
 ral cavity, and the uj^per part of the parietal and visceral portions of the 
 pleura was covered by a moderately thick layer of fresh lymph. The right 
 lung was congested and somewhat compressed, but not at all inHamed. 
 There was nothing abnormal in the left lung or pleura. Theheart weiglied 
 fifteen and a half ounces. The left ventricle was dilated and hypertrophied. 
 The leaflets of the aortic valve were thickened ; this alteration was most 
 marked along the edges of the leaflets and in the corpora aurantii ; the latter 
 were increased in size, being about as large as a split pea. Both leaflets of 
 the mitral valve were thickened, and they were fused along their edges so as 
 to form a funnel-shaped projection into the cavity of the left ventricle, with 
 only a slitlike opening, through which the end of the thumb could scarcely 
 be passed; the valve thus coalesced was the seat of calcareous deposit. The 
 right ventricle was also moderately dilated and hypertrophied ; the pulmo- 
 nary and tricuspid valves were healthy. 
 
 The liver weighed ninety-seven ounces, and Avas very fatty. The fciclneys 
 were lobulated, and weighed, together, fourteen ounces ; they were, there- 
 fore, somewhat enlarged, and also congested ; but in other respects they 
 appeared normal to the naked eye. On microscopical examination, the 
 renal tul)ules were in part lined with healthy epithelium, or with epithelium 
 which was only slightly granular; in other portions, however, the epithe- 
 lium was highly fatty. There was also slight increase in the interstitial 
 fibrillar tissue. Xo trace of amyloid degeneration could be detected by the 
 iodine test.
 
 DIABETES MELLITUS. 227 
 
 DIABETES. 
 
 SECTION I. 
 
 DIABETES MELLITUS GLYCOSURIA. 
 
 Notwithstanding the recent numerous and important con- 
 tributions to our knowledge of glycogenesis, and the acknowl- 
 edgment that saccharine urine, like albuminuria, is a symptom 
 of disease rather than a disease itself, we are still far from that 
 precise information upon which alone we dare base a classifi- 
 cation. Until such knowledge is attained, we may define 
 diabetes meUiius as distinguished from diabetes insipidus, as an 
 excessiye secretion of urine surcharged with sugar, associated 
 at times with evident lesions of the nervous system, at others 
 with as vet imperfectly understood derangements of the diges- 
 tive apparatus, and especially the liver. 
 
 Residence, Age, and Sex of Patients. 
 
 Diabetes is not a very common disease anywhere, but there 
 would appear to be ditJ'erences in the frequency of its occur- 
 rence in different countries. Thus it would seem to be less 
 common in the United States than in England. Statistics 
 are proverbially unreliable in this country, but in Philadelphia, 
 where we may expect to find a fair combination of the various 
 causes of the disease, together with as much accuracy as can 
 be expected, during the past eleven years, from 1870 to 1880 
 inclusive, there were 206 deaths from diabetes out of a total 
 of 181,879, stillborn excluded, or 1 in 882, as will be seen 
 from the following table, compiled from the records of the 
 Philadelphia Board of Health, through the kindness of its 
 president, Dr. William H. Ford.
 
 228 
 
 DIABETES. 
 
 It will be seen, also, that the ratio of deaths from this cause 
 to the total of each year is tolerably constant, and that for each 
 year approximates that for the total. 
 
 In New York city, according to G. M. Smith, out of 80,016 
 deaths in three and a quarter years, 58 were diabetics, or 1 in 
 1379, a smaller ratio even than in Philadelphia; but the ratio 
 in the latter city, covering a longer period, is probably more 
 nearly correct for the entire country. On the other hand, in 
 England and Wales, according to Dickinson, during ten years 
 there occurred 1 death from diabetes to 632 from all other 
 causes, and in Scotland 1 to 916. Furthermore, according to 
 Dickinson, the disease is more prevalent in the agricultural 
 counties of England, and of these the cooler ones — Xorfolk, 
 Suffolk, Berkshire, and Huntingdon. According to Senator, it 
 is prevalent in France, in Xormandy ; it is particularly rare, 
 statistically, in Holland, Russia, Brazil, and the West Indies, 
 while it is common in certain regions of India, especially 
 Ceylon, and relatively very frequent in modern times in Thu- 
 ringia and AVurtemberg. Seegen says it is more frequently ob- 
 served among Jews than Christians. 
 
 Diabetes mellitus most frequently affects adults in middle 
 life, while it does also occur in children. Thus Dr. Dickinson 
 had a case which proved fatal after six months' illness at 6 
 years of age; Dr. Bence Jones's youngest patient was 3h, Dr. 
 Roberts's 3; but from the latter's work I learn that in the reports 
 of the Registrar-General of England for the years 1851-60, ten
 
 DIABETES MELLITUS. 229 
 
 deaths under the age of 1 year and thirty-two under tlie age 
 of 3 are registered. The youngest patient I ever had was 
 a boy of 12, who passed from under my observation before 
 the case terminated. The disease is most frequent between the 
 ages of 30 and 6G, the oldest patient of whom I have notes 
 being the latter age. He probably acquired the disease, how- 
 ever, at 64. Senator had a case in which the earliest symp- 
 toms were observed in the 69th year, and Dickinson reports 
 one developing in the 71st year. ]\Iost important in this 
 connection is the fact that the disease is very fatal in young 
 subjects, recovery being almost unknown. Diabetes insipidus, 
 on the other hand, is said to be quite common in infancy. 
 
 Very singular and inexplicable is the fact that the disease 
 is v^ery much more frequent in males than females, in the pro- 
 portion of nearly two to one. I never happen to have had a 
 case iu a female, either in hospital or private practice. Sena- 
 tor's* statistics show that under the age of 20, more females are 
 affected than males. 
 
 It so happens that of seven cases of diabetes which have 
 recently come to my notice four are physicians, of whom two 
 at least have been engaged in very laborious country practice. 
 In connection with the well-known fact that anxiety, mental 
 strain, and fatigue are admitted causes of diabetes, it is not 
 unlikely that the peculiarly wearing life of the country phy- 
 sician should make him rather more than usually liable to the 
 disease. 
 
 Patliology and Pathogenesis. 
 
 The etiology of diabetes is so intimately blended with its 
 pathology, that it is scarcely possible to separate their consid- 
 eration. What is known, therefore, of its immediate causation 
 will be developed in connection with the pathology, while its 
 more remote causes will be briefly considered iu the ensuing 
 section. Inseparably connected, also, with the pathology of 
 diabetes, are the phenomena of sugar formation in the economy. 
 
 * See Senator's article on Diabetes Mellitus in Zierassen's Cyclopjedia of 
 Medicine, vol, xvi, p. 8G6, ad fin.
 
 230 DIABETES. 
 
 A brief ex])osition of the latter seems, therefore, essential. It 
 is very well known that during life there is constantly being 
 produced and stored in the liver of man and the lower ani- 
 mals an avii//oid substance, which was named by its discoverer, 
 Claude Bernard, (//t/cogen* Its formula is CgH,yO., that of 
 starch, and the term zoamylin or animal starch was at one 
 time suggested for it. The glycogen formation takes place 
 whether animal or vegetable food is taken, but it is much more 
 abundant upon a vegetable diet. It is commonly held that it 
 does not occur at all with a diet of pure fats, but Salomonf 
 claims that it is produced in the livers of rabbits fed on olive oil. 
 All physiologists agree that the amyloid substance is derived 
 mainly from the starchy and saccharine principles of food, but 
 partly also by a splitting up and rearrangement of the elements 
 of nitrogenous food, resulting in urea, — a soluble diffusible sub- 
 stance which passes into the blood, — and glycogen, which is 
 stored in the liver-cells. 
 
 The most im])ortant property of glycogen is its ready con- 
 vertibility at the temperature of the body into glucose or 
 grape-sugar. For this is required, also, the action of an amylo- 
 lytic ferment, the blood itself being such a ferment, although 
 a separate ferment, derived either from the blood or the liver- 
 cells, is generally considered as the agent of conversion. Ber- 
 nard isolated such a ferment from the liver, and assumed that 
 it was contained in only a certain number of the liver-cells, 
 while glycogen was found in the others ; nervous influence 
 regulating the action of the two on each other. Pavy, on the 
 other hand, believes that the ferment resides in the blood. 
 
 According to Bernard and his school, the conversion of starch 
 into glucose is constantly taking place during life, and there is 
 as constantly being passed into the blood of the hepatic veins 
 grape-sugar, which is carried through the heart and lungs, and 
 finally oxidized in the capillaries; it being held by them that 
 there is less sugar in venous than in arterial blood. The mean 
 difference is put at 0.3 part per 1000 ; the figures showing the 
 
 '* Bernnrd, Nov. Fonc. dii Foie, Paris, 1853. 
 t Virchovv's Archiv, Bd. 61, Heft. 3, 1874, IS.
 
 DIABETES MELLITUS. 231 
 
 least difference being 1.10 per 1000 for arterial, and 1.08 for 
 venous blood, those showing the greatest difference being 1,51 
 per 1000 for arterial, and .95 for venous blood. Formerly it 
 was thought that the destruction takes place wholly in the 
 lungs, but at the present day this view is, I believe, held by 
 none. It is in the peri|)hcral capillaries generally, and more 
 especially in those of the muscles, that the sugar is believed to 
 be destroyed during their contraction, the oxidation generating 
 a part of the force procbiced in muscular contraction. 
 
 Dr. Pavy and his school, on the other hand, contend that to 
 a very slight degree only does this conversion of glycogen into 
 sugar take place in the liver during life. They claim that the 
 latter organ is an assimilating one for starchy and saccharine 
 substances, which being reduced by the action of the pancreatic 
 juice into glucose, are absorbed as such and carried by the 
 portal vein through the liver, whose cells pick out the glucose 
 and convert it into amyloid substance.* According to this 
 view there is a very slight amount of sugar in the l)lood, which 
 Pavy's experiments show to be about the same in venous and 
 arterial blood, — 0.94 of one part in 1000. Corresponding to 
 this, also, there is always in health a small quantity of sugar 
 in the urine, 0.5 part per 1000, too small to be detected by 
 ordinary tests, and therefore of no clinical importance. It is, 
 however, easily recognizable by special chemical methods, as 
 Mas long ago shown by Briicke.f 
 
 * The farther steps of the assimilative action referred to, Pavy admits 
 are not precisely known, l)ut he considers there is every reason to believe 
 that the amyloid substance is converted into fat, of which it is a preliminary 
 stage intermediate between sugar and fat.^ 
 
 t Dr. Pavy's results have been confirmed by Schifl^, Henzen, Meissner, Jae- 
 ger, Pliiiger, Ritter, and McDonnell of Dublin. Professor A. Flint, Jr. (New 
 York j\Ied. Jour., Jan. 1869), of New York, found sugar in tlie blood of the 
 hepatic vein of a dog within a minute after death, by ligature of the vena 
 cava inferior. Professor Lusk (New York Med. Jour., July, 1870) found 
 that tlie blood in the right side of the lieart removed during life by cathe- 
 terization through the jugular vein, contained from two to four times more 
 
 ' Pavy, Some Poiuls connected with Diabetes, Lonilon, 1.S78, p. 110; also Pavy on Food 
 and Dietetics, Philadelphia, 1874, p. i:!4 ; or the author's article ou Food and Driuk, la 
 Buck's Hygiene, New York, 1879, vol. i, p. 165.
 
 232 DIABETES. 
 
 In diabetes, according to Pavy,* this assimilating action of 
 tlie liver does not take place, but the glucose derived from 
 absorption passes directly through the organ into the general 
 circulation, and appears in the urine in quantities appreciable 
 by the ordinary tests. Pavy says it may be that the conversion 
 into amyloid substance occurs, and that this, through the con- 
 dition of the blood, is broucrht back again into sugar. His 
 own language is as follows : " The fact stands, that the sugar 
 from ingestion is not stopped from reaching the general circu- 
 lation as it ought to be, and I incline to the opinion that a 
 simple passage through the liver occurs, "f But Pavy admits 
 also that in the diabetic, sugar reaches the general circulation 
 partly by a true glycogenic action upon nitrogenous matter ; 
 since if lean meat be consumed, sugar continues to be found 
 in the urine, although in greatly diminished quantity. 
 
 Bernard, on the other hand, held, that in diabetes the 
 amyloid substance or glycogen is too rapidly converted into 
 glucose to be consumed in the ordinary processes of oxidation, 
 and therefore appears in the urine, so that in all instances of 
 diabetes the excess of sugar in the blood is derived from gly- 
 cogen, and it is an exaggeration of sugar formation rather than 
 a lessening of its destruction. 
 
 These, then, are the two prevailing theories, according to 
 one of which, that of Bernard, the excess of grape-sugar in 
 the blood, which is the necessary antecedent to its presence in 
 
 sugar than the blood of the jnguhir vein in the same animals. Professor 
 Dalton (Physiology, 1871, p. 192), by means of a comminuting instrument 
 which enabled him to treat large quantities of liver substance in a very 
 short time, found 1.8 part of glucose per 1000 of liver at the end of o sec- 
 onds after death, 6.8 parts in 15 minutes, and 10.2 parts in 1 hour. Harley 
 (Proceedings of the Eoyal Soc, vol. ix, p. 300) found sugar in the liver 
 within 20 seconds after the death of the animal. The conclusion of all 
 these last-named experimenters is that sugar is constantly produced from 
 glycogen in the liver during life, but it is so rapidly removed by the circu- 
 lation that only very small amounts accumulate in the organ. Hence, after 
 death, tiie quantity of sugar in the liver constantly increases. 
 
 * Pavy, Some Points connected with Diabetes, London, 1878, p. 3 and p. 
 110. 
 
 t Pavy, op. citat., p. 110.
 
 DIABETES MELLITUS. 203 
 
 the nrine, is due to an excessive conversion of glycogen ; while 
 according to the second, that of Pavy, it is in the main the 
 result of a defective conversion of grape-sugar into glycogen. 
 We are not compelled to adopt either of these views to the 
 exclusion of the other, nor to the exclusion of any view which 
 is consistent with experiment or clinical observations. In 
 point of fact it will be found that we are compelled to admit 
 both of these, and perhaps several additional explanations of 
 the presence of sugar in the urine. 
 
 In the meantime, however, we must study also the influence 
 of the nervous system in the production of saccharine urine. 
 Thus, Bernard early discovered that by puncturing, by which 
 is meant irritating, the medulla oblongata in the floor of the 
 fourth ventricle, anywhere between a point 4 or 5 mm. above 
 the nib of the calamus scriptorius and another about 4 mm. 
 higher up,* the urine in a day or two acquired a considerable 
 amount of sugar, and was increased in quantity. The amount 
 of su<2;ar is laro-er the better fed the animal, while if all food 
 is removed the sugar is trifling in amount, or disappears alto- 
 gether from the urine. The point thus punctured corresponds 
 W'ith the roots of the pneuraogastric nerves. Hence it was 
 supposed that the diabetes was the direct result of irritation of 
 these nerves. But it was found on section of the vagus, that 
 galvanization of the distal end of the cut nerve produced no 
 effect, while the same irritation applied to the central end re- 
 sulted in glycosuria. Wlience it was learned that the pneumo- 
 gastric is not an excitor but a sensory nerve of diabetes, and 
 that the glycosuria produced by irritation of the roots of the 
 vagi or their central cut ends, is the result of a reflex action 
 called into play through the pneumogastric as a sensory, and 
 some other nerve as a motor nerve. 
 
 Schifl't produced slight glycosuria by vertical section of the 
 optic thalami and the great crura cerebri; and more marked 
 
 * The area thus bounded, which was marked out by Eckhard as the 
 "diabetic area," corresponds very closely with the " vasomotor " area as 
 defined by Owsjannikow. Ludwig's Arbeiten, 1871, p. 21. 
 
 f SchiQJ Untersuchung iiber Zuckerbildung in der Leber, 1859.
 
 234 DIABETES. 
 
 glycosuria by destructive lesions of the pons and the middle 
 and posterior crura of the cerebellum; by complete division of 
 the cord at the level of the second dorsal vertebra, and some- 
 times, but not invariably, by division of the separate columns 
 of the cord, sometimes the anterior and sometimes the posterior. 
 Finally, SehiiF })roduced glycosuria by section of the nerve- 
 trunks of the limbs, as the sciatic. 
 
 Transverse section of the medulla oblongata always causes 
 glycosuria, and as constantly section of the cord above the 
 second dorsal vertebra, that is above the lower end of its 
 cervical enlargement. But below this point, this effect is not 
 produced, at least with any degree of constancy, while sec- 
 tion of the filaments of the sympathetic acconn)anying the 
 vertebral artery are again attended by it. Now these nerves 
 are vasomotor nerves, and section of their trunks paralyzes 
 their action and results in a dilatation of the bloodvessel walls 
 — those of the hepatic artery chiefly — and a more rapid move- 
 ment of the blood through them. Such dilatation and rapid 
 movement of the blood is always attended by glycosuria. 
 
 Pavy* cut through the crura cerebri, completely separating 
 the cerebrum from the parts below, without exciting glyco- 
 suria, but produced marked glycosuria by section of the sympa- 
 thetic filaments ascending from the superior thoracic ganglion 
 to accompany the vertebral artery in its canal in the foramina 
 of the transverse processes of the cervical vertebrae; also by 
 removal or injury of the superior cervical ganglion ; also occa- 
 sionally, but not always, by division of the ganglionated cord 
 of the sympathetic in the chest. Division of all the nerves 
 immediately belonging to the liver as they passed to the organ 
 in company with the hepatic artery, hepatic duct, and portal 
 vein, failed in every instance to occasion glycosuria. His re- 
 sults were communicated to the Royal Society in 1859, and 
 published in Guy's Hospital Reports for the same year. 
 
 * Pavy, On Diabetes, 2d edition, 1869, p. 164 et scq. This difference in 
 the results of Schiff and Pavy can be explained on the ground that Pavy's 
 section was without irritation, and that Schiff's involved some irritation.
 
 DIABETES MELLITUS. 235 
 
 Cvon and Aladoff * produced glycosuria in dogs after section 
 or careful extirpation of the last cervical or upper thoracic 
 ganglion, as well as bv section of the two vertebral branches, 
 or the two nerve-filaments which form the annulus of Vieus- 
 sens as they pass round the subclavian artery in proceeding 
 from the upper thoracic ganglion to the lower cervical. Ex- 
 tirpation of the lowest cervical ganglion after division of the 
 dorsal ganglionated cord of the sympathetic between the 10th 
 and 12th ribs, or of the splanchnics, was not followed by gly- 
 cosuria. But if the glycosuria had already been induced by 
 the previous extirpation of the ganglion, subsequent section of 
 the ganglionated cord and of the splanchnics did not cause the 
 glycosuria to disappear. 
 
 From the result of these experiments it is inferred that the 
 glycosuric influence leaves the cord by the filaments (c, Fig. 
 34) of the sympathetic nerve which accompany the vertebral 
 artery, and thence through them into the lower cervical gan- 
 glion, thence by the fibres (cZ) forming the annulus of Vieussens, 
 to the first dorsal ganglion (e), and thence through the prever- 
 tebral cord of the sympathetic (/), the splanchnics {h), to the 
 coeliac ganglion {{), and along the hepatic bloodvessels to the 
 liver itself, as j^hown in the appended diagram from Dr. Brun- 
 ton's lecture on diabetes mellitus.f 
 
 It has been stated that Schitf J has found that diabetes some- 
 times results from section of' the anterior column of the spinal 
 cord between the medulla and fourth cervical vertebra, and as 
 the experiments of Eckhard§ show that diabetes is not the in- 
 variable result of section of the fibres which accompany the 
 vertebral artery, the last cervical or first dorsal ganglion, or of 
 the fibres of the annulus of Vieussens, Dr. Brunton su2:2:ests 
 that the glycosuric influence does not always pass from the 
 
 * Cvon and Aladoff, reprint from Melanges Biologiques, and Bulletin de 
 I'Academie Imperiale de Petersbourg, vol. iii, p. 91 ; cited by Dr. Brunton 
 in the paper named below ; also British Medical Journal, December 23d, 
 1871, p. 732. 
 
 t T. Lauder Brunton, Lectures on the Pathology and Treatment of Dia- 
 betes Mellitns, reprinted from the British Medical Journal. London, 1874. 
 
 X Schiff, Untersuchung iiber Zuckerbildung in der Leber, 1859, p. 108. 
 
 ^ Eckhard, Beitriigezor AnatomieundPhysiologie, vol. vii, 1, 1873, p. 19.
 
 236 
 
 DIABETES. 
 
 spinal cord by tlie filaments above mentioned, but may some- 
 times pass further down the spinal cord and leave it by the 
 communicating branches going to some of the dorsal ganglia, 
 
 Fir;. 34. 
 
 Fig Z'k 
 
 Fig. 34. — Diujtram showing the course of the vasomotor nerves of the liver aceordiiig 
 to Cyou and Aladotf. These nerves are indicated by the dotted line which accompanies 
 them ; a, vasomotor centre ; 6, trunk of the vagus ; c, passage of the hepatic vasomotor 
 nerves from the cord along the vertebral artery ; d, fibres going on each side of the sub- 
 clavian artery, and forming the aunulus of Vienssen-. ; e, first dorsal ganglion ; /, gan- 
 glionattd cord of the sympathetic ; g, the spinal cord ; /*, splanchnic nerves; i, coeliac 
 ganglion, from which vasomotor fibres pass to the hepatic and inlestinsil vessels; A-, the 
 lungs, to which the fibrfs of the vagus are seen to be distributed ; /, the liver; m, the 
 intestines ; n, ihe arch of the aorta. 
 
 Fig. 35.— Diagram showing another course which the vasomotor nerves of the liver 
 may possil)ly take. The letters indicate the same parts as in Fiic. 34. The hepatic vaso- 
 motor nerves are here represented as passing lower down the cord than in Fig. 34, and 
 leaving it by the communicating branches to the second dorsal ganglion ; or it may leave 
 it, at other times, by l)ranches to the first, or even a lower dorsal ganglion. In the latter 
 event irritation of the third or other of the cervical ganglia may cause diabetes by 
 being conveyed along the vertebral artery and up the cord, as indicated by tlie<iark line, 
 to the vasomotor centre, where it may cause reflex inhibition, in the same way as any 
 irritation to the vagus. — After Brunton.
 
 DIABETES MELLITUS. 237 
 
 as indicated by the dotted line in Fig. 35. In this event, irri- 
 tation of the lower (3d) cervical ganglion, might canse gly- 
 cosuria by being conveyed along the vertebral artery and up 
 the cord, as indicated by the dark line, to the vasomotor 
 centre, where it may cause reflex inhibition as does irritation of 
 the vagus. 
 
 Wliatever may be the precise course pursued, it is evident 
 that it is through the vasomotor fibres of the symj)athetic that 
 the glycogenic influence is regulated, whence the oneness of the 
 centre for the two regulations. The etfect of section of these 
 nerves is easily explained, since dilatation of the vessels and in- 
 creased ra})idity of the movement of the blood is the conse- 
 quence. And although the dilating influence may be pecu- 
 liarly exerted upon the hepatic artery and its branches, yet in- 
 creased rate of movement of the blood in the latter must also 
 accelerate the movement of the blood in the portal vein and 
 its branches. The effect of irritation upon the glycogenic func- 
 tion, whether propagated through the pneumogastric or some 
 other sensory nerve, is nearly as simple. The eifect of the irri- 
 tation conveyed to the glycogenic centre is to inhibit the usual 
 tonic influence of the vasomotor nerves on the vessel-walls. 
 The inhibition of this influence results in a dilatation of the 
 vessels of the liver and a s])eeding of their contents. Thus 
 the same result is brought about in two different ways, — the 
 one being direct, the other reflex.* 
 
 * It sliould be stated that the effect of irritation of the vasomotor centre 
 is not ascribed by all experimenters to the withdrawal of an accustomed 
 nervous influence, that is, to a paralysis, but rather to an excitation. Eckhard 
 (Beitriioe, iv, 1, 1869 ; vii, 1, 1873) is one of these, and he bases his objection 
 to the usual view on the ground that, while mechanical injury to the first 
 thoracic ganglion will produce glycosuria, no such effect follows careful re- 
 moval of the ganglion, or the severing of its connections with the remainder 
 of the thoracic chain. Bernard also, in his lectures at the College of France, 
 in 1873, reversing his original view, concluded that the glycosuric nerve- 
 filaments, which, starting from the floor of the fourtli ventricle, lie believed to 
 pass through the substance of the cord to the fourth dorsal vertebra, and thence 
 through the sympathetic to the liver, are excitor in their character and analo- 
 gous to the chorda tyrnpani nerve. Their irritation, according to hhn, pro- 
 duced active hypersemia and increased sugar-formation, as irritation of the 
 chorda tympani causes hyperseiuia of the submaxillary gland and increased 
 secretion of saliva.
 
 238 DIABETES. 
 
 Among the experimental irritations already mentioned, be- 
 sides puncture of the fourth ventricle, which produce glycosuria 
 by a reflex action, are injuries of the cerebral lobes and cere- 
 l)cHum, superior cervical ganglion, optic thalami, cerebral pe- 
 duncles, pons varolii, middle cerebellar peduncles, cervical, 
 sympathetic, and even sciatic nerv^e, and brachial plexus. It 
 may be reasonably inferred, therefore, that pathological irrita- 
 tions of these same situations will result in diabetes; that if 
 permanent the diabetes resulting will be permanent, and if tem- 
 porary the diabetes will be temporary. And in point of fact, 
 observation has in numerous instances confirmed this supposi- 
 tion, as will be seen later, when the pathological anatomy of 
 diabetes is discussed. 
 
 But it is not to irritations alone applied to nerve-centres or 
 to trunks in their continuity that glycosuria is due, Irrita- 
 
 More recently M. Lafont (Medical News and Abstract, December, 1880, p. 
 730, from Lancet of October 23d, 1880), isolated in dogs a segment of the spinal 
 cord containing the first and second dorsal pairs of nerves. He next exposed 
 the liver and irritated bv faradization the isolated segment of the cord, where- 
 upon the liver was observed to present a disseminated congestion, accompa- 
 nied by a corresponding injection of the intestine and tui-gidity of the spleen. 
 He also ascertained that the stimulation of these nerve-roots by a weak faradic 
 current always caused a fall in the arterial pressure in the abdominal organs, 
 if the root is carefully isolated. The least extension of the current to the 
 spinal cord itself caused an increase in pressure. He found, too, that inter- 
 mittent stimulation by a weak faradic current of the central extremities of 
 the depressor branch of the vagus in the rabbit produced glycosuria ; tlial 
 stimulation of the central extremities of the pnenmogastrics themselves pro- 
 duced the same result ; and that division of the first two pairs of dorsal 
 nerves caused a decided diminution of the glycosuria excited by the diabetic 
 punctui'e. He found also that feeble stimulation of the central ends of the 
 pneumogastric and any degree of stimulation of the dejjressor nerve always 
 produced a fall of blood-pressure, while after division of the first three or 
 four dorsal nerves, such stimulation produced a rise in blood-pressure. 
 
 Finally he found that painful stimulation of any mixed nerve, frequently 
 repeated, caused glycosuria. 
 
 M. Lafont concludes from these experiments that lie has confirmed the 
 view of Bernard, that the glycosuria whicii results from stimulation of the 
 central extremities of the pneumogastric in the dog, the depressor nerves in 
 the rabbit, and the sensory nerves generally, is the result of an impression 
 conveyed to the bulbar vaso-dilator centre, the path from which is by the cer- 
 vical cord, the first dorsal nerve-roots, and the sympathetic and splanchnic 
 nerves ; and that it is irritative rather than paralytic.
 
 DIABETES MELLITUS. 239 
 
 tion of the peripheral distribution of nerves has a similar 
 effect. Thus, embarrassed respiration, whether due to disease 
 of the respiratory passages, strangulation, or inhalation of 
 irrespirable gases, as carbonic acid, carbonic oxide, etc., and 
 anaesthetics, as ether, chloroform, nitrite of amyl, is capable of 
 producing glycosuria in dogs and rabbits, although the symp- 
 tom has rarely been shown to attend these conditions in the 
 human subject. In all these instances it is probably irritation 
 of the terminal filaments of the pneumogastric — the sensory 
 nerve of glycosuria — which causes the diabetes, by inhibiting 
 the usual tonic action of the vasomotor nerves and producing 
 hyperjemia of the liver. So, also, "substances introduced into 
 the blood, as woorara, and even strychnia, morphia, and phos- 
 phoric acid, produce diabetes probably in the same way, by 
 irritating the terminal filaments of the vagi. Schiff asserts 
 that woorara and strychnia act, not by directly irritating the 
 filaments of the pneumogastric, but through the resulting em- 
 barrassed respiration, in the course of which the terminal fila- 
 ments of the pneumogastric are irritated ; and this may be true 
 in part. Bernard found that woorara produced, first, increased 
 saccharinity of the blood, and, second, glycosuria when given 
 in quantities insufficient to paralyze the muscles of respiration? 
 and, therefore, independently of embarrassed respiration ; in 
 other words, that it acts like puncture of the floor of the fourth 
 ventricle, paralyzing the vasomotor nerves of the liver by 
 inhibition. He considered that morphia acted in the same 
 way. While admitting that this is true with regard to woo- 
 rara, Lauder Brunton believes that the glycosuria which 
 appears after injecting woorara into the blood is also in part 
 due to the deficient consumption of sugar in the muscles 
 which it paralyzes, and in part also to the artificial respiration 
 employed to keep the animal alive. 
 
 Finally, Schiff* has shown that irritation of the liver by 
 needles and by galvanic currentsf passed through them pro- 
 
 * SchifF, Untersuchungen iiber Znckerbildung in der Leber, 1859, p. 106. 
 t Pavy, On Diabetes, 1869, p. 137.
 
 240 DIABETES. 
 
 duces glycosuria. This is also clue to resulting liyperaBmia, 
 whether direct or indirect; whence it maybe inferred that 
 congestion of the liver from any cau.53 may produce glyco- 
 suria, although it is not unreasonable to suppose that the 
 results of active and passive hyperaBinia may be somewhat 
 different in this respect. The hyperiemia of the liver from 
 embarrassed respiration is passive so far as results from the 
 backing of blood, but active so far as it is a reflex phe- 
 nomenon.* That an active rather than a passive hyperemia 
 is essential for the production of glycosuria would appear from 
 the fact ihat valvular disease of the heart is almost never 
 attended by glycosuria, while it is always accompanied by pas- 
 sive congestion of the liver. 
 
 Irritation of other peripheral branches of the pneumo- 
 gastric, as of the stomach and intestines, are less frequently 
 attended by glycosuria ; but that their irritation may be thus 
 attended is shown by a case mentioned by Brunton,f in which 
 the presence of tapeworm in the intestine caused diabetes, 
 which was immediately cured by its removal. 
 
 Dr. Pasy discovered that the injection of oxygenated blood 
 into the portal system produced glycosuria ; also, that surcharg- 
 ing the blood with oxygen through the medium of respiration 
 produced the same results. The introduction of venous blood 
 produced no such eifect ; whence he concluded that oxygenated 
 blood promotes the transformation of amyloid substance into 
 sugar, but whether it interferes with the conversion of the 
 sugar absorbed from the alimentary canal, or whether the 
 formation takes place and then the transformation back again, 
 cannot be stated. Xow this, he believes, is just the state into 
 which the portal blood is thrown by the vasomotor jjaralysis 
 affecting the vessels of the chylopoetic viscera, including the 
 
 * Dr. Pavy suggests (Certain Points connected with Diabetes, p. Ill) an- 
 other explanation of the production of sugar under these circumstances of 
 hepatic congestion. In this state he says the hepatic cells are subjected to 
 undue pressure, which may lead to more or less transudation and direct ad- 
 mixture of their contents with the blood. 
 
 t Brunton, op. citat., p. 14.
 
 DIABETES MELLITUS. 2-il 
 
 liver, the resulting hyperremia causing the blood to flow 
 through the organ too rapidly to admit its dearterialization.* 
 But the movement of the blood through the vessels of the 
 liver may be accelerated in other ways than by nervous influ- 
 ences which dilate them. Anything which raises the blood- 
 pressure in a part of the circulation, including the liver, at the 
 expense of another, as by ligation or compression of a large blood- 
 vessel, has this eflect. Such causes as these are found to increase 
 the quantity of sugar in the blood, and to cause it to appear in the 
 urine. • Not only this, but it has been shown by Cyon that dila- 
 tation of the bloodvessels, unaccompanied by accelerated move- 
 ment of the blood in the liver, is not sufficient to cause diabetes. 
 Section of the sympathetic between the tenth and twelfth ribs, and 
 of the splanchnics, produces dilatation of the bloodvessels of the 
 liver, but not glycosuria, even if the fourth ventricle be afterwards 
 punctured. Cyon's explanation is as follows : As the lower 
 sympathetic and the splanchnics contain also the vasomotor 
 nerves of the bloodvessels of the intestine, section of these nerves 
 not only paralyzes and dilates the bloodvessels of the liver, but 
 also those of the entire digestive canal. The vascular capacity 
 of the latter canal, especially in rabbits, in which it is unusually 
 long, is very great, indeed equal to that of the entire vascular 
 system outside of it. Section of the splanchnics and lower 
 sympathetic is, therefore, followed by a diversion of the blood 
 from the liver into the digestive canal, so that, although the 
 bloodvessels of the former are also dilated, there is a lack of 
 blood necessary to secure an accelerated movement. If, how- 
 ever, the celerity of circulation in the liver be first secured, by 
 puncture of the fourth ventricle, section of the splanchnics is not 
 followed by arrest of sugar-formation, as the celerity of the 
 
 * Pavy, Certain Points connected with Diabetes, p. 96 et seq. Dr. Pavy 
 considers that carbonic oxide acts in the same manner as oxygen in pro- 
 ducing glycosuria, either through the direct action of tlie gas itself, or a 
 compound between it and haemoglobin ; the more temporary efi'ect of the 
 oxygen being due to the very feeble combination between oxygen and hsemo- 
 glcbin, the gas being readily displaced from the corpuscle by carbonic acid, 
 while carbonic oxide, on the other hand, is displaced with extreme diffi- 
 culty, p. 103. 
 
 16
 
 242 DIABETES. 
 
 circulation once established is easily maintained, in spite of 
 subsequent section of the vasomotor nerves of the intestine. 
 
 Thus we have seen that hyperemia of the liver, however, 
 induced, is an important condition of glycosuria. But is it 
 possible for glycosuria to be brought about independently of 
 such hypersemia? Whatever maybe its bearing upon our 
 subject, it must be admitted that there are several ways in 
 which this may occur: 1st. There maybe an excessive in- 
 gestion of saccharine and amylaceous food over and above 
 the power of the liver to convert into glycogen. It is well 
 known that a moderate amount of cane-sugar may be intro- 
 duced into the stomach without appearing in the urine. But 
 if an excessive quantity of sugar is thus introduced it cannot 
 be converted into glycogen, but, passing through the liver into 
 the general circulation, promptly shows itself in the urine. 
 Xow it is evident that such excessive ingestion may occur in 
 man, and, as a consequence, sugar appear in the urine, while 
 the normal converting power of the liver remains unchanged. 
 Such glycosuria is called by Dr. Dickinson normal alimentary 
 glycosuria. It is not likely, however, that this cause would 
 ever operate in the production of a permanent diabetes. At 
 most there could be but a temporary glycosuria. 
 
 2d. The same thing may, possibly, result from the too rapid 
 conversion of starch and sugar into glucose in the intestines, 
 in consequence of which it is introduced into the liver too 
 rapidly and abundantly to admit its conversion into glycogen; 
 whence its appearance in the urine. In looking about for a 
 cause for such rapid digestion of saccharine and starchy food 
 in the intestine it has been suggested that an excess of pancre- 
 atic ferment poured into the intestine might occasion it ; and, 
 in confirmation of this view, Niemeyer asserts that there is 
 always hypertrophy of the pancreas in diabetes. But it is not 
 any more common than atrophy of the same organ, and it is 
 much more reasonable to suppose, as Brunton suggests, that if 
 diabetes has anything to do with either condition, it is the result 
 of an irritation of the nerves of the organ, which produce a 
 reflex dilatation of the hepatic bloodvessels, or, with Klebs,
 
 DIABETES MELLITUS. 243 
 
 that it is due to some concurrent changes in the coeliac axis, 
 which produce at once the mellituria and pancreatic disease. 
 Whatever may be the cause of such rapid conversion, it is not 
 impossible that a certain number of cases of diabetes easily- 
 remedied by dietetic treatment may be due to it. 
 
 3d. There may be but a normal ingestion of saccharine food, 
 which, being absorbed as grape-sugar, tnay still fail to undergo 
 conversion into glycogen in its transit through the liver, and 
 ao-ain surcharg-ino; the blood shows itself in the urine. And 
 although such an occurrence is usually the result of hypersemia, 
 yet it is conceivable that it may occur independently of this 
 condition, as from a deficiency of ferment. Dr. Dickinson be- 
 lieves that a certain number of cases of diabetes met with in 
 practice are of this kind, and he calls the glycosuria thus aris- 
 ing abnormal alimentary glycosuria."^ 
 
 4th. It is conceivable that there may be an increased con- 
 version of glycogen into glucose in the liver independent of 
 hyperemia, as the result of an increased activity of the dias- 
 tatic ferment, either from increased quantity or some other 
 unknown peculiarity. To account for such an occurrence, 
 various hypotheses have been suggested, none of which are suf- 
 ficient to account for more than a temporary glycosuria. One 
 of these is the increased absorption of pancreatic ferment, which 
 is thus assigned the power of converting glycogen into grape- 
 sugar in the liver, as well as of converting sugar and starch into 
 grape-sugar in the intestine. To account for this the hyper- 
 trophy of the pancreas already alluded to, has been also adduced. 
 
 An interesting discovery is that of Plosz and Tiegel,t that 
 the ferment in the blood is contained in the corpuscles alone, 
 and when the latter are destroyed, the ferment being set free 
 acts energetically ; and Griesinger has shown that the blood- 
 corpuscles are diminished in diabetes. Whatever, therefore, 
 may be the truth with regard to increased quantity of fer- 
 ment in the blood as a cause of diabetes, there are no facts 
 either to sustain or disprove it. It is a mere hypothesis. 
 
 * Dickinson, On Diabetes, London, 1875, p. 24. 
 
 t Pfluger's Archiv, 1873, Bd. vi, s. 249, and Bd. vii, s. 391.
 
 244 DIABETES. 
 
 5th. Senator* suggests that an abnormal amount of sugar 
 may be taken up with the chyle by the lacteals by reason of 
 some impediment to portal absorption, and carried directly into 
 the general circulation, instead of through the liver, and thus 
 upon the glycsemia thus induced might ensue a glycosuria. 
 
 6th. Again, if a part of the sugar ingested is normally 
 converted into lactic acid, as is held by some physiologists, and 
 the unchanged remainder absorbed by the radicles of the portal 
 vein, any interference with such conversion would leave a 
 larger residue of sugar to be absorbed by the portal radicles, 
 and thus introduce a larger proportion of glucose into the liver 
 than could be converted into amyloid substance. 
 
 7th. It is quite easy to conceive that diabetes may be the 
 result of a diminished consumption of the small quantity of 
 sugar normally supplied to the tissues by the blood. Its pos- 
 sibility is further substantiated by the occasional results of 
 treatment by muscular exercise, to which especial attention has 
 been called by Dr. William Richardson, of London, in his 
 little work on Diabetes and Its Treatment ,-\ and which he 
 so successfully applied to the treatment of his own and other 
 cases. It dare not be inferred, how^ever, that because muscular 
 exercise is useful in getting rid of the extra glycogen in the 
 blood, diabetes is the result of deficient consumption of sugar in 
 the tissues. There are, however, some other facts which have a 
 bearing upon the subject. In the first place, Ludwig and Gen- 
 ersich,;}: and Bernard§have shown that the blood which issues 
 from a contracting muscle by the vein, contains much less 
 sugar than that which enters it by the artery. Ludwig and 
 Scheremetjewskill have sliown that grape-sugar, as such, is 
 not burnt off in the body, while lactic acid and glycerin are; 
 and Bernard that as sugar disappears from the blood it is 
 replaced by lactic acid, while SchultzenT[ concludes from his 
 
 * Senator, article, Diabetes, in Zienissen's Cyclopaedia of Practical ]Medi- 
 cine, vol. xvi, p. 952, New York, 1877. 
 
 f London, 1871. J Lndwig's Arbeiten, 1871, s. 75. 
 
 ^ Bernard, Revue Scientifique, 2d series, tome iv, p. 1022. 
 
 II Ludwig's Arbeiten, 1869, pp. 141 and 144. 
 
 T[ Schultzen, Berliner Klinische Wochenscbrift, No. 35, 1872, s. 417.
 
 DIABETES MELLITUS. 245 
 
 experiments that the sugar, which is normally present in the 
 blood, is split up by the action of a ferment into lactic acid 
 and glycerin, which undergo combustion, and thus sustain the 
 temperature of the body. If the ferment which Sehultzeu 
 considers necessary for the conversion of the sugar into lactic 
 acid and glycerin should be absent or deficient, the sugar is 
 not split up, is not burnt up, and, therefore, appears in the 
 urine. This Schultzen believes to be the case with certain 
 diabetics. 
 
 ■ Otherreasons are adduced by Dr. Brunton* in favor of such 
 a view. Among these are the results of the experiments of 
 Dockf and of Weiss. Weiss| discovered that a considerable 
 amount of glycogen remains in the muscles of starved animals 
 after it has completely disa[)peared from the liver. Dock 
 showed that after glycogen has entirely disappeared from the 
 stomach of the starving rabbit, puncture of the floor of the 
 fourth ventricle does not produce glycosuria, while poisoning 
 by woorara does. Whence Brunton infers that the presence of 
 sugar in the urine of starv^ed animals after woorara-poisoning 
 is due to the fact that while the glycogen in the muscles 
 undergoes conversion into sugar, the sugar thus produced is 
 not transformed into lactic acid and glycerin, and does not, 
 therefore, undergo combustion as it should. Again, Dock 
 has shown that if the fourth ventricle of the starving rabbit 
 is punctured and then a few injections of cane-sugar made 
 into the stomach, no glycogen is formed in the liver, and no 
 sugar appears in the urine. If, under the same circum- 
 stance, the animal is poisoned by woorara, instead of punc- 
 tured, again no glycogen is formed, but sugar is copiously 
 present in the urine. In the former case, in consequence of 
 the dilatation of the hepatic vessels, the absorbed grape-sugar 
 passes too rapidly through the liver to be converted into gly- 
 cogen ; but it does not appear in the urine, because it is used 
 up by the muscles, which are here intact. In the second in- 
 
 * Brunton, op. citat., p. 20 et seq. 
 
 f Dock, Pfliiger's Arcliiv, Bd. v, s. 571. 
 
 i Weiss, Sitzungsberichte der Wiener Acad., Bd. Ixiv, s. 2S4.
 
 246 DIABETES. 
 
 stance the woorara dilates the bloodvessels by paralyzing them, 
 just as puncture does, and the sugar passes through the liver 
 too rapidly to be converted into glycogen. But in this in- 
 stance sugar appears in the urine, because the muscles also 
 are paralyzed by the woorara, and therefore cannot consume it. 
 
 There can be no doubt that the above reasoning is leg-itimate 
 if the premises ou which it is based are correct. But accord- 
 ing to Senator, Luchsinger has disproved that in woorara-poi- 
 soning mellituria occurs without glycogen-formation, and it 
 must be admitted that all experiments of the kind involvefl 
 are more or less to be distrusted, because of the difficulties in 
 the M^ay of their accuracy. Senator,* in alluding to the view 
 which would place the origin of diabetes partly in the liver, 
 and partly in the muscles, says that " it is chiefly supported 
 by mere conjecture, and does not comport well with a number 
 of recently discovered facts." Of course no one claims de- 
 ficient consumption of sugar in the muscles to be the sole origin 
 of diabetes. Zimmer, who is alluded to by Senator as the 
 author of this double view, says "the muscles are implicated, 
 particularly in the severer cases," and such I presume to be 
 all that is claimed by any. 
 
 Undoubtedly the sugar serves some purpose in the economy, 
 and is, therefore, in its proper proportion a necessary constitu- 
 ent of the blood. Doubtless, too, it is consumed in performing 
 its office, whether the lattter be force production by combustion, 
 or something else, and its cessation must result in the accumu- 
 lation of sugar in the blood. However insufficient the proof 
 therefore, I feel that we dare not deny the possihility of such 
 a contribution to the cause of diabetes. 
 
 It has been shown that there is a very evident relation between 
 experimental lesions of the nervous system, glycosuria and poly- 
 uria in animals. It should be further remarked that no other 
 symptoms of diabetes, so far as discoverable, attend these ex- 
 perimental lesions. It remains to consider any relation which 
 may exist between diabetes in man and lesions of the nervous 
 system. Some relation undoubtedly exists. Numerous cases 
 
 * Op. citat., p. 94S.
 
 DIABETES MELLITUS. 247 
 
 are reported in which injuries, not only in the vicinity of the 
 raeduUu oblongata and sympathetic tract, but also of the cere- 
 bral hemispheres and cerebellum, are attended by a glycosuria 
 which is undoubtedly a consequence of them. ]Moreover, many 
 of these cases have been accompanied by all the other essential 
 symptoms of diabetes. At the same time there are many cases 
 of diabetes, I think I may say the majority, which, not only 
 at the beginning, but during years of observation, fail to show 
 any symptoms which can be ascribed to lesions of the nervous 
 system, and if towards the close such symptoms are manifest, 
 they cannot reasonably be ascribed to primary lesions ; while 
 the most carefully conducted autopsies have failed in many 
 cases to discover such lesions. It is true that Dr. Dickinson* 
 has described a series of lesions about the bloodvessels, espe- 
 cially of the pons varolii and medulla oblongata, to be again 
 referred to, Avhich he makes the primary and essential lesion 
 of diabetes. But, npart from this fact, these lesions are of a 
 kind we would expect to find as the result of long-continued 
 malnutrition, W. Muellerf has found them in the vessels of 
 non-diabetics, and has failed to find them in other diabetics, 
 while Kuelz| and Drs. Frederick Taylor and Goodhart§ have 
 also failed to confirm Dr. Dickinson's observations. 
 
 Summavi/. 
 
 It must be admitted that the foregoing is a somewhat chaotic 
 collection of facts bearing upon the subject of diabetes. At 
 the same time it is necessary, where we are still ignorant of the 
 precise pathology of a disease, to bring together all facts bearing 
 on it, to sift therefrom such as seem to be of major importance, 
 and from them deduce the most reasonal)le conclusions. From 
 the foregoing the following inferences may be made : 
 
 * Dickinson, op. citat., p. 33. 
 
 t W. Mueller, Beitriige zur Pathol. Anat. des Eiickenmarks, Leipzig, 
 1871. 
 
 X Knelz, Beitriige zur Path, und Ther. des Diabetes Mellitus, Marburg, 
 1874, s. 10. 
 
 § Taylor and Goodhart, On the iSTervous System in Diabetes, Guy's Hos- 
 pital Reports, 1877.
 
 248 DIABETES. 
 
 First, the liver is constantly storing up in its cells a sub- 
 stance identical in its composition with vegetable starch, and 
 readily convertible by a diastatic ferment into grape-sugar. 
 
 Second, this substance, called by Bernard ^/yco^r^n, and by 
 Pavy amyloid suhdanee, is derived chiefly from the amylaceous 
 and saccharine articles of food, but partly, also, from albumi- 
 nous food ; possibly only is it formed from fat. 
 
 Third, the blood contains at all times a small projiortion of 
 grape-sugar, which in health is mainly derived from the gly- 
 cogen in the liver-cells. A very minute and probably unrec- 
 ognizable trace is absorbed directly from the intestine by the 
 lacteals. So long as the quantity of sugar present in the blood 
 is restricted within certain limits, which are not precise, but 
 which may be put down as from .25 to .6 per cent, in dogs, 
 sugar does not appear in the urine, but if these amounts are 
 exceeded glycosuria occurs. 
 
 Fourth, various injuries to the nervous system, among which 
 puncture of the fourth ventricle, transverse section of the 
 medulla oblongata, and section of the cervical sympathetic 
 nerve and certain of its branches are conspicuous, produce 
 pathological glycsemia and glycosuria, which are the result of 
 increased sugar-formation and not diminished consumption. 
 
 Fifth, it is very generally conceded that the immediate result 
 of these nervous lesions, and therefore the immediate cause of 
 the glycosuria thus induced, is an active hypersemia of the 
 liver. 
 
 Sixth, the sources of the sugar in the blood and urine under 
 these circumstances are probably two: 1st, the grape-sugar 
 absorbed from the intestine, which is carried through the liver 
 too rapidly to permit its conversion into glycogen ; and, 2d, 
 the glycogen itself, which is more rapidly converted into grape- 
 sugar by the ferment in the blood than in health. This is 
 likely, because it is acknowledged that glycogen is very readily 
 and rapidly convertible into grape-sugar, while the grape-sugar 
 requires a longer time to convert it into glycogen. Hence an 
 acceleration of the blood-current would operate differently ou 
 the two substances.
 
 DIABETES MELLITUS. 249 
 
 Seventh, in diabetes there exists a similar excess of sugar in 
 the blood, which in like manner is the "result of increased 
 sugar-formation rather than diminished consumption, because 
 although certain results of woorara-poisoning in animals go to 
 show that diminished sugar-consumption may cause an accu- 
 mulation of sugar in the blood and glycosuria, the difficulties 
 which surround the performance of these experiments are too 
 great and the sources of error too numerous to permit any in- 
 ference from them. 
 
 Eighth, although we can conceive the possibility of diabetes 
 resulting from simple overingestion of saccharine food, or un- 
 due rapidity of conversion of starch and cane-sugar into grape- 
 sugar in the intestine, and more frequently from failure of 
 the liver to intercept and convert into glycogen the normally 
 ingested sugar and starch, in the more serious cases there is 
 probably superadded the too rapid conversion of glycogen into 
 sugar. This is at first derived from saccharine alimentary 
 principles, but sooner or later comes from the albuminous prin- 
 ciples. In no other way can we account for the emaciation 
 and exhaustion which invariably attend the severer forms. 
 
 Finally, while we are able to trace a certain number of cases 
 of diabetes to direct lesions of the nervous system, most fre- 
 quently injuries or morbid growths in the vicinity of the 
 medulla oblongata and cerebellum, there are at least as many 
 in wdiich no such association can be shown to exist. In many 
 of the latter class, on the other hand, there is evident primary 
 derangement of digestion as shown by their causes, their 
 symptoms, and the results of treatment; so that the disease 
 in these cases may be said to consist, primarily at least, in a 
 malassimilation dependent upon derangement of the digestive 
 organs, among which I, of course, include the liver. This 
 organ may or may not be involved, but it is likely that in all 
 but the simplest and most easily curable cases, it is. In what, 
 however, the derangement immediately consists we are com- 
 pelled to admit ourselves ignorant.
 
 250 DIABETES. 
 
 Causes of Diabetes Mellitus. 
 
 Excepting the injuries to the nervous system which are known 
 to cause diabetes, our knowledge of its causes is not precise. 
 With regard to the former it is well known that blows upon the 
 skull, with or without fracture, and concussions communicated 
 to the brain, spinal cord, and vasomotor centres in other 
 ways, as by falls, in which the patient lights elsewhere than 
 upon the head, are such causes. Nor does it seem necessary 
 that injuries thus resulting need be applied to parts adjacent 
 to the nerve-centres; blows upon the abdomen, back, legs, 
 thorax, kidneys, and liver have all been followed by symptoms 
 of diabetes. Succeeding such injuries to the nerve-centres, the 
 diabetes is not always immediate but may appear weeks after 
 the injury. The number of cases succeeding injury are how- 
 ever few as compared with those resulting from other causes. 
 Thus Griesinger has collected 225 cases, of which but 13 were 
 traumatic, being 5.7 per cent. 
 
 Next, disease of the nervous system, either acute or chronic, 
 may be attended by diabetes. Among these meningitis, 
 tubercular as well as traumatic, epilepsy, apoplexy, and tumors 
 of the brain, especially those in the neighborhood of the me- 
 dulla oblongata are conspicuous. A large number of cases thus 
 caused have been collected by Fritz,* Goolden,t and Fischer.| 
 In some of the cases thus induced there is simply transient 
 glycosuria, while in others mental emotion and anxiety and 
 mental strain have been sufficiently associated with diabetes to 
 make it reasonable to consider them causes of the disease, 
 especially when combined with bodily fatigue and exposure. 
 Fright and anger may be placed in the same category. The 
 latter two causes alone have been assigned a position among 
 the causes of the disease. 
 
 Next may be mentioned hereditaiion. Almost all authors 
 narrate instances wherein this cause must be acknowledged to 
 have been in operation. 
 
 * Fritz, Gazette Hebdomidaire, vol. vi, 1859. 
 
 t Goolden, London Lancet, June and July, 1854, March and May, 1802. 
 X Fischer, P., Du Diabete Consecutif aux Traumatismes, Archives Gen^r- 
 ales de Medecine, 5 serie, t. xx, 1862, pp. 257 et seq.
 
 DIABETES MELLITUS. 251 
 
 We have only to recall the acknowledged effects of diet on 
 diabetes to make it reasonable to suppose that the constant use 
 of certain foods may cause diabetes. Such foods would of 
 course be the farinaceous and saccharine, and it may be this cir- 
 cumstance that makes diabetes more common in the agricultural 
 counties of England and in Thuringia, while it is possible also 
 that the comparative rarity of diabetes in the United States 
 may be due to the fact that nowhere in the world, perhaps, is 
 animal food so freely consumed by all classes. It is well 
 known that in some countries the people live almost exclu- 
 sively upon bread and potatoes. Among these we should expect 
 diabetes to be more prevalent. But cases directly traceable to 
 dietetic causes are not numerous, and may occasionally be due to 
 the indigestion which often results from so monotonous a diet. 
 
 Dr. George Harley* insists that alcohoUc stimulants are a 
 common cause of diabetes. His belief is based chiefly upon 
 experimental results of his own, of Bernard,f and of Rosen- 
 stein. Harley himself showed that if alcohol is injected into 
 the portal vein of dogs, glycosuria promptly appears; Bernard, 
 that if alcohol is introduced into the small intestine of dogs 
 the same result follows ; while E,osenstein| showed by experi- 
 ments upon human subjects, that Bavarian beer and wine di- 
 minish the elimination of urea and increase that of chloride of 
 sodium and sugar. To these results of experiment he adduces 
 the fact that diabetes is a much more common disease in Great 
 Britain than on the Continent, where the quantity of alcoholic 
 drinks consumed is much less than in the former country. 
 
 Of the older authors, Willis§ and Prout (Prout more par- 
 ticularly as to cider) hold the same view, but of modern ob- 
 servers I know no one who agrees with Harley. Dickinson, 
 Pavy, and Senator all say that alcoholic drinks cannot reason- 
 ably be charged with being causes of diabetes, and all the cases 
 
 * Harley, The Urine and its Derangements, Philadelphia, 1872, p. 229 ; 
 also, Harley, On Diabetes, London, 1866, p. 44. 
 
 t Bernard, Gazette Mfedicale de Paris, May 10th, 1856. 
 
 X Eosenstein, Virchow's Archiv, 1858, s. 461. 
 
 § Willis, On the Operations of Medicines in Man's Body, p. 74,
 
 252 DIABETES. 
 
 of diabetes I have seen have been in decidedly temperate per- 
 sons. 
 
 It is true there are some beverages containing alcohol which 
 are contra indicated where diabetes is present, but it is more 
 particularly on account of the sugar they contain than on ac- 
 count of the alcohol. These are the sweet wines and apparently 
 new cider. At least cases are reported in which symptoms of 
 diabetes which had disappeared, returned after free drinking of 
 cider. It may also be said with regard to fresh beer and ale, 
 which contain considerable unfermeuted sugar, that while there 
 is no sufficient reason to believe they have ever caused diabetes, 
 the pro])riety of their use by diabetics may be questioned. 
 
 Malaria, continued fevers, gout, rheumatism, the action of 
 cold, both externally and by the use of cold drinks, have all 
 been charged with producing diabetes without sufficient reason. 
 Dr. Pavy relates a case associated with extravagant sexual in- 
 dulgence. 
 
 Pathological Anatomy. 
 
 Except the lesions of the nervous system occasionally caus- 
 ing it, diabetes can hardly be said to have an essential morbid 
 anatomy. That is, except in the instances alluded to, the mor- 
 bid lesions which are found after post-mortem examination to 
 have been associated with diabetes are, in the main, such as are 
 the consequence of the continued presence of the condition, 
 rather than such as cause the symptoms. Sometimes there 
 are absolutely no alterations discoverable either by the naked 
 eye or the microscope. 
 
 To begin with the organ which is apparently immediately 
 responsible for the symptoms, the liver, it frequently pre- 
 sents the appearances of a hyperremic organ ; that is, it is 
 darker and harder than the normal organ, while it is also en- 
 larged, sometimes extremely, at others only slightly. The 
 maximum enlargement reported is three times the size in health. 
 Corresponding to this, the microscope, by very moderate am- 
 plification, shows enlarged and di.>?tinct acini, with capillaries 
 dilated and distended with blood in various degree. Hiy-her 
 magnifying powers — 300 to 400 diameters — show the liver-cells
 
 DIABETES MELLITUS. 253 
 
 to be enlarged, distinctly nucleated, rounded, and disposed to 
 fuse into each other. If a weak solution of iodine is added they 
 strike a wine-red color, which, according to Rindfleisch, is con- 
 fined to the nucleus; but, according to Senator, may extend to 
 the whole of the cell. Klebs ascribes this reaction to post- 
 mortem changes in the glycogenic substance. The minute 
 changes described are said by Rindfleisch to be more striking in 
 the peripheral zone of the lobule, that of the portal vein ; while 
 the intermediate zone, or that of the hepatic artery, is fatty, and 
 the central part, including the rootlets of the hepatic vein, is 
 nearly uormal. Stockvis and Frerichs assert that the enlarge- 
 ment of the liver is partly contributed to also by a new forma- 
 tion of liver-cells. In one instance Dickinson* found, in ad- 
 dition to general venous thrombosis and apparently in con- 
 nection with it, patches of a remarkable spongy transformation, 
 which he ascribed to "extravagant dilatation of the capillaries 
 belonging to the hepatic vein." Under the microscope sections 
 had a worm-eaten or honeycombed look. The threads of the 
 network were chiefly composed of glandular epithelium com- 
 pressed and elongated ; the cavities were empty, and proved to 
 be contorted tubes, which opened into branches of the hepatic 
 vein ; whence he concluded them to be dilatations of the capil- 
 laries in connection with this venous trunk. The description 
 sugG;ests that of an angeioma of the liver. 
 
 Dickinson describes an overgrowth of connective tissue as 
 well as of epithelium resulting in a " hypertrophic cirrhosis," to 
 which Trousseau also alludes in connection with diabetes, and 
 of which Buddf reports a single case. Klebs says that as the 
 disease continues, the liver again becomes reduced, and a di- 
 minished size has occasionally been observed. 
 
 A diminution in the normal proportion of fat in the liver- 
 cells is quite a regular occurrence, according to Beale, and 
 quantitative analysis by FolwarcznyJ sustains this view, while 
 Frerichs also found the hepatic cells destitute of fat in four 
 
 * Dickinson, op. citat., p. 50. 
 
 t Budd, Diseases of the Liver, London, 1845. 
 
 X Leberanalysen bei Diabetes niellitus, Wiener Zeitsclir., N. F., 1859, ii, 6.
 
 254 DIABETES. 
 
 cases and greatly diminished in another. This observation is 
 very interesting in connection with the statement of Pavy that 
 glycogen is normally converted into fat, which is stored up for 
 further use in the economy, but that in diabetes this conversion 
 fails to be made. 
 
 As to the pancreas, the statement of Niemeyer,* that " hyper- 
 trophy of the pancreas occurs with remarkable frequency, con- 
 sidering how seldom this organ is the seat of disease," has al- 
 ready been alluded to. Senatorf also says this organ " is found 
 diseased with surprising frequency, in particular either atro- 
 phied or, in addition, degenerated." These diverse statements 
 illustrate the true position of the morbid anatomy of diabetes. 
 It may be well to mention, however, the changes included by 
 Senator under atrophy and degeneration. " Sometimes," he says, 
 " the degeneration consists merely in primary fatty destruction 
 of the gland-cells, but sometimes it is induced by cancer, by 
 the formation of calculi, and by obstruction of the efferent ducts 
 with cystic dilatation of the body of the gland. In certain cases 
 the wasting of the gland has reached the highest degree, so that 
 scarcely any discernible remnant of the secreting parenchyma 
 was to be found." He says further : " The frequency of these af- 
 fections of the pancreas was not noted until somewhat recently, in 
 consequence of Bouchardat's contributions. Only isolated data 
 in regard to this point have come down tons from earlier times, 
 such as the discovery of calculi in the pancreas of a diabetic by 
 Cowley, and that of cancer by Bright. Griesinger, who had found 
 the pancreas atrophied in one of the five diabetics whose bodies 
 he examined after death, still believed that this lesion was of 
 no significance whatever. But the observations which have 
 been published in great numbers (Hartsen, Fles, v. Reckling- 
 hausen, Frerichs, Klebs, Harnock, Kuelz, Schaper, and others) 
 allow us to assume that diseases of the pancreas are present in 
 about one-half of all the cases of diabetes. Among nine cases 
 Frerichs saw atrophy or fatty degeneration of the gland five 
 
 * Niemeyer, Textbook of Practical Medicine, translated by Hackley. 
 Third American edition, 1870, vol. ii, p. 751. 
 f Senator, loc. citat., p. 887.
 
 DIABETES MELLITUS. 255 
 
 times, and in the Vienna dead-house the pancreas was found 
 strikingly small, soft, and anaemic in thirteen out of thirty 
 diabetics. (Seegen.)" 
 
 To the above may be added the following cases mentioned 
 by Dr. Richardson,* one of Dr. Elliotson's in which the pan- 
 creatic duct and large lateral branches were crammed with 
 white calculi, and four successive cases of Dr. Hyde Salter, in 
 which the pancreas was degenerated, so that he thought he had 
 discovered the pathology of the disease. 
 
 It may be, as Senator says, that this cannot be an accidental 
 coincidence. He believes further that Klebs's view, that the 
 coexistence of diabetes mellitus and diseases of the pancreas 
 depends upon lesions of the cceliac 'plexus, is the best founded : 
 " Either the disease (cancer, formation of calculus, and in- 
 flammation of the surrounding tissue) starts from the pancreas, 
 encroaches upon the plexus, and gives rise to diabetes by 
 destroying its ganglion, or else the coeliac axis is first affected, 
 and in consequence thereof circulatory disturbances arise in the 
 territory supplied by the coeliac artery, which lead to degen- 
 eration and atrophy of the pancreas." 
 
 In 1877 Lancereauxf presented to the French Academy of 
 Medicine specimens of profound lesions of the pancreas from 
 patients who had died of diabetes mellitus, and argued for 
 their causal relation to the symptoms of the disease from the 
 effect of extirpation of the pancreas in the lower animals, 
 which became voracious, grew thin, and died speedily. 
 
 It would appear from the above at least, that in the future 
 closer attention should be given to this organ than in the 
 past. 
 
 The hklneys, primarily unaffected, are undoubtedly sooner 
 or later influenced by the constant hyperemia to which they 
 are subject in eliminating the sugar, although, as the hyper- 
 semia is an active one and there is a free movement of the 
 blood through the organ, it is not to be expected that this 
 
 * Op. citat., p. 65. 
 
 t La France Medicate, Nov., 1877.
 
 256 DIABETES. 
 
 should appear early or be invariably present. The appear- 
 ances commonly met are those of hyperemia and overgrowth 
 of epithelium ; in a word, those of catarrhal nephritis. Occa- 
 sionally the changes are more advanced, and the epithelium 
 is fatty. These changes need not necessarily be attended 
 by albuminuria previous to death. 
 
 When, however, albuminuria is present in diabetes, as is not 
 very unfrequently the case, the lesions of the kidney described 
 may be expected as secondary to the primary disease ; although 
 it may also result from amyloid degeneration of the kidney, 
 which may itself be due to the exhaustive drain to which the 
 organism is subject, or to the phthisis which so constantly su- 
 pervenes upon diabetes mellitus. 
 
 As to the proportion of cases in which the kidneys reveal 
 morbid alterations, it is a decided majority. Thus Griesinger 
 found them in 32 out of 64 autopsies, Seegen in 20 out of 30 
 cases examined at the Vienna dead-house, and Dickinson in 
 25 out of 27 autopsies at St. George's Hospital, London. 
 
 Catarrh of the pelvis of the kidney and of the ureters is 
 mentioned by Senator as rather frequently found, and as due 
 partly to the final complications which prove fatal, and partly 
 to the irritating eifect of the sugar and other abnormal elements 
 of the urine. 
 
 Atrophy of the testes is mentioned by the same author, on 
 the testimony of Komberg and Seegen, as occasionally present 
 in young persons. 
 
 The lungs are almost invariably the seat of cheesy deposits 
 and cavities resulting from their softening, the result of cir- 
 cumscribed catarrhal pneumonias, which so constantly attend 
 the latter stages of diabetes. The changes in the lung are 
 clearly not tubercular, but cheesy, nor is tuberculosis prone to 
 occur by infection from the cheesy foci. Gangrene of the 
 lung is sometimes present. 
 
 Many other isolated lesions are described as occurring in 
 diabetes mellitus, but as they bear no necessary or evident re- 
 lation to the disease they attend, they need not be especially
 
 DIABETES MELLITUS. 257 
 
 mentioned. Among these are gastric and intestinal catarrhs, 
 hemorrhagic erosions of the gastric mucous membrane, pleu- 
 ritic exudations, etc. 
 
 The Alterations in the Nervous Centres described by Dr. Dick- 
 inson as the Essential Morbid Anatomy of Diabetes. 
 In addition to the more palpable lesions of the nervous sys- 
 tem so often alluded to, which are attended by glycosuria as 
 an isolated and more or less harmless symptom. Dr. Dickinson 
 claims that there is found, upon close examination even by the 
 unaided eye, a set of changes which are essentially associated 
 with diabetes, and which may be said indeed to constitute its 
 pathology, insomuch that he defines diabetes as a disease of the 
 nervous system characterized by saccharine urine. In conse- 
 quence of the extreme importance of this subject, I extract 
 almost entire Dr. Dickinson's description of these changes : 
 
 "Tliey consist, to tlie naked eye, of a fine porosity or cribriform appear- 
 ance in liniitod patches of the white matter, as if closely beset with pinholes, 
 each puncture containing a vessel much smaller than itself. More rarely, 
 considerable cavities, such as might hold peas, are seen, especially in the 
 pons, in connection with one of the processes of the pia mater. . . . 
 
 "The microscope is not necessary for their detection, though it is for 
 their description. For their recognition it is only necessary that the brain 
 should be looked at while fresh, or for their more clear display should be 
 hardened in any way which allows of the exposure of clear and hard 
 sections. . . . 
 
 "The excavations are found about arteries, or in positions which arteries 
 once occupied. . . . They are caused by a destruction and absorption of the 
 nervous matter along the course of arteries, and are, at least in some instances, 
 caused by an escape of the contents of the vessel into the surrounding tissues, 
 with consequent degeneration, softening, and removal of the nervous matter 
 which has been permeated by the intrusion. The escape appears to be 
 rather of corpuscles by migration, than of blood in bulk by rupture. . . . 
 
 " When tlie disease has proceeded to its natural end, the excavations are 
 widely scattered through the brain ; numerous, small, and closely set in the 
 white matter of the convolutions, fewer and larger about the central parts. 
 The corpoi-a striata, optic thalanii, pons, medulla, and cerebellum are the 
 chosen seats for the largest and most striking of the holes, in which situations 
 the cavities are determined by the course of considerable arteries or by 
 penetrating folds of the pia mater. . . . 
 
 "These holes are evidently exaggerations of the perivascular spaces. . . 
 According to their date they contain degenerate remains of nerve-tissue, 
 
 17
 
 258 DIABETES. 
 
 remnants of vessels or of cxtnidecl liloorl, or are empty. Tlic products of 
 nervous defeneration are first removed, then for awhile the cavity contains 
 only dilated or shrunken and obsolete arteries, with areolar tissue, derived 
 apparently from the perivascular sheath, and crystals of hsematin. Lastly, 
 these disappear also, and mere vacuity is left. 
 
 " In rapidly fatal cases, the cavities are sometimes filled with a translucent 
 gelatinous substance, containing, besides vascular elements, the granular or 
 globular products of nervous disintegration, with delicate fibrillse and nuclei, 
 derived, in part, from the perivascular sheath, and partly from the condensed 
 remains of the connective tissue of the destroyed nervous substance. 
 
 " This transparent substitute for brain-matter is soft and elastic, and often 
 eludes the edge of the razor, so that, although conspicuous enough to the 
 naked eye, it requires some care to obtain sections for the microscope. 
 
 " Among the contents of such cavities it must be mentioned that large 
 nerve-cells, displaced and somewhat degenerated, are sometimes seen among 
 the debris, as if such cells, the place of which had been usurped by the ex- 
 cavations, survived the destructive process longer than the nerve fibre. 
 
 " In the more chronic forms of the disease, as it occurs in elderly persons, 
 the excavations are usually empty, though the remnants of nervous decay 
 are usually to be found fringing tlieir margins or collected as an irregular 
 sheath upon the dilated or shrunken artery. 
 
 " Tiie changes in the cord are similar to those in the brain, but less de- 
 clared. Erosions about the arteries are evident, especially in the trans- 
 verse commissure, the white band of which is sometimes completely divided 
 in the track of one of its large vessels. Holes such as have been described 
 in the brain, sometimes, though rarely, perforate the gray horns. The most 
 striking change in the cord, however, is dilatation of the central canal, which 
 in the dorsal and lumbar regions is sometimes expanded to many times its 
 normal diameter, and forms a conspicuous object immediately the cord is 
 divided. This expansion of the channel (sic) is not constantly present, but 
 when it is, it is snflSciently remarkable. I am not aware, at present, how 
 far it is peculiar to diabetes." 
 
 With regard to these views of Dr. Dickinson's I will here 
 merely repeat what was mentioned on page 247, that AV. 
 Mueller has found these changes in the muscles of non- 
 diabetics, and has failed to find them in other diabetics, while 
 Kuelz and Drs. Frederick Taylor and Goodhart have also 
 failed to confirm Dr. Dickinson's observations. Also, that 
 others alley;e these alterations are seeondarv, being the result 
 of long saturation of the bloodvessels and tissues with sugar, 
 which finally comes to jiervade all tissues of the diabetic. To 
 this Dr. Dickinson replies that in such an event the seat of 
 emigration or of rupture would be in the area of the capillaries 
 rather than of the arterioles.
 
 DIABETES MELLITUS. 259 
 
 Symptoms, Course, Duration, etc. 
 
 Almost invariably the earliest symptoms noted by the dia- 
 betic are thirst and frequent micturition. One or the other of 
 the two may be noticed first, or the patient's attention may be 
 called to both simultaneously. It occasionally happens that 
 a dryness of the fauces and a glutinous viscid character of the 
 saliva attracts attention before any other symptom. Fre- 
 quently the first words addressed to the physician are, "Doc- 
 tor, I am burning up with thirst," or it is observed that a 
 drop of urine falling upon the boots or clothing, and there 
 evaporating. leaves a persistent white spot, which is sugar. 
 A dryness and hai'shness of the skin, due to absence of perspira- 
 tion, soon make their appearance and early attract the atten- 
 tion of those who ordinarily perspire easily, and occasion 
 varying amounts of discomfort. Itching of the skin is also 
 sometimes present. Notwithstanding the dryness of the 
 skin, the temperature of the body is not increased, at this 
 stage scarcely altered, although later in the disease it is de- 
 cidedly lowered. If the further progress of the disease is 
 not arrested by reason of the physician's attention being called 
 to it, a voracious appetite becomes the next symptom, but, not- 
 withstanding the latter, the patient observes that he slowly 
 loses in weight and grows daily ^^'eaker. The rate at which 
 these symptoms succeed each other is not uniform. Some- 
 times it is with great raj)idity, at others the successive stages 
 are exceedingly slow in developing. 
 
 The above category includes all the symptoms which present 
 themselves in the milder form of the disease, such as occurs in 
 adults past middle life, and is ordinarily quite amenable to 
 treatment. But unless averted, all of these symptoms become 
 intensified. The patient complains of constant burning thirst, is 
 constantly urinating and as constantly drinking water to quench 
 his thirst, and, while eating enormously, grows emaciated, 
 although at the onset of the disease he may have been a robust 
 and even portly man. 
 
 Dyspeptic symptoms appear at various stages, seldom very 
 early, because they are generally the result of the large
 
 260 DIABETES. 
 
 amounts of food ingested. Acid eructations, flatulence, and 
 epigastric pain, or an indescribable sensation spoken of as 
 "sinking" of the epigastrium, are among them. Constipation, 
 probably in consequence of the free ingestion of food and al)un- 
 dant waste therefrom, is not, in my experience, a very early 
 symj)tom ; but, sooner or later, the general "dryness" makes 
 itself felt here, and more or less obstinate constipation results. 
 On the contrary, diarrhcjca sometimes is present. 
 
 Soon succeeding the constipation is a peculiar vinous or 
 acetous odor of the breath, Avhich has been compared to that 
 of stale beer, and by Sir Thomas Watson to the odor of a place 
 in which apples are kept. This is believed to be due to ace- 
 tone, and probably also to alcohol, both of which exist in the 
 blood of profound diabetics during life, and both of which are 
 derived from the sugar. 
 
 Cough sooner or later presents itself as the result of bron- 
 chitis and catarrhal pneumonia, and, with the copious expecto- 
 ration incident to them, adds to the debilitating agencies 
 already at work. Roberts thinks })hthisis occurs in one half 
 the cases. The consumption thus induced sometimes rapidly 
 hastens the fatal termination, while at others it appears 
 to have but a trifling influence in this respect. The other 
 symptoms characteristic of pulmonary consumption are also 
 present, not even excepting hectic sweats. The perspiration 
 thus arising may contain sugar. 
 
 The early loss of sexual desire is said to be characteristic, 
 but whether more so than in exhausting diseases generally I 
 cannot say from my own experience. 
 
 In advanced stages the temperature of the body, unless 
 influenced by intermittent febrile disease, is almost invariably 
 lowered from 1° to 2|° F. Dr. Dickinson refers to the case 
 of a boy of six, in whom the temperature ranged from 93.G° to 
 94.8° F., and who died of pneumonia, during which the tem- 
 perature rose to 97.8° F. 
 
 The above-recorded symptoms include those which may be 
 considered essential to the disease, or at least are invariably 
 present if it remain unchecked. There are many others which 
 occur more or less frequently, but not constantly, in its course.
 
 DIABETES MELLITUS. 261 
 
 Anions: these is cataract, the association of which witli dia- 
 betes was long ago noted by Proiit. Griesinger found it had been 
 present twenty times in 225 cases collected, Bouchardat once 
 in 38, Roberts once in 45, and Dickinson once in 28 cases 
 dying of diabetes in St. George's Hospital, London. It usually 
 occurs in advanced stages, but has even been the first symp- 
 tom of the disease noticed. It develops rapidly, and is nearly 
 always symmetrical, involving both eyes simultaneously, but 
 not to the same degree. 
 
 The experiments of Kunde,* Dr. S. Weir Mitchell, f of this 
 city, and Dr. B. W. RichardsonJ led them to conclude that 
 the cataract is due to an exosmotic loss of fluid from the lens, 
 but Von Graefe, from the vantage-ground of a large experi- 
 ence, concluded it was the result of an impaired nutrition, 
 itself caused by the vitiated sugar-laden blood. 
 
 In an admirably studied case of diabetes occurring in the 
 practice of Dr. Louis Starr, in which there was also cataract, 
 Dr. Albert G. Ileyll discovered and pictured an extraordhiary 
 condition of the fundus not heretofore described, to which he 
 gives the name intraocidar Hjxemia. This condition is charac- 
 terized by the light-salmon color of the blood contained in the 
 branches of both retinal vein and artery, as contrasted with 
 the yellow-red color of the arteries and the dark cinnabar-red 
 of the veins in health, by the apparently large diameter of these 
 vessels, and by the verj' light color of the fundus, these ap- 
 pearances being due to the presence of molecular fat in abnor- 
 mal amount in the blood. 
 
 This appearance is reproduced in the colored frontispiece, 
 which was lithographed from a painting of the right fundus 
 of the patient, by Dr. C. B. Xancrede. The appended descrip- 
 tion of the plate is furnished by Dr. Heyl. 
 
 "■ A glance at the picture will show that there is no indication 
 
 * Kunde, Wnrzburger Verhandlung., vii, 1856 ; Arehiv fiir Oplitlialm., 
 Bd. iii, p. 275. 
 
 t Mitchell, On the Production of Cataract in Frogs by the administration 
 of Sugar, Anier. Joiirn. Med. Sci., N. S., vol. xxxix, 18G0, p. 106. 
 
 X Journal de la Physiologie, par P>rown-Sequard, 1860. 
 
 § Lipaemia and Fat Embolism in Diabetes Mellitus, New York Medical 
 Eecord, vol. xvii, 1880, p. 477.
 
 2G2 DIABETES. 
 
 of intraocular inflammation, /. e., no tortuosity of the vessels, ob- 
 scuration of the scleral ring, haemorrhage, structural change in 
 retina or choroid. The marked features which arrest attention are : 
 
 " 1. The peculiar color of the fundus ; it may be described as 
 a salmon-red. The painting was made with the aid of gas- 
 light and the ordinary ophthalmoscope with concave mirror. 
 The color of the fundus thus obtained will be best represented 
 by taking the picture to a well-lighted window and allowing 
 the direct rays of the sun to foil upon it. 
 
 " The retinal vessels were of nearly the same color as the rest 
 of the fundus. When the light from the ophthalmoscope fell 
 directly upon them the appearance of the vessels was as rep- 
 resented in the picture; if, however, the handle of the mirror 
 were slightly rotated, so as to deflect the light, a dark axis 
 could be seen in some of the vessels, whic^h were probably veins. 
 By color alone, arteries could not be distinguished from veins. 
 
 " 2. The breadth of the retinal vessels. It was apparently 
 about double what it ought to have been under normal cir- 
 cumstances. This was not caused by distension and increase 
 in the vessel's calibre, but is to be explained in this way : 
 AVhen a bloodvessel of a living tissue is examined with a mi- 
 croscope the blood-current is seen to consist of two portions : 
 (a) a peripheral portion, consisting of traus])arent serum ; (b) an 
 axial portion, containing the corpuscles. Now, under normal 
 circumstances in ophthalmoscopic examinations, the axial 
 current alone is easily seen, and what appears to be the 
 breadth of a retinal vessel is really only the breadth of the 
 axial current ; owing to the transparency of the peripheral 
 portion it can only be seen by a trained eye, and even then 
 only under favorable circumstances. If, however, the serum 
 of the blood become sufficiently opaque it will be visible, 
 and the retinal vessels will appear of full width, which 
 is about double the diameter of the axial current. This 
 is what happens Mhen finely divided fat exists in sufficient 
 amount in the serum as in this case of lipjemia. It must be 
 remembered that the abnormal a|)pearances just described re- 
 quire for their production a sufficient amount of finely di- 
 vided flit. It is possible, as I have experienced in a case of
 
 I 
 
 DIABETES MELLITUS. 263 
 
 diabetes mellitus, for numerous oil-molecules to be visible 
 under the microscope, and yet no appreciable change to occur 
 in the gross appearances of the blood or in the fundus of the eye. 
 '' The only knowu condition with which intraocular Upsemia 
 is liable to be confounded is that seen in the eyes of leuco- 
 cythtemic patients ; for a discussion of the differential diagnosis 
 I must refer to my paper in the Trans. Aiiier. Ophth. Society 
 for 1880. As in ophthalmoscopic examination the details of 
 the background of the eye appear magnified, the details of the 
 picture hav^e been represented as magnified 11.25 times. It 
 ought also to be stated that the patient from whom the picture 
 was taken had very light hair, irides, etc. ; the fundus there- 
 fore, under normal circumstances, would have been light in 
 color, but not to the extent represented." 
 
 Dr. Dickinson says also, that the ophthalmoscopic examina- 
 tions of his diabetic cases by his colleagues, Messrs. Power 
 and Brudenell Carter, mostly revealed dilatation of the retinal 
 vessels. In one instance only was anaemia observed. Finally, 
 atrophy and hsemorrhagic and inflammatory affections of the 
 retina have been observed. 
 
 Among functional derangements of vision said to occur are 
 amblyopia, presbyopia, and loss of accommodating power from 
 defect of the ciliary muscle. Occasionally total blindness has 
 occurred from atrophy of the retina.* 
 
 Other derangements of the special senses said to attend dia- 
 betes are impairment of hearing, roaring in the ears, and de- 
 rangements of smell and taste. 
 
 JBoils and carbuncles in the skin are also of more or less 
 frequent occurrence as consequences of the malnutrition grow- 
 ing out of diabetes, although it is said that the former are oc- 
 casionally the first symptoms recognized. The latter never 
 occur early, but when present are frequently the immediate 
 cause of death. 
 
 Gangrene of various parts of the body is another of this 
 class of symptoms. It is sometimes spontaneous, but more 
 frequently is immediately caused by some trifling injury, which 
 
 * Dufresne, De I'Amblyopie Diabetiqiie, Gaz. Heb., November, 18G1.
 
 2G4 DIABETES. 
 
 under otlier circumstances would be without result. It has 
 been known to start from a blister. This mode of origin 
 makes it nnnecessary to seek any farther immediate cause such 
 as inflammation, degeneration, obliteration of arteries, etc. 
 Beginning most frequently in those parts of the body most 
 remote from the centre of the circulation, as the toes, its prog- 
 ress and appearances are like those of senile gangrene. 
 
 A spongy state of the gums with recession and excavation 
 are sometimes present, resulting in extreme cases in absorption 
 of the alveolar processes and falling out of the teeth. 
 
 Albuminuria is a symptom which sometimes attends the 
 advanced stages of diabetes. It is the result of tJie alterations 
 in the kidney already described (p. 255), as consequent upon 
 the long-continued hypersemia. It is not usually large, but 
 may be considerable. 
 
 Eczema, with itching and burning of the labia and vicinity, 
 is a symptom sometimes met in females, which is incident to 
 the extremely frequent micturition. In the male, the meatus 
 urinarius is sometimes the seat of a similar irritation. 
 
 Unilateral sweating has been observed. Senator refers to 
 tliree cases, one by Koch and Nitzenadel in a man of 30, where 
 the left half of the face was involved ; one by Kuelz in a man 
 of 51, in which the left half of the face was affected, and a 
 third by the same observer in a man of 46, in which the right 
 half was involved. Some lesion of the sympathetic is believed 
 to lie at the bottom of this symptom. 
 
 Oedema, which also sometimes appears late in the dis- 
 ease, is not usually the result of the renal involvement. This 
 symptom, when coincident with the enormous diuresis, is a 
 truly remarkable one. It is usually explained on the ground 
 of the profound ansemic cachexia which is always established 
 before it appears, but it is difficult to conceive the transudation 
 of water from so dense a fluid as the blood under these cir- 
 cumstances without some resistance to its onward movement. 
 Such resistance might be afforded by the viscidity of the sugar- 
 laden blood. On the other hand, we can conceive the inges- 
 tion of fluid by reason of thirst to be so large that the kidneys
 
 DIABETES MELLITUS. 
 
 265 
 
 cannot, with sufficient rapidity, eliminate it; whence a filtra- 
 tion of it into the tissues. 
 
 The term diabetic coma has been applied to a form of coma 
 which sometimes is the immediate cause of, or at least imme- 
 diately precedes, death. The condition is one of suddenly or 
 gradually supervening unconsciousness, with or without pre- 
 vious irritability or uneasiness. Convulsions do not occur. 
 In addition to coma there are frequent and feel)le pulse, rapid 
 and deep inspiration. It has been variously ascribed to poison- 
 ing by sugar, acetone, alcohol, or other unknown substances, 
 and by Professor Sanders and D. J. Hamilton* to slow car- 
 bonic acid poisoning due to fat embolism of the pulmonary 
 
 a, Supposed fatty emboli in the capillaries of tha luns;, stained black by perosmic acid ; 
 6, oblong, branching masses of the same; c, transverse sections of arterioles showing 
 globules of fat among the blood-corpuscles. 
 
 vessels, the result of lipoemia. In Dr. Starr's case of diabetes, 
 alluded to on p. 261, a careful study by Dr. J. H. C. Simes of 
 sections of the lung, treated by perosmic acid, "demon- 
 strated the fact that the pulmonary bloodvessels were occluded 
 by fat emboli," as shown in Fig. 36. But as Dr. Starr cor- 
 rectly says, the share of the embolism in producing the coma 
 
 * Edinburgh Med. Journ., July, 1879. The conclusions of these gentle- 
 men were based upon the clinical histories and the results of the post-mortem
 
 2G6 DIABETES. 
 
 and death of the patient is very uncertain, since on account 
 of his debilitated condition a croupous pneumonia which su- 
 pervened, although limited in extent, was quite sufficient to 
 determine the fatal issue. 
 
 Alterations in the Blood, Urine, and other Secretions. 
 
 The Blood. — It has already been mentioned, that in diabetes 
 the blood becomes highly charg^ed with sugar, and that acetone 
 and alcohol are also found in it. Both of these latter are de- 
 rived from the sugar. From the presence of the first, we 
 should naturally expect a visciditv and higher specific gravity 
 of the blood serum, which has been found as high as 1033, 
 the specific gravity of the normal serum being 1028. On the 
 other hand, the serum has been found thinner than normal, 
 containing, according to different analyses, from 80.2 to 84.8 of 
 water instead of the normal 78-79 per cent. From the fact that 
 no sugar at all has been found in the blood in certain cases after 
 death, it does not follow that sugar was not present before 
 death, since it very rapidly undergoes decomposition in cada- 
 veric blood. 
 
 I have already mentioned that accordins: to Griesing-er the 
 red blood-corpuscles are diminished. This statement is sus- 
 tained by the study of the case of Dr. Starr, already alluded 
 to, in which the corpuscles were carefully counted by Dr. F. 
 P. Hemy by means of a Gower's hsemacytometer with the 
 following result, viz. : number of red. corpuscles to cubic mil- 
 limeter, 4,205,000, the normal being at least 5,000,000 ; num- 
 ber of white corpuscles to cubic millimeter, 50,000, or 1 white 
 to 84 red cells, the normal being 1 white to 350 or 400 red 
 cells. 
 
 examinations of several cases. For these I mnst refer the reader to their 
 original paper in the Edinburgh Medical Journal. A summary of the data 
 leading to their hypothesis will be found in Dr. Starr's paper on Lipjemia 
 and Fat Embolism in Diabetes Mellitus, published in the New York Med. 
 Becord, vol. xvii, 1880, p. 476.
 
 DIABETES MELLITUS. 267 
 
 Very interesting, in connection with the pathology of dia- 
 betes, is the presence of flit in the blood, producing the tech- 
 nical Upmnki. This was observed by the earliest students of 
 diabetes, and is attested by many analyses, as well as by the 
 milky appearance of the serum, and the intraocular appear- 
 ances described by Dr. Heyl. The analyses of Simon show 
 from 2 to 2.4 per cent, instead of the normal 1.6 to 1.9 per cent. 
 
 Tlte Urine. — The most noticeable peculiarity of diabetic 
 urine, to the patient at least, is its enormous quantiiy, which 
 has been known to exceed 70 lbs. (31.78 kilograms) in 24 
 hours, while apocryphal accounts of larger amounts are extant. 
 Frank records 52 lbs. (23.6 kilograms). Bardsloy* 36 pints 
 (20.4 liters) and 32 pints (18.16 liters). Bence Jones found 
 56 pints (31.78 liters). Sir Thomas Watson and Dr. Dickinson 
 26 pints (14.77 liters), and Dr. Pavy 32 pints (18.16 liters). 
 From 70 to 100 ounces (2100 to 3000 cubic centimeters) are 
 common quantities. 
 
 The quantity of urine passed may be put down as limited 
 by the amount of fluid ingested. For while it is possible that 
 the amount of urine secreted may exceed for a very short 
 period that ingested, it is evident that this cannot continue for 
 any length of time, and in point of fact it is found to be almost 
 invariably a little less, the remainder being removed by the 
 lungs, skin, and bowels. 
 
 On the other hand, it was early observed by Cowleyf (1778), 
 that the quantity of water occasionally is not at all, or but 
 slightly increased. To this condition Frank,J another old 
 author, gave the name of diabetes decipiens. But all modern 
 observers unite in saying that this phenomenon, though occa- 
 sionally occurring, is but a temporary one. It may character- 
 ize the beginning, or appear in the course of the disease. 
 
 It is well known, also, that intercurrent disease, especially 
 
 * Bardsley, article on Diabetes in the Cyclopiedia of Practical Medicine, 
 Philadelphia, 1845, p. 607. 
 
 t Cowley, Th., London Medical Journal, 1788. 
 
 X Frank, J. P., Decnrandis hora. morbis epitome. Lib. v, De Profluviis, 
 Pars, i, Manheimii, 1794.
 
 268 DIABETES. 
 
 febrile affections, sometimes diminish tlie qnantity of urine as 
 well as the amount of sugar excreted ; while the same diminu- 
 tion of urine and sugar also occasionally occurs towards the 
 fatal termination of the disease. 
 
 But the most important change in the urine is the presence 
 of sugar. Of this the quantity varies greatly in different 
 cases and at different times in the same case. Every case of 
 trifling and temporary glycosuria should not however be 
 considered a case of diabetes. The sugar should be easily 
 recognizable by the ordinary tests, and should be constant. 
 From what may be indicated as " evident traces " the pro- 
 portion of sugar may reach as much as 15 per cent. The 
 twenty-four hours' quantity varies similarly. The maximum 
 quantity secreted in this time appears to be that re])orted by 
 Dickinson, wherein a man 25 years of age voided 50 ounces, 
 or 1500 grams, in 24 hours. But the more usual quantity 
 is from 10 to 80 milligrams to the cubic centimeter, or 
 from 20 to 25 grams in 24 hours, according to the metric 
 system ; this corresponds nearly to from 5 to 30 grains to the 
 fluid ounce of the English system, or from 300 to 3800 grains 
 in the 24 hours. 
 
 The effect of intercurrent febrile disease in jiroducing a 
 diminution in the amount of sugar excreted has been alluded 
 to ; also a similar decrease and even disappearance towards 
 the fatal termination of a case. The possibility of this occur- 
 rence should be remembered, lest an illusory improvement 
 thus produced be mistaken for an actual one. 
 
 A diminution and even disappearance of sugar from the 
 urine has been observed by Bouchardat, and more recently by 
 Kuelz, in consequence of muscular exercise, while it is scarcely 
 necessary to say that accidental as well as intended changes in 
 diet are followed by consequent variations. So, too, urine 
 passed after fasting, as on rising in the morning, contains gen- 
 erally less sugar than that passed after a meal, and in testing 
 urine whence sugar is disappearing, it is well to remember this 
 circumstance also, as sugar may entirely have disappeared from
 
 DIABETES MELLITUS. 269 
 
 a urine passed on rising, whil^'it may be present in that passed 
 after a meal. 
 
 Consistently with this increased amount of solid matter in 
 solution, the specific gravity of diabetic urine is, as a rule, high, 
 1040 being very common, while Bouchardat found it as high 
 as 1074 in one instance. The well-known disposition of dia- 
 betic urine to become frothy on shaking, and to maintain this 
 frothy condition, is a natural ])hysieal result of its increased 
 density. The urine of lowest specific gravity in which I have 
 found sugar easy of detection was 1018. Pavy, however, re- 
 cords a specific gravity of saccharine urine as low as 1010, and 
 Dickinson as low as 1008. Such low s])ecific gravities may be 
 due, as Senator suggests, to previous destruction of sugar by 
 fermentation, as well as to low proportion of other normal in- 
 gredients. 
 
 Concurrent with the increase in quantity of urine is a pale- 
 ness, which proceeds in extreme degrees to an almost absolute 
 absence of color, so that the urine, at least in moderate bulk, 
 is as colorless as spring-water. This clearness may be di- 
 minished by exposure, and almost all diabetic urine, sooner or 
 later after exposure at a moderate temperature, becomes a little 
 cloudy from the development of fungi coincident with fermen- 
 tation. 
 
 The odor of the urine is usually normal when first passed, 
 but sooner or later, in consequence of fermentation setting up, 
 it acquires an acetous odor. The latter change also increases 
 the degree of the normal acid reaction, and maintains it much 
 longer after exposure to the air than is the case with normal 
 urine. This acetous odor is ascribed to acetone and alcohol. 
 The urine may have a sweetish odor when passed, an odor 
 which has been compared by one of my correspondents afflicted 
 with the disease, a very intelligent physician, to "sweet brier." 
 
 Along with the absence of color in diabetic urine, the absence 
 of sediment is a conspicuous feature. This is not invariable, 
 however, for a copious uric acid sediment is sometimes early 
 present, and at others appears sooner or later coincidently with 
 the increased acidity of the urine resulting from fermentation.
 
 270 DIABETES. 
 
 It is thouglit by snine to be a 'favorable symptom. In the 
 sediment may also be included the fungus known as pen icilhim 
 f/laueum, common to acid urine, as well as the more character- 
 istic yeast or sugar fungus, the torula cerevisice. This also 
 sometimes appears as a mould on the surface of the urine. 
 
 Of the normal chemical constituents of the urine urea is 
 almost invariably increased. This is contributed to by two 
 causes, and possibly by a third. The first is the ingestion of 
 large amounts of nitrogenous food, whether to appease the 
 appetite or by the physician's advice. Such ingestion is, of 
 course, followed by an augmented excretion of urea. The 
 second cause is the increased discharge of water by the kid- 
 neys, such increase always carrying out with it an increased 
 quantity of urea, washed out of the tissues, as it were, by the 
 water passing through them. The third cause is the decom- 
 position of the tissues themselves. If this cause operates at 
 all, it is only in the severest cases or in the last stages, where 
 the stroncjest evidence in its favor is the irresistible wasting 
 which characterizes these cases, in spite of the enormous food- 
 consumption. In such event, the tissues would be split up 
 into urea and sugar. And although emaciation may occur, 
 because the albumen of the food ingested is not assimilated 
 but passed directly through the economy, chiefly as urea, the 
 comparative researches of Reich, Gaethgens, Pettenkofer, and 
 Voit show that certain diabetics voided with the urine more 
 nitrogen than corresponded with the nitrogen ingested.* If 
 these researches are to be received, then must we admit that in 
 certain very advanced cases the increased urea-excretion, as well 
 as sugar-elimination, must be at the expense of the tissues. 
 
 Whether the urea is derived from the tissues or the food 
 ingested, it is not impossible that the albumen is split up into 
 urea and sugar as already suggested. For Dr. Haughton has 
 shown that albumen, by the addition of small quantities of 
 water, carbonic acid, and oxygen, furnishes the elements to pro- 
 duce glucose and urea in the proportion by weight of nearly 
 
 * Senator, loc. citat., p. 899.
 
 DIABETES MELLITUS. 271 
 
 five grains of glucose and one grain of urea. According to 
 this theory, as Dr. Dickinson neatly puts it, "albumen is put 
 into the mill, sugar and urea come out; and, like the flour and 
 the bran, wax and wane together." According to this theory, 
 such a splitting up takes place in health, but the sugar is not 
 discharged in the urine as the urea is, because it is oxidized for 
 the production of heat, or possibly converted into fat and 
 stored up as such. And if the ratio of urea to sugar, as ascer- 
 tained by actual analysis, be not very definite after allowing for 
 the normal excretion of urea, it is questionable whether this 
 fact should be admitted as an objection against the theory, for 
 under any circumstances there must be a very great difference 
 in the rate in which the two substances enter the blood, on 
 account of the marked difference in their physical properties, 
 as to osmosis, etc. 
 
 As regards uric acid, some observations tend to show that it 
 is slightly diminished in diabetic urine. From my own ob- 
 servation I only know that, as a sediment, it is not infrequently 
 present in diabetic urine. 
 
 Of the other constituents of the urine sulphuric acid is sub- 
 ject to its normal variations ; chlorine, phosphoric acid, lime, 
 and raar/nesia are said to be increased, phosphoric acid and lime 
 especially so. Neubauer, Boecker, Benecke, Vogel, Gtcthgens, 
 and Dickinson are all agreed to this. While admittino- that 
 most of the phosphoric acid, that combined with the alkalies, is 
 derived from the food. Dr. Dickinson is inclined to think that 
 the smaller part, that combined with the earths, is specifi- 
 cally increased by the disease. The phosphoric acid is derived 
 from the disintegration of nervous tissue, while the lime which 
 does not exist in nervous tissue is dissolved out of the other 
 tissues by the acid in its transit.* 
 
 Of abnormal constituents, albumen is occasionally present. 
 I have found it twice in seven cases. It is not generally large, 
 but I believe that ordinarily it is the result of renal involve- 
 ment, which is of the nature of congestive catarrhal nephritis, 
 
 * Dickinson, op. citat., p. 124.
 
 272 DIABETES. 
 
 though mild in degree. Thus might be accounted for the 
 granuhir and hyaline casts I have found attending these small 
 albuminurias, symptoms Avhieh, under other circumstances, 
 Would point to contracted kidney. Of course it is not impos- 
 sible to have a contracted kidney accompany diabetes, but 
 reasoning from the state of the circulation, epithelial changes 
 are what we would expect, and autopsies, so far as they reveal 
 organic changes, show them to be of the latter character. It 
 is scarcely necessary to say that the urine may become albu- 
 minous from any of the causes of albuminuria independent of 
 diabetes, as pus from pyelitis, cystitis, etc. 
 
 I)iosit or muscle-sugar occasionally replaces the grape-sugar 
 in diabetes, but more frequently accompanies it. Gallois* 
 found it in five out of thirty-five diabetics. 
 
 Finally alcohol and acetone have both been found in dia- 
 betic urine, the former by Rupstein and Kuelz, and the latter 
 first by Fetters and afterwards by others. Acetone is believed 
 to be derived from the decomposition of the diacetic acid of 
 diacetate of ethyl, also present ; alcohol partly from the same 
 source and partly perhaps from the sugar. To acetone and 
 alcohol is ascribed the vinous odor sometimes present in the 
 urine, more particularly some time after it has been passed, 
 though it may be immediately after it. A very simple test for 
 acetone, discovered by C. Gerhardt, is a solution of chloride 
 of iron, l)y which the urine is colored red. 
 
 Of the other secretions the jjerspiration, when present, fre- 
 quently, although not invariably, contains sugar, sometimes a 
 notable amount, as much as 6 J grains having been extracted 
 by Fletcher from a piece of flannel three inches square, which 
 had lain upon the skin 48 hours. The saliva has rarely been 
 found to contain sugar inde])endently of that which it acquires 
 from the food. Whether the gastric juice ever contains it 
 under similar conditions is disputed, but it has been found in 
 effusions and exudations, as might be expected. 
 
 * Gallois, Comptes Rendus, 1863, I, p. 533 ; also De I'inosurie. Paris, 
 1864.
 
 DIABETES MELLITUS. 
 
 273 
 
 Duration. 
 
 Acute diabetes may be said to be unknown, and although 
 cases are related by Becquerel, Wallach, Senator, Dr. Bence 
 Jones, Roberts, and Dickinson, in which death followed within 
 a very short time after its detection, — periods ranging from six 
 days to six weeks, — yet in no instance can it be averred that 
 the disease was of as short duration as it seemed, while in sev- 
 eral there was reason to believe that it has lasted longer. It 
 mfty be said then that diabetes mellitus is a disease almost 
 invariably of long duration. A case of intermittent diabetes, 
 under the successive observation of Dr. Prout and Dr. Bence 
 Jones, lasted 16 years, and one was under similar observation 
 of the last-named physician and Dr. Dickinson for 15 years. 
 Lebert mentions a case which had lasted 18 years, the patient 
 enjoying good health while on appropriate diet, but lapsing 
 immediately to diabetisra on an indiscriminate diet. The 
 younger the age the shorter the duration and the more prompt- 
 ly fatal the result, while after middle age under treatment the 
 duration may be indefinite. 
 
 The following table from Dr. Dickinson's work contains 
 the duration of 100 cases collected by Griesinger, and along- 
 side of it that of 25 which ended fatally at St. George's Hos- 
 pital : 
 
 Durat 
 
 ion 
 
 
 
 
 Less tlian } 
 
 year, 
 
 
 Between 
 
 1 
 
 ind 
 
 1 
 
 2 
 
 rear, . 
 
 
 2 
 
 
 3 
 
 
 
 3 
 
 
 4 
 
 
 
 4 
 
 
 5 
 
 
 
 5 
 
 
 6 
 
 
 
 6 
 
 
 7 
 
 
 
 7 
 
 
 8 
 
 
 Undeter 
 
 mined 
 
 
 
 St. George's 
 
 Collected by 
 
 Hospital. 
 
 Griesinger. 
 
 1 
 
 1 
 
 2* 
 
 2 
 
 8 
 
 13 
 
 6 
 
 39 
 
 5 
 
 20 
 
 1 
 
 7 
 
 
 
 2 
 
 
 
 1 
 
 
 
 2 
 
 
 
 1 
 
 2 
 
 12 
 
 25 
 
 100 
 
 * In both these instances death occurred at six months. 
 18
 
 274 DIABETES. 
 
 From which it maybe conchuled that diabetes rarely proves 
 fatal in less than six months after its accession, while few cases 
 last more than four years. It must be remembered, however, 
 that these statistics are drawn from hospital cases, which before 
 admission were necessarily under much more unfavorable con- 
 ditions than patients in private practice. Hence it is almost 
 certain that the average duration of cases would considerably 
 exceed that deduced from this table. 
 
 Complications. 
 
 The only complications of frequent occurrence in diabetes 
 are the catarrhal pneumonias already referred to, which are 
 rather to be considered a consequence. The same may be said 
 of the boils and furuncles with which the skin is sometimes 
 infested, and the occasional renal catarrh. Jaundice sometimes 
 occurs, and having presented itself twice in the history of a 
 case under my observation, can hardly be considered accidental, 
 although I am at a loss how to account for it. Senator says 
 that, when not an accidental complication due to a catarrh of 
 the duodenum, it may result from compression of the biliary 
 capillaries V)y the overloaded bloodvessels or enlarged gland- 
 cells of the liver.* 
 
 Diagnosis. 
 
 The diagnosis of diabetes mellitus is very easy after it is 
 once suspected. Unnatural thirst and copious diuresis should 
 always suggest a chemical examination of the urine, but un- 
 fortunately these symptoms are not always present, and it is 
 only by adopting a careful habit of testing the urine in all 
 cases of disease, the least doubtful in their nature, that some 
 obscure cases are detected. And although there are sources of 
 error in testing for small quantities of sugar in urine, which 
 are only overcome with considerable trouble, the quantities of 
 sugar thus difficult of detection are not usually of clinical sig- 
 nificance. Almost any one of the tests, therefore, which are 
 found in the various manuals for the examination of urine, 
 
 * Senator, loc. citat., p. 912.
 
 DIABETES MELLITUS. 275 
 
 applied with ordinary care, will respond to such quantities of 
 sugar. Such response being obtained, it may be concluded 
 witliout hesitation that diabetes is present. In my own hands, 
 no test for qualitative purposes has proved more delicate than 
 Tromnier's method of using the copper test.* Its ingredients 
 are easily attainable, and there is no risk of error from changes 
 to which Fehling's and Pavy's qualitative solutions are subject 
 from age, Avhile the latter are subject to the same sources of 
 error, either from reduction by other substances than sugar, 
 and to obscuration of the reduced oxide, which is occasionally 
 held in partial solution by other constituents, as ammonia, 
 creatin, etc. ; thus making it difficult to assert positively that 
 a reduction has taken place. In the latter instance a greenish 
 or brownish-yellow results according as the quantity of cop- 
 per solution added is large or small. All practical difficulties 
 are removed by filtering the urine through animal charcoal, 
 which removes the substances which interfere with the test 
 either by reducing the copper or keeping it in solution; and 
 often diluting the urine with water will be sufficient to secure 
 an unmistakable reaction. 
 
 My method of using Trommer's test is as follows : 
 1. A drop or two of a (i)referably weak — say 1 to 30) solu- 
 tion of cupric sulphate is added to the suspected urine, and 
 then liquor potassse or sodse equal to half the total volume. 
 On first adding the alkali there is immediately liberated, in 
 addition to the earthy phosphates, a blue precipitate of hy- 
 drated cupric protoxide, ivhich, if sugar is present, is redissolved 
 on adding more alkali, producing a clear blue transparent 
 liquid. If, on the other hand, no sugar is present, the fluid 
 
 * A reviewer of the second edition of my little booic on the Examination 
 of Urine, in the Medical Times and Gazette (London), was pleased to 
 characterize my fondness for this test as old-fashioned. I do not think this 
 view will be snstained by those wlio are in the liabit of making very many 
 qualitative testings of urine, using both Trommer's test and the quantitative 
 solutions of Fehling, and I am glad to be able to quote the very explicit 
 language of Senator, who says (article Diabetes, Ziemssen's Cyclopa?dia of 
 Medicine, vol. xvi, p. 963) : " Trommer's test deserves to be ranked foremost 
 on account of its certainty and ready applicability."
 
 276 DIABETES. 
 
 will not be thus blue after the addition of the copper and 
 alkali, but exhibit rather a turbid greenish hue. This, how- 
 ever, is not alone relied upon, but the mixture is heated just to 
 boiliuf/, and if sugar is present, a copious yellow precipitate of 
 hydrated cupric suboxide takes place. This subsequently loses 
 its water and becomes the red suboxide which falls to the bot- 
 tom or sides of the test-tube, to M'hich it often closely adheres. 
 Occasionally the precipitate of earthy phosphates is so copious 
 as decidedly to obscure the reaction. In this event they may 
 be removed by filtration after adding the alkali and slightly 
 warming the mixture, before adding the copper and further 
 heating. 
 
 2. A second similarly prepared mixture of these ingredients 
 should be made and set aside for from 1 to 24 hours without 
 the addition of heat. If sugar is present a similar precipitate 
 of suboxide of copper will take place. This repetition of the 
 test is very important, since, according to Xeubauer, the other 
 organic substances which reduce the salts of copper do so only 
 after long boiling. Hence also prolonged boiling should always 
 be avoided. 
 
 When Fehling's or Pavy's solutions are used, the following 
 method should well be found delicate: 
 
 A small quantity should be placed in a test-tube, diluted 
 with about five times its bulk of water, and boiled alone for a 
 few seconds. If the solution remains clear on thus boiling, 
 add immediately the suspected urine drop by drop. If sugar 
 is present in any quantity, the first few drops will usually 
 cause the yellow precipitate, but if the reaction does not occur, 
 the dropping may be continued until an equal volume of the 
 urine has been added, when the mixture is again boiled.* If 
 no precipitate occurs, sugar is absent. These tests are undoubt- 
 edly the most brilliant. 
 
 * One of the sources of error in this mode of testing is the prolonged 
 boiling which a specimen is almost sure to receive. A few drops of urine 
 are added to tiie test fluid, the mixture is then boiled, a few more drojjs are 
 added, the mixture is again boiled, and thus a constant boiling is kcjit up 
 until finally a reduction takes place, which may be from prolonged boiling 
 alone.
 
 DIABETES MELLITUS. 277 
 
 If a precipitate occurs on boiling the test fluid atone, a new 
 supply may be obtained, or a little more soda or potash may 
 be added, the fluid filtered, and it is again ready for use. The 
 preci[)itate referred to is a suboxide of copper, the result of a 
 spontaneous reduction of the protoxide which sometimes occurs 
 when Fehling's or Pavy's solutions are kept for some time. 
 Boiling causes its precipitation, and hence the necessity of 
 boiling a solution which has been kept for any length of time, 
 before adding the suspected fluid. All possibility of such 
 source of error may be avoided by keeping the solution of 
 copper separate from that of the potash and potassic tartrate, 
 and mixing them at the moment they are required for use. 
 
 In doubtful cases, also, urine passed two or three hours after 
 a meal should be tested, as well as that passed fasting, for the 
 former will often contain sugar when the latter does not. 
 
 In judging of the progress of a case of diabetes under treat- 
 ment, it is not sufficient to test the urine qualitatively, but a 
 quantitative determination of sugar must be made. This may 
 be done by the volumetric processes described in the manuals 
 for the examination of urine, but the simplest method is the 
 fermentation method of Dr. Roberts. In this the specific 
 gravity of the urine is taken before and after fermentation, 
 and the difference in the specific gravity indicates the number 
 of grains of sugar in each fluid ounce of urine. Then sup- 
 pose the specific gravity before fermentation to be 1045, and 
 after fermentation 1035, the quantity of sugar per fluid ounce 
 is 10 grains. 
 
 Prognosis. 
 
 The prognosis of diabetes is generally considered unfavora- 
 ble, but depends very much upon the age at which the disease 
 makes its appearance, the time which has been allowed to 
 elapse before treatment is instituted, and the treatment itself. 
 Once thoroughly established early in life, or before 25 years of 
 age, recovery would seem to be impossible, while even at this 
 age, if treatment is instituted sufficiently early, much may be 
 done to avert the end. Diabetes is a disease in which the ex- 
 pectant plan of treatment is disastrous. It is a disease which
 
 278 DIABETES. 
 
 nev^er getS'well of itself, and always gets worse if not properly 
 treated. 
 
 When the disease appears after middle life, is early recog- 
 nized and promptly treated, it is ordinarily easily controlled ; 
 and although it is almost never safe to declare a case of dia- 
 betes absolutely cured, it does occasionally happen that recov- 
 ery is so complete that the patient may be left to his own mode 
 of living. As a rule, however, even cases which have appar- 
 ently recovered have to keep a watch upon their diet, and 
 should at intervals have their urine examined with a view to 
 sounding, as it were, their condition. 
 
 When diabetes depends upon recognized nervous lesions the 
 prognosis is altogether that of the lesion itself. 
 
 The cause of death is very frequently some intercurrent or 
 consequent disease, as consumption. The extreme debility 
 which ensues sooner or later is of such a character that there 
 is no power of resistance, and a disease which would ordinarily 
 be trifling, becomes, on this account, often a fatal one. 
 
 Treatment of Diabetes Mellitus. 
 
 I have already said that diabetes is a disease in which the 
 expectant plan of treatment is disastrous, that it never gets 
 well of itself, and that when left alone it almost invariably 
 gets worse. The importance of a prompt and correct treat- 
 ment is therefore evident. 
 
 From the discussion of the pathogeny of the disease it is 
 also plain that at least an abatement of the most important 
 symptom, glycosuria, may be expected by regulating the diet. 
 Experience justifies such expectation, and it so happens that 
 the abatement of this symptom is almost invariably followed 
 by an abatement of all. The treatment, therefore, naturally 
 divides itself into dietetic and hygienic and medicinal. 
 
 I. Dietetic and Hygienic Treatment. 
 
 By far the most important line of treatment, without which 
 indeed no sufficient results have ever been attained, is the die-
 
 DIABETES MELLITUS. 279 
 
 tetic. This consists essentially in the elimination from the 
 food of the patient of such articles as are readily convertible 
 into sugar. It is generally acknowledged that in the early 
 stage of the disease all the sugar which appears in the urine is 
 derived in some way, whether directly or indirectly, from the 
 saccharine and amylaceous alimentary principles; that the 
 liver has lost its power to assimilate these, and they pass di- 
 rectly through the latter organ unconverted. Hence, if these 
 be excluded from the diet and their place supplied by other 
 assimilable articles, the symptom disappears, and the disap- 
 pearance of this symptom seems to be, for the time being at 
 least, the cure of the disease. For with it disappear also the 
 frequent micturition, thirst, dryness, etc. 
 
 If it were necessary to select a diet absolutely free from 
 sugar and starch it would indeed be restricted, as there are 
 comparatively few articles of food thus constituted. Such are, 
 however, meats of every kind, fresh or salted, including tripe, 
 tongue, ham, bacon, and sausage ; soups made from meat 
 without flour ; game, poultry, fish, oysters, lobsters, crabs, eggs, 
 in every shape ; butter and new cheese, oils and fats. Hap- 
 pily, however, it is not necessary to use articles absolutely free 
 from the two baneful principles, and in this manner quite a 
 variety of palatable articles may be added to the dietary. 
 Among these are cream, curds, milk and buttermilk, all green 
 vegetables, including spinach, endive, the green leaves of let- 
 tuce, dandelion, cabbage, coleslaw, brussels sprouts, cauliflower, 
 broccoli, string beans, watercress, celery tops, asparagus tops, 
 turnip tops, young onions, cucumbers, pickles, and olives. To 
 these may be added unsweetened jellies (preparations of gela- 
 tin), and especially a variety of nuts, including almonds, wal- 
 nuts, butternuts, filberts, pecan nuts, Brazil nuts, but not 
 chestnuts; also, all acid fruits, as apples, oranges, lemons, 
 strawberries, etc. Tea and coffee, with cream and without 
 sugar, cocoa-nibs, but not chocolate, are permitted ; also, all 
 wines which contain little or no sugar, including claret. Bur- 
 gundy, Rhine, and still Moselle wines, together with very dry 
 sherry, unsweetened brandy, and whiskey; and gin when re-
 
 280 DIABETES. 
 
 quired. Tlie carbonated waters, natural or artificial (tlie so- 
 called soda-water of the shops), are pre-eminently suitable. 
 
 Water is to be allowed ad libitum, for water is the media ni 
 by which the sugar is carried out of the blood and tissues. Its 
 supply should therefore be liberal, and with the diminished 
 sugar-formation comes diminished thirst. 
 
 Beer, ale, porter, cider, and the fermented liquors generally, 
 are not allowable because of the sugar they contain. They are 
 less objectionable when fermentation is carried to a high degree, 
 resulting in a more complete destruction of the sugar. This 
 is the case with certain bottled lager beers and English ales. 
 
 It is not simply on account of the small quantity of sugar 
 and starch contained in them which renders the vegetable sub- 
 stances named admissible, for many of them contain a good 
 deal of sugar ; but these sugars, unlike grape-sugar, are assimi- 
 lable. Such are pre-eminently mannite, the sugar of manna, 
 lactin or sugar of milk, Icevulose or fruit-sugar, and probably, 
 also, inosit or the sugar of muscle and the sugar of honey. 
 Such is also inulin, a hydrocarbon and starchy principle found 
 in the inula hclenium or elecampane, but especially in Iceland 
 moss. Hence, too, the impunity with which milk can often be 
 taken by diabetics, although it contains from three to six per 
 cent, of lactin. On this account, too, mannite may be used for 
 sweetening tea and coffee where th's addition is indispensable 
 to the patient. Glycerin is also sometimes used for the same 
 purpose, i. c, as a substitute for sugar, but although less objec- 
 tionable than sugar, it is not only theoretically unsuitable, but 
 experience has shown it to be so; for glycerin is probably 
 converted into glycogen or sugar in the liver, nearly two mole- 
 cules of glycerin (CgllgOg) being required to furnish one of 
 sugar (CgHjgOg), or glycogen (CgHj^Oj). Further, under the 
 careful olxservation of Dr. I'avy,* it was noted that under the 
 use of glycerin the urine increased from 3 and 3| pints to be- 
 tween 5 and 6 pints, and the sugar from 1100 grains to 3000 
 grains j/^er diem in the course of three days. Its withdrawal 
 
 * Pavy, On Diabetes, London, 18G9, p. 259.
 
 DIABETES MELLITUS. 281 
 
 was followed by a ])rompt fall in both the urine and sugar, a 
 return to it by a second increase, and subsequent withdrawal 
 by another decline. With the increase in the quantity of 
 urine and sugar, came an increase in the thirst and discomfort; 
 so that it would seem conclusive that the tendency, at least, of 
 glycerin is to aggravate the sjnuptoms, and its use, therefore, 
 contraindicated. Mannite is therefore much to be preferred to 
 glycerin, either for sweetening or to substitute the part of sugar 
 in force- product ion. 
 
 It will be noted that not only all saccharine substances of 
 animal or vegetable origin, and all vegetables largely composed 
 of starch, as potatoes, rice, and corn, are omitted from the 
 category of admissible articles, but that bread, and all prepa- 
 rations made of wheat, rye, rice, or corn-flour, are conspicuous 
 by their absence. This is found to be a very important omis- 
 sion from the dietary of most persons, and very numerous 
 have been the attempts to devise substitutes for it, with vary- 
 ing success. 
 
 Perhaps the best substitute for ordinary wheat-flour is the 
 gliden-Jlour. It was suggested in 1841 by Bouchardat, and is 
 made by washing the ordinary wheat-flour to free it from 
 starch. Although this is not completely accomplished, a quite 
 pure article of gluten may be obtained, containing, it is said, 
 but one ])er cent, of starch, and some starch is necessary, if it 
 is desired to make it into dough. It is perhaps best used in 
 the shape of a mush or porridge, but it can be made into al- 
 most any of the various forms of bread and biscuit into which 
 flour is made, and the ingenuity of bakers has been exercised 
 in many ways to devise a palatable article. It is more nutri- 
 tious than the bran-flour. As heretofore made, the salts have 
 also been washed out by the process employed, but it is now 
 made in such way as to retain the salts.* It is less irritating 
 
 * The Healtli Food Company, of 74 Fourth Avenue, New York, make a 
 gluten of this kind by first removing tlie five bran coats, pulverizing the 
 cleaned berry by the " cold-blast process," stirring the powder into ice water, 
 precipitating the gluten, cellulose, and mineral matters, siphoning off the 
 water, holding in suspension the starcli, and drying out the precipitate.
 
 282 DIABETES. 
 
 to the bowels than the bran, and where this property, so often 
 desirable, is objectionable it is more suitable than the latter. 
 
 Senator gives another method of getting rid of the starch and 
 sugar in bread as tried by Vogel at the suggestion of Liebig. 
 It consists in converting the starch into sugar by the action of 
 diastase, and dissolving out the sugar thus produced. It is 
 done by treating thin slices of bread with an infusion of mult. 
 The bread is then washed, dried, and slightly toasted. 
 
 Another of these substitutes is the hran-jlour deprived of 
 its starch by washing. The bran itself is not wholly innutri- 
 tions, containing, according to Parkes,* sometimes as much as 
 15 per cent, of nitrogenous matter, 3.5 per cent, of fats, and 
 5.7 per cent, of salts, although, in consequence of its indigesti- 
 ble character, it is probably not much availed of in nutrition. 
 Moreover the salts are washed out in removing the starch 
 which is mixed with it. But it is especially valuable in con- 
 tributing a desirable bulk to the food of which it forms a part, 
 and by its slightly irritant properties aids in maintaining a 
 proper action of the bowels. These properties may be dimin- 
 ished, arid the bran made much more suitable for its purposes 
 by being very finely comminuted. It may be made by the 
 ingenious cook into a variety of more or less palatable cakes. 
 But sometimes, even when most carefully prepared, it is too 
 irritant to be borne. Dr. Prout very early recommended, as a 
 substitute for bread, a compound of bran, milk and eggs, which 
 he declared not unpalatable.t 
 
 A purified gluten made by them is deprived of the ceHulose walls of the 
 cells in which the gluten-granules are held. 
 
 They also furnish directions for making gluten bread and gluten cakes 
 of various kinds, as well as the gluten porridge, which is made by stirring 
 the gluten into boiling water until thick enough, and then keeping up tiie 
 boiling process for fifteen minutes. A little salt and butter are added at the 
 close, to improve tlie flavor, and it may be eaten with milk or cream. 
 
 * Parkes, Practical Hygiene, oth ed., Philadelphia, 1878, p. 222. 
 
 f A very carefully prepared bran-flour, as well as a wheat-f/lnten flour, is 
 made by John \V. Shedden, pharmacist, corner Broadway and Thirty-fourth 
 Street, New York city. 
 
 The following are Dr. Caniplin's directions for making biscuit of the bran- 
 flour : To one-quarter of a pound of flour add three or four fresh eggs, one
 
 DIABETES MELLITUS. 283 
 
 In cases which do not require an extreme regulation of diet, 
 I am in the habit of recommending the ordinary "bran 
 bread " of the bakers, which is really bread made of unbolted 
 flour, and contains the starch along with the gluten and bran ; 
 but the former is in much smaller proportion than in the bolted 
 flour, and I note from its use an immediate diminution in the 
 quantity of sugar excreted as compared with that under the 
 use of the ordinary bread. From what I can learn of it, I 
 have no doubt the " cold-blast whole wheat-flour would be 
 better."* 
 
 Still another substitute for wheaten bread is the almond 
 food suggested by Dr. Pavy. The almond is composed of 
 54 per cent, of oil, 24 per cent of nitrogenized matter known 
 as emulsin, 6 per cent, of sugar, 3 per cent, of gum and no 
 starch. Chemically speaking, it is therefore admirably adapted 
 for diabetic food, and when the sugar and gum are extracted 
 leaves nothing to be desired. The sugar and gum are removed 
 by treating the powdered almonds with boiling water slightly 
 acidulated with tartaric acid, or soaking the almonds in a 
 boiling acidulated liquid, which may form part of the process 
 for blanching. The boiling and acid fluid are necessary in order 
 to precipitate the einulsin, which would otherwise emulsify the 
 oil of the almond. I have had no experience with the almond 
 food. Dr. Pavy speaks very highly of biscuits made of almond- 
 flour and eggs, which, he says, go very well with a little sherry 
 or other wine. He admits that they are found too rich by 
 
 and a half ounces of butter, and Iialf a pint of milk ; mix the eggs with a 
 little of the milk, and warm the butter with the other portion, then stir the 
 whole together well ; add a little nutmeg or ginger or other agreeable fla- 
 voring, and bake in small forms or pattipans. The cake when baked should 
 be about the thickness of an ordinary captain's biscuit. The pans must be 
 well buttered. Bake in rather a quick oven for half an hour. 
 
 These cakes or biscuits may be eaten by the diabetic with meat or cheese 
 for breakfast, dinner, or supper; at tea they require rather a free allowance 
 of butter, or they may be eaten with curd or any of the soft cheese. 
 
 * This is another product of the Health Food Company, which contains 
 the nutritious but not the innutritions portions of the bran. It is made by pul- 
 verizing the carefully cleaned wheat by a compressed cold-air blast, which 
 strikes the wheat and dashes it to atoms.
 
 284 DIABETES. 
 
 some for ordinary consumption. A pliysiclan, himself a dia- 
 betic, witli whom I am in correspondence, says he ate them 
 but once and found them most unpalatable. He may, how- 
 ever, have hit upon a spoiled or imperfect article.* 
 
 Biscuits made of iaulin, the starchy principle already re- 
 ferred to on page 280, were suggested by Kuelz.f Lichenin, 
 or moss-starch, abundant in Iceland moss, is a variety of inulin 
 and would be the material used for the purpose. Being very 
 cheap it would be suitable on this account. Though a starch, 
 it is, according to Kuelz, one of the assimilable starches already 
 alluded to, of which small quantities, at least, do not increase 
 the excretion of sugar. The biscuits are made with the addi- 
 tion of milk, eggs, and salt. 
 
 Under the head of dietetic treatment belongs the skim-milk 
 treatment, of which Dr. A. Scott Donkin is the chief exponent 
 and advocate. This treatment is based upon the view that 
 lactose or sugar of milk is a material assimilable in diabetes, 
 " and does not in the slightest degree contribute to the formation 
 of sugar;" that in this respect it is even superior to casein, 
 which, however, resists the sugar-forming process of tlie malady 
 " to a degree immeasurably greater than any other albuminous 
 alimentary substance, so that in all but the most severe and 
 advanced or complicated cases it is complete."| With regard 
 to casein, an albuminous substance, I presume no one will 
 dispute, in general, the view taken by Dr. Donkin, although 
 all may not agree with him in assigning to it the highest posi- 
 
 * Seegen recommends an almond food made as follows : Beat a quar- 
 ter of a pound of blanched sweet almonds in a stone mortar for about 
 three-quarters of an hour, as fine as possible ; put the flour thus pro- 
 duced into a linen bag, which is then immersed for an hour and a quar- 
 ter in boiling water, acidulated with a few drops of vinegar. The mass 
 is then thoroughly mixed with three ounces of butter and two eggs; the 
 yolks of three eggs and a little salt are added, and the whole is to be 
 stirred briskly for a long time. A fine froth is to be made by beating the 
 white of the three eggs, and added. The whole paste is now put into a form 
 smeared witli melted butter and baked by a gentle fire. 
 
 f Kuelz, Bietrage zur Path, und Therapie des Diabetes Mellitus, Mar- 
 burg, 187-i, Bd. i, s. 145. 
 
 J Donkin, Diabetes and Food, New York, 1875, p. 132.
 
 DIABETES MELLITUS. 285 
 
 tion in this respect. But as to lactose, the most prominent 
 Engh'sh physicians, among whom may be named Drs. Pavy, 
 Roberts, and Dickinson, seem to be with singular unanimity 
 opposed to him, while in their criticisms a tone of bitterness 
 is not altogether wanting. In addition, however, to the results 
 of his own observations,* Dr. Donkin is sustained in his 
 views as to the assimilability of lactin by the modern German 
 }>hysicians and physiological chemists. It will be remembered 
 that mannite, inulin, and Irevulose are placed in the same 
 category of assimilable carbohydrates by Kuelz. There is, 
 further, considerable clinical testimony in favor of this treat- 
 ment from others than Dr. Donkin who have tried it, and 
 although I have as yet had insufficient personal experience 
 Math a pure skim-milk treatment as directed by Dr. Donkin, 
 I know of at least one case in which the patient, a very intel- 
 ligent physician, declares himself cured by a rigid adherence 
 to it, and should opportunity present, where the ordinary 
 dietetic measures failed to be followed by sufficient results, 
 I would try it with no little hope of success. The instances 
 in which I have tried it were hospital cases, where I met the 
 usual difficulty, an unwillingness on the part of patients to 
 submit to it; and in private practice I have up to the present 
 time been satisfied with the results of the ordinary dietetic 
 plan. 
 
 In what may be regarded with our present knowledge of 
 the subject, and without pretension to too precise accuracy, as 
 the first stage of diabetes, the dietetic measures above indicated 
 are usually followed by the most prompt and decided results, 
 occasionally by the permanent removal of all symptoms, at 
 others by a continued absence of them so long as a watchful- 
 ness over diet is maintained. In a more advanced stage of the 
 disease, in which a more rapid emaciation and loss of strength 
 show themselves, such a regimen is followed by a decided dimi- 
 
 * For ail account of Dr. Donkin's experiments the reader is referred to 
 Dr. Donkin's conimunications to the London Lancet from 1868 to 1875; to 
 his work on The Skim-milk Treatment of Diabetes, London, 1871, and 
 the Transactions of the Clinical Society of London, vol. vii, 1874.
 
 286 DIABETES. 
 
 nation in the quantity of sugar excreted, l)ut it fails to disap- 
 pear altogether, and a more rigid elimination of saccharine and 
 amylaceous articles must be attempted. Although it is com- 
 monly believed that sooner or later even the albuminous prin- 
 ciples of food fail to be assimilated but largely reappear as 
 sugar in the urine, Senator calls attention to the fact " that 
 the formation of sugar or glycogen out of pure albumen 
 (fibrin, white of eggs) has not thus far been proved, but is 
 yet quite doubtful, and that still less has any diabetic been ob- 
 served to pass sugar while using a diet absolutely free from 
 sugar and the elements which form sugar or glycogen ; that is 
 to say, a diet consisting only of albumen, the necessary salts, 
 extractive matters and drink."* 
 
 The importance of this statement will be further appreciated 
 when it is remembered that even a so-called exclusively meat 
 diet does not consist of albumen alone, but contains also 
 glycogen, as well as undoubted glycogen producers and hydro- 
 carbons in the shape of gelatin, glycerin (in the fat), and inosit. 
 It will be remembered that the experiments of Salomon go to 
 show that glycogen appears in the livers of animals fed on fats 
 alone, the glycerin therein contained being probably its imme- 
 diate source, and that Dr. Donkin's observations go to show 
 that in aggravated cases of diabetes the ingestion of fat is fol- 
 lowed by increased elimination of sugar; so that it is prob- 
 ably impossible to secure a thoroughly non-glycogenic diet, 
 and it is questionable whether, even if it were possible, other 
 urgent needs of the economy would be sufficiently supplied by 
 it. On the other hand, it is evident that further observation 
 and experiment are still necessary on the matter of diet in 
 diabetes, and that valuable additions to our knowledge may be 
 expected therefrom. 
 
 * Senator, loc. citat., p. 859. On page 957, however, Senator, admits that 
 one albuminoid snb.stance, cjdatin, has been proved a producer of glycogen, 
 and that even the chemical i)rodnction of saccharine matters outside of the 
 body has been achieved with it, though with it alone, and not with true 
 albuminates.
 
 DIABETES MELLITUS. 287 
 
 In conclusion, the following suniniaiy of articles admissi- 
 ble for diabetics will be found convenient for reference : 
 
 Food and Drink. 
 
 Shell-Jiiih. — Oysters and clams, raw or cooked, in any way, 
 without the addition of flour. 
 
 Fifih of all kinds, fresh or salted, including lobsters, crabs, 
 sardines, and other fish in oil. 
 
 Meats of every variety except livers, including beef, mut- 
 ton, chipped dried beef, tripe, ham, tongue, bacon, and sau- 
 sages. xVlso poultry and game of all kinds, with which, how- 
 ever, sweetened jellies and sauces should not be used. 
 
 Soups. — All made without flour, rice, vermicelli, or other 
 starchy substances or without the vegetables named below as 
 inadmissible. Animal soups not thickened, beef tea and 
 broths. 
 
 Vegetables. — Cabbage, cauliflower, brussels sprouts, broccoli, 
 green string-beans, the green ends of asparagus, spinach, dan- 
 delion, mushrooms, lettuce, endive, coleslaw, olives, cucumber 
 fresh or pickled, radishes, young onions, watercresses, mustard 
 and cress, turnip tops, celery tops, or any other green vege- 
 tables. 
 
 Vec/efcJ)les to be especially Avoided. — Potatoes, white and 
 sweet, rice, beets, carrots, turnips, parsnips, peas, and beans ; all 
 vegetables containing starch or sugar in any quantity. 
 
 Bread and cakes made of gluten, bran, or almond flour, or 
 inulin, with or without eggs and butter. Griddle-cakes, pan- 
 cakes, biscuit, porridges, etc., made of these flours. No pastry 
 permitted unless made of the admitted flours and without 
 sugar. 
 
 Eggs in any quantity and prepared in all possible ways, 
 without sugar or ordinary flours. 
 
 Nuts. — All except chestnuts, including almonds, walnuts, 
 Brazil nuts, hazelnuts, filberts, pecan nuts, butternuts, cocoa- 
 nuts. 
 
 Condiments. — Salt, vinegar, and pepper in moderate quan- 
 tity.
 
 288 DIABETES. 
 
 Jellies. — None except tliose unsweetened. They may be 
 made of calf's foot or gelatin, and flavored with wine. 
 
 Drinks. — Coffee, tea, and cocoa-nibs with milk or cream, but 
 without sugar. Also milk, cream, soda (carbonated) water, 
 and all mineral waters freely; acid wines, including claret, 
 Rhine, and still Moselle wines, very dry sherry. Unsweet- 
 ened brandy, whiskey, and gin. No malt liquors except those 
 ales and beers which have been long bottled and in which the 
 suo;ar has all been converted into carbonic acid and alcohol. 
 
 II. Hygienic Treatment. 
 
 Next in Importance to the dietetic is the hygienic treatment 
 of diabetes. This consists in providing perfect ventilation, 
 bathing, and attention to the skin, together with muscular ex- 
 ercise. 
 
 The diabetic should breathe the freshest and purest air. "While 
 the cases are not numerous in which embarrassed respiration 
 results in glycosuria, there are undoubted instances in which this 
 has occurred, as in croup and whooping-cough ; and it is well 
 known that asphyxiated lower animals are apt to have glyco- 
 suria. And although the glycosuria thus resulting is probably 
 reflex, it can hardly be expected that the diabetic should improve 
 under unfavorable respiratory conditions. He should not, 
 therefore, live, M'ork, or sleep in a confined atmosphere, but 
 secure the most perfect ventilation, spending much of his time 
 out of doors, and sleeping in large, well-ventilated chambers, 
 with windows open, etc. Especially should he avoid exposure 
 to irrespirable gases. Attention to the skin, or skin-culture ( Haut 
 cultur), as it is termed by the Germans, is most imj)ortant to 
 the diabetic. He should bathe at least twice a week in tepid or 
 hot water, on going to bed in winter, and on rising, or both on 
 risinc: and retiring;, in summer. He should groom his skin thor- 
 oughly daily, either after the bath or independent of it on the 
 days on which he does not bathe. A tablesjioonful or two of 
 sodium carbonate to an ordinarv bath is a suitable addition to
 
 DIABETES MELLITUS. 289 
 
 the latter, softening the skin and facilitating its action by re- 
 moving the effete epithelium. 
 
 Attention to other secretions, particularly the bowels, is of 
 the greatest importance to the diabetic. It is probably partly 
 on account of their action in this respect that the alkaline and 
 alkaline saline aperient waters, as those of Vichy and Carlsbad; 
 are of so much advantage. To those who visit these springs, a 
 part of the advantage resulting therefrom is ascribable to the 
 other favorable hygienic influences, such as rest, fresh air, and 
 exercise, by which they are surrounded. Independently of 
 these influences, however, I think there is reason to believe 
 that the waters of Carlsbad and Vichy are of service to diabetics. 
 And where their cost is not a consideration, from half a pint 
 to a i)int of A^ichy and half as much Carlsbad, early in the 
 morning, may be taken by the patient as an adjuvant in the 
 treatment. The Vichy is a more alkaline water, containing 
 35 grains of carbonates to a pint, while Carlsbad contains but 
 11, but contains twice the proportion of chlorides, 8 grains to 
 a pint, and nearly ten times as much sodium sulphate, or 19 
 grains to the pint; hence its more purgative quality. Since 
 Carlsbad has the highest reputation it is more likely that it is 
 through the action of the sulphates and chlorides on the liver 
 rather than that of the alkalies they contain, that these waters 
 are efficient. This is the more likely, as other alkaline waters 
 nearly as rich as those of Vichy, and richer than Carlsbad in 
 sodium carbonate, but without sulphate of sodium, are without 
 reputation. The alkalies may, however, increase the effect, 
 and are especially of service where there is acidity. 
 
 The only American waters known tome which approach these 
 very closely as to both chlorides and sulphates, are those of Crab 
 Orchard Springs in Kentucky, of which Sowder's Spring con- 
 tains 25 grains of sulphate of sodium and magnesium, and 7 
 grains of sodium chloride to the pint, yet I am not aware that 
 these waters have any reputation in diabetes. Other springs 
 which approach them in the proportion of sulphates of sodium 
 and magnesium are the Estill Springs and Harrodsburg Springs 
 in Kentucky, and the Bedford Springs in Pennsylvania. The 
 
 19
 
 290 DIABETES. 
 
 latter waters contain a little iron, which may be of aflvantage. 
 The celebrated Saratoga Springs, in this country, have an un- 
 doubted action on the liver, probably through the chlorides 
 they contain, which are in very large proportion, reaching in 
 the Geyser Spring 70 grains to the pint, and in the Einjnre 
 and Hathorn 63 grains to the pint. They contain no sul- 
 phates, according to Professor Chandler's analyses, but the car- 
 bonates are in considerable proportion, though much less than 
 in the Yichy waters. In the absence of the Carlsbad and 
 Vichy \vaters, I would use the purgative Saratoga waters, 
 especially the Hathorn.* 
 
 31i(scular exercise should be taken daily by the diabetic, 
 both by walking and gymnastics. It is likely that glycogen is 
 consumed to a degree in the muscles during their action, and 
 that in diabetes there is an undue accumulation of surar in 
 the muscles is quite certain. The sense of muscular weariness 
 so characteristic of diabetes is ascribed by some to this accu- 
 mulation of sugar in the muscles. Dr. William Richardson, f 
 of London, illustrates by his own case and that of others under 
 his care, the undoubted benefit of exercise. It should be sus- 
 tained regularly day by day, even in wet weather, care being 
 taken to keep the feet dry, while it should never be carried to 
 real fatigue. Dr. R. relates of himself, that at one time he 
 had so little muscular power that he could not walk 100 yards 
 without great fatigue, falling two or three times, and requiring 
 always the greatest vigilance to prevent falling. He began to 
 take exercise regularly two or three times a day, wet or fine. 
 
 * Some of the American waters whicli are most vaunted and advertised 
 as useful in diabetes contain a surprisingly small quantity of either sul- 
 pliates or chlorides, indeed of any of the ingredients which go to make a 
 mineral Avater. Thus Bethesda water contains 1.7 grain carbonate of so- 
 dium and magnesium to the pint, .14 grain of chloride of sodium, and 1.1 
 grain of sulphates of sodium arid potassium together, to the pint. Clysmic 
 water about the same. The same may be said of the Poland and Capon 
 waters. It is possible, however, that by drinking very large amounts of 
 these waters, using them as table-waters and as substitutes for all other drinks, 
 effects may be produced. 
 
 f Kichardson, op. citat., p. 91.
 
 DIABETES MELLITUS. 291 
 
 He gradually gained strength, so as to walk five or six miles 
 a day M^thout fatigue. I cannot too strongly urge upon dia- 
 betics the following of Dr. Richardson's example according to 
 his method. 
 
 Bouchardat (1835) and Trousseau early advised muscular 
 movements, and recently (1875) Kuelz has strongly advocated 
 them. 
 
 On the other hand, it is even more important that extreme 
 fatigue should be guarded against, especially by those in ad- 
 vanced stages. Dr. Richardson reports two cases of sudden 
 death after long journeys. 
 
 For a similar reason venereal excesses should be avoided, 
 being peculiarly exhausting to one already weakened by dia- 
 betes. 
 
 III. The 3Iedicmal Treatment. 
 
 Like all diseases in which treatment by drugs is relatively 
 inefficient, diabetes has its full share of reputed remedies, most 
 of which are useless. This dare not, however, be said of all. 
 
 In the first place I would call attention to the natural 
 waters already referred to as adjuvants under the head of hy- 
 gienic treatment. What was said of them there, might with 
 equal propriety be said here. 
 
 At present, the first drug of which I make use in diabetes 
 mellitus is ergot, not because it is invariably useful, but be- 
 cause I think I have been able to trace to it results more di- 
 rectly than to any other remedy. Moreover, the principle of 
 treatment is a rational one. Ergot is supposed to produce 
 contraction of the bloodvessel walls, and there is every reason 
 to suppose it does. In diabetes there is dilatation of those of 
 the liver. I give either the fluid extract in half-drachm doses, 
 or preferably the gelatin-coated pills, of which one is equal to 
 30 minims of the fluid extract. Of these I give three a day, 
 and continue the treatment for a month, if the stomach bears 
 it. I have seen the sugar diminish and disappear under its 
 use when the hospital diet was only modified by the addition 
 of three pints of milk. At first the sugar reappeared after 
 omitting the remedy, but finally disappeared not to return.
 
 292 DIABETES. 
 
 On the other liand, I have known it to be faithfully used for 
 a month without evident results. I should be afraid, under 
 ordinary circumstances, to rely upon it to the exclusion of the 
 dietetic treatment. 
 
 It seems that opium was used for diabetes as early as the 
 second century, by Archigenes. It was also used by ^tius 
 of the ancients, and in the latter part of the eighteenth century 
 and beginning of the nineteenth, by Hollo, Frank, Tommas- 
 son, and especially the English physician, Pelham Warren, in 
 1812. 
 
 It is certainly a useful agent in diabetes, and it is a rem- 
 edy I would early use; but its use is united with disadvan- 
 tages in the locking-up of the secretions which attends its 
 use. Aperient remedies should therefore be used with it, and 
 very suitable are the natural aperient waters, including the 
 bitter waters, Friedrichshalle, Hunyadi Janos, Racoczy, 
 Piillna, etc. Dr. Pavy* is a strong advocate of the use of 
 opium, and has been astonished at the highly successful re- 
 sults. He has seen a patient entirely relieved under its use, 
 and the use of it alone. It was given in increasing doses until 
 the quantity reached nine grains in a day.f At first the glyco- 
 suria returned after its discontinuance, but on returning to its 
 use the disease finally disappeared not to return. There was 
 no restriction of diet whatever. 
 
 llorphia may, of course, be substituted for opium, and of 
 the other alkaloids, codeia has been found useful by Pavy, 
 Foster, and Image (quoted by Brunton). The latter gave it 
 in doses of ^ a grain three times a day, increased ^ a grain every 
 four days, until the patient took 5 grains three times a day. 
 Reasoning from their physiological action, it would appear 
 that opium and its alkaloids should be useful in cases where 
 diabetes is the result of irritation. 
 
 * Pav}', op. citat., p. 275. 
 
 t McGregor (London Medical Gazette, 1837) allowed the quantity to 
 reach, in one case, 60, and in another 90 grains within 24 liours. Whence 
 it is inferred that diabetics bear opium without disadvantage in doses which 
 ■would not be tolerated under ordinary circumstances.
 
 DIABETES MELLITUS. 293 
 
 Iodide of potassium 1ms been found useful, and is a remedy- 
 to be early thought of. 
 
 Secgen has seen sugar entirely disappear under the use of 
 20 to 30 drops of tincture of iodine daily, but the sugar re- 
 appeared after discontinuing the remedy. 
 
 The bromide of potassium has been used by some with ap- 
 parent advantage, and by others without eifect. 
 
 Strychnia is one of the most useful adjuv^ants, acting as a 
 tonic to the stomach and nervous system. It is best given in 
 the form of the sulphate in acid solution, or it may be com- 
 bined with iro7i, and especially with iron and arsenic. To the 
 latter drug has been ascribed special influence in diminishing 
 the formation of sugar, based upon the observation of Saikow- 
 sky, that glycogen diminishes in the liver of animals poisoned 
 with arsenic. At any rate, the well-known pill of strychniiB 
 sulph., gr. j'q-, ac. arsenios., gr, ^q, and ferr. sulph., gr. 2, is 
 here a very useful remedy. I would prefer, however, to give 
 the strychnia in acid solution, and give the other remedies 
 separately as required. Leube gave arsenic in doses of ^ grain 
 three times a day, with advantage. 
 
 To make up the deficiency in phosphates, which is the neces- 
 sary result of the use of gluten bread, the preparation known 
 as " Compound Syrup of the Phosphates " or Parrish's Chem- 
 ical Food, is a good remedy. Each f5j contains 2| grains cal- 
 cium phosphate, 1 grain phosphate of iron, with fractions of a 
 grain of phosphates of sodium and potassium, besides free 
 phosphoric acid. It is administered in doses of a teaspoonful 
 three times a day. The preparation of phosphoric acid and 
 the phosphates* recently suggested by Professor William Pep- 
 
 * Tlie formula is as follows : 
 
 R. Calcis pJiosphat., gr**- iij 
 
 Magnes. phosphat., gr. ss. 
 
 Potas. phosphat., gr. iv 
 
 Ferri phosphat., gr. ss- 
 
 Ac. phosphoric (60 per cent.), .... ^vi f 
 
 AquiS, q. s. ad f^j. — M. 
 
 Dose, a teaspoonful three times daily, diluted.
 
 294 DIABETES. 
 
 per, probably serves these purposes better, while it also fulfils 
 the constaJit indication for a tonic. 
 
 Lactic acid was recommended by Cantani as a substitute for 
 sugar, which in this disease is unavailable for the purposes it 
 ordinarily serves in the economy. Adopting the view that the 
 sugar ingested is converted into lactic acid in the liver, he would 
 furnish the lactic acid already prepared to the latter organ, and 
 thus, by giving it a rest, effect a cure. Senator, also, is inclined 
 to favor its use, but on another ground. He believes that sugar 
 is normally converted into lactic acid in the intestine, and that 
 in diabetes the normal conversion may be interfered with. 
 
 The administration of lactic acid itself furnishes this im- 
 portant ingredient to the blood, where, as shown by Scherem- 
 etjewsky,* it is completely oxidized and becomes a force-pro- 
 ducer. Therefore we must not look to a reduction in the 
 quantity of sugar eliminated under its use, but regard it as a 
 source of jjower, the patient getting the same advantage from 
 it as the healthy individual does from sugar. They are said 
 to gain in weight, become stronger, etc., and if they belong to 
 the class in which the sugar disappears from the urine under 
 an exclusively animal food, the disease may, by the employ- 
 ment of lactic acid at the same time, be wholly suppressed, 
 and a condition of perfect health take place without excessive 
 ingestion of food. f Cantani recommends that from 75 to 150 
 grains of the acid should be taken daily in from eight to ten 
 fluid ounces of water. Larger quantities sometimes cause 
 diarrhoea and pains in the joints, which disappear after its 
 omission. A medical friend, who has apparently recovered 
 from diabetes, used in conjunction with Carlsbad water and a 
 pill of iron, quinine, and arsenic, 30 drops of lactic acid three 
 times daily. My impression of lactic acid thus used as an 
 adjuvant, is a good one, and I should be inclined to use it for 
 the purposes named. 
 
 Glycerin has also been recommended by Schultzen as a sub- 
 stitute for sugar, on the supposition that sugar in health is de- 
 
 * Scliereraetjewskv, Siichs. acad. Sitzungsb., 1869, p. 154. 
 t Senator, loc. citat., p. 999.
 
 DIABETES MELLITUS. 295 
 
 composed into glycerin and aldehyde of glycerin. But it has 
 already been explained that glycerin is easily convertible into 
 sugar, and that this conversion probably takes place in the intes- 
 tines, while the experiments of Pavy and others have shown that 
 glycosuria increases under its use. It is, nevertheless, not un- 
 likely that in the early stages of diabetes, glycerin is assimilable, 
 and it may be used in moderate amount for sweetening pur- 
 poses, if the latter must be served, but I should hardly think, 
 from what is now known of its properties and chemical com- 
 position, of using it as a remedy for the disease- 
 In view of the presence of glycerin in the fats themselves, 
 in combination with the fatty acids. Senator suggests that the 
 latter, viz., oleic, palmitic, stearic, and butyric, be administered 
 in a separate form, on the same principle that lactic acid is 
 substituted for sugar, that their force-producing power may be 
 availed of. To this end he prescribed soap in the shape of 
 pills, containing 2J grains each, of which he directed four or 
 five to be taken three times a day. In one instance he con- 
 joined the treatment with cod-liver oil. In this there was no 
 diminution in the amount of sugar excreted, but the patient 
 gained in weight (11 ounces in fourteen days); and another 
 thought there was a diminution in hunger and thirst. In both 
 instances the diet was unrestricted, and the treatment Avas con- 
 tinued "several weeks" without digestive disturbances. 
 
 It might be expected that codliver oil would be a valuable 
 remedy, or rather food, in diabetes. For while most experiment- 
 ers deny that glycogen is ever produced under a diet of pure oil, 
 those who claim that it is admit that, in the earlier stages at 
 least of diabetes, all fats are assimilable. Cod-liver oil is one of 
 these whose tonic and roborant properties have been too often 
 tried to be any longer doubted. When well borne by the stom- 
 ach, therefore, it maybe early administered with the expectation 
 that the general health and strength of the patient will improve 
 while the excretion of sugar will diminish. The further indi- 
 cation for its use by the presence of phthisis in so many cases 
 of diabetes, and the results of experience where phthisis is ab- 
 sent as well as when it is present, confirm the propriety of
 
 296 DIABETES. 
 
 placing it in tlie category of eminently suitable adjuvants to 
 the dietetic treatment. 
 
 Tlie alkalies, and especially the alkaline carbonates, at one 
 time enjoyed considerable reputation in the treatment of dia- 
 betes, after Mialhe claimed for them the power of destroying 
 the sugar in the blood, and of neutralizing the volatile acids 
 retained within the organism in consequence of the defective 
 action of the skin. These views were subsequently refuted, 
 but the carbonates continue to be used occasionally by many 
 physicians, both in Germany and in England, i^ut none seem 
 to have had such favorable results as Dr. Pavy, who reports 
 quite satisfactorily upon the use of potassium bicarbonate, in 
 ten, fifteen, or twenty grain doses, in combination with aro- 
 matic spirit of ammonia. His experiments with large doses of 
 sodium carbonate, four drachms a day; potassium acetate, six 
 drachms; potassium citrate, six drachms; and rochelle salts, 
 one ounce ; were not, however, satisfactory. These were sug- 
 gested by the results of his own experiments, in which he pre- 
 vented the occurrence of glycosuria after operations on the 
 sympathetic, by injecting sodium carbonate into the blood. It 
 would seem, therefore, that when of service, it is by correcting 
 the stomach and improving the digestion that the bicarbonates 
 act. 
 
 In the essay already referred to l)y Dr. Dougherty, of New 
 Jersev, he recommends a combination suocrested bv Dr. Whit- 
 tingham, of potassium bicarbonate, sodium phos})hate, salicylic 
 acid, and sodium salicylate, made up with glycerin, compound 
 tincture of cardamom and water, in the dose of Sh grains of the 
 first, 2| of the second and third, and 4| of the fourth. My 
 friend Dr. Andrew Nebinger informs me that he has used the 
 salicylate of sodium in a single case with great advantage, in 
 doses of 20 grains four times a day, after each meal and at bed- 
 time, in equal parts of syrup and water. 
 
 Among the remedies which have acquired some reputation, 
 is the nitrate of uranium. Attention was first called to it by 
 Dr. J. Y. Dale,* of Lemont, Pennsylvania, who claims that 
 * Boston Medical and Surgical Journal, 1877.
 
 DIABETES MELLITUS. 297 
 
 it has been remarkably efficient in liis hands in tlie treatment 
 of diabetes. He prescribes it in doses of 1 grain three times 
 a day, increased to three, if necessary, either in pill or in powder, 
 or in solution, by the aid of a small quantity of nitric acid. 
 He always uses it in connection with appropriate diet. Dr. H. 
 A. Wilson has published in the Medical Bulletin (Philadel- 
 phia), for iSIarch, 1880, the results of treatment by this remedy, 
 accompanied by a record of volumetric analyses; from which 
 it appeared that there was a decided diminution in the quan- 
 tity of sugar excreted. The dose was ^ a grain increased to a 
 grain three times a day, but the diet was also restricted. I have 
 tried it in several cases, both with and without selected diet. 
 In the former it was without effect, and in the latter there was 
 none which I could not ascribe to the diet.
 
 298 DIABETES. 
 
 SECTION II. 
 
 DIABETES INSIPIDUS. 
 
 If diabetes mellitus is considered to be an imperfectly under- 
 stood disease, still more must this be said of the insipid 
 diabetes or chronic polyuria, for even still less is known of its 
 essential or remote causes. 
 
 The term is applied to any excessive secretion of non-sac- 
 charine and non-albuminous urine which has continued for a 
 long time, and which is accompanied by extreme thirst. 
 » The condition, unlike diabetes mellitus, affects rather young 
 persons, being rare in those over 50 years of age, relatively 
 frequent in infancy, and most common between the ages of 
 twenty and thirty, as is shown in the appended table from Sen- 
 ator's article in Ziemssen's Ci/dopcedla, of cases collected by 
 Roberts, Strauss, and von der Heijdeu : 
 
 Age. Roberts, 
 
 Less than 5 years, 7 
 
 5 to 10 years, 15 
 
 10 to 20 years, 1.3 
 
 20 to 30 years, 16 
 
 30 to 40 years, •> — 
 
 40 to 50 years, J 15 
 
 50 to 60 years, -i — 
 
 60 to 70 years, / 40 
 
 70 85 87 
 
 Its contrast to diabetes mellitus in this respect, has been al- 
 luded to in connection with the former disease. As to thes^.r 
 of those affected, the same peculiarity is common to both ; it is 
 much more frequent in males than females, two to three times 
 as many of the former sex being affected by it as the latter. 
 
 Strauss. 
 
 vou 
 
 de 
 
 r Heijden 
 
 9 
 
 
 
 2 
 
 12 
 
 
 
 5 
 19 
 
 57 
 
 
 
 23 
 
 19 
 
 7 
 
 
 
 9 
 6 
 4
 
 DIADETES INSIPIDUS.' 299 
 
 Etiology and PatJwIogij. 
 
 As to causes, the same uncertainty prevails as with diabetes 
 mcllitus. An examination of cases shows an association with 
 a certain number of conditions, such ascerebral disease, includ- 
 ing tumor of the brain, sunstroke, cerebro-spinal fever, blows on 
 the head, and falls, exposure to cold, and drinking cold fluids, 
 drunkenness, pregnancy, hysteria, emotion, hereditary influence, 
 previous disease, etc., but this does not show causation. The pro- 
 portion, however, of cases in which the condition is associated 
 with brain diseases and injuries to the head, taken in connec- 
 tion w' ith the fact of Bernard's discovery that puncture of the 
 floor of the fourth ventricle above the diabetic centre, produces 
 increased secretion of urine without glycosuria, but frequently 
 with albuminuria, makes it very likely that central nervous 
 irritation, however induced, is at the bottom of the symptom. 
 Ecklmrd* confirmed this observation, and showed also that in 
 dogs, at least, the channel through which the stimulus to in- 
 creased secretion takes place is probably the spinal cord, at least 
 as far as the seventh cprvieal vertebra, for section of the cord 
 above tliis point abolished altogether the secretion of urine. 
 0;i the other hand section of the greater splanchnic nerve 
 caused an increased flow of urine on the same side, while irri- 
 tation of the peripheral extremity of this nerve caused a dimi- 
 nution and even cessation of the secretion of urine. 
 
 Again, irritation of the floor of the fourth ventricle, after the 
 splanchnic was cut, caused a further increase in the urine se- 
 creted. Whence it is evident that the splanchnics are inhibi- 
 tory of the act of secretion of urine, Avhile the excitor influence 
 passes through another channel, for a certain distance at least, 
 in the spinal cord. The experiments of Pcyranif upon dogs, 
 cats, and rabbits go to show also that the excitor influence 
 travels through the sympathetic, since electrical irritation of 
 the cervical sympathetic lasting for several hours resulted in 
 
 * Eckhard, Beitriige zur Anatomie unci Physiologie, iv, v, and vi. 
 t Peyrani, Comptes Eendus, 1870, i, p. 300.
 
 300 DIABETES. 
 
 an incrensed excretion of botli nrinc and urea, while section re- 
 sulted in a dec'ideiWyd imuiished secretion of both. In a word, 
 the channel through which increased secretion of non-saccha- 
 rine urine takes place is the same as that through which sac- 
 charine diabetes results, the difference being that in the latter 
 sugar is added, while in the former it is absent. 
 
 The immediate cause is a dilatation, first, of the arterioles, 
 and then of the capillary bloodvessels of the kidney, through 
 whose thinned and stretched walls the water osmoses readily, 
 so that the whole act is probably one of increased filtration, 
 although it has been suggested and deemed not improbable by 
 Eckhard that at least in polyuria from irritation of the floor 
 of the fourth ventricle, there is an excito-secretory influence ex- 
 erted upon the gland-cells, increasing their activity, and in con- 
 sequence the secretion of urine. But no nerves have ever been 
 traced to the cells of the kidney, and while the cells are prob- 
 ably active in separating some of the organic constituents of 
 the urine, there is every reason to believe that the water, at 
 least, is simply filtered out. 
 
 Hence it may be inferred that diabetes insipidus is always 
 the result of some irritation, either direct or reflex, of this centre 
 in the medulla obh^ngata, or of the sympathetic ganglia in the 
 abdomen, a conclusion which is confirmed by the fact already 
 mentioned, that the largest number of cases associated with any 
 single condition is found in connection with diseases and inju- 
 ries of the brain, and still more by the fact that in a consider- 
 able number of cases the lesion has been found to be in the 
 medulla oblongata, or the floor of the fourth ventricle. It 
 would seem to difl'er also from diabetes mellitus in having 
 purely this mode of origin. That is, it can never be said to 
 result from purely local hepatic or intestinal derangements, as 
 there seems every reason to believe may be the case with dia- 
 betes mellitus. 
 
 3Iorbkl Anatomy. 
 
 J^ The essential morbid anatomy of diabetes insipidus would be 
 the lesions of the nerve-centres or sympathetic ganglia which
 
 DIABETES INSIPIDUS. 301 
 
 may underlie the symptoms. But as these are often undiscov- 
 erable, or at least indefinite, it is impossible to describe them. 
 
 As a secondary phenomenon and consequence, rather than 
 an essential morbid lesion, is an atrophy and degeneration of 
 the renal substance, which may be trifling or have proceeded 
 to a degree of complete sacculation of "the organ. Out of eleven 
 cases in which autopsies had been made, collected and reported 
 by Dr. Roberts in his work on Urinar-y Diseases, four pre- 
 sented this alteration ; in one, the glandular tissue was entirely 
 wanting. In a fifth, multiple abscesses were found in one kid- 
 ney, the other was hypertemic. In a sixth, there was a tubercu- 
 lar tumor in the left hemisphere at the border of the longitu- 
 dinal sinus, and another in the cerebellum. In the seventh 
 and eighth cases, fatty degeneration of the nervous tissues of 
 the walls of the fourth ventricle was present; in the eighth, 
 there was also great vascularity of the kidneys. In the ninth, 
 there was a glio-sarcoma as large as a walnut in the floor of the 
 fourth ventricle, filling the entire cavity. In the tenth, there 
 was miliary tubercle at the base of the brain, near but not in 
 the fourth ventricle, and on the upper surface of the cerebel- 
 lum. In an eleventh, there were no changes in the kidney, 
 except congestion of the INIalpighian bodies. 
 
 It will be noticed that nervous lesions when present are 
 found more frequently in the vicinity of the base of the brain. 
 
 Symptoms of Diabetes Insipidus. 
 
 These are not numerous. The enormous secretion of urine, 
 of almost spring-w^ter-like clearness and of specific gravity 
 often as low as 1003, is the most conspicuous symptom, but 
 more annoying, probably, is the extreme thirst which always 
 attends it. 
 
 These may be said to include all the essential symptoms, 
 others which may or may not be present being rather their 
 consequence. Very constantly among them are dryness of the 
 skin and absence of perspiration. The health is otherwise 
 often perfect. 
 
 Occasionally there are derangements of digestion, and some-
 
 302 DIABETES. 
 
 times also the appetite is large, as in diabetes mellitiis. Al- 
 ways, the effect of increased discharge of water by the kidneys 
 is to increase the rapidity of tissue-metamorphosis and to wash 
 out thoroughly the urea and extractiv^es from the blood and 
 tissues, so that it might be expected that there would be some 
 increase of appetite from this source. 
 
 These symptoms may occur suddenly in the midst of appar- 
 ent health, or they may supervene upon or be superadded to 
 others, chiefly of a nervous character, which may be the result 
 of the same nervous lesion causing the polyuria. Such symp- 
 toms are headache, restlessness, irritability, more rarely con- 
 vulsions, delirium, paralyses, indeed any one or more of the 
 great variety of symptoms which result from organic or func- 
 tional nervous disease. Sometimes these symptoms succeed 
 upon the polyuria, or are increased by it. It is certain that 
 the milder nervous symptoms are sometimes the result simply 
 of the inconvenience and annoyance caused by the two cardi- 
 nal symptoms, polyuria and thirst. The patient is kept 
 busy, as it were, night and day, in passing water. It is not 
 surprising that such a patient should be fretful and irritable, 
 and that sooner or later his health should be broken if the 
 symptoms are not relieved. 
 
 In addition to the symptoms detailed, there are said to occur 
 at times dryness of the tongue, epigastric and lumbar pains, 
 diarrhea, debility, impainnent of mental faculties and, sexual 
 function. The debility is sometimes extreme. In some in- 
 stances there is the most extraordinary tolerance of alcoholic 
 drinks, while at others there is an exaggerated susceptibility to 
 their influence. A very slight loioering of the body tempera- 
 ture has been observed, amounting, however, to but a few 
 tenths of a degree, and is never below 97° F. This slight lower- 
 ing has been ascribed to the refrigerant effect of cold drinks, 
 which are constantly ingested. The tendency to boils observed 
 in mellituria is not found in diabetes insipidus. In advanced 
 stages of the disease aclema of the ankles sometimes occurs. 
 
 The duration of the condition is very various. Sometimes 
 it continues through life with no inconvenience except that
 
 DIABETES INSIPIDUS. 303 
 
 from tbe constant diuresis and thirst, and no disadvantage when 
 the latter is supplied. Dr. Willis records a case lasting fifty 
 years. On the other hand, it is seldom of brief duration ; 
 indeed, there is needed a certain chronicity in order to admit 
 it in the category of diseases. One case is reported as ter- 
 minating fatally in seven weeks. Under prognosis will be 
 found some further information as to duration, but it may be 
 said, in general, that most cases which terminate unfavorably 
 and most which recover completely, do so Avithin a year. 
 
 It has no compUcations except such as are its cause or its re- 
 sults. Among the latter is occasionally dilatation of the pelvis 
 of the kidney and atrophy of the latter, due to pressure of the 
 accumulated urine, and resulting in a sacculated condition of 
 the organ. Its symptoms are almost always influenced, and 
 sometimes even cut short, by intercurrent disease, especially of 
 a febrile character, or even by a profound physical impression, 
 as long-continued suppuration after a blister. Thus Willis* 
 cites the case of a young man who had thirst and diuresis up 
 to 18 years of age. At that time he was attacked with pleurisv, 
 and a blister was applied which suppurated for 25 days. With 
 the healing of the blister disappeared both the pleurisy and 
 the diabetes. Dr. Robertsf cites a case which had existed " in 
 intensity " for 18 years, in which an attack of acute rheuma- 
 tism treated with nitrate of potash suspended it completely. 
 Kuelz, Charcot, and Lacombe record cases in which temporary 
 improvement occurred during varioloid, and Senator]; of simi- 
 lar improvement during pneumonia, and again in the same 
 man during erysipelas. On the other hand, Dickinson§ re- 
 cords a case in which scarlatina supervened without effect on the 
 symptoms. It has been known to occur during pregnancy and 
 to disappear with it, while in other instances it has been un- 
 influenced by the latter condition. 
 
 * Willis, op. citat., p. 24. 
 
 t Roberts, Urinary and Renal Diseases, 3d Am. edit., 1879, p. 202. 
 
 X Senator, op. citat., 1031. 
 
 I Dickinson, op. citat., p. 203.
 
 304 DIABETES. 
 
 Physical and Chemical Characters of the Urine. 
 
 As to the quantity of urine passed, it is enormous, exceeding 
 often the amount passed in saccharine diabetes. As many as 
 43 liters (90 pints) are recorded by Trousseau, and one-fourth 
 this quantity is common. It has been said, even, that the quan- 
 tity secrete J sometimes exceeds that ingested, but this is impos- 
 sible, at least for any length of time, unless water is absorbed 
 from the atmosphere, which is not likely. In point of fact the 
 water excreted is always a little less than that ingested, either 
 as drink or in the solid food. 
 
 As the quantity of urine excreted increases, or its normal 
 acidity diminishes, its color disappears and its specific gravity 
 declines. In one case under my care the specific gravity was 
 scarcely 1001, while the urine in moderate bulk was absolutely 
 colorless. Again, a faint greenish tinge is exhibited l)y the 
 urine in bulk. 
 
 As to the other constituents of the urine, it may be said in 
 general that they are all increased, except possibly uric acid. 
 Thus the urea is increased to three and even four times its 
 normal amount, — 70 and 72 grams (1080.10 and 1110.96 
 grains) are recorded by Senatoi-, in an adult, and 30 grams 
 (462.9 grains) by Dickinson, in a child of 8 years. It has al- 
 ready been explained how this naturally results from the wash- 
 ing out of the tissues. In a case reported by Da Costa* the 
 urea was diminished. 
 
 With regard to uric acid, its estimation is difficult, on ac- 
 count of the extreme dilution of the urine, but analyses would 
 goto show that it is diminished, which is what one would ex- 
 pect where the urea is so much increased, oxidation being more 
 complete. 
 
 Suljjhuric and jjhosphoric acids are both increased, and es- 
 pecially, according to Dickinson, the combination of phosphoric 
 acid with the earths, lime and magnesia. 
 
 * Transactions of the College of Physicians of Philadelphia, 3d series, 
 vol. i, 1875, p. 139.
 
 DIABETES INSIPIDUS. 305 
 
 The same is true of the chlorides, which are increased for the 
 same reason as urea, sulphates and phosphates. 
 
 Of abnormal constituents, inosit has been found, and it is 
 said albumen very rarely, but care should be taken not to con- 
 found the polyuria with small albuminuria of a contracted kid- 
 ney with an albuminous polyuria in which there is no organic 
 disease of the kidney. 
 
 Unlike the urine of saccharine diabetes, that of diabetes 
 insipidus rapidly decomposes, becomes putrescent, and at the 
 same time turbid with bacteria. A further peculiarity of the 
 secretion of urine is that an increase does not rapidly follow 
 the ingestion of fluid as is the case in health, but ensues at a 
 an interval, and is kept up during a longer period. This is 
 ascribed to the constant dilatation of the renal capillaries which 
 is supposed to exist in diabetes insipidus, as compared with 
 the alternate dilatation and contraction which occur in health 
 in the reflex accommodation which is always taking place be- 
 tween the ingestion of fluids and their secretion by the skin and 
 kidneys. In health the ingestion of an undue amount of fluid 
 is promptly followed by dilatation of the renal or cutaneous 
 capillaries or both, and the transudation of an increased 
 amount of urine or perspiration or of both. If, on the other 
 hand, the quantity of liquid ingested is small, these two sets 
 of capillaries remain contracted and the water is retained in 
 the economy. In diabetes insipidus, on the other hand, the 
 renal capillaries are always dilated, and are always therefore 
 in a condition to permit the transudation of water, while they 
 in turn cannot respond as promptly to the ingestion of fluid as 
 they do in health. A longer time, therefore, intervenes before 
 the increased secretion takes place, while it is also longer kept. 
 
 Some of the accounts published as to the quantity of water 
 consumed and excreted are almost incredible, yet they seem 
 well authenticated. The following illustrative instances are 
 condensed from Dr. Willis's work on Urinary Diseases :*^ 
 A small artisan, 55 years old, had had constant thirst with 
 commensurate diuresis since he was 5 years of age. From 
 
 * American edition, Philadelphia, 1839, p. 23. 
 20
 
 306 DIABETES. 
 
 the age of 16 he had drank, on an average, no less than two 
 pailfuls daily. While in the Hotel Dieu, to which he was 
 admitted for an injury of the knee, he drank on an average 
 33 pints of water every day, often swallowing two liters or 
 about two quarts at a draught. He passed daily about 34 
 pounds of urine and 1 pound of faeces. He otherwise enjoyed 
 good health, and was the father of several children.* 
 
 Again, a Frenchwoman, aged 40 years, had been afflicted from 
 her birth with a drought beyond example. She drank every 
 day nearly two pails of water, and was eventually driven from 
 home by the ill-treatment she received in consequence of this 
 expensive habit. At 22 she married a cobbler. She drank four 
 pailfuls a day, and became the mother of 11 children, drink- 
 ing more when she was pregnant and least when out of health. 
 When 40 years old she was examined by a scientific com- 
 mission, and drank in the presence of its members 14 quarts 
 of water within ten hours, and voided 10 quarts of nearly 
 colorless urine. t 
 
 Dr. Dickinson reports the case of a farmer, 51 years old,, in 
 good general health, and equal to severe farm labor, who usually 
 drank a quart of water at a time, and repeated the draught 
 sixteen or eighteen times in the day and night, passing about 
 as much urine as he drank water. In one night, under obser- 
 vation, he passed between 5 and 6 quarts of urine without 
 sediment.;}; 
 
 These cases show also the extreme duration of some cases, 
 and the otherwise excellent health enjoyed by them. Very 
 little serious disturbance seems to result as long as water is 
 supplied to quench the resulting thirst. In extreme cases 
 patients have even been known to drink their own urine. Dr. 
 Dickinson had two cases which did so. 
 
 An extraordinary flow of saliva was met in one instance by. 
 
 * This case was reported by M. Boissat, in the Kecueil de Sedillot, tome 
 Ixxx, p. 164. 
 
 f This case was reported by Mr. Maxwell to Dr. S. F. Simmons, who 
 published it in Medical P^acts and Observations, vol. ii, p. 73. It was las 
 seen in 1791. 
 
 :j; Also from " Medical Facts and Observations," vol. ii.
 
 DIABETES INSIPIDUS. 307 
 
 Kuelz* along with polyuria in a hysterical girl of 18 years, 
 from whom as much as 525 cubic centimeters (17.72 ounces) 
 were collected in twenty-four hours, while the quantity ranged 
 during four months from 360 to the former amount. The 
 quantity of urine passed during this time ranged from 6000 to 
 7800 centimeters (200 to 260 ounces). The increased flow of 
 saliva is explained by the fact that in some of the experiments of 
 Eckhard^t Loeb| and Gruetzner,§ puncture of the medulla 
 oblongata was followed by ptyalism. 
 
 Diagnosis. 
 
 The diagnosis of diabetes insipidus is very easy. The per- 
 sistent thirst, polyuria, and absence of sugar from the urine are 
 pathognomonic. It is simply necessary to be sure of these, to 
 make the diagnosis positive. The only possible error is mis- 
 taking the polyuria of chronically contracted kidney of inter- 
 stitial nephritis for that of diabetes insipidus. This I have 
 known to occur from overlooking the presence of a very 
 minute quantity of albumen. In addition, however, to the 
 fact that a careful examination for albumen will discover it in 
 the urine of contracted kidney, the quantity of urine is never 
 inordinately large, nor is the thirst extreme; so that it would 
 seem only necessary to mention the possibility of such an error 
 in order to avoid it 
 
 Prognosis. 
 
 It is extremely rare for a case of diabetes insipidus to ter- 
 minate unfavorably unless there have been also present symp- 
 toms pointing to serious nervous lesion, that is, it is not fatal 
 by the virulence of any symptoms peculiar to it. On the 
 other hand, recovery is almost as infrequent as death. Accord- 
 ing to Dr. Roberts, of 67 cases collected, 16 are reported as 
 complete recoveries, and 14 ended fatally, nearly an equal pro- 
 portion. The remaining 37 were still in progress. In cases 
 
 * Diabetes Mellitus and Insipidus, Marburg, 1875. 
 
 f Eckliard, Beitrage zur Anat. und Physiol., iv, p. 191. 
 
 X Loeb, Et'khard's BeitrJige, v, p. 1 ; and Dissertation, Giessen, 1869. 
 
 ^ Gruetzner, Piiiiger's Archiv, vii, p. 552.
 
 3C8 DIABETES. 
 
 of recovery or death, the duration is comparatively short. Of 
 the 16 recoveries, in 9, the duration was less than a year; in 1, 
 four years ; in 2, eighteen and nineteen years, and in the re- 
 mainder some years. Of the 14 fatal cases, 9 terminated in 
 less than a year, 1 in seven xceeks, 2 in tsvo months; the other 
 5 survived for periods varying from eighteen months to 
 twenty years. Of the 47 cases in progress only 5 had con- 
 tinued for a year or under. The remainder had continued for 
 periods ranging from something over a year to fifty-nine years. 
 
 These results seem to be tolerably independent of treatment. 
 It may be said, therefore, that, as a rule, cases that last more 
 than a year are apt to continue, but ordinarily only require to 
 be furnished with an abundance of water to keep them toler- 
 ably comfortable. According to Dr. Dickinson, cases from 
 drunkenness are very apt to run a severe and rapid course, 
 usually terminating fatally within a few months, and one ter- 
 minated thus in two months. 
 
 The disease appears to me altogether less serious than dia- 
 betes mellitus. This I infer to be the opinion of Roberts and 
 Dickinson. It certainly is that of Senator, who says "it is 
 rather a troublesome than a dangerous complaint." But 
 Trousseau and Da Costa are inclined to consider it more serious 
 than diabetes mellitus. 
 
 Treatment. 
 
 The treatment of diabetes insipidus would naturally resolve 
 itself into the treatment for the disease of which it is the symp- 
 tom, than of the symptom itself; but as the former is very 
 frequently undiscoverable it must consist mainly of eiforts to 
 diminish the secretion of urine, and with it the thirst. 
 
 First, it is generally conceded that there should be no re- 
 striction in the drinking of water or other harmless fluids, 
 for the diuresis is not so much caused by the large ingestion 
 of water as the thirst is caused by the diuresis. To cut off the 
 supply of drink must therefore result in a draining of the tis- 
 sues to their disadvantage, and a corresponding increase in the 
 thirst. It should be mentioned, however, that one or two
 
 DIABETES INSIPIDUS. 309 
 
 instances are reported wherein improvement seems to have 
 resulted from such restriction. To relieve the diuresis is 
 therefore to relieve the thirst. Rational remedies to this end 
 would seem to be astringents and other drugs which tend to 
 produce contraction of the capillaries and arterioles. But ex- 
 perience does not seem to sustain our expectations in these 
 respects, probably for the reason that the lesion which causes 
 the capillary dilatation resides elsewhere than in the kidneys 
 themselves. Da Costa* reports a case of recovery from the use 
 of eiyot in drachm doses of the fluid extract three times daily, 
 increased after ten days to two fluid drachras as often. I my- 
 selff have found the symptoms to subside under the use of 
 gallic acid after I had failed with full doses of ergot. Rea- 
 soning from the reputed action of ergot on the capillaries of 
 the nerve-centres as well as those of the kidney, we would ex- 
 pect it to be the more efficient remedy, and from my present 
 knowledge of the subject I should begin treatment with it 
 rather than any other remedy of which I know, although 
 Dickinson says that " remedies designed to restrain the urinary 
 secretion seldom fail to do harm." So far as they may have 
 any efifect in disturbing digestion I would also discard them. 
 Among the remedies to be cautiously used on this account is 
 opium, which has had some reputation. 
 
 Trousseau and Rayer claimed extraordinary results from 
 the use of valerian, the former using the extract in enormous 
 doses, — two and a half drachras a day, which was increased 
 to an ounce daily in one instance. Rayer used the powdered 
 valerian and the valerianate of zinc, giving the latter in pills 
 in gradually increasing doses until 20 grains a day were given. 
 
 Reasoning from the effect of intercurrent disease and power- 
 ful physical and nervous impressions, Roberts suggests a large 
 blister at the nape of the neck or epigastrium, according as the 
 associated symptoms and the anamnesis point to the nervous 
 
 * Da Costa, Diabetes Insipidus and its Treatment by Ergot, Transac. Col- 
 lege of Physicians, Philadelphia, 3d ser., vol. i, 1875, p. 139. 
 
 f Tyson, Case of Diabetes Insipidus Treated by Ergot and Gallic Acid, 
 Transac. College of Phys., Philadelphia, 3d ser,, yoL ii, 1876, p. 180-
 
 310 DIABETES. 
 
 or digestive system, a suggestion which may be acted upon 
 with advantage. 
 
 Recently the use of the constant galvanic current has been 
 recommended, and in cases of spinal lesion may be expected to 
 be of advantage. Seidel and Kuelz have both used it with 
 good results. The former applied one pole of a " strong bat- 
 tery " over the loins near the spine, and the other as deeply as 
 possible over the hypochondrium, upon each side daily for five 
 minutes. In eight days the urine fell from 5957 cc. to 4600 
 cc. per diem, in three weeks to 2300 cc, and the next month 
 1904 cc, while the weight of the body increased nine pounds. 
 
 Kuelz applied one pole of a battery of 30 to 40 cells as high 
 as possible in the nape of the neck, and the other to the loins 
 or epigastrium, the best results being apparently obtained with 
 the positive pole to the. nape of the neck, and the negative 
 first to the loins for four minutes, and then to the pit of the 
 stomach for four minutes. 
 
 Tonics and nervines, such as strychnia, iron, arsenic, salts 
 of quinia, cod-liver oil, etc., are appropriately added to the 
 treatment with a view to sustaining the strength of the patient, 
 which is apt to give way. To these are to be added fresh air, 
 sea air, exercise, and all possible favorable hygienic influences. 
 
 Senator says : " Since diabetes insipidus is rather a trouble- 
 some than a dangerous complaint, it is advisable in the lighter 
 cases to avoid the administration of drugs, and to recommend 
 to the j^atients only a careful attention to the skin, warm cloth- 
 ing, warm baths, frictions, etc, in order to divert a portion of 
 the stream of fluid from the kidneys to the skin." He also 
 advises, in addition, in severer cases, to quench the thirst, not 
 by excessive drinking, but by bits of ice and acidulous fluids. 
 I have already expressed ray preference for a treatment ia 
 which, under ordinary circumstances at least, the supply of 
 water should be unlimited. 
 
 Among other remedies which have been recommended are, 
 in addition to opium and its alkaloids, acetate of lead, tannin, 
 digitalis, belladonna, bromide of potassium, iodide of potassium, 
 iodide of mercury, camphor, jaborandi, lime-water, bitartrate 
 of potassium, etc. I have had no experience with any of them.
 
 INDEX. 
 
 Aladoff and Cyon, experiments produc- 
 ing glycosuria, 235 
 Albumen, cause of transudation of, "18; 
 tests for, 50 ; to indicate approximately 
 quantity of in urine, 54; quantitative 
 estimation, 50 
 Albuminoid disease of kidney, 148 
 Albuminous nephritis, 85 
 Albiniiinuria, 5(i-Gl 
 
 its mechanism and production, 50 
 Amyloid kidney, 118 
 Asthma, unemic, 105 
 Author's classification of kidney diseases, 
 
 83 
 Bartels's classification of kidney diseases, 
 
 82 
 Bernard, theoi-y of diabetes, 230-233 
 Bldod-casls, fi2 
 
 Blindness in acute urcemia, 104; in dia- 
 betes mellitus, 263 
 Bright's disease, acute, 83, 85 
 chronic, 84 
 classification of, 79 
 Brunton, on dialietes, 2:35-240 
 Casts. Sec Tuhi'-casts 
 Catarrhal nephritis, acute, 85 
 
 chronic, 124 
 Charcot, views on classification of kidney 
 
 disease. 82 
 Clironicvilly contracted kidney, 165 
 Cirrhosis, renal, 165 
 Cirrhotic kidney, 165 
 Classification of Bright's disease, 79 
 Cohnheim's experiments upon inflamma- 
 tion, 58 
 Coma, diabetic, 265 
 Contracteil kidney, 165 
 Connective tissue of the kidney, 37 
 Beale's views on, 38 
 Beer's views on, 37 
 Goodsir's views on, 37 
 Henlc's views on, 37 
 Johnsim's views on, 38 
 Key, Azel, views on, 40 
 Kfiiliker's views on, 39 
 Ludwig's views on, 39 
 Schweigger-Seidel's yiews on, 39 
 Croupous nephritis, 80, 81, 85 
 Cyanotic Induration of the kidney, 80, 84, 
 219 
 diagnosis of, 222; etiology and pa- 
 thogeny of, 219 ; morbid anatomy of, 
 220; prognosis of, 222; symptoms of, 
 2'21 ; svnonvms of, 219 ; treatment of, 
 223 
 Cyon and Aladoif, experiments producing 
 
 glyc()suria, 2.35 
 Depurative disease of kidney, 148 
 Desquamative nephrits, acute, 85 
 
 chronic, 124 
 Dickinson, classification of Bright's dis- 
 ease, 83 
 morbid anatomy of diabetes mel- 
 litus, 257 
 Diffuse nephritis, 124 
 Diabetes, 227 
 Diabetes insipidus, 298 
 diagnosis of, 307 
 etiology and pathology of, 299 
 frequency of, 298 
 morbid anatomy of, 300 
 
 Diabetes insipidus, prognosis of, 307 
 
 svmptoms of, .301 
 
 treatment of, 308 
 
 urine in, :'.ii4 
 Diabetes mellitus. 227 
 
 blood, tlie alterations in, 266 
 
 causes of, 22'.l, 25(1 
 
 complications in, 274 
 
 course of, 2-59 
 
 Cyon's and AladotF's experiments pro- 
 ducing, 2.35 
 
 death-rate from diabetes, 228 
 
 diagnosis of, 274 
 
 Dickinson's description of the essen- 
 tial mor)>iil anatomy of, 257 
 views on dial)ett's, 242 
 
 dietetic treatment of, 278 
 
 Donkin, Dr. A. Scott, on treatment of, 
 284 
 
 duration of 273 
 
 foo<l and drink in, 287 
 
 hygienic treatment of, 278 
 
 patliokigy and jjathogenesis of, 229 
 
 ])rognosis of, 277 
 
 Sehiff's experiments producing glyco- 
 suria, 233 
 
 symptoms of, 259 
 
 treatment of, 278 
 
 treatment, medicinal, of, 291 
 
 urine, alterations in, 267 
 Diabetic coma, 265 
 
 Dickinson, classification of kidney dis- 
 ease, 83 
 Eckhardt on diabetes, 235, 237, note. 
 Fatty and contracting kidney, 124, 128 
 Frerichs on the unity of Bright's disease, 
 
 80 
 Glomerulo-nephritis, desquamative, 96 
 
 glycosuria. See Diabetes, 
 abnormal alimentary, 243 
 normal alimentary, 242 
 Gouty kidney, 165 
 
 (Jranular degeneration of kidney, 165 
 Granular kidney, 11)5 
 Ileideidiain on structure of the kidney, 26 
 Heller, liacteria in bloodvessels of kidney 
 
 in pytemia, 91 
 Heyl, A. G., retinal changes in diabetes, 
 
 261 
 Hypera-mia of the kidney, acute, 85 
 
 jiassive, so, S4, 219 
 Interstitial nephritis, 165 
 
 causes of, 165 
 
 complications of, 182 
 
 connective tissue, overgrowth of, in, 
 173 
 
 cvsts, origin of, in, 173 
 
 diagnosis of, 183 
 
 duration of, 182 
 
 etiology of, 165 
 
 minute structure of kidnej' in, 172 
 
 nu)rl)id anatomy of, 170 
 
 prognosis of, 183 
 
 symptoms and course of, 177 
 
 symi)toms of, 181 
 
 treatment of, ls3 
 
 supiairative nephritis, 200 
 .Johnson, views fm kidney disease, 83 
 Kidney, cirrhotic, 165 
 
 contracted, 165 
 
 gouty, 165
 
 312 
 
 INDEX. 
 
 Kidney, granular, 165 
 large white, 124, 12') 
 large contracting, 124, 12S 
 fatty and contracting, 124, 128 
 surgical, 200 
 Kidney, normal, 17 
 anatomy of, 17 
 arrangement of uriniferous tubules, 
 
 21, 23 
 bloodvessels of, 32 
 capsule of, 17, 40 
 connective tissue of, 37 
 glomcmles of, 30 
 ciiitlirliiini of tubules, 25 
 Heidenhain, on structure of, 26 
 Klein's view on structure of tubules, 
 
 27,28 
 lymphatic vessels of, 40 
 Malpighian cayjsules of, 20 
 Malpighian tufts orglomerules, 24,30, 
 
 33 
 medullary rays, 18, 19, 20, 44 
 methods of studying histology of, 42 
 nerves of, 41 
 
 pyramids of Ferrein in, 44 
 preparation of sections of, 45 
 spiral tubes of Schacowa in, 20 
 uriniferous tubules of, 20 
 vasa afferentia, 33 
 vasa efferentia, 33 
 vasa recta, 35 
 weight of normal, 17 
 passive congestion of, 219 
 Klebs's classification of kidney dis- 
 ease, 81 
 bacteria in suppurative nephritis, 
 201, 202 
 Lafont on diabetes, 238, note. 
 Langhan-;'s views on changes in the glom- 
 
 erules of the kidney in disease. 94 
 Lardacoons disease of the kidney, 84, 148 
 complications of, 159 
 diagnosis of, 160 
 Dickson's, Dr., views on, 157 
 duration of, 1.59 
 etiology of, 148 
 morbid" anatomy of, 149 
 prognosis of, 162 
 treatment of, 163 
 suppuration, as a cause of, 148 
 symptoms and clinical history of, 1.57 
 Lipai'mia, intraocular, in diabetes, 201 
 Nephritis, acute, 85 
 acute diffuse, 85 
 chronic diffuse, 124 
 interstitial, 165 
 interstitial suppurative, 200 
 parencliyniatous, acute, 85 
 parenchymatous, chronic, 124 
 supjiuiative, 200 
 Norris, W. F., retinitis in Bright's disease, 
 
 192 
 Oertel, micrococci in nephritis, following 
 
 di]>htlici-ia,'.il 
 Passive congestion of kidney, 219 
 Parenchymatous nephritis, "acute, 83, 85 
 cau.ses of, 85; complications of, 108; 
 diagnosis of, 110; duration of, 108; 
 etiology of, 85; interstitial changes 
 in, 85 ; micrococci in, 91 ; morbid 
 anatomy of, 88 ; prognosis of. 111 ; 
 symptoms and course of. 100 ; syno- 
 nyms of, 85; treatment of, 113; urte- 
 mia in, 103; urine in, 101 
 Parenchymatous nephritis, chronic, 84, 124 
 causes of, 124; complications of, 1:>5; 
 connective tissue, increase of, in, 
 I'iS; diagnosis of, 135; duration of, 
 
 135; etiology of, 124; morbid anat- 
 omy of, 12.5; prognosis of, 136; stage 
 of atrophy in, 128; svmptoms of, 
 130 ; synonyms of, 124 ; "treatment of, 
 130 ; urine in, 131 ; uremia, rarity of, 
 in, 133, i;i5 
 Pavy, views on diabetes, 231, 232, 2.34 
 Pyelo-nephritis, 84, 200 
 Rayer's views on kidnev disease, 80 
 Reinhardt on the unity of Bright's dis- 
 ease, 80 
 Retinitis in Bright's disease, 192 
 
 albuminuric retinitis, exceptional 
 
 forms of, in, 195 
 bibliography of, 199 
 changes in"the color of the fundus 
 and of the retinal blood columns, 
 in, 194 
 curability of, 195 
 forms of kidney disease in which it 
 
 may be developed in, 195 
 morbid anatomy of, 196 
 statistics of, 197 
 
 symptoms and description of, 193 
 treatment of, 198 
 typical cases of, 194 
 ura-mic amaurosis of, 199 
 Rol)erts, morbid anatomy of diabetes in- 
 sipidus, 301 
 Rokitansky's views on kidney disease, 80 
 Rose, George H., on the arransement of 
 the uriniferous tubules of the kidnev, 23 
 Rosenstein, views on kidney disease, "81 
 Sclerosis, renal, 165 
 
 Schiff, experiments in producing glyco- 
 suria, 23:?-235 
 Stewart, classification of kidnev diseases,83 
 Suppurative interstitial nephritis, &1, 200 
 bacteria in, 201 
 
 calculous concretions of, in, 201 
 course and duration of, 208 
 diagnosis of, 213 
 etiology of, 200 
 infectious emboli in, 201 
 morbid anatomy of, 202 
 prognosis of, 214" 
 symptoms and course of, 205 
 treatment of, 216 
 urine, character of, in, 206 
 Surgical kidnev, 200 
 Tube-casts, 62 
 
 blood-ca.sts, 62; dark granular casts, 
 64; epithelial casts, 63; granular 
 casts, 64; hyaline casts, 66, 67; oil- 
 casts, 65, 67 ; pale granular casts, 64 ; 
 waxy ca^ts, 67 
 Bartels's views on the nature of, 72; 
 Beale's views, 70 ; Burkhardt on, 69 ; 
 Dickinson's views on, 70, 71; John- 
 son's views on, 79 ; Key's, Axel Ernst, 
 views on, 71 ; Langhans's views on, 
 71; RindHeisch's views on, 73; Rob- 
 in's views on, 71 ; Rovida's observa- 
 tions on nature of, 72; Stewart's 
 views on, 71; nature and clinical 
 significance of, 62 
 Tubules of kidney. 20 
 Treatment of Bright's disease, etc. See In- 
 dex of Special Diseases. 
 Tranlie, views on kidney disea.se, 80, 81 
 Fnity of Bright's disease, viewson, 80, 81 
 Uriemia, acute, Ki;! 
 
 treatment of, 120 
 Frremic asthma, 105 
 
 Virchow on classification of kidney dis- 
 ease, 81 
 Waxy casts, 67 
 kidney, 148
 
 Feb. 1, 1881. 
 
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